Eyeworld

EW FEATURE 94 Challenging and complicated cataract surgery • October 2016 likely be a small amount of vitreous left after the previous vitrectomy that will require cleanup. Third, he said his capsulotomy is large and cir- cular; as such he would prefer not to leave a large floater in any remain- ing vitreous gel. Dr. Tipperman said he prefers a YAG capsulotomy over a posterior capsule capsulorhexis. The fact that some residual opacification could remain is something he prepares his patients for, telling them it will be addressed later. Taking retinal pathology into consideration is also important when selecting an IOL. "I think most people who are conservative would recognize that if patients have had a vitrectomy for retinal detachment or proliferative Achieving continued from page 92 retinopathy, there is a decent chance they may have more retinal surgery later down the road, and their care is going to be a lot easier if they have a hydrophilic acrylic lens in," Dr. Tipperman said. "If the retina person needs to use silicone oil, there won't be an issue of the oil sticking to an acrylic lens." Dr. Henderson also said she would prefer an acrylic IOL over a silicone IOL for these reasons. Setting patient expectations Dr. Miller said it is especially import- ant to set realistic visual expecta- tions with these patients. "All of their friends have 20/20 vision; they're all elated. These post-vitrectomy patients go in and they're waiting for their perfect 20/20 'wow' postop day 1 visit, but they had a macular hole or an epiretinal membrane in the eye, and it is important to temper their ex- pectations so that they're realistic," Dr. Miller said. If a patient, for example, has a persistent or recurrent epiretinal membrane, he or she may not have noticed distortions prior to cataract surgery. "The patient may think, 'What happened, what went wrong?' The surgeon just made it so that the pa- tient could see the distortion better, and now the membrane has to be peeled," Dr. Miller said. "We have to manage expectations in this crowd of patients a little bit more than some others." EW Reference 1. Grusha YO, et al. Phacoemulsification and lens implantation after pars plana vitrectomy. Ophthalmology. 1998;105:287–294. Editors' note: Dr. Tipperman has finan- cial interests with Alcon (Fort Worth, Texas) and Diopsys (Pine Brook, New Jersey). Drs. Devgan, Henderson, Miller, and Rahimy have no financial interests related to their comments. Contact information Devgan: devgan@gmail.com Henderson: bahenderson@eyeboston.com Miller: kmiller@ucla.edu Rahimy: erahimy@gmail.com Tipperman: rtipperman@mindspring.com The chopper is used to temporarily tent up the iris to break the pupillary block and equalize the pressure between the anterior and posterior chambers. The cataract is completely removed and the capsular bag is filled with viscoelastic in preparation for IOL insertion. Source: Uday Devgan, MD Upon insertion of the probe, the infusion pressure and lack of vitreous induce a reverse pupillary block resulting in an overly deep anterior chamber. The surgeon can now proceed with cataract removal with an anterior chamber that is of normal depth.

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