Eyeworld

151 EW MEETING REPORTER The key feature of surgery is appropriate sizing and placement of the anterior capsulotomy, he said. A strong case can be made for use of the femtosecond laser for the cap- sulotomy, and Dr. Masket prefers to avoid nuclear division to prevent gas bubble distension of the bag. He recommended a centered capsulotomy, hydrodelineation not hydrodissection, not allowing the chamber to shallow, emulsifying the nucleus without rotation, viscodis- section of the epinucleus and cortex, and not polishing the posterior capsule. Dr. Masket mentioned the Vasavada modification of "inside out" delineation and Osher's "low flow." Less Drops and Dropless cataract surgery The necessity to use prophylactic treatment before and after cataract surgery is well-established, but the traditional approach—topical appli- cations of an antibiotic, NSAID, and steroid—has many limitations that could reduce the efficacy of these compounds. Issues primarily include patient compliance. As such, using an injection to deliver these compounds or combin- ing the drops into one topical solu- tion could be advantageous. Studies looking at the safety and efficacy of these options compared to tradition- al topical solutions were presented during a free paper session. Helga Sandoval, MD, Charles- ton, South Carolina, described a prospective, randomized, contralat- eral study involving patients having bilateral cataract surgery. The pur- pose of the study was to evaluate the efficacy of an intravitreal injection that included Dropless (Imprimis Pharmaceuticals, San Diego) with or without a topical NSAID compared to the standard pre- and postopera- tive treatment. There was no difference in IOP, macular thickness, pachymetry, or inflammation between the two groups, yet the injection option was preferred by most patients, Dr. Sandoval said. Combined Symposium of Cataract & Refractive Societies (CSCRS) During the CSCRS session, Brian Little, MD, London, presented on dealing with the rock hard cataract, which he said is always a challenge. One key concept is to plan very carefully because you can expect comorbidities both ocularly and systemically, he said. These cases take time, Dr. Little said. But he recommended physi- cians go slowly and not rush because that's when they can run into trou- ble. Stay calm and don't panic, and allow more time. Surgical planning becomes very important to anticipate the predict- able challenges. In terms of surgical technique, Dr. Little said it's easy to get focused on the splitting itself, but there are special considerations that come into every stage of the surgery. Dr. Little said he routinely uses phenylephrine in the pupil in these cases. There's no downside to using this, he said. The capsule itself can be any sort of composition, and he added that there's no excuse for not using trypan blue. Dr. Little also discussed capsule properties, hydrodissection, nu- clear fragmentation and fragment removal, using a capsular tension ring (which he said is "almost man- datory" in these cases), and use of viscoelastic. He highlighted the importance of looking for lost chips, which are small fragments that could break off and get trapped in the incisions, on the iris, in the irido-corneal angle, or in the sulcus or posterior cham- ber. These could be camouflaged, so look carefully, Dr. Little said. He said to irrigate the sulcus, angle, and all incisions to flush them out. Samuel Masket, MD, Los Ange- les, spoke about posterior polar cat- aracts. He offered several important tips for surgery in these cases. Most patients become symp- tomatic around the presbyopic age, Dr. Masket said. Surgery is indicat- ed based upon symptoms, most typically reduced reading ability and glare disability. The symptoms can increase with parapolar changes. it was quite difficult to break the central stromal bonds, Dr. Ivarsen said. It became obvious that this would not be an easy procedure. He again asked for the opinion of those in the audience on how they would proceed if the lenti- cule was stuck. Again, most (55%) indicated that they would abort the procedure at this time. The surgeon again continued trying to extract the lenticule. After a number of minutes, there was some success in folding the lenti- cule over. Eventually, forceps were introduced, and the lenticule was extracted. There were further complica- tions after surgery. After 1 day, the patient had a visual acuity of 0.4, Dr. Ivarsen said, and after 2 weeks, he had a visual acuity of 0.67, which was very poor with a lot of ghost images. After an OCT, it became apparent that there was some kind of tissue or lenticule remnant. How do you proceed with an irregular topography 2 weeks after SMILE? Most of the audience members (67%) indicated that they would wait and perform topogra- phy-guided excimer treatment. In this case, the patient was tak- en back to the OR to try to extract the lenticule remnant. Dr. Ivarsen said he thinks this problem was derived from the epithelium. It was likely due to epithelial irregularity after the abrasion, he said. Surgical complications David Chang, MD, Los Altos, California, and Rudy Nuijts, MD, Maastricht, Netherlands, co-moder- ated a video session on surgical com- plications, which featured audience voting on how they would handle certain complications. Anders Ivarsen, MD, Aarhus, Denmark, presented another sur- geon's case of complicated lenti- cule extraction in SMILE. The case involved a 32-year-old healthy male with a normal preoperative exam, but when he presented for surgery, he had an epithelial abrasion. He was sent home and came back 3 weeks later for surgery. Dr. Ivarsen explained that with SMILE, the femtosecond laser cuts a lenticule in the cornea. The patient is docked into an interface where small suction keeps the eye under control. The laser cuts both the back surface of the lenticule and the front surface of the lenticule. This partic- ular patient had a suspicious large black area in the middle of the eye when it was docked on the laser. Dr. Ivarsen asked the audience how they would proceed in this case, and most (58%) indicated that they would abort the procedure. In this case, the surgeon decided to proceed. With the incision open, the surgeon was trying to dissect the lenticule within the corneal stroma with a blunt instrument, but when the suspicious area was approached, October 2016 continued on page 152 View videos from ESCRS 2016: EWrePlay.org Nir Shoham-Hazon, MD, discusses outcomes with CO2 laser-assisted sclerectomy surgery for glaucoma when combined with phacoemulsification.

• Cover