Eyeworld

95 EW FEATURE October 2016 • Challenging and complicated cataract surgery AT A GLANCE • For patients with soft lenses, a standard capsulorhexis size of 5.0 to 5.5 mm can still be ideal. • Using a vacuum-based system can be particularly helpful to remove the nucleus, and minimal phaco power should be needed. • Surgeons should be aware of the "bowl" effect, which occurs when they are unable to effectively draw the entire piece of the nucleus out of the capsular bag. by Ellen Stodola EyeWorld Senior Staff Writer Pearls for soft lenses 5.0 and 5.5 mm. Although phy- sicians can use a standard capsu- lorhexis size, these cases can be challenging when not handled appropriately, she said. "The key Considerations for patients with soft lenses W hen it comes to han- dling patients with soft lenses, surgeons may need to consider specific techniques, machine settings, and other tools to help enhance surgical outcomes. Elizabeth Yeu, MD, Virginia Eye Consultants, Norfolk, Virginia; David R. Hardten, MD, Minnesota Eye Consultants, Minneapolis; and Deepinder K. Dhaliwal, MD, LAc, professor of ophthalmology and director of the cornea and refractive surgery services, UPMC Eye Center, Pittsburgh, commented on their preferred techniques and machine settings in these cases and shared pearls for avoiding complications. Preferred capsulorhexis size, technique, and viscoelastic In these cases, Dr. Yeu uses her routine capsulorhexis size and aims for one that is between 5.0 and 5.5 mm. "I try not to go too small as the density or gumminess of the lens when I start the case will often dictate whether I use a chop or supracapsular technique for nuclear disassembly," she said. For very soft lenses, such as pediatric or adolescent cataracts, Dr. Yeu prefers to prolapse the lens forward. "For a lens that has some sclerotic change to it but is a softer cataract, my go-to is either a hor- izontal chop with the Nagahara chopper or a reverse chop technique using the Koch spatula," she said. For soft lenses, Dr. Yeu prefers a cohesive viscoelastic, like BD Visc (Beaver-Visitec International, Waltham, Massachusetts) or ProVisc (Alcon, Fort Worth, Texas). Dr. Dhaliwal also uses a stan- dard capsulorhexis size of between The OASIS IRIS EXPANDER (OASIS Medical) is a molded poly- propylene ring that expands the pupil and maintains access and visibility throughout the surgical procedure. The pupillary expansion device's four pockets gently cradle the iris rim without pinching or clamping. Once the expander is removed, the iris returns to its normal shape and function. I have been using the OASIS IRIS EXPANDER for 3 years. I use it for small pupils that will not dilate well for cataract surgery and for patients with intraoperative floppy iris syndrome, which can manifest as an adverse reaction to some medications. I prefer to use these iris expanders because they go through the main inci- sion and they are less expensive than other expanders. There is a small learning curve when first using the OASIS IRIS EXPANDER, but after the first few uses it becomes routine. The device is simple and safe to remove at the end of the procedure, which I see as an advantage. When first learning to use this device, I recommend insertion for a pupil that is not too small, perhaps 4 mm or so. Do not try catching the iris in the pockets during initial insertion, simply insert and float the device on top of the iris. Then, I start by placing each of the four pockets, or corners, beginning with the corner closest to me and then going counter-clockwise until all four corners are in place. I use a lens manipulator to put each corner in place, and I always make sure the manipulator is positioned 90° straight up and down so that I can easily remove it from the positioning hole. Postoperatively, I often increase the patient's steroids for several days because any manipulation of the iris can cause an inflammatory response. This article presents two cases in which I used the OASIS IRIS EXPANDER. CASE NO. 1 I performed cataract surgery on a 64-year-old woman with a small pupil (about 2 mm) who had anterior synechiae. The pupil would not dilate, so to perform the surgery I attempted to free her pupil from the anterior capsule with viscoelastic. However, her pupil still would not dilate. At that point, I decided to use the OASIS IRIS EXPANDER. The device comes in two sizes. If patients have a very small pupil, I choose a 6.25-mm expander, and if they have a medium- sized pupil (about 4.5 mm or larger), I use a 7-mm expander. I do not want to stretch the pupil too much and risk tearing it. I only want to expand it enough so that visibility is sustained throughout the procedure. The patient did very well. The pupil stretched, and her pupillary margin did not tear. When the sur- gery was complete, her pupil was larger than 2 mm, but it was round and symmetrical. The iris expander provided sufficient visualization for me to perform the surgery. CASE NO. 2 This is an interesting case because the patient, a 56-year-old woman, started with a large pupil. I performed a femtosecond laser procedure on this patient, but by the time I moved her from the laser suite to the surgery suite, which took about 5 minutes, her pupil had decreased in size to 2 mm. I decided to use a 7-mm expander because of her previously large pupil. I also wanted to ensure that I did not catch the capsulorhexis with the pupillary expander. I like the OASIS IRIS EXPANDER because I can slip it into the anterior chamber and then catch one edge of the iris. The patient's iris was near the center of the pupil, so I knew I would not catch the capsule. When the first two pockets of the expander were in place, I moved the whole iris expander toward my incision to make sure I was engaging the iris' margin and that I would not tear the anterior capsule. It was simple to place the device without trapping the anterior capsule with the iris. The surgery was a success. Request more pupil expansion device information by contacting (844) 820-8940 or sending an email to customerservice@oasismedical.com. Article reprinted from the June 2016 issue of CRST. OASIS IRIS EXPANDER Using an iris expander for small pupil cases provides sufficient visualization to perform surgery. BY ADELAIDE PRIESTER, DO Adelaide Priester, DO ✦ surgeon at Better Vision Ahead in Tulsa, Oklahoma ✦ alpmiowa@earthlink.net V I S I T O A S I S ® A T A A O C H I C A G O | B O O T H 4 0 2 1 OASIS IRIS EXPANDER GENTLE & EFFECTIVE EXPANSION Available in 7.0mm and 6.25mm for an unimpeded view during complicated small pupil surgeries. SOFT SHIELD ® Collagen Corneal Shields For ocular surface protection. © 2016 OASIS Medical. SOFT SHIELD and OASIS IRIS EXPANDER are trademarks of OASIS Medical, Inc. 514 S. Vermont Ave, Glendora, CA 91741 For more information: www.oasismedical.com | 844-820-8940 A D V E R T O R I A L This insert was independently produced by OASIS Medical. EyeWorld magazine had no part in its production. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld magazine and ASCRS. for soft lenses are the hydro steps: hydrodissection and hydrodelinea- tion." If one can achieve good hy- drodissection and hydrodelineation, continued on page 97

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