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EW CATARACT 40 November 2016 ourselves: What would I do if this was my mom?" Dr. Al-Mohtaseb also noted that optical biometry is more accurate than ultrasound at measuring axial length in these patients because it measures to the fovea, not a possible posterior staphyloma. Drs. Berdahl and Ciralsky said they'd prefer optical biometry to measure length as well. Intraoperative challenges While having a larger anterior chamber depth makes cataract sur- gery easier than if it were small, as in hyperopic eyes, Dr. Al-Mohtaseb said complications such as reverse pupillary block or lens/iris dia- phragm retropulsion syndrome can occur, especially in post-vitrectomy patients. In the event of a pupillary block, a second instrument can lift the iris off the capsule to allow fluid to circulate back to the posterior chamber and return the iris/lens diaphragm to its normal position, Dr. Al-Mohtaseb said. But the issue is the pupil can be smaller after this happens. "It's best to avoid this from occurring instead of dealing with it when it occurs," she said. "I do not enter the wound irrigating—I am on foot position zero—since the an- terior chamber is filled with OVD. I insert my phaco tip and then use my second instrument to lift up the iris before going to foot position two." Dr. Berdahl said physicians should not only prepare for the potential of a reverse pupillary block but for the eye to feel bouncier and the cataract softer than usual as well. IOL calculations IOL power formulas tend to select lower powers than needed for long eyes, resulting in hyperopic errors, Dr. Al-Mohtaseb said. As such, the axial length needs to be adjusted, rather than the lens constant, she explained, citing work by Douglas Koch, MD, and Li Wang, MD. "For patients with axial lengths greater than 25.2 mm, which we consider long eyes, the Wang-Koch AL adjustment reduces the risk of these hyperopic errors," Dr. Al- Mohtaseb said. "The AL optimiza- tion adjustment can be used with traditional formulas (Holladay 1, Haigis, SRK/T, Hoffer Q) and was found to result in less postoperative hyperopic surprise, especially in patients needing IOL powers less than 6 D. "More recently, the Barrett Universal II formula, which is based on paraxial ray tracing, has also been shown to be very accurate in predicting IOL power in long eyes," Dr. Al-Mohtaseb continued. Dr. Ciralsky said she uses a tra- ditional formula, typically the SRK/T formula with the Wang-Koch ad- justment. Dr. Berdahl said he leans heavily toward the Barrett Universal I formula but does look at a number of formulas for these eyes. "I'm hopeful that the Hill- Radial Basis Function (RBF) will make us even better at this," Dr. Berdahl said, referencing the Hill- RBF Calculator, a tool available on the ASCRS website. "I also use intraoperative aberrometry; that's my tie-breaker if a patient is looking to be spectacle independent. The challenge in these highly myopic eyes is getting them firm enough to get an accurate ORA [Alcon, Fort Worth, Texas] reading, which may take additional viscoelastic." Patient conversation The conversation about expected outcomes needs to be tailored for these patients as well. If the patient is highly myopic in both eyes but only has a cataract in one, that's an important consid- eration. "Are you going to condemn patients to high myopia for the rest of their life by leaving them myopic so they don't develop anisometropia afterward? Are they going to tolerate a contact lens well in the other eye? Are you going to plan for cataract surgery in the second eye even though there may not be a cataract there yet? Those are important dis- cussions," Dr. Berdahl said. In these cases, Dr. Berdahl said his preference is to shoot for plano or a little bit of myopia and see if they tolerate a contact lens. If they can't, then he would perform a lens exchange or cataract surgery on the second eye. Highly myopic cataract pa- tients are also often on the younger side, which Dr. Berdahl pointed out means they have a lot to gain as much of their myopia could be fixed. At this point in their lives though, they're often only in the early or mid-stages of presbyopia. "You need to have a good conversation about what it means if you're going to use a monofocal lens, that they're not going to be able to read up close anymore," he said. "For all of their lives, their safety blanket has been if they hold something right in front of their eyes, they can read it. That's going to go away with cataract surgery." As such, Dr. Berdahl said you might have to set the expectation for spectacle dependence. "If patients are expecting spectacle independence, let them know that there's a decent chance they'll need a LASIK enhancement or an IOL exchange afterward, but that you'll do your best to try and accomplish it with the first surgery," he said. Dr. Ciralsky said due to the complications associated with cat- aract surgery in long eyes and the difficulty in IOL calculations, she would advise beginning surgeons to postpone these cases until they are more experienced. EW Editors' note: Dr. Berdahl has financial interests with Alcon, Abbott Medical Optics (Abbott Park, Illinois), and Bausch + Lomb (Bridgewater, New Jersey). Drs. Ciralsky and Al-Mohtaseb have no financial interests related to their comments. Contact information Al-Mohtaseb: zaina@bcm.edu Berdahl: john.berdahl@vancethompsonvision.com Ciralsky: jessciralsky@gmail.com of 2016. The U.S. Food and Drug Administration (FDA) approved BromSite in April 2016 to treat post- operative inflammation and prevent ocular pain in patients undergoing cataract surgery. "BromSite is an ingenious con- coction of what many of us believe to be the most potent nonsteroidal anti-inflammatory molecule—brom- fenac," said John Sheppard, MD, president, Virginia Eye Consultants, Norfolk, Virginia, and one of the first surgeons in the U.S. to use the DuraSite platform. "We're excited by another improvement in the brom- fenac molecule franchise, now in by Lauren Lipuma EyeWorld Contributing Writer New formulation with sustained-release drug delivery reduces treatment burden in cataract patients U. S. eye surgeons will soon have a new drug in their arsenal: the first sustained-release NSAID formulated with the DuraSite drug delivery plat- form. BromSite (bromfenac ophthal- mic solution 0.075%, Sun Pharma, Mumbai, India) is set to enter the U.S. market in the final months BromSite poised to enter U.S. market Cataract continued from page 38 Source: Sun Pharma

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