Eyeworld

EW MEETING REPORTER 108 February 2017 dealing with small pupils. When you have small pupils, they can come along with other problems, such as pseudoexfoliation. Loose zonules can also make a simple case very challenging. It's important to take your time with the capsulotomy and ensure good lens mobility. Dr. Donaldson likes to make a larger than average capsulorhexis. She suggested hydro- dissecting well so the lens can move freely in the bag. The problem with small pupils, she said, is you've reduced the view by a lot, and there are many risks associated. However, there are tools and techniques that can help with this. Dr. Donaldson suggested some avoidance strategies, like preopera- tive NSAIDs, phenylephrine/ketoro- lac, or phenylephrine/lidocaine. She also suggested intraoperative tools including hooks, rings, and other expansion devices. Dr. Donaldson spoke about femtosecond laser-assisted cataract surgery (FLACS) in small pupils. The laser can induce pupillary miosis, al- though it is generally reversible. You have to be careful when placing the rings in these cases so as not to grab the edge of the capsule, she added. Terry Kim, MD, Durham, North Carolina, highlighted capsular tension rings (CTRs) versus capsule retractors in his presentation. There are a host of conditions that cause In Dr. Chang's case, he was having trouble rotating the lens. He asked what the audience would do. Forty-two percent indicated they would sculpt/crack the lens without rotation, while 27% indicated they would sculpt and then rotate. It's important not to force it, said Sonia Yoo, MD, Miami, because you can loosen the zonules and cre- ate more problems. She likes to use a vertical chop in these cases. Dr. Chang said to remember that this particular patient had pseu- doexfoliation, so zonules would be a concern. Further discussion on this case focused on options in poste- rior capsule rupture with a nuclear quadrant and how to approach a vit- rectomy with torn PC with vitreous prolapse. Editors' note: Dr. Chang has financial interests with Abbott Medical Optics, Allergan, and Carl Zeiss Meditec. Dr. Olson has no financial interests related to his comments. Dr. Yoo has financial interests with Allergan. Cataract and pseudoexfoliation A session delved into surgical chal- lenges for cataract and pseudoex- foliation, with surgeons presenting their own pearls and highlighting different approaches. Kendall Donaldson, MD, Plan- tation, Florida, shared her pearls for quality of vision at distance," Dr. Donnenfeld said, and when patients pay for a presbyopia IOL, they ex- pect to be able to read, but they also demand good visual acuity. He spoke about trifocals, which are an "exciting new technology" that are not yet available in the U.S. but are being used in Europe. "We've entered a new era of presbyopia," he said. New low add multifocal, extended depth of focus, and accommodating IOLs are more forgiving with dramatically less glare and halo and high patient satisfac- tion, he concluded. Editors' note: Dr. Donnenfeld has financial interests with Alcon, Ab- bott Medical Optics, Bausch + Lomb (Bridgewater, New Jersey), and Carl Zeiss Meditec (Jena, Germany). Cataract surgery complications A session that included a series of video case presentations asked audi- ence members to weigh in on their own clinical decisions in these cases. David Chang, MD, Los Altos, Cali- fornia, presented a number of cases, with panelists also weighing in. One case dealt with a 66-year- old patient with a rock hard lens and pseudoexfoliation. Dr. Chang first asked the audi- ence how they would approach the cataract surgery in this case; 32% indicated they would use manual phaco and 24% said they would use manual extracapsular cataract extraction (ECCE) with a large inci- sion. Panelists commented on the phaco technique they would use for this type of case as well. Randall Olson, MD, Salt Lake City, shared his preference. "Obviously, you've got a hard nucleus and want to min- imize the overall ultrasound time," he said, noting that a chop is his preferred method in this case. By chopping hard lenses, you create a pit and use that so when you engage the phaco tip against the chopper, you're well down into nu- cleus, he said. These lenses are large, so it's not uncommon for them not to rotate. You can still chop even if it won't rotate, Dr. Olson said. View videos from Hawaiian Eye 2017: EWrePlay.org John Berdahl, MD, describes a non-IV method of anesthesia for cataract surgery. Reporting from Hawaiian Eye 2017, January 14–20, Kauai, Hawaii Sponsored by

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