EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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January 2012 EW NEWS & OPINION 19 between incisions to create a stan- dard 2.5-3.0 mm clear corneal inci- sion without crossing any RK incision. Careful location of the main and paracentesis incisions may be all that is necessary. However, if the RK incisions are too numerous to allow a standard phaco incision to be made in the peripheral clear cornea without violating an RK inci- sion, then alternative phaco inci- sions should be considered. Scleral tunnel: A posteriorly placed scleral tunnel incision with a posterior entry into the anterior chamber will avoid the peripheral ends of most RK incisions. This type of incision would, however, require a peritomy and possibly a suture. There remains a risk that the ante- rior aspect of the corneal tunnel would incorporate a deep peripheral RK incision, resulting in splitting of the internal opening of the incision and resultant decreased water-tight- ness. The posterior aspect of the in- cision, however, would be expected to remain intact. Biaxial micro-incisions (<1.5 mm): Using clear corneal micro-in- cisions in conjunction with biaxial phacoemulsification is a technique that effectively avoids manipulation of the RK incisions and also avoids the need for peritomy and cautery. The small incisions can frequently be placed entirely between old RK incisions in the peripheral clear cornea and can therefore allow the surgeon to perform the procedure in the standard fashion while incurring minimal increased risk (Figures 1-4). In the absence of micro-incision IOLs, it is still necessary to create a larger incision for the insertion of the lens implant. This IOL incision should be made separately from the two micro-incisions and should be made in the far-peripheral (near- clear) cornea (Figure 5). In patients with many RK incisions, it may not be possible to avoid incising a meridian that contains an RK inci- sion. It is therefore of utmost impor- tance to avoid stretching or torquing this incision. Stretching can be avoided by making a slightly gener- ous incision for a given IOL injector; the tip can then be inserted through the incision with minimal distortion or stress. If the incision does split at this point in the procedure, it will cause less difficulty and pose less risk than at earlier points in the case. Once the lens is injected, I/A and all further intraocular manipulations should be performed through the micro-incisions to avoid torquing or other manipulation and potential splitting of the delicate IOL incision. Capsular tension rings: Axially myopic eyes (ALM>27 mm) tend to have extremely deep anterior cham- bers and large, floppy lens capsules. In addition, these eyes have often undergone extreme versions of ra- dial keratotomy, with a high number continued on page 21 An ASCRS Membership For every stage of your career Whether you're just beginning or experienced in cataract and refractive surgery, ASCRS is the professional society that's right for every stage of your career. Young Ophthalmologists & Residents When you're the newest member of the team, things can be a little overwhelming. ASCRS can help with the transition. Our monthly Journal of Cataract and Refractive Surgery, Annual Symposium, and online educational initiatives work to continuously augment your formal training. Through them you'll meet like-minded young ophthalmologists facing similar challenges and concerns, along with those who've successfully navigated the waters and can provide the guidance to answer your clinical, financial, and practice management questions. For young practitioners, ASCRS is where the anterior segment ophthalmology community comes together. ASCRS offers U.S. residents and fellows an unmatched opportunity to experience anterior segment ophthalmology beyond your training program—all at no cost! Resident and fellow membership, which includes the Annual Symposium, is free during your training. ASCRS makes it easy to gain real-world experience and education with no added cost. Join ASCRS today! The Society for Surgeons AMERICAN SOCIETY OF CATARACT AND REFRACTIVE SURGERY 4000 Legato Road, Suite 700, Fairfax, VA 22033 • 703-591-2220 • www.ASCRS.org