JAN 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 23 of 71

24 EW CATARACT January 2012 Cataract editor's corner of the world Contemplating pars plana procedures for cataract surgeons by Maxine Lipner Senior EyeWorld Contributing Editor Weighing the current wisdom magine you are performing a routine cataract surgery when there is a turn of events. In that brief moment, the routine case becomes a heart- pounding thriller. The posterior capsule is torn and the lens has dislocated into the anterior vitreous cavity. Unfortu- nately, this situation occurs not too in- frequently. Should the cataract surgeon proceed if he/she feels comfortable operating via the pars plana? Are there boundaries, and if so, who defines the boundaries? I Bonnie An Henderson, M.D., cataract editor I t is something that remains an area of contention—should an- terior segment surgeons be entering the pars plana for procedures such as planned PPV or posterior assisted levitation (PAL)? EyeWorld spoke with two leading ophthalmologists to get their perspectives on this. Point Richard Packard, M.D., senior con- sultant, Prince Charles Eye Unit, Windsor, England, sees the issue of entering the pars plana as one that reflects anterior surgeons' comfort level. "I think that it depends on whether they feel comfortable there and whether they're prepared to do a complete peripheral retinal check afterward to make sure that there aren't any breaks," he said. "If they don't [feel comfortable] then they shouldn't." He pointed out that many of those who express interest in doing this have a rigorous back- ground in it. "The people who are keen on doing this, a lot of them have been trained as ER surgeons anyway," he said. When it comes to a rescue tech- nique like PAL, Dr. Packard acknowl- edged that ER surgeons caution an- terior segment practitioners against this. He, however, has been doing this on occasion for 20 years. Decid- ing whether or not to undertake the PAL maneuver as an anterior seg- ment surgeon depends on the indi- vidual case, he believes. "If the nucleus is sort of hovering on the front of the anterior hyaloid, then doing some sort of PAL maneuver is probably perfectly acceptable for an anterior segment surgeon," Dr. Packard said. "But if it has gone any further than that, the surgeon shouldn't start fishing around in the vitreous cavity." Dr. Packard's experience here has been pretty positive. "I've done the PAL maneuver probably a half dozen times in the last 20 years, and I have not in any of those cases needed to call in the services of a vitreoretinal surgeon," he said. He recommended that any ante- rior practitioner who is thinking of performing procedures in the poste- rior segment such as posterior vitrec- tomy or PAL be prepared to thoroughly check for peripheral breaks afterward. "If the surgeon sees a break, he needs to call a col- league, or if he feels comfortable he can deal with it as required," Dr. Packard said. From a medical legal perspec- tive, anterior segment surgeons need to abide by the facility's guidelines. "If it says in the guidelines that it's acceptable for anterior segment sur- geons to go through the pars plana and they feel that they've had ade- quate training to be able to do it, then I wouldn't think that there are any medical legal consequences," Dr. Packard said. If something unto- ward does happen, the anterior sur- geon has the backing of the guidelines, just as a retinal surgeon would. Overall, Dr. Packard sees pros and cons to all of this. "The most important thing is that when sur- geons undertake any procedure, they have to be able to deal with the consequences of their actions," he said. "That's what it comes down to." Counterpoint Steve Charles, M.D., clinical profes- sor of ophthalmology, Hamilton Eye Institute, University of Tennessee, Memphis, and founder, Charles Retina Institute, Memphis, has an- other view. He sees entering the vitreous cavity as appropriate only in very limited circumstances. "This should be done only for vitreous loss after posterior capsule rupture during cataract surgery, traumatic cataract cases with a damaged capsule, or secondary IOL implantation with vitreous in the anterior chamber— never for floaters or asteroid hyalo- sis," Dr. Charles said. Trouble can brew quickly, he pointed out. "The problem with sim- ple cases is that they're no longer simple if you make a complication," Dr. Charles said. "Simple cases can become radically complicated and patients can have a bad outcome." There are a myriad of pitfalls Dr. Charles enters the vitreous in very limited circumstances, such as during vitreous loss after posterior capsule rupture (pictured here) Source: David Allen, F.R.C.Ophth. that the anterior surgeon can face. "There can be retinal detachment caused by intraoperative vitreoreti- nal traction from cellulose sponges or sweeping the wound using any- thing less than maximum cutting rates, using excessive vacuum or flow rates, or withdrawing the cutter while vacuum is applied," Dr. Charles said. Before a practitioner who was attempting a "simple vit- rectomy" because the IOL was dislo- cated in the vitreous cavity knows it, continued on page 26

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