EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78788
60 EW RESIDENTS August 2012 Cataract M&M rounds Hole noted in surgery by James Banta, M.D., Ayman Naseri, M.D., Elizabeth Yeu, M.D., and Thomas Oetting, M.D. L ast year, we introduced two new regular EyeWorld columns ("Cataract tips from the teachers" and "EyeWorld journal club") geared to- ward residents and young ophthalmolo- gists, but of general interest to all of our readers. This month, we launch our third such column, "Cataract M&M rounds." One of the best learning experiences for every surgical resident is "morbidity and mortality rounds," in which complications are presented to and discussed by the fac- ulty and fellow trainees. In ophthalmology, such rounds are conducted weekly at resi- dencies across the country and are of greatest value if there is a video of the case. A valued member of our ASCRS Cataract Clinical Committee, Thomas Oetting, M.D., is full professor and residency program director at the University of Iowa and has distinguished himself as one of the most innovative and best-known resident teachers in the world. Dr. Oetting has been involved in evaluating and improving all areas of resident surgi- cal education, from core competency stan- dards to wet labs. He has pioneered the use of social media for disseminating cataract surgical education, including his blog "Cataract Surgery for Greenhorns" and a Facebook collection of several hundred narrated short teaching videos (facebook.com/cataract.surgery). An expert surgeon in his own right, what I find so impressive about Dr. Oetting is his abil- ity to guide his residents through compli- cated cases and maneuvers, while later sharing the credit with them for the teach- ing videos that they generate. The ability to teach such advanced skills to others is the sign of a true surgical master, and I am delighted that Dr. Oetting has agreed to be the lead editor for this new regular EyeWorld column. As you can see from this initial installment, for each column Dr. Oetting will ask guest faculty, who them- selves are experienced resident instruc- tors, to provide their analysis. David F. Chang, M.D., chief medical editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) Figure 1: The phaco needle went deep during the groove in the area of the arrow Figure 2: During nucleofractis a hole is noted through at least the epinuclear material (arrow) Source (all): Thomas Oetting, M.D. A 72-year-old man presented to our clinic with a visually significant cataract. He had no history or findings on exam, suggesting an increased risk for complications during surgery. We took him to the operating room for surgery on his cataract expecting a routine case. His surgery started off well with a round and continuous anterior capsulotomy. Dur- ing the grooving, however, at least one pass seemed to go more deeply than usual (Figure 1). The lens was only moder- ately dense and the zonules were secure. When the lens was fragmented into halves, a hole was noted (Figure 2), but it was not clear if the hole was restricted to just the epinuclear material or if the hole passed all the way through the posterior capsule. James Banta, M.D., Ayman Naseri, M.D., and Elizabeth Yeu, M.D., were invited to provide their insights into this challenging case. Thomas Oetting, M.D., Cataract M&M rounds editor James Banta, M.D. Associate professor of clinical ophthalmology Bascom Palmer Eye Institute Miller School of Medicine University of Miami Ayman Naseri, M.D. Vice chair, residency program director, Department of Ophthalmology, University of California, San Francisco (UCSF) Stephen P. Shearing Chair in Ophthalmology, Department of Ophthalmology, UCSF Chief, Ophthalmology Section, San Francisco Veterans Administration Medical Center Questions for the case How can you tell if the hole goes all the way through the capsule or if it only involves the epinuclear mate- rial? If the hole did go all the way through the posterior capsule, how would you manage the remainder of the case? How can we prevent this from happening in the future? Dr. Banta: More than once in my career, I've had the sinking feel- ing that I made a deep pass with the phaco needle. Of the multiple times this has occurred, only once did it actually make it all the way through the posterior capsule. In that case I was left with a small round hole and completed the case without compli- cation. It is difficult to tell until the nucleus and epinucleus are removed whether a hole is truly present. Ex- tensive manipulation to determine the presence or absence of a hole in the posterior capsule is probably not warranted. If during phaco there are signs of posterior capsular instability (inability to rotate the lens, tilting of the nucleus, sudden deepening of the anterior chamber), one must assume that a capsular tear is present rather than a small hole. An attempt to bring nuclear material into the supracapsular space and compart- mentalize the eye with viscoelastic is advisable. If successful, your phaco settings can be adjusted to keep the viscoelastic in the eye while the nuclear material is slowly emulsified in the supracapsular space. If nuclear removal is successful, a bimanual an- terior vitrectomy can be performed (after suturing closed your main in- cision) followed by cortical cleanup with the vitrectomy handpiece. IOL