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EW CATARACT 66 March 2017 to convert to a manual expression technique. His next pearl was to have hooks, rings, and capsule retractors available. The pupil is often miotic when nuclear density is high, so you need to have a way of manag- ing this problem. Capsule retractors and support devices are useful when the zonules are loose or broken, Dr. Miller added. His last pearl was to minimize the amount of phaco energy used. Consider chopping techniques over sculpting techniques for brunescent lenses, Dr. Miller said. Also, con- sider torsional or elliptical phaco modes over longitudinal phaco for improved efficiency. Pulse modula- tion could also decrease the applied energy. Dr. Miller offered a bonus pearl: Use the femtosecond laser if you have access to one in these cases. Femtosecond laser-assisted cataract surgery (FLACS) has been proven to reduce the amount of phaco energy required to remove cataracts, he said. EW Editors' note: Dr. Miller has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Alcon (Fort Worth, Texas), and Calhoun Vision (Pasadena, California). Contact information Miller: kmiller@ucla.edu Additionally, patients with dense cataracts tend to have deep set eyes from orbital fat atrophy, trouble positioning on the operating table because of back and neck problems, narrow lid fissures, and floppy irises. Dr. Miller's first pearl was to be ready to perform an extracapsular cataract extraction (ECCE), intra- capsular cataract extraction (ICCE), or small incision cataract extraction (SICS). Know how to remove the nucleus in one piece using a variety of manual expression techniques, he said. These techniques are especially helpful if the zonules are weak. Dr. Miller added that it's important to know how to convert if phaco isn't going well and to have a lens loop available on your tray or in the OR. Using a lot of ophthalmic viscosurgical devices (OVD) was Dr. Miller's second pearl. "Dispersive OVD is your friend in these difficult cases," he said. You can use it to coat and protect the corneal endotheli- um. Dr. Miller also recommended topping off the OVD frequently during the phaco. Third, he said to use a capsule dye to enhance visualization. Trypan blue won't help a lot when the lens is brown, but it may help a little. You need all the help you can get in these cases, he said, recommending to make the capsulorrhexis larger than normal in case there is a need Presentation spotlight by Ellen Stodola EyeWorld Senior Staff Writer longed surgery and recovery times and increases the risk of posterior capsule rupture and dropped lens material. Meanwhile, the miotic pu- pil increases the likelihood of iris prolapse, iris chafe, pupil sphincter damage, and other trauma. It also makes it more difficult to create an adequately sized capsulorrhexis, Dr. Miller said, and makes it more difficult to align a toric IOL. Zonular laxity also adds difficulty. Dr. Miller said it makes it difficult to remove lens material because of a lack of stability and counter traction during surgery. There is increased likelihood of vitreous prolapse around the lens equator and increased likelihood of posterior capsule rupture. Tips for successfully managing this challenging situation D uring the "Spotlight on Cataract" session at the 2016 American Academy of Ophthalmology (AAO) meeting in Chicago, Kevin M. Miller, MD, Los Angeles, shared with attendees how to deal with the rock hard nucleus, offering his top pearls. He first discussed the "rock hard nucleus triad," which includes a dense brunescent cataract, a miotic pupil, and zonular laxity. The dense brunescent cataract increases the risk of phaco burn, endothelial cell loss, and postoperative cornea edema, he said. It also increases the risk of pro- Pearls for dealing with a rock hard nucleus This patient has a dense brunescent cataract and marked zonular laxity. The lens sits further behind the iris than normal. " Dispersive OVD is your friend in these difficult cases. You can use it to coat and protect the corneal endothelium. " —Kevin Miller, MD This slit lamp microscope photo shows a dense brunescent cataract in cross section. Source (all): Kevin M. Miller, MD

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