Eyeworld

Reporting from the Asia-Pacific Academy of Ophthalmology (APAO) Congress March 1–5, 2017 Singapore EW MEETING REPORTER 180 Los Altos, California, all included the simple technique of using an IOL as a scaffold in their presenta- tions, among other pearls. In one of her cases—a patient with a refractive surprise requir- ing an IOL exchange—Dr. Athiya Agarwal knew she would have to cut the IOL and bring it out. But first, she injected the second IOL with the correct power under the first, pro- tecting the capsule from damage. In what he called the "nev- er-ending case," Dr. Amar Agarwal saw a patient needing treatment for retinal vein occlusion, glaucoma, and dropped nucleus. He used a sleeveless phaco tip-assisted levi- tation technique to bring the lens above the iris, which he found was floppy and meant he couldn't ini- tially use an IOL scaffold technique, he said. So he first did a glued IOL and then used it as the scaffold, go- ing in with phaco to take care of the nucleus and move onto the other surgical procedures. Dr. Chang, in describing the case of a black cataract with weak zonules in which there was a poste- rior capsule tear with vitreous during phaco, said he put a remaining large, dense fragment of the nucleus on top of the iris and performed a vitrectomy. Then, he began putting a 3-piece IOL into the sulcus, leaving only one haptic in as he phacoed the last piece of the lens out, using the optic to prevent fragments of the nucleus from falling backward. arise, especially if settings are not modified. For those who are on the "harder side of soft" where the lens is just crackable, Dr. Yeoh said when you engage a nuclear fragment, you immediately need to chop; the mo- ment you activate phaco, immedi- ately chop. Some nuclear fragments will "autochop" into quadrants by themselves after impaling, but you won't always get that lucky, he said. For "true" neither here nor there cataracts, Dr. Yeoh offered three strategies. The first strategy is to con- duct hydrodelamination after hydro- dissection, so you can see the golden ring, indicating that the nucleus is free. Pull the nucleus out of the bag, and proceed with phaco. The second strategy involves manual prechopping and proceed- ing with phaco. If you have access to a femtosecond laser, you can use that technology to fragment the nucleus, but Dr. Yeoh pointed out that with this as the third strategy, you will have to use a prechopper to break the posterior plane. "Match the technique to the nuclear density and beware of the neither here nor there cataract, and you won't have the nightmares like Amar and Athiya are going to show us," Dr. Yeoh said, referencing the presentations by Amar Agarwal, MD, and Athiya Agarwal, MD, both of Chennai, India. Dr. Athiya Agarwal, Dr. Amar Agarwal, and David Chang, MD, said is an automated and objective topo-tomographic screening sys- tem for forme fruste keratoconus linked to the Orbscan (Bausch + Lomb, Bridgewater, New Jersey). The software combines Placido imaging with elevation data and pachyme- try to objectively quantify the risk of keratoconus. A zero or positive "score" using the analyzer indicates a topographic risk of ectasia. She also discussed percent tissue altered (PTA), defined as the sum of flap thickness and ablation depth divided by minimum cornea thick- ness. The PTA describes the relative extent of anterior tissue that is mod- ified during excimer laser surgery. It should be noted that PTA is based on the flap thickness a surgeon intends to create, and there is an un- predictable discrepancy between the intended and eventual, measured flap thickness, she said. Assessing risk, Dr. Chan said, remains a work in progress. To date, no single system used in isolation is able to accurately detect all eyes at risk of ectasia. Topography as- sessment alone is not enough and topography/tomography interpre- tation remains one of the most important aspects of ectasia preven- tion. Ultimately, she said, a combina- tion of systems is the best option to provide good sensitivity and speci- ficity balance. Experts tackle phaco nightmares and other worst-case scenarios A lively video-based course showed how experts in the field manage phaco nightmares and worst-case scenarios in cataract surgery. Soft cataracts can be hard to manage, said Ronald Yeoh, MD, Singapore. In particular, the chal- lenge comes with "neither here nor there" cataracts, he said. These aren't truly soft cataracts that can just be aspirated but they aren't truly hard. "More and more of these pa- tients are coming around," Dr. Yeoh said. "You need a strategy when you're faced with these soft-ish cataracts," he added, after showing several videos of the issues that can April 2017

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