Eyeworld

181 April 2017 EW MEETING REPORTER They also center the capsular bag (if there are sufficient zonules) and tighten the posterior capsule. So at what stage should a CTR be implanted during surgery? Dr. Malyugin said a CTR should be used as soon as you know there's a problem. It can be utilized as early as immediately after the rhexis to as late as after the IOL is in place, he said, noting that there are special considerations at each stage. His fourth pearl was the fish-tail technique of conventional CTR im- plantation, which he said will help avoid zonular stress. Finally, the last pearl was that there are modified CTR options and different variations. Femtosecond laser refractive surgery, technologies, techniques, and complication management The currently available technologies and techniques for femtosecond la- ser refractive surgery, as well as new- er advances and pearls for success, were presented in a symposium. Addressing LASIK, Wing Kwong Chan, MD, Singapore, discussed the perfect femtosecond flap technique, "if there is such a technique," he said. "LASIK is a two-part procedure. One is a good flap … and the second part is good laser ablation that is ac- curate and predictable. So in LASIK [the flap] is half of the procedure," Dr. Chan said. His technique for making the flap involves using the IntraLase la- ser (formerly Abbott Medical Optics [AMO], now Johnson & Johnson Vision [J&J Vision, Santa Ana, Cali- fornia]) without a lid speculum. He uses the laser's microscope to fit the suction ring and prefers to center the ring on the pupil, rather than the limbus, especially for hyperopic corrections. Start with 9 mm diam- eter flaps at 120 μm thick, but Dr. Chan noted that not all eyes require such a large diameter, especially Asian eyes. Choosing the right diam- eter, he added, avoids cutting into the peripheral corneal vessels while maintaining and adequate ablation area. He was then able to capture the lens in the continuous curvilinear capsulorhexis. Dr. Chang presented a second case of a rock hard, black lens, but this time, the patient had a very crowded anterior chamber, small pupil, and synechiae. "As good as we think we are at phaco, phaco may not be the best approach for all of these cases," Dr. Chang said, adding that he's been fortunate enough to learn small inci- sion extracapsular cataract surgery. To remove the cataract, Dr. Chang first had to enlarge the small pupil, using scissors to make partial thickness sphincterotomies. He made a can-opener capsulotomy, hydrodissected, and used a cannula to prolapse the nucleus out. In this case, Dr. Chang said small-incision extracap was far more gentle on the cornea, sparing the patient all the phaco energy that would have gone into the lens. Top pearls in pseudoexfoliation/ weak zonules Surgeons shared their top pearls in complicated phaco cases. Boris Malyugin, MD, PhD, Moscow, Russia, discussed pseudoexfoliation and weak zonules. Dr. Malyugin's first pearl was surgical technique. He mentioned thorough hydrodissec- tion and low fluidic parameters. He also stressed "zonule-friendly" lens manipulations, which include quick chop phaco, vertical chop, and in-si- tu fracture, among others. His second pearl was that good visualization is key, and he added that it's important to avoid blind maneuvers. The third pearl related to using conventional capsular tension rings (CTR) and ophthalmic viscosurgical device. When considering CTR after the capsule is open but before lens is out, Dr. Malyugin said to inject an ophthalmic viscosurgical device behind the anterior capsulorhexis edge. If you implant a CTR at an ear- ly stage of the procedure, irrigation/ aspiration can be difficult, he said. Conventional CTRs, he said, support missing or weakened zonules by circularizing the bag and evenly redistributing zonular ten- sion between the remaining zonules. continued on page 182

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