Eyeworld

79 July 2017 EW MEETING REPORTER with the potential to regenerate. A study of this technique involving 12 pediatric patients less than 2 years old found all eyes regained visual function. Yan Hong, MD, Xi'an, China, discussed the complications that have occurred with lens regenera- tion, but Dr. Nischal said later in the discussion that he thinks this technique "will be the way of the future." Dr. Yan, in providing an update on congenital cataract surgery man- agement and amblyopia treatment, discussed 23-gauge vitrectomy via a corneal approach for cataract treat- ment, femtosecond laser-assisted cataract surgery (FLACS), and visual rehabilitation. In terms of future directions, Dr. Yan said there will be capsule- irrigating devices customized for pediatric eyes, dexamethasone-coat- ed IOLs, an IOL calculation formula customized for pediatric eyes, and multicomponent adjustable IOLs to combat refractive surprises. "The management of congeni- tal cataract poses unique challeng- es because of visual development and ocular growth," Dr. Yan said. "Emerging techniques may help us improve visual outcomes and mini- mize adverse events." Abhay Vasavada, MD, Ahmed- abad, India, discussed the use of IOLs in infants. While primary IOL implantation is becoming the accepted modality, in children under 2 years old, especially in bilateral cataract cases, IOL implantation is still unclear, he said. Dr. Vasavada described a pro- spective, randomized clinical trial with 5 years of follow-up that looked at the safety and efficacy of bilat- eral aphakia versus bilateral pseu- dophakia. At 5 years, Dr. Vasavada reported that eyes with glaucoma in the aphakia group required surgical viscoelastic to protect the clear cornea, enter the bag of the lens, go into the cataract, and "suck out the lens material." Putting in more viscoelastic, Dr. Nischal said he then will cut the adhesion with scissors. During questions at the end of the session, a delegate asked what Dr. Nischal would advise if OCT was unavailable. He said he would use an MVR blade, a vitreoretinal blade, or even a needle to go up into and cut the cornea. "You're going to do a corneal transplant anyway, better to cut into the cornea to cut the stalk," Dr. Nischal said, noting that you would need to do ultrasound beforehand. Boris Malyugin, MD, PhD, Moscow, Russia, said several studies have shown that if you switch off the microscope and use a light pipe, aiming it to the corneal opacity, it may help visualize the anterior chamber structure. "If you don't have sophisticated machines … use side illumination" in these cases, Dr. Malyugin said. Li Junhong, MD, PhD, Shanxi, China, presented on the general management of pediatric cataract. There are decisions to be made in terms of scleral tunnel vs. corneal in- cision, techniques to create the ante- rior capsulorhexis (Dr. Li noted this is more difficult due to the elasticity in pediatric cases), management of the posterior capsulotomy before or after IOL implantation, vitrectomy, and more. In general, Dr. Li said it's important to never touch the iris during pediatric cataract surgery to avoid posterior synechia, and she thinks there is less of a postop reac- tion using the minimally invasive, sutureless 25-gauge pars plana vitrec- tomy for posterior capsulotomy. A relatively new approach presented by Dr. Li was stem cell regeneration of the lens. Removing the cortex preserves the endogenous lens epithelial cells as stem cells "It's a matter of efficiency of manpower," Dr. Tabin said. Howev- er, as with all things, quality is still paramount. "You don't want to start out trying to do 12 cases per hour," he said. "You want to do every case absolutely perfectly." MasterClass on pediatric cataract surgery draws crowd It was standing room only in the pe- diatric cataract surgery MasterClass sponsored by the World Society of Paediatric Ophthalmology and Strabismus. Ken Nischal, MD, Pittsburgh, director of the course, welcomed attendees with a practiced Mandarin "good morning." Dr. Nischal gave a presentation on surgical techniques for special circumstances in pediatric cataract surgery. One special circumstance Dr. Nischal described is when the cornea is attached to the lens (keratolentic- ular adhesion), occurring either due to trauma or Peters anomaly. Dr. Nis- chal explained how he uses intraop- erative OCT to visualize where to cut the adhesion, or stalk, with scissors. "When you have severe lens attached to cornea, it's not always a good idea to do a cornea trans- plant," Dr. Nischal said. "It's a better idea to remove the lens and make the pupil big." Showing a video, Dr. Nischal described how one should put in stages of this team approach, describing a work flow resembling a factory assembly line. For the anesthesia stage, the team requires a doctor and a senior nurse; preparing the patient for surgery requires a running nurse; draping and apply- ing the speculum requires a scrub nurse; the surgery is performed by an ophthalmologist; end of surgery activities are performed by a scrub or running nurse; and surgical record writing are performed by a running nurse. Dr. Tabin went on to present an actual series of cases as performed using this work flow, which has one surgeon performing cataract surgery at two operating tables. Beginning about 1:15 minutes into cataract surgery on one pa- tient, a second patient is brought in and prepped for surgery on the second operating table. Around 1:20 minutes, the surgeon has begun ex- tracting the cataract; the cataract is out at 1:50. The IOL is inserted by 3 minutes, the next patient is prepped, and the first surgery is completed by around 3:30 minutes. Less than 10 seconds later, the surgeon has begun surgery on the next patient; the first patient is led off the table 40 seconds into the second patient's surgery. By around 1:15 minutes into the second cataract surgery, the third patient is on the table. continued on page 80

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