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October 2012 Challenging cataract cases February 2011 EW FEATURE 69 "very common" to cause further zonular damage and for the capsulorhexis to run radially. "If I caused zonular dehiscence, I would have used a capsular tension ring," Dr. Donnenfeld said. Dr. Tipperman did have a CTR on hand, but the zonules held up enough so its use wasn't warranted, he said. Dr. Trattler said ensuring a good circular capsulorhexis is the key to these kinds of surgeries and "maybe making it a little smaller than nor- mal." He also said a CTR would help to keep both bag and lens centered. "Some of the smaller nuances Surgical view of the eye following the femtosecond laser portion of the procedure. The red arrows can be seen to delineate the region of the zonular dehiscence. The blue arrows show the capsulorhexis edge that can be seen to extend for 360 degrees. The long yellow arrow shows a single arcuate incision inferiorly, and the short yellow arrow shows the primary cataract incision Source: Richard Tipperman, M.D. never see a case of traumatic cataract, the zonular laxity is similar to a very bad pseudoexfoliation case, which we see each and every day." In this case, some vitreous strands presented where the zonules were missing and were removed with a vitrector; on post-op day 1, no vitreous remained. "Making the capsulorhexis is the most challenging part of the procedure, and sometimes it's very Poll size: 463 hard to do as there's no tension on the capsular bag," Dr. Donnenfeld said. Surgeons can perform one of two techniques: make a second inci- sion using small forceps to grab the capsule and hold it in place, or "go in with an MVR blade [Escalon, Lake Success, N.Y.] or a super blade and make the opening in the capsule and then complete the capsu- lorhexis under the viscoelastic," he said. Dr. Donnenfeld warned it's are that it's still a little controversial whether or not to place a one-piece or a three-piece lens. I tend to put a three-piece lens in because the haptic adds support to the capsular bag," Dr. Donnenfeld said. Without an arcuate incision the patient cannot be billed for the use of the femtosecond technology; Dr. Donnenfeld noted the arcuate incisions in this case provided a "safe harbor" to be able to bill for the femtosecond laser. Without the femtosecond … The ability to use a femtosecond laser in these kinds of difficult cases "is just huge," Dr. Tipperman said— and pointed to very dense cataracts, shallow chambers, corneal guttata, and pseudoexfoliation as examples where the femtosecond laser can remove some of the risk. Without a femtosecond laser, "my results might have been as good as this one, but the chances of it coming out as beautifully are much smaller," Dr. Trattler said. Without a femtosecond laser, he's also more likely to use a three-piece IOL, in case he needs to suture the lens. The take-home message? "Every- one needs to determine what level of bad cases they're willing to take," Dr. Tipperman said. "This isn't a simple cataract surgery, and the patient needs additional education. It's more involved, it's more compli- cated, there's a longer follow-up, but if you can create a perfect 360- degree capsulorhexis and ensure a centered IOL, you've had a great day. The femtosecond laser can give surgeons that confidence." EW Editors' note: Dr. Tipperman has financial interests with Alcon (Fort Worth, Texas). Dr. Donnenfeld has financial interests with Alcon and Abbott Medical Optics (Santa Ana, Calif.). Dr. Trattler has financial interests with LensAR (Orlando, Fla.). Contact information Donnenfeld: 516-446-3525, eddoph@aol.com Tipperman: 484-434-2716, rtipperman@mindspring.com Trattler: 305-598-2020, wtrattler@gmail.com EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email daniela@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2012