EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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Leaders in Managing the Business of Ophthalmology CER TIFIED O Challenging cataract cases October 2012 An open continued from page 70 OPHTHALMIC E EXECUTIVE interesting case is a very extreme example of what traditionally has been a fairly rare occurrence. "I say traditionally it has been a John L. S o MONTG rare problem because I think it's going to become more common as we see more patients undergoing pars plana procedures, particularly the pars plana injections that we perform so frequently in the office for intravitreal medication delivery," he explained. Dr. Arbisser was able to achieve an excellent outcome because she adhered to very important funda- mental principles in operating on a complex eye, particularly in an eye that has an open capsule, Dr. Nichamin said. First of all, the surgeon should "E arning the C COE designation ed the dot OE de exp erienced practice administrattor. She became sought aftfte istrra oators in other l administr o connected the dots for our highly or. er for advic bye by ors in other local practices who wer e newer in the ophthalmology game,e, and she pointed them t o ASOA. Besides cer tification trainingg, ASOA pro vides a non- competitivve forum for ongoing dialogue with administrattors ar ound the countrry t o ons t to problems,s, e forum for on explore and share solutions t which for our administrat tor is a v valuable resource." The American Society of Oph thalmic Administrat ors— the fastest, most reliable, and accurate resourc e for ophthalmic practice staffff. . Sign your staff up f @ r staff up f for a free trial membership! Call Susan at 703-591-2220 or email susan@asoa.or g. www.ASOA.org maintain a closed chamber environ- ment, avoid fluctuation of intraocu- lar pressure, avoid high levels of infusion and/or aspiration, and maintain chamber volume with viscoelastic agents, he said. Dr. Vold agreed, "In these types of cases, the liberal use of viscoelas- tic can be helpful in achieving a stable and formed anterior chamber throughout cataract surgery." In addition, utilizing trypan blue under viscoelastic may be bene- ficial in staining the anterior capsule to improve capsular visualization, he said. Dr. Arbisser did a manual lens extraction, which again was very appropriate. She manually irrigated out the soft lens material, thereby maintaining the remaining integrity of the capsule that she had, and she was able to slowly identify the capsular anatomy that was present, preserve it, and thereby implant an intraocular lens, Dr. Nichamin said. In younger patients like this woman, gentle automated or man- ual aspiration of the lens material may be all that is needed to success- fully remove the entire cataract, Dr. Vold said. If a posterior capsule break is suspected, vigorous irriga- tion should be avoided to prevent posterior displacement of the lens material into the vitreous cavity. Furthermore, utilization of a pars Establishing adequate capsule coverage for IOL IOL implanted adding Triessence to confirm absence of vitreous for anti-inflammatory effect Source (all): Lisa Arbisser, M.D. plana incision with injection of dispersive viscoelastic posterior to the lens prior to removal of the cataract should be considered in cases of suspected posterior capsule rupture as well. Another important point is surgeons need to understand the different physical properties of the viscoelastics that they use, Dr. Nichamin said. Dr. Arbisser used dispersive and cohesive agents appropriately. One also has to have appropriate surgical instrumentation on hand to handle these types of cases, and devices such as endocap- sular tension rings and capsular support hooks, he said. With some vitreoretinal experi- ence of his own, Dr. Nichamin said he would have started off in a simi- lar fashion as Dr. Arbisser, with a small paracentesis, maintaining a closed chamber using viscoelastic, applying capsular dye in order to visualize the capsular anatomy, and then he would tiptoe his way through the remainder of the case, preferring manual maneuvers over automated, high-flow technique. Dr. Arbisser said that her main takeaway from this case is that in order not to further rupture the capsule or lose lens material, surgeons have to have the patience to do a dry removal of all cortex and nucleus if necessary. In addition, in all open capsule cases and trauma cases where the status of the capsule is unknown, it may not be possible or appropriate to place a lens at the time of sur- gery, so the patient has to be warned of the potential for aphakia and needing a secondary lens later, she said. EW Editors' note: Drs. Arbisser, Nichamin, and Vold have no financial interests related to this article. Contact information Arbisser: 563-323-2020, drlisa@arbisser.com Nichamin: 814-849-8344, nichamin@laureleye.com Vold: 479-366-4570, svold@cox.net