EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/87458
76 EW FEATURE Diving continued from page 75 fissure and the shallow anterior chamber," he said. Given the fact that the case was performed by a resident, however, Dr. Jeng finds this understandable. "The first thing that I would have done differently is I would have used topical anesthesia to prevent such a boost in pressure," he said. "The second thing I would have done is make sure that my wounds were more anterior than normal." If the paracentesis is right at the limbus, as is typically done, and if there is any floppiness to the iris in a shallow eye, this kind of expulsion can occur, Dr. Jeng finds. Furthermore, he would have in- jected a minimal amount of trypan blue and left this in the eye. In addition, he would have injected viscoelastic from the outset. "Maybe that would have prevented things from coming out (of the eye)," he said. With the second eye, while Dr. Jeng agreed that general anesthesia would keep the patient from valsal- vaing during the procedure and pre- vented the posterior pressure from a block, he would have taken a differ- ent tack. "If just the valsalva caused all of this, I don't know that I can justify putting a patient to sleep for that," he said. "I still would have used the topical (anesthesia)." Since general anesthesia was used here, Dr. Jeng isn't convinced that a canthotomy cantholysis was necessary. With this method there were no concerns about a tight orbit with nothing being injected behind the eye and no chance of the patient valsalvaing. However, Dr. Jeng agreed that the use of the heavier viscoelastic and the soft shell technique was useful here. Cynthia S. Chiu, M.D., associ- ate professor of ophthalmology, University of California, also ques- tioned the use of a block in the first eye. "In a small eye it tends to push things forward even more," she said. Compounding things is the ten- dency that residents have to overin- flate the eye with material, she said. "I think that's mainly because they don't know how much to put in safely," Dr. Chiu said. As the resident was irrigating the trypan blue out, too much fluid might have been used, partly causing the valsalva reaction. In such small eyes, Dr. Chiu stressed the need for extra careful wound construction. "A well-con- structed incision can be one way to keep the iris from sneaking out of the eye," she said. As for the second eye, she sees the use of general anesthesia here as a good way to both circumvent the issue of patient cooperation and avoid a sub-Tenon's block. Dr. Chiu also applauds the use of canthotomy cantholysis here. "This is not used frequently enough in situations where patients have small palpebral fissures," she said. However, when it comes to the use of systemic mannitol, she would have taken another tack, using a Honan balloon instead. This would avoid cardiovascular concerns if there were any. She also sees the use of the heavy Healon as a nice precaution- ary measure to immobilize the iris and to keep this from coming out of the eye. Overall, Dr. Chiu thinks that the approach used in the second eye demonstrates a real understanding of the issues with the first. "I think that they should be applauded for approaching the second eye differently so that they ended up with a much safer procedure," she concluded. EW Editors' note: The physicians have no financial interests related to this article. Contact information Chiu: 415-353-2739, chiuc@visionucsf.edu Jeng: 415-206-8302, jengb@vision.uscf.edu Ramanathan: 415-206-8304, RamanathanS@vision.ucsf.edu February 2011 Challenging cataract cases October 2012 OVER 34 MILLION AMERICANS And they are walking into your practice everyday HAVE HEARING LOSS Increase Your Bottom Line ADD A HEARING CENTER TO YOUR PRACTICE A program designed to generate incremental sales Easy: Minimal eơort required from Physicians and staơ. No hiring, staƥng, ordering or other tasks. Avada does that for you. Simple Integration: Avada provides a seamless integration designed to flow with your current practice. To learn about the potential sales impact to your practice, call us today. 1-888-982-8232 Avada Hearing Care Partnering Vision & Hearing © 2012 Hearing Healthcare Management, Inc.