Eyeworld

Reporting from YES Advanced Cataract Training, September 23–24, New York EW MEETING REPORTER 130 October 2017 Editors' note: Dr. Donnenfeld, Dr. McCabe, and Dr. Crandall have finan- cial interests with various ophthalmic companies. Management of the very mature lens In her presentation, Dr. Gupta high- lighted white cataracts and dense brunescent cataracts, first defining each of these mature cataracts. A white cataract is complex because it has poor visualization of red reflex, the capsule is under tension, and things move more quickly and feel "less controlled." Meanwhile, a dense brunescent cataract is com- plex because of poor visualization of red reflex, nuclear disassembly is tough due to bridging fibers/posteri- or plate, more energy is required for nuclear disassembly, and surround- ing structures can be damaged. In these cases, Dr. Gupta said there are important preoperative considerations. Look for zonular laxity. You should ask about pri- or surgeries, assess the anterior chamber depth, ask yourself if it's "phaco-able," B-scan the posterior segment if there is no view, and prepare the patient for potential complications. When managing a white cat- aract, Dr. Gupta said to stain the capsule with trypan blue and create a controlled environment. She also offered several pearls in these cases: stain the capsule, decompress the lens, and start your rhexis small. For dense cataracts, Dr. Gupta said to again stain the capsule with trypan blue. She added that it's im- portant to protect the endothelium with dispersive viscoelastic, and gen- tle hydrodissection should be used to avoid capsular block. She added that chop techniques work well in these cases, and she suggested that a vertical chop is better with limited epinucleus. Dr. Gupta highlighted the role of the femtosecond laser. With white cataracts, the femtosecond laser is most helpful for the capsulotomy. There is risk of radialization or incomplete tags due to obscuration of the laser by milky fluid that is liberated. Meanwhile, with dense a lot of people are using, but she thinks that physicians will begin to incorporate more in the future. Editors' note: Dr. Yeu has financial interests with Shire. Turning a case of vitreous loss 'into a normal cataract result' "One person told me he never in his entire career lost vitreous. He knew where it was all the time," Dr. Donnenfeld quipped in a session that covered pearls for managing complex cataract cases. While vitreous loss will happen to every cataract surgeon at one point or another, he said with the right management "you can take a case of vitreous loss and turn it into a normal cataract result." With several video examples, Dr. Donnenfeld engaged the panel on their tips for how to deal with vitreous in the anterior chamber. Cathleen McCabe, MD, Bradenton, Florida, said in these cases, stabiliza- tion of the anterior chamber to pre- vent further vitreous loss is key and an ophthalmic viscoelastic device (OVD) is your friend. "Put viscoelas- tic in, take some deep breaths, and analyze your situation." Dr. McCabe said she prefers to use a dispersive OVD in these cases, but David Crandall, MD, Detroit, said, "The viscoelastic I use in this situation is the first one I can get my hands on." Dr. Donnenfeld agreed with these points and added that he uses irriga- tion/aspiration for more control at this point to clean up lens particles and places a three-piece IOL in these cases. In the case of an IOL exchange where he knows there is going to be vitreous loss, Dr. Donnenfeld recommended using Triesence (triamcinolone, Alcon, Fort Worth, Texas), which he said will demarcate where the vitreous is and reduce postop inflammation. In this case, Dr. Donnenfeld performed bimanual vitrectomy through two incisions. At one point of the video, he showed vitreous had made its way up to the wound. He said to just snip it away and stressed not pulling it up to cut it. good choice. It's preferable to have zero spherical aberration, a polished or round edged design, and complex optics in the bag, he said. In terms of placement of the piggyback IOL, Dr. Tyson suggested cohesive viscoelastic under the iris. He said to use a lens inserter to place the leading haptic under the iris into the sulcus. Then dial the lens into the sulcus and place the haptics 90 degrees to primary lens haptics. He said to use I/A viscoelastic and to check the piggyback centration. The anterior chamber may be shallow. A corneal stitch may be used if neces- sary, Dr. Tyson added. Editors' note: Dr. Tyson has finan- cial interests with several ophthalmic companies. Dry eye breakfast In a breakfast session sponsored by Shire (Lexington, Massachusetts), Elizabeth Yeu, MD, Norfolk, Vir- ginia, highlighted several key points related to dry eye disease. Symptoms may include blurred or fluctuating vision, burning, sting- ing, irritation, watery eyes, foreign body sensation, grittiness, itching, and photophobia. Dr. Yeu said there are close to 30 million American adults who report symptoms consistent with dry eye disease, but only about half are estimated to be diagnosed and even less are being treated. Signs and symptoms of dry eye do not always correlate, she said. Changes in tear composition can lead to inflammation, Dr. Yeu said. Xiidra (lifitegrast, Shire) is thought to interrupt the inflamma- tory cycle of dry eye disease, Dr. Yeu said. Xiidra is the first and only eye drop approved to treat signs and symptoms of dry eye disease, Dr. Yeu said, and it was studied in four 12- week clinical trials in 2,133 patients. Inclusion criteria was recognized and adapted over time, with inclu- sion criteria more stringent over time in later studies. Dr. Yeu also discussed some of the tools available to diagnose signs of dry eye disease. History and clin- ical exam on the slit lamp are what

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