Eyeworld

131 October 2017 EW MEETING REPORTER you, it's not necessarily true. Change your technique," Dr. Koplin said, noting that you could try it on a large pupil until you're comfortable. Naveen Rao, MD, Boston, gave a brief overview of the pharmaco- logic agents and devices (namely hooks and rings) that can be used to expand small pupils. Dr. Rao said he prefers pupils to be at least 6 mm, ideally 7 mm, for cataract surgery. Potential complications of moving forward with cataract surgery with too small of a pupil, Dr. Rao said, are the tendency to make too small of a capsulorhexis, which could lead to rhexis tearing; incomplete hydro- dissection; the potential for capsule tearing; complications with chop- ping maneuvers; iris capture during phaco; and difficulty seeing periph- eral nuclear fragments and where the haptics are. Other hot topics discussed in the session included the fulcrum effect in phaco fluidics driving lens fragments into the zonules and potentially causing late-stage CME, intracameral antibiotics, therapeutic femtosecond laser-assisted cataract surgery, and refractive cataract sur- gery in complex cornea patients. EW Editors' note: Dr. Koplin and Dr. Rao have no financial interests related to their comments. Richard Koplin, MD, New York, hasn't used a ring or a hook in 20 years, he said. And that's thanks to a technique he developed called the "lateral sweep." "On the surface, it seems like a no-brainer and you'll yawn," he said of the technique, which he described as non-rotational nuclear disassembly that mitigates zonular stress. The technique involves mak- ing a capsulorhexis followed by a standard vertical groove—don't hydrodissect, don't rotate the lens. Make a Maltese cross, and then with equal and opposite force to keep the capsule immobilized, crack the lens into four quadrants. With high vacuum draw out the quadrants and the case is done, as Dr. Koplin demonstrated in a couple of videos. This technique, he said, works better on harder lenses and can be a good "fallback technique" in dicey lens cases. It preserves anatomic integrity and can be cost-saving by eliminat- ing the need for a ring or hook. The difficult part of using this technique is getting the lens in in a timely fashion. "Many times you're taught something and you just follow it, so we got into the ring system. You've been taught there's a danger in op- erating in small pupils with a small capsulorhexis, and I'm here to tell "Don't assume your patients won't want laser or surgery. Many will be relieved they can be free from drops … offer it," Dr. Sarkisian said. Dr. Crandall presented on the basics of intraoperative gonioscopy and the current MIGS technolo- gies available for trabeculotomy procedures. When to perform a trabeculotomy in combination with phacoemulsification cataract surgery —before or after—is a consideration. In his practice, Dr. Crandall said he will implant the iStent (Glaukos, San Clemente, California) or Hydrus (Ivantis, Irvine, California) and per- form ab interno canaloplasty before phaco. He'll leave gonioscopy-as- sisted transluminal trabeculotomy (GATT), Kahook Dual Blade (New World Medical, Rancho Cucamonga, California), Trab360 (Sight Sciences, Menlo Park, California), and Trabec- tome (NeoMedix, Tustin, California) for after cataract surgery. Robert Noecker, MD, Fairfield, Connecticut, discussed the CyPass Micro-Stent (Alcon, Fort Worth, Texas), an FDA-approved device that targets the supraciliary space. While cataract surgery alone can have an IOP-lowering effect, Dr. Noecker pointed out that it's hard to predict who will get adequate IOP lowering from cataract surgery alone. What the clinical trials leading to CyPass' approval showed, Dr. Noecker said, is that the device increases the probability of IOP-lowering success as well as the potential for reducing medications. Dr. Sarkisian spoke about the XEN Gel Stent (Allergan, Dublin, Ireland), an FDA-approved device for placement in the subconjunctival space that creates an ab interno bleb and does not need to be combined with cataract surgery. Editors' note: Dr. Sarkisian, Dr. Cran- dall, and Dr. Noecker have financial interests with various ophthalmic companies. Hot topics in cataract surgery While pharmacologic agents and expansion devices are typically what surgeons turn to in small pupil cas- es, another idea was shared as well. brunescent cataracts, the femto- second laser may be most helpful for nuclear disassembly and phaco energy reduction. The fragmentation pattern debulks the lens. The risk in these cases is that there may be retained lens fragments with reduc- tion in fragment size. In summary, Dr. Gupta said surgeons should use trypan blue if there is any question about visual- ization. She stressed that you should use a lot of viscoelastic to protect the endothelium and consider repeated instillation as the nucleus is disassembled to keep the posterior capsule back. Watch out for wound burn, she cautioned. Dr. Gupta advised learning a chop technique. Focus on good occlusion of the nucleus prior to chopping, and be patient with the posterior plates and assure you're deep enough to crack the plate. Editors' note: Dr. Gupta has no finan- cial interests related to her comments. Managing glaucoma from drops to MIGS A discussion on glaucoma treatment highlighted both medical therapies and surgical procedures. Steven Sarkisian, MD, Okla- homa City, hit upon all the reasons why glaucoma patients might be non-compliant with their drops and how to encourage improved compli- ance. Reasons for non-compliance can include cost, side effects, and lack of a routine. Even if a patient is attempting to instill drops, Dr. Sarki- sian said some might find the bottle too hard to squeeze, they could apply too many drops, or they could miss their eye entirely. "Stop thinking your patients are taking their drops," Dr. Sarkisian said. To try to increase compliance he suggested asking open-ended, non-judgmental questions, provid- ing personal examples, showing them memory aids (apps, instill- ing drops at the same time you do something else every day), and considering primary selective laser trabeculoplasty or earlier phaco with microinvasive glaucoma surgery (MIGS). View videos from YES ACT 2017: EWrePlay.org Eric Donnenfeld, MD, explains the differences between extended depth of focus and conventional multifocal IOLs.

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