Eyeworld

EW CATARACT 42 October 2017 Pulse of ophthalmology: Survey of clinical practices and opinion by Mitchell Gossman, MD piece IOL in the capsular bag 90 degrees from the radial tear; so far, no breach of the posterior capsule has resulted. The third question was, "During phacoemulsification, the radial tear progresses resulting in a posterior capsular tear, with vitreous prolapse, with the end result that the suitabil- ity of the remaining capsular bag is in doubt and may not support even placement of a sulcus fixated IOL. What intraocular lens(es) do you have with a consignment of powers? Please specify brand and model." tear methods work, but result in loss of the continuous capsulorhexis. If you have not tried the "Little ma- neuver" yet, I urge you to view some videos, practice with cellophane or paper, and the next time you have a need, try it out. It has not failed yet in my hands, including in cases of pressurized mature cataracts at risk even for the Argentinian flag sign. The second question was, "De- spite your best efforts, a radial tear has resulted. If you normally place a one-piece foldable acrylic IOL in the bag for an uncomplicated case, do you:" Fortunately, anterior radial tears seldom spread around the equator to create a posterior capsular tear and vitreous prolapse. However, this possibility exists so many surgeons (most, in this survey) prefer to place a single-piece IOL into the capsular bag, probably due to their inher- ently gentle unfolding properties and with less tension placed on the capsular bag compared to the spring- ier haptics of the three-piece IOL. However, placing a three-piece in the bag can be done very gently us- ing techniques beyond the scope of this discussion. Another advantage of the three-piece IOL is if the radial tear should propagate posteriorly during insertion, rather than having to extract the one-piece acrylic IOL, you may, if the lens is suitable for sulcus implantation, simply trans- fer it to the sulcus. Many prefer to go straight to sulcus implantation to avoid the possible breach of the posterior capsule, but because there is a radial tear, reverse optic capture is not possible to stabilize the IOL, thus there is risk of decentration. I personally gently place the one- exactly we strive to remain current in surgical techniques if the method is particularly challenging, mostly a part of subspecialty training, or infrequently needed. A survey was performed of 63 ophthalmologists who weighed in from the ranks of participants of the EyeConnect online community and volunteers in North America. Responses are anonymous in order to encourage candor. Totals may not equal 100% due to rounding. We started out by considering one way the chain of events leading to a complication can happen: a radial tear. The first question was, "In the course of performing cataract surgery, you begin the capsulorhexis and it starts to 'go radial.' How do you attempt to salvage this?" The "quick pull" method, I can certify from personal experience, does work, but requires considerable courage to perform, especially under stressful circumstances. The fresh T hanks to innovations by experts in our field, quality of training, maintenance of our skills, and our own hard work, cataract surgery has become one of the safest surgical procedures, not just for the eyes, but for any surgical field. With compli- cation rates on the order of 0.1% to 2%, depending on how one defines "complication," patients can under- go surgery with high confidence in a satisfactory result. There is that 0.1%–2%, however. While we do counsel our patients on the possibility of complications, these are never welcome and gen- erate stress for surgeon and patient alike. Fortunately, most of these are salvageable to some degree, and total loss of vision is rare. We all do our best to remain current in surgical techniques. But what are we doing, and how are we doing, with respect to management of complications of cataract surgery that occur during and after surgery? That will be the subject of this series of articles. A recent series of conversations on EyeConnect has taken place on the challenges of current methods of implantation of secondary intraocu- lar lenses, or placement of IOLs in a location other than the capsular bag due to complications, particularly when it comes to the disadvantag- es of anterior chamber intraocular lenses. Another question was raised, most recently by Ryan Smith, MD, currently a fellow in glaucoma at the University of Kentucky, on how Management of cataract surgery complications during and after surgery, part 1 "Quick pull" method: a quick, snapping "toilet tissue tear" tangentially toward the desired path 8% "Little maneuver," named after Dr. Brian Little, whereby the advancing flap is unfolded back against cortex, pulled backward until slightly taught, and the flap simultaneously pulled centrally, keeping it in the plane of the cortex 87% Start a fresh tear in the opposite direction and rejoin the offending tear 5% Start a fresh tear in the same direction via a fresh cut with intraocular scissors 0% Convert to "can opener" 0% Carefully place a one- piece acrylic IOL in the capsular bag 60% Carefully place a three- piece IOL in the capsular bag 16% Place a three-piece IOL in the sulcus 24% AC IOL 78% Three-piece acrylic IOL specific for emergency use 27% Three-piece silicone, the same standard IOL I use for uncomplicated cases 14% Three-piece silicone IOL specific for emergency use 11% Three-piece acrylic, the same standard IOL I use for uncomplicated cases 10% No specific consignment, schedule secondary IOL placement at a later date 10% PMMA IOL suitable for transscleral sutured fixation 2% Three-piece collamer IOL specific for emergency use 2% Akreos AO four-haptic one-piece acrylic (Bausch + Lomb) 2% Three-piece collamer, the same standard IOL I use for uncomplicated cases 0% Mitchell Gossman, MD

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