Eyeworld

EW CATARACT 46 October 2017 by Maxine Lipner EyeWorld Senior Contributing Writer In pseudoexfoliation cases, loose zonules may be an issue. "Loose zonules can occur at any point, but they're more likely to occur in older patients or those with a specific disease like pseudoexfoliation," Dr. Teymoorian said. "The best way to minimize issues with zonular instability would be to do a cata- ract procedure that is less traumatic and as efficient as possible." Better dilation will help the practitioner to more effectively and quickly take out the cataract. "With the addition- al steps that are required in a smaller pupil, more stress is put on the eye and that magnifies the loose zonular issues," Dr. Teymoorian said. With better dilation, practi- tioners may be able to avoid ad- ditional steps that are required in small pupils, such as using a pupil- expanding ring. "That indirectly helps with the outcomes because it will make cataract surgery quicker, with less phaco time," Dr. Teymoo- rian said, adding that even if a ring is needed, with the better dilation there is less manipulation of the surrounding tissues including the capsule and zonules. Dr. Matossian also stressed the importance of minimizing manipu- lation. "Additional manipulation is going to generate more prostaglan- din release and more inflammation is something that can take on partic- ular significance for cataract patients with glaucoma. "During surgery, we know that every millimeter of dila- tion significantly improves surgical outcomes," he said, adding that this is especially true for patients with pseudoexfoliation glaucoma. Instead of being limited to drops, if this medication can be adminis- tered through the irrigating solution during the cataract procedure, it can make a difference, Dr. Teymoorian noted. said, adding that this can include retained nuclear fragments, cortical lens material, and viscoelastic as well as difficulty dialing the hap- tics in the bag. There may also be difficulty aligning the dots on a toric implant due to limited visibility in an inadequately dilated pupil. Dialing up dilation With Omidria, practitioners can get the pupil to dilate and stay dilated during the procedure, Dr. Teymoori- an said. The phenylephrine helps to promote dilation, he explained. This Physicians share views on using Omidria for glaucoma patients W hile it's important for all cataract patients to have excellent outcomes, the stakes are particularly high for those with glaucoma, according to Savak "Sev" Teymoorian, MD, specialist in glaucoma and cataract surgery, Harvard Eye Associates, La- guna Hills, California. "The biggest issue with glaucoma patients is their visual fields," Dr. Teymoorian said. "We're going to be limited from glaucoma, and we don't want to make it even worse with a cataract procedure that doesn't work out as well as we'd like." Such patients, he finds, may benefit from Omidria (Omeros, Seattle), the agent used during cataract procedures that combines the pupil-expanding ca- pabilities of phenylephrine with the NSAID ketorolac. Likewise, Cynthia Matossian, MD, Matossian Eye Associates, Doylestown, Pennsylvania, views the addition of Omidria as an asset in such complex cases. "Studies have shown that the smaller the pupil gets—less than 6 mm—the great- er the risk of complications," she Beyond simple cataract cases fragmentation. One of the applica- tions of the femtosecond laser in cataract surgery is for fragmentation. Dr. Lindstrom pointed out that the femtosecond laser does not perform full thickness fragmentation, while miLOOP does. "The miLOOP separates the nu- cleus from the capsule—we do that typically with hydrodissection—but this is a bit of a manual separation, and it is an adjunct to that as well," he said. When it comes to cost between the two methods that can aid in nu- clear disassembly without phaco, the miLOOP, though a single-use device, costs about $150 per unit compared to several hundreds of thousands of dollars for a femtosecond laser, maintenance fees, and click fees, Dr. Newsom said. "I use it on patients who have the least amount of money because those are the ones who have cata- racts that should have been done a long time ago," Dr. Newsom said. "I'm using this because it's deliver- ing the best care to my patients ... and not upcharging my patients for it. I think getting good results, pro- viding great patient care will always benefit a practice." Dr. Newsom recommended doc- tors watch videos of the technique to get comfortable with the concept. He then advised them to not rush it, giving it 10 to 20 seconds to rotate around the lens. He also advised making one cut in your first case, then doing a second or third cut in your next few cases. In the end, he said, you'll find "it's not that diffi- cult to become proficient with it." Dr. Ianchulev also hinted at oth- er work the company is researching that would create a "micro interven- tional kit" for end-to-end phaco-free cataract surgery. "If you could eliminate phaco energy, you eliminate a vibrating probe or jackhammer inside your eye, which generates heat. If you eliminate that, you eliminate the need for irrigation because you don't need to cool a vibrating probe, and if you eliminate vibration and irri- gation, you eliminate the need for aspiration. ... We've solved the first of the two major steps, which is we can fragment any lens, any density in a minute, the question is what happens with the segments. In the Third World, we can just take them New continued from page 44 out, but in the First World, we have to take them out through a 2–2.5 mm incision and for that, we have a second instrument that will take them out that will be phaco-free," he said. EW Editors' note: Drs. Ianchulev and Lindstrom have financial interests with Iantech. Dr. Newsom has no financial interests related to his comments. Contact information Ianchulev: tianchul@privatemedicalequity.com Lindstrom: rllindstrom@mneye.com Newsom: hunter@newsomeye.net " If you know it's going to be a complex case from the history and the existing comorbidities, why not try to control one thing to make [the case] a little smoother, in order to help the final outcome for patients. " —Cynthia Matossian, MD

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