Eyeworld

Reporting from the XXXV Congress of the ESCRS, October 7–11, Lisbon, Portugal EW MEETING REPORTER 86 There are benefits of ultrasound power modulation in these cases, including increased efficiency of torsional ultrasound, greatly reduced repulsion, decreased turbulence, enhanced followability, less risk of thermal burns, and less endothelial trauma. Dr. Kim highlighted several other techniques, like using the Ul- traChopper tip (Alcon, Fort Worth, Texas) designed by Luis Escaf, MD; using the miLOOP (Iantech, Reno, Nevada); and using femtosecond la- ser-assisted fragmentation patterns. In the end, Dr. Kim said he prefers to use phaco with dense brunescent cataracts, and he said there are many choices available regarding phaco strategies. "Choose the technique that's going to make you feel the most comfortable and relaxed with these cases," Dr. Kim said. Many of these patients end up with very clear corneas and excel- lent vision. Daniel Badoza, MD, Bue- nos Aires, Argentina, focused his presentation on cataract surgery in eyes with more than 30 mm of axial length. He highlighted preoperative, intraoperative, and postoperative potential issues. Postoperative com- plications of phaco in these patients may include cystoid macular edema, IOL miscalculation, retinal detach- ment, endophthalmitis/TASS, and cataract extraction (ECCE), longer postoperative and intraoperative times, and risk of corneal decom- pensation. So why are these cataracts so dif- ficult to remove? Dr. Kim said they are very dense in nature and usually dark orange to reddish brown in col- or. There is a large endonucleus and minimal epinucleus and cortex. The posterior epinucleus becomes firm, adherent, and difficult to fracture due to bridging posterior lens fibers. There is resistance of the posterior nucleus to full cleavage regardless of the phaco technique, he said. This is most apparent in the poste- rior aspect of the central nucleus, resulting in inability to engage the apex of the nuclear fragment in the phaco tip. Dr. Kim discussed surgical strat- egies for the dense brunescent cata- ract, first stressing the use of a stain, like trypan blue. He also said to use dispersive viscoelastic with repeated injection for corneal and posterior capsule protection, to use a larger capsulorhexis, and to use gentler hydrodissection but ensure nucleus rotation. You have the option to approach these with ECCE or small incision cataract surgery (SICS). There are a host of phaco tech- niques to apply here, Dr. Kim said, noting that he likes to use a phaco chop technique in many dense lenses. Pattern recognition is highly flexible without bias and is continually evolving, he said. What's more, it is not limited to possibilities that are already understood, and it has the capability to go through a number of solutions that would not be man- ually possible. Dr. Hill said the system looked at four parameters: spherical equiva- lent, axial length, average keratom- etry, and anterior chamber depth. From there it can make models continuously. "What comes out is a calculation with special tools built into it that allow us to predict [IOL power] … free of calculation bias," Dr. Hill said. A prospective study of 459 eyes found that calculations using the Hill-Radial Basis Function (RBF) calculator resulted in 90% of cases getting within 0.5 D of target. The enhanced Hill-RBF formula was recently released, and Dr. Hill said work is underway to develop a similar formula based on artificial intelligence pattern recognition for Asian eyes. CSCRS symposium The Combined Symposium of Cata- ract and Refractive Societies (CSCRS) covered the topic "Complicated cataract surgery: Doing it my way." Representatives from ASCRS, ESCRS, APACRS, and LASCRS spoke on a variety of subjects, including white mature cataracts, cataract and pte- rygium, dense brunescent cataracts, pseudo lens exfoliation, intrascleral haptic fixation, cataract surgery in eyes with more than 30 mm of axial length, cataract surgery in patients with keratoconus, and cataract with repair of an iris defect. Terry Kim, MD, Durham, North Carolina, spoke about dense brunes- cent cataracts and shared some old and new management strategies. One step often overlooked for these patients is a preoperative evaluation, he said, stressing the importance of a good slit lamp exam. Biometry and keratometry may be difficult to obtain because of the dense cataracts. Dr. Kim said you need to have a conversation with the patient and family to go over the risk of complications, possibility of having to convert to extracapsular November 2017 continued on page 88 View videos from ESCRS 2017: EWrePlay.org Farhad Hafezi, MD, PhD, discusses crosslinking as adjunctive therapy for fungal and bacterial corneal ulcers.

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