EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/906004
89 December 2017 EW MEETING REPORTER Spotlight on cataracts A "Spotlight on Cataracts" session chaired by David Chang, MD, Los Altos, California, and Mitchell Weikert, MD, Houston, featured eight of Dr. Chang's cases, each highlighting a specific complication. Presenters shared their thoughts and pearls for these complications in general, while a panel discussed Dr. Chang's cases specifically. One topic was cataract surgery post-vitreoretinal procedures with a known or suspected posterior capsule defect. Vitreoretinal proce- dures are on the rise, and all phakic eyes with pars plana vitrectomy (PPV) will develop a cataract within 2 years, said Steven Safran, MD, Lawrenceville, New Jersey. For all post-vitreoretinal proce- dure cataract cases, Dr. Safran said physicians should advise patients preoperatively that their cataract case is not "business as usual." Make a capsulorhexis that is suitable for optic capture of the IOL, avoid aggressive hydrodissection, lower phaco parameters, and keep close track of chopped pieces of the nu- cleus and remove them with phaco immediately, if possible, Dr. Safran said. A three-piece lens for sulcus placement should be on hand as a backup as well. Another topic was zonulopathy. Kevin Miller, MD, Los Angeles, stressed the importance of preparing for zonular problems before getting into the operating room, distin- guishing between sectoral zonular loss and diffuse zonular weakness. Look for iridodonesis, phacodo- nesis, a lens deep to the iris, and occasionally vitreous in the anterior chamber. Surgically, vitreous, if pres- ent, should be removed from the anterior chamber; stabilize the bag with capsule retractors to create an artificial zonule for stability during phaco; and remove the cataract as gently as possible to avoid further zonular stress, Dr. Miller said, adding that he thinks a capsular tension ring should always be used in these cases. Following, a capsule tension segment should be sutured in the are typically used to correct less than 1.25–1.5 D of corneal astigmatism. A limbal relaxing incisions (LRI) is placed in the peripheral cornea near the limbus, while astigmatic kera- totomy is placed more central than an LRI. Manual LRIs have been the mainstay of management of low astigmatism for years. This is a well-established technique, with several nomograms in the literature, and it is cost effective. Risks include epithelial disruption, decreased cor- neal sensation, regression of effect, corneal perforation, and infection. Using the femtosecond laser is an option, and Dr. Gupta noted that advantages of this include the precise depth and placement, con- tinuous curvature, and the ability to titrate incisions. She stressed several key dif- ferences between using femto and manual techniques. Femto is photodisruptive, and the incision architecture is different from manual because you are using laser energy to disrupt tissue. Additionally, Dr. Gupta said you can't use the same nomograms with femto because there will be overcorrection if using a manual nomogram. Finally, she said that centration is the most crit- ical step, and with femto, decentra- tion may be an issue. Her personal preference is to use the femtosecond laser to create an LRI, though she noted more studies are needed. Dr. Gupta thinks the laser can increase efficiency at the time of cataract surgery, is more predictable in her hands, and makes her think about treating astigmatism in all cases. In summary, she said manual LRI and femto AK are both excellent options for astigmatism correc- tion. Astigmatism management at the time of cataract surgery is an essential component to provide high uncorrected quality of vision, and surgeons striving to achieve refrac- tive outcomes should be comfort- able with manual LRIs and femto corneal incisions. Editors' note: Dr. Gupta has financial interests with a number of ophthalmic companies. Of these, 750,000 require hospital- ization. He said that there are 19 million people with unilateral blind- ness or low vision from injuries, 2.3 million people who have bilateral low vision, and 1.6 million people who are blind. Jessica Ciralsky, MD, New York, highlighted techniques for repair of ruptured globes. Dr. Ciralsky again stressed the epidemiology and esti- mated number of people with eye injuries. "The first thing to do is take a detailed history and do a thorough exam," she said. This would include visual acuity, pupil examination, a slit lamp exam, and dilated exam- ination of the fellow eye, and it would also include looking at the whole face and taking a CT scan without contrast with thin cuts through the orbit. "I advocate 48 hours of antibiotics," she said. The goals of surgical repair in these cases are to restore vision, to reestablish anatomic relationships, and to prevent complications, which can include glaucoma, infection, amblyopia, and secondary surgeries, Dr. Ciralsky said. She highlighted the three zones of injury: zone I, where wound involvement is isolated to the cornea; zone II, where a full-thick- ness wound involves the sclera no more posteriorly than 5 mm from the corneoscleral limbus; and zone III, where a full-thickness wound is posterior to zone II. Dr. Ciralsky went on to describe the surgical approach, including anesthesia, preparation, and in- struments to use. She highlighted the principles of surgery and what suture strategy should be used. Editors' note: Drs. Ciralsky and Hsu have no financial interests related to their presentations. Refractive cataract surgery today: Maximizing outcomes During a symposium co-sponsored by ASCRS, Preeya Gupta, MD, Durham, North Carolina, discussed manual vs. femto arcuate inci- sions. Corneal arcuate incisions are incisions made in the peripheral cornea within the steep meridian to reduce corneal astigmatism. They Refractive surgery pearls shared A potential refractive surgery patient should have a stable sphere and cylinder with no more than a 0.5 D variation for at least 12 months preoperatively, recommended Ronald Krueger, MD, Cleveland, speaking at "Introduction to Corneal and Lens-Based Refractive Surgery for Residents." To help measure the refraction, Dr. Krueger asks patients to avoid contact lens wear for 3 days initially and then for 14 days before a more detailed exam. Dr. Krueger reviewed the various tests that should occur prior to refractive surgery, including vision quality, contrast sensitivity, refractive sta- bility, and corneal pachymetry. Sur- geons should also be cautious about surgery in patients who have used medications such as isotretinoin, Dr. Krueger said. Diabetes is not neces- sarily a contraindication to refractive surgery, but it should be avoided if the patient has advancing diabetes. In a session on topography and tomography, J. Bradley Randle- man, MD, Los Angeles, said that refractive surgeons should aim for optimal refractive results even in cataract surgery patients. "All of you cataract surgeons, like it or not, are also refractive surgeons," he said. Marguerite McDonald, MD, Lynbrook, New York, addressed the stronger safety profile of PRK versus LASIK and pointed out that PRK has fewer published cases of related patient lawsuits. However, with rare exceptions, "If you wouldn't do LASIK, don't do PRK," she said. Editors' note: Dr. Randleman has no financial interests related to his presen- tation. Dr. Krueger has financial inter- ests with Alcon and other ophthalmic companies. Dr. McDonald has financial interests with Bausch + Lomb, Johnson & Johnson Vision (Santa Ana, Califor- nia), and other ophthalmic companies. Spotlight on ocular trauma Jason Hsu, MD, Cherry Hill, New Jersey, gave an update to start the spotlight session on ocular trauma, highlighting the impact of ocular trauma. There are 55 million eye injuries per year around the world. continued on page 90