Eyeworld

135 February 2018 EW MEETING REPORTER edema. Audience members and panelists noted the importance of removing nuclear fragments, with 53% saying they'd remove the frag- ment even if there were no current problems. Dr. Al-Mohtaseb said that the course of action would depend on if the fragment was cortical or nuclear. If it's nuclear, it needs to be removed, she said. Another case shared was a patient who had traumatic zonulop- athy. Dr. Chang asked the audience if they would operate on a trau- matic cataract. There was a mix in responses, with the largest number of respondents (34%) indicating that they would unless there was a subluxated lens. Dr. Chang said that performing the capsulorhexis is a "zonular stress test." During the capsulorhexis, he noticed a lot of wrinkles and knew that he was dealing with zonulopa- thy. He asked audience members and panelists to weigh in on what their next step would be in severe zonulopathy, with 65% of audience respondents indicating they would insert capsule retractors. Kendall Donaldson, MD, Plantation, Florida, said she likes to use the femtosecond laser in these cases because she can get a perfect capsulotomy and avoid manipula- tion of the nucleus. In a loose lens, once you have the perfect capsuloto- my, you can get capsule retractors in there easily, she said. When choosing an option for IOL fixation, several panelists suggested that a number of options could work, including using a cap- sular tension ring (CTR) or a three- piece IOL in the sulcus. Dr. Don- aldson said she thinks a three-piece lens can add a little bit of support in conjunction with the CTR. Dr. Chang used a three-piece in the sulcus in this case. He wanted the additional two-point fixation wherever the haptics touch the sulcus. One case discussed was a recent patient of Dr. Chang's who had a rock hard cataract and had been on tamsulosin for some time. Dr. Chang asked the audience their strategy for handling this tam- sulosin 5-mm pupil. The majority of audience members voted in favor of using a pupil expansion ring (69%). Zaina Al-Mohtaseb, MD, Hous- ton, said that she likes using pupil expansion devices, however, she noted that she will use iris retrac- tors if there is a shallow chamber or zonule loss. Audience members overwhelm- ingly (88%) voted to use capsular dye if there was poor red reflex. Dr. Chang went on to discuss what the phaco strategy should be; 48% of audience members indicated they would use divide and conquer, and 40% said they would use phaco chop. Dr. Chang used the miLOOP (Iantech, Reno, Nevada) for this patient, which Dr. Al-Mohtaseb noted is an appropriate option for this case. She said there is a learning curve for using the miLOOP, and the key is to make sure you're under the anterior capsule and have good dilation. She said you want to make a slight twist of your hand to make sure it's angled up and down so you can go centrally in the lens. When you're about to make the cut, sur- geons should "go in with a second instrument because you'll bring the lens with you if you're not cogni- zant of that." You can use a second instrument or the miLOOP itself to rotate the lens. Dr. Chang agreed that the key is that second instrument to keep it from popping out. With a soft- er lens, you could do it with one hand, but he said anytime you have enough bulk, there's nothing to stabilize the lens. You want to do at least 10 with routine cataract surgery and get the technique down before trying it in complicated case, Dr. Chang said. Dr. Chang questioned how au- dience and panelists would address their phacoemulsification strategy with no epinucleus and how they would handle a small nuclear frag- ment after surgery with no noted handpieces without increasing their weight to eliminate occlusion break surge. Dr. Miller also said to measure or estimate the temperature of the phaco needle inside the incision and turn off ultrasound whenever a temperature threshold is reached to prevent incision burn. 3. Make extended range single- piece IOLs available on a special order basis from –30 D to –5 D and from +40 D to +65 D, with pow- er-appropriate optic diameters and haptic diameters. 2. Make single-piece acrylic IOLs, rather than three-piece IOLs, with 6.5-mm optics in the –5 to +5 D range. 1. Manufacture a single-piece acrylic IOL with a 7.0- or 7.5-mm round edge optic and round edge haptics suitable for passive place- ment in the ciliary sulcus in eyes with capsular bag compromise or scleral suture fixation in eyes with absent capsular support. Editors' note: Dr. Miller has financial interests with Alcon and Johnson & Johnson Vision (Santa Ana, California). Cataract surgery complications David Chang, MD, Los Altos, California, shared a number of complicated cases, with panelists and audience members weighing in on how they would handle certain complications. 9. Provide an option for near body temperature balanced salt solution to be infused at the end of a procedure when the viscoelastic is being aspirated. 8. Stop hyping premium IOLs in direct-to-consumer advertising. He noted that every patient is not a candidate for a premium IOL, and every premium IOL implantation does not result in a glasses-free result. 7. Create a last quadrant or last fragment setting on phaco machines to alert surgeons to the importance of fluidics during the last quadrant or last fragment removal. He also suggested changing the "pre-phaco" setting to "working space" to em- phasize the importance of clearing a working space in the OVD to prevent phaco burn. 6. Create U-shaped femtosecond laser troughs so that we can more easily separate nuclear fragments from each other. Dr. Miller said that the current slit-like chop patterns do not allow the instruments to get between the nuclear fragments to separate them. 5. Postoperative power adjust- able IOLs are the future of cataract and lens-based surgery. Dr. Miller said that every company that works in the IOL space should be pursuing technologies that advance that goal. 4. Place infusion and aspira- tion pumps on the phaco and I/A continued on page 136 View videos from Hawaiian Eye 2018: EWrePlay.org Kendall Donaldson, MD, discusses the anterior segment implications of diabetes in cataract surgery.

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