Eyeworld

EW CATARACT 33 July 2018 integrity, she will also place a suture through the trailing loop and free- pass it into the eye. In terms of size, Dr. Arbisser said the larger CTRs can be stiffer and more difficult to manipulate. Dr. Ayres and Dr. Schallhorn said they don't view the size of a CTR as critical. If too large of a CTR is used, Dr. Ayres said it will just overlap itself, which he doesn't think will cause a problem. As a general rule, Dr. Schallhorn uses a 10–11 mm CTR for small eyes, a 12 mm CTR for medium eyes, and a 13 mm for large eyes. Capsular tension segments Dr. Schallhorn uses an Ahmed seg- ment (FCI Ophthalmics) if there are more than 3 clock hours of zonular dialysis. Though some surgeons will put their Gore-Tex suture knot in a scleral groove, Dr. Schallhorn said she finds this difficult and thinks it might put too much tension on the rhexis; thus, she prefers to create a 3-mm, square scleral flap hinged at the limbus. Before making scleroto- mies with a 25-gauge MVR blade, she makes sure there is enough viscoelastic over the capsular bag, below the iris, to avoid spearing the bag. After threading Gore-Tex through the segment loop, Dr. Schallhorn passes the thread to 25-gauge MaxGrip (Alcon) retinal forceps through the sclerotomy in a handshake technique, repeating the process for the second end of Gore- Tex. Afterward, she fills the bag with OVD and inserts the segment, positioning it with a Sinskey hook. Dr. Schallhorn finds the correct ten- sion with three throws total in the Gore-Tex and careful tightening. "I want to see the capsulorhexis centered but with minimal distor- tion where the eyelet overlaps the edge of the rhexis," she explained. "Once I have the tension correct, I put in a second throw, making sure not to tighten it further. I then put in a third throw and cut the suture, leaving small tails. After that, I glue down the flap using Tisseel [Baxter Healthcare, Deerfield, Illinois], then glue the [conjunctiva] back into place." Dr. Ayres said if he needs to stabilize the capsular bag, he'll place a capsular segment after a CTR, thinking that if you need to use a capsular tension segment, most of the time you should be putting in a ring as well for expansion of the bag and even distribution of equatorial forces. Dr. Ayres marks on the limbus where he wants to pull the lens toward, makes an X that extends beyond that mark, and goes 2 mm posterior to the limbus to make sclerotomies 3–4 mm apart. Similar to Dr. Schallhorn, Dr. Ayres uses a handshake technique with forceps through the sclerotomy to pass the two ends of the Gore-Tex suture from the main incision. Once the segment is placed, Dr. Ayres ties a slipknot on the scleral surface to apply tension until the IOL in the bag looks centered. Though she admitted she doesn't have a lot of experience with capsular tension segments, Dr. Arbisser said they are "a wonderful invention." She mostly uses Ci- onni-modified CTRs, which provide both the effect of a CTR and scleral fixation. She prefers an ab externo approach with a 26-gauge hollow bore needle into which is docked the straightened 8-0 Gore-Tex needle. This allows the knot to be tied over the 26-gauge perforation and pushed intrascleral through the perforation with a Sinskey hook. She specifically likes the AssiAnchor (Hanita Lenses, Hanita, Israel) de- veloped by Ehud Assia, MD, which currently has the CE marking, because of its broad pressure on the capsulorhexis edge that doesn't tent the circular rhexis opening like the Ahmed segment. When to tackle and when to pass Even as an experienced surgeon, Dr. Arbisser said there has been an occa- sional case where she would give the patient the option for a referral to someone with even more experience if they'd prefer. If it's a one-eyed or otherwise high-risk patient in the fellow eye, Dr. Arbisser said it would be reasonable to refer a patient to a colleague who does extreme surgery every day. But taking on the learning curve of these techniques is something all surgeons have to go through, Dr. Arbisser continued. Dr. Ayres said gaining experience with all of these devices for the management of loose zonules is important because they will come up in your practice. When a case of known zonular dehiscence is coming up, he suggested talking over your plan A, B, and C with a more experienced surgeon ahead of time to gain tips and confidence. Dr. Arbisser recommended practicing some of these techniques on the eye models that are available or in a skills transfer wet lab. "At some point, everyone who is going to be doing cataract surgery is going to have to deal with this. … Everybody should know the ABCs of how to deal with loose zonules, even if it wasn't in your plan or wasn't intended. Knowing what tools, tricks, and instruments are out there to help you is important," Dr. Ayres said. EW Editors' note: Dr. Ayres has financial interests with Alcon and MST. Dr. Schallhorn and Dr. Arbisser have no financial interests related to their comments. Contact information Arbisser: drlisa@arbisser.com Ayres: brandonayres@me.com Schallhorn: jschallhorn@gmail.com Managing continued from page 31 Interested in getting hands-on experience? The Combined Ophthalmic Symposium on August 24–26 in Austin, Texas, and YES Advanced Cataract Training on September 15–16 in San Francisco have advanced phaco stations that will include hooks and rings, MIGS, limbal relaxing incisions, lens folding, and more. Placement of a CTS in a patient with Marfan syndrome. A Gore-Tex suture is placed through the eyelet in the CTS and externalized through sclerotomies. The suture and eyelet are positioned above the capsular bag while the ring segment is located in the capsular bag. The knot is tied on the scleral surface allowing proper positioning of the capsular bag and IOL. In this case an IOL and CTR have already been placed in the capsular bag. Three capsular hooks are placed through limbal wounds holding a lens with severe zonu- lopathy in place, allowing safe removal. In this case the patient had idiopathic zonulopathy. Notice how the hook is placed through the capsulorhexis with the tip of the hook at the equator of the lens. Source (all): Brandon Ayres, MD

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