Eyeworld

EW FEATURE 42 Challenging cases • July 2018 Three continued from page 40 A toxic posterior segment syndrome and severe cystoid macular edema developed from the methylene blue exposure. Endothelial keratoplasty solved the corneal failure. She requires glaucoma medications for IOP control. After many years of topical and intravitreal treatment, she still suffers from low-grade CME. Her VA has improved to 20/30 –2. Source: Kevin M. Miller, MD Appearance of Dr. Miller's patient's left cornea 3 months after cataract surgery, which was complicated by TASS from exposure to methylene blue. She had finger counting VA at presentation. Horizontal approach to laser capsulotomy Richard Tipperman, MD, attending surgeon, Wills Eye Hospital, Phil- adelphia, treated a 3-year-old girl with bilateral retinoblastoma who was enucleated in one eye. She had multiple treatments for the other eye to try and salvage it. "These children all get cataracts, and there is always an issue of whether to open the posterior capsule with a primary posterior capsulorhexis," he said. "Although primary posterior capsulorhexis does obviate the need for a future laser capsulotomy, this needs to be balanced with the in- creased risk of endophthalmitis as- sociated with opening the posterior capsule, as well as the potential for taking a straightforward routine cat- aract case with assured IOL fixation and turning it into a more complex case," Dr. Tipperman said. After pediatric patients with retinoblastoma are treated by ocular oncologists Carol Shields, MD, and Jerry Shields, MD, both of Wills Oncology Service, Philadelphia, cataract formation is common. This can make clinical observation of tu- mor regression difficult. "Although by the time these children develop cataracts, the retinoblastoma is usu- ally regressed and quiescent, there is the potential in an active tumor for cells to seed the anterior segment," Dr. Tipperman said. Because he has opted not to perform a primary posterior capsulorhexis, he must use another technique to manage the capsule when it opacifies. Dr. Tipperman has a technique to use a YAG laser under anesthesia and shares his approach to help other surgeons working with a very young or uncooperative patient. "In most laser slit lamps, the bars for the head and chin rest can be removed, allowing the laser to be brought right up to the side of the surgical stretcher, and the capsulotomy is performed with the child turned on his or her side," Dr. Tipperman said. "If the surgical table and laser is constructed so that the laser cannot be brought close enough to the surgical stretcher, a backer board like those found on crash carts for cardiac suppression can be placed to extend the head of the bed, providing a thin but firm support for the patient's head and shoulders. This allows the laser capsulotomy to be performed hori- zontally." This approach to perform laser capsulotomy was used successfully on the 3-year-old girl with retino- blastoma, but it also could be used on adults with severe orthopedic deformities such as kyphosis, which might otherwise preclude perform- ing a laser capsulotomy in a seated position, Dr. Tipperman said. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Braga-Mele: rbragamele@rogers.com Miller: kmiller@ucla.edu Tipperman: rtipperman@mindspring.com

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