EyeWorld Asia-Pacific June 2012 Issue

June 2012 50 EWAP NEWS & OPINION is what is encountered whenever a new technology is introduced: a completely different (intraocular) environment. That said, the result of mismanaging that “new” environment does echo back to what cataract surgeons—even those performing standard phaco—experience very much in the here and now: Dislocated IOLs. For whatever reason, cases of dislocated IOL appear to be increasingly commonplace, said Abhay Vasavada, MD, India. At the Grand Round, he recommended a stepwise strategy that includes assessing the position of the IOL, assessing the residual capsular support, getting a preoperative retinal opinion, thorough counseling, and knowing the type of IOL involved. Dr. Vasavada demonstrated his approach using a modified injector to retrieve the dislocated IOL. The IOL retrieval mechanism, developed by one of Dr. Vasavada’s colleagues, can be made by any surgeon following instructions that can be found online. Speaking of capsular support, Y.C. Lee, MD, Malaysia, demonstrated his preferred technique for sclerally fixating an IOL in a case with insufficient capsular support—without using sutures or glue. Dr. Lee’s technique involves exteriorizing the IOL’s haptics through tiny sclerotomies and then inserting them into scleral tunnels made using a slightly curved small-gauge needle. Sutures are, in fact, used, but rather than anchoring the haptics, they simply stabilize the scleral fixation. Dr. Lee emphasized that, in a review comparing various approaches to scleral fixation— with or without sutures or glue— it’s been found that the technique matters less than surgical skill, experience, and comfort with whatever technique is used. It is entirely up to the surgeon to develop the skill and find the technique that best suits her hands. Editors’ note: Dr. Vasavada receives research support from Alcon (Fort Worth, Texas, USA/Hünenberg, Switzerland). Drs. Roberts and Lee have no financial interests related to their lectures. ‘Very important that blindness be addressed’ While developed parts of the world are rapidly trying to improve the premium experience of cataract surgery, such as the latest in lens and laser designs, Sanduk Ruit, MD, and colleagues are using a simple, low-cost extracapsular procedure to help eradicate blindness in the mountains of Nepal and beyond. “There is an extreme inequity in terms of quality and quantity [in developing areas]. It’s very important that blindness be addressed,” Dr. Ruit told the audience during his APAO/SOE Busan 2012 Lim lecture titled, “Global perspective of cataract blindness: Our experience of quality cataract surgery in community.” The Arthur Lim Award recognizes ophthalmologists who have exhibited exemplary leadership in ophthalmology, leading to substantial improvements in ophthalmic teaching and training in their region and beyond. Dr. Ruit, co-founder and director of the Himalayan Cataract Project, uses a manual, sutureless, small incision extracapsular procedure, called manual SICS (small incision cataract surgery), on patients he described as deprived socially, economically and hard to reach geographically. Because teams have to be employed in remote locations, sometimes only accessible by foot, the surgery needs to be simple and effective, which is the case with SICS. Wound construction for the SICS procedure is key, Dr. Ruit said. A temporal section has been proven to produce better outcomes, he said. In keeping his surgeries simple, when he needs to perform an anterior capsulotomy, Dr. Ruit uses a straight needle. “It is more controlled with a closed chamber,” he said, adding that the capsulotomy in these cases needs to be quite large. Dr. Ruit has performed more than 100,000 of these surgeries himself. He co-founded the Himalayan Cataract Project with Geoffrey Tabin, MD. In the afternoon Challenging Cases session, Zaheer ud Din Aqqil Qazi, MD, director and chief consultant of LRBT Free Eye Hospital in Pakistan, gave the Susruta Lecture, which recognizes contributions to cataract surgery, giving priority to clinicians who have contributed to the control of mass cataract blindness. Dr. Qazi’s lecture titled “High Volume, High Quality, Low Cost Cataract Surgery,” focused partly on how his hospital tries to minimize endothelial cell loss in the many cataract surgery performed there. The latest advances in surgery make it easier to have a high volume, he added. Endothelial health cannot be determined by routine slit lamp evaluation unless there is a gutatte or fuch’s dystrophy, and routine specular microscopy can not be performed in every cataract case,” Dr. Qazi noted. “Endothelial trauma done during surgery becomes apparent after 5-6 hours of surgery,” he said. “The latest [phaco] tip designs have helped a lot in minimizing trauma and completing the procedure in the shortest time.” Editors’ note: Drs. Ruit and Qazi do not have financial interests related to their comments. The latest on femto Femtosecond lasers, once again, were the hot topic at an early afternoon session in which surgeons discussed how they use the lasers in refractive surgery. Eui-Sang Chung, MD, PhD, Seoul, South Korea, used the Visumax laser (Zeiss, Jena, Germany) to perform small incision lenticule extraction (SMILE) during refractive lenticule exchange (ReLEx) and said he uses a 3-5 mm midperiphery linear incision to remove the lenticule, instead of creating a flap. “It’s a very simple procedure,” Dr. Chung said, adding that there are disadvantages to making side cuts, which are avoided in these procedures. “Seventy-five percent of the weakening in corneal biomechanics in refractive surgery comes from the side cut, not from the cuts to the lamellar bed,” he said. “Although there is still some weakening of the cornea, it is dramatically less when a small diameter, no side cut, thin lamellar cut is created in ReLEx SMILE.” The small diameter cut is less than 7 mm. Michael Lawless, MD, Sydney, Australia, said his busy practice made a conscious decision not to make a big splash when they started using their new LenSx (Alcon, Fort Worth, Texas, USA/ Hünenberg, Switzerland) laser for cataract surgery. “We took a relatively low-key approach,” he said. “We didn’t do any paid advertising at all. We did do some media interviews.” The primary factor for success is surgeon engagement, Dr. Lawless said. Meanwhile, Michael Knorz, MD, Mannheim, Germany, said combining femtosecond laser incisions and toric multifocal IOLs may eventually improve optical quality for patients. Today, “laser refractive cataract surgery improves refractive outcomes with better IOL centration and less tilt,” he said. EWAP Editors’ note: Dr. Chung has no financial interest in his subject matter. Dr. Lawless has financial interests with Alcon. Dr. Knorz has financial interests with Alcon. APAO/SOE - from page 49