EyeWorld Asia-Pacific September 2013 Issue

55 EWAP DEVICES September 2013 Views from Asia-Pacific CHEE Soon Phaik, MBBS, FRCS(G), MMed(Ophth), FRCS(Ed), FRCOphth Senior Consultant and Head Cataract Subspecialty Ocular Inflammatory & Immunology Subspecialty Singapore National Eye Centre 11 Third Hospital Ave., Singapore 168751 Tel. no. +65-6227-7255 chee.soon.phaik@snec.com.sg T hese complicated or potentially complicated cases should be identified at the clinic. A thorough assessment of the case, planning the surgery and penning it in the case notes and also discussing this with the patient are all very important steps. I routinely take slitlamp photos of difficult cases, do an endothelial cell count, look carefully at the fundus, where relevant, assess the patient in a supine position and pay special attention to the fellow eye, which can teach us some lessons of what to anticipate. When listing for surgery, all the devices I intend or may resort to using are itemized so that my staff are prepared the day before the surgery. If I need to have a vitreoretina colleague on standby, I ensure that he is aware of the case and is available at the time the case is being done. My special instruments for complicated cataract surgery are kept in a special place in the operating theater, and all these instruments together with devices such as iris hooks, capsular tension rings and segments, pupil expanders and the whole range of intraocular microforceps and scissors are brought into the operating room, ready for use when called upon. My anesthetist is informed how much time the surgery will require so that appropriate sedation is given. I do most of the complicated surgeries with peribulbar anesthesia unless they are children. These days, I am also using the femtosecond laser to assist my surgery in many of these complicated cases. I perform most of these surgeries without an assistant and have developed techniques which do not rely on an additional pair of hands. It is important to have staff who know what instrument the surgeon is asking for and who know how to set up the instruments and maintain them carefully. Many intraocular microinstruments are very delicate and can be easily ruined. They are also rather costly to replace. All these surgeries are done on one day while the straightforward cases are done on a separate list so that I am mentally prepared for the challenge when I start surgery that day. So a typical morning would include a couple of posterior polar cataracts, lens exchange, lens explants with glued implants and subluxated implants. Subluxated cataracts tend to take longer and I prefer doing them on a separate session, usually at the end of the day when I do not have to rush down to start an outpatient clinic. Such surgery can be extremely complicated especially when the cataract is tilting into the mid-vitreous cavity and vitreous is encountered in the anterior chamber. I usually examine such patients at the slitlamp in the operating theater just before I start the case to take note of the position of the cataract which may have shifted in position since the previous time they had visited the clinic so as to strategize the surgery. Surgery can be rather stressful and unless the surgeon is capable of handling the situation, it would be best if he had an experienced surgeon as an assistant/teacher. Some days, nothing goes according to plan and one must be armed with the appropriate tools and skill to handle the unexpected! Editors’ note: Prof. Chee is a consultant for Bausch+Lomb and Technolas Perfect Vision but has no financial interests related to her comments. YAO Ke, MD Professor, Eye Center, Second Affiliated Hospital, College of Medicine, Zhejiang University, China 88 Jiefang Road, Hangzhou 310009, Zhejiang Province, China Tel./Fax no. +86-571-87783897 xlren@zju.edu.cn S enior surgeons always have to manage many complicated cataract surgeries during their daily work. In our eye center, commonly patients have to wait a long time for an appointed surgery. Therefore, ordinary cases are mostly admitted by the relatively young surgeons, while complicated and risky cases are often referred to m e or other senior surgeons. Just as mentioned in the article, a series of conventional rules to process the complicated cases have also been established in our eye center. I quite agree with the professors’ comments in the article, such as reserving the complicated cases for later in the day and kids earlier. The surgical assistant will watch and learn videos of similar surgeries to get familiar with the process in advance. Nurses will be routinely notified to prepare predicted necessary instruments, materials and backups one day in advance. Moreover, besides the examples mentioned in the article, some other cases merit our consideration. 1. Posterior capsular rupture is liable to occur in the case of posterior polar cataract, traumatic cataract or hard nucleus. A vitrectomy or even phaco- fragment unit should be on hand to deal with vitreous prolapse or a nucleus fragment falling into the vitreous. In this situation, the cataract surgeon should inform a senior retina-vitreous surgeon to standby if he cannot handle it independently. 2. Anatomic difficulties including deep set eyes, blepharophimosis or protruding brow will lead to accumulation of irrigating fluid and decreased visibility, a suction speculum is recommended in such a surgery. 3. Intumescent white cataract often hinders continuous circular capsulorhexis and makes capsular rupture. Suspensory intraocular lens or iris-claw intraocular lens could be a concern when ciliary sulcus implantation is impossible. 4. Capsular tension rings (CTRs) are conventionally applied in zonular chalasia and/or subluxated lens. Standard CTRs can be used for mild subluxated lens (less than 4 clock hours of zonulysis), and modified CTR which can be sutured to sclera for severe subluxated lens (more than 4 clock hours and less than 6 clock hours of zonulysis) or progressive zonulysis. 5. In the case of cataract combined with glaucoma, phacoemulsification combined with trabeculectomy can be performed for primary angle-closure glaucoma and open angle glaucoma. Recently, we have prepared Ex-PRESS drainage devices for combined surgery in primary open angle glaucoma if needed. There is a Chinese idiom that states “Precaution averts perils”; in other words, full preparations will greatly favor successful surgery and enhance patient outcomes. Editors’ note: Prof. Yao has no financial interests related to his comments.