EyeWorld Asia-Pacific September 2013 Issue

64 September 2013 EW PHARMACEUTICALS Pearls on the posterior capsule by Ellen Stodola EyeWorld Staff Writer and Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer T he Combined Symposium for Cataract and Refractive Societies (CSCRS) is “an opportunity for the different regional societies to get together, share a platform, and bring their best speakers,” said APACRS president Graham Barrett, MD , Australia. Dr. Barrett chaired the session together with Peter Barry, MD (ESCRS), Roger Steinert, MD (ASCRS), and William de la Peña, MD (LASCRS). This year’s combined symposium focused on the posterior capsule—“a very thin, almost invisible membrane, but something that plays a very important role in our practice,” said Dr. Barrett. Dr. Steinert, U.S., discussed “The PCO-Multifocal IOL Connection” and said he wanted to explore the issue of posterior capsular opacification (PCO) with multifocal IOLs and some optical realities that multifocal IOLs can present. Dr. Steinert explained the way a person will see with a multifocal IOL. He said with a multifocal, you will see the combination of the sharp focused image with the out- of-focus image. There will be some blurring of the edge but will still have an element of a sharp edge. “If you add those two things together, you have an understanding of why contrast sensitivity must be impaired with a multifocal lens,” he said. Sometimes with PCO with a multifocal IOL, physicians automatically think to use an IOL exchange, but Dr. Steinert said, sometimes physicians jump and look at posterior capsule and assume the problem is there. “It’s very easy to start doing a YAG capsulotomy on these patients hoping to make them better,” he said. However, he said that an IOL exchange should be the last option. He offered tips for how to attempt to assess PCO clinically. “The way that most physicians get deceived by the posterior capsule is the lack of understanding of the difference between back scattering and forward scattering,” he said. He said you can get a view of retina detail with a direct ophthalmoscope. However, his preferred way is to “look at the red reflex with the posterior capsule in focus.” If the capsule is causing optical disruption, the red reflex will be disrupted, he said. To look for evidence of this, you need to have that capsule in focus with the oblique slit beam but rotate that around to see the red reflex, Dr. Steinert said. Luis Izquierdo, Jr., MD , Peru, discussed how to avoid posterior capsule rupture (PCR). He said in the discussion of this problem, the two main causes for capsule rupture is either the lens or you. That’s the simple point, he said. There are a number of risk factors surrounding the lens and PCR, including the age of the patient, the age of the lens, the history, and previous surgeries. Dr. Izquierdo said it is very important to try to avoid these ruptures. However, he said that there is a learning curve, so over time and experience a surgeon can expect to have less risk of PCR. Abhay Vasavada, MD , India, discussed his technique for posterior continuous curvilinear capsulorhexis (PCCC). Dr. Vasavada said that he performs PCCC in all his pediatric cases to the age of 6 or 7 years. The technique, he added, requires the use of a cohesive viscoelastic. PCCC, he said, is unlike anterior capsulorhexis, owing mainly to the risk of disrupting the anterior vitreous face. “The trick is to have a slant and a swiping motion lifting the capsule and lifting it up towards the endothelium so that your chance of disrupting the anterior vitreous face is minimized,” he said. “At the start, instead of injecting through the initial puncture toward the vitreous in children—which rather than pushing this solid vitreous back would push the posterior capsule forward—I would recommend that you consider pasting the heavy viscoelastic around the hole in the area you want to fashion the posterior capsulorhexis.” Dr. Vasavada performs PCCC through a small 1-mm incision and using bimanual or microincision forceps. “Forceps would be the superior instrument compared to