EyeWorld Asia-Pacific December 2015 Issue

3 EWAP EDITORIAL December 2015 Letter from the Editor Dear Friends C ataract surgery has become an extremely sophisticated operation with a low incidence of complications and highly predictable outcomes. Nevertheless, there is always a small risk of unexpected complications which can be minimized with constant vigilance throughout the procedure. The fundamentals of performing cataract surgery safely in routine cases remain when performing complex cataract surgery. Success in these cases requires technical skill but also experience in being able to anticipate the consequence of each step in the procedure. This philosophy is evident in the recommendations of our experts in this issue discussing the management of mature intumescent lenses, deficient zonules and surgery in eyes with extremely short or long axial lengths. Perhaps one of the greatest challenges is how to secure an intraocular lens implant when there is inadequate capsular support. Options include suturing lenses to the sulcus or iris, securing the haptic in an intrascleral tunnel, iris clip lenses and anterior chamber lenses. My personal preference is to secure a lens by suturing to the sclera, either with 9-0 prolene or more recently 8-0 Gore-Tex. Experience has shown us that 10-0 prolene tends to degrade with time and although less common this can still occur with 9-0 polypropylene. Gore-Tex appears to be more durable but technically requires different techniques as the long fine needles so well suited to transcapsular suturing of a displaced IOL/capsular bag complex are not available with the larger diameter suture. Similarly, this issue contains many suggestions to manage intumescent white cataracts and avoid the “Argentinean flag” when the capsule is punctured. These include the use of retentive viscoelastics to counteract the raised intralenticular pressure and flatten the anterior capsule, initial aspiration of fluid through a needle, and even the use of a reverse bevel phaco tip to simultaneously puncture and decompresses the lens. In addition, I have found a preoperative dose of mannitol use to be helpful in reducing the vitreous and possibly intralenticular pressure. The typical dose recommended for mannitol is 0.50 g to 1.0 g per kilogram but lower doses as little as 0.25 g per kilogram are also effective and the diuretic response is reduced. Phacoemulsification of brunescent dense cataracts can be challenging. Additional thoughts that may be helpful in managing these cases are to avoid performing a small rhexis and always to use a more retentive viscoelastic to protect the endothelium. Typically, the nucleus has to be subdivided into multiple sectors with a vertical chop technique as the characteristic of dense brunescent cataracts is the presence of a posterior leathery plate which tends to resist fracture. The fractured nucleus consequently resembles an open flower with petals that can then be individually removed. Another helpful maneuver at this point is to inject viscoelastic behind the plaque protecting the posterior capsule and facilitating removal of the final fragments. One should always be aware of the possibility of associated weak zonules and utilize capsular tension rings with additional suturing if required. Our regional and international expert surgeons provide invaluable advice in managing these complex cases and I’m sure our readers will find their collective experience helpful in managing complex cases and avoiding complications. I would like to take this opportunity to wish everyone an enjoyable festive season and a healthy, happy and prosperous New Year. Warmest regards Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific EYEWORLD ASIA-PACIFIC EDITORIAL BOARD C HIEF MEDICAL EDITOR Graham BARRETT, Australia MEMBERS Abhay VASAVADA, India ANG Chong Lye, Singapore CHAN Wing Kwong, Singapore CHEE Soon Phaik, Singapore Choun-Ki JOO, Korea Hiroko BISSEN-MIYAJIMA, Japan ASIA-PACIFIC CHINA EDITION Editors-in-Chief ZHAO Jialiang ZHAO Kan Xing Deputy Editor HE Shouzhi Assistant Editor ZHOU Qi ASIA-PACIFIC INDIA EDITION Regional Managing Editor S. NATARAJAN ASIA-PACIFIC KOREA EDITION Regional Editor-in-Chief Hungwon TCHAH Regional Managing Editor Chul Young CHOI Hungwon TCHAH, Korea John CHANG, Hong Kong Johan HUTAURUK, Indonesia Kimiya SHIMIZU, Japan Pannet PANGPUTHIPONG, Thailand Ronald YEOH, Singapore S. NATARAJAN, India Sri GANESH, India YAO Ke, China Y.C. LEE, Malaysia