EyeWorld Asia-Pacific December 2015 Issue

32 EWAP SECONDARY FEATURE Retina: A cataract surgeon’s guide to anti-VEGFs December 2015 Make sure that the retina is not in focus when visualizing the floater. Start with large, well-defined floaters like the one pictured here. Avoid treating floaters directly in front of the macula, optic nerve, or major blood vessels (circled in white). Source (all): Karl Brasse, MD Multifocal IOLs can divide the YAG laser beam, so avoid treating floaters in multifocal IOL patients. patient and the right floater are crucial to success when starting out. “The key for me is picking the right patient, picking the right floater, and then practicing beforehand with the visualization,” Dr. Singh said. To avoid causing a traumatic cataract by accidentally hitting the lens or posterior capsule, start with pseudophakic patients. Avoid patients with multifocal lenses, however, because the lens’ multiple focal points will divide the YAG laser beam. A divided laser beam makes visualization more difficult. It could also cause the laser to hit other ocular structures and may not achieve enough energy to vaporize the floater. Start with large, fibrous floaters such as Weiss rings that are easy to visualize and vaporize with the laser. Avoid treating the diffuse, cloud-like floaters caused by vitreous syneresis; treat these floaters only after gaining sufficient experience with the laser. Remember that the larger and more amorphous the floater, the more laser shots and treatment sessions will be needed. It is important to set expectations ahead of time. If the floaters are larger, denser, and more amorphous, patients need to be aware that they might need multiple sessions. If the floaters are too far posterior, near the retina, or anterior near the lens, patients must be aware that the surgeon may not be able to remove the entire floater due to its proximity to the retina or lens. Surgical technique Before starting, make sure that the patient has no active inflammation, retinal pathology, or signs of acute posterior vitreous detachment. To avoid causing damage to any ocular structures, only treat floaters in the “safe zone”—at least 3 mm from both the retina and the lens. Dr. Singh’s rule of thumb is that when he can visualize the floater (when it’s in focus), if the retina is also in focus, the floater is too close to the retina to treat. “If the retina is not in focus, and the floater is in the middle of the vitreous, you’re not going to hit any other structures,” he said. Make sure that the floater is visible preoperatively at the slit lamp so that you don’t have to search for it after the patient sits down at the laser. If you have trouble finding the floater initially, one of Dr. Singh’s tricks is to ask patients where they’ve seen the floater lately. “The key in this procedure is visualization,” he said. “If you can’t visualize it, do not do it.” Often times, Dr. Singh needs to increase the magnification compared to what he normaly uses for a YAG capsulotomy. It takes some time to find the right magnification for each surgeon. YAG vitreolysis - from page 30