EyeWorld Asia-Pacific December 2016 Issue

December 2016 20 EWAP FEATURE the IOLMaster in such cases, he tends to avoid multifocal lenses as results may not be as accurate. With posterior polar cataract cases, there remains some controversy over whether or not femtosecond laser-assisted cataract surgery should be performed. Currently there are conflicting views on this. Dr. Safran cited a study that appeared in the December 2014 issue of the Journal of Cataract & Refractive Surgery 1 that showed there was a risk to rupturing the capsular bag due to gas from the femtosecond laser. On the other hand, a study published in the December 2015 issue of the Journal of Refractive Surgery 2 indicated that with a modified program using a hybrid pattern of cylinders and chops, the laser could be used safely. Still, he urges caution. “I think one thing to keep in mind is there are reports of higher radial tear-out rates, which affects the anterior capsule with the femtosecond,” Dr. Safran said, adding that if the surgeon can make a rhexis that can allow for optic capture, there will be less likelihood of experiencing a tear-out. EWAP References 1. Alder BD, et al. Comparison of 2 techniques for managing posterior polar cataracts: Traditional phacoemulsification versus femtosecond laser-assisted cataract surgery. J Cataract Refract Surg . 2014;40:2148–51. 2. Titiyal JS, et al. Femtosecond laser- assisted cataract surgery technique to enhance safety in posterior polar cataract. J Refract Surg . 2015;31:826–8. Editors’ note: Dr. Chan and Dr. Safran have no financial interests related to their comments. Contact information Chan: clarachanmd@gmail.com Safran: safran12@comcast.net try to give it a little peripheral viscodissection to help mobilize the nucleus.” In cases with denser nuclei, Dr. Safran does minimal or no initial hydrodelineation or dissection. He just chops and rechops the lens, then takes a quadrant out and tries to mobilize the lens. “What you don’t want to do is reveal a posterior capsule defect early in the case and drop the nucleus,” he stressed, adding that this is why it’s far better to leave the plaque in place until the end after you’ve removed the lens so the nucleus doesn’t fall through the potential defect behind it. “Also, you want to make sure you don’t aggressively distend the bag,” Dr. Safran continued. Imagine putting scotch tape on a balloon; if you blow the balloon up, it is going to pop right where the scotch tape is so even if there is no preexisting defect under the plaque, there is more stress on the capsule adjacent to the plaque when it is distended. “It’s important to be as gentle as possible throughout the case to avoid this type of rupture as long as plaque is present. If the plaque comes off during the case and the posterior capsule looks normal at that point, you are out of the woods, but as long as the plaque is there, the risk of a posterior capsule tear is present if it is disturbed,” he said. In cases of posterior polar cataract, the IOL choice may be affected depending on whether or not a hole develops, Dr. Chan noted. “If the posterior capsule remains intact, a one-piece IOL can be implanted,” she said, adding that practitioners should, however, have calculations available for a three-piece lens as well since the rate of posterior capsule rupture is much higher in these cases. In the event of a rupture, she advised practitioners to be prepared to implant a three- piece IOL in the sulcus, with or without optic capture. Dr. Chan also warned that premium IOLs should be avoided here. “Advanced technology IOLs may not be suitable should complications arise,” she said. Likewise, Dr. Safran uses a standard one-piece lenses, including torics, but stressed the importance of having a three-piece IOL on hand. He also modifies his technique. “You should make your rhexis a little smaller than the optic so that you can do optic capture,” he said, adding that there is an increased chance that it may be warranted. “Some physicians might want to do a posterior rhexis, but I think that optic capture with a three-piece lens is just as good,” he said. However, if the patient has a lot of astigmatism, then the surgeon may want to consider a posterior rhexis so that a toric IOL can be placed. If the plaque is left alone or comes out without leaving a defect, he finds that usually the surgeon can put any lens in the bag. He does, however, recommend avoiding the Crystalens (Bausch + Lomb, Bridgewater, New Jersey) if there is a posterior capsule plaque remaining because that puts tension on the posterior capsule. “I don’t think that’s absolutely contraindicated, but personally I would avoid it in that situation,” he said. Since it can be difficult getting a reading with Index to Advertisers HOYA Page: 34 , 35 www.hoya.co.jp OCULUS Optikgeräte Page: 51 www.alcon.com Ziemer Page: 68 www.ziemergroup.com ASCRS Page : 5, 24 , 40 , 46 , 48 www.ascrs.org APACRS Page 2, 10, 11, 17 , 23 , 45, 67 www.apacrs.org EyeWorld Pag e 7, 30 , 36 , 38 www.eyeworld.org Warming up - from page 19