EyeWorld Asia-Pacific December 2016 Issue

3 EWAP December 2016 Letter from the Editor Dear Friends W hen I cast my mind back to when I first performed cataract surgery, it is easy to appreciate how revolutionary the improvements in technique and technology have been in the past decades. The change from intracapsular to extracapsular surgery and now phacoemulsification (phaco) has culminated in an operation which provides one of the most predictable outcomes of any surgical procedure. It remains, however, a complex and sophisticated procedure which can be extremely challenging as complications can significantly impair visual acuity. This issue examines situations which are particularly challenging and contains valuable suggestions on how to prevent and manage complications in these circumstances. Posterior polar cataracts can usually be identified prior to cataract surgery and require a different approach to our usual procedure. Typically, there is a preexisting weakness rather than a defect in the posterior capsule in proximity to the lens opacity. It is important to avoid a buildup of intralenticular pressure and therefore hydrodelineation rather than hydrodissection should initially be performed. This breaks the seal between the cortical lens fibers and anterior capsule and a gentle multi-sector hydrodissection can safely be performed after completing hydrodelineation. In addition, it is important to prevent shallowing of the chamber when removing instruments which can be achieved by injecting viscoelastic during removal of the phaco and IA tips and balanced salt solution (BSS) at the end of the procedure. There is some discussion whether femtosecond laser cataract surgery may be a preferred in the presence of a posterior polar cataract; however, there are reports to the contrary. Small pupils and floppy iris syndrome can be managed with iris hooks or a Malyugin ring and sutured capsular tension rings have enabled us to perform surgery when in the presence of deficient zonules. Dealing with vitreous prolapse into the anterior chamber after rupture of the posterior has also improved with our understanding of the importance of performing a vitrectomy in a closed chamber with separate ports for vitrectomy and infusion. These principles are more important than whether a vitrectomy is performed through the anterior chamber or pars plana. The use of triamcinolone has also facilitated the identification of residual strands of vitreous and ensuring complete removal of vitreous from the anterior chamber. Conversion to manual extraction of the nucleus was often recommended as the preferred option in the presence of a torn capsule to prevent loss of nuclear fragments posteriorly. Personally, however, I believe it is less traumatic to remove as much of the nucleus as possible with phaco, perform a vitrectomy, and insert an intraocular lens if feasible. Any residual fragments in the posterior segment can be removed later more elegantly by our vitreoretinal colleagues via the pars planar with less risk than converting to extracapsular, which requires a wider incision and is more likely to be associated with the rare but devastating choroidal or expulsive hemorrhage. Finally, surgeons share their thoughts on their preferred surgical technique. Divide and Conquer remains the most commonly utilized technique; however, there are many advantages to performing a phaco chop procedure. My personal preference is a vertical chop technique as this avoids having to access the periphery of the nucleus. There is certainly a learning curve; however, the phaco energy can be reduced by approximately 50% by avoiding sculpting of the nucleus. One of the appealing features of femtosecond laser surgery may be the laser fracture of the nucleus which may facilitate vertical chopping to those unaccustomed with this surgical technique. Complications are rare but can often be avoided in challenging cases by being familiar with the recommendations of experts contained in this issue. Equally important is the ability to remain focused and to deal with complications effectively along the lines suggested by our contributing surgeons. I hope that the suggestions within this edition are helpful in dealing with challenging cases and managing complications approximately. Warmest regards, Graham Barrett Chief Medical Editorial 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