EyeWorld Asia-Pacific December 2016 Issue

39 EWAP CATARACT/IOL December 2016 by Liz Hillman EyeWorld Staff Writer Considerations for cataract surgery in short eyes Preventing iris prolapse, increasing chamber depth, IOL calculations, and more W hen faced with cataract surgery in a short eye, one interesting piece of advice doesn’t depend on surgical technique or skill: Just speak with your patient, recommended Leela Raju, MD , associate professor, Department of Ophthalmology, NYU Langone Medical Center, New York. “Reassuring patients throughout the procedure, or ‘vocal local,’ can help keep patients from holding their breath due to anxiety that could also increase posterior pressure,” she said. Of course, there are many clinical and surgical things you can do to help manage these cases and achieve safe and targeted outcomes. Preoperative preparation During the preop examination, Dr. Raju tells patients there may be a need for additional medications in the surgery as well as the possibility for more intraoperative procedures to make sure everything goes smoothly. “Prior discussion of possibilities can always help the patient feel more informed and comfortable. But we have to assure them we have a plan in place in case the surgery varies a little from the standard operation,” Dr. Raju said. Zachary Zavodni, MD , The Eye Institute, Salt Lake City, said that patients with extremely short axial lengths (less than 20 mm) and small white-to-white measurements (less than 11 mm) may be at higher risk for suprachoroidal hemorrhage, which should be discussed. In addition, even a maximum power IOL (i.e., 40 D) might not fully correct the refractive error. In these cases, Dr. Zavodni said he tells patients they may still need to wear glasses or perhaps consider a piggyback IOL in the future. During the exam, Dr. Zavodni said he looks closely at the extent of anterior segment crowding. “Short, hyperopic eyes tend to have narrow angles, which can be exacerbated by phacomorphic narrowing in eyes with more advanced cataracts,” he said. “In eyes with notably narrow angles, I will perform gonioscopy prior to dilation to assess if the angle is occludable. I look closely for both anterior and posterior synechiae, as these are more common in hyperopic eyes with previous angle closure episodes and they are more likely to result in poor intraoperative dilation.” Intraoperative situations Intraoperatively, there are many considerations for cataract surgery in short eyes. First, Dr. Raju said she makes sure that the speculum is not placed too wide as it could contribute to posterior pressure. Perhaps the most immediate consideration in these cases is the prevention of iris prolapse. “I try to make my incision longer than average in these cases,” Dr. Zavodni said. “I also have a very low threshold to place a Malyugin ring, as placement often helps to minimize iris prolapse. The rhexis can be more difficult to control because of ergonomic adjustments necessary to accommodate the crowded anterior chamber and because these lenses often have increased anterior capsule convexity, which will steer a rhexis tear peripherally.” To prevent iris prolapse, Dr. Raju said she might create a scleral tunnel versus a clear corneal incision. She also said she’d consider using iris hooks if the anterior chamber is shallow, although she noted that just because an eye is short does not mean it has a shallow chamber. She also uses a dispersive viscoelastic to maintain the space, refilling with it often, especially when she removes instruments from the anterior chamber. For the very crowded chamber, digital massage or a vitreous tap might be in order. To start though, continued on page 41