EyeWorld Asia-Pacific December 2016 Issue

December 2016 62 EWAP NEWS & OPINION particularly aware of tough eyes were also important points that Dr. Koch discussed, concluding with the importance of being skeptical. Combined Symposium of Cataract & Refractive Societies (CSCRS) During the CSCRS session, Brian Little, MD , London, presented on dealing with the rock-hard cataract, which he said is always a challenge. One key concept is to plan very carefully because you can expect comorbidities both ocularly and systemically, he said. These cases take time, Dr. Little said. But he recommended physicians go slowly and not rush because that’s when they can run into trouble. Stay calm and don’t panic, and allow more time. Surgical planning becomes very important to anticipate the predictable challenges. In terms of surgical technique, Dr. Little said it’s easy to get focused on the splitting itself, but there are special considerations that come into every stage of the surgery. Dr. Little said he routinely uses phenylephrine in the pupil in these cases. There’s no downside to using this, he said. The capsule itself can be any sort of composition, and he added that there’s no excuse for not using trypan blue. Dr. Little also discussed capsule properties, hydrodissection, nuclear fragmentation and fragment removal, using a capsular tension ring (which he said is “almost mandatory” in these cases), and use of viscoelastic. He highlighted the importance of looking for lost chips, which are small fragments that could break off and get trapped in the incisions, on the iris, in the iridocorneal angle, or in the sulcus or posterior chamber. These could be camouflaged, so look carefully, Dr. Little said. He said to irrigate the sulcus, angle, and all incisions to flush them out. Samuel Masket, MD , Los Angeles, spoke about posterior polar cataracts. He offered several important tips for surgery in these cases. Most patients become symptomatic around the presbyopic age, Dr. Masket said. Surgery is indicated based upon symptoms, most typically reduced reading ability and glare disability. The symptoms can increase with parapolar changes. The key feature of surgery is appropriate sizing and placement of the anterior capsulotomy, he said. A strong case can be made for use of the femtosecond laser for the capsulotomy, and Dr. Masket prefers to avoid nuclear division to prevent gas bubble distension of the bag. He recommended a centered capsulotomy, hydrodelineation not hydrodissection, not allowing the chamber to shallow, emulsifying the nucleus without rotation, viscodissection of the epinucleus and cortex, and not polishing the posterior capsule. Dr. Masket mentioned the Vasavada modification of “inside out” delineation and Osher’s “low flow.” Past, present, and future of femtosecond lasers in ophthalmology The background, current uses, and possible future applications of the femtosecond laser in ophthalmology were presented during an ESCRS/EuCornea symposium. Mats Lundström, MD , Lund, Sweden, led the discussion with a case control study using data from the European Registry of Quality Outcomes for Cataract and Refractive Surgery to evaluate outcomes of femtosecond laser- assisted cataract surgery (FLACS) in terms of visual acuity, refractive outcomes, and complications. The study involved 18 clinics from 10 countries providing data on 3,379 FLACS cases from December 2013 through May 2015. Visual and refractive outcomes in these FLACS cases, overall, were good. Out of the whole group, 2.9% of cases had surgical complications, which were either classical complications associated with cataract surgery or laser- related, though Dr. Lundström said the latter were not visually threatening. Postop complications occurred in 3.3% of cases, measured at the 3-month followup. “We conclude that this is a registry study of what’s happening in the real world. If we want to go into details and get more information, we need randomized, clinical studies in order to find out the relationship and postop complications with this technique,” Dr. Lundström said. The use of femtosecond laser in the context of lamellar procedures, small incision lenticule extraction (SMILE), to correct astigmatism, and in capsulotomy creation were discussed in depth by the symposium’s presenters. Holger Lubatschowski, PhD , Hanover, Germany, spoke about some of femto’s other, less common applications. These included intratissue refractive index shaping, in situ IOL modification, presbyopia reversal, and noninvasive bleaching of the human lens. As for application in the posterior segment, Dr. Lubatsch- owski said it is possible to go deeper in the eye; however, there is a loss of precision because of the vitreous. He said adaptive optics could someday be used to compensate for this aberration. “In conclusion we see femtosecond where we can do 3D cutting, imaging, and chemistry, and I’m convinced … the femto era of ophthalmology has just begun,” Dr. Lubatschowski said. Nanolaser cataract surgery Nanolaser cataract surgery was featured in three presentations during a free paper session about femtosecond lasers and other types of lasers for cataract surgery. “Femtosecond laser allows us to perform laser-assisted cataract surgery, but the lens material still needs to be removed by ultrasound and aspiration,” Jerome Vryghem, MD , Brussels, Belgium, said before going on to explain how nanolasers can be used to emulsify the lens for aspiration. The advantages of nanolaser over ultrasound phacoemulsification, according to Dr. Vryghem, include less energy applied in the eye, more endothelial protection, and less intraocular trauma due to no mechanical or thermal side effects. Dr. Vryghem conducted a trial with 141 patients who had nanolaser cataract surgery and received a trifocal IOL. He used the Cetus laser (A.R.C. Laser, Nuremberg, Germany), which connects to any phacoemulsification system at the vitrectomy port and is triggered by the air impulse, controlled by the foot pedal. His first impression postop day 1 was that the eyes appeared calm with less wound leakage and seemed to have a faster visual recovery. Further analysis showed a small mean spherical equivalence and average cell Reporting - from page 61