EyeWorld Asia-Pacific December 2019 Issue

FEATURE 14 EWAP DECEMBER 2019 Dr. Gayton added that the capsular opening is key. “Take as much time as you need to get a good result for the patient,” he said. Dense white cataracts Dense white cataracts are unpredictable, and surgeons often do not know what is causing them to be white. “When you approach a white cataract, be ready for anything,” said Paul Kang, MD. “If you can get [details] from the patient history or by looking at the cataract, it can help. Oftentimes, it’s not possible.” Denise Visco, MD, MBA, likens a dense white cataract to driving in a blizzard. “Eventually, as you begin working, everything gets kind of white, and you don’t have good contrast between the capsule and lens,” she said. “White cataracts can either behave like any other cataract, or they can have increased intraocular pressure with a high risk of anterior capsule tear out—the dreaded Argentinian y>} È}˜]» Ã>ˆ` /> ,>ۈÛ] ° To help better manage these challenging cataracts and avoid additional surgical surprises, the surgeons shared a few suggestions: • Create a good incision at the beginning that will not leak during the case. “It all starts with a good incision,” Dr. Visco said. “If you’re burping out viscoelastic or have poor chamber stability, it’ll make ̅ˆ˜}à “œÀi `ˆvwVՏ̰» • Make sure the patient is 6JG FTGCFGF #TIGPVKPKCP ƃCI UKIP QH ECRUWNCT TCFKCNK\CVKQP Source: Tal Raviv, MD Hypermature cataract. Source: Johnny Gayton, MD dilated widely. Dr. Kang will use epi-Shugarcaine to help with the view. • Stain the capsule with trypan blue. “If there’s not a good Ài` ÀiyiÝ] ˆÌ½Ã `ˆvwVÕÌ ˆv ˜œÌ impossible to see without some stain,” Dr. Kang said. • Be mindful of your choices for an ophthalmic viscosurgical device (OVD). Dr. Kang uses a combination of Viscoat Ü`ˆÕ“ V…œ˜`ÀœˆÌˆ˜ ÃՏv>ÌiÉ sodium hyaluronate, Alcon) on the endothelium along with Healon5 (sodium hyaluronate, Johnson & Johnson Vision) or a similar OVD. “In this case, I’m using Viscoat because I’m anticipating the cataract may be a little denser, and I want to protect the endothelium. I’m also anticipating the lens might be under pressure, which is why I’ll want to use a viscoelastic with a higher molecular weight so it won’t readily escape the anterior chamber,” he said. • Keep the chamber pressurized, and release pressure if needed in a controlled manner. During ̅>Ì Ìˆ“i] ÞœÕ œvÌi˜ V>˜ w˜` out if the cataract is rock hard or soft, Dr. Kang said. • If an advanced white cataract has capsular plaque, try to plan the capsulotomy around the plaques so they will not tear, Dr. Raviv recommended. “If they are extensive, curved microscissors will be necessary to complete the rhexis,” he said. • Use a stop-and-chop technique to disassemble the nucleus, Dr. Kang said. A femtosecond laser can potentially help with capsulorhexis creation as it’s quick, Dr. Visco said. However, surgeons should use whatever is most comfortable for them, be it manual or with the femto laser, she added. “Femtosecond laser ‘These stories are why we do what we do’ B etter management of challenging cataracts gives patients incredible life improvement. Dr. Gayton shared three stories about treating hypermature cataracts and how it changed patients’ lives. “These stories and millions more like them are why we do what we do,” he said. • While launching phaco in Mongolia a few years back and doing surgery on a hypermature cataract on an important person in that country, the host whispered to Dr. Gayton, “Do you realize that if you mess up, you are going to cause an international incident?” The pearl: Know how to handle hypermature cataracts, especially if you are doing surgery in third-world countries. • A female patient had dense white cataracts for years in both eyes. Dr. Gayton performed simultaneous, bilateral surgery for the only ̈“i ˆ˜…ˆÃ V>ÀiiÀ° º7i «œÃˆÌˆœ˜i`…iÀ `>Õ}…ÌiÀ Ü ̅>Ì Ì…i wÀÃÌ Ì…ˆ˜} she saw when opening her eyes was her daughter. There wasn’t a dry eye in the house,” he said. • A patient with only weeks to live had bilateral hypermature cataracts. In the recovery area, the patient looked up, saw his daughter, and said, “That is the prettiest thing I’ve ever seen.”