EyeWorld Asia-Pacific December 2019 Issue

FEATURE 16 EWAP DECEMBER 2019 capsulotomy has helped with white cataracts, though it’s not foolproof,” Dr. Raviv said. Another advantage with the laser is that you can obtain -V…iˆ“«yÕ} œÀ " / ˆ“>}ˆ˜} of the lens to see what is happening internally. If imaging shows that the chamber is shallow or the lens appears under pressure, Dr. Visco will adjust the laser parameters to perform the capsulotomy even faster, to help decrease the chance of an incomplete rhexis or a tear out. As Dr. Raviv concurred, “A slower [capsulotomy] will likely be incomplete, since as soon as ̅i V>«ÃՏi ˆÃ i˜ÌiÀi`] ˆµÕˆwi` cortex exits, blocking the femto, moving the capsule, and still leaving a risk of radialization.” “The challenge with a white cataract is if you’re using a femto laser, the energy for softening the lens won’t penetrate,” Dr. Kang said. The bottom line is: Keep the laser in mind as a tool, but don’t expect it to be your go-to for all dense white cataracts you treat. That said, it still could be helpful for astigmatism correction if needed, Dr. Kang said. Dr. Visco recommends having intraocular scissors on hand for whichever approach you use, be it femtosecond or manual. These can help you adjust the course for a capsulotomy that has gone wrong with either approach. Another pearl from Dr. Visco: Don’t assume what kind of IOL or astigmatism correction the patient wants just because they have a white cataract. Although many of these patients may not qualify for premium technology due to other diseases present, such as diabetes, she still has treated patients who have wanted a premium refractive result. “It’s our due diligence to make sure the patients know all their options,” she said. EWAP Editors’ note: Dr. Al-Mohtaseb is associate professor of ophthalmology at Baylor College of Medicine, Houston. Dr. Gayton practices at Eyesight Associates, Warner Robins, Georgia. Dr. Kang is assistant clinical professor at the Department of Ophthalmology, Georgetown University Washington, DC. Dr. Katsev practices at Sansum Clinic Ophthalmology, Santa Barbara, California. Dr. Raviv practices at Eye Center of New York, New York. Dr. Visco is Medical Director, Eyes of York, York, Pennsylvania. None of the doctors FGENCTGF CP[ TGNGXCPV ƂPCPEKCN KPVGTGUVU that’s too wide, she said. The incision needs to be properly placed and not too far posteriorly because this will also facilitate iris egress from the incision. If you do get iris prolapse, decompress the AC by releasing yՈ` œÀ ۈÃVœi>Ã̈V vÀœ“ ̅i paracentesis and gently reposit the iris, she said. To do that, she uses a dispersive viscoelastic because, as you reposit the iris, you can use the viscoelastic to create a gentle blockade that pushes the iris posterior to the incision’s inner lip. If the main incision is poorly constructed, it may make sense to create a better incision adjacent to the original incision, Dr. McCabe said. Small pupils present another challenge. Steps to help facilitate a successful case include very good hydration and good lens mobility prior to removing any segments of the nucleus during phaco. Take extra time with hydrodissection to make sure the lens is freely mobile. Dr. McCabe added that with a small pupil, be sure that you have all the cortical pieces and no nuclear fragments are hiding, especially as you’re }iÌ̈˜} ̜ ̅i Vœ“«ïœ˜ œv ÉƂ and cortex removal. With the anterior chamber >˜` L>} wi` ܈̅ۈÃVœi>Ã̈V œÀ ܈̅̅i ÉƂ…>˜`«ˆiVi ˆ˜ the AC, she uses a Kuglen or second instrument through the paracentesis and carefully moves the edge of the pupil and dilates it 360 degrees around by moving the pupil and iris margin peripherally, peeking underneath to make sure there’s no retained cortex or missed nuclear material. She also recommended looking again after placing the IOL. In cases of IFIS when the iris comes out, Dr. Williamson said he likes to depress from the back œv ̅i ܜ՘` ̜ `iy>Ìi ̅i Ƃ >˜` œÜiÀ ̅i «ÀiÃÃÕÀi° º w˜` ̅>Ì LÞ iÌ̈˜} > ̅i yՈ` Vœ“i out of the AC by depressing the posterior lip of the main incision, you can easily deposit the iris back in,” he said. After that, he places a cohesive viscoelastic onto the iris for good spacing between the incision and iris. Preoperatively, Dr. Williamson said to look for any signs of trauma and synechiae. He also said to be aware if the patient has had laser surgery on the iris and to review any medications that patient is on. He said to be very careful with being as atraumatic as possible with iris expander devices in cases of iris prolapse. Even with moderate manipulation of the iris, you can get iris atrophy. Dr. Williamson also mentioned IFIS when using the femtosecond laser, adding that he uses the femtosecond laser for about 60–70% of his patients. “I’ve taken great care in these patients to put several dilating drops in after the femtosecond laser is completed,” Dr. Williamson said. EWAP Editors’ note: Dr. Agarwal practices at Dr. Agarwal’s Eye Hospital, Chennai, +PFKC CPF FGENCTGF PQ TGNGXCPV ƂPCPEKCN interests. Dr. McCabe practices at The Eye Associates, Bradenton, Florida, and has interests in Omeros. Dr. Williamson practices at Williamson Eye Center, Baton Rouge, Louisiana, and declared PQ TGNGXCPV ƂPCPEKCN KPVGTGUVU Dealing with the unruly iris - from page 11