EyeWorld Asia-Pacific December 2019 Issue

EWAP DECEMBER 2019 3 EDITORIAL L ooking back over the past 12 months, it is ˆ˜ÌiÀiÃ̈˜} ̜ ÀiyiVÌ on the broad variety of topics that have been covered in '[G9QTNF #UKC 2CEKƂE . Our end of the year issue in December has a particularly interesting feature considering special cases in cataract surgery, covering the consideration of monocular patients, dealing with the unruly iris, management of brunescent and dense white cataracts, being prepared for loose zonules, >˜` > }Ո`i ̜ ÀiwÝ>̈œ˜ >˜` " iÝV…>˜}i° /…iÃi ̜«ˆVà >Ài covered comprehensively, but I thought I would provide some additional comments on each of the topics. Monocular patients are a particular challenge, especially in deciding when to operate. Personally, my advice to patients is not dissimilar to that for patients contemplating cataract surgery with useful vision in LœÌ…iÞið /…i ÀˆÃŽÃ œv ÃÕÀ}iÀÞ œLۈœÕÏޅ>Ûi ̜ Li iÝ«>ˆ˜i` in detail but essentially once the patient feels their vision is ˆ“«>ˆÀi` ÃÕvwVˆi˜ÌÞ >˜` ̅iÞ are not coping adequately >˜` `ˆÃÃ>̈Ãwi` ̅iÀi ˆÃ ˆÌ̏i sense in deferring surgery. I’m sure we have all encountered patients where surgery has been deferred to a level where ̅i V>Ì>À>VÌ ˆÃ ˜œÜ iÝÌÀi“iÞ dense and brunescent. One would not consider surgery if the cataract was not visually È}˜ˆwV>˜Ì] LÕÌ `iviÀÀˆ˜} ÃÕÀ}iÀÞ until the density of the cataract increases the risk of surgery should also be avoided. What is interesting to consider are the additional measures that surgeons commenting on the article discuss. Personally, I also consider additional antibiotic «Àœ«…ޏ>݈à ˆ˜VÕ`ˆ˜} > ÃÞÃÌi“ˆV antibiotic in addition to topical >˜` ˆ˜ÌÀ>V>“iÀ> «Àœ«…ޏ>݈à >Ì the time of surgery /…i ՘ÀÕÞ ˆÀˆÃ ˆÃ > challenging situation and is often encountered in patients with no history of the classical smooth muscle dilatation >ÃÜVˆ>Ìi` ܈̅œ“>ÝÌÀ>° Certain antihypertensives are likely to be a contributing factor ˆ˜ ̅ˆÃ Vœ˜ÌiÝÌ° /…i ÕÃi œv > ˜œ˜‡ «ÀiÃiÀÛi` £°Óx œÀ Ó°x¯ ˜œ˜‡ preserved phenylephrine can be helpful in improving dilation and also increasing tone in patients ܈̅> ºyœ««Þ» ˆÀˆÃ° Brunescent and dense white cataracts are more challenging and the appropriate phaco technique can help reduce the required energy. A vertical chop technique is my preferred technique in this situation, and ̅i >``ˆÌˆœ˜ œv œÜ‡`œÃi “>˜˜ˆÌœ (0.25 g per kg) preoperatively in the presence of an intumescent cataract can be helpful in reducing «œÃÌiÀˆœÀ ۈÌÀiœÕà >à Üi >à ˆ˜ÌÀ>‡ lenticular pressure. Being prepared for loose Special cases in cataract surgery zonules is an important part of surgery and being prepared ܈̅>``ˆÌˆœ˜> wÝ>̈œ˜ `iۈVià and appropriate implants is a key strategy in managing this situation successfully. ˆ˜>Þ] ÀiwÝ>̈œ˜ >˜` iÝV…>˜}i ˆÃ ˜œÌ ˆ˜vÀiµÕi˜ÌÞ encountered, particularly with the use of multifocal implants. Removing an IOL is straightforward if IOL iÝV…>˜}i ˆÃ «iÀvœÀ“i` ˆ˜ ̅i wÀÃÌ “œ˜Ì…œÀ Ìܜ >vÌiÀ ̅i initial surgery, but can be more challenging if this is deferred… not an uncommon occurrence. An important consideration ˆ˜ iÝV…>˜}ˆ˜} " à >vÌiÀ > long period is to remove any regenerated or retained cortical material which can be associated ܈̅ˆ˜y>““>̈œ˜ ˆv `ˆÃÌÕÀLi` ˆ˜ ̅ˆÃ Vœ˜ÌiÝÌ° Although the vast majority of cataract surgery that we perform is straightforward and uncomplicated, being aware of ̅i >`ۈVi œv œÕÀ iÝ«iÀÌà ŜՏ` assist the successful management of these special cases despite the additional challenges. ܜՏ` >Ãœ ˆŽi ̜ iÝ«ÀiÃà my appreciation to the staff of '[G9QTNF #UKC 2CEKƂE for ̅iˆÀ…>À` ܜÀŽ >˜` iÝ«iÀ̈Ãi in preparing each issue and in particular wish you, our readers, a restful and enjoyable festive season and all health, happiness, and prosperity for the coming New Year. EWAP Graham Barrett Chief Medical Editor EyeWorld ƂÈ>‡*>VˆwV