EyeWorld Asia-Pacific June 2019 Issue

EWAP JUNE 2019 41 CATARACT the cornea, you have to stop at least once, if not more, to replenish the OVD in the eye LiV>ÕÃi œv ̅i…ˆ}…iÀ yœÜ >˜` the higher amounts of time spent on the removal process. ˜ V>Ãià ̅>Ì ÀiµÕˆÀi ✘Տ>À protection, if any weakness is noted early on, use hooks to vÕÀ̅iÀ ÃÌ>Lˆˆâi ̅i ✘Տià Ü ̅>Ì ÞœÕ V>˜ “ˆ˜ˆ“ˆâi disruption, Dr. Foster advised. While sometimes surgeons will use a capsular tension ring in the iÞi ˆ˜ ̅i v>Vi œv œœÃi ✘ՏiÃ] ̅ˆÃ ˆÃ «>À̈VՏ>ÀÞ `ˆvwVÕÌ Ìœ `œ in these cases because the lens is so big and noncompliant. “Sometimes there’s no room to õÕiiâi ̅>Ì V>«ÃՏ>À Ìi˜Ãˆœ˜ ring in between the capsule and the large nucleus, so you have ̜ ÃÌ>Lˆˆâi ˆÌ ܈̅…œœŽÃ >˜` «ÕÌ the capsular tension ring in later when there’s actually room to place it,” Dr. Foster said. ̽à >Ãœ ˜œÌ ՘Vœ““œ˜ ̜ have to deal with small pupils in these rock-hard cases. When trying to decide between placing a pupil expansion ring versus hooks in a rock-hard cataract case, if there is any µÕiÃ̈œ˜ >LœÕÌ Ì…i ✘ՏiÃ] À° Foster is more likely to opt for hooks. Then he not only has these in place for expanding ̅i «Õ«ˆ] LÕÌ >Ãœ ˆv ̅i ✘Տià prove to be somewhat lax, it’s easy to push these forward and grab the capsule edge. Emerging instrumentation À° œÃÌiÀ w˜`à ̅i “ˆ ""* (Carl Zeiss Meditec, Jena, Germany) is also potentially helpful in managing such cases. This instrument has a nitinol ring that when retracted becomes very small so that it can go through an incision, Dr. Foster explained. “But once it’s in the eye, you can slowly open the ring and you can feed that loop underneath the capsule until at full extension it can be rotated around so that it’s back behind the entire cataract,” he said. “Then, as you close the loop L>VŽ ̜ ˆÌà Ó> Èâi] ˆÌ «…ÞÈV>Þ cuts through the lens.” One advantage of it is that it applies great pressure from the posterior to the anterior through the posterior leathery plate, which V>˜ Li `ˆvwVÕÌ Ìœ ÌÀi>Ì ÜˆÌ… standard phaco since you can’t crack it. Meanwhile, when trying to cut this with a vibrating phaco needle, you’re just 0.5 mm away from the posterior capsule, Dr. Foster pointed out. Overall, Dr. Foster hopes that practitioners come away from this study on rock-hard cases aware that these can usually be effectively managed to the Li˜iwÌ œv ̅i «>̈i˜Ì >˜` ̅>Ì Ì…iÀi >Ài “œ`ˆwV>̈œ˜Ã ̅>Ì are required to increase the V…>˜Vià œv ÃÕVViÃð º v V>ÀivՏÞ implemented, surgeons and patients alike can anticipate good results even though it’s a more challenging circumstance,” he concluded. EWAP Reference £° œÃÌiÀ ] iÌ >° *…>Vœi“ՏÈwV>̈œ˜ of the rock-hard dense nuclear cataract: options and recommendations. J Cataract Refract Surg . 2018;44:905–916. D i˜Ãi V>Ì>À>VÌ i“ՏÈwV>̈œ˜ «œÃià > V…>i˜}i iÛi˜ ̜ ̅i “œÃÌ experienced surgeons; hence, it is important that the surgeon have in their kitty special techniques and tips to deal with dense cataracts. /…i vœÀi“œÃÌ V…>i˜}ià ˆ˜ `i˜Ãi V>Ì>À>VÌ i“ՏÈwV>̈œ˜ >Ài\ a) Preoperative assessment and counseling. These cataracts may …>Ûi >ÃÜVˆ>Ìi` V>«ÃՏ>À «>µÕià œÀ ✘Տ>À Üi>Ž˜iÃà `Õi ̜ the longstanding bulky nature of the cataracts. Therefore, the patients and their family should be counseled about possibility of a postoperative corneal edema and the possibility of using a capsule tension ring. b) Achieving a complete division of the nucleus, especially the central leathery core. Unless the division of fragments is complete, removing ̅i“ ˆÃ ˜œÌ œ˜Þ…>â>À`œÕà ̜ ̅i VœÀ˜i> i˜`œÌ…iˆÕ“] LÕÌ >Ãœ ̜ ̅i «œÃÌiÀˆœÀ V>«ÃՏi° ˜ ̅iÃi iÝÌÀi“iÞ `i˜Ãi V>Ì>À>VÌÃ] V…œ««ˆ˜} ÌiV…˜ˆµÕià “>Þ Li “œÀi ivviV̈Ûi >˜` ivwVˆi˜Ì ̅>˜ `ˆÛˆ`i >˜` conquer maneuvers. Divide and conquer would require a huge amount of ultrasound energy in order to achieve a thin posterior «>Ìi ̅>Ì >œÜà VÀ>VŽˆ˜} œv ̅i ˜ÕViÕð 7…iÀi>à LœÌ……œÀˆâœ˜Ì> >˜` ÛiÀ̈V> V…œ« ÌiV…˜ˆµÕià >Ài ivviV̈Ûi] ̅i `ˆÀiV̅œÀˆâœ˜Ì> V…œ« œÀˆ}ˆ˜>Þ `iÃVÀˆLi` LÞ >}>…>À> ˆÃ «>À̈VՏ>ÀÞ ivwVˆi˜Ì° Ƃ Ó> central trench may or may not be created for this technique. Having maximal vacuum is important to achieve a good hold that will allow chopping of the nucleus. Further, despite all attempts, often the ˜ÕViÕà `œià ˜œÌ `ˆÛˆ`i Vœ“«iÌiÞ° ˜ ÃÕV…V>ÃiÃ] ÃÕÀ}iœ˜Ã “>Þ resort to the multi-level chop technique 1 wherein, the phaco tip is occluded progressively deeper within the central trench so that the crack can be extended to the depth. The aim should be to create multiple small fragments that are not joined in the center. V® ,i“œÛˆ˜} ̅i `ˆÛˆ`i` ˜ÕVi>À vÀ>}“i˜Ìà Ã>viÞ° Ì ˆÃ ˆ“«œÀÌ>˜Ì ̜ use interrupted modes of ultrasound energy, particularly when using longitudinal ultrasound so that thermal injury to the corneal i˜`œÌ…iˆÕ“ ˆÃ “ˆ˜ˆ“ˆâi`° ,i«i>Ìi` ÕÃi œv `ˆÃ«iÀÈÛi ۈÃVœi>Ã̈V ܈ also protect the endothelium. Care should be taken to remove the divided fragments as far as possible from the corneal endothelium to further offer more endothelial protection. Often, if the fragments are large, they may mechanically rub against the pupil margin during removal and this may cause progressive miosis. Thus, the right combination of technique, surgical technology and viscoelastics can ensure predictable outcomes in dense cataracts time after time. Reference 1. Vasavada AR, et al. Multilevel chop technique. J Cataract Refract Surg. 2011;37:2092-4. 'FKVQTUo PQVG &T 8CUCXCFC FGENCTGF PQ TGNGXCPV ƂPCPEKCN KPVGTGUVU ASIA-PACIFIC PERSPECTIVES Vaishali Vasavada, MD Consultant Ophthalmologist, Raghudeep Eye Hospital ÕÀՎՏ ,œ>`] Ƃ…“i`>L>` ] ˜`ˆ> vaishali@raghudeepeyeclinic.com Website: www.raghudeepeyehospital.com