17 EyeWorld Asia-Pacific | September 2024 EDITOR’S PICKS Selected cataract surgical tips presented at the Wisdom of the Kung Fu Masters symposium The Recommended Technique The OVD cannula tip is placed just inside the lip of the corneal incision and OVD is injected away from the incision filling the anterior chamber, ‘trapping’ the intracameral anesthetic in the anterior chamber, significantly enhancing patient comfort. Patient Selection Not all patients are suitable for TA. If you are considering transitioning, topical anesthesia works best with clear corneal incisions. It is best to avoid challenging or difficult cases which are likely to require a longer operating time. I’d recommend in the early stages avoiding eyes with dense cataract, weakened zonules, a poorly dilating pupil, or shallow anterior chamber. Patients with anxiety/claustrophobia, nystagmus, severe dementia or developmental delay and language barriers need to be carefully assessed to determine the most appropriate anesthetic technique. Surgical Technique Reasonable surgical speed is required as patient comfort and cooperation decrease exponentially, the longer the process of surgery carries on. Other tips: avoid excessive light by initially dimming the illumination of the operating microscope, so that the patient is not startled by the bright light at the beginning of the procedure. Use a Liebermanstyle speculum to avoid excess eyelid pressure; minimize instrumentation and frequent inflation of the Anterior Chamber (AC) as pressure fluctuation is a common cause of patient discomfort. Also, develop a conjunctival ‘notouch’ technique (avoid forceps or fixation rings). It is helpful to avoid talking to your patient too much during surgery, as this avoids sudden re-fixation movements when the patient responds. The eye assumes a neutral position when the patient is in a relaxed ‘dreamy’ state. Occasional updates on the surgery, e.g. “I’ve safely removed the cataract and I’m polishing the capsule before implanting the intraocular lens” and reassuring comments that “all is going well’ and “not long to go” are sufficient, and provide the most comfort. Reference: 1. Roberts TV et al (2008). Adverse medical events associated with cataract surgery performed under topical anaesthesia. Clin Exp Ophthalmol. 2008 Dec;36(9):8426. doi: 10.1111/j.1442-9071.2009.01924.x. PMID: 19278479. 2. Minakaran N et al (2020). Topical anaesthesia plus intracameral lidocaine versus topical anaesthesia alone for phacoemulsification cataract surgery in adults. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD005276. DOI: 10.1002/14651858.CD005276.pub4. Accessed 13 July 2024 3. Roberts TV et al (2002). A comparison of cataract surgery under topical anesthesia with and without intracameral lignocaine. Clinical and Experimental Ophthalmology 2002;30(1):19-22. [PMID: 11885789] Editors’ note: This article focuses on cataract surgical tips selected by the EyeWorld Asia-Pacific Editors, and it is not intended to be a full report on all the tips presented at the Wisdom of the Kung Fu Masters symposium. About the Physicians Ishtiaque Anwar, MD | Consultant (Cataract & Refractive Surgery), Bangladesh Eye Hospital & Institute | ishtiaqueanwar1976@gmail.com Naren Shetty, MD | MS Ophthalmology, H.O.D Cataract & Refractive Narayana Nethralaya | Narayana Nethralaya, Bangalore, India | narenshetty.27@gmail.com Thanapong Somkijrungroj, MD | Vitreoretinal Research Unit, Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand | thanapongmd@gmail.com Tim Roberts, MD | Clinical Associate Professor of Ophthalmology, The University of Sydney School of Medicine, Faculty of Medicine and Health, Consultant Ophthalmic Surgeon, Royal North Shore Hospital, Vision Eye Institute, Sydney | tim.roberts@vei.com.au Relevant Disclosures Anwar: Zeiss Meditec Shetty: Alcon, Zeiss, Johnson & Johnson, Bausch and Lomb, Casulaser Somkijrungroj: ALCON, Zeiss Roberts: None
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