EyeWorld India December 2013 Issue

26 EWAP CAtArACt/IOL December 2013 Pearls from the Orient by Chiles Aedam r. Samaniego EyeWorld Asia-Pacific Senior Staff Writer Top Phaco Pearls from the 26th APACRS annual meeting in Singapore F ollowing a tradition that began in 2010 in Cairns, Australia, the 26th APACRS annual meeting in Singapore concluded with one of the meeting’s signature sessions: “Top Phaco Pearls”, during which some of the meeting’s top speakers share their most valuable cataract surgery pearls. APACRS president Graham Barrett, MD , Australia, Pannet Pangputhipong, MD , Thailand, Roger Steinert, MD , U.S., and Ronald Yeoh, MD , Singapore, comprised the session’s panel. The audience was asked to choose their three favorite pearls— the ones they thought they were most likely to apply in their operating theaters as soon as the very next day—at the end of the session. But first, a rundown of the nonwinning but no less priceless pearls, in the order in which they were presented. top phaco pearls 1. In cases of posterior capsule rupture with cataract fragments in the anterior chamber, Amar Agarwal, MD , India, suggests performing the intraocular lens scaffold technique, in which, following a vitrectomy, a 3-piece IOL is inserted into the eye to provide—as the name implies—a scaffold for phacoemulsification, eliminating the fear of having fragments fall into the posterior chamber. 2. Presenting for David Hardten, MD , U.S., Dr. Steinert directed surgeons to astigmatismfix.com to help manage problems with malpositioned toric IOLs. Typically, he said, surgeons can actually be more accurate during repositioning than during the initial surgery. 3. Returning to the problem of posterior capsule rupture, this time with a dropped or dropping nucleus, Mohan Rajan, MD , India, suggested that even anterior segment surgeons with little expertise in vitreous surgery can perform either AAL or PAL: anterior assisted levitation or posterior assisted levitation. Don’t chase the nucleus, he cautioned; instead, in some of these cases, these techniques can be very helpful. 4. In an eye that develops cataract after a KAMRA corneal inlay (Acufocus, Irvine, Calif., USA) has been implanted to address presbyopia, surgeons can opt to proceed with standard phaco surgery with the inlay in place, said Damien Gatinel, MD , France. In fact, the inlay can even be helpful, providing a template that the surgeon can trace during capsulorhexis. It makes the procedure a little more difficult, admits Dr. Gatinel, but it is doable, and certainly less invasive than having to explant the inlay first. 5. Sometimes, a pupil fails to dilate because it is held by a membrane that can be stripped, said Dr. Steinert. Unfortunately, as in the case he presented, sometimes even the most careful stripping can create a tear in the anterior capsule. To prevent peripheral extension, Dr. Steinert created other weak spots following the principle of canopener capsulotomies. This may not always be the best approach, but in this particular case, it worked for Dr. Steinert. 6. First year residents, said Sri Ganesh, MD , India, can use a safe, non-contact technique for polishing the posterior capsule called hydropolishing: a 27-gauge cannula attached to a 5-cc syringe is used to clean the capsule. There is no need to use viscoelastic; if the surgeon does want to use viscoelastic to protect the cornea, Dr. Ganesh recommended using a minimal amount to allow the jet of fluid to do its work. Also, instead of an AC maintainer, let the posterior capsule bulge anteriorly to create a shearing effect between the convex surface of the posterior capsule and the fluid jet. 7. Rock hard cataract? Hungwon Tchah, MD , Korea, suggests his own multichop technique, in which a combination of horizontal and vertical chops, chopping and crushing are used to create smaller and smaller fragments out of a hard cataract nucleus, allowing the surgeon to use low phaco power to emulsify the lens. The technique combined with an appropriate dispersive viscoelastic keeps the anterior chamber stable, even when high vacuum is used to hold the lens in place for the multichop. 8. A self-professed newcomer to femto-phaco, Hiroko Bissen- Miyajima, MD , Japan, said she sometimes finds that the femtosecond laser’s initial “crack” doesn’t always go all the way through, sometimes leaving a layer of nucleus or epinucleus somewhat intact. Instead of turning the bevel down or pulling the phaco tip out to inject OVD under the remaining layer (which, she said, could further injure the incision), she suggests a different approach: turning the phaco off and using irrigation, the surgeon can flip the remaining nucleus or epinucleus, allowing the surgeon to then manipulate and phacoemulsify the remaining layer. 9. As the only glaucoma specialist presenting at the session, Shamira Perera, MD , Singapore, advised cataract surgeons dealing with phaco in angle closure cases: “If you fail to prepare, prepare to fail”; the key to