EyeWorld India December 2014 Issue

12 December 2014 EWAP FEATURE burn is certainly possible with the prechopper,” Dr. Pettey said. In cases of mild wound burn, a simple suture will suffice, he noted. However, if there is significant gape resulting in visually debilitating astigmatism, he recommends suturing filler tissue such as amniotic membrane into the wound with the intention of sealing it. Then it is just a matter of the epithelium closing over the top. With dense lenses, one heightened concern postoperatively can be corneal edema. Keeping this in mind, Dr. Pettey increases the frequency of Pred Forte (prednisolone acetate, Allergan, Irvine, Calif., U.S.) use in dense cataract cases. He also sometimes uses Durezol (difluprednate ophthalmic emulsion, Alcon, Fort Worth, Texas, U.S.) to quell persistent postoperative inflammation for those who he thinks are not compliant with the Pred Forte regimen. Dr. Pettey waits between 8 and 12 weeks before he is willing to consider referring a patient for DSEAK. Promising pearls To help ensure the best outcomes, Dr. Pettey recommends having a plan for different types of dense lenses. For any ultra dense lenses, he recommends use of trypan blue. This enables him to spot a capsule problem quickly. He also advises practitioners to have both a cohesive and a dispersive viscoelastic on hand. “I’ll use them very deliberately in the case depending on what the need is at the time, whereas in normal cases, I typically only use DisCoVisc [Alcon] or even an Amvisc [Bausch + Lomb, Bridgewater, NJ, U.S.],” he said. Meanwhile, Dr. Page prefers to use a truly dispersive viscoelastic in these cases to protect the endothelium. In normal cases, he usually uses a combined dispersive cohesive viscoelastic at this stage. Because these dense cases tend to be a bit longer, he urges practitioners to frequently reapply the dispersive viscoelastic throughout the removal process because it can wash away. Dr. Page also stressed the importance of being careful of post occlusion as the dense lens can be larger than the average cataract. When using a peristaltic system to help combat this, he recommends dropping the volume down by 100 mmHg when working on the last nucleus segment. Going forward, Dr. Page is optimistic that removal of dense cataracts will become easier with the aid of the femtosecond laser. “Probably one of its greatest applications would be in assisting us with dense nuclei,” he said. In these dense cases, he tightens the fragmentation pattern from a standard of 500 µm down to around 250 or 300 µm to further soften the lens. “I think that’s a significant contribution of the femtosecond laser,” he said. EWAP Editors’ note: Dr. Page has financial interests with Abbott Medical Optics (Santa Ana, Calif., U.S.) and Bausch + Lomb. Dr. Pettey has financial interests with MicroSurgical Technology (Redmond, Wash., U.S.). Contact information Page: TPageMD@yahoo.com Pettey: jeff.pettey@hsc.utah.edu “I generally put them in after I’ve taken the lens and the cortex out,” said Dr. Hart. IOL choice Since accommodating lenses depend on normal capsule-zonule function and multifocal, toric, and aspheric monofocal lenses depend on good centration, these lenses are contraindicated in pseudoexfoliation patients, said Drs. Hart, Gedde, and Giaconi. The surgeons also tend to use 3-piece IOLs more often than 1-piece IOLs because they are more rigid and can be more easily fixated if the lens dislocates. One-piece lenses tend to tilt and torque when sutured into place, said Dr. Hart, which can cause vision problems later on for the patient. “Soft 1-piece acrylic lenses are easy on the zonules during lens placement intraoperatively so they avoid additional stress on the zonules, but they don’t resist capsular contraction very well,” Dr. Giaconi said. “The 3-piece lenses can resist capsular contraction, at least in the areas of the haptics, more than the 1-piece lenses.” Postoperative implications “These patients can have great vision postoperatively, but one must be aware that this can change over time since the zonulopathy is progressive,” Dr. Giaconi said. As a result, pseudoexfoliation patients must be followed closely to monitor IOL position as well as to check for inflammation and elevations in IOP—often for life. “Complaints of decreased vision after cataract surgery in pseudoexfoliative eyes aren’t always due to posterior capsule opacity, as they are in many pseudophakic eyes,” Dr. Giaconi said. If the patient has vision problems, the surgeon must look specifically for lens subluxation or dislocation and correct the problem as soon as possible. Dr. Gedde uses topical steroids more frequently and for a longer duration in pseudoexfoliation patients, as abnormalities in the blood-aqueous barrier make them more prone to postoperative inflammation. Pseudoexfoliation is a risk factor for glaucoma, so IOP should also be monitored after surgery. “Combined cataract and glaucoma surgery may be indicated in select patients with pseudoexfoliation, depending on the IOP level, medication tolerance, stability of glaucoma, and degree of glaucomatous damage,” Dr. Gedde said. With these considerations, close monitoring of the patient after surgery is essential to track the progress of the disease and address any complications that may arise. EWAP Editors’ note: The physicians have no financial interests related to their comments. (Sunnyvale, Calif., USA). Dr. Lorente has no financial interests related to this article. Dr. Malyugin has financial interests with MST. Contact information Hart: j.c.hartjr@sbcglobal.net Gedde: sgedde@med.miami.edu Giaconi: Giaconi@jsei.ucla.edu Cataract - from page 9 Cracking - from page 11