EyeWorld India December 2014 Issue

66 EWAP NEWS & OPINION December 2014 Dr. Amar Agarwal, Chennai, India, described the pre-Descemet’s endothelial keratoplasty (PDEK) procedure he developed following the discovery of the Dua layer by Dr. Dua, Nottingham, UK. Dr. Agarwal has modified the procedure to use his glued IOL technique. The glued IOL, he said, can be used to act as a trampoline pushing the air up against the graft. Dr. Keiki Mehta, Mumbai, India, has called the PDEK procedure potentially the definitive iteration of EK. Day 4: Sunday, 16 November 2014 Jewels of Jaipur The 27th APACRS annual meeting closed with its customary closing symposium in which the best minds at the meeting offered their “Top Cataract and Refractive Surgery Gems.” The raison d’être of the symposium is to ensure that attendees bring home at least one surgical pearl that they can apply the very next day at their respective clinics and surgical theaters. At the end of the symposium the audience voted for their favorite pearl. The audience highly favored a cataract surgery pearl from Dr. Pangputhipong, Bangkok, Thailand. He described his technique for “The Best Wound Closure.” He constructs the primary cataract incision as a leaf valve that he closes intraoperatively by inflating the bag with the irrigation line, causing the internal lip of the incision to press against the ceiling. To ensure a safe IOP of around 30 mmHg, he also lowers the bottle height to 50 or 60 cm. In addition, he recommends doing 1-site as opposed to the typical 2-site stromal hydration, performing the hydration closer to the lip in the middle rather than at both ends ensuring a better seal. Jewels - from page 64 However, it was Dr. Chee, Singapore, who gave the audiences their favorite cataract surgical pearl. She gave a tip for managing intumescent cataracts. With these cataracts, she said, visualization is often difficult. The capsule can be very thin and fibrotic, the bag highly pressurized, and the cortex can spill out a cloudy fluid further obscuring visibility in the anterior chamber once the capsule is ruptured during the initiation of the rhexis. There is also a risk for rhexis runaway even despite bag decompression. To avoid complications during rhexis, Dr. Chee first recommends using IV mannitol to shrink the vitreous, reduce posterior vitreous pressure, shrink the swollen lens, and decrease IOP. During surgery itself, she demonstrated her “stroke” technique: using a viscoelastic canula, she stroked the anterior capsule to flatten it before initiating capsulorhexis. Each stroke can be accompanied by injection of OVD to help press the capsule down. Among the refractive surgery pearls, the audience favored a LASIK flap tip given by Dr. Chan Wing Kwong, Singapore. During LASIK, the flap is typically reflected and laid on the sclera. However, this is difficult in small eyes, in which surgeons typically put the flap on the eyelid and speculum. This increases the risk of flap dessication. Dr. Chan suggested tucking the flap under the upper lid, eliminating the risk of flap dessication and ensuring full reflection throughout ablation. The one caveat to the technique is that the eyelids should be draped and the flap irrigated thoroughly to make sure it is clear of meibomian gland secretions. The audience’s favorite refractive surgery pearl was provided by Dr. Ganesh, Bangalore, India. Dr. Ganesh said that while IOL manufacturers frequently change their lens designs, they do not actually change recommendations for using viscoelastic with those lenses. With the introduction of IOLs with a central hole, Dr. Ganesh examined the standard company recommendation for using HPMC rather than hyaluronic acid. IOL manufacturers have long recommended using HPMC because hyaluronic acid used to get trapped under the lens. With the central hole, Dr. Ganesh found that it was actually much easier and quicker to aspirate hyaluronic acid than HPMC—22 seconds versus around 3 minutes, respectively. Dr. Ganesh’s pearl, however, extended beyond this specific case. He said that surgeons should change their thinking whenever there is a change in the designs of the IOLs they use in order to ensure the utmost efficiency of their surgery. Dr. Chee and Dr. Ganesh each received a 1-Tb portable external harddrive for their pearls. The symposium marked the end of the 27th APACRS annual meeting. “It’s been fantastic, everyone has done such an excellent job,” APACRS President Dr. Barrett, Perth, Australia, said. “Thank you very much, India, you should be very proud.” EWAP