EyeWorld India March 2014 Issue

March 2014 13 EWAP FEATURE that point and proceeding, versus thinking, ‘I just want to get out of here,’” Dr. Condon said. Then, move on to determine the full situation, he said. “Look at what you have to deal with and say, ‘I want to go through the pars plana here because I have a bunch of vitreous up here extending into the anterior chamber wound,’” Dr. Condon said. “That’s versus, ‘I think I have a little small opening in the posterior capsule; I’m going to tamponade that with some viscoelastic, maybe put the lens in the eye because I have good enough capsule support or zonular support to do that.” “Then at the end, it’s a micro-clean up, which might be a perfectly appropriate time to remove viscoelastic with a vitrector from the anterior chamber, and remove any little strands of vitreous,” he said. This is where a 23-gauge limbal vitrectomy incision has advantages, he said, because “you don’t want to go in with high aspiration flow rates to remove residual viscoelastic for fear of inviting more vitreous prolapse.” Vitrectomy instrumentation is highly effective at removing viscoelastic agent in cases that are precarious and where further vitreous prolapse has to be avoided, he said. Dr. Fine said that if the cataract surgeon thinks that vitreous loss has occurred, he should take a moment to create a plan of action. Stabilize the eye with adjunctive tools, which could include viscoelastic to hold the vitreous back, triamcinolone acetonide to show vitreous, and a capsular tension ring for capsular bag stabilization. But if the cataract surgeon is not comfortable with the outcome of the situation, the next step is to seek assistance, Dr. Fine said. “Prompt referral to your retina colleagues is advisable if there is posterior dislocation of large cataract fragments or the IOL, suspected retinal tear or detachment, or choroidal hemorrhage,” he said. Referring can be a good idea with some cases using the pars plana approach, Dr. Dewey said. “I think what’s most important is if a pars plana approach is performed, then either the operating surgeon needs to be comfortable with a good peripheral retinal examination or refer the patient to someone who is.” Two approaches For the limbal approach, cataract surgeons are often more comfortable because of introducing surgical instruments through corneal incisions, Dr. Fine said. “There is direct visualization of the vitrectomy probe at all times. Utilize a biaxial approach, with the infusion and vitrectomy probe separate,” he said. For the pars plana approach, cataract surgeons can be a little less comfortable, but it has many advantages, including: “The vitreous is drawn posteriorly, minimizing vitreous incarceration in the corneal wounds. Vitreous and retained lens fragments can be more easily removed posterior to the capsule without risking further capsular damage. Posterior levitation of subluxing lens fragments and removal with the cutter can be performed, albeit with caution,” Dr. Fine said. There are dangers to this approach, he said, especially for those surgeons who are not experienced with it. Dr. Condon said he does not want cataract surgeons to overlook the limbal approach because it is effective in the cases that it is indicated. He described the process: “You make the incision in the limbus, put the instrument in, push it all the way down back through the pupil, and then start to vitrectomize. So you’re not doing it in the anterior chamber, you’re doing it in the posterior chamber, but you made the incision to get there in the cornea rather than the pars plana. The pars plana incision is 3.5 mm behind your limbal incision. The difference is the iris is between the two.” Dr. Condon said there is currently a fallacy that going through the limbus pulls vitreous into the front of the eye, but this is not true, and cataract surgeons should not let this dissuade them from using it. “You can go through the limbus, place the tip of the instrument over the optic nerve and do your vitrectomy. It’s the tip of the instrument where the action is happening. So if you place the tip of that instrument far enough posteriorly, it accomplishes the same thing as doing it through the pars plana—it’s all about accessibility of the stuff you want to remove besides the vitreous,” he said. EWAP Editors’ note: The physicians have no financial interests related to this article. Contact information Condon: garrycondon@gmail.com Dewey: deweys@prodigy.net Fine: h_f_fine@yahoo.com Index to Advertisers Shanghai Mediworks Page : 2 www.mediworks.com.cn/en/ Carl Zeiss Southeast Asia Page: 35 www.zeiss.com.sg Topcon Page: 11 www.topcon.com.sg/ Ellis Ophthalmic Page: 19 www.eye-ellis.com Moria Page: 43 www.moria-surgical.com Rayner Intraocular Lenses Page: 24 www.rayner.com/home OCULUS Optikgeräte GmbH Page: 49 www.oculus.de World Ophthalmology Congress (WOC2014) Page 16 www.woc2014.org ASCRS Page 20 , 27 , 31 , 38 www.ascrs.org APACRS Page : 5, 7, 30 , 47 , 52 www.apacrs.org