EyeWorld India June 2015 Issue

42 EWAP CATARACT/IOL June 2015 by Lauren Lipuma EyeWorld Staff Writer Complex cataract pearls Expert tips for handling difficult phaco cases W hether it is pseudoexfoliation syndrome, white cataracts, or a floppy iris, complications can easily turn a routine cataract surgery into a challenging one. With proper preoperative planning and careful intraoperative techniques, however, cataract surgeons can achieve successful outcomes even in the most difficult cases. Speaking at the 2014 Combined Ophthalmic Symposium, W. Barry Lee, MD, FACS, cornea service, Eye Consultants of Atlanta, and medical director, Georgia Eye Bank, Atlanta, shared his top pearls for operating on complex cataracts. Assess phacodonesis preop- eratively In cataracts with a history of trauma, look for phacodonesis preop, Dr. Lee said. Having the patient abduct the eye and quickly recenter can often show movement of the lens at the slit lamp; however, signs of phacodonesis can often be subtle. Look for evidence of vitreous prolapse, iris sphincter damage, or poor pupil dilation as well. Looking for these signs before surgery can help you decide if you need to use an extracapsular extraction technique rather than phaco, he said. Be prepared for floppy iris Prepare yourself to handle intraoperative floppy iris syndrome (IFIS) by accurately assessing the patient’s risk preoperatively, Dr. Lee said. Ask male patients if they have prostate issues, and ask all patients about bladder dysfunction. If there is good pupil dilation in the presence of iris prolapse, inserting just one iris hook subincisionally can prevent further prolapse and damage to the iris throughout the case, he added. If pupil dilation is poor, you have the option of using 4 iris hooks or iris expansion devices, Dr. Lee said. His preferred device is a Malyugin ring (MicroSurgical Technology, Redmond, Wash.), and he recommends becoming familiar with efficient placement and removal in these situations. Tackling the capsulorhexis Dr. Lee offered several pearls for creating the capsulorhexis on a white cataract. First, remember to keep the anterior chamber pressurized. “Sometimes you try to be efficient and you don’t think to stop and reinflate the anterior Views from Asia-Paci c LU Yi, MD Professor, EYE and ENT Hospital of Fudan University 83 Fenyang Road, Shanghai, China Tel. no. +086-13816880546 Fax no. +086-021-64377151 luyi0705@126.com B asically, I agreed with Dr. Lee on his tips for handling dif cult cataract cases. Dr. Lee provided useful tips for the recognition of lens subluxation before cataract surgery. Still, not all subluxation cases can be diagnosed before cataract surgery, even with careful and comprehensive examination. Therefore, for cases with a risk of lens subluxation, e.g. those with a history of trauma, we would have the capsular tension ring prepared, and also take other surgical plans into account, including the suture xation of IOL or the implantation of iris clip IOL in case no stable capsule is available (I prefer suture xation of posterior IOLs over iris clip IOLs for better stabilization). Phaco can be performed by experienced surgeons in most subluxation cases. Only in a case with a very hard nucleus would I perform extracapsular extraction rather than phaco. And in cases with complete luxation of the lens, intracapsular extraction technique will be used. I agree that the most important thing to handle the intraoperative oppy iris syndrome (IFIS) is to assess the patient’s risk preoperatively. Surgeons should be aware of patients with a high risk of IFIS, fully dilate the pupil, and try to avoid any pause in the surgery, performing the surgery as consistently and quickly as possible. Most patients with a risk of IFIS can still present with good pupil dilation, and experienced surgeon can perform phaco quickly enough before severe miosis of the pupil sets in. For cases with poor pupil dilation, iris hooks are helpful. Editors’ note: Dr. Lu declared no relevant nancial interests.