EyeWorld India June 2015 Issue

43 EWAP CATARACT/IOL June 2015 Views from Asia-Paci c Soosan JACOB, MS, FRCS, DNB Director and Chief, Dr. Agarwal’s Refractive and Cornea Foundation Dr. Agarwal’s Group of Eye Hospitals 19, Cathedral Road, Chennai, TN, India; PIN-600086 Tel. no. +91-44-28112811 dr_soosanj@hotmail.com I would like to congratulate Dr. Lee on his astute observations and the tips he has shared with the readers. Subluxated cataracts are always a challenge and I agree with Dr. Lee on the need to identify the condition preoperatively and plan for surgery accordingly. Depending on the degree of subluxation, there are various options right from phacoemulsi cation with a CTR for mild degrees of non-progressive subluxation to scleral xation of the bag–IOL complex for moderate subluxation. My personal preference in subluxations that extend greater than one quadrant is via a device that I term the glued capsular hook for sutureless trans-scleral xation of the bag–IOL complex. This technique utilizes a capsular hook that is passed trans- sclerally under a lamellar scleral ap to engage the margin of the rhexis. It is then trimmed and tucked into an intrascleral Scharioth tunnel followed by gluing the ap down. This allows sutureless scleral xation, easy intraoperative centration of the bag–IOL complex and allows easy surgery. For dangling cataracts, cataract extraction followed by glued IOL is my personal preference. For patients with endothelial dystrophy, my personal approach is to perform cataract surgery and, if required, to combine it with pre-Descemet’s endothelial keratoplasty (PDEK). This transplants the newly described pre-Descemet’s layer (PDL) along with the Descemet’s membrane and endothelium. PDEK offers two major advantages over DMEK: the ability to use young donor corneas of any age (personal experience with corneas as young as 1 year) thereby increasing the number of endothelial cells that can be transferred and the robust, tough nature of the PDL that prevents the graft from tearing. Editors’ note: Dr. Jacob has a patent pending for modi ed versions of the glued capsular hook. chamber with viscoelastic,” he said. “So take a break, don’t worry about speed, and take a moment to reinflate [the anterior chamber].” Use trypan blue and beware of the Argentinian flag sign, Dr. Lee added. “I like to fill my incision with viscoelastic so it traps the trypan blue in the anterior chamber and doesn’t leak out as much,” he said. To prevent the Argentinian flag sign, take a 19-gauge or 21-gauge needle to make the initial opening into the anterior capsule and aspirate some of the fluid, he said. If the capsule does tear, make sure to stop and refill the chamber with viscoelastic before you do anything else—refilling the chamber can help to save the rhexis in those situations, he said. Additionally, do not place a 1-piece lens in the sulcus after an anterior capsule tear. If a large anterior tear is noted, a 3-piece lens can be placed in the sulcus with orientation of the haptics 90 degrees away from the tear. Making a reverse rhexis can also be helpful when the rhexis starts to tear out, Dr. Lee said. Using a cystotome needle, nick the capsule just opposite to where the rent is, find the initial starting point, and tear the opposite way, he said. “This can save you on some of those tough cases.” Operating on patients with Fuchs’ dystrophy Fuchs’ dystrophy patients are at risk for needing endothelial keratoplasty (EK) even with intermediate-grade disease, so leave these patients myopic and avoid hydrophilic IOLs, Dr. Lee said. EK procedures leave patients hyperopic, even with advanced surgical techniques. “Even with DMEK we still see hyperopic shifts, anywhere from –0.5 [to] –1 D,” Dr. Lee said. Aim for about –0.50 [to] –1 D of residual myopia if you think the patient will need EK surgery in the future, he said. IOL opacification has also been described in Fuchs’ patients who have undergone DSAEK (Descemet’s stripping automated endothelial keratoplasty) after cataract surgery. The opacification is due to hydroxyapatite deposition on the IOL surface as a result of a reaction to the air bubble, Dr. Lee said. It occurs in the center of the visual axis and often requires an IOL exchange, he said, so avoid placing hydrophilic IOLs in Fuchs’ patients to circumvent this problem. EWAP Editors’ note: Dr. Lee has no financial interests related to his comments. Contact information Lee: lee0003@aol.com