EyeWorld India March 2016 Issue

47 EWAP Cataract/IOL March 2016 small incision cataract surgery (MSICS) is a great first step, Dr. Oliva said. For the types of cataracts that physicians encounter in many parts of the world, the MSICS outcomes are equivalent to phacoemulsification—at a fraction of the cost, he said. Drs. Oliva and Ambati agreed that donating time for service, training ophthalmologists in other countries, and raising awareness among their patients about the problem are 3 things that any cataract surgeon can do. “I encourage individuals to serve as ambassadors for promoting cataract surgery in the world and publicizing the huge number of blind patients needing cataract surgery,” Dr. Oliva said. “Many of our happy cataract patients here at home can be recruited to donate toward eliminating needless blindness in the world.” Pearls for operating in the field Posterior capsule rupture, vitreous loss, zonular dialysis, and iris prolapse can all happen in the field, Dr. Ambati said, and hard cataracts can make removal difficult and lead to corneal edema. Trypan blue, Malyugin rings, capsule tension rings, a good chopper, and knowing how to do MSICS would all be great skills to have in one’s armamentarium, he said, and retrobulbar blocks are helpful when there is a language barrier. Although surgeons experienced with MSICS can have very low complication rates, it is important to work with experienced surgeons as part of a team and always work with local partners, ideally as part of a comprehensive ophthalmic system that has the capacity to manage complications, Dr. Oliva said. “Always strive to ‘leave no patient behind’ and transport patients with complications from the field to a tertiary care center,” he said. “Having negative outcomes can seriously damage local reputations and dampen surgical demand for years to come.” Dr. Oliva thinks that performing careful biometry in rural or remote areas is undervalued by surgeons. “Most patients in the developing world will never access postoperative spectacles, and therefore doing everything possible to give the best postoperative uncorrected vision is critical,” he said. Strive to create less surgically induced astigmatism by using temporal incisions with MSICS rather than superior incisions, he added. Dr. Oliva’s and Ambati’s experiences show that combating blindness with effective and inexpensive treatments would have a huge return on investment, and individual surgeons can do much to further this effort. “Cataract blindness can be beaten if experienced surgeons donate their time not only to perform services but also to train surgeons in other parts of the world, and if local governments put resources into programs that fight blindness,” Dr. Ambati said. EWAP Editors’ note: Drs. Ambati and Oliva have no financial interests related to this article. Contact information Ambati : bala.ambati@utah.edu Oliva : moliva@cureblindness.org promotes greater difficulty sealing as well as iris prolapse. Perhaps a simple approach with a predictable incision length with the straight in and out methods makes it easier to achieve just the right length, but no doubt the other methods, with experience, could achieve the same. The third question was, “Do you check incision integrity prior to taking steps to seal, i.e., if leak proof, leave it alone?” Yes 48% No 52% Say you have finished the case completely and inflated the globe, and when checking the main clear cornea incision, it is bone dry. What to do? On the one hand, to “fix it,” i.e., seal with your preferred methods, does take time and potentially could make it worse, reminding us of the advice “If it ain’t broke, don’t fix it.” On the other hand, your normal seal method takes only a moment, and perhaps it will enhance security even more and promote a more lasting seal for the overnight period. The responses show an essentially even split on this. The fourth question was, “How do you seal your incision, first attempt?” Hydrate side(s) of incision 63% Hydrate roof of incision 15% Hydrate supraincisional pocket (“Wong” incision) supraincisional pocket (“Wong” incision) 7% Suture always 3 Needle hydration of roof 2% Adhesive 0 (The total is less than 100% due to comments regarding combining multiple methods.) The fifth question was, “What initial incision width, in millimeters, do you use for the phaco procedure?” 1.8 3% 2.0 2% 2.2 18% 2.3 1% 2.4 35% 2.5 5% 2.6 5% 2.65 2% 2.7 4% 2.75 9% 2.8 6% 2.85 2% 3.0 1% 3.2 2% Selection of incision size has to do with the particular phaco instrumentation you have at hand, the minimum incision size compatible with your favored intraocular lens inserter, and your personal feelings as to what is a more “sealable” incision and with minimal influence on astigmatism. I’ve personally found the 2.2 incision to be a pleasing compromise of all factors and continue to use it after a period of using a 1.8 mm incision proved to result in more difficult-to-seal incisions, no doubt related to wound stretch and small tears during phaco and IOL insertion. As you can see, there is a great deal of diversity in methods here. EWAP Editors’ note: Dr. Gossman is in private clinical practice at Eye Surgeons & Physicians, St. Cloud, Minn. He has no financial interests related to this article. Contact information Gossman: n1149x@gmail.com How are we constructing - from page 43