EyeWorld India June 2017 Issue

June 2017 EWAP NEWS & OPINION 11 mentioned several caveats to the technology. The advantage of circularity, sizing, and strength, however, result in more accurate outcomes, Dr. Packard continued, leading to the creation of other devices to create the capsulotomy. CAPSULaser (Los Gatos, California, U.S.) which works by staining the anterior capsule, creating a selective target for a continuous laser, which is applied while the patient wears a contact lens, creates laser energy that facilitates a molecular phase change. The resulting capsulotomy has a high degree of elasticity and strength. In fact, Dr. Packard said studies show it has a 50% greater stretch compared to the manual capsulotomy. CAPSULaser has been used to create the posterior capsulorhexis in the lab and will begin human trials soon, he added. The CE Mark trial for the device, which included 124 eyes, is complete, with results expected in September, Dr. Packard said. Other devices for capsulotomy creation include Zepto (Mynosys, Fremont, California, U.S.)—a nitinol ring and suction cup, placed on the capsule through a 2.5–mm incision, which uses multipulse energy to cause a phase transition in water molecules to create the cut—and ApertureRx (International Biomedical Devices, North Charleston, South Carolina, U.S.)—similar in design to Zepto but without the suction ring. ApertureRx has not been used clinically, Dr. Packard said, and Zepto has received the CE Mark. Wrapping up the symposium, Boris Malyugin, MD, PhD , Moscow, Russia, presented on pupil expansion devices, specifically iris hooks and the Malyugin ring, which he said should be used at the “end of the decision tree” after other forms of pupil dilation have failed. While hooks are easy to implant and are useful in cases of small pupils or weak zonules, Dr. Malyugin said one has to be careful to not overextend the eye. Hooks also create a square pupil with the tendency to overstretch or traumatize the pupil. “That’s why I designed several years ago the Malyugin ring,” Dr. Malyugin said. The original Malyugin Ring (MicroSurgical Technology, Redmond, Washington, U.S.) comes in a 6.25 and 7 mm size, it is inserted through a 2.4–2.5-mm incision, and gives eight points of iris retention, which avoids overextending the pupil. “This device was quite successful,” Dr. Malyugin said, noting that it has been used in 1 million cataract surgeries. “But innovation never stops.” The newer Malyugin Ring 2.0 can be inserted through a 2-mm incision. Its 5-0 polypropylene material makes it more flexible, which causes less compression to the iris tissue. The two ring designs have identical profiles, but the scroll depth of the newer version is bigger and provides easier engagement and disengagement of the ring. While there is 30% less compression force with the new ring vs. the original, Dr. Malyugin said he will still use the original in cases of fibrotic pupils. With either device, Dr. Malyugin operates under topical or injected lidocaine to avoid unwanted insertion. He injects an OVD bolus under the iris at the four scrolls of the device before insertion to lift it above the anterior lens capsule. When removing the ring, he presses on the lateral scrolls before they merge together, which Dr. Malyugin said helps them slide easily into the injector. Spirit of APACRS embodied by ‘Kung Fu Masters’ At its annual meetings, the APACRS constantly strives to provide attendees with a concise yet comprehensive, always practical, and ultimately relevant educational experience, packing as much useful content as it can in a svelte 3 days. In that sense, “Wisdom from the Kung Fu Masters,” the final session of the 30th APACRS Annual Meeting, best embodies the meeting’s spirit. At this symposium, experts were asked to share surgical tips any surgeon can apply the very next time they visit the operating room, tips that, rather than showing off each master’s skill, instead give away some of the secrets to their apparently arcane mastery. Gaurav Luthra, MD , Dehradun, India, kicked off with a pair of tips to manage small pupils without iris hooks or rings. First, inserting a cannula through a side port, an injection of BSS enlarges the pupil. Second, in case of floppy iris, pull out of the eye and allow the aqueous to escape. Going back in, distend the chamber with BSS. If some aqueous redirection caused the pupil to constrict, it should now expand with ease. Dr. Luthra also offered tips to manage leaky incisions. Using trypan blue to identify leaky incisions, he demonstrated the use of supraincisional tunnels or small pockets made above the leaky incisions. These tunnels or pockets can be hydrated to help seal the incisions over which they lie. Kendall Donaldson, MD , Plantation, Florida, U.S., demonstrated the “modified chip and flip” or “upside down chop” technique for soft cataracts. Often at these meetings, she said, the focus is on hard cataracts, but soft cataracts can be just as challenging. In the modified chip and flip, after the cataract is broken into two hemisections, the chopper is exchanged for a smooth, flat instrument such as a Koch spatula. The surgeon slips it under the nucleus and cracks upward, then essentially folds each piece over into the phaco handpiece. The instrument stays within the capsular bag, going under the nuclear material, and up to crack. Chee Soon Phaik, MD , Singapore, shared her technique for inserting a premium IOL into the bag even after a posterior capsule tear. How often have you had to give up a premium IOL for a 3-piece because of PCR? she asked. Instead of switching immediately to a 3-piece, first inject OVD to create space. Inject the desired premium IOL into the sulcus or anterior chamber, rotating it to the desired axis. Then, to place the IOL into the bag, gently flex each haptic near the optic–haptic junction to ease the IOL into the bag. The technique can even be used for plate haptics, though the optic will require additional support. Hadi Prakoso, MD , Jakarta, Indonesia, gave the audience’s second favorite tip. In case your knife doesn’t seem as sharp as it should be, Dr. Prakoso suggested putting pressure on the cornea to, not create counterforce, but raise the IOP slightly to make the cornea stiffer, more rigid, making it easier to make an incision. Guo Hai-ke, MD , Guangdong, China, gave the audience’s favorite tip. In dealing with a small pupil, Dr. Guo showed how the surgeon can still make a CCC beyond the diameter of the pupil. He then proceeded to perform phacoemulsification through the small pupil, using his second instrument to protect the iris. EWAP