EyeWorld India December 2018 Issue

by Liz Hillman EyeWorld Senior Staff Writer Preparing for anterior vitrectomy Proper planning and practice can result in positive outcomes T here’s a saying that “the only surgeon who doesn’t have complications is the one who doesn’t operate.” It’s a saying that John Hovanesian, MD , Harvard Eye Associates, San Clemente, California, cites, espe- cially as it applies to complica- tions during cataract surgery that might require anterior vitrectomy. “Every surgeon needs to have some basic vitrectomy skills in order to handle what may arise in the operating room,” Dr. Hov- anesian said. “It’s a skill that we think of with a little bit of dread because of the situations where it arises, but it’s something we can’t wish away.” The most common need for anterior vitrectomy occurs when the posterior capsule is opened, inadvertently, during cataract sur- gery and vitreous presents itself into the capsular bag or anterior chamber, Dr. Hovanesian said. Charles Weber, MD, EyeHealth Northwest, Portland, Oregon, and adjunct assistant professor, Moran Eye Center, University of Utah, Salt Lake City, said the most common situations to necessitate anterior vitrectomy in his prac- tice are subluxated and dislocated lenses. “These cases might already have vitreous presenting to the anterior segment preoperatively, vitreous presenting anteriorly intraoperatively, or a high enough risk of postoperative vitreous pro- lapse to necessitate vitrectomy,” Dr. Weber explained. Nicole Fram, MD , Advanced Vision Care, Los Angeles, said that while the unplanned situations that require anterior vitrectomy are stressful, understanding the basic principles of how to handle these cases will improve patient safety and help ensure a positive result. In any case, Dr. Hovanesian said thorough cleaning up of vit- reous is necessary before implant- ing an IOL in order to leave the eye with a round pupil and reduce the risk of cystoid macular edema and other complications. The first thing to do when vitreous presents itself intraop- eratively is to stop and take stock of the situation, leaving in any instruments already in the eye, Dr. Hovanesian said. “You want to have flow natu- rally moving from the anterior chamber to the posterior segment, so if you’ve got a phaco needle in the eye and you’ve got irriga- tion on, that’s usually good,” he explained. “You should leave it on until you can exit the eye. Often, putting a second instrument through a side port allows you to infuse fluid or viscoelastic before removing the phaco instrument or whatever instrument is in the main incision. That keeps the positive pressure, and it prevents unnecessary movement of vitre- ous forward.” Dr. Weber said he always uses micronized triamcinolone—a 1:10 dilution with balanced salt solu- tion—in cases where vitreous is present in the anterior chamber, or if there is enough concern that its presence or absence should be verified. “The risk of postoperative complications secondary to unad- dressed vitreous within the ante- rior segment requires a surgeon to rule out the presence of vitreous,” he explained. Dr. Fram also said she rou- tinely stains the capsule to visualize vitreous strands, using preservative-free triamcinolone diluted 1:10 with balanced salt solution. She added that she usually performs the bulk of the vitrectomy first, using a bimanual approach, then stains to identify any remaining strands. “There are two reasons to consider the use of preservative- continued on page 38 EWAP CATARACT/IOL 35 December 2018