EyeWorld India December 2018 Issue

free triamcinolone,” Dr. Fram said. “One is diagnostic: improved visualization of vitreous strands and understanding of when the vitrectomy is complete; and two is therapeutic: often there is a pro- longed surgical time and increased risk of macular edema postopera- tively. Intracameral use of diluted steroid may help with postopera- tive rehabilitation and decrease risk of prolonged postoperative inflammation.” While Dr. Weber finds the limbal approach is often sufficient for anterior vitrectomy, provided the tip of the vitrector is kept posterior to avoid vitreous traction anteriorly, Dr. Hovanesian said he only uses this approach if the vitreous is very minimal. In other cases, Dr. Hovanesian prefers a pars plana approach, pulling the vitreous back to its more natural space. He said he will put fluid infusion through a limbal incision in the ante- rior chamber, so fluid is flowing into the eye then out of the eye through the pars plana vitrectomy port. “You want to sweep vitreous into the back of the eye,” Dr. Hov- anesian said. Dr. Fram said she prefers to initially use a limbal approach for unplanned anterior vitrectomy during routine phaco. Only after lens fragments are removed and with adequate corneal visualiza- tion would she select a pars plana approach. For planned vitrectomy, such as in the case of reposition- ing an IOL, for example, she rou- tinely uses a pars plana approach combined with a limbal approach prior to intrascleral, scleral, or iris fixation. Dr. Fram always uses a bi- manual approach to vitrectomy, keeping her settings on cut/IA. She uses the Centurion Vision System (Alcon, Fort Worth, Texas) at a 4,000 cut rate, lowering the bottle height and filling the an- terior chamber with viscoelastic or balanced salt solution before removing instruments from the eye to prevent chamber collapse and further vitreous prolapse. “Each surgeon should work within his or her experience and comfort level,” Dr. Fram said. If there is still retained lens material, Dr. Hovanesian said he prefers to remove the vitre- ous that’s in the way and then, inserting viscoelastic to keep the chamber full, use manual irriga- tion/aspiration to remove the re- maining cortex. Dr. Weber said if lens fragments present during the vitrectomy, the surgeon should reduce the vitrector to a low cut rate. Using viscoelastic to fill the anterior chamber prior to remov- ing the phaco tip in the event of a posterior capsule tear can not only prevent further vitreous prolapse, but it can “plug” this hole to allow for safe removal of lens fragments, Dr. Fram said. These fragments Anterior vitrector used to remove residual Soemmering’s ring near the completion of an IOL exchange following secondary IOL placement via double-needle intrascleral haptic xation. Note the lower cut rate. Source: Charles Weber, MD Preparing for anterior – from page 35 38 EWAP CATARACT/IOL December 2018