EyeWorld India December 2018 Issue

pupil, which is a technique Robert Osher, MD, has called viscomydriasis. “We can then make the capsu- lorhexis right at the pupil margin or, even better, just underneath it,” Devgan said. “Most experienced surgeons can make the capsu- lorhexis larger than the pupil with- out directly visualizing it.” Dr. Devgan used balanced salt solution to hydrodissect the nucleus out of the capsular bag and tilt it into the iris plane. The iris sphincter held the nucleus in place while he used a phaco chop tech- nique to emulsify and aspirate it. “This technique brings the nucleus out of the capsular bag in order to minimize stress on the zonules,” Dr. Devgan said “Even in cases in which there is zonular lax- ity, this supracapsular technique can be safer than intracapsular techniques such as divide and conquer.” Due to the shallowness of the anterior chamber, Dr. Devgan performed as much of the phaco- emulsification as possible at the iris plane. Another key to good outcomes in this patient was to ensure that the zonules were secure when he removed the cortex. That involved watching the edge of the capsu- lorhexis during cortex removal for any signs of movement in the capsule or capsulorhexis. “Take your time on this part; it should be done in slow motion even,” Dr. Devgan said. A pseudoexfoliation case for cataract surgery Deposits of pseudoexfoliative material identi ed preop in a cataract patient Range of deposits of pseudoexfoliative material identi ed in a preop exam Use of bilateral choppers to manually and gently stretch the pupil A zone of clearance on the anterior lens capsule stemming from the iris margin clearing the surface of the anterior capsule to remove pseudoexfoliative deposits in the ring-shaped area. Source: Uday Devgan, MD A full instructional video with narration of this case can be seen at www.CataractCoach.com . Postop keys Dr. Devgan added preservative-free triamcinolone (0.5–1 mg) in the anterior chamber at the end of sur- gery to quell the inflammation. Due to weak zonules, patients with pseudoexfoliation face the risk of capsular phimosis in the months or even years postop. When normal capsule contraction occurs, the opening in the capsule can become very small and the lens may dislodge. In the postop months in such patients Dr. Devgan looks for ex- cessive contraction on the capsule. If that occurs, he performs a YAG laser of that anterior capsule to break the phimotic ring. Another long-term precaution is to watch for progressive zonular weakness, which could allow a complete dislocation of the lens and capsular bag into the vitreous. “This patient had a beautiful outcome,” Dr. Devgan said. “It showed that with proper planning and certain techniques we can do a beautiful job on patients with pseudoexfoliation, and it’s not too much of a burden for us.” EWAP Editors’ note: Dr. Devgan is a princi- pal in www.IOLcalc.com and www. CataractCoach.com. Contact information Devgan: Devgan@gmail.com Overcoming challenges – from page 51 52 EWAP CATARACT/IOL December 2018