EyeWorld India September 2018 Issue

10 EWAP FEATURE September 2018 integrity of the eye and to make sure it did not decompress. At 5 days postoperatively, the patient was 20/20. Even when you have the best-laid surgical plans, consider what could go wrong and pre- pare accordingly, Dr. Braga-Mele advised. She also said that using a little “verbal anesthesia” to talk to the patient before going in for the capsulorhexis would have been helpful. She could have asked the patient not to move at that point or she could have told the anesthesiologist to give a bit more sedation. “I learned my lesson,” she said. Avoiding methylene blue When cataract surgeons present challenging cases, there tends to be a lot of focus on how they han- dle them in the moment. What’s shared less often is the long-term management. That led Kevin M. Miller, MD , Kolokotrones Chair in Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, to present the manage- ment of a woman in her 50s who experienced toxic anterior seg- ment syndrome (TASS) and macu- lar edema in the left eye after the intraoperative use of methylene blue in the eye in December 2010, as performed by another surgeon. The patient’s management contin- ues to the present time. “Methylene blue is toxic to the inside of the eye. It’s a fairly easy mistake to make in the OR, especially with nurses floating between rooms,” Dr. Miller said. “If a surgeon doesn’t check, he or she could end up with problems.” Surgeons should make sure trypan blue is used instead for intraocu- lar surgery. Dr. Miller began to see the patient in March 2011. During his various appointments with her, he was able to track her TASS and macular edema. The patient even- tually underwent a Descemet’s stripping endothelial keratoplasty (DSEK), although there was a brief rejection episode when a retina specialist withheld topical corti- costeroids following an intravitreal corticosteroid injection, he said. Various problems encountered by the patient in addition to TASS and macular edema included a slightly higher IOP, abnormal central corneal thickness, and an abnormal endothelial cell count. At her last exam in May 2018, the patient’s vision was 20/30 –2 , compared with nonfunctional vi- sion when she was first seen. “She’s not 20/20, and she may never be,” he said. “For now she’s doing OK, but that may change down the road. She may end up with graft failure and another DSEK at some point.” It’s hard to reassure a patient with acute insults at the initial con- sultation because you do not know what their final outcome will be, Dr. Miller said. He recommended any surgeon managing a difficult situation to be honest but upbeat and to encourage the patient to col- laborate with the physician. The take-home message of Dr. Miller’s case is that some issues will continue for a prolonged time pe- riod. “There’s the acute insult, but then they deal with complications for the rest of their life,” he said. Horizontal approach to laser capsulotomy Richard Tipperman, MD , attending surgeon, Wills Eye Hospital, Philadelphia, treated a 3-year-old girl with bilateral retinoblastoma who was enucle- ated in one eye. She had multiple treatments for the other eye to try and salvage it. “These children all get cataracts, and there is always an issue of whether to open the posterior capsule with a primary posterior capsulorhexis,” he said. “Although primary posterior capsulorhexis does obviate the need for a future laser capsul- otomy, this needs to be balanced with the increased risk of endoph- thalmitis associated with opening the posterior capsule, as well as the potential for taking a straight- forward routine cataract case with assured IOL fixation and turning it into a more complex case,” Dr. Tipperman said. After pediatric patients with retinoblastoma are treated by ocular oncologists Carol Shields, MD, and Jerry Shields, MD, both of Wills Oncology Service, Philadelphia, cataract forma- tion is common. This can make clinical observation of tumor regression difficult. “Although by the time these children develop cataracts, the retinoblastoma is usually regressed and quiescent, there is the potential in an active tumor for cells to seed the an- terior segment,” Dr. Tipperman said. Because he has opted not to perform a primary posterior cap- sulorhexis, he must use another technique to manage the capsule when it opacifies. Dr. Tipperman has a technique to use a YAG laser under anesthesia and shares his approach to help other surgeons working with a very young or uncooperative patient. “In most laser slit lamps, the bars for the head and chin rest can be removed, allowing the laser to be brought right up to the side of the surgical stretcher, and the capsulotomy is performed with the child turned on his or her side,” Dr. Tipperman said. “If the surgical table and laser is con- structed so that the laser cannot Challenging...cataract surgery – from page 9