EyeWorld India September 2018 Issue

EWAP FEATURE 9 Challenging cases in cataract surgery by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Always have a back-up plan for things that could go wrong, even during the best-planned surgeries. • Provide “verbal anesthesia” before more challenging steps of cataract surgery to encourage patients not to move. • Be honest but upbeat when managing patients with long-term problems after cataract surgery. Problems can occur when you least expect it E ven the most seasoned cataract surgeons can and will experience challenging cases from time to time. Three cataract surgeons shared with EyeWorld how they managed difficult cases, both in the moment and over the long term. Take a page from their playbook for better surgical pre- paredness. The best-laid plans Rosa Braga-Mele, MD, professor of ophthalmology, University of Toronto, Canada, had a resident with her when she was about to perform surgery in a 55-year-old woman with bilateral cataracts, including a right eye with a white cataract. The patient had no history of ocular trauma. Dr. Braga-Mele’s goal was to teach the resident what to do to avoid the Argentinian flag sign. Of course, things don’t always work out as planned. Dr. Braga-Mele performed proper wound construction to avoid chamber shallowing and put in a dispersive ophthalmic visco- surgical device (OVD). She painted the capsule with trypan blue and then put in more dispersive OVD to flatten out the front. “I could see the capsule dimpling as I compressed it,” she said. She then used a 27G needle to decompress the cortical fluff and relieve any posterior pressure on the anterior capsule. “I then put in more visco, and I go in with my cystotome and start the capsulorhexis, and it just ruptures,” she said. When Dr. Braga-Mele went in with the cystotome, the patient had coughed. “A case that wasn’t supposed to be an Argentinian flag sign became one,” she said. If this happens during sur- gery, don’t panic, Dr. Braga-Mele advised. Also, do not let the eye decompress. She put more OVD on top of the capsule and behind the white cataract to provide a bed of viscoelastic material. “At this point, I don’t know if the rupture is 360 degrees all around. I try to put visco behind to make the capsule more taut or if it has run, to prevent the nucleus from dropping, and hopefully it will lift up to the anterior cham- ber,” Dr. Braga-Mele said. She went in using high vacuum and embedded the phaco tip into the nucleus and scaffolded the nucleus on top of the iris. “I use the viscoelastic as a second instrument and eat that whole nu- cleus piece in what I call Pacman style, nibbling around the edge in a controlled fashion,” Dr. Braga- Mele said. She kept the bag height at a moderate level. She then used her multiple vials of dispersive OVD to maintain the anterior chamber and bag pressure before pulling out of the eye. She also saw at this point that the posterior capsule had remained intact. The OVD was used to viscodissect the cortex off the capsule, making it easier to remove. She then went in with a gentle irrigation/aspiration tip. Dr. Braga-Mele chose a soft, foldable, and stickier IOL and put the haptics where the two flaps were; she also put the optic in the center. “At this point, I gingerly take out visco with the second instrument to hold the lens pos- teriorly against the capsular bag. I only remove about 70% of the visco. I don’t want to go under- neath the IOL,” she said. She also put in a stitch to maintain the Argentinian ag sign after trypan blue and attempted capsulotomy Source: Rosa Braga-Mele, MD continued on page 10 September 2018