EyeWorld India December 2019 Issue

26 EWAP DECEMBER 2019 SECONDARY FEATURE by Christina Chintanaphol and Chiles Aedam R. Samaniego I t always seems impossible until it is done.” Former South African president and anti-apartheid revolutionary Nelson Mandela’s wisdom remains true even in the world of ophthalmology—we have to keep on being challenged in clinical research and new technologies. Tetsuro Oshika, MD, delivered his 2019 APACRS LIM Lecture, “The Quest for Safer and More Accurate Cataract Surgery,” `ˆÃVÕÃȘ} Ìܜ È}˜ˆwV>˜Ì ̜«ˆVÃ\ endophthalmitis prevention and toric IOL misalignment. Endophthalmitis prevention According to Dr. Oshika, previous research has demonstrated that washing out the anterior and posterior chambers after IOL implantation is of “critical importance” in order to prevent IOP spikes and, more pertinently, prevent infection. He listed a number of “i̅œ`à vœÀ Ü>ŜÕÌ\ w݈˜} ̅i irrigation/aspiration cannula in the anterior chamber, the “rock’n’roll” technique, and the behind-the-lens technique. The behind-the-lens technique, he said, is “claimed to be the most effective,” though there were currently no data to support this claim. Dr. Oshika did however conduct a study to provide `>Ì> ÃÕ««œÀ̈˜} ̅i ivwV>VÞ œv behind-the-lens washout itself. In a prospective study led by Dr. Oshika in 9,100 cataract surgery cases, the incidence of endophthalmitis was statistically È}˜ˆwV>˜ÌÞ…ˆ}…iÀ ˆ˜ V>Ãià ̅>Ì did not utilize the behind-the- lens washout method (3 out of 3,077 cases) than in cases that did utilize behind-the-lens (zero out of 5,294 cases, p=0.05). 1 “I think this is very clear iۈ`i˜Vi ̜ ÃÕ««œÀÌ Ì…i ivwV>VÞ of this technique,” he said. /…ˆÃ Ü>à ̅i wÀÃÌ Ì>Ži‡…œ“i “iÃÃ>}i œv…ˆÃ Ì>Ž\ 7>Å̅i space behind the lens. This, he said, is very easy with modern foldable IOLs, which unfold slowly, giving the surgeon ̈“i ̜ w˜` ̅i ë>Vi >˜` wash it out. Dr. Oshika said that the behind-the-lens technique can even be used in challenging cases such as eyes with small pupils, or, as in one case he presented, cases with a small tear in the CCC. In this case, he rounded out the tear, continuing it into a CCC. Successfully doing so, he was able to insert the IOL and take time to rotate and wash behind it. Another thing to consider to prevent endophthalmitis is the bacteria at the surgical site. There is bacteria everywhere, Dr. Oshika said, even during surgery. As such, it is not practical to kill all the bacteria. Surgeons should do their best to achieve temporal asepsis at least intraoperatively—at least for the 20 minutes that the surgeon requires to perform surgery. Antibiotics in this case aren’t the best option since they take time to achieve asepsis— in eye drop form, antibiotics require 15–60 minutes; delivered by irrigation, about 140 minutes. As such, the best option intraoperatively is the use of povidone iodine, which takes 15–60 seconds to clear bacteria. Dr. Oshika cited a paper ‘The Quest for Safer and More Accurate Cataract Surgery’ 2019 APACRS LIM Lecture This article expands on a report that previously appeared in an EyeWorld #UKC 2CEKƂE /GGVKPI 4GRQTVGT RWDNKUJGF FWTKPI VJG PF #2#%45 CPPWCN OGGVKPI JGNF HTQO VQ 1EVQDGT