EyeWorld India December 2019 Issue

EWAP DECEMBER 2019 3 L ooking back over the past 12 months, it is interesting to reflect on the broad variety of topics that have been covered in EyeWorld Asia- Pacific . Our end of the year issue considers special cases in cataract surgery. In monocular patients, the risks of surgery obviously have to be explained in detail, but essentially once the patient feels their vision is impaired sufficiently there is little sense in deferring surgery. One would not consider surgery if the cataract was not visually significant, but deferring surgery until the density of the cataract increases the risk of surgery should also be avoided. I also consider additional antibiotic prophylaxis including a systemic antibiotic in addition to topical and intracameral prophylaxis at the time of surgery. The unruly iris is often encountered in patients with no history of Flomaxtra use. Certain antihypertensives are likely to be a contributing factor. The use of a non-preserved 1.25 or 2.5% non-preserved phenylephrine can be helpful in improving dilation and also increasing tone in these cases. For brunescent and dense white cataracts, a vertical chop technique is my preferred technique, and the addition of low- dose mannitol (0.25 g per kg) preoperatively in the presence of an intumescent cataract can be helpful in reducing posterior vitreous as well as intralenticular pressure. Being prepared for loose zonules with additional fixation devices and appropriate implants is a key strategy in managing this situation successfully. Finally, removing an IOL is straightforward if IOL exchange is performed in the first month or two after the initial surgery, but can be more challenging if this is deferred. An important consideration in exchanging IOLs after a long period is to remove any regenerated or retained cortical material which can be associated with inflammation if disturbed. Although the vast majority of cataract surgery we perform is straightforward and uncomplicated, being aware of the advice of our experts should assist the successful management of these special cases despite the additional challenges. I would also like to express my appreciation to the staff of EyeWorld Asia-Pacific for their hard work and expertise in preparing each issue and in particular wish you, our readers, a restful and enjoyable festive season and all health, happiness, and prosperity for the coming New Year. EDITORIAL Special cases in cataract surgery Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific T he focus of this final issue of 2019 is how to make cataract surgery safer and more effective. Today, we as surgeons are fortunate to have a better machines and techniques. We need to understand and plan a surgical strategy jointly with the patient. Preparedness to deal with the situation is vital. Surgery in a monocular patient should be planned carefully since any complication can be disastrous. Meticulous attention to details and use of single-use devices will reduce the possibility of infection and inflammation. Timing of surgery is often the dilemma, and risks and benefits should be judiciously balanced when making the decision. Iris trauma and prolapse occurs if excessive fluid or ophthalmic viscosurgical device (OVD) goes behind the iris raising the pressure in posterior chamber more than in front of the iris. A limbal incision with a long tunnel would reduce the chance of iris prolapse. When necessary, pupil expanding devices the surgeon is most familiar with should be used at any stage of surgery. Low phaco parameters would help. For mature and brunescent cataracts, trypan blue staining and use of cohesive OVD help achieve sufficiently large capsulorhexes. Complete division with multiple small fragments, and use of dispersive OVD help surgeons to achieve clear corneas. Femtosecond laser- assisted cataract surgery (FLACS) has an advantage in white cataracts for capsulorhexis and reduces phaco energy in brunescent cataracts. The Zepto / Capsulaser for performing capsulorhexis and miLOOP for division of the hard nucleus also could help. For zonular dehiscence intraoperatively or postoperatively, the basic principles are to be as minimally invasive as possible, perform as few surgical maneuvers, and attempt to preserve the natural compartmentalization of the eye. Having a primary surgical plan, and then backup plans if the primary one fails are vital. In cases with limited zonular laxity, the surgeon should aim at preserving all residual zonules. The use of appropriate OVDs, micro-instrumentation, and zonule-friendly technique comes in handy. The use of supporting devices such as Assia Anchor, capsular hooks and capsule tension rings and segments are invaluable. Whenever performing vitrectomy, the long-term consequences especially those of glaucoma and retinal detachment should be kept in mind. In all cases of late decentration / dislocation of IOLs, refixation, wherever possible, should be the first choice. However, in case of a single-piece IOL, exchange with sutured or sutureless scleral fixation is often the best option. In cases of sufficient anterior capsular support, a three-piece IOL is placed in the sulcus and captured through the anterior capsulorhexis. Overall, it is fair to say that we all need to master the art of managing challenging situations, and emerge victorious using a judicious combination of techniques, technology, and proper planning. I would like to wish all the team of EyeWorld Asia-Pacific and the readers a very happy and fruitful festive season and New Year! Abhay Vasavada Deputy Regional Editor EyeWorld Asia-Pacific