EyeWorld India June 2019 Issue

40 EWAP JUNE 2019 CATARACT by Maxine Lipner EyeWorld Senior Contributing Writer Up to the challenge Learning to roll with a rock-hard nuclear case Editors’ note: Dr. Foster has PQ ƂPCPEKCN KPVGTGUVU TGNCVGF VQ JKU EQOOGPVU Contact information Foster: gjlfos@gmail.com D ealing with a rock- hard cataract can be very different than performing ÃÌ>˜`>À` «…>Vœi“ՏÈwV>̈œ˜° As part of a study that appeared in the Journal of Cataract and Refractive Surgery , 1 members of the ASCRS Challenging and Complex Cataract Surgery Subcommittee honed in on how to most safely address challenges in such cases, according to Gary Foster, MD , Fort Collins, Colorado. Treating rock-hard lenses differs from a typical «…>Vœi“ՏÈwV>̈œ˜ ˆ˜ > Û>ÀˆiÌÞ of ways. “First, the overall density of the lens requires more phaco energy to dismantle the nucleus, so you need to make provisions to protect the cornea in the face of that greater energy,” Dr. Foster said. “Second, the lens is usually much thicker than a traditional lens, so you have more girth to deal with but also the working conditions are a little tighter.” /…ˆÀ`] ȘVi ̅i Ài` ÀiyiÝ ˆÃ œvÌi˜ È}˜ˆwV>˜ÌÞ `ˆ“ˆ˜ˆÃ…i`] accomplishing the capsulorhexis ˆÃ “œÀi `ˆvwVՏÌ]…i Vœ˜Ìˆ˜Õi`] adding that the capsule itself may also be more scarred, making its “>˜>}i“i˜Ì `ˆvwVՏ̰ ˜ >``ˆÌˆœ˜] often there’s a particularly leathery posterior plate, which may keep the nucleus from cracking, Dr. Foster noted. Altering management techniques Slightly different management principles may apply in these ÀœVŽ‡…>À` V>Ãið º v ޜսÀi going to hydro-dissect, it needs to be a very gentle dissection because the lens is so big that ˆÌ½Ã i>ÃÞ vœÀ ̅i yՈ` Ü>Ûi ̜ become entrapped, and the subsequent pressure would blow out the posterior capsule,” Dr. Foster said. “One of the general recommendations of the Committee is that you create a trench if you’re going to chop the nucleus,” he said, adding that this can be located central to the capsulorhexis and moving up one-third of the nucleus toward the center. This creates working room for practitioners to try and pull pieces in centripetally. For surgeons who prefer a divide and conquer technique, investigators recommended that the troughs be about twice as wide as they would for a standard nucleus to create the needed working distance. “These are hard enough and brittle enough that except in the posterior leathery plate, you can crack these through and that wide distance doesn’t work against you,” he said. The wider space would be an issue with a softer nucleus, in which you want to keep all of the nuclear bulk that you can so that you have something to push against but is not an issue in rock-hard cases. “Plus, all of that energy to create a trench is delivering phaco energy the maximum distance away from the cornea,” Dr. Foster said. With phaco energy in rock- hard cases, you generally have to work with higher phaco settings in terms of stroke length, Dr. Foster noted. “Some surgeons advocate using higher levels of vacuum and aspiration to overcome the repulsive forces of greater stroke length and to overcome the more dense nuclei,” he said, adding that in most of these cases, to protect Burnescent dense cataract. Source: Rosa Braga-Mele, MD 6JKU CTVKENG QTKIKPCNN[ CRRGCTGF KP VJG (GDTWCT[ KUUWG QH EyeWorld . It JCU DGGP UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ RGTOKUUKQP HTQO VJG #5%45 1RJVJCNOKE 5GTXKEGU %QTR