amputating the distal loop to facilitate hook removal. Terry Kim, MD, USA, explained that prevention strategies for avoiding this complication include holding and/or lifting the retractor(s) during CTR insertion, aiming the CTR posteriorly, and loosening the retractor(s) before CTR insertion. Another challenging situation surgeons may face is the management of small pupils in cataract surgery. Sang Mok Lee, MD, South Korea, explained that diverse strategies may be used to enlarge the small pupil in surgery, though the strategies may depend on the availability of instruments and/or devices, patient abnormalities such as possible zonular weaknesses, and, of course, the surgeon’s skill and preferences. With the recent development of diverse pupil expansion devices, surgery on small pupils can be made easier. Posterior polar cataracts (PPC), may also present itself as a challenging case. Though PPCs can be a congenital effect, Pannet Pangputhipong, MD, Thailand, explained that it can also occur as a result of localized absence or thinning of the posterior capsule. Strategies to manage PPCs include avoiding hydrodissection and minimizing hydrodelineation, triangular cracking for medium to hard cataracts, half bowl and rim aspiration techniques for soft cataracts, maintaining anterior chamber depth, and avoiding polishing the capsule. The various challenging situations that present in cataract surgery provided ample opportunity for surgeons to explore and share their management techniques through many different patient case videos in today’s session. Just as there are many rules and high stakes in Squid Game, one misstep in a challenging cataract case may lead to undesired outcomes. Unhappy after Successful Presbyopia Cataract Surgery… What are We Missing? As patients are top priority to all surgeons, patient satisfaction after cataract surgery is one aspect to consider in terms of successful surgery. Many patients may set high expectations for their vision after presbyopic cataract surgery. They may desire high contrast at all distances or great near and distance vision, but Hiroko Bissen-Miyajima, MD, Japan, explained that this high expectation may result in patients being unhappy with their postoperative vision. In fact, a patient’s visual acuity will be different than the level of contrast in their vision. This idea must be explained to patients in order to manage their expectations. Visual cues and simulated images may be used to explain the quality of vision patients will experience after surgery. One interesting aspect of managing patient expectations is neural adaptation of vision. Because optical quality does not necessarily equal visual quality, neural receiving of images (retinal sampling and neural processing) affect how one perceives an optical image. In short term neural adaptation, the human brain can enhance an image. If an image is perceived as too sharp, the brain will want to make it softer. Subjective image quality, then, does depend on neural adaptation. In his practice in South Korea, Myoung Joon Kim, MD, instructs his patients to avoid and ignore sources of distraction and to keep focusing on the lines and contours of objects. This technique of removing noises is one way to train a patient’s brain to improve their perception and vision. Such vision training can help patients become adapted to their new vision after surgery. How quickly can neural adaptation take place? Dr. Kim said that the neural adaptation period may last about 3 months and can even take 6 months to one year. Age plays a role, and the older a patient is, the longer it may take to adapt. Old age is also a factor in decreasing contrast sensitivity. Ronald Yeoh, MBBS, FRCS, Singapore, as part of the discussion panel, stated that one of his cases took one year to finally adapt to her new vision after IOL implantation. In the end, if patients are not able to adapt, the patient may just be incompatible with the IOL. One prevailing point that all surgeons can take to their practice in managing patients is being empathetic and being able to talk to patients. “We need to take patients seriously. Then, they will feel trusted and understand that you’re caring for them,” said Michael Knorz, MD, Germany. 2022 APACRS Film Festival Symposium and Awards “A Whole New World,” produced by Viraj Vasavada, MD, India, took home this year’s grand prize at the 2022 APACRS Film Festival Symposium and Awards Ceremony. The film tells the touching story of how Dr. Vasavada’s experience EWAP meeting reporter banner.indd 1 27/07/2022 10:22 AM
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