eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons Vol. 19 No. 4 December 2023 www.eyeworldap.apacrs.org INDIA
2 EWAP DECEMBER 2023 Visit www.apacrs2024.org to submit your abstract. AbstrAct submission DeADline 18 Jan 2024 Film submission DeADline 18 mar 2024 call for Film submissions cAtegories cataract/implant surgery cataract complications/ challenging cases refractive/corneal surgery general interest in-house Productions sPonsor
EWAP DECEMBER 2023 3 EDITORIAL EyeWorld Asia-Pacific • December 2023 • Vol. 19 No. 4 Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India A s phacoemulsification technology and surgical techniques have vastly improved over recent decades, complications are less frequent but still can occur. When they do, with appropriate management, surgeons and patients can “sail through” complications to a favorable outcome. One of the more challenging complications covered in the issue is that of malignant glaucoma, also called ciliary block glaucoma. This occurs most frequently in eyes with very short axial lengths, particularly in nanophthalmic eyes. During surgery, typically toward the end of the procedure, the anterior chamber may become progressively shallow due to fluid misdirection. This may preclude the implantation of an IOL. Historically, aspiration of vitreous with a fine needle has been suggested. A more elegant solution would be a 25-gauge pars plana vitrectomy to relieve the pressure, though caution is required with nanophthalmic eyes as the ora serrata extends more anteriorly. Prior to performing either of these interventions, it is important to examine the red reflex and the fundus to ensure there is no choroidal hemorrhage. If present, then the eye should be closed and the surgery completed at a later date with drainage of the choroidal hemorrhage if required. My personal suggestion in these cases is to first exclude choroidal hemorrhage and then, rather than removing vitreous, simply close the eye, administer mannitol 0.25 g/kg. Typically, the eye will soften. Rescheduling the surgery towards the end of the list allows sufficient time for the pressure to reduce and the anterior chamber to deepen so the surgery can be completed. In extremely short including nanophthalmic eyes, the risk of expulsive hemorrhage can be reduced by using prophylactic mannitol 0.25 g/kg; also, avoid shallowing of the chamber when removing instruments during surgery. Cycloplegics such as atropine also reduce the likelihood of malignant glaucoma occurring in the postoperative period. Although scleral drainage procedures such as sclerotomy or sclerectomy have been recommended with modern phacoemulsification, this is probably not required. Choroidal efffusion can occur in the postoperative period and requires treatment with systemic steroids. One important consideration in a nanophthalmic eye is to avoid trabeculectomy or other drainage procedures as these are likely to precipitate the development of ciliary block. Removal of the lens is a more effective treatment with the additional precautions noted previously. If cycloplegics do not address malignant glaucoma then a pars plana vitrectomy combined with irido-zonular hyloidectomy is required to establish continuous flow of fluid from the posterior segment. Perhaps the best recommendation for managing complications in cataract surgery is to be prepared. The measures described above in relation to malignant glaucoma are a good example but equally relevant is having additional devices at hand prior to surgery such as CTRs, Ahmed segments, and Cionni rings, as well as an alternative lens for scleral fixation in patients with pseudoexfoliation, zonular dialysis, and subluxated cataracts. I hope you find this issue interesting and useful in your clinical practice. No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.” – Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science This is what being a good surgeon is all about: Since complications are a part of every surgeon’s life, the way they are managed plays an important role in defining the surgeon’s expertise—and more importantly the patient’s life. Drs. Rai and Rubenstein discuss their pearls for dealing with anterior and posterior capsule rupture where a toric IOL was planned. In such cases, the first priority is to limit any further damage and deal with the lens material and any vitreous in the anterior chamber. Follow the principles of low aspiration and irrigation parameters and the appropriate use of adjuncts such as ophthalmic viscosurgical devices (OVDs) and triamcinolone acetonide. After, take your time to assess the situation. With any IOL, but particularly with a toric, ensuring both anteroposterior and rotational stability is of paramount importance. If one feels confident in placing the IOL and ensuring stability, one may consider going ahead with a toric IOL. However, as stressed in the feature, never implant a single-piece acrylic IOL in the ciliary sulcus. Whenever in doubt, the safer option is a three-piece foldable IOL positioned in the ciliary sulcus with optic capture or left in the sulcus. Where a three-piece toric IOL is unavailable, a monofocal IOL should be implanted. The next step is communication with the patient and subsequent follow-ups. Most of the time, being an empathetic clinician and being honest with the patient works wonders. I like to sit the patient and family down and discuss the fact that though we could not implant the IOL as planned, we have done what was best for the eye in the long term. We let them know that we are doing what is best for them and will continue to work as a team to make sure they end up with the best outcomes. These patients will require extra chair time even in the postoperative period; do not forget to involve your retinal and glaucoma colleagues whenever the need arises. The true test of any procedure is the kind and severity of complications that surgeons will face during their learning curve and how well they can be tackled. All in all, this issue is a must read, and I am sure you will all gain meaningful insights into how you can manage your complications better! Abhay Vasavada Trending in Ophthalmology Deputy Regional Editor EyeWorld Asia-Pacific “
4 EWAP DECEMBER 2023 The 36th APACRS annual meeting will return to China, the most populous nation in the world where we expect an even larger crowd. The hunger for more knowledge and quality education in our delegates means that we always strive to present an up-todate yet relevant and practical scientific meeting. This 36th APACRS meeting jointly organized with the 24th CSCRS (Chinese Society of Cataract & Refractive Surgery) annual meeting promises to deliver a great learning experience in 2024. MASTERCLASSES Covering the most relevant and focused topics and conducted by some of the world’s leading surgeons! Expect the hotest topics in ophthalmic surgery today, where you will learn to master IOL Fixation, Vitrectomy and OCT for the Cataract Surgeon, MIGS for Beginners - Tips and Tricks, Chopping & Pre-Chopping, Corneal Endothelial Transplantation, Phakic IOLs, Biometry, Refractive Surgery Complications, Anterior Segment Ocular Trauma, Toric IOLs, Paediatric Cataract Surgery, and Phaco Fluidics. APACRS LIM LECTURE The APACRS LIM Lecture is the highest award of the society. Since 1991, outstanding ophthalmologists who have made extraordinary contributions to the development of cataract and refractive surgery have been invited to deliver this prestigious lecture. Join us as Dr Shin Yamane delivers the 2024 APACRS LIM Lecture titled The Tales of Flanging Technique. He will reveal everything about the flanging technique: How the flanging technique was developed; what other techniques exist besides the original flanged IOL fixation technique; and the problems with the flanging technique and how to overcome them. Not to be missed! APACRS FILM FESTIVAL The APACRS Film Festival entertains and educates, creatively displaying new innovations and breakthroughs in anterior segment ophthalmic surgery. Don’t miss this exciting session on the evening of Friday, 31 May 2024. COMBINED SYMPOSIUM OF CATARACT & REFRACTIVE SOCIETIES (CSCRS) PATHWAYS TO PRECISION & PERFECTION This combined symposium of the three leading cataract and refractive societies (APACRS, ASCRS, and ESCRS) will take a critical look at precision and perfection in Light Adjustable IOL vs. Formulae, Phaco vs. Femto, and SMILE vs. LASIK. SCIENTIFIC SYMPOSIA Exciting symposia covering Cataract & Complications, Controversies in Refractive Surgery, Challenging Cases, What’s New in IOLs? and IIIC Lectures – The Perfect Save! [NEW] BITS & BYTES FOR THE FUTURE – Digital & AI in Ophthalmology In this new age, digitization is all pervasive in all walks of life and so it is in cataract and refractive surgery. Join us as we look into the benefits and limitations of digital technology in our practice. WISDOM FROM THE KUNG FU MASTERS – Top Cataract Surgery Tips Some of the most renowned cataract surgeons each offer practical cataract surgery tips that surgeons can use immediately on their next visit to the operating theatre. Program HigHligHts Wisdom From The Kungfu Masters Visit www.apacrs2024.org for regular updates!
EWAP DECEMBER 2023 5 FEATURE 08 What to do? A compromised capsule when a toric IOL was planned by Liz Hillman 11 Yamane complications and management pearls by Liz Hillman CONTENTS 03 Editorial 20 Management and options for patients with post-refractive surgery ectasia by Liz Hillman 22 Common complications associated with MIGS by Liz Hillman 24 Malignant glaucoma: Why it happens and its management by Liz Hillman REFRACTIVE 36 Incorporating the IC-8 Apthera in practice by Ellen Stodola CORNEA 40 Losartan for the cornea, conjunctiva, glaucoma, and beyond by Ellen Stodola CATARACT 32 Using CTRs in practice by Ellen Stodola SAILING THROUGH COMPLICATIONS NEWS & OPINION 44 Eliminating operating room waste: A paradigm - altering global movement among ophthalmologists by Sjoerd Elferink, MD, and Shefali Sood, MD
30 MAY - 01 JUNE 2024 chengdu, china MASTERCLASSES Visit www.apacrs2024.org for regular updates! Time room 1 room 2 room 3 09:00 – 10:30hrs MASTERCLASS (MC1) MASTERING IOL FIXATION Course Directors: CHEE Soon Phaik & XU Wen MASTERCLASS (MC2) MASTERING VITRECTOMY AND OCT FOR THE CATARACT SURGEON Course Directors: Thanapong SOMKIJRUNGROJ, Nikolle TAN & LU Yi MASTERCLASS (MC3) MASTERING MIGS FOR BEGINNERS - Tips and Tricks Course Directors: Chelvin SNG & WANG Kaijun Tea Break 11:00 – 12:30hrs MASTERCLASS (MC4) MASTERING CHOPPING & PRE-CHOPPING Course Directors: Ronald YEOH & GUO Haike MASTERCLASS (MC5) MASTERING CORNEAL ENDOTHELIAL TRANSPLANTATION Course Directors: Donald TAN & HONG Jing MASTERCLASS (MC6) MASTERING PHAKIC IOLS Course Directors: John CHANG & WANG Xiaoying Industry Lunch Symposia 14:00 – 15:30hrs MASTERCLASS (MC7) MASTERING BIOMETRY Course Directors: FAM Han Bor & JIN Haiying MASTERCLASS (MC8) MASTERING REFRACTIVE SURGERY COMPLICATIONS Course Directors: Marcus ANG & HAN Wei MASTERCLASS (MC9) MASTERING ANTERIOR SEGMENT OCULAR TRAUMA Course Directors: Anshu ARUNDHATI & JIANG Yongxiang Tea Break 16:00 – 17:30hrs MASTERCLASS (MC10) MASTERING TORIC IOLS Course Directors: Tetsuro OSHIKA & SHENTU Xingchao MASTERCLASS (MC11) MASTERING PAEDIATRIC CATARACT SURGERY Course Directors: Vaishali VASAVADA & BAO Yongzhen MASTERCLASS (MC12) MASTERING PHACO FLUIDICS Course Directors: Pannet PANGPUTHIPONG & FAN Wei
EWAP DECEMBER 2023 7 CORNEA 34 Innovations in the treatment of endothelial dysfunction by Ellen Stodola GLAUCOMA 37 Combining MIGS procedures by Ellen Stodola 40 MicroPulse for the anterior segment surgeon by Liz Hillman EYEWORLD ASIA-PACIFIC APACRS Publisher: EyeWorld Asia-Pacific Edition (ISSN 1793-1835) is published quarterly by the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Printed in Singapore. Editorial Offices: EyeWorld Asia-Pacific Edition: Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. AdvertisingOffice: EyeWorldAsia-PacificEdition:Asia-PacificAssociationofCataract&RefractiveSurgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (1-703) 975-7766, email don@apacrs.org. Copyright 2021, Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Licensed through the American Society of Cataract & Refractive Surgery (ASCRS), 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003, USA. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. The ideas and opinions expressed in EyeWorld Asia-Pacific do not necessarily reflect those of the editors, publishers or its advertisers. Subscriptions: Requests should be addressed to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Back copies: Subject to availability. Contact the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Requests to reprint, use or republish: Requests to reprint or use material published herein should be made in writing only to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@ apacrs.org. Change of address: Notice should be sent to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, six weeks in advance of effective date. Include old and new addresses and label from a recent issue. The APACRS publisher cannot accept responsibility for undelivered copies. KDN number: PPS1766/07/2013(022955) MCI (P) 039/02/2022 CHINESE EDITION Regional Managing Editor Yao Ke, MD Deputy Regional Editor He Shouzhi, MD Zhao Jialiang, MD Assistant Editors Zhouqi, MD Shentu Xingchao, MD INDIA EDITION Regional Managing Editor S. Natarajan, MD Deputy Regional Editor Abhay Vasavada, MD KOREAN EDITION Regional Managing Editor Hungwon Tchah, MD Deputy Regional Editor Chul Young Choi, MD EDITORIAL BOARD Chief Medical Editor Graham Barrett, MD Chief Publisher Ronald Yeoh, MD Executive Director Kathy Chen kathy.chen@apacrs.org Publishing Consultant Donald R Long don@apacrs.org PUBLISHING TEAM Senior Staff Writer Chiles Aedam R. Samaniego chiles.samaniego@apacrs.org Production Team Javian Teh Gretel Tan Christine Shimmon Aileen Bian ewap@apacrs.org Chan Wing Kwong, MD, Singapore Ronald Yeoh, MD, Singapore John Chang, MD, Hong Kong SAR Pannet Pangputhipong, MD, Thailand YC Lee, MD, Malaysia Hiroko Bissen-Miyajima, MD, Japan Kimiya Shimizu, MD, Japan Sri Ganesh, MD, India Chee Soon Phaik, MD, Singapore Johan Hutauruk, MD, Indonesia EDITORIAL MEMBERS
FEATURE 8 EWAP DECEMBER 2023 Creation of a peripheral corneal relaxing incision with a pre-set 600-micron diamond blade. Peripheral corneal relaxing incision completed. Precise placement and subsequent stability of a toric IOL are of the utmost importance for success in correcting astigmatism. Capsule tears can threaten both factors. So what do you do when a capsule tear occurs during cataract surgery when you planned to implant a toric IOL? Amandeep Rai, MD, FRCSC, said recognition is the first step with any case of capsule rent, whether or not a toric IOL is planned. “Once recognized, the surgeon should try to immediately tamponade the vitreous behind the compromised capsule with a dispersive viscoelastic device. It is incumbent on the surgeon to ensure that the anterior chamber remains formed; sudden shallowing may cause the rent to suddenly enlarge,” Dr. Rai said. “Depending on the stage of the surgery, the surgeon should attempt to keep all lens material anterior to the rent and remove the cataract with altered fluidics. Generous use of viscoelastic can help compartmentalize the lens fragments in the anterior chamber and keep the vitreous posterior. “A surgeon should alter the fluidics by reducing the flow rate, irrigation pressure, and vacuum,” Dr. Rai continued. “Irrigation and aspiration may be done manually or at low flow settings. Surgeons should ensure that there is no vitreous prolapse, and this may be aided by the use of diluted triamcinolone intracamerally. Any vitreous should be removed using a vitrector, and the Contact information Rai: amandeep.rai@mail.utoronto.ca Rubenstein: jonathan_rubenstein@rush.edu What to do? A compromised capsule when a toric IOL was planned by Liz Hillman Editorial Co - Director This article originally appeared in the September 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. surgeon should be vigilant and check for vitreous regularly through the remainder of the case. Suturing the main wound is suggested, as this patient may require a vitrectomy and is also at increased risk of postoperative endophthalmitis. Intracameral antibiotics should also be considered.” When it comes to IOL selection, Dr. Rai said it depends on capsular support and the type of rent. If it is an anterior capsule (AC) rent, Dr. Rai said that a single-piece IOL can be placed if the surgeon is confident in the long-term axial and rotational stability. “This depends on appropriate placement of the haptics so that a haptic does not tilt forward; if a single haptic is in the bag and the other haptic tilts forward into the sulcus, the patient is
FEATURE EWAP DECEMBER 2023 9 at high risk for postoperative uveitis - glaucoma - hyphema (UGH) syndrome,” he said. “The tilt can also induce astigmatism and/or coma. The ideal scenario would be a small AC rent that happens to coincide with the steep axis of corneal astigmatism. This would allow the physician to orient the toric IOL such that the haptic-optic junction is around the area of the rent, and both haptics will be entirely secured under the remaining capsulorhexis edge.” A single-piece IOL may also be an option in the setting of a posterior capsule rupture (PCR), provided the posterior capsule surface area is large enough to support the IOL long term. “If the surgeon is able to keep the PCR small and controlled throughout the remainder of the surgery, a single-piece IOL is certainly a plausible outcome; in that scenario, a toric IOL should be considered,” he said. “This is especially true if the PCR can be converted to a posterior continuous curvilinear capsulorhexis. If the PCR is large and the surgeon thinks that the remaining posterior capsule cannot support an IOL, a common IOL placement is in the sulcus (with or without optic capture). In this scenario, the surgeon should not place a single-piece toric IOL in the sulcus due to the increased risk of UGH syndrome. Instead, a three-piece IOL with PMMA haptics should be used. An alternate option for placement of a single-piece IOL in the setting of a PCR is reverse optic capture; a single-piece IOL can be placed with the haptics in the capsular bag and the optic anterior to the capsulorhexis opening. This technique of reverse optic capture would allow a surgeon to still implant a single-piece toric IOL in a compromised capsule.” If capsular support is entirely insufficient, Dr. Rai also mentioned anterior chamber IOLs, iris-sutured IOLs, scleral- sutured IOLs, and intrascleral haptic fixation as possibilities. Jonathan Rubenstein, MD, shared his thoughts on what to do when there is a compromised capsule and a toric IOL was planned. If there is a PC tear, he said you need to make sure you can visualize the entire extent of the tear to ensure that it won’t tear out, producing instability. If it’s localized (and ideally round), Dr. Rubenstein said it’s unlikely to tear out, and thus OK to place a toric IOL, provided the zonules A toric IOL on axis, placed after a localized posterior capsular tear. Source (all): Jonathan Rubenstein, MD are still good. “During placement, avoid further extension of the posterior capsule, using OVD to protect the capsular bag,” he said. Dr. Rubenstein said if it’s not advisable to place a toric IOL, you can still address astigmatism in the OR. If you’ve planned for it or have a nomogram and the proper equipment available, you could perform limbal relaxing incisions (LRIs), he said. He added that he doesn’t think many surgeons are comfortable or have the equipment/information available to them in the OR to perform this procedure, if they weren’t already planning for it. Postop management of astigmatism, if a monofocal IOL was placed due to the compromised capsule, includes glasses, toric contact lenses, or a refractive procedure, such as corneal refractive surgery, LRIs, astigmatic keratectomy, and opposite clear corneal incision. Dr. Rubenstein said these are options for patients who had a three-piece lens in the sulcus or placed with optic capture. He lets these patients stabilize for 3 months post-cataract surgery because “at that point, it’s refractive astigmatism rather than astigmatism based on corneal measurement.” The physicians also addressed the patient counseling aspect of this complication. “The discussion,” Dr. Rubenstein said, “is: ‘Our first
FEATURE 10 EWAP DECEMBER 2023 priority is to get your cataract out safely and completely, which we were able to accomplish. … Second, we want to put a lens implant in your eye that is as Presbyopia eye drops in development Dr. Rubenstein said he has taught skills transfer labs for astigmatic keratectomy (AK) and limbal relaxing incisions (LRIs) at major medical meetings for many years, and every year, ahead of the lab, he would think, “This is dying.” However, attendance would prove him wrong. “Every year there is still interest. People think this should still be in surgeons’ toolbox,” he said. It’s good for very small amounts of astigmatism, Dr. Rubenstein continued, noting that in the U.S., toric IOLs correct 1–1.25 D of astigmatism minimum. LRIs, in contrast, can correct less than that. Another indication, Dr. Rubenstein said, is higher amounts of astigmatism. LRIs can be performed in addition to a toric IOL to improve quality of vision. “I think there still is a place for this, and based on what happens at our meetings each year, there is still an interest in them,” Dr. Rubenstein said, noting that his program trains residents to perform LRIs and AKs. “It’s part of the surgical armamentarium we should know about.” Is there still a place for AK and LRIs? Drs. Rai and Rubenstein discuss many possible scenarios when the lens capsule is compromised and a toric IOL is planned. This clinical situation is not uncommon given the inexorable trend towards correcting all amounts of corneal cylinder with the better formulae and IOLs available today. Of course, if a toric multifocal IOL is planned in a second eye, the imperative to implant the lens is even greater! As elegantly discussed, the size, location and morphology of the capsular tear is important in deciding how to achieve the desired toric correction. Capsular complications include anterior radial tears, posterior capsule ruptures (PCRs) and zonular dehiscences which can exist in isolation or in combination. In most cases of anterior radial tears without posterior extension, it is possible to place a single-piece IOL in the bag securely, the critical point being to ensure that the haptic does not protrude through the radial tear into the sulcus. PCRs when small, rounded, and clearly defined are compatible with in-the-bag IOL placement and, as mentioned, anterior optic capture is an excellent maneuver that stabilizes the IOL very nicely. Single-piece IOLs whether toric or not should not be placed in the sulcus. Finally, there are times when the zonular ligaments are compromised and the placement of a single-piece toric implant challenging. These cases can still benefit from a single-piece toric lens if the vitrectomy using triamcinolone is carefully done and then capsular tension segments or capsular tension rings with eyelets can be sutured in place to stabilize the bag. The single-piece toric IOL can then easily be placed with good results. The modern refractive cataract surgeons needs to have all these techniques at his disposal to achieve optimal outcomes for his patients. Editors’ note: Dr. Yeoh has no relevant financial interests. Ronald Yeoh, FRCS, FRCOphth, DO, FAMS Consultant Eye Surgeon & Medical Director, Eye & Retina Surgeons Clinical Associate Professor Duke-NUS Grad Med School, Singapore National Eye Centre ry@ers.clinic ASIA-PACIFIC PERSPECTIVES close to the correct power and as stable as possible, and we were able to accomplish that. Third is to try to produce the lowest residual refractive error … as possible, and we’re able to correct hopefully the spherical part of your refraction, but you still have astigmatism, which we were not able to correct in surgery, and we will offer you the opportunity to correct that later.’ We’ll say something like, ‘During surgery we assessed that your eye was not stable enough to support the type of lens implant that we originally had planned to correct astigmatism; we thought it was unsafe to use that kind of lens because we couldn’t be assured it would stay in the position that was needed to fully correct your astigmatism, and therefore we put in a lens implant that does not correct astigmatism because it was the most stable lens for your eye. We can always come back later and correct your astigmatism.’” Dr. Rai also said it’s important to thoroughly discuss this situation with the patient and their family postop, namely because these patients are at increased risk for complications, such as high intraocular pressure in the first few hours postop, endophthalmitis in the days postop, and/ or retinal tear/detachment, CME, or pseudophakic bullous keratopathy in the weeks postop. continued on page 15
FEATURE EWAP DECEMBER 2023 11 In the years since Shin Yamane, MD, PhD, presented on flanged double-needle intrascleral haptic fixation (2017), 1 many surgeons have adopted the technique, but it’s not without complications that require preparation and management. “There are many potential complications from intrascleral haptic fixation techniques, such as the Yamane technique. Herein we discuss some of the most relevant and worst,” Austin Nakatsuka, MD, and Jeff Pettey, MD, wrote in an email to EyeWorld. D. Brian Kim, MD, also weighed in on the topic. A literature search, he said, failed to reveal exact incidence of complications with this technique, but “it’s safe to say the incidence is higher while on the learning curve, and it tends to be steep,” he added. “These technical challenges have led surgeons to develop various adaptations, such as using a trocar instead of needles while others externalize the right side needle outside of the main incision to more easily cannulate the more challenging trailing haptic,” Dr. Kim said. “It’s difficult to assess frequency of complications when there are so many variations. With my own modifications, I have been fortunate to reduce the frequency and avoid catastrophic complications thus far, and currently, I do not tend to struggle with problems related to the technique.” Dr. Kim, Dr. Pettey, and Dr. Nakatsuka provided their thoughts on some of the more common complications that can occur with intrascleral haptic fixation as well as pearls for handling each situation. Choroidal hemorrhage: When passing needles through the sclera, Dr. Nakatsuka said the needles may intersect blood vessels and cause bleeding, which can be more significant in older individuals on anticoagulation medications but can also happen in younger individuals. See Figure 1 for an example. “In our experience, this happens in roughly 1–5% of cases,” he wrote. “Depending on the severity of the bleeding, it may be treated medically with topical and/or oral steroids and cycloplegics versus surgical drainage.” Dr. Pettey and Dr. Nakatsuka’s pearl for this situation was to stop anticoagulant use, if possible, in high-risk patients and to cauterize scleral vessels if needed. Uveitis - glaucoma - hyphema (UGH) syndrome: “After placement of the lens, the optic or haptics can come in contact with the posterior face of the iris, leading to the dreaded trifecta of UGH,” Dr. Pettey said. “Ironically, the Yamane technique is sometimes used as a surgical treatment for UGH caused by previously implanted IOLs,” Dr. Nakatsuka added. “Still, it can cause UGH in its own right and most often requires a revision to address the negative sequela.” To avoid UGH, Dr. Pettey and Dr. Nakatsuka said to ensure the lens is centered without tilt after viscoelastic removal. “Always place at least one iridotomy, and consider placing haptics further Contact information Kim: docdbk100@gmail.com Pettey: jeff.pettey@hsc.utah.edu Nakatsuka: austin.nakatsuka@hsc.utah.edu Yamane complications and management pearls by Liz Hillman Editorial Co - Director Figure 1. If needles intersect blood vessels, hemorrhagic choroid can occur. This article originally appeared in the September 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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FEATURE EWAP DECEMBER 2023 13 from the limbus (e.g., 2.5–3 mm instead of 2 mm), especially in cases where the iris is highly mobile and floppy. Although controversial, one can consider shortening the haptics,” Dr. Nakatsuka wrote. Dr. Kim also said that if the needles are pierced through the sclera too anteriorly, it could cause the haptics to rub the overlying uveal tissue resulting in UGH or CME. IOL decentration or tilt: This complication can occur due to asymmetrical scleral tunnels at different lengths or angles, Dr. Pettey and Dr. Nakatsuka said. To ensure proper centration, Dr. Pettey and Dr. Nakatsuka advised “meticulous pre-surgical marking with calipers and a Mendez ring to ensure targets are precisely 180 degrees apart, and mark the center of the cornea. Close observation of the scleral indentation during the docking procedure can alert the surgeon to an asymmetry between each side to ensure symmetric tunnels. Ensure that the globe is firm during the scleral needle insertion and avoid hypotony throughout the procedure. We recommend maximal pupil dilation to facilitate visualization during the docking step.” (See Figure 2). Dr. Nakatsuka experienced a few cases of rotation of the haptic at the optic-haptic junction with the CT LUCIA lens (Carl Zeiss Meditec), although it appears to be isolated to a particular batch of these lenses. Dr. Kim also mentioned the recent issues observed with the CT LUCIA lenses, which he described as a “rotisserie rotation.” “Surgeons have observed that these haptics are not completely fused within the optic, causing them to rotate,” he said. “There is a technique called laser - lock, 2 which uses the endolaser to essentially melt the haptic to the optic to address this.” Lens/optic capture: Dr. Nakatsuka has experienced a few cases where the lens optic moves in front of the iris pupil. Floppy iris appears to be a risk factor for this complication (see Figure 3). In addition to similar pearls for avoiding UGH, Dr. Pettey and Dr. Nakatsuka said that treatment options include miotics, supine positioning with miotics, laser iridoplasty, or surgical pupilloplasty to prevent the lens from coming forward. They said some surgeons recommend multiple peripheral iridotomies but noted the efficacy is still unclear. Dr. Yamane recommends a 7.0-mm optic X-70 IOL (Santen) to avoid pupillary capture of the optic, but Dr. Kim said optic capture can still occur if the IOL is too close to the iris plane. “Rather than placing the needles 2 mm posterior to the limbus, I prefer to place them further back at 2.5 mm and target –0.50 D for a plano refractive result,” he said. “With this modification, along with always placing a temporal surgical peripheral iridectomy to avoid reverse pupillary block, I have not experienced any cases of optic capture.” Flagpole sign: Dr. Kim said that there needs to be adequate scleral support for the haptics with this technique. “If there is inadequate scleral support for the haptics because the needles are not tunneled through the sclera, the haptics may point up in a more vertical orientation, which I’ve coined the ‘flagpole sign,’” he said. “If there is a flagpole sign, this means the optic is sagging posteriorly within the vitreous space, which would induce optic tilt and astigmatism. A self-check to know the IOL is placed correctly is when you observe the haptics are lying flat to the sclera when the needles are pulled out.” Hypotony: Dr. Pettey and Dr. Nakatsuka said the Yamane technique requires the use of thin gauge needles (30 gauge) and long, oblique tunnels, but they are still prone to leaking. “On the extreme end of the spectrum,” they wrote, “Marfan patients or others with very long axial length have thin sclera and are considerably more prone to leaking. Additionally, we often do these cases combined with retina providers, whose ports may not consistently seal.” Recently, Dr. Nakatsuka had a patient with a completely collapsed eye after the procedure, which he thought was likely due to a small leak from a retina port in combination with aqueous suppression that can occur with ciliary body trauma. “Hypotony is a more frequently encountered Figure 2. Lens tilt or decentration can occur due to a variety of reasons during intrascleral haptic fixation, especially of the scleral tunnels.
14 EWAP DECEMBER 2023 FEATURE complication and most often resolves as small leaks self-seal. However, long-term hypotony may lead to secondary complications, such as hypotony maculopathy. Initial medical treatment includes topical steroids, cycloplegics, or surgical closure of persistent leaks.” Other complications: CME, ocular hypertension, iris trauma, and retinal trauma are common complications of any secondary lens replacement, regardless of technique, Dr. Pettey and Dr. Nakatsuka wrote. CME, they said, can be managed with topical NSAIDs and steroids or, if needed, intravitreal anti-VEGF or steroid injections. The Yamane technique, according to Dr. Pettey and Dr. Nakatsuka, is susceptible to retained viscoelastic, which can cause elevated IOP. Dr. Nakatsuka has experienced this in up to 20% of cases and usually treats it prophylactically with oral acetazolamide or topical anti - hypertensives. As for retinal trauma, Dr. Kim said if needles are positioned too posteriorly, in theory, they could pierce the peripheral retina and cause a retinal tear or detachment. Dr. Nakatsuka said extra care should be taken with small eyes that may have a shorter pars plana and a more anterior retina insertion leaving the retina vulnerable to puncture and trauma. If there is retinal or corneal damage, such as a retinal tear, CME, or corneal endothelial decompensation, Dr. Kim said these conditions must be treated before IOL replacement or scleral refixation. “As long as there is no permanent damage, when the IOL is replaced and scleral refixation is properly executed, Figure 3. Lens/optic capture can occur after intrascleral haptic fixation, being more common with floppy irises. Source (all): Jeff Pettey, MD, and Austin Nakatsuka, MD Drs. Pettey, Nakatsuka, and Kim have described the common issues encountered during the learning curve of the Yamane IOL fixation technique well. Seeming simple, the technique is not forgiving and every step is crucial. Sources of error contributing to IOL tilt and decentration include failure to mark the limbus at diametrically opposite sites, wrongly identifying the limbus when conjunctivalized, premature or delayed entry into the globe, and asymmetrical scleral tunnel angles. The modifications I describe here are suited to using an IOL with either PMMA or PVDF haptics. Although a thin-walled, small-gauge needle is recommended, using a larger bore needle is easier for threading of the haptic. It would be wise to test if the haptic fits the needle prior to the procedure. Use regional anesthesia but avoid inducing chemosis. I prefer aligning the IOL vertically, as the vertical diameter is shorter than the horizontal. Mark diametrically opposite positions using a toric ring or markerless system, centered on Purkinje 1 image. Mark another point 2.25 mm posterior to the limbus where the haptics are retrieved and adjust this according to the axial length. Create a superior iridectomy and have the pupil miosed a little to prevent the IOL from slipping posteriorly. Create symmetrical scleral tunnels of 2-3 mm length at mid scleral depth, passing the needles circumferential to the limbus. As this is a blind passage into the globe, I palpate the needle tip to ensure that the scleral tunnel length is as planned before the needle enters the eye. I thread the trailing haptic before the leading haptic. Threading more than half the haptic makes threading the second haptic more difficult. The haptics are retrieved simultaneously. This minimizes stress on the haptic optic junction. Flange 1 to 1.5 mm of haptic length and ensure IOL is centered before pushing flange completely into tunnel to avoid hypotony. I suture the incisions if pars plana vitrectomy has been done. These modifications have given me consistent outcomes. I always stop the patient’s anticoagulants as mild vitreous hemorrhage is my most common complication. Hypotony may occur if the flange is not completely buried into the sclera or in a post vitrectomy eye. Optic capture is uncommon provided a peripheral iridectomy has been created, the IOL is fixated posterior to the iris plane and there is no IOL tilt and decentration. I target the first myopic outcome to get plano. Certainly, practice makes perfect. Once mastered, the results are rewarding. Editors’ note: Dr. Chee disclosed no relevant financial interests. Soon-Phaik Chee, MD Senior Consultant, Ophthalmology Eye & Retina Surgeons, #13-03 Camden Medical Centre, 1 Orchard Boulevard, Singapore 248649 cheesp313@gmail.com ASIA-PACIFIC PERSPECTIVES
FEATURE EWAP DECEMBER 2023 15 “They may also need further surgery for retained fragments. As such, patient education is important so they may seek immediate and appropriate care for any postoperative complications. These patients should also be scheduled for close follow-up to monitor for complications and ensure a safe recovery,” Dr. Rai said. Overall, Dr. Rai said that patients with astigmatism can benefit from a well-placed toric IOL, and even in the setting of some capsular complications, it is still possible, depending on a few factors, to deliver the best possible uncorrected distance visual acuity to patients. EWAP Editors’ note: Dr. Rai is Residency Program Director, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada, and has interests with Alcon and Bausch Health. Dr. Rubenstein is Professor and Chairman, Department of Ophthalmology Rush University Medical Center Chicago, Illinois, and has interests with Alcon. A compromised...planned- from page 10 the patient can have an excellent outcome,” Dr. Kim said, adding that he’s been referred patients like these and they have done well after surgery. More advice on avoiding complications Dr. Kim said it’s important to practice intrascleral haptic fixation on artificial eyes, by attending skills transfer courses, and/or by finding and working with an experienced mentor. “I would also be cautious and selective when choosing which technique. Whether you try Dr. Yamane’s original technique or some other variant, ask yourself, does this cause undue stress on the haptics? Although the PVDF haptics are strong, they are not indestructible, so I would be wary of techniques that exert significant stress on the haptics. Are you having trouble with certain steps such as cannulating the trailing haptic? Find a safe technique that flattens the learning curve,” Dr. Kim said. Dr. Kim said many surgeons have personalized the intrascleral haptic fixation technique with their own approach. He said he began using the Sensar IOL (Johnson & Johnson Vision) a few years ago when access to the CT LUCIA 602 was limited. “With my modifications to the technique, I have been able to completely transition to the Sensar with excellent results despite the delicate PMMA haptics because of my gentle approach,” he said. “Since I use the Sensar and not the CT LUCIA 602 as my primary IOL, I have been able to avoid the recently described rotisserie optic tilt complication. The surgeons who adopted my techniques in response to this problem have informed me that it has helped them switch to the Sensar. To be clear, the PVDF haptics of the CT LUCIA are the most forgiving, thus the best IOL to use when learning the technique. However, once you master it, I would strongly advise trying other IOLs so you aren’t trapped with just one lens.” EWAP References 1. Yamane S, et al. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology. 2017;124:1136–1142. 2. Scoles D, Wolfe J. Laser to the Rescue. American Academy of Ophthalmology ONE Network. Dec. 15, 2022.www.aao. org/education/1-minute-video/laser-torescue-2. Editors’ note: Dr. Kim practices with Professional Eye Associates, Dalton, Georgia, and declared no relevant financial interests. Dr. Pettey is Clinical Vice Chair, Moran Eye Center, University of Utah, Salt Lake City, Utah, and has interests with Carl Zeiss Meditec. Dr. Nakatsuka is Assistant Professor, Glaucoma / Cornea / Anterior Segment, Moran Eye Center, University of Utah, Salt Lake City, Utah, and declared no relevant financial interests. ADVERTISER LISTING Alcon Page 28 - 31 www.alcon.com Johnson & Johnson Vision Page 16-19 www.jjvision.com Oculus Page 12 www.cornealbiomechanics.com APACRS Page 2, 4, 6, 7, 35, 46, 47, 48 www.apacrs.org
Elevating Surgeon and Patient Satisfaction with Cataract Innovations Supplement to EyeWorld Asia-Pacific September 2022 Supplement to EyeWorld Asia-Pacific December 2023 APACRS The news magazine of the Asia-Pacific Association of Cataract & Refractive Surgeons The Johnson & Johnson lunch symposium held at the APACRS 2023 Singapore on Friday June 9 gathered three cataract experts who shared their experiences with having true ease and total control over their cataract surgery procedures. Customized IOL Selection to Meet Patient Needs Prin ROJANAPONGPUN, MD Thailand Placing a focus on the patient experience is one of the most important aspects in providing exceptional care and improving patient outcomes. These days, “our patient is changing,” Prin Rojanapongpun, MD (Thailand) said. “They have different needs and lifestyles.” Thus, it is important to individualize treatment and consider all the details pertinent to their care. “At the end, it’s about whether the patient is happy or not.” In today’s modern day lifestyle, multifocality, or multi-distance function, becomes a high priority. The current cataract patient is not the same as that of the last decade. These days, patients are requesting more. They are multi-tasking, living a modern lifestyle, and desiring spectacle freedom. Dr. Rojanapongpun stressed the importance of a multimodal approach when planning for cataract surgery. By understanding a patient’s challenges and needs, surgeons can customize their intraocular lens (IOL) selection and adapt visual care to fit the patient’s lifestyle. In one patient case study, Dr. Rojanapongpun introduced an elderly female who wished to be spectacle free because she struggled with reading near, had neck and eye discomfort while wearing spectacles, and required good near vision due to her family business of stone-cutting. Additionally, she needed to drive every night. After Dr. Rojanapongpun customized the IOL to this patient’s needs, she was very happy after the surgery, stating that she felt like she had the eyesight of a 15 year-old. However, Dr. Rojanaponpun cautions that surgeons must also compromise in each patient situation. “We need to fine-tune their needs and priorities,” he said. “Patients will have to give up something to gain something. Discuss a compromise with the patient.” Perhaps one patient prioritizes better contrast sensitivity over spectacle independence or vice versa. He recommends that surgeons individualize each case and work with the patient to achieve a good balance of happiness in the outcome of the surgery. In one case of a 71 year-old female, the patient worried about glares and halos due to driving at night, but did not want to wear spectacles. She also was performing a lot of work using near vision. After discussion, Dr. Rojanapongpun used a mix and match approaching and selected the TECNIS Eyhance™ IOL for the right eye and the TECNIS Synergy™ IOL for the left eye. In the end, this patient achieved great visual acuity (20/20 uncorrected distance visual acuity for both eyes, 20/25 uncorrected intermediate visual acuity for Sponsored by Johnson & Johnson Vision “ With a legacy of 20 years, the TECNIS bio-polymer material has no glistenings, no surface discolouration, a low refractive index, a consistent A-constant and reduced capsule contraction. ” Prin ROJANAPONGPUN, MD Thailand
During the panel discussion, an audience member asked whether mixing and matching the TECNIS Eyhance™ and Synergy™ IOLs was an issue for the patient regarding contrast. Dr. Rojanapongpun replied that the patient did not complain about contrast and color differences. “After a while, they may forget about it. It could be neuroadaptation,” he said. If the patient did come back and complain, what would he do? “I would try to persuade the patient not to do anything if overall the surgery has been successful in terms of visual outcomes. But if it’s really a problem, do I have to do an IOL exchange for both eyes? Yes; there are very few cases that I have to do an exchange. Ultimately, it depends not on the number. It depends on the happy patient.” Clinical Experience Copyright 2023 APACRS. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or publisher, and in no way imply endorsement by EyeWorld, Asia-Pacific or APACRS. All other trademarks are the intellectual property of their respective owners. © Johnson & Johnson Surgical Vision, Inc. 2023 PP2023MLT6431 “ Patients will have to give up something to gain something. Discuss a compromise with the patient. Surgeons should work with the patient to achieve a good balance of happiness in the outcome of the surgery. ” Prin ROJANAPONGPUN, MD Thailand Using TECNIS Synergy™: Continuous Range of Vision PCIOL vs. Trifocal Hiroko BISSEN-MIYAJIMA, MD, Japan Hiroko Bissen-Miyajima, MD (Japan) brought her experience of using the TECNIS Synergy™ IOL to share with attendees. Presbyopia-correcting IOLs (PC IOLs) have been developing over the last 20 years with most of the technological changes being made due to patient needs. The TECNIS Synergy™ IOL is a mixture of two lenses: a diffractive bifocal IOL and an EDOF IOL. While the EDOF IOL provides good distance and intermediate vision along with good contrast sensitivity, patients may still need reading spectacles. The combination of the EDOF IOL with the diffractive bifocal IOL provides the near vision that the EDOF IOL alone lacks. “Synergy™ has the optical benefit of both IOLs,” Dr. Bissen-Miyajima said. The TECNIS Synergy™ IOL gives patients continuous vision from distance to near and provides superior image contrast in all lighting conditions by modifying chromatic aberrations. Furthermore, patients may experience less dysphotopsia through violet light filtration technology. For a patient who has healthy eyes, Dr. Bissen-Miyajima usually implants Synergy™. However, if a patient presents with ocular comorbidities such as glaucoma or previously the script of Asian languages is so complex and small, this population of patients needs stronger near vision and good intermediate vision. Dr. Rojanapongpun believes that the TECNIS Synergy™ IOL fulfills this unique need of the Asian population. Synergy™ provides the widest range of continuous vision with high-quality near vision. At the same time, this IOL provides superior contrast during the day and night. The TECNIS Synergy™ IOL is the most advanced IOL yet, going beyond trifocal technology. “Getting a happy patient takes passionate practice, communication skills, and a depth of knowledge and experience,” Dr. Rojanapongpun said. By making a goal-based decision with the patient, surgeons will be more equipped to produce outcomes and satisfy patients’ needs. Perhaps some patients require perfect clarity or complete spectacle freedom. Some patients may want an outcome that lies in between visual clarity and spectacle freedom. Thus, it is crucial for surgeons to have the discussion with the patient to meet their needs. both eyes, and 20/32 uncorrected near visual acuity at 33 cm for both eyes) and was very happy with her results. Her combined defocus curve at 1 month after surgery showed that although the distance-corrected defocus curve for the eye implanted with the Eyhance™ IOL dropped off at near vision, the eye implanted with the Synergy™ IOL maintained good near visual acuity. Combining the two IOLs allowed for the patient’s defocus curve to keep good near visual acuity. Another benefit of the TECNIS Synergy™ IOL that Dr. Rojanapongpun appreciates is its bio-polymer material. With a legacy of 20 years, the TECNIS™ bio-polymer material has no glistening, no surface discoloration, a low refractive index, a consistent A-constant, and reduced capsule contraction. Additionally, the lens merges the diffractive and extended depth of focus (EDOF) properties with chromatic aberration correction, which helps widen the range of focus and maintain a high quality of vision. In the Asian population, there are other challenges surgeons have to think about. Because
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