13 EyeWorld Asia-Pacific | June 2025 CATARACT Prevention While anatomical factors such as small eyes or dense lenses cannot be altered, Saba Al-Hashimi, MD, emphasized that certain protective strategies can help mitigate postoperative edema. These include the use of a dispersive viscoelastic and maintaining the phaco tip near the iris plane. “Additionally, the use of a femtosecond laser can help fragment the nucleus, and chopping techniques can also be used to reduce the cumulative dissipated energy from the phaco tip, which can also reduce the chances of developing edema,” he said. Dr. Al-Hashimi outlined several practical strategies: • For very dense cataracts, replenish with OVD multiple times during surgery • Aspirate any hyperthermic OVD over the cataract prior to applying high phaco energy during sculpting • Construct wounds carefully to avoid jagged internal main wounds, which elevate the risk of Descemet’s detachment • Ensure adequate fluidics by optimizing phaco machine settings and avoiding crimping of the phaco needle sleeve • Angle the phaco tip downward and keep the eye parallel to the ground • Pause before IOL insertion to confirm lens selection • Avoid posterior capsule rupture (PCR) by refraining from over-hydrating dense lenses • Hydrate wounds gently and maintain physiologic intraocular pressure IOP to reduce Descemet’s detachment risk “Longer operating times are associated with corneal edema.” Dr. Al-Hashimi said. “When a case is complicated or the cataract is particularly challenging, the likelihood of postoperative edema rises. Intraoperatively, using a dispersive viscoelastic—and replenishing it when needed— helps protect the endothelium. If bubbles in the anterior chamber appear mobile rather than fixed, this may indicate that the dispersive viscoelastic is no longer present in adequate quantity—serving as a cue to pause and replenish, especially in high-risk patients.” In smaller chambers, Dr. Goyal said to consider doing a pars plana vitrectomy to help deepen the chamber—if the surgeon is comfortable with the technique—or using preoperative mannitol to reduce vitreous volume. “Part of the reason pseudophakic bullous keratopathy has become less common is that our phaco machines and surgical techniques have become more efficient, making our surgeries shorter and requiring less energy.” Dr. Goyal said. “A key advancement in phaco systems is the ability to adjust intraoperative IOP. Normally, I operate at physiologic eye pressure, but if I need to deepen the chamber, I can raise the IOP. While higher IOP can disturb dispersive viscoelastic, keeping the irrigation ports angled laterally and ensuring the wound is sealed around the phaco sleeve helps minimize this disturbance.” Dr. Goyal said she also thinks there is value in using a smaller than standard speculum for patients with deepset or smaller eyes. Improved patient comfort may reduce surgical duration and the associated risk of postoperative edema. Patient was referred for persistent corneal edema following an uncomplicated cataract surgery; at the initial visit (3 weeks postoperative), vision was count fingers (CF), with a superior, welldemarcated area of corneal edema. Air bubble was placed using a 30-gauge needle at the slit lamp. Slit beam examination revealed a detached Descemet’s membrane. Complete resolution of Descemet’s membrane detachment was observed 1 week later, with visual acuity improving to 20/30. Source (all): Himani Goyal, MD
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