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August 2009
 

COVER FEATURE
 

challenging cataract cases
Physicians vary on best tool for the job




by David Laber EyeWorld Staff Writer
 

 

 

As microincisional cataract surgery becomes more popular, physicians discuss what tools they are using during their surgeries

Sam Masket, M.D., in the initial stage of performing a capsulorrhexis on a mature cataract Source: Samuel Masket, M.D.



Having the right tool for the job is a classic cliché, and in ophthalmic terms, is somewhat incomplete given that there is no one right tool for cataract surgery.
With more physicians transitioning to microincisional cataract surgery (MICS), several new tools such as 1.8mm capsulorrhexis forceps, have entered an already crowded market of cataract surgery instrumentation.
Surgeons also are finding ways to perform cataract surgery through smaller incisions while keeping their current tools. Yet not all physicians are ready to jump on the MICS bandwagon.


Defending the status quo


One physician who has not yet adopted a MICS approach is Harry S. Geggel, M.D., Seattle, who said he achieves desirable results going through a 2.65 mm incision, so he has not felt the need to go smaller.
That is not to say that Dr. Geggel’s technique has remained static. Actually, he said he has reduced his incision size from 2.75 mm to his current 2.65 mm approach. “When I check my surgical induced astigmatism, it is usually 0.5 diopters or less,” Dr. Geggel said. “There is discussion about going down to 2.4 mm or smaller, but I do not feel compelled [to do so].”
He added that for some physicians, going to the 2.4 mm incision size or smaller has made it increasingly difficult to create a capsulorrhexis.
Dropping 0.1 mm has not prompted Dr. Geggel to alter his instrumentation any, so he is able to continue to use a 2.65 mm microkeratome. For his procedure, he makes a bi-beveled incision rather than going straight in, which improves the likelihood of creating a self-sealing paracentesis with a microvitreoretinal blade. “One of the things I do because I’m of older vintage is that I still make a scleral ‘frown’ incision whereas I think more than half the doctors are doing clear corneal incisions,” Dr. Geggel said.
As Samuel Masket, M.D., clinical professor of ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, and others have stressed, Dr. Geggel said he tries to have a tunnel that is of at least 2 mm in length and of a square shape to have a better chance of having a self-sealing incision.
He said he also makes his incisions superiorly because this way, most of his wounds will be covered by conjunctiva and the upper lid. Most others are doing it temporally, he admitted, which he said he also will do when implanting a toric intraocular lens (IOL) or for patients with high brows.
And finally, Dr. Geggel said that if the wound is leaking, he will close with a suture whereas other physicians will hydrate the wounds with fluid. “Don’t be hesitant to use a suture to close a wound if it’s leaking to minimize risk of endophthalmitis,” he said.


Going 2.4mm and smaller


While Dr. Geggel remains comfortable with a larger incision, other physicians have gone smaller including J.E. “Jay” McDonald II, M.D., Fayetteville, Ark., and EyeWorld’s EyeCONNECT e-mail discussion editor; and Sonia H. Yoo, M.D., associate professor of clinical ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, who go through 1.8mm and 2.4mm incisions, respectively.
Both Dr. McDonald and Dr. Yoo said they use a nasal lid speculum for a temporal approach to give clearance, and both physicians also use two .12 forceps to control the eye, but they use different instruments for their paracenteses.
Dr. Yoo said she uses a stainless-steel, disposable super blade for paracentesis. She said she likes the single-usage, disposable blades because it guarantees the instrument will remain sharp for every patient. In a high-volume center with several surgeons, disposable items helps to minimize the number of instruments that needs to sterilized.
As far as corneal wound construction, Dr. Yoo said she uses a stainless steel crescent knife to make a half thickness corneal groove. Then she uses a stainless steel microkeratome to make her corneal tunnel. This creates a true tri-planar wound that closes well. In addition to using disposable blades, she said it is hospital policy to use guarded blades as well to minimize the risk of inadvertent punctures. She mentioned that some physicians are using diamond knives and there are some new blade materials being used including a silicone blade.
For the capsulorrhexis, she uses a disposable cystotome and utrata capsulorrhexis forceps. Some prefer to use only the cystotome, and there are capsulorrhexis forceps for which the surgeon can perform the entire capsulorrhexis with only the forceps.
Dr. Yoo added that if a surgeon drops to 2.2 mm incision, a physician can get by with his/her existing capsulorrhexis forceps, though it will require a modified technique to pivot the instrument more rather than moving it side to side. For surgeons dropping below a 2.2 mm incision, then they might need to convert to a smaller instrument to get through.
Dr. McDonald said he uses a bent .25 gauge needle with the bevel down for his capsulorrhexis instead of forceps. He bends a new needle for each of his cases because the sharp tip of the needle is the secret to a successful for a capsulorrhexis.
He has been doing continuous curvilinear capsulorrhexis (CCC) as they were just developing forceps. The key is to use a .25 gauge needle as opposed to the disposable .27 gauge needle, because, in his opinion, “there is not enough inertia or mass to a .27-gauge tip; you get a bigger area of contact.”
After making the tear, many physicians use forceps, but as the incision shrinks, forceps become harder to use. “There are some specially made forceps for a 1.8 mm incision that helps,” Dr. McDonald said, but with the needle, he can do the tear and the capsulorrhexis. “You don’t have to enter with another instrument, plus in a 1.8 incision, it is easy to oarlock with a capsulorrhexis forceps.”
Dr. McDonald differs from other physicians, such as Dr. Geggel, in that he does not pay much attention to whether or not the wound is leaking. “I don’t mind if some of the fluid leaks out the sideport incision; I know some people are real sticklers about that, but it is just what I’m comfortable with.”
But at the end of the case, he uses a disposable .30-gauge needle on a 2cc syringe and inject vancomycin (Vancocin, Eli Lilly, Indianapolis) in the corneal stromal adjacent to his incision.



Editors’ note: Drs. Geggel, McDonald, and Yoo have no financial interests related to their comments.



Contact information

Geggel: 206-223-6840, ophhsg@vmmc.org
McDonald: 479-521-2555, mcdonaldje@mcdonaldje.com
Yoo: 305-326-6322, syoo@med.miami.edu







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