Reporting from the 2021 AAO Annual Meeting
November 12–15, 2021 • New Orleans, Louisiana
- Spotlight on cataract complications
- Rock hard cataracts
- Dealing with halos and starbursts
- Handling posterior polar cataracts
- Non-capsular IOL fixation
- Advanced techniques and innovations in MSICS
Spotlight on cataract complications
The 20th annual AAO Spotlight on Cataract Complications session was moderated by David Chang, MD, and Nicole Fram, MD. The session featured the Charles D. Kelman Lecture, given by Michael Snyder, MD, on “Niche Devices for Special Eyes.”
The first case of the session highlighted the challenge of capsulotomy in a white cataract, a small pupil, and a shallow anterior chamber. The patient was an 83-year-old who had a trabeculectomy 4 years prior, an IOP of 4 mm Hg, and an anterior chamber depth of 1.89 mm. Presenters provided pearls for how to handle the challenges in this case.
Eric Donnenfeld, MD, shared his thoughts on capsulotomy in a white lens, which can also be described as a presentation on “how to avoid the Argentinian flag sign,” he said. You need to optimize vitreous pressure, which can be done with preop mannitol, peribulbar anesthesia that’s started at least 20 minutes before surgery, placing the patient in a Fowler’s position, using a self-retaining lid speculum, avoiding patient squeezing or manual pressure on the eye, and if the pressure is really high, considering a pars plana vitrectomy.
Anterior chamber pressure needs to be increased or maintained until the capsulotomy is complete. Dr. Donnenfeld said this can be done by hyperinflating the anterior chamber with a cohesive viscoelastic. He also said to use the smallest incision possible.
Capsular bag pressure needs to be reduced. Dr. Donnenfeld said to use trypan blue, and insert a 25- or 27-gauge needle to milk the fluid out of the bag before extending the rhexis.
Dr. Donnenfeld also discussed the use of femtosecond laser for capsulotomy creation in these cases. His pearls included a faster laser setting, a water bath interface is better than an applanation interface, increase the gates, and increase the capsulotomy energy. He said to expect tags with the femto technique.
Zepto (Centricity Vision) is a technology for instantaneous capsulotomy creation with a device that makes 360-degree contact with the capsule, Dr. Donnenfeld said.
Deepinder Dhaliwal, MD, shared her thoughts on handling a small pupil. Small pupils not only reduce the field of view but also increase the risk of complications. She shared a small pupil treatment grid for when to use a Malyugin ring or hooks (intracameral dilation was recommended for all cases). Ultimately if the case is complex or shallow, Dr. Dhaliwal said to use hooks.
Her pearls for using iris hooks were to make all five incisions at once, aim toward the pupil, place all five hooks, then engage the iris. To remove the hooks, hold, push, rotate, and pull.
Dr. Dhaliwal’s tips for using the Malyugin ring included: Do not overinflate the chamber; use viscoelastic under the iris where the scrolls will be; enter upside down (or lift up the wound with forceps); engage the distal end, then the right scroll followed by the left; use a second instrument to disengage, if needed; and center the entire device prior to making the capsulorhexis. When it’s time to remove, Dr. Dhaliwal said to disengage the distal segment from the iris first, then the lateral scrolls followed by subincisional. Use extra OVD, if necessary, retracting until both lateral scrolls overlap, depress slightly, and remove the ring. Do not retract the entire device into the injector.
Doug Koch, MD, shared his five pearls for achieving optimal outcomes in the setting of a shallow anterior chamber:
- IOL calculations are unpredictable. He said that less than 80% of eyes are within 0.5 D of target when they have an AL of 22 mm or less.
- Use your usual tools to create adequate AC depth. These tools include topical or general anesthesia, avoiding peri/retrobulbar anesthesia, use of mannitol, and orbital compression. Vitrectomy could be used but only at the beginning of surgery or you could exacerbate choroidal effusion.
- Don’t let the chamber shallow during surgery. Avoid this by using a viscoelastic OVD and refilling every time you exit the eye. Dr. Koch said it’s also a good idea to suture at the end.
- Manage the choroid. Dr. Koch said this management includes making a scleral window.
- Be ready for intractable shallow anterior chamber (malignant glaucoma). Postop management of this includes use of atropine, topical or systemic anhydrase inhibitors, or iridozonulohyaloidectomy.
Editors’ note: Dr. Koch has financial interests with Alcon, Bausch + Lomb, Carl Zeiss Meditec, and Johnson & Johnson Vision. Dr. Dhaliwal has financial interests with various ophthalmic companies. Dr. Donnenfeld does not have financial interests related to his comments.
Rock hard cataracts
Several presentations in the Spotlight on Cataract Complications session covered handling rock hard cataracts.
Steve Arshinoff, MD, shared phaco pearls for the rock hard lens. He noted that since he practices in Canada, some of his tips may be off label in the U.S.
Dr. Arshinoff discussed the importance of using intracameral dilation. He uses a combination of lidocaine and phenylephrine to facilitate cataract surgery, which he said attains fantastic dilation quickly. He added that Omidria (ketorolac and phenylephrine, Omeros) can be used.
Next, Dr. Arshinoff discussed his phaco machine strategy. He aims to reduce chatter and uses pulse.
Discussing his capsulorhexis strategy, Dr. Arshinoff suggested not making the capsulorhexis bigger than 4.7 mm. With a dense cataract, if something goes wrong, you want a good rhexis to capture the lens.
Dr. Arshinoff spoke about using a slice technique in these cases. He suggested lowering vacuum and flow, using the Nichamin quick chopper to slice, burying the phaco tip deeply before slicing, hydrodissecting “more than you think you have to,” making more, smaller slices, and slicing 360 degrees before removing any pieces. “The slower you go, the less time it takes,” he said.
Next he discussed the importance of learning to use OVD and capsular dye. The only two things you can adjust are phaco modulation or the OVDs you use in surgery.
He also mentioned the use of moxifloxacin, which he said is now the most used intracameral antibiotic in the world.
As a “bonus pearl,” Dr. Arshinoff mentioned using the femtosecond laser for hard cataracts. Femtosecond laser is better for very dense cataracts, he said, adding that if you can see the retina on an OCT image in the office, the femtosecond laser can see and soften the nucleus.
Editors’ note: Dr. Arshinoff has no financial interests related to his comments.
Dealing with halos and starbursts
Julie Schallhorn, MD, discussed halos and starbursts and how to proceed when patients present with these.
She first described diffractive optics. Knowing what these lenses will do in the eye means knowing about diffractive optics, she said, adding that this means there are two or more focal points of light inside the eye. When you have this, you will get photic phenomena.
Preventing patients’ issues with glare and halos starts preoperatively. Compared to a monofocal lens, Dr. Schallhorn said that all of the current lens technologies have issues with glare and halos after surgery. It’s important to tell patients prior to surgery to expect this.
Dr. Schallhorn then shared her postop photic phenomena checklist, adding that you should go from the front to the back of the eye and look at anything that could be causing more difficulty than normal with these issues.
First, she mentioned residual refractive error. Patients can be 20/20 and have significant ametropia, and manifest refraction is a must.
Next, she discussed the ocular surface, which is the biggest reason for patients to have issues after surgery. Tear film disruption and disruptions of the epithelium can have a negative impact on light when entering the eye. Patients reporting more dry eye at postop month 3 are more likely to have photic phenomena.
Dr. Schallhorn also mentioned looking for any posterior capsular opacification or maculopathy.
After that, she said to spend some time with the patient. You could try something simple, like decreasing pupil size. It’s also important to let patients know that it might take some time to adapt and see if it’s still an issue in a month or two.
Consider doing something about the second eye, Dr. Schallhorn said. If they still have a cataract in the second eye, talk about this.
If all else fails, you can tell them that there’s the possibility to take out the lens. Sometimes knowing that there’s the option to remove the lens helps the patient.
The best way to prevent issues like photic phenomena is to head them off, Dr. Schallhorn said. Unhappy patients need a good exam and good refraction; 20/20 doesn’t mean no refractive error, especially with modern lenses. “Spend time with patients,” she said. “Sometimes they just need to feel heard.”
Editors’ note: Dr. Schallhorn has no financial interests related to her comments.
Handling posterior polar cataracts
Thomas Oetting, MD, offered pearls for dealing with posterior polar cataracts.
With a posterior polar cataract, Dr. Oetting said the risk of a preexisting posterior capsule defect is around 30%. It’s hard to predict who has a defect, he said.
Dr. Oetting’s main pearl was to avoid hydrodissection in these cases. Instead, you can use hydrodelineation; however, this may be hard to do.
It’s hard to control, and often some fluid tracks just under the capsule. It may be difficult to get only hydrodelineation, and you could tear the capsule.
Dr. Oetting offered tips for nuclear disassembly with a posterior polar cataract, depending on how dense the lens is.
For soft lenses, Dr. Oetting recommended sculpting the bowl then viscodissecting.
For medium lenses, he recommended a technique to groove, divide, then use hydrodelineation. Create a wide groove and divide the lens into two. Then hydrodelineate into the groove. Fluid vents anterior through the divided lens, and the nucleus can collapse into the space of the wide groove. This ensures there is less pressure on the capsule.
For the very dense lens, Dr. Oetting suggested using a “V groove” technique for when you can’t do hydrodelineation. To do this, make two intersecting grooves that intersect in the subincisional space. Once you have these grooves, you can divide the lens into three pieces without any rotation or dissection.
Editors’ note: Dr. Oetting has no financial interests related to his comments.
Non-capsular IOL fixation
During his presentation, Kevin Miller, MD, discussed non-capsular IOL fixation. He mentioned the three basic IOL models: anterior chamber, iris clips, and posterior chamber. He also discussed the three places inside the eye where you can put the IOL: the capsular bag, the ciliary sulcus, and the anterior chamber. Finally, he said you can do passive or active fixation.
He shared ways to do non-capsular IOL fixation, offering a number of tips.
If you implant an AC IOL, Dr. Miller said to size it appropriately, do a good vitrectomy, establish a peripheral iridectomy, rotate the lens haptics away from the corneal incision, and don’t tuck the iris.
If you suture a PC IOL to the iris, use a lens with a round anterior optic edge. Capture the optic in the pupil while you are passing the sutures and pass the sutures as peripheral as possible to avoid ovalizing the pupil.
If suturing a PC IOL to the sclera, Dr. Miller again suggested using a lens with a round anterior optic edge. Make sure the sutures are attached securely to the apex of each haptic.
If you perform intrascleral haptic fixation, use a lens with a round anterior optic edge and long, flexible haptics. Make sure the scleral tunnels are made well and make sure there is no wound leak at the end of the procedure.
If you perform transscleral haptic fixation, Dr. Miller said to use a lens with a round edge and haptics suitable for the flange technique. Make sure your scleral passes are made well and the flanges will not pull into the eye or contact the tear film.
Editors’ note: Dr. Miller has financial interests with a number of ophthalmic companies.
Advanced techniques and innovations in MSICS
An instructional course on Monday covered advanced techniques and innovations in manual small incision cataract surgery (MSICS). Brenton Finklea, MD, described the course as beyond the basics of MSICS, designed for those who have already gotten their feet wet with the technique and are ready to expand their skillset.
Dr. Finklea gave an overview of MSICS, explaining how it was born out of necessity for a low-cost, low-resource cataract surgery option with high-volume potential. It’s still applicable in our own cities, he continued, and it can still deliver excellent refractive outcomes.
John Cropsey, MD, discussed how to manage surgically induced astigmatism (SIA) with MSICS. He said that in many low-resource settings, UCVA is particularly important because of the potential for limited access to glasses.
There are many different wound construction techniques, but he advocated for a shape and size that keeps the length of the wound while getting the endpoints closer together, such as a frown shape. This reduces SIA while still allowing the lens to come out. Another way to get the size down is to break up the lens with a technique called phacofracture. Dr. Cropsey said this is not recommended when learning MSICS. He described how part of the lens is brought into the tunnel and cracked on the roof of the tunnel. Once that piece is removed, the remaining lens is put back into the chamber, rotated, and brought out. He also mentioned miLOOP (Carl Zeiss Meditec), which is becoming a popular mode of manual nuclear fragmentation.
The size of the wound is a balance between small enough to reduce SIA but large enough to get the lens out and, for some cases, a rigid PMMA lens in, Dr. Cropsey said. The sweet spot for wound placement is 1–2 mm from the limbus.
It’s important to make SIA work for you, Dr. Cropsey continued. Children are more likely to have with-the-rule astigmatism, so operate superiorly. Older patients are more likely to have against-the-rule astigmatism, so operate temporally. Dr. Cropsey said temporal wound placement induces with-the-rule astigmatism and less overall astigmatism. It also avoids the superior conjunctiva for possible glaucoma surgery in the future. He said superotemporal wound placement induces the least amount of astigmatism and has an oblique angle of induced astigmatism.
Another tip he offered was don’t over cauterize, if you use cautery, to avoid additional SIA. Dr. Cropsey said he almost never uses sutures, opting for big air bubbles instead.
For astigmatic correction, Dr. Cropsey said LRIs are an option and toric IOLs are possible, if available.
Matt Oliva, MD, shared several case videos showcasing advanced MSICS techniques for challenging situations. His take-home points included: 1) When in doubt, enlarge the wound. 2) Make sure the capsulotomy is adequate. 3) Use an inferior paracentesis for subincisional cortex. 4) Microsphincterotomies are helpful for small pupils. 5) He likes the envelope technique for capsulotomy creation; it works for everything and can be done with a keratome or cystotome. 6) Rotate the eye downward; it helps the lens come out of the eye. 7) Use intracameral moxifloxacin.
Editors’ note: The physicians do not have financial disclosures related to their comments.
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