- Posterior polar cataract
- Pseudoexfoliation and zonulopathy
- Phaco with mild to moderate glaucoma
- Pars plana anterior vitrectomy
- Pseudophakic dysphotopsia
- Improving approach to cataract surgery
David F. Chang, MD, and Surendra Basti, MD, led the “Spotlight on Cataract” session, which featured presenters sharing their top five pearls on a variety of complicated phaco and IOL cases. The session also featured panelists discussing these topics.
Posterior polar cataract
Ashvin Agarwal, MD, shared his tips for handling posterior polar cataracts, which he said are mostly bilateral and common in young adults. There are often complaints of progressively worsening glare and difficulty in reading, and these may also be associated with nuclear sclerosis. Posterior polar cataract with congenital defect in the posterior capsule can lead to posterior capsular rupture, vitreous loss, or dropped nucleus.
He shared several steps he uses to try to avoid complications in these cases. First, he said to make a small rhexis. He also advocated for doing visco pockets, which help prevent fluid that goes between the cortex and the bag. Dr. Agarwal also mentioned the importance of hydrodelineation and phaco without nucleus rotation. He stressed the importance of trying to release cortex from all sides until you just have the last bit left.
Editors’ note: Dr. Agarwal has financial interests with Elisar.
Pseudoexfoliation and zonulopathy
Beeran Meghpara, MD, shared pearls for handling pseudoexfoliation and zonulopathy.
His first pearl was to have the right tools in the OR with you ahead of time. You can use capsular hooks, CTR, capsular tension segments, something to dilate the pupil, and other tools. Don’t forget about sutures, in case you need to scleral fixate anything, he said.
The second pearl was that the capsulorhexis can be the challenging part. This is often the first time you’re going to realize you have zonular instability, Dr. Meghpara said. It’s important to determine where the center is. A second instrument may be helpful to keep the bag stable, and capsular stability hooks can be placed to move the lens to complete the capsulorhexis. Be careful not to put too much stress on the capsule, as you could create a radial tear.
Dr. Meghpara’s third pearl was to use capsule stability hooks. Don’t use iris hooks, he said. An iris hook has a sharper tip. If you place with phaco and accidentally hit the hook, this can create a tear. A capsule hook is longer and has a more rounded end. It supports the equator of the bag, is gentler, and will provide greater support. These are a little bulkier, so you have to create paracenteses.
His fourth pearl was to know when and how to use CTRs and capsular tension segments. There are many insertion techniques, Dr. Meghpara said. In general, a CTR is used as the sole support of the capsule with less than four focal hours of zonulopathy. He said not to use with an anterior or posterior capsule tear and to inject away from the area of zonular instability. If a CTR is not adequate, you may need to place a capsular tension segment. This is a partial PMMA ring with a raised eyelet. You can place one or two.
Dr. Meghpara’s last pearl was to be prepared for vitreous. It’s not uncommon in these situations, he said. Be comfortable with a cut-down block and bimanual anterior vitrectomy. Use triamcinolone to help visualize vitreous. If you’re uncomfortable with vitrectomy, operate with a vitreoretinal surgeon.
Editors’ note: Dr. Meghpara has financial interests with several ophthalmic companies.
Phaco with mild to moderate glaucoma
Sarah Van Tassel, MD, discussed pearls for patients with mild to moderate glaucoma.
First, she suggested “staging” the glaucoma, which she said means looking beyond the RNFL. Severity guides the surgical plan and IOL choice, she said. Her next pearl was to discuss MIGS as an option. Her surgical plan often involves MIGS in mild to moderate eyes.
Next, she said to pick MIGS that give confidence. Dr. Van Tassel suggested mastering 1–3 MIGS options targeting different portions of the outflow pathway. She said to also be prepared (for mischief). Glaucomatous eyes are often at the extremes of axial lengths, could have small pupils, zonulopathy, etc.
Finally, her last pearl was to reevaluate eye drops. This includes identifying target IOP, considering non-drop therapies (SLT or intracameral bimatoprost), considering changes to existing regimen, or looking at new drops since the regimen was created, among other considerations.
Editors’ note: Dr. Van Tassel has financial interests with several ophthalmic companies.
Pars plana anterior vitrectomy
Kevin Miller, MD, shared his pearls for pars plana anterior vitrectomy, noting that he had numerous pearls, but he distilled his presentation down to his “pet peeve” pearls.
- Anesthetize the patient really well – If the eye is under topical anesthesia, he said to inject additional intracameral lidocaine. Inject sub-Tenon’s anesthesia where you plan to make any sclerotomies, he said, and administer additional intravenous sedation. If it is a planned vitrectomy, Dr. Miller said to perform an orbital injection or administer general anesthesia.
- Pay attention to fluidics – Close the phaco incision, if there is one, with sutures. Dr. Miller also said to match the size of the sclerotomy to the gauge of the vitrector and any other instruments you will be using. Make the sclerotomies with the eye pressurized and ramp up the IOP slowly. Maintain a steady and comfortable IOP (around 30 mmHg is good pressure).
- Know the difference between vitrectomy modes
- Stay away from the iris – When cutting vitreous near the iris, always turn the port on the vitrector away from the iris. The iris likes to jump into the port. Use the highest cutting rate available on your machine
- Eliminate vitreous traction and incarceration – Dr. Miller said to move the vitrector very slowly and deliberately during the initial stages of a vitrectomy. Check the incisions for vitreous before you wrap up. He also added that a peaked pupil is a tell-tale sign of vitreous prolapse. He said to stain the vitreous with triamcinolone if you can’t see it. He said that vitreous to the incision can cause decentration and wound leak.
Editors’ note: Dr. Miller has financial interests with Alcon and Johnson & Johnson Vision.
Pseudophakic dysphotopsia
Sam Masket, MD, shared pearls for dealing with pseudophakic dysphotopsia. He first said it’s important to know the different types of dysphotopsia. Pseudophakic dysphotopsia are undesired photic phenomena associated with otherwise uncomplicated cataract surgery. He noted diffractive optic dysphotopsia, positive dysphotopsia, and negative dysphotopsia.
His second pearl was to know how to exchange single-piece IOLs and to be aware of varying haptic designs. Pearl three was that positive dysphotopsia is induced by a square edge design and high index of refraction (it is IOL specific). Dr. Masket added that miotics may help positive dysphotopsia symptoms.
His next pearl was that negative dysphotopsia is induced by any IOL type or design. It is related to the position of the lens in the eye, he said, and miotics worsen negative dysphotopsia symptoms. His last pearl was that the dysphotopsia patient is not crazy, and it’s a team effort to help them.
Editors’ note: Dr. Masket has no relevant financial interests.
Improving approach to cataract surgery
Mitchell Weikert, MD, gave the Kelman Lecture on the topic of demystifying technology: understanding the diagnostic black boxes can improve our approach to cataract surgery.
As cataract surgery has evolved, we’ve been fortunate to gain access to increasingly sophisticated technologies, Dr. Weikert said, but we still have postop surprises on a regular basis. If you dig a little deeper you can find ways to avoid potential problems, improve results, and increase patient satisfaction.
Dr. Weikert went on to discuss some of the various calculation formulas that are available. He also discussed the importance of keratometry and biometry and how these are calculated, as well as updates to these technologies through the years.
Editors’ note: Dr. Weikert has financial interests with several ophthalmic companies.
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