- ‘Spotlight on Cataract Complications’
- Phaco after suspected PC rupture
- IOL fixation with diffuse zonulopathy
- Vitreous prolapse during phaco
- Retrocapsular lens fragments
- Dead bag syndrome
- Anterior chamber lenses
- Kelman Lecture
‘Spotlight on Cataract Complications’
Monday morning’s programming featured a cataract spotlight session led by David F. Chang, MD, and Surendra Basti, MD. Presenters shared pearls for different scenarios, and rotating panelists discussed how they would handle different case presentations, with audience members weighing in as well.
Phaco after suspected PC rupture
Brandon Ayres, MD, shared pearls for when it’s likely that a PC rupture has occurred. First, he said it’s going to be OK as long you have a good anterior rhexis. The anterior rhexis is critical when PC support is in question. He has a low threshold to use capsular stain if red reflex is poor, and make sure the rhexis is small enough to capture the optic of the IOL.
His second pearl was don’t hydrodissect, hydrodelineate only. Hydrodissection may open the posterior capsule.
His next two pearls were to not spin the lens and to remove the nuclear component first. Spinning may propagate a tear of the posterior capsule. There are a variety of techniques that can be used to remove the nucleus. You should also minimize chamber shallowing and consider the use of bimanual I/A.
Next, he said not to be afraid to do vitrectomy. With this, Dr. Ayres said it may be helpful to refresh frequently to be sure you know how to do vitrectomy. With anterior vitrectomy, you can use triamcinolone to help visualize the vitreous strands. Make sure you use two ports. You can use both anterior and posterior incisions, he said, adding that you should use position three to make sure you’re aspirating. You can also use I/A cut for residual cortex. Lastly, Dr. Ayres said to capture the IOL in the anterior rhexis.
Editors’ note: Dr. Ayres has financial interests with a variety of ophthalmic companies.
IOL fixation with diffuse zonulopathy
Nicole Fram, MD, discussed if it’s possible to place an advanced IOL in the setting of diffuse zonulopathy, and she shared several pearls for successfully doing this. She first noted some of the signs of diffuse zonulopathy after the IOL is placed and noted fragments that go retrocapsular.
You need to put in capsule retractors early, and Dr. Fram suggested that you don’t need to tie them too tight. You just have to go to the equator to give you support.
Polishing the anterior capsule can help avoid phimosis. Over time, phimosis can lead to zonulopathy.
CTRs can be helpful, and Dr. Fram said to place a CTR prior to segments and to use countertraction. When putting in a CTR, you want the capsular bag filled, not just the anterior chamber.
It’s important to learn to use a CTS/Cionni ring. She also said to have a 3-piece ready for sulcus optic capture just in case.
Editors’ note: Dr. Fram has financial interests with a variety of ophthalmic companies.
Vitreous prolapse during phaco
Thomas Oetting, MD, discussed handling vitreous prolapse and offered several tips. He joked that denial is the first sign of vitreous loss, and you should know the signs. Don’t chase the nucleus south. It’s also important to maintain the chamber, and dispersive OVD can aid with this. Know when to punt to retina.
Dr. Oetting also mentioned a dispersive OVD barrier and the Osher slow motion phaco (lowering the bottle height and vacuum and slowing everything down).
Moving on to anterior vitrectomy, irrigate high and cut low. He likes to use a 23-gauge cortex extractor. Lastly, Dr. Oetting said to know how to capture a 3-piece IOL.
Editors’ note: Dr. Oetting has no relevant financial interests.
Retrocapsular lens fragments
Boris Malyugin, MD, PhD, discussed retrocapsular lens fragments. He noted that at the end of surgery, you can sometimes see tiny dark dots against the red reflex. These are not vitreous opacities, but small fragments of the lens. They come from the anterior chamber and accumulate behind the posterior capsule. There’s evidence in literature showing the presence of these fragments. The incidence varies between 6–46.5%, Dr. Malyugin said, adding that the incidence is dependent on comorbidities and patient population.
Fluid misdirection syndrome, where fluid accumulates behind the posterior capsule and pushes the capsule forward, contributes to these. Fluid misdirection syndrome is one of the risk factors for PC aspiration and rupture. These retrocapsular lens fragments appear due to irrigation fluid misdirection into the retrolenticular space, creating anterior vitreous detachment. Major contributing factors are excessive irrigation and zonular apparatus weakness, Dr. Malyugin said.
He also noted that correlation between these fragments and postop anterior and posterior segment inflammation is unclear. They could increase anterior segment inflammation and cystoid macular edema, but correlation is not yet established.
So, how do you prevent these fragments and anterior vitreous detachment? Dr. Malyugin said that using a low fluidics system can help decrease irrigation pressure and prevent fragments from entering the posterior segment. He also noted the visco-block technique, where you inject dispersive viscoelastic behind the iris at the beginning of surgery.
Editors’ note: Dr. Malyugin has financial interests with Alcon, MicroSurgical Technology, Morcher, and Ziemer.
Dead bag syndrome
Sam Masket, MD, presented on dead bag syndrome. A “dead bag,” he said, is a late postoperative capsule bag that has little/no LEC proliferation, no anterior capsule fibrosis or phimosis, and little/no Soemmering’s ring formation or PCO. It is nearly free of viable LECs.
Clinically, dead bag syndrome induces malpositioned IOLs. Initially, the lack of fibrosis may allow the IOL to move freely in the capsule bag, but eventually, the capsule may deteriorate, and the IOL can dislocate. Zonulysis will occur if the capsule degenerates in the periphery, Dr. Masket said. The IOL can decenter within the bag, out of the bag, or with the bag.
Dr. Masket said there are more questions than answers with dead bag syndrome. He offered some tips for surgical management. Be aware of possible dead bag syndrome because it’s a “ticking time bomb.” Surgery in these cases differs from usual zonulopathy cases. He said not to use the capsule bag for long-term fixation, and scleral fixation by any means is preferred.
Editors’ note: Dr. Masket has no relevant financial interests.
Anterior chamber lenses
Jonathan Rubenstein, MD, shared a presentation on how to avoid complications with anterior chamber lenses. One of the things he specifically discussed was knowing the difference between good and bad candidates for these lenses.
Good candidates are those with normal anterior segment anatomy. This includes a healthy corneal endothelium, normal iris anatomy, normal angle anatomy, and a deep anterior chamber.
Poor candidates, he said, are those with corneal endothelial compromise, insufficient iris support, iridocorneal angle damage, or shallow anterior chamber.
Editors’ note: Dr. Rubenstein has no relevant financial interests.
Kelman Lecture
Bonnie Henderson, MD, gave this year’s Kelman Lecture on “Enhancing the Paradigm of ‘See One, Do One, Teach One’ with Technology.” She focused on her commitment to education and the ways that education has evolved over the years. Dr. Henderson noted that education has been a focus and passion of hers, and she said this likely started with her parents. Her family immigrated to Chicago when she was 4 years old.
Surgical education is not something that starts and stops, she said. It’s constant because we have to continue learning all the time. Dr. Henderson noted advancements like MIGS, intravitreal injections, and corneal refractive procedures, adding those were all invented after her training.
Traditional methods of education include lectures, discussions with colleagues, and courses and skills transfer labs. But she added that there weren’t always easily available wet labs, internet videos, or virtual reality simulators to help with learning.
Dr. Henderson said that as she transitioned to becoming an educator, people were all teaching in their own ways. This prompted her to help put together the Harvard Intensive Cataract Course in 2005.
Dr. Henderson also discussed the evolution of surgical ophthalmic education, saying that when she first started teaching, it was stressful for not just the trainee but also the trainer. She helped develop a cognitive simulation software program to create a virtual instructor. This is now called Cataract Master (Mass Eye and Ear), and it’s used to show problems and how you can handle them.
Dr. Henderson still thinks you need that physical simulation in addition to software programs. You need wet labs, dry labs, or physical simulators.
Dr. Henderson said the next step is a quantum leap to artificial intelligence, and she went into some explanation and terminology of artificial intelligence. She discussed machine learning, deep learning, transfer learning, and the convolutional neural network (CNN).
Editors’ note: Dr. Henderson has no relevant financial interests.
EyeWorld Onsite is a digital publication of the American Society of Cataract and Refractive Surgery.
For sponsorship opportunities or membership information, contact: ASCRS • 12587 Fair Lakes Circle • Suite 348 • Fairfax, VA 22033 • Phone: 703-591-2220 • Fax: 703-591-0614 • Email: ascrs@ascrs.org
Opinions expressed in EyeWorld Onsite do not necessarily reflect those of ASCRS. Mention of products or services does not constitute an endorsement by ASCRS.
Click here to view our Legal Notice.
Copyright 2024. All rights reserved.
