July 2019


YES Connect
Challenging and complicated cases covered in YES symposium

by Liz Hillman EyeWorld Senior Staff Writer

Dr. Al-Mohtaseb, Dr. Khandelwal, and Dr. Rao at the YES-sponsored symposium at the 2019 ASCRS ASOA Annual Meeting
Source: ASCRS


Every year at the ASCRS ASOA Annual Meeting, the YES Clinical Committee holds a symposium of challenging cases and complications. Members of the committee present their mistakes, saves, and tips for many common issues that surgeons face. I’ve learned something useful each time I’ve been involved in the meeting and highly encourage young surgeons to attend.  
This is my final column as YES Connect co-editor. Samuel Lee, MD, and I are passing the baton to the excellent Julie Schallhorn, MD, and Claudia Perez-Straziota, MD, who I know will continue to make this column a useful and interesting resource for young surgeons. We are very thankful to the EyeWorld staff for all they do. 

David Crandall, MD,
YES Connect co-editor

Attendees at a symposium sponsored by the Young Eye Surgeons (YES) Clinical Committee at the 2019 ASCRS ASOA Annual Meeting learned about the challenging cases and complications faced by the committee’s panelists. Here’s a recap of a few of the presentations from the symposium.

Anterior capsular fibrosis

Zaina Al-Mohtaseb, MD, addressed creating a capsulorhexis in the presence of anterior capsular fibrosis. In cases where she is worried about zonular loss and where there is a lot of synechiae, Dr. Al-Mohtaseb said she likes using iris hooks, premarking hook locations so that her paracentesis and wound are well positioned.
Capsules with anterior fibrosis are at higher risk for tearing during the capsulorhexis formation, Dr. Al-Mohtaseb said. In the case she shared, she inserted intracameral epinephrine, then stained the capsule with trypan blue. She irrigated it out and injected OVD and used the cannula to break the synechia and lift the iris. This step, Dr. Al-Mohtaseb said, is key to prevent the anterior capsule from tearing. She then inserted a Malyugin ring.
There was still pigment on the anterior capsule from the synechiae, which she advised removing, otherwise it’s difficult to make the capsulorhexis. After removing the pigment, Dr. Al-Mohtaseb removed the OVD (a cohesive) with irrigation and aspiration and stained with trypan again. She reinserted OVD and using Utrata forceps, pulled centrally with little maneuvers as she began the capsulorhexis (not circumferentially). She noted some zonular loss in this case during this step. After removing the nucleus and the cortex, she placed a capsular tension ring through the paracentesis, holding onto the ring with a Sinskey hook until it was in place.

Starting out with miLOOP

Leela Raju, MD, provided pearls for those starting out with miLOOP (Carl Zeiss Meditec). First, stain with trypan blue to visualize the capsule. Then, hydrodissect away from the areas that you’re going to have the loop come out of so that you can clearly see your edge.
Dr. Raju noted the black mark on the handpiece of miLOOP that serves as a guide to avoid over insertion. It might feel like you are stretching the capsule, Dr. Raju said, but it has the capacity to do that. Dr. Raju advised tilting the device a bit as you start to deploy it, making sure you get under the capsule edge.
Sumitra Khandelwal, MD, said to watch where your hands are. You need to be at a 20-degree angle. If you’re too flat, you’ll push the lens down, she said. If you’re too steep, you could put stress on the zonules 180 degrees away.
“The miLOOP doesn’t come out straight; it comes out and back, so understanding the anatomy of it is important,” Dr. Khandelwal said.
Dr. Raju uses a second instrument to hold down one of the cut pieces, as it can sometimes pop up. She recommended bisecting the nucleus for your first few cases before attempting to create quadrants when you are just starting out. Some people are comfortable rotating with the miLOOP, but Dr. Raju said she uses her second instrument.

Small pupil management

There are several ways to enlarge the pupil, Naveen Rao, MD, said, noting dilating drops, viscoelastic, epi-Shugarcaine, phenylephrine/lidocaine, Omidria (phenylephrine and ketorolac, Omeros), and mechanical options such as pupil expansion rings and iris hooks.
Dr. Rao focused his discussion on the use of rings and hooks. When creating the paracentesis incisions for iris hooks, Dr. Rao said to aim slightly down, rather than flat. He usually starts with four hooks, but if there is iris prolapse through the main incision, it’s helpful to place an extra hook just posterior to the main incision by creating a paracentesis through the anterior sclera.
Dr. Rao said he prefers the 7.0 mm Malyugin ring (versus the 6.5 mm) because it maximizes visualization and is no more difficult to insert than the 6.5 mm size. The first step to insertion is putting in dispersive viscoelastic to protect the endothelium, followed by cohesive viscoelastic to elevate the iris off of the anterior capsule. The distal scroll is engaged first, followed by at least one of the side scrolls, and after the injector hook is disengaged, the subincisional scroll is engaged using the Osher manipulator. When it comes time to take it out, disengage all the scrolls starting with the distal scroll. Then, give a slight clockwise rotation of the ring to make the subincisional scroll more accessible to engage with the hook on the inserter device.
Other advice from the panel included tightening iris hooks only after all of them are placed, avoid making incisions too posterior, and iris hooks and capsule hooks are not necessarily interchangeable. If the iris billows when you inject lidocaine at the beginning of the case, Dr. Rao said it’s probably a better candidate for epi-Shugarcaine or iris hooks rather than a Malyugin ring because a very floppy iris can become disengaged from the ring halfway through the case.

Not a routine IOL positioning

Manjool Shah, MD, described a case that no one wants to get at 4:45 p.m. on a Friday. The patient was referred for recurrent hyphema after an IOL exchange earlier in the week. A dislocated Crystalens (Bausch + Lomb) in the bag was removed in a procedure Monday, and a scleral-fixated IOL was placed using the Yamane double-needle flanged haptic technique. The patient was seen Tuesday, Wednesday, and Thursday with blood from the back to the front of the eye.
When seen by Dr. Shah, the patient’s IOP was in the 40s, vision was hand motion, and ultrasound biomicroscopy showed improper positioning of the IOL to the iris anatomy. The IOL was implanted too anterior (1.5 mm from the limbus), and endoscopy showed haptics going through the ciliary body, Dr. Shah said.
Dr. Shah went in, noting how fibrosed the haptics were even after a few days, and cut off the flanges. Sclera fixation was redone with the haptics fixated 2.5 mm from the limbus. Measuring back from the scleral spur correlates with intraocular anatomy while the limbus does not and is variable, Dr. Shah said. He also noted the importance of making sure the needle for the Yamane technique is perpendicular to the sclera. This, he said, ensures that you don’t end up too anterior in the eye.

Contact information

Al-Mohtaseb: zaina1225@gmail.com
Khandelwal: Sumitra.Khandelwal@bcm.edu
Raju: Leela.Raju@nyumc.org
Rao: naveen.k.rao@lahey.org
Shah: manjool@med.umich.edu

About the doctors

Zaina Al-Mohtaseb, MD
Assistant professor
Department of Ophthalmology
Baylor College of Medicine

Sumitra Khandelwal, MD
Assistant professor
Department of Ophthalmology
Baylor College of Medicine

Leela Raju, MD
Clinical associate professor
Department of Ophthalmology
New York Langone Health
New York

Naveen Rao, MD
Assistant professor of ophthalmology
Tufts University School of Medicine

Manjool Shah, MD
Assistant professor of ophthalmology
Kellogg Eye Center
University of Michigan
Ann Arbor, Michigan

Financial interests

Al-Mohtaseb: Alcon, Bausch + Lomb, Johnson & Johnson Vision, Carl Zeiss Meditec
Khandelwal: Carl Zeiss Meditec
Raju: None
Rao: Parexel, Shire, W.L. Gore
Shah: Allergan, Glaukos, Katena

Challenging and complicated cases covered in YES symposium Challenging and complicated cases covered in YES symposium
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