April 2019

NEWS

Presentation Spotlight
Video highlights from the 2019 Surgical Summit


by Ellen Stodola and Liz Hillman EyeWorld Senior Staff Writers


Fully extended miLOOP illustrating the size of the snare and the angulation relative to the handle
Source: Mitchell Weikert, MD

 

The 2019 Surgical Summit included interactive video sessions that touched on various topics involving cataract surgery challenges, dislocated IOLs and IOL fixation, MIGS-related procedures, and more. Here are a few selections from those sessions.

Managing dense cataracts with miLOOP

Mitchell P. Weikert, MD, and Sumit “Sam” Garg, MD, spoke about using the miLOOP (Carl Zeiss Meditec) for dense cataract cases.
“Ever since this came out, it has been my go-to for dense cataracts. I’m not one for hyperbole, but for me this has been a game changer,” Dr. Weikert said, before presenting the case of a red brunescent cataract.
Dr. Weikert offered several miLOOP pearls:
• Stain the capsule.
• Get an adequately sized capsulorhexis (approximately 5 mm); using a capsulorhexis marker can be very helpful.
• Hydrodissect thoroughly so the lens moves easily.
• Understand how the miLOOP snare expands and contracts.
• Visualize the angle of the handle relative to the snare; angle up a bit (20 degrees).
• Pass the snare under a stained capsule, maintaining the black ring on the instrument at the incision. As the snare is contracted, use a second instrument to apply pressure to the distal pole to keep the lens from rotating out of the capsule.
• Recognize that the loop doesn’t close completely so you will need to carefully break the nuclear bridge.
• When performing phaco, work in the plane of the lens and capsule and refill periodically with a dispersive viscoelastic to protect the corneal endothelium.

Dr. Weikert said that he now sees dense lens cases that are 20/20 on postop day 1 after using the miLOOP.
Dr. Garg described using miLOOP as a rescue technique. He encountered an extremely dense lens that he initially used the femtosecond laser on to create the capsulorhexis, LRIs, and fragmentation. When he tried to impale the lens with his phaco probe, despite the femto treatment, he couldn’t. He attempted both vertical and horizontal chops as well as trying to groove the lens, and all were unsuccessful. At this point, he turned to miLOOP to segment the lens and proceeded to phaco. Given the density of the lens, Dr. Garg felt that despite using the femtosecond laser, without the miLOOP, he would have had to convert to an extracapsular cataract extraction to complete this surgery.
Deepinder K. Dhaliwal, MD, spoke about dense lenses as well. On dense lenses, she uses a stop and chop technique with a wide groove and horizontal chop. On denser lenses, she makes a deeper and wider groove and uses vertical chop. For the densest lenses, Dr. Dhaliwal recommended miLOOP and showed a video of her first miLOOP case. Other pearls she offered included staining the anterior capsule; making an extra paracentesis; assessing the anterior chamber depth and using preoperative mannitol if it’s shallow; keeping phaco energy far from the corneal endothelium by debulking the lens in the capsular bag; and further protecting the endothelium and the posterior capsule by using dispersive viscoelastic, replenishing it as necessary.

CyPass explantation

Peter T. Chang, MD, shared a case where he had to explant a CyPass Micro-Stent device (Alcon). A 69-year-old patient came to him unhappy with a CyPass surgery that she had had performed 3 months ago out of state. When Dr. Chang saw the patient, the pressure was 26 mm Hg and refraction was hyperopic.
Dr. Chang said some of the potential options he considered included leaving the CyPass alone and placing a new CyPass, leaving the CyPass alone and placing a tube shunt, pushing the CyPass further into the supraciliary space, or exchanging for a new CyPass.
When Dr. Chang went in to exchange the CyPass, he found severe fibrosis in the supraciliary space, and the CyPass didn’t move when he tried to tap on it, yank on it, and cut it.
When he did finally manage to remove it, Dr. Chang said he decided not to use another CyPass or tube shunt in light of the resulting cyclodialysis cleft.
He concluded that the CyPass scars quickly in the supraciliary space, and though removal of the device is difficult, it’s not impossible. The company recommends trimming the device, he said, but this may be difficult as well. Specialists need better ways to deal with improperly implanted CyPass devices, he added.
On August 29, 2018, Alcon voluntarily withdrew the CyPass from the market due to safety concerns. An ASCRS task force provided monitoring, intervention, and revision considerations that were published in the October 2018 issue of EyeWorld.

About the doctors
Peter T. Chang, MD
Associate professor of ophthalmology
Cullen Eye Institute
Baylor College of Medicine
Houston

Deepinder K. Dhaliwal, MD
Professor of Ophthalmology
University of Pittsburgh School of Medicine
Pittsburgh

Sumit “Sam” Garg, MD
Medical director
Gavin Herbert Eye Institute
University of California, Irvine

Mitchell P. Weikert, MD
Associate professor of ophthalmology
Cullen Eye Institute
Baylor College of Medicine
Houston

Financial interests
Chang: Allergan
Dhaliwal: None
Garg: Johnson & Johnson Vision, Carl Zeiss Meditec
Weikert: Alcon

Contact information
Chang: ptchang@bcm.edu
Dhaliwal: dhaliwaldk@upmc.edu
Garg: gargs@uci.edu
Weikert: mweikert@bcm.edu

Video highlights from the 2019 Surgical Summit Video highlights from the 2019 Surgical Summit
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