Monday’s Cataract Spotlight Session focused on complicated phacoemulsification cases, with speakers offering their top 5 pearls derived from hard-won clinical experience. Here are some selected cases.
The mature white cataract. 1) To begin with, “You have to have good visualization,” said Robert H. Osher, MD. His additional suggestions are as follows: 2) Don’t overhydrate. “You don’t want to increase the pressure behind the nucleus.” He also advised, “You want the fluid to have an escape route.” 3) Have an adequate rhexis size. “You can get handcuffed by the size of your rhexis. The smaller rhexis is a mistake in these cases.” 4) Employ patience. “We’re in no hurry, especially with the leathery cortex.” 5) Use caution with trypan blue. “The capsule loses its elasticity with trypan blue, which is why the pediatric ophthalmologists like it,” he said. And if you do use it, “be careful about putting pressure against the capsular edge.”
The rock-hard nucleus. Kevin M. Miller, MD, noted that rock-hard nuclei are usually accompanied by the challenging triad of dense brunescent cataract, miotic pupil, and zonular laxity. He presented the following pearls: 1) Be ready to perform extracapsular cataract extraction, intracapsular cataract extraction, or small-incision manual cataract surgery. “Know how to remove the nucleus in 1 piece using a variety of manual techniques,” he said. “Know how to convert if phaco isn’t going well. Have a lens loop available on the tray in your OR.” 2) Use lots of ophthalmic viscosurgical device (OVD). “Dispersive OVD is your friend in these cases,” Dr. Miller said. “And be sure to top it off frequently.” 3) Consider using a capsular dye. “Trypan blue may help a little. And make the capsulorrhexis larger than normal.” 4) Have tools such as hooks, capsular tension rings, and capsule retractors at the ready in case they’re needed. 5) Do what you can to minimize the amount of phaco energy used. For instance, he said, “Consider chopping techniques over sculpting techniques; consider torsional or elliptical phaco modes; use pulse modulations to minimize energy.” In addition, he said, this might be the time to use a femtosecond laser if you have access to one, as they have been proven to reduce ultrasound energy. “That’s especially important for grade 3 and grade 4 nuclear cataracts.”
The diabetic patient. As a retina surgeon, Julia A. Haller, MD, said that her goal is to “tee that [diabetic] eye up so that you cataract surgeons will be successful.” In other words, it’s “all about the health of the eye going into cataract surgery.” Her top 5 pearls are as follows: 1) Do a medical tune-up. “It’s all about partnership with other medical professionals—we know that these patients have glycemia control issues, hypertension, and elevated lipids.” In addition, there is ample evidence that comorbid conditions—notably sleep apnea, depression, and eating disorders—need to be addressed. 2) Do a retinal tune-up. “You’re looking for preproliferative levels of diabetic retinopathy [DR], and drying up that diabetic macular edema [DME].” 3) Use pharmacotherapy/laser for DR. 4) And also use pharmacotherapy/laser for DME. “We know that it’s important to keep these eyes dry,” Dr. Haller said, noting that DR improves if DME is treated. 5) Prophylactically treat for postcataract edema. “This is my least evidence-based recommendation,” she said, as many questions remain in this area.
The eye with very weak zonules. Thomas W. Samuelson, MD, offered his pearls on dealing with cases of very weak zonules. 1) Address the full picture in your preoperative assessment. “Make the diagnosis, and make it known to the patient and the patient’s family—they need to know that there’s an increased risk of exfoliative glaucoma.” 2) Get to know the uncommon zonulopathies. 3) Get a good view and work in the middle. And when in doubt, use expanders. “There are terrific pupil expanders now; there’s no need to go through all that manipulation.” He added that surgeons should avoid working the periphery and use tangential I&A. 4) Consider using the femtosecond laser. That said, he acknowledged, “I’ve been trained on 2 femto platforms, but I actually don’t use it that often. I learn a great deal from my initial capsulotomy incision” with these patients. 5) Don’t destroy the capsule trying to save it. “Don’t be a hero; know your limits,” he said. “Use slow methodical I&A.”—Jean Shaw
Financial disclosures. Dr. Haller: Celgene: O; Janssen: C; KalVista: C; Merck & Co., Inc.: C; ThromboGenics, Inc.: S; Dr. Miller: Alcon Laboratories, Inc.: C,L,S; Calhoun Vision Inc: S; Dr. Osher: Alcon Laboratories, Inc.: C; Bausch & Lomb Surgical: C; Beaver-Visitec International, Inc.: C; Carl Zeiss Meditec: C; Clarity: C; Microsurgical Technology: C; Omeros: C; Video Journal of Cataract & Refractive Surgery: O; Dr. Samuelson: Abbott Medical Optics Inc.: C; AcuMems: C; Aerie Pharmaceuticals: C; Akorn Inc.: C; Alcon Laboratories, Inc.: C; Allergan: C; AqueSys: C,O; Endo Optiks, Inc.: C; Equinox: C,O; Glaukos Corporation: C,O; Ivantis: C,O; Ocular Surgery News: C; Shire: C; SLACK, Incorporated: C; Transcend: C.
Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.