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8 | EYEWORLD DAILY NEWS | MAY 4, 2019 ASCRS NEWS ASCRS ASOA ANNUAL MEETING by Ellen Stodola EyeWorld Senior Staff Writer/ Meetings Editor including pilocarpine. Chronic pilocarpine is a "tell," Dr. Brown said, which is telling you that you need to be doing cataract surgery. He concluded by saying that cataract surgery in angle clo- sure may require use of all your surgical skills, but most of the time, surgery is routine. The main challenge is not how, but why and when. Phaco is effective glaucoma treatment in all stages of angle closure, Dr. Brown added. Editors' note: Dr. Zhang has no finan- cial interests related to her comments. Dr. Brown has financial interests with Aerie Pharmaceuticals. T he 2019 ASCRS Glauco- ma Day kicked off with a joint symposium from ASCRS and the American Glaucoma Society (AGS) on "Optimizing Surgical Outcomes of Cataract Surgery in the Complex Glaucoma Patient." Amy Zhang, MD, Ann Arbor, Michigan, presented on cataract surgery in the pseudo- exfoliation glaucoma patient and shared some of the tools she uses for these cases. First, she discussed the impor- tance of a preoperative evalua- tion. She said to note the signs of pseudoexfoliation, as well as the degree of pupillary dilation and the degree of zonular laxity. Next, you have to consider what kind of procedure you're go- ing to do, whether it's a combined glaucoma procedure or phaco alone. When deciding, she said to consider intraocular pressure, medication tolerance, stability of the glaucoma, and the degree of glaucomatous damage. Dr. Zhang went on to discuss intraoperative considerations. The use of a soft shell technique with a combination of OVDs is very important, she said. Be careful not to overinflate the anterior chamber because if you do that, it will add further stress to the zonules. She also said to note the amount of pupillary dilation, and if there's not adequate dilation, use pupil expansion devices. Dr. Zhang stressed the importance of the creation of a 5–6 mm capsulor- hexis. "I also like to viscodissect in addition to hydrodissect to mobi- lize the nucleus before proceeding with phaco," she said. Capsular retractors can help facilitate hydrodissection and cata- ract fragmentation, while capsular tension rings (CTRs) support areas of zonular dehiscence and allow for optimal IOL centration. "In terms of the phaco technique, you want to pick techniques that minimize stress on the zonules," Dr. Zhang said. She recommended using a pre- chopper/ultrachopper technique, a horizontal or vertical chop, or prolapsing the lens out of the bag. For cortical removal, Dr. Zhang said you might want to consider tangential stripping instead of traditional radial stripping, and for IOL insertion, she recommended considering a three-piece or one- piece IOL. If there's presence of vitre- ous, Dr. Zhang recommended a limited anterior vitrectomy and filling the anterior chamber with viscoelastic prior to removing instruments. She also suggested using extensive I/A. Postoperatively, Dr. Zhang said you may need to consider tapering these patients off steroids and NSAIDs for an extended time, and it's important to observe them for postoperative pressure spikes. Reay Brown, MD, Atlanta, presented on "Cataract Surgery of the Chronic Angle Closure Glaucoma Patient: Different Tech- niques for Different Stages." Dr. Brown discussed a woman he first saw about 11 years ago. She had 20/20 vision but had had closed angles for 6 years and was on maximum medications in both eyes (in the eye of concern, the pressure was 23 with a spike to 31). The field was normal in both eyes. Dr. Brown used cataract extraction with goniosynechialysis for this patient, but he also noted that when he first saw this patient 11 years ago, the go-to procedure was a trabeculectomy. He noted that the patient's angle was completely closed when the cataract surgery was done, but after a successful surgery, Dr. Brown said the patient is now 20/20 in both eyes with no med- ications at 11 years postop. "That shows the power of cataract sur- gery in these patients," he said. Dr. Brown shared a case that demonstrated the value of using viscoelastic to open a closed angle, as well as another case he handled of a 64-year-old man with a clear lens who was on five medications, Glaucoma Day explores cataract surgery outcomes for the complex glaucoma patient Dr. Zhang discusses cataract surgery in pseudoexfoliation glaucoma patients.

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