Eyeworld Daily News

10 | EYEWORLD DAILY NEWS | MAY 5, 2019 ASCRS NEWS ASCRS ASOA ANNUAL MEETING by Lauren Lipuma EyeWorld Contributing Writer C hoosing the proper pre- mium IOL for cataract patients requires accurate preoperative imaging, so surgeons and staff should strive to get the best results possible, said instructors at Saturday morning's Technicians and Nurses Program course on preoperative imaging for premium cataract surgery patients. In this session, Kenneth Co- hen, MD, and Sarah Armstrong, ophthalmic imaging manager at Kittner Eye Center, Chapel Hill, North Carolina, discussed how surgeons use preop test results to choose the best premium lens and surgical method for each patient. They also gave attendees pearls for acquiring accurate imaging results and interpreting those results correctly. "The best intraocular lens power selection depends on the very best preoperative measure- ments, which are unique to each patient," Dr. Cohen said. "If one individual component is perfect- ed, outcomes are not significantly different. However, if one compo- nent is incorrect, a refractive miss is guaranteed." All staff should be experts All imaging staff need to be experts in acquiring and analyzing preop optical biometry, corneal to- pography, and retinal OCT scans, according to the instructors. When acquiring corneal topography measurements, it's important to understand where the instrument's focal plane is and how that affects the results, Ms. Armstrong said. The analysis report may show everything as green, meaning good measure- ments were made, but imaging staff should look more closely at the data, she said. Ms. Armstrong and Dr. Cohen use the Galilei (Ziemer Ophthalmic Systems) for Placido disc topography and Scheimpflug tomography. For Scheimpflug imaging, the instrument manufac- turer says the focal plane should be within one corneal thickness of the corneal surface. But Dr. Co- hen said that's not good enough; ideally it should be touching the anterior surface of the cornea. The focal plane can be somewhere within the corneal stroma, but it should never be on the posterior cornea, he added. When analyzing Placido disc topography, there should be less than 10 breaks inside the second light blue ring, Ms. Armstrong said. Holding the patient's eyelids can affect the astigmatism mea- surement, so she tries to avoid do- ing this as often as possible. If she does have to hold the patient's lid, she makes sure to make a note of that on the chart, so the surgeon knows to take that into consider- ation when analyzing the data. Include the retina Retinal pathology can affect postoperative vision, so Ms. Arm- strong and Dr. Cohen always per- form retinal OCT scans on their premium cataract patients. The most common issues they find are epiretinal membranes and cysts, but lamellar macular holes can also be common, Dr. Cohen said. Retinal pathologies don't nec- essarily disqualify a patient from surgery or from a premium lens; the best thing to do is refer the patient to a retina specialist and manage their expectations, Ms. Armstrong said. "For the most part, we can do the surgery with the different diseases, we just set their expecta- tions," she said. Preoperative imaging pearls for premium cataract surgery continued on page 12 Cataract experts share surgical nightmares by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer S aturday morning kicked off with a video-based instructional course on phaco nightmares and worst-case scenarios as expe- rienced by some of today's most skilled surgeons. The course's instructor, Amar Agarwal, MD, Chennai, India, said that "learning from mistakes" was the target of the course and vital for surgeons who want their patients to benefit after even the toughest of surgeries. A reliable solution to one of Dr. Agarwal's "worst nightmares" is performing pupilloplasty in eyes with pupillary defects. His approach includes a single-pass four-throw technique that involves the creation of only one initial approximating loop, followed by four throws that form an intertwining of sutures with a self-locking mechanism and no suture loosening. He approximates the stray ends of the iris using this knot method until a round pupil aperture is formed. Dr. Agarwal has successfully implemented this technique in patients with angle closure glaucoma, eyes with silicone oil, with glued IOLs, PDEK cases, and to create a pinhole pupil. According to Athiya Agarwal, MD, Chennai, India, IOL implantation in problematic eyes can be a source of sleepless nights. Her first video showed the painstaking steps she takes in eyes with Marfan's syndrome in which the lack of zonules requires the use of a glued IOL beneath scleral flaps. In another case, Dr. Agarwal described the advantage of a glued IOL scaffold in an eye with Soemmering rings, an annular swelling of the periphery of the lens capsule. She stabilizes the eye behind the rings before attempting to remove them, while carefully keeping any ring pieces from falling into the posterior segment. When complications pop up during surgery, making the right choice to either replace or stick with the chosen IOL in premium IOL patients can be a weighty decision. David Chang, MD, Los Altos, California, takes it case by case. He explained that a patient who has his heart set on a ReSTOR multifocal IOL (Alcon), for instance, after successful first-eye surgery would be disappointed to discover that complications kept the surgeon from implanting the same IOL into the second eye. A case-in-point involved a posterior capsular tear that might not have provided enough stable posterior capsular tissue to support the chosen lens. Alternatives for this case scenario include implantation of a three-piece monofocal IOL, putting off surgery and ordering a different three-piece multifocal lens, or using the ReSTOR, as planned. Dr. Chang overcame the challenge by using reverse optic capture to implant the ReSTOR, as there was no zonular dialysis or decentered CCC, and he was certain the patient would have been very disappointed with any other decision. Editors' note: The physicians have no related financial interests. Dr. Cohen discusses how all imaging staff need to be experts in acquiring and analyzing preoperative optical biometry, corneal topography, and retinal OCT scans.

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