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32 | EYEWORLD DAILY NEWS | MAY 5, 2019 ASCRS SYMPOSIA ASCRS ASOA ANNUAL MEETING by Liz Hillman EyeWorld Senior Staff Writer and pay attention to the anterior capsule to avoid eating it up with your vitrector. Michael Patter- son, DO, Crossville, Tennessee, said he will always do a pars plana vitrectomy. "I think your best bet is to clear the vitreous posteriorly, that way it won't come anteriorly," Dr. Patterson said. Editors' note: Drs. Al-Mohtaseb, Schallhorn, and Crandall have financial interests with a number of ophthalmic companies. Drs. Perez-Straziota, Za- vodni, Rao, Khandelwal, and Patterson do not have financial interests related to their comments. Dr. Crandall showing what not to do. When you notice a break and vitreous coming forward, take out your second instrument but leave irrigation in to maintain the anteri- or capsule, Dr. Schallhorn advised. Put in viscoelastic at the break first, she continued, then fill. At that point, Dr. Schallhorn said to make a second paracentesis (one that's not too long), intro- duce the vitrector, and put irriga- tion in to keep the eye inflated. Clean up vitreous that's coming up into the anterior chamber in a slow and steady manner, Dr. Schallhorn said. Following, you can address the residual lens mate- rial and cortex with phaco or with the vitrector. Other pearls Dr. Schallhorn offered were to use triamcinolone to stain for remaining vitreous Perez-Straziota discussed rotat- ing the lens with the patient, but noted that the existing tear made for a more delicate procedure that might require conversion to a different approach. Zachary Zavodni, MD, Salt Lake City, gave some basics for capsular tension ring placement. CTRs redistribute forces in the bag, preventing asymmetric phi- mosis of the bag, recenter the bag, and allow you to put something in the bag that you might not have otherwise been able to do, Dr. Za- vodni said. These devices are used in cases of loose zonules and mild zonular weakness or dialysis. Ideally, CTRs are placed after phaco and cortex removal, Dr. Zavodni said. It is important to fill the capsular bag to provide space for CTR placement and keep iris hooks in place. The goal is for a soft, broad-based landing of the CTR, Dr. Zavodni said. This can be done with an inserter or manually, depending on surgeon preference. Dr. Zavodni said he prefers using a 10.0 nylon suture or a Sinskey hook to aid in inser- tion. Dr. Al-Mohtaseb said she prefers to insert manually, using a Sinskey, though not through the eyelet but around the CTR as she threads it into the anterior cham- ber. Naveen Rao, MD, Burling- ton, Massachusetts, said you could also use micrograsping forceps to guide insertion. Sumitra Khandelwal, MD, Houston, pointed out the impor- tance of getting the CTR into the capsule, not leaving a portion in the sulcus. A sign that an edge is in the sulcus is if the capsulorhex- is is no longer round. Julie Schallhorn, MD, San Francisco, and David Crandall, MD, Detroit, both spoke about anterior vitrectomy, with Dr. Schallhorn providing pearls and T he Young Eye Sur- geons (YES) Clinical Committee sponsored a symposium on Saturday that included rapid-fire complicated case presen- tations and panel dis- cussion, providing attendees with several pearls and lessons learned. Claudia Perez-Straziota, MD, Los Angeles, led the session with the case of a tumultuous toric patient. The patient was 1 month postop and 20/200 in the right eye. Dr. Perez-Straziota found the IOL rotated 30 degrees from its intended axis and noted the presence of an anterior cap- sule tear. "What would you do when you have a tear intraoperatively and you were planning to implant a toric lens?" Dr. Perez-Straziota asked the panel. The question is how much astigmatism there is, said Zaina Al-Mohtaseb, MD, Houston. If it's a lot of astigmatism, this would eliminate options like an LRI or laser vision correction. If the an- terior capsule tear is small and the orientation is reasonable for the lens, a toric can be used, she said. "It's all about stability of the lens," Dr. Al-Mohtaseb explained. What about handling this patient with the tear and sub- sequent rotation postop? Dr. Perez-Straziota said due to signif- icant anisometropia, she would discourage spectacles. Laser vision correction was discussed, but the amount of astigmatism would make this option challenging. The patient also did not want to wear rigid gas permeable lenses to min- imize anisometropia. As such, Dr. Learning from challenging and complicated cases Dr. Zavodni discusses pearls for capsular tension ring placement.

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