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50 | EYEWORLD DAILY NEWS | MAY 6, 2019 ASCRS SYMPOSIA by Lauren Lipuma EyeWorld Contributing Writer The epithelium is traditionally re- moved with ethanol or an Amoils brush, but these can damage Bow- man's membrane, a considerable risk for keratoconus patients, Dr. Hatch said. An alternative is the EBK procedure using the Epi-Clear device (Orca Surgical). The Epi- Clear device is made of a biocom- patible polymer that collects the epithelium layers into grooves on the device. The procedure causes no trauma and doesn't damage Bowman's membrane. A study comparing the EBK procedure to PRK found EBK pa- tients healed faster, had less pain, and better postop visual acuity. Editors' note: Drs. Donaldson, Farid, Hatch, and Yeu have no financial inter- ests related to their comments. rior lamella is excised with cres- cent blades and the corneal edge is tapered with Vannas scissors. Finally, the tissue segments are custom tailored to the extent of the remaining defect. Multiple segments can be used to cover the entire affected area. Diplopia in the primary gaze was resolved for all patients who have received this type of graft and had no symblepharon recur- rences onto the keratolimbal al- lograft tissue itself, Dr. Farid said. Kathryn Hatch, MD, Waltham, Massachusetts, de- scribed a new tool for removing the corneal epithelium prior to crosslinking that reduces pain and expedites healing. The complications of corneal crosslinking are mostly associated with the epithelium removal, and can involve poor healing, infec- tion, pain, vision loss, and haze. Dr. Donaldson described a technique called the upside-down phaco chop, or the modified chop and flip, to better fragment and remove soft cataracts. The technique is a modified version of a technique developed by Howard Fine, MD, in 1993. Dr. Don- aldson likes to make a larg- er-than-usual capsulotomy in these cases and use extra viscoelastic to protect the en- dothelium. Her technique requires first making a central groove in the lens with the phaco handpiece and switching the second instrument to something flat, like a Drysdale or Koch spat- ula. Next, use the flat instrument to flip the lens and chop it from the other side. This technique can be especially helpful in a patient where you don't have a great view, she said. Marjan Farid, MD, Irvine, California, shared with attendees a new ocular surface reconstruction technique for treating recurrent symblephara using keratolimbal allograft tissue. This tissue is traditionally used for limbal stem cell transplantation, but it's a ro- bust tissue alternative to amniotic membrane or conjunctival auto- grafts for recurrent disease, she said. The tissue preparation for a keratolimbal allograft is similar to that for a limbal stem cell trans- plant, where the central corneal button is discarded from the donor tissue and the corneoscleral rim is then sectioned. The poste- S peakers at yesterday's "Mastering it All" session offered attendees useful pearls for dealing with soft and brunescent cat- aracts and described new approaches to treating recurrent symblephara and remov- ing the corneal epithelium prior to crosslinking. Elizabeth Yeu, MD, Nor- folk, Virginia, had several pearls for removing mature brunescent cataracts. If there is any intumes- cence under the anterior capsule, needle decompression will be your best friend, Dr. Yeu said. Insert your needle bevel down to aspi- rate some of the fluid and release some of the pressure, she said. She also recommends taking the time to fragment the nucleus into at least eight fragments and using repeated dispersive visco- elastic after each quarter to protect the corneal endothelium. Hard lenses often get a bad rap, but soft lenses can be just as difficult to fragment and remove, said Kendall Donaldson, MD, Plantation, Florida. Soft cataracts can give you a false sense of confidence, but don't be fooled; they don't crack or chop easily, can cause bowling out of the nucleus, and can create a posterior sheet of residual lens material. In addition, patients with soft cataracts are often younger and have higher demands, and they may expect a perfect outcome, Dr. Donaldson said. "A lot of the time we don't put as much thought and planning as maybe we should into these softer lenses, and a lot of times soft lenses can be a challenge," she said. Pearls for cataracts and ocular surface procedures Top: Dr. Hatch describes a new tool for removing the corneal epithelium prior to crosslinking that reduces pain and expedites healing. Bottom: Dr. Donaldson describes a method for removing soft cataracts.

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