Eyeworld Daily News

MAY 7, 2019 | EYEWORLD DAILY NEWS | 31 ASCRS SYMPOSIA by Stefanie Petrou Binder, MD EyeWorld Contributing Writer presented by Michael Snyder, MD, Cincinnati, who had to think fast when a sudden suprachoroidal hemorrhage took him by surprise during nucleus hydrodissection. The surgeon slipped in a Cionni ring to hold the capsule taut while first dealing with the bleeding that became heavier each minute. He advised eye surgeons who find themselves in this situation to secure and pressurize the globe first and perform a cautious sclerotomy to drain large lesions, which they should keep open. He used IV mannitol and topical IOP medication and advised addition- al surgery only when clotted or, ideally, when resolved. His patient received a secondary IOL and an iStent (Glaukos) after 2 months, achieving a visual acuity of 20/25 and an IOP of 18 mm Hg. Sometimes it is "simple" IOL placement that has a surgeon sweating the most. A case presented by Ehud Assia, MD, Tel-Aviv, Israel, involved the implantation of a trifocal toric IOL in the second eye of a patient who received the same IOL in his first eye. The calculated IOL position at 14 degrees shifted to 80 degrees postoperatively, leaving the patient with 20/200 visual acuity. The case now required back calcula- tion, a CTR due to a torn capsule, IOL repositioning and secure iris fixation that resulted in a resid- ual astigmatism of more than 3 D. Dr. Assia said that while the repositioning and refixation of toric multifocal IOLs was feasible, the refraction of the decentered toric IOL might be inaccurate and should not be used for back calculation. Editors' note: The physicians have no related financial interests. loss of zonules, things went from bad to worse. After IOL implan- tation and a well-positioned iris prosthesis, Dr. Koch noted a radial tear and a wildly off-center IOL and loose Ahmed capsular tension ring segment. IOL replacement eventually led to 20/25 visual acu- ity and a good cosmetic outcome, but the development of glaucoma later on that required a tube shunt made this a case the surgeon will never forget. The case of a 66-year-old female patient with dense cataract and a history of trauma from the impact of a bungee cord on her left eye was a scary case scenario to salvage rather than remove the lens, Dr. Masket used 10-0 prolene sutures, a bent, 27-gauge hypoder- mic needle, and an AC maintainer to secure the IOL, creating two lassos that pull the lens back into place centrally through sequen- tial tension on the ends of both sutures. Complicated cases can some- times end up worse than they started, despite the surgeon's best efforts. In one such case described by Douglas Koch, MD, Hous- ton, involving a 49-year-old male patient who had a self-inflicted knife wound from age 9 in one eye with hand motion vision and 40% E ven the most skilled oph- thalmic surgeon can expe- rience a case that has him or her sweating bullets. "Sweating Bullets" invited 12 renowned surgeons to share a video of one case that really made them sweat. Robert Osher, MD, Cincinnati, moderated the divided panel of American and international teams, each vying to be the winner of this year's competition. Some of the cases presented were extremely complex from the get-go, while others seemed simple enough, but flew out of control. The first case, presented by international team member Fernando Trindade, MD, Belo Horizonte, Brazil, was a traumatic eye after a severe car crash that would make even the best surgeon sweat. Shards were removed from the eye that had lacerated the cor- nea and sclera, with deep scleral lacerations over the ciliary body. The surgeon noted iridodialysis, which he tucked in and secured with a corneal suture. Dr. Trindade advised that surgeons never suture anything without good visualiza- tion. Not knowing the state of the lens capsule required very careful lens manipulation and three-piece IOL implantation, followed by pupilloplasty, leaving the patient with 20/40 visual acuity and an aesthetically acceptable eye. "Less is more," according to Sam Masket, MD, Los Angeles, hitting for the American team, who implemented the basket suture technique to manage a mal- positioned posterior chamber IOL in the eye of a one-eyed 57-year- old male patient with scleral buckling, conjunctival scarring, high myopia, and a three-piece IOL with capsular fibrosis. Opting Complicated surgeries that make surgeons sweat Top: Dr. Trindade describes a complicated case that caused him to sweat bullets. Bottom: Dr. Masket describes his basket suture technique to secure the lens in a complicated eye.

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