Eyeworld Daily News

MAY 7, 2019 | EYEWORLD DAILY NEWS | 35 ASCRS SYMPOSIA by Stefanie Petrou-Binder, MD EyeWorld Contributing Writer capsular support. While hard piec- es of nuclear cortex are not used in many surgery centers, the panel agreed that it was a clever solution. The Golden Apple Award was given to Sergio Canabrava, MD, Belo Horizonte, Brazil, for his presentation on a new approach to microspherophakia. Editors' note: Dr. Canabrava has fi- nancial interests related to his comments. The other physicians have no related financial interests. the surgery. The case involved an absorbed sclerotic cataract and zonular dehiscence in a 72-year- old patient who opted against femtosecond laser-assisted cataract surgery. Dr. Parkash performed a slow-motion rhexis, going easy on the weakened zonular fibers. Once the rhexis was achieved, he con- sidered hooks, CTR, or a nuclear scaffold for extra zonular support. He inserted a CTR for horizontal support and left a sizable nuclear piece for scaffolding in an area with zonular weakness. He advised surgeons to consider a nuclear scaffold with hard cataracts in eyes exhibiting a generalized zonular weakness, lens subluxation of less than 90 degrees, and in eyes with antero-posterior and horizontal Another case by Lorenzo Cervantes, MD, Shelton, Con- necticut, weighed the option of saving or scrapping the capsular bag, a situation every surgeon finds himself in at some point. The case involved a 77-year-old male patient who was seeing triple in his right eye. His histo- ry included dissatisfaction with the quality of vision with the Crystalens (Bausch + Lomb), which was followed by an IOL exchange 7 months prior. The Crystalens optic was amputated at the hinges and a three-piece IOL was placed in the sulcus. Diplopia was immediate and soon followed by triplopia and glare. Dr. Cervantes followed a methodical preoperative and surgical plan that ultimately led to a happy patient. His surgical plan included gain- ing access to the bag by cutting through adhesions, freeing first the inferior then the superior haptics with the use of a disper- sive viscoelastic (viscodissection), taking measures to prevent further capsular contraction with a CTR (was not possible due to equatorial capsular fibrosis), and implement- ing radial capsule relaxing inci- sions at the rhexis for better optic capture. Plan B involved removing the lens and capsule, performing a vitrectomy, and implementing the Yamane technique. After stable optic positioning, posterior YAG laser capsulotomy helped to relieve the stress on the zonules, and ultimately the stress on the patient and surgeon as well. Saving the bag allows for a predictable effective lens position, prevents vitreous loss, and allows stable IOL support, and although not the easiest thing to do, it is often the right thing to do, he said. What are other ways to stabilize the lens capsule? Rohit Om Parkash, MD, Punjab, India presented a case in which the nuclear cataract was so hard, he could actually implement a piece of it as a capsular scaffold during M any surgical scenar- ios test the surgeon to use his best judgment and keep cool under pressure. Monday morning's Challenging Cases in Cataract Surgery Video Sympo- sium moderated by Kevin Miller, MD, Los Angeles, included eight "teachable" cases from different surgeons whose methods and decisions were weighed by a panel of 13 distinguished surgeons. The case handled best was awarded the Golden Apple Award for the best teaching case. Ahmed Assaf, MD, Cairo, Egypt, described the surgeon's di- lemma to revive a fibrotic capsule and keep or replace the IOL. His patient presented with right-sid- ed decreased vision, dull pain, and hyperemia 6 months after cataract surgery and single-piece sulcus-fixated IOL implantation. The patient had an IOP of 16 mm Hg and was scheduled for an IV injection of anti-VEGF when he came in for a second opinion. Using ultrasound biomicroscopy, Dr. Assaf saw that the single-piece IOL was poorly placed and decid- ed to replace it. After removing the IOL from the capsule and into the anterior chamber, he cut it into smaller pieces for easier removal through the 2.4 mm aperture, without wound extension. Dr. As- saf needed to break the adhesions between the anterior and posterior capsule leaflets, attacking first the areas of maximum fibrosis, and succeeding with meticulous care and patience. He found that the capsule, thus freed, provided good support for the new lens optic. He advised surgeons to avoid sin- gle-piece IOLs in the sulcus and always have a back-up three-piece lens at the ready. Challenging cataract cases we can learn from Dr. Miller awards Dr. Canabrava (left) the Golden Apple Award for his presentation on a new approach to microspherophakia.

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