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20 | EYEWORLD DAILY NEWS | MAY 18, 2020 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING support, an iris hook can be used at the edge of the cap- sulorhexis to provide counter traction for completing the rhexis. If the surgeon is going to continue the rhexis periph- eral to an existing iris hook on the capsulorhexis edge, that existing hook should be re- moved or repositioned to avoid creating unusual force and an uncontrollable rhexis situation. Dr. Ogawa also mentioned that capsular support hooks are useful for intraoperative bag support when there are absent or weak zonules. However, the hooks do not support the equator everywhere, so one should use low-flow settings to reduce the chance of aspi- rating the peripheral capsule. The Cionni CTR with ePTFE, or Gore-Tex, through two suture arms creates essentially per- manent capsule support, Dr. Ogawa said. When making the scleral incisions for the suture, dispersive OVD can help create space between the iris and cap- sule where the MVR blade is placed. If the surgeon sees the peripheral iris moving centrally during blade placement, the blade is likely too far anterior. Placing a loop of 10-0 nylon suture through the lead eyelet minimizes stress on the capsu- lar bag. Minu Mathen, MD, Trivan- drum, India, shared case presentations of Morgagnian cataracts. He started with one case where the plan was to perform phaco. The anterior capsule was stained with try- pan blue and the capsulorhexis initiated. The leaking, liquid cortex was aspirated. Once the capsular bag was partially emptied, the hard nucleus be- came visible. The capsular bag by Ellen Stodola Editorial Co-Director A symposium live- streamed on Sunday afternoon included videos showcasing challenging cases in cataract surgery. Gregory Ogawa, MD, Albu- querque, New Mexico, shared a case of a traumatic cataract. His patient was a 65-year-old male who had right eye trauma from a bungee cord 3 months prior to surgery. The patient had a probable traumatic optic neuropathy from the injury. He had previously had LASIK. Preop BCVA was 20/50 with a +2.75 D hyperopic shift. The patient had a trau- matic cataract, subluxation of the natural lens from exten- sive zonular rupture, vitreous prolapse into the anterior chamber, and traumatic mydri- asis. As the case began, the jig- gling cataract was visible with a very large pupil. Dr. Ogawa used a 23-gauge trocar can- nula tangentially through the sclera then headed posteriorly. He used a vitrector through the limbus to remove vitreous from the anterior chamber, then through the pars plana to remove vitreous in the poste- rior segment and support the lens for commencement of the rhexis and placement of the iris retractor on the rhexis edge. The iris retractor allows for counter traction to perform the capsulorhexis, he said, until a second retractor is needed for completion of the rhexis under the area of the first retractor. He also placed capsular sup- port hooks and completed phaco with a low-flow setting. Because of the absence of zonules and vitreous, extra care was required to get all the lens material out. A manual aspirator re- moved the cortex, while the two capsular support hooks were loosened to make the scleral incisions. Cohesive OVD was used to reform the capsu- lar bag, then Dr. Ogawa used 10-0 nylon and a modified CTR. The ring was carefully placed into the capsular bag, and gentle traction with the 10-0 nylon was used to min- imize stress on the capsular bag. Once the second suture arm neared the outside of the main incision, a 3-cm piece of ePTFE was placed on that arm before continuing with place- ment of the ring into the eye. Once the ring was fully in the capsular bag, it was rotated to position the suturing eye- lid near the scleral incisions. Curved 25-gauge coaxial for- ceps were placed through one scleral incision to grasp and externalize one suture arm. They were then placed through the other scleral incision to grasp and externalize the other suture arm. The ePTFE suture arms were gently tied together with a two-wrap throw. At this point in the case, Dr. Ogawa said the capsule support hooks can usually be removed. Cohesive viscoelas- tic separates the capsular bag and iris, and the angled MVR blade makes a scleral incision. In this case, it was a little too far anterior and moving the peripheral iris, he said, so it was repositioned farther back. Another 3-cm piece of ePTFE was grasped with the 25-gauge forceps, passed down, and externalized through the other scleral incision before another two-wrap throw was placed. At this time, one side of the 10-0 nylon loop may be cut and the suture removed, he said. A single-piece acrylic IOL was placed into the capsular bag. Once centration of the bag was confirmed, the suture arms were tied with four additional single-wrap throws to secure the knot. The same throws were also placed on the oth- er side prior to trimming the sutures and burying the knots inside the eye. The posteriorly rolled iris was unfurled prior to placing a curved trans-chamber needle on 10-0 polypropylene through one of the paracenteses with a cyclodialysis spatula to open the paracentesis. The needle was woven through the iris and back out through another paracentesis before the knot was tied. At 1-month postop, Dr. Ogawa said the patient had trace pigment on the optic of the acrylic IOL and 20/20 un- corrected vision. To close, Dr. Ogawa shared several "teaching points" from the case. He noted that placing a pars plana trocar cannula transiently creates very high intraocular pressure. He rec- ommended placing one before any other incisions are made in the eye or placing with other incisions well sealed. He said there tends to be a debate as to whether a limbal approach or pars plana approach is bet- ter for anterior vitrectomy. In some situations, like this case, both approaches are required for adequate management of the vitreous. "We see in this case the usefulness of using a pars plana vitrectomy probe for supporting a cataract with extensive zonular loss, particularly for starting the capsulorhexis," Dr. Ogawa said. In situations with no zonular Challenging cataract cases showcased in video format continued on page 22

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