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36 | EYEWORLD DAILY NEWS | MAY 18, 2020 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING Later Dr. Hovanesian said you should always pull toward you, never pushing away, with the cannula. The second technique—the in-the-bag technique—also involves a 27-gauge cannula. Dr. Hovanesian said to cross the eye, go inside the capsu- lar bag, and begin sweeping before you inject. Advantages of this technique include that the optic serves as a barrier to keep the Dexycu peripheral, Dr. Hovanesian said. It's also easier to view the drug and there is little risk of damaging the iris with this approach. Other presentations in this skills transfer lab covered intrascleral suture fixation, ectopia lentis and IOL-sutured capsular tension segment, and capsular tension rings for zonulopathy. See all of the pre- sentations in STL-1. Editors' note: Dr. Hovanesian has financial interests with Ocular Therapeutix. Dr. Devgan and Dr. Kim have no financial interests related to their presentations. by Liz Hillman Editorial Co-Director P haco techniques and drug delivery systems for cataract surgery were covered in a skills transfer lab. Several phaco techniques were presented, including di- vide and conquer and stop and chop for dense lenses. A third technique discussed was the double chop and cross chop. D. Brian Kim, MD, Dalton, Geor- gia, said he's heard people say they've had an anterior capsule tear when trying this technique or have avoided it due to this fear. He hoped to provide cor- rect instrument positioning to give viewers confidence. "As long as you place the instruments correctly, there should be no anterior capsular tear, there should be no iridodi- alysis, doing these techniques," he said, noting that you have to use the right chopper for this technique. He uses the Kim Double Chopper (Katena). He said to place the chop- per on the surface of the endonucleus, sliding it toward the periphery to go under the epinuclear ridge and into the capsular fornix. At this point, rotate the chopper tip down, and you're now between the epinucleus and endonucleus to facilitate an effective double chop and cross chop technique. "In this configuration, there is no way you can cause an anterior capsule tear or zonu- lar dialysis or some type of capsular complication due to the position of the chopper," he said. Uday Devgan, MD, Los An- geles, California, presented on options for IOL explantation. One technique—twisting—in- volves holding the optic on the side and using a spatula to protect the corneal endotheli- um and to roll the lens around the holding forceps. Once rolled, it's pulled through the standard incision size. "We don't get a full 360 here, maybe not even 180, but enough roll to compact the lens to explant," Dr. Devgan said. The other option is cutting the lens with microscissors. Dr. Devgan said one should not cut fully in half because keeping the pieces together makes it easier to explant. Dr. Devgan also noted that some people implant a new IOL before cutting out the old lens for protection. Other presentations ad- dressed drug delivery. Two newer options are Dexycu (EyePoint Pharmaceuticals) and Dextenza (Ocular Thera- peutix). John Hovanesian, MD, Laguna Hills, California, gave insertion techniques for both options. For Dextenza, a dexameth- asone-eluting intracanalicular insert, after cataract surgery with the patient still draped and the lid speculum still in, Dr. Hovanesian said he uses a punctal dilator to make the punctum large enough to accommodate the insert. He noted later that you don't need a lid speculum to insert Dex- tenza. Dry the surface using a cotton swab before inserting Dextenza because the insert swells when hydrated. "If it starts to swell before we insert it, it's more difficult to get it to move forward," Dr. Hovanesian said. When inserting, Dr. Hov- anesian said it's important to "remember to turn that corner. The punctum enters 1–2 mm vertically, then takes a sharp, 90-degree turn." In most cases, Dr. Hovanesian places Dexten- za in the lower lid; he said it is possible to place in the upper punctum as well. Dextenza stays in place for about a month after the proce- dure in most cases. If needed, it can be removed by squeezing it out or flushing it out through the lacrimal gland, Dr. Hovane- sian said. In a separate presentation, Dr. Hovanesian discussed two Dexycu insertion techniques. There are a few prior consider- ations: Center the lens, hydrate the wound, make the IOP nor- mal to low-normal, and make sure the patient is not squeez- ing against the lid speculum. The classic insertion technique of the sustained-re- lease dexamethasone intraocular suspension, Dr. Hovanesian said, involves use of a 27-gauge cannula to enter the eye (not the 25-gauge that it comes with). Go deep under the iris root and while sweep- ing, inject the drug. "Inject while the cannula is in motion, then stop injecting, take your thumb off before you withdraw the cannula," Dr. Ho- vanesian said, adding that this "lays down the Dexycu deep in the iris root where it will stay put." Skills transfer lab looks at phaco techniques, drug delivery systems, and more For the cross chop technique, Dr. Kim said you need to use the right type of chopper, and he explained how it should be inserted between the epinucleus and endonucleus. Source: D. Brian Kim, MD, screenshot from presentation.

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