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6 | EYEWORLD DAILY NEWS | APRIL 23, 2022 ASCRS ANNUAL MEETING DAILY NEWS PUBLISHER Steve Speares MANAGING DIRECTOR Stacy Jablonski EDITORIAL CO-DIRECTORS Ellen Stodola Liz Hillman GRAPHIC DESIGNERS Susan Steury Katherine Beutner PRODUCTION MANAGER Cathy Stern SALES, SPONSORSHIPS, AND CORPORATE PROGRAMS Jessica Donohoe Joe Dooley Cathy Stern Pressure management is key to avoiding prolapse of the iris, Dr. Gupta said. Avoid overfilling with OVD and consider where the gradient is. She also said that hydrodissection increas- es "force," so it's important to make a track for the fluid to escape. Use low flow phaco. Incision management matters, Dr. Gupta said. Making anterior incisions helps to avoid the iris from prolapsing as easily. She also suggested using a longer incision tunnel. A low threshold to suture or place glue can be used to avoid postoperative prolapse of the iris. Commonly used mechanical devic- es for pupil expansion include manual stretching with instruments, iris hooks, and rings, Dr. Gupta said. Iris hooks are soft, flexible devices inserted via the paracentesis incision to fixate the iris. Advantages are that they can be used to fixate the iris and capsule, can be placed at surgeon discretion to support weaker areas when needed, and can be used with any size pupil. However, a disadvantage is that this option is more time consuming than other devices. T his year, the joint session of ASCRS and the American Glaucoma Society (AGS) on the Glaucoma Day program helped attendees to "sharpen your tools, re- charge your mind." Manjool Shah, MD, discussed how to handle rock hard cataracts, noting that these will not be quick cases, and you want to be prepared for a lon- ger, slower procedure. Dr. Shah said it's important to recognize comorbid conditions, including trauma, angle closure, pseudoexfoliation, and uveitis. It's important to get a good look, and a pupil expansion technique can be used to optimize your view. Dr. Shah prefers iris hooks, as they are low profile and customizable. He also recommended staining the anterior capsule if the red reflex is poor. In suspected zonulopathy, paint under the viscoelastic cover to prevent posterior migration. Dr. Shah also discussed nuclear disassembly techniques for these cases, recommending a technique that avoids excessive lateral separation or posterior depression. His preferred technique is to create a deep central trench with low flow and high phaco energy titrat- ed to the density of the lens. Then he will embed the phaco tip in the nasal wall of the trench and initiate a vertical chop. Place the chopper sequentially deeper to separate the nucleus and avoid excessive lateral separation and use bimanual rotation of the nucleus to continue chopping. It's also important to protect the cornea, Dr. Shah said. Frequent reapplication of dispersive OVD, emulsification in the iris/capsule plane, keeping the chopper above the nucle- us/phaco needle to keep pieces down and in front of you, and using appro- priate phaco settings to avoid chatter can all help with this. During the session, Preeya Gupta, MD, discussed managing small pu- pils and the misbehaving iris. There are many causes of a small pupil, which may include iris atrophy, loss of iris tone, metabolic changes, and synechiae. Intraoperative floppy iris syndrome is defined by intraoperative miosis, poor iris tone, and iris prolapse is often seen. Both men and women are at risk. Dr. Gupta shared some of the management options for small pupils: intracameral epinephrine/lidocaine, using heavier viscoelastic, modification of fluidics, femtosecond laser for pupils greater than 3.5 mm, and mechanical devices. Cohesive and dispersive properties of OVDs act as a mechanical agent to hold the iris down and away from the wounds. This helps create space in the eye. ASCRS/AGS joint session kicks off Glaucoma Day continued on page 9 [With rock hard cataracts], "these will not be quick cases, and you want to be prepared for a longer, slower procedure." —Manjool Shah, MD

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