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24 | EYEWORLD DAILY NEWS | MAY 6, 2023 ASCRS ANNUAL MEETING DAILY NEWS penetrating keratoplasty, she said mannitol/Flieringa ring can be used. There is often a lot of positive pressure, she said, recommending the sandwich technique. Remember to do peripheral iridotomies in these cases and use a large graft, Dr. Ham- mersmith said. Christopher Sales, MD, discussed complex DMEK cases. It's important to have a game plan, he said, two important things you need to do in these cases are to open the tissue and retain the bubble. In a routine case, you can do endo-out DMEK, he said, but in a complex case, there's no guarantee you'll have a chamber that does what you want it to do. He suggested doing a dress rehearsal before every complex case. He said that sponges may help. He also said the double scrolls can help, ensuring less work inside the eye. Dr. Sales noted that vitrectomized eyes lack posterior pressure, and unicameral eyes will not shallow at all. In some cases, you would need to do an endo-in DMEK technique, and Dr. Sales stressed the importance of using an AC maintainer opposite the main incision. He also said he likes to have the eye bank place two dots on the tissue, so he knows where to grab. In terms of maintaining the bubble, he said, where possible, to repair the iris lens diaphragm. He also shared his Add-a-Bubble Early technique if the bubble cannot be maintained, where he connects a syringe to an IV tube. Editors' note: Dr. Meghpara has finan- cial interests with a variety of oph- thalmic companies. Dr. Hammersmith has no relevant financial interests. Dr. Sales has financial interests with a variety of ophthalmic companies. D uring an afternoon session at ASCRS Cornea Day on complex surgical cornea cas- es, Beeran Meghpara, MD, discussed open sky secondary IOLs. "This is my least favorite thing to do in the OR," he said. We're trying to figure out a way to do this as effi- ciently and as safely as possible, he said. He noted that specific tools that can be utilized in these cases are 1) the CZ70BD IOL (Alcon), which has a large PMMA optic and haptic with eyelets for scleral fixation, 2) suture (either polytetrafluoroethylene or polypropylene), and 3) accessories like trocars, micro instruments, and handheld cautery. The first technique he showed was suture fixation and then also showed a flanged prolene technique. Kristin Hammersmith, MD, discussed corneal perforation, which she said can occur due to inflamma- tion (non-infectious or infectious), exposure, or neurotrophia. With inflammatory non-infec- tious cases, she said it's important to identify the cause of inflammation and address/attempt to control inflammation. She added that im- munotherapies may cause an issue as well. A smaller graft is better in inflammatory cases, she said. With inflammatory infectious cases, she said to culture and treat the infec- tion. The perforation often occurs later in the infection, she said. Not all infections are created equally, Dr. Hammersmith added. So how do you fix corneal perforations? Dr. Hammersmith said you can use cyanoacrylate glue. She also said the peripheral divot without iris incarceration is best. When you glue a patient, you want to remove adjacent epithelium, dry it off, and less glue is best. A patch graft may also be used, and she said the corneal tissue is best for perforations. If you don't have an eye bank, she said you can use a shelf-stable VisionGraft. Another option is a crescentic graft, which might be used for a larg- er perforation. Some patients need a full penetrating keratoplasty or scleral graft, Dr. Hammersmith said. With Complex surgical cornea topics examined

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