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EW SHOW DAILY 22 ASCRS Symposia Tuesday, May 10, 2016 by Ellen Stodola EyeWorld Senior Staff Writer Complicated video cases presented A Monday morning sympo- sium titled "Complicated and Challenging Cases in Cataract Surgery," was a video-based session with presenters highlighting a number of complicated cases with issues like stuck rhexis, small pupil problems, phaco and glued IOLs, and posterior pressure, among others. Amar Agarwal, MD, Chennai, India, presented on "Longest Day Part 10: Small Pupil Woes," where he encountered a number of problems on 1 case. This particular patient came in with a small pupil, and Dr. Agarwal used an I-Ring (Beaver-Visitec Inter- national, Waltham, Massachusetts) to expand the pupil. Dr. Agarwal injected the ring and he caught the iris, but he still thought the case would be fine. It was a mature cataract, so Dr. Agarwal used trypan blue to stain but didn't notice that there was an- other problem forming. The rhexis was running away, he said. Dr. Agarwal then moved on to phaco, but after only a few seconds, there was a posterior capsule rupture and the nucleus dropped. The rhexis extended posteriorly, he said, and the nucleus was gone. The next step Dr. Agarwal took was to do irrigation/aspiration, but he said he should not have done this because there was vitreous in the AC. He used a little viscoelastic and moved on to making 2 scleral flaps for a glued IOL and prepared for a vitrectomy. Slowly, as Dr. Agarwal pro- ceeded, the dropped nucleus piece floated up and he stabilized it. The nucleus piece was caught with the suction of the vitrectomy probe and he was able to stabilize it and bring it up anteriorly. Through his maneuvers, Dr. Agarwal was able to create his own posterior capsule, which acted like a scaffold. The IOL acts like a posterior capsule, he said. Dr. Agarwal used a 22-g needle and created a scleroto- my 1 mm behind the limbus. "I had to take the haptic and from the anterior chamber put it into the posterior chamber," he said. However, it was getting locked onto the I-Ring without Dr. Agarwal noticing. He ended up losing the hap- tic and turned his attention to the second haptic, which was a risky choice. He used the handshake technique and hoped the lens would not go down because if the haptic slipped, the IOL would drop. He thought he would remove the I-Ring because things were looking better, but he realized too late that he should have dislodged it from the iris. This ended up caus- ing iridodialysis. With 3 hands (Dr. Agarwal and his assistant) working on the case, the I-Ring was eventual- ly grabbed and brought out. He sutured a posterior sclerot- omy so that he would not have hypotony postoperatively. Once he had done that, he put air in the AC, took out the cannula, and applied fibrin glue. At 2 months postop, the patient's vision had improved to 6/6. The panel of the session felt that Dr. Agarwal had quite adequately critiqued himself during the case. The panel asked why the I-Ring ended up causing iridodialysis, and Dr. Agarwal said he should have dislodged it from the iris and could have pulled it out. However, he in- stead used the injector to pull it out. Other presenters were James Lehmann, MD, San Antonio, Texas, Arup Bhaumik, MD, West Bengal, India, Samuel Masket, MD, Los Angeles, Naveen Rao, MD, Burling- ton, Massachusetts, Debashis Dutta, MS, Kolkata, India, Ricardo Nose, MD, Sao Paulo, Brazil, and Michael Mahr, MD, Rochester, Minnesota. At the end of the session audi- ence members voted on the "best teaching case," and awarded it to Dr. Agarwal. EW Editors' note: Dr. Agarwal has financial interests with Beaver-Visitec Interna- tional. by Rich Daly EyeWorld Contributing Writer Addressing corneal crosslinking myths E ven after the recent Food and Drug Administration (FDA) approval of corneal collagen crosslinking (CXL), the procedure continues to be shadowed by a series of myths, according to 1 surgeon experienced with the procedure. "Corneal crosslinking has a bright future in the management of keratoconus," said Gustavo Tamayo, MD, Bogota, Colombia. In April, the FDA approved marketing of corneal crosslinking using riboflavin and UV light (KXL System, Avedro, Waltham, Massa- chusetts). Among the lingering misunder- standings of the procedure is that it is a novel procedure, is little studied in the peer-review research, has un- proven results, is still experimental, is not studied for long-term effects, and that no clear reason exists for its use, Dr. Tamayo noted. Dr. Tamayo said that the first pilot study of the treatment was in 1998 in the American Journal of During a session on keratoconus treatment, attendees gained insights on the newly approved corneal crosslinking procedure. Ophthalmology, in which keratoco- nus was stopped in all 23 eyes in a prospective non-randomized study. Long-term results included another study of 480 eyes with a best corrected visual acuity, among other improvements. "This study proves clearly that crosslinking works," Dr. Tamayo said. mean follow-up of 6 years, which found only 2 patients' keratoconus progressed. Meanwhile, 53% of eyes retained 1 line of improvement in

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