Eyeworld Daily News

EW SHOW DAILY 16 ASCRS News Today Monday, May 8, 2017 by Liz Hillman EyeWorld Staff Writer A wild day in the OR Dr. Miller presents his wildest day in the OR, the case of a dropped DSEK graft on the macula. "What did I learn? Don't forget to suture the graft to the cornea if the eye has an artificial iris." Dr. Fram describes a complicated case involving the lost haptic of a sutured posterior chamber IOL and its retrieval. specialist was able to retrieve it after an hour. Dr. Miller removed the graft and reinserted it in the right orientation; this time, he sutured it to the cor- nea. Postop, however, the graft did not fully attach; Dr. Miller decided to perform a new DSEK procedure. "What did I learn? Don't forget to suture the graft to the cornea if the eye has an artificial iris," Dr. Miller said. Other complicated cases were presented by Eric Donnenfeld, MD, Rockville Centre, New York, Amar Agarwal, MD, Chennai, India, Ashvin Agarwal, MD, Chennai, India, and Susan MacDonald, MD, Peabody, Massachusetts. EW Editors' note: Drs. Ahmed, Fram, and Miller have no financial interests relat- ed to their comments. Physicians share their OR mishaps and techniques for preventing them in the future S hallowing chambers, dropped DSEK graft, zonu- lar dehiscence, dangling IOL, subluxated cataract, and more were present- ed in a video-based discussion on Sunday morning—My Wildest Day in the OR: My Technique to Prevent it from Happening Again. "I'm sure all of us have these wildest days," said moderator Soosan Jacob, MD, Chennai, India, introducing Iqbal "Ike" Ahmed, MD, Toronto, as the first speaker. Dr. Ahmed focused on shallow- ing chambers. His videos showed how even a small amount of cham- ber shallowing can lead to intense positive pressure and thus compli- cations, such as iris prolapse and suprachoroidal hemorrhage. "All it takes is one shallowing event … to cause serious complica- tions," Dr. Ahmed said. To keep chambers formed, especially in small eyes, Dr. Ahmed said one should inject balanced salt solution or viscoelastic before com- ing out of the eye. Next, Nicole Fram, MD, Los An- geles, presented the case of a sutured posterior chamber IOL in a patient who had a planned future endothe- lial keratoplasty. The patient had advanced MMG, corneal edema, and a surgical iris. He had two tubes— one in the anterior chamber and one in the pars plana—making it difficult to know where to put incisions. She ended up doing an inferotemporal incision, a limited pars plana inci- sion, and made sclerotomies behind the main incision. The complication came while Dr. Fram was working on placing her IOL. Something got caught on her needle holder and the lens disappeared; it was hanging on the sclera from the other side. She was able to push on the eye to retrieve the other haptic with another instrument. Dr. Fram called it luck that she was able to thread GORE-TEX through this haptic's eye- let, still in the eye, and successfully complete the case. "Experience is the hardest kind of teacher. It gives you the test first and the lesson afterward," Dr. Fram said, referencing a quote from Oscar Wilde. "When you do these cases, just be ready for a little instability and anticipate that." Kevin Miller, MD, Los Angeles, presented on a patient who had a history of ruptured globe due to a surfboard injury, followed by several different surgeries. At the time Dr. Miller saw him, the patient was pseudophakic with an artificial iris and scheduled for a DSEK. As he was getting the graft into position, it shifted and "Oh no, where did it go?" The graft had slipped behind the iris implant and dropped onto the macula. Dr. Miller said a retina

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