Eyeworld Daily News

EW SHOW DAILY 24 ASCRS Symposia Tuesday, May 9, 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer do Trindade, MD, Belo Horizonte, Brazil, the Xtra Focus Pinhole IOL (Morcher, Stuttgart, Germany), a novel implant made of black, opaque, hydrophobic material, is an excellent choice as a piggyback lens for patients with irregular corneal astigmatism, particularly after trau- ma. The Xtra Focus was implanted in one patient who suffered from a knife wound to the eye, resulting in poor vision and debilitating glare, which was further complicated by a highly abberrated cornea and large pupil. The device is 14 mm overall in size and the central pinhole is 1.3 mm. The lens allowed a complete resolution of glare and 20/25 vision. Trusting your laser's tracking system is a matter of experience. In a case shown of a young man with B rilliant and innovative solutions were present- ed as case studies at the "Symposium of Challeng- ing Cases," sponsored by the Brazilian Society of Cataract and Refractive Surgery (BRASCRS), in which Brazilian and U.S. investiga- tors shared some of their toughest clinical challenges and how they solved them. The session began with a simple case of a dislocated IOL, which due to symptoms of recurring blurred vi- sion, ocular pain, and headache last- ing for 3 years after cataract surgery, was passed off as idiopathic anterior uveitis, and treated accordingly. Ac- cording to Aileen Walsch, MD, Rio De Janeiro, Brazil, who examined the 46-year-old male patient, a fresh look at the patient was enough to notice that although he had signs of pigmentary dispersion, there was a lack of goniosynechiae, and a nasal decentration of the IOL was evident upon pupil dilatation. She urged surgeons to implant in-the-bag IOLs carefully, as haptics remaining outside the bag would ultimately dislocate the lens, and IOLs implant- ed in the sulcus would similarly shift position. Dislocated IOLs are often misdiagnosed as recurrent uveitis, which usually occurs if the surgeon does not take the time to rotate the lens and make sure it is actually situated in the bag. Multiple surgeries present a complicated starting point for sur- geons to help patients regain vision. A case presented by Victor Antunes, MD, São Paolo, Brazil, described a post-traumatic patient who under- went numerous ocular surgeries including vitrectomy, trabeculecto- my, tube shunt, ICCE, pupilloplasty, PK, and a second PK, among other surgeries, following a motorcycle accident. The patient had hand motion vision, 12 mm Hg IOP, and a normal macula. Descemet's stripping automated endothelial keratoplasty (DSAEK) and an anterior chamber IOL in this patient achieved im- proved vision. DSAEK is reproduc- ible, efficient and safe in complicat- ed cases. Patients with failed PK do not benefit from Descemet's mem- brane stripping as the membrane can be atrophic and stripping could damage the underlying stroma, he explained. Trauma cases can be highly complicated. According to Fernan- horizontal nystagmus, the Wavelight EX500 (Alcon, Forth Worth, Texas) could reliably reshape the cornea and was able to track the 5+ Hz frequency of the patient's eye move- ments. The patient was 19 years old, had stable vision over time, and had plans to join the Navy. According to Roberto Pineda, MD, Boston, who presented the case study, saccades are some of the fastest movement produced by the human body. Femtosecond laser-assisted astigmatic keratotomy (FLAAK) can improve the precision and pre- dictability of residual astigmatism correction, even in post-PKP eyes. A case series of 12 post-PKP patients presented by Karolinne Rocha, MD, PhD, Charleston, South Carolina, showed the use of this technique in the management of extreme astig- matism. In one case involving a 69-year-old female patient with ma- ture cataract who underwent PKP 18 years prior, who had hand motion visual acuity and 14 D of residual astigmatism, Dr. Rocha implanted a T9 lens and made limbal relaxing in- cisions. FLAAK reduced the astigma- tism to 10 D and allowed the use of contact lenses. FLAAK gives a huge amount of cyclic correction, and vision is stable in 3 to 6 months, she reported. In another case of extreme astigmatism that she treated simi- larly, the patient's astigmatism was reduced to 5 D and vision was im- proved from 20/400 to 20/25 1 day postop. FLAAK is extremely helpful for enhancements in pseudophakic post-PK patients, she said. EW Editors' note: The physicians have no financial interests related to their comments. Brilliant solutions for tough cases Dr. Walsch and Brazilian investigators share innovative solutions at the "Challenging Cases" symposium. be entering the eye in this fashion. Dr. Solomon said an aspirating spec- ulum could reduce this fluid. Another presentation from the ASCRS team came from Robert "Dangerous" Osher, MD, Cincinna- ti. "If you put an IOL into the eye, you should know how to take it out, otherwise, you're dangerous," Dr. Osher said, offering two techniques for lens removal in the case of a broken haptic. The Eguchi technique involves prolapsing the lens out of the bag into the anterior chamber, enlarging the incision to allow for scissors, which will be used to cut halfway through the lens. Rotate the lens 90 degrees and cut again to meet the first cut; remove the quadrant and the rest of the lens can then be explanted safely, Dr. Osher said. Another technique, the Ernest technique, also involves prolapsing the lens into the anterior chamber. Make a beveled penetrating stab incision 180 degrees away from the main incision and use a smooth spatula to come under the lens and use another instrument to fold the lens over it, explanting it in this configuration through the incision. Other members of the ASCRS team included Robert "Bo" Cionni, MD, Salt Lake City, Rosa "Rock Star" Braga-Mele, MD, Toronto, Mitchell "Cyclops" Weikert, MD, Houston, Richard "Slicer" Hoff- man, MD, Eugene, Oregon, and Elizabeth "Slick Chopper Chick" Yeu, MD, Norfolk, Virginia. EW Editors' note: Dr. Jacob has financial interests with Morcher (Stuttgart, Germany). The other physicians have no financial interests related to their comments. ASCRS continued from page 23

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