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EW SHOW DAILY 42 ASCRS Symposia by Vanessa Caceres EyeWorld Contributing Writer you're ready. "If in doubt, convert to manual cataract extraction. It's still a viable surgical option," Dr. Lee said. Posterior capsule rupture, vitreous loss, and a dropped nucleus are all problems associated with capsular tears, Dr. Lee said. Research finds that many capsular tears happen during continuous curvilinear capsu- lorhexis, but they are also common before phaco. Richard Hoffman, MD, Eugene, Oregon, addressed how to manage a shallow anterior chamber. If a patient is nanophthalmic, it's espe- cially important to diagnose it pre- operatively. Perform an ultrasound biomicroscopy scan before surgery, and look for a thickened sclera or uveal effusion, among other factors. If uveal effusion is present, treat it with steroids or cycloplegics pre- operatively. During surgery, use a temporal clear cornea incision, a dispersive ophthalmic viscosurgical device, and avoid hypotony. The symposium also addressed hard nuclei, vitreous loss, and zonu- lar loss. EW Editors' note: Dr. Auffarth has financial interests with Alcon (Fort Worth, Tex- as), Allergan (Dublin, Ireland), Bausch + Lomb (Bridgewater, New Jersey), and other ophthalmic companies. Dr. Hjortdal has financial interests with Carl Zeiss Meditec (Jena, Germany). Dr. Hoffman has financial interests with Carl Zeiss Meditec and MicroSurgical Technology (Redmond, Washington). Dr. Otero has financial interests with Alcon, Allergan, and Johnson & John- son Vision (Santa Ana, California). Dr. Lee has no related financial interests. talk patients into using a multifocal IOL if they are not convinced they want it. If a patient appears to have a too-demanding personality, avoid these IOLs altogether, Dr. Auffarth advised. Another issue that may cause complications for cataract surgeons is Fuchs' dystrophy, said Jesper Hjortdal, MD, Aarhus, Denmark. Signs of Fuchs' include blurry morning vision that gets worse with time and pain. Surgeons must decide in these patients whether cataract surgery alone or a double or triple procedure is appropriate. If you decide to perform a triple procedure, you don't need to change the type of IOL you use, Dr. Hjortdal said. However, you should add 1 to 1.5 D of myopia if Descemet's stripping automated endothelial keratoplasty will be performed and 0.5 to 1 D of myopia if Descemet's membrane en- dothelial keratoplasty will be used, he suggested. Avoid same-day bilat- eral surgery in a patient with Fuchs.' Give up to 3 months to assess visual recovery, Dr. Hjortdal advised. Small pupils are another surgical challenge, said Ernesto Otero, MD, Bogota, Colombia. As dilation can be tough in patients with small pupils, Dr. Otero recommended the use of lidocaine and unpreserved epinephrine or phenylephrine 1.5%. Iris expansion devices, a Malyugin ring, and iris hooks also are helpful, he said. If you encounter the surgical problem of capsular tears, Mun Wai Lee, MD, Ipoh, Malaysia, advises slowing down and not panicking. In fact, plan in advance how you may want to handle this problem so said Gerd Auffarth, MD, Heidelberg, Germany. Common medical causes for this dissatisfaction include pos- terior capsule opacification, residual ametropia, and dry eye, according to a recent study that Dr. Auffarth shared. In that study, 7% of the dissatisfied patients needed an IOL exchange. Intraocular lens factors that may lead to dissatisfaction in- clude dysphotopsia and photic phe- nomena, and patient-related factors that may cause unhappiness include a demanding personality and high demands on contrast vision. Surgeons should try and set realistic expectations about multifo- cal IOLs with patients, Dr. Auffarth said. Listen to what patients want, let them know that there is a longer postop adaptation period, and don't F rom capsular tears to small pupils, there are a lot of potential issues that could cause problems during cataract surgery. During the Sunday symposium "Surgical Essen- tials: Getting You Out of Trouble in Cataract Surgery," surgeons shared tips to handle challenges including capsular tears, vitreous loss, and unhappy multifocal IOL patients. The symposium was sponsored by the Alliance of Cataract and Refractive Specialty Societies and featured surgeons from cataract and refractive surgical societies from around the globe. With the growth in popularity of multifocal IOLs, it's not uncom- mon to encounter patients who may be unhappy with their outcomes, Monday, April 16, 2018 Symposium addresses how to manage cataract surgery challenges with ease Dr. Hjortdal discusses Fuchs' dystrophy management for cataract surgery. design, Dr. Eydelman said, adding that the number of submissions for early feasibility studies have in- creased drastically. She also mentioned recent workshops, panels, and task forces working together. Dr. Eydelman spent some time highlighting the breakthrough devices program. Criteria for this is that it's a more effective treatment or diagnosis of life threatening or irreversibly debilitating disease, along with one of the following: represents breakthrough technology, no approved or cleared alternatives exists, offers significant advantages over existing approved/cleared alter- natives, or availability is in the best interest of patients. So far in 2018, she said 25% of CDRH breakthrough designations are for ophthalmic devices. Dr. Eydelman noted the total time to decision (TTD) and said the goal is to reduce the TTD by almost 25% within 4 years. She noted some potential reasons that could cause delay in TTD for ophthalmic sub- missions. Dr. Eydelman supplied her own tips and best practices in submitting applications: submit a completed checklist with each submission, be organized, provide information needed to support review, proofread your final submission, contact the review branch if you have clarifica- tion questions, stay informed and up to date on guidance documents, and reference FDA recognized con- sensus standards. Before closing, Dr. Eydelman highlighted what's ahead for 2018 and beyond, noting employee en- gagement, opportunity, and success; simplicity; and collaborative com- munities. She said that the measure of success is that by Dec. 31, 2020, more than 50% of manufacturers of novel technologies for the U.S. mar- ket intend to bring their devices to the U.S. first or in parallel with other major markets. EW Symposium continued from page 41

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