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EW SHOW DAILY 20 ASCRS Symposia Tuesday, April 17, 2018 by Erin L. Boyle EyeWorld Contributing Writer cinolone to prevent infection. Two weeks later, Dr. Gomes removed the sutures and did a complete exam and refraction. To her surprise, the child had high astigmatism in both eyes, and visual acuity was 20/130 OD and 20/30 OS. They started occluding the left eye a few hours a day. The child's vision continued to improve, and 6 months postop, he was 20/100 OD and 20/25 OS. "We kept doing the rehabilita- tion, and he kept improving. Now at 16 months' follow-up, he's 20/40 [OD], 20/25 [OS]," she said. At this last follow-up visit, he had regular astigmatism. Anterior segment OCT showed there were still a few strands remaining, but these were not causing visual issues. She diagnosed the child with persistent pupillary membranes (PPM), with hyperplastic PPM obstructing the visual axis. "Anterior segment OCT helped me to evaluate this case, and I could do a removal of the membranes without the lens being obstructed and rehabilitate this child," Dr. Gomes said. In these cases, she cau- tioned that physicians need to look at all parts of the case, first doing membrane removal before consider- ing lens extraction. EW Editors' note: The physicians have no financial interests related to their comments. T he "Symposium of Chal- lenging Cases" on Sunday featured an array of difficult surgical situations and puzzling cases, including in cataract and cornea specialties. The symposium, chaired by Gustavo Baptista, MD, PhD, Cu- ritiba, Brazil, and Roberto Piñeda, MD, Boston, was sponsored by the Brazilian Association of Cataract and Refractive Surgery (BRASCRS) and featured a panel of Brazilian phy- sicians who presented video cases. They included difficult surgical cases from Nicolas Cesário Pereira, MD, São Paulo, Brazil, and Lucio Maran- hão, MD, Fortaleza, Brazil, of DMEK, and DALK after EK, presented by Dr. Piñeda. Rachel Gomes, MD, São Paulo, Brazil, presented the case of a 3-year-old with possible anterior polar cataract, but the case proved a puzzling one because she wasn't sure what the anterior opacity in the pupil was. "In front of the pupil, I saw a membrane. I kept thinking, how can I evaluate if the membrane is impacting vision?" she said. She was called into the case because while she's a cataract surgeon, she treats many congenital cataract cases. The patient was 20/200 in both eyes at the first visit. Using anterior segment optical coherence tomography (OCT), she saw that the membrane was in the eye, covering the pupil and over the iris, but it did not appear to be impacting the anterior capsule. Dr. Gomes was concerned, she said, because she needed to remove the membrane without harming the crystalline lens while preserving accommodation in the child. "I didn't know how the sur- gery would go. My initial plan was to only remove the opacity in this surgery, but I was prepared for anything I had to do. If I had to do phacoemulsification, I was prepared for that," Dr. Gomes said. At the symposium, she showed a video of the surgery. In the right eye, she did the main incision and in using viscoelastic, tried to dissect, but the membranes didn't move. So she used her capsulorhexis forceps to detach the membrane from the pupil. "There was one normal iris and a lot of strands over the normal iris," Dr. Gomes said. "How could I remove and enlarge this without damaging the lens and the cornea? I have some small incision instru- ments, and I decided to use them to remove these strands." The surgical video showed her using small incision scissors to cut the membrane strands in the visual axis with care with a dilated pupil. Dr. Gomes was concerned about bleeding during the surgery, but as the video showed, the case conclud- ed without any bleeding issues. She had another concern as well: "I was afraid of touching the crystalline lens at any time, so I went very carefully removing the strands. Colleagues asked why I didn't use an anterior vitrectomy, but I thought a vitrectomy would be more traumatic to the eye in a child so I was more comfortable using small incision instruments," she said. "We can see he has a normal pu- pil and the crystalline lens is trans- parent. I tried to remove most of [the membrane]," she said. She finished the surgery with sutures and triam- Symposium of difficult cases showcases unique ocular surgeries Dr. Gomes shares a video of her surgery on a possible anterior polar cataract in a 3-year-old. Final symposia cover hot issues for anterior segment surgeons T oday may be the last day of the 2018 ASCRS•ASOA Annual Meeting, but there's still plenty of learning going on. The first symposium scheduled is "Laser Cataract Surgery: Questions, Answers, Alternatives." Hot topics related to laser cata- ract surgery will be covered so attendees can assess if they are right for their practice. The session will take place from 8:00–9:30 a.m. on Level 1, 152AB. "X-Rounds: Refractive Cataract Surgery to the Max" is a fast- paced session that will feature the latest and greatest in refractive cat- aract surgery. Leading surgeons will discuss new advances in cataract surgery, femtosecond laser cataract surgery, refractive IOLs, and case management. This one will be held from 10:00–11:30 a.m. on Level 3, ballroom C. Finally, the Latin American Society of Cataract and Refractive Surgeons is sponsoring "Best of ASCRS – Presented in Spanish," from 10:00–11:30 a.m. on Level 1, 152AB. EW

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