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EW SHOW DAILY 10 Wednesday, April 18, 2018 by Erin L. Boyle EyeWorld Contributing Writer Surgeons 'sweating bullets' in the OR the edge of the capsule. That would be a good option in this case," he said. Dr. Osher's take was that this was a situation where ego leads the way, when a physician thinks he or she can do anything (as he had as a second year resident with that 5 mm pupil)—and it's in those very moments that surgeons should be most cautious. "Every time I sit down and the pupil is suboptimally dilated, part of me says, I'm going to save money for my surgery center, I'm not going to reach for a Malyugin ring. Part of me says, I'm a good enough surgeon that I can do this," he said. But as early as the 1980s, when he and colleagues Ike Ahmed, MD, Toron- to, Canada, Alan Crandall, MD, Salt Lake City, and Howard Gimbel, MD, Calgary, Canada, examined pseudoexfoliation cases, they found that a suboptimal pupil was the number one cause of complications in cataract surgery. "Surgery is all about visualization, and complica- tions are all about pupil size," he said. "I know I can phaco a small pupil," Dr. Osher said. His bottom line is: "I have man- aged to put a cage around my ego, and if I have 5 mm pupil, I'll always use a pharmacological dilatation. The moment I get to 4-and-a-half mm, I'll reach for a Malyugin ring. I need to see the edges of the rhexis, I'm not taking any chances," he said. EW Editors' note: The physicians have no financial interests related to their comments. W hen Robert Osher, MD, Cincinnati, was a second year resident at Bascom Palmer Eye Institute, Miami, Edward Norton, MD, founding chairman, wouldn't let residents do phacoemulsification. So they had to wait until he was out of town to perform the surgery. Dr. Osher had practiced and practiced and was ready. He waited until the time was right and per- formed surgery on his first patient, who had a 5 mm pupil. "Right in the middle of the phaco, I heard Dr. Norton walk into the room," Dr. Osher recalled. "The chief was back! I'm in big trouble. And I was in big trouble, but the case went OK." Dr. Osher told the story at the Sweating Bullets! symposium, which featured videos of challenging cases from Abhay Vasavada, MS, Ahmed- abad, India, Fernando Trindade, MD, Belo Horizonte, Brazil, Boris Malyugin, MD, Moscow, Russia, Richard Packard, MD, London, U.K., and Graham Barrett, MD, Perth, Australia. Dr. Vasavada opened the sym- posium sharing the case of a patient undergoing cataract surgery with pseudoexfoliation and a "small- ish" pupil that had dilated, but not enough. "You're in a dilemma: Should you use hooks, rings, or you can do it [without]? You always have a kind of denial that you can do it without all of these things, and you can manage," Dr. Vasavada said. But he soon found himself struggling to see the capsulorhexis and needing assistance from a re- tractor and hook mid-surgery. What did he learn from the case? "You need visualization," he said. "Trypan blue in some cases, or exposure and the Malyugin ring is the best. I should have started in the beginning [with it] because I don't like to use it down the way because I'm not very proficient once I've started, so I decided on a retractor. Any of this should have been done earlier." He added that surgeons should be cautious and not ambitious in such cases because he was lucky that the rhexis was successful. The other physicians in the symposium discussed each case following the surgical videos. They agreed with Dr. Vasavada. Dr. Pack- ard said that trypan blue can be vital for better visualization in these cases. Dr. Malyugin said the rhexis can be created without any addition- al help. "I think sometimes if you don't have any device or hook, at that moment I would consider using sight or instrument to retract the iris and expose that area and try to find cataracts (PSCs)—slightly larger in the right eye, but quite small in both eyes. Ultrasound scans, however, suggested thinning that could be interpreted as ectasia. Dr. Hovanesian asked the panel how such a case should be man- aged—should he perform crosslink- ing with the inlay in place? Remove the inlay first, then try rigid gas permeable lenses? Use intracorneal inserts? Or should he perform cata- ract surgery for the PSCs? Going back over the results, Dr. Hovanesian said he began to doubt the corneas were ectatic because the map did not have steepening. An OCT confirmed his suspicion: The scan showed no actual thinning. He thus went on to perform cataract surgery, leaving the KAMRA implant in place. He said the pro- cedure was no more difficult than operating with a corneal opacity. When confronted with a patient with a KAMRA inlay, he cautioned, be suspicious of diagnostics—optical biometry works, but the inlay may interfere with ultrasound. Dr. Hovanesian added that advanced formulas such as those used in post-LASIK eyes should be used to calculate IOL power, and that in general negatively aspheric IOLs should be used; aberrations are ameliorated by the KAMRA's small aperture, but an inlay and an IOL with a dilated pupil will cause the patient to see diplopic rings around light sources. In addition, lasers, whether fem- tosecond, excimer, or argon, should not be used; the dark inlay may absorb the energy, interfering with the laser's function and potentially disperse the heat, damaging the tissue. EW Editors' note: The physicians have no financial interests related to their presentations. Dr. Vasavada shares a case of a cataract surgery patient with pseudoexfoliation and a small pupil. The perfect continued from page 6

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