AAO 2019 DailyOCT 14, 2019

Cataract Spotlight: Surgical Pearls

This year’s Cataract Spotlight session featured 16 speakers presenting their “top five pearls” for a variety of challenging cases. Here is a brief overview of three presentations; full coverage of all 16 presentations—including expert commentary from panel members and audience responses to questions—will appear in the February 2020 EyeNet.

How to handle the white cataract. To begin with, said Elizabeth Yeu, MD, “understand your opponent—intumescent lenses behave differently.” With regard to surgical steps, she recommended decompressing the nucleus before performing the capsulorrhexis. She also noted that creating the anterior capsular opening may be the most difficult step. “You may need to decompress the lens material repeatedly, and the capsule may be fibrotic and/or fragile.”

Moreover, Dr. Yeu warned, “Nuclear densities differ from eye to eye. They may be brittle and crumbly,” although young eyes or traumatic cataracts may be soft. She also said, “Watch out for hypermature lenses; they may be thick and leathery, and they’re pressurized and difficult to crack. You have to be patient with these.”

Finally, Dr. Yeu advised, “You must vigilantly protect the posterior capsule. White cataracts often have very little cortex and can be floppy.”

How to anticipate and manage intraoperative iris prolapse. Cataract surgeons need to keep their guard up for intraoperative floppy iris syndrome (IFIS), said Sumit Garg, MD.

“Start by asking the right questions” during the initial evaluation. “Ask what they’re on. Look at their charts. Ask, ‘Do you take anything to help you urinate at night?’” Although the alpha-blocker tamsulosin is the leading suspect, other drugs, including benzodiazepines and the herbal remedy saw palmetto (Serenoa repens), have been implicated. And don’t presume that you’re in the clear if they aren’t taking one of these drugs at present: Even previous short-term use has been linked to nonreversible iris dysfunction in some patients.

Dr. Garg also warned that IFIS affects women as well as men. “Women are on tamsulosin as well; it’s used to treat urinary retention in women, and it’s used for kidney stone management in both women and men.” In addition, when IFIS occurs in women, there is a higher rate of complications.

Surgeons need to be prepared both pre- and intraoperatively, Dr. Garg noted. With regard to incision management, he said, anterior incisions—and longer incisions—are preferred, and he has a low threshold for suturing. Pressure management and low flow phaco are two of his recommended phaco strategies.

Coping with the rock-hard nucleus. These are some of the most challenging cases that cataract surgeons will see, said Susan M. MacDonald, MD. “Set yourself up to succeed—pre-op planning is essential.” As part of this, “communicate with your team,” Dr. MacDonald said. “Let your team know that this is going to be a complicated case.”

During surgery, she recommended that the surgeon stay at the iris plane: “We need to pay attention to the distance that we are phacoing” as a way of avoiding damage to the endothelial cells. She also recommended limiting the amount of energy that is used; she prefers using the burst/pulse mode.

Dr. MacDonald recommended keeping on top of new techniques for nuclear disassembly; she particularly likes using the miLoop (ianTech/Zeiss). Finally, she said, “it’s time for U.S. surgeons to ‘get unplugged’”—that is, to become proficient in small-incision cataract surgery (SICS). “We don’t have a lot of training in SICS in the United States, but it’s an excellent approach.”— Jean Shaw

Financial disclosures. Dr. Garg: Aerie Pharmaceuticals: C; Allergan: C; Avedro: E; EyePoint: C; Eyevance: C; Johnson & Johnson: C; Kala: C; New World Medical: C; OcuTrx: O; Shire/Takeda: C,L; SightLife Surgical: C; Verana Health: C; Vision Care: C; Zeiss: C. Dr. MacDonald: ianTech/Zeiss: C,O; Perfect Lens: C,O. Dr. Yeu: Alcon: C,L; Allergan: C,L; ArcScan: C; Bausch + Lomb: C; Bio-Tissue: C,L; Carl Zeiss: C,L; Glaukos: C,L; Innovation Labs: O; iOptics: C,S; Johnson & Johnson Vision: C,L; Kala: C,S; Katena: C; Modernizing Medicine: O; Novartis/Alcon: C; Ocular Science: C,O; OcuSoft: C; Omeros: L; ScienceBased Health: C; Shire: C,L; Sight Sciences: C; Sun Ophthalmics: L; TearLab: C; TearScience: C; TissueTech: C,L; Topcon: S.

Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.