ASCRS Session Notes from Challenging Video Cases for the Young Surgeon

Faculty: J. Randleman; D. M. Blackmon; D. H. Chang; D. A. Goldman; T. M. Harvey; S. W. Reeves; D. L. Seldomridge; E. A. Davis; U. Devgan; T. Kim; P. A. Majmudar; S. H. Yoo; D. T. Vroman

Toric IOLs:

• Need to remove viscoelastic from behind lens to prevent rotation.
• Don’t overinflate eye with BSS at end of case, BSS can get behind IOL and cause rotation as well.
• Can also use second instrument through para to hold lens in exact position then I/A through main incision.
• Mark axis with patient sitting up to avoid cyclotorsion effects
• Staar toric is cheaper than Alcon lens ($200 vs $600) – an issue if you work at an ASC.
• Watch out when you inject the staar lens, it has a “kick” at the end as it pops out of the injector. Also, with the Staar lens, don’t make a small rhexis, it has a tendency to have anterior capsule phimosis. Lastly, you can implant the Staar lens upside down to prevent rotation.

For broken Posterior Capsules:

• Put a 3-piece IOL in the sulcus
• Never put a 1-piece IOL in the sulcus (iris chafe, UGH)
• If 1 piece already in place in the bag, can leave haptics in the bag and pop the optic anterior to the capsulorhexis (reverse capture)
• If PCO is small and you are very careful, you can put a 1-piece IOL in the bag. Acrysof and Tecnis 1 open up slow enough so that you can control this process
• If you get a PCO with an IOL in the opening, don’t pull out I/A tip. Lower bottle height, then inject viscoelastic through the para. Then can pull out I/A tip.

Consents:

• Make sure that the patient knows that sometimes the lens, procedure, etc. that you plan on doing may not get done (e.g. Crystalens, toric IOL vs LRI with sulcus lens

To remove a lens from the bag:

• Enlarge the wound
• If you cut it, do a pac man so that you don’t lose pieces. But be careful because the sharp edge can damage the angle and cause bleeding.
• If you want to fold the lens, use extra viscoelastic to protect the endothelium. Fold the lens in the AC.
• Make a para 180 deg from main wound.
• Use a cyclodialysis spatula through the para to help fold the lens with forceps through the main wound.

For decentered IOLs:

• If the haptics are normal, try to reposition it.
• Don’t explant a PMMA lens if you don’t have to. It will require a very large wound.
• Can either suture the lens to the iris with 10-0 prolene or use scleral fixation.

For small pupils:

• Can use a combination of anything per the panel. Healon 5, iris stretching, iris hooks, or the malyugin ring

For mature white lenses:

• Go under iris when you use trypan blue so that you stain the entire capsule.
• The key is to decompress the bag as quickly as possible so that you don’t get the Argentinian flag sign.
• If you do get it, consider converting to an extracap surgery. Recommend closing the clear corneal wound, changing sites and making a proper sclera tunnel at another site.
• You can also try to phaco it out, but be careful with hydrodissection, it can extend tear to the posterior capsule.
• Consider using small scissors to remove the capsule first.

For Anterior vitrectomy:

• Stain vitreous with triamcinolone
• Don’t use wekcel sponges to check for vitreous, it causes traction and can cause an RD or giant retinal tear
• Use bimanual vitrectomy to prevent the vitreous hydration that is caused by coaxial vitrectors
• Check for vitreous in the AC at the end of the case by injecting sterile air or triamcinolone.