Uday Devgan, MD, selected 12 cases from his 2,000+ video library on CataractCoach.com for a morning symposium on Sunday, April 27. Throughout each of the cases, panelists Deepinder Dhaliwal, MD, and Rosa Braga-Mele, MD, who had not seen the videos prior to the session, shared what they would have done throughout the case as it proceeded. Dr. Devgan said the cases would be interesting, challenging, and complicated.
The first case Dr. Devgan shared was performed by a guest surgeon showing a traumatic cataract with segmental zonular loss. From the get-go, Dr. Devgan showed how the case had “so much zonular loss.” What’s your next step? Dr. Dhaliwal said she would put in viscoelastic, while Dr. Braga-Mele said she would put in a little triamcinolone to reveal any vitreous.
The surgeon performing the case did put in triamcinolone, and it revealed more vitreous than you imagined, Dr. Devgan said. As the vitreous is being removed, Dr. Devgan said it seemed like the vitreous was helping stabilize the lens.
When injecting trypan next, it was important to inject it under viscoelastic so it wouldn’t go into the vitreous cavity; if you don’t, you would not have a red reflex.
Source: ASCRS
To stabilize the capsular bag, Dr. Devgan showed that the surgeon used a CTS and an iris hook to hold the CTS eyelet.
Later in the case, Dr. Devgan asked why does it still look white? That’s too much triamcinolone, which is why there is a “crummy” red reflex. Dr. Devgan said he dilutes triamcinolone to about 1 mm/cc.
The IOL choice in this was a single-piece in the bag with its eyelet fixated to the sclera with Gore-Tex. Any pearls for working with Gore-Tex? Dr. Braga-Mele said she probably would have straightened the needle ahead of time to make it easier to pass. Dr. Devgan said this is a good tip. With Gore-Tex being slick and slippery, it means it’s important to not be too square or to cinch down too much. Dr. Dhaliwal said it’s important to not pull too tight, center the lens, and make sure you bury the knot.
Another case Dr. Devgan presented was one of his own: a tiny hyperopic eye that had a 19 mm axial length and a 2 mm anterior chamber depth. Dr. Dhaliwal said she would use preop mannitol for sure, and Dr. Devgan said it’s important to give the mannitol “way in advance.”
When it comes to splitting the nucleus in these conditions, Dr. Dhaliwal suggested using the technique that works best in your hands, while Dr. Braga-Mele said she would use whatever makes space. “I love your idea of debulking it,” Dr. Devgan said, noting that he used a stop-and-chop technique, making the groove double wide so each half of the nucleus isn’t really half but more like 40%. Another trick he described is after he cracks the nucleus, he uses the chopper to pull one nuclear piece toward himself to make room to get up the other piece.
Dr. Degan said the highest power lens available in the U.S. is 40, so that’s what he used in this case. Dr. Braga-Mele said she would consider a piggyback IOL.
Another lesson learned is to check under the iris for retained cortex. Dr. Devgan discovered some and promptly removed it. If you don’t get it out, it will fluff up and be in the pupil the next day.
A third case was the opposite—a large myopic eye that had a 31 mm axial length, 13 mm white-to-white, and 3.8 mm anterior chamber depth. Dr. Devgan said for cataract removal, he got it up out of the bag and removed it easily, but he praised Dr. Dhaliwal’s suggestion of using whatever technique you’re most comfortable and successful with.
He used a 3-piece lens in this case and discussed lens-iris diaphragm retropulsion syndrome (LIDRS). He said he wouldn’t fix LIDRS in the setting of this syndrome because it makes it so easy to get all the cortex cleaned up. Dr. Dhaliwal said she also doesn’t fix it unless the patient is uncomfortable. It’s so important in these cases to not let the anterior chamber shallow. “I never come out unless I put viscoelastic in the eye,” she said.
In terms of targeting the IOL when the patient wants 20/20, all the surgeons said they would target myopia because if there’s an error in these eyes, it would be a hyperopic miss.
Financial disclosures
Braga-Mele: Alcon
Dhaliwal: Bausch + Lomb, Johnson & Johnson, STAAR Surgical
Devgan: Johnson & Johnson
