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Top Gun phaco showdown

Cataract surgery pearls from the world’s best phaco instructors

Howard Larkin

Posted: Wednesday, January 22, 2020

Boris Malyugin MD, PhD

Even the sunniest cataract extraction can turn suddenly cloudy when a detached Wieger’s ligament unexpectedly allows aspiration of the posterior capsule. That’s when it’s time to soar back into the blue with a posterior continuous curvilinear capsulorhexis (CCC), Boris Malyugin MD, PhD, Moscow, Russia, told the Top Gun session at the ASCRS ASOA 2019 Annual Meeting in San Diego, USA.

“Whoops, I did it again,” quipped Dr Malyugin, who represented ESCRS under the call sign “Danger Zone-ules” in this high-flying dogfight of phaco instructors from across the globe.

The first step to successful recovery is to leave the irrigation probe in place and fill the anterior chamber with viscoelastic, Dr Malyugin said. This makes the tear visible for evaluation. If the anterior hyaloid membrane is intact, any vitreous that appears to prolapse often can be pushed back with additional visco.

“This is a very important procedure to keep the vitreous stable and located behind the posterior capsule.” The posterior tear can then be converted to a CCC using micro-forceps, he explained.
To minimise stress on the capsule and zonules, Dr Malyugin recommended injecting the intraocular lens into the anterior chamber rather than the capsule, then inserting the haptics into the capsule one at a time. “These gentle manoeuvres help keep the vitreous in place to avoid any herniation.” Remove the viscoelastic and you’re done. “If everything is done properly you will have a very nice result,” Dr Malyugin concluded.

SEALING CORNEAL INCISIONS
The key to sealing corneal incisions after surgery is creating self-sealing incisions in the first place, said Soon-Phaik Chee FRCSEd, FRCOpth, Singapore. To avoid leaks, side-port incisions should be longer than they are wide, and main clear corneal incisions with a ratio of length to width of 4:5 to 3:5 have long been shown to seal better than incisions that are closer to square (Ernest PH et al. J Cataract Refract Surg 1994;20:626-629), she noted.

More recently, trapezoidal incisions that are wider internally than externally have been shown to seal better, said Dr Chee, representing APACRS under call sign “Phaiko Savant”.

“This allows you to move your instruments around without stretching [the incision].”

On closure, seal the side port by stroking the incision while maintaining irrigation. Use irrigation infusate to hydrate the main incision and simply massage externally to seal it without need for injecting additional BSS.

MiLoop FOR HARD CATARACTS
Dense cataracts got you frustrated? Just loop it, said Mitchell P Weikert MD, Houston, USA, representing ASCRS as “Cyclops – so my patients don’t have to be”.

Staining is the first step to successfully using the miLoop device (ZEISS) for segmenting the nucleus, said Dr Weikert.

“Even if you have a decent red reflex, with these dense cataracts you want to be able to see the capsule when you are passing your loop around.”

A good-size, round capsulorhexis is worth a little extra time to mark and carefully execute, Dr Weikert said. “If I’m going to err, it’s going to be a little bit on the larger side.” Complete hydrodissection is essential both to free the nucleus to spin and create enough room for the loop to get behind it, he added.

It’s important to understand how the snare extends, first toward the surgeon and then away, and its angulation to safely deploy along the anterior surface of the crystalline lens. The snare should slide under the stained capsule edge, extended under the capsule, and rotated posteriorly to ensuring the instrument is properly inserted. As you rotate the snare around the lens it will be a little delayed, so go past the midpoint and then back to ensure it is centered. Constrict the snare slightly to grab the nucleus, and use a second instrument to prevent the distal nucleus edge from rising as you close the snare, segmenting the lens, Dr Weikert advised.

“I like to do two passes to quarter the lens. You can even do more if you want to,” Dr Weikert said.
The greatest advantage is the complete absence of posterior leathery attachments that can substantially increase phaco time and fluid usage. Applying additional viscoelastic to protect the endothelium throughout nucleus removal helps produce clear corneas on day one, he concluded.

Boris Malyugin: boris.malyugin@gmail.com
Soon-Phaik Chee: chee.soon.phaik@singhealth.com.sg
Mitchell P Weikert: mweikert@bcm.edu