Complicated surgeries

Every trainee must face the first complication when learning how to perform cataract surgery. Seasoned veterans at a session of the 21st Annual ESCRS Winter Meeting in Maastricht provided suggestions for how young surgeons could handle some of the more common situations. Angela Panico MD tackled the difficult issue of the capsulorhexis running out. “The basic reason for this is a capsular bag pressure that is higher than the pressure in the anterior chamber,” explained Dr Panico, Ophthalmic Unit, San Donà di Piave Hospital, Venice, Italy. She described three “rescue” techniques to bring the rhexis back from the edge. “The pull-back technique” requires the surgeon to grasp the flap near the root of the tear and pull in the direction opposite the tear, which reverses the force applied to the flap,” she said, while showing a video of the manoeuvre. The second rescue technique, an anterior zonulotomy, is performed if the tear has reached the zonular fibres. Additional traction may cause the tear to extend through the zonule to the posterior capsule. In this case, cut the bridging zonular fibres using micro scissors, she suggested. This will release the traction on the capsule and allow for completion of the rhexis. The “quick-pull technique”, the third manoeuvre described by Dr Panico, is a rapid forward movement reserved for experienced surgeons as a last resort. Panellist José Güell MD, Barcelona, Spain, advised delegates to consider a femtosecond laser capsulotomy in cases with a significant risk of the rhexis running out. Professor Rudy MMA Nuijts, Maastricht, the Netherlands, suggested making a small initial rhexis, performing the phaco and then creating a larger rhexis at the end of the procedure. Catarina Pedrosa MD, Lisbon, Portugal, presented next, advising attendees on how to avoid problems when performing cataract surgery in cases of posterior polar cataract, and how to solve them once they occur. “Traditional hydrodissection should be avoided. Instead, perform hydrodelineation, in which the epinucleus is separated from the nucleus. This forms a cushion between the nucleus and the capsule,” she advised. An alternative is viscodissection, which also forms a cushion and will help avoid vitreous prolapse into the bag in case of posterior rupture. Dr Nuijts agreed, and said he often takes it a step further, fully luxating the nucleus into the anterior chamber for removal far away from the posterior capsule. “Treat all posterior polar cataracts as though there is a pre-existing hole in the capsule, performing slow-motion surgery to minimise all risk,” concluded Dr Pedrosa. Angela Panico: angy.panico@gmail.com Catarina Pedrosa: pedrosa.catarina@gmail.com