CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
Conquering the Rock Hard Cataract by Brooke Herron
H
ard cataracts can complicate just about every step of surgery, from incision, to capsulorhexis and phacoemulsification. For the lowdown on these hard-to-breakdown cataracts, ophthalmologists shared their tips on these challenging cases during a session titled Conquering the Rock Hard Cataract on the third day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).
“When you want to do a very dense cataract surgery, make sure you have strategies for all the different parts of the surgery.” Dr. Steve Arshinoff University of Toronto Canada
Managing hard cataracts isn’t easy “Phacoemulsification in rock hard cataracts poses challenges for even the most experienced cataract surgeon,” said Prof. Alaa El Zawawi from the University of Alexandria, Egypt. One reason? Hard Grade 4 (brown) and very hard Grade 5 (brown-black) cataracts come with their own comorbidities: loose zonules, a low endothelial cell count, a shallow anterior chamber, pseudoexfoliation and inadequate pupillary dilation. These brown cataracts are usually present in older, fragile persons — they
have associated systemic disease, and are on medication. All of these must be considered when operating in these cases, he continued. So, what about surgery? “Phacoemulsification itself is a real challenge [in these cases],” said Dr. Zawawi, who then offered a few tips on the different techniques. “The sleeve must be retracted to better impale the nucleus if you are using the chopping technique; using the vertical chopper, it must be very sharp to incise the dense nucleus without displacing it; and at the end of the surgery, you will change to horizontal chopping for the remaining large brunescent fragments.
Other tips and techniques “When you want to do a very dense cataract surgery, make sure you have strategies for all the different parts of the surgery,” said Dr. Steve Arshinoff from the University of Toronto, Canada, who extensively covered the use of OVDs (ophthalmic viscosurgical devices) in hard cataract surgery. “If you want to remember OVDs, there’s a very simple way: The higher viscosity cohesives create space and induce and sustain pressure, while the lower viscosity dispersives have prolonged retention and you can partition spaces,” he summarized. Next, speaking on surgical techniques was Dr. Vladimir Pfeifer from the University Eye Hospital in Ljubljana, Slovenia, who asked and answered: “Why would we perform quick chop?
“Because in a lot of difficult, complicated cases that’s the best technique to use, especially in brunescent cataracts and in other cases,” he explained. “This technique has only three steps: 1) impale the nucleus with the phaco tip; 2) incise the nucleus with the chopper; and 3) crack the nucleus.” Lastly, Dr. R.D. Ravindran from the Aravind Eye Hospital in India, compared phaco and manual small incision cataract surgery (MSICS) in cases of hard cataract – he explained that with phacoemulsification, there is less induced astigmatism, better uncorrected vision and early refractive stabilization. “At the same time, it needs good equipment and some of that is quite expensive; it also needs special viscoelastics, which can cost a lot; and in addition, the surgeon should have higher skill and additional resources, like femtosecond laser,” added Dr. Ravindran.
“MSICS can be done in all cases, it’s faster and less expensive… and in a country like ours [India], it’s an affordable option for us.” Dr. R.D. Ravindran Aravind Eye Hospital India Furthermore, Dr. Ravindran highlighted that not all cataracts are suitable for phacoemulsification and in these cases MSICS is the best option. Besides, this procedure uses less sophisticated equipment; requires less skill, the cost is lower; the complications are fewer; and the surgical time is shorter as well. After reviewing both procedures, Dr. Ravindran concluded that both phacoemulsification and MSICS achieved excellent outcomes with low complication rates in patients with certain types of brown cataract — although he emphasized that phacoemulsification cannot be done in all cases. “MSICS can be done in all cases, it’s faster and less expensive . . . and in a country like ours [India], it’s an affordable option for us.”
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