Clinical pearls abound in conquering the rock hard cataracts

Conquering the Rock Hard Cataract

by Brooke Herron

Hard 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 37 th 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. 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.”

Learning from the Drama

with Oculoplastic Trauma by Joanna Lee

What would you do if a patient presents with 75% of his face “eaten up” in a cannibalistic attack for 18 minutes? Dr. Andrea Kossler of Stanford University in California, United States, brought her audience at the 37 th World Ophthalmology Congress (WOC2020 Virtual®) through a detailed but structured account of her patient, a 65-year-old homeless man who suffered total hyphema in the right eye, flat globe in the left complex eyelid laceration after having his face chewed by an assailant.

When dealing with bear attacks, or any other traumatic injuries, it is best to cling to basic surgery principles at all times in oculoplastic trauma cases.

To enucleate or not to enucleate?

After much deliberation, she performed bilateral enucleation (evisceration) with implants. She also advanced a pericranial flap for the posterior lamella. The patient eventually recovered but had declined additional ocular or nasal surgery or prosthesis fitting. “Don’t be intimidated” she said, as she shared her learning points. “Remember the principles of surgery in any situation,” she added. On hindsight, she would avoid primary enucleation when possible, especially if bilateral.

The next case presented in the same session was a bear attack victim with complex and unusual facial laceration. Dr. Rohit Saiju of the Tilganga Institute of Ophthalmology in Kathmandu, Nepal, presented two cases. The first was a 19-year-old victim who has had extensive facial laceration, huge tissue loss from periorbital region with traumatic avulsion of his right eyeball and exposed left eyeball. Subsequently, Dr. Saiju used the medial forehead flap to reconstruct the lower retracted eyelid while donor scleral graft became the posterior lamella.

Unfortunately, the forehead flap did not work. Eventually, Dr. Saiju performed the free radial forearm flap (Chinese flap). The second case was a 55-year-old bear attack victim from Nepal. Dr. Saiju concluded that extensive periorbital laceration repairs were difficult as the lacerations were a threat to vision due to exposure. He found a multidisciplinary approach necessary.

Of deformed structures from trauma

The next two presentations dealt with dacryocystitis. Prof. Kyung In Woo from Sunkyunkwan University School of Medicine, in Seoul, South Korea, learned that for this type of trauma, the periciliary v-line incision was useful for both medical canthoplasty and external dacryocystorhinostomy (DCR). She also learned that deformed structures from trauma around lacrimal sac were managed efficiently during external DCR.

Dr. Jane Olver said: “In lacrimal trauma, all roads lead to the Jones’ tube,” when she discussed her presentation titled All Post-traumatic Dacryocystitis-Managed Endoscopically. For Dr. Olver, lacrimal trauma remains a challenge because the orbito-naso-ethmoid fractures affect the nasolacrimal duct (NLD) obstruction.

Orbital fracture revisions could present as challenges as Dr. Suzanne Freitag from Harvard Medical School in Boston, Massachusetts (USA) had found out. A 39-year-old healthy male had had a motor vehicle accident 7 months ago and was referred to her. His orbital fracture had been repaired with a titanium mesh by a general plastic surgeon two weeks after the accident. He suffered from vertical diplopia in all directions of gaze even though he has no diplopia prior to surgery and cicatricial entropion.

A call for custom orbital implants

After correcting his surgery, he had no improvement in his globe position, and still had diplopia and entropion. She then introduced a patient-specific porous polyethylene implant to create symmetric bony volume. Two months post-implant, his diplopia is gone and globe position has improved. Dr. Freitag concluded that orbital fracture repairs should only be done if there are clear indications (like enophthalmos or diplopia issues). The patient had neither, pre-operatively. Also, she thinks titanium mesh is not an ideal orbital implant. It’s traumatic to insert and remove and it causes significant scarring. Lastly, patient-specific custom orbital implants should be considered.

Experts Discuss Challenging Cases in Neuro-Ophthalmology by Hazlin Hassan

We use almost half of the brain for vision-related activities, including sight and moving the eyes. Sometimes, when problems occur for the eye, brain, nerves and muscles, they may involve conditions that can cause permanent visual loss, or become life threatening.

Several speakers at the 37 th World Ophthalmology Congress (WOC2020 Virtual®) on Sunday shared their insights on a few hot topics in neuroophthalmology.

Cerebral venous stenting for idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IHH) is a rare condition but becoming more common, said Dr. Susan Mollan of the University Hospitals Birmingham in the United Kingdom. Some 90% of those affected are obese women of childbearing age. Symptoms range from headaches, visual disturbances, pulsatile tinnitus, double vision and mild cognitive changes. The majority is benign with a low risk of visual loss but the minority is bad with a high risk of rapid visual loss.

“There are no clear trials helping to guide us when patients are losing vision rapidly, and the drug treatments for symptoms are quite poorly tolerated and the care is very variable around the world,” said Dr. Mollan. The rationale for stenting in IIH includes partial occlusion, or stenosis with resultant venous sinus hypertension. A link between venous sinus hypertension (a cerebral venous system disease that obstructs venous blood outflow) and IIH was demonstrated in 1995 when manometry was performed on nine patients with IHH. Raised pressure in the SSS and proximal TS was found in all of them.

The reported incidence of venous sinus stenosis in patients with IHH ranges from 30 to 93% compared with 6.8% among the general population. Dr. Mollan feels that clinical trials are needed to look into the matter further.

AI in neuro-ophthalmology

Artificial intelligence (AI) is playing an increasingly important role in the detection of neuro-ophthalmic optic disc abnormalities on ocular fundus images instead of ophthalmoscopy. The use of deep-learning methods to discover abnormal optic discs could revolutionize the practice of neurologists and other non-ophthalmic healthcare providers.

“We had high accuracy for papilledema detection which can be very useful for emergency rooms, in neurological clinics, or in situations where ophthalmologists are not readily available,” said Prof. Dan Milea of the Singapore Eye Research Institute (SERI). “Are ophthalmologists going to be replaced by artificial intelligence? The right answer is that ophthalmologists who use AI will replace ophthalmologists who don’t,” he said.

Controversies in the treatment of NA-AION

Nonarteritic ischemic optic neuropathy (NA-AION) is a multicomplex disorder with predisposing and precipitating factors, said Prof. Dr. Sansal Gedik of Selcuk University Faculty of Medicine in Turkey.

In order to treat the condition, doctors must avoid risk factors and night time antihypertensive medication. Aspirin therapy may reduce associated disorders like CVE and MI. Can optic nerve decompression surgery (ONSD) be used to treat NA-AION? Dr. Gedik’s short answer is no. “It is not effective and may be harmful,” he noted.

According to a National Institute of Health (NIH) report from the United States in 1995, there was a 12% additional visual loss in the observation group, 24% additional visual field loss in ONSF administered group, and 42% improvement of visual loss in the observation group.

Other controversies in NA-AION include questions over whether it is a cerebrovascular event of the eye, is iatrogenic NA-AION possible, what is the role of heredity and do erectile dysfunction drugs cause it?

Although the etiology of NA-AION is still debated, the lesion is based on a sudden or rapidly progressive ischemic insult to the anterior optic nerve, resulting in capillary and retinal ganglion cellaxonal dysfunction, followed by astrocyte activation, oligodendrocyte distress and death, and inflammation.

The timing of the ON inflammatory response, oligodendrocyte death, and multiple effects of inflammation on repair and recovery are poorly understood. A study showed that steroids may reduce the capillary permeability and stabilize cell membrane in the acute phase and inhibit damage by free radicals.

We Stand We Stand With The World of With The World of Ophthalmology Ophthalmology

during this time of during this time of challenge, and also of hope. challenge, and also of hope.

All around the globe we stand All around the globe we stand united with colleagues, united with colleagues, organizations, ophthalmologists organizations, ophthalmologists and industry, to make 2020 and and industry, to make 2020 and beyond what it should be: beyond what it should be:

Clearly, a better future. Clearly, a better future.