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Up Front | Mar 2008

Practical Information for Cataract Complications Management

Last month's Annual IOL Issue highlighted the exciting new developments in presbyopia-correcting IOLs and microincision cataract surgery. Keeping in line with our annual traditions, the March issue represents our Third Annual Cataract Complications Issue. This compilation of articles covers new techniques and devices for complicated and challenging cataract surgery.

There is still an ongoing debate about whether a capsular tension ring (CTR) should be implanted in cases with severe and/or generalized zonular dehiscence. If the decision is made to use a CTR, a second dilemma arises: Can we obtain sufficient fixation of the capsular bag with a regular CTR, or should a Cionni Modified CTR (Morcher GmbH, Stuttgart, Germany) with one or two eyelets be sutured to the scleral wall? Prior to implanting the ring, one can also choose to temporarily stabilize the capsular bag with iris hooks or an Ahmed Capsular Ring Segment (Morcher GmbH).

Now, a couple of devices and techniques may be added as future options to this list. The first is a new and smart capsular anchoring device designed by Ehud Assia, MD, of Israel, which may also be used in combination with a CTR. The second innovation is the Henderson CTR (Morcher Gmbh), designed by Bonnie An Henderson, MD, of Boston, which facilitates cortex removal. When a traditional CTR is implanted before cortex removal, we know how cumbersome it can be to pull the cortical material from its trapped position between the ring and the capsule. I really look forward to trying these two devices; anything that can help overcome the challenging problems associated with zonular dehiscence/weakness is extremely welcome.

The third, and for me the most inspiring development, is the fish-tail implantation technique for CTRs, created by Brian Little, MA, DO, FRCS, FRCOphth. I already successfully tried this technique after attending his presentation at last year's ESCRS Congress in Stockholm. I recommend reading Dr. Little's article carefully because he provides practical tips and tricks for his technique. I think it is a very logical concept for implantation of a tension ring, because it reduces stress to the zonules significantly.

Boris Malyugin, MD, PhD, of Moscow, Russia, gives us an update on the most recent version of his Maylugin Ring System (MicroSurgical Technology, Redmond, Washington). It looks like the most sensible solution for small pupils. It really facilitates surgery, looks safe to use, and reduces trauma to the pupillary sphincter compared with other devices and techniques. Unfortunately, the price tag of this single-use device will probably withhold me from using it too frequently.

The Dual Coaxial Irrigation Kit (Alcon Laboratories, Inc., Fort Worth, Texas) is a new tool to optimize fluidics control in complicated cases. It allows surgeons to work with very low bottle heights and eliminates leakage.

Other authors contributed with very interesting overview articles: Abhay R. Vasavada, MS, FRCS, and Shetal M. Raj, MS, of India, on managing posterior polar cataracts; A. John Kanellopoulos, MD, and Thanos D. Papakostas, MD, of Greece, on malpositioned IOLs; and Rudy M.M.A Nuijts, MD, PhD, of the Netherlands, on how to minimize endothelial cell damage. In cases with a compromised corneal endothelium, we should take all potential harmful factors into account in order to achieve the best patient outcome.

Bong-Hyun Kim, MD, of South Korea, also contributed to this issue by explaining his new device, the BK Kim Intraocular Mirror (Katena Products, Inc., Denville, New Jersey). Hüseyin Bayramlar, MD, and Cihan Ünlü, MD, of Turkey, suggest earlier surgical intervention in pseudoexfoliative eyes to reduce the risk of capsular complications.

I truly think that this year's cataract complications issue will provide us with practical information on how to further improve our surgical outcomes. One of the great advantages of serving as a Co-Chief Medical Editor for a journal like this is that I am obliged to read all articles carefully. This has helped me enormously in dealing with difficult cases. I sincerely hope that you will benefit to the same extent as I have!