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Up Front | Mar 2009

Fourth Annual Cataract Complications Issue

After featuring a series of hot and exciting refractive topics in CRST Europe, we return to a cataract focus, with our traditional cataract complications issue. This is our fourth annual cataract complications cover focus, revisiting and introducing techniques for complications management.

There is still a hint of refractive elements in this month's cover focus, however. The first article I would like to draw your attention to is in the hybrid zone between cataract and refractive surgery. Michael Amon, MD, presents an innovative solution for correcting refractive surprises following cataract surgery. I have long waited for such a supplementary IOL, specifically designed for sulcus fixation with the in-the-bag primary IOL. I had the same idea in mind more than 7 years ago, but I could not find a company interested in the concept at that time. I know how much effort it takes to initiate a research project and to pull it through the painful pathway of the development process. I admire Dr. Amon's dedication to this project. I already have a few patients lined up for this new device.

Despite many technological advances and improved surgical techniques, posterior capsular rupture is still a dreaded and frequent cataract complication. All too often, I hear many colleagues attest to low posterior capsular rupture rates. In contrast, I also hear some manufacturers report approximately 4% anterior vitrectomy unit sales relative to their total cataract procedures sales. My final conclusion is that this subject will always remain interesting to many of our readers.

In his article, Mark Wood, MD, advises us on the prevention and management of posterior capsular rupture. To add to Dr. Wood's preoperative assessment tips and tricks, I would like to point out the clear warning sign of potential zonular weakness: capsular folds during capsulorrhexis. After this danger signal, I convert to my "as gentle as I can" technique and try to avoid stress to the zonules as much as possible. I also switch to a low flow strategy, which I use quite frequently. I have described the use of low fluidics settings in previous articles in CRST Europe. In this month's issue, I report on the use of low flow settings in combination with a dispersive ophthalmic viscosurgical device (OVD) to manage an unexpected intraoperative floppy iris syndrome case.

Masaki Sato, MD, PhD, provides us with pearls for the visco-shell technique. He also proposes the combination of a viscoadaptive OVD (Healon 5 [Advanced Medical Optics, Inc., Santa Ana, California] or DiscoVisc [Alcon Laboratories, Inc., Fort Worth, Texas]) with low flow settings. He uses the OVD to envelope the nucleus in morgagnian cataracts. I would add the possibility of using a dispersive OVD (eg, Viscoat [Alcon Laboratories, Inc.] or Healon D [Advanced Medical Optics, Inc.]) as another alternative. They are widely used for similar purposes and share with the viscoadaptive substances the property of not being aspirated at low flow rates.

Returning to the topic of posterior capsular rupture and the possible thinning of the capsule, I immediately think about a presentation by a Japanese colleague many years ago, which left a firm imprint on my memory. He showed four brunescent cataract cases in which the nucleus started to drop immediately after careful and gentle hydrodissection. Ever since, I am aware of the potential for a fragile posterior capsule in mature cataracts.

If the nucleus or a nuclear piece has moved to the posterior segment but has not descended too far, posterior assisted levitation and/or Viscoat levitation can salvage the case. Although this technique may seem scary to many anterior segment surgeons and difficult to perform, I highly recommend reading the practical article by Richard Packard MD, FRCS, FRCOphth, who is one of the early proponents of this useful technique. I have had to use it three times in my career; it was not as difficult as I had anticipated.

You will also find interesting cover focus articles from Liv Drolsum, MD, PhD; Vishal Jhanji, MD; Kabul Kapur, MD; and Ewa Mrukwa-Kominek, MD, PhD. Finally, I encourage you to send an e-mail or letter to the editor, with suggestions for future articles in CRST Europe.