This is my sixth editorial for CRST Europe’s Annual Cataract Complications issue. Surgical challenges are continually of interest to cataract surgeons all over the world, as we all experience disastrous cases once in a while. Recently, for instance, I was forced to confront a serious complication in an eye with a posterior polar cataract when, in a split second, a large posterior capsular tear occurred. Retrospectively, I made one very bad decision that led to a cascade of serious complications. The surgery was less than perfect, but I walked away from the case having learned a lesson: Be even more meticulous in every step during every procedure.
Lisa Brothers Arbisser, MD, describes another split-second complication in her article (and accompanying video on Eyetube.net). In this case, pupil bounce occurred as an early warning sign of posterior capsular rupture. It is always comforting for me to note that other surgeons also experience surgical complications. I particularly admire Dr. Arbisser and others who dare to share their mistakes with us. We can, and should, learn from the mistakes we have made as well as those of others.
Craig Parkes, MBChB; Manish Nagpal, MS, DO, FRCS(UK); Brian C. Little, MA, FRCS, FRCOphth; and Som Prasad, MS, FRCS(Ed), FRCOphth, FACS, provide us with a magnificent overview of stopping the drop of a nucleus. This expert team of anterior and posterior segment surgeons has organized numerous instructional courses on the management of the posterior capsular rent and prevention of the dropped nucleus for international congresses. Reading the written descriptions of their techniques in their article and watching the three associated videos on Eyetube.net is almost like being in attendance at their course.
Alin Stefanescu-Dima, MD, PhD, shares one more potential nightmare case, a hypermature dense cataract with generalized weak zonules. His article is supplemented by an Eyetube.net video that revives my own similar nightmare cases. In his article, Dr. Stefanescu-Dima recommends some important preemptive measures. I suggest watching the video and reading the entire article, paying specific attention to the last part.
Another factor that has the potential to complicate our surgical cases is the small pupil. Thierry Amzallag, MD, describes his synechiarrhexis technique to manage a fixed narrow pupil. He advocates peeling the fibrotic membrane from the pupillary margin with forceps. In my own experience this can often be carried out successfully, but do not be completely disappointed if you fail to pull the membrane off easily. I have to admit that I am not 100% successful in removing the fibrotic membrane in all cases.
Two articles, one by Alessandro Franchini, MD, the other by Oliver Findl, MD, MBA, focus on creating a good continuous curvilinear capsulorrhexis (CCC). The CCC is a crucial step in the early stage of a phacoemulsification procedure. Both articles provide excellent guidelines on capsulorrhexis management. Interestingly, they both mention femtosecond laser technology, which has been highly praised for its precision and accuracy in creating the perfect capsulorrhexis. Dr. Findl also mentions that the potential benefits of a femtosecond laser CCC may not necessarily lead to visual outcomes superior to those with a manual CCC. I have heard many similar comments from fellow surgeons in casual conversations in the hallways of convention centers and around the dinner table.
It will be interesting to see how the ophthalmic community embraces this technology in the coming months and years. Cost-effectiveness and efficiency will play an enormous role in the acceptance of femtosecond laser technology in lens surgery. Dr Findl says he is interested to see data from proper randomized trials comparing femtosecond laser and manual capsulorrhexes. I share his skepticism but acknowledge that the technology by itself is promising.