On Day 2 of the 36th Annual Meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2024), Symposium 9: A Break in the Clouds—Cataract & Complications, provided insightful talks on complications in cataract surgery. From managing iris prolapse to enhancing toric IOL implantation precision, APAC specialists shared their practical tips and expertise.
Iris prolapse
Dr. Joon Young Hyon (South Korea) shared practical insights on managing iris prolapse during cataract surgery. Highlighting key factors like incision, pressure and flow, he explained how a well-constructed, incision placed more posteriorly can prevent prolapse. “A square, slightly unclear incision helps keep the iris in place,” he noted.
Dr. Hyon also emphasized the importance of decompressing the anterior chamber to balance pressure, and recommended gentle tapping on the incision roof to reposition the iris, calling it “a simple yet effective technique.” For severe cases, constricting the pupil or suturing the main incision might be necessary.
Dr. Abhay Vasavada (India) then took to the podium to shed light on the pesky problem of iris prolapse during cataract surgery. In his easy-going manner, he highlighted the importance of paying attention to wound construction, the early detection of iris prolapse and the role of pressure gradients.
Dr. Vasavada touched on corticocapsular adhesions (CCAs). He explained how adhesions can block hydrodissection, causing fluid to push behind the iris and exacerbate prolapse. “I’m not able to see the vein behind it, so I go to the other quadrant. Many times, these CCAs require multi-quadrant hydrodissection,” Dr. Vasavada shared, narrating a video of the procedure,
He illustrated the common mistake of injecting more viscoelastics or ophthalmic viscosurgical devices (OVDs) and injecting in the middle of the eye. Instead, he recommends injecting the OVD peripheral anterior to the iris to keep the iris concave or flat.
Steep meridians and toric IOLs
Dr. Tsutomu Ohashi (Japan) presented a fascinating comparison between digital and manual methods for determining steep meridians for toric IOL implantation. He revealed that manual marking often diverges significantly from digital image-guided systems (IGS), leading to potential misalignment of the toric IOL axis.
A survey conducted at ESCRS 2021 revealed that while 37% of doctors rely on manual ink marking, 23% prefer digital imaging registration for accuracy.
Dr. Ohashi’s study showed that the IGS method, which uses real-time tracking and overlay adjustment, provides more reliable results, allowing surgeons to place toric IOLs precisely on the intended meridian.1
This reduces the risk of misalignment and enhances surgical outcomes. Dr. Ohashi’s findings underscore the benefits of investing in advanced digital systems for better precision in toric IOL implantation.
Relocating decentered IOLs
Dr. Arup Chakrabarti (India) shared his expertise on addressing decentered and dislocated intraocular lenses (IOLs) by leveraging the residual capsular bag support using proper surgical techniques.
He presented a case where a patient had a significantly decentered IOL cutting the pupillary space, leading to poor vision quality. Through meticulous surgical techniques, including closed chamber micro-maneuvers and the use of dispersive OVD to form the anterior chamber and protect the corneal endothelium, he successfully repositioned the IOL back into place.
Dr. Chakrabarti emphasized that many such cases can be resolved by utilizing the residual capsular support. “Employing proper surgical techniques often yields both anatomical and functional success,” he noted.
Post-LASIK IOL calculations
Dr. Yeo Tun Kuan (Singapore) presented a comprehensive multicenter study on post-LASIK IOL calculation outcomes. Analyzing 900 eyes, Dr. Yeo’s research highlighted the standout accuracy of EVO PK, EVO, Barrett True-K PK and PEARL-DGS TK formulas.
Notably, measured TK or PK improved results across the board. The study also revealed that errors increased with axial length, underscoring the importance of patient counseling based on these findings.
“This study shows us that we can actually counsel our patients when they come for cataract surgery,” he explained. “Depending on their axial length, we can see how confident we are in achieving their refractive target.”
“Using the latest formulas like EVO and Barrett True-K ensures we achieve the best outcomes, while legacy methods like Haigis-L and Shammas-PL have the lowest accuracy and probably shouldn’t be used in practice today,” Dr. Yeo concluded.
Tackling complications
Dr. Mahbubur Chowdhury (Bangladesh) gave an insightful presentation that addressed handling complications in phaco surgery. He emphasized that complications are an inevitable part of a surgeon’s career. “Only those who don’t operate never have complications,” he firmly stated.
Drawing from personal experience, he stressed the importance of honesty with patients. He recounted a case involving a national singer where secrecy about complications led to long-term issues. “From that day onward, I decided it’s not at all good to hide things from patients,” he shared, highlighting the need for transparency.
The presentation covered managing personal complications and handling cases referred by other surgeons. He advocated for a multidisciplinary approach, involving retina specialists, glaucoma experts and cornea doctors to ensure comprehensive care. “The confidence the patient gets is immense,” he noted.
Dr. Chowdhury also discussed the financial and legal aspects, recommending policies that avoid additional costs to patients and preparing for potential legal challenges. “We have to be humble, sympathetic and bold,” he advised.
Ultimately, the presentation offered practical strategies and urged surgeons to remain humble, collaborative and patient-centered. This approach builds trust with patients and strengthens the professional community, fostering mutual respect and continuous learning.
Complicated presbyopia lens exchange
Dr. Lu Yi (China) presented on the complexities of presbyopic IOL exchanges. As the demand for presbyopic IOLs grows, particularly for replacing monofocal IOLs, surgeons face unique challenges due to the varying characteristics of these lenses.
Dr. Lu detailed several cases where high technical expertise was crucial, particularly emphasizing the importance of maintaining the integrity of the capsular bag.
For instance, one patient with severe astigmatism required a careful exchange to achieve better near vision, while another patient with presbyopia and hyperopia experienced significant improvement after switching to a trifocal IOL.
Dr. Lu also highlighted the intricate process of scleral fixation, noting that it is not routine but can be essential for certain cases.
Neuro-ophthalmic disorders
Dr. Anuchit Poonyathalang (Thailand) discussed neuro-ophthalmic disorders after cataract and refractive surgery. He emphasized that although these disorders are rare, surgeons should be aware of them.
Factors such as small cup-to-disc ratio and systemic diseases may contribute to ischemic optic neuropathy after cataract surgery, and post-surgery diplopia can result from pre-existing strabismus or surgical trauma to extraocular muscles.
Effective management strategies include careful patient evaluation and monitoring.
Editor’s Note: Reporting for this event took place during the 36th Annual Meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2024), held from May 30 to June 1, 2024 in Chengdu, China. The 36th APACRS annual meeting is jointly organized with the 24th CSCRS (Chinese Society of Cataract & Refractive Surgery) annual meeting.
Reference
- Ohashi T, Kojima T. Comparison of the orientation of the corneal steep meridien determined by image-guided system and manual method in the same eye. Clin Ophthalmol. 2020;14:4135-4144.