In a dynamic session reminiscent of martial arts mastery, the 36th Annual Meeting of the Asia-Pacific Society of Cataract and Refractive Surgeons (APACRS 2024) brought the house down with Symposium 20, titled Wisdom from the Kung Fu Masters – Top Cataract Surgery Tips.
Like seasoned warriors sharing their secrets, the world’s leading cataract surgeons presented surgical maneuvers that could make even the trickiest operations seem effortless. With energy as vibrant as a kung fu movie, these experts left attendees armed with practical techniques to elevate their surgical prowess to new heights.
Toric IOL positioning
Dr. Robert Ang (Philippines) delivered an engaging and practical presentation, perfectly aligning with the symposium’s theme. He shared his “MMA” (mixed martial art) tips for implanting toric IOLs, complete with an energetic mixed-martial arts theme and fight music to keep the audience pumped.
Dr. Ang’s MMA tips are designed to tackle the common issues surgeons face when dealing with toric IOLs, like the IOL snapping back or getting stuck during positioning. Using fun acronyms and clear steps, he offered solutions for both C-loop haptics and plate haptics, or double C-loop haptic IOLs.
Dr. Ang introduced the BIG APA technique with a smile, saying, “Let me help you with my MMA tips for toric IOL positioning.” He then went on to explain each step in his BIG APA method:
- Irrigate-aspirate beneath the IOL to start.
- Inject Gel over the IOL.
- Align the IOL to axis.
- Patiently wait for one minute.
- Aspirate remaining gel.
Dr. Ang’s AUTO technique applies to plate haptics and double C-loop haptic IOLs:
- Align IOL to target axis.
- Irrigate-aspirate under the IOL
- Fine-tune axis alignment
- Irrigate-aspirate over the IOL
His presentation, complete with rolling credits and MMA-style energy, left the audience with memorable and practical strategies to handle toric IOLs with the precision of a kung fu master.
A difficult cataract case
Dr. Sri Ganesh (India) delivered a captivating presentation titled Enter the Dragon, where he proudly showcased his skills as a cataract surgery kung fu master. Dr. Ganesh shared a fascinating case involving a 31-year-old male with posterior polar cataracts in both eyes, cylinder astigmatism in his left eye, and a large dehiscence of the posterior capsule, which he poetically described as the “dragon mouth sign,” depicting a dragon waiting to swallow the nucleus.
The patient didn’t want to wear glasses after the surgery, and he wanted to be able to drive at night. He went to five other ophthalmologists who couldn’t promise him the results he wanted. And so, he ended up getting a sixth opinion from Dr. Ganesh who took up the challenge.
After peeling off the anterior capsule flap, Dr. Ganesh performed a precise hydrodelineation to avoid disrupting the posterior capsule and filled the chamber with viscoelastic to prevent any fluctuations. The kung fu master then employed his secret weapon: a bimanual IA for the tricky sub-incisional cortex removal.
From there, Dr. Ganesh cleared the vitreous. Using a capsulotomy fixated lens, Dr. Ganesh demonstrated how to ensure stability and prevent lens movement. He meticulously rotated and aligned the lens, ensuring a perfect fit. “This is a non-diffractive lens, so the patient will not have any halos, and it’s a toric lens aligned perfectly along the axis,” he explained.
The results were outstanding. The patient’s lens was perfectly centered, and he had an uncorrected vision of 6/5 and N5. “The patient was very happy and said he now has HD vision,” Dr. Ganesh proudly shared.
His parting wisdom? “Think out of the box, use the correct tools and materials, and you can achieve premium results. This is how I, the Kung Fu master, solved this case.”
More tips from cataract surgery masters
Dr. Ishtiaque Anwar (Bangladesh) introduced the sleeve hydrodissection technique to prevent iris prolapse in IFIS cases, demonstrating how it stabilizes the iris and maintains pupil size throughout the procedure.
Dr. Surendra Basti (USA) emphasized the strategic use of multiple phaco incisions, advocating for their use in complex cases like rhexis run-out or IOL exchanges, to enhance surgical outcomes.
Dr. Sheetal Brar (India) presented a simplified “one at a time” modification for the four-flanged technique of non-foldable IOL scleral fixation, emphasizing that, “multitasking is good, but sometimes it can cost us safety and quality.” She advised surgeons to slow down to avoid complications like suture crossing and IOL tilting.
Dr. So-Hyang Chung (South Korea) shared methods for safely removing different types of phakic IOLs, using specific incisions and forceps to minimize trauma.
Dr. Sorcha Ni Dhubhghaill (Belgium) highlighted the importance of knowing the anatomy behind the lens for performing primary posterior capsulorhexis, a technique she has mastered through thousands of cases. She underscored the significance of staying calm and using appropriate instruments like capsulorhexis micro forceps.
To get a nice round continuous curvilinear capsulorhexis (CCC), Dr. Lee Mun Wai (Malaysia) advised simply to, “stick it in.” Elaborating further, she said, “Use two hands, start the case by using your side port, filling up the eye with your side port cannula and viscoelastic, then gently puncture the anterior capsule with your keratome.”
Dr. Boris Malyugin (Russia) noted that while the VISCOBLOCK procedure significantly reduces the chance of anterior vitreous detachment (AVD), it is at the expense of a higher chance of iris prolapse. He concluded that there is a need for more effective strategies in preventing AVD.
Dr. Mohan Rajan (India) discussed strategies for managing white cataracts, highlighting his punchorhexis technique as a cost-effective solution, requiring a simple learning curve and offering consistent results.
Meanwhile, Dr. Nic Reus from the Netherlands detailed his approach to hydrodissection, focusing on creating both anterior and posterior fluid waves for a good rotating lens.
Dr. Timothy Roberts (Australia) shared a crucial insight into intracameral lidocaine application, revealing that directing the OVD away from the wound keeps the anesthetic in place, significantly enhancing patient comfort.
Dr. Naren Shetty (India) offered a simple yet effective tip for maintaining posterior capsule stability during occlusion breaks by orienting the phaco probe’s irrigation ports vertically.
For a hard cataract case, Dr. Bruno Trindade (Brazil) performed a large capsulorhexis, debulked the anterior nucleus, and flipped it to attack the leathery plaque from the top.
On the topic of dislocated IOLs, Dr. Yu Yibo (China) presented a streamlined technique for aspirating and repositioning dislocated IOLs without using perfluorocarbon liquid, reducing intraoperative risks and speeding up recovery.
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.