Global leaders in cataract run the Olympic gauntlet of surgery

The "Cataract Surgery Olympics" featured surgeons from four global leadership organisations. Image credit: ©lazyllama – stock.adobe.com

At the 2024 American Society of Cataract and Refractive Surgeons (ASCRS) meeting in Boston, Massachusetts, attendees were treated to a special session like no other. “I think there’s a misconception that the Summer Olympics are not starting until Paris in August,” said Master of Ceremonies David F. Chang, MD, clinical professor of ophthalmology, University of California, San Francisco. “But this is actually the first event. It’s the Cataract Surgery Olympics.”

Dr Chang was joined onstage by participants, in teams which represented the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS), European Society of Cataract and Refractive Surgeons (ESCRS), Latin American Society of Cataract and Refractive Surgeons (LASCRS) and ASCRS. While the surgeons on stage donned sport-themed outfits which tended on the outlandish side—including inflatable horse costumes for the “equestrian” bout—their surgical strategies were seriously useful. All presenters were accompanied with videos of the surgical techniques discussed. Below, Ophthalmology Times Europe has assembled highlights from the Olympics-themed session.

The first segment of the event was dedicated to technological complications which serve as a barrier in the surgical suite. Zaina Al-Mohtaseb, MD, ABO, presented the first surgical demonstration, “Yamane Fixation of a Light-Adjustable Lens (LAL).”

“This is a patient with a dislocated IOL. It’s a three-piece lens, with pretty poor zonular loss,” Dr Al-Mohtaseb said. To remove the IOL there are many techniques, but cutting the lens upon the removal is “the most controlled,” she said. Walking through the procedure, Dr Al-Mohtaseb shared strategies to set surgeons and patients up for success. “It’s really important to have very good dilation using iris hooks in these complex cases,” Dr Al-Mohtaseb said.

“The other important part, during these complex procedures, is having an anterior chamber maintainer throughout the surgery,” she noted. “Especially when you’re doing the anterior vitrectomy portion, and throughout, when you’re doing the scleral tunnel.”

“Recently, I’ve been using the light-adjustable lens. It does have PMMA haptics, and you have to be very careful, because the optic haptic junction can come off if you go with the wrong angle. I like removing the initial haptic, cauterising it, and then removing the second haptic, after having a couple of episodes where the haptic drops down, especially in patients with long axial length.” Dr Al-Mohtaseb also noted that, by entering and exiting through the scleral opening, she had previously avoided a need the need to suture.

Roger Zaldivar, MD, MBA, MSc, continued the session with his presentation, “Mastering the Pre-Chopper.” His intention was to send viewers home with a surgical technique they could implement right away. Introducing his demonstration, Dr Zaldivar said, “I’m going to give you something extremely practical that you can start doing next week.” In an informal poll of the audience, he asked how many attendees were already using a pre-chopping technique in standard cases; a show of hands reflected a minority of audience members.

“Most of our cases are not extremely hard cases,” Dr Zaldivar said. Despite its reputation as a solution for complicated cases, a pre-chopper could be a helpful tool in every case, and recommended its implementation as a standard part of cataract surgery. He showed video footage of a standard cataract procedure, preceded by use of a pre-chopper to break up the nucleus. “You can see how controlled, delicate and accurate this surgery is,” he added. “See how easily [the fragments] come out.”

Robert Edward T. Ang, MD, presented his techniques with a short film on toric IOL alignment. “Has this ever happened to you?” Dr Ang asked. “Your surgery has gone well so far. You’re simultaneously removing the remaining viscoelastic and nudging the IOL into the intended axis. However, the toric IOL just keeps snapping back.” Dr Ang showed footage of the IOL getting stuck in the wrong location, or moving past its intended axis.

“First, implant the IOL and leave it around 15 degrees short of the target axis,” he recommended. “Go beneath the IOL, switch on the irrigation and aspirate the viscoelastic. Inject more gel over the IOL. Align the IOL. With the chamber more stable, you can align to the target axis.” For patients with toric IOLs, Dr Ang said, it can be beneficial to wait 1 minute after inserting the IOL to let the haptics to unfold to the equator and to keep the IOL from rotating.

Surgeons continued to wrestle with IOLs in the following segments. Bruna V. Ventura, MD, PhD, presented a case study of a 52-year-old woman who underwent IOL explantation. “She had had a refractive lens exchange in her left eye 6 weeks before, with implantation of a trifocal IOL,” Dr Ventura explained. “Her main complaint was, ‘I have unbearable positive dysphotopsia.’” In her operated eye, a corneal exam showed regular symmetrical corneal astigmatism of around 4 diopters and minimal corneal aberrations.

“Among all techniques for IOL explantation, I decided to use the twist and out,” Dr Ventura said. “It consists of first releasing the IOL from the capsular bag, in very gentle maneuvers. This was a recent surgery, so it was easy to take the lens out.” After placing the lens in the anterior chamber, Dr Ventura injected a monofocal toric lens in the bag to protect the posterior capsule, then exteriorised one of the haptics. “I used a MacPherson forceps with my hand in a supine position to grasp the lens, placed my iris spatula through my paracentesis, and [started] rotating, counterclockwise, my lens.” Dr Ventura reiterated the importance of patience. Beginning with the hand in a supine procedure, and completing the procedure slowly, would allow the lens to fold, coming out in one piece.

“This was my first case using the technique, and I loved it,” Dr Ventura said. She’s since learned some additional pearls for using the technique. “It’s very important to remember, always protect your corneal endothelium throughout the surgery…You might have to enlarge your incision if you have a high IOL diopter.”

Oliver Findl, MBA, MD, FEBO, shared his pearls for scleral haptic fixation. In the video example, Prof Findl showed multiple attempts at sterile fixation of different lenses. He attempted using a 30-gauge thin-walled needle, then again with a thicker needle, which could create a thicker tunnel. “So, what is happening here? Why do we have variability?” he asked. “We’re using the same kind of needle, same time, same company, same box even.”

The variability could be attributed to differences in the inner needle diameter, which had variability even within the same manufacturer. In addition, the haptic diameters of different lenses varied, too. “There are quite huge differences between manufacturers,” he said. “You can see that some combinations simply won’t fit, and there are some that will fit very well.” Prof Findl said the key to creating the correct pairing was research, and customising the choices to the lens at hand. “You really need to check the fit beforehand, either from the literature, or trying it before you start surgery,” he advised. “That’s what makes this surgery a lot easier.”