The surgical management of ectopia lentis presents the ophthalmic surgeon with numerous challenges and options. From the clinical evaluation to the surgical approach, ectopia lentis patients require additional methodologies, techniques, and devices to ensure the best possible outcome. The continued refinement of surgical techniques and adjunctive prosthetic devices has led to incremental improvements in the ability to achieve successful in-the-bag placement and centration of intraocular lenses while reducing complications. A thorough understanding of the challenges inherent in ectopia lentis cases and the management of intraoperative complications will ensure that surgeons approaching the correction of these eyes will achieve the best possible surgical results.
Dysfunctional tear syndrome (DTS) is a common and complex condition affecting the ocular surface. The health and normal functioning of the ocular surface is dependent on a stable and sufficient tear film. Clinician awareness of conditions affecting the ocular surface has increased in recent years because of expanded research and the publication of diagnosis and treatment guidelines pertaining to disorders resulting in DTS, including the Delphi panel treatment recommendations for DTS (2006), the International Dry Eye Workshop (DEWS) (2007), the Meibomian Gland Dysfunction (MGD) Workshop (2011), and the updated Preferred Practice Pattern guidelines from the American Academy of Ophthalmology pertaining to dry eye and blepharitis (2013). Since the publication of the existing guidelines, new diagnostic techniques and treatment options that provide an opportunity for better management of patients have become available. Clinicians are now able to access a wealth of information that can help them obtain a differential diagnosis and treatment approach for patients presenting with DTS. This review provides a practical and directed approach to the diagnosis and treatment of patients with DTS, emphasizing treatment that is tailored to the specific disease subtype as well as the severity of the condition.
We describe the essential steps in the successful phacoemulsification of the rock-hard, dense cataract. Appropriate and directed preoperative history, physical examination, and diagnostics allow the surgeon to select the best incision, anesthesia, and intended surgical technique for a given dense nuclear challenge. Hard nucleus-specific approaches for hydrodissection, pupil management, and zonular protection then allow the surgeon to approach the rock-hard nucleus with maximum safety. Dense nuclear dismantling options are then discussed in detail along with fluidic and power modulation considerations. Various specific phacoemusification machine settings for rock-hard cataracts from the authors representing several different phaco systems are then presented. The combination of these steps and considerations allow a more successful dense cataract removal and potential restoration of vision for patients. This paper represents the collective experience and advice of the Challenging and Complex Cataract Surgery Subcommittee.
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