The crowd that packed a large hall for the popular program “Pearl Jam: High-Impact, No-Nonsense Pearls for the Anterior Segment Surgeon” on Saturday afternoon at the ASCRS meeting in Boston was not disappointed. For about 90 minutes, a group of expert speakers provided tips and techniques of broad interest to cataract and cornea surgeons. Some of the highlights included:

• Both Brandon D. Ayres, MD, the head of the cornea service at Wills Eye Hospital in Philadelphia, and Minas Coroneo, AO, chairman of the department of ophthalmology at the University of New South Wales in Sydney, Australia, provided advice on the use of iris hooks to help manage retropulsion, along with the use of trypan blue to “paint” the capsule in cases of zonulopathy. (Dr. Ayres recommended “rolling” the stain, while Professor Coroneo preferred the “spray” method.) Each of these experts shared techniques for making the proper incisions. “Be comfortable placing capsular tension rings,” said Dr. Ayres. “In severe cases of zonulopathy a sutured segment or ring may be necessary.”
• Many surgeons experience pain in their neck, back, arms and legs after a day in the operating room, noted Deepinder K. Dhaliwal, MS, L.Ac, the chief of refractive surgery at the University of Pittsburgh Medical Center. “That’s not OK,” she said. “It’s kind of expected after a long day, but we should not have any pain after doing our job if we want to sustain this pace.” Dr. Dhaliwal made major modifications to improve her posture after a painful herniated disk forced her to stop working for several weeks. She reminded surgeons to avoid bending their necks forward, using photos to show proper posture at the slit lamp or ophthalmoscope and while seated during surgery. In the ideal posture, the head is up and shoulders are back, not sagging or internally rotated, she explained. She also showed stretches that surgeons can do between cases, as well as exercises that can help strengthen the core muscles.
• Using nearly a dozen videos to demonstrate various situations, and the appropriate technique to address each, Steven G. Safran, MD, discussed the benefits of optic capture, which can stabilize the IOL/capsular bag complex, prevent the IOL from coming into contact with the iris, and prevent rotation of a toric IOL. “Beware the ‘dead bag,’” he told the audience, defining this as a thin, diaphanous bag with no fibrosis, no capsular contraction, weak zonules and prone to dislocation. “Don’t try to optic capture in the dead bag — you cannot optic capture in a case like this. Remove and replace.”
• Ike K. Ahmed, MD, FRCSC, ABO, discussed surgical management of the iris and pupil abnormalities. “Iris surgery is one of the most taxing surgeries,” he noted, discussing the importance of proper hand position and instrument management. A key consideration is whether there is sufficient iris to manipulate or suture, or if there is a need for an iris prosthesis. He discussed several types of iris sutures, demonstrating the technique through images and videos. “You have to be slow, careful and purposeful — this really is the art of surgery,” said Dr. Ahmed, a professor of ophthalmology at the University of Utah and research director at the Kensington Eye Institute at the University of Toronto.
• Joshua C. Teichman, MD, MPH, FRCSC, an assistant professor of ophthalmology and co-director of the cornea, external disease and refractive surgery fellowship at the University of Toronto, offered advice on recognizing and addressing zonulopathy, stressing solid technique as the key to avoiding complications. “Patients are allowed to have weak zonules, but you’re not allowed to weaken them further,” he noted. He discussed the use of iris hooks and capsule retractors for good visualization, and reminded audience members not to pull on the rhexis nor put excessive traction on the equator of the bag with retractors. “When you place hooks, you don’t want it so that it tents up,” he said. “A little pull is inevitable, but you want to be careful or it’s game over.”