Rethinking the Drop with iDose TR: Patient Access

I. Paul Singh, MD; Deborah Ristvedt, DO; and Kevin Talbot, MD

Eyetube

In this special podcast episode, I. Paul Singh, MD, speaks with Deborah Ristvedt, DO, and Kevin Talbot, MD, regarding the use of iDose TR (Glaukos), a procedural pharmaceutical, as an interventional glaucoma approach. They outline who the optimal patients are for this procedure, how to educate patients about drug delivery technology, and share pearls on reimbursement.

Stepwise Management of Zonular Instability

A practical intraoperative sequence for restoring capsular stability while minimizing additional zonular stress.

J. Morgan Micheletti, MD, FACS, and Evan Dackowski, MD

Cataract and Refractive Surgery Today

KEY TAKEAWAYS Zonular instability turns routine cataract maneuvers into stress tests for the capsular bag, so stabilization should precede rotation, chopping, and cortical removal Small, repeated ophthalmic viscosurgical device additions and capsule retractors can restore chamber control and capsular centration without abruptly deepening the anterior chamber Horizontal chop, tangential rotation, bimanual cortical cleanup, and timed capsular tension ring or segment placement reduce zonular stress while preserving fixation options Zonular instability during cataract surgery exists on a spectrum that ranges from diffuse weakness to focal or extensive dialysis. Regardless of the etiology, once instability is present, even routine maneuvers such as nuclear rotation and cortical removal can place additional stress on the remaining zonules. When we encounter zonular instability, we slow down and stabilize the capsular bag before proceeding. Rather than rely on a single maneuver or device, we manage these cases in a deliberate sequence that progressively restores capsular stability while minimizing additional zonular stress. RECOGNIZING INSTABILITY Zonular instability may be recognized preoperatively or discovered intraoperatively. Preoperative Recognition In select eyes with preexisting dialysis or zonular instability, we consider performing the capsulotomy with a femtosecond laser because it can create a centered, reproducible opening without relying on zonular countertraction, which can be helpful when the capsule is unstable. Intraoperative Recognition and Capsulorhexis Strategy Sometimes, zonular instability becomes apparent intraoperatively—often during the capsulorhexis. In these eyes, the capsule frequently moves with the tearing force because the zonules cannot provide adequate countertraction. The capsulorhexis may be smaller than intended because the capsule follows the vector of the tear. We try to maintain chamber stability with an OVD, frequently regrasp the capsule with forceps, and deliberately direct the tear outward to compensate for this tendency.

Peripheral Firestorm: The Ischemic Retina

Proliferative disease may still be progressing despite good vision.

Apoorva Jadhav, MBBS, DNB; Unnikrishnan Nair, MS, FRCS, FMRF; and Manoj Soman, DNB, FICO, FRCS

Retina Today

A 62-year-old man with a history of diabetes for the past 10 years presented with complaints of bilateral blurred vision for 2 months with a BCVA of 20/30 OU. Findings on color fundus photography were suggestive of proliferative diabetic retinopathy with fibrovascular proliferation around the optic disc and along the vascular arcades (Figure 1). Widefield OCT demonstrated mild alteration of the foveal contour with minimal parafoveal cystic spaces (Figure 2). The left eye also showed internal limiting membrane folds with vitreomacular adhesion. No significant macular edema was noted. Figure 1 Figure 2 Widefield OCT angiography (OCTA) demonstrated extensive peripheral microvascular alterations consistent with a severe ischemic retinopathy (Figure 3). The most striking feature was the presence of large areas of capillary nonperfusion involving the mid- and far-peripheral retina bilaterally. These regions appeared as well-demarcated flow voids on widefield OCTA, indicating significant capillary dropout and retinal ischemia. At the junction of perfusion and nonperfusion, there were multiple abnormal vascular proliferations visualized as bright, irregular, high-flow networks. These frond-like vascular complexes exhibited disorganized branching and looping patterns, characteristic of neovascularization elsewhere.