- Evaluating the cataract and refractive patient
- Corneal and lenticular refractive surgery by the decades
- Tips and techniques in cataract and refractive surgery
- Craziest video cases
Evaluating the cataract and refractive patient
Kourtney Houser, MD, spoke about getting started with refractive cataract surgery in a Sunday morning session at the ASCRS Summer Meeting. She mentioned the importance of patient selection in this process, adding that there are many patient questionnaires that physicians can use. It’s important to discuss what’s realistic before surgery.
Dr. Houser also highlighted the team-based approach that she uses for patient selection and education. First, a call center helps to gauge the patient’s interest in spectacle independence; a technician asks the patient a series of lifestyle questions and provides educational material; the MD/OD can then confirm candidacy and discuss; and schedulers/counselors discuss technology based on MD recommendations, she said.
Dr. Houser mentioned the preoperative evaluation, noting the importance of biometry, tomography, and macular OCT. It’s also important to optimize the ocular surface because this is one of the most common reasons that patients are unhappy with these lenses. When selecting the appropriate technology and treatment to use for each patient, Dr. Houser said to customize and simplify.
Knowing how to manage dissatisfied patients is another important factor. Dr. Houser noted the importance of characterizing the complaint and what’s causing it. When managing dissatisfied patients, Dr. Houser said to optimize what you can (surface, refractive error, CME); do not YAG if unhappy from postop day 1; discuss the option of implanting a monofocal in the dominant/fellow eye; and discuss an exchange but emphasize trade-offs (will lose all reading vision).
Cathleen McCabe, MD, discussed dealing with different patient personality types and what she recommends. For the type A patient, Dr. McCabe recommended giving them a lot of data, with very specific pros and cons of the technology. You want them to have all the information they need to make the decision and own the decision, she said, adding that it’s important to also discuss compromise because there isn’t a perfect lens. Sometimes you have patients who have done a lot of research and are testing you more than listening to you, so it’s important to make sure they’ve learned from you as well.
The opposite type of patient, the indecisive patient, can also be challenging, she said. These patients may repeat the same questions and concerns over and over and be overly anxious. In these patients, Dr. McCabe said it’s important to have other ears there, and you might want to consider recording the discussion. Give these patients printed material, and emphasize that there are no bad choices. Often these patients may be paralyzed by finality of choice. Dr. McCabe cautioned against using a Light Adjustable Lens (RxSight) on the indecisive patient because you need a solid endpoint.
She also discussed patients with a complacent personality who just want the doctor to decide what to do. These patients can be difficult, too, and it’s important to provide concise and clear information. You need to be sure they are hearing the risks and benefits, and make sure the patient is involved in the choice, Dr. McCabe said.
Editors’ note: Dr. Houser has relevant disclosures with Bausch + Lomb and Rayner. Dr. McCabe has relevant disclosures with a variety of ophthalmic companies.
Corneal and lenticular refractive surgery by the decades
Beeran Meghpara, MD, spoke about patients in their 40s–50s with a dysfunctional lens and options in drops, lasers, and lenses for this group. This is not a homogenous group, he said.
In terms of options in drops, the only currently approved presbyopia drop is Vuity (pilocarpine, Allergan). The underlying principle is using the pinhole effect. By reducing pupil size, we know we can extend depth of focus, Dr. Meghpara said, and the trial for this drop showed a three-line improvement in near vision. It was also recently approved for BID dosing. The best candidate is the motivated patient, so this won’t work for everyone, Dr. Meghpara said, but it may be helpful for patients looking for a non-invasive presbyopia treatment.
Dr. Meghpara said it’s important to share the potential side effects of this product, which may include headache, hyperemia, and dimming of vision. He noted that these frequently subside within the first few days. There is also a potential risk of retinal detachment, though rare. Everyone should get a dilated exam, Dr. Meghpara said. It’s also important to define success because the goal is functional near vision, not J1+. Dr. Meghpara noted that there are several other presbyopia drops currently in the pipeline in various stages of research and trials.
In terms of laser options, Dr. Meghpara said the only real option in the U.S. is monovision. PresbyLASIK is another OUS option, which creates different zones in the cornea using an excimer laser. Laser blended vision combines micro-/mini-monovision and induction of spherical aberration to create extended depth of focus.
Dr. Meghpara also discussed patients in this range who might be good candidates for lens options. A lens option could be useful for those with early lens changes, hyperopia, moderate to high myopia, and emmetropia in their late 50s. However, he cautioned against lens options for those with low myopia, most patients in their 40s, very high myopia, and those who are happy with monovision.
Editors’ note: Dr. Meghpara has relevant disclosures with a variety of ophthalmic companies.
Tips and techniques in cataract and refractive surgery
Kamran Riaz, MD, shared five biometry pearls in his presentation. 1) The first sheet on the biometry printout is not the most important one. He thinks it’s the second or third page, which includes a warning box about short/long axial length, information on quality of the scan, B-scan, “poor man’s” topography, and angle alpha measurements. 2) Angle alpha values matter when considering diffractive optics in presbyopia-correcting IOLs. 3) Pay attention to lens thickness measurements. 4) You can use K and TK values to determine whether myopic LVC or hyperopic LVC was performed. 5) Take advantage of the built-in macular OCT in biometry devices.
Richard Tipperman, MD, discussed managing the unhappy patient. He said that it’s important to note when patients are making observations versus complaining. Sometimes they’re just observing because they don’t necessarily know what’s normal postoperatively. We can internalize and think of them as complaints, and that sets up a cascade that makes it difficult to deal with, he said.
Having a strategy to deal with unhappy patients is important. Dr. Tipperman said you need to be sure to allow enough time, and he suggested slotting these patients before a gap or double book an appointment. He also said it’s important to actively listen and be sure to empathize and don’t minimize how the patient is feeling. People will mirror your affect, he said, so it’s important to be calm, compassionate, and caring. You can also offer to facilitate a second opinion.
Dr. Tipperman noted that small residual refractive error is something that can frequently lead to an unhappy patient. But it’s easy to deal with if you tell them ahead of time that you can’t guarantee a perfect result. Glare/halo and unwanted optical images are other common things that cause dissatisfaction among patients, and Dr. Tipperman said it’s important to stress that these are normal optical phenomena. Make sure patients know that they must give themselves time to adapt, he said.
Editors’ note: Dr. Riaz has relevant disclosures with Bausch + Lomb and CorneaGen. Dr. Tipperman has relevant disclosures with Alcon.
Craziest video cases
Faculty at the ASCRS Summer Meeting shared some of their craziest video cases on Saturday afternoon and Sunday morning.
Steven Yeh, MD, shared a case that was an atypical presentation of endophthalmitis. The patient presented with anterior chamber inflammation and angle closure and reported decreased vision over a 2- to 3-day period. The patient had mild irritation and denied pain, and visual acuity was hand motion.
Dr. Yeh presented several options for postoperative endophthalmitis treatment. First, he suggested anterior chamber tap for culture and intravitreal injection of antibiotics, but he said the anterior chamber in this case was too shallow for anterior chamber tap. Another option is vitreous tap for culture and intravitreal injection of antibiotics. However, Dr. Yeh said there is higher risk for retinal tear or detachment, a higher possibility of dry tap, increasing volume of the eye could further precipitate angle closure, and the patient was traveling from a distance and didn’t want to come back to the city.
He decided to take the patient to the OR urgently for anterior chamber reformation/PPV/intravitreal injection of antibiotics. The patient was in no pain, had no hypopyon on exam, and it had been 5 days since the onset of symptoms.
Postop day 1, the patient still had hand motion vision, with a little inflammation in the anterior chamber that was steadily improving. Dr. Yeh said debulking the infection and injecting antibiotics was key. This was an atypical case of postoperative endophthalmitis, with the patient presenting with angle closure glaucoma due to the formation of a membrane over the IOL. Operating room management was elected given the risks inherent to clinic-based procedures, and while post-cataract endophthalmitis rates are rare, a high index of suspicion is required.
Janice Law, MD, shared a case of foreign body sensation where the patient had a foreign body from metal shrapnel hitting his left eye. Upon exam, Dr. Law saw that the patient had an intraocular foreign body entering the cornea, and it was in the retina. She said it was important to determine if it was a penetrating or perforating injury, which proved to be challenging, even with imaging.
Dr. Law had to exercise caution in this case because she was particularly worried about bleeding. She lasered first before taking the foreign body out, then lasered to cauterize after as well. She noted the preplacement of indirect laser spots, the use of prophylactic scleral buckle in posterior segment injuries, air fluid exchange prior to extraction of retinal foreign bodies, and she said to always use intravitreal antibiotics.
Editors’ note: Dr. Law has no relevant disclosures. Dr. Yeh has relevant disclosures with Alcon and Bausch + Lomb.
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