October 2015




Complex cataract cases

10 pearls for mastering cataract surgery with ocular comorbidities

by Lauren Lipuma EyeWorld Staff Writer

Boys with Balls

In a patient with glaucoma who is undergoing cataract surgery, surgeons may want to consider doing ECP or an ab interno procedure at the time of the cataract surgery.

Source: National Eye Institute

How best to remove cataracts while managing dry eye, glaucoma, or macular degeneration

Cataract surgeons now have the tools and techniques to offer their patients better visual outcomes after surgery than ever before. But with more individuals suffering from glaucoma, dry eye, and age-related macular degeneration (AMD), caring for cataract patientsbefore, during, and after surgerybecomes far more complex. The presence of dry eye, glaucoma, or AMD increases the risk of complications, but with proper planning and technique, cataract surgeons can achieve good visual outcomes even with these comorbidities. Here, 4 leading ophthalmologists share pearls for managing cataracts in the presence of these coexisting diseases.

Dry eye and glaucoma

Optimize the ocular surface before proceeding with surgery. Dry eye is likely to get worse after cataract surgery, so optimize the ocular surface prior to operating and continue treatment after surgery, said Preeya Gupta, MD, assistant professor of ophthalmology, Duke Eye Center, Durham, N.C. Address meibomian gland dysfunction (MGD) as soon as possible with treatments such as thermal pulsation or omega-3 supplements. Treat any ocular surface inflammation with topical cyclosporine and/or steroids, she added. Be aware of the total preservative load youre placing on the ocular surface. Topical medications can be toxic to corneal epithelial cells, so be aware of the total preservative load, especially when using generics, Dr. Gupta said. For patients with corneal staining postop, consider switching to preservative-free medications or altering the dosage. I often discontinue the NSAID or lower the dosage, as this class of drugs can be epitheliotoxic in some patients, she said. Recognize that cataract surgery is an opportunityand dont waste it. With the eye open, viscoelastic in place, and access to the angle, cataract surgery is a perfect opportunity to enhance a patients glaucoma treatment, said Nathan Radcliffe, MD, assistant professor of ophthalmology, New York University Langone Medical Center, New York. If a patient has mild glaucoma, consider doing endocyclophotocoagulation (ECP) or an ab interno procedure such as trabecular micro bypass or gonioscopy-assisted transluminal trabeculotomy (GATT). For moderate glaucoma, Dr. Radcliffe recommends combining ECP with an ab interno procedure. For severe glaucoma, think carefully about how to proceed, Dr. Radcliffe said. If the glaucoma is severe but stable, an ab interno procedure could be an option, but if theres higher risk and the glaucoma is less stable, consider combining it with a filtration procedure. Its in the patients best interest to get as much out of that cataract surgery as they can, Dr. Radcliffe said. Do everything you can to make sure the surgery goes as smoothly as possible. When operating on a cataract and glaucoma patient, make sure the surgery goes as perfectly as possible, that the IOL is well-placed, and that all the lens material is removed from the eye. Cataract surgery is a grand transition for any eye, but particularly for an eye with glaucoma, Dr. Radcliffe said. If the surgery goes well, the patients tend to do well after and the glaucoma tends to be more stable. Problems that occur and are not resolved at the time of cataract surgery for a glaucoma patient will stick with that patient and can tend to be a negative inflection point for the future of glaucoma progression. Keep IOP under control in the intermediate postop period. Im fairly aggressive with oral or even intravenous acetazolamide at the time of cataract extraction, particularly in patients with severe glaucoma, Dr. Radcliffe said. A perioperative intraocular pressure elevation can present a problem, so we want to do our best to keep the pressure under great control in that intermediate period. Avoid multifocal IOLs in patients with persistent dry eye or glaucoma. Multifocal IOLs require near-perfect optics, so avoid placing them in patients with a consistently dry ocular surface or with glaucoma that involves central vision or could involve central vision in the future.

Macular degeneration

Identify risk factors for AMD progression. Conducting a careful preop assessment of the macula is a critical step for every cataract surgeon, said Timothy Olsen, MD, director, Emory Eye Center, Emory University, Atlanta. High-risk clinical features, such as the presence of sub- or intraretinal blood, fluid, or hard exudates, should prompt immediate referral to a retina specialist, Dr. Olsen said. Carefully assess the macula for the presence of drusen and search for areas of depigmentation, geographic atrophy, and areas of pigment hyperplasia. In addition, determine if the patient has untreated wet AMD and assess whether the AMD will limit vision postop because of scarring or atrophy, said Chirag Shah, MD, MPH, Ophthalmic Consultants of Boston, and assistant professor, Tufts New England Eye Center, Boston. Consider checking potential acuity meter (PAM) vision in these cases to estimate the macular potential after the cataract is removed, Dr. Shah said, but be aware that PAM is not always predictive of a patients subjective response.

Communicate risks to the patient. The risk of the disease progressingwith or without cataract surgeryis important to communicate to each patient, Dr. Olsen said. Careful preop counseling should prepare the patient for future changes in macular function and give the patient more realistic postop expectations, he said. It is very important to thoroughly counsel patients preoperatively about the possibility of cataract surgery unmasking the nuances of their vision, Dr. Shah said. Patients may note distortion once their cataract is removed because the vision is more clear, not necessarily because their AMD progressed. Refer to a retina specialist when uncertain. If macular features appear atypical or if youre unclear about the severity of the AMD, refer the patient to a retina specialist for a more accurate risk assessment. Retina specialists who are familiar with other clinical signs may be able to better inform the patients of their macular risk and the need for high-dose antioxidant supplements, Dr. Olsen said. Retina specialists may also help to detect the presence of other conditions that may influence the prognosis such as basal laminar drusen, reticular pseudodrusen, or a pattern dystrophy, he added. Use imaging techniques to your advantage. OCT offers the surgeon a highly valuable tool to explore a clinical suspicion for many other macular abnormalities, Dr. Olsen said, and is extremely helpful to risk-assess the macula prior to placement of a multifocal IOL. Epiretinal membranes with retinal thickening, vitreomacular traction, and early macular holes are important features to note in an OCT scan that may require vitreoretinal intervention. Mastering cataract surgery article summary

Editors note: The physicians have no financial interests related to this article.

Contact information

: preeya.gupta@duke.edu
Olsen: tolsen@emory.edu
Radcliffe: drradcliffe@gmail.com
Shah: cpshah@eyeboston.com

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Cataract surgery with corneal comorbidities by Ellen Stodola EyeWorld Staff Writer

10 pearls for mastering cataract surgery 10 pearls for mastering cataract surgery
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