September 2019

IN FOCUS

Challenging Cataract Cases
Considerations for cataract surgery in monocular patients


by Liz Hillman EyeWorld Senior Staff Writer


The stakes might feel higher when performing surgery on a monocular patient, but many physicians go through the same steps and thought processes with monocular and binocular patients. This photo shows anterior capsule removal on the eye of a monocular patient who had a posterior polar cataract. The full case is described in the October 2018 issue of EyeWorld.
Source: Kevin M. Miller, MD

 

“At a minimum, get a second opinion and, when appropriate, a retina consult preoperatively if the patient has retinal disease or is a high myope.”
—Richard Lindstrom, MD


A monocular patient arrives for a preop workup and cataract surgery consultation. Given that functional sight is only in one remaining eye, do ophthalmologists treat these patients any differently than binocular patients?
The ophthalmologists EyeWorld spoke with about cataract surgery in functionally monocular patients said, in short, no. For the most part, they counsel and perform surgery the same way in these patients.
“I think every time we operate, we should be as careful in that operation on a binocular patient as we would be on a monocular patient,” said Howard Gimbel, MD.
While this was the overarching sentiment from Dr. Gimbel, Richard Lindstrom, MD, Robert Osher, MD, and Abhay Vasavada, MD, there are some considerations that are different for these patients. When to do surgery is an example.
Dr. Lindstrom said he’s somewhat more conservative in recommending cataract surgery to a monocular patient, especially if the first eye was lost from complications of cataract surgery.
“As always, it remains the patient’s choice, with the help of their family or trusted advisors, as to when they think the benefits of surgery outweigh the risks in their particular case,” Dr. Lindstrom said. “I find it helpful to remind the patient that surgery does not become easier and safer if it is delayed excessively, as the cataract grows larger and harder with time. This helps some patients who are suffering with a significant handicap to make the decision to proceed. To me it is an awesome responsibility for the patient and surgeon to proceed with surgery in an only eye.”
Dr. Lindstrom said he encourages all patients (monocular and binocular) to wait until they are truly having visual problems before proceeding with cataract surgery, and there are things patients can do to improve vision while waiting for the proper surgical time.
“In the patient who wants to delay surgery with good spectacle correction, yellow lenses to enhance contrast, anti-reflective coatings on glasses to reduce forward light scatter, good lighting, low-vision aids, and in some cases mild dilation with dilute phenylephrine can be helpful,” he said.
Dr. Osher also said he encourages his patients to wait on surgery until they’re having trouble.
“When the patient is unhappy and we’ve exhausted all conservative alternatives, that’s when I think surgery is justified,” he said.
The counseling of monocular patients, the physicians said, is similar to that of binocular patients, but Dr. Lindstrom said he finds it can take longer.
“I make sure the patient understands that cataract surgery is an elective surgery and they can wait until they are ready but remind them that it does not become safer or easier as the years pass,” he said. “I usually end by telling them that it is a big responsibility for them to choose to have surgery on an only eye, but it is also a big responsibility for me to operate on the eye of a monocular patient. I reassure them that I or if preferred one of my highly experienced and expert associates do a high volume of cataract surgery and are willing to assume that risk when they are ready to proceed.”
Dr. Vasavada stressed the importance his clinic places on bringing another family member to preoperative counseling for both monocular and binocular patients. It not only helps with the patient’s decision making but it provides another set of ears for setting appropriate postoperative expectations.
In terms of lens choice, the doctors were split on whether they would implant a multifocal or accommodating lens in a monocular patient, but all said they would offer torics. Dr. Gimbel said he would advise against a multifocal due to degraded quality of optics. He also said monocular patients are often encouraged to wear shatterproof glasses anyway for protection, reducing this benefit of a multifocal or accommodating lens.
Dr. Osher said he would not put in a multifocal or accommodating lens unless the patient insisted. Dr. Vasavada said he would consider a multifocal or accommodating lens for a monocular patient if they desired spectacle independence and were otherwise suitable and healthy enough for a multifocal. If a patient was a long-time diabetic, for example, Dr. Vasavada said he would caution against these lenses due to the increased likelihood of degradation of vision associated with that disease. Dr. Lindstrom said he has implanted premium lenses in monocular patients.
“The decision-making process for me remains the same as in the binocular patient, except that customized matching with different IOLs in each of two eyes is not available,” he said.
One aspect Dr. Osher does differently with monocular patients is he prescribes an extended preoperative antibiotic regimen. Instead of ordering 1 day of a preop antibiotic, he has monocular patients on it for 3–4 days preop.
Most said the surgical procedure itself is the same. Dr. Osher said he doesn’t have anesthesia provide retrobulbar injections, opting for peribulbar or topical in these cases. Following surgery, Dr. Osher said he always gives 125 mg of acetazolamide to avoid “a really rare, ridiculous pressure spike.”
“Your surgery has to be meticulous, you can’t be rushed. It should be like your very best preparation,” Dr. Osher said. “I used to coach a lot of baseball. … I always say throw your best pitch, and that’s what you’ve got to do with not just your one-eyed patients but everyone.”
Dr. Lindstrom said you have to be honest with yourself and your experience level in these cases. If you’re faced with a small pupil, pseudoexfoliation with loose zonules, corneal guttata, glaucoma, epiretinal membrane, and the patient is on tamsulosin—which he said often present together in monocular patients who had complicated surgery in their first eye—you might need to refer this case.
“You will sleep much better and you will not notice losing one or two cases a year to a colleague,” he said. “When a surgeon experiences a major sight-threatening complication in an only eye, and I speak from experience, it is never forgotten. Some of us have trained to be put in that position as consultative ophthalmologists, but not every ophthalmic surgeon has to suffer the experience of a poor outcome in an only eye. At a minimum, get a second opinion and, when appropriate, a retina consult preoperatively if the patient has retinal disease or is a high myope.”

At a glance

• Many aspects of counseling, decision making, and surgery for monocular patients remain the same as for binocular.
• These patients may require more time in preoperative counseling.
• Monocular patients should be encouraged to wait for surgery until they are truly having visual trouble but not so long that the cataract size and density increases surgical risks.
• Toric lenses can be encouraged in these patients, but surgeons should proceed with caution with multifocal and accommodating.

Contact information

Gimbel: hvgimbel@gimbel.com
Lindstrom: rllindstrom@mneye.com
Osher: RHOsher@cvphealth.com
Vasavada: icirc@abhayvasavada.com

About the doctors

Howard Gimbel, MD
Professor
Loma Linda University
Calgary, Canada

Richard Lindstrom, MD
Founder and attending surgeon
Minnesota Eye Consultants
Minneapolis

Robert Osher, MD
Professor of ophthalmology
University of Cincinnati
Medical director emeritus
Cincinnati Eye Institute

Abhay Vasavada, MD
Founder and director
Raghudeep Eye Clinic
Ahmedabad, India

Relevant financial interests

Gimbel
: None
Lindstrom: None
Osher: None
Vasavada: None

Considerations for cataract surgery in monocular patients Considerations for cataract surgery in monocular patients
Ophthalmology News - EyeWorld Magazine
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