Cataract Co-management from the Optometric perspective

R. Fernando Auza, O.D.

Visionary Ophthalmology

Bethesda, MD

OD/MD Cataract Co-Management

Why? Expansion of patient variety and opportunity for practice growth Educational process that expands your knowledge Opportunity to become an expert With development of Multifocal/Toric IOL’s, Cataract Surgery has

evolved into “Refractive Cataract Surgery” Potential for added revenue through premium IOL co-

management 50+ market is expected to grow seven times faster than any

other segment OD’s play an integral role in selecting and recommending IOL

Before referring your patient to a Cataract surgeon

Discontinue Contact Lens wear two to three weeks in advance so that axial length and keratometry measurements are accurate for precise IOL calculation. RGP’s Soft lenses with low dK/t Patients on Extended Wear Contac Lenses

Careful evaluation of Ocular Surface

Management of surface disease will improve final visual outcome

Tear dysfunction syndrome

Lid margin disease

Evaluation of Ocular Surface

Map-dot-fingerprint dystrophy

Post Op – Day 1

History – Problem focused Exam

VA – Usually should be 20/40 or better Anterior Segment Exam

Corneal Surface/Stroma Anterior chamber inflammation Lens centration and PCO

IOP Plan – Medications – Antimicrobial/Anti-inflamatory

therapy Zymar or Vigamox/Xibron/Prednisolone 1% t.i.d.

Follow up visit – three weeks/sooner PRN

Potential complications one day after surgery

IOP Spike Bollous Keratopathy Decentered/Dislocated/Rotated Toric IOL Tilted Lens Peaked pupil – vitreous prolapse Retained lens fragments RD

Post-Op Visit Two – Two to three weeks after surgery

Problem focused history Exam

VA Anterior segment

Ocular Surface/Cornea Anterior changer Lens centration – crucial with multifocal IOL Axis location – must dilate toric IOL’s

IOP – Inflammation/Steroid Responders Refraction Medications – Discontinue antimicrobials. Tapper off steroids and

NSAID if A/C quite. Continue steroid/NSAID therapy if necessary Follow up visit – one month

Complications at week at second post-op visit

Poor visual outcome – must investigate

Previous pathology? Front to back approach

Ocular Surface- (not a post-operative complication)

Dry eye MGD EBMD

Corneal Edema/Bollous Keratopathy

Endothelial dysfunction Persistent A/C reaction

Treat with steroids and Muro 128 ung or sol.

Keep IOP low

Severe Iritis - Must Investigate

May just take longer to resolve in some patients History of previous iritis/autoinmune disease Irido-Lenticular contact if IOL tilted

Can affect VA May have to reposition IOL

IOL outside capsular bag inferiorly

Persistent Iritis - Continued

Retained Lens Fragments If iritis is persistent – must perform carefull DFE

looking for small fragments Fragments may be within the capsular bag

Posterior Capsular Opacity Treat early PCO greatly affects VA and contrast sensitivity

specially with multifocal IOL’s Decentered/Dislocated

Surgeon will have to reposition IOL

Cystoid Macular Edema

More common in diabetics

Sub-Clinical CME may be difficult to detect without OCT or Fluorescein angiography

Post Operative Epiretinal Membrane

Incidence - 22% - only 3.6% visually significant Visually insignificant ERM also known as

Cellophane Macular Reflex Visually Significant ERM – Maculr Pucker

Post-Operative Endophthalmitis

Incidence 0.1% Patient present with pain, photophobia,

floaters, reduced vision, an inflamed anterior segment including a variable hypopyon, and vitritis

May present four to seven days after surgery