let’s talk about disclosures cataract surgery!

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LET’S TALK ABOUT CATARACT SURGERY!

SEAN W. SMOLENYAK, O.D.

COPE #

DISCLOSURES

• The content of this CE activity was prepared independently by Dr. Sean W.

Smolenyak without input from members of the ophthalmic community.

• Dr. Sean W. Smolenyak is affiliated with Allergan, Aerie, Glaukos, Kala, Notal

Vision and Sun Pharmaceuticals as a speaker or consultant.

• Dr. Sean W. Smolenyak has no direct financial or proprietary interest in any

companies, products or services mentioned in this presentation.

• The content and format of this course is presented without commercial bias and

does not claim superiority of any commercial product or service.

WHY IS CATARACT SURGERY IMPORTANT?

• Cataracts are the leading cause of treatable blindness in the world

• By 2032, 38.5 million people in the U.S. will have a cataract and that

number increases to almost 50 million by 2050

• Declining number of number of cataract and corneal specialists

compared to the expected growth of cataract cases (3+M cases/year

and growing)

• Most common surgical procedure

• Increasing rates of co-management (40% as of 2013)

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Graph courtesy of Optometric Management, June 2002

WHO SEES CATARACT PATIENTS FIRST?

ODs perform an estimated 88 million comprehensive eye exams annually of the total of 104 million

performed by all eye care professionals, or 85 percent of all comprehensive eye exams.1

1. http://reviewob.com/wp-content/uploads/2016/11/8-21-13stateofoptometryreport.pdf

Optometrists

Ophthalmologists

88M

(85%)

16M

(15%)

40,000

18,000

58,000 eye care professionals are licensed to perform comprehensive eye exams

THE EXPECTATIONS? HISTORY OF CATARACT SURGERY

600 B.C.

• Early written description of Couching

17th Century

• Sir Isaac Newton’s work in Optics

• Eyeglasses developed

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18th & 19th Century

• 1st Extracapsular Cataract Extraction –April 8, 1747

• 1851 – Invention of the Ophthalmoscope

Nov. 29, 1949

• The 1st IOL used in cataract surgery –PMMA IOL

HISTORY OF CATARACT

SURGERY

20th Century

• 1967 1st use of Phaco-emulsification

21st Century

• Advanced Technology IOLs

• Laser-assisted Cataract Surgery

• Dropless Cataract Surgery

HISTORY OF CATARACT SURGERY

PRE-OPERATIVE CONSIDERATIONS

• Ocular Surface

• Instruments and Measurements

• Formulas

• IOLs, Targets and Astigmatism

PRE-OPERATIVE:OCULAR SURFACE

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PRE-OPERATIVE:OCULAR SURFACE

•Optimize ocular surface prior to referring for cataract surgery

• Treat how you feel appropriate: OTC, RX, PLUGS, PROCEDURES

• DEWS II: Restore HOMEOSTASIS

• Asymptomatic dry eye patients can have significant dry eye

complaints following cataract surgery (but will blame surgery!)

• Dry eye can directly impact the K readings which are used to

calculate the IOL power…Inaccurate Ks = Incorrect IOL power

selection

• The numeric correlation is 1:1 (compared to AXL 1:3)

PRE-OPERATIVE: OCULAR SURFACE

• In a 2017 “PHACO” study of prospective cataract surgery patients - 143

subjects/9 centers

• Study overwhelming demonstrated that Dry Eye disease is highly

prevalent in cataract surgery patients HOWEVER the

recognition/diagnosis is very low PRIOR to referral for cataract

surgery

• 80.9% patients had level 2, 3 or 4 dry eye according to the ITF

guidelines…only 22.1% had a prior diagnosis of Dry Eye

• 76.8% had corneal staining and 50% had central staining

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PRE-OPERATIVE:INFECTION PREVENTION

•Blepharitis, eyelid and nasolacrimal infections are all risk

factors for a PO infection

•Widespread use of off-label topical antibiotics pre-

operatively (no topical AB has this indication!)

•At surgery center, BETADINE skin prep & diluted BETADINE

drop instilled

•Endophthalmitis rate 0.08% - 0.68%

PRE-OPERATIVE:UVEITIS

•Uveitis

•A quiet eye is a good eye!

•Standard of practice, if possible, is for the eye to be

quiet for 2-3 months OFF steroid drops prior to surgery

•What about pre-operative use of steroids in a healthy

eye? Any help?

PRE-OPERATIVE: OCULAR SURFACE

•Corneal Dystrophies & Previous Refractive Surgery

• EBMD/Map-Dot

• Salzmann’s Nodules

• Fuchs Dystrophy

• RK/LASIK/PRK

PRE-OPERATIVE: EBMD

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PRE-OPERATIVE: EBMD TOPOGRAPHYEBMD POST-OP IMAGE

EBMD POST-OP IMAGE

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PRE-OPERATIVE: SALZMANN’S NODULE PRE-OPERATIVE: SALZMANN’S NODULE

PRE-OPERATIVE: SALZMANN’S NODULE REMOVEDFUCHS DYSTROPHY

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HOW TO ADDRESS FUCH’S PREOPERATIVELY

• Estimated prevalence of 1/2000 but probably under-reported

• Most common in FEMALES and those >50 y/o

• Treatments include HYPERTONIC SOLN/UNG, STEROIDS, HAIR DRYERS and

DSEK/DMEK transplants

• Transplants for FUCHs account for >50% of all corneal transplants

• Monitor with VISION and PACHYMETRY

RK/LASIK/PRK

PRE-OPERATIVE: RK

AM K’s: 37.19/37.61x089 PM K’s: 36.47/37.32x045

HOW TO BEST MANAGE RK PATIENTS

•Have to manage OSD/Dry Eye

•Will need to take multiple measurements at different times

of day (but why?) How do you target outcome?

•Counseled that due to prior RK, visual outcomes less

predictable and may take longer to achieve

•What kind of IOLS and Formulas provide the most

accuracy?

•ORA recommended due to RK and AXL differences

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LASIK/

PRK

(myopic)

LASIK/

PRK

(hyper)

PRE-OPERATIVE: CONTACT LENSES

•Contact Lens Wear

•Why do we have patients discontinue their contact

lenses prior to their cataract evaluation?

•Gas Permeable CL: out at least 3 weeks prior to

evaluation, but stable measurements determine

•Soft CL: out 3 days prior to evaluation

PRE-OPERATIVE:CONTACT LENSES& KERATOMETRY

Measurement #1

H/O RGP CL wear x 57 years

RGP CL out x 3 weeks and patient had

been wearing SCL during the 3 week

period – SCL out 3 days prior

OD 44.82/46.17 x 157, Res Cyl 1.35D

OS 44.82/45.42 x 008, Res Cyl 0.6D

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PRE-OPERATIVE: CONTACT LENSES& KERATOMETRY

MEASUREMENT #2

• RGP CL out 6 weeks

• SCL out 2 weeks

OD 45.06/46.36x014

Res Cyl 1.3D

OS 45.42/46.23x067

Res Cyl 0.81D

MEASUREMENT #3

SCL out an additional 2

weeks

OD 45.24/46.23x148

Res Cyl 0.99D

OS 45.42/46.11x048

Res Cyl 0.87D

MEASUREMENT #4

• OS only –

remeasured 10 days

following

Measurement #3

OS 45.36/45.92x036

Res Cyl 0.56D

PRE-OPERATIVE: RETINAL DISEASE

• No clear evidence that cataract surgery worsens AMD (dry or wet)

• If patient is receiving injections, best to get written clearance

• Studies indicate cataract surgery can worsen DIABETIC RETINOPATHY

• Whether undergoing treatment (injections, laser) or only being monitored,

best to get written clearance

• As their OPTOMETRIST, you are the gate keeper (not the cataract surgeon)

• You control the narrative and timeline/referral patterns

PRE-OPERATIVE: MEASUREMENTS

IOL Master

• Gold-Standard in instrumentation for

pre-operative measurements for

cataract surgery. Non-contact &

maximizes patient comfort.

• Quickly and precisely performs the

necessary measurements: Axial Length,

Keratometry, Anterior Chamber Depth

(ACD) and White-to-White (WTW).

https://www.zeiss.com/meditec/us/products/ophthalmology-optometry/cataract/diagnostics/optical-biometry/iolmaster-500.html

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PRE-OPERATIVE: MEASUREMENTS

Immersion Ultrasound A-scan

• Employed in different situations:

dense cataract; axial length

difference between eyes when

measured by the IOL Master; or when

the patient cannot safely use the IOL

Master.

• The patient is seated in a semi-

reclined position, and an ultrasound

probe submersed in a water bath is

used on the corneal surface. The

ultrasound unit measures the time is

takes for the ultrasound wave to

travel from the probe tip to the retina

and back. A one-dimensional scan is

produced measuring eye axial length.

A

Probe

Cornea

Anterior

Surface of Lens

Posterior

Surface of

Lens

Retina

PRE-OPERATIVE: TOPOGRAPHY

Topography

• Pentacam – utilizes a rotating Scheimpflug camera that

maps/measures corneal astigmatism by acquiring 50

measurements of the anterior & posterior corneal

surfaces in 2 seconds.

• The Pentacam is utilized to perform corneal power

measurements across different corneal zones in patients

including those who have previously undergone

refractive procedures.

• Cross reference cylinder amounts with IOL Master

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PRE-OPERATIVE:TOPOGRAPHY

• Cassini – measures

anterior and posterior

astigmatism as well as

total corneal power

• Topcon

• Marco

• S4Optik

CASSINI PRINTOUT

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PRE-OPERATIVE:UNMASKING ASTIGMATISM

PRE-OPERATIVE: WHEN K’S DON’T AGREE

PRE-OPERATIVE: WHEN K’S DON’T AGREE PRE-OPERATIVE: WHEN K’S DON’T AGREE

•The Pentacam K’s were used to calculate Crystalens IOL

power OU; Manual AK performed in lieu of Femto AK

•OD POD#1 UCDV 20/60; POW#3 20/20

•OS POD#1 UCDV 20/40

•At 4.5 months PO, pt presented for a YAG Capsulotomy

evaluation

• UCDV OD 20/20-1 OS 20/25

•UCNV OU J1

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PRE-OPERATIVE: WHAT’S IN A FORMULA?

•1st & 2nd Generation Formulas

•Theoretical formulas and Regression formulas:

Fyodorov, Binkhorst I and II, Shamas, SRK and SRK II.

•Prior to 1980, Effective Lens Position (ELP) was a

constant of 4mm for every patient & IOL

•During the 1980’s Binkhorst used AXL as a scaling factor for

ELP

PRE-OPERATIVE: WHAT’S IN A FORMULA?

•3rd & 4th Generation Formulas

• 3rd generation Hoffer-Q, Holladay I and SRK-T utilize Ks and

AXL to predict ELP

• 4th generation Holladay II, Haigis, Olsen and Barrett Universal

II utilize 7 variables (Ks, AXL, ACD, Lens thickness, horizontal

WTW, age and pre-op refraction)

PRE-OPERATIVE: WHICH FORMULA IS BEST?

• Not a “one-size fits all

eyes” approach

• Post-refractive Sx:

Holladay II

• Long Eyes: Barrett

• Consider the IOL to be

implanted

• The future will use AI

w/automated refraction

devices to optimize

formulas

PRE-OPERATIVE: A-CONSTANT & SURGEON FACTOR

• A-Constant: an IOL constant used with the regression IOL

power formulas. It is a value assigned by the

manufacturer that corresponds with the anticipated

position of the IOL in the eye.

• Surgeon Factor: an IOL constant based on the distance

from the iris plane to the optical plane of an IOL

implant used with the Holladay formula

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PRE-OPERATIVE:EFFECTIVE LENS POSITION (ELP)

•ELP is the “Holy Grail” of cataract surgery

•The position of the IOL in the eye. Specifically, the distance

that the primary plane of the IOL sits behind the cornea.

•Unable to calculate – limiting factor in IOL Power Accuracy

•More critical in short eyes and long eyes

•Where the IOL actually sits will dictate final refraction

PRE-OPERATIVE:EFFECTIVE LENS POSITION (ELP)

PRE-OPERATIVE: IOLS AND TARGETS

• Great time to have cataract surgery, greater number of IOL and surgical

options available, and patients have the opportunity to choose how they

would like to see for the rest of their lives

• There is not an IOL that is “perfect” - Recommend surgical options that are

best for each patient and each eye

• Educate patients that they have multiple diagnoses affecting their vision:

Cataract, Astigmatism, Myopia, Hyperopia and Presbyopia

• Counsel, counsel, counsel. Under-promise and over-deliver!

INTRA-OPERATIVE: EVOLUTION OF IOL MATERIALS

• Polymethylmethacrylate (PMMA) 1949 Dr. Ridley

• Foldable IOLs: Silicone

• Associated with increased ocular inflammation, posterior/anterior capsular opacification

• Contraindicated in Silicone Oil filled eye

• Acrylic

• Hydrophobic: can be brittle, increased glistenings, dysphotopsia

• Hydrophilic: more biocompatible than other materials

• Lower PCF rates than silicone but still high (50% at 5 years)

• Why OD’s need capsulotomy privileges! SCOPE EXPANSION!

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PRE-OPERATIVE: INTRAOCULAR LENSES

• Monofocal

• “Traditional” cataract surgery

lens implant

• Will typically require glasses

after surgery

• Can manipulate the AIM of the

IOL to achieve desired

outcome

• Haptic and plate IOLs

• 3-piece IOLS

PRE-OPERATIVE: ADVANCED TECHNOLOGY IOLS

•Toric IOL (Monofocal)

•Allows for the treatment of cataract and

corneal astigmatism within the IOL

•Ability to treat 0.75 to 5.0 D of astigmatism

•Patients will need glasses for Intermediate and Near

Vision (unless monovision/MF/EDOF/Trifocal Toric)



•Toric IOL alignment is critical

•3° Misalignment = 10% loss of effective

cylinder correction

•10° Misalignment = 33% loss effect

•15° Misalignment = 50% loss effect (back

to OR!)

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PRE-OPERATIVE: ADVANCED TECHNOLOGY IOLS-MULTIFOCALS

• Alcon ReSTOR, Activefocus

• +4.00/+3.00/+2.75 Add

• Tecnis Multifocal

• +2.75: 5 concentric rings




•Accommodating

•Monofocal IOL with hinged

optic designed to allow IOL

flexing

•Bausch & Lomb Crystalens and

Trulign

•Aspheric design


•Accommodating

• IOL position in eye is important. Can get surprises

due to hinges: Vault and Z Syndrome

•Educate patient they will still need readers when

reading fine print and/or in dim lighting

• J3 is a GREAT NVA outcome without readers


•Extended Depth of Focus (EDOF)

•Extended echelette design allows for an elongated focal

point to enhance a range of vision/depth of focus.

•Patient Selection: seeking improved DV & IV without glasses

while continuing to need readers for small print or dim

lighting

•Educate regarding glare and halos PO (neuro-adaptation)

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PRE-OPERATIVE:ADVANCED TECHNOLOGY IOLS-TRIFOCALS

PRE-OPERATIVE: TARGETING

•Monofocal IOL – the goal is emmetropia (usually?)

•Monovision-How much? (focal point) Which eye?

History w/CL?

•Hyperopes easy to please; watch those myopes!

•How do you target advanced technology IOLS?

TREATING ASTIGMATISM & MANAGING PRESBYOPIA IN CATARACT SURGERY

Every patient over the age of 50 is impacted by

presbyopia, yet only 6.5% of patients receive a

presbyopia-correcting IOL

67%

8%

25%

33%

% of Patients receiving ToricIOL

■Patients > 1.0D Astigmatism

■Patients receiving Toric IOL

1/3 of Patients have > 1.0D of astigmatism but

only 1/4 of those patients are receiving a Toric

IOL

6.5%

93.5%

% of Patients receiving PC IOL

PC IOL

Monofocal IOL

Patients who do not have astigmatism and presbyopia treated at the time of cataract

surgery must treat those conditions with glasses for the rest of their lives.

2016 Market Scope Data

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INTRA-OPERATIVELY

• Injectables and Drug Eluting Plugs

•Femtosecond laser-assisted cataract surgery (FACS)

•What is ORA? When is ORA recommended?

•Flomax

•Viscoelastics

•Posterior Capsular Rupture/Lens Remnants

•Future: Posterior Capsulotomy (POC)

INTRA-OPERATIVELY:DROP-LESS CATARACT SURGERY

•3 C’s for the patient: Convenience, Compliance and Cost-

saving

•An injection given at the time of surgery of premixed

drug(s)

•Can be suspensions or solutions

•Typically not used with Advanced Technology IOLs

•Any concern with a compounding pharmacy?

INTRA-OPERATIVELY:DROP-LESS CATARACT SURGERY

•Not “Drop-free” surgery

•Solution to rising cost of eyedrops including generics

•Trimoxi alone: 10% break-through rate (Imprimis)

•Dex-Moxi: Increased risk of IOP rise (Imprimis)

•Adding NSAID: cuts break-through rate in half

INTRA-OPERATIVELY:

TRIMOXI

•Educate patients

•Floaters after surgery due to suspension

•Blurry vision on average 3-5 days following surgery

•May need an additional PO drop

•Elevated IOP

•Other ocular pathology

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INTRA-OPERATIVELY:INJECTIONS AND PLUGS

• OMIDRIA (phenylephrine & ketorolac solution): Indicated for maintaining pupil

size and reducing postoperative ocular pain; added to irrigating solution

• DEXYCU (dexamethasone suspension): Indicated for treatment of

postoperative inflammation; only FDA approved, single dose, intracameral

steroid

• DEXTENZA (dexamethasone ophthalmic insert): Placed in inferior puncta for

30 day steady release of drug; done in operating room

FEMTOSECONDSURGERY (FACS)

INTRA-OPERATIVELY:FEMTOSECOND LASER-ASSISTED SURGERY

•Primary Benefit: Used to treat corneal astigmatism (or

how you can bill a patient for FACS)

•Patients must have a minimum of 0.5 D corneal

astigmatism to be a candidate


•Secondary Benefits:

•Allows the surgeon to make a precise capsulorrhexis

•Uses less phaco power

•Softens dense cataracts

•Commonly bundled with any Advanced Technology IOL

•Most studies have yet to prove significant difference

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MANUAL PHACOEMULSIFICATION SURGERY INTRA-OPERATIVELY:FEMTOSECOND LASER-ASSISTED SURGERY

• Total treatment time <2 minutes

• Average laser treatment time 20-35 seconds

• Easy docking

• Outcomes more predictable as compared to

standard cataract surgery (?)

• Utilizes less energy

• Still not widely accepted…(but neither was

phaco!)


OCT OF LASER CATARACT INCISION OCT OF MANUAL INCISION

INTRA-OPERATIVELY: FACS

• Non-reimbursable technology by

Medicare and Commercial Carriers

• Allows for less phaco energy =

“gentler” procedure

• Precise, replicable capsulorrhexis

• Outcome of cataract surgery is

dependent upon the skill of the

surgeon not the laser

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INTRA-OPERATIVELY:WHAT IS ORA?

INTRA-OPERATIVELY:WHAT IS ORA?

•ORA is an intraoperative aberrometer used during surgery

to analyze the eye in an aphakic state

•ORA System® with VerifEYE® has been shown to improve

outcomes by taking into account anterior and posterior

astigmatism

INTRA-OPERATIVELY:ORA

• Recommended to patient’s who are s/p RK, PRK, LASIK

•Unusually long or short AXL

•ORA is not infallible

• Takes into account patient’s previous refractive treatment:

Hyperopic vs. Myopic

•Not all patients have pre-refractive K’s nor remember if

they were hyperopic or myopic

• Some ablation patterns cause you to scratch your head

INTRA-OPERATIVELY: ORA SCRATCH YOUR HEAD

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INTRA-OPERATIVELY: ORA SCRATCH YOUR HEAD SPLIT VISUAL AXIS S/P LASIK

SPLIT VISUAL AXIS S/P LASIKINTRA-OPERATIVELY: ORA DATA

FIRST 100 CASES

• ORA cases primarily post-refractive and AXL differences on measurement

• WHEN ORA recommended the Same IOL power or the surgeon chose NOT to

change the IOL power: 52% reaching UCDVA 20/30 or better

• WHEN ORA recommends a Different IOL power and the surgeon chose to use

the ORA recommendation: 60% reaching UCDVA 20/30 or better

• Typically IOL power changes are 0.5D, however few have been 1.0D+

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INTRA-OPERATIVELY:FLOMAX

•Can affect the ability of the pupil to dilate and constrict

•Floppy-Iris Syndrome: characterized by a flaccid iris which

billows in response to normal intraocular fluid currents, a

propensity for this floppy iris to prolapse towards the area

of cataract extraction during surgery and progressive

intraoperative pupil constriction despite standard

procedures to prevent this.

INTRA-OPERATIVELY:FLOMAX

•Malyugin ring

INTRA-OPERATIVELY: VISCOELASTIC

• Ideal viscoelastic has both dispersive and cohesive

properties

•Maintain AC depth

•Corneal endothelium protection

•Help minimize iris prolapse

•Aid in IOL delivery by lubricating the injector

•Expansion of the capsular bag

INTRA-OPERATIVELY: POSTERIOR CAPSULAR TEAR

•Occurs when a perforation occurs which could allow vitreous to

come forward into the front of the eye. Anterior vitrectomy

performed to remove the prolapsed vitreous. Might have to

change type of IOL (always have a back-up)

• Nucleus can fall into the vitreous cavity – have retina on speed

dial!

• According to a February 2012 article in CRSToday the best

estimated rate of capsular complications during surgery is 2%

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INTRA-OPERATIVELY:IN-THE-BAG IOL PLACEMENT

INTRA-OPERATIVELY:SULCUS IOL PLACEMENT

NEWER SURGICAL TECHNOLOGIES

ZEPTO: Handpiece that creates capsulotomies

MiLOOP: Handpiece that fragments lens with zero-

energy

CapsuLaser: Attaches to surgical scope to create

capsulotomies (no need for femtosecond room)

ApertureCTC: Creates capsulotomies

POST-OPERATIVE CONSIDERATIONS

•POD #1and Common Issues

•POW#1-2 / POM #1

•CME…Who’s at risk?

•Refractive surprises!

•Dysphotopsia

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COMMON DAY 1 ISSUES

• Vision is blurry

• Corneal edema. Wide range of day one

vision from 20/20 to CF

• Floaters in vision

• Injectables. Often can see the normal

floaters/PVD more clearly

• Nausea, headaches, dizziness

• After effects from anesthesia. Advise

drinking lots of water and rest as needed

• Flashing or flickering of vision

• Lens settling into capsule

• Can see the edge of the lens

• Sometimes is the actual edge of lens or

temporal edema from incision

• Photosensitivity

• Much more light coming through the lens

then before cataract surgery

COMMON

• Corneal Edema

• Improved with steroid use

• Can add sodium chloride

ophthalmic solution TID

• Cell/Flare

• Improved with steroid use

• Rebound Iritis 2-4 weeks

postop

ELEVATED IOP

• How do you “burp” the wound?

• Day one: IOP >40 perform paracentesis, “burp” the

wound.

• Add hypotensive medication. Avoid prostaglandins

• After one week: Possible steroid responder (or PDS)

Consider hypotensive medication, changing steroids or

D/C steroids completely.

LENS FRAGMENTS

• Anterior: Do not taper steroids! If

no resolution refer back for

removal

• Posterior: Refer to Retina for

removal (usually)

• Cortical: Clear-white translucent

• Nuclear: Yellow-brown. Not likely

to be absorbed

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IOL DISLOCATION• Risk: pseudoexfoliation,

chronic uveitis, diabetes

• Treatment

•Observation if minimal.

Vision correction with

refractive means

• Suture in place

• Remove and Replace

UVEITIC-GLAUCOMA-HYPHEMA (UGH) SYNDROME

• Mechanical irritation of anterior

segment structures by an intraocular

lens

• Transilumination defects,

hyphema/microhyphema, pigment

dispersion

• Treatment

• Steroids for inflammation

• Ocular hypotensive medication for IOP

• Ultimately surgical intervention

VITREOUS PROLAPSE

• Vitreous Strand to wound

• Following zonular dehiscence, capsular

rupture or anterior vitrectomy

• Creates peaked pupil

• Sequelae: Increased risk of

endopthalmitis, CME

• Treatment with nD:YAG vitreolysis

IRIS PROLAPSE

• Risk: accidental trauma, wound

leak, increased IOP

• Floppy Iris Syndrome:

Tamsulosin(Flomax)

• Could try PILOCARPINE

• Refer to cataract surgeon for

repair

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WOUND LEAK

• Shallow Anterior chamber (not always)

• Epiphora, blurred vision

• Low IOP

• (+) Seidel

• Bandage Contact lens. Decrease or stop

steroid. Cycloplegic.

• If unable to seal consider SUTURE or

SEALANT

• ReSure Sealant (Ocular Therapeutix)

TOXIC ANTERIOR SEGMENT SYNDROME

• Incidence: 0.22%, thought to

be reaction to introduced

chemical

• 12-72 hours post-op

•Minimally painful

• Hypopyon, fibrinous uveitis,

NO VITRITIS

• Topical Steroids Q1hr

POST-OPERATIVE ENDOPHTHALMITIS

• Incidence: 0.08-0.68%

• 3-7 days post-op

• Painful

• Hypopyon, Vitritis

• Refer to Retina for

intravitreal antibiotic

injection, culture

POSTERIOR CAPSULAR OPACIFICATION

• Incidence: 20-50% within 2-5

years

• Younger patients faster

• Can vary with IOL design and

material

• Watch with AT IOLs

• Nd:YAG Capsulotomy

• Increased risk of RD is debated

• Watch for vitreous prolapse, CME

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CYSTOID MACULAR EDEMA

• “Irvine-Gass Syndrome”

• ~ 4-6 weeks post-op

• Risk: Compromised macula (ERM,

DM Retinopathy, vascular event,

broken bag, vitreous prolapse)

• Treatment topical NSAID and

steroid (combo is best)

• IVK if necessary

POST-OPERATIVE:POD #1

•How did the patient sleep? Any headache or brow pain?

•Are they using their drops?

•Trimoxi patients vs Full Regimen

•How is the vision in the operative eye?

•2nd eye complaint – Blame Medicare! Needs to be

documented

POST-OPERATIVE:POD #1

•Visual acuity

• IOP – some will have IOP spike POD #1; patients

with nerves at risk or symptoms might need a

paracentesis or additional medications

•Slit lamp exam: Seidel negative or positive?; Corneal

edema; A/C Reaction; IOL in position; any

abnormalities?

POST-OPERATIVE:POW#1-2

•POW#1-2

•VA check with quick refraction

•Especially important to see if on target for patient

prior to surgery in the 2nd eye with ATIOL or specific

refractive target

• IOP

•Don’t hesitate to dilate if something seems amiss

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POST-OPERATIVE:POM #1

•POM #1

•VA check with refraction

•IOP

•Dilate PRN

POST-OPERATIVE:WHY IS PO DATA VALUABLE?

•To determine IOL power for the 2nd eye

• Identify refractive surprises

•To refine surgical processes

•Targets

• IOL Power selection

•Astigmatism reduction

POST-OPERATIVE:REFRACTIVE SURPRISES!

•Case study:

• s/p LASIK OU (in Canada) 1998 and revision OS

• Pre-op MRx: OD +0.25+0.50x45 20/25 / OS +1.00+0.50x180

20/20

• Surgical recommendation: MonoVA OS DV / OD NV with ORA OU

• AXL difference: IOL Master 21.57/21.92 Immersion Ascan

21.46/21.80


•OS POD #1: OS UCVA 20/50, IOP 32, trace AC cell.

Treated IOP in office with Combigan

•Pt called the day prior to her 2nd surgery: no longer had

to wear CL OD for reading.

•When asked to cover OD and describe OS VA: DV blurry

but able to read with OS. Scheduled pt to come in that

afternoon.

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• POD#13:

•OS UCDV 20/100, UCNV J1

•MRx -2.00+1.75x135 20/25

• IOP 23

• SLE:

• K Seidel negative

• A/C deep & quiet

• Implant PC/IOL, few wrinkles, slight anterior position?



•How would you treat this patient at POD#13 given the

measurements and physical findings?

•OS VA settled out to UCDV 20/60, UCVA J1 over 1 month

time

•Delayed surgery OD by 1 month


•Recommended OD DV and ORA to fine-tune IOL power

•POD#1 OD UCDV 20/60

•Pre-Op IOL choice: Tecnis PCB00 23.50

•ORA recommended 24.0

• IOL Implanted: Tecnis PCB00 23.50

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•Over the course of the PO period VA remained stable &

patient elected no further treatment as NV important

•OD 20/40, J1 OS 20/40, J2

•OU 20/30, J1

•MRx OD -1.50+1.00x050 20/25

OS -1.00+1.00x140 20/20-

NV OU no add J3

POST-OPERATIVE:DYSPHOTOPSIA38

•Patient can see, doctor cannot

•Positive and Negative

•Positive: Rainbows, streaks, glare, rings, halos, crescents,

haze and fog

•Negative: absolute scotomas

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•Positive

•Streaks – look at high cylinder; capsule due to PCF

•Crescents – IOL decentered, light entering aphakic

pupil

•Rainbows – possibly decentered diffractive MF IOL;

usually small water droplets in the epithelium; could

also be related to older FEMTO lasers


•Positive

•Glare, haze or fog – scattered, diffused light due to

lens fibers, early PCF

•Can also develop due to missing rays from internal

reflections and sharp anterior or posterior IOL edge

POST-OPERATIVE:DYSPHOTOPSIA

•Negative

•Patient will note a dark, temporal crescent-shaped

shadow which increases with bright light.

•Will resolve on own in 2 years in 80% of cases

•Could consider: removing nasal annulus of anterior

capsule; IOL exchange; inserting piggyback IOL;

reverse optic capture; or, iris suture fixation of the

IOL bag complex

PARTNERSHIP FOR HAPPIER PATIENTS

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• Cataract surgery has evolved to a type of refractive

surgery

• Open and flowing communication between

Optometrists and Ophthalmologists

• How important is co-management to MDs?

• Someone founded OD LIASON UNIVERSITY

(www.odluniversity.com)


•The best offense is a good defense

•Discuss presbyopia and astigmatism with your patient

prior to referral

•Discuss how your patient would like to see after

cataract surgery and the different IOL options now

available

•Healthy ocular surface

THANK YOU!

let’s talk about disclosures cataract surgery!

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