Eyeworld

NOV 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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November 2012 EW CATARACT 51 week prior to surgery, 1 week rest around the immediate post-op period, and then continue the NSAIDs for 1-2 months following surgery. These patients should be followed with your retina colleagues after the surgery, typically at 1 month after the surgery. Patients with poor control with pre-existing neovascularization of the retina, or even worse, neovascu- larization of the iris, require close attention.3 In these patients, a monofocal acrylic lens is the best choice, and I typically will use a three-piece intraocular lens or a cap- sular tension ring (CTR) with a SPA, as these patients are at risk for future pars plana vitrectomy and possible weakening of the zonular apparatus. This set of patients need a retinal consult with most likely an OCT and fluorescein angiography and are often treated with panretinal photocoagulation (PRP) and VEGF inhibitors prior to the surgery. Operatively, these patients will have a small pupil, particularly if they have had previous PRP.2,3 These pa- tients do well with either iris hooks or devices such as the Malyugin ring. I typically will add a suture to the incision as they may require a contact lens for further laser imme- diately following the surgery. The post-op period includes close collaboration with retinal colleagues typically at 1 week and 4 weeks following surgery (Table 1). Neovascularization Monofocal acrylic Table 1 History Type II good control Type I good control Poor control Poor control Retinopathy None None None Background DR DME IOL Consider acrylic Consider monofocal acrylic Consider monofocal acrylic Monofocal acrylic Monofocal acrylic Pre-op NSAID NSAID NSAID NSAID; OCT to r/o DME NSAID; OCT; retina consult; VEGF inhibitor NSAID; OCT; retina consult; VEGF inhibitor; PRP s/p Vitrectomy Monofocal acrylic Usually already w/u from retina; silicone oil makes IOL selection tricky Patients who have had vitrec- tomy in the past for their diabetic retinopathy can present problems for the cataract surgeon especially if silicone oil was used.5 These patients should get a monofocal acrylic lens and may need a CTR. The surgeon should be prepared for sulcus place- ment as always with a large acrylic optic. Usually these patients have al- ready had a pre-op retina evaluation, which will most likely include OCT to evaluate for pre-existing macular edema. Patients following a vitrec- tomy often have a small pupil, par- ticularly if they have had significant PRP in the past. Rarely, particularly in patients with an early cataract following vitrectomy, the posterior capsule can be damaged from the vitrectomy. In these patients, the surgery can be quite difficult. Pa- tients with an early cataract follow- ing vitrectomy should be dealt with similar to a patient with a posterior polar cataract where the assumption is that there is a hole in the posterior capsule and one should avoid hydrodissection (Figure 1). Rarely these patients will have silicone oil in place following extensive retinal surgery. Silicone oil can be quite difficult and presents issues both for IOL power estimation and for sur- gery. If one can use the IOLMaster (Carl Zeiss Meditec, Dublin, Calif.), and if one is going to remove the silicone oil, then these patients can be relatively routine. However, if the silicone oil is going to remain in place, it presents issues due to the difference in refractive index of the silicone oil and how it interfaces with the intraocular lens. See the website of Warren Hill, M.D., for more information on how to calcu- late intraocular lens power in this situation.9 Silicone oil can leak into Figure 2. Silicone oil bubbles in anterior chamber following uncomplicated phacoemulsification in patient with history of complex retinal detachment repair Source (all): Thomas Oetting, M.D. the anterior chamber during surgery, which must be removed by the end of the case (Figure 2). Post-op, these patients should have continued retinal consultation, typically at the 1 week and 1 month visit (Table 1). Cataract surgery in patients with diabetes can range from being quite Normal May have small pupil; add suture for early laser May have small pupil; may have loose zonules; may have posterior cap- sule damage (Figure 1) NSAID; retinal consultation NSAID; retinal consultation NSAID; continued retina consultation routine to being quite complex de- pending on the level of retinopathy and the amount of prior procedures for the retinopathy. Diabetes is ex- tremely common, particularly in the set of patients that we are dealing with for cataract surgery, and it is important that cataract surgeons are comfortable managing these patients. EW References 1. National Diabetes Clearing House. diabetes.niddk.nih.gov. Accessed on September 30, 2012. 2. Ostri C, Lund-Andersen H, Sander B, La Cour M. Phacoemulsification cataract surgery in a large cohort of diabetes patients: visual acuity outcomes and prognostic factors. J Cataract Refract Surg. 2011;37(11):2006- 2012. Epub 2011 Sep 1. 3. Suto C, Kitano S, Hori S. Optimal timing of cataract surgery and panretinal photocoagula- tion for diabetic retinopathy. Diabetes Care. 2011;34(7):e123. 4. Elman MJ, Bressler NM, Qin H, et al. Dia- betic Retinopathy Clinical Research Network. Expanded 2-year follow-up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology. 2011;118(4):609-614. 5. Horozoglu F, Yanyali A, Aytug B, et al. Macular thickness changes after phacoemul- sification in previously vitrectomized eyes for diabetic macular edema. Retina. 2011;31(6):1095-1100. 6. Akinci A, Muftuoglu O, Altınsoy A, Ozkılıc E. Phacoemulsification with intravitreal beva- cizumab and triamcinolone acetonide injection continued on page 53 Operative Normal Normal Normal Normal Post-op NSAID NSAID NSAID NSAID

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