Eyeworld

I CHALLENGING CATARACT CASES N FOCUS 50 | EYEWORLD | SEPTEMBER 2019 Contact information Gimbel: hvgimbel@gimbel.com Lindstrom: rllindstrom@mneye.com Osher: RHOsher@cvphealth.com Vasavada: icirc@abhayvasavada.com by Liz Hillman EyeWorld Senior Staff Writer Dr. Lindstrom said he encourages all patients (monoc- ular and binocular) to wait until they are truly having visual problems before pro- ceeding 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 experi- enced 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 A monocu- lar patient arrives for a preop work- up 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 monocu- lar 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 signifi- cant 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." Considerations for cataract surgery in monocular patients 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 encour- aged in these patients, but surgeons should proceed with caution with multifocal and accommodating. "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

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