Eyeworld

I CHALLENGING CATARACT CASES SEPTEMBER 2019 | EYEWORLD | 51 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 extend- ed 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 anes- thesia 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, ridicu- lous 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 hon- est 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 experi- ences 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 ophthalmol- ogists, 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 preop- eratively if the patient has retinal disease or is a high myope." the patient's decision making but it provides another set of ears for setting appropriate post- operative expectations. In terms of lens choice, the doctors were split on whether they would implant a multi- focal or accommodating lens in a monocular patient, but all said they would offer torics. Dr. Gimbel said he would advise against a multifo- cal due to degraded quality of optics. He also said monocular patients are often encouraged to wear shatterproof glasses anyway for pro- tection, reducing this benefit of a multifocal or accommodating lens. Dr. Osher said he would not put in a multi- focal or accommodating lens unless the patient insisted. Dr. Vasavada said he would consider a multifocal or accommodating lens for a mon- ocular patient if they desired spectacle indepen- dence 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, 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 The stakes might feel higher when performing sur- gery 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

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