JUN 2013

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

Issue link: https://digital.eyeworld.org/i/137624

Contents of this Issue


Page 58 of 74

This CME supplement is supported by an unrestricted educational grant from Alcon Laboratories. Continuing Medical Education (CME) The American Society of Cataract and Refractive Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASCRS takes responsibility for the content, quality, and scientific integrity of this CME activity. Educational Objectives Ophthalmologists who participate in this course will: • Identify conditions putting patients at higher risk for inflammatory reaction after cataract surgery and the clinician impact of this reaction; • Develop perioperative strategies to better address ocular inflammation. Designation Statement The American Society of Cataract and Refractive Surgery designates this live educational activity for a maximum of 0.5 AMA PRA Category 1 Credits.™ Physicians should claim only credit commensurate with the extent of their participation in the activity. Claiming Credit To claim credit, participants must visit www.CMESupplement.eyeworld.org to review expanded educational content and download the postactivity test and credit claim. All participants must pass the post-activity test with a score of 75% or higher to earn credit. Standard internet access is required. Adobe Acrobat Reader is needed to view the materials. CME credit is valid through December 31, 2013. CME credit will not be awarded after that date. Notice of Off-Label Use Presentations This activity may include presentations on drugs or devices or uses of drugs or devices that may not have been approved by the Food and Drug Administration (FDA) or have been approved by the FDA for specific uses only. ADA/Special Accommodations ASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services should contact Laura Johnson at ljohnson@ascrs.org or 703-591-2220. Financial Interest Disclosures The faculty have disclosed the following financial interest relationships within the last 12 months: Clara C. Chan, MD, has received a retainer, ad hoc fees, or other consulting income from: Alcon, Bausch & Lomb, PRN, and Wyeth. She has received travel reimbursement from Alcon and is a member of Allergan's speakers bureau. David A. Goldman, MD, has received a retainer, ad hoc fees, or other consulting income from: Alcon, Allergan, Bausch & Lomb, Gerson Lehman Group, Leerink Swann & Co., Modernizing Medicine, Ophthalmologyweb.com, and SARCode. Bonnie An Henderson, MD, has received a retainer, ad hoc fee, or other consulting income from: Alcon and ISTA. Edward J. Holland, MD, has received a retainer, ad hoc fees, or other consulting income from and is a member of the speakers bureau of: Abbott, Alcon, Bausch & Lomb, Senju Pharma, and TearScience. He has received travel reimbursement from Alcon and Bausch & Lomb, and has received research funding from Alcon. The impact of cataract surgery stress on ocular inflammation and refractive cataract outcomes Introduction by Edward J. Holland, MD W e know it is important to address inflammation in cataract surgery, particularly to prevent cystoid macular edema (CME). In a recent online survey of 36 surgeons, 82.9% said they would lengthen the duration of anti-inflammatory therapy postoperatively in patients with known risk factors for inflammation, and 51.4% said they would use different anti-inflammatory agents. When asked about the acceptable level of inflammation on postoperative day one, 45.7% said trace to 1+ was acceptable, and the same percentage (45.7%) said 1+ to 2+ was acceptable. Additionally, 85.7% said their primary reason for using non-steroidal anti-inflammatory drugs was to prevent CME. Although surgeons are split on the acceptable level of inflammation, I think eliminating clinically significant inflammation, especially in premium IOL cases, is a better approach than trying to "catch up" and treat escalating inflammation. The goal for surgeons should be prevention of CME, not treating CME. Inflammation has a greater impact on patients and on visual acuity than many surgeons think. Dr. Holland is in practice at the Cincinnati Eye Institute. He can be contacted at eholland@holprovision.com. The true impact of inflammation by Bonnie An Henderson, MD M any systemic and ocular conditions can predispose patients to inflammation and edema after cataract surgery. However, it is not always predictable. Ultimately, we are concerned about three things: cystoid macular edema (CME); corneal edema; and pain/discomfort. CME is the most serious and sightthreatening type of inflammation, but it is also the most predictable. The incidence of clinical CME is only approximately 1% to 2% in most studies; however, the incidence of angiographic CME is probably closer to 20% to 30%. CME has an impact on postoperative vision, and the effect can be long term or short term. It can also influence patient satisfaction (Figure 1). Case study The impact of corneal edema was highlighted in a recent case of mine. A 77year-old woman was referred to me by another physician. She was hyperopic with narrow angles and had laser peripheral iridotomies in both eyes. She had moderate cataracts in both eyes, and her best-corrected visual acuity was approximately 20/60. She underwent uncomplicated routine cataract surgery in her left eye. Due to her short anterior chamber depth, the phacoemulsification energy was probably closer to the cornea than in a typical case. On the day after surgery, she was unhappy. She was experiencing the usual postoperative symptom of foreign body sensation, and she stated that her vision was "like looking through glass." In fact, her vision was not great. It was 20/200, which improved to 20/60 pinhole vision. She had diffuse corneal edema with more edema centrally. One week after surgery, she was better (1+ corneal edema and folds) but still had foreign body sensation and was not happy with her vision. At this time, her vision was 20/80, and her cornea had persistent edema. It took approximately two months for her cornea to clear, and she was not happy Figure 1. Inflammation after cataract surgery can ultimately result in a negative patient experience. with the long, drawn-out postoperative course. This case shows that even in standard uncomplicated surgery, some eyes will become very inflamed. This inflammation can delay visual recovery, which may delay the ability to return to normal activities. Postoperative pain and inflammation Patients with certain pre-existing conditions (diabetes and autoimmune diseases) are more likely to experience postoperative inflammation. Postoperative pain can range from a foreign body sensation to moderate to severe pain. A study surveyed 306 patients about their pain immediately after cataract surgery.1 Interestingly, 37% of those surveyed had mild to moderate pain in the recovery room immediately postoperatively, and the postoperative pain was the most significant predictor of how satisfied they were with their care. Postoperative pain was associated with low ratings of the quality of the surgical experience. Today, speedy visual recovery is more important than ever. Compared to 30 years ago, people are living longer and working longer, everyone has a cell phone, and everyone uses a computer, so patients require fast visual recovery. Many people have unrealistic expectations because they have heard from friends that cataract surgery is not a big deal, they will see well immediately after surgery, and there should not be any pain. If the patient's experience is different than this scenario, he or she is often convinced that something went wrong. In summary, corneal edema is unpredictable and can have an effect on cataract patients' postoperative recovery. Postoperative surgical pain is common, and even low levels of pain negatively affect patients' perceptions of their surgery. Reference 1. Fung D, Cohen MM, Stewart S, Davies A. What determines patient satisfaction with cataract care under topical local anesthesia and monitored sedation in a community hospital setting? Anesth Analg. 2005;100(6):1644-1650. Dr. Henderson is in private practice, Ophthalmic Consultants of Boston, and clinical professor of ophthalmology, Tufts University School of Medicine. She can be contacted at bahenderson@eyeboston.com.

Articles in this issue

Links on this page

Archives of this issue

view archives of Eyeworld - JUN 2013