Eyeworld

60 | EYEWORLD | SPRING 2024 ATARACT C YES CONNECT by Ellen Stodola Editorial Co-Director About the physicians Sahar Bedrood, MD, PhD Glaucoma & Cataract Surgeon Advanced Vision Care Los Angeles, California JoAnn Giaconi, MD Stein Eye Institute University of California Los Angeles, California the correct axial length in short eyes can lead to large refractive error. Therefore, I do mea- surements with both partial coherence inter- ferometry (IOLMaster, Carl Zeiss Meditec) and optical low coherence reflectometry (Lenstar, Haag-Streit). This allows me to cross check the measurements for accuracy. I would also con- sider doing a UBM to measure scleral thickness, as we know that is a risk factor for choroidal effusions and possible malignant glaucoma following surgery." If the axial length is <18 mm or the sclera appears thickened and Dr. Bedrood notices a uveal effusion (high IOP and shallowing of chamber at the time of surgery), she said she anticipates the possibility of scleral windows at the time of surgery. Dr. Bedrood said that a short eye might leave patients at a slightly higher risk for postop complications like iris prolapse, corneal edema, malignant glaucoma, and CME. Dr. Giaconi said that she will let patients know that a short eye tends to have crowded anatomy and that it is at higher risk for certain complications, like iris prolapse, which can lead to transillumination defects postoperatively. It can also be more difficult to remove the lens, and therefore, there is a higher risk for corneal ede- ma. "Predicting where the lens implant will end up in the eye is also more difficult, so hitting the refractive target is less certain," she said. Dr. Bedrood agreed that lens calculations may be different with these short eyes. "I make the patient aware that the lens calculations are made based on formulas that consider the dimensions of the eye," Dr. Bedrood said. "Since the dimensions of their eyes fall in an 'abnor- mal' range, then we have some limitations with the formulas and a possibility of postoperative refractive error is possible. Over the last few years, however, we have had newer lens for- mulas developed to help reduce the chance of refractive error." Dr. Giaconi recommends newer IOL calcula- tion formulas. "There are some studies showing the Kane formula as promising for short axial lengths," she said. "I like the new [ESCRS] IOL calculator which shows multiple formulas of the newest generation and allows me to compare multiple formulas." Short eyes are often the most challenging for cataract surgeons. Preoperatively, lens selection can be tricky, as the effective lens position is hard to predict in these eyes. These patients are often hyperopic to start and may be less accepting of a myopic result. Intraoperatively, issues with effu- sions and iris prolapse can make a routine case very complicated. Even after surgery, patients may need to be monitored for chronic angle closure from peripheral anterior synechiae or may need to be treated for aqueous misdirection should it occur. JoAnn Giaconi, MD, and Sahar Bedrood, MD, PhD, are both glaucoma specialists and cataract surgeons who have dealt with their fair share of short eyes. In this month's YES Connect column, they review their approach to short eyes. They discuss their methods for lens selection and pro- vide pearls on how to avoid complications like iris prolapse and effusions. One final pearl: Do not underestimate how helpful relieving some posterior pressure at the start of cataract surgery can be. Placing a pars plana trocar and removing some vitreous will immediately deepen the anterior chamber, and the rest of the surgery will go routinely. – Mitra Nejad, MD, YES Connect Editor P erforming cataract surgery in short eyes comes with certain challenges and considerations. Two surgeons discussed how to approach these patients, as well as certain formulas and surgical approaches that can help in these cases. Sahar Bedrood, MD, PhD, and JoAnn Giaconi, MD, defined a short eye as one that is less than 22 mm in axial length. "Less than 21 mm is where I personally will start making some adjustments to technique. For others it is less than 20 mm," Dr. Giaconi said. Dr. Bedrood said that patients with an axial length of less than 22 mm typically are hyper- opic and may have narrow angles. "I perform intraocular pressure checks and gonioscopy to rule out angle closure, which would require IOP-lowering drops or more im- minent cataract surgery for lens removal," she said. "Accurate axial length measurements are key because we know that small deviations from Cataract surgery in short eyes Contact Bedrood: saharbedrood@gmail.com Giaconi: giaconi@jsei.ucla.edu

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