EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/274531
E W MEETING REPORTER 9 9 "When I end up off target, I think of myself as a detective," said William B. Trattler, MD, Miami. "I w ant to figure out what's going on and make sure there's nothing else that's an issue and then address the refractive error." "For example, if we do topogra- phy after surgery, we'll always OCT the macula to make sure there's nothing affecting the macula; the most common issues, of course not s urprisingly, are either dry eye or [meibomian gland dysfunction], and that can cause visual fluctuation as well as poor vision." In his talk "Techniques for enhancing cataract surgery patients with residual refractive error," Dr. Trattler said in his center, 50% of eyes achieve 20/25 or better UCVA, with approximately 25% of eyes after conventional laser enhance- ment at 20/40 or worse UCVA. "The key is to end up on target with your primary procedure be- cause you can enhance patients in a variety of ways, but you're not guaranteed to end up on target afterward," Dr. Trattler said. He said there are cases at an in- creased risk for not achieving target refraction, including those that had previous refractive surgery, corneal disease, long or short eyes, or some astigmatism cases. For those patients who are off target, LASIK, PRK, piggyback IOL, and IOL exchange are some ways of improving refractive outcomes, he said. He shared results of PRK and LASIK touch-ups after IOL implanta- tion, concluding that they can improve outcomes. Editors' note: Dr. Trattler has no finan- cial interests related to his presentation. Pearls for cataract surgery following corneal graft Two primary considerations in cases with previous corneal grafts that need cataract surgery are the health of the corneal graft, and if the pa- tient should return to a corneal sur- g eon for a repeat cornea transplant or "will this graft sustain the minor trauma of going through a cataract surgery?" said Marjan Farid, MD, Irvine, Calif. In her talk, "Cataract surgery after keratoplasty," Dr. Farid presented an overview on what to do in corneal graft cases that have c ataracts. She outlined the three ob- jective measurements in these cases. The first is specular microscopy, looking at the endothelium's quan- tity and general health, which is minimally useful, she said. The second is slit lamp examination, looking at whether there is visually significant thickening, haze, or guttae, which is useful. The third objective measure- ment, and the most useful, is pachymetry, which can determine the "true measure of endothelial pump function," Dr. Farid said. "As a general rule of thumb, if the central corneal thickness is greater than 650 microns, I think there's going to be significant thick- ening there that would push me to- ward either doing repeat graft first or thinking about a combo surgery," she said. "If the corneal thickness centrally is less than 600 microns, I think we're in the clear to proceed with cataract surgery alone." "If they fall in that in-between zone, then I go back to number two, and I look at them under the slit lamp to try to get an idea of how the cornea is doing, is it clear enough to proceed with cataract surgery." One pearl for cataract surgery in these cases is to use a generous amount of a dispersive OVD, which helps shield against phacoemulsifi- cation energy and mechanical and irrigation trauma, she said. Another pearl is to use quick chop techniques for nuclear disas- sembly, Dr. Farid said. This helps because the divide and conquer technique needs higher phaco energy and time. E ditors' note: Dr. Farid has no financial interests related to her presentation. Tuesday, Jan. 21, 2014 Pearls for challenging cataract surgery cases Two panels of leading experts of- fered their opinions and pearls for p erforming cataract surgery in challenging cases, including weak zonules and rock hard lenses. In the "Cataract surgery complications" symposium, David F. Chang, MD, Los Altos, Calif., moderated the session and led the discussion with videos of six complicated cataract surgeries that he encountered in his practice. The separate panels of experts weighed in on what they would do in those cases, and the audience also partici- pated by answering questions that Dr. Chang posed. The cases included an unhappy multifocal IOL case, a posterior polar cataract case, a weak zonules/pseu- doexfoliation case, a trauma case, a rock hard lens case, and a white cataract case. In the rock hard lens case, an 84-year-old patient had a monocular cataract (the other eye had angle c losure glaucoma). The patient had a small, shallow anterior chamber and a surgical PI, with vision at 20/70. "He's been living for some time now with a brunescent cataract," Dr. Chang said. "Naturally, he's fearful, and he can live with this." Dr. Chang asked the audience if they would recommend delaying c ataract surgery, waiting until symp- toms were worse, referring the pa- tient out, leaving the decision to the patient, or recommending perform- ing the surgery now. Approximately 40% of the audience responded that they would recommend the surgery now. Dr. Chang asked the panel if they would delay surgery. Sonia H. Yoo, MD, Miami, said that delaying surgery is an option, but must be weighed alongside the patient's health. "This is tough," she said. "The fear is real, and you can't guarantee that you won't have a complicated case here. I think it would be fine to delay. I do have a case of a 95-year- old monocular patient with a dense cataract and we said wait, and she's 105 now." Dr. Chang proceeded with surgery. He said he published previ- February 2014 View it now ... EWrePlay.org Dr. Steinert discusses "Toric IOL misalignment: The vectors add up." Monday on EWrePlay 98-105 MR Hawaii_EW February 2014-DL2_Layout 1 1/30/14 11:57 AM Page 99