MAR 2014

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

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E W RESIDENTS 1 43 months. Since these studies rely on single surgeon, single nomogram methods, it is not clear if these results are either nomogram or sur- geon dependent. As femtosecond laser technology and its promise of technical precision becomes more widespread, 3 it would be interesting to compare the results of PCRI using this technology compared to man- ual PCRI evaluated in these studies. Second, Koch et al have reported a trend to overcorrect with- the-rule astigmatism while undercor- recting against-the-rule astigmatism when using toric IOLs. They have suggested that this trend may be due to the previously unrecognized effect of posterior corneal astigma- tism. 4,5 As further understanding of this effect informs toric IOL calcula- tions, future studies may show even g reater accuracy with toric IOLs, since their efficacy is less dependent on patient variables important to PCRI outcomes such as patient age and tissue repair mechanisms. Finally, comparison of patient- centered assessments of the per- ceived quality of vision following these procedures would be interest- ing since these patients can provide d irect comparison of the two tech- nologies. Mingo-Botin et al assessed satisfaction with the VF-14 question- naire, but a future comparison might also include dry eye sensa- tion, recovery period, and other visual aberrations that could ulti- mately impact patient preference when choosing a surgical procedure f or astigmatic correction. Conclusion Overall this study is a valuable addition to a growing literature on surgical correction of refractive astig- matism at the time of cataract sur- gery. As in prior studies, the data show that the use of toric IOLs re- sults in significantly less postopera- tive astigmatism with potentially better uncorrected visual acuity. Although PCRI may also achieve acceptable results, there is a note- worthy regression of effect over six months demonstrated in this study. Thus, this trial suggests that the use o f toric IOL allows for more com- plete, predictable, and stable correc- tion of astigmatism compared to the combination of PCRI with standard monofocal IOLs. EW References 1. Mingo-Botin D, Muñoz-Negrete FJ, Won Kim HR, Morcillo-Laiz R, Rebolleda G, Oblanca N. Comparison of toric intraocular lenses and p eripheral corneal relaxing incisions to treat astigmatism during cataract surgery. J Cataract Refract Surg 2010; 36:1700-8. 2. Poll JT, Wang L, Koch DD, Weikert MP. Correction of astigmatism during cataract surgery: toric intraocular lens compared to peripheral corneal relaxing incisions. J Refract Surg 2011; 27:165-71. 3. Wu, E. Femtosecond-assisted astigmatic k eratotomy. Int Ophthalmol Clin 2011; 51(2):77-85. 4. Koch DD, Ali SF, Weikert MP, Shirayama M, Jenkins R, Wang L. Contribution of posterior corneal astigmatism to total corneal astigma- tism. J Cataract Refract Surg 2012; 38:2080- 2087. 5. Koch DD, Jenkins RB, Weikert MP, Yeu E, Wang L. Correcting astigmatism with toric intraocular lenses: Effect of posterior corneal astigmatism. J Cataract Refract Surg 2013; 39:1803-1809. Contact information Naseri: Ayman.Naseri@va.gov UCSF residents Sundeep K. Kasi, MD, and Michael Geske, MD Source: Ayman Naseri, MD or medications such as sulfonamide- containing oral medications includ- ing topiramate. Diagnostic and clinical course The patient was being treated by her psychiatrist for bipolar I disorder. She experienced a 90-pound weight gain while on lamotrigine and wished to switch to a new medica- tion. A week and a half before pres- entation, her psychiatrist had started topiramate at 25 mg BID, and three days before presentation he in- structed her to double the dose to 50 mg BID. Anterior and posterior seg- ment ultrasound examination was remarkable for diffuse choroidal effusions and an anteriorly rotated ciliary body (Figure 1). The patient was told to immediately stop topira- mate as this was the likely offending agent. Cyclopentolate 1% and atropine 1% were started three and two times a day, respectively. Timo- lol 0.5% was initiated to both eyes two times a day. Artificial tears and ointments were recommended for any discomfort from the chemosis and any associated lagophthalmos. The patient was seen the follow- ing day, where IOP was 15 mm in the right and 12 mm in the left eye. Repeat evaluation after two weeks demonstrated open angles in both eyes and ultrasound resolution of choroidal effusions and normal position of the ciliary body (Figure 2). Best corrected visual acuity was 20/30 in the right eye and 20/40 in the left eye. Discussion Topiramate-associated acute angle closure glaucoma is a well-docu- mented adverse event. 1-4 Initial symptoms are normally blurred vision, followed by pain. 4 It is an idiosyncratic reaction and can occur in patients with open angles. In the vast majority of cases, the angle clo- sure glaucoma occurs within two to three weeks of starting the medica- tion and often immediately after a dosage increase. 2,4 The presumed mechanism is related to drug- induced changes in choroidal membrane potential. This results in choroidal effusions, ciliary body de- tachment and anterior rotation of the ciliary body with narrowing of the angle. 4 Treatment involves im- mediate cessation of the offending medication, aggressive cycloplegia, and topical or oral aqueous suppres- sant therapy. 2 Important considerations in the case include the value of performing a detailed history for each patient. If a careful review of the patient's medications and recent changes was omitted, the case may be approached very differently. Addi- tionally, the typical angle closure treatments of pilocarpine and laser iridotomy may be of no benefit or may actually make symptoms worse. 2 Finally, patients should be kept aware of this potential compli- cation and advised to urgently seek medical care should they begin to have blurred vision or eye pain. EW References 1. J. Banta, K. Hoffman, D Budenz, E. Ceballos, D. Greenfield. Presumed topiramate-induced bilateral acute angle-closure glaucoma. Am J Ophthalmol, 2001. 132:112-4. 2. K. Chalam, T. Tillis, F. Syed, S. Agarwal, V. Brar. Acute bilateral simultaneous angle clo- sure glaucoma after topiramate administra- tion: a case report. Journal of Medical Case Reports, 2008. 2:1. 3. J. Craig, T. Ong, D. Louis, J. Wells. Mechanism of topiramate-induced acute- onset myopia and angle closure glaucoma. Am J Ophthalmol, 2004. 137: 193-195. 4. J. Levy, R. Yagev, A. Petrova, T. Lifshitz. Topiramate-induced bilateral angle-closure glaucoma. Can J Ophthalmol, 2006. 41:221-5. Contact information Mian: smian@med.umich.edu It's all continued from page 141 March 2014 astigmatism during cataract surgery: corneal relaxing incisions" 138-143 Residents_EW March 2014-DL2_Layout 1 3/6/14 4:16 PM Page 143

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