MAR 2014

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

Issue link: https://digital.eyeworld.org/i/276058

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Page 30 of 210

E W NEWS & OPINION 28 I d iscussed this case with some colleagues, Brian Kim, MD, Professional Eye Associates, Dalton, Ga., Kevin Waltz, MD, Eye Surgeons of Indiana, Indi- anapolis, Jeff Horn, MD, Vision for Life, Nashville, Tenn., and Jeff Liegner, MD, Eye Care Northwest, Sparta, N.J., to get some thoughts on h ow they would approach the case. Dr. Waltz commented first: "The left eye in this patient has a very small anterior capsulotomy. The small capsulotomy with softer IOL materials, like the AcrySof (Alcon) material, can sometimes create unusual HOAs with a small anterior capsulotomy. This may be contribut- i ng to the unusual diplopia pattern in this patient. I would first do a YAG posterior capsulotomy with ra- dial relaxing cuts by the YAG in the anterior capsule. It would not sur- prise me to find a different manifest refraction and a different diplopia pattern after the YAG treatment. After the YAG in the left eye, I would reassess the refraction and motility." "This case demonstrates the need to consider preop and postop- erative astigmatism when using pres- byopia-correcting IOLs. Leaving a patient with 1.5 D of residual astig- matism with a multifocal IOL will usually result in a dissatisfied patient. It might be useful to provide the patient with a pair of glasses, temporarily, to demonstrate the benefit of correcting the residual cylinder." When I evaluated this patient I did not consider the role the small anterior capsulotomy might be play- ing in terms of distorting the optics of the lens, but I did weigh the pos- sible effect it might have on an IOL exchange as a surgical option, per- haps making that surgery a bit more difficult. I did not consider a YAG capsulotomy here because the poste- rior capsule did not appear to be limiting the patient's visual acuity, and I did not want to limit my potential surgical options. Dr. Kim commented: "This pa- tient does not want to wear glasses. She also had successful (implied distance and near) vision prior to cataract surgery wearing a multifocal contact lens in the right eye and a toric contact lens in the left eye. If this was the case, I would try to mimic what was working so success- f ully for 20 to 30 years, thus I would explant her ReSTOR IOL in the left eye and exchange it for a toric IOL implant. I would also reduce the residual refractive error in the right eye with laser vision correction, LASIK, or PRK. The toric implant should eliminate the left eye monoc- ular diplopia. The right eye laser v ision correction will enhance the right eye such that it optimizes not only the distance vision, but also the near and intermediate vision through the multifocal technology." "As to why she has a 2 base down prism diopter in the right eye: This means she has a right hyper- tropia. She probably has a mild but l atent fourth cranial nerve palsy in the right eye. After wearing monovi- sion type contacts for 20 to 30 years, it caused her fusion to decompen- sate and manifest her right hyper- t ropia. As to why the binocular diplopia disappears at near, I believe it's because she has suppression of one of her eyes at near causing the diplopia to go away." Dr. Horn commented: "She had an undiagnosed RHT (maybe R con- genital fourth nerve palsy?) but was not symptomatic before cataract sur- g ery. This may have been due to the cataract reducing vision to the point that she didn't see well enough to be aware of diplopia. But it may also have been due to the fact that she wore monovision contacts and the distance blur/suppression from her left eye again left her (and her eye surgeon) unaware of the hyper- t ropia." "The monocular diplopia from OS after cataract surgery is clearly from her residual refractive astigma- March 2014 by Steven G. Safran, MD Double trouble T his is the case of a 76-year-old woman who came to me for a second opinion. She had cataract s urgery elsewhere a few months previously with ReSTOR lenses (Alcon, Fort Worth, Texas) OU and feels that the right eye did very well, but the left eye did poorly because she has seen "double" since this eye was done. Her uncorrected vision is 20/30 OD (corrects with +0.25 0.5X 120 to 20/25++), but in the left eye she has monocular diplopia. She corrects in the O S, however, with +0.75–1.75X 70, which eliminates the monocular diplopia and allows 20/20 vision in this eye, but when I trial frame it unmasks the fact that she also has binocular diplopia. She now requires 2 D base down OD to eliminate a vertical diplopia in primary gaze. Interestingly, how- ever, without this prism she is able to fuse in down gaze when reading. In other words, giving her the astigmatic correction without prism corrects her monocular diplopia OS but leaves her with binocular diplopia in every field of gaze except when reading. The astigmatic correction with prism clears up the diplopia in primary gaze. I explained to her that to eliminate the diplopia she will need to wear glasses with prism for distance, even if I surgically cor- rect her astigmatism, but she is horrified because "I paid all this money for implants that would allow me NOT to wear glasses and now I'm going to need them anyway?" She then asks me, "How come I never had this problem before surgery?" I ask her, "Did you have prism in your glasses before the cataract surgery?" She replied, "I never wore glasses. I had monovision in contact lenses for the last 20 to 30 years. I had a multifocal contact lens in the right eye and a toric lens in the left." Her surgery had been done a few months ago, and she has been miserable since. Steven G. Safran, MD, ASGR editor Anterior segment grand rounds The ReSTOR in the OD (top) and the ReSTOR in the OS (bottom) continued on page 30 Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) 18-47 News_EW March 2014-DL2 copy_Layout 1 3/6/14 2:46 PM Page 28

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