Eyeworld

EW RESIDENTS April 2014 57 by Ellen Stodola EyeWorld Staff Writer Cataract management in long eyes Although ASCRS has a reputation for providing the most advanced and up- to-date surgical education, many of our members are at earlier stages of their surgical careers. This is also true of EyeWorld's national and international readership, and for this reason we have created a new column devoted to cataract and refractive surgical funda- mentals. Elizabeth Yeu, MD, was previously on the faculty at Baylor's Cullen Eye Institute before entering private practice in Virginia, and is an outstanding cataract and refractive surgeon and teacher. As the vibrant chair of the ASCRS Young Physician and Resident (YPR) Clinical Commit- tee, Elizabeth has brought wonderful energy and new ideas to the ASCRS Governing Board. Her committee is comprised of individuals who, by virtue of their talent and hard work, are des- tined to become strong educators and opinion leaders in our field. The YPR Clinical Committee members will develop the topics for this regular new column, under Elizabeth's leadership as the column editor. The new ASCRS online Phaco Fun- damentals Classroom, phaco.ascrs.org, was created for these same reasons. This classroom is free for any ophthal- mologist and is a dynamic collection of some of the best courses and teaching resources for mastering the fundamen- tals of phaco. All of the articles from this EyeWorld column will be archived in the online classroom, along with other EyeWorld columns of special interest to residents and fellows— "EyeWorld journal club, "Cataract M&M rounds," and "Cataract tips from the teachers." –David F. Chang, MD, chief medical editor Special considerations should be taken into account for highly myopic patients W hen managing cataract patients, axial length and complica- tions that can arise in highly myopic pa- tients are important to consider. Daniel Chang, MD, Empire Eye and Laser Center, Bakersfield, Calif.; Warren Hill, MD, East Valley Oph- thalmology, Mesa, Ariz.; Douglas Koch, MD, professor and Allen, Mosbacher and Law Chair in Oph- thalmology, Cullen Eye Institute, Baylor College of Medicine, Hous- ton; Leela Raju, MD, clinical assis- tant professor of ophthalmology, and vice chair of clinical services, University of Pittsburgh School of Medicine; and Gary Wortz, MD, Koffler Vision Group, Lexington, Ky., discussed these specific types of patients. Preoperative retina consults Dr. Koch would not automatically send a highly myopic patient to a retina specialist but would definitely conduct a careful retinal exam him- self. "Were I to see any vitreoretinal pathology, such as lattice degenera- tion or evidence of any tufts or holes, I would send the patient to a retinal specialist," he said. Dr. Wortz would not routinely send a patient to a retina specialist unless that patient had an identified retinal defect. However, he noted that he utilizes his retina colleagues regularly and would not hesitate to send a high myope if something about the exam was abnormal. "Getting clearance from a retinal doctor is never a bad idea in a long axial myope," he said. One indicator of an occult reti- nal tear is a positive Shafer's sign, he said. "If a patient has a [posterior vitreous detachment] with a positive Shafer's sign, it is an indication of a retinal tear, as the pigment has come from the [retinal pigment epithelium]," he said. Dr. Raju will send a highly my- opic cataract patient to a retina spe- cialist if the patient has not had a retina exam in the last few years. Formula of choice for long eyes For eyes with axial myopia, Dr. Koch uses formulas that modify axial length values when calculating the IOL power with the Holladay 1 and 2, SRK-T, Haigis, and Hoffer Q formulas. These formulas were developed by Li Wang, MD, PhD, and himself, and they apply to patients with an axial length greater than 25.2 mm. The concept is to take the original axial length and insert it into these formulas to come out with a value that is lower than the original axial length value, he said. This smaller number is reinserted into the IOL T he management of cataracts in eyes that are outside the average axial length (<22.0 mm or >25.0 mm) can be uniquely challenging, from the preoperative IOL calculations to the surgical techniques. With axial myopes, basic IOL calculations can be less predictable, zonules can be weaker, and surgeons have to operate within an abnormally deep chamber—all components that can test any surgeon's patience and confidence, especially those who have less experience managing longer eyes. Drs. Chang, Hill, Koch, Raju, and Wortz provide their insights to help with the management of these cataracts. Elizabeth Yeu, MD, Cataract and refractive surgical fundamentals editor Wang-Koch formulas for adjusting axial length in eyes greater than 25.2 mm. These adjustments help with inaccuracies when using these formulas in long eyes. Source: Douglas Koch, MD Cataract and refractive surgical fundamentals continued on page 58

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