Eyeworld

EW FEATURE 88 by Michelle Dalton EyeWorld Contributing Editor Co-morbidities demand different approaches When patients have more than one ocular issue, treatment strategies are not as straightforward W hen a patient presents with visually signifi- cant cataract and no other ocular issues, the biggest decision facing a surgeon is which type of lens will be the most appropriate for that particular patient. If that same patient presents with additional ocu- lar problems—such as corneal or retinal disease or glaucoma—sur- geons must determine which disease is causing the most visual distur- bance, if a step-wise approach for the treatment of one disease will al- leviate the symptoms of the other, if concurrent or sequential surgery is advised, etc. For patients best served by a combined procedure, surgeons must also manage patient expecta- tions about visual recovery times and likely acuity. General advice The real issue for clinicians is deter- mining which of the two diseases is more visually debilitating for the pa- tient and who would be a good can- didate for a combined procedure, said Stephen S. Lane, M.D., medical director, Associated Eye Care, and adjunct clinical professor, University of Minnesota. For instance, if a pa- tient presents with a co-morbidity, surgeons must determine which problem is more significant. A pa- tient with both cataract and en- dothelial cell dystrophy or a patient with a high refractive error and high levels of astigmatism would be treated differently than a patient who presented with only one dis- ease, he said. In eyes with multiple anterior segment problems—and especially in those with retinal co-morbidi- ties—"we need to determine the safest and most effective surgery and emphasize to the patients that, be- cause of the co-morbidities, we can't guarantee the visual outcome," said Mark A. Terry, M.D., director of Corneal Services, Devers Eye Insti- tute, and professor of clinical oph- thalmology, Oregon Health & Sciences University, Portland. "We have to determine if it is safer to February 2011 COMBINED SURGERY March 2011 After trabeculectomy, the eye developed corneal edema Source: Sonia H. Yoo, M.D. The eye, post-DSAEK, but before undergoing phacoemulsification Source: Sonia H. Yoo, M.D. AT A GLANCE • In co-morbid cases, determining which of the two (or more) diseases is most visually disturbing will help create a treatment strategy • Spending extra time explaining how each disease affects vision can help ease patient concerns over combined surgery have one extended surgery to treat multiple problems or to treat just the major visual problem and then reassess post-operatively the need for further surgery. It's all about risk/ benefit ratio and patient expecta- tions." Tempering patient expectations is particularly important in private practice, said Uday Devgan, M.D., in private practice, Los Angeles, and chief of ophthalmology, Olive View– UCLA Medical Center. In the county hospital where he also practices, many patients have not had eyecare visits for years and often have much more serious conditions than the pa- tients he sees in private practice. "That said, some of the world's most appreciative patients are those who have not been able to afford eyecare in the past and are at a point where they can no longer work because of their poor sight," Dr. Devgan said. "These expectations are sometimes easier to manage than those of someone with, say, com- bined cataract and corneal disease."

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