Eyeworld

EW FEATURE 68 February 2011 Challenging cataract cases September 2011 I believe that this survey trends toward a more progressive group of surgeons than what would be seen in the general population of ophthalmologists. For example, the response that 27% of the doctors in this sur- vey handle "all their own complications" is a very high number. I also think that it's a very forward stance to report that just about 3/4 of doctors in this sample are moving toward PAL. I am also somewhat surprised to see that 22% are still giving subconjunctival injections ... I would have predicted that number to be lower. The even split between iris fixation (21%) and scleral fixation (21%) is not surprising, nor is the fact that both these add up to less than the utilization of ACIOLs (54%). Still, the number of people suturing in lenses is far higher than what I would expect in the general population of all ophthalmologists doing surgery. All in all, I think that the answers here reflect the progressive nature of the readership of Eyeworld and those willing to participate in a poll of this sort. –Steve Safran, cataract editorial board member T he results for this month's Pulse probably reflect the increased comfort level of EyeWorld's readership with handling complications of cataract surgery. The vast majority of respondents manage most of their own complications and a surprising 71% perform or would like to learn PAL. I was also encouraged to see that 42% felt comfortable with sutured IOLs; however I suspect these numbers would be lower if the re- sults were extrapolated to all cataract surgeons. Although the use of intracameral antibiotics has probably in- creased in the last few years since the 2007 ESCRS study, most respondents still rely on topical alone or in combination with subconjunctival antibiotics for infection prophylaxis. - –Mitchell Weikert, cataract editorial board member Monthly Pulse Keeping a Pulse on Ophthalmology Pterygia continued from page 66 Dr. Tseng recommends using a cotton swab to dry the bare sclera Source: Scheffer C.G. Tseng, M.D. Planned sequential surgery Both the keratometry and topogra- phy will help determine if the ptery- gium can be left as is, needs to be excised first, or should be excised si- multaneously with cataract removal, Dr. Palmon said. There's no debate that large pterygia need to be removed before patients undergo cataract surgery. Dr. Nasser recommended letting the cornea stabilize after pterygia re- moval, for "about 6-8 weeks" before taking K readings. Both Drs. Palmon and Tseng agreed "at least a month" is neces- sary between the two surgeries. "If there's any sign of inflamma- tion or any chance of recurrent pterygium, you're going to know typically in the first month to 6 weeks," Dr. Palmon said. Dr. Tseng "always" removes the pterygia before scheduling patients for cataract surgery. "Pterygium surgery should not be trivialized—it's more than just cutting it out and pasting on a graft," he said. His goal is to provide patients with an aesthetic outcome as well as a good surgical outcome. Surgical pearls Because the pterygia he removes are larger and more prominent, Dr. Tseng "prefers the use of amniotic membrane [in lieu of conjunctival autograft] first because with larger incisions I want the aesthetic out- come to be superior." (Editors' note: Dr. Tseng noted he has a proprietary stake in amniotic membrane, both by holding patents on the technology and as founder of the company that pro- vides cryopreserved amniotic mem- brane.) Dr. Nasser prefers to use a con- junctival autograft and fibrin glue, "being careful to remove excess in- flamed subconjunctival tissue while not compromising the muscle cap- sule or the semi-lunar fold (nasal le- sions). I mark the autograft tissue on the epithelial side with a sterile marking pen prior to excision to en- sure it is placed in the correct orien- tation," he said. Using glue rather than sutures on the pterygium bed not only reduces healing time but improves patient comfort, he said. Dr. Palmon also uses conjuncti- val autografts when faced with a pri- mary pterygium. "I'll use amniotic membrane grafts when people pres- ent with recurrences or if they've had surgery elsewhere and there's not enough healthy corneal epithe- lium." Dr. Nasser added he uses mito- mycin C (MMC) 0.02% "for a minute in the larger inflamed ptery- gia, especially in younger patients whose occupation requires them to work outdoors. In my area most, but not all, of these patients are His- panic." Dr. Tseng also uses MMC, but where most surgeons apply MMC on bare sclera after the pterygium exci- sion, "I think that could be risky and may present some complications," he said. Refractive continued from page 64 surgery at the same time of day. "A piggyback or any exchange would then be carried out in the same manner as any refractive surprise. I do not recommend LASIK or PRK following RK," he said. If the refractive surprise is ex- treme, Dr. Koch will perform a lens exchange. If it's something smaller, he will do LASIK or PRK. He also has another go-to approach. "I select what I think is the correct power of lens to replace the current one, and I select a piggyback lens. I go into the OR prepared for a lens exchange. If that seems ill advised, I'll place a piggyback lens. That said, I've never had to do this, but I think it's a good fall back, especially if you're not comfortable getting the lens out of the eye," Dr. Koch said. EW Editors' note: Dr. Hill has financial in- terests with Alcon (Fort Worth, Texas), Bausch & Lomb (Rochester, N.Y.), Carl Zeiss Meditec, and other ophthalmic companies. Dr. Koch has financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.), Alcon, Calhoun Vision (Pasadena, Calif.), and other ophthalmic companies. Drs. Blecher, Huang, Wang, and Wiley have no financial interests related to their comments. Contact information Blecher: 215-339-8100, mhbmd@earthlink.net Hill: 480-981-6111, k7wx@earthlink.net Huang: 301-897-3322, h3md@comcast.net Koch: 713-798-5143, dkoch@bcm.edu Wang: 713-798-7946, liw@bcm.tmc.edu Wiley: 216-621-6132, drwiley@clevelandeyeclinic.com

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