Eyeworld

EW CATARACT 30 June 2014 "People are bothered by them cosmetically, but they don't cause any pain," he said. Dr. Bakewell has seen this occur in his femtosecond LASIK patients. However, in the cataract population, he believes the issue is accentuated. "The problem is in the LASIK popu- lation, most of these folks are rela- tively young, and they're not usually on blood thinners," he said. "With the majority of the cataract patients in their 60s and 70s, a lot of folks are on blood thinners." A subcon- junctival hemorrhage in those peo- ple will be more significant, he said. "Certainly anyone who is going to have femtosecond cataract sur- gery needs to be warned that they're probably going to have some sub- conjunctival hemorrhages," Dr. Bakewell said, adding that while these are just cosmetic, it can take 2 or even 3 weeks to completely go away when a patient is on blood thinners. However, stopping blood thin- ners is not always necessary and some patients cannot medically stop them, Dr. Bakewell said. He added that for those who are taking them electively because they heard it might be helpful, they certainly could stop their aspirin for a few weeks. Because aspirin is an irre- versible platelet inhibitor, however, patients need to be off it for 2 weeks before the effect is reversed. In keeping with Dr. Bakewell's thinking, the literature does show that age can be a factor in develop- ment of femtosecond-related subconjunctival hemorrhage. Study results in the 2010 issue of Ophthalmologica evaluating the loca- tion and extent of subconjunctival hemorrhages indicate that these tend to increase with age. In addi- tion, the study showed that subcon- junctival hemorrhages were usually more common in inferior areas than in superior ones. However, when the hemorrhages were caused by trauma, the temporal area was more likely affected than the nasal, investigators reported. Minimization techniques Phenylephrine can help minimize the occurrence of subconjunctival hemorrhage, Dr. Donaldson said. She uses 10% phenylephrine for dilating all femtosecond patients be- fore surgery (unless contraindicated by uncontrolled hypertension), which will constrict some of the blood vessels. In turn, this helps to reduce the incidence of subconjunc- tival hemorrhage. Another possible option may be use of brimonidine. A January 2010 study published in the Journal of Refractive Surgery indicates that this can help to keep subconjunctival hemorrhage at bay. In the study in- volving 200 myopic eyes undergoing IntraLASIK, 1 eye was treated with brimonidine tartrate 0.2% 30 minutes before surgery, while the other eye underwent the procedure without it. Investigators reported that only 3% of brimonidine-treated eyes suffered subconjunctival hem- orrhage, compared to 79% of those that did not receive this pretreat- ment. There was also no incidence of flap complications in the bri- monidine-treated eyes versus the untreated eyes, which showed an 11% flap retraction, according to study results. However, Dr. Donaldson does not favor this approach. "There was a controversial issue with brimoni- dine years ago with LASIK, thinking that it may cause some (flap) slip- page and that the suction may not be as stable, so we don't use that," she said. Dr. Pendse stressed the need to keep femtosecond docking attempts to a minimum. "I like to have the patient in the best position possible and try to only dock once," Dr. Pendse said. "I think with femto it's critical that you spend time getting patients in the proper position so they're comfortable and they're not going to move around; the more times you lose suction, the more irritated the conjunctiva gets and the more likely that you're going to have this occur." Overall, Dr. Pendse emphasized that despite the possibility of subconjunctival hemorrhage, the femtosecond laser is still a great technology. "I think it's going to be part of our repertoire for what we can offer patients moving forward," he said. "I don't think this should be a major deterrent for utilizing the femtosecond laser." EW Editors' note: The physicians have no financial interests related to their comments. Contact information Bakewell: eyemanaz@aol.com Donaldson: kdonaldson@med.miami.edu Pendse: sagunpen@hotmail.com A clear-eyed view continued from page 28 The applanating interface of the LenSx tends to press harder on the eye and can cause subconjunctival hemorrhage. Source (all): Kendall E. Donaldson, MD LenSx, now sporting a new patient interface, has improved its design. "Before the SoftFit Patient Interface for the LenSx was available, the pres- sure used to go up much higher," she said. "Now it's only about a 16 mmHg increase from baseline." With the Catalys, pressure only rises about 10 to 12 mmHg, she said. Sagun Pendse, MD, clinical professor of ophthalmology, Wills Eye Hospital, Philadelphia, agreed that the new SoftFit Patient Interface has made a difference in occurrences of subconjunctival hemorrhages with the LenSx. "With the original patient interface the majority of patients had subconjunctival hemorrhages," Dr. Pendse said. Currently, he finds the incidence has been reduced. "The new SoftFit Patient Interface is smaller and uses a kind of contact lens to create an interface so it does- n't need as high a level of suction; as a result the pressure does not go up quite as high," he said. With the Catalys, which he uses as well, he feels that incidence of subconjuncti- val hemorrhage may be even lower. Population issues Subconjunctival hemorrhages are not medically significant, although they can be vexing, according to Brock K. Bakewell, MD, assistant clinical professor, University of Utah, Moran Eye Center, and clinical lecturer, University of Arizona, Tucson. 20-31 Cataract_EW June 2014-DL_Layout 1 6/3/14 12:21 PM Page 30

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