Eyeworld

EW CATARACT 80 March 2015 "You have a cataract in your right eye—that is why you have poor vision and glare. We can remove the cataract and give you good distance vision, but you will need glasses to see the computer and read with the right eye after surgery. Your left eye is very nearsighted, meaning you can see things without glasses when you hold them very close to your eye. After surgery on your right eye, your 2 eyes will be very different, with the right eye clear in the distance and the left one clear at near. Unfortunately, glasses will not work for you after surgery since the right and left eye need such differ- ent prescriptions. A contact lens for your left eye will allow you to see clearly in the distance and your eyes will work together after surgery if you wear one. I suggest we have you try a contact lens before surgery to make sure you are able to use it. If you are happy with the contact lens we can proceed with cataract surgery to give you distance vision in the right eye." I start with the statement above. I then ask patients if they have any questions, and try to make sure they understand that glasses will not work for them. Patients will often eye, which we operated on, that needs very little spectacle power. The optics of having one strong lens and one weak lens in spectacles can be awkward. The eye with a lot of spectacle power will see smaller im- ages, while the eye with the artificial lens and little spectacle power will have larger images." At this point, I have the family members look at the patient in her glasses and show how her eye looks smaller. "To counteract the awkward spectacle problem if you choose this option, you will need to wear a contact lens in the eye we did not operate on. This matches it up optically with the operative eye and eliminates the awkward problem of a high power lens in just one specta- cle lens. "However, as you have never worn contacts before we will have you see one of our optometrists and make sure you can comfortably wear a contact lens before the surgery so we are sure this is even an option for you. "In summary, the decision is a little tough. You could go for a long-term homerun and wear a contact lens in the unoperated eye while you wait a few years for the cataract to develop in that eye. When it develops, we could place an intraocular lens with the cata- ract surgery then so you won't need correction in either eye to see far away. Or if you don't mind wearing glasses, we could set the intraocular lens in our surgery so you are about as nearsighted as now and just plan on continuing to wear glasses as you always have. "You don't have to decide now. You can think about it for awhile. Here is my card with my email. Let me know some time before the sur- gery so I get the correct lens ready for you." Richard J. Mackool Jr., MD Mackool Eye Institute, Astoria, New York Anisometropia decoded continued from page 79 Expert tips for handling difficult phaco cases W hether it is pseudoex- foliation syndrome, white cataracts, or a floppy iris, com- plications can easily turn a routine cataract surgery into a challenging one. With proper preoperative planning and careful intraoperative techniques, however, cataract surgeons can achieve suc- cessful outcomes even in the most difficult cases. Speaking at the 2014 Combined Ophthalmic Symposium, W. Barry Lee, MD, FACS, cornea service, Eye Consultants of Atlanta, and medical director, Georgia Eye Bank, Atlanta, shared his top pearls for operating on complex cataracts. Assess phacodonesis preoperatively In cataracts with a history of trauma, look for phacodonesis preop, Dr. Lee said. Having the patient abduct the eye and quickly recenter can often show movement of the lens at the slit lamp; however, signs of phaco- donesis can often be subtle. Look for evidence of vitreous prolapse, iris sphincter damage, or poor pupil dilation as well. Looking for these signs before surgery can help you decide if you need to use an extra- capsular extraction technique rather than phaco, he said. Be prepared for floppy iris Prepare yourself to handle intraop- erative floppy iris syndrome (IFIS) by accurately assessing the patient's risk preoperatively, Dr. Lee said. Ask male patients if they have prostate issues, and ask all patients about bladder dysfunction. If there is good pupil dilation in the presence of iris prolapse, inserting just one iris hook subincisionally can prevent further prolapse and damage to the iris throughout the case, he added. If pupil dilation is poor, you have the option of using 4 iris hooks or iris expansion devices, Dr. Lee said. His preferred device is a Malyugin ring (MicroSurgical Technology, Red- mond, Wash.), and he recommends becoming familiar with efficient placement and removal in these situations. Tackling the capsulorhexis Dr. Lee offered several pearls for cre- ating the capsulorhexis on a white cataract. First, remember to keep the anterior chamber pressurized. "Sometimes you try to be effi- cient and you don't think to stop and reinflate the anterior chamber with viscoelastic," he said. "So take a break, don't worry about speed, and take a moment to reinflate [the anterior chamber]." Use trypan blue and beware of the Argentinian flag sign, Dr. Lee added. "I like to fill my incision with viscoelastic so it traps the trypan blue in the anterior chamber and doesn't leak out as much," he said. To prevent the Argentinian flag sign, take a 19-gauge or 21-gauge needle to make the initial opening into the anterior capsule and aspirate some of the fluid, he said. If the capsule does tear, make sure to stop and refill the chamber with viscoelastic before you do anything else—refilling the chamber can help to save the rhexis in those situations, he said. Additionally, do not place a 1-piece lens in the sulcus after an anterior capsule tear. If a large anterior tear is noted, a 3-piece lens can be placed in the sulcus with orientation of the haptics 90 degrees away from the tear. Making a reverse rhexis can also be helpful when the rhexis starts to tear out, Dr. Lee said. Using a cysto- tome needle, nick the capsule just opposite to where the rent is, find the initial starting point, and tear the opposite way, he said. "This can save you on some of those tough cases." by Lauren Lipuma EyeWorld Staff Writer Complex cataract pearls ask why a contact lens will work while glasses will not. At this point I ask them if they have noticed that their eyes look smaller through their glasses when they look in the mirror than they do without their glasses. Surprisingly, many highly myopic patients will say they have not noticed. If a family member is in the room I ask them to look at their rela- tive with the glasses flipped up and then down. Once the family mem- ber is on board I show the patient in a mirror. Once the patient and a family member understand this concept, it is easier to explain that not only does the eye look smaller through the glasses, but the world looks smaller to the eye through the thick glasses. I then tell them that after surgery the eye that has no prescription will see things as larger than the eye with the thick eyeglass, and therefore glasses will make them unbalanced. I explain that contact lenses work differently so that the 2 eyes see things as the same size. EW Contact information Arbisser: drlisa@arbisser.com Mackool: richardmackool@aol.com Oetting: thomas-oetting@uiowa.edu continued on page 82

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