Eyeworld

EW CATARACT 36 June 2015 by Scott W. Tunis, MD, FACS LOCS grading, and observed rates of cataract surgery are not necessarily reproducible and comparable among subjects, examiners, or studies. To date, quantitative measures of cataract development, which are purely objective and independent of subject or observer input, have not been used. What to tell patients? Given the conflicting nature of the evidence, how do we respond to this typical patient inquiry at the time of diagnosis of an early, non-surgical cataract: "What else can I do to slow my cataracts?" Our current "stan- dard" discussion includes the advice to limit UV exposure, discontinue smoking, maintain a healthy diet and lifestyle, and keep regular ex- aminations. It may also include the advice to consider nutritional sup- plementation. But what, when, how the design and the interpretation of results of studies examining the effects of antioxidants on cataract development. First, the interval of time over which cataracts develop is typically long, necessitating long intervals of subject observation, usu- ally a decade or more. Compliance with alternate arms of treatment and strict follow-up are difficult over long periods of time. Furthermore, during long intervals of observation a myriad of uncontrolled conditions in the subject population may arise such as new onset disease, new med- ications, and varying degrees of en- vironmental exposure, all of which may affect cataract progression and are difficult to account for. The second challenge has been that endpoint parameters of cataract development, which have been used for outcome analysis, are highly subjective. Snellen visual acuity, followed for an average of 11 years indicated that long-term daily multi- vitamin use modestly yet significant- ly decreased the risk of cataract. 1 A questionnaire-based nutrition survey of more than 30,000 women greater than age 49 followed for more than 7 years found a 13% lesser risk of developing cataract in those with a higher dietary intake of antioxi- dants. 2 Conversely, other studies have suggested that there is no beneficial effect of nutritional antioxidants on the inhibition of cataract develop- ment. A review of 9 clinical trials involving more than 117,000 pa- tients suggested that beta-carotene, vitamin E, and vitamin C had no effect in preventing or slowing the progression of age-related cataract. 3 Study challenges Two distinct challenges have faced Nutritional supplements and cataract T here are conflicting reports on the effectiveness of nu- tritional supplements and antioxidants in preventing or slowing the growth of age-related cataracts, despite exten- sive evidence suggesting that oxida- tive damage to lens epithelial cells is a common underlying etiologic factor in cataractogenesis. A number of studies have indi- cated that nutritional supplements have a long-term inhibitory effect on the development of visually significant cataract. A random- ized trial of more than 14,000 U.S. male physicians over the age of 50 Scott W. Tunis, MD, FACS Pseudophakic dysphotopsia continued from page 34 have some odd visual phenomenon postoperatively, and this is a period where the eye and cortical visual system are adjusting. "The lens is a new part of your visual system, it is man-made and not perfect, but as your brain adapts (neuroadaptation), most times symptoms fade." I suggest that the patient can help this symptom fade by not focusing or ruminating on it. When they notice the phenomenon they should tell themselves it is nothing to worry about and stop focusing on it. "The good news is most peo- ple are able to learn to adapt and integrate these lenses into their visual system. I will give you some tips on how to do this. Most have to do with keeping both eyes open and not testing your eyes, not looking for the phenomenon. The second part is when you do experience this, tell yourself it is nothing to worry about. Removing the anxiety associ- ated with the symptom will reduce the brain's focus on it." Finally I say that rarely, we find a patient who is terribly bothered by persistent dysphotopsias and this patient will need to consider further treatment. For positive dysphotop- sias we will try a miotic agent such as pilocarpine 0.5% or brimonidine 0.15% For patients with negative dysphotopsias I will offer them the miotic treatment and expect it will probably not be useful but worth trying. If we have tried the above and the patient is still very unhappy, we will discuss IOL exchange and repositioning. I prefer to do an IOL exchange repositioning within the first 6 months. I discuss the risks and benefits with the patient. I rely on the work of Sam Masket, MD, to guide me on the treatment approach. I will have a plan that will include a few options. One is to remove the lens and replace it with a sulcus 3-piece IOL with optic capture; the second option is reverse optic capture of the original IOL; and the third option is a piggyback sulcus 3-piece IOL. My clinical experience has led me to believe that these patients are not "difficult patients," but they are usually a bit scared, frustrated, and nervous. They are appreciative of you listening to them and treating their dysphotopsias. They are our patients and deserve our time and assistance. It may also be related to the size of your pupil, which is why some pa- tients report it more frequently than others. However, as the eye heals, it fades away." The reason I start the conversa- tion by reiterating their symptoms in my own words is to impart a sense of "I understand exactly what you are describing, am familiar with the symptom, and I am not con- cerned about it." I don't feel compelled to go into a lengthy description of causative theories such as truncated lenses because we still do not fully under- stand the root cause of the symp- tom. This statement is truthful. To go into explanation of theory, such as lens design, can raise the concern for patients of a faulty lens. I do counsel my patients on the symptoms of retinal tear and de- tachment and how they differ from these symptoms and the importance of immediately reporting them. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Arbisser: drlisa@arbisser.com Dodick: Jackdodick@aol.com MacDonald: susan.m.macdonald@lahey.org Jack M. Dodick, MD Professor and chairman, Department of Ophthalmology, New York University School of Medicine, New York I tell my patients before surgery: "You may experience a dark shad- ow, flashes, or halos shortly after surgery, but these eventually disap- pear." I tell my patients after surgery, when they report these symptoms: "It is as if you are experiencing a dark arc at the side of your vision or on occasion a flash or halos. To this day we are not certain what causes these symptoms but I do know that they are of no concern and will eventually disappear. We do not understand it well, but think it is a reflection of light from the edge of the lens and is quite common.

• Cover