Eyeworld

67 EW RETINA August 2015 by Maxine Lipner EyeWorld Senior Contributing Writer Outsourcing complicated cataract cases I t's one of those things that hap- pens to every cataract surgeon from time to time: the need to refer a cataract patient to a retinal colleague. Knowing just when such consultations are neces- sary and how to prepare the patient can help to serve the patient better. Nancy J. Christmas, MD, Colorado Retina Associates, Den- ver, advises cataract practitioners to keep potential retinal issues on their radar. During cataract surgery, some- thing like a dropped lens nucleus is a strong indication that the patient should be sent to a retinal specialist, she said. Likewise, retained lens ma- terial may warrant special attention. "Also, a suprachoroidal hemorrhage, which is a rare complication but serious, is something that [a cataract surgeon] would refer to us pretty soon after," Dr. Christmas said. those," Dr. Christmas said. If the patient's eye pressure is high after surgery and is not responding, that's a different story. "Then we're going to be seeing them sooner because they're more likely to need the frag- ments removed. Also, if the patient is diabetic, [he or she is] more likely to have other issues with retained lens material." This is because with retained material any patient is at risk of CME inflammation, but diabetic patients are at a higher risk, she explained. When a practitioner is dealing with a dropped lens or retained lens material, wherever possible, Dr. Christmas recommends proceeding with implanting the IOL at the time of the cataract removal. Otherwise, the patient will need another sur- gery to implant the IOL. For exam- ple, if something inadvertently goes to the back of the eye, Dr. Christmas recommends doing a controlled an- terior vitrectomy and then putting in either a sulcus-fixated or anterior chamber IOL depending on how well the IOL is supported. She sug- gested using sutures in the wound because if the patient needs another surgery, it will be important that the wound remains watertight. If the practitioner is doing a vitrectomy through a smaller gauge cannula, which puts more pressure on the wound, it won't open up. She also stressed the importance of explaining to the patient exactly what happened during the cataract surgery. "During the consenting process, [the surgeon] should go over the risks of all of these things," Dr. Christmas said. The idea is to remind patients of this and explain how a trip to a retina specialist may help. For example, if there is lens material remaining in the eye, the practitioner can explain that the retina specialist is necessary to evaluate whether the eye has too much inflammation, which may mean that the material needs to be removed. Cataract surgeons should also prepare the patient that another surgery may be needed to remedy the situation, she said. Dr. Christmas said that retinal surgeons will likely remain part of the cataract care continuum for some time to come. "Unfortunately, we don't see in the near future a time when there won't be compli- cations of any kind of eye surgery," she said. Although much has changed over the last 10 or 15 years with cataract surgery now becoming a smoother procedure, complica- tions still remain a factor. "It's about educating patients that things can still happen," Dr. Christmas said. EW Editors' note: Dr. Christmas has no financial interests related to this article. Contact information Christmas: nchristmas@retinacolorado.com Retinal referral time Patients with diabetes such as this one are at higher risk of developing issues during cataract surgery. Source: National Eye Institute Retina consultation corner In addition, endophthalmitis is an urgent condition that often requires referral to the retinal spe- cialist. This is something physicians should be alert for early on follow- ing cataract surgery. "If it's going to happen, it's usually in the first week or 2," Dr. Christmas said. Subtle concerns Other concerns voiced by cataract surgeons may involve more subtle conditions. "A lot of it comes down to the fact the vision is not as good as they expected it to be," she said. For example, cystoid macular edema (CME) cases are something that Dr. Christmas finds are frequently referred to her. "[The patients] use anti-inflammatory drops but some- times they still get CME a month after surgery. I will usually keep them on drops, but sometimes they'll end up needing a steroid or anti-VEGF injection," she said. Complaints of floaters or flashes of light after cataract surgery may also get a patient referred to the retina specialist. "Sometimes [patients] can get reflections off the IOL, but if they're seeing new flashes, there is some risk of a tear or detachment with surgery," she said. Also, the surgery can cause the start of a posterior vitreous detachment (PVD). "If they're seeing a shadow, it could mean a retinal detachment," Dr. Christmas said. "But with a PVD, they could still have flashes and floaters." If the cataract surgeon notices some hemorrhage in the retina after surgery, it may be hard to determine if this happened during or after surgery because there is a small risk of vein occlusion or bleeding from other causes. Sometimes it may have been there prior to surgery, but the cataract had prevented an adequate view. Watching it happen There are also occasions when the practitioner is aware that a compli- cation is occurring, such as when they are faced with a posterior cap- sule rupture, with migration of small fragments of lens material. Not all such cases require intervention from a retina specialist, but some do. "If it's just small amounts of cortical material, we don't usually remove S tandard phacoemulsification and refractive cataract surgery represent great advances in technology and provide better outcomes for patients today. With the advent of multifocal lens technolo- gy and femtosecond laser-assisted cataract surgery, expectations of the physician and patient are at an all-time high. Unfortunate- ly, despite these advances, complications and postoperative inflammation can and still do occur. Today's anterior segment surgeon must know how to address these uncommon problems and when to refer them to their retina colleagues. Timely identification of the clinical problem and prompt treatment and/or referral can result in excellent outcomes today. In this "Retina consultation corner," Nancy Christmas, MD, discusses several clinical entities that occur following cataract surgery and their treatment strategies. In addition, she will address which entities require prompt referral and key pointers in how to manage them. Keith A. Warren, MD, Retina consultation corner editor

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