Eyeworld

73 EW FEATURE October 2015 Complex cataract cases recommended retractors or CTSs (he invented the latter), reserving rings for cases of "moderate to severe zonular deficiency." Also, the liberal use of OVDs, "cannot be stressed enough," Dr. Cionni said. A complete hydrodissection, and possibly hydrodelineation, will decrease the zonular stress. Dr. Henderson advised using a chopping technique to minimize the number of times the lens must be rotated. Her preference is to place hooks after the capsulorhexis to help "transform a difficult case into a manageable one." Suturing Always be prepared to suture the ring in these cases, even if you don't believe it will be necessary, Dr. Cionni said. "Usually we can salvage the capsular bag, so the real ques- tion becomes if there's going to be a sutured CTR or CTS," he said. "If the area of dialysis is large (more than 4–5 clock hours) and the CTR is not sutured in place, a simple CTR will succeed in centering the IOL in the short term but even- tually the entire IOL/capsular bag/ CTR complex can dislocate," Dr. Henderson said. INDICATIONS AND USAGE ZYLET® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) is a topical anti-infective and corticosteroid combination for steroid-responsive infl ammatory ocular conditions for which a corticosteroid is indicated and where superfi cial bacterial ocular infection or a risk of bacterial ocular infection exists. Ocular steroids are indicated in infl ammatory conditions of the palpebral and bulbar conjunctiva, cornea and anterior segment of the globe such as allergic conjunctivitis, acne rosacea, superfi cial punctate keratitis, herpes zoster keratitis, iritis, cyclitis, and where the inherent risk of steroid use in certain infective conjunctivitides is accepted to obtain a diminution in edema and infl ammation. They are also indicated in chronic anterior uveitis and corneal injury from chemical, radiation or thermal burns, or penetration of foreign bodies. The use of a combination drug with an anti-infective component is indicated where the risk of superfi cial ocular infection is high or where there is an expectation that potentially dangerous numbers of bacteria will be present in the eye. The particular anti-infective drug in this product (tobramycin) is active against the following common bacterial eye pathogens: Staphylococci, including S. aureus and S. epidermidis (coagulase-positive and coagulase- negative), including penicillin-resistant strains. Streptococci, including some of the Group A-beta-hemolytic species, some nonhemolytic species, and some Streptococcus pneumoniae, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Enterobacter aerogenes, Proteus mirabilis, Morganella morganii, most Proteus vulgaris strains, Haemophilus infl uenzae, and H. aegyptius, Moraxella lacunata, Acinetobacter calcoaceticus and some Neisseria species. IMPORTANT SAFETY INFORMATION • ZYLET® is contraindicated in most viral diseases of the cornea and conjunctiva including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in mycobacterial infection of the eye and fungal diseases of ocular structures. IMPORTANT SAFETY INFORMATION (continued) • Prolonged use of corticosteroids may result in glaucoma with damage to the optic nerve, defects in visual acuity and fi elds of vision. Steroids should be used with caution in the presence of glaucoma. If this product is used for 10 days or longer, intraocular pressure should be monitored. • Use of corticosteroids may result in posterior subcapsular cataract formation. • The use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation. In those diseases causing thinning of the cornea or sclera, perforations have been known to occur with the use of topical steroids. The initial prescription and renewal of the medication order should be made by a physician only after examination of the patient with the aid of magnifi cation such as a slit lamp biomicroscopy and, where appropriate, fl uorescein staining. • Prolonged use of corticosteroids may suppress the host response and thus increase the hazard of secondary ocular infections. In acute purulent conditions, steroids may mask infection or enhance existing infections. If signs and symptoms fail to improve after 2 days, the patient should be re-evaluated. • Employment of corticosteroid medication in the treatment of patients with a history of herpes simplex requires great caution. Use of ocular steroids may prolong the course and exacerbate the severity of many viral infections of the eye (including herpes simplex). • Fungal infections of the cornea are particularly prone to develop coincidentally with long-term local steroid application. Fungus invasion must be considered in any persistent corneal ulceration where a steroid has been used or is in use. • Most common adverse reactions reported in patients were injection and superfi cial punctate keratitis, increased intraocular pressure, burning and stinging upon instillation. Please see Brief Summary of Prescribing Information for ZYLET® on adjacent page. ®/™ are trademarks of Bausch & Lomb Incorporated or its affi liates. © 2015 Bausch & Lomb Incorporated. All rights reserved. Printed in USA. US/ZYL/15/0013 Dr. Safran recommended suture support for the capsular bag/IOL complex be performed at the time of cataract surgery if the zonules are compromised and it's likely the patient will require a "secondary sur- gical intervention for dislocation or symptomatic pseudophacodonesis at a future date otherwise." If once the IOL is in place and the OVD removed "things look stable without significant pseudophacodonesis," he may forsake suturing, especially in an older, less active patient. "I find it difficult to know exact- ly how many clock hours of zonules are missing or damaged because I can't always directly inspect them, so I go by how the capsular bag feels to me during rhexis forma- tion, phacoemulsification, and the amount of stability that is present once the IOL is in place and the viscoelastic removed. If in doubt I'll lean toward adding suture support," he said. Dr. Ahmed said if the clock hours of dialysis are superior or if the bag is "very mobile," then he'll suture, and he errs on the side of caution in cases of pseudoexfolia- tion where he's quicker to use and suture a segment. "The tissue in those eyes is very poor; pseudoexfoliation affects all the zonules and it's not necessarily a localized issue," he said. Finally, these experts agreed watching patients carefully for the first month is recommended, and perhaps be a bit quicker to use a laser to disrupt anterior capsule contraction after 1 month. EW Editors' note: Dr. Ahmed has finan- cial interests with Alcon (Fort Worth, Texas), Abbott Medical Optics, and Bausch + Lomb (Bridgewater, N.J.). Dr. Cionni developed the modified Cionni ring (Morcher, Stuttgart, Germany). Dr. Henderson has financial interests with Alcon, Abbott Medical Optics, and Bausch + Lomb and developed the Henderson ring (Morcher). Dr. Safran has no financial interests related to this article. Contact information Ahmed: ike.ahmed@utoronto.ca Cionni: (801) 266-2283 Henderson: BAHenderson@eyeboston.com Safran: safran12@comcast.net

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