Eyeworld

EW FEATURE 78 Complex cataract cases October 2015 by Lauren Lipuma EyeWorld Staff Writer AT A GLANCE • Optimize the ocular surface before proceeding with surgery. • With the eye open and access to the angle, cataract surgery is an opportunity to treat glaucoma, and surgeons should take advantage of it. • Avoid multifocal IOLs in patients with persistent dry eye or glaucoma. • Identify risk factors for AMD progression before surgery and communicate those risks to the patient. Be aware of the total preser- vative load you're placing on the ocular surface. Topical medications can be toxic to corneal epithelial cells, so be aware of the total preser- vative load, especially when using generics, Dr. Gupta said. For patients with corneal staining postop, con- sider switching to preservative-free medications or altering the dosage. "I often discontinue the NSAID or lower the dosage, as this class of drugs can be epitheliotoxic in some patients," she said. Recognize that cataract sur- gery is an opportunity—and don't waste it. With the eye open, visco- elastic in place, and access to the angle, cataract surgery is a perfect opportunity to enhance a patient's glaucoma treatment, said Nathan Radcliffe, MD, assistant professor of ophthalmology, New York Univer- sity Langone Medical Center, New York. If a patient has mild glaucoma, 10 pearls for mastering cataract surgery with ocular comorbidities How best to remove cataracts while managing dry eye, glaucoma, or macular degeneration C ataract surgeons now have the tools and techniques to offer their patients bet- ter visual outcomes after surgery than ever before. But with more individuals suffering from glaucoma, dry eye, and age-re- lated macular degeneration (AMD), caring for cataract patients—before, during, and after surgery—becomes far more complex. The presence of dry eye, glau- coma, or AMD increases the risk of complications, but with proper planning and technique, cataract surgeons can achieve good visual outcomes even with these comor- bidities. Here, 4 leading ophthal- mologists share pearls for managing cataracts in the presence of these coexisting diseases. Dry eye and glaucoma Optimize the ocular surface before proceeding with surgery. Dry eye is likely to get worse after cataract surgery, so optimize the ocular sur- face prior to operating and continue treatment after surgery, said Preeya Gupta, MD, assistant professor of ophthalmology, Duke Eye Center, Durham, N.C. Address meibomian gland dysfunction (MGD) as soon as possible with treatments such as thermal pulsation or omega-3 sup- plements. Treat any ocular surface inflammation with topical cyclospo- rine and/or steroids, she added. consider doing endocyclophotoco- agulation (ECP) or an ab interno procedure such as trabecular micro bypass or gonioscopy-assisted transluminal trabeculotomy (GATT). For moderate glaucoma, Dr. Radcliffe recommends combining ECP with an ab interno procedure. For severe glaucoma, think carefully about how to proceed, Dr. Radcliffe said. If the glaucoma is severe but stable, an ab interno procedure could be an option, but if there's higher risk and the glaucoma is less stable, consider combining it with a filtration procedure. "It's in the patient's best interest to get as much out of that cataract surgery as they can," Dr. Radcliffe said. Do everything you can to make sure the surgery goes as smoothly as possible. When oper- ating on a cataract and glaucoma patient, make sure the surgery goes as perfectly as possible, that the IOL is well-placed, and that all the lens material is removed from the eye. "Cataract surgery is a grand transi- tion for any eye, but particularly for an eye with glaucoma," Dr. Radcliffe said. "If the surgery goes well, the patients tend to do well after and the glaucoma tends to be more stable. Problems that occur and are not resolved at the time of cataract surgery for a glaucoma patient will stick with that patient and can tend to be a negative inflection point for the future of glaucoma progression." Keep IOP under control in the intermediate postop period. "I'm fairly aggressive with oral or even in- travenous acetazolamide at the time of cataract extraction, particularly in patients with severe glaucoma," Dr. Radcliffe said. "A perioperative intraocular pressure elevation can present a problem, so we want to do continued on page 80 In a patient with glaucoma who is undergoing cataract surgery, surgeons may want to consider doing ECP or an ab interno procedure at the time of the cataract surgery. Source: National Eye Institute

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