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EW FEATURE 80 immediate referral to a retina specialist, Dr. Olsen said. Carefully assess the macula for the presence of drusen and search for areas of depig- mentation, geographic atrophy, and areas of pigment hyperplasia. In addition, determine if the patient has untreated wet AMD and assess whether the AMD will limit vision postop because of scarring or atrophy, said Chirag Shah, MD, Macular degeneration Identify risk factors for AMD progression. Conducting a careful preop assessment of the macula is a critical step for every cataract surgeon, said Timothy Olsen, MD, director, Emory Eye Center, Emory University, Atlanta. High-risk clini- cal features, such as the presence of sub- or intraretinal blood, fluid, or hard exudates, should prompt MPH, Ophthalmic Consultants of Boston, and assistant professor, Tufts New England Eye Center, Boston. Consider checking potential acuity meter (PAM) vision in these cases to estimate the macular potential after the cataract is removed, Dr. Shah said, but be aware that PAM is not always predictive of a patient's subjective response. Communicate risks to the patient. The risk of the disease pro- gressing—with or without cataract surgery—is important to communi- cate to each patient, Dr. Olsen said. Careful preop counseling should prepare the patient for future chang- es in macular function and give the patient more realistic postop expec- tations, he said. "It is very important to thor- oughly counsel patients preop- eratively about the possibility of cataract surgery unmasking the nu- ances of their vision," Dr. Shah said. "Patients may note distortion once their cataract is removed because the vision is more clear, not necessarily because their AMD progressed." Refer to a retina specialist when uncertain. If macular features appear atypical or if you're unclear about the severity of the AMD, refer the patient to a retina specialist for a more accurate risk assessment. Retina specialists who are familiar with other clinical signs may be able to better inform the patients of their macular risk and the need for high- dose antioxidant supplements, Dr. Olsen said. "Retina specialists may also help to detect the presence of other conditions that may influence the prognosis such as basal laminar drusen, reticular pseudodrusen, or a pattern dystrophy," he added. Use imaging techniques to your advantage. OCT offers the surgeon a highly valuable tool to explore a clinical suspicion for many other macular abnormalities, Dr. Olsen said, and is extremely help- ful to risk-assess the macula prior to placement of a multifocal IOL. Epiretinal membranes with retinal thickening, vitreomacular traction, and early macular holes are im- portant features to note in an OCT scan that may require vitreoretinal intervention. EW Editors' note: The physicians have no financial interests related to this article. Contact information Gupta: preeya.gupta@duke.edu Olsen: tolsen@emory.edu Radcliffe: drradcliffe@gmail.com Shah: cpshah@eyeboston.com Complex cataract cases October 2015 The FEMTO LDV Z2, Z4 and Z6 are CE marked and FDA cleared and are available for immediate delivery. The FEMTO LDV Z8 is CE marked and pending FDA approval for the use in the United States. For other countries, availability may be restricted due to regulatory requirements; please contact Ziemer for details. THE ONE FEMTO PLATFORM for cornea, presbyopia and cataract. Presenting the unparalleled Ziemer FEMTO LDV Z Models – a technical revolution in ocular surgery. No laser is more precise, more powerful or more progressive when it comes to meeting all your procedural needs in a single platform. With Ziemer's FEMTO LDV Z Models, now you can operate with a modular femtosecond laser system that is easy to configure and efficient to use. www.femtoldv.com Visit us at AAO Booth #955 for Wet Lab Demonstrations. our best to keep the pressure under great control in that intermediate period." Avoid multifocal IOLs in patients with persistent dry eye or glaucoma. Multifocal IOLs require near-perfect optics, so avoid placing them in patients with a consistently dry ocular surface or with glaucoma that involves central vision or could involve central vision in the future. 10 pearls continued from page 78

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