Eyeworld

EW CATARACT 38 November 2016 by Liz Hillman EyeWorld Staff Writer Meeting the challenges that come with eyes of long axial lengths J ust as eyes with short axial lengths come with their own set of preop, perioper- ative, and postop pearls— as discussed in the "YES Connect" column in the October issue of EyeWorld—eyes with long axial lengths also have special con- siderations for cataract surgery. Just what is a long eye? Each surgeon has a slightly different benchmark. John Berdahl, MD, Vance Thompson Vision, Sioux Falls, South Dakota, said he gives special- ized attention to eyes as they start Cataract surgery in long eyes L ong eyes can present their own specific challenges before, during, and after cataract surgery. For ex- ample, a predisposition to retinal tear and detachment requires heightened concern both preoperatively and postoperatively. Ocular biometry and intraocular lens power selection carries its own inherent pitfalls in these patients. During surgery, reverse pupillary block and weak zonular support of the capsular bag may need to be specifi- cally acknowledged and addressed. In this month's column, we call upon the expertise of John Berdahl, MD, Jessi- ca Ciralsky, MD, and Zaina Al-Mohtaseb, MD. They discuss their approach to surmounting these challenges. In addition, they share at what axial length they start to modify their approach, under what circumstances they might involve their posterior segment colleagues, and how they set expectations for patients regarding postoperative refractive outcomes. One additional pearl: To avoid reverse pupillary block, a simple tip shared with me by Robert Cionni, MD, is to enter the eye with infusion off, place a second instrument or the handpiece tip between the posterior iris and anterior capsule, and then turn on infusion by depressing the foot pedal to position one (not two or three). This maneuver avoids reverse pupillary block altogether. Charles Weber, MD, YES Connect co-editor Excessive dilation and deep anterior chamber once the phaco handpiece enters the eye A second instrument (chopper) is used to lift the iris off the capsule to allow fluid to circulate back to the posterior chamber and "break" the pupillary block. measuring 28 mm or greater in axial length. Jessica Ciralsky, MD, assis- tant professor of ophthalmology, Weill Cornell Medical College, New York, said she'll start altering her decision-making regarding biometry in eyes greater than 26 mm. Preoperative exam A peripheral retinal exam is imper- ative for patients with long axial lengths. If peripheral retinal pa- thology is found, Drs. Berdahl and Ciralsky said they would bring in a retinal specialist for his or her opin- ion prior to cataract surgery. "That's particularly true because we do intravitreal injections. … Because we are putting something in the vitreous, it's ideal to have retinal input sometimes," Dr. Berdahl said. Zaina Al-Mohtaseb, MD, assistant professor, Baylor College of Medicine, Houston, said within the last few months she and her colleagues have been obtaining OCT images of maculas preoperatively, in addition to a dilated retina exam, on all of their cataract patients. "We are placing more premium lenses, including low add multi- focals … and extended depth of focus and toric IOLs," she said. "We want to diagnose any subtle retinal abnormality, such as drusen or ERMs [epiretinal membranes], to avoid putting premium lenses in, since blurry vision, glare, and halos can be magnified in these situations, and to discuss postoperative outcome expectations." Dr. Al-Mohtaseb said she doesn't get a retina specialist involved in all of her highly myopic cases, but if she diagnoses ERM, macular edema, lattice, or retina tears, for example, she will. The risk of retinal detach- ments or tears after cataract surgery is higher in myopic patients and that is important to discuss with them, she said. "I think that it's a comfort level. If you feel comfortable with your peripheral retinal exam and you're treating the patient the way you would treat your mother if she was your patient, then I think you're good to go," Dr. Berdahl said. "But if it was your mom and you would get a peripheral retinal exam by a retinal specialist, then you should. It's one of the best questions we can ask The iris/lens diaphragm returns to its normal position and the pupil is less dilated. Source: Zaina Al-Mohtaseb, MD continued on page 40 YES Connect

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