JAN 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 40 of 71

January 2012 Retina co-morbidity for the anterior segment surgeon February 2011 EW FEATURE Evaluating the risks of retinal detachment in cataract patients by Michelle Dalton EyeWorld Contributing Editor Family history and refrac- tive error are but two risk factors that increase the risk of a retinal detach- ment. Here, retinal experts discuss when—or if—to treat tears and holes R etinal detachments (RD) are more likely to occur in patients with higher myopia, and the risk in- creases if there's a family history of RD or if a patient's fellow eye has had one. In these patients, retinal specialists recommend extra vigilance when looking at the pe- ripheral retina during normal pre-op exams before cataract surgery. Re- fractive lens exchange patients un- dergoing an IOL exchange are also at a higher risk. Complicated cataract surgery—cases involving vitreous loss or capsular rupture—also puts the patient at an increased risk of developing an RD. Another patient group at risk is people who have un- dergone refractive surgery and no longer consider themselves myopic. Anatomically, those eyes are still longer and at risk, retina specialists said. Sometimes, regardless of how meticulous the surgeon is, an RD may still occur. Educating the patient about the signs and symptoms of RD can go a long way toward catching a tear be- fore it becomes a full-blown detach- ment, experts said. "If patients are aware of the signs and symptoms of RD, they'll be less likely to ignore floaters," said Cataract continued from page 40 tions of the multifocal lenses may be different." Dr. Mahmoud advised surgeons to use "regular, single-spot lasers" until adequate safety data on other lasers become available. "At each spot you're trying to look through the center of the mul- tifocal lens or any of the segments," he explained. "Make sure that spot is very focused on the retina, and deliver that spot safely." One tip that could help with vi- sualization is to position the pa- tient's head so that his nasal bridge is not in the way during subsequent laser treatments, allowing you to easily access the nasal side with a vitrectomy probe and any other in- struments used. "Usually, if we're doing a proce- dure that involves peeling, we would like the head to be as straight as possible so it would be easy to focus on the macula and safely peel the membrane and not tilt the head beforehand," he explained. "This step is even more important if the patient has a multifocal lens. The head has to be straight up because in this case, you have to focus through the center of the multifocal IOL to be able to safely peel." EW Editors' note: The doctors interviewed have no financial interests related to this article. Contact information Loewenstein: john_loewenstein@ meei.harvard.edu Mahmoud: thmahmoud@yahoo.com Telander: david.telander@yahoo.com Dr. Fawzi agreed, noting ante- rior segment surgeons should edu- cate patients to pay attention to any floaters, flashing light, or curtain/ veil coming across their visual field in the first few weeks after cataract surgery. What to treat and when Any suspicious lesion in the retinal periphery bears examination and in- vestigation, Dr. Stewart said. Retinal tears should be treated before the patient undergoes cataract surgery, and Dr. Boyer recommended allow- ing the tear to heal for "several weeks" before any other surgery. "Tears put patients at a marked An example of a macula-off retinal detachment Source: David S. Boyer, M.D. David S. Boyer, M.D., clinical professor of ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles. "Wound integrity is crucial as well. If someone has a clear corneal cataract surgery and you see vitreous in the wound, that's a risk factor for retinal tears," said Andrew A. Moshfeghi, M.D., assistant professor of ophthalmology, and medical di- rector, Bascom Palmer Eye Institute, Palm Beach Gardens, Fla. Likewise, if patients do have in- creased risk factors, silicone IOLs and multifocal IOLs can make treat- ment of a detachment more difficult because visualization is hampered, said Amani Fawzi, M.D., associate professor of ophthalmology, Fein- berg School of Medicine, Northwest- ern University, Chicago. Lastly, a younger patient age can also increase the risk, said Jay M. Stewart, M.D., associate professor of ophthalmology, School of Medicine, University of California, San Fran- cisco. "A study by Ripandelli and co- workers published in Ophthalmology in 2007 found that younger patients had a higher likelihood of develop- ing a retinal detachment following cataract surgery, and most post- operative posterior vitreous detach- ments occurred in young patients."1 Patients who seek treatment "too late in the course of the disease because they're unfamiliar with the symptoms" are most likely to have poor visual outcomes as well, Dr. Stewart said. "Once central vision has been impacted by an RD, the outcomes are not as good." increased risk of developing a de- tachment. It takes about 17-18 days to get an 80% bond if you're using lasers to treat," he said. Most horseshoe retinal tears need to be treated immediately, Dr. Moshfeghi said, unless there's ade- quate pre-existing retinal scarring. Drs. Fawzi and Stewart are slightly more cautious, noting they'll follow rather than treat asymptomatic patients. "In most cases, the incidental finding of a hole in an asymptomatic patient with no strong family history or no underlying medical conditions (for example, Marfan's) probably doesn't need treatment," Dr. Stewart said. Everyone agreed, however, that tears are more worrisome than full- on holes, regardless of geography. "People can go their entire life with an atrophic round hole and never need treatment," Dr. Moshfeghi said. What about lattice? Lattice—one of the most common peripheral retina changes—may or may not cause an RD, and hence its treatment is controversial. "Lattice is commonly found in eyes that harbor RD, but may not be a causative agent. And 10-15% of the normal population has lattice," Dr. Moshfeghi said. Lattice puts a patient at a "slightly greater risk" for RD, Dr. Boyer said. Lattice is autosomal dominant, with a variable degree of expressivity. "About one-third of all RDs will have a patch of lattice in it, and many times—about 18-20% of the time—lattice will have holes in it," he said. continued on page 42 41

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