SEP 2012

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

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Page 61 of 103

62 EW FEATURE Managing continued from page 61 "Occasionally, I've seen a hyper- ope end up with post-op myopia, but most of the time it's because the IOL ends up sitting very anteriorly in the eye," she said. "They can be off by as much as 2 or 3 diopters." In general, Dr. Koch treats low myopic surprises (up to –2 D) with PRK and will treat low hyperopic surprises (up to +1 D) with PRK as well. "Anything more than that and I'll exchange the lens," he said. He also prefers to wait 2-3 months for the eye to settle before retreating. Although piggyback lenses are an option, "I try to avoid it because it can cause iris chafing," Dr. Koch said. "Assuming I can open the bag comfortably and the zonules look OK, I'd rather exchange. For IOL exchanges I will have a piggyback lens as a backup in case the bag is too densely scarred to be opened. Fortunately, I have not had to resort to this if the bag is intact." The exception to that rule is in cases of zonular weakness, in which he will try to avoid any additional intraocu- lar surgery. In contrast, Dr. Trattler recom- mended placement of a piggyback IOL in patients with more than 1 D of hyperopia, in case the IOL is slightly mislabeled, or in patients who have had previous PRK or LASIK for large refractive errors. "We know exactly how far off Get There Faster with EYEJET CTR Approved FDA Pre-loaded to Save Time Between Surgeries Single Use Pre-loaded Capsular Tension Ring Disposable Unit Eliminates Sterilization Procedure Available with Standard Morcher CTRs Only Choose Right or Left Insertion For more information, visit fci-ophthalmics.com or call 800.932.4202. ® we are, so it is simple to calculate the correct piggyback IOL power and place the IOL in the sulcus. Have a portfolio of techniques ready to treat these cases," Dr. Trattler said. "Have a plan going into these surgeries," Dr. Talley Rostov agreed. "If an IOL exchange is out of your comfort zone, educate yourself on how to perform them or know who to recommend in your community. If you don't have access to a laser for touch-ups, develop working rela- tionships with surgeons and centers that do have access to them." At continued from page 60 Cystoid macular edema can be a worry in multifocal lens cases. Bonnie An Henderson, M.D., assistant clinical professor, Harvard Medical School, Boston, pretreats high-risk patients with NSAIDs for 3 days prior to surgery. "After surgery, I continue the NSAIDs for 3 months for high-risk patients and for patients who had a complicated, prolonged surgery," she said. Likewise she urged practitioners to guard against decentration in multifocal lens cases. "I recommend operating under topical anesthesia in order to accurately center the IOL with the visual axis of the patient," Dr. Henderson said. "If the IOL is centered based on the pupillary center, angle kappa errors can occur, and if centered on the limbus, angle alpha errors can occur." Therefore, if the patient is under topical anesthe- sia she suggested having him focus on the microscope light and center- ing the light reflex together with the innermost ring of the multifocal IOL. Of course, in some cases it may become necessary to consider an IOL exchange. "If there is a large re- fractive surprise, I will perform an IOL exchange for either monofocals or premium IOL types," Dr. Hender- son said. "The sooner the IOL ex- change, the easier it is to remove the lens." Dr. Henderson will only bring the idea of doing an early Nd:YAG capsulotomy into the equation if she is certain that there will be no need for such an IOL exchange. "If there is a possibility that an IOL ex- change will be needed, I avoid a YAG capsulotomy until after the IOL exchange is performed," she said. Overall, as a backstop, Dr. Henderson believes in testing for eye dominance and operating on the non-dominant eye first in bilat- eral premium IOL cases. "If the pa- tient has difficulty or is dissatisfied with the outcome of the first eye, then a different type of IOL can be implanted in the dominant eye to address what was lacking or disappointing with the first eye's outcome," she said. EW Editors' note: Dr. Colin has financial interests with Alcon (Fort Worth, Texas), Abbott Medical Optics (Santa Ana, Calif.), Addition Technology (Des Planes, Ill.), Thea (Clermont-Ferrand, France), Optical Express (Glasgow), and Bausch + Lomb (Rochester, N.Y.). Dr. Foster has financial interests with Alcon and AcuFocus (Irvine, Calif.). Dr. Henderson has financial interests with Alcon and ISTA Pharmaceuticals (Irvine, Calif.). Contact information Colin: 33-05-56-79-56-08, joseph.colin@chu-bordeaux.fr Foster: 970-221-2222, gjlfos@aol.com Henderson: 781-487-2200, bahenderson@eyeboston.com While refractive surprises are undesirable, they are not insur- mountable obstacles to providing patients with good visual outcomes, Dr. Trattler said. "We have both cornea- and lens-based treatments— an honest, open discussion about the options is the best way to proceed." EW Editors' note: Dr. Koch has financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.) and Alcon (Fort Worth, Texas). Dr. Talley Rostov has financial interests with Addition Technology (Des Plaines, Ill.), AMO, Allergan (Irvine, Calif.), and Bausch + Lomb (Rochester, N.Y.). Dr. Trattler has financial interests with AMO, Allergan, and Bausch + Lomb. Contact information Koch: 713-798-6443, dkoch@bcm.edu Talley Rostov: 206-930-5804 Trattler: 305-598-2020, wtrattler@gmail.com February 2011 Refractive cataract surgery September 2012

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