EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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64 EW FEATURE February 2011 Refractive cataract surgery September 2012 Keeping refractive cataract surgery patients happy by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Refractive cataract surgery patients can present unique challenges for surgeons • Surgeons should generally avoid toric or multifocal IOLs in ABMD patients • Surgeons should always have a backup plan in place in case premium IOL plans do not work out • Patients may have a harder time adjusting to multifocal IOLs in one eye if they continuously compare the vision in that eye to vision in their fellow eye Lessons learned from satisfied—and not so satisfied—patients H E ow do you manage diffi- cult and sometimes surprising refractive cataract cases? Although there's no easy answer to that question, some physicians at this year's ASCRS•ASOA Symposium & Congress in Chicago attempted to tackle that dilemma during the "Letting the Cat Out of the Bag" symposium. Sonia H. Yoo, M.D., professor of ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, prepared two difficult cases for attendees to consider. Considering ABMD In her first case, an 83-year-old male patient had cataracts in both eyes and had mild dry eye. The patient had toric lenses implanted. How- ever, the patient and Dr. Yoo had a post-op surprise—anterior basement membrane dystrophy (ABMD) that was asymptomatic pre-op. The ABMD caused the patient to dislike the toric lenses. The experience with this patient prompted Dr. Yoo to share her algorithm for treatment of ABMD patients. If ABMD is mild, Dr. Yoo usually prefers to steer clear of toric or multifocal IOLs. If the patient's post-op vision is less than desired, she will perform a superficial kerate- ctomy. There are also cases where she will treat the cornea first with a superficial keratectomy and then perform surgery. "It's important to emphasize that these patients can be unpre- dictable. Even if they are asympto- matic, you need to stop and counsel the patients carefully," Dr. Yoo said in a recent interview with EyeWorld. Happy with an unpredictable outcome Dr. Yoo's second case presentation was a 65-year-old female with cataracts in both eyes and an iris Source: Sonia H. Yoo, M.D. coloboma in the left eye. "This pa- tient was a high myope with a lot of astigmatism," Dr. Yoo said. She and the patient planned on the use of toric lenses. "Unfortunately, intraop- eratively, it became a complicated cataract surgery with a broken cap- sule. The patient needed a vitrec- tomy and lensectomy, so I ended up putting in a sulcus IOL and limbal relaxing incisions," Dr. Yoo said. Funny enough, the patient was happy with the outcome in the right eye and wanted the same procedure done in the left eye. "I talked to her and said I'd try to do the toric lens in the bag without any disruption," Dr. Yoo said. That second surgery was more successful, and the patient eventually had 20/25 uncorrected visual acuity in both eyes, although visual recovery took several weeks longer to achieve in the first eye. "My lesson learned there was to always have a backup plan," Dr. Yoo said. "Let the patient know that even if you plan for a premium lens, it might not always work out. You have to prepare for all scenarios." Surgery timing, IOL choice in an amblyopic eye At the symposium, D. Rex Hamilton, M.D., associate clinical professor of ophthalmology, and Monthly Pulse Keeping a Pulse on Ophthalmology yeWorld conducted a survey of surgeons to discuss what they would do in various situations after cataract surgery. In regard to femtosecond laser cataract surgery con- cerns, 40% were most concerned about docking of the laser, while 34% were concerned about programming parameters on the laser, and 25% were concerned about adjusting their current nomogram for astigmatism correction. Another question asked what intraocular lens implant sur- geons prefer for placement in cataract surgery in a patient with 1.25 D of astigmatism. The monofocal lens was preferred by the majority of surgeons, with 33% choosing a monofocal toric lens for distance, 26% choosing a monofocal spherical lens for dis- tance, and 20% choosing a monofocal toric lens for monovision. For healthy eyes undergoing cataract surgery, the contrast be- tween lens designs was much less with 35% choosing a mono- focal spherical lens implant and 33% choosing a multifocal lens implant, with 26% choosing a monofocal toric lens implant. W. Barry Lee, M.D., cornea editorial board member