DEC 2012

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

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December 2012 ���The topical steroid can be started at four times daily dosing, with a quick taper. It can be discontinued over 8 to 12 weeks,��� she explained. Dr. Akpek uses preservative-free dexamethasone as well in patients with a very severe ocular surface as a steroid since it would not cause preservative-associated toxicity. Rheumatologist Thomas G. Osborn, M.D., Mayo Clinic, Rochester, Minn., said he and ophthalmologists who treat his patients will use drops and nighttime ointments to make SS patients��� eyes less dry. He also finds that punctal plugs can be successful, albeit sometimes only temporarily. Some SS patients will find their dry eye to be well managed with these various treatments, Dr. Latkany said. In other patients, their dryness is so severe, the treatments help but do not completely stop the dryness. ���Still, their appearance and symptoms should be improved,��� he said. Examining for hydroxychloroquine use A number of SS patients use the disease-modifying anti-rheumatic drug Plaquenil (hydroxychloroquine, Sanolfi Aventis, Bridgewater, N.J.). This drug is also commonly used to treat inflammation in other autoimmune diseases, including rheumatoid arthritis and lupus, Dr. Akpek said. However, macular toxicity is a side effect of the drug, especially in older patients, patients with pre-existing retinal disease, and patients with liver or kidney problems. It���s important to find out if your SS patients are using Plaquenil and if they are, perform a full retinal exam, Dr. Akpek said. An annual retinal screen is recommended after a patient has used Plaquenil for 5 years���sooner if the patient has the other predisposing factors,1 Dr. Akpek said. That said, there���s no reason for patients to stop using Plaquenil just because they will have cataract surgery, Dr. Osborn said. He sometimes sees SS patients who have read about Plaquenil���s side effects and ask if they have to stop the drug prior to cataract surgery. However, he knows of no specific contraindications with cataract surgery. Dr. Akpek also recommends a 10-2 automated visual field test in these patients prior to surgery as well as one of the following tests: optical coherence tomography, multifocal electroretinogram, or fundus autofluorence. These tests can help reveal other possible retinal damage. Intra- and post-op concerns Although the surgery itself should be the same as in non-SS patients, there might be one difference in a select group of SS patients. ���One complication in a small group of Sj��grens patients can be lung problems, such as bronchitis or recurring pneumonia. In these patients, their bronchial moisturizing glands don���t work well. Patients may have a persistent clearing of the throat and a hacking cough. It could be hard to hold them still for surgery if they do that every 15 seconds,��� Dr. Osborn said. Additionally, patients with severe dry eye and SS may have a good deal of corneal epithelial and subepithelial haze because of their poor tear film and ocular surface inflammation. ���The corneal haze might impair visualization during surgery, making it more challenging at times,��� Dr. Akpek said. Dr. Akpek recommends avoiding multifocal or accommodating IOLs in SS patients because of possibly significant glare post-op. She believes toric IOLs are OK if pre-op IOL calculations are consistent and reliable. Although non-steroidal anti-inflammatory (NSAID) eye drops are commonly used in cataract surgery patients, they should be used with care in SS patients because of possible effects on tear secretion and corneal epithelial regeneration, Dr. Akpek said. Dr. Latkany recommends non-generic NSAIDs for SS patients post-op. An SS patient���s vision may fluctuate a bit more than a non-SS patient post-op due to dry eye, Dr. Akpek said. So it may take a bit longer to help the patient settle into the long-term post-op visual acuity. EW Reference 1. Marmor MF, Kellner U, Lai TY, Lyons JS, Mieler WF; American Academy of Ophthalmology. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011 Feb;118(2):415-22. Editors��� note: Dr. Akpek has financial interests with Alcon (Fort Worth, Texas) and Allergan. Drs. Latkany and Osborn have no financial interests related to this article. EW CATARACT 21 Contact information Akpek: 410-955-5214, esakpek@jhmi.edu Latkany: 212-689-2020, relief@dryeyedoctor.com Osborn: 507-284-2511, Theimer.Sharon@mayo.edu The Jorge N. Buxton Microsurgical Education Foundation is pleased to announce its 2013 calendar of EDUCATIONAL TRAINING ACTIVITIES Cataract Surgery for 3rd Year Residents: Tackling Advanced and Challenging Surgical Problems January 5/ open to Greater New York Metropolitan Area third-year residents *DMEK vs. DSAEK Is Thinner Better? April 13/ open to all interested cornea surgeons *Introduction to Phacoemulsification for 2nd Year Residents May 18/ open to Greater New York Metropolitan Area second-year residents Advanced Anterior Segment & IOL Surgery Course October 12/ open to all interested anterior segment surgeons Uveitis for the Comprehensive Ophthalmologist: Updating the Evolving Paradigm October 26 / open to all general ophthalmologists For more information and registration details, please contact: Barbara Aubel, CME Coordinator Institute for Continuing Medical Education New York Eye & Ear Infirmary 310 East 14th Street - ICME New York, NY 10003 Phone: 212-614-8269 E-mail: baubel@nyee.edu *Courses held in the state-of-the-art Jorge N. Buxton Microsurgical Education Center Lab of The New York Eye and Ear Infirmary and sponsored by educational grants as a service to the medical community.

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