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Consultation section
CONSULTATION SECTION
f The original cataract procedure was performed with
f Although the patient remains at high risk because of
the specter of continual seeding of the ocular surface by several potential pathogens emanating from the mouth of the Jones tube. Fortunately, the case was performed successfully, with the refractive error the only remaining problem. The use of ciprofloxacin topically and systemically is important to continue for the next surgery. However, I prefer ofloxacin topically because of increased anterior chamber penetration and ofloxacin systemically because of a decreased incidence of resistant organisms when compared with systemic ciprofloxacin. How would I deal with this disappointed patient? I would perform hyperopic LASIK at no cost to the patient. This has the advantage over photorefractive keratectomy of presenting a much smaller epithelial wound, allowing for rapid visual rehabilitation in 24 hours or less. The small epithelial defect created by LASIK is unlikely to develop an infection, even in a contaminated theater. This is the result of our close observation and liberal use of topical fluoroquinolones. In this patient, performing holmium laser LTK (Sunrise Technologies) might be less traumatic. Theoretically, it would not leave the patient with corneal epithelial defects. However, the early results of this laser suggest that 2.75 D may be a little too much error for it to handle, and present experience seems to indicate that 1.00 or 1.50 D would be the limit of its usefulness. This patient has positive cultures in the area of the Jones tubes for P aeruginosa, S aureus, and M catarrhalis. The presence of these organisms is ominous for successful cataract surgery. In view of this problem with regard to the incorrect IOL, a common course of action would be to remove the IOL by bisecting it in the anterior chamber and then replacing it. Yet, in the face of a chronic ocular surface problem that could lead to intraocular infection, I think secondary lens replacement or piggyback IOL implantation is contraindicated. In summary, I think this patient would benefit from hyperopic LASIK, my first choice for visual rehabilitation. Second, for the next cataract surgery, I would prescribe the same antibiotics and perform a scleral tunnel procedure.
the bilateral Jones tubes, I favor an IOL exchange for the ametropia if the same preoperative management is used as in the first operation. My reasons are as follows:
HENRY D. PERRY, MD Rockville Centre, New York, USA
1. Especially in the case of a foldable lens, IOL exchange can be done through the same small incision. 2. The probability of reaching the target refraction this time is high. 3. Refractive corneal measures carry an equally high risk of a bacterial infection as the recommended surgery and can only be performed at a later date. 4. An IOL exchange results in quick rehabilitation and supports confidence between patient and surgeon. 5. I do not consider surgery in the other eye with a target refraction of ⫹2.00 D or similar to be adequate. TOBIAS NEUHANN, MD Munich, Germany
f In the case involving an inappropriate hyperopic refractive error postoperatively, my choice for management would be to culture the patient again and treat her both systemically and topically before implanting an appropriately powered Staar Surgical AQ 5010V foldable silicone IOL in the sulcus. This lens has a 6.3 mm optic with polyamide haptics, is stable in the sulcus, and is available in minus powers. This method could result in a rapid surgical procedure with minimal risk because one can inject the lens with a cartridge through a 2.5 mm incision. This would address the patient’s intolerable anisometropia and allow for continued delay in addressing the cataract in the fellow eye. I. HOWARD FINE, MD Eugene, Oregon, USA
f First, it would be important to know the actual uncorrected visual acuity (UCVA) in the problem eye because not every eye refracted with ⫹2.75 D has the same vision. If UCVA were 20/40 or better, I would first consider performing surgery in the fellow eye with the goal of leaving it with ⫹1.00 D. I would ensure the patient fully understood the problem. If UCVA were worse than 20/40, the problem eye must be corrected. I would never do corneal refractive
J CATARACT REFRACT SURG—VOL 26, SEPTEMBER 2000
1275
f The original cataract procedure was performed with
f Although the patient remains at high risk because of
the specter of continual seeding of the ocular surface by several potential pathogens emanating from the mouth of the Jones tube. Fortunately, the case was performed successfully, with the refractive error the only remaining problem. The use of ciprofloxacin topically and systemically is important to continue for the next surgery. However, I prefer ofloxacin topically because of increased anterior chamber penetration and ofloxacin systemically because of a decreased incidence of resistant organisms when compared with systemic ciprofloxacin. How would I deal with this disappointed patient? I would perform hyperopic LASIK at no cost to the patient. This has the advantage over photorefractive keratectomy of presenting a much smaller epithelial wound, allowing for rapid visual rehabilitation in 24 hours or less. The small epithelial defect created by LASIK is unlikely to develop an infection, even in a contaminated theater. This is the result of our close observation and liberal use of topical fluoroquinolones. In this patient, performing holmium laser LTK (Sunrise Technologies) might be less traumatic. Theoretically, it would not leave the patient with corneal epithelial defects. However, the early results of this laser suggest that 2.75 D may be a little too much error for it to handle, and present experience seems to indicate that 1.00 or 1.50 D would be the limit of its usefulness. This patient has positive cultures in the area of the Jones tubes for P aeruginosa, S aureus, and M catarrhalis. The presence of these organisms is ominous for successful cataract surgery. In view of this problem with regard to the incorrect IOL, a common course of action would be to remove the IOL by bisecting it in the anterior chamber and then replacing it. Yet, in the face of a chronic ocular surface problem that could lead to intraocular infection, I think secondary lens replacement or piggyback IOL implantation is contraindicated. In summary, I think this patient would benefit from hyperopic LASIK, my first choice for visual rehabilitation. Second, for the next cataract surgery, I would prescribe the same antibiotics and perform a scleral tunnel procedure.
the bilateral Jones tubes, I favor an IOL exchange for the ametropia if the same preoperative management is used as in the first operation. My reasons are as follows:
HENRY D. PERRY, MD Rockville Centre, New York, USA
1. Especially in the case of a foldable lens, IOL exchange can be done through the same small incision. 2. The probability of reaching the target refraction this time is high. 3. Refractive corneal measures carry an equally high risk of a bacterial infection as the recommended surgery and can only be performed at a later date. 4. An IOL exchange results in quick rehabilitation and supports confidence between patient and surgeon. 5. I do not consider surgery in the other eye with a target refraction of ⫹2.00 D or similar to be adequate. TOBIAS NEUHANN, MD Munich, Germany
f In the case involving an inappropriate hyperopic refractive error postoperatively, my choice for management would be to culture the patient again and treat her both systemically and topically before implanting an appropriately powered Staar Surgical AQ 5010V foldable silicone IOL in the sulcus. This lens has a 6.3 mm optic with polyamide haptics, is stable in the sulcus, and is available in minus powers. This method could result in a rapid surgical procedure with minimal risk because one can inject the lens with a cartridge through a 2.5 mm incision. This would address the patient’s intolerable anisometropia and allow for continued delay in addressing the cataract in the fellow eye. I. HOWARD FINE, MD Eugene, Oregon, USA
f First, it would be important to know the actual uncorrected visual acuity (UCVA) in the problem eye because not every eye refracted with ⫹2.75 D has the same vision. If UCVA were 20/40 or better, I would first consider performing surgery in the fellow eye with the goal of leaving it with ⫹1.00 D. I would ensure the patient fully understood the problem. If UCVA were worse than 20/40, the problem eye must be corrected. I would never do corneal refractive
J CATARACT REFRACT SURG—VOL 26, SEPTEMBER 2000
1275