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May Consultation # 5
CONSULTATION SECTION
undercorrection) with a large (O6.0 mm) optical zone diameter and MMC treatment should the stromal surface appear quite regular. I would inform the patient that contact lens correction still might be required postoperatively even if the quality of vision improves. Gu¨nther Grabner, MD Salzburg, Austria
- This young patient has had visual problems, including high myopia and amblyopia, her entire life that are the result of her likely history of anisometropia. The surgery in her right eye has reduced the refractive error but negatively affected the quality of vision in that eye. She now presents with a very significant decrease in vision in the left eye, which is her more important eye as it is the dominant, nonamblyopic, virgin eye. This patient needs cataract surgery with IOL implantation in the left eye. I would not recommend further treatment in the right eye until after the patient’s left eye is fully rehabilitated. For cataract surgery in the left eye, utmost care must be taken to prevent complications and to maximize the patient’s vision. It is an opportunity to correct everything at once: clearing the opacity from the visual axis, reducing the corneal astigmatism, and eliminating a massive amount of myopia while maintaining a high quality of vision. Preoperative preparation would include dosing of topical nonsteroidal antiinflammatory drugs (NSAIDs) to prevent intraoperative miosis, pain, inflammation, and cystoid macular edema. Because of the high level of myopia, the patient is at greater risk for retinal complications from an otherwise routine cataract surgery and, as such, she should be referred to a retina colleague to ensure there are no preexisting breaks or defects requiring prophylactic treatment. Preoperative dosing of a newer generation fluoroquinolone antibiotic may play an important role in preventing infection. For the IOL calculation, I would use a newer generation theoretical formula with a goal of erring on the side of myopia. Because of the high myopia, the IOL will be minus powered and will have to be special ordered. My preference in this situation would be a 3-piece acrylic aspherical IOL with a large optic diameter. For surgery, I would use a diamond knife to create a clear corneal cataract incision temporally, which would correspond to the steep axis of the cornea. This young patient has a soft nucleus with primarily posterior subcapsular changes, so a minimum amount of phaco energy would be required. Fluidic control is the most important aspect of cataract removal as it
763
will determine the ease of the procedure, likelihood of posterior capsule rupture, and postoperative risk for retinal detachment. These young myopic eyes tend to have thinner and more elastic sclera, so overpressurization with the infusion should be avoided by using a lower bottle height. A smaller phaco needle (20 gauge instead of 19 gauge) will ensure that the outflow of fluid does not exceed the inflow, limiting surge. After hydrodissection, the nucleus can be gently prolapsed out of the capsular bag and an ophthalmic viscosurgical device (OVD) injected behind it. This barrier of OVD between the nucleus and the posterior capsule will help minimize the risk for capsule rupture. It is important to avoid depressurizing the globe upon removing the phaco probe or irrigation/aspiration probe from the eye. This sudden depressurizing followed by forceful reinflation puts stress on the vitreous base and likely increases the risk for retinal break and detachment. The IOL should be inserted completely in the capsular bag with 360-degree capture of the optic edge with the capsulorhexis to ensure long-term stability. Use of intracameral antibiotics per the European Society of Cataract & Refractive Surgeon’s study1 is at the surgeon’s discretion. This patient will likely be ecstatic the day after the surgery as her vision will be the best that she has ever experienced. I routinely prescribe a topical fluoroquinolone antibiotic for 1 week, a topical steroid for 3 weeks, and a topical NSAID for 6 weeks. I would refer the patient back to my retina colleague for careful evaluation of the retinal periphery within the first few weeks. Should the patient end up somewhat myopic and not find it useful for her daily activities, this could easily be treated at a later time. (Dr. Devgan is a consultant to Advanced Medical Optics and Bausch & Lomb). Uday Devgan, MD Los Angeles, California, USA REFERENCE 1. Seal DV, Barry P, Gettinby G, et al. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: case for a European multicenter study; for the ESCRS Endophthalmitis Study Group. J Cataract Refract Surg 2006; 32:396–406
- This patient has a distinct problem in each of her eyes, and they should be considered independently based on the patient’s desired optical outcomes from future procedures. The right eye has corneal haze as a result of excessive surface tissue photoablation, high-order optical aberrations (also likely the result of the PRK), and a residual hyperopic and astigmatic error following IOL exchange after cataract surgery–induced hyperopia.
J CATARACT REFRACT SURG - VOL 33, MAY 2007
undercorrection) with a large (O6.0 mm) optical zone diameter and MMC treatment should the stromal surface appear quite regular. I would inform the patient that contact lens correction still might be required postoperatively even if the quality of vision improves. Gu¨nther Grabner, MD Salzburg, Austria
- This young patient has had visual problems, including high myopia and amblyopia, her entire life that are the result of her likely history of anisometropia. The surgery in her right eye has reduced the refractive error but negatively affected the quality of vision in that eye. She now presents with a very significant decrease in vision in the left eye, which is her more important eye as it is the dominant, nonamblyopic, virgin eye. This patient needs cataract surgery with IOL implantation in the left eye. I would not recommend further treatment in the right eye until after the patient’s left eye is fully rehabilitated. For cataract surgery in the left eye, utmost care must be taken to prevent complications and to maximize the patient’s vision. It is an opportunity to correct everything at once: clearing the opacity from the visual axis, reducing the corneal astigmatism, and eliminating a massive amount of myopia while maintaining a high quality of vision. Preoperative preparation would include dosing of topical nonsteroidal antiinflammatory drugs (NSAIDs) to prevent intraoperative miosis, pain, inflammation, and cystoid macular edema. Because of the high level of myopia, the patient is at greater risk for retinal complications from an otherwise routine cataract surgery and, as such, she should be referred to a retina colleague to ensure there are no preexisting breaks or defects requiring prophylactic treatment. Preoperative dosing of a newer generation fluoroquinolone antibiotic may play an important role in preventing infection. For the IOL calculation, I would use a newer generation theoretical formula with a goal of erring on the side of myopia. Because of the high myopia, the IOL will be minus powered and will have to be special ordered. My preference in this situation would be a 3-piece acrylic aspherical IOL with a large optic diameter. For surgery, I would use a diamond knife to create a clear corneal cataract incision temporally, which would correspond to the steep axis of the cornea. This young patient has a soft nucleus with primarily posterior subcapsular changes, so a minimum amount of phaco energy would be required. Fluidic control is the most important aspect of cataract removal as it
763
will determine the ease of the procedure, likelihood of posterior capsule rupture, and postoperative risk for retinal detachment. These young myopic eyes tend to have thinner and more elastic sclera, so overpressurization with the infusion should be avoided by using a lower bottle height. A smaller phaco needle (20 gauge instead of 19 gauge) will ensure that the outflow of fluid does not exceed the inflow, limiting surge. After hydrodissection, the nucleus can be gently prolapsed out of the capsular bag and an ophthalmic viscosurgical device (OVD) injected behind it. This barrier of OVD between the nucleus and the posterior capsule will help minimize the risk for capsule rupture. It is important to avoid depressurizing the globe upon removing the phaco probe or irrigation/aspiration probe from the eye. This sudden depressurizing followed by forceful reinflation puts stress on the vitreous base and likely increases the risk for retinal break and detachment. The IOL should be inserted completely in the capsular bag with 360-degree capture of the optic edge with the capsulorhexis to ensure long-term stability. Use of intracameral antibiotics per the European Society of Cataract & Refractive Surgeon’s study1 is at the surgeon’s discretion. This patient will likely be ecstatic the day after the surgery as her vision will be the best that she has ever experienced. I routinely prescribe a topical fluoroquinolone antibiotic for 1 week, a topical steroid for 3 weeks, and a topical NSAID for 6 weeks. I would refer the patient back to my retina colleague for careful evaluation of the retinal periphery within the first few weeks. Should the patient end up somewhat myopic and not find it useful for her daily activities, this could easily be treated at a later time. (Dr. Devgan is a consultant to Advanced Medical Optics and Bausch & Lomb). Uday Devgan, MD Los Angeles, California, USA REFERENCE 1. Seal DV, Barry P, Gettinby G, et al. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: case for a European multicenter study; for the ESCRS Endophthalmitis Study Group. J Cataract Refract Surg 2006; 32:396–406
- This patient has a distinct problem in each of her eyes, and they should be considered independently based on the patient’s desired optical outcomes from future procedures. The right eye has corneal haze as a result of excessive surface tissue photoablation, high-order optical aberrations (also likely the result of the PRK), and a residual hyperopic and astigmatic error following IOL exchange after cataract surgery–induced hyperopia.
J CATARACT REFRACT SURG - VOL 33, MAY 2007