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Co-managing Cataracts in Complex

EyesPaul Phillips M.D.

Sightline Ophthalmic AssociatesSightline Continuing Education

2/25/18

The Cataract Referral(a general side note…)

• A cataract referral form or a brief letter is worth its weight in gold!!

• If you have an opinion regarding the refractive outcome for your patient you should let your surgeon know.

• The more information you give to your surgeon the better.

• What other ocular pathology do you know your patient has? (Glaucoma, AMD, Fuchs, Amblyopia etc…)

• Is your patient nervous or hesitant about surgery?

• Do they have special needs? Timing of surgery?

Goals of Talk• Discuss pre-operative complex cataract findings

• Discuss “complex” post-operative issues

• Video Demonstrations:

• Specific intra-operative issues and considerations in complex cataracts

• Post-operative issues requiring surgical intervention

Pre-operative Evaluation

Pre-Operative Evaluation of the Cataract Patient

• Identification of important pathology

• Patient Education

• Help co-managing ophthalmologist to identify issues

• Examples of pre-op conditions that affect surgery or outcomes

• Zonulopathies (Ectopia Lentis)

• PXF, Marfan’s, Homocystinuria, Ehlers-Danlos, Weill-Marchesani syndrome and other more rare conditions…

• Posterior Polar Cataract

• Uveitis history

• Intumescent-white lens

• Flomax and Narrow angles (Floppy Irises…)

• Axial myopia and Lattice Degeneration.

Zonulopathies and Ectopia Lentis• Ocular conditions

• Trauma (most common cause of Ectopia Lentis)

• Pseudoexfoliation (PXF) (most common zonulopathy)

• Simple Ectopia Lentis (mutations in ADAMSTL4 or FBN1 gene leads to degeneration of zonular fibers.)

• Aniridia, Magalocornea, Axonfeld Riegers, Congenital glaucoma, Syphillis and others…

• Systemic conditions

• Marfan’s

• Homocystinuria

• Weill-Marchesani syndrome, Ehlers-Danlos syndrome and many other more rare..

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Pseudoexfoliation (PXF)

• Age-related systemic disease:

• Highest prevalence at 69-75 years

• More common in females

• Occurs with varied frequency in many populations, but high prevalence in the Scandinavian and Arabic populations

Pseudoexfoliation (PXF)• Ocular manifestations

• Characterized by deposition of PXF fibrillogranular amyloid-like material

• Anterior capsule, zonules, cilliary body, pupillary margin of iris, corneal endothelium, anterior vitreous and trabecular meshwork

• Main findings: Elevated IOP, Poor dilation, Zonular weakness, Endothelial decompensation, posterior synechiae

• PXF is linked to systemic vascular diseases and cardiac abnormalities

• Recent research has found increased TIAs, stroke, heart disease and abdominal aortic aneurysms.

PXF and Cataract Surgery Identifying Risk Factors

• How likely will it be to run into loose zonules and surgical complications? Unfortunately it is very difficult to stratify risk pre-operatively…

• Factors known to influence risk:

• Noted areas of zonular loss or Phacodonesis

• Shallow anterior chamber (<2.5mm)

• Factors suspected to increase risk

• Patient Age (ie. 90yo with PXF compared to 50yo)

• Lens density

• The amount of PXF material has not been proven to be an increased risk factor

PXF - often asymmetrical

MicrospherophakiaMicrospherophakia-Severe laxity of zonules- Spherical shaped lens

-Forward dislocation of lens-Angle closure glaucoma

Weill Marchesani - syndromeBrachydactyly (short fingers and toes)

Short statureJoint stiffness

Some have arrhythmias

Posterior Polar Cataract• Bilateral congenital cataracts

• Autosomal Dominant

• Central dense opacity with “whorl-like” appearance

• Stationary - Well circumscribed

• Progressive - Concentric ring appearance

• Rate of posterior capsule rupture: 26%. Due to:

• Adherence of cat to capsule

• Thinned or absent capsule below lesion

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Posterior Polar cataract with capsule “tear”

Uveitis and Cataract Surgery• Treatment depends on the cause and severity of the uveitis

condition…

• Linked to systemic causes (HLA-B27, Sarcoidosis, IBD…)

• Linked to HSV or VZV

• (Severe vs. Mild) or (Multiple vs. Single) episode

• Bilateral?

• Chronic?

• Patient ideally is being treated for any active systemic issues and in an “ocular quiescent” period for 3-4 months.

Cataract Patient with History of Uveitis• If one mild unilateral previous episode:

• No pre-treatment or simply start topical steroids 3 days before surgery.

• Possibly use more potent steroid: Durezol and add an NSAID

• Follow closely

• If multiple mild episodes or single mild bilateral episode:

• Consider oral steroid (Pred 60-80mg pre-surgery and with taper over week following surgery)

• Durezol q2hrs and NSAID

• If severe past episode or chronic uveitis

• Oral steroids as above. Some advocate IV Solumedrol dose

• Consider sub tenons injection of Kenalog

• Durezol q1-2hrs and NSAID

• In all cases: Watch carefully after discontinuation of steroids for rebound uveitis and CME.

Cataract - History of HSV or VZV Uveitis

• Treatment is the same as for uveitis caused by systemic disease with the addition of an oral antiviral:

• Valacyclovir 500-1000 BID to TID, 1 week pre and 1 week post surgery, then consider low dose (500qday) for a few weeks. (Acyclovir can also be used)

• Really only anecdotal evidence that this is necessary…

Cataract Patient with History of Uveitis

• Other considerations

• Posterior synechiae are often present and must be lysed during surgery.

• Careful manipulation of iris, when possible, is ideal to avoid unnecessary trauma and increased blood aqueous barrier break down.

• Low endothelial cell counts may be present due to previous inflammation. Low phaco energy and gentle surgical manipulation is ideal.

Intumescent Cataract• Mature cataract that

becomes swollen due to osmotic effect of degenerated lens proteins.

• Rapidly progressing cataracts

• Uncontrolled diabetes

• Chemotherapeutic agents

• Idiopathic?

• May lead to the dreaded “Argentinian Flag” Sign

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“Floppy Iris Syndrome”• Flomax (Tamsulosin) is a specific

Alpha-1A Adrenergic receptor antagonist

• Relaxes smooth muscle tone to allow urinary outflow

• Other non-specific Alpha adrenergic antagonists have been implicated, but not as problematic.• Cardura, Hytrin, Rapaflo, Uraxatrol,

Requip, Mianserin, Labetalol, Saw Palmetto

• Narrow angle eyes: Often just as “floppy” and MORE likely to lead to iris prolapse into the wound.

Retinal Detachment after Cataract Surgery in Axial Myopia• A Large retrospective study evaluated retinal

detachment rate after cataract surgery1

• Normal eyes = 0.32-1.17%

• “Axial myopes” (>27mm) = 1.5-2.2%

• Study Conclusions: There is a higher rate of retinal detachment in this group of patients, but the spontaneous retinal detachment rate in this population is similar…

• Some studies link younger age and axial myopia with a higher rate of retinal detachment

• Previous Posterior Vitreous Detachment (PVD) is known to be protective.

• Younger patients are less likely to have had a PVD already and this may explain the higher rate of RD in younger myopes having cataract surgery…

Retinal Detachment after Cataract Surgery in Axial Myopia

Should Asymptomatic Retinal Breaks and Lattice Degeneration be treated with

Prophylactic laser?

• C.P. Wilkinson et al. Conducted review of literature in 2000 and published in Ophthalmology

• Conclusion: “Current literature regarding prevention of retinal detachment does NOT provide sufficient information to support strongly prophylactic treatment of lesions other than symptomatic flap tears.”

• “Asymptomatic tears with vitreous traction maybenefit from laser”

• However, this study was not evaluating patients who were soon to undergo cataract surgery…

So what should we do with our cataract patients with axial myopia?

• Education is key

• The patient must understand their true increased risk of spontaneous RD and the possible increased risk of RD after cataract surgery, especially if no PVD present.

• Flashes, Floaters or Veils = Immediate evaluation

• What if extensive Lattice or Asymptomatic tears?

• I recommend pre-operative retinal evaluation

• Not all tears are equal:

• Asymptomatic tears with vitreous traction may benefit from laser.

• Can you confidently rule out vitreous traction? How good is your scleral depressed retinal exam…Me neither.

• Patient gets to meet the retinal specialist to discuss risks and understand importance of pathology.

Post-operative Evaluation

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Post-op Day 1 “Issues”• Wound leak

• Suspect if low IOP

• Test wounds with wet fluorescein strip

• Inform surgeon

• Bandage contact lens

• Give Aqueous suppressant drops: Timolol, Brimonidine, Dorzolamide etc.

• Educate patient NOT to rub

• Excessive inflammation

• Always consider Endophthalmitis (but not likely day one…)

• TASS - usually inflammation in associating with SEVERE corneal edema

• Discuss with surgeon, Increase steroids and refer back or to retinal specialist

• Corneal Edema - may be normal - pachymetry is useful for following

• Elevated IOP

Post-op day 1 “issues”• Elevated IOP no glaucoma:

• If IOP<35mmHg - usually no treatment (possibly recheck IOP 1-3 days)

• If IOP 35-55mmHg

• Treat with IOP drops and recheck in 1-2 hours

• If improving significantly continue meds and follow up day 2

• If not improving consider “burping” paracentesis (apply Betadine prior to burping for sterility)

• If IOP >55mHg - Find out if complicated surgery. Likely there is retained viscoelastic.

• Diamox 500mg, IOP drops and consider burping or refer back to surgeon if complicated surgery is the cause…

• Elevated IOP and glaucoma: Have a lower threshold for burping and treating, but realize that glaucoma surgeons often have significant pressure elevation after Trabeculecomty or Tube shunt surgery.

Post-op week 1 “issues”• Endophthalmitis

• Must consider if patient calls with worsened vision, pain or redness (not necessary to have all three!)

• Must consider if significant or worsening cellular reaction

• If KP or FIBRIN reaction = Endophthalmitis until proven otherwise…

• Increase antibiotics and steroids (q1/2hr) and emergent referral for “tap and injection” of antibiotics

Post-op week 1 “issues”• Retinal tears and detachments

• Must evaluate any patient with complaints of new flashes, floaters or peripheral visual disturbances - Dilation is required!

• Look for vitreous debris or blood - “where there is smoke there is fire.”

• New IOP elevation

• Treat and keep in mind possible early steroid response

• Corneal edema

• Should be minimal at this point unless very dense cataract, complicated surgery, endothelial disease.

• If diffuse edema: Look for associated intra-ocular inflammation.

• If focal edema: Look for endothelial trauma

• If inferior edema: Consider a retained lens fragment

• Look carefully - ideally with gonioscopy for view of inferior angle.

Post-op week 1 “issues”• Scratch lens

• Now is a good time to take a close look at the lens. Most scratches or “dings” on the lens are asymptomatic.

• Recognition of these findings may help in future if patient complains later of symptoms…

• Dysphtopsias (negative and positive)

• Encourage patient these will resolve…

• Hand holding may be necessary for couple of months

• If still bothered by 3 mo, refer back to surgeon to consider options.

Post-op week 1 “issues”• Missed refractive target

• Refraction at this visit is most important in first eye…

• Inform surgeon to make possible adjustment in lens calculation for second eye

• But, we take one week refractions with a “grain of salt.”

• If a TORIC lens and residual or new astigmatism, check position of lens

• If MULTIFOCAL lens and reading vision is only complaint, get an uncorrected near vision and assess the near point.

• Remember that often final near vision is best once both lenses are placed… but it is important to keep the surgeon informed

• If MULTIFOCAL lens and “glare” is complaint

• Define symptoms: Rings/Halos vs. Streaks of light/Blur

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Post-op (week 1 - month 1) “issues”• Cystoid Macular Edema (CME)

• More common

• After complex surgery (Vit loss, iris trauma, capsule rupture etc…)

• In Diabetics

• In Uveitic eyes

• In eyes with Epiretinal Membrane (ERM)

• Initial treatment:

• Start NSAID (if not already on) or increase dose

• Increase steroid dose or strength

• If improving at one month: continue and treat for one month after resolution.

• If not improving or worsening: consider retinal consult for possible steroid or anti-VEGF injection.

• Keep in mind this is usually a self limit problem unless continued inflammation or vitreous traction

Post-op (week 1 - month 1) “issues”

• Early Posterior Capsular Opacification (PCO)

• Early YAG laser may have a higher incidence of CME

• Ideal to wait a few months, but probably not a significant difference after one month.

• PCO seems to affect vision more in MULTIFOCAL lenses, so if these patients were happy and begin complaining of vision issues, consider YAG.

• This can be tricky: Determining “glare” complaints vs. “halos” as a cause of dissatisfaction is critical…

Post-op beyond 1 month “issues”• Rebound iritis

• Treat with steroids and NSAIDS

• If rebound occurs multiple times or uveitis worsens despite treatment uveitis “work-up” is required.

• If negative work-up, must consider indolent endophtalmitis = p. acnes

• If infectious cause may require lens and capsule removal…

• Consider Uveitis glaucoma Hyphema (UGH) syndrome.

• Especially if “complex” surgery required a sulcus positioned lens

• One piece lenses cannot reside in the sulcus!

• Essentially 100% of these will eventually cause problems and require explantation…

• Consider retained lens fragment: Gonioscopy should be performed to rule this out even months after surgery.

Post-op Long Term “issues”

• Lens dislocation

• More common after complex surgery with sulcus positioned lens

• In-the-bag dislocation is more common in PXF or traumatic cataracts

• General rule

• Stable dislocation with good vision is best left along

• Progressive dislocation or symptomatic (diplopia) dislocations need surgical intervention.

A Few Final Thoughts…• The co-managing optometrist and ophthalmologist must

trust and respect each other!

• Open communication is absolutely necessary.

• The ophthalmologist must be comfortable communicating complications and issues he/she encountered during the surgery.

• The optometrist must be comfortable asking questions about and discussing abnormal post-operative findings with the surgeon and recognize his/her own comfort level with a given problem.

• There is no room for pride or large egos on either side!

• With a team approach we can achieve the best outcomes possible for our patients.

Thank You!My Cell: (412) 287-1962