CATARACT CARE
Educational Objectives
| The goal of this program is to improve the management of cataracts. After hearing and assimilating this program, the clinician
will be better able to:
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 | Account for the higher rate of ocular comorbidity in monocular patients.
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| Discuss characteristics and utility of the Ophtec lens.
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| Manage cataracts in patients with associated medical conditions.
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| Recognize the importance of obtaining a good ophthalmic history before cataract surgery.
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| Utilize fluorescein angiography and optical coherence tomography appropriately in patients with cataracts.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not
a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Miller receives grant
support from Hoya Corporation and Alcon Laboratories and is on the Speakers’ Bureau for Alcon Laboratories. Dr. Gorin
and the planning committee reported nothing to disclose.
Acknowledgments
Dr. Miller was recorded at the 2008 Annual Meeting, Current Trends and Advances in Ophthalmology, held March 27-28,
2008, in Seattle, WA, and sponsored by the Washington Academy of Eye Physicians and Surgeons. Dr. Gorin was recorded
at Controversies in Ophthalmology, held January 12, 2008, in Los Angeles, CA, and sponsored by The Research
Study Club of Los Angeles. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
| CATARACT CARE IN MONOCULAR PATIENTS—Kevin M. Miller, MD, Kolokotrones Professor of Clinical Ophthalmology,
Jules Stein Eye Institute, David Geffen School of Medicine at University of California, Los Angeles
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| Surgical outcome studies: 3 studies; participants functionally monocular, with vision worse than 20/100 in “bad” eye
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| Study 1 (retrospective): cohort of 93 consecutive patients; 10 patients had surgery under general anesthesia; median
best corrected visual acuity (BCVA) 20/60 preoperatively, 20/30 after surgery, and 20/25 at final visit; researchers looked
at etiology for unoperated blind eye (in 13 cases, due to surgical conditions, and in 80 cases, due to medical conditions,
22 of which caused by macular degeneration); medical comorbidity likely present in surgical eye and found almost identical
to blind eye; conclusions—BCVA improved by median of 3 to 4 lines; safety appeared satisfactory; monocular patients
appeared to have unusually high degree of ocular comorbidity
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| Study 2: comparison of 100 consecutive monocular participants with 100 binocular controls matched for age, sex, and date
of surgery (within 2 mo); 13 patients in monocular group had general anesthesia (none in binocular group); for monocular
group, BCVA improved from 20/50 to 20/25 (vs change from 20/40 to 20/20 in binocular group); few patients lost vision in
monocular group (only 1 in binocular group); monocular group required more planned and unplanned surgeries; monocular
group had significantly more comorbidity (83%) than binocular group (which also had high level [60%] of ocular comorbidity);
no difference in likelihood of complications and postoperative procedures; number one complication of
cataract surgery posterior capsule opacification (number one procedure after cataract surgery, neodymium: yttrium-aluminum-garnet
[Nd:YAG] capsulotomy); conclusions—both groups experienced 3-line improvement in BCVA; final BCVA
20/25 for monocular group (20/20 for binocular); monocular group required more planned and unplanned surgeries; rate of
ocular morbidity significantly higher for monocular group
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| Study 3: used Visual Function Index (VF-14) questionnaire as measure of functional vision; scale from 0 (no functional vision)
to 100 (no problems with any task); before surgery, monocular group had average score of 58; after surgery, score 78;
binocular patients improved from score of 83 presurgery to score of 93 postsurgery; monocular patients obtained more
functional improvement because binocular patients have fellow eye that props up functional vision; conclusion—
monocular patients experienced twice as much improvement in functional vision (compared to binocular group), despite
similar gains in BCVA; take-home point—expect more ocular comorbidity that may prompt other surgeries in monocular
patients
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| COMBINED PENETRATING KERATOPLASTY AND IRIS RECONSTRUCTION LENS IMPLANTATION—Dr.
Miller
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| Study of Ophtec 311 iris reconstruction lens: originally intended to recruit patients with congenital aniridia who
also had cataracts; most patients coming to clinical trial had traumatic aniridia; subset of patients had “bad” corneas requiring
penetrating keratoplasties (PKs)
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| Case 1: man punched in eye by person wearing brass knuckles; globe ruptured and contents of eye came out; retina detached;
speaker saw patient 1 yr later with complaints of blurred vision, photophobia, and glare sensitivity; patient had
failed cornea, reattached retina, and macular scar
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| Case 2: woman has retinitis pigmentosa (RP) and central fields ≈10° to 15°; gardening when metal stake impaled eye, resulting
in significant cataract
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| Case 3: woman has worn contact lenses most of her life; inadequate maintenance of contact lenses led to contact lens-induced
corneal ulcer; patient had corneal transplant; also history of cataract surgery; patient subsequently hit in eye by
electrical cord, causing rupture of corneal transplant (lens implant and iris extruded); patient underwent emergengency
surgery to reattach cornea (failed); surgically and traumatically aphakic and aniridic; solution, Ophtec lens
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| Ophtec lens: available in 3 colors (green, blue, and brown); 4-mm pupil; power 10 to 30 diopters (D); 9.5-mm artificial
iris; rigid; 13.75-mm haptic dimension, with suture fixation eyelet holes; advantage of combining with corneal transplantation
that clinician able to drop lens through hole in eye, rather than having to create another opening for implantation;
“open sky” approach simplifies lens implantation; requires preparation of scleral beds into which to suture implant; cornea
removed; speaker uses two 10-0 prolene sutures; concern about late prolene suture breakage; suture does not degrade,
but over time, movement of implant causes mechanical cutting of suture; difficult to center lens; exercise caution when
implanting blue lens implant; patients ultimately need rigid contact lens for best vision; visual acuity (VA) results varied;
several complications seen; simultaneous implantation of Ophtec lens and PK reduced visual disturbances and improved
cosmetic appearance of eyes; long-term safety mixed
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| INTERESTING CATARACT CASE PRESENTATIONS—Dr. Miller
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| Case: patient, 74 yr of age, presented with reduced VA in left eye (LE) in 2001; BCVA 20/40; had 2+ nuclear sclerosis
(NS), 1+ cortical, and 1+ posterior subcapsular (PSC) cataract, consistent with symptoms and BCVA; patient also had
chronic open-angle glaucoma (COAG), which was being successfully treated (ie, pressure well controlled) with timolol
and latanoprost; right eye (RE) had no light perception (NLP), due to complications of age-related macular degeneration
(AMD), choroidal neovascularization, vitreous hemorrhage, ghost cell glaucoma, and ultimately, retinal detachment; after
multiple surgeries, RE phthisical; recommendations—patient likely needs cataract surgery in future; continued observation;
patient returned 3 mo later complaining that vision worsening and getting darker; patient seen for retinal
consultation, and mild pigmentary changes of early AMD noted; no additional treatment recommended; cataract surgery
performed; speaker believes many false-positive and false-negative results with potential acuity testing (not reliable in
presence of macular disease); immediate macular laser photocoagulation failed, and patient developed submacular hemorrhage;
4 vitrectomies later, NLP; take-home message—if first eye had negative course, anticipate similar course in second
eye, even with intervention
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| Previous studies: AMD most common cause of monocular status; in one series, 6% of patients had lost vision at follow-
up of 11.2 mo; if patient monocular and fellow eye lost to complications of AMD, have low threshold for obtaining preoperative
fluorescein angiography (FA) and optical coherence tomography (OCT) or both
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| Case: man, 80 yr of age, with visually significant cataracts in both eyes; seen by speaker in 2003; had severe degenerative
joint disease and severe kyphosis; in examining chair, patient unable to straighten his back sufficiently to place chin in
chin rest; with considerable back-straightening effort, patient only able to elevate head sufficiently to look 30° below horizon
(patient most comfortable when looking at floor); before seeing speaker, patient had consulted another ophthalmologist
who had scheduled him for cataract surgery, which was subsequently cancelled in operating room (OR); previous
ophthalmologist used hoist to lift patient’s legs off operating table and position beneath operating microscope; approach
failed because patient unable to endure lower back pain; on examination, BCVA in RE counting fingers, and in LE, 20/
40-; slit lamp examination (SLE) showed brunescent cataract in RE and moderately dense nuclear and PSC cataract in
LE; to position patient beneath operating microscope, speaker made patient comfortable in supine position by placing 3
pillows under his head and 11 pillows under buttocks and legs, with operating table in reverse Trendelenberg; outcome—
both cataract operations performed uneventfully; postsurgical uncorrected VA (UCVA) 20/20
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| Case: man, 48 yr of age, with multiple myeloma and corticosteroid-induced cataracts; had strabismus surgery at 3 yr of age;
slightly amblyopic in LE; RE dominant and more symptomatic; BCVA in RE, 20/15, and in LE, 20/25-, glaring to 20/40
and 20/40-, respectively; median preoperative BCVA in speaker’s practice, 20/25-; SLE demonstrated 2+ PSC cataract in
RE and 1 to 2+ PSC cataract in LE; Kelman phacoemulsification performed; immersion A scan used to measure axial
length; intraocular lens (IOL) calculated using SRK/T formula; first hyperopic power chosen for target refraction of +0.17
D; preoperative corneal astigmatism 0.88 D; 2 wk after surgery, patient complained of ghost images and blurred vision;
UCVA 20/40-; BCVA 20/15, but slightly hyperopic; speaker performed IOL exchange 2 mo after original surgery; 2 wk
postoperatively, UCVA 20/15-; options for patient included contact lenses, glasses, refractive surgery, and lens exchange
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| Case: woman, 44 yr of age, with myotonic dystrophy, presented to ophthalmology inpatient consultation service in early
1990s; also suffered from severe interstitial lung disease, obesity, cervical kyphosis, and hypothyroidism; patient wheelchair-bound
and O2 -dependent; unable to recline without becoming severely dyspneic; complained of blurred vision and
glare sensitivity in both eyes, related to cataracts; BCVA 20/100 and dense PSC cataracts in both eyes; in OR, patient unable
to recline >15° from vertical position without becoming severely dyspneic; anesthesiology service refused to give
general anesthesia; surgery performed with patient sitting upright on table; instead of using operating microscope, surgeon
used loupes and fiberoptic headlamp illumination system; obtained good red reflex; administered Nadbath and retrobulbar
facial nerve blocks; speaker stood at patient’s side and used patient’s cheek to brace hands for surgery; operated
through inferotemporal clear cornea approach; posterior capsule rent created during phacoemulsification; speaker performed
limited anterior vitrectomy, and 3-piece IOL placed in ciliary sulcus; incision closed with 10-0 nylon suture; surgery
performed in one eye only; postoperative recovery uneventful; 6 mo postoperatively, patient’s BCVA 20/20
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| RETINAL ISSUES FOR THE REFRACTIVE AND CATARACT SURGEON—Michael B. Gorin, MD, PhD, Harold and
Pauline Price Professor of Ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine at University of California,
Los Angeles
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| History: determine whether previous blunt trauma, episodes of transient vision changes, and/or diabetes present; generally,
cataract surgeons not too worried about performing cataract surgery on diabetics (particularly those with minimal
disease), but risk for macular edema increased; issue even in patients who had gestational diabetes; review of systems—
determine if patient had previous surgery or significant medical problems; check for sickle cell trait and hyperextensible
joints (Marfan syndrome and pseudoxanthoma elasticum); ask about herbal exposures (eg, niacin, ginkgo), and antiprostaglandin
and prostate medications; also obtain good family history; in RP, high percentage of patients develop macular
edema spontaneously before surgery; ask about retinal symptoms (eg, flashing lights, light-to-dark or dark-to-light adaptations);
visual hallucinations and images (Charles Bonnet syndrome) major issue in patients with macular degeneration
who have central vision loss; evidence suggests that performing cataract surgery in patient with central vision loss may
improve mobility; Charles Bonnet syndrome may not disappear after cataract surgery; considering cataract surgery for
patient with vision loss from retinal pathology—determine percentage of loss in VA attributable to cataract or macular
disease; check whether visual resolution changes under different lighting conditions; cataract surgery being performed
for variety of patients, representing spectrum of vision (eg, NLP, hand motion); recognition that vision more than acuity
(color perception and light perception important in orientation to daylight or maintaining circadian rhythm); document
goals and patient’s expectations
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| Examination: OCT valuable tool for determining presence of macular edema; ≈50% of patients with macular edema acetazolamide
(eg, Diamox)-responsive; FA useful; OCT and FA especially valuable in diabetics and those with vein occlusions;
speaker rarely (if ever) uses grid lasers in macula for diabetic macular edema (instead, uses combination of anti-
vascular endothelial growth factor [VEGF] therapy and panretinal photocoagulation to ischemic areas and periphery with
ongoing VEGF production); in those patients, anti-VEGF therapy not definitive, but used as adjunct to reduce VEGF production;
visual fields useful to rule out other causes of vision loss; high-resolution OCT gives excellent views of retina;
increasing number of patients with hereditary retinal dystrophies of later onset; while multifocal electroretinography
(mfERG) and full-field ERG involve measuring electrical response of retina, mfERG designed to look at macular function
(valuable tool, particularly in patient with unexplained VA loss); if patient can see blood vessels in eye when light
shined through eyelids, visual potential 20/40 or better (speaker recommends performing test first on eye with better vision)
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| Preoperative management: growing evidence that nonsteroidal anti-inflammatory drugs helpful to reduce macular
edema; speaker uses intravitreal steroids on occasion for patients with RP or diabetics with significant macular edema not
adequately controlled due to cataracts; for diabetics and those with vein occlusions, speaker prefers bevacizumab (Avastin)
or ranibizumab (Lucentis) to intravitreal steroids; speaker recommends panretinal photocoagulation for patients with ischemia,
and retinal surgery if breaks or tears present that need to be addressed
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| Operative issues: speaker not in favor of monovision; timing of surgery for second eye important; obtain OCT if concerned
about postoperative inflammation and risk for CME; do not hesitate to delay surgery until other eye stabilized; in
diabetics, important to control diabetic retinopathy as much as possible before surgery; when such control not possible in
patient with vitreous hemorrhage and dense cataract, speaker uses bevacizumab injections while hemorrhage clearing, before
scheduling cataract surgery; for patient with AMD, OCT recommended if patient has significant drusen and pigmentary
changes (to ensure absence of subretinal fluid); FA more effective than OCT in detecting pathology if cataract
moderately dense; retina specialist should examine patient after cataract surgery; if possible, check all patients for macular
edema before surgery and attempt to treat with acetazolamide (which should be continued through postoperative period);
since number of patients with RP experience visual decline after cataract surgery (for unexplained reasons), do not
follow practice of 6-wk interval between 2 eyes (needs to be extended); minimize light exposure; avoid iris damage; anything
that triggers inflammation inadvisable in patient with RP; avoid postoperative inflammation; choose patients carefully;
goal not always 20/20 vision
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Suggested Reading
Braunstein RE et al: A blue-blocking intraocular lens should be used in cataract surgery. Arch Ophthalmol 123:547,
2005; Carrillo MM et al: Effect of cataract extraction on the visual fields of patients with glaucoma. Arch Ophthalmol
123:929, 2005; Christopoulos V et al: In vivo corneal high-speed, ultra high-resolution optical coherence tomography.
Arch Ophthalmol 125:1027, 2007; Freeman EE et al: Is there an association between cataract surgery and age-related
macular degeneration? Data from three population-based studies. Am J Ophthalmol 135:849, 2003; Fujikado T et al:
Wavefront analysis of eye with monocular diplopia and cortical cataract. Am J Ophthalmol 141:1138, 2006; Hardten DR:
The importance of the refractive aspects of cataract surgery. Am J Ophthalmol 139:906, 2005; Hayashi K et al: Correlation
between posterior capsule opacification and visual function before and after Neodymium: YAG laser posterior capsulotomy.
Am J Ophthalmol 136:720, 2003; Hodge W et al: The consequences of waiting for cataract surgery: a systematic
review. CMAJ 176:1285, 2007; Kiss CG et al: Informed consent and decision making by cataract patients. Arch Ophthalmol
122:94, 2004; Lane SS: Posterior capsule opacification and YAG capsulotomy. Am J Ophthalmol 138:635, 2004; Marcus
EN et al: Medical evaluation of patients before ocular surgery. Am J Ophthalmol 136:338, 2003; Pomberg ML et
al: Functional visual outcomes of cataract extraction in monocular versus binocular patients. Am J Ophthalmol 138:125,
2004; Wilson ME Jr et al: The ongoing battle against posterior capsular opacification. Arch Ophthalmol 125:555, 2007;
Woodcock M et al: Recent advances in customising cataract surgery. BMJ 328:92, 2004.
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