Managing Complications of Cataract Surgery: Lessons Learned

Educational Objectives

The goal of this program is to improve the outcomes of cataract surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Avoid complications associated with a large pterygium in patients undergoing cataract surgery.

2. Correct a decentered IOL by suturing or removing IOL.

Summary

Case example #1: 55-yr-old photographer with bilateral cataracts desired freedom from spectacles; before surgery, right eye had -2.50 D and left had -0.75 D; requested multifocal lenses; surgery performed first on left eye with uncomplicated phacoemulsification; vision 20/25 and J5 at day 1, with unremarkable examination; at week 1, distance vision good with no glare or halos, but near vision J10 and 20/200; multifocal lenses generally provide good uncorrected near vision; at week 2, distance vision of 20/30, but near vision even worse (J16) and patient unable to read more than 20/200; ReSTOR apodized refractive multifocal lens had been injected correctly and centered; no posterior capsule opacification or phacodonesis observed; pupil size normal; caused by suppression — speaker patched unoperated (dominant) eye, and vision improved to 20/20 at distance and J1 at near

Case example #2: 77-yr-old male patient had cataract and quiet 4-mm nasal pterygium; phacoemulsification proceeded normally; before surgery, targeted emmetropia with axial length of 22.8 and ≈1 D of corneal astigmatism (steep at 117°); speaker operates on steep axis, so performed operation at ≈117°; vision 20/400 on day 1 after surgery, with slight corneal edema; at 1 wk, vision remained poor with normal pupil, manifest refraction of +5.5 D -4.50 D giving vision of 20/30; at 1 mo, vision 20/200, manifest refraction unchanged, axial length off by 1 mm, causing hyperopic surprise (≈+3 D); speaker concluded astigmatism caused by pterygium; at 10 wk, patient’s vision had not changed, with flattening seen on topography; after 3 mo, speaker excised pterygium and performed conjunctival autograft; 1 mo later, astigmatism improved (hyperopic surprise remained) but deteriorated again after 3 mo; pterygium had not recurred, and no Salzman degeneration observed; speaker hypothesized problem caused by elastotic weakness resulting from pterygium; treatment options — use contact lenses or glasses or perform corneal incision, lens exchange, or LASIK; speaker performed hyperopic LASIK treatment 6 mo after cataract surgery; fellow eye — hyperopic (+2.25 D) and pseudophakic; speaker planned to correct enough hyperopia to produce ≈+2 D and correct as much astigmatism as possible (astigmatism often recurs, especially in older patients); 4 wk after LASIK, vision improved (≈+3.25 D) with some astigmatism remaining; 1 yr after LASIK, astigmatism had come back, but patient happy with spectacles; effects of pterygium — if >≈3 mm in size and especially if it extends to >45% of radius (fairly central) and within 3.2 mm of visual axis, pterygium can induce astigmatism; injection of mitomycin 4 wk before concurrent removal of cataract and pterygium prevented recurrence in 1 study; β irradiation rarely used; removing large pterygium causes change (steepening after removal related to size of pterygium); speaker recommends removing pterygium first and 3 to 6 mo later performing IOL calculations and cataract surgery; consider using scleral tunnel because clear corneal incision may cause flattening in meridian; scleral tunnel possibly more predictable

Case #3: 66-yr-old patient had uncomplicated cataract surgery 2 yr previously and vitrectomy 10 yr previously for macular pucker; patient noticed fluctuating vision; 1-piece AcrySof lens in capsular bag had decentered centrally; patient had history of pseudoexfoliation; pseudophakodonesis observed on examination in plane of capsular bag; cannot place 1-piece AcrySof lens in sulcus because uniplanar lens can cause abrasion on posterior surface of iris; necessary to either remove or suture lens within capsular bag away from iris (eg, use scleral pocket and suture with lasso technique); speaker initially planned to suture lens; to remove lens, take out entire IOL and capsular bag and place anterior chamber (AC) IOL or suture in posterior chamber (PC) IOL; speaker prefers to suture IOL to iris rather than sclera to minimize trauma to eye; at initial examination, patient’s lens had decentered and appeared flat with some movement but did not go posteriorly into vitreous; by time of surgery, lens had tilted and dangled downward; surgery — speaker recommends scheduling such cases in combination with retina specialist; because patient had had previous vitrectomy and retina specialist unavailable at time of surgery, speaker performed posterior-assisted levitation (PAL) technique with 6.5-mm pars plana incision; injected dispersive viscoelastic but overinflated eye with some egress of viscoelastic; lifted lens with viscoelastic as cushion; used microforceps to hold IOL and make posterior paracentesis; used second instrument to buttress IOL into AC; added more viscoelastic to protect cornea; widened incision to deliver IOL in 1 piece; suturing lens vs AC IOL — outcomes similar, so use most familiar method; always do peripheral iridotomy (PI) and vitrectomy; ensure no strands come through wound; test pars plana incision and suture closed; make sure conjunctiva covered

Readings

Agresta B et al: Visual acuity improvements after implantation of toric intraocular lenses in cataract patients with astigmatism: a systematic review. BMC Ophthalmol 12:41, 2012; Behndig A et al: Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study. J Cataract Refract Surg 38:1181, 2012; Cervantes-Coste G et al: High-cylinder acrylic toric intraocular lenses: a case series of eyes with cataracts and large amounts of corneal astigmatism. J Refract Surg 28:302, 2012; Hill W et al: Simulation of toric intraocular lens results: manual keratometry versus dual-zone automated keratometry from an integrated biometer. J Cataract Refract Surg 37:2181, 2011; Kunavisarut P et al: Accuracy and reliability of IOL master and A-scan immersion biometry in silicone oil-filled eyes. Eye (Lond) Aug 10, 2012 [Epub ahead of print]; Mednick AD, Rocha G: Top 5 pearls to consider when implanting advanced technology IOLs in patients with unusual circumstances. Int Ophthalmol Clin 52:81, 2012; Ouchi M, Kinoshita S: AcrySof IQ toric IOL implantation combined with limbal relaxing incision during cataract surgery for eyes with astigmatism >2.50 D. J Refract Surg 27:643, 2011; Rho CR, Joo CK: Effects of steep meridian incision on corneal astigmatism in phacoemulsification cataract surgery. J Cataract Refract Surg 38:666, 2012; Sahin A, Hamrah P: Clinically relevant biometry. Curr Opin Ophthalmol 23:47, 2012; Shah GD et al: Rotational stability of a toric intraocular lens: influence of axial length and alignment in the capsular bag. J Cataract Refract Surg 38:54, 2012; Rubenstein JB, Raciti M: Management of astigmatism: LRIs. Int Ophthalmol Clin 52:31, 2012; Whang WJ et al: Comparison of postoperative refractive outcomes: IOLMaster versus immersion ultrasound. Ophthalmic Surg Lasers Imaging Aug 2, 2012 [Epub ahead of print]; Yong Park C et al: Predicting postoperative astigmatism using Scheimpflug keratometry (Pentacam) and automated keratometry (IOLMaster). Curr Eye Res Aug 23, 2012 [Epub ahead of print].

Disclosures

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. Henderson is a consultant for Alcon. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Henderson addressed Current Concepts in Ophthalmology 2012, held January 6-7, 2012, in Atlantic City, NJ, and presented by SUNY Downstate Medical Center (to attend the next Current Concepts in Ophthalmology, to be presented January 4-5, 2013, visit www.eyecurrentconcepts.org). The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP502102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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