Complications in Refractive Cataract Surgery

Educational Objectives

The goal of this program is to improve the management and use of the femtosecond laser (FSL) in cataract surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Analyze case studies in complicated refractive cataract surgery.

 

Summary

Complications in Refractive Cataract Surgery

Case 1: typically, keratometry measurements in postmyopic laser in situ keratomileusis (LASIK) lead to underestimation of IOL power; 51-yr-old man reported blurry vision in left eye (OS); had history of LASIK and bilateral cataract extraction; pre-LASIK refraction reported as -5.00 sph right eye (OD) and -4.50 sph OS; preoperative keratometry measurements noted as -3.00 sph OD and -1.00 sph OS; he underwent bilateral cataract extraction and at postoperative month 1, OD plano but OS surprisingly myopic with IOL in bag bilaterally; options for management of this refractive surprise include LASIK enhancement, surface ablation, piggybacking lens, use of spectacles or contact lenses, or lens exchange; patient opted for lens exchange, and on postoperative day 1 had 20/20 vision OS

Case 2: after radial keratotomy (RK), IOL power often underestimated, leading to hyperopia after cataract surgery; 48-yr-old man presented with desire for better vision; had history of RK in 1986; in 2006, he has consecutive hyperopia with astigmatism, particularly in OD; he had good spectacle-corrected vision, but could not tolerate spectacles due to his anisometropia, and patient not interested in contact lenses; topography showed 8 fairly regular RK incisions; techniques to minimize risk for RK wound dehiscence during cataract surgery include lowering infusion pressure, operating between radial incisions, and using scleral tunnel in lieu of corneal tunnel; postoperatively, patient still had hyperopia; at 5 mo postoperatively, he reported halos at night with vision worsening throughout day; options for management included LASIK, photorefractive keratectomy, IOL exchange, or piggyback lens; patient opted for piggyback lens; Holladay formula or Masket nomogram (speaker’s preference) used to calculate IOL power; speaker prefers Staar AQ 5010 IOL for piggybacking because its silicone composition reduces chance of interface opacification with underlying acrylic lens, and it folds easily into sulcus; postoperatively, patient’s vision much improved; Staar AQ 5010 IOL has large 6.3-mm optic with 14.0-mm diameter; important to order cartridge and inserter to assist with folding

Case 3: 70-yr-old man with mixed astigmatism, decreased best corrected vision, and bilateral cataracts; topography noted as irregular, perhaps due to forme fruste keratoconus or pellucid marginal degeneration; speaker decided on phacoemulsification and toric lens implantation bilaterally; postoperative uncorrected vision very good

 

Readings

Suggested Reading

Bali SJ et al: Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012 119:891-9; Conrad-Hengerer I et al: Effect of femtosecond laser fragmentation on effective phacoemulsification time in cataract surgery. J Refract Surg 2012 28:879-83; Conrad-Hengerer I et al: Femtosecond laser-assisted cataract surgery in eyes with a small pupil. J Cataract Refract Surg 2013 39:1314-20; Dick HB et al: Laser cataract surgery: curse of the small pupil. J Refract Surg 2013 29:662; Nagy ZZ et al: Complications of femtosecond laser-assisted cataract surgery. J Cataract Refract Surg 2014 40:20-8; Nagy Z et al: Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg 2009 25:1053-60; Reinstein DZ et al: Lenticule thickness readout for small incision lenticule extraction compared to artemis three-dimensional very high-frequency digital ultrasound stromal measurements. J Refract Surg 2014 May;30(5):304-9; Ruckl et al: Femtosecond laser-assisted intrastromal arcuate keratotomy to reduce corneal astigmatism. J Cataract Refract Surg 2013 39:528-38; Shah R et al: Results of small incision lenticule extraction: All-in-one femtosecond laser refractive surgery. J Cataract Refract Surg 2011 Jan;37(1):127-37; Shen Y et al: Comparison of corneal deformation parameters after SMILE, LASEK, and femtosecond laser-assisted LASIK. J Refract Surg 2014 30:310-8; Titiyal JS et al: Toric intraocular lens implantation versus astigmatic keratotomy to correct astigmatism during phacoemulsification. J Cataract Refract Surg 2014 May;40(5):741-7; Vaddavalli PK et al: Complications of femtosecond laser-assisted re-treatment for residual refractive errors after LASIK. J Refract Surg 2013 29:577-80; Yoo SH, Al-Ageel S: Femtosecond laser (WaveLight FS200) customized keratoplasty for keratoconus: case report. J Refract Surg 2012 28:S826-8; Yoo SH, Hurmeric V: Femtosecond laser-assisted keratoplasty. Am J Ophthalmol 2011 151:189-91; Ziebarth NM et al: Surface quality of human corneal lenticules after SMILE assessed using environmental scanning electron microscopy. J Refract Surg 2014 30:388-93.

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. Yoo is a consultant for Abbott Medical Optics (part of Abbott Laboratories), Alcon, Bausch & Lomb, and Carl Zeiss Meditec. Members of the planning committee reported nothing to disclose.

Acknowledgements

Dr. Yoo was recorded at Eye to the Future: Explorations in Cornea, Cataract, Pediatrics, and Retina, presented by the New Orleans Academy of Ophthalmology, and held March 21-23, 2014, in New Orleans, LA. For more on the upcoming annual symposium presented by the New Orleans Academy of Ophthalmology, scheduled for January 30 to February 1, 2015, please visit noao.org. For further information about continuing medical education from the Bascom Palmer Eye Institute, please visit bascompalmer.org. The Audio-Digest Foundation thanks Dr. Yoo and the Bascom Palmer Eye Institute 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:

OP521604

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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