2/6/2018. Andrew Siedlecki, M.D.

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1 Andrew Siedlecki, M.D. Siedlecki Cataract and Vision Care Optimization- Improved Uncorrected VA Reduced Spectacle Dependency Minimize Complications Fast Rehabilitation Provide Options for Patients Optometrists are the primary eye care providers and best positioned to know their patients lifestyle and occupational needs. By working with the surgeon as a team, this shared care alliance will result in the best visual outcome. Both parties must ensure that the patients best interests are at the forefront of everything they do. An extension in the trust the OD and MD have in one another is communication. It is always important to keep each other informed about any variation from the norm from the choice of IOL to any complications during the post op period. The choice of surgeon is paramount and OD s should be welcome to observe surgery so they can detail the process with their patients. It is also important to spend time in the clinic to see how the pre and post op care is provided. This will also help in getting to know the staff which improves communication and care. A- When the VA is less than 20/40 B- When the glare testing is below 20/100 C- When a patient can no longer drive at night D- When a NS cataract is 3+ or more E- If a patient s occupational or lifestyle needs are not being met History and Chief Complaint are crucial and part of the operative report. Occupational and Recreational Complaints are vital to understanding how a cataract is affecting the patients lifestyle. Do they golf? Do they like to read? A jeweler, for example, would not be able to grade diamonds accurately even with a mild NS cataract. The time to refer is when a patients visual needs are not being met. 1

2 Refractive Surgery- Aspheric Corneal Surface Reduces Ability to Target Plano Vitrectomy-Loose Zonules Can Lead to Capsular Rupture or IOL Dislocation Use of Flomax- Poor Dilation and Visualization May Require Iris Ring which can cause irregular pupil and more pigment in A C in post op period Injections for AMD- Can cause loose zonules All of the above may be a contra-indication for a premium IOL and help the OD direct the conversation about IOL options. A- Visual Acuity of 20/40 B- Reduced Contrast Sensitivity C- Glare testing below 20/80 D- Greater than 2+ NS E- When the patients occupational or lifestyle needs are not being met Uncorrected Best Corrected Glare Testing Contrast Acuity alone is quite often not the primary reason for surgery as lifestyle issues vary from one patient to another. Those who need sharp contrast, good night vision as well as color perception can be affected even with vision that is 20/30 or better. Golfers, musicians, interior decorators, painters, photographers as well as jewelers and truck drivers quite are disabled and unable to perform at their desired level even with early nuclear sclerosis. Ptosis Needs Documented Prior to Surgery Entropion and Ectropion May Require Repair Prior to Cataract Surgery Patients often notice ptosis after surgery due to the improved vision so important to document this prior to surgery. Ocular Surface Disorders are quite common in this demographic Treatment Prior To Surgery Is Essential To Achieve The Best Visual Outcome Dry Eye Protocol Should Include PF Drops, Cyclosporins, Omega-3s, as well as punctal plugs and meibomian gland therapy such as LipiFlow 2

3 Dense NS narrows angles and wide dilation can lead to angle closure glaucoma PI helpful prior to surgery to allow more room to work in the AC Cohesive visco elastics such as Healon 5 often used to deepen AC during surgery and protect cornea Look for PXE-Loose Zonules Type of Cataract:Brunescent=Higher Energy and Nucleus Tighter Against Capsule PSC=More Glare and Faster Growing Macular Health Is Essential For Premium IOL s Vitreous Floaters: Will Be More Obvious to Patient After Surgery Peripheral Retinal Disease Could Increase Risk of Retinal Tears May Require Consultation With Retina Specialist A- Corneal Topography B- OCT of Macula C- OCT of Anterior Segment D- Automated Keratometry E- Glare Testing F- Gonioscopy Can Be Affected by Ocular Surface Disease History of LASIK Requires Multiple Corneal Measurements OCT of Macula for Suspected Traction or Degeneration Out of GPCL for One Month Out of SCL for One Week Communicate Results to Surgeon Irregular Astigmatism Common After LASIK Poor Quality Tear Film Creates False Readings Accurate Topography Vital For Good Visual Outcome 3

4 Provides Axial Length and Keratometry Readings which help determine IOL choice Various formulas are used depending on axial length as well as ACD Each IOL has a specific surgeon factor that is part of IOL calculation Provides a variety of useful information including Keratometry readings, axial length, ACD, and white to white corneal measurements to help with calculations. For each patient there is the primary IOL along with two back up IOL s that are calculated. One back up is for a sulcus fixated IOL and one for AC if no zonules Each IOL is available in the OR to cover any circumstance Proper Wound Construction Design Should Induce Minimal Astigmatism Can Move Incision Location Two or Three Plane Incision to Allow Proper Healing Continuous Tear Capsulorrhexis Very Strong and Stable White Cataract May Require Dye to Stain Capsule A- The use of a premium IOL B- A patient with glaucoma as well as a cataract C- Use of the Femto Laser D- Using a surgical device to expand and dilate the pupil E- None of the above 4

5 Dispersive Visco-Elastics Atropine Pre Op Omidria in Irrigation Solution Epinephrine Malyugin Ring Reduces Complications This defines complex cataract surgery which is a different CPT code this is important if you are billing for co-management fee. Optometrist Begins Discussion With Patient Pre Op Testing Will Confirm Options and Contra-Indications Education of Patient Vital To Decision Making Treatment of Ocular Surface Disease Requires Compliance for Best Outcome Excellent For Patients With Minimal Astigmatism at a Single Distance Can Do Mono Vision for Patients With Prior Experience Acrylic Vs. Silicone: Outcomes Identical Macular disease such as epiretinal membrane or macular hole Significant corneal irregularity or scarring History of cme or central serous retinopathy Uncontrolled diabetic retinopathy Prior vitrectomy, retinal detachment or ongoing treatment for AMD Prior refractive surgery especially RK PXE due to potential late IOL dislocation Corneal disease such as Cogan map-dot dystrophy as well as Fuch s dystrophy Prior strabismus surgery with ongoing diplopia that requires prism Excellent for Regular Astigmatism Requires Pre Operative and Intra Operative Alignment Good For Distance and Mid-Range Reading Limited Flexibilty Can Cause Late Movement of IOL and Change in Refraction Aspheric Design Allows Use After LASIK 5

6 Extended Depth Of Focus with Very Good Distance to Near Vision Reduced Complaints of Glare Comes With Astigmatic Correction Tecnis (replaces ReZoom) Multifocal has two different add powers Alcon ReSTOR Multifocal also has two add powers plus astigmatic correction. Now available in clear acrylic as well as blue blocker IOL Good reading with both but reduced contrast due to the design Increased incidence of night time glare with both Ruptured Capsule and Zonular Disruption Hyphema-Can Occur with Use of Ring Especially with Patients on Blood Thinners Iris Trauma-Most Often With Small Pupils High IOP can occur on day one. Most can be treated simply with beta blocker but if great than 40mmHG, surgeon should be notified. Wound leak with Seidel s sign can be treated with bandage contact lens if anterior chamber is formed, IOP stable and VA good. Follow up in 24 to 48 hours. Corneal edema can be present if very dense cataract, small pupil that requires a ring or if patient has prior corneal dystrophy. Usually resolves within one week. Reduced acuity with premium IOL can occur with a widely dilated pupil especially with a multifocal or Crystalens. Reassure patient this will improve. Endophthalmitis-Reduced Vision, Pain and Redness with Hazy Media Usually occurs during first 3-5 days Any patient complaining of pain needs seen immediately. If any signs of reduced VA, increased cells especially in anterior vitreous, fibrin in AC or hypopyon contact the surgeon immediately Cystoid Macular Edema- Sudden Drop in VA around 4 to 6 weeks. Occurs clinically in less than 1% but OCT can identify some CME in as many as 10-20% of patients. Those at risk include diabetics, smokers, patients with known vascular disease, history of iritis or prior macular edema. Topical NSAIDS and steroids reduce risk. May Require Steroid Injection Or TPPV In Rare Instances. OCT and possible FA essential to make diagnosis and if VA below 20/40, contact surgeon. 6

7 A-Visual Acuity less than 20/50 B-Glare greater than 20/100 C-Change in refraction of + or -.75D D-Patient complaints of Fluctuating Vision E-Difficulty driving F-Vision that does not meet the patients occupational or lifestyle needs Can occur quickly in younger patients and those with dense PSC More bothersome for multi-focal and Crystalens patients Refer back to surgeon when patient feels it affects their lifestyle Cataract Surgery Is One Of The Most Successful Surgeries Performed In The US The Number Of Patients Requiring Exceptional Care Continues To Increase Optometrists Need To Be Prepared To Be Involved With Pre And Post Op Care Training And Communication With Surgeon Is Key Ultimate Goal Is Superior Visual Outcome 7