2/6/2018 RAPID FIRE PANEL: CO-MANAGEMENT OF UNUSUAL SITUATIONS IN CATARACT SURGERY. Andrew Siedlecki, M.D. Richard Orlando, M.D.

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1 POLL QUESTION: HOW DID YOU DEVELOP THE CLINICAL SKILLS TO CO MANAGE RAPID FIRE PANEL: CO-MANAGEMENT OF UNUSUAL SITUATIONS IN CATARACT SURGERY Andrew Siedlecki, M.D. Richard Orlando, M.D. A) Working in an ophthalmology practice B) Optometry School C) Personal Observation in the OR and clinic with a surgeon D) Self taught E) CE Programs F) Online Webinars AGE RELATED MACULAR DEGENERATION OFTEN REFERRED BY RETINAL SURGEON Density of Cataract Reduces Visualization Quality of OCT and FA Poor with Dense Cataract Will Improve Management of AMD Retinal Laser Treatment Difficult with Dense Cataract INTRA-OCULAR INJECTIONS REQUIRES GOOD VISUALIZATION OF VITREOUS PATIENT BENEFITS Improved Peripheral Vision Helps With Balance Reduces Sun Downing in Patients with Dementia Improved Vision in Dim Lighting Reduces Risk of Falling Reduced Glare Which Helps the Better Seeing Eye with Driving Beneficial to Normal Sleep Cycle 1

2 POLL QUESTION: WHAT IS INCLUDED IN YOUR PROTOCOL FOR CHRONIC DRY EYE OCULAR SURFACE DISORDERS A) PF Topical Drops B) Cyclosporin Drops C) Omega 3 Gel Capsules D) Punctal Plugs E) Lid Scrubs F) LipiFlowTreatment Often Related to Specific Medical Conditions Auto-Immune Disease Post Menopausal Women Thyroid Disease Vitamin A Deficiency Diabetes Rosacea MEDICATIONS THAT AFFECT TEAR FILM AFFECT ON PRE OP TESTING Antihistamines Hormone Replacement Therapy Antidepressants Birth Control Pills Diuretics Acne drugs ESSENTIAL TO MANAGE PRIOR TO TESTING AFFECT ON OUTCOMES Treatment Must Be Multi-Faceted Cyclosporin Lid Hygiene Omega 3 Therapy Thermal Pulsation Treatment of any skin disorders Delayed Healing Reduced Contrast and Quality of Vision with Multi-Focal Reduced Depth of Focus with Symfony and Crystalens 2

3 POST OP MANAGEMENT POLL QUESTION: WHEN WOULD I NOT RECOMMEND A PREMIUM IOL TO A PATIENT Long Term Treatment is Essential Patient Compliance is Key Frequent Follow Up Visits Are Vital A) If there is Pseudo- Exfoliation B) Any patient with prior Refractive Surgery C) A history of retinal detachment D) Chronic dry eye E) Flomax use with floppy iris syndrome F) Past history of uveitis PSEUDO-EXFOLIATION TECHNICAL CHALLENGES Usually Very Poor Dilate Often Have Secondary Glaucoma Risk of Zonular Weakness Can Be Very Subtle and Difficult to Diagnose DISLOCATION OF IOL POSSIBLE YEARS LATER IOL OPTIONS Probable Contra-Indication for Multi-Focal IOL Certain Contra-Indication for Crystalens If Zonular Structures Weak, Sulcus IOL Necessary Anterior Chamber IOL Option Should Be Available 3

4 POST REFRACTIVE SURGERY PATIENTS RK Have High Expectations Willing to Pay for Premium IOL s Can Be Difficult to Target to Plano Not Ideal Candidates for Specialty IOL s MULTIPLE ISSUES AFFECT OUTCOME POST LASIK PATIENTS Old RK Incisions Can Rupture During Surgery Very Small Optical Zones With Irregular Astigmatism Can Have Severe Dry Eye Issues Significant Hyperopic Shifts in Post Op Period Refractions Can Change for Months CORNEAL ISSUES Interface Scars Can Reduce Visualization for Surgeon Positive Spherical Aberration Induced for Myopic Lasik Negative Spherical Aberration Induced for Hyperopic Lasik Topography Essential Relative Contra-Indication for Premium IOL s 4

5 ONLINE IOL CALCULATOR TARGET IOL TO REDUCE SA For Myopic Lasik Choose IOL With Negative SA Tecnis ZCBOO For Hyperopic Lasik Choose IOL with Positive SA B and L EnVista Complex Lasik With Scarring Choose IOL With Zero SA B and L LI61AO FLOPPY IRIS SYNDROME FLOMAX Most Common Cause of Floppy Iris Very Poor Dilation Pupil Constricts During Surgery Flomax Use Increasing Every Year Always Ask About Use Even If Not Currently Taking MALYUGIN RINGS SIDE EFFECTS Increased Inflammation When Using Ring Cosmetic Defects in Pupil Irregular or Small Capsulorhexis Centration and Function of Multi-Focal IOL 5

6 CATARACT AND RETINAL SURGERY COMBINED APPROACH ADVANTAGES POST VITRECTOMY CATARACT Allows Better View of Macula for Retinal Surgeon Saves Patient from Having Two Separate Procedures Zonules Are More Stable IOL Can Be Placed In Capsular Bag Very Fast Growing Can Be Very Dense and Difficult to Remove Unstable Zonules May Require Sulcus Fixation or A/C IOL POLL QUESTION: IN REGARDS TO LASER ASSISTED CATARACT SURGERY LASER ASSISTED FEMTO CATARACT SURGERY A) I am not currently working with surgeons performing this procedure B) I have co managed some patients undergoing LACS C) I work exclusively with a surgeon that performs LACS D) I trust the surgeon to determine who is the best candidates for LACS E) Taking a wait and see approach to this technology 6

7 ADVANTAGES Precise Incisions Perfectly Sized Capsulorrhexis Can Soften Very Dense Nuclei DISADVANTAGES TAKE AWAY Increased Expense Increased Surgery Time Very Steep Learning Curve Not Useful In Small Pupil Cases There are always unique clinical situations that requires adjustment in surgery Intra Operative Circumstances can change the surgeons choice of IOL Communication between surgeon and treating OD is vital Documentation of your discussion with patient sets post op expectations Be prepared to work with retinal surgeon in certain cases Outcomes The Same As Phaco Surgery 7