Advanced Techniques to Optimize Cataract Surgery Outcomes Charlie Ficco, O.D. Clayton Eye Center
Disclosure Speaker / Advisor: Allergan Pharmaceuticals Speaker / Advisor: Vistakon Speaker: Abbott Medical Optics Speaker: Inspire/Merck Pharmaceuticals Advisor: Ista Pharmaceuticals Advisor: Essilor
Pre-Operative Care Comprehensive Exam Accurate Refraction Manual Ks Careful Cornea Evaluation Guttata or other dystrophic changes Dysfunctional Tear Syndrome Blepharitis / MGD +/- Inflammation Careful DFE
Dysfunctional Tear Syndrome Demographics Over 20 million people affected. Baby Boomers: 2000-2030 >65 = 35 mil. To 71 mil. >80 = 9 mil. To 20 mil. 2011: 78 million Medicare eligible 40 million are peri or post-menopausal Females U.S. Census Bureau. International database. Table 094. Midyear population, by age and sex. Available at http://www.census.gov/population/www/projections/natdet-d1a.html.
Dysfunctional Tear Syndrome Clinical Si and Sx Conjunctival injection Anterior/Posterior Blepharitis Abnormal tear meniscus Lissamine Green Staining Fluorescein Staining Rose Bengal Staining
DTS w/ Lid Margin Dz Anterior Blepharitis Telangiectasia Hyperemia Scales, Crusting Madarosis Tear film Debris
DTS w/ Lid Margin Dz Posterior Blepharitis Saponification Meibomitis Lid notching Palpebral Conj. Injection
Mixed Blepharitis
Blepharitis Treatment Warm Compresses 15 min. Lid Scrubs Ocusoft Steri Lid Azasite Combo Meds Tobradex ung Tobradex ST Doxycycline 20-50 mg
Blepharitis Treatment Warm compresses Decreases the viscosity of the meibum Loosens collarettes Must be no less than 15 min. Combo Meds Antibiosis (Staph, Strep) Anti-inflamatory Olson C, Korb D, Greiner J. Increase in Tear Film Lipid Layer Thickness Following Treatment with Warm Compresses in Patients with Meibomian Gland Dysfunction. Eye and Contact Lens. April 2003; 29(2):96-99.
Blepharitis Treatment Azasite (Azithromycin, Inspire) Significant anti-inflamatory properties Mod. NF-kB thus inhibiting MMP9 MMP9 exp. Increases with Level of DTS Doxycycline 20mg - 50 mg Ianaro A, Ialenti A, Maffia P, et al. Anti-inflammatory activity of macrolide antibiotics. J Pharmacol Exp Ther. 2000;292:156-163. Abstract Scaglione F, Rossoni G. Comparative anti-inflammatory effects of roxithromycin, azithromycin and clarithromycin. J Antimicrob Chemother. 1998;41:47-50. Golub LM, Lee HM, Ryan ME, et al. Tetracyclines inhibit connective tissue breakdown by multiple non-antimicrobial mechanisms. Adv Dent Res. 1998;12:12-26.
DTS w/o Lid Margin Dz Level 1 Mild to Mod. Sx no Si Mild to Mod. Conj. Si Counseling / Education Enviornmental mod. Sys. Med. Eval. Preserved Tears Allergy Control
DTS w/o Lid Margin Dz Level 2 Mod. To Sev. Sx Tear film Si Mild K punct. stain Conj. Staining Visual sx
DTS w/o Lid Margin Dz Level 2 Treatment W/O inflammation Unpres. Tears Gels, p.m. ung. W/ inflammation Steroids Cylcosporine A Secretagogues Nutrition supp.
DTS w/o Lid Margin Dz Level 3 Severe Symptoms Marked K staining Central K staining Filamentary K Treatment Tetracyclines Autologous serum Punctal Plugs*
Pre-Operative Care Special Testing BAT K Topography BLPH OCT IOL Master / A-Scan IOL Calculations
Images: Geocities.com Corneal Topography
Brightness Acuity Tester
Potential Acuity Meters
Bright Light Pinhole Test
OCT
IOL Master
Premium IOLs Patient Selection DVa, IVa, NVa most important? Age Profession Ocular Health Patient Education Manage patient expectations Compromise, compromise, compromise!
Premium IOLs Toric IOLs Acrysof IQ (Alcon) STAAR Toric (STARR surgical) 0.75D K astig. or greater LRI for > 3.00D
Premium IOLs Multifocal / Accommodating IOLs Technis Multifocal IOL (AMO) ReZoom Multifocal IOL (AMO) ReSTOR Multifocal IOL (Alcon) Crystalens (B&L)
ReZoom Technis
ReSTOR
Crystalens
Pre-Operative Meds 4 th Gen. Fluoroquinolones Steroids NSAID Tears Continue all others! qid 3 days b/f surg.
C C Phaco Clear Cornea Phaco Incision S/P LASIK
Post-Operative Care Day 1 Va Careful Slit Lamp Examination Goldman Tonometry Complications? TASS (Toxic Anterior Segment Syndrome) IOP Spike Wound Leak Keratitis Endophthalmitis
Post-Operative Care Day 7 Va* SLE* IOP* Meds. D/C Antibiotic in 2 d Steroid, NSAID, Tears continue.** * OU if this is the second eye ** Continue meds. for 8 weeks.
Post-Operative Care Day 21 Va OU Refraction SLE IOP +/- dilate if second cataract is to be removed Use Steroid and NSAID for 8 weeks* * 8 weeks is necessary for pts. who have a tendency to develop complications, i.e. Diabetics and uveitis patients.
COMPLICATIONS T. A. S. S. IOP SPIKES WOUND LEAKS KERATITIS REBOUND ANTERIOR INFLAMATION ENDOPHTHALMITIS
T. A. S. S. Toxic Anterior Segment Syndrome Non infxs inc. ant. seg. inflammation K edema, inc. cell and flare, fibrosis, hypopyon Causes? Inappropriate instrument sterilization Pre-Op. meds. and/or solutions Talc from gloves Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg 2006;32:324--33 American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Registered Nurses. Recommended practices for cleaning and sterilizing intraocular surgical instruments. Fairfax, VA: American Society of Cataract and Refractive Surgery; 2007. Available at http://www.ascrs.com/upload/asornspecialtaskforcereport.pdf.
T. A. S. S. Treatment Antibiotic qid Steroid = q1h NSAID qid Lubrication qid Follow patient daily until you see a clinically significant decrease in a/c rxn.
IOP Spikes Causes Poor clearance of viscoelastic GL patients Steroid responders* 10% of population Treatment Combo Meds. Alphagan P Beta Blockers Topical CAIs Wound Tap
IOP Spikes Clinical Pearls If the patient has a 0.4 C/D or less and IOP is < 30 mmhg no tx may be necessary but check daily. If the patient has a 0.5 C/D or greater treat any spike above 25 mmhg and check daily.
Wound Leak / Keratitis Wound Leak Pressure on CC no suture incision IOP < 10mmHg Ck for Seidel sign Tx Suture Keratitis Dysfunctional Tear Syndrome Preservative Reaction
Tx Keratitis Optimal DTS Tx Pre-Op Increase PF tear usage Stop NSAID!!!!!!
Rebound Uveitis Causes Lack of steroid taper Hx of uveitis Treatment Re-start Steroid, NSAID, and Tears. Taper Steroid
CME Cystoid Macular Edema Irvine-Gass Syndrome Vasogenic / Cytotoxic factors Peri-fov. Breakdown 1-12 mo. p. o. Treatment Steroid NSAID Tears
Endophthalmitis Avg. time of presentation = 9 days Incidence 0.07% - 0.2% Moxi., Gati. = Similar Staph. most common org. MRSA* Strep. second most common Moshirfar M, Feiz V, Vitale A, et. al. Endophthalmitis after Uncomplicated Cataract Surgery with the Use of Fourth-Generation Fluoroquinolones. Ophthalmology April 2007;114(4):686-91.
Endophthalmitis Clinically Increasing a/c rxn. Pain Photophobia Injection Causes Lid disease Poor hygiene Healthcare settings Surgical Instruments
Endophthalmitis Treatment STAT referral to VR Specialist Vitreous cultures Intravitreal Antibiotics Vancomycin (1 mg/0.1cc) and Ceftazidime (2.25 mg/0.1cc) Prognosis depends on beginning Va Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vi-trec-to-my Study Group. Arch Ophthalmol 1995;113:1479-96.
PEARLS Aggressively treat ocular surface disease pre-operatively. Educate patients on si and sx of complications. Use 4 th gen. Fluoroquinolones. Don t be afraid to use the steroid longer for optimal inflammatory control especially in at risk patients.
Pearls Treat IOP spikes > 25 mmhg if C/D is > 0.5. Treat IOP spikes > 30 mmhg if C/D is < 0.4. Time is critical if endophthalmitis is suspected. Manage patient s expectations when suggesting premium IOLs.