EyeWorld Asia-Pacific June 2011 Issue

3 June 2011 Letter from the Editor Dear Friends P atients undergoing cataract and refractive surgery expect a predictable outcome. Although risks associated with these procedures have certainly diminished, there are situations such as a lack of zonular integrity during cataract surgery or folds in the flap after LASIK that pose additional challenges and are addressed in this issue. Other situations that can be problematic are cases with patients presenting with combined pathology. I chose this topic as the major theme for our current issue as the decision-making process is certainly more complex and requires careful consideration. When a patient with a scarred cornea or early corneal decompensation as well as a significant cataract presents with poor acuity, the surgeon has several options. He or she can elect to perform a transplant prior to, simultaneously with, or after cataract surgery. Initial keratoplasty is attractive as the required IOL power can be more accurately predicted, but the visual recovery is prolonged compared with the classic triple procedure. In many cases, a traumatic cataract surgery can be performed without triggering corneal decompensation. The more rapid visual rehabilitation associated with DSEK has impacted the decision-making process and, increasingly combined phacoemulsification and DSEK, has become the preferred option for patients with cataract and Fuchs’ dystrophy. If the cornea retains clarity, however, even in the presence of extensive guttata, it is still often worthwhile to perform a careful phacoemulsification, possibly avoiding corneal transplantation. Similarly, the decision whether to perform glaucoma surgery alone, combined with phacoemulsification, or delaying glaucoma surgery after cataract surgery has been influenced by the availability of more effective glaucoma medication. Twenty years ago, I often performed combined glaucoma and cataract surgery, but with improved glaucoma medications and an appreciation of the pressure lowering effect of cataract surgery alone, I now perform combined phaco-trabeculectomy infrequently. The more widespread use of antimetabolites and glaucoma drainage devices makes the option of delaying glaucoma surgery more attractive as good control can usually be achieved with these approaches even after cataract surgery has been performed. The availability of toric intraocular implants has had a major impact on our approach to patients who present with cataract and significant pre- existing corneal astigmatism. I have not performed astigmatic keratotomy for many years and now only rarely combine cataract surgery with limbal relaxing incisions. It is interesting therefore to reflect on how new techniques and technology have changed our approach to patients presenting with combined pathologies associated with cataracts and have increased our ability, not only to address the problem of cataract, but also the associated pathology. Our Asia-Pacific panel of experts have provided their own individual thoughts on these issues and I am sure our readers will find their experience and approach to these problems helpful. Warmest regards Graham Barrett, MD President, APACRS Chief Medical Editor, EyeWorld Asia-Pacific