EyeWorld Asia-Pacific June 2011 Issue

June 2011 7 EW FEATURE After trabeculectomy, the eye developed corneal edema When patients have more than one ocular issue, treatment strategies are not as straightforward W hen a patient presents with visually significant cataract and no other ocular issues, the biggest decision facing a surgeon is which type of lens will be the most appropriate for that particular patient. If that same patient presents with additional ocular problems—such as corneal or retinal disease or glaucoma— surgeons must determine which disease is causing the most visual disturbance, if a stepwise approach for the treatment of one disease will alleviate the symptoms of the other, if concurrent or sequential surgery is advisable, etc. For patients best served by a combined procedure, surgeons must also manage patient expectations about visual recovery times and likely acuity. General advice The real issue for clinicians is determining which of the two diseases is more visually debilitating for the patient and who would be a good candidate for a combined procedure, said Stephen S. Lane, MD, medical director, Associated Eye Care, and adjunct clinical professor, University of Minnesota, Minneapolis, Minn., USA. For instance, if a patient presents with a co-morbidity, surgeons must determine which problem is more significant. A patient with both cataract and endothelial cell dystrophy or a patient with a high refractive error and high levels of astigmatism would be treated differently than a patient who presented with only one disease, he said. In eyes with multiple anterior segment problems—and especially in those with retinal co-morbidities—“we need to determine the safest and most effective surgery and emphasize to the patients that, because of the co-morbidities, we can’t guarantee the visual outcome,” said Mark A. Terry, MD, director of Corneal Services, Devers Eye Institute, and professor of clinical ophthalmology, Oregon Health & Sciences University, Portland, Ore., USA. “We have to determine if it is safer to have one extended surgery to treat multiple problems or to treat just the major visual problem and then reassess postoperatively the need for further surgery. It’s all about risk/benefit ratio and patient expectations.” Tempering patient expectations is particularly important in private practice, said Uday Devgan, MD, in private practice, Los Angeles, and chief of ophthalmology, Olive View–UCLA Medical Center, Calif., USA. In the county hospital where he also practices, many patients have not had eyecare visits for years and often have much more serious conditions than the patients he sees in private practice. “That said, some of the world’s most appreciative patients are those who have not been able to afford eyecare in the past and are at a point where they can no longer work because of their poor sight,” Dr. Devgan said. “These expectations are sometimes easier to manage than those of someone with, say, combined cataract and corneal disease.” When patients do present with more than one disease, “the first thing they want to know is what we are going to do for them. I defer a recommendation until after they’ve been evaluated and all the diagnostic tests have been performed,” said Eric D. Donnenfeld, MD, a partner at Ophthalmic Consultants of Long Island, Rockville Centre, NY, USA, and clinical professor of ophthalmology, NYU Medical School, New York, NY, USA. These patients need additional counseling about each of their diseases, how they can be managed, and the risks and benefits of managing the diseases together or separately, he said. “I prefer a stepwise approach to that patient where we diagnose the problem, thoroughly evaluate the problem, provide solution options, and work with the patient to decide what’s best for him or her,” Dr. Donnenfeld said. Ophthalmology is very technology-oriented, with diagnostic tools now available that were not on the market even 5 years ago, said Sonia H. Yoo, MD, professor of ophthalmology, Bascom Palmer Eye Institute, Miami, Fla., USA. For instance, she said, optical coherence tomography “completely changed the way we practice. It’s brought a level of sophistication to our diagnoses. Newer technologies are now emerging that are giving us better ways to differentiate lenticular from retinal from corneal abnormalities.” She also advised surgeons to take the time to explain the various disease states and what the implications of the disease are on the surgery and vice versa. Co-morbidities demand different approaches by Michelle Dalton EyeWorld Contributing Editor AT A GLANCE • In co-morbid cases, determining which of the two (or more) diseases is most visually disturbing will help create a treatment strategy • Spending extra time explaining how each disease affects vision can help ease patient concerns over combined surgery The same eye, post-DSAEK and post-phaco Source: Sonia H. Yoo, MD The eye, post-DSAEK, but before undergoing phacoemulsification continued on page 8