EyeWorld Asia-Pacific June 2011 Issue

June 2011 8 EW FEATURE “It’s particularly important with a progressive disease, like with some corneal disturbances,” she said. “Once patients understand what’s going on in their eye, they’re generally quite happy with their outcomes.” For Dr. Devgan, in the county hospital he will often recommend a combined procedure from the get- go, especially in cases of cataract and retinal disease. “If we perform a vitrectomy first, cataract removal at a later stage is more difficult, so I will often perform both simultaneously, even if the cataract is not a high grade,” he said. Dr. Lane agreed and emphasized the importance of managing patient expectations in co-morbid situations. “You have to clearly explain that they have different diseases, and their outcomes may be different than those of their next-door neighbor who only had a cataract,” he said. “They are at a disadvantage, but they understand that.” For instance, in cases of corneal disease and cataract, removing the cataract alone may save 3-6 months of recovery time, but those patients are still going to need spectacles and “are obviously not candidates for multifocal technology because of their concurrent disease,” Dr. Lane said. In Dr. Donnenfeld’s practice, certain procedures are planned to be sequential, such as Descemet’s- stripping endothelial keratoplasty (DSEK) in patients with borderline corneas, when the procedures are not being performed in the same session as cataract surgery or LASIK after cataract surgery. (For more on elective refractive procedures, see sidebar.) Since DSEK can result in hyperopia, he recommended aiming for –1.0 to –1.5 D of myopia and avoiding using multifocal technology because of the increased contrast sensitivity loss. In contrast to sequential surgery, Dr. Terry said, “If we have determined preoperatively that both the cataract and the cornea are contributing to visual loss, we always do the DSAEK and phaco/ IOL together, reducing the time, expense, and risk of two surgeries.” Cataract and glaucoma Dr. Devgan said he has a “specific algorithm for certain diagnoses, such as neovascular glaucoma.” In those patients, if a drainage tube is recommended, Dr. Devgan performs both the glaucoma and cataract surgeries concurrently if the patient is over age 60. “If the patient is age 50 to 60 and has any significant cataractous changes, we also do the cataract/ IOL surgery at the same time as the glaucoma surgery. If under age 50, we only combine with a cataract/ IOL if there is clearly a visually significant cataract present. This is because the patient is more likely to get a cataract after the glaucoma surgery, and it is difficult to do a controlled cataract/IOL surgery in an eye with a functioning drainage tube,” he said. Dr. Donnenfeld said he is “very interested in and following longer-term outcomes with the micro-invasive glaucoma devices”, even though he is not a glaucoma specialist. The results to date indicated these devices are safe and well tolerated over the long term, and that adds to his comfort as an anterior segment surgeon to have them in his repertoire. “Quality of life is also important, and many glaucoma patients are not compliant with their medication; missing doses could result in subtle visual field loss. I strongly consider combined surgery in patients with cataract and glaucoma even if the glaucoma is well controlled,” he said. For some glaucoma patients, cataract surgery alone will lower pressures enough that a second procedure can be put on hold, Dr. Donnenfeld said. Conversely, he will likely increase the number of combined procedures he performs once the microinvasive devices are approved in the US. “For patients with both primary open-angle glaucoma and cataract, I feel it is better to do a stepwise approach—first fix the cataract and see what happens to the pressure,” Dr. Devgan said. “Then you can go back and do the trabeculectomy if needed.” Because trabeculectomy is a “very invasive procedure with less control of post-op results than other surgeries,” Dr. Devgan believes the future holds more combined cataract and glaucoma device surgeries, such as the iStent (Glaukos, Laguna Hills, Calif., USA), canaloplasties (iScience, Menlo Park, Calif., USA), and suprachoroidal shunts (CyPass, Transcend Medical, Menlo Park, Calif., USA). “Those three will change the game since they are easier to implant and offer a more predictable post-op response,” he said. On occasion, Dr. Donnenfeld said patients with cataract and concomitant glaucoma need even more—a triple procedure consisting of phaco, DSEK, and endolaser for ciliary body ablations. “In the future, I think the microinvasive devices will be used more in these types of cases,” he said. Corneal disease and the lens Visually debilitating corneal disease can present in the presence Co-morbidities continued from page 7 Elective procedures C ombining cataract and refractive procedures may not seem as difficult as treating multiple pathologies, but patients opting for elective surgery “want superior visual rehabilitation and are much more demanding”, Dr. Donnenfeld said. Depending on the initial refractive error, patients may need cataract surgery followed by a LASIK procedure weeks later. “High myopes or hyperopes—especially with astigmatism—will not be helped by conventional cataract surgery to the level they want,” he said. “They’re going to need additional refractive correction, and LASIK can offer a very rapid visual rehabilitation.” Because high myopes are not candidates for LASIK but are for phakic lenses, “you need to provide them with good uncorrected vision, but you can’t leave 2.5 D of astigmatism,” Dr. Lane said. “You’re not going to give them excellent visual results unless you perform a double procedure of phakic IOL implantation and LASIK.” For patients with significant astigmatism (more than 1.00 D), Dr. Yoo’s approach is “to cut the LASIK flap, but not lift it”, she said. “Then I’ll insert the phakic IOL in one eye, wait a week, and put the IOL in the other eye.” About 4 weeks after the second eye surgery, she’ll bring the patient back and perform LASIK on both eyes. “That’s been my approach for years,” she said. “There are some patients who get phakic IOLs who aren’t candidates for LASIK because their corneas are too thin. They may fare better with astigmatic keratectomy or concomitant LRIs at the phakic IOL stage of the surgery.” She said it’s a surgeon’s preference and comfort level in terms of performing combined or sequential surgery in those needing phakic IOLs. For Dr. Lane, the key is to prepare patients that the initial refractive error will warrant additional surgery. “You need to set their expectations,” he said. “Before the advent of the femtosecond laser, we’d make the flaps ahead of time, lift both, and do LASIK after the lens implantation. It used to take a few months from start to finish.” Dr. Donnenfeld now performs LASIK about 1 month after implanting premium IOLs. “One caveat to this is the Crystalens [Bausch & Lomb, Rochester, NY, USA],” he said. “Those need a posterior capsulotomy and about a 4-month wait.” He advised aiming for a myopic residual error, as myopic LASIK corrections are more predictable and can heal more rapidly. continued on page 10