EyeWorld Asia-Pacific March 2012 Issue

44 March 2012 EW RETINA “I don’t think it makes a difference whether we’re using a multifocal IOL or a standard IOL or toric IOL,” Dr. Reichel continued. “I think they all need careful macular evaluations. I think the questions are, can we account for visual acuity and can we be sure there is no underlying maculopathy that may explain part of the vision loss?” Although it might not be feasible to have every cataract patient undergo OCT examination, especially if health insurance or Medicare won’t pick up the tab, Dr. Reichel said it’s important to have a good working relationship with a retina specialist or access to the device to keep track of changes in the back of the eye. “In general, if you’re a comprehensive ophthalmologist or do a lot of cataract surgery, I think it’s good to document the structural changes in the macula,” he explained. “It’s good medicine because it’s for documentation of changes, and we want to educate our patients and say, ‘We’re going to do cataract surgery. I expect this much improvement in vision, but there may be a problem that limits the improvement in vision, or there may be underlying pathology with the human eye that requires vitreoretinal intervention.’” Vision’s potential tested Surgeons can use a potential acuity meter (PAM) test to estimate how much a cataract is affecting a patient’s vision loss, as well as to assess the patient’s potential visual acuity after surgery. The test projects a Snellen chart onto the eye through a small “pinhole” in the cataract. A chart of letters or numbers is then imaged onto the macula to measure its acuity. Prior to the PAM test, a doctor should examine the anterior segment to find the clearest areas of the cataract. The PAM mounts onto the slit lamp, and the background illumination should be used at a low level, according to the device’s operating manual. The microscopic beam of light is focused on the iris of the patient’s right eye, and the operator moves the dot into the pupil while looking through the slit lap. The patient then reads the lines of the chart as far as he or she can. “When a difficult line is reached, it may be necessary to slowly move the light beam to other areas,” the manual states. “Alternately, a new quadrant or even the center of the pupil may be slowly scattered. Further encouragement and repositioning of the beam should be made until the examiner is confident that the patient cannot read any smaller numbers or letters.” Clinicians remain divided on whether the PAM test is ultimately reliable. “I find it relatively reliable. It does help differentiate patients, meaning a lot of patients do get that much better,” said Anne Fung , MD , Pacific Eye Associates, Consider - from page 42 read a book in the nursery to their grandchild. It’s for people who want to go out to the bank and do their own finances.” “When people come in and bring pictures or a piece of art or tell you a story, it’s just amazing,” said Dr. Hudson. “When you pick the right candidate, it’s one of the most rewarding things ever, as rewarding as a patient with a retinal detachment getting 20/20 vision back. This is an opportunity to make a difference. It’s a real opportunity for multiple specialties—optometry, comprehensive ophthalmology, vitreo-retinal surgery, and occupational therapy—to take a team approach to go after this one particular disease, central visual blindness from AMD, and make an impact.” EW Editors’ note: Drs. Colby, Hudson, and Primo have no financial interests related to this article. Dr. Kumar is vice president of VisionCare. Contact information Colby: kacolby@meei.harvard.edu Hudson: henhud@msn.com Kumar: chet@visioncareinc.net Primo: sprimo@emory.edu Implantable - from page 27 Will - from page 32 Anxiously - from page 39 phaco surgery, such as rupture of the posterior capsule before completing nucleus fragmentation, it is much easier for them to either make a new, larger incision or extend the same opening and deliver the nucleus through the wound. After careful cortical cleanup and anterior vitrectomy, a single-piece PCIOL can be implanted in the sulcus. Phacoemulsification is no doubt a controlled surgical technique which gives extremely predictable results. However, due to many reasons the application of this technique as the only technique in our situation is not possible. It is very important for our young ophthalmologists to master the technique of MSICS so that they can serve the community. Finally, cataract surgery is one of the most dynamically evolving branches of medicine. We should be open to future developments and training procedures may continue to evolve in the future. The basic objective is to give the best to the patient. EW Contact information Braga-Mele: rbragamele@rogers.com Dodick: jackdodick@aol.com Gattey: gatteyd@ohsu.edu Pangputhipong: p annetp@hotmail.com Ruit: sruit@tilganga.com.np riboflavin under the flap and waited awhile and then irrigated again, is there a higher incidence of microstriae?” While he hasn’t heard of any reports that there is, it would certainly be concerning, he said. “We’re waiting for published clinical studies before getting involved with that.” While clinicians in the U.S. wait for FDA approval, Dr. Donnenfeld said: “In the meantime, I don’t think it’s fair to our patients to allow them to develop progressive keratoconus and ectasia. Any patient who comes in to a clinician’s office with progressive corneal thinning and ectasia should be directed to a doctor who is performing this treatment or sent abroad to another country where it’s approved. We can’t wait any longer and allow our patients to be needlessly harmed by the lack of approval of riboflavin UV crosslinking.” EW Editors’ note: Drs. Donnenfeld, Stein, and Stulting have no financial interests related to this article. Contact information Donnenfeld: 516-766-2519, eddoph@aol.com Stein: 416-960-2020 , rstein@bochner.com Stulting: 770-255-3330, dstulting@woolfsoneye.com California Pacific Medical Center, San Francisco, Calif., USA. “It is reflective of the post-cataract outcome in my experience.” Dr. Ober said he uses the PAM test, but he considers it “a rough test.” “There’s a lot of things that could make a PAM give an underestimate of the vision,” he said. “Rarely I’ve had it overestimate vision, although it’s hard to tell if there wasn’t some other factor that changed during the surgery. I think it’s a rough estimate, but we can sometimes get better vision with a PAM in a patient who has macular edema than we could without the PAM, even after cataract surgery.” Dr. Reichel said he falls in the “not terribly reliable” camp when it comes to the PAM test. “A negative PAM test doesn’t necessarily mean we are going to have an unexpected poor visual result after cataract surgery,” he cautioned. Still, he said, it is the “best test for determining visual acuity that’s related to cataract, although if the patient has a maculopathy, his vision could still be poor, despite doing the test.” EW Editors’ note: Drs. Fung, Ober, and Reichel have no financial interests related to this article. Contact information Fung: 415-923-3918, annefungmd@yahoo.com Ober: 757-622-2200, obermike@gmail.com Reichel: 617-636-1648, ereichel@tuftsmedicalcenter.org