From Darkness to Dawn Turning IOL misses into hits eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons ASIA-PACIFIC Vol. 18 No. 2 June 2022 Licensed Publication
EWAP JUNE 2022 3 EDITORIAL Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India EyeWorld Asia-Pacific • June 2022 • Vol. 18 No. 2 In this issue, several contributors address the various reasons for patient dissatisfaction after cataract and implant surgery. Dry eye, dysphotopsia, and reduced contrast due to multifocals are not uncommon but perhaps not as frequent as missed refractive targets. IOL “misses” can be turned into “hits” prior to cataract surgery and selection of lens power during preoperative counseling. With modern IOL formulas, well over 80% of patients are within 0.5 D of predicted power; errors over 0.75 D are quite rare. But regardless of one’s confidence in one’s refractive prediction, it is always wise to counsel patients regarding the risks and limitations of surgery to explain that perfect prediction is not always achievable; although unlikely, spectacles may be required. Similarly, I recommend topography or tomography as well as OCT as essential to preoperative biometry. It is important to identify an irregular cornea which may not be apparent on slit lamp examination. The patient can then be counseled on the possible impact on prediction and increased likelihood of spectacle correction. Patients with extremely short axial lengths should similarly be counselled. Optimizing the corneal surface prior to measurements is another important component. Traditionally, errors in axial length were the most common contributor to refractive surprises. Modern swept-source biometers make this less likely; corneal power estimation errors are now more likely to cause surprises. The use of multiple instruments and methods to obtain a median corneal power prediction can be helpful for toric and spherical power prediction. Postoperative residual astigmatism can be minimized by careful selection of toric lens power as well as care in achieving accurate alignment. If an error occurs, the outcome in the second eye can be improved by taking the first eye’s error into account. It is important to exclude other factors such as residual viscoelastic or measurement errors by repeating biometry and refraction. Having excluded these factors, the refractive prediction can be adjusted by considering the prediction error in the first eye. The adjustment coefficient depends on the IOL formula. For traditional formulas, a value of 0.5 is appropriate, whereas for more modern formulas such as the Barrett Universal, a more modest adjustment coefficient of 0.3 is sufficient; 0.3 times the error in prediction is added to the predicted refraction of the second eye. The most accurate method of correcting an unexpected refractive error is with either PRK or LASIK. Lens options include rotation of the toric lens, a piggyback lens, and exchange. The latter is often preferred for large refractive errors though often simple rotation of a toric IOL is sufficient. The Rx formula available on the APACRS website provides solutions for all three options. An important note is that the Rx formula requires the preoperative phakic anterior chamber depth (ACD) and not the post-surgery ACD. The adjustable IOL not currently widely used in the Asia-Pacific region provides another option. I hope that the suggestions contained in this issue help in preventing and managing unexpected outcomes in your practice.
4 EWAP JUNE 2022 CONTENTS FEATURE From Darkness to Dawn Turning IOL misses into hits 07 IOL power misses: Why, what, and how by Liz Hillman 10 Unhappy patients after cataract surgery: Reasons for dissatisfaction and how to help by Ellen Stodola 12 An algorithm for ‘Getting to Happy’ after cataract surgery by Liz Hillman From Darkness to Dawn 07 – 14 Turning IOL misses into hits REFRACTIVE 15 The value of genetic testing for keratoconus by Ellen Stodola 17 Greater awareness needed about impact of eye rubbing by Liz Hillman CORNEA 22 Nothing to sniff at: Intranasal spray for dry eye by Liz Hillman 03 Editorial NEWS & OPINION 33 Review of ‘Refractive and keratometric outcomes of supervised novice surgeonperformed limbal relaxing incisions: 1-year results’ by Andrea C. Arteaga, MD, Maria Soledad Cortina, MD, Peter MacIntosh, MD 29 The state of SLT: Advancing the technology and its adoption by Liz Hillman 31 Using virtual reality for glaucoma training by Ellen Stodola 24 Signs of rosacea and how to treat by Ellen Stodola GLAUCOMA 19 How refractive procedures impact future implant choices by Ellen Stodola 27 ‘Pinnacle of MIGS-related complications’ dissected by Liz Hillman
References: 1. Rangarajan R, Kraybill B, Ogundele A, Ketelson H. Effects of a hyaluronic acid/hydroxypropyl guar artificial tear solution on protection, recovery, and lubricity in models of corneal epithelium. J Ocul Pharmacol Ther. 2015;31(8):491-497. 2. Davitt WF, Bloomenstein M, Christensen M, Martin AE. Efficacy in patients with dry eye after treatment with a new lubricant eye drop formulation. J Ocul Pharmacol Ther.2010;26(4):347-353. 3. Rolando M, Autori S, Badino F, Barabino S. Protecting the ocular surface and improving the quality of life of dry eye patients: a study of the efficacy of an HP-guar containing ocular lubricant in a population of dry eye patients. J Ocul Pharmacol Ther. 2009;25(3):271-278. 4. Ogundele A, Kao W, Carlson E. Impact of Hyaluronic Acid Containing Artificial Tear Products on Re-epithelialization in an In Vivo Corneal Wound Model. Poster presented at: 8th International Conference on the Tear Film & Ocular Surface; September 7-10, 2016; Montpellier, France. See instructions for use, precautions, warnings and contraindications © 2021 Alcon Inc. ASIA-SYH-2100002
EYEWORLD ASIA-PACIFIC APACRS Publisher: EyeWorld Asia-Pacific Edition (I-- 173-1835) is published µuarterly by the Asia-Pacific Association of ataract E Refractive -urgeons (APA R-), cÉo -ingapore ational Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Printed in Singapore. Editorial Offices: EyeWorldAsia-Pacific Edition\ Asia-Pacific Association of ataract ERefractive -urgeons (APA R-), cÉo -ingapore ational Eye entre, 11 Third ospital Avenue, -ingapore 1È8751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. AdvertisingOffice: EyeWorldAsia-PacificEdition\Asia-PacificAssociationof ataractERefractive-urgeons (APA R-), cÉo -ingapore ational Eye entre, 11 Third ospital Avenue, -ingapore 1È8751, telephone (1-703) 975-7766, email don@apacrs.org. opyright 2021, Asia-Pacific Association of ataract E Refractive -urgeons (APA R-), cÉo -ingapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) È327-8È30, email ewapJapacrs.org. icensed through the American -ociety of ataract E Refractive Surgery (ASCRS), 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003, USA. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. The ideas and opinions eÝpressed in EyeWorld Asia-Pacific do not necessarily reyect those of the editors, publishers or its advertisers. Subscriptions: Reµuests should be addressed to the APA R- publisher, cÉo -ingapore ational Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Back copies: -ubect to availability. ontact the APA R- publisher, cÉo -ingapore ational Eye entre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Requests to reprint, use or republish: Requests to reprint or use material published herein should be made in writing only to the APA R- publisher, cÉo -ingapore ational Eye entre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@ apacrs.org. Change of address: otice should be sent to the APA R- publisher, cÉo -ingapore ational Eye entre, 11 Third Hospital Avenue, Singapore 168751, six weeks in advance of effective date. Include old and new addresses and label from a recent issue. The APACRS publisher cannot accept responsibility for undelivered copies. D number\ PP-17ÈÈÉ07É2013(02255) M I (P) 03É02É2022 CHINESE EDITION Regional Managing Editor Yao Ke, MD Deputy Regional Editor He Shouzhi, MD Zhao Jialiang, MD Assistant Editors Zhouqi, MD -hentu 8ingchao, MD INDIA EDITION Regional Managing Editor S. Natarajan, MD Deputy Regional Editor Abhay Vasavada, MD KOREAN EDITION Regional Managing Editor Hungwon Tchah, MD Deputy Regional Editor Chul Young Choi, MD EDITORIAL BOARD Chief Medical Editor Graham Barrett, MD Chief Publisher Ronald Yeoh, MD Executive Director Kathy Chen athy°VhenJapaVrs°org Publishing Consultant Donald R Long don@apacrs.org PUBLISHING TEAM Senior Staff Writer Chiles Aedam R. Samaniego chiles.samaniego@apacrs.org Production Team Javian Teh Huang Weitian Sunshine Ng Gretel Tan Christine Shimmon Aileen Bian ewap@apacrs.org Chan Wing Kwong, MD, Singapore Ronald Yeoh, MD, Singapore John Chang, MD, Hong Kong SAR Pannet Pangputhipong, MD, Thailand YC Lee, MD, Malaysia Hiroko Bissen-Miyajima, MD, Japan Kimiya Shimizu, MD, Japan Sri Ganesh, MD, India Chee Soon Phaik, MD, Singapore Johan Hutauruk, MD, Indonesia EDITORIAL MEMBERS True-K Formula ToricCalculator Universal II Formula RX Formula True-K Toric available at www.APACRS.org The latest update to the Barrett True K Formula, version 2.5, addresses yet another challenge to IOL power calculations—keratoconus. Selecting the option in the presence of keratoconus significantly improves the prediction of refractive outcomes and avoids unexpected hyperopia. Log on to www.apacrs.org and try it today! BARRETT IOL CALCULATOR NEWUPDATE!
FEATURE EWAP JUNE 2022 7 by Liz Hillman Editorial Co-Director IOL power misses: Why, what, and how A n IOL power miss — is it a complication or not? The answer is nuanced. Some patients experience residual refractive error that is relatively significant and are still happy with their outcome, while others with a seemingly small residual refractive error are unhappy. David Salz, MD, and H. John Shammas, MD, discussed why IOL power misses occur, what the options are for corrective action, and how to avoid such misses in the first place. Dr. Shammas said an error in IOL power calculation is usually suspected when a patient presents postop with unexpected, induced myopia, hyperopia, or aniseikonia. ºWhen we first started using IOLs after cataract extraction 40 years ago, results within This article originally appeared in the April 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. ±2 D were acceptable and deemed superior to any aphakic correction. With the refinement of IOL formulas, patients and surgeons are now expecting a more accurate final refraction in the operated eye. Nowadays, 80% of our patients are expected to be within 0.50 D and 100% within 1 D,” he said. However, Dr. Shammas noted that some patients with 1 D of error are happy with their results while patients with error as low as 0.5 D can be unhappy. “It boils down to patient expectations,” he said. Dr. Salz said that even patients off by as little as a quarter of a diopter can be unhappy if they are very sensitive about their vision. “The misses we dwell on more are when patients are unhappy, though obviously we try to minimize any amount of error period,” he said. Why misses occur Dr. Salz said there is variability within different formulas that can be used to calculate IOL power. “The reality is there is a margin of error for surgery with IOL calculations even with all the technology we now have,” he said. Another source of variability is effective lens position. Formulas can try to predict effective lens position, but they’re not perfect, Dr. Salz said. The number one source of error leading to IOL power misses, Dr. Salz said, occurs with biometry. “Most physicians have some kind of optical biometry that they use, so most variability is with the corneal measurements, the steepness of the cornea. If those numbers are off a little bit — someone has dry eye, for example — the measurements of the cornea could be off because that’s one of the main things that goes into these calculations,” he said. Dr. Shammas said most studies show that almost no errors occur over 1 D, but he still oc-casionally sees a referral with an error between 2 D and 5 D, resulting in myopia or hyperopia in the operated eye. “Occasionally, we see the inadvertent use of a different Contact information Salz: dasalz@gmail.com Shammas: hshammas@aol.com
FEATURE 8 EWAP JUNE 2022 With good biometry and modern IOL power calculation formulas, we can expect 80% of our postoperative cataract patients to achieve 80% or better within 0.5 D. However, about 5% and 1% of patients may still end up with more than 0.75 D and 1.0 D outside the targeted refraction, respectively. -verker in his 2008 paper identified postoperative E P as the biggest source of errors. Since then, with newer formulas, the variability of E P has been narrowed significantly. Here is my approach to refractive surprises. 1. Examine the eye with the pupil dilated. a. Exclude wound leakage, tight sutures, and shallow anterior chamber as these would distort the natural anatomy of the eye. b. Ascertain that the position of the IOL is well-placed within an intact capsular bag and that the bag is intact. c. For cylindrical power misses, exclude rotated and misaligned toric IOLs. 2. Review the biometry calculation sheet and the patient case record. a. Ensure the correct IOL model and power are being implanted in the correct eye of the right patient. Reaffirm that the IO constant is correct. Establish that the appropriate formulas are used to determine the IOL power and calculated for the intended refraction. Recalculate with other formulas for comparison. Newer updated formulas are available online (www.apacrs.org, ascrs.org/tools, evoiolcalculator.com) and are useful tools for comparison. b. An infrequent error is that the refractive history is overlooked during calculation. Using normal formulas for eyes with a history of corneal refractive surgery will results in IOL power misses. 3. Re-refract the patient. As pointed out by Sverker Norrby in his paper, postoperative refraction is the second commonest source of error. Hopefully, the initial refraction is amiss. {. inally, after having gone through the above and failing to find any plausible reason for the surprise, re-measure the eye again to rule out inaccurate preoperative axial lengths or keratometry. Incorrect keratometry or wound-induced keratometric changes can be a factor, especially in toric misses. If the patient is happy with his vision despite the refractive error, no further treatment is necessary. Various options are available to treat residual refractive errors. For residual cylindrical power, a simple realignment may be adequate. Spectacles are a simple and noninvasive option. Refractive surgery, IOL exchange, or supplemental IOL are other options available. It is best to discuss this with the patients. A good biometer and taking the proper steps in biometry preoperatively reduce these misses. Editors’ note: Dr. Fam is a consultant for Alcon, Carl Zeiss Meditec, Nidek, and Johnson & Johnson. Fam Han Bor, MD Senior Consultant & Head, Cataract and Anterior Segment Service The Eye Institute @ Tan Tock Seng Hospital 11, Jalan Tan Tock Seng famhb@singnet.com.sg ASIA-PACIFIC PERSPECTIVES power IOL due to human error,” he said, adding, “The most common cause is an error in axial length measurement. These errors are often seen in long or short eyes, especially if the eyes present with advanced cataracts that could not be measured by optical biometry; the technician will resort to measuring these eyes with ultrasound, with a greater possibility of error measurements.” What options for ‘treatment’ First and foremost, Dr. Shammas said to identify the source of postoperative error. • Recheck the power of the IOL against the calculated power to rule out human error. Dr. Shammas recommended the surgeon personally check the IOL power prior to implantation. • Remeasure both eyes to rule out error in axial length measurement. • Recalculate corneal power to rule out postoperative steepening of the cornea. Dr. Shammas said tight sutures can occasionally cause steepening. • Assess the IOL’s position to rule out forward placement with or without tilt. How to treat the eye with residual refractive error depends on the patient’s level of unhappiness, Dr. Salz said. If the refraction isn’t perfect but the patient is happy with the overall quality of vision, Dr. Salz said there is no reason to subject them to another procedure. Dr. Shammas said patients are more likely to complain if the error is in their dominant eye with an unexpected anisometropia and/ or aniseikonia. Dr. Salz said most patients with some residual refractive error are corrected with glasses. However, if a patient does not want glasses, there are other options. “We’ll say, ‘The effective lens position ended up –0.5 in the other eye; I need to take that into account for the selection of the IOL power for the second eye,’” he explained. Dr. Salz said he’s making this second eye adjustment in 5–10% of cases, though it’s not necessarily because the patient is unhappy. It’s because “I think I can get their other eye even better.” Dr. Shammas said his practice follows a protocol based on a comprehensive study that found patients who had refractive error eÝceeding 0.5 D in their first eye could benefit from modifying the IOL power in the second eye.1 Dr. Shammas said this protocol can correct up to 50% of the error in the first eye. A study published earlier found
FEATURE EWAP JUNE 2022 9 that “accounting for 50% of the observed error of predicted refraction in the first eye reduced the error of predicted refraction in the second eye.” 2 If a patient doesn’t want to move on to their second eye until they are happy with the vision in their first, Dr. -alâ said options include IOL exchange (his preference in the immediate postop period unless there are issues precluding it), laser vision correction, or a piggyback lens (the latter is the least used of all the options, he said). How to avoid misses in the first RNCEe Dr. Salz said he always performs measurements on a different day than when the patient comes in for an exam or evaluation. “It’s important for the cornea to be as pristine as possible. … If you put drops in the eye, you’re going to distort the surface,” he said, adding that if the patient is found to have dryness or blepharitis, that should be well treated before performing measurements. He said if a patient has posterior subcapsular cataracts, it can be difficult to obtain accurate axial length measurements with optical biometry. Dr. Salz said if the patient wants to defer surgery for later, he’ll get axial length measurements earlier so he doesn’t need to do immersion A-scan later. Dr. Shammas also noted that most misses are due to errors in axial length measurements, often due to advanced cataracts that cannot be measured with optical biometry. “Newer biometers based on swept-source OCT, such as Argos [Alcon] or IOLMaster 700 [Carl Zeiss Meditec], have a much higher rate of acquisition, thus decreasing the need for ultrasound biometry. Also, these new biometers will display a two-dimensional B-scan image that can be used to ensure an accurate measurement has been performed,” he said. Dr. Shammas said surgeons should review their measurements preoperatively and ensure the correct IOL power is used during surgery. This “cannot be underestimated,” he said. EWAP Reference 1. Jivrajka RV, et al. Improving the second-eye refractive error in patients undergoing bilateral sequential cataract surgery. Ophthalmology. 2012;119:1097–1101. 2. Covert DJ, et al. Intraocular lens power selection in the second eye of patients undergoing bilateral, sequential cataract extraction. Ophthalmology. 2010;117:49–54. Editors’ note: Dr. Salz is in practice with The Eye Specialists, Bridgewater, New Jersey, and declared no relevant financial interests. &r. 5JaOOas Rractices at 5JaOOas '[e /eFical %enter .[nYQQF %aliHQrnia anF Jas interests with Alcon and Oculus. The Next Generation NEW Pentacam® AXL Wave The first device to combine Scheimpflug Tomography with Axial Length + Total Wavefront + Refraction + Retroillumination The new Pentacam® AXL Wave is a reliable partner for your refractive and cataract practice, creating the best prerequisites for surgery, based on pre-op metrics, and providing post-op measurements for reliable monitoring, in just one device ! With high-end hardware and software for optimum treatment and satisfied patients, the new Pentacam® AXL Wave makes no compromises on quality. OCULUS Asia Ltd. Hong Kong pentacam.com/axl-wave • info@oculus.hk
FEATURE 10 EWAP JUNE 2022 by Ellen Stodola Editorial Co-Director Unhappy patients after cataract surgery: Reasons for dissatisfaction and how to help Even with a technically perfect outcome after cataract surgery, physicians may find that some patients are unhappy. This dissatisfaction can be due to a number of factors that go beyond visual outcome. Surendra Basti, MD, and Daniel H. Chang, MD, shared what can cause unhappiness and how they discuss it with patients. Dr. Basti said it’s not uncommon for patients to be unhappy after what is otherwise a successful cataract surgery. He said that about a quarter of patients who experience this dissatisfaction will not actually spell it out for the surgeon, but if you probe, you’ll get to why they are unhappy. In the majority of these cases, Dr. Basti thinks it’s a lack of proper understanding. “A proper conversation with the patient can potentially fiÝ the source of unhappiness,” he said. “Infrequently, there may be a need for surgery, but it depends on what the primary source of unhappiness is.” Dr. Basti generally groups unhappiness after otherwise perfect cataract surgery into three categories. The first are patients whose refractive outcomes or the point where they expected vision to be is not exactly where it is. The patient may be a little more or less This article originally appeared in the April 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Basti: sbasti@northwestern.edu Chang: dchang@empireeyeandlaser.com nearsighted than expected. It may be that the patient wanted to be able to read, and the surgeon targeted a refractive error of –2.0 or –2.25, but some people are used to reading at different distances than others. Frequently, it’s the distance for working or using a computer that patients are not happy about, Dr. Basti said, estimating that half of unhappy patients after successful surgery would fall into this category. The second category of unhappy patients Dr. Basti sees are those with quality of vision issues. This group would include patients experiencing dysphotopsia and those with multifocal lenses who don’t quite like the contrast sensitivity. He estimated that around 30% of the unhappy patients he sees after cataract surgery fall into this category. The third category of patients unhappy after cataract surgery are those with physical discomfort, like dry eye or a stinging sensation from eye drops, Dr. Basti said. This problem can usually be corrected and isn’t something that lasts. It is possible after surgery to be a little off from the target, Dr. Basti said, so it’s important to mention to patients that they may have to adjust the distance at which they’re reading. He always brings this up in the preoperative discussion. He is also very sensitive to treating dry eye preoperatively. “But sometimes a patient’s eyes might look moist, and after surgery, they find the medication uncomfortable. So on our postop sheet, we spell out that they may have discomfort from the eye drops, and using artificial tears is a good first line of defense.” Dr. Basti said he doesn’t overemphasize quality of vision in the preoperative discussion, but he will tell patients, “You can be fairly certain if you don’t like vision at end of this, there is the possibility of exchanging the lens.” Dr. Basti said that this is done infrequently. Similar to how Dr. Basti differentiated among the different complaints after cataract surgery, Dr. Chang suggested that these could be categorized as “visual” and “non-visual.” Visual complaints, Dr. Chang said, include positive and negative dysphotopsias. Positive dysphotopsias, such as glare, halo, and starbursts, are generally noticed at night when driving and are especially associated with presbyopia-correcting IOLs. Therefore, it’s important to counsel patients preoperatively and set expectations. “As a rule
FEATURE EWAP JUNE 2022 11 of thumb, the more range of vision you provide, the more dysphotopsia you may create,” he said. He added that it’s important not to proceed with the second eye until you’re certain the patient is happy with the first. Dr. Chang said patients may see positive dysphotopsia early in the postoperative period due to capsular striae as well. He noted that the pressure change at the tip of IOL haptics can induce capsular striae and lead to starbursts. Since the capsule contracts within a few weeks, these dysphotopsias generally improve with time or can be fiÝed with a 9A laser. Negative dysphotopsia, which generally involves an arc or shadow in the temporal vision, is a complaint that patients often eÝpress. Dr. hang finds that around 1 in 5 patients will mention these symptoms. enerally, the better the early postoperative visual acuity, the more they complain. “Computer modeling suggests that every pseudophakic eye has some arc of shadow on the retina, so it’s curious why some patients complain about it and others do not,” he said. Usually, you just have to reassure the patient. “The more I can preemptively describe the symptoms and resolution to the patient, the more it seems to diffuse their concerns,” Dr. Chang said. Non-visual complaints include foreign body sensation, ptosis, and eyelid edema. Usually these symptoms improve with time, though they can sometimes drag on for a few weeks. Patients may also be feeling the edge of the incision or even components of their eye drops, so it’s important to look for an abrasion, foreign body, or irregularity in the wound. “Typically, if they’re on drops, I suggest that they wait until after they finish drops before investigating further,” Dr. Chang said. Preop counseling and trials Dr. Basti said he doesn’t generally do a contact lens trial prior to surgery because it’s often hard to simulate quality of vision with a cataract in the eye. What he will do is discuss with the patient the distances at which he or she likes to hold things. “But beyond that, I don’t try to do too much simulation.” Dr. Chang said that he doesn’t do lens trials because he doesn’t put someone in monovision who hasn’t been in monovision before. His preferred approach is the use of EDOF or hybrid IOLs that give a fuller range of vision, so both eyes have distance, compared to monovision where there is a discrepancy, he said. This approach likely minimizes the risk of falls due to loss of contrast and depth perception, he added. When counseling patients preoperatively, Dr. Chang doesn’t mention every possible complication that can occur because he doesn’t want to overload the patient. Other than a discussion of positive dysphotopsias with patients electing presbyopia correction, “the six things that I point out to all cataract patients are swelling, inyammation, retained lens fragment, retinal detachment, bleeding, and infection.” e finds that patients will generally adapt to other visual disturbances as long as they’re aware that their symptoms are not the manifestation of a surgical or postoperative complication. Deciding when to intervene Dr. Chang said that most patients will know by postop day 1 if they have any of these issues. For those who received presbyopia-correcting lenses, he will see them at week 1 as well. For patients receiving monofocal lenses, Dr. Chang said he generally doesn’t see them between eyes; if they do have a complaint, he makes sure the issue is addressed before operating on the second eye. The second eye rarely needs to be postponed. Deciding whether to remove a lens is probably the most difficult management decision with presbyopic lenses, Dr. Chang said. Fortunately, most issues can be resolved with treatment of dry eye, a refractive enhancement, and/ or a 9A laser capsulotomy. He will typically wait several months before proceeding with an exchange. For symptoms of negative dysphotopsia, Dr. Chang said he would wait at least 6–12 months before considering any surgical intervention, which he has never had to do. If surgical intervention does become necessary after cataract surgery because the patient is unhappy, Dr. Basti said it’s important not to make decisions on lens eÝchange in the first months after surgery. Patients need to be given some time, and sometimes they just need to have a better understanding of the situation and explore it before making a big decision to exchange a lens. “I almost never intervene in the first month,» he said, adding that 3 months is about the time he thinks the patient needs in order to adapt or at least give it a true attempt. For those with dryness, continued on page 14
FEATURE 12 EWAP JUNE 2022 by Liz Hillman Editorial Co-Director An algorithm for ‘Getting to Happy’ after cataract surgery A patient comes in for a postop visit unhappy with their vision after they’ve received a presbyopia-correcting IOL—now what? Tal Raviv, MD, said that his practice is doing more presbyopia-correcting IOL surgeries than ever before with the latest generation of lenses. While many patients are pleased with their outcomes postop, not every patient is thrilled. “We needed a way for all of our doctors to be able to compassionately and effectively treat any patient who needed extra care,” Dr. Raviv said. So he created an algorithm— the Raviv º etting to appy» Post-IO Algorithmpto help Contact information Koch: dkoch@bcm.edu Raviv: talraviv@eyecenterofny.com Williamson: blakewilliamson@weceye.com This article originally appeared in the April 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. guide physicians through the process of managing a patient who is unhappy with their presbyopia-correcting IOL. “I would estimate about 10% of premium IOL patients have some issue, with about three quarters of those able to be resolved medically or by choosing another IOL in the fellow eye and the rest needing some form of enhancement, such as PR É A-I or IO exchange,” Dr. Raviv said. He added that he tells presbyopia-correcting IOL patients that about 3–4% will need an enhancement. “I see a number of unhappy post-refractive patients who are coming in for a second opinion following surgery elsewhere.” Dr. Raviv’s algorithm starts at the postop visit with a well-centered IOL in the bag. From there, refract the patient and follow the paths based on the outcome of the refraction and subsequent testing. In general, Dr. Raviv said it’s critical to teach patients interested in presbyopia- correcting IOLs preop that “even with the most exacting surgery and latest generation of customized IOLs, there is a small likelihood of needing an enhancement procedure.” “There are some patients who tell us preoperatively that they don’t ever want a second surgery, and in those we rule out a multifocal IOL,” Dr. Raviv continued. “Our profession still The Raviv “Getting to Happy” Post-IOL Algorithm. Source: Tal Raviv, MD
FEATURE EWAP JUNE 2022 13 can’t get to 100% within ±0.25 D with any presbyopic IOL solution, so enhancements are critical.” Case example Dr. Raviv provided a case to illustrate how he used his algorithm. Three weeks after receiving a trifocal toric IOL, a patient was in his office complaining of a ºfilm» and “blurry/hazy” vision. Dr. Raviv said the patient had some dry eye preop and had been on topical cyclosporine for a month. First, he refracted the patient. She was correcting to 20/25- with a slight myopic correction. “Since the BCVA wasn’t a crisp 20/20, we pursued treatment to improve the vision,” he said, noting that OCT showed the macula was yat and unchanged and there was no significant P O. ºThere was some punctate corneal staining. The topical steroid was increased and NSAID was discontinued. Restasis [cyclosporine, Allergan] and preservative-free tears were maintained.” At 2 months postop, the patient’s BCVA with a –0.75 D improved to 20/20. From there, Dr. Raviv did an in-office contact lens trial, in which the patient noted significant improvement in distance and near vision. The plan was to continue dry eye drops for a few months, then proceed with PR . At postop month 4, BCVA was 20É{0- and 1³ P O was present. A 9A capsulotomy was performed followed by another refraction. Dr. Raviv then performed PR . One month after PR , the eye was plano 20/20 (and J2), and the patient was very happy, Dr. Raviv said. Other perspectives Blake Williamson, MD, shared his perspective on patients who are unhappy after cataract surgery. He said the question is in what percent of the lenses that you place is there unhappiness such that the surgeon needs to do something about it? Dr. Williamson said his explant rate is less than 1%. “I think that’s a testament to how we educate the patients on the preop side, making sure they understand the limitations, set appropriate expectations, pick the right patients, etc.,” he said, adding that if surgeons are using presbyopia-correcting lenses, they should have the skills to explant or perform a touch-up or be prepared to refer should the need arise. Reasons for patient unhappiness can be any number of things. Dr. Williamson said often it’s an issue between eyes. “It’s like having a cowboy boot on one foot and a roller Avery interesting perspective has been shared by Dr. Tal Raviv on his strategy of handling an unhappy postoperative patient after a presbyopia correcting IOL. With the introduction of the new generation trifocal IOLs, the incidence of unhappy patients has been significantly reduced. The most common cause of an unhappy patient is residual ametropia, particularly astigmatism, and I would urge all colleagues to do a toric IOL calculation for each eye using the Barrett’s Toric Calculator, and try and correct the least amount of astigmatism that can be treated with a toric IOL. I would always forewarn patients during preoperative counseling that there is nothing like a “zero number” and all patients are likely to have some residual number even after the best surgery; however, very few require the need to use them after binocular surgery. It is very rare to get a very gross refractive surprise. I would be very hesitant in doing any form of laser vision correction on these patients as I do not want a multifocal cornea over a multifocal IOL, and since the majority of these patients are elderly, there is a significant worsening in their dry eye status. -o, if correcting the residual refractive error makes them happy, I would not hesitate in prescribing a pair of glasses which they can use in selective activities. I also believe 9A capsulotomy is being advocated far too liberally in patients with multifocal IOLs. One must remember the consequences of 9A capsulotomy in terms of increased incidence of retinal detachment, and also the fact that it would be very difficult to then perform an exchange of IOL if required with an open posterior capsule. 1nless the P O is severe, which it rarely is in the early postop period, I would rarely perform a 9A . I would consider IOL exchange only in very rare cases where the patient is eÝtremely bitter after the first eye. I would eÝplain to such a patient that an IOL exchange surgery could have its own complications such as âonular compromise, P R, corneal edema, and ME, and that he will now need glasses for both distance and near. I have found that talking to patients at every visit, listening to their same complaints every visit, not being defensive in our approach and yet reassuring them that there is no serious vision-threatening condition in their eyes, eventually helps me to win over these patients over a period of time and avoid any form of second surgery with its potential risks. ditors½ note\ r° 6asaÛada deVlared no releÛant finanVial interests° Shail Vasavada, MD Consultant Ophthalmologist, Raghudeep Eye Hospital, Ahmedabad, India shail@raghudeepeyeclinic.com ASIA-PACIFIC PERSPECTIVES
FEATURE 14 EWAP JUNE 2022 skate on the other. … Everything is off because they need to have the other eye done,” he said. “We educate them on the front end and let them know they’re not going to love [the time] between eyes.” Other issues include glare and halo in the early postop period. Dr. Williamson said patients need to be reminded that it can take 3–4 months for them to neuroadapt. Another issue could be that the patient doesn’t love their near vision. They might like it but not love it, Dr. Williamson said. The same issue could happen with distance. It might be a case where mixing and matching IOLs could help. Dr. Williamson said he doesn’t think of these as complaints from patients but rather observations. He said he listens to these observations and often uses them to inform what the best course of action is for the second eye. Douglas och, MD, discussed the challenge of cataract surgery in patients who have had prior refractive surgery. These patients elected for spectacle independence with initial refractive surgery, so they might have the same expectation after cataract surgery, if they’re opting for a presbyopia-correcting IO . Dr. och said that these patients often have multifocal corneas whose depth of focus can compensate in part for residual refractive error, but it’s not uncommon for them to be off target, and residual refractive error is more problematic with most EDOF and multifocal IOLs. It’s especially important that these patients be educated about the added challenge their prior refractive surgery poses for hitting the post-cataract surgery refractive target, Dr. och said. e thinks that the Tecnis Symfony lens (Johnson & Johnson Vision), with its large “landing zone,” is more forgiving in this regard, and in his practice he largely avoids other EDOF and multifocal IOLs in post-refractive eyes. If the needed postop correction is small, Dr. och said he½ll propose PR . 1sually A-I is not feasible, but sometimes he will do a yap recut and lift, if the cornea is amendable to further yap surgery. or residual refractive error of –2 or more or +1.5 or more, he prefers IOL exchange. As for taking lessons learned from the first eye and applying them to the second, Dr. och said it’s more nuanced in postrefractive surgery patients. “If they½ve had a modest A-I , you could probably learn something from the first eye, but if they½ve had a large A-I correction, and especially in post-R eyes, one cannot rely as much on the outcome of the first eye when calculating the IOL for the second one,” he said. Dr. Williamson said that patients who are unhappy with their refractive outcome want to be heard and confident that their surgeon is understanding and has a plan for them. He said the staff often has an accurate pulse on just how unhappy a patient might be (e.g., the patient might be more honest with the staff than the physician). Dr. Williamson said it’s important to remind the patient with a presbyopia-correcting IOL of what they do have—“awesome near vision”—and at 3 months postop consider more significant action if they’re still not happy, such as a 9A capsulotomy (don½t 9A too early, Dr. Williamson cautioned) or explant. “Never do [an explant] before a month unless it was a refractive miss,” he said. “If you hit the refractive target … but the patient is unhappy with side effects, give it at least a month, then get it out and refund.” EWAP Editors’ note: Dr. Koch is in practice at tJe &eRartOent QH 1RJtJalOQlQI[ %Wllen '[e +nstitWte $a[lQr %QlleIe QH /eFicine *QWstQn 6eZas anF Jas interests YitJ #lcQn %arl <eiss /eFitec and Johnson & Johnson Vision. Dr. Raviv is in Rractice at tJe '[e %enter QH 0eY York, New York, New York, and has interests with Johnson & Johnson Vision. &r. 9illiaOsQn Rractices at 9illiaOsQn Eye, Baton Rouge, Louisiana, and has interests with Johnson & Johnson Vision. routine postop drops have usually stopped around this time, he said, and many patients with dysphotopsia will see it resolve after several months as well. For those with problems that still persist, Dr. Basti again stressed that there is the possibility of surgically exchanging the lens. “For someone unhappy with the outcome, convey to them that you will continue to monitor and get them to a good place,» he said. ºProviding that reassurance is key here.” EWAP 'FitQrso nQte &r. $asti is &irectQr QH tJe %ataract 5erXice &eRartOent QH 1RJtJalOQlQI[ 0QrtJYestern 7niXersit[ %JicaIQ +llinQis anF Jas interests with Johnson & Johnson Vision. &r. %JanI is %ataract anF 4eHractiXe 5WrIeQn 'ORire '[e anF .aser %enter $aMersfielF %aliHQrnia anF Jas interests with AcuFocus and Johnson & Johnson Vision. Unhappy patients - from page 11
REFRACTIVE EWAP JUNE 2022 15 Contact information Donnenfeld: ericdonnenfeld@gmail.com Yeu: eyeulin@gmail.com W ith keratoconus, it’s important to diagnose patients as early as possible in order to treat them before more drastic procedures, like a corneal transplant, might be needed. Crosslinking has aided in the early treatment of keratoconus, and the use of genetic testing is another tool for doctors to add to their armamentarium. Eric Donnenfeld, MD, and Elizabeth Yeu, MD, discussed AvaGen, a test from Avellino that can be used to assess genetic risk for keratoconus and other corneal dystrophies. Genetic testing is one of the newest topics in all of medicine, Dr. Donnenfeld said. Looking at genetic risk factors gives doctors a heads up on better management. Being able to tell if a patient is at risk for a disease allows physicians to diagnose and potentially start therapy earlier. “Keratoconus has been one of the most difficult diseases I½ve treated in the course of my career,” Dr. Donnenfeld said. “Now that we have genetic testing to go along with crosslinking, not only can we diagnose it sooner, but we can treat it sooner and prevent it from progressing.” Dr. 9eu finds genetic testing a great tool for keratoconus screening for a variety of The value of genetic testing for keratoconus by Ellen Stodola Editorial Co-Director patients, such as those in which refractive screenings are not straightforward and family members of known keratoconus patients. She uses this testing in about one of every four refractive screenings. Where does it fit into testing and treatment? Keratoconus is polygenic, meaning there are a lot of genetic variations, so you can’t just look at one gene type, Dr. Donnenfeld said. “You have to look at the entire genetic pool and correlate this with other risk factors. Having the genetic testing allows me to know who’s at risk to counsel them,” he said. When someone has keratoconus, family members are at increased risk. Testing siblings and children of keratoconus patients allows them to understand the risks associated with genetic predisposition and how they should be followed. ºI find it eÝtremely disconcerting when someone has had keratoconus for several years and the first time I see them, they½re ready for a corneal transplant,” Dr. Donnenfeld said. ºI want to diagnose these patients earlier before they get to this stage.” Dr. Donnenfeld said he is using genetic testing frequently, but he thinks that it is still being used primarily by corneal specialists at this point. ºI think it’s something that will be adopted by refractive surgeons who want to have a better understanding of the risks for patients,” he said. In addition to genetic testing, Dr. Donnenfeld uses a number of other tests for these patients. Everyone who comes in gets a topography and tomography. He looks at posterior cornea, corneal thickness, and corneal curvature, and he said that epithelial cell mapping is a new technique that physicians are using as well. Dr. Donnenfeld said he also looks at pachymetry maps. Crosslinking is an effective therapy, he said. ºIf you know someone is at risk and you follow them carefully and as soon as you see the first sign of development, treat right then, they can lead a normal life,» he said. If you don½t treat them, they could end up needing corneal transplants, have rejection, and are at risk for trauma. ºI think having a test that allows us to diagnose keratoconus earlier is very eÝciting,» Dr. Donnenfeld said. Though this is not an absolute indication for therapy, it provides more information to “steer me in the right direction and augments the other tests that I½ve been doing.” Understanding the inherent This article originally appeared in the April 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
REFRACTIVE 16 EWAP JUNE 2022 So-Hyang Chung, MD Professor, The Catholic University of Korea Banpo-Ro 555, Seoul, South Korea chungsh@catholic.ac.kr ASIA-PACIFIC PERSPECTIVES Nowadays, when the importance of genetics is emphasized in the medical field, it is encouraging that various studies using genetics are being conducted in ophthalmology. I am very interested in the presented issue and eÝpect that it will be of great help in the early diagnosis and treatment of keratoconus. To the siblings and offspring of keratoconus patients, genetic tests could provide valuable information. During refractive surgery screening, these tests would be especially beneficial for the patient with abnormal clinical eÝaminations and risk factors and help surgeons make decisions for phakic IO s and refractive surgery with crosslinking. -ince the cost of testing is not small, more specific guidelines for when to perform genetic testing (e.g. corneal thickness, astigmatism, topographic characteristic) might be needed. There is no objection to conducting the test in patients with a family history or abnormal clinical eÝamination, but I don½t think these biomechanical tests would be necessary for normal patients. ditors½ note\ *rov° hÕng deVlared no releÛant finanVial interests° risk for keratoconus based on a patient’s corneal genetics provides invaluable information, Dr. 9eu said. ºI think corneal genetic screening is essential for any refractive screening patients who present with other risk factors on the initial visit, i.e., thinner corneas, young patients with against-the-rule astigmatism, higher astigmatism, more centrally steep astigmatism. Also, I always screen patients who I½m seeing for an enhancement evaluation for the first time, or in situations where I µuestion the topographic pattern for inferior steepening. Furthermore, I reµuest corneal genetic screening at the initial visit for keratoconus suspect evaluations, and I always recommend it to my known keratoconus patients for their siblings or offspring.” Dr. Yeu said she offers this test to patients in cases where she thinks the information would be truly additive to the clinical decision-making process. Currently, the test is paid for out of pocket. Dr. Yeu estimated that patients are charged $350–500. It½s important to still use other screening tools to make the keratoconus diagnosis. Dr. Yeu uses pachymetry, topography, and tomography. Corneal epithelial mapping with O T and biomechanical testing can further enhance the ectasia screening process. She also noted the importance of looking at family history, eye rubbing, systemic comorbidities, ethnicity, and other risk factors. Dr. Yeu said eye rubbing can be a big cause for concern. She strongly urges her patients with known keratoconus or suspicious corneal astigmatism to avoid this. Contact lens intolerance can also point to worsening progression of corneal astigmatism. ºI watch the corneal astigmatism closely in these patients, as contact lens intolerance can be from dry eye disease or contact lens conjunctivitis,” she said. Availability of tests The first commercially available test for corneal dystrophies was made in Korea by Avellino Precision Medicine in 2008, Dr. Yeu said. This only tested for one T I mutation known to cause Avellino corneal dystrophy (now also known as GCD2). The launch of that test led to more testing in South Korea and Japan, and eventually, more mutations were defined. The Avellino test was modified by Avellino Precision Medicine to include five mutations of the T I gene. “Today, 42 labs offer corneal disease genetic testing, according to a search on the Genetic Testing Registry,” Dr. Yeu said. “Universities with their own labs are also able to offer this type of testing.” In 201, Avellino launched the AvaGen test, which Dr. 9eu said uses neÝt-generation sequencing to look for more than 70 mutations of the T I gene for corneal dystrophies, as well as markers across 75 other genes associated with keratoconus and related diseases. The developments in testing and therapy resulted in FDA approval of voretigene neparvovec-râyl ( uÝturna, Spark Therapeutics) in 2017, the first gene therapy of its type approved for confirmed biallelic RPE65 mutation-associated retinal dystrophy. “While the prevalence of this genetic disease is considerably less than other eye diseases, the promise that this process of testing and continued on page 18
REFRACTIVE EWAP JUNE 2022 17 Contact information Baartman: brandon.baartman@ vancethompsonvision.com Greenwood: michael.greenwood@ vancethompsonvision.com T o patients, eye rubbing might seem innocuous, but to the ophthalmologist, it’s an action that can have sight- threatening consequences and is something that patients should be warned against. Eye rubbing has been associated with keratoconus most commonly 1 but also retinal detachments 2 and dislocated implants. 3 It½s also eÝperimentally been shown to significantly cause a rise in IOP. 4 Sometimes, when patients rub their eyes hard enough, they see lights, yashes, or dots. randon Baartman, MD, described this as not actually light but mechanical traction put on the retina by the vitreous. “The retina then communicates any stimulus, be it mechanical traction during a retinal tear or eye rubbing, as ‘light’ to the brain,” he said. Dr. Baartman said he’ll often ask patients to think about what structures they’re rubbing or pressing on. “Rubbing over the inner corner and pressing on bone is very different than the rubbing of the actual vulnerable structure of the eye itself,” he said. Michael Greenwood, MD, said he also tells people that rubbing the bridge of the nose or close to the temple is O . º ust don½t put your fingers on the soft part of the eye,” he said. Greater awareness needed about impact of eye rubbing by Liz Hillman Editorial Co-Director Dr. Greenwood added later that sometimes what the physician might think of as eye rubbing is not what the patient thinks of. Having the patient demonstrate how they rub their eyes can be helpful, as can having a family member in the room. Dr. Greenwood said when he asks a patient if they rub their eyes, they’ll say no, but the other person in the room with them is nodding their head yes. “People who rub their eyes aren’t always aware that they’re doing it,” he said. Dr. Baartman also said he asks a loved one, if present, if the patient says they don’t rub their eyes. ºI then usually describe the type of eye rubbing that can be harmful to an eye and eÝplain that it will lead to new or continued ‘warping’ of the ocular structures,” he said. “Particularly useful is the old basketball This article originally appeared in the April 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. analogy; nearly everyone in their school-aged days has been to a gym with that old basketball that has been bounced repeatedly and develops weakening in the wall of the ball, such that the wall then develops that ‘lump’ irregularity. Every time they rub their eye, it’s like bouncing that basketball, and their cornea may develop that same irregularity over time.” Patients to specifically counsel against eye rubbing include keratoconus patients, refractive surgery patients, patients with phakic IO s, dry eye and allergy patients, and patients with Down syndrome. For keratoconus patients, Dr. Greenwood said, it½s important to eÝplain to them that the goal of crosslinking is to halt progression. If they continue to rub their eyes, they might need another procedure. Refractive surgery patients
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