EyeWorld India March 2014 Issue

10 March 2014 EWAP FEAturE Doing - from page 8 membrane, for example, may be disappointed with results after lens removal if the membrane is still in place. “You want to make it clear why you’re doing what you’re doing—that it’s not the end of the road for the patient,” Dr. Safran said. Also, depending on how the IOL calculations are done these may change after the surgery to remove the membrane. “If you’re using the IOLMaster [Carl Zeiss Meditec, Jena, Germany], it shouldn’t be too much of a change, but if you’re using ultrasound, certainly it can change what your axial length measurements are,” Dr. Safran said. Another clear downside of staging procedures, he pointed out, is that the patient needs to undergo two surgeries. “Doing it in one shot, the patient goes in once, gets everything done, and they’re all fixed.” On the other hand, logistics for combined procedures can be anything but simple, with each surgeon’s equipment in tow. “I used to do this with a retina surgeon and have two machines and two microscopes in the same room,” Dr. Safran said, adding. “It looked like we were going to be separating Siamese twins or something.” Kevin M. Miller, MD, Kolokotrones professor of clinical ophthalmology, Jules Stein Eye Institute, Los Angeles, Calif., U.S., agreed that logistics can be difficult. “It’s hard to schedule a busy retinal specialist and get a busy cataract guy in the operating room at the same time,” Dr. Miller said. What’s more, Dr. Miller pointed out that the patient may be better off with staged procedures. He explained that oftentimes you can’t tell how much of the visual difficulty is the result of the cataract and how much is from the epiretinal membrane. “I would say more than half the time patients are quite happy with the visual improvement they get with cataract removal and then we don’t have to proceed to a membrane peel. So, if done in stages the patient may be spared the second procedure.” The combined procedure can also be more problematic for surgeons. For example, retinal specialists may have to deal with leaky cataract incisions that have not had time to heal, he pointed out. What’s more, with a combined operation the lens implant tends not to stay centered well. “If you need to do a membrane peel and the eye has been given plenty of time to heal from the cataract operation, you don’t have to worry about a leaky incision or the lens decentering or capturing in the pupil,” Dr. Miller said. He generally reserves combined surgery for those whose general health would preclude two trips to the operating room. To make this work from a scheduling perspective, Dr. Miller finds that the combined procedure must be slotted as either the first or last surgery of the day. “If you try to time this in the middle of the day it almost never works out,” he said. “The only time that we’re in sync is the first case of the day.” If it is scheduled as the last case of the day and one of the doctors is delayed, then it is only the other practitioner who is inconvenienced and not a whole group of patients. Dr. Safran pointed out that the good news for those in private practice who want to do combined surgery is that these days for many it is possible. It is no longer reserved for those at big centers. “There are retina guys now who work out of surgery centers and general ophthalmologists who work out of hospitals—so there’s a crossover,” he said. “I do some cases over at the hospital so there are days where I can team up with the retina guy and we can do procedures together.” Adding new choreography When Dr. Safran does combined procedures, he finds that most of the time he removes the cataract first and then lets the retina specialist proceed. One rare situation where the combined surgery might be done the other way around would be in the case of a vitreous hemorrhage with no red reflex. In such cases it can be a little dicey removing a complicated cataract, he said. For his part, Dr. Lahey has added something to the combined procedure that is not normally done. He now does posterior capsulotomies at the end of the cataract procedure to head off the potential need for laser YAG surgery down the road. “The big advantage we see of the combined procedure is that patients come to a final visual acuity much sooner than they would if you allowed the cataract to grow for three to six months, harvested it, and allowed a posterior opacity to grow for another three to six months, then laser it,” he said. In cases where patients also have diabetic retinopathy, Dr. Lahey does another thing differently. He routinely uses an indirect laser ophthalmoscope and depresses the sclera to look for possible retinal tears. “We often will add laser to anything that looks suspicious,” he said, adding, “Our retinal detachment rate is quite low—it’s about 2%.” Overall, Dr. Lahey stressed that for those who handle combined surgery alone, one of the things that the procedure demands is having good skills for both phacoemulsification and vitreoretinal techniques. “It’s definitely not for everyone, but it is satisfying having one person responsible for the entire thing,” Dr. Lahey said. “Also, I think patients appreciate that they’re not sent to all of these different appointments to different doctors and bounced around in between their YAGs and their cataracts and their glasses.” Meanwhile, Dr. Safran thinks there’s something to be said for working with those from other specialties. “I think one of the nice things about doing cases with the retina people is that you get to watch how they do things and pick up some of their techniques,” he observed, adding, “That can be helpful if you do those kinds of things yourself.” EWAP Editors’ note: Drs. Lahey and Miller have no financial interests related to this article. Dr. Safran has financial interests with Bausch + Lomb, Heidelberg (Heidelberg, Germany), and Ellman (Oceanside, NY, U.S.). Contact information Lahey: +1-510-675-3020, nektar_99@yahoo.com Miller: +1-310-206-9951, kmiller@ucla.edu Safran: +1-215-962 5177, safran12@comcast.net