EyeWorld India March 2016 Issue

41 EWAP Cataract/IOL March 2016 eye that has any kind of irregular ocular surface.” Dr. Silverstein will consider performing a superficial keratectomy with mitomycin-C to help reduce risk of a central recurrence in those with EBMD, but agrees that the potential visual outcome after cataract surgery is what drives his recommendations. “We may get a refractive change as a result of the keratectomy, and that needs to be considered in the IOL calculations,” he said. “If the patient has a good central clearing and the rest of the cornea is healthy, advanced implants can be considered.” But in cases of significant Fuchs’ dystrophy with 3+ guttae or more, who do not need grafts right now, “I do not recommend a premium lens implant because it’s more likely than not that they will require a DSEK and that will change their refractive outcome,” Dr. Silverstein said. Although a pseudoaccommodating lens might be an option, “they may not get the true value of the lens implant long term, since they will progress.” Dr. Devgan is more conservative —even if the patient’s underlying condition is treated, surgeons have to ask if the surface is going to remain healthy or if there is a progressive disease. “If there’s Fuchs,’ in 5 years the corneal endothelium is going to look worse than it does today,” he said. “A toric lens could be appropriate if they have some degree of regular symmetric astigmatism, however.” Prep the patient Patients don’t understand that dry eye and Fuchs’ are chronic conditions that can be controlled but not cured, Dr. McDonald said, and that makes patient education not only crucial but difficult. “Some people just can’t make the leap that they have to come to terms with it, just like high cholesterol or diabetes. I find a lot of patients follow my instructions for a month but don’t embrace the chronicity of the disorder,” so when the initial prescription runs out (in the case of dry eye treatments), they don’t refill, she said. Whenever there is more than one cause of blur, surgeons need to explain both the disease and the cataract to the patient and that multiple preop visits might be necessary before the cataract surgery, Dr. Thompson said. For Dr. Devgan, those preop visits are the most crucial aspect of the entire process. “If you do a good job of explaining the issues and the slower recovery time, everything that happens postop is expected,” he said. “If you predict the problem, patients think you’re a genius for predicting it, but if you never tell them about the potential problem and it happens, you’re a bad guy for causing it.” Consider the patient as well as the diseases, Dr. McDonald said. “If you intervene, if you’re aggressive and improve their dry eye, will they maintain that health in 2–3 years? Does Alzheimer’s run in their family? Crippling arthritis? You need to consider a controllable disease today may not be controllable in a few years. In Fuchs,’ maybe they’ll be lucky and plateau for a few years, but they are going to get worse eventually.” She also avoids multifocal lenses in these patients. Be cautious in patients with severe ocular surface disease that cannot be controlled, Dr. Thompson said; these eyes are slightly more prone to melting. Everyone agreed that preop visits with these patients are significantly longer and more are needed compared to patients without compromised corneas. “The additional visits are necessary to not only stabilize the cornea (in cases of chalazion or Salzmann’s nodule), but I’ll get a better biometry and better IOL calculations and be able to provide them with better potential vision,” Dr. Devgan said. And “always, always, always” explain to the patient that recovery times are going to be longer, their visual recovery may be more eventful than Mrs. Jones’ down the street (more visits, for example), and they may never regain “perfect” vision, Dr. McDonald said. Preoperative plan Because K measurements and IOL powers “are almost linked 1:1, if you’ve got an irregular corneal surface, you’re going to get worse K measurements and here is the danger. If you read the cornea as 2 D lower than it really is, it will affect the IOL power by 2 D,” Dr. Devgan said. “Always choose the machine with the lowest K value of all the devices you used, as that will tend to calculate a slightly higher IOL power. Then if there’s any postop variant in the calculations, they’ll err on the side of myopia.” Some patients may not have any obvious evidence of a corneal irregularity—such as dry eye—that affects vision. “You don’t want to necessarily add a multifocal implant for that because a dry irregular tear film can be a tremendously multifocal surface,” Dr. Thompson said. He added that the newer diagnostic technologies such as the HD Analyzer (Visiometrics, Terrassa, Spain) and the iTrace (Tracey Technologies, Houston) can measure the health of the tear film and provide enough information to help guide physician choices. If the tear film is rehabilitated, these technologies can quantify if its optical quality has improved enough to consider something like a multifocal lens. Dr. Thompson said they also use laser-assisted cataract surgery in Fuchs’ dystrophy patients because it can lessen phacoemulsification time and thus lessen stress on the corneal endothelium. It’s not just about informed consent, Dr. Silverstein said. “It’s our responsibility. It’s not just about handholding, it’s about education. At the end of the day, for me, it’s answering the question, ‘Would I have a premium lens implant in my eye if I had these corneal abnormalities?’ And if so, which one? There are times that it’s perfectly appropriate. There are times that it is contraindicated, and it is our responsibility to help guide the patient as we would choose for ourselves.” EWAP Editors’ note: Dr. Thompson has financial interests with Abbott Medical Optics (Abbott Park, Ill.), Alcon (Fort Worth, Texas), and Bausch + Lomb. Drs. Devgan, McDonald, and Silverstein have no financial interests related to this article. Contact information Devgan: devgan@gmail.com McDonald: margueritemcdmd@aol.com Silverstein: ssilverstein@silversteineyecenters.com Thompson: vance.thompson@vancethompsonvision.com