EyeWorld India December 2017 Issue

December 2017 EWAP FEATURE 25 patients for slightly myopic, rather than plano. Dr. Matossian pointed out that these patients, if wanting to read or do near tasks, might have trouble remembering where they put their reading glasses. For this reason, she said she has used multifocals in some dementia patients. “They’re not driving so halos and starbursts are not a big prob- lem for them, and this way they don’t have to rely on glasses,” she said. Dr. Hart said multifocal IOLs for these patients would be the preference “in a perfect world,” but the expense and the likeli- hood of other ocular comorbidi- ties usually preclude them from being multifocal candidates. Dr. MacDonald said she thinks maintaining good dis- tance vision is important for these patients. While monovi- sion or a multifocal could be use- ful if the patient is likely to lose reading glasses, Dr. MacDonald stressed the importance of good depth perception. Postop care and other considerations With dementia patients, Dr. Matossian said she’ll often do a “double prep,” expanding the area where she applies betadine and also uses SteriLid (Ther- aTears, Ann Arbor, Michigan) because sometimes their hygiene might not be as well accounted for. She used to put in one suture just in case patients forgot they were not to rub their eye. For the last few years, however, she’s been using ReSure Sealant (Ocu- lar Therapeutix, Bedford, Massa- chusetts) instead. “I also place a plastic shield over their eye when they leave the OR; I don’t do that for my typical cataract patients. They wear it home while the eye is still numb since I don’t want them to touch their eye. I recommend the shield be used during naps and every night for a minimum of 7 days,” Dr. Matossian said. Dr. MacDonald has all of her cataract patients where a shield for a week. Both Drs. Hart and Matossian said they make sure the patient has someone who will help them remember their drops or instill the drops for them. However, because some patients might fight instillation of these drops, Dr. Matossian said in her more confused patients she will use an intracameral antibiotic and ster- oid combination requiring only a topical NSAID, the latter of which she noted is branded and only requires one drop a day. “I decrease the drop burden to the patient postoperatively,” Dr. Matossian said. Dr. MacDonald said she’ll consider subconjunctival deliv- ery of antibiotics and steroids as well if she fears noncompliance. “I try to keep it as simple as possible,” she said. “I’ll work with the family to try and figure out how we can taper them off any drops as quickly as possible.” What about other consid- erations, such as immediately sequential bilateral cataract surgery (ISBCS)? Dr. Hart thinks there are several very real bar- riers to its implementation in any patient, whether or not the patient has dementia. These include the risk for TASS or en- dophthalmitis occurring in both eyes, less reimbursement, and, he noted, medical malpractice doesn’t cover it. Dr. Matossian said she doesn’t do ISBCS, but added that sometimes she’ll do just one of the cataracts. “Most of the time, just doing the one eye is all they need because then they see well enough to navigate, see their food,” she said. There may be patients who are not good candidates for cataract surgery at all. Patients with serious medical situations, who cannot follow commands, nor watch television, for exam- ple, Dr. Matossian said. Dr. Hart said it might not be worth going through surgery for a patient who is near the end of life. “At the end of the day, the days of doctors telling patients what to do are long gone. We’re in a partnership with our pa- tients and their families and we try to help them make good decisions and explain to them the options. These are not easy answers,” Dr. Hart said. As a final piece of advice, Dr. Hart said it’s important to talk to not over the patient, regardless of the level of dementia. “It’s easy, because they don’t talk back, to cut them out of the informed consent, but I think it’s important to keep them involved and let the family see that you’re keeping them involved because it’s the right thing to do,” Dr. Hart said. “Because they can’t express themselves, we don’t know exactly what’s going on in- side their mind. We have to treat them like we would any other human being.” EWAP Reference 1. Ishii K, et al. The impact of cataract surgery on cognitive impairment and depressive mental status in elderly patients. Am J Ophthalmol . 2008;146:404–9. Editors’ note: Drs. Matossian, Mac- Donald, and Hart have no financial interests related to their comments. Contact information Hart: j.c.hartjr@sbcglobal.net MacDonald: Susan.M.MacDonald@lahey.org Matossian: cmatossian@matossianeye.com