EyeWorld India December 2019 Issue

FEATURE 8 EWAP DECEMBER 2019 A monocular patient arrives for a preop workup and cataract surgery consultation. Given that functional sight is only in one remaining eye, do ophthalmologists treat these patients any differently than binocular patients? The ophthalmologists EyeWorld spoke with about cataract surgery in functionally monocular patients said, in short, no. For the most part, they counsel and perform surgery the same way in these patients. “I think every time we operate, we should be as careful in that operation on a binocular patient as we would be on a monocular patient,” said Howard Gimbel, MD. While this was the overarching sentiment from Dr. Gimbel, Richard Lindstrom, MD, Robert Osher, MD, and Abhay Vasavada, MD, there are some considerations that are different for these patients. When to do surgery is an example. Dr. Lindstrom said he’s somewhat more conservative in recommending cataract surgery to a monocular patient, especially ˆv ̅i wÀÃÌ iÞi Ü>à œÃÌ vÀœ“ complications of cataract surgery. “As always, it remains the patient’s choice, with the help of their family or trusted advisors, as ̜ ܅i˜ ̅iÞ Ì…ˆ˜Ž ̅i Li˜iwÌà œv surgery outweigh the risks in their particular case,” Dr. Lindstrom Ã>ˆ`° º w˜` ˆÌ…i«vՏ ̜ Ài“ˆ˜` the patient that surgery does not become easier and safer if it is delayed excessively, as the cataract grows larger and harder with time. This helps some patients who are suffering with a È}˜ˆwV>˜Ì…>˜`ˆV>« ̜ “>Ži ̅i decision to proceed. To me it is an awesome responsibility for the patient and surgeon to proceed with surgery in an only eye.” Dr. Lindstrom said he encourages all patients (monocular and binocular) to wait until they are truly having visual problems before proceeding with cataract surgery, and there are things patients can do to improve vision while waiting for the proper surgical time. “In the patient who wants to delay surgery with good spectacle correction, yellow lenses to enhance contrast, anti- ÀiyiV̈Ûi Vœ>̈˜}à œ˜ }>ÃÃià to reduce forward light scatter, good lighting, low-vision aids, and in some cases mild dilation with diluted phenylephrine can be helpful,” he said. Dr. Osher also said he encourages his patients to wait on surgery until they’re having trouble. “When the patient is unhappy and we’ve exhausted all conservative alternatives, that’s ܅i˜ ̅ˆ˜Ž ÃÕÀ}iÀÞ ˆÃ ÕÃ̈wi`]» he said. The counseling of monocular patients, the physicians said, is similar to that of binocular patients, but Dr. Lindstrom said …i w˜`à ˆÌ V>˜ Ì>Ži œ˜}iÀ° “I make sure the patient understands that cataract surgery is an elective surgery and they can wait until they are ready but remind them that it does not become safer or easier as the years pass,” he said. “I usually end by telling them that it is a big responsibility for them to choose to have surgery on an only eye, but it is also a big responsibility for me to operate on the eye of a monocular patient. I reassure them that I or if preferred one of my highly experienced and expert associates do a high volume of cataract surgery and are willing to assume that risk when they are ready to proceed.” Dr. Vasavada stressed the Considerations for cataract surgery in monocular patients by Liz Hillman EyeWorld Senior Staff Writer AT A GLANCE • Many aspects of counseling, decision making, and surgery for monocular patients remain the same as for binocular. • These patients may require more time in preoperative counseling. • Monocular patients should be encouraged to wait for surgery until they are truly having visual trouble but not so long that the cataract size and density increases surgical risks. • Toric lenses can be encouraged in these patients, but surgeons should proceed with caution with multifocal and accommodating lens. Contact information Gimbel: hvgimbel@gimbel.com Lindstrom: rllindstrom@mneye.com Osher: RHOsher@cvphealth.com Vasavada: icirc@abhayvasavada.com This article originally appeared in the September 2019 issue of EyeWorld . +V JCU DGGP UNKIJVN[ OQFKƂGF CPF appears here with permission from the ASCRS Ophthalmic Services Corp. Anterior capsule removal on the eye of a monocular patient who had a posterior polar cataract. The stakes might feel higher when performing surgery on a monocular patient, but many physicians go through the same steps and thought processes they would with a binocular patient. The full case is described in the October 2018 issue of EyeWorld . Source: Kevin M. Miller, MD