CATARACT 10 EWAP MARCH 2024 he said. In a discussion of factors that could sway a surgeon or patient to have surgery done sooner, one of the most common is the desire of the patient to reduce spectacle dependence. He often counsels patients, “Don’t do cataract surgery just to eliminate glasses because I cannot ensure that 100% of the time.” However, there are some circumstances where less spectacle dependence can play a role. “If the patient has presbyopia and is a high hyperope or myope who has already undergone vitreous separation, you could consider the desire to reduce spectacle dependence because there is also a significant quality of life improvement in those circumstances.” Another example would be someone who is a long-time contact lens wearer with monovision. Those patients may not tolerate their monovision any longer, which can be unsettling. “If they desire to stay in functioning monovision and they no longer can, cataract surgery may be indicated,” he said. Patients with glaucoma who are on multiple drops and have trouble taking them consistently may be another case in which to operate earlier, when combined with MIGS procedures to improve compliance. Dr. Rai said patients may present with comorbid conditions that add complexity to their cataract surgery. Common ocular comorbidities include pseudoexfoliation syndrome, previous vitrectomy, and poorly dilating pupils that may predispose to intraoperative floppy iris syndrome. “We know these patients may be at increased risk for intraoperative complications, and allowing the cataract to become hypermature only serves to elevate the complexity of the surgery for the surgeon and the corresponding risk for the patient,” Dr. Rai said. “I have been referred patients who previously had complicated surgery elsewhere for their first eye, and their second eye was canceled and has subsequently progressed to a hypermature cataract,” Dr. Rai continued. “Understandably, these patients are concerned about proceeding with cataract surgery in their ‘good eye,’ but they have paradoxically increased the risk for complications by delaying surgery. Of course, when there is a surgical complication, the first priority is to rehabilitate that eye to its visual potential, which is often quite good. Once that is accomplished, the other eye should not be ignored, and the patient should be offered cataract surgery in a reasonable timeframe. A referral to a colleague can help reduce stress for both the patient and ophthalmologist. Another example is a patient who presents with a rapid onset white cataract in one eye and an early posterior subcapsular cataract in the other eye. I would proceed with removing both cataracts as soon as possible instead of allowing the mild posterior subcapsular cataract to rapidly progress into a more complicated surgical case.” When deciding when to move forward with cataract surgery, Dr. Kandavel said he will ask patients to clear their schedules for 3–4 weeks after surgery in case anything occurs in the postop period. “I also tell them on initial consultation that they won’t be able to go in the pool or in the water at the beach. I always tell them if they plan to go outside the continental U.S. to take that trip before they have surgery. I generally don’t recommend doing one eye, going on vacation, and coming back and doing the other,” he said. “I frequently will have a husband and wife come in for a simultaneous consultation, and I always tell them that only one person can have surgery at a time because they need someone to be the driver, and they may need someone to put in drops if that ends up being a problem.” If patients decide at the end of the consultation to postpone surgery, Dr. Kandavel said that he advises them that he will repeat testing and the dilated exam 90 days after the consultation. “Patients are highly educated about cataract surgery and their lens options even prior to their consultation with me,” Dr. Rai said. “They have consulted their friends and the internet to learn about their intraocular lens options, and many patients are seeing cataract surgery as an opportunity to improve their clarity and best corrected vision and their pre-existing refractive error. “Patients who have more advanced cataracts are very easy to please because the postoperative difference in best-corrected visual acuity is more appreciable. However, with improved IOLs and biometry, modern cataract surgery allows great predictability with respect to reducing refractive error. As a result, patients who have significant pre-existing refractive error also tend to be quite pleased following cataract surgery as they notice a large benefit in their uncorrected distance visual acuity and possibly a presbyopic benefit as well,” Dr. Rai said. EWAP Editors’ notes: Dr. Kandavel practices at Colvard-Kandavel Eye Center, Encino, California, and has interests with Alcon, Bausch + Lomb, Glaukos, and Tarsus. Dr. Nejad is Assistant Professor of Ophthalmology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, and declared no relevant financial interests. Dr. Rai is Residency Program Director, Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Canada, and has interests with Alcon and Bausch Health.
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