Advances In Cataract Surgery Show The Value Of Tools And Technology To Surgeons
Although modern cataract surgery is already a mature and refined procedure, I have been delighted to see that new technologies continue to make surgery easier for me and my staff, with better results for patients.
Here I will discuss 3 recent cases that illustrate the value of new technologies in cataract surgery.
Case 1: Patient with cataract with severe untreated glaucoma
The patient was a 73-year-old non-English speaking woman referred by a local retinal specialist. She suffered from non-insulin-dependent diabetes, as well as high cholesterol and hypertension.
His ocular history was significant for diabetic retinopathy and macular cysts in both eyes. She was not taking any topical eye drops.
Upon examination, I found her best corrected visual acuity (BCVA) to be 20/50 OD and 20/40 OS. She had 3+ nuclear sclerosis and 1+ cortical cataracts in both eyes.
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The IOP was not elevated (17-18 mm Hg), but it showed severe constriction of the visual field in both eyes, as well as loss of the retinal nerve fiber layer and retinal ganglion cells, worse in the eye. left eye than in the right eye.
The cup / disc ratios were 0.76 oculus dextus (OD) and 0.72 oculus sinister (OS).
The pachymetry was slightly finer than the average OU; the angles were narrow but open. I diagnosed the patient with normal tension glaucoma and mature cataracts.
To treat already severe glaucoma, we needed to reduce its pressure significantly.
Given that along with the patient’s language barrier and the financial challenges expressed by her family interpreter, I determined that the drops alone might not be successful.
Fortunately, we have several options for performing minimally invasive glaucoma surgery (MIGS). I particularly like the combination of microstent (Hydrus Microstent; Ivantis, Inc) and viscocanalostomy with a surgical system (Omni Surgical System; Sight Sciences).
Not only do the 2 together significantly reduce IOP by improving flow, but performing a 180 ° canaloplasty gives me the ability to come back later and treat the remaining 180 °, with or without goniotomy, if I have need more pressure reduction in the future.
Related: The path to faster visual recovery after glaucoma surgery
In addition, performing the Omni procedure first opens the canal and makes the insertion of the microstent. (Figure 1) quick and easy.
The MIGS procedure only added a few minutes to the case, and this patient had an excellent result: Visual acuity OU of 20/20 and a reduction in her IOP in the range of 12 to 13 mm Hg without drops.
I do not have a glaucoma specialist nearby to refer patients to and would prefer to avoid trabeculectomy for my patients, so being able to use these new technologies to titrate MIGS based on the severity of the disease at the time of surgery. cataracts had a major impact on the way I manage glaucoma.
Case 2: Cataract and disease of the ocular surface
A 68-year-old retired patient presented for a cataract assessment, complaining of decreased vision over the past year (worsening left eye) and difficulty driving at night due to glare.
She was previously diagnosed with dry eye, MGD and mild age-related macular degeneration. Systemic conditions included arthritis and seasonal allergies.
On examination, her BCVA was 20/25 OU, decreasing to 20/50 with glare. She had a visually significant regular astigmatism and wanted the independence of glasses.
Optical coherence tomography examination showed only a few drusen and very slight disruption of the retinal pigment epithelium, with normal thickness and macular outline.
Related: Analyzing the Classifications of Macular Dystrophy
His IOP was in the order of 18 to 20 mm Hg, with a cup / disc ratio of 0.5 OD and 0.45 OS. There was no history of glaucoma.
I decided to implant toric IOLs and use an intraoperative sustained release formulation of 9% dexamethasone injectable suspension (Dexycu; EyePoint Pharmaceuticals Inc) to deliver a decreasing dose of steroids for the first few weeks after surgery.
In my experience, this intracameral steroid controls inflammation very effectively with little impact on IOP and is a great choice for most patients undergoing cataract surgery.
The ability to reduce or eliminate postoperative drops dramatically improves the surgical experience for patients, which is especially important for those receiving high quality IOLs and anyone with ocular surface disease (OSD) because it reduces the amount of toxic preservatives on the eye.
Because this patient had OSD, I wanted to be as gentle on the ocular surface as possible and minimize any discomfort after surgery. It was 20/20 uncorrected, and the toric lens was in the perfect position after surgery.
On postoperative day 1, the patient had 1-2 + anterior chamber cells, with almost no cells at the 1 week visit and none at the 1 month visit.
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While 9% dexamethasone is a great option for most cataract patients, I recommend using it first for patients with social, physical, or cognitive limitations that prevent them from administering drops in a meaningful way. reliable or for patients with severe OSD.
Once you are comfortable with the injection technique, you can expand your use of dexamethasone 9% more widely.
Also, rather than injecting the spherule behind the iris, as we were initially taught, I prefer to inject it (Figure 2A) in the capsular bag, where the capsulorhexis overlaps the optic of the lens and the lower edge of the lens haptic can hold the spherule in position (Figure 2B).
With this approach, the drug remains
firmly in place rather than coming out, especially in a patient with larger pupils.
Case 3: Presbyopia corrector IOL candidate
A 56-year-old pastor presented for a cataract assessment with complaints of decreased vision interfering with daily activities and night driving.
He wore contact lenses to correct moderate myopia and was previously diagnosed with MGD.
Related: IOL Correcting Presbyopia Improves Patients’ Vision
On examination, the BCVA in the left eye was 20/40, worsening to 20/80 with glare. The macula, optic nerve, and IOP were all normal.
He had 1+ nuclear sclerosis, with 2+ posterior subcapsular cataract (PSC) OS and 1+ PSC OD.
He wanted show independence, with a strong need for good intermediate vision for computer work and the ability to see his notes on the pulpit in church. I planned femtosecond laser assisted cataract surgery on the left eye with a PanOptix (Alcon) trifocal lens.
We discussed that he would wear an OD multifocal contact lens until that eye could be treated and that he would have to stop wearing contact lenses for 2-4 weeks before the biometrics.
With a patient who has OSD and potential contact lens deformity, it is important to closely examine the keratometry and ensure that several measurements match before proceeding with a higher quality IOL.
Related: Posterior Corneal Elevation: Is There a Role for Higher Quality IOLs?
In the past this involved having multiple screens open on my computer and switching between screens and prints.
Since I started using Veracity Surgical preoperative planning software (Carl Zeiss Meditec), I have been able to quickly view all patient preoperative data from multiple diagnostic devices in our office and compare refractions and keratometry. on different devices. (Figure 3).
I can run multiple IOL power calculation formulas (including toric and post-refractive formulas, if needed) to ensure the correct choice of IOLs.
Truthfulness is so much more effective than the “old” way of doing things. I can tell right away, while the patient is still in the hallway, if I will have to bring him back for more biometrics after a period of intensive ocular surface management.
The system also pulls information from our electronic health record system and alerts me to any medical or eye problems. (Illustration 4) that could affect the result, providing an additional measure of safety.
This patient’s Ks were in good agreement at baseline. He ended up with an uncorrected visual acuity result of nearly 20/20 and is eagerly awaiting surgery with the same IOL in the other eye.
These are just a few of the cutting edge advancements in the field of cataract surgery.
About the Author
Lisa K. Feulner, MD, PhD
E: [email protected]
Feulner is the founder of Advanced Eye Care & Aesthetics in Bel Air, Maryland. She is a paid consultant for EyePoint Pharmaceuticals, Inc.