2000 Nov;85(5):708-11. doi: 10.1093/bja/85.5.708. Cataract surgery itself is painless. “There may not be a benefit there. seudoexfoliation has long been known to be a concern when performing cataract surgery. Dr. Zhang says she finds these helpful when managing a pseudoexfoliation patient. Dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia. HHS A cataract is a cloudy film that grows over the eye's lens and impairs vision. Dr. Giaconi notes that in terms of a mechanical device, both iris hooks and a pupil expander have pros and cons. “An eye that has pseudoexfoliation will usually present with pseudoexfoliation material on the pupil margin and the anterior lens capsule that’s visible during the slit lamp exam,” notes Uday Devgan, MD, FACS, FRCS, chief of ophthalmology at Olive View UCLA Medical Center, an associate clinical professor at the UCLA School of Medicine, and in private practice at Devgan Eye Surgery in Los Angeles. “You always need to have vitrectomy equipment on hand.”, • If you think the lens may need to be sutured in, consider referring the patient to someone with extensive experience doing that. They get the job done, although they’re not approved for that. “That way the nurses won’t have to go searching for things in the middle of surgery.”, • Make sure you’re comfortable performing an anterior vitrectomy and are prepared to do so. This can restore vision in cases where vision has been impaired because of cataracts. Cataract surgery is generally performed with minimal sedation and typically takes less than 30 minutes. So, if I find a lot of zonulopathy, I’d probably go ahead and put in an anterior chamber lens.”, • Use a phaco technique that won’t stress the zonules. Current evidence suggests that warfarin therapy significantly improves prognosis in patients with atrial fibrillation with coexisting cerebrovascular disease, and those with non-tissue prosthetic heart valves. “Not everyone does this, but if you do, check the angle for fibrillary deposits,” advises Dr. Zhang. However, I am not surprised by it. “I wouldn’t put a CTR in a pseudoexfoliation patient with 360-degree zonular weakness,” he says. COVID-19 is an emerging, rapidly evolving situation. J Cataract Refract Surg. Dr. Giaconi notes that this is another sign of loose zonules. “The incidence of vitreous loss tends to be higher, especially in those patients that have much narrower anterior chambers.”, Dr. Giaconi agrees. • Look for material on the lens capsule and iris. It is difficult to accurately measure risks of local anaesthetic blockade in anticoagulated patients as techniques are not standardized. When to seek help. “Capsule hooks would be ideal to provide capsular support, but when capsule hooks aren’t available, I’ve used iris hooks. Eye (Lond). My doctor said the reason is because I have small eyes. “Right now I’m not aware of any prospective studies that go out 10 years. To prevent that, you want to create at least a 5-mm or 5.5-mm-diameter capsulorhexis. Nearly 10 million cataract surgeries are performed around the world every year, making it one of the most common surgical procedures.. Cataract surgery can be completed in 15 minutes as an outpatient procedure. Prognosis for visual acuity with retrobulbar haemorrhage is generally good, given an experienced surgeon is present to rapidly decompress the eye. To restore a clear vision, a surgeon performs the cataract surgery where he makes a small 2 mm cut on the cornea to enter into the eye and remove the clouded lens by opening the bag in which it lies. If you see that the anterior capsule remnant has contracted or is phimotic, you can use the YAG laser in the clinic to make some relaxing incisions, for example at 3, 6, 9 and 12 o’clock. It is reasonable to have cataract surgery in only one eye. “In one of my online educational videos I did a comparison; I did one eye using a Malyugin ring and did the other using my [no-device] approach. “Suppose the pupil dilation is acceptable, so you start the capsulorhexis,” Dr. Devgan says. Cataract surgery separates the cataract from the lens capsule. When you’re using iris hooks for this purpose, aim for a slightly steeper angle, so the pivot of the hook can capture the capsule. Some surgeon are very specific about which medications may be continued and which need to be stopped prior to surgery. Use of anticoagulation in elderly patients with atrial fibrillation who are at risk for falls. “In many cases of pseudoexfoliation, glaucoma or ocular hypertension are present,” Dr. Zhang points out. That tells you right away that you’re dealing with loose zonules. Surgery Overview. This minimizes the impact of any shrinkage.”, Dr. Giaconi points out a second reason to make a large capsulorhexis. It will make the initial surgery take longer and impact patient comfort as well.”, • Remember: If a big problem occurs, you don’t have to solve it that day. “The strength of the dilating drops is very different. All rights reserved. Giaconi, Zhang and Devgan report no financial ties to any product discussed. “For uncomplicated cases, a drop of dorzolamide-timolol in the OR immediately following surgery has been reported to help with IOP in the first 24 hours,” says Dr. Giaconi. The thing that’s great about iris hooks is that you can place them anywhere, and use as many or as few as you like.”, • Make a large capsulorhexis. “Pseudoexfoliation isn’t a potential disaster, as long as surgeons know what they’re doing. In the OR the patient has sedation on board, so you can shine that bright microscope light in their eye and they’re very cooperative. It's often carried out as day surgery under local anaesthetic and you should be able to go home on the same day. Typical Cataract Surgery […] I routinely advise people who are able to drink (in other words, they are not alcoholics, pregnant, or have a medical condition or treatment which precludes drinking) to drink sparingly when taking any psychoactive medication such as bupropion (Zyban). Once you’ve determined that pseudoexfoliation is present, these strategies can help ensure successful cataract surgery: • Let the patient know that the surgery has a slightly higher risk because of the pseudoexfoliation. NLM That’s because the zonules are so loose that the lens moves forward and back.”. “As a glaucoma specialist, I do this routinely.”. However, as with any surgery, complications can occur and are related to the procedure itself or to the anaesthesia. “The material that weakens the zonules also clogs up the trabecular meshwork,” Dr. Devgan points out. However, a recent study conducted at Aravind Eye Hospital in India looked at uncomplicated pseudoexfoliation cases—patients with no zonulopathy where the pupils dilated reasonably well. The lens is enclosed in a lining called the lens capsule. “Another clue, which is a little more subtle, is the anterior chamber depth relative to the axial length,” Dr. Devgan points out. A team of highly qualified professionals, including an ophthalmologist who specializes in managing visual impairments, is also essential to surgical success. In most cases, the lens will be replaced with an intraocular lens implant (IOL). The anticoagulated patient presenting for cataract surgery presents many dilemmas for anaesthetist and surgeon alike. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. “In terms of timing, if you put it in early in the procedure, you’re going to have trouble removing some of the cortex or nuclear material,” she says. Copyright © 2020 Jobson Medical Information LLC unless otherwise noted. “I only suture a lens once or twice a year, so it may not be in the patient’s best interest for me to spend an extra hour and a half doing that. “A CTR isn’t really designed to support that many clock hours. And in which situations is it not likely to be helpful? 2015 Aug 27;(8):CD006291. For those with 360-degree weakness, my preference is getting a three-piece lens, putting the haptics in the sulcus and capturing the optic behind the capsulorhexis so the optic is in the bag. “I wouldn’t insert a capsular tension ring if there’s more than four clock hours of zonular laxity,” she adds. You don’t have to do it at the same time.”. Cataract surgery complications are few, and cataract surgery is among the most common and most successful surgical procedures performed today.. The chance of vitreous loss will be higher in those patients.”, Because a common effect of pseudoexfoliation is a pupil that fails to expand sufficiently, the surgeon has to decide how to compensate. Dr. Devgan says he prefers not to use any device or pharmaceutical at all. Here, surgeons share their experience and advice for making sure these patients have the best outcomes possible. Cataract surgery and astigmatism correction in patients with connective tissue disease commonly associated with dry eye are feasible, according to a … If it’s borderline—in the mid-20s or so—I’d probably bring them back in a couple of days to reassess, and I might start them on a topical drop for pressure control.”. “Because these lenses aren’t used that often today, our OR doesn’t stock all of the options. Vision is better, but I will still will need readers. I'm just not looking forward to the pain again and I … I tell them: ‘If you start to feel a headache coming on, take a tablet.’, “I check these patients the morning after surgery,” she adds. So, I’ll measure the white-to-white distance and calculate the power, and ask the OR to pre-order the appropriate lens so it’s available if needed.”, • Make sure pupil expansion tools will be available in the OR. Current evidence suggests that warfarin therapy significantly improves prognosis in patients with atrial fibrillation with coexisting cerebrovascular disease, and those with non-tissue prosthetic heart valves. Oral bupropion resulted in high significant protection from cataract development and there was no change in pupil diameter, positive light reflex, positive corneal sensation, no conjunctival redness, decreased level of MDA and increased level of GSH. “When the patient has pseudoexfoliation, a vitrectomy may be necessary,” notes Dr. Zhang. Risk of Intraocular Bleeding With Novel Oral Anticoagulants Compared With Warfarin: A Systematic Review and Meta-analysis. “Also, compare the anterior chamber depth to that of the fellow eye. “You’re not stopping its progression by doing the cataract surgery. A typical procedure doesn’t take very long — only about 15 minutes. • Consider keeping your pseudoexfoliation patient on medications longer. Br J Anaesth. | 6. “When zonular support is weak, pseudoexfoliation patients tend to develop capsular phimosis three, six or even 12 months after surgery,” Dr. Devgan explains. If the lens has landed back on the retina, you should call a vitreoretinal colleague.”, Dr. Giaconi points out that pseudoexfoliation during cataract surgery isn’t the problem it once was. Colors are much better. “However, when you’re following-up a pseudoexfoliation patient, you won’t be able to see the anterior chamber rim, or any phimosis, unless you dilate. If it’s still very close to the iris when you see the patient, you may be able to retrieve it by yourself; then you’ll have to suture the lens in place. Our outcomes are better than they were 20 years ago. The anticoagulated patient presenting for cataract surgery presents many dilemmas for anaesthetist and surgeon alike. “The edges of the iris may have a white fibrillary appearance,” she says. Most of the complications from cataract surgery are minor and can be corrected. Dr. Devgan notes that it’s sometimes easier to see pseudoexfoliation on the operating table than it is to see it in the clinic. Attempted cessation and recommencement of warfarin therapy may not only reverse anticoagulation for unpredictable periods of time but may also expose patients to a transient yet dangerous hypercoagulable state. We recruited patients who received new diagnoses of glaucoma, either primary open-angle glaucoma (POAG) (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 365.1) or primary angle-closure glaucoma (PACG) (ICD … “On the other hand, if the surgery was complicated, and there’s no contraindication, I usually give these patients a dose of Diamox in the OR to try to prevent an overnight spike in pressure. While the recovery is uneventful, there are restrictions after cataract surgery. 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