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LET’S TALK ABOUT DISCLOSURES • The content of this CE activity was prepared independently by Dr. Sean W. CATARACT Smolenyak without input from members of the ophthalmic community. • Dr. Sean W. Smolenyak is affiliated with Allergan, Aerie, Glaukos, Kala, Notal SURGERY! Vision and Sun Pharmaceuticals as a speaker or consultant. • Dr. Sean W. Smolenyak has no direct financial or proprietary interest in any companies, products or services mentioned in this presentation. SEAN W. SMOLENYAK, O.D. • The content and format of this course is presented without commercial bias and COPE # does not claim superiority of any commercial product or service.

WHY IS CATARACT SURGERY IMPORTANT?

• Cataracts are the leading cause of treatable blindness in the world • By 2032, 38.5 million people in the U.S. will have a cataract and that number increases to almost 50 million by 2050 • Declining number of number of cataract and corneal specialists compared to the expected growth of cataract cases (3+M cases/year and growing) • Most common surgical procedure • Increasing rates of co-management (40% as of 2013)

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WHO SEES CATARACT PATIENTS FIRST?

58,000 eye care professionals are licensed to perform comprehensive eye exams

16M Optometrists (15%) 18,000

Ophthalmologists 40,000 88M (85%)

ODs perform an estimated 88 million comprehensive eye exams annually of the total of 104 million performed by all eye care professionals, or 85 percent of all comprehensive eye exams.1 Graph courtesy of Optometric Management, June 2002

1. http://reviewob.com/wp-content/uploads/2016/11/8-21-13stateofoptometryreport.pdf

THE EXPECTATIONS? HISTORY OF CATARACT SURGERY 600 B.C. 17th Century

• Early written description of • Sir Isaac Newton’s Couching work in Optics • Eyeglasses developed

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Nov. 29, 1949 HISTORY OF CATARACT SURGERY • The 1st IOL used in cataract surgery – PMMA IOL 20th Century 21st Century • 1967 1st use of • Advanced Phaco- Technology IOLs 18th & 19th Century emulsification • Laser-assisted • 1st Extracapsular Cataract Surgery Cataract Extraction – • Dropless Cataract April 8, 1747 Surgery • 1851 – Invention of the Ophthalmoscope HISTORY OF CATARACT SURGERY

PRE-OPERATIVE: PRE-OPERATIVE OCULAR SURFACE CONSIDERATIONS • Ocular Surface • Instruments and Measurements • Formulas • IOLs, Targets and Astigmatism

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PRE-OPERATIVE: PRE-OPERATIVE: OCULAR OCULAR SURFACE SURFACE

• Optimize ocular surface prior to referring for cataract surgery • In a 2017 “PHACO” study of prospective cataract surgery patients - 143 • Treat how you feel appropriate: OTC, RX, PLUGS, PROCEDURES subjects/9 centers • DEWS II: Restore HOMEOSTASIS • Study overwhelming demonstrated that Dry Eye disease is highly • Asymptomatic dry eye patients can have significant dry eye prevalent in cataract surgery patients HOWEVER the complaints following cataract surgery (but will blame surgery!) recognition/diagnosis is very low PRIOR to referral for cataract • Dry eye can directly impact the K readings which are used to surgery calculate the IOL power…Inaccurate Ks = Incorrect IOL power • 80.9% patients had level 2, 3 or 4 dry eye according to the ITF selection guidelines…only 22.1% had a prior diagnosis of Dry Eye • The numeric correlation is 1:1 (compared to AXL 1:3) • 76.8% had corneal staining and 50% had central staining

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PRE-OPERATIVE: PRE-OPERATIVE: INFECTION PREVENTION UVEITIS

•Blepharitis, eyelid and nasolacrimal infections are all risk •Uveitis factors for a PO infection •A quiet eye is a good eye! •Widespread use of off-label topical antibiotics pre- operatively (no topical AB has this indication!) •Standard of practice, if possible, is for the eye to be quiet for 2-3 months OFF steroid drops prior to surgery •At surgery center, BETADINE skin prep & diluted BETADINE drop instilled •What about pre-operative use of steroids in a healthy eye? Any help? •Endophthalmitis rate 0.08% - 0.68%

PRE-OPERATIVE: PRE-OPERATIVE: EBMD OCULAR SURFACE

•Corneal Dystrophies & Previous Refractive Surgery • EBMD/Map-Dot • Salzmann’s Nodules • Fuchs Dystrophy • RK/LASIK/PRK

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PRE-OPERATIVE: EBMD TOPOGRAPHY EBMD POST-OP IMAGE

EBMD POST-OP IMAGE

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PRE-OPERATIVE: SALZMANN’S NODULE PRE-OPERATIVE: SALZMANN’S NODULE

PRE-OPERATIVE: SALZMANN’S NODULE REMOVED FUCHS DYSTROPHY

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RK/LASIK/PRK HOW TO ADDRESS FUCH’S PREOPERATIVELY

• Estimated prevalence of 1/2000 but probably under-reported • Most common in FEMALES and those >50 y/o • Treatments include HYPERTONIC SOLN/UNG, STEROIDS, HAIR DRYERS and DSEK/DMEK transplants • Transplants for FUCHs account for >50% of all corneal transplants • Monitor with VISION and PACHYMETRY

PRE-OPERATIVE: RK HOW TO BEST MANAGE RK PATIENTS •Have to manage OSD/Dry Eye •Will need to take multiple measurements at different times of day (but why?) How do you target outcome? •Counseled that due to prior RK, visual outcomes less predictable and may take longer to achieve •What kind of IOLS and Formulas provide the most accuracy? •ORA recommended due to RK and AXL differences AM K’s: 37.19/37.61x089 PM K’s: 36.47/37.32x045

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LASIK/ LASIK/ PRK PRK (myopic) (hyper)

PRE-OPERATIVE: PRE-OPERATIVE: CONTACT LENSES CONTACT LENSES & KERATOMETRY •Contact Lens Wear Measurement #1 Why do we have patients discontinue their contact • H/O RGP CL wear x 57 years lenses prior to their cataract evaluation? RGP CL out x 3 weeks and patient had •Gas Permeable CL: out at least 3 weeks prior to been wearing SCL during the 3 week period – SCL out 3 days prior evaluation, but stable measurements determine OD 44.82/46.17 x 157, Res Cyl 1.35D •Soft CL: out 3 days prior to evaluation OS 44.82/45.42 x 008, Res Cyl 0.6D

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PRE-OPERATIVE: CONTACT LENSES & KERATOMETRY PRE-OPERATIVE: RETINAL DISEASE

MEASUREMENT #2 MEASUREMENT #3 MEASUREMENT #4 • No clear evidence that cataract surgery worsens AMD (dry or wet) • RGP CL out 6 weeks SCL out an additional 2 • OS only – • SCL out 2 weeks weeks remeasured 10 days • If patient is receiving injections, best to get written clearance OD 45.06/46.36x014 OD 45.24/46.23x148 following • Studies indicate cataract surgery can worsen DIABETIC RETINOPATHY Measurement #3 Res Cyl 1.3D Res Cyl 0.99D • Whether undergoing treatment (injections, laser) or only being monitored, OS 45.36/45.92x036 best to get written clearance OS 45.42/46.23x067 OS 45.42/46.11x048 Res Cyl 0.56D • As their OPTOMETRIST, you are the gate keeper (not the cataract surgeon) Res Cyl 0.81D Res Cyl 0.87D • You control the narrative and timeline/referral patterns

PRE-OPERATIVE: MEASUREMENTS IOL Master • Gold-Standard in instrumentation for pre-operative measurements for cataract surgery. Non-contact & maximizes patient comfort. • Quickly and precisely performs the necessary measurements: Axial Length, Keratometry, Anterior Chamber Depth (ACD) and White-to-White (WTW).

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PRE-OPERATIVE: MEASUREMENTS Posterior Immersion Ultrasound A-scan Surface of • Employed in different situations: Probe Lens dense cataract; axial length difference between eyes when measured by the IOL Master; or when the patient cannot safely use the IOL A Retina Master. Cornea • The patient is seated in a semi- reclined position, and an ultrasound Anterior probe submersed in a water bath is Surface of Lens used on the corneal surface. The ultrasound unit measures the time is takes for the ultrasound wave to travel from the probe tip to the retina and back. A one-dimensional scan is produced measuring eye axial length.

PRE-OPERATIVE: TOPOGRAPHY Topography • Pentacam – utilizes a rotating Scheimpflug camera that maps/measures corneal astigmatism by acquiring 50 measurements of the anterior & posterior corneal surfaces in 2 seconds. • The Pentacam is utilized to perform corneal power measurements across different corneal zones in patients including those who have previously undergone refractive procedures. • Cross reference cylinder amounts with IOL Master

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CASSINI PRINTOUT PRE-OPERATIVE: TOPOGRAPHY

• Cassini – measures anterior and posterior astigmatism as well as total corneal power • Topcon • Marco • S4Optik

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PRE-OPERATIVE: PRE-OPERATIVE: WHEN K’S DON’T AGREE UNMASKING ASTIGMATISM

PRE-OPERATIVE: WHEN K’S DON’T AGREE PRE-OPERATIVE: WHEN K’S DON’T AGREE

•The Pentacam K’s were used to calculate Crystalens IOL power OU; Manual AK performed in lieu of Femto AK •OD POD#1 UCDV 20/60; POW#3 20/20 •OS POD#1 UCDV 20/40 •At 4.5 months PO, pt presented for a YAG Capsulotomy evaluation • UCDV OD 20/20-1 OS 20/25 • UCNV OU J1

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PRE-OPERATIVE: WHAT’S IN A FORMULA? PRE-OPERATIVE: WHAT’S IN A FORMULA?

•1st & 2nd Generation Formulas 3rd & 4th Generation Formulas •Theoretical formulas and Regression formulas: • rd Fyodorov, Binkhorst I and II, Shamas, SRK and SRK II. • 3 generation Hoffer-Q, Holladay I and SRK-T utilize Ks and AXL to predict ELP •Prior to 1980, Effective Lens Position (ELP) was a • 4th generation Holladay II, Haigis, Olsen and Barrett Universal constant of 4mm for every patient & IOL II utilize 7 variables (Ks, AXL, ACD, Lens thickness, horizontal •During the 1980’s Binkhorst used AXL as a scaling factor for WTW, age and pre-op refraction) ELP

PRE-OPERATIVE: WHICH FORMULA IS BEST? PRE-OPERATIVE: A-CONSTANT & SURGEON FACTOR • Not a “one-size fits all eyes” approach • A-Constant: an IOL constant used with the regression IOL • Post-refractive Sx: power formulas. It is a value assigned by the Holladay II manufacturer that corresponds with the anticipated • Long Eyes: Barrett position of the IOL in the eye. • Consider the IOL to be implanted • Surgeon Factor: an IOL constant based on the distance • The future will use AI from the iris plane to the optical plane of an IOL w/automated refraction implant used with the Holladay formula devices to optimize formulas

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PRE-OPERATIVE: PRE-OPERATIVE: EFFECTIVE LENS POSITION (ELP) EFFECTIVE LENS POSITION (ELP)

•ELP is the “Holy Grail” of cataract surgery •The position of the IOL in the eye. Specifically, the distance that the primary plane of the IOL sits behind the cornea. •Unable to calculate – limiting factor in IOL Power Accuracy •More critical in short eyes and long eyes •Where the IOL actually sits will dictate final refraction

PRE-OPERATIVE: INTRA-OPERATIVE: IOLS AND TARGETS EVOLUTION OF IOL MATERIALS

• Great time to have cataract surgery, greater number of IOL and surgical • Polymethylmethacrylate (PMMA) 1949 Dr. Ridley options available, and patients have the opportunity to choose how they • Foldable IOLs: Silicone would like to see for the rest of their lives • Associated with increased ocular inflammation, posterior/anterior capsular opacification • There is not an IOL that is “perfect” - Recommend surgical options that are • Contraindicated in Silicone Oil filled eye best for each patient and each eye • Acrylic • Educate patients that they have multiple diagnoses affecting their vision: • Hydrophobic: can be brittle, increased glistenings, dysphotopsia Cataract, Astigmatism, Myopia, Hyperopia and Presbyopia • Hydrophilic: more biocompatible than other materials • Lower PCF rates than silicone but still high (50% at 5 years) • Counsel, counsel, counsel. Under-promise and over-deliver! • Why OD’s need capsulotomy privileges! SCOPE EXPANSION!

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PRE-OPERATIVE: PRE-OPERATIVE: INTRAOCULAR LENSES ADVANCED TECHNOLOGY IOLS • Monofocal • “Traditional” cataract surgery •Toric IOL (Monofocal) lens implant •Allows for the treatment of cataract and • Will typically require glasses after surgery corneal astigmatism within the IOL • Can manipulate the AIM of the Ability to treat 0.75 to 5.0 D of astigmatism IOL to achieve desired • outcome •Patients will need glasses for Intermediate and Near • Haptic and plate IOLs Vision (unless monovision/MF/EDOF/Trifocal Toric) • 3-piece IOLS

PRE-OPERATIVE: PRE-OPERATIVE: ADVANCED TECHNOLOGY IOLS ADVANCED TECHNOLOGY IOLS •Toric IOL alignment is critical •3° Misalignment = 10% loss of effective cylinder correction •10° Misalignment = 33% loss effect •15° Misalignment = 50% loss effect (back to OR!)

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PRE-OPERATIVE: PRE-OPERATIVE: ADVANCED TECHNOLOGY IOLS-MULTIFOCALS ADVANCED TECHNOLOGY IOLS

• Alcon ReSTOR, Activefocus • Tecnis Multifocal •Accommodating • +4.00/+3.00/+2.75 Add • +2.75: 5 concentric rings •Monofocal IOL with hinged • +3.25: 18 concentric rings optic designed to allow IOL • +4.00: 22 concentric rings flexing •Bausch & Lomb Crystalens and Trulign •Aspheric design

PRE-OPERATIVE: PRE-OPERATIVE: ADVANCED TECHNOLOGY IOLS ADVANCED TECHNOLOGY IOLS •Extended Depth of Focus (EDOF) Accommodating • •Extended echelette design allows for an elongated focal •IOL position in eye is important. Can get surprises point to enhance a range of vision/depth of focus. due to hinges: Vault and Z Syndrome •Patient Selection: seeking improved DV & IV without glasses •Educate patient they will still need readers when while continuing to need readers for small print or dim reading fine print and/or in dim lighting lighting •J3 is a GREAT NVA outcome without readers •Educate regarding glare and halos PO (neuro-adaptation)

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PRE-OPERATIVE: ADVANCED TECHNOLOGY IOLS-TRIFOCALS

PRE-OPERATIVE: TREATING ASTIGMATISM & MANAGING TARGETING PRESBYOPIA IN CATARACT SURGERY

Every patient over the age of 50 is impacted by 1/3 of Patients have > 1.0D of astigmatism but •Monofocal IOL – the goal is emmetropia (usually?) only 1/4 of those patients are receiving a Toric presbyopia, yet only 6.5% of patients receive a IOL presbyopia-correcting IOL % of Patients receiving Toric •Monovision-How much? (focal point) Which eye? IOL % of Patients receiving PC IOL 6.5% History w/CL? PC IOL 25% 67% 33% Monofocal IOL Hyperopes easy to please; watch those myopes! 8% • 93.5% ■Patients > 1.0D Astigmatism •How do you target advanced technology IOLS? ■Patients receiving Toric IOL Patients who do not have astigmatism and presbyopia treated at the time of cataract surgery must treat those conditions with glasses for the rest of their lives.

2016 Market Scope Data

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INTRA-OPERATIVELY INTRA-OPERATIVELY: DROP-LESS CATARACT SURGERY •Injectables and Drug Eluting Plugs •3 C’s for the patient: Convenience, Compliance and Cost- Femtosecond laser-assisted cataract surgery (FACS) • saving What is ORA? When is ORA recommended? • •An injection given at the time of surgery of premixed •Flomax drug(s) •Viscoelastics •Can be suspensions or solutions •Posterior Capsular Rupture/Lens Remnants •Typically not used with Advanced Technology IOLs •Future: Posterior Capsulotomy (POC) •Any concern with a compounding pharmacy?

INTRA-OPERATIVELY: INTRA-OPERATIVELY: DROP-LESS CATARACT SURGERY TRIMOXI

•Educate patients •Not “Drop-free” surgery •Floaters after surgery due to suspension •Solution to rising cost of eyedrops including generics •Blurry vision on average 3-5 days following surgery •Trimoxi alone: 10% break-through rate (Imprimis) •May need an additional PO drop •Dex-Moxi: Increased risk of IOP rise (Imprimis) •Elevated IOP •Adding NSAID: cuts break-through rate in half •Other ocular pathology

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FEMTOSECOND INTRA-OPERATIVELY: SURGERY (FACS) INJECTIONS AND PLUGS

• OMIDRIA (phenylephrine & ketorolac solution): Indicated for maintaining pupil size and reducing postoperative ocular pain; added to irrigating solution • DEXYCU (dexamethasone suspension): Indicated for treatment of postoperative inflammation; only FDA approved, single dose, intracameral steroid • DEXTENZA (dexamethasone ophthalmic insert): Placed in inferior puncta for 30 day steady release of drug; done in operating room

INTRA-OPERATIVELY: INTRA-OPERATIVELY: FEMTOSECOND LASER-ASSISTED SURGERY FEMTOSECOND LASER-ASSISTED SURGERY

•Secondary Benefits: •Allows the surgeon to make a precise capsulorrhexis •Primary Benefit: Used to treat corneal astigmatism (or how you can bill a patient for FACS) • Uses less phaco power •Softens dense cataracts •Patients must have a minimum of 0.5 D corneal astigmatism to be a candidate •Commonly bundled with any Advanced Technology IOL •Most studies have yet to prove significant difference

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MANUAL PHACOEMULSIFICATION SURGERY INTRA-OPERATIVELY: FEMTOSECOND LASER-ASSISTED SURGERY • Total treatment time <2 minutes • Average laser treatment time 20-35 seconds • Easy docking • Outcomes more predictable as compared to standard cataract surgery (?) • Utilizes less energy • Still not widely accepted…(but neither was phaco!)

INTRA-OPERATIVELY: INTRA-OPERATIVELY: FACS FEMTOSECOND LASER-ASSISTED SURGERY

• Non-reimbursable technology by OCT OF LASER CATARACT INCISION OCT OF MANUAL INCISION Medicare and Commercial Carriers • Allows for less phaco energy = “gentler” procedure • Precise, replicable capsulorrhexis • Outcome of cataract surgery is dependent upon the skill of the surgeon not the laser

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INTRA-OPERATIVELY: INTRA-OPERATIVELY: WHAT IS ORA? WHAT IS ORA?

•ORA is an intraoperative aberrometer used during surgery to analyze the eye in an aphakic state •ORA System® with VerifEYE® has been shown to improve outcomes by taking into account anterior and posterior astigmatism

INTRA-OPERATIVELY: INTRA-OPERATIVELY: ORA SCRATCH YOUR HEAD ORA

• Recommended to patient’s who are s/p RK, PRK, LASIK • Unusually long or short AXL • ORA is not infallible • Takes into account patient’s previous refractive treatment: Hyperopic vs. Myopic • Not all patients have pre-refractive K’s nor remember if they were hyperopic or myopic • Some ablation patterns cause you to scratch your head

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INTRA-OPERATIVELY: ORA SCRATCH YOUR HEAD SPLIT VISUAL AXIS S/P LASIK

SPLIT VISUAL AXIS S/P LASIK INTRA-OPERATIVELY: ORA DATA FIRST 100 CASES

• ORA cases primarily post-refractive and AXL differences on measurement • WHEN ORA recommended the Same IOL power or the surgeon chose NOT to change the IOL power: 52% reaching UCDVA 20/30 or better • WHEN ORA recommends a Different IOL power and the surgeon chose to use the ORA recommendation: 60% reaching UCDVA 20/30 or better • Typically IOL power changes are 0.5D, however few have been 1.0D+

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INTRA-OPERATIVELY: INTRA-OPERATIVELY: FLOMAX FLOMAX

•Can affect the ability of the pupil to dilate and constrict •Malyugin ring •Floppy-Iris Syndrome: characterized by a flaccid iris which billows in response to normal intraocular fluid currents, a propensity for this floppy iris to prolapse towards the area of cataract extraction during surgery and progressive intraoperative pupil constriction despite standard procedures to prevent this.

INTRA-OPERATIVELY: VISCOELASTIC INTRA-OPERATIVELY: POSTERIOR CAPSULAR TEAR •Ideal viscoelastic has both dispersive and cohesive • Occurs when a perforation occurs which could allow vitreous to properties come forward into the front of the eye. Anterior vitrectomy •Maintain AC depth performed to remove the prolapsed vitreous. Might have to •Corneal endothelium protection change type of IOL (always have a back-up) •Help minimize iris prolapse • Nucleus can fall into the vitreous cavity – have retina on speed dial! •Aid in IOL delivery by lubricating the injector • According to a February 2012 article in CRSToday the best •Expansion of the capsular bag estimated rate of capsular complications during surgery is 2%

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INTRA-OPERATIVELY: INTRA-OPERATIVELY: IN-THE-BAG IOL PLACEMENT SULCUS IOL PLACEMENT

NEWER SURGICAL TECHNOLOGIES POST-OPERATIVE CONSIDERATIONS

ZEPTO: Handpiece that creates capsulotomies •POD #1and Common Issues MiLOOP: Handpiece that fragments lens with zero- •POW#1-2 / POM #1 energy •CME…Who’s at risk? CapsuLaser: Attaches to surgical scope to create •Refractive surprises! capsulotomies (no need for femtosecond room) •Dysphotopsia ApertureCTC: Creates capsulotomies

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COMMON DAY 1 ISSUES COMMON

• Corneal Edema • Vision is blurry • Flashing or flickering of vision • Improved with steroid use • Corneal edema. Wide range of day one • Lens settling into capsule • Can add sodium chloride vision from 20/20 to CF • Can see the edge of the lens ophthalmic solution TID • Floaters in vision • Sometimes is the actual edge of lens or • Injectables. Often can see the normal temporal edema from incision floaters/PVD more clearly • Cell/Flare • Photosensitivity • Improved with steroid use • Nausea, headaches, dizziness • Much more light coming through the lens • After effects from anesthesia. Advise then before cataract surgery • Rebound Iritis 2-4 weeks drinking lots of water and rest as needed postop

ELEVATED IOP LENS FRAGMENTS

• How do you “burp” the wound? • Anterior: Do not taper steroids! If no resolution refer back for • Day one: IOP >40 perform paracentesis, “burp” the removal wound. • Posterior: Refer to Retina for • Add hypotensive medication. Avoid prostaglandins removal (usually) • After one week: Possible steroid responder (or PDS) • Cortical: Clear-white translucent Consider hypotensive medication, changing steroids or • Nuclear: Yellow-brown. Not likely to be absorbed D/C steroids completely.

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UVEITIC-GLAUCOMA-HYPHEMA (UGH) IOL DISLOCATION SYNDROME • Risk: pseudoexfoliation, chronic uveitis, diabetes • Mechanical irritation of anterior segment structures by an intraocular • Treatment lens • Observation if minimal. • Transilumination defects, Vision correction with hyphema/microhyphema, pigment dispersion refractive means • Treatment • Suture in place • Steroids for inflammation • Remove and Replace • Ocular hypotensive medication for IOP • Ultimately surgical intervention

VITREOUS PROLAPSE IRIS PROLAPSE

• Risk: accidental trauma, wound • Vitreous Strand to wound leak, increased IOP • Following zonular dehiscence, capsular rupture or anterior vitrectomy • Floppy Iris Syndrome: Tamsulosin(Flomax) • Creates peaked pupil Could try PILOCARPINE • Sequelae: Increased risk of • endopthalmitis, CME • Refer to cataract surgeon for • Treatment with nD:YAG vitreolysis repair

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WOUND LEAK TOXIC ANTERIOR SEGMENT SYNDROME • Shallow Anterior chamber (not always) • Incidence: 0.22%, thought to • Epiphora, blurred vision be reaction to introduced • Low IOP chemical • (+) Seidel • 12-72 hours post-op • Bandage Contact lens. Decrease or stop • Minimally painful steroid. Cycloplegic. • Hypopyon, fibrinous uveitis, • If unable to seal consider SUTURE or SEALANT NO VITRITIS • ReSure Sealant (Ocular Therapeutix) • Topical Steroids Q1hr

POST-OPERATIVE ENDOPHTHALMITIS POSTERIOR CAPSULAR OPACIFICATION

• Incidence: 20-50% within 2-5 • Incidence: 0.08-0.68% years • Younger patients faster • 3-7 days post-op • Can vary with IOL design and • Painful material • Hypopyon, Vitritis • Watch with AT IOLs • Refer to Retina for • Nd:YAG Capsulotomy intravitreal antibiotic • Increased risk of RD is debated injection, culture • Watch for vitreous prolapse, CME

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POST-OPERATIVE: CYSTOID MACULAR EDEMA POD #1

• “Irvine-Gass Syndrome” •How did the patient sleep? Any headache or brow pain? • ~ 4-6 weeks post-op •Are they using their drops? • Risk: Compromised macula (ERM, •Trimoxi patients vs Full Regimen DM Retinopathy, vascular event, broken bag, vitreous prolapse) •How is the vision in the operative eye? • Treatment topical NSAID and •2nd eye complaint – Blame Medicare! Needs to be steroid (combo is best) documented • IVK if necessary

POST-OPERATIVE: POST-OPERATIVE: POD #1 POW#1-2

•Visual acuity •POW#1-2 •IOP – some will have IOP spike POD #1; patients •VA check with quick refraction with nerves at risk or symptoms might need a •Especially important to see if on target for patient paracentesis or additional medications prior to surgery in the 2nd eye with ATIOL or specific •Slit lamp exam: Seidel negative or positive?; Corneal refractive target edema; A/C Reaction; IOL in position; any •IOP abnormalities? • Don’t hesitate to dilate if something seems amiss

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POST-OPERATIVE: POST-OPERATIVE: POM #1 WHY IS PO DATA VALUABLE?

•To determine IOL power for the 2nd eye •POM #1 •Identify refractive surprises •VA check with refraction •To refine surgical processes •IOP •Targets •IOL Power selection •Dilate PRN •Astigmatism reduction

POST-OPERATIVE: POST-OPERATIVE: REFRACTIVE SURPRISES! REFRACTIVE SURPRISES!

•Case study: •OS POD #1: OS UCVA 20/50, IOP 32, trace AC cell. • s/p LASIK OU (in Canada) 1998 and revision OS Treated IOP in office with Combigan • Pre-op MRx: OD +0.25+0.50x45 20/25 / OS +1.00+0.50x180 •Pt called the day prior to her 2nd surgery: no longer had 20/20 to wear CL OD for reading. • Surgical recommendation: MonoVA OS DV / OD NV with ORA OU • AXL difference: IOL Master 21.57/21.92 Immersion Ascan •When asked to cover OD and describe OS VA: DV blurry 21.46/21.80 but able to read with OS. Scheduled pt to come in that afternoon.

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POST-OPERATIVE: REFRACTIVE SURPRISES! POST- • POD#13: OPERATIVE: • OS UCDV 20/100, UCNV J1 • MRx -2.00+1.75x135 20/25 REFRACTIVE SURPRISES! • IOP 23 • SLE: • K Seidel negative • A/C deep & quiet • Implant PC/IOL, few wrinkles, slight anterior position?

POST-OPERATIVE: POST-OPERATIVE: REFRACTIVE SURPRISES! REFRACTIVE SURPRISES!

•Recommended OD DV and ORA to fine-tune IOL power •How would you treat this patient at POD#13 given the measurements and physical findings? •POD#1 OD UCDV 20/60 •OS VA settled out to UCDV 20/60, UCVA J1 over 1 month •Pre-Op IOL choice: Tecnis PCB00 23.50 time •ORA recommended 24.0 •Delayed surgery OD by 1 month •IOL Implanted: Tecnis PCB00 23.50

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POST- POST- OPERATIVE: OPERATIVE: REFRACTIVE REFRACTIVE SURPRISES! SURPRISES!

POST-OPERATIVE: POST-OPERATIVE: REFRACTIVE SURPRISES! DYSPHOTOPSIA38

•Over the course of the PO period VA remained stable & •Patient can see, doctor cannot patient elected no further treatment as NV important •Positive and Negative •OD 20/40, J1 OS 20/40, J2 •Positive: Rainbows, streaks, glare, rings, halos, crescents, •OU 20/30, J1 haze and fog •MRx OD -1.50+1.00x050 20/25 •Negative: absolute scotomas OS -1.00+1.00x140 20/20- NV OU no add J3

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POST-OPERATIVE: POST-OPERATIVE: DYSPHOTOPSIA38 DYSPHOTOPSIA38

•Positive •Positive •Streaks – look at high cylinder; capsule due to PCF •Glare, haze or fog – scattered, diffused light due to •Crescents – IOL decentered, light entering aphakic lens fibers, early PCF pupil •Can also develop due to missing rays from internal •Rainbows – possibly decentered diffractive MF IOL; reflections and sharp anterior or posterior IOL edge usually small water droplets in the epithelium; could also be related to older FEMTO lasers

POST-OPERATIVE: PARTNERSHIP FOR HAPPIER PATIENTS DYSPHOTOPSIA •Negative •Patient will note a dark, temporal crescent-shaped shadow which increases with bright light. •Will resolve on own in 2 years in 80% of cases •Could consider: removing nasal annulus of anterior capsule; IOL exchange; inserting piggyback IOL; reverse optic capture; or, iris suture fixation of the IOL bag complex

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PARTNERSHIP FOR HAPPIER PATIENTS PARTNERSHIP FOR HAPPIER PATIENTS

• Cataract surgery has evolved to a type of refractive •The best offense is a good defense surgery •Discuss presbyopia and astigmatism with your patient • Open and flowing communication between prior to referral Optometrists and Ophthalmologists •Discuss how your patient would like to see after • How important is co-management to MDs? cataract surgery and the different IOL options now • Someone founded OD LIASON UNIVERSITY available (www.odluniversity.com) •Healthy ocular surface

THANK YOU!

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