sign in sign up
<<
Home , Enophthalmos

Disclosure Statement:

Allergan Pharmaceuticals Speaker’s Bureau Bio-Tissue IOP Ophthalmics Minnesota Optometric Association Board of Trustees Illinois College of Optometry Alumni Council Board AAO Anterior Segment Section Board COA Monterey Symposium 2017

Nicholas Colatrella, OD, FAAO, Dipl AAO, ABO, ABCMO Jeffrey R. Varanelli, OD, FAAO, Dipl ABO, ABCMO

Nicholas Colatrella, OD, FAAO, Dipl AAO, Jeffrey Varanelli, OD, FAAO, Dipl ABO, Number of Americans > 40 who are affected by ABO, ABCMO ABCMO 22 million Number of surgeries performed worldwide in 2010 Approximately 20 million Number of surgeries performed worldwide by 2020 Approximately 32 million Annual amount spent through Medicare to treat cataracts $6.8 billion Number of Americans who have surgery each year 3,000,000 Success rate of cataract surgery 98% Percentage of patients without severe post-op complications 99.5%

One of the most commonly Time performed procedures in the Pre-Operative United States Intra-operative Personal experience Early post-operative (first few days) Co-management Late post-operative (weeks to months)

Location Anterior (, anterior chamber, IOL, capsule) Posterior (vitreous, )

1 Pre-existing Ocular Conditions Pre-existing Medical Conditions

High Age Sex High Hyperopia Race abnormalities Diabetes Mellitus Atherosclerotic Vascular disease Hypertension Dry Allergies/reactions to Fuch’s Dystrophy sedatives/anesthetics Bleeding tendencies Pseudoexfoliation BPH ERM Breathing problems Systemic medications Anti-coagulants Alpha-adrenergic receptor antagonists Diabetic Narcotics OTC Pigmentosa NSAIDS Saw palmetto Planning combined procedure Ginkgo biloba Surgeon Choice

Several studies report inc risk among Men Older >60 assoc w increased postsurgical complications 44% higher odds of Oldest patients at increase risk for endophthalmitis Behavioral difference key Compliance Differences in bacterial flora between sexes Use of a-blockers Race Diabetes • Several studies vary on whether whites or African • Those with ophthalmic manifestations of DM had 33% Americans have higher complication rates. inc risk for complications • Higher endophthalmitis rates among African Americans • Complication risk increased with level of DR severity • Altered immunity • Poor dilation • Bleeding tendencies

Common to stage two procedures together to help address multiple issues at once Stein et al found 151% inc risk for severe adverse events in combined procedures Longer time in operating room Exposure to additional instruments More incisions ??MIGS Surgeon Factor • Surgeon Volume • AE 70% lower in surgeons who performed 501-1000 surgeries / yr • 86% lower among surgeons >1000 sx • Highest risk in surgeons performing 50-250 cases / yr

2 Strong association with IFIS Most widely prescribed first reported in 2005 treatment worldwide for BPH billowing and floppiness $1.9 billion 2009 Iris prolapse to main and Systemic Alpha1 antagonist side incisions Highly selective for A1a receptor Progressive Relaxes smooth muscles Classified: Mild (17%) bladder neck and prostate Moderate (30%) permitting more complete emptying Severe (43%) iris dilator smooth muscle Canadian study Doubling rate of serious postoperative complications following Cat Sx RD, retained fragments, severe inflamm, endophthalmitis

Most common intraoperative complication (1.9-3.5%) IFIS can occur more than Vitreous Loss Need for vitrectomy 1 year after tamsulosin has Placement of intraocular in been discontinued ciliary sulcus or AC Eventually produce a permanent atrophic change in the iris Additional surgical interventions dilator muscle that is not reversed by discontinuation IFIS has occurred within 3 – 7 days of initiating tx Risk factors for Post Cap Rupture • Stopping pre-operatively is of unpredictable and Increasing age Exfoliation syndrome / questionable value Male sex phacodonesis Comorbid glaucoma • Small pupil Iris dilator muscle 23% thinner • Axial length >26mm Important to make surgeon and patient aware Brunescent /white cataract • α-antagonist use Poor views of the fundus • Inability to lay flat • Trainee surgeon

Jason Jones, MD Sioux City, Iowa

3 Critical evaluation of the operated eye during the immediate post-operative and peri-operative period is In evaluating reduced post-operative acuity, one should extremely important know both the timing and severity of the visual 1 day complaint in order to determine an etiology. 1 week Early 1 month Severe (20/200 or worse) Moderate (20/100 or better) Thorough DFE is mandatory in any patient who does not meet or exceed expected VA Delayed Visual Recovery

Vascular Occlusion Epithelial Irregularity Irregular or Marked Corneal Infectious Endophthalmitis Corneal Edema Toxic Anterior Segment Syndrome Dislocated / subluxated IOL Delayed Suprachoroidal Hemorrhage Operative / Post-operative bleeding Damage Retained Cortex or Nuclear fragments Rupture or Perforation Hypotony Intraocular aminoglycoside toxicity Photoretinal Toxicity Extraocular Muscle paresis These often occur through vascular insult, direct mechanical , or retinal toxicity These complications predominantly affect optical clarity, macular function or refractive state

Retinal Detachment Vascular Occlusion Occurs in 1% (85% within 3 years) CRVO, CRAO Increases to 5% with loss of vitreous Choroidal Infarction If immediately after surgery– usually tractional or May occur in Sx if complicated from globe perforation by : Tractional RD assoc with vitreous to wound or retrobulbar hemorrhage aspiration instrument, or dropped nucleus nerve sheath injection elevated IOP

4 Retinal Detachment If RD from Globe perforation usually by retrobulbar needle & most commonly at equator or post pole (Vit heme & hypotony)

Higher risk if high myopia, prior scleral buckle, staphyloma, enophthalmos

Acute Bacterial Endophthalmitis Acute Endophthalmitis Usually manifests 2-7 days Clinical Appearance after surgery, most within 6 Ant chamber cell weeks Pain, injection, significant decrease in VA, purulent Fibrin discharge Focal Corneal edema Incidence 1:1000 edema Most acute cases due to Chemosis Staphylococci (aureus and Hyperemia epidermidis) Vitreal Involvement Act as soon as possible Pt has Pain Key to Dx is culturing aqueous 21% with underlying DM and vitreous

Endophthalmitis Vitrectomy Study (EVS) Endophthalmitis Vitrectomy Study (EVS) Patients with LP vision or worse with an early vitrectomy did Multicenter randomized trial carried out at 24 centers in U.S. favorably with final VA (1990-1994) 20/40 or better was achieved 3x more often following PPV Looked at 420 patients with clinical evidence than needle tap To determine the role of IV and systemic antibiotics Patients with better than LP VA, do not require a vitrectomy only required tap/biopsy To determine role of immediate PP Vitrectomy Results No difference in final visual acuity or media clarity with or without use of systemic / IV antibiotics Therefore recommend intravitreal injection of AB

Arch Ophthalmol. 1995 Dec;113(12):1479-96. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Overall 53-60% achieved >20/40 following AB therapy

5 ESCRS Protocol European Society of Cataract and Refractive Surgeons protocol of 1mg cefuroxime (10mg/ml) (Ceftin) 2nd Gen cephalosporin

Prior to protocol 2299 pts Cat Sx – 6 cases of postop endophthalmitis (0.26%) After protocol 13,390 pts Cat Sx – 0 cases of endophthalmitis

Eur J Ophthalmol. 2013 Dec 16:0. doi: 10.5301/ejo.5000417. [Epub ahead of print] Postcataract surgery endophthalmitis after introduction of the ESCRS protocol: a 5-year study. Tap and Inject for Endophthalmitis using 25G Trocar Beselga D, Campos A, Castro M, Fernandes C, Carvalheira F, Campos S, Mendes S, Neves A, Campos J, Violante L, Sousa JC. Cannula, Theodore Leng, MD, FACS

Toxic Anterior Segment Syndrome Careful Hx and exam help Monson et al. first used the term differentiate between the TASS in 1992 two and timely intraocular received greater attention because cultures and intravitreal of a national outbreak in 2005 that AB must be utilized when affected 112 patients treated at interpretation difficult seven sites in six states and was linked to endotoxins in Advanced Medical Optics Endosol balanced Most common clinical salt solution (BSS). symptom is significantly Develop in response to blurred vision retained lens, toxic Corneal Edema is most intraocular reaction, common clinical finding Limbus to limbus mechanical irritation, Indicative of widespread exacerbation of pre-existing endothelial damage

Marked ant seg Treatment inflammation Immediate high dose topical corticosteroid Hypopyon Follow closely Fibrin from surface Same day of iris onto surface Daily to IOL, to wound IOP monitoring and side ports Usu low to start but can rise rapidly Can create Acute trabeculitis significant iris PAS development – gonio damage Specular Microscopy Permanently dilate Monitor for permanent endo damage Transillumination Damage to TM leading to 2nd Glc No help to wash out the AC

6 CLINICAL FEATURES TASS INFECTIOUS Corneal Irregularity Epithelial edema, corneal drying, epithelial toxicity, or OnsetClinical of symptoms Features Relatively immediateTASS (12-48 SomewhatInfectious delayed hoursRelatively) (2 -7Somewhat days) delayed direct mechanical injury may contribute to corneal surface Onset of symptoms (2 to 7d) irregularity following surgery Pain Mostimmediate patients do not (12 –48h) >75% of patients have pain experience >75% of patients Pain Most patients do Corneal Edema Diffusenot “ experiencelimbus-to-limbus ” Focalhave corneal pain edema Focal corneal edema Corneal Edema Diffuse “limbus-to- Anterior Segment Inflammation Increasedlimbus cell/flare, hypopyon, Increased cell/flare, hypopyon, marked fibrin reaction moderate to severe fibrin Ant Seg inflamm Increased cell flare, Increased cell/flare, hypopyon, marked hypopyon, moderate Iris/pupil Irisfibrin atrophy, reactionwith dilated, non- Changesto severe relatively fibrin uncommon Iris / pupil reactive pupil iris atrophy with changes relatively dilated nonreactive uncommon Vitreous Vitreous UsuallyUsually clear, rare clear, spillover rare OpacifiedOpacified spillover

Corneal edema Epithelial edema often associated with elevated IOP Corneal Irregularity Stromal edema from endothelial dysfunction mechanical injury, cell toxicity or pre-existing Corneal punctate Cataract surgery accompanied by anterior vitrectomy epithelial 3x more likely to be associated with chronic post- keratopathy operative corneal edema Exposure Topical drug toxicity Irregular tear wetting patterns

Common causes of corneal edema Dense cataracts Post-Op pressure Shallow anterior chamber elevation Pre-existing corneal disease Viscoelastic High IOP Inflammation Management of corneal edema Ciliary or pupillary Time block Ocular hypotensive agents Topical hyperosmotics Mechanical angle closure

7 Corneal Irregularity Refraction performed over Irregular or high post- RGP will neutralize effect operative astigmatism may and help determine etiology Post-operative Bleeding substantially reduce visual Hyphema acuity Vitreous Hemorrhage Results from excessive Intracapsular blood suture tension or wound Minor ant./post. Seg heme usu. misalignment clear in days to weeks Thermal injury with If interfere with fundus exam – resultant collagen shrinkage ultrasound R/O RD, etc. Keratometry or topography Patients taking anticoagulants do will help quantify the not appear to have significantly problem increased rates of serious post- op bleeding

Retained lens fragments Hypotony Aasuri and colleagues Wound leak or globe perforation Overall Incidence 1:300 1:500 experienced Serous or hemorrhagic choroidal detachment 1:165 novice Cyclodialysis cleft Risk factors Limited pupil dilation Marked inflammation Traumatic cataract Patient movement during surgery Retinal detachment Disorders that predispose to zonular weakness? Causes variable visual symptoms depending on amount and location Nuclear more than cortical incite inflammation, corneal edema, elev. IOP, RD Medical Tx directed toward controlling IOP and inflammation Determining the etiology requires examination of the PPV for large particles wound, gonioscopy of the angle, BIO, B-scan, etc.

Photoretinal toxicity Temporary Photoretinal injury from pre-existing sensory worsening operating microscope the prismatic effect of a new spectacle correction Patients complain of prolonged anesthetic effect transient myotoxicity If injury near fovea, VA will low-grade operative trauma to the orbital soft tissues. be compromised Appears as subtle pale oval lesion, commonly located ? Forced duction testing inferior to fovea Healing results in mottling of RPE – Prognosis excellent if outside fovea Eye (Lond). 2008 Aug;22(8):1057-64. Epub 2007 Apr 27. Diplopia following cataract surgery: a review of 150 patients. Nayak H, Kersey JP, Oystreck DT, Cline RA, Lyons CJ.

8 Cornea Epithelial Irregularity Hypotony IOL Persistent Corneal Edema Posterior Vitreous Inflammation Irregular or high corneal Detachment Retina astigmatism Pre-existing condition IOL subluxation, tilt, or Photoretinal Toxicity capture UnDx pre-existing Ant. Seg. Inflammation conditions Post. Seg. Inflammation Incorrect IOL power Others By 6 weeks, intraocular inflammation and minor corneal edema should be resolved, IOP should be normal, and the macula should be distinct without edema.

Chronic Endophthalmitis May become apparent after Rebound Inflammation manifest as AC cell / vit Yag Cap cells, mod VA red, ocular responds transiently to Occurs in 5% of patients discomfort, 1-4 months topical steroid More common in dark iridies following cataract surgery intravitreal ab therapy gives More common in patients with DM Propionibacterium Acnes favorable visual outcome Occurs when steroids are discontinued to early or -an anaerobic tapered too quickly pleomorphic gram Always look for retained lens material with gonio positive bacillus White plaque on PC and granulomatous KP

Rebound Inflammation Cystoid Macular Edema Treatment Resume topical steroids Consider Consider tap and injection to rule out chronic endophthalmititis

9 CME Cystoid Macular Edema Most common cause of decreased vision after cataract Presents 4-12 weeks after Major contributing factors surgery uncomplicated Sx with intraocular inflammation Incidence? reduced VA Higher risk patients? vitreous traction (wound, iris, or modest ocular inflamm macula) leakage of FL from optic pre-existing microvascular disease nerve and macula biomicroscopy and fundus contact Results from retinal leakage lens exam in perifoveal region and accum. of fluid in the outer yellowish spot in fovea plexiform layer of the retina ERM, retinal striae & tortuosity of the retinal vessels is assoc. 10-20%

Courtesy of Steven Silverstein, MD

CME CME Fluorescein angiography Optical Coherence Tomography Early to mid arteriovenous phase shows selective appears as non-reflective cystoid spaces in the outer leakage of the perifoveal capillaries plexiform and inner nuclear layers Late phase shows discrete lobules of hyperfluorescence in petaloid app., usu with assoc. hyperfluorescence of the optic nerve Poor correlation between the degree of leakage seen in FA and VA – Retinal thickness a better indicator of decreased VA, ie OCT much less-invasive than fluorescein angiography Clinical CME vs. Angiographic CME Also measures retinal thickness, which is invaluable in monitoring the course of therapy

Avastin Posterior Capsular Opacity Initially approved to treat colo-rectal cancer “Secondary Cataract” Inhibits VEGF Occurs in 40% of patients Study in 2008 at University of Wisconsin Occurs a few weeks to many years after surgery Macular degeneration Peak incidence is 2-6 months after surgery Diabetic macular edema Caused by: ROP epithelial cell proliferation and migration Pre-surgical treatment for diabetic vitreous hemorrhage Subconjunctival for corneal neovascularization epithelial-mesenchymal transition collagen deposition lens fiber generation

10 Types of capsular opacification Elschnig pearls Fibrosis Age Dependent low incidence in older patients, high in young Ways To Decrease Incidence Attempted removal of lens epithelial cells Apsiration of the anterior capsule Pharmacological dispersion Manual polishing of the anterior and posterior capsule IOL material and design • Proliferation of lens epithelium • Usually occurs within 2-6 months

• Occurs after 3-5 years • May involve remnants of anterior Sharp-edge optic IOLs and those made of acrylic capsule and cause phimosis and silicone have lower rates of PCO

Treatment Diplopia persistent for 6 mo after Sx Nd:YAG laser capsulotomy Incidence 0.17% creates a clear (3mm) opening in the 34% - Decompensation of pre-existing asymptomatic strabismus posterior lens capsule 25% - Extraocular muscle restriction or paresis Not performed within 3 months of surgery 8.5% - Refractive 5% - Concurrent onset of systemic disease (including sixth nerve Risks: palsies) Retinal detachment 5% - Central fusion disruption (acquired loss of fusion) 2.5% - Monocular double vision Damage to IOL 20% - Undetermined etiology CME Increased IOP

Corneal edema Eye (Lond). 2008 Aug;22(8):1057-64. Epub 2007 Apr 27. Diplopia following cataract surgery: a review of 150 patients. Nayak H, Kersey JP, Oystreck DT, Cline RA, Lyons CJ.

First human LCS performed 2008 Budapest, Hungary Study of 1230 eyes using Alcon-Lensx bet Aug 2008- Aug 2012 Creation of precise Complications reported anterior capsulotomies All complications occurred in first 100 eye Liquefaction of Suction Break Nuclear (N1) Conjunctival Redness or Hemorrhage Fragmentation of N2 Capsule Tags and Bridges and N3 lenses Creation of corneal Anterior Capsule Tear wounds in any Endothelial Damage position and size Capsular Blockage Syndrome and Posterior Capsule Rupture Treatment of preoperative Miosis astigmatism Vitrectomy

11 Capsule Tags and Bridges Anterior Capusle Tear Miosis Endothelial Damage Femtosecond creates shockwave that can affect the Endothelial cut is serious complication of femto tx surrounding tissue in a 1.0mm area. High hyperopes at higher risk due to shallow AC Therefore with a 5.0mm dia capsulotomy, width of pupil should be 6.5mm Less common with systems that have integrated OCT Larger the pupil the less chance of shockwave hitting the margin Capsular Blockage Syndrome with consecutive (ie dilation should begin min 1hr before sx) Posterior Capsule Rupture Hitting the pupil margin further increases the miosis and Serious complication creates inflammatory debris and fibrin Intralenticular gas bubbles form due to excessive energy Highly myopic eyes and pseudoexfoliation are prone to miotic reaction after femtosecond dissipation in the lens material After capsulotomy the gas bubbles tend to move toward the Vitrectomy anterior chamber Can be avoided with Rock N Roll technique which allows air bubbles to leave the crystalline lens

Imprimis, dropless.com Injurious falls between first and Second eyes Transzonular injection into Hospitalization for falls Doubled between 1st and 2nd eye sx vitreous (time released over post nd op period) ? Expedited 2 eye cat sx Tri-Moxi Mental health visits Tri-Moxi + Vanco decrease of 18.80% (p ≤ 0.001) in number of mental health Patient doesn’t need to buy drops contacts for depression and/or anxiety the year after cataract after Cat Sx surgery More like “Less Drops” cataract 28% reduction in health care costs surgery Driving Risk 30 to 50% of patients notice , bubbles, swirls, etc risk for driving-related difficulties was reduced by 88% after sx Decreased vision last less than 24 Age Ageing. 2013 Nov 4. [Epub ahead of print] hours The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study. 10-14 day spike in inflammation Meuleners LB, Fraser ML, Ng J, Morlet N. ? Inc risk of IOP spike Acta Ophthalmol. 2013 Sep;91(6):e445-9. doi: 10.1111/aos.12124. Epub 2013 Apr 16. The impact of first eye cataract surgery on mental health contacts for depression and/or anxiety: a population-based study Potential for additional using linked data. complications including CB Meuleners LB, Hendrie D, Fraser ML, Ng JQ, Morlet N. Bleeding and retinal holes, breaks J Cataract Refract Surg. 2010 Jan;36(1):13-9. doi: 10.1016/j.jcrs.2009.07.032. tears and detachment Vision improvement and reduction in falls after expedited cataract surgery Systematic review and metaanalysis. Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena LA, Pike I.

81 year old AA female Medical history: HTN Ocular history: unremarkable Uncomplicated cataract surgery Uncorrected VA @ 3 months: 20/20 OD, OS

Returned two months later BCVA 20/30 OD, 20/60 OS

12 85 yo wf uneventful cataract surgery 1 day visit (out of town) so pt saw surgeon At 1 week post op 20/25 Had discontinued AB and on Pred and NSAID BID plano Rx Pt reports had been doing fine but now noticing some redness and mild discomfort.

Had 1+ cell and 1+ injection Ta 20mmHG Dx with probably rebound Iritis from Tapering too quickly and Increased pred back to QID and told to return in 1-2 week.

RTO at 3 week visit and eye white and quiet and not complaining of discomfort Has been using Pred Forte QID and NSAID BID

Thought to myself that we successfully averted a rebound iritis crisis….

13 76 year old Caucasian male What are differentials? Uncomplicated cataract surgery 3 days prior OS TASS Woke up with complaint of redness, pain, and Increased IOP decreased VA CME Subluxated IOL Endophthalmitis

BCVA: Hand Motion at 3’

4+ cell / fibrin in chamber No view of fundus Plan?

Spring 2001 71 white male 1 day uncomplicated Cataract Post Op evaluation Pt reports slept well and in no acute distress No real pain or discomfort but blurry 20/200 SLE 2-3+ Diffuse limbus to limbus Corneal edema 3+ Fibrin in AC emanating from pupil to wound + Hypopyon Pupil mid dilated Ta 18 mmHg Ant Vitreous – difficult to view but appeared clear

14 Evidence has shown a steady decline in rates of serious adverse events over the past few decades Cataract Surgery is a relatively safe procedure in experienced hands Patients who are at inc risk include older age, male sex, comorbid DR, combined procedures, those taking a-antagonists Complications are less likely to lead to visual loss if handled promptly and properly Newer technologies have ability to decrease future complications

Please feel free to contact us:

Nicholas Colatrella, OD, FAAO, Dipl AAO, ABO, ABCMO [email protected]

Jeffrey Varanelli, OD, FAAO, Dipl ABO, ABCMO [email protected]

15