Cataract Surgery and LASIK
Update 2013
Random Case Studies
Jeffrey Martin, M.D. FACS
Managing Partner
North Shore Eye Care...
The lenses are non-glare…perfect for
those moments you’re frozen in
headlights…
CASE STUDY
• 23 year old male

• One day post PRK
• Presents with 20/40 vision
• Moderate discomfort

• Contact lens in pl...
CASE STUDY
CASE STUDY

• What do we do first?
1. Scream, “Why me? Why me?”
2. Remove the contact lens and culture
3. Increase antibio...
CASE STUDY

• We increased steroid to q2 hours.
• Patient improved over 2 to 4 days.
CASE STUDY #2

• 32 year old hospital worker
• Presents 5 days post LASIK with pain,
redness, and photophobia
• Vision of ...
CASE STUDY #2
CASE STUDY #2
• What do we do?
1. Scream, “Oh no, not again!”
2. Lift flap, culture and keep on Zymaxid
3. Lift flap, cult...
CASE STUDY #2

• What is the significance about place of
employment?
1. No significance
2. Less worried, hospital workers ...
BACTERIAL KERATITIS

• Symptoms
– Red eye
– Moderate to severe pain
– Photophobia
– Decreased vision
– Discharge
BACTERIAL KERATITIS
• Signs
– Focal white opacity
• Infiltrate if in corneal
stroma
• Ulcer with epithelial
defect
– Mucop...
DIFFERENTIAL OF BACTERIAL KERATITIS

• Which is true about Fungal Keratitis?
1. Should be treated aggressively with steroi...
BACTERIAL KERATITIS

• Differential
– Fungal
•
•
•
•
•

Infiltrates have feathery borders with satellite lesions
Traumatic...
FUNGAL KERATITIS
DIFF. OF BACTERIAL KERATITIS

• Which is false about Acanthamoeba Keratitis?
1. It can be misdiagnosed as HSV keratitis
2....
BACTERIAL KERATITIS
• Differential
– Acanthamoeba
• Extremely painful
–
–
–
–
–

Out of proportion to physical findings
Ci...
ACANTHAMOEBA
DIFF BACTERIAL KERATITIS
• Which is true about HSV Keratitis
1. Is often bilateral
2. Presents with decreased corneal sens...
BACTERIAL KERATITIS

• Differential
– HSV Keratitis
•
•
•
•

Eyelid vesicles
Epithelial dendrites
Reduced corneal sensatio...
HERPES SIMPLEX KERATITIS
HERPES SIMPLEX

• Neurotrophic ulcer
– Sterile ulcer with
smooth borders
– May be associated
with stromal melting
and perf...
HERPES SIMPLEX

• Stromal disease
– Disciform keratitis
• Disc shaped stromal
edema with intact
epithelium
• Mild iritis
•...
HERPES SIMPLEX

• Stromal disease
– Necrotizing interstitial keratitis
•
•
•
•

Uncommon
Multiple or diffuse whitish corne...
NECROTIZING IK
HERPES SIMPLEX

• Uveitis
– As a result of stromal involvement
– Less common
• Anterior chamber reaction and granulomatous...
DIFF BACTERIAL KERATITIS
• Which is true about Atypical Mycobacteria
Keratitis?
1. Typically aggressive course
2. Years ag...
BACTERIAL KERATITIS

• Differential
– Atypical mycobacteria
• Follows ocular injuries with vegetative matter or
surgery
• ...
ATYPICAL MYCOBACTERIA KERATITIS
BACTERIAL KERATITIS

• Which is not one of the most common bugs?
1. Staph
2. Strep
3. Pseudomonas
4. Moraxella
5. Atypical...
BACTERIAL KERATITIS

• Etiology
– Most common
• Staph
– Well defined graywhite stromal infiltrate
– May enlarge to form
de...
BACTERIAL KERATITIS

• Etiology
– Most common
• Strep
– Purulent
» Severe anterior chamber reaction and hypopyon
common
– ...
BACTERIAL KERATITIS
• Strep keratitis
• Strep Crystalline keratitis
BACTERIAL KERATITIS

• Etiology
– Most common
• Pseudomonas
– Rapidly progressive
supprative and necrotic
– Hypopyon and d...
BACTERIAL KERATITIS

• Etiology
– Most common
• Moraxella
–
–
–
–
–

Preexisting ocular surface disease
Immunocompromised
...
BACTERIAL KERATITIS

• Treatment
– Low risk
• Small nonstaining peripheral
• Broad spectrum topical antibiotics every hour...
BACTERIAL KERATITIS
• Treatment
– Borderline risk
•
•
•
•
•

Medium size 1 to 1.5 mm peripheral infiltrate
Smaller infiltr...
BACTERIAL KERATITIS
• Treatment
– Vision threatening
•
•
•
•
•

Larger than 1 to 2 mm
Visual axis
Unresponsive to treatmen...
BACTERIAL KERATITIS

• Treatment
– Sometimes topical steroids are used
•
•
•
•

Sensitivities are known
Infection under co...
STAPH HYPERSENSITIVITY

• Symptoms
–
–
–
–

Mild pain
Mild photophobia
Localized red eye
Chronic blepharitis
• Eyelid crus...
STAPH HYPERSENSITIVITY

Blepharitis
STAPH HYPERSENSITIVITY
• Signs
– Singular or multiple unilateral or bilateral peripheral corneal
stromal infiltrates
– Cle...
STAPH HYPERSENSITIVITY

• Treatment
– Antibiotic and steroid

• Recurrent episodes
– Oral doxy or tetracycline
– Restasis
...
STAPH HYPERSENSITIVITY
• Differential
– Infectious corneal infiltrate
• Round
• Painful
• Anterior chamber reaction

– Oth...
• Peripheral Corneal Thinning
– Connective Tissue Disease
• Peripheral corneal thinning/ulcers may be associated
with infi...
RHEUMATOID PERIPHERAL CORNEAL THINNING
RHEUMATOID PERIPHERAL CORNEAL THINNING

• What is true about Connective Tissue
Disease Cornea Thinning?
1. Nothing can be ...
RHEUMATOID PERIPHERAL CORNEAL THINNING

• Treatment
–
–
–
–
–
–
–
–
–

Management usually coordinated with a rheumatologis...
• Peripheral corneal thinning
– Terrien marginal degeneration
•
•
•
•
•
•
•
•

Often asymptomatic usually bilateral
Slowly...
TERRIEN MARGINAL DEGENERATION

• Which is false about Terrien Marginal
Degeneration?
1. Rarely is there significant morbid...
TERRIEN
• Peripheral Corneal Thinning
– Mooren ulcer
•
•
•
•
•
•
•
•

Unilateral or bilateral
? Autoimmune
Painful corneal thinnin...
MOOREN ULCER
MOOREN ULCER

• Which is true about Moorens Ulcer?
1. Treatment is rarely necessary
2. Is a diagnosis of exclusion
3. Oral...
MOOREN ULCER
• Treatment
–
–
–
–
–
–
–

Rule out underlying systemic disease
Topical corticosteriods
Topical cyclosporine
...
• Peripheral Corneal Thinning
– Furrow Degeneration
•
•
•
•
•
•

Painless
Adjacent to area of arcus
Elderly
Noninflammator...
FURROW DEGENERATION
• Peripheral corneal thinning
– Dellen
•
•
•
•

Painless oval corneal thinning
From corneal drying and stromal dehydration...
DELLEN
DELLEN

• Audience participation question
1. Stop with the corneal thinning already
2. I find corneal thinning so interest...
CATARACT SURGERY @ NSEC
• Technique
– Topical anesthesia with IV sedation

– Anticoagulants ok
– No injections around eye
...
CATARACT SURGERY
• What about laser cataract surgery?
– Strong future
– Incisions
• Penetrating and nonpenetrating
• Capsu...
CATARACT SURGERY

• Meds
– Three days prior
• Antibiotic and NSAID

– After Surgery
• Antibiotic, NSAID and Steroid
• Anti...
CATARACT SURGERY
•

•

Intraocular lens implants
– Choice depends on preexisting astigmatism
– Monofocal
– Toric
– Multifo...
LASIK @ NSEC
• iLASIK
– Bladeless and custom
– Nearsightedness, farsightedness and astigmatism

• State of the art LASIK c...
PRK
• Better in some cases
– Thin corneas
– Irregular corneas
– High prescriptions
– Dry eyes
– Contact sports
• Higher co...
LASER VISION CORRECTION MEDS
• LASIK
– Antibiotic and steroid for 10 days
• PRK/LASEK
– Antibiotic until contact lens out ...
THANK YOU
Cataract Surgery and LASIK Update 2013 - Dr. Jeff Martin of North Shore Eye Care
Cataract Surgery and LASIK Update 2013 - Dr. Jeff Martin of North Shore Eye Care
Cataract Surgery and LASIK Update 2013 - Dr. Jeff Martin of North Shore Eye Care
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Cataract Surgery and LASIK Update 2013 - Dr. Jeff Martin of North Shore Eye Care

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A selection of case studies relating to cataract surgery and LASIK procedures

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Cataract Surgery and LASIK Update 2013 - Dr. Jeff Martin of North Shore Eye Care

  1. 1. Cataract Surgery and LASIK Update 2013 Random Case Studies Jeffrey Martin, M.D. FACS Managing Partner North Shore Eye Care Assistant Clinical Professor of Ophthalmology at SUNY Stony Brook
  2. 2. The lenses are non-glare…perfect for those moments you’re frozen in headlights…
  3. 3. CASE STUDY • 23 year old male • One day post PRK • Presents with 20/40 vision • Moderate discomfort • Contact lens in place
  4. 4. CASE STUDY
  5. 5. CASE STUDY • What do we do first? 1. Scream, “Why me? Why me?” 2. Remove the contact lens and culture 3. Increase antibiotic to q2 hours and stop steroid 4. Increase steroid to q2 hours and leave antibiotic at standard dose
  6. 6. CASE STUDY • We increased steroid to q2 hours. • Patient improved over 2 to 4 days.
  7. 7. CASE STUDY #2 • 32 year old hospital worker • Presents 5 days post LASIK with pain, redness, and photophobia • Vision of 20/40 • Pt on Durezol and Zymaxid
  8. 8. CASE STUDY #2
  9. 9. CASE STUDY #2 • What do we do? 1. Scream, “Oh no, not again!” 2. Lift flap, culture and keep on Zymaxid 3. Lift flap, culture and switch to tobramycin 3 % 4. Lift flap, culture and start fortified antibiotics
  10. 10. CASE STUDY #2 • What is the significance about place of employment? 1. No significance 2. Less worried, hospital workers are really clean 3. More worried, hospital workers are filthy 4. More worried, resistant bugs
  11. 11. BACTERIAL KERATITIS • Symptoms – Red eye – Moderate to severe pain – Photophobia – Decreased vision – Discharge
  12. 12. BACTERIAL KERATITIS • Signs – Focal white opacity • Infiltrate if in corneal stroma • Ulcer with epithelial defect – Mucopurulent discharge – Stromal edema – Anterior chamber reaction • Hypopyon possible – Conjunctival injection diffuse – Corneal thinning – Upper eyelid edema – Posterior synechiae
  13. 13. DIFFERENTIAL OF BACTERIAL KERATITIS • Which is true about Fungal Keratitis? 1. Should be treated aggressively with steroids 2. Is commonly bilateral 3. Often has satellite lesions 4. Has been linked to Dr. Mauro’s eye exams
  14. 14. BACTERIAL KERATITIS • Differential – Fungal • • • • • Infiltrates have feathery borders with satellite lesions Traumatic injury from vegetative matter Contact lens wear is a risk factor Fusarium and aspergillus most common Candida in diseased eyes – Dry eye, herpes simplex or zoster, exposure keratopathy
  15. 15. FUNGAL KERATITIS
  16. 16. DIFF. OF BACTERIAL KERATITIS • Which is false about Acanthamoeba Keratitis? 1. It can be misdiagnosed as HSV keratitis 2. A ring infiltrate is seen early 3. It is typically painful
  17. 17. BACTERIAL KERATITIS • Differential – Acanthamoeba • Extremely painful – – – – – Out of proportion to physical findings Circumcorneal injection and photophobia Minimal discharge Cells and flare Epithelial pseudodendrites early • Contact lens wearer with poor hygiene, swimming with contact lenses • In late stages (3 to 8 weeks), infiltrate becomes ring shaped • Can be misdiagnosed as HSV
  18. 18. ACANTHAMOEBA
  19. 19. DIFF BACTERIAL KERATITIS • Which is true about HSV Keratitis 1. Is often bilateral 2. Presents with decreased corneal sensitivity 3. More common in promiscuous people (like Dr. Mauro) 4. I am only picking on John because he is not lecturing today, therefore no pay back.
  20. 20. BACTERIAL KERATITIS • Differential – HSV Keratitis • • • • Eyelid vesicles Epithelial dendrites Reduced corneal sensation History of recurrent unilateral episodes – Recurrence due to fever, stress, trauma, UV light • Bacterial superinfections possible
  21. 21. HERPES SIMPLEX KERATITIS
  22. 22. HERPES SIMPLEX • Neurotrophic ulcer – Sterile ulcer with smooth borders – May be associated with stromal melting and perforation
  23. 23. HERPES SIMPLEX • Stromal disease – Disciform keratitis • Disc shaped stromal edema with intact epithelium • Mild iritis • Keratitc precipitates • Increased IOP
  24. 24. HERPES SIMPLEX • Stromal disease – Necrotizing interstitial keratitis • • • • Uncommon Multiple or diffuse whitish corneal stromal infiltrates With or without epithelial defect Stromal inflammation, thinning, and neovascularization • Iritis, hypopyon and glaucoma may be present
  25. 25. NECROTIZING IK
  26. 26. HERPES SIMPLEX • Uveitis – As a result of stromal involvement – Less common • Anterior chamber reaction and granulomatous KP without corneal disease • High IOP
  27. 27. DIFF BACTERIAL KERATITIS • Which is true about Atypical Mycobacteria Keratitis? 1. Typically aggressive course 2. Years ago, seen in a high percentage of LASIK infections 3. Resolve quickly with treatment
  28. 28. BACTERIAL KERATITIS • Differential – Atypical mycobacteria • Follows ocular injuries with vegetative matter or surgery • Represented high percentage of LASIK infections • Indolent course • Need prolonged treatment – Every hour for one week then gradual tapering – Fluoroquinolones, amikacin, clarithromycin or tobramycin
  29. 29. ATYPICAL MYCOBACTERIA KERATITIS
  30. 30. BACTERIAL KERATITIS • Which is not one of the most common bugs? 1. Staph 2. Strep 3. Pseudomonas 4. Moraxella 5. Atypical mycobacteria
  31. 31. BACTERIAL KERATITIS • Etiology – Most common • Staph – Well defined graywhite stromal infiltrate – May enlarge to form dense stromal abscess
  32. 32. BACTERIAL KERATITIS • Etiology – Most common • Strep – Purulent » Severe anterior chamber reaction and hypopyon common – Crystalline » Patients on chronic topical steroids
  33. 33. BACTERIAL KERATITIS • Strep keratitis • Strep Crystalline keratitis
  34. 34. BACTERIAL KERATITIS • Etiology – Most common • Pseudomonas – Rapidly progressive supprative and necrotic – Hypopyon and discharge – Soft contact lens use
  35. 35. BACTERIAL KERATITIS • Etiology – Most common • Moraxella – – – – – Preexisting ocular surface disease Immunocompromised Indolent infiltrates in the inferior cornea Full thickness May perforate
  36. 36. BACTERIAL KERATITIS • Treatment – Low risk • Small nonstaining peripheral • Broad spectrum topical antibiotics every hour or two – Fluoroquinolone • Contact lens wearer – Add tobramycin or ciprofloxacin ointment
  37. 37. BACTERIAL KERATITIS • Treatment – Borderline risk • • • • • Medium size 1 to 1.5 mm peripheral infiltrate Smaller infiltrate with epitheilial defect Anterior chamber reaction Discharge Fluoroquinolone q1h around the clock – Loading dose q5 min times 5 – Then q 30 min for a few doses
  38. 38. BACTERIAL KERATITIS • Treatment – Vision threatening • • • • • Larger than 1 to 2 mm Visual axis Unresponsive to treatment Corneal scrapings for smears and culture Fortified Abx – Fortified tobra or gent – Fortified vanco or cephaloporins – Alternating q1 hour… they get a drop every 30 minutes » Load with q 5 min times 5
  39. 39. BACTERIAL KERATITIS • Treatment – Sometimes topical steroids are used • • • • Sensitivities are known Infection under control Severe inflammation persists Keratitis may worsen – Fungus – Atypical mycobacteria – pseudomonas
  40. 40. STAPH HYPERSENSITIVITY • Symptoms – – – – Mild pain Mild photophobia Localized red eye Chronic blepharitis • Eyelid crusting • History of chalazia or styes • Foreign body sensation
  41. 41. STAPH HYPERSENSITIVITY Blepharitis
  42. 42. STAPH HYPERSENSITIVITY • Signs – Singular or multiple unilateral or bilateral peripheral corneal stromal infiltrates – Clear space between infiltrates and limbus – Variable staining with fluorescein – No anterior chamber reaction – Sectoral conjunctival injection – Others • Blepharitis, inferior spk, peripheral scarring, corneal neovascularization
  43. 43. STAPH HYPERSENSITIVITY • Treatment – Antibiotic and steroid • Recurrent episodes – Oral doxy or tetracycline – Restasis – Blepharitis treatment
  44. 44. STAPH HYPERSENSITIVITY • Differential – Infectious corneal infiltrate • Round • Painful • Anterior chamber reaction – Other causes or peripheral corneal thinning or ulceration • • • • Connective tissue disease Terrien marginal degeneration Mooren ulcer Dellen
  45. 45. • Peripheral Corneal Thinning – Connective Tissue Disease • Peripheral corneal thinning/ulcers may be associated with infiltrates • Unilateral or bilateral • May involve the entire peripheral cornea • Perforation can occur • Can be first sign of disease
  46. 46. RHEUMATOID PERIPHERAL CORNEAL THINNING
  47. 47. RHEUMATOID PERIPHERAL CORNEAL THINNING • What is true about Connective Tissue Disease Cornea Thinning? 1. Nothing can be done 2. Treatment is often coordinated with a Rheumatologist 3. Standard corneal transplants are very successful
  48. 48. RHEUMATOID PERIPHERAL CORNEAL THINNING • Treatment – – – – – – – – – Management usually coordinated with a rheumatologist Antibiotic ointment Cycloplegia Oral doxycycline for metalloproteinase inhibition Systemic steroids Immuosuppressives Punctal occlusion for dry eye Have patients wear glasses for protection Avoid topical steroids… increase risk of perforation
  49. 49. • Peripheral corneal thinning – Terrien marginal degeneration • • • • • • • • Often asymptomatic usually bilateral Slowly progressive thinning Typically superior more often in males AC quiet, conjunctiva white Yellow lipid line with corneal pannus over involved area Against the rule astigmatism can occur Epithelium remains intact Perforation possible with minor trauma
  50. 50. TERRIEN MARGINAL DEGENERATION • Which is false about Terrien Marginal Degeneration? 1. Rarely is there significant morbidity 2. Steroids are useful for excessive thinning 3. Against the rule astigmatism is common
  51. 51. TERRIEN
  52. 52. • Peripheral Corneal Thinning – Mooren ulcer • • • • • • • • Unilateral or bilateral ? Autoimmune Painful corneal thinning and ulceration with inflammation Starts focally nasal or temporal No limbal sparring Epithelial defect, stromal thinning, leading edge Perforation can occur Associated with Hepatitis C
  53. 53. MOOREN ULCER
  54. 54. MOOREN ULCER • Which is true about Moorens Ulcer? 1. Treatment is rarely necessary 2. Is a diagnosis of exclusion 3. Oral immunosuppressives not necessary
  55. 55. MOOREN ULCER • Treatment – – – – – – – Rule out underlying systemic disease Topical corticosteriods Topical cyclosporine Oral steroids Oral immunosuppressives Corneal glue Lamellar keratoplasty
  56. 56. • Peripheral Corneal Thinning – Furrow Degeneration • • • • • • Painless Adjacent to area of arcus Elderly Noninflammatory without neovascularization Perforation is rare Does not require treatment
  57. 57. FURROW DEGENERATION
  58. 58. • Peripheral corneal thinning – Dellen • • • • Painless oval corneal thinning From corneal drying and stromal dehydration Epithelium intact Adjacent to abnormal conjunctiva or corneal elevation
  59. 59. DELLEN
  60. 60. DELLEN • Audience participation question 1. Stop with the corneal thinning already 2. I find corneal thinning so interesting, please continue 3. Mauro, please intervene
  61. 61. CATARACT SURGERY @ NSEC • Technique – Topical anesthesia with IV sedation – Anticoagulants ok – No injections around eye – Small incision, no sutures – No eye patch necessary • Start medications right away – Co-management encouraged
  62. 62. CATARACT SURGERY • What about laser cataract surgery? – Strong future – Incisions • Penetrating and nonpenetrating • Capsulorrhexis • Lens division – Still improvement to be had at each stage – Looking at 3 platforms
  63. 63. CATARACT SURGERY • Meds – Three days prior • Antibiotic and NSAID – After Surgery • Antibiotic, NSAID and Steroid • Antibiotic stops after 2 weeks • NSAID, Steroid for 4 weeks… sometimes 6
  64. 64. CATARACT SURGERY • • Intraocular lens implants – Choice depends on preexisting astigmatism – Monofocal – Toric – Multifocal – Accommodating Technique important – Control astigmatism – Hit target • Iol master • Modern IOL formulas – Dry eye
  65. 65. LASIK @ NSEC • iLASIK – Bladeless and custom – Nearsightedness, farsightedness and astigmatism • State of the art LASIK center in Smithtown – Humidity and temperature controlled – Excellent staff • Run by RN • Co-management encouraged • Lifetime Commitment • More cases qualify for LASIK because flaps can be 100 micron
  66. 66. PRK • Better in some cases – Thin corneas – Irregular corneas – High prescriptions – Dry eyes – Contact sports • Higher corrections due to mitomycin c • Longer recovery • More dicomfort
  67. 67. LASER VISION CORRECTION MEDS • LASIK – Antibiotic and steroid for 10 days • PRK/LASEK – Antibiotic until contact lens out (5 days) – Steroid for 1 to 2 months
  68. 68. THANK YOU

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