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Cataract co management oct 03 2010


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Cataract Co-management from the Optometric Perspective by Dr. Fernando Auza

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Cataract co management oct 03 2010

  1. 1. Cataract Co-management from the Optometric perspective<br />R. Fernando Auza, O.D.<br />Visionary Ophthalmology<br />Bethesda, MD<br />
  2. 2. OD/MD Cataract Co-ManagementWhy?<br />Expansion of patient variety and opportunity for practice growth<br />Educational process that expands your knowledge <br />Opportunity to become an expert<br />With development of Multifocal/Toric IOL’s, Cataract Surgery has evolved into “Refractive Cataract Surgery”<br />Potential for added revenue through premium IOL co-management<br />50+ market is expected to grow seven times faster than any other segment <br />OD’s play an integral role in selecting and recommending IOL <br />
  3. 3. Before referring your patient to a Cataract surgeon <br />Discontinue Contact Lens wear two to three weeks in advance so that axial length and keratometry measurements are accurate for precise IOL calculation.<br />RGP’s<br />Soft lenses with low dK/t<br />Patients on Extended Wear Contac Lenses<br />
  4. 4. Careful evaluation of Ocular Surface<br />Management of surface disease will improve final visual outcome<br />Tear dysfunction syndrome<br />Lid margin disease<br />
  5. 5. Evaluation of Ocular Surface<br />Map-dot-fingerprint dystrophy<br />
  6. 6. Post Op – Day 1<br />History – Problem focused<br />Exam<br />VA – Usually should be 20/40 or better <br />Anterior Segment Exam<br />Corneal Surface/Stroma<br />Anterior chamber inflammation <br />Lens centration and PCO<br />IOP <br />Plan – Medications – Antimicrobial/Anti-inflamatorytherapy<br />Zymar or Vigamox/Xibron/Prednisolone 1% t.i.d. <br />Follow up visit – three weeks/sooner PRN<br />
  7. 7. Potential complications one day after surgery<br />IOP Spike<br />BollousKeratopathy<br />Decentered/Dislocated/Rotated Toric IOL<br />Tilted Lens<br />Peaked pupil – vitreous prolapse<br />Retained lens fragments<br />RD<br />
  8. 8. Post-Op Visit Two – Two to three weeks after surgery<br />Problem focused history<br />Exam<br />VA<br />Anterior segment<br />Ocular Surface/Cornea<br />Anterior changer<br />Lens centration – crucial with multifocal IOL<br />Axis location – must dilate toric IOL’s<br />IOP – Inflammation/Steroid Responders<br />Refraction<br />Medications – Discontinue antimicrobials. Tapper off steroids and NSAID if A/C quite. Continue steroid/NSAID therapy if necessary<br />Follow up visit – one month<br />
  9. 9. Complications at week at second post-op visit <br />Poor visual outcome – must investigate<br />Previous pathology?<br />Front to back approach<br />Ocular Surface- (not a post-operative complication)<br />Dry eye<br />MGD<br />EBMD<br />
  10. 10. Corneal Edema/Bollous Keratopathy<br />Endothelial dysfunction<br />Persistent A/C reaction <br />Treat with steroids and Muro 128 ung or sol.<br />Keep IOP low <br />
  11. 11. Severe Iritis - Must Investigate<br />May just take longer to resolve in some patients<br />History of previous iritis/autoinmune disease<br />Irido-Lenticular contact if IOL tilted<br />Can affect VA<br />May have to reposition IOL<br />
  12. 12. IOL outside capsular bag inferiorly<br />
  13. 13. Persistent Iritis - Continued<br />Retained Lens Fragments<br />If iritis is persistent – must perform carefull DFE looking for small fragments<br />Fragments may be within the capsular bag<br />
  14. 14. Posterior Capsular Opacity<br />Treat early<br />PCO greatly affects VA and contrast sensitivity specially with multifocal IOL’s<br />Decentered/Dislocated<br />Surgeon will have to reposition IOL<br />
  15. 15. Cystoid Macular Edema<br />More common in diabetics<br />Sub-Clinical CME may be difficult to detect without OCT or Fluorescein angiography<br />
  16. 16. Post Operative Epiretinal Membrane<br />Incidence - 22% - only 3.6% visually significant<br />Visually insignificant ERM also known as Cellophane Macular Reflex<br />Visually Significant ERM – Maculr Pucker<br />
  17. 17. Post-Operative Endophthalmitis<br />Incidence 0.1%<br />Patient present with pain, photophobia, floaters, reduced vision, an inflamed anterior segment including a variable hypopyon, and vitritis<br />May present four to seven days after surgery<br />