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Dr . Mohamed ELShafie, MD
Prepared and presented by
Free, focused mini-lessons
Cataract surgery is safe…
•No complications in 95%,
•91% achieving vision ≥6/12, 50% ≥6/6…
…but some patients
still fail to achieve a
satisfactory vision
Don’t lose sight
of retinal disease
when visualizing
outcomes
6
KSU Hospital
provide a good visual outcome without exacerbating
underlying retinal disease or creating any new
problems with the retina.
“ “
Massive
X
presentation
to
DesignBall
team
7
b
C
c
ARMD
01
02
03
03
Reports on the effect of
cataract surgery on AMD
progression
but not proving causation
clearly states cataract surgery
did not increase risk of
developing advanced AMD up
to 10 years of follow-up
average gain in VA persisting
for at least 18 months
9 COVID19 IN CHILDREN
Eyes with
mild AMD, significant
cataract
ARMD.
01
02
assessment of visual function
objectively
03
snellen acuity
amsler grid testing
dark adaptation
KSU
HOSPITAL
11
post-injections
pre-cataract surgery
1. patient response to injections
2. Date of most recent injection
KSU
HOSPITAL
12
eight weeks post-
cataract surgery with
recurrent activity.
01
Setting realistic
expectations.
02
MF-IOLs
EDOF IOLs
reduced contrast
sensitivity.
03
pseudophakic monovision
binocular vision will be
compromised
Treatment considerations
Massive
X
presentation
to
DesignBall
team
14
b
C
c
1
4
5
3
2
compromise retinal
monitoring and treatment
Capsular opacification
and contraction
posterior subcapsular
cataracts
develop cataracts
earlier
need good glycaemic
and blood pressure
control before surgery
compromised blood-
aqueous barrier
increases
postoperative
inflammation
Diabetic
patients
01
02
reports increased rates of new
onset retinopathy and worsening
of DME and existing retinopathy
after cataract surgery
double in the first postoperative year
diabetic patients who received
postoperative subconjunctival
injection with triamcinolone
acetonide had a lower macular
thickness and macular volume
at 6 and 12 weeks
postoperatively than patients
who did not.
1
2
3
4
5
larger rhexis
complete cortical
clean-up
larger optic
IOLs
aggressive control
of postoperative
inflammation
early retinal therapy
within one to two
weeks after cataract
surgery
Massive
X
presentation
to
DesignBall
team
18
b
C
c
RVO
significant improvement in
postoperative vision has
been found following
cataract surgery
increased risk of CME
30 times higher
01
02
When considering cataract
surgery
completely free of retinal ischemia
macular oedema resolved and remains stable
for 2 to 3 months without intervention
03
04
unless the cataract precludes
visualization of the posterior pole
NSAID drops one week prior to surgery
and to continue
Anti- VEGF intraoperative minimise the risk.
05
21
KSU HOSPITAL
Once IVI
Phaco
IVI 3 times
Phaco with subtenon kenakort
KSU
HOSPITAL
22
What do you think ???
Massive
X
presentation
to
DesignBall
team
23
b
C
c
ERM
24 COVID19 IN CHILDREN
1
2
3
Grading of ERM.
4
COVID19 IN CHILDREN 25
KSU HOSPITAL
b C
c
 proceed with cataract surgery alone.
 increased risk of post-operative CMO
 ERMs may progress more quickly
following cataract surgery
Treatment considerations
vision is affected primarily
by
 Vitrectomy, ERM peeling cataract 3-12 m. later.
 Cataract vitrectomy, ERM peeling 3-12 m. later.
 phacovitrectomy, ERM peeling.
Surprise after phaco
surgery: Discrepancy
BCVA to lens opacity
Massive
X
presentation
to
DesignBall
team
27
b
C
c
High myopia
01
02
When considering
cataract surgery major risk factors for RD
PCO after cataract surgery
03
IOL calculations are less reliable
esp AL > 30mm
04 no benefit in implanting zero power IOL !!!
cataracts and chronic symptomatic floaters.
05
Massive
X
presentation
to
DesignBall
team
29
b
C
c
Peripheral
Retinal
Degenerations
30
KSU Hospital
Lattice degeneration is associated with an increased risk of a
retinal detachment
“ “
COVID19
IN
CHILDREN
KSU
HOSPITAL
31
b
C
c
1
2
3
4
Atrophic holes
symptoms of vitreous
traction (flashing lights)
fellow eye has a history of RD
positive family history of RD.
Massive
X
presentation
to
DesignBall
team
32
b
C
c
After
Scleral Buckle
01
02
When considering
cataract surgery Long axial length affecting IOL power
Conjunctival scaring
03
Risk of scleral perforation during
anaesthesia injection
Massive
X
presentation
to
DesignBall
team
34
b
C
c
After
vitrectomy
01
02
When considering
cataract surgery Soft globe than normal
Unstable zonules
03 Deep anterior chamber
04 Intraoperative miosis, fluctuation of AC depth
Posterior capsule instability.
05
Cataract progression ?!
06
Pseudophakic CME.
01
02
Preoperative risk for CME
Diabetic retinopathy
Uveitis
03 Retinal vein occlusion
04 Use of prostglandines
Epiretinal membrane.
05
Postoperative CME-development partner eye.
06
•Vision loss due to AMD?
01
02
Preoperative considerations for
OCT of fundus Discrepancy lens opacity-vision (age!)
Pre-existingretinal diseases:
AMD, RVO, uveitis, diabetes
03
Vitreoretinal diseases:
epiretinal membranes, macular holes
04 Use of prostglandines
Postoperative complications fellow eye.
05
Legal issues
The police are often involved therefore,
accurate record keeping is essential.
Photographs can be of additional use.
Informed
Consent
47
KSU Hospital
patient selection is key
Massive
X
48
1
2
3
Cataract surgery
Notes
possible impact of
surgery on
monitor and treat underlying
retinal pathology
COVID19 IN CHILDREN 49
KSU HOSPITAL
b C
c
THANK YOU

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Retinal consideration in cataract surgery

Editor's Notes

  1. protects retina against blue light in visible spectrum. cataract protective against development of AMD, making removal of cataract a potential risk factor for AMD development 8.4% of patients who were diagnosed with non neovascular AMD prior to surgery were found to have neovascular changes that went undiagnosed until after cataract surgery due to lens opacity.
  2. similar visual outcomes among advanced AMD sub-types (geographic atrophy/choroidal neovascularization,
  3. recovery of vision when going from daylight to darkness,
  4. defer cataract surgery until the patient has not required intervention for a 90-day period IV injection 1-2 w before cataract to make sure work of anti vegf in postop period
  5. They wont get back their central vision but appreciate brightness of peripheral vision after operation dominant eye plano and the non-dominant eye myopic.
  6. Decreased lens volume after cataract surgery causes a forward shift of vitreous and release of angiogenic factors and cytokines. higher with extracapsular cataract surgery and in patients with combined diabetic retinopathy and hypertensive retinopathy
  7. fluctuations in intraocular pressure (IOP) during the surgery contributed to RVO development
  8. Distort layers Perseve fovea Distort layers foveoschisis Retinal thickening Distort fovea Pseudohole d2 erm
  9. Blurred (cat) or distorted vision (erm) Foveal contour persreved do cataract only
  10. 2 IOL does not stretch large capsular bag reduced posterior capsule adhesion to IOL optic, facilitating lens epithelial cell migration onto posterior capsule 4 physical barrier between anterior and posterior segments. prevent the vitreous from prolapsing into anterior chamber, generate peripheral vitreoretinal traction and cause RD, filter UV light prevent retinal phototoxicity 5 cataract surgery also promotes vitreous liquefaction leading to additional floaters, phacovit
  11. 5 Careful hydro dissection like post polar 6 vitreous absorbs oxygen released from retinal circulation and protects lens from oxidation. Following vitrectomy oxygen reaches lens more quickly, acceleration of nuclear cataract in 70% of patients within 3 years of surgery
  12. 5 Careful hydro dissection like post polar 6 vitreous absorbs oxygen released from retinal circulation and protects lens from oxidation. Following vitrectomy oxygen reaches lens more quickly, resulting in an acceleration of nuclear cataract in 70% of patients within three years of surgery