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Inside Eyetube.net | Jul/Aug 2013

To Boldly Go Where No Cataract Surgeon Has Gone Before

As more ophthalmologists elect to practice in a subspecialty—be it refractive, cataract, retinal, or glaucoma surgery—there is less reason for us to focus on other parts of the human eye. Developments in other subspecialties therefore do not always get our full attention, which in turn can lead to less accurate decision-making skills when a complication outside of our comfort zone arises. Vitrecomized eyes, for example, require special attention and a carefully planned cataract surgery technique.

For most of us practicing cataract and refractive surgery, the retina is the most difficult part of the eye to understand. With this in mind, our cover series this month is dedicated to the topic of cataract surgery and the retina. In his article, Arup Chakrabarti, MS, helps us to understand the major surgical considerations in eyes with retinal pathologies, and in their articles, Michael Amon, MD, and Abhay R. Vasavada, MS, FRCS, discuss the key points in IOL selection. In lens-based surgical procedures, one of the major goals for anterior segment surgeons is to consider the performance of the IOL and its overall effect on visual quality. Not only are the clarity of the cornea and the posterior capsule important, but also the macula should be checked, preferably with optical coherence tomography. Pre- and postoperative regimens should be adapted to each specific case rather than using a one-size-fits-all approach, Professors Amon and Vasavada both mention in their articles.

Complications rarely occur during phacoemusification, and they are becoming even less frequent now that femtosecond–laser-assisted lens surgery is being implemented. However, it is wise for all of us to be prepared with step-by-step plans for any complication, should one arise. Take the occurrence of a dropped nucleus: In these cases, it is important not to rush. Do not overthink the possibilities but instead close the eye properly. What all retinal surgeons hope for in these cases is a relatively quiet eye with a clear cornea, good intraocular pressure control, and a round pupil. Vitreoretinal specialist Christopher Gorman, BSc (Path), MB ChB (Hons), FRCOphth, provides a nice step-by-step plan for managing a dropped nucleus in his article.

Investigators in the European Society of Cataract and Refractive Surgeons (ESCRS) Prevention of Macular Edema After Cataract Surgery (PREMED) study hope to establish evidence-based clinical guidelines for the prevention of cystoid macular edema (CME) after cataract surgery. In patients with diabetic retinopathy who are undergoing cataract surgery, this complication is predominantly caused by surgical manipulation. The PREMED study is being conducted in 12 centers throughout Europe, and results will be available in 2015.

Similar published studies have showed that the use of bromfenac eyedrops and intravitreal injection of a vascular endothelial growth factor (VEGF)-inhibiting agent at the conclusion of surgery can be used as prophylaxis against the development of edema in patients with diabetes, thereby reducing the incidence of CME significantly. This is also the experience of A. John KaneIlopoulos, MD, who reports on his good results with anti-VEGF intravitreal injections with up to 5-year followup. Carlos Vergés, MD, PhD, and Joan Casado, MD, who share their protocols for cataract surgery in eyes with retinal pathology, also recommend intravitreal injection of a VEGF inhibitor. In their practice, it is injected either 2 to 4 days preoperatively or at the end of surgery in eyes with suspected or confirmed macular membranes, cystoid macular degeneration, DME, or other macular pathologies that are likely to experience further decompensation.

The last article of our cover series describes a patient who presents with a visually significant cataract and an impending macular hole. The surgeons point out the significance of spectral domain optical coherence tomography and the referral to a retinal specialist.

Many governments consider cataract surgery as a 5-minute, routine procedure. It is our duty to explain to them, and to our patients, that cataract surgery requires a thorough preoperative diagnostic examination, careful step-by-step planning, and a meticulous surgical technique. We have a huge responsibility in restoring our patients' quality of vision, and we should not take this lightly. The retina plays an important role in the end result of this so-called simple procedure.