why am i seeing poorly after my cataract...
TRANSCRIPT
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Why am I
seeing poorly
after my
cataract
surgery?Dr. Derek Yu
Specialist in Ophthalmology
HKDU presentation
18/8/2015
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Cataract Surgery- Recent
Concept
Cataract surgery and refractive lens
surgery is now seen as a surgical spectrum
Improved surgical safety and quick
recovery time has seen cataract surgery
being offered earlier
Hong Kong Association of Private Eye
Surgeons estimates 40,000 cases done
per year
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Aim of modern cataract SurgeryRoyal College of Ophthalmologists
Restoration of vision
Achievement of desired refractive
outcome
Improvement Quality of Life
Ensuring safety and satisfaction
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Earlier Cataract Operations
Surgery should be performed for
symptoms rather than a number on a
vision chart e.g (6/12)
- Common symptoms
other than blurriness:
- Haloes
- Glares
- Increasing myopia
- Double vision
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Earlier Cataract Operations (3) Allow patients to minimise glasses wear
Have the surgery at an age when you are still
healthy and active
Improved vision, via cataract surgery, minimises
falls.
Fractured hip aged 75, 40% survive one year.
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Earlier Cataract Operations (4)
Minimize future Acute Angle Closure
glaucoma
Improves glare and night driving
Up to 97% of patients are achieving vision
>0.8 (6/9)
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Why unhappy?
Complications?
1 )Preoperative complications
2) Intraoperative complications
3) Postoperative complications
- early (days to 1 month)
-late (1 month to years)
-Intraocular lens related
4 )Other concomitant eye diseases
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Preoperative issues- Diabetes
Diabetic control MUST be optimal for cataract surgery
Risks: 1) worsening diabetic retinopathy
2) endophthalmitis
3) postoperative uveitis
4) cystoid macular edema
Ensure tight control for at least 3 months pre and post surgery
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Preoperative Issues-
Antiplatelets and
anticoagulants
Increased risk of thromoboembolic event
if stopped
For simple cataract surgery generally no
need to stop aspirin, warfarin or
clopidrogel.
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Posture
Patient must be able to lie at 45 degree
for 20 minutes
Problem:
1) Orthopnea
2) Parkinsons disease, tremors
3) Scoliosis
4) Reflux esophagitis
5) Anxiety
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Early Postoperative
Complications
1) Corneal edema
2) Uveitis
3) Endophthalmitis
4) Raised intraocular pressure
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Corneal Edema
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Endophthalmitis
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WOUND LEAK(SIEDELS TEST)
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Late Complications
1) persistent corneal edema,
2) posterior capsule opacification
3) cystoid macula edema
4) retinal detachment
5) refractive error
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Persistnet edema-
descemet folds
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Posterior Capsular
Opacification
http://flylib.com/books/en/3.283.1.8/1/http://flylib.com/books/en/3.283.1.8/1/
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IOL WITH PCO Post laser capsulotomy
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Cystoid Macula Edema
Fundus Photo Fluorescein Angiogram
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OCT- Cystoid Macula EdemaNormal
Cystoid Macula Edema
OCT Machine
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Cystoid macular edema (CME)A condition in which fluid accumulates within the sensory retina in the macular areaMay occur after intraocular surgery Cataract Filtration procedures RD surgeryAssociated with other systemic & ocular conditions including: Diabetes uveitis Retinitis Pigmentosa
Onset: 6-10 wks after cataract surgery
Signs: Hyperopic shift Macular haze Petaloid appearance on FA is the hallmark of CME (or flower petal) Evidence suggests inflammation plays a roleManagement: May improve without treatment if no other surgical complications
70% of post-CE CME resolves spontaneously within 6 months NSAIDs
CME may be recurrent
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Better way to do cataract?
Femtosecond Laser Cataract
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Better way to do cataract surgery?
Femtosecond laser cataract:
Advantages
1) Laser constructed
corneal wound,
no blade needed
2) Laser fragmentation of cataract nucleus,
less ultrasound energy
3) Better Intraocular lens centration
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So why still unhappy?
Increased expectations
Patients prefer to have refractive errors
corrected simultaneously
Correctable refractive errors:
1) myopia
2) hyperopia
3) astigmatism
4) presbyopia
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• Toric lenses are designed to work
with the shape of your cornea to
focus light to a single point at
the back of your eye to improve
your quality of vision.
• By doing this, Toric lenses will
make you less dependant on
your glasses for distance vision
• Toric lenses only correct
astigmatism and do not correct
presbyopia
• You will have to wear reading
glasses after cataract surgery
Key points for patients to
understand
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Ferrer-Blasco T,Monté s-Micó R,Peixoto-de-Matos SC,Gonzá lez-
Mé ijome JM,Cerviño A.Prevalence of corneal astigmatism before
cataract surgery.J Cataract Refract Surg.2009;35(1):70-75. N = 4540
eyes.
87% of cataract surgery patients have
preoperative astigmatism
64% of patients fall within 0.50 to 1.25
36% of patients having greater than 1.26 D
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TORIC IOLs- New Standard of careWolffsohn,JCRS,Effect of uncorrected astigmatism
on vision March 2011
Modest amounts of astigmatism can
have major effect on vision
Effect independence – night,rain driving
Quality of life, well being – reading speed
Higher risks of fall
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Putting in a toric intraocular lens -
Toric markings
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Dilated exam post Toric
Implantation
Toric Implant at
axis 90 degrees
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Presbyopic Correction in
cataract surgery
Dominant eye
corrected for distance
vision
Non-dominant eye
corrected for near vision,
with residual myopia
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Monovision
“blended” vision of seeing near and distance
together
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Multifocal IOLs
The Goal: To make patients less
dependent on their glasses for all
distances
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MULTIFOCAL IOLs
Mechanism:
Diffractive gratings on
the intraocular lens
allows for light rays from
distance, intermediate
and near to focus on
the retina
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Other conditions affecting
vision after cataract surgery
Floaters
Macula Diseases:
1) Age Related Macular Degeneration
2) Idiopathic Choroidal Vasculopathy
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Floaters
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Floaters
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A GALLERY OF FLOATERS
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SCOPE OF PROBLEM -
FLOATERS
Common aging changes- liquefaction of vitreous gel
Often considered that no treatment is available
Most common advice: “ Learn to live with it”
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DISABILITY FROM FLOATERS
Patient’s self assessed “disability” from floaters
Equal to Age Macular Degeneration
Worse than diabetic retinopathy, glaucoma
Worse than mild angina, mild stroke, colon CA
1. Wagle AM, Lim WY et. Al., Utility values associated with vitreous floaters. Am J Ophthalmol 2011; 152(1): 60-65
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Liquefaction of vitreous body
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Yag laser vitreolysis
Power concentrated to 4-8 micron spotDuration 4 nanosecondsEffect of plasma formation and optical breakdownCollagen converted to gas and resorbedBreaks floater down AND vaporizes material
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LASER ENERGY PROFILE
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Laser vitreolysis Video
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Macular diseases
1) Age-related Macular degeneration
2) Polypoidal Choroidal Vasculopathy
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Age-related macular degeneration
The incidence increase with each decade over age 50
Main blind-causing disease in elderly
Severe central visual loss
Etiology:
Long-term chronic macular light damage、heredity、metabolism、nutrient factors
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Dry ARMDClinical findings:
1) Drusen
2) Retinal Pigment Epithelium atrophy
3) Degeneration of photoreceptor
4)Choroid capillary atrophy
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Wet ARMD –
Choroidal Neovascularization
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Treatment: Intravitreal anti-
VEGF injection - Vascular Endothelial Growth
Factor promotes new blood
vessel growth
- Anti-VEGF blocks growth
factors
- Currently 3 agents:
- 1) Avastin
- 2) Lucentis
- 3) Eyelea
- Potential side effects:
General: Stroke
Ischemic heart
disease
Ocular: Endophthalmitis
Retinal detachment
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Idiopathic Choroidal
Vasculopathy
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IPCV
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Treatment- Photodynamic
Therapy
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Verteporforin : Targeted
occlusion of leaking vessels
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Summary
Cataract is now performed earlier when
visual symptoms are present
A desired refractive outcome is essential
for a happy patient
Femtosecond laser technology enhances
a positive cataract outcome
Signficant visual floaters can be
considered for laser vitreolysis