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Not long ago, the surgeon I work with returned from an ophthalmology meeting with a practice management book by John Pinto, MD. The book was written for ophthalmologists, but I was curious, so I borrowed it and read the following intriguing thought: “A few surgeons use optometrists as refractionists only. This is vast underutilization of resources. Practices with a diversified service base that includes dispensing and primary care should be delegating all appropriate patients to an optometric provider, rather than tying up surgeon time.”1
In our practice, I am one of three optometrists, and we have one ophthalmologist who routinely performs LASIK, cataract surgery, and corneal grafts. When we optometrists are not busy building our own autonomous portion of the practice through routine exams, glasses, and specialty contact lens fits, we also provide support for surgical cases and patients. My intent in this article is to detail the workings of our practice to illustrate one way in which optometrists and ophthalmologists can perform collaborative cataract surgery management to ultimately provide the best efficiency and patient outcomes.
Many of our cataract patients are referred from our established patient base. When one of our optometrists performs a routine annual exam that shows evidence of vision deterioration due to cataracts, we begin to discuss with that patient the basics of cataract surgery. This includes a brief review of IOL options, including presbyopia-correcting premium lenses such as the Tecnis Multifocal (Abbott) and the Crystalens AO (Bausch + Lomb), as well as the basics of the surgery itself.
If scheduling permits, we find time for the surgeon to briefly meet the patient and evaluate his or her cataracts on the same day. If the schedule does not permit, then that introduction and evaluation is scheduled for a later date.
PLANNING FOR SUCCESS BEFORE SURGERY
Dry Eye Considerations
We have learned that, no matter how perfectly a lens implant is selected and placed, patients will struggle with quality of vision if they have dry eye disease (DED) that has not been adequately addressed before surgery (Figure 1). Typical DED management options include topical drops such as Retaine MGD (OcuSoft) and Restasis (cyclosporine ophthalmic emulsion 0.05%; Allergan).
We may also recommend an in-office procedure such as Mibo ThermoFlo (Mibo Medical Group) or BlephEx (BlephEx). ThermoFlo is particularly beneficial for patients with meibomian gland dysfunction and inspissation of glands. BlephEx is preferred for anterior blepharitis in which the eyelid margins are red and itchy as a result of debris at the base of the eyelashes (Figures 2 and 3). These procedures are not covered by insurance, but either can have a positive impact on patients’ surgical outcomes.
DED is not the only enemy of quality vision. Higher-order aberrations such as coma, trefoil, and spherical aberration can also lead to dissatisfaction, especially in patients receiving multifocal IOL implants. We use a topographer that is equipped with wavefront aberrometry to evaluate second-order aberration, and we have a general rule that a coma aberration value greater than 0.342 µm is considered significant, especially with a multifocal IOL implant. This helps guide our recommendations for or against multifocal IOL options and is part of our preoperative discussion with patients.
EARLY POSTOPERATIVE CONSIDERATIONS
One Day Postop, First Eye
All patients returning for their day 1 postoperative visit are seen by an optometrist first thing in the morning, before our routine clinic. This facilitates a quick, no-wait experience for the patient. At this visit, a technician checks visual acuity, reviews postoperative drop instructions, and checks intraocular pressure (IOP). The posterior chamber IOL and eye health are then evaluated at the slit lamp by an optometrist.
If the IOP is elevated, the optometrist will perform a port release (also known as burping the wound). This is usually indicated when IOP is above 30 mm Hg, in which case microcystic corneal edema may also be observed. Before the wound is burped, an anesthetic drop is instilled. The side port paracentesis is then gently pressed with the tip of a sterile needle or cannula. If no fluid is released, this is usually the result of pressing the wrong location rather than of not applying enough pressure. A little pressure can go a long way when applied in the correct spot. Antibiotic drops are applied after the fluid release (Figures 4 and 5).
An unusually low IOP postoperatively could indicate a wound leak, which can be evaluated at the slit lamp with the cobalt blue filter after fluorescein is instilled (Seidel test). A slow leak may seal effectively after the application of a bandage contact lens, but larger leaks may have to be sutured by the surgeon.2
Anisometropia Between Surgeries
In most cases, a patient’s two cataract surgeries are performed 2 weeks apart. For some patients the intervening period is a visually awkward stage secondary to newly created anisometropia. If the patient has a relatively high level of imbalance (> 1.50 D) between the two eyes, we place a prescription soft contact lens on the nonoperated eye to reduce the anisometropia. We prefer to use Oasys (Acuvue) lenses on an extended-wear schedule for the 2 weeks before the second cataract surgery. If the amount of anisometropia is not significant, it may be preferable to replace the spectacle lens for the patient’s operated eye with a plano lens that we can have edged in our optical lab.
LATE POSTOPERATIVE CONSIDERATIONS
Two-Week Postop, First Eye
By 2 weeks, the refractive status of the first eye can be checked with reasonable precision. An optometrist performs the refraction to determine the accuracy of the IOL selection for the first eye. This then helps guide the surgeon to make midcourse corrections, if necessary, for the second eye.
Dilation of Postop Patients
From a medicolegal perspective and to provide comprehensive postoperative care, it is recommended that all cataract patients receive a dilated fundus examination soon after their surgery. We dilate patients at 2 weeks postoperative and take a fundus photograph with optomap (Optos) ultrawide digital retinal imaging.
The dilated exam also allows evaluation of lens centration. Some decentration is tolerable, depending on which multifocal IOL was implanted (Figure 6).3 Dislocation of an IOL can sometimes be seen years later, especially in patients with pseudoexfoliation syndrome (Figure 7).4 This may require an IOL exchange with implantation of a three-piece IOL. The surgical solution will depend on the details of the case. The IOL may be placed in the ciliary sulcus with support by the anterior capsular leaflet, it may require suturing to the iris or sclera, or it may have to be fixated in a scleral pocket (Figures 8-10).
Posterior Capsular Opacification
Posterior capsular opacification (PCO) is a result of proliferation and migration of cells across the back surface of the capsule. PCO may be seen from weeks to years after cataract surgery, and it often requires intervention with an Nd:YAG laser. We prefer to wait 8 to 12 weeks to allow capsular constriction (Figure 11). Three states (Oklahoma, Kentucky, and Louisiana) allow optometrists to perform YAG laser capsulotomy for PCO.
Cystoid Macular Edema
If a patient’s postoperative visual acuity is worse than expected, cystoid macular edema (Irving-Gass syndrome) must be ruled out (Figure 12). Although its causes are likely multifactorial, it is believed that inflammatory mediators are upregulated due to surgical manipulation, and inflammation then leads to a breakdown in the aqueous and blood-retina barriers.5 This syndrome is more common in diabetic patients than in those without the condition. Initial treatment is a topical steroid and a topical nonsteroidal antiinflammatory drug. Secondary treatment modalities can include sub-Tenon or intravitreal injection of a steroid.
The most successful surgeons and practices recognize that optimal outcomes are achieved through good teamwork. This requires optometrists to practice at their full scope, to counsel patients appropriately preoperatively, and to recognize adverse events after cataract surgery. Many complications that arise can be effectively managed by optometrists. n
1. Pinto JB. Simple: The Inner Game of Ophthalmic Practice Success. Fairfax, VA: American Society of Ophthalmic Administrators; 2015.
2. Reddy MK. Complications of cataract surgery. Indian J Ophthalmol. 1995;43(4):201-209.
3. Soda M, Yaguchi S. Effect of decentration on the optical performance in multifocal intraocular lenses. Ophthalmologica. 2012;227(4):197-204.
4. Chang DF. Prevention of bag-fixated IOL dislocation in pseudoexfoliation. Ophthalmology. 2002;109:1951-1952.
5. Williams GA, Haller JA, Kuppermann BD, et al. Dexamethasone posterior-segment drug delivery system in the treatment of macular edema resulting from uveitis or Irvine-Gass syndrome. Am J Ophthalmol. 2009;147(6):1048-1054.
Pierce Kenworthy, OD, FAAO
• Private practice at Eye Excellence, Houston, Texas
• (713) 791-9494; firstname.lastname@example.org
• Financial interest: none acknowledged