Why am I

seeing poorly

after my

cataract

surgery?Dr. Derek Yu

Specialist in Ophthalmology

HKDU presentation

18/8/2015

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

Aim of modern cataract SurgeryRoyal College of Ophthalmologists

Restoration of vision

Achievement of desired refractive

outcome

Improvement Quality of Life

Ensuring safety and satisfaction

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

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.

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)

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

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

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.

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

Early Postoperative

Complications

1) Corneal edema

2) Uveitis

3) Endophthalmitis

4) Raised intraocular pressure

Corneal Edema

Endophthalmitis

WOUND LEAK(SIEDELS TEST)

Late Complications

1) persistent corneal edema,

2) posterior capsule opacification

3) cystoid macula edema

4) retinal detachment

5) refractive error

Persistnet edema-

descemet folds

Posterior Capsular

Opacification

http://flylib.com/books/en/3.283.1.8/1/http://flylib.com/books/en/3.283.1.8/1/

PCO

http://dro.hs.columbia.edu/pco2.htm

IOL WITH PCO Post laser capsulotomy

Cystoid Macula Edema

Fundus Photo Fluorescein Angiogram

OCT- Cystoid Macula EdemaNormal

Cystoid Macula Edema

OCT Machine

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

Better way to do cataract?

Femtosecond Laser Cataract

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

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

• 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

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

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

Putting in a toric intraocular lens -

Toric markings

Dilated exam post Toric

Implantation

Toric Implant at

axis 90 degrees

Presbyopic Correction in

cataract surgery

Dominant eye

corrected for distance

vision

Non-dominant eye

corrected for near vision,

with residual myopia

Monovision

“blended” vision of seeing near and distance

together

Multifocal IOLs

The Goal: To make patients less

dependent on their glasses for all

distances

MULTIFOCAL IOLs

Mechanism:

Diffractive gratings on

the intraocular lens

allows for light rays from

distance, intermediate

and near to focus on

the retina

Other conditions affecting

vision after cataract surgery

Floaters

Macula Diseases:

1) Age Related Macular Degeneration

2) Idiopathic Choroidal Vasculopathy

Floaters

Floaters

A GALLERY OF FLOATERS

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”

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

Liquefaction of vitreous body

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

LASER ENERGY PROFILE

Laser vitreolysis Video

Macular diseases

1) Age-related Macular degeneration

2) Polypoidal Choroidal Vasculopathy

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

Dry ARMDClinical findings:

1) Drusen

2) Retinal Pigment Epithelium atrophy

3) Degeneration of photoreceptor

4)Choroid capillary atrophy

Wet ARMD –

Choroidal Neovascularization

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

Idiopathic Choroidal

Vasculopathy

IPCV

Treatment- Photodynamic

Therapy

Verteporforin : Targeted

occlusion of leaking vessels

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