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EW SHOW DAILY 48 ASCRS Symposia by Rich Daly EyeWorld Contributing Writer "Clearly the refraction we were getting right before the surgery is not what you want to hang your hat on by any stretch of the imagina- tion," Dr. Cionni said. "We always ask our patients to bring in their old glasses, and we look at that, we look at the refraction, we look at the Ks measured three or four different ways, and we make certain that it all makes sense." EW Editors' note: Drs. Berdahl, Yeu, and Cionni have financial interests with various ophthalmic companies. "Even then you can cause it to tear out from the force of the CTR," Dr. Cionni said. Dr. Cionni confronted simi- larly unknown outcomes in one of his cataract cases where a female patient's preop refraction and K readings appeared unaligned. In such cases, Dr. Cionni urged confirming that the recorded refrac- tion actually is for that patient. He also urged checking earlier refrac- tions by using their glasses. In that case, a refraction obtained 4 years earlier differed sharply from his preop refraction. that we can't see," Dr. Cionni said. If the patient agreed to such a stipulation, as well as the likely inability to restore youthful near vision, then he would consider a low add multifocal lens that behaves much like a distance lens. Dr. Berdahl noted that the pa- tient's uncorrected visual acuity ini- tially was good after the blunt force trauma but it had declined over the last decade. Opting to install a multifocal lens, Dr. Berdahl's colleague found some movement of the capsular bag complex during the cataract surgery. However, a key point in decid- ing to remain with the multifocal lens was that this type of zonulop- athy is not progressive, unlike that which occurs in some diseases. "We don't anticipate that he's going to get looser with time," Dr. Berdahl said. The panel of surgeons discussing that case in a symposium sponsored by the ASCRS Refractive Surgery Clinical Committee were split on whether they would administer a block on such a patient. Dr. Ber- dahl's colleague did not administer such a block. A CTR was inserted and cen- tered well. "Importantly, we felt like his zonules were stable enough that if we had to take it out, we could," Dr. Berdahl said. Dr. Berdahl's colleague opted not to polish the patient's posterior capsule, the patient obtained 20/40 uncorrected vision, and was "really happy." Following an early YAG capsulo- tomy at 6 weeks postop, the patient had 20/20 –2 vision in the left eye, restored binocular depth perception, and was spectacle independent. Dr. Cionni generally waits at least a month to perform a YAG cap- sulotomy "just to be certain that you got some peripheral fibrosis." Capsulotomies performed short of 2 months postop should be very small, Dr. Cionni said. A history of blunt force trauma can complicate the approach needed in cataract cases. A 62-year-old man with a unilateral cataract in the left eye—stemming from an incident decades earlier—presented recently at the practice of John Berdahl, MD, Sioux Falls, South Dakota. The patient's eyes both had a 20/25 uncorrected visual acuity (+0.50 – 1.25x103 20/20). The patient desired spectacle independence and had 0.60 D of corneal cylinder, which led Dr. Berdahl's colleague treating him to consider using either a toric or mul- tifocal lens. The situation was complicated by the fixed traumatic mydriasis in the left eye. Among the considerations in such cases, said Elizabeth Yeu, MD, Norfolk, Virginia, is the patient's macular health, as well as the skill set of the treating surgeon. "The trauma alone will mean a [capsular tension ring]; there's going to be a greater amount of zonular lysis, and if there is a very obvious zonulopathy, the only way he should consider a presbyopia-cor- recting technology is if you can truly fix the centration," Dr. Yeu said. "We would have to have good capsular fixation to the scleral wall—toric IOLs as a monofocal could do very well in a patient like this." Other considerations include proper management of the expecta- tions of the patient, who is paying for a premium IOL but may not obtain great vision. "If everything goes well, we will put the lens in to get you out of those glasses," Robert Cionni, MD, Salt Lake City, said about a possible way to discuss the approach with the patient. "So at a minimum, we can do a toric." However, the patient needs to know that even if the surgery goes well and the implant is positioned perfectly, "there may not be func- tional vision because of something Monday, April 16, 2018 Insights offered on cataract case with trauma history Dr. Cionni says that cataract patients who have suffered blunt force trauma to the eye need to know that even if the surgery goes well, they may not obtain functional vision due to unseen risks.

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