Pearls From the Cataract Spotlight Session

Four experts presented their top pearls for managing complicated cataract cases during the first of two “Spotlight on Cataract” sessions (Spo3V).

Phaco with uveitis. Jessica B. Ciralsky, MD, provided the following tips:

• Identify the underlying cause. Start by identifying and controlling the underlying problem. Etiology can guide your therapy choice. Once the underlying problem is under control, wait for a period of quiescence (at least three months, preferably six months) before operating.
• Plan ahead for surgery. Prior to surgery, remember to rule out other pathology such as band keratopathy, glaucoma, and retinal diseases. Have a surgical plan (and a backup plan) along with a contingency tray including hooks, rings, and scissors at your disposal.
• Control the iris. For eyes with synechiae, Dr. Ciralsky prefers to start under a nonadhered area and sweep with the viscoelastic cannula. Avoid stretching an atrophic iris. Use hooks in eyes with shallow anterior chambers and small pupils.
• Choose your IOL (or lack thereof) wisely. Avoid multifocal and silicone lenses in uveitic patients. Dr. Ciralsky prefers to use a three-piece IOL in the bag in case of late dislocation. Some patients, such as children, may be better left aphakic.
• Actively manage corticosteroids. Plan out the patient’s pre-, peri- and postoperative steroid regimen. Dr. Ciralsky uses an aggressive postoperative topical steroid regimen, beginning with dosing every hour and tapering over two months.

Preventing and managing cystoid macular edema (CME). Rudy Nuijts, MD, offered the following advice.

• Which anti-inflammatory drops are most effective? Findings from the ESCRS PREMED randomized trial showed that a combination of topical bromfenac and dexamethasone was more effective than either drug alone in preventing CME.
• What about patients with diabetes? In diabetic populations, subconjunctival triamcinolone—in addition to topical bromfenac and dexamethasone—has been found to effectively prevent the development of CME.
• In the absence of diabetic retinopathy, should I do anything differently? For patients with diabetes and without diabetic retinopathy, Dr. Nuijts recommends proceeding as in a routine cataract surgery (i.e., using a combination of NSAIDS and steroids).
• What about diabetic macular edema (DME)? Intravitreal anti-VEGF injections and steroids can be combined with cataract surgery and are effective if DME is present.
• How should I treat CME after surgery? Current evidence backs the use of postoperative topical NSAIDs, which can be combined with steroids, for managing post–cataract surgery CME.

Reducing postop drops. Neal H. Shorstein, MD, described his approach as follows:

• Starting point. Shorstein’s regimen begins with an injection of LidoPhen 1%/1.5% (cyclopentolate/tropicamide) at the beginning of the surgery.
• Intracameral antibiotics. Shorstein uses moxifloxacin 0.1% for two purposes. First, for stromal hydration because recent data indicate the antibiotics remain in the wound for about 24 hours. He also uses at least 0.5 mL moxifloxacin intracamerally. There is still no solid evidence that topical antibiotics are effective at preventing endophthalmitis, he noted.
• Steroid injection. For inflammation control, Dr. Shorstein uses 0.4 mL of commercially available dilute form of triamcinolone (10 mg/mL), injecting 5 mm inferior to the limbus. Injecting more anteriorly addresses pain and iritis but carries a higher risk of intraocular pressure (IOP) elevations. Injecting more posteriorly, on the other hand, is better for preventing CME with less chance of IOP spikes, but pain and iritis control may be reduced. If using subconjunctival injections, he offered the following tips:
  • To avoid conjunctival hemorrhage, visualize the needle tip and avoid large vessels.
  • To avoid drug reflux, tunnel the needle 2 to 4 mm under the conjunctiva and inject slowly.
  • Provide written information to patients regarding the white depot. Assure them it will disappear in two months.
  • Emphasize a one-month IOP check. Risk factors for IOP increase include advanced glaucoma, younger age (<65 years), and longer axial length (>29 mm).

Phaco with glaucoma. Douglas J. Rhee, MD, shared the following advice:

• When should you add on a minimally invasive glaucoma surgery (MIGS) procedure? Indications for adding MIGS to cataract surgery include uncontrolled IOP, controlled IOP on three or more medications, high risk for IOP spike (e.g., pseudoexfoliation), and high risk for loss of central fixation.
• Use iris hooks or a Malyugin ring. Use these tools if you suspect you need them, Dr. Rhee advises. “I have rarely regretted using iris hooks,” he said. An extra tip: When capsular tension rings are used in eyes with pseudoexfoliation syndrome, there can be up to 0.8-D difference in the final spherical equivalent.
• Should I adjust IOL calculations? There is no change in surgically induced astigmatism if surgeons use the main cataract wound or paracentesis for the MIGS procedure. By contrast, there can be surgically induced astigmatism or a hyperopic shift with trabeculectomy and tube shunts.
• Avoid multifocal IOLs. In patients with glaucoma, Dr. Rhee recommends avoiding multifocal IOLs as they can degrade contrast sensitivity.
• Use topical NSAIDs if the patient is on a prostaglandin analogue (PGA). Because PGAs can increase the risk of postoperative CME, Dr. Rhee advises prescribing postoperative topical NSAIDs. Do not stop preop PGA use; doing so could lead to IOP elevations. —Keng Jin Lee, PhD

Watch the symposium in full. If you are registered for AAO 2020 Virtual, you have access to the archived presentations on the virtual meeting platform until Feb. 15, 2021. Log in to the virtual meeting platform: Next, from the Lobby screen, select “Sessions” from the top navigation; click “Agenda”; click the “Sunday” tab; and type “Spo3V” into the filter field.  

Disclosures: Dr. Ciralsky: Bruder Healthcare Company: C. Dr. Nuijts: Alcon Laboratories: C,L,S; Carl Zeiss Meditec: S; Johnson & Johnson: S; OPHTEC: L. Dr. Shorstein: None. Dr. Rhee: Aerie: C,L,O; Alcon Laboratories: C; Allergan: C,S; Bausch + Lomb: L; Glaukos: S; Ivantis: S,C,L; Ocular Therapeutix: C.

Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.

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