Optimizing Suboptimal Results Following Cataract Surgery

Refractive and Non Refractive Management 1st Edition

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Optimizing Suboptimal Results Following
Cataract Surgery
Refractive and Non-Refractive Management

Priya Narang, MS
Director
Narang Eye Care and Laser Centre
Ahmedabad, Gujarat, India

William B. Trattler, MD
Director of Cornea
The Center for Excellence in Eye Care
Volunteer Faculty
Florida International University College of Medicine
Miami, Florida

142 illustrations

Thieme
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Library of Congress Cataloging-in-Publication Data

Names: Narang, Priya, editor. | Trattler, Bill, editor.
Title: Optimizing suboptimal results following cataract
surgery : refractive and non-refrative management /
[edited by] Priya Narang, William Trattler.
Description: New York : Thieme, [2019] | Includes
bibliographical references.
Identifiers: LCCN 2018025288| ISBN 9781626238954
(hardcover) | ISBN 9781626238961 (eISBN)
Subjects: | MESH: Cataract Extraction--adverse effects |
Refractive Surgical
Procedures--adverse effects | Treatment Outcome
Classification: LCC RE451 | NLM WW 260 | DDC 617.7/
42059--dc23 LC record available at
https://lccn.loc.gov/2018025288

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 I would like to dedicate the book to my beautiful, talented daughter Rhea
who too aspires to be an ophthalmologist one day. I am also thankful to my
family for being my strength and for their continued support and love
throughout the writing of the book and also within my life as they have
helped me in more ways than anyone else.
Priya Narang

I dedicate this book to my parents, Marcia and Henry, who both make such
a difference to their friends and family. Their positive energy and zest for
making a difference have been inspirational. I am very grateful, and I hope
that I can carry on their kindness, compassion and positive outlook on life.
William B. Trattler
Contents
Video Contents
Foreword
Preface
Contributors

Part I Introduction
1 Overview of the Causes of Suboptimal Outcomes Following
Cataract Surgery: Role of Preoperative Screening and Adequate
Counseling
Samir Narang and Priya Narang
2 Tear Film and Corneal Disorders
Laura M. Periman and Priya Narang
3 Postrefractive Intraocular Lens Power Calculation: Choosing the
Right Nomogram
Aazim A. Siddiqui and Uday Devgan
4 Residual Refractive Error
Lisa Y. Chen and Edward E. Manche
5 Posterior Corneal Astigmatism: Basics and Clinical Implications
Fernando Antonio Faria-Correia, José Carlos Ferreira Mendes, and
Renato Ambrósio Jr.
6 Considerations in Cataract Surgery Following Postrefractive
Error Correction
William B. Trattler

Part II Refractive Enhancement Procedures

7 Corneal-Based Procedures: Astigmatic Keratotomy, LASIK,
PRK, and SMILE
Jennifer Loh and William B. Trattler
8 Intraocular Lens Exchange
Thomas A. Oetting
9 Piggyback Intraocular Lens
Johnny L. Gayton, Riley N. Sanders, and Val Nordin Sanders
10 Toric Intraocular Lens
Eric Clayton Amesbury and Kevin M. Miller
11 Premium Intraocular Lenses and Associated Problems
Elizabeth Yeu and Mario J. Rojas

Part III Nonrefractive Enhancement Procedures

12 Dysphotopsias and Surgical Management
Samuel Masket and Nicole R. Fram
13 Bullous Keratopathy and Endothelial Keratoplasty
Jonathan K. Kam and Jacqueline Beltz
14 Malpositioned Intraocular Lens and Capsular Bag: Intraocular
Lens Complex Issues
Amar Agarwal
15 Posterior Capsular Rupture and Intraocular Lens Implantation
Priya Narang

Part IV Miscellaneous
16 MiLoop: Micro-Interventional, Phaco-Free, Lens Fragmentation
Tsontcho Ianchulev and Susan MacDonald
17 Keratoconus and Cataract Surgery
Arthur B. Cummings and Sheraz Daya
18 Bilensectomy (Phakic IOL Explantation with Coincidental
Cataract Surgery and IOL Implantation)
Veronica Vargas Fragoso and Jorge L. Alió
19 Cystoid Macular Edema and Management
J. Fernando Arevalo, Carlos F. Fernández, and Fernando A. Arevalo
20 Endophthalmitis, Toxic Anterior Segment Syndrome, and Vitritis
Andrzej Grzybowski and Magdalena Turczynowska
21 Intraoperative Aberrometry
Kathryn M. Hatch
22 Futuristic Approach and Advancements
Gary Wörtz
23 Telescopic Intraocular Lenses
Isaac Lipshitz and Amar Agarwal
Index
Video Contents

Chapter 8 Intraocular Lens Exchange

Video 8.1 Intraocular lens (IOL) exchange for broken haptic.
Video 8.2 Removal of opacified memory lens.
Video 8.3 Intraocular lens (IOL) exchange in phimotic capsule.
Chapter 14 Malpositioned Intraocular Lens (IOL) and Capsular Bag –
IOL Complex Issues
Video 14.1 L-shaped pocket incision and subluxated one-piece
intraocular lens (IOL).
Video 14.2 Subluxated one-piece foldable intraocular lens (IOL) with
single-pass four-throw (SFT) pupilloplasty.
Video 14.3 Subluxated intraocular lens (IOL) with broken haptics.
Video 14.4 Subluxated anterior chamber intraocular lens (ACIOL) with
haptic protrusion in the sclera.
Video 14.5 Malpositioned three-piece intraocular lens (IOL) in sulcus.
Video 14.6 Dropped intraocular lens (IOL).
Chapter 15 Posterior Capsular Rupture and Intraocular Lens
Implantation
Video 15.1 Sulcus placement of an intraocular lens (IOL) in posterior
capsule rupture.
Video 15.2 Posterior assisted levitation and intraocular lens (IOL)
scaffold.
Video 15.3 Sleeveless phacotip assisted levitation (SPAL) with
intraocular lens (IOL) scaffold.
Video 15.4 Refractive glued intraocular lens (IOL) exchange.
Video 15.5 Triumvirate technique.
Video 15.6 Glued intraocular lens (IOL) scaffold.
Video 15.7 Gluing the intraocular lens (IOL) beneath the subluxated
cataractous lens.
Video 15.8 Glued intraocular lens (IOL) scaffold for Soemmering’s
ring.
 Video 15.9 Phimotic capsular bag–intraocular lens (IOL) complex
dislocation.
Video 15.10 L-shaped scleral incision with refractive intraocular lens
(IOL) exchange with Soemmering’s ring and glued IOL.
Video 15.11 No-assistant technique for glued intraocular lens (IOL).
Video 15.12 Handshake technique for glued intraocular lens.
Video 15.13 Complications of glued intraocular lens (IOL).
Chapter 18 Bilensectomy (Phakic IOL Explantation with Coincidental
Cataract Surgery and IOL Implantation)
Video 18.1 Bilensectomy: Kelman’s intraocular lens (IOL)
explantation.
Video 18.2 Bilensectomy: Artisan’s intraocular lens (IOL) explantation.
Video 18.3 Implantable contact lens (IPCL) explantation.
Chapter 22 Futuristic Approach and Advancements
Video 22.1 Demonstration of the mechanism of action of light-
adjustable intraocular lens.
Chapter 23 Telescopic Intraocular Lenses
Video 23.1 Superman returns.
Foreword
A generation ago, the first step in refractive cataract surgery began when we
routinely began to implant intraocular lenses (IOLs) to provide visual
rehabilitation for the management of aphakia in the cataract surgery patient.
Today, the opportunities for these same cataract surgical patients have
expanded dramatically with the next generation of refractive cataract
surgery. Multifocal, extended depth of field, toric, accommodating, and
aspheric IOLs have improved visual quality and empowered us with
additional opportunities to meet our patients’ needs. However, the IOL is
only a portion of the cataract surgical procedure. We continue to advance
our profession by improving the safety and accuracy of cataract surgery as
well. Accuracy has been improved with the addition of better keratometry,
biometry, posterior cornea evaluation, and IOL formulas. Our most
challenging and often our most demanding patients are those who have
undergone previous corneal refractive surgery and have an increased
expectation of excellent uncorrected visual acuity. Intraocular aberrometry
has been a major advance for these difficult IOL calculations as well as for
improving accuracy of toric IOL implantation. When there is residual
refractive error following cataract surgery, astigmatic keratotomy, LASIK
(laser in situ keratomileusis), PRK (photorefractive keratectomy), IOL
exchange, piggyback IOLs, and in the near future light-adjustable IOLs are
all viable options to resolve the refractive error. Safety has also increased as
we have become more proficient in managing the most difficult surgical
cases with the aid of better techniques and technology. However, serious
complications such as endophthalmitis and retinal detachment continue to
occur, but with precautions these complications can be reduced. Dry eye,
while rarely vision threatening, is the single most common complication
associated with cataract surgery, and recent advances in the diagnosis and
treatment of this disorder have dramatically improved patient satisfaction
following cataract surgery.
As patient expectations have increased, there is more of a need today
than ever before to improve our surgical outcomes and to address the
patient whose expectations have not been met. The true measure of a
successful cataract surgeon is not how he or she treats the happy surgical
patient but how they prevent complications, increase the quality of surgical
outcomes, and most importantly resolve the issues that result in an unhappy
cataract surgery patient. This is the core message of Optimizing Suboptimal
Results Following Cataract Surgery. There are several important steps that,
when executed correctly, dramatically increase postoperative success with
refractive IOL cataract surgery. In general, cataract surgery, and more
specifically premium IOL cataract surgery, requires careful patient selection
and counseling, along with precise surgical technique. The preoperative
evaluation is extraordinarily important to determine which lens is best for a
specific patient. High hyperopia, myopia, corneal disease, concomitant
glaucoma, and previous vitreoretinal disease all create unique challenges
for the cataract surgeon. Recent design advances in IOLs have resulted in
excellent visual outcomes after cataract surgery. As a result, many patients
now have higher expectations for vision following surgery, including
complete spectacle independence.
Priya Narang and William Trattler are two of the unique thinkers of our
time in the field of ophthalmic anterior segment surgery. There is an
enormous unmet need for a book that addresses the prevention and
management of the suboptimal surgical result in the cataract patient. This
unmet need has been answered with this book, Optimizing Suboptimal
Results Following Cataract Surgery. The challenges cataract surgeons deal
with every day are presented by Drs. Narang and Trattler and their
superlative faculty to give every ophthalmologist the opportunity to learn
from the best and to enhance their surgical results. This book is founded on
the basic principle that the patient always comes first and we should do
everything to maximize their visual outcome. No case is too complex for
the carefully selected international faculty of skilled ophthalmic surgeons
who are authors in this book.
Optimizing Suboptimal Results Following Cataract Surgery is a
comprehensive analysis of the advances in the field of cataract surgery that
improve patient outcomes. It summarizes all of the best, most useful, and
practical pearls that have been recently developed and gives the reader a
glimpse of the future of refractive cataract surgery. Drs. Narang and Trattler
are to be congratulated for bringing together an internationally recognized
group of authors and a comprehensive series of videos to demonstrate their
most useful techniques. There is no surgical procedure that improves
quality of life with greater efficacy than modern cataract surgery. This
bookdelivers to its readers the experience of leading ophthalmic surgeons
on how to realize the promise of refractive cataract surgery and will be
widely read and appreciated by anterior segment surgeons who wish to add
to their surgical armamentarium and will be an important contribution to
ophthalmology.

Eric Donnenfeld, MD
Clinical Professor of Ophthalmology
New York University Medical Center
Trustee, Dartmouth Medical School
Immediate Past President, ASCRS
Preface
The editors are delighted to present their joint venture entitled Optimizing
Suboptimal Results Following Cataract Surgery: Refractive and Non-
Refractive Management. The book has been written and presented with the
concept of highlighting the suboptimal outcomes that follow a cataract
surgery, which may serve as a major disappointment to the surgeon as well
as the patient. The unique feature of the book is that it serves as a concise
review and as a comprehensive guide on the concerned topic for all the
ophthalmologists, residents, and fellows along with subspecialists. The
book focuses on the aspect of untutored and unversed technicality that is an
essential and an indispensable knowledge tool for the operating surgeon,
and it brings to the forefront the arsenal of discreet medical facts.
The book has 23 chapters with illustrative details authored by renowned
ophthalmologists who are specialized in their respective field of handling
the clinical challenges. In addition to this, the book is also accompanied by
surgical videos that serve as an additional valuable learning tool.
We deeply appreciate the generous efforts of all the authors and
contributors in enabling us to pursue the completion of the book.

Priya Narang, MS
William B. Trattler, MD
Contributors
Amar Agarwal, MS, FRCS, FRCOphthal
Chairman
Dr. Agarwal’s Group of Eye Hospitals and Eye Research Centre
Chennai, India

Jorge L. Alió, MD
Professor and Chairman of Ophthalmology
Miguel Hernandez University
Alicante, Spain

Renato Ambrósio Jr., MD, PhD

Founder
Rio de Janeiro Corneal Tomography and Biomechanics Study Group
Professor of Ophthalmology
Federal University of The State of Rio de Janeiro (UNIRIO)
Federal University of São Paulo (UNIFESP)
Clinical Director
Insistuto de Olhos Renato Ambrósio
VisareRIO
Refracta Perosnal Laser
Rio de Janeiro, Brazil

Eric Clayton Amesbury, MD

Staff Ophthalmologist
Veterans Administration Medical Center
Assistant Professor of Ophthalmology
Medical College of Virginia
Virginia Commonwealth University
Richmond, Virginia

Fernando A. Arevalo, BS
Student