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Dr. Fahad alzwaidi R2

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diabetes mellitus, pulmonary dysfunction, cardiovascular dysfunction (e.g., poorly controlled blood pressure, heart failure), musculoskeletal disorders causing positional difficulties, tremor, hearing impairment, anxiety, mental retardation, dementia, and coagulopathies.

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systemic alpha-1 antagonists. avoid the initiation of alpha-1 antagonists until their cataract surgery is completed. Discontinuing does not typically prevent IFIS, which may occur long after drug cessation. severe in patients taking the alpha-1A subtype specific antagonist, tamsulosin.

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Several uncontrolled case series reported minimal or no complications in patients who were maintained on (alternatives to retrobulbar ) associated with medical morbidity. (In patients with new coronary stents, stent thrombosis )

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No recommendations from AHA, AAOO to prescribe systemic antibiotic prophylaxis for patients with artificial heart valves or joint prostheses who are undergoing cataract surgery.

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Deeply set eye : visibility, access to the limbus,Pooling of irrigation fluid wound deformation and leakage. Dense brunescent nuclear cataract : zonular laxity and miosis, Little cortex to protect the capsule, phacoemulsification time.

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High hyperopia : endothelial trauma, iris trauma and prolapse, calculating lens power, suprachoroidal effusion (particularly in nanophthalmic eyes). High myopia : depth fluctuation due to reverse pupillary block, calculating power, decreased ocular rigidity, difficult sealing the wound, risk of retinal detachment.

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Miotic pupil : capsule tear/vitreous prolapse, iris damage and prolapse Prior scleral buckling surgery : Change in axial length,Conjunctival scarring Increased risk of sclera perforation with injection anesthesia.

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options include : . Glaucoma surgical options : trabeculectomy, drainage devices, and endocyclophotocoagulation

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Benefits are protection against a potential postoperative IOP spike and long-term IOP control with a single operation. potentially indicated in eyes with active uveitis, neovascularization, or multiple anterior segment problems. Glaucoma surgery prior : anesthetic risks, inducing filtration failure as a result of subsequent cataract surgery.

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Cataract surgery with IOL implantation alone suspected or confirmed primary angle closure. mild to moderately severe open-angle glaucoma controlled on medication. modest reduction of IOP.

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Studies have found that the degree of IOP reduction is greater with higher preoperative IOP levels and that the benefit may last for several years.

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Phacoemulsification combined with trabeculectomy provides good IOP control. But its not as effective as glaucoma surgery alone. Both one-site and two-site combined procedures appear to provide similar IOP reduction.

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New glaucoma technologies like : Canaloplasty, ab interno trabeculotomy, and ab interno trabecular bypass microstents may reduce the risk of hypotony and bleb complications, but they may not lower the IOP as much.

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uses of antifibrotic agents (mitomycin-C and 5-fluorouracil) to reduce the potential for bleb failure remains controversial. mitomycin-C may be effective in producing lower long-term IOPs, 5-fluorouracil is not.

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Evaluation of the corneal endothelium. microcystic edema or stromal thickening, central corneal pachymetry greater than 640 microns and/or low central endothelial cell counts by specular microscopy. History : prolonged "foggy vision" upon awakening in the morning.

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reasons to consider combining cataract extraction with corneal transplantation. i. Cataracts may progress more rapidly after corneal transplantation. ii. corticosteroids following surgery may hasten PSC cataract development. iii. Cataract surgery subsequent to corneal transplantation may damage the corneal graft. iv. Visual rehabilitation is more rapid.

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With borderline endothelial reserve : A more peripheral incision, either temporal clear cornea or corneoscleral, and repeated instillation of OVD may preserve more endothelial cells.

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some surgeons prefer to perform penetrating keratoplasty first, followed by cataract removal later after the corneal graft has stabilized. this approach reducing the amount of time the eye is open during the penetrating keratoplasty surgery.

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An alternative procedure : transplantation of the endothelium and posterior stroma or replacement of the endothelial layer with Descemet's membrane alone. I. Can combined with phacoemulsification and foldable IOL implantation. II. preserves the anterior corneal curvature.

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Descemet's stripping endothelial keratoplasty : ( change posterior corneal contour) Induce a hyperopic refractive shift. (+0.6 D after 12 months in one study,+1.47 D ) should be considered if there is significant risk of corneal decompensation following cataract surgery.

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If the indication for considering corneal transplantation is the presence of a central opacity : performing cataract surgery followed by a sphincterotomy, establishing a clear entrance pupil.

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postoperative problems : adhesions between the iris and lens capsule, membrane formation, IOL deposits, zonular problems, and CME.

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special issues When patients with uveitis undergo cataract surgery Inactive or at its best level of control. Even if the patient is on chronic anti- inflammatory therapy, additional topical or oral corticosteroids. In one study pre op oral sreroid : > decrease the risk of postoperative CME.

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medical regimen should be individualized. (the severity and sequelae of past episodes ) Surgical planning should take into account the possible need for other procedures. Prcedure modify bec. pre-existing posterior synechiae, pupillary membranes, and fibrotic scarring of the pupillary margin.

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lens material does not seem to be a major influence on the course of postoperative inflammation. IOL haptics into the capsular bag is preferred. ( large diameter capsulorhexis ) Aphakic. Complications I. inflammatory deposits, II. surface membrane formation, and III. inflammatory capsular complications capable of causing IOL subluxation.

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excessive iris manipulation should be avoided. Postoperative use of topical mydriatic agents. ( short-acting ) Adjunctive corticosteroids at the time of surgery(intravenous, periocular, or intraocular) Postoperatively frequency and duration of corticosteroid. should be monitored closely.

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it is often necessary. Vitreoretinal procedures may cause pre- existing cataracts to progress. so Management of such cataracts may be more complex, because capsular defects or weakened zonules may be present.

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A wide range of vitreoretinal disorders may be dealt with concomitantly including : vitreous hemorrhage, diabetic retinopathy, epiretinal membrane, macular hole, and retinal detachment. in-the-bag placement of a foldable IOL is a good option. Myopic shift.

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complex cases : pars plana lens fragmentation with simultaneous or later sulcus placement of a posterior chamber IOL. Secure wound closure is important to permit safe vitreoretinal maneuvers. nature of the posterior segment pathology for visualization ( ie. silicone optic )

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Disadvantages : prolonged surgical time, cataract-wound dehiscence during subsequent vitreoretinal surgery, Intraoperative miosis after cataract extraction, IOL decentration or optic capture.

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challenges : in addtion to IOL calculation. IOL formulas predict the effective lens position based on the corneal steepness this will introduces a formula artifact.

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Following radial keratotomy : Need to avoid the new incision cross pre- existing incisions. ( leak, delayed healing, and irregular astigmatism) Induced central corneal flattening automated computerized videokeratography (topography or tomography).

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Following excimer laser refractive surgery : all corneal power readings incorrect as result surgical alteration of the anterior corneal curvature and, the changed relationship between anterior and posterior corneal powers. myopic photoablation ---- hyperopic refractive errors So, beneficial to utilize the Aramberri Double-K method to refine IOL power determination.

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indications for surgery same as for other patients. delaying surgery until the cataract is very advanced may increase surgical risk and slow visual recovery.

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Clinical studies have provided that binocular summation occurs in similar visual acuities in the two eyes and at low illuminance levels. with dissimilar acuities in the two eyes may exhibit binocular inhibition. that stereoacuity increased from 32% to 90% after second-eye surgery.

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Determining the appropriate interval : the patient's visual needs and preferences, visual acuity and function of the second eye, the medical and refractive stability of the first eye, and degree of anisometropia.

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Immediate Sequential (Same Day) Bilateral Cataract Surgery need for general anesthesia. when the health of the patient may limit surgery to one surgical encounter. rare occasions where travel for surgery is hardship for pt.

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Criteria : Vital signs are stable. Preoperative mental state is restored. Nausea and vomiting are controlled. Pain is absent or minimal. Postsurgical care has been reviewed follow up.

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hospitalization include hyphema, uncontrolled elevated IOP, threatened or actual expulsive suprachoroidal hemorrhage, retrobulbar hemorrhage, severe pain,

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The ophthalmologist has an obligation to inform patients about signs and symptoms of possible complications, eye protection, activities, medications, required visits, and details for access to emergency care. In the absence of complications, postoperative visits depend largely on the size of incision R/O suture, refraction.

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Interval history, including use of postoperative medications, new symptoms, and self-assessment of vision. Visual acuity, including P.H testing or refraction. Measurement of IOP SLE Counseling/education for the patient or patient's caretaker.

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fundus examination if there is a reasonable suspicion or higher risk of posterior segment problems. visual improvement is less than anticipated : diagnostic test ie. if maculopathy is suspected, OCT or fluorescein angiography. Optical correction : 1 and 4 wks small-incision 12 wks large-incision.

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evidence supports a lower PCO rate when the anterior capsulorrhexis completely overlaps the entire optic. Polishing of the anterior capsule has a variable effect on reducing PCO rates. But it do in --- anterior capsule fibrosis and contracture reduce this phenomena.

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Nd:YAG laser capsulotomy : indicated earlier in patients with multifocal IOLs because of a greater functional impact of early PCO in low-contrast and glare conditions. Complications : increased IOP, retinal detachment, damage to the IOL, and dislocation of the IOL. In the presence of risk factors, agents to lower IOP have demonstrated efficacy at blunting IOP elevation.

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