Phaco Training: 1. Dilate exam 2. Keratoplasty History

By | December 2, 2013

Dilate exam

The incidence of RD after cataract surgery is around
1%  ( ref:, while the
incidence of retinal detachment after LASIK is around 0.25%
( Some
studies quote an even lower rate for RD after LASIK
Looking at these stats, will it be safe to assume that
cataract surgery poses a similar (if not greater) risk for
retinal detachment as a LASIK procedure? So why is
peripheral retina evaluation a regular part of LASIK workup
but a not a cataract surgery workup (provided the cataract
allows sufficient viewing). Pls guide..

Answer 1.

It is preferable to do a fundus examination prior to cataract surgery and we used to treat predisposing lesions prior to the same. Guess it is not being followed any more!


Answer 2.

As residents at RPC (AIIMS) and as fellows at Sankara Nethralaya, we were taught that dilated fundus examination with indirect ophthalmoscopy should be routine part of preoperative examination for cataract surgery when the media are clear enough. After coming into practice, in past 6 years, I have realised its not the routine in most of places. The reason behind it, I suppose, is that the practice of camps for cataract surgery wherein, patients are screened without dilating pupils and operated without full examination. Being an age old practice, it has become a routine even in private practice now. LASIK is something which came into practice with strict guidelines since the beginning of its era. And that too it is being performed on high risk eyes. So routine I/O screening has become part of pre-procedure evaluation.

In most of camps or charity surgeries or even in some high profile private practices, I have noticed that they dont do B-scan ultrasonography for total cataracts and end up in problems if they find posterior segment pathology after surgery.
Just to mention a related example:
During a pediatric cataract camp, a Surgeon from UK came to operate and he called me into OT while operating a case as retina was seen behind lens. It was stage 5 ROP with clear lens! The surgeon himself examined the baby before surgery! If one gets streamlined in one direction, these kind of mishaps keep happening. That is why there is need for CME programs..


Answer 3. 

ALL intraocular procedures warrants a good retinal screening. It may be intravitreal injections, Trabeculectomy, Phaco or Lasik, even squint. Atleast we were taught to do indirect ophthalmoscopy in ALL our patients we see in the OPD. High risk cases of trauma, those posted for surgery, flashes, floaters etc needed a closer observation and evaluation. Even after cataract surgery an indirect is required especially if we have encountered a hazy media preop. If PCR again after surgery routine indirect more often is a must. Before and after Yag too an indirect ophthalmoscopy is a must. There are centres in India that do not allow or have a direct ophthalmoscope. Slit lamp examination and indirect being stressed upon.


Answer 4. 

On many occasions one finds that pre-cataract posterior pole examination is ignored, let alone peripheral examination!
I guess it might be something to do with the fact that while cataract surgery is therapeutic (hence slightly easier to justify I guess!), lasik is cosmetic. :-)

Answer 5.

Pre cataract screening of fundus is still done. At least in our centre we do it and that too by retina specialist. And we also do B scan for all mature cataracts.


Answer 6.

As suggested by everyone,  dilated fundus exam is must for all ophthalmic procedures.  At our centre,  we even screen pt prior to extra ocular sx like squint and pterygium. You dont want to be explaining to pt latter why his VA is less.
The problem is, ophthalmic practice is becoming volume oriented and probably quality is taking back seat due to economic consideration.
Another thing is Lasik pt are demanding and come back to haunt u while cataract pt being elderly accept poor outcomes/ complications far more easily.
You will notice as retina surgeon trying to protect ur ant segment friends in case of poor outcome due to retinal pathology. Do we have heart to tell them to change their practice or we wont protect them? NO.
So unless they want to change for better, this practice will continue.
Lets just keep doung what we do and hope things change for better :)


Keratoplasty evolution
Corneal transplantation has a long and evolved history, with many facets of change and great future possibilities, Edward J. Holland, MD, Cincinnati, said.
Dr. Holland delivered the Castroviejo Lecture at the “Advances in Keratoplasty: Where we are in 2013” symposium.
The evolution of corneal transplantation began with an unsuccessful first attempt in 1838, followed by the discussion of the lamellar keratoplasty approach to corneal disease starting in the late 1800s.
The first successful penetrating keratoplasty (PK) using human tissue was performed in 1906, Dr. Holland said.
“Finally, Ramon Castroviejo, of which this medal and lecture is named after, became the preeminent figure in the modern era of corneal transplantation,” Dr. Holland said. “He was very innovative with his surgical techniques … he was a high volume surgeon and made great contributions to our field.”
PK remained the dominant procedure for decades.
“I think back to all the American Academy of Ophthalmology meetings that I went to for years, and we talked about one procedure really—it was just PK,” Dr. Holland said. “And I think we all, as surgeons, got very comfortable with that.”
Reasons existed for PK’s continued dominance—one was excellent outcomes, which Dr. Holland said was actually not the case.
“We all, I think, fooled ourselves in saying we had great outcomes because we were defining outcomes as graft clarity. We weren’t talking about quality of vision,” Dr. Holland explained.
However, when compared to outcomes of other subspecialties, such as refractive or cataract surgery, corneal results were not as good, he said. These cases had high astigmatism, with many large studies of PK finding that the average astigmatism was more than 4 D.
“We didn’t even try to measure irregular astigmatism,” he said. “It was off the charts.”
There were others issues, including significant intraoperative complications. Dr. Holland said that while many surgeons thought they were doing a good job in the field, “in retrospect, we really weren’t.”
The last decade has seen a rapidly altering corneal surgery paradigm. There was a need for more anatomic targeted procedures, and those procedures sought to avoid the removal of healthy corneal tissue. Endothelial keratoplasty—DSEK or DMEK—was created to treat endothelial disease, while deep anterior lamellar keratoplasty (DALK) was developed to target stromal disease. In more challenging cases, an ocular surface transplant procedure was useful in those instances when PK was not effective.
“It’s been a pretty rapid change in our approach to patients with endothelial disease,” Dr. Holland said.
The statistical report from the Eye Bank Association of America, which tracks corneal transplants in the U.S., found that last year, endothelial keratoplasty for the first time “became the most common corneal transplant procedure, overtaking PK, and this is going to continue to rise,” according to Dr. Holland.
“Endothelial keratoplasty has been one of the most significant advances in corneal surgery,” he said. “It’s now the leading indication for keratoplasty, with about 40 to 50% of the patients that we operate on.”
Gerrit Melles, MD, Rotterdam, the Netherlands, had the “breakthrough” paper in Cornea in 2004 that first described DSEK, and that research had a major impact in the field that reverberates today, Dr. Holland said.
“[DSEK] became the procedure that corneal surgeons across the world embraced and really changed the way we manage our patients with endothelial disease,” Dr. Holland said.
The procedure is still undergoing evolution, with new insertion devices, thin DSEK techniques, and the transition underway to DMEK. The future looks bright, he said. Possibilities include culture endothelial cells and a biosynthetic cornea.
“Where are we going with corneal transplantation? We’ve had quite a bit of
change in the last decade and some exciting things going on. I think we’re moving to the cellular level,” Dr. Holland said.
Editors’ note: Dr. Holland has no financial interests related to his presentation.

Femtosecond laser technology
In the “Advanced Application of Femtosecond Lasers for Refractive Surgery” session, a number of surgeons discussed the development and advancement of the femtosecond technology and the ways in which it has changed corneal and refractive surgery.
Perry Binder, MD, San Diego, presented a short overview of femtosecond laser technology and said the diagnosis of its capabilities began on accident. Now, he said, there are numerous platforms that have evolved.
He cited several goals moving forward with femtosecond laser technology, including increasing procedure speed, reducing the laser energy to eliminate potential side effects, creating additional applications and trying to find one laser that will be able to do it all.
Steven Schallhorn, MD, San Diego, discussed using the femtosecond laser for LASIK procedures. “I believe the femtosecond laser, particularly for a LASIK flap, is more consistent,” Dr. Schallhorn said. He also said that it allows for more control, a greater safety profile, improved visual outcomes and faster visual recovery.
Technology will drive more innovation and improved results, he said. And new uses for this technology are beginning to be seen. The femtosecond laser is clearly representing a paradigm shift in corneal surgery and now in cataract surgery, Dr. Schallhorn said. There have been numerous innovations in flap technology, as well as other advances for smoother cuts, customized flaps and improved graphics for the user interface.
Dr. Schallhorn said that not only is femtosecond laser technology attractive to surgeons, but many patients are showing a preference for it as well.
“The femtosecond laser for LASIK has revolutionized the procedure,” Dr. Schallhorn said. “It has allowed us to do LASIK in aviators. It’s allowed us to do LASIK in astronauts. It’s allowed us to do LASIK in any population of patients safer, more effectively, with fewer complications.”
Editors’ note: Dr. Schallhorn has financial interests with AMO. Dr. Binder has financial interests with AMO, Accelerated Vision, AcuFocus, Outcomes Analysis Software, and Stroma Medical.

june 10, 2010 brett n marcie


Having steak and beer with Bret and Marcie at the Outback on June 10, 2010