Safe, successful cataract surgery possible in eyes with comorbidities
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Cataract surgery is a highly refined procedure nowadays.
Multiple technological innovations have contributed to enhance safety and efficiency and to provide outcomes that satisfy the growing demands of an aging population that wants to maintain an active lifestyle. However, routine surgery may be complicated by preexisting ocular comorbidities. Surgeons need to be aware of these conditions and learn how to manage them appropriately before, during and after cataract surgery, working in team with other specialists. They also need to discuss with patients the implications of these conditions and manage expectations.
Source: Carlos Puma/Puma Images
“The goal in cataract surgery is to have optimized refractive outcomes, and in eyes with other ocular morbidities, the success and patient satisfaction will be affected if they are not properly addressed,” Healio | OSN Cornea/External Disease Board Member Marjan Farid, MD, said.
Ocular surface issues
Evaluation of the cornea and ocular surface has become a standard of care for patients who present for cataract surgery. Many ocular surface and corneal comorbidities, such as dry eye disease, Salzmann’s nodules or anterior basement membrane dystrophy, are amenable to treatment and should be addressed before surgery and IOL planning, Farid said.
“It is incumbent upon the surgeon to pause, treat them and then bring the patient back to look for regularity on topography. At that point, you can be more confident about intraocular lens selection, and the patient may also be a better candidate for premium lens technology,” she said.
“Nowadays, I find that even patients without premium IOLs have very high expectations,” Y. Ralph Chu, MD, a cataract, cornea and glaucoma specialist, said.
The screening process should encompass topography, tomography, keratography, tear film evaluation, meibomian gland assessment, tear production and osmolarity.
“We use multiple tools in our practice and take the extra time to educate the patient about their ocular surface as part of their whole preoperative cataract surgery journey, a great way to prevent postoperative issues afterward. If needed, we delay surgery to manage that condition,” Chu said.
There are plenty of options available to treat specific problems of the ocular surface, from Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals) for Demodex blepharitis to intense pulsed laser for meibomian gland dysfunction, from Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) to target tear evaporation to Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) to address inflammation and Tyrvaya (varenicline solution, Viatris) to increase tear production.
“We often prescribe an anti-inflammatory for about 6 to 8 weeks postoperatively. It helps to stabilize refraction and give better vision faster, which is super important for patient expectation management,” Chu said.
Keratoconus
Most patients with keratoconus are not at high risk for progression when they reach the age for cataract surgery, but there are exceptions to watch for.
“I even had a patient who was not aware of having keratoconus. He had been wearing glasses for many years, had some astigmatism, and we performed topography as part of our standard preoperative workup. We found, to our surprise, that he had undiagnosed keratoconus, and his astigmatism was very irregular,” Farid said.
It is important in these cases to make sure that the cornea is stable. If keratoconus looks to be progressive, corneal cross-linking should be performed before cataract surgery to stabilize the cornea.
“This will help with intraocular lens planning and long-term refractive stability,” Farid said.
Patients with advanced keratoconus require a lot of preoperative counseling because they most likely will need to continue wearing their contact lenses to get good vision after surgery, Chu said.
“Oftentimes, we talk to patients about using a toric IOL to help reduce the astigmatism, but if the patient still needs to wear contacts, it’s a tricky situation with a toric, and they may need special design lenses afterward, like a bitoric,” he said.
A monofocal IOL may be a safer choice in these cases. The thing to avoid, both Farid and Chu said, are limbal relaxing incisions (LRIs) because any kind of incision can cause the keratoconus to progress, even the cataract incision itself.
“We still use clear-corneal incisions, but I would avoid LRIs in keratoconus patients,” Chu said.
Some eyes with irregular corneas can do well with a pinhole optic IOL, such as the Apthera (Bausch + Lomb), according to Farid.
“We can decrease their higher-order aberrations. This is off label, but it can be implanted in both eyes of patients with irregular corneas,” she said.
When corneal grafting is needed
Patients with endothelial dystrophy, such as Fuchs’, typically have reduced endothelial cell count and in some cases might have corneal edema. In those cases, Farid often performs cataract surgery with endothelial keratoplasty at the same time.
“In patients with milder disease of the cornea, we sometimes do the cataract surgery first, see how they do, and we may be able to postpone keratoplasty for some time,” she said.
However, if full-thickness keratoplasty is needed for corneal scar or corneal ectasia, her preference is to do the penetrating keratoplasty first and wait until the sutures are removed.
“Then, do the cataract surgery at that point, once the final corneal curvature is defined,” she said.
Intraoperatively, in patients with a history of corneal transplant, the endothelial cells of the graft should be protected by using a fair amount of dispersive viscoelastic and quick chop techniques to minimize damage from ultrasound energy. The bottle height must be kept down to minimize water pressure on the endothelial cells, Farid recommended.
“These are all important precautions to minimize intraoperative trauma,” she said.
Pseudoexfoliation and glaucoma
Pseudoexfoliation presents some potential risks during cataract surgery due to looser zonules and smaller pupils that dilate poorly.
“We need to discuss with the patients the potential need for pupil manipulation, which might cause cosmetic changes, as well as the need for a possible further surgery, whether it would be by us or even by a retina specialist in case of retained lens fragments,” Chu said.
Eyes with glaucoma need to be protected from postoperative pressure spikes, and it is important to know what types of viscoelastics should and should not be used to manage small pupils and shallow chambers. Thorough removal of viscoelastic at the end of surgery is paramount.
“Sometimes, when we are doing MIGS and other glaucoma procedures, we purposely hyperinflate the eyes slightly at the end of surgery to prevent hyphema or just to manage the IOP postoperatively,” Chu said.
As a cataract specialist who also performs glaucoma surgery, Deborah G. Ristvedt, DO, has many patients referred to her practice from primary eye care providers.
“We have a specific assessment system for patients with glaucoma when they’re coming in for cataract surgery. We like to know what their maximum IOP was before they were placed on a glaucoma drop, if they’ve ever had any prior surgeries for glaucoma, and then we look at prior testing so that we can compare our visual field and OCT analysis to prior history. This is so crucial when we are going to perform cataract surgery, in addition to really looking at their stage of glaucoma and considering the opportunity that we have to manage both,” she said.
Combining cataract and glaucoma surgery
There are many minimally invasive glaucoma surgery options to choose from, depending on the individual patient, but Ristvedt’s advice is to become proficient in one or two at first and then move beyond to avoid being overwhelmed by so many devices and technologies.
“If patients have mild disease, no visual field loss and are on one medication, we can get a lot of stability and lessen their drop dependence by bypassing the trabecular meshwork. If patients are on multiple medications or have skipped pigmented areas in the angle, I like to implant Hydrus (Alcon) to dilate the canal and bypass the trabecular meshwork. Alternatively, I might do a canaloplasty with goniotomy to address the possible resistance from collapsed Schlemm’s canal or herniation of tissue into the aqueous collector channels,” Ristvedt said.
For patients who have ocular hypertension or are high-risk glaucoma suspects, she is still proactive by performing goniotomy to open up the trabecular meshwork.
Chu also likes to combine MIGS with cataract surgery. He predominantly uses stents and goniotomy, and although in clinical trials MIGS was performed after cataract surgery, experience has taught him that the reverse is better.
“If we put the stent first or do the goniotomy first, the eye is firmer, and it is easier to sit the goniolens on the eye to visualize the angle. Also, you consume less viscoelastic because you can fill the anterior chamber, do your MIGS and complete the capsulorrhexis right after that without refilling the anterior chamber,” he said.
Ristvedt expressed the same opinion: “It’s more cost-effective, and it reduces waste of consumables,” she said. “I also find I have less bleeding at the end of the case because I’m pressurizing the eye taking the cataract out, and I have a faster visual recovery.”
In more advanced glaucoma in which filtering surgery is needed, the combined phaco-trabeculectomy procedure raises the issue of inflammation, scarring and bleb failure over time. If the cataract is mild to moderate and glaucoma is severe, glaucoma should be addressed first, postponing cataract surgery to a later stage, Ristvedt said.
“However, we’re not out of the woods, whether we do combined or staged surgery. There are always challenges to both,” she said.
Minimally invasive bleb surgery with the Xen gel stent (Allergan) offers the opportunity to minimize inflammation to the conjunctiva.
“We don’t have to make a flap that could also scar down, and we cause less trauma to the conjunctiva, which really helps for success,” she said.
IOL choice and postop management
Glaucoma is a progressive disease, and IOL choice should be made considering the long term, according to Chu.
“We prefer a high-contrast IOL, and we’ve had success with the Light Adjustable Lens (LAL, RxSight) because of its good contrast sensitivity postoperatively,” he said.
Ristvedt takes the patient’s lifestyle into consideration, their motivation to be spectacle-free as well as the status of their cornea and dilation of their pupil. Monofocal plus lenses are a good option in patients with moderate visual field loss, and so are toric IOLs in case of astigmatism. She also agrees that the LAL is a good choice.
“This lens has been a game changer for managing glaucoma patients. As long as they dilate well, we can fine-tune and dial in a prescription that they’re happy with over time,” she said.
Postoperatively, patients with glaucoma need to be managed closely, making sure from day 1 that their IOP is not elevated and watching closely for pressure spikes from steroid use, Ristvedt recommended.
“If glaucoma is severe, it’s OK to keep them on their ocular hypertensives until they’re done with their steroid medication, then do a washout at 4 to 6 weeks, and recheck their pressure off of all of their drops to reassess that new baseline,” she said.
In case of comanagement, she makes sure that every optometrist and every referring doctor has her cell phone number and her practice on call.
“I want to be sure that I’m being a team player in the management of these patients,” she said.
Macular degeneration
In patients with retinal disease, the main thing is to understand ahead of time what percent of the vision issues are related to the retina and what percent are due to the cataract, according to Healio | OSN Section Editor Uday Devgan, MD.
“That’s going to help you set patient expectations. If 80% of issues are on the retina and the cataract is relatively mild, after cataract surgery, the patients are not going to be happy because they expected much more from the surgery,” he said.
In these patients, his advice is to wait until the cataract has worsened to be at least half of the visual problem. In case of bilateral, asymmetric disease, his advice is to do cataract surgery on the eye with better visual potential. The patient will be reasonably surprised and more encouraged to do surgery in the other eye.
However, patients with age-related macular degeneration need to be made aware that cataract surgery will not address visual distortion and the loss of central vision.
“I explain to patients that the eye is like a camera: There is film in the camera, and there is the lens. What we are doing is fitting a brand-new lens and making sure the focus is great. But we can’t change the film of the camera, which is unfortunately damaged. They need to understand that the cataract is only going to help to a certain degree,” Devgan said.
Working with the retina specialist
Working with the retina specialist and having them also explain what can and cannot be expected will be of further help. It is also important in terms of decision-making to establish whether it is time for cataract surgery and how to schedule anti-VEGF injections in view of the surgery.
“With wet AMD, we may need to fit in the cataract surgery in between injections. With dry AMD, the decision to be made is whether cataract surgery will be beneficial, given that many of these patients have geographic atrophy and have scotomas,” Sophie J. Bakri, MD, a retina specialist, said.
If a patient has a large scotoma, she will wait longer, but in many cases, the improvement of peripheral vision can make a difference in terms of quality of life.
Bakri recommended that patients on anti-VEGF therapy should be as dry as possible before considering cataract surgery.
“By the time I consider cataract surgery, they are on a maintenance injection phase. Several patients have fluid that is resistant to treatment, but as long as it’s stable fluid, it’s fine to do cataract surgery,” she said.
Around the time of surgery, she maintains patients on their last fixed interval, and only a few months later she considers further extensions.
Diabetic eye disease
While studies do not agree on whether cataract surgery increases the risk for incident AMD or AMD progression, there is clear evidence that it can worsen diabetic retinopathy and diabetic macular edema.
“I would control DME as best as I can with anti VEGF-therapy or steroid therapy if needed. With the more severe stages of DR, my advice is to use preoperative steroids and NSAID drops for a week or two beforehand and a week or two afterward,” Bakri said.
Devgan works closely with the primary care doctor to make sure the patient has a good HbA1c, indicating that the blood sugar level is well controlled before surgery.
“Another important issue with diabetic patients is if they are taking semaglutide or other GLP-1 agonists because these drugs delay gastric emptying. Anesthesiologists want to be sure that those injections are stopped 1 week before surgery; otherwise, there would still be food in the stomach even after 10 hours of fasting,” he said.
Diabetes damages the small blood vessels in the retina and in the anterior segment of the eye. Patients with diabetes are also more likely to have a poorly dilated pupil due to an ischemic iris and to have weakness in the anterior segment structures.
“You need to be extra careful with these eyes during surgery because they are more likely to have complications,” Devgan said.
The pupils may need to be stretched with expansion rings or iris hooks, and it is important to carefully look at the capsule before performing the capsulorrhexis.
“If the capsule is wrinkly, that’s an indication of weakened zonular support. You need to minimize postoperative inflammation, using less ultrasound energy and running less fluid through the eye. Remember, the volume of the anterior chamber is about one-quarter of a cc. If you run 300 cc of balanced salt solution, that means you wash out the anterior part of the eye 1,000 times. You can do the whole surgery with 30 cc, and that’s only 100 times, and there will be less inflammation,” Devgan said.
Bakri recommended caution with patients who have Ozurdex (dexamethasone intravitreal implant, Allergan) in place. If the posterior capsule breaks, the implant moves anteriorly and touches the cornea, leading to decompensation.
“It is rare, but extra care is needed,” she said.
Monofocal lenses should be the only option in patients with retinal diseases, according to both Bakri and Devgan, because these patients have problems with contrast sensitivity.
“If they have a lot of astigmatism, you could do a toric monofocal, but I don’t see a role for any of the light-splitting or light-spreading technologies. These patients are not overly concerned with the use of glasses — they just want to be able to see,” Devgan said.
Postoperatively, these patients need to be kept under observation because of the possibility of developing macular edema.
“You may need to keep them on anti-inflammatory agents for longer, for 6, 8 or even 10 weeks. And you need to watch not only their anterior segment, but do a macular OCT,” Devgan said.
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- For more information:
- Sophie J. Bakri, MD, of the Mayo Clinic in Rochester, Minnesota, can be reached at bakri.sophie@mayo.edu.
- Y. Ralph Chu, MD, of Chu Vision Institute in Bloomington, Minnesota, can be reached at yrchu@chuvision.com.
- Uday Devgan, MD, of Devgan Eye Surgery in Los Angeles, can be reached at devgan@gmail.com.
- Marjan Farid, MD, of Gavin Herbert Eye Institute, University of California, Irvine, can be reached at mfarid@uci.edu.
- Deborah G. Ristvedt, DO, of Vance Thompson Vision in Alexandria, Minnesota, can be reached at deborah.ristvedt@vancethompsonvision.com.
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