Jules Stein Eye Institute

In this episode, Arthur Benjamin, MD, discusses dry eye treatment and trends, the challenges dry eye patients and the eye care professionals treating them and more.

Most people consider high myopia to be about –10 D or greater, but what about patients who are –20 D or more? For these patients with very long axial lengths and extreme levels of myopia, cataract surgery can be life-changing, but it is also quite challenging. If your patient has an axial length of at least 30 mm or more than 15 D of myopia, be warned that the IOL power calculations, as well as the surgery, will be more challenging, as seen in Figure 1.

The patient is a relatively young construction worker who sustained a blunt traumatic ocular injury that was fortunately nonpenetrating. This resulted in the development of a focal lens opacity initially, which then progressed to a visually significant cataract requiring surgery. He is part of our charity surgery program given his inability to afford the cost of surgery.

Posterior capsule opacification, or PCO, is common after cataract surgery, especially after a few years have passed. Even a perfect surgery by a master surgeon still leads to PCO in many cases. Fortunately, we have the ability to use the YAG laser to perform a posterior capsulotomy, which is safe and highly effective and takes just a few minutes. Because of the high prevalence of PCO, every cataract surgeon needs to know how to perform an effective YAG laser capsulotomy.

A patient presents to our resident ophthalmology clinic with a 1-day history of a nail piercing his eye while doing construction work. Fortunately, the trauma is not high speed and the damage is limited to the anterior segment of the eye. There is a central corneal laceration and the anterior lens capsule has been ruptured, as seen in Figure 1. The posterior lens capsule is intact, and there is no posterior segment trauma. No retained foreign bodies are found.

Average life expectancy is at an all-time high in the U.S. at 79 years, with even better news for people who are already seniors, who are expected to live to 85 years. This means that we will see more patients age 90 years and older having cataract surgery. In my practice, I see multiple patients every month who have reached the age of 90 and now require cataract surgery. But cataract surgery in these patients is not the same as in younger patients. I recommend three important considerations when performing cataract surgery in nonagenarian patients.

When Dr. Nagahara introduced the phaco chop technique 25 years ago, it improved cataract surgery dramatically. Total ultrasound energy was reduced, surgery was more efficient, and safety improved. There did remain one challenge, however, and that is the steep learning curve for this technique. With direct mentoring, most of my resident ophthalmologists over the past two decades have been able to learn phaco chop and become adept with the technique. For an experienced surgeon, access to hands-on teaching is difficult, and most revert back to the divide-and-conquer technique that works sufficiently well in their hands. By combining the advantages of the horizontal and vertical chop techniques, we can simplify the learning process and allow more surgeons to upgrade to this method of nucleus disassembly.

An experienced cataract surgeon has developed an intuition after having done thousands of cases over the course of many years. If you ask this surgeon about IOL power selection, you will hear many pearls that we know ring true: use the Holladay 2 for very short axial lengths, for longer axial lengths look at the SRK/T formula and choose a higher power to avoid residual hyperopia, if the keratometry values are unusual then avoid the SRK/T and choose the lowest keratometry power in the central zone, the Hoffer Q formula tends to work better in shorter eyes, the Haigis formula is useful for unusual anterior chamber depths, and more. But how can we convert this intuition into an approach that is available and useful to even the novice surgeon?

There are two types of doctors who never have surgical complications: those who do not operate and those who are not quite fully truthful. This humorous adage emphasizes that no matter how rare, all surgeons have complications. Even master surgeons, with decades of experience over tens of thousands of surgeries, will occasionally encounter an intraoperative or postoperative complication. When a surgical complication happens, we need to appropriately deal with it to restore a good visual outcome to our patient and we need to learn from it so that we can minimize the risk of future occurrence.

Patients with dense brunescent cataracts have typically delayed having cataract surgery for many years. During this time, the nuclear sclerosis progresses to the point where it causes additional challenges and poses higher risks for complications. For some patients, fear is the reason why they keep postponing surgery, whereas for others, lack of access to health care is the primary problem. With a careful approach and modified techniques, we can perform safe cataract surgery and restore vision to these patients.