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BOARDS2: Cornea/lens/prepostop > Cataract Sx > Flashcards

Cataract Sx Flashcards

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1
Q

Vision with cortical cataracts

A

Pretty good vision, can be 20/20, problems with glare

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2
Q

Vision problems with NS

A

Myopic shift

Can be white

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3
Q

PSC vision problems

A

Central VA decrease, problems reading

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4
Q

DiffDx for TID in midperiphery

A

PDS

Young myope

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5
Q

When can the abx be stopped post op cataract surgery

A

1 week if things look good

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6
Q

If a patient presents with a postindustrial siedel sign post op cat sx, what is there an increased chance of

A 
Endophthalmitis 
Hypotony 
Iris prolapse 
Choroidal detachment 
Shallow AC
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7
Q

How to perform Seidels test

A

Touch a NaFL strip to the surgical incision site.

  • (+) sign appears as a dark stream of Aq humor within the green NaFL dye in the tears; use cobalt blue for analysis
  • indicates a wound leak, which most commonly occurs in Rotherham early post op period due to trauam, suture failure, or valsalva maneuver.
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8
Q

Endophthalmitis post op cat sx

A
  • 0.02-0.05%
  • 50% of patients become legally blind
  • as early as day 1 post op (bacterial 2-4 days post op) or several months post op (fungal)
  • 70% are from gram + bac, most commonly staph epidermidis then staph aureus
  • usually more the normal bacteria on the eyelids, surgical contaminants can be responsible
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9
Q

Signs and symptoms of endophthalmitis

A

Severe pain, loss of vision, corneal edema, conjunctival injection, severe AC reaction with a possible hypopyon and fibrinous exudate, vitreous cells, mucus discharge, and eyelid swelling

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10
Q

Management of endophthalmitis

A

Immediately refer back to the surgeon for a vitreous tap (culture), aggressive anti-infective treatment (topical, intravitreal, subconjunctival, or IV), and possible vitrectomy

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11
Q

Hypotony

A
  • Loss of Aq humor through the open wound, can causes shallow AC
  • IOP that is low enough to cause physiological and/or anatomical changes to the eye. For most patients, an IOP < 6mmHg results in hypotony, however IOP can be lower in older patients without causing complications because the sclera is more rigid and is thus able to maintain the shape of the eye
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12
Q

Choroidal detachment

A

Occur secondarily to fluid accumulation in the suprachoroidal space in hypotonous eyes. The choroid will appear elevated with distinct borders. Severe chorodial detachments are referred to as kissing choroids.

DiffDx

  • RD
  • retinoschisis
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13
Q

Management of choroidal detachment

A

If mild, topical ophthalmic steroids and cycloplegics are indicated. If severe, the patient should be immediately referred back to the surgeon for possible drainage

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14
Q

Iris prolapse

A

The iris may be pulled up into the wound site, resulting in a peaked pupil (will point towards the wound leak)

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15
Q

Treatment options for a wound leak

A

Pressure patch with cycloplegia (to deepen the AC and prevent posterior synechiae), and consulting with the surgeon regarding additional sutures

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16
Q

Post op pupillary block

A

Develops if the IOL or vitreous blocks the pupil, preventing the flow of AqH from the posterior to the AC, and resulting in angle closure and acutely elevated IOP. Mid dilated pupil, shallow AC, vitreous prolapse, displaced IOL.

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17
Q

Pressure spike post op cat sx

A

WBCs from inflammation can block the TM, mostly from 4+ cells, not something like 1+ cells.

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18
Q

Steroids post op cat sx

A

May cause increased IOP

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19
Q

pseudoexfoliation syndrome and cat sx

A

Increased rate of complications with cat sx due to weakened lens zonules, there is a greater risk of IOL dislocation with subsequent pupillary block and acutely elevated IOP. IOP may also be elevated if PXF deposits obstruct AqH outflow through the TM

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20
Q

When would you expect a steroid response post op

A

1 week and on

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21
Q

What is the most common cause of unilateral glaucoma

A

PXF

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22
Q

Retained visco and cat sx

A

Acutely raised IOP
1 day PO
-visco material is the fluid injected into the eye during cat sx in order to protect the corneal endothelium during phacoemulsification. It must be removed before completion of the surgery. If accidentally left, it may obstruct AqH outflow through the TM. Retained visco is one of the most common causes of IOP elevation in the early post op period

Goes away in 3 days

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23
Q

What is the most common cause of raised IOP in the early post op period

A

Retained visco

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24
Q

RBCs and increased IOP post op cat sx

A

May be released from the iris vessels during the surgery and can obstruct the TM

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25
Early cataract post op complications
``` IOL subluxation Ptosis Diplopia Corneal edema Subchoroidal hemorrhage TASS (1-2 days) Endophthalmitis (2-4 days) Hypotony Choroidal detachment Iris prolapse ```
26
IOL subluxation
Rare, caused by pupillary capture and poor capsular support, findings that are common in conditions with weak zonulse including PXF and Marfans
27
Treatment for IOL subluxation
Observation, topical ophthalmic miotics, or surgical repair
28
Most common cause of lens or IOL subluxation
Trauma | -ED, Weill-Marchesani, and homocystinuria are systemic causes
29
Ptosis after cat sx
Temporary ptosis may occur secondary to post op swelling or use of local anesthesia; permanent ptosis may be due to levator dehiscence by the eyelid speculum
30
Diplopia post op cat sx
Occurs in appx 3% of cases; may be secondary to a decompensating, pre-existing strab, EOM restriction/paresis, monocular diplopia, central fusion disruption, or idiopathic. Usually occurs i the patient had retrobulbar anesthesia, which is rarely used now
31
Corneal edema post op cat sx
Most common occurs in the early post op period: common causes include - elevated IOP (microcystic corneal edema) - hypotony-classically causes descemets folds - surgical trauma-results in edema due to shock waves from the phacoemulsification; this is less common with the intraoperative use of visco - pre-existing corneal disease (fuchs) - haptic rubbing on the corneal endothelium-results in endothelial cell damage and subsequent edema
32
Signs of corneal edema
Microcystic and/or stromal thickening with descemets folds. Bullous keratopathy occurs later in the post op periods and is more common in aphakia and with AC IOLs
33
Management of corneal edema post op cat sx
Dependent on the cause of corneal edema and includes lowering the IOP (if elevated), a BCL (for painful bullous keratopathy), and topical hypertonic drops (Munro 128), if the corneal epithelium is intact
34
Suprachoroidal hemorrhage post op cat sx
Rare complication characterized by the accumulation of blood between the choroid and the sclera during intraocular surgery; it is a devastating complication that us more common in the elderly. The etiology is unknown
35
TASS
Sterile inflammatory reaction that results in toxic damage to the AC structures. It typically is a result of chemical exposure during surgery -12-48 hours post op with decreased vision, mild to no pain, diffuse limbus to limbus corneal edema, hypopyon, fibrous membrane, no vitritis or mild spillover, and elevated IOP
36
Treatment for TASS
Topical steroids | Infectious endophthalmitis MUST be ruled out
37
What ocular hypotensive is contraindicated post op cat sx
PGs due to possible increased risk of inflammation
38
Why are CAIs not first line therapy for lowering IOP
Because of side effects
39
When is an LPI indicated for elevated IOP
Only if the IOP is elevated due to angle closure secondary to pupillary block. It has NO IOP lowering effect in the pressure of an open anterior chamber angle
40
If someone is suspected to be a steroid responder, what should be done post op cat sx
Switched to a soft steroid like lotemax
41
At the one month post op, patient is doing well and RXed glasses. The patient returns at 3 months post op and notes a decrease in vision. Fundus exam reveals CME. What is the standard INITIAL treatment for this condition
Topical steroids and topical NSAIDs
42
When does CME occur post op cat sx
6-10 weeks
43
Who is at risk of CME
Those with - ERM - DM - vein occlusion
44
CME following cat surgery
Irvine gass syndrome Most common causes of decreased acuity in the post op period. Surgical trauma results in anterior segment inflammation, which then spreads to the posterior pole due to disruption of the lens-vitreous interface. Posterior inflammation results in a breakdown of the BRB with subsequent leakage and edema with Henles layer (OPL) of macula
45
Peak incidence of CME post op cat sx
6-10 weeks
46
Incidence of CME post op cat sx
1.5%
47
Treatment for CME
Topical ophthalmic steroid QID Topical ophthalmic NSAID QID Most cases resolve with treatment within 6 months
48
Recalcitrant cases of CME post op cat sx
Steroid injection
49
Additional causes of CME (besides cat sx)
``` DME Vein occlusions Uveitis RP ARMD ERM Retinal vasculitis ```
50
What makes Irvine gass syndrome unique from other causes of CME
All causes of CME are characterized by petaloid leakage at the macula, but IRvine Gass CME presents with additional leakage around the optic nerve, as noted on FA
51
Late complications post op cat sx
``` CME (6-10 weeks) Ptosis Diplopia Increased IOP Corneal decompensation Chronic uveitis PCO RD UGH ```
52
Diplopia as late complication of cat sx
Monocular -due to uncorrected refractive error, IOL dislocation, DED, induced astigmatism, macular disease, or corneal irregularity Binocular -decompensated phoria, surgical trauma, or the uncovering of a pre existing strab. Treatment includes prism or strab surgery
53
Chronic anteiror uveitis post op cat sx
Secondary to surgical trauma, retained lens material (fluffy white material posterior to the iris), the IOL haptic rubbing against the iris, or endophthalmitis; may also occur in an eye that is pre-disposed to uveitis and is then aggravated by surgery Rebound iritis-1 month, JUST stopped steroids and rebounding. Longer taper needed
54
Treatment for chronic uveitis post op cat sx
Topical NSAIDS and steroids | If endophthalmitis is suspected, refer back to surgeon immediately
55
The most common post op complication following cat sx
PCO
56
When does PCO most commonly occur
2-6 months
57
Percentage of patients that get PCO
41-51% over 5 years
58
What causes PCO
Equatorial epithelial cells migrating to and proliferating over the posterior capsule; opacification most commonly occurs within 2-6 months after surgery
59
Elschnig pearls
Type of PCE that is most common in children who have cat sx
60
Treatment of PCO
YAG CAP (wait 3-6 months)
61
Risks of YAG CAP
Transient IOP spikes, pox marks and/or pitting of the IOL, CME, iritis, and RD
62
RD post op cat sx
Uncommon (1.5-2%) that typically occurs within the first 6 months. May present with Schaffer’s sign (tobacco dust signs, pigment in the anteiror vitreous). Management includes an urgent referral for retinal surgery
63
Pateitns with increased risk of RD post op cat sx
Axial length > 25mm, previous retinal tear or detachment in either eye, family Hx of a retinal detachment, and lattice degeneration
64
UGH
Uveitis-glaucoma-hyphema syndrome -most often occurs secondary to a poor fitting AC IOL that rubs the iris, resulting in hyphema and uveitits. The accumulation of RBCs and WBCs leads to an obstruction of aqueous outflow through the TM, with a subsequent increase in IOP. This condition is rare now that ACIOLs are less commonly used
65
Treatment for UGH
Topical ophthalmic steroids, ocular hypotensive agents, cycloplegic agents, and possibly an IOL exchange
66
Drops used post op cat sx
- ABX (usually FQ)x 1 week - steroids (pred forte) x 4 weeks (tapered) - NSAIDS x 4 weeks Patients should continue all hypotensive drops during the post op period, except PGs
67
General post op FU schedule cat sx
One day One week One month 3-6 months
68
Post op cat sx and glasses
Glasses are typically RXed at the one month visit. Most surgeons plan for emmetropia or a small myopic refractive error. Patients will rewuire reading glasses, as they will no longer have the ability to naturally accommodate
69
When should you not RX glasses at the one month post op cat sx
If corneal suture May need to be cut in the future. If it is necessary to cut suture, the suture in the steepest meridian (90 degrees from the cyl axis) should be cut first at 4-6 weeks post op
70
ICCE
Lens and capsule are removed, resulting in aphakia. Second surgery performed to insert an ACIOL or iris suture IOL. This surgery is no longer performed - large incision required because the entire lens and capsule removed in one piece - a surgical PI required in order to prevent vitreous prolapse and subsequent pupillary block and angle closure. - of a secondary ACIOL is NOT inserted, the patient requires “cataract glasses” resulting in greater distortion of images. - ICCE is associated with higher risk of RD
71
ECCE
- extracap - lens is removed, but the capsule remains. Similar to ICCE, ECCE, requires a large incision (9-11mm), as the entire lens is removed in one piece. An IOL can be placed in the intact posterior capsule (PCIOL) - this sx is only performed If the lens is too hard to break up. If the patient has a poor corneal endothelium (increased energy from phacoemulsifcation may increase damage to the corneal endothelium, resulting in greater post op corneal edema), or in 3rd world countries.
72
Similarities of ICCE and ECCE
Both require large incisions with sutures, as the entire lens is removed I n one piece. This increases the risk of wound leaks, as well as post op induced corneal astigmatism
73
Phacoemulsification
This is a form of ECCE where the lens is removed and capsule remains in place; however, the crystalline lens is fragmented withultrasound prior to removal. A small, clear corneal incision (1-3mm) can be used, and sutures are typically not necessary, as AqH pushes against the corneal incision to close it. An IOL is placed in the intact posterior capsule. This technique is the most common cat sx performed at this time
74
Day 1 post op complications
Increased IOP (visco) - Oc hypotensive - lasts couple of days TASS -steroid
75
1 week post op complications
``` Increased IOP (steroid response) -oc hypotensive ``` Endophthalmitis -culture, IV Abx
76
1 month post op complications
CME -steroids/NSAID PCO -YAG (after 3m) Rebound iritis -long steroid taper
77
FLACS
Femtosecond laser. Used tocreated the corneal incisions, the anterior capsulorhexis, and lens fragmentation Good for fuchs, insurance doesn’t cover it
78
IOL options
- monofocal IOL (both eyes distance) - monovision (one eye D, one N) - multifocal IOL (reSTOR, Technis, reZOOM), no intermediate - accommodating IOL (Crystalens, haptics on hinge) - astigmatic (toric) IOL (up to 4D corneal astigmatism) - sulcus fixed IOL: typically used if capsule is lost during surgery - iris fixed IOL: IOL stitched to the iris at the pupil margin, no longer performed - ACIOL: used in ICCE or if complications occur during phacoemulsifcation - secondary IOL: secondary surgery performed to insert an IOL in aphakic patients - IOL exchange: if complications develop with the current IOL, it can be replaced with a new IOL - EDOF: D and computer, not near
79
What should you never do with an iris fixed IOL
Never dilate

BOARDS2: Cornea/lens/prepostop (5 decks)

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