Ocular Potpourri

Educational Objectives

The goal of this program is to improve the efficiency of ophthalmologic surgery, and the management of various chal­lenges encountered in the practice of ophthalmology. After hearing and assimilating this program, the participant will be better able to:

1.   Develop efficient routines for surgical preparation and management of patients’ records.

2.   Describe the risk factors for suprachoroidal hemorrhage.

3.   Recognize and treat suprachoroidal hemorrhage.

4.   Plan accurate implantations of toric intraocular lenses and thereby minimize postoperative astigmatism.

5.   Diagnose and treat infectious keratitis after refractive surgery.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following was reported: Dr. Patterson is a consultant for Bausch and Lomb, and Dr. Serafano is a consultant for Alcon Surgical. Drs. Fisher and Randleman and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Patterson’s lecture was recorded at the 27th Annual Meeting: Update for the Comprehensive Ophthalmologist 2009, held April 24, 2009, in Cleveland, OH, and presented by University Hospitals Case Medical Center, and Case Western Reserve University, School of Medicine, Cleveland, OH. Dr. Fisher spoke at the 2009 Vitreoretinal Course Update, held May 1-2, 2009, in Miami, FL, and sponsored by the Bascom Palmer Eye Institute, Miami, FL. Dr. Serafano addressed the 2009 Annual Meeting r–  Current Trends and Advances in Ophthalmology, held March 26-27, 2009, in Seattle, WA, and sponsored by the Washington Academy of Eye Physicians and Surgeons. Dr. Randleman spoke at 3rd Annual Innovations in Ophthalmology, held March 16-19, 2009, in Key Largo, FL, and sponsored by the Cole Eye Institute of Cleveland Clinic, Cleveland, OH. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Improving Efficiency in the Operating Room

Larry E. Patterson, MD, Medical Director, Eye Centers of Tennessee, and Cataract and Laser Center, Cross­ville, TN

Efficiency vs speed: high efficiency leads to some increase in speed, but not vice versa

Surgical coordinators: communicate between surgery center, patient, and surgeon; counsel patients, perform intra­ocular lens (IOL) biometry, and attend surgery

Forgo anesthesia preregistration appointment: unless clearance by nonophthalmologist required, general assess­ment done at time of eye examination; patient completes paperwork at home

Computerize patients’ records: use merge function to combine forms into single program, including patient infor­mation, instructions, consent, and surgery center paperwork; preprinted operative note  —  part of merge program; check boxes at time of surgery; note deviations from routine at bottom

Scheduling: like eyes together (eg, schedule only right eyes on given day); use notes section on surgery schedule for documenting unique features (eg, special needs, complications, first eye operated on elsewhere) for patients; sched­ule difficult cases last to reduce stress

Before day of surgery: perform chart review with coordinator; have several (³3) people check to verify correct im­plant

Day of surgery: stretcher serves as operating table; place monitor on footplate at end of bed; patient hooked up only once; put preprinted cards showing patient information (eg, preoperative vision, density of nuclear sclerosis, size of dilated pupil, age, follow-up appointment, limbal relaxing incisions (LRIs), power of implant) on intravenous (IV) pole

Anesthesia: oral sedation  —  speaker uses IV anesthesia in only 5% to 10% of patients (controversial); administers liquid sublingual midazolam (Versed) mixed with more palatable liquid; patient holds under tongue for 5 to 10 sec, then swallows; 5 to 10 mg adequate; topical  —  apply drop of proparacaine to eye; mix cocktail of equal parts anti­biotic, nonsteroidal anti-inflammatory drug (NSAID), viscous neosynephrine, and tropicamide; soak lint-free sur­gical sponge (eg, Ocucel) in cocktail and use in inferior, or both inferior and superior cul-de-sacs; perform final adjustments in postanesthesia care unit (PACU); 5 to 10 min before surgery, add one additional drop of propara­caine, then povidone-iodine (eg, Betadine) to allow adequate time for maximum bactericidal effect (skin prepara­tion performed in operating room), and viscous tetracaine

Advanced preparation: sterile surgical tray contains items (eg, postoperative injections, lidocaine, and viscoelastic) on upper shelf; on lower shelf, set up unopened viscoelastic, other supplies, and emergency vitrectomy kit; 3 streamlined surgical trays contain only instruments needed for that case; store extra peel-packed instruments alpha­betically in file folders; prepare fourth tray with everything individually packed; custom packs should include only essentials (eg, 2 gowns, 2 pair gloves, one patient drape, one pack of cellulose sponge spears [eg, Weck-cel], cysto­tome, cannula); after morning scrub, use alcohol foam scrub between patients

In operating room (OR): perform verbal confirmation upon patient’s entry; Weck-assisted draping  —  pull eyelid up with sponge spear and attach drape with adhesive portion; support drape with oxygen tube attached to bed; place instruments in cleaning solution after use; provide viewing room for family to watch procedure, accompanied by staff member; begin preparation for next case during procedure

After surgery: provide postoperative counseling room in which family can wait, attend patient during final recovery, and review postoperative instructions

Management of Suprachoroidal Hemorrhage

Yale L. Fisher, MD, Voluntary Clinical Professor of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL

Definition of suprachoroidal hemorrhage (SCH): blood within suprachoroidal space separating choroid from sclera, except where vortex veins go through sclera, which causes cushion appearance; can be extensive or lim­ited (limited hemorrhages often found at first postoperative visit and disappear over weeks or months); nonsurgi­cal etiology  —  blood accumulates as result of trauma, tumor, choroidal neovascularization, polypoidal choroidal vasculopathy, microaneurysm, glaucoma, uveitis, or thrombolytic agents; usually small because eye closed and bleeding becomes tamponaded; detect by ultrasonography (US), especially if vitreous cavity cloudy; surgical etiology  —possible during almost all types of eye surgery, including photocoagulation, cataract extraction, pene­trating keratoplasty, retinal detachment, glaucoma filtering devices, and pars plana vitrectomy

Incidence and timing: rare, but may even occur during scleral buckling surgery; one-third occur during surgery, one-third just after surgery, and one-third occur 7 hr to 9 days later; usually accompanied by severe pain

Risk factors: include hypotony, advanced age, glaucoma (risk increases with pressure), aphakia, severe myopia, in­creased axial length, cardiovascular disease, hypertension, diabetes, elevated intraoperative pulse pressure, and bucking under anesthesia  

Mechanism: hypotony most commonly involved in development of SCH because of change in pressure gradient, and obstruction of venous channels from vortex vessels with rupture of long or short ciliary arteries; choroidal effusion usually occurs beforehand; during anterior segment surgery, darkening of visual field (most often from temporal portion of eye) occurs and covers normal red reflex

Management: success depends on recognizing SCH and pressurizing globe immediately; primary drainage at time of operation no longer used; when eye closed and pressurized, locate SCH with US (if necessary) and look for associ­ated retinal detachment and serous vs hemorrhagic clots; use US to determine when clot has melted (may take 7-12 days)

Treatment: pressurize globe (more difficult with glaucoma or open eyes with grafts); drain later, if needed (eg, cases of retinal touch or appositional choroidals, prolonged elevated pressures, persistent closed angles and inflamma­tion, retinal detachment, retained lens material, or macular involvement)

Chart review: 48 cases of massive SCH divided into 4 categories, based on complexity (ie, nonappositional, apposi­tional, with vitreous incarceration, and with retinal incarceration); 23% of cases had no light perception; 19% had persistent hypotony; retinal detachment occurred in 66%, of which only 66% repairable; only 35% chance of achieving 5/200 final visual acuity

SCH during vitrectomy: watch for dark image that appears rapidly in wide-angle viewing; raise pressure and stop hemorrhage, then decide whether to continue surgery

Accurate Alignment of Toric IOLs

Donald N. Serafano, MD, Associate Professor, Department of Ophthalmology, Keck School of Medicine of the University of Southern California, Los Angeles

Planning: necessary to get to know patient (including hobbies, work, medications, and symptoms) to plan optimum treatment; eg, patient wants better vision without glasses, but may not qualify for presbyopia-correcting IOL be­cause of glaucoma, other pathology, or concerns about contrast sensitivity; possible to achieve good near or dis­tance vision and improved astigmatism

Minimizing postoperative astigmatism: examine topography; if astigmatism irregular, setting axis may not help; options include toric contact lenses or incisions; however, limbal relaxing incisions (LRIs) unpredictable; for pa­tients receiving toric IOL, document topography and results of automated, manual, and IOL master keratometry; speaker uses manual and IOL master keratometry for toric calculator because many sources of error in measure­ment (eg, preoperative marking, marking of axis during surgery, rotation of IOL, inadequate removal of viscoelas­tic, setting of IOL) can accumulate and lead to poor results; if everything performed correctly, rotation of 4° expected; refraction  —  in patient with history of refractive surgery or radial keratotomy (RK), topography poor; consider using pre-cataract axis of cylinder on refraction

Surgically induced corneal astigmatism (SICA): previously, patients with spherical refraction might have 2 diop­ters (D) of cylinder after removal of cataract because lenticular lens neutralized refractive cylinder; if patient’s au­tomated K shows 1.5 D of cylinder and steep axis at 90º,  postsurgery measurement will be closer to 2 D; plan to correct astigmatism while removing cataracts, and consider SICA when determining cylinder power and axis for implantation

Toric IOLs: speaker does not use Staar toric IOL (plate haptic IOL) because of problems with rotation; lens may en­ter vitreous if large hole created during use of yttrium aluminum garnet (YAG) laser; important to use posterior rhexis if using YAG laser on Staar lens; aspheric toric lens  available soon; can be used with higher D and “D” car­tridge; previous toric lens neither aspheric nor validated for “D” cartridge; surgeon must use “C” cartridge with 2.8 mm incision; aspheric lens validated £27 D for “D” cartridge

AcrySof toric IOL calculator: version specific for ReSTOR lens that gives residual astigmatism without toric lens; print surgeon’s view and place in OR

Marking procedure: make first mark with patient sitting; use level; mark at 0°, 180°, and inferior 90°; ask patient to lie down, and augment mark on limbus under microscope; augment again intraoperatively, if necessary; perform alignment, remove ophthalmic viscoelastic device (OVD), and perform final alignment; speaker suggests aligning lens just short of mark (in case lens shifts); stabilize IOL during removal of OVD; AcrySof material shown to cause development of fibronectin; helps  adhere IOL to posterior capsule; for toric lenses, speaker uses 0.1% epinephrine to further dilate pupil and allow better visualization of marks

Infectious Keratitis After Refractive Surgery

J. Bradley Randleman, MD, Associate Professor of Ophthalmology, Section of Cornea, External Disease, and Refractive Surgery, Emory Eye Center, Emory University, Atlanta, GA

Case examples: 37-yr-old man had laser in situ keratomileusis (LASIK) enhancement and developed pain, blurred vision, and photophobia 2 wk later; culture revealed Mycobacterium abscessus; 45-yr-old man with similar symp­toms after LASIK had Aspergillus that infiltrated through flap; 52-yr-old woman developed pain, photophobia, and blurred vision 1 wk after photorefractive keratectomy (PRK) and had bilateral methicillin-resistant Staphylococcus aureus (MRSA) resistant to fluoroquinolones

Incidence: ranges between 1 in 1000 and 1 in 5000; significantly higher after PRK than LASIK

Review: in >10,000 eyes, keratitis found in 279 (mostly noninfectious); 10 (0.1%) with nonviral infectious etiologies

Risk factors: include preoperative blepharitis, dry eye, eye rubbing, trauma, prophylactic (long-term) antibiotics for other conditions; occupation (eg, medical personnel)

Evolution of infectious etiologies: during 1980s, Acanthamoeba common with contact lenses; in 1990s, mycobacte­ria became more prevalent; during early 2000s, fungus important; more recently, MRSA of concern

American Society of Cataract and
Refractive Surgery (ASCRS)

Survey results: pathogens  —  in 2002, most infections mycobacterial; in 2005, staphylococcal species prominent; in 2008, Staphylococcus still prevalent, with MRSA gaining importance; prophylactic antibiotics  —  fluoroquinolones used most frequently in 2005; by 2008, fourth generation fluoroquinolones used in 50%; no mycobacterial infec­tions in patients who received fourth generation fluoroquinolones

Recommendations: onset of infection £2 wk after surgery suggests gram-positive organisms (eg, MRSA); if late on­set (not late diagnosis), consider opportunistic pathogens (eg, fungus, Mycobacterium); within 3 days of onset, lift flap, scrape for stain and cultures, discontinue topical steroids, and start doxycycline to inhibit collagenases; per­form Gram’s stain to rapidly identify pathogen

Antibiotics: for infections with early onset, speaker does not routinely treat with cefazolin; uses fortified vancomy­cin instead; for later onset, use fourth generation fluoro-quinolone and amikacin until pathogen identified; flap amputation  —  limits visual recovery, but may improve outcomes by removing infection, increasing penetration of antimicrobials, and providing sample for culture

Questions and answers: should physician treat patient initially with amikacin and vancomycin to target atypical my­cobacteria, Neisseria species, and methicillin-resistant organisms regardless of time of onset? speaker does not find amikacin overly toxic and does not disagree with this approach

Suggested Reading

Amesbury EC, Miller KM: Correction of astigmatism at the time of cataract surgery. Curr Opin Ophthalmol 20:19, 2009; Chen WL et al: Unilateral Candida parapsilosis interface keratitis after laser in situ keratomileusis: case report and review of the literature. Cornea 28:105, 2009; Dardzhikova A et al: Early experience with the AcrySof toric IOL for the correction of astigmatism in cataract surgery. Can J Ophthalmol 44:269, 2009; Ghadhfan FE, Khan AO: Delayed suprachoroidal hemor­rhage after pediatric glaucoma surgery. J AAPOS 13:283, 2009; Haigis W: IOL calculation using paraxial matrix optics. Oph­thalmic Physiol Opt 29:458, 2009; Hill W, Potvin R: Monte Carlo simulation of expected outcomes with the AcrySof Toric intraocular lens. BMC Ophthalmol 8:22, 2008; Healey PR et al: Management of suprachoroidal hemorrhage. J Glaucoma 16:577, 2007; Jeganathan VS et al: Risk factors for delayed suprachoroidal haemorrhage following glaucoma surgery. Br J Ophthalmol 92:1393, 2008; Kapamajian M et al: Suprachoroidal hemorrhage as an intraoperative complication of 25-gauge pars plana vitrectomy. Semin Ophthalmol 22:197, 2007; Ma JJ, Tseng SS: Simple method for accurate alignment in toric pha­kic and aphakic intraocular lens implantation. J Cataract Refract Surg 34:1631, 2008; Mei H et al: Suprachoroidal hemor­rhage during pars plana vitrectomy in traumatized eyes. Retina 29:473, 2009; Mendicute J et al: Toric intraocular lens versus opposite clear corneal incisions to correct astigmatism in eyes having cataract surgery. J Cataract Refract Surg 35:451, 2009; Mohammadpour M: Risk for recurrent suprachoroidal hemorrhage during cataract surgery. J Cataract Refract Surg 35:408, 2009; Navaleza JS et al: Choosing anesthesia for cataract surgery. Ophthalmol Clin North Am 19:233, 2006; Nomi N et al: Two cases of methicillin-resistant Staphylococcus aureus keratitis after Epi-LASIK. Jpn J Ophthalmol 52:440, 2008; Semoun O et al: Early bacterial keratitis after presbyopic LASIK. Cornea 27:114, 2008; Stein JD et al: Longitudinal rates of postoper­ative adverse outcomes after glaucoma surgery among Medicare beneficiaries 1994 to 2005. Ophthalmology 115:1107, 2008; Tan CE et al: Polypoidal choroidal vasculopathy causing massive suprachoroidal haemorrhage. Eye 21:132, 2007; Vieira AC et al: Late-onset infections after LASIK. J Refract Surg 24:411, 2008; Wang LC et al: Clinical characteristics and visual out­come of non-traumatic suprachoroidal haemorrhage in Taiwan. Acta Ophthalmol 86:908, 2008.