OPTOMETRY CPD EVENING

14 MARCH 2018

ANGLERS TAVERN - RIVERSIDE

ACO 6 CPD POINTS (INCLUDING THERAPEUTIC) ON COMPLETION QUESTIONNAIRE

DR HAKKI SEMERLI

CATARACT SURGEON - MiGs - PTERYGIUM - EYELIDS

“IMPROVING CATARACT SURGERY OUTCOMES - PRACTICAL TIPS FOR THE OPTOMETRIST”

DR MEI TAN

MEDICAL & SURGICAL RETINA SPECIALIST

“AN APPROACH TO UVEITIS DIAGNOSIS AND MANAGEMENT”

● Dr Hakki Semerli● Principle, Director● Cataract, Pterygium, Eyelids, Glaucoma & General

● Dr Mei Tan

● Retina – Diabetes, Macular Degeneration, Vein occlusion

● Retinal surgery (DR, detachments)

● Dr Nishant Gupta● Cornea, Cataract, Refractive surgery● Keratoconus, Corneal grafts, Contact lens, Glaucoma

Location - MOONEE PONDS

● Cataracts

● Glaucoma

● Corneal & refractive surgery

● Medical & Surgical retina

● Diabetic eye disease

● Macula degeneration

● Orbital & Oculoplastic

● TESTING● OCT Cirrus 5000 High definition scans● Visual Field testing- glaucoma, neuro, binocular driving tests● Fluorescein Retinal Angiography● Ocular Photography● Topography – Atlas and CSO Sirius

● LASERS● Capsulotomy – for PCO if Hx cataract surgery● Iridotomy – Angle closure glaucoma risks● SLT- Selective Laser Trabeculoplasty for Open angle glaucoma● Retinal laser- Diabetic retinopathy, Retinal Tears, Vein occlusion● Vitreolysis Floater laser

● Treatment Room● Intraocular Anti-VEGF injections

● AMD, Diabetic Macula Oedema, Vein Occlusions

● Pterygium surgery● Chalazion, Stye ● Epiphora treatments – flushing, 3Snip● Eyelid surgery – lid tightening, wedge excisions● Upper eyelid reduction surgery

● PANCH Day surgery

● Bell St

● Privately insured facility

● Sunbury Day Hospital

● 10-15min past airport

● Insured and Uninsured patients

● Significant cost savings

And last but not least...

Special Mentions

My Amazing Staff !

Anglers Tavern Team

Megan Loft for coordinating

Novartis, Robyn Lally for generous sponsorship

Disclosures

No direct financial interests in my presentation

Novartis sponsorship - Robyn Lally

DR HAKKI SEMERLI

“IMPROVING CATARACT SURGERY OUTCOMES - PRACTICAL TIPS FOR THE OPTOMETRIST”

FRANZCO - MBBS (Hons)

SPECIALIST EYE SURGEONS - FOUNDER & DIRECTOR

CATARACT SURGEON - MiGs - PTERYGIUM - EYELIDS

My specialties

Cataract

Conventional and FLACS

MiGs

iStent inject, Cypass

Pterygium

Sutured and Glued grafting

Eyelids

Upper eyelid reduction surgery (Dermatochalasis)

OverviewIMPROVING CATARACT SURGERY OUTCOMES - PRACTICAL TIPS FOR THE OPTOMETRIST

● Post-op painful red eye● Post-op inflammation in a uveitis patient● Post-op High IOPs● Delayed macular oedema● Glaucoma and MiGs post-op● Intraocular Lenses review, and Toric lenses● The tear film● Limbal relaxing incisions● Presbyopia corrections options

Post op red painful eye

24 hours after uneventful cataract surgery

Red eye, mild discharge, pain, photophobia

Important considerations:

● Endophthalmitis● TASS

Surgical inflammation?

Endophthalmitis

Usually 4-7 days post op

At least 75% have significant pain

Corneal oedema

Cf more diffuse and marked in TASS

Refer immediately

Contact surgeon, Hospital emergency

“Tap and Inject vs Vitrectomy”...

TASS

...vs Endophthalmitis?

TASS

Usually within 24-48 hours

Mostly pain free, but not always

Can see hypopyon just like I.E.

Diffuse corneal oedema more characteristic in TASS

TASS Aetiology

Any substance used during or immediately after surgery.. Entering the eye

Irrigation solutions

Anaesthetics

Antiseptics

Intraocular medications

*Characterised by toxic reaction to the anterior segment of the eye, and the endothelium is particularly susceptible, hence the marked diffuse oedema

TASS Management

Urgent referral

Differentiate from early aggressive endophthalmitis

Identification of source

Follow up of other patients from same facility

Anti-inflammatories, (antibiotics)

PO inflammation in a Uveitis patient

45yo man, idiopathic anterior uveitis history

Initially improving vision and ocular comfort after surgery

Treated with QID pred forte & Chlorsig

Day 5, moderate AC inflammation, P.S

Vitreous/Retina clear

PO inflammation in Uveitis patient

Most likely?

● Surgical inflammation - AAU inflammation● NB. Infection/Endophthalmitis

Requires:

● Increase steroids● Dilation/Cycloplegia for comfort and PS● Watch for pupil block

Post-op Day 0 high IOP

70 yo lady, had surgery in the morning... It’s Friday... 8pm.. You’re tired..

No ocular history, no Glaucoma

VA 6/12

Deep aches

Mild post-operative inflammation

Corneal oedema

And...

Post Op raised IOP

IOP of 45!

PS.. what’s wrong with this picture..?

Most likely causes...

Retained viscoelastic

Dispersive vs Cohesive

Viscoat vs Provisc.. Thicker=Less IOP

Other...

Inflammation, haemorrhage, pigment dispersion, retained lens material, damage to angle structures

Risk Factors: Glaucoma, higher pre-op IOP, Longer axial length >25mm, (PXF)

(NB.. Corneal thickness can rise by >5% PO, normalising by 1wk... overestimation)

https://eyetube.net/video/viscoelastic-insertion-and-removal/

PO raised IOP.. what to do?

Depends

Mild: 22-30, not glaucoma patient, may observe and repeat the next day.

Mod: 30-40 (or persisting mild), best to Rx

BBlockers, Alpha agonists, CAI’s (check allergies, CVD)

Severe: >40 is not usual, and requires Rx and refer asap

Where possible, contact the surgeon/clinic

Eye and Ear hospital 24 hours

What about.... PO Day 2 very high IOP?

70 yo Female

Diabetic, Hypertension

Pre-op was +5.0 D hypermetrope with short/small eye & borderline AC

Pain, Shallow AC, poor vision, AC formed

Possibilities?

-Delayed suprachoroidal haemorrhage, common in those vasculopathic history

-Angle closure glaucoma, which can still occur post op after initially an open angle.

-Retrobulbar haemorrhage from periocular anaesthetics, pushing on the globe posteriorly.

-Aqueous misdirection syndrome, with aqueous directed into the vitreous.

Aqueous misdirection

Aka. Malignant glaucoma

Aqueous misdirected to vitreous

Thickened anterior hyaloid face

Pushes iris-CB forward

Secondary angle closure

A.M Management

Urgent IOP lowering

Systemic and Topical treatments

Cycloplegia

Aqueous suppression

Shrinking the vitreous

Refer asap - or involve local physician

Iridotomy and Hyalotomy to relieve the block

*Avoid Miotics - can make it worse

Poor vision 8 weeks Post cataract surgery...

Routine uncomplicated surgery

BCVA now 6/12 D=N

Prior vision several years ago recorded as 6/6 (ie not amblyopia)

Eye looks good! Quiet, clear anterior segments and IOL

No inflammation.. Not infection or other inflammatory condition

Retina looks ok.. I think...?

CMO

Cystoid macular oedema

Usually occurs 8wks post operatively

Often in otherwise routine surgery

Often clinically mild or unnoticable, after initially good vision

NSAIDS vs Steroids for cataracts

“I’ve never replaced steroids with NSAIDs for a patient not responding to steroids” -Physician

The NSAID vs Topical Steroids Study:

Steroids vs Steroids AND NSAID

Not Steroids vs More STEROIDS vs Steroids & NSAIDs

What about simply increasing the steroids?

Steroids vs NSAIDs

Why steroids alone?

Potent

Simplicity

Availability

Less stinging eyes

Less cost $30-40

What I do...

Prednefrin Forte drops 2 hourly for 2 days, then 4x daily for 3wks

Chlorsig drops 2 hourly for 2 days then STOP

Modify for complicating factors

Eg. Uveitis patient

● more steroid, oral prednisolone, IV dexamethasone

Eg. Higher risk patient (pc diabetic, chemotherapy, past infections

● Fluroquinolones eg Ofloxacin - used in microbial keratitis...

Glaucoma & MiGs

A reasonable option in mild-moderate glaucoma

Increasing range of options

● iStent inject● Alcon Cypass● Others...

Minimal complications

May continue usual medications initially (varying approaches)

MiGs complications - Uncommon

Failure to lower the pressure

Hyphaema

microhyphaema common

Macrohyphaema uncommon

Obstruction

Dislodgement

Hypotony

Infection

MiGs complications

Management depends on the issue

Hyphaema usually self limited and resolves

IOP elevation needs to be managed cautiously

Hypotony usually limited and resolves - MiMiGs eg Cypass

Nb. Numerical vs Clinical hypotony

iStent video

Attached...

Types of Intraocular Lenses IOLs

Monofocal

Multifocal (Bifocal/Trifocal) or ‘MultiZone’

Toric

Pinhole lenses

Location of insertion:

Posterior chamber, in the bag, sulcus, iris clip, scleral sutured

Anterior chamber IOLs, iris clip

Pseudophakic and Phakic

Types of refractive outcomes

Emmetropia

Monovision

MFIOL

(Accom vs Pseudoaccom)

Guided by optometrist usually

QuizACIOL problem?

ACIOL

Problem solved

Pupil block

Toric lenses

Significant advance in cataract surgery

Now able to correct ‘regular astigmatism’ in most intraocular lens options

Eg. Unifocal lenses, Panoptix Multifocal

Advances in calculations have improved our accuracy

Barrett Universal II, Hill RBF (AI, ‘Big Data’)

(Very good but doesn’t always work perfectly - other factors, posterior cornea, macula)

Toric lenses range example - Alcon Acrysof

Regularly regular (44 vs 46D)

Regularly (orthogonal) irregular (47-50 vs 43D)

Toric lens axis alignment

Digital platforms, eg Zeiss Callisto

Manual, eg Mendez gauge

Correct alignment is very important!

Toric lens rotation

Every 1 degree = 3 degree of reduced effect

30 deg = total loss of toric effect

Rotation usually occurs early, before capsular adhesion

Lens can be rotated if in early phase, especially 1st mth

Only if high astigmatism and patient unhappy even in glasses - another surgery

Measuring lens axis at the slit lamp

Role of the Tear Film

Increasingly recognised importance in planning surgery

Poor tear film = inaccurate calculations = suboptimal outcomes

Topography includes Placedo ring and Scheimflug, then latter being less effected eg CSO Sirius, Pentacam..

If poor tear film, best to address this, based on cause

Eg tear film supplements, blepharitis management, antiinflammatories

Testing tear film

Examining the ocular surface

Tear BUT

Schirmer test

*A common cause of unexpected outcomes

What about Presbyopia correction options?

Wide variety of proposed options

● Laser refractive surgery● Corneal inlays eg Kamera● Phakic lenses● Lens replacement

If not presbyopic, then aim to maintain accommodation

Eg 35 yo, 5D myope, otherwise healthy eye, not presbyopic

1. Talk them out of it?!2. Maintain accommodation where possible3. May consider refractive surgery, but may be limited by cornea4. Inlays possibility5. Intraocular options

a. Phakic IOLs - AC, PC

Limbal relaxing incisions

Bring back the 80s..

Limbal relaxing incisions

Toric IOLs available in Australia several years

Some patients pre-toric IOLs

May have high astigmatism

Difficult to correct even in glasses or CL

Case example: Patient AG

75yo man, RE cataract surgery ~5yrs ago

Over 3.0 D astigmatism

Keratometry RE 43.84 x104

47.21 x14

Ref -3.25 cyl axis 88

Vision 6/12 unaided cf 6/6 in Left eye

Patient would like improvement if possible

LRI

Various Nomograms available

Online calculators

Minimally invasive

Incision along steep axis = flattening

In room procedure cf Laser refractive

LRI

Paired incisions

Some immediate improvement

LRI Mr AG

Wk 1, refraction improved by 1D astigmatism

VA already 6/9 and patient happy with progress

TBC.. will review in 4wks

--------

SummaryIMPROVING CATARACT SURGERY OUTCOMES - PRACTICAL TIPS FOR THE OPTOMETRIST

Dr Hakki Semerli

● Post-op painful red eye○ Endophthalmitis○ TASS○ Surgical inflammation

● Post-op inflammation in a uveitis patient○ Must differentiate from infection○ Requires lots of steroid

● Post-op High IOPs○ Multiple factors○ Depends on timing and extent

● Delayed macular oedema○ Uncommon with current treatment○ Initially good vision then declines○ Identifying risk factors

SummaryIMPROVING CATARACT SURGERY OUTCOMES - PRACTICAL TIPS FOR THE OPTOMETRIST

Dr Hakki Semerli

● Glaucoma and MiGs post-op○ iStent, Cypass○ Good efficacy○ Low risk, mostly self resolving

● Intraocular Lenses review, and Toric lenses○ Wide variety of options○ Toric lens alignment importance○ Identifying axes

● Limbal relaxing incisions○ Back to the future.. Or past..○ A good in-office option

● The tear film○ Very important in measuring toricity○ Identification improves outcome

● Presbyopia corrections options○ Tread with caution and patient information very important

What I do in my practice

● Work with optom for outcomes, emmetropia, monovision● Manage any risks for infection - Diabetes, immune suppressed● Treat the tear film● Repeat the AScans and Topo● Betadine, intracameral antibiotics● Post op antibiotics● Recognise risk patients for glaucoma● Communicate outcomes● No cheap readers!● Send them back to you at 4-6 weeks for glasses

Thank you

Thank you!

Questions?

Time for a break..

Refreshments

8.15 Dr Tan

Dr Mei Tan...

DR MEI TAN

“AN APPROACH TO UVEITIS DIAGNOSIS AND MANAGEMENT”

Thank you

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