Cataract surgery is not always straightforward, but with careful planning by the surgical team, patients with complex conditions can still have a successful outcome

Wanjiku Mathenge

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 Cataract surgery in patients with complex conditionsEye HealthCommunityJournalV O L U M E  3 1  •  N U M B E R  1 0 4  •  2 0 1 9Cataract surgery is not always straightforward, but with careful planning by the surgical team, patients with complex conditions can still have a successful outcome.Every ophthalmologist encounters patients with challenging or complicated cataract presentation from time to time, which tests our surgical skills and ability to manage difficult circumstances. The challenge may come from zonular weakness; cataract in very young patients; cataract with corneal opacities; cataract with co-morbidities, such as uveitis, glaucoma, diabetic eye disease or age-related macular degeneration; or intraoperative complications, such as posterior capsule tears and zonule or iris dialyses.As surgeons, we must rely on our surgical skills, intelligent decision making, and the numerous new technologies that have revolutionised our ability to not just complete the operation, but achieve the best outcome possible.When I encounter a challenging case, I rely on the following generic guiding principles, which I have learnt from my mentors and from experience, on how best to optimise surgical outcomes in these patients.• Know your own surgical limitations and refer to a more experienced surgeon when necessary.• Be vigilant: recognise and anticipate challenges before surgery and ensure you have the correct tools in the operating theatre to help manage any issues that arise. • Manage the basics to reduce the challenges you are facing. Dilate the pupil as widely as possible, use the appropriate anaesthetic technique, stain the capsule for more predictable capsulorrhexis, choose the Continues overleaf ➤Nurses being briefed before a cataract operation. MALAWIRACHEL PALMER/SIGHTSAVERSWanjiku MathengeConsultant Ophthalmologist and Director of Training and Research: Rwanda National Institute of Ophthalmology and Dr Agarwal’s Eye Hospital, Kigali, Rwanda.77   COMMUNITY EYE HEALTH JOURNAL | VOLUME 31 | NUMBER 104 | 2019VOLUME 31 • NUMBER 104 • 2019Eye HealthCommunityJournalEditorElmien Wolvaardt Ellison editor@cehjournal.org Consulting editor for Issue 104John BuchanEditorial administratorAnita Shahanita.shah@lshtm.ac.uk Editorial committeeNick AstburyMatthew BurtonSally CrookAllen FosterClare GilbertSuzanne GilbertHannah KuperPriya MorjariaGV MurthyDaksha PatelNoela PrasadBabar QureshiCEHJ onlineVisit the Community Eye Health Journal online. All back issues are available as HTML and PDF.Visit: www.cehjournal.orgOnline edition and newsletterweb@cehjournal.orgPlease support usWe rely on donations / subscriptions from charities and generous individuals to carry out our work. We need your help. Subscriptions in high-income countries cost UK £100per year. Contact Anita Shah admin@cehjournal.orgor visit our website: www.cehjournal.org/donateSubscriptions Readers in low- and middle-income countries receive the journal free of charge. Send your name, occupation, and postal address to the address below. French, Spanish, and Chinese editions are available. To subscribe online, visit www.cehjournal.org/subscribeSerge ResnikoffRichard WormaldDavid YorstonRegional consultantsHannah Faal (AFR)Kovin Naidoo (AFR) Wanjiku Mathenge (AFR)Van Lansingh (AMR)Andrea Zin (AMR)Ian Murdoch (EUR)Janos Nemeth (EUR)GVS Murthy (SEAR)R Thulsiraj (SEAR)Babar Qureshi (EMR)Mansur Rabiu (EMR)Leshan Tan (WPR)Hugh Taylor (WPR) DesignLance BellersPrintingNewman Thomsonright viscoelastic for difficult steps and use reliable instruments and microscopes.• Develop skills using a range of techniques and technologies because every eye is different. For example, the use of capsular support systems, scleral fixation techniques, small pupil management techniques and vitreous management and optic capture techniques in paediatric cataract.• Have a plan, and have a back-up plan. This helps the surgeon to stay calm, which keeps the patient calm. For example, anticipate poor pupil dilation in uveitic eyes or weak zonules in pseudoexfoliation, and plan for the worst.• Manage inflammation and complications such as macular oedema as well as you can before and during surgery. This is important in patients with uveitis and diabetes, as well as those with ocular surface disease.• Use the appropriate technology, or a combination of techniques, for each challenging case to improve surgical effectiveness and efficiency. Ask yourself the following questions: will there really be any added benefit in using a toric or multifocal IOL in this case? Would a combined cataract-glaucoma procedure produce better outcomes for this patient? Should I give an anti-VEGF injection at the time of surgery? Other techniques that help improve outcomes include scraping off the corneal epithelium to increase visibility when appropriate, and the use of adrenergic agents in eyes with floppy irises. • Follow the correct postoperative regimen for challenging cases in order to improve outcomes. This may include good refractive management, long-term steroids after surgery for uveitic patients, or the use of non-steroidal anti-inflammatory drugs to prevent worsening macular oedema in patients with diabetes.In conclusion, prepare yourself, your team and your patient for difficult cataract surgery. Always communicate known and expected challenges to the patient before surgery so that you set realistic expectations about the outcome. Discussing the appropriate postoperative care, especially where it is different from routine care, will then be easier.About this issueCataract is still the leading cause of blindness worldwide. The majority of cataracts are relatively straightforward to remove, but there is a substantial group of patients in whom cataract surgery will be more challenging. Whether this is due to factors related to the patient, such as diabetes or a systemic inflammatory condition; or factors related to the eye itself, such as corneal endothelial dystrophy, glaucoma or a small pupil; preparation of the surgeon, the equipment and the eye team will ensure that patients receive the best possible visual outcomes.Contents77 Cataract surgery in patients with complex conditions Wanjiku Mathenge79 Complicated cataract surgery: strong leadership protects patients John Buchan80 Making the most of cataract surgery in patients with diabetes Tunde Peto, Frank Sandi and Vineeth Kumar82 Managing cataract surgery in patients with uveitis Aravind Harapriya and Eliza Anthony84 Managing cataract surgery in patients with small pupils Mariano Yee Melgar and John Buchan86 Cataract surgery in patients with Fuchs’ endothelial corneal dystrophy Soujanya Kaup and Suresh K Pandey88 Managing cataract surgery in patients with glaucoma Fatima Kyari91 Improving the practice of cataract surgical outcome measurement Nathan Congdon, Sarity Dodson, Ving Fai Chan and Wanjiku Mathenge92 TRACHOMA: TT Tracker app aims to improve surgical outcomes and patient care Kimberly Jensen, Sarah Bartlett and Tim Jesudason93 ONCHOCERCIASIS: The beginning of the end? Adrian Hopkins94 Questions and answers on complicated cataract surgery95 Picture quiz95 Announcements and resources96 KEY MESSAGESEDITORIAL Continued Cataract surgery in patients with complex conditionsEye HealthCommunityJournalV O L U M E  3 1  •  N U M B E R  1 0 4  •  2 0 1 9Cataract surgery is not always straightforward, but with careful planning by the surgical team, patients with complex conditions can still have a successful outcome.Every ophthalmologist encounters patients with challenging or complicated cataract presentation from time to time, which tests our surgical skills and ability to manage difficult circumstances. The challenge may come from zonular weakness; cataract in very young patients; cataract with corneal opacities; cataract with co-morbidities, such as uveitis, glaucoma, diabetic eye disease or age-related macular degeneration; or intraoperative complications, such as posterior capsule tears and zonule or iris dialyses.As surgeons, we must rely on our surgical skills, intelligent decision making, and the numerous new technologies that have revolutionised our ability to not just complete the operation, but achieve the best outcome possible.When I encounter a challenging case, I rely on the following generic guiding principles, which I have learnt from my mentors and from experience, on how best to optimise surgical outcomes in these patients.• Know your own surgical limitations and refer to a more experienced surgeon when necessary.• Be vigilant: recognise and anticipate challenges before surgery and ensure you have the correct tools in the operating theatre to help manage any issues that arise. • Manage the basics to reduce the challenges you are facing. Dilate the pupil as widely as possible, use the appropriate anaesthetic technique, stain the capsule for more predictable capsulorrhexis, choose the Continues overleaf ➤Nurses being briefed before a cataract operation. MALAWIRACHEL PALMER/SIGHTSAVERSWanjiku MathengeConsultant Ophthalmologist and Director of Training and Research: Rwanda National Institute of Ophthalmology and Dr Agarwal’s Eye Hospital, Kigali, Rwanda.77   COMMUNITY EYE HEALTH JOURNAL | VOLUME 31 | NUMBER 104 | 201978   COMMUNITY EYE HEALTH JOURNAL | VOLUME 31 | NUMBER 104 | 2019

Cataract surgery in patients with complex conditions

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Cataract surgery in patients with complex conditions

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