Ophthalmic Consultants of Long Island

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1 Case History Improving Cataract and Refractive Surgery Outcomes Through Ocular Surface Optimization 59 year old healthy white female History increased IOP Mother has history of glaucoma Presents for refractive surgery Contact lens wearer (monovision) Eric D. Donnenfeld, M.D. ASCRS 2008 Case Study: Unhappy Multifocal IOL Patient Pre-operative refraction OD x 90 20/20 OS x 87 20/25- Central pachymetry OD 540 microns OS 530 microns Keratometry OD 42.62/43.12 OS 42.25/42.87 History Patient underwent sequential bilateral uneventful phacoemulsification with simultaneous in-the the-bag implantation of a ReStor multifocal IOL. Patient c/o glare, halo and decreased visual acuity. Seeks second opinion. Exam Refraction OD Plano x /30- OS x 5 20/50+ 1

2 Inferior nerve fiber layer thinning OD Moderate cystoid macular edema OD + Epiretinal membrane Suspicious visual fields Recommendations Moderate cystoid macular edema OS + Epiretinal membrane Possible retinal hole Retinal/Glaucoma Referral Topical ketorolac 0.4% / prednisolone acetate 1% qid Improvement in CME and moderate improvement in quality of vision over 2 months. Vcc 20/30 OD 20/40 OS Can anything else be done? 2

3 Recommendations Ketorolac 0.4% continued qid Cyclosporine 0.05% bid added Additional improvement in quality of vision over 6 weeks Vcc 20/25 OD, 20/30 OS Normal corneal topography, WTR astigmatism Conclusions Topography Before and After Restasis Visual acuity and quality of vision both start with the tear film. The preoperative and postoperative use of topical CsA 0.05% significantly improves visual outcomes in patients undergoing conventional and advanced technology IOL surgery. Before After Topography of Patient Requesting Enhancement Case Study 3 Improving the ocular surface improves Hartman- Shack images 3

4 Case Study 3 which improves visual outcomes. 39 year old female History of dry eyes Patient contact lens intolerant and requests a refractive consultation Diopter Hyperope OU TBUT 5 seconds Case Study Informed Consent: Phakic IOLs Phakic IOLs Phakic IOLs Not FDA approved. Glaucoma/Cataract/ Endophthalmitis/ Retinal Detachment risk with phakic IOLs. Enhancements difficult. Informed Consent: CK CK CK Minimal effect on dry eye. Fluctuating vision and regression with need for multiple enhancements. 4

5 Informed Consent Informed Consent: No risk of flap complications Return of corneal sensation faster with than Prolonged visual rehabilitation Enhancements difficult Contact lens wear difficult in dry eye patients. Increased risk of: Haze Infectious keratitis Pain Pre-Treat Dry Eye Disease Dry eye patients treated with Restasis and who underwent also reported fewer dry eye sensations. 1 Patients treated with Restasis had fewer enhancements. 2 1 Salib, McDonald ASCRS Ursea, Schanzlin ASCRS 2005 and Restasis Small chance of worsening dry eye for the long term. Rapid visual rehabilitation. Minimal pain. Enhancements easy. Wavefront ablations Restasis makes it possible. 5