Refraction at this stage should be close to intended. If BCVA is reduced, firstly rule out amblyopia (given population that does ICL) and also consider CME.
When referring for enhancement, please either include last 3 refractions, or a comment on stability of refraction
Chamber should be well formed with no reaction. If any issues, likely unrelated to cataract surgery and should be investigated as appropriate.
Any uveitis at this stage of healing is likely unrelated to surgery. Need a second opinion, or just want someone else to manage a uveitis? Send to me and I’ll manage the acute condition, while you remain the primary eyecare provider!
If lens is too tight as evidenced by excessive conjunctival conjestion and excessive pain, consider removing and replacing the BCL
Volcano effect:"Bent" Optic section shows iris pushed forward from the implant
Volcano effect: the ICL is pushing the iris forwards. May indicated a larger lens. If IOP normal, angles open, and pupil reaction normal, ok to monitor.
Suspect Pupil Block if:
The fenestrated ports in the EVO ICL design have significantly lowered the risk of an IOP spike and pupil block. If you see a high vault, with volcano effect and narrow angles, send to the surgery centre to assess, even if the IOP is normal
The halos at night may remain up to 6 months, as there can be some traumatic palsy of the pupillary muscle which can impact reaction slightly. If halos bothersome, try off-label use of Alphagan 0.2% prn up to bid, instilling 1/2 hour prior to going out at night.
***Ideally done undilated. Patient may arrive still dilated in the first few days after surgery, which will affect your assessment
The fenestrated ports in the EVO ICL design have significantly lowered the risk of cataract formation. If vault is 0.5 or less, consider sending to the surgery centre for more exact measurement/monitoring. If vault is greater than 2, watch closely for pupil block.
You can also measure vault in microns on some OCTs and Pentacam
If you notice new transillumination defects and/or progressive pigment on the ICL, that would indicate implant to iris interaction and should be evaluated by the surgery centre.
***Ideally done undilated. Patient may arrive still dilated in the first few days after surgery, which will affect your assessment
How many "corneal thicknesses" can you fit in between the crystalline lens and the ICL?
The fenestrated ports in the EVO ICL design have significantly lowered the risk of cataract formation. If vault is 0.5 or less, consider sending to the surgery centre for more exact measurement/monitoring. If vault is greater than 2, watch closely for pupil block.
You can also measure vault in microns on some OCTs and Pentacam
If you can't quite see the markings due to poor dilation, use the bevelled edge of the implant as an alternative reference
Anterior subcapsular opacity (not an ICL patient)
ASC associated with ICLs occur on average 3 years post surgery. This is another good reason to maintain yearly comprehensive eye exams with you.
This is a good opportunity to educate the patient on the importance of ongoing eye health care with you, even though their refractive error has been corrected.
(Keep scrolling down to learn signs of pupil block)
With EVO ICL's fenestrated ports, an acute IOP spike from pupil block is rare. It can also mean that the IOP is not necessarily high- but the structures can still risk angle closure and should be assessed nonetheless.
Treat pupil block as an emergency. Always start IOP lowering medications (from your IOP kit) prior to sending the patient to Clarity Laser Vision immediately. Help us triage the patient appropriately by asking for Amera when you call the emergency line. She will ensure that one of the doctors will attend to the patient without delay.
You may have noticed that the patient experience is quite different between the two clinics. Seema Eye Care is a very popular specialty clinic that sees a very high volume of patients, striving to help all those in need of our care. For this reason, it takes more time to process patients through the system. There is also an expected waiting time for surgery for AHS covered cataract surgeries, which is influenced by AHS policies and outside the control of Seema Eye Care centre. Clarity is designed to offer a higher touch, premium experience for our private pay Refractive clients. Clarity sees less volume, therefore can accommodate more timely referrals and appointments.
Truth: Having a pre-planned IOP kit available in office reduces the anxiety of the doctor and the patient and saves precious time in an urgent situation. It is highly recommended that you have a well stocked IOP Emergency Kit and Emergency IOP Protocol.
In almost all cases*, a high IOP early post op is associated with trapped viscoelastic from the surgery. It takes up to 72 hours to resolve, and in the meantime, you'll need to manage the IOP.
*Don't forget to consider a high IOP in the context of your other findings, though. A high IOP in the presence of Toxic Anterior Segment Syndrome (TASS), or fibrotic membrane formation would require a different approach.
IOPs greater than 40 mm Hg need timely intervention- tell our staff to get our manager Amera right away, and let her know it is an emergency - she can then traige appropriately.
Patients with these conditions should absolutely not consider refractive surgery:
We evaluate each individual as a whole and carefully weigh the risks/benefits of surgery. If refractive surgery is not in their best interest, we won't do the surgery. If you are unsure, send them our way- be sure to include any questions/concerns you may have!
***looks like a rolled up carpet
- a small detachment can be observed
- a large detachment needs to be assessed by the surgeon
***both are required to notify the surgeon. It is imperative
to differentiate the two so you can implement timely
treatment correctly
Maassen JL, Folk JC: Endophthalmitis: 82-year-old male status post phacoemulsification in the left eye with acute decrease in vision. Eyerounds.org. December 5, 2005; Available from: http://www.EyeRounds.org/cases/45- Endophthalmitis-After-Cataract-Surgery.htm.
Both require urgent attention by the surgery centrenotify the surgeon immediately. If you suspect endophthalmitis this is an emergency and every hour counts!
It is recommended to wait a minimum of 3 months after surgery before performing a YAG capsulotomy to ensure a stable capsule/zonule system.
Some symptoms that would suggest considering a YAG are:
Send for YAG capsulotomy if patient is symptomatic and they present with one of the following in the posterior capsule:
Sometimes if a patient has an unwanted residual refractive error, we will perform a YAG capsulotomy prior to intervening with more invasive surgery to see if the IOL placement would be improved.
Striaie are common and sometimes will dissipate with time as the capsule "shrink wraps" over the IOL. Sometimes there is even "torquing" of the IOL in the bag. But there are times when the striaie are relevant:
Some symptoms that would suggest considering a YAG are:
To determine Maddox Rod effect, have the patient close one eye and shine the transilluminator towards their eye from 16 inches away. Have the patient describe the direction of the starbursts. Will usually be perpendicular to the striaie present.
***looks like "lobes" of choroidal elevation in up to 4 quadrants
- differentiate from retinal detachment
- can have shallowing of the anterior chamber
- may have increased pain
- look for wound leak
- look for hypotony
- although some small choroidal effusions can be monitored for self resolution, it is best to notify the surgery centre, as this can potentially be a vision-threatening condition requiring surgical intervention
Contributor: Jesse Vislisel, MD
Photographer: Brice Critser, CRA
***injectable corticosteroid during cataract surgery - used in complex cataract cases to help reduce inflammation and visualize vitreous especially if there was trauma during surgery
Contributor: Eric Chin, MD
Photographer: Cindy Montague, CRA
**this is a guideline only, the doctor should use their discretion
IOPs greater than 40 mm Hg need timely intervention - tell our staff to get our manager Amera right away, and let her know it is an emergency - she can then triage appropriately.
Phimosis is a fibrotic metaplasia of the anterior capsule causing the anterior capsulotomy to "shrink" and create visual disturbances.
It is recommended to wait a minimum of 3 months after surgery before performing a YAG capsulotomy to ensure a stable capsule/zonule system. However if the phimosis is visually significant, can send sooner for surgeon to evaluate.
Contributor: Jesse Vislisel, MD
Photographer: Stefani Karakas, CRA
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/capsular-phimosis/index.htm
Volcano effect: "Bent" Optic section shows iris pushed forward from the implant
Volcano effect: the ICL is pushing the iris forwards. May indicated a larger lens. If IOP normal, angles open, and pupil reaction normal, ok to monitor.
Suspect Pupil Block if:
The fenestrated ports in the EVO ICL design have significantly lowered the risk of an IOP spike and pupil block. If you see a high vault, with volcano effect and narrow angles, send to the surgery centre to assess, even if the IOP is normal
Hyperopic ICLs are not EVO lenses, and do not have fenestrated
ports throughout the implant. This means they require a
prophylactic PI
My hyperopic mixed astigmatism
patient got myopic toric EVO
ICLs. What's going on?
This is a mathematical mindbender. Optometrists usually refract in minus cyl, but the ICLs are manufactured in plus cyl. This is why some mixed astigmatism refractions can be treated with a myopic toric ICL.
For example: if your refraction is +2.00-4.00 x 180, then if you convert to plus cyl form, that is -2.00+4.00 x 090, which is available in myopic toric ICLs!
Don't shy away from the hyperopic cases! Send them to me for evaluation. I know which ones can use a myopic toric lens (which will do quite well with SBK!) . By the way, we can now order hyperopic toric ICLs in limited ranges as well! (But they are V4C lenses, not EVO.)
In very high myopes, they sometimes want to "eat up the minus" resulting in low myopia post surgery. Often, accommodative testing and some vision therapy is successful in avoiding further refractive surgery. If you suspect this, we encourage you to explore this avenue before sending for enhancement.
If the patient is NOT 20/happy, then we need to validate the patient concerns. The Snellen Visual Acuity and manifest refraction are faulty metrics for outcome at best. If you feel, despite all of your testing being within normal limits, that the patient is not happy with their outcome, send patient to the surgery centre for a consult. We will analyze in great detail the refraction (in 0.01D increments), aberrometry, and corneal healing pattern. We will do everything within our power to address the patient concerns.
In very high myopes, they sometimes want to "eat up the minus" resulting in low myopia post surgery. Often, accommodative testing and some vision therapy is successful in avoiding further refractive surgery. If you suspect this, we encourage you to explore this avenue before sending for enhancement.
If the patient is NOT 20/happy, then we need to validate the patient concerns. The Snellen Visual Acuity and manifest refraction are faulty metrics for outcome at best. If you feel, despite all of your testing being within normal limits, that the patient is not happy with their outcome, send patient to the surgery centre for a consult. We will analyze in great detail the refraction (in 0.01D increments), aberrometry, and corneal healing pattern. We will do everything within our power to address the patient concerns.
Don't be myopic in the pursuit of perfection. If patient is 20/happy with their outcome then the risk of intervention, even glasses, outweighs the benefit. Remember, even a mild mixed astigmatism may be beneficial for some near benefit. It's not always about a perfect plano result. Happy patient= happy surgeon!
Don't be myopic in the pursuit of perfection. If patient is 20/happy with their outcome then the risk of intervention, even glasses, outweighs the benefit. Remember, even a mild mixed astigmatism may be beneficial for some near benefit. It's not always about a perfect plano result. Happy patient= happy surgeon!
