Cataract Surgery - Science topic

Modern phacoemulsification with IOL implantation is the only safe option in this case. The surgeon must be prepared for possible zonular insufficiency during the surgery.

I am answering this as a patient as I have no medical qualifications whatsoever, thus it's an experiential report. I recently acquired a clear implant, vs the other one, implanted two years ago, which was yellowish. I believe both have a UV filter, but the tinting is different: that can clearly be seen by shutting each eye in quick succession and comparing. When both eyes are used, I see something in between: the difference does not bother me in terms of everyday vision, but I do prefer the yellow tint (warmer) in terms of perception. I am very happy with the results so far, but had I been given a choice of 'coloring' I would probably have chosen tinted in both eyes, provided there were no medical disadvantages. I also prefer warm lights in general (say inside the home etc.), but I know people who prefer cold lights - perhaps they would prefer non-tinted implants. Still- having both 'options' is also interesting: each eye sees differently, and sometimes better, more detail etc., compared to the other, in differing light conditions, so that could be regarded as an advantage I suppose, a kind of (slightly) improved potency.

My practice is till 5 years of age, all the cases undergo primary posterior capsulotomy with anterior vitrectomy. After 5 years of age, for co-operative child, I do YAG capsulotomy at 6 weeks post op.

But when the follow-up is an issue, we should perform PPC with AV at the primary surgery itself in children.

Respected Vadim S. Gorshkov , Aparna Sathya Murthy , Sunny Chi Lik Au and Guangbin Zhong - Thanks for your valubale suggestions and insights. This is very useful information for me.

I don’t think routine use of NSAIDs for all patients is necessary. we usually add it to patients who had a complicated surgery (PCR + Vitreous loss), or those who have a significant corneal edema due to excessive ultrasound power (CDE 15++).

I’ve also worked with consultants who like to add NSAID drops for all diabetic patients undergoing cataract surgery.

It did. It did not set the grounds for a guideline.

There is a cost-effectiveness issue, since as W. G. Meyers points out (https://www.jcrsjournal.org/article/S0886-3350(18)30858-7/fulltext), it is wiser to increase the topical steroid dosage or to wait 12 weeks for symptomatic cystoid macular edema (CME ) and treat it with intra-vitreal triamcinolone. Most CME cases recover spontaneously . A total of 99.93% of patients have to be treated so that 0.07% (1:1500) can be spared chronic CME, which implies a cost of $369 000 000 of extra expense to prevent 20 000 cases of chronic CME in the United States per year, or $18 450 per eye spared.

From the results of the PREMED 1, we may conclude that most differences were related to CRT. We do not treat OCTs, but patients with insufficient vision gain.

Indeed, CME was not significantly different in a pair-wise comparison, CSME was not statistically significantly different (SSD) at 12 weeks, mean BCVA was never SSD different .

Of note, the amount of patients with basal BCVA ≥ 20/25 per group was not provided and that was crucial for clinically significant macular edema (CSME) definition, since there might have been a "ceiling effect" (gain of at least 2 lines of vision, e.g. 10 letters). The PREMED study might have caused a surplus of CME cases to be considered CSME, since many patients with basal BCVA ≥20/25 were included.

Additionally, floppy iris syndrome, youngsters, previous anti-VEGF therapy and history of CSME in the fellow eye ought were not provided for each group and were thought not to increase the risk of CME, which is questionable.

I have always started the capsulotomy with very low energy (1.3 - 1.6mJ) and increasing from there on according to posterior capsule disruption. I always start in the center and move through the apexes of the rupture to widen the opening. I try to deliver the least laser shots as possible, and never go very far into the periphery.

The causes could be:-

1. Sphicter tear

2. Atonic pupil.

3. Iatrogenic - some staff had used atropine eye drops by mistake.

4. Raised IOP due to unwashed viscoelastic.

5. Neurological cause -a missed internal ophthalmoplegia

Adding my sophomoric 2 cents here: Using the metaphor of riding a bicycle. The epistemology of riding a bike is the description, theory, strategies, anything that is written. The phenomenology is that which impacts one such as the person going down the street with their legs off the ground at a rate faster that one can walk on a device that has two wheels. The ontology, the 'being' , of a bicycle rider is one who is so-to-speak used by the distinction balance. They are 'being' a bicycle rider. How on accesses this being is by getting on the bike and falling off repeatedly until one 'gets' balance. We could say that epistemology does not provide access to balance. Perhaps the phenomena of practice does. The "being' is pretty much and all-of-a-sudden phenomena.

With regards to your "barriers to cataract surgery among cataract blindness patients" you could look at the shift in the "being" that the post surgery patients report. (Husdon's Index of Self Esteem, or Contentment, or Locus of control measures, or self reporting Likert scales for instance). You could look at the phenomena of post surgery people to see what phenomena is there that was not before. What is impacting them, and in this way it may impact those considering surgery.

When a person is considering surgical intervention, there is some concern that colors and shapes their decision. The concern(s) are past based. What have they heard about it? What have the read or been told? What do they believe? What do they know from past surgical procedures? Once these concerns have been heard, and the data from people who are doing studies such as yours is considered, then a conversation about what could be possible, that is based on what is known can be pursued.

I appreciate the impact you are making.

Jeff

@pabita dhungel I think aniseikonia is not an issue for a one eyed patient. I would prefer a contact lens. Given the history of complicated cataract surgery the risk for an iol exchange and a piggy back would be equal. I wouldn't risk piggy back due to risk of corneal decompensation..

If the patients doesn't want a contact lens..next option would be an iol exchange...

On top of that.. I would also make sure that every next patient would get their biometry accurate.

Νot really

--Posterior displacement of IOL

--Zonular dehiscence

--Very short axial length (high hyperopia)

A meticulous slitlamp examination could suffice the need for specular microscopy. It may however be needed in case to case basis.

Lower PCO rate has been associated with the presence of posterior square edges. Studies have shown that shrink wrapping of the capsular bag around the IOL optic is an important mechanism to prevent PCO and in theory 3 piece IOL may have better outcomes regarding this complication however no randomised trials have been performed to confirm this theory. In addition 3 piece IOL are much less used nowadays which make it more difficult to perform studies to compare both IOL's.

As far as oral antiobiotics are concerned, it should be used to control any infection already present. Once the infection is resolved, a few weeks later surgery can be done without resorting to another round of oral antibiotics for prophylaxis. I do not remember giving oral antibiotic for prophylaxis in any patient. Unnecessary antibiotics can only develop antibiotic resistance. Wonder if any guidelines mention about this aspect?

Cataract surgeries have been performed in upright positions also though the technique needs a slightly better skillset. And also, the ease and safety would depend on the technique used.

Contact lenses [ CLs, whether soft or hard (rigid gas permeable), but usually soft) are not routinely used and should be avoided after uncomplicated cataract extraction (whether intra-capsular, extra-capsular, small incision cataract surgery or phacoemulsification) specially to act as a bandage or cover (referring to your question). This is because:

1. Cataract patients are usually elderly people and may have an increased chance of dry eye. The central and optical part of the cornea is dependent on the tear film to get its nutrition from, of particular critical importance is oxygen (used for corneal cell metabolism), which comes from the air in front of the cornea. If the patient's eye is dry and a low water content (usually a <or = 30% water, thin CL like disposables) is used, these conditions cause oxygen deprivation to the cornea and usually results in corneal metabolic change which leads to corneal edema. This even true for high Dk value CL of >130 if it is not wet by tear substitute regularly and as the need arises. Even high Dk value thin soft hydrogel CL need to be wet to allow oxygen through them.

2. CL use may increase the risk for post-operative infection. The basic rule of contact lens wear is to take it out when no longer needed because the longer the it is on the eye the higher the rate of infection as shown in several studies before. There is a risk to benefit ratio observed in the use of CL which is another topic.

May be the bettter question is: When a CL can be used post-cataract surgery? Here are some of the relative indications for its use:

1. In cases of persistent epithelial defects usually experienced in diabetic patients (usually with concomitant dry eye) and other diseases after 2-3 weeks post-cataract extraction [usually what is suggested is pressure patching for the first 2-3 weeks (which allows minimal surface epithelial cell growth disturbance when blinking) and this could also be supported by oral intake or topical use of Vitamin A which increases epithelial cell mitosis] who have basement membrane abnormalities in attachments. The use of thin Bandage CL (not CL used as a bandage per se) with high Dk value may be appropriate since its main mechanism of action is allowing adhesion complexes to establish since usually the defect is due a failure of epithelial cell and attachment complexes adhesion (reference: Jouranal of The Ophthalmological Society of United Kingdom, 1970's, Topic : Cornea and Dry eye)

2. In cases of corneal edema, CLs can be used to flatten and make the epithelial surface more regular specially if bullae are present. It also decreases the foreign body sensation or even pain when these bullae rupture. It has the added benefit of acting as a depot of topical eye drops in particular 5% sodium chloride, antibiotics and steroids. A naked eye being treated with hypersalt solution should ideally be without corneal epithelial defects as the hypersalt solution normally take out water by osmosis. The primary difference between osmosis and diffusion is the presence of a semi-permeable membrane (represented in the cornea as an intact epithelium) which allows only water to exit a less concentrated medium to the more concentrated medium allowing water to be drawn out from the corneal stroma to decrease its edema. In cases of cornea's with epithelial defects the process may involve diffusion where the concentrated solute (sodium in particular) with its solvent (water mainly) may enter the defect an equilibrate in the corneal stroma minimizing or negating the hypersalt solution effect on corneal edema. With the use CL in corneal epithelial defects with corneal edema, it can act as a temporary but imperfect semi-permeable membrane which may slightly decrease corneal edema. This is the reason that in our Cornea and External Eye Subspecialty Clinics in Manila Central University Hospital and Ospital ng Makati, hypersalt solutions are used together with bandage contact lens or used in end stage endotheliopathies with chronic edema unresponsive to other previous medical treatments.

3. In some cases of leakage of the cataract wound site where a regular thick extended wear wide diameter scleral soft CL may be appropriate. This may include corneal perforations of usually < 2mm assisted by other forms of medical management,

Hope I answered your question and clarified some other points

i have one question, what parameters are you planning to evaluate? (schirmer, BUT, Lissamine green..?)

The recently developed and enhanced Ngenuity visual system is a breakthrough system and is a landmark work by Alcon-Truevision team. The graphics are very crisp, sharp and even the feedback has very low latency. The magnification is high without compromising on the field f view, depth perception or clarity. It perfectly amplifies the visual effects of the best of microscopes.

Only drawback is the initial setup. Unless one does a proper primary color, white-balance setup, the system may feel as a drawback due to poor visual quality. So, it needs a person to correct for any changes that maybe required intra-operatively.

Another important benefit that we at RPC, AIIMS, India noted was the use of the color filters to enhance picking up the macular staining with/without vital dyes for macular procedures. It can aid in reducing the harmful effects of vital dyes by totally extinguishing its per-op use.

Dear Anatoly, thank you for answering my questions.

please help to understand what target adjustment is.

Looking at the attached Figure, it is clear, that having pre-op MSRE of patient  and statistical data, we can get A, B and R linear coefficient for equation.

So we can predict SA for patient with certain MSRE value.

Question is how surgeon or femtosecond device can use the predicted SA value to reduce it? What actions should be made during operation to avoid SA?

Is this relevant to defocus of laser beam during operation? depth per pulse?

Is this relevant to a particular area at cornea or retina?

You can tape them to the eye drapes. Would you not manage better with an Ahmed capsular tension segment hold in place with an iris hook and place a permanent CTR at the end?

1. HPMC

2. HPMC - reason being lower propensity for IOP rise, as some OVD is bound to remain posterior to the ICL

3. Injection the ICL into the AC first is safer. Then tuck each haptic gently under the iris with mutiple small nudging movements.

4. Try not to sweep the haptic under the iris with one stroke, multiple small nudges are better. 

5. I do use pilocarpine at the end of surgery.

The best age is once all facial bones have matured & the development of the face is complete. Usually attained by the age of 9 to 10 years.

It depends on individual case. Even then some cases with absolutely no reaction respond to NSAID drops initially, some require steroid drops intensively at the end of PO first week. This is due to multi factorial causes.

You can have an assistant holding the trailing suture and keeping it from entangling. Otherwise, keep it sufficiently long and then clamp it to the drape.

Sir,

I have few suggestions and few queries:-) 

1. Can you provide K-readings also?  We can go for AK to reduce corneal part of astigmatism.

2. Sometimes early central PCO decreases near vision first as pupil constricts while viewing at near distance. So if PCO is there, we can go for YAG Cap.

3. Is NEAR VISION not improving with higher addition too?

    It will be my pleasure if this caters to your need. Please find this article-

Alberth M, Wu WM, Winwood D, Bodor N. Lipophilicity, solubility and permeability of loteprednol etabonate: a novel, soft anti-inflammatory steroid. Journal of biopharmaceutical sciences 1991;2:115–25.

Hi Avadesh,

A number of things could significantly increase the risk of post-op infection in your patient; he is elderly, the treatment protocol he may be on presently (especially if dexamethasone or prednisolone is part of it) the disease (particularly if there are significant hypogammaglobulinaemia, and/or neutropaenia) and probably other co-morbidities (such as significant renal impairment). I will suggest your patient gets full (therapeutic) coverage of broad spectrum antibiotics for the procedure and the immediate post-op period, if any of the above (or indeed any other additional infection risk) is present, otherwise the prophylaxis could suffice.

All the best in your work.

John.

Generally speaking, patients are wary about being operated in the better seeing eye.

My routine practice is to start with the worse BCVA eye regardless of the visual potential.

If the patient is not oriented about the co-morbidities he's suffering from in this eye he should be educated thoroughly about his condition, and a detailed informed consent should be collected, specifically mentioning the expected results.

In our experience patients' fear the most from the operation itself as much as or even more than their concern about their postoperative vision potential. Still it is much easier for them to accept the fact that it is their weaker eye that will be operated upon.

Following the surgery, patients realize that their fears were exaggerated, especially if the outcome is worth it (at least they have to have minor improvement, otherwise surgery is not indicated for them in the first place). Now they become much more confident into venturing into the more concerning fellow eye.

Of course this is a psychological approach more than a medical one. Nonetheless, other factors such as mentioned in Dr. Maimone's reply have to be taken into consideration.

I'll be the contrarian: In general, I agree. However, you might consider it in younger men. Younger myopic men with lattice are at much higher risk for RD after cataract surgery, especially if there is capsular rupture (which most surgeons don't plan). Prophylactic laser retinopexy is generally safe and simple, and in this particular type of patient it may be a good idea. I also try to get the cataract surgeons to avoid silicone IOLs in patients like this, who are at increased risk for needing a vitrectomy. 

Flomax in particular has no effect on zonules as there are no such receptors on lens zonules for FLOMAX to bind.

Local:  Topical Paracaine/lignocaine or peribulbar block . Povidone Iodine paint .

Topical broad spectrum antibiotics starting a day before surgery , dilating agent(Tropicamide phenylephrine) on day of surgery with or without flurbiprofen. Antiglaucoma drugs for glaucoma cases ( Stop prostaglandins and pilocarpine atleast 7 days before surgery)

Oral: Minimal dosage of wide spectrum antibiotics in susceptible cases, analgesics as per need, oral acetazolamide as per surgeon and the case

Regards - Dr Lipi Chakrabarty, Director LIPIKA NETRADHAM, Bhilai-Durg, Chhattisgarh, India

oertli phaco machine is the best for this job, I've friend in yemen who perform 700 case on one cassete, and 1500 case without changing the phaco tip. personaly I've tried this machine it was not convenient for me as I am using infinity from Alcon

Dear Peter,

you can use anti veg F injection either bevacizumab or ranibizumab, if the patient has macular oedema and steroid responder wrt IOP

best regards

thirumalesh

It is multifactorial, patient side that they are phobic and uncooperative coughing all the time, eye examination before surgery that may affect results postoperatively,surgeon experience also plays an important part.

Cataract Surgery is the leading surgery performed in the field of Ophthalmology. Vitrectomy is no way comparable to the number of catarct extractions performed worldwide. But the percentage of Vitrectomies is on the rise due to more trained personnel available in the field I.e. there are more vitreoretinal surgeons today than in the past years and they treat many retinopathies with Vitrectomies. Since the prevalence and incidence of Diabetic retinopathy is increasing worldwide, the number of Vitrectomies is expected to increase but not in proportion to That of cataract surgeries. 

We can not add much but usually most of us avoid surgery to diabetic patients unless the control is good, the surgery necessary for treating significant diabetic retinopathy and for the patient visual needs.

Also avoid high power adjusment in quadrant removal setting.

Hi,

Dose of  dexamethasone in an eye drop containing dexamethasone is usually 0.1%. This means that there is 1 mg dexamethasone in 1 ml of eyedrop. Each ml makes 20 drops. So each drop contains 0.05 mg. İf patient is using 4 drops a day, it makes 0.2 mg Dexamethasone per day. Even if all of the drug is absorbed into systemic circulation, it is too small an amount to take into consideration for systemic effects.

To my knowledge there is no valid prospective data out about a possible cataractogenic effect of MMC after pterygium surgery.  I would rather question whether MMC is necessary? I would prefer covering the defect with a conjunctival transplant or flap. 

I prefer 4,8 mm capsulorhexis size especially if you use premium lenses such as toric multifocal, multifocal and toric IOL's      

Thorough viscoelastic removal is essential to avoid intraocular pressure elevation after cataract surgery. Especially dispersive viscoelastics should be avoided towards the end of phaco surgery due to their hard removal. Viscoelastics may remain inside the capsular bag or behind the İOL. They should be cleaned meticulously by irrigation- aspiration. I allways observe some trapped viscoelastic between posterior capsule and intraocular lens during surgery, and routinely enter behind İOL with irrigation handpiece and remove them. 

Regardless of its molecular size or physical properties, any viscoelastic remaining in the anterior chamber is a challenge to trabecular meshwork. Especially in patients with pseudoeexfoliation or pseudoexfoliative glaucoma, filtering capacity of trabecular meshwork is seriously decreased and any challenge may cause intraocular pressure rise. 

After an atraumatic and uncomplicated surgery, if you do not leave viscoelastic inside the eye, usually you do not observe postoperative intraocular pressure rise.

To Ann Payne,

Thank you for describing  your clinical observations,  adding to the evidence of this issue.  I believe that the recognition and awareness of the possibility of this condition, needs more research. Since I posed the question, I've been reading the research. In my recent reading and career experience this is "convergence insufficiency" due to muscles not working together. It is a condition that occurs in children and young people without having cataract surgery; vision therapy or specific eye exercises are the treatment of choice. In the past, prism eyeglasses were prescribed. In practice, There are simple strategies for screening.

The front-runner of treatment and research was Dr. Constantine “Gus” Forkiotis, a developmental optometrist, since deceased. His seminal research and publications are worth reading.

Something to consider while taking  the medical history in psychiatric assessment.

Janet

.

According to what Dr.Stojanovic just mentioned, COMA is the major cause of irregular astigmatism induced by keratoconus.

You cannot correct coma with toric IOL, you can only "optimize" the astigmatism and the patient will remain with high order aberrations after the surgery.

If keratoconus is not progressive (and you don't need CXL), you can program a toric IOL implant exspecially if astigmatism is not completely irregular or scotopic pupil is small.

In case of high irregularity, in my opinion the best option to correct it simultaneously with cataract surgery, is to perform the first surgery implanting a single inferior intracorneal ring (according to the nomogram), correcting only topo-tomographic COMA-AXIS. After the implant, is recomended to wait up to 3 months for corneal astigmatism stability and perform a cataract surgery with a toric IOL on the residual ASTIGMATISM AXIS.

I reported to ESCRS in Barcelona this very interesting case not yet published, done one year ago with a very nice result, have a look on this link:

All the best

Large capsulorhexis and multiple hydro delineation waves performed gently. Try to prolapse the smallest central ring nuclear piece first and emulsify it. Then using epinuclear settings engage the more peripheral rings. Obviously avoid hydro dissection.

Reviews are good, I do not have a hands on experience of the machine itself.

I agreee with my colleagues indicated that it is so-named "cataract of IOL" due to hydrophylic material of IOL. The only option is to replace the lens.

In my opinion as a rule no, but exception is possible for immunocompromised patient.

Review  old records of the patient. Most of the times the patient has history of chronic inflammation after surgery, which never settled or sometimes there could be plaque in the capsular bag in these patients which was missed. There could also be history of some precipitating event like suture removal. The incidence of slow growing organisms, fungal infections stays high. Immediate vitreous biopsy in these patients with cultures from undiluted vitreous biopsy samples could clinche the diagnosis.

This issue is very relevant in day to day practice!! The ideal choice is topical wherever possible, but actually even stopping the drug does not make much difference. The chances of bleed during block almost remain the same.

controlling blood glucose of diabetic patients is of graet importance before refractive surgery because uncontrolled blood glucose  will result in flalctuation of refractive errors.

it is more important to strictly follow up diabetic patient after cataract surgery for possible rapid progression of diabetic retinopathy 

We use 8-0 prolene 

Absolutely, I would also think that a comprehensive evaluation prior to surgery will be of benefit. We have primary eye care clinics in South Africa that deal with many indigent patients requiring cataract surgery but strict treatment protocols are in place to prevent unnecessary surgery and complications.

You have presented an interesting case of an adult male with a history of poor vision OD since childhood, a sensory exotropia, healthy nerves and vessels, and a unilateral pigmentary retinopathy. Most likely this is due to old infection, but other possibilities include an old foreign body with siderosis, inflammatory causes such as Harada's disease or AZOOR, old retinal vascular occlusive events or perhaps an atypical presentation of a bilateral process such as retinitis pigmentosa or vitamin A deficiency. Likely infectious causes are onchocerciasis, diffuse unilateral subacute neuroretinitis, syphilis, ophthalmomyiasis, toxoplasmosis, or rubella. As he is from Africa, there are probably several more infectious diseases that may cause a pigmentary retinopathy that I am unfamiliar with. Perhaps someone with expertise in tropical medicine could add to my list. I recommend a careful history, consider a plain-film x-ray if there is a chance of a retained foreign body, then a laboratory work-up for the most likely infectious diseases. If that does not lead to a diagnosis then I would consider electrophysiology studies to rule out unilateral retinitis pigmentosa, but this is unlikely. There are many good papers on the differential diagnosis of unilateral pigmentary retinopathy. Here is one:

Silveira C, Belfort R Jr, Nussenblatt R, Farah M, Takahashi W, Imamura P, Burnier M Jr. Unilateral pigmentary retinopathy associated with ocular toxoplasmosis. Am J Ophthalmol. 1989 Jun 15;107(6):682-4.

Thank you again for presenting an interesting case. Please let us know what you find.

Not yet. The high costs of femtolasers are paid by the patient and, moreover, one has to consider the discomfort of moving the patient in the middle of the intervention.

Multifocal IOLs usually are not indicated for patients with retinal damage because they split light beam on two different main focuses. Some surgeons and me used this lenses without any side effects on contrast sensitivity or glare in Low vision patients. In my experience multifocal lenses aid in reducing magnification power of spectacle lens for near vision (i.e. 3x effect may be obtained with +3 addiction on the lens and +4 on spectacles 4x3=12D) but this affects reading speed.

Factors to be considered before deciding to perform the surgery:

1. BSCVA

2. Occupational needs

3. quality of vision ( glare , halo,...)

4. The reason of loosing the other eye ( be careful if it was related to cataract surgery complications! or RRD)

5. The refractive error of the patient ( extra risk of RRD after vitreous loss in high myopic or risk of glaucoma in sulcus IOLs in occludable angle of hyperopic patients should be considered)

6. Baseline IOP

7.Your expertise and previous experience with pos. polar cataracts

8. Your estimate of the degree of confidence that patient has to your competence and your system ( it is not necessarily related to your abilities and is more related to the popularity)

You can use pentacam and or ant. Segment OCT to evaluate the posterior capsule- though not very accurate). Explain your concerns to the patient.

If you decided to go for surgery , perform a relatively small (~5 mm) ant. Capsulorrhexis - in case you need to insert the lens in the sulcus- and have a 3 piece IOL available.

In my hands, pos polar cataract is not very challenging when I try to aspirate the lens first in the periphery then proceed to the center.ant. Vitrectomy can remove the residual nucluar and epinuluar material in case the pos. capsule is open.

But for this case, to be honest, I would prefer to ask a retinal surgeon to operate on this patient to be able to handle the case in the same session, in case more clinically significant nucleus drop occurs!

BTW, good luck :)

At the same time with specific general antisyphilitic therapy for ME is indicated topical nonsteroid antiinflamatory drops - voltarene ( diclophenac) indomethacine, etc. and PredForte , each four times dayli 1- 3 months, if not enough after 1 mo add Diamox oral or topical, if no response -Diprospan subtenonian injection or IV TA control of IOP

If you have access to one, it may be helpful to get an aberrometry examination. You can divide the straylight parameters into the corneal and total internal eye parameters and that may help you divide the corneal optical effect from the cataract effect. It's not without problems and the corneal elements are predominantly from the curvature rather than the dystrophic proportion but if you see a major lens effect that may help you inform your patients and assist decision making.

I discontinue topical anti-glaucoma prostglandin analogues 3 days before cataract surgery and replace it with brimonidine- timolol combination or dorzolamide-timolol combination ( Care is taken in patients with bronchial asthma or heart disease not to add timolol maleate) and 2 months post-operatively in uneventful cataract surgery patients topical prostaglandin analogue can be started again.

5% topical povidone iodine is a gold standard and the comment about leaving it in the conjunctival sac for 3 minutes to achieve its full effect is good practice. We concentrated on that preoperatively, along with promoting intracameral cefuroxime postoperatively and had a run of 10,000 cases of phacoemulsification with IOL without a case endophthalmitis at the Birmingham and Midland Eye Centre.

Why have you posted this same exact outdated statement three times?

Thank you Nabin. I have seen his article on SICS in the Community eye health journal but that did not discuss trabbies. I have been unable to get the relevant article. I would appreciate a link if possible.

Thank you Niveditha,

you stated "in your casereport you have selected monofocals, so for the other eye it has to be the same", and this is exactly my question: why?

Could you elaborate a bit more on the topic?

I use an aspheric (toric if necessary) monofocal IOL. With a unilateral cataract, the visual quality from a multifocal IOL will be noticeably poorer than the unoperated eye, with lower contrast and halos. The multifocality can never match the good eye in a young patient, so at least a monofocal gives perfect binocular vision for distance. Still it is important to counsel the patient since different patients have different priorities.

We must resolve major issues of concern in pediatric cataract surgery particularly younger then three years. The problems are as mentioned IOL power calculation, IOL sizing of IOL and how to do visual correction or rehabilitation. We do under-correction of IOL power in children 2-8 years by approx 20% and in children less than 2 years by 10%. Dahan's guidelines.These are helpful in adjusting initial hypermetropia and late myopic shift. No double contact lenses is one of the solution in managing anisokonia/ image size difference and provide full field. Still our first choice remain IOL implantation where it is not contraindicated and equally important choice is Contact lenses.

I would generally recommend against using multifocal IOLs in children under age 15-16 years at this time for two reasons: 1) in the potentially amblyopia age group- say under 6-8 years- the loss of image sharpness and contrast sensitivity at all focal lengths may, at least theoretically, have negative effects on vision development. In addition, retinoscopic refraction or confirmation of refraction is extremely difficult in the presence of an IOL which will reduce over refraction accuracy and may also lead to some amblyopia. But even in older children, since the lenses work optimally only if the final distance refraction is within a very narrow range of emmetropia, since the changes in final refraction caused by growth of the eye during puberty prevent predicting the final refraction, even within 1D, until very late, the benefits of the lens in terms of spectacle independence in children can easily be negated by refractive changes during the early teen years. Thus leaving all the disadvantages of the lenses without the advantages.