February 1, 2023

And starting with the basics we are going to have the next topic is risk factor and pre-operative assessment by dr vipul arora so good afternoon everybody at the outset i would like to thank aus and dr virus for giving me this opportunity i shall be presenting my talk on risk factors and pre-operative assessment for imitropia and cataract surgery i have no financial

Disclosures for this presentation i shall be focusing on the following points in my presentation starting with patient counseling ocular in systemic examination ocular surface and dry eye disease followed by biometry and astigmatism coming to newer modalities fundus examination and oct and lastly is stratification system everyone wants perfect vision from cataract

Surgery but we should try to keep patients expectation at practical level and follow the mantra of under promise and over deliver whatever we do in cataract surgery there is always some level of compromise as we still do not have a perfect i will that matches natural lengths of a 20 year old patient so it is our job to figure out which compromise suits best to the

Patient if we look at the benchmark standards for cataract surgery we see 55 percent of patients are within half a diopter of target and 85 percent are within one diopter of target refraction that leaves about 15 percent of the patient that are still outside one diopter of indented target so there is room for improvement there generally every hospital has team

Of pre-operative workup which consists of optometrist counselor pre apart from operating surgeon every patient who has come for cataract surgery also need a dedicated time and attention to know the expectation and lifestyle of the patient and also to make him understand what is best that can be offered to him in examination like always as most credential will do

Always examine both eyes at same time it should not be only for visual equity but also for all parameters at same time we should we should also not forget to take history of any prior ocular surgery or any history of blunt trauma to avoid any surprises during surgery pre-operative evaluation begins with good history taking history of drug tamisulosin which is an

Alpha blocker can cause floppy irish syndrome aspirin and warfarin can be continued if inr is in therapeutic range apart from routine blood pressure and sugar we check ecg and oxygen saturation or for all patients of cataract surgery viral markers are must for any surgical procedure foreign examination is most underrated examination and cataract surgery a study by

Luca central have shown 59 percent of patients posted for cataract surgery had blepharitis we should always try to look for any strike lazion already traction in the eye and should also examine the tear film by tear film breakup time or sharma’s test good set alarm examination is corner store for cataract surgery it helps us to rule out any other ocular comorbidity

And also help in making grid stratification plan it helps to preempt any intraocular complication during surgery and be better prepared for it spend few extra minutes to look for any cornell’s car prior classic or rk cuts cornell get it fine old kps size of pupil is important then grade of cataract whether it’s a posterior polar cataract subcapsular cataract it

Helps in managing the case more efficiently we’ll talk about funders in next few slides dry eye is almost everywhere it is one of the most common thing that we see in our general practice but sometimes we are so focused on cataract that we might overlook this issue going on in our patient this can be debilitating condition for many patients and it really affects

Our outcome it is really frustrating for a surgeon and after doing uh the perfect surgery patient is six six they still feel that surgery is a failure because they are struggling with irritation and dry ice after surgery they consider it as our fault as this irritation was not there earlier there is a landmark study called prospective health assessment of cataract

Patients ocular surface or popularly known as fecal study that looked into the incidence of dry eyes in cataract surgery in this study 63 percent of patient had tear film breakup time of less than 5 seconds 77 percent had positive corneal staining sharma scovers low in 21.3 percent of cases and only 22 percent of these cases carried an established diagnosis of dry

Ice so still 78 percent of the patients are undiagnosed case of dry eyes who presented for cataract surgery there is another study by dr priya gupta regarding same and they found that 57 percent had abnormal osmolarity in tear film and 40 percent had positive corneal staining we have lot of different tests to assess ocular function it’s better to be consistent

With one or two tests and do it regularly in all the pre-operative patients screening along with clinical examination there are a lot of different symptoms that patient can manifest in many different ways for dry ice which we see here standard patient evaluation of dryness questionnaire or the speed test as popularly knows it’s a modification of ocular surface

Disease index questionnaire and it’s a way of knowing the status of ocular surface we also have to take into account ocular and systemic medications and systemic conditions that can impact the ocular surface mammography is a new and efficient way of detecting and treating women gland obstruction in patients for cataract surgery uh like in this example we see a

60-year 68 year old female with history of dry eye disease and lasik surgery who presented for cataract evaluation her dry eye disease was causing poor quality of topography irregular miles and also astigmatism of a pseudo cylinder of around 2.37 diapers but after treating the dry eye disease the topography showed more regular mice and there was resolution of pseudo

Cylinder so a bad ocular surface can lead to unreliable biometry foreign body sensation after cataract surgery chances of infection and delayed rehabilitation a tear film is the most important refractive surface optimizing it leads to more accurate measurements more predictable healing and overall improve outcome treatment is by thermal position immunomodulators

Lit scrubs but we should remember that we we should delay the surgery until the ocular surface is stabilized a specular microscopy should be done when we suspect clinically poor endothelium there is a risk of corneal decompensation when the count is less than thousand cells per cubic mm coming to biometry it’s a topic will will be separately covered i will just

Highlight few important points we all use immersion biometry in clinical practice and it’s an excellent tool to calculate il power in normal range of actual lens and this has also been proved by studies but since all the major guidelines on cataract now recommend optical biometry as a method of choice but as it is a method of choice uh it is helpful a tool for

Refractive cataract surgery it gives refractive axial length as it measures the center of macula it also incorporates the actual thickness of retina it is operator independent repeatable and precise however like in cases of dense cataract or where patient is unable to fix we may need to go back to immersion biometry the it’s based on optical barometers are based

On various principles most commonly being used is swept source or city based and their newer advances in this third generation formulas are used with immersion biometry whereas fourth and fifth generation formulas are used with optical barometer but if we want to use a fifth generation formula with immersion we can go to various websites like aacrs websites which

Provide free calculation on this formulas another important aspect is astigmatism 47 percent of cases who presented with cataract surgery had more than one diaper of astigmatism there are multiple ways in which key reading can be taken and there are additional topography is also available if we have to if we are not and if we are not sure about the access i usually

Take an auto k reading and confirm it with an optical biometer which is more reliable than above to confirm the axis or in case of any doubt one can use a pentagram i usually refer my patient to my colleague if i have to use so coming to newer modalities to further refine our results of refractive cataract surgery multiple machines are available and in industry

We realize that there are so many diagnostic machines and all trade fairs are completely full of newer machines now it lands on to us to understand which works best for us now in this there are two like corner topographer and cornell tomography cornell topography measures the anterior corneal surface like opscan or nitek opd scan is a 3d image of cornea and it

Measures the interior and posterior surface like pentacam the major use of topography is in refractive surgery post surgery astigmatism surgical planning in cases with astigmatism and also incision planning sometimes these topographers again are based on various principles most commonly used being shamford based principles like pentacam or hybrid topographer or

Oct based topographers abrameter is an another investigation that has gained attention especially in premium oil practice it measures the higher order aberrations of cornea as well as a whole eye it is also useful in dysfunctional lens syndrome as well as to measure angle alpha for multipocal ions so if we have a high volume cataract practice we should go with

Either a topographer with the abrometer like opt3 scan or eye trace or we can go with topographer and a biometry like anterion or a pentagram excel a dilated fundus examination examination with high specificity but low sensitivity and it is considered standard of care for macular evaluation before cataract surgery in presence of cataract its sensitivity reduces so

We cannot diagnose properly all the cases foreign practice in a recent study by v letter in jcrs 2021 macular pathology was detected in 40.6 percent of cases who had a normal fundus nominal macular in examination and out of these 26 percent cases the management was modified and in the form of intravitual injection laser or surgery before cataract like in this

Example we have vitriumacular traction but again the clinical examination fundus is normal oct shows vmt in this case in a high mile case there is flattening of fovial contoured fobial thinning but again fundus is normal and in this case we have a mild erm so the role of ocd is to detect overlooked macular pathology and better assessment of macular abnormalities

It helps in a better informed consent process and realistic patient expectation b scan is done when we cannot visualize the posterior segment in dense and mature cataracts to rule out rd which is hemorrhage intraocular foreign body coming to last there is stratification system it it’s a very good tool if incorporated in one’s practice it is specially helpful

In meaningful counseling and what to expect after surgery it also helps to alert regarding unusual interoperative events and allotment of cases in teaching hospitals again in this a case a study by muntaseb in bmj 2004 it’s a landmark study to uh for this stratification in this points are allocated to risk factors depending on weightage of each risk factor in

Peer-reviewed literature there are three categories allotment to the of the points or score per risk factor like a in category b each earn each thing earns one point whereas in category c returns three points and so based on the cumulative score surgical patience is grouped into one of the four groups group one having no risk factors and group high risk factors

So this inc the complication increases from group 1 to group four and overall complication rate in group 4 is much more and so to summarize a systemic and comprehensive examination consists of patient counseling regarding realistic expectation identifying ocular comorbidities a precise perfect biometry appropriate incorporation of neurotechnology and developing a

Risk stratification system and it help us achieve not only 2020 but uh 20 happy patient thank you thank you thank you so much for an excellent talk dr vipul i think this uh i can’t say this uh one has to do the thorough examination that’s a must for systemic and i also and uh going uh next to is you have to have accurate io power calculation that’s the backbone

Of contract refractive surgery and all this uh accurate biometry we have none other than that dr cmavika with us dr vavika is an authority in biometry he’ll be giving us a lot of tips all right so i think dr vipul made a valid point you have to look for the ocular surface first that is not to be neglected you have to look for the comorbidities also because in

Nowadays we are not getting patients who don’t have karma morbidity getting a clean catered case is become a rare these days most of the patients have some sort of problem they have taken some medicines or something so uh we have to have a very good history of whatever is a systemic illness or the medicine is taking any family history like these things we had to

Be to a thorough examination of the face eyes and fundus also whatever the instruments you have it’s good uh but even with minimal instruments you can do a very good evolution of the patient even with a simple select time or even with a simple keratometer you can give away accurate results most of the biometry is now available uh the style calculation they are

Available online also so you can use a simple biometer also to get a good result with this country

Transcribed from video
AIOC2022 GP5 topic Dr VIPUL ARORA Risk Factor & Pre Operative assessment By AIOS Editor Proceedings 2