This document discusses the opportunities and responsibilities of optometrists in co-managing cataract patients with ophthalmologists. It outlines the benefits of co-management including practice growth and expanded knowledge. It provides guidance on pre-operative evaluation, post-operative exams up to one month, and potential complications to monitor for at each visit such as intraocular pressure spikes, corneal edema, inflammation, and visual outcomes. Regular follow-up is important to identify and manage issues that could impact the surgical results.

1. Cataract Co-management from the Optometric perspective R. Fernando Auza, O.D. Visionary Ophthalmology Bethesda, MD

2. OD/MD Cataract Co-ManagementWhy? Expansion of patient variety and opportunity for practice growth Educational process that expands your knowledge Opportunity to become an expert With development of Multifocal/Toric IOL’s, Cataract Surgery has evolved into “Refractive Cataract Surgery” Potential for added revenue through premium IOL co-management 50+ market is expected to grow seven times faster than any other segment OD’s play an integral role in selecting and recommending IOL

3. Before referring your patient to a Cataract surgeon Discontinue Contact Lens wear two to three weeks in advance so that axial length and keratometry measurements are accurate for precise IOL calculation. RGP’s Soft lenses with low dK/t Patients on Extended Wear Contac Lenses

4. Careful evaluation of Ocular Surface Management of surface disease will improve final visual outcome Tear dysfunction syndrome Lid margin disease

5. Evaluation of Ocular Surface Map-dot-fingerprint dystrophy

6. Post Op – Day 1 History – Problem focused Exam VA – Usually should be 20/40 or better Anterior Segment Exam Corneal Surface/Stroma Anterior chamber inflammation Lens centration and PCO IOP Plan – Medications – Antimicrobial/Anti-inflamatorytherapy Zymar or Vigamox/Xibron/Prednisolone 1% t.i.d. Follow up visit – three weeks/sooner PRN

7. Potential complications one day after surgery IOP Spike BollousKeratopathy Decentered/Dislocated/Rotated Toric IOL Tilted Lens Peaked pupil – vitreous prolapse Retained lens fragments RD

8. Post-Op Visit Two – Two to three weeks after surgery Problem focused history Exam VA Anterior segment Ocular Surface/Cornea Anterior changer Lens centration – crucial with multifocal IOL Axis location – must dilate toric IOL’s IOP – Inflammation/Steroid Responders Refraction Medications – Discontinue antimicrobials. Tapper off steroids and NSAID if A/C quite. Continue steroid/NSAID therapy if necessary Follow up visit – one month

9. Complications at week at second post-op visit Poor visual outcome – must investigate Previous pathology? Front to back approach Ocular Surface- (not a post-operative complication) Dry eye MGD EBMD

10. Corneal Edema/Bollous Keratopathy Endothelial dysfunction Persistent A/C reaction Treat with steroids and Muro 128 ung or sol. Keep IOP low

11. Severe Iritis - Must Investigate May just take longer to resolve in some patients History of previous iritis/autoinmune disease Irido-Lenticular contact if IOL tilted Can affect VA May have to reposition IOL

12. IOL outside capsular bag inferiorly

13. Persistent Iritis - Continued Retained Lens Fragments If iritis is persistent – must perform carefull DFE looking for small fragments Fragments may be within the capsular bag

14. Posterior Capsular Opacity Treat early PCO greatly affects VA and contrast sensitivity specially with multifocal IOL’s Decentered/Dislocated Surgeon will have to reposition IOL

15. Cystoid Macular Edema More common in diabetics Sub-Clinical CME may be difficult to detect without OCT or Fluorescein angiography

16. Post Operative Epiretinal Membrane Incidence - 22% - only 3.6% visually significant Visually insignificant ERM also known as Cellophane Macular Reflex Visually Significant ERM – Maculr Pucker

17. Post-Operative Endophthalmitis Incidence 0.1% Patient present with pain, photophobia, floaters, reduced vision, an inflamed anterior segment including a variable hypopyon, and vitritis May present four to seven days after surgery