Special Considerations for Cataract Surgery in the Face of Pathologic Myopia
Cataract surgery in eyes with high myopia is a special situation. Careful preoperative, perioperative, and postoperative planning is mandatory. This chapter discusses epidemiology, risk evaluation, intraocular lens calculations, appropriateness for premiu
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Jack M. Dodick and Jonathan B. Kahn
21.1
Introduction
Modern-day, small-incision cataract surgery by phacoemulsification enjoys a high success rate and safety profile. Eyes with axial myopia present special considerations and increased risks in cataract surgery that require careful planning and management by the cataract surgeon. All aspects of the cataract surgery require special attention, including preoperative planning, surgical techniques, and postoperative care.
21.2
Epidemiology
Few population-based studies have attempted to generate a link associating myopia and cataract. The cross-sectional association between myopia and nuclear cataract was supported by data from the Beaver Dam Eye Study. In that study, myopia was not directly linked to cataract formation but rather to incident cataract surgery (odds ratio, OR 1.99) [1]. The Blue Mountains Eye Study found a statistically significant association between high myopia (−6.0 diopter (D) or less) and incident nuclear cataract (OR 3.3). Moderate and high myopia (−3.5 D or less) was also associated with posterior subcapsular cataract (OR 4.4). The high myopia group had the highest incidence of cataract surgery (OR 3.4) among all groups. Furthermore, it was found that early onset myopia (before age 20 years) was a strong and independent risk factor for posterior subcapsular cataract. A dose response relationship was suggested between levels of myopia and posterior subcapsular cataract. High myopia was associated with all types of cataract [2, 3].
J.M. Dodick, MD (*) • J.B. Kahn, MD Department of Ophthalmology, New York University School of Medicine, 462 First Avenue, NBV 5N18, New York, NY 10016, USA e-mail: [email protected]; [email protected]
21.3
Preoperative Planning
The cataract surgeon must perform a careful preoperative assessment, often in conjunction with the vitreoretinal specialist. The preoperative evaluation should be meticulous and methodical to ensure completeness and appropriate preparedness. The first step in the preoperative evaluation is a careful ophthalmic history. Previous surgery of either eye should be identified. Patients may have undergone cataract surgery in the fellow eye, in which case any surgical or postoperative complications, such as retinal detachment or refractive surprise, should be discovered. Appropriate precautions or modifications in calculations and technique could then be undertaken to avoid future surgical complications. Patients who have had refractive surgery in one or both eyes should describe their previous refractive status and current refractive goals. For example, some patients may strongly prefer monovision or wish to avoid it completely, depending on previous experiences and the outcomes of prior refractive surgery. Other patients may report a history of refractive re-treatments, which are not uncommon in high myopia. In any case, the full refractive records must be sought and evaluated prior to cataract surgery [4]. Specific considerations for intraocular lens calculations in eyes with prev
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