Cataract/Anterior Segment
Conference Roundup

Removing Cataracts After Previous Refractive Surgery

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Microincision cataract surgery is the best option when removing cataracts in patients who have had prior excimer last surgery, noted Jorge L Alio, MD, PhD, chairman of ophthalmology at the Instituto Oftalmologico de Alicante in Alicanta, Spain, during the American Academy of Ophthalmology’s 2018 annual meeting in Chicago. 

With the prevalence of excimer laser procedures, chances are you will encounter such patients when they ultimately require cataract surgery. It is important to conduct a complete preoperative exam, including corneal topography, aberrometry, and biometry. Additionally, use advanced methods of IOL power calculation. New technology such as corneal tomography and corneal ray tracing can help measure the corneal power changes following excimer laser surgery. 

Still, refractive surprises and patient dissatisfaction are bound to occur. Thus, be sure to set patient expectation preoperatively. In fact, between 60% and 70% of eyes can be expected to have an absolute prediction error within 0.5 diopters. That means a prediction error outside that range may occur in ~one-third of patients. “Patients should always be advised that a prediction error in refraction can occur in these cases, even with the most advanced technologies,” said Dr Alio. 

In a related presentation, Rafael I. Barraquer, MD, PhD, chairman of ophthalmology at the International University of Catalonia in Barcelona, provided postoperative management tips for cataract surgery patients who previously had refractive surgery. In general, he explained, treatment does not differ significantly from standard cases. Still, there are a few special considerations: 

  • Patients who previously had radial keratotomy may experience refractive fluctuations, mostly due to hydration changes and biomechanical instability. Thus, monitor intraocular pressure (IOP) and treat if elevated. Also, suggest that the patient use a hypertonic solution and ointment at bedtime to control excessive hydration. 
  • In patients who previously had PRK/LASIK, compensate IOP measurements for thin cornea, and treat accordingly. 
  • Patients who previously had phacoemulsification and IOL explantation may need more intense anti-inflammatory cover, closer IOP control, and hypertonic solutions to control transient corneal edema. This is particularly true if rigid anterior chamber IOLs are explanted. 

Alio J, Barraquer R. Surgical keys for successful cataract surgery after previous refractive surgery. Talk presented at: AAO 2018 annual meeting; October, 26-30, 2018; Chicago. 

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