Zaina Al-Mohtaseb, MD, introduced the “Cataract Crossover” symposium, which she described as looking at cataract surgery through the subspecialist’s eyes. The session covered cataract surgery in patients with oculoplastic disease, neuro-ophthalmic disease, glaucoma disease, retinal disease, and corneal disease.
Seanna Grob, MD, discussed where cataract surgery and oculoplastics meet.
The eyelids and orbit are protectors of the globe, she said. The eyelids have a huge impact on the eye and the ocular surface. Lacrimal drainage and orbital disease also have significant impact. “When I look back to when I was doing cataract surgery, the anatomy around the eye can have a huge impact on your surgical experience,” Dr. Grob said, adding that things like prominent brow or deep-set eyes can make surgery more challenging, especially for new learners.
She went on to discuss several specific oculoplastics issues and cataract surgery: ptosis or eyelid irregularity and astigmatism, facial nerve palsy, thyroid eye disease, retrobulbar tumor and hyperopia, and tear drainage obstruction.
Ptosis: If significant, it may affect IOL calculation preoperatively, Dr. Grob said, adding that it’s also known to occur postoperatively following eye surgery.
She mentioned a study in an oculoplastics journal that looked at changes in corneal astigmatism after ptosis surgery. The mean axial change of corneal astigmatism was 17.4 degrees after blepharoptosis surgery, and with severe blepharoptosis, the average was 22.7 degrees.
Postoperatively, the incidence of postop ptosis after ocular surgery can range from less than 5% to up to 30%.
If there is significant ptosis and you’re concerned about accurate IOL calculations, Dr. Grob said to consider a referral prior to surgery. She also said to discuss the risk of ptosis after surgery.
Facial nerve palsy: This can complicate cataract surgery due to eyelid dysfunction, poor blink, lagophthalmos, and corneal exposure. This may affect IOL calculations and postop healing.
Dr. Grob said these patients must be monitored closely, and you might want to consider lubrication and whether the function may return of the facial nerve. She suggested referring for consideration of eyelid surgery to improve eyelid closure and corneal exposure.
Other eyelid malpositions to consider could include entropion, ectropion, retraction, and floppy eyelid syndrome.
Thyroid eye disease: Cataract surgery or other periocular procedures can worsen thyroid eye disease, Dr. Grob said. Care must be taken to identify patients with thyroid eye disease and still in active phase of disease prior to surgical intervention. Ask about any history of thyroid disease to help identify patients at risk.
Aggravation of thyroid eye disease has been reported in association with onabotulinumtoxin A, filler, medication, ocular surgery, strabismus surgery, decompression, retrobulbar anesthesia, facelift, and forehead lift.
Consider delaying cataract surgery in high-risk patients, especially when patients are still in the active phase of disease.
Retrobulbar tumor and hyperopia: A tumor posterior to the globe can place pressure on the globe, causing hyperopia, Dr. Grob said, adding that vision can also be affected by choroidal folds.
It’s important to know that some of the findings don’t actually resolve after you’ve taken the tumor out, and it can be unmasked after cataract surgery if they have a bad cataract.
Tear drainage dysfunction: The nasolacrimal duct may pose a risk of infection if there is acute infection or poor tear drainage. Dr. Grob added that excessive tearing may affect the patient’s clinical exam due to blurry vision.
She concluded by stressing that periocular conditions can have significant impacts on cataract surgery, and the eyelids need to be well-positioned to do their job since they are the “protectors of the globe.”
Relevant disclosures
Grob: None
