Managing Complex Cases
By Araliya Gunawardene, BS, MS
Key Takeaways:
Cataract Surgery Post-Vitrectomy: Careful techniques, like using capsular tension rings and maintaining chamber depth, are essential to avoid stressing the zonules and ensure successful outcomes.
Non-Healing Corneas: Treatment strategies depend on the underlying cause and may include preservative-free tears, serum drops, amniotic membranes, and emerging therapies.
Glaucoma Progression: Long-term trend analysis using multiple tools, including fundus photography, OCT, and visual field tests, is crucial for monitoring progression and managing patients effectively.
“Managing Complex Cases” was a session held at the Spring RWO virtual meeting “Tell Me Your Secrets” in April 2024. Moderated by Dr. Leslie Jones and Dr. Alomi Parikh, speakers discussed different ocular regions and the unique challenges that may conjoined. Difficult cataract challenges, non-healing corneas, ocular surface damage risks, glaucoma progression, geographic atrophy, and stubborn blepharitis were discussed in this session.
Complex Cataract Surgery
The session started off with Dr. Josh Teichman discussing how to tackle cataract surgery after a vitrectomy. Dr. Teichman offered salient advice when patients have zonulopathies. He advices to use a capsular tension ring, hydrodissect without stressing the zonules, and chop gently. For capsule breaches, treat them like a posterior polar cataract. Overall, treat every step with respect, never let the AC become shallow, and be kind to existing zonules.
Non-healing Cornea
For the non-healing cornea, Dr. Nadia Hadiqqe encourages us to understand what the etiology may be. Treatment may vary depending on whether epithelial disease, inflammation, or neurotrophic causes may be at play, for example. Medical management options are vast and may include frequent use of preservative-free artificial tears, oral antibiotics, bandage contact lens with high O2 permeability, steroid drops, topical immunomodulators, serum tears, amniotic membrane, glue with BCL, patch graft/keratoplasty, or tarsorrhaphy. Keep your eye out for human mesenchymal stem cell secretome on the horizon.
Oncologic Therapy and the Ocular Surface
The ocular surface may also be at danger when patients are using oncologic therapeutics, says Dr. Laura Periman. Ocular surface adverse events with antibody-drug conjugates may occur and are highly variable. Patients may experience blurred vision, tearing, photophobia, and pain due to epithelial changes, microcystic changes, or even limbal stem cell dysfunction. Pathophysiology is uncertain, but these ADCs seem to have a dose and duration dependent fashion and may resolve with discontinuation.
Managing Glaucoma
Dr. Nina Goyal offered insight into signs of glaucoma progression and urged to not rely on IOP or isolated imaging. Rather, it is critical to observe several years of trends using fundus photography, optical coherence tomography, and the holy grail, visual field tests. It may be also worthwhile to obtain baseline imaging for patients at risk of developing glaucoma (i.e. family history of glaucoma).
Geographic Atrophy
Dr. Joe Nezgoda discussed geographic atrophy (GA), an advanced form of age-related macular degeneration that involves the progressive loss of retinal pigment epithelium (RPE) cells in the macula. Pathophysiology involves chronic inflammation due to overactivation of the complement system that leads to the loss of photoreceptors, RPE and the underlying choriocapillaris. The disappearance of these structures appears as sharply demarcated atrophic lesions that are typical of GA. The best imaging to show GA is OCT, which will show loss of outer retinal layers, and autofluorescence with hypo-autofluorescent areas corresponding to regions of RPE atrophy and outer retinal loss. Finally, best-corrected visual acuity does not correlate well with GA lesions or progression, but rather the enlargement rate of GA lesion area and drusen changes.
Severe Blepharitis
Dr. Alison Early, consultant for Tarsus, presented a fascinating case of severe blepharitis. Typical treatments generally include baby shampoo, lid scrubs, hypochlorous acid spray, topical/oral antibiotics, tea tree oil, and topical metronidazole, all of which tend to have variable effects. Xdemvy, a lotilaner ophthalmic solution 0.25% and GABA-gated chloride channel inhibitor selective for mites, targets collarettes, a sign of Demodex blepharitis. Patients of Dr. Early use Xdemvy 2x/day for 6 weeks and have seen incredible results.
Conclusion
The panelists left off with some great advice when trying to navigate complex cases as an attending. Look to senior residents who you trained with, providers you meet at meetings or your local county eye society, and mentors. Ultimately, the goal is to help patients so don’t hesitate to reach out for guidance.
Register for the next RWO Virtual Meeting on Saturday, April 26, 2025. Registration is free for all young ophthalmologists! This is an excellent opportunity to connect with peers, learn from experts, and enhance your understanding of key topics in ophthalmology. Save the date and secure your spot today!
Araliya Gunawardene, BS, MS
Araliya joined the RWO writing and communications team in the spring of 2024. She is a 4th-year medical student at Nova Southeastern University (NSU MD) in Fort Lauderdale, FL. She has a master’s in nutrition from Columbia University and completed a one-year research fellowship in cornea at Bascom Palmer Eye Institute. Araliya enjoys cooking, surfing, and studying theology in her free time.