Practicing Ophthalmologists Curriculum Cataract/Anterior Segment

292 Pages·2014·2.05 MB·English

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P R A C T I C I N G O P H T H A L M O L O G I S T S
C U R R I C U L U M 2 0 1 4 - 2 0 1 6
Cataract/
Anterior
Segment
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Cataract/Anterior Segment 2 © AAO 2014-2016
Practicing Ophthalmologists Curriculum
Disclaimer and Limitation of Liability

As a service to its members and American Board of Ophthalmology (ABO) diplomates, the American
Academy of Ophthalmology has developed the Practicing Ophthalmologists Curriculum (POC) as a tool
for members to prepare for the Maintenance of Certification (MOC) -related examinations. The
Academy provides this material for educational purposes only.
The POC should not be deemed inclusive of all proper methods of care or exclusive of other methods of
care reasonably directed at obtaining the best results. The physician must make the ultimate judgment
about the propriety of the care of a particular patient in light of all the circumstances presented by that
patient. The Academy specifically disclaims any and all liability for injury or other damages of any
kind, from negligence or otherwise, for any and all claims that may arise out of the use of any
information contained herein.
References to certain drugs, instruments, and other products in the POC are made for illustrative
purposes only and are not intended to constitute an endorsement of such. Such material may include
information on applications that are not considered community standard, that reflect indications not
included in approved FDA labeling, or that are approved for use only in restricted research settings. The
FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or
device he or she wishes to use, and to use them with appropriate patient consent in compliance with
applicable law.

The Practicing Ophthalmologists Curriculum is intended to be the basis for MOC examinations in 2014,
2015 and 2016. However, the Academy specifically disclaims any and all liability for any damages of any
kind, for any and all claims that may arise out of the use of any information contained herein for the
purposes of preparing for the examinations for MOC.

THE AMERICAN ACADEMY OF OPHTHALMOLOGY DOES NOT WARRANT OR GUARANTEE THAT USE OF
THESE MATERIALS WILL LEAD TO ANY PARTICULAR RESULT FOR INDIVIDUALS TAKING THE MOC
EXAMINATIONS. THE AMERICAN ACADEMY OF OPHTHALMOLOGY DISCLAIMS ALL DAMAGES, DIRECT,
INDIRECT OR CONSEQUENTIAL RELATED TO THE POC.

Any questions or concerns related to the relevance and validity of questions on the MOC
examinations should be directed to the American Board of Ophthalmology.

COPYRIGHT © 2014
AMERICAN ACADEMY OF OPHTHALMOLOGY
ALL RIGHTS RESERVED

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Practicing Ophthalmologists Curriculum
Authors and Financial Disclosures
The Practicing Ophthalmologists Curriculum was developed by a group of dedicated ophthalmologists
reflecting a diversity of background, training, practice type and geographic distribution.

Jeffrey A. Nerad, M.D., American Academy of Ophthalmology Secretary for Knowledge Base
Development, serves as the overall project director for the acquisition and review of the topic outlines.

The Academy gratefully acknowledges the contributions of the American Society for Cataract and
Refractive Surgery.

Practicing Ophthalmologists Curriculum Panel
James T. Banta, M.D., Chair
Devin M .Gattey, M.D.
Thomas M. Harvey, M.D.
Cathleen M. McCabe, M.D.
Thomas A. Oetting, M.D.
Roberto Pineda II, M.D.
Stephen K. Sauer, M.D.
Richard Tipperman, M.D.

Financial Disclosures
The Academy’s Board of Trustees has determined that a financial relationship should not restrict expert
scientific clinical or non-clinical presentation or publication, provided appropriate disclosure of such
relationship is made. All contributors to Academy educational activities must disclose significant
financial relationships (defined below) to the Academy annually.

Contributors who have disclosed financial relationships:
Thomas M. Harvey, M.D.
Consultant/Advisor: Alcon Laboratories, Inc., Lenstec, Inc.
Lecture Fees: Merck & Co., Inc.
Equity Owner: TLC Laser Eye Centers
Cathleen M. McCabe, M.D.
Consultant/Advisor: Bausch Lomb
Lecture Fees: Alcon Laboratories, Inc., Bausch Lomb
Roberto Pineda II, M.D.
Consultant/Advisor: Amgen, Angiotech/Sharpoint
Richard Tipperman, M.D.
Consultant/Advisor: Alcon Laboratories, Inc., Marco

The following panel members have no significant financial relationships to disclose:
James T. Banta, M.D.
Devin M .Gattey, M.D.
Jeffrey A. Nerad, M.D.
Thomas A. Oetting, M.D.
Stephen K. Sauer, M.D.

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Background on Maintenance of Certification (MOC)

Developed according to standards established by the American Board of Medical Specialties (ABMS), the
umbrella organization of 24 medical specialty boards, Maintenance of Certification (MOC) is designed as
a series of requirements for practicing ophthalmologists to complete over a 10-year period. MOC is
currently open to all Board Certified ophthalmologists on a voluntary basis; time-limited certificate
holders (ophthalmologists who were Board Certified after July 1, 1992) are required to participate in this
process. All medical specialties participate in a similar process.

The roles of the American Board of Ophthalmology (ABO) and the American Academy of Ophthalmology
relative to MOC follow their respective missions.

The mission of the American Board of Ophthalmology is to serve the public by improving the quality of
ophthalmic practice through a process of certification and maintenance of certification that fosters
excellence and encourages continual learning.

The mission of the American Academy of Ophthalmology is to advance the lifelong learning and
professional interests of ophthalmologists to ensure that the public can obtain the best possible eye care.

The role of the ABO in the MOC process is to evaluate and to certify. The role of the Academy in this
process is to provide resources and to educate.

Background on the Practicing Ophthalmologists Curriculum (POC)
At the request of the ABO, the Academy developed the Practicing Ophthalmologists Curriculum (POC), a
knowledge base that identifies and defines areas of knowledge important to the delivery of quality eye
care as a basis for the content of examinations for the MOC process. The content in the POC is
comprised of the information deemed as the most relevant clinical information for a practicing
ophthalmologist.

The ABO has agreed that their Periodic Ophthalmic Review Test (PORT) and closed-book Demonstration
of Ophthalmic Cognitive Knowledge (DOCK) examinations will be based on the POC. The ABO is solely
responsible for creating the PORT and DOCK exams and for certifying MOC candidates. The Academy has
developed study tools based on the POC to assist doctors preparing to meet these MOC requirements.

Organization of the POC
The Practicing Ophthalmologists Curriculum comprises 10 practice emphasis areas (PEA), plus Core
Ophthalmic Knowledge. The ABO has designated the following as practice emphasis areas:
• Comprehensive Ophthalmology
• Cataract/Anterior Segment
• Cornea/External Disease
• Glaucoma
• Neuro-Ophthalmology and Orbit
• Oculoplastics and Orbit
• Pediatric Ophthalmology/Strabismus
• Refractive Management/Intervention
• Retina/Vitreous
• Uveitis

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In addition to two practice emphasis areas of choice, every diplomate sitting for the DOCK examination
will be tested on Core Ophthalmic Knowledge. Core Ophthalmic Knowledge is defined as the
fundamental knowledge every practicing ophthalmologist must have whatever their area of practice.

Each PEA is categorized into topics presented in an outline format for easier reading and understanding
of the relevant information points by the reader. These outlines are based on a standard clinical
diagnosis and treatment approach found in the Academy’s Preferred Practice Patterns.

For each topic, there are Additional Resources that may contain journal citations and reference to
textbooks. These resources are supplemental to the topic outline, and should not be necessary for MOC
exam preparation purposes.

Creation of the POC
The POC was developed by panels of practicing ophthalmologists in each of the ten practice emphasis
areas. The panels reflect a diversity of background, training, practice type and geographic distribution,
with more than 90 percent of the panel members being time-limited certificate holders.

The panels ranked clinical topics (diseases and procedures) in terms of clinical relevance to the
subspecialist or comprehensive ophthalmologist. The panelists created outlines for the topics deemed
Most Relevant, based on what an ophthalmologist in a specific practice emphasis area needs to know to
provide competent, quality eye care (i.e., directly related to patient care). These outlines were reviewed
by subspecialty societies and the American Board of Ophthalmology.

Revision Process
The POC is intended to be revised every three years. The POC panels will consider new evidence in the
peer-reviewed literature, as well as input from the subspecialty societies, the American Board of
Ophthalmology and the Academy’s Self-Assessment Committee, in revising and updating the POC.

Prior to a scheduled review the POC may be changed only under the following circumstances:
• A Level I (highest level of scientific evidence) randomized controlled trial indicates a major
new therapeutic strategy
• The FDA issues a drug/device warning
• Industry issues a warning

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Cataract/Anterior Segment
Diagnostic Tests
1. Evaluation of reduced vision not fully explained by degree of cataract ...........................12
2. Estimation of intraocular lens power ................................................................................14
3. Evaluation of glare disability: subjective and objective .....................................................17
Anterior Segment Disorders
4. Anterior basement membrane dystrophy (ABMD) (map-dot-fingerprint corneal dystrophy or
Cogan microcystic corneal epithelial dystrophy) ...................................................................19
5. Iridodialysis ........................................................................................................................22
6. Pterygium ...........................................................................................................................24
7. Lens-induced glaucoma - phacolytic ..................................................................................30
8. Lens-induced glaucoma - lens particle ...............................................................................33
9. Lens-induced glaucoma - phacomorphic ...........................................................................36
10. Traumatic cataract ...........................................................................................................38
Types of Cataracts
11. Anterior polar cataracts ...................................................................................................42
12. Posterior polar cataracts ..................................................................................................44
13. Ectopia lentis ....................................................................................................................46
14. Nuclear cataracts .............................................................................................................49
15. Intumescent cortical cataract ..........................................................................................51
16. Hypermature cataract ......................................................................................................53
17. Morgagnian cataract ........................................................................................................56
18. Posterior subcapsular cataracts .......................................................................................58
19. Traumatic dislocation and subluxation ............................................................................60

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20. Diabetes mellitus and cataract formation .......................................................................63
21. Cataract associated with uveitis ......................................................................................66
22. Perforating and penetrating injury of the lens ................................................................69
Anesthesia/Infection Prophylaxis/Viscosurgical Devices
23. General anesthesia ..........................................................................................................71
24. Retrobulbar anesthesia ....................................................................................................74
25. Peribulbar anesthesia ......................................................................................................77
26. Sub-Tenon anesthesia ......................................................................................................80
27. Topical/intracameral anesthesia .....................................................................................83
28. Infection prophylaxis .......................................................................................................86
29. Ophthalmic viscosurgical devices ....................................................................................89
Surgical Techniques/Instrumentation
30. Incision construction (limbal, scleral pocket, clear corneal) ...........................................93
31. Astigmatic keratotomy - peripheral corneal (limbal) relaxing incisions ..........................98
32. Extracapsular cataract extraction ....................................................................................101
33. Ultrasound - clinical principles .........................................................................................105
34. Phacoemulsification fluidics ............................................................................................108
35. Anterior capsulotomy - capsulorrhexis and can opener .................................................111
36. Hydrodissection and hydrodelineation ...........................................................................114
37. Phacoemulsification techniques - nuclear removal .........................................................116
38. Capsule staining ...............................................................................................................118
39. Clear lens extraction - refractive lensectomy ..................................................................120
Intraocular Lenses/IOL implantation
40. Intraocular lens material and design ...............................................................................122

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41. Toric intraocular lenses (IOLs)..........................................................................................128
42. Intraocular lens calculation following refractive surgery ................................................130
43. Special cases: primary piggy-back lenses .........................................................................133
44. Special cases: secondary piggy-back lenses .....................................................................135
45. Posterior chamber intraocular lens implantation ...........................................................137
46. Special cases: ciliary sulcus fixation and capsulorhexis capture of posterior chamber
intraocular lenses ...................................................................................................................140
47. Special cases: sutured posterior chamber intraocular lens implantation .......................144
48. Anterior chamber intraocular lens implantation .............................................................148
49. Special cases: secondary intraocular lens implantation ..................................................150
50. Intraocular lens implantation in children ........................................................................154
51. Presbyopic correcting intraocular lenses (IOLs) ..............................................................158
Intraoperative Complications
52. Intraoperative shallowing of the anterior chamber ........................................................161
53. Incisional thermal injury or "phaco burn" .......................................................................164
54. Detachment of Descemet membrane .............................................................................167
55. Toxic anterior segment syndrome (TASS) ........................................................................169
56. Retrobulbar hemorrhage .................................................................................................173
57. Suprachoroidal hemorrhage ............................................................................................175
58. Surgical trauma - hyphema ..............................................................................................177
59. Microscope induced light toxicity ....................................................................................179
60. Postoperative elevated intraocular pressure ..................................................................181
61. Intraoperative signs of posterior capsular rupture .........................................................183
62. Errant continuous curvilinear capsulorrhexis rescue and management .........................186

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63. Intraoperative management of dropped nucleus ...........................................................189
64. Intraoperative management of iris prolapse ...................................................................191
65. Management of intraoperative vitreous loss ..................................................................193
Postoperative Complications
66. Postoperative shallow or flat anterior chamber..............................................................196
67. Corneal complications of phacoemulsification and intraocular lenses ...........................199
68. Cystoid macular edema ...................................................................................................202
69. Retinal detachment (complication of cataract surgery) ..................................................206
70. Endophthalmitis (complication of cataract surgery) .......................................................208
71. Corneal melting with ocular surface disease (complication of cataract surgery) ...........213
72. Wound leak or filtering bleb (complication of cataract surgery) ....................................216
73. Iridodialysis (complication of cataract surgery) ...............................................................219
74. Aqueous misdirection (malignant glaucoma) ..................................................................221
75. Delayed postoperative inflammation after cataract surgery ..........................................224
76. Vitreous incarceration in wound .....................................................................................227
77. Induced astigmatism (complication of cataract surgery) ................................................229
78. Pupillary capture (complication of cataract surgery) ......................................................231
79. Undesired optical images associated with intraocular lens implants .............................233
80. Posterior capsule opacification ........................................................................................235
81. Anterior capsule fibrosis and phimosis ............................................................................238
82. Neodymium yttrium-aluminum-garnet (Nd:YAG) laser posterior capsulotomy .............240
83. Intraocular lens decentration and dislocation .................................................................244
84. Incorrect intraocular lens power .....................................................................................247
Cataract Surgery in Special Situations

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