Treatment options for unstable lens patients

A new field of treatment for patients who cannot have standard cataract surgery was discussed when Louisa Wickham took to the Main Stage at 100% Optical 2024 (24–26 February).

The session, entitled Management options for the unstable lens - a vitreoretinal perspective, sought to introduce practitioners to management of “patients who have complex lens requirements that don’t allow them to have standard cataract surgery, or indeed those patients who have had standard cataract surgery, and then develop problems such that we can't use the capsular support anymore,” Wickham said.

The aim was to “highlight symptoms and signs of patients who would require surgery referral from optometry to specialist hospital eye services,” she added.

Wickham presented under her role as medical director for Moorfields Eye Hospital. She is also national clinical director for eye care at NHS England.

She began the session by discussing the symptoms that patients with unstable lenses might present with.

These symptoms could include vision changes in different lighting conditions, monocular diplopia, eye pain, raised interocular pressure, corneal decompensation, uveitis, and/or retinal tears.

Other details in the patient history, for example trauma or genetic conditions would also help determine whether standard cataract surgery might not be possible, Wickham advised.

She also noted that a patient could be asymptomatic. “You may find that they have come to you for a standard eye examination, and it is only when perhaps you have dilated the patient that you begin to see that their lenses aren’t in a stableposition,” Wickham said. “Patients can tolerate quite a substantial dislocation in their lens before they begin to get symptomatic, particularly if they have a small pupil,” she emphasised, adding: “As long as the optic of the lens remains on the visual axis for most of the time, they may not notice a dislocation at all.”

Assessment of the unstable lens patient

Practitioners should first assess why the patient has an unstable lens, Wickham said.

This could potentially be down to genetics, trauma, complicated previous cataract surgery, or dislocation of a lens implant.

“One of the main histories that you should try and elicit from a patient is, have they had any trauma? That could be trauma in the sense of an injury, but it also could be trauma in terms of surgery. For example, something like cryotherapy for retinal detachment, obviously is very well applied for, but it is still trauma, nonetheless,” Wickham said.

She added: “Any form of trauma, whether it be medical or otherwise, is important to understand. Have they had cataract surgery in the past, and what was it like? Was it complicated cataract surgery, or was it straightforward?”

Wickham emphasised that a patient might not know whether their cataract surgery was complicated, so some digging in order to establish the details might be needed.

She advised that, “sometimes there is a little bit of investigation that has to be done to understand whether or not cataract surgery was completely routine or whether something was just a little bit unusual.”

“It is important in these patients that when you do recognise that the lens is dislocated, you cross-check for a number of other features that are going to indicate to you whether or not this patient requires an urgent referral, routine referral or whether this could be managed conservatively initially by you in the community,” Wickham said.

Key factors that would cause a referral into the hospital eye service were identified as:

• Raised interocular pressure (IOL)
• Co-existing ocular pathology, for example glaucoma or high myopia
• Age, mobility and lifestyle
• Unstable anterior segment, potentially due to a mobile anterior chamber intraocular lens or an anterior lens dislocation
• Recurrent uveitis
• Pupil block, with raised IOP
• Corneal decompensation
• Retinal tears and/or retinal detachment.

“If you’re seeing corneal decompensation, and you suspect it is as a result of an unstable lens, we would recommend an early and urgent referral, because by taking the lens out, even if we don’t put another lens in, that is sufficient to stop that process from progressing,” Wickham said.

She added that surgical decision making for secondary IOL should include consideration of a number of patient factors such as the patient’s corneal health,the role of contact lenses rather than secondary lens insertion, and that practitioners should also consider whether secondary IOL would improve the quality of their vision.

“Just because we can operate, doesn’t mean we actually should operate,” she said.

Wickham emphasised that whether the patient understands and accepts the risks included in surgery should also be established.

“These are some of the signs that it will be useful to look for in a patient, just so that you can understand the whole picture and what the potential treatment options for them are,” Wickham noted.

“It’s important to understand the patient themselves. What are their lifestyle choices? Certain lens types will be more appropriate for certain age groups, and for certain lifestyles and degree of mobility. When we’re trying to assess patients for their lens choices going forward, it’s quite important to understand these aspects too,” she added.

 
Surgery choices have changed a lot over the past 10 years, Wickham emphasised, and it is important to understand that this is an evolving field.

“Not all surgeons have learned a number of different techniques to deal with these patients,” she noted. “The number of different techniques that exist also have different learning curves, and have different skill sets required to learn. What you may find is that some surgeons will predominantly deal with one type of lens type, others will deal with another.

“Understanding that is useful, because if you have someone who is very keen and interested in it, they will probably have a whole load of techniques that they can offer.”

She added: “None of the current lenses that we have are perfect. There is no one perfect lens that deals with all the situations that you find in this quite complex group of patients.”

Wickham went on to share video clips demonstrating various surgery options, along with the decision tree that she uses to decide on initial treatment options and whether the patient needs further surgery.

She ended the session by offering a note of caution.

There is not yet any high-level evidence or long-term data as to the relative merits of any technique, Wickham acknowledged, largely because some of the lenses have only been around for 10 or 15 years – there is only experiential advice.

When making an assessment, optometrists should “have a degree of caution, and that caution needs to be conveyed to our patients,” Wickham said.

Optometrists can emphasise that this is a very good treatment, she said, but the patient should be aware that they might need a replacement in 20 years’ time.

“It’s not just the case that all patients will benefit from the same type of lenses, and not all surgeons will be embracing the fact that you do need different types of lenses for different types of patient characteristics,” Wickham said.

She continued: “It is probably worth understanding who in your area likes to do this kind of surgery. It is almost exclusively vitreoretinal surgeons, because we need to go to the back of the eye, although there are some anterior segment surgeons who also work in this space.”

The preferred technique of the surgeon is key, she said, adding: “It’s important that surgeons are seen to be sharing that knowledge across the department, because not everyone will be suitable for some of the lenses.”

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After her session, OT spoke to Louisa Wickham about the subject of vitreoretinal surgery for the unstable lens patient.

 

What do you hope that optometrists who are practising the community take away from this session?

I’m hoping that after the session, optometrists will be able to recognise patients who can’t otherwise have standard cataract surgery, and understand the routes for referral for those patients.

What are the red flags that you would advise optometrists from the community to look for when they are deciding whether to make a referral?

I think the most important ones are raised intraocular pressure, a drop in vision, and signs of inflammation and corneal decompensation.

When optometrists are making the referral, are there any key things that they should include?

What I was trying to get across today is the complexity that these patients often represent, in that they rarely come with no other past medical, family or social history. For me, one of the key aspects of referral, because optometrists are so well placed to understand the full history for patient, is to provide that full history, and that richer context of what has gone on. It’s a little bit investigative, with these patients.

Do you have any advice on what sort of questions should be asked?

Sometimes open-ended questions, such as ‘what has happened to your eye before?’ can allow patients to surface everything. And also then to move on purely from the eye and talk more broadly about it: have they had any accidents?

Sometimes patients will tell you, ‘no, I have had no trauma to the eye,’ and then you’ll find that actually, they played professional rugby for 10 years, and they constantly had elbows in their eye. They don’t really associate that with having a trauma. So, it’s asking those probing questions, to figure out a little bit about why they’ve ended up in this position.

Do you have a strong relationship with community optometry through your Moorfields role?

Recently, we set up a single point of access with our organisational partners across North Central London. Part of that has includedincreased communication with local optometrists. What we have seen, by enhancing communication and by ensuring that we have two-way communication, is that we have improved referrals. That has allowed us to better place patients in the right clinics. That has then led to significant decreases in terms of referrals to treatment times for patients. Emphasising how we communicate with optometry colleagues is fundamental to patient care.

You spoke about this as a development in lens technology, and the techniques to manage these cases. Do you see a lot of development in that area in the near future?

Yes, I hope so. One of the things I was trying to explain today was, we haven’t got a lens that addresses all the needs of our complex group of patients. I hope that this field will continue to innovate and that we will continue to see adaptations, and new lenses coming through, as the industry recognises that there is a group of patients who really do need the wider option of lenses available to them.

I hope that this field will continue to innovate and that we will continue to see adaptations, and new lenses coming through, as the industry recognises that there is a group of patients who really do need the wider option of lenses available to them

Could you tell me about the pioneering work going on via Moorfields Private Hospital in terms of technological development?

I think the first thing to emphasise is that the techniques I’ve showed today are available to all patients, regardless of whether they are NHS patients or private patients.

Within Moorfields Private, we have the opportunity to access existing and new lenses more quickly as they come to market.

In some cases, there are compensation schemes where patients can be allowed to have their lenses replaced with the cost covered, depending on what the lens manufacturer or the surgeon has agreed. Patients should be aware that in certain conditions, they can discuss that with their surgeon.