 I am Alice Epitropolis. I am an ophthalmologist in Columbus, Ohio and specialize in cataract and refractive surgery. Cataract refractive surgery has literally undergone a revolution with significant advances in technology. In fact, it's the most common and most successful procedure that exists. This success depends on a thorough preoperative evaluation performing accurate biometry, evaluating and treating pre-existing conditions, and finally educating our patients and setting realistic expectations. So the purpose of obtaining a good ocular history is to get a complete understanding of the patient's ocular problem and the impact that it has on their activities and quality of life. So it's also important to make note of any other ocular and medical problems, including diabetes, hypertension, asthma. Patient medications should be elicited with specific reference to anticoagulants, chronic steroids, or history of alpha blockers such as flowmax, which can really cause a loss of iris muscle tone, increasing the risk of complications. Essential preoperative testing includes biometry, keratometry, and IOL calculations using modern IOL formulas, careful slit lamp exam, and dilated fundus exam. And I perform topography on every patient undergoing cataract surgery. I'm also a huge fan of OCT, especially in patients that are interested in multifocal technology. Vision should be determined for both distance and near, along with a refraction to test for best corrected vision. Glare testing helps to document disability that patients are experiencing, especially at night time. And this is particularly important in patients who have significant complaints despite good distance vision. In fact, lack of adequate documentation of these visual impairments may result in denial of coverage for cataract surgery. All cataract patients should undergo a detailed slit lamp examination prior to surgery. Pre-existing corneal conditions can predispose patients to complications or suboptimal results after cataract surgery. Patients with Fuchs corneal dystrophy, for example, are at increased risk of corneal decompensation postoperatively. Fuchs is represented by diseased endothelial cells that are located on the posterior part of the cornea, and loss of too many of these endothelial cells with cataract surgery can lead to edema or blisters in the cornea, deterioration of vision, and may eventually require a corneal procedure called DESEC to replace these diseased cells that you'll be hearing more about. Another fairly common condition that can lessen patient satisfaction is epithelial basement membrane dystrophy. In fact, this, along with Fuchs, can potentially be the cause for their reduced vision preoperatively, and is not necessarily, you know, their reduced vision may not necessarily be due to their cataract, but due to their corneal changes. Another very common underdiagnosed condition that can affect your preoperative assessment, delay healing, and lessen patient satisfaction is dry eye disease. Attention to preoperative measurements and calculations will improve your success and visual outcome. The tear film is the most important refracting surface of the eye, so an unstable tear film can lead to unpredictable measurements and inaccurate biometry. So never hesitate to delay surgery until the ocular surface is healthy enough to generate accurate measurements. Otherwise you may end up missing your refractive target. Patients should be made aware of these conditions preoperatively and not postoperatively. Otherwise it's going to be your fault when their vision is still blurry postoperatively. As Eric Donenfeld has said in the past, if you tell them about this condition before surgery, it's an expectation. But if you don't tell them until afterwards, then it's a complication. Different types of cataracts can cause different symptoms. Nucleosclerotic cataracts, for example, can cause a myopic shift, decreasing the distance vision, but improving the close-up vision. Posture subcapsular cataracts notoriously cause disabling glare at night time and can progress more rapidly. So I'd like to present a case presentation of a patient that might come into your office. A 70-year-old female comes in to you for cataract evaluation. She's got a history of pseudo-exfoliation, glaucoma, and 3-plus Nucleosclerotic PSC cataract. Her vision is reduced to 2080, and she has a very small pupil. So it's important to make note of the pupil size preoperatively. The presence of a small pupil can really significantly increase the risk of complications. So what it does is it reduces your depth of field and may necessitate pupil expansion during cataract surgery. So the increased risk and guarded prognosis associated with these conditions should be explained to the patient preoperatively. This is another case, a 58-year-old female complaining of decreased vision that fluctuates, especially when she's at the computer or reading. She complains of burning, grittiness, and tearing with about 1-2-plus Nucleosclerotic and Cortical changes. So again, we want to determine if the patient's visual complaints are consistent with the degree of the cataract. So again, it's important to listen to the patient's complaints very carefully. If the patient's complaining of fluctuations in their vision, difficulty reading after an hour, this is most likely not due to their cataract but due to their dry eye condition. So you want to treat what's causing the problem. If you schedule this patient for cataract surgery, they're only going to get worse postoperatively unless you treat their dry eye condition. This is a 64-year-old female that comes into your office presenting for a cataract evaluation. And again, she's interested in reducing her dependence on corrective lenses. She has moderate Nucleosclerotic cataracts with a best-corrected vision of 2100, mild distortion in the vision, and her cornea and topography look normal. But her fundus exam shows a little bit of an irregular fovea. So again, you want to ask yourself, is the cataract what's causing the patient complaints here? And is it consistent with the visual acuity? So again, never hesitate to get an OCT on your patients preoperatively, especially if you don't feel like the vision is consistent with the cataract. And as you can see in this slide to the right, the OCT is normal, and the OCT on the bottom shows a macular hole. So again, if you went ahead and proceeded with cataract surgery and didn't mention anything about the fundus changes, then that patient's going to be pretty disappointed postoperatively. So we now have quite a few choices, IOL choices to offer our patients. A basic monofocal lens will correct one distance. Patients still need to wear glasses postoperatively. Then there's a toric lens to correct astigmatism, which many times can allow patients to just get by with reading glasses postoperatively, rather than wearing a bifocal correcting their astigmatism. And then there's the presbyopic implants, the accommodative lenses allow clear vision at distance and intermediate. Patients again, typically need to wear glasses for reading. And then there's also the multifocal lenses, which allows patients to be able to see distance and close up. But these patients need to be warned that they may experience some glarenhalos at nighttime. And if they have any even mild macular pathology, that can really affect their final visual outcome and affect their contrast sensitivity. Communication with the patient is extremely important. And informed consent must include detailed discussion of the prognosis and possible complications of surgery. And this is really a must in today's litigious society. I always like to have a family member present listening because I think it helps to have a couple sets of ears listening. And this, you know, this way more of the information is absorbed. You know, there have been studies that only 20% of information that you present to patients is actually understood. So we want to identify and minimize risk factors that might increase the risk of complications, such as infection, for example, in patients with blepharitis and nursing home patients should be treated aggressively, preoperatively with lid cleansers, pre and postoperative drops. The only factor that's been really shown to reduce the risk of endothelitis preoperatively is applying betadine topically on the eye preoperatively. But again, I think that the majority of surgeons do prescribe preoperative drops to help minimize the risks of inflammation, infection, postoperatively. Thank you so much for your attention. Again, my name is Alice Epitopolis and good luck to you.