*2.3.1 Automatic refraction*

*Current Cataract Surgical Techniques*

symblepharon.

be overlooked.

*dilation)*

decision for the IOL type selection.

dysfunction should be treated preoperatively, since tear-film abnormalities may influence postoperative visual outcomes leading to suboptimal visual quality and performance, regardless of the type of IOL to be implanted. Slit lamp evaluation of corneal endothelium should not be omitted. Corneal dystrophies, such as Fuchs' corneal dystrophy, as well as corneal scars (central or peripheral), pterygium and keratoconus signs should be taken into consideration for the selection of the most appropriate presbyopia correction method.

• *Conjunctiva:* Conjunctival disorders should be assessed, such as conjunctival hyperemia, papillae, hyperplasia of lymphoid follicles, erosions, scarring and

• *Iris:* The pupil size and shape should be evaluated before and after mydriasis. Pupils with an irregular shape could interfere with desired refractive outcome. Inadequate mydriasis is a well-known risk factor associated with numerous intra- or postoperative complications [15]. In addition, anterior and/or posterior synechiae could increase the risk for inadequate mydriasis and intraoperative complications. Finally, iris neovascularization should not

• *Anterior chamber:* The anterior chamber depth (ACD) should be evaluated with slit lamp biomicroscopy. A shallow anterior chamber can be present in hypermetropic eyes with short axial length (AL). However, it might also be caused by an intumescent cataract or other pathological causes. Regardless of the cause, a shallow anterior chamber could increase the difficulty of a lens extraction surgery. Finally, gonioscopy could be performed, if considered necessary,

to reveal angle abnormalities like synechiae and neovascularization.

of the IOL, that could influence the visual outcome negatively.

*2.2.3 Slit lamp examination of the posterior segments of the eye (under pupil* 

• *Lens:* The cataract type and density should be evaluated in order to predict possible technical difficulties in performing cataract surgery. In addition, the presence of Pseudoexfoliation Syndrome (PEX), which is the most common cause of zonular weakness, should be identified. PEX can be better revealed after pupil dilation. This should be taken into account for the IOL type selection, since it increases the risk of a possible late decentration and misalignment

• *Optic nerve:* Any abnormality of the optic nerve could influence the surgeon's

• *Macula:* The macular anatomy should be assessed. The presence of acquired macular disorders including age-related macular degeneration (ARMD) findings and macular edema, or hereditary macular disorders, such as Stargardt's disease and retinitis pigmentosa, could be considered as relative or absolute contraindications for pseudophakic presbyopic corrections. The evaluation of the appropriateness of a pseudophakic presbyopic correction in the presence of a macular disease should depend on the stability of the disease, the expected progression over time, and the availability and usefulness of its treatment.

• *Rest fundus:* Retinal ischemia, vitreous retinal traction, lattice degeneration,

and macular hole should be sought especially in diabetic patients.

**96**

Measurements taken by an automatic kerato-refractometer can be co-evaluated with manifest refraction and corneal topography for the confirmation of the refractive error.
