Dr. Pooja Kharbanda Ppt - Dr. a. C Agarwal Trophy Paper

PRESENTED BYDR. POOJA KHARBANDAM. S. OPHTHALMOLOGY

SENIOR RESIDENTESI HOSPITAL , NEW DELHI

TOPIC:-

A STUDY OF

ASSESSMENT OF MANAGEMENT OUTCOMES

BY Q-SWITCH ND:YAG LASER FOR

POSTERIOR CAPSULAR OPACIFICATION

- A 1 YEAR STUDY

DR. POOJA KHARBANDA DOS 64TH ANNUAL CONFERENCE

Posterior Capsular Opacification-

Also known as ‘After cataract’ or ‘Secondary cataractIt is the commonest complication of cataract surgery with an incidence of 10 – 50% by 2 years postoperatively

PCO is caused by lens epithelial cells that remain in the capsular bag after cataract surgery that migrate, proliferate and transform to produce Elschnig’s pearls and capsular fibrosis

It causes reduction in Visual Acuity and contrast sensitivity by obstructing the view or by scattering the light that is perceived by patients as the glare

INTRODUCTION

The Nd: YAG laser is a solid state laser that uses a neodymium-doped yttrium-aluminum-garnet crystal as the lasing medium

It is optically pumped with a lamp or diode and most commonly emits infrared light at 1064nm

It can be used in either a pulsed or continuous mode. Pulsed YAG lasers are typically Q-switched to achieve high-intensity pulses, which can be frequency doubled to emit light at 532nm


Redley perfomed first intraocular lens implantation in 1949, himself noted these complications in his earliest patients

He also recognized the problem of PCO and designated it as “the principal complication” that is not easy to treat, which requires division of posterior capsule, i.e. surgical posterior capsulotomy

Nd: YAG laser posterior capsulotomy now ranks as the second most expensive surgical cost to the US health care system, the cost of the original cataract operation being the first


AIMS AND OBJECTIVES

1. To study the visual outcome following Q-switched ND: YAG Laser posterior capsulotomy

2. To study the complications following Q-switched ND: YAG laser posterior capsulotomies


PATHOGENESIS OF ‘AFTER CATARACT’ OR PCO

Opacification of the posterior capsule is an inadequate term, because it is not the capsule that opacifies but an opaque membrane that grows, originating from the epithelial cells that were retained, which proliferate and migrate on the posterior capsule


CLINICAL TYPES :–

Elschnig’s pearlsSoemmering’s ringDense membrane


MANAGEMENT OF PCO :–

Nd: YAG laser posterior capsulotomy Surgical capsulotomyPeeling or removal of epithelial cells


•Rise in intra-ocular pressure•Damage to cornea •IOL Pitting•Iris bleed / Hyphaema•Iritis•Vitreous haemorrhage•Vitreous liquefaction•Rupture of anterior hyaloid face•Cystoid macular oedema•Retinal detachment•Retinal hole•Recurrence•Endophthalmitis•Subluxation/Dislocation of lens

COMPLICATIONS OF ND:

YAG LASER

CAPSULOTOMY


LASER:-“Laser”– Light Amplification by Stimulated Emission of Radiation

Milestones in the development of ophthalmic lasersPRE 400 B.C. :- Effect of solar radiation, i.e. eclipse blindness was recognised by ancients and were quite aware of this untoward effect1956 Xenon-arc Photocoagulator was commercially manufactured by Zeiss on the basis of pioneering work of Gerd Meyer-Schwickerath. He successfully used this photocoagulator to produce adhesive chorioretinitis surrounding retinal holes clinically1960 In July, Theodore Maiman built the first laser (or optical maser, termed during that period) which employed ruby crystal as medium. It produced a pure beam of monochromatic light of 694.3 nm wavelength1962 The era of photodisruption began. Hellwarth and McClung developed Q-switching to produce brief giant pulses of high peak power from ruby laser


Chronology of development of YAG Lasers


MATERIALS AND METHODS:

My study was conducted on 100 patients who attended ophthalmic OPD at our tertiary health care set-up, during the period of January 2010- 2011. All of these patients had previously undergone cataract surgery and were diagnosed to have posterior capsular opacification

PATIENT SELECTION Inclusion Criteria-Age group between 16-80 yrspatients with PCO giving consent for the treatment and studyThe criteria for entry into study was decreased visual acuity or visual symptoms due to posterior capsular opacification or wrinkling, in patients who had undergone cataract extraction by ECCE, SICS or Phaco. with or without PCIOL implantationNo gender barPatients younger than 16 years were not selectedPatients ready to come for follow up


Exclusion criteria: patients not giving consentpatients unable to come for follow upPatients having other associated ocular pathologies of anterior or posterior segment, like corneal opacity, diabetic retinopathy, hypertensive retinopathy, retinal diseases, optic nerve diseases, glaucoma, etc Contraindications to laser capsulotomy

Absolute Contraindications Difficulty in target visualization like in corneal opacity irregularities

or oedemaInadequate stability of eyeAcute InfectionRelative Contraindications Known or suspected CMEActive uveitisHigh risk for RD


PRELASER ASSESSMENT

OPD Examination, written informed consent was taken and pupils were dilated after-Ocular Examination:- Thorough eye examination was done

which comprised of assessment of visual acuity, slit lamp biomicroscopy, Shiotz indentation tonometry/applanation tonometry including diurnal variation of intra-ocular pressure and ophthalmoscopy( Both Direct and Indirect).

I - Slit Lamp Biomicroscopy:- The patients were examined on slit lamp to look for:-Condition of ConjunctivaAnterior chamber IrisPupillary reactionsTransparency and position of lensState of vitreous and opacities in vitreous, if any DR. POOJA KHARBANDA DOS 64TH ANNUAL CONFERENCE

II- Retinoscopy :- It was done at a distance of 1 metre and subjective acceptance and best corrected visual acuity was recorded for distance and for nearIII- The fundus examination with 90D lens/ Ophthalmoscopy( Direct and Indirect ) allowing accurate assessment of capsular clouding and maculaIV- Fluorescein angiography was indicated in cases where cystoid macular oedema was suspected6) Preparation of the patient-After a proper informed consent was obtained, Patient was explained the reasons , steps and duration of the procedure to seek his/her co-operation during surgery. Its painless nature was explained and the importance of steady fixation was emphasizedAntiglaucoma medication-Timolol 0.5% or apraclonidine was administered one hour before the actual procedure to prevent blunt post-op spike of IOP along with Antibiotic-steroid-antiglaucoma medication given post-op eratively


7) Instruments used:- Torch Light

Slit Lamp Biomicroscope

Snellen’s Distant vision chart

Snellen’s Near vision chart

Direct Ophthalmoscope

Indirect Ophthalmoscope

Schiotz Indentation Tonometer

Nd: YAG Laser Machine

Paymen ‘s contact lens


8)Procedure-Peyman contact lens was used to stabilize the eye, improve laser optics and facilitate accurate focussing. It increases the convergence angle from 16 degree to 24 degrees, decreases the area of laser at posterior capsule to 14 m from 21 m and increases beam diameter both the cornea and retinaThe capsulotomy was started eccentrically with minimum energy level of 0.2 – 1.6 mJ and then increasing in 0.2 mJ steps until an adequate response was noticed reaching upto 2 – 2.8 mJ9)Technique: After patient was seated on Nd: YAG laser slit lamp. The patient is asked to fix his gaze on the fixation lamp attached. The laser beam is used to focus the posterior capsule. The punctures are created on the posterior capsular in pupillary area to create an opening of minimum 3 mm size with energy and number of shots as per required. The bottom integration in the joy stick is used to release Nd: YAG laser pulses


Age (in Years)

4 4.0

14 14.0

28 28.0

39 39.0

15 15.0

100 100.0

Age (in years)

< 40

40 - 50

50 - 60

60 - 70

>= 70

Total

Frequency Percent

OBSERVATIONS

TABLE - 1AGE WISE DISTRIBUTION OF STUDY SUBJECTS

GRAPH - 1 AGE WISE DISTRIBUTION OF STUDY SUBJECTS

As seen from the above table, Maximum patients were from the age group 60 – 70 years witha mean age of 60.94 ± 9.94

0

5

10

15

20

25

30

35

40

No

. o

f p

ers

on

s

< 40 40 - 50 50 - 60 60 - 70 >= 70

Age (in Years)

Age Distribution


TABLE – 2GENDERWISE DISTRIBUTION OF STUDY SUBJECTS

GRAPH-2 GENDERWISE DISTRIBUTION

OF STUDY SUBJECTS

The table above shows that maximum patients i.e., 56% were males and44 % were females

Gender

56 56.0

44 44.0

100 100.0

GenderMale

Female

Total

Frequency Percent

Gender Distribution

56%

44%

Male

Female


TABLE – 3DISTRIBUTION OF PATIENTS ACCORDING TO AGE AND GENDER

GRAPH-3 DISTRIBUTION OF PATIENTS

ACCORDING TO AGE AND GENDER

In both males (39.3%) and females(38.6%) the maximum patients were from the age group of 60 – 70 years , as seen in the table above

2 2 4

3.6% 4.5% 4.0%

8 6 14

14.3% 13.6% 14.0%

18 10 28

32.1% 22.7% 28.0%

22 17 39

39.3% 38.6% 39.0%

6 9 15

10.7% 20.5% 15.0%

56 44 100

100.0% 100.0% 100.0%

< 40

40 - 50

50 - 60

60 - 70

>= 70

Age(inYears)

Total

Male Female

Gender

Total

< 4040 - 50

50 - 6060 - 70

>= 70

Male

Female0

5

10

15

20

25

No

. of

per

son

s

Age (in years)


TABLE – 4POST-OPERATIVE DURATION OF PCO ( IN MONTHS ) AFTER

CATARACT SURGERY

GRAPH-4 POST-OPERATIVE DURATION OF PCO

( IN MONTHS ) AFTER CATARACT SURGERY

Maximum patients (37%) in the study belonged to the >= 24 months group after the cataract surgery surgery . Second largest group comprised of 18% patients who underwent cataract surgery within 6 – 12 months before laser

The mean no. of months post cataract surgery for the patients was 34.74 ± 51.62

Months Postop. (after Cataract Surgery)

13 13.0

18 18.0

15 15.0

17 17.0

37 37.0

100 100.0

Months< 6

6 - 12

12 - 18

18 - 24

>= 24

Total

Frequency Percent

0

5

10

15

20

25

30

35

40N

o. o

f p

ers

on

s

< 6 6 - 12 12 - 18 18 - 24 >= 24

Months after Cataract Surgery


Grade of PCO

29 29.0

42 42.0

29 29.0

100 100.0

Grade

1

2

3

Total

Frequency Percent

TABLE – 5GRADEWISE DISTRIBUTION OF PCO

GRAPH-5GRADEWISE DISTRIBUTION OF PCO

It was found that most of the patients i.e., 42% were having Grade 2 of PCO.Incidence of grade 1 PCO was found to be 29% and grade 3 was also 29%

Grade of PCO Distribution

29%

42%

29%

Grade 1

Grade 2

Grade 3


Descriptive Statistics

1.73 0.74Energy (mJ)Mean Std. Deviation

Energy (mJ)

19 19.0

38 38.0

43 43.0

100 100.0

Energy (mJ)< 1

1 - 2

>= 2

Total

Frequency Percent

TABLE – 6DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO ENERGY OF LASER

USED IN VARIOUS GRADES OF PCO

GRAPH-6 DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO

ENERGY OF LASER USED IN VARIOUS GRADES OF PCO

It was found that most of the patients i.e., 42% were having Grade 2 of PCO. Incidence of grade 1 PCO was found to be 29% and grade 3 was also 29%

Higher energy was used for higher grade and in this case we used around 2 mJ as we had maximum patients having grade 2 PCO .19% of the patients were given < 1 mJ of energy. 38% were treated with energy ranging from 1-2 mJ.The energy (in mJ) for most of the patients was >=2.The mean energy was 1.73 ± 0.74

Energy (mJ) Distribution

19%

38%

43%

< 1

1 - 2

>= 2


0

10

20

30

40

50

60

70

80

No.

of p

erso

ns

Anterior

hyaloid

rupture

Cystoid

macular

oedema

IOL Pitting Iris bleed Iritis None Recurrence

of PCO

Rise in IOP Vitreous

haemorrhage

Vitreous

liquefaction

Complications

TABLE – 7DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO COMPLICATIONS

AFTER YAG LASER GRAPH-7

DISTRIBUTION OF STUDY SUBJECTS ACCORDING TO COMPLICATIONS AFTER YAG LASER

The rare complications like cystoid macular edema and retinal detachment were also noted in our study.Most of the patients presented with no complications. 8 % presented with IOL Pitting, 7 with rise in IOP , 3 of them with Iritis , and rest of the complications with fewer no. of cases

Complications Noticed

1 1.0

2 2.0

8 8.0

2 2.0

3 3.0

72 72.0

2 2.0

7 7.0

2 2.0

1 1.0

100 100.0

ComplicationsAnterior hyaloid rupture

Cystoid macular oedema

IOL Pitting

Iris bleed

Iritis

None

Recurrence of PCO

Rise in IOP

Vitreous haemorrhage

Vitreous liquefaction

Total

Frequency Percent


Months Postop. (after Cataract Surgery)>= 2418 - 2412 - 186 - 12< 6

Co

un

t

25

20

15

10

5

0

Bar Chart

Complications NoticedNo Complications

Complications

TABLE – 8RELATIONSHIP BETWEEN POST ND:YAG LASER COMPLICATIONS AND THE

POST-OPERATIVE DURATION IN MONTHS

GRAPH-8 RELATIONSHIP BETWEEN POST ND:YAG LASER

COMPLICATIONS AND THE POST-OPERATIVE DURATION IN MONTHS

It was found that most of the patients i.e., 42% were having Grade 2 of PCO.Incidence of grade 1 PCO was found t

According to the above table, all the complications were maximally noted when laser capsulotomy was done within 6 months of cataract surgery except iritis. But, this finding is not significant statistically. (x2=0.761, df=1, p=0.383)Post- operative duration in months after cataract treatment was significantly associated with the occurrence of post – ND Yag Laser

Crosstab

Count

5 8 13

15 3 18

13 2 15

14 3 17

25 12 37

72 28 100

< 6

6 - 12

12 - 18

18 - 24

>= 24

Months Postop.(after CataractSurgery)

Total

NoComplica

tionsComplications Noticed

Complications

Total

X2=11.265 df=4 P<0.05


TABLE – 9ASSOCIATION OF COMPLICATIONS WITH LASER

ENERGY (MJ) USED GRAPH-9

ASSOCIATION OF COMPLICATIONS WITH LASER ENERGY (MJ) USED

Above table shows that, out of total 79 patients who developed one or the other complication after capsulotomy, majority i.e. 53 patients received 1.1-2 mJ of laser energy. Amongst the patient who received less than 1 mJ energy, only 9 patients developed complications. As many as 70.83% (17 out of 24) who received more than 2 mJ energy developed complication. Thus, overall frequency of complications is significantly associated with the total laser energy used for capsulotomy (x2=12.284,df=2, p<0.005).Relationship between ND:Yag Laser energy used and occurrence of complications was significant..

Energy (mJ)>= 21 - 2< 1

Co

un

t

30

20

10

0

Bar Chart

Complications NoticedNo Complications

Complications


Crosstab

17 2 19

29 9 38

26 17 43

72 28 100

< 1

1 - 2

>= 2

Energy(mJ)

Total

NoComplica

tionsComplications Noticed

Complications

Total

Count

TABLE – 10BEST CORRECTED VISUAL ACUITY BEFORE AND AFTER LASER

TREATMENT GRAPH-10

BEST CORRECTED VISUAL ACUITY BEFORE AND AFTER LASER TREATMENT

Majority of patients who presented with a poor vision had a significant improvement. In fact, all the patients with visions beyond 6/60 had an enhanced vision of better than 6/9 post 6 months of laser.

Visual Acuity Pre-Laser

Post-Laser (6months)

< 3/60 40 0

3/60 to 6/60 7 0

6/60 to 6/12 53 35

>= 6/12 0 65

0

10

20

30

40

50

60

70

No.

of p

erso

ns

< 3/60 3/60 to 6/60 6/60 to 6/12 >= 6/12

Visual Acuity

Pre-Laser

Post-Laser(6months)


TABLE – 11COMPARISON OF VISUAL ACUITY WITH RESPECT TO

COMPLICATIONS

The Visual acuity for all the three groups viz., No complications, Complications and overall had significantly improved (p-value < 0.05) across various follow-ups as compared to Pre-Laser. Moreover, we also notice that the Vision for “No complications” was significantly better than those of complications across all the follow-ups. However, we cannot say that Laser shows better results in “No Complications” cases as compared to “Complications” case because even at pre-laser the vision of “No complication” was better than the other group. So laser gives similar results immaterial of the complications

Visual Acuity

No Complications

(n=72)p-value

compared to pre-laser

Complications Seen

(n=28)p-value


Overall

(n=100)p-value


Mean S.D Mean S.D Mean S.D

Pre-Laser 0.98 0.61 - 1.28 0.52 - 1.06 0.60 -

Immediate Post-Laser 0.62 0.40 0.00 0.81 0.37 0.00 0.67 0.40 0.00

1 Hr Post-Laser 0.59 0.38 0.00 0.76 0.36 0.00 0.64 0.380.00

3 Hr Post-Laser 0.52 0.29 0.00 0.68 0.33 0.00 0.56 0.310.00

24 Hr. Post-Laser 0.37 0.26 0.00 0.53 0.26 0.00 0.42 0.270.00

3 Day Post-Laser 0.32 0.23 0.00 0.49 0.24 0.00 0.37 0.250.00

1 Wk Post-Laser 0.29 0.21 0.00 0.46 0.25 0.00 0.33 0.230.00

1 Month Post-Laser 0.19 0.20 0.00 0.39 0.19 0.00 0.24 0.22

0.00

3 Month Post-Laser 0.17 0.19 0.00 0.39 0.22 0.00 0.23 0.220.00

6 Month Post-Laser 0.13 0.19 0.00 0.38 0.22 0.00 0.20 0.230.00


GRAPH– 11COMPARISON OF VISUAL ACUITY WITH RESPECT TO

COMPLICATIONS

In terms of log MAR scale , the visual acuity nearing zero is considered to be the best ( 6 / 6 ) and those moving away from zero highlight a deteriorating vision

.

0.000

0.200

0.400

0.600

0.800

1.000

1.200

1.400

Pre-Laser ImmediatePost-Laser

1 Hr 3 Hr 24 Hr 3 Day 1 Week 1 Month 3 Month 6 Month

Mean

Vis

ual

Acu

ity

No Complications

Complications Seen

Overall


TABLE – 12COMPARISON OF IOP WITH RESPECT TO COMPLICATIONS

Majority of patients in our study (67.5%) did not have significant IOP rise after laser as shown in above table. Reduction in IOP was noticed and there was significant difference in Pre – Laser IOP and all Post – Laser IOPs except for 24 hrs Post- Laser IOP. During first immediate 3 examinations , there was a noticeable increase in the IOP recordings. The IOP increases significantly till the 3rd hour of Laser but then falls back to pre-laser levels at the 24 th hours and then stabilizes at a lower level than the pre-laser value

Visual Acuity

No Complicationsp-value


Complications Seenp-value


Overallp-value


Mean S.D Mean S.D Mean S.D

Pre-Laser 14.40 1.54 - 14.23 1.38 - 14.35 1.49 -

Immediate Post-Laser 14.89 1.92 0.00 16.45 1.92 0.00 15.33 2.04 0.00

1 Hr Post-Laser 14.97 1.49 0.00 16.80 2.57 0.00 15.48 2.02 0.00

3 Hr Post-Laser 14.79 1.53 0.00 16.80 2.79 0.00 15.36 2.15 0.00

24 Hr. Post-Laser 14.40 1.47 0.985 16.38 2.97 0.03 14.96 2.18 0.01

3 Day Post-Laser 14.15 1.47 0.03 16.28 2.93 0.00 14.75 2.19 0.07

1 Wk Post-Laser 14.04 1.52 0.00 16.08 2.94 0.00 14.61 2.21 0.25

1 Month Post-Laser 13.95 1.23 0.00 16.10 3.23 0.01 14.55 2.21 0.39

3 Month Post-Laser 13.87 1.26 0.00 15.85 2.84 0.01 14.42 2.04 0.74

6 Month Post-Laser 13.85 1.28 0.00 15.75 2.84 0.01 14.38 2.02 0.88


GRAPH– 12COMPARISON OF IOP WITH RESPECT TO COMPLICATIONS

In terms of log MAR scale , the visual acuity nearing zero is considered to be the best ( 6 / 6 ) and those moving away from zero highlight a deteriorating vision

.

13.000

13.500

14.000

14.500

15.000

15.500

16.000

16.500

17.000

Pre-Laser ImmediatePost-Laser

1 Hr 3 Hr 24 Hr 3 Day 1 Week 1 Month 3 Month 6 Month

Mean

IO

P

No Complications

Complications Seen

Overall


TABLE – 13 CORRELATION OF COMPLICATIONS WITH ENERGY (mJ)

The above table shows correlation between different complications noticed with energy used in millijoules. Since the p- value(0.73 ) is in significant, therefore no correlation

X2=11.265 df=4 P<0.05


1 1.8000 .

2 1.7000 .42426

8 2.0250 .76672

2 1.7000 1.55563

3 2.1667 .05774

72 1.6403 .77217 .735

2 1.8000 .00000

7 2.2000 .47610

2 1.8000 .84853

1 1.8000 .

100 1.7380 .74234

Anterior hyaloid rupture

Cystoid macular oedema

IOL Pitting

Iris bleed

Iritis

None

Recurrence of PCO

Rise in IOP

Vitreous haemorrhage

Vitreous liquefaction

Total

N Mean Std. Deviation p-valueEnergy (mJ)

GRAPH– 13 CORRELATION OF COMPLICATIONS WITH ENERGY (mJ)

.

0

0.5

1

1.5

2

2.5

Mean

En

erg

y

Anterior

hyaloid

rupture

Cystoid

macular

oedema

IOL Pitting Iris bleed Iritis None Recurrence

of PCO

Rise in IOP Vitreous

haemorrhage

Vitreous

liquefaction

Complications


DISCUSSION

Data was collected from areas in and around Nashik during the year 2010 in our study. The data was entered on MS Excel spreadsheet and was analysed on SPSS Version 15.0All the summary tables and statistics were suitably illustrated through needed graphs to enhance layman understanding and visual appeal wherever tests of significance were performed. A 5 % level of significance were used as test criteria

A p value < 0.05 was deemed significant where as p value < 0.01 was deemed highly significantThe tests used in the subsequent analysis were 1 – t-test for correlation2 – paired t – test for evaluating the difference in means3 – Chi – square test for finding the association between two variables


Age Distribution:There were more cases in the age group of 60-70 yrsSex Distribution : Maximum patients i.e., 56% were malesOut of 100 patients ,56 were males and 44 were femalesAge Wise distribution in Accordance with gender:In both males (39.3%) and females(38.6%) the maximum patients were from the age group of 60 – 70 years.Post Operative Duration of PCO after Cataract Surgery:In our study, the time of laser capsulotomy from cataract surgery ranged from as early as 2 months to as late as 241 monthsDistribution of Grades of PCO:Most of the patients i.e., 42% were having Grade 2 of PCOEnergy of LASER used in various grades of PCO:The energy (in mJ) for most of the patients was >=2 mJ. The mean energy was 1.73 ± 0.74234


BCVA –In our study , pre-operative visual acuity in 64 % ranged from HMCF to 6/ 36 and in 36 % , it was between 6/24 to 6/18 , visual improvement was seen in 91 patients , out of which 60 improved from 6/9 to 6/6 and 31 patients improved from 6/36 to 6/12

In terms of log MAR scale , the visual acuity nearing zero is considered to be the best ( 6 / 6 )and those moving away from zero highlight a deteriorating vision


Visual acuity scales

Foot Metre Decimal LogMAR

20/200 6/60 0.10 1.00

20/160 6/48 0.125 0.90

20/125 6/38 0.16 0.80

20/100 6/30 0.20 0.70

20/80 6/24 0.25 0.60

20/63 6/19 0.32 0.50

20/50 6/15 0.40 0.40

20/40 6/12 0.50 0.30

20/32 6/9.5 0.63 0.20

20/25 6/7.5 0.80 0.10

20/20 6/6 1.00 0.00

20/16 6/4.8 1.25 -0.10

20/12.5 6/3.8 1.60 -0.20

20/10 6/3 2.00 -0.30

SNELLEN - LOGMAR VISUAL ACUITY CALCULATOR


Distribution Of Complications:Majority of patients (72%) presented with no complications. Of patients who presented complications, majority were either IOL pitting or Rise in IOPAssociation of complications with laser energy:As per data found in our study , As energy is increasing, the number of complications were seen to be significantly increasing (p-value=0.048)Complications of laser capsulotomy:In our study of 100 cases , we performed laser capsulotomy using Abraham’s contact lens with maximum cases done with enegy setting >=2mJ . We started with energy level of 0.2 – 1.6 mJ initially and then increasing in 0.2 mJ steps until an adequate response was noticed reaching upto 2 – 2.8 mJ . The mean energy was 1.73 ± 0.74234.


Complications of laser capsulotomy-In our study of 100 cases , we performed laser capsulotomy using Abraham’s contact lens with maximum cases done with enegy setting >=2mJ . We started with energy level of 0.2 – 1.6 mJ initially and then increasing in 0.2 mJ steps until an adequate response was noticed reaching upto 2 – 2.8 mJ . The mean energy was 1.73 ± 0.74234The various complications observed were:-1. Rise in Intra Ocular Pressure:-There was a transient elevation of IOP noticed immediately post laser in maximum patients


The various complic ations observed were:-


The various complications observed were:-1. Rise in Intra Ocular Pressure:-There was a transient elevation of IOP noticed immediately post laser in maximum patients2. IOL Pitting:-IOL Pitting was observed in 8 patients in our study3. Iris bleed :-We noticed Iris bleed in 2 cases post – laser which was manageable with the treatment given4 – Iritis:-In our study , mild iritis was observed in 3 cases which was treated immediately with steroid, mydriatic and NSAID eye drops


5- Vitreous Haemorrhage / Vitreous Liquefaction :-Vitreous Haemorrhage was observed in 2 cases which was conservatively managedcapsulotomy leading to enzymatic changes in the vitreous.6- Rupture of anterior Hyaloid Face :–We noticed Rupture of anterior Hyaloid face in one patient which could be due to difficulty in distinguishing between anterior hyaloid face and posterior capsule during laser capsulotomy7- Cystoid macular oedema:- In our study we found 2 cases of CME8 – Recurrence :–Recurrence (Elschnig’s pearls ) was observed in 2 patients following the laser treatment9- Other complications :–We did not notice any case of damage to cornea, retinal detachment, retinal hole , subuxation/dislocation of lens or endophthalmitis


SOME INTERESTING FACTS & TAKE HOME MESSAGE

Prevention of Posterior Capsule Opacification

Hydrodissection-enhanced Cortical Clean-up

In-the –Bag Fixation of IOL

Capsulorrhexis Edge on the IOL Surface

Biocompatibility of IOL

Maximum IOL Optic Posterior Capsule Contact

Pharmacological Techniques and Immunological inhibitors for PCODaunomycinm, Methotrexate, 5-Flurouracil and Colchicine


THANK YOU FOR PATIENT LISTENING

REFERENCES: 1.Parsons’ Diseases of the eye 2.Kanski- clinical ophthalmology 3.Dutta: Modern ophthalmology 4.A.K.Khurana 5.Basak- Essentials of ophthalmology Mahtab Alam Khanzada , Shafi Muhammad Jatoi , Ashok kumar Narsani , Syed Asher Dabir

and Siddiqa Gul . Experience of ND:YAG Laser posterior capsulotomy in 500 cases.JLUMHS September – December 2007

Hollick EJ, Spalton DJ, Ursell PG, Pande MV. Lens epithelial cell regression on the posterior capsulewith the different intraocular lens materials.Br J Ophthalmol. 1998; 82: 1182-88.

Col PS Moulick , Col FEA Rodrigues (Retd)’’,Lt Col K Shyamsundar . Evaluation of posterior Capsular Opacification Following Phacoemulsification , Extracapsular and Small Incision Cataract Surgery . MJAFI 2009; 65: 225-228

Paulsson LE, Sjostrand J. Contrast sensitivity in the presence of a glare light. Theoretical concepts and preliminary clinical studies. Invest. Ophthalmol Vis Sci. 1980; 19: 401-6

Tan JCH,Spalton DJ, Arden GB. Comparision of methods to assess visual impairment from glare and light scattering with posterior capsule opacification. J Cataract Refract Surg. 1998; 24:1626-31

Kanski JJ. Clinical ophthalmology, a systemic approach. 4th edition: Butterworth-Heinemann, London. 1999: 169-70

Martin RG,Sanders DR, Souchek IOL design and surgical placement upon postoperative outcome. J Cataract Refract Surg. 1992 : 18:333-41

DR. POOJA KHARBANDAM. S. OPHTHALMOLOGY

SENIOR RESIDENTESIC HOSPITAL , NEW DELHI

PRESENTED FOR DOS 64TH ANNUALCONFERENCE

2013

Dr. Pooja Kharbanda Ppt - Dr. a. C Agarwal Trophy Paper

Documents

Transcript of Dr. Pooja Kharbanda Ppt - Dr. a. C Agarwal Trophy Paper