Nw2012 cataract surgery11

Nawat WatanachaiChiangmai University Hospital2013

Cataract

“Even we have had the much advanced treatment for it for a while and we keep doing better, but sometimes, in some occasions, cataract can be very challenging disease that we, ophthalmologists, will be the ones to treat.”

Prof. Ian Jeffrey Constable Director of Lions Eye Institute, University of Western

Australia first president of APAO

terms

phakos (Greek) - Lens

Katarraktes (Greek) a down rushing, or

waterfall

Originally thought that congealed brain fluid was flowing in front of lens.

Timeline of Cataract Surgeries

Femto cataract2010

Phaco1967

History :at the beginning

--- Couching ---

Sushruta (Hippocrates of India), 600 BC The Indian tradition of cataract surgery

Couching with jabamukhi salaka soaked with warm butter and then

bandaged

History : Couching

History:Couching

India

Egypt Greek, europe

Burma thaichina

Rome (29 AC) De Medicinae,

(Aulus Cornelius Celsus)

Persia (100 AC) Choice of Eye Diseases

(Ammar ibn Ali)

History : Couching

Large lens shadow severe uveitis retinal detachment/ VH Endophthalmitis

History : ICCE and ECCE

1753 Jaques Daviel (FRA) : ECCE Uveitis from left cortex High incidence of PC tear Success rate ~30%


1752-53 Intra Capsular Cataract Extraction ICCE Sharp, de la Faye.

1900 Henry Smith (IRE): ICCE Erysophake Capsule forceps

>20,000 ICCE Sx

History : ICCE and ECCE 1949 Harold Ridley (GB) : ICCE c IOL

29 Nov 1949 : the first IOL was implanted failed

8 th Feb 1950 : the first permanent insertion of intraocular lens

1953 Harold Ridley (GB) : ECCE c IOL


1957 Joaquin Barraquer (SPA): chymotrypsin

1961 Krawicz (POL): Cryo-extraction

History : ICCE and ECCE 1964 Baron and Strampilli (GB) :

angle-type AC IOL 1968 Binkhorst (NED) :

Iris-claw AC IOL

History : ICCE and ECCE ICCE : cons

Vitreous loss RD, VH disfigured pupils, ACG

Wound integrity/ astigmatism AC IOL : cons

Corneal decompensate UGH syndrome Unable to dilate pupil

History : ECCE(and PE)

1967 Charles Kelman (US): PE (1966 Peristaltic Pump First Phaco on animals)

4 hrs, 3 L of fluid sonic-ultrasonic device made by Cavitron

1974 American Intraocular Lens Implant Society* (US): ECCE *- American Society of Cataract and Refractive Surgery (ASCRS)

History : ECCE(and PE) 1975 AILIS (US)

PC IOL 1980 Pape and Balazs

Hyaluronic acid 1980 Danielle Aron-Rosa (FRA)

Nd:YAG capsulotomy

History : ECCE

ECCE : pros Much safer than ICCE Simple instruments Little more skill is needed

ECCE : cons Wound integrity/ astigmatism Long op time

History : PE

1983 Clifford Terry (US): astigmatic keratotomy

1986 Mazzoco (US), Barrett (AUS) : foldable IOL 1986 Kimiya Shimizu (JAP) : topical

ansthesia 1987 Gimbel (CAN) : CCC and

hydrodissection 1995 Howard Fine (US): temporal clear corneal incision

Phacoemulsification

Pros Small wound

Better wound integrity Less astigmatism

Perserve conj/ less bleeding Short op time

Cons Needs more skill/ learning curve Needs more instruments/ maintainance

Let start doing cataract Sx

Extracapsular

Cataract Extraction

ECCE : Steps

1. +/-Bridle traction suture 2. Peritomy (Conj opening) 3. Partial thickness corneoscleral wound and AC

Entering 4. Can-opener capsulotomy 5. Extend corneoscleral wound and Lens

extraction 6. remove cortex +/- suture 7. IOL implantation and close wound

ECCE step 1 : Superior Bridle suture

Grab bulbar conjunctiva and tenon from the superior fornix

Pull the globe down Pass needle through

conj-tenon-sclera Potential cpx

driving needle into vitreous

cryo check for RD/ VH

ECCE step 2 : conj opening (peritomy)

Conjunctival flap fornix-based flap

Radial snip Blunt dissection of conj-tenon from

sclera Create limbal wound Another radial snip

150-180’ Clean tenon/ stop bleeding

Surgeon view

ECCE step 3 : Partial thickness corneoscleral wound and AC Entering Blade no.15 (not 15’ blade)

Partial thickness wound depth 50-80% Enter the AC with 15’blade/ needle/ razor

blade +/-stain capsule c ICG,trypan blue

Air bubble Dye Washout

fill the AC with OVD

Surgeon view

ECCE step 4 : Can-opener capsulotomy

Cystotome Complete the circle Make it LARGE May do CCC with relaxing incision

ECCE step 5 :Extend corneoscleral wound and lens extraction

Extend corneoscleral wound Corneal scissor 150-180’

Make sure this wound fit to the size of the necleus

Avoid hitting endothelium/ DMMB Inside-out technique

Surgeon view

ECCE step 5 : extend corneoscleral wound

and lens extraction

Lens extraction Instruments

Forceps Lens loop Hooks Corneal

Suture cryo

ECCE step 5 : extend corneoscleral wound and lens extraction

Lens extraction Major

problems Small wound Wrong lens

direction Keys

Big wound Tilt the

nucleus

ECCE step 6 : IOL Implantation and close wound

Put 2-3 stitches to hold the AC

Remove cortex with simcoe double barrel cannula

Fill the bag+AC with OVD

Insert IOL Put more sutures Remove OVD with

simcoe

ECCE step 6 : IOL Implantation and close wound

Closing corneosclearl wound 3-7 stitches of Nylon 10-0 Terry notches Aim : little WTR astigmatism

Close conj wound Topical steroid/ ABO/ miotic

Phacoemulsification

Phacoemulsification : Steps 1. Capsulorhexis 2. Corneal/ scleral incision 3. Hydrodissection 4. Phacoemulsification 5. Cortex removal/ capsule polishing 6. IOL implantation

Phaco step 1 : capsulorhexis

Paracentesis Inject OVD capsulorhexi

s


paracentesis Needle, #75 blade, or other

knife stabilize the eye

Bond/ 0.12 forceps/ fixation ring/ cotton bud

Paracentesis 1-2 1 for 2nd instrument 2 for 2nd instrument and CCC


Paracentesis Potential complications:

put in wrong place make another paracentesis

too small make another wound too big suture later nick lens capsule include nick during

capsulorhexis nick iris not serious and forget about it


Inject viscoelastic Slow and steady Push the aqueous

out


Potential complications: shoot loose cannula into anterior

chamber tighten it better next time

Air bubbles remove air with syringe +BSS place OVD distal and force out


CCC : Continuous Curvilinear Capsulorhexis Aim

Complete circle without radial tear Centration Size : 0.5-1.0 mm less than optical part of the

IOL (5-6 mm) Too large more iris capture Too small anterior capsule phimosis

Phaco step 1 : capsulorhexis 3 basic techniques

Cystitome Forceps Combo

initial cut with cystitome

most of tear with forceps

*Need major wound to use forceps

Phaco step 1 : capsulorhexis with cystotome

Phaco step 1 : capsulorhexis with cystotome/ forceps


Keys for good CCC Adequate viscoelastic/ dilation Balance the pressure Good visualization : may need

staining eg. Trypan blue, ICG Control eye mobility

Phaco step 1 : capsulorhexis Potential complications:

Poor red reflex stain with Trypan Blue or ICG

Tear starting to go radial add OVD Use forceps, your senior (and pray)

Radial tear Use scissors to restart in other direction Can opener +/- conversion to ECCE Debulk lens by sculpting out bowl prior to

hydrodissection


Potential complications: too small

Fill more OVD and do the larger one with forceps

enlarge after placing IOL too big

forget about it because this is not a serious issue

Miostat to prevent capture zonular laxity

consider placing iris hooks/ CTR to stabilize the capsular bag

Phaco step 2 : corneal/ scleral incision

Phaco step 2 : corneal/ scleral incision, table

Scleral tunnel

Clear cornea

Leakage Less More

Management of burnt wound

Easier More difficult

Sx-induced astigmatism Less* More

Infection Less More

Time consuming More Less

Bleeding/ conj scar More Less

Handpiece mobility Less more

Phaco step 2 :corneal incision

3 types Single-plane Williamson incision Langerman incision

Phaco step 3 : Hydrodissection

Aim : to free the nucleus/ epinucleus/ cortex from the capsule

10:00 2:00 Create fluid wave at 10 and 2 o’clock


Phaco setp 3 : Hydrodissection

Option : Hydrodeliniation Separate nucleus from epinucleus Golden ring sign (Abe T, JJO 2001)


Potential complications Radial tear


Potential cpx : capsular blockage syndrome

Small CCC Large/hard nucleus Fast injection

If everything is too late don’t scream, stay calm and call your retina

surgeon.


Potential complications No fluid wave

try again in different spot

increase force use bursts and

gently push on nucleus between bursts

Phaco setp 3 : Hydrodissection Iris Prolapse

Remove dispersive OVD. If using a clear cornea wound, then use sub-incisional iris hook

Prolapse nucleus Brown technique or Pop n Chop, flip

into ciliary sulcus, or push back into bag

Phaso step 4 : Phacoemulsification Peizoelectric crystal ultrasound 35,000-40,000Hz, 1/1,000 ‘’

Low freq less effective High freq more heat

Phaco power Stroke length Duration : pulse mode, burst mode Bevel (0, 15, 30, 45, 60’)

Phaso step 4 : Phacoemulsification

The goal is to remove lens with the minimum u/s

Trend is to use increasing vacuum and decreasing u/s power

Techniques Endocapsular - keeping the nucleus in bag during phaco Supracapsular - prolapsing nucleus into sulcus during phaco Anterior chamber shell - prolapsing shelled out nucleus into

anterior chamber ½ bag ½ anterior chamber --tipping nucleus on side ½ in bag;

½ in anterior chamber – a.k.a., Brown Technique, Pop-n-Chop.

Phaco step 4 : Phaco

Basic Technique 1. Divide-and-conquer

Grooves Width 1.5-2x of phaco tip Depth : close to the

posterior cortex Tips

NO occlusion Each stroke depth~1/3-1/2

phacotip

1 2

DIVIDE & CONQUER

34

5 6

DIVIDE & CONQUER

DO NOT occlude the tip during sculpting

sculpting

3

7

8

DIVIDE & CONQUER

1312

DIVIDE & CONQUER

cracking

Divide and conquer

Phaco step 4 : Phacoemulsification

Basic technique 2. slow-motion phacoemulsification

Divide-and –conquer with Low flow rate, low vacuum

For beginner/ soft nucleus-PSC-posterior polar


Basic Technique 3. phacochop

Kunihiro Nagahara 1993 Tip 0, 15, 30’ High flow rate,high vac Bevel down>up Phacochopper Chop/ quick chop Not recommmeded for

soft nucleus

1 2

3

Phaco chop

45

6 7

Phaco chop

8 9

10 11

Phaco chop

12 13

14 15

Phaco chop


Basic technique 4. Stop and Chop

phaco For very hard nucleus

Create groove as in divide-and-conquer

Crack Rotate the nucleus

60-90’ phacochop

32

1

Stop and chop

7

5 6

8

Stop and chop

Phaco step 4 : Phacoemulsification Basic technique 5. Chip and Flip (Bowl-out)

For very soft nucleus Complete

hydrodissection+hydrodeliniation Emulsified the nuclear core Flip the nuclear shell Emulsified the shell (low power, low

vacuum, high flow rate)

Phaco step 4 : Phaco

Some other techniques Quick chop Phaco flip (supracapsular)

Phaco step4:phacoemulsification

Phaco step 5 :Cortex removal I/A handpiece Start at the area under the phaco

wound 1. Rotate tip 90’ for safe occlusion 2. Pull to the center/ tip up 3. max vacuum 4. re engage

Phaco step 5 : Cortex removal

Situation : problem removing cortex under the wound

Solutions U-shape I/A tip Use the side port + blunt tip cannula Place IOL and then I/A

Phaco step 5 : cortex removal

Capsule polishing For less/ later PCO Anterior capsule : high vac Posterior capsule

vac 5-10 mmHg, flow rate 5-6 cc/min Slow tip movement

Not recommend in Loose capsule eg. PXS Radial tear Zonule lysis

Phaco step 6 : IOL implantation

Inject viscoelastic to fill the capsular bag/ AC Do not pierce the PC with your blunt needle

Insert IOL Rigid IOL

need to extend the wound IOL diameter 5-5.5 mm 1-3 stitches

Foldable IOL Use injector or forceps 0-1 stitch

Remove viscoelastic : bag AC


Potential complication Place IOL up-side down

Can leave as is - accept myopic shift Take one haptic out of wound with

Sinsky hookFill with OVD above and below IOLOne hook above and one below -- Flip IOL


Inadvertent sulcus placement Fill with OVD -- Rotate into bag with hook If a 3 piece can leave in sulcus with myopic

shift Do not leave single piece acrylic (eg. Alcon

SA60) in sulcus

Phaco step 6 :IOL implantation

IOL doesn't center Usually one haptic in sulcus one in bag dial both into bag or both into sulcus

Possible zonular dialysis if nearly centered leave it alone rotate IOL carefully for best centration

with 3 piece often haptics best at weak area

check wound for vitreous, miostat consider placement of CTR


Tear in Descemet's Double AC sign Use care to not

extend tear Place Air Bubble at

end of case – post opposition wound up -- bubble seals Descemets

Phaco step 6 : IOL implantation Lens Material behind IOL Rotate haptic 90 deg from wound

Toe down with I/A and get under IOLWith aspiration tip showing at all times aspirate

Note – make sure that you have an INTACT capsule

Special IOL Placement Conditions

Anterior Capsular Tear Single piece acrylic in the bag - creates

little tension on the bag 3 piece with both haptics in the sulcus

Zonular Dialysis Capsular Tension Ring with any IOL 3 piece IOL with PMMA haptic oriented

toward weak area of zonules

Special IOL Placement Conditions

Posterior Capsular Tear Dispersive OVD in the post capsular hole -- gently

place IOL into bag Place 3 piece in sulcus +/- capture of optic by

centered anterior CCC No Capsular Support

AC IOL: there are 3 sizes depending on white to white size

Iris Sutured PC IOL Scleral Sutured PC IOL

Phaco step 6 : IOL implantation Viscoelastic removal

OVD is removed with I/A device As always keep tip opening up Go under IOL to remove OVD,

especially if you have been having IOP problems post op

One Last Step

Check the wound integrity Stop leaking

Corneal stromal hydration Fill AC with air bubble

The New Comers

Femtosecond cataract surgery

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Femto cataract, Hx 2005

Image-guided laser cataract surgery was first conceptualized

D. Palanker and M. Blumenkranz patents US 8394084; US 8403921; US 8425497

2005-2010 OptiMedica Corp. developed and tested integrated Optical Coherence

Tomography and femtosecond laser Palanker DV, Blumenkranz MS, Andersen D, et al. Femtosecond

laser-assisted cataract surgery with integrated optical coherence tomography. Sci Transl Med 2010;2:58ra85.

Femto cataract, Hx

2008 first used clinically in cataract surgery Prof. Zoltan Nagy Budapest, Hungary

2010 Dr Steven Slade in the USA 2011 Dr Michael Lawlwss in Asia/

AUS

”The Future of Laser Cataract Surgery” Keynote Lecture American Academy of Ophthalmology, Subspecialty Day, Chicago, November, 2012

Femtosecond cataract Sx cone pattern To avoid distortion of the

incoming laser beam on gas bubbles and tissue fragments applied first posterior to the target advances anteriorly

Femtosecond cataract surgery What femto can do?

Create corneal flap/tunnels CCC Nuclear fragmentation LRI

corneal incision Controlled reproducible configuration

less risk of wound leak --> less infection

Femtosecond

clear corneal incision

Femtosecond capsulotomy

near perfect, round opening in the anterior capsule

strength of the capsule as good as or greater than a manual capsulorhexis

smoothness of the capsulotomy edge similar to manually created openings

Femtosecond capsulotomyincidence of anterior capsular tears

Manual CCC 0.79% in very experienced hands 5.3% within teaching institutions Marques et al

40% of anterior capsular tears extended to the posterior capsule

20% required further surgery

Lawless in November 2012 0.2% incidence of anterior tears throughout his initial 500 cases

Marques FF, Marques DM. Fate of AC tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42.

Unal M, Yücel I, Sarici A et al. Phaco with topical anesthesia: Resident experience. J Cataract Refract Surg. 2006;32:1361-5.

Marques FF, Marques DM. Fate of anterior capsule tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42.

Lawless M. ”The Future of Laser Cataract Surgery” Keynote Lecture American Academy of Ophthalmology, Subspecialty Day, Chicago, November, 2012

Femtosecond capsulotomy Precised CCC means

Less tear/ nucleus dropping/ uveitis/ VH/ RRD/ endophthalmitis Less IOL decentration

Lawless : mean circularity 0.942 in 29 lasered eyes 0.774 in 30 manual eyes 12X improvement in the precision of the capsulotomy diameter

Freidman : deviation from intended diameter 29 µm ± 26μm for laser capsulotomies (mean deviation 6%) 337μm ± 258μm for a manual technique (mean deviation 20%)

Friedman NJ, Palanker DV, Schuele G. Femtosecond laser capsulotomy. J Cataract Refract Surg. 2011 Jul;37(7):1189-98.

Femtosecond phacofragmentation

reduce the average time and energy required to break up and remove the lens by approximately 50-98%

Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg 2009;25:1053-60.

Batlle JF, Feliz R, Culbertson WW. OCT-guided femtosecond laser cataract & surgery: precision and efficacy. Association for Research in Vision and Ophthalmology Annual Meeting. A4694 Poster #D633. Fort Lauderdale, FL; 2011. www.arvo.org

Edwards K, Uy HS, Schneider S. The effect of laser lens fragmentation on use & of ultrasound energy in cataract surgery. Association for Research in Vision and Ophthalmology Annual Meeting. A4710 Poster #D768. Fort Lauderdale, FL; 2011. www.arvo.org

Femtosecond LRI

better refraction correction --> + visual outcomes

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Femtosecond cataract surgery : Video

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Femtosecond cataract surgery : Video

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Femtosecond cataract surgery : cons Need suction

Rise IOP SCH

Can not do well in some dense cataract Failure during PC scanning

PRICE

Machines

Alcon LenSx (Alcon Laboratories, Ft Worth, TX, USA)

OptiMedica Catalys (Optimedica Corp, CA, USA)

LensAR (LensAR Inc, FL, USA)

Technolas (Technolas Perfect Vision GmbH,

Germany)

Now you guys are ready to ROCK!!!!

Nw2012 cataract surgery11

Health & Medicine

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