Undergraduate Lecture-Visual rehabilitation after Cataract Surgery

Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs

Visual rehabilitation after Cataract Surgery

Dr. Zia-Ul-MazhryDr. Zia-Ul-MazhryFCPS(Pak), FRCS(Edin),FCPS(Pak), FRCS(Edin),

FRCS(Glasgow), CIC Ophth- (UK)FRCS(Glasgow), CIC Ophth- (UK)

Consultant Eye Surgeon & Consultant Eye Surgeon & Head, Department of Head, Department of

Ophthalmology Ophthalmology Wapda Hospital Complex Lahore.Wapda Hospital Complex Lahore.


Discussion Plan1949 to 2009 & Beyond

Cataract surgery

Couching Extractionextra capsular

In toto removalICCE

Micro surgeryE Cap+IOL

E Cap IOL

phaco LS Aq MICS

?

PMMA Soft m focal acc

?

Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS

Can we learn

about the futurefrom the past?


golden age for ophthalmology OphthalmologyOphthalmology first emerged as an independent first emerged as an independent

subspecialty in the early 19thsubspecialty in the early 19th century. century. Acquisition of knowledge proceeded rapidly and Acquisition of knowledge proceeded rapidly and

importantimportant discoveries were made.discoveries were made. Pioneers, as exemplified by vonPioneers, as exemplified by von Graefe, von Graefe, von

Helmholtz, Fuchs, and Gullstrand, to mention a few Helmholtz, Fuchs, and Gullstrand, to mention a few contributed a lot.contributed a lot.

This rapid progress was slowed between 1914 and This rapid progress was slowed between 1914 and 1945 by the1945 by the darkness of the World Wars.darkness of the World Wars.

Ridley's work and the successRidley's work and the success of many others of many others during and after World War II helped remedy this.during and after World War II helped remedy this.


Cataract Surgery in Antiquity

Arab to Latin / Europe

ArabsK itab-e-susrud

8th cent

G reece/R om an28-40AD

IndiaSushruta

1000 yrs BC


1000 years BC Sanskrit Sanskrit

manuscripts 5th manuscripts 5th century B.C. century B.C. describe describe couching. couching.

Couching was Couching was perfected by perfected by Sustruta (the Sustruta (the Hippocrates of Hippocrates of India) in the 6th India) in the 6th century BC.century BC.

Mentioned in Mentioned in Mahabartha Mahabartha 1000yrs bc1000yrs bc


Partial Extracapsular Cataract Extraction

Predecessor- ArabsPredecessor- Arabs– Ammar ibn-e- Ali Almousali 100ADAmmar ibn-e- Ali Almousali 100AD

» Used metallic hollow needle (al miqdah) to aspirateUsed metallic hollow needle (al miqdah) to aspirate John Daviel 1745-48John Daviel 1745-48

– E Cap from Inferior limbusE Cap from Inferior limbus


In Toto Extraction(ICCE)

Samuel Sharp LondonSamuel Sharp London– Ideal InstrumentIdeal Instrument

» The thumb Col SmithThe thumb Col Smith» Capsular forceps H AurugaCapsular forceps H Auruga» Erysiphake(Phako erysis} Ignacio Barraquarre Erysiphake(Phako erysis} Ignacio Barraquarre

19171917» Cryo ExtractionCryo Extraction


Cataract Surgery in the 20th Century

Enzymatic ZonulysisEnzymatic Zonulysis» In 1957, Barraquer of Spain used In 1957, Barraquer of Spain used

alpha-chymotrypsin to enzymatically alpha-chymotrypsin to enzymatically dissolve the zonules for removal of the dissolve the zonules for removal of the lens. lens.

Cryo SurgeryCryo Surgery» In 1961, Krawicz of Poland removed In 1961, Krawicz of Poland removed

the lens with a tiny probe attached by the lens with a tiny probe attached by freezing a small area on the surface of freezing a small area on the surface of the cataract. the cataract.

Ultrasonic EmulsificationUltrasonic Emulsification» In the late 1960s, Charles Kelman of In the late 1960s, Charles Kelman of

New York developed a technique for New York developed a technique for emulsifying the lens contents using emulsifying the lens contents using ultrasonic vibrations and aspirating ultrasonic vibrations and aspirating the emulsified cataract. the emulsified cataract.


Development of Micro Surgery

– AnesthesiaAnesthesia» Topical (Koller- Cocain 1884)Topical (Koller- Cocain 1884)» Reterobulbar(Elchnig 1928)Reterobulbar(Elchnig 1928)

– SuturesSutures» Silk (Williams 1865)Silk (Williams 1865)» Conjunctival (JA Barraquarre 1880)Conjunctival (JA Barraquarre 1880)» Corneoscleral (Kalt 1894)Corneoscleral (Kalt 1894)

– Microscopes Microscopes – The first eye surgery performed with an operating The first eye surgery performed with an operating

microscope was done in Portland, Oregon, in 1948 microscope was done in Portland, Oregon, in 1948 » Zeiss 1955Zeiss 1955» JJB 1964-1966JJB 1964-1966

– Instruments & Mechanization& adjuvantsInstruments & Mechanization& adjuvants» I/A machines, Phaco, ViscoelasticsI/A machines, Phaco, Viscoelastics


Sir Harold Ridley, Kt, MD, FRCS, FRS the inventor of IOL

– Dr Ridley was born in Dr Ridley was born in Kibworth, Leicestershire, Kibworth, Leicestershire, England, onEngland, on July 10, July 10, 1906.1906.

– One of the founders of One of the founders of the modern the modern subspecialty of cataract subspecialty of cataract and refractive surgery, and refractive surgery, passed away on May passed away on May 25, 2001, just 6 weeks 25, 2001, just 6 weeks before his 95th birthdaybefore his 95th birthday


First IOL: A Secondary Procedure

– The insertion of the The insertion of the pseudophakos pseudophakos manufacturedmanufactured by by Rayner Ltd, Rayner Ltd, London, was a London, was a secondary secondary procedure procedure performed onperformed on

February 8, 1950, February 8, 1950, after Ridley had after Ridley had verified that the eye verified that the eye waswas quiet and quiet and suitable for suitable for implantationimplantation

(David Spalton, MD, written(David Spalton, MD, written communication, December 1998).communication, December 1998).


"foreign body" in the eye?

– Sir Harold Ridley Sir Harold Ridley performed first performed first IOL implantation IOL implantation on November 29, on November 29, 1949.1949.

long-standing long-standing dogma that one dogma that one "should never "should never put a foreign put a foreign body into the body into the delicate tissues delicate tissues of the eye“of the eye“


non–IOL-related contributions

– A pigmented fundus tumor A pigmented fundus tumor treated by irradiation, 1971treated by irradiation, 1971

– an early keratoprosthesis, an early keratoprosthesis, fabricated from pmma fabricated from pmma designed by Ridleydesigned by Ridley

– Ridley was the first to televise Ridley was the first to televise eye operations in 1950eye operations in 1950


Sir Harold Ridley, Kt, MD, FRCS, FRS the inventor of IOL

– Sir Harold Ridley Sir Harold Ridley performed first IOL performed first IOL implantation on implantation on November 29, November 29, 1949.1949.

long-long-standing standing dogma that dogma that one "should one "should never put a never put a foreign body foreign body into the into the delicate delicate tissues of tissues of the eye“the eye“


Era of IOLs

» Rigid AC IOLRigid AC IOL Barron, Strampeli Barron, Strampeli

1952-19531952-1953» Flexible AC IOLFlexible AC IOL

Closed Loop Closed Loop Danheim 1956Danheim 1956

Open Loop J Open Loop J shaped J Barraquer shaped J Barraquer 19581958

» Pupil SupportedPupil Supported Epstein Epstein

Binkhorst,Worst Binkhorst,Worst 60s-70s60s-70s

» New AC IOLNew AC IOL Choyece, KelmannChoyece, Kelmann

»PC IOLPC IOLShearing 1976 (J Shearing 1976 (J Loop)Loop)SinskieSinskieSimcoe (C Loop)Simcoe (C Loop)KartzKartz

»Intra Bag IOLsIntra Bag IOLs

»Foldable IOLFoldable IOL

»Phaco-Ersatz Phaco-Ersatz

»M B focal/ accomM B focal/ accom


The greatest fear known to man is a new idea.

PhacoemulsificationPhacoemulsification was first was first introduced in 1967introduced in 1967– 1969 “Charlie has produced an operation which will

take all the fun out of cataract surgery.”– 1974 “The use of the phaco machine for the

removal of a cataractous lens is analogous to the shooting of game birds with guided missiles.”

If you have strong reasons to believe in your If you have strong reasons to believe in your ideas, have confidence—face the brickbats and ideas, have confidence—face the brickbats and go ahead.—Harold Ridley, MA, MD, FRCS. go ahead.—Harold Ridley, MA, MD, FRCS.


Evolution of Phaco The 1960s - The BeginningThe 1960s - The Beginning The 1970s - Moving PosteriorlyThe 1970s - Moving Posteriorly The 1980s - The Capsulorrhexis EraThe 1980s - The Capsulorrhexis Era The 1990s - The Era of Reduced Emulsification The 1990s - The Era of Reduced Emulsification

EnergyEnergy From 1985 to 1995- a From 1985 to 1995- a ““dramatic phaco revolutiondramatic phaco revolution””

The The less than 10% of surgeons using less than 10% of surgeons using phaco in the phaco in the early 1980s rocketed to 95% by early 1980s rocketed to 95% by 1995. 1995.

The 2000s - An Era of Alternative Energies and The 2000s - An Era of Alternative Energies and Further Further Reduction of Ultrasound Reduction of Ultrasound EnergyEnergy

Cataract & Refractive Surgery Today

Treatment Options

GlassesGlasses: Cataract alters the refractive power of the natural : Cataract alters the refractive power of the natural lens so glasses may allow good vision to be maintained.lens so glasses may allow good vision to be maintained.

Surgical removalSurgical removal: when visual acuity can't be improved : when visual acuity can't be improved with glasses.with glasses.

Surgical techniquesSurgical techniques– Phacoemulsification method….Phacoemulsification method….– Extracapsular method.Extracapsular method.– Intracapsular methodIntracapsular method

Pre-op assesments General health evaluation including blood pressure checkGeneral health evaluation including blood pressure check Assessment of patients’ ability to co-operate with the procedure Assessment of patients’ ability to co-operate with the procedure

and lie reasonably flat during surgeryand lie reasonably flat during surgery Instruction on eye drop instillationInstruction on eye drop instillation The eyes should have a normal pressure, or any pre-existing The eyes should have a normal pressure, or any pre-existing

glaucoma should be adequately controlled on medications.glaucoma should be adequately controlled on medications. An operating microscope is needed, in order to reach the lens, a An operating microscope is needed, in order to reach the lens, a

small corneal incision is made close to the limbus for the phaco-small corneal incision is made close to the limbus for the phaco-probe.probe.

It is important to appreciate anterior chamber depth and to keep It is important to appreciate anterior chamber depth and to keep all instruments away from the corneal endothelium in the plane all instruments away from the corneal endothelium in the plane of the iris.of the iris.

Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The same tip is used to suction out the lens

Phacoemulsification:1.1. Corneal incision 2.75-3.2 mmCorneal incision 2.75-3.2 mm2.2. Viscoelastic to anterior chamber.Viscoelastic to anterior chamber.3.3. CapsulorhexisCapsulorhexis4.4. Hydrodissection.Hydrodissection.5.5. Phacoemulsification of the nucleus.Phacoemulsification of the nucleus.6.6. Aspiration of the cortex.Aspiration of the cortex.7.7. More viscoelastic.More viscoelastic.8.8. FoldedFolded intraocular lens (IOL) is inserted under a intraocular lens (IOL) is inserted under a

cushion of viscoelastic fluid which protect the corneal cushion of viscoelastic fluid which protect the corneal endothelium, the lens endothelium, the lens unfold unfold spontaneously within the spontaneously within the capsular bag.capsular bag.

9.9. Vescicoelastic removed and replaced with balanced Vescicoelastic removed and replaced with balanced salt solution.salt solution.

10.10. Self sealing wound.Self sealing wound.11.11. Sub conjunctival injection of steroid and antibioticsSub conjunctival injection of steroid and antibiotics12.12. Eyepad and protection eye shield.Eyepad and protection eye shield.

Postoperative care after cataract surgery

• SteroidSteroid drops (inflammation) drops (inflammation)• AntibioticAntibiotic drops (infection) drops (infection)• AvoidAvoid

• Very strenuous exertion (rise the pressure in the eyeball)Very strenuous exertion (rise the pressure in the eyeball)• Ocular trauma.Ocular trauma.


History of foldable IOLs

.

OCULAR SURGERY NEWS 6/1/2007

Erin L. Boyle

“I longed for a method of IOL insertion

that would not require me to

enlarge the [phaco] wound.”

Thomas R Mosacco MD


FDA approved the lenses forinsertion in 1984, (Figure 2)

Early lenses by STAAR Surgical Company included the first foldable posterior chamber IOL, model AA 4004 and the AQ 2010V .

STAAR Surgical STAAR Surgical Company producedCompany producedboth one- and three-both one- and three-piece IOLspiece IOLs


The Ideal Foldable IOL Smaller IncisionsSmaller Incisions Surgeon friendly implantationSurgeon friendly implantation

– Durable and flexibleDurable and flexible– Compatible delivery systemCompatible delivery system

Centration & Fixation in Capsular BagCentration & Fixation in Capsular Bag Excellent visual out comeExcellent visual out come No Inflammatory responseNo Inflammatory response No PCONo PCO Spectacle IndependenceSpectacle Independence


Foldable IOL Materials

SiliconeSilicone AcrylicAcrylic

– Hydrophylic(Hydrogel)Hydrophylic(Hydrogel)– HydrophobicHydrophobic

CollamerCollamer

Foldable IOL MaterialsSTAAR Collamer

Alcon SA-60

STAAR Plate

AMO Sensar


What Criteria are Most Important to Surgeons

Wound sizeWound size CentrationCentration Ease of Ease of

InsertionInsertion Optical QualityOptical Quality BiocompatibilityBiocompatibility

OPC ratesOPC rates YAG YAG

ResistanceResistance Post-op Post-op

InflammationInflammation DysphotopsiasDysphotopsias


So How Do We Choose?

No one perfect lensNo one perfect lens Many very good to excellent IOLSMany very good to excellent IOLS Patient SelectionPatient Selection Try and get good with severalTry and get good with several Continually re-evaluateContinually re-evaluate


Approach to the Cataract Patient

Education Spectacle

Independence? Multifocal? Accommodating?


Choosing an IOL?


Choosing an IOL Surgeon’ ViewSurgeon’ View

– The LensThe Lens» MaterialMaterial» DesignDesign» CostCost

– The ProcedureThe Procedure» Wound SizeWound Size» Easy, Safe, Quick, Easy, Safe, Quick,

InsertionInsertion– Post OpPost Op

» Visual OutcomeVisual Outcome» InflammationInflammation» PCOPCO» DysphotopsiaDysphotopsia

Patient FactorsPatient Factors– MotivationMotivation– Life StyleLife Style– Different Models and Different Models and

Makes?Makes?– Cost Cost CostCost Cost Cost


Choosing an IOL-The Material

SiliconeSilicone AcrylicAcrylic

– Hydrophylic(Hydrogel)Hydrophylic(Hydrogel)– HydrophobicHydrophobic

CollamerCollamer


The Acrysof Family


The Acrysof Family-Premium IOLs


Choosing an IOL-The Procedure

Avoid small errors to add up into a big Avoid small errors to add up into a big surprisesurprise

minimize SIAminimize SIA Aim at Thorough Cortical clearance&Aim at Thorough Cortical clearance& In the Bag Implantation with sub optical In the Bag Implantation with sub optical

RhexisRhexis


Choosing an IOL-The Insertion Systems

ForcepsForceps Injection SystemsInjection Systems

I/A with foldable IOL


Phacoemulsification of hyper mature cataract with multifocal iol implantation




Acrisof SPAlcon Collamer STAR


Acrisof Restore Idea Excellens




Wound sizeWound size CentrationCentration Ease of Ease of

InsertionInsertion Optical QualityOptical Quality BiocompatibilityBiocompatibility

OPC ratesOPC rates YAG YAG

ResistanceResistance Post-op Post-op

InflammationInflammation DysphotopsiasDysphotopsias



No one perfect lensNo one perfect lens Many very good to excellent IOLSMany very good to excellent IOLS Patient SelectionPatient Selection Try and get good with severalTry and get good with several Continually re-evaluateContinually re-evaluate


Experience with Acrysof Platform

Since the Jan 2007 to Dec 2008, 200 Acrysof IOLs were implanted during

phacoemulsification cataract surgery. All patients were between 40 and 85 years of age (female – 119, male – 81).

In the first 150 cases we used 3.2 mm incisions. In the other 50 cases 2.75 mm clear corneal incisions were utilized.


Experience with Acrysof Platform

The surgery went smooth, with no intra- or postoperative complications. It was very convenient to attach the cartridge with IOL inside to the injector. During the implantation controlled smooth unfolding was observed. We did not observe any adverse effects related to the lens and/or the injection system.


21st Century Cataract surgery will have to be:

Highly efficient and safeHighly efficient and safe Universally availableUniversally available Economically affordableEconomically affordable Able to restore true functionality of LensAble to restore true functionality of Lens

– Truly continuous dynamic accomodationTruly continuous dynamic accomodationMission impossible


What’s Ahead Preloaded LensesPreloaded Lenses Multi-focal LensesMulti-focal Lenses Thin LensesThin Lenses Phakic LensesPhakic Lenses Adjustable LensesAdjustable Lenses Accommodating LensesAccommodating Lenses Injectable IOLsInjectable IOLs Toric LensesToric Lenses Custom LensesCustom Lenses


Multifocal IOLs

DiffractveDiffractve RefractiveRefractive


Accomodating IOLs


Light Adjustable IOLs


What’s a Surgeon to do?

Enhance Two Handed SkillsEnhance Two Handed Skills Try to manage patient expectationsTry to manage patient expectations Minimize ComplicationsMinimize Complications Select IOL based on objective dataSelect IOL based on objective data


Summary-Choosing an IOL The MaterialThe Material

– HydrophobicHydrophobic– HydrophylicHydrophylic

DesignDesign– Square edgeSquare edge– Two haptics SPTwo haptics SP– Four ears SPFour ears SP– Plate?Plate?

CostCost

Insertion SystemInsertion System– PreloadedPreloaded– Monarch 2 Acrysof Monarch 2 Acrysof

PlatformPlatform CentrationCentration

– Surgeon’ roleSurgeon’ role PCOPCO

– Square edge more Square edge more important than important than materiamateria

The Whole Package

Rapid, Safe, Smooth Two Handed Rapid, Safe, Smooth Two Handed Surgery with time tested lens implant Surgery with time tested lens implant aiming at true spectacle independenceaiming at true spectacle independence


IOL a Miracle

"Even when a miracle becomes routine, it still "Even when a miracle becomes routine, it still remains a miracle." We thank Harold Ridley remains a miracle." We thank Harold Ridley for providing us with this miracle. for providing us with this miracle.

Lay sans bhi ahista keh nazuk hai buht kamAfaq ki is kargah – e -shisha gari ka

Undergraduate Lecture-Visual rehabilitation after Cataract Surgery

Health & Medicine

Transcript of Undergraduate Lecture-Visual rehabilitation after Cataract Surgery