• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Nw2012 cataract surgery11
 

Nw2012 cataract surgery11

on

  • 427 views

cataract surgery

cataract surgery
- brief history
- ECCE and Phaco for beginners

Statistics

Views

Total Views
427
Views on SlideShare
427
Embed Views
0

Actions

Likes
0
Downloads
55
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Nw2012 cataract surgery11 Nw2012 cataract surgery11 Presentation Transcript

    • Nawat Watanachai Chiangmai University Hospital 2013
    • 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 cataract 2010 Phaco 1967
    • 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 thaichina  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%
    • History : ICCE and ECCE  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
    • History : ICCE and ECCE  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 Surgeon view  Another radial snip  150-180’  Clean tenon/ stop bleeding
    • 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  capsulorhexis
    • Phaco step 1 : capsulorhexis  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
    • Phaco step 1 : capsulorhexis  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 
    • Phaco step 1 : capsulorhexis  Inject viscoelastic  Slow and steady  Push the aqueous out
    • Phaco step 1 : capsulorhexis  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
    • Phaco step 1 : capsulorhexis  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
    • Phaco step 1 : capsulorhexis  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
    • Phaco step 1 : capsulorhexis  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 Leakage Clear cornea 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
    • Phaco step 3 : Hydrodissection 10:00 2:00 Create fluid wave at 10 and 2 o’clock
    • Phaco step 3 : Hydrodissection
    • Phaco setp 3 : Hydrodissection  Option : Hydrodeliniation  Separate nucleus from epinucleus  Golden ring sign (Abe T, JJO 2001)
    • Phaco setp 3 : Hydrodissection  Potential complications  Radial tear
    • Phaco setp 3 : Hydrodissection  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.
    • Phaco setp 3 : Hydrodissection  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
    • DIVIDE & CONQUER 1 2
    • DIVIDE & CONQUER 4 3 5 6
    • sculpting 3 DO NOT occlude the tip during sculpting
    • DIVIDE & CONQUER 7 8
    • DIVIDE & CONQUER 12 13
    • 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
    • Phaco step 4 : Phacoemulsification  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
    • 2 1 Phaco chop 3
    • Phaco chop 5 4 6 7
    • Phaco chop 8 10 9 11
    • Phaco chop 12 13 14 15
    • Phaco step 4 : Phacoemulsification  Basic technique  4. Stop and Chop phaco  For very hard nucleus  Create groove as in divide-and-conquer  Crack  Rotate the nucleus 6090’  phacochop
    • Stop and chop 1 2 3
    • Stop and chop 5 6 7 8
    • 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
    • Phaco step 6 : IOL implantation
    • Phaco step 6 : IOL implantation  Potential complication  Place IOL up-side down  Can leave as is - accept myopic shift  Take one haptic out of wound with Sinsky hook Fill with OVD above and below IOL One hook above and one below -- Flip IOL
    • Phaco step 6 : IOL implantation  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
    • Phaco step 6 : IOL implantation  Tear in Descemet's  Double AC sign  Use care to not extend tear  Place Air Bubble at end of case – post op position 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 IOL With 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 95
    • 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 laserassisted 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
    • Femtosecond clear corneal incision  corneal incision  Controlled  reproducible  configuration  less risk of wound leak  --> less infection
    • 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 capsulotomy incidence 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;32:13615.  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 105
    • Femtosecond cataract surgery : Video 106
    • Femtosecond cataract surgery : Video 107
    • 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!!!!