Lens & Cataract: Notes

Lens & Cataract
Dr Yong Meng Hsien
Lecturer & Ophthalmologist, UKM & HCTM
yongmenghsien@ppukm.ukm.edu.my
Last edited: Feb 2022

Lens Pathology (Clinical)
• Cataract VS Non-Cataract
• Cataract: congenital VS acquired
• Acquired cataract: senile/age related VS secondary
• Secondary cataract: systemic VS local causes
• Aphakia & pseudo-phakia related
• Abnormal lens location
– Ectopia lentis
• Abnormal lens shape
– Lenticonus/globus
– Micro-sphero-phakia
– Coloboma

Acquired Cataract
– Age related
– Systemic disease
• DM- cortical vacuole, snow flakes, early NS
• MD- cortical iridescent/Christmas tree (30s) → wedge/star
like/stellate CC (50s)
• Atopic dermatitis (severe case, 10%, 20-40s)- ASCC (Shield-like), PSCC
• NF2 (60%)- early PSCC/CC
– Secondary
• Inflammation/uveitis- PSCC/ASCC @poles +- polychromatic
• Steroid- PSCC
• AACG- glaukomflecken (focal infarct of epiT)/ASCC
• High myopia- early NS/PSCC
• Hereditary fundus dystrophy (RP/Stickler/gyrate/Leber)- PSCC
– Traumatic
• Blunt trauma- vossius ring, flower A/PSCC
• Others: electric (stellate/snowflake/milky white), infrared
(exfoliation), ocular radiation (PSCC)

Cataract- Special names/Signs
• Christmas tree CC- age-related, MD (30s)
• Multicolour flecks- MD, hypoPTH
• Snowflakes CC- classic diabetic cataract (young/acute), electric shock
• Star like/Stellate CC- MD (50s), electric
• Shield like ASCC- atopic dermatitis
• Flower A/PSCC- blunt trauma
• Green sunflower- Wilson
• Thin disciform- Lowe
• Vacoular- DM
• Vossius ring- blunt trauma
• Glass blower cataract- true exfoliation (ant capsule)
• Glaukomflecken- ant epiT necrosis at AACG
• Oil-droplet cataract- galactosemia (days/weeks of life)
• Punctate in spokelike pattern PSCC- mannosidosis, Fabry
• Pearly NS- intrauterine rubella (15%)
• Lamellar opacities/riders (radial extension)- congenital (>AD or metabolic/intrauterine ifx)
• Nuclear, blue dot opacities- congenital, Down’s
• Coronary (supranuclear)- congenital (sporadic/hereditary)
• Posterior polar- Mittendorf dot, post lenticonus
• Anterior polar- ant seg dysgenesis (aniridia/Peter), PPM, ant lenticonus (Alport’s)
• Y/sutural- Nance Horan female carrier
• Soemmering ring- epithelium proliferation at CCC/capsulorhexis edge (from equatorial lens fiber)
• Wedl/bladder cell/Elschnig pearl - PSCC swollen migratory epiT cells or PCO
• Brunescent (hard brown NS)/intumescent (swelling)
• Morgagnian globule/cataract- CC eosinophilic fluid with sinking nucleus
• Golden/dark ring sign- cleavage btw endo-epi-nucleus @hydrodeniation
• Argentina flap sign- extended CCC with lens material bulging fwd
• Pupil-snap sign- PCR with pupil constrict then dilate back

PSCC- causes
• senile (but younger)
• steroid
• DM
• radiation (PC punctate/AC feathery)
• trauma (PC/AC rosette)
• alcohol
• inflammation/uveitis
• muscular dystrophia
• NF2
• atopic dermatitis
• degenerative myopia

Traumatic Cataract- Causes & Signs
Mechanical (blunt/penetrating trauma)
• Vossius ring (iris pigment)
• Rosette
• Subluxated/dislocated (zonule)
Physical
• radiation PC punctate/AC feathery
• UV/sunlight CC
• microwave AS/PSCC
• IR/glass bower exfoliation/outer lamellar (capsule)
• electrical ant vacuole/linear ASCC (protein coagulation)
• chemical alkali cataract (reduce Aq glucose/ascorbic acid)
• iron siderosis AS/PSCC or CC
• copper chalosis sunflower/petal-shaped ASCC

+ Ehlers-Danlos syndrome
+ Hyperlysinemia
+ isolated EL
+ EL et pupillae
+ lens coloboma
+ micro/sphero-phakia

Ectopia Lentis
• Primary (familial/sporadic)
• Secondary (systemic dz/IEM & ocular abn/trauma)
• Mx: optical correction (pre/post-dilatation) → surgery (scleral/iris-claw IOL/aphakia)
Ocular
1. Isolated EL: AD, BL/sym/sup-tem, a/w glaucoma
2. EL et pupillae: AR, BL/sym/lens sup-nasal + pupil inf-tem, a/w miosis
3. Micro-Sphero-phakia (small & sphere): dislocated to AC/pupillary block glaucoma, a/w
EL et pupillae, Weill-Marchesani
4. Coloboma (flattening/notch @inf. nasal, abn/absent zonule): +-suptem dislocation
5. Trauma
6. Aniridia
Systemic
1. Marfan: AD (Chr15/fibrillin), BL/sym/sup tem (intact zonule), a/w
CVS/MSK/miosis/corneal plana/myopic
2. Homoscystinuria: AR (cystathionine B synthase defect), BL/inf (to AC, broken zonule),
a/w MSK (marfan-like)/CNS (mental/fits)/vascular (thromboembolic)
3. Weill-Marchesani: AD/AR, microspherophakia to AC, a/w MSK (opposite Marfan)
4. Sulfite oxidase defeciency: Molybdenum cofactor defect, a/w severe CNS
(hemiplegia/fits)/brain damage by 5yo

Microspherophakia- DDx
• association
– Weil Marchesani
– Peter
– Marfan
– Alport
– Lowe
– congenital rubella
• Other risk
– ACG (pupillary block)
– high myopia

Subluxated IOL/Decentration
• Causes
– Primary: surgical placement
– Secondary (external): trauma, rubbing, laser capsulotomy
– Secondary (internal): scarring/fibrosis/ contraction/PAS, size disparity, large
CCC
• Course
– Early: PCR/zonular dialysis
– Late: zonular weakness (trauma/PEX/surgery/CTD)
• Complications
– complete drop to retina +- tear/RD
– VH due to uvea contact (CB)
– VMT with traction/CMO/RD
– IOL block glaucoma
– corneal contact (IOL/vitreous)

Aim
Monofocal
• Emmetropia/low myopia (avoid hyperopia)
• Astig <1.0D
• Monovision
–1 eye emmetropia (SE-0 for far) 1 eye myopia (SE -0.5 to -1.5 for near,
micro-mini-classic)
•Need adaptation
•Affect depth perception/BSV
Multifocal/EDOF
• Emmetropia for multifocal
• micro-monovision (0.5D) for EDOF
• Astig <0.5D

Cataract & Biometry
•+- 0.5D = acceptable
•Old formula = 80%, new formula 90%
•Types
–Regression: SRK/T
–Vergence (optic) with variables: 2 (SRK/T, Holladay I, Hoffer Q),
3 (Haigis), 5 (Barrett), 7 (Holladay II), Barrett II (theoretical
paraxial ray tracing, Gaussian optic),)
–AI/data driven: Hill-RBF (in or out bound- 90% +-0.5D)
–Ray tracing: Olsen (asphericities & aberration of cornea & IOL)
• Generation
– 3rd Gen: SRK-T, Holladay, Hoffer Q
– 4th/5th Gen: Haigis, Holladay II, Barrett II, Hill-RBF, Oslen (need
ACD/Lens thickness)

Biometry
• challenge in
– high myopia
– post refractive surgery
• doctor-hill.com
• iolcal.ascrs.com
– Triangular principle (multiple source/scan)

Biometry for high myope
• Optical biometers- uses single index of
refraction for AXL  intrinsic error increases
in a linear fashion as the AXL increases 
longer myopic eyes = largest error 
overestimated AXL  hyperopic surprise
• Wang-Koch (W-K) formula:
– Adjusted AXL= (measured AXL x 0.8289) + 4.2663
– for AXL >26
• +- use CTR to stabilize EPL

Keratometry
• optimised ocular surface
• CL discontinuation:
– soft 7 days, toric 14 days,
– RGB: initial & 14 & 21 days until stability

Previous refractive surgery
• difficult to accurately assess anterior and posterior corneal power and
astigmatism  proper counselling (refractive surprise)
• utilize more than one methods
• Calculation of corneal power
– corneal tomo (total corneal power, TK, TNP, TCRP)
– refractive history method
– contact lens method
– Agreement between various K values should be checked while erring toward
selecting lower K values.
• Calculation of IOL power
– new formula
– different methods
– software/calculator
– Imaging (aberrometer)

Biometry for Post LASIK
• IOL power is underestimated (hyperopic surprise) post-myopic LASIK and RK
• overestimated post-hyperopic LASIK.
• Better to err toward postoperative myopia, which is easier to correct than
hyperopia
– aim -0.50D if K> 41
– aim -0.75D if K< 41
• Formula: Wang-Koch-Hill ASCRS online calculator; Barrett True K No History; No
History Shammas-PL; Haigis-L
• Methods: Aramberri Double K method corrects effective lens position in SRK/T,
Holladay-1 and Hoffer-Q formulas.
• Software: Hoffer-Savini LASIK IOL power tool allows simultaneous calculation of
various formulas to obtain possible K values.
• Intraoperative aberrometry. (not for post RK- the incision opened during op/IOP
fluctuation)
• Negative spherical aberration IOLs benefit patients with previous myopic LASIK.
Hyperopic LASIK induces negative spherical aberration and they benefit with
traditional spherical IOLs.

Biometry for premium IOL
• total corneal irregular astigmatism <0.300um.
• All premium lenses are aspheric to control
chromatic aberration
–respective total corneal spherical aberration is
between 1.00um and 3.00um.
• These features minutely affect the quality of
vision but can add to ghosting, glare, halos,
and overall patient dissatisfaction.

Types of IOL
• Monofocal
• Monofocal plus
• Toric
– cylinder component
– positioning
Presbyopic correcting:-
• Multifocal
– refractive
– diffractive
– accommodative (IOL flex)
– +- post op glare
• EDOF
• EDOF + multifocal
• Adjustable
– post op UV radiation  molecule polymerization  change power

IOL- Properties
• Piece- one, three
• Material- acrylic (hydro-phobic/philic), silicone, PMMA
• Haptic- plate/square, C/J loops, 2 or 4
• Spheric/aspheric (like corneal surface, better contrast sensitivity)
– aspheric: less aberration but not for abn corneal curvature (more
aberration)
• Square-edge optic
– less PCO
– more glare/dysphotopsia
• Filter/coat
– heparin coated: less inflam/uveitic cell attachment
– UV filter (all IOL)
– blue filter/yellow tinted: retina protection but poorer scotopic vision

Compare IOL material
Acrylic
(hydrophobic)
Acrylic
(hydrophilic/
hydrogel)
Silicone PMMA
(polymethyl-
methacrylate )
Thinner
(higher refractive
index)
Thicker but >
biocompatible
>biocompatible unfoldable
> Glare < Glare
< PCO > PCO >> PCO >>>PCO
> Reaction (in
uveitic eye)
Old incidence of
calcification
Reaction with SO-
filled eye
Collamer: composed of collagen, a poly-HEMA-based copolymer and an
ultaviolet-absorbing chromophore.

IOL Specific
• previous myopic LASIK  negative spherical
aberration
• previous hyperopic LASIK (induced negative
spherical aberration)  traditional spherical
IOLs.

Cataract & Cochrane
•Multifocal IOL VS monofocal/monovision 2016 June
–Multifocal:
•better near V (same as monovision)
•less spectacle dependent  deciding factor!
•but more halo & glare
•IOL in uveitis eyes 2014 March
–Acrylic hydrophobic: superior in only single study-
insufficient data
•Blue filter protects macula 2018 May
–No evidence of superiority (VA/macula health)
•NSAIDS for post op CMO
–Acute (4/12) & chronic: 2 trials positive effect in chronic

New IOL- small aperture
• for very high degrees of irregular corneas such as after
keratoplasty or RK/LASIK
• Small-aperture IOL AcuFocus IC-8
– single-piece/hydrophobic acrylic
– centrally located opaque annular mask 3.23mm with 1.36
mm central aperture
– pinhole effect  3.0D of extended depth of focus by
blocking unfocussed peripheral light rays and isolating
more focused central and paracentral rays through the
centre aperture
• XtraFocus Pinhole implant (Morcher)
– sulcus IOL made of black acrylic with a central pinhole.

OVD
The Rheologic characteristics:
Visco Elastics Should Possess CCD
• Viscosity (reflects a solution's resistance to flow, which is in part a function of the
molecular weight of the substance
• Elasticity (Elasticity refers to the ability of a solution to return to its original shape
after being stressed)
• Surface tension
• Pseudoplasticity = rheofluidity (refers to a solution's ability to transform when
under pressure, from a gel-like substance to a more liquid substance)
• Coatability: It measures the adhesion capacity of OVDs. It is inversely proportional
to surface tension and the contact angle between the OVD and a solid material.
• Cohesiveness: Cohesiveness is the degree to which material adheres to itself.
• Dispersiveness: It is the tendency of a material to disperse when injected into the
anterior chamber.

Astigmatism & Cataract
& Toric IOL

Astigmatism for cataract operation
• Astigmatism with only anterior corneal topo
1. Set the limit of astigmatism you need to correct, e.g 1D in monofocal,
0.5D in multifocal
2. If ATR, post astig is underestimated (~0.3)
3. If WTR, post astig is overestimated (~0.6)
4. WTR the D is higher  the overestimate is more
5. ATR the D is higher  the underestimate is relatively stable
Hence 
1. If pt +borderline high astig (e.g -0.75D), ATR KIV offer toric
(underestimate), WTR no need offer (overestimate)
2. If pt +very high astig (> -2D) and planned for toric, need multi
measurements (preferably posterior measurement) in WTR (vs ATR)
3. Use Barrett toric calculator- with predicted PCA

Astigmatism for cataract operation & Toric IOL
• Astigmatism with only anterior corneal topo
2. Set the limit of astigmatism you need to correct, e.g 1D in monofocal, 0.5D in
multifocal
3. Post corneal curv = ATR lens -0.3 to -0.8 (WTR +0.3 to +0.8)
4. If ATR, total astig is underestimated (~0.3)
5. If WTR, total astig is overestimated (~0.6)
6. WTR the D is higher  the overestimate is more
7. ATR the D is higher  the underestimate is relatively stable
Hence 
1. If pt +borderline high astig (e.g -0.75D), ATR KIV offer toric (underestimate),
WTR no need offer (overestimate)
2. If pt +very high astig (> -2D) and planned for toric, need multi measurements
(preferably posterior measurement) in WTR (vs ATR)

Astigmatism & Corneal Curvature
• Post corneal curv = ATR lens -0.3 to -0.8 (WTR +0.3 to
+0.8)
• Increasing age toward ATR but more @ant curv, less
@post curv
• Young pt >WTR, post curv (>ATR) compensate the ant
curv.
• WTR  > predictable for PCA vs ATR  less
predictable for PCA
• Corneal ref surg  error in std corneal power & ELP
prediction
– underestimate iol power @prev myopic LRS
– overestimate iol power @prev hyperop LRS

Tomography for Astigmatism
• identify irregular astigmatism and avoid toric
• Scheimpflug- error 0.6D in WTR, 0.1D in ATR
• Baylor nomogram
• Regression approach
• Fixed ratio error 0.5D
• Intraop aberrometry

Calculation for toric IOL
• Preferably 2 different devices for K 
integrated K
• Take into account PCA
• Barrett toric calculator
– with predicted PCA
– with measured PCA

• leave about 0.25 D of WTR astigmatism  allow aging
toward ATR
– corneal astigmatism continues to change towards ATR
astigmatism over 20 years after cataract surgery, similar in
eyes that did not have surgery
• flipping axis
• lowest available cylinder power at the IOL plane is 1D,
which corresponds to 0.67D at the corneal plane
• SIA variability (same meridian/incision size/surgeon)
•

Toric IOL realignment
• Confirm residual astig = result of lens rotation = BCVA
> UCVA
• BCVA = close to a SE of plano. (if refractive surprise
then IOL exchange or LVC)
• astigmatismfix.com showed can reduce astig till <0.5D
• wait a few days  cornea to refractively stabilize
• wait a week or so  capsule to contract slightly,
which helps keep the lens in a more stable position
after re-rotation
• OVD to inflater/open bag + make sure IOL is free
• late rotation of the IOL or in high myopes- consider
CTR

Residual Astig After Toric
• toric IOL rotation
• website astigmatismfix.com
• excimer laser vision correction

Toric Results Analyzer
(astigmatismfix.com)
• Data to enter
– patient’s manifest refraction with cylinder in plus
power
– the toric IOL model,
– the magnitude of astigmatism and axis of the toric
lens.
•Results
– the ideal position of the toric IOL for minimizing the
residual refractive error
– the magnitude and direction of rotation needed,
– expected residual refraction

Presbyopia & Cataract
& Presbyopic correcting IOL

Multifocal IOL
•General aspects
–Patient selection: not high demand/not understand
–Pre-op assessment:
surface/cornea/pupil/zonule/macula/ON
–Pre-op counseling: aberration, enhancement, neuroadapt
–Intra-op consideration: centration & stable
–Post-op: suboptimal result  Ix  Mx
•Aims
–Good near + distance (+- intermediate) V
–Spectacles independent (lifestyle IOL)
–Binocular multifocality without aberration (SE plano +
astig < 0.5 + stable center implantation)

Multifocal Pre-op
• Consideration
– occupation, demand on near-intermediate-far vision
– night glare, contrast/colour, ocular pathology
– questionnaire form, chair time
• Surface/cornea:
–Astig not > 0.5D (if more + toric), not irregular
–Aberration profile (pentacam HOA:
–Dry eye to treat
–Prev corneal ref surgery: high aberration, already multifocal
• Pupil
–Size <5mm (scotopic pupil increase glare)
–Iris no atrophy, zonule not weak, no PEX
–Decentered CCC/IOL 1mm poor outcome
• Macula/ON
–Good function, baseline OCT macula
–Angle kappa: Px+ Py <0.6 (Kappa angle)
–Multifocal IOL impaired TPPV visualization
• Biometry/AXL
–Optical biometry + new formula
–lens tilt, fixation OCT macula
–High AXL formula: Haigis/Holladay 2/SRK-T

Factors for multifocal IOL
•discourage premium IOLs in low-to-moderate
myopes with a low-grade cataract; similarly, due
to the added risk of postoperative peripheral
retinopathy, we never offer young myopic
patients multifocal clear lensectomy surgery.
• Hyperopic uncorrected distance vision is poor
and near is worse so overall, they’re easier to
please. Multifocal implant lenses can be very
rewarding when used in the appropriate patient.

Multifocal Post-op
•Optical aberration
–Reduced contrast & halo (esp at night)
–Photic phenomenon (decentered)
–Negative dysphotopsia (temporal shadow)
•Enhancement
–Piggyback IOL
–Corneal refractive surgery
–Exchange
•Neuroadaptation

Rescue radial tear @ CCC
• starting the capsulorhexis toward the centre of the anterior capsule and
tearing outward in a spiral that intersects itself at the desired diameter.
• Should a radial tear begin, the capsulotomy may be recovered by picking it
up from outside the tear and bringing it back toward the centre, rather
than trying to continue the tear from the inside out.
• If the tear extends past the iris, he recommends using hooks to get a
better view, which may allow completion of a circular capsulotomy.
• tear cannot be recovered, converting to a can-opener capsulotomy is an
option
• can-opener capsulotomy is at risk for additional radial tears, so the lens
should be prolapsed out of the bag before phacoemulsification, if
possible.
• The can-opener also may render the capsule unsuitable for in-the-bag
lenses

•Causes include difficulty initiating the tear,
poor visualisation due to white cataracts,
small pupils, young patients and calcified
capsules, each requiring its own approach.
•Flat anterior chambers can create abnormal
vector forces that push tears in unpredictable
directions, as do forceps with tips that don’t
quite line up

Mono-Vision
•micro monovision: – 0.5 D or less;
•mini monovision: 0.75 D to 1.00 D;
•modest monovision: 1.25 D to 1.50 D;
•traditional monovision: 1.75 D to 2.50 D.
•limiting the anisometropia to approximately –1.25 D
reduces the likelihood of a reduction in binocular contrast
sensitivity, asthenopia, and loss of stereoacuity that can
occur with higher levels of anisometropia.
• total spectacle independence is less frequent with a lower
level of myopia

Mini monovision with Eyhance
•ocular dominance with finger hole test
•Dominant: for distance. Aim -0.25
•Non dominant: for near. Aim -0.75
•Anisometropia 0.5-0.75

Phaco convert to ECCE
• identifying patients at risk
– Weak zonule/risk, hard lens, small pupil, floppy iris
– Consider: subtenon/peribulbar anest, sup limbal wound, stop anticoagulant, CTR
• indications for conversion
– PCR, zonular dialysis, anterior capsule tear/extended capsulorhexis, white cataract
• conversion from topical to sub-Tenon’s
• wound preparation
– New incision: close original incision (Nylon 10-10) → peritomy → limbal 3-step wound
– Extending incision: bring toward limbus then extend
• expressing the lens material
– zonules are weak/posterior capsule is torn: remove vitreous → OVD ++ → loop out lens in AC (min
pressure)
– If not: normal manual lens express (lens loop with counter pressure)
• closure of the wound
• placement of the IOL
– PC/sulcus/ACIOL (intact zonule/PC/AC)
• post-operative issues
• anterior vitrectomy
– tell-tale signs of vitreous prolapse: 1) deepening of the AC, 2) widening of the pupil, 3) lens material no
longer centered, 4) lens particles no longer come to phaco or I/A, and 5) the lens no longer rotates freely
– Cut low irrigate high
– cutting rate as high as possible when cutting vitreous and low when cutting cortical lens material
% incidence: 0.07% (ESCRS)
Prognosis: 50% VA improved/better than 6/12 (ESCRS)

Signs of PCR/Vitreous loss
PCR
• ring reflex @post capsule
• inability to aspirate
• outline of PCR
• pupil snap
• sudden deepening of AC
• fragment disappear
• vitreous loss
Vitreous loss
• sponge tap
• peaked pupil
• sweep test (rykoff) swing
pupil margin
• air bubble
• triamcinolone stain

PCR- Mx
• Principle: no panic, stop phaco/aspiration but keep
continuous irrigation, assess condition
– PCR to confirm & extension
– Vitreous loss
– nucleus/IOL/lens drop
• BSS plain, 2nd instrument out, OVD in (float last
segment/coat PC/tamponade ant vitreous) → phaco probe
min setting then out
• Residual lens: manual IA/vitrec cut/extend wound w rectis
loop/forcep, posterior assisted levitation (PAL) with
needle/OVD, IOL scaffold technique/lens glide
• Vitreous assess (x5) → ant vitrectomy (cut I/A setting/max
cut rate/bottle ht 40-50, vacumm 100)
• IOL placement/assess
• Post op CMO/endoph risk (gutt NSAIDs/steroid/Ab)

•IOL scaffold technique:
•A) Intravitreal triamcinolone acetonide is used to
stain vitreous. Vitrectomy performed.
•B) A three-piece IOL is injected under the nuclear
fragments.
•C) Phacoemulsification with the IOL acting as a
scaffold.
•D) Pars plana vitrectomy is performed for any
residual vitreous prolapse and aspirating residual
cortex by alternating between cut and aspirate
modes. The IOL is then transferred to the sulcus.

Retained lens material/lens drop
• risk: 0.3-1%
• Types:
– nucleus > inflam  glaucoma/CME/RD 15%
– cortex +- reabsorption (observe if low inflam)
• Mx: surgery
– if high IOP/inflam, nuclear fragment >2mm, no
PVD with liquefied vitreous (highly mobile)
– TPPV/nucleus removal (fragmentome or US
emulsification)/KIV tamponade/EL (if break)

Malpositioned IOL
• Def: decentered/tilted/dislocated (ant/post)
• Causes:
– Primary/Intraop: zonule/bag/capsule (esp PEX), placement
– Secondary/Postop: capsule/iris/vitreous, trauma/rubbing/fall,
early YAG capsulotomy
• SSx: edge bisect pupil/axis
– Cx: UGH/pupillary block/angle/cornea decomp/retina
• Mx: depends Sx/severity/Cx
– Decentered: Miotic/optical/PI/exchange
– Dislocated (ant): constrict pupil, lie supine, remove/exchange
– Dislocated (post): observe (blunt edge/periphery/solid
vitreous/N retina), tppv/reposition/explant

Post op High IOP
Early
• complicated op with
– aphakia/ACIOL/subluxated IOL
related glaucoma
– high inflammatory glaucoma
– retained lens particle/vitreous
@AC
–malignant glaucoma
• suprachoroidal hemorrhage
• OVD
• If DSEK: air bubble without PI
• If TPPV: gas/SO overfill
• If SB: over-tension
• If trabec: PI block/under filtration
Late
• Steroid induce
• Progress/worsening of
inflam/ischemia/NVG
• UGH
• Malignant glaucoma
• Epithelial down growth
• If TPPV: SO @AC/angle
• IF RD/VH: ghost
cell/hemolytic/Schwart
z Marsuo

Refractive surprise
• Preop
– biometry (operator/wrong eye/corneal surface d/o/post RS/CL
warpage)
– wrong formula/IOL selection/velocity selection
– Falsely shorter AXL @biometry
• > liquid (SO/aphakia/corneal edema)
• > front retina (choroidal effusion, RD)
• Intraop
– IOL location/tilted/upside down (more ant induce myopia, more post
induce hyperopia)
– complicated op/CCC/PCR
• Post op
– IOL shift (capsular fibrosis), dislocated/subluxated
– suture/wound induce astig (tight suture)
– CMO (hyperopic shift)
– corneal edema/inflam

IOL explant
•3-4mm incision (half of optic size)
•IOL to AC: OVD isolation fr bag/capsule, +180 degree
rotation free
•Cut IOL in AC to 60-80% (>half)
•Cutter: intraocular scissor, capsulorrhexis scissor
•IOL holding: grasper, tying forceps
•Grasp 1 end haptic then optic  explant  twist to
facilitate another end out (consider the haptic orientation)
•Others:
–New explanter: Alcon A catridge cut open on both side + 3’0
prolene attach to 20G needle
–Fold IOL in AC

TASS
• Toxic Anterior Segment Syndrome
• Acute/sterile/12-48H post op
– rarely: late onset
• Mx
– TRO endophthalmitis
– Steroid: topical

Myopic shift
• dry
• axial vs curvature vs index
• AC flattening
• Corneal steepening
• High IOP in paeds (elongated)
• Cataract (NS, oil droplet)

Hyperopic shift
• Lens/accommodation loss
–aging, botox, drug (cycloplegic/anti depressant)
• Lens position backward/posteriorly
–subluxation, small CCC
• Cornea flattening
–post op
• Retina/macula
–CSCR/ERD
• Globe shortening/compression
–retro-orbital mass

Compromised
bag/capsule/zonule

SFIOL (sutureless)
scleral flaps or scleral tunnels parallel to the limbus, or Hoffman pockets
Haptics can be externalized using 25-or 27-gauge forceps or 30G-thin wall needle
Scleral flaps can then be closed with 10-0 nylon or fibrin glue
IOL: sensar, CT lucia
Yamane technique involves externalizing the haptics of the IOL using a double needle technique, and
then using cautery to form a mushroom-shaped or button-like tip at the end of each haptic. This
objective is achieved as each haptic is threaded into the lumen of a pair of thin walled 30-gauge
needle introduced via a pair of transscleral tunnels introduced 180° apart. The haptics are threaded
using micro-forceps introduced via paracenteses cut adjacent to the plane of the scleral tunnels
using a 15° blade. As the needles are externalized, the haptics are drawn through the transscleral
tunnel, with the leading edge temporarily externalized. After cautery, gentle manipulation is used to
depress the haptics back into the scleral tunnels and achieve centration of the lens.
•
• place a 6-0 silk suture on the trailing haptic to ensure the IOL stays secure as attention is directed
to the leading haptic
• anterior or posterior chamber infusion is essential
• IOL, intraocular microforcep, needle,

SFIOL with suture
• IOL (with eyelets)
– Alcon CZ70BD PMMA lens
– TGM 90L acrylic foldable
– B&L enVista MX60 IOL (eyelets @ optic haptic junction)
– Biometry: aim more negative (more anterior position in sulcus
VS in-the-bag)
– suture
– 9-0 or 10-0 double-armed Prolene or Gore-tex, needle straight
(STC-6) or curved (CIF-4 or CTC-6)
– hollow 27-gauge or 30-gauge needle as a docking guide
– sclerotomy
– scleral flaps, tunnels, or grooves to cover knots
– location: 2-3mm from limbus (ciliary sulcus)

•Complications of scleral-fixated IOLs include corneal
edema, retinal detachment, intraocular hemorrhage
(due to the passage of suture through uveal tissue),
suture erosion and infection (due to externalized or
exposed sutures), and IOL dislocation or tilt. Caution is
necessary in patients with a history of high myopia,
hypertension, scleritis, or scleromalacia as well as
those on anticoagulant medication. The risk of
complications may correlate with increased surgical
time and manipulation. Hypotony, which occurs when
IOL implantation is performed with penetrating
keratoplasty, also increases the risk of suprachoroidal
hemorrhage

Special Cataract
• Small pupil
- Floppy iris syndrome
- PEX
- DM
• Weak Zonule
- PEX
- Glaucoma/intumescent
- trauma
• Glaucoma
– PAC/AACG
– Phacomorphic/intumescent
– PEX +-glaucoma
• Fuchs FED
• Brunescent
• High myopic
• Polar
• Uveitis
• AMD/receiver of IVT

Pseudoexfoliation
• Issues: small pupil, fragile capsule/difficult
capsulorhexis, difficult rotating the nucleus, weak
zonules, late postoperative subluxation
• Glaucoma issues & high postoperative IOP
spikes.
• Systemic issues
• capsule phimosis may be a risk factor for late
subluxation- large CCC, polish, Nd:YAG laser
anterior capsulotomy.
• three-piece IOL might be preferred over a
single-piece

Small pupil
• Pre-op
– identify high risk cases
– dilating eyedrops (1weeks/intensive pre op)
• Intra op
– subconj mydriacaine
– subtenon lignocaine
– intracameral adrenaline 1:100 000 (0.1ml) or 1:1000 in BSS
– Viscomydriasis
– Peeling of inflammatory membrane/synaechiolysis (26G cannula with OVD)
– Iris stretching with Kugren hook
– Iris hook, 26 needle bent & hold w needle holder beaver up
– Expansion/retention device: Malyugin, circular Visitec I-ring, APX System;
Morcher Graether or Perfect Pupil
– Sphinterectomy
– Iridectomy/temy (basal/sectoral)
• phenylephrine 1%/ketorolac 0.3% (Omidria, Omeros Corp.)
• epinephrine in the irrigation bottle

Weak Zonule
• phacodonesis with eye movement as well as by a decrease in anterior chamber
depth
• wrinkling of the capsule when you touch it at the start of capsulorhexis
• During the removal of cortical material, zonular instability can often manifest as
folds in the peripheral posterior capsule, collapse of the capsular equator, or frank
visualization of the peripheral capsular fornix in eyes with PXF
• Capsular phimosis is another warning sign of weakened zonules because the
capsule is tugging on the zonular space
• avoid op in small pupil
• avoid small rhexis
• rotating the nucleus with a bimanual approach to apply the force more evenly
• remove the cortex tangentially, not radially
• CTR: help to center the lens. if late subluxation easier to grab onto. But doent
prevent subluxation

IntraOp floppy iris syndrome (IFIS)
• Intro: progressive miosis/poor dilatation/iris
billowing/prolapse intraop
• Cause: alpha blocker (tamsulosin/tera-alfu-
doxa-zosin), 50% risk, stop? unknown effect
• Intraop
– small pupil Mx
– floppy iris Mx
• corneal wound > long tunnel > anterior > self seal
• fluidic less aggreesive (> stable AC)

Cataract & Glaucoma
• General
• Ocular surface (drug toxicity)
• Corneal haziness
• ACG related
– AC shallow (ACG)
– Intumescent cataract/high intra bag pressure (ACG)
– PI related: fibrosis/inflam, Eagle study no PI
• PEX related:
– Small pupil
– Weak zonule/iris
• IOP related
• spike @DBE (mannitol to OT/dilate on table)
• OD vulnerable to IOP fluctuation/stable AC
• Steroid responder (post op)
• Risk of suprachoroidal hrge
• Others: preserve sup conj for trabec, ECP intraop

Intumescent
• Problem:
– shallow AC
– Ant capsule visualization
– high +ve pressure @CCC → extension (Argentina sign)
• Intraop
– Vision blue/ant capsule staining
– needle aspiration (26G)
– high cohesive OVD
– Double rhexis, phaco-capsulotomy, disposable
capsulotomy device (Zepto)

Brunescent
• Problem
– hard/high phaco power
– high manipulation (weak zonule/PCR)
• Intraop
– phaco-chop
– large CCC
– good hydrodisection/deneation
– creates a small crater in the center of the nucleus and then
chop (6-8 fragments).
– New:
– MiLoop (Iantech) can be used with hard cataracts and loose
capsular bags

Polar
• Preop
• Polar?  BL (80%), inherited/spontaneous, 3D/plaque, a/w Mittendorf/PPV
• Capsule defect?  halo/bull eye/satellite opacities/concentric ring,
preexisting PCR/dislocated lens
• Couselling + OT standby (PCR/convert ECCE/ant vitrect/drop nucleus)
• Intraop
– No hydrodissection
– good hydrodeneation → remove nucleus  epinucleus first (slow motion: low
aspiration/vaccum) or Inside-out technique (after sculpting)
– OVD cortex dissection + removal till polar (from different direction/clock
hours) Reverse flower bloom technique
– Avoid lens rotation/manipulation/AC fluctuation
• Postop
– YAG capsulotomy
• DDx: posterior lenticonus (>uniocular/females/1st decade of life)

High Myope
• Preop
– corrected AXL (if >26mm)
• 0.8289 X measured AXL + 4.2663
• Barrett Universal II formula

FED
• phaco low power/Not ACIOL
• combine or stage (severity of FED/cataract)
• soft shell technique
– visco-dispersive to coat/protect endoT
– vsico-cohesive to maintain AC space
• avoid vision blue stain sick endoT
– big bubble technique
– soft shell technique
– single drop of vision blue
• Hydrophobic IOL is preferred as hydrophilic IOLs can opacify if air/gas tamponade is required
during a possible future endothelial keratoplasty (EK).
• IOL power: aim low myope for endoT keratoplasty (hyperopic shift), emmetrope for PK.
• possible slower postoperative recovery as well as possible need for an EK
• If EK- remove a non-cataractous crystalline lens too as the risk of cataract developing secondary to
air tamponade, prolonged steroid usage, inflammation, natural ageing etc. is high and can result in
the need for surgery, which can in turn cause loss of precious graft endothelial cells
• Visualisation: Removing the oedematous epithelium, good quality microscope, capsular staining
with trypan blue and use of an endoilluminator as an external oblique light source

Cataract challenge (cornea)
•Refractive surgery
–Online calculator
–Intraoperative aberrometer/Optiwave Refractive Analysis-
aphakic ref status
–Consider neutralise aspherical aberration (e.g. myopic
LASIK/PRK – negative aspheric IOL for the positive aspheric
cornea)
–Not for multifocal
•Ocular surface d/o or dry eye
–Worsen aft op
–Inaccurate biometry
–Infection with blepharitis

Small Eye
• Problem: shorter AXL/ACD (<22/2mm), narrow angle/ACG,
small corneal diameter, effective lens position (IOL) more
difficult to calculate (use Hoffer Q/Holladay2)
• But >hyperopic (>+3D) & pre op dependent on glasses for
all, open narrow angle
• Short ACD: >OVD, endothelial care, PPV (last resort) + OVD
in AC
• Small cornea: small incision, watertight wound
• Hyperopic: high power IOL +- piggy back
• Choroidal hemorrhage precaution

Narrow angle
• reduced IOP post cataract op either
– preexisting PI or bleb
– no previous treatment
• anterior chamber deepening and angle widening following cataract extraction
• IOP reduction influenced by:
– pre op IOP
– degree of narrowing in ACD
• To consider combine ECP + cataract in high IOP cases/preexisting glaucoma,
• To consider combine goniosynaechiolysis (in case of PAS)- lysed by
viscodissection, with a blunt cyclodialysis spatula, or by pulling the iris centrally
with microforceps
• EAGLE (Effectiveness of early lens extraction with intraocular lens implantation for
the treatment of primary angle-closure glaucoma) Study found clear-lens
extraction is also efficacious and cost-effective.
– 50 years of age or older, didn’t have cataracts, and had newly diagnosed primary angle
closure with an intraocular pressure of 30 mmHg or greater, or primary angle-closure
glaucoma

AMD & Cataract
• Risk-benefit
– cataract surgery induces inflammation and increases exposure
to UV light postop
– studies do not suggest a strong association between cataract
surgery and the development or progression of AMD
• PC rent risk
– 2.6 times higher if received =/>10 inj
• IOL
– single-piece, hydrophobic acrylic IOL made of clear material for
in-the-bag implantation
–If the visual acuity is severely compromised due to AMD, a
special, secondary AMD lens such as the Scharioth Macula Lens
(SML) for secondary implant in the sulcus.

Thrombocytopenia & cataract op
• Normal platelet : 150,000–400,000/μL
• Minimal to prevent spontaneous bleed: aim
>20,000/μL
• Invasive procedures: aim >50,000/μL
• Expect of platelet transfusion: increase 5000--
7000/mL per unit in a 70-kg adult.
• Reported cataract cases with bleed: all
≤55,000/μL.

Uncooperative Patients
• Communication difficulties, dementia/memory problems, hearing
loss, difficult posturing
• Pre op reassurance and a good explanation
• Sedation is rarely helpful in patients with dementia
• Sub-Tenon’s block for ocular akinesia/anaesthesia
• Head-taping
• Difficulty in positioning: foam beneath their neck, patient sit up
slightly with their neck hyper-extended
• Kyphosis: patient’s head is lying fairly flat on the bed, but the rest
of their body is tilted upward
• Claustrophobia: Cutting the drape or using a clear drape +-
sedation
• Anxiety: hand holding, oral/IV sedation

MIGS with Cataract Op
• Trabecular bypass devices are especially commonly used in combination with
cataract surgery for patients with co-existing cataract and early-to-moderate
glaucoma as ease of surgery, quick recovery, safety and efficacy make it an
attractive solution despite being less effective than traditional glaucoma surgeries.
They are, however, not effective if the episcleral venous pressure is raised
• i-Stent (Glaukos Corp): This is an FDA-approved trabecular bypass device that is
placed ab interno through a clear corneal incision into the Schlemm’s canal. It is a
heparin-coated, nonferromagnetic, surgical grade titanium stent less than 1mm in
length with a pointed tip that is self-retaining once implanted through the
trabecular meshwork into the Schlemm’s canal. Two stents are reported to give
greater IOP reduction than one. The i-Stent Inject via a single entry, delivers two
pre-loaded trabecular micro-bypass stents to be implanted two-to-three clock
hours apart. These devices are preferred to be placed in areas with the highest
density of collector channels thereby targeting a large aqueous vein, generally in
the infero-nasal quadrant of the eye.
• Adequate skills in intraoperative gonioscopy and visualisation of the angle are
important in successful placement of the iStent. Placement is easier in patients
with wide open angles, pigmented trabecular meshwork and in those without
systemic or local conditions that preclude proper positioning of the eye and head.
It is easier to place after removing the cataract as the anterior chamber is deeper.

Principles in Phaco
• Phacodynamic x 4
– flow
• depends on vaccum, tube compliance & size
• 25-28 ml/min
– vaccum
• peristaltic vs venturi
• = holding power
– bottle height
• AC stability
– power
• Fluidic

Basic setting
• in situ chop
– vaccum high 250-300
– bottle height high
– flow moderate
– hard lens: high power high vaccum
– soft lens: low power + high vaccum (or vice verse)
• segment chop
– vaccum 200-300
– power 20-40%
– flow 25-35 ml/min
• last segment
– vaccum 150
– power 20-30% +-pulse
– flow low 20-25

Power Modulation
•Newer: wave form shaping micropulse
micropulse (stellaris), customized

Cutting Pattern
• Longitudinal vs Torsional
• Newer: elliptical/combine (Ellips EX)
• kHz: OZil 32, Signature Pro 38, Stellaris 28.5

Infiniti/Centurion
• Ozil torsional
• Active fluidic
• IP

Phacodynamic parameters
• used during phacoemulsification, namely,
power (AVG %), ultrasound time, and elliptical
motion
• CDE, cumulated dissipated energy.

Teaching Part II
• Cataract- causes
• Lens pathology
• Ectopia lentis
• PCR
• Small pupil
• Post op refractive surprise
• Post op high IOP
• Cataract & glaucoma
• Cataract & FED

Part 1 Syllabus- Lens/Cataract
Embryo
Anatomy
Physio- Biochemical composition
Physio- Metabolisms
Physio- Lens transparency
Physio- Pump & leak theory
Physio- Accommodation
Patho- cataract (types/classifications)
Patho- subluxated/dislocated lens/extopia lentis
Patho- lens related glaucoma
Patho- presbyopia
Pharm- capsular dye/vision blue
Pharm- mydriatic & miotic agents
Pharm- anestheis for eye surgery
IOL types/material/design
OVD
Biometry
Steps in cataract operations
Astigmatism & cataract operation
Visual acuity & tests

Lens Anatomy
• I: biconvex/crystalline/transparent
• E: surface ectoderm (placode/vesicle/primary-secondary fibres)
• F: optical transparency media, refractive power, accommodation
• Ma: DiaM/AP/Wt/Radius of curvature/RI, relation
• Mi: capsule (elastic/4x3/um/barrier), epiT (cuboidal/single/only ant/tight
jx/equatorial-germinative-Bow-mitotic/ATP), cortex (epi to
fiber/columnar/bowing/meridional row/suture), nucleus
(embryonic/fetal/infantile), zonule (relation/size/non collagenous)
• No vascular/nerve
• Biochem: H20 (vary), Protein (H20 soluble vs not/crystallinsx3 vs albuminoid/urea
soluble vs not, cytoskeleton VAT+FP, MIP/aquaporin), Others

Accommodation & Presbyopia
• Normal process: parasympathetic with stimuli,
ciliary muscle/zonule/attachment/globular AP
diameter/ant curvature/RI & diopter power
• Von Helmholtz theory: AP increased/bulging of
center ant capsule (thinner vs periphery) —>
zonule attachment change >closer to axis/>ant
curvature —> zonule relax —> lens sink down
• Presbyopia: nucleus stiffness (increased
size/mechanical), capsular stiffness, geometrical
changes of zonular attachment.

New Development
for Cataract Surgery

OMIDRIA
• OMIDRIA® (phenylephrine and ketorolac intraocular solution) 1% / 0.3%, for addition to
ocular irrigating solution
• OMIDRIA is an alpha 1-adrenergic receptor agonist and nonselective cyclooxygenase inhibitor
indicated for:
–Maintaining pupil size by preventing intraoperative miosis (1)
–Reducing postoperative pain (1)
• Each vial of OMIDRIA must be diluted prior to use for administration to a single patient
undergoing cataract surgery or intraocular lens replacement.
• Dilute 4 mL of OMIDRIA in 500 mL of ocular irrigating solution. Irrigation solution is to be used
as needed for the surgical procedure. (2)
• femtosecond cataract surgery, followed by IFIS or history of IFIS in the other eye, a resident
performing the procedure, suboptimal dilation in the clinic (less than 6 mm), and history of
alpha blocker
• CONTRAINDICATIONS
• Hypersensitivity to any component of this product (4)
• WARNINGS AND PRECAUTIONS
• Systemic exposure to phenylephrine may cause elevations in blood pressure. (5.1)
• ADVERSE REACTIONS
• The most common reported adverse reactions (≥2%) are eye irritation, posterior capsule
opacification, increased intraocular pressure, and anterior chamber inflammation. (6.1)

Post Cataract Care
• LEADER7- non-inferiority of
one-week
levofloxacin/dexamethasone
FDC eye drops, followed by
one-week dexamethasone
alone, versus the standard of
two-week
tobramycin/dexamethasone.

Automated capsulotomy
• A uniform capsulorhexis, in terms of size and
shape, whether it’s done with a femtosecond
laser or using a thermal device like the Zepto

Cataract Surgery- Keys
•Each step of phaco builds upon the preceding
step
•three key points: good visualisation, a stable
anterior chamber, and being efficient
•protecting the endothelium and posterior
capsule and zonules.

Stabilizing eye ball
•second instrument in the side port incision
•.12 forceps rest on conjunctiva

Clear Cornea Incision
• Paracentesis
– 2 or 3 clock hours away from the incision
– straight entry plane parallel to the iris
– OVD instilled to protect intraocular structures and allow more control during creation of the phaco
incision.
• Clear Corneal Incision Phaco
– 2.8 mm wide or less (just large enough to accommodate the phaco handpiece).
– 1.5mm tunnel
– Globe stabilization with toothed forceps, cotton bud with counter pressure
– multiplanar incision technique
• Langerman: 0.3-mm-deep groove perpendicular to the corneal surface → tip is then directed tangentially to the
corneal surface
• Shimuzu and Fine: beveled, multiplanar self-sealing incision, as advocated by. A beveled 3-mm diamond blade is
flattened against the eye, and the tip is used to enter the cornea just anterior to the vascular arcade. The blade is
advanced tangentially to the corneal surface until the shoulders of the blade are fully buried in the stroma. The point
of the blade is then redirected posteriorly so that the point and the rest of the blade enter the anterior chamber
parallel to the iris. This technique ideally creates a 3 x 2-mm corneal incision that is watertight. Disposable steel
blades of varying dimensions can also be used to create these incisions. Newer beveled, trapezoidal diamond blades
(Fig 7-24) have been developed for self-sealing clear corneal incisions. Such blades can be advanced in one motion
and in one plane, from clear cornea into the anterior chamber. The blade is oriented parallel to the iris (0°), and the
tip is placed at the start of the clear cornea, just anterior to the vascular arcade. The blade is tilted up and the heel
down so that the blade is angled 1 0° from the iris plane and then advanced into the anterior chamber in one
smooth, continuous motion. Regardless of which type of clear corneal incision is used, the goal is to keep the
incision just large enough to accommodate the folded IOL with its inserter, generally 2.7-3.2 mm.
• A third type is the "near clear" approach, in which the incision begins within the vascular arcade. Proponents of this
approach cite better closure and reduced incidence of induced astigmatism. However, slight bleeding may occur
during surgery; conjunctival ballooning may occur; and a subconjunctival hemorrhage may be present
postoperatively.

incision
•a clear corneal wound tunnel that is as long as the
width of the wound
•inadvertent nicking of the capsule entering the
anterior chamber with the keratome vertical
•Keratome heel down, heel of the blade flush against
the sclera
•Heel up, wrinkling around the tip
•single plane corneal incision, biplanar, and three-step
scleral incision.
•When entering the anterior chamber, the most stable
incisions are square (not too short and not too long)

Scleral tunnel incision
• 5 mm conjunctival peritomy at limbus  blunt dissection of Tenon 
hemostasis
• Stabilizing the eye with .12 forceps for ½ thickness scleral groove
• 1-2 mm posterior to the limbus  blade perpendicular to the surface of the
sclera  approximately 3 mm in width
– sharp edge of the crescent blade (#66 blade) or a #74 or #64 blade
• The tip of the crescent blade in the groove  blade heel down  tunneled
forward into the sclera by gentle circular movements  to clear cornea 
the heel remains down but the tip is elevated to tunnel slightly forward into
clear cornea.
• The metal microkeratome placed into the tunnel and up into clear cornea,
with the heel down. Further tunneled 1 mm into clear cornea the heel of the
keratome is raised and the tip pointed down until wrinkling around the tip is
seen. The anterior chamber is entered with the blade to its full width and
then removed

Hydrodissection
• Separate cortex-capsule
• Cannula slightly lift up ant capsular flap
• BSS injection slow/steady
• Wave of cleavage circumferentially
• Press down the lens (side of cannula) if lens
looked bulge forward/enlarged capsulorhexis
• Repeat in opposite quadrant

ECCE Q
• Wound
– where (pro & cons of sclera/limbus/cornea)
– 3 steps (perpendicular, beveled)
• Suturing principle
– pre-post-placed
– astig (tightness, length, depth, spacing)

Immediately sequential bilateral
cataract surgery (ISBCS)
• VS delayed sequential bilateral cataracts surgery (DSBCS)
• less expensive, reduces personal protective equipment
use, is more efficient, and provides faster binocular
recovery of vision for the patient
•extra spacing, cleaning, and time between patients,
resulting in increased costs. When considering the
additional patient costs for travel, family and caregiver
time, and absence from work with the extra postoperative
visits and recovery requirements
•Reduce Anesthesia, COVID exposure & traveling risks
•risk of bilateral postoperative endophthalmitis or toxic
anterior segment syndrome and second-eye refractive
planning

International Society of Bilateral Cataract Surgeons
•ISBCS General Principles for Excellence
•treating each eye as a separate independent procedure
with new instruments, packs, gloves, gowns, drapes, and
different lot numbers for pharmaceuticals and OVD.
• Intracameral antibiotics are recommended.
• Caution is suggested in those eyes with a higher risk of
refractive surprises (prior refractive surgery, extreme axial
lengths) and increased risk of complications because of
ocular comorbidities.
• If a complication occurring in the first eye of a planned
ISBCS is unresolved at the time of surgery, it is advised to
defer the second eye

•when high-quality operating room (OR) standards and
sterilization routines are met
• informed consent for ISBCS, being free to choose ISBCS or
DSBCS
• risk for Right – Left eye errors should be minimized by
listing all surgical parameters in visible board
• confirm the IOL choice
• Complete aseptic separation of the first and second eye
surgeries
• ISBCS patients should not be patched
• Post-operative review of patients should be at 1 day post-
operatively, and then 2 weeks followed by prn.

• a. Nothing in physical contact with the 1st eye surgery should be used for
the 2nd .
• b. The separate instrument trays for the two eyes should go though
complete and separate sterilization cycles with indicators.
• c. There should be no cross-over of instruments, drugs or devices between
the two trays for the two eyes at any time before or during the surgery of
either eye.
• d. Different OVDs, and different manufacturers or lots of surgical supplies
should be used, whenever reasonable (where the device or drug type has
ever been found to be causative of endophthalmitis of toxic anterior
segment syndrome) and possible (if different lots or manufacturers are
available) for the Right and Left eyes.
• e. Nothing should be changed with respect to suppliers or devices used in
surgery without a thorough review by the entire surgical team, to assure
the safety of proposed changes.
• f. Before the operation of the second eye, the surgeon and nurse shall use
acceptable sterile routines of at least re-gloving after independent
preparation of the second eye’s operative field.
• g. Intracameral antibiotics have been shown to dramatically reduce the
risk of post-operative endophthalmitis. Their use is strongly
recommended for ISBCS.

ISBCS- Relative CI
• diabetics with macular edema
• lid infections such as blepharitis or chalazia
• Fuchs’ endothelial dystrophy with
pachymetry > 630-650 microns
• complex cases, such as cataracts with
colobomas, severe pseudoexfoliation, IFIS,
• anyone younger than age 25-30

https://aao-resources-enformehosting.s3.amazonaws.com/resources/Cataract_Master/index.html

Lens & Cataract: Notes

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Lens & Cataract: Notes

Similar to Lens & Cataract: Notes (20)

More from Meng Hsien Yong

More from Meng Hsien Yong (14)

Recently uploaded

Recently uploaded (20)

Lens & Cataract: Notes