Visual rehabilitation after Cataract Surgery

Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
2121stst
century IOLscentury IOLs
Visual
rehabilitation after
Cataract Surgery
Dr. Zia-Ul-MazhryDr. Zia-Ul-Mazhry
FCPS(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 ofHead, Department of
OphthalmologyOphthalmology
Wapda Hospital Complex Lahore.Wapda Hospital Complex Lahore.

2121stst
Discussion Plan
1949 to 2009 & Beyond
Cataract surgery
Cataract surgery
Couching
Couching
Extraction
extra capsular
Extraction
extra capsular
In toto removal
ICCE
In toto removal
ICCE
Micro surgery
E Cap+IOL
Micro surgery
E Cap+IOL
E Cap
E Cap
IOL
IOL
phaco
phaco
LS
LS
Aq
Aq
MICS
MICS
?
?
PMMA
PMMA
Soft
Soft
m focal
m focal
acc
acc
?
?

Can we learn
about the future
from the past?

golden age for
ophthalmology
OphthalmologyOphthalmology first emerged as an independentfirst emerged as an independent
subspecialty in the early 19thsubspecialty in the early 19th century.century.
Acquisition of knowledge proceeded rapidly andAcquisition of knowledge proceeded rapidly and
importantimportant discoveries were made.discoveries were made.
Pioneers, as exemplified by vonPioneers, as exemplified by von Graefe, vonGraefe, von
Helmholtz, Fuchs, and Gullstrand, to mention a fewHelmholtz, Fuchs, and Gullstrand, to mention a few
contributed a lot.contributed a lot.
This rapid progress was slowed between 1914 andThis 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 othersof many others
during and after World War II helped remedy this.during and after World War II helped remedy this.

Cataract Surgery in Antiquity
A r a b t o L a t in / E u r o p e
A r a b s
K it a b - e - s u s r u d
8 t h c e n t
G r e e c e / R o m a n
2 8 - 4 0 A D
I n d ia
S u s h r u t a
1 0 0 0 y r s B C

1000 years BC
SanskritSanskrit
manuscripts 5thmanuscripts 5th
century B.C.century B.C.
describedescribe
couching.couching.
Couching wasCouching was
perfected byperfected by
Sustruta (theSustruta (the
Hippocrates ofHippocrates of
India) in the 6thIndia) in the 6th
century BC.century BC.
Mentioned inMentioned in
MahabarthaMahabartha
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 BarraquarreErysiphake(Phako erysis} Ignacio Barraquarre
19171917
» Cryo ExtractionCryo Extraction

Cataract Surgery in the 20th
Century
Enzymatic ZonulysisEnzymatic Zonulysis
» In 1957, Barraquer of Spain usedIn 1957, Barraquer of Spain used
alpha-chymotrypsin to enzymaticallyalpha-chymotrypsin to enzymatically
dissolve the zonules for removal ofdissolve the zonules for removal of
the lens.the lens.
Cryo SurgeryCryo Surgery
» In 1961, Krawicz of Poland removedIn 1961, Krawicz of Poland removed
the lens with a tiny probe attached bythe lens with a tiny probe attached by
freezing a small area on the surfacefreezing a small area on the surface
of the cataract.of the cataract.
Ultrasonic EmulsificationUltrasonic Emulsification
» In the late 1960s, Charles Kelman ofIn the late 1960s, Charles Kelman of
New York developed a technique forNew York developed a technique for
emulsifying the lens contents usingemulsifying the lens contents using
ultrasonic vibrations and aspiratingultrasonic 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)
– MicroscopesMicroscopes
– The first eye surgery performed with an operatingThe first eye surgery performed with an operating
microscope was done in Portland, Oregon, in 1948microscope 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 inDr Ridley was born in
Kibworth, Leicestershire,Kibworth, Leicestershire,
England, onEngland, on July 10,July 10,
1906.1906.
– One of the founders ofOne of the founders of
the modernthe modern
subspecialty of cataractsubspecialty of cataract
and refractive surgery,and refractive surgery,
passed away on Maypassed away on May
25, 2001, just 6 weeks25, 2001, just 6 weeks
before his 95th birthdaybefore his 95th birthday

First IOL: A Secondary
Procedure
– The insertion of theThe insertion of the
pseudophakospseudophakos
manufacturedmanufacturedbyby
Rayner Ltd,Rayner Ltd,
London, was aLondon, was a
secondarysecondary
procedureprocedure
performed onperformed on
February 8, 1950,February 8, 1950,
after Ridley hadafter Ridley had
verified that theverified that the
eye waseye wasquiet andquiet and
suitable forsuitable for
implantationimplantation
(David Spalton, MD, written(David Spalton, MD, written communication, December 1998).communication, December 1998).

"foreign body" in the eye?
– Sir Harold RidleySir Harold Ridley
performed firstperformed first
IOL implantationIOL implantation
on November 29,on November 29,
1949.1949.
long-standinglong-standing
dogma that onedogma that one
"should never"should never
put a foreignput a foreign
body into thebody into the
delicate tissuesdelicate tissues
of the eye“of the eye“

non–IOL-related
contributions
– A pigmented fundus tumorA pigmented fundus tumor
treated by irradiation, 1971treated by irradiation, 1971
– an early keratoprosthesis,an early keratoprosthesis,
fabricated from pmmafabricated from pmma
designed by Ridleydesigned by Ridley
– Ridley was the first to televiseRidley was the first to televise
eye operations in 1950eye operations in 1950

2121stst
Sir Harold Ridley, Kt, MD, FRCS,
FRS the inventor of IOL
– Sir Harold RidleySir Harold Ridley
performed first IOLperformed first IOL
implantation onimplantation on
November 29,November 29,
1949.1949.
long-long-
standingstanding
dogma thatdogma that
one "shouldone "should
never put anever put a
foreign bodyforeign body
into theinto the
delicatedelicate
tissues oftissues of
the eye“the eye“

2121stst
Era of IOLs
» Rigid AC IOLRigid AC IOL
Barron, StrampeliBarron, Strampeli
1952-19531952-1953
» Flexible AC IOLFlexible AC IOL
Closed LoopClosed Loop
Danheim 1956Danheim 1956
Open Loop JOpen Loop J
shaped J Barraquershaped J Barraquer
19581958
» Pupil SupportedPupil Supported
EpsteinEpstein
Binkhorst,WorstBinkhorst,Worst
60s-70s60s-70s
» New AC IOLNew AC IOL
Choyece, KelmannChoyece, Kelmann
»PC IOLPC IOL
Shearing 1976 (JShearing 1976 (J
Loop)Loop)
SinskieSinskie
Simcoe (C Loop)Simcoe (C Loop)
KartzKartz
»Intra Bag IOLsIntra Bag IOLs
»Foldable IOLFoldable IOL
»Phaco-ErsatzPhaco-Ersatz
»M B focal/ accomM B focal/ accom

The greatest fear known to
man is a new idea.
PhacoemulsificationPhacoemulsification was firstwas 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 yourIf you have strong reasons to believe in your
ideas, have confidence—face the brickbatsideas, have confidence—face the brickbats
and go ahead.—Harold Ridley, MA, MD,and go ahead.—Harold Ridley, MA, MD,
FRCS.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 EmulsificationThe 1990s - The Era of Reduced Emulsification
EnergyEnergy
From 1985 to 1995- aFrom 1985 to 1995- a ““dramatic phaco revolutiondramatic phaco revolution””
TheThe less than 10% of surgeonsless than 10% of surgeons
using phaco in theusing phaco in the early 1980s rocketedearly 1980s rocketed
to 95% by 1995.to 95% by 1995.
The 2000s - An Era of Alternative Energies andThe 2000s - An Era of Alternative Energies and
FurtherFurther Reduction of UltrasoundReduction 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 procedureAssessment 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-existingThe 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, aAn 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 keepIt is important to appreciate anterior chamber depth and to keep
all instruments away from the corneal endothelium in the planeall 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 mm
2.2. Viscoelastic to anterior chamber.Viscoelastic to anterior chamber.
3.3. CapsulorhexisCapsulorhexis
4.4. 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 aintraocular lens (IOL) is inserted under a
cushion of viscoelastic fluid which protect the cornealcushion of viscoelastic fluid which protect the corneal
endothelium, the lensendothelium, the lens unfoldunfold spontaneously within thespontaneously within the
capsular bag.capsular bag.
9.9. Vescicoelastic removed and replaced with balancedVescicoelastic 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 antibiotics
12.12. 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 for
insertion 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 SurgicalSTAAR Surgical
Company producedCompany produced
both 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 Materials
STAAR Collamer
Alcon SA-60
STAAR Plate
AMO Sensar

What Criteria are Most
Important to Surgeons
Wound sizeWound size
CentrationCentration
Ease ofEase of
InsertionInsertion
Optical QualityOptical Quality
BiocompatibilityBiocompatibility
OPC ratesOPC rates
YAGYAG
ResistanceResistance
Post-opPost-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?

2121stst
Choosing an IOL?

2121stst
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 andDifferent Models and
Makes?Makes?
– Cost Cost CostCost Cost Cost

2121stst
Choosing an IOL-The Material
SiliconeSilicone
AcrylicAcrylic
– Hydrophylic(Hydrogel)Hydrophylic(Hydrogel)
CollamerCollamer

2121stst
The Acrysof Family

2121stst
The Acrysof Family-
Premium IOLs

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Choosing an IOL-
The Procedure
Avoid small errors to add up into a bigAvoid 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 opticalIn the Bag Implantation with sub optical
RhexisRhexis

2121stst
Choosing an IOL-
The Insertion Systems
ForcepsForceps
Injection SystemsInjection Systems

2121stst
Choosing an IOL-

I/A with foldable IOL
2121stst

Phacoemulsification of hyper mature
cataract with multifocal iol implantation
2121stst

2121stst
Choosing an IOL-
Acrisof SP
Alcon Collamer STAR

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Acrisof Restore Idea Excellens
Choosing an IOL-

2121stst
Wound sizeWound size
Ease ofEase of
InsertionInsertion
Optical QualityOptical Quality
BiocompatibilityBiocompatibility
OPC ratesOPC rates
YAGYAG
ResistanceResistance
Post-opPost-op
InflammationInflammation
DysphotopsiasDysphotopsias

2121stst
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

2121stst
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.

2121stst
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.

2121stst
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 accomodation
Mission impossible

2121stst
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

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Multifocal IOLs
DiffractveDiffractve
RefractiveRefractive

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Accomodating IOLs

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Light Adjustable IOLs

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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

2121stst
Summary-Choosing an IOL
The MaterialThe Material
– HydrophylicHydrophylic
DesignDesign
– Square edgeSquare edge
– Two haptics SPTwo haptics SP
– Four ears SPFour ears SP
– Plate?Plate?
CostCost
Insertion SystemInsertion System
– PreloadedPreloaded
– Monarch 2 AcrysofMonarch 2 Acrysof
PlatformPlatform
– Surgeon’ roleSurgeon’ role
PCOPCO
– Square edge moreSquare edge more
important thanimportant than
materiamateria

The Whole Package
Rapid, Safe, Smooth Two HandedRapid, Safe, Smooth Two Handed
Surgery with time tested lens implantSurgery with time tested lens implant
aiming at true spectacle independenceaiming at true spectacle independence

2121stst
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 Ridleyremains 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 kam
Afaq ki is kargah – e -shisha gari ka

Visual rehabilitation after Cataract Surgery

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