This document discusses cataract surgery in special situations. It covers considerations for combined cataract extraction and glaucoma surgery, cataract surgery in patients with high myopia, uveitis, small pupils, mature cataracts, diabetes, and Fuchs endothelial dystrophy. Key factors include preoperative evaluation, managing increased risks during surgery such as weak zonules or poor visibility, and postoperative care to prevent complications related to the underlying conditions. Surgical techniques are adapted based on the situation, such as using pupil expansion devices, minimizing phaco power, or coating the endothelium with viscoelastic.
This document discusses special considerations for cataract surgery in situations with potential visualization problems or involvement of the anterior or posterior eye segments. It outlines challenges and recommendations for cases involving corneal opacities, small pupils, high myopia, corneal dystrophy, uveitis, mature cataracts, pseudoexfoliation, diabetes, glaucoma and other conditions. Key points addressed include preoperative assessment and preparation, intraoperative techniques, and postoperative management to help reduce risks and optimize outcomes for these more complex cases.
This document provides guidance on drawing corneal pathology as a method for standardized documentation, follow-up, teaching, and lower cost compared to photography. It outlines color-coding conventions for different corneal features and structures: black for scars, sutures, etc.; blue for edema; yellow for infiltrates; green for defects and staining; red for blood vessels; and brown for pigments. Detailed instructions are given for depicting the frontal and slit views of the cornea, including dimensions, landmarks, and representations of specific conditions. Following a systematic clock-hour approach is emphasized for accurate drawings.
This document discusses posterior capsule tears that can occur during cataract surgery. It covers the predisposing factors, mechanisms, identification, and management strategies for posterior capsule tears with or without vitreous loss. Key points include identifying tears early, stabilizing the anterior chamber with viscoelastic, deciding whether to continue phacoemulsification or convert to extracapsular extraction based on the situation, performing anterior vitrectomy when needed with caution to minimize further vitreous disturbance, and properly placing an IOL. The goal is to remove all lens material and prevent further complications while minimizing additional surgery.
Optical coherence tomography in glaucoma - Dr Shylesh DabkeShylesh Dabke
This document discusses optical coherence tomography (OCT) in evaluating glaucoma. It begins by outlining the importance of early glaucoma detection to prevent vision loss. OCT is described as the most appropriate technology for detecting glaucoma as it can assess retinal nerve fiber layer (RNFL) thickness before visual field or optic disc changes occur. RNFL thinning is an early sign of glaucoma. The document then provides details on OCT technology and analysis of RNFL thickness, optic nerve head, and macula to diagnose and monitor glaucoma. RNFL analysis, especially of the inferior quadrant, is highlighted as the most useful OCT assessment for detecting early glaucoma.
This document discusses various vitreous substitutes and intraocular gases used to replace the vitreous humor after surgery. It describes the anatomy and composition of the natural vitreous and ideal properties for substitutes. Common substitutes discussed include gases like air, sulfur hexafluoride and perfluorocarbons; liquids like silicone oil, perfluorocarbon liquids and semi-fluorinated alkanes; and experimental polymers and implants. The document compares different options and provides details on how each works, associated complications, and appropriate uses.
This document discusses choroidal neovascularization (CNV), which is the abnormal growth of blood vessels from the choroid into the retina or subretinal space. It is a cause of vision loss and the main feature of exudative age-related macular degeneration. The document defines CNV and lists various conditions that can cause it. It then focuses on CNV caused by age-related macular degeneration, covering risk factors, pathogenesis, symptoms, diagnostic findings on fluorescein angiography and OCT, and various treatment options including anti-VEGF drugs, photodynamic therapy, and laser photocoagulation.
This document summarizes several studies and clinical trials related to the treatment of diabetic retinopathy and diabetic macular edema. It discusses the Diabetic Retinopathy Study (DRS) and Early Treatment Diabetic Retinopathy Study (ETDRS) which established laser photocoagulation as the standard treatment for proliferative diabetic retinopathy and diabetic macular edema. It also summarizes the Diabetic Retinopathy Clinical Research Network (DRCR.Net) which conducted several clinical trials comparing treatments for diabetic macular edema such as anti-VEGF injections and laser photocoagulation. The document provides high-level overviews of many landmark studies that helped advance the treatment of diabetic eye disease.
Indirect ophthalmoscopy and fundus drawingSonali Singh
This document provides an overview of binocular indirect ophthalmoscopy and fundus drawing techniques. It discusses the history and working principles of the indirect ophthalmoscope. Examination techniques are described, including positioning, use of the condensing lens, and scleral indentation. Fundus drawing methods such as color coding retinal findings are also outlined. Proper cleaning and sterilization of equipment is emphasized.
This document discusses special considerations for cataract surgery in situations with potential visualization problems or involvement of the anterior or posterior eye segments. It outlines challenges and recommendations for cases involving corneal opacities, small pupils, high myopia, corneal dystrophy, uveitis, mature cataracts, pseudoexfoliation, diabetes, glaucoma and other conditions. Key points addressed include preoperative assessment and preparation, intraoperative techniques, and postoperative management to help reduce risks and optimize outcomes for these more complex cases.
This document provides guidance on drawing corneal pathology as a method for standardized documentation, follow-up, teaching, and lower cost compared to photography. It outlines color-coding conventions for different corneal features and structures: black for scars, sutures, etc.; blue for edema; yellow for infiltrates; green for defects and staining; red for blood vessels; and brown for pigments. Detailed instructions are given for depicting the frontal and slit views of the cornea, including dimensions, landmarks, and representations of specific conditions. Following a systematic clock-hour approach is emphasized for accurate drawings.
This document discusses posterior capsule tears that can occur during cataract surgery. It covers the predisposing factors, mechanisms, identification, and management strategies for posterior capsule tears with or without vitreous loss. Key points include identifying tears early, stabilizing the anterior chamber with viscoelastic, deciding whether to continue phacoemulsification or convert to extracapsular extraction based on the situation, performing anterior vitrectomy when needed with caution to minimize further vitreous disturbance, and properly placing an IOL. The goal is to remove all lens material and prevent further complications while minimizing additional surgery.
Optical coherence tomography in glaucoma - Dr Shylesh DabkeShylesh Dabke
This document discusses optical coherence tomography (OCT) in evaluating glaucoma. It begins by outlining the importance of early glaucoma detection to prevent vision loss. OCT is described as the most appropriate technology for detecting glaucoma as it can assess retinal nerve fiber layer (RNFL) thickness before visual field or optic disc changes occur. RNFL thinning is an early sign of glaucoma. The document then provides details on OCT technology and analysis of RNFL thickness, optic nerve head, and macula to diagnose and monitor glaucoma. RNFL analysis, especially of the inferior quadrant, is highlighted as the most useful OCT assessment for detecting early glaucoma.
This document discusses various vitreous substitutes and intraocular gases used to replace the vitreous humor after surgery. It describes the anatomy and composition of the natural vitreous and ideal properties for substitutes. Common substitutes discussed include gases like air, sulfur hexafluoride and perfluorocarbons; liquids like silicone oil, perfluorocarbon liquids and semi-fluorinated alkanes; and experimental polymers and implants. The document compares different options and provides details on how each works, associated complications, and appropriate uses.
This document discusses choroidal neovascularization (CNV), which is the abnormal growth of blood vessels from the choroid into the retina or subretinal space. It is a cause of vision loss and the main feature of exudative age-related macular degeneration. The document defines CNV and lists various conditions that can cause it. It then focuses on CNV caused by age-related macular degeneration, covering risk factors, pathogenesis, symptoms, diagnostic findings on fluorescein angiography and OCT, and various treatment options including anti-VEGF drugs, photodynamic therapy, and laser photocoagulation.
This document summarizes several studies and clinical trials related to the treatment of diabetic retinopathy and diabetic macular edema. It discusses the Diabetic Retinopathy Study (DRS) and Early Treatment Diabetic Retinopathy Study (ETDRS) which established laser photocoagulation as the standard treatment for proliferative diabetic retinopathy and diabetic macular edema. It also summarizes the Diabetic Retinopathy Clinical Research Network (DRCR.Net) which conducted several clinical trials comparing treatments for diabetic macular edema such as anti-VEGF injections and laser photocoagulation. The document provides high-level overviews of many landmark studies that helped advance the treatment of diabetic eye disease.
Indirect ophthalmoscopy and fundus drawingSonali Singh
This document provides an overview of binocular indirect ophthalmoscopy and fundus drawing techniques. It discusses the history and working principles of the indirect ophthalmoscope. Examination techniques are described, including positioning, use of the condensing lens, and scleral indentation. Fundus drawing methods such as color coding retinal findings are also outlined. Proper cleaning and sterilization of equipment is emphasized.
This document discusses non-penetrating glaucoma surgery techniques that facilitate the drainage of aqueous humor through the trabecular meshwork and Schlemm's canal without opening the anterior chamber. It describes several procedures including deep sclerectomy, viscocanalostomy, canaloplasty, ab-externo trabeculectomy, and laser trabecular ablation. The goal is to bypass the highest resistance point to outflow in the juxtacanalicular meshwork. Advantages include lower risks of complications like hypotony compared to penetrating surgeries. Indications and contraindications are provided for various non-penetrating glaucoma procedures.
This document discusses target intraocular pressure (IOP) for treating glaucoma. It defines target IOP as the upper limit of IOP that prevents further glaucoma damage. Establishing an individualized target IOP is important to slow retinal ganglion cell loss and glaucoma progression over a patient's lifetime with minimal effects on quality of life. The target IOP should be based on factors like the amount of existing eye damage, maximum past IOP levels, life expectancy, and risk factors. The target is dynamic and must be reevaluated periodically, lowering it if damage progresses or raising it if side effects occur from low IOP. Clinical studies show that greater IOP reductions correlate with less glaucoma progression
Corneal graft failure and rejection are the nightmares for an Ophthalmologist. Here is an overview on Rejection vs Failure, identification of risk factors, prevention and Mx of a failure
Phacodynamics refers to the fundamental principles of inflow, outflow, vacuum, and phaco power modulation during cataract surgery. Understanding these principles helps optimize machine settings for different surgical techniques. The foot pedal controls irrigation, aspiration, and ultrasound energy. Position 1 provides irrigation only, position 2 adds aspiration, and position 3 engages ultrasound. Peristaltic and venturi pumps differ in how they create vacuum. Peristaltic pumps require tip occlusion while venturi pumps create vacuum instantly. Factors like compliance, surge, and vent type impact fluidics and safety. Mastering phacodynamics leads to independent surgical skill.
Iol power calculation in pediatric patientsAnisha Rathod
- Many factors affect intraocular lens (IOL) power calculation in pediatric patients including age at surgery, laterality, amblyopia, axial length, keratometry, and expected myopic shift due to ongoing eye growth.
- Normal eye development involves rapid growth of the axial length and changes in lens power in the first years of life.
- Target postoperative refraction must account for this myopic shift and generally involves undercorrecting more in younger patients.
- Accurate biometry using immersion ultrasound or optical techniques is important to minimize errors from corneal compression.
- Formulas, IOL type and position can further influence outcomes.
This document provides guidance on managing failing blebs after glaucoma surgery. It discusses risk factors for bleb failure, the histology of functioning vs failed blebs, typical appearances of failed blebs, identifying the cause of failure as internal or external blockage, and various management techniques. These include increasing digital pressure, medications, laser suture lysis, and bleb needling with or without anti-metabolites like mitomycin C or 5-fluorouracil to restore bleb function and control intraocular pressure. Complications of bleb needling are also reviewed.
This document discusses minimally invasive glaucoma surgery (MIGS) procedures. It defines MIGS as glaucoma surgery that is ab interno, uses a small incision, spares the conjunctiva, causes minimal trauma and tissue disruption, has a high safety profile, allows for rapid visual recovery, and can be combined with cataract surgery. It then describes various MIGS procedures including trabecular micro-bypass stents, gonioscopy assisted transluminal trabeculotomy, excimer laser trabeculotomy, the iStent, and suprachoroidal shunts. It provides details on the mechanisms, surgical techniques, indications, and complications of these different MIGS procedures.
Ophthalmic viscosurgical devices (OVDs) are used in eye surgeries to protect tissues and maintain spaces. Common OVDs include sodium hyaluronate, chondroitin sulfate, and hydroxypropyl methylcellulose. OVDs can be classified as cohesive, dispersive, or viscoadaptive based on their rheological properties such as viscosity and elasticity. Cohesive OVDs are highly viscous and stick together, while dispersive OVDs coat tissues well but are less viscous. OVDs are used in cataract surgery for tasks like protecting the endothelium, maintaining the anterior chamber, and implanting IOLs. Complications can include increased intraocular
Meibomian gland dysfunction (MGD) is a chronic abnormality of the meibomian glands characterized by terminal duct obstruction and changes in glandular secretion that can alter the tear film. It is a common cause of dry eye and estimated to affect 70% of Americans over age 60. Diagnosis involves examining the glands and assessing ocular surface damage. Treatment focuses on eyelid hygiene, warm compresses, and lubricating eye drops, with options for antibiotics, steroids, or procedures like probing, LipiFlow, or intense pulsed light. MGD is a chronic condition with periods of exacerbation and remission.
This document discusses retinal vein occlusion, specifically branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). It covers the epidemiology, risk factors, pathogenesis, clinical presentation, treatment options including laser photocoagulation, corticosteroids and anti-VEGF drugs, and complications such as macular edema and neovascularization. Key points include that BRVO most commonly affects the superotemporal quadrant and that perfusion status on fluorescein angiography helps determine prognosis for CRVO.
This document discusses cataract surgery in glaucoma patients. It notes that cataract and glaucoma commonly occur together, requiring management of both conditions. Cataract surgery can significantly lower IOP for up to 4 mmHg by improving outflow, and also aids in glaucoma evaluation. Options for surgical management include cataract surgery alone, combined cataract and glaucoma surgery, or staged surgeries. Factors like glaucoma severity, number of medications, and target IOP determine the best approach. Cataract surgery alone provides quick recovery but less IOP control than combined procedures.
Keratoconus is a non-inflammatory, progressive thinning and protrusion of the cornea that results in irregular astigmatism and decreased vision. It typically presents after puberty with no gender or racial predilection. Diagnosis is made based on corneal thinning, Fleischer ring, Vogt's striae, and irregular astigmatism seen on keratometry and topography. Mild cases are managed with spectacles while more severe cases require rigid gas permeable contact lenses, Intacs, or corneal transplantation.
Serous choroidal detachment occurs when fluid accumulates between the choroid and sclera, lifting the choroid. It is often related to low intraocular pressure after surgery or trauma. Hemorrhagic choroidal detachment results from rupture of short posterior ciliary arteries due to trauma, surgery, or increased pressure. Ultrasound shows a smooth dome-shaped elevation and OCT may show retinal pigment epithelium thickening. Management includes cycloplegia, corticosteroids, increasing intraocular pressure, and sometimes choroidal drainage surgery. Prognosis depends on extent of detachment and hemorrhage, with limited detachments having better outcomes.
This document discusses potential complications of trabeculectomy, both intraoperative and postoperative. Intraoperative complications include buttonholing of the conjunctiva, scleral flap tears, lens injury, vitreous prolapse, hyphema, and suprachoroidal hemorrhage. Postoperative complications can be early such as hypotony, elevated intraocular pressure, choroidal effusions or late such as thin blebs, infections, and cataracts. Management strategies are provided for addressing complications depending on the specific issue.
Glaucoma drainage devices (GDDs) provide an alternative pathway for aqueous humor outflow and are used to treat refractory glaucoma. The document discusses the history, design, and types of various GDDs including non-valved devices like Baerveldt and Molteno implants as well as valved devices like the Ahmed Glaucoma Valve. The key components, materials, and surgical techniques for GDD implantation are also summarized.
This document summarizes corneal anatomy and transplantation techniques. It provides an in-depth review of Descemet's stripping automated endothelial keratoplasty (DSAEK), including indications, surgical technique, outcomes, complications, and future directions. DSAEK involves stripping the recipient's Descemet's membrane and inserting a donor posterior corneal graft to treat endothelial dysfunction. It has advantages over penetrating keratoplasty like faster visual recovery and less astigmatism. Complications include graft dislocation and failure. Newer techniques like DMEK may provide better outcomes.
Newer modalities in diagnosis of glaucomaBipin Bista
Digital imaging technologies like confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP), and optical coherence tomography (OCT) provide objective and reproducible measurements of the optic nerve head and retinal nerve fiber layer thickness to detect and monitor glaucoma. These modalities have improved over the past decade with enhancements like enhanced corneal compensation and spectral domain OCT. Detection of glaucomatous damage relies on progressive changes in neuroretinal rim area, cupping of the optic disc, retinal nerve fiber layer thinning, and trend-based or event-based analyses of measurements over time. While SLP may detect nerve fiber layer damage earlier than OCT, detection of damage requires analysis of changes in measurements rather
This document discusses deep anterior lamellar keratoplasty (DALK), a type of corneal transplant surgery. It provides:
1) A brief history of DALK, beginning with early successful transplants in the late 19th century and developments in techniques in the 1950s and 1980s.
2) Indications for DALK including keratoconus, post-LASIK ectasia, hereditary stromal dystrophies, infectious keratitis, and tectonic indications.
3) An overview of various surgical techniques for DALK including manual dissection, air-assisted dissection, and techniques using viscoelastic or femtosecond lasers.
4) Preparation of
1) Intraocular lenses (IOLs) are artificial lenses implanted during cataract surgery to replace the clouded natural lens and correct vision. 2) IOLs have evolved over generations from rigid PMMA lenses to modern foldable designs made of silicone, acrylic, or hydrogel materials. 3) IOLs can be mono-focal, providing a single vision correction, or multi-focal, attempting to provide both near and distance vision without glasses. Accommodating IOL designs also aim to restore the eye's ability to focus at different distances.
Glaucoma post cataract extraction, vitreoretinal surgery, keratoplasty and re...Haitham Al Mahrouqi
Glaucoma is a common complication of ocular surgeries such as cataract extraction, keratoplasty, vitreoretinal surgery, and refractive surgery. The mechanisms of glaucoma include retained viscoelastic, inflammation, pupillary block, and changes to the angle structure. Glaucoma can occur early due to these mechanisms or late due to factors like steroid response or inflammation. Careful case selection, prevention of complications, and close monitoring are important to manage glaucoma risk in postoperative patients.
Surgeries for glaucoma An Overview by Dr. Iddi.pptxIddi Ndyabawe
This document provides an overview of surgeries for glaucoma, including their evolution and mechanisms. It discusses non-filtering surgeries like iridotomy and trabeculotomy, as well as filtering surgeries like trabeculectomy. The document also covers combined cataract extraction and trabeculectomy, cyclo-destructive procedures, and the use of surgery in specific glaucoma subtypes. It aims to educate physicians on the various surgical options available to treat glaucoma.
This document discusses non-penetrating glaucoma surgery techniques that facilitate the drainage of aqueous humor through the trabecular meshwork and Schlemm's canal without opening the anterior chamber. It describes several procedures including deep sclerectomy, viscocanalostomy, canaloplasty, ab-externo trabeculectomy, and laser trabecular ablation. The goal is to bypass the highest resistance point to outflow in the juxtacanalicular meshwork. Advantages include lower risks of complications like hypotony compared to penetrating surgeries. Indications and contraindications are provided for various non-penetrating glaucoma procedures.
This document discusses target intraocular pressure (IOP) for treating glaucoma. It defines target IOP as the upper limit of IOP that prevents further glaucoma damage. Establishing an individualized target IOP is important to slow retinal ganglion cell loss and glaucoma progression over a patient's lifetime with minimal effects on quality of life. The target IOP should be based on factors like the amount of existing eye damage, maximum past IOP levels, life expectancy, and risk factors. The target is dynamic and must be reevaluated periodically, lowering it if damage progresses or raising it if side effects occur from low IOP. Clinical studies show that greater IOP reductions correlate with less glaucoma progression
Corneal graft failure and rejection are the nightmares for an Ophthalmologist. Here is an overview on Rejection vs Failure, identification of risk factors, prevention and Mx of a failure
Phacodynamics refers to the fundamental principles of inflow, outflow, vacuum, and phaco power modulation during cataract surgery. Understanding these principles helps optimize machine settings for different surgical techniques. The foot pedal controls irrigation, aspiration, and ultrasound energy. Position 1 provides irrigation only, position 2 adds aspiration, and position 3 engages ultrasound. Peristaltic and venturi pumps differ in how they create vacuum. Peristaltic pumps require tip occlusion while venturi pumps create vacuum instantly. Factors like compliance, surge, and vent type impact fluidics and safety. Mastering phacodynamics leads to independent surgical skill.
Iol power calculation in pediatric patientsAnisha Rathod
- Many factors affect intraocular lens (IOL) power calculation in pediatric patients including age at surgery, laterality, amblyopia, axial length, keratometry, and expected myopic shift due to ongoing eye growth.
- Normal eye development involves rapid growth of the axial length and changes in lens power in the first years of life.
- Target postoperative refraction must account for this myopic shift and generally involves undercorrecting more in younger patients.
- Accurate biometry using immersion ultrasound or optical techniques is important to minimize errors from corneal compression.
- Formulas, IOL type and position can further influence outcomes.
This document provides guidance on managing failing blebs after glaucoma surgery. It discusses risk factors for bleb failure, the histology of functioning vs failed blebs, typical appearances of failed blebs, identifying the cause of failure as internal or external blockage, and various management techniques. These include increasing digital pressure, medications, laser suture lysis, and bleb needling with or without anti-metabolites like mitomycin C or 5-fluorouracil to restore bleb function and control intraocular pressure. Complications of bleb needling are also reviewed.
This document discusses minimally invasive glaucoma surgery (MIGS) procedures. It defines MIGS as glaucoma surgery that is ab interno, uses a small incision, spares the conjunctiva, causes minimal trauma and tissue disruption, has a high safety profile, allows for rapid visual recovery, and can be combined with cataract surgery. It then describes various MIGS procedures including trabecular micro-bypass stents, gonioscopy assisted transluminal trabeculotomy, excimer laser trabeculotomy, the iStent, and suprachoroidal shunts. It provides details on the mechanisms, surgical techniques, indications, and complications of these different MIGS procedures.
Ophthalmic viscosurgical devices (OVDs) are used in eye surgeries to protect tissues and maintain spaces. Common OVDs include sodium hyaluronate, chondroitin sulfate, and hydroxypropyl methylcellulose. OVDs can be classified as cohesive, dispersive, or viscoadaptive based on their rheological properties such as viscosity and elasticity. Cohesive OVDs are highly viscous and stick together, while dispersive OVDs coat tissues well but are less viscous. OVDs are used in cataract surgery for tasks like protecting the endothelium, maintaining the anterior chamber, and implanting IOLs. Complications can include increased intraocular
Meibomian gland dysfunction (MGD) is a chronic abnormality of the meibomian glands characterized by terminal duct obstruction and changes in glandular secretion that can alter the tear film. It is a common cause of dry eye and estimated to affect 70% of Americans over age 60. Diagnosis involves examining the glands and assessing ocular surface damage. Treatment focuses on eyelid hygiene, warm compresses, and lubricating eye drops, with options for antibiotics, steroids, or procedures like probing, LipiFlow, or intense pulsed light. MGD is a chronic condition with periods of exacerbation and remission.
This document discusses retinal vein occlusion, specifically branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). It covers the epidemiology, risk factors, pathogenesis, clinical presentation, treatment options including laser photocoagulation, corticosteroids and anti-VEGF drugs, and complications such as macular edema and neovascularization. Key points include that BRVO most commonly affects the superotemporal quadrant and that perfusion status on fluorescein angiography helps determine prognosis for CRVO.
This document discusses cataract surgery in glaucoma patients. It notes that cataract and glaucoma commonly occur together, requiring management of both conditions. Cataract surgery can significantly lower IOP for up to 4 mmHg by improving outflow, and also aids in glaucoma evaluation. Options for surgical management include cataract surgery alone, combined cataract and glaucoma surgery, or staged surgeries. Factors like glaucoma severity, number of medications, and target IOP determine the best approach. Cataract surgery alone provides quick recovery but less IOP control than combined procedures.
Keratoconus is a non-inflammatory, progressive thinning and protrusion of the cornea that results in irregular astigmatism and decreased vision. It typically presents after puberty with no gender or racial predilection. Diagnosis is made based on corneal thinning, Fleischer ring, Vogt's striae, and irregular astigmatism seen on keratometry and topography. Mild cases are managed with spectacles while more severe cases require rigid gas permeable contact lenses, Intacs, or corneal transplantation.
Serous choroidal detachment occurs when fluid accumulates between the choroid and sclera, lifting the choroid. It is often related to low intraocular pressure after surgery or trauma. Hemorrhagic choroidal detachment results from rupture of short posterior ciliary arteries due to trauma, surgery, or increased pressure. Ultrasound shows a smooth dome-shaped elevation and OCT may show retinal pigment epithelium thickening. Management includes cycloplegia, corticosteroids, increasing intraocular pressure, and sometimes choroidal drainage surgery. Prognosis depends on extent of detachment and hemorrhage, with limited detachments having better outcomes.
This document discusses potential complications of trabeculectomy, both intraoperative and postoperative. Intraoperative complications include buttonholing of the conjunctiva, scleral flap tears, lens injury, vitreous prolapse, hyphema, and suprachoroidal hemorrhage. Postoperative complications can be early such as hypotony, elevated intraocular pressure, choroidal effusions or late such as thin blebs, infections, and cataracts. Management strategies are provided for addressing complications depending on the specific issue.
Glaucoma drainage devices (GDDs) provide an alternative pathway for aqueous humor outflow and are used to treat refractory glaucoma. The document discusses the history, design, and types of various GDDs including non-valved devices like Baerveldt and Molteno implants as well as valved devices like the Ahmed Glaucoma Valve. The key components, materials, and surgical techniques for GDD implantation are also summarized.
This document summarizes corneal anatomy and transplantation techniques. It provides an in-depth review of Descemet's stripping automated endothelial keratoplasty (DSAEK), including indications, surgical technique, outcomes, complications, and future directions. DSAEK involves stripping the recipient's Descemet's membrane and inserting a donor posterior corneal graft to treat endothelial dysfunction. It has advantages over penetrating keratoplasty like faster visual recovery and less astigmatism. Complications include graft dislocation and failure. Newer techniques like DMEK may provide better outcomes.
Newer modalities in diagnosis of glaucomaBipin Bista
Digital imaging technologies like confocal scanning laser ophthalmoscopy (CSLO), scanning laser polarimetry (SLP), and optical coherence tomography (OCT) provide objective and reproducible measurements of the optic nerve head and retinal nerve fiber layer thickness to detect and monitor glaucoma. These modalities have improved over the past decade with enhancements like enhanced corneal compensation and spectral domain OCT. Detection of glaucomatous damage relies on progressive changes in neuroretinal rim area, cupping of the optic disc, retinal nerve fiber layer thinning, and trend-based or event-based analyses of measurements over time. While SLP may detect nerve fiber layer damage earlier than OCT, detection of damage requires analysis of changes in measurements rather
This document discusses deep anterior lamellar keratoplasty (DALK), a type of corneal transplant surgery. It provides:
1) A brief history of DALK, beginning with early successful transplants in the late 19th century and developments in techniques in the 1950s and 1980s.
2) Indications for DALK including keratoconus, post-LASIK ectasia, hereditary stromal dystrophies, infectious keratitis, and tectonic indications.
3) An overview of various surgical techniques for DALK including manual dissection, air-assisted dissection, and techniques using viscoelastic or femtosecond lasers.
4) Preparation of
1) Intraocular lenses (IOLs) are artificial lenses implanted during cataract surgery to replace the clouded natural lens and correct vision. 2) IOLs have evolved over generations from rigid PMMA lenses to modern foldable designs made of silicone, acrylic, or hydrogel materials. 3) IOLs can be mono-focal, providing a single vision correction, or multi-focal, attempting to provide both near and distance vision without glasses. Accommodating IOL designs also aim to restore the eye's ability to focus at different distances.
Glaucoma post cataract extraction, vitreoretinal surgery, keratoplasty and re...Haitham Al Mahrouqi
Glaucoma is a common complication of ocular surgeries such as cataract extraction, keratoplasty, vitreoretinal surgery, and refractive surgery. The mechanisms of glaucoma include retained viscoelastic, inflammation, pupillary block, and changes to the angle structure. Glaucoma can occur early due to these mechanisms or late due to factors like steroid response or inflammation. Careful case selection, prevention of complications, and close monitoring are important to manage glaucoma risk in postoperative patients.
Surgeries for glaucoma An Overview by Dr. Iddi.pptxIddi Ndyabawe
This document provides an overview of surgeries for glaucoma, including their evolution and mechanisms. It discusses non-filtering surgeries like iridotomy and trabeculotomy, as well as filtering surgeries like trabeculectomy. The document also covers combined cataract extraction and trabeculectomy, cyclo-destructive procedures, and the use of surgery in specific glaucoma subtypes. It aims to educate physicians on the various surgical options available to treat glaucoma.
This document discusses the relationship between glaucoma and the cornea. It describes how developmental disorders, keratitis/keratouveitis, dystrophies, trauma, and surgery can lead to cornea changes that secondarily cause glaucoma. It also describes how primary glaucoma can lead to secondary cornea changes due to elevated pressure and medications. Risk factors, mechanisms, investigations, and management strategies are provided for various cornea-glaucoma interactions.
1) Trabeculectomy is a glaucoma surgery that creates an opening in the eye to drain fluid from the anterior chamber and reduce intraocular pressure.
2) It involves making a partial thickness scleral flap, removing a block of tissue underneath, and suturing the flap loosely to allow fluid drainage.
3) Antifibrotic agents like mitomycin C or 5-fluorouracil are often applied to reduce scarring and improve surgical success rates.
Indication of combined cataract & glaucoma surgery .pptxMdShahjahanSiraj2
Combined cataract and glaucoma surgery can provide benefits of reduced costs, stress, and risks compared to staged surgeries. However, it also carries risks like increased inflammation and complications affecting the success of both procedures. The choice depends on factors like glaucoma severity and damage, medications, prior surgeries, and surgeon expertise. Successful outcomes require minimizing these risks through techniques like two-site surgeries and addressing challenges like poor dilation.
Complications of cataract surgery by Dr. Iddi.pptxIddi Ndyabawe
Apply pressure on globe to prevent further drop
Surgeon: Stop phaco, inject OVD, pars plana vitrectomy to remove nucleus
Prevention: Stable AC, well constructed CCC, proper hydrodissection, dispersive OVD
Surgery for proliferative diabetic retinopathyAmit Srivastava
- Eckardt forceps
- Horizontal scissors
- Vertical scissors
Surgeon:
- Membrane pick
- Knobbed spatula
- Scissors
- Gently lift the edge of the membrane with
forceps and cut it with scissors
- Dissect the membrane from the retina using
scissors or pick
- Dissect in a circumferential manner from the
periphery towards the center
- Apply endodiathermy to bleeding vessels
- Remove all membranes
- Use scleral depression to flatten the globe and
facilitate dissection
- Use bimanual technique for difficult membranes
- Apply PRP after membrane removal
1) Posterior capsule rent (PCR) is a breach in the posterior capsule of the crystalline lens during cataract surgery that can lead to suboptimal visual outcomes if not properly managed.
2) Predisposing factors for PCR include patient-related factors like age and ocular conditions, surgeon-related factors like experience, and intraoperative factors like cataract type and surgical techniques.
3) Preventive strategies include comprehensive preoperative evaluation, proper wound construction, ensuring an intact capsulorhexis, and gentle hydrodissection. Management of PCR involves anterior vitrectomy using techniques like bimanual vitrectomy and triamcinolone to visualize vitreous, followed by careful cortical removal
This document provides information on evaluating patients for refractive surgery. It discusses examining the patient's medical, ocular, and refractive history. Important tests include visual acuity, refraction, corneal topography and tomography to check for ectasia risk, wavefront analysis, and evaluating dry eye and ocular surface disease. Key considerations are patient expectations, corneal health, stability of refractive error, and identifying contraindications.
This document discusses cataracts, including their classification, causes, symptoms, diagnosis, and treatment. It notes that cataracts are the opacification and clouding of the lens of the eye. They are classified morphologically or etiologically. Senile cataracts related to aging affect over 90% of people by age 70 and are the most common type. Examination involves assessing visual acuity, eye pressure, and examining the anterior segment and fundus. Treatment options include glasses initially, but surgery such as phacoemulsification is often needed for more advanced cases. Complications of surgery can include inflammation, edema, and retinal detachment.
This document discusses cataracts, including their classification, causes, symptoms, diagnosis, and treatment. It notes that cataracts are the opacification and clouding of the lens of the eye. They are classified morphologically or etiologically. Senile cataracts related to aging affect over 90% of people by age 70 and are a major global cause of blindness. Examination involves assessing visual acuity, intraocular pressure, and lens appearance with a slit lamp. Treatment options include glasses initially, but surgery such as phacoemulsification is often needed, with risks of complications if not performed carefully.
Congenital glaucoma is present from birth to age 3, affects males more than females, and can be caused by genetic mutations. It is characterized by increased eye pressure, corneal clouding, enlarged eye size, and optic nerve damage. Treatment involves surgery such as trabeculotomy or trabeculectomy to reduce eye pressure and stop further vision loss. Early detection and treatment are important to prevent long-term eye damage.
Glaucoma is a group of eye disorders characterized by optic nerve damage and vision loss caused by increased pressure in the eye. The document discusses the definition, epidemiology, causes, clinical features, diagnosis, and management of primary open angle glaucoma and primary angle-closure glaucoma. Key points include that glaucoma has various clinical manifestations, causes include blockage of aqueous outflow, signs involve optic nerve changes and visual field loss, and treatment aims to lower intraocular pressure through medication, laser treatment, or surgery.
This document provides an overview of glaucoma, including:
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Initially performed as a full-thickness (“unguarded”) procedure.
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1. CATARACT SURGERY
IN SPECIAL
SITUATIONS
P R E S E N T E R : D R . I D D I N D YA B AW E
M O D U L ATO R : D R . L U S O BYA R E B E C C A
M A K E R E R E U N I V E R S I T Y, D E PA R T M E N T O F
O P H T H A L M O L O G Y
M A R C H , 2 0 2 1
2. OUTLINE
• Glaucoma and cataract
• Combined cataract extraction and trabeculectomy
• Potential problems in removing a cataract in a patient with high myopia
• Potential problems in removing a cataract in a patient with uveitis
• How to manage a small pupil during cataract surgery
• Problems operating on a mature (brunescent/white) cataract.
• Issues in cataract extraction for diabetic patients
• Mature cataracts
• Soft cataracts
• Posterior polar cataracts
• Fuchs endothelial dystrophy and cataract surgery
4. FACTORS THAT DETERMINE THE
MANAGEMENT OF GLAUCOMA AND
CATARACT
• 1. Severity and progression of glaucoma:
• -IOP level (most important factor)
• -Optic nerve head changes
• -Visual field changes
• 2. Severity and progression of cataract:
• -VA and visual requirements
• -Ocular co-morbidities/visual potential
5. 3. PATIENT FACTORS
• Age
• Race (black higher rate of glaucoma progression)
• Family history of blindness from glaucoma
• Fellow eye blinded from glaucoma
• Concomitant risk factors for glaucoma (DM, HTN, myopia, other vascular diseases)
• Compliance to follow-up and medication use
10. INDICATIONS FOR COMBINED CATARACT
EXTRACTION AND TRABECULECTOMY
• General principle:
• Indications for trabeculectomy – when IOP is raised to a level that there is evidence of
progressive VF or ON changes despite maximal medical treatment plus indication for
cataract surgery (visual impairment)
• Medical indications of cataract surgery:
• -Phacoantigenic uveitis
• -Phacolytic glaucoma
• -Phacomorphic glaucoma
• -Anterior disclocation of crystalline lens
• -Inability to view the posterior segment
11. WHAT ARE THE COMMON SCENARIOS
FOR TRABECULECTOMY?
• Uncontrolled POAG with maximal medical treatment
-Failure of medial treatment (IOP not controlled with progressive VF or ON damage)
-Side effects of medical treatment
-Non-compliance with medical treatment
• -Additional considerations:
-Young patient with good quality of vision
-One-eyed patient (other eye blind from glaucoma)
-Family history of blindness from glaucoma
-Glaucoma risk factors (HTN, DM)
• Uncontrolled PACG after laser PI and medical treatment
• Secondary OAG or ACG
12. ADVANTAGES OF COMBINED CE AND
TRAB
• One operation
• Faster visual rehabilitation
• Patient may be able to be taken off all glaucoma medications
• Prevents post-op IOP spikes
• HVF monitoring easier with clear media
• No subsequent cataract operation needed (lower risk of bleb failure)
13. DISADVANTAGES OF COMBINED CE
AND TRAB
• Strong evidence that IOP control with trab alone is better than combined surgery
• More manipulation during the combined operation (higher risk of bleb failure)
• Vitreous loss during cataract surgery (higher risk of bleb failure)
• Larger wounds created (higher risk of wound leakage and shallow AC)
14. WAYS TO PERFORM THE COMBINED OP
. CORNEAL SECTION ECCE + TRAB
• ADVANTAGES:
• -More control
• -Less conjunctival manipulation
• -Smaller wound (lower risk of leakage
and shallow AC)
• DISADVANTAGES:
• -Longer
• -Higher corneal astigmatism
15. LIMBAL SECTION ECCE + TRAB
• ADVANTAGES:
• -Faster
• -Less astigmatism
• DISADVANTAGES:
• -Larger wound
• -More conjunctival manipulation
• -Increased risk of flat AC
16. PHACOEMULSIFICATION + TRAB
• ADVANTAGES:
• -More control of AC
• -Less conjuctival manipulation (main
reason)
• -Smallest wound of the 3 techniques
• -Less astigmatism
• -Faster
• DISADVANTAGES:
• -More difficult operation for the
inexperienced surgeon
17. CE IN SPECIFIC SUBSETS OF
GLAUCOMA
• WHO survey in 2002 highlight cataract and glaucoma as the two greatest sources of
visual impairment worldwide, with 17 (47.8%) and 4.4 million (12.3%) persons affected
• Africa, in particular, has the highest prevalence of glaucoma in the adult population
• CE lowers IOP by 2-4mmHg
• CE in specific subsets of patients with glaucoma – primary OAG (POAG), ACG and
pseudoexfoliation (PXE).
• ‘MIGS’+CE better than CE alone
18. CE AND POAG
• A 2002 Cochrane literature review by Friedman et al. reported a consistent (albeit
weak) 2–4 mmHg reduction in IOP by either phacoemulsification or extracapsular
cataract extraction.
• Same results in the mid-1990s by Matsumura et al and the 1970s by Bigger and Becker
• The higher the initial IOP, the greater the magnitude of the IOP reduction following
surgery.
24. MECHANISMS OF IOP CHANGE IN CE
• Still debatable!!!
• A positive relationship between IOP reduction and preoperative lens vault measured
by AS-optical coherence tomography (OCT)
• Reduction of glycosaminoglycan deposition in the trabecular meshwork due to higher
fluid flow rates
• Inflammation induced morphologic changes in the trabecular meshwork akin to the
effects of laser trabeculoplasty;
• Remodeling of the trabecular endothelium secondary to ultrasonic vibrations
• Alterations in the blood-aqueous barrier
• Changes in anterior chamber architecture
• Increased posterior zonular traction due to cataract surgery (whether due to lens
removal alone or other technical aspects like small capsulorhexis) has been postulated
to improve patency of the trabecular meshwork and result in lower IOP
25. CATARACT SURGERY AND THE DIAGNOSTIC
MANAGEMENT OF GLAUCOMA
• CE greatly enhances the practitioner’s ability to diagnose and follow glaucomatous
progression by improving visibility and has the added benefit of improved visual acuity
for the patient
• Fundoscopic examination of the optic nerve, OCT, and stereoscopic disc photos are
more accurate after cataract removal
• Kim et al. found that the presence of a cataract significantly affects measurements of
both spectral domain-OCT (SD-OCT) and time domain-OCT (TD-OCT).
• -Specifically, patients evaluated by SD-OCT were measured to have increased retinal nerve fiber layer thickness after cataract
surgery as well as changes in signal strength values.
• In addition, clinical perimetry is improved by more reliable patient performance and
the elimination of lens-induced artifacts.
26. CE AND THE SURGICAL MANAGEMENT OF GLAUCOMA
• Roles of CE in glaucoma patients:
• -decreases the IOP
• -enhanced diagnostic monitoring of glaucoma
• - distinct surgical advantages when performed first in patients who will later require
standard glaucoma-filtering surgery
• -Early cataract extraction avoids development of cataract - a common adverse effect of
many glaucoma procedures. Within 5 years of trabeculectomy or tube shunt surgery, half of phakic patients
develop a visually significant cataract.
31. POTENTIAL PROBLEMS IN CE IN A
PATIENT WITH HIGH MYOPIA
• PREOPERATIVE STAGE
• -Need to access visual potential (amblyopia, myopic macular degeneration)
• Choose IOL power carefully (counselling for anisometropia)
• Harder to do biometry (need special formulas to adjust for longer axial lengths)
• IOL Master biometry in view of high prevalence of staphyloma
32. INTRAOPERATIVE STAGE
• Risk of perforation with retrobulbar anaesthesia)
• Lower IOP (harder to express nucleus during ECCE)
• Deeper AC (harder to aspirate soft lens material)
• Increased risk of PCR:
• -Due to weak zonules – avoid stressing zonules/angle instruments downwards
• -Due to large capsular bag/floppy PC – beware of surge
• Increased risk of LIDRS:
• -Lower bottle height
• -Use second instrument to lift iris at pupillary margin
• Postop stage: RD risk
33. CE IN A PATIENT WITH UVEITIS
• PREOPERATIVE STAGE:
• Need to control inflammation
• -consider waiting for 2-3 months until inflammation settles after an acute episode
• -consider course of preoperative steroids
• Assess visual potential (CME, optic disc edema)
• Dilate pupil in advance (atropine, subconjunctival mydriacaine)
• Perform gonioscopy (if synechiae is severe superiorly, consider corneal section)
• Need to assess for potential intraoperative problems – weak zonules, small pupil
• Check for phacodonesis, subluxation
• Check how well pupil dilates/posterior synechiae
• Density of cataract
34. INTRAOPERATIVE STAGE
• Problem of small pupil
• Increased risk of PCR (weak zonules, dense cataracts, poor view – hazy cornea)
• Increased inflammation (consider heparin coated IOL or leave aphakic)
• Increased risk of bleeding
35. POST OPERATIVE STAGE
• Higher risk of complications:
• -corneal edema
• -flare up or inflammation
• -glaucoma or hypotony
• -choroidal effusion
• -CME
• Consider prophylaxis for infectious etiologies (e.g. herpetic lesions)
37. SMALL PUPIL DURING CE
• PREOPERATIVE STAGE:
• High risk patients (uveitis, DM, PXF, Marfan’s syndrome, glaucoma on pilocarpine)
• Prior to operation, prescribe mydriatics (3 days of homatropine 2% three times a day)
• 2 hours before operation, intensive dilation with:
-Tropicamide 1%
-Ocufen 0.03%
-Phenylephrine q0%
38. INTRAOPERATIVE STAGE
• Infuse AC with BSS mixed with a few drops of 1:1000 adrenaline
• Use viscoelastics to dilate pupil
• Remove pupillary membrane (previous inflammation)
• Stretch pupil gently (with Kuglen hooks)
• Perform sphincterotomy at 3, 6, 9 and 12 o’clock positions
• Perform broad iridectomy at 12 o’clock position
• Perform basal iridectomy and mid-peripheral iridotomy (better apposition than broad
iridectomy)
• Iris hooks
• Pupil expansion devices (e.g. Morcher pupil expansion ring, Malyugin Ring)
45. PROBLEMS ON OPERATING ON A MATURE
(BRUNESCENT/WHITE) CATARACT
• 1. Need to assess visual potential:
• -Pupils (optic nerve function)
• -Light projection (gross retinal integrity), color perception
• -Potential acuity meter (macular function)
• -B-scan ultrasound (gross retinal anatomy)
• 2. Poor view of capsulotomy/capsulorrhexis edge:
• -Consider endocapsular technique
• -Consider using air instead of viscoelastics
• -Use of capsular stains (vision blue/trypan blue): possibly toxic to endothelium,
capsular fragility, teratogenic
46. .
• 3. High intra-capsular pressure
-CCC runs out/splits easily (Argentinian flag sign)
• 4. Floppy capsule due to chronic bulky lens: viscoelastic tamponade
• 5. Increased phacoemulsification power - corneal decompensation, higher risk of PCR
from surge
• 6. More zonular stress - harder to separate nuclear fragments
• 7. White cataract
• -possibility of posterior polar cataract: may rupture PC during hydrodissection
• -mobile nucleus with no SLM tamponade
49. ISSUE OF CE IN DM PATIENTS
• 1. Issues:
• -Difficult cataract surgery
• -Progression of DR after operation
• 2. Preoperative stage:
• -Assess visual potential: consider FFA
• -Laser PRP if necessary prior to the surgery
• -Medical consult (stable DM –good control)
• -List for first case in morning (avoid hypoglycemia)
50. INTRAOPERATIVE STAGE
• Protect corneal endothelium (risk of abrasion and poor healing)
• Problems with small pupils
• Consider stitching wound
• Selection of IOLS:
• -Large optics (7mm)
• -Use acrylis IOL (avoid silicone IOL)
• -Avoid IOL if PDR (risk of neovascular glaucoma)
• -Avoid AC IOL
• -Consider heparin-coated IOL
51. POSTOPERATIVE STAGE
• Control of inflammation (especially in eyes with PDR)
• Risk of PDR/CSME
• Risk of rubeotic glaucoma – especially if PCR with vitreous loss
• Risk of PCO
• Poor wound healing
• Risk of endophthalmitis
52. WHY DOES DR PROGRESS?
• Removal of anti-angiogenic factor in lens
• Secretion of angiogenic factors from iris
• Increased intraocular inflammation
• Decreased anti-angiogenic factor from RPE
• Migration of angiogenic factors into AC
53. MATURE CATARACTS
• Consider phaco-chop techniques to disassemble nucleus to small pieces – minimizing
phaco power dispersed
• Phaco away from the PC – be mindful of surge, especially with last fragment
• Consider using a non-sharp second instrument
• Manage vitreous pressure — give IV mannitol if no contraindications
• Manage intracapsular pressure — decompress bag with 27G needle before initiating
capsulorrhexis and decompress the periphery as wel
54. SOFT CATARACTS
• Achieve a good hydrodissection to allow easy rotation of the nucleus
• Divide and Conquer to disassemble the nucleus
• Consider using a non-sharp second instrument e.g. mushroom to avoid cheese wiring
• Decrease the exposure of the tip of the phaco probe
55. POSTERIOR POLAR CATARACTS
• Hydrodelineate rather than hydrodissect to avoid stressing PC weakness
• Peel away the epinuclear material from the periphery and leave the central (polar) part
to the last
• Fill AC with viscoelastic before removing probe to avoid sudden AC fluctuations and
movements of the PC
57. FUCHS ENDOTHELIAL DYSTROPHY
AND CATARACT SURGERY
• Soft shell technique — Dispersive viscoelastic to coat the endothelium followed by
cohesive viscoelastic to form the AC
• Minimize power dispersed — lowered phaco settings, efficient phaco-chop techniques,
phaco in the bag
• Minimize trauma to endothelium — frequent topping up of viscoelastic, avoid tumbling
of fragments
59. CE IN FECD: PREOP
• Corneal transplant and CE, or triple … discuss
• Ultrasound pachymetry
• Endothelial cell density
• Pachymetry measurements greater than 640 µm and/or endothelial cell density of less
than 1000/mm2 place a patient at increased risk for corneal decompensation following
cataract surgery
• Benefits of a triple procedure:
• -avoiding a second surgery,
• -speeding up visual recovery,
• -reducing the costs
• -risks associated with sequential surgery.
60. SURGICAL TECH OF CE IN FECD
• special considerations to minimize intraoperative corneal endothelial cell loss and
optimizing visual outcomes.
• IOL selection:
• -monofocal recommended.
• -A hyperopic shift is expected in eyes that undergo EK due to changes in posterior
corneal curvature. As a result of this known phenomenon, most surgeons target slight
myopia during IOL selection. Typically -0.75 to -1.00 for DMEK and -1.00 to -1.25 for DSAEK
• OVDs:
• -soft-shell technique
• Capsulorrhexis: It is advisable to create a capsulorrhexis that is smaller than the IOL
optic, to prevent movement of the IOL after implantation. Trypan blue.
61. TECHNIQUE OF CE IN FECD
• FLACS was found to reduce endothelial cell loss in eyes with FECD, as compared to
traditional phacoemulsification.
• In patients with denser nuclear cataracts, phaco-chop had significantly less endothelial
cell loss when compared to divide-and-conquer and stop-and-chop techniques.
• if corneal thickness is greater than 640 um or endothelial cell density is less than 1000
cells/mm2, a triple procedure may be considered over cataract surgery alone.
62. POST OP MANAGEMENT
• Patients should be counseled on prolonged visual recovery
• Same mgt as other CE patients
• More significant and prolonged corneal edema that can negatively impact visual
acuity: 5% hypertonic saline.
• If postcataract surgery edema persists past 6 weeks, preparation for EK is
• Studies have indicated risk factors for greater endothelial cell loss in patients with
decreased endothelial cell counts:
• - shorter axial length,
• -diabetes mellitus,
• -longer phacoemulsification time,
• -higher phacoemulsification intensity, and
• -posterior capsular rupture