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Nw2012 cataract surgery11

Irrigation! Surgeon: Thank you! 9 10 Phaco step 4 : Phaco  Basic Technique  2. Phaco chopping  Chopping the nucleus into small pieces  Tips  NO occlusion  Each stroke depth~1/3-1/2 phacotip  Chop into small pieces  Irrigate frequently Phaco chopping 1 2 3 4 5 6 7 8 9 10 11 12 13 14

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Nawat Watanachai Chiangmai University Hospital 2013
Cataract  “Even we have had the much advanced treatment for it for a while and we keep doing better, but sometimes, in some occasions, cataract can be very challenging disease that we, ophthalmologists, will be the ones to treat.”  Prof. Ian Jeffrey Constable  Director of Lions Eye Institute, University of Western Australia  first president of APAO
terms  phakos (Greek) - Lens  Katarraktes (Greek)  a down rushing, or waterfall  Originally thought that congealed brain fluid was flowing in front of lens.
Timeline of Cataract Surgeries Femto cataract 2010 Phaco 1967
History : at the beginning --- Couching -- Sushruta (Hippocrates of India), 600 BC  The Indian tradition of cataract surgery  Couching with jabamukhi salaka  soaked with warm butter and then bandaged
History : Couching
History:Couching  India   Egypt Greek, europe   Burma thaichina  Rome (29 AC)  De Medicinae, (Aulus Cornelius Celsus)  Persia (100 AC)  Choice of Eye Diseases (Ammar ibn Ali)
History : Couching  Large lens shadow  severe uveitis  retinal detachment/ VH  Endophthalmitis
History : ICCE and ECCE  1753 Jaques Daviel (FRA) : ECCE  Uveitis from left cortex  High incidence of PC tear  Success rate ~30%
History : ICCE and ECCE  1752-53 Intra Capsular Cataract Extraction ICCE Sharp, de la Faye.  1900 Henry Smith (IRE): ICCE  Erysophake  Capsule forceps  >20,000 ICCE Sx
History : ICCE and ECCE  1949 Harold Ridley (GB) : ICCE c IOL  29 Nov 1949 : the first IOL was implanted  failed  8 th Feb 1950 : the first permanent insertion of intraocular lens  1953 Harold Ridley (GB) : ECCE c IOL
History : ICCE and ECCE  1957 Joaquin Barraquer (SPA):  chymotrypsin  1961 Krawicz (POL):  Cryo-extraction
History : ICCE and ECCE  1964 Baron and Strampilli (GB) :  angle-type AC IOL  1968 Binkhorst (NED) :  Iris-claw AC IOL
History : ICCE and ECCE  ICCE : cons  Vitreous loss   RD, VH   disfigured pupils, ACG  Wound integrity/ astigmatism  AC IOL : cons  Corneal decompensate  UGH syndrome  Unable to dilate pupil
History : ECCE(and PE)  1967 Charles Kelman (US): PE  (1966 Peristaltic Pump First Phaco on animals)  4 hrs, 3 L of fluid  sonic-ultrasonic device made by Cavitron  1974 American Intraocular Lens Implant Society* (US): ECCE  *- American Society of Cataract and Refractive Surgery (ASCRS)
History : ECCE(and PE)  1975 AILIS (US)  PC IOL  1980 Pape and Balazs  Hyaluronic acid  1980 Danielle Aron-Rosa (FRA)  Nd:YAG capsulotomy
History : ECCE  ECCE : pros  Much safer than ICCE  Simple instruments  Little more skill is needed  ECCE : cons  Wound integrity/ astigmatism  Long op time
History : PE  1983 Clifford Terry (US): astigmatic keratotomy  1986 Mazzoco (US), Barrett (AUS) : foldable IOL  1986 Kimiya Shimizu (JAP) : topical ansthesia  1987 Gimbel (CAN) : CCC and hydrodissection  1995 Howard Fine (US): temporal clear corneal incision
Phacoemulsification  Pros  Small wound  Better wound integrity  Less astigmatism  Perserve conj/ less bleeding  Short op time  Cons  Needs more skill/ learning curve  Needs more instruments/ maintainance
Let start doing cataract Sx
Extracapsular Cataract Extraction
ECCE : Steps  1. +/-Bridle traction suture  2. Peritomy (Conj opening)  3. Partial thickness corneoscleral wound and AC Entering  4. Can-opener capsulotomy  5. Extend corneoscleral wound and Lens extraction  6. remove cortex +/- suture  7. IOL implantation and close wound
ECCE step 1 : Superior Bridle suture  Grab bulbar conjunctiva and tenon from the superior fornix  Pull the globe down  Pass needle through conj-tenon-sclera  Potential cpx  driving needle into vitreous  cryo  check for RD/ VH
ECCE step 2 : conj opening (peritomy)  Conjunctival flap  fornix-based flap  Radial snip  Blunt dissection of conj-tenon from sclera  Create limbal wound Surgeon view  Another radial snip  150-180’  Clean tenon/ stop bleeding
ECCE step 3 : Partial thickness corneoscleral wound and AC Entering  Blade no.15 (not 15’ blade)  Partial thickness wound depth 50-80%  Enter the AC with 15’blade/ needle/ razor blade  +/-stain capsule c ICG,trypan blue  Air bubble  Dye  Washout  fill the AC with OVD Surgeon view
ECCE step 4 : Can-opener capsulotomy  Cystotome  Complete the circle  Make it LARGE  May do CCC with relaxing incision
ECCE step 5 : Extend corneoscleral wound and lens extraction  Extend corneoscleral wound  Corneal scissor  150-180’  Make sure this wound fit to the size of the necleus  Avoid hitting endothelium/ DMMB  Inside-out technique Surgeon view
ECCE step 5 : extend corneoscleral wound and lens extraction  Lens extraction  Instruments  Forceps  Lens loop  Hooks  Corneal Suture  cryo
ECCE step 5 : extend corneoscleral wound and lens extraction  Lens extraction  Major problems  Small wound  Wrong lens direction  Keys  Big wound  Tilt the nucleus
ECCE step 6 : IOL Implantation and close wound  Put 2-3 stitches to hold the      AC Remove cortex with simcoe double barrel cannula Fill the bag+AC with OVD Insert IOL Put more sutures Remove OVD with simcoe
ECCE step 6 : IOL Implantation and close wound  Closing corneosclearl wound  3-7 stitches of Nylon 10-0  Terry notches  Aim : little WTR astigmatism  Close conj wound  Topical steroid/ ABO/ miotic
Phacoemulsification
Phacoemulsification : Steps  1. Capsulorhexis  2. Corneal/ scleral incision  3. Hydrodissection  4. Phacoemulsification  5. Cortex removal/ capsule polishing  6. IOL implantation
Phaco step 1 : capsulorhexis  Paracentesis  Inject OVD  capsulorhexis
Phaco step 1 : capsulorhexis  paracentesis  Needle, #75 blade, or other knife  stabilize the eye  Bond/ 0.12 forceps/ fixation ring/ cotton bud  Paracentesis 1-2  1 for 2nd instrument  2 for 2nd instrument and CCC
Phaco step 1 : capsulorhexis  Paracentesis  Potential complications:  put in wrong place  make another paracentesis  too small  make another wound  too big  suture later  nick lens capsule  include nick during capsulorhexis  nick iris  not serious and forget about it 
Phaco step 1 : capsulorhexis  Inject viscoelastic  Slow and steady  Push the aqueous out
Phaco step 1 : capsulorhexis  Potential complications:  shoot loose cannula into anterior chamber  tighten it better next time  Air bubbles  remove air with syringe +BSS  place OVD distal and force out
Phaco step 1 : capsulorhexis  CCC :  Continuous Curvilinear Capsulorhexis  Aim  Complete circle without radial tear  Centration  Size : 0.5-1.0 mm less than optical part of the IOL (5-6 mm)  Too large  more iris capture  Too small anterior capsule phimosis
Phaco step 1 : capsulorhexis  3 basic techniques  Cystitome  Forceps  Combo  initial cut with cystitome  most of tear with forceps  *Need major wound to use forceps
Phaco step 1 : capsulorhexis with cystotome
Phaco step 1 : capsulorhexis with cystotome/ forceps
Phaco step 1 : capsulorhexis  Keys for good CCC  Adequate viscoelastic/ dilation  Balance the pressure  Good visualization : may need staining eg. Trypan blue, ICG  Control eye mobility
Phaco step 1 : capsulorhexis  Potential complications:  Poor red reflex  stain with Trypan Blue or ICG  Tear starting to go radial  add OVD  Use forceps, your senior  (and pray)  Radial tear  Use scissors to restart in other direction  Can opener +/- conversion to ECCE  Debulk lens by sculpting out bowl prior to hydrodissection
Phaco step 1 : capsulorhexis  Potential complications:  too small  Fill more OVD and do the larger one with forceps  enlarge after placing IOL  too big  forget about it because this is not a serious issue  Miostat to prevent capture  zonular laxity  consider placing iris hooks/ CTR to stabilize the capsular bag
Phaco step 2 : corneal/ scleral incision
Phaco step 2 : corneal/ scleral incision, table Scleral tunnel Leakage Clear cornea Less More Management of burnt wound Easier More difficult Sx-induced astigmatism Less* More Infection Less More Time consuming More Less Bleeding/ conj scar More Less Handpiece mobility Less more
Phaco step 2 :corneal incision  3 types  Single-plane  Williamson incision  Langerman incision
Phaco step 3 : Hydrodissection  Aim : to free the nucleus/ epinucleus/ cortex from the capsule
Phaco step 3 : Hydrodissection 10:00 2:00 Create fluid wave at 10 and 2 o’clock
Phaco step 3 : Hydrodissection
Phaco setp 3 : Hydrodissection  Option : Hydrodeliniation  Separate nucleus from epinucleus  Golden ring sign (Abe T, JJO 2001)
Phaco setp 3 : Hydrodissection  Potential complications  Radial tear
Phaco setp 3 : Hydrodissection  Potential cpx : capsular blockage syndrome  Small CCC  Large/hard nucleus  Fast injection  If everything is too late  don’t scream, stay calm and call your retina surgeon.
Phaco setp 3 : Hydrodissection  Potential complications  No fluid wave  try again in different spot  increase force  use bursts and gently push on nucleus between bursts
Phaco setp 3 : Hydrodissection  Iris Prolapse  Remove dispersive OVD. If using a clear cornea wound, then use sub-incisional iris hook  Prolapse nucleus  Brown technique or Pop n Chop, flip into ciliary sulcus, or push back into bag
Phaso step 4 : Phacoemulsification  Peizoelectric crystal  ultrasound  35,000-40,000Hz, 1/1,000 ‘’  Low freq  less effective  High freq  more heat  Phaco power  Stroke length  Duration : pulse mode, burst mode  Bevel (0, 15, 30, 45, 60’)
Phaso step 4 : Phacoemulsification  The goal is to remove lens with the minimum u/s  Trend is to use increasing vacuum and decreasing u/s power  Techniques  Endocapsular - keeping the nucleus in bag during phaco  Supracapsular - prolapsing nucleus into sulcus during phaco  Anterior chamber shell - prolapsing shelled out nucleus into anterior chamber  ½ bag ½ anterior chamber --tipping nucleus on side ½ in bag; ½ in anterior chamber – a.k.a., Brown Technique, Pop-n-Chop.
Phaco step 4 : Phaco  Basic Technique  1. Divide-and-conquer  Grooves  Width 1.5-2x of phaco tip  Depth : close to the posterior cortex  Tips  NO occlusion  Each stroke depth~1/3-1/2 phacotip
DIVIDE & CONQUER 1 2
DIVIDE & CONQUER 4 3 5 6
sculpting 3 DO NOT occlude the tip during sculpting
DIVIDE & CONQUER 7 8
DIVIDE & CONQUER 12 13
cracking
Divide and conquer
Phaco step 4 : Phacoemulsification  Basic technique  2. slow-motion phacoemulsification  Divide-and –conquer with Low flow rate, low vacuum  For beginner/ soft nucleus-PSC-posterior polar
Phaco step 4 : Phacoemulsification  Basic Technique  3. phacochop  Kunihiro Nagahara 1993  Tip 0, 15, 30’  High flow rate,high vac  Bevel down>up  Phacochopper  Chop/ quick chop  Not recommmeded for soft nucleus
2 1 Phaco chop 3
Phaco chop 5 4 6 7
Phaco chop 8 10 9 11
Phaco chop 12 13 14 15
Phaco step 4 : Phacoemulsification  Basic technique  4. Stop and Chop phaco  For very hard nucleus  Create groove as in divide-and-conquer  Crack  Rotate the nucleus 6090’  phacochop
Stop and chop 1 2 3
Stop and chop 5 6 7 8
Phaco step 4 : Phacoemulsification  Basic technique  5. Chip and Flip (Bowl-out)  For very soft nucleus  Complete hydrodissection+hydrodeliniation  Emulsified the nuclear core  Flip the nuclear shell  Emulsified the shell (low power, low vacuum, high flow rate)
Phaco step 4 : Phaco  Some other techniques  Quick chop  Phaco flip (supracapsular)
Phaco step4: phacoemulsification
Phaco step 5 : Cortex removal  I/A handpiece  Start at the area under the phaco wound  1. Rotate tip 90’ for safe occlusion  2. Pull to the center/ tip up  3. max vacuum  4. re engage
Phaco step 5 : Cortex removal  Situation : problem removing cortex under the wound  Solutions  U-shape I/A tip  Use the side port + blunt tip cannula  Place IOL and then I/A
Phaco step 5 : cortex removal  Capsule polishing  For less/ later PCO  Anterior capsule : high vac  Posterior capsule  vac 5-10 mmHg, flow rate 5-6 cc/min  Slow tip movement  Not recommend in  Loose capsule eg. PXS  Radial tear  Zonule lysis
Phaco step 6 : IOL implantation  Inject viscoelastic to fill the capsular bag/ AC  Do not pierce the PC with your blunt needle  Insert IOL  Rigid IOL  need to extend the wound  IOL diameter 5-5.5 mm  1-3 stitches  Foldable IOL  Use injector or forceps  0-1 stitch  Remove viscoelastic : bag  AC
Phaco step 6 : IOL implantation
Phaco step 6 : IOL implantation  Potential complication  Place IOL up-side down  Can leave as is - accept myopic shift  Take one haptic out of wound with Sinsky hook Fill with OVD above and below IOL One hook above and one below -- Flip IOL
Phaco step 6 : IOL implantation  Inadvertent sulcus placement  Fill with OVD -- Rotate into bag with hook  If a 3 piece can leave in sulcus with myopic shift  Do not leave single piece acrylic (eg. Alcon SA60) in sulcus
Phaco step 6 :IOL implantation  IOL doesn't center Usually one haptic in sulcus one in bag  dial both into bag or both into sulcus  Possible zonular dialysis  if nearly centered leave it alone  rotate IOL carefully for best centration with 3 piece often haptics best at weak area  check wound for vitreous, miostat  consider placement of CTR
Phaco step 6 : IOL implantation  Tear in Descemet's  Double AC sign  Use care to not extend tear  Place Air Bubble at end of case – post op position wound up -bubble seals Descemets
Phaco step 6 : IOL implantation  Lens Material behind IOL  Rotate haptic 90 deg from wound Toe down with I/A and get under IOL With aspiration tip showing at all times aspirate  Note – make sure that you have an INTACT capsule
Special IOL Placement Conditions  Anterior Capsular Tear  Single piece acrylic in the bag - creates little tension on the bag  3 piece with both haptics in the sulcus  Zonular Dialysis  Capsular Tension Ring with any IOL  3 piece IOL with PMMA haptic oriented toward weak area of zonules
Special IOL Placement Conditions  Posterior Capsular Tear  Dispersive OVD in the post capsular hole -- gently place IOL into bag  Place 3 piece in sulcus +/- capture of optic by centered anterior CCC  No Capsular Support  AC IOL: there are 3 sizes depending on white to white size  Iris Sutured PC IOL  Scleral Sutured PC IOL
Phaco step 6 : IOL implantation Viscoelastic removal  OVD is removed with I/A device  As always keep tip opening up  Go under IOL to remove OVD, especially if you have been having IOP problems post op
One Last Step  Check the wound integrity  Stop leaking  Corneal stromal hydration  Fill AC with air bubble
The New Comers  Femtosecond cataract surgery 95
Femto cataract, Hx  2005  Image-guided laser cataract surgery was first conceptualized  D. Palanker and M. Blumenkranz  patents US 8394084; US 8403921; US 8425497  2005-2010  OptiMedica Corp. developed and tested  integrated Optical Coherence Tomography and femtosecond laser  Palanker DV, Blumenkranz MS, Andersen D, et al. Femtosecond laserassisted cataract surgery with integrated optical coherence tomography. Sci Transl Med 2010;2:58ra85.
Femto cataract, Hx  2008  first used clinically in cataract surgery  Prof. Zoltan Nagy  Budapest, Hungary  2010 Dr Steven Slade in the USA  2011 Dr Michael Lawlwss in Asia/ AUS  ”The Future of Laser Cataract Surgery” Keynote Lecture American Academy of Ophthalmology, Subspecialty Day, Chicago, November, 2012
Femtosecond cataract Sx  cone pattern  To avoid distortion of the incoming laser beam on gas bubbles and tissue fragments  applied first posterior to the target  advances anteriorly
Femtosecond cataract surgery  What femto can do?  Create corneal flap/tunnels  CCC  Nuclear fragmentation  LRI
Femtosecond clear corneal incision  corneal incision  Controlled  reproducible  configuration  less risk of wound leak  --> less infection
Femtosecond capsulotomy  near perfect, round opening in the anterior capsule  strength of the capsule  as good as or greater than a manual capsulorhexis  smoothness of the capsulotomy edge  similar to manually created openings
Femtosecond capsulotomy incidence of anterior capsular tears  Manual CCC  0.79% in very experienced hands  5.3% within teaching institutions  Marques et al  40% of anterior capsular tears extended to the posterior capsule  20% required further surgery  Lawless in November 2012  0.2% incidence of anterior tears  throughout his initial 500 cases  Marques FF, Marques DM. Fate of AC tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42.  Unal M, Yücel I, Sarici A et al. Phaco with topical anesthesia: Resident experience. J Cataract Refract Surg. 2006;32:13615.  Marques FF, Marques DM. Fate of anterior capsule tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42.  Lawless M. ”The Future of Laser Cataract Surgery” Keynote Lecture American Academy of Ophthalmology, Subspecialty Day, Chicago, November, 2012
Femtosecond capsulotomy  Precised CCC means  Less tear/ nucleus dropping/ uveitis/ VH/ RRD/ endophthalmitis  Less IOL decentration  Lawless : mean circularity  0.942 in 29 lasered eyes  0.774 in 30 manual eyes  12X improvement in the precision of the capsulotomy diameter  Freidman : deviation from intended diameter  29 µm ± 26μm for laser capsulotomies (mean deviation 6%)  337μm ± 258μm for a manual technique (mean deviation 20%)  Friedman NJ, Palanker DV, Schuele G. Femtosecond laser capsulotomy. J Cataract Refract Surg. 2011 Jul;37(7):1189-98.
Femtosecond phacofragmentation  reduce the average time and energy required to break up and remove the lens by approximately 50-98%  Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg 2009;25:1053-60.  Batlle JF, Feliz R, Culbertson WW. OCT-guided femtosecond laser cataract & surgery: precision and efficacy. Association for Research in Vision and Ophthalmology Annual Meeting. A4694 Poster #D633. Fort Lauderdale, FL; 2011. www.arvo.org  Edwards K, Uy HS, Schneider S. The effect of laser lens fragmentation on use & of ultrasound energy in cataract surgery. Association for Research in Vision and Ophthalmology Annual Meeting. A4710 Poster #D768. Fort Lauderdale, FL; 2011. www.arvo.org
Femtosecond LRI  better refraction correction  --> + visual outcomes 105
Femtosecond cataract surgery : Video 106
Femtosecond cataract surgery : Video 107
Femtosecond cataract surgery : cons  Need suction  Rise IOP  SCH  Can not do well in some dense cataract  Failure during PC scanning  PRICE
Machines  Alcon LenSx  (Alcon Laboratories, Ft Worth, TX, USA)  OptiMedica Catalys  (Optimedica Corp, CA, USA)  LensAR  (LensAR Inc, FL, USA)  Technolas  (Technolas Perfect Vision GmbH, Germany)
Now you guys are ready to ROCK!!!!

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Nw2012 cataract surgery11

  • 1.
  • 2.
    Cataract  “Even wehave had the much advanced treatment for it for a while and we keep doing better, but sometimes, in some occasions, cataract can be very challenging disease that we, ophthalmologists, will be the ones to treat.”  Prof. Ian Jeffrey Constable  Director of Lions Eye Institute, University of Western Australia  first president of APAO
  • 3.
    terms  phakos (Greek)- Lens  Katarraktes (Greek)  a down rushing, or waterfall  Originally thought that congealed brain fluid was flowing in front of lens.
  • 4.
  • 5.
    History : at thebeginning --- Couching -- Sushruta (Hippocrates of India), 600 BC  The Indian tradition of cataract surgery  Couching with jabamukhi salaka  soaked with warm butter and then bandaged
  • 6.
  • 7.
    History:Couching  India  Egypt Greek, europe   Burma thaichina  Rome (29 AC)  De Medicinae, (Aulus Cornelius Celsus)  Persia (100 AC)  Choice of Eye Diseases (Ammar ibn Ali)
  • 8.
    History : Couching Large lens shadow  severe uveitis  retinal detachment/ VH  Endophthalmitis
  • 9.
    History : ICCEand ECCE  1753 Jaques Daviel (FRA) : ECCE  Uveitis from left cortex  High incidence of PC tear  Success rate ~30%
  • 10.
    History : ICCEand ECCE  1752-53 Intra Capsular Cataract Extraction ICCE Sharp, de la Faye.  1900 Henry Smith (IRE): ICCE  Erysophake  Capsule forceps  >20,000 ICCE Sx
  • 11.
    History : ICCEand ECCE  1949 Harold Ridley (GB) : ICCE c IOL  29 Nov 1949 : the first IOL was implanted  failed  8 th Feb 1950 : the first permanent insertion of intraocular lens  1953 Harold Ridley (GB) : ECCE c IOL
  • 12.
    History : ICCE andECCE  1957 Joaquin Barraquer (SPA):  chymotrypsin  1961 Krawicz (POL):  Cryo-extraction
  • 13.
    History : ICCEand ECCE  1964 Baron and Strampilli (GB) :  angle-type AC IOL  1968 Binkhorst (NED) :  Iris-claw AC IOL
  • 14.
    History : ICCEand ECCE  ICCE : cons  Vitreous loss   RD, VH   disfigured pupils, ACG  Wound integrity/ astigmatism  AC IOL : cons  Corneal decompensate  UGH syndrome  Unable to dilate pupil
  • 15.
    History : ECCE(andPE)  1967 Charles Kelman (US): PE  (1966 Peristaltic Pump First Phaco on animals)  4 hrs, 3 L of fluid  sonic-ultrasonic device made by Cavitron  1974 American Intraocular Lens Implant Society* (US): ECCE  *- American Society of Cataract and Refractive Surgery (ASCRS)
  • 16.
    History : ECCE(andPE)  1975 AILIS (US)  PC IOL  1980 Pape and Balazs  Hyaluronic acid  1980 Danielle Aron-Rosa (FRA)  Nd:YAG capsulotomy
  • 17.
    History : ECCE ECCE : pros  Much safer than ICCE  Simple instruments  Little more skill is needed  ECCE : cons  Wound integrity/ astigmatism  Long op time
  • 18.
    History : PE 1983 Clifford Terry (US): astigmatic keratotomy  1986 Mazzoco (US), Barrett (AUS) : foldable IOL  1986 Kimiya Shimizu (JAP) : topical ansthesia  1987 Gimbel (CAN) : CCC and hydrodissection  1995 Howard Fine (US): temporal clear corneal incision
  • 19.
    Phacoemulsification  Pros  Smallwound  Better wound integrity  Less astigmatism  Perserve conj/ less bleeding  Short op time  Cons  Needs more skill/ learning curve  Needs more instruments/ maintainance
  • 20.
    Let start doingcataract Sx
  • 21.
  • 22.
    ECCE : Steps  1.+/-Bridle traction suture  2. Peritomy (Conj opening)  3. Partial thickness corneoscleral wound and AC Entering  4. Can-opener capsulotomy  5. Extend corneoscleral wound and Lens extraction  6. remove cortex +/- suture  7. IOL implantation and close wound
  • 23.
    ECCE step 1: Superior Bridle suture  Grab bulbar conjunctiva and tenon from the superior fornix  Pull the globe down  Pass needle through conj-tenon-sclera  Potential cpx  driving needle into vitreous  cryo  check for RD/ VH
  • 24.
    ECCE step 2: conj opening (peritomy)  Conjunctival flap  fornix-based flap  Radial snip  Blunt dissection of conj-tenon from sclera  Create limbal wound Surgeon view  Another radial snip  150-180’  Clean tenon/ stop bleeding
  • 25.
    ECCE step 3: Partial thickness corneoscleral wound and AC Entering  Blade no.15 (not 15’ blade)  Partial thickness wound depth 50-80%  Enter the AC with 15’blade/ needle/ razor blade  +/-stain capsule c ICG,trypan blue  Air bubble  Dye  Washout  fill the AC with OVD Surgeon view
  • 26.
    ECCE step 4: Can-opener capsulotomy  Cystotome  Complete the circle  Make it LARGE  May do CCC with relaxing incision
  • 27.
    ECCE step 5: Extend corneoscleral wound and lens extraction  Extend corneoscleral wound  Corneal scissor  150-180’  Make sure this wound fit to the size of the necleus  Avoid hitting endothelium/ DMMB  Inside-out technique Surgeon view
  • 28.
    ECCE step 5: extend corneoscleral wound and lens extraction  Lens extraction  Instruments  Forceps  Lens loop  Hooks  Corneal Suture  cryo
  • 29.
    ECCE step 5: extend corneoscleral wound and lens extraction  Lens extraction  Major problems  Small wound  Wrong lens direction  Keys  Big wound  Tilt the nucleus
  • 30.
    ECCE step 6: IOL Implantation and close wound  Put 2-3 stitches to hold the      AC Remove cortex with simcoe double barrel cannula Fill the bag+AC with OVD Insert IOL Put more sutures Remove OVD with simcoe
  • 31.
    ECCE step 6: IOL Implantation and close wound  Closing corneosclearl wound  3-7 stitches of Nylon 10-0  Terry notches  Aim : little WTR astigmatism  Close conj wound  Topical steroid/ ABO/ miotic
  • 32.
  • 33.
    Phacoemulsification : Steps  1.Capsulorhexis  2. Corneal/ scleral incision  3. Hydrodissection  4. Phacoemulsification  5. Cortex removal/ capsule polishing  6. IOL implantation
  • 34.
    Phaco step 1: capsulorhexis  Paracentesis  Inject OVD  capsulorhexis
  • 35.
    Phaco step 1: capsulorhexis  paracentesis  Needle, #75 blade, or other knife  stabilize the eye  Bond/ 0.12 forceps/ fixation ring/ cotton bud  Paracentesis 1-2  1 for 2nd instrument  2 for 2nd instrument and CCC
  • 36.
    Phaco step 1: capsulorhexis  Paracentesis  Potential complications:  put in wrong place  make another paracentesis  too small  make another wound  too big  suture later  nick lens capsule  include nick during capsulorhexis  nick iris  not serious and forget about it 
  • 37.
    Phaco step 1: capsulorhexis  Inject viscoelastic  Slow and steady  Push the aqueous out
  • 38.
    Phaco step 1: capsulorhexis  Potential complications:  shoot loose cannula into anterior chamber  tighten it better next time  Air bubbles  remove air with syringe +BSS  place OVD distal and force out
  • 39.
    Phaco step 1: capsulorhexis  CCC :  Continuous Curvilinear Capsulorhexis  Aim  Complete circle without radial tear  Centration  Size : 0.5-1.0 mm less than optical part of the IOL (5-6 mm)  Too large  more iris capture  Too small anterior capsule phimosis
  • 40.
    Phaco step 1: capsulorhexis  3 basic techniques  Cystitome  Forceps  Combo  initial cut with cystitome  most of tear with forceps  *Need major wound to use forceps
  • 41.
    Phaco step 1: capsulorhexis with cystotome
  • 42.
    Phaco step 1: capsulorhexis with cystotome/ forceps
  • 43.
    Phaco step 1: capsulorhexis  Keys for good CCC  Adequate viscoelastic/ dilation  Balance the pressure  Good visualization : may need staining eg. Trypan blue, ICG  Control eye mobility
  • 44.
    Phaco step 1: capsulorhexis  Potential complications:  Poor red reflex  stain with Trypan Blue or ICG  Tear starting to go radial  add OVD  Use forceps, your senior  (and pray)  Radial tear  Use scissors to restart in other direction  Can opener +/- conversion to ECCE  Debulk lens by sculpting out bowl prior to hydrodissection
  • 45.
    Phaco step 1: capsulorhexis  Potential complications:  too small  Fill more OVD and do the larger one with forceps  enlarge after placing IOL  too big  forget about it because this is not a serious issue  Miostat to prevent capture  zonular laxity  consider placing iris hooks/ CTR to stabilize the capsular bag
  • 46.
    Phaco step 2: corneal/ scleral incision
  • 47.
    Phaco step 2: corneal/ scleral incision, table Scleral tunnel Leakage Clear cornea Less More Management of burnt wound Easier More difficult Sx-induced astigmatism Less* More Infection Less More Time consuming More Less Bleeding/ conj scar More Less Handpiece mobility Less more
  • 48.
    Phaco step 2:corneal incision  3 types  Single-plane  Williamson incision  Langerman incision
  • 49.
    Phaco step 3: Hydrodissection  Aim : to free the nucleus/ epinucleus/ cortex from the capsule
  • 50.
    Phaco step 3: Hydrodissection 10:00 2:00 Create fluid wave at 10 and 2 o’clock
  • 51.
    Phaco step 3: Hydrodissection
  • 52.
    Phaco setp 3: Hydrodissection  Option : Hydrodeliniation  Separate nucleus from epinucleus  Golden ring sign (Abe T, JJO 2001)
  • 53.
    Phaco setp 3: Hydrodissection  Potential complications  Radial tear
  • 54.
    Phaco setp 3: Hydrodissection  Potential cpx : capsular blockage syndrome  Small CCC  Large/hard nucleus  Fast injection  If everything is too late  don’t scream, stay calm and call your retina surgeon.
  • 55.
    Phaco setp 3: Hydrodissection  Potential complications  No fluid wave  try again in different spot  increase force  use bursts and gently push on nucleus between bursts
  • 56.
    Phaco setp 3: Hydrodissection  Iris Prolapse  Remove dispersive OVD. If using a clear cornea wound, then use sub-incisional iris hook  Prolapse nucleus  Brown technique or Pop n Chop, flip into ciliary sulcus, or push back into bag
  • 57.
    Phaso step 4: Phacoemulsification  Peizoelectric crystal  ultrasound  35,000-40,000Hz, 1/1,000 ‘’  Low freq  less effective  High freq  more heat  Phaco power  Stroke length  Duration : pulse mode, burst mode  Bevel (0, 15, 30, 45, 60’)
  • 58.
    Phaso step 4: Phacoemulsification  The goal is to remove lens with the minimum u/s  Trend is to use increasing vacuum and decreasing u/s power  Techniques  Endocapsular - keeping the nucleus in bag during phaco  Supracapsular - prolapsing nucleus into sulcus during phaco  Anterior chamber shell - prolapsing shelled out nucleus into anterior chamber  ½ bag ½ anterior chamber --tipping nucleus on side ½ in bag; ½ in anterior chamber – a.k.a., Brown Technique, Pop-n-Chop.
  • 59.
    Phaco step 4: Phaco  Basic Technique  1. Divide-and-conquer  Grooves  Width 1.5-2x of phaco tip  Depth : close to the posterior cortex  Tips  NO occlusion  Each stroke depth~1/3-1/2 phacotip
  • 60.
  • 61.
  • 62.
    sculpting 3 DO NOT occludethe tip during sculpting
  • 63.
  • 64.
  • 65.
  • 66.
  • 67.
    Phaco step 4: Phacoemulsification  Basic technique  2. slow-motion phacoemulsification  Divide-and –conquer with Low flow rate, low vacuum  For beginner/ soft nucleus-PSC-posterior polar
  • 68.
    Phaco step 4: Phacoemulsification  Basic Technique  3. phacochop  Kunihiro Nagahara 1993  Tip 0, 15, 30’  High flow rate,high vac  Bevel down>up  Phacochopper  Chop/ quick chop  Not recommmeded for soft nucleus
  • 69.
  • 70.
  • 71.
  • 72.
  • 73.
    Phaco step 4: Phacoemulsification  Basic technique  4. Stop and Chop phaco  For very hard nucleus  Create groove as in divide-and-conquer  Crack  Rotate the nucleus 6090’  phacochop
  • 74.
  • 75.
  • 76.
    Phaco step 4: Phacoemulsification  Basic technique  5. Chip and Flip (Bowl-out)  For very soft nucleus  Complete hydrodissection+hydrodeliniation  Emulsified the nuclear core  Flip the nuclear shell  Emulsified the shell (low power, low vacuum, high flow rate)
  • 77.
    Phaco step 4: Phaco  Some other techniques  Quick chop  Phaco flip (supracapsular)
  • 78.
  • 79.
    Phaco step 5: Cortex removal  I/A handpiece  Start at the area under the phaco wound  1. Rotate tip 90’ for safe occlusion  2. Pull to the center/ tip up  3. max vacuum  4. re engage
  • 80.
    Phaco step 5: Cortex removal  Situation : problem removing cortex under the wound  Solutions  U-shape I/A tip  Use the side port + blunt tip cannula  Place IOL and then I/A
  • 81.
    Phaco step 5: cortex removal  Capsule polishing  For less/ later PCO  Anterior capsule : high vac  Posterior capsule  vac 5-10 mmHg, flow rate 5-6 cc/min  Slow tip movement  Not recommend in  Loose capsule eg. PXS  Radial tear  Zonule lysis
  • 82.
    Phaco step 6: IOL implantation  Inject viscoelastic to fill the capsular bag/ AC  Do not pierce the PC with your blunt needle  Insert IOL  Rigid IOL  need to extend the wound  IOL diameter 5-5.5 mm  1-3 stitches  Foldable IOL  Use injector or forceps  0-1 stitch  Remove viscoelastic : bag  AC
  • 83.
    Phaco step 6: IOL implantation
  • 84.
    Phaco step 6: IOL implantation  Potential complication  Place IOL up-side down  Can leave as is - accept myopic shift  Take one haptic out of wound with Sinsky hook Fill with OVD above and below IOL One hook above and one below -- Flip IOL
  • 85.
    Phaco step 6: IOL implantation  Inadvertent sulcus placement  Fill with OVD -- Rotate into bag with hook  If a 3 piece can leave in sulcus with myopic shift  Do not leave single piece acrylic (eg. Alcon SA60) in sulcus
  • 86.
    Phaco step 6:IOL implantation  IOL doesn't center Usually one haptic in sulcus one in bag  dial both into bag or both into sulcus  Possible zonular dialysis  if nearly centered leave it alone  rotate IOL carefully for best centration with 3 piece often haptics best at weak area  check wound for vitreous, miostat  consider placement of CTR
  • 87.
    Phaco step 6: IOL implantation  Tear in Descemet's  Double AC sign  Use care to not extend tear  Place Air Bubble at end of case – post op position wound up -bubble seals Descemets
  • 88.
    Phaco step 6: IOL implantation  Lens Material behind IOL  Rotate haptic 90 deg from wound Toe down with I/A and get under IOL With aspiration tip showing at all times aspirate  Note – make sure that you have an INTACT capsule
  • 89.
    Special IOL Placement Conditions Anterior Capsular Tear  Single piece acrylic in the bag - creates little tension on the bag  3 piece with both haptics in the sulcus  Zonular Dialysis  Capsular Tension Ring with any IOL  3 piece IOL with PMMA haptic oriented toward weak area of zonules
  • 90.
    Special IOL Placement Conditions Posterior Capsular Tear  Dispersive OVD in the post capsular hole -- gently place IOL into bag  Place 3 piece in sulcus +/- capture of optic by centered anterior CCC  No Capsular Support  AC IOL: there are 3 sizes depending on white to white size  Iris Sutured PC IOL  Scleral Sutured PC IOL
  • 91.
    Phaco step 6: IOL implantation Viscoelastic removal  OVD is removed with I/A device  As always keep tip opening up  Go under IOL to remove OVD, especially if you have been having IOP problems post op
  • 92.
    One Last Step Check the wound integrity  Stop leaking  Corneal stromal hydration  Fill AC with air bubble
  • 93.
    The New Comers Femtosecond cataract surgery 95
  • 94.
    Femto cataract, Hx 2005  Image-guided laser cataract surgery was first conceptualized  D. Palanker and M. Blumenkranz  patents US 8394084; US 8403921; US 8425497  2005-2010  OptiMedica Corp. developed and tested  integrated Optical Coherence Tomography and femtosecond laser  Palanker DV, Blumenkranz MS, Andersen D, et al. Femtosecond laserassisted cataract surgery with integrated optical coherence tomography. Sci Transl Med 2010;2:58ra85.
  • 95.
    Femto cataract, Hx 2008  first used clinically in cataract surgery  Prof. Zoltan Nagy  Budapest, Hungary  2010 Dr Steven Slade in the USA  2011 Dr Michael Lawlwss in Asia/ AUS  ”The Future of Laser Cataract Surgery” Keynote Lecture American Academy of Ophthalmology, Subspecialty Day, Chicago, November, 2012
  • 96.
    Femtosecond cataract Sx cone pattern  To avoid distortion of the incoming laser beam on gas bubbles and tissue fragments  applied first posterior to the target  advances anteriorly
  • 97.
    Femtosecond cataract surgery What femto can do?  Create corneal flap/tunnels  CCC  Nuclear fragmentation  LRI
  • 98.
    Femtosecond clear corneal incision  cornealincision  Controlled  reproducible  configuration  less risk of wound leak  --> less infection
  • 99.
    Femtosecond capsulotomy  nearperfect, round opening in the anterior capsule  strength of the capsule  as good as or greater than a manual capsulorhexis  smoothness of the capsulotomy edge  similar to manually created openings
  • 100.
    Femtosecond capsulotomy incidence ofanterior capsular tears  Manual CCC  0.79% in very experienced hands  5.3% within teaching institutions  Marques et al  40% of anterior capsular tears extended to the posterior capsule  20% required further surgery  Lawless in November 2012  0.2% incidence of anterior tears  throughout his initial 500 cases  Marques FF, Marques DM. Fate of AC tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42.  Unal M, Yücel I, Sarici A et al. Phaco with topical anesthesia: Resident experience. J Cataract Refract Surg. 2006;32:13615.  Marques FF, Marques DM. Fate of anterior capsule tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42.  Lawless M. ”The Future of Laser Cataract Surgery” Keynote Lecture American Academy of Ophthalmology, Subspecialty Day, Chicago, November, 2012
  • 101.
    Femtosecond capsulotomy  PrecisedCCC means  Less tear/ nucleus dropping/ uveitis/ VH/ RRD/ endophthalmitis  Less IOL decentration  Lawless : mean circularity  0.942 in 29 lasered eyes  0.774 in 30 manual eyes  12X improvement in the precision of the capsulotomy diameter  Freidman : deviation from intended diameter  29 µm ± 26μm for laser capsulotomies (mean deviation 6%)  337μm ± 258μm for a manual technique (mean deviation 20%)  Friedman NJ, Palanker DV, Schuele G. Femtosecond laser capsulotomy. J Cataract Refract Surg. 2011 Jul;37(7):1189-98.
  • 102.
    Femtosecond phacofragmentation  reduce theaverage time and energy required to break up and remove the lens by approximately 50-98%  Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg 2009;25:1053-60.  Batlle JF, Feliz R, Culbertson WW. OCT-guided femtosecond laser cataract & surgery: precision and efficacy. Association for Research in Vision and Ophthalmology Annual Meeting. A4694 Poster #D633. Fort Lauderdale, FL; 2011. www.arvo.org  Edwards K, Uy HS, Schneider S. The effect of laser lens fragmentation on use & of ultrasound energy in cataract surgery. Association for Research in Vision and Ophthalmology Annual Meeting. A4710 Poster #D768. Fort Lauderdale, FL; 2011. www.arvo.org
  • 103.
    Femtosecond LRI  betterrefraction correction  --> + visual outcomes 105
  • 104.
  • 105.
  • 106.
    Femtosecond cataract surgery: cons  Need suction  Rise IOP  SCH  Can not do well in some dense cataract  Failure during PC scanning  PRICE
  • 107.
    Machines  Alcon LenSx (Alcon Laboratories, Ft Worth, TX, USA)  OptiMedica Catalys  (Optimedica Corp, CA, USA)  LensAR  (LensAR Inc, FL, USA)  Technolas  (Technolas Perfect Vision GmbH, Germany)
  • 108.
    Now you guysare ready to ROCK!!!!