nw2012 cataract surgery11
DESCRIPTION
cataract surgery - brief history - ECCE and Phaco for beginnersTRANSCRIPT
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Nawat WatanachaiChiangmai University Hospital2013
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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
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terms
phakos (Greek) - Lens
Katarraktes (Greek) a down rushing, or
waterfall
Originally thought that congealed brain fluid was flowing in front of lens.
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Timeline of Cataract Surgeries
Femto cataract2010
Phaco1967
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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
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History : Couching
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History:Couching
India
Egypt Greek, europe
Burma thaichina
Rome (29 AC) De Medicinae,
(Aulus Cornelius Celsus)
Persia (100 AC) Choice of Eye Diseases
(Ammar ibn Ali)
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History : Couching
Large lens shadow severe uveitis retinal detachment/ VH Endophthalmitis
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History : ICCE and ECCE
1753 Jaques Daviel (FRA) : ECCE Uveitis from left cortex High incidence of PC tear Success rate ~30%
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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
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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
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History : ICCE and ECCE
1957 Joaquin Barraquer (SPA): chymotrypsin
1961 Krawicz (POL): Cryo-extraction
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History : ICCE and ECCE 1964 Baron and Strampilli (GB) :
angle-type AC IOL 1968 Binkhorst (NED) :
Iris-claw AC IOL
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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
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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)
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History : ECCE(and PE) 1975 AILIS (US)
PC IOL 1980 Pape and Balazs
Hyaluronic acid 1980 Danielle Aron-Rosa (FRA)
Nd:YAG capsulotomy
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History : ECCE
ECCE : pros Much safer than ICCE Simple instruments Little more skill is needed
ECCE : cons Wound integrity/ astigmatism Long op time
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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
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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
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Let start doing cataract Sx
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Extracapsular
Cataract Extraction
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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
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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
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ECCE step 2 : conj opening (peritomy)
Conjunctival flap fornix-based flap
Radial snip Blunt dissection of conj-tenon from
sclera Create limbal wound Another radial snip
150-180’ Clean tenon/ stop bleeding
Surgeon view
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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
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ECCE step 4 : Can-opener capsulotomy
Cystotome Complete the circle Make it LARGE May do CCC with relaxing incision
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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
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ECCE step 5 : extend corneoscleral wound
and lens extraction
Lens extraction Instruments
Forceps Lens loop Hooks Corneal
Suture cryo
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ECCE step 5 : extend corneoscleral wound and lens extraction
Lens extraction Major
problems Small wound Wrong lens
direction Keys
Big wound Tilt the
nucleus
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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
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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
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Phacoemulsification
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Phacoemulsification : Steps 1. Capsulorhexis 2. Corneal/ scleral incision 3. Hydrodissection 4. Phacoemulsification 5. Cortex removal/ capsule polishing 6. IOL implantation
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Phaco step 1 : capsulorhexis
Paracentesis Inject OVD capsulorhexi
s
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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
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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
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Phaco step 1 : capsulorhexis
Inject viscoelastic Slow and steady Push the aqueous
out
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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
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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
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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
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Phaco step 1 : capsulorhexis with cystotome
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Phaco step 1 : capsulorhexis with cystotome/ forceps
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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
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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
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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
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Phaco step 2 : corneal/ scleral incision
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Phaco step 2 : corneal/ scleral incision, table
Scleral tunnel
Clear cornea
Leakage 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
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Phaco step 2 :corneal incision
3 types Single-plane Williamson incision Langerman incision
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Phaco step 3 : Hydrodissection
Aim : to free the nucleus/ epinucleus/ cortex from the capsule
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10:00 2:00 Create fluid wave at 10 and 2 o’clock
Phaco step 3 : Hydrodissection
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Phaco step 3 : Hydrodissection
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Phaco setp 3 : Hydrodissection
Option : Hydrodeliniation Separate nucleus from epinucleus Golden ring sign (Abe T, JJO 2001)
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Phaco setp 3 : Hydrodissection
Potential complications Radial tear
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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.
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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
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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
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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’)
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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.
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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
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1 2
DIVIDE & CONQUER
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5 6
DIVIDE & CONQUER
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DO NOT occlude the tip during sculpting
sculpting
3
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7
8
DIVIDE & CONQUER
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1312
DIVIDE & CONQUER
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cracking
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Divide and conquer
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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
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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
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1 2
3
Phaco chop
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45
6 7
Phaco chop
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8 9
10 11
Phaco chop
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12 13
14 15
Phaco chop
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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
60-90’ phacochop
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1
Stop and chop
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7
5 6
8
Stop and chop
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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)
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Phaco step 4 : Phaco
Some other techniques Quick chop Phaco flip (supracapsular)
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Phaco step4:phacoemulsification
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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
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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
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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
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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
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Phaco step 6 : IOL implantation
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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 hookFill with OVD above and below IOLOne hook above and one below -- Flip IOL
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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
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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
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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 opposition wound up -- bubble seals Descemets
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Phaco step 6 : IOL implantation Lens Material behind IOL Rotate haptic 90 deg from wound
Toe down with I/A and get under IOLWith aspiration tip showing at all times aspirate
Note – make sure that you have an INTACT capsule
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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
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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
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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
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One Last Step
Check the wound integrity Stop leaking
Corneal stromal hydration Fill AC with air bubble
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The New Comers
Femtosecond cataract surgery
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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
laser-assisted cataract surgery with integrated optical coherence tomography. Sci Transl Med 2010;2:58ra85.
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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
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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
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Femtosecond cataract surgery What femto can do?
Create corneal flap/tunnels CCC Nuclear fragmentation LRI
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corneal incision Controlled reproducible configuration
less risk of wound leak --> less infection
Femtosecond
clear corneal incision
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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
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Femtosecond capsulotomyincidence 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;32:1361-5.
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
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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.
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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
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Femtosecond LRI
better refraction correction --> + visual outcomes
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Femtosecond cataract surgery : Video
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Femtosecond cataract surgery : Video
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Femtosecond cataract surgery : cons Need suction
Rise IOP SCH
Can not do well in some dense cataract Failure during PC scanning
PRICE
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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)
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Now you guys are ready to ROCK!!!!