Steinert's Cataract Surgery

Front Cover
Steinert’s Cataract Surgery
Copyright Page
Acknowledgments
Contributors
Contents
Video TOC
Introduction
I. Preoperative Considerations​
1
Pathology and Classification of Cataracts
Key Points
Lens Embryology
The Crystalline Lens
Cataract Formation
Oxidative Stress
Osmotic Stress
Lens Opacities Classification System
Types of Cataracts
Congenital Cataracts
Nuclear Cataracts
Cortical Cataracts
Posterior Subcapsular Cataracts
Anterior Subcapsular Cataracts
Traumatic Cataracts
Pseudoexfoliation and True Exfoliation
summary
References
2
Preoperative Evaluation and Preparation of the Cataract Patient
Key Points
Introduction
Evaluation Of Visual Disability
Contrast Sensitivity Function
Glare Disability
Ocular Scatter Index And Higher Order Aberrations
Assessment of Visual Potential
Obtaining A History
Evaluation of Subjective Visual Impairment
Contact Lens Use
Prior Corneal Refractive Surgery
Medical History
Anticoagulation and Antiplatelet Therapy
Spinal Disease, Dementia, and Tremor
Preoperative Examination and Concomitant Conditions
Ocular Surface Disorder
Blepharitis
Corneal Endothelial Disease
Glaucoma
Uveitis
Intraoperative Floppy Iris Syndrome
Zonular Support
Patient Counseling and Informed Consent
Potential Risks and Complications of Cataract Surgery (Not All Inclusive)
Astigmatism Management
General Risks and Potential Complications of Astigmatism Correction
Peripheral Corneal Relaxing Incisions
Toric Intraocular Lens
Presbyopia Correction
Timing of Sequential Cataract Surgery
Immediately Sequential Bilateral Cataract Surgery
Advantages
Disadvantages
Flowchart For Evaluation of a Patient With Cataracts
Summary
References
3
Current Concepts in Intraocular Lens Power Calculations
Key Points
Introduction
Biometry
Axial Length
Corneal Power
Astigmatism
Other Variables
Formulas
Types
Astigmatism
Intraoperative Aberrometry
Usage
Personalization
Clinical Variables
Patient Needs and Desires
Special Circumstances
Postoperative Problems and Errors
Future Work
Summary
References
4
Intraocular Lens Calculations After Refractive Surgery
Introduction
Problems Induced by Corneal Refractive Surgery
Solutions to Problems Induced By Corneal Refractive Surgery
Use Pre-LASIK/PRK Data
Use Current Measurements with Regression Formulas Based on LASIK/PRK-Induced Refractive Change and Modify Them
Modification to Measured Anterior Corneal Power
Modification to Calculated Intraocular Lens Power
Use Only Current Corneal Measurements
Modification to Measured Anterior Corneal Power Based on Regression Formulas
Directly Measure Anterior and Posterior Corneal Curvature
Tools for Intraocular Lens Power Calculation
Web-Based Postrefractive Intraocular Lens Calculator at ASCRS.org
Barrett True-K and True-K No History Formulas
Optical Coherence Tomography–Based Intraocular Lens Formula
Intraoperative Measurements
Comparative Data for the Modern Formulas Including Intraoperative Measurements
Premium Intraocular Lens Use in PostRefractive Patients
Postoperative Intraocular Lens Adjustment
Summary
References
II. Intraocular Lenses​
5
Principles of Intraocular Lens Design and Biomaterials
Key Points
Introduction
The Evolution of the Intraocular Lens
Intraocular Lens Construction and Sites of Fixation
Anterior Chamber
Posterior Chamber
Intraocular Lens Optics
Intraocular Lens Materials
Optic
Filters
Haptics
Intraocular Lens Pathology
Uveal Biocompatibility
Capsular Biocompatibility
IOL Opacification
Summary
References
6
Polymethyl Methacrylate Posterior- and Anterior-Chamber Intraocular Lenses
Key Points
Introduction
Indications
Lack Of Capsular/Zonular Support
Secondary Lens Implantation
In Association with Penetrating Keratoplasty
Patient Selection
Anterior-Chamber Intraocular Lens Implants
Posterior-Chamber Intraocular Lens Implants
Preoperative Management
PMMA ACIOL
PMMA PCIOL
Surgical Procedure
PMMA ACIOL Surgical Steps
Scleral-Fixated PMMA PCIOL Surgical Steps
Potential Complications
Early Complications
Late Complications
Postoperative Management
Summary
Video 6.1: PMMA ACIOL Surgical Steps
Video 6.2: Scleral-Fixated PMMA PCIOL Surgical Steps
References
7
Posterior Chamber Intraocular Lenses
Key Points
Introduction
Intraocular Lens Material and Biocompatibility
Polymethyl Methacrylate
Silicone Polymers
Hydrophilic Foldable Acrylic Intraocular Lenses
Hydrophobic Foldable Acrylic Intraocular Lenses
Intraocular Lens Adjustment Postoperatively
Surface Modification
Capsular Biocompatibility and Edge Design
Dysphotopsia
Novel Intraocular Lens Designs to Reduce Dysphotopsia
Single- and Three-Piece Intraocular Lenses
Intraocular Lens Optic
Haptic Material and Design
Alternative Fixation of the Intraocular Lens in the Posterior Chamber
Iris Fixation
Scleral Fixation
summary
references
8
Toric Intraocular Lenses
Introduction
Causes
Comorbidities
Preoperative Management
Patient Selection
Toric Intraocular Lens Calculation
Toric Intraocular Lens Overview
Surgical Procedure
Potential Complications
Postoperative Management
Summary
References
9
Presbyopia-Correcting Intraocular Lenses
Key Points
Introduction
Causes
Comorbidities
Dry Eye Disease
Corneal Dystrophies
Age-Related Macular Degeneration or Retinal Disorders
Glaucoma
Pseudoexfoliation Syndrome or ­Post trauma
Indication and Preoperative Management
Patient’s Motivations
Indication and Patient Selection
Preoperative Examinations
Presbyopia-Correcting INTRAOCULAR LENSES
Monovision
Optical Principles
Results
Multifocal INTRAOCULAR LENSES
Optical Principles
Results
Extended Depth-of-Focus INTRAOCULAR LENSES
Optical Principles
Results
Accommodating INTRAOCULAR LENSES
Optical Principles
Results
Potential Complications
Optical Phenomena
Dry Eye Disease
Residual Refractive Error
Secondary Cataract
Surgical Procedure
Femtosecond Laser Assisted Cataract Surgery
Astigmatism
Previous Refractive Surgery
Postoperative Management
Summary
References
10
Adjustment Of Intraocular Lens Power
Introduction
Directly Modifiable IOLS
Light-adjustable Lens
Patient Considerations for Light-adjustable Lens
Refractive Index Shaping
Indirectly Modifiable IOLs
Summary
References
11
Modular Intraocular Lenses
Key Points
Introduction
Precisight
Clinical Data
Harmoni
Preclinical Data
Synchrony
Preclinical Data
Clinical Data
Opira
Clinical Data
Fluidvision
Preclinical Data
Clinical Data
Gemini Refractive Capsule
Clinical Data
Atia Vision
Juvene
Clinical Data
Summary
References
III. Anesthesia and Initial Steps​
12
Anesthesia for Cataract Surgery
Key Points
Introduction
Systemic Anesthesia
General Anesthesia
Oral Sedation
Regional Anesthesia (Retrobulbar, Peribulbar, Sub-Tenon’s)
Retrobulbar Block Technique
Complications of Ophthalmic Regional Block Anesthesia
Topical Anesthesia
Additional Uses for Intracameral Anesthesia
Use of Intracameral Lidocaine for Pupil Dilation During Cataract Surgery
Techniques for Topical Anesthesia
References
13
Ophthalmic Viscosurgical Devices
Key Points
Introduction
Rheological Characteristics of OVD
Categories of OVDs
Viscoelastic Compounds
Current Commercial OVDs
Clinical Uses of Ophthalmic Viscosurgical Devices
Protection of Ocular Structures
Maintenance of Space
Special Considerations
Complications of Ophthalmic Viscosurgical Devices
Intraocular Pressure Elevation
Other
Summary
References
14
Antibiotic Prophylaxis and Endophthalmitis
Key Points
Introduction
Risk Factors
Signs and Symptoms
Acute POE
Chronic POE
Differential Diagnosis
Microbiology
Outcomes
Endophthalmitis Prevention
Preoperative Considerations
Surgical Preparation
Intraoperative Measures
Treating Endophthalmitis
Complications of POE
summary
References
15
Inflammation in Cataract Surgery
Key Points
Introduction
Pathogenesis
Preoperative Considerations
Pre-Existing Uveitis
Herpetic Disease
Diabetes
Intraoperative Strategies For Control Of Inflammation
Intraocular Injection Of Steroid
Intracameral Nsaid Delivery
Intracameral Insert
INTRACANALICULAR Insert
Future Of Drug Delivery
Postoperative Inflammation
Treatment
Acute Postoperative Inflammation
Chronic Postoperative Inflammation
Pseudophakic Cystoid Macular Edema
SUMMARY
References
16
Incision Construction
Key Points
Indications For Clear Corneal Incisions
Clear Corneal Surgical Technique
Profiles Of Clear Corneal Incisions
Femtosecond Laser–Assisted Corneal Wound
Intraoperative and Postoperative Complications
SUMMARY
References
17
Capsulotomy
Key Points
Introduction
History
The Ideal Capsulotomy
Early and Late Postoperative Capsulotomy Considerations
Prevention Of Capsular Fusion Syndrome
The Purkinje I and IV Methods For Visual Axis Identification And Centration
Modern-Day Capsulotomy Methods
Manual Refractive Capsulotomy
Current Standard Techniques Of Capsulorrhexis
Learning Capsulorrhexis
Precision Pulse Refractive Capsulotomy
Femtosecond Laser Refractive Capsulotomy
Complications And Special Situations
Posterior Capsulorrhexis
summary
References
18
Hydrodissection and Hydrodelineation
Key Points
Introduction
Hydrodissection Surgical Technique
Hydrodelineation Surgical Technique
Discussion
References
IV. Nuclear Disassembly​
19
Basic Principles of the Phacoemulsifier
Overview
Components of the Phacoemulsifier
Key Points
Components
Function
Intraocular Pressure, Flow, and Aspiration
Key Points
Control of Fluidic Circuit
Flow Pump/Peristaltic, Aspiration, And Vacuum
Key Points
Control of Aspiration and Vacuum (Flow Pump/Peristaltic)
Vacuum Pump/Venturi, Aspiration, And Vacuum
Key Points
Control of Aspiration and Vacuum
Ultrasound Power And The Phaco Needle
Key Points
Function of the Ultrasonic Handpiece
The Four Forces that Create Emulsification
Key Points
Linear Movement of the Phaco Needle
Continuous, Pulse, and Burst Modes for Phacoemulsification3
Modulation Of Ultrasound
Key Points
Continuous Phaco Mode
Pulse Phaco Mode
Burst Phaco Mode
Hyperpulse Phaco Mode
Postocclusion Surge
Key Points
Fluidics
Corneal Incision Contracture/Corneal Wound Burn
Key Points
Be Mindful
Components
References
20
Advanced Principles of Phacoemulsification Platforms
The Alcon Centurion
Graphical User Interface
Ultrasound Motion: Torsional Phacoemulsification
Fluidics Control: Active Fluidics
Handpiece: Active Sentry System
Bausch & Lomb Stellaris
Graphical User Interface
Ultrasound Motion
Fluidics: Vacuum Pump
Post occlusion Surge Prevention: Stellaris Vacuum Pump
Adaptive Fluidics
Dual Linear Foot Pedal Control
Standard Foot Pedal Control
Dual Linear Pedal Control
Johnson & Johnson Veritas Vision System
Fluidics
Ultrasound Motion: Transversal Ultrasound
Handpieces
Foot Pedal
Graphical User Interface
ZEISS QUATERA 700
QUATTRO Pump
QUATERA 700 as the Data Hub in the Operating Room
Power on Demand Ultrasound
summary
References
21
Extracapsular Cataract Extraction and Manual Small-Incision Cataract Surgery
Large Incision Manual Ecce
Indications and Comorbidities
Anesthesia
Surgical Procedure (Converting From Phaco to Manual Ecce) [Video 21.1]
Potential Complications
Postoperative Management
Summary (Manual ECCE)
Manual Small-Incision Cataract Surgery
Indications and Comorbidities
Anesthesia
Surgical Procedure (Msics) [Videos 21.2-21.5]
Incision
Capsulotomy
Nuclear Prolapse and Delivery
Cortical Removal and IOL Implantation
Potential Complications
Postoperative Management
Summary (MSICS)
References
22
Principles of Nuclear Disassembly
Key Points
Introduction
Basic Principles of Nuclear Disassembly
Exposure of the Nucleus
Freeing the Nucleus
Phacoemulsification
Disassembly Location
Classic Nuclear Disassembly Techniques
Divide-and-Conquer Technique
Phaco-Chop Technique
Stop-and-Chop Technique
Nuclear Density
Soft Lenses
Hard Lenses
Disassembly in Special Situations
Corneal Endothelial Issues
Capsular Tears
Soft Lens
Medium Lens
Hard Lens
Zonular Deficiency
Learning Nuclear Disassembly
Transition to Phaco Chop
Simulation
Summary
References
23
Phaco Chop Techniques
Key Points
Introduction
Advantages of Chopping
Reduction in Ultrasound
Reduction in Zonular Stress
Supracapsular Emulsification
Decreased Reliance on the Red Reflex
Greater Reliance on the Chopper than the Phaco Tip
Phaco Chop Variations
Stop and Chop
Prechop Techniques
Horizontal Chop Technique
Initial Chop
Removing the Chopped Fragments
Pearls for the Initial Horizontal Chop
Potential Pitfalls During the Initial Horizontal Chop
Vertical Chop Technique
Comparing Horizontal and Vertical Chop: Which Technique?
Diagonal/Vertical Chop for Brunescent Nuclei
Pearls for the Initial Vertical Chop
Potential Pitfalls During the Initial Vertical Chop
Comparison of Horizontal and Vertical Choppers
Complications
Summary
References
24
Tilt and Tumble Supracapsular Phacoemulsification
Indications
Preoperative Preparation
Operative Procedure
Technique
Phaco Machine Equipment, Settings, and Instruments
Postoperative Care
Summary
25
Biaxial Microincision Phacoemulsification
Key Points
Introduction
Surgical Technique
SUMMARY
References
26
Femtosecond Laser-Assisted Cataract Surgery
Key Points
Introduction
The Technology
Steps of the Procedure
Preoperative Evaluation and Planning
Patient Positioning and Docking
Potential Pitfalls
Surgical Pearls
Capsulotomy
Surgical Pearls
Surgical Pearls
Lens Fragmentation
Corneal Incisions
Arcuate Incisions
Lens Removal
Potential Pitfalls
Learning Curve of FLACS
Available Platforms
Comparison of FLACS and Traditional Phacoemulsification
Phacoemulsification Energy
Endothelial Cell Loss
Capsular Complications and Vitreous Loss
Capsulotomy Size and Centration
Visual and Refractive Outcomes
Postoperative Inflammation
Elevated Intraocular Pressure
The Utility of FLACS in Complex Cases
Dense Nucleus
Shallow Anterior Chamber
Corneal Endothelial Dystrophy
Traumatic Cataract, Subluxed Lenses, and Zonular Dialysis
White Cataract
Multifocal and Accommodative Intraocular Lenses
Pediatric Cataract
Cost Effectiveness of FLACS
Summary
References
27
Cortical Removal
Introduction
Key Points
Cortex: Managing the Inconsistencies
Techniques for Routine Challenges
Subincisional Cortex (Table 27.1)
Biaxial Irrigation and Aspiration
Irrigate Then Aspirate: J-Cannula Irrigation11
Capsule Polishing
Cortical Removal And Femtosecond Laser-Assisted Cataract Surgery
Strategies For Stubborn Cortex
Cortical Removal After Posterior Capsule Rupture
Capsule Polishing
SUMMARY
References
V. Astigmatism Management​
28
Preoperative Evaluation and Considerations of Astigmatism
Introduction
The Measurement of Corneal Astigmatism
Measuring Devices
The Ocular Surface
Data Validation
How to Choose the Proper Radius/Keratometry Values
The Posterior Cornea
Lens Tilt
Toric IOL Calculators
Corneal Surgically Induced Astigmatism
Toric iol Calculators for the Unusual Corneas
Post-Corneal Refractive Surgery
Keratoconus and Eyes After Endothelial Replacement Surgery
Single-Angle and Double-Angle Plots for Astigmatism Data Presentation
SUMMARY
References
29
Corneal Incisional Approaches for Reducing Astigmatism During Cataract Surgery
Key Points
Introduction
Corneal Incisional Approaches
Manual Corneal Incisional Approaches
Femtosecond Laser-Assisted Corneal Incisional Approaches
Preoperative Evaluation And Planning
Nomograms
Manual PCRIs
Femtosecond Penetrating CRIs
Femtosecond Intrastromal CRIs
Surgical Procedure
Manual PCRIs
Femtosecond Cris
Outcomes
Manual PCRIs
Femtosecond Penetrating CRIs
Femtosecond Intrastromal CRIs
Prospective Comparative Studies
Potential Complications
Summary
References
30
Toric Intraocular Lenses: Selection and Alignment Methods
Key Points
Introduction
Definitions
Comorbidities
Preoperative Management
Prediction
Refractive Target
History
Slit Lamp Exam
Measurements
Measuring the Anterior Corneal Surface
Measuring the Posterior Corneal Surface
IOL Selection
Surgical Procedure
Preoperative Management
Alignment
Intraoperative Management
Surgical Incision
Capsulorrhexis
IOL Insertion and Alignment
Outcomes With toric IOLs
Potential Complications
Aberrations
Asthenopia
Residual Refractive Astigmatism
Other Complications
Complex Cataract Surgery
Postoperative Management
Summary
References
31
Managing Residual Postoperative Astigmatism
Key Points
Introduction
Causes
Initial Assessment
Management Options
Corrective Lenses
IOL Rotation, Repositioning, and Exchange
Toric IOL Rotation
IOL Exchange
IOL Exchange
Limbal Relaxing Incisions (Lri)
Corneal Refractive Surgery
Light Adjustable Lens (LAL)
Summary
References
VI. Complex Cases​
32
Ultradense Cataract
Key Points
Introduction
Risk Factors
Age
Ultraviolet Exposure
Trauma
Previous Ocular Surgery
Uveitis
Preoperative Management
Potential Visual Acuity
Lens Calculations
Density Measurement
Posterior Evaluation
Surgical Procedure
Preoperative Modifications
Instrument Modifications
Wound Construction
Capsulorrhexis
Hydrodissection
Phacomodulation
Nuclear Disassembly Techniques
Cortical Irrigation and Aspiration
Lens Placement
Potential Complications
Zonulopathy
Vitreous Loss
Corneal Incision Contracture (Wound Burn)
Retinal Detachment
Corneal Decompensation
Postoperative Management
Summary
References
33
Intumescent Cataract
Key Points
Introduction
Causes
Senile Intumescent Cataract
Comorbidities
Glaucoma
Phacomorphic Glaucoma
Phacolytic Glaucoma
Preoperative Management
Subtype Classification
Pearly White Cataract
Equatorial Block
Morgagnian Cataract
Surgical Procedure
Surgical Principles
Capsule Staining
Pressure Gradient
Shallow Anterior Chamber
Hydrodissection
Capsular Fibrosis
Pearly White Cataract
Pearly White Cataract Without Fluid
Pearly White Cataract With Fluid
Morgagnian Cataract
Femtosecond Laser-Assisted Cataract Surgery in Intumescent Lenses
Potential Complications
Argentinean Flag Sign
Posterior Capsule Rupture
Zonulopathy
Postoperative Management
Summary
References
34
Management of Weak Zonules
Key Points
Introduction
Causes
Comorbidities
Ocular Comorbidities
Systemic Comorbidities
Preoperative Management
Surgery
Capsulorhexis
Capsule Stabilization
Temporary Stabilization
Long-Term Stabilization
Mild Zonulolysis
Moderate and Severe Zonulopathy and/or Zonulolysis
Capsule-Stabilizing Devices
Traditional Capsular Tension Rings
Modified “Cionni” Capsular Tension Rings
Anterior Capsular Supporting Devices
Tips and Tricks
Complication Prevention and Management
Special Considerations
Capsule-Stabilizing Devices in Children
Subluxated Intraocular Lens/Capsular Bag Complexes
Placement of an In-the-Bag Iris Prosthesis with a Fixated Capsular Bag
Summary
References
35
Cataract Surgery in the Small Pupil
Key Points
Introduction
Causes
Uveitis
Pseudoexfoliation Syndrome (PXE)
Trauma
Use of Medications: IFIS
Narrow-Angle Glaucoma
Preoperative Management
Pharmacologic Pupil Expansion
Surgical Procedure
Overview of Intraoperative Small Pupil Enlargement Techniques
Specific Small Pupil Scenarios
Phacoemulsification Surgery
Potential Complications
Postoperative Management
Summary
References
36
Phacoemulsification in the Glaucoma Patient
Key Points
Introduction
The Effect of Cataract Extraction on IOP
Angle Surgery Concomitant with Cataract Extraction
Angle Surgery Preoperative Evaluation
Anticoagulation and Blood Reflux
Combined Angle Surgery or Phacoemulsification: Which Goes First?
Gonioscopic Visualization
Subconjunctival Stent Method
Trabecular Meshwork Unroofing Method
Trabecular Meshwork Stent Method
Tube Shunts and Trabeculectomy
Maintaining a Bleb During Cataract Extraction
Considerations for Combining Advanced-Stage Glaucoma Surgery With Phacoemulsification
Combined Phacoemulsification-Tube Shunt
Preoperative Setup
Surgical Procedure
Combined Phacoemulsification-Trabeculectomy
Postoperative Management and Complications of Combined Surgeries
Hypotony
Corneal Damage
Summary
References
37
Cataract Surgery in Combination With Corneal Surgery
Key Points
Introduction
Anterior Cornea
Epithelial Basement Membrane Dystrophy (EBMD)
Salzmann’s Nodular Degeneration
Pterygium
Corneal Stroma
Keratoconus
Biometry in Keratoconus
Treatment of Astigmatism in Keratoconus
IOL Asphericity and Keratoconus
Intraoperative Considerations In Keratoconus
Pinhole Implant
Penetrating Keratoplasty (PK) and Deep Anterior Lamellar Keratoplasty (DALK)
Cataract Surgery After PK
Combined Cataract Surgery and PK
Preoperative Diagnostic Testing
Biometry
Anesthesia
Surgery
Corneal Endothelial Disease
Fuchs’ Endothelial Corneal Dystrophy (FECD)
Cataract Surgery Alone
Cataract Surgery with Transplant for Fuchs’ Dystrophy
DSAEK, Cataract Extraction, and IOL Implantation
Cataract Extraction After DSAEK
DMEK, Cataract Extraction, and IOL Implantation
Descemet’s Stripping Only (DSO) Combined with Cataract Surgery
Decompensated Fuchs’ Dystrophy with a Clear Crystalline Lens
Presbyopia-Correcting IOLs
Summary
References
38
Cataract Surgery in Uveitic Patients
Key Points
Introduction
Causes
Comorbidities
Preoperative Evaluation and Management
Counseling
Decision to Place an Intraocular Lens (or not)
Perioperative Medications
Corticosteroids
Antimicrobial Prophylaxis
Immunosuppressive Medications
Surgical Planning
Surgical Procedure
Band Keratopathy
Phacoemulsification
Incision
Small Pupils and Posterior Synechiae
Capsulorrhexis
Zonular Weakness
Phacoemulsification Technique
Intraoperative Medical Management
Potential Complications
Cystoid Macular Edema
Hypotony
Ocular Hypertension/Glaucoma
Delayed Complications
Posterior Capsule Opacification
Anterior Capsule Phimosis
Late in-the-Bag Dislocation of Intraocular Lens
Inflammatory Deposits on Intraocular Lens
Indications for Intraocular Lens Explantation
Postoperative Management
Postoperative Medical Management
Topical Steroids
Topical NSAIDs
Cycloplegia
Oral Steroids
Summary
References
39
Retinal Considerations in Cataract Surgery
Key Points
Introduction
Preoperative Assessment
Peripheral Retinal Pathology
Diabetic Retinopathy
Proliferative Disease
Diabetic Macular Edema
Other Nondiabetic Vascular Retinopathies
Age-Related Macular Degeneration
Dry Age-Related Macular Degeneration
Wet Age-Related Macular Degeneration
Other Causes of Choroidal Neovascular Membrane
Medication Toxicities
Retinitis Pigmentosa and Other Inherited Retinal Diseases
Prior Posterior Segment Interventions
Posterior Segment Operative Complications
Combined Cataract Extraction And Pars Plana Vitrectomy
The Lens Must Be Removed
The Lens Should Be Removed
The Lens May Be Removed
The Lens Should Be Left Alone
Intraocular Lens Considerations in the Retina Patient
Toric Intraocular Lense
Multifocal Intraocular Lenses
Summary
References
40
Pediatric Cataract Surgery
Key Points
Introduction
Causes
Comorbidities
Microphthalmos and Microcornea
Microspherophakia
Congenital Aniridia
Persistent Fetal Vasculature
Lenticonus5
Anterior Lenticonus
Posterior Lenticonus (Video 40.2)
Zonulopathy11
Preoperative Management
Indications of Surgical Treatment
Anesthesia
Surgical Procedure
Pars Plana, Limbal, or Combined Approach
Incision
Anterior Capsulorhexis
Cataract Removal
Endocapsular Tension Ring Implantation
Posterior Capsulorhexis
Anterior Vitrectomy
Intraocular Lens
Final Surgical Steps
Postoperative Management
Potential Surgical Complications
Fibrinous Uveitis
Secondary Visual Axis Opacification
Glaucoma
Other Rarer Surgical Complications
Amblyopia Treatment and Visual Rehabilitation
Summary
References
41
Intraocular Lens Exchange and Secondary Intraocular Lens Placement
Key Points
Introduction
Indications
Patient Comorbidities
Intraoperative Complications During Phacoemulsification
Postcataract Surgery Complications
Patient Dissatisfaction
Patient Population
History
Eye Examination
Surgical Techniques
IOL Exchange for Power or Type with Intact Capsular Bag
Opening the Capsular Bag
Extraction of Existing IOL
Placement of Secondary Intraocular Lens
Capsule or Sulcus-Supported Intraocular Lens
Scleral-Fixated Intraocular Lens
Scleral-Suture Fixated Intraocular Lenses
Sutureless Scleral Fixation
Flanged Technique
“Glued” Sharioth Pocket Technique
Iris-Fixated Posterior-Chamber Intraocular Lens
Anterior-Chamber Intraocular Lenses
Complications of Secondary Intraocular Lenses
Intraocular Lens Malposition and Tilt
Postoperative Uveitis
Iris Chafe
Suprachoroidal Hemorrhage
Postoperative Endophthalmitis
Retinal Detachment
Refractive Outcome
Summary
References
42
Traumatic Cataract
Key Points
Introduction
Causes
Preoperative Clinical Exam
Vitreous Prolapse
Iris Status
Structural Iris Damage
Functional Iris Damage
Zonular Weakness
Extent of Zonulopathy
Capsular Status
Angle Status
Imaging
Surgical Procedure
Timing
Anesthesia Alternatives
Vital Dyes
Anterior Vitrectomy
Viscoelastics/Ocular Viscosurgical Devices (OVDs)
Small Pupil Management
Capsulorrhexis
Hydro/Viscodissection
Lens Removal
Zonular Weakness Management
Intraoperative Zonular Support
Long-Term Support
PCIOL Choice
Aphakia Management/Preparedness
Iris Reconstruction (see Chapter 43 for more detailed information)
Potential Complications
Postoperative Management
Summary
References
43
Iris Repair and Iris Prosthesis
Key Points
Introduction
Iris Repair vs. Iris Prosthesis
Preparations for Iris Repair
Globe Pressurization
Sutures and Needles
Instrumentation
Vitreous Removal
Pharmacologic Agents
Clear Crystalline Lens
Intraocular Knots For Iris Suturing
Siepser Knot (and Osher, Cionni, Snyder Square Knot Variants)
Ogawa Knot (Throws Formed Externally, Tightened With an Instrument Internally)
Ahmed Knot (Two Intraocular Forceps)
Types of Iris Repair
Iridodialysis Repair
Interrupted Pupil Margin Suture
Iris Gathering/Oversew Suture for Iris Transillumination Defects
Congenital Iris Coloboma Repair
Iris Cerclage for Permanent Mydriasis
Bridging and Coat-Hanger Repair for Large Iris Defects
Diathermy Contouring of Pupil Shape and Position
Iris Prostheses
Iris Defects That May Not Be Amenable to Repair
Slit Lamp Examination for Consideration of Iris Prosthesis
Device Selection
Device Ordering
Implantation Techniques
Pitfalls/Complications of Iris Prostheses
Summary
References
44
Surgery in Short and Eyes
Key Points
Introduction
Short Eyes
Definitions
Comorbidities
Amblyopia
Anatomic Narrow Angle
Preoperative Management
Slit Lamp Exam
IOL Selection
Surgical Procedure
Preoperative Management
Intraoperative Management
Potential Complications
Aqueous Misdirection
Choroidal Effusion and Hemorrhage
Corneal Edema
Other Complications
Postoperative Management
Long Eyes
Definition
Comorbidities
Preoperative Management
Slit Lamp Exam
Posterior Segment Exam
IOL Selection
Nonoptical IOL Properties to Consider When Selecting an Implant for an Axial Myope
Surgical Procedure
Anesthesia
Intraoperative Considerations
Potential Complications
Postoperative Management
Summary
References
VII. Intraoperative Complications​
45
Risk Management in Cataract Surgery
Key Points
Introduction
Preoperative Considerations
Informed Consent
Advertising
Fraud and Abuse
Comanagement and Antikickback Statute
Charging for Noncovered Refractive Services
Deciding on Second-Eye Surgery
Stark Law
Intraoperative Issues
Anesthesia Complications
Intracameral Medications
Problems With Toric and Presbyopia-Correcting IOLs
Wrong Eye/Wrong IOL
Postoperative Issues
Endophthalmitis
Retinal Detachment and Retained Lens Fragments
Toxic Anterior Segment Syndrome
Discussing Complications
Summary
References
46
Intraoperative Complications
Key Points
Anesthesia
Patient Movement
Prevention
Management
Retrobulbar Hemorrhage
Wound Construction
Incision
Placement
Depth
Anterior Chamber Entrance
Incision Leak
Tear of Descemet’s Membrane
Iris Prolapse
Management
Capsulorhexis
Peripheral Capsulorrhexis Extension
Small Capsulectomy
Complications During Phacoemulsification
Traumatic Tip Insertion
Crowded Anterior Chamber
Lens Iris Diaphragm Retropulsion Syndrome
Chamber Shallowing During Phacoemulsification
Insufficient Inflow
Excessive Outflow
Positive Pressure During Phacoemulsification
Causes of Positive Pressure
Iris Trauma
Posterior Capsule Tears
Prevention
Management
Four Special Maneuvers
Intraocular Lens Placement in the Presence of a Capsular Tear
Dropped Nucleus
Vitreous Loss
Acute Corneal Clouding
Inadvertent Cannula Injection
Expulsive Suprachoroidal Hemorrhage
Summary
References
47
Vitrectomy for the Anterior Segment Surgeon
Key Points
Introduction
Anatomic Considerations
Indications For Vitrectomy
Principles of Vitrectomy
Anterior Versus Pars Plana Vitrectomy
Managing Vitreous Loss
Managing Retained Lens Fragments
Post Vitrectomy Management And Referral
References
48
Issues in Wound Management
Introduction
Wound Construction
Wound Healing
Compromise of Wound Integrity
Wound Leakage
Wound Thermal Burns
Wound Dehiscence
Factors Predisposing to Wound Dehiscence
Manifestations and Management of Wound Dehiscence
Inadvertent Filtering Bleb.
Wound Rupture
Epithelial Downgrowth and Fibrous Ingrowth
Long-Term Flattening Along the Meridian of the Incision
summary
References
49
Surgical Instrument Care and Toxic Anterior Segment Syndrome
Key Points
Introduction
Surgical Instrument Care
General Principles
Cleaning Surgical Instruments (Fig. 49.1)
Enzymatic Detergents
Ultrasonic Cleaners
Sterilizing Surgical Instruments
Toxic Anterior Segment Syndrome (Tass)
Background
Clinical Presentation
Treatment and Clinical Course
Etiology and Recommendations
Summary
References
VIII. Postoperative Complications​
50
Corneal Edema After Cataract Surgery
Key Points
Introduction
Causes
Preoperative
Advanced Age
Ethnicity
Medications
Systemic Diseases
History of Ocular Disease, Surgery, or Trauma
Shallow Anterior Chamber
Dense Cataract
Corneal Endothelial Dystrophies
Intraoperative
Surgical trauma
Toxic Anterior Segment Syndrome (TASS) and Chemical Injuries
Descemet’s Membrane Detachment
Postoperative
IOL-Related
Retained Lens Fragment
Glaucoma
Brown-McLean Syndrome
Preoperative Assessment
Postoperative Assessment
Symptoms
Signs
Management
Hypertonic Solutions
Anti-inflammatory Therapy
Descemet’s Membrane Detachment
Anterior-Chamber Iol
Corneal Transplantation
Future Therapeutics
SummarY
References
51
Glaucoma After Cataract Surgery
Key Points
Introduction
Causes
Retained OVD
Malignant Glaucoma
Steroid Response
Uveitis-Glaucoma-Hyphema Syndrome
Comorbidities
Management Considerations
Retained OVD and Early Postoperative IOP Spikes
Malignant Glaucoma
Steroid Response
Uveitis-Glaucoma-Hyphema Syndrome
Potential Complications
Summary
References
52
Retinal Complications of Cataract Surgery
Key Points
Introduction
Pseudophakic Cystoid Macular Edema/Irvine-Gass Syndrome
Risk Factors
Imaging Studies
Treatment
CME Refractory to Topical Treatment
Surgical Treatments
Retained Lens Fragments
Medical Management
Surgical Management
Retinal Detachment
Pathogenesis
Treatment
Recommendations
Endophthalmitis
Treatment
Prophylaxis
Outcomes
Hemorrhagic Occlusive Retinal Vasculitis
Pathophysiology
Clinical Characteristics of HORV
Prognosis
Recommendations for Management of HORV
Summary
References
53
Subluxated Intraocular Lenses
Key Points
Introduction
What Is Subluxation of IOL?
What Is Dislocation/Luxation of IOL?
Incidence and Etiology
Preoperative
Primary
Secondary
Intraoperative
Postoperative
Symptoms and Signs
Patient Evaluation
Management
Conservative Management
Surgical Management
Indications
The Surgical Management of Subluxated IOLs Includes an Organized Approach to a Wide Range of Decision Making
Decision 1: Reposition Primary IOL versus Primary IOL Explantation and Secondary IOL Implant (Fig. 53.9)
Primary IOL Repositioning Techniques
Anterior Dislocated IOL (IOL Present in Anterior Chamber)
Posterior Assisted Levitation (PAL) of Posterior Dislocated IOL:4
Primary IOL Explantation Techniques
Anteriorly Dislocated IOL (IOL Present in Anterior Chamber)
Posterior Assisted Levitation (PAL) of Posteriorly Dislocated IOL
Decision 2: Method to Refix the Primary IOL (Or Implant a Secondary IOL)
Subluxated IOL Because of Zonular Weakness (Intact Capsular Bag)
Choice of Endocapsular Devices Largely Depends on Degree of Subluxation/Zonular Dialysis (Fig. 53.11) (Table 53.3)
Zonular Dehiscence Up to 3 to 4 Clock Hours (90 degrees)
Zonular Dehiscence of 3 to 6 Clock Hours (90–180 Degrees)
Zonular Dehiscence of 6 to 9 Clock Hours (180–270 degrees)
Management of Subluxated IOL With Damaged Capsular Bag and Discontinuity in Capsular Margins (Posterior Capsular Compromise ...
Scharioth’s Intrascleral Tunnel Technique and Glued IOL (Key Points)
summary
References
54 Neodymium:Yttrium-Aluminum-Garnet Laser Applications in the Cataract Patient
Key Points
Introduction
Procedure Specifics
Nd:Yag Laser Capsulotomies
Posterior Capsule Opacification (PCO)
Anterior Capsule Contracture
Negative Dysphotopsia
Considerations
Postcataract Extraction Timing of Nd:YAG Posterior Capsulotomy
Multifocal IOLs
Accommodative IOLs
Capsular Bag Distension Syndrome (CBDS)
Preoperative Management
Nd:YAG Laser Posterior Capsulotomy
Nd:YAG Posterior Capsulotomy for Posterior Capsule Opacification
Nd:Yag Anterior Capsulotomy For Capsular Contraction Syndrome
Postoperative Management and Complications
Nd:Yag Laser Iridotomy
Preoperative Management
Nd:YAG Laser Peripheral Iridotomy
Nd:YAG Iridotomy for Pupillary Block Glaucoma
Nd:Yag Anterior Hyaloid Vitreolysis For Malignant Glaucoma
Postoperative Management and Complications
Nd:Yag Laser Vitreolysis
Preoperative Management
Nd:YAG Laser Anterior Vitreolysis
Nd:YAG Laser Anterior Vitreolysis
Postoperative Management and Complications
Summary
References
55
Management of Dysphotopsia
Key Points
Positive Dysphotopsia
Nonsurgical Management of PD
Negative Dysphotopsia
Nonsurgical Management of ND
Diffractive-Optic Dysphotopsia (DD)
Nonsurgical Management of DD
IOLs Designed to Prevent Dysphotopsia
Surgical Strategies for Management of Dysphotopsia
References
56
Refractive Enhancements After Cataract Surgery
Key Points
Introduction
Causes
Factors Confounding Keratometry Measurements
Factors Confounding Axial Length Measurements
Lens-Based Issues
Evaluation
Surgical Management
Corneal-Based Surgery
Lens-Based Surgery
Refractive Enhancements to Address Presbyopia
Future Developments
Summary
References
Index