- •Dedication
- •Preface
- •Acknowledgements
- •Contributors
- •Contents
- •1. Minimally Invasive Oculoplastic Surgery
- •1.1 General Points
- •1.2 Lower Lid Entropion
- •1.2.1 Introduction
- •1.2.2 Lower Lid Entropion Sutures
- •1.2.3 Lower Lid Entropion Botulinum Toxin
- •1.3 Lower Lid Ectropion
- •1.3.1 Introduction
- •1.3.2 The Royce Johnson Suture
- •1.3.3 The Pillar Tarsorrhaphy
- •1.4 Distichiasis
- •1.4.1 Introduction
- •1.4.2 Direct Excision of Lashes
- •1.5 Ptosis
- •1.5.1 Introduction
- •1.5.3 Anterior Approach – One Stitch Aponeurosis Repair
- •1.5.4 Supramid Brow Suspension
- •1.6 Lid Retraction
- •1.6.1 Introduction
- •1.6.2 Koornneef Blepharotomy
- •1.6.3 Botulinum Toxin
- •1.7 Lid Tumours
- •1.7.1 Mohs’ Micrographic Surgery
- •1.7.2 Lamella Sparing Tumour Excision
- •References
- •2. Minimally Invasive Conjunctival Surgery
- •2.1 Conjunctival Surgery
- •2.2 Conjunctivochalasis
- •2.2.1 Background of the Disease
- •2.2.2 Indication for Surgery
- •2.2.3 Basic Concept of Surgery
- •2.2.4 Surgical Procedure
- •2.2.5 Postoperative Follow-Up
- •2.3 Pterygium
- •2.3.1 Background of the Disease and the Concept of Minimally Invasive Surgery
- •2.3.2 Indication for Surgery
- •2.3.3 Basic Concept of Surgery
- •2.3.4 Surgical Procedures
- •2.3.5 A Biologic Adhesive for Sutureless Pterygium Surgery
- •2.3.6 Postoperative Follow-Up
- •2.4 Limbal and Conjuntival Dermoids
- •2.4.1 Background of the Disease
- •2.4.2 Basic Concept of Surgery
- •2.4.3 Surgical Procedure
- •2.4.4 Postoperative Follow-Up
- •2.5 Strabismus Surgery
- •2.6 Conclusion
- •References
- •3. Minimally Invasive Lacrimal Surgery
- •3.1 Introduction
- •3.1.1 Causes of Stenoses of the Lacrimal Drainage System
- •3.1.3 General Remarks Regarding Surgical Management
- •3.2 Endonasal Endoscopic (Microscopic) Dacryocystorhinostomy (EDCR)
- •3.2.1 Indication for EDCR
- •3.2.2 Surgical Technique
- •3.2.3 Silicone Stenting for EDCR
- •3.2.2.1 Silicone “Cones” (Lacrimal Duct Stent, Bess, Berlin)
- •3.2.4 Use of Mitomycin C for EDCR
- •3.2.5 Post-Operative Care After EDCR
- •3.2.6 Results of EDCR
- •3.3 Endonasal Endoscopic Laser Dacryocystorhinostomy (ELDCR)
- •3.3.1 Indications for ELDCR
- •3.3.2 Contraindications for ELDCR
- •3.3.3 Surgical Technique for ELDCR
- •3.3.4 Potential Problems with ELDCR
- •3.3.5 Post-Operative Care After ELDCR
- •3.3.6 Results of ELDCR
- •3.4 Dacryoendoscopy with Transcanalicular Laserdacryoplasty (TLDP)
- •3.4.1 Indication for TLDP
- •3.4.2 Contraindication for TLDP
- •3.4.3 Surgical Technique for TLDP
- •3.4.4 Results of TLDP
- •3.5 Microdrill Dacryoplasty (MDP)
- •3.5.1 Indication for MDP
- •3.5.2 Contraindication for MDP
- •3.5.3 MDP Procedure
- •3.5.4 Results of MDP
- •3.6 Balloon Dilatation
- •3.6.1 Indications for Balloon Dilatation
- •3.6.2 Anaesthesia for Balloon Dilatation
- •3.6.3 Surgical Technique with 2 mm or 3 mm Balloon for Incomplete Stenosis
- •3.6.3.1 Post-Operative Care
- •3.6.3.2 Complications
- •3.6.3.3 Results
- •3.6.4.1 Post-Operative Care
- •3.6.4.2 Results
- •3.6.4.3 Complications
- •3.7 Stent Placement
- •3.7.1 Indications for Stent Placement
- •3.7.3 Surgical Technique for Stent Placement
- •3.7.5 Results of Stent Placement
- •References
- •4. Minimally Invasive Corneal Surgery
- •4.1 Penetrating Keratoplasty
- •4.1.1 Introduction
- •4.1.2 Indications
- •4.1.3 Preoperative Evaluation of the Keratoplasty Patient
- •4.1.4 Preparation for Penetrating Keratoplasty
- •4.1.4.1 Eyelid Speculum
- •4.1.4.2 Scleral Fixation Rings
- •4.1.4.3 Large and Fine-Tipped Needle Holder
- •4.1.4.4 Toothed Forceps
- •4.1.4.5 Trephine Blades
- •4.1.4.6 Radial Marker
- •4.1.4.7 Cornea Punch
- •4.1.4.8 Cutting Block
- •4.1.4.9 Scissors
- •4.1.4.10 Cannulas and Blades
- •4.1.5 Preoperative Medications
- •4.1.6 Penetrating Keratoplasty Surgical Procedure
- •4.1.6.1 Placement of the Scleral Fixation Ring
- •4.1.6.2 Marking of the Host Cornea
- •4.1.6.3 Sizing of the Trephine
- •4.1.6.4 Trephination of the Host Cornea
- •4.1.6.5 Trephination of the Donor Cornea
- •4.1.6.6 Removal of the Host Cornea
- •4.1.6.7 Placement of the Donor Cornea Tissue in the Host Stromal Bed
- •4.1.6.8 Placement of the Cardinal Sutures
- •4.1.6.9 Completion of Suturing
- •4.1.6.10 Suture Techniques
- •4.1.6.11 Subconjunctival Medications
- •4.1.7 Intraoperative Complications
- •4.1.7.1 Scleral Perforation
- •4.1.7.2 Damage to the Donor Button
- •4.1.7.4 Posterior Capsule Rupture
- •4.1.7.5 Vitreous Loss
- •4.1.7.6 Anterior Chamber Hemorrhage
- •4.1.7.7 Choroidal Hemorrhage
- •4.1.8 Postoperative Management
- •4.1.8.1 Postoperative Immunosuppressive Regimen
- •4.1.9 Postoperative Complications
- •4.1.9.1 Wound Leaks
- •4.1.9.2 Epithelial Defects
- •4.1.9.3 Suture-Related Problems
- •4.1.9.4 Increased Intraocular Pressure
- •4.1.9.5 Post-Keratoplasty Astigmatism
- •4.1.10.1 Wedge Resections and Compression Sutures
- •4.1.10.2 Relaxing Incisions
- •4.1.10.3 LASIK
- •4.1.10.4 Photorefractive Keratectomy with Mitomycin C
- •4.1.11 Corneal Allograft Rejection
- •4.1.11.1 Host Risk Factors
- •4.1.11.2 Vascularized Corneas
- •4.1.11.3 Prior Graft Loss
- •4.1.11.4 Graft Diameter
- •4.1.11.5 Anterior Synechiae
- •4.1.11.6 Previous Intraocular Surgery
- •4.1.11.7 Herpes Simplex
- •4.1.12 Treatment of Allograft Rejection
- •4.1.13 Large Diameter Penetrating Keratoplasty
- •4.1.14 Summary
- •References
- •4.2 Descemet’s Stripping Endothelial Keratoplasty
- •4.2.1 Introduction
- •4.2.2 Descemet’s Stripping Endothelial Keratoplasty Surgical Technique
- •4.2.2.1 Donor Cornea Preparation
- •4.2.2.2 Host Cornea Preparation
- •4.2.2.3 Insertion of the Donor Cornea
- •4.2.3 Postoperative Medications
- •4.2.4 Donor Dislocation Risks
- •4.2.5 Repositioning Donor Tissue
- •4.2.6 Treatment of Rejection Episodes
- •4.2.7 Visual and Refractive Outcomes
- •4.2.8 Other Complications
- •4.2.9 Summary
- •References
- •4.3 Pterygium
- •4.3.1 Introduction
- •4.3.2 Treatment of Pterygium
- •4.3.3 Surgical Technique
- •4.3.3.1 Removal of the Pterygium
- •4.3.3.2 Harvesting the Conjunctival Autograft
- •4.3.3.3 Securing the Conjunctival Autograft
- •4.3.3.4 Fibrin Glue vs. Nylon Sutures
- •4.3.4 Postoperative Management
- •4.3.5 Recurrent Pterygium
- •4.3.6 Other Techniques in Pterygium Removal
- •4.3.6.1 Bare Scleral Technique
- •4.3.6.2 Adjunctive Agents
- •Mitomycin C
- •Beta-Irradiation
- •4.3.6.3 Amniotic Membrane Transplantation
- •4.3.7 Complications in Pterygium Removal
- •4.3.8 Summary
- •References
- •5. Minimally Invasive Refractive Surgery
- •5.1 Trends in Refractive Surgery
- •5.2 Introduction
- •5.3 Cornea Refractive Surgery
- •5.3.1 Laser In Situ Keratomileusis (LASIK)
- •5.3.1.1 Advances in Flap Creation Technology
- •Microkeratomes
- •Femtosecond Laser
- •5.3.1.2 Technological Advances in Laser Delivery Platforms
- •5.3.1.3 Faster Excimer Lasers
- •5.3.1.4 Reduction of Collateral Thermal Tissue Damage
- •5.3.1.5 Advanced Eye Trackers
- •5.3.2 PRK and Advanced Surface Ablations (ASA)
- •5.3.2.1 Decrease Thermal Load on the Cornea
- •5.3.2.2 Use of Wound-Healing Modulators
- •5.3.2.3 Trend Towards EPI-LASIK
- •5.3.3 Summary
- •5.4 Intraocular Refractive Surgery
- •5.4.1 Phakic Intraocular Lens Surgery
- •5.4.1.1 Advances in Diagnostic Equipment
- •5.4.1.2 Types of Phakic Intraocular Lens
- •5.4.1.3 Kelman-Duet Phakic Intraocular Lens
- •Lens Design
- •Surgical Technique
- •Pre-Operative Preparation
- •Operative Procedure
- •Post-Operative Care
- •Results
- •Refractive Outcomes
- •Corneal Endothelium
- •5.4.1.4 Visian Implantable Collamer Lens
- •Lens Design
- •Surgical Technique
- •Pre-Operative Preparation
- •Operative Procedure
- •Post-Operative Care
- •5.4.1.5 Results
- •5.4.2 Summary
- •5.5 Lens and Cataract Surgery
- •5.5.2 The Ideal MICS Intraocular Lens
- •5.5.2.1 Aspheric Intraocular Lenses
- •5.5.2.2 Toric Intraocular Lenses
- •5.5.2.3 ACRI.LISA 366D and ACRI.LISA TORIC 466TD
- •Lens Design
- •5.5.2.4 Surgical Technique
- •Operative Procedure
- •Post-Operative Care
- •5.5.2.5 Results
- •5.5.3 Summary
- •5.6 The Future: Beyond the Horizon of Refractive Surgery Today
- •Reference
- •6. Minimally Invasive Strabismus Surgery
- •6.1 Introduction
- •6.2 Nonsurgical Treatment
- •6.4 Rectus Muscle Procedures
- •6.4.1 MISS Rectus Muscle Recession
- •6.4.2 MISS Rectus Muscle Plication
- •6.4.3 Parks’ Rectus Muscle Recession
- •6.4.4 Parks’ Rectus Muscle Plication
- •6.4.5 MISS Rectus Muscle Posterior Fixation Suture
- •6.4.7 MISS Rectus Muscle Repeat Surgery
- •6.4.8 MISS Rectus Muscle Transposition Surgery
- •6.5 Oblique Muscle Procedures
- •6.5.1 MISS Inferior Oblique Muscle Recession
- •6.5.2 MISS Inferior Oblique Muscle Plication
- •6.5.3 MISS Superior Oblique Muscle Recession
- •6.5.4 MISS Superior Oblique Muscle Plication
- •6.5.6 Mühlendyck’s Partial Posterior Superior Oblique Tenectomy for Congenital Brown’s Syndrome
- •6.6 Postoperative Handling
- •6.7.1 Intraoperative Complications
- •6.7.2 Postoperative Complications
- •6.8 Suggestions on How to Start Doing MISS
- •6.8.1 Instruments Suitable for MISS
- •6.8.2 Suture Materials Used for MISS
- •6.8.3 General Remarks Regarding MISS Procedures
- •6.8.4 MISS Dose–Response Relationships
- •References
- •7. Minimally Invasive Iris Surgery
- •7.1 Instrumentation
- •7.2 Sutures
- •7.3 Surgical Principles of Iris Suturing
- •7.3.1 Mobilization
- •7.3.2 Intraocular Suturing and Knot Tying
- •7.3.3 Reattachment of Iris to Sclera
- •7.3.4 Pupil Repair
- •7.3.5 Adjunctive Pupil Repair Techniques
- •References
- •8. Minimally Invasive Glaucoma Surgery
- •Introduction
- •8.1.1 Introduction to Deep Sclerectomy
- •8.1.2 Anesthesia
- •8.1.3 Surgical Technique
- •8.1.3.1 Preparation
- •8.1.3.3 Deep Flap Preparation
- •8.1.3.5 Peeling of Schlemm’s Canal and Juxtacanalicular Meshwork
- •8.1.3.6 Drainage Device
- •8.1.3.7 Wound Closure
- •8.1.4 Postoperative Management and Medication
- •8.1.4.1 Medication
- •8.1.4.2 Management
- •8.1.5 Adjunctive Treatments
- •8.1.5.1 Bleb Needling
- •8.1.5.2 Nd:YAG Goniopuncture
- •8.1.6 Complications and Management
- •8.1.6.1 General
- •8.1.6.2 Perioperative Complications
- •8.1.6.3 Early Postoperative Complications
- •8.1.6.4 Late Postoperative Complications
- •Open-Angle Glaucoma
- •Pigmentary Glaucoma
- •Pseudoexfoliation Glaucoma
- •Aphakic Glaucoma
- •Sturge–Weber Syndrome
- •Glaucoma Secondary to Uveitis
- •Congenital and Juvenile Glaucoma
- •Narrow-Angle Glaucoma
- •Posttrauma Angle-Recession Glaucoma
- •Neovascular Glaucoma
- •Narrow-Angle Glaucoma in a Young Patient
- •Pseudophakic Glaucoma with an A/C IOL
- •8.2.1.4 Preoperative Considerations
- •8.2.2 Anesthesia
- •8.2.4 Postoperative Management and Medication
- •8.2.5 Outcomes and Comparison with Other Techniques
- •8.2.6 Complications and Management
- •8.2.6.1 General
- •8.2.6.4 Summary and Key Points
- •References
- •8.3 New Minimally Invasive, Sclerothalamotomy Ab Interno Surgical Technique
- •8.3.1 Introduction to the Sclerothalamotomy Ab Interno
- •8.3.1.1 Indications for the Sclerothalamotomy Ab Interno
- •8.3.2 Anesthesia
- •8.3.3 Surgical Technique
- •8.3.3.1 Preparation
- •8.3.3.2 Diathermy Probe Insertion
- •8.3.4 Postoperative Management and Medication
- •8.3.5 Outcomes and Comparison with Other Techniques
- •8.3.6 Complications and Management
- •8.3.6.1 General
- •8.3.6.3 Conclusions
- •References
- •Type of Glaucoma
- •Stage of Glaucoma
- •Combined Surgery
- •8.4.2 Anesthesia
- •8.4.3 Surgical Technique
- •8.4.3.1 Preparation
- •8.4.3.2 Implantation of the Micro-Bypass Stent
- •8.4.4 Postoperative Management and Medication
- •8.4.5 Outcomes and Combination with Other Techniques
- •8.4.5.1 Trabecular Implant in Refractory Glaucoma Patients
- •8.4.6 Conclusions
- •References
- •9. Minimally Invasive Cataract Surgery
- •10. Minimally Invasive Vitreoretinal Surgery
- •10.1 Introduction
- •10.2 Microincision Vitrectomy
- •10.2.1 Models of Wound Architecture
- •10.2.2 Vitrectomy
- •10.2.3 Adjuncts
- •10.2.4 Common Surgical Techniques
- •10.2.4.1 Macular Surgery
- •10.2.4.2 Proliferative Diabetic Retinopathy
- •10.2.4.3 Retinal Detachment
- •10.2.4.4 Pediatric Vitreoretinal Surgery
- •10.2.5 Complications
- •10.2.6 Future Developments in Minimally Invasive Vitrectomy
- •10.3 Endoscopic Vitreoretinal Surgery
- •10.3.1 Introduction
- •10.3.2 History and Development of Endoscopic Ophthalmic Surgery
- •10.3.3 The Endoscope
- •10.3.4 Applications of Intraocular Endoscopy
- •10.3.4.1 Media Opacity
- •10.3.4.3 PVR and Subretinal Surgery
- •10.3.4.4 Retained Lens Fragments
- •10.3.4.5 Anterior and Retrolental Vitrectomy in Malignant Glaucoma
- •10.3.4.5 Sutured IOL and ECP
- •10.3.5 Limitations and Challenges
- •10.4 Future Directions of Minimally Invasive Vitreoretinal Surgery
- •References
- •INDEX
4 Minimally Invasive Corneal Surgery |
93 |
on its effectiveness in the prevention of pterygium recurrence [2, 14Ð16]. Recurrence rates have been reported to a range of less than 10% in some cases [15].
Despite its effectiveness in the prevention of pterygium recurrence, we do not advocate the use of MMC in routine cases of pterygium removal. MMC has been associated with signiÞcant sight-threatening complications including scleral necrosis, infectious scleritis, perforation, and endophthalmitis [2]. Avisar et al. reported a signiÞcant effect on endothelial cell density with a 21% decrease in endothelial cell counts following application to the bare sclera after pterygium removal [17]. We have noted several cases of limbal stem cell deÞciency in patients referred to our clinic as a result of the use of MMC following pterygium removal.
If a patient has undergone previous multiple pterygium removals for recurrences associated with severe subconjunctival Þbrosis, MMC may be used with success [18]. MMC should only be used when the patient has failed a combination of amniotic membrane transplantation (AMT) and conjunctival autograft placement [18]. The same aforementioned complications with MMC and should be detailed to the patient prior to surgery.
Beta-Irradiation
Beta-irradiation is another adjunct to pterygium removal that may help prevent recurrence. There are not many studies available on beta-irradiation following pterygium removal. Beta-irradiation is administered postoperatively as several applications, given over several days to 2 weeks. Chayakul showed that beta-irradiation is associated with higher recurrence rates than postoperative MMC drops [2]. Betairradiation is also associated with some of same sightthreatening complications as MMC use such as scleral necrosis, infectious scleritis, corneal perforation, and endophthalmitis. We do not recommend the use of beta-irradiation following pterygium removal.
4.3.6.3 Amniotic Membrane Transplantation
AMT has been used for a variety of ocular surface diseases since Kim and Tseng reintroduced the procedure in 1998 [18]. AMT has been shown to suppress Þbrosis when used for pterygium removal [4, 18]. Transforming growth factor betas are potent Þbrinogenic growth
factors. Suppression of this signaling pathway has an antiÞbrosis effect [18]. Tseng et al. demonstrated that the transforming growth factor beta pathway in Þbroblasts is suppressed when in contact with the stromal side of the amniotic membrane [4, 18]. It is through this mechanism that the amniotic membrane may help reduce scarring and Þbrosis following pterygium removal. The amniotic membrane has an anti-inßam- matory effect as well, so this may help contribute to postoperative wound healing [4, 18].
Despite the theoretical advantages, clinical results of AMT for pterygium removal have been variable. Prabhasawat et al. reported a recurrence rate of 37.5% in recurrent pterygia treated by AMT [4]. The rate was signiÞcantly higher than those treated by conjunctival autograft. Tananuvat et al. found that the recurrence rate was signiÞcantly higher in a group of patients that underwent AMT as compared to a group that had conjunctival autograft (40 vs. 4.8%) [4]. Ma et al. compared the recurrence rates after excision of primary pterygium combined with amniotic membrane graft, conjunctival autograft, and topical MMC and found that the recurrence rates were low and comparable among all three groups [4].
The reasons for such high variability in reported recurrence rates are unclear, but variation in surgical technique, demographic differences, and different definitions of recurrence may be factors [4].
When very large pterygia require extensive removal of Þbrovascular tissue such that there is a large bare scleral defect, a large enough conjunctival autograft may not be available. In these instances, AMT may be combined with the conjunctival autograft to ensure coverage of the entire bare sclera defect. The AMT is secured stromal side down Þrst with Þbrin glue or 10-0 nylon suture depending on the surgeonÕs preference, and the conjunctival autograft is laid on top, epithelial side up and secured in the same fashion. Shimazaki et al. demonstrated this to be a safe and effective method for recurrent pterygium that are often associated with symblepharon and ocular motility restriction and thus require large area of excision [18].
4.3.6.4Various Techniques in Conjunctival
Autografting
Variations in conjunctival autograft surgery include the use of limbal-conjunctival autografts, conjunctival