- •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
10 Minimally Invasive Vitreoretinal Surgery |
227 |
directly visualized at all times using the endoscope [28].
10.3.4.3 PVR and Subretinal Surgery
Even when the retina may be examined using wideangle viewing, there are locations in the posterior segment that are inaccessible, such as the ciliary body, or are otherwise unable to be seen without manipulation such as scleral depression. These areas become important when evaluating for proliferative membranes.
Proliferative vitreoretinopathy remains the most common cause of failed retinal detachment surgery. Complete dissection and removal of proliferative membranes at the time of surgery is advisable; however, retinotomy and retinectomy are frequently indicated in order to prevent persistent reproliferation and traction on the ciliary body, and decrease the risk of redetachment and hypotony. Endoscopy has been used to inspect the anterior retina and ciliary body in postvitrectomy patients undergoing large retinectomies. Ciliary body detachment and distortion of anatomy can be directly visualized and may be associated with hypotony, which may aid in postoperative management [127]. Furthermore, endoscopy may be useful for interior inspection of sclerotomies; proliferation in these locations after surgery may lead to recurrent detachment [112].
The use of micro-endoscopy has also been advocated for technically challenging subretinal surgery. Working through an iatrogenic retinotomy, subretinal choroidal neovascular membranes are directly visualized using a 20-gauge endoscope following standard three-port pars plana vitrectomy, then dissected manually or ablated using Nd:YAG laser [128–130].
10.3.4.4 Retained Lens Fragments
Complicated cataract extraction with retained lens fragments may require extensive surgery, and presents several difficulties, including localizing lens fragments in the vitreous cavity secondary to blood or fibrin in the vitreous base, as well as marked inflammation causing poor visualization through the anterior segment. Endoscopic vitrectomy for removal of lens fragments or dislocated IOL has been described, anecdotally shortening and simplifying cases, with good visual
outcomes [131]. Visualization of the vitreous base for 360°, as well as the posterior lens capsule, and zonules allows for complete dissection of adhesions and removal of blood and fibrinous debris, which may contribute to a lower risk of postvitrectomy detachment in these cases. Endoscopy also provides the advantage of direct visualization of retinal breaks and traction from multiple angles without external manipulation such as scleral depression.
10.3.4.5Anterior and Retrolental Vitrectomy in Malignant Glaucoma
Ciliary block glaucoma is characterized by shallowing of the anterior chamber despite a patent iridectomy, classically occurring following intraocular surgery. It is believed to be caused by aqueous misdirected posteriorly. Surgical treatment with anterior vitrectomy is reserved for cases when medical treatment with cycloplegia and aqueous suppression or laser treatment with YAG hyaloidotomy fail. One of the difficulties with anterior vitrectomy in phakic patients lies in dissecting the anterior vitreous without inadvertent lens damage. Endoscopic visualization during anterior vitrectomy has been described as a useful adjunct in this case, in order to determine the extent of vitrectomy needed [132].
10.3.4.5 Sutured IOL and ECP
Endoscopic cyclophotocoagulation is used increasingly for intractable glaucoma, with reported benefits of less inflammation, less distortion of architecture, and direct visualization of ciliary processes in order to titrate treatment. Endoscopy is also advocated to aid in suturing intraocular lenses in the ciliary sulcus. Description of these techniques is beyond the scope of this discussion.
10.3.5 Limitations and Challenges
Endoscopic vitreoretinal surgery has several limitations. There is a learning curve, as with any new technique. The loss of stereoscopic viewing using the endoscope is compounded by the lack of other lighting