Ординатура / Офтальмология / Английские материалы / The Art and the Science of Cataract Surgery_Boyd, Barraquer_2000

CHAPTER 3

PREPARING FOR SURGERY

37

Making Patients Confident

37

Patients Encounter with the Physician

37

Ingredients of a Strong Relationship

38

Evaluating the Patient's Cataract

38

Approaching the Day of Surgery

39

Patient's Expectations

39

IOL POWER CALCULATION IN STANDARD

39

AND COMPLEX CASES

Postop Refractive Errors No Longer Admissible

40

The Challenge of the Complex Cases

43

The Most Commonly Used Formulas

44

Main Causes of Errors

44

Targeting Post-Op Refraction

45

Monocular Correction

45

Binocular Correction

46

Good Vision in the Non-Operated Eye

46

When Cataracts in Both Eyes

46

IOL POWER CALCULATION IN COMPLEX CASES

47

Specific Methods to Use in Complex Cases

47

Practical Method for Choosing Formulas in Complex Cases

47

High Hyperopia

47

The Use of Piggyback Lenses in Very High Hyperopia

48

High Myopia

49

DETERMINING IOL POWER IN PATIENTS WITH

49

PREVIOUS REFRACTIVE SURGERY

Methods Most Often Used

52

The Clinical History Method

52

The Trial Hard Contact Lens Method

53

Example as Provided by Holladay

53

The Corneal Topography Method

54

THE IMPORTANCE OF DETECTING IRREGULAR

54

ASTIGMATISM

IOL POWER CALCULATION IN PEDIATRIC CATARACTS

54

Different Alternatives

55

Alternatives of Choice

55

IOL POWER CALCULATION FOLLOWING VITRECTOMY

57

CHAPTER 4

PREVENTING INFECTION AND INFLAMMATION

Use of Antiseptics, Antibiotics and Antiinflammatory Agents

63

Effective Preoperative Antibiotic Treatments

63

Regimens Recommended

64

Gills Formulas to Prevent Infection

64

1) For High Volume Cataract Surgery

64

2) Non-Complex, Effective and Safe Alternative for

65

Prevention of Infection

PREPARATION, SEDATION AND ANESTHESIA

71

Preparation of Patient

71

Sedation

71

Pupillary Dilation

72

ANESTHESIA

72

Topical

72

Selection of Anesthetic Method

72

Unassisted Topical Anesthesia

74

The Anesthetic Procedure of Choice

75

Technique for Irrigation of Lidocaine in AC

75

Injection of Viscoelastic

75

What Can be Done with the Combined Anesthesia

75

Side Effects of the Combined Anesthesia

75

How to Manage Patients Who Feel Pain and Discomfort

75

PHOTOTOXICITY IN CATARACT SURGERY

75

COMPARING PLANNED EXTRACAPSULAR WITH

83

PHACO EXTRACAPSULAR

ADVANTAGES OF THE PHACO TECHNIQUE

83

MAIN TECHNICAL DIFFERENCES ASSOCIATED WITH PHACO

84

LIMITATIONS OF PHACOEMULSIFICATION

86

CHAPTER 7

PREPARING FOR THE TRANSITION

GENERAL OVERVIEW AND STEP BY STEP CONSIDERATIONS

93

Equipment - Dependent and Phase-Dependent Technique

93

Mental Attitude

93

UNDERSTANDING THE PHACO MACHINE

94

Becoming Familiar with the Equipment

94

Two Hands, Two Feet and Special Sounds

95

Main Elements of Phaco Machines - Their Action on Fluid Dynamics 95

COMPARISON OF SURGICAL TECHNIQUES FOR

96

TRANSITION VS EXPERIENCED SURGEONS

Techniques Which Are the Same for the Transition and for

96

Advanced Surgeons

Techniques that Vary According to the Skill of the Surgeon

96

SURGICAL TECHNIQUE IN THE TRANSITION

97

Anesthesia

97

The Incision

97

How to Make a Safe Transition from Large to Small Incision

97

Role of Conjunctival Flap

101

Anterior Capsulorhexis

102

Hydrodissection

104

THE MECHANISM OF THE PHACO MACHINE

106

Getting Ready to Use Phaco During Transition

106

Optimal Use of the Phaco Machine

106

The Rationale Behind It - Main Functions

106

Parameters of the Phaco Machine

112

How to Program the Machine for Optimal Use

114

Fluid Dynamics During Phaco

114

Fluidics and Physics of Phacoemulsification

116

Importance of and Understanding the Surge Phenomenon

119

Lessening Intraoperative

121

Complications from the Surge

121

NUCLEUS REMOVAL - APPLICATION OF PHACO

123

FRACTURE AND EMULSIFICATION

123

The Divide and Conquer Technique

124

Emulsification of the Nuclear Fragments

126

FINAL STEPS

126

Aspiration of the Epinucleus

126

Aspiration of the Cortex

126

Intraocular Lens Implantation

128

Removal of Viscoelastic

128

Closure of the Wound

129

What to Do if Necessary to Convert

130

Testing the Wound for Leakage

131

Immediate Postoperative Management

131

INSTRUMENTATION

137

Eye Speculum

137

Fixation Ring

137

Knives and Blades

137

Hydrodissection Cannula

140

Cystotomes or Capsulorhexis Forceps

141

Nuclear Manipulators or Choppers (Second Instrument)

142

Forceps and Cartridge Injector Systems for Insertion of

144

Foldable Intraocular Lenses

THE PHACO PROBES AND TIPS

147

Phaco Tips

148

Surgical Principles Behind the Different Phaco Tips

149

PHACOEMULSIFICATION SYSTEMS

150

The Alcon Legacy

150

The Allergan Sovereign

150

The Bausch & Lomb - Storz Millennium

150

The Pulse and Burst Modes

151

Differences Between Them

151

Clinical Applications of the Pulse Mode

152

Clinical Applications of the Burst Mode

154

Its Role in Transition to Chopping

154

Advances with the Sovereign Phaco System

154

CHAPTER 9

MASTERING PHACOEMULSIFICATION

The Advanced, Late Breaking Techniques

General Considerations

159

Trauma-Free Phacoemulsification

159

Faster Operations

160

Do They Sacrifice Patient Care?

160

Readiness and Know-How to Become Efficient

160

THE ADVANCED, LATE-BREAKING TECHNIQUES

160

Anesthesia

160

Fixation of the Globe

161

THE INCISIONS

161

The Primary Incision

161

Essential Requirements for a Self-Sealing Corneal Incision

162

Position of the Clear Cornea Tunnel Incision

162

Reservations About the Clear Corneal Incision

164

Advantages to the Temporal Approach

164

Importance of the Length of the Tunnel

166

Placing and Making the Primary Incision

166

Surgeon's Position

167

Controversy Over the Strength and Safety of the Wound

167

Testing the Wound for Leakage

167

Closing a Leaking Wound Without Sutures

167

THE ANCILLARY INCISION

169

ANTERIOR CAPSULORHEXIS

169

Key Role

169

Technique for Performing a First Class CCC

170

Size of the Capsulorhexis

170

STAINING THE ANTERIOR CAPSULE IN WHITE CATARACTS 172

HYDRODISSECTION - HYDRODELAMINATION

175

Technique of Hydrodissection

175

Hydrodelamination

175

MANAGEMENT OF THE NUCLEUS

176

General Considerations

176

Concepts Fundamental to All Techniques

176

The Essential Principles

177

THE ENDOCAPSULAR TECHNIQUES

177

THE HIGH ULTRASOUND ENERGY AND LOW VACUUM GROUP

177

THE GROOVING AND CRACKING METHODS

177

The Divide and Conquer Four Quadrant Nucleofractis Technique

177

Principles of the Divide and Conquer Techniques

180

The Role of D & C Techniques in Cataracts of

180

Different Nucleus Consistency

Present Role of Original Four Quadrant Divide and Conquer

181

THE LOW ULTRASOUND ENERGY AND HIGH VACUUM GROUP

181

THE CHOPPING TECHNIQUES

183

Main Instruments Used

183

Surgical Principles of the Original Phaco Chop

184

Chopping Techniques Presented in this Volume

184

THE STOP AND CHOP TECHNIQUE

184

Surgical Principles

184

Absolute Requirements to Perform the Stop and Chop

188

Importance of the Phaco Chopper

188

Highlights of the Stop and Chop Technique

189

FUNDAMENTAL DIFFERENCES BETWEEN CHOPPING

190

AND DIVIDE AND CONQUER (D & C) TECHNIQUES

THE CRATER PROCEDURES

191

The Crater Divide and Conquer (Mackool)

191

The Crater Phaco Chop for Dense, Hard Nuclei

191

THE NUCLEAR PRE-SLICE OR NULL PHACO CHOP

194

TECHNIQUE

Disassembling the Nucleus

194

How Is the Null-Phaco Chop Done

194

Potential Complications

198

Contributions of this Technique

198

THE CHOO-CHOO CHOP AND FLIP

198

PHACOEMULSIFICATION TECHNIQUE

Origin of the Name “Choo-Choo”

199

Comparison With Other Techniques

202

Fine's Parameters

202

THE TRANSITION TO CHOPPING TECHNIQUES

204

REMOVAL OF RESIDUAL CORTEX AND EPINUCLEUS

205

INTRAOCULAR LENS IMPLANTATION

207

The Increased Interest in Foldable IOL's

207

The Most Frequently Used IOL's

207

MONOFOCAL FOLDABLE LENSES

208

THE FOLDABLE ACRYLIC IOL'S

208

THE FOLDABLE MONOFOCAL SILICONE IOL's

209

OTHER MONOFOCAL LENSES

210

The Hydrogel, Foldable Monofocal IOL

210

The Foldable Toric Lens

210

Bitoric Lens But Not Foldable

210

THE FOLDABLE MULTIFOCAL IOL

211

The Array Multifocal Silicone Lens

211

How Does the Array Foldable Multifocal Lens Work?

212

Quality of Vision with Array Multifocal

212

Patient Selection and Results

212

Specific Guidelines for Implanting the Array Lens

213

Special Circumstances for Array Implantation

213

Need for Spectacle Wear PostOp

214

Halos at Night and Glare

214

SURGICAL PRINCIPLES AND GUIDELINES FOR

214

IOL IMPLANTATION

PREFERRED METHODS OF IOL IMPLANTATION

214

Use of Forceps vs Injectors

214

Advantages and Disadvantages

214

New Trends for Folding and Insertion of IOL's

214

Guidelines for Insertion of Different Types of Lenses

218

Surgical Technique with Array Lens

218

Carreño's Technique of Acrylic IOL Implantation

218

Through a 2.75 mm Incision

Dodick's AcrySof's Implantation Technique

220

Implantation Technique for Silicone Foldable IOL's

222

Using Cartridge-Injector System

TESTING THE WOUND FOR LEAKAGE

223

CHAPTER 10

FOCUSING PHACO TECHNIQUES ON THE

HARDNESS OF THE NUCLEUS

MULTIPLICITY OF TECHNIQUES

229

The Essential Criteria for Success

229

DIFFERENT NUCLEUS CONSISTENCY -

229

TECHNIQUES OF CHOICE

Representative Experts

230

LINDSTROM'S PROCEDURES OF CHOICE

230

Advantages of the Supracapsular

231

Disadvantages of the Supracapsular

232

Contraindications of Supracapsular

232

HIGHLIGHTS OF THE SUPRACAPSULAR

233

IRIS PLANE TECHNIQUE

CENTURION'S TECHNIQUES RELATED

234

TO NUCLEUS CONSISTENCY

CARREÑO'S NUCLEAR EMULSIFICATION TECHNIQUE

237

OF CHOICE (PHACO SUB 3)

Adjusting the Equipment Parameters to Remove Cataracts

237

of Various Nuclear Density

Three Sets of Values Programmed Into Memory

237

Technique of Choice and Consistency of Cataract

238

NISHI'S TECHNIQUES OF CHOICE FOR

245

NUCLEI OF DIFFERENT CONSISTENCIES

CHAPTER 11

COMPLICATIONS OF PHACOEMULSIFICATION

INTRAOPERATIVE COMPLICATIONS

249-268

General Considerations

249

Main Intraoperative Complications

249

Incidence

249

Facing the Challenges

250

COMPLICATIONS WITH THE INCISION

250

COMPLICATIONS RELATED TO ANTERIOR

254

CAPSULORHEXIS

COMPLICATIONS WITH HYDRODISSECTION

258

COMPLICATIONS DURING NUCLEUS REMOVAL

259

COMPLICATIONS DURING REMOVAL OF THE CORTEX

260

COMPLICATIONS DURING FOLDABLE IOL's IMPLANTATION 260

COMPLICATIONS WITH POSTERIOR CAPSULE RUPTURE

262

Pars Plana Vitrectomy for Dislocated Nucleus

266

POSTOPERATIVE COMPLICATIONS

269-290

MEDICAL

269

Cystoid Macular Edema

269

Diabetes and Cystoid Macular Edema

273

PHOTIC MACULOPATHY

273

AMINOGLYCOSIDE TOXICITY

275

POSTERIOR CAPSULE OPACIFICATION

277

Overview

277

Role of IOL in PCO

277

Role of Continuous Curvilinear Capsulorhexis in PCO

278

Main Factors that Reduce PCO

278

PERFORMING THE POSTERIOR CAPSULOTOMY

279

Size of Capsulotomy

279

Posterior Capsulotomy Laser Procedure

279

Complications Following Nd:YAG Posterior Capsulotomy

281

POSTOPERATIVE ASTIGMATISM IN CATARACT PATIENTS

281

MANAGEMENT

281

Procedure of Choice

282

Highlights of AK Procedure

283

EXPLANTATION OF FOLDABLE IOL'S

284

RETAINING THE BENEFIT OF THE SMALL INCISION

284

RETINAL DETACHMENT

286

POSTOPERATIVE ENDOPHTHALMITIS

286

INTRAOCULAR LENS DISLOCATION

288

Aims of this Chapter

295

Broadening of Indications

295

Complex Cases Already Discussed in Previous Chapters

296

FOCUSING ON THE MAIN COMPLEX CASES

296

THE DIFFERENT TYPES OF VISCOELASTICS

296

Their Specific Roles

296

Cohesive and Dispersive Viscoelastics

296

The Cohesive VES - Specific Properties

296

The Dispersive VESSpecific Properties

297

PHACOEMULSIFICATION AFTER PREVIOUS

298

REFRACTIVE SURGERY

PHACOEMULSIFICATION IN HIGH MYOPIA

298

CHALLENGES OF PHACOEMULSIFICATION IN HYPEROPIA

299

REFRACTIVE CATARACT SURGERY

299

Why and When Do Refractive Cataract Surgery

299

TECHNIQUE FOR REFRACTIVE CATARACT SURGERY

300

CATARACT AND GLAUCOMA

302

Overview - Alternative Approaches

302

COMBINED CATARACT SURGERY AND

303

TRABECULECTOMY

Indications

303

Evolution of the Incision for Combined Cataract Extraction

303

and Trabeculectomy

A. Extracapsular Cataract Extraction with Trabeculectomy

304

B. Phacoemulsification with Trabeculectomy

308

Intraocular Lens Implants

308

Preoperative Preparation

308

SURGICAL TECHNIQUES STEP BY STEP

310

ECCE and Trabeculectomy With Single, Unbroken Tunnel Incision

310

Phacoemulsification With Trabeculectomy

315

Antimetabolites in Combined Procedures

318

Results of Combined Cataract Surgery and Trabeculectomy

320

PHACOEMULSIFICATION IN DISEASED CORNEAS

322

PHACOEMULSIFICATION AND IOL IMPLANTATION

322

IN THE PRESENCE OF OPAQUE CORNEA

Overview

322

Padilha’s Timing and Technique

322

Specific Recommendations

324

PHACOEMULSIFICATION, IOL IMPLANTATION

325

AND FUCHS’ DYSTROPHY

Preoperative Evaluation

325

Special Precautions During Phacoemulsification

325

PHACOEMULSIFICATION IN SMALL PUPILS

328

Pharmacological Mydriasis

328

Mechanical Dilatation with Viscoelastics

328

Mechanical Strategies

328

TRAUMATIC CATARACTS

333

Overview

333

Assessment of the Injured Eye

333

Highlights of Examination

333

Diagnostic Imaging

333

Combined Injuries of Anterior and Posterior Segment

334

Traumatic Cataracts in the Presence of Anterior

334

Segment Penetrating Wounds

MANAGEMENT OF TRAUMATIC CATARACT

334

HIGHLIGHTS OF SURGICAL TECHNIQUE

334

The Incision

334

Anterior Capsulorhexis

334

Lens Removal

334

Role of Intracapsular Tension Ring in Traumatic Cataracts

335

Removal of Cortex

336

Selection of IOL

339

IOL Implantation

339

Selection of Viscoelastic in Traumatic Cataracts

339

Phacoemulsification Advantages in Traumatic Cataract

340

PHACOEMULSIFICATION IN SUBLUXATED CATARACTS

340

Strategic Management

340

MANAGEMENT DEPENDING ON SIZE OF

340

ZONULAR DIALYSIS

Special Precautions with Subluxated Cataracts

342

Increasing the Safety of Posterior Lens Implantation in

344

Extensive Zonular Disinsertion

Fixation of the Anterior Capsule to the Ciliary Sulcus

345

CATARACT SURGERY IN CHILDHOOD

347

Previous Controversies Now Resolved

347

1) Age and Timing for Surgery

347

Bilateral Cataracts

347

Unilateral Cataracts

347

Preoperative Evaluation

348

History

348

Examination

349

The Special Case of Lamellar Cataracts

350

Rubella Cataracts

350

The Need for Close Monitoring

350

Preoperative Considerations

350

The Decision to Implant IOL’s in Children with Cataract Surgery

351

Surgical Technique

351

The Posterior Approach to Cataract Extraction in Children

355

CATARACT SURGERY IN UVEITIS

355

Overview

359

PERFORMING A FLAWLESS PLANNED EXTRACAPSULAR 361

CATARACT EXTRACTION (with an 8 mm Incision and

Posterior Chamber IOL Implantation)

General Anesthesia

361

Local Anesthesia

362

Technique for Extracapsular Cataract Extraction

364

with an 8 mm Incision (ECCE)

THE MANUAL, SMALL INCISION EXTRACAPSULARS

375

THE MINI-NUC TECHNIQUE

375

SURGICAL TECHNIQUE

376

Anesthesia, Paracentesis, ACM

376

Capsulorhexis

377

Conjunctiva

377

Sclerocorneal Pocket Primary Incision and Tunnel

378

Hydrodissection and Nucleus Dislocation

378

Nucleus Expression Using Glide and High IOP

381

Epinucleus and Cortex Extraction

383

IOL Implantation

384

Pupil Enlarged by Increased IOP

386

Advantages of the Continuous Flow of BSS

387

during Manual ECCE

Complications

387

THE SMALL INCISION PHACO SECTION

389

MANUAL EXTRACAPSULAR TECHNIQUE

Overview

389

Evolution of Technique

389

Indications

389

PHACO SECTION MOST IMPORTANT FEATURES

389

Capsulorhexis

390

Completing the Tunnel Incision

390

Anterior Chamber Maintainer

391

Aspiration of the Anterior Cortex and Epinucleus

392

Phacosection

393

Transition from Extracapsular Extraction to Phacosection

395

THE SMALL INCISION MANUAL PHACOFRAGMENTATION

400

Benefits of (MPF)

400

Experiences with Other Phaco Fragmentation Techniques

400

Why Use Gutierrez' Technique?

400

Surgical Technique

402

Complications

405