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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5222_Библиотеки_им_академика_М_И_Перельмана.pdf
88
U. Spandau
Fig. 7.6 After implantation of a hand painted Human
Optics iris prosthesis into the sulcus
Fig. 7.7 An eye with an old traumatic mydriasis and
natural lens
Video 7.2: Combo IOL-iris prosthesis (long
version).
Video 7.3: Combo IOL iris prosthesis in lens
capsule (short version).
Fig. 7.8 After implantation of a hand painted Human
Optics iris prosthesis together with a 3-piece IOL into
the lens capsule
Fig. 7.9 An aniridia and aphakia after a blunt perforation with an i-pad
Instruments
• 10 mm corneal trephine (Opthec)
• 23G or 25G endgripping forceps
• IOL injector
Material
• Iris prosthesis (Human Optics)
• MA60AC IOL (Alcon)
Fig. 7.10 Scleral fixation of a combined Human Optics
iris prosthesis + 3-piece IOL
Fig. 7.11 Scleral fixation of a hard Opthec iris-IOL
prosthesis (12 mm diameter)
897 Iris Surgery
Fig. 7.14 Cutting the Human Optics iris prosthesis (12 mm body) with a 10 mm trephine for sulcus
implantation
Fig. 7.12 Intraoperative view on an eye with a recent
traumatic mydriasis and aphakia after blunt trauma. The
Hattenbach iris instruments in action
Fig. 7.13 After performing a purse string suture a retropupillar iris-claw IOL is implanted. Postoperative
VA = 1.0
Fig. 7.15 A 3-piece IOL (Alcon, AMO) will be combined with the foldable prosthesis
Fig. 7.16 The haptics of the 3-piece IOL were inserted
into the iris prosthesis
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U. Spandau
Fig. 7.17 The preoperative status after an explosive
trauma. A healed corneal perforation, partial aniridia and
aphakia
Fig. 7.18 Implantation of the combined iris prosthesis
with 3-piece IOL with a regular IOL injector
Fig. 7.20 Immediate postoperative status. The 3-month
postoperative VA = 0.4
Fig. 7.21 A recent traumatic mydriasis and aphakia
after a blunt trauma with a plastic ball
Fig. 7.19 Scleral fixation of the IOL
Fig. 7.22 Insert the suture into the anterior chamber
with a Sinskey hook
Fig. 7.23 Purse string suture with Hattenbach iris
instruments
917 Iris Surgery
• Preparation of an iris-IOL prosthesis
The size of the iris prosthesis depends on an
implantation in the sulcus or in the capsular bag.
In case of a capsular bag implantation we use a
9.0 mm corneal trephine. In case of a sulcus
implantation we use a 10.0 mm corneal trephine
(Fig. 7.14). Place the 3-piece IOL on the backside
of the foldable iris and place two incisions at each
haptic with a 15 deg. knife (Alcon). Tunnel the
25G endgripping forceps through the two incisions, grab an end of a haptic and pull the haptic through the incisions (Figs. 7.15 and 7.16).
Repeat the manoeuvre with the other haptic.
2. Insertion of iris-IOL prosthesis into a
cartridge
3. Implantation of iris-IOL prosthesis
Fold or roll the combo prosthesis and insert it
into an IOL cartridge (Alcon) and finally into an
injector. Continue with a 2.4 mm main incision
and implant then the combo iris-prosthesis into
the anterior chamber (Fig. 7.18).
Fig. 7.24 After implantation of an Artisan IOL and
closing the knot of the purse string suture. The 1-week
postoperative VA = 0.9
Individual steps
• Preparation of an iris-IOL prosthesis
• Insertion of iris-IOL prosthesis into a
cartridge
• Implantation of iris-IOL prosthesis
• Fixation of iris prosthesis
The surgery step-by-step: Figs. 7.14, 7.15,
7.16, 7.17, 7.18, 7.19, and 7.20
4. Fixation of iris prosthesis
Rotate the combo iris-IOL prosthesis into
the lens capsule. If a lens capsule is not present a scleral fixation has to be performed: (1)
Intrascleral Scharioth method or (2) scleral
fixation with sutures (Figs. 7.19 and 7.20). For
details read the book “Complications during and
after cataract surgery” from Ulrich Spandau and
Gabor Scharioth.
Iridoplasty and Iris-Claw IOL Implantation
Video 7.4: Iridoplasty for traumatic mydriasis.
Video 7.5: Iridoplasty for traumatic mydria-
sis + iris claw IOL.
Instruments
• Iris instruments (Geuder)
• 23G or 25G intravitreal scissors
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U. Spandau
Material
• Onalene suture (Geuder)
Individual steps
1. Anterior chamber maintainer or pars
plana infusion
2. Four paracentesis at 12, 3, 6 and 9 o’clock
3. Insert the Onalene suture into the anterior
chamber with a Sinskey hook
4. Perform a 360° suture around the pupillary margin (purse string suture)
5. Retropupillary implantation of the irisclaw IOL
6. Tying of the Onalene suture
The surgery step-by-step: Figs. 7.21, 7.22,
7.23 and 7.24.
1. Anterior chamber maintainer or pars plana
infusion
Place the needle behind the iris, pierce the tissue
at the pupillary margin, grasp the needle with
the second forceps and pull the needle completely through. Continue 360°. Before tying
the suture we must implant the IOL (Fig. 7.23).
Alternatively you could tie the suture now and
implant the iris-claw IOL antepupillary.
5. Retropupillary implantation of the iris-claw
IOL
6. Tying of the Onalene suture
Perform a 6 mm broad incision at the limbus or
at the sclera. Place the IOL on the iris and rotate
the claws at the 3 and 9 o’clock position. Hold
the IOL in an upside-down position with the IOL
forceps (AMO), place the IOL behind the iris.
Now the assistant must pull on both ends of the
purse string suture so that the pupil is constricted.
Using an iris spatula from Sekundo (Geuder)
enclavate the iris tissue within the iris claws. Tie
finally the purse string suture (Fig. 7.24).
Eyes with aphakia tend to be hypotony under
surgery because the lens-iris diaphragma is
impaired. In order to avoid intraoperative hypotony I recommend the use of an anterior chamber
maintainer or even better a pars plana infusion.
The anterior chamber maintainer may disturb
the suturing within the anterior chamber.
2. Four paracentesis at 12, 3, 6 and 9 o’clock
3. Insert the Onalene suture into the anterior
chamber
Perform a paracentesis at 12, 3, 6 and 9 o’clock.
Then push the suture with a Sinskey hook
(push–pull instrument) into the anterior chamber
(Fig. 7.22).
4. Perform a 360° suture around the pupillary
margin (purse string suture)
Material and Companies Address
Opthec BV
• Schweitzerlaan 15
• 9728 NR Groningen
• Netherlands
• Phone: + 31 050 5,251,944
• www.opthec.com
Human Optics
• Dr. Schmidt Intraocularlinsen GmbH
• Westerwaldstraße 11–13
• 53,757 Sankt Augustin
• Germany
• e-mail: iris@humanoptics.com
• http://www.artificial-iris.com
937 Iris Surgery
Geuder
• Hertzstr. 4
• 69,126 Heidelberg
• Germany
• Tel: 06,221/3066
• Fax: 06,221/303122
• info@geuder.de
• www.geuder.de
Part V
Cataract: Femto-Cataract, Laser
Phaco, Congenital Cataract
The most exciting development in cataract surgery is surely the advent of
the laser. Prof. Nagy from Budapest, Hungary, is the developer of the femto
cataract. He will present his technique step-by-step and show the pros and
cons of this exciting new surgery. Dr. Sauder from Stuttgart, Germany,
will demonstrate a novel phaco handpiece which removes the nucleus with
laser instead of ultrasound. And finally will Dr. Nyström from Gothenburg,
Sweden, demonstrate congenital cataract surgery with implantation of a
Tassignon IOL.
Femtosecond Laser Assisted Cataract Surgery: Principles and Results
Zoltan Z. Nagy
8
Abstract
Ophthalmology always had a pioneer
role in use of lasers (Light Amplification
by Stimulated Emission of Radiation). A
great variety of lasers have been employed
since the first laser appeared within the
ophthalmic armamentarium for more
than 50 years. The German ophthalmologist Meyer-Schwickerath applied the first
laser for photocoagulation in the retina in
1949 (Meyer-Schwickerath in Ber Dtsch
Ophthalmol Ges. 55:256–9, 1949). A laser
is a special surgical device which emits specific electromagnetic light via stimulated
emission. Ophthalmic lasers operate at one
specific fixed wavelength, pulse pattern,
energy, duration, repetition rate, spot size and
The most exciting development in cataract surgery
is surely the advent of the laser. Prof. Nagy from
Budapest, Hungary, is a developer of femtosecond
cataract surgery. He will present his technique step
by step and show the pros and cons of this exciting
new surgery.
Supplementary Information The online version
contains supplementary material available at https://
doi.org/10.1007/978-3-031-84204-7_8.
Z. Z. Nagy (*)
Director of Department of Ophthalmology,
Semmelweis University, Budapest, Hungary
e-mail: zoltan.nagy100@gmail.com
causing most of the time thermal effects, but
photocoagulation, evaporation and non-thermal effects also important, regarding lasertissue interaction.
Keywords
Optical coherence tomography · Femtosecond
laser · Cataract surgery · Crystalline lens ·
Corneal incision
Ophthalmology always had a pioneer role in
use of lasers (Light Amplification by Stimulated
Emission of Radiation). A great variety of
lasers have been employed since the first laser
appeared within the ophthalmic armamentarium
for more than 50 years. The German ophthalmologist Meyer-Schwickerath applied the first
laser for photocoagulation in the retina in 1949
[1]. A laser is a special surgical device which
emits specific electromagnetic light via stimulated emission. Ophthalmic lasers operate at one
specific fixed wavelength, pulse pattern, energy,
duration, repetition rate, spot size and causing
most of the time thermal effects, but photocoagulation, evaporation and non-thermal effects also
important, regarding laser-tissue interaction.
Femtosecond lasers (Fig. 8.1) first applied
in refractive surgery to replace mechanical
and blade-operated microkeratomes to create
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
U. Spandau and G. B. Scharioth (eds.), Cutting Edge of Ophthalmic Surgery,
https://doi.org/10.1007/978-3-031-84204-7_8
97
98
Z. Z. Nagy
Fig. 8.1 The Alcon-LenSx femtolaser. The left monitor is for to set the treatment parameters, the right LCD
monitor helps the surgeon throughout the femtolaser
corneal flaps during laser in situ keratomileusis (LASIK) [2]. Thereafter the indication has
changed and widened to all types of lamellar
and penetrating keratoplasties, ring-segment
implantation in keratoconus and presbyopia
inlay pocket creation [3, 4].
The femtosecond laser beam is sharply
focused and generates plasma within the
affected corneal tissue. This plasma rapidly
expands causing an acoustic shock wave and by
this way displacing the surrounding tissue, cavitation bubbles and a cut plane are formed. At tissue level, photodisruption occurs exactly at the
laser’s focal point without any thermal effect
or collateral tissue damage. Due to the photodisruptive effect, the femtolasers are capable
of creating very precise cuts within the cornea,
lens capsule and crystalline lens (Fig. 8.2) by the
principle of tissue separation [5].
The repetition rate of femtosecond lasers has
doubled recently from 30 to 60 kHz and recently
a 160 kHz femtosecond laser has also became
available, which is able to create a corneal flap
within 10–12 s. The higher the repetition rate,
treatment, underneath the patient interface (PI) which
comes into contact with the treated eye
the less energy is needed to achieve the same
tissue effect. Femtosecond lasers used in laser
assisted cataract surgery perform with a pulse
duration of 400–800 femtosecond (fs) and the
energy range is in micro Joules (10−6 J). During
the surgery of the crystalline lens of the eye, the
femtosecond laser energy is usually increased to
8–15 μJ.
The femtosecond laser generated plasma rapidly expands causing an acoustic shock wave
which displacing the surrounding tissue. When
the plasma cools, cavitation bubbles are being
formed [2, 3, 5]. At tissue level, photodisruption
occurs without any thermal effect of the collateral tissue.
Cataract surgery at the moment is the most
commonly performed ocular implantation procedure not only within ophthalmology, but
within medicine worldwide [6]. It is estimated
that approximately 32 million cataract operations will be performed globally by 2020 with
a gradual increase year by year, due to aging
population, demographic changes, and the
change in indications for surgery [9]. Cataract
998 Femtosecond Laser Assisted...
Fig. 8.2 Screen of the Alcon-LenSx femtolaser
surgery and refractive surgery are being merged,
so cataract surgery is not only a purely vision
restoration entity, regarding the clarity of the
optic media, but became a refractive procedure
as well. Ophthalmic surgeons now also change
the refractive power of the eye, compensate for
astigmatism, spherical and other higher order
aberrations of the eye. Further, the restoration
of near vision has also become possible with the
use of premium artificial lenses, such as multifocal or accommodating intraocular lenses [7, 8].
Patient expectation has also risen, doctors
need to take longer chair time with patients
explaining the benefits and drawbacks of different surgical approaches and using different
intraocular lenses. [10]. To avoid refractive surprises possible solutions include better intraocular lens calculation using more precise formulas
and performing a better and more thorough
preoperative assessment, especially when the
patient had refractive surgery before [11]. Now
more consistent surgical results came in the
focus of ophthalmic community which is no
longer depending on the dexterity of the surgeon. In this field, femtolasers offer new possibilities and potential for surgeons and patients
alike. Regarding the new trends in ophthalmology, compound and coupled diagnostic and surgical tools helping surgeons to achieve the final
goal: the postoperative refraction should be
within ± 0.5 Dpt to ± 0.25 Dpt as was achieved
already in refractive surgery.
The Surgical Technique (Videos 8.1 and 8.2)
Docking Maneuver
The first and one of the most important steps
of femtosecond laser assisted cataract surgery
is the docking procedure with any types of
femtosecond lasers. The Alcon-LenSx femtosecond laser (Fig. 8.1) operates with a curved