Minimizing Incisions and Maximizing Outcomes in Cataract Surgery

Preface

Contents

Contributors

Chapter 1

Introduction

Literature Review

Major Issues

Major Studies

Negative Studies

References

Chapter 2

The Transition Towards Smaller and Smaller Incisions

1.1 Micro-Coaxial Phacoemulsifi cation with Torsional Ultrasound

1.1.1 Introduction

1.1.2 Micro-Coaxial Phacoemulsification

1.1.3 Torsional Ultrasound

1.1.4 Our Procedure for Emulsifying the Nucleus

1.1.5 Combining Micro-Coaxial Phacoemulsification with Torsional Ultrasound

References

Chapter 3

1.2 Transitioning to Bimanual MICS

1.2.1 Introduction

1.2.2 Technique

1.2.3 Summary

Chapter 4

1.3 0.7 mm Microincision Cataract Surgery

1.3.1 Sub 1 mm MICS: Why?

1.3.2 Potential Drawbacks of a Sub-1 m Incision

1.3.3 Instrumentation

1.3.3.1 Phaco Tip (0.7 mm)

1.3.3.2 0.7 mm Irrigating Instruments

1.3.4 Surgery

1.3.4.1 Incision

1.3.4.2 Capsulorhexis

1.3.4.3 Hydrodissection

1.3.4.4 Prechopping

1.3.4.5 Phacoemulsification

1.3.5 0.7 mm MICS Combined Procedures

1.3.5.1 0.7 mm MICS and Glaucoma Surgery

1.3.5.2 0.7 mm MICS and 25-GaugeTransconjunctival SuturelessVitrectomy

1.3.6 Summary

References

Chapter 5

MICS Instrumentation

2.1 MICS Instrument Choice: The First Step in the Transition

2.2 MICS Incision

2.3 MICS Capsulorhexis

2.4 MICS Prechopping

2.5 MICS Irrigation/Aspiration Instruments

2.5.1 19 G Instruments

2.5.2 21 G Instruments

2.6 MICS Auxiliary Instrument

2.6.1 Scissors

2.6.2 Gas Forced Infusion

2.6.3 Surge Prevention

2.7 New MICS Instruments

2.7.1 Flat Instruments

References

Chapter 6

Evolution of Ultrasound Pumps and Fluidics and Ultrasound Power: From Standard Coaxial Towards the Minimal Incision Possible in Cataract Surgery

3.1 Introduction

3.2 Power Generation

3.3.1 Tuning

3.2.2 Phaco Energy

3.2.2.1 Low Frequency Energy

3.2.2.2 High Frequency Energy

3.2.3 Transient Cavitation

3.2.4 Sustained Cavitation

3.3 Modifi cation of Phaco Power

3.3.1 Alteration of Stroke Length

3.3.2 Alteration of Duration

3.3.2.1 Burst Mode

3.3.2.2 Pulse Mode

Micro Pulse (Hyper-Pulse)

Pulse Shaping

3.3.3 Alteration of Emission

3.4 Fluidics

3.5 Vacuum Sources

3.6 Surge

3.6.1 Non-Longitudinal Phaco: Modification of Fluid Control by Power Modulations

3.6.2 Partial-Occlusion Phacoemulsification

3.7 Phacoemulsifi cation Technique and Machine Technology

3.7.1 Micro-incisional Phaco

3.7.2 Bimanual Micro-Incisional Phaco

3.7.3 Micro-Incisional Coaxial Phaco

3.7.3.1 Irrigation and Aspiration

3.8 Conclusion

Reference

Further Reading

Chapter 7

Coaxial Microincision Cataract Surgery Utilizing Non-Linear Ultrasonic Power: An Alternative to Bimanual Microincision Cataract Surgery

4.1 Introduction

4.2 The Fluidics of Coaxial Microincisional Phacoemulsification

4.3 Incision Size

4.4 Torsional Ultrasound

4.5 Conclusion

References

Chapter 8

Technology Available

5.1 How to Better Use Fluidics with MICS

5.1.1 Physical Considerations

5.1.1.1 Aspiration Effi ciency

5.1.1.2 Chamber Stability

5.1.1.3 Holdability

5.1.2 Surgical Considerations

5.1.2.1 Incision Configuration

5.1.2.2 Phaco Technique

5.1.2.3 Infusion-Assisted High-Flow High-Vacuum Phacoaspiration (Hybrid Phaco)

5.1.2.4 The OS3 and CataRhex SwissTech Platforms

Equipment

Machine Settings

References

Chapter 9

5.2 How to Use Power Modulation in MICS

5.2.1 Introduction

5.2.2 What Do Phacoemulsifi cation Machines Really Do?

5.2.3 The Concept of Unoccluded Flow Vacuum

5.2.4 The Intricacies of Ultrasound Power Modulation

5.2.5 The Variable Incidence of Wound Burn Rates

5.2.6 Measuring the Amplitude of Post-Occlusion Surge

References

Chapter 10

5.3 MICS with Different Platforms

5.3.1 MICS with the Accurus Surgical System

5.3.1.1 Introduction and Historic Background

5.3.1.2 Surgical Features of the Accurus Surgical System Useful for MICS Procedures

5.3.1.3 Surgical Parameters for MICS with Accurus

5.3.1.4 Final Considerations

References

Chapter 11

5.3.2 Using the Alcon Infi niti and AMO Signature for MICS

5.3.2.1 Introduction

5.3.2.2 Technology on the Alcon Infi niti

5.3.2.3 Setting Up the Infi niti for MICS

5.3.2.4 Importance of Tip Size on Machine Fluidics Settings with the Infiniti

5.3.2.5 Setting the Ultrasound Power and Modulation with the Infiniti for MICS

5.3.2.6 The Infiniti and BMICS

5.3.2.7 Technology for MICS on the AMO Signature

5.3.2.8 Applying Signature Technology to CMICS and BMICS

Chapter 12

5.3.3 MICS with Different Platforms: Stellaris Vision Enhancement System

5.3.3.1 Innovations in Phacoemulsifi cation

5.3.3.2 Evaluating the Stellaris Vision Enhancement System

5.3.3.3 The Advantages of BMICS

References

Chapter 13

Surgical Technique – How to Perform a Smooth Transition

References

Chapter 14

6.1 Pupil Dilation and Preoperative Preparation

6.1.1 Managing the Small Pupil

6.1.2 Techniques that Depend on the Manipulation of the Pupil

6.1.3 Iris Surgery

6.1.4 Preoperative Preparation and Infection Prophylaxis

6.1.5 Evaluating Risk

6.1.6 Assessing Your Approach

6.1.7 Preventing Infection, Step by Step

6.1.8 Sample Protocol Outline

6.1.9 A Careful, Critical Eye

References

Chapter 15

6.2 Incisions1

6.2.1 Side-Port Incisions

References

Chapter 16

6.3 Thermodynamics1

6.3.1 Introduction

6.3.2 Corneal Thermal Damage

6.3.3 Heat Generation

6.3.4 Factors that Contribute to Thermal Incision Damage

6.3.4.1 Energy Emission: Amount and Pattern of How the Energy Is Delivered

6.3.4.2 Incision: Incision Construction and Possible Constriction of the Sleeve

6.3.4.3 Viscoelastic Devices and Possible Occlusion of the Aspiration Line

6.3.4.4 Irrigation Flow

6.3.4.5 Position of the Tip Inside the Incision

6.3.4.6 Tip Design

6.3.4.7 Surgical Technique

6.3.5 Conclusion

References

Chapter 17

6.4 Using Ophthalmic Viscosurgical Devices with Smaller Incisions

6.4.1 Introduction

6.4.1.1 The Nature of OVDs: Rheology

6.4.1.2 The Classifi cation of OVDs

6.4.1.3 Soft Shell and Ultimate Soft Shell Technique (SST & USST)

6.4.2 Routine, Special and complicated Cases

6.4.2.1 Phakic and Anterior Chamber IOLs

6.4.2.2 Trabeculectomy and Phaotrabeculectomy

6.4.2.3 Fuchs’ Endothelial Dystrophy

6.4.2.4 Zonular Defi ciency

6.4.2.5 Capsular Staining for White & Black Cataracts

6.4.2.6 Flomax® Intraoperative Floppy Iris Syndrome USST

6.4.3 Discussion

References

Chapter 18

6.5 Capsulorhexis

References

Chapter 19

6.6 Hydrodissection and Hydrodelineation1

References

Chapter 20

6.7 Biaxial Microincision Cataract Surgery: Techniques and Sample Surgical Parameters

Chapter 21

6.8 Biaxial Microincision Phacoemulsification: Transition, Techniques, and Advantages

6.8.1 Surgical Technique

6.8.2 Advantages

6.8.3 Disadvantages

6.8.4 Final Thoughts

References

Chapter 22

6.9 BiMICS vs. CoMICS: Our Actual Technique (Bimanual Micro Cataract Surgery vs. Coaxial Micro Cataract Surgery)

6.9.1 Introduction

6.9.2 Historical Background

6.9.3 BiMICS. BiManual MicroIncision Cataract Surgery

6.9.3.1 Introduction

6.9.3.2 Instrumentation

6.9.3.3 Microphacodynamics

6.9.3.4 Irrigation-aspiration

6.9.3.5 Phacotips

6.9.3.6 Capsulorhexis

6.9.3.7 Phaco Knives

6.9.3.8 The Phaco Machines

6.9.3.9 Phaco Pumps

6.9.3.10 Ultrasound Power Delivery

6.9.3.11 IOL Implantation

6.9.3.12 Astigmatism

6.9.4 CoMICS: Coaxial MicroIncision Cataract Surgery

6.9.4.1 Capsulorhexis

6.9.4.2 Phacotips

6.9.4.3 The Phaco Machines

6.9.4.4 Phaco Pumps

6.9.4.5 Ultrasound Power Delivery

6.9.4.6 Irrigation-Aspiration

6.9.4.7 Incision-Assisted IOL Implantation

6.9.5 Conclusion

References

Chapter 23

6.10 Endophthalmitis Prevention

6.10.1 Antibiotic Prophylaxis

6.10.2 Wound Construction

6.10.3 Summary

References

Chapter 24

Biaxial Microincision Phacoemulsifi cation for Diffi cult and Challenging Cases

7.1 High Myopia

7.2 Posterior Polar Cataract

7.3 Posterior Subluxed Cataracts

7.4 Mature Cataract with Zonular Dialysis

7.5 Punctured Posterior Capsule

7.6 Posterior Capsule Rupture

7.7 Pseudoexfoliation

7.8 Rock-Hard Nuclei

7.9 Switching Hands

7.10 Microcornea or Microphthalmos

7.11 Large Iridodialysis and Zonular Defects

7.12 Intraoperative Floppy Iris Syndrome (IFIS)

7.13 Every Small Pupil Must Be Viewed as a Potential IFIS

7.14 Iris Bombé

7.15 Very Shallow Anterior Chambers

7.16 Refractive Lens Exchange

7.17 Refractive Lens Exchange in Post Radial Keratotomy (RK)

7.18 Intraocular Cautery

7.19 Biaxial Microincision Instruments

References

Chapter 25

7.1 MICS in Special Cases: Incomplete Capsulorhexis

7.1.1 Introduction

7.1.2 Avoiding Complications While Constructing Your Microcapsulorhexis

7.1.3 Avoiding Complications During Biaxial Phaco with an Incomplete Capsulorhexis

7.1.4 Avoiding Complications During IOL Insertion with an Incomplete Capsulorhexis

7.1.5 Conclusions

References

Chapter 26

7.2 MICS in Special Cases (on CD): Vitreous Loss

7.2.1 Introduction

7.2.2 Posterior Capsule Tears and Vitreous Prolapse

7.2.3 Vitreous and the Epinucleus or Cortex

7.2.4 Different Techniques Other than Pars Plana Vitrectomy for Nuclear Loss in Vitreous

7.2.5 Pars Plana Vitrectomy

7.2.6 Zonulolysis

References

Chapter 27

7.3 How to Deal with Very Hard and Intumescent Cataracts

7.3.1 Introduction

7.3.2 Types of Cataracts

7.3.3 Management of Hard Cataracts Through Biaxial Technique

7.3.4 Incision

7.3.5 Capsulorrhexis

7.3.6 Hydrodissection

7.3.7 Phacoemulsifi cation

7.3.8 Conclusion

References

Chapter 28

IOL Types and Implantation Techniques

8.1 MICS Intraocular Lenses

8.1.1 Introduction

8.1.2 Lenses

8.1.2.1 Zeiss – Acri.Tec MICS IOLs (Zeiss – Acri.Tec Berlin, Germany)

8.1.2.2 ThinOptX MICS IOLs (ThinOptX, Abingdon, VA)

8.1.2.3 Akreos MI60 AO Micro Incision IOL (Bausch & Lomb, Rochester, NY)

8.1.2.4 IOLtech MICS lens (IOLtech, La Rochelle, France; and Carl Zeiss Meditec, Stuttgard, Germany)

8.1.2.5 TetraFlex KH-3500 and ZR-1000 (Lenstec, St. Petersburg, FL)

8.1.2.6 MicroSlim and SlimFlex MICS IOLs (PhysIOL, Liège, Belgium)

8.1.2.7 CareFlex IOL (W20 Medizintechnik AG, Bruchal, Germany)

8.1.2.8 AcriFlex MICS 46CSE IOL (Acrimed GmbH, Berlin, Germany)

8.1.2.9 Hoya Y-60H (Hoya Corporation, Tokyo, Yapan)

8.1.2.10 Miniflex IOL (Mediphacos Ltda., Minas Gerais, Brasil)

8.1.3 Optical Quality of MICS IOLs

8.1.4 Conclusion

References

Chapter 29

8.2 Implantation Techniques

8.2.1 Defi nition

8.2.2 Prerequisites to a Sub-2 Injection

8.2.3 IOLs Used for Injection Through Microincision

8.2.3.1 Material

8.2.3.2 Design

8.2.3.3 Optic Design

8.2.3.4 Haptic Design

8.2.3.5 Posterior Barrier (360°)

8.2.4 Injectors Meant for Microincision

8.2.4.1 Objectives of Injectors Meant for Microincision

8.2.4.2 Characteristics of Sub-2 Injectors

8.2.4.3 The Cartridges

Loading Chambers

Injection Tunnels and Cartridge Tips

8.2.4.4 The Plunger Tips (or plunger)

8.2.4.5 Pushing Systems

8.2.4.6 Injector Bodies

8.2.4.7 Principal Sub-2 Injectors

8.2.5 Visco Elastic Substances and Injection Through Microincision

8.2.6 Techniques of Sub-2 Injection

8.2.6.1 Visco-Injection Using Wound-Assisted Technique

8.2.6.2 Incision Construction

8.2.6.3 Pressurization of the Anterior Chamber

8.2.6.4 Loading the Cartridge

8.2.6.5 Loading the Injector

8.2.6.6 Insertion of the Plunger Tip

8.2.6.7 Injection in the Anterior Chamber

8.2.6.8 Positioning the IOL in the Capsular Bag

8.2.6.9 Removing the VES

8.2.6.10 Thin Roller Injector

8.2.6.11 Conclusion

Reference

Chapter 30

8.3 Special Lenses

8.3.1 Toric Posterior Chamber Intraocular Lenses in Cataract Surgery and Refractive Lens Exchange

8.3.1.1 Introduction

8.3.1.2 Definitions

8.3.1.3 T-IOL Calculation

8.3.1.4 Current T-IOL Models

8.3.1.5 Preoperative Marking

8.3.1.6 Clinical Indications

8.3.1.7 Custom-Made Lenses

8.3.1.8 Conclusion for Practice

References

Chapter 31

8.3.2 Special Lenses: MF

8.3.2.1 Discussion

8.3.2.2 Conclusion

8.3.2.3 Outlook

References

Chapter 32

8.3.3 Special Lenses: Aspheric

References

Chapter 33

8.3.4 Intraocular Lenses to Restore and Preserve Vision Following Cataract Surgery

8.3.4.1 Introduction

8.3.4.2 Why Filter Blue Light?

Summary

8.3.4.3 Importance of Blue Light to Cataract and Refractive Lens Exchange Patients

Summary

8.3.4.4 Quality of Vision with Blue Light Filtering IOLs

Summary

8.3.4.5 Clinical Experience

Summary

8.3.4.6 Unresolved Issues and Future Considerations

References

Chapter 34

8.3.5 Microincision Intraocular Lenses: Others

8.3.5.1 ThinOptX®

8.3.5.2 Smart IOL

8.3.5.3 Afi nity™

8.3.5.4 AcriTec

8.3.5.5 Akreos

8.3.5.6 Tetraflex

8.3.5.7 Rayner

8.3.5.8 Injectable Polymers

8.3.5.9 Final Comments

References

Chapter 35

Outcomes

9.1 Safety: MICS versus Coaxial Phaco

9.1.1 Introduction

9.1.2 Visual Outcomes

9.1.3 Incision Damage

9.1.4 Corneal Incision Burn

9.1.5 Corneal Changes

9.1.6 Infection

9.1.7 Summary

References

Chapter 36

9.2 Control of Corneal Astigmatism and Aberrations

9.2.1 Introduction: Impacts of MICS Incision on the Outcomes of Cataract Surgery

9.2.2 Objective Evaluation of Corneal Incision

9.2.3 Control of Corneal Aberration and Astigmatism with MICS

9.2.4 Role of Corneal Aberrometry in Evaluating MICS Incision

9.2.5 Role of OCT in Evaluating MICS Incision

9.2.6 Our Experience in Corneal Aberrations and Astigmatism After MICS

9.2.7 Conclusion

References

Chapter 37

9.3 Corneal Endothelium and Other Safety Issues

References

Chapter 38

9.4 Incision Quality in MICS

9.4.1 Introduction: History of Incision Size Reduction

9.4.2 The Trends Towards Microincision Cataract Surgery (BMICS)

9.4.3 Advantages of Minimizing the Incision Size

9.4.4 Model for the Analysis of Corneal Incision Quality [21]

9.4.5 Our Protocol for Evaluation of Incision Quality in BMICS [21]

9.4.6 Results

9.4.6.1 Visual, Refractive and Biomicroscopic Outcomes

9.4.6.2 Incision Imaging (OCT) Outcomes

9.4.6.3 Topographic and Aberrometric Outcomes

9.4.7 Special Focus on the Role of OCT in the Evaluation of Incision Quality in BMICS

9.4.8 Conclusion

References

Index