Evidence-based Approach in Cataract Surgery

Sankara Nethralaya. Shri Ganapati Nethralaya. Chennai Ex-Consultant. Jalna LONDON AND NEW YORK A MARTIN DUNITZ BOOK .Evidence-based Approach in Cataract Surgery Jay Bhopi MS (Ophthalmology) Ex-Fellow.

London W1P OLP. a member of the Taylor & Francis Group. we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention.© 2004 Jay Bhopi Jaypee Brothers Medical Publishers (P) Ltd. USA .net. 90 Tottenham Court Road.co. FL 33431. Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency. 2005. 23/23B Ansari Road.vsnl. Neither the publishers nor the authors can be held responsible for errors or for any conse quences arising from the use of information contained herein. mechanical. To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to http://www. Exclusively distributed worldwide (excluding the Indian Subcontinent) by Martin Dunitz. photocopying. Visit our website: http://www. To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to http://www.uk/ This edition published in the Taylor & Francis e-Library.uk/. First published in India in 2004 by India.: +44 (0) 20 7842 2298 E-mail: info@dunitz. or transmitted. Daryaganj. 2005. please consult the prescribing information or instructional material issued by the manufacturer.ebookstore.dunitz. 23272703. India Phones: 23272143. Fax: +91–011–23276490 e-mail: jpmedpub@del2.uk/. recording. or otherwise. New Delhi. Although every effort has been made to ensure that drug doses and other information are pre sented accurately in this publication. stored in a retrieval system.co. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication.co. New Delhi 110 002. a member of the Taylor & Francis Group in 2004. without the prior permission of the publisher or in accordance with the provisions of the Copyright.: +44 (0) 20 7583 9855 Fax. First published in the United Kingdom by Taylor & Francis. Tel. A CIP record for this book is available from the British Library.co.ebookstore.jaypeebrothers. 23282021. the ultimate responsibility rests with the prescribing physi cian. ISBN 0-203-32029-8 Master e-book ISBN ISBN 1 84184 465 9 (Print Edition) Distributed in North and South America by Taylor & Francis 2000 NW Corporate Blvd Boca Raton.uk Website: http://www. EMCA House.com/ This edition published in the Taylor & Francis e-Library. 23245672 m\. electronic. in any form or by any means.in. For detailed prescribing informa tion or instructions on the use of any product or procedure discussed herein. All rights reserved. No part of this publication may be reproduced.tandf.tandf.

: 800 374 3401 Outside Continental USA Tel.: 561 361 6018 E-mail: orders@crcpress.uk This book is dedicated to my wife Suhasini who always encouraged me in writing this book and also my son Shreyas who allowed me to work on this book daily for long hours.Within Continental USA Tel.co. Hampshire SP10 5BE.: 561 994 0555. UK Tel.com Distributed in the rest of the world (excluding the Indian Subcontinent) by Thomson Publishing Services Cheriton House North Way Andover. .: +44 (0)1264 332424 E-mail: salesorder. Fax.: 800 272 7737. Fax.tandf@thomsonpublishingservices.


This is a book that should remain in an ophthalmologist’s shelf for many years. Who would have imagined our present abilities to remove cataracts using topical anesthesia. This book would be beneficial not only to the practicing ophthalmologists for improving their surgical skills but also to resident doctors who are interested in updating their knowledge. through a small self-sealing incision and correcting vision by implantation of a foldable intraocular lens? Scientific knowledge and literature is growing exponentially and now time has come to spread this knowledge.Preface There have been rapid advances relating to technology and clinical management in the practice of ophthalmology. Jay Bhopi .


1. Newer Anesthesia Modalities for Cataract Surgery 2. Newer Incision Techniques in Cataract Surgery 3. New Phacoemulsification Technologies 4. Recent Advances in Intraocular Lens Material and Design 5. Phacoemulsification in Difficult Situations 6. Recent Trends in Management of Cataract Surgery Complications 7. IOL Power Calculation in Special Situations 8. Posterior Capsule Opacification 9. Prophylaxis for Postoperative Endophthalmitis Index 1 6 14 23 35 50 60 68 77


EVIDENCE-GUIDED OPHTHALMOLOGY Evidence-based medicine is the ability to provide our patients with care, that is based on the best evidence currently available. It has become necessary for ophthalmologists to make clinical decisions, based on valid information or evidence rather than intuition, hearsay and peer practice. Knowledge about new techniques and approaches collected from peer reviewed journals provides framework for evidence-guided ophthalmology. Patients have become very demanding and expect the health care system to offer best practice, based on the latest evidence. There are certain distinct advantages of practicing evidence-guided ophthalmology. 1. Evidence-based medicine helps to improve clinical practice by evaluating the quality of clinical evidence and ensuring that only the best evidence from clinical research is used in the management of individual patients. 2. Evidence-based medicine has contributed to make the clinicians understand the benefit and harm of treatment as reported in the literature and it acts as an aid to clinical decision making. Getting the Evidence The best sources for information are the databases maintained by the National Library of Medicine, such as MEDLINE. After getting a list of references from the search interfaces, the full text of the articles from peer reviewed journals is necessary to learn the results of a study. Evaluating the Evidence 1. The study design should be considered for validity. 2. The methods of the study should be evaluated to assess, to what degree bias, confounding or chance could have affected the results of the study. 3. The applicability of the results to the practitioner and the patient should be assessed. 4. Finally, all the information is synthesized and assessment-based on the benefits and risks is considered. This approach of implementing evidence-based practice will help to maximize the chances for good patient outcomes.

LASIK: Laser-in-situ-keratomileusis 14. PcIOL: Posterior chamber intraocular lens 7. PCO: Posterior capsular opacification 6. BSS: Balanced salt solution 11. CTR: Capsular tension ring 4. CME: Cystoid macular edema 10. Eto: Ethylene oxide 8. ECCE: Extracapsular cataract extraction 9. RK: Radial keratotomy 12. HSM IOL: Heparin surface modified intraocular lens 5. IOL: Intraocular lens 3. PRK: Photorefractive keratectomy 13.Abbreviations 1. LEC: Lens epithelial cell . CCC: Continuous curvilinear capsulorhexis 2.


Chapter 1 Newer Anesthesia Modalities for Cataract Surgery Recently. Addition of sodium bicarbonate leads to alkalization of a local anesthetic solution. Lidocaine and bupivacaine: Bupivacaine is added to lidocaine to combine the advantages of rapid onset of action with lidocaine and longer duration of action with bupivacaine. This should be freshly prepared just before giving block. ii.e. pH adjustment of anesthetic solution: Recent studies have demonstrated that pH adjusted solutions of local anesthetics (pH 6. The baseline pH of 0.25% bupivacaine. 0.0) produce more rapid onset of action compared to unmodified commercial preparations. 2. It prolongs periorbital akinesia iii. there is a trend toward minimally invasive cataract surgery technique. Mechanism of action: The cation form of any local anesthetic is the active form of the drug.5% bupivacaine. adjustment of pH increases nerve penetration and decreases onset time.8–6. It reduces orbital volume by causing vasoconstriction.01 to 6. . This alkalization of local anesthetic increases the availability of the noncation form. if punctured. The local anesthetics exist in various ratios of cation to noncation concentration. Epinephrine: Epinephrine in the concentration of 1:1.5% of bupivacaine in a 1:1 ratio dilutes the anesthetic mixture to 1% lidocaine and 0. Mechanism of action: It acts by hydrolyzing C1–C2 bonds between glucosamine and glucuronic acid in ground substance.2 4.00.5% solution of bupivacaine and hyaluronidase without lignocaine improves the efficacy of block in patients undergoing vitreoretinal surgery.5% bupivacaine has to be increased from 5. Hyaluronidase (5 units/ml): It helps in spreading anesthetic solution within the orbit.0. This has led to a similar evolutionary process in anesthesia for cataract surgery.08 ml of sodium bicarbonate has to be mixed in 20 ml vial of 0.000 when added to local anesthetic solution helps in many ways. In addition to advances in different techniques of administration of local anesthetic another concept that has evolved is choice of local anesthetic agent. depending on the pH of the drug. It diminishes bleeding from small vessels. i. Tarun Sharma et al1 showed that bicarbonate buffered 0. But mixing 2% of lidocaine and 0. This noncation form penetrates soft tissues and nerve sheath faster. 1. This leads to reduction in efficacy of both anesthetics. i. Hence. Hence.8–7.6–7. 3.

Optic nerve damage. 2. Prolonged surgery. 5. The local and systemic complication due to retrobulbar and peribulbar anesthesia are well-known (Table 1. Deaf patients. Accidental injection of anesthetic agent in retrobulbar blood vessels.1: Complications of injectional anesthesia 1. Conjunctival and lid hemorrhage. Some surgeons call it “vocal local” and it is in one way a surgical skill that has to be acquired. It can be grossly divided into injectional and topical. and topical anesthetic eyedrop application. it is well-known that cataract surgery anesthesia requires not only analgesia but also akinesia and amaurosis. The most attractive aspect of this topical anesthesia is its simplicity. eyedrop plus intracameral application and gel application come under “topical” anesthesia. Difficult surgery. 2. d. Preoperative surgeon-patient interaction is required which is not necessary for conventional injectional techniques. a. Absolute a b. the most important development in anesthesia for cataract surgery is introduction of topical anesthesia. However.1). Nystagmus Allergy to topical anesthetic eyedrops. Table 1. 3. Uncooperative patients. peribulbar. While converting to this technique certain modifications during surgery are required: a. The newer sub-Tenon’s technique provide akinesia and amaurosis. Language barrier between surgeon and patient.Evidence-based approach in cataract surgery 2 TOPICAL ANESTHESIA In the past decade. sponge anesthesia. c. Cataract surgery is routinely done under local anesthesia. Relative . Table 1. There is no evidence in the literature that these are essential for safe cataract surgery in a cooperative patient (Table 1.2). It is now accepted that clear corneal phacoemulsification can be done under topical anesthesia. Retrobulbar. 4 Globe perforation. b. Retrobulbar hemorrhage. sub-Tenon’s and sub-conjunctival injections of local anesthetic agent come under “injectional” anesthesia. e.2: Contraindications to topical anesthesia 1.

Newer anesthesia modalities for cataract surgery


b. The brightness of the operating microscope light has to kept low. It is kept at the lowest level throughout the surgery. This will prevent retinal bleaching and will allow rapid vision recovery.3 Advantages of Topical Anesthesia* 1. Avoidance of severe complication, though rare, that may occur due to injectional anesthesia, i.e. globe perforation, retrobulbar hemorrhage, optic nerve damage, intravascular injection of anesthetic agent. 2. Popularly called “no needle, no patch” technique will allow patients to return home the same day with better vision. Topical Eyedrop Anesthesia Alone The recommended dose is three drops of lidocaine 4% (unpreserved) instilled every 5 minute starting 15 minutes before surgery. Bupivacaine hydrochloride 0.75% can also be used similarly.4 Johnston et al5 compared topical with peribulbar anesthesia for clear corneal phacoemulsification. Pain during surgery was slightly more in topical anesthesia group but it was not statistically significant. None of the patients in both the groups required supplemental anesthesia or sedation. Topically applied anesthetics block the trigeminal nerve endings in the cornea and to a lesser extent, the conjunctiva. The analgesic effect on the iris and ciliary body is very minimal or none and it depends on penetration of anesthetic agent in the anterior chamber. It is documented in literature that patients may subjectively feel pain during surgery which involve iris manipulation and globe expansion.6 This led to the concept of topical plus intracameral anesthesia. Topical Plus Intracameral Anesthesia* The recommended dosage is 0.5 ml of non-preserved lidocaine 1 % given intracamerally at the start of surgery. Also, 0.5 ml of bupivacaine hydrochloride 0.5% can be used similarly. Safety of intracameral injection of preservative-free lidocaine 1% or bupivacaine 0.5%. 1. Effect on corneal endothelium: There is no difference in the endothelial cell count and morphology noted after 3 months of surgery.6 This may be due to washout effect caused by irrigation during phacoemulsification. This limits the exposure of endothelium to intracameral anesthetics.8
* Fichman first presented his paper on topical anesthesia in American Society of Cataract and Refractive Surgery (ASCRS) meeting in April 1992 that the ventured back in time to revisit the old topical anesthesia approach7

Evidence-based approach in cataract surgery


2. Retinal toxicity in case of posterior capsular tear: Liang et al9 showed that posterior movement of intraocularly injected anesthetics in moderate amounts do not cause long-term adverse effects on retina. Advantages over topical anesthesia alone: Pain during phacoemulsification with topical anesthesia alone may be perceived in two circumstances: i. Deepening of the anterior chamber causes posterior displacement of the iris lens diaphragm may be perceived as pain.
* Gills first augmented the depth of local anesthesia with intracameral lidocaine injection10

ii. IOL implantation and associated zonular stretching may be perceived as pain. Intracameral lidocaine causes direct anesthetic effect on the iris ciliary body zonular complex. Carino et al6 demonstrated that topical anesthesia with intracameral lidocaine is more effective than topical anesthesia alone. Lidocaine Gel 2% Advantages: i. It provides sustained release of anesthetic hence gives prolonged anesthetic effect. ii. Single application of gel is enough instead of multiple topical anesthetic drops. iii. Risk of systemic side effects is less since it is poorly absorbed from ocular mucosa. iv. Anesthetic effect is comparable to topical plus intracameral lidocaine with double application of gel.11 There is no effect on endothelial cell count and morphology.12 Sub-Tenon’s (Parabulbar) Anesthesia Since Tenon’s capsule is an anterior extension of dura, it provides access to the retrobulbar space. Procedure: A dissection is made in conjunctiva and Tenon’s capsule down to bare sclera. A blunt curved, metal cannula is used to inject local anesthetic. A few ml of local anesthetic is forced to dissect posteriorly to get the required anesthetic effect. Onset of action: The anesthesia is of rapid onset and it takes few minutes for the globe akinesia to occur.13 Advantages over peribulbar anesthesia: i. The chances of globe perforation, retrobulbar hemorrhage, optic nerve damage are almost nil because of the blunt cannula which is used. ii. Re-injection of local anesthetics is possible, if surgery time is prolonged as required in vitreoretinal surgeries.

Newer anesthesia modalities for cataract surgery


1. Sharma T, Gopal L et al: pH adjusted periocular anesthesia for primary vitreoretinal surgery. Indian J Ophthalmol 1999, 47:223–227. 2. Khurana AK: Peribulbar anesthesia for ocular surgery. In Gupta AK (Ed): Current Topics in Ophthalmology-IV New Delhi: B-I Churchill Livingstone Pvt Ltd. 1995. 3. Claoue C: Simplicity and complexity in topical anesthesia for cataract surgery. J Cataract Refract Surg 1998, 24:1546–1547. 4. Risto J Uusitalo, Eeva-Liisa Maunuksela et al: Converting to topical anesthesia in cataract surgery. J Cataract Refract Surg 1999, 25:432–440. 5. Johnston RL, Whitefield LA, Giralt J, Harrun S, Akerele T, Bryan SJ, et al: Topical versus peribulbar anesthesia, without sedation, for clear corneal phacoemulsification. J Cataract Refract Surg 1998, 24:407–410. 6. Carino NS, Slomovic AR, Chung F, Marcovich AL: Topical tetracaine versus topical tetracaine plus intracameral lidocaine for cataract surgery. J Cataract Refract Surg 1998, 24:1602–1608. 7. Fichman RA: Use of topical anesthesia alone in cataract surgery. J Cataract Refract Surg 1996, 22:612. 8. Anderson NJ, Woods WD, Kim T, Rudnick DE, Edelhauser HF: Intracameral anesthesia in vitro iris and corneal uptake and washout of 1% lidocaine hydrochloride. Arch Ophthalmol 1999, 117:225–232. 9. Liang C, Peyman GA, Sun G: Toxicity of intraocular lidocaine and bupivacaine. Am J Ophthalmol 1998, 125:195–196. 10. Gills JP, Cherchio M et al: Unpreserved lidocaine to control discomfort during cataract surgery using topical anesthesia. J Cataract Refract Surg 1997, 23:545–550. 11. Koch PS: Efficacy of lidocaine 2% jelly as a topical agent in cataract surgery. J Cataract Refract Surg 1999, 25:632–634. 12. Barequet IS, Soriano ES, Green WR, O’Brien TP: Provision of anesthesia with single application of lidocaine 2% gel. J Cataract Refract Surg 1999, 25:626–631. 13. Alan S Cradall: Anesthesia modalities for cataract surgery. Curr Opin Ophthalmol 2001, 12:9– 11.

This has led to the concept of incisional funnel. Low risk of postoperative leakage. Avoid suture-related complications. 3. Minimal surgical trauma. Minimal postoperative surgically-induced astigmatism. Management of pre-existing astigmatism is possible by cataract surgery alone. 6.1: Advantages of small incision 1. 9. More stability of anterior chamber. Clear corneal incision.0 mm in intracapsular cataract surgery to 10. 2.0 mm or smaller. 4. 7. The size of wound has progressively decreased from 12.25 mm with the advent of phacoemulsification. Theoretically low risk of endophthalmitis. TYPES OF INCISION The two main types of incision according to anatomic location are as follows: 1. 2.Chapter 2 Newer Incision Techniques in Cataract Surgery There has been progressive decrease in size of the cataract incision along with newer cataract surgical techniques.5 mm in early extracapsular surgery to 5. Scleral tunnel incision. Table 2. Controlled capsulorhexis and hydrodissection. 8. Foldable IOLs has further reduced the size of incision to 3. Healing is rapid hence short postoperative rehabilitation period. Incisional . Advantages of small size of incision are given in Table 2.1. Scleral Tunnel Incision Concept of Incisional Funnel Surgically induced astigmatism is inversely proportional to the distance of the incision constructed from the limbus. 5.

2: Curvilinear incision fall out of funnel .1: Incisional funnel Incision constructed within this imaginary funnel are astigmatically neutral. (b) straight. 2.Newer incision techniques in cataract surgery 7 funnel is made up of two imaginary curved lines which represent the relationship between induced astigmatism and length of incision. 2. 2. The boundaries of curvilinear incision fall out of funnel. giving rise to an unstable wound and greater astigmatism (Fig. 2. This gap is the cause for against the rule of astigmatism. Fig. longer incisions should be made away from the limbus to make it astigmatically neutral. small incisions can be made close to the incision. Scleral tunnel incision can be (a) curvilinear.2). Fig. There is lack of support to prevent the incision edge from falling away from the superior edge. Hence. They diverge and separate as the distance from the limbus increases (Fig. It has highest potential to cause against the rule astigmatism. The two curved lines start from the limbus.1). Curvilinear incision: This incision is constructed along the curve of the limbus. (c) frown.

Frown incision: To make the incision more stable.3: Straight incision falls out of the funnel from the limbus in a curved fashion1 exactly opposite to that of curvilinear incision. the two terminal points of incision are secured within the sclera.Evidence-based approach in cataract surgery 8 Straight incision: In this incision. The chances of sagging of inferior edge of the incision from the superior edge are further minimized. the wound is more stable and induces less astigmatism (Fig. Hence.3). 2.4: Frown incision lie entirely within the astigmatic funnel . the ends of the incision are placed further superiorly in the sclera. The straight incision constructed at the same distance as curvilinear incision falls out of the funnel. but not as much as the curvilinear incision. the chances of sagging of inferior edge of the incision are minimized. The ends of the incision are swept superiorly away Fig. 2. 2. The frown incision at the same distance as straight incision lie entirely within the astigmatic funnel hence induces minimal postoperative astigmatism (Fig.4). 2. Hence. Fig.

External configuration: It is constructed 0. 2.5 to 1.5: Chevron incision Internal Configuration of Scleral Tunnel Incision Koch’s basic incision (Fig. from conventional curvilinear incision to self-sealing incision. 2.6): i. 2. . ii.5) devised by Sam Pallin2 is similar to that of frown incision except that it consists of two straight cuts rather than single curved cut. This incision can be performed in transition phase of surgeon.0 mm from the cornea. Internal configuration: The groove is dissected upto the limbus and only a small distance into the cornea before entering the anterior chamber.6: Koch’s incision Advantages: i. 2. Fig.Newer incision techniques in cataract surgery 9 Chevron incision (Fig. Fig.

Advantages: i. Internal configuration: Scleral tunnel dissected from the groove toward the anterior chamber. External configuration: A vertical groove is made about 2 mm behind the blue zone of the limbus. Kratz’s scleral pocket incision (Fig. The anterior chamber is entered with a keratome according to the width of the phaco tip. ii. The anterior chamber is then entered with a keratome in a vertical fashion.7): i. This dissection is carried further into the cornea about 1 mm.8): i. making the third step of the incision. 2. 2. More secure wound as compared to Koch’s basic incision ii.7: Kratz’s incision Three-step corneal valve incision (Fig. This third step acts as a valve (corneal).8: Three-step scleral tunnel incision . Less surgical induced astigmatism Fig. Postoperatively as the intraocular pressure builds up. Limitations: The scleral pocket makes easy maneuverability of instruments difficult. 2. 2.Evidence-based approach in cataract surgery 10 ii. it gives easy maneuverability of instruments during surgery.3 Fig. ii. External configuration: The incision is similar to Kratz’s scleral pocket incision. Being relatively anteriorly situated. the sealing effect of the wound increases. Internal configuration: About half thickness scleral tunnel dissected from the groove toward the anterior chamber.

6 Location of Clear Corneal Incision and Induced Astigmatism Surgically induced astigmatism is highest after superior followed by superolateral and lowest after a temporal 3. Site of incision: At surgical limbus.8 Hence. Clear corneal incision of 5. a larger clear corneal incision induces greater flattening effect.0 mm scleral tunnel incision.0 mm temporal clear corneal incision induces approx 0.0 mm.0 D can be managed by taking clear corneal incision on the steepest meridian to benefit from its flattening effect. corneal tunnel is constructed approximately 1.0 mm temporal clear corneal incision* and approximately 1. Opposite clear corneal incision has been suggested when preexisting astigmatism is more than 2.0 mm superolateral clear corneal incision by 3 months. 2.0 mm clear corneal incision induces same amount of astigmatism as with 3.0 mm in length. * Fine IH in February 1992 first described a new concept of a planar temporal clear corneal sutureless incision for phacoemulsification . More corneal flattening in superior and superolateral incisions as compared to temporal might be due to stroking of the upper eyelid in the superior and superolateral clear corneal incision. There is no effect on the nasal-corneal curvature. Internal configuration: A 200 µm deep precut made.84 D of flattening with the rule of astigmatism by one year.7 Clear Corneal Incision and Management of Pre-existing Astigmatism A 3.9). 4. Instrumentation: Diamond blade which has four depth settings and a sharp side cut. Corneal flattening of approx 0.7 This astigmatism do not extend upto the center of cornea.5 3.Newer incision techniques in cataract surgery 11 Clear Corneal Incision 1. 2.0 mm induces more surgically-induced astigmatism as compared to scleral frown incision of 5.9 Hence pre-existing astigmatism upto 1. A 5.7 D occurs in 3.53 D to 0.2 D in 3.0 mm clear corneal incision. Length of incision: Usually 3.7 to 2.0 mm in length.2 mm temporal clear corneal incision can induce 0.0 D (Fig.4 But 3.70 D of temporal flattening.

J Cataract Refract Surg 1998. 1995. 2. Gupta AK: Wound construction and closure in modern cataract surgery. Singer JA: Frown incision for minimizing induced astigmatism after small incision cataract surgery with rigid optic intraocular lens implantation. 17(Suppl):677–688. Huang FC. i. Its probably due to bacterial invasion through a temporal corneal incision may be easier than through a superior corneoscleral incision. J Cataract Refract Surg 1991. New Delhi: BI Churchill Livingstone Pvt Ltd. 24:477–481. by phaco tip and IOL implantation. Scleral tunnel incision being posteriorly placed as compared to clear corneal incision.e. 2. clear corneal incision taken at the steepest meridian and similar incision made exactly opposite to the first to enhance flattening effect. J Cataract Refract Surg 1991. In Gupta A K (Ed): Current Topics in Ophthalmology-IV. 17(Suppl):706–709. there is less direct trauma to endothelium.9: Opposite clear corneal incision In this. 3. Tseng SH: Comparison of surgically induced astigmatism after sutureless temporal clear corneal and scleral frown incisions.11 INCISION SITE AND RISK OF POSTOPERATIVE INFECTION Recent literature reported increased risk of postoperative endophthalmitis in temporal clear corneal incision as compared to superior sclerocorneal incision.Evidence-based approach in cataract surgery 12 Fig. Pallin SL: Chevron sutureless closure: A preliminary report. . Grover AK. 4.12 REFERENCES 1.10 INCISION SIZE AND SITE AND CORNEAL ENDOTHELIUM The scleral tunnel incision causes less postoperative endothelial damage as compared to clear corneal incision.

7. Salvetal ML et al: Effect of incision size and site on corneal endothelial changes in cataract surgery. Lever J. . J Cataract Refract Surg 1997. Menapace R et al: Corneal Shape changes after temporal and superotemporal 3. 10. Hayashi H et al: The correlation between incision size and corneal shape changes in sutureless cataract surgery. Hayasaka S et al: Bacterial endophthalmitis after small incision cataract surgery. Effect of incision placement and intraocular lens type. 25:1121–1126. 8. Beltrame G. J Cataract Refract Surg 2000. 28:118–125. Nielsen PJ: Prospective evaluation of surgically induced astigmatism and astigmatic keratotomy effects of various self-sealing small incision. Tsujikawa K et al: Comparative study of intraocular lens implantation through 3. Oshima Y. 102:550–556. Dahan E: Opposite clear corneal incision to correct pre-existing astigmatism in cataract surgery. 23: 347–353. 24:84–88.Newer incision techniques in cataract surgery 13 5. 21:43–48. 9. 26:803–805. J Cataract Refract Surg 2003. J Cataract Refract Surg 1999.0 mm clear corneal incision. 6. J Cataract Refract Surg 2002. 12.0 mm temporal clear corneal and superior scleral tunnel self-sealing incisions. Langerman DW: Architectural design of a self sealing corneal tunnel: Single hinge incision. 11. Nagaki Y. 29:20–26. Ophthalmology 1995. Rainer G. J Cataract Refract Surg 1994. J Cataract Refract Surg 1995. Hayashi K.

To achieve these two goals various modifications in phacoemulsification systems have been done (Table 3. ultrasonically cleaned . b. Heat is produced by frictional forces. In case of diminished flow.1 The irrigation sleeve diameter is larger than the phaconeedle diameter. 1.1). The heat is removed from the eye by fluid flowing through an irrigation sleeve and around the incision that surrounds the phacoemulsification needle. * Dr. Reduction of heat produced due to friction during ultrasound phacoemulsification. a. The recent trend is toward less traumatic cataract surgery and early visual rehabilitation. This has emerged new phacoemulsification technologies for reducing the size of incision and using less phaco energy. The phaco-needle tip is used to emulsify the lens material at frequencies between 25 and 62 KHz. conventional ultrasonic phacoemulsification with an irrigation sleeve has the potential for thermal injury. 2. CONVENTIONAL PHACOEMULSIFICATION Conventional ultrasonic phacoemulsification is created in a phacoemulsification handpiece when an electric current is passed through piezoelectric crystals.Chapter 3 New Phacoemulsification Technologies Since Dr Charles Kelman* has invented phacoemulsification it has undergone plenty of modifications. Sonic phacoemulsification system is a new approach for elimination of heat thus reducing chances of thermal injury. Charles Kelman got an inspiration for inventing phacoemulsification in the dentist’s chair while having his teeth. Modification of ultrasound energy through refinement of power modulation is another route leading to decrease of heat and reduction in incision size (WhiteStar technology). Reduction of power required for cataract extraction. These crystals convert electrical energy to mechanical vibrations at the tip of the phaco-needle. MODERN PHACOEMULSIFICATION SYSTEM Modern phacoemulsification systems has two goals for atraumatic cataract surgery.

1: Newer phacoemulsification system 1. iii. Sonic phacoemulsification system 2. Hard cataract with nuclear sclerosis of grade 3 or more cannot be removed. The introduction of innovative oscillatory tip motion in association with power modulation allows further reduction of phaco power (NeoSonix phacoemulsification system). WhiteStar technology 3.94 µm. Phacoemulsification time is usually longer than the ultrasound phacoemulsification. Decreased chances of thermal injury to the cornea. Laser systems a. Minimal energy required for removal of cataract. Dodick photolysis ii. iii. And only these lasers are commercially available. Instrumentation i. YAG laser phacoemulsification i. The incision size is reduced to 1. . Frequency: It is available in variable frequency from 10 to 100 Hz. Neodymium. The megatron has a peristaltic pump with Venturi-like effect. which falls in infrared spectrum.0 mm. Advantages Over Ultrasound Phacoemulsification i. d. Table 3. ii. NeoSonix phacoemulsification system 4. Limitations i. Photon laser phacolysis Erbium: YAG Laser System Laser phacoemulsification is one of the emerging technology for removal of cataract. Erbium: YAG laser (Phacolase) and Neodymium: YAG laser such as Photon phacolysis and Dodick photolysis offers new approach for eliminating thermal energy and decreasing power during phacoemulsification. Erbium: YAG laser system b. These two laser systems are being clinically investigated and clinical trials are underway. iv. Erbium: YAG laser: It has produces a wavelength of 2.New phacoemulsification technologies 15 c. ii. The phacolase Er: YAG laser: It has variable pulse energy from 5 to 50 mJ. Irrigation/aspiration (I/A) pump: The phacolase system is coupled to a Megatron I/A pump. ii.

3. The shock waves here come in contact with the . Mechanism of Action Cavitation bubble formation: Cavitation is the formation of vacuoles in a liquid by a swiftly moving solid body. No heat is produced at the laser tip. 3. The laser beam travels across the first bubble and forms a second bubble in line with the first. Neodymium: YAG Laser Phacoemulsification Dodick Photolysis Photolysis is a Q-switched Nd: YAG laser introduced first by Dodick in 1991. On this titanium surface there is optical breakdown and plasma formation.1). The collapse of the vacuoles releases energy that vaporizes and crushes lens material (Fig. But. Similarly if the third bubble is formed. Mechanism of action: Pulsed Nd: YAG laser of energy transmitted through quartz fiber strikes a titanium target. This optical breakdown produces shock waves which move toward the distal end of the probe which is open.2 ii. Foot pedal if pushed down gives control of vacuum linearly.0 mm. These cavitation bubbles form and collapse instantaneously. the collapse of the bubbles occurs more slowly in the nucleus. Advantages: i. Silicone sleeve for cooling is not required as no heat is produced thus cataract extraction is possible through 1. Handpiece: The phacolase handpiece contains laser fiber inside the aspiration port.25 mm incision. An emulsate is created which is aspirated from eye. effective range of the laser is increased to 3. Footswitch: The footswitch is bidirectional which separates irrigation and aspiration from laser energy.Evidence-based approach in cataract surgery 16 v. Fig.1: Cavitation buble formation due to vacuum from phacoemulsification needle backstroke Direct concussive effect: Direct concussive effects of laser energy propagation wave causes disruption of lens material. vi. Foot pedal if moved laterally increases the repetition rate in linear fashion. Instrumentation: 1064 nm Nd: YAG laser system.

2). 3.5 mm). This prevents the laser beam from damaging non-target tissues (Fig. i. Groove and crack technique with the laser. 3. The nuclear fragments which occur are removed from the eye by aspiration and irrigation. The shock waves disrupt the lens material at the distal end of the probe and fragmented material is aspirated out.4 .2: Mechanism of nucleus removal by Dodick photolysis Surgical technique i. Sculpting in a bimanual fashion then cracking the nucleus methods are described. ii.e. delivered through a special tip of the probe.8 mm. The nuclear material is aspirated into this zone (2.3). Fig. Laser energy travels along an optical fiber and also across an open area called photofragmentation zone. fragmentation.3 Plasma formation and these shock wave generation produce photolysis of lens material (Fig. its diameter being 1. Photon Laser Phacolysis Instrumentation: 1064 nm Nd: YAG laser. The tip has three functions. 3.New phacoemulsification technologies 17 lens material. The distal end of the tip is bent upward to provide backstop of the laser energy. aspiration and irrigation.

Advantage of NeoSonix Handpiece The lower frequency. Instrumentation In the NeoSonix mode. The sonic tip moves back and forth without changing its dimentional length as against ultrasonic tip motion.Evidence-based approach in cataract surgery 18 Fig. The NeoSonix thus permits non-thermal cataract extraction when used alone and with reduced energy when used in conjunction with ultrasonic energy. the phaco tip has a variable rotational oscillation upto 2 degrees at 120 Hz. 3. The operating frequency is in the range of 40 to 400 Hz. there is no heat generation and no generation of cavitational energy. The modes can be used alternately or simultaneously with varying percentages of sonic and ultrasonic energy. Hence. as in sonic phacoemulsification does not produce significant thermal energy and thus minimizes the risk of thermal injury. . NeoSonix Phacoemulsification NeoSonix technology consists of dual mode comprising of low frequency oscillatory movement that may be used alone or in combination with conventional high frequency ultrasonic phacoemulsification.3: Mechanism of nucleus fragmentation using photon laser photolysis Sonic Phacoemulsification Sonic technology uses sonic rather than ultrasonic technology for removing cataract. The same handpiece and tip can be used for both sonic and ultrasonic modes.

concept of separating irrigation from aspiration came forward and removing the cataract through two stab incisions. irrigation through the same tip helps to keep the temperature down of the phaco tip. In conventional phacoemulsification. This can be done by setting the lower limit of NeoSonix to 0% phacopower. It was then evaluated length of downtime (ultrasound off) that can be kept in relation to on time (ultrasound on) without loosing its efficiency.4). When straight tip is used. iii. WhiteStar Technology Recent advances in phacoemulsification are mainly toward decreasing the incision size for removal of cataract. 3. it acts like an apple cores to impale the nucleus. Experiments were conducted in rabbits. The low frequency mode may be used to burrow the tip into the nucleus for stabilization before chopping. And it was apparent that ultrasound pulses could be very short as to produce effective phacoemulsification of the nucleus. . ii. For this.New phacoemulsification technologies 19 Use of NeoSonix Handpiece During Surgery i.5 Evolution of WhiteStar Technology It was assessed if the ultrasound is turned on and off in millisecond (ms) and possibly even submillisecond ranges. It was found that down-time could go to double the on time with minimal and often no sense of loss of efficiency (Fig. Softer grades of nuclear sclerosis may be completely removed by low frequency modality and denser grades of cataracts may be removed by additional use of ultrasound mode. NeoSonix handpiece may be used in conjunction with ultrasound at 10 or 20% power level. whether it will of any practical benefit for removing that cataract. WhiteStar micropulse technology is a software modification that allows extremely short bursts of ultrasound energy. Thus decreases heat build-up with the retained efficiency of continuous ultrasound. thus preventing wound burn.

With conventional ultrasound. can minimize this decrease and more efficiently use cavitational energy than contineous ultrasound.Evidence-based approach in cataract surgery 20 Fig. the aspirational flow brings the particle back to the ultrasound tip where contact again occurs which is necessary for removal of nuclear fragment. Cavitation is the formation of vacuoles in a liquid by a swiftly moving solid body such as the ultrasound tip. During the down-time in WhiteStar. Followability is certainly related to a decrease of microchatter. has been reported. We know that “contact” is critical in the removal of nuclear fragments. with the off time allowing aspirational forces to more efficiently hold the particles in place for eventual emulsification. 3. . in which ultrasound energy along with irrigation flow pushes a nuclear fragment away from the tip. The collapse of the vacuoles releases energy that vaporizes and crushes lens material. and also creates cavitational energy. Jackhammer effect and cavitational energy: Ultrasound creates a mechanical Jackhammer effect from the oscillation of the tip. the more evident the chatter. but turning off so fast. cavitational energy is greatest when the ultrasound is first turned on and drops after a few milliseconds of utilization due to air dispersal and depletion from water (the sourse of cavitation).4: Phacoemulsification using WhiteStar technology showing phacoemulsification tip without irrigation sleeve and irrigating chopper through side port Advantages Chatter and microchatter: Chatter is a phenomenon. WhiteStar ultrapulse technology. The harder the nuclear fragment. Fragment followability: Increased followability wherein nuclear fragments stay with the emulsification tip and dont bounce off. Cavitational effect is more important of the two in emulsifying nucleus fragments. Pulsing technology in WhiteStar helps to eliminate chatter.

6 This pushes more fluid into the eye through irrigating chopper and prevents surge. Agrawal A. Possible implications for Nd: YAG laser phacolysis of the cataractous human lens. one can have same efficiency with one-half to one-third the energy utilization in comparison with cavitational energy. Radall J Otson. Adequate cooling of the vibrating tip and b. i. 5. Absence of thermal energy obviates the need for an irrigation sleeve on the phaco tip.New phacoemulsification technologies 21 Thus extremely short bursts of ultrasound energy leads to decrease in chatter and microchatter. Grabner G: Dodick Laser phacolysis: Thermal effects. surge. Patel N: Antichamber Collapser. placed through the side port. J Cataract Refract Surg 1999. • Irrigating chopper: It has dual function. Curr Opin Ophthalmol 2003.e. A Y-shaped infusion (transurethral resection commercially available) is used to connect these 2 bottles to the irrigating chopper. REFERENCES 1. Surendra Basti: Laser-assisted cataract surgery and other emerging technologies for cataract removal. 25:800–803. 14(1):31–34. . Murali K Aasuri. 17:794–797. • Assistant has to continuously pour cooled balanced salt solution over the phaconeedle. Rajiv Kumar: WhiteStar technology. J Cataract Refract Surg 2002.2 Various modifications are made for the following: a. • Pump with micropore air filter is used to push sterile air in the bottle. Katerina Kurteeva et al: Advantec Legacy system and the NeoSonix handpiece. anterior chamber maintainer and chopper. Indian J Ophthalmol 1999. i. 2. 6.e. permitting a reduction in incision size and allowing irrigation through a second instrument. • Two BSS bottles instead of one is suggested to improve irration inside the anterior chamber. To prevent destabilization of the anterior chamber. A constant irrigation fluid is required for sufficient cooling of the phaco-needle.9 mm incision. Phaconit The main difference from conventional phacoemulsification is that phaco tip is used without the infusion sleeve and separating the irrigation. increased fragment followability with improved cavitational energy. Lal V. The function of sleeve is to prevent thermal burns by insulating and continuously irrigating the vibrating tip and reducing the temperature rise from ultrasonic vibration. J Cataract Refract Surg 1991. Alzner E. • Antichamber collapser is used which injects air into the infusion bottle. 3. 47:215–222. Sandra J Sofinski. Dodick JM. 28:1085–1086. Christiansen J: Experimental studies on the development and propagation of shock waves created by the interaction of short Nd: YAG laser pulses with a titanium target. Hence. Agrawal S. Curr Opin Ophthalmol 2003. 14:20–23. This allows removal of cataract through 0. 4. Howard V Gimbel. Agrawal A.


first successful penetrating keratoplasty on a leper. b. Multifocal ii.1 Sir Harold Ridley*. Better refractive correction postoperatively. refractive index and tensile strength. The IOL which Ridley implanted was of polymethyl-methacrylate (PMMA). Hydrophilic ii. Single piece plate type i. Spherical Three-piece i. Acrylic IOL (Foldable) a. used for presentations in seminars and congresses today39 .1: Various intraocular lens materials 1. in 1949. Various intraocular lens materials have evolved in this process with varying water content. first to televise eye operations and take fundus photograph. Silicone IOL (Foldable) a. very few of us know he did pioneering work in other fields of ophthalmology like definitive characterization of onchocerciasis.1). Polymethyl-methacrylate is still considered the standard with which other materials are compared (Table 4. Table 4. first introduced an intraocular lens. Toric * Sir Nicholas Harold Ridley besides inventing an IOL. Polymethyl methacrylate (PMMA) IOL 2. b. Minimal incidence of posterior capsular opacification. Smaller incision size. Similarly intraocular lens design has undergone changes to restrict lens epithelial cell migration and reflection of internal and external light. c.Chapter 4 Recent Advances in Intraocular Lens Material and Design Intraocular lens material and design is constantly evolving and improving as also occurring with modern cataract surgery. Hydrophobic b. did ground work on power point presentation. Improvements in intraocular lens material and design are aimed at the following: a. Monofocal 3.

11 . non-adherent to tissue and stable at a variable range of temperatures. Limitations i. which has an angle of water contact of 73. Water content of <1% 2. Advantages Decreased cell adhesion: Silicon’s angle of water contact is 99° which makes it more hydrophobic when compared to hydrophobic acrylic.8 It is known that hydrophobicity may decrease host cell responses.5–7 Silicone IOL Silicone intraocular lenses are made of polymers of silicone and oxygen. The most common silicone in IOLs are elastomers baged on the dimethylsiloxane backbone. Inert. which is higher than silicone but less than some acrylic copolymers. Higher incidence of posterior capsular opicification than hydrophobic acrylic and some silicone IOLS. Limitations Biocompatibility of PMMA is already proven but with few limitations: i. Intraocular lenses made of PMMA are rigid hence cannot be implanted through small (3. ii. Incidence of posterior capsular opacification—with first generation silicone IOLs. Hence these lenses have thinner optics. 3.10.2–4 However.2 mm) incision.Evidence-based approach in cataract surgery 24 INTRAOCULAR LENS MATERIALS Polymethyl-Methacrylate (PMMA) Intraocular lens made of PMMA has following characteristics: 1. the incidence of PCO is more than foldable hydrophobic acrylic IOLs and is found to be equal to that of PMMA.9 Newer generations of silicone: They have a higher refractive index of 1.41 to 1-46. Second generation silicone IOLs have been found to be equal to hydrophobic acrylic IOLS with truncated edges. durable and resistant to changes caused by aging. These IOLs are relatively inert. light weight. It is found that giant cell deposition on silicone IOLs is comparable to hydrophobic foldable acrylic IOLs. for the development of PCO. resulting in smaller wound size.49. lens design is considered an important factor for development of PCO than the lens material. Refractive index of 1.

Being slippery. 4. it is difficult to manipulate.16. Limitations: i. The large contact area with the anterior capsule makes these lenses more susceptible to contraction and fibrosis of the anterior capsule and formation of anterior capsule opacification.Recent advances in intraocular lens material and design 25 ii. Not suitable for patients with vitreoretinal disease needing silicone oil implantation.14 Designs There are various designs of silicone IOLs i.12.2 mm) as against PMMA IOL. Because there is tendency for adherence of silicone oil to the silicone IOL. .13 iii.17 Fig. especially if wet.2).1) Advantages: It can be inserted through a small incision (3. Postoperative toric IOL rotation of 30° off axis still shows astigmatism reducing effect. 4.18 Plate haptic IOL design does not induce a specific deviation of rotation (clock wise or anticlockwise) (Fig. iv. Three-piece (monofocal and multifocal) Single Piece Plate Type (Fig. During insertion in the bag it unfolds rapidly. Single piece plate type (spherical and toric) ii.1: Single piece plate type silicone IOL Toric Single Piece Plate Type Silicone IOL The major requirements for a toric IOL are rotational stability and contraction which is provided by this IOL. These IOLs have tendency to dislocate posteriorly after Nd: YAG capsulotomy.15 ii. 4. Silicone IOLs show a lower threshold for YAG laser damage as compared to hydrophobic acrylic IOL. which can lead to uncontrolled insertion and intraocular damage.

Evidence-based approach in cataract surgery 26 Fig. The squared edge is known to create capsular bend which prohibits migration of lens epithelial cells and thus PCO. iii. Eyes with high axial myopia. cylindrical axis is marked on the corneal limbus with the aid of a Mendez gauge. The stepheight is in the range of the wavelength of light (Fig. Implantation axis: More rotation of IOL is seen when the axis of IOL implantation is vertical. Staar SRK/T toric version 1.2: Single piece plate type toric IOL Factors affecting IOL rotation: i. Before making incision. A multifocal IOL provides clear vision both for distance and for near without wearing bifocal spectacle lenses. 4.20 Multifocal IOL A pseudophakic patient usually needs spectacle bifocal lenses postoperatively to achieve best visual acuity for distance and near. ii.19 Three-piece Monofocal Silicone IOL Silicone IOL with squared off and truncated lens edge prevents PCO formation comparable with that of hydrophobic acrylic IOL. 4.18 Preoperative and intraoperative modifications for implanting toric single piece plate type silicone IOL: i. Large capsular bag diameter.0 software is used for calculating IOL power. Defractive multifocal IOL: Approximately 25 concentric annular zones are cut on the posterior surface of a conventional IOL with microscopic steps between coterminous annuli. ii.3). .

Hence. both distance and near vision correction is possible postoperatively. these IOLs have evolved. intermediate and near foci. both distance and near objects are simultaneously in focus.22 The optic of the lens is of silicone which is 6. the lens can be inserted through clear corneal or scleral tunnel incision that is 2. .8 mm wide. the higher the add. Refractive multifocal IOL: To overcome the problems of glare and halos due to defractive IOLs.23 In conclusion. Thus. The lens has an aspherical component and thus each zone repeats the entire refractive sequence corresponding to distance.21 There is no loss of light through defraction and hence no degradation of image quality as a result of surface discontinuities.0 mm.0 mm in diameters. Decreased contrast sensitivity and haloes at sight may be disturbing to patients with multifocal IOLS. Zones 1.3: Annular concentric zones cut on posterior surface of IOL optic The spacing of the rings and the step-profile of these lenses determine the near add.Recent advances in intraocular lens material and design 27 Fig.4a and b).24–26 Defractive multifocal IOLs cause more decrease in contrast sensitivity and haloes as compared to newer refractive multifocal IOLs (Figs 4. whereas zones 2 and 4 are for near. decreasing the need for spectacles. This IOL is a zonal progressive IOL with five concentric zones on the anterior surface. these lenses may result in excessive glare and halos. Hence. Refractive multifocal IOL such as Array. The haptics are made of polymethyl-methacrylate and its diameter is 13. The AMO Array foldable silicone multifocal IOL is the single refractive multifocal IOL commercially available. 3 and 5 are for distance. 4. is superior to defractive multifocal IOLs by giving better contrast sensitivity and less glare. with the defractive IOL. These are very difficult to tolerate more so if the IOL is decentered. The closer the rings on the IOL.

This sharp. iv.12. They have refractive index of 1.Evidence-based approach in cataract surgery 28 Figs 4. The softer nature of this acrylic copolymer makes it fragile and more susceptible to cracks. Comparison with Silicone IOL i. In patients who had underwent vitreoretinal surgery with silicone oil implantation the acrylic lenses have less problems with adherence with the silicone oil than silicone IOLs. which make them flexible. truncated edge creates a capsular bend.49).13 v.4a and b: Multifocal IOLs. preventing migration of lens epithelial cells to form PCO (Figs 4. ii.41 to 1. The acrylic copolymers allow for a slower unfolding action hence provides a more controlled insertion and manipulation as against silicone IOLs. Hydrophobic acrylic IOLs have bean shown to have the least amount of damage from the Nd: YAG laser as against silicone IOL. iii.6 .14 Newer acrylic IOLs have a squared off edge profile. Hence these lenses are thinner.5a and b).55 which is higher than silicone (1.44 to 1.46) and PMMA (1. because of their lack of elasticity and increased stiffness. dents and scratches. (a) Defractive IOL. (b) Refractive array multifocal IOL Hydrophobic Foldable Acrylic IOL Hydrophobic acrylic lenses are made of copolymers of acrylate and methacrylate. they require larger wounds than similar silicone IOLs. Hydrophobic acrylic IOLs.

28 Newer designs with a frosted edge or rounded anterior edge may diminish these unwanted images. squared off edge These squared off edges. These IOLs have varying water content. truncated. because of their soft flexible surface. Hydrophilic Acrylic IOL Hydrophilic acrylic IOLs are composed of a mixture of a hydroxyethyl methacrylate (poly-HEMA) backbone and a hydrophilic acrylic monomer. patients report a higher rate of glare. (b) Hydrophobic acrylic IOL with sharp.30 2.Recent advances in intraocular lens material and design 29 Figs 4. These granules are distributed in a line parallel to the anterior and posterior curvatures of the optic.5a and b: (a) IOL with rounded edge. 1.27. however allow for reflection of light internally and thus. These IOLs show little or no surface alterations or damage from folding with insertion. Jehan FS et al31 reported delayed onset.14 Types Hydrophilic acrylic lenses can be of several types depending on its water content.13 These IOLs have low surface energy and in patients requiring vitreoretinal surgery. sterile. with a clear zone beneath the optic . Hydroview lenses: Werner L et al reported vision threatening granular deposits of variable sizes within this lens optics. they have a low incidence of epitheloid and giant cells deposition. Most patients with TASS improved with intensive topical steroids. If a Nd: YAG capsulotomy is needed these lenses have high threshold for Nd: YAG laser damage. Residual polishing compound on IOL is considered the underlying cause. acute. These patients present postoperatively with unexplained inflammation in the anterior segment. visual aberrations and pseudophakic dysphotopsia. Memory lens: It is a poly-HEMA acrylic mixture with a moderate water content and polypropylene loops. toxic anterior segment syndrome (TASS) with these memory lens. and are soft and have excellent relatively hydrophilic lens surface.29 In terms of the host foreign body response. these IOLs have minimal adherence to silicone oil.

38 Another example of pediatric IOL is a palmlens.0 mm in overall diameter because ciliary sulcus rarely exceeds 11. Oversized and malpositioned IOL can cause damage to intraocular structures. ii. The mechanism of this calcification is still unclear.33 It is found in one study that metal implantation forces can damage the heparin surface coating over IOL surface.Evidence-based approach in cataract surgery 30 surface.e.5 mm in diameter. It is found that heparin surface modified PMMA IOLs show reduced adhesion of inflammatory cells in these cases. There is increased deposition of inflammatory cells seen where the heparin surface coating is accidentally removed by forceps. made of 34% water content HEMA. and optic diameter is 5. Foldable hydrophilic material is found to be more biocompatible than PMMA and silicone. The flanges . this long safety record should not be ignored until similar follow-up is done with other biomaterials.75 mm (Fig. Its overall diameter is 10.75 mm.6a).6b).37 An example of PMMA pediatric IOL is kidlens (IOL Technologies. 4. These modified IOLs have better biocompatibility than PMMA lenses.32 Heparin Surface Modified PMMA IOLs The surface of the PMMA is modified with heparin. Size of implantation whether in the bag or ciliary sulcus. France). Factors Deciding the Size of IOL i.34 INTRAOCULAR LENS IMPLANTATION IN CHILDREN Ideal IOL Material Polymethyl-methacrylate (PMMA) has been in use since 50 years now. Pediatric IOLs should be in diameters of 10. This can be prevented by using a forceps with silicone sleeves covering the tips.36.5 mm. X-ray spectroscopy revealed presence of calcium within these deposits.75 mm. i. 4. diabetes and traumatic cataract.5 mm (Fig. The haptics are encircling and contain eyelet holes. Age at the time of IOL implantation. 11 mm and 12 mm.33 More inflammatory reaction is expected in patients undergoing cataract surgery with uveitis. Pediatric IOLs should not exceed 12.35 Ideal IOL Size It is not true that large sized IOL is more stable. while insertion. Its overall diameter is 10. the next biomaterial which is suitable for pediatric IOLs is hydrophilic acrylic. hydroxy ethylmethacrylate (HEMA) and its derivatives. and optic diameter is 5. due to breakdown of blood aqueous barriers. It is found to reduce inflammatory cell adhesion to the IOL surface. Hence. Corneal diameter iii.

Recent advances in intraocular lens material and design 31 of the lens are structured like the webs of aquatic birds feet or fish fins. REFERENCES 1.75 mm. Richard S Haffman. the lens fills the entire capsule it may prevent the migration of lens epithelial cells and thus prevents PCO. Howard Fine Mark Packer: Refractive lens exchange with a multifocal intraocular lens. . (b) Palmlens.75 mm Future Intraocular Lens Thermodynamic injectable IOL (Smartlens Medennium): It is reducible at room temperature to a rod 2.0 to 3. no edge glare or spherical aberration.5 mm with an average thickness of 2.6a and b: (a) Kidlens. 13:24–29. single piece PMMA posterior chamber IOL of overall diameter 10. This means that small changes in the central thickness will result in large changes in accommodative amplitude. Since. Curr Opin Ophthalmol 2003.0 mm in diameter which can be inserted through a microincision.0 mm. Once inside the eye. Figs 4. These membranes can absorbs the eventual capsular bag contraction without causing lens valuating. It is impossible to decenter. it will unfold to a diameter of 9. This lens is easily exchangeable because HEMA material does not adhere strongly to ocular structures. The gellike hydrophobic acrylic material of the lens is pliable and has a high refractive index. It is a biconvex lens and will fill the entire capsular bag and remain perfectly centred without the aid of haptics. a foldable posterior chamber IOL of overall diameter 10.

10. 23:536–544. 19. Nishi K: Preventing posterior capsule opacification by creating a discontinuous sharp bend in the capsule. Ghazizdeh M. Oner FH. Rootman DS: Dislocation of plate haptic silicone intraocular lens into the anterior Chamber. 13. 6. Hayashi H. 26:1022–1027. 15. et al: The effect of polymethyl methacrylate. Wichstrom K: Preventing lens epithelial cell migration using intraocular lenses with sharp rectangular edge. 20. 22. Gerstmeyer K: Long-term results of the foldable CeeOn Edge intraocular lens. silicone and polyacrylic intraocular lenses on posterior capsular opacification 3 years after cataract surgery. Setty SS: Prospectively randomized trial comparing the pseudo accommodation of the AMO Array multifocal lens and a monofocal lens. 26:1543–1549. 26:817– 823. 11. 116:1579–1582. J Cataract Refract Surg 1999. Bluth LL. polymethyl methacrylate and silicone intraocular lenses: two-year results of a randomized prospective trial.Evidence-based approach in cataract surgery 32 2. Ruhswurm I. Campion M: Delayed posterior dislocation of silicone plate haptic lenses after neodymium: YAG Capsulotomy J Cataract Refract Surg 2000. 26:722–726. 27:817–824. 26:1172–1175. Hayashi K. J Cataract Refract Surg 2000. et al: Toric intraocular lenses for correcting astigmatism in 130 eyes. silicone and soft acrylic intraocular lens implantation. 17. Spalton DJ. Nishi O. Buchen S Y. Nakao F. Ursell PG. 18. Pandey SK. Hayashi H. J Cataract Refract Surg 2001. 25:521–526. 5. 27:775–780. 9. 7. Ophthalmology 1999. Cunanan CM. J Cataract Refract Surg 2000. et al: Contact angle analysis of intraocular lenses. . Udompunturak S: Neodymium: YAG laser damage threshold of foldable intraocular lenses. 27:608–613. et al: Experimental neodymium: YAG laser damage to acrylic. Kent DG. Spalton DJ. Ophthalmology 2000. Werner L. 14:24–30. 14. J Cataract Refract Surg 2001. 27: 169–171. Escobar Gomez M. Curr Opin Ophthalmol 2003. Ophthalmology 2000. Trinavarat A. Nakao F. Montgomery P. 4. Vicary D. et al: Silicone oil adhesion to intraocular lenses: An experimental study comparing various biomaterials. 19:26– 31. Richard Hoffman. 107:1776–1781. Mc dermott ML. Atchaneeyasakul L. Howard Fine et al: Refractive lens exchange with a multifocal intraocular lens. polymethyl methacrylate and silicone intraocular lens materials. Zehet mayer M. Faucher A. J Cataract Refract Surg 1999. Percival SPB. Ferliel ST: Posterior capsular opacification after phacoemulsification Foldable acrylic versus polymethyl methacrylate intraocular lenses. et al: Effect of round edged acrylic intraocular lenses on preventing posterior capsule opacification. Ursell P G et al: Posterior capsular opacification with hydrogel. et al: Anterior capsule opacification: A histopathologic study comparing different IOL styles. J Cataract Refract Surg 1997. Nishi O. J Cataract Refract Surg 2000. Sunday X. Hollick EJ. 26:1827–1829. 25:72–76. 12. Akura J. J Cataract Refract Surg 1993. Gunenc U. Nishi K. Nishi K. Hollick EJ. 106:49–55. Hayashi K. 8. 3. Schmack WH. Eliott D. 107:463–471. Apple DJ. 21. et al: Quantitative comparison of posterior capsule opacification after polymethyl metharylate. Petersen AM. 129:577–584. Newland TJ. 16. J Cataract Refract Surg 1998. Am J Ophthalmol 2000. J Cataract Refract Surg 2001. Kreiger RA: Evaluation of giant cell deposits on foldable intraocular lenses after combined cataract and glaucoma surgery. 24:341–351. J Cataract Refract Surg 2000. J Cataract Refract Surg 2000. Chu YR. Scholz U. Nishi O. et al: Astigmatism correction with a foldable toric intraocular lens in cataract patients. Samuelson TW. Isaacs RT. Arch Ophthalmol 1998. et al: Changes in posterior capsule opacification after polymethyl methacrylate. silicone and acrylic intraocular lens and implementation. J Cataract Refract Surg 2001.

et al: Objective and subjective evaluation of photic phenomena after monofocal and multifocal lens implantation. functional and quality of life outcome. . Salmenson BD: Pseudophakia in children: Precautions. Dick HB. Dahan E. 39. et al: Quantitative performance of bifocal and multifocal intraocular lenses in a model eye: Point spread function in multifocal intraocular lenses. Davison J A: Positive and negative dysphotopsia in patients with acrylic intraocular lenses. Mamalis N. Wilson ME. Arch Ophthalmol 2002. 36. 120:1198–1202. J Cataract Refract Surg 2001. J Cataract Refract Surg 2000. Wang XH. J Pediatr Ophthalmol Strabismus 1996. 31. Bluestein EC. 22:1342–1350. J Cataract Refract Surg 1991. 30. 34. FRCS: Contributions in addition to the intraocular lens. J Cataract Refract Surg 1996. et al: Cataract extraction with multifocal intraocular lens implantation: Clinical. Multicenter clinical trial in Germany and Austria. Apple DJ. Daniele Tognetto. 27:1061–1064. Schwenn O. Krummenauer F. 27:239–244. et al: Short-term results of scleral intraocular lens fixation in children. Javitt JC. Amon M. 27:734–740. 38. 29. Koch DD: Scanning electron microscopic analysis of foldable acrylic and hydrogel intraocular lenses. Giuseppe Ravalico: Inflammatory cell adhesion and surface defects on heparin surface modified polymethyl methacrylate intraocular lenses in diabetic patients. Marvan P. J Cataract Refract Surg 1998. J Cataract Refract Surg 2001. Ellis M: Sharp edged intraocular lens design as a cause of permanent glare. Elie Dahan: Intraocular lens implantation in children. 33. David J Apple. Schauersberger J et al: Cellular reaction on the anterior surface of 4 types of intraocular lenses. Jehan FS. Steinert RF: Cataract extraction with multifocal intraocular lens implantation: Clinical. 32. Ophthalmology 1999. 37. Leung ATS. Chua JKH. Curr Opin Ophthalmol 2000. Javitt JC.Recent advances in intraocular lens material and design 33 23. 26:1346–1355. J Cataract Refract Surg 1990. 35. 33:18–20. J Cataract Refract Surg 2001. 26. functional and quality of life outcomes. 107:2040–2048. Kohnen T. 120:23–28. Pieh S. Arch Ophthalmol 2002. Werner L. Jacobi KW. Kaskaloglu M. 28. Magdowski G. 24. Ng JSK. Fan DSP. Mulner-Eidenbock A. 11:51–55. 106:1878– 1886. Spencer TS. 24:1474–1479. Kt. J Cataract Refract Surg 2000. Brauweiller HP. et al: Sir Nicholas Harold Ridley. Ophthalmology 2000. 27. 27:1485–1492. Apple DJ: Dimension of the pediatric crystalline lens: Implications for intraocular lenses in children. Lam DSC. J Cataract Refract Surg 2001. Wenzel MR: Spontaneous breaks in proteinaceous membranes on intraocular lenses. et al: Postoperative sterile endophthalmitis (TASS) associated with memory lens. 26:1356–1366. J Cataract Refract Surg 2000. 26:1773–1777. Wolder JR. techniques and feasibility. 16:75–82. Pandey SK: Dense opacification of the optical component of a hydrophilic acrylic intraocular lens: A clinicopathological analysis of 9 explanted lenses. Rust PF. 25. MD. 17: 617–621.


subluxated cataract. In addition. this crack never reaches the bottom of the nucleus.Chapter 5 Phacoemulsification in Difficult Situations In the last decade several advances have taken place in surgical techniques for removal of cataracts in difficult situations such as posterior polar cataract. posterior polar cataract) are not very favorable.2 The phacoemulsification tip is buried into the cracked nuclear half at 6 O’clock. initial smaller one enables phacoemulsification in the bag followed by larger. The left hand. This central space is necessary for maneuvering the divided lens fragments. Double capsulorhexis is recommended. continues chopping and dividing the large fragments into small pieces till all the fragments are phacoaspirated (Fig. 2.1). The movement extends the crack to the bottom and nuclear piece is separated. Modifications in surgical technique for removal of hard cataracts are as follows: 1. There are more chances of burns during phacoemulsification of hard cataracts because of excessive phacoenergy used.g. . In this way. The chopper is placed adjacent to the phacoemulsification tip. with a chopper.1 PHACOEMULSIFICATION IN HARD CATARACTS The fibers of a hard nucleus are described as leathery which are cohesive and tenacious. Vasavada et al has described step by step chop in situ followed by lateral separation in hard nuclei. However. Especially first nuclear piece is difficult to remove. Peribullar anesthesia is preferred over topical anesthesia. 4. total cataract. Sculpting by Kelman tip is recommended since deep sculpting is possible with it. There is also risk of hard nuclear fragments coming in contact with corneal endothelium and damaging it. Hard cataract itself can pose a challenge to surgeons. These fibers resist all the conventional methods of nuclear division like divide and conquer. Pure chop technique for nuclear division provides little room for the pieces to be removed. fragments of small size are created. weak zonular apparatus leading to subluxated cataract) and conditions around it (e. and cataract in patients with uveitis. The vertical element of the chopper is depressed posteriorly. This leads to initiation of a crack. The chopper is positioned next in the depth of the crack and pushed laterally. Hence wide temporal clear corneal incision and high aspiration flow rates are recommended. Creation of central space in the form of trench or crater is necessary. 3. 5. phacoemulsification can be difficult if the structures (e.g. 5.

.Evidence-based approach in cataract surgery 36 Fig.2) Diameter of continuous curvilinear capsulorhexis should not be larger than 5.0 mm. Continuous Curvilinear Capsulorhexis (CCC) (Fig. The incidence of posterior capsule rupture during phacoemulsification is reported as 26% by Osher et al3 and 36% by Vasavada et al. an IOL can be implanted in the ciliary sulcus with optic capture through the capsulorhexis. 5. 5.4 Serious complications like dropped nucleus can be avoided if appropriate alternative techniques for cataract surgery are employed.1: Step by step chop in situ and lateral separation Posterior Polar Cataract Surgeons should be careful when operating eyes with posterior polar cataract because the capsule around the opacity tends to be weak leading to posterior capsule rupture. In the event of posterior capsular tear during phacoemulsification.

2: Continuous curvilinear capsulorhexis not larger than 5.0 mm in posterior polar cataract Hydrodissection and Hydrodelineation Hydrodissection should be avoided as posterior polar opacities adhere firmly to the posterior capsule around the opacity.3: Careful hydrodelineation in posterior polar cataract Phacoemulsification of Nucleus Infusion bottle should be lowered and extremely low power settings for phacoemulsification is used. 5.2 cc of irrigating fluid should be used for hydrodissection and hydrodelineation (Fig. The quadrants are then phacoaspirated.3). 5.5 A fine Nagahara chopper is used to incise the endonucleus in perpendicular meridians. . it should be performed gently in multiple quadrants with minimal fluid. 5. dividing the nucleus into small quadrants.4. A fluid wave should not be allowed to pass across the posterior capsule in the center where the posterior capsule is weak. This should be done without countertraction and embedding the phacoemulsification tip. Not more than 0. Fig. If at all it is done. Hydrodelineation is also performed with minimal fluid.Phacoemulsification in difficult situations 37 Fig.

Nylon hooks. Weill- . To avoid fluctuations in anterior chamber depth an attempt should be made to keep the I/A tip always occluded. The causes for weak zonular apparatus can be hereditary like Marfan syndrome. Then the central epinucleus is elevated and aspirated using I/A handpiece (Fig. The epinucleus is Fig.6 Sometimes the opacity comes off spontaneously due to infusion pressure during removal of the peripheral cortex. but in some cases.4). 5.Evidence-based approach in cataract surgery 38 Epinucleus Removal Epinucleus can be effectively removed using viscodissection.4: Viscodissection of the epinucleus in posterior polar cataract elevated with viscoelastic and is injected under the floor of epinucleus. Viscoelastic is injected under the anterior capsular margin in one quadrant. Cortex Aspiration The peripheral cortex is aspirated first using I/A handpiece.6.7 Thus. In such cases. the amount of material that can enter the vitreous is reduced. Capsular tension ring 2. Phacoemulsification in Subluxated Cataract Reinforcement of zonules in eyes with zonular dehiscence is necessary before phacoemulsification . Capsular Tension Ring Capsular tension ring is an implantation device made of polymethyl methacrylate (PMMA) which is used for zonular reinforcement in eyes with weak zonular apparatus. This can be done by the following: 1. conversion of posterior defect into posterior capsulorhexis. part of the opacity remains adhered firmly to the posterior capsule and could not be separated. With all these precautions. followed by anterior vitrectomy is necessary. The central posterior portion of cortex is elevated with viscoelastic and aspirated. residual plaque can be left in place during surgery and later removed by Nd: YAG caplulotomy. if the defect in posterior capsule is seen. 5. IOL can be implanted in the ciliary sulcus and optic is captured in the bag.

iv. emanating at an angle of 90°. 5. This CTR is used with profound zonular deficiency. In profound zonular weakness. homocystinuria. It is available in three sizes 12. horseshoe shaped filament of polymethyl methacrylate (PMMA). at the distal end of this filament is another eyelet (Fig. Eyelets can be engaged .5 mm. Other conditions like pseudoexfoliation syndrome and high myopia can have weak zonular apparatus. Capsular tension ring inserter consists of a spring loaded plunger assembly with a hook at its distal end. a CTR can be inserted above the anterior capsular rim. 5. Easiest way is by Macpherson forceps or a Sinskey hook.5a and b: (a) Capsular tension ring.5.5a).8 Designs: The capsular tension ring is composed of an open. etc. with fixation eyelets at either end (Fig. In such cases. The CTR can be inserted with forceps or by injectors. 13. (b) Modified capsular tension ring A modification of the ring designed by Cionni consists of a comma shaped filament of PMMA swedged onto the main ring. Technique of insertion: i. ii. Another method is. Figs 5.Phacoemulsification in difficult situations 39 Marchesani syndrome. a CTR should not be dialed into the capsular bag. It can be inserted through tunnel or paracentesis. flexible.5b). Trauma either blunt or penetrating can lead to weak zonular apparatus. iii.5 and 14. the leading fixation hole is positioned at its desired location and then “tireironed” into the capsular bag.

a CTR should be positioned so that the body of the ring is coincident with the weakened zonular fibers. 5.Evidence-based approach in cataract surgery 40 Fig. For localized zonular dehiscence.7). The ring is then inserted in the capsular bag and the fixating element captures itself anterior to the residual anterior capsular rim (Fig. 5.6). v.6: Capsular tension ring being “tire-ironed” into the capsular bag with two Sinskey hooks and drawn toward one another thereby compressing the ring and delivering it into the capsular bag (Fig. Preplaced 10–0 prolene suture taken through eyelet.7: Modified capsular tension ring by cionni sutured to the scleral wall . In profound zonular weakness. 5. the modified ring by Cionni can be sutured to the scleral wall.9 Fig. vi. Each of the two needles is then placed through the incision and diverted over the area of maximum zonular dialysis to exit through the ciliary sulcus and scleral wall. 5.

the cannula should depress the posterior lip of the incision. Two handed rotations of the lens nucleus is recommended because the forces can be truely tangential and divided by using opposite sides of the same meridian.10–13 Disposable Nylon Hooks Disposable nylon iris hooks are placed in the capsulorhexis in the quadrant where zonules are weak to support the lens. This allows easy outflow of viscoelastic or fluid out of the eye and thus will prevent overinflation of anterior chamber with irrigating solution. Aspiration of anterior and equatorial cortex. During phacoemulsification following are extremely useful: i. 5. High cavitation tip (e. multiple locations are used for partial cortical cleaving hydrodissection. but there are chances of cortex getting trapped against the capsular bag making cortical clean-up difficult later.8).Phacoemulsification in difficult situations 41 Time of insertion during surgery: The CTR can be inserted after capsulorhexis.g. . 5. then without rotating the nucleus. following steps are advisable: i. Hydrodissection should be performed .8: Disposable nylon iris hooks placed under the capsulorhexis in subluxated cataract before phacoemulsification Hydrodissection and Hydrodelineation One has to be extremely careful. ii. Kelman tip) have a great advantage because they can obliterate nuclear material in advance of the tip without exerting forces on the lens or the lens zonules. A viscoelastic is placed under anterior capsular rim thus displacing the remaining cortex posteriorly and creating space for the insertion of CTR. Variation of phaco sweep procedure can be performed in which initial groove formed. To prevent this. iii.14 Fig. During hydrodissection. ii. This can be done after capsulorhoxis is performed (Fig. a lateral and rotational motion of the phaco probe grooves is made in a lateral direction.

Nonrotational cracking is least traumatic method. Nucleus has to be stabilized during sculpting. Dispersive viscoelastic material. Classic air bubble technique. through sideport with second instrument. iv. Phacoemulsification is ideally suited for immature cataracts in which red reflex is adequate for a continuous curvilinear capsulorhexis. Most of it removed during flipping and evacuation of the epinuclear shell. Cortical aspiration is biggest threat to the zonules.12 PHACOEMULSIFICATION IN WHITE CATARACT In India. The coaxial light of the operating microscope produces red fundus reflex which is necessary to visualize the anterior capsule while performing capsulorhexis.Evidence-based approach in cataract surgery 42 iii. Continuous curvilinear capsulorhexis technique has improved significantly the safety of phacoemulsification technique (emulsifying the nucleus safely in the bag). mature and hypermature cataracts constitute a significant proportion of cataracts. The advancing edge of the anterior capsulorhexis is very difficult to visualize in this situation. this retroillumination is absent. There is risk of peripheral extension of the advancing edge of the capsulorhexis with its attendant complications. Viscodissection can be helpful to separate cortex from capsule. Continuous curvilinear capsulorhexis 2. vii. The two steps that make phacoemulsification challenging in eyes with white cataract are as follows: 1. . PMMA haptics helps to increase haptic resistance and attempt to prevent capsule contraction syndrome and lens decentration. Emulsification of the hard nucleus—the uses of vital dyes like trypan blue has made it possible to deliver the benefits of phacoemulsification in these cases. vi. Techniques Trypan blue dye can be injected using the following: i. Foldable IOL optic with PMMA haptics sized for in-the-bag placement is ideal. ii. Aspiration of residual cortex is safer after the IOL has been implanted because IOL stabilizes the capsular bag. v. iii. In mature and hypermature cataracts. This can be avoided if the anterior capsule is temporarily stained with contrasting dye trypan blue (0.1%) that can be used to stain the anterior capsule thus helping its visualization during CCC. Intracameral subcapsular injection.

giving sufficient time for the surgeon to perform CCC.0%— condroitin sulfate 4. Air is injected in the anterior chamber through a 26 gauge needle.18 Intracameral Subcapsular Injection The dye is trapped in the subcapsular space.9: Trypan blue (0. b.1%) injected under air bubble through 26 gauge needle (Fig.Phacoemulsification in difficult situations 43 Classic Air Bubble Technique Steps: a. 5. 5.1% by this method. Single large uniform bubble essential for homogenous staining.9).17 Fig. it enhances visualization of the advancing edge.15 The air allows to spread the dye over the capsule and also prevents dilution of the dye. A 0.16 c. The dye is bordered by the peripheral rim of the iris thus preventing direct endothelial touch.2 ml trypan blue (0. . It is possible. Posterior surface of the anterior capsule is stained hence when capsular flap is inverted during CCC. Anterior chamber is thoroughly irrigated with irrigating solution after 5 to 10 seconds.0%) instead of air bubble. to stain the anterior capsule with concentrations lower than 0.1%) injected under single large air bubble through 26 gauge needle Using Dispersive Viscoelastic Material Alternatively the dye can be injected under viscoat (sodium hyaluronate 3.

it does not hamper surgical view while phacoemulsification either by coating the endo thelium or by causing corneal edema. however hypermature cataracts are relatively hard to emulsify.20 Its dis-advantage being fibrosis of margins of CCC due to development of heat and its margins possess less strength than usual CCC margin. Emulsification of Nucleus in Total White Cataract In white cataract. 2.19 Hence. hydrodissection and hydrodelineation are not necessary because the nuclei are mobile as the corticocapsular adhesions are minimal. Hence. i. Nonstaining Techniques Various nonstaining techniques for performing CCC in mature and hypermature cataracts are as follows: 1. CCC using diathermy is described in case of intumescent cataract in absence of red reflex. 2. Trypan blue does not stain the corneal endothelium because it selectively stain dead corneal endothelial cells. Hydrodissection can make the nucleus excessively mobile by washing out the cortical material.23 The mature and intumescent cataracts are not very hard.22 For nuclear fragmentation and aspiration divide and conquer and phaco chop techniques are equally effective. Use of endoilluminator described for visualizing anterior capsule during CCC.15 . This prevents rupture of the posterior capsule as it is not protected by an epinuclear cushion. Deep anterior chamber should be maintained everytime during phacoemulsification.21 3. Gimble reported two-step CCC method in which small CCC created first followed by second CCC around the first. it has to be reconstituted and its shelf life is only 10 hours. He found phacoemulsification difficult with small CCC and there were increased chances of rupture of CCC margin during phacoemulsification. Precautions Trypan blue being potentially carcinogenic vital dye its lowest effective concentration.1% should be used. hydrogel IOL should be avoided. Peripheral stained rim of anterior capsule is visible during phacoemulsification thus avoiding damage to the capsular rim by phaco tip. Indocyanine green (ICG) dye can be as effective as trypan blue in staining the anterior capsule. Its disadvantages being apart from expensive.18 Permanent blue discoloration of hydrogel IOL by intraoperative use of trypan blue has been reported. Initially.e. 0.Evidence-based approach in cataract surgery 44 Advantages of Trypan Blue Staining 1.

4. Oral nonsteroidal anti-inflammatory agent twice daily and a topical nonsteroidal antiinflammatory agent such as flurbiprofen four times daily. Figs 5. And these are increasingly being used during phacoemulsification in small pupils. 2. Meticulous control of perioperative inflammation.25 Simple stretching of the iris is effective when pupil diameter is 4 to 5 mm (Fig. 3. Disposable nylon iris hooks are most effective means of increasing the size of rigid small pupils. 2.10a and b: Disposable nylon iris hooks for increasing pupil size: (a) Classic technique. 5. Appropriate surgical timing. (b) Modified diamond technique .10). Modified surgical techniques to remove cataract in presence of posterior synechia and undilating pupils. One mg/kg/day of prednisone and a drop of 1% prednisolone acetate eight times a day 2 days before surgery.24 Surgical Technique in Uveitic Cataract A small pupil presents a challenging problem for cataract surgeons. Preoperative Control of Intraocular Inflammation Complete abolition of all active inflammation for at least 3 months prior to surgery is necessary for good surgical outcome in uveitic cataract.Phacoemulsification in difficult situations 45 CATARACT SURGERY IN A PATIENT WITH UVEITIS Cataract surgery in a patient with uveitis is more complex because it involves the following: 1. Supplementary perioperative anti-inflammatory therapy recommended is as follows: 1. One exception for this is protein leaking lens (phacolytic glaucoma) in which immediate surgery is mandatory. Type and material of IOL to be used.

peripheral iredectomy. Difficulty encountered during capsulorhexis is irregular fibrotic anterior capsular bands.10b). Complications The use of these iris hooks may lead to certain intraoperative problems: i. Iris prolapse: It can occur through clear corneal incision in classic method. Modified diamond technique: This technique is a modified form of classic technique. Between the two iris hooks there is wide platform of iris. Localized Descemet’s membrane detachment: This can occur during insertion and removal of iris hooks hence one has to be gentle while doing this maneuver. This can lead to entanglement of an instrument and iris chafing. Another fact influencing capsule shrinkage is lens epithelial cells. The more epithelium is left. Hence subincisional iris hooks with a diamond shaped configuration of the pupil is recommended. iii. . During phacoemulsification: Small nuclear fragments may get stuck underneath the iris hooks. synechiolysis are additional procedures needed in uveitic cataract surgeries. that is elevated. 5. Damage to anterior capsule: During engagement of pupillary edge with iris hooks. 5. It is found that twice as much epithelium can be removed with 5.26 In addition to adequate pupil dilatation. Hence. the greater the potential for capsule contraction syndrome. The capsulorhexis may be extended through the fibrous bands with capsulotomy scissors and then continued with forceps. These are used to retract the iris. This can be prevented by doing in -the.10a).5 mm capsulotomy as with a 4. It is recommended to do a wellcentered capsulorhexis which should be as circular as possible.0 mm.0 mm anterior capsulotomy. The phaco incision is shifted 45° to an area just anterior to one of the iris hooks. Iris chafing and iridodialysis: In a fully dialated pupil. capsulorhexis should have a minimum diameter of 5. These tend to inhibit consistent tearing of the anterior capsule. devised mainly to prevent iris prolapse during surgery through a clear corneal wound. giving the shape of diamond to the pupil instead of square (Fig. the tip of the hook may damage anterior capsule. Thus. the iris lies anterior to its anatomical position. vacuuming the undersurface of the anterior capsule to remove maximum lens epithelial cells28 is recommended. a bolus of viscoelastic material has to be injected between iris and capsule.0 mm capsulotomy. because it allows the surgeon to be certain that the IOL is in-the-bag. iv. Capsule contraction syndrome27 is found frequently with capsulorhexis postoperatively. Some authors proposed a 6.Evidence-based approach in cataract surgery 46 Technique Classic technique for using iris hooks: Four flexible nylon iris retractors are used and inserted at 90° apart from one another. The anterior capsulotomy recommended is capsulorhexis. Hence. resulting in a pupil of square shape (Fig. ii. This is frequently encountered with small capsulorhexis. v. which is posterior to the limbus. The retractors are placed through 4 paracentesis wounds at the limbus. Hence.bag phacoemulsification.

hydrophilic acrylic and silicone) after 6 months of surgery. PMMA optic with polypropylene haptics should be avoided because polypropylene haptics are known to cause complement mediated inflammation. Addition of Heparin in the Irrigating Solution Heparin. anterior chamber reaction. All these may decrease the inflammatory response compared to ECCE.29 In Juvenile rheumatoid arthritis.35 . is known to have anti-inflammatory and antiproliferative effects. in addition to its anticoagulant activity. hydrophilic acrylic. In-the-bag posterior chamber lens is only well-tolerated in patients with uveitis. But carefully done ECCE with complete cortex removal is likely to achieve similar long-term results. IOL Implantation A posterior chamber IOL resting on the ciliary body or anterior chamber lens should be avoided to minimize haptic uveal contact in eyes with uveitis. amount of posterior synechia formation and IOL deposits. Though. it is not advocated as an alternative to HSM IOLs because the surface modification has a longer acting effect on flare and the cellular reaction on the IOL. lens implantation should be aborted. Adding heparin sodium to irrigation might help control of easily postoperative inflammation after cataract surgery. Hence.34 However. in uveitic eyes apart from IOL material optic edge design. In addition. PMMA and HSM PMMA IOLs. it is recommended a combination of surgical procedures like phacoemulsification followed by pars plana vitrectomy for total removal of lens. there was no statistically significant difference in postoperative visual acuity.31 Hydrophobic acrylic IOL has the lowest incidence of aqueous cells in the first postoperative week as compared with the silicone. which may explain its anti-inflammatory effects. Heparin surface modified (HSM) IOL has been recommended in patients with uveitis. it is safe and economical. Hydrophobic material IOL has shown to have a good effect on capsular biocompatibility33 and a sharp edged optic design reduces most effectively the formation of PCO in nonuveitic uncomplicated eyes. all polymethylmethacrylate (PMMA) IOLs are recommended.Phacoemulsification in difficult situations 47 The advantages of phacoemulsification are small incision. If the posterior capsule ruptures to an extent that precludes IOL implantation in the bag. corneal edema. shorter surgical duration and thus less surgical trauma. over the long-term. One ml of heparin sodium adding to irrigating solution which makes a diluted concentration of 10 IU/ml. the grade of postoperative inflammation is important factor in the development of PCO. Short-term clinical evaluation revealed significantly less anterior chamber reaction and lower IOL deposits in eyes with HSM IOL. However. Heparin has been shown to induce apoptosis in human peripheral neutrophils.32 But cell reaction was similar in all these foldable IOL (Hydrophobic acrylic.30 There are fewer chances of loss of lens fragments in vitreous with pars plana lensectomy and vitrectomy. though similar results can be achieved with this technique.

4. 12. Vasavada A. Indian J Ophthalmol 2002. 13. 49:177–180.Evidence-based approach in cataract surgery 48 REFERENCES 1. Findl O. 20(7). J Cataract Refract Surg 1990. 23:160–165. Clinical Modules for Ophthalmologists. et al: The capsular tension ring: Designs. Richard G: Investigations on diathermy for anterior capsulotomy. J Cataract Refract Surg 2002. 25:238–245. Focal points. Paolo Lanzetta. 19. J Cataract Refract Surg 1998. J Cataract Refract Surg 2002. Jain S. Fine IH. 29:45–49. J Cataract Refract Surg 1993. Melles GRJ. 7. Hoffman RS: Phacoemulsification in the presence of pseudoexfoliation: Challenges and options. 11. Yu BC-Y. 28:1819–1825. 5. Chakarabati A. 3. Cionni RJ. et al: Trypan blue as an adjunct for safe phacoemulsification in eyes with white cataract. Singh R. et al: Phacoemulsification of white mature cataracts. 18. 15. Shah N: Anterior capsular staining with trypan blue for capsulorhexis in mature and hypermature cataract. 28:742–744. Vasavada A. September 2002. 17. 21. 19:116–117. Hideyuki Hayashi. Allen D. J Cataract Refract Surg 1997. et al: Phacoemulsification in eyes with white cataract J Cataract Refract Surg 2000. Mark Packer. et al: Permanent blue discoloration of a hydrogel intraocular lens by intraoperative trypan blue. 23. J Cataract Refract Surg 1999. Jacob S. Osher RH. Raffaella Gortana Chiodiniet: Use of capsular tension ring in phacoemulsification: Indications and technique. Vasavada AR. J Cataract Refract Surg 1999. et al: Management of posterior polar cataract. Osher RH: Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation. 2. 10. Vasavada A. Kothari K. 24:1299– 1306. J Cataract Refract Surg 2003. et al: Outcomes of surgery for posterior polar cataract. Ken Hayashi. Menapace R. . 24:156–159. 22. and techniques. J Cataract refract Surg 1998. 14. 26:1041–1047. Mansour AM: Anterior capsulorhexis in hypermature cataracts (letter). Howard Fine. J Cataract Refract Surg 2003. 28:988–991. Indian J Ophthalmol 2001. applications. et al: Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. Kenneth J Rosenthal: The capsular Ring: Indications and surgery. 32:155–159. 6. Singh R: Phacoemulsification in eyes with posterior polar cataract. et al: Surgical techniques for difficult cataracts. 16. J Cataract Refract Surg 2000. John C. J Cataract Refract Surg 2002. Koch DD: Posterior polar cataracts: A predisposition to intraoperative posterior capsule rupture. Invest Ophthalmol Vis Sci 1991. Warner L. 9. Apple DJ. Curr Opin Ophthalmol 1999. J Cataract Refract Surg 2002. Singh S.Merriam. Devranoglu K. Wood C: Minimizing risk to the capsule during surgery for posterior polar cataract. 26:898–912. 28:1279–1286. 29:16–19. Hausmann N. 25:7–9. A preliminary study. Yetik H. 10:46–52. Singh R: Step-by-step chop in situ and aspiration of very dense cataracts J Cataract Refract Surg 1998. J Cataract Refract Surg 1997. Robert H Osher: Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation. 50:333–37. 8. 23:1295–1297. Agrawal A. de Waard PWT. 24:270–277. Robert J Cionni. J Cataract Refract Surg 1998. 24:1299–1306. et al: Ins hooks for phacoemulsification of the subluxated lens. 20. et al: Determining the lowest trypan blue concentration that satisfactorily stains the anterior capsule. 16:157–162.

J Cataract Refract Surg 2002. and silicone intraocular lenses in uveitic eyes with cataract: Comparison to a contract group. 116: 1579–1582. Foster CS. Arch Ophthalmol 1998. Part II: Effect on prevention of fibrinous reaction J Cataract Refract Surg 1989. Foster CS: Cataract extraction in patients with pars planitis. 100:809–817. Dadu T. 30. et al: Quantitative comparison of posterior capsule opacification after polymethylmethacrylate. 28. 28:1141–1152. Foster CS. Foster RE. et al: Results of hydrophilic acrylic. 31. 28:87–92. 2002. Kaufman AH. J Cataract Refract Surg 1993. Abela Formanek C. 100:1210–1217. Amon M. . Ophthalmology 1992. Kruger A. Lowder CY. 19:582–589. Mhomas A Oetting. et al: Effect of heparin in the irrigation solution on postoperative inflammation and cellular reaction on the intraocular lens surface J Cataract Refract Surg 2002. Hayashi H. 99:1234–1240. 34. Nishi O: Intercapsular cataract surgery with lens epithelial cell removal. 25. 27:1579–1585. 26. et al: Modified technique using flexible iris retractors in clear corneal cataract surgery. Schuersberger J. et al: Comparison of the biocompatibility of 2 foldable intraocular lenses with sharp optic edges. Amon M. Philadelphia: WB Saunders Company. Ophthalmology 1993. 28: 596–598. 29. Sethi HS. et al: Extracapsular cataract extraction and posterior chamber intraocular lens implantation in uveitis patients. Ophthalmology 1993.Phacoemulsification in difficult situations 49 24. 35. J Cataract Refract Surg 2003. J Cataract Refract Surg 2001. Amon M. Hayashi K. 32. Barrett F: Cataract development and cataract surgery in patients with juvenile rheumatoid arthritis-associated iridocyclitis. J Cataract Refract Surg 2002. Vitale AT: Diagnosis and Treatment of Uveitis. 29:412–413. et al: Using nylon hooks during small pupil phacoemulsification. silicon and soft acrylic intraocular lens implantation. hydrophobic acrylic. 15:301–303. 33. Davison J A: Capsule contraction syndrome. 27.

orbital hemorrhage produces positive pressure which needs canceling the surgery. Management i. Increased resistance to retropulsion. 3.1 In patients with bleeding disorders anticoagulation therapy should be discontinued before surgery. Cataract surgeons should be able to avoid. Surgery can be safely done in cases of mild orbital hemorrhage. 2. if 1. 2. ii.Chapter 6 Recent Trends in Management of Cataract Surgery Complications Technological advances has evolved cataract surgery dramatically over the last two decades. iii. Patient movement during block retrobulbar (30%) and less commonly peribulbar (0. A tight orbit. Alternative forms of anesthesia such as topical anesthesia should be preferred in whom anticoagulation therapy cannot be discontinued. . There is progressive proptosis.3 Orbital hemorrhage is considered severe. Very rarely orbital hemorrhage leads to elevation of intraocular pressure which is enough to threaten vision. quickly identify and manage these complication efficiently.44%) 3.2. Excessive needle manipulation by the surgeon. This increased instrumentation and technology has lead to increased complexity of cataract surgery and the advent of complications unique to these advances. CATARACT SURGERY COMPLICATIONS Orbital Hemorrhage Factors that can lead to orbital hemorrhage during injectional anesthesia are as follows: 1. Patients on anticoagulant therapy. In severe cases.

Recent trends in management of cataract surgery complications 51 In such cases. iii. Shallowing of the anterior chamber. urgent decompression should be performed. Makes introduction of instruments into the anterior chamber difficult. ii. At the conclusion of surgery a miotic agent is injected intracamerally. This reduces the possibility of spontaneous prolapse with iris incarceration in the wound. Improper placement of speculum. Dissection of the periocular space with a scissor. . iv. 4. 3. Posterior capsule becomes convex. Difficult to aspirate cortex and implantation of IOL. Because it leads to the followings: i. ii. It can be done by the followings: i. If retinal arteriolar pressure is compromised. Then the prolapsed iris can be gently repositioned. Causes i. This neutralizes the pressure gradient between anterior and posterior chamber. Risk of trauma to the iris. making it more susceptible to tearing.4 Intraoperative Iris Prolapse with Small Incision Surgery Intraoperative iris polapse can be very frustrating to the surgeon. If this maneuver fails. Increased intraocular pressure from external or internal etiologies. Wound can be secured by placing deep sutures. Iris prolapse. iii. retinal arterioles should be evaluated for flow and pulsations. Positive Pressure Positive pressure can lead to the followings: 1. Judicious use of viscoelastic materials injected in the anterior chamber to maintain the iris within the anterior chamber. Aspiration of fluid and viscoelastic material from the anterior chamber via the second incision leads to lowering of intraocular pressure. This will help reposition the iris in the anterior chamber. iii. Distorts the pupil leading to cosmetic havoc. Lateral cantholysis. v. ii. Management i. ii. 2. Incision that is too large or placed too posterior. small peripheral iridectomy should be performed at the site of prolapse.

Before withdrawing instruments from the anterior chamber it is necessary to stabilize and replace volume in the anterior . 6. 2. Intravenous mannitol for dehydrating vitreous.Evidence-based approach in cataract surgery 52 Cause 1. 2.5. Use highly viscous viscoelastic agents. 4. Avoid excessive hydrodissection. Tight lids due to narrow palpebral fissures. zonular disruption or any tear of the posterior capsule. iv. To prevent loss of nuclear and cortical material in the vitreous. Maintaining a stable anterior chamber. it increases the intraoperative risk of dropped nucleus or lens fragments and postoperative risks of cystoids macular edema and retinal detachment. ii. v. following maneuvers are recommended: i. This can occur due to a radial tear in the anterior capsule with extension to the posterior capsule. To prevent vitreous movement into the anterior chamber.6 When positive pressure exists. Fig. Excessive traction from a fixation suture. Posterior Capsular Tear Posterior capsular tear during phacoemulsification is the most significant complication for a cataract surgeon. Immediate lowering of the infusion bottle 2. iii. 3. Low aspiration rate.1: Rent in posterior capsule during phacoemulsification Immediate steps in case of posterior capsular tear are as follows: 1. Inadequate lid akinesia. Because.7 The main objectives in management of posterior capsular tear are as follows: 1. Short bursts of phacoemulsification power. Misdirection of irrigating fluid into the vitreous cavity.

This avoids removing the viscoelastic and promoting vitreous prolapse. (b) Posterior CCC done by using cystitome. that is too difficult to remove must be left behind. Viscoelastic agent should be introduced over the rent (Fig. Cortex. If additional cortical removal is required. The irrigation and aspiration tip should be embedded into the cortex before the initiation of vacuum.1). The infusion bottle should be lowered immediately. A lens glide is effective in securing the nucleus in the anterior segment. Hence. 2. (c) Posterior CCC This has following advantages: . The safest way to remove the remaining cortex is by dry manual irrigation and aspiration.2a to c). 2. low aspiration and irrigation rates. 3. Figs 6. low bottle height.2a to c: (a) Closed chamber vitrectomy through separate incisions. conversion of tear to posterior continuous curvilinear capsulorhexis (PCCC) must be attempted (Figs 6. But every attempt should be made to clear the visual axis. it can be done by the followings: 1. If automated irrigation and aspiration is to be performed: 1. low vacuum and short bursts of ultrasound power are used. Automated irrigation and aspiration. Surgeons’ new objective should be avoiding the extension of the tear.Recent trends in management of cataract surgery complications 53 chamber with irrigating solution or viscoelastic. Manual irrigation and aspiration. 6. This will decrease inflow and turbulence that may enlarge the capsule tear. If additional phacoemulsification is required.

helps surgeon in easily identifying and removing the vitreous from the anterior chamber. retinal detachment and persistent ocular inflammation.8 Vitrectomy If vitreous prolapse occurs. making it clearly visible. vitrectomy is necessary.8 ii. It is then re-suspended in 5 ml of BSS and recaptured to thoroughly remove the preservative. The Kenalog particles are trapped on and within the vitreous gel. In-the-bag IOL implantation becomes possible. This reduces tendency for vitreous strands to remain incarcerated within the wound after vitrectomy. i. It increases the risk of postoperative cystoid macular edema. This is a method of visualizing vitreous gel in the anterior chamber. This will create a closed system and therefore will minimize fluid outflow through the main incision during vitrectomy. Dry vitrectomy: Alternatively. 2. Anterior vitrectomy: Anterior vitrectomy can be performed by one-handed or twohanded technique. The one-handed technique allows the surgeon to use other instruments in the second-hand such as light pipe to better visualize the vitreous strands. Method: 0. In this technique. A suspension of Kenalog (triamcinolone acetonide) can be used to highlight and help visualize vitreous in the anterior chamber. The two-handed technique gives better control of the placement of infusion and thus allows better followability of the aspiration vitrector. dry vitrectomy is very effective for limiting the amount of vitreous removed.9 Dropped Nucleus A dropped nucleus is one of the cataract surgeons biggest fears because of the followings: 1.Evidence-based approach in cataract surgery 54 1. The Kenalog particles are ultimately resuspended in 2 ml of BSS and injected into the anterior chamber using 27 gauge cannula. 2. During vitrectomy. Anterior chamber is filled with viscoelastic and either an anterior or posterior vitrectomy is performed behind the viscotemponade. Thus. It strengthens posterior capsule which allows vitrectomy with decreased chance of tear enlargement. iii. It requires additional surgery by the vitreoretinal specialist. Posterior vitrectomy: This is an alternative to anterior approach and has to performed through pars plana. Vitrectomy can be performed either by anterior or by posterior approach. care must be taken to preserve anterior capsulorhexis. vitrectomy cutter should be inserted in the anterior chamber through a new paracentesis.10.2 ml of injectable triamcinolone 40 mg/ml captured in a 5 mm filter and rinsed with 2 ml of balanced salt solution (BSS).11 .

following procedures have to be performed to prevent descent of the lens material. This has to be performed quickly. Attempts to retrieve a sinking nucleus by anterior approach usually fails. If the surgeon decides to continue with phacoemulsification. create a stable shelf to prevent dislocation of the nucleus posteriorly.Recent trends in management of cataract surgery complications 55 Anticipation of this complication before it happens and pre-emptively works to prevent it is necessary. Viscoelastic is injected behind the nucleus to establish a barrier. Descent of the nucleus and cortical material should be prevented. If the surgeon decides to convert into extracapsular cataract extraction. Immediately steps necessary on anticipating this complication are as follows: 1. Hyperviscous agents such as sodium hyaluronate* can 1. 2. the use of lens glide to cover the tear may be beneficial. And. 2. Infusion should be immediately reduced by lowering the bottle height. 3. manual removal of nucleus and cortex can be done. it may actually push the nucleus further back. . Kelman advocates performing this maneuver even on the suspicion of a posterior capsule rupture (Fig. Posterior Assisted Levitation Posterior assisted levitation is a challenge to the surgeon when during phacoemulsification. Kelman’s posterior assisted levitation (PAL) technique can be performed to save a dropped nucleus. 6. In this situation Kelman’s posterior assisted levitation * Andre Balaz in the mid 1970s pioneered the first successful viscoelastic sodium hyaluronate which allowed ophthalmic surgerns to protect corneal ensotheluim during cataract surgery21 (PAL) maneuver is invaluable. which is an emergency maneuver. the entire nucleus or part of it starts to sink in the vitreous cavity.3).

secure the wound with sutures and refer the patient to a vitreoretinal specialist. bottle height. it can be recovered by PAL technique.13 . If the nucleus becomes visible. Acute suprachoroidal hemorrhage is more likely to occur in older patients. 6.3: Posterior assisted levitation Method: A spaluta is inserted via the pars plana and placed behind the nucleus or its major remnant. ii. when the bleeding pushes choroids and retina out of the wound and nonexpulsive when the bleeding remains confined within the globe. iii. If the nucleus does not appear during vitrectomy. Relaxing incision to the anterior capsular rim may be required if anterior capsulorhexis is small and its rim is intact. Then it is lifted forward into the anterior chamber.12 Phacoemulsification can be continued with low settings of flow. Expulsive. viscoelevation or by inserting a lens loop behind it. systemic hypertension. place an appropriate IOL over the anterior capsular rim. vacuum and aspiration. diabetes and patients on anticoagulant therapy.Evidence-based approach in cataract surgery 56 Fig. surgeon can direct stream of irrigation fluid into the vitreous. Short bursts of ultrasound energy minimizes the chance of prolonged occlusion and surge with associated fluctuations in anterior chamber pressure and volume. It can be expulsive or nonexpulsive. If the lens nucleus disappears then: i. the surgeon should remove cortex as much as possible. If the nucleus does not appear. Acute Suprachoroidal Hemorrhage Acute suprachoroidal hemorrhage is one of the most serious vision threatening complications of cataract surgery. The cortex should be removed in combination with an anterior vitrectomy. history of arteriosclerosis.

Incision should be closed as quickly as possible.15 Or an acute suprachoroidal effusion can develop into a secondary hemorrhage. creates a gradient between intravascular and extravascular pressure in the eye. The sudden drop in IOP when the eye is opened. glaucoma. The surgery should be aborted once the eye is closed. ii. Loss of red reflex.15 or a primary hemorrhage when a weakened artery ruptures.Recent trends in management of cataract surgery complications 57 Local factors like pre-existing uveitis. iii.17 ii. The arteries in the suprachoroidal space are stretched and then rupture because of increased distance between the sclera and the detached choroids. . The early signs are as follows: i. incidence of acute suprachoroidal hemorrhage is more in patients undergoing extracapsular cataract extraction (0. causes primary diffusion of fluid from the veins into the suprachoroidal space creating a suprachoroidal effusion.03%). The incision should be closed with strong sutures. Visual activity is often permanently reduced despite aggressive treatment.14 Mechanism of Occurrence Sudden drop in IOP when the eye is opened.13%) as compared to patients undergoing phacoemulsification (0. Sudden shallowing of anterior chamber. Creation of sclerotomies to drain the hemorrhage. This can be done with manual tamponade using an index finger. This dehydrates the vitreous and decreases the intraocular pressure. iv. Administration of mannitol intravenously. abruptly. Globe becomes firm. Once it is detected following steps are recommended: i. high myopia are predisposing factors for development of acute suprachoroidal hemorrhage. Patient complains of pain in spite of adequate anesthesia.18 Descemet’s Membrane Detachment Large Descemet’s membrane detachment results in persistent postoperative corneal edema with a severe reduction in the patient’s visual acuity. This is made with stab sclerotomies in the involved quadrant 5 to 7 mm posterior to the limbus.14 An essential factor in the development of acute suprachoroidal hemorrhage is sudden intraocular hypotension during surgery. Hence.16 Management Cataract surgery in patients with all these predisposing factors should be performed using a small incision technique. iv. If at all it occurs early recognition is important for proper management. iii.

Hence. 106:2341– 2345 . Murray TG. it can be reattached by applying pressure on the posterior lip of the incision at the site of the tear to generate an egress of fluid. J Cataract Refract Surg 2000. experimental and biophysical study. Br J Opthalmol 1995. 2. 3. ii. Wadood AC. Mandel MR: Efficacy and complication rate of 16. Mulhern M. Bullock JD.19 ii. Hence.Evidence-based approach in cataract surgery 58 Prevention i. Flynn HWJr. Chaudhry NA. Kelly G. Theng J: Capsular block syndrome and pseudoexpulsive haemorrhage. 6. Am J Ophthalmol 2000. A sharp blade is used to made the incision to avoid detachment of Descemet’s membrane. Grein WR: Ocular explosions from periocular anesthetic injections: A clinical histopathologic. Ophthalmology 1999. 129:387– 388. Avoiding forcing an instrument or IOL through a tight incision. Davis DB 11. 79:1133–1137. J. 224 consecutive peribullar blocks: A prospective multicenter study. Yeoh R. Dhillon B. Large or total detachment of Descemet’s membrane: i. J Cataract Refract Surg 2002. 26:1082–1084. ii. Bates A. it is necessary to push the tip posterior when entering the anterior chamber. intracameral injection of sulfur hexafluoride (SF6) or perfluropropane (C3F8) is most effective means of managing this complication. Singh J: Inadvertent ocular perforation and intravitreal injection of an anesthetic agent during retrobulbar injection. Injury 1999. 30:485–490. 5. 4. the phaco tip should be introduced in a similar fashion. Management Small Descemet’s membrane detachment: i. A small air bubble or viscoelastic agent can be used to tamponade a Descemet’s membrane flap into position during suturing of the wound. iii. et al: Pars plana vitrectomy during cataract surgery for prevention of aqueous misdirection in high risk follow eyes. Barry P: Effects of posterior capsule disruption on the outcome of phacoemulsification surgery. . 7. 20:327–337. Warwar RE. Brahma A. Reattachment of Descemet’s membrane is done by taking transcorneal mattress sutures to fixate Descemet’s membrane to the cornea in combination to intracameral air injection. Goodall KL. Cataract Refract Surg 1994. At the conclusion of surgery. 28:562–565. discussion 2352–2353. et al: Lateral canthotomy and inferior cantholysis: An effective method of urgent orbital decompression for sight threatening acute retrobulbar haemorrhage. Air does not last long enough to hold totally detached Descemet’s membrane.20 REFERENCES 1. Corneal incision are usually triplanar.

Gimbel HV. Seregard S. Osher M: Emergency treatment of vitreous bulge and wound gaping complicating cataract surgery. et al: Techniques for managing common complications of cataract surgery. Teichmann KD: Posterior assisted levitation. 120:181–183. 29:645–651. Manschot WA: The pathology of expulsive hemorrhage. Kompella VB. 127:88–90. 24:793–800. Schneider S. Burk SE. 44:409–411. Sekine Y. Saiyid Akbar Hasan: A new technique for repairing Descemet’s membrane detachments using intracameral gas injection. Sun R. Lu H. 19. Acute intraoperative choroidal effusion. 18. Jiang YR. Curr Opin Opthalmol 2003. Terry Kim. Takci K. Daniela MV Marques. Osher RH. Palay DA: Technique for repair of Descemet’s membrane detachment. 100:147–154. 27:1428–1432. 40:15–24.Recent trends in management of cataract surgery complications 59 8. J Cataract Refract Surg 1999. 14:7–19. Grabow HB: Managing a dropped nucleus during the phacoemulsification learning curve. 14. 21. 13. Ophthalmologica 1996. et al: Risk of acute Suprachoroidal hemorrhage with phacoemulsification. . Maumence AE. 87:699–705. discussion 2190–2192. Michael L Nordlund. Pape LG. Amaral CE. De Mata AP. J Cataract Refract Surg 1998. 17. 47–78. et al: Survey of risk factors for expulsive choroidal haemorrhage case reports: Substantiation of the risk factors and their incidence. Majji AB: Risk factors for and management of dropped nucleus during phacoemulsification. Eriksson A. J Cataract Refract Surg 2001. Aasuri MK. 9. Cionni RJ: Visualizing vitreous using Kenalog suspension. 12. Snyder ME. 16. Balazs EA: The use of sodium hyaluronate (Healon) in human anterior segment surgery. Am J Opthalmol 1957. Schwartz MF. Surv Opthalmol 2002. Nakano H. 210:344–347. Opthalmology 1980. 108:2186–2189. 11. Am J Opthalmol 1985. 20. J Cataract Refract Surg 2003. 15. Arch Ophthalmol 2002. 10. Am J Ophthalmol 1955. Koranyi G. Ferensowicz M. 25:447–450. et al: Intraoperative management of posterior capsule tears in phacoemulsification and intraocular lens implantation Ophthalmology 2001. Am J Ophthalmol 1999.

5 Principle: Principle is similar to conventional ultrasound A-scan which uses ultrasonic pulse echo-imaging technique.Chapter 7 IOL Power Calculation in Special Situations The refractive results of cataract surgery has greatly improved due to recent advances in biometry.0 diopter is seen in 15% of eyes. 3.2 The established method for determining axial length is ultrasound A-scan biometry. an error of 1.1 and 7. The resolution of ultrasound is limited to 200 µm (using 10 MHz transducer). Accuracy is reported to be between 5 µm and 30 µm. Since the velocity of light is high. noninvasive optical biometry methods for measuring axial length has been developed.2: Advantages of partial coherence interferometry 1. Local anesthetic has to be used. Risk of corneal epithelial abrasion and infection. hence minimal error is avoided due to indentation of cornea as in ultrasound A-scan biometry method. It is made commercially available as (IOL Master by Carl Zeiss (Tables 7. Partial coherence interferometry by IOL Master and corneal topography have improved spherical correction to the point that the new standard of error is only 0.1 Under ideal circumstances. Accurate measurement of preoperative axial length is required for accurate IOL power calculation. 2.50 diopters. It measures the echo-delay and intensity using infrared light reflected back from internal tissue interfaces. 4. Accuracy reported is 100 to 200 µm. 2. They are based on the principle of partial coherence interferometry (PCI). . Table 7. Postoperative refractive surprises due to error in axial length and keratometry measurements are common. Noncontact method.2). 3.4 Recently. A 54% of all IOL power calculation surprises are due to wrong axial length measurements. No topical anesthesia required.3 Table 7.1: Disadvantages of ultrasound A-scan biometry for axial length measurement 1.

2.IOL power calculation in special situations 61 echo-delay times cannot be measured directly and interferometric techniques have to be used. The IOL Master can also measure corneal radius and anterior chamber depth.3: Limitations of partial coherence interferometry 1. automated keratometers may be more accurate than manual keratometers. Keratometry* Manual keratometry analyzes only four points on two orthogonal meridians separated 3 mm on the paracentral cornea. Measurements not possible in total cataract. But the corneal radius and anterior chamber depth measurements are not based on the PCI principle but on the image analysis principle. Ophthalmometer was the first device to measure corneal curvature accurately. Although cataract extraction seams to be possible without major technical obstacles. In post-RK eyes with optic zone less than 3 mm. later modifications led to clinically useful models like keratometer7 . Computerized topography system * Hermann von Helmholtz had five major accomplishments relating to ophthalmology. Although. his ophthalmometer was a research tools.3). Measurements not possible in patients with associated nystagmus. i. invention of an ophthalmoscope (1850). IOL POWER CALCULATION IOL Power Calculation after Corneal Refractive Surgery An increasing number of cataract surgeries in eyes after keratorefractive surgery is expected within next few decades. in which distances between light reflection on cornea. elucidation of the mechanism of accommodation (1854) and development of an ophthalmometer (1854).6 mm) is taken into consideration. Table 7. hence underestimation of IOL power leading to postoperative hyperopia. Automated keratometry was found to be as accurate as manual keratometry with less variability than manual keratometry.e. Hencc asymmetry of corneal surface cannot be measured with this keratometry. confirmation of the Thomas Young theory of color vision (1852). Feeding of measured average K-reading into standard IOL power calculation formulas results into overestimation of keratometric diopters. iris and lens are measured.6 This IOL Master provides axial length measurements comparable to those by the immersion method (A-scan) and provides observer independent measurement results (Table 7.8 A still small central area of the cornea (2. IOL power calculation turned out to be problematic.

this method calculating keratometric diopters from anterior radius of curvature becomes inaccurate. The main reason for underestimation of IOL power after keratorefractive surgery (RK.9. Cause of inaccurate determination of keratometric diopters in PRK and LASIK: i.10 * Herman von Helmholtz in his book “Handbook of Physiologic Optics” published the first accurate model eye. Alvar Gullstrand. Current keratometers and topography systems primarily measure radius of curvature of anterior surface of central cornea.10 Causes of inaccurarate determination of keratometric diopters in RK: i. This effective refractive index is considered valid as long as radius of anterior and posterior surface of the cornea are proportionate and resembles that of the model eye (Fig. in the model.1: Anterior corneal curvature.and post-PRK iii. (*Gullstrands model eye). Keratometric diopters are derived from this radius of curvature using an effective refractive index. ii. Hence. Such an effective refractive index characterizes the refraction of a fictitious single refractive lens representing single anterior and posterior surface.1). pre. Fig. the radius of curvature of anterior surface is considerably increased and distance between both refractive surface is decreased. main reason for inadequate prediction of keratometric diopters. There is mismeasurement of the anterior radius of curvature. iv. that is used today as “Gullstrands model eye”7 . Helmholtz’s numbers were later slightly modified by his student.Evidence-based approach in cataract surgery 62 measures more than 1000 points within the central 3 mm and more than 5000 points over the entire cornea. 7. 7. PRK and LASIK) lies in inaccurate determination of keratometric diopters. Hence topography analysis provides greater accuracy in determining the corneal power with irregular astigmatism compared with keratometers. In PRK and LASIK.

The location of the keratometry mires which are 3 mm apart from each other fall over an area of the paracentral “Knee” (Fig.00 D +10. Power (P) and base curve (BC) of rigid contact lens. Following parameters are needed to calculate the postrefractive surgery keratometric diopters.2: Anterior corneal curvature.00 D ii.IOL power calculation in special situations 63 ii.00 D−10.00 D) 0+10. (K pre) e. iii. K post=K pre−SEQ K post=44. The stable postoperative refraction should not be due to cataract.g. This has to be subtracted from preoperative keratometric power. ii. preoperative refraction and stable postoperative refraction. Change in spherical equivalent refraction (post-refractive surgery refraction—prerefractive surgery refraction). Spherical equivalent refraction with contact lens on (ORx). SEQ=OD−(−10.00 sphere and has stable postoperative refraction of plano. 7. The contact lens over refraction method: When pre-refractive surgery data are not available this method is used. The clinical history method: This method requires preoperative average reading.00 sphere undergoes LASIK for correction of full −10. e. a patient of −10. Steps: i. Fig. post-RK Methods of Estimating Keratometric Power Indirect method: a.00 D iii. iii. 44 D.00 D K post=34. 7. i.g. This results in measurement that is too steep. Spherical equivalent refraction without contact lens (MRx).2). .

00+0+[−3−(−2)] =41. when myopic shift occurs.g. As against the axial length. Average corneal power (ACP): Maeda N et al developed the average corneal power parameter. the eye continues to grow.13 The problem with each of these techniques is that none of them take into account the posterior curvature. IOL Power Calculation in Pediatric Cataract In infants.00+0+[−1] =40. e. there is rapid growth of the eye and thus increase in axial length during the first 2 years of life. the corneal power drops considerably during the first 2 years of life. IOL Power Calculation in Patients with High Myopia . while corneal power drops from 54 D to 44 D. In toddlers and older children.15–17 Dehan E et al advices to categorize the children as children younger than 2 years and children older than 2 years of age. K post=41. i. It is recommended that childrens’ eyes should be undercorrected at the time of surgery. central 3 or 5 mm optic zone. offsetting 10 D. For children older than 2 years they advice to undercorrect IOL power by 10%. This helps in minimizing the need for an IOL exchange later in life. which looks at the corneal power within the region demarcated by the entrance pupil of the TMS-1 tomography unit. Gordon RA et al showed a steep axial length growth rate.00 D and over-refraction of −3.15 For children under 2 years they advice to undercorrect the IOL Power by 20%. increasing by 6 mm (~20 D).g.12 iii. to offset the myopic shift that occurs in there growing eyes.4 mm per year and only increases another 1 mm from 5 to 10 years.00 D if used and a patient has a spherical equivalent manifest refraction of −2. from premature babies to age 2 years. This must be taken into account when choosing the diopteric power of the IOL in infants. since axial length and keratometry readings change rapidly. Sim-K: Simulated keratometric diopter or Sim-k measures more than 1000 points over a 3 mm annular zone. K post will be K post=BC+P+(ORx–MRx) e.14 Between the ages 2 to 5 years axial length growth slows to about 0.11 ii. which is believed to be a highly variable between normal individuals. while corneal power remains stable.00 D.Evidence-based approach in cataract surgery 64 The post-refractive surgery keratometric diopters. Effective refractive power (Eff R P): It is the mean refractive power of the cornea over the central 3 mm. although at a slower pace.00 D Direct Method (Ignoring Posterior Curvature Change) Modern corneal topography machines has various algorithms to calculate estimated keratometric diopters. They can give power of the anterior corneal surface over a specified area. A plano rigid contact lens of base curve 41.

Annette Vogel. editorial 1994. With a plano convex lens. Drexler W. J Cataract Refract Surg 1992. Wolfgang Drexler. 7. Hence. H Burkhard Dick. Carones F. 11:856–858. 5. 27:1961–1968) 3. 126:524–534. Manning CA. Olsen T: Sources of error in intraocular lens power calculation. Boseman P III. Findl O. Opthalmic Surg 1980.18–21 Posterior pole staphyloma temporal to the fovea is commonly present in eyes with axial lengths longer than 30 mm. 2 to 3 D must be added to the IOL power to compensate for this effect. leaving patients with postoperative hyperopia. Schachar RA. Oliver Findl. et al: Partial coherence interferometry: A novel approach to biometry in cataract surgery. The distance from corneal vertex to fovea is 0. A century later Arch Ophthalmol. The refractive index of silicone oil is much less than that of vitreous. Am J Ophthalmol 1998. J Cataract Refract Surg 1998. Levy NS. This silicone oil refractive effect must be offset with more power in the IOL. 18:125–129. Few refinements in preoperative measurement techniques helps to improve the accuracy of IOL calculation in eyes with extreme myopia.5 mm shorter than the distance from corneal vertex to the bottom of the staphyloma. 28:235–238. A biconvex IOL creates the worst problem and a concave posterior surface (no longer available) causes practically none.22 Hence. et al: Reproduction of optical biometry using partial coherence interferometry: Intraobserver and interobserver reliability. IOL Power Calculation of Silicone Oil Filled Eyes This condition arises when vitreous is replaced with silicone oil as in vitreoretinal surgeries. 24:202–211. The use of B-scan ultrasonography to identify the location of a posterior pole staphyloma is necessary. et al: Partial coherence interferometry: A novel approach to biometry in cataract surgery.IOL power calculation in special situations 65 The various formulas for calculation of IOL power work best for eyes with normal axial lengths. 10. Kloess PM: Comparison of portable automated keratometry and manual kertometry for IOL calculation. . Hermann von Helmholtz. 26: 524–534. et al: Keratometric index. et al: Accuracy of intraocular lens powers calculated from A-scan biometry with the Echo -oculometer. J Cataract Refract Surg 2002.23 REFERENCES 1. video keratography. Plano convex lens which is between the two is recommended. 6. Connors R III. 10:125–128. Gobbi PG. Mandel RB: Corneal power correction factor for photorefractive keratometry. 4. J Cataract Refract Surg 1994. and refractive surgery.5 to 1. 2. J Cataract Refract Surg 1997. The A-scan usually finds the perpendicular axis between corneal vertex to the bottom of the staphyloma and records the axial length. 9. 23:1213–1216. The effect is dependent on the back surface of the IOL. it acts as negative lens in the eye. J Cataract Refract Surg 2001. et al: Accuracy and reproducibility of biometry using partial coherence interferometry. 8. Am J Ophthalmol 1998. 112:1524–1525. current third and forth generation IOL power calculation formulas have a tendency to give the IOL power lower than what is necessary.

22. 15. Focal points clinical modules for ophthalmologists. Kenneth J Hoffer: Modern IOL power calculations Avoiding errors and planning for special circumstance. Mitchell C.Evidence-based approach in cataract surgery 66 11. Dahan E. J Cataract Refract Surg 1997. 109:349–353. Maeda N. J Cataract Refract surg 1995. 17:187–193. and refraction. 13. 14. Olsen T: Sources of error in intraocular lens power calculation. Br J Ophthalmol 1999. Arch Ophthalmol 1991. Cornea 1997. . et al: Myopic shift after intraocular lens implantation during childhood. J Cataract Refract Surg 1991. J Cataract Refract Surg 1992. Ophthalmology 1997. Drusedau MU: Choice of lens and diopteric power in pediatric psendophakia. Gimbel H: Intraocular lens power calculation with an improved anterior chamber depth prediction algorithm. J Cataract Refract Surg 1997. Arch Ophthalmol 1985. 15:667–672. 12. Roberto Zaldivar. Flitcroft DI. 16:517–524. 23:618–623. 83:265–269. Hutchinson AK. 18. et al: Intraocular lens power calculations in patients with extreme myopia. 20. et al: Intraocular lenses in children: Changes in axial length. J Cataract Refract surg 2000. Knight-Nanan D. Gordon RA. 16. Wilson SE. 17. 26: 668–674. 13:209–221. Holladay JT: Corneal topography using the Holladay diagnostic summary. 104:1752–1757. 19. Corydon L. 18:125–129. 103:785–789. Klyce SD: Quantitative descriptors of corneal topography: A clinical study. 21:313–315. et al: Disparity between keratometry style readings and corneal power within the pupil after refractive surgery for myopia. 21. Drews Botsch C. 1995 volume XVII. Klyce SD. Donzis PB: Refractive development of the human eye. Effectiveness of intraocular lens calculation in high emmetropia. Olsen T. Huber C. Olsen T: Thim K et al: Accuracy of the newer generation intraocular lens power calculation formulas in long and short eyes. J Cataract Refract Surg 1989. corneal curvature. 12. 23.


1a). ii. Intraocular Lens Material Sandwich Theory An IOL can be biocompatible in a bioinert or bioactive way. 2. posterior capsular fibrosis and Elshnig pearls. Minimum postoperative posterior capsular folds. PMMA and silicone are bioinert and acrylic is bioactive. 4. Thorough clean-up of cortical matter. in patients who have significant postoperative inflammation following cataract surgery. Inflammatory cells also plays a role in formation of PCO. 8. 3. Table 8. it continues to stimulate important work toward understanding its causes and thus preventing it from occurring (Table 8. 5. Another bioactive bond is formed between LECs. When the bond is complete. .1: Factors known to decrease posterior capsule opacification 1. Overlap of anterior capsular rim on the anterior IOL surface 360°. Minimum aspiration of anterior capsular lens epithelial cells.1b). posterior capsule and bioactive IOL (acrylic) which has 90° edge to its optic (Fig. The anterior rim of continuous curvilinear capsulorhexis forms a bond over the IOLs bioactive (acrylic) surface.1). 8. Trauncated squared posterior IOL edge 360°. the IOL and the capsular bag are a closed system (Fig. INHIBITION OF POSTERIOR CAPSULE OPACIFICATION Posterior capsule opacification being most common complication of primary cataract surgery. Migration and proliferation of lens epithelial cells (LECs) onto the posterior capsule is considered the primary step in two major forms of PCO.Chapter 8 Posterior Capsule Opacification Posterior capsule opacification (PCO) a major post-operative complication following cataract surgery occurs in 20 to 50% of adult patients. For an IOL which is bioactive sandwich theory of PCO is proposed which is as follows: i.

and anterior capsule contraction or retraction can occur. posterior capsule and bioactive IOL (acrylic) which has 90° edge to its optic Hence without this bond.0 mm CCC constrict. thus preventing PCO.1 Anterior Capsule Rim Stability and PCO Continuous curvilinear capsulorhexis (CCC) has become common because it increases surgical safety during phacoemulsification and allows fixation of IOL in the bag. Initial large CCC≥5. as seen in PMMA and silicone IOL. Figs 8. Overlap of the anterior capsular rim for 360 on the anterior surface of IOL optic helps in preventing PCO. This is because. LEC freely migrate and proliferate behind the IOL.12 The relationship of the anterior capsule to the IOL is dynamic.5 mm tends to retract and smaller than 5. causing higher rate of PCO. A “shrink-wrap” phenomenon is produced due to sequestration of the IOL in the capsule. when the CCC is large.Posterior capsule opacification 69 The sandwich is formed and the cell-posterior capsule and the cell-bioactive IOL surface junctions prevent more cells from migrating behind the IOL. there is small area between the IOL and anterior capsular rim causing the retraction forces to dominate.1 a and b: (a) Bioactive bond is formed between IOL anterior surface and capsulorhexis. . (b) Bioactive bond is formed between LECs.

a similar inhibition effect is observed. aggressive removal of lens epithelial cells on the anterior capsule may increase PCO. Position of Intraocular Lens The IOL haptics both in-the-bag creates a barrier effect for development of PCO. of the different methods for management of posterior capsule and anterior vitreous. But when the edges of PMMA lens were also squared off. This prevents migration of the LECs behind the IOL. the anterior capsule remains in the same position on the anterior surface of the IOL from the immediate postoperative phase till 1 year after surgery. i. hydrophilic acrylic and silicone IOLs. This is the best position to place the IOL for preventing development of PCO. This also explains clear anterior capsule and less PCO in acrylic IOL as compared to PMMA and silicone IOL. 2.8 3. relatively more LECs come in contact with the IOL surface and undergoes fibrous metaplasia. the only method which prevents PCO formation is posterior continuous curvilinear capsulorhexis with anterior vitrectomy. hydrophobic acrylic. phacoemulsification and extracapsular cataract extraction.Evidence-based approach in cataract surgery 70 With small CCC. An in vitro study found no significant difference in the rate of cell growth on the posterior capsule with the two surgical techniques. Retained cortex increases inflammation and inflammation has been shown to increase PCO formation. Polishing the undersurface of anterior capsular rim and posterior capsule removes remaining LECs. The reason for this is that there is bioadhesion between the anterior capsular rim and the IOL. this helps in preventing PCO. In pediatric cataract surgeries. causing a constriction of the capsular opening.9 . The reason behind this is.e. there is decrease in anterior capsular reaction which is necessary in pushing the truncated edge of IOL over the posterior capsule thereby producing a discontinuous bend. A convex plano IOL was found to be superior to the biconvex lens in inhibiting migration of LECs. Even posterior capsulorhexis without vitrectomy with or without optic capture does not prevent development of PCO. A convex plano IOL forms a firm contact between IOL and the posterior capsule which blocks migration of LECs migration behind the IOL.6 The truncated edges is equally effective in PMMA. Conversely. The impact of the truncated edge of an IOL is overcome by this retained cortex allowing lens epithelial cell growth behind IOL.4 2.5 A typical PMMA IOL with rounded edge do not prevent migrating LECs.7 Surgical Technique 1. In acrylic IOL. The squared off edge of the acrylic IOL creates a sharp bend in the posterior lens capsule.3 Intraocular Lens Design 1.

wedge is checked if 50% of the wedge is opacified . The ring is inserted Figs 8. (b) Slit lamp retroillumination photograph. The idea is to induce contact inhibition of the migrating LECs after cataract surgery. A capsule bending ring made of PMMA which has a sharp edge is inserted in the bag.Posterior capsule opacification 71 4.2a and b: (a) Slit lamp retroillumination photograph. thus preventing PCO.

ASSESSMENT OF PCO Amount of PCO can be quantified.3: Software for quantification of posterior capsular opacification into the capsular fornix before IOL insertion. haptics that are too short and flaccid will also result in PCO by not filling out the capsular bag.Evidence-based approach in cataract surgery 72 Fig. However. The PCO is found to be reduced in eyes with this ring. 8.10 Capsular Folds Folds in the posterior capsule increase the incidence of PCO. The folds occur due to long haptic length or if the haptics are too stiff. Various methods described are as follows: .

due to compartmentalization of anterior chamber. Elschnig pearl formation along the posterior capsulotomy margin after Nd: YAG laser capsulotomy is a common and significant complication. intravitreal growth factors can directly affect LECs. IOL in the bag. The authors feel it is a safe and effective procedure in human eyes also. High resolution digital retroillumination imaging: A system is developed that uses coaxial illumination and imaging with a digital camera directly linked to a computer for varification of image analysis (Fig. 8. Photographic image analysis system: Standardized slit lamp retroillumination photographs are analysed (Figs 8.13 2. hinders the dilution of these factors. A posterior capsule opacification score calculated by multiplying the density of the opacification graded from 0 to 4 by the fraction of the capsule area behind the IOL optic that is opacified. Probable causes are as follows: • Falling of pearls into the vitreous through the capsulotomy • Phagocytosis of pearls by macrophages • Cell death by apoptosis14 * Doctor Danielle Avon Rosa first demonstrated that Nd: YAG laser posterior capsulotomy was a safe and effective therapy for the treatment of PCO19 Newer Treatments of PCO Posterior capsule polishing by neodymium: YLF picosecond laser in a model eye is studied. It can be noted within 1 year after capsulotomy.11 2.3. Elimination of LECs at Time of Surgery Caffeic acid phenethyl ester which is the active component of propolis produced by Honeybees was studied in rabbit eyes. The polishing effect was seen with all energy settings. IOL was found to be safe with energy setting below 5 ml. Intraocular lens implantation and CCC may promote Elschnig pearl formation.12 Treatment of PCO Nd: YAG laser posterior capsulotomy is the definitive treatment of PCO. .2a and b. Plate 2). It may take several years after capsulotomy. 1. This eye model consisted of a latex posterior capsule facsmile to demonstrate micron level polishing to treat posterior capsule opacification. Spontaneous disappearance of Elschnig pearls after Nd: YAG laser posterior capsulotomy* is described. Energy treatment levels ranged from 5 to 15 ml. Mechanism of formation: When the posterior capsule is disrupted by the Nd: YAG laser.Posterior capsule opacification 73 1. Aqueous humor may dilute these factors to diminish their activities in aphakic eyes. Plate 1). This is because.

Apple DJ. Visessook N. Ram J. Nishi O. Randal J Olson. Tetz MR. 29:749–753. J Cataract Refract Surg 1997.16 iii. 11. 23:1539–1542. Kohnen T: Retrospective comparison of techniques to prevent secondary cataract formation after posterior chamber intraocular lens implantation in infants and children. 23:1521–1527. Nishi K: Posterior capsule opacification. J Cataract Refract Surg 1997. Wormstone I. Quinlon M. Nishi O.Evidence-based approach in cataract surgery 74 i. Salinas M. This material shows selective toxicity to certain transformed fibroblasts in carcinoma cell lines but not to normal cells. Pande M. Part II choosing the current haptic fixation and intraocular lens design to help eradicate posterior capsule opacification. Schoderbek RJ. The degree of PCO was found to be much less as compared to placebo group in which corneal absorption of catalin is very poor. Am J Ophthalmol 2003. 23:1556–1560. 23:1515–1520. Ursell P. 10. .17 iv. 106:891–900. 6. 2. et al: Cataract treatment in the beginning of the 21st century. Kato K. part 1: Experimental investigations. Catalin was examined in rabbit eyes to test its inhibitory effects on PCO. Ursell P. Koch D. 23: 657–663. 23:866–872. Linnola R: Sandwich theory: Bioactivity-based explanation for posterior capsule opacification. Peng Q. 3. et al: Spontaneous disapperance of Elschnig pearls after neodymium: YAG laser posterior Capsulotomy. 136:146–154. Cebellero A. The IMT is specific to human LECs and has been shown to be cytotoxic to these cells in υitro. J Cataract Refract Surg 1997. Pande M: Anterior capsule stability in eyes with intraocular lenses made of polymethylmethacrylate silicone. Nishi O. 9. et al: Phacoemulsification versus extracapsular cataract extraction: A comparative study of cell survival and growth on the human capsular bag in vitro. 8. 25:106–117. 14. et al: Update on fixation of rigid and foldable posterior chamber intraocular lenses.15 ii. Jr. Ophthalmology 1999. 7. Auffarth GU. J Cataract Refract Surg 1997. Nishik. et al: High-resolution digital retroillumination imaging of the posterior lens capsule after cataract Refract surgery. J Cataract Refract Surg 1997. Nishi K: Preventing posterior capsule opacification by creating a discontinuous sharp bend in the capsule. A new immunotoxin (IMT) is studied for its effectiveness to inhibit PCO following cataract surgery. Eguchi G: Effect of intraocular lens design on migration of lens epithelial cells onto the posterior capsule. hence the frequency of its administration to produce these results should be more. J Cataract Refract Surg 1997. 23:1590–1594. J cataract refract surg 1997. et al: Photographic image analysis system of posterior capsule opacification. J Cataract Refract Surg 1999. Nagamoto T. J Cataract Refract Surg 1999. and Acrysof. 4. Br J Ophthalmol 1997. 5. A major limitation of this technique is laser probe has to be used under air. Kurosaka D. 23:1532–1538.18 REFERENCES 1. 13. J Cataract Refract Surg 1997. Auffarth GV. because a viscoelastic agent plugs the hollow probe and absorbs laser energy. 81:907–910. Spalton D. et al: Elschnig pearl formation along the posterior capsulotomy. et al: Capsular opacification a preliminary report: Ophthalmic Surg Lasers 1998. 12. Nick Mamalis. 25:521–526. Carbon dioxide laser has been used in sheep and rabbits to burn the LECs in the equatorial and anterior peripheral regions of lens capsule.

et al: Prevention of posterior capsule opacification with the CO2 laser. et al: Use of the neodumium: YAG laser to open the posterior capsule after lens implant surgery: A preliminary report. 24:1614–1620. Michacli-Cohen A. 29: 985–990. Clark DS. 19. Emerg IM. Ophthalmic Surg Lasers 1998. et al: Inhibition of posterior capsule opacification with an immunotoxin specific for lens epithelial cells: 24-month clinical results. . 18. J Cataract Refract Surg 1997. 6:352– 354. 31:140–142. Ophthalmic Res 1999. 17. J Cataract Refract Surg 1998. et al: Animal study on the effects of catalin on after cataract and posterior capsule opacification. 23:1572–1576. 16. Bayramlar H. Am Intraocular Implant Soc J 1980. Belkin M.Posterior capsule opacification 75 15. et al: Caffeic acid phenethyl ester to inhibit posterior capsule opacification in rabbits. Mongre PK. Avon Rosa D. Avon JJ. Hepsen I. Biswas WR.


mask and slippers. changing room. The length of the scrubbing area should be such that one surgeon and one assistant can scrub simultaneously without touching each other elbows.Chapter 9 Prophylaxis for Postoperative Endophthalmitis MODERN OPHTHALMIC OPERATING ROOM AND INSTRUMENT STERILIZATION TECHNIQUES PREVENTION OF INFECTIONS IN OPERATING ROOM Prevention of postoperative endophthalmitis is the final goal in any cataract surgery.5 Design of the operating room complex should be such that asepsis maintenance can be managed easily in all its four areas. The washbasin should be at waist height so as to avoid the arms touching the basin. These many facets that may be divided into four main components as in Table 9. Entrance door from where one enters with usual clothes and exit through which one enters inside the operating room complex with operation room dress. Hence maintenance of asepsis in operating room rather operating room complex is important. There should be a separate room for changing clothes. scrubbing area. Operating room should have scrubbing area which is situated just outside. It should be situated at the entrance of the operating room complex. Location of Operating Room Complex Operating room complex should be located on a separate floor (top floor) of a building or at least in a separate wing of a floor. Running tap water from an overhead tank preferably through a filter (Aquaguard) should be used for hand scrubbing. . The prevention of surgical infection in the operating theater is a complex pursuit. cap. i.4 Toilets for both patients and operating room staff should not be in operating room complex. It should be away from wards where indoor patients are admitted to avoid cross-contamination. Operating room should be exclusively for ophthalmic surgical procedures and should never be shared with other surgical specialities. The tap should have a long handle for opening or closing with ones elbow with arms folded.1. transfer area and operating room proper.e. Window air conditioner is preferable over central air conditioning since the filter from window air conditioner can be easily removed and cleaned regularly. It should have separate entrance and exit doors.

intermediate level and lower level disinfectants. The sterilized instrument trays and linen can be supplied from the sterilization room to the operating room through the service window (Fig. sodium hypochlorite and quaternary ammonium compounds are considered as lower level disinfectants.2). The high efficiency particulate air (HEPA) filter system removes microorganisms ranging in size from 0. Glutaraldehyde 2%. Each operating room should not have more than one operating table. Hairs of operating room personal should be properly covered under the cap. 9. formaldehyde 6% and hydrogen peroxide 6% are considered as high level disinfectants. Number of people inside the operating room should be kept minimum. Use of brush during scrubbing should be discouraged. Phenol is considered as intermediate level disinfectant. dirt resistant less porous material (granite or marble) should be used for flooring and walls with minimum joints.9. .1). Alcohols 70 to 90%. Operating Room Environment Circulating air entering inside the operating room should be filtered air. There should be separate entrance to the patient in the operating room complex. This area contains a redline drawn on the floor.5 to 5. The door should be swing door. This redline demarcates the area where patient is shifted from outer trolley to inner one. Opening of an overhead tank should always be kept closed and its regular cleaning is necessary.5 to 5. The operating room door should be always kept closed. The operating room proper* should not be more than 20×20 feet in length and breadth. Washbasin should have a sufficient depth so that water running down from scrubbed hands should not spillover it again (Fig. To enable proper cleaning and disinfection. As sizes of most bacteria and fungi are in the range of 0. 9.10 Temperature inside the operating room should be 18 to 24°C and humidity of 55 to 80%.0 µ.0 µ diameter. It should have one entrance door and a separate service window for receiving sterilized surgical trays and instruments and disposing them after use.Evidence-based approach in cataract surgery 78 And stored water in a container should never be used. As it itself can cause minute skin abrasions which can harbor bacteria. Frequent opening and closing of doors should be avoided. Sterile Corridor This area has operating room on one side and sterilization room on other side. so that it remains closed all the time. Cleaning and Disinfection of the Operating Room Disinfectants can be divided into high level. The head end of the operating table should be away from the entrance door and it should be placed in such a way that there is enough space around it at all sides. Operating room door should be closed from inside just before starting the surgery and opened only after completion of surgery.8 If multiple serial surgeries are to be performed instrument tray for next surgery should be opened only after shifting previous patient outside and next patient inside the operating room.

Formaldehyde Fumigation Before fumigation. instrument which touches mucous membrane. the operating room is kept closed. This mixture is put into an electric boiler or a large bowl is kept over an electric hot plate. adhesive tape is applied to all apertures in doors and windows of the operating room. also high level disinfectant needed for semicritical items. Consider operating room of dimension 10 feet×10 feet of length and breadth and 10 feet in height. before shifting first patient inside the operating room. e. the operating room is sealed. After each patient’s surgery is over. stools and chairs and floor. Infected cases should be operated in separate operating room meant for the same. Regimen for Frequency of Decontamination in the Operating Room In the morning. lipophilic viruses but not against spores and tubercle bacilli. 10 to 15 ounces of formalin (40%) diluted with equal amount of water is poured over it. items recommended for cleaning are operating table mat and sides. chair. A high level disinfectant destroys all these and also spores. one litre of water plus one litre of ammonium solution used. recommended items for cleaning are entire operating table. cleaning of operating table mat and sides. instrument trolleys. punctum dilator and intermediate to low level disinfectant for noncritical items which touches intact skin. anesthesia equipment and walls. a violent effervescence takes place and formaldehyde is set free. stools. i. suture removal forceps. Rutala WA divided operating room items into critical.For the next 8 to 10 hours. Bowman’s lacrimal probe.11 Frequent wet mopping of all hard surfaces using a phenolic solution is recommended to keep the operating room environment clean. 5 ounces (1 ounce=28. For every 1 litre of 40% formaldehyde used.Prophylaxis for postoperative endophthalmitis 79 Low level disinfectants are effective against bacteria. One litre of water is mixed with 500 ml of formaldehyde (40%).13 Alternative Methods for Fumigation Permanganate method: Operating room of 1000 cu ft space. semicritical and noncritical for determining which level of disinfectant needed for which item. This enhance the effect of daily cleaning and disinfection. After turning on the boiler or hot plate. As soon as these reagents are mixed.12 Washing of operating room walls. Samples should be taken from various areas in the operating room for culture of microorganisms after fumigation.11 High level disinfectant needed for critical items like operating instruments. instrument trolleys and floor is necessary.2 gm) of potassium permangnate is placed in a jar.e. An intermediate level disinfectant destroys all these and tubercle bacilli but not spores. Operating room should be fumigated with formal-dehyde once in fortnight or after surgery on an infected case.g. ammonium solution is introduced and kept in the room for another few hours. fungi. tables and trolleys with detergent should be done weekly. If the operating room is soiled or contaminated due to any reason. . To neutralize the formaldehyde. floor.

ii. The various types of paper used are follows: i. Cleaning and drying of surgical instruments should be done before packaging. Aeromax vaporizer is used to fumigate an operating room in this method. Prevacuum sterilizer. b. Disadvantages: Spraying is not a satisfactory method as compared to vaporization of formaldehyde by boiling because fine aerosol has poor penetration. This makes dilution of 1:20. It should be of a good quality muslin having a specification of 140 thread count.e. Medical grade Kraft paper. In the west. It should be used in a minimum of two thicknesses.14 The linen wrappers are being substituted by paper products for packaging recently. Hence. Manual cleaning with high level disinfectant is considered more effective infection control measure. Microprocessor control (i. iii.3a and b): a.Evidence-based approach in cataract surgery 80 Paraform method: Formalin when heated. Crepe paper. Downward displacement sterilizer (Gravity displacement sterilizer). The reason being linen is poorly water repellant and also not a good bacteriological barrier. sterilization is much faster in prevacuum sterilizer than gravity displacement sterilizer because speed of air removal is faster in the prevacuum sterilizer. linen or textile is reusable. . the aldehyde changes into the solid polymeride paraform. Laminated paper.2). automatic control of the sterilization process by computer or microprocessor) system is preferred over manual control system. Gas is generated by heating paraform tablets. Prevacuum sterilizer displaces air from the chamber and load by vacuum pump. cheap it is commonly used for wrapping surgical trays. formalin fogging is no longer a preferred method because of its carcinogenic nature. Effective sterilization is considered when holding time of 121°C for 15 minutes is recorded. For 1000 cu feet space of operating room 30 tablets are needed. Since. Packaging After cleaning and drying of surgical instruments. they should be properly packaged for loading into the sterilizer. The downward displacement sterilizer displaces air from the chamber and load (packed instrument tray to be autoclaved) by gravity.12 STERILIZATION PROCESSES Sterilization processes can be divided into following heads (Table 9. This is vaporized for 30 minutes. Steam Sterilization Steam sterilizers are of two types (Figs 9. Formalin spray: In this method 250 cc formalin (40%) is mixed with 5 liters of tap water.

Indications Sterilization of sharp instruments which can be damaged by moist heat in steam sterilization method. a highly resistant spore forming microorganism used in spore form on paper strips for checking effectiveness of sterilization in steam sterilizer. trays should be left in the sterilizer till all the steam has escaped and it has undergone initial cooling. This sheet is placed at center of a folds of multiple towels above and below.14 Chemical indicators: It should be used in each pack and in every cycle. Monitoring of Sterilization Process For prevacuum sterilizer. . Sterilizer rack should be used inside the sterilizer so that all the surfaces of instrument trays are directly exposed to steam. These indicators show exposure to sterilization processes by means of physical or chemical change.Prophylaxis for postoperative endophthalmitis 81 iv.glazed butter paper. by which sterilization is achieved. The instrument trays should be perforated (Holes) at the bottom. Plastic film cannot be used as packaging material for steam sterilization as water cannot penetrate plastic films in liquid or vapor form. Dry Heat Sterilization Working Principle Heat is distributed equally throughout the chamber which is done by forced circulation of air with the help of fan. dry heat sterilization is less effective than steam sterilization. It should be done daily. Efficacy Since. Biological indicators are indicated during installation and after major repairs. After sterilization. The color change should occur within 3½ minutes at 135°C. These should be used inside and outside individual backs. Internal chemical indicator indicates whether penetration of sterilant was adequate. Indirectly. Bowie Dick test: It is a diagnostic test of a sterilizers’ ability to removes air from the chamber. hot air is a poor conductor and does not penetrate well. Biological indicators: Bacillus stearothermophilus. Instrument trays should be placed upright. it checks vacuum pump in a high vacuum sterilizer. An adhesive tape which is printed with chemical substance (indicator) is fixed in a shape of a cross to a piece of suitable paper. Non. This is loaded inside the sterilizer.

Specially designed plastic bags made of polyethylene are used for packing instruments. light pipe and vitrectomy culters. e. Plastic pouches designed for Eto should have paper on one side. Efficacy Ethylene oxide sterilization kills all organisms including tubercle bacilli and spores. laser probes. Temperature 37 to 60 °C depending on items. Sterilization Procedure Recommended parameters are as follows: i. There is minimal damage to sterilized instruments. Automatically controlled dry heat sterilizers are preferred over manually controlled. Exposure time 105 to 300 minutes. phacoemulsification tubings. The plastic films should be in the range of 1 to 3 mils (fractions of a inch) in thickness. Biological indicator (Bacillus subtilis) should be used once a weak. ii. ii. There is destructive oxidation of constituents inside the cell (Bacterial) by sterilization. Indications The Eto should be used only for those instruments that are liable for damage due to heat. Chemical indicator should be used with each sterilization cycle.g. . Advantages i. cryoprobes. Chemical Sterilization: Ethylene Oxide (Eto) Sterilization Working Principle Ethylene oxide alters the DNA of microorganisms by a process of alkylation thus killing them.Evidence-based approach in cataract surgery 82 Sterilization Procedure The sterilization of contents occurs at a temperature of 160°C for 60 minutes or 180°C for 30 minutes. Excess of air should be removed before sealing the plastic bag to avoid bursting of seams during sterilization. Humidity 45 to 75%. Monitoring i. iii.

When used for an extended time it destroys all spores and is considered sterilant. hence can be used for plastic or rubber material. 3. It has low surface tension which allows easy access to inner surfaces of instruments. Intermediate level disinfectant. Lack of adequate monitoring system. Disadvantages i. High level disinfectant. A 2% glutaraldehyde is the commonest high level disinfectant used. 2. Eto sterilized material that absorb Eto have to be properly aerated before use. Eto is toxic gas hence proper training of operating persons is necessary. ii. hence it is available commercially with separate alkaline buffer which has to be added before its use. Indications For sterilization of sharp instruments which are liable to get damaged by heat. Only high level disinfectant destroys all bacteria. iii. Effect of several variables on the efficacy of the process. Thorough rinsing of instruments with normal saline is necessary before use because residual glutaraldehyde is very irritating to ocular tissues. Low level disinfectant.Prophylaxis for postoperative endophthalmitis 83 ii. fungi. lipophylic virus and spores. ii. Limitations Sterilization by glutaraldehyde is not recommended due to: 1. Hence. 2. Properties of 2% Glutaraldehyde i. Stable in alkaline solution. Procedure Instruments to be sterilized are left in the solution for few hours. Cleaning of Surgical Instruments . It is noncorrosive. surgical instruments require high level disinfectant for sterilization. Chemical Sterilization by Liquid Chemical Agents Liquid chemical agents are classified according to their germicidal activity as: 1. Can pack the instruments before hand and once sterilized can be stored for relatively long time.

Hence.16 Postoperative endophthalmitis is one of the most serious conditions that can occur after routine and otherwise uncomplicated cataract surgery. Cleaning method can be either manual or mechanical.) through liquids. carefully controlled prospective and masked studies of systems for infection prevention have not been reported.15 Phaco and irrigation/aspiration handpieces which contain lumen should not be cleaned in ultrasonic cleaners. a.14. ii. iv.12. Method i.Evidence-based approach in cataract surgery 84 i.17 There are large number of variables in operating techniques among various surgeons. By this action bacteria are disintegrated and there is coagulation of protein matter. e.g. iii. Alkaline detergents easily removes protein soils and protein-enzyme dissolving solution should be used for devices having lumens. Tip of the instruments are cleaned using distilled water. as evidenced by the good matches between bacteria of infected wounds and those of the team or the patient and by the poor matches between bacteria of infected wounds and airborne bacteria. b. Any blood or debris are removed from its surface using an instrument wipe or sponge. Manual method: It includes rinsing the instrument with plenty of tap water to remove detergents (deionized and distilled water preferred over tap water) followed by drying. Fortunately its occurrence is rare (5 to 10 cases/1000). PROCEDURES FOR POSTCATARACT SURGERY ENDOPHTHALMITIS PROPHYLAXIS The surgical team and the patient are the prime sources of contamination during an operation. When these bubbles collapse they create a negative pressure on the particles in the suspension. In ultrasonic cleaners. ii. iii. Because the presence of soil on instruments inhibits the contact of a sterilant with microbial cell thus reducing its effectiveness. Mechanical method: It is done in ultrasonic cleaners. v. Then washing of instruments done in detergent solution.000 Hz. The instruments. Submicroscopic bubbles are generated by these waves. All reusable operating instruments should be cleaned thoroughly prior to sterilization. if composed of more than one part should be disassembled before cleaning. iv. This can be one of the factors that hinders investigation of prophylactic measures. It is not possible to sterilize an instrument without cleaning it first. Cleaning should be started as soon as possible after use. phacoemulsification tips. Drying of instruments is necessary before packing in trays. sound waves are passed at high frequency (100. Irrigating their lumen with high pressure water jet is recommended before sterilization.18 SOURCES OF INFECTIONS .

Surgical instruments. It is found to reduce rate of nosocomical infections more effectively than alcohol and soap. . Patients own ocular flora. It is recommended to scrub hands and arms above elbow for 7–8 minutes with soap alone. Recommended methods of hand hygiene include handwashing (washing hands with plain soap). irrigating solutions. Scrubbing twice with 7. IOLs. for 2 minutes each is adequate (Fig. 4. 7% of organisms are gram-negative bacteria and fungi constitutes only 3% of all causative organisms.20 Various prophylactic interventions recommended for this are preoperative topical antibiotic.4.23 Patients own ocular flora was found to be the main source of postoperative infection.19 Staphylococcus epidermidis and Staphylo-coccus aureus are the two most common organisms causing postoperative endophthalmitis.22. hygienic handwash (washing hands with medicated soap) and hygienic hand-rub (use of antiseptic rubs).5% povidone iodine scrub is another hand disinfecting agent. preoperative use of povidone iodine.5% povidone iodine scrub. Chlorhexidine can be used for hand disinfection system. Irrigating solutions and viscoelastics are recommended to inspect before the use for intact packing and for obvious contamination of vial in the form of particulate matter. etc.25 The 7.Prophylaxis for postoperative endophthalmitis 85 Origins for infection includes the followings: 1. lids and adnexa. viscoelastics. Operating room environment. Skin and respiratory flora of surgeon and assistant. 3. Causative Organisms Ninety percent of causative organisms are gram-positive aerobic bacteria.20. 9. 2. Plate 3).21 These organisms are the most common organisms which can be recovered from patients eyelids.24 Of these hygienic hand-rub is the best technique.

5% povidone iodine scrub .Evidence-based approach in cataract surgery 86 Fig.4: 7. 9.

Povidone iodine is bactericidal in 30 seconds. Commonly used prophylactic interventions can be applied preoperatively. 9.5: 5% povidone iodine PROCEDURES A number of sources of postoperative infection may be targeted for prophylaxis.26 Topical antibiotics should be instilled only one day before surgery and should never be instilled more than 6 to 8 times on that day.Prophylaxis for postoperative endophthalmitis 87 Fig. There are a number of prophylactic techniques to decrease the risk of postoperative endophthalmitis. There is no need for irrigating it out of one eye before surgery. Preoperative Use of Povidone lodine Topical 5% povidone iodine applied once preoperatively has been shown to reduce the incidence of endophthalmitis by a factor of three (Fig. Instillation of topical antibiotics for more than one day preoperatively leads to alteration of patients own bacterial flora and replaced by more virulent organisms. Plate 3). Preoperative Topical Antibiotics The role of topical preoperative antibiotics in reducing postoperative infection is documented. intraoperative and postoperatively.5. But. 9. justification of their use from the past literature is unclear.28 .27 Hence it should be discouraged.

Current literature strongly recommends the use of preoperative povidone iodine antiseptic for postoperative endophthalmitis prophylaxis in cataract surgery. But. Beigi B et al found 20% positive anterior chamber aspirate cultures in the group that received no antibiotics in irrigating solution as compared to 2. i. There is no evidence supporting lash trimming as a means of decreasing the ocular surface flora. studies evaluating aqueous contamination rates show mixed results.33 On the contrary. The adhesive drape is applied after opening the lids widely. lid margins and adjacent skin with 5% povidone iodine.34 ii. This intervention has not been shown to reduce ocular surface flora aqueous contamination. Exposure to antibiotics for a short duration as in intraocular surgery has little effect on organisms responsible for endophthalmitis.31 Schmitz S et al showed that lash trimming is not associated with any reduction in the incidence of postoperative infection. lid margins and adjacent skin.32 Antibiotics in Irrigating Solution Another intervention for postcataract surgery endophthalmitis prophylaxis is supplementing irrigating solutions with antibiotics.27 iii. 3. 2.29 Preoperative Preparation of the Eye The regimens for preoperative antisepsis used to prepare the ocular surface are as follows: 1. lid margins and surrounding skin after cleaned with 5% povidone iodine twice and allowed to dry. Hence.30 ii. This prevents to reduce passage of microorganisms into the eye.7% cultures from group that received antibiotics in irrigating solution (vancomycin 20 mg/L and gentamicin 8 mg/L). Saline irrigation of conjunctiva. Schmitz S et al found no reduction in the incidence of endophthalmitis with this intervention. is an effective method of eliminating microbes.32 Current trend is not trimming the lashes but isolating them with sterile adhesive drapes. few literatures suggest no beneficial effect of antibiotics in irrigating solution as postoperative endophthalmitis antisepsis. Cleaning the lids. i. It is cleared from the anterior chamber very quickly.Evidence-based approach in cataract surgery 88 There are no adverse reactions due to topical povidone iodine noted. Saline irrigation of conjunctival sac. The reasons for this being as follows. Five percent povidone iodine used for cleaning of lids. preoperatively is commonly practiced.35 . The drape is cut between the lids and the eye speculum is applied such that the drape is under the arms of speculum thus isolating the eyelashes.30 Recommended procedure: Lids. Eyelash trimming. The half-life of gentamicin in the anterior chamber after completion of phacoemulsification is 51 minutes. the bactericidal levels required for reliable antibiotic prophyaxis is never maintained.

49:59–69. Tamai S: History of microsurgery—from the beginning until the end of the 1970s. 100–101. Haeseker B: Microsurgery: A ‘small’ surgical revolution in the medical history of the 20th century. epidermidis to regular PMMA IOLs. Heudorf U. 12(5): 271–275.12(3):158–160. 3.38 REFERENCES 1. 12. A publication from the hospital infection society-India. Indian J Ophthalmol 2001. 58(4):439–445. 18:99–117. Gesundheitswesen. Voigt K: Hygienic procedures in operation theatres—guidelines and reality. 14. Kaushik S. there is no significant difference found in the rate of culture positive anterior chamber aspirates between the heparinized group and the control group. 104. Guidelines for Infection control practice in APIC guideline for selection and use of disinfectants. Arking L: Ophthalmology operating room standards and infection control concerns. Indian J Ophthalmol 1996. Med Instrum. Fitzgerald RH Jr: Microbiologic environment of the conventional operating room. S. S. epidermidis. Arch Surg 1979 Jul. Bynum PS. devices. Ayliffe GA: Role of the environment of the operating suite in surgical wound infection.37 Subconjunctival Antibiotics Subconjunctival antibiotics after cataract surgery is found to reduce postoperative infection but this reduction was found to be statistical insignificant. Bacterial strains.143(16):858–864. 13 Suppl 10:S800– S804. 1993. 1978 May–Jun. Au YK. Ram J. Rev Infect Dis. 14(1):6–13. 5. 1991 Sep–Oct. Data obtained on hygiene control measures by public health service at Frankfurt am Main. 11. Mehtra G: The sterile supply department. Pfetzing H. i. 65(5):312–320.Insight: The value of the ORN. Poole T: Increasing OR efficiency with a specialty services manual. Am J Infect Control. 1997. Literature is not conclusive regarding the choice of antibiotic though gentamicin is found to be most effective drug. and discipline in operating room infcction control. Laufman H: Design. Sharma S. 114(7):772–775. Rutala WA. Kutzke G. 2. Bansal AK. areuginosa were found attached in significantly lower numbers to heparin surface modified IOLs than to PMMA IOLs alone. Ruehl C. . Guidelines for planning and quality management. 1984 Oct. AORN J 1996 Jul. This is due to heparin reduces adherence of those bacteria by placing a highly hydrated layer between the bacteria and surface of IOL. Heparin in irrigating also inhibits attachment of S. 4. Ophthalmic Registered Nurse. Microsurgery. Jun 22(2):37–38. Schonholtz GJ: Maintenance of aseptic barriers in the conventional operating room: General principles. Am J Inf Control 1990. 2003 May. 1999 Apr 17. Saravolatz LD.Prophylaxis for postoperative endophthalmitis 89 Heparin in Irrigating Solution and Heparin Surface Modified IOL This intervention for postcataract surgery endophthalmitis prophylaxis also has mixed result. et al: Asepsis in Ophthalmic operating room.e. Hentschel W. Ned Tijdschr Geneeskd. et al: Prevention of postoperative Infections in ophthalmic surgery. 8. 7. J Bone Joint Surg Am 1976 Jun. 9. 13. 10. 64(l):96–98. aureus and P. 44:173–177. 6.36 But.

Beigi B. et al: Results in the treatment of postoperative endophthalmitis. 109:13–26. J Cataract Refract Surg 1997. 29. Kaushik S. Ophthalmology 1991. Gritz D C.10 50–53. 87:313–319. Olson JC. et al: Antibiotics supplementation of intraocular irrigating solutions. discussion 650. Flynn HW Jr. J Cataract Refract Surg 97. Kattan HM. Manners TD. et al: Endophthalmitis in cataract surgery.98:1769–1775. 122:1–17. et al: Reduced bacterial adhesion to heparin surface modified intraocular lenses. et al: Nosocomial endophthalmitis survey. An in vitro model of antibacterial action. Results of a German Survey. Milch FA. 103:1204–1208. 21. Br J Ophthalmol 1997. 18. . Reducing cataract related complications. et al: Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. 31. 27. 24:725–726. Ophthalmology 1991. 24. et al: Spectrum and susceptibilities of microbiologic isolates in the endophthalmitis vitrectomy study [published erratum appears in Am J Ophthalmol 1996. J Cataract Refract Surg 1998. et al: Comparative efficacy of alternative hand washing agents in reducing nosocomial infections in intensive care units. Refojo MF. Ophthalmology 1994. 19. 26. Speaker MG. norfloxacin and ofloxacin into the aqueous humour. et al: Prevention of postoperative infections in ophthalmic surgery. Ophthalmic Surg 1977. 106:1869–1877. diagnosing and treating endophthalmitis. 23. Ram J. Michael B Starr. 25. 19: 755–759. 32. 37.Evidence-based approach in cataract surgery 90 15. 22. Portoles M. Flynn HW Jr. Ram J. 98:639–649. 23:883–888. et al: heparinized intraocular infusion and bacterial contamination in cataract surgery. Donnenfeld ED. Wisniewski SR.Meinikoff JA: Prophylaxis of endophthalmitis with povidone-iodine. Thompson JP. Mistlberger A. 38. Ophthalmology 1991. Masket S: Preventing. Am J Ophthalmol 1996. et al: Lid flora in blepheritis. Cevallos AV. 48 Suppl A: S23–S28. 36. 33. et al: The effect of intracameral. J Cataract Refract Surg 1993. 12:390–394. Groden LR. Ruckhofer J. Starr MM: Prophylactic antibiotics for Ophthalmic surgery. Turner DPJ. Ophthalmology 1983. 101:902–905. Lehmann OJ. Arch Surg 1979 Jul. Current incidence of infection after intraocular surgery. 30. Ophthalmology 2002. Skaggs C: Preoperative topical antibiotics and lash trimming in cataract surgery. Speaker MG. Han DP. 47:153–154. Murphy B. 34. 81:949–952. per-operative antibiotics on microbial contamination of anterior chamber aspirates during phacoemulsification. Eye 1998. Am J Ophthalmol 1982. Schrier A. 17. 28. Cornea 1991. Laufman H: Airflow effects in surgery. 114(7): 826–830. 27:353– 373. et al: Anterior chamber contamination during cataract surgery with intraocular lens implantation. 20. Indian J Ophthalmol 1999. Perry L D. et al: Penetration of topically applied ciprofloxacin. Wendt C: Hand hygiene—comparison of international recommendations. Ophthalmology 1996. 8:44–28. Doebbeling BN. 49:59–69. Stanley GL. Surv Ophthalmol 1983. Ophthalmology 1999. et al: Half-life of intracameral gentamicin after phacoemulsification. Dick H B. 98:227–238. Indian J Ophthalmol 2001. discussion 1208–1209. 122:920]. 16. Schmitz S. 93:518– 519. N Engl J Med 1992 Jul 9. Westlake W. et al: Bacterial Endophthalmitis prophylaxis for cataract surgery. J Hosp Infect 2001 Aug. 35. Austin GC: Efficient storage of sterilized surgical instruments. 23:1064–1069. 327:88–93. Thomas A Ciulla.


99 Disposable nylon hooks 69 Dodick photolysis 28 Dropped nucleus 94 E Erbium: YAG laser system 26 Extracapsular cataract surgery 12 F Foldable IOLs 12 Formaldehyde fumigation 138 Future intraocular lens 53 G Glutaraldehyde 136 H Hard cataract 60 .Index A A-scan biometry 104 Acrylic IOL 40 Acute suprachoroidal hemorrhage 97 Antibiotics in irrigating solution 154 C Capsular folds 123 Capsular tension ring 66 Capsulorhexis 79 Cataract surgery 1. 120 Conventional phacoemulsification 24 D Defractive multifocal IOL 45 Descemet’s membrane detachment 79. 76. 86 complications 86 in a patient with uveitis 76 newer anesthesia modalities 1 newer incision techniques 11 Classic air bubble technique 72 Clear corneal incision 18 Continuous curvilinear capsulorhexis (CCC) 63. 11.

118 polymethyl-methacrylate (PMMA) 41 silicone IOL 42 IOL implantation 80 IOL power calculation 103. 111 in patients with high myopia 112 in pediatric cataract 111 of silicone oil filled eyes 113 K Kelman tip 61 Keratometric diopters 107 Keratometry 106 Koch’s basic incision 16 Kratz’s scleral pocket incision 17 L Laboratory microscope 133 LASIK 107 Layout of an ideal operating room complex 135 M Modern phacoemulsification system 25 Multifocal IOL 45 N Nd:YAG laser posterior capsulotomy 124 Neodymium: YAG laser phacoemulsification 28 93 .Index Heparin surface modified (HSM) IOL 81 Heparin surface modified PMMA IOLs 51 Hydrodelineation 63 Hydrodissection 63 Hydrophilic acrylic IOL 49 Hydrophobic foldable acrylic IOL 48 I Incision clear corneal 12 scleral tunnel 12 Injectional anesthesia 4 Intracameral anesthesia 7 Intracameral subcapsular injection 73 Intracapsular cataract surgery 12 Intraocular inflammation 76 Intraocular lens position of 121 Intraocular lens design 121 Intraocular lens implantation in children ideal IOL material 51 ideal IOL size 52 Intraocular lens materials 41.

59. 65. 71 in difficult situations 59 in hard cataracts 60 in subluxated cataract 65 in white cataract 71 of nucleus 64 Phaconit 35 Photon laser phacolysis 30 Polymethyl methacrylate (PMMA) IOL 40 Posterior assisted levitation 96 Posterior capsular tear 89 Posterior capsule opacification 117 Posterior polar cataract 62 Postoperative endophthalmitis 149 Preoperative preparation of the eye 152 Preoperative topical antibiotics 152 Preoperative use of povidone iodine 152 Prophylaxis for postoperative endophthalmitis 129 R Recent advances in intraocular lens 39 Refractive multifocal IOL 46 S Sandwich theory 118 Scleral tunnel incision 13 chevron incision 15 curvilinear incision 13 frown incision 14 94 . 60. 64.Index NeoSonix phacoemulsification 31 New phacoemulsification technologies 23 O Operating room 130 cleaning 136 disinfection 136 environment 134 location 130 prevention of infections 130 Orbital hemorrhage 86 P Partial coherence interferometry (PCI) 104 advantages 105 limitations 105 PCO assessment of 123 newer treatments 125 treatment of 124 Peribullar anesthesia 60 Phacoemulsification 12.

Index 95 incisional funnel 13 internal configuration 16 straight incision 14 Silicone IOL 40 Small incision advantages 12 Small incision surgery 87 Sonic phacoemulsification 30 Sterilization processes 139 chemical sterilization: ethylene oxide (Eto) sterilization 144 chemical sterilization by liquid chemical agents 146 dry heat sterilization 143 steam sterilization 140 Sub-Tenon’s (Parabulbar) anesthesia 8 Subconjunctival antibiotics 155 Subluxated cataract 65 T Thermodynamic injectable IOL 53 Three-piece monofocal silicone IOL 45 Three-step corneal valve incision 17 Topical anesthesia 3 advantages 5 contraindications 5 Topical eyedrop anesthesia 6 Toric IOL 44 Trypan blue 73 Trypan blue staining 74 U Ultrasound phacoemulsification 26 V Vitrectomy 92 W White cataract 71 WhiteStar technology 32 .

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