31/07/2017

CATARACT SURGERY
PAST-PRESENT-FUTURE

Presenter- Moderator -
Dr. Rohit Agrawal Dr. Sachin Daigavane Sir

Conductor-
Dr. Archana Thool Ma’am
PAST PRESENT FUTURE
INTRODUCTION
• HISTORY OF CATARACT SURGERY
• COUCHING
• ICCE
• CONVENTIONAL ECCE
• ERA OF IOL
• SICS
• PHACOEMULSIFICATION
• MICS
• FEMTO SECOND LASER CATARACT SURGERY
• ZERO ENERGY CATARACT SURGERY
• FUTURE ON-GOING RESEARCH
 HISTORY OF CATARACT SURGERY
 4000 YEARS BACK- SHUSHURUTA - COUCHING
 1600 A.D.- DEVIES - ICCE
 20th CENTURY- ECCE
 40 YEARS BACK- SUTURES + ICCE WITH IOL
 20 YEARS BACK- SUTURES + ECCE WITH IOL
 15 YEARS BACK- PHACO EMULSIFICATION
 RECENTLY- TOPICAL TORSIONAL MICROPHACO WITH
FOLDABLE MULTIFOCAL/TORIC LENSES
 NOW & FUTURE - FEMTO CATARACT
COUCHING
• Also known as “LENS DEPRESSION”
• Involves using a sharp instrument to push the cloudy lens to the bottom of the
eye
• It was done “WITHOUT A MICROSCOPE”
• A sharp instrument, such as a thorn or needle, is used to pierce the eye either at
the edge of the cornea or the sclera, near the limbus
• The opaque lens is pushed downwards, allowing light to enter the eye.
• Once the patients sees shapes or movement, the procedure is stopped
• The patient is left without a lens (aphakic)
ICCE- INTRACAPSULAR CATARACT
EXTRACTION
• In this technique, the entire cataractous lens along with the intact capsule is
removed.
• Weak and degenerated zonules are a pre-requisite for this method.
• A cryoprobe is used to remove the lens complete with its capsule
• After which anterior chamber IOLs are implanted
• It has been almost entirely replaced by planned extracapsular technique
• At present the only indications of ICCE is markedly subluxated and dislocated
lens.
• ADVANTAGES OF ICCE:
• Simple, cheap, easy and does not need sophisticated microinstruments
• ICCE is less time consuming
• Can be done in dislocated or subluxated lens

• DISADVANTAGES OF ICCE:
• PCIOL cannot be implanted
• Post-op complications like C.M.E., R.D., endophthalmitis are more
CONVENTIONAL EXTRA CAPSULAR
CATARACT EXTRACTION-
• In this technique cataract is extracted by making an opening in the anterior
capsule of the lens known as anterior capsulotomy.
• Corneo-scleral section from 10-2 o’ clock is made for cataract extraction
• In this type of operation rigid PCIOL is inserted in the capsular bag.
• And corneo-scleral section is then sutured with 9-0 or 10-0 sutures
Types of Capsulotomy-
• CAN OPENER CAPSULOTOMY

• CONTINUOUS CURVILINEAR CAPSULORRHEXIS

• LINEAR CAPSULOTOMY (ENVELOPE TECHNIQUE)
ERA OF IOLs-
• Sir Harold Ridley was the first to successfully implant an intraocular lens on
November 29, 1949, at St Thomas' Hospital , London.
• That first intraocular lens was manufactured from Polymethylmethacrylate
(PMMA)
TYPES OF IOL-

ACIOL PCIOL
 EVOLUTION OF IOLs
1. First generation IOLs

• Ridley lenses
• Disadvantages – posterior dislocation
poor surgical technique

2. Second generation IOLs

• Rigid and semi-rigid anterior chamber IOLs

• Advantages – reduce posterior dislocation
• Disadvantage – corneal decompensation
UGH syndrome
3. Third generation IOLs

• Iris supported lens

• Advantages- less corneal decompensation
• Disadvantages – iris chaffing
pupillary distortion
inflammation
4. Fourth generation IOLs

• Modern anterior chamber lens

• Flexible loops and multiple point fixation
• Advantages – more stable, better design, less complications
• Disadvantages – anterior chamber is not the physiological site for IOL
5. Fifth generation IOLs

• PMMA lenses
• Rigid posterior chamber iol
6. Sixth generation IOLs

Foldable IOL

7. Seventh generation IOLs

Multifocal IOL
8. Eighth generation IOLs

Accomodative IOL

Phakic refractive IOL

SICS- MANUAL SMALL INCISION CATARACT
SURGERY
• In this technique ECCE with intraocular lens implantation is
performed through a sutureless self-sealing valvular
sclerocorneo tunnel incision.
• Types of incision in SICS-
1. Frown incision

2. Straight incision
Steps in manual SICS

SUPERIOR
RECTUS BRIDLE
SUTURE

CONJUNCTIVAL
FLAP

SCLERAL
INCISION
 SCLERO-CORNEAL
TUNNEL WITH
CRESENT KNIFE

SIDE PORT ENTRY

AND ANTERIOR
CAPSULOTOMY

ENTRY INTO
ANTERIOR CHAMBER
FROM TUNNEL AND
ITS EXTENSION
HYDRODISSECTION
AND
HYDRODELINATION

NUCLEUS PROLAPSE
INTO ANTERIOR
CHAMBER

NUCLEUS DELIVERY
IRRIGATION AND
ASPIRATION OF
THE CORTEX

PCIOL
IMPLANTATION IN
THE CAPSULAR
BAG

WOUND CLOSURE
PHACOEMULSIFICATION-
• Phacoemulsification, introduced by Kelman in 1967, is
undoubtedly one of the most important innovations in
ophthalmology.
• This allows the removal of cataract through a 3.0 mm incision,
thus eliminating many of the complications of wound healing
related to large incision surgery and greatly shortens the recovery
period.
• Cataract is emulsified using ultra-sonic energy.
• Ultrasonic power is most often produced by enclosed
piezoelectric crystals which convert electricity into mechanical
vibration.
• Normal frequency of various phaco machines ranges from 20,000
to 80,000 (20-80 KHz) Hertz.
• Phaco machines come with a foot switch to control functions of
the machine.
STEPS IN PHACOEMULSIFICATION-
CLEAR
CORNEAL
INCISION

SIDE PORT
ENTRY

CAPSULOTOMY
 INITIAL
TRENCHING

FOUR QUADRANT
DIVIDE AND
CONQUER

PHACO CHOP
IRRIGATION AND
ASPIRATION

PCIOL
IMPLANTATION
(MOSTLY
FOLDABLE IOL)

WOUND
APPOSITION BY
HYDRO
MICS- MICRO INCISIONAL CATARACT
SURGERY
• Micro incision cataract surgery (MICS) is an approach to cataract surgery
through incision less than 1.8 mm with the purpose of reducing surgical
invasiveness, improving at the same time surgical outcomes.
• The main confirmed advantages of MICS are the control and avoidance of
surgically induced corneal astigmatism and the decrease of postoperative
corneal aberrations.
• Microincision cataract surgery (MICS) was described first time by one of the
authors named Jorge Alió in 2002 in Spain
• Agarwal et al. and Tsuneoka et al. described in parallel this surgical approach to
cataract surgery with other denominations such as Phaconit or bimanual
phacoemulsification-aspiration.
Phaco probe tips-
• These are made up to titanium.
• It can have an opening angulation of 0°,
15°, 30°, and 45°.
• Greater angulation facilitates sculpting
whereas lower angle is good for occlusion.
• The tip is covered with silicon sleeve that
insulates and protects the tissue at the
incision site.
FEMTO SECOND CATARACT SURGERY-
• Current femtosecond laser technology systems use
neodymium:glass 1053 nm (near-infrared) wavelength light.
• This feature allows the light to be focused at a 3 mm spot size,
accurate within 5 mm in the anterior segment
• It works on the principle of photodisruption.
• Uses-
1. CLEAR CORNEAL INCISION
2. ARCUATE INCISION
3. CCC
4. LENS FRAGMENTATION
FEMTOSECOND CATARACT SURGERY Video….
ZERO ENERGY CATARACT SURGERY-
• Laser assisted cataract surgery has opened the door towards zero
energy(ultrsonic) cataract surgery.
• Through femtosecond laser it is possible to fragment the nucleus
into very small aspirable particles
• This results in zero or negligible use of phacoenergy for breaking
the nucleus
• Can be done for grade 2-3 cataracts
NEW INNOVATIONS-
• VERION
• It is a image guided system for phaco catarct surgery
• It gets linked to the operating microscope
• It takes into consideration keratometry readings of the patient
• Has 3 functions-
• Shows the surgeon exact position for incision which will cause least
astigmatism
• Shows the size of capsulorhexis
• Centration after IOL implantation
• CAPSULAR TENSION RINGS

• MALYUGIN RING
 FUTURE ON GOING RESEARCH
• The idea of rebuilding the crystalline lens by
filling it with an appropriate substance goes
back at least to Julius Kessler (1959).
• Initial experiments in this field date from
1981, and in 1987 the group led by Jean-
Marie Parel in Miami demonstrated on
primates the viability to recover
accommodation by means of replacement of
the lens material by a transparent gel
• Various laboratories throughout the world
are currently working on a project named
Phaco-Ersatz (substitution of the crystalline
lens)
References-
• PARSON’S DISEASES OF EYE
• A.K. KHURANA
• KANSKI CLINICAL OPHTHALMOLOGY
• DOS JOURNAL
THANK YOU….
NEXT PG ACTIVITY
• 01/08/2017
• CASE PRESENTATION
• PRESENTER- DR. SAPAN SIR
• MODERATOR- DR. KAMBLE MADAM
• CONDUCTOR- DR. ARCHANA MADAM