undergraduate lecture-visual rehabilitation after cataract surgery
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Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Visual rehabilitation after Cataract Surgery
Dr. Zia-Ul-MazhryDr. Zia-Ul-MazhryFCPS(Pak), FRCS(Edin),FCPS(Pak), FRCS(Edin),
FRCS(Glasgow), CIC Ophth- (UK)FRCS(Glasgow), CIC Ophth- (UK)
Consultant Eye Surgeon & Consultant Eye Surgeon & Head, Department of Head, Department of
Ophthalmology Ophthalmology Wapda Hospital Complex Lahore.Wapda Hospital Complex Lahore.
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Discussion Plan1949 to 2009 & Beyond
Cataract surgery
Couching Extractionextra capsular
In toto removalICCE
Micro surgeryE Cap+IOL
E Cap IOL
phaco LS Aq MICS
?
PMMA Soft m focal acc
?
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Can we learn
about the futurefrom the past?
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
golden age for ophthalmology OphthalmologyOphthalmology first emerged as an independent first emerged as an independent
subspecialty in the early 19thsubspecialty in the early 19th century. century. Acquisition of knowledge proceeded rapidly and Acquisition of knowledge proceeded rapidly and
importantimportant discoveries were made.discoveries were made. Pioneers, as exemplified by vonPioneers, as exemplified by von Graefe, von Graefe, von
Helmholtz, Fuchs, and Gullstrand, to mention a few Helmholtz, Fuchs, and Gullstrand, to mention a few contributed a lot.contributed a lot.
This rapid progress was slowed between 1914 and This rapid progress was slowed between 1914 and 1945 by the1945 by the darkness of the World Wars.darkness of the World Wars.
Ridley's work and the successRidley's work and the success of many others of many others during and after World War II helped remedy this.during and after World War II helped remedy this.
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Cataract Surgery in Antiquity
Arab to Latin / Europe
ArabsK itab-e-susrud
8th cent
G reece/R om an28-40AD
IndiaSushruta
1000 yrs BC
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
1000 years BC Sanskrit Sanskrit
manuscripts 5th manuscripts 5th century B.C. century B.C. describe describe couching. couching.
Couching was Couching was perfected by perfected by Sustruta (the Sustruta (the Hippocrates of Hippocrates of India) in the 6th India) in the 6th century BC.century BC.
Mentioned in Mentioned in Mahabartha Mahabartha 1000yrs bc1000yrs bc
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Partial Extracapsular Cataract Extraction
Predecessor- ArabsPredecessor- Arabs– Ammar ibn-e- Ali Almousali 100ADAmmar ibn-e- Ali Almousali 100AD
» Used metallic hollow needle (al miqdah) to aspirateUsed metallic hollow needle (al miqdah) to aspirate John Daviel 1745-48John Daviel 1745-48
– E Cap from Inferior limbusE Cap from Inferior limbus
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
In Toto Extraction(ICCE)
Samuel Sharp LondonSamuel Sharp London– Ideal InstrumentIdeal Instrument
» The thumb Col SmithThe thumb Col Smith» Capsular forceps H AurugaCapsular forceps H Auruga» Erysiphake(Phako erysis} Ignacio Barraquarre Erysiphake(Phako erysis} Ignacio Barraquarre
19171917» Cryo ExtractionCryo Extraction
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Cataract Surgery in the 20th Century
Enzymatic ZonulysisEnzymatic Zonulysis» In 1957, Barraquer of Spain used In 1957, Barraquer of Spain used
alpha-chymotrypsin to enzymatically alpha-chymotrypsin to enzymatically dissolve the zonules for removal of the dissolve the zonules for removal of the lens. lens.
Cryo SurgeryCryo Surgery» In 1961, Krawicz of Poland removed In 1961, Krawicz of Poland removed
the lens with a tiny probe attached by the lens with a tiny probe attached by freezing a small area on the surface of freezing a small area on the surface of the cataract. the cataract.
Ultrasonic EmulsificationUltrasonic Emulsification» In the late 1960s, Charles Kelman of In the late 1960s, Charles Kelman of
New York developed a technique for New York developed a technique for emulsifying the lens contents using emulsifying the lens contents using ultrasonic vibrations and aspirating ultrasonic vibrations and aspirating the emulsified cataract. the emulsified cataract.
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Development of Micro Surgery
– AnesthesiaAnesthesia» Topical (Koller- Cocain 1884)Topical (Koller- Cocain 1884)» Reterobulbar(Elchnig 1928)Reterobulbar(Elchnig 1928)
– SuturesSutures» Silk (Williams 1865)Silk (Williams 1865)» Conjunctival (JA Barraquarre 1880)Conjunctival (JA Barraquarre 1880)» Corneoscleral (Kalt 1894)Corneoscleral (Kalt 1894)
– Microscopes Microscopes – The first eye surgery performed with an operating The first eye surgery performed with an operating
microscope was done in Portland, Oregon, in 1948 microscope was done in Portland, Oregon, in 1948 » Zeiss 1955Zeiss 1955» JJB 1964-1966JJB 1964-1966
– Instruments & Mechanization& adjuvantsInstruments & Mechanization& adjuvants» I/A machines, Phaco, ViscoelasticsI/A machines, Phaco, Viscoelastics
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Sir Harold Ridley, Kt, MD, FRCS, FRS the inventor of IOL
– Dr Ridley was born in Dr Ridley was born in Kibworth, Leicestershire, Kibworth, Leicestershire, England, onEngland, on July 10, July 10, 1906.1906.
– One of the founders of One of the founders of the modern the modern subspecialty of cataract subspecialty of cataract and refractive surgery, and refractive surgery, passed away on May passed away on May 25, 2001, just 6 weeks 25, 2001, just 6 weeks before his 95th birthdaybefore his 95th birthday
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
First IOL: A Secondary Procedure
– The insertion of the The insertion of the pseudophakos pseudophakos manufacturedmanufactured by by Rayner Ltd, Rayner Ltd, London, was a London, was a secondary secondary procedure procedure performed onperformed on
February 8, 1950, February 8, 1950, after Ridley had after Ridley had verified that the eye verified that the eye waswas quiet and quiet and suitable for suitable for implantationimplantation
(David Spalton, MD, written(David Spalton, MD, written communication, December 1998).communication, December 1998).
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
"foreign body" in the eye?
– Sir Harold Ridley Sir Harold Ridley performed first performed first IOL implantation IOL implantation on November 29, on November 29, 1949.1949.
long-standing long-standing dogma that one dogma that one "should never "should never put a foreign put a foreign body into the body into the delicate tissues delicate tissues of the eye“of the eye“
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
non–IOL-related contributions
– A pigmented fundus tumor A pigmented fundus tumor treated by irradiation, 1971treated by irradiation, 1971
– an early keratoprosthesis, an early keratoprosthesis, fabricated from pmma fabricated from pmma designed by Ridleydesigned by Ridley
– Ridley was the first to televise Ridley was the first to televise eye operations in 1950eye operations in 1950
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Sir Harold Ridley, Kt, MD, FRCS, FRS the inventor of IOL
– Sir Harold Ridley Sir Harold Ridley performed first IOL performed first IOL implantation on implantation on November 29, November 29, 1949.1949.
long-long-standing standing dogma that dogma that one "should one "should never put a never put a foreign body foreign body into the into the delicate delicate tissues of tissues of the eye“the eye“
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Era of IOLs
» Rigid AC IOLRigid AC IOL Barron, Strampeli Barron, Strampeli
1952-19531952-1953» Flexible AC IOLFlexible AC IOL
Closed Loop Closed Loop Danheim 1956Danheim 1956
Open Loop J Open Loop J shaped J Barraquer shaped J Barraquer 19581958
» Pupil SupportedPupil Supported Epstein Epstein
Binkhorst,Worst Binkhorst,Worst 60s-70s60s-70s
» New AC IOLNew AC IOL Choyece, KelmannChoyece, Kelmann
»PC IOLPC IOLShearing 1976 (J Shearing 1976 (J Loop)Loop)SinskieSinskieSimcoe (C Loop)Simcoe (C Loop)KartzKartz
»Intra Bag IOLsIntra Bag IOLs
»Foldable IOLFoldable IOL
»Phaco-Ersatz Phaco-Ersatz
»M B focal/ accomM B focal/ accom
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
The greatest fear known to man is a new idea.
PhacoemulsificationPhacoemulsification was first was first introduced in 1967introduced in 1967– 1969 “Charlie has produced an operation which will
take all the fun out of cataract surgery.”– 1974 “The use of the phaco machine for the
removal of a cataractous lens is analogous to the shooting of game birds with guided missiles.”
If you have strong reasons to believe in your If you have strong reasons to believe in your ideas, have confidence—face the brickbats and ideas, have confidence—face the brickbats and go ahead.—Harold Ridley, MA, MD, FRCS. go ahead.—Harold Ridley, MA, MD, FRCS.
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Evolution of Phaco The 1960s - The BeginningThe 1960s - The Beginning The 1970s - Moving PosteriorlyThe 1970s - Moving Posteriorly The 1980s - The Capsulorrhexis EraThe 1980s - The Capsulorrhexis Era The 1990s - The Era of Reduced Emulsification The 1990s - The Era of Reduced Emulsification
EnergyEnergy From 1985 to 1995- a From 1985 to 1995- a ““dramatic phaco revolutiondramatic phaco revolution””
The The less than 10% of surgeons using less than 10% of surgeons using phaco in the phaco in the early 1980s rocketed to 95% by early 1980s rocketed to 95% by 1995. 1995.
The 2000s - An Era of Alternative Energies and The 2000s - An Era of Alternative Energies and Further Further Reduction of Ultrasound Reduction of Ultrasound EnergyEnergy
Cataract & Refractive Surgery Today
Treatment Options
GlassesGlasses: Cataract alters the refractive power of the natural : Cataract alters the refractive power of the natural lens so glasses may allow good vision to be maintained.lens so glasses may allow good vision to be maintained.
Surgical removalSurgical removal: when visual acuity can't be improved : when visual acuity can't be improved with glasses.with glasses.
Surgical techniquesSurgical techniques– Phacoemulsification method….Phacoemulsification method….– Extracapsular method.Extracapsular method.– Intracapsular methodIntracapsular method
Pre-op assesments General health evaluation including blood pressure checkGeneral health evaluation including blood pressure check Assessment of patients’ ability to co-operate with the procedure Assessment of patients’ ability to co-operate with the procedure
and lie reasonably flat during surgeryand lie reasonably flat during surgery Instruction on eye drop instillationInstruction on eye drop instillation The eyes should have a normal pressure, or any pre-existing The eyes should have a normal pressure, or any pre-existing
glaucoma should be adequately controlled on medications.glaucoma should be adequately controlled on medications. An operating microscope is needed, in order to reach the lens, a An operating microscope is needed, in order to reach the lens, a
small corneal incision is made close to the limbus for the phaco-small corneal incision is made close to the limbus for the phaco-probe.probe.
It is important to appreciate anterior chamber depth and to keep It is important to appreciate anterior chamber depth and to keep all instruments away from the corneal endothelium in the plane all instruments away from the corneal endothelium in the plane of the iris.of the iris.
Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The same tip is used to suction out the lens
Phacoemulsification:1.1. Corneal incision 2.75-3.2 mmCorneal incision 2.75-3.2 mm2.2. Viscoelastic to anterior chamber.Viscoelastic to anterior chamber.3.3. CapsulorhexisCapsulorhexis4.4. Hydrodissection.Hydrodissection.5.5. Phacoemulsification of the nucleus.Phacoemulsification of the nucleus.6.6. Aspiration of the cortex.Aspiration of the cortex.7.7. More viscoelastic.More viscoelastic.8.8. FoldedFolded intraocular lens (IOL) is inserted under a intraocular lens (IOL) is inserted under a
cushion of viscoelastic fluid which protect the corneal cushion of viscoelastic fluid which protect the corneal endothelium, the lens endothelium, the lens unfold unfold spontaneously within the spontaneously within the capsular bag.capsular bag.
9.9. Vescicoelastic removed and replaced with balanced Vescicoelastic removed and replaced with balanced salt solution.salt solution.
10.10. Self sealing wound.Self sealing wound.11.11. Sub conjunctival injection of steroid and antibioticsSub conjunctival injection of steroid and antibiotics12.12. Eyepad and protection eye shield.Eyepad and protection eye shield.
Postoperative care after cataract surgery
• SteroidSteroid drops (inflammation) drops (inflammation)• AntibioticAntibiotic drops (infection) drops (infection)• AvoidAvoid
• Very strenuous exertion (rise the pressure in the eyeball)Very strenuous exertion (rise the pressure in the eyeball)• Ocular trauma.Ocular trauma.
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
History of foldable IOLs
.
OCULAR SURGERY NEWS 6/1/2007
Erin L. Boyle
“I longed for a method of IOL insertion
that would not require me to
enlarge the [phaco] wound.”
Thomas R Mosacco MD
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
FDA approved the lenses forinsertion in 1984, (Figure 2)
Early lenses by STAAR Surgical Company included the first foldable posterior chamber IOL, model AA 4004 and the AQ 2010V .
STAAR Surgical STAAR Surgical Company producedCompany producedboth one- and three-both one- and three-piece IOLspiece IOLs
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
The Ideal Foldable IOL Smaller IncisionsSmaller Incisions Surgeon friendly implantationSurgeon friendly implantation
– Durable and flexibleDurable and flexible– Compatible delivery systemCompatible delivery system
Centration & Fixation in Capsular BagCentration & Fixation in Capsular Bag Excellent visual out comeExcellent visual out come No Inflammatory responseNo Inflammatory response No PCONo PCO Spectacle IndependenceSpectacle Independence
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Foldable IOL Materials
SiliconeSilicone AcrylicAcrylic
– Hydrophylic(Hydrogel)Hydrophylic(Hydrogel)– HydrophobicHydrophobic
CollamerCollamer
Foldable IOL MaterialsSTAAR Collamer
Alcon SA-60
STAAR Plate
AMO Sensar
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
What Criteria are Most Important to Surgeons
Wound sizeWound size CentrationCentration Ease of Ease of
InsertionInsertion Optical QualityOptical Quality BiocompatibilityBiocompatibility
OPC ratesOPC rates YAG YAG
ResistanceResistance Post-op Post-op
InflammationInflammation DysphotopsiasDysphotopsias
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
So How Do We Choose?
No one perfect lensNo one perfect lens Many very good to excellent IOLSMany very good to excellent IOLS Patient SelectionPatient Selection Try and get good with severalTry and get good with several Continually re-evaluateContinually re-evaluate
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS
Approach to the Cataract Patient
Education Spectacle
Independence? Multifocal? Accommodating?
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Choosing an IOL?
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Choosing an IOL Surgeon’ ViewSurgeon’ View
– The LensThe Lens» MaterialMaterial» DesignDesign» CostCost
– The ProcedureThe Procedure» Wound SizeWound Size» Easy, Safe, Quick, Easy, Safe, Quick,
InsertionInsertion– Post OpPost Op
» Visual OutcomeVisual Outcome» InflammationInflammation» PCOPCO» DysphotopsiaDysphotopsia
Patient FactorsPatient Factors– MotivationMotivation– Life StyleLife Style– Different Models and Different Models and
Makes?Makes?– Cost Cost CostCost Cost Cost
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Choosing an IOL-The Material
SiliconeSilicone AcrylicAcrylic
– Hydrophylic(Hydrogel)Hydrophylic(Hydrogel)– HydrophobicHydrophobic
CollamerCollamer
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
The Acrysof Family
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
The Acrysof Family-Premium IOLs
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Choosing an IOL-The Procedure
Avoid small errors to add up into a big Avoid small errors to add up into a big surprisesurprise
minimize SIAminimize SIA Aim at Thorough Cortical clearance&Aim at Thorough Cortical clearance& In the Bag Implantation with sub optical In the Bag Implantation with sub optical
RhexisRhexis
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Choosing an IOL-The Insertion Systems
ForcepsForceps Injection SystemsInjection Systems
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Choosing an IOL-The Insertion Systems
I/A with foldable IOL
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Phacoemulsification of hyper mature cataract with multifocal iol implantation
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Choosing an IOL-The Insertion Systems
Acrisof SPAlcon Collamer STAR
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Acrisof Restore Idea Excellens
Choosing an IOL-The Insertion Systems
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
So How Do We Choose?
Wound sizeWound size CentrationCentration Ease of Ease of
InsertionInsertion Optical QualityOptical Quality BiocompatibilityBiocompatibility
OPC ratesOPC rates YAG YAG
ResistanceResistance Post-op Post-op
InflammationInflammation DysphotopsiasDysphotopsias
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
So How Do We Choose?
No one perfect lensNo one perfect lens Many very good to excellent IOLSMany very good to excellent IOLS Patient SelectionPatient Selection Try and get good with severalTry and get good with several Continually re-evaluateContinually re-evaluate
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Experience with Acrysof Platform
Since the Jan 2007 to Dec 2008, 200 Acrysof IOLs were implanted during
phacoemulsification cataract surgery. All patients were between 40 and 85 years of age (female – 119, male – 81).
In the first 150 cases we used 3.2 mm incisions. In the other 50 cases 2.75 mm clear corneal incisions were utilized.
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Experience with Acrysof Platform
The surgery went smooth, with no intra- or postoperative complications. It was very convenient to attach the cartridge with IOL inside to the injector. During the implantation controlled smooth unfolding was observed. We did not observe any adverse effects related to the lens and/or the injection system.
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
21st Century Cataract surgery will have to be:
Highly efficient and safeHighly efficient and safe Universally availableUniversally available Economically affordableEconomically affordable Able to restore true functionality of LensAble to restore true functionality of Lens
– Truly continuous dynamic accomodationTruly continuous dynamic accomodationMission impossible
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
What’s Ahead Preloaded LensesPreloaded Lenses Multi-focal LensesMulti-focal Lenses Thin LensesThin Lenses Phakic LensesPhakic Lenses Adjustable LensesAdjustable Lenses Accommodating LensesAccommodating Lenses Injectable IOLsInjectable IOLs Toric LensesToric Lenses Custom LensesCustom Lenses
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Multifocal IOLs
DiffractveDiffractve RefractiveRefractive
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Accomodating IOLs
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Light Adjustable IOLs
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
What’s a Surgeon to do?
Enhance Two Handed SkillsEnhance Two Handed Skills Try to manage patient expectationsTry to manage patient expectations Minimize ComplicationsMinimize Complications Select IOL based on objective dataSelect IOL based on objective data
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
Summary-Choosing an IOL The MaterialThe Material
– HydrophobicHydrophobic– HydrophylicHydrophylic
DesignDesign– Square edgeSquare edge– Two haptics SPTwo haptics SP– Four ears SPFour ears SP– Plate?Plate?
CostCost
Insertion SystemInsertion System– PreloadedPreloaded– Monarch 2 Acrysof Monarch 2 Acrysof
PlatformPlatform CentrationCentration
– Surgeon’ roleSurgeon’ role PCOPCO
– Square edge more Square edge more important than important than materiamateria
The Whole Package
Rapid, Safe, Smooth Two Handed Rapid, Safe, Smooth Two Handed Surgery with time tested lens implant Surgery with time tested lens implant aiming at true spectacle independenceaiming at true spectacle independence
Dr. Mazhry FRCS, FCPSDr. Mazhry FRCS, FCPS 2121stst century IOLs century IOLs
IOL a Miracle
"Even when a miracle becomes routine, it still "Even when a miracle becomes routine, it still remains a miracle." We thank Harold Ridley remains a miracle." We thank Harold Ridley for providing us with this miracle. for providing us with this miracle.
Lay sans bhi ahista keh nazuk hai buht kamAfaq ki is kargah – e -shisha gari ka