info@nelep.org.uk

Action on cataract

Whipps Cross HospitalHarold Wood Hospital

North East London Eye Partnership

Cataract surgery

Indications for surgerySurgical planSurgical procedurePostoperative careDischarge

Indications

Visually significant cataractAffecting quality of life

WorkDrivingReadingHobbiesActivities of daily living

No Snellen acuity limit! (except driving)

Surgical plan

Mode of anaesthesiaSurgical procedureRefractionAdditional surgeryLens implant: power & material

Anaesthesia

LocalTopicalRegional

• Peribulbar

• Retrobulbar

• Sub-Tenons

• sub-conjunctival

General

Surgical procedure

Pupil dilation cyclopentolate 1% + phenylephrine 2.5%

Surface cleansing povidone iodine 5%

Draping disposable self-adhesive waterproof drape

Lid speculumCataract removal Lens implantation

Cataract - phacoemulsification

Section: cornea or scleralViscoelastic instillationCapsulorrhexisPhacoemulsificationSoft lens removalIOL implantationViscoelastic removal

Additional surgery

Pupil enlargementRefractive surgeryGlaucomaVitreoretinal

Macular holeEpiretinal membrane peelRetinal detachmentVitrectomy for vitreous haemorrhage

Surgical section

Self-sealing - sutureless Astigmatically neutralPosition

TemporalSuperioron-axis

Size: limited by IOL size – 3 to 3.5mm

Capsulorrhexis

T Neuhann 1987 Theory and surgical technic of capsulorhexis Klin Monatsbl Augenheilkd 1987;190:542-5

“Kapsulorhexis is a surgical technique for opening the anterior lens capsule with a circular, smooth-edged and continuous margin. Basically, the technique consists of a precisely controlled continuous capsular tear (rhexis), using only a sharp disposable needle with a bent tip. The method is reproducible, requires minimal instrumentation, is compatible with all current techniques of extracapsular surgery, and can be learned at no risk.”

Dense cataract without red reflex: Vision Blue

Phacoemulsification

Charles Kelman 1967 – CavitronUltrasound fragmentation of lens1967 - no capsulorrhexis or foldable IOLs

TechniquesDivide & conquerNucleus chopping

Phaco – “divide and conquer”

Intraocular lens implants

RigidPMMA

FoldableSiliconeAcrylic – hydrophobic e.g. AcryosofAcrylic – hydrophilic e.g. Hydroview, Centerflex

Complications – intra-operative >92% no intra-operative complications Posterior capsule rupture - around 4-5% Zonule dehiscence Vitreous loss Iris trauma & bleeding Corneal endothelial damage Thermal corneal burns Dropped nucleus or lens fragments

Post-operative care

Clinic review: Next day unnecessary 7-14 days post-operative clinic review Topical therapy e.g Maxitrol x 4/3/2/1 per week

Post-operative refraction Stability Attainment of target refraction Dispensing for non-emmetropic eyes e.g -3D target

Laser capsulotomy

Discharge to Optometrist

Refract & dispense at 4-6 weeksRefraction feedback for audit

Visual outcomeTarget refraction & biometry precision

Planned surgery on second eyeCapsule opacification & Laser capsulotomy