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7/28/2019 Cataract and Vitrectomy
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Cataract and Vitrectomy
Jenni Webb
RN OphthalmologyCabrini Procedure Centre
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JEEPERS CREEPERSWHATS HAPPENED
TO MY PEEPERS
STUFF I FIND INTERESTING
BY
JENNI WEBB
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Cataract
What is it? A clouding of the lens proteins causing reduced visualacuity.
The different types of cataracts are NUCLEAR . located at the centre of the lens and the
cataract most commonly associated with ageing CORTICAL . On the perimeter of the lens extending
toward the centre often seen in diabetics
SUBCAPSULAR . Begins at the back of the lens and isalso associated with diabetes, highly miopic patients,
retinitis pigmentosa or high doses of steroids CONGENITAL
INFANTILE
SECONDARY related to other systemic diseases/problems
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CATARACT Causes
AGEING ULTRAVIOLET LIGHT
2005 Iceland study showed airline pilots
are at risk which may be attributed to
cosmic radiation as are astronauts
People with diabetes or those who use
steriods, diuretics and major tranquilizers
are at a higher risk Other risk factors include smoking ,air
pollution heavy alcohol consumption
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CATARACT Symptoms
CLOUDY OR BLURRED VISION COLOUR FADING
GLARE Headlights lamps and sunlight mayappear too bright and a halo may appear aroundlights
POOR NIGHT VISION
DOUBLE VISION This symptom may resolveas cataract get larger.
FREQUENT PRESCRIPTIONCHANGES
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CATARACT SURGERY
COUCHINGFirst described in India and Eygpt around
600B.C
Physicians would place a sharp instrument
through the cornea and push the lens untilit fell into the back of the eye.
Vision was restored temporarily asinflammation and infection caused otherproblems
Couching is still performed in some povertystricken parts of Africa
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CATARACT SURGERY
In the first half of the 20th Century 2 mainsurgical techniques were developed forcataract removal
INTRACAPSULAR CATARACT EXTRACTION ICCE (removal of the entire lens andcapsule from eye)
EXTRACAPSULAR CATARACTEXTRACTION ECCE( removal of lensnucleus and cortex through an opening inthe anterior capsule)
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I.C.C.E SURGERY A large incision and flap were created in the
cornea.
Liquid nitrogen cooled cryo probe was frozen tothe lens and entire lens and capsule removed
Corneal wound was then closed with up to 18sutures (post WW2 lenss were implanted)
Patients had long recovery periods being requiredto stay almost motionless for up to 3 weeks
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I.C.C.E. SURGERY
ADVANTAGES
The lens andcapsule not lodgedin vitreous body
Enabled lensimplantation whenthey becameavailable
Disadvantages
Trauma generalanaesthetic,sutures and pain
Large wound longhealing times,infection andcorneal distortion.
Vitreous movementcausing retinaldetachment
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E.C.C.E SURGERY
First described in1753 by French oculist DAVIEL
but didnt gain merit until the development of theI.O.L. in the early 1970
9mm-11mm incision was made in the limbus
A bent cystitome made a can opener type of tear inthe anterior capsule
The lens was then expresses through the wound
Any remaining cortex was then sucked out using asimcoe
I.O.L. was implanted and the wound sutured
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E.C.C.E SURGERY
ADVANTAGES
Lens capsule intact allowing I.O.L.implant
Intact capsule keeping vitreous in place
Smaller wound less sutures less pain
DIS ADVANTAGES
Much the same as I.C.C.E
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E.C.C.E SURGERY
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K.P.E Kelman Phaco
Emulsification
In 1960 Dr Charles E Kelman had the ideathat incision size could be reduced if thelens could be fragmented.
During a visit to the dentist he observed aninstrument used to break up tough toothenamel
He contacted manufacturer CAVITON Inc.which led to the Caviton Phaco machinewhich used ultrasonic vibration tofragment the lens.
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ADVANCES IN PHACO
SURGERY
Technology has gone well beyondthat of the original phaco machine
Ozil technology -combination of ultrasonicpower and tortional amplitude allow more efficiency and
create less heat thus avoiding corneal wound damage.
Wound size original wound size was 3.2 mm thisis now reduced to 2.2mm reducing wound leakage and
the necessity to suture
Lens technology
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EVOLUTION OF I.O.L.s
1795 was the first recorded attempt at replacing
the natural lens it was attempted by an Italian
oculist called CASAMATA . He used glass and when
implanted it fell to the back of the eye
1949 Introduction of the RIDLEY LENS named after
its founder Dr Harold Ridley, these lenses were likea flying saucer, weighed about 112m
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EVOLUTION OF I.O.L.s
1953-1973 Introduction of IRISsupported lenses examples are
Binkhorst clip, Epstein stud and
the Copeland clip.
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EVOLUTION OF I.O.L.s1963- 2001 Development of the
modern Anterior Chamber Lens.A Kelman 4 point fixation lens
which came in various lengths.
Patient was measured white to
white to determine length.
The soft flexible haptics
minimized compression onthe trabeculum and
prevented spinning.
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EVOLUTION OF I.O.L.s
1975- 2001 Modern Posterior chamber lenses.
Influenced by the development of the Phaco also finemicroscopes and changing lens materials
There were a variety of designs (as seen above) Incision
lengths varied from 7-11 mm. Haptic design maximized
contact in bag. The problem was the surgically inducedastigmatism.
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EVOLUTION OF I.O.L.s
1991- 2009 SMALL INCISION (FOLDABLE ) LENSES
As Phaco became routine so did the quest for smaller
incision sizes Softer more malleable materials were
developed allowing lenses to be folded without damage.
The 1st 3 piece foldable lens was implanted in Australia in
1995. This allowed wound incisions to reduced from6.2mm
to 3.2 mm
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EVOLUTION OF I.O.L.s
2000 Introduction one piece (jelly bean) lens.
This enabled lens to be injected throughcartridges further reducing incision sizes(2.8
mm down to 2.2mm)
Other changes are the addition of blue lightfilters (1st available in 2003)
Restor lenses a multifocal lens negating the
need for glasses
Toric lens -to correct astigmatism
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EVOLUTION OF I.O.L.s
WHO KNOWS
WHATS
NEXT
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NO SURGERY IS
WITHOUT RISK
INTRA-OPERATIVE POSTERIOR CAPSULAR RUPTURE - resulting invitreous leak . Treatment is an anterior vitrectomyand if the tear jeopardizes the stability of IOL an AClens may have to be inserted
EXPULISIVE HEMORRAGE - acute drop intraocularpressure causing bleeding followed by raiseintraocular pressure pushing out the content of theeye .Treatment is to close the wound QUICKLY
reduce the intraocular pressure and post opsteroids visual outcome is usually poor
DISSLOCATION OF LENS lens falls to P.C.Treatment call the V.R. Surgeon
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Early Post-Operative
ACUTE BACTERIAL ENDOPTHAMITIS - Occurs in
1/1000 cases (all cases reported to eye and ear
hospital) Treatment include topical, intravitreal
periocular and systemic antibiotics
IRIS PROLAPSE iris may prolapse through wound,
this is due largely to poor surgical closure
HIGH IOP occurs with incomplete removal of
viscoelastics (block trabecular mesh work)
CORNEAL EDEMA Increase in thickness of cornea
caused by Phaco (heat) and surgical manipulation .Post-operatively the cornea will cloud but clear as
the edema settles
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LATE POST-OPERATIVE
POSTERIOR CAPSULE OPACIFICATION (PCO) -
Extremely common in children . Treatment isposterior capsulotomy done with the YAG laser.
RETINAL DETATCHMENT (Especially in highmyopia) following a posterior capsular rupture.
CYSTOID MACULAR EDEMA (CME) -fluidsaccumulate at the macular reducing visual acuity.A/C IOLs are associated with higher risk.
ASTIGMATISM more common when suture wereused
MALPOSITION OF THE IOL. If the lens has moved orbeen incorrectly placed in the bag ,requiressurgical intervention
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20 years on
OPERATION TIME reduced from 60 min to 10 min
SURGICAL EFFECTIVENESS with increased technology
and instrumentation surgical side effects have been
reduced.
PATIENT IMPACT Most cataract patients are not sick
just older. With that in mind we no longer fully undressour patients for surgery , we have reduced the impact of
unnecessary movement with the introduction of
operating trolleys. Post- Operatively (having fulfilled
discharge criteria ) Patients are taken straight to the
discharge lounge ( and a long awaited cup of tea) The day may come when cataracts are no longer treated
in hospitals
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VITRECTOMY
VITRECTOMY is the removal orpartial removal of vitreous
humor from the posterior
segment of the eye , to gainaccess and to treat underlying
conditions, this operation is
known as PARS PLANAVITRECTOMY
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VITRECTOMY SURGERY
ORIGINATED BY ROBERT MACHEMER the first
vitrectomy was done in 1969 to remove blood andother opacities from the vitreous. Since then the
advances in retinal surgery have been largely
technology driven.
Explosion of new instrument and surgicaltechniques through the 1970s and 1980s was
spear headed by engineer/surgeon STEVE CHARLES
More recent advances include the introduction of
23g vitrectomy
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VITRECTOMY SURGERY
UNTIL 2007 all Retinal Surgery at Cabrini was
done with the 20g approach .This entailed openingthe sclera and making holes in which to place theinstruments. The exposure of bare sclera and post operative suturing caused inflammation and addedextra time to an already complicated procedure.
In 2007 at we introduced a 23g approach, in theyear prior to that we experimented with the 25gapproach but found the instruments flexibility toolimiting. Since2007 we have used the 23g system
for over 99% of all our retinal cases. 23g retinal surgery is very similar in principle to
Laparoscopic surgery ( ports, gas/fluid, light )
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RETINAL
DETATCHMENT
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RETINAL
DETATCHMENT
Most retinal detatchments areRHEGMATOGENOUS caused bydegenerative changes to the Vitreous (old
age vitreous) causing a hole in the retina
allowing fluid into the subretinal space.
TRACTIONAL when membranes pull up on
the retinal surface causing a hole (common
in diabetics) EXUDATIVE caused by break down in the
blood retinal barrier
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RETINAL
DETATCHMENT
Clinical symptoms Floaters and flashes
Peripheral field loss
Loss of red reflex on
examination
As detachment reaches macularcentral vision is lost
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TREATMENT
The earlier the treatment the better the
outcome
VITRECTOMY relief of V-R traction
(membranes) by peeling. Removal of the
sub retinal fluid. Closure of the break usingeither laser or cryo, and finally adhesion
with the use of silicone oil or heavy gases
Scleral Buckle repair which is an externalapproach
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OCT SCANS
.
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VITRECTOMY SURGERY
Macular hole
Macular pucker
Diabetic retinopathy
Vitreous Hemorrhages
Vitreous opacities (floaters)
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ARE YOU STILL AWAKE
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VITRECTOMY
Recovery if patients have had a gas
bubble inserted positioning may be
required for the first 24 hours
Patients may not undertake air travel (or
climb Mt Everest ) to avoid raised IOP Patients wear warning band with a bubble
as any agents causing expansion ie
Nitrous anesthetics.
Most patient will develop a cataract within
2 -3 years of surgery
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10 YEARS ON
Operation times reduced
Light source improved halogen to xenon
Introduction of retinal stains- to identify
membranes
Introduction of wide field viewing systems
Introduction of small guage vitrectomy
with the accompanying instrumentation
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THANK YOU FOR YOURATTENTION
ENJOY THE REST OF
YOUR EVENING