Mx Cataract Modif

8/3/2019 Mx Cataract Modif

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MANAGEMENT OF CATARACT


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TREATMENT OF CATARACT ESSENTIALLY

CONSIST OF ITSSURGICAL REMOVAL..

NON SURGICAL MEASURESMAY BE OF HELPTILL SURGERY IS TAKEN UP.


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NON SURGICAL MEASURES TREATMENT OF CAUSE OF CATARACT

MEASURES TO DELAY PROGRESSION OFCATARACT

MEASURES TO IMPROVE VISION INPRESENCE OF IMMATURE CATARACT.


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NON SURGICAL.1.Treatment of cause of cataract:Control of diabetes mellitus.

Avoid cataractogenic drugs.Corticosteroids

Phenothiazines

Miotics

Removal of irradiation.

Rx of Ocular diseases.


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NON SURGICAL:2.Measures to delay progression:

Iodide salts of calcium andpotassium

Vitamin E & Aspirin


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NON SURGICAL:

3.Measures to improve vision inpresence of immature cataract:Refraction correction.

Arrangement of illumination.brilliant illumination peripheral opacitydull light central opacity

Use of dark goggles.

Mydriatics : Phenylephrine 5% /Tropicamide 1%Allows clear paraxial lens to participate in light transmission,image formation & foccussing


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SURGICAL MANAGEMENT:Indications:Visual improvement

Medical indications- lens induced glaucoma,

phacoanaphylactic endophthalmitis,

retinal diseases

Cosmetic indication


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Pre operative evaluation

General examination ocular examination

Retinal function tests IOP

Infections anterior segment

by slit lamp


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Preoperative evaluations:

General medical examination:

R/O DM, HTN, cardiacproblems,obstructive lungdiseases,any potential source of

infection.


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Preoperative evaluations:

Retinal function tests PL

A test for RAPD

PR(peripheral retina fn)

2 light discriminationtest(macula fn)

Maddox rod test


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Colour perceptionEntoptic visualisation(rubbingpoint source of light against closed

eyelids)

Laser interferometry(measurin

macular potential for visual acuityin d presenc f opaque media)

Objective tests ERG,EOG,VER(Visually

evoked response)


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Preoperative evaluations:Anterior segment pathology

Slit lamp examination

Gross focal sepsis: Conjunctival infections.

Lacrimal sac

IOP


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Pre-op preparation:

Informed & detailed consent. Topical antibiotics.

Gentamycin, Tobramycin,ciprofloxacin-QID, 3days prior. (endophthalmitis)

Preparation of the eye. Scrub bath, care of hair.

Lower IOP:

Acetazolamide 500mg stat, 2hrs before. IV mannitol 1 gm/kg, 1/2hr before or glycerol 60

ml mixed with H2O or lemon juice 1 hr b4


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Pre-op preparation:Dilate pupil:

1% tropicamide, 5% phenylephrine.

every 10 min 1 hr before surgery

Anti prostaglandin eyedrops:

indomethacin,flurbiprofen.3 times the previous day

hourly for 2 hours before surgery


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Anaesthesia:GA & LA

LA is preferred whenever possible


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Cataract surgery:Intracapsular cataract

extraction-ICCE

Extracapsular cataractextraction-ECCEConventional ECCE.

Manual small incision cataractsurgery.(SICS)

Phacoemulsification.


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ICCEWhole lens with intact capsule

removed.

Prerequisite- weak &degenerated zonules


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ICCE


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ICCEIndications

Markedly subluxated & dislocatedlens

About 50 yrs of age(40-50 yrs alpha chymotrypsin)


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ICCE Procedure

Superior rectus suture to fix eye in downwardgaze

Preparation of conjunctival flap-expose limbus

Making a partial thickness groove or gutter Corneoscleral section-ant.chamber is opened

(3.2mm keratome or razor blade)

Peripheral Iridectomy

to prevent post- op pupil block glaucoma


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Methods of lens delivery-

Indian smith method,

cryoextraction,capsule forceps method,

irisophake method,

wire vectis method


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ICCE Procedure

Formation of anterior chamber(irisreposited n sterile air /BSS)

Implantation of anterior chamber lens

Closure of incisionReposition of conjunctival flapSubconjunctival injection-

Dexamethasone .25ml & gentamycino.5ml

Patching of eye


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ECCE

Major portion of anterior

Capsule withepithelium,nucleus & cortexremoved

Leave intact posteriorcapsule


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ECCE


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ECCE

Indication

Surgery of choice

Contraindication

Markedly subluxated & dislocatedlens


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ECCE Procedure

1.. Superior Rectus (bridle)suture

to fix the eye in downward gaze.2. Conjunctival flap preparation

to expose the limbus Haemostastis by wet field cautery


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ECCE Procedure6. Corneo-scleral section razor blade or 3.2mm

keratome

7. Anterior chamber opened

8. Injection of viscoelastic substance into anterior

chamber (2% methyl cellulose or 1%SodiumHyaluronate)

maintains the anterior chamber n protectsendothelium

9. Anterior capsulotomy ( can opener(cystitome) ,linear capsulotomy or continuous circularcapsulorrhexis, CCC)

10.Removal of anterior capsule(Kelman

McPhersons forceps)


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ECCE Procedure

11. Completion of corneoscleral section

12. Hydrodissection inj BSS:separatescorticonuclear mass from capsule.

13. Nucleus deliveryPressure & counter pressure method

Irrigating wire vectis technique

14. Aspiration and irrigation (BSS or Ringer lactateis used as irrigating fluid) of cortex

15. Filling of lens capsule (capsular bag) with viscoelastic substance


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ECCE Procedure

16. Insertion of posterior chamberIOL in the capsular bag

17.Closure of the incision18.Removal of viscoelastic

substance and AC filled with BSS

19.Reposition of conjunctival flap20.Subconjunctival injection

21.Patching of eye


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Advantage of ECCE over ICCE

ECCE- In all age gp ICCE- above 40yrsPCIOL cannot be implanted after ICCE

Postoperative vitreous relatedproblems with ICCE

Postoperative complication-endophthalmitis,cystoid macularedema,RD.less after ECCE

Postoperative astigmatism is less inECCE as smaller incision in ECCE


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Advantage of ICCE over ECCE

Simple,easy & cheap

Postoperative opacificationof posterior capsule absent

Less time consuming- massscale operation


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SICSECCE with IOL implantation.Surgery is performed thru a

sutureless self sealing valvularsclerocorneo tunnel incisionIncision size- 5.5 to 7.5 mm

Lens nucleus and cortex removedCapsular bag left behind.Post operative astigmatism less


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Sics Superior rectus suture to fix eye in downward gaze

Preparation of conjunctival flap & Haemostasis

sclerocorneal tunnel incision:consist of

Ext Scl(straight,frown or chevron) incision sclero corneal tunnel

Internal corneal incsn

Side-port entry: valvular corneal incision @ 9 oclock

position (aspirtn of subincisional cortex & deepeningant chamb)

Ant capsulotomy

Hydrodissectn


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Nuclear management:

Prolapse of nucleus during HD& compl eted wtSinskeys hook

Delivery of the nucleus outside by wire vectis/blumenthal/Phacosandwich/Phacofracture/

Fishhook techniques

Aspirn of cortex IOL implntn & removal of visco elastic substance

Wound closure


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Phacoemulsification:


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Phacoemulsification

Corneo scleralincision is verysmall

CCC (continuouscircularcapsulorrhexis) is

preferred overother methods ofant.capsulotomy


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Phacoemulsification

The surgeonthen uses theprobe, which

vibrates withultrasoundwaves, to breakup (emulsify)the cataract andsuction out thefragments


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Phacoemulsification

Once the cataractis removed, aclear artificial

lens is implantedto replace theoriginal cloudedlens

IOL- Foldable orrollable type


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Phacoemulsification

Sutureless self sealing smallincision

Visual rehabilitation quicker

Postoperative astigmatism less


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Laser phacoemulsificn

under trial

ADVANTAGE: laser energy used for emulsification not

exposed to other IO structures.


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SICS Phacoemulsification

Universal,easier,non machinedep,less time ,cost effective

Less complicn

Conjunctival congestn 5-7d

post op hyphaema ,surgicalind astigmatism is more

Machine dep,high cost

small incisn

More complications lyknuclear drop

Congesn minimum &

Post op astigmatism is less

Visual rehab quickr


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Mx Cataract Modif