Cataract and Vitrectomy

7/28/2019 Cataract and Vitrectomy

1/43

Cataract and Vitrectomy

Jenni Webb

RN OphthalmologyCabrini Procedure Centre


2/43

JEEPERS CREEPERSWHATS HAPPENED

TO MY PEEPERS

STUFF I FIND INTERESTING

BY

JENNI WEBB


3/43


4/43


5/43

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


6/43

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


7/43

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


8/43

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


9/43

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)


10/43

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


11/43

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


12/43

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


13/43

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


14/43

E.C.C.E SURGERY


15/43

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.


16/43


17/43

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


18/43

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


19/43


20/43


1953-1973 Introduction of IRISsupported lenses examples are

Binkhorst clip, Epstein stud and

the Copeland clip.


21/43

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.


22/43


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.


23/43


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


24/43


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


25/43


WHO KNOWS

WHATS

NEXT


26/43

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


27/43

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


28/43

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


29/43

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


30/43

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


31/43


32/43

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


33/43

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 )


34/43

RETINAL

DETATCHMENT


35/43

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


36/43

RETINAL

DETATCHMENT

Clinical symptoms Floaters and flashes

Peripheral field loss

Loss of red reflex on

examination

As detachment reaches macularcentral vision is lost


37/43

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


38/43

OCT SCANS

.


39/43

VITRECTOMY SURGERY

Macular hole

Macular pucker

Diabetic retinopathy

Vitreous Hemorrhages

Vitreous opacities (floaters)


40/43

ARE YOU STILL AWAKE


41/43

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


42/43

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


43/43

THANK YOU FOR YOURATTENTION

ENJOY THE REST OF

YOUR EVENING

Documents

Cataract and Vitrectomy