1

Cynthia S. Chiu, MD, FACSDirector, Comprehensive Ophthalmology & Optometry

University of California San Francisco

Cataracts: A Surgical Revolution

http://www.nylasergroup.com/UserFiles/iols.png http://jokelibrary.net/occupations/b_to_l/doc-supp-ophthalmogist2.jpg

No financial disclosures

Demographics

Leading cause of blindness worldwide (WHO)

51% of world blindness (20 million people)

$3.4 billion each year from Medicare

Risk factors: female gender, tobacco, diabetes, UV and other radiation, obesity

2

What is a Cataract?

“Clouding” of the natural lensCauses blurry vision

Difficulty reading Difficulty driving Glare Double vision/multiple images Loss of color vision Difficulty in the dark

http://www.johnsparkermd.com/yahoo_site_admin/assets/images/lens_anatomy.95231805_large.jpg http://gemclinic.ca/wcm-docs/images/images%202/Anatomy.jpg

Anatomy of the Lens

http://www.images.missionforvisionusa.org/anatomy/uploaded_images/ASpelAtlas-775282.jpghttp://www.oculist.net/downaton502/prof/ebook/duanes/graphics/figures/v8/0100/005f.gif

Biochemistry

3

Biochemistry Embryology

Embryology

Tunica Vasculosa Lentis

What Causes Congenital Cataract?

Genetic Inheritance Autosomal dominant Autosomal recessive

Intrauterine infection

Sporadic

Risk of amblyopia

http://4.bp.blogspot.com/-Uh2AfoOn4I8/UVNWBUtjwPI/AAAAAAAAAPs/LisgzmUe7cM/s1600/cropeye.jpg

4

http://www.opt.indiana.edu/riley/HomePage/congenital_cats/Text_Congen_cats.htmlhttp://dro.hs.columbia.edu/antsutural.htm

Polar

Sutural

Congenital Cataract Congenital Cataract

http://www.jceh.co.uk/images/ceh_17_50_022_f01.jpghttp://arapaho.nsuok.edu/~fulk/Images/Img0072.JPGhttp://www.opt.indiana.edu/NewHorizons/Graphics/Tray1/Slide24.jpg

Coronal

Cerulean

Lamellar

Secondary Congenital Cataracts

Rubella Persistent Fetal Vasculature

What Causes Senile Cataract?

Increasing age Family historyDiabetesMedicationsRadiation Trauma Eye surgery

http://www.molvis.org/molvis/v15/a149/images/mv-v15-1407-f5.jpg

5

Senile Cataract

http://www.uku.fi/silmat/verkkokurssi/cataracta/tumakaihi2.jpg

Nuclear

Senile Cataract

http://www.missioneyeclinic.bc.ca/eyecareservices/oculardisease/images/cortcataract2.jpghttp://hubnet.buffalo.edu/ophthalmology/site/Home/Eye_Disorders/Posterior_subcapsular_cataract.jpg

Cortical Subcapsular

Mature Cataract

http://homepage2.nifty.com/KatoEyeClinic/cataract%20surgery2/17949mature-2.jpghttp://www.uku.fi/silmat/verkkokurssi/cataracta/cataracta,%20mature.jpg

http://www.tedmontgomery.com/the_eye/eyephotos/pics/CataractMorgagnian.jpg

Mature Cortical Mature Nuclear Morgagnian

Toxic Insults

http://dro.hs.columbia.edu/lc1/psc1b.jpghttp://www.opt.indiana.edu/NewHorizons/Chlorpromazine.html

Phenothiazines Steroids

Iron

6

Traumatic Cataract

http://dro.hs.columbia.edu/lc1/traumacatb.jpghttp://arapaho.nsuok.edu/~fulk/Images/Img0068.JPG

http://www.emedicine.com/oph/images/152traumatic3_1.jpg

Blunt Injury

ElectricShock

VossiusRing

Cataracts Associated withSystemic Disease

Wilson’s Disease(sunflower cataract)

Diabetes(snowflake cataract)

Myotonic Dystrophy(Christmas tree cataract)

http://galleryhip.com/sunflower-cataract.html

Pre-Op Evaluation

http://www.pjsaine.com/OphthalmicPhotography/Images/PseudoExfoliation.jpghttp://dro.hs.columbia.edu/ced5/fuchs3rb.jpg

Corneal dystrophies Pseudoexfoliation

Pre-Op Evaluation

http://retina.umh.es/Webvision/imageswv/retina.jpeg

Retina and Optic Nerve

7

Primitive Cataract Surgery“Couching”

http://www.mrcophth.com/Historyofophthalmology/cataractcouching.JPGhttps://c1.staticflickr.com/7/6103/6283625108_6df5190dcb.jpg

IntracapsularCataract Extraction

http://www.visualedge.org.uk/images/Cat%20De5.jpghttp://www.visionaidoverseas.org/data/Blogs/Ethiopia_blog/Patient-before.jpg

The Artificial Lens

http://www.ridleyeyefoundation.org/media/images/fader/980/21192_22455_harold_ridley2.jpghttp://upload.wikimedia.org/wikipedia/commons/f/fd/Plaque_for_Harold_Ridley%27s_first_intraocular_lens_at_St_Thomas%27_Hospital.jpg

http://www.ridleyeyefoundation.org/media/images/fader/980/92511_spitfiremontage.jpg

Extracapsular Cataract Extraction

8

Small, Self-Sealing Incision

http://telemedicine.orbis.org/data/1/rec_imgs/2596_cataract%20sug.new%208.JPG

The Phaco Machine

http://joneseyecenters.com/images/content/joneseyecenters/infiniti01.jpghttp://www.revophth.com/publish/images/1_397_1.jpg

High-frequency Ultrasound and Vacuum

Foldable Intraocular Lens (IOL)

http://www.eri.harvard.edu/faculty/peli/Opthalm_Mngt_0803_files/xNat.beauty.jpg

Inject through 2.8mm Incision

http://stahlvision.com/laser-eye-surgery/restor-lens.jpg

Phacoemulsification

9

Femtosecond Laser

http://awakeninteractive.com/images/clients/lensxlasers/lensx_machine.png

http://i.ytimg.com/vi/E6FJxXSS0E4/maxresdefault.jpg

Femtosecond Laser

Goals of Cataract Surgery

Primary: Remove cataract Clear pathway for visual function Assist in treatment of other ocular disease

Secondary: Provide best optical system for individual needs of the patient Lens implant Corneal shape

The Optical System of the Eye

http://figures.boundless.com/16509/full/vision-20diagram.jpe

10

Monofocal Lens Implant

Mono-focal = single focal pointDistance visionNear visionMono-vision

One eye for distance One eye for near

Current standard of careCovered by most insurances

http://donelsoneye.com/files/1413/2518/8784/Greenville-South-Carolina-LASIK-Cataracts-Eye-Care-iol.png

Premium Lens Implants

http://www.meals-on-wheels.org/blog/wp-content/uploads/2013/10/bigstock-Senior-Couple-Enjoying-Beach-H-13918268.jpg

Multifocal Lens Implant

Multi-focal = multiple focal pointsDiffractive light technology allows near and

distance focal points

Davison JA, Simpson MJ. J Cataract Refract Surg. 2006 May;32(5):849-58.

Multifocal IOL: Benefits

Can achieve distance, intermediate, and near vision without glasses

http://www.eyeworld.org/images/New_Articles/2011/06/27_b.jpghttp://www.garyfostermd.com/wp-content/uploads/2013/07/restor1.jpg

11

Multifocal IOL: Drawbacks

Out-of-pocket cost Rings and halos Decreased image quality Difficulty with night vision Need implants in both

eyes for reading

http://www.crystalclearvision.com/Content/images/ccv-Starburst-or-haloes.png

Accommodative Lens Implant

Accommodation = movement of the lensto improve near vision

Crystalens

http://www.norwicheyes.com/imgs/diagrams/nearfarneutral.jpg

Crystalens: Benefits

Can achieve distance and intermediate vision without glasses

No rings or halos No difficulty with night

vision

http://www.bausch.in/-/m/BL/India/Images/Products/Surgical/202x218-crystalens-ao.png

Crystalens: Drawbacks

Out-of-pocket cost Unable to achieve near vision Often need laser capsulotomy Difficult to exchange

12

Astigmatism

Astigmatism = Cornea is not spherical Steep axis Flat axis

Blurry imagesat all distances

http://www.tedmontgomery.com/the_eye/eyephotos/pics/Astigmatism-grphc.jpg

Toric Lens Implant

Toric lens corrects astigmatism Toric monofocal Toric Crystalens

Out-of-pocket cost

http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/graphics/figures/v6/0060/005f.gifhttp://www.garyfostermd.com/wp-content/uploads/2013/07/toric-193x300.jpg

Limbal Relaxing Incisions

Surgical incisions on the cornea Alternative to toric IOL for low corneal

astigmatism

http://www.capecoraleyecenter.com/assets/images/Stock%20Photos/LRI.jpg

Light-Adjustable Lens Implant

Irislight light

“lock-in”

Decreasedpower

light

Increasedpower

“lock-in”light

Iris

Courtesy of Dan Schwartz, MD, Calhoun Vision Inc.

13

Complications

Endophthalmitis Retinal Detachment Corneal Decompensation

Vitreous Loss Cystoid Macular Edema Choroidal Hemorrhage

UCSF Division of Comprehensive Ophthalmology

Cynthia S. Chiu, MD, FACS chiuc@vision.ucsf.edu 415.353.2802Michele M. Bloomer, MD bloomerm@vision.ucsf.edu 415.514.6853Saras Ramanathan, MD ramanathans@vision.ucsf.edu 415.353.2802

Thank You!

http://fc03.deviantart.net/fs71/f/2013/239/5/d/minions_wallpaper__cap____by_nabolsi_gfx-d6k0pyo.png