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Cynthia S. Chiu, MD, FACSDirector, Comprehensive Ophthalmology & Optometry
University of California San Francisco
Cataracts: A Surgical Revolution
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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
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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
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Biochemistry
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Biochemistry Embryology
Embryology
Tunica Vasculosa Lentis
What Causes Congenital Cataract?
Genetic Inheritance Autosomal dominant Autosomal recessive
Intrauterine infection
Sporadic
Risk of amblyopia
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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
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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
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Phenothiazines Steroids
Iron
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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
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Corneal dystrophies Pseudoexfoliation
Pre-Op Evaluation
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Retina and Optic Nerve
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Primitive Cataract Surgery“Couching”
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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
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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
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Femtosecond Laser
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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
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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
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Premium Lens Implants
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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
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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
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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
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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.
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Complications
Endophthalmitis Retinal Detachment Corneal Decompensation
Vitreous Loss Cystoid Macular Edema Choroidal Hemorrhage
UCSF Division of Comprehensive Ophthalmology
Cynthia S. Chiu, MD, FACS [email protected] 415.353.2802Michele M. Bloomer, MD [email protected] 415.514.6853Saras Ramanathan, MD [email protected] 415.353.2802
Thank You!
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