Recent Advances and Innovations in Cataract Surgery
Professor Zia ul Mazhry
OSP KPK honoured Professor Doctor Zia ul Mazhry as he was invited to deliver a talk in plenary session of Khyber Eye Con 2019. The topic was "Recent Advances and Innovations in Cataract Surgery". This prestigeous session was chaired by living legend Professor Dawood Khan. It was really a great oppertunity to present and talk along with international speakers like Professor Babar Qureshi and Professor Carlo Schonfeld from Germany. The summary of the talk with glimpses is presented in this article.
Discussion Plan
- The Cataract Treatment Strategies
- The Concept of Neuroadaptation
- Innovations and Advances in Cataract Diagnosis
- Trends in Cataract Surgery
- The Pursuit of an Ideal Intraocular Lens
- Innovations to Manage Challenging Cataract Cases
- Prevention and Management of Complications
- Summary and Conclusion
Section -1
The Cataract Treatment Strategies
- Uniqueness of The Crystalline Lens
- Cataract Surgery in Antiquity
- Cataract – Can it be Prevented or Slowed ?
No definitive proof that intake of vitamins or nutrients or ‘catalina’ eyedrops decrease incidence of cataract
Anatomic Types of Cataract & Their Visual Implications
Cataract is an Age Related Eye Disease
Treatment Strategies
- When cataract mild, a change in eyeglasses helps vision
- In patients with more advanced cataracts or in patients with glare, surgical treatment is indicated
- Cataract Dissolving Eye Drops reported Successful in Dog Eyes
Section - 2 Neuroadaptation
خود ہی تو کہتے تھے مجھے خود کو بدل لو
بدلا ہوں تو کہتے ہو کہ اب وھ نہ رہا میں
آنکھ سے اک روز بے حد ناز سے بولا دماغ
عقل کی اندھی ہے تو الٹا نظر آئے تجھے
آنکھ بولی میں نہیں تو الٹا سیدھا کچھ نہیں
میں ہوں دریچہ نور کا کون سمجھائے تجھے
Lens Changes and Psychophysics of Vision
The image on the top left was painted when Monet had a moderately progressed cataract (1915), and the image on the top right provides us with the perspective of how Monet would have seen the picture. The lower image shows us the great detail and contrast that Monet was capable of seeing, and subsequently creating, once the cataract was removed in 1926
Section -3
Innovations in cataract Diagnosis
- Advances in Diagnosis and Pre Op Planning
- The Biometric Accuracy
- Understanding of Corneal Biophysics
- Role of OCT
- Intraoperative Aberometery
Section -3-B
Advances in Cataract Surgery
Cataract Surgery
- Most commonly performed eye surgery
- Among most successful surgeries that can be performed on the human body.
- Still Not a procedure without risk.
- Topical Anesthesia, out-patient procedure
What Criteria are Most Important to Surgeons
- Wound size and Construction
- Rhexis Techniques and Centration
- Phacoemulsification
- Ease of Insertion of IOL
- Optical Quality
- Biocompatibility
- PCO rates
- YAG Resistance
- Post-op Inflammation
- Dysphotopsias
Wound Construction
- Location
- Size
- Contour
- Neutral
Capsular Rhexis
- Rhexis Margin
- The Rhexis
- Needle Assisted
- Forceps Assisted
- Femto/Zapto/RF Assisted
- Femto CCC
- Most advanced way of making a perfectly sized, absolutely circular CCC
- Depth and diameter of CCC is determined by OCT and rhexis done automatically
- The detached flap is manually removed by forceps
Hydrodissection/ Hydrodelineation
Phacoemulsification
- The greatest fear known to man is a new idea.
- Phacoemulsification was first introduced in 1967
1969 “Charlie has produced an operation which will take all the fun out of cataract surgery.”
1974 “The use of the phaco machine for the removal of a cataractous lens is analogous to the shooting of game birds with guided missiles.”
If you have strong reasons to believe in your ideas, have confidence—face the brickbats and go ahead.—Harold Ridley, MA, MD, FRCS.
Evolution of Phaco
The 1960s - The Beginning
The 1970s - Moving Posteriorly
The 1980s - The Capsulorrhexis Era
The 1990s - The Era of Reduced Emulsification Energy
From 1985 to 1995- a “dramatic phaco revolution” The less than 10% of surgeons using phaco in the early 1980s rocketed to 95% by 1995.
The 2000s - An Era of Alternative Energies and Further Reduction of Ultrasound Energy
Phaco with Preloaded RayOne Hydrophilic aspheric Implantation
Step 1. Insert OVD into cartridge via port
Step 2. Lock cartridge ready for implantation
Phaco Preloaded RayOne Hydrophobic aspheric Implantation
Step 1. Insert OVD into cartridge via port
Step 2. Lock cartridge ready for implantatione
Section - 5
The Pursuit of an Ideal Intraocular Lens
آنکھ کا بینائی سے منظر کا اپنے عکس سے
رشتہ نازک سا ہے لیکن جوڑتے جاتے ہیں ہم
The Ideal Foldable IOL
- Smaller Incisions
- Surgeon friendly implantation
- Durable and flexible
- Compatible delivery system
- Centration & Fixation in Capsular Bag
- Excellent visual out come
- No Inflammatory response
- No PCO
- Spectacle Independence
History of foldable IOLs
“I longed for a method of IOL insertion
that would not require me to
enlarge the [phaco] wound.”
Thomas R Mosacco MD
So How Do We Choose?
- No one perfect lens
- Many very good to excellent IOLS
- Patient Selection
- Try and get good with several
- Continually re-evaluate
Choosing an IOL
Surgeon’ View
- The Lens
- Material
- Design
- Cost
- The Procedure
- Wound Size
- Easy, Safe, Quick, Insertion
- Post Op
- Visual Outcome
- Inflammation
- PCO
- Dysphotopsia
Patient Factors
- Motivation
- Life Style
- Different Models and Makes?
- Cost Cost Cost
Choosing an IOL- The Procedure
- Avoid small errors to add up into a big surprise
- minimize SIA
- Aim at Thorough Cortical clearance&
- In the Bag Implantation with sub optical Rhexis
Cataract Surgery-Refractive Surgery
- Refractive IOLs involve the same skills set as that of cataract surgery
- Multifocal and accommodating lenses are dramatically changing the way all eye doctors practice refractive surgery
Recent Advances in Cataract Surgery
- Cataract Surgery may be looked upon as an opportunity to give patients freedom from eyeglasses
- This is possible with the use of newer IOLs that focus light at most distances
- (these lenses are multifocal as opposed to previous lenses which are monofocal)
The Mindset
Patients are interested in lifestyle, not pathology and are happy to pay for the enhanced quality of life
- Old paradigm: Patient want to see better than they did with their cataracts
- New paradigm: Patients want to see better than they did before they developed cataracts
Presbyopia IOL options
- Monovision
- Refractive
- Diffractive
- Accommodative
- Extended depth of Focus(EDOF)
Multifocal IOLs-The basics
- Diffractve
- Refractive
- Diffractive Refractive
- Extended Depth of Focus
- Accomodative
The focality
- Monofocal
- Bifocal
- Trifocal
- Panfocal
- EDOF
- Variable Focus
The Concerns
- problems with intermediate vision
- reduced contrast sensitivity
- halos
- glare
- ‘Vaseline vision’ / waxy vision
- reduced tolerance to astigmatism
Combining Economy with Quality
LUCIDIS is an advanced monofocal lens designed to correct the vision post-cataract surgery. Raising the standard of the IOLs, LUCIDIS ideally combines the proven robustness of the monofocal lenses with the unprecedented performances of the revolutionary EDOF technology “Instant Focus”.
The future
- Configure Your Lens
- https://sav-iol.com/products/harmonis/
Lenses with Variable Focus
- Shifting fluid from haptic Pockets
- Minimizing Glare halos and Dysphotopsia
Sifi Miniwell Progressive with EDOF Technology
Refractive Lens Exchange
- New IOLs have an out-of-pocket cost similar to LASIK surgery
- Considerable freedom from eyeglasses possible with these IOLs
- Some surgeons/patients extend the above to patients who don’t have a cataract but want freedom from reading glasses (Refractive Lens Exchange)
Section - 7
Innovations in Management of Challenging Cataract
Cataract Challenges
Phaco of a dense hypermature cataract using Dye Staining
Cataract Challenges
Argentinian Flag Management
Cataract Challenges
Posterior polar cataract
Cataract Challenges
Posterior polar cataract Hydrodelineation
Cataract Challenges
Phaco Trab
Cataract Challenges
Cataract and uveitis
Cataract and uveitis
Pupillary Hooks and Iris Expanders
Cataract Challenges
Phaco IOL in siliconized eye
Cataract Challenges
Marphanoid Subluxation - Iris hooks, tension ring, haptic externalization
Take Home Message
Clinicians wishing to undertake implantation of multifocal (non-accommodative) IOLs during cataract surgery should ensure that patients understand the risks of the procedure, including the possibilities of halo and glare, and reduced contrast sensitivity. Patients should also be made aware that the lenses may be difficult to remove or replace. They should be provided with clear written information.
Cataract - Summary
- Cataract Surgery only when patient bothered by existing vision
- Cataract surgery among most successful surgical procedures but is not without risk
- Cataract - Summary
- Cataract surgery is an outpatient procedure done using local anesthesia and involves removal of cataract with Ultrasound and placement of IOL
- For patients desiring freedom from eyeglasses, options of new IOLs available
Conclusion
- Innovations in IOL design and phacoemulsification instrumentation have potentiated:
- improved surgical outcomes,
- reduced perioperative morbidity
- and increased likelihood of spectacle independence.
- As a result, surgeons are attaining unprecedented safety, efficiency and precision.
The Whole Package
Rapid, Safe, Smooth Two Handed Surgery with time tested lens implant aiming at true spectacle independence. Remember that you are now a refractive surgeon
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1- Comprehensive Primary Eye Exam/ Consultation
Consultation ::: Adult Eye Examination and Consultation
Consultation ::: Children Eye Examination Refraction Consultation
Consultation ::: Infant Eye Examination Refraction Consultation
2-Secondary Follow up Eye Exaamination and Consultations
Followup ::: Examination under Sedation for Kids (After Initial Consultation)
Followup ::: Dilated Fundus Examination(DFE)
Followup ::: Cycloplegic Refraction and DFE
3-Diagnostic Eye Test
Diagnostic ::: OCT
Diagnostic ::: Angio OCT
Diagnostic ::: Anterior Segment OCT
Diagnostic ::: Pachymetery
Diagnostic ::: Perimetery/Visual Fields
Diagnostic ::: Hess Chart/Digital Squint Assessment/Digital Diplopia Test
Diagnostic ::: Digital Colour vision test