2019-Recent Advances and Innovations in Cataract Surgery

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

1. The Cataract Treatment Strategies
2. The Concept of Neuroadaptation
3. Innovations and Advances in Cataract Diagnosis
4. Trends in Cataract Surgery
5. The Pursuit of an Ideal Intraocular Lens
6. Innovations to Manage Challenging Cataract Cases
7. Prevention and Management of Complications
8. 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 - 2Neuroadaptation

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 cataractHydrodelineation

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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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