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Couching (extra capsular) (intracapsular) Microsurgery (extracap. + IOL) LsLsLsLs Aq Mics PMMA Soft Bi/M f Acc Ph-E ?

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Presentation on theme: "Couching (extra capsular) (intracapsular) Microsurgery (extracap. + IOL) LsLsLsLs Aq Mics PMMA Soft Bi/M f Acc Ph-E ?"— Presentation transcript:

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2 Couching (extra capsular) (intracapsular) Microsurgery (extracap. + IOL) LsLsLsLs Aq Mics PMMA Soft Bi/M f Acc Ph-E ?

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4 phaco. complication Preo.Intraop.Postop.

5 Preoperatory complication

6 GA LA TOPICAL

7 secondary to posterior diffusion of an ophthalmic viscosurgical device-lidocaine solution during complicated phacoemulsification. Falzon K - J Cataract Refract Surg - 01-AUG-2009; 35(8):

8 The main drawback of local anesthesia is to enable the patient to perform movements during operation.

9 Intra operatory complications

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13 All cases where conjunctival hydration occurred were clear corneal incisions.

14 There was no need to convert the capsulorhexis into an can-opener in # any situation. In intumescences cataracts we performed a smaller rexis to avoid its failure. After closing the rexis and cortex aspiration, broadening the rexis, bringing it to the normal diameter. In white cataracts (mature, hyper mature) used a colored substance to reveal the anterior capsule, under air protection.

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17 The anterior chamber should be reinflated with an OVD. The vector forces of the tear should be changed to redirect the tear in a more central direction. If the tear is lost beneath the iris, the capsulorrhexis should be restarted from its origin, proceeding in the opposite direction (if possible, this new capsulorrhexis should finish by incorporating the original tear in an outside- in direction; however, the original tear is often too peripheral to permit this, and a single radial tear is created).. An alternative approach to a “lost” capsulorrhexis is to convert to a can-opener capsulectomy. Preventing radial tears in the anterior capsule

18 Hydro dissection or hydro delineation is performed gently The IOL should be placed with the haptics 90° away from the tear. Cracks during emulsification are made gently away from the area(s) with radial tears. the chamber is deepened each time the phacoemulsification or irrigation-aspiration tip is removed from the eye Minimizing complications when radial tears are present

19 Endocapsular phacoemulsification without hydrodissection: an effective technique for cataract surgery following anterior capsular tear

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21 Excessively small capsulorrhexis

22 Two major complications of hydro dissection are: - inadequate hydro dissection - over inflation of the capsular bag.

23 the viscodissection technique was safer and more efficient than the non-dissection technique.

24 Detachment of Descemet’s membrane can be a major postoperative complication; it results in persistent corneal edema and decreased visual acuity. To prevent Descemet’s detachment, the surgeon should carefully observe the inner lip at each phase of the procedure. To avoid blunt stripping of Descemet’s membrane during enlargement of the wound, a sharp metal or diamond blade is recommended.

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26 usually is caused when the anterior chamber is entered too posteriorly, such as near the iris root. If this is noted early in the case and interferes with the easy introduction of instruments into the eye, it is advisable to suture the incision & move to another location. A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by choroidal effusion or hemorrhage.

27 Bleeding in the anterior chamber can come from intra operatory damage of iris. This occurs most frequently in temporal incisions located more posterior and deeper than normal. In these cases there are reached the blood vessels with higher risk of bleeding. it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant

28  Temporarily elevating the IOP with a balanced salt solution or an OVD.  Injecting a dilute solution of preservative-free epinephrine 1:5000 (or a weaker solution).  Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe. Iris bleeding is caused by iris trauma. Intraocular bleeding can be stopped by:

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30 Temporary loss of the chamber After adjusting the parameters of aspiration and irrigation and the introduction of viscoelastic substances with high molecular weight the situation was resolved favorably.

31 (2.81%)? All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier, the correlation being statistically significant. hypertonic eye & posterior capsule rupture has been reported ( was needed vitrectomy) Correlation was not statistically significant.

32 If for any reason the flow is blocked, a corneal burn can occur within 1–3 s

33 additional suturing was required several days later. Postoperatively, the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years. Yanoff & Duker: Ophthalmology, 3rd ed.

34 the surgeon should attempt to identify the cause and lower the IOP. Sometimes digital massage on the eye, pressing directly on the incision, can successfully lower the pressure. It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists. With choroidal effusion, aspiration of vitreous can be helpful, as can the administration of intravenous mannitol. If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment, it usually is best to terminate surgery. The wound is sutured carefully; intraocular miotics are administered, and a peripheral iridectomy may be performed to help reposition the iris. For effusions, surgery can be deferred until later in the day or the next day, when the fluid dynamics of the eye have returned to a more normal state. If a limited choroidal hemorrhage has occurred, it is best to wait 2–3 weeks before attempting further surgery.

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37 presumably occurs from the rupture of a blood vessel that is placed under stretch. Risk factors include : hypertension, glaucoma, nanophthalmos, high myopia, and chronic intraocular inflammation. [26]26

38 still occur at a rate between 0.45% for very experienced surgeons [1] & up to 14.7% for residents in training [2]. The frequency of retained lens fragments is estimated at 0.3% to 1.1% [3,4]. The challenge of cataract surgery is to minimize the risk of complications and to manage optimally complications that do occur.

39 B-scan ultrasonography 1 day after dislocation of a lens nucleus into the vitreous cavity in a patient who has high myopia.

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41 the early signs of posterior capsular rupture include: unusual deepening of the anterior chamber, decentration of the nucleus, or loss of efficiency of aspiration, which suggests occlusion of the tip with vitreous.

42 Usually Posterior capsular rupture is the most common intraoperative complication in initial cases.

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46 The key factors are to minimize ocular trauma, meticulously clean prolapsed vitreous from the anterior segment, if present, and ensure secure fixation of the IOL.

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48 The review yielded 392 patients. Six (1.53%) had intraocular pressure (> or = 30 mm Hg) requiring treatment, 1 (0.26%) had painless iris prolapse, 11 (2.81%) had corneal abrasions, and 7 (1.78%) were given a more intensive steroid regime (UVEITIS) Corneal edema No cases of fibrinous uveitis were recorded. J Cataract Refract Surg Jul;25(7):985-8.

49 Corneal edema is categorized according to severity in reversible and irreversible. reversible corneal edema: - in 7 days: 8.42%; - in 30 days: 1.03%; irreversible corneal edema : – edemato bullous keratopathy (Corneal endothelial damage) a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract,

50 Most common in pre-existing endothelial disorder Edema is most often caused by : Mechanical trauma, Prolonged intraocular irrigation, Inflammation, And elevated IOP. Toxic Solutions Vitreocorneal Adherence and Persistent Corneal Edema

51 Points in Management:  If epithelial edema is present in the face of a compact stroma immediately after surgery, it is likely due to elevated lOP with intact endothelium.  Corneal edema generally resolves completely within 4-6 weeks. As a rule, if the corneal periphery is clear, the corneal edema will usually resolve with time. Corneal edema persisting after 3 months usually does not clear and may require penetrating keratoplasty.

52 Small wounds, under 3.2 mm, are much less prone to this complication The sealing of the wound depends : the quality of the corneo-scleral tissue. the quality of incision This in turn depends on certain intraoperatory complications certain chronic diseases thermal injury of the wound If needed case can use a therapeutic contact lens.

53 Intraoperatory injury with the phaco tip or instruments. (complicate cases) & some local or general associated conditions may cause pupil asymmetries. This will translate clinically by decreased visual acuity, lack of adaptation to strong light.

54 Post operatory intraocular inflammation can be acute and chronic (endophthalmitis). Chronic uveal inflammation may occur in weeks, months or years after cataract chronic inflammation significant statistical correlations between post-intraocular inflammation on the one hand and rupture of thecapsule.

55 Cystoid macular edema Retinal detachment Persistent increase in intraocular pressure Intraocular lens dislocation or subluxation Choroidal detachment Endophthalmitis Corneal edema

56 There were more cases of posterior capsule tears and vitreous loss in the first 80 cases performed by the residents, the posterior capsule tear rate peaked at more than 10% after 40 cases.

57 Spontaneous in-the-Bag Intraocular Lens Luxation into the Vitreous Cavity: A Balestrazzi, G M Tosi, M Alegente, C Mazzotta, et al. Ophthalmologica. Basel: Aug Vol. 223, Iss. 5; pg. 339, 4 pgsOphthalmologicaAug 2009

58 National Cataract Register (NCR) type of anesthesia, history of trauma, ocular comorbidity, axial length, miosis, cornea pathology, and poor visibility, previous intraocular operation, iris synechias, small pupil, white cataract, brunescent/hard cataract, phacodonesis, presence of pseudoexfoliation, surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent phacoemulsification practice,

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62 Major complications occurred in 15 of 320 cases (4.7%) and involved 10 cases of vitreous loss; the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2), wrong IOL power requiring reoperation (1), corneal wound burn (1), and postoperative iris prolapse requiring wound revision. The mean postoperative BCVA was 20/26 (logMAR 0.11).

63 Severity of retro bulbar bleeding is varied. Eyeball protrusion may occur, Massive subconjunctival hematoma appears. Consequent an increase of the intraocular pressure may involve structural changes in the eyeball.

64 Visual results and complications of temporal incision phacoemulsification performed with the non-dominant left hand by junior ophthalmologists Ophthalmology trainees could successfully learn the technique with both hands. The authors consider that the skill of the non- dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts. all parameters had no difference in both sides. Br J Ophthalmol 2002;86: doi: /bjo Scientific correspondence

65 An iatrogenic Descemetorhexis is an extremely rare complication &, to our knowledge, has been described only once previously in literature by Altmann and Tympner. 2 In this instance, our case study presented a hazy cornea immediately postoperatively along with corneal oedema, both of which had resolved within one month of surgery and continued to remain clear at the two-year postoperative follow-up. This positive outcome was a result of the spread and enlargement of the remaining endothelial cells, which successfully reformed the endothelial cell layer.

66 prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy and can predispose to posterior synechiae formation. If iris damage is produced inferiorly through contact with the phacoemulsification tip, loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip. Another option is to use a single iris hook to retract the inferior iris, holding it away from the phacoemulsification tip for the duration of the procedure.

67 the nucleus seems to be trapped within the capsular bag; This usually indicates a nucleus that requires further hydrodissection,viscodissection can be performed. When re-entering the eye with the phacoemulsification tip, irrigation should not be used until a second instrument has been inserted through the stab incision and placed below the nucleus; when irrigation and aspiration begin and the OVD is removed, the second instrument prevents the nuclear piece from falling back into the posterior chamber. After the nucleus has been sufficiently thinned, an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue; this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder.

68 Fig Vacuum rise-time as a function of aspiration rate. Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels.

69 POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge. Yanoff & Duker: Ophthalmology, 3rd ed. Copyright © 2008 Mosby,2008 Mosby,

70 A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification (P<0.001). We suspect that the higher inherent vacuum levels present in the venturi driven system may have led to an increased incidence of posterior capsule tears and vitreous loss in the beginning resident surgeon. Other factors that were analyzed and may be important include attending surgeon experience, phacoemulsification technique, machine parameters used, and the content of preparatory phacoemulsification courses Ophthalmology & Vis Sci University Chicago Chicago IL 2 Ophthalmology and Visual Science The University of Chicago Chicago IL

71 Most surgeons recommend completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material. In general, IOL implantation is permissible; one exception might be loss of an extremely hard, dense nucleus that would require removal through a limbal incision. If a significant amount of nuclear material has been retained, vitreoretinal surgery needs to be performed 1–2 days postoperatively. Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops. Some surgeons advocate irrigating the vitreous with fluid in an attempt to float the nucleus back into position. An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears.

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73 during phacoemulsification complicated by a posterior capsule tear nylon are tied to the trailing haptic of the IOL Then, the IOL is inserted into the sulcus.

74 Poor pupillary dilation Zonular dehiscence Capsular rupture Vitreous loss & dropped nucleous IOP control in the early postoperative period seems to be more important in patients with PEX. Ophthalmologica 2008;222:

75 Improve & stabilize blood glucose A1c < 6.5% (ideally) Strive for a low standard deviation Phacoemulsification when prudent or necessary Much higher risk of post- operative CME and worsening retinopathy Always address retinopathy prior to surgery

76 - Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007; 55(3): 238-9

77 may occur at the rate of 1% after uncomplicated cataract surgery and increases to between 6.8% and 8.6% following intraoperative vitreous loss [6].

78 Complications of Phacoemulsification  Holding the phaco tip too close to the cornea.  Performing phacoemulsification or allowing lens fragments to circulate in the anterior chamber.  Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema.  These cases may demonstrate corneal edema / on the first postoperative day, / or months to years following surgery.  Removing retained nuclear material may allow for the corneal edema to resolve.


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