Action on cataract Whipps Cross Hospital Harold Wood Hospital North East London Eye Partnership

Cataract surgery Indications for surgery Surgical plan Surgical procedure Postoperative care Discharge

Indications Visually significant cataract Affecting quality of life Work Driving Reading Hobbies Activities of daily living No Snellen acuity limit! (except driving)

Surgical plan Mode of anaesthesia Surgical procedure Refraction Additional surgery Lens implant: power & material

Anaesthesia Local Topical Regional Peribulbar Retrobulbar Sub-Tenons sub-conjunctival General

Surgical procedure Pupil dilation cyclopentolate 1% + phenylephrine 2.5% Surface cleansing povidone iodine 5% Draping disposable self-adhesive waterproof drape Lid speculum Cataract removal Lens implantation

Cataract - phacoemulsification Section: cornea or scleral Viscoelastic instillation Capsulorrhexis Phacoemulsification Soft lens removal IOL implantation Viscoelastic removal

Additional surgery Pupil enlargement Refractive surgery Glaucoma Vitreoretinal Macular hole Epiretinal membrane peel Retinal detachment Vitrectomy for vitreous haemorrhage

Surgical section Self-sealing - sutureless Astigmatically neutral Position Temporal Superior on-axis Size: limited by IOL size – 3 to 3.5mm

Capsulorrhexis T Neuhann 1987 Theory and surgical technic of capsulorhexis Klin Monatsbl Augenheilkd 1987;190:542-5 “Kapsulorhexis is a surgical technique for opening the anterior lens capsule with a circular, smooth-edged and continuous margin. Basically, the technique consists of a precisely controlled continuous capsular tear (rhexis), using only a sharp disposable needle with a bent tip. The method is reproducible, requires minimal instrumentation, is compatible with all current techniques of extracapsular surgery, and can be learned at no risk.”

Dense cataract without red reflex: Vision Blue

Phacoemulsification Charles Kelman 1967 – Cavitron Ultrasound fragmentation of lens no capsulorrhexis or foldable IOLs Techniques Divide & conquer Nucleus chopping

Phaco – “divide and conquer”

Intraocular lens implants Rigid PMMA Foldable Silicone Acrylic – hydrophobic e.g. Acryosof Acrylic – hydrophilic e.g. Hydroview, Centerflex

Complications – intra-operative >92% no intra-operative complications Posterior capsule rupture - around 4-5% Zonule dehiscence Vitreous loss Iris trauma & bleeding Corneal endothelial damage Thermal corneal burns Dropped nucleus or lens fragments

Post-operative care Clinic review: Next day unnecessary 7-14 days post-operative clinic review Topical therapy e.g Maxitrol x 4/3/2/1 per week Post-operative refraction Stability Attainment of target refraction Dispensing for non-emmetropic eyes e.g -3D target Laser capsulotomy

Discharge to Optometrist Refract & dispense at 4-6 weeks Refraction feedback for audit Visual outcome Target refraction & biometry precision Planned surgery on second eye Capsule opacification & Laser capsulotomy