cataract ,history,ECCE AND SICS.pptx

cataract

1. Cataract S urgery-History , ICCE,ECCE,SICS Dr. Ramesh Bhandari Resident, Ophthalmology BPKLCOS, MMC, IOM

2. CONTENTS History of Cataract Surgery Introduction Major Indications Procedures-at a glance Advantages and Disadvantages Complications References 7/18/2022 2

3. History- The Ancient Era Early writings say that cataract surgery used to be performed as early as 300 BC with no description of methods and techniques. For more than 20 centuries, couching was the primary method for dislodging the cataract away from the pupil. The first written description of couching came from Sushruta , an ancient Indian surgeon ( 600 BC) 7/18/2022 3

4. COUCHING Also known as “LENS DEPRESSION” Involves using a sharp instrument to push the cloudy lens to the bottom of the eye It was done “without a microscope.” A sharp instrument, such as a thorn or needle, is used to pierce the eye either at the edge of the cornea or the sclera, near the limbus The opaque lens is pushed downwards, allowing light to enter the eye. Once the patient sees shapes or movement, the procedure is stopped The patient is left without a lens ( aphakic ) 7/18/2022 4

5. 7/18/2022 5 Bronze instruments of the roman period (1 st century AD) for cataract couching , found at Montbellet , France

6. The Modern Era The father of modern cataract surgery, Jacques Daviel , introduced the incisional extraction of the cataract ( extracapsular catract extraction)in 1753. 7/18/2022 6

7. Between 1753 and 1862, three milestones took place that profoundly affected the direction of cataract surgery: 1 .  Pierre–Francois– Benezet Pamard of Avignon shifted the surgical incision to the upper part of the eye. He had the patient lie on his or her back and operated from the head of the table. 2 .  Carl Himly , a German oculist, improved the surgeon's view by introducing pharmacologic mydriasis . 3 .  Albert Mooren of Düsseldorf added a preliminary iridectomy to combat the complication of pupillary block. 7/18/2022 7

8. Introduction of ICCE Samuel Sharp (1753) described surgery that introduced the subject of taking the entire lens out of the eye with the capsule intact through limbal incision using pressure from his thumb. Albrecht von Graefe (1867) devised his long, thin, sword-like corneal knife that created better apposed incision. Christiaen (1845) wrote on breaking the zonules with a curved blunt probe passed into the anterior chamber (AC). 7/18/2022 8

9. Techniques (ICCE)  Smith’s method  Arruga’s method  Erysiphakes  Cryo surgery  Chemical dissolution of zonular fibers 7/18/2022 9

10. The return to ECCE 7/18/2022 10 During World war II, Ridley treated pilots with perforated foreign body injuries to the eyes that had occurred through splinters of the Plexiglas domes in the cockpits. He learned that these splinters remained relatively inert in the internal eye .

11. Harold Ridley performed his first artificial lens implant at St Thomas’ Hospital in London on Nov 29, 1949. After trying only two posterior chamber lenses in patients after ICCE; he put all the rest in ECCE patients. Lens luxation- major problem 7/18/2022 11

12. Harold Scheie described a procedure for aspirating a soft congenital cataract from the eye through small incisions.He performed aspiration through a single needle and irrigation with AC maintenance through a separate needle. In 1967 , Kelman introduced Phacoemulsification . Technically difficult and dangerous :high risk of corneal damage, capsular rupture, vitreous loss, and nucleus dislocation into the vitreous 7/18/2022 12

13. William Simcoe (1977) introduced his Simcoe curved 23-gauge cannula connected to a small irrigating bulb. In1980, Miller and Stegman use Healon to stabilize AC. Gimbel and Neuhann described CCC which allowed safe in-the-bag nuclear emulsification. In 1990, McFarland demonstrated that a properly created scleral tunnel would make a corneal valve effect that sealed any egress of AC fluid. Fine in February 1992 described a planar temporal clear-corneal sutureless incision,which was a self-sealing. 7/18/2022 13

14. In 1998 ,Amar Agarwal described Phaconit using bare phaco tip & irrigating chopper through 0.9mm clear corneal incision . 7/18/2022 14

15. ICCE- INTRACAPSULAR CATARACT EXTRACTION • In this technique, the entire cataractous lens along with the intact capsule is removed . • Weak and degenerated zonules are a pre-requisite for this method. • A cryoprobe is used to remove the lens complete with its capsule • After which anterior chamber IOLs are implanted • It has been almost entirely replaced by planned extracapsular technique • At present the only indications of ICCE is markedly subluxated and dislocated lens . 7/18/2022 15

16. Preferred surgical technique before the refinement of modern ECCE surgery However there remained 5% rate of potentially blinding complications including: Infection Hemorrhage RD CME 7/18/2022 16

17. Indications of ICCE  Operating microscopes not available  Unstable / luxated cataracts  Week zonular support 7/18/2022 17

18. Advantages of ICCE • Entire lens removed with no capsule left behind to: Opacify Require additional surgery • Less sophisticated instrumentation required • Non automated extraction devices : Cryoprobes Capsular forceps Erysiphakes 7/18/2022 18

19. Disadvantages of ICCE Large ICCE incision 12 – 14 mm (160° - 180 °) Delayed healing Iris incarceration Delayed visual rehabilitation Vitreous incarceration Postoperative wound leaks with inadvertent filteration Endothelial cell loss > following ICCE than ECCE Corneal / endothelial cell trauma from lifting / folding of the cornea (lens delivery / cryprobe ) Cystoid macular edema (transient 50%, persistent 2 %- 4 %) 7/18/2022 19

20. Vitreous complications: In young patients PC is firmly adherent to anterior hyaloid ; attempted ICCE will usually result in vitreous loss Intact vitreous face may opacify and decrease vision Adherence to corneal endothelium (corneal edema) Adherence to iris (pupillary block glaucoma) Broken vitreous face may incarcerate in the wound with vitreous traction causing:  RD  CME  Vitreous in AC causing open angle glaucoma IOL implantation problematic since posterior capsular support is missing  IOL choices include : ACL /Sutured PC IOL (Iris fixation IOLs no longer available)  These significant disadvantages and risks led to loss of popularity of ICCE 7/18/2022 20

21. Procedure Patient preparation : - Informed consent - Dilation of pupil - Local anaesthesia and orbital massage - Cleaning of periocular skin & ocular surface - Draping -Eyelid speculum Superior rectus bridle suture 7/18/2022 21

22. Incision : - Fornix based or limbal based conjunctival flap. - Wet-field cautery used for homeostasis. - Partial thickness groove or gutter made through about 2/3 rd depth of anterior limbal area from 9:30 to 2:30 O’clock with razor blade knife. 7/18/2022 22

23. 7/18/2022 23 - AC entered with razor blade knife or with 3.2mm keratome . - Corneoscleral section completed with scissors. - α -chymotrypsin injected via a cannula through the pupillary space into the posterior chamber.

24. Iris retractor used to expose the superior surface of the lens. Cellulose sponge is used to dry the anterior capsule. Cryoprobe placed on the lens surface & foot pedal pressed. After formation of iceball , gentle maneuvers used to deliver lens. 7/18/2022 24

25. Iris reposited into AC & chamber formed by injecting BSS. After instillation of acetylcholine, ACIOL or PCIOL with iris or scleral fixation can be inserted. Conjunctival flap secured. Subconj or subtenon antibiotics & steroids given. Patch or shield. 7/18/2022 25

26. ICCE Today Though obsolete today, ICCE is still performed: 1. Markedly subluxated or dislocated lens 2. In less previledged part of world, this has some role because of the following: - Less sophisticated instrumentation required - Visual rehabilitation with temporary aphakic spectacles is usually possible soon after surgery. 7/18/2022 26

27. Extracapsular cataract extraction (ECCE) Extracapsular cataract extraction (ECCE) has replaced ICCE, almost entirely in most parts of the world: 1. Better operating microscopes 2. More sophisticated surgical aspiration systems 3. More sophisticated IOL implants ECCE involves removal of the nucleus and cortex through an opening in the anterior capsule (anterior capsulotomy ), leaving the posterior capsule in place. 7/18/2022 27

28. Methods: ECCE 7/18/2022 28

29. Merits of ECCE A posterior chamber IOL is usually implanted along with ECCE,which is an ideal Intraocular lens. Chances of vitreous loss is very minimal. The occurrence of vitreous-related anterior segment complication is negligible. Less chance of cystoid macular edema due to intact posterior capsule. Less chance of retinal detachment. An intact posterior capsule guards against infection (like endophthalmitis ) for a prolonged period. 7/18/2022 29

30. Demerits of ECCE A difficult microsurgical technique,costly and takes time to master. Iridocyclitis and glaucoma due to lens particles are common. Opacification of posterior capsule(after cataract) occurs in a significant number of cases,requiring YAG-Laser capsulotomy ECCE cannot be done in dislocation and is difficult in subluxation of the lens. 7/18/2022 30

31. Conventional ECCE-Procedures Patient preparation Superior rectus bridle suture Fornix based conjunctival flap made and homeostasis achieved by wet-field cautery. A groove incision- 11 or 12mm , made in sclera behind the posterior limbal margin using a diamond knife, round-tipped steel blade or sharp microknife . AC is entered with razor blade knife or keratome . Viscoelastic substance is injected into the AC. 7/18/2022 31

32. Anterior capsulotomy : 1 ) Can-opener’s technique: Irrigating cystitome or a bent tipped, 1 inch, 22 gauge needle is introduced into AC Series of connected radial cuts made in anterior capsule for 360°. 7/18/2022 32

33. 2 ) Envelope technique: Several punctures are made horizontally in the anterior capsule at 6 O’clock position. A puncture is made at 10 O’clock & incision extended to 2- O’clock position. After expression of nucleus & insertion of PCIOL, diagonal incision made on the right which connects with the end of can-opener incision at 6 o’clock. Similar incision made on the left. Anterior capsule is grasped with smooth forceps , torn free & removed. 7/18/2022 33

34. 3) Continuous curvilinear capsulorhexis (CCC): - A puncture or small tear is made at the center of the lens, the edge of which is grasped with cystotome tip or with forceps & pulled around smoothly, removing a circular portion of anterior capsule. The fragment of the anterior capsule is removed with forceps. 7/18/2022 34

35. 7/18/2022 35 Hydrodissection : of the lamellar planes may be performed using a cannula. Nucleus may be maneuvered in several directions to separate it from cortex.

36. The incision is enlarged using corneoscleral scissors along the entire length of the previously prepared groove . Nucleus delivery The most popular method- scleral depression. Irrigating wire vectis method. Injecting viscoelastic material will act as a cushion from the nucleus to prevent corneal endothelial cell damage. 7/18/2022 36

37. Aspiration of cortex : The I/A handpiece with 0.3mm aspiration port passed into AC.The orifice is directed medially or laterally to engage the cortex in the periphery. It is drawn towards the center of the pupil and aspirated 7/18/2022 37

38. The posterior capsule is then polished with low aspiration pressure & with port directed against posterior capsule. If the posterior capsule inadvertently becomes engaged into the aspiration port, aspiration must be quickly disengaged and the reflex system employed 7/18/2022 38

39. PCIOL implantation: 1)In-the-bag: 7/18/2022 39

40. 7/18/2022 40 Viscoelastic injected behind the iris compressing anterior capsule to posterior capsule . Superior haptic is passed behind the superior portion of the iris. IOL rotated- haptics lie horizontally & no iris retractions. Inferior haptic going beneath the iris in the sulcus.

41. Sutured PCIOL - In ICCE - Zonular dialysis or PCR where PCIOL couldn’t be supported. Nonabsorbable sutures passed through eyelets. Partial thickness flaps Sutures are passed underneath the iris into the sulcus and out into the bed of the previously made scleral flaps The IOL is placed gently into position as the sutures are drawn out through the openings. 7/18/2022 41

42. Wound closure By several radial sutures placed in an interrupted or in a running fashion. Tissues brought into approximation without excessive tissue compression. Suture depth of somewhat less than the full thickness of the wound 7/18/2022 42

43. Advantages of ECCE over ICCE Posterior chamber IOL can be implanted after ECCE , while it cannot be implanted after ICCE. Postoperative vitreous related problems (such as herniation in anterior chamber, pupillary block and vitreous touch syndrome) associated with ICCE are not seen after ECCE. Incidence of postoperative complications such as endophthalmitis , cystoid macular oedema and Retinal detachment are much less after ECCE. Postoperative astigmatism is less, as the incision is smaller. 7/18/2022 43

44. Small Incision cataract Surgery(SICS) Brief history of SICS • The scleral tunnel incision was introduced in early eighties in an attempt to provide better wound healing with less surgically induced astigmatism . • This became the most favoured incision technique in the recent past for sutureless , small incision, non- phaco cataract surgery. • Richard Kratz , in 1983 was the first surgeon to move the cataract incision from the limbus to the sclera thereby increasing the surfaces of apposed wound to produce enhanced wound healing and less astigmatism. • Girard and Hoffman in 1984 were the pioneer to call this posterior incision as scleral tunnel incision. 7/18/2022 44

45. Jack A Singer in 1991 conducted a prospective clinical trial to evaluate induced astigmatism with PMMA IOL implantation through a modified pocket incision, curved opposite to the limbus , which was named, “ Frown incision ”, because of its appearance to the surgeon • The purpose of the frown configuration was to reduce wound induced astigmatism • Paul H Ernest introduced the concept of an internal corneal lip ( triplanar incision); acting as a one-way valve and imparting selfsealing wound properties 7/18/2022 45

46. Procedures- In this technique ECCE with intraocular lens implantation is performed through a sutureless self-sealing valvular sclerocorneo tunnel incision. • Types of incision in SICS- 1. Frown incision 2. Straight incision 7/18/2022 46

47. Superior rectus (bridle) suture Conjunctival flap and exposure of sclera - Fornix based conjunctival flap is made along the limbus from 10 to 2 O’clock positions . - Conjunctiva and the Tenon's capsule are dissected , separated from the underlying sclera and retracted to expose about 4mm strip of sclera along the entire incision length. Hemostasis maintained with wet-field cautery. 7/18/2022 47

48. Sclero -corneal tunnel incision 1)External scleral incision: - A one-third to halfthickness external scleral groove is made about 1.5 to 2mm behind the limbus . - 5.5mm to 7.5 mm in length . - straight, frown shaped or chevron in configuration. 7/18/2022 48

49. 2) Sclero -corneal tunnel -It is made with the help of a crescent knife . - Extends 1-1.5mm into the clear cornea. 3) Internal corneal incision - Made with a sharp 3.2 mm angled keratome . 7/18/2022 49

50. Side-port entry of about 1.5-mm valvular corneal incision is made at 9 o'clock position. Anterior capsulotomy : Can-opener , envelope or CCC. Hydrodissection to separate corticonuclear mass from the posterior capsule 7/18/2022 50

51. Nucleus delivery: - Prolapse of nucleus into AC initiated during hydrodissection & completed by rotating it with sinskey’s hook. - Delivery of nucleus outside done by * Irrigating wire vectis * Fish hook 7/18/2022 51

52. Aspiration of cortex: - The remaining cortex is aspirated out using a two-way irrigation and aspiration cannula from the main incision and/or side port entry. IOL implantation: - A posterior chamber IOL is implanted in the capsular bag after filling the bag with viscoelastic substance. 7/18/2022 52

53. Removal of viscoelastic material : -done thoroughly from the anterior chamber and capsular bag with the help of two-way irrigation aspiration cannula. Wound closure: -The AC is deepened with BSS injected through side port entry. This leads to self sealing of the sclero -corneal tunnel incision due to valve effect. Rarely, a single infinity suture may be required to seal the wound. -The conjunctival flap is reposited back and is anchored with the help of wet-field cautery. 7/18/2022 53

54. 7/18/2022 54

55. Advantages of Manual SICS over ECCE Smaller incision & sutureless so less induced astigmatism. No post-operative suture related problems (irritation , suture abscess) No wound leaks, shallowing of AC, iris prolapse. 7/18/2022 55

56. 7/18/2022 56

57. LITERATURE REVIEW 7/18/2022 57

58. 7/18/2022 58

59. 7/18/2022 59

60. 7/18/2022 60

61. Original Article Br j ophthal,200:85-18 Corneal thickness and endothelial density before and after cataract surgery A C Sobottka Ventura 1001 ,  R Wälti 1002  and  M Böhnke 1001 Dra A C Sobottka Ventura, Av 11 de Junho 22, apto 73, Vila Clementino , CEP 04041-000, São Paulo, Brazil Abstract BACKGROUND/AIMS   Deturgescence of the corneal stroma is controlled by the pumping action of the endothelial layer and can be monitored by measurement of central corneal thickness ( pachymetry ). Loss or damage of endothelial cells leads to an increase in corneal thickness, which may ultimately induce corneal decompensation and loss of vision. Little is known about the effect of moderate reductions in endothelial cell number on the thickness of the corneal stroma . This study aimed to investigate this matter further using patients who had incurred moderate decreases in their endothelial cell counts as a result of cataract surgery. METHODS  Central corneal thickness was measured 1 day before surgery, 1 day after surgery, and again at 3 months or 1 year. Endothelial cell counts were also performed 1 day before surgery and thereafter at 3 months or 1 year after surgery. The relationship between these two parameters was assessed statistically. Precise measurements of central corneal thickness were made by optical low coherence reflectometry . For comparative purposes, this parameter was also determined by ultrasonic pachymetry . Central corneal endothelial cell numerical density was estimated on photomicrographs taken with a specular microscope. RESULTS  All patients had significant postoperative corneal swelling on the day after surgery; preoperative values were restored by 3 and 12 months, even though significant endothelial cell losses had occurred. No correlation existed between central corneal thickness and central corneal endothelial cell numerical density. Measurements estimated by ultrasonic pachymetry were more variable and significantly higher than those determined by optical low coherence reflectometry . CONCLUSION  As long as the numerical density of the corneal endothelial cells does not fall below the physiological threshold, a moderate decrease in this parameter does not compromise the pumping activity of the layer as a whole. 7/18/2022 61

62. 62 7/18/2022

63. PAST PRESENT FUTURE 63

64. References Principles and P ractice of Ophthalmology , third edition ,Albert Jackobiec’s . American Academy of Opthalmology , Basic Techniques of Ophthalmic Surgery, Third Edition Fundamentals of Clinical Ophthalmology, Cataract Surgery, Andrew Combes and David Gartry . Cataract Surgery ,Third Edition , Roger F. Steinert Manual Small Incision Cataract Surgery Springer International ,AAO 2016-17 Kanski’s clinical ophthalmology, a systematic approach- eighth edition Various internet sources and Journals 7/18/2022 64

65. THANK YOU 7/18/2022 65