Complex cases in Cataract surgery and its management.pptx

Complex case scenarios in Cataract surgery. Small pupil , hard Cataract, posterior polar Cataract, Fuch's endothelial dystrophy, run away rhexis. Management of complicated Cataract.

1. Complex cases in Cataract surgery and its management Mentor- Dr Sharat sir Sharat maxivision eye hospital Presenter Madhumita Prasad Maxivision eye hospital, Somajiguda 7/7/2023 1

2. Table of content Small pupil surgeries Hard cataract and its management Posterior polar cataract Cataract in Fuch’s corneal dystrophy Runaway rhexis 7/7/2023 2

3. Introduction In ophthalmology the clinical management of patients is constantly evolving and complication rate is getting low. Although routine cataract surgery considered as low-risk surgery for both patients and the surgeon, some eyes have higher risk of complications. It is extremely important to recognize when eyes are at greater risk, and manage accordingly to reduce the complications. The common goal is to completely remove the cataract while preserving the zonules and capsular bag for the placement of an IOL. 7/7/2023 3

4. In the following slides we will discuss some frequently encountered difficult situations and their solutions. 7/7/2023 4

5. Small Pupil Surgeries Most common mechanisms of small pupil formation ETIOLOGY MECHANSIM Age related Iris atrophy Pseudoexfoliation Iris dilator and sphincter muscle atrophy Intraoperative Floppy iris syndrome Dilator muscle atony- atrophy Posterior Synechaie Uveitis, angle closure glaucoma 7/7/2023 5

6. Technical challenges of small pupil surgery 7/7/2023 6

7. Small pupil management 7/7/2023 7

8. Surgery technique Capsulorhexis can be made larger than the pupil size. Complete hydrodissection Vertical chopping technique is preferred to separate nucleus 7/7/2023 8 (If fibrous membrane is found behind the pupil, it is removed using forceps)

9. PHARMACOLOGICAL MYDRIASIS The use of preoperative anti- infl ammatory agents (NSAIDs) decreased occasions of intraoperative pupillary constrictions greatly. 1:1000 preservative free epinephrine intracameral injection ( epitrate ) 7/7/2023 9

10. Ocular viscoelastic devices - OVDs are non active, clear, gel like chemical compounds with viscous and elastic properties. Classified as- Cohesive- high viscosity, high molecular weight, act like a gel, create space . Examples – healon GV/ healon , provisc Dispersive- lower viscosity, lower molecular weight, adhesive and protective effect, high coating ability. Like viscoat , healon D, ocucoat Viscoadaptive OVDs- super cohesive viscoelastic substances, creating more space, healon 5 7/7/2023 10 Management with OVD Visco elastic agent Iris stretching can be done Deepening of AC Pupil dilatation

11. Mechanical devices Hydroview iris protector ring Malyugin Ring 3. B-HEX pupil expander 4. I-ring pupil expander 5. Iris hooks Malyugin B. Cataract surgery in small pupils. Indian J Ophthalmol . 2017 Dec;65(12):1323-1328. doi : 10.4103/ijo.IJO_800_17. PMID: 29208812; PMCID: PMC5742960. 7/7/2023 11

12. Surgical maneuvers - Synechiolysis Stretch pupilloplasty - 2 instruments Iris cutting with vanas 7/7/2023 12

13. Management of hard cataract Problems encountered by surgeons- Capsular zonular problems Corneal edema Wound burn Post operative inflammations PC rupture Main aim is to minimize the endothelial cell loss and protect the PC. Reason being- Lens fibre are totally adherent, making chopping difficult. There is very little or no cortical cushion between lens and the capsule. 7/7/2023 13

14. Pearls and strategies to follow- Capsular dye, Bigger rhexis Gentle hydrodissection High vaccum and burst mode Sculpt a central pit prior to chop Subchop fragments Using OVD more frequently to coat the endothelium 7/7/2023 14

15. Recent advancements are evolving. One of them FLACS. Major advantage is the potential to decrease intraocular phaco energy time, save the endothelium, decrease the zonular stress and tackle astigmatism. Another device is the miLOOP - Manual micro-interventional endocapsular disassembly technique. Fragmentation device. Used to bisect the nucleus. It uses a disposable microfilament made of nickel and titanium ring (nitinol). It can open 10.5 mm radius and then can be contracted to 1.5 mm radius. 7/7/2023 15

16. POSTRIOR POLAR CATARACT Another challenging presentation with a heightened risk for intraoperative complications is the posterior polar cataract. Why PPC important? Strong adherence of the opacity to posterior capsule. 26% chances of defective PC. High rate of intraoperative PC rupture ( upto 36%). Osher RH et al. J Cataract Refract Surg. 1990;16(2):157-162. Vasavada AR, Singh R. Phacoemulsification in posterior polar develop­mental cataracts. In: Lu LW, Fine IH, Phacoemulsification in Difficult and Challenging Cases. New York, NY: Thieme : 1999: 121-128. 7/7/2023 16

17. MAIN ISSUES 7/7/2023 17

18. Surgical technique Capsulorrhexis - oval 5.5 mm Rotation of nucleus should be avoided. Low aspiration flow rate and low vaccum technique. Hydro delineation is preferred. DO NOT ATTEMPT hydro dissection. Bimanual I/A. Inject visco before removing instruments. 7/7/2023 18

19. FEW TIPS Identify PC defect before surgery- fish tail sign Good adequate rhexis- prefer oval shape No hydro-dissection- no rotation Low parameter phaco Avoid shallowing of anterior chamber Cortex and epinuclear plate removal- bimanual I/A No PC polishing 7/7/2023 19

20. Cataract with Fuch’s endothelial dystrophy Fuchs’ endothelial corneal dystrophy (FECD) is a condition that affects the corneal endothelium, resulting in a reduction in the number of Na+/K+ ATPase pumps [1]. Clinically, this manifests as corneal edema, which can lead to symptomatic glare and halos, and ultimately decreased visual acuity. Presentation- blurring of vision (more in the morning hours), glare. Detection- guttae External Disease and Cornea, Section 8. Basic Clinical Science Course, American Academy of Ophthalmology. 2018. 7/7/2023 20

21. Dilemma Whether to operate only cataract or should be combined with endothelial keratoplasty. Pre-operative considerations- The surgeon should consider the individual factors cataract density, the health and thickness of the cornea, the anterior chamber depth and the size of the dilated pupil. The presence of microcystic oedema, pachy >640 microns, stromal thickening and a low central endothelial cell count (less than 1,000 cells/mm2), indicates an increased likelihood of corneal decompensation after cataract surgery. In these patients, cataract surgery should be combined with endothelial keratoplasty. 7/7/2023 21

22. Algorithm describing an approach to Fuchs endothelial corneal dystrophy (FECD) with cataract 7/7/2023 22

23. Patient counselling- Postoperative recovery time may be longer than usual. Endothelial keratoplasty may be required in case of corneal decompensation. Patients may have to come for regular follow-up visits. Choice of IOL- standard monofocal IOL is recommended Surgical technique- To reduce EC loss such as tri-soft shell technique (TSST), Phaco -Chop technique and low-flow irrigation may be considered. 7/7/2023 23

24. Errant Rhexis Management of the capsulorrhexis is a fundamental step in cataract surgery. Best capsulorrhexis are round, continuous, well centered, and overlapping the edge of the IOL around its circumference. FACTORS PREDISPOSING TO AN ERRANT RHEXIS Shallow AC convex anterior lens capsule poor visualization small pupil traumatic cataract with anterior capsular tear white mature or Morgagnian cataract are some of the reasons a rhexis may run out. 7/7/2023 24

25. Run away rhexis Blind pulling is avoided to avoid posterior capsular extension. The Little rhexis trick, popularised by Brian C Little, is very useful. The capsule flap is unfolded to lie flat. (Fig A) While holding it as close to the root of the tear as possible, (fig B) it is first pulled backwards in a horizontal plane along the circumference of the completed segment of rhexis (Fig C) and then with flap held stretched, directed more centrally to initiate the tear. (Fig D) If the rhexis run-out is irretrievable, it may be attempted to be completed by creating a cut on the flap and continuing forwards or by creating a nick on the opposite side and completing it backwards. Alternatively, can-opener cuts can be done in the incomplete area 7/7/2023 25