Management of Cataract - child adult.pptx

management of cataract

1. Management of Cataract .

2. Investigations - Complete blood count. Blood sugar level. Hepatitis B ,Hepatitis C,HIV Testing. Urine examination. Bleeding time and Clotting time.

3. Local investigations- Tonometry Slit lamp examination for grading of nuclear hardness. R etinal function tests- -projection of light - Maddox rod test - entoptic view of retina - B scan - foveal electroretinogram .

4. Treatment of cataract Non surgical methods- treatment of cause of cataract- - Adequate control of D.M - Removal of Cataractogenic Drugs such asCorticosteroids strong miotics , phenothiazines . -Removal of irradiation. - Early and adequate use of ocular diseases.

5. Measures to delay progressions- -Iodine salts of calcium and potassium. -Role of aspirin and vitamin E.

6. Surgical treatment- To calculate IOL power – Biometry- SRK 2 formula-Sanders- Retzlaff – Kraff formula – P=A-0.9L-2.5K A- constant(manufacturer’s const.) K- Keratometry reading L – Axial length.(A scan) Newer formulas –SRK T ,Holladay 1&2,Hoffer Q , Haigis , Barret , Olsen,Hiel -RBF.

7. Intraocular lenses- Classification – Based on site of implantation. -Anterior chamber IOL-Angle fixated -Iris fixated -Posterior Chamber –Supported within capsul - -Sulcus fixated anterior to anterior lens capsule. -Iris fixated - Scleral fixated.

8. Based on optical correction- Monofocal Multifocal-refractive -diffractive Toric IOL-to correct preexisting astigmatism.

9. Accomodating IOL- After surgery patient cannot accommodate ,so accommodating IOLs are used . Example- crysta lens.

10. Contraindications of IOL- Significant and proliferative diabetic retinopathy Senile macular choroidal degeneration. Juvenile rheumatoid arthritis Endothelial corneal dystrophy Rubella cataracts .

11. Preoperative medications and preparations- Consent with detailed information about the procedure risks involved and outcome expected should be obtained from each patient. scrub bath, marking of eye, and proper care of hair should be taken. preoperative antibiotics and disinfectants are required to prevent postoperative endophthalmitis . -topical antibiotics such as fourth generation fluoroquinolone may be used to QID for 3 days before surgery and every 15 minutes for 2 hours before surgery to eradicate conjunctival bacterial flora.

12. - povidone iodine 10% solution should be used to paint the lids and facial skin preferably 2 to 3 hours before surgery. povidone iodine 5% solution instilled as eye drops in the conjunctival sac 10 to 30 minutes before surgery is one of the most effective measure to decrease the bacterial Flora IOP lowering is must for ECCE. Some surgeons also Prefer for SICS and Phacoemulsification. It is done with the help of digital massage.

13. Mydriasis sustained throughout the procedure is required for successful completion of the surgery it can be obtained by- topical tropicamide 1% plus phenylephrine 2.5% should be instilled every 15 minutes 4 to 6 times before surgery.

14. Surgical Techniques-

15. Steps in Cataract surgeries- Anaesthesia –general anaesthesia for children -Local anaesthesia – Retrobulbar nerve block ( 2% xylocaine with added hyaluronidase 5IU/ml with or without adrenaline) - Peribulbar nerve block( consist of 2% lignocaine and 0.52 0.75% bupivacaine with hyaluronidase 5 international unit per ml and adrenaline 1 in 100000. - Topical Anaesthesia -LIGNOCAINE ,PARACAINE - only for phaco through corneal incision. -Should be supplemented with intracameral preservative free lignocaine

16. Incisions- ECCE- 8-9mm in length superior limbal incision is made , peritomy (cut and open conjunctiva )is done before. SICS- Sclero corneal tunnel is made.It is self sealing incision.It is of 6-7 mm in length. Phocoemulsification - Periperal clear corneal incision is made.(3.2 to 3.5 mm or 2.7 to 3.2 mm).

17. Surgical steps in ECCE- Superior rectus bridle suture-to fix the eye in the downward gaze position. Conjunctival flap is made to expose the limbus . Partial thickness groove or gutter about 2/3 depth of anterior limbal area from 10 to 2 o clock position. Entry into anterior chamber. Injection of the viscoelastic substance. Anterior capsulotomy - Dye used to stain anterior capsule is trypan blue. Three techniques are used- Can opener - Continuou curvilinear tech nique . - Envelop technique.

18. Removal of cataractous lens –with the help of Kelmann mc phersons forceps. Completion of corneoscleral section Hydro dissection- Inject fluid beneath the capsule ,fluid cleaves capsule and the cortex. Removal of the nucleus- Pressure and counter pressure technique.* -Irrigating wire vectis technique* Aspiration of the cortex Implantation of IOL –Rigid IOL. Closure of the incision –interrupted 3-5 sutures or continuous 10 sutures are done. Before tying last suture viscoelastic substance is removed with 2 way canula and anterior chamber is filled with BSS* Conjunctival flap is repositioned and secured by wet field cautery. Subconjunctival incision of gentamicin(0.5ml) and dexamethasone(0.25ml) is given.Patching of eye is done.

19. Steps of Manual small incision cataract surgery. Superior rectus suture. Conjunctival flap (fornix based) from 10 to 2 o clock position with the help of sharp tipped suture. Hemostasis is achieved by wet field cautery. Sclerocorneal tunnel incision- 1/3 to ½ thickness external scleral groove is made about 1.5-2mm behind the limbus . It varies from 5.5 to 7.5 mm in length depending upon the hardness of the nucleus. Tunnel is made with the help of crescent knife. It usually extends 1 -1.5 mm into clear cornea. Internal corneal incision is made with the help of sharp angled keratome . side port entry of about 1.5 mm value le corneal incision is made at 9 o’clock position. This helps in in respiration aspiration of the sub incisional and deepening the anterior chamber at the end of surgery

20. Anterior Capsulotomy . Hydrodissection . Nuclear management- 1)Prolapse of nucleus out of the capsular bag is initiated during hydrodissection and completed by using rotating nucleus with sinskey’s hook. 2)Delivery of nucleus following methods are used. -Irrigating wire vectis method - Blumenthal’s technique - Phacosandwich technique - Phacofracture technique. - Fishhook technique.

21. Aspiration of cortex- using two way irrigation canula . IOL Implantation – Posterior chamber IOL is implanted . Removal of viscoelastics Wound closure- Anterior chamber is deepened with the help of BSS Injected through side port entry.This lesds to self sealing of the sclera corneal tunnel.Conjuctival flap is reposited and is anchored with the help of wet field cautery.

22. Steps in Phacoemulsification Clear corneal incision-2.8-3mm , Self sealing. Continuous curvilinear capsulorrrhexis . Hydrodissection Nucleus is emulsified and aspirated by phacoemulsifier . Phacoemulsifier acts through a hollow 1 mm titanium needle which vibrates at an ultrasonic speed of 40000 times a second and emulsifies the nucleus. Different techniques are used for nucleotomy - -Chip and flip technique. -Divide and conquer technique. - Stop and Chop Technique. -Direct Phaco chop technique. Remaining cortical matter is removed with irrigation aspiration technique.

23. IOL implantation-Foldable IOL is implanted by using Injector. Removal of Viscoelastics and wound closure are similar to SICS.

24. Femto second laser assisted Cataract Surgery.(FLACS) Principle – Photodisruption . Femtosecond laser. Steps-1) Flattening of Cornea 2) Capsulorrhexis 3)Nuclear Fragmentation 4) Corneal incisions are made. 5) Corneal incisions are opened with fine iris repositor 6)Anterior chamber is filled with viscoelastic material. 7) Capsulorrhexis flap is removed with forceps.

25. Lens fragments are Phacoaspirated . Foldable IOL is implanted in the capsular bag and the procedure is completed.

26. postoperative management after cataract operation patient is asked to lie quietly upon the back for about two to three hours and advised to take nil orally. diclofenac sodium may be given orally for mild to moderate postoperative pain.

27. Bandage for iPatch is removed next morning and eye is inspected for any postoperative complication. when phaco emulsification is done under topical anaesthesia there is no need of eye patching and postoperative eye drops can be started immediately. antibiotic eye drops moxifloxacin are used for 4 times day for 10 to 14 days. topical steroids prednisolone eye drops 3 to 4 times a day are used for 6 to 8 weeks.

28. Topical ketorolac or any other NSAID eye drops 2 to 3 times a day are used for 4 weeks. topical timolol . 5% eye drops price daily are used for about 5 to 7 days. Topical cycloplegic mydriatic example- homatropine eye drops may be used for one day for 10 to 14 days final spectacles are prescribed after about 6- 28 weeks of S ICS operation and three to four weeks of phaco emulsification.

29. Complications of Cataract Surgery- Preoperative Complications – Excessive Anxiety with anxiety induced exacerbated hypertension or angina attack Attack of angle closure glaucoma precipitated by dilatation of pupil for ECCE in a patient with shallow anterior chamber or swollen LENS. complications of anaesthesia include the following- retrobulbar or parabulbar hemorrhage - accidental perforation of the globe with intraocular injection of the anaesthetic . - accidental injection into the optic nerve sheath with intracranial spread.

30. Anaphylactic shock vasovagal reflex with collapse Intraoperative Complications- due to poor preoperative preparations- -excessive bleeding from conjunctiva if conjunctival flap is made and the patient is on anticoagulants. -rise in blood pressure or attack of angina if the patient forgot to take usual dose of medications. - hypoglycemic attack if patient is fasting and has taken his or her antidiabetic medications. - patient starts moving and coughing during surgery if not properly counselled preoperatively .

31. due to poor surgical techniques- - damage to Superior rectus muscle while passing bridle suture. - poorly constructed wound with irregular edges. - damage to delicate intraocular tissues specially corneal endothelium, Iris, lens zonules and posterior capsules. Other Complications.- -subluxation of lens - posterior dislocation of lens - rupture of posterior capsule for capsular rent with vitreous loss. - nuclear dropping back into vitreous cavity through posterior capsular rent.

32. - expulsive choroidal hemorrhage Failure to implant the intraocular lens in the bag damage to the intraocular lens with scratches on the optic for breaking of the haptic .

33. After Surgery or Post-operative Complications Early postoperative complications (within first few days to 4 weeks): Endophthalmitis Uveitis Retained lens matter Corneal oedema

34. Wound leak Wound dehiscence Hyphaema Astigmatism Retinal detachment

35. Posterior vitreous detachment with retinal tear or vitreous haemorrhage Exacerbation of diabetic retinopathy Refractive surprise, i.e. high refractive error due to wrong power intraocular lens Toxic anterior segment syndrome Toxic lens syndrome

36. Late post-operative complications (after 1 month to years): Delayed chronic Endophthalmitis Retinal detachment Cystoid macular oedema Exacerbation of diabetic retinopathy Displacement of intraocular lens Pseudophakic bullous keratopathy .-due to damage to healthy corneal endothelium.

37. Persisting astigmatism Epithelial ingrowth and fibrous downgrowth into anterior chamber Secondary glaucoma Posterior capsule opacification

38. Cystoid macular edema Collection of fluid in thre form of cystic loculi in henle’s layer of macula. Frequent Complication In few cases it causes visual dimunition in 1-3 months Prostaglandins are considered in the etiopathogenesis . Fluoroscein angiography –Flower Petal Appearance. Fundoscopy - Honeycomb Appearance.

39. Prevention by immediate use of antiprostaglandins eye drops Preoperatively and postoperatively(indomethacin, ketorolac.) Treatment- I n cases of CME with vitreous incarceration ,anterior vitrectomy along with steroids and antiprostaglandins may be useful.

40. Delayed chronic postoperative endophthalmitis - - caused by organism with low virulence- propionibacterium acne or staph epidermidis . - onset- after 4 weeks to years - follows an uneventful cataract extraction. - fungal endophthalmitis may also occur.

41. After Cataract- -Most common postoperative complication. Causes – Residual opaque lens matter may persists as after cataract. - Proliferative type of after cataract may develop from left out anterior epithelial cells. Clinical types-tenures posterior capsular opacification . -Dense membranous after cataract. - Soemmering’s ring –thick ring enclosed between two capsules.

42. Elschnig’s pearls-Vacuolated subcapsular epithelial cells are clustered like soap bubbles along posterior capsule. Treatment – YAG laser capsulotomy - Dense membranous after cataract needs surgical Membranectomy . - Peripheral soemmering’s require no treatment.