Cataract and Vitrectomy

Jenni Webb RN Ophthalmology Cabrini Procedure Centre

JEEPERS CREEPERS WHATS HAPPENED TO MY PEEPERS

STUFF I FIND INTERESTING BY JENNI WEBB

Cataract
What is it?
A clouding of the lens proteins causing reduced visual acuity. NUCLEAR . located at the centre of the lens and the cataract most commonly associated with ageing CORTICAL . On the perimeter of the lens extending toward the centre often seen in diabetics SUBCAPSULAR . Begins at the back of the lens and is also associated with diabetes, highly miopic patients, retinitis pigmentosa or high doses of steroids CONGENITAL INFANTILE SECONDARY related to other systemic diseases /problems

The different types of cataracts are

CATARACT Causes
AGEING ULTRAVIOLET LIGHT 2005 Iceland study showed airline pilots are at risk which may be attributed to cosmic radiation as are astronauts People with diabetes or those who use steriods, diuretics and major tranquilizers are at a higher risk Other risk factors include smoking ,air pollution heavy alcohol consumption

CATARACT Symptoms
CLOUDY OR BLURRED VISION COLOUR FADING GLARE Headlights lamps and sunlight may

POOR NIGHT VISION DOUBLE VISION This symptom may resolve FREQUENT PRESCRIPTION CHANGES
as cataract get larger.

appear too bright and a halo may appear around lights

CATARACT SURGERY
COUCHING
First described in India and Eygpt around 600B.C Physicians would place a sharp instrument through the cornea and push the lens until it fell into the back of the eye. Vision was restored temporarily as inflammation and infection caused other problems Couching is still performed in some poverty stricken parts of Africa

CATARACT SURGERY
In the first half of the 20th Century 2 main surgical techniques were developed for cataract removal INTRACAPSULAR CATARACT EXTRACTION ICCE (removal of the entire lens and capsule from eye) EXTRACAPSULAR CATARACT EXTRACTION ECCE( removal of lens nucleus and cortex through an opening in the anterior capsule)

I.C.C.E SURGERY

A large incision and flap were created in the cornea. Liquid nitrogen cooled cryo probe was frozen to the lens and entire lens and capsule removed Corneal wound was then closed with up to 18 sutures (post WW2 lenss were implanted) Patients had long recovery periods being required to stay almost motionless for up to 3 weeks

I.C.C.E. SURGERY
ADVANTAGES The lens and capsule not lodged in vitreous body Enabled lens implantation when they became available Disadvantages Trauma general anaesthetic, sutures and pain Large wound long healing times, infection and corneal distortion. Vitreous movement causing retinal detachment

E.C.C.E SURGERY
First described in1753 by French oculist DAVIEL but didnt gain merit until the development of the I.O.L. in the early 1970 9mm-11mm incision was made in the limbus A bent cystitome made a can opener type of tear in the anterior capsule The lens was then expresses through the wound Any remaining cortex was then sucked out using a simcoe I.O.L. was implanted and the wound sutured

E.C.C.E SURGERY
ADVANTAGES Lens capsule intact allowing I.O.L.implant Intact capsule keeping vitreous in place Smaller wound less sutures less pain DIS ADVANTAGES Much the same as I.C.C.E

E.C.C.E SURGERY

K.P.E Kelman Phaco Emulsification

In 1960 Dr Charles E Kelman had the idea that incision size could be reduced if the lens could be fragmented. During a visit to the dentist he observed an instrument used to break up tough tooth enamel He contacted manufacturer CAVITON Inc. which led to the Caviton Phaco machine which used ultrasonic vibration to fragment the lens.

ADVANCES IN PHACO SURGERY

Technology has gone well beyond that of the original phaco machine Ozil technology -combination of ultrasonic

power and tortional amplitude allow more efficiency and create less heat thus avoiding corneal wound damage. is now reduced to 2.2mm reducing wound leakage and the necessity to suture

Wound size original wound size was 3.2 mm this Lens technology

EVOLUTION OF I.O.L.s
1795 was the first recorded attempt at replacing the natural lens it was attempted by an Italian oculist called CASAMATA . He used glass and when implanted it fell to the back of the eye 1949 Introduction of the RIDLEY LENS named after its founder Dr Harold Ridley, these lenses were like a flying saucer, weighed about 112m

EVOLUTION OF I.O.L.s

1952- 1962 introduction of A.C. lenses. The optic was placed on a plate fixed in the iris angle. Problem was the plate would spin in the A/C damaging the trabecular meshwork (glaucoma) also contact with the cornea would cause damage.

EVOLUTION OF I.O.L.s

1953-1973 Introduction of IRIS supported lenses examples are Binkhorst clip, Epstein stud and the Copeland clip.

EVOLUTION OF I.O.L.s
1963- 2001 Development of the modern Anterior Chamber Lens. A Kelman 4 point fixation lens which came in various lengths. Patient was measured white to white to determine length.

The soft flexible haptics minimized compression on the trabeculum and prevented spinning.

EVOLUTION OF I.O.L.s

1975- 2001 Modern Posterior chamber lenses. Influenced by the development of the Phaco also fine microscopes and changing lens materials There were a variety of designs (as seen above) Incision lengths varied from 7-11 mm. Haptic design maximized contact in bag. The problem was the surgically induced astigmatism.

EVOLUTION OF I.O.L.s

1991- 2009 SMALL INCISION (FOLDABLE ) LENSES As Phaco became routine so did the quest for smaller incision sizes Softer more malleable materials were developed allowing lenses to be folded without damage. The 1st 3 piece foldable lens was implanted in Australia in 1995. This allowed wound incisions to reduced from6.2mm to 3.2 mm

EVOLUTION OF I.O.L.s

2000 Introduction one piece (jelly bean) lens. This enabled lens to be injected through cartridges further reducing incision sizes(2.8 mm down to 2.2mm) Other changes are the addition of blue light filters (1st available in 2003) Restor lenses a multifocal lens negating the need for glasses Toric lens -to correct astigmatism

EVOLUTION OF I.O.L.s

WHO KNOWS WHATS NEXT

NO SURGERY IS WITHOUT

RISK

INTRA-OPERATIVE

POSTERIOR CAPSULAR RUPTURE - resulting in vitreous leak . Treatment is an anterior vitrectomy and if the tear jeopardizes the stability of IOL an AC lens may have to be inserted EXPULISIVE HEMORRAGE - acute drop intraocular pressure causing bleeding followed by raise intraocular pressure pushing out the content of the eye .Treatment is to close the wound QUICKLY reduce the intraocular pressure and post op steroids visual outcome is usually poor DISSLOCATION OF LENS lens falls to P.C. Treatment call the V.R. Surgeon

Early Post-Operative
ACUTE BACTERIAL ENDOPTHAMITIS - Occurs in 1/1000 cases (all cases reported to eye and ear hospital) Treatment include topical, intravitreal periocular and systemic antibiotics IRIS PROLAPSE iris may prolapse through wound, this is due largely to poor surgical closure HIGH IOP occurs with incomplete removal of viscoelastics (block trabecular mesh work) CORNEAL EDEMA Increase in thickness of cornea caused by Phaco (heat) and surgical manipulation . Post-operatively the cornea will cloud but clear as the edema settles

LATE POST-OPERATIVE
POSTERIOR CAPSULE OPACIFICATION (PCO) Extremely common in children . Treatment is posterior capsulotomy done with the YAG laser. RETINAL DETATCHMENT (Especially in high myopia) following a posterior capsular rupture. CYSTOID MACULAR EDEMA (CME) -fluids accumulate at the macular reducing visual acuity. A/C IOLs are associated with higher risk. ASTIGMATISM more common when suture were used MALPOSITION OF THE IOL. If the lens has moved or been incorrectly placed in the bag ,requires surgical intervention

20 years on
OPERATION TIME reduced from 60 min to 10 min SURGICAL EFFECTIVENESS with increased technology and instrumentation surgical side effects have been reduced. PATIENT IMPACT Most cataract patients are not sick just older. With that in mind we no longer fully undress our patients for surgery , we have reduced the impact of unnecessary movement with the introduction of operating trolleys. Post- Operatively (having fulfilled discharge criteria ) Patients are taken straight to the discharge lounge ( and a long awaited cup of tea) The day may come when cataracts are no longer treated in hospitals

VITRECTOMY
VITRECTOMY is the removal or partial removal of vitreous humor from the posterior segment of the eye , to gain access and to treat underlying conditions, this operation is known as PARS PLANA VITRECTOMY

VITRECTOMY SURGERY
ORIGINATED BY ROBERT MACHEMER the first vitrectomy was done in 1969 to remove blood and other opacities from the vitreous. Since then the advances in retinal surgery have been largely technology driven. Explosion of new instrument and surgical techniques through the 1970s and 1980s was spear headed by engineer/surgeon STEVE CHARLES More recent advances include the introduction of 23g vitrectomy

VITRECTOMY SURGERY
UNTIL 2007 all Retinal Surgery at Cabrini was done with the 20g approach .This entailed opening the sclera and making holes in which to place the instruments. The exposure of bare sclera and post operative suturing caused inflammation and added extra time to an already complicated procedure. In 2007 at we introduced a 23g approach, in the year prior to that we experimented with the 25g approach but found the instruments flexibility too limiting. Since2007 we have used the 23g system for over 99% of all our retinal cases. 23g retinal surgery is very similar in principle to Laparoscopic surgery ( ports, gas/fluid, light )

RETINAL DETATCHMENT

RETINAL DETATCHMENT

Most retinal detatchments are RHEGMATOGENOUS caused by degenerative changes to the Vitreous (old age vitreous) causing a hole in the retina allowing fluid into the subretinal space. TRACTIONAL when membranes pull up on the retinal surface causing a hole (common in diabetics) EXUDATIVE caused by break down in the blood retinal barrier

RETINAL DETATCHMENT
Clinical symptoms Floaters and flashes Peripheral field loss Loss of red reflex on examination As detachment reaches macular central vision is lost

TREATMENT
The earlier the treatment the better the outcome VITRECTOMY relief of V-R traction (membranes) by peeling. Removal of the sub retinal fluid. Closure of the break using either laser or cryo, and finally adhesion with the use of silicone oil or heavy gases Scleral Buckle repair which is an external approach

OCT SCANS

VITRECTOMY SURGERY
Macular hole Macular pucker Diabetic retinopathy Vitreous Hemorrhages Vitreous opacities (floaters)

ARE YOU STILL AWAKE

VITRECTOMY
Recovery if patients have had a gas bubble inserted positioning may be required for the first 24 hours Patients may not undertake air travel (or climb Mt Everest ) to avoid raised IOP Patients wear warning band with a bubble as any agents causing expansion ie Nitrous anesthetics. Most patient will develop a cataract within 2 -3 years of surgery

10 YEARS ON
Operation times reduced Light source improved halogen to xenon Introduction of retinal stains- to identify membranes Introduction of wide field viewing systems Introduction of small guage vitrectomy with the accompanying instrumentation

THANK YOU FOR YOUR ATTENTION

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