Principles of Sterile Technique All articles used in an operation have been sterilized previously.

n sterilized previously. Persons who are sterile touch only sterile articles; persons who are not sterile touch only unsterile articles. Sterile persons avoid leaning over an unsterile area; non-sterile persons avoid reaching over a sterile field. Unsterile persons do not get closer than 12 inches from a sterile field. If in doubt about the sterility of anything consider it not sterile. If a non-sterile person brushes close consider yourself contaminated. Gowns are considered sterile only from the waist to shoulder level in front and the sleeves to 2 inches above the elbows. Keep hands in sight or above waist level away from the face. Arms should never be folded. Articles dropped below waist level are discarded. Sterile persons keep well within the sterile area and follow those rules from passing: Face to face or back to back. Turn back to a non-sterile person or when passing. Face a sterile area when passing the area. Ask a non-sterile person to step aside rather than trying to crowd past him. Step back away from the sterile field to sneeze or cough. Turn head away from sterile field to have perspiration mopped from brow. Stand back at a safe distance from the operating table when draping the patient. Members of the sterile team remain in the operating room if waiting for the case. Do not wander around the room or go out in the corridors. Sterile persons keep contact with sterile areas to a minimum. Do not lean on the sterile tables or on the draped patient. Do not lean on the nurses mayo tray. Non-sterile persons when you are observing a case, please stay in the room until the case is completed. Do not wander from room to room as traffic in the operating room should be kept as a minimum. Patient privacy needs to be respected. Keep non-essential conversation to a minimum. The circulating nurse is in charge of the room if you have any questions, please refer them to her, the supervisor or your instructor. Ask circulating nurse when it is an appropriate time to ask questions so that explanations/rationale can be given.

Sterile Members Surgeon The surgeon is in charge of the surgical team. He or she is the person who performs the operation and directs the activities of other members of the surgical team. Surgeons usually specialize in the treatment of specific surgical conditions, like orthopedics or cardiac surgery. Becoming a surgeon involves 4 years of college, 4 years of medical school, then 3 to 5 years of specialized residency. Certified Surgical Technologist The surgical technologist is responsible for the preparation of the sterile supplies, equipment and instruments, then assists the surgeon in their use. The surgical technologist most frequently serves as instrument handler, 1

setting up the instruments, then passing them to the surgeon. Surgical technologists also serve as second assistants, utilizing instruments to perform tasks such as retracting incisions, cutting suture and manipulating tissue. With advanced training or education, some surgical technologists act as first assistants. This role may also be preformed by another physician, a physician assistant or a registered nurse. Becoming a surgical technologist involves 1 to 2 years of college or specialized training. Non Sterile Members Anesthesiologist The anesthesiologist is a physician who specializes in administering drugs to the patient so he or she is pain free during the operation. They monitor the patients response to anesthesia. Registered Nurse The Registered Nurse role is generally that of the circulator. The circulator is responsible for the patient care during the operation. He or she assesses the patient, assists the anesthesiologist, completes operating room records and dispenses items to the sterile team. Becoming a nurse in the operating room requires 2 to 4 years of college, then specialized training on the job to learn surgical patient care. Gowning and Gloving If you are the scrub corpsman, you will have opened your sterile gown and glove packages in the operating room before beginning your hand scrub. Having completed the hand scrub, back through the door holding your hands up to avoid touching anything with your hands and arms. Gowning technique is shown in the steps of figure 2-4. Pick up the sterile towel that has been wrapped with your gown (touching only the towel) and proceed as follows: Dry one hand and arm, starting with the hand and ending at the elbow, with one end of the towel. Dry the other hand and arm with the opposite end of the towel. Drop the towel. Pick up the gown in such a manner that hands touch only the inside surface at the neck and shoulder seams. Allow the gown to unfold downward in front of you. Locate the arm holes. Place both hands in the sleeves. Hold your arms out and slightly up as you slip your arms into the sleeves. Another person (circulatory) who is not scrubbed will pull your gown onto you as you extend your hands through the gown cuffs. To gown and glove the surgeon, follow these steps: Pick up a gown from the sterile linen pack. Step back from the sterile field and let the gown unfold in front of you. Hold the gown at the shoulder seams with the gown sleeves facing you. Offer the gown to the surgeon. Once the surgeons arms are in the sleeves, let go of the gown. Be careful not to touch anything but the sterile gown. The circulator will tie the gown. Pick up the right glove. With the thumb of the glove facing the surgeon, place your fingers and thumbs of both hands in the cuff of the glove and stretch it outward, making a circle of the cuff. Offer the glove to the surgeon. Be careful that the surgeons bare hand does not touch your gloved hands. Repeat the preceding step for the left glove. The two techniques of gloving:

Eye Anatomy Overview

The human eye is both tough and delicate, simple and complex. It is a slightly asymmetrical sphere inside a rounded area of the skull (the eye orbit), and is filled with fluid. Some of the main eye structures are easily visible and some are beneath the surface. Find out about Early Eye Development. The Cornea The cornea is the transparent front surface that curves over the iris and pupil. It is a lens which refracts (bends) incoming light to focus it at the back of the eye. LASIK and its alternative procedures such as PRK and iLASIK work on the corneal curvature to correct vision defects. The cornea is part of the eyeballs wall and connects with the sclera. Read More about the Cornea The Iris This circular muscle behind the cornea is the colored part. It controls the size of the pupil in its center, which determines how much light can enter the eye. The pupil itself is not a separate structure; it is just the opening in the iris. Read More about the Iris The Sclera Around the iris is the white of the eye, the sclera. It is part of the total wall of the eyeball and connects with the cornea. The Lens Behind the iris is a cavity called the anterior chamber, filled with fluid, and behind that is the lens. After the cornea admits light and bends it to a focus, the lens bends it further. In a 20/20 eye, the combined refraction of cornea and lens focuses the light clearly on the retina at the back of the eye. The lens curvature is controlled by a circular muscle around it called the ciliary muscle. Read More about the Lens The Retina Behind the lens is a second fluid-filled area called the posterior chamber. It makes up most of the eyes entire size. The retina is the surface that borders it in a large curve extending almost to the ciliary muscle around the lens. Retinal cells are highly light-sensitive and receive the images in incoming light, converting them to electrical energy. Read More about the Retina The Optic Nerve Near the center of the retina is an opening where the large optic nerve leaves the eye. In a network across the entire retina are millions of tiny nerve fibers, each one connected to a single retinal cell. They pick up the electrical energy created by that cell from image information. They converge to form the optic nerve and leave the eyeball within a nerve sheath. The optic nerve runs to the brains vision center, where the electrical energy it carries is interpreted by the brain. Read More about the Optic Nerve

The anterior chamber, between the cornea and the lens, is filled with a fluid called aqueous humor. It bathes the lens, seeping around to its posterior side through small openings. The lens and cornea have no blood vessels and receive their nutrients from this aqueous fluid. The posterior chamber, between the lens and the retina, is filled with a fluid called vitreous humor. It is 99 percent water although it has a gel-like consistency. It is transparent to allow light through and helps to maintain the eyes shape. Read More about Internal Eye Fluids Each eye has a lacrimal gland for tear production and external muscles which enable it to direct vision in any direction. There are arteries supplying it with oxygen and nutrients and veins that remove waste products. There are also nerves other than the optic nerve. They enable tear production, and carry sensory data to the brain from the eyes parts and messages from the brain to the eye muscles.

cataract is a clouding of the lens inside the eye which leads to a decrease in vision. It is the most common
cause of blindness and is conventionally treated with surgery. Visual loss occurs because opacification of the lens obstructs light from passing and being focused on to the retina at the back of the eye.[1] It is most commonly due to biological aging but there are a wide variety of other causes. Over time, yellow-brown pigment is deposited within the lens and this, together with disruption of the normal architecture of the lens fibers, leads to reduced transmission of light, which in turn leads to visual problems. Those with cataract commonly experience difficulty appreciating colors and changes in contrast, driving, reading, recognizing faces, and experience problems coping with glare from bright lights.[2] Signs and symptoms

Bilateral cataracts in an infant due to congenital rubella syndrome Signs and symptoms vary depending on the type of cataract, though there is considerable overlap. People with nuclear sclerotic or brunescent cataract, often notice a reduction of vision. Those with posterior supcapsular cataract usually complain of glare as their major symptom.[3] The severity of cataract formation, assuming that no other eye disease is present, is judged primarily by visual acuity test. The appropriateness of surgery depends on a patient's particular functional and visual needs and other risk factors, all of which may vary widely.[4] [edit]Causes [edit]Age Age is the most common cause.[5] Lens proteins denature and degrade over time and this process is accelerated by diseases such as diabetes and hypertension. With the passage of time, environmental factors including toxins, radiation and UV light have an accumulative effect. These effects are worsened by the loss of protective and restorative mechanisms due to alterations in gene expression and chemical processes within the eye.[6] [edit]Trauma Blunt trauma causes swelling, thickening and whitening of the lens fibers. While the swelling normally resolves with time, the white color may remain. In severe blunt trauma, or injuries which penetrate the eye, the capsule in which the lens sits can be damaged. This allows water from other parts of the eye to rapidly enter the lens leading to swelling and then whitening, obstructing light from reaching the retina at the back of the eye. [edit]Radiation Ultraviolet light, specifically UV-B, has been shown to cause cataract and there is some evidence that sunglasses worn at an early age can slow its development in later life.[7] Most UV light from the sun is filtered out by the atmosphere but airline pilots often have high rates of cataract because of the increased levels of UV radiation in 4

the upper atmosphere.[8] It is hypothesised that depletion of the ozone layer and a consequent increase in levels of UV light on the ground may increase future rates of cataracts.[9] It has also been recognized, from experimental animal studies and epidemiological studies in humans, that microwaves can cause cataract. The mechanism is unclear but may include changes in heat sensitive enzymes that normally protect cell proteins in the lens. Another mechanism that has been advanced is direct damage to the lens from pressure waves induced in the aqueous humor. Cataracts have also been associated with ionizing radiation such as X-rays. In addition to the mechanisms already mentioned, the addition of damage to the DNA of the lens cells has been considered.[10] Finally, electric and heat injuries denature and whiten the lens itself as a result of direct protein coagulation.[6] This is the same process through which the clear albumin of an egg becomes white and opaque after cooking. These types of cataract are often seen in glass blowers and furnace workers. [edit]Genetics There is a strong genetic component in the development of cataract, most commonly through mechanisms that protect and maintain the lens. The presence of cataract in childhood or early life can occasionally be due to a particular syndrome. Examples of Chromosome abnormalities associated with cataract include: 1q21.1 deletion syndrome, Cri-du-chat syndrome, Down syndrome, Patau's syndrome, Trisomy 18 (Edward's syndrome) and Turner's syndrome. Examples of Single-gene disorder include: Alport's syndrome, Conradi's syndrome, Myotonic dystrophy, Oculocerebrorenal syndrome or Lowe syndrome [edit]Skin diseases The skin and the lens have the same embryological origin and can be affected by similar diseases. Those with Atopic dermatitis and Eczema will occasionally develop shield ulcers cataract. Ichthyosis is an autosomal recessive disorder associated with cuneiform cataract and nuclear sclerosis. Basal-cell nevus and Pemphigus have similar associations. [edit]Drug use Smoking has been shown to lead to a two-fold increase in the rate of nuclear sclerotic cataract and a three-fold increase in posterior subcapsular cataract.[11] There is conflicting evidence over the effect of alcohol. Some surveys have shown a link but others that have followed patients over time have not.[12] [edit]Medications Some drugs, such as corticosteroids, and the antipsychotic drug quetiapine can induce cataract development,[13] as may haloperidol,[14] miotics,[15] and triparanol.[16] Cataracts can also be caused by iodine deficiency.[17] Cataracts may be partial or complete, stationary or progressive, or hard or soft. The main types of age-related cataracts are nuclear sclerosis, cortical, and posterior subcapsular. Nuclear sclerosis is the commonest type of cataract and involves the central or 'nuclear' part of the lens. Over time, this becomes hard or 'sclerotic' due to condensation of lens nucleus and deposition of brown pigment within the lens. In advanced stages it is called brunescent cataract. This type of cataract can present with a shift to nearsightedness and causes problems with distance vision while reading is less affected.[18] Cortical cataracts are due to opacification of the lens cortex (outer layer). They occur when changes in the water content of the periphery of the lens causes fissuring. When these cataracts are viewed through an ophthalmoscope or other magnification system, the appearance is similar to white spokes of a wheel pointing inwards. Symptoms often include problems with glare and light scatter at night.[18] Posterior subcapsular cataracts are cloudy at back of the lens adjacent to the capsule (or bag) in which the lens sits. Because light becomes more focused toward the back of the lens, they can cause disproportionate symptoms for their size. A mature cataract is one in which all of the lens protein is opaque while the immature cataract has some transparent protein. In the hypermature cataract, also known as Morgagnian cataract the lens proteins have become liquid. Congenital cataract, which may be detected in adults, has a different classification and includes lamellar, polar, and sutural cataract.[13][19] 5

Cataracts can be classified by using Lens Opacities Classification System III. In this system, cataracts are classified based on type as nuclear, cortical, or posterior. The cataracts are further classified based on severity on a scale from 1 to 5. Research has demonstrated that the LOCS III system is highly reproducible.[20] [edit]Prevention Risk factors such as UV-B exposure and smoking can be addressed but are unlikely to make large difference to visual function. Although there has been no scientifically proven means of preventing cataracts, wearing ultraviolet-protecting sunglasses may slow the development.[21][22] While it had been thought that regular intake of antioxidants (such as vitamins A, C and E) would protect against the risk of cataracts, clinical trials have shown that their use as a supplement is not.[23] On the other hand, research is mixed, but weakly positive, for a potential protective effect of the nutrients lutein and zeaxanthin.[24] There is some evidence that statin use is associated with a lower risk of nuclear sclerotic cataract.[25] [edit]Treatment Cataract surgery Cataract surgery, using a temporal approach phacoemulsification probe (in right hand) and "chopper" (in left hand) being done under operating microscope at a Navy medical center Slit lamp photo of posterior capsular opacification visible a few months after implantation of intraocular lens in eye, seen on retroillumination Cataract removal can be performed at any stage and no longer requires ripening of the lens. Surgery is usually 'outpatient' and performed using local anesthesia. Approximately 90% of patients can achieve a corrected vision of 20/40 or better after surgery.[18] Several recent evaluations found that surgery can only meet expectations when there is significant functional impairment from poor vision prior to surgery. Visual function estimates such as VF-14 have been found to give more realistic estimates than visual acuity testing alone.[18][26] In some developed countries a trend to overuse cataract surgery has been noted which may lead to disappointing results.[27] Phacoemulsification, typically comprises five steps, not including the anaesthetic. Anaesthetic - The eye is numbed with either a subtenon injection around the eye or using simple eye drops. Corneal Incision - Two cuts are made through the clear cornea to allow insertion of instruments into the eye. Capsulorhexis - A needle or small pair of forceps is used to create a circular hole in the capsule (or bag) in which the lens sits. Phacoemulsification - A handheld probe is used to break up and emulsify the lens into liquid using the energy of ultrasound waves. The resulting 'emulsion' is sucked away. Irrigation and Aspiration - The cortex which is the soft outer layer of the cataract is aspirated or sucked away. Fluid removed is continually replaced with a salt solution to prevent collapse of the structure of the anterior chamber (the front part of the eye). Lens insertion - A plastic foldable lens is inserted to the capsular bag that is used to contain the natural lens. Some surgeons will also inject an antibiotic in to the eye to reduce the risk of infection. The final step is to inject salt water in to the corneal wounds to cause the area to swell and seal the incision. Extracapsular cataract extraction (ECCE), consists of removing the lens manually, but leaving the majority of the capsule intact. The lens is expressed through a 1012 mm incision which is closed with sutures at the end of surgery. Extracapsular extraction is less frequently performed than phacoemulsificaction but can be useful when dealing with very hard cataracts or other situations where emulsification is problematic. Manual small incision cataract surgery (MICS) has evolved from extracapsular cataract extraction. In MSICS, the lens is removed through a self-sealing scleral tunnel wound in the sclera which, ideally, is watertight and does not require suturing. 6

Although "small", the incision is still markedly larger than the portal in phacoemulsion. This surgery is increasingly popular in the developing world where access to phacoemulsification is still limited. Intracapsular cataract extraction (ICCE) is rarely performed. The lens and surrounding capsule are removed in one piece through a large incision while pressure is applied to the vitreous. The surgery has a high rate of complications. Post-operative care Slit lamp photo of anterior capsular opacification visible a few months after implantation of intraocular lens in eye, magnified view The post-operative recovery period (the period after cataract extraction is done) is usually short. The patient is usually ambulatory on the day of surgery but is advised to move cautiously and avoid straining or heavy lifting for about a month. The eye is usually patched on the day of surgery and at night using an eye shield is often suggested for several days after surgery.[4] In all types of surgery, the cataractous lens is removed and replaced with an artificial lens, known as intraocular lens, which stays in the eye permanently. Intraocular lenses are usually monofocal, correcting for either distance or near vision, however, multifocal lenses may be implanted to improve near and distance vision simultaneously, but these lenses may increase the chance of unsatisfactory vision.[6] [edit]Complications of Surgery Serious complications of cataract surgery are retinal detachment and endophthalmitis. In both cases, patients will notice a sudden decrease in vision. In endophthalmitis, patients will often describe pain. Retinal detachment frequently presents with unilateral visual field defects, blurring of vision, flashes of light or floating spots. The risk of retinal detachment was estimated as approximately 0.4% within 5.5 years, corresponding to a 2.3x risk increase compared to naturally expected incidence, older studies reporting a substantially higher risk. The incidence is increasing in approximately linear manner and the risk remains increased for at least 20 years after the procedure. Particular risk factors are younger age, male sex, longer axial length and complications during surgery. In highest risk group of patients the incidence of pseudophakic retinal detachment may be as high as 20%.[28][29] The risk of endophthalmitis occurring after surgery is less than 1 in 1000.[30] Corneal oedema and cystoid macular oedema are less serious but more common and occur because of persistent swelling at the front of the eye in corneal oedema or back of the eye in cystoid macular oedema. They are normally the result of excessive inflammation following surgery and in both cases, patients may notice blurred, foggy vision. They normally improve with time and with application of anti-inflammatory drops. The risk of either occurring is around 1 in 100. Posterior capsular opacification, also known as after cataract, is a condition in which months or years after successful cataract surgery, vision deteriorates or problems with glare and light scattering recur. This is usually due to thickening of the back or posterior capsule surrounding the implanted lens, so-called ' posterior lens capsule opacification'. Growth of natural lens cells remaining after the natural lens was removed may be the cause, and the younger the patient, the greater the chance. Management involves cutting a small, circular area in the posterior capsule with targeted beams of energy from a laser, a procedure called YAG laser capsulotomy, after the type of laser used. The laser can be aimed very accurately and the small part of the capsule which is cut falls harmlessly to the bottom of the inside of the eye. This procedure leaves sufficient capsule to hold the lens in place but removes enough to allow light to pass directly through to the retina. Serious side effects are rare.[31] Posterior capsular opacification is common and occurs following up to 1 in 4 operations but these rates are decreasing following the introduction of modern intraocular lenses together with a better understanding of the causes. Cataract surgery -is the removal of the natural lens of the eye (also called "crystalline lens") that has developed an opacification, which is referred to as a cataract. Metabolic changes of the crystalline lens fibers over time lead to the 7

development of the cataract and loss of transparency, causing impairment or loss of vision. Many patients' first symptoms are strong glare from lights and small light sources at night, along with reduced acuity at low light levels. During cataract surgery, a patient's cloudy natural lens is removed and replaced with a synthetic lens to restore the lens's transparency.[1] Following surgical removal of the natural lens, an artificial intraocular lens implant is inserted (eye surgeons say that the lens is "implanted"). Cataract surgery is generally performed by an ophthalmologist (eye surgeon) in an ambulatory (rather than inpatient) setting, in a surgical center or hospital, using local anesthesia (either topical, peribulbar, or retrobulbar), usually causing little or no discomfort to the patient. Well over 90% of operations are successful in restoring useful vision, with a low complication rate.[2] Day care, high volume, minimally invasive, small incision phacoemulsification with quick post-op recovery has become the standard of care in cataract surgery all over the world. Types Two main types of surgical procedures are in common use throughout the world. The first procedure is phacoemulsification (phaco) and the second involves two different type of extracapsular cataract extraction (ECCE). In most surgeries an intraocular lens is inserted. Foldable lenses are generally used for the 2-3mm phaco incision, while non-foldable lenses are placed through the larger extracapsular incision. The small incision size used in phacoemulsification (2-3mm) often allows "sutureless" incision closure. ECCE utilises a larger incision (1012mm) and therefore usually requires stitching, and this in part led to the modification of ECCE known as manual small incision cataract surgery (MSICS). Cataract extraction using intracapsular cataract extraction (ICCE) has been superseded by phaco & ECCE, and is rarely performed. Phacoemulsification is the most commonly performed cataract procedure in the developed world. However, the high cost of a phacoemulsification machine and of the associated disposable equipment means that ECCE and MSICS remain the most commonly performed procedure in developing countries. Types of surgery

Cataract surgery, using a temporal approach phacoemulsification probe (in right hand) and "chopper"(in left hand) being done under operating microscope at a Navy medical center

Cataract surgery recently performed, foldable IOL inserted. Note small incision and very slight hemorrhage to the right of the still dilated pupil. There are a number of different surgical techniques used in cataract surgery: Phacoemulsification (Phaco) is the most common technique used developed countries. It involves the use of a machine with an ultrasonic handpiece equipped with a titanium or steel tip. The tip vibrates at ultrasonic frequency (40,000 Hz) and the lens material is emulsified. A second fine instrument (sometimes called a "cracker" or "chopper") may be used from a side port to facilitate cracking or chopping of the nucleus into smaller pieces. Fragmentation into smaller pieces makes emulsification easier, as well as the aspiration of cortical material (soft part of the lens around the nucleus). After phacoemulsification of the lens nucleus and cortical material is completed, a dual irrigation-aspiration (I-A) probe or a bimanual I-A system is used to aspirate out the remaining peripheral cortical material. Manual small incision cataract surgery (MSICS): This technique is an evolution of ECCE (see below) where the entire lens is expressed out of the eye through a self sealing scleral tunnel wound. An appropriately constructed scleral tunnel is watertight and does not require suturing. The "small" in the title refers to the wound being relatively smaller than an ECCE, although it is still markedly larger than a phaco wound. Head to head trials of 8

MSICS vs phaco in dense cataracts have found no different in outcomes, but shorter operating time and significantly lower costs with MSICS.[3] Extracapsular cataract extraction (ECCE): Extracapsular cataract extraction involves the removal of almost the entire natural lens while the elastic lens capsule (posterior capsule) is left intact to allow implantation of an intraocular lens.[4] It involves manual expression of the lens through a large (usually 10 12 mm) incision made in the cornea or sclera. Although it requires a larger incision and the use of stitches, the conventional method may be indicated for patients with very hard cataracts or other situations in which phacoemulsification is problematic. Intracapsular cataract extraction (ICCE) involves the removal of the lens and the surrounding lens capsule in one piece. The procedure has a relatively high rate of complications due to the large incision required and pressure placed on the vitreous body. It has therefore been largely superseded and is rarely performed in countries where operating microscopes and high-technology equipment are readily available.[4] After lens removal, an artificial plastic lens (an intraocular lens implant) can be placed in either the anterior chamber or sutured into the sulcus. Cryoextraction is a form of ICCE that freezes the lens with a cryogenic substance such as liquid nitrogen.[5] In this technique, the cataract is extracted through use of a cryoextractor a cryoprobe whose refrigerated tip adheres to and freezes tissue of the lens, permitting its removal. Although it is now used primarily for the removal of subluxated lenses, it was the favored form of cataract extraction from the late 1960s to the early 1980s.[6] [edit]Intraocular lenses Intraocular lens implantation: After the removal of the cataract, an intraocular lens (IOL) is usually implanted into the eye, either through a small incision (1.8 mm to 2.8 mm) using a foldable IOL, or through an enlarged incision, using a PMMA (polymethylmethacrylate) lens. The foldable IOL, made of silicone or acrylic material of appropriate power is folded either using a holder/folder, or a proprietary insertion device provided along with the IOL. The lens implanted is inserted through the incision into the capsular bag within the posterior chamber (inthe-bag implantation). Sometimes, a sulcus implantation (in front or on top of the capsular bag but behind the iris) may be required because of posterior capsular tears or because of zonulodialysis. Implantation of posterior chamber IOL (PCIOL) in patients below 1 year of age is controversial due to rapid ocular growth at this age and the excessive amount of inflammation, which may be very difficult to control. Optical correction in these patients without intraocular lens (aphakic) is usually managed with either special contact lenses or glasses. Secondary implantation of IOL (placement of a lens implant as a second operation) may be considered later. New designs of multifocal intraocular lens are now available. These lenses allow focusing of rays from distant as well as near objects, working much like bifocal or trifocal eyeglasses. Preoperative patient selection and good counselling is extremely important to avoid unrealistic expectations and post-operative patient dissatisfaction. Acceptability for these lenses has become better and studies have shown good results in selected patients. Brands in the market include: AT LISA and AT LISA toric(R) from Carl Zeiss Meditec, ReSTOR (R), Rezoom (R), Rayner M-flex (R) and Tecnis MF (R). In addition, there is an accommodating lens that was approved by the US FDA in 2003 and made by Eyeonics,[7] now Bausch & Lomb. The Crystalens (R) is on struts and is implanted in the eye's lens capsule, and its design allows the lens' focusing muscles to move it back and forth, giving the patient natural focusing ability. Artificial intraocular lenses are used to replace the eye's natural lens that is removed during cataract surgery. These lenses have been increasing in popularity since the 1960s, but it was not until 1981 that the first U.S. Food and Drug Administration (FDA) approval for this type of products was issued. The development of intraocular lenses brought an innovation into the optical world as before they could be used; patients would not have their natural lens replaced and as a result, they had to wear very thick eyeglasses or some special type of contact lenses. Nowadays, IOLs are especially designed for patients with different vision problems. The main types of IOLs that now exist are divided into monofocal and multifocal lenses. The monofocal intraocular lenses are the traditional ones, which may provide vision at one distance only: far, intermediate, or near.[8] Patients who choose these lenses over the more developed types will have to overcome the disadvantage of wearing eyeglasses or contact lenses for reading or using the computer. These intraocular lenses are usually spherical, and they have their surface uniformly curved. 9

The multifocal intraocular lenses are ones of the newest types of such lenses. They are often referred to as "premium" lenses because they are multifocal and accommodative and allow the patient to visualize objects at more than one distance, removing the need to wear eyeglasses or contact lenses. Premium intraocular lenses are those used in correcting presbyopia or astigmatism. Premium intraocular lenses are typically not covered by insurance companies as their additional benefits are considered a luxury and not a medical necessity.[8] An accommodative intraocular lens implant has only one focal point, but it acts as if it is a multifocal IOL. The intraocular lens was designed with a hinge similar to the mechanics of the eye's natural lens.[9] The intraocular lenses used in correcting astigmatism are called toric and have been FDA approved since 1998. The STAAR Surgical Intraocular Lens was the first such lens ever developed in the United States and it may correct up to 3.5 diopters. A different model of toric lenses is created by Alcon and may correct up to 3 diopters of astigmatism. In order to achieve the most benefit from a toric lens, the surgeon must rotate the lens to be on axis with the patients astigmatism. Intraoperative wavefront analysis, such as that provided by the ORA System developed by Wavetec Visions Systems, can be used to assist the doctor in toric lens placement and minimize astigmatic errors.[10] The Alpins Method of astigmatism analysis is also used both to plan and assess the use of toric IOLs.[11][12][13] Cataract surgery may be performed to correct vision problems in both eyes, and in these cases, patients are usually recommended to consider monovision. This procedure involves inserting in one eye an intraocular lens that provides near vision and in the other eye an IOL that provides distance vision. Although most patients can adjust to having implanted monofocal lenses in both eyes, some cannot and may experience blurred vision at both near and far. IOLs that emphasize distance vision may be mixed with IOLs that emphasize intermediate vision in order to achieve a type of modified monovision. Bausch and Lomb developed in 2004 the first aspheric IOLs which provide better contrast sensitivity by having their periphery flatter than the middle of the lens. However, some cataract surgeons have debated the benefits of aspheric IOLs, because the contrast sensitivity benefit may not last in older patients.[8] Some of the newly launched IOLs are able to provide ultraviolet and blue light protection. The crystalline lens of the eye filters these potentially harmful rays and many premium IOLs are designed to undertake this task as well. According to a few studies though, these lenses have been associated with a decrease in vision quality. Another type of intraocular lenses is the light-adjustable one which is still undergoing FDA clinical trials. This particular type of IOLs is implanted in the eye and then treated with light of a certain wavelength in order to alter the curvature of the lens. In some cases, surgeons may opt for inserting an additional lens over the already implanted one. This type of IOLs procedures are called "piggyback" IOLs and are usually considered an option whenever the lens the result of the first implant is not optimal. In such cases, implanting another IOL over the existent one is considered safer than replacing the initial lens. This approach may also be used in patients who need high degrees of vision correction. No matter which IOL is used the surgeon will need to select the appropriate power of IOL (much like an eyeglass prescription) to provide the patient with the desired refractive outcome. Traditionally doctors use preoperative measurements including corneal curvature, axial length, and white to white measurements to estimate the required power of the IOL. These traditional methods include several formulas including Hagis, Hoffer Q, Holladay 1, Holladay 2, and SRK/T to name a few.[14] Refractive results using traditional power calculation formulas leave patients within 0.5D of target (Correlates to 20/25 when targeted for distance) or better in 55% of cases and within 1D (Correlates to 20/40 when targeted for distance) or better in 85% of cases. Recent developments in interoperative wavefront technology such as the ORA System from Wavetec Vision Systems, have demonstrated in studies to provide power calculations that lead to improved outcomes, yielding 80% of patients within 0.5D (20/25 or better).[10] Statistically, cataract surgery and IOL implantation seem to be ones of the safest and with highest success rates procedures when it comes to eye care. However as any other type of surgery it implies certain risks. The cost is another important aspect of these lenses. Although most insurance companies cover the costs of traditional IOLs,

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patients may need to pay the price-difference in case they choose more advanced lenses, such as the premium ones.[15] [edit]Preoperative evaluation An eye examination or pre-operative evaluation by an eye surgeon is necessary to confirm the presence of a cataract and to determine if the patient is a suitable candidate for surgery. The patient must fulfill certain requirements such as: The degree of reduction of vision due, at least in large part, to the cataract should be evaluated. While the existence of other sight-threatening diseases, such as age-related macular degeneration or glaucoma, does not preclude cataract surgery, less improvement may be expected in their presence. The eyes should have a normal pressure, or any pre-existing glaucoma should be adequately controlled on medications. In cases of uncontrolled glaucoma, a combined cataract-glaucoma procedure (Phacotrabeculectomy) can be planned and performed. The pupil should be adequately dilated using eyedrops; if pharmacologic pupil dilation is inadequate, procedures for mechanical pupillary dilatation may be needed during the surgery. The patients with retinal detachment may be scheduled for a combined vitreo-retinal procedure, along with PCIOL implantation. In addition, it has recently been shown that patients taking tamsulosin (Flomax), a common drug for enlarged prostate, are prone to developing a surgical complication known as intraoperative floppy iris syndrome (IFIS), which must be correctly managed to avoid the complication posterior capsule rupture; however, prospective studies have shown that the risk is greatly reduced if the surgeon is informed of the patient's history with the drug beforehand, and has appropriate alternative techniques prepared.[16] [edit]Operation procedures The surgical procedure in phacoemulsification for removal of cataract involves a number of steps. Each step must be carefully and skillfully performed in order to achieve the desired result. The steps may be described as follows: Anaesthesia, Exposure of the eyeball using a lid speculum, Entry into the eye through a minimal incision (corneal or scleral) Viscoelastic injection to stabilize the anterior chamber and to help maintain the eye pressurization Capsulorhexis Hydrodissection pie Hydro-delineation Ultrasonic destruction or emulsification of the cataract after nuclear cracking or chopping (if needed), cortical aspiration of the remanescent lens, capsular polishing (if needed) Implantation of the, usually foldable, intra-ocular lens (IOL) Viscoelastic removal Wound sealing / hydration (if needed). The pupil is dilated using drops (if the IOL is to be placed behind the iris) to help better visualise the cataract. Pupil-constricting drops are reserved for secondary implantation of the IOL in front of the iris (if the cataract has already been removed without primary IOL implantation). Anesthesia may be placed topically (eyedrops) or via injection next to (peribulbar) or behind (retrobulbar) the eye. Oral or intravenous sedation may also be used to reduce anxiety. General anesthesia is rarely necessary, but may be employed for children and adults with particular medical or psychiatric issues. The operation may occur on a stretcher or a reclining examination chair. The eyelids and surrounding skin will be swabbed with disinfectant. The face is covered with a cloth or sheet, with an opening for the operative eye. The eyelid is held open with a speculum to minimize blinking during surgery. Pain is usually minimal in properly anesthetised eyes, though a pressure sensation and discomfort from the bright operating microscope light is common. The ocular surface is kept moist using sterile saline eyedrops or 11

methylcellulose viscoelastic. The discission into the lens of the eye is performed at or near where the cornea and sclera meet (limbus = corneoscleral junction). Advantages of the smaller incision include use of few or no stitches and shortened recovery time.[4][17] A capsulotomy (rarely known as cystotomy) is a procedure to open a portion of the lens capsule, using an instrument called a cystotome.[18] An anterior capsulotomy refers to the opening of the front portion of the lens capsule, whereas a posterior capsulotomy refers to the opening of the back portion of the lens capsule. In phacoemulsification, the surgeon performs an anterior continuous curvilinear capsulorhexis, to create a round and smooth opening through which the lens nucleus can be emulsified and the intraocular lens implant inserted. Following cataract removal (via ECCE or phacoemulsification, as described above), an intraocular lens is usually inserted. After the IOL is inserted, the surgeon checks that the incision does not leak fluid. This is a very important step, since wound leakage increases the risk of unwanted microrganisms to gain access into the eye and predispose to endophathalmitis. An antibiotic/steroid combination eye drop is put and an eye shield may be applied on the operated eye, sometimes supplemented with an eye patch. Antibiotics may be administered pre-operatively, intra-operatively, and/or post-operatively. Frequently a topical corticosteroid is used in combination with topical antibiotics postoperatively. Most cataract operations are performed under a local anaesthetic, allowing the patient to go home the same day. The use of an eye patch may be indicated, usually for about some hours, after which the patient is instructed to start using the eyedrops to control the inflammation and the antibiotics that prevent infection. Occasionally, a peripheral iridectomy may be performed to minimize the risk of pupillary block glaucoma. An opening through the iris can be fashioned manually (surgical iridectomy) or with a laser (called Nd-YAG laser iridotomy). The laser peripheral iridotomy may be performed either prior to or following cataract surgery. The iridectomy hole is larger when done manually than when performed with a laser. When the manual surgical procedure is performed, some negative side effects may occur, such as that the opening of the iris can be seen by others (aesthetics), and the light can fall into the eye through the new hole, creating some visual disturbances. In the case of visual disturbances, the eye and brain often learn to compensate and ignore the disturbances over a couple of months. Sometimes the peripheral iris opening can heal, which means that the hole ceases to exist. This is the reason why the surgeon sometimes makes two holes, so that at least one hole is kept open. After the surgery, the patient is instructed to use anti-inflammatory and antibiotic eye drops for up to two weeks (depending on the inflammation status of the eye and some other variables). The eye surgeon will judge, based on each patient's idiosyncrasies, the time length to use the eye drops. The eye will be mostly recovered within a week, and complete recovery should be expected in about a month. The patient should not participate in contact/extreme sports until cleared to do so by the eye surgeon. [edit]Complications Complications after cataract surgery are relatively uncommon. PVD Posterior vitreous detachment does not directly threaten vision. Even so, it is of increasing interest because the interaction between the vitreous body and the retina might play a decisive role in the development of major pathologic vitreoretinal conditions. PVD may be more problematic with younger patients, since many patients older than 60 have already gone through PVD. PVD may be accompanied by peripheral light flashes and increasing numbers of floaters. Some people can develop a posterior capsular opacification (PCO, also called an after-cataract). As a physiological change expected after cataract surgery, the posterior capsular cells undergo hyperplasia and cellular migration, showing up as a thickening, opacification and clouding of the posterior lens capsule (which is left behind when the cataract was removed, for placement of the IOL). This may compromise visual acuity and the ophthalmologist can use a device to correct this situation. It can be safely and painlessly corrected using a laser device to make small holes in the posterior lens capsule of the crystalline. It usually is a quick outpatient procedure that uses a Nd-YAG laser (neodymium-yttrium-aluminum-garnet) to disrupt and clear the central portion of the opacified posterior lens capsule (posterior capsulotomy). This creates a clear central visual axis for improving visual acuity.[19] In very 12

thick opacified posterior capsules, a surgical (manual) capsulectomy is the surgical procedure performed. A YAG capsulotomy is, however, a factor which must be taken in consideration in the event of IOL replacement as vitreous can migrate toward the anterior chamber through the opening hitherto occluded by the IOL. Posterior capsular tear may be a complication during cataract surgery. The rate of posterior capsular tear among skilled surgeons is around 2% to 5%. It refers to a rupture of the posterior capsule of the natural lens. Surgical management may involve anterior vitrectomy and, occasionally, alternative planning for implanting the intraocular lens, either in the ciliary sulcus, in the anterior chamber (in front of the iris), or, less commonly, sutured to the sclera. Retinal detachment is an uncommon complication of cataract surgery, which may occur weeks, months, or even years later. Toxic Anterior Segment Syndrome or TASS is a non-infectious inflammatory condition that may occur following cataract surgery. It is usually treated with topical corticosteroids in high dosage and frequency. Endophthalmitis is a serious infection of the intraocular tissues, usually following intraocular surgery, or penetrating trauma. There is some concern that the clear cornea incision might predispose to the increase of endophthalmitis but is no conclusive study to corroborate this suspicion. Glaucoma may occur and it may be very difficult to control. It is usually associated with inflammation, specially when little fragments or chunks of the nucleus get access to the vitreous cavity. Some experts recommend early intervention when this condition happens (posterior pars plana vitrectomy). Neovascular glaucoma may occur, specially in diabetic patients. In some patients, the intraocular pressure may remain so high that blindness may ensue. Swelling or edema of the central part of the retina, called macula, resulting in macular edema, can occur a few days or weeks after surgery. Most such cases can be successfully treated Other possible complications include: Swelling or edema of the cornea, sometimes associated with cloudy vision, which may be transient or permanent (pseudophakic bullous keratopathy). Displacement or dislocation of the intraocular lens implant may rarely occur. Unplanned high refractive error (either myopic or hypermetropic) may occur due to error in the ultrasonic ecobiometry (measure of the length and the required intra-ocular lens power). Cyanopsia, in which the patient sees everything tinted with blue, often occurs for a few days, weeks or months after removal of a cataract. Floaters commonly appear after surgery.

Slit lamp photo of IOL showing Posterior capsular opacification visible few months after implantation of Intraocular lens in eye, seen on retroillumination intraocular lens is the procedure considered the state-of-the-art.

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