Complications During and After Cataract Surgery: From Phacoemulsification Over Secondary IOL Implantation to Dropped Nucleus

350 Pages·2022·17.412 MB·English

by  Ulrich Spandau, Gabor B. Scharioth

Complications
During and After
Cataract Surgery
From Phacoemulsification Over
Secondary IOL Implantation
to Dropped Nucleus
Ulrich Spandau
Gabor B. Scharioth
Second Edition
Complications During and After Cataract
Surgery
Ulrich Spandau (cid:129) Gabor B. Scharioth
Complications During
and After Cataract Surgery
From Phacoemulsification Over
Secondary IOL Implantation to Dropped
Nucleus
Second Edition
123
Ulrich Spandau Gabor B.Scharioth
St.Eriks hospital Aurelios Augenzentrum
University of Stockholm Recklinghausen, Germany
Stockholm, Sweden
ISBN978-3-030-93530-6 ISBN978-3-030-93531-3 (eBook)
https://doi.org/10.1007/978-3-030-93531-3
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2ndedition:©TheEditor(s)(ifapplicable)andTheAuthor(s),underexclusivelicensetoSpringer
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Introduction
How to manage a posterior capsule rupture or a zonular lysis? How to operate a
droppednucleus?WhattodowithasubluxatedIOL?Ifyouareseekinganswersto
these questions, then you found the right book. In this book, these questions and
many, many more will be answered.
Whatisnewinthissecondedition?Thecompletebookisupdated.Weincluded
severalnewtechniquessuchasIOLrolling,Yamanetechnique,IOLfixationtothe
iris with suture and many more. Not last but least, the posterior segment section is
completelyredone.Anexcitingnewtechniqueforsurgicalmanagementofdropped
nucleus with a phacoemulsification handpiece is demonstrated. In addition, we
demonstrate a trocar cannula technique which increases the surgical spectrum of a
cataractsurgeonimmensely.Foralloperations,onlyaphacoemulsificationmachine
was used.
The operations are described like in a cookbook. First, the ingredients and then
the step-by-step preparations. These steps are illustrated with many pictures and
drawings, followed by several surgical videos.
In my opinion, there are three parameters that make a good surgeon. They are
surgical skill, experience and mastery of different surgical techniques.
Everysurgeonisafraidofcomplications.Thisbooktakesthecataractsurgeon's
fearofcomplicationsbygivinghimaclearschemeinhishandafterwhichhemust
proceed. Complications cannot be avoided, butyou can learn tomaster them. And
at the same time, you will also become a better surgeon.
All videos can be found in a playlist of my YouTube channel:
https://www.youtube.com/playlist?list=PL0dKYclPD7yMJRuQAIt9Dr7pOtuI0
Seex
I wish you much fun in the OR!
Stockholm, Sweden Ulrich Spandau
Recklinghausen, Germany Gabor B. Scharioth
v
Contents
Part I Fundamentals for Complication Management
1 Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Difficulty of Cataract Surgery in Relation to Density
of Nucleus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Difficulty of Cataract Surgery in Relation to Other Factors . . . . 5
1.3 Anatomy of Different IOL Implantation Sites
at the Slit Lamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4 Anatomic Requirements for an IOL Implantation . . . . . . . . . . . 9
1.5 1-piece IOL Versus 3-piece IOL . . . . . . . . . . . . . . . . . . . . . . . 11
1.6 Correct IOL Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 Essential Surgical Techniques for Complication Management . . . . 15
2.1 Surgical Technique: SICS, the Modified ECCE . . . . . . . . . . . . 15
2.2 Trocar Surgery for Cataract Surgeons. . . . . . . . . . . . . . . . . . . . 16
2.3 Get Acquainted with Your Surgical Equipment. . . . . . . . . . . . . 17
2.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3 Planning for Surgical Complications. . . . . . . . . . . . . . . . . . . . . . . . 19
3.1 Different Cases for Surgical Planning. . . . . . . . . . . . . . . . . . . . 20
Part II Easy and Difficult Phacoemulsification
4 Phacoemulsification of an Easy Cataract . . . . . . . . . . . . . . . . . . . . 25
4.1 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.2 Surgery of an Easy Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5 Phacoemulsification of a Difficult Cataract . . . . . . . . . . . . . . . . . . . 53
5.1 How to Approach a Difficult Cataract . . . . . . . . . . . . . . . . . . . 54
5.2 Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5.3 Instruments for a Difficult Phacoemulsification . . . . . . . . . . . . . 54
5.4 Problems During Side Incisions. . . . . . . . . . . . . . . . . . . . . . . . 55
5.5 Problems During Main Incision. . . . . . . . . . . . . . . . . . . . . . . . 55
5.6 Problems During Capsulorhexis. . . . . . . . . . . . . . . . . . . . . . . . 56
vii
viii Contents
5.7 Problems DURING Capsulorhexis. . . . . . . . . . . . . . . . . . . . . . 65
5.8 Problems During Hydrodissection . . . . . . . . . . . . . . . . . . . . . . 71
5.9 Problems During Phacoemulsification . . . . . . . . . . . . . . . . . . . 72
5.9.1 Posterior Capsule Rupture and Dropping Nucleus . . . . 74
5.10 Problems During I/A—Implantation of Capsular
Tension Ring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
5.11 Problems During Removal of Cortex . . . . . . . . . . . . . . . . . . . . 78
5.12 Problems During IOL Implantation . . . . . . . . . . . . . . . . . . . . . 79
5.13 Problems During Final Steps. . . . . . . . . . . . . . . . . . . . . . . . . . 83
Part III Complication Management with Trocar Cannulas
6 Anterior Vitrectomy and Other Surgeries with Trocars
from Pars Plana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
6.1 Equipment for Surgery of Anterior Segment with Trocars. . . . . 89
6.1.1 Setup of Anterior Vitreous Cutter . . . . . . . . . . . . . . . . 94
6.2 Surgical Setup for Trocar Surgery . . . . . . . . . . . . . . . . . . . . . . 94
6.3 Settings for Anterior Vitrectomy with Phacoemulsification
Machine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
6.4 Surgical Basics of Anterior Vitrectomy with Trocars. . . . . . . . . 97
6.5 Trocar Surgery with One Trocar . . . . . . . . . . . . . . . . . . . . . . . 101
6.6 Trocar Surgery with Two Trocars . . . . . . . . . . . . . . . . . . . . . . 102
6.7 Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
6.8 The Surgical Technique of Insertion of Trocar Cannulas. . . . . . 104
6.8.1 Anatomy of Pars Plana. . . . . . . . . . . . . . . . . . . . . . . . 104
6.8.2 Insertion of Trocar Cannulas. . . . . . . . . . . . . . . . . . . . 106
7 How to Approach a Surgical Complication. . . . . . . . . . . . . . . . . . . 109
8 Posterior Capsular Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
8.1 Management of Posterior Capsule Rupture. . . . . . . . . . . . . . . . 113
8.2 IOL Scaffolding for Residual Lens Pieces in Capsular
Rupture (Agarwal Technique) . . . . . . . . . . . . . . . . . . . . . . . . . 125
9 Surgical Management of Subluxated IOL from Pars Plana . . . . . . 131
10 Surgical Management of Dislocated Cortical Fragments. . . . . . . . . 133
11 Surgical Management of Posterior Capsular Opacification
from Pars Plana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
12 Surgical Management of Positive Vitreous Pressure (PVP)
During Cataract Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Contents ix
Part IV Surgical Techniques for Advanced Complication
Management
13 Small Incision Cataract Surgery (SICS = Modified ECCE) . . . . . . 145
13.1 Standard Instruments for SICS. . . . . . . . . . . . . . . . . . . . . . . . . 146
13.2 SICS Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
14 Surgical Management of Zonular Lysis . . . . . . . . . . . . . . . . . . . . . 155
14.1 Cataract Surgery with Zonular Lysis . . . . . . . . . . . . . . . . . . . . 155
14.2 Zonular Lysis of 1 Quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . 157
14.3 Zonular Lysis of 1–2 Quadrants. . . . . . . . . . . . . . . . . . . . . . . . 161
14.4 Zonular Lysis of 2–3 Quadrants: ICCE . . . . . . . . . . . . . . . . . . 165
Part V IOL Extraction Techniques, Iris Capture and Capsular
Phimosis
15 Extraction of an Acrylic IOL Through Cutting of IOL . . . . . . . . . 169
16 Extraction of an Acrylic IOL Through IOL Refolding . . . . . . . . . . 177
17 Extraction of a Silicone IOL Through Bi-secting of IOL . . . . . . . . 181
18 IOL Explantation with Intraocular Rolling. . . . . . . . . . . . . . . . . . . 187
19 Iris Capture by the IOL Optic . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
20 Peeling of Fibrosis in Capsular Phimosis . . . . . . . . . . . . . . . . . . . . 197
Part VI Secondary IOL Implantation Techniques
21 IOL Implantation in the Sulcus . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
21.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
21.2 Correct IOL Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
21.3 Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
21.4 Sulcus Implantation with Intact Anterior Capsule . . . . . . . . . . . 209
21.5 Sulcus Implantation with Defect Anterior Capsule . . . . . . . . . . 211
22 Iris-Claw IOL Implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
22.1 Special Instruments for Iris-Claw IOL Implantation . . . . . . . . . 219
22.2 Iris-Claw IOL Implantation Surgery. . . . . . . . . . . . . . . . . . . . . 221
22.3 Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
22.4 FAQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
23 Intrascleral IOL Implantation (Scharioth Technique). . . . . . . . . . . 229
23.1 Standard Instruments for Intrascleral IOL Implantation . . . . . . . 230
23.2 Intrascleral IOL Implantation Surgery . . . . . . . . . . . . . . . . . . . 230
x Contents
24 Intrascleral IOL Fixation with Flanged Haptics
(Yamane Technique). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
25 Scleral IOL Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
26 Scleral Fixation of Dislocated IOL In-The-Bag
(Hoffmann Technique) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
27 Fixation of IOL with Iris Suture. . . . . . . . . . . . . . . . . . . . . . . . . . . 263
27.1 Suturing an IOL to the Iris . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
27.2 Suturing an IOL-Capsular Bag Complex to Iris . . . . . . . . . . . . 273
27.3 Intra- and Postoperative Complications. . . . . . . . . . . . . . . . . . . 274
PartVII AdvancedComplicationManagementofPosteriorSegment
Using a Phacoemulsification Machine
28 Introduction and Possible Indications for Trocar Surgery
of Posterior Segment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
28.1 Checklist for Trocar Surgery of Posterior Segment . . . . . . . . . . 280
28.2 Possible Indications for Trocar Surgery of Posterior
Segment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
28.3 Anatomy of Pars Plana Vitrectomy . . . . . . . . . . . . . . . . . . . . . 282
28.4 Surgical Set-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
28.5 Equipment for Trocar Surgery of Posterior Segment . . . . . . . . . 284
28.5.1 Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
28.5.2 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
29 Intraocular Pressure During Vitrectomy—Clinical Assessment
and Surgical Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
30 Surgical Management of a Dropping and Dropped Nucleus . . . . . . 295
30.1 Recovery of a Dropping Nucleus from Pars Plana . . . . . . . . . . 296
30.2 Operative Planning and Strategies for Surgical Management
of Dropped Nucleus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
30.3 Extraction of a Posteriorly Dislocated Soft Nucleus
with Vitreous Cutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
30.4 Extraction of a Posteriorly Dislocated Hard Nucleus
with Intravitreal Phacoemulsification . . . . . . . . . . . . . . . . . . . . 303
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Part VIII Surgical Pearls of Ocular Trauma
31 Corneal Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
32 Traumatic Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Contents xi
33 Traumatic Mydriasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
34 Iridodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
34.1 Iris Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
35 Surgical Management of a Traumatic Aniridia and Aphakia
with Iris and IOL Prosthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
35.1 Fixation of a 3-Piece IOL in a Foldable Iris Prosthesis
(Human Optics®) and Implantation of Combo IOL–Iris
Prosthesis Through a 2.4 mm Incision . . . . . . . . . . . . . . . . . . . 340
36 Corneal, Lens and Retinal Perforation with a Nail. . . . . . . . . . . . . 347
Materials and Companies.... ..... .... .... .... .... .... ..... .... 357
List of All Pits and Pearls ... ..... .... .... .... .... .... ..... .... 363
Index .... .... .... .... .... ..... .... .... .... .... .... ..... .... 367