UGC NET Paper 1 Mathematical Reasoning & Aptitude.pdf
Premier IOL choices Technique & Decision Making do we really need femtosecond laser cataract surgery
1. Premier IOL choices
Technique & Decision Making
or earlier cataract surgery
or do we really need femtosec
laser cataract surgery
Dr. Inderjit Singh
FRCS(E)., FRCOphth., FRANZCO
Chatswood , Sydney
2. Aim of modern cataract Surgery
Royal College of Ophthalmologists
Restoration of vision
Achievement of desired refractive
outcome
Improvement QOL
Ensuring safety and satisfaction
A VA is not mentioned
Meticulous pre-op;intra-op;post op mng
3. Earlier Cataract Operations
(1)
Outcomes in small incision is more predictable
Glasses free vision-Toric and Multifocal IOLs
Safer operation because of smaller incisions
Meet the visual demands that patient expects
Short recovery period
5. Earlier Cataract Operations
(3)
Allow patients to minimise glasses wear
Have the surgery at an age when you are still healthy
and active
Improved vision, via cataract surgery, minimises falls.
Fractured hip aged 75, 40% survive one year.
Contralateral hip fracture, in such a patient
10. FOCUS Autumn 2010
Pt. Expectations
The success of refractive cataract surgery depends on
achieving a predictable refractive outcome for defocus
(spherical equivalent) and astigmatism.
Refractive surprises can seriously compromise patient
satisfaction and also give rise to potential problems of
anisometropia, dominance switch in which the dominant
eye ends up with the weaker uncorrected vision and, above
all, give rise a sense of failure in patients expecting good
uncorrected visual acuity.
11. FOCUS – Autumn 2010
Ocular comorbidities
Small hyperopic eyes, large myopic eyes, eyes with very
steep or flat corneas, shallow anterior chamber depths,
history of refractive surgery, vitrectomy, corneal ectasia,
peripheral corneal melt syndromes and contact lens use
(when measured without an adequate contact lens holiday)
are at significant risk of refractive surprises. It is important
to warn these patients of the increased risk of refractive
surprise as part of the informed consent process and prepare
the patients for a second stage enhancement procedure
12. Refractive Surprise
Refractive Cataract
Surgery
Restore transparency of
ocular media +correct any
refractive aberrations of the
eye (ametropia,astigmatism)
Reduce spec dependence
QOL and economic benefits
Refractive Surprise
Anisometropia
Dominance switch
Sense of failure in pts
expecting good
uncorrected va
13. Refractive Surprise - Sources of Error
Norrby,S. JCRS 34/3 March 2008
IOL power calculations- SRKT, HofferQ, Haigis,HolladayII,
Post op Effective Lens position(36%) ( Optimising IOL constant
most important factor,Anstodemon,JCRS Jan 2011)
Error in post op refraction(27%)
AXL Measurements(17%)
Pupil Size(8%) – only if there is spherical aberration
Keratometry(10%)- ant curvature with keratometer,topographers;post
curvature
IOL Power –very small variability,(desired outcome deviation =max
0.18D)
Other Sources of error- corneal thickness,post surface
asphericity,higher order,chromatic aberrations,change in corneal power
(Norrby,S JCRS 34/3 March 2008)
14. What about Astigmatism
Pre-existing corneal astig –TORIC IOL
Surgeon induced astig – astigmatic neutral
incision.
Nailing +/- 0.50 D for both sphere
and cylinder is important
+1.00-2.00x90(SE=0)
+0.25-0.50x90(SE=0)
15. Ferrer-Blasco T,Montés-Micó R,Peixoto-de-Matos SC,GonzálezMéijome JM,Cerviño A.Prevalence of corneal astigmatism before
cataract surgery.J Cataract Refract Surg.2009;35(1):70-75. N =
4540 eyes.
87% of cataract surgery patients have
preoperative astigmatism
64% of patients fall within 0.50 to 1.25
36% of patients having greater than 1.26 D
16. ASTIGMATISM (contd)
16%
of all eyes had astig of 1.5D or more
46.8% WTR(minus cyl @180) , 34.3% ATR
Temp clear corneal incision will reduce
astig in 34% of pts but worsen for 47%
Corneal astig did not increase with age
Correlations -AXL,Ks,ACD,WTW-normal
and abnormal eyes – effect on effective
IOL position
17. TORIC IOLs- New Standard of care
Wolffsohn,JCRS,Effect of uncorrected astigmatism on
vision March 2011
Modest amounts of astigmatism can have
major effect on vision
Effect independence –
night,rain driving
Quality of life, well being – reading speed
Higher risks of falls
Worse with WTR
19. Surgeon Factor
The surgically induced astigmatic factor is usually in the
range between 0.25 and 0.50 D when a 2.2- to 2.4-mm
incision is used. Ideally, a surgeon should review the
outcomes of one’s previous 20 or more cases, comparing
preoperative keratometric measurements with
postoperative readings. Routinely reexamining one’s
surgically induced astigmatic factor to monitor for any
changes can also be beneficial.
20. Astigmatism
aim for both spherical and
astigmatic outcomes of 0.5 D to
avoid symptoms of ghosting and
shadows.
A patient with >=0.75 D of regular
corneal astigmatism and who
desires spectacle independence for
distance vision may be considered
for a toric IOL. Evidence supports
the use of toric IOLs even in
patients with low levels of
astigmatism
Statham M, Apel A, Stephensen D. Comparison of
the AcrySof SA60 spherical intraocular lens and the
AcrySof Toric SN60T3 intraocular lens outcomes in
patients with low amounts of corneal astigmatism.
Clin Experiment Ophthalmol. 2009;37:775–779
24. Toric IOLs
2.2mm incision at mark
5-5.5mm CCC
Cohesive viscoelastic (provisc) for easy and
complete removal from behind IOL
Precise alighnment using I/A tip
start 10-20 shy of markings
25. Other Factors affecting postop astigIOL Tilt and Shift
Small rhexis- hyperopic shift
Post capsule debris (viscoelastic) and
fibrotic bands-myopic shift and cyl
Irregular rhexis
One loop in bag only
26. Toric IOLS
(140 eyes )
Stable IOL in the bag
After 1yr.- 100% within 10*
96% within 5*
Markings can be 5* off
> 10* from axis reduces effect by 1/3
> 30* from axis causes increased astig
27. Toric IOLs-Pre Op Prep
Accurate Ks and Axl
Contact Lens wearers - 1-3 weeks
Measure undisturbed corneas
Get pt to blink often whilst measuring Ks
28. Toric IOLs Pre Op
Mark 180 meridian
steep meridian and
incision site at Slit
lamp.
Keep limbus dry
Use thin fine mark –
thick pen = upto
10degrees
34. Scanning electron micrographs
of the excised capsule disk edge produced by
manualcapsulorhexisA) and laser capsulotomy(B).
White arrows in B point to the microgrooves
produced by the laser
NJ Friedman -J Cataract Refract Surg. 2011 Jul;37
35. Stable Effective IOL position
depends on
100 eyes
Selected at random
CCC measured at slit lamp
Range of CCC size 5.0- 5.3 mm
All covered optic
CCC with bent cystotome(15c)
CCC covering optic edge
36. Toric IOLS
(140 eyes )
Stable IOL in the bag
After 1yr.- 100% within 10*
96% within 5*
Markings can be 5* off
> 10* from axis reduces effect by 1/3
> 30* from axis causes increased astig
37. Refractive cataract surgery
1.astigmatism can be corrected
2.repeatable sized CCC = stable effective
lens position
3.small astig neutral incision
1 + 2 + 3 = predictable stable refrective
outcome.
BUT WHAT ABOUT NEAR VISION ?
40. End Points for
Successful Cataract Surgery
=quality of vision
High contrast va maintained long term
Aspheric IOL
Residual refraction defecit = 0.50 for both
SE and astig – Aspheric Toric and
Multifocal Toric