prepared during lens session

1. Indications & Techniques
of lens surgery
Bipin Bista
Resident
Ophthalmology

2. Introduction
• 2 main categories : Medical & Optical
• Medical arises from pathological states of the lens of varying
usually lens clarity, position , or other ocular inflammation ,
glaucoma or threat of glaucoma.
• Refractive indication for clear lens ammetropic state: Phakic IOL
surgery.

3. Medical indications for lens surgery
• Lenticular Opacification
• Lenticular malposition – subluxation , dislocation
• Lenticular malformation –
coloboma,lenticonus,lentiglobus,spherophakia.
• Lens induced inflammation – phacotoxic uveitis, phacolytic
glaucoma, phacomorphic glaucoma.
• Lenticular tumor – epithelioma, epitheliocarcinoma
• Facilitatory (surgical access) : Vitreous base, ciliary body, ora
serrata

4. Lenticular Opacification
• True pathological states
• Major ocular function (Vision) is obscured
• Reduces availability of light, scatters light off the axis, reduces
contrast sensitivity, diminishes color intensity, reduces resolution,
decrease in accommodation amplitude , myopic alterations.
• Laser interferometry : measure light obstruction
• Progressive change in cataract density : LOCS-III (Chylak & co-
workers) by Scheimpflug photography

5. Lenticular Opacification
• The degree of better vision & risk-outcome ratio can be different
in factors like amblyopia, corneal opacification, vitreous
opacification, maculopathy, retinopathy, glaucoma and optic
neuropathy.
• Lens surgery only for ambulatory functions.
• Collaborative endeavour : Diabetic, Alzheimer’s , mental
disorders, stroke, blood disorders.
• Holistic evaluation.

6. Lenticular malposition
• Subluxation
• Dysfunctional zonules
• Connective tissue disorders
• Chronic inflammation & exfoliation
• Ocular trauma : Obvious cause
• Glare, fluctuation vision & monocular diplopia.

7. Lenticular malformation
• Congenital
• Genetic, hereditary, or the result of intrauterine infection or
trauma.
• Rubella & lowe syndrome
• Aniridia & iris coloboma
• Early detection & surgical intervention.

8. Lens induced ocular inflammation
• Phacoanaphylatic endophthalmitis
• Lens induced glaucoma (phacolytic, phacomorphic)

9. Refractive indications for lens surgery
• Accurate and successful correction of refractive errors.
• Refinements in measurement and surgical techniques.
• Location for refractive surgical modulations : corneal epithelial
surface, corneal stroma, corneal endothelial surface, anterior
chamber, iris , pupil, posterior chamber, lens and sclera.
• Lens has its presumative popular location for refractive surgery.
• Multi-focal IOLs, intra-ocular injection of liquid silicone,
intracapsular placement of high water content poly-HEMA lenses,
a liquid silicon filled intra-capsular balloon, multiple IOLs
(Polypseudophakia), flexing haptic accommodative IOLs.

10. Indications for different lens surgery
techniques
• Intracapsular extraction : Zonular absence/dialysis, lens
subluxation, lens dislocation.
• Nuclear delivery : low endothelial cell count, guttate dystrophy,
brunescent cataract, cataracta nigra, torn posterior capsule
during phacoemulsification, zonuldialysis.
• Phacosection : astigmatism & other nuclear delivery conditions.
• Phacoemulsification : normal endothelial cell count, no guttate
dystrophy, immature nuclear sclerosis, cortical or subcapsular
cataract & astigmatism.

11. History of cataract surgery techniques

12. Year Technique Place Surgeon
800 Couching India Unknown
1015 Needle aspiration Iraq Unknown
1100 Needle aspiration Syria Unknown
1500 Couching Europe Unknown
1745 ECCE inferior incision France Daviel
1753 ICCE by thumb expression England Sharp
1860 ECCE superior incision Germany Von graefe
1880 ICCE by muscle hook zonulysis and lens tumble India Smith
1900 ICCE by capsular forceps Germany Verhoeff / Kalt
1940 ICCE capsule suction erysiphake Europe Stoewer / Barraquer
1949 ECCE by PCIOL & operating microscope England Ridley
1951 AC IOL Italy / Germany Strampelli / Dannheim
1957 ICCE by enzyme zonulysis Spain j. Barraquer
1961 ICCE by capsule cryadhesion Poland Krewicz/kelman
1967 ECCE by phacoemulsification U.S J.Shock
1975 Iris-pupil supported IOLs Netherlands Binkhorst/ worst
1984 Foldable IOLs U.S / S.A Mazzocco/Epstein

13. Intracapsular Extraction
• Not been a method choice since 1970.
• Has higher rate of PS complications : haemorrhage, vitreous loss,
RD, and CME.
• Indications : isolated congenital anomaly, absence or decreased
zonular fibers, pseudoexfoliation, trauma , following pars plana
surgery.
• Large incision (12-14 mm)
• Most case undergo secondary IOLs implanted.

14. Intracapsular Extraction

15. Extracapsular Extraction
• Popular since 1980s
• Intact posterior chamber & posterior chamber implantation
• Performed in large numbers in 3rd world nations.
• Done in cases of hard nuclei, capsule rupture with vitreous
presentation, high risk corneas.
• Small Incision are now the procedure of choice.

16. Extracapsular Extraction

17. Extracapsular Extraction

18. Phacoemulsification
• Incision ranging from 3.2 mm down to less than 1.0 mm.
• Foldable lens implantation
• Smaller the incision lesser the astigmatism
• Newest : femtosecond laser assisted phaco-cut precise corneal
incision and truely circular capsulorrhexis & partial fragmentation
of nucleus, permitting less ultrasonic energy

19. Surgery of lens capsule - capsulorrhexis
• The Continuous Curvilinear Capsulorrhexis : Capsulectomy of
choice
• Size : 4.5-5.5 mm sufficient to cover the IOL optic edge for ‘in the
bag’ placement of IOL.
• Keeps the IOL in the bag, away from the iris pigments, holds the
IOL optic and haptic in position for refractive stability and
posterior capsule clarity.
• Execution done through good red reflex, visualisation through
staining of capsule .
• New generation square-edged IOLs

20. Phaco

21. Surgery for presbyopia
• Many attempts has been made.
• Scleral implants to expand the anterior peripheral sclera in
attempts to allow further space for ciliary action
• Substances for injecting in capsular bag to restore youthful
accommodation ( yet not commercialised)
• Monovision : state of anisometropia geared towards emmetropia in
one eye.

22. Astigmatism
• Holistic approach
• Accurate correction of the optical state of the eye (Biometry &
formulas, astigmatism induction avoidance, and pre-existing
correction).
• ‘on axis’ incision for SICS : incision on the steep axis of the
astigmatism
• Higher level of correction by cause secondary higher order
aberration induction – Different toric IOLs

23. References
• Ophthalmology : yanoff and duker : 4th Edition
• American academy of ophthalmology : section 11 : 2014-2015

24. THANK YOU