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120 Cards in this Set

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calculation ready for IOL
bag, sulcus, anterior chamber
Hoffer Q
measure short and avg eyes
measure avg to medium long eyes
long eyes
5 data points
1. desired post op refraction
2. avg K reading
3. Axial Length
4. AC chamber depth
5. lens constant - difference b/w natural lens plane of refraction and implant plane of refraction
K readings
1. cornea must be unmolested
2. tear film integrity
3. keratometer must be calibrated
4. power/radius - cheek weekly
5. eyepiece - check b4 each reading
K's --> repeat/ or do topography
K < 40 or > 48
avg K > 1.00 D btw eyes
astig > 1.5 D
Axial length
< 21 or > 26
AL difference is > 0.3 btw eyes
AL does not match refractive data
if difference in IOL pwr > 1.00 D btw eyes
weak zonules
usually associated PXE
look for gap btw post iris & cataract
-- in PXE, have them look up and then straight check to see if lens jiggles (PHACODONESIS) on slit lamp
1 day prior and 1 wk post
vigamox or zymar qid
more soluble, better penetration into aqeous, better coverage against gram (+), atypical mycobacteria, maintain potency against gram (-)
several wks post op,
DONT TAPER unless AC is completely quiet, if there is ANY AC rxn DON T TAPER
4 days prior for everyone
1 or more wks post ( CME risk)
NSAIDS and steriod 4 days prior to decrease capsular contraction
decrease pt anxiety
be safe/effective
respect cosmetic apperance
not retard VA
retrobulbar/peribular anesthesia
restricts EOM motion, wear patch til it wears off (1-2 days)
Advantages of topical anesthesia
1. avoids potential complication w/ retrobulbar block
3. no patching
4. avoids many meds CI to cat sx
5. more cost effective
6. less regulation
7. no anesthesiologist
8. facilitates sx for cooperative pt
9. provides imediate useful vision, shorter healing time
Disadv of topical anesthesia
1. potential eye mvmt
2. pt anxiety
3. increases surgeon stress
iris/ciliary sensation relieved w/ -->
intracameral lidocaine
1. lidocaine 4% soln or 2% gel
2. Bupivicaine 0.75%
3. Proparacaine 0.5%
4. tetracaine 0.5%
intracameral ( Into AC) : lidocaine 1% preservative free
increases pt tolerance
reduces iris/ciliary/zonular sensation
induces mild amaurosis ( partial or full loss of vision)
TYPES of CATs incision
1. clear cornea
2. scleral tunnel
3. near clear cornea
4. other
TYPES of incisions
1. temporal
2. @ 12
3. along steepest axis
4. oblique
5. other
Techniques for astigmatism
1. untreated ( most common) 2. LRI @ limbus
3. toric IOL
4. Astig keratectomy
Clear corneal incision
1. less trauma to the eye
2. less surgery time
3. more instant visual recovery
CCI/topical small incision challenges
1. miotic
2. mature cats
3. zonulysis
4. post vitrectomy
5. post refractive sx
6. high ametropia
start @ 1.5-2 mm perph to limbus
rounded blade w/ angled handle
dissect scleral flap forward into clear cornea
STOP when you HIT AC
scleral tunnel incision
scleral tunnel incision
1. longer tunnel than CCI- better seal (keeps out bacteria, lower risk of endophthalmitis
2. more watertight
3. lower risk of wound leak, iris prolapse, & perhaps endophthalmitis
Scleral tunnel incision
1.conjunctival peritomy required
2. requires greater amts of local anesthesia bc of the need for cautery
3. longer tunnel has greater restriction of instrument manipulation
4. hyphema
minimize surgically induced astigmatism and decrease pre existing astigmatism
refractive cats sx
Limbal relaxing incision (LRI)
600u groove @ limbus
DO NOT WANT full-thickness incision
place incision in steepest corneal meridian
if tx regular astigmatism, it wil be 2 incision opposite each other (nasal- temporal)
LRI : limitation
< 2.5 D of astigmatism
ATR corneal cyl
you can use CCI (temp incision) & LRI nasally to decrease cyl ; can extend CCI for higher amts of cyl
can also correct for hyperopia or presbyopia
conductive keratoplasty
5% povidone iodine in cul-de-sac, lids, lashes (reduces risk of endophthalmitis 75-80%)
- 1 mm clear corneal stab incision is made
- diamond blade
cause IOP spikes
hydrodissection and hydrodelination
4.5-5mm in diameter
peel off central part of capsule
capsulotomy - continous curvilinear capsulorhexis(CCC)
use ultrasound to scoop out chunks of cats, gets big chunk out
used to remove smaller chunks of cats
irrigation and aspiration
remove lens in one piece, along with ant &post capsule, requires large incision
remove lens in one piece and most of ant caps, the post cap is intact, large incision
break up the lens with ultrasound & vacuum out thru smaller incision
99% of cat sx done currently
ATR corneal cyl
use CCI and LRI (nasal and temp) combo to reduce cyl
1. a central deep groove is sculpted down the middle of the lens
2. the nucleus is fractured into 2 pieces
traditional longitudinal phaco and 2 handed divide and conquer
1. uses Ozil torsional handpiece
2. less likely to cause wound burn, less thermal energy induced
3. works a lower frequency
4. use smaller incision
5. decreased repulsion, decreased turbulence, increased cutting efficiency
6. uses circular motion
torsional phaco
phaco tip embedded in nucleus and chopper used to break off piece
chopping technique
intraoperative complication
1. corneal wound burn
2. ruptured post cap
3. dropped nucleus
4. choroidal/expulsive heme
5. iridodialysis
6. microscope burn
7. IOL damage
8. floppy iris syndrome
Must suture wound, bandage CL may assist closure,
suture = induced astigmatism more likely
make scleral relaxing incision just peripheral to corneal incision to minimize induced astigmatism
increase of wound leakage
corneal wound burn
if antibiotics is in BSS, NEED TO CHANGE BOTTLE
dont want antibiotics in the retinal layers
Kenalog stains :
vitreous making it easier to see
ruptured posterior cap increase the risk of :
1. CME
2. RD
3. retinal traction post surgery
DONT GO FISHIN for nucleus-
TPPL - tran par plana lensectomy
dropped nucleus
remove vitreous & lens together
S&S: dark chorodial mass with or w/out vitreous heme
firmness of the globe
bleeding thru the surgical wound
Suprachoroidal hemorrhage
RISK FACTORS of suprachoroidal hemorrhage
increase IOP and HR
atherosclerosis, HTN, DM
pt > 70 yo
cough,strain, vitreous loss during surgery
iris billows when pt moves their eye
iris prolapse thru incision site
pupil constriction not easily fixed
ineffective pupil strecth
ineffective small sphincterotomies
secondary flomax
intraoperative floppy iris syndrome
atropine helps
iris hooks help
healon 5 ( thicker visco)
intraoperative floppy iris
problems of hypermature cat
1. increase power on phaco portion of sx, more corneal edema
2. long procedure
3. anterior capsule looks the same color as cat
stains lens capsule
washed out with viscoelastic
capsule looks green
CCC is perfomed
useful for delinating anterior capsular trauma
stains in the vitreous may be toxic to retina so use least amt
Trypan blue( vision blue)
cheaper,better, faster
- absolute # of implanted IOLs
- improved optical performance
- elastic properties
- injector delivery systems for several styles
advantages of silicone
difficulty viewing with silicone oil
slippery when wet
high rebound energy
disadvantage of silicone
- biocompatibility w/ the eye
- lack of capsular opacification
slow unfolding
high refractive index & thinness
can be used in pt with retinal pathology
can inserty with folder or shooter
less pitting with YAG capsulotomy
ADVANTAGES of acrylic
lack of compressibility
tacky surface- less slippery when wet
occasional cosmetic concern
highly hydrophilic
high refractive index
non sticky surface
slow unfolding
ADV of hydrogel
fewer cases
larger incision size
TOO slow to unfold
DISADV of hydrogel
currently smallest possible incision size
ease of insertion with injector delivery
reduced PCO
Advantage of single piece plate
rare fibrinoid rxn
requires intact CCC
DO NOT YAG for 3 months
disadvantage of single piece plate
single piece plate NOT optimal for :
axial myopes
loose zonules, PXE
dense posterior capsular plaques ( will have to YAG it early )
pt. that may require vitreoretinal sx
call if RSVP
red, sensitivity to light, vision decrease, pain
Shallow AC with decreased IOP
ciliary shutdown
excessive aqueous drainage
1. wound leak
2. intentional glc procedure
TX: need to reform AC, pressure patch with cycloplegia, DC steroids (+) seidel
Shallow AC with elevated IOP
pupillary block iris bombe
TX: Oral CAI, mannitol , pupil dilation to break post synech
NO PILO, laser iridotomy
Elevated IOP due to :
1. retained viscoelastic
2. inflammatory debris
3. pupillary block
4. steroid responder : later complication
5. prior damage to TM
6. PG production
7. PAS
pupillary block
requires PI if cant break with dilation, use phenyl 10%
BURP incision @ 24 hr
sterile punctal dilator, touch peripheral to paracentesis incision- releases fluid
expected 1 week post-op
healing response
factors associated with endophthalmitis
poor wound constriction
ruptured posterior cap
clinical pearls of endophthalmitis
1 pain
2 decrease VA
3. hypopyon
4. lid swelling
non infectious, acute inflamm
12-24 hrs post-op
diffuse edema (limbus to limbus) mod. severe AC rxn, FIBRIN, hypopyon possible
Etiology of TASS
- irrigation soln
- preservatives in BSS
- polishing cmpd used on IOLs
- denatured viscoelastic in a reusable cannula
- endotoxin contamination
- insufficient cleaning of phaco handpiece
tx of TASS
intense topical corticosteroids @ least every hr
iris falls behind lens, causing distortion
- how to manage
pupil capture
dilate pupil, lay pt back, REVERSE DILATION may take several hrs
what are the sequelae if vitreous adheres to the wound?
iritis due to mechanical irritation
distorted pupil
displaced IOL
traction on retinal base
increased risk of infection (endophthlamitis)
can appear 4-12 wks, most common 4-6 wks post op
1. small intraretinal cysts on fovea, IVFA
2. decreased VA after previous visual improvement
3. may have mild AC rxn or vitreous to the wound
4. normal foveal thickness = 170-240 micron, CME = 768 microns
TX for CME
topical PF qid
NSAIDS topical and oral, ibuprofen 600mg tid, exceeds recommended dosage but OK for a short time if NO stomach ulcers and no blood thinning issues
post op @ 1mon, 3 month you can get ??
Causes of RD
pre existing retinal breaks or tears
vitreous traction causing hole or tear
surgical trauma with vitreal problems
lattice degeneration
topical anesthesia is superior to retro or peribulbar block - few SE
smaller the incision the better
cat sx is a refractive procedure
corrects only distance vision
does not accommodate in eye
gls required
single pwr
multiple, fixed focal pts
does NOT accommodate
must find appropriate focal pt
extensive neurological adaptation
single focal pt
dist and intermediate vision
not very good near vision
uses eye's natural focusing mechanism
crystalens = an accommodating IOL
GOOD candidates for multifocal/accommodating IOL
1. < 1 D cyl
2. not retinal or corneal pathology
3. bilateral cat in old peep or unilateral traumatic cat young pt
4. pupil > 2.5 , < 7 mm for crystalens
5. previous hyperopia OR moderate myopia
miotic pupil
glare phobes
most versatile
active lifestyle
good distance and intermediate
OK with fine print
some night vision symptoms
Diffractive optic to achieve a range of quality vision
1 piece IOL
Hydrophobic Acrylic material
High quality uncorrected near and distance vision
acrySof ReSTOR IOL
hydrophobic acrylic material
3 piece design
PMMA haptics, acrylic optic
6.0 mm optic, 13 mm total
squarish edge
135 = distance
24= near
AMO reZoom
near dominant zones provide +3.5 D near add pwr @ the IOL plane
provides near add greater than the 2.0 D (spect plane) needed by most adults over 50
strenghts of reZOOM
excellent distance vision during the day
independence from gls for MOST activities
natural transition from dist to near
ability to perform daily activities w.out reading gls for most peeps
SQUARE post edge may reduce risk PCO
limitation of reZOOM
1. halos
2. longer adaptation period
3. reading gls
20/20 or better uncorrected DISTANCE vision
restoration of accommodation
Eyeonics crystalens
components of the crystalens accommodative IOL
1. 3rd generation SILICONE
2. square edge
3. hinges
4. plate
Poor candidates of eyeonics crystalens
1. older, sicker pts do NOT get much accommodation
2. DM, ARMD, uveitis
3. uncontrolled glc
4. previous RD
5. irregular astigmatism
6. PXE/zonular weakness
7. capsular tears
WORST candidate of crystalens
1. cats one eye
2. previously PLANO, fellow eye PLANO
3. 44 yo
4. 1.25 D of WTR corneal astigmatism
5. engineer
6. referred by friendly college
Crystalens complication
1. myopic
2. type 1 anterior vaults
3. type 2 anterior vaults
4. type 3 anter vaults
5. hyperopic
6. capsular contraction syndrome
7. phimotic anterior capsule
MYOPIC (crystalens complication myope)
anterior lens vaults
Type 1 anterior vault
EARLY & symmetrical
typically not from wound leak or AC decompression
RE of - 1.00 to -2.00
may resolve spontaneouly
respond to cyclogel
type 2 anterior vault
early & symmetrical
-2.00 to -3.00, striae in PC,
REQUIRES surgical repositioning
type 3 anterior vault
late & asymmetrical
PC fibrosis and contraction due to retained cortex
posterior vaulting
not in equator of bag
hyperinflation at closing
corrected by repositioning
Capsular Contraction syndrome
asymmetrical vaults
SLE: one plate forward, the other back
tilted optic
straie in the posterior capsule most obvious behind the forward plate, radiating towards optic
gradual myopic shift in refraction with new NON keratometric cylinder
peripheral YAG
Phimotic anterior capsule
hyperopic RE
TX = small YAG notches in the AC
avoid the area of the plate haptics or the lens may vault more anteriorly
does not contribute to pre-existing HOA
anterior surface is steeper than posterior
decentration does not increase HOA
consider for post hyperopic LASIK or CK
sofport AO
reduces positives spherical aberration
improve image quality
thinner optic
Cant use after hyperopic LASIK or CK
improved fxal vision
produces -0.27 spherical aberr
improved night driving performance
improved constrast sensitivity
CANT use after hyperopic LASIK or CK
Tecnis amo
less likely to cause inflammation, slightly lower incidence of needing YAG
IOL material acrylic
1. adherence to PC
2. square posterior edge - sticks onto post capsule, doesnt allow cells to get past
IOL barrier effect