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120 Cards in this Set
- Front
- Back
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calculation ready for IOL
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bag, sulcus, anterior chamber
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Hoffer Q
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measure short and avg eyes
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holladay
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measure avg to medium long eyes
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SRK/T
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long eyes
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LENS SELECTION
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 |
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K readings
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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 |
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VALIDATION GUIDELINES
K's --> repeat/ or do topography |
K < 40 or > 48
avg K > 1.00 D btw eyes astig > 1.5 D |
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VALIDATION GUIDELINES
Axial length |
< 21 or > 26
AL difference is > 0.3 btw eyes AL does not match refractive data |
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VALIDATION GUIDELINES
IOL PWR |
if difference in IOL pwr > 1.00 D btw eyes
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weak zonules
SLE |
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 |
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MEDS
Antibiotics WHY |
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 (-) |
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steriod
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several wks post op,
DONT TAPER unless AC is completely quiet, if there is ANY AC rxn DON T TAPER |
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NSAID
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4 days prior for everyone
1 or more wks post ( CME risk) |
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crystalens
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NSAIDS and steriod 4 days prior to decrease capsular contraction
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anesthetic
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decrease pt anxiety
be safe/effective respect cosmetic apperance not retard VA |
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retrobulbar/peribular anesthesia
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diplopia
restricts EOM motion, wear patch til it wears off (1-2 days) |
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Advantages of topical anesthesia
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1. avoids potential complication w/ retrobulbar block
2. INSTANT VISION 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 |
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Disadv of topical anesthesia
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1. potential eye mvmt
2. pt anxiety 3. increases surgeon stress |
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iris/ciliary sensation relieved w/ -->
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intracameral lidocaine
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TOPICAL
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1. lidocaine 4% soln or 2% gel
2. Bupivicaine 0.75% 3. Proparacaine 0.5% 4. tetracaine 0.5% |
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intracameral ( Into AC) : lidocaine 1% preservative free
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increases pt tolerance
reduces iris/ciliary/zonular sensation induces mild amaurosis ( partial or full loss of vision) |
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TYPES of CATs incision
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1. clear cornea
2. scleral tunnel 3. near clear cornea 4. other |
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TYPES of incisions
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1. temporal
2. @ 12 3. along steepest axis 4. oblique 5. other |
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Techniques for astigmatism
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1. untreated ( most common) 2. LRI @ limbus
3. toric IOL 4. Astig keratectomy |
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Clear corneal incision
ADVANTAGES: |
1. less trauma to the eye
2. less surgery time 3. more instant visual recovery |
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CCI/topical small incision challenges
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1. miotic
2. mature cats 3. zonulysis 4. post vitrectomy 5. post refractive sx 6. high ametropia |
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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
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scleral tunnel incision
ADVANTAGES |
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 |
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Scleral tunnel incision
DISADVANTAGES |
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 |
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minimize surgically induced astigmatism and decrease pre existing astigmatism
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refractive cats sx
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Limbal relaxing incision (LRI)
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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) |
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LRI : limitation
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< 2.5 D of astigmatism
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ATR corneal cyl
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you can use CCI (temp incision) & LRI nasally to decrease cyl ; can extend CCI for higher amts of cyl
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can also correct for hyperopia or presbyopia
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conductive keratoplasty
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5% povidone iodine in cul-de-sac, lids, lashes (reduces risk of endophthalmitis 75-80%)
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CCI
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- 1 mm clear corneal stab incision is made
- diamond blade |
CCI
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Viscoelastic
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cause IOP spikes
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BSS
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hydrodissection and hydrodelination
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4.5-5mm in diameter
peel off central part of capsule |
capsulotomy - continous curvilinear capsulorhexis(CCC)
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use ultrasound to scoop out chunks of cats, gets big chunk out
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phacoemulsification
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used to remove smaller chunks of cats
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irrigation and aspiration
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remove lens in one piece, along with ant &post capsule, requires large incision
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ICCE
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remove lens in one piece and most of ant caps, the post cap is intact, large incision
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ECCE
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break up the lens with ultrasound & vacuum out thru smaller incision
99% of cat sx done currently CCI or ST |
phacoemulsification
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ATR corneal cyl
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use CCI and LRI (nasal and temp) combo to reduce cyl
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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
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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
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NO GROOVE
phaco tip embedded in nucleus and chopper used to break off piece |
chopping technique
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intraoperative complication
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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 |
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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
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if antibiotics is in BSS, NEED TO CHANGE BOTTLE
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dont want antibiotics in the retinal layers
RUPTURED POSTERIOR CAP |
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Kenalog stains :
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vitreous making it easier to see
RUPTURED POSTERIOR CAP |
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ruptured posterior cap increase the risk of :
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1. CME
2. RD 3. retinal traction post surgery |
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DONT GO FISHIN for nucleus-
TPPL - tran par plana lensectomy |
dropped nucleus
remove vitreous & lens together |
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S&S: dark chorodial mass with or w/out vitreous heme
SHALLOWING of the AC firmness of the globe bleeding thru the surgical wound |
Suprachoroidal hemorrhage
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RISK FACTORS of suprachoroidal hemorrhage
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increase IOP and HR
atherosclerosis, HTN, DM pt > 70 yo cough,strain, vitreous loss during surgery |
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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
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atropine helps
iris hooks help healon 5 ( thicker visco) |
intraoperative floppy iris
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problems of hypermature cat
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1. increase power on phaco portion of sx, more corneal edema
2. long procedure 3. anterior capsule looks the same color as cat |
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ICG
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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 |
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Trypan blue( vision blue)
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cheaper,better, faster
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- absolute # of implanted IOLs
- improved optical performance - elastic properties - injector delivery systems for several styles |
advantages of silicone
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difficulty viewing with silicone oil
slippery when wet high rebound energy |
disadvantage of silicone
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- 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
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lack of compressibility
tacky surface- less slippery when wet occasional cosmetic concern |
DISADVANTAGE of acrylic
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highly hydrophilic
stable high refractive index non sticky surface slow unfolding |
ADV of hydrogel
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fewer cases
larger incision size TOO slow to unfold |
DISADV of hydrogel
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currently smallest possible incision size
ease of insertion with injector delivery reduced PCO |
Advantage of single piece plate
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rare fibrinoid rxn
requires intact CCC DO NOT YAG for 3 months |
disadvantage of single piece plate
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single piece plate NOT optimal for :
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axial myopes
loose zonules, PXE dense posterior capsular plaques ( will have to YAG it early ) pt. that may require vitreoretinal sx |
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call if RSVP
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red, sensitivity to light, vision decrease, pain
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Shallow AC with decreased IOP
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ciliary shutdown
excessive aqueous drainage 1. wound leak 2. intentional glc procedure TX: need to reform AC, pressure patch with cycloplegia, DC steroids (+) seidel |
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Shallow AC with elevated IOP
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pupillary block iris bombe
TX: Oral CAI, mannitol , pupil dilation to break post synech NO PILO, laser iridotomy |
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Elevated IOP due to :
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1. retained viscoelastic
2. inflammatory debris 3. pupillary block 4. steroid responder : later complication 5. prior damage to TM 6. PG production 7. PAS |
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pupillary block
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requires PI if cant break with dilation, use phenyl 10%
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BURP incision @ 24 hr
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sterile punctal dilator, touch peripheral to paracentesis incision- releases fluid
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Iritis
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expected 1 week post-op
healing response |
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factors associated with endophthalmitis
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poor wound constriction
immunosuppression ruptured posterior cap |
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clinical pearls of endophthalmitis
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1 pain
2 decrease VA 3. hypopyon 4. lid swelling |
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TASS
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non infectious, acute inflamm
12-24 hrs post-op diffuse edema (limbus to limbus) mod. severe AC rxn, FIBRIN, hypopyon possible |
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Etiology of TASS
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- irrigation soln
- preservatives in BSS - polishing cmpd used on IOLs - denatured viscoelastic in a reusable cannula - endotoxin contamination - insufficient cleaning of phaco handpiece |
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tx of TASS
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intense topical corticosteroids @ least every hr
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iris falls behind lens, causing distortion
- how to manage |
pupil capture
dilate pupil, lay pt back, REVERSE DILATION may take several hrs |
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what are the sequelae if vitreous adheres to the wound?
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iritis due to mechanical irritation
distorted pupil displaced IOL traction on retinal base cME increased risk of infection (endophthlamitis) |
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can appear 4-12 wks, most common 4-6 wks post op
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CME, AVOID PG
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SIGNS of CME
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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 |
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TX for CME
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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 |
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post op @ 1mon, 3 month you can get ??
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RD
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Causes of RD
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pre existing retinal breaks or tears
vitreous traction causing hole or tear surgical trauma with vitreal problems lattice degeneration |
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PEARLS:
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topical anesthesia is superior to retro or peribulbar block - few SE
smaller the incision the better cat sx is a refractive procedure |
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corrects only distance vision
does not accommodate in eye gls required |
single pwr
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multiple, fixed focal pts
does NOT accommodate must find appropriate focal pt extensive neurological adaptation |
multifocal
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single focal pt
dist and intermediate vision not very good near vision uses eye's natural focusing mechanism |
accommodating
crystalens = an accommodating IOL |
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GOOD candidates for multifocal/accommodating IOL
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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 |
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miotic pupil
glare phobes |
crystalens
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BOOKWORM
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ReSTOR
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most versatile
active lifestyle good distance and intermediate OK with fine print some night vision symptoms |
ReZoom
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dominant
nondominant |
ReZoom
ReSTOR |
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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
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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
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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 |
reZOOM
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strenghts of reZOOM
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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 |
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limitation of reZOOM
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1. halos
2. longer adaptation period 3. reading gls |
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20/20 or better uncorrected DISTANCE vision
restoration of accommodation |
Eyeonics crystalens
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components of the crystalens accommodative IOL
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1. 3rd generation SILICONE
2. square edge 3. hinges 4. plate |
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Poor candidates of eyeonics crystalens
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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 |
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WORST candidate of crystalens
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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 7. UNREALISTIC EXPECTATION |
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Crystalens complication
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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 |
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MYOPIC (crystalens complication myope)
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anterior lens vaults
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Type 1 anterior vault
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EARLY & symmetrical
typically not from wound leak or AC decompression RE of - 1.00 to -2.00 may resolve spontaneouly respond to cyclogel |
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type 2 anterior vault
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early & symmetrical
WOUND LEAK FIRST FEW DAYS -2.00 to -3.00, striae in PC, WILL NOT RESPOND TO Cycloplegia REQUIRES surgical repositioning |
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type 3 anterior vault
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late & asymmetrical
CCS PC fibrosis and contraction due to retained cortex |
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Hyperopia
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posterior vaulting
not in equator of bag hyperinflation at closing corrected by repositioning |
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Capsular Contraction syndrome
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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 |
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Phimotic anterior capsule
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hyperopic RE
TX = small YAG notches in the AC avoid the area of the plate haptics or the lens may vault more anteriorly |
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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
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reduces positives spherical aberration
improve image quality thinner optic Cant use after hyperopic LASIK or CK |
AcrySof
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improved fxal vision
produces -0.27 spherical aberr improved night driving performance improved constrast sensitivity CANT use after hyperopic LASIK or CK |
Tecnis amo
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less likely to cause inflammation, slightly lower incidence of needing YAG
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IOL material acrylic
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1. adherence to PC
2. square posterior edge - sticks onto post capsule, doesnt allow cells to get past |
IOL barrier effect
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