Cataract Surgery: Advanced Techniques for Complex and Complicated Cases (Essentials in Ophthalmology)

Foreword
Preface
Contents
Contributors
1: Key Elements in the Risk Evaluation
	Introduction of Key Elements in the Risk Evaluation
		Risk Assessment
	History
		History of Present Illness
		Past Ocular History
		Past Ocular Surgical History
		Past Medical History
		Past Surgical History
		Family History
		Social History
		Review of Systems
	Physical Examination
		General Appearance
			Visual Acuity
			Intraocular Pressure
			Pupil Examination
		Extraocular Motility
		Confrontation Visual Fields
		Red Reflex
	External Structures
		Orbit and Eyelid
	Conjunctiva Sclera
	Cornea
		Anterior Chamber
	Iris
	Lens
	Vitreous
	Optic Nerve
	Fundus
	Conclusion
	References
2: Technology and Devices Involved in Cataract Surgery in Special Cases
	Introduction
	Status Post Radial Keratotomy
	Zonular Weakness
	Small Pupil
	IOL Exchange
	Kyphosis
	Macular Degeneration
	Corneal Endothelial Cell Compromise
	Conclusion
	References
3: The Hard Cataract
	The Preoperative Evaluation
		Preoperative Testing
	Intraoperative Tools and Techniques
		Tools
		Surgical Techniques
			Femtosecond Laser Pre-fragmentation of the Lens
		The Capsulorrhexis
		Hydrodissection
		Nuclear Removal
		Wound Integrity
	Postoperative Care
	Conclusion
	References
4: Intumescent Cataract and Preventing the Argentinian Flag Sign
	Introduction
	Etiology
		Senile White Cataract
	Comorbidities
		Glaucoma
			Phacomorphic Glaucoma
			Phacolytic Glaucoma
	Preoperative Management
	Subtype Classification
		Pearly White Cataract
			Equatorial Block
		Morgagnian Cataract
	Surgical Procedure
		Surgical Principles
			Capsule Staining
			Pressure Gradient
			Hydrodissection
			Capsular Fibrosis
		Pearly White Cataract
			Pearly White Cataract Without Fluid
			Pearly White Cataract with Fluid
		Morgagnian Cataract
	Potential Complications
		Argentinean Flag Sign
		Posterior Capsule Rupture
		Zonulopathy
	References
5: Pediatric Cataract
	Epidemiology and Pathology
	Timing of Cataract Surgery
	Pre- and Intraoperative Considerations
	Primary and Secondary IOL Implantation
	Pediatric Cataract Surgery with the Femtosecond Laser
	Postoperative Management
	Conclusion
	References
6: The Unstable Lens in the Adult Patient
	Introduction
	Etiology
	Preoperative Evaluation
	Instrumentation
		Hooks
			Iris Hooks
			Capsule Hooks
		Capsular Tension Rings
			Conventional Capsular Tension Rings
			Cionni Ring
			Scleral Fixation Devices
			Ahmed Segment
			Other Devices
	Our Surgical Strategy
	Surgical Algorithm
	Surgical Technique
		Anesthesia
		Incision
		Vitrectomy
		Capsulorhexis
		Hydrodissection and Hydrodelineation
		Phacoemulsification
		Cortical Aspiration
		Intraocular Lens Implantation
		Femtosecond Laser Role
	References
		Other References
7: IOL Implantation with Zonulopathy
	Preoperative Signs of Zonulopathy
	Capsulorrhexis
	Hydrodissection
	Capsular Tension Rings
	Capsule Retractors
	Nuclear Emulsification
	Cortical Cleanup
	IOL Selection and Implantation
	References
8: Cataract Surgery in Eyes with Ocular Surface Problems and Severe Dry Eye
	Part 1
		Definition of DED and Epidemiology
		Causes of Ocular Surface Problems/Severe Dry Eye
		Causes of Cataract in DED
		Impact of Cataract Surgery on DED
		Impact of DED on Cataract Surgery
			Preoperatively
				Lens Power Calculation
				Choice of IOL
				Timing of Surgery
			Intraoperatively
				Anesthesia
				Surgical Preparations
				Incision
				Adjunctive Measures
				Lens Removal
				IOL Placement
			Postoperatively
				Postoperative Routine Management
				Complications
		Conclusion
	Part 2
		Recommendations
			Preoperatively
			Intraoperatively
			Postoperatively
	Part 3
		Case and Video
	References
9: Cataract Surgery in Stevens-Johnson Syndrome and Pemphigoid Diseases
	Literature
10: Cataract Surgery in Keratoconus
	Introduction
	Preoperative Evaluation: How to Evaluate the Postop Vision and How Relevant Is the Cataract for the Vision of the Patient?
	Planification of the Surgical Technique and Preventing Surgical Problems in the OR
	Intraocular Lens Calculation Targeting the Right Power
	Intraocular Lens Choice
	Postoperative Complications: Management of Postoperative Residual Astigmatism
	Conclusion
	References
11: Cataract in Cases with Previous Corneal Graft Surgery; High Astigmatism
	Introduction
	Conventional Penetrating Keratoplasty (PKP) and Cataract Surgery
		Concurrent PKP and Cataract Surgery
		Sequential PKP and Cataract Surgery
		Astigmatism Management
	Anterior Lamellar Keratoplasty (ALK) and Cataract Surgery
		Concurrent ALK and Cataract Surgery
		Sequential ALK and Cataract Surgery
	Endothelial Keratoplasty (EK) and Cataract Surgery
		Concurrent EK and Cataract Surgery
		Sequential EK and Cataract Surgery
		Astigmatism Management
	Conclusion
	References
12: Cataract Surgery in Eyes with Fuchs Endothelial Corneal Dystrophy
	Introduction
	Cataract Surgery in Eyes with FECD: When to Do It and How
	Combined Cataract Surgery with Endothelial Keratoplasty and IOL Implantation: Technical Aspects and IOL Calculation
	Technical Aspects of Cataract Surgery Only in Eyes with Corneal Guttae/FECD
	Complication Management During Cataract Surgery in Eyes with Corneal Guttae/FECD
		Posterior Capsule Rupture
		Cystoid Macular Edema
		IOL Calcification
	References
13: The Posterior Polar Cataract
	The Patient Discussion
	Preoperative Testing and Biomicroscopy
	The Surgical Procedure: Filling the Anterior Chamber with OVD
	Capsulorhexis
	Hydrodissection or Hydrodelineation
	Phacoemulsification
	The Escape Route
	Cortical Removal
	Central Plaque Management
	Maintaining the Chamber
		IOL Insertion
	Final Maneuvers
	Conclusion
	References
14: Cataract Surgery in the Edematous, Partially Opaque Cornea and After Corneal Graft
	Introduction
	Cataract Surgery in Eyes with Corneal Opacity
	Cataract Surgery in Eyes with Low Endothelial Cell Count and Fuchs’ Endothelial Dystrophy
		Preoperative, Surgical, and Postoperative Recommendations
	Cataract Surgery in Eyes with Previous Keratoplasty
		In Cases with Previous PK or DALK
	Stability of the Corneal Scar at the Graft-Host Junction
		Preoperative Astigmatism
			The Condition of the Existing Corneal Endothelium
			Stability of the Corneal Scar at the Graft-Host Junction
	Cataract Surgery in Cases with Previous Endothelial Keratoplasty
	References
15: Cataract Surgery in Previous Refractive Corneal Surgery Cases
	Overview
	Preoperative Evaluation
	IOL Power Calculations in Post-Refractive Eyes
		Intraoperative Wavefront Aberrometry
	IOL Selection
		Aspheric IOL
		Toric IOL
		Multifocal and Extended Depth-of-Focus IOLs
		Small-Aperture IOL
		Future Directions: Postoperative IOL Adjustment
	Surgical Considerations
	Postoperative Considerations
	Discussion
	References
16: Complications of Phakic Intraocular Lenses
	Introduction
	Intraoperative Complications
		Iris-Fixated pIOLs
		Posterior Chamber pIOLs
	Postoperative Complications
		Optical Quality: Glare/Halos
		Pupil Ovalization
		Pigment Dispersion
		Inflammatory Reactions
	Intraocular Pressure Elevation
		Acute Postoperative IOP Elevation
		Chronic IOP Elevation
		Corneal Endothelial Cell Loss
		Cataract
			Iris-Fixated pIOLs
			Posterior Chamber pIOLs
	Retinal Detachment
	Endophthalmitis
	References
17: Safety and Visual Outcomes Following Phakic Intraocular Lens Bilensectomy
	Introduction
	Historical Overview
		Angle-Supported pIOLs
		Iris-Fixated pIOLs
		Posterior Chamber pIOLs
	Phakic Intraocular Lens Explantation: Timing and Reasons
	Bilensectomy Technique
		Ancillary Tests
		Surgery
		Angle-Supported pIOL Bilensectomy Technique
		Artisan pIOL Bilensectomy Technique
		Artiflex pIOL Bilensectomy Technique
		Posterior Chamber pIOL Bilensectomy Technique
	Clinical Outcomes
		PIOL Models Explanted
		Causes of Bilensectomy
		Cataract
		Endothelial Cell Loss
		Pupil Ovalization
	Complications
		Hyphema
		Posterior Capsule Rupture
		Ocular Hypertension
		Severe Endothelial Cell Loss
		Retinal Detachment
	Conclusions
	References
18: Intraocular Lens Explantation and Exchange
	Introduction
	Main Causes Leading to IOL Explantation
		IOL in-the-Bag Dislocation/Decentration
		Incorrect Lens Power
		IOL Opacification
		Multifocal IOL Explantation
	IOL Explantation Techniques
		Techniques
		Outcomes
	Conclusions
	References
19: Cataract Surgery in Uveitis
	Preoperative Time
		Surgical Evaluation
		Medical Evaluation
			Risk Factor # 1: Etiology of Uveitis
			Risk Factor # 2: Degree of Anterior Chamber Inflammation
			Risk Factor # 3: Presence or History of Macular Edema
			Risk Factor # 4: Use of a DMARD (Disease-Modifying Antirheumatic Drug)
			Risk Factor # 5: History of Inflammatory Relapse in the First Operated Eye
	Interoperative Time
		Surgical Strategy
		Medical Strategy
	Postoperative Time
		Inflammatory Recurrences
		Ocular Hypertension and Glaucoma
		Macular Edema
		Endophthalmitis
		Posterior Capsule Opacification (PCO)
		Late Dislocation of in-the-Bag Intraocular Lens
	Challenging Situations
		Childhood Uveitis
		Cataract Surgery and Viral Uveitis
			Indications
			Perioperative Management
	Conclusion
	References
20: Prevention and Treatment of Negative and Positive Dysphotopsia
	Introduction
	Positive Dysphotopsia
	Nonsurgical Management of PD
	Negative Dysphotopsia
	Nonsurgical Management of ND
	IOLS Designed to Prevent Dysphotopsia
	Surgical Strategies for Management of Dysphotopsia
	References
21: Cataract Surgery in the Vitrectomized Eye
	Epidemiology
	Pathogenesis of Cataract Formation After Pars Plana Vitrectomy
	Clinical Presentation
	Preoperative Assessment and IOL Power Calculation
	Surgery: Surgical Technique, Intraoperative Risks and Complications
	Functional Outcomes and Complication Rate
	Conclusion
	References
22: Combined Cataract Surgery with Pars Plana Vitrectomy
	Advantages to Combined Phaco/Vitrectomy
	Disadvantages of Combined Phaco/Vitrectomy
	Preoperative Considerations
		Patient Selection
		IOL Selection
		Surgical Planning
	Intraoperative Technique and Considerations
		Surgical Management Pearls
		Complex Case Example
	Postoperative Considerations
	Summary
	References
23: Cataract Surgery in High and Extreme Myopia
	Preoperative Discussion, Examination, and Planning
	Intraoperative Considerations
	Postoperative Follow-Up
	References
24: Relative Anterior Microphthalmos, High Hyperopia, Nanophthalmos
	Introduction
	Definitions
	Relative Anterior Microphthalmos (RAM)
		Preparation and Indication for Cataract Surgery in RAM Patients
		IOL Calculation
		Intraoperative Challenges and Surgical Approaches
			Shallow Anterior Chamber Morphology/Small Corneal Diameter
				Greater Intraoperative Endothelial Cell Loss and Postoperative Corneal Edema
			Small Pupil Diameter/Pseudoexfoliation Syndrome
			Comorbidities: Glaucoma
			Comorbidities: Synechiae of the Iris and Low Iris Stability
	Nanophthalmos
		IOL Power Calculation
		High-Power IOL Manufacturing and Availability
		Piggyback IOL Option
		Intraoperative Complications
		Postoperative Outcomes
		Management of Patient Expectations
		Case Report: Cataract Surgery in Extreme Nanophthalmos [34]
	High Hyperopia
	References
25: Cataract Surgery in the Diabetic Eye
	Epidemiology and Pathology
	Timing of Cataract Surgery
	Pre- and Intraoperative Considerations
	Complications of Cataract Surgery in Diabetic Eyes and Their Prevention
	Cataract Surgery and Diabetic Retinopathy
	Cataract Surgery and Diabetic Macular Edema
	Visual Outcomes
	Conclusion
	References
26: Cataract Surgery in Aniridia
	Introduction
	Aniridia as a Complex Disorder of the Eye
	Aniridia and Secondary Glaucoma
	Aniridia and Corneas
	Differentiation from Acquired Aniridia
	Aniridia and Cataract
	Preoperative Specificities in Patients with Cataract and Aniridia
	Choice of IOL for Implantation
	Anatomical Specialties in Aniridia
	Iris Reconstruction: Useful or Not?
	Intraoperative Specificities in Patients with Cataract and Aniridia
	Postoperative Specialties in Patients with Cataract and Aniridia
	Summary
	References
27: Floppy Iris Syndrome
	Introduction
	Pathophysiology of IFIS
	Risk Factors
		Medication
			Tamsulosin
			Other α1-Blockers
			Finasteride
			Neuromodulators
			Antihypertensives
		Gender and Age
		Arterial Hypertension
		Dilated Pupil Diameter
	Preoperative Assessment and Prophylaxis
	Surgical Management of IFIS
	References
28: Iris Repair
	Introduction
	Non-surgical and Alternative Approaches
	Cataract Surgery Combined with Iris Repair: A One-Step or Two-Step Procedure?
	Comorbidities
	Strategic Considerations for Iris Reconstruction
		Defect Type 1: Traumatic Iris Coloboma (Sector Defect)
			McCannel Suture
			Siepser Slipknot
			Bimanual Intraocular Microsuturing
			Pupilloplasty for Corectopia
			Sector Iris Implants for Larger Iris Colobomas
		Defect Type 2: Traumatic Iridodialysis
		Defect Type 3: Traumatic Mydriasis
		Defect Type 4: Subtotal or Total Aniridia
			Aniridia Iris Diaphragm Intraocular Lens
			Segmental Prosthetic Iris Devices
			Artificial Iris Prosthesis
			Surgical Technique
	Conclusion
	References
29: Artificial Iris Implantation: Overview of Surgical Techniques
	Introduction
	Artificial Iris Design
		A Short History of Artificial Iris Devices
		Custom-Made Silicon Iris Prosthesis
	Preoperative Patient Evaluation
	Surgical Techniques
		Partial Artificial Iris Implantation
		Complete Artificial Iris Implantation into Capsular Bag or Ciliary Sulcus
			Sulcus-Fixation in Pseudophakic Eyes
			Capsular Bag Implantation with a Combined Standard Cataract Surgery
		Complete Artificial Iris Implantation with Scleral Fixation
			Four-Floating Suture Technique (Pfeifer Technique)
			Artificial Iris-IOL Complex Scleral Fixation Technique: The Modified Yamane Technique
			Artificial Iris-IOL Complex Scleral Fixation Technique: Pfeifer-Canabrava Technique
			Artificial Iris and Non-foldable IOL Implantation Sutured to Sclera
			Artificial Iris and IOL Complex Implantation Sutured to the Sclera
		Other Surgical Approaches
			Open-Sky Implantation During a Perforating Keratoplasty
			A Sectoral Artificial Iris Implantation in Phakic Eye
	Clinical Outcomes, Complications and Their Management
	Conclusions
	References
30: Advanced Iris Repair
	Introduction
	Iris Repair Versus Iris Prosthesis
	Preparations for Iris Repair
		Globe Pressurization
		Sutures and Needles
	Instrumentation
	Vitreous Removal
	Pharmacologic Agents
	Crystalline Lens
	Types of Iris Repair
		Iridodialysis Repair
		Multibite Interrupted Pupil Margin Suture
		Iris Gathering Suture for Iris Transillumination Defects
		Congenital Iris Coloboma Repair
		Iris Cerclage for Permanent Mydriasis
	“Coat Hanger” Repair for Large Iris Defects
	Diathermy Contouring of Pupil Shape and Position
	Intraocular Knots for Iris Suturing
	Osher, Cionni, Snyder Variant of the Original Siepser Knot – Throws Formed Externally and Tightened with no instrument inside the Eye
	Ogawa Knot – Throws Formed Externally, Tightened with an Instrument Internally
	Ahmed Knot – Two Intraocular Forceps
	Corneal Tattooing for Iris Abnormalities
	Conclusion
	References
31: Correction of Severe Iris Defects and Cases of Traumatic Aniridia with Aphakia by Combined Scleral Fixated Intraocular Lens and Keratopigmentation
	Introduction
	Surgical Technique
	Case Reports
		Case 1
		Outcome
		Case 2
		Outcome
		Case 3
		Outcome
		Case 4
		Outcome
	Discussion
	References
32: Cataract Surgery in the Traumatized Anterior Segment
	Definitions
		Open- Versus Closed-Globe Injury
		Interventions for Traumatic Cataract: Primary Versus Secondary Procedure Timing
	Traumatic Cataract Surgery in the Pediatric Population
		Pediatric
		Causes of Pediatric Ocular Trauma
	Open Eye Injuries with Traumatic Cataracts
		Closure with Primary Lensectomy
		Immediate Repair – Primary Closure with Lensectomy and IOL Placement
		Late Repair, Staged Procedures
	Closed Eye Injuries with Traumatic Cataracts
	Special Techniques
	Special Concerns
	Outcomes of Surgical Repair
	Complications and Other Ocular Manifestations
		Structural Damage
		Amblyopia
		Posterior Capsule Opacification
		Fibrinous Uveitis
		Glaucoma
		Other Complications
	Traumatic Cataract Surgery in the Adult Population
		Causes of Injury
		Anatomical Surgical Approach
		Open Eye Injuries with Traumatic Cataracts
			Closure with Primary Lensectomy
			Immediate Repair – Primary Closure with Lensectomy and IOL Implantation
			Late Repair, Staged Procedures
		Closed Eye Injuries with Traumatic Cataracts
		Pediatric Closed-Globe Injury Case (Surgical Video is Included)
		Special Techniques
			Foreign Body Removal
			Vitrectorhexis
			Capsular Tension Rings
			Femtosecond Laser
		Special Concerns
			IOL Calculations
			Posterior Capsule Rupture (PCR)
		Outcomes: Visual and Anatomic
		Complications and Other Ocular Manifestations
			Corneal Involvement
			Posterior Capsule Rupture
			Zonulolysis and Lens Subluxation
			IOP Elevation
			Inflammatory Sequelae
			Structural Damage
			Retinal Involvement
			Endophthalmitis
	References
33: Traumatic Cataract
	Briefly
	Mechanism of Lens Trauma
	Vitreous First
	Capsulotomy
	Supporting the Zonules for Surgery
	Nuclear Disassembly with Capsular Tears
	Supporting the Intraocular Lens
	Repair the Iris Last
	Practicing These Techniques
	References
34: Femtosecond Laser in Complex and Complicated Cases
	Introduction
	Corneal Pathologies
	Brunescent and Intumescent White Cataracts
	Small Pupil – Primary or Laser Induced
	Posttraumatic Cases
	Zonular and Capsular Instability
	Retinal Disease
	Glaucoma
	Postvitrectomy and Postkeratotomy Eyes
	Eyes After Radial Keratotomy
	Alport Syndrome
	Posterior Capsulotomy
	When Really Not to Resort to LCS
	Evidence-Based Indications of Using the Femtosecond Laser in Cataract Surgery
	Evidence-Based Contraindications Against Using the Femtosecond Laser in Cataract Surgery
	Conclusion
	References
35: Complications of Femtosecond Laser-Assisted Cataract Surgery
	Preoperative Complications
	Intraoperative Complications
	.Postoperative Complications
	Conclusion
	References
36: Hard Cataract Management with Modern Extracapsular Cataract Surgery
	Introduction
	Preoperative Evaluation in Dense Cataracts
	Anesthesia in Dense Cataract Surgery
	Phacoemulsification in Dense Cataracts
		Incision and Anterior Capsulorhexis
			Cortical Cleaving Hydrodissection
			Principles for Nucleus Division and Fragment Removal
			Sculpting
			Chopping
			Direct Chop
			Step-by-Step Chop In Situ and Separation Technique
			Multilevel Chopping
			Nuclear Fragment Removal
	Extracapsular Cataract Extraction (ECCE) and Manual Small Incision Cataract Surgery (MSICS) for Dense Cataract Emulsification
	Newer Techniques/Devices for Dense Cataract Surgery
		Endocapsular Manual Nucleus Fragmentation in Phacoemulsification
		Femtosecond-Laser-Assisted Cataract Surgery (FLACS) – Role in Dense Cataract Removal
	Complications During Dense Cataract Surgery
	Conclusion
	References
37: Managing Complications During Cataract Surgery
	Anesthesia Complications
	The Incision
	The Constricting Pupil
	Descemet’s Tear or Detachment
	Complications of Hydrodissection
	Anterior Capsule Complications
	Iris Prolapse
	Thermal Injury
	Nuclear Chip Management
	Posterior Capsule Tear
	Dropped Nucleus
	Zonular Dialysis
	Anterior Chamber Shallowing and Positive Pressure
	The Excessively Deep Chamber
	Fired Cannula
	Acute Corneal Clouding
	Hemorrhage
	Patient Movement
	IOL Problems
	Conclusion
	References
38: Dislocated IOLs
	Introduction
	In-the-Bag and out-of-the-Bag Dislocation of the IOL
	Classification System of IOL Dislocation Sites
	IOL Dislocation Sites
	Explantation of Dislocated IOLs
	Vitrectomy
	Scleral Fixation of IOL
	References
39: Management of Dropped Nucleus in Complicated Cataract Surgery
	Introduction
	Dropped Nucleus: Causes and Preoperative Risk Factors
	Dropped Nucleus: What to Do?
		Anterior Segment
		Posterior Segment
	References
40: The Miscalculated IOL: Postoperative Refractive Surprise
	Preoperative Measurements of the Eye
		Axial Length
		Keratometry
	Choosing the Right Formula
	Previous Corneal Refractive Surgery
		Laser Vision Correction
		Prior Radial Keratectomy (RK)
	Toric IOLs
	Ocular Pathologies
		Keratoconus and Other Ectatic Disorders
		Other Corneal and Ocular Pathologies
	Conclusion
	References
41: MIGS in Special Cases
	Introduction
	iStent
	Hydrus Microstent
	Kahook Dual Blade
	Cataract Extraction and Effect on Intraocular Pressure
		Cataract Extraction and Angle Closure Glaucoma
		Cataract Extraction and Pseudoexfoliation Glaucoma
		Cataract Extraction and Open Angle Glaucoma
		Furthering Our Understanding
	MIGS and Endothelial Cell Density
	Standalone Filtering Procedures Versus Combined with Phacoemulsification
	References
Epilogue
A Glance at the Future
Index