Catarata

Cataract referrals

Cataract surgery
Aachal Kotecha 02 Introduction to Eye Disease module

The most commonest cause of referral of a patient
has a great impact on quality of life notable improvement following successful surgery (c.f glaucoma surgery)

Approximately 270,000 operations p.a
longevity of population

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

Referral pathway forcataracts 1
Px see optom- refers to GP Px sees GP- refers to HES Px sees consultant- decision to operate Px returns 4x
Biometry Surgery Post op day 1 Post op for dx

Referral pathway for cataracts 2
Px has eye test, provisional diagnosis, counselling, referred to HES (GP informed) Px sees ophthalmologist and decision to operate with patient ‘work-up’ on same day Px returns for sx Px returnsfor post op check Px returns to optom for post op check and supply of spex

Sent back to optom for spex

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

AK/0106/03 (C)

1

Preop visit

Cataract surgery

Decision to operate Importance of accurate IOL implant power calculation Precise measurements of axial length and corneal curvature Variety of IOL lens power calculationsavailable
Surgeon factors

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

Anaesthesia

Operative procedures

Topical Retrobulbar block Peribulbar block Sub-Tenon’s block

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

AK/0106/03 (C)

2

Anaesthesia
Topical- aim to block nerves that supply cornea and conjunctiva
Long & short ciliary, nasociliary and lacrimal nervesRetrobulbar- aim to block oculomotor nerve before enters rectus muscles in the posterior intraconal space
injection

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

Anaesthesia
Peribulbar- instills local anaesthetic outside the cone
Shorter needle

Sub-Tenon’s block- conjunctiva anaesthetised, tiny area dissected to reveal sclera, injection placed under Tenons
Small incision means thatanaesthetic forced posteriorly
(C)AKotecha/02/03_2006 (C)AKotecha/02/03_2006

AK/0106/03 (C)

3

Operative procedures
Extracapsular cataract extraction (ECCE) Phacoemulsification lens extraction Usually implantation of an IOL

Protection of endothelium
I

Viscoelastic agents introduced in 1980’s
I

I

Protect cornea from mechanical trauma and maintain intraocular space when openincision Physical contact between IOL and endo will result in damage

I

Prophylactic antibiotics

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

ECCE
I

‘large’ incision surgery
I I I

anterior capsulectomy nucleus removed cortex (soft lens matter, SLM) removed by aspiration

I I

IOL positioned within capsular bag Viscoelastic replaced with BSS

(C)AKotecha/02/03_2006(C)AKotecha/02/03_2006

AK/0106/03 (C)

4

Phacoemulsification
Small incision surgery (3mm incision)
Anterior capsulorhexis Hydrodissection then phacoemulsification of nucleus Aspiration of SLM

Posterior chamber IOL’s
Harold Ridley 1949
Post op refraction -18.00/-6.00x120

Incision enlarged to facilitate insertion of IOL (or foldable IOL) Viscoelastic replaced with BSS

One piece(PMMA) Foldable (silicone elastomers) Multifocal

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

IOL’s

Complications of cataract surgery

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

AK/0106/03 (C)

5

Intra-operative
Posterior capsule rupture
Vitreous prolapse into lens elements Lens material into posterior chamber Loss of support for IOL (decentration)

All fragments mustbe removed
Cause inflammation, fibrosis and glaucoma

(C)AKotecha/02/03_2006

(C)AKotecha/02/03_2006

Loss of IOL support
Can put IOL in ciliary sulcus
Successful & used commonly previously

Anterior chamber IOL

Suture IOL in place
Difficult and centration problems

Use anterior chamber IOL
Risk of prolonged ocular inflammation and corneal decompensation due to endo contact...