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