Suchen und Finden
Preface
6
Contents
8
Contributors
11
Chapter 1
14
Introduction
14
Literature Review
14
Major Issues
14
Major Studies
14
Negative Studies
16
References
16
Chapter 2
18
The Transition Towards Smaller and Smaller Incisions
18
1.1 Micro-Coaxial Phacoemulsifi cation with Torsional Ultrasound
18
1.1.1 Introduction
18
1.1.2 Micro-Coaxial Phacoemulsification
18
1.1.3 Torsional Ultrasound
19
1.1.4 Our Procedure for Emulsifying the Nucleus
21
1.1.5 Combining Micro-Coaxial Phacoemulsification with Torsional Ultrasound
22
References
23
Chapter 3
24
1.2 Transitioning to Bimanual MICS
24
1.2.1 Introduction
24
1.2.2 Technique
25
1.2.3 Summary
26
Chapter 4
27
1.3 0.7 mm Microincision Cataract Surgery
27
1.3.1 Sub 1 mm MICS: Why?
27
1.3.2 Potential Drawbacks of a Sub-1 m Incision
28
1.3.3 Instrumentation
30
1.3.3.1 Phaco Tip (0.7 mm)
30
1.3.3.2 0.7 mm Irrigating Instruments
31
1.3.4 Surgery
32
1.3.4.1 Incision
32
1.3.4.2 Capsulorhexis
32
1.3.4.3 Hydrodissection
32
1.3.4.4 Prechopping
32
1.3.4.5 Phacoemulsification
33
1.3.5 0.7 mm MICS Combined Procedures
34
1.3.5.1 0.7 mm MICS and Glaucoma Surgery
34
1.3.5.2 0.7 mm MICS and 25-GaugeTransconjunctival SuturelessVitrectomy
35
1.3.6 Summary
36
References
36
Chapter 5
38
MICS Instrumentation
38
2.1 MICS Instrument Choice: The First Step in the Transition
38
2.2 MICS Incision
40
2.3 MICS Capsulorhexis
41
2.4 MICS Prechopping
43
2.5 MICS Irrigation/Aspiration Instruments
44
2.5.1 19 G Instruments
44
2.5.2 21 G Instruments
46
2.6 MICS Auxiliary Instrument
47
2.6.1 Scissors
47
2.6.2 Gas Forced Infusion
47
2.6.3 Surge Prevention
48
2.7 New MICS Instruments
48
2.7.1 Flat Instruments
48
References
49
Chapter 6
50
Evolution of Ultrasound Pumps and Fluidics and Ultrasound Power: From Standard Coaxial Towards the Minimal Incision Possible in Cataract Surgery
50
3.1 Introduction
50
3.2 Power Generation
50
3.3.1 Tuning
50
3.2.2 Phaco Energy
51
3.2.2.1 Low Frequency Energy
51
3.2.2.2 High Frequency Energy
51
3.2.3 Transient Cavitation
51
3.2.4 Sustained Cavitation
52
3.3 Modifi cation of Phaco Power
53
3.3.1 Alteration of Stroke Length
53
3.3.2 Alteration of Duration
53
3.3.2.1 Burst Mode
53
3.3.2.2 Pulse Mode
53
Micro Pulse (Hyper-Pulse)
53
Pulse Shaping
54
3.3.3 Alteration of Emission
54
3.4 Fluidics
55
3.5 Vacuum Sources
56
3.6 Surge
57
3.6.1 Non-Longitudinal Phaco: Modification of Fluid Control by Power Modulations
58
3.6.2 Partial-Occlusion Phacoemulsification
59
3.7 Phacoemulsifi cation Technique and Machine Technology
60
3.7.1 Micro-incisional Phaco
60
3.7.2 Bimanual Micro-Incisional Phaco
60
3.7.3 Micro-Incisional Coaxial Phaco
60
3.7.3.1 Irrigation and Aspiration
61
3.8 Conclusion
61
Reference
61
Further Reading
62
Chapter 7
63
Coaxial Microincision Cataract Surgery Utilizing Non-Linear Ultrasonic Power: An Alternative to Bimanual Microincision Cataract Surgery
63
4.1 Introduction
63
4.2 The Fluidics of Coaxial Microincisional Phacoemulsification
64
4.3 Incision Size
66
4.4 Torsional Ultrasound
67
4.5 Conclusion
68
References
68
Chapter 8
69
Technology Available
69
5.1 How to Better Use Fluidics with MICS
69
5.1.1 Physical Considerations
69
5.1.1.1 Aspiration Effi ciency
69
5.1.1.2 Chamber Stability
70
5.1.1.3 Holdability
71
5.1.2 Surgical Considerations
74
5.1.2.1 Incision Configuration
74
5.1.2.2 Phaco Technique
75
5.1.2.3 Infusion-Assisted High-Flow High-Vacuum Phacoaspiration (Hybrid Phaco)
77
5.1.2.4 The OS3 and CataRhex SwissTech Platforms
78
Equipment
78
Machine Settings
79
References
80
Chapter 9
81
5.2 How to Use Power Modulation in MICS
81
5.2.1 Introduction
81
5.2.2 What Do Phacoemulsifi cation Machines Really Do?
81
5.2.3 The Concept of Unoccluded Flow Vacuum
81
5.2.4 The Intricacies of Ultrasound Power Modulation
82
5.2.5 The Variable Incidence of Wound Burn Rates
83
5.2.6 Measuring the Amplitude of Post-Occlusion Surge
84
References
86
Chapter 10
87
5.3 MICS with Different Platforms
87
5.3.1 MICS with the Accurus Surgical System
87
5.3.1.1 Introduction and Historic Background
87
5.3.1.2 Surgical Features of the Accurus Surgical System Useful for MICS Procedures
89
5.3.1.3 Surgical Parameters for MICS with Accurus
92
5.3.1.4 Final Considerations
94
References
95
Chapter 11
96
5.3.2 Using the Alcon Infi niti and AMO Signature for MICS
96
5.3.2.1 Introduction
96
5.3.2.2 Technology on the Alcon Infi niti
96
5.3.2.3 Setting Up the Infi niti for MICS
96
5.3.2.4 Importance of Tip Size on Machine Fluidics Settings with the Infiniti
96
5.3.2.5 Setting the Ultrasound Power and Modulation with the Infiniti for MICS
98
5.3.2.6 The Infiniti and BMICS
98
5.3.2.7 Technology for MICS on the AMO Signature
99
5.3.2.8 Applying Signature Technology to CMICS and BMICS
100
Chapter 12
101
5.3.3 MICS with Different Platforms: Stellaris Vision Enhancement System
101
5.3.3.1 Innovations in Phacoemulsifi cation
101
5.3.3.2 Evaluating the Stellaris Vision Enhancement System
103
5.3.3.3 The Advantages of BMICS
104
References
105
Chapter 13
107
Surgical Technique – How to Perform a Smooth Transition
107
References
111
Chapter 14
111
6.1 Pupil Dilation and Preoperative Preparation
111
6.1.1 Managing the Small Pupil
111
6.1.2 Techniques that Depend on the Manipulation of the Pupil
112
6.1.3 Iris Surgery
113
6.1.4 Preoperative Preparation and Infection Prophylaxis
115
6.1.5 Evaluating Risk
115
6.1.6 Assessing Your Approach
116
6.1.7 Preventing Infection, Step by Step
117
6.1.8 Sample Protocol Outline
118
6.1.9 A Careful, Critical Eye
119
References
119
Chapter 15
120
6.2 Incisions1
120
6.2.1 Side-Port Incisions
125
References
128
Chapter 16
129
6.3 Thermodynamics1
129
6.3.1 Introduction
129
6.3.2 Corneal Thermal Damage
129
6.3.3 Heat Generation
130
6.3.4 Factors that Contribute to Thermal Incision Damage
130
6.3.4.1 Energy Emission: Amount and Pattern of How the Energy Is Delivered
130
6.3.4.2 Incision: Incision Construction and Possible Constriction of the Sleeve
132
6.3.4.3 Viscoelastic Devices and Possible Occlusion of the Aspiration Line
133
6.3.4.4 Irrigation Flow
133
6.3.4.5 Position of the Tip Inside the Incision
133
6.3.4.6 Tip Design
133
6.3.4.7 Surgical Technique
134
6.3.5 Conclusion
134
References
135
Chapter 17
136
6.4 Using Ophthalmic Viscosurgical Devices with Smaller Incisions
136
6.4.1 Introduction
136
6.4.1.1 The Nature of OVDs: Rheology
137
6.4.1.2 The Classifi cation of OVDs
137
6.4.1.3 Soft Shell and Ultimate Soft Shell Technique (SST & USST)
138
6.4.2 Routine, Special and complicated Cases
138
6.4.2.1 Phakic and Anterior Chamber IOLs
140
6.4.2.2 Trabeculectomy and Phaotrabeculectomy
141
6.4.2.3 Fuchs’ Endothelial Dystrophy
141
6.4.2.4 Zonular Defi ciency
141
6.4.2.5 Capsular Staining for White & Black Cataracts
141
6.4.2.6 Flomax® Intraoperative Floppy Iris Syndrome USST
142
6.4.3 Discussion
143
References
144
Chapter 18
145
6.5 Capsulorhexis
145
References
147
Chapter 19
148
6.6 Hydrodissection and Hydrodelineation1
148
References
152
Chapter 20
153
6.7 Biaxial Microincision Cataract Surgery: Techniques and Sample Surgical Parameters
153
Chapter 21
157
6.8 Biaxial Microincision Phacoemulsification: Transition, Techniques, and Advantages
157
6.8.1 Surgical Technique
157
6.8.2 Advantages
159
6.8.3 Disadvantages
160
6.8.4 Final Thoughts
161
References
161
Chapter 22
162
6.9 BiMICS vs. CoMICS: Our Actual Technique (Bimanual Micro Cataract Surgery vs. Coaxial Micro Cataract Surgery)
162
6.9.1 Introduction
162
6.9.2 Historical Background
163
6.9.3 BiMICS. BiManual MicroIncision Cataract Surgery
163
6.9.3.1 Introduction
163
6.9.3.2 Instrumentation
163
6.9.3.3 Microphacodynamics
163
6.9.3.4 Irrigation-aspiration
164
6.9.3.5 Phacotips
165
6.9.3.6 Capsulorhexis
165
6.9.3.7 Phaco Knives
165
6.9.3.8 The Phaco Machines
165
6.9.3.9 Phaco Pumps
165
6.9.3.10 Ultrasound Power Delivery
165
6.9.3.11 IOL Implantation
165
6.9.3.12 Astigmatism
165
6.9.4 CoMICS: Coaxial MicroIncision Cataract Surgery
166
6.9.4.1 Capsulorhexis
166
6.9.4.2 Phacotips
166
6.9.4.3 The Phaco Machines
167
6.9.4.4 Phaco Pumps
167
6.9.4.5 Ultrasound Power Delivery
167
6.9.4.6 Irrigation-Aspiration
167
6.9.4.7 Incision-Assisted IOL Implantation
167
6.9.5 Conclusion
167
References
168
Chapter 23
169
6.10 Endophthalmitis Prevention
169
6.10.1 Antibiotic Prophylaxis
169
6.10.2 Wound Construction
172
6.10.3 Summary
173
References
173
Chapter 24
176
Biaxial Microincision Phacoemulsifi cation for Diffi cult and Challenging Cases
176
7.1 High Myopia
176
7.2 Posterior Polar Cataract
176
7.3 Posterior Subluxed Cataracts
177
7.4 Mature Cataract with Zonular Dialysis
177
7.5 Punctured Posterior Capsule
178
7.6 Posterior Capsule Rupture
178
7.7 Pseudoexfoliation
179
7.8 Rock-Hard Nuclei
179
7.9 Switching Hands
180
7.10 Microcornea or Microphthalmos
180
7.11 Large Iridodialysis and Zonular Defects
180
7.12 Intraoperative Floppy Iris Syndrome (IFIS)
181
7.13 Every Small Pupil Must Be Viewed as a Potential IFIS
183
7.14 Iris Bombé
184
7.15 Very Shallow Anterior Chambers
184
7.16 Refractive Lens Exchange
184
7.17 Refractive Lens Exchange in Post Radial Keratotomy (RK)
185
7.18 Intraocular Cautery
186
7.19 Biaxial Microincision Instruments
186
References
187
Chapter 25
188
7.1 MICS in Special Cases: Incomplete Capsulorhexis
188
7.1.1 Introduction
188
7.1.2 Avoiding Complications While Constructing Your Microcapsulorhexis
189
7.1.3 Avoiding Complications During Biaxial Phaco with an Incomplete Capsulorhexis
192
7.1.4 Avoiding Complications During IOL Insertion with an Incomplete Capsulorhexis
198
7.1.5 Conclusions
198
References
199
Chapter 26
200
7.2 MICS in Special Cases (on CD): Vitreous Loss
200
7.2.1 Introduction
200
7.2.2 Posterior Capsule Tears and Vitreous Prolapse
201
7.2.3 Vitreous and the Epinucleus or Cortex
204
7.2.4 Different Techniques Other than Pars Plana Vitrectomy for Nuclear Loss in Vitreous
205
7.2.5 Pars Plana Vitrectomy
205
7.2.6 Zonulolysis
205
References
206
Chapter 27
208
7.3 How to Deal with Very Hard and Intumescent Cataracts
208
7.3.1 Introduction
208
7.3.2 Types of Cataracts
209
7.3.3 Management of Hard Cataracts Through Biaxial Technique
209
7.3.4 Incision
209
7.3.5 Capsulorrhexis
211
7.3.6 Hydrodissection
213
7.3.7 Phacoemulsifi cation
214
7.3.8 Conclusion
218
References
220
Chapter 28
221
IOL Types and Implantation Techniques
221
8.1 MICS Intraocular Lenses
221
8.1.1 Introduction
221
8.1.2 Lenses
222
8.1.2.1 Zeiss – Acri.Tec MICS IOLs (Zeiss – Acri.Tec Berlin, Germany)
222
8.1.2.2 ThinOptX MICS IOLs (ThinOptX, Abingdon, VA)
224
8.1.2.3 Akreos MI60 AO Micro Incision IOL (Bausch & Lomb, Rochester, NY)
225
8.1.2.4 IOLtech MICS lens (IOLtech, La Rochelle, France; and Carl Zeiss Meditec, Stuttgard, Germany)
226
8.1.2.5 TetraFlex KH-3500 and ZR-1000 (Lenstec, St. Petersburg, FL)
226
8.1.2.6 MicroSlim and SlimFlex MICS IOLs (PhysIOL, Liège, Belgium)
226
8.1.2.7 CareFlex IOL (W20 Medizintechnik AG, Bruchal, Germany)
227
8.1.2.8 AcriFlex MICS 46CSE IOL (Acrimed GmbH, Berlin, Germany)
227
8.1.2.9 Hoya Y-60H (Hoya Corporation, Tokyo, Yapan)
227
8.1.2.10 Miniflex IOL (Mediphacos Ltda., Minas Gerais, Brasil)
228
8.1.3 Optical Quality of MICS IOLs
228
8.1.4 Conclusion
229
References
231
Chapter 29
232
8.2 Implantation Techniques
232
8.2.1 Defi nition
233
8.2.2 Prerequisites to a Sub-2 Injection
233
8.2.3 IOLs Used for Injection Through Microincision
233
8.2.3.1 Material
234
8.2.3.2 Design
234
8.2.3.3 Optic Design
235
8.2.3.4 Haptic Design
235
8.2.3.5 Posterior Barrier (360°)
235
8.2.4 Injectors Meant for Microincision
235
8.2.4.1 Objectives of Injectors Meant for Microincision
236
8.2.4.2 Characteristics of Sub-2 Injectors
237
8.2.4.3 The Cartridges
238
Loading Chambers
238
Injection Tunnels and Cartridge Tips
238
8.2.4.4 The Plunger Tips (or plunger)
239
8.2.4.5 Pushing Systems
239
8.2.4.6 Injector Bodies
239
8.2.4.7 Principal Sub-2 Injectors
240
8.2.5 Visco Elastic Substances and Injection Through Microincision
241
8.2.6 Techniques of Sub-2 Injection
242
8.2.6.1 Visco-Injection Using Wound-Assisted Technique
243
8.2.6.2 Incision Construction
243
8.2.6.3 Pressurization of the Anterior Chamber
243
8.2.6.4 Loading the Cartridge
243
8.2.6.5 Loading the Injector
244
8.2.6.6 Insertion of the Plunger Tip
244
8.2.6.7 Injection in the Anterior Chamber
244
8.2.6.8 Positioning the IOL in the Capsular Bag
245
8.2.6.9 Removing the VES
245
8.2.6.10 Thin Roller Injector
245
8.2.6.11 Conclusion
245
Reference
247
Chapter 30
247
8.3 Special Lenses
247
8.3.1 Toric Posterior Chamber Intraocular Lenses in Cataract Surgery and Refractive Lens Exchange
247
8.3.1.1 Introduction
247
8.3.1.2 Definitions
248
8.3.1.3 T-IOL Calculation
249
8.3.1.4 Current T-IOL Models
249
8.3.1.5 Preoperative Marking
250
8.3.1.6 Clinical Indications
250
8.3.1.7 Custom-Made Lenses
251
8.3.1.8 Conclusion for Practice
253
References
255
Chapter 31
256
8.3.2 Special Lenses: MF
256
8.3.2.1 Discussion
257
8.3.2.2 Conclusion
257
8.3.2.3 Outlook
259
References
260
Chapter 32
261
8.3.3 Special Lenses: Aspheric
261
References
267
Chapter 33
269
8.3.4 Intraocular Lenses to Restore and Preserve Vision Following Cataract Surgery
269
8.3.4.1 Introduction
269
8.3.4.2 Why Filter Blue Light?
269
Summary
270
8.3.4.3 Importance of Blue Light to Cataract and Refractive Lens Exchange Patients
270
Summary
271
8.3.4.4 Quality of Vision with Blue Light Filtering IOLs
271
Summary
272
8.3.4.5 Clinical Experience
272
Summary
273
8.3.4.6 Unresolved Issues and Future Considerations
273
References
273
Chapter 34
275
8.3.5 Microincision Intraocular Lenses: Others
275
8.3.5.1 ThinOptX®
276
8.3.5.2 Smart IOL
277
8.3.5.3 Afi nity™
277
8.3.5.4 AcriTec
278
8.3.5.5 Akreos
281
8.3.5.6 Tetraflex
282
8.3.5.7 Rayner
283
8.3.5.8 Injectable Polymers
285
8.3.5.9 Final Comments
287
References
288
Chapter 35
289
Outcomes
289
9.1 Safety: MICS versus Coaxial Phaco
289
9.1.1 Introduction
289
9.1.2 Visual Outcomes
290
9.1.3 Incision Damage
290
9.1.4 Corneal Incision Burn
291
9.1.5 Corneal Changes
292
9.1.6 Infection
295
9.1.7 Summary
296
References
296
Chapter 36
298
9.2 Control of Corneal Astigmatism and Aberrations
298
9.2.1 Introduction: Impacts of MICS Incision on the Outcomes of Cataract Surgery
298
9.2.2 Objective Evaluation of Corneal Incision
298
9.2.3 Control of Corneal Aberration and Astigmatism with MICS
298
9.2.4 Role of Corneal Aberrometry in Evaluating MICS Incision
299
9.2.5 Role of OCT in Evaluating MICS Incision
299
9.2.6 Our Experience in Corneal Aberrations and Astigmatism After MICS
299
9.2.7 Conclusion
301
References
303
Chapter 37
304
9.3 Corneal Endothelium and Other Safety Issues
304
References
307
Chapter 38
309
9.4 Incision Quality in MICS
309
9.4.1 Introduction: History of Incision Size Reduction
309
9.4.2 The Trends Towards Microincision Cataract Surgery (BMICS)
309
9.4.3 Advantages of Minimizing the Incision Size
309
9.4.4 Model for the Analysis of Corneal Incision Quality [21]
310
9.4.5 Our Protocol for Evaluation of Incision Quality in BMICS [21]
311
9.4.6 Results
316
9.4.6.1 Visual, Refractive and Biomicroscopic Outcomes
316
9.4.6.2 Incision Imaging (OCT) Outcomes
316
9.4.6.3 Topographic and Aberrometric Outcomes
318
9.4.7 Special Focus on the Role of OCT in the Evaluation of Incision Quality in BMICS
322
9.4.8 Conclusion
323
References
324
Index
325
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