Minimally Invasive Ophthalmic Surgery

Dedication

Preface

Acknowledgements

Contents

Contributors

Chapter 1

Minimally Invasive Oculoplastic Surgery

1.1 General Points

1.2 Lower Lid Entropion

1.2.1 Introduction

1.2.2 Lower Lid Entropion Sutures

1.2.3 Lower Lid Entropion Botulinum Toxin

1.3 Lower Lid Ectropion

1.3.1 Introduction

1.3.2 The Royce Johnson Suture

1.3.3 The Pillar Tarsorrhaphy

1.4 Distichiasis

1.4.1 Introduction

1.4.2 Direct Excision of Lashes

1.5 Ptosis

1.5.1 Introduction

1.5.2 Posterior Approach Muller’s Muscle-Conjunctival Resection

1.5.3 Anterior Approach – One Stitch Aponeurosis Repair

1.5.4 Supramid Brow Suspension

1.6 Lid Retraction

1.6.1 Introduction

1.6.2 Koornneef Blepharotomy

1.6.3 Botulinum Toxin

1.7 Lid Tumours

1.7.1 Mohs’ Micrographic Surgery

1.7.2 Lamella Sparing Tumour Excision

References

Chapter 2

Minimally Invasive Conjunctival Surgery

2.1 Conjunctival Surgery

2.2 Conjunctivochalasis

2.2.1 Background of the Disease

2.2.2 Indication for Surgery

2.2.3 Basic Concept of Surgery

2.2.4 Surgical Procedure

2.2.5 Postoperative Follow-Up

2.3 Pterygium

2.3.1 Background of the Disease and the Concept of Minimally Invasive Surgery

2.3.2 Indication for Surgery

2.3.3 Basic Concept of Surgery

2.3.4 Surgical Procedures

2.3.5 A Biologic Adhesive for Sutureless Pterygium Surgery

2.3.6 Postoperative Follow-Up

2.4 Limbal and Conjuntival Dermoids

2.4.1 Background of the Disease

2.4.2 Basic Concept of Surgery

2.4.3 Surgical Procedure

2.4.4 Postoperative Follow-Up

2.5 Strabismus Surgery

2.6 Conclusion

References

Chapter 3

Minimally Invasive Lacrimal Surgery

3.1 Introduction

3.1.1 Causes of Stenoses of the Lacrimal Drainage System

3.1.2 Diagnosis of Stenoses of the Lacrimal Drainage System

3.1.3 General Remarks Regarding Surgical Management

3.2 Endonasal Endoscopic (Microscopic) Dacryocystorhinostomy (EDCR)

3.2.1 Indication for EDCR

3.2.2 Surgical Technique

3.2.3 Silicone Stenting for EDCR

3.2.2.1 Silicone “Cones” (Lacrimal Duct Stent, Bess, Berlin)

3.2.4 Use of Mitomycin C for EDCR

3.2.5 Post-Operative Care After EDCR

3.2.6 Results of EDCR

3.3 Endonasal Endoscopic Laser Dacryocystorhinostomy (ELDCR)

3.3.1 Indications for ELDCR

3.3.2 Contraindications for ELDCR

3.3.3 Surgical Technique for ELDCR

3.3.4 Potential Problems with ELDCR

3.3.5 Post-Operative Care After ELDCR

3.3.6 Results of ELDCR

3.3.7 Post-Operative Complications After ELDCR

3.4 Dacryoendoscopy with Transcanalicular Laserdacryoplasty (TLDP)

3.4.1 Indication for TLDP

3.4.2 Contraindication for TLDP

3.4.3 Surgical Technique for TLDP

3.4.4 Results of TLDP

3.4.5 Post-Operative Care and Complications of TLDP

3.5 Microdrill Dacryoplasty (MDP)

3.5.1 Indication for MDP

3.5.2 Contraindication for MDP

3.5.3 MDP Procedure

3.5.4 Results of MDP

3.5.5 Post-Operative Care and Complications of MDP

3.6 Balloon Dilatation

3.6.1 Indications for Balloon Dilatation

3.6.2 Anaesthesia for Balloon Dilatation

3.6.3 Surgical Technique with 2 mm or 3 mm Balloon for Incomplete Stenosis

3.6.3.1 Post-Operative Care

3.6.3.2 Complications

3.6.3.3 Results

3.6.4 Surgical Technique with 5 mm Balloon for Complete Stenosis or Revision Cases of DCR According to Ref.

3.6.4.1 Post-Operative Care

3.6.4.2 Results

3.6.4.3 Complications

3.7 Stent Placement

3.7.1 Indications for Stent Placement

3.7.3 Surgical Technique for Stent Placement

3.7.4 Post-Operative Care and Complications After Stent Placement

3.7.5 Results of Stent Placement

References

Chapter 4

Minimally Invasive Corneal Surgery

4.1 Penetrating Keratoplasty

4.1.1 Introduction

4.1.2 Indications

4.1.3 Preoperative Evaluation of the Keratoplasty Patient

4.1.4 Preparation for Penetrating Keratoplasty

4.1.4.1 Eyelid Speculum

4.1.4.2 Scleral Fixation Rings

4.1.4.3 Large and Fine-Tipped Needle Holder

4.1.4.4 Toothed Forceps

4.1.4.5 Trephine Blades

4.1.4.6 Radial Marker

4.1.4.7 Cornea Punch

4.1.4.8 Cutting Block

4.1.4.9 Scissors

4.1.4.10 Cannulas and Blades

4.1.5 Preoperative Medications

4.1.6 Penetrating Keratoplasty Surgical Procedure

4.1.6.1 Placement of the Scleral Fixation Ring

4.1.6.2 Marking of the Host Cornea

4.1.6.3 Sizing of the Trephine

4.1.6.4 Trephination of the Host Cornea

4.1.6.5 Trephination of the Donor Cornea

4.1.6.6 Removal of the Host Cornea

4.1.6.7 Placement of the Donor Cornea Tissue in the Host Stromal Bed

4.1.6.8 Placement of the Cardinal Sutures

4.1.6.9 Completion of Suturing

4.1.6.10 Suture Techniques

4.1.6.11 Subconjunctival Medications

4.1.7 Intraoperative Complications

4.1.7.1 Scleral Perforation

4.1.7.2 Damage to the Donor Button

4.1.7.4 Posterior Capsule Rupture

4.1.7.5 Vitreous Loss

4.1.7.6 Anterior Chamber Hemorrhage

4.1.7.7 Choroidal Hemorrhage

4.1.8 Postoperative Management

4.1.8.1 Postoperative Immunosuppressive Regimen

4.1.9 Postoperative Complications

4.1.9.1 Wound Leaks

4.1.9.2 Epithelial Defects

4.1.9.3 Suture-Related Problems

4.1.9.4 Increased Intraocular Pressure

4.1.9.5 Post-Keratoplasty Astigmatism

4.1.10 Correction of Post-keratoplasty Astigmatism

4.1.10.1 Wedge Resections and Compression Sutures

4.1.10.2 Relaxing Incisions

4.1.10.3 LASIK

4.1.10.4 Photorefractive Keratectomy with Mitomycin C

4.1.11 Corneal Allograft Rejection

4.1.11.1 Host Risk Factors

4.1.11.2 Vascularized Corneas

4.1.11.3 Prior Graft Loss

4.1.11.4 Graft Diameter

4.1.11.5 Anterior Synechiae

4.1.11.6 Previous Intraocular Surgery

4.1.11.7 Herpes Simplex

4.1.12 Treatment of Allograft Rejection

4.1.13 Large Diameter Penetrating Keratoplasty

4.1.14 Summary

References

Chapter 5

4.2 Descemet’s Stripping Endothelial Keratoplasty

4.2.1 Introduction

4.2.2 Descemet’s Stripping Endothelial Keratoplasty Surgical Technique

4.2.2.1 Donor Cornea Preparation

4.2.2.2 Host Cornea Preparation

4.2.2.3 Insertion of the Donor Cornea

4.2.3 Postoperative Medications

4.2.4 Donor Dislocation Risks

4.2.5 Repositioning Donor Tissue

4.2.6 Treatment of Rejection Episodes

4.2.7 Visual and Refractive Outcomes

4.2.8 Other Complications

4.2.9 Summary

References

Chapter 6

4.3 Pterygium

4.3.1 Introduction

4.3.2 Treatment of Pterygium

4.3.3 Surgical Technique

4.3.3.1 Removal of the Pterygium

4.3.3.2 Harvesting the Conjunctival Autograft

4.3.3.3 Securing the Conjunctival Autograft

4.3.3.4 Fibrin Glue vs. Nylon Sutures

4.3.4 Postoperative Management

4.3.5 Recurrent Pterygium

4.3.6 Other Techniques in Pterygium Removal

4.3.6.1 Bare Scleral Technique

4.3.6.2 Adjunctive Agents

Mitomycin C

Beta-Irradiation

4.3.6.3 Amniotic Membrane Transplantation

4.3.6.4 Various Techniques in Conjunctival Autografting

4.3.7 Complications in Pterygium Removal

4.3.8 Summary

References

Chapter 7

Minimally Invasive Refractive Surgery

5.1 Trends in Refractive Surgery

5.2 Introduction

5.3 Cornea Refractive Surgery

5.3.1 Laser In Situ Keratomileusis (LASIK)

5.3.1.1 Advances in Flap Creation Technology

Microkeratomes

Femtosecond Laser

5.3.1.2 Technological Advances in Laser Delivery Platforms

5.3.1.3 Faster Excimer Lasers

5.3.1.4 Reduction of Collateral Thermal Tissue Damage

5.3.1.5 Advanced Eye Trackers

5.3.1.6 Newer Ablation Profi les

5.3.2 PRK and Advanced Surface Ablations (ASA)

5.3.2.1 Decrease Thermal Load on the Cornea

5.3.2.2 Use of Wound-Healing Modulators

5.3.2.3 Trend Towards EPI-LASIK

5.3.3 Summary

5.4 Intraocular Refractive Surgery

5.4.1 Phakic Intraocular Lens Surgery

5.4.1.1 Advances in Diagnostic Equipment

5.4.1.2 Types of Phakic Intraocular Lens

5.4.1.3 Kelman-Duet Phakic Intraocular Lens

Lens Design

Surgical Technique

Pre-Operative Preparation

Operative Procedure

Post-Operative Care

Results

Refractive Outcomes

Corneal Endothelium

5.4.1.4 Visian Implantable Collamer Lens

Lens Design

Surgical Technique

Pre-Operative Preparation

Operative Procedure

Post-Operative Care

5.4.1.5 Results

5.4.2 Summary

5.5 Lens and Cataract Surgery

5.5.1 Surgery: Micro-Incisional Cataract Surgery (MICS)

5.5.2 The Ideal MICS Intraocular Lens

5.5.2.1 Aspheric Intraocular Lenses

5.5.2.2 Toric Intraocular Lenses

5.5.2.3 ACRI.LISA 366D and ACRI.LISA TORIC 466TD

Lens Design

5.5.2.4 Surgical Technique

Operative Procedure

Post-Operative Care

5.5.2.5 Results

5.5.3 Summary

5.6 The Future: Beyond the Horizon of Refractive Surgery Today

Reference

Chapter 8

Minimally Invasive Strabismus Surgery

6.1 Introduction

6.2 Nonsurgical Treatment

6.3 Types and Classifi cation of Conjunctival Openings

6.4 Rectus Muscle Procedures

6.4.1 MISS Rectus Muscle Recession

6.4.2 MISS Rectus Muscle Plication

6.4.3 Parks’ Rectus Muscle Recession

6.4.4 Parks’ Rectus Muscle Plication

6.4.5 MISS Rectus Muscle Posterior Fixation Suture

6.4.6 Priglinger’s Rectus Muscle Y-Split Recession

6.4.7 MISS Rectus Muscle Repeat Surgery

6.4.8 MISS Rectus Muscle Transposition Surgery

6.5 Oblique Muscle Procedures

6.5.1 MISS Inferior Oblique Muscle Recession

6.5.2 MISS Inferior Oblique Muscle Plication

6.5.3 MISS Superior Oblique Muscle Recession

6.5.4 MISS Superior Oblique Muscle Plication

6.5.5 Boergen’s Modifi ed Harada-Ito Operation

6.5.6 Mühlendyck’s Partial Posterior Superior Oblique Tenectomy for Congenital Brown’s Syndrome

6.6 Postoperative Handling

6.7 Specifi c Complications of MISS

6.7.1 Intraoperative Complications

6.7.2 Postoperative Complications

6.8 Suggestions on How to Start Doing MISS

6.8.1 Instruments Suitable for MISS

6.8.2 Suture Materials Used for MISS

6.8.3 General Remarks Regarding MISS Procedures

6.8.4 MISS Dose–Response Relationships

References

Chapter 9

Minimally Invasive Iris Surgery

7.1 Instrumentation

7.2 Sutures

7.3 Surgical Principles of Iris Suturing

7.3.1 Mobilization

7.3.2 Intraocular Suturing and Knot Tying

7.3.3 Reattachment of Iris to Sclera

7.3.4 Pupil Repair

7.3.5 Adjunctive Pupil Repair Techniques

References

Chapter 10

Minimally Invasive Glaucoma Surgery

Introduction

8.1 Deep Sclerectomy: A Nonpenetrating Filtering Surgery

8.1.1 Introduction to Deep Sclerectomy

8.1.2 Anesthesia

8.1.3 Surgical Technique

8.1.3.1 Preparation

8.1.3.2 Superfi cial Flap Preparation

8.1.3.3 Deep Flap Preparation

8.1.3.4 Dissection of the Trabeculo-Descemet’s Membrane

8.1.3.5 Peeling of Schlemm’s Canal and Juxtacanalicular Meshwork

8.1.3.6 Drainage Device

8.1.3.7 Wound Closure

8.1.4 Postoperative Management and Medication

8.1.4.1 Medication

8.1.4.2 Management

8.1.5 Adjunctive Treatments

8.1.5.1 Bleb Needling

8.1.5.2 Nd:YAG Goniopuncture

8.1.6 Complications and Management

8.1.6.1 General

8.1.6.2 Perioperative Complications

8.1.6.3 Early Postoperative Complications

8.1.6.4 Late Postoperative Complications

References

Chapter 11

8.2 Minimally Penetrating Glaucoma Surgery with the Ex-PRESS™ Miniature Shunt

8.2.1 Introduction to Glaucoma Surgery with the Ex-PRESS™

8.2.1.1 Indications for MPGS with the Ex-PRESS™ Mini-Shunt Under a Scleral Flap

Open-Angle Glaucoma

Pigmentary Glaucoma

Pseudoexfoliation Glaucoma

Aphakic Glaucoma

Sturge–Weber Syndrome

Glaucoma Secondary to Uveitis

8.2.1.2 Relative Contraindications for MPGS with the Ex-PRESS™ Mini-Shunt Under a Scleral Flap

Congenital and Juvenile Glaucoma

Aniridia and Anterior Segment Dysgenesis Syndromes

Narrow-Angle Glaucoma

Posttrauma Angle-Recession Glaucoma

Neovascular Glaucoma

8.2.1.3 Absolute Contraindications for MPGS with the Ex-PRESS™ Mini-Shunt Under a Scleral Flap

Narrow-Angle Glaucoma in a Young Patient

Pseudophakic Glaucoma with an A/C IOL

8.2.1.4 Preoperative Considerations

8.2.2 Anesthesia

8.2.3 Surgical Technique and Potential Modifications

8.2.4 Postoperative Management and Medication

8.2.5 Outcomes and Comparison with Other Techniques

8.2.6 Complications and Management

8.2.6.1 General

8.2.6.2 Specifi c to the Technique

8.2.6.3 Several Characteristics of the Ex-PRESS™ Are Unique

8.2.6.4 Summary and Key Points

References

Chapter 12

8.3 New Minimally Invasive, Sclerothalamotomy Ab Interno Surgical Technique

8.3.1 Introduction to the Sclerothalamotomy Ab Interno

8.3.1.1 Indications for the Sclerothalamotomy Ab Interno

8.3.2 Anesthesia

8.3.3 Surgical Technique

8.3.3.1 Preparation

8.3.3.2 Diathermy Probe Insertion

8.3.4 Postoperative Management and Medication

8.3.5 Outcomes and Comparison with Other Techniques

8.3.6 Complications and Management

8.3.6.1 General

8.3.6.2 Specifi c to the Technique

8.3.6.3 Conclusions

References

Chapter 13

8.4 Glaukos® iStent® Trabecular Micro-Bypass Implant

8.4.1 Introduction to Glaucoma Surgery with a Micro-Bypass Implant

8.4.1.1 Indications for Implantation of Glaukos® iStent® Micro-Bypass Implant

Type of Glaucoma

Stage of Glaucoma

Combined Surgery

8.4.2 Anesthesia

8.4.3 Surgical Technique

8.4.3.1 Preparation

8.4.3.2 Implantation of the Micro-Bypass Stent

8.4.4 Postoperative Management and Medication

8.4.5 Outcomes and Combination with Other Techniques

8.4.5.1 Trabecular Implant in Refractory Glaucoma Patients

8.4.5.2 Phacoemulsifi cation Cataract Surgery Combined with Implantation of a Trabecular Stent

8.4.5.3 Phacoemulsifi cation Cataract Surgery Combined with Implantation of Two Trabecular Implants

8.4.6 Conclusions

References

Chapter 14

Minimally Invasive Cataract Surgery

9.1 Instrument List

9.2 Topical Anesthesia Protocol

9.2.1 Topical Technique

9.2.1.1 Materials

9.2.1.2 Procedures

9.2.3.3 Operating Room

9.2.3.4 Helpful Hints

9.3 Surgical Procedure

9.3.1 Incision Construction

9.3.2 Capsulorhexis

9.3.3 Hydrodissection and Hydrodelineation

9.3.4 Chopping and Phacoemulsifi cation

9.3.5 Cortical Clean-up

9.3.6 Limbal Relaxing Incisions

9.3.7 IOL Implantation

9.3.8 Stromal Hydration and Testing of Incisions

9.4 Postoperative Management

References

Appendix 1

Appendix 2

Appendix 3

Appendix 4

Appendix 5

Chapter 15

Minimally Invasive Vitreoretinal Surgery

10.1 Introduction

10.2 Microincision Vitrectomy

10.2.1 Models of Wound Architecture

10.2.2 Vitrectomy

10.2.3 Adjuncts

10.2.4 Common Surgical Techniques

10.2.4.1 Macular Surgery

10.2.4.2 Proliferative Diabetic Retinopathy

10.2.4.3 Retinal Detachment

10.2.4.4 Pediatric Vitreoretinal Surgery

10.2.5 Complications

10.2.6 Future Developments in Minimally Invasive Vitrectomy

10.3 Endoscopic Vitreoretinal Surgery

10.3.1 Introduction

10.3.2 History and Development of Endoscopic Ophthalmic Surgery

10.3.3 The Endoscope

10.3.4 Applications of Intraocular Endoscopy

10.3.4.1 Media Opacity

10.3.4.2 Subretinal Fluid Drainage and Fluid–Gas Exchange

10.3.4.3 PVR and Subretinal Surgery

10.3.4.4 Retained Lens Fragments

10.3.4.5 Anterior and Retrolental Vitrectomy in Malignant Glaucoma

10.3.4.5 Sutured IOL and ECP

10.3.5 Limitations and Challenges

10.4 Future Directions of Minimally Invasive Vitreoretinal Surgery

References

Index