Cataract surgery in long eyes
Eyeworld Nov, 2016
Long eye: benchmark: > 26mm or 28mm
PRE-OP
Check the retina condition
INTRA-OP
1. pupillary block: a second instrument can lift the iris off the capsule to allow fluid to circulate back to the PC.
2. DO NOT enter the wound irrigating
IOL CALCULATION
1. >25.2mm: Wang-Koch AL adjustment, with Holladay1, Haigis , SRKT and HofferQ
PATIENT CONVERSATION
1. plano or a little bit of myopia
2. Decent chance of LASIK enhancement if expecting spectacle independence
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
2017年1月6日 星期五
Cataract surgery in short eyes
Considerations for cataract surgery in short eyes
YES Connect, Eye World Oct, 2016
Speak to your patients, can help keep patients from holding their breath.
PRE-OP
Higher risk for suprachoroidal hemorrhage: AXL < 20mm, WTW<11mm,
Take a look at gonioscopy prior to dilation
INTRA-OP
1. The speculum is not placed too wide.
2. Low threshold to place a Malyugin ring
3. CCC carefully, incrreased anterior capsule convexity
4. Iris hook
5. Refill dispersive viscoelastic more oftenly
6. Avoid RA
IOL Calculation
1. Holladay 2 and Barrett Universal 2
2. Holladay 2 and Hoffer Q
EXTRA
1. Head a little higher with eye above the level of the chest
2. Avoid large pressure fluctuation
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
YES Connect, Eye World Oct, 2016
Speak to your patients, can help keep patients from holding their breath.
PRE-OP
Higher risk for suprachoroidal hemorrhage: AXL < 20mm, WTW<11mm,
Take a look at gonioscopy prior to dilation
INTRA-OP
1. The speculum is not placed too wide.
2. Low threshold to place a Malyugin ring
3. CCC carefully, incrreased anterior capsule convexity
4. Iris hook
5. Refill dispersive viscoelastic more oftenly
6. Avoid RA
IOL Calculation
1. Holladay 2 and Barrett Universal 2
2. Holladay 2 and Hoffer Q
EXTRA
1. Head a little higher with eye above the level of the chest
2. Avoid large pressure fluctuation
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
IFIS and Small pupils
IFIS and Small pupils
Eyeworld Oct, 2016
AT A GLANCE
1. Patients who have used tamsulosin may experience IFIS
2. Ask patients preoperatively about therir use of tamsulosin as well as the herb saw palmetto
3. Special dilating mixes can assist with dilation in eyes at risk for IFIS
4. Use devices like the Malyugin ring or iris hooks as necessary
DILATING MIXES
1. epinephrine + lidocaine in fortified BSS
formula:
a.) 0.025% Epi + 0.75% lido
2. preOp pladgets: 10% pheylephrine, 1% tropicamide, 2% cyclogyl and a NSAID
3. Inject a mix of 1.5% phenylephrine and 1% lidocaine
Shugarcaine
The recipe in whole cc quantities is 9 cc BSS Plus (Alcon), 3 cc 4% preservative-free lidocaine (Hospira) and 4 cc 1:1000 preservative-free, bisulfite-free epinephrine (American Regent).
If wishing to make up a small quantity, the easiest way is to draw up 1 cc of non-preserved, 4% lidocaine into 3 cc of BSS Plus, which makes 4 cc of regular Shugarcaine. Then discard 1 cc of this mixture (or use it for a case just requiring intracameral anesthetic) and draw 1 cc of the above specified 1:1000 epinephrine, which yields 4 cc of epi-Shugarcaine, enough for at least two cases.
1cc lido + 3cc BSS=Shugarcaine
Discard 1cc of mixture(Shugarcaine) then add 1 cc of epinephrine=epi-Shugarcaine
MALYUGIN RING
1. Insert: engage the scroll farthest away from you first and the two side ones
2. Remove: Use a second instrument to remove the ring, UNHOOK the DISTAL side first and work your way around in a circle
3. Remove the ring before removing the OVD
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
Eyeworld Oct, 2016
AT A GLANCE
1. Patients who have used tamsulosin may experience IFIS
2. Ask patients preoperatively about therir use of tamsulosin as well as the herb saw palmetto
3. Special dilating mixes can assist with dilation in eyes at risk for IFIS
4. Use devices like the Malyugin ring or iris hooks as necessary
DILATING MIXES
1. epinephrine + lidocaine in fortified BSS
formula:
a.) 0.025% Epi + 0.75% lido
2. preOp pladgets: 10% pheylephrine, 1% tropicamide, 2% cyclogyl and a NSAID
3. Inject a mix of 1.5% phenylephrine and 1% lidocaine
Shugarcaine
The recipe in whole cc quantities is 9 cc BSS Plus (Alcon), 3 cc 4% preservative-free lidocaine (Hospira) and 4 cc 1:1000 preservative-free, bisulfite-free epinephrine (American Regent).
If wishing to make up a small quantity, the easiest way is to draw up 1 cc of non-preserved, 4% lidocaine into 3 cc of BSS Plus, which makes 4 cc of regular Shugarcaine. Then discard 1 cc of this mixture (or use it for a case just requiring intracameral anesthetic) and draw 1 cc of the above specified 1:1000 epinephrine, which yields 4 cc of epi-Shugarcaine, enough for at least two cases.
1cc lido + 3cc BSS=Shugarcaine
Discard 1cc of mixture(Shugarcaine) then add 1 cc of epinephrine=epi-Shugarcaine
MALYUGIN RING
1. Insert: engage the scroll farthest away from you first and the two side ones
2. Remove: Use a second instrument to remove the ring, UNHOOK the DISTAL side first and work your way around in a circle
3. Remove the ring before removing the OVD
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
Soft Lenses
Soft Lenses
Eyeworld Oct, 2016
AT A GLANCE
1. CCC size of 5.0 to 5.5mm can still be ideal
2. Using a vacuum-based system can be particularly helpful
3. Be aware of the "bowl" effect
TECHNIQUE
1. CCC size 5.0 to 5.5mm
2. Prolapse the lens forward
3. Horizontal chop with Nagahara chopper
4. or Reverse chop technique using the Koch spatula
***5. The Key for soft lenses: achieve good hydrodissection and hydrodelineation
6. Supracapsular technique: by using initial hydrodissection and then keeping the cannula in the same location while you continue to slowly inject fluid.
DEALING WITH A "BOWL"
1. switch to the Koch spatula and perform a reverse chop
2. Performing a viscodissection of the epinuclear shell and removing its adhesion to the capsular bag
PATIENT SELECTIONS
be careful: high myopic patients
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
Eyeworld Oct, 2016
AT A GLANCE
1. CCC size of 5.0 to 5.5mm can still be ideal
2. Using a vacuum-based system can be particularly helpful
3. Be aware of the "bowl" effect
TECHNIQUE
1. CCC size 5.0 to 5.5mm
2. Prolapse the lens forward
3. Horizontal chop with Nagahara chopper
4. or Reverse chop technique using the Koch spatula
***5. The Key for soft lenses: achieve good hydrodissection and hydrodelineation
6. Supracapsular technique: by using initial hydrodissection and then keeping the cannula in the same location while you continue to slowly inject fluid.
DEALING WITH A "BOWL"
1. switch to the Koch spatula and perform a reverse chop
2. Performing a viscodissection of the epinuclear shell and removing its adhesion to the capsular bag
PATIENT SELECTIONS
be careful: high myopic patients
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
Post-vitrectomized eye
Post-vitrectomized eye
EyeWorld Oct, 2016
TIMING
If the patient develops a white cataract within a few weeks of the PPV: 99% an iatrogenic break of the PC=> high risk of the entire lens nucleus falling onto the retina
Wait at least 3 months after routine VT
PREOP EVALUATION
White opacities or plaques on the PC: points of weakness
Zonular instability: compare the ACD with noncontact biometry of the two eyes
INTRAOPERATIVE ADJUSTMENTS
1. Minimize the rotation of the lens
2. Remove the inner nuclear core by chopping
3. No hydrodissect
4. Low bottle height or infusion pressure
5. Large CCC
SETTING PT EXPECTATIONS
It is important to temper their expectations
**If a patient has a ERM, he may not have noticed distortions prior to cataract surgery.
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
EyeWorld Oct, 2016
TIMING
If the patient develops a white cataract within a few weeks of the PPV: 99% an iatrogenic break of the PC=> high risk of the entire lens nucleus falling onto the retina
Wait at least 3 months after routine VT
PREOP EVALUATION
White opacities or plaques on the PC: points of weakness
Zonular instability: compare the ACD with noncontact biometry of the two eyes
INTRAOPERATIVE ADJUSTMENTS
1. Minimize the rotation of the lens
2. Remove the inner nuclear core by chopping
3. No hydrodissect
4. Low bottle height or infusion pressure
5. Large CCC
SETTING PT EXPECTATIONS
It is important to temper their expectations
**If a patient has a ERM, he may not have noticed distortions prior to cataract surgery.
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
Capsule Rupture
Capsule Rupture
EyeWorld_Oct_2016
Signs:
pupil suddenly bouncing or snapping
increase or decrease in the AC depth
Momentary spider of the PC
Lenticular material suddenly stops coming to the phaco tip
FIRST of ALL:
Keep irrigating and have the OVD in the eye
THEN:
Compartmentalizing the eye prior to lens remnant removal
Use of triamcinolone
Approach to vitreous
1. Cut first, then I/A
2. CUT: highest cut rate
3. I/A: slow flow rate: peristaltic flow setting: 15 to 20
Vitrectomy approaches
pars plana: preferred with a risk of hemorrhage
Lens placement
three-piece IOL in the sulcus with capture of the optic inside
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
EyeWorld_Oct_2016
Signs:
pupil suddenly bouncing or snapping
increase or decrease in the AC depth
Momentary spider of the PC
Lenticular material suddenly stops coming to the phaco tip
FIRST of ALL:
Keep irrigating and have the OVD in the eye
THEN:
Compartmentalizing the eye prior to lens remnant removal
Use of triamcinolone
Approach to vitreous
1. Cut first, then I/A
2. CUT: highest cut rate
3. I/A: slow flow rate: peristaltic flow setting: 15 to 20
Vitrectomy approaches
pars plana: preferred with a risk of hemorrhage
Lens placement
three-piece IOL in the sulcus with capture of the optic inside
Dr. Yu-Hao Lin, MD
Deputy superintendent, Brand New Eye Clinic
http://www.eyeDrLin.tw
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