Minimizing Incisions and Maximizing Outcomes in Cataract Surgery appears at a moment in which cataract surgery is probably making the last evolution in technology and surgical practice, according to the postulates that Charles Kelman started in the early 70s. The progressive transition from the initial concept of small inicision cataract surgery, the development of more and more sophisticated technology to support the surgeon’s practice of the procedure, the development of intraocular lenses capable of correcting virtually all types of refractive errors, and the scientific knowledge available today on flidics, micromechanics, biomaterials, viscomaterials, and surgical instrument technology has made cataract surgery experience one of the greatest progressions and advances of a surgical technique throughout the history of medicine and surgery.
Cataract surgery at the moment is transforming into a practice in which minimal agressiveness and optimized outcomes are targeted and tried to achieve by surgeons. Better diagnostic technology, sophistication in calculation formulas for IOL implantation, better instruments for incisions, and deeper knowledge into the structure of the cornea and corneal optics, greater knowledge into issues related intraocular lens performance, the approach to solve pseudophakic presbyopia by multifocal or accommodative lenses are, among many others, issues that have been recently advancing cataract surgery toward its next stage.
Throughout this process, the history of cataract surgery has been related to the decrease in incision size. This is why an important part of this book is targeting biaxial microincisional surgery, which seems to be mandatory in the future evolution of cataract removal. Simplification of the procedure and separation of irrigation and aspiration seems to be related to better outcomes supported by current scientific evidence. This is possible, thanks to a better knowledge of the instrumentation, fluidics, use of ultrasound power, and indeed surgical knowledge and training. The development of new lenses capable of fitting through smaller incisions than those currently available seems to be a limit to the development of the technology. Today, we can precisely limit our capabilities for cataract removal to 1.6 mm and to 1.8 mm with IOL implantation. Throughout this book, the reader will be able to learn about the methods to achieve this benchmark of cataract surgery at this moment.
As we have already mentioned in our opinion, this book appears during the final stage of the evolution of cataract surgery as conceived today. We anticipate that sub 1 mm surgery will require new technologies, and especially, new IOL technology and biomaterials. Most probably, we are at the end of the revolution that was started by Charlie Kelman in the early 70s and in the next decade we shall start a new evolution toward new issues such as lens replacement through new biomaterials, new accommodating lenses, regenerating surgery, and new technologies to soften the cataract and to eliminate it through punctures rather than through incisions.
Contents
Introduction
1 The Transition Towards Smaller and Smaller Incisions
1.1 Micro-Coaxial Phacoemulsifi cation with Torsional Ultrasound
1.2 Transitioning to Bimanual MICS
1.3 0.7 mm Microincision Cataract Surgery
2 MICS Instrumentation
3 Evolution of Ultrasound Pumps and Fluidics and Ultrasound Power: From Standard Coaxial Towards the Minimal Incision Possible in Cataract Surgery
4 Coaxial Microincision Cataract Surgery Utilizing Non-Linear Ultrasonic Power: An Alternative to Bimanual Microincision Cataract Surgery
5 Technology Available
5.1 How to Better Use Fluidics with MICS
5.2 How to Use Power Modulation in MICS
5.3 MICS with Different Platforms
5.3.1 MICS with the Accurus Surgical System
5.3.2 Using the Alcon Infi niti and AMO Signature for MICS
5.3.3 Stellaris Vision Enhancement System
6 Surgical Technique – How to Perform a Smooth Transition
6.1 Pupil Dilation and Preoperative Preparation
6.2 Incisions
6.3 Thermodynamics
6.4 Using Ophthalmic Viscosurgical Devices with Smaller Incisions
6.5 Capsulorhexis
6.6 Hydrodissection and Hydrodelineation
6.7 Biaxial Microincision Cataract Surgery: Techniques and Sample Surgical Parameters
6.8 Biaxial Microincision Phacoemulsification: Transition, Techniques, and Advantages
6.9 BiMICS vs. CoMICS: Our Actual Technique (Bimanual Micro Cataract Surgery vs. Coaxial Micro Cataract Surgery)
6.10 Endophthalmitis Prevention
7 Biaxial Microincision Phacoemulsifi cation for Difficult and Challenging Cases
7.1 MICS in Special Cases: Incomplete Capsulorhexis
7.2 MICS in Special Cases (on CD): Vitreous Loss
7.3 How to Deal with Very Hard and Intumescent Cataracts
8 IOL Types and Implantation Techniques
8.1 MICS Intraocular Lenses
8.2 Implantation Techniques
8.3 Special Lenses
8.3.1 Toric Posterior Chamber Intraocular Lenses in Cataract Surgery and Refractive Lens Exchange
8.3.2 Special Lenses: MF
8.3.3 Special Lenses: Aspheric
8.3.4 Intraocular Lenses to Restore and Preserve Vision Following Cataract Surgery
8.3.5 Microincision Intraocular Lenses: Others
9 Outcomes
9.1 Safety: MICS versus Coaxial Phaco
9.2 Control of Corneal Astigmatism and Aberrations
9.3 Corneal Endothelium and Other Safety Issues
9.4 Incision Quality in MICS
Cataract surgery at the moment is transforming into a practice in which minimal agressiveness and optimized outcomes are targeted and tried to achieve by surgeons. Better diagnostic technology, sophistication in calculation formulas for IOL implantation, better instruments for incisions, and deeper knowledge into the structure of the cornea and corneal optics, greater knowledge into issues related intraocular lens performance, the approach to solve pseudophakic presbyopia by multifocal or accommodative lenses are, among many others, issues that have been recently advancing cataract surgery toward its next stage.
Throughout this process, the history of cataract surgery has been related to the decrease in incision size. This is why an important part of this book is targeting biaxial microincisional surgery, which seems to be mandatory in the future evolution of cataract removal. Simplification of the procedure and separation of irrigation and aspiration seems to be related to better outcomes supported by current scientific evidence. This is possible, thanks to a better knowledge of the instrumentation, fluidics, use of ultrasound power, and indeed surgical knowledge and training. The development of new lenses capable of fitting through smaller incisions than those currently available seems to be a limit to the development of the technology. Today, we can precisely limit our capabilities for cataract removal to 1.6 mm and to 1.8 mm with IOL implantation. Throughout this book, the reader will be able to learn about the methods to achieve this benchmark of cataract surgery at this moment.
As we have already mentioned in our opinion, this book appears during the final stage of the evolution of cataract surgery as conceived today. We anticipate that sub 1 mm surgery will require new technologies, and especially, new IOL technology and biomaterials. Most probably, we are at the end of the revolution that was started by Charlie Kelman in the early 70s and in the next decade we shall start a new evolution toward new issues such as lens replacement through new biomaterials, new accommodating lenses, regenerating surgery, and new technologies to soften the cataract and to eliminate it through punctures rather than through incisions.
Contents
Introduction
1 The Transition Towards Smaller and Smaller Incisions
1.1 Micro-Coaxial Phacoemulsifi cation with Torsional Ultrasound
1.2 Transitioning to Bimanual MICS
1.3 0.7 mm Microincision Cataract Surgery
2 MICS Instrumentation
3 Evolution of Ultrasound Pumps and Fluidics and Ultrasound Power: From Standard Coaxial Towards the Minimal Incision Possible in Cataract Surgery
4 Coaxial Microincision Cataract Surgery Utilizing Non-Linear Ultrasonic Power: An Alternative to Bimanual Microincision Cataract Surgery
5 Technology Available
5.1 How to Better Use Fluidics with MICS
5.2 How to Use Power Modulation in MICS
5.3 MICS with Different Platforms
5.3.1 MICS with the Accurus Surgical System
5.3.2 Using the Alcon Infi niti and AMO Signature for MICS
5.3.3 Stellaris Vision Enhancement System
6 Surgical Technique – How to Perform a Smooth Transition
6.1 Pupil Dilation and Preoperative Preparation
6.2 Incisions
6.3 Thermodynamics
6.4 Using Ophthalmic Viscosurgical Devices with Smaller Incisions
6.5 Capsulorhexis
6.6 Hydrodissection and Hydrodelineation
6.7 Biaxial Microincision Cataract Surgery: Techniques and Sample Surgical Parameters
6.8 Biaxial Microincision Phacoemulsification: Transition, Techniques, and Advantages
6.9 BiMICS vs. CoMICS: Our Actual Technique (Bimanual Micro Cataract Surgery vs. Coaxial Micro Cataract Surgery)
6.10 Endophthalmitis Prevention
7 Biaxial Microincision Phacoemulsifi cation for Difficult and Challenging Cases
7.1 MICS in Special Cases: Incomplete Capsulorhexis
7.2 MICS in Special Cases (on CD): Vitreous Loss
7.3 How to Deal with Very Hard and Intumescent Cataracts
8 IOL Types and Implantation Techniques
8.1 MICS Intraocular Lenses
8.2 Implantation Techniques
8.3 Special Lenses
8.3.1 Toric Posterior Chamber Intraocular Lenses in Cataract Surgery and Refractive Lens Exchange
8.3.2 Special Lenses: MF
8.3.3 Special Lenses: Aspheric
8.3.4 Intraocular Lenses to Restore and Preserve Vision Following Cataract Surgery
8.3.5 Microincision Intraocular Lenses: Others
9 Outcomes
9.1 Safety: MICS versus Coaxial Phaco
9.2 Control of Corneal Astigmatism and Aberrations
9.3 Corneal Endothelium and Other Safety Issues
9.4 Incision Quality in MICS