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Ophthalmic Surgery—The Cutting Edge
Sandeep Saxena
SECTION 1:
1:
Anesthesia in Ophthalmology
INTRODUCTION
Features
GENERAL ANESTHESIA
Indications
Stages
Stage I
Stage II
Stage III
Stage IV
Technique
Premedication
Induction
Endotracheal Intubation
Maintenance
Extubation
Recovery
Special Considerations
Diabetes
Hypertension
Intraocular Pressure Maintenance
Complications
Hyperthermia
Oculocardiac Reflex
LOCAL ANESTHESIA
Topical Anesthesia
Advantages
Intracameral Anesthesia
Anesthesia by Orbital Injection
Parabulbar Anesthesia
Peribulbar Anesthesia
Retrobulbar Anesthesia
Regional Blocks
Facial Nerve Block
Adjuvants of Anesthetic Agents
Vasoconstrictor
Hyaluronidase
pH alteration
SPECIAL CONDITIONS
Anesthesia in Children
Anesthesia for Vitreoretinal Surgery
Anesthesia for Lacrimal Surgery
SECTION 2:
2:
Corneal and Refractive Surgery
CORNEAL TRAUMA
Assessment of the Eye
Surgical Principles
Penetrating Trauma—Management
Perforating Trauma—Management
Outcomes of Corneal Trauma Management
PTERYGIUM SURGERY
Indications for Surgery
Problems with Assessment of Surgical Outcomes after Pterygium Surgery
Bare Sclera Excision
Adjuncts to Bare Sclera Excision
Conjunctival and Amniotic Membrane Grafting
PENETRATING KERATOPLASTY
Indications and Patient Assessment
Contraindications
Surgical Technique
Postoperative Care
Therapeutic Penetrating Keratoplasty
Total Corneoscleral Transplantation
Future Directions
ANTERIOR LAMELLAR CORNEAL REPLACEMENT
Rationale
Direct Surgical Dissection
Injection to Separate Descemet's Membrane
Closed Dissection Using Spatulated Dissectors
Donor Preparation
DEEP LAMELLAR ENDOTHELIAL KERATOPLASTY
Microkeratome Flap-Assisted Deep Lamellar Endothelial Keratoplasty
Large Incision Deep Lamellar Endothelial Keratoplasty
Small Incision Deep Lamellar Endothelial Keratoplasty
Results
CORNEAL TRANSPLANTATION—AUTOGRAFTS
Rationale
Types
Ipsilateral Non-rotational Autografts
Ipsilateral Rotational Autografts
Contralateral Autografts
LIMBAL STEM CELL TRANSPLANTATION
Limbal Stem Cell
Stem Cell Dysfunction
Correction of Limbal Stem Cell Dysfunction
Surgical Procedures
Limbal Autografting
Live-related Limbal Allograft
Cadaver Limbal Allografting
Experience With Ex Vivo Stem Cell Cultivation
Future Directions
AMNIOTIC MEMBRANE TRANSPLANTATION
History of Amniotic Membrane use
Properties of the Membrane
Preparation and Storage
Surgical Technique
Review of Current Indications
Cornea
Conjunctiva
Sclera
Eyelid
OCULAR SURFACE RECONSTRUCTION
Ocular Surface
Lid and Tear function
Conjunctiva and Sclera
Corneal Surface
Keratoprosthesis
Future Prospects
PUNCTAL OCCLUSION
Tear Function and Drainage
Indications
Approaches
Surgical Technique
Complications
TECTONIC CORNEAL SURGERY
Limbal Fistula and Bleb Repair
Corneal Perforations
Band-Shaped Keratopathy
Anterior Stromal Puncture
Conjunctival Hooding
Epithelial Inclusion Cysts
Surface Inclusion Cysts
Intracorneal Inclusion Cysts
Intraocular Inclusion Cyst
CORNEAL REFRACTIVE SURGERY
Basics of Surgical Corneal Reprofiling
Photorefractive and Phototherapeutic Keratectomy
Excimer Laser Phototherapeutic Keratectomy
Subepithelial Laser Keratectomy
Laser in Situ Keratomileusis (LASIK)
Technique and Complications
Customized Ablation
Conductive Keratoplasty and Presbyopia
3:
Diagnostic Evaluation in Glaucoma Surgery
INTRODUCTION
ULTRASOUND BIOMICROSCOPY
Principle
Uses of Ultrasound Biomicroscopy in Glaucoma Surgery
Preoperative Applications
Postoperative Applications
Filtration surgery
OPTICAL COHERENCE TOMOGRAPHY
Principle
Advantage
Uses of Optical Coherence Tomography in Glaucoma Surgery
Hypotonous Maculopathy
Cystoid Macular Edema
Retinal Nerve Fiber Layer Thickness Measurements
HIGH-SPEED CORNEAL AND ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRAPHY
SCANNING LASER POLARIMETER
CONFOCAL SCANNING LASER OPHTHALMOSCOPY
VISUAL FIELDS
4:
Glaucoma Surgery
APPLIED ANATOMY FOR GLAUCOMA SURGERY
Corneolimbal Junction
Sclerolimbal Junction
Blue Zone Transition
SURGICAL INSTRUMENTS FOR GLAUCOMA SURGERY
Kelly-Descemet Membrane Punch
Harms Trabeculotome
TRABECULECTOMY
Exposure of the Surgical Site
Conjunctival Flap Dissection
Limbus-based Flap
Fornix-based Flap
Use of Antimetabolites
Fashioning Scleral Flap
Removal of the Inner Block: Sclerectomy
Inner Block Removal with Scissors
Inner Block Removal with Descemet's Punch
Peripheral Iridectomy
Closure of the Scleral Flap
Conjunctival Closure
Limbus-based Flap
Fornix-based Flap
Technique
COMBINED CATARACT AND GLAUCOMA SURGERY: TECHNIQUES
Extracapsular Cataract Extraction Combined with Trabeculectomy
Preoperative Precautions
Intraoperative Procedure
Precaution
Extracapsular Cataract Extraction: Variations
Phacoemulsification Combined with Trabeculectomy
Phacoemulsification Combined with Trabeculectomy: Variations
Blumenthal Surgery Combined with Trabeculectomy
WOUND MODULATION
Antimetabolites
Mitomycin-C
Complications
Dose and Duration of Mitomycin-C Application
Subconjunctival Injection
5-Fluorouracil
Fluorouracil Filtering Surgery Study
Releasable Sutures
Technique
Modifications
Argon Laser Suturelysis
GLAUCOMA IMPLANTS
Indications
Choice of Implant
Surgical Technique
Other Modifications in Implant Surgery for Glaucoma
Implant Specific Instructions
Molteno Implant
Baerveldt Implant
Postoperative Care for Modification of Intraocular Pressure in Implant Surgery
Complications
EXTERNAL TRABECULOTOMY
PROCEDURES RELATED TO COMPLICATIONS FOLLOWING TRABECULECTOMY
Prevention of Complications
Intraoperative Complications
Anesthesia Related
Traction Sutures
Conjunctival Complications
Scleral Flap Complications
Suprachoroidal Hemorrhage
Hyphema
Early Postoperative Complications (Day 2–6 Weeks)
Low Intraocular Pressure with Shallow Anterior Chamber
Elevated Intraocular Pressure with Shallow Anterior Chamber
Elevated Intraocular Pressure with Normal Anterior Chamber
Late Complications
Bleb Leak
Bleb-related Ocular Infection
Blebesthesia
VISCOCANALOSTOMY
SUCCESS RATES FOR GLAUCOMA SURGERY
5:
Advances in Phacoemulsification Technology and Instrumentation
INTRODUCTION
INTRAOCULAR LENS MATERIALS AND DESIGNS
Square Edge Effect
Intraocular Lens Haptics
Intraocular Lens Materials
Acrylate/methacrylate Polymer
Foldable intraocular lenses
Silicone Elastomers
Toric Intraocular Lens
Multifocal Lens Designs
INTRAOCULAR LENS IMPLANTATION TECHNIQUE
Implantation of Rigid Intraocular Lenses
Foldable Lens Delivery System
Folding and Implantation Forceps for Three-piece Foldable Intraocular Lenses
Implantation of Foldable Intraocular Lenses Using Folders and Forceps
Cartridge Injector System
INNOVATIONS IN PHACOEMULSIFICATION
Ultrasonic Handpiece
Mechanism of Phacoemulsification
Irrigation-Aspiration Handpiece
Aspiration Pump
Peristaltic Pump
Venturi Pump
Diaphragmatic Pump
Concentrix Pump
Burst and Pulse Mode Phaco
Burst Mode
Pulse Mode Phaco
Foot Pedal
Specifications of a Basic Model Phacomachine
PHACO TIPS
Types
Standard Phaco Tip
Kelman Tip
Microflow Tip
Microseal Tip
Masket Ergo Tip
Cobra Tip
Mackool Tip
Mackool-Kelman Tip
INSTRUMENTS USED FOR INCISIONS
PHACO CHOPPERS
Hydro Choppers
ENDOCAPSULAR RING
VISCOELASTIC SUBSTANCES
Properties of Viscoelastic Substances
Toxicity of Viscoelastics
FUTURE TRENDS IN PHACOEMULSIFICATION
PhacoNIT or Micro-Incision Cataract Surgery
Phacotmesis
Phaco Laser
Why Laser-Assisted Cataract Surgery
Cold Phaco
New Cold Phaco Technologies
Whitestar
Sonics versus Whitestar
Goals and Future Applications of Cold Phaco Technologies
A Pulsed Hot Water System
6:
Cataract Lens Implant Surgery, Ophthalmic Dyes, and Ophthalmic Viscosurgical Devices
RIGID AND FOLDABLE INTRAOCULAR LENSES FOR CATARACT SURGERY
Rigid and Soft Implants: Terminology, Biocompatibility, and Mechanical Properties
Implant Biocompatibility
Refractive Index
Mechanical Properties
Glass Transition Temperature
Surface Energy
Biomaterials, Designs of Rigid and Foldable Implants: Current Trends, Overview, and Future Applications
Cataract Surgery and Rigid Polymethylmethacrylate Implants
Cataract Surgery and Foldable Silicone Implants
Cataract Surgery and Hydrophilic Acrylic (Hydrogel) Implants
Cataract Surgery and Hydrophobic Acrylic Implants
Newly Introduced Implant Designs
INTRAOCULAR LENS OPACIFICATION
Delayed Opacification of Polymethylmethacrylate Intraocular Lens Optic Biomaterial: “Snowflake” or Crystalline Opacification
Clinicopathological Study of Explanted Lenses
Opacification of Foldable Hydrophilic Acrylic Lenses
Clinicopathological Analyses
Late Postoperative Opacification of CibaVision Memory® Lens
Opacification of the Silicone Lenses
Prevention and Treatment
POSTERIOR CAPSULE OPACIFICATION
Reasons to Eradicate Posterior Capsule Opacification
Etiopathogenesis
Lens Epithelial Cells Proliferation: Role of Growth Factors
Clinical Manifestations and Treatment
Surgical and Implant Related Factors for Prevention of Posterior Capsule Opacification
Confirmation of Surgical and Implant Related Factors in the Laboratory and Clinical Studies
Laboratory Analysis of Nd: YAG Posterior Capsulotomy Rates in Pseudophakic Human Eyes Obtained Postmortem
Confirmation of the Six Factors in Clinical Studies
Pharmacological Prevention of Posterior Capsule Opacification
Sealed Capsule Irrigation for Maintaining Postoperative Capsular Bag Transparency
Modulation of the Lens Epithelial Cells
Removal of Lens Epithelial Cells using AquaLase® Liquefaction Device
ANTERIOR CAPSULE STAINING FOR CATARACT SURGERY
How to Achieve Capsulorhexis in the Absence of Red Reflex?
Dye-assisted Anterior Capsulorhexis
Surgical Techniques
Safety and Efficacy
Guidelines and Recommendations for Surgeons
INTRODUCTION
CLASSIFICATION OF THE OPHTHALMIC VISCOSURGICAL DEVICES
High Viscosity Cohesive Ophthalmic Viscosurgical Devices
Superviscous-Cohesive Ophthalmic Viscosurgical Devices
Lower Viscosity-dispersive Ophthalmic Viscosurgical Devices
Soft Shell Technique
Viscoadaptive Ophthalmic Viscosurgical Device—Healon-5®
Characteristics and Advantages of the Viscoadaptive Ophthalmic Viscosurgical Devices
SURGICAL APPLICATION OF THE OPHTHALMIC VISCOSURGICAL DEVICES
Capsulorhexis
Cleavage of Lens Structure
Nuclear Emulsification
Irrigation and Aspiration
Capsular Bag Filling and Intraocular Lens Implantation
Cataract Surgery in Pediatric Cases
USE OF THE OPHTHALMIC VISCOSURGICAL DEVICES IN GLAUCOMA SURGERY
Viscocanalostomy
OPHTHALMIC VISCOSURGICAL DEVICES FOR INTRAOCULAR DELIVERY OF DYES OR ANESTHETIC AGENTS
Viscostaining of the Anterior Lens Capsule
Use of Ophthalmic Viscosurgical Devices in Topical Ophthalmic Anesthesia (Viscoanesthesia)
REMOVAL OF THE OPHTHALMIC VISCOSURGICAL DEVICES
COMPLICATIONS OF OPHTHALMIC VISCOSURGICAL DEVICES
Increase in Intraocular Pressure
Crystallization on the Intraocular Lens Surfaces
Capsular Block Syndrome or Capsular Bag Distension Syndrome
Pseudoanterior Uveitis
7:
Phacoemulsification
INTRODUCTION
LENS HARDNESS GRADING SYSTEM IN CATARACT
Lens Opacities Classification Systems
ANESTHESIA
Topical Anesthesia
Intracameral Anesthesia
Technique
Bloomberg Supernumb Anesthetic Ring
Deep Topical Nerve Block Anesthesia
Lignocaine Jelly
CATARACT INCISION
Side Port Entry
Scleral Flap Incisions
Different Types of Scleral Incisions
Corneal Valve Incision
Technique
Limbal Incision
Wound Architecture
Temporal Limbal Incision
Hinge Incisions
CAPSULORHEXIS
Mechanics
Tearing by Stretching
Tearing by Shearing
Special Circumstances
Intumescent Cataract
Milky White Cataract
HYDROPROCEDURES
Terminology and Classification
Technique of Hydrodissection and Hydrodelineation
Hydrodissection
Hydrodelineation
NUCLEOFRACTIS TECHNIQUES
Principles of Phacoemulsification
Isolation of Phacoemulsification Tip into Manipulation, Cutting and Suction
Nuclear Rotation
Nuclear Segmentation
Nuclear Fragment Removal
ENDOCAPSULAR PHACOEMULSIFICATION
Endocapsular Phacoemulsification without Nuclear Cleavage
Endocapsular Phacoemulsification with Nucleus Cleavage
Chip and Flip Phacoemulsification
Spring Surgery
ENDOCAPSULAR EMULSIFICATION TECHNIQUES WITH NUCLEUS CRACKING
Phacoemulsification by Divide and Conquer
Four-Quadrant Cracking
Technique
Fractional 2:4 Phaco
Cracking the Nucleus
Crater Divide and Conquer
V-Style
Down Slope Sculpting
Phaco-Sweep
Multidirectional Divide and Conquer Technique
Phaco Chop
Stop and Chop
Modification of Stop and Chop
Quick Chop
Prerequisite
Autocrack Chop
Choo-Choo Chop and Flip Phacoemulsification
Petalloid Phacoemulsification
Akahoshi Pre-Chopping Technique
EPINUCLEUS MANAGEMENT
CORTICAL CLEAN UP
FOLDABLE LENS INSERTION
Technique
COMPLICATIONS AND MANAGEMENT
Wound Construction
Hyphema
Anterior Capsulotomy
Corneal Complications
Iris Injury
Vitreous Loss
Conversion to Extracapsular Cataract Extraction
CHALLENGING SITUATIONS
Intraocular Lens Power Calculation after Refractive Surgery
Clinical History Method
Contact Lens Method
Intraocular Lens Power Calculation in Corneal Transplant Eyes
Hard Nucleus
The Central Flip
Other Technique
Phaco in White and Black Cataracts
White Cataract
Black Cataract
Subluxated Lens
Preoperative Evaluation
Anesthesia
Incision
Capsulorhexis
Hydrodissection
Implantation of the Capsular Ring
Phacoemulsification Technique
Cortical Aspiration
Implantation of Intraocular Lenses
Small Pupil
Postvitreoretinal Surgery
SECONDARY INTRAOCULAR LENS IMPLANTATION
8:
Phakonit (Bimanual Microphacoemulsification)
INTRODUCTION
TERMINOLOGY
Synonyms
TECHNIQUE OF PHAKONIT
Incision
Capsulorhexis
Hydrodissection
Phakonit
ANTICHAMBER COLLAPSER
THINOPTX ROLLABLE INTRAOCULAR LENS
Lens Insertion Technique
Topography
ACRI.TEC INTRAOCULAR LENS
Lens Loading Technique
Lens Insertion Technique
THREE-PORT PHAKONIT
9:
Small Incision Cataract Surgery
INTRODUCTION
ADVANCES IN CATARACT SURGERY
Lens Removal Techniques
Intraocular Lens Designs
Incision Site, Design and Size
THE TECHNIQUE OF SMALL INCISION CATARACT SURGERY
The incision
Problems during Wound Construction
Capsulotomy
The Hydroprocedures
Hydrodissection
Hydrodelineation
Nucleus Prolapse
Nucleus Delivery
Other Options for Nucleus Delivery
Problems in Nucleus Delivery
Delivery of the Epinucleus and Cortex Aspiration
Intraocular Lens Implantation
Wound Closure
PRACTICAL TIPS FOR BEGINNERS
THE FUTURE
Advantages of Small Incision Cataract Surgery
Advantages of Small Incision Cataract Surgery over Extracapsular Cataract Surgery
Advantages of Small Incision Cataract Surgery over Phacoemulsification
Advantages of Phacoemulsification
Disadvantages of Phacoemulsification
SMALL INCISION CATARACT SURGERY: THE FISHHOOK TECHNIQUE
Small Incision Cataract Surgical Techniques
The Fishhook Technique
Tunnel Construction
Capsulotomy
Hydrodissection and Nucleus Extraction
Completing the Surgery
Outcome
Transition from Sutured to Sutureless Cataract Surgery
Stepwise Approach
10:
Principles and Paradigms of Pediatric CataractSurgery and Intraocular Lens Implantation
INTRODUCTION
DIAGNOSIS OF PEDIATRIC CATARACTS
CATARACT SURGERY IN CHILDREN
How Does Pediatric Cataract Surgery Differ from Adult?
Indications for Treatment
Optical Rehabilitation
Aphakic Glasses
Contact Lenses
Epikeratophakia
Intraocular Lens Implantation
WHY ARE INTRAOCULAR LENSES PREFERRED FOR PEDIATRIC CATARACT SURGERY?
IS INTRAOCULAR LENS IMPLANTATION FEASIBLE FOR INFANTILE CATARACTS?
INTRAOCULAR LENS POWER SELECTION
HOW IMPORTANT IS INTRAOCULAR LENS SIZING?
Types of Intraocular Lenses
Guidelines
Changes in Ocular and Refractive Growth
SURGICAL TECHNIQUES
Historical Perspective
Anesthesia
Wound Construction
Viscoelastic Substances
Anterior Capsule Management
Manual Continuous Curvilinear Capsulorhexis
Modified Continuous Curvilinear Capsulorhexis Technique in a Rabbit Model
Small Peripheral Anterior Capsulorhexis in a Rabbit Model
How to Create an Intact Manual Capsulorhexis in Pediatric Eyes?
Can-opener Anterior Capsulotomy
Vitrector-cut Anterior Capsulectomy (Vitrectorhexis)
How to Create a Successful Vitrectorhexis in Pediatric Eyes?
Bipolar Radiofrequency Capsulotomy
Fugo Plasma Blade™ Anterior Capsulotomy
Lens Substance Removal
Primary Intraocular Lens Implantation
Secondary Intraocular Lens Implantation
Management of the Posterior Capsule
Primary Posterior Capsulotomy and Anterior Vitrectomy
Posterior Capsulorhexis with Intraocular Lens Optic Capture
Neodymium (Nd): YAG Laser Posterior Capsulotomy
Options for Primary Posterior Capsulotomy
DYE-ENHANCED PEDIATRIC CATARACT SURGERY
PEDIATRIC TRAUMATIC CATARACTS AND THEIR MANAGEMENT
Epidemiology and Etiology
Surgical Management
Visual Results and Postoperative Complications
Perioperative and Postoperative Treatment
Postoperative Complications and Management
Early Onset
Intermediate/Late Onset
RESIDUAL REFRACTIVE ERROR
Piggyback Foldable Intraocular Lenses in Infants
Management of Amblyopia
11:
Surgery in Uveitis
INTRODUCTION
CATARACT SURGERY IN UVEITIS
Indications for Cataract Surgery
Visual Rehabilitation
Therapeutic Indication
Preoperative Evaluation
Establishing the Diagnosis
Timing of Surgery
Predicting the Outcome
Preoperative Management
Surgical Considerations
Phacoemulsification versus Extracapsular Cataract Extraction
Pars Plana Approach
Problems Specific to the Uveitic Patient and their Management
Selection of the Intraocular Lens
Patient Selection
Intraocular Lens Material and Biocompatibility
Determinants
Current Thinking
Postoperative Care
Postoperative Complications
Excessive Inflammation
Intraocular Pressure
Cystoid Macular Edema
Posterior Capsular Opacification
Anterior Capsular Opacification
Summary of Present Recommendations for Cataract Surgery in Patients of Uveitis
Principles
VITRECTOMY FOR UVEITIS
Classification
Diagnostic Pars Plana Vitrectomy
Indications
Preoperative Preparation
Preoperative Counseling
Surgical Technique
Anterior Segment Tap/Paracentesis
Vitreous Tap/Aspiration
Vitreous Biopsy
Chorioretinal Biopsy
12:
Implications of Diagnostic Tests in Posterior Segment Surgery
INTRODUCTION
OPTICAL COHERENCE TOMOGRAPHY
Macular Hole
Patterns
Epiretinal Membrane
Classification
Surgical Implications
Vitreomacular Traction
Patterns
Surgical Implications
Macular Edema
Surgical Implications
B-SCAN ULTRASONOGRAPHY
Vitreous Hemorrhage
Advantages
Endophthalmitis
Implications
Ocular Trauma
Clinical Implications
FUNDUS FLUORESCEIN ANGIOGRAPHY AND INDOCYANINE GREEN ANGIOGRAPHY
Significance
Prognostic Implications
ELECTROPHYSIOLOGICAL TESTS
ULTRASOUND BIOMICROSCOPY
Surgical Implications
13:
Advances in Vitreoretinal Surgery
WIDE-ANGLE VIEWING SYSTEMS
Optics of Conventional Vitreous Surgery
Contact Wide-angle Viewing Systems
Non-contact Wide-angle Viewing Systems
Binocular Indirect Ophthalmomicroscope and Stereoscopic Diagonal Inverter (BIOM/SDI)
EIBOS Wide Field Non-contact Viewing System
Ocular WFVS/P-W-L Wide Field Non-contact Viewing System
VITREORETINAL ENDOSCOPE
HI-SPEED VITREOUS CUTTING
25-GAUGE TRANSCONJUNCTIVAL SUTURELESS VITRECTOMY
RETINAL PROSTHESIS
VIRTUAL-REALITY VITREOUS SURGERY SIMULATOR
VITREORETINAL ERBIUM: YAG LASER SCALPEL
14:
Laser in Posterior Segment Disorders
INTRODUCTION
LASER TREATMENT IN CHOROIDAL NEOVASCULAR MEMBRANES
Choroidal Neovascularization in Age-related Macular Degeneration
Conventional (Direct) Laser Treatment
Photodynamic Therapy
Transpupillary Thermotherapy
Feeder Vessel Treatment
Trans-scleral Diode Laser Photocoagulation
Choroidal Neovascularization from Non-Age-Related Macular Degeneration
Etiology
Parafoveal Telengiectasis
Osseous Choristoma
Myopia
Choroidal Rupture
Angioid Streaks
Idiopathic Polypoidal Choroidal Vasculopathy
Retinal Angiomatous Proliferation
PROPHYLACTIC LASER FOR DRUSEN
LASERS IN DIABETIC RETINOPATHY
Focal and Grid Laser in Diabetic Maculopathy
Technique
Focal laser photocoagulation
Grid laser photocoagulation
Subthreshold Diode Laser in Diabetic Macular Edema
Scatter Laser in Diabetic Retinopathy
Technique98
LASERS IN RETINAL VENOUS OCCLUSION
Management of Branch Retinal Vein Occlusion (Branch Vein Occlusion Study Recommendations)
Management of Central Retinal Vein Occlusion (Central Vein Occlusion Study Recommendations)
Laser Induced Chorioretinal Anastomosis
LASER IN CENTRAL SEROUS RETINOPATHY
LASERS IN RETINAL LESIONS PREDISPOSING TO DETACHMENT AND RETINAL TEARS
High-risk Characteristics
LASERS IN RETINAL DETACHMENT: PROPHYLACTIC/DELIMITING
LASERS IN INFLAMMATORY DISEASES
Post-vasculitis Retinal Proliferation
Laser in Intermediate Uveitis
Laser in Idiopathic Retinal Vasculitis, Aneurysms and Neuroretinitis
LASER IN OPTIC DISC PIT
LASER IN RETINAL VASCULAR ANOMALIES
Retinal Artery Macroaneurysm
Coats' Disease
Retinal Capillary Hemangioma
LASER IN CHOROIDAL TUMORS
Choroidal Hemangioma
Laser Photocoagulation for Choroidal Melanomas
LASER IN RETINOPATHY OF PREMATURITY
MISCELLANEOUS PROCEDURES
YAG Laser Hyaloidotomy
Recommendations
Procedures to Improve Posterior Segment Visualization
YAG Laser Capsulotomy
Neodymium: YAG Sweeping
Coreoplasty
Technique
Nd: YAG Vitreolysis
15:
Surgical Management of Vitreoretinal Diseases
INTRODUCTION
SYMPTOMATOLOGY
CLINICAL FEATURES
Retinal Break
Traction–related Tears
Other Features
EVALUATION
Identifying the Retinal Break
Rules
DIAGNOSIS
Differential Diagnosis
MANAGEMENT
COMMON METHOD OF RETINAL REATTACHMENT
Scleral Buckling
Localization of the Retinal Break
The Buckle
Subretinal Fluid Drainage
Indications for drainage
Complications of Scleral Buckling
Intraoperative complications
Early postoperative complications
Late postoperative complications
ALTERNATE METHODS OF RETINAL REATTACHMENT
Pneumatic Retinopexy
Principle
Indications
Contraindications
Surgical Technique
Follow-Up
Complications
Balloon Buckle
Absorbable Buckling Materials
Primary Vitrectomy for Rhegmatogenous Retinal Detachment
Revision Surgery
Approach to Management of Recurrent/Persistent Retinal Detachment
RESULTS OF SCLERAL BUCKLING AND PNEUMATIC RETINOPEXY
Scleral Buckling
Anatomical Results
Visual Results
Pneumatic Retinopexy
DEFINITION
CLASSIFICATION
PATHOGENESIS
Information from Clinical Studies
Information from Basic Studies
PATHOLOGY
MANAGEMENT
Surgical Management of Rhegmatogenous Retinal Detachment with Proliferative Vitreoretinopathy
Do All the Cases of Rhegmatogenous Retinal Detachment with Proliferative Vitreoretinopathy Need Vitrectomy?
When to Operate in an Eye with Proliferative Vitreoretinopathy?
Role of Buckle along with Vitrectomy
Role of Lens Sacrifice
Advantages of Lens Removal
Disadvantages of Lens Removal
Procedure of Lens Removal
Role of Intraocular Lens Sacrifice
Extent of Vitrectomy
Membrane Peeling Techniques
Subretinal Band Removal
Role of Retinotomies and Retinectomies
Retinal Reattachment
Uses of Perfluorocarbon Liquids
Retinopexy
Choice of Tamponade
Silicone Oil Removal
Results
RECENT INNOVATIONS IN THE MANAGEMENT OF PROLIFERATIVE VITREORETINOPATHY
Endoscopic Surgery
Erbium: YAG Laser Vitrectomy
Pharmacological Modulation
INTRODUCTION
ETIOLOGY
CLINICAL PRESENTATION
Variables
MANAGEMENT
Technique of Scleral Buckling
Vitreoretinal Surgery
Management of Inverted Flap
Present Technique
Choice of Visualization System
Surgical Technique
Lens Management
Intraocular Lens Management
Management of Edge of Tear
Management of the Anterior Flap
Management of Proliferative Vitreoretinopathy
Role of Perfluorocarbon Liquids
Retinal Reattachment
Technique of Air Fluid/Air Perfluorocarbon Liquid and Silicone Oil Fluid/Silicone Oil Perfluorocarbon Liquid Exchange
Retinopexy
Role of Peripheral Buckle
Iridectomy
Postoperative Positioning
Recurrent Retinal Detachment
Silicone Oil Removal
Fellow Eyes with Giant Retinal Tear
INTRODUCTION
CLINICAL SCENARIO
Dislocated Crystalline Lens
Clinical Evaluation
Management Options
Dislocated Nucleus/Lens Fragments/Cortex
Subsequent Management
Surgical Management
Dislocated Intraocular Lens
Management
INTRODUCTION
CLINICAL PRESENTATION
Postoperative Endophthalmitis
Time of Onset
Symptomatology
Signs
Endogenous Endophthalmitis
Traumatic Endophthalmitis
Bleb-Related Endophthalmitis
Corneal Involvement with Endophthalmitis
Panophthalmitis
ULTRASONOGRAPHIC FEATURES OF ENDOPHTHALMITIS
MANAGEMENT
Diagnosis
Microbiological Investigations
Specimens for Processing
Collection of Specimens
Processing of the Specimens
Interpretation
Medical Therapy
Route of Administration
Choice of Antibiotics
Vitrectomy
Indication for Vitrectomy
Surgical Procedure
Management of the Intraocular Lens
Procedure for Removal of Intraocular Lens
Management in the Presence of Corneal Involvement
Cases with Retinal Detachment on Ultrasonography
Second Intervention
Complications
Prognosis
Routine Antiseptic Measures that can Reduce the Occurrence of Postoperative Infections
Intravitreal Drug Dosage and Formulation
IMPORTANT MESSAGES FROM THE ENDOPHTHALMITIS VITRECTOMY STUDY
INTRODUCTION
ETIOPATHOGENESIS
INTERNATIONAL CLASSIFICATION OF RETINOPATHY OF PREMATURITY
Stages
Stage 1. Demarcation Line
Stage 2. Ridge Formation
Stage 3. Extra Retinal Proliferation
Stage 4. Partial Retinal Detachment
Stage 5. Total Retinal Detachment
EXAMINATION PROTOCOL
Examination Procedure
TREATMENT
Treatment of Threshold Disease
Technique of Laser Therapy
Technique of Cryotherapy
Effect of Treatment
Sequelae of Regressed Retinopathy of Prematurity
Treatment of Retinal Detachment
Scleral Buckling
Vitreoretinal Surgery
RESULTS
INTRODUCTION
PATHOLOGY
Configurations
The Concept of Vitreoschisis and Second Membrane
Tractional Retinoschisis
Other Factors
SURGICAL MANAGEMENT
Indications for Vitrectomy
Contraindications
Surgical Procedure
Intraoperative Complications
Postoperative Complications
RESULTS
INTRODUCTION
CENTRAL RETINAL VEIN OCCLUSION
Radial Optic Neurotomy
BRANCH RETINAL VEIN OCCLUSION
Sheathotomy
INTRODUCTION
CLINICAL PICTURE
EVALUATION
Ultrasonography
Radiology
MANAGEMENT
Decision Regarding the Removal of the Intraocular Foreign Body
Decision Regarding the Timing of Surgery
Decision Regarding the Approach to Remove the Intraocular Foreign Body
SURGICAL PROCEDURE
Initial Steps
Management of the Lens
Vitrectomy
Role of Encircling Band
Difficulties:
RESULTS
16:
Macular and Submacular Surgery
EPIRETINAL MEMBRANE
Clinical Features
Natural History
Surgical Case Selection
Surgical Technique
Trypan Blue-assisted Epiretinal Membrane Removal
Indocyanine Green-assisted Epiretinal Membrane Removal
Complications
Results
Role of Optical Coherence Tomography
VITREOMACULAR TRACTION SYNDROME
Clinical Features
Natural History
Surgical Case Selection
Surgical Technique
Complications
Results
IDIOPATHIC MACULAR HOLE
Clinical Features
Natural History
Surgical Case Selection
Management
Internal Limiting Membrane Peeling
Rationale
Surgical Technique
Internal Limiting Membrane Peeling
Indocyanine Green-assisted Internal Limiting Membrane Peeling
Infracyanine Green-assisted Internal Limiting Membrane Peeling
Trypan Blue-assisted Internal Limiting Membrane Peeling
Triamcinolone-assisted Vitrectomy
Perfluorocarbon Liquid-assisted Internal Limiting Membrane Peeling in Macular Hole Associated with Detachment
Tamponade
Results
Impending Macular Holes
Stage II Macular Holes
Stages III and IV Macular Holes
Complications
Internal Limiting Membrane Peeling Complications
Miscellaneous
Role of Optical Coherence Tomography
SUBFOVEAL CHOROIDAL NEOVASCULARIZATION
Natural History
Management
Case Selection
Clinical Findings
Angiographic Findings
Instrumentation
Angled Subretinal Pic
Subretinal Infusion Cannula
Subretinal Forceps
Subretinal Scissors
Surgical Technique
Sclerotomy Site
Removal of Posterior Hyaloid
Retinotomy
Creation or Enhancement of Neurosensory Detachment
Removal of Neovascular Membrane
Complications
Postoperative Management
Adjuncts to Surgery
Subretinal Endophotocoagulation
Pharmacologic Therapy
Tissue Plasminogen Activator
Liquid Perfluorocarbons
Results
Selected Cases
Case 1
Case 2
Submacular Surgery Trial
SUBMACULAR HEMORRHAGE
Mechanism of Retinal Injury
Natural History
Management
Case Selection
Observation
Thermal Laser and Photodynamic Therapy
Vitrectomy with Mechanical Clot Extraction, without Tissue Plasminogen Activator (t-PA)
Vitrectomy with Clot Removal Following Subretinal Tissue Plasminogen Activator Injection
Pneumatic Displacement with or without Tissue Plasminogen Activator
Vitrectomy, Subretinal Injection of t-PA and Fluid-gas Exchange
Other Techniques
Special Considerations
Subretinal Hemorrhage in Other Clinical Conditions
Complications
Results
Clinical Characteristics
Rationale
Surgical Technique
Results
Vitrectomy for Diffuse Diabetic Macular Edema with Taut Posterior Hyaloid
Vitrectomy for Diffuse Diabetic Macular Edema without Taut Posterior Hyaloid
Vitrectomy with Internal Limiting Membrane Peeling
Triamcinolone-assisted Vitrectomy
Vitrectomy for Removal of Submacular Hard Exudates
Effect of Pre-operative Factors on Vitrectomy
Effect on Focal Macular Electroretinogram After Vitrectomy
Role of Plasmin in Vitrectomy
Complications
Role of Optical Coherence Tomography
Rationale
Indications
Terminology
Classification
Surgical Principles
Mechanisms for Foveal Displacement
Disinsertion of Retina from its Anterior Attachment
Redundancy of Retina Relative to Underlying Eyewall
Stretching of Retina
Pattern of Postoperative Retinal Displacement
Effective Macular Translocation
Estimation of Postoperative Foveal Displacement
LIMITED MACULAR TRANSLOCATION
Surgical Procedure
SURGICAL TECHNIQUES OF MACULAR TRANSLOCATION WITH 360-DEGREE RETINOTOMY
Visual Outcomes
Complications
17:
Management of Intraocular Tumors
ENUCLEATION
Preoperative Considerations
Anesthesia
Technique of Enucleation
Special Considerations
Retinoblastoma
Malignant Melanoma
Complications
CRYOTHERAPY
Special Considerations
Retinoblastoma
Retinal Angioma
Coat's Disease and Acquired Hemangioma of the Retina
Malignant Melanoma
Complications of Cryotherapy
PHOTOCOAGULATION
Special Considerations
Retinoblastoma
Choroidal Hemangioma
Retinal Angioma
Malignant Melanoma
PHOTODYNAMIC THERAPY
Special Considerations
Circumscribed Choroidal Hemangioma
Retinal Angioma
TRANSPUPILLARY THERMOTHERAPY
Special Considerations
Retinoblastoma
Uveal Melanomas
Choroidal Hemangioma
Retinal Angioma
Complications of Transpupillary Thermotherapy
BRACHYTHERAPY
Complications
Special Considerations
Retinoblastoma
Choroidal Hemangioma
EXTERNAL BEAM RADIATION THERAPY
Anterior Field Techniques
Lateral Field Techniques
Accurate Lens-sparing Technique (Utrecht Method)26
Choroidal Hemangioma
EXTERNAL BEAM PARTICLE RADIOTHERAPY
EYE WALL RESECTION
Anterior Segment Tumors
Iridectomy
Iridocyclectomy
Partial Lamellar Sclerouvectomy
Complications
INTERNAL RESECTION
Technique
Complications
FINE-NEEDLE ASPIRATION BIOPSY
Indications
Prerequisites
Materials
Procedure
Routes of Approach
Pars Plana Approach
Clear-Corneal Approach
Trans-scleral Approach
Limbal Approach
Specimen Handling
Complications
CHEMOTHERAPY
RETINOBLASTOMA
Genetics
Age at Diagnosis
Clinical Features
Classification
Histopathology
Rosettes
Fleurettes
Management of Retinoblastoma
Enucleation
Cryotherapy
Photocoagulation
External Beam Radiotherapy
Brachytherapy
Chemoreduction
Transpupillary Thermotherapy
Thermochemotherapy
Prognosis
MELANOCYTOMA
Melanocytoma of the Iris and Ciliary Body
Treatment of Iridociliary Melanocytoma
Optic Disc Melanocytoma
Differential Diagnosis
Complications
Treatment
CHOROIDAL HEMANGIOMA
Management
Results of Various Treatment Modalities in Choroidal Hemangioma
Laser Photocoagulation
Radiation
Transpupillary Thermotherapy
INTRAOCULAR METASTASIS
Management of the Metastatic Tumor
CHOROIDAL OSTEOMA
UVEAL MELANOMA
Predisposing Factors
Melanoma of the Iris
Diagnosis
Treatment
Ciliary Body Melanoma
Clinical Signs
Differential Diagnosis
Choroidal Melanoma
Differential Diagnosis
Pathophysiology and Prognosis of Uveal Melanoma
Diagnosis
Current Management of Malignant Melanoma of the Choroid
Factors
Treatment Modalities
Periodic Observation
Enucleation
Local Resection
Internal Resection
Photocoagulation
Radiotherapy
Brachytherapy
Transpupillary Thermotherapy
CAPILLARY HEMANGIOMA OF THE RETINA
Treatment
CAVERNOUS HEMANGIOMA OF THE RETINA
Ocular Features
RACEMOSE HEMANGIOMA
VASOPROLIFERATIVE TUMOR OF THE RETINA
PRIMARY INTRAOCULAR LYMPHOMA
Treatment
INTRAOCULAR LEUKEMIA
MEDULLOEPITHELIOMA
RETINAL ASTROCYTOMA
Systemic Associations
CONGENITAL HYPERTROPHY OF THE RETINAL PIGMENT EPITHELIUM
Multifocal Congenital Hypertrophy of the Retinal Pigment Epithelium
Associated Extraocular Findings
COMBINED HAMARTOMA OF THE RETINA AND RETINAL PIGMENT EPITHELIUM
Clinical Features
Histopathology
COATS' DISEASE
18:
Surgical Treatment of Strabismus
INTRODUCTION
AIMS OF STRABISMUS SURGERY
INDICATIONS FOR SURGERY
PATIENT EVALUATION
Objectives
Factors
ANATOMICAL CONSIDERATIONS
Extraocular Muscles
Fascial Coverings
Tenon's Capsule
Intermuscular Septum
Muscle Capsule
Check Ligaments
The Orbital Fat
Capsulopalpebral Fascia and Ligament of Lockwood
SURGICAL TECHNIQUES
Anesthesia
Exposure of the Muscle
Recti
Inferior Oblique
Superior Oblique
SURGICAL PROCEDURES
Weakening Operations
Recession
Marginal Myotomy
Tenotomy or Myectomy
Posterior Fixation Suture (Faden's Operation)
Botulinum Toxin to Weaken the Action of a Muscle
Strengthening Operations
Resection Operation
Combined Weakening-Strengthening Operations
Adjustable Sutures
Operations to Modify the Action of an Extraocular Muscle (Muscle Transposition Operations)
Paralytic Strabismus
Correction of A-V Patterns
Anteroplacement of Obliques
Use of Plastic Materials
AMOUNT OF OPERATION
Guidelines
Horizontal Deviations
Cyclovertical Deviations
PARALYTIC SQUINT
SPECIAL FORMS OF STRABISMUS
Suturing the Muscle to the Sclera
Closure of the Wound
POSTOPERATIVE CARE
COMPLICATIONS
Peroperative
Excessive Bleeding
Scleral Perforation
Lost Muscle
Oculocardiac Reflex
Anatomical Variations in the Extraocular Muscles
Postoperative
Overcorrections and Undercorrections
Diplopia
Decreased Muscle function
Infection
Allergic Reactions
Conjunctival Cysts
Corneal Dellen
Anterior Segment Ischemia
RESULTS
19:
Eyelid and Lacrimal Surgery
INTRODUCTION
GENERAL CONSIDERATIONS IN EYELID SURGERY
Asepsis
Perioperative Antibiotics
Anesthesia
Tissue Handling
Cautery
Placement of Surgical Incisions
Hemostasis
Wound Closure
Postoperative Care
PTOSIS SURGERY
Timing of Ptosis Surgery
Congenital Ptosis and Acquired Aponeurotic Ptosis
Mechanical and Neurogenic Ptosis
Traumatic and Myogenic Ptosis
Choice of Surgery for Congenital Ptosis
Choice of Surgery for Acquired Ptosis
Surgical Techniques
Fasanella-Servat Procedure
Levator Resection
Tarsofrontal Sling
Complications
EYELID RECONSTRUCTION
Anterior Lamellar Defects
Healing by Granulation
Primary Closure
Free Skin Graft
Myocutaneous Flaps
Full-Thickness Eyelid Defects
Small Defects (Pentagon Excision)
Moderate Defects (Tenzel's Semicircular Flap)
Large Defects (Cutler-Beard Procedure)
Stage I
Complications
ECTROPION
Choice of Surgery
Surgical Techniques
Full-thickness Skin Grafting
Lateral Tarsal Strip Procedure
Kuhnt-Szymanowski Procedure
Complications
ENTROPION
Congenital Entropion
Involutional Entropion
Jones Procedure
Cicatricial Entropion
Procedure of Tarsal Wedge Resection
Complications
BOTULINUM TOXIN IN CHEMODENERVATION
Pharmacology
Commercial Preparations
Toxin Reconstitution
Clinical Applications
Facial Dystonias
Chemotarsorrhaphy
Upper Eyelid Retraction
Lower Eyelid Senile Entropion
Facial Nerve Palsy and Aberrant Regeneration
Synkinetic Facial Movements
Lacrimal Gland Hypersecretion and Dry Eye
COSMETIC OCULOPLASTY
Migraine and Tension Headache
CONGENITAL LACRIMAL DISORDERS
Abnormalities of the Puncta and Canaliculi (Upper System Block)
Abnormalities of the Lacrimal Sac
Congenital Lacrimal Fistulas
Congenital Dacryocystocele (Amniotocele)
Neonatal Acute Dacryocystitis (Lacrimal Abscess)
Congenital Lacrimal Disorders in Craniofacial Anomalies
Congenital Nasolacrimal Duct Obstruction
Procedure of Probing
ACQUIRED LACRIMAL DISORDERS
Puncta and Canalicular Stenosis
Nasolacrimal Duct Stenosis
Technique of External Dacryocystorhinostomy
20:
Orbital Surgery
INTRODUCTION
BASICS OF ORBITAL IMAGING
Plain Radiography
B-scan Ultrasonography
Computed Tomography
Magnetic Resonance Imaging
ORBITAL BIOPSY
OPERATIVE PRINCIPLES OF ORBITAL SURGERY
Bloodless Field
Adequate Exposure and Visualization
Proper Instrumentation
Atraumatic Tissue Manipulation
Types of Orbitotomy
Anterior Orbitotomy
Lateral Orbitotomy
Superior Orbitotomy
SURGICAL APPROACHES TO THE ORBIT
Approach to the Anterior Orbit (Anterior Orbitotomy Techniques)
Transseptal Approach
Extraperiosteal Approach
Transconjunctival Approach
Approach to the Deep Medial Orbit
Vertical Upper Eyelid Split Anterior Orbitotomy
Transcaruncular Anterior Orbitotomy
Transcutaneous Frontoethmoidal Anterior Orbitotomy (Lynch Incision)
Approach to the Deep Lateral Orbit (Lateral Orbitotomy)
Approach to the Orbital Apex (Transcranial Orbitotomy)
Combined Approach
Lateral and Medial Orbitotomy
Orbital Decompression for Thyroid Orbitopathy
COMPLICATIONS
SECTION 3:
21:
Plasma Blade (Fugo Blade™)
INTRODUCTION
FDA APPROVAL
APPLICATIONS
Anterior and Posterior Capsulotomy
Posterior Capsular Plaque
Pupillary Membranectomy
Cutting Fibrovascular Tissue
Capsulotomy in Dislocated Lens
Iridotomy
Pupilloplasty
Transciliary Filtration
Microtrack (Dot) Filtration Surgery
Squint Surgery
Vitreoretinal Surgery
Surgical Reversal of Presbyopia
22:
Sutures, Needles and Bioadhesives
INTRODUCTION
SUTURES
Ideal Suture
Size of Suture
Memory of Suture
Form of Suture
Monofilament
Multifilament
Classification of Sutures
Absorbable Sutures
Natural
Synthetic
Non-absorbable Sutures
Natural
Synthetic
NEEDLES
Anatomy
Shapes of Needle
Round Bodied (Taper Point)
Taper Cut
Reverse Cutting
Micropoint Spatula
CS Ultima
P Needle
TISSUE APPROXIMATION
Lid Approximation
Primary Wound Healing
Secondary Wound Healing
Basic Suturing Techniques
Full-thickness Lid Lacerations
Conjunctival Approximation
Principle
Corneal Approximation
Pathophysiology of Corneal Wound Healing
Valve Rule of Eisner
Principles of Corneal Suturing
Tissue Adhesives
Cyanoacrylate Glue
Advantages
Outcomes
Patient Preparation
Technique
Other Considerations
Scleral Approximation
Pathophysiology
Iris Approximation
Factors that Retard Wound Healing
Local Factors
Systemic Factors
23:
Sterilization
INTRODUCTION
TERMS AND DEFINITIONS
TECHNIQUES FOR STERILIZATION
Cleaning
Hand Washing
Soaking
Ultrasonic Cleaners
Sterilization
METHODS OF STERILIZATION
Physical Agents for Sterilization
Dry Heat
Moist or Wet Heat
Radiation
Burning or Incineration
Chemicals for Sterilization
Gaseous Chemicals
Chemical Disinfection
PREPARATION OF THE OPERATING ROOM
Operating Room Environment
Operating Room Sterilization
Sterilization of Various Items in Operating Room
Articles
For Anesthesia
SURGEON'S PREPARATIONS
Scrubbing
Dressing
PATIENT PREPARATION
PREPARATION FOR SURGERY
Instrument Trolley
Preparation of Operating Room Staff
Preparing for the Surgery
POSTOPERATIVE MANAGEMENT
Managing any Blood or Fluid Spills
Managing Sharp Instruments or Material
Managing Biomedical Waste
INDEX
TOC
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