Biaxial Lens Surgery Arturo Pérez Arteaga
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1Step by Step®: Biaxial Lens Surgery
2Step by Step®: Biaxial Lens Surgery
Editor Arturo Pérez-Arteaga MD Medical Director Centro Oftalmológico, Tlalnepantla. Vallarta # 42, Tlalnepantla, México, 54000, México. Phone: +52 555 384 1121 Fax: + 52 555 5654422 drarturo@prodigy.net.mx
3
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Step by Step® Biaxial Lens Surgery
© 2008, Arturo Pérez-Arteaga
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the materials provided by editor is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2008
9788184482218
Typeset at JPBMP typesetting unit
Printed at Ajanta Press
4Dedicated to
6Contributors
8Foreword
It is a personal honor and a pleasure to have the opportunity to write this prologue of such an important contribution to the knowledge of the ophthalmic community. I have the privilege of knowing Dr Arturo Pérez-Arteaga, editor of this important book, and also to be aware of the high academic level, and international importance of all the authors who participated in this opus.
I think like in other chapters of the history of medicine, we are living in a constant evolution and revolution of the concepts, techniques and instrumentation in all the fields of our profession but especially in ophthalmology this changes are very fast and some times very radical.
As you will see when you travel through the different chapters of this book, that the purpose of the authors is to guide you step by step, provide a solid theoretical information, the best way to get the benefits of using a new surgical technique avoiding as it is possible the most common pitfalls or mistakes to get a successful outcome, and believe me as a teacher it is not so easy to analyze and summarize all the tiny details that give you an impeccable technique.
I wish that you as a reader of this book gets the most comprehensive and useful information for the benefit of your patients and for all the contributors of this edition my most sincerely congratulation for achieving an absolutely great opus.
Rene Cano Hidalgo MD
President of the Mexican Society of Ophthalmology
9Introduction  
 
Initial Concepts
Cataracts are affecting more and more people worldwide each year. They are currently the main important diagnosis for taking a patient to the operating room in many countries. The most frequent cause of cataracts is the senile and the metabolic; even other important etiologies can be seen in the field, like traumatic or congenital.
The causes of the rapid spread of this pathology are in the efforts that humans are doing in order to increase the expectancy of life. To live more years has been one of the goals of humanity through the centuries and many people in many cultures have done tremendous efforts to achieve this goal.
Since the final years of nineteenth century, humanity started to discover sciences like microbiology, pharmacology, antibiotic therapy, immunology and genetics between others that contributed widely to increase the expectancy of life during the last decades, in a way never seen before by our species. Also surgery, and then microsurgery took also an important role in the efforts of extending the life.
To live more years brought to humans a challenge: in one hand the opportunity to see the growth of new generations, the direct pass of generational knowledge and the time required for self-enrichment activities during the retirement years. But in the other hand the elderly of the population has brought a fight in the fields of the source of resources for a constant 10increasing population, the damage to the environment and the learning of living with chronic-degenerative diseases.
The rapid spread of elderly people and the daily increasing of diabetic population worldwide due to genetic and environmental factors are adding each year millions of humans with cataracts all around the globe. This is moving to be a major problem of public health.
Some of this people are finding an easy way to give a solution to this impaired vision pathology, in particular in the developed countries, where the health systems has found some degree of equilibrium between social cost, medical education and benefit for their population. But millions of patients with cataracts in countries with growing economies are not having the same good luck; we are seeing many patients that arrive to the dead with blindness having no other thing in their eyes but cataracts, because they are unable to have access to some medical care. But even worst is the rate of patients that remains with some degree of impaired vision because of a bad-quality cataract surgery due to the deficient medical education and knowledge actualization that we are suffering in some countries. For many universities involved in the education of health resources the amount of medical doctors is more important than the medical quality of the professionals.
So while in developed countries and in some areas of growing economies countries we are seeing more exigency from the patients to their ophthalmic surgeons, because after the cataract surgery the patients want to have a perfect uncorrected far and near vision (just like a refractive procedure in a young patient), in some other areas of the world we are still watching surgical disasters after cataract surgery performed not only by the learning ophthalmic surgeons, even worst, performed by the surgeon representative of the system of health, turning this way, a reversible cause of visual loss into an irreversible one.
How we, the surgical ophthalmic community can face this challenge? How we can be able to have a uniformity of the surgical lens procedures? How we can be able to create a stand point for the results? How we can be able to work with “state 11of the art” techniques and technology without increasing the cost for our patients? How we can learn to obtain the adequate fare between patient and physician for the surgical work?
The solutions to these questions are still far away to solve; despite the difference in training and in demographics, currently the cataract surgeon who is trying to be in the “state of the art” of the lens procedures, is facing now multiple choices of techniques and technologies. We can see in out current times many different procedures in use for cataract extraction like traditional extracapsular cataract surgery, small incision extra capsular surgery like phacofracture and mininucleus techniques, standard coaxial phacoemulsification, microcoaxial cataract surgery, biaxial phacoemulsification and microbiaxial cataract surgery or microphaconit. Which shall we choose? What is according my population, my technological capacities, my technical capacity and the economy of my socio-geographic area?
But the problem is growing when we think about cataract surgery in function of the implant. The industry of intraocular lenses (IOLs) is growing very fast. They can be classified by materials, implantation incision size, multifocal or monofocal, accommodative, diffractive, aberration free, toric and much within the evolution of time. Sometimes the cataract surgeon don't know exactly what to choose, sometimes the economic factors play an important role, sometimes the patients think they know exactly what they need (because day by day the general population is learning more and more about ophthalmic surgery procedures) and sometimes the industry is pushing too much for the surgeons in order to choose one model or another.
And finally, because of this evolution, the phacoemulsifi-cation procedure is extending to the refractive field, not only because the cataract patients are demanding a high level of refractive performance; furthermore, because of the limitations of refractive corneal procedures and the slow spread of phaquic 12lenses, refractive lens exchange (RLE) has become for some surgeons a very important tool to solve refractive problems. But RLE is a challenge procedure because rather than the IOL the surgeon is going to use, it requires extreme precision, since the patient selection, passing through the IOL power calculation, until the surgical technique it self. RLE requires a perfect surgical procedure, with no mistakes at all, or maybe a surgeon with skills enough to solve the potential transoperative complications in order to achieve at the end, the exact refractive result that he purposed to the patient. And the refractive patient is much more exigent than the cataract patient, as a general rule; they sometimes exceed the expectations. All the surgeons that have done refractive and cataract surgery have experienced this situation.
So, which is the safest technique that can give us the best result, the fewer rates of complications, the increase in the possibility to solve complications and the economic benefit for the surgeon and the patient?
 
Biaxial Cataract Surgery
The reasons that motivated me to write this book are in the results that I have obtained during the last 5 years in the patients of my practice. I declare my self as a biaxial surgeon and my objective is to demonstrate to the cataract surgeons of the world the advantages that I found for my patients, for my practice and even for my health (decreasing the surgical stress), because of the use of the biaxial techniques.
The only things you might need to convert to biaxial lens procedures are a phaco machine, selected biaxial instrumentation, good knowledge of the technique, surgical skills and the strength enough to start.
I strongly believe that there are three main reasons why most of the cataract surgeons do not want to convert from coaxial to biaxial techniques:13
  1. The first reason is that the medical education in cataract surgery is currently under the basis of the coaxial procedures. That was the way Charles Kelman described phacoemulsification, as a coaxial technique. So most of the surgeons are receiving this “coaxial education” during the residence or fellowship programs (as it happened to me); they have to go through another learning curve when they are completely satisfied with the coaxial technique they are using. Does the challenge have a real worth?
  2. The second reason is the IOL for micro incision. At the beginning the biaxial cataract surgery was born as a procedure that was able to give the surgeon the opportunity to implant an IOL through an incision under 2 mm; that was the idea in the first descriptions performed by pioneers like Agarwal, Alió, Tsuneoka and others. But with time many people worldwide started to perform and improve biaxial techniques like Fine, Packer, Bovet, Weinstock, Metha and others, noticed the advantages as a minimally invasive procedure. Now we know that the advantages are not in the IOL, they are in the procedure it self, like enhanced chamber stability, better followability due to separation of infusion and aspiration, access to 360 degrees of anterior segment, the ability to use the force of the irrigation fluid as a tool and the advantages of an always pressurized system.
    But only the people that have gone through the entire learning curve and dominate the biaxial technique have found these advantages during the process. For those who have not gone through this field, biaxial procedures have no sense because there is not still an IOL capable to go through an incision under 1mm.
  3. The third reason is in the industry. If good biaxial surgeons pushed to the industry to decrease the incision size, we can see the idea that micro coaxial technology gives exactly the same result according to the incision size and IOL implantation than biaxial surgery, but without the problems that appear with the increasing difficulty and complications 14when going through the learning curve of biaxial procedures. It is a good idea to sell: “you do not have to accept the challenge; you can improve your surgical procedures, staying with the technique that you feel comfortable”. The industry is making us believe that we must have the last generation of phacoemulsification machines (and all the cost that it adds to each case) to be in the “state of the art” for the surgical lens procedures, while the biaxial surgeons are trying to convince to their colleagues that they can be at the “state of excellence” in lens surgical procedures, staying with the same phaco machine that they have been working with for the last few years (and of course with less cost), with only dominating the biaxial technique, and the low cost of one set of basic instrumentation to perform it. It is also a matter of economics.
For all these reasons, at this point in the history of lens surgery, some cataract surgeons feel afraid to convert from coaxial to biaxial techniques, some of them have done, but not with enough tools and some others have no interest at all, because they feel they have nothing to win after the challenge of converting.
 
Objective
Many books are now worldwide in the medical market about the topic of biaxial lens surgery with many names (e.g. MICS, Phakonit, and Bimanual). Most of them are developed in chapters according to the surgical steps and some others according to the different surgical techniques of different surgeons; so the reader surgeon takes different ideas and there is not a sequence of steps in his mind to achieve a good enough learning curve. I believe this is one of the causes of the loss of strength, charm and good feeling about biaxial surgery.
This book is an attempt to illustrate the current techniques and technology for the performance of biaxial cataract surgery. But furthermore this book is trying to take “by the hand” the 15coaxial cataract surgeon to go step by step, one after another, in a sequential mode, to convert from one technique to the next. The idea is to do this in a safe way, avoiding almost by complete the inherent risks. Also the steps are following a mode in which the converting surgeon is able to feel and appreciate the benefits of the technique in every step. It is an easy approach to learn, just follow the rules!
 
Book Description
In the first section, we are doing a review of history, current concepts and technology involved in cataract surgery and after in the particular field of biaxial cataract surgery. It is the theory needed to go further with the learning curve. The main objective is to make the learning surgeon understand that biaxial surgery is not a matter of incision size, it's a matter of fluidics and search for the excellence.
In the second section, the core of this book we are taking the learning surgeon in a sequential teaching-learning process where the surgeon is able to go one step after another converting in a safe way and feeling all the advantages of each new step he is doing in the biaxial technique. The structure of this sequence allows the surgeon to go back to the technique he is accustomed to perform at any time he wants, he needs or he feels afraid to go further. In this mode each surgeon can choose the speed of converting according to their capacities, abilities, cases, patients and feelings.
In the third section we show different situations and complications that can be more easily solved with biaxial techniques, rather than coaxial. We show how to go through these particular situations with the concepts and steps learnt in the second section.
This book HAS NOT a financial interest; we do not like to promote any particular company of the industry; any phaco machine, any instrument, any device, nothing at all. We just 16want that the learning surgeon make sense of the medical and economical advantages of the biaxial techniques, and be able to offer them to the patients.
I hope these concepts can be very useful for you, your practice and of great benefit for your patients.
From the bottom of my heart…
Arturo Pérez-Arteaga