Editors-in-Chief Ashok Garg MS, PhD, FRSM, ADM, FAIMS, FICA
International and National Gold Medalist Chairman and Medical Director, Garg Eye Institute and Research Centre
235-Model Town, Dabra Chowk Hisar-125005 (India)
Jorge L Alio MD, PhD
Professor and Chairman of Ophthalmology Medical Director Instituto Oftalmologico De Alicante
Avda. Denia S/n 03016 Alicante, Spain
Foreword David F Chang
- Marie Jose Tassignon
- md, phd
- Professor
- Department of Ophthalmolgoy
- Univesity Hospital Antwerp
- Wilrijkstraat 10, B-2650
- Edegem (Antwerp), Belgium
- Robert J Weinstock
- md
- Director
- Cataract and Refractive Surgeon
- The Eye Institute of West Florida
- 148, 12th Street SW
- Largo, Florida 33770, USA
- Keiki R Mehta
- ms, do, fios
- Chairman and Medical Director
- Mehta International Eye Institute
- 147, Shahid Bhagat Singh Road
- Colaba Road
- Mumbai-400005
- India
- Jerome Jean - Philippe Bovet
- md
- Consultant Ophthalmic Surgeon, FMH
- Clinique de I'oeil
- 15, Avenue du Bois-de-la-Chapelle
- CH-1213 Onex
- Switzerland
- Shui H Lee
- md, frcs, faao
- Medical Director of Sunray
- Outpatient Aesthetic Multi-specialty
- Surgical Center
- Medical Director of Central
- Square Medical Eye Clinic
- Unit 255-4231 Hazel Bridge Way
- Richmond B.C. V6X 3L7
- Canada
- Boris Malyugin
- md, phd
- Professor of Ophthalmology
- Chief of Department of Cataract and Implant Surgery
- Dy. Director General
- S. Fyodorov Eye Microsurgery
- Complex State Institution
- Beskudnikovsky blvd 59A
- 127486 Moscow
- Russia
- D Ramamurthy
- ms
- Director
- The Eye Foundation
- 582-A, RS Puram, DB Road
- Coimbatore-641002
- Tamil Nadu
- India
- Mahipal S Sachdev
- md
- Chairman and Medical Director
- Centre for Sight
- B-5/24, Safdarjung Enclave
- New Delhi-110029
- India
- CS Dhull
- ms, phd, fiao
- Senior Professor and Head Regional Institute of Ophthalmology and Director PGIMS
- Rohtak-124001 (Haryana)
- India
- Gian Maria Cavallini
- md
- Director Institute of Ophthalmology
- University of Modena and Reggio Emilia
- via del Pozzo 71-41100, Modena
- Italy
- Roberto Pinelli
- md
- Director Instituto Laser Microchirurgia Oculare
- Crystal Palace
- Via Cefalonia, 70
- 25124 Brescia, Italy
- Bojan Pajic
- md, febo
- Swiss Eye Research Foundation
- Eye Clinic Orasis,
- Titlisstrasse 44, 5734, Reinach
- Switzerland
- Arturo Perez - Arteaga
- md
- Medical Director
- Centro Oftalmologico Tlalnepantla
- Dr. Perez - Arteaga Vallarta No.42
- Tlalnepantla, Centro, Estado de Mexico
- 54000, Mexico
- Cyres K Mehta
- ms, fsvh, fage
- Director and Consultant
- Mehta International Eye Institute
- Seaside, 147, Colaba Road
- Mumbai-400005
- India
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Surgical Techniques in Ophthalmology (Catract Surgery)
© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
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 editors and the publisher.
First Edition: 2010
9788184487763
Typeset at JPBMP typesetting unit
Printed at
7Dedicated to
– My Respected Param Pujya Guru Sant Gurmeet Ram Rahim Singh Ji for his blessings & motivation.
– My Respected Parents, teachers, my wife Dr. Aruna Garg, son Abhishek and daughter Anshul for their constant support and patiencxe during all these days of hard work.
– My dear friend Dr. Amar Agarwal, a leading International Ophthalmologist from India for his continued support & guidance.
— Ashok Garg
– To Mayca, Jorge, Fernando and Maria Lucia and most especially to my beloved wife Maria, for the hours that were taken from our family life to make this book possible.
— Jorge L Alio
– Nothing will be cherished more than you to come, my first grand child.
— Marie Jose Tassignon
– My father Stephen M. Weinstock, MD. In addition to his tremendous success as an ophthalmologist, he continues to inspire and support me in all that I do. With patience and understanding he has taught me the importance of honesty and balance in my life.
— Robert J Weinstock
– Zena the light of my life.
— Keiki R Mehta
– Yveric, Luc and Fanny Laure.
– Silvio Korol, who was not only a teacher but also an intellectual guide and a friend.
— Jerome Bovet
– My parents for their inspiration, teaching and motivation.
– My brother Peter for his continued support, guidance and inspiration in my professional career.
— Shui H Lee
– To my father Edvard Malyugin for everything and to my wife Natalia for her continuous support and love.
— Boris Malyugin
– To my family, who make it all so worthwhile.
— D Ramamurthy
– My family without whose help it would not have been possible to do book.
— Mahipal S Sachdev
– My dear wife Dr. Indira Dhull and my children Tushar and Chirag.
— CS Dhull
– My wife Lorena and my sons Pier Francesco, Enrico Maria, Massimiliano and Chiara that, with their love and patience, enable me to get energies and ardor for my work.
— Gian Maria Cavallini
– I dedicate this book to India's Talented ophthalmologists, in the fervent hope that they may become increasingly devoted to refractive surgery.
— Roberto Pinelli
– To my son Valentin Aleksandar.
— Bojan Pajic
– I dedicate my work to all the people in the world with ophthalmic diseases, with the best wish that we can improve with this kind of material our quality of care. I also dedicate this opus to Prof. Ashok Garg, because he has trusted in my work many times.
— Arturo Perez-Arteaga
– My parents for everything.
– To Vini my Best friend.
— Cyres K Mehta
8Contributors
- Ahmad K Khalil md,phd
- Associate Professor of Ophthalmology
- Saridar Clinic Tower
- 92, Tahrir St., Dokki
- Cairo (Egypt)
- AK Grover md, frcs
- Chairman
- Deptt. of Ophthalmology
- Sir Gangaram Hospital
- Rajender Nagar
- New Delhi, India
- Albrecht Hennig md
- Lahan Eye Hospital
- C/o UMN, P.O. Box 126
- Kathmandu, Nepal
- Amar Agarwal ms, frcs, frc ophth
- Consultant
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Antonio Toso md
- Consultant
- Bassano del Grappa City Hospital
- Ospedale San Bassiano, Unità Operativa di Oculistica, 36061
- Bassano del Grappa (VI) Italy
- Armando Capote md
- Vice Chairman Microsurgery Center
- Cuban Institute of Ophthalmology
- Ramon Pando Ferrer
- Havana, Cuba
- A Divya
- Consultant
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Arturo Perez-Arteaga md
- Medical Director
- Centro Oftalmologico Tlalnepantla
- Dr. Perez - Arteaga Vallarta No.42
- Tlalnepantla, Centro, Estado de Mexico 54000, Mexico
- Arun C Gulani md
- Director
- Gulani Vision Institute
- 8075 Gate Parkway (W)
- Suite 102 and 103, Jacksonville,
- Florida-32216, USA.
- Ashok Garg ms, phd, frsm
- Chairman and Medical Director
- Garg Eye Institute and Research Centre
- 235-Model Town, Dabra Chowk
- Hisar-125005 (India)
- Athiya Agarwal md, do, frsh
- Consultant
- Dr. Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Bassam El Kady md, phd
- Clinical Research Fellow
- Vissum-Instituto Oftalmologico de Alicante
- Department of Research and Development, Alicante, Spain
- Belkis Rodriguez md
- Microsurgery Centre
- Cuban Institute of Ophthalmology
- Ramon Pando Ferrer, Havana, Cuba
- Bojan Pajic md,febo
- Swiss Eye Research Foundation
- Eye Clinic Orasis,
- Titlisstrasse 44, 5734, Reinach
- Switzerland
- Boris Malyugin md, phd
- Professor of Ophthalmology
- Chief of Department of Cataract and Implant Surgery
- Dy. Director General
- S. Fyodorov Eye Microsurgery
- Complex State Institution
- 127486 Moscow
- Beskudnikovsky blvd 59A
- Russia
- Brigitte Pajic-Eggspuehler md
- Augen Zentrum Pajic (AZP) Research Institute
- Titlisstrasse 44, 5734
- Reinach, Switzerland
- Carlo Francesco Lovisolo md
- Medical Director
- Quattro Elle Eye Center
- via Cusani, 7-9, 20121
- Milano, Italy
- Chandresh Baid md
- Consultant
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Charu Khurana md
- Consultant Ophthalmologist
- Centre for Sight
- B-5/24, Safdarjung Enclave
- New Delhi-110029, India
- Chitra Ramamurthy md
- Director
- The Eye Foundation
- D.B. Road, Coimbatore-641002
- Tamil Nadu, India
- Cristina Masini md
- Institute of Ophthalmology
- University of Modena and Reggio
- Emilia via del Pozzo 71-41100 Modena, Italy
- CS Dhull ms, phd fiao
- Director and Senior Professor and Head
- Regional Institute of Ophthalmology
- PGIMS, Rohtak-124001 (Haryana)
- India
- Cyres K Mehta ms, fsvh, fage
- Director and Consultant
- Mehta International Eye Institute
- Seaside, 147, Colaba Road
- Mumbai-400005, India
- D Endriss md
- Department of Congenital Cataract
- Cornea and External Eye Diseases
- Altino Ventura Foundation and Pernambuco Eye Hospital
- Pernambuco
- Brazil
- David F Chang md
- Clinical Professor of Ophthalmology
- University of California
- 762, Altos Oaks Drive, Suite-1
- Los Altos, CA 94024
- USA
- D Ramamurthy ms
- Director
- The Eye Foundation
- D.B. Road
- Coimbatore-641002
- Tamil Nadu
- India
- Elizabeth A Davis md
- Minnesota Eye Consultants,
- 9117, Lyndale Aves
- Bloomington
- MN 55420
- USA.
- Frank Goes md
- Director Goes Eye Centre
- W.Klooslaan 6 B2050
- Antwerp
- Belgium
- Frederic Hehn md
- Centre de La Vision
- Nations - Vision,
- 23, Boulevard de l'europe
- 54500, Vandoeuvre
- France
- Gian Maria Cavallini md
- Director
- Institute of Ophthalmology
- University of Modena and Reggio Emilia via del Pozzo 71-41100, Modena
- Italy
- Gilles Lesieur md
- 32, Place Jean Jaures
- 81000
- Albi-France
- 060-9706266
- GL Arun Kumar md
- Director
- Appasamy Eye Hospital and Research Centre, Aruumbakkam
- Chennai
- India
- I Howard Fine md, facs
- Oregon Eye Surgery Centre
- 1550, Oak Street
- # 5, Eugene, OR - 97401
- USA
- Jasna Ljubic md
- Swiss Eye Research Foundation
- Eye Clinic Orasis
- Titlisstrasse 44, 5734, Reinach
- Switzerland
- Jerome Bovet md
- Consultant Ophthalmic Surgeon, FMH
- Clinique de I'oeil
- 15, Avenue du Bois-de-la-Chapelle
- CH-1213 Onex
- Switzerland
- Jes Mortensen md
- The Eye Department
- Orebro University Hospital
- SE-701 85 Orebro
- Sweden
- JJ Rozema md
- Department of Ophthalmology
- University Hospital Antwerp
- Wilrijkstraat 10, B-2650
- Edegem (Antwerp)
- Belgium
- Jorge Alvarez Marin md, phd
- Hospital Ntra, Sra. de La Candelaria,
- Ctra. del Rosario s/n
- Santa Cruz de Tenerife,
- Spain
- Jorge L Alio md, phd
- Instituto Oftalmologico De Alicante
- Avda. Denia 111, 03015
- Alicante
- Spain
- Jorg Muller md
- Nova Optik,
- Hauptplatz 6, 6431 Schwyz
- Switzerland
- Kadil Jojo Jr Sinolinding md, dpbo
- Sinolinding Eye Clinic
- Desert Ambulatory Referral Center
- Cotabato Doctors Clinic Buidling
- Sinsuat Avenue
- Cotabato City 9600
- Philippines
- Kayo Nishi md
- Nishi Eye Hospital
- Osaka
- Japan
- Keiki R Mehta ms, do, fios
- Chairman and Medical Director
- Mehta International Eye Institute
- 147, Shahid Bhagat Singh Road
- Colaba Road
- Mumbai-400005
- India
- Kumar J Doctor ms
- Director
- Doctor Eye Institute
- Spenta Mansion, 1st Floor
- S.V. Road, Andheri (West)
- Mumbai-400048, India
- L Gobin phd
- Department of Ophthalmology
- University Hospital Antwerp
- Wilrijkstraat 10, B-2650
- Edegem (Antwerp), Belgium
- LO Ventura md, phd
- Department of Pediatric Ophthalmology and Strabismus
- Altino Ventura Foundation and Pernambuco Eye Hospital
- Pernambuco
- Brazil
- Luca Campi md
- Institute of Ophthalmology
- University of Modena and Reggio Emilia
- via del Pozzo 71-41100, Modena
- Italy
- Mahipal S Sachdev md
- Chairman and Medical Director
- Centre for Sight
- B-5/24, Safdarjung Enclave
- New Delhi-110029
- India
- Marcelino Rio md
- Microsurgery Centre
- Cuban Institute of Ophthalmology
- Ramon Pando Ferrer, Havana
- Cuba
- MC Ventura md
- Department of Cataract, Retina and Vitreous
- Altino Ventura Foundation and Pernambuco Eye Hospital
- Pernambuco
- Brazil
- Marie Jose Tassignon md, phd
- Professor
- Department of Ophthalmology
- University Hospital Antwerp
- Wilrijkstraat 10, B-2650
- Edegem (Antwerp)
- Belgium
- Mark Packer md
- Oregan Eye Surgery Centre
- 1550, Oak Street
- # 5, Eugene, OR- 97401
- USA
- Mohan Rajan do, dnb
- Medical Director,
- Rajan Eye Care Hospital
- 5, Vidyodaya East II Street
- T-Nagar
- Chennai-600017
- India
- Neel Desai md
- Cataract and Refractive Surgeon
- The Eye Institute of West Florida
- 148, 12th Street SW
- Largo, Florida 33770
- USA
- Okihiro Nishi md
- Director
- Nishi Eye Hospital
- Osaka
- Japan
- Pawel Klonowski md, phd
- Vissum-Instituto Oftalmologico de Alicante,
- Department of Research and Development,
- Alicante
- Spain
- P Kaushik ms
- Doctor Eye Institute
- Spenta Mansion, 1st Floor
- S.V. Road, Andheri (West)
- Mumbai-400048
- India
- Peter Cikatricis md
- Department of Ophthalmology
- Royal Hallamshire Hospital
- Glossop Road
- S10 2JF Sheffield
- United Kingdom
- Peter G Kansas md, facs
- Clinical Professor of Ophthalmology
- Albany Medical College
- Albany, New York
- President
- Kansas Eye Surgery Associates
- PC 24, Century Hill Drive
- Latham, New York
- USA
- Priye Suman Rastogi ms
- Rajan Eye Care Hospital
- # 5, Vidyodaya East II Street, T-Nagar
- Chennai-600017
- India
- Ranjit S Dhaliwal ms,doms
- Director
- Eye Infirmary
- Hira Mahal, Radha Soami Marg
- Nabha-147201, Punjab
- India
- Richard L Lindstrom md
- Minnesota Eye Consultants, PA
- 710 East, 24th Street, Suite 106
- Minneapolis, MN 55404
- USA
- Richard S Hoffman
- Oregon Eye Surgery Centre
- 1550, Oak Street, # 5 Eugene
- OR - 97401, USA
- Roberto Bellucci md
- Chief of Ophthalmic Unit
- Hospital of Verona
- University of Verona, Italy
- Robert J Weinstock md
- Director
- Cataract and Refractive Surgeon
- The Eye Institute of West Florida
- 148, 12th Street SW
- Largo, Florida 33770, USA
- Roberto Pinelli md
- Director
- Instituto Laser Microchirurgia Oculare, Crystal Palace
- Via Cefalonia, 70
- 25124 Brescia, Italy
- Rohit Om Parkash ms
- Director
- Dr. Om Parkash Eye Institute
- 117-A, The Mall, Amritsar, India
- Sanjay Chaudhary ms
- Director,
- Chaudhary Eye Centre and Laser Vision Centre
- 4802, Bharat Ram Road
- Daryaganj, New Delhi
- India
- Shaloo Bageja ms
- Consultant
- Deptt. of Ophthalmology
- Sir Gangaram Hospital
- Rajender Nagar
- New Delhi
- India
- Shilpa Kodkany ms
- Doctor Eye Institute,
- Spenta Mansion, 1st Floor
- S.V. Road
- Andheri (West)
- Mumbai-400048
- India
- S Sivagnanam be
- Appasamy Eye Hospital and Research Centre,
- Aruumbakkam
- Chennai
- India
- Simonetta Morselli md
- Director of Anterior Segment Surgery
- Ophthalmic Unit
- Hospital of Verona
- University of Verona
- Italy
- Simon Pelloni md
- Institute of Ophthalmology
- University of Modena and Reggio Emilia
- via del Pozzo 71-41100, Modena
- Italy
- Shiao Chang md
- Nishi Eye Hospital
- Osaka, Japan
- Shui H Lee md, frcs,faao
- Medical Director of Sunray
- Outpatient Aesthetic Multi specialty Surgical Center
- Medical Director of Central Square
- Medical Eye Clinic
- Unit 255-4231 Hazel Bridge Way
- Richmond B.C. V6X 3L7
- Canada
- Soosan Jacob
- Consultant
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- Sujatha Mohan md
- Rajan Eye Care Hospital
- # 5, Vidyodaya East II Street
- T-Nagar, Chennai-600017, India
- Sunita Agarwal ms, do, psvh
- Dr. Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086, India
- 15, Eagle Street, Langford Town
- Bangalore, India
- Sumit Sachdeva ms
- Assistant Professor
- Regional Institute of Ophthalmology, PGIMS
- Rohtak-124001 (Haryana), India
- TKJ Chan frcophth, frcs
- Consultant Ophthalmic Surgeon
- Department of Ophthalmology
- Royal Hallamshire Hospital
- Glossop Road
- S10 2JF Sheffield
- United Kingdom
- Vaijayanti Deodhar ms doms
- Deodhar Eye Hospital
- 39/25, Erandawane
- Karve Road
- Pune-411 004, India
- Yutaro Nishi md
- Nishi Eye Hospital
- Osaka, Japan
Complicated cataract cases challenge all ophthalmologists, regardless of their level of experience. Although complex cases may comprise only 5–10% of all patients in a typical cataract practice, much of our continuing surgical education is devoted to solving problems posed by these eyes. As with most challenging problems in medicine and surgery, there is no single approach that works ideally and consistently well for everyone. This is what makes these patients so difficult, and why having an armamentarium of different strategies to select from is prudent.
In their new book on Surgical Techniques in Ophthalmology (Cataract Surgery), renowned Editors Ashok Garg and Jorge Alio have assembled an impressive collection of chapters devoted to complex cases and advanced topics in cataract surgery. Equally noteworthy is their lineup of international contributors who have written detailed descriptions of their pearls and strategies. In most cases, these experts have taken a step-by-step approach to describing their techniques, which are illustrated with a generous number of photos and diagrams. The editors have wisely decided to invite multiple authors to describe differing approaches to advanced problems and topics. The geographic diversity of these experts assures that the reader will be exposed to a variety of different techniques and technologies.
There is appropriate emphasis on the removing the dense cataract and multiple contributors describe a wide assortment of strategies ranging from biaxial and coaxial microincisional surgery to several methods of manual small incision extracapsular surgery. The entire gamut of phaco methods is covered as well. Finally, many new and innovative technologies and approaches are introduced in this book. These range from using intraoperative wavefront aberrometry, to glue-fixating IOL haptics to the sclera in the absence of capsular support.
With new technological advances arriving at such a rapid rate, it is a remarkably exciting time to be a cataract surgeon. Of course, these developments challenge us to constantly assimilate and incorporate new ideas and devices. This timely and comprehensive book seeks to provide cutting edge knowledge about advanced cataract surgical topics as clearly as possible. A host of international experts have generously shared their clinical experience and pearls. This reference will undoubtedly benefit all experienced cataract surgeons and their patients.
David F Chang md
Professor of Ophthalmology
762, Altos Oaks Drive, Suite 1
Los Altos, CA 94024, USA
Ph. 001-650-948-9123
Fax : 001-650-948-0563
E-mail dceye@earthlink.net
13Preface
Ophthalmic Surgery technology has undergone rapid advancements and innovations in last two decades. From Modest and conventional surgical techniques in early eighties, now it has become high-tech surgery with least indoor stay and excellent visual outcomes. Microincision surgery in both anterior and posterior segments, corneal and lenticular refractive surgery, modern keratoplasty techniques, pediatric and strabismus surgery, oculoplastic and reconstructive surgery and stem cell transplantation have entirely changed the scenario in ophthalmic surgery today.
Modern ophthalmic surgery is a vast subject. It is important for ophthalmologists to master various surgical steps in the ophthalmic surgery procedures of their interest. There are very few qualities international Surgical Techniques in Ophthalmology books which can teach and guide the ophthalmologists to master various surgical techniques properly. Keeping in view of this factor, we have conceptualized the present series of Surgical Techniques in Ophthalmology books which shall contain 8 volumes. These volumes shall cover all aspects of ophthalmic surgery in a comprehensive and easy-to-read format. These volumes shall focus on especially Cataract surgery, Corneal and Lenticular Refractive surgery, Glaucoma surgery, Corneal surgery, Retinal surgery, Pediatric surgery, Oculoplastic and Reconstructive surgery, Strabismus and Neuroophthalmic surgery. A panel of International Eminent ophthalmologists are contributing chapters in these volumes for the benefit of ophthalmologists worldwide.
First volume deals with all important topics of cataract surgery. In this volume, International cataract experts show surgical steps of various cataract surgery techniques, management of complex cataracts, complications and recent advances in cataract surgery technology in a lucid manner.
Our gratitudes are due to Shri Jitendar P Vij (CEO), Mr. Tarun Duneja (Director, Publishing) and all staff members of our publisher M/s Jaypee Brothers Medical Publishers (P) Ltd. who took keen interest in this project and for speedy completion of this mega task.
We expect that present series of Surgical Techniques in Ophthalmology books shall serve as quick look reference books for ophthalmologists worldwide to sharpen their surgical skills.
— Editors