Phacoemulsification Amar Agarwal, Athiya Agarwal, Soosan Jacob
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1Phacoemulsification2
3Phacoemulsification
FOURTH EDITION
Editors Amar Agarwal MS FRCS FRCOphth Athiya Agarwal MD DO FRSH Soosan Jacob MS FRCS DNB MNAMS All of Dr Agarwal's Group of Eye Hospitals & Eye Research Centre 19 Cathedral Road, Chennai, India Foreword to the First Edition John J Alpar Foreword to the Second Edition Spyros Georgaras Foreword to the Third Edition Robert H Osher Foreword to the Fourth Edition Thomas John
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Jaypee Brothers Medical Publishers (P) Ltd.
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© 2012 Editors
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This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the contributors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author(s). Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
Publisher: Jitendar P Vij
Publishing Director: Tarun Duneja
Editor: Dr Richa Saxena
Cover Design: Seema Dogra
Phacoemulsification
First Edition: 1998
Second Edition: 2000
Third Edition: 2004
Fourth Edition: 2012
9789350254837
Printed in India
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To
A True Visionary
Steve Arshinoff
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7Contributors
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11Foreword to the Fourth Edition
Worldwide, seniors are the fastest growing population and this will contribute to continued increase in age-related eye diseases of which cataract is an important clinical entity that all ophthalmologists will be spending a significant segment of their clinical time in the surgical management and postoperative follow-up in the road to postcataract, visual rehabilitation of our patients. Such an age-related segmental increase in population towards the elderly group can be related to the incremental advances in the fields of medicine, science, and technology. According to the United Nation News Center, the world population is expected to surpass 9 billion by the year 2050 from the current 6.7 billion. This population growth is most concentrated in the 60-plus age group according to H Zlotnik, Director, UN Population Division. Due to the high prevalence of cataracts among the aging population worldwide, cataract surgery will continue to dominate the center stage as the most common ophthalmic surgery among general ophthalmologists. As such, cataract surgery will be one of the main surgical revenue sources for the ophthalmic surgeon. It is certainly very timely to introduce the fourth edition of Professor Amar Agarwal's book on Phacoemulsification published by Jaypee-Highlights Medical Publishers, a world leader in medical publishing.
Professor Amar Agarwal is a recognized world leader in ophthalmic surgery who has received prestigious awards from leading ophthalmic societies both in India and globally. He has edited numerous textbooks in both medical and surgical aspects of ophthalmology, a true attestation to his continued dedication to ophthalmic education. He is the pioneer of phakonit and microphakonit cataract surgery that focuses on cataract removal using a 0.7 mm phaco tip. He has also contributed to secondary intraocular lens (IOL) implantation using a glued IOL technique. His interests do expand beyond the anterior to posterior segment of the eye with his pioneering surgical implantation of the new mirror telescopic IOL (LMI) for macular degeneration. He has improved epiretinal membrane visualization during retinal surgery by using intraoperative trypan blue staining technique. Truly, we are all fortunate to have Professor Agarwal bring this latest edition of his surgical textbook on phacoemulsification for us to rely upon to refer and learn both the well-established and the most-advanced techniques, and everything in between, and thus continue to raise our own skill set in the area of cataract surgery to the benefit of our patients.
Professor Amar Agarwal, Athiya Agarwal, and Soosan Jacob have channeled their energies to bring together a group of world leaders in cataract surgery whose cohesive input and countless hours of dedication has resulted in this excellent, current, state-of-the-art cataract surgery book on Phacoemulsification which covers all aspects of phacoemulsification from the historic perspective, to phaco-hardware (phaco machines and pumps) and phaco-software (fluidics, software-assisted torsional phaco), viscosurgical devices, surgical techniques, to premium IOLs, complication management, and much more, “all-in-one” comprehensive textbook on Phacoemulsification. It is a “one-stop-shopping” approach to learn all aspects of modern-day cataract surgery and hence I recommend this book as a must have surgical textbook for all those interested in cataract surgery from residents in training, to practicing ophthalmologists at all levels of surgical expertise in cataract and IOL surgery. The book should be incorporated in all medical libraries worldwide as an important source of comprehensive information on cataract surgery for all those who have an interest in age-related eye diseases especially, cataract.
Thomas John md
Clinical Associate Professor
Loyola University at Chicago
Visiting Professor
Department of Defense, MMA, Belgrade
Private Practice in Oak Brook
Oak Lawn and Tinley Park, Illinois
USA
12Foreword to the Third Edition
Authoring a medical textbook is a labor of love. For months and months, the act of writing, correcting, rewriting, editing, proofreading, corresponding, negotiating, etc. replaces hobbies and recreational pursuits. Yet when all is said and done, an immense sense of satisfaction embraces the author, who by this time has aged considerably.
The authors of the third edition are to be congratulated for bringing this collaborative work to fruition. The encyclopedic table of contents in combination with an erudite and highly experienced international faculty offer two volumes of information to the reader. Moreover the microphacoemulsification section reflects the leading contribution that Dr. Agarwal's group is making in the evolution toward even smaller incision surgery.
Being on the “cutting edge” can be a mixed blessing, but investing the time and effort necessary to share information is always a rewarding task for those surgeons who have contributed their work. I hope that the reader is also rewarded by becoming a more knowledgeable cataract surgeon after digesting the contents of the third edition of this textbook on phacoemulsification.
Robert H Osher md
Professor of Ophthalmology
University of Cincinnati
College of Medicine
Medical Director Emeritus
Cincinnati Eye Institute
13Foreword to the Second Edition
Dr Amar Agarwal's brilliant mind has captured the idea of presenting the most advanced techniques of Cataract Surgery, at the dawn of the new millennium in this splendid book, Phacoemulsification, Laser Cataract Surgery and Foldable IOLs.
The reader can enjoy not only a skilful description of classic cataract surgery, but also Dr Agarwal's great experience, opening new horizons in this field. I whole-heartedly recommend the book and am honored to Foreword this second edition which will almost certainly be as great a success as the first one. I am very proud to share the knowledge arising from Dr Agarwal's book who is one of the leaders in the field of cataract surgery and a great colleague and friend.
Spyros Georgaras md
President of the
Hellenic Union of Specialized Ophthalmologists
Greek Intraocular Implant and Refractive Surgery Society
Research & Therapeutic Institute “Ophthalmos”
Ophthalmological Center “Hygeia-Ophthalmos”
14Foreword to the First Edition
One of the great joys and honors in my life was my frequent visits to India and my meetings with great clinicians, surgeons, teachers and human beings of the Indian ophthalmological community… among them, the wonderful Agarwal family of Chennai. So I am very much honored by their request to write a Foreword to the new book edited and written by them and by other superb surgeons and teachers such as Keiki R Mehta, Mahipal Singh Sachdev, Kenneth J Hoffer, I Howard Fine and all the other internationally known and respected teachers and experts. The table of contents, both concerning the titles of the chapters and the authors, speaks for itself. Some of the world's greatest authorities on the subject, speaking from both scientific and clinical experience, are gracing this book. Every aspect of modern successful cataract surgery is covered, so the book will be extremely useful—not only for the beginners, but also for the accomplished surgeons who need to look at some different points of views and approaches to surgery or for information. The worldwide brotherhood of ophthalmic surgeons, researchers and teachers is deeply and greatly indebted to the editors of the book who assembled the panel and chose the topics and to the writers of the chapters who devoted their time and knowledge to this undertaking. I congratulate and thank the authors and wish them God's blessings.
John J Alpar md facs
Clinical Professor at Texas Tech University
Honorary Member of All India Ophthalmological Society
15Preface to the Fourth Edition
When the concept of Phacoemulsification was developed by Charles Kelman, it revolutionized cataract surgery but it has today come a long way from where it started. From being essentially a therapeutic procedure for elderly people with cataracts, it has now also come to encompass people of all ages and expectations. With the baby boomer generation coming of age, there is a large population who not only want their cataracts removed but also want it to be done in a faster, better and smarter manner. In keeping with this, there have been huge developments in phacoemulsification in all aspects right from the techniques used to the instruments, machines and intraocular lenses.
Newer machines with enhanced software and hardware features, better power modulation and fluidics are being introduced in a regular manner by the industry. We, as surgeons, also tend to constantly evolve and improve our techniques be it in moving to smaller and smaller incisions utilizing biaxial phaco, microincisional coaxial phaco and so on or in incorporating newer techniques to manage complex situations such as small pupils or subluxated lenses. Add to all this, the desire to regain their youthful vision by the cataract patient – the need to see clearer and sharper for all distances without spectacles has meant a very demanding and aware patient. In response to this, a host of newer intraocular lenses with varying properties for distance, intermediate and near; dark and light have been introduced into the market and it becomes imperative for the surgeon desiring to perform refractive cataract surgery to be aware of the intricacies, potential advantages and disadvantages of all these lenses.
This onslaught of newer information which is required to be engrained into their practice by the cataract surgeon is a daunting task. In an effort to make this easier, we have brought out this fourth edition of Phacoemulsification. The entire gamut of cataract surgery right from the basics such as IOL power calculation in simple and complex cases, phaco machine, phaco steps, etc. to advanced phaco such as microincision phaco, challenging cases and premium IOLs to the very recent advances such as femtosecond laser-assisted cataract surgery and 3-dimensional viewing systems for cataract surgery have been covered in detail. We have also included a section on complications as every surgeon needs to know how to manage these undesirable scenarios. The chapters have been written by world renowned authors from an international faculty of cataract experts in an easy-to-understand format. We sincerely hope that this book will serve the reader as an excellent resource material and guide for enhancing his/her cataract practice.
Editors
16Preface to the Third Edition
A lot of toil, blood, tears, and sweat has been poured through these pages from so many authors working in so many countries serving so many people. This two volume book on cataract surgery in its most advanced fashion, is an attempt to spread knowledge and letting you know that each one of us believes a much greater force has helped us compile this into fruition.
We may have claimed many a research project, however each one who has done any research knows fully well and can hear fully well that inner voice calling out. Every time we write whether it is for our own gratification or towards a more sublime learning and teaching once again whether we want to accept it or not we know that it is something else that makes us do these things. It is something far more powerful than we can ever imagine that guides our thinking, our hands, our profession or whatever direction the guide wants us to. And yet there is a choice of free will given to all of us. And yet we choose to burn the midnight oil, we choose to forsake sensual pleasures in a quest of that something that gives us much more peace and understanding of the world, much more joy than owning all the gold in Fort Knox would ever give us.
Here my dear friends is where we are today to say Thank You to the world to the Cosmos to everyone of you who read this and to those who benefit through your reading because this may just be a small drop in the ocean of knowledge, yet it is a small drop in the right direction. In the spirit of serving the human race and all who come after us our attempt is to give them a springboard where they can take off where we have left off.
Editors
17Preface to the Second Edition
Coming from a background where ophthalmology ordained the dining table conversation for over seven decades and three generations it is not surprising that the need for revised second edition was thought necessary and mandatory. Especially since our understanding of cataract surgery has been in a perpetually accelerating flux.
Sometimes revelations have been quite by accident however most often progress is steady and slow, depending on many factors like available resources and necessity. The more we read and more we try to assimilate information the more we realize how far we are from the understanding of the topic.
Of late it is difficult to understand progress in the coming years of the new millennium without the assistance and utilization of lasers, computers and advanced technology. More often than nought the space traveler it seems enjoys more information and technological advancements than does the mundane operation theater of medical personnel. However even this equation seems to be changing and much like a science fiction movie our operation theaters reel away progress only thought of to exist in future centuries.
Retaining the same concept of cataract surgery this edition throws much light on the why and wherefores with an insight into the modalities of treatment. Along comes research from the offices of Dr David Apple, a person who has brought glamor into ocular pathology and the understanding of different treatment types, along with Dr SK Pandey have explained the reasons why they have come to a conclusion where there seems to be no difference between intracameral anesthesia, topical anesthesia, and now venturing into new grounds—No anesthesia itself.
However good a surgery comes to nought when plagued with bacterial or microbial invasion, many ophthalmic surgeons have gone through sleepless nights in the pursuit of infection control and its management. This leads us to believe that it was essential to have detailed chapter written on the subject. Much to our chagrin there was hardly any material on the topic of Sterilization. It seems to be we all know about it, understand its importance in the surgical field, yet have never really written about it. The maximum one finds in known literature is something written as a chapter of a microbiology book. Still nothing much from a clinician's point of view, still nothing much in terms of explaining to us what works best, and still nothing more telling us how to work it. Quoting a cop friend of mine, “An assassin has to be lucky just once, I have to be lucky every day, every instant.” In the same light we as surgeons have to be on our guard every time, every instant, the bacteria need be lucky only once. Add to this is sometimes the diplomatic approach of instrument engineers who wave aside grave consequences to patient's wellbeing in the interest of their product image. Sometimes we overlook the obvious, just like we look for the source of light standing right under the sun, similarly the internal tubing of an ultrasound machine that gauges the pressure inside the eye, is actually the prime source of infection in phacoemulsification.
With the Mediterranean influence of L Burrato we have a new chapter on the adversities of a small pupil and still manage to perform phacoemulsification with the greatest of finesse, “Pushing an elephant through a keyhole”. Giving importance to Incisions is S Pallin, small steps of the surgery which go a long way in its success. Posterior Polar Cataract has new light from A Vasavada whose immense knowledge on phacoemulsification makes him a leader in this field.
Coupled with this progress is the inroads made by Indian ophthalmology along with Indian engineering and scientific skill that have been displayed for all to see at the pinnacle body internationally as far as cataract and refractive surgery are concerned, the American Society for Cataract and Refractive Surgery (ASCRS) were witness to live surgery telecast from India to America at the 1999 ASCRS meeting. This instruction course made history with it being the first time such an event had occurred and displayed live—No Anesthesia Laser Phakonit (under 1 mm) Cataract Surgery. Thus all that we had written about came to pass when delegates were able to see the surgery in its full form. Such feats would be repeated more often at different meetings since seeing is believing!
As the volume of knowledge has expanded, so too the need for multiple contributors. To strengths of diversity and multiple forms of expertise, this trend has created a burden on the editorial. Thus consistency of writing form is difficult to maintain, however this also adds to the texts’ value as a learning and teaching tool. The whole volume of the book has therefore extended and with more color plates and more reading material, we hope dear reader you enjoy reading this as much as we have in writing it!
Editors
18Preface to the First Edition
Forewords rarely touch the reader's heart unless the writer sends them out from the same location. That gives us a fighting chance, because we have spent our entire life in the pursuit of ophthalmic sciences and still count this as one of our good friends that always reserves its gratitude and encourages our chances of discovering further and further in its wake.
To write a book today in the world of entertainment with video, movies and the whirlwind of computers seems gratuitous. Still the beauty and magic of reading will never fade and the history of writing that dates back more than 5000 years can never be surpassed. To the memory of the writers of yore and to encourage the many more writers to come, we have taken the task of bringing you the latest synopsis of the trends in cataract surgery through the nineties.
The scientists and researchers of today are full time clinicians who have placed their energy in the development of new ideas. In fact if you go back in time, most discoveries and inventions have been made by the person attempting to correct human malady, and while doing so perchance steps onto some discovery or invention.
It was in this same manner the father of Intraocular lenses while treating pilots from the Royal Airforce during the Second World War came to the conclusion that IOLs were a possibility. He noticed that pieces of windshield material lay immersed in ocular tissue producing no reaction and were transparent and could thus be implanted into the eye (in the place) of spectacles. Dr Harold Ridley thus brought about one of the greatest advancements in this century as far as ophthalmic sciences are concerned. To him and his batch of pioneers, ophthalmology down the ages will always have a place of honor. Salutations to such torchbearers and more to come.
When we look down at the achievements that the human mind has achieved in the realm of ophthalmology and its progress, we are baffled by its enormity especially when we know that there is still so much more to be discovered and so much more to be invented. The scientific progress that has occurred in the last 100 years has bypassed all that could have occurred in the last 5000 years from the Neanderthal cousin of ours, and that which will occur in the next decade itself will be a renaissance in ophthalmology. We still know only a drop in the ocean of the ophthalmic sciences and we realize that what we can dream, we can certainly achieve in the forthcoming years. This book aims at giving you dear Reader not only food for thought but also in contributing to this Renaissance, thereby, achieving the dreams our forefathers had in this beautiful world of Vision.
Through the reading of this book you will find subjects divided into six basic structures to ease you in the understanding of what cataract and its management mean today. The contributing authors are themselves authorities on the topics of their choice. All stages of learning have been taken care of through these six stages from the learner through the advanced surgeon, bringing you to bear down on mayhap a forgotten episode, for we all know “Trifles make perfection, though perfection is no trifle.”
The computer has brought into our world a dream of precision and this has come to become a part of every machinery developed in the modern world. In fact when we look into what “robotics” have done to this factor, we realize we are very close to making the blind man see. Many have been the times that patients have asked their eye surgeon, “Cannot you change my eye itself?” Yes, now we can reply them with the idea of repositioning a video camera and sending the signals into the brain directly. Unthought of till only yesterday, and today will soon be a reality.
A surgeon in the midst of surgery in his or her home town can now think of operating in orbit around the world with a little help from satellites and robotics. Now most distant of patients can get the precise expertise from the dexterous experience of the surgeon. Very soon no one will be bereft of resourceful opinion and/or surgery in this world and that beyond the stars.
Marching towards the next millennium we have accessed cataract surgery with an intraocular lens insertion under the 2 mm mark with the latest “laser cataract surgery,” becoming a reality. Coupled with changes in ultrasound technology it will create many newer trends in the years “beyond 2000”. Phakonit has brought the incision of cataract surgery to 0.9 mm. Computers and lasers have crossed many marks, and “intrastromal lasers” will soon see the light of the day. Spectacles will not be worn for the want of refractive errors with the latest modalities of the LASIK laser and its contemporaries.
This reading hopes to take you down the lane from humble beginnings of a retrobulbar to peribulbar anesthesia and now to the present exodus of topical anesthesia to the advanced “No anesthesia” ophthalmic surgery, taking its first few steps of infancy in India. After all, have we all not seen sudden injuries to the eye reflecting no pain to the patient? It hopes to give you food for thought and may 19be rethink the corneal reflex, rethink the anatomy and physiology of the eye itself and delve into the basic sciences of our specialty, “the eye”.
It is said that the pen is mightier than the sword (here the surgical knife) and in this case both go hand in hand, and thus, whatever the knife has done the pen has put it down for you to read.
Contributing authors have already left footprints on the sands of time. Let us further your objective in strengthening the armor of ophthalmology.
Editors
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