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Advances in Cataract Surgery Arbisser_BOOK.qxp 31/10/06 3:11 pm Page 20 Cataract Surgery Advances in Cataract Surgery a report by Lisa Brothers Arbisser, MD Founding Member of Eye Surgeons Associates and Adjunct Clinical Associate Professor, University of Utah Moran Eye Center DOI: 10.17925/USOR.2006.00.00.20 Lisa Brothers Arbisser, MD, is a Cataract surgery transformed radically this past century. or when one lens is in the bag and the other is in the Founding Member of Eye Surgeons From cocaine topical anesthesia, immobilized patients, sulcus. Piggybacking proves useful to correct refractive Associates and performs eye procedures at Spring Park Surgery and extracapsular technique on ‘ripe’ cataracts we surprises without a lens exchange, thereby minimizing Center. She is an Adjunct Clinical advanced to retrobulbars, sutured incisions, and the risk of bag rupture and inaccurate calculation. Associate Professor at the University intracapsular technique. Today’s techniques recapitulate Existing low plus and minus power foldable IOLs of Utah Moran Eye Center. Dr Arbisser serves on the Board of those of old, with topical anesthesia and intact capsular provide an almost unlimited range of correction. Directors of the American College of bag support of implants enabling virtually instant visual Narrow-profile sulcus lenses minimize the risk of Eye Surgeons and is a past recovery,minimal discomfort, and immediate resumption pigmentary dispersion. Low-power multifocal or President. She is a diplomate of the American Board of Ophthalmology of full activity,often spectacleless, with unparalleled safety. pseudo-accommodative lenses to piggyback over pre- and certified in cataract and existing monofocal lenses for pseudophakic presbyopia implant surgery by the American The ability to remove the cloudy lens through a small, remain rarely used but available. Board of Eye Surgery stable incision, leaving the zonular capsule complex intact combined with technology to refocus light rays Pre-existing refractive error is addressed by proper lens clearly onto the retina facilitate today’s extraordinary selection for spherical power and treatment of outcomes.These results are often achieved even in eyes astigmatism. Toric lenses provide an alternative to with compromised anterior segment anatomy. corneal incisional techniques such as astigmatic keratotomy.In the majority of cases, with pre-operative Technique topography and intra-operative keratoscopic confirmation, both methods are predictable up to two Phacoemulsification, capsulorhexis with its subtleties diopters. ‘Bioptics’—intentionally planning laser- and viscoelastics permit the removal of any stage cataract assisted in situ keratomileusis, (LASIK) combined with through a tiny self-sealing clear corneal incision. IOL implantation—can be used for higher degrees of Advanced incision architecture nearly eliminates astigmatism. Healing is rapid, and complications few. induced astigmatism and permits immediate stable post- operative refractions. Reliable intracapsular implantation New IOL technology neutralizes the normal cornea’s enhances accurate implant power calculation. positive spherical aberration improving contrast sensitivity and modulation transfer function. The Pursuit of Spectacle Freedom Theoretically, with wave front analysis, individual customized implants may become possible. A new Intraocular lens (IOL) selection formulae have been polymer that redistributes molecules when exposed to evolving with the realization that eyes are not always a particular wavelength of light—known as light proportional in size. By incorporating white-to-white adjustable lens technology—may allow post-operative measurement into calculations traditionally only adjustment of implants’ shape and power to eliminate including axial length and corneal shape, the higher and lower order imperfections post-operatively. significant percentage of myopes and hyperopes with normal size anterior segments are accounted for, A blue filtering chromophore in addition to the routine thereby reducing outliers. IOL ultraviolet blocker has been introduced.This subtle and typically imperceptible hue resembles a 40–50- Two lenses are rarely piggybacked since high hyperopia year-old’s human crystalline lens brunescence, but can now be addressed with aspheric IOLs measuring up features an absorption curve closer to that of a four- to 40 diopters.The potential benefit of two lenses must year-old than the clear ultraviolet (UV) standard lens be weighed against the risk of inter-lenticular opacity, provides. It will take years to ascertain whether this will which could defy yttrium aluminum garnet (YAG) significantly protect macular health in the long-term laser correction. This incidence may approach zero but it may rapidly become standard care. when the capsulorhexis does not cover the IOL edges Baby boomers’ presbyopia frontier has been breached 20 US SENSORY DISORDERS 2006 Arbisser_BOOK.qxp 31/10/06 3:12 pm Page 21 Advances in Cataract Surgery with monovision through contact lenses and refractive vary from no prophylaxis to topical, intracameral procedures. Some surgeons espouse pseudophakic irrigation, or subconjunctival injection usually at the ‘blended vision’ with one eye focused 1.50 diopters near conclusion of the case. to achieve relative spectacle independence but pseudo- accommodative lenses provide the best range of Recently, a multicenter study showed a five-fold uncorrected vision without compromising depth reduction in the incidence of endophthalmitis with the perception. Emerging technologies are anticipated to use of intracameral antibiotic. Fluoroquinolone (FQ) eliminate the disadvantages of simultaneous vision from antibiotics achieved rapid acceptance because of their diffractive and refractive multifocal strategies and provide ability to penetrate both blood-retinal barrier and true accommodation eliminating the neuro-adaptation cornea and their broad-spectrum activity against the requirement of the most popular lenses today. usual pathogens. Owing to the pure tonnage, agriculture and general medicine’s use of second- and Anesthesia third- generation FQs led to a rapid increase in gram- positive resistance. Currently, fourth- generation FQs Although rare, the risks of intraconal anesthetic provide better coverage and require two mutations of injection were reduced with peribulbar (extraconal) the DNA gyrase for organisms’ resistance. These injection. Remaining risks were further minimized by antibiotics sterilize the ocular surface and penetrate sub-Tenon’s cannula anesthesia and topical anesthetics. aqueous and ciliary body tissue better than any Once the surgeon forgoes akinesia—requiring keen antibiotic historically. Improved defenses and greater pre-operative assessment and heightened skills of emphasis upon proper wound construction may result patient communication—instant functional recovery in a reduction of infection in the near future. and reduced anesthetic complications occur. Topical with intracameral preservative-free lidocaine anesthesia Other complications associated with cataract surgical keeps surgery comfortable, minimizes the need for technology are consistently falling. The on-going sedation and enables procedures for even the most refinement of phacoemulsification machines in fragile patient with appropriate monitoring. When controlling ultrasound delivery and improved combined with clear corneal incisions risk of significant understanding of fluidics and their effect on the bleeding is essentially eliminated. Anticoagulants need intraocular environment are advancing rapidly. Reduced not be discontinued, and patients can resume vigorous tube and cassette compliance and fluid restrictors, more activity without risk of hemorrhage or iris prolapse. I sophisticated software, and our ability to work in a nearly used to dread anesthetic injections and post-operative closed system help overcome surge and turbulence occlusive patches for monocular patients. challenges. Many strategies use non-continuous ultrasound energy including hyperburst and hyperpulse at Complications the millisecond level. Both on and off times can be varied to create different duty cycles, which increase efficiency Endophthalmitis’s occurrence of 1:1100 since the and virtually eliminate thermal damage to tissues.A recent advent of extracapsular surgery has possibly recently addition to our toolbox is torsional phacoemulsification. increased.17 Some associate this apparent increase with The to and fro motion of the ultrasound tip results in the rise of clear corneal sutureless incisions, yet many improved followability and further reduction of thermal believe that properly constructed incisions remain safe damage. The efficiency of Torsional phaco efficiency at and stable. The rise of bacterial resistance may be 32,000hz exceeds that of sonic energy at 100hz in a contributory.Although uncommon, this one seemingly torsional plane used in synergy with traditional uncontrollable, potentially devastating complication ultrasound. Cavitation and its controversial effects may be traditionally precludes same-day bilateral surgery. reduced as well. New research is starting to shed light on the issue of free radical production and its effect on Ophthalmology remains surgical prophylaxis’s stepchild. corneal endothelium. Laser cataract disruption has been In general surgery, statistically confirmed classic abandoned while Aqualase—pulsed jets of warm fluid— treatment reduces post-operative infection. Appropriate is touted as more capsule-friendly for
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