Surgical technique and lens implantation Controlled open angle glaucoma Clear corneal phacoemulsification withposterior chamber IOL implantation is associatedwith a significant sustained
Trang 1IOL into the sulcus, endothelial loss is initially
similar to that with posterior chamber lens
implantation101 and should subsequently be
lower than that with an anterior chamber IOL
However, the risks associated with a sutured
IOL (see Chapter 8) usually only make this the
preferred option in young patients, in whom
long term preservation of the endothelial cell
count takes priority
Implant power in triple procedures
The inaccuracy associated with lens implant
power calculation during a triple procedure
reflects the unpredictability of keratometry
following corneal grafting The options to
minimise this source of error are discussed in
Chapter 6 The variation in refractive outcome
has led to the suggestion that non-simultaneous
penetrating keratoplasty, cataract extraction,
and lens implantation (or two-stage surgery)
should be adopted.102,103 As mentioned above,
cataract surgery as a second procedure inevitably
causes some endothelial damage and may cause
graft rejection A two-stage operation also has
the disadvantage that keratometry does not
stabilise until graft sutures are removed (up to
two years after surgery), which delays visual
rehabilitation In addition, many graft patients
have to wear a contact lens to correct residual
astigmatism irrespective of spherical error As a
result, two-stage surgery may only be advisable
when early cataract is present and its visual
significance is uncertain.104
Postoperative management
In patients with dry eyes or cicatrising
conjunctival disease, intensive preservative free
topical lubricants should be used in conjunction
with the usual topical antibiotics and steroids
(also preservative free if available) Close and
regular follow up is essential in these patients,
who have a high rate of serious complications
Persistent epithelial defects should be treated
with a soft bandage contact lens or tarsorrhaphy
In cases refractory to this treatment, amniotic
membrane transplantation may be requiredand cyanoacrylate glue is useful if perforationoccurs Dry eyes associated with a systemicconnective tissue disorder have more frequentcomplications, such as corneal melting, infectivekeratitis, and endophthalmitis, followingcataract extraction In ocular cicatricialpemphigoid the disease may reactivate aftersurgery Close review allows systemicimmunosuppression to be commenced early ifnecessary
Herpes simplex keratitis, a common indicationfor penetrating keratoplasty, may be reactivatedfollowing intraocular surgery This is of particularconcern because of the need for topical steroidsafter cataract extraction In such casespostoperative prophylactic oral antiviral treatment
is advisable (aciclovir 400 mg twice a day)
Glaucoma
Glaucoma and cataract may coexist in a widevariety of situations This includes patients whohave controlled open angle glaucoma but mayrequire drainage surgery in the future, or thosewho have uncontrolled open angle galucomaand require drainage Other glaucoma patientswith cataract may have had a trabeculectomy
to lower intraocular pressure or peripheraliridotomies to prevent or treat acute angleclosure glaucoma Glaucoma also occurs inassociation with extremes of axial length andconditions such as pseudoexfoliation Cataractsurgery in these patients, like in those who havehad previous procedures, presents a surgicalchallenge In addition, phacomorphic andphacolytic glaucoma are caused by hypermaturecataract and treatment is by lens extraction
Preoperative management
Miotics such as pilocarpine are in decline as atopical treatment for glaucoma, but historicallymany patients have been treated with theseagents A small pupil may accentuate the effect ofearly cataract, and simply changing to a different
147
Trang 2medication may be sufficient to delay the need for
cataract surgery Stopping miotic treatment may
also improve pupil dilatation if cataract surgery is
planned When a patient with narrow angles and
cataract is examined at the preoperative stage, the
intraocular pressure should be measured
following dilated fundoscopy If a significant
increase in pressure occurs, then medical
treatment or peripheral iridotomy to lower it may
be required in the perioperative period
The presence of cataract may affect the
accuracy of both field testing and optic disc
examination, which complicates the assessment
of glaucoma progression This may have
implications for the timing of cataract and
drainage surgery Trabeculectomy may accelerate
the development of cataract because of
intraoperative lens trauma, inflammation, and
the use of topical steroids following surgery
This should be borne in mind if early cataract
exists and drainage surgery alone is planned
The patient should be informed of the possible
need for cataract extraction in the future, or that
a combined procedure may be indicated
Lens induced glaucoma
Lens induced glaucoma is usually caused by
an advanced hypermature cataract Phacolytic
glaucoma may also follow traumatic capsule
rupture, and is caused by leakage of high
molecular weight lens proteins from the capsular
bag that obstruct the trabecular meshwork.Phacomorphic glaucoma results from atumescent lens that causes pupil block and acuteangle closure (Figure 10.25) In both phacolyticand phacomorphic glaucoma the intraocularpressure may be very high in conjunction with amarked inflammatory response and cornealoedema Phacomorphic glaucoma appears
to be more common in patients withpseudoexfoliation syndrome, reflecting zonularlaxity and anterior movement of the lens–irisdiaphragm
Treatment in the first instance is medical,using topical and systemic agents to lowerintraocular pressure as well as to treatinflammation Where angle closure existstemporary success has been reported usingNd:YAG laser peripheral iridotomy.105 Topicalmiotics may reduce intraocular pressure but theymay also exacerbate pupil block, and dilatation
is required before cataract extraction
Surgical technique and lens implantation
Controlled open angle glaucoma
Clear corneal phacoemulsification withposterior chamber IOL implantation is associatedwith a significant sustained drop in intraocularpressure in the order of 1–3 mmHg in normalpatients as well as glaucoma suspect andglaucoma patients.106 This may prove to bebeneficial, allowing a reduction in topicalglaucoma medication Surgery that involves theconjunctiva is known to compromise thesuccess of future drainage surgery,107 andphacoemulsification through a clear cornealincision minimises disturbance to the ocularsurface If patients have been treated with mioticsthen the pupil may fail to dilate or dilate onlypoorly, and techniques to enlarge the pupil may
Figure 10.25 Angle closure glaucoma with a
phacomorphic component.
Trang 3require drainage surgery When cataract is also
present the surgical options are sequential
trabeculectomy and cataract extraction or
combined surgery Combined trabeculectomy
and cataract extraction offers the advantage of a
single operation However, trabeculectomy
combined with ECCE is not as effective as
trabeculectomy alone.108 Phacoemulsification
combined with trabeculectomy may be performed
at a single site using a modified scleral tunnel
incision, and this has been shown to provide better
long term postoperative control of intraocular
pressure than does ECCE combined with
trabeculectomy.109Although phacotrabeculectomy
may be performed under general or local
anaesthesia, topical anaesthesia requires the
addition of subconjunctival anaesthetic.110
Numerous phacotrabeculectomy techniques have
been described, but a fornix based conjunctivalflap combined with a scleral tunnel incision iseasiest to perform and does not compromiseoutcome.111 To provide an adequate superficialscleral flap, the tunnelled incision should becommenced more posteriorly than usual Thismay reduce movement of the phaco probe andcause compression of the irrigation sleeve, withheating of the wound and phaco burn A lateralscleral relieving incision, partly opening thesuperficial scleral flap, reduces these problems(Figure 10.26) Following phacoemulsificationand folding lens implantation, the scleral flap isproduced by incising anteriorly from the lateraledges of the incision A sclerostomy is most easilyproduced using a scleral punch (Figure 10.27),and a peripheral iridectomy is then performedwith scissors The scleral flap may then be suturedwith adjustable or releasable 10/0 nylon sutures.The conjunctiva is closed in a manner similar toany trabeculectomy with either absorbable ornon-absorbable sutures
Studies of single site phacotrabeculectomyhave suggested that its success may be lower thanthat with trabeculectomy performed in isolation.112This may be due to trauma, inflammation, andsubsequent scarring caused by phacoemu-lsification at the trabeculectomy site A singleintraoperative application of an antimetabolite,such as 5-fluorouracil (5FU), modifies thehealing response and improves the outcome of
149
Figure 10.26 Single site phacotrabeculectomy:
lateral relieving incision in a scleral tunnel (arrow) to
aid phaco probe movement and reduce the risk of
phacoburn.
Figure 10.27 Kelly sclerostomy punch (Altomed).
Trang 4trabeculectomy alone.113 Antimetabolites have
therefore been used as an adjunct to improve the
performance of phacotrabeculectomy Comparison
of phacotrabeculectomy and 5FU with
trabeculectomy and 5FU followed later by
phacoemulsification has shown similar long term
results in terms of intraocular pressure.114
Mitomycin C has also been shown to be effective
in conjunction with phacotrabeculectomy,115but
this antimetabolite has more potential for early
and late complications To minimise tissue
manipulation that occurs with a single site
phacotrabeculectomy, two site surgery may offer
advantages Typically, a temporal clear corneal
incision is used for phacoemulsification and a
separate trabeculectomy is performed
superiorly.116 Although good results have been
reported using this approach, it does require the
surgeon to move position during surgery
Previous glaucoma surgery
Patients who have undergone trabeculectomy
may develop cataract, or pre-existing cataract
may progress following filtration surgery
Poorly dilating pupils or a shallow anterior
chamber may then complicate cataract
extraction Cataract surgery must also avoid
damage to a functioning bleb and, as far as
possible, must not compromise long term
control of intraocular pressure Unless bleb
revision is planned as part of surgery, a corneal
incision anterior to the bleb is usually adopted
during ECCE This avoids injury to the bleb,
but the anterior position of the incision makes
postoperative astigmatism and endothelial cell
loss more likely In patients who have had
filtration surgery and subsequently had cataract
extraction, intraocular pressure is better
controlled by phacoemulsification than by
ECCE.117 Clear corneal phacoemulsification
using a temporal approach minimises the risk
to the filtering bleb and is the operation of
choice
Lens induced glaucoma
Cataract surgery is the definitive treatmentfor lens induced glaucoma, which should ideally
be performed soon after intraocular pressure iscontrolled This is particularly relevant inphacomorphic glaucoma, in which permanentperipheral anterior synechiae may develop andprevent a return to normal pressures Ifpermanent peripheral anterior synechiae arepresent, then a combined procedure is usuallyrequired Corneal oedema, the risk of unstablezonules, and difficulty in obtaining a capsulorhexismay be indications for an ECCE.118Capsulorhexis is complicated both by the lack ofred reflex and the tension a tumescent lensplaces on the anterior capsule Puncture of theanterior capsule with a standard rhexis needle orcystotome may then result in a rapidlypropagating radial tear This can usually beovercome by using a suitable viscoelastic totamponade the anterior chamber and aspiration
of lens material through a narrow (30 G) needle(see Chapter 3).119 Although poor pupildilatation and unstable zonules may also bepresent, phacoemulsification may then bepossible and provide the advantages of smallincision surgery with “in the bag” IOLimplantation
Lens implantation
In most glaucoma patients anterior chamberlens implantation should be avoided, and theideal position for the IOL is the posteriorchamber within the capsular bag.Phacoemulsification allows the use of a foldableposterior chamber lens implanted through asmall incision During phacotrabeculectomy afoldable lens can be inserted either through thetrabeculectomy opening or a separate cornealincision without the need for woundenlargement Foldable silicone lens implantation
in conjunction with single site culectomy does not appear to impact negatively
phacotrabe-150
Trang 5on bleb formation or control of intraocular
pressure when compared with the use of a
PMMA lens.120Anterior chamber inflammation,
as measured by the laser flare meter, is more
prolonged after phacoemulsification than after
trabeculectomy.121 Postoperative inflammation
may be a relevant factor in the failure of
drainage procedures, and the biocompatibility
of the IOL material is therefore of particular
importance in combined procedures (see
Chapter 7).122 Implant biocompatibility and
IOL selection is also relevant following cataract
surgery in eyes that may be associated with
increased postoperative inflammation, for
example those with phacomorphic or phacolytic
glaucoma
Postoperative management
It is important that all viscoelastic is removed
from the anterior chamber at the end of surgery
because this is recognised to cause a
postoperative pressure rise.123 Despite this the
intraocular pressure frequently elevates during
the first 24 hours following cataract surgery and
may exceed 35 mmHg.124 In patients with
existing glaucoma and optic nerve damage,
medical prophylaxis to prevent this pressure
spike is required, such as a single dose of oral
Diamox SR 250 mg (Wyeth) Six hours after
cataract surgery, intraocular pressure has been
shown to be statistically higher in patients with a
scleral tunnel incision as compared with a clear
corneal incision.125 Following cataract surgery,
patients with glaucoma may be more likely to
have additional postoperative inflammation,
particularly those that have suffered an episode
of acute angle closure glaucoma Topical
steroids may be required at a higher
concentration or frequency These patients
should be carefully followed up in view of the
risk of a steroid response and intraocular
pressure elevation
Paediatric cataract
The treatment of paediatric cataract is acomplex subspeciality area It often requires amultidisciplinary team of doctors and eyeprofessionals to work closely with the child andparents Ocular examination may be difficultand surgery is technically challenging At allstages of treatment it is imperative that thechild’s parents fully understand the relevantissues and are able to be actively involved in thedecision making process This is particularlyimportant because intensive management ofamblyopia and refractive error after surgery arethe key to effective treatment Despite this, asuccessful outcome is not guaranteed,particularly in unilateral cataract
Preoperative management
Ophthalmologist, optometrist, orthoptist, andpaediatric anaesthetist all play important roles inthe management of paediatric cataract Ageneticist and paediatrican may also be required
if a cataract is associated with a systemicdisorder Clear information should be provided
to the parents of the affected child from theoutset It is often difficult to determine the visualimpact of a cataract on a preverbal infant The
151
Figure 10.28 Altered red reflex in a typical congenital cataract.
Trang 6appearance of the red reflex (Figure 10.28) and
fixation pattern may be useful indicators, but
fixed choice preferential looking and visual
evoked potentials provide a subjective
assessment of acuity Examination under
anaesthesia allows the appraisal of cataract
morphology, which may also be an indicator of
its visual significance Features that favour
surgery include large, axial, dense, or posterior
cataracts Pupil dilatation may benefit eyes with
less significant cataract but success can be
limited by loss of accommodation and glare
Patients with bilateral visually significant
cataracts should undergo surgery within three
months of age to minimise the risk of developing
irreversible amblyopia and nystagmus.126 The
second eye should have surgery within one week
of the first (intermittently patching the operated
eye in the interim) The management of unilateral
visually significant cataract is more controversial.127
The results of cataract surgery in these
circumstances are variable and good outcomes are
only obtainable with early surgery (as early as six
weeks of age128) and intensive treatment of
amblyopia This has a risk of inducing amblyopia
in the non-affected eye and requires substantial
long term commitment from the child’s parents
Surgery is unlikely to be effective if there is a
coexisting ocular disorder such as retinopathy of
prematurity or sclerocornea The decision to
operate on unilateral cataract should also be
carefully considered if severe systemic disease is
present or if the parents or child are unlikely to
manage amblyopia treatment
Cataract presenting later in infancy poses a
management problem because surgery may be of
little use if visually significant cataract has existed
since birth but has gone undetected Lack of
strabismus or nystagmus in an older infant with a
substantial lens opacity may indicate that an
initially insignificant cataract has progressed, and
surgery may be worthwhile in such cases
Surgical technique
Spin-off techniques from phacoemulsification
have been incorporated into paediatric cataract
extraction, but there are several aspects of thissurgery that differ from that in adults Theserelate to the soft lens, anatomical differences,and the need to address the high incidence ofposterior capsular and anterior hyaloid opacityfound postoperatively.129 Scleral or cornealtunnelled incisions can be used in infants buthave a tendency to leak and should be sutured atthe end of the procedure
The thin flexible sclera in the paediatric eye isthought to account for the tendency of theanterior chamber to collapse during surgery,particularly when instruments are removed fromthe eye This may be minimised by using ananterior chamber maintainer (Figure 10.29)throughout surgery and ensuring thatanaesthesia is deep enough to preventextraocular muscle contraction The lenscapsule is also highly elastic as compared withthat in adults, and this makes anteriorcontinuous curvilinear capsulorhexis difficult.Alternative techniques that have been suggestedinclude radiofrequency diathermy capsulorhexis130and central anterior capsulotomy performedwith a vitrector The vitrector can then be used
to aspirate the lens and perform a posteriorcapsulotomy with anterior vitrectomy Thisremoves the need for secondary surgicalintervention to clear the visual axis Posteriorcapsulorhexis has been reported as an effectivealternative, which allows “in the bag” IOL152
Figure 10.29 A self-retaining Lewicky anterior chamber maintainer (BD Ophthalmic Systems).
Trang 7implantation.131Although a phacoemulsification
probe can be used for lens removal, irrigation
and aspiration equipment, especially bimanual
instruments, are probably less traumatic and
safer An aspiration port with a diameter larger
than that usually found on a standard
instrument (0·35 mm) may be more effective
Pars plana lensectomy has been used to
remove paediatric cataracts,132but the long term
risk of posterior segment complications are largely
unknown and usually little capsule remains to
support an IOL Intracapsular surgery is not
appropriate in children because of the strong
attachments between the posterior capsular and
the anterior vitreous, which may cause substantial
vitreous loss and risk retinal detachment
Lens implantation and selection of power
Lens implantation as a primary procedure is
increasingly common in all children.133The long
term complications of anterior chamber lenses
preclude their use, and the ideal site for an IOL
is within the capsular bag in the posterior
chamber PMMA is the only implant material
that has sufficient follow up to allow safe
implantation in infants Although lenses with
optics constructed from highly biocompatible
foldable materials may offer advantages, at
present their long term outcomes are unknown
Lenses designed specifically for the paediatic eye
are available but adult lenses can be used,
providing their overall diameter is not greater
than 12 mm
During the first six to eight years of life the
infant eye undergoes a substantial myopic shift
from hypermetropia to emmetropia.134 There
is general agreement that an IOL implant
should aim to anticipate this with an initial
hypermetropic over-correction.133The extent of
intentional hypermetropia depends on the age of
the child at time of surgery Residual refractive
error must then be corrected with spectacles
(bifocals), contact lenses, or a combination (to
prevent amblyopia) Relative contraindications
to IOL implantation are anatomical ocular
abnormalities such as microphthalmos orpersistent hyperplastic primary vitreous Contactlenses are the main alternative to IOLimplantation, although aphakic spectacles may
be used Refractive corneal techniques, forexample epikeratophakia, have largely beenabandoned in favour of lens implantation
Postoperative management
The key to the treatment of paediatric cataract
is the postoperative management of amblyopiaand refractive error This requires a major inputfrom the child’s parents that may put a strain onfamily life The parents may need supervision andhelp in many aspects of postoperative careincluding, for example, contact lens care andhandling In young infants incremental part timepatching reduces the risk of inducing amblyopia inthe better or normal eye Daily wear or extendedwear contact lenses can be used to correctrefractive error, usually with a lens power designed
to achieve near vision (i.e induce a low degree ofmyopia)
Refraction and postoperative assessment mayrequire multiple examinations under generalanaesthesia Intraocular inflammation commonlycomplicates paediatric cataract surgery, and mayrequire intensive topical steroids and, in somecases, recombinant TPA Other frequentcomplications include glaucoma and, aspreviously mentioned, posterior capsule andanterior hyaloid opacification.135 The latterrequires either Nd:YAG capsulotomy or a surgicalprocedure to clear the visual axis Because of thelifetime risk of glaucoma and retinal detachment,patients should be monitored in the long term.136
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