Series Editor: Susan Lightman Fundamentals of Clinical Ophthalmology Cataract Surgery Andrew Coombes and David Gartry Fundamentals of Clinical Ophthalmology: Cataract Surgery Fundamentals of Clinical Ophthalmology series Cornea Edited by Douglas Coster Glaucoma Edited by Roger Hitchins Neuro-ophthalmology Edited by James Acheson and Paul Riordan-Eva Paediatric Ophthalmology Edited by Anthony Moore Plastic and Orbital Surgery Edited by Richard Collin and Geoffrey Rose Scleritis Edited by Paul McCluskey Strabismus Edited by Frank Billson Uveitis Edited by Susan Lightman and Hamish Towler Fundamentals of Clinical Ophthalmology: Cataract Surgery Edited by ANDREW COOMBES St Bartholomew’s Hospital and The Royal London Hospital, London, UK DAVID GARTRY Moorfields Eye Hospital, London, UK Series editor SUSAN LIGHTMAN Department of Clinical Ophthalmology, Institute of Ophthalmology/Moorfields Eye Hospital, London, UK © BMJ Publishing Group 2003 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 2003 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7279 1201 1 Typeset by SIVA Math Setters, Chennai, India Printed and bound in Malaysia by Times Offset v Contents Contributors vii Preface to the Fundamentals of Clinical Ophthalmology Series ix Preface xi Acknowledgements xiii 1 Teaching and learning phacoemulsification 1 2 Incision planning and construction for phacoemulsification 11 3 Capsulorhexis 25 4 Phacoemulsification equipment and applied phacodynamics 36 5 Phacoemulsification technique 46 6 Biometry and lens implant power calculation 66 7 Foldable intraocular lenses and viscoelastics 84 8 Non-phacoemulsification cataract surgery 102 9 Anaesthesia for cataract surgery 115 10 Cataract surgery in complex eyes 125 11 Vitreous loss 158 12 Postoperative complications 168 CONTENTS vi 13 Cataract surgery in the Third World 193 14 Cataract surgery: the next frontier 200 Index 208 vii Charles Claoe Consultant Ophthalmologist Harold Wood Hospital Essex, UK Andrew Coombes Consultant Ophthalmologist St Bartholomew’s Hospital and The Royal London Hospital London, UK Jack Dodick Chairman of the Department of Ophthalmology Manhattan Eye, Ear and Throat Hospital New York, USA Jonathan Dowler Consultant Ophthalmologist Moorfields Eye Hospital London, UK David Gartry Consultant Ophthalmologist Moorfields Eye Hospital London, UK Peter Hamilton Consultant Ophthalmologist Moorfields Eye Hospital London, UK Colm Lanigan Consultant Anaesthetist Lewisham Hospital London, UK Thomas Neuhann Consultant Ophthalmologist Munich, Germany Contributors Marie Restori Consultant Medical Physicist Moorfields Eye Hospital London, UK Paul Rosen Consultant Ophthalmologist The Radcliffe Infirmary Oxford, UK Helen Seward Consultant Ophthalmologist Croydon Eye Unit Surrey, UK Hamish Towler Consultant Ophthalmologist Whipps Cross Hospital London, UK Sarah-Lucie Watson Specialist Registrar Moorfields Eye Hospital London, UK David Yorston Specialist Registrar Moorfields Eye Hospital London, UK CONTRIBUTORS viii ix Preface to the Fundamentals of Clinical Ophthalmology series This book is part of a series of ophthalmic monographs, written for ophthalmologists in training and general ophthalmologists wishing to update their knowledge in specialised areas. The emphasis of each is to combine clinical experience with the current knowledge of the underlying disease processes. Each monograph provides an up to date, very clinical and practical approach to the subject so that the reader can readily use the information in everyday clinical practice. There are excellent illustrations throughout each text in order to make it easier to relate the subject matter to the patient. The inspiration for the series came from the growth in communication and training opportunities for ophthalmologists all over the world and a desire to provide clinical books that we can all use. This aim is well reflected in the international panels of contributors who have so generously contributed their time and expertise. Susan Lightman [...]... Hollick (Figures 7.4, and 12 . 21) , Alex Ionides (Figure 10 .29), James Kirwan (Figure 8 .13 b, 10 .23, 10 .24, 10 .26, 12 .13 , and 12 .22b), Frank Larkin (Figure 12 .14 ), Graham Lee (Figure 7.3a,b), Ordan Lehmann (Figures 8 .14 , 12 .12 , 12 .15 , 12 .18 , 12 .22a, 12 .24, and 12 .26), Martin Leyland (Figure 10 .16 ), and Chris Liu and Babis Eleftheriadis (Figure 7 .13 ) The staff in the day surgery unit at Chelsea and Westminster... exist Professor Susan Lightman and all at BMJ Books, particularly Mary Banks, must also be thanked for their part (and patience) Many individuals have contributed photographs and their help has been very much appreciated These include David Anderson (Figures 2 .14 , 3.3, 3.5, 5.3, 5.6, 5 .14 , and 7.20), Bill Aylward (Figure 10 . 21) , Caroline Carr (Figure 9.2a–f), Emma Hollick (Figures 7.4, and 12 . 21) , Alex... and is, without doubt, a fundamental part of ophthalmology This book aims to cover the subject comprehensively, particularly the technical aspects of learning, performing, and teaching phacoemulsification The inclusion of chapters on the Third World and the future of cataract surgery provide the reader with a broader perspective The structure of the text, cross-referencing between chapters, and a detailed... introductory course should consist of several key lectures, including the following: q The physics of phacoemulsification q Phacoemulsification incisions (corneal and scleral) q Capsulorhexis 1 CATARACT SURGERY q Principles of nuclear sculpting q Nuclear management q Aspiration of soft lens matter following phacoemulsification q Rigid, folding, and injectable lens insertion q Management of complications All trainees... theatre under the supervision of an experienced surgeon A period of 40–45 minutes dedicated to training, at the start of each operating list, enables the trainee to have regular teaching time This also ensures that a patient is not subjected to a particularly long operation, both in terms of the need for them to lie still and of macular light exposure (turning the operating light off or only using axial... example, once step 1 has been learnt steps 2, 3, and 1 may be combined Similarly once steps 4 and 5 are learnt, they can be combined with steps 1, 2, and 3 to build up to a complete case Table 1. 3 surgeons Sequence of steps for experienced cataract Step Details 1 Continuous curvilinear capsulorhexis through extracapsular incision or paracentesis Automated irrigation and aspiration for soft lens matter... skills Simulated surgery practice Figure 1. 1 A typical wet lab Note the use of the Maloney head (latrotech) to hold the artificial eyes Equipment A well equipped surgical wet laboratory (wet lab) (Figure 1. 1) is an ideal environment in which to practice phacoemulsification, and this should be supervised by an experienced surgeon A wet lab station should consist of the follwing items: q Microscope q Phacoemulsification... phacoemulsification, a different training plan is suggested (Table 1. 3) Capsulorhexis and hydrodissection are essential aspects of phacoemulsification techniques, and for the experienced surgeon they should become 8 Table 1. 2 trainees Reverse chain: sequence of steps for Step Details 1 2 3 4 5 Viscoelastic irrigation and aspiration Soft lens matter irrigation and aspiration Intraocular lens insertion... position 1 The sequence is then repeated The tip of the phaco needle should never be completely occluded, although the amount of the lens engaged by the phaco needle depends on the density of the nucleus In a soft nucleus up to half of the needle can be engaged and the phaco tip can be moved reasonably quickly Conversely, in a hard nucleus only about one fifth of the needle should be engaged and it must... within a single case For example, step 1 combined with step 2, followed by steps 1, 2, and 3 together part of their extracapsular surgery Following capsulorhexis, relieving incisions in the capsule opening allow expression of the crystalline lens, or it may be possible to simply viscoexpress or hydroexpress the nucleus Using automated irrigation and aspiration to remove soft lens matter familiarises the . 12 .22b), Frank Larkin (Figure 12 .14 ), Graham Lee (Figure 7.3a,b), Ordan Lehmann (Figures 8 .14 , 12 .12 , 12 .15 , 12 .18 , 12 .22a, 12 .24, and 12 .26), Martin Leyland (Figure 10 .16 ), and Chris Liu and Babis. Non-phacoemulsification cataract surgery 10 2 9 Anaesthesia for cataract surgery 11 5 10 Cataract surgery in complex eyes 12 5 11 Vitreous loss 15 8 12 Postoperative complications 16 8 CONTENTS vi 13 . Aylward (Figure 10 . 21) , Caroline Carr (Figure 9.2a–f), Emma Hollick (Figures 7.4, and 12 . 21) , Alex Ionides (Figure 10 .29), James Kirwan (Figure 8 .13 b, 10 .23, 10 .24, 10 .26, 12 .13 , and 12 .22b), Frank