This morning... Indications for surgery Normal cataract operation Common complications Premium IOLs

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1 This morning... Indications for surgery Normal cataract operation Common complications Premium IOLs

2 Cataract surgery is the commonest operation in the western world Age Success Poor vision 300,000 ops pa in UK (6/1000 pts)

3 Visual acuity in the operated eye on admission % 6/12 or better 45.1 <6/12 6/ <6/18 6/ <6/36-3/ <3/60 7.7

4 Cataract surgery has evolved from a sight saving procedure to an improved quality of vision procedure

5 Victim of its own success More ops - ferocious attack on costs Technology increases, cost increases Debate on what is necessary vs what is nice Who - consultant, non consultant, trainee?? Where - hospital, public/private facility, surgeon owned??

6 When to operate? Limited resources - entry criteria?? Acuity? second eye surgery? Need to be sensible

7 Snellen visual acuity is a poor index of Measures high contrast black on white vision only vision Daily life happens at lower contrast levels

8

9 Glare from scattered light

10 Posterior subcapsular cataract Good distance acuity Gross glare disability Disproportionate reading problems

11 Visual outcome 95% of patients with no comorbidity see >6/12 About 30 % pts have co morbidity (AMD, CSG, diabetic retinopathy)

12 Unhappy patients

13 Swedish Database 10,979 patients op pre and post op Catquest, 857 (7.8%) no benefit postop Correlation of poor patient reported outcomes Ocular co morbidity Surgical complication Postop complications Postop refraction Little preop disability Mats Lundstrom ESCRS 2013

14 Beware Patients with little functional disability Reasonable unaided near vision Loss of myopia/multifocality from nuclear sclerosis Improved UCDVA, worse UCNVA = unhappy

15 Studies show patients get as much satisfaction from second eye op as first Removes anisometropia Feel more balanced Better binocular vision ( esp co morbidity eg AMD, glaucoma etc)

16 Ideal situation Operate as soon as visual disability Rapid second eye surgery 85% rate outcome as good or excellent (Catquest) Economic - less visits, quicker rehabilition

17 The lens is about the same size as a Smartie and the problem is to get this out of the eye through the smallest possible incision!!

18

19 What can go wrong? Many things! Serious problems Posterior Capsular rupture - about 2% of cases Infection - about 3 cases / 10,000 Cystoid macular oedema

20 Rupture of posterior capsule - 2% of operations Risk of nuclear fragments falling into vitreous Lens fragments cause glaucoma and uveitis unless removed Needs dedicated vitreo-retinal procedure Difficulty placing IOL Risk of retinal detachment and cystoid macular oedema

21 Posterior Capsular Rupture

22 Factors associated with PCR * * * * Odds ratio Age > * Male gender 1.28 Glaucoma 1.3 Mature/brunescent lens 2.99* Pseudo lens exfoliation 2.92* Small pupil 1.45 Long axial length >26mm 1.47 Inability to lie flat 1.27 Alpha blocker 1.51 Trainee surgeon 3.73* Recognise risk factors and take precautions

23 Cystoid Macula Oedema 2% of patients Caused by inflammation in the eye Comes on 2 4 wks postop Commoner diabetics, surgical complications etc

24 OCT scans Prophylaxis G Tobradex QDS, G Yellox (NSAID) BD 3/52

25 Spectacle independence after surgery Premium Intraocular Lenses Treatment of astigmatism Restoration of accommodation (near vision without glasses)

26 Expensive IOLs Not available on the NHS Not reimbursed by Insurance Compamy

27 Astigmatism is a shape change of the cornea A sphere has the same radius of curvature in all axis With astigmatism there is a steep radius of curvature and a flatter radius of curvature

28 Treatment of Astigmatism By incisions on the steep axis With a toric intraocular lens

29 Correction of astigmatism Any eye with > 1diopter, very worthwhile Surgical incisions for small amounts Toric IOLs more predictable Precision is extremely important 10⁰ off axis (1mm) results in 33% loss of effect

30

31 Restoration of accommodation - good distance and near vision without glasses no such thing as a truly accommodative IOL multifocal IOLs multifocality

32 Single focus Monofocal Multifocal

33 Multifocal IOLs Very sophisticated diffractive optics Diffraction grating on surface of the IOL Rapidly moving field

34 Apodised diffractive optics

35 Diffractive optics - multifocal intraocular lens

36 Problems Loss of contrast - 40% of light at each focus, 20 % lost Fixed focal distances, reduced intermediate vision Glare and haloes Cost Convenience at the expense of some loss of quality of vision Suitable for about 10% of patients - patient selection is crucial Rapidly changing area

37 Conclusion The ball never stops rolling.

38 Eye Services At Parkside Very well equipped for front of the eye - cataract, glaucoma State of the art equipment Superb theatres and nursing

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