Cataract Surgery in Complicated Cases

255 Pages·2013·34.589 MB·English

by  Lucio Buratto MD, Stephen Brint MD, Luigi Caretti MD

Lucio Buratto, MD
Centro Ambrosiano Oftalmico
Milan, Italy
Stephen F. Brint, MD, FACS
Associate Clinical Professor of Ophthalmology
Tulane University School of Medicine
New Orleans, Louisiana
Luigi Caretti, MD
Chief Consultant
UOC (Complex Operative Unit)
Eye Department of ULSS 16 Health Trust
Padua, Italy
www.Healio.com/books
ISBN: 978-1-61711-607-0
Copyright © 2013 by SLACK Incorporated.
Illustrations courtesy of Massimiliano Crespi and Lucio Burrato.
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Lucio Buratto, MD, has no financial or proprietary interest in the materials presented herein.
Stephen F. Brint MD, FACS, has no financial or proprietary interest in the materials presented herein.
Luigi Caretti, MD, has no financial or proprietary interest in the materials presented herein.
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Library of Congress Cataloging-in-Publication Data
Buratto, Lucio.
Cataract surgery in complicated cases / Lucio Buratto, Stephen Brint, Luigi Caretti.
; cm.
Rev. ed. of: Cataract surgery in complicated cases, c2000.
Includes bibliographical references and index.
ISBN 978-1-61711-607-0 (hardback : alk. paper)
I. Brint, Stephen F., 1946- II. Caretti, Luigi. III. Cataract surgery in complicated cases. IV. Title.
[DNLM: 1. Cataract Extraction. WW 260]

617.7’42059--dc23
2012039642
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D
EDICATION
To my little grandchildren, Bianca, Achille, and Kaito.
Lucio Buratto, MD
To Mark and those who have taught me cataract surgery through the years.
Stephen F. Brint, MD, FACS
To my father and my mother.
Luigi Caretti, MD
C
ONTENTS
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Chapter 1 Pediatric Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 2 Congenital Subluxation of the Crystalline Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Chapter 3 Cataract and Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Chapter 4 Pseudoexfoliation Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Chapter 5 Phacoemulsification With a Small Pupil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Chapter 6 Cataract Surgery in Age-Related Macular Degeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Chapter 7 Brunescent Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Chapter 8 Cataract in High Myopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Chapter 9 Cataract in Severe Hyperopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Chapter 10 Cataract in Retinitis Pigmentosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Chapter 11 Cataract Surgery in Patients With Uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Chapter 12 Floppy Iris Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Chapter 13 Management of Cataract in Diabetic Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Chapter 14 Role of Vitreoretinal Surgery in Cataract Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Chapter 15 Traumatic Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Chapter 16 Cataract in Aniridic Eyes and Other Iris Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapter 17 Cataract and Corneal Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Chapter 18 Cataract Surgery Following Implantation of a Phakic Intraocular Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203
Chapter 19 Secondary Intraocular Lens Implants in Eyes With or Without Capsular Support . . . . . . . . . . . . . . . . . . . . . 213
Chapter 20 Intraocular Lens Explantation and Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
A
CKNOWLEDGMENTS
Publishing a book is a very exhausting task. There is an incredible amount of work involved. All this would not have
been possible without the smooth-running organization and help of a number of people who I would now like to thank
personally: Luigi Caretti, with his surgical knowledge and his clinical background, contributed to the highly scientific con-
tent of this book. My sincere appreciation to Steve Brint for his invaluable contribution, his scientific skill, and for supervi-
sion of the English translation. My sincere thanks goes to Massimiliano Crespi, the artist who realized all the magnificent
drawings and particularly for his ability to transfer the author’s thoughts onto paper; also Salvatore Ferrandes, who was
responsible for the clinical iconographic portions. I also would like to thank the staff of Medicongress Camo, in particular
Monica Gingardi, for the organizational and operational support provided. My translator, Fiona Johnston for her precise
and accurate translation of the Italian texts. Many thanks also to Vittorio Picardo, a warm friend, for supervision of the
final text in Italian and AISO (Accademia Italiana di Scienze Oftalmologiche) for the scientific support and grant for the
publication of this work. Finally I would like to thank SLACK Incorporated, my publisher, for asking me to produce a new
book on cataract surgery.
Lucio Buratto, MD
A A
BOUT THE UTHORS
Lucio Buratto, MD, is a leading international expert in cataract and myopia surgery and a pioneer in ocular techniques,
intraocular lens (IOL) implantation, in the phacoemulsification procedure for the cataract, and in laser techniques for
myopia, astigmatism, and hyperopia. In 1978, he began using the Kelman phacoemulsification technique and in 1979,
started using posterior chamber IOLs. Since 1980, he has organized and presided over 48 updating congresses on the
cataract and glaucoma surgeries and on laser therapy, has taken part as spokesman and teacher for more than 400 courses
and congresses, and has organized 54 practical courses for the teaching of eye surgery. In 1989, he presented the excimer
laser intrastromal keratomileusis, and was the first surgeon in the world to use it, while concurrently he started to treat
low myopia using PRK techniques. In 1995, he was appointed Monitor of the US Food and Drug Administration (FDA).
In 1996, he was the first surgeon in the world to use the Down-Up LASIK technique that improved the previous LASIK
procedure for the correction of myopia and for which he holds a USA patent. For teaching purposes, he has performed
surgical operations during live surgery sessions for more than 200 international and Italian congresses and has performed
surgery during satellite broadcasts to 54 countries on 4 different continents. He has designed and produced 143 instru-
ments for ocular surgery. In 2004, he was a speaker at the Binkhorst Medal Lecture during the XXII Annual Meeting of the
European Society of Cataract and Refractive Surgeons (ESCRS; Paris, France) and was the first European surgeon to use
the new Intralase laser for refractive surgery. In 2011, he was the first western European surgeon to use the Femtosecond
laser for cataract surgery.
Dr. Buratto has been published in more than 125 scientific publications and 59 monographs (of which 24 are on cataract
surgery, 5 are on glaucoma surgery, and 11 are on myopia). Recent works include Phakic IOLs: State of the Art, LASIK: The
Evolution of Refractive Surgery, and PPRK: The Past, Present, and Future of Surface Ablation.
Stephen F. Brint, MD, FACS, was the first physician in the United States to perform the LASIK procedure in June 1991,
after working with Dr. Lucio Buratto in Milan to perfect the technique. He was the Medical Monitor of the first US FDA
LASIK study and has been a lead investigator for both the Alcon Custom Cornea LASIK procedure as well as the Medical
Monitor for all of the US FDA Wavelight Allegretto Wavefront Optimized and Custom studies. He graduated from Tulane
University School of Medicine, New Orleans, Louisiana, and completed his residency there as well in 1977, and continues
to serve as Associate Clinical Professor of Ophthalmology. In addition to his vast LASIK experience of over 30,000 LASIK
procedures, many with the Intralase All Laser LASIK technique, he is a renowned cataract/lens surgeon, having partici-
pated in the US FDA clinical trials of the new IOLs including the ReSTOR, ReZoom, and toric IOLs.
Dr. Brint is Board Certified by the American Board of Ophthalmology and a Fellow of the American College of
Surgeons. He has been recognized as “The Best Doctor in New Orleans” by New Orleans Magazine for the last 10 years
and has been selected by his peers for the 2000 to 2012 editions of The Best Doctors in America. He is a leading cataract
surgeon and instructor and the author of the 3 definitive textbooks on LASIK and cataract surgery including the most
recent Custom LASIK.
Dr. Brint performs surgery and lectures around the world, including Europe, Russia, China, Japan, Australia, Singapore,
Africa, and South America.
Dr. Brint has a passion for education and research, and, most recently, has been involved with the refinement of the
intraoperative aberrometer for selecting IOL power and femtosecond laser-assisted cataract surgery.
Luigi Caretti, MD, is the Chief Consultant at UOC (Complex Operative Unit) in the Eye Department of ULSS 16 Health
Trust in Padua, Italy.
He has considerable experience in surgery of the anterior and posterior segments and associated ocular structures;
as primary surgeon, he has performed more than 5000 surgical procedures. He manages the Vitreo-Retinal Surgery
Department of UOC (Complex Operative Unit) in the Eye Department in Padua. He has published 12 scientific articles
in national and international journals. He has been appointed Director of Vitreo Retinal Surgery in the UOS of ULSS 16
of Padua.
I
NTRODUCTION
During my professional life, I have published many books on cataract surgery; taking into account the foreign language
editions, there are 24.
Atlas of Intraocular Lenses, published in 1984, was the first Italian work to introduce the world of modern intraocular
lenses to Italian ophthalmologists. The last, Phacoemulsification: Principles and Techniques, published with Stephen Brint
by my American publisher SLACK Incorporated in 2003, was an internationally acclaimed work that has provided impor-
tant information covering the entire operative procedure; this work is still being used today.
Now, almost 10 years later, I am publishing 5 new works on cataract surgery with the help of 5 promising, young oph-
thalmologists.
The first of this series to be published with Mario Romano is Cataract Surgery Complications, about the difficult subject
of intra- and postoperative complications, their prevention, and treatment.
The next volume is Cataract Surgery in Complicated Cases, with Luigi Caretti, on the surgery of complicated cases—
another topic of great interest.
Finally, a three-part series titled Cataract Surgery, with each part addressing a different topic. Part 1, with Laura Sacchi,
deals with patient preparation and the initial part of the operation. Part 2, with Rosalia Sorce, addresses phacoemulsifica-
tion. Part 3, with Domenico Boccuzzi, addresses intraocular lenses.
With all those books there is the invaluable contribution of Stephen Brint, a renowned cataract surgeon and a very good
friend of mine.
I hope that these books will be useful and will constitute a source for teaching and consultation for all eye surgeons
lasting many years, resulting in continuous improvement.
Lucio Buratto, MD

1
Pediatric Cataract
The congenital cataract can be described as an opacity optical correction, intensive occlusive therapy, and good
of the lens, present at birth in one or both eyes. Due to its compliance of the family. It has been demonstrated that if
potential inhibitory effect on sight development, it is con- surgery can be postponed until the patient has reached his
sidered the world’s greatest cause of pediatric blindness, or her first birthday, the postoperative results will be better
affecting Third World countries in particular.1 because of greater ease and a lower incidence of postoperative
There are a number of factors that contribute to the man- complications. It is also important that the young patient be
agement difficulties of the congenital cataract, even though supervised long-term by a pediatric ophthalmologist with
surgery used to correct this defect has improved consider- considerable experience in this area. Contact lenses can be
ably over the past 30 years. In these cases, the most impor- used if necessary, if an IOL has not been implanted. However,
tant factor is the young patient’s age; the operation should in the majority of cases, the intermediate option of operat-
be performed very early in the first months of life. This ing when the child is between the ages of 3 and 7 months is
will avoid the onset of amblyopia from sight deprivation usually the most appropriate.
even though the literature reports statistically significant
increase in complications with surgery performed earlier
T P E
than 2 months of life. Consequently, it is recommended to HE REOPERATIVE XAMINATION
wait until the patient is at least 3 months old. Management
of the pediatric cataract is completely different from an Given that congenital cataract is sometimes associated
adult for a number of different reasons. Surgery in very with genetic syndromes, metabolic disorders, intrauterine
young patients is challenging to say the least; the tissues of infections, and ocular conditions with associated anomalies
a child’s eye react in a completely different way from adult of the iris and the angle, it is advisable that the preopera-
tissue. This means that the anterior segment surgeon has to tive examination by the pediatric ophthalmologist follows
use a number of unique maneuvers. that of the pediatrician. Through genetic tests, the pedia-
A good outcome requires absolute precision in every step trician will be able to classify whether the specific case is
of surgery; having said that, late complications may develop a syndrome that affects other organs or systems of the
with even the most successful surgery, and these may lead to newborn; a negative work-up will confirm the diagnosis of
a poor anatomical and functional result. Also these eyes may an isolated congenital cataract (ie, a child who is clinically
be affected by ocular anomalies that could jeopardize the out- healthy and an absence of infections affecting the mother
come of the operation (eg, miosis, capsular, zonular, iris, and and fetus during pregnancy). In this case, the family his-
angle anomalies) and greatly increase the degree of difficulty. tory can indicate whether there have been other cases in
In several scientific studies, even when the sample group the same family and provide an opportunity to construct
has not been randomized,2-5 a good clinical outcome has a model of hereditary transmission (through a dominant,
been achieved when the treatment is performed within the or more infrequently, a recessive gene). If the condition is
first 2 months of life (even though there is a much higher risk hereditary, the ophthalmologist and the pediatrician will
of complications), without the implantation of an intraocular inform the child’s parents of the risks that may affect other
lens (IOL), and accompanied by a prolonged and optimal pregnancies, depending on the mode of gene transmission
- 1 - Buratto L, Brint SF, Caretti L.
Cataract Surgery in Complicated Cases (pp 1-10).
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