Minimally Invasive Ophthalmic Surgery (eBook)

Dedication 5
Preface 6
Acknowledgements 7
Contents 8
Contributors 9
Chapter 1 11
Minimally Invasive Oculoplastic Surgery 11
1.1 General Points 11
1.2 Lower Lid Entropion 11
1.2.1 Introduction 11
1.2.2 Lower Lid Entropion Sutures 12
1.2.3 Lower Lid Entropion Botulinum Toxin 13
1.3 Lower Lid Ectropion 14
1.3.1 Introduction 14
1.3.2 The Royce Johnson Suture 15
1.3.3 The Pillar Tarsorrhaphy 15
1.4 Distichiasis 18
1.4.1 Introduction 18
1.4.2 Direct Excision of Lashes 19
1.5 Ptosis 19
1.5.1 Introduction 19
1.5.2 Posterior Approach Muller’s Muscle-Conjunctival Resection 19
1.5.3 Anterior Approach – One Stitch Aponeurosis Repair 20
1.5.4 Supramid Brow Suspension 22
1.6 Lid Retraction 23
1.6.1 Introduction 23
1.6.2 Koornneef Blepharotomy 23
1.6.3 Botulinum Toxin 25
1.7 Lid Tumours 25
1.7.1 Mohs’ Micrographic Surgery 25
1.7.2 Lamella Sparing Tumour Excision 28
References 29
Chapter 2 32
Minimally Invasive Conjunctival Surgery 32
2.1 Conjunctival Surgery 32
2.2 Conjunctivochalasis 32
2.2.1 Background of the Disease 32
2.2.2 Indication for Surgery 33
2.2.3 Basic Concept of Surgery 33
2.2.4 Surgical Procedure 33
2.2.5 Postoperative Follow-Up 35
2.3 Pterygium 35
2.3.1 Background of the Disease and the Concept of Minimally Invasive Surgery 35
2.3.2 Indication for Surgery 37
2.3.3 Basic Concept of Surgery 37
2.3.4 Surgical Procedures 37
2.3.5 A Biologic Adhesive for Sutureless Pterygium Surgery 38
2.3.6 Postoperative Follow-Up 38
2.4 Limbal and Conjuntival Dermoids 39
2.4.1 Background of the Disease 39
2.4.2 Basic Concept of Surgery 39
2.4.3 Surgical Procedure 39
2.4.4 Postoperative Follow-Up 39
2.5 Strabismus Surgery 39
2.6 Conclusion 39
References 41
Chapter 3 42
Minimally Invasive Lacrimal Surgery 42
3.1 Introduction 42
3.1.1 Causes of Stenoses of the Lacrimal Drainage System 42
3.1.2 Diagnosis of Stenoses of the Lacrimal Drainage System 42
3.1.3 General Remarks Regarding Surgical Management 43
3.2 Endonasal Endoscopic (Microscopic) Dacryocystorhinostomy (EDCR) 44
3.2.1 Indication for EDCR 44
3.2.2 Surgical Technique 44
3.2.3 Silicone Stenting for EDCR 47
3.2.2.1 Silicone “Cones” (Lacrimal Duct Stent, Bess, Berlin) 48
3.2.4 Use of Mitomycin C for EDCR 48
3.2.5 Post-Operative Care After EDCR 49
3.2.6 Results of EDCR 49
3.3 Endonasal Endoscopic Laser Dacryocystorhinostomy (ELDCR) 50
3.3.1 Indications for ELDCR 51
3.3.2 Contraindications for ELDCR 51
3.3.3 Surgical Technique for ELDCR 52
3.3.4 Potential Problems with ELDCR 53
3.3.5 Post-Operative Care After ELDCR 54
3.3.6 Results of ELDCR 54
3.3.7 Post-Operative Complications After ELDCR 54
3.4 Dacryoendoscopy with Transcanalicular Laserdacryoplasty (TLDP) 55
3.4.1 Indication for TLDP 55
3.4.2 Contraindication for TLDP 56
3.4.3 Surgical Technique for TLDP 56
3.4.4 Results of TLDP 56
3.4.5 Post-Operative Care and Complications of TLDP 56
3.5 Microdrill Dacryoplasty (MDP) 56
3.5.1 Indication for MDP 57
3.5.2 Contraindication for MDP 57
3.5.3 MDP Procedure 57
3.5.4 Results of MDP 57
3.5.5 Post-Operative Care and Complications of MDP 57
3.6 Balloon Dilatation 57
3.6.1 Indications for Balloon Dilatation 58
3.6.2 Anaesthesia for Balloon Dilatation 58
3.6.3 Surgical Technique with 2 mm or 3 mm Balloon for Incomplete Stenosis 58
3.6.3.1 Post-Operative Care 60
3.6.3.2 Complications 60
3.6.3.3 Results 60
3.6.4 Surgical Technique with 5 mm Balloon for Complete Stenosis or Revision Cases of DCR According to Ref. 60
3.6.4.1 Post-Operative Care 61
3.6.4.2 Results 61
3.6.4.3 Complications 62
3.7 Stent Placement 62
3.7.1 Indications for Stent Placement 62
3.7.3 Surgical Technique for Stent Placement 62
3.7.4 Post-Operative Care and Complications After Stent Placement 63
3.7.5 Results of Stent Placement 63
References 64
Chapter 4 67
Minimally Invasive Corneal Surgery 67
4.1 Penetrating Keratoplasty 67
4.1.1 Introduction 67
4.1.2 Indications 67
4.1.3 Preoperative Evaluation of the Keratoplasty Patient 68
4.1.4 Preparation for Penetrating Keratoplasty 70
4.1.4.1 Eyelid Speculum 70
4.1.4.2 Scleral Fixation Rings 70
4.1.4.3 Large and Fine-Tipped Needle Holder 70
4.1.4.4 Toothed Forceps 70
4.1.4.5 Trephine Blades 71
4.1.4.6 Radial Marker 71
4.1.4.7 Cornea Punch 72
4.1.4.8 Cutting Block 72
4.1.4.9 Scissors 72
4.1.4.10 Cannulas and Blades 72
4.1.5 Preoperative Medications 73
4.1.6 Penetrating Keratoplasty Surgical Procedure 73
4.1.6.1 Placement of the Scleral Fixation Ring 74
4.1.6.2 Marking of the Host Cornea 74
4.1.6.3 Sizing of the Trephine 74
4.1.6.4 Trephination of the Host Cornea 74
4.1.6.5 Trephination of the Donor Cornea 75
4.1.6.6 Removal of the Host Cornea 75
4.1.6.7 Placement of the Donor Cornea Tissue in the Host Stromal Bed 75
4.1.6.8 Placement of the Cardinal Sutures 75
4.1.6.9 Completion of Suturing 76
4.1.6.10 Suture Techniques 76
4.1.6.11 Subconjunctival Medications 76
4.1.7 Intraoperative Complications 76
4.1.7.1 Scleral Perforation 77
4.1.7.2 Damage to the Donor Button 77
4.1.7.4 Posterior Capsule Rupture 77
4.1.7.5 Vitreous Loss 77
4.1.7.6 Anterior Chamber Hemorrhage 78
4.1.7.7 Choroidal Hemorrhage 78
4.1.8 Postoperative Management 78
4.1.8.1 Postoperative Immunosuppressive Regimen 79
4.1.9 Postoperative Complications 79
4.1.9.1 Wound Leaks 79
4.1.9.2 Epithelial Defects 79
4.1.9.3 Suture-Related Problems 80
4.1.9.4 Increased Intraocular Pressure 80
4.1.9.5 Post-Keratoplasty Astigmatism 81
4.1.10 Correction of Post-keratoplasty Astigmatism 82
4.1.10.1 Wedge Resections and Compression Sutures 82
4.1.10.2 Relaxing Incisions 82
4.1.10.3 LASIK 82
4.1.10.4 Photorefractive Keratectomy with Mitomycin C 83
4.1.11 Corneal Allograft Rejection 83
4.1.11.1 Host Risk Factors 84
4.1.11.2 Vascularized Corneas 84
4.1.11.3 Prior Graft Loss 84
4.1.11.4 Graft Diameter 84
4.1.11.5 Anterior Synechiae 85
4.1.11.6 Previous Intraocular Surgery 85
4.1.11.7 Herpes Simplex 85
4.1.12 Treatment of Allograft Rejection 86
4.1.13 Large Diameter Penetrating Keratoplasty 87
4.1.14 Summary 88
References 89
Chapter 5 91
4.2 Descemet’s Stripping Endothelial Keratoplasty 91
4.2.1 Introduction 91
4.2.2 Descemet’s Stripping Endothelial Keratoplasty Surgical Technique 92
4.2.2.1 Donor Cornea Preparation 93
4.2.2.2 Host Cornea Preparation 93
4.2.2.3 Insertion of the Donor Cornea 93
4.2.3 Postoperative Medications 93
4.2.4 Donor Dislocation Risks 94
4.2.5 Repositioning Donor Tissue 94
4.2.6 Treatment of Rejection Episodes 94
4.2.7 Visual and Refractive Outcomes 95
4.2.8 Other Complications 95
4.2.9 Summary 95
References 96
Chapter 6 97
4.3 Pterygium 97
4.3.1 Introduction 97
4.3.2 Treatment of Pterygium 97
4.3.3 Surgical Technique 98
4.3.3.1 Removal of the Pterygium 98
4.3.3.2 Harvesting the Conjunctival Autograft 98
4.3.3.3 Securing the Conjunctival Autograft 99
4.3.3.4 Fibrin Glue vs. Nylon Sutures 99
4.3.4 Postoperative Management 99
4.3.5 Recurrent Pterygium 101
4.3.6 Other Techniques in Pterygium Removal 101
4.3.6.1 Bare Scleral Technique 101
4.3.6.2 Adjunctive Agents 101
Mitomycin C 101
Beta-Irradiation 102
4.3.6.3 Amniotic Membrane Transplantation 102
4.3.6.4 Various Techniques in Conjunctival Autografting 102
4.3.7 Complications in Pterygium Removal 103
4.3.8 Summary 103
References 104
Chapter 7 105
Minimally Invasive Refractive Surgery 105
5.1 Trends in Refractive Surgery 105
5.2 Introduction 105
5.3 Cornea Refractive Surgery 106
5.3.1 Laser In Situ Keratomileusis (LASIK) 106
5.3.1.1 Advances in Flap Creation Technology 106
Microkeratomes 106
Femtosecond Laser 107
5.3.1.2 Technological Advances in Laser Delivery Platforms 110
5.3.1.3 Faster Excimer Lasers 110
5.3.1.4 Reduction of Collateral Thermal Tissue Damage 111
5.3.1.5 Advanced Eye Trackers 112
5.3.1.6 Newer Ablation Profi les 114
5.3.2 PRK and Advanced Surface Ablations (ASA) 114
5.3.2.1 Decrease Thermal Load on the Cornea 114
5.3.2.2 Use of Wound-Healing Modulators 115
5.3.2.3 Trend Towards EPI-LASIK 115
5.3.3 Summary 116
5.4 Intraocular Refractive Surgery 116
5.4.1 Phakic Intraocular Lens Surgery 116
5.4.1.1 Advances in Diagnostic Equipment 117
5.4.1.2 Types of Phakic Intraocular Lens 118
5.4.1.3 Kelman-Duet Phakic Intraocular Lens 118
Lens Design 118
Surgical Technique 118
Pre-Operative Preparation 118
Operative Procedure 119
Post-Operative Care 119
Results 119
Refractive Outcomes 119
Corneal Endothelium 119
5.4.1.4 Visian Implantable Collamer Lens 122
Lens Design 122
Surgical Technique 122
Pre-Operative Preparation 122
Operative Procedure 122
Post-Operative Care 123
5.4.1.5 Results 123
5.4.2 Summary 123
5.5 Lens and Cataract Surgery 123
5.5.1 Surgery: Micro-Incisional Cataract Surgery (MICS) 124
5.5.2 The Ideal MICS Intraocular Lens 125
5.5.2.1 Aspheric Intraocular Lenses 125
5.5.2.2 Toric Intraocular Lenses 125
5.5.2.3 ACRI.LISA 366D and ACRI.LISA TORIC 466TD 126
Lens Design 126
5.5.2.4 Surgical Technique 126
Operative Procedure 126
Post-Operative Care 127
5.5.2.5 Results 127
5.5.3 Summary 127
5.6 The Future: Beyond the Horizon of Refractive Surgery Today 127
Reference 128
Chapter 8 131
Minimally Invasive Strabismus Surgery 131
6.1 Introduction 131
6.2 Nonsurgical Treatment 131
6.3 Types and Classifi cation of Conjunctival Openings 132
6.4 Rectus Muscle Procedures 132
6.4.1 MISS Rectus Muscle Recession 134
6.4.2 MISS Rectus Muscle Plication 137
6.4.3 Parks’ Rectus Muscle Recession 137
6.4.4 Parks’ Rectus Muscle Plication 137
6.4.5 MISS Rectus Muscle Posterior Fixation Suture 139
6.4.6 Priglinger’s Rectus Muscle Y-Split Recession 140
6.4.7 MISS Rectus Muscle Repeat Surgery 140
6.4.8 MISS Rectus Muscle Transposition Surgery 145
6.5 Oblique Muscle Procedures 147
6.5.1 MISS Inferior Oblique Muscle Recession 149
6.5.2 MISS Inferior Oblique Muscle Plication 150
6.5.3 MISS Superior Oblique Muscle Recession 150
6.5.4 MISS Superior Oblique Muscle Plication 151
6.5.5 Boergen’s Modifi ed Harada-Ito Operation 151
6.5.6 Mühlendyck’s Partial Posterior Superior Oblique Tenectomy for Congenital Brown’s Syndrome 151
6.6 Postoperative Handling 154
6.7 Specifi c Complications of MISS 154
6.7.1 Intraoperative Complications 154
6.7.2 Postoperative Complications 156
6.8 Suggestions on How to Start Doing MISS 157
6.8.1 Instruments Suitable for MISS 157
6.8.2 Suture Materials Used for MISS 158
6.8.3 General Remarks Regarding MISS Procedures 159
6.8.4 MISS Dose–Response Relationships 159
References 160
Chapter 9 161
Minimally Invasive Iris Surgery 161
7.1 Instrumentation 161
7.2 Sutures 161
7.3 Surgical Principles of Iris Suturing 161
7.3.1 Mobilization 161
7.3.2 Intraocular Suturing and Knot Tying 162
7.3.3 Reattachment of Iris to Sclera 163
7.3.4 Pupil Repair 165
7.3.5 Adjunctive Pupil Repair Techniques 167
References 167
Chapter 10 168
Minimally Invasive Glaucoma Surgery 168
Introduction 168
8.1 Deep Sclerectomy: A Nonpenetrating Filtering Surgery 168
8.1.1 Introduction to Deep Sclerectomy 168
8.1.2 Anesthesia 169
8.1.3 Surgical Technique 169
8.1.3.1 Preparation 169
8.1.3.2 Superfi cial Flap Preparation 170
8.1.3.3 Deep Flap Preparation 170
8.1.3.4 Dissection of the Trabeculo-Descemet’s Membrane 171
8.1.3.5 Peeling of Schlemm’s Canal and Juxtacanalicular Meshwork 172
8.1.3.6 Drainage Device 173
8.1.3.7 Wound Closure 173
8.1.4 Postoperative Management and Medication 174
8.1.4.1 Medication 174
8.1.4.2 Management 174
8.1.5 Adjunctive Treatments 175
8.1.5.1 Bleb Needling 175
8.1.5.2 Nd:YAG Goniopuncture 175
8.1.6 Complications and Management 175
8.1.6.1 General 175
8.1.6.2 Perioperative Complications 176
8.1.6.3 Early Postoperative Complications 176
8.1.6.4 Late Postoperative Complications 177
References 178
Chapter 11 179
8.2 Minimally Penetrating Glaucoma Surgery with the Ex-PRESS™ Miniature Shunt 179
8.2.1 Introduction to Glaucoma Surgery with the Ex-PRESS™ 179
8.2.1.1 Indications for MPGS with the Ex-PRESS™ Mini-Shunt Under a Scleral Flap 180
Open-Angle Glaucoma 180
Pigmentary Glaucoma 180
Pseudoexfoliation Glaucoma 181
Aphakic Glaucoma 181
Sturge–Weber Syndrome 181
Glaucoma Secondary to Uveitis 181
8.2.1.2 Relative Contraindications for MPGS with the Ex-PRESS™ Mini-Shunt Under a Scleral Flap 181
Congenital and Juvenile Glaucoma 181
Aniridia and Anterior Segment Dysgenesis Syndromes 182
Narrow-Angle Glaucoma 182
Posttrauma Angle-Recession Glaucoma 182
Neovascular Glaucoma 182
8.2.1.3 Absolute Contraindications for MPGS with the Ex-PRESS™ Mini-Shunt Under a Scleral Flap 182
Narrow-Angle Glaucoma in a Young Patient 182
Pseudophakic Glaucoma with an A/C IOL 182
8.2.1.4 Preoperative Considerations 182
8.2.2 Anesthesia 183
8.2.3 Surgical Technique and Potential Modifications 183
8.2.4 Postoperative Management and Medication 186
8.2.5 Outcomes and Comparison with Other Techniques 186
8.2.6 Complications and Management 186
8.2.6.1 General 186
8.2.6.2 Specifi c to the Technique 187
8.2.6.3 Several Characteristics of the Ex-PRESS™ Are Unique 187
8.2.6.4 Summary and Key Points 188
References 188
Chapter 12 190
8.3 New Minimally Invasive, Sclerothalamotomy Ab Interno Surgical Technique 190
8.3.1 Introduction to the Sclerothalamotomy Ab Interno 190
8.3.1.1 Indications for the Sclerothalamotomy Ab Interno 190
8.3.2 Anesthesia 190
8.3.3 Surgical Technique 190
8.3.3.1 Preparation 191
8.3.3.2 Diathermy Probe Insertion 191
8.3.4 Postoperative Management and Medication 192
8.3.5 Outcomes and Comparison with Other Techniques 192
8.3.6 Complications and Management 193
8.3.6.1 General 193
8.3.6.2 Specifi c to the Technique 193
8.3.6.3 Conclusions 195
References 196
Chapter 13 198
8.4 Glaukos® iStent® Trabecular Micro-Bypass Implant 198
8.4.1 Introduction to Glaucoma Surgery with a Micro-Bypass Implant 198
8.4.1.1 Indications for Implantation of Glaukos® iStent® Micro-Bypass Implant 199
Type of Glaucoma 199
Stage of Glaucoma 199
Combined Surgery 199
8.4.2 Anesthesia 200
8.4.3 Surgical Technique 200
8.4.3.1 Preparation 200
8.4.3.2 Implantation of the Micro-Bypass Stent 200
8.4.4 Postoperative Management and Medication 201
8.4.5 Outcomes and Combination with Other Techniques 201
8.4.5.1 Trabecular Implant in Refractory Glaucoma Patients 201
8.4.5.2 Phacoemulsifi cation Cataract Surgery Combined with Implantation of a Trabecular Stent 202
8.4.5.3 Phacoemulsifi cation Cataract Surgery Combined with Implantation of Two Trabecular Implants 203
8.4.6 Conclusions 203
References 203
Chapter 14 205
Minimally Invasive Cataract Surgery 205
9.1 Instrument List 205
9.2 Topical Anesthesia Protocol 207
9.2.1 Topical Technique 207
9.2.1.1 Materials 207
9.2.1.2 Procedures 207
9.2.3.3 Operating Room 207
9.2.3.4 Helpful Hints 209
9.3 Surgical Procedure 209
9.3.1 Incision Construction 209
9.3.2 Capsulorhexis 211
9.3.3 Hydrodissection and Hydrodelineation 212
9.3.4 Chopping and Phacoemulsifi cation 214
9.3.5 Cortical Clean-up 217
9.3.6 Limbal Relaxing Incisions 217
9.3.7 IOL Implantation 217
9.3.8 Stromal Hydration and Testing of Incisions 217
9.4 Postoperative Management 218
References 218
Appendix 1 220
Appendix 2 221
Appendix 3 222
Appendix 4 223
Appendix 5 224
Chapter 15 225
Minimally Invasive Vitreoretinal Surgery 225
10.1 Introduction 225
10.2 Microincision Vitrectomy 225
10.2.1 Models of Wound Architecture 227
10.2.2 Vitrectomy 227
10.2.3 Adjuncts 228
10.2.4 Common Surgical Techniques 229
10.2.4.1 Macular Surgery 230
10.2.4.2 Proliferative Diabetic Retinopathy 231
10.2.4.3 Retinal Detachment 231
10.2.4.4 Pediatric Vitreoretinal Surgery 232
10.2.5 Complications 232
10.2.6 Future Developments in Minimally Invasive Vitrectomy 232
10.3 Endoscopic Vitreoretinal Surgery 233
10.3.1 Introduction 233
10.3.2 History and Development of Endoscopic Ophthalmic Surgery 233
10.3.3 The Endoscope 233
10.3.4 Applications of Intraocular Endoscopy 234
10.3.4.1 Media Opacity 234
10.3.4.2 Subretinal Fluid Drainage and Fluid–Gas Exchange 234
10.3.4.3 PVR and Subretinal Surgery 235
10.3.4.4 Retained Lens Fragments 235
10.3.4.5 Anterior and Retrolental Vitrectomy in Malignant Glaucoma 235
10.3.4.5 Sutured IOL and ECP 235
10.3.5 Limitations and Challenges 235
10.4 Future Directions of Minimally Invasive Vitreoretinal Surgery 236
References 236
Index 240