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Today's Practice | May 2009

Cataract Surgery Coursework

The seventh module in this series focuses on cataract surgery.

This series of articles follows the nine modules of the University of Ulster's short E-learning courses in cataract and refractive surgery. This course can be taken online or as part of the postgraduate diploma. Students with the diploma can progress to a year of research, which results in the award of a Masters of Science in cataract and refractive surgery.

The subjects covered within this particular 4-week cataract course include: ophthalmic viscosurgical devices (OVDs), extracapsular cataract extraction (ECCE), endophthalmitis prophylaxis, IOL design, phacoemulsification, refractive cataract surgery, piggyback IOLs, postoperative cataract complications, Nd:YAG capsulotomy, biometry following laser refractive surgery and postoperative examination of the cataract patient.

WEEK 1
Professor Shah delivered the lecture on OVDs. Despite their relatively recent introduction into microsurgery, OVDs have become ubiquitous and invaluable in all facets of ophthalmic surgery. There are three categories: dispersive, which coat and protect the ocular structures well but are difficult to remove; cohesive, which maintain space well but are easily removed, which limits their ability to protect ocular structures; viscoadaptive, which combine benefits of both cohesive and dispersive OVDs.

Dr. Kadyan covered the origins of cataract and gave a brief history on the evolution of cataract surgery. Intra- and extracapsular surgery were discussed, including indications, techniques, and advantages and disadvantages. The lecture focused on ECCE, comparing traditional large incision surgery with small and microincision cataract surgery (SICS and MICS, respectively).

Professor Moore introduced endophthalmitis prophylaxis, noting that the causes include surgical intervention, trauma, and endogenous (interior of the eye is seeded with microbes that come from another distant site of infection).

The various clinical appearances of endophthalmitis were described. Discussions centered around the difficulties determining what form of prophylaxis or treatment regimen was most appropriate to reduce the rate of endophthalmitis. Participants also discussed how molecular diagnostic techniques may evolve to assist in prophylaxis, diagnosis, and treatment of endophthalmitis.

WEEK 2
Dr. Claoué discussed the conceptual aspects of IOL design, concentrating on IOL platforms, materials, construction, design, blue-blocking IOLs, IOL calculations, lower- and higher-order aberrations, multifocal IOLs, and future designs.

Drs. Avgikos, Tu, and Aslanides provided a lecture on phacoemulsification, including the divide-and-conquer, horizontal chop, stop-and-chop, quick chop, and phaco prechop techniques. Each technique was evaluated through the personal experience of course members. Common agreement was that the stop-and-chop was the easiest to adopt after previously using divide-and-conquer.

Professor Shah discussed the recent advances in optimizing outcomes from cataract surgery and applying certain aspects to other forms of intraocular surgery.

Control of astigmatism at the time of cataract surgery was a major theme of the lecture, with the use of techniques such as limbal relaxing incisions. Different IOL types were considered in terms of material, edge design, and pseudoaccommodative abilities. Additional techniques were described that could be employed after cataract surgery to fine-tune results, such as LASIK, LASEK, or PRK.

Dr. Aralikatti and Professor Shah provided the final lecture this week, which discussed the indications, types, power calculations, advantages over IOL exchange, techniques, and complications of piggyback IOLs.

WEEK 3
Professor Shah provided a lecture on postoperative complications, which were divided into two groups: early (ie, wound complications, edema, corneal abrasion, raised intraocular pressure, IOL displacement, dropped nucleus [Figure 1], uveitis, and endophthalmitis) and late (cystoid macular edema, retinal detachment, refractive surprise, posterior capsular opacification and anterior capsular contraction, and IOL opacification [Figure 2]).

Intravitreal triamcinolone was advocated as particularly useful to delineate vitreous strands. Its other benefits include reducing postoperative inflammation and cystoid macular edema.

Drs. Avgikos, Tu, Kundu, and Aslanides delivered the second lecture, considering the principles of Nd:YAG laser along with its indications, procedures, and complications.

WEEK 4
Week 4 covered the topics of biometry and cataract surgery following refractive surgery. Problems facing accurate ocular biometry following corneal refractive surgery and how to allow for errors with conventional ocular biometry were discussed. Participants discussed the prevention of interlenticular opacification with the use of piggyback IOLs. Sulcus implantation was the preferred method for the second IOL. The final lecture covered the postoperative examination of the cataract patient. This lecture complemented the guidelines issued by the Royal College of Ophthalmologists.1

Antonio Leccisotti, MD, PhD, is a Visiting Professor at the School of Biomedical Sciences, University of Ulster, Coleraine, Northern Ireland, and Director of the Ophthalmic Department, Casa di Cura Rugani, Siena, Italy. Dr. Leccisotti states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +39 335 8118324; fax: +39 0577 578600; e-mail: leccisotti@libero.it.

Colm McAlinden, BSc (Hons), MCOptom, is an optometrist currently undertaking a PhD in refractive surgery with the School of Biomedical Sciences, University of Ulster, Coleraine, Northern Ireland. Mr. McAlinden states that he has no financial interest in the products or companies mentioned. Mr. McAlinden may be reached at: e-mail: colm.mcalinden@gmail.com.

Damien McConville, MSc, MBCS, FHEA, is a Learning Technologist at the Institute of Lifelong Learning, University of Ulster. Mr. McConville states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +44 0 2890368537; e-mail: d.mcconville@ulster.ac.uk.

Johnny E. Moore, FRCOphth, PhD, is a Visiting Professor at the School of Biomedical Sciences, University of Ulster, Coleraine, Northern Ireland, and Department of Ophthalmology, Mater Hospital, Belfast Hospital Trust Northern Ireland, and Director of Leeson Eye Institute, Dublin, Ireland. Dr. Moore states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +353 0 16674778; e-mail: johnnymoorebal@gmail.com.

Tara Moore, PhD, NTF, is a Course Director and Senior Lecturer at the School of Biomedical Sciences, University of Ulster, Coleraine, Northern Ireland. Dr. Moore states that she has no financial interest in the products or companies mentioned. She may be reached at tel: +44 0 7793226873; e-mail: t.moore@ulster.ac.uk.

Sunil Shah, FRCOphth, FRCSEd, FBCLA, is a Visiting Professor at the School of Biomedical Sciences, University of Ulster, Coleraine, UK, Visiting Professor at the School of Life & Health Sciences, Aston University, Birmingham, UK, Medical Director, Midland Eye Institute, Solihull, UK, Consultant Ophthalmic Surgeon, Heart of England Foundation Trust, Birmingham, UK, and Consultant Ophthalmic Surgeon, Birmingham & Midland Eye Centre, Birmingham, UK. Dr. Shah states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +44 1217112020; fax: +44 1217114040; e-mail: sunilshah@doctors.net.uk.

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