Kataraktchirurgie beim Glaukom

The development of intraocular pressure (IOP) following standard cataract surgery is extremely dependent on the type of glaucoma and the prognosis is especially good for primary angle-closure glaucoma. Cataract extraction usually induces a mid-term and long-term increase of IOP in a well-working filtering bleb. Concerning the choice of intraocular lens (e.g. multifocal or toric) the surgeon has to consider the probability of subsequent incisional glaucoma surgery and the risk of decentration of the capsular bag (e.g. in exfoliative glaucoma or hydrophthalmos). According to the results of recent studies topical prostaglandin therapy does not seem to increase the risk of postoperative macular edema if given before cataract surgery.     

Femtosekundenlaser in der Kataraktchirurgie

Background

The use of femtosecond lasers (FSL) is increasingly spreading in cataract surgery. Potential advantages over standard manual cataract surgery are the superior precision of corneal incisions and capsular openings as well as the reduction of ultrasound energy for lens nucleus work-up. Exact positioning and dimensioning of the anterior capsular opening should help reduce decentration and tilt of the intraocular lens (IOL) optics and thus achieve better target refraction. Together with the possibility to correct low-grade corneal astigmatism by precise arcuate incision, FSL technology is expected to convert cataract surgery from a purely curative into a refractive procedure.

Methods

Apart from own experiences this review article critically analyses the pertinent literature published so far as well as congress presentations and personal reports of other FSL surgeons. The advantages and disadvantages are scrutinized with regard to their impact on the surgical and refractive results and compared with those experienced by the authors with manual cataract surgery over several decades. Economic and healthcare political aspects are also addressed.

Results

The use of FSL surgery improves the precision and reproducibility of corneal incisions and the capsular opening and reduces the amount of ultrasound energy required for lens nucleus work-up. However, the clinical benefits must be put into perspective due to the subsequent surgical manipulation of the incisions (during lens emulsification, aspiration and IOL injection), the lacking possibility to visualize the crystalline lens equator as the reference for correct capsulotomy centration and the relativity of ultrasound energy consumption on the corneal endothelial trauma. This is of particular relevance against the background of the significantly higher costs. Conversely, tears of the anterior capsule edge which, apart from interfering with correct IOL positioning, may entail serious complications presently occur more frequently with all FSL instruments. From the economic and healthcare political viewpoint, thought should be given to the possible acquisition of the cataract surgical business by the industry or investors, as cataract surgery is a high-volume standardized procedure with enormous future potential. This could fundamentally change our currently decentralized and individualized structures and subsequently the steam of patient and make surgeons largely dependent or superfluous.     

Aktuelle Kataraktchirurgie bei Uveitis im Kindesalter

Cataract formation is a frequent complication in childhood uveitis. The management of cataracts in childhood uveitis may be particularly difficult. Patient selection is important for successful surgery. Preoperative evaluation is required in order to specify the course and etiology of uveitis. Complete quiescence of the inflammation in required before surgery. The surgical trauma should be minimized. Intraocular lens implantation may be proposed for selected uveitis children and may be considered in well controlled juvenile idiopathic arthritis associated uveitis, e.g. with the use of immunosuppressive drugs or TNF-alpha inhibitors. Postoperatively, the anti-inflammatory medication must be increased and continued for 8-10 weeks.     

Mikrochirurgische Qualit?tssicherung am Beispiel der Kataraktchirurgie

Hintergrund. Die Neuregelungen im Gesundheitswesen fordern von allen Krankenh?usern, ein Qualit?tsmanagement vorzuhalten und sich an qualit?tssichernden Ma?nahmen zu beteiligen. Grundvoraussetzung hierfür ist eine kontinuierliche Erfassung und Evaluierung aller relevanten medizinischen Daten in der Klinikroutine.     

Subluxatio lentis und Glaukom-Indikationen und Risiken Kataraktchirurgie

BACKGROUND: Iridodonesis is the clinical sign of lens subluxation. Acute glaucoma caused by a ciliolenticular block may develop. YAG iridotomy or peripheral iridectomy are rarely effective in controlling intraocular pressure. The results of phacoemulsification and posterior lens implantation for subluxated lens and glaucoma are reported. PATIENTS AND METHODS: Seven patients aged 69+/-9.5 years were followed up. All 10 eyes with subluxated lens and glaucoma had phacoemulsification and posterior chamber lens implantation. Two different groups relating to axial length could be analyzed. Intraoperative findings and postoperative glaucoma situation are reported. RESULTS: Six eyes had average axial length of 21.5+/-0.17 mm and previous acute glaucoma. Five of these eyes had therapeutic YAG iridotomy and one, peripheral iridectomy. All eyes had dysregulated glaucoma despite antiglaucomatous medications. After cataract surgery five of six eyes had regular intraocular pressure without any medication. Four eyes had average axial length of 24. 4+/-1.1 mm and chronic glaucoma. After complicated phacoemulsification three of these eyes had regular intraocular pressure with antiglaucomatous medication, one eye without. CONCLUSIONS: For short eyes with subluxated lens and preceding acute glaucoma, cataract surgery with posterior chamber lens implantation is an effective therapeutic procedure for IOP regulation. For chronic glaucoma with subluxated lens, conventional or surgical approach to glaucoma remains dominant.     

Korneale Topographie nach Kataraktchirurgie mit Tunnelschnitt auf dem steileren Meridian bei Astigmatismus inversus und obliquus

Die sklerale Tunnelinzision bei 12 Uhr zur nahtlosen Kataraktchirurgie führt durch eine Abflachung des vertikalen Hornhautmeridians zu einer Zunahme eines vorbestehenden Astigmatismus gegen die Regel. Eine schr?ge Achslage kann sich operativ induziert erheblich ?ndern. In einer prospektiven Studie sollte untersucht werden, ob durch die Verlagerung des Tunnelschnitts auf den steileren Hornhautmeridian in solchen F?llen eine Reduktion des Astigmatismus erzielt werden kann. 18 Augen mit seniler Katarakt und einem Astigmatismus gegen die Regel oder mit schr?ger Achslage von mindestens 0,7 dpt wurden standardisiert über einen 5×6 mm² skleralen Tunnelschnitt mit einer 6 mm-PMMA-Hinterkammerlinse versorgt. Pr?operativ und mittlere 6 Monate postoperativ wurde der Astigmatismus mit dem Videokeratoskop TMS-I bestimmt. Der absolute korneale Astigmatismus betrug pr?operativ mittlere 1,8 und postoperativ 1,5 dpt. In 72% der F?lle war eine Verringerung der Astigmatismush?he erzielt worden, in 17% blieb der Astigmatismus unver?ndert. Die operative Astigmatismusinduktion nach der Vektormethode von Jaffe und Clayman betrug durchschnittlich 0,68 dpt. Die Technik der skleralen Tunnelinzision mit lateralem oder schr?gem Zugang ist geeignet, einen vorbestehenden Astigmatismus gegen die Regel oder mit schr?ger Achslage zu reduzieren.