Protecting the Corneal Endothelium ● Corneal Endothelium - The Challenge ● Claes Feinbaum Msc...
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Transcript of Protecting the Corneal Endothelium ● Corneal Endothelium - The Challenge ● Claes Feinbaum Msc...
![Page 1: Protecting the Corneal Endothelium ● Corneal Endothelium - The Challenge ● Claes Feinbaum Msc PhD ● Department of Ophthalmology ● Barzilai Medical Center.](https://reader037.fdocuments.in/reader037/viewer/2022103022/56649d8a5503460f94a710b4/html5/thumbnails/1.jpg)
Protecting the Corneal Endothelium
●Corneal Endothelium - The Challenge
●Claes Feinbaum Msc PhD
●Department of Ophthalmology
●Barzilai Medical Center
●Ashkelon, Israel
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Protecting the endothelium during cataract surgery can be a
challenge for seasoned or novice surgeons alike depending on the
status of patients
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Factors are as varied as the patients’ cases
Recognized non-corneal risk factors preventing injury to corneal endothelial cells:
1. Shallow A.C.
2. Crowded A.C.
3. Density of nucleus
4. Small pupils
5. Volume of infusion
6. Amount of ultrasound used
7. Type of IOL to be implanted
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Corneal characteristics that may cause problems
1. Older patient age characterized by a lower endothelial cell density
and
2. Presence of Fuchs’ dystrophy and diabetes mellitus
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Surgical factors to consider
●Decision making during the preoperative testing.
● In high-risk patients:
●1. Performing a cataract extraction
●or
●2. Descemet’s stripping endothelial keratoplasty (DSEK) triple procedure including:
●a. corneal transplant
●b. cataract removal
●c. IOL insertion
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Patient symptoms duringpre-operative examination.
1. Severity of guttae (specular reflection)
2. Stromal edema
3. Lens density
4. A.C. Depth
5. Other symptoms
Examination should also include pachymetry and specular microscopy.
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Phacoemulsification techniques and technology.
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The phacoemulsification technique
1. Horizontal or vertical chop procedure reduces both energy used in eye and ultrasound time.
2. Benefits of ultrasound power modulation:
a. greatly reduced repulsion
b. decreased turbulence
c. enhanced followability
d. lower risk of thermal burns
e. less endothelial trauma
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Resulting in less total energy used and less endothelial cellular loss at 6
months postoperatively
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Phaco technology:Femtosecond-assisted cataract surgery
1. The effective phaco time can be reduced from about 1 minute to less than 30 seconds
2. From an average power of about 23.5% with phaco-only to about 13.5% with Femto
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Use of viscoelastics.
Three types of viscoelastics are used in the eye depending on the patient:
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Dispersives
Viscoat, Healon D, and Ocucoat
1. Have shorter chains
2. Coat the endothelium well
3. More difficult to remove
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Cohesives
Healon, Healon 5, Provisc and Amvisc
1. Have longer chains
2. Easy to remove
3. Facilitate optimal visualization in the eye
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Adaptives
Healon 5 and DiscoVisc
1. Cohesive under low-flow conditions
2. Dispersive in high-flow conditions
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Irrigation and aspiration
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Of Importance
Removing all nuclear fragments
Identify by slit lamp evaluation, gonioscopy, and ultrasound biomicroscopy
Most lens fragments found in the inferior angle
80% of patients with corneal edema diagnosed with lens fragment after day 1 postoperatively.
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Intracameral medications.
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Toxic anterior segment syndrome (TASS)
1. Onset 12 to 48 hours following cataract or anterior segment surgery
2. Sterile postoperative inflammatory reaction
3. Caused by a noninfectious substance entering the anterior segment
4. Causing toxic damage to the intraocular tissues
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TASS Treatment
improves after treatment with corticosteroids
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Ocular medications implications
1. Incorrect concentrations
2. pH
3. Osmolality; a vehicle with incorrect pH or osmolality
4. Preservatives in a medication solution
identified as causes.
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Postoperative medications.
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Medical Therapy
1. Instillation of corticosteroids prednisolone acetate 1% and difluprednate 0.05%
2. Newer delivery systems via nanoparticles and punctal plugs
3. Future medications such as Rho-kinase inhibitors
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These were the pearls