Moran CORE

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Superficial Keratectomy Technique Utilizing Femtosecond Spatula for Patients with Salzmann’s Nodular Degeneration

Home / Refractive Surgery / The Science of Refractive Surgery

Title: Superficial Keratectomy Technique Utilizing Femtosecond Spatula for Patients with Salzmann’s Nodular Degeneration
Author: Vance Thompson, MD and Russell Swan, MD
Date: 12-27-17
Keywords/Main Subjects:  Superficial keratectomy, SK, Salzmann’s Nodular Degeneration, SNG, Astigmatism
Diagnosis: Salzmann’s Nodular Degeneration, Astigmatism


Brief Description:  This video demonstrates a surgical technique for Salzmann’s nodular degeneration (SND) that does not respond to conservative treatment. We utilize a femtosecond spatula to more easily identify a sub-nodular dissection plane to aid in efficient and safe removal of nodules. This technique has been utilized on 31 eyes of 19 patients with good success.

Introduction

Salzmann’s nodular dystrophy (SND) is a non-inflammatory, progressive degeneration of the cornea which is normally characterized by multiple nodular blue-gray opacities. It was first described by Maximilian Salzmann in 1925.1 SND typically presents in people age 50-60, is bilateral in approximately 60% cases, and has a female preponderance of 70-80%.2,3 While many patients with SND may be asymptomatic, a proportion of patients will complain of irritation, watering, foreign body sensation and decreased vision.3 The nodules can induce refractive shifts including most often irregular astigmatism and a hyperopic shift.4 Patients with peripheral, small, non-visually significant nodules are often managed conservatively with medical treatment. This is often geared towards improving ocular surface homeostasis by improving tear volume, lid hygiene, and reducing inflammatory stimuli. In cases that do not respond to conservative treatment or in the case of visually significant nodules surgical management is often necessary. Most large case series report less than 10% of patients with SND will require surgical intervention.2,3,4 The most common procedure performed is a superficial keratectomy (SK). Adjuvant therapy include phototherapeutic keratectomy (PTK), amniotic membrane transplantation (AMT), or intraoperative mitomycin-C (MMC). This article describes a technique for superficial keratectomy utilizing a femtosecond spatula to assist in identifying the sub-nodular plane of dissection.

Description of Technique

The patient is prepped and draped in the usual fashion for ophthalmic surgery. The complete technique can be seen in the linked video. Often an irregular corneal light reflex will be noted secondary to the nodules (Figure 1A). The corneal epithelium is then removed at the anterior leading edge of the nodules (Figure 1B). A femto-second spatula is passed under the nodule to define the sub-nodular plane (Figure 1C). Once the plane is identified there will be minimal resistance to dissection. The spatula creates a dissection plane utilizing broad posterior to anterior sweeps. The posterior margin of the dissection can then be completed with either a blade or scissors.

Our preference is to treat these patients with adjuvant MMC to reduce risk of haze formation. In order to treat with MMC the remaining corneal epithelium is removed in the central 8.0 mm. A 8.0mm corneal well is utilized to treat the cornea with MMC 0.02% for 30 seconds (Figure 1D). The MMC is absorbed with surgical sponges and the ocular surface is rinsed aggressively. At the end of the case a bandage contact lens is placed on the eye. This is left in place until the cornea is completely epithelialized.

To date this technique utilizing the femtosecond spatula to assist in the dissection has been performed on 31 eyes of 19 patients between May 2013 and November 2016.

Discussion

SND may cause visually significant hyperopia and astigmatism that may require surgical intervention. Many techniques have been described in the treatment of SND. These include but are not limited to SK2, SK with AMT5, SK with intraoperative MMC6, SK with PTK7, and SK with PTK and MMC6. One of the most important steps in SK for SND is to identify the sub-nodular plane of dissection. Traditionally this has been described by utilizing epithelial debridement to identify the edge and then forceps to remove the nodule. Some surgeons prefer use of a scalpel blade or diamond burr to help identify the leading edge.8 One of the challenges with these techniques is that in many cases it can be difficult to identify the plane of dissection. This is particularly true for smaller nodules. In addition, using a scalpel or other sharp dissection technique may risk creating an artificial dissection plane leading to incomplete removal of the nodule or too deep of a dissection resulting in a partial lamellar dissection. The benefit of utilizing a femtosecond spatula is that it is far less likely to create an artificial dissection plane and makes identification of the sub-nodular plane easier. The use of intraoperative topical MMC 0.02% for 30 seconds has been demonstrated to reduce hyperopia and scar formation6 and is the preferred technique at our center.


Format: Video
Series: 
References:

  1.   Salzmann, M. About a variation of nodular dystrophy. Z. Augenheilkd. 1925; 57:92-9. German
  2.   Graue-Hernandez, EO, Mannis, MJ, Eliasieh K, et al. Salzmann nodular degeneration. Cornea 2010; 29:283-9
  3.   Farjo, AA, Halperin, GI, Syed N, et al. Salzmann’s nodular corneal degeneration clinical characteristics and surgical outcomes. Cornea. 2006; 25:11-5
  4.   Das S, Link B. Salzmann’s nodular degeneration of the cornea: a review and case series. Cornea 2005; 24:772-7
  5.   Rao A, Sridhar U, Gupta AK. Amniotic membrane transplant with superficial keratectomy in superficial corneal degenerations: efficacy in a rural population of north India. Indian J Ophthalmology 2008; 56:297-302
  6.   Bowers Jr PJ, Price MO, Seldes, SS et al. Superficial keratectomy with mitomycin-C for the treatment of Salzmann’s nodules. J Cataract Refract Surg 2003; 29:1302-6
  7.   Sharma N, Prakash G, Titiyal JS, et al. Comparison of automated lamellar keratoplasty and phototherapeutic keratectomy for Salzmann nodular degeneration. Eye Contact Lens 2012; 38:109-11

Identifier: Moran_CORE_24822
Copyright statement: Copyright 2017. Please see terms of use page for more information.


Supraciliary Microstent Implantation

Home / Glaucoma / Surgical Therapy for Glaucoma

Title: Supraciliary Microstent Implantation
Author (s): Tanner Ferguson, MSIV, University of South Dakota School of Medicine, Craig Chaya, MD, Moran Eye Center, University of Utah
Date: 09/24/17
Keywords/Main Subjects: MIGS (minimally invasive glaucoma surgery), glaucoma surgery, glaucoma
Diagnosis: POAG; Glaucoma
Description of Case: This video demonstrates the implantation of a CyPass microstent as a sole procedure by Craig Chaya, MD from the Moran Eye Center, University of Utah. Below is our surgical technique for implantation of the CyPass micro-stent and standard postoperative regimen.

Note: This video is best viewed in high resolution (720p).

Summary of the Case:
Notable Surgical Instruments

Surgical Technique

  1. Two clear corneal incisions are created; one superiorly and one temporally, approx. 90 degrees from superior paracentesis.
  2. OVD is instilled through superior incision to stabilize and maintain anterior chamber.
  3. OVD is injected onto surface of cornea as coupling medium between the cornea and lens.
  4. The patient’s head is tilted approximately 30 degrees away from the surgeon and the patient is instructed to look opposite the surgeon. The microscope is adjusted to a comfortable position.
  5. The gonioprism is placed on the surface of the cornea with the non-dominant hand.
  6. The guidewire is inserted through the primary temporal incision with the dominant hand.
  7. After the anterior chamber angle anatomy is identified, the surgeon aims for the scleral spur landmark.
  8. The guidewire is inserted directly below (posterior) the scleral spur and the micro-stent stent is inserted into the supraciliary space.
    1. Note: The microstent should guide through the space with minimal resistance. If the surgeon encounters resistance, the surgeon should consider adjustment or an alternative location.
  9. After the microstent is inserted, the surgeon taps on the proximal edge with the inserting device to secure placement and the retention rings on the device should be visible.
  10. The residual viscoelastic in the anterior chamber is removed with irrigation/aspiration.

Drops

Visits

Format: Video
Faculty Approval by: Craig Chaya, MD
Identifier: Moran_CORE_24341
Copyright statement: Ferguson ©2017. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/

 


Implantation of two trabecular micro-bypass stents for POAG

Home / Glaucoma / Surgical Therapy for Glaucoma

Title: Implantation of two trabecular micro-bypass stents for POAG
Author (s): Tanner Ferguson, MSIV, University of South Dakota School of Medicine, Craig Chaya, MD, Moran Eye Center, University of Utah
Date: 09/24/17
Keywords/Main Subjects: MIGS (minimally invasive glaucoma surgery); glaucoma surgery; glaucoma
Diagnosis: POAG; Glaucoma
Description of Case: This video demonstrates the implantation of 2 trabecular microbypass stents prior to phacoemulsification by Craig Chaya, MD at the Moran Eye Center. Below is our surgical technique for implantation of the 2 stents and standard postoperative regimen.

Note: This video features a repositioning of the second stent. After initial insertion, the stent was not securely placed and the surgeon removed and repositioned the stent.

Note: This video is best viewed in high resolution (720p).

Summary of the Case:
Notable Surgical Instruments

Surgical Protocol

  1. Two clear corneal incisions are created; one superiorly and one temporally, approx. 90 degrees from superior paracentesis.
  2. OVD is instilled through superior incision to stabilize and maintain anterior chamber.
  3. OVD is injected onto surface of cornea as coupling medium between the cornea and lens.
  4. The patient’s head is tilted approximately 30 degrees away from the surgeon and the patient is instructed to look opposite the surgeon. The microscope is adjusted to a comfortable position.
  5. Swan Jacob gonioprism placed on surface of cornea with non-dominant hand while pre-loaded stent injector device is inserted through main incision.
  6. After angle anatomy is identified and the trabecular meshwork is visualized, the first stent (on tip of inserting device) is guided at approx. the 2 o’clock position at 20-degree angle into the posterior portion of the trabecular meshwork.
    1. Note: More pigmented regions of the trabecular meshwork are targeted if visualized that may suggest presence of collector channels.
  7. Once the stent is released, the inserting device is used to tap or nudge the heel of the stent to ensure it is securely placed.
  8. Steps 6-7 are repeated for the second stent and the second stent is typically inserted 3-4 clock hours away from the first stent.
  9. Once both stents are securely placed, the remaining viscoelastic in the anterior chamber is washed out using irrigation and aspiration.

Postoperative Guidelines

Drops

Visits

Format: Video
Faculty Approval by: Craig Chaya, MD
Identifier: Moran_CORE_24336
Copyright statement: Ferguson ©2017. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


Glaucoma Ahmed Tube Shunt

Home / Ophthalmic Surgery / Glaucoma Surgery

Title: Glaucoma Ahmed Tube Shunt
Author (s): Russell Swan, MD; Craig Chaya, MD
Date: 7/18/2016
Keywords/Main Subjects: Glaucoma; Tube Shunt
Secondary CORE Category: Glaucoma / Surgical Therapy for Glaucoma
Diagnosis: Glaucoma; POAG
Brief Description: This video demonstrates a standard surgical technique for Ahmed tube shunt at the University of Utah Moran Eye Center with Dr. Craig Chaya. Below is our standard protocol:

  1. Mark the superior and temporal conjunctiva
  2. Perform conjunctival dissection and ensure carried to bare sclera. Relaxing incisions should be made at 12 and 3 oclock (left eye) and 12 and 9 oclock (right eye)
  3. Blunt dissection into superior temporal subconjunctival space to create space for placement of shunt
  4. May use brimonidine soaked sponge for additional hemostasis
  5. Isolate lateral and superior rectus muscles and mark insertions
  6. Prime valve using 27 gauge cannula and tying forceps
  7. Deliver Ahmed plate into the superior temporal sub-Tenons space
  8. Mark sclera 7.0mm posterior to the limbus
  9. Pass 7-0 vicryl suture partial thickness through eyelet holes at anterior edge of place of tube
  10. Tie off tube with 7-0 vicryl suture (double loop so that the tube is not amputated)
  11. Ensure no flow through the tube
  12. Create wick suture through tube with 7-0 vicryl suture
  13. Create fenestration in tube anterior to wick suture. These two will help with IOP control in the immediate post op time period.
  14. Measure position of tube and cut bevel up with scissors
  15. Bend 23 gauge needle to use for entering the anterior chamber
  16. Mark 3.0mm posterior to the limbus in the location you wish the tube to enter (preferably superior)
  17. Create temporal paracentesis to have access to reform AC as needed
  18. Initiate partial thickness scleral tunnel with 23 gauge needle and rotate eye into neutral position. Try to enter the ac just anterior to the iris root so that the tube will not be against the cornea
  19. Flare scleral tunnel edge upon exit to make passage of tube easier
  20. Pass tube into scleral tunnel and into AC
  21. Use 7-0 vicryl suture to secure tube location with ‘X’ stitch
  22. Measure patch graft material and cut to size
  23. Secure anterior edge of patch graft with 7-0 vicryl suture
  24. Mobilize conjunctiva and Tenon’s over the tube and plate
  25. Close conjunctiva:
    1. Start with buried horizontal matress suture. Ensure episcleral bite to help prevent flap from slipping.
    2. Cut short end of suture and then use a running suture to close the relaxing incision
    3. Close the second relaxing incision in a similar fashion
    4. This can be done with the same 7-0 vicryl suture or a 10-0 vicryl suture

Tube Shunt Post-Op Guidelines

Drops:

Visits:

Misc:

Format: video
Faculty Approval by: Craig Chaya, MD
Identifier: Moran_CORE_21536
Copyright statement: Russell Swan, MD, ©2016. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/
Attribution/citation suggestions:
Swan, R and Chaya, C. Glaucoma Ahmed Tube Shunt. Moran CORE. Available at: http://morancore.utah.edu/section-14-ophthalmic-surgery/glaucoma-ahmed-tube-shunt/. Accessed July 27, 2016.


Phaco-Trabeculectomy

Home / Ophthalmic Surgery / Glaucoma Surgery

Title: Phaco-Trabeculectomy
Author (s): Russell Swan, MD; Craig Chaya, MD
Date: 7.18.2016
Keywords/Main Subjects: Glaucoma, Trabeculectomy, Trab, Cataract, Phacoemulsification, Phaco
Secondary CORE Category: HomeGlaucoma / Surgical Therapy for Glaucoma
Diagnosis: Glaucoma, Primary open-angle glaucoma (POAG), Cataract
Brief Description: This video demonstrates a standard surgical technique for phaco-trabeculectomy at the University of Utah Moran Eye Center with Dr. Craig Chaya. Below is our standard protocol for the trabeculectomy portion of the surgery. Of note the cataract surgery is still performed with a standard temporal clear corneal incision which is closed with a 10-0 nylon suture at the end of the cataract portion of the surgery. The microscope is then rotated superiorly for the trabeculectomy portion of the surgery:

  1. Place 7-0 Vicryl traction suture partial thickness in superior cornea to provide infraduction
  2. Inject subconjunctival lidocaine superior and displace across superior conjunctival bed
  3. Place corneal light shield soaked in BSS
  4. Inject subconjunctival Mitomycin C (0.2ml of 0.2mg/ml) superiorly
  5. Displace across superior conjunctival bed while blocking limbus with surgical sponge
  6. Superior conjunctival peritomy leaving 1-2mm limbal skirt for improved closure
  7. Ensure underlying Tenon’s is free.
  8. Blunt dissection in the superior sub Tenons space
  9. Cautery to scleral bed where flap will be located
  10. Measure 3.0mm posterior to the limbus for dimensions of scleral flap
  11. Initiate posterior edge of scleral flap at ~50% depth (may use guarded diamond blade or scleratome blade
  12. Carry scleral flap dissection anterior into the cornea trying not to enter the AC at this time
  13. Create medial and lateral edges of scleral flap
  14. Ensure flap is free of adhesions
  15. Pre-place 2 10-0 nylon sutures at corners of scleral flap. These should actually be about 2/3 the distance posterior along the flap so that they will promote posterior flow through flap
  16. Ensure adequate pressurization of the AC. May consider using small amount of dispersive OVD in the angle to maintain AC upon entrance
  17. Use keratome to enter AC. Ensure that you do not cut your 10-0 sutures
  18. Use Kelly punch to remove cornea tissue. Pass punch into AC and catch posterior lip of tunnel. Once posterior lip is engaged then rotate instrument and hand vertical before engaging punch.
  19. Use sliding knot to tighten sutures. Tie 1-1 first and check for no/minimal passive flow through the flap.
  20. Pressure on the posterior edge of the flap with a surgical sponge should provide flow
  21. If adequate flow then tie of suture (total 1-1-1), cut short, and rotate the knot
  22. Begin conjunctival closure with 10-0 vicryl suture. This is a critical step to reduce risk of post op hypotony after surgery.
  23. Start with buried suture at far corner of peritomy
  24. Continue with modified Wise closure1. Please refer to Figure below for closure tips
  25. To end closure there will be two buried episcleral bits that emerge and re-enter near the limbus. Using loop of suture from this and free end of suture the closure is tightened, tied and cut short. NOTE: In figure the green loop at the limbus is tied to the free end of suture to finish the closure.

Phaco-Trab-1-21527

Trab Post-op Guidelines

Drops:

Visits:

Misc:

Format: Video
Faculty Approval by: Craig Chaya, MD
Identifier: Moran_CORE_21527
Copyright statement: Russell Swan, MD, ©2016. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/
Attribution/citation suggestions:
Swan, R and Chaya, C. Phaco-Trabeculectomy . Moran CORE. Available at: http://morancore.utah.edu/section-14-ophthalmic-surgery/phaco-trabeculectomy/. Accessed July 27, 2016.


Medial Spindle

HomeOphthalmic/Refractive Surgery / Oculoplastic Surgery

Title: Medial Spindle
Authors: Bhupendra C.K. Patel, MD, FRCS; Zachary P. Joos, MD
Date: 5/18/2016
Keywords/Main Subjects: Ectropion; Eyelid Surgery; surgical techniques
Diagnosis: Medial Ectropion
Description of Video: Medial Spindle
Format: video
References:
Faculty Approval by: BCK Patel, MD
Identifier: Moran_CORE_21388
Copyright statement: Copyright BCK Patel, MD, ©2016. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


Temporal Artery Biopsy

HomeOphthalmic/Refractive Surgery / Oculoplastic Surgery

Title: Temporal Artery Biopsy
Author (s): Bhupendra C.K. Patel, MD, FRCS; Zachary P. Joos, MD
Date: 5/18/2016
Keywords/Main Subjects: Temporal arteritis; Giant cell arteritis; Surgical techniques
Diagnosis: Giant Cell Arteritis
Description of Video: Temporal artery biopsy.
Format: video
References:
Faculty Approval by: BCK Patel, MD
Identifier: Moran_CORE_21385
Copyright statement: Copyright BCK Patel, MD, ©2016. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


External Ptosis Repair

HomeOphthalmic/Refractive Surgery / Oculoplastic Surgery

Title: External Ptosis Repair
Author (s): Bhupendra C.K. Patel, MD, FRCS; Zachary P. Joos, MD
Date: 5/18/2016
Keywords/Main Subjects: Ptosis, Eyelid Surgery, Surgical Techniques; Oculoplastic Surgery
Diagnosis: Inovlutional Ptosis
Description of Video: External Levator Resection
Format: video
References:
Faculty Approval by: BCK Patel, MD
Identifier: Moran_CORE_21372
Copyright statement: Copyright BCK Patel, MD, ©2016. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


Small Incision Cataract Surgery (SICS)

Home / Ophthalmic Surgery / Lens and Cataract Surgery

Title:  Small Incision Cataract Surgery (SICS)
Authors: Russell Swan, MD; Jeff Pettey, MD
Date: 04/06/2016
Keywords/Main Subjects:
Hypermature cataract; SICS; Small incision cataract surgery
Diagnosis: Hypermature Cataract
Brief Description: 

This case is from a 72 year old women who presented with a hypermature cataract and light perception with projection vision in the surgical video eye and count finger vision from a mature cataract in the other eye. She had no known history of trauma and her posterior segment was attached on ultrasound.  After a discussion of the risks benefits and alternatives to surgery the patient elected to proceed with surgery. Given the significant density of her lens the decision was made to proceed with small incision cataract surgery (SICS) so as to better preserve her endothelium.

This video demonstrates one technique to SICS. It is important to note that for many steps of this surgery (capsulotomy, prolapse of nucleus into anterior chamber, prolapse of lens out of eye, conjunctival closure, ect) there are numerous techniques that have been described. In this case, given the time and resources available in our OR we elected to use trypan blue and create a large continuous curvilinear capsulorrhexis. We used bi-manual irrigation and aspiration which may not be available in all settings. In addition, conjunctival peritomy closure was achieved with dissolvable Vicryl suture as opposed to cautery or sub-conjunctival antibiotic injection.

The true key to this surgery lies in the architecture and construction of the shelved self-sealing scleral tunnel. This incision can be made tangential to the limbus or frown-shaped. The initial groove is ideally 33-50% depth, 6-7 mm in width, 1.5-2.0mm posterior to the limbus and carried 1-1.5mm into the clear cornea. It is trapezoid in shape to allow easy prolapse of the nucleus. A temporal approach counteracts most likely against the rule astigmatism in the elederly patient population and also provides easier access without having to worry about the brow.

SICS_Fig_1_Moran_CORE_21288

It is important to note that Dr. Pettey performed the creation of the initial wound and Dr Swan performed the entirety of the rest of the case using whatever techniques he was most confortable with. This was Dr Swan’s first SICS case and highlights the fact that with a well created self-sealing incision the rest of the case can be comfortably completed.

Format: video
References:

Natchiar, G. Manual Small Incision Cataract Surgery 2nd edition. Arivand Eye Hospitals. Available as iBook free. 2004.

Ruit, S.  et al. Standard Operating Procedure Manual for Modern Small Incision Cataract Surgery. Tilganga Eye Centre. Available as iBook free. 2006.

Tabin, G., Feilmeier, M. Cataract Surgery in the Developing World. Focal Points Clinical Modules for Ophthalmologists.  Volume 29:9. September 2011

Faculty Approval by: Jeff Pettey, MD
Identifier: Moran_CORE_21288
Copyright statement: Copyright 2016. Please see terms of use page for more information.


Implantable Collamer Lens (ICL) Explantation and Cataract Surgery

Home / Ophthalmic Surgery / Lens and Cataract Surgery

Title: Implantable Collamer Lens (ICL) Explantation and Cataract Surgery

Author (s): Russell Swan, MD; Mark Mifflin, MD

Date: 2/4/2016

Keywords/Main Subjects: Implantable Collamer Lens; ICL; Cataract; Anterior subcapsular cataract; Myopia

Diagnosis: Anterior subcapsular cataract; Cataract; ICL

Description of Video: This patient is a 42 year old male who presented to the ophthalmology clinic for decreased vision and symptoms of glare in his left eye after having implantable collamer lenses placed 4 years prior. On exam he was found to have 20/40 vision and a primarily anterior subcapsular cataract of that eye. He also had mild nuclear and posterior subcapsular changes. After a discussion of the risks benefits and alternatives to ICL explantation with simultaneous cataract surgery the patient elected to proceed with surgery.

This video demonstrates the surgical approach to ICL removal and also emphasizes the importance of correctly sizing the ICL at the time of implantation to reduce the risk of cataract formation.

Most studies examining the incidence of cataracts after ICL implantation report a rate between 1-5%1. It is worth noting that the most study with 8 year follow-up reports a 4.9% rate of visually significant cataract formation and an additional 10% of patients who have asymptomatic cataract formation. In addition, they reported an average 6.2% endothelial cell loss over 8 years in these patients. In this series at 8 years 68.3% of patients were within 0.5 diopters of their targeted correction and 85.4% were withing 1.0 diopter. In this series there was no significant change in intraocular pressure (IOP) over the 8 year time period.

Format: video

References:

Igarashi, A. et al. Eight-Year Follow-up of Posterior Chamber Phakic Intraocular Lens Implantation for Moderate to High Myopia. American Journal of Ophthalmology. 157.3:532-539. March 2014.

Faculty Approval by: Mark Mifflin, MD
Identifier: Moran_CORE_21195
Copyright statement: Russell Swan, MD, ©2015. For further information regarding the rights to this collection, please visit: Terms of Use