Moran CORE

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Open source ophthalmology education for students, residents, fellows, healthcare workers, and clinicians. Produced by the Moran Eye Center in partnership with the Eccles Library

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Akreos secondary IOL placement with iris repair

Home / Ophthalmic Surgery / Lens and Cataract Surgery

Title: Akreos secondary IOL placement with iris repair
Authors: Russell Swan, MD; Jeff Pettey, MD
Date: 2/11/2016
Keywords/Main Subjects: Aphakia; Akreos; Iris repair; Siepser; Anterior vitrectomy; Secondary IOL; Scleral sutured IOL
CORE Category: Lens and Cataract / Surgery for Cataract
Diagnosis: Aphakia, Iris defect
Description of Video: This case is from a 70 year old male who had previously complex cataract surgery from a traumatic cataract with diffuse zonulopathy. During the course of his first surgery his capsular bag was removed, he developed a wound burn, iris damage and was left aphakic. After 3 months of healing the patients cornea had healed and he had a stable refraction and keratometry. The decision was made to proceed with secondary IOL placement with an Akreos lens as well as an iris repair with a sliding siepser knot.

This video demonstrates a technique for secondary scleral sutured IOL placement with an Akreos intraocular lens utilizing gortex suture. In addition, this video also demonstrates an iris repair using a sliding siepser knot and 9.0 prolene suture.

Format: video

References: Osher, R.  et al. Modification of the Siepser slip-knot technique. JCRS. Volume 31:6. 2005. 1098-1100

Faculty Approval by: Jeff Pettey, MD

Identifier: Moran_CORE_20538
Copyright statement: Russell Swan, MD ©2015. For further informationregarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/ 

Laser-Assisted In-Situ Keratomileusis (LASIK)

Home / Refractive Surgery / The Science of Refractive Surgery

Title: Laser-Assisted In-Situ Keratomileusis (LASIK)
Author (s): Russell Swan, MD; Mark Mifflin, MD
Date: 01/30/2016
Keywords/Main Subjects: refractive surgery, myopia, hyperopia, astigmatism, Laser-Assisted In-Situ Keratomileusis, LASIK
Diagnosis: Myopia, astigmatism
Description: This video demonstrates a standard surgical technique for LASIK at the University of Utah Moran Eye Center with Dr. Mark Mifflin. Below is our standard protocol:

  1. Calibrate and program the femtosecond and excimer lasers
  2. Prepare the operative cart with the instruments and supplies necessary to perform the procedure
  3. Prepare the patient with the proper sedation
  4. Instill topical anesthesia, antibiotics and NSAID drops into the operative eye(s)
  5. Clean the eyelashes and fornices
  6. Position the patient on the laser table
  7. +/- use of eyelid holder for femtosecond flap creation
  8. Align red dots of femtosecond laser on limbus
  9. Using gentle pressure engage the suction ring (centered over the limbus) by pressing on the right side of the foot pedal
  10. Lower applanation cone into suction ring and engage second automatic suction (securing applanation cone in suction ring)
  11. Align flap as desired on computer monitor
  12. Engage femtosecond laser: first a tunnel will be created at the hinge of the flap to decrease formation of opaque bubble layer (OBL) by allowing for escape of gas during creation of the flap. Next the flap is created followed by the side cut
  13. Disengage applanation cone and suction ring
  14. Shift patient from FS200 (femtosecond) laser to EX500 (excimer) laser
  15. Drape the eye, being sure to isolate the eyelashes and meibomian glands
  16. Place a locking eyelid speculum to obtain adequate exposure
  17. Center the eye in the operative field by adjusting the microscope and/or head position
  18. Place the alignment markings
  19. Irrigate the cornea with BSS
  20. Dry the fornices of excess fluid with a microsurgical sponge
  21. Lift the corneal flap with a Lasik flap lifter (create small opening in gutter and then use hook to pass all the way across the flap near the hinge. Next, back out to 50% width and free 50% of the flap moving gently away from the hinge. Finally free the remaining 50% of the flap
  22. Flip the LASIK flap over placing it on the superior conjunctiva
  23. Remove any OBL with gentle pressure from the LASIK flap lifter
  24. Use a microsurgical sponge to remove excess fluid from the bed to obtain uniform hydration
  25. Ablate the stromal bed with programmed refraction in the laser while covering the flap with a wet microsurgical sponge
  26. Place BSS on the stromal bed and re-approximate the flap with the irrigating cannula
  27. Irrigate beneath the flap to remove debris and float the flap into position
  28. Dry the keratectomy gutter with a moistened surgical sponge
  29. Check corneal alignment markings and symmetry of the keratectomy gutter space to ensure correct positioning of the flap
  30. Wipe the corneal flap with a moistened microsurgical sponge to smooth any wrinkles
  31. Wait 1-2 minutes for flap adhesion
  32. Place a viscous lubricant on the eye and carefully remove the eyelid speculum without touching the cornea. Also remove the eyelid drapes.
  33. Instill antibiotic and steroid drops
  34. Recheck the flap alignment at the slit lamp prior to discharge to assure correct flap alignment
  35. Place protective shields over the eye(s) and discharge the patient.

Format: video
Identifier: Moran_CORE_20263
Faculty Approval by: Mark Mifflin, MD

Russell Swan, MD, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


Photorefractive Keratectomy (PRK)

Home / Refractive Surgery / The Science of Refractive Surgery

Title: Photorefractive Keratectomy (PRK)
Author (s): Russell Swan, MD; Mark Mifflin, MD
Date: 01/30/2016
Keywords/Main Subjects: Photorefractive keratectomy; PRK, Refractive surgery; Myopia; Hyperopia; Mitomycin C; Astigmatism
Diagnosis: Myopia, astigmatism
Description: This video demonstrates a standard surgical technique for photorefractive keratectomy at the University of Utah Moran Eye Center with Dr. Mark Mifflin. Below is our standard protocol:

  1. Calibrate and program the excimer laser
  2. Prepare the operative cart with the instruments and supplies necessary to perform the procedure
  3. Prepare the patient with the proper sedation
  4. Instill topical anesthesia, antibiotics and NSAID drops into the operative eye(s) and clean the eyelashes and fornices
  5. Position the patient on the laser table
  6. Drape the eye, being sure to isolate the eyelashes and meibomian glands
  7. Place a locking eyelid speculum to obtain adequate exposure
  8. Center the eye in the operative field by adjusting the microscope and/or head position
  9. Use 8.0mm alcohol well to place 20% alcohol on the epithelium for 40 seconds to loosen it
  10. Rinse the eye with 3cc of BSS
  11. Dry the fornices of excess fluid with a microsurgical sponge
  12. Use Sloane micro-hoe and Mahoney hockey stick to remove epithelium and smooth Bowmans
  13. Use a microsurgical sponge to remove excess fluid from the bed to obtain uniform hydration
  14. Ablate the stromal bed with programmed refraction in the laser
  15. For hyperopic ablations or myopic ablations >-6.0D use MMC (typically 12 seconds).
  16. Copiously flush surface with BSS, particularly if MMC is used
  17. Instill antibiotic and steroid drops
  18. Place bandage contact lens in eye

Format: video
Identifier: Moran_CORE_20259
Faculty Approval by: Mark Mifflin, MD

Russell Swan, MD, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


Phaco DSAEK

Home/ Ophthalmic Surgery / Corneal and Ocular Surface Surgery

Title: Phaco DSAEK
Author: Russell Swan, MD; Mark Mifflin, MD
Date: 01/28/2016
Keywords/Main Subjects: Cornea transplant; DSAEK; Endothelial transplant; cataract; Phacoemulsification; Fuchs
Diagnosis: Cataract, Fuchs
Description: This patient is a 78 year old man who presented to the ophthalmology clinic with complaints of progressive vision loss, fluctuating vision throughout the day and difficulty with glare. His best corrected visual acuity was 20/60 in both eyes. He had normal pupils, IOP, EOM, and confrontational visual fields. His slitl lamp exam was notable for bilateral 4+ confluent gutata and mild stromal edema. He was pseudophakic in his right eye and phakic with 2+ nuclear sclerotic changes in his left eye. After discussion of the risks benefits and alternatives to surgery the patient elected to proceed with combined cataract surgery with DSAEK of the left eye. Given geographic limitations to his follow-up including long distance traveled and significant elevation changes the decision was made to proceed with DSAEK instead of DMEK for this patient

This video demonstrates a standard surgical technique for combined cataract surgery with DSAEK.

Format: video
Identifier: Moran_CORE_20251
Faculty Approval by: Mark Mifflin, MD

Russell Swan, MD, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


Lateral Rectus Recession – Hoffman

Home / Ophthalmic Surgery / Strabismus Surgery

Title: Lateral Rectus Recession – Hoffman
Author (s): Brian Stagg, MD; Robert Hoffman, MD.
Date: 12/28/2015
Keywords/Main Subjects: Strabismus surgery; Eye muscle surgery; Lateral rectus recession
Diagnosis: Exotropia
Description: This video outlines the steps for a lateral rectus recession.
Format: video
Identifier: Moran_CORE_20249

Copyright Stagg and Hoffman, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


PKP with Running Suture

Home / Ophthalmic Surgery / Corneal and Ocular Surface Surgery

Title: PKP with Running Suture
Author (s): Russell Swan, MD; Bala Ambati, MD
Date: 01/01/2016
Keywords/Main Subjects: Penetrating Keratoplasty; PK; Cornea transplant; Running suture; Keratoconus; KCN
Diagnosis: Keratoconus, Penetrating Keratoplasty
Description: This patient is a 14 year old with a history of keratoconus who presented to the ophthalmology clinic with decreased vision in the right eye. His best corrected manifest refraction was 20/300 and he was no longer tolerant of contact lenses. He had a previous episode of corneal hydrops that prevented consideration of a DALK for this patient. On corneal topography his steep K was 71 and the flat K was 62 and his corneal tomography (Pentacam) was consistent with keratoconus.  After a discussion of the risks, benefits and alternatives to surgery the patient elected to proceed with a penetrating keratoplasty.

This video demonstrates a standard penetrating keratoplasty utilizing a 24 bit running suture in order to minimize post-operative corneal astigmatism.

Format: video
Identifier: Moran_CORE_20244
Faculty Approval by: Bala Ambati, MD

Russell Swan, MD, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


Marfan syndrome ectopia lentis lens extraction

Home / Ophthalmic Surgery / Lens and Cataract Surgery

Title: Marfan syndrome ectopia lentis lens extraction
Author (s): Russell Swan, MD; Alan Crandall, MD
Date: 01/01/2016
Keywords/Main Subjects: Cataract, Ectopia lentis; Marfan; Phacoemulsification; CTR; CTS
Diagnosis: Marfan’s syndrome; Ectopia lentis; Cataract
Description: This case is from a 5 year old girl who presented to ophthalmology clinic with decreased vision in both eyes, known history of Marfan’s syndrome who was found to have bilateral subluxated natural lenses. After a long discussion with the family they elected to proceed with lens extraction and intraocular lens placement.

This video demonstrates the difficulty associated with these cases due to the diffuse zonulopathy often found. While a femto-assisted capsulorhexis would have helped in this case the patient’s age and need for general anesthesia prevented the use of this technology at our institution. Given the age of the patient and the need for general anesthesia the decision was made to perform bilateral same day surgery.

A capsular tension ring and Ahmed Capsular tension segment were utilized in this case to secure the capsular bag and provide support for the lens placement. Given the likely myopic shift over time in this patient +2.0 diopters of hyperopia was targeted. Sulcus fixation was selected given that this would make potential IOL exchange easier in the future if the patient developed significant myopic shift. A 3-piece lens was thus selected as to reduce IOL related complications from the sulcus placement.

It should be noted that there are many surgical approaches to young patients with ectopia lentis related to Marfan syndrome. These include but are not limited to lensectomy with or without anterior vitrectomy, pars plana vitrectomy and lensectomy. The patient can be left aphakic, or corrected with an iris fixated IOL, anterior chamber IOL, or scleral fixated posterior chamber IOL.

Format: video
References:
Crema, A. et al. Femtosecond Laser-assisted Cataract Surgery in Patents With marfan Syndrome and Subluxated Lens. Journal Refractive Surgery. 2015 May: 31(5): 388-41
Miraldi, U., Coussa, R., Traboulsi, E. Surgical management of lens subluxation in Marfan syndrome. Journal AAPOS. 2014 Apr: 18(2):140-6
Identifier: Moran_CORE_20240
Faculty Approval by: Alan Crandall, MD

Russell Swan, MD, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/


Iris fixation of dislocated IOL in a patient with pseudoexfoliation

Home / Ophthalmic Surgery / Lens and Cataract Surgery

Title: Iris fixation of dislocated IOL in a patient with pseudoexfoliation
Author (s): Russell Swan, MD; Alan Crandall, MD
Date: 01/01/2016
Keywords/Main Subjects: Pseudoexfoliation; Iris fixated; Dislocated IOL
Diagnosis: Pseudoexfoliation; Dislocated IOL

Description: This case is from a 74 year male with a history of pseudoexfoliation and previous cataract surgery at an outside institution 14 months prior who presented with a sudden decrease in vision.  He was found to have a partially dislocated IOL/capsular bag complex. After discussion of the risks/benefits/alternatives to surgery with the patient the patient elected to proceed with surgery and planned iris fixation of the existing 3 piece IOL.

This video demonstrates the technique for iris fixation of a dislocated IOL. An advantage of this approach is that it only requires paracentesis incisions and does not require the creation of a main incision.  A few keys to success are placing the sutures as peripheral as possible to reduce ovalizing of the pupil. Elevation of the IOL complex prior to placing the suture helps to identify the location of the haptic for suture placement. The modified Siepser slip-knot provides an excellent way to fixate the lens. Our preferred sutures are either a 9.0 prolene suture or 10.0 polyester suture. We use a 2-1-2 tie off of the suture.

Below is the original diagram of the knot as described by Osher that could be used for iris repair or iris fixation of an IOL.
Iris_Fixated_20230_knot
Format: video
References: Osher, R.  et al. Modification of the Siepser slip-knot technique. JCRS. Volume 31:6. 2005. 1098-1100
Identifier: Moran_CORE_20230
Faculty Approval by: Alan Crandall, MD

Copyright statement: Russell Swan, MD, ©2015. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/

 


Cataract Surgery Showing Hand Positions

Home / Ophthalmic Surgery / Corneal and Ocular Surface Surgery


Title: Cataract Surgery Showing Hand Positions

Author (s): Brian Stagg, MD. Alan Crandall, MD.
Date: 12/28/2015
Keywords/Main Subjects: Cataract Surgery; Phacoemulsification.
Description: Video of Dr. Crandall performing cataract surgery with side-by-side footage showing his hand position.
Format: video
Identifier: Moran_CORE_20223
Copyright statement: Copyright Stagg and Crandall ©2015. For further informationregarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/ 

Descemets Membrane Endothelial Keratoplasty (DMEK)

Home / Ophthalmic Surgery / Corneal and Ocular Surface Surgery

Title: Descemets Membrane Endothelial Keratoplasty (DMEK)
Author(s): Russell Swan, MD, Geoff Tabin, MD
Date: 11/12/2015
Keywords/Main Subjects: Descemets Membrane Endothelial Keratoplasty; DMEK; Cornea transplant; EK; Fuchs
Secondary CORE Category: Ophthalmic Surgery
Diagnosis: Descemets Membrane Endothelial Keratoplasty
Brief Description:
DMEK surgical technique as adapted from recommendations from Dr Mark Terry and Michael Straiko

  1. A 3.2-mm clear corneal incision is made at a depth of 300 μm at the temporal limbus
  2. Two paracentesis incisions are made superior and inferior to the main incision
  3. In pseudophakic cases, the pupil is constricted with acetylcholine (Miochol; Bausch and Lomb, Rochester, NY)
  4. In triple procedures (DMEK combined with phacoemulsification cataract surgery), the pupil is dilated with minimal to no cycloplegia agents preoperatively and the phacoemulsification and IOL placement are performed first
  5. Cohesive viscoelastic material (Healon; Abbott Medical Optics) is used to fill the AC for intraocular maneuvers before graft placement
  6. Inferior PI performed with angled 30 gauge needle tip passed posterior to the pupil and a Sinskey hook (Bausch and Lomb) is used to scrape down on the needle tip to create a hole (this can be done pre-operatively with a laser PI)
  7. AC is refilled with a cohesive viscoelastic material
  8. 0mm diameter central recipient Descemet membrane is stripped and removed
  9. Viscoelastic material is removed with I/A handpiece
  10. Short acting pupillary constriction is achieved with acetylcholine and the pressure is normalized

Donor Table:

  1. Pre-stripped tissue from eye bank with S Stamp and hinge attachment identified by notch in sclera
  2. Trypan blue is placed to stain the tissue and identify the edges
  3. Donor corneal/sclera tissue is placed endothelial side up on trephine block (Moria) and centered
  4. Donor diameter is slightly undersized (7.5 or 7.75mm) and with direct visualization a trephine is lowered onto the tissue
  5. Tapping and gentle pressure are used to cut Descemets and the trephine is removed
  6. Donor tissue peripheral to the cut is removed
  7. Donor graft is covered with BSS
  8. Donor graft gently picked up with tying forceps to complete the stripping of the hinge area
  9. Donor corneal-scleral tissue well is the filled with trypan and the tissue deposited back into the pool of trypan for 4 minutes
  10. Injector device is prepared using a 15mm length single lumen #14 French nasogastric catheter plastic tubing as a coupler
  11. One end to the modified Straiko/Jones tube and the other end to a 3 or 5cc syringe
  12. Syringe and injector are filled with BSS and tested using the previously stripped peripheral donor tissue fragments (aspirate and inject into a petri dish filled with BSS
  13. After 4 minutes the donor tissue is visualized initially by diluting the trypan with progressive infusions of BSS and absorption with sponges
  14. Tip of Straiko/Jones tube is submerged bevel up into the well and the tissue scroll aspirated to a position just proximal to the tip. The injector is brought to the operative field then.

Placement of Graft

  1. Pressure in the chamber is reduced to near zero and the tip of the injector is placed into the AC through the main 3.2 mm wound
  2. Injector tube may be rotated to ensure proper orientation of graft
  3. Tissue injected while AC pressure is lowered by releasing fluid from paracentesis
  4. Remove the injector while externally compressing the wound central to the tip with a cannula to prevent the tissue from following the injector tip out of the wound
  5. Place 1 interrupted 10.0 nylon (or 10.0 vicryl) suture in wound
  6. Chamber is kept very shallow for unscrolling
  7. Modified Yoeruek tap technique with NO air bubble to create fluid waves to unscroll the transplant
  8. Dirisamer double cannula compression technique for unfolding taco orientation
  9. Peripheral limbus taps for moving entire graft to center
  10. Once centered use slow injection of 20% SF6 gas using a 1cc syringe and a 27 gauge cannula. Place cannula through a paracentesis site, nto the surface of the iris, below the donor
  11. Take care NOT to inject until the tip of the cannula is visualized in the genter of the graft and the eye in primary position
  12. Originally a 8-9mm bubble is injected
  13. Once orientation of graft is confirmed and no scrolls remain then complete AC fill is performed and left for a few minutes (if any paracentesis are leaking they can be sutured as well)
  14. Gas released and replaced with BSS leaving an ~80% fill ensuring the inferior PI is uncovered in the supine position
  15. Collagen shield soaked in steroid and antibiotic is placed
  16. Patch and shield the eye and leave in place until it is removed at the POD 1 appointment
  17. The patient is held in the holding area in the supine position for 1 hr prior to discharge

Patient Instructions:

Relative Contra-indications to DMEK

Format: .video
Identifier: Moran_CORE_17963
References:
Terry, M. et al. Standardized DMEK Technique: Reducing COmplciations Using Pre-stripped Tissue, Novel Glass Injector, and Sulfur Hexafluoride (SF6) Gas. Cornea. 2015. Aug 34(8) 845-52
Faculty Approval by: Geoff Tabin