Moran CORE

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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IOL Exchange

Home / Ophthalmic Surgery / Lens and Cataract Surgery

Title: IOL exchange

Author (s): Russell Swan, MD; Bala Ambati, MD

Date: 2/27/2016

Keywords/Main Subjects: IOL exchange; Dysphotopsia; Multifocal IOL; Monofocal IOL; Cataract surgery

Diagnosis: Dysphotopsia; Multifocal IOL

Description: This 72 year old male presented to the ophthalmology clinic with complaints of glare, haloes, and progressive decrease vision. He had previously undergone cataract surgery with placement of multifocal lenses in both eyes at an outside institution.  On exam eh was noted to have 20/30 vision with a well cenetered multifocal IOL and posterior capsule obstruction. After discussion of the risks benefits and alternatives to IOL exchange versus YAG capsulotomy the patient elected to proceed with IOL exchange with placement of a monofocal IOL. He tolerated the procedure well and was 20/20 post-operative day one with polishing of his posterior capsule intraopertively.

In the largest published American study of IOL exchange1, the most common indications for IOL exchange were as follows: IOL dislocation (46%), incorrect IOL power (23%), patient dissatisfaction (21%), and optic opacification (7Of the dissatisfied patients, 42% (5/11) had undesired visual acuity without symptoms of glare/optical aberrations. Overall in there series of 59 eyes, the mean logMAR BCVA improved significantly (P < .001) and 88% of all eyes were 20/40 or better, including 73% in the IOL dislocation group and 100% in all other groups. No vision-threatening complications occurred in this series.

Format: video

References:

  1. Jones, J. et al. Indications and outcomes of intraocular lens exchange during a recent 5-year period. Am J Ophthalmol. 2014 Jan;157(1):154-162

Faculty Approval by: Bala Ambati, MD
Identifier: Moran_CORE_21190
Copyright statement: Russell Swan, MD, ©2015. For further information regarding the rights to this collection, please visit: Terms of Use

DMEK: Pros, Cons and Lessons Learned From Our First Case

Home / External Disease and Cornea / Clinical Approach to Corneal Transplantation

Title: DMEK: Pros, Cons and Lessons Learned From Our First Case
Author: Jason Feuerman
Date: 06/10/2015
Keywords/Main Subjects: DMEK, Corneal tranplant, Fuchs’ Dystrophy
Diagnosis: DMEK
Brief Description: This is a review of endothelial keratoplasty and the use of DMEK. A presentation of a surgical case and surgical pearls in DMEK are shown. Surgical techniques for DMEK are presented.
Format: video
Series: Moran Eye Center Grand Rounds
Identifier: Moran_CORE_20779
Copyright statement: Copyright 2015. Please see terms of use page for more information.

Conjunctival Nevus Excision

Home / Ophthalmic Surgery / Globe Trauma/Anterior Segment Surgery

Title: Conjunctival Nevus Excision
Authors: Russell Swan, MD; Mark Mifflin, MD
Date: 2/26/16
Keywords/Main Subjects: Conjunctival Nevus; Melanoma; Nevus;
Diagnosis: Conjunctival Nevus
Description of Video:

This case is from a 32 year old male who presented to the ophthalmology clinic for evaluation of a melanocytic lesion of his conjunctiva. This lesion had been noticeable to the patient since adolescence and was causing mild irritation as well as cosmetic frustration to the patient. After a discussion of the risk benefits and alternatives to surgical excision with the patient including continue observation the patient elected to proceed with excision. The video demonstrates a no-touch technique for removing a conjunctival lesion. Given extremely low suspicion of malignancy in this case (given history and appearance consistent with conjunctival nevus) only a 1mm rim of normal conjunctiva was excised with the lesion.

The review article by Shileds et al provides a nice overview of a large series of patients with giant (>1cm) conjunctival nevus. A few highlights worth mentioning:

Format: video

References: Shileds, C. et al. Giant conjunctival nevus: clinical features and natural course in 32 cases. JAMA Ophthalmology 2013 Jul;131(7):857-63

Faculty Approval by: Mark Mifflin, MD

Identifier: Moran_CORE_20545

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

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, Department of Ophthalmology, Moran Eye Center, University of Utah
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.  This is a limbal approach.
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 could 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.

After a capsulorhexis is initiated, capsular tension hooks are used to facilitate completion of a continuous curvilinear capsulorhexis. Gentle hydrodissection is carried out and an I/A hand piece is used to remove the crystalline lens. A capsular tension ring is placed in the capsular bag. A conjunctival peritomy is completed and then two adjacent sclerotomy sites are created with a bent 25-gauge trochar. An Ahmed capsular tension segment is threaded with 8-0 Gore-Tex and placed in the anterior chamber. Each end of the Gore-Tex is externalized through the sclerotomy sites. These capsular tension devices are utilized to secure the capsular bag to the sclera and provide support for safe intraocular lens placement. The IOL is placed in the sulcus. Once the IOL is in an appropriate position, the Gore-Tex is secured.  Given the 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/

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