?
Whats next
clock h’rs (<1 quadrant):3 piece lens haptic 1-2.
In the axis of zonular loss
clock hr’s (1-2quadrants): capsule tension ring 3-4 .
to 3 quadrants :simple fixation ring or double 2 .
Fixation ring or CT segment (Ahmed)
:quadrants 3> .
EECE,ICCE -
Scleral fixated(sutured)IOL -
Glued IOL -
Yamane Technique -
iris fixated or sutured IOL -
,The Morcher ring ( Stuttgardt , Germany)
:available in three sizes.
.type 14(12.3mm diameter , compresses to 10.0mm)-
.type 14c (13.0mm diameter, comprsses to 11.0mm)-
type 14 A (14.5mm diameter , compresses to 12.0mm)-.
The Ophtec ring (Groningen ,The Netherlands)-.
:Available in two sizes .
model 275 (12.0mm diameter, compresses to 11.0 mm)-.
model 276 (13.0mm diameter , compresses to 11.0mm)-.
The Morcher ring is slightly stiffer than the Ophtec ring.
PRESBY OPIA CRYSTALLINE LENS CORRECTIOR
In 2020 ,Trifocal Diffractive IOLs -
:Are the Gold standard
:Howeverm ,limitations .
Anatomic contraindications.
Undesirable visual effects
Non- recommended activities .
Logistic-econnmic limitations for its.
Implementation
EDOF IOLs OPTICAL STRATEGIES
LOW addition Refractive Extended
Small Aperture
Diffactive Zonal EDOF - Monofocal
EDOF IOLS
Optics EDOF IOLS IOLS Plus EDOF IOLS
Monofocal- :Tecnis Eyhance (Johnson&Johnsos)
Negative Spherical Aberration in 3.5 mm central
Anterior surface of the IOL Plus
extended focus Isopure (BVI –Physiol):Increased Negative
IOLs
Spherical Aberration in both anterior and
posterior
Full optical surfaces of the IOL, customized fore
Every Dioptric Power
Vivity (Aicon): Transition phase elements,in the
central2.2 mm of the optic IOL
RayOne EMV ( Rayner) : Increased Positive
Spherical Aberration anteriior surface of the IOL
[Link] be associated to Monovision
Monofocal-Plus versus Diffractive& zonal Refractive
MultifOC al/ ED OF IOLS
They provide SIMPLICITY in patient
Management
Fewer patient medical contraindications
Fewer professional contraindications
Fewer psychological contraindications of
Patient
Less demanding on any need for preoperative
Technology
Less time spent explaining to the patient
Influence of pregnancy on onset of ectasia after LASIK/PRK
Pregnancy – related exacerbation of iatrogenic
Keratectasia despite corneal corenel collagen crosslinking
Refractive
Surgery
Selective tissue estrogenic activity regulator (STEAR)
Most Downloaded Journal of Cataract
Refractive Surgery Articles&
The most progression of keratoconus after threapy with
Selective tissue estrogenic activity regulator
Dirisamer - Technique
TIPPS & TRICKS
Soft eye preoperatively.
Eyeball massage.
Honan balloon for 10 minutes .
anti – Trendelenburg - Position.
Descemetorhexis under air.
! Do not overhydrate.
!Mind the main incision.
Check the orientation – ALWAYS .
Use appropriate (different) unfold techniques.
Supine position postoperatively.
! THANK YOU
Martin Dirisamer,MD,PhD
Cornea consultant University Munich (LMU), Gremany
Eyes Linz, Austria Co-Owner Smile
INTRAOPERATIVE COMPLICATIONS
Inadvertent injection of the graft into the.
Posterior chamber. Higher risk in presence
Of iris defect and aphakia
Ejection of the graft from the anterior chamber .
.Through one of the incisions
Loss of graft staining and upside down graft.
Placement
Anterior chamber bleeding and formation .
POST- OPERATIVE MEDICATIONS
Verify 1st Purkinje reflex in the observation position.1
Apply suction after =80-85% applanation.2
Do not apply suction >3 times.3
Do not treat sleep corneas .4
Mark 0 -180 axis and adjust the suction cone, if >105 D.5
**cyl
Use 6.5mm zone as default .6
If decentration still occur, topography guided PRK/LASIK.7
Usullay improves the situation
*Incidence 0.6%- 4% in 2013.
Avoid (lakes ):aspirating speculum.1
Get the nose out of the system.2
Wet ,not irrigate the surface on the way .3
to the treatment position
Keep treatment under 25 ses.4
Talk to the patient & make sure she/he.5
Knows the procedure
!DO not panic, you’ve got time
:Visu Max assists you in decision making
Abort, if unsure. You can do any eximer.1
.Based procedure later
Re- dock ,if suction loss during 2nd cut .2
Wait for the clearance of the central.1
zone-/ massage
SmILE with lager cap.2
Convert to FLEx.3
No entering incision.3
Side cut with a presal knife.1
Stop ,do CIRCLE later.2
what is “black stop” ? .No laser cut occurred
Oily tear film or make –up btweeen.1
corne and contact glass especially
After several docking trials
Energy is too low.2
Prevention .wipe the surface gently with sponge
.Always drape eye lashes
Don’t push the pedal,unless clear view of the.
cornea
Otherwise clean and redock
Epithelial slugh off (basement membrane dystrophy.
Or erosion at the entering site : Contact lens , increase
steroids (DLK)
.Cap perforation & lear : I usually use > 120 um cap .
Adapt and leave: usually heals well
Tear at the incision site for SMILE: usually not a big .
Problem: use forceps to support globe
: Wrong plane.
use hook “movement “ from anterior lip-
Or separete from distal end with Mehta
*Reversed dissecttor
Observe.
Scrape off only if progressive.
Put a stich after removal .
Very serious complication , if .
Usually at the edge in myopic
Treatment
Dissect from the muddle toward
-The periphery, respect counter
Action. Sekundo’s spatula helps
Use forceps only after complete dissection in a rhexis - like fashion
”Use milk steroid to “stain
Remnants ( M. Abdalla)
Convert cap to flap and remove
in ” open sky” fashion
Topography guided sufrace
Ablation helps in recalcitrant
cases
DLK
*Incidence 1.6%-
erosion at the opening incision .
thin lenticules =100um-
Use steroids vigorously-
)topical and oral(
Irrigate if stage 2-
Same management as for Lasik