Similarly, surgical removal of the lens immediately and permanently alters the refractive state of the eye. Thus, when one applies a risk-benefit ratio with such a high degree of success, surgery is usually the mutually agreed on course. Newer emulsification techniques, such as phaco chop  and high vacuum, have also been shown to greatly reduce ultrasound times, providing further protection to the cornea ( Box 42-5 ). In most cases, the goal of this type of lens surgery is the same as that for eyes without a compromised zonule: to remove the contents of the capsular bag though a CCC and replace the contents with a foldable IOL. Today, therefore, all lens surgery, for whatever indication, has properly come to be considered refractive surgery. However, such may not be the case when the cataract is associated with other disorders, especially if they are contributing factors to the loss of vision of an eye. Newer modalities of nuclear emulsification not involving ultrasound include sonic mode (Staar Wave), with axial movements of the tip reduced from 40,000 to 400 cycles per second; neodymium: YAG laser      ; erbium: YAG laser    ; pulsed water jet; “plasma blade” molecular bond disruption; impeller aspiration-emulsification; and others. However, in these cases, the goal is extended to include performing the surgery without further compromising the zonule, without disrupting the vitreous, without jeopardizing the long-term integrity of the capsulozonular apparatus, and, if possible, to recircularize and recenter a subluxed capsule. A national lecturer to both optometrists and ophthalmologists, Dr.Shatz is an assistant clinical professor at Philadelphia College of Osteopathic Medicine.• All lens surgery should be considered form of refractive surgery. Visual acuity of 20/50 or worse when tested with bright light imposition on the pupil, or glare testing, is considered a surgical level of cataract dysfunction in many states in the United States. Lens enhancement: reversal of presbyopia by scleral expansion A. Radial anterior ciliary sclerotomy endophthalmitis. Considering current technology, there may be no indications for extracapsular couching today. Although it may be possible to continue to emulsify the nucleus over ophthalmic visco-surgical device or over a lens glide (Michelson technique), a large capsular tear with presentation of vitreous may preclude safe emulsification, necessitating incision enlargement and nuclear delivery.
Non-lens-related conditions may also be an indication for lens surgery, such as aniridia. Loss of functional impairment due to visual impairment may range from minor impairment in luxury lifestyles, such as inability to follow a golf ball; to moderate impairment, such as inability to see well enough to drive an automobile; to severe impairment of life support functions, such as inability to see the units on an insulin syringe or the instructions on a bottle of cardiac medication—or even food on the table. The small sections may then be removed linearly with forceps through incisions as small as 3–4? Outcome of cataract operations performed to permit diagnosis, to determine eligibility for laser therapy, or to perform laser therapy of retinal disorders.
He also sits on several clinical advisory panels and has developed various surgical instruments to aid in cataract surgery. Shatz has operated on leaders in the entertainment, sports, and business world, and has developed techniques and instruments for use in lens surgery. Shatz often teaches his surgical techniques to other ophthalmologists in the country, and is frequently called upon by his colleagues to treat their most difficult cases.
A prototype of a novel dual-mode, accommodating-disaccommodating intraocular lens with zonular capture haptics has been fabricated successfully.
Section 4 – Lens surgery 315 Chapter 42 – Indications for Lens Surgery and Different Techniques HARRY B. Therefore, in developed societies where surgical technology is advanced, perceived economic conditions may be the factors that determine the prevalence and definition of “cataract blindness” for a population, and this changes as conditions change. In Europe, Japan, and the United States, where phacoemulsification and foldable lens implantation are widely standard, the only ocular indication for planned nuclear delivery may be an advanced nucleus that is too hard to be emulsified safely.
GRABOW KEY FEATURES • Lens surgery is the most common eye operation. In many underdeveloped nations, the prevalence of cataract blindness is determined by the availability of care. Corneas at risk for developing irreversible edema, such as those with low endothelial cell counts or guttate dystrophy, may be relative indications for nuclear delivery.