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Acta Ophthalmol. 2010: 88: 675–680 Abstract. Purpose: To describe and evaluate a cryo-assisted, minimally invasive, anterior approach for orbital tumour surgery. Methods: Retrospective, non-comparative, consecutive, interventional case series of 103 patients who were operated on by the same surgeon for retroocular orbital tumours over the last 16 years. Results: A cryo-assisted, minimally invasive, anterior approach was employed in 63 out of the 103 patients (61.2%). In 37 patients (35.9%), anterior orbitotomy without the use of cryoprobe was employed for biopsy or excision of small, anteriorly located lesions. Lateral orbitotomy was used in three patients (2.9%). In a subgroup of 61 patients with circumscribed lesions (mainly cavernous haemangiomas and schwannomas), cryoextraction was used in 51 (83.6%). None of the procedures required conversion to lateral orbitotomy and there were no intraoperative complications. Conclusion: In contrast to other reports on the treatment of orbital lesions, in the current case series surgery of most solid tumours and many other cystic or infiltrative lesions was achieved here via an anterior, cryo-assisted approach, and thus with minimal trauma to the orbit. This approach warrants more favourable consideration because the combination of the anterior approach with the use of cryoprobe and surgical microscope can yield successful results, even in patients with large or deeply located tumours – obviating in most of them the need for lateral or transcranial orbitotomies with bone flaps.

Background Cavernous hemangioma is the most common benign intraorbital tumor found in adults. Most cavernous hemangiomas are located within the intraconal space. When indicated, complete surgical removal is the only treatment option. Several surgical techniques have been refined over the past decades. We describe our experience over transconjunctival approach in 24 patients with retrobulbar intraconal orbital cavernous hemangiomas. Method This retrospective study includes 24 nonrandomly selected patients who had retrobulbar intraconal tumors. The presumptive preoperative diagnosis was based on magnetic resonance imaging findings. Compression on the optic nerve and/or the globe and proptosis constituted indications for surgery. The tumor was exposed via a transconjunctival route after temporarily disinserting an extraocular muscle depending on the location of the lesion. Results In all patients, the tumor was in touch with the globe and in most cases extended to the orbital apex. All tumors were removed intact. In 14 patients, tumors were extirpated with the aid of a cryoprobe. Visual acuity increased in 8 patients and remained stable in the rest. No serious or permanent complications were observed during or after the operation. Conclusions Retrobulbar intraconal cavernous hemangiomas can be removed successfully through a transconjunctival approach with minimal damage to surrounding tissues. This method is best for tumors whose anterior borders are in contact or very close to the eye even if the posterior border abuts the orbital apex.

Kecova, H. , A. Neaas: Phacoemulsification and Intraocular Lens Implantation: Recent Trends in Cataract Surgery. Acta Vet. Brno 2004, 73: 85-92. This review article summarizes the evolution of cataract surgery techniques and intraocular lens (IOL) implantation. It emphasizes the necessity of appropriate patient selection for the surgery and precise surgical technique for successful outcome of this procedure in dogs. The history of cataract surgery, factors critical for good outcome of the procedure, timing of surgery, preoperative medication, phacoemulsification technique and types of implanted intraocular lenses are discussed. Cataract, phacoemulsification, intraocular lens, dog Cataract (Plate XIII, Fig. 1) is a leading cause of unilateral and more often bilateral blindness in dogs. The only effective mean of its treatment is surgery – extraction of diseased lens (Dziezyc 1990) and its replacement by an artificial intraocular lens (IOL = “intraocular lens”). The opinions on cataract surgery have been changing continually with advancement of the procedure. The success rate of cataract surgery has risen significantly during last decades, especially thanks to development of more precise microsurgical techniques and with introduction of phacoemulsification (Boldy 1988; Dziezyc 1990) and IOL implantation. History of cataract surgery The initiation of “cataract surgery” is mentioned in ancient India as early as 2000 years B.C.; at that time the only attempt was to restore vision by iatrogenic posterior luxation of cataractous lens reclination. Until now reclination remains a method of choice of shamans in some parts of Africa (Ghana). In 1745 Daviel performed the first extracapsular cataract extraction (ECCE). In 1753 Sharp performed the first intracapsular cataract extraction (ICCE) by expression of the nucleus using a thumb. During the 17th, 19th and the beginning of 20th century, the most popular method of cataract extraction was ICCE (different methods of mechanical zonulolysis). After the 2nd World War, the ECCE became more popular with development of better operating microscopes. In 1949 Harold Ridley implanted first posterior chamber IOL in a 60-year-old woman after previous ECCE (Ridley 1952). However, due to a large degree of secondary cataract, glaucoma and anterior chamber inflammation following “primitive” ECCE (without irrigation/aspiration of remaining cortical material), this method was again replaced by intracapsular extraction. In 1957, Barraquer carried out the first ICCE using enzymatic zonulolysis (Barraquer 1958) and in 1961 first cryoextraction was done by Krawicz. In 1970s, with improved irrigation/aspiration devices and capsulotomy techniques, surgeons again returned to ECCE (now with complete removal of remaining cortical material). With the development of ultrasound machines creating low ACTA VET. BRNO 2004, 73: 85–92 Address for correspondence

With the development of mechanically stable cryoprobes, direct endoscopic removal of tissue from the bronchial system with cryotherapy is now possible. Tissue is frozen to the tip of the probe and removed by pulling on the probe together with the fiberscope. This procedure, also referred to as cryoextraction, additionally provides good quality biopsy specimens for histopathological examination. We report here on four patients with different forms of bronchial obstruction, in whom cryoextraction was performed for rapid recanalization. In addition to the immediate effect, the procedure has few complications and is cost-effective. Indications were mucoid impaction, foreign body aspiration, removal of suprastomal granulation tissue prior to decannulation after prolonged mechanical ventilation, and obstruction of the trachea and the main bronchi by a carcinosarcoma. In the latter case, the diagnosis was additionally based on a specimen obtained by cryobiopsy.

Hydatidosis of the orbit has been reported in about 1 % of all cases of hydatid disease. Its prevalence has been reported from 0.3 to 5 % of all the orbital diseases in the literature. Usually the cyst is located in the intraconal space of the orbit. Hydatidosis is common among children and young adults, who usually present with unilateral, progressive axial proptosis of a few months’ duration, associated with pain or discomfort and defective vision. Clinical suspicion and appropriate investigations are important. Serology may be positive but imaging is definitive for diagnosis. Computed tomography scan of orbit is preferred over orbital ultrasonography. Evaluation for associated systemic hydatidosis is mandatory. If neglected, the cyst can assume a very large size and lead to total loss of vision. Surgical excision of the cyst is recommended which is facilitated by aspiration of the fluid from the cyst after the cyst wall has been exposed and cryoextraction. Other modalities include percutaneous aspiration and injection of hypertonic saline and reaspiration and medical management.

A 55-year-old Caucasian woman presented with an orbital cavernous haemangioma superior to the optic nerve in the orbital apex. Preoperative imaging demonstrated a mass involving the superomedial and superolateral quadrants of the posterior orbit. A stereotactic fronto-orbital approach was performed by the neurosurgical team, and cryoextraction of the lesion was accomplished by the ocular plastic surgical team.

Samples of the hexagonal close-packed phase (h.c.p.) of fullerite C 60 with a low (less then 7%) content of more stable face-centered cubic (f.c.c.) phase were synthesized using cryoextraction with n -hexane. X-Ray diffraction analysis and thermogravimetry were applied for characterization of the samples. The role of n -hexane in the formation of the h.c.p. structure is discussed.

A step-by-step description of a surgical technique for episcleral Miragel® buckle removal is reported. After dissection of the conjunctiva and the capsule surrounding the Miragel® element, the extremity of the buckle is pulled out with a cryoprobe. The removal of Miragel® episcleral buckle with the cryoprobe is a safe and effective technique with a low fragmentation rate and a reduction of the surgical risk related to the use of sharp forceps near a possibly weakened sclera. Procedure time seems also to be reduced. [Ophthalmol Surg Lasers 2002;33:237-239]

Purpose The aim of this course is to share our experience with transconjunctival or transcutaneous anterior orbitotomy using surgical microscope and cryoextraction approach for surgery of retroocular orbital tumors. Methods Data regarding the used of this anterior surgical approach to retro-ocular orbital tumors was collected from our case series of 103 patients who, over 16 years, were operated on for retroocular orbital tumors and from a newer case series of 24 patients who, over the last 5 years were operated on for orbital cavernous hemangioma. Results A cryo-assisted, minimally invasive, anterior approach was employed in most patients. During more than 20 years lateral orbitotomy was needed only in 3 patients. The operations with anterior approach lasted 57.9 + 15.0 minutes. In none there was need for transformation into lateral orbitotomy and there were no intra-operative complications. No post operative deterioration of visual acuity was evident. Conclusion In contrast to other reports on treatment of orbital lesions, in our experience, surgery of most solid tumors and of many other cystic or infiltrative lesions can be achieved via an anterior, cryo-assisted approach, and thus with minimal trauma to the orbit. This approach warrants more favorable consideration as it can yield successful results even in cases with large or deeply located tumors. In most cases it obviates the need for extra-ocular muscle disinsersion and lateral or transcranial orbitotomies with bone flaps.

Cryoextraction is a procedure for recanalization of obstructed airways caused by exophytic growing tumors. Biopsy samples obtained with this method can be used for histological diagnosis. The objective of this study was to evaluate the parameters influencing the size of cryobiopsies in an in vitro animal model. New flexible cryoprobes with different diameters were used to extract biopsies from lung tissue. These biopsies were compared with forceps biopsy (gold standard) in terms of the biopsy size. Tissue dependency of the biopsy size was analyzed by comparing biopsies taken from the lung, the liver, and gastric mucosa. The effect of contact pressure exerted by the tip of the cryoprobe on the tissue was analyzed on liver tissue separately. Biopsy size was estimated by measuring the weight and the diameter. Weight and diameter of cryobiopsies correlated positively with longer activation times and larger diameters of the cryoprobe. The weight of the biopsies was tissue dependent: lung < liver < stomach. Only little tissue dependency was found for the biopsy diameter. The biopsy size increased when the probe was pressed on the tissue during cooling. Cryobiopsies can be taken from different tissue types with flexible cryoprobes. The size of the samples depends on tissue type, probe diameter, application time, and pressure exerted by the probe on the tissue. Even the cryoprobe with the smallest diameter can provide larger biopsies than a forceps biopsy in lung. It can be expected that the same parameters influence the sample size of biopsies in vivo.

Vitreoretinal surgery allows the effective removal of soft to moderately dense crystalline lens fragments, using the vitrectomy probe and the ultrasonic fragmentation probe. Hard lenses cannot be removed with these instruments. Previously described techniques for removal of hard lenses include trapping the lens anteriorly with needles, cryoextraction of the lens in an air-filled eye, and manipulation with sodium hyaluronate. These methods are difficult and dangerous in some cases. We used perfluorocarbon liquid to facilitate the safe removal of a surgically luxated hard crystalline lens. Injection of the perfluorocarbon liquid floated the lens off the retinal surface and into the anterior vitreous cavity. In this location, the lens was delivered by using standard extracapsular cataract extraction techniques. This technique allowed removal of the hard crystalline lens with minimal manipulation, and was helpful in the setting of poor media clarity.

BACKGROUND The cavernous haemangioma (cavernoma) is the most common orbital tumour in adults. Various surgical approaches have been described so far. We prefer a transconjunctival approach and analyse herein how our outcomes compare with those of transcutaneous or transosseous approaches. METHODS A retrospective series of 10 cases was analysed with regard to surgical success and complications. RESULTS The tumour could be completely removed in all cases. In one case, preoperative diplopia disappeared after surgery. Another case suffered from postoperative diplopia, which resolved within two months. Two cases developed a long-lasting partial tonic pupil. CONCLUSION A retrobulbar cavernoma can be safely removed via a transconjunctival approach through shrinkage by coagulation and subsequent cryoextraction.

The authors report a case of an infant in whom orbital capillary hemangioma was diagnosed using technetium-99m-labeled red blood cell scintigraphy. The tumor was subsequendy removed by transconjunctival cryoextraction. [Ophthalmic Surg Lasers 1997;28:954-956.]

Patient A 35-years-old female patient with Marfan's syndrome presented with fast progressive reduction of visual acuity (hand movements) of her right eye and lens-related glaucoma on both eyes. On examination, subluxation of the lens and nuclear cataract were seen on both eyes. Diurnal pressure curve showed great fluctuations in pressure with normal IOP in the morning and elevated pressure in the evening. Pressure measurement revealed great fluctuations depending on positioning. Because of cataractous lens in the right eye blocking the visual axis and uncontrollable, phacogenic glaucoma removal of the lens by cryoextraction was necessary. Visual acuity increased to 0.5 and IOP was normal after three weeks. To improve safety of topical medication of lens-related glaucoma in Marfan's syndrome regular measurement of IOP at different times of the day is especially important. Measurement of IOP at different positions seems to be an effective provocation test in cases of phacogenic glaucoma in Marfan's syndrome. Examination of all members of a family with Marfan's syndrome should include regular measurement of IOP at different times of the day. In suspected cases, measurement of IOP at different positions that may provoce IOP-increase could be useful in the early detection of lens-related glaucoma.

This article is dedicated to the life and work (research, medical, educational) of V.V. Shmeleva, professor and Great Patriotic War participant. She was the head of ophthalmology department at the City Clinical Hospital No 67 and promoted the implementation of cataract cryoextraction into clinical practice. As a professor at the Order of Lenin Central Institute of Advanced Medical Training she was engaged in postgraduate training of ophthalmologists. V.V. Shmeleva is the author of Cataract monograph and many scientific articles. She was also the senior secretary of the Vestnik oftal'mologii journal for more than 25 years.

Four patients with relatively large orbital tumors are described. These patients had superomedial rhabdomyosarcoma, inferomedial cavernous hemangioma, lateral primitive neuroectodermal tumor, and superior neurofibroma, respectively. Continuing enlargement and encroachment upon vital ocular structures and suspicion of malignancy warranted surgical intervention. Following exposure of the anterior portions of these tumors, a cryoprobe was used for the complete removal of the mass. Cryoextraction greatly facilitates the excision of well-defined, solid, encapsulated, benign or malignant tumors excluding the lacrimal gland and thus minimizes trauma to adjacent tissues. More importantly, the tumor can be removed intact without capsular rupture and risk of tumor spill-over or hemorrhage. At the histopathological level, the application of a cryoprobe did not alter the microscopic structures of the lesions and did not cause any difficulty for histopathologic interpretation.

In India are approximately 4 million blind people by advanced or mature cataract. For only 10 US$ one patient can be operated in eye camps in the villages by an intracapsular cataract cryoextraction an + 12.00 dptr. aphakia glasses. Also estimated four million people are blind by xerophthalmia. The project is to examine all the babies and little children in the villages and to give them for 2 years each month vitamin-A-medication. On the other side the parents of children suffering from xerophthalmia are instructed to plant vegetables rich in vitamin A. The goal of both projects is to make a cataract and xerophthalmia free zone in Uttar Pradesh, which should spread over the entire country. Both projects are sponsored by Combat Blindness Foundation, P.O. Box 5, 332 Madison Wisconsin 53705 USA, Professor Suresh Chandra, chairman.

The extraction of aspirated foreign bodies can prove challenging at times, requiring even rigid bronchoscopy. Cryotherapy probes have been reported to help with extraction of foreign bodies. We present a case where successful "cryoextraction" was performed on an aspirated chewing gum. The case highlights the fact that this technique is useful to extract all materials that have water content. This technique can be performed through flexible bronchoscopy and can save patients from more aggressive approaches.

Owing to the use of wide-angle observation systems 1,2 the lens can be preserved during the vast majority of pars plana vitrectomies. When such lenses later develop cataracts, they frequently exhibit nuclear sclerosis of such a degree that phacoemulsification would no longer be a safe procedure, even for experienced anterior-segment surgeons who are more and more comfortable emulsifying denser and denser lenses. The vitreous cavity of these eyes is filled with aqueous or silicone oil. This fact renders standard extracapsular cataract extraction with expression of the lens nucleus potentially hazardous because pressure on the globe may lead to collapse of the posterior segment in eyes filled with aqueous or to a localized rupture of the zonule and subsequent formation of a persistent pathway through which silicone oil can pass from the vitreous cavity into the anterior chamber. To avoid such complications, extracapsular cryoextraction, followed by an irrigation-aspiration procedure, has proven

A surgical technique is described for cryoextraction of the inner germinal layer of orbital hydatid cysts. The technique was adopted in two cases. It is simple and effective and causes minimal postoperative reaction or complications. There were no recurrences over a period of 24 and 18 months respectively.

In 123 cases of lens luxation the lens was removed from the vitreous by cryoextraction. It was a success in 119 cases, always intracapsular, and in the majority of cases without or only with a minimal loss of vitreous. A vitrectomy or vitreous suction was never necessary. Evaluating these results, one would advise to employ this procedure early before an advanced vitreous destruction may occur.

A case of Serratia marcescens endophthalmitis following an intracapsular cataract cryoextraction in a diabetic patient is delineated. Appropriate antibiotic therapy failed to control the infection. Intravitreal administration in rabbit eyes of the culture of live bacteria, broth suspension of the dead-disrupted form of the organism, or the bacteria-free culture filtrates produced an infection that mimics the case presented.

For generations, ophthalmic surgeons have worked toward perfecting the intracapsular extraction of cataracts. Yet, on occasion, even the most experienced and dexterous of surgeons unavoidably ruptures the capsule. Cryoextraction, in contrast to extraction by means of erisophake or forceps, by placing the tractive stress not on the fragile capsule but on the whole lens invariably assures a successful intracapsular operation. It is rather surprising that cryoextraction has found little acceptance in this country since Krwawicz first reported his technique in 1961. 1,2 Perhaps this has been due to a lack of completely satisfactory instrumentation. Krwawicz merely immersed a metal probe into a mixture of alcohol and solid carbon dioxide, lowering the temperature effectively but for a relatively short period that made rapid surgery (or repeated immersions and applications) necessary. Other instruments that are now available are the liquid nitrogen unit originally developed for brain surgery (involving a massive monitoring unit)

The size of the crushed cataractous bag was determined by measuring the diameters and widths of 50 cataracts removed by cryoextraction and then mathematically determining their individual areas and crushed bag size. These lenses had a collapsed bag size of 10.8 +/- 1.4 mm.

The presently employed methods for cataract operations are characterized by a high success quota. Some details from the fields of anesthesia, separation of the lids, cutting and stitching form, stitching material, cryoextraction which contribute to this success quota are discussed.

SUMMARY In a village hospital in Pakistan, where the work load demands very efficient surgical technique, a new system of cryoextraction featuring a very efficient method of freon delivery into a very effective cryoextractor was introduced. The system reduced complications without reducing the efficiency of the operation. It is recommended for use in situations where a large surgical load calls for efficiency and as a back-up system in other situations.

A case of electrical shock occurred with a heater-equipped cataract cryopencil. The short circuit resulted from apparent mistreatment of the cataract probe. Steps are listed for the prevention of such an occurrence. The probe tip should be grounded. Any evidence of muscle contraction when the probe is activated constitutes a danger signal.

THE APPLICATION of low temperatures to ocular surgery has resulted in numerous reports of the value of this modality in the treatment of cataract, retinal detachment, and to a lesser degree, glaucoma. Other ocular conditions have been treated by cryosurgical techniques 1 and currently constitute "minor" indications for the use of this modality. Recent favorable experience with cryoextraction of clotted blood in cases of total hyphema prompts the present report. Total hyphema carries a grave prognosis. Its deleterious effects require surgical removal of the blood from the anterior chamber when secondary glaucoma in uncontrollable by medical means or when corneal hemosiderosis occurs. Fibrinolytic agents and aspiration have been advocated by some investigators, 2 while others have recommended removal of the anterior chamber clot by forceps or the erysiphake. 3-4 All of these techniques have been successful, but all have their drawbacks. Cryosurgery, although not ideal, appears to offer some advantages

Life threatening event due to central airway obstruction caused by very large blood clot formation with profuse on going bleeding its very challenging to manage. Interventional pulmonologist must aware about this situation which can lead to respiratory failure. There are several choices to treat this unlikely situation, in example flexible bronchoscopy with forceps, bronchial lavage, and suction. We present a case with post-surgical tracheostomy bleeding which caused a giant blood clot formation in a disseminated intravascular coagulation due to severe sepsis in end stage renal disease patient, successfully managed with cryoextraction and argon plasma coagulation. Combinations of two endobronchial approaches can give a quick, safe and cost effective lifesaving treatment.

Traumatic cataracts occurring after ocular trauma were removed by phacoemulsification, cryoextraction or extracapsular cataract extraction, depending on the degree of lens absorption. All eyes received sputnik-style iridocapsular lenses. Most cases were complicated by the presence of synechiae and/or the need for iridoplasty. The surgical technique varied with the specific nature of the ocular pathology. Eyes with penetrating injuries had a higher complication rate. Anterior chamber shallowing or collapse was the most frequent intraoperative complication, and was directly related to the incidence of postoperative complications. Most postoperative complications were typical of those associated with cataract surgery in complicated situations.