Ординатура / Офтальмология / Английские материалы / Jaypee Gold Standard mini Atlas Series Lasik_Aragawal, Jacob_2009
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Figure 4.6A
Figure 4.6B
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Figure 4.6C
Figure 4.6D
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Figure 4.6E
Figure 4.6F
Figure 4.6G
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Figure 4.6H
Figure 4.6I
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Figure 4.6J
Figure 4.6K
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Figure 4.6L
Figures 4.6A to L: Mirlex:bimanual phaco/phakonit/MICS.
(A) Clear corneal incision made with a special knife (MST, USA). Note the left hand has a globe stabilization rod to stabilize the eye (Geuder, Germany). This knife can create an incision from sub 1mm to 1.2 mm; (B) Rhexis started with a needle; (C) MST Rhexis forceps used to perform the rhexis in a mature cataract. Note the trypan blue (blurhexDr. Agarwal Pharma) staining the anterior capsule; (D) Two designs of Agarwal irrigating choppers. The one on the left has an end opening for fluid (Microsurgical Technology). The one on the right has two openings on the sides (Geuder–Germany); (E) Duet handles from MST, USA. The advantage of these handles is that one can change the irrigating chopper tips; (F) Various irrigating chopper tips designed by various surgeons. These can be fixed onto the duet handles. (MST, USA); (G) Phakonit irrigating chopper and phako probe without the sleeve inside the eye; (H) Phakonit done. Notice the irrigating chopper with an end opening. (Figure Courtesy: Larry
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Laks, MST, USA); (I) Bimanual irrigation aspiration completed;
(J)Soft tip I/A from MST, USA. (Figure Courtesy: Larry Laks MST);
(K)Thinoptx roller cum injector inserting the IOL in the capsular bag; (L) Comparision between phako foldable and phakonit Thinoptx IOL. The figure on the left shows a case of phako with a foldable IOL and the figure on right shows Phokonit with a ThinOptx rollable IOL
On August 15th 1998 the author (Amar Agarwal) performed the first 1 mm cataract surgery by a technique called phakonit (Figure 4.6). In this the cataract was removed through a bimanual phaco technique. It was performed without any anesthesia. The first live surgery in the world of phakonit was performed on August 22nd 1998 at Pune, India by the author (Amar Agarwal) at the phako and refractive surgery conference. This was done in front of 350 ophthalmologists.
The problem with this technique was to find an IOL, which would pass through such a small incision. Then on October 2nd 2001 the author (Amar Agarwal) did a case of phakonit with the implantation of a rollable IOL. This was done in their Chennai (India) hospital. The lens used was a special lens from ThinOptx. This lens used a fresnel principle and was designed by Wayne Callahan from USA. The first such ultrathin lens was implanted by Jairo Hoyos from Spain. One of the authors (Amar Agarwal) then modified this into a special 5 mm optic rollable IOL.
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The name phakonit has been given because it shows phaco (Phako) being done with a needle (N) opening via an incision (I) and with the phako tip (T). This is also because it is phako being done with a needle incision technology. In Mirlex we are doing microincisional refractive lens exchange.
Synonyms
1.Bimanual phaco
2.Microincision cataract surgery
3.Microphaco
4.Bimanual microphaco
5.Sleeveless phaco.
TECHNIQUE OF PHAKONIT FOR CATARACTS
Anesthesia
The technique of phakonit can be done under any type of anesthesia. In the cases done by the authors no anesthetic drops were instilled in the eye nor was any intracameral anesthetic injected inside the eye. This was No Anesthesia Cataract Surgery. The authors have analyzed that there is no difference between topical anesthesia cataract surgery and no anesthesia cataract
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surgery. If there is a difficult case the authors use a peribulbar block.
Incision
In the first step a needle with viscoelastic is taken and pierced in the eye in the area where the side port has to be made. The viscoelastic is then injected inside the eye. This will distend the eye so that the clear corneal incision can be made. Now a temporal clear corneal incision is made. A special knife can be used for this purpose. This keratome and other instruments for Phakonit are made by Huco (Switzerland), Gueder (Europe) and Microsurgical technology (MST-USA).
Rhexis
The rhexis is then performed of about 5-6 mm. This is done with a needle In the left hand a straight rod is held to stabilize the eye. This is the Globe stabilization rod. The advantage of this is that the movements of the eye can get controlled as one is working without any anesthesia. Microsurgical Technology (USA) have designed an excellent rhexis forceps for Phakonit. This goes through a 1 mm incison. Those comfortable with a forceps in phako can use this special forceps in phakonit.
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Hydrodissection
Hydrodissection is performed and the fluid wave passing under the nucleus checked. Check for rotation of the nucleus.
Phakonit
After enlarging the side port a 20 or 21 gauge irrigating chopper connected to the infusion line of the phaco machine is introduced with foot pedal on position 1. There are various irrigating choppers. Depending on the convienence of the surgeon, the surgeon can decide which design of irrigating chopper they would like to use.
The Agarwal irrigating chopper with a special design of Larry Laks from USA has been made by the MST (Microsurgical Technology) company. This is incorporated in the Duet system Other excellent irrigating choppers by various surgeons are present with the same company.
The phaco probe is connected to the aspiration line and the phaco tip without an infusion sleeve is introduced through the clear corneal incision Using the phaco tip with moderate ultrasound power, the center of the nucleus is directly embedded starting from the superior edge of rhexis with the phaco probe directed obliquely downwards
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