Ординатура / Офтальмология / Английские материалы / Manual of Practical Cataract Surgery_Sundararajan_2009
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How to Prevent Complications in Manual Phaco? 9
Fig. 1.13
•Another operational convenience is to make the major portion of the Tunnelling incision in the right side of the eye.
Fig. 1.14
•Temporal side incision is also practiced by sitting on the temporal side of patient.
Fig. 1.15
SIDE PORT INCISION
This incision can be made at any place.
•If incision is made at limbus, there is an immediate gush of aqueous out, making the anterior chamber shallow subsequently producing iris prolapse.
•In case without our knowledge the incision is deep, there is a chance of iridodialysis, tear of zonules, leading on to disturbance to vitreous face.
10 Manual of Practical Cataract Surgery
•Prefereably in case, the side port incision is made at 6 O'clock position of limbus, it makes the further procedure difficult by iris prolapse. Whether it is at limbus on inside cornea.
Fig. 1.16A and B
•So, it is better to make S.P.I (Side port incision) at 8 or 9 O'clock position 1 mm inside the limbus i.e., in the cornea.
•This S.P.I also should be a step incision to act as a valve and self-sealing.
Figs 1.17A and B
•When we are using a big angled keratome, the breadth of the incision is more and so there is a chance of leak of aqueous once the surgery is over.
•So, it is better to make an incision smaller so as to admit the tip of 26 G needle for injection of air or Trypan blue dye.
•In case a pterygium is present, it is preferable to avoid and make S.P.I below the margin of pterygium.
How to Prevent Complications in Manual Phaco? 11
Fig. 1.18
•When you make a S.P.I, it is better to catch the opposite, side limbus or sclera and fix it with toothed forceps or colibri and then introduce S.P.I blade or angled keratome.
Fig. 1.19: Fix at opposite side.
The purpose of S.P.I is to aspirate the 12 O'clock position cortex, through this hole.
When once the S.P.I is done, anterior chamber becomes shallow. Fill the anterior chamber immediately with air or Viscomet with blunt 26 G needle.
While introducing the needle for air injection, there is always a chance of damage to anterior capsule. So the procedure should be quick and damage free.
Figs 1.20A to C
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Once the air bubble is injected into anterior chamber and A/c is formed, the trypan blue dye may be injected under the air bubble and smear the anterior capsule with the dye. BSF wash is subsequently given to wash the dye and then fill the chamber again with the Viscomet to push the air out.
Fig. 1.21
If you are confident of washing 12 O'clock cortex without S.P.I, you can skip this procedure and similarly the dye also. Once the surgery is over, S.P.I can be closed by injecting intralamellar BSF, if necessary.
Now the surgeon can open the sclerocorneal incision and open incision at 10 - 12 O'clock position to make anterior capsulotomy. Inject viscomet immediately to fill and to prevent shallowing of anterior chamber.
CAPSULORHEXIS; (UNDER HIGH MAGNIFICATION) 1.0X OR 1.5X
Bend the 26 G needle a little bigger than suggested in planned ECCE where it is ½ mm
45° - 60°
Fig. 1.22
How to Prevent Complications in Manual Phaco? 13
Here the purpose of bending the needle is not only to cut the anterior capsule but also to push the capsule towards the center while making a 5 mm size circular incision with the tip of the bent needle. The dyed anterior capsule appears blue.
Fig. 1.23: This portion of anterior capsule is elevated and separated.
Inject viscomet into anterior chamber. Now, introduce the bent needle through the sclerocorneal incision, horizontally to avoid damage to endothelium of cornea or anterior capsule of lens and then rotate anti, clockwise.
Start from the centre i.e., tear the capsule at the centre in a curved fashion. With the tip of the needle, push the capsular free edge, close to the junction and tear. Make a gentle pushing with the direction towards the centre, slowly millimeter by mellimeter till you achieve a circular rhexis with clear border. This can also be achieved using Mcpherson forceps or Utratas forceps by simple tearing circularly the free elevated end of capsule.
Make a oblique C-shaped incision at the centre of lens capsule.
The elastic capsule recoils as shown in the picture. The curvature 'C' is to create circular linear tear and to create a free border of capsule to fold. Fold the free edge of the capsule.
14 Manual of Practical Cataract Surgery
CAPSULORHEXIS
Figs 1.24A to H: Capsulorhexis
CAPSULORHEXIS WITH 26 G NEEDLE (BENT) MAGNIFIED.
Figs 1.25A to H: Capsulorhexis with 26G needle
How to Prevent Complications in Manual Phaco? 15
Then, slightly elevate the capsule and push the folded border of the free end of the capsule in such a way to create a circular tear as shown in the figure.
The difficulty arises when the bent needle pushes the anterior lens capsule to tear at left side - 3 O'clock position. The problem can be solved by meticulous, patient handling.
The ideal way to learn is by practicing the same with a red tomato or sapota fruit (chippu).
You are at liberty to make a can-opener method and proceed, instead of rhexis. The advantage of this rhexis is to avoid the unnecessary tags of capsule.
Big or wide rhexis is always better for manual phaco procedure.
In small rhexis, when the BSF is injected under the capsule for hydrodissection the BSF stays in the posterior pole to form a pool and finds it difficult to create a wayout and so it creates a posterior capsular rent followed by vitreous disturbances.
Fig. 1.26
In case you make a bigger rhexis, fluid easily finds its way out and does not pool in the posterior capsule.
Fig. 1.27
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HYDRODISSECTION
Inject 1 cc of BSF under the cut edge of anterior capsule at the periphery at 6 O'clock to 9 O'clock. This produces the separation of posterior capsule from the cortical fibers and raises the nucleus slightly above and floats.
Figs 1.28A and B
EXTENTION OF INCISION
After filling the Anterior Chamber A/c with Viscomet the small wound in the corneo-scleral incision at 11-12 O'clock position may be extended with the help of wound extension blade or angled keratome on either side of the wound so as to allow the easy delivery of nucleus. For this, the wound extendor is comfortable.
Fig. 1.29
As the incision is small the wound may be extended inside only on either side, the inner C.S opening should be bigger than the outer side C.S opening.
How to Prevent Complications in Manual Phaco? 17
Figs 1.30A and B
MANUAL ROTATION OF NUCLEUS
Fig. 1.31
In each and every step of the procedure, you should not fail to notice the anterior chamber becoming shalow.
When it becomes shallow, it produces endothelial damage, so you have to inject then and there sufficient Viscomet to prevent endothelial damage to cornea.
Now, inject BSF under anterior capsule after a successful Rhexis at 5-6-7-8 O'clock position to raise the nucleus above pupil.
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NUCLEUS DELIVERY
Fig. 1.32
Once the hydrodissection is done, inject viscomet into anterior chamber with the help of nucleus dialor (IOL Dialor) engage the tip of dialor a 7 to 8 O'clock position of periphery of nucleus near the dilated margin or pupil.
Fig. 1.33
Rotate the nucleus in a clockwise pattern while gradually raising and elevating the nucleus, so that the equator of the nucleus is tilted up and appears well into the anterior chamber.
After having seen the equator or nucleus in anteiror chamber the nucleus is slightly tilted.