Ординатура / Офтальмология / Английские материалы / Manual of Practical Cataract Surgery_Sundararajan_2009
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How to Prevent Complications in Manual Phaco? 29
2.In case direction of the irrigating vectis is more oblique and tilted towards 6 O'clock position, there is a chance of the irrigating fluid to flash through the posterior capsule and anterior vitreous face and disturbing the vitreous.
Fig. 1.55
3.While introducing the vectis, if the fluid has already started flowing, there is a chance of damaging the endothelium of the cornea, when fluid hits against it.
Figs 1.56A to H
30 Manual of Practical Cataract Surgery
1.Fluid pressure pushes nucleus out.
2.Hook the nucleus out.
3.Depress the posterior scleral lip so that nucleus comes out easily.
EPINUCLEUS DELIVERY
After the nucleus delivery, there will always be a bulk of epinucleus left over at the anterior chamber, which will be seen as a hazy media.
This can be cleared by injecting viscomet again into Anterior chamber introducing the viscomet cannula at 6 O'clock position of the periphery and see that the remaining epinucleus is drifted out, by pushing viscomet. Remember to depress the posterior lip of wound by the same cannula, so that the epinucleus finds its way out easily. Some surgeons prefer to syringe out using BSF in the cannula.
Fig. 1.57
In my experience the injection of viscomet does a good clearing.
When once this procedure is over, the media appears still slightly hazy, due to the remaining cortex.
This can be well washed with BSF in the 21 G cannula or 22 G needle and aspirate.
How to Prevent Complications in Manual Phaco? 31
For the Beginners
It is better to use the 22 G cannula needle to aspirate this thin cortex. This takes a little time to aspirate.
For a quick washing of cortex use of 21 G needle Cannula with BSF is better. This is possible only with some experienced surgeons. The method of syringing the cortex has already been discussed.
INSERTION OF IOL
Fill the anterior chamber once again with viscomet.
Introduce the IOL of your choice into the anterior chamber and then in between the anterior and posterior capsule at 6 O'clock position in such a way that the dialor, when engaged, can rotate the IOL clockwise, i.e. the lower haptic curvature should be facing left side.
Fig. 1.58
Before doing this procedure perform the following procedure.
a.Catch the upper haptic with the Mcpherson or IOL lens holder.
32 Manual of Practical Cataract Surgery
Figs 1.59A to D
b.Remember the possibility of creating a damage to the surface of the optic when engaging the IOL with Mcpherson or lens holder.
c.Wash the IOL with distilled water on both the sides and then smear the IOL with viscomet on both sides to avoid damage to endothelium of cornea.
After having placed the IOL in position, wash the IOL with BSF and the anterior chamber.
Closure
As the incision is smaller, the approximation of both the corneal lip and scleral lip is perfect as it is a step incision. This does not require suturing.
CONJUNCTIVAL CLOSURE
Bring the conjunctiva to its original position. Catch the both ends (vertical) as shown in the picture and using wet field cautery, inside BSF and cauterise.
How to Prevent Complications in Manual Phaco? 33
Figs 1.60A to C
While cauterising, catch the base (lower) position of conjunctival flap and cauterise under BSF.
Fig. 1.61
INTRAOPERATIVE COMPLICATIONS AND HOW TO TACKLE IT
Iridodialysis
1.If it occurs at 6 O'clock position inject viscomet in anterior chamber to push the flap back. When you see that the flap is nearing limbus, carefuly catch the free end of iris, start suturing, take the first bite at 6 O'clock position at the limbus as shown in the picture. 2nd bite at the root of iris. 3rd bite at 6 O'clock position of the cornea and suture with 8 or 10 suture.
Figs 1.62A to C
34 Manual of Practical Cataract Surgery
If necessary two more sutures, one on either side.
Fig. 1.63
2.When the iridodialysis is at 11-2 O'clock position take the 1st bite at sclera take out, then 2nd bite at root of iris, take out and then 3rd bite at the cornea and suture or vice versa.
Figs 1.64A to D
Nucleus Sinking
This should not be allowed to happen - this is a dreaded complication.
In case nucleus starts sinking, put a stab puncture at pars plana with 24 G needle at 7 O'clock position or at a
How to Prevent Complications in Manual Phaco? 35
suitable position, push in the needle under the nucleus, make the nucleus float. Ask your assistant to push up the nucleus carefully, quickly introduce the Macpherson, catch either the haptic or optic or nucleus and pull out.
Figs 1.65A and B
After having removed the nucleus out, have a look at the pupil to find out where the vitreous is peeping out. Pupil will be peaking at one place as shown in picture.
Figs 1.66A and B
HALF NUCLEUS DELIVERY
Vectis should be passed under the nucleus upto the equator and the nucleus dialor should also be at the same place engaged similarly to bring out in full.
Sometimes, if you engage the nucleus at the centre with both the vectis and the dialor, it is likely that only one half of the nucleus alone comes out breaking the nucleus into half.
36 Manual of Practical Cataract Surgery
Fig. 1.67
The remaining half of the nucleus will be retained in the anterior chamber. In such circumstances, it is better to inject viscomet at 6 O'clock position of anterior chamber which forces the remaining nucleus to be drifted out.
In case it is not possible, engage the nucleus again with vectis and nucleus dialor and pull out. Now introduce Vannas scissors cut the vitreous at the pupillary border, make the pupil round or circular or inject pilocar or acetylcholine to make it round and reconstricted. Inject air to reform the anterior chamber put in anterior chamber IOL. Do peripheral iridectomy and close.
When once the nucleus is sunk. Abandon the surgery and leave it to retinal surgeon.
Figs 1.68A and B
Catching the IOL at the optic surface will produce scratches or rough surface on IOL.
It is always better to catch the haptics.
How to Prevent Complications in Manual Phaco? 37
DESCEMETS DETACHMENT IN SICS
There is a chance of descemets and endothelial detachment and hanging into the anterior chamber giving a false impression. When any instrument is introduced through the step incision. At this circumstances the surgeon has to understand that the descemets -endothelium complex in the scleral side is projecting, whereas the same in corneal side is far behind, concealed and out of direct view. Anterior chamber may be shallow.
The surgeon has to be more careful and deal without excitement. It is better, he removes the nucleus quickly by some uncomplicated method and insert the IOL, wash with BSF to remove cortex. The purpose is to proceed without complicating it anymore.
Now fill in air in the anterior chamber to push back the descemets and endothelium complex in its original position. Reform anterior chamber and if necessary, limbal suture may be placed to keep the descemets complex well reapproximated in the post operative period.
Fig. 1.69
Remove nucleus quickly, wash the cortex.
Fig. 1.70
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WHEN THE PUPIL IS NOT DILATED.
As in pseudoexfoliation syndrome or in iritis.
Sweep the iris with iris-repositor through the pupil all around. Break the synechia.
Some surgeons dilate the pupil by dialors by keeping it in opposite direction and dilate, sometimes tear occurs.
Fig. 1.71
Some make one cut at 5 O'clock and 8 O'clock position at pupillary border which is not sufficient.
Fig. 1.72
My opinion is to make a peripheral iridectomy at 12 O'clock position then vertical cut make a keyhole iridectomy. This produces sufficient dialatation, pull out iris at 12 O'clock position, suture the pigmentary epithelium side and put it back (after introducing the IOL).