Ординатура / Офтальмология / Английские материалы / Manual of Practical Cataract Surgery_Sundararajan_2009

How to Prevent Complications in Manual Phaco? 39

Fig. 1.73

IN DIABETES AND OLD AGE

There is always a possibility of iritis and choroiditis, posterior synechia. Under such condition, dialing or rotating the nucleus is not possible. In our attempt to dial, the nucleus becomes suddenly vertical, producing posterior capsular rent.

Find out where the rent is?

Find out whether the vitreous is above or below the nucleus, use a cotton bud and pull, see whether the pupil distorts. In such circumstances, cut the vitreous at the pupillary margin and prevent sinking of nucleus by passing 24 G needle at pars plana below the nucleus, lift the nucleus up with the help of Mcpherson forceps-remove the nucleus.

For a beginner the success of the surgery depends on

1.Correct superior rectus fixation

2.The sufficient pupillary dilatation, and

3.A procedure to prevent sinking of the nucleus by any means.

40 Manual of Practical Cataract Surgery

WHEN WILL YOU INJECT VISCOMET INTO ANTERIOR CHAMBER?

The principle is

•To avoid injury to the endothelium of the cornea.

•To clear the hazyness of the cornea put a drop on the cornea.

•When anterior chamber is opened inadverdantly or without our knowledge during surgery.

•During incision when anterior chamber is opened.

•Side port incision (S.P.I) immediate gush of aqueous inject viscomet to reform anterior chamber or if you want to inject dye, inject air.

•After injecting trypan blue dye-inject viscomet to reform anterior chamber.

•When C. S incision opened aquous comes out. Inject viscomet to reform anterior chamber.

•Before making anterior capsulotomyinject viscomet.

•After making anterior capsulotomy - inject viscomet.

•Before injecting BSF under anterior capsule to separate.

•Before using dialor for nuclear rotation.

•When rotating the under surface of the nucleus at its equator.

•When once nucleus comes out into anterior chamber.

•Inject at 6 O'clock position of anterior chamber to drift out nucleus when incision is bigger simultaneously depressing the posterior lip of sclera.

•Before introducing the vectis under the nucleus and dialor above. Inject viscomet both above and below the nucleus.

•After the nucleus is out reform anterior chamber with viscomet and also at 6 O'clock position to push the epinucleus out.

•Before aspirating the remaining cortex.

•Before introducing the IOL.

How to Prevent Complications in Planned ECCE ... 45 CHAPTER 2

How to Prevent Complications in Planned ECCE with PCIOL?

This portion is specially included for-this method is still practiced in most of the centres and is also a basic for the advanced procedures. Secondly, in case of failures in manual phaco or micro phacos one can quickly change over or convert it to this method to restore the vision rather than dealing unnecessarily with complications. So it becomes absolutely essential to master this basic method to restore vision to the patient.

COMPLICATIONS

The following are the usual complications that can occur during surgery:

1.Retrobulbar hemorrhage.

2.Wound gaping.

3.IRIS prolapse and infection.

4.Descemets detachment

5.Endothelial damage—leading to striate Keratitis in the post-operative period.

Retrobulbar Haemorrhage

For local analgesia-peribulbar analgesia followed by massage by placing a balanced weight or with or without facial analgesia.

46 Manual of Practical Cataract Surgery

Retrobulbar injection of 2% xylocaine, adrenaline and hyalase with 2.5 cm length or 2.0 cm length needles is likely to tear either the blood vessels or pierce into meningeal sheath or damage to optic nerve by entry of the needle. Or double puncture of the globe, in myopic eyes or big eyes.

In case, the analgesia expires prematurely, it is advisable to give an injection of ½ to 1 ml of 2% Xylocainesubconjuntivally at 6 O'clock or fornix. During the middle of surgery. To avoid infection it is preferable to use a fresh 2 ml disposable syringe and fresh sterile bottle of 2% Xylocaine.

HOW TO PREVENT COMPLICATIONS IN PLANNED ECCE WITH PCIOL?

Now, it has become inevitable that all cases who are getting operated should face "SUCCESS" otherwise we are getting into troubles with consumers problems. As such, each step of surgery has become important so that we can be cautious about the possible complications.

This is helpful for beginners though it is not much useful for surgeons who performs "small incision surgeries".

Basically, the microscope should have excellent illumination, wide field coverage, with good optics. All aseptic precautions should be strictly followed. Including general like dental sepsis, otitis media, ulcers, etc.

First exclude diabetes, hypertension, dacryocystitis and glaucoma mainly.

Dilate the pupil with Tropicamide and Phenylephrine combined drug.

Proper preoperative/Eyelash cutting.

Betadine painting, instillation in eye followed by washing.

48 Manual of Practical Cataract Surgery

SMALL SCLERAL SIDE CAPSULOTOMY IS BETTER.

If more central scleral side capsulotomy nucleus has to find a longer way to sweep and come out.

In this process nucleus becomes vertical and so damages endothelium of cornea and posterior capsule.

Excessive depression with central incision of anterior capsule may itself press and tear posterior capsule causing vitrous disturbance.

Perfectly sharp blade (blunt blade produces ragged incision-followed by descemets detachment) should be used.

Fig. 2.2

UNDER LOW MAGNIFICATION

After applying the speculum-take a wider bunch of conjunctiva on either side of the superior rectus musclepassing the curved needle under the muscle (since partial bite of superior rectus deviates the position of the eye, to an unwanted position ) by depressing the lower fornix.

Conjunctiva is reflected from right side to left side with radial cut at 10 O'clock close to limbus (limbal based ) and extended to 2-3 O'clock left side.