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

50 Manual of Practical Cataract Surgery

Figs 2.6A and B

Step incision acts as valve and avoids iris prolapse, wound gaping and less number of sutures are enough.

Center position

Tip | ↓

Figs 2.7A and B

Now, open anterior chamber obliquely with tip of blade at 10.30 O'clock to 11.30 O'clock position -at Pre-descemets level.

Fig. 2.8

Once the aquous starts coming, introduce the Viscoelastic needle with syringe and inject it. Otherwise anterior chamber becomes shallow introduction of instruments will separate descemets membrance.

Figs 2.9A to C

How to Prevent Complications in Planned ECCE ... 51

If air bubbles are present, push the needle tip upto 6 O'clock position of anterior chamber and inject viscomet (viscoelastic) till the air bubbles are drifted away through the limbal opening at 11 O'clock position.

Fig. 2.10

UNDER HIGH MAGNIFICATION

Carefully Watch the Anterior Capsulotomy Margin

Introduce the tip of the needle so that bent tip is horizontally introduced parallel to the surface of iris, then tilt vertically down.

I prefer to do anterior capsulotomy in "Smiling face technique" - as I find it useful, because-in case a rent at 12 O'clock position occurs, you can notice it easily when the pupil becomes slightly oval or a pull - distorted, after removal of nucleus.

Figs 2.11A to D

52 Manual of Practical Cataract Surgery

The anterior capsulotomy should be done towards the scleral side of the capsule.

Instead of making anterior capsulotomy by 26 G needle, Smiling face technique, the same can be done with the tip of the blade on a handle to create a linear border.

Fig. 2.12

This incision can be made after fully opening the anterior chamber, subsquently filling the chamber with Viscoelastic substance.

The needle anterior capsulotomy produces capsular tags which may disturb the surgeon during aspiration of cortex at 12 O'clock position.

By doing knife blade incision, the incision borders are clear cut and there is no capsular tags.

Figs 2.13A to C

Aspiration of capsular tags sometimes produces extension into posterior capsule.

Figs 2.14A and B

54 Manual of Practical Cataract Surgery

Fig. 2.17

Extend the incision on either side with curved scissors.

Figs 2.18A to E

Enlarging the incision at limbus will be difficult with scissors. So enlarge incision on either side with end of the blade on blade holder from inside out (anterior chamber should be deeper with viscomet-otherwise whallow anterior chamber may produce cut and shaving of endothelium).

Fig. 2.19

Now, hydrodissection-In multiple injections under the anterior capsules in smaller amounts in different directions.

How to Prevent Complications in Planned ECCE ... 55

Fig. 2.20

(The bulk injection or 1 cc or 2 cc of BSF fluid may rupture the very thin posterior capsule at the centre)

Fig. 2.21

Deliver the nucleus making pressure at 6 O'clock position with either wire vectis or depressor about 1-2 mms above the limbus in cornea and counter pressure to unsleeve the anterior capsule at 12 O'clock position for easy squeezing and sliding delivery of the nucleus from the equatorial position.

Figs 2.22A and B

Making pressure at the centre of the cornea will depress the central cornea followed by pushing the nucleus down to tear the posterior capsule.

56 Manual of Practical Cataract Surgery

Figs 2.23A and B

Gentle counter-pressure at 12 O'clock position of sclera can be done with another wire vectis or spatula.

Pass the cannula with aspiration port above.

Fig. 2.24

Pass the cannula parallel to the surface of the iris, then slightly dip to enter under the anterior capsule and again raise up so that fluid speed is not directed towards posterior capsule.

Figs 2.25A and B

The flow of BSF is sufficient to float the cortex and aspirate from periphery to the center.

Figs 2.26A and B

How to Prevent Complications in Planned ECCE ... 57

Speed should be adjusted so that anterior chamber should never be made shallow, as it may suck the centre of the cornea, as well as the posterior capsule creating rupture vitreus disturbance. Fluid speed either moderate or a little faster.

If bulk of epinucleus is present, depress the scleral side opening' inject viscomet at 6 O'clock position of anterior chamber to push out (kindly refer the topic on posterior capsular rent).

Keep always the pupil well dialated to have clear views of the procedure what you are doing. In pseudo exfoliation syndrome, old uveitis with posterior synechia patients, pupil will not dialate. Under such condition, key-hole iridectomy should be done to have a clear view.

Fig. 2.27

One or two drops of adreneline in BSF solution in a 2 ml syringe, if injected may dilate the pupil.

Nuclear cataract (brown cataract) will be bigger and harder. So bigger incision and liberal use of viscoelastic material will be needed to protect the cornea.

Inject viscomet under anterior capsule and raise it. Fill in anterior chamber.

Figs 2.28A and B

58 Manual of Practical Cataract Surgery

When cortex is cleared, IOL should be introduced as per the calculations made by SRK formula under anterior capsule.

Catch haptic IOL with Mcpherson forceps with the (angled bent) to the right and the lower haptic to the left so that if introduced, it should rotate clockwise as shown in the figure.

Figs 2.29A and B

If corretly done-and rotated, anterior capsule will be lying over the IOL and raise it with viscomet.

Fig. 2.30

Cut anterior capsule obliquely or curved at 3 and 9 O'clock position - and peel off capsule in the form of rhexis with Mcpherson.