Wound Closure

Requires suture when the wound is not selfsealing.

True Effects of Suture Methods :

1.Radial sutures: Generally used to approximate the edges of the incision, which pulls the scleral flap and cornea to a new unphysiologic position and disturbs internal incision causing more astigmatism.

2.Horizontal sutures: Used simply to flatten the tunnel resulting in waterlight incision with less disturbance to the internal incision hence less astigmatism.

3.Infinity sutures: Used to close 6.5 mm incision.

Horizontal Suture Closure for 4 to 7.0 mm Incisions

Concept introduced by Shepard and Masket reported alternative method for 4 to 7.0 mm length incisions called as “horizontal anchor suture”.

SURGICAL PROCEDURE

Tunnel Incision (Figure 41.4)

•Post lip clearing with crescent.

•Central dissection upto vascular arcade.

•Foot plate of the crescent should always rest on the sclera.

•Dissect the tunnel from inside-outside.

•Proper care not to open the anterior chamber.

•Pocketing in cornea as well as sclera.

Side Post Incision

•With MVR blade (18 G)

•Let the aqueous leak as much as possible.

Figure 41.4A: Crescent knife position

Figure 41.4B: Cystitome

Figure 41.4C: Crescent cutting direction

Figure 41.4D: Keratome direction for internal incision

CCC

•Anterior chamber filled with viscoelastic substance till the anterior curved surface of the lens becomes flat (It is always easier to do CCC with good control on flat surface).

•Magnification—more.

•Use cystitome (bend 26 G niddle) with the beveledges.

Corneal Lip Incision

•Keratome-entry from sides and not from the tip (fear of creating multiple tracks).

•Cut corneal lip with the movement outside-inside with keratome.

Hydrodissection—Delineation

•Rotation of the nucleus and bringing the nucleus into anterior chamber.

•Viscoexpulsion of the nucleus.

•Epinuclear plate.

•Cleaning of the residual cortex.

•12 o’ clock cortex cleaning.

•Polishing posterior capsule as well posterior surface of rim of CCC.

•Viscoelastic.

•IOL insertion in the bag.

•Aspiration of viscoelastic substance.

•Side port hydration.

•Conjunctival wound closure by cautery—forceps.

INTRODUCTION

Manual SICS involves the manual removal of nucleus through a scleral tunnel.1,2 To achieve this one has to safely prolapse the nucleus from the capsular bag into the anterior chamber. As is the case with most surgical techniques, this looks simple when one observes an experienced surgeon performing the prolapse. But there are few hurdles for the beginners; this does not imply that it is a difficult step. It is just a matter of learning few techniques and of course lot of practice.

The technique of nucleus prolapse into the anterior chamber depends on the type of capsulotomy done. Either a canopener or a capsulorhexis can be performed to prolapse the nucleus. As there are more advantages of having an intraocular lens in the bag it is preferable to prolapse the nucleus from the capsular bag through a capsulorhexis with an intact rim.

NUCLEUS PROLAPSE THROUGH CAN-OPENER CAPSULOTOMY

With Can-opener capsulotomy the nucleus can be prolapsed mechanically without any of the hydro procedures. The simple Sinskey hook or the lens dialer is used for performing this step. The hook is placed at the edge of the equator or slightly posterior to it at the 12 o’clock position by retracting the pupillary border of the iris. The nucleus is then pushed down towards 6 o’clock till the superior equator of the nucleus clears the pupillary margin. At this point, the nucleus is lifted up using the shaft of the hook and rotated so that the superior pole of the nucleus gets prolapsed over the iris. Once one part of the nucleus is out, it is engaged and

Venkatesh Rengaraj, RD Ravindran (India)

rotated either in a clockwise or anticlockwise direction, until the whole nucleus is in the anterior chamber.

Some surgeons find it easier to engage the nucleus at the 9 o’ clock position to perform the step described above. In patients with white cataracts, the loose and fluffy superficial cortex is aspirated exposing the firm nucleus underneath, before prolapsing it mechanically with the Sinskey hook.

This technique is ideal for surgeons converting from ECCE with sutures to Manual SICS, who are yet to master capsulorhexis. With Can-opener capsulotomy, we loose the advantages of having intraocular lens in an intact bag. In addition with the manipulation of nucleus and subsequent contact with the iris tissue during prolapse we often find the pupil constricted resulting in difficulty during aspiration of the lens matter.

NUCLEUS PROLAPSE THROUGH

CAPSULORHEXIS

Prolapsing the nucleus into anterior chamber after capsulorhexis using fluid (Hydroprolapsing method) is a crucial step. Normally hydrodissection or fluid injection underneath the capsule breaks the adhesions between cortex and capsule.3,4 Here we use the same step for creating hydrostatic pressure within the bag without putting any stress on the zonules to prolapse the nucleus.5

First pre-requisite is an adequate sized rhexis. The margin of the rhexis is highly elastic and can allow safe expression of nucleus, which is larger than the opening.6-10 Hydroprolapsing method is safe when the diameter of the rhexis is 5 mm or more.11,12 Getting a right-sized capsulorhexis is crucial and its significance

in small incision cataract surgery cannot be overemphasized. With smaller or incomplete rhexis, it is safer to make a few relaxing cuts and proceed as described under Can-opener capsulotomy. If one is experienced and skill permits, one can go in for a double rhexis. Second pre-requisite is to have a soft eye. Overfilling the anterior chamber with viscoelastic increases the resistance to nucleus prolapse. Partially emptying the anterior chamber of viscoelastic by pressing the floor of the incision with shaft of the cannula will permit the nucleus to easily prolapse.

Partial Hydroprolapse and Wheeling

Hydrodissection is usually done at 9 or 3 o’ clock position and the fluid injection is continued without decompressing the bag as in phacoemulsification, until one part of the equator of nucleus is forced out of the rhexis. The purpose of continued injection of fluid is to increase the hydrostatic pressure within the bag to pop out the nucleus. This maneuver is safe, as the posterior capsule can withstand a pressure of 59+/– 10 mm Hg without rupturing.12 Once part of the equator is out, hydroprolapse is stopped (Figure 42.1). Viscoelastic is injected beneath the exposed equatorial region. Then using a Sinskey hook the nucleus is wheeled either clockwise or anticlockwise to bring the whole nucleus into the anterior chamber (Figure 42.2).

Intracapsular Flip

In this technique of intracapsular flip, hydrodelineation or fluid injection between the hard nucleus and

Figure 42.3: Intracapsular flip in progress

epinucleus is performed prior to hydroprolapse. It helps in minimizing the size of the nucleus facilitating easy maneuverability of the nucleus and also creates a soft epinuclear shell protecting the posterior capsule during the flipping procedure. Here again the hydroprocedures are continued until one part of the equator of the nucleus is forced out of the bag. Then by using the same hydro dissection cannula, the part of the equator opposite to the prolapsed area is rotated towards the posterior capsule (Figure 42.3). The maneuver is continued through 180° within the capsular bag (flipping of the nucleus), till it comes out of the bag, into

Figure 42.4: Nucleus lying in the anterior chamber

the anterior chamber. The use of hydrodissection cannula to flip the nucleus within the capsular bag is safe as only the shaft of the cannula comes in contact with the epinucleus.

The manipulation of nucleus during intracapsular flip has minimal contact with uveal tissue. Hence if one masters this technique it will be possible to prolapse the nucleus without altering the size of the pupil thereby epinucleus and cortex can be swiftly removed. In addition the whole process of nucleus prolapse is achieved using a single instrument, resulting in lesser surgical time. This technique is not safe in eyes with very hard cataracts or poor zonular support (Figure 42.4).

TECHNIQUES FOR SPECIFIC TYPE OF CATARACTS

Mature Cortical Cataracts

White cataracts can be managed by doing a capsulorhexis after staining the capsule with 0.1 ml of 0.06% Trypan blue dye.13 Nucleus can be levered out of the bag using a Sinskey hook even without hydroprocedures if the cortical attachment is loose with the nucleus. It will be also worthwhile to debulk the cortical matter using a Simcoe cannula before prolapsing the nucleus. The staining here not only helps for the rhexis but also for the safe prolapse of the nucleus without damaging the zonules (Figure 42.5).

Hypermature Cataracts

Here again after staining the capsule, a small trap door is created in the anterior capsule. Through this trap door

Figure 42.5: Trypan blue assisted nucleus prolapse in white cataract

the liquid cortex is aspirated using a Simcoe cannula. The capsular bag with the nucleus is inflated with viscoelastics and then a capsulorhexis is completed. As described earlier the nucleus can be safely prolapsed using a Sinskey hook or even a Simcoe cannula by flipping, if the nucleus is small as seen in Morgagnian cataracts.

Hard Brown/Black Cataracts

In these cases, the safest technique will be to perform a Can-opener capsulotomy and prolapse as described earlier. If the surgeon is keen to perform a capsulorhexis, it will be safe to stain the capsule and perform a larger capsulorhexis (6.0-6.5 mm) followed by less forceful hydrodissection. As the capsule is stained, it will be easy to retract the capsule and lever out a part of the nucleus with a Sinskey hook. Then gently wheel the nucleus out, watching the movement of the capsular bag throughout the procedure. If the capsular bag seems to be compromised few relaxing incisions in the capsule can avoid intracapsular extraction of nucleus. Alternatively a bimanual technique can be tried which is described under the small pupil approach.

Small Pupil Approach

One can resort to procedures like stretch pupilloplasty with Kuglen’s hooks or sphincterotomies. In certain

high-risk cases like pseudoexfoliation with a small rigid pupil and an associated hard nucleus it would be prudent to go in for a small sector iridectomy or a key holeiridectomy. In case, it is a pliable small pupil and one’s aesthetic sense does not allow mutilating the pupil, there is still an alternative technique, namely what we have termed the bimanual technique. This technique is useful, if one has failed to prolapse the nucleus by the mechanical method or in case of a small pupil with hard cataracts.

Bimanual Technique

Normally a Can-opener capsulotomy is prefered and two instruments are used for bimanual prolapse. One is a Sinskey hook in the right hand and the other a cyclodialysis spatula in the left. As described before, with the Sinskey hook the nucleus is pushed towards 6’o clock. Once the superior part of the nucleus is visualized the cyclodialysis spatula is inserted under it, either through the main wound or through the paracentesis. The exposed part of the nucleus is then tipped up with the spatula. The role of the spatula is not only to tip out the superior pole but also to act as a fulcrum over which the nucleus is rotated out. The nucleus is dialed out by repeatedly engaging the equator with the Sinskey hook till the nucleus cmpletely prolapses into the anterior chamber.

Subluxated Cataracts

Manual SICS can be done in selected cases of subluxated cataracts where in the pupil is well-dilated and nucleus is not very hard.14 Here, again staining the capsule with Trypan blue stain will facilitate in capsulorhexis as well as in implanting the CTR and in safely prolapsing the nucleus.

Technique

After assessing the extent of subluxation and density of nucleus, the capsule is stained, capsulorhexis is followed by cortical cleaving hydrodissection, and CTR is inserted manually through the paracentesis. The nucleus is then hydrodelineated and irrigation continued until one pole of the nucleus prolapses out of the capsular bag. Rest of the nucleus is wheeled into the anterior chamber using a Sinskey hook

DO’S AND DON’TS

To summarize the technique of nucleus prolapse requires only simple instrumentation, namely a Sinskey

hook and a 2 ml syringe with a 26G cannula. During the learning process one can perform the Can-opener capsulotomy and prolapse the nucleus mechanically. For reasons discussed earlier, capsulorhexis with hydroprolapse or intracapsular flip is ideal as the surgeon masters the technique. Moreover the management of white and brown cataracts has become easier with the availability of cost-effective capsular stains, which can be effectively used, and the whole procedure made safe.

REFERENCES

1.Bayramlar H, Cekic O, Totan Y. Manual tunnel incision extracapsular cataract extraction using the Sandwich technique. J Cataract Refract Surg 1999;25:312-5.

2.Akura J, Kaneda S, Hatta S, Matsuura K. Manual sutureless cataract surgery using a claw vectis. J Cataract Refract Surg 2000;26:491-6.

3.Thim K, Krag S, Corydon L. Capsulorhexis and nucleus expression. Eur J Implant Ref Surg 1990;2:37-41.

4.Fine IH. Cortical cleaving hydrodissection. J Cataract Refract Surg 1992;18:508-12.

5.Assia E, Blumenthal M, Apple DJ. Hydrodissection and viscoextraction of the nucleus in planned extracapsular cataract extraction. Eur J Implant Ref Surg 1992;4:3-8.

6.Krag S, Thim K, Corydon L. The stretching capacity of capsulorhexis. An experimental study on animal cadaver eyes. Eur J Implant Ref Surg 1990;2:43-5

7.Thim K, Krag S, Corydon Leif. Stretching capacity of capsulorhexis and nucleus delivery. J Cataract Refract Surg 1991;17:27-31.

8.Assia EI, Apple DJ, Tsai JC, Lim ES. The elastic properties of the lens capsule in capsulorhexis. Am J Ophthalmol 1991;111:628-732

9.Assia EI, Apple DJ, Morgan RC, Legler UFC, et al. The relationship between the stretching capability of the anterior capsule and zonules. Invest Ophthalmol Vis Sci 1991;32:2835-9.

10.Tana P, Belmonte J. Elasticity of the capsulorhexis and delivery of the nucleus. Eur J Implant Ref Surg 1993; 5:103-8.

11.Vasavada A, Desai J. Capsulorhexis: Its safe limits. Indian J Ophthalmol 1995;44:185-90.

12.Krag S, Thim K, Corydon L. Strength of the lens capsule during hydroexpression of the nucleus. J Cataract Refract Surg 1993;19:205-8.

13.Melles GRJ, de Waard PWT, Pameyer JH, Beekhuis WH. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J cataract Refract Surg 2000; 26:1052-9.

14.Venkatesh R. Use of Capsular tension ring in phacoemulsification: Indications and technique (Letter). Indian J Ophthalmol 2003;51:197.

A

3 mm manual SICS stop and chop 85 capsulorhexis 86

hydrodissection 86 incision 85

3-in-1 approach 6 advantages 8 basic questions 7 technique 7

ACM in phacoemulsification 143 Anis cortex aspirating 43

B

Bluementhal’s technique 108 anterior chamber maintainer 108 capsulotomy 109

closing up 114 cortical clean-up 113

hydroprocedures and nucleus prolapse 111

IOL insertion 113 nucleus expression 112 principle 108

scleral incision 110

side ports and ACM port 109 tunnel and internal opening 110

C

Cauterization of vessels 91 Cautery 31

Chop multisection and chopsticks technique 50

advantages 54 complications 54 disadvantages 55 instrumentation 50

postoperative management 53 surgical technique 51

anesthesia 51 capsulotomy 51 extraction of cortex 52 hydrodissection 51 incision 51

IOL implant and incision closure 53

luxation of nucleus 51

nuclear fragmentation 51 preoperative management 51

Closed chamber manual phacofragmentation 97

procedure 97

Complications and their avoidance 241 complication during cortical aspira-

tion 250

posterior capsular rupture 251 retained lens matter 250

complications during hydroprocedures 247

complications during nucleus delivery 248

dropped nucleus 249 incomplete rotation of nucleus in

bag 248 prevention 248 small CCC 248

small pupil or miosis 248 complications related to intraocular

lens 253 decentered IOL 253

erosion and perforation of ciliary body 254

intraoperative complications and their avoidance 241

capsulotomy 242

dialysis or rupture of the posterior capsule 242

iris trauma 242 nuclear luxation 242

wound construction 241 pupillary capture 253

posterior dislocation of IOL 254 posterior iris shafing syndrome 254 postoperative complications 254

conjunctival flap retraction 257 corneal complications 255 decentered IOL 256

distorted or irregular pupil 257 expulsive hemorrhage 259 hyphema 256

hypotony 257 iris prolapse 255 iritis 256

posterior capsular opacification 258

postoperative management 259

pseudophakic bullous keratopathy 257

pupillary capture of IOL 258 raised intraocular pressure/

secondary glaucoma 257 shallow AC 255

wound leak 254

postoperative complications and their avoidance 243

corneal edema 243

high intraocular pressure 243 postoperative endophthalmitis

243

shallow anterior chamber 243 shallow anterior chamber 253 UGH syndrome 254

Windshield Wiper syndrome 254 Conjunctival dissection of vessels 91 Cortical cleaning 90

Crescent knife 43

D

Delivery of nucleus into anterior chambers 224

Descemet’s stripping 54

Detachment of Descemets’s membrane 246

Double nylon loop 60 complications 62 contraindications 61 indications 60 principle 60

results and visual outcomes 62 surgical techniques 61

Double wire snare splitter technique 169, 235

surgical technique 170

F

Fishhook technique 136 capsular opening 137 learning curve 139

nucleus hook extraction 138 completing the surgery 138

outcome 138 technique 137

tunnel construction 137

Frown incision 31

Fry cannula 43

Fry infusion handle 43

H

Hydroprocedure 89

I

Irrigating vectis technique and suprahard cataract 116

operation 116 anesthesia 117 cortical cleaning 121 hydrodissection 120

incision on the lens 119 incisional considerations 117 nucleus delivery 120 nucleus rotation 120 prolapse of nucleus 120

J

Jaws slider pincer technique 175 complications 180 instrument 175

results 178 variations 179

technique 175

K

Kelly’s punch 194 Keratome blade 43 Kongsap technique 184

anesthesia 184 contraindications 190 instrumentation 184 recommendations 189 surgical results 187 surgical technique 184

anterior cortical debris removal 186

capsulorhexis 184 cortical aspiration 187 hydrodissection 186 incision 184

IOL implantation 187 nuclear fragmentation 186 nuclear removal 186

side ports 184 Kuglne iris hook 43

L

Lens implant 90

Lidocaine instillation 30

Limbal relaxing incision 31

M

Management of anterior segment complications in SICS 244

anesthetic complications 244 complications related to anterior

capsulotomy 246

wound related complications 244 depth of the incision 245 length of incision 246

width of wound 246 Management of astigmatism in SICS

278

astigmatically neutral funnel 279 distance from cornea 279

effect of surgery 278 entry point at cornea 279 incision type 279

length of incision 279

managing preexisting astigmatism 279

with the rule and against the rule astigmatism 278

Management of intraoperative complications in MSICS 260

IOL insertion 275 capsulorhexis 270 cortical clean up 274 hydroprocedures 271 incision construction 269

deep incision 269 Descemet’s membrane 269 superficial tunnel 269

nucleus prolapse and delivery 272 peribulbar anesthesia 260

Management of nucleus prolapse in MSICS 285

nucleus prolapse through canopener capsulotomy 285

nucleus prolapse through capsulorhexis 285

intracapsular flip 286

partial hydroprolapse and wheeling 286

techniques for specific type of cataracts 287

hard brown/black cataracts 287 hypermature cataracts 287 mature cortical cataracts 287 small pupil approach 287 subluxated cataracts 288

Manual multiphacofragmentation 46 anterior capsulotomy 47

extraction of the cortex and remains of nucleus 48

hydrodissection and luxation of nucleus 47

incision 47

IOL implantation and wound closure 48

manipulation of nuclear fragments 48

nuclear fragmentation 48 surgical technique 46

Manual phacocracking 56

advance in manual phacocracking 58

complications 57 contraindications 58

do’s and dont’s of procedure 58 principles 56

surgical techniques 56 visual outcomes 57

Manual phacofragmentation with nylon sling 103

beauty of manual surgery 103 surgical technique 103

personal technique 104 strategic consideration 103

Manual small incision cataract surgery 3

advantages 5

clinical significance 3 disadvantages 5 objectives 3 relevance 3

Micro-incisional surgery 144 Modification in MSICS for large volume

surgeries 221

conversion to topical anesthesia 221 disposales 221

non-peritomy scleral tunnel 222 preoperative preparation of the

patient 221 side-port incisions 222

cortical aspiration 223 nucleus fragmentation and

nucleus delivery 223 silicon bulb 223

Modified Blumenthal technique 141 assisted delivery 142

insertin of ACM 141 principle of technique 142

Modified snare and new foldable IOL 150

anesthesia and preoperative preparation 154

anterior capsulotomy 157 capsulorhexis 158 capsulotomy 157

anterior chamber entry 156 bimanual irrigation aspiration 164

automated 164 manual 164

cannula 151

hydrodelineation cannula 150 hydrodissection cannula 150 modified viscoelastic cannual 151 nucleus prolaps cannula 151

cartico-cleavage dissection 159 complications 166 contraindication 154

cortical clean up 164 visco expression 164

extension of corneal incision 158 hydrodelineation 159 hydrodissection 159 hydroprocedure 159

indications 154 lens implant 165

intraocular lens 166 nucleus fragmentation 161

bisection 161 trisection 162 nucleus prolapse 160

methods 160 preparation of wound 154 removal of nucleus half 163

for soft cataract 163 for hard cataract 163 scleral tunnel incision 154

advantages of temporal incision 154

with 11 and 15 number blade 155 side port incision 156

snare 152 advantages 152

staining of capsule 156 Morrison lens loop 43

MSICS in difficult situations 210 cataracts with existing filtration

blebs 214

cataracts with pseudoexfoliation 213 hard black cataract 212

small pupil 210

managing intraoperative miosis 210

managing non-dilating pupil 211 technique of stretching small

pupil 211 subluxated cataracts 213

MSICS phacoemulsification and ECCE techniques 8

additional instrument for phacoemulsification 9

anesthesia 9

complications 21 planning and evaluation 8

patient selection 8 surgical procedure 9 technique 9

incision phase 11 initial phase 9 IOL insertion 18

lens delivery phase 16

MSICS under combined topical and pinpoint anesthesia 122

anesthesia 122

material required 122 procedure 122

anterior chamber maintainer 122 advantages 122 disadvantages 122

material required 122 procedure 122

conjunctival closure 124 advantages 123 disadvantage 123 material required 123 procedure 123

hydroprocedure 123 advantages 123 material required 123 procedure 123

IOL implantation 124 advantage 123 disadvantages 123 material required 123 procedure 123

nucleus delivery and cortical cleanup 123

advantages 124 cortical clean-up 123 disadvantages 124 material required 123 procedure 123

side port incision 122 advantages 123 disadvantages 123 material used 122 procedure 122

speculum removal 124 stromal-hydration 124 advantages 123 disadvantage 123

procedure 123 tunnel 123

advantages 123 disadvantages 123 material required 123 procedure 123

MSICS using irrigating vectis 207

management of hard cataracts 209 irrigation-aspiration of cortex 209

surgical procedure 207 capsulotomy 207 nucleus removal 208 peritomy 207 scleral tunnel 207

side port incision 207

N

Nucleus delivery 89

Nucleus extraction in MSICS 6

O

Ocular complications of peribulbar anesthesia 181

P

Pearls and pitfalls in SICS 281 aims 281

corneal lip incision 282 advantages 282

external incision 282 surgical procedure 283

CCC 283

corneal lip incision 284 hydrodissection-delineation 284 side post incision 283

tunnel inision 283 wound architecture 281 wound closure 283

Peritomy 30

Phaco sandwich technique in SICS 202 complications 205 instrumentation 202

preoperative preparation 202 anesthesia 202

surgical technique 202 capsulotomy 203 cortical clean-up 205

hydrodissection-hydrodelinea- tion 204

IOL implantation 205 nuclear delivery 204 nuclear luxation 204 wound closure 205 wound construction 202

Phacofracture and phacosection 143 Phacofracture technique in SICS 74

anesthesia 74 capsulorhexis 74 complications 76 hydroprocedure 75