Fig. 6.12 The operative eye is covered with an ophthalmic drape. This drape is fenestrated and has an attached fluid collection pouch (Allegiance #7445 48″ × 68″)

−The upper and the lower eyelashes should be covered with Tegaderm. One Tegaderm, cut it in half, should be used. (3M NDC 8333-1624-05)

−The operative eye should be draped with the ophthalmic drape which is fenestrated and has an attached fluid collection pouch (Allegiance #7445 48 × 68 in.)

6.Immediate postoperative drops

Gatifloxacin 0.3%, pilocarpine 2%, diclofenac, prednisolone acetate 1%, genteal gel

6.1.9 A Careful, Critical Eye

Asurgeon’sprimarychallengeinpreventingendophthalmitis consists of keeping a critical perspective on infection prophylaxis. Many reports are heard and multiple studies are seen, some of which contain relevant information and provide thoughtful insights. We should always evaluate the conclusions and opinions of others in the light of our own experience. The best way to build knowledge is to document outcomes; as human beings we are generally too much concerned with the results of our most recent or most unusual experiences. Documenting outcomes and tracking one’s own data allows an objective measure of risk as well as the potential to improve results by following up on alterations in protocol and technique, after they are made.

Take Home Pearls

ßExpanding the small pupil facilitates phacoemulsification; the techniques described

here should be used in a stepladder approach, tailored to the severity of the condition.

ßPreventing infection requires a multifactorial analysis of the present practices and an aggressive

adoption of the best methods.

References

1.Gimbel HV (1991) Divide and conquer nucleofractis phacoemulsification: development and variations. J Cataract Refract Surg 17:281–291

2.Shepherd JF (1990) In situ fracture. J Cataract Refract Surg 16:436–440

3.Fine IH, Maloney WF, Dillman DM (1993) Crack and flip phacoemulsification technique. J Cataract Refract Surg 19: 797–802

4.Fine IH (1998) The choo-choo chop and flip phacoemulsification technique. Oper Tech Cataract Refract Surg 1(2):61–65

5.Kelman CD (1979) Phacoemulsification in the anterior chamber. Ophthalmology 86:1980–1982

6.Kratz RP, Colvard DM (1979) Kelman phacoemulsification in the posterior chamber. Ophthalmology 86:1983–1984

7.Frye LL (1992) Pupil stretch maneuver. Course No. 454 (Modern Phaco/ECCE Implant Surgery: XII). American Academy of Ophthalmology, Dallas, TX

8.McReynolds WU (1976) Pupil dilator for phacoemulsification. In: Emery JM, Paton D (eds) Current concepts in cataract surgery, selected proceedings of the first biennial cataract surgery congress. CV Mosby, St. Louis

9.Mackool RJ (1992) Small pupil enlargement during cataract extraction: a new method. J Cataract Refract Surg 18(5): 523–526

10.Nichamin LD (1993) Enlarging the pupil for cataract extractions using flexible nylon iris retractors. J Cataract Refract Surg 19:795–796

11.Fishkind WA, Koch PS (1991) Managing the small pupil. In: Koch PS, Davison JA (eds) Textbook of advanced phacoemulsification techniques. Slack, Thorofare, NJ, pp 79–90

12.Drews RC (1984) Straight needle technique. In: Emery JM, Jacobson AC (eds) Current concepts in cataract surgery, selected proceedings of the eight biennial cataract surgical congress. Appleton-Century-Crofts, Norwalk, CT

13.Masket S (1992) Preplaced inferior iris suture method for small pupil phacoemulsification. J Cataract Refract Surg 18(5):518–522

14.Fine IH (1994) Pupilloplasty for small pupil phacoemulsification. J Cataract Refract Surg 20:192–196

15.Osher RH (1991) Pupillary membranectomy [Videotape]. Audiovisual J Cataract Implant Surg 7(3)

16.Chang DF (2007) Reducing the risk of endophthalmitis after cataract surgery. J Cataract Refract Surg 33(12):2008–2009; author reply 2009

17.Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M (2007) ASCRS Cataract Clinical Committee. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg 33(10): 1801–1805

18.Buzard K, Liapis S (2004) Prevention of endophthalmitis. J Cataract Refract Surg 30(9):1953–1959

19.Nichamin LD, Chang DF, Johnson SH, Mamalis N, Masket S, Packard RB, Rosenthal KJ (2006) American Society of Cataract and Refractive Surgery Cataract Clinical Committee. ASCRS white paper: what is the association between clear corneal cataract incisions and postoperative endophthalmitis? J Cataract Refract Surg 32(9):1556–1559

20.Lundström M, Wejde G, Stenevi U, Thorburn W, Montan P (2007) Endophthalmitis after cataract surgery: a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology 114(5):866–870

21.Solomon R, Donnenfeld ED, Azar DT, Holland EJ, Palmon FR, Pflugfelder SC, Rubenstein JB (2003) Infectious keratitis after laser in situ keratomileusis: results of an ASCRS survey. J Cataract Refract Surg 29(10): 2001–2006

22.Schein OD (2007) Prevention of endophthalmitis after cataract surgery: making the most of the evidence. Ophthalmology 114(5):831–832

23.Fine IH (2003) Clear corneal cataract incisions require attention to detail. In: Packer M, Hoffman RS (eds) Cataract corner. Ophthalmology Times (15 January 2003) 28(2):12–13

24.Ciulla TA, Starr MB, Masket S (2002) Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based update. Ophthalmology 109(1):13–24

25.Ng JQ, Morlet N, Bulsara MK, Semmens JB (2007) Reducing the risk for endophthalmitis after cataract surgery: population-based nested case-control study: endophthalmitis population study of Western Australia sixth report. J Cataract Refract Surg 33(2):269–280

26.Mandal K, Hildreth A, Farrow M, Allen D (2004) Investigation into postoperative endophthalmitis and lessons learned. J Cataract Refract Surg 30(9):1960–1965

27.MamalisN,EdelhauserHF,DawsonDG,ChewJ,LeBoyerRM, Werner L (2006) Toxic anterior segment syndrome. J Cataract Refract Surg 32(2):324–333

6.2 Incisions1

I. Howard Fine, Richard S. Hoffman,

and Mark Packer

Core Messages

ßClear corneal incisions have proven to be safe, effective, and advantageous, and require proper

and precise construction.

ßThe most desirable architecture is achieved through proper incision construction and the

use of trapezoidal knives;

ßPostoperative endophthalmitis prophylaxis requires not only proper incision construction

and architecture, but also the use of antibiotics, precise surgical technique, and the testing of incisions at the end of the procedure.

The role of unsutured clear corneal incisions for cataract surgery in the apparent increased incidence of postoperative endophthalmitis is under intense scrutiny and the literature is not conclusive [2–9].

Clear corneal incisions, which involve an incision in the plane of the cornea with a length equal to 2.0 mm, were first described in 1992 [10] and continue to be constructed in essentially the same manner in practice today. In 1992, the incisions were wide as 4.0 mm, but more recently the maximum width is 3.5–3.8 mm, if not sutured. Figure 6.13 shows an artist’s view of what the profile of clear corneal incisions was thought to look like. Part A shows the single plane incision and its

Cornea 24(6):699–704

29.Lehmann OJ, Roberts CJ, Ikram K, Campbell MJ, McGill JI (1997) Association between nonadministration of subcon-

junctival cefuroxime and postoperative endophthalmitis. J Cataract Refract Surg 23(6):889–893

30.Lundström M (2006) Endophthalmitis and incision construction. Curr Opin Ophthalmol 17(1):68–71

31.Masket S (2005) Is there a relationship between clear corneal cataract incisions and endophthalmitis? J Cataract Refract Surg 31:643–645

32.Fine IH, Hoffman RS, Packer M (2007) Profile of clear corneal cataract incisions demonstrated by ocular coherence tomography. J Cataract Refract Surg 33(1):94–97

Baton Rouge, innovated an alteration of the incision,

1Portions of this chapter were originally published as Fine et al. [1].

I. H. Fine ( )

Oregon Health & Science University, Drs. Fine, Hoffman and Packer, 1550 Oak Street, Suite 5, Eugene, OR 97401, USA

e-mail:hfine@finemd.com