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Phakonit with the Acritec IOL
Amar Agarwal
History
On August 15th 1998 the authors (Amar Agarwal) performed the first 1 mm cataract surgery by a technique called PHAKONIT.1,2 Today companies have started manufacturing IOL’s that can pass through ultra-small incisions of 1.5 mm or less. One such IOL is the Acri. Lyc IOL made by the Acritec company (Berlin, Germany).
Terminology
The name PHAKONIT has been given because it shows phaco (PHAKO) being done with a needle (N) opening via an incision (I) and with the phako tip (T). This shows phaco done with Needle Incision Technology.
Incision
In the first step a needle with viscoelastic is taken and pierced in the eye in the area where the side port has to be made (Fig. 35.1). A special keratome (Micro Surgical Technology, USA) is then used to create an incision of 1.2 mm (Fig. 35.2). The viscoelastic is then injected inside the eye.
Rhexis
The rhexis is then performed. This is done with a needle (Fig. 35.3). In the left hand a straight rod is held to stabilize the eye. The advantage of this is that the movements of the eye can get controlled as one is working without any anesthesia. Hydrodissection is performed and the fluid wave passing under the nucleus checked.
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FIGURE 35.1 A 26 gauge needle with viscoelastic making an entry in the area where the side port is. This is for entry of the irrigating chopper
FIGURE 35.2 Clear corneal incision made with the keratome. Note the left hand has a rod to stabilize the eye as the case is done without any anesthesia. These instruments are made by Katena (USA)
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FIGURE 35.3 Rhexis started with a needle
Phakonit
After enlarging the side port a 20 gauge irrigating chopper connected to the infusion line of the phaco machine is introduced with foot pedal on position 1. The phaco probe is connected to the aspiration line and the phaco tip without an infusion sleeve is introduced through the incision (Fig. 35.4). Using the phaco tip with moderate ultrasound power, chopping of the nucleus is done (Fig. 35.5). The whole nucleus is finally removed (Fig. 35.6). Note in Figure 35.6 no corneal burns are present. Cortical wash-up is done with the bimanual irrigation aspiration technique (Figs 35.7 and 35.8).
Acritec IOL
The Acry.Lyc IOL is manufactured by the Acri.Tec company in Berlin, Germany. This lens is a sterile foldable intraocular lens made of hydrophobic acry late. The intraocular lens consists of highly purified biocompatible hydrophobic acrylate with chemically bonded UV-absorber. It is a single piece foldable IOL like a plate-haptic IOL. The lens is
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FIGURE 35.4 Phakonit irrigating chopper and phako probe without the sleeve inside the eye
FIGURE 35.5 Phakonit started. Note the phako needle in the right hand and an irrigating chopper in the left hand.
Phakonit being performed. Note the crack created by karate chopping. The assistant continuously irrigates the
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phaco probe area from outside to prevent corneal burns
FIGURE 35.6 Phakonit completed. Note the nucleus has been removed and there are no corneal burns
FIGURE 35.7 Bimanual irrigation aspiration started
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sterilized by autoclaving. The lens comes in a sterile vial, filled with water and wrapped in a sterile pouch.
FIGURE 35.8 Bimanual irrigation aspiration completed
Lens Loading Technique
To remove the IOL one should open the Medipeel pouch at the defined spot. The lens vial or bottle (Fig. 35.9) is then taken out and placed on the sterile tray. The lens is like a plate haptic IOL (Fig. 35.10). The next step is to prepare the injector (Fig. 35.11). First of all the injector tip is fitted with a sponge tip (Figs 35.12 and 35.13) which comes with the cartridge. This will prevent the injector tip from damaging the lens while inserting it inside the eye. The lens is then taken out from the bottle/vial. The lens is then held with a forceps. The lens is then placed in the cartridge (Fig. 35.14). Viscoelastic is injected in the cartridge and once the flanges of the IOL are in the groove of the cartridge the cartridge is closed and then inserted in the injector (Fig. 35.15). Once the cartridge is fixed onto the injector the injection of the lens is done by the spongy tip (Fig. 35.16) till one can see the lens coming into the nozzle of the cartridge (Fig. 35.17).
Lens Insertion Technique
After the Phakonit procedure is completed, the incision is increased to 1.5 mm. Then the tip of the
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FIGURE 35.9 The Acri. Lyc foldable IOL in the sterile vial
FIGURE 35.10 The Acri. Lyc foldable IOL
cartridge is kept at the site of the incision (Fig. 35.18). Remember the cartridge is not inserted inside the anterior chamber. Now, the lens is gradually inserted through the incision (Fig. 35.19).
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FIGURE 35.11 The Acri. Tec injector
FIGURE 35.12 The soft spongy tip being fixed onto the tip of the Acri. Tec injector
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FIGURE 35.13 Tip of the injector with the spongy tip. This will prevent any damage to the lens when inserting the lens
FIGURE 35.14 The Acri. Lyc IOL placed in the cartridge
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FIGURE 35.15 The cartridge fixed onto the injector
FIGURE 35.16 The tip of the injector with the spongy tip ready in place to push the IOL
FIGURE 35.17 The IOL coming out into the nozzle of the cartridge
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FIGURE 35.18 The tip of the nozzle of the cartridge is at the incision site but not inside the anterior chamber
FIGURE 35.19 The IOL inserted through a 1.5 mm incision
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FIGURE 35.20 The IOL being inserted inside the bag
One can watch the lens unfolding inside the capsular bag. The inferior haptic goes into the bag (Fig. 35.20) and the superior haptic is gradually tucked inside the capsular bag. Viscoelastic is then removed with the Bimanual irrigation aspiration probes (Fig. 35.21).
FIGURE 35.21 Viscoelastic removed using bimanual irrigation aspiration probes
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Summary
With the advent of Phakonit the size of the incision has drastically reduced. Now with more companies moving into manufacturing ultra-small incision IOL’s which can pass through 1.5 mm incisions or less the advantage of Phakonit becomes even more. With time more surgeons will move into this technology thus benefiting more patients.
References
1.Agarwal S, Agarwal A, Sachdev MS, et al: Phacoemulsification, Laser Cataract Surgery and Foldable IOL’s (2nd edn) New Delhi: Jaypee Brothers, 2000.
2.Boyd BF, Agarwal S, Agarwal A, et al: Lasik and Beyond Lasik; Highlights of Ophthalmology;
Panama, 2000.
Section VII
Laser Cataract Surgery
36.Laser Phaco Cataract Surgery
37.Erbium-YAG Laser Cataract Surgery
38.Cataract Surgery with Dodick Laser Photolysis