Small Incision Cataract Surgery

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Small Incision
Cataract Surgery
(Manual Phaco)
Small Incision
Cataract Surgery
(Manual Phaco)
Kamaljeet Singh MS
Associate Professor
Department of Ophthalmology
MLN Medical College
and
Consultant Ophthalmologist
State Institute of Ophthalmology
Allahabad, India
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Small Incision Cataract Surgery (Manual Phaco)

2002, Kamaljeet Singh
All rights reserved. No part of this publication should be reproduced, stored in a
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of the editor and the publisher.
This book has been published in good faith that the material provided by the
editor is original. Every effort is made to ensure accuracy of material, but the
publisher, printer and editor will not be held responsible for any inadvertent
error(s). In case of any dispute, all legal matters to be settled under Delhi
jurisdiction only.
First Edition: 2002
Publishing Director: RK Yadav
ISBN 81-7179-932-9
Typeset at JPBMP typesetting unit
Printed at Lordson Publishers (P) Ltd., C-5/19, RP Bagh, Delhi 110 007
To
My respected parents
Pitaji, Late S Amar Singh Saluja
and
Mataji, Smt Ram Rakhi Saluja
Contributors
AK Grover MD
Senior Consultant
Ganga Ram Hospital
New Delhi, India
Amar Agarwal MS FRCS FRCOphth (Lon)
Medical Director
Agarwal's Eye Hospital
13 Cathedral Road
Chennai, India
Amporn Jongsareejit MD
Mettapracharak (Raikhing) Hospital
Sampran Nakornpathom
Thailand
BK Singh MS
Eye Surgeon
Allahabad, India
BN Chaudhary MBBS
Senior Divl Medical Officer (NE Rly)
Junior Resident
MLN Medical College
Allahabad, India
D Swarup MS
Medical Superintendent
Allahabad, India
Daljit Singh MS
Amritsar, India
Dinesh Talwar MD
Addl Professor
Dr RP Centre for Ophthalmic Sciences
All India Institute of Medical Sciences
New Delhi, India
Francisco J Gutirrez-Carmona MD PhD
Hospital General de Segovia
Segovia, Spain
Gagandeep Singh Brar MD

Assistant Professor
Postgraduate Institute of Medical
Education and Research
Chandigarh, India
Gopal S Pillai
Senior Resident
New Delhi, India
HC Chandola MD
Associate Professor
Department of Anaesthesiology
MLN Medical College
Allahabad, India
HK Tiwari MD
Professor and Chief
New Delhi, India
Harinder Sethi MD
New Delhi, India
Harpreet Singh
Registrar
Ganga Ram Hospital
New Delhi, India
Hector Bryson Chawla FRCS
Consultant Ophthalmic Surgeon
Royal Infirmary
Edinburgh, UK
Jagat Ram MD
Postgraduate Institute of Medical Education
and Research, Chandigarh, India
KS Kathait MS
Eye Surgeon
Jaunpur, India
viii
KPS Malik MD
Head, Department of Ophthalmology
Safdarjung Hospital
New Delhi, India
Kamaljeet Singh MS
Associate Professor
MLN Medical College and
Allahabad, India
Kuldeep Kr Srivastava MS
Arvind Eye Hospital and
Postgraduate Institute of Ophthalmology
1, Anna Nagar,
Madurai, India
Lalit Verma MD
Additional Professor
New Delhi, India
MK Rathore MS
Head and Professor of Ophthalmology
Rewa Medical College
Rewa, India
MP Tandon MS
Associate Professor
MLN Medical College
Allahabad, India
Mahipal S Sachdev MD
Medical Director
New Delhi Centre for Sight
New Delhi, India
P Mishra MS
Professor and Head
RMMCH, Annamalai University
Annamalainagar
Tamil Nadu, India
P Venkatesh MD
Lecturer
New Delhi, India
P Vijayalakshmi MS DO
Arvind Eye Hospital and
Postgraduate Institute of Ophthalmology
1, Anna Nagar
Madurai, India
PC Saxena MD DM (Card)
Head and Professor
Department of Cardiology
MLN Medical College
Allahabad, India
Pankaj Puri MD
Senior Registrar
Ganga Ram Hospital
New Delhi, India
Prashant Bhartiya MD
Senior Registrar
New Delhi, India
RN Misra MS
Ex-Director, Professor
MLN Medical College
Allahabad, India
Monika Joshi
Senior Resident
Lady Harding Medical College
New Delhi, India
RP Singh MS
Senior Eye Surgeon
Allahabad, India
Mool Chand
Senior Resident
New Delhi, India
Rajesh Sinha MD DNB

Senior Registrar
New Delhi, India
Nikhilesh Trivedi MS
Ophthalmic Surgeon
Balaghat, India
Rajiv Vaish MS
Allahabad, India
Contributors
Rasik B Vajpayee MS
Professor of Ophthalmology
New Delhi, India
Ruchi Goel MD
Safdarjung Hospital
New Delhi, India
S Thanikachalam MD
Lecturer in Ophthalmology
RMMCH, Annamalai University
Annamalainagar
Tamil Nadu, India
Sarita Bajaj MD DM (Endo)
Department of Medicine
MLN Medical College
Allahabad, India
Shweta Pandey MS
Ex-Resident
Allahabad, India
Subodh K Agarwal MS
Lucknow, India
Sumeet Jain MBBS
Junior Resident
MLN Medical College
Allahabad, India
Sunita Agarwal MS
Consultant Ophthalmology
Agarwal's Eye Hospital
Bangalore, India
TN Vyas MS
MLN Medical College
Allahabad, India
Tanuj Dada MD
Lecturer
New Delhi, India
VK Srivastava MS
Senior Eye Surgeon
Allahabad, India
VP Gupta MS
Vipin Bihari MS
Director, Professor
MLN Medical College
Allahabad, India
ix
Foreword
he aim of quality modern cataract surgery is to achieve an optimal visual result by the
removal of a reduced nucleus through a small incision without inflicting irreparable
damage on the corneal endothelium.
Contrary to fashionable belief, expensive equipment is no obligatory, indeed, particularly if
not well maintained, it can be a positive hindrance. It certainly raises the cost at the outset and can
often increase the possibility of things going wrong at any time later.
Manual phaco is relevant to both the developing and the developed world and DrKamaljeet
Singh and his co-authors have succeeded admirably in their attempt to cover the subject in all its
aspects. Each chapter gives step by step instruction that will delight the converted and tempt
those not yet persuaded of its importance.
From the start of my career I have tried not to be dependent on complicated equipment except
where necessity commands and not only is manual phaco-section my chosen approach to the
cataract of others, it would also be to my own, where surgery ever to be necessary.
Hector Bryson Chawla FRCS (Ed.)
Consultant Ophthalmic Surgeon
Royal Infirmary, Edinburgh
Scotland
Preface
he sense of sight, according to Sydney Smith, is indeed the highest bodily privilege, the
purest physical pleasure, which man has derived from his Creator. The onus of maintaining
this wonderful gift throughout life rests on the skills of an ophthalmic surgeon. Through the
period of time these surgical skills have undergone many innovations and advances. The journey
of cataract surgery has evolved from the eighteenth century Jacques Daviels extracapsular surgery
to the present-day extracapsular surgery of phacoemulsification with foldable lenses. Modern day
phacoemulsification with foldable intraocular lenses is being practiced in almost ninety percent of
the patients in the developed countries of the world. The surgery has improved to a level where
surgeons are implanting intraocular lenses through less than 1mm incision, giving patients almost
instant vision. Today Indian surgeons are marching shoulder to shoulder with their Western
counterparts in the progress made in the world of ophthalmology. Many surgeons in India have
proved beyond doubt that they are highly skilled and given the opportunity they can perform
equally well if not better than the more fortunate Western ophthalmologists.
Unfortunately, the benefits of improved technology and technique in phacoemulsification are
being availed by a fortunate, comparatively wealthy few in the developing world. Majority of the
masses has to go through the ordeal of intracapsular surgery with its attendant hazards of aphakic
spectacles. In recent times at least ECCE IOL has been made available to the teeming millions of
the developing world, thanks to the untiring efforts of the WHO. But sutures, astigmatism and
complications like posterior capsular opacification and decentration accompany this surgery.
Therefore, on one end of the spectrum we have phaco surgery with foldable lenses practiced by
the resourceful surgeons and availed by the wealthy few. While on the other, patients coming from
the lower strata of society have to bear with aphakic spectacles. In fact, in a developing country like
India, our primary goal should be to strive hard to provide all the benefits to the common man at
minimum possible costs. In achieving this goal, manual phaco or the non-phaco small incision
cataract surgery (SICS) can be extremely helpful. It has almost all the advantages of
phacoemulsification, namely, less astigmatism, early mobility, less decentration and at the same
time, is as inexpensive as ECCEIOL. This book has been written precisely with the above-mentioned
goal in mind. The main purpose of this book is to explain the various surgical manouvers with
diagrams, photographs and a detailed text. Simple steps, explained in easy language, are the
hallmark of this book. It is hoped that this may stimulate the reader towards this surgery, which
may prove to be significant for easy transition. An attempt has been made to acquaint the reader
with almost all the subjects of IOL surgery by this technique so that he does not feel the need to
turn to any other book.
The book begins with the history of cataract surgery, which is so important to understand as the
technique has evolved tremendously in a very short span of time. Preoperative evaluation and
various anesthetic techniques are very significant in giving good surgical results. Subjects like diabetes
and hypertension management have been specially included in the book as they have become so
widespread that their effective management must be clear to all the surgeons. An effort has been
made to describe all the techniques of nucleus delivery to achieve the same objective, that is, a
sutureless anastigmatic result. Readers are requested to go through each chapter with care and
form their own impression of the benefits and risks involved in each technique. It is advisable to
follow the systemic approach of one step and one technique at a time. Postoperative complications
and their management pertaining to this particular surgery have also been dealt with exhaustively.
Management of endophthalmitis, posterior dislocation of lens and posterior capsular opacification
xiv
form separate chapters in this book due to their significance in obtaining good surgical outcome.
Paediatric cataract surgery through tunnela complicated subject has also been extensively covered.
Eminent surgeons, of national and international repute, who have a vast experience and
knowledge in this particular field of surgery, have contributed in this book. They are confident of
this surgery, have provided excellent results and through their concisely written chapters, with
photographs and diagrams, have provided substance to this book. I am extremely grateful to them
for giving their best in the shortest possible time. Finally, this book would be considered successful
only if the reader could deliver the objective of providing good vision at economical cost to maximum
number of patients.
Kamaljeet Singh
Contributors
xv
Acknowledgements
n presenting this work I have been supported by several friends, teachers, colleagues and family
members. I am deeply indebted to my friends Dr Mahipal S Sachdev and Dr Amar Agarwal
who mainly motivated me to write this book. I am immensely thankful to Prof RN Misra who
encouraged me to initiate this work and has been a constant source of inspiration for me. I am also
grateful to Prof Vipin Bihari for permitting me to use the existing facilities in the department.
I am indebted to many colleagues and residents in the department who have not only drawn
the diagrams but also painstakingly read the proofs for which I especially acknowledge Dr Sanjay
Sharma, Dr Sumeet Jain, Dr Pawan Kumar and Dr Riyaz Khan. I also thank Dr JD Jain and Dr AK
Chadha for their valuable suggestions.
I extend my gratitude to my two special residentsDr BN Chowdhary and Dr KS Kathait, who
have worked with me for over three years and have suggested several improvements in the technique
of manual small incision cataract surgery.
My thanks are also extended to Alcon Labs (India) for providing beautiful illustrations as well as
to the Journal Survey of Ophthalmology (Elsevier) and The Highlights of Ophthalmology for their
copyright permission for the Table No and Figure No.
I also wish to express my gratitude to Mr Jitendar Vij and the staff of Jaypee Brothers who never
got ruffled by my regular urgent calls for preparation of this manuscript. Mr Vinod and Mr Vivek
Naithani of Allahabad, the father and son team, did the typing work with meticulous accuracy, to
them I am highly obliged.
I will fail in my duty if I do not thank my wife Dr Anuja for her help and timely suggestions, as
also for calming me in my moments of anxiety while I was preparing this book.
My special appreciation to Anuja, my daughter Manika and my son Pranav, for patiently bearing
the loss of special moments in the preparation of this mammoth task.
I am extremely grateful to Dr Hector Bryson Chawla, who despite his busy schedule always gave
me a helping hand and never disappointed for any demand. I am also thankful to Dr Jongsareejit
for his timely response.
Contents
1. .Anatomy of the Lens ......................................................................................... 1
BN Chaudhary, Kamaljeet Singh
2. .History of Cataract Surgery ............................................................................... 4
Kamaljeet Singh, KS Kathait
3. .Sterilization ...................................................................................................... 9
Sunita Agarwal, Amar Agarwal
4. .Viscoelastics ................................................................................................... 35
VP Gupta
5. .Comparison of Various ECCE Techniques ....................................................... 43
Kamaljeet Singh, Vipin Bihari
6. .Management of Diabetes in Cataract Surgery .................................................. 47
Sarita Bajaj
7. .Management of Hypertension in Cataract Surgery ........................................... 52
PC Saxena
8. .Preoperative Evaluation for SICS .................................................................... 54
Kamaljeet Singh, Sumeet Jain
9. .Biometry ......................................................................................................... 56
D Swarup
10. Ocular Anaesthesia ......................................................................................... 61
Kamaljeet Singh, VK Srivastava
11. Anaesthetist's Role in Ocular Surgery ............................................................. 65
HC Chandola
12. Postoperative Infections: Prevention and Management .................................... 68
Jagat Ram, Gagandeep Singh Brar
13. The Manual Small Incision: Surgical AspectsI ............................................. 75
Mahipal S Sachdev, P Mishra, S Thanikachalam
14. The Manual Small Incision: Astigmatic ConsiderationsII ............................. 84
Mahipal S Sachdev, Pradeep Venkatesh
15. Capsulotomy for Small Incision Cataract Surgery ........................................... 86
AK Grover, Pankaj Puri, Harpreet Singh
16. Hydroprocedures ............................................................................................ 94
Subodh K Agarwal
17. Nucleus Prolapse from Capsular Bag .............................................................. 98
RP Singh, BK Singh, BN Chaudhary
18. The Phaco Sandwich Technique .................................................................... 101
Kamaljeet Singh
19. Modified Fish Hook Technique...................................................................... 107
Rajiv Vaish
20. Manual Phaco-fracture .................................................................................. 110
Rajesh Sinha, Prashant Bhartiya, Rasik B Vajpayee
xviii
21. Microvectis Technique .................................................................................. 1 1 3

P Mishra, S Thanikachalam
22. Modified Blumenthal's Technique ................................................................. 1 1 7
KPS Malik, Ruchi Goel
23. Small Incision Manual Phaco-section Using the
.Anterior Chamber Maintainer ....................................................................... 1 2 3
Hector Bryson Chawla
24. Manual Multiphacofragmentation: A New Technique for Cataract Surgery .... 1 2 8
Francisco J Gutirrez-Carmona
25. The New Method of Manual-phacofragmentation (Phaco-drainage) ................ 1 3 2
Amporn Jongsareejit
26. Temporal Tunnel Incision in SICS ................................................................. 1 3 6
MK Rathore
27. Cortical Clean-up ......................................................................................... 1 4 0
RN Misra, TN Vyas
28. Intraocular Lenses ........................................................................................ 1 4 4
Tanuj Dada, Harinder Sethi
29. The Technique of IOL Implantation in SICS .................................................. 1 5 5
Nikhilesh Trivedi
30. Wound Closure ............................................................................................. 1 5 8
MP Tandon, TN Vyas
31. When and How to Convert? ........................................................................... 1 6 3
Kamaljeet Singh
32. Current Status of Medications in Cataract Surgery ........................................ 1 6 5
Kamaljeet Singh, Shweta Pandey, Monika Joshi
33. Complications of Manual Phaco .................................................................... 1 6 9
Kamaljeet Singh
34. Management of Posteriorly Dislocated Lenses ............................................... 1 7 3
Lalit Verma, Pradeep Venkatesh, HK Tiwari
35. Post-surgical Endophthalmitis ...................................................................... 1 7 9
Lalit Verma, Pradeep Venkatesh, HK Tiwari
36. Posterior Segment Disorders and SICS ......................................................... 1 9 5
Dinesh Talwar, Mool Chand, Gopal S Pillai
37. Glaucoma and SICS ..................................................................................... 2 0 5
P Mishra, S Thanikachalam
38. Paediatric Cataract: My Experiences ............................................................. 2 1 0
Daljit Singh
39. SICS in Paediatric Cataracts ........................................................................ 2 1 5
Kuldeep Kr Srivastava, P Vijayalakshmi
40. Posterior Capsule Opacification ................................................................... 2 2 0
Jagat Ram, Gagandeep Singh Brar
Index ............................................................................................................................. 227
Anatomy of
the Lens
he adult human lens is an asymmetrical spheroid,

which does not possess nerves, vessels or connective tissue. It is located behind the iris and pupil
in the anterior compartment of the eye (Fig. 1.1).
The diameter of the lens is 9-10 mm and thickness 45 mm, which varies greatly as the eye accommodates
for near and distant vision
The lens has anterior and posterior surfaces and the
border where the two meet is known as the equator
The anterior surface is less convex than the posterior,
radius of curvature being about 9 mm, while that of
posterior surface is 5.5 mm
The posterior surface lies in a fossa lined by the hyaloid
membrane in front of the vitreous. It is separated from
the vitreous by a slight space filled with primitive
vitreous
The equator of the lens forms a circle lying 0.5 mm
within the cilliary processes. The equator is not smooth
but shows a number of dentations, which correspond
to the attachment of zonular fibres. These dentations
BN Chaudhary
Kamaljeet Singh
disappear when zonules are loose during accommodation.

Microscopic Structure of the Lens
The lens consists of:

i. Capsule
ii. The anterior epithelium
iii. The cement substance of amorphous material
iv. The lens fibres.
Capsule The capsule forms a transparent structure-less

highly elastic envelope, which encapsulates the lens
material. The anterior capsule is much thicker than
posterior. The anterior and posterior capsules are thicker
at the equator than at the poles, where the suspensary
ligaments are attached. The thickest region up to 23 is
located close to the equator on both the anterior and
posterior surfaces. The posterior pole is the thinnest
region (4 ) while at the equator (17 m) and anterior
pole (9-14 ) is of intermediate thickness.
Fig. 1.1: Anatomy of the adult human lens
The anterior epithelium This is a single layer of cubical

cells beneath the anterior capsule (There is no corresponding posterior epithelium). This layer is responsible
for all the metabolic and mitotic activity of the lens. This
layer produces the lens fibres.
The cubical cells of the anterior epithelium gradually
become columnar and elongate towards the equator and
are eventually converted into lens fibres.
As these cells elongate into lens fibres, the part, which
is in contact with the capsule becomes the posterior part
of lens fibres, while the opposite end grows into the
anterior portion of the lens fibre.
The cement substance of amorphous material The
various elements forming the lens are bound together
by an amorphous substance. The cement substance glues
the various fibres to each other.
It is found at following sites:
1. Beneath the capsule both in front and behind.
2. A thin layer deep to the anterior epithelium.
3. The central strand.
The central strand occupies the axis of the lens from
anterior to posterior pole. Extending towards the equator
from this axial collection the amorphous material is
collected in the form of Y. The anterior Y is vertical and
posterior is inverted (). The lens fibres get inserted into
these.
The lens fibres Each lens fibre is a long, prismatic sixsided band. Lens fibre is a collection of albuminoid
material enclosed in a pseudo-membrane. The
membrane is called pseudo because it is composed of
the same material as its contents but is denser.
During embryonic development the first lens fibres
arise from posterior epithelium, which run from the back
to the front of the vesicle. The later fibres are derived
from the equatorial portion of the anterior epithelium.
The newer fibres are laid external to the deep older fibres
and this give the lens a laminated structure.
New lens fibres are laid on throughout life and as the
central portion, which corresponds to the keratin layer
of the skin cannot be shed, the lens keeps on growing.
However, the growth is not proportional to the number
of fibres, because the deeper older fibres get shrunken.
The lens at the age of 65 years is one-third larger than at
the age of 25 years. Hence, we can anticipate bigger
nucleus and may need bigger incision while performing
surgery in older persons.
The consistency of the lens varies and superficial cortex
is softer than central part of nucleus. The nucleus increases
in size with age and this becomes flatter with age. However,
the refractive power of lens is retained by an increase in
the refractive index of the nucleus.
The colour of the lens also changes with age. In the

infant and young, it is quite colourless. After about 35
years the central portion develops yellow tinge and
gradually becomes darker and more extensive with age.
In the older people the lens has amber colour.
Sometimes the lens appears gray in old people when
seen by indirect illumination and can be mistaken as
cataract by the beginners.
Ciliary Zonule The ciliary zonules consist of fibres

arising from the ciliary body to the lens. It holds the lens
in position and enables the ciliary muscles to act on it.
The zonular fibres are attached at the equator and the
anterior and posterior capsule near the equator.
The zonular fibres can be classified in two groups: Main
and Auxillary fibres.
A. Main fibres consists of following fibres:
i. Orbiculoposterior capsular They originate from the
ora serrata and are inserted into the posterior
capsule.
ii. Orbiculoanterior capsular They are the thickest
and strongest of the zonular fibres. They originate
from the pars plana of ciliary body and inserted
into the anterior capsule of the lens.
iii. The cilio-posterior capsular fibres They are the
most numerous fibres. They arise from the valleys
and sides of the ciliary processes. They are directed
posteriorly and cross the anteriorly directed fibres
and are inserted into the posterior capsule.
iv. The cilio-equatorial fibres They are present only
in youthful eyes, originate from ciliary valleys and
inserted to the equator of the lens. With age these
fibres disappear.
B. The auxillary fibres Some of these fibres strengthen
the main fibres and help to anchor the individual
portions of the zonule, while others hold the ciliary
body together. These are very fine and run from
without inwards and forward.
It is noteworthy that in old age a large number of zonular fibres disappear but some fibres also get thickened.
Surgical Anatomy of the Lens
For the purpose of cataract surgery lens can be anatomically divided into:
i. Capsular bag with sub-capsular epithelium.
ii. Superficial cortex, i.e. soft lens matter that can be
aspirated.
iii. Immediate epinucleus with semi-soft lens matter that
can be expressed out.
iv. Deep nucleus or a hard core that can be expressed
fractured, fragmented or phacoemulsified.
Anatomy of the Lens
Fig. 1.2: Surgical anatomy of limbus
The capsular bag encapsulates the lens substance. It

is highly elastic and hence a big nucleus can be expressed
out from a comparatively small capsulotomy or
capsulorhexis.
The capsular bag provides support to the IOL within
the bag allowing for good haptic placement. The anterior
epithelium consisting of cubical cells beneath the anterior
capsule is responsible for all the metabolic and mitotic
activity of the lens. The cells migrate and elongate towards
equator and produce lens fibres. After extra-capsular
cataract extraction the remaining lens epithelium
especially those in the equator region undergo metaplasia
and migrate towards posterior capsule and lead to
posterior capsule opacification.
The zonules are inserted into the capsule in a
continuous fashion at the equator, anteriorly 2-2.5 mm
into the capsule and 1-1.25 mm into the posterior
capsule. Hence only a 5-6 mm of zonular free zone of
capsule is left for capsulorhexis or capsulotomy.
The lens nucleus has a configuration with a welldefined hard inner nucleus surrounded by semi-soft
epinucleus and soft cortical matter. During hydrodelineation the nucleus is separated from epinucleus and
this reduces the size of the overall nucleus which can be
expressed out from a smaller incision. The epinucleus
also forms a cushion beneath the nucleus during
phacoemulsification.
Surgical Anatomy of the Limbus
Limbus is an important structure from surgical point of

view as all the surgery for cataract and glaucoma is
performed at the limbus. The external landmarks of the
surgical limbus are (Fig. 1.2):
i. The anterior limbal border It is identified by the
insertion of conjunctiva and Tenons capsule into
the cornea, which creates a prominent ridge. This

ridge overlies the termination of Bowmans
membrane.
ii. The midlimbal line When the conjunctiva is separated from the limbus a bluish transluscent zone 1
to 1.2 mm wide is seen posterior to the anterior
limbal border. Posterior to this bluish zone is the
white sclera. The line formed at the junction of bluish
zone and white sclera is called midlimbal line and it
overlies the Schwalbes line (which is the termination
of Descemets membrane).
iii. Posterior limbal border It lies 1 mm behind the midlimbal line and can be seen only with the use of
sclerotic scatter illumination. Posterior limbal border
lies approximately over the scleral spur.
The width of the blue limbal zone varies in different
quadrants. Maximum width is in the superior quadrant
about 1mm. In the temporal and nasal quadrant it is
0.4 mm and in the inferior quadrant 0.8 mm wide. The
width of the white limbal zone remains constant throughout.
The midlimbal line is a very important landmark,
which overlies the Schwalbes line and we can remember this by the phrase, where the white meets the blue
Schwalbes line waits for you.
But the difficulty is that this landmark is frequently
indistinct. Anterior limbal line can be easily distinguished
in a limbus based conjunctival flap, but in a fornix-based
flap it is frequently irregular and is not a helpful landmark.
FURTHER READING
2. Gholam Peyman (Ed): Principles of Ophthalmology Jaypee
Brothers; 489-91, 532-33, 1987.
1. Wolfs Anatomy of the Eye 5: 138-42, 1961.
3. Yanoff M, Duker JS (Ed): Ophthalmology Mosby International
Ltd: 4-(1.1-1.4), 1999.
History of
Cataract Surgery
istorians suggest that Egyptians, Greeks and

Romans performed operations. Sushruta is
considered to be the father of cataract surgery,
who used to push the lens towards the retina, by a needle.
This technique, called couching was mastered by Indians
and is still being practiced at some remote areas.
With certainty only this can be said that Arabians
performed cataract surgery by reclination or depression.
Daviel extracted the lens in recent times in 1745. He
made a section in the limbus with a triangular knife. The
cut was enlarged with a scissors or small knife having a
dull point. The cornea was then raised and cataract
removed with a Lancet, which pierced the pupil. The
surgery remained in abeyance since infections used to
occur and eyes were lost due to this. It was only after
1870, when the antisepsis was discovered, that cataract
surgery became popular and all the ophthalmologists
started performing this technique. von Graefe (1865)
used a knife for making the cornea scleral incision. This
knife has been used till eighties by many surgeons
especially in camp surgery. Graefe also advocated
iridectomy for the first time. Till this time, interestingly
the surgery was extracapsular and sutureless, Williams
started sutures in 1967.
The technique remained extracapsular for long.
Pagenstecher (1877) tried intracapsular surgery by
pressing the lower corneal limbus with a fixation forceps
and depressing the scleral border by introducing a spatula
behind the lens through the incision. Stoever in 1902,
presented technique of removing the lens by creating a
vacuum through a cupping device joined to a rubber
bulb, called erisophake. This technique gained popularity
only when Barraquer (1917) presented his cannula cup
and suction apparatus. Forceps removal of lens was first
time advocated by Staneuleann but became popular only
after publication of his results by Elschnig (1924).
Smiths technique was published in 1910 for performing the intracapsular cataract operation. He did the
Kamaljeet Singh
KS Kathait
surgery by making a corneal incision and pressing the

lower limbus with the end of a strabismus hook.
Despite these techniques, most of the ophthalmologists
performed extracapsular technique. Intracapsular technique was fraught with complications due to non-availability of anaesthesia. It was only in 1919 that Willard
for the first time described the akinesia of orbicularis,
later Tochat in 1920 published his work. Later Van Lints
(1920) and OBriens (1929) facial block techniques
became popular and are being still practiced world over.
In 1930, Elschnig and Arruga advocated the retrobulbar
anaesthesia.
Jacquina Barraaquer used alphachymotrypsin in 1958
for destroying the zonules for removing the cataract by
intracapsular technique to avoid undue pressure by the
zonules. This enzyme remained in use for long dissolving
the zonules for intracapsular surgery especially in the
young patients.
IOL Implantation
Casanova has mentioned in his memoirs that he met

Tadini in 1766, who showed him a box with small spheres
that were well-polished and looked like beautiful crystals.
The oculist then had remarked, One may put such
globes under the cornea in place of crystalline lens.
Casanova although doubted that Tadini used to perform
such operations, but he can be said to be the first person,
who probably mentioned the possibility of lens
implantation.
Casaamata, the Count Eye Doctor of Dresden, in 1795
used to perform cataract operations and also implanted
an artificial lens. Mnchow (1964) cited a book, named
Schiferli (1797) in his study About the History of Intraocular Correction of Aphakia. It states, Casaamata
performed the procedure by inserting a glass lens through
the wound of the cornea into the eye. He realised, however, that the glass lens could not substitute for the natural
History of Cataract Surgery
lens because during the experiment, the glass fell into

the bottom of the eye. Therefore, Casaamata can be said
to be first surgeon to attempt an intraocular correction
of aphakia.
But so far as the history of modern lens implantation
goes Harold Ridley of London is considered as father of
intraocular lens implantation. Ridley (1952) mentions in
British Journal of Ophthalmology that while he was
performing a cataract operation in 1949 a medical
student asked why he did not replace the sick lens with a
new one. This initiated Ridley to implant the first lens.
Thus, the first lens was implanted into the capsular bag
following extracapsular cataract extraction at St. Thomas
Hospital in London on November 28, 1949 and the
second on August 23, 1950 (Ridley, 1951). Both of these
lenses had too high a refractive power and patients had
high myopic error ( 20.0D and 15.0D). This gave an
idea to Ridley to measure the radius of curvature. He
operated 750 patients with new lenses. But later in 1959
gave up implantation because there were lots of
complications. These lenses, weighed 110 mg, were made
of acrylic. Acrylic was used because it was found that
during World War II, some members of the British Air
Force sustained perforating eye injuries from airplane
canopies. Those were made of acrylic glass, it was noticed
by the ophthalmologists, that it did not cause any irritation
to the eyes.
Second generation lenses, which were supported in
the angle of anterior chamber. These were called, second
generation lenses (Strampelli, 1954). Many
ophthalmologists around the world implanted these
intraocular lenses with their own designs, but they
produced complications like corneal decompensation,
glaucoma and iritis and fell into disrepute. The problem
was basically of the manufacturing designs and
sterilization. Amongst these second generation lenses
Choyce produced several designs, ultimately Choyce
Mark VIII lens was perfectly designed and was used by
several surgeons from 1963 until 1978.
Third generation lenses Epstein and Binkhorst produced the iris fixed lenses, which caused iritis in many
patients. Later they produced iris plane lenses or pupillary
lenses. These lenses were used in USA for quite a long
period from 1968 until 1980s, but these implants used
to cause chronic irritation and cystoid macular oedema.
During this time Binkhorst produced four-loop iris clip
lenses. It had two clips anterior to iris and two behind
the iris and they did not reach the angle. These lenses
produced the iritis, glaucoma and hyphaema due to its

designs. Later several modifications by these two
ophthalmologists and by Fyodorov also appeared.
Fyodorovs sputnik lens became quite popular.
Fourth generation lenses Since the Binkhorsts lenses
loops were tying in front and back of iris he was not too
happy and produced a design in which posterior loops
would be placed in the capsular bag. These lenses were
called Binkhorsts iridocapsular lenses. Worst, came up
with another idea of fixing lens with iris by applying sutures. These lenses were called Worsts Madallion lenses.
Worst used steel sutures for fixing these lenses. In India,
Dr Daljit Singh is the pioneer, who used iris-claw lenses
in thousands with excellent results.
Fifth generation lenses Pearce and Simocoe in 1977
used the posterior chamber lenses by modifying the
Binkhorsts four-loop lenses. They sacrificed the posterior
loops of these lenses and placed in the back after during
ECCE. He sutured these lenses with the iris or capsule in
the superior position.
These lenses gave an idea to Shearing who introduced
J-loop lenses, which was basically the lens, being used
by Barraquer also. Barraquer used to place these lenses
in the anterior chamber, whereas Shearing placed them
behind the iris after ECCE. The haptic made its own
place on the ciliary body, which he called ciliary lenses.
This was, in fact, the beginning of true PCIOLs, which
were excellent and reduced the incidence of corneal decompensation, iritis and glaucoma. Later came the
Simcoes C modified C lenses.
generation VI lenses In the early nineties the era of
PC-IOLs through can-opener technique started ending.
The main drawbacks of canopener technique with
ciliary sulcus fixated lenses are IOL instability and
decentration. Posterior capsular opacification was
another problem seen in 50% of the cases. Now came
the era of surgery within in the bag implantation through
envelope or capsulorhexis. The extracapsular surgery
with long incision and in the bag placement of one
piece IOLs is included in Generation VIA. When the
same surgery is done by phacoemulsification technique
with capsulorhexis and in the bag placement of single
piece or foldable IOL it is included in Generation VIB
(Table 2.1).
Evolution of Small Incisions
With the advent of phacoemulsification, Kelman predicted that incisions 3 mm wide be astigmatism-neutral

Table 2.1: Evolution of extracapsular cataract surgery*
1977
1982
1987
1992
2000
Pre-capsular Surgery, Generation V
Capsular Surgery, Generation VI
V-a
V-b
VI-a
VI-b
Beginning phase
Transitional period
Large incision
Small incision
1. No viscoelastic
2. Can-opener anterior
capsulotomy
3. No hydrodissection
This period combined one or

more elements of generation V-a
with one or more of the advances
leading to generation VI-a
4. Simple ECCE
5. IOL Fixation with one or
both haptics out-of-the-bag
(precapsular fixation)
6. Early 3-piece PC-IOLs,
often poor designs and
manufacture
Complications were common,
especially:
1. Decentration
2. PCO
3. Zonular capsular ruptures
1. Use viscoelastic
2. Continuous curvilinear
Capsulorhexis (CCC) or
Envelop (intercapsular)
technique, (especially for
large hard nuclei)
3. hydrodissection-enhanced
cortical clean-up
Same as generation VI-a, but

with increased use of phacoemulsification and foldable IOLs
inserted through a small incision
4. Advanced ECCE or phaco

5. Consistent in-the-bag
Complications rare
(capsular) haptic fixation
6. High quality PC-IOLs, especially one-piece all-PMMA
(capsular designs)
Few complications
*Capsular in-the-bag
(Reprinted from: Survery of Ophthalmology, Vol 45, David J Apple et al: Cataract surgery with regid and foldable PCIOLs, ECCE and
phacoemulsification 77, 2000, with permission from Elsevier Science)
because of their reduced size. However, within a very

short time after the introduction of phacoemulsification,
intraocular lens (IOL) implants became more common
place. This necessitated enlargement of the phacoemulsification incision to 6.5 to 7 mm for lens implantation.
Kratz is generally credited as the first surgeon to move
from the limbus posteriorly to the sclera, increasing
appositional surfaces to enhance wound healing and
attempt to exert less traction on the cornea, thereby
controlling surgically induced astigmatism. Girard and
Hoffman were the first to call the posterior incision a
scleral tunnel incision and were perhaps the first to make
a point of actually entering the anterior chamber from a
slightly corneal location.
With the availability of small incision lenses that could
be introduced through incisions of 4 mm or less; the stage
was set for the development of technique that resulted
in the achievement of both relative astigmatism neutrality
and self-sealing incisions. In 1989, Shepherd introduced
the single horizontal suture, which was actually a vertical
mattress suture, for the closure of 4 mm scleral tunnel
incisions in phacoemulsification and foldable lens
implantation. The achievement of astigmatism neutrality

was impressive. Others rapidly recognized that the
compressive force of the single horizontal suture was
tangential to the limbus and therefore exerted no force
on the cornea, which would alter its curvature. As a result
variations of the Shepherd single stitches were soon
developed for closure of incision 5 to 7 mm wide, including the fine infinity suture, Maskets horizontal anchor
suture and Fishkinds horizontal overlap suture.
In 1989, McFarland in Pine Bluff, Arkansas introduced
an incision architecture that allowed the phacoemulsification and implantation of lenses without the
need for suturing. This involved lengthening the scleral
tunnel and in his early attempts, creating partial thickness
grooves in the floor of the scleral tunnel parallel to the
long axis of the tunnel so that the incision could be
reversibly stretched to admit a foldable lens.
Ernest observed McFarlands surgery and recognized
that McFarlands long scleral tunnel incision terminated
in a decidedly corneal entrance and that the posterior
lip of the incision, the so called corneal lip, acted as a
one way valve imparting to this incision its self-sealing
History of Cataract Surgery
characteristic. Koch in Warwick, Rhode island described

what he called the incisional tunnel, indicating that there
were certain characteristics of self-sealing incisions with
respect to length and configuration that imparted not
only self-sealability but also astigmatism neutrality to
these incisions.
Self-sealing scleral tunnel incisions have varied with
respect to width and the configuration of the groove
(which represents the external or scleral incision as
opposed to the internal or corneal portion of the incision).
The groove has varied from circumlimbal to straight to
frown or chevron-shaped.
The rebirth of extracapsular cataract extraction in its
modern, refined microsurgical version has brought with
it the need for an adequate technique for anterior
capsulectomy. Thats why in 1984, Gimbel in Calgary,
Alberta and Neuhann in Munich developed a technique
that essentially consisted of tearing rather than cutting
out, a central anterior capsular window. Neuhann termed
it capsulorhexis.
While SICS is certainly possible with linear and canopener type capsulotomy, it is the continuous curvilinear
capsulorhexis (CCC) that has made modern techniques
of endolenticular phacoemulsification possible.
Capsulorhexis leaves a capsular bag with mechanical and
structural integrity, in spite of an opening large enough
to deliver the lens.
The hydrodissection method was first described by
Micheal Blumenthal but the term hydrodissection was
given by Faust.
In hydrodissection the infusion fluid is injected exactly
between the anterior capsule and the cortex so that the
fluid wave dissects all around the capsular bag and separates it. This facilitates nucleus rotation and manipulation
during phaco and non-phaco techniques.
Hydrodelineation was a concept introduced by Aziz
Y Anis. In hydrodelineation, the infusion fluid is injected
between the epinucleus and nucleus. This fluid wave
appears as a golden ring under the surgical microscope.
A reliable classification of nuclear hardness based on
the diameter of the smallest circle delineated is listed in
Table 2.2.
Measuring the diameter of the delineated circle is
reasonable by comparing it to the measured limbal
incision.
Table 2.2: Classification of nucleus hardness

Diameter as seen in
operating microscope
Less than
1
1-2
3-4
5-6
7
mm
mm
mm
mm
mm or more
Degree of
nuclear hardness
0
1
2
3
4
forceps to crack the nucleus. For safety reasons, this technique was abandoned is favour of the nuclear prolopse
method.
Blumenthal Technique
Blumenthal technique is an ingenious method of cataract

surgery introduced by Blumenthal of lsrael, and is the
preferred form of manual SICS. Its essential feature is
hydrodissection and hydrodelineation of the core nucleus
followed by its dislocation into the anterior chamber. The
nucleus delivery is by hydrodynamic expression.
The advantages of this technique are that the AC is
formed at all times, it is not viscoelastic dependent and
there are no instruments used within the AC for nucleus
delivery. Moreover, no sophisticated instrumentation is
required; it can be used with all tyes of nuclei and with
all types of capsulotomies, thus, increasing its universal
appeal.
Phacosandwich Technique
Luther Fry et al introduced Phacosandwich technique.

He discovered that nucleus can be captured between
two instruments and moulded through a 7.5 mm incision
with ease.
Luther Fry first attempted to cut the nucleus in two
and remove the pieces separately through the same
incision in 1985 (unaware that Gerald Keener had developed a nucleus bisection technique two years ago). He
found it difficult to do what he attempted but in the process
discovered that by squeezing the nucleus between a lens
spatula and lens loop, it could be extracted through a
smaller incision, leaving the softer peripheral nuclear and
cortical matter to be aspirated. Today, almost a decade
later, Luther Fry uses this technique in almost 70 per cent
of his planned ECCE cases with an incision of 7.5 mm
size. Gills a few years later, described a similar method
where a lens loop alone is used to extract the nucleus.
Nuclear Extraction in
Manual Small Incision Techniques
Phacofracture Technique
The concept of fracturing or cracking the nucleus is

not new. As far back as 1967, Kelman used Ringberg
This technique pioneered by Kansas and designed by

Francisco J, Gutierrez C accomplishes nucleus removal
in the following way. After CCC or can-opener capsulotomy, hydrodelineation of the nucleus is performed and
the nucleus is prolapsed into the AC. Viscoelastic was
used to protect the endothelium and needs to be
replenished as liberally as required. A solid curved vectis
is introduced under the nucleus and a special instrument
called the nucleotome is introduced above the nucleus.
The nucleus is sandwiched between these two
instruments. The nucleotome is manoeuvred towards the
nucleus till it comes in contant with the vectis. Keping
nucleotome in place, a spatula is introduced, and using
it and the nucleotome the cleavage is confirmed and the
pieces of the nucleus separated. Viscoelastic is replenished
and a special nucleus forceps with 9 mm jaws, each with
a double row of teeth, is introduced into the AC. Nuclear
fragments were then positioned in the axis of the wound
and removed. Removal of cortical debris mixed with
viscoelastic (viscoelastic sludge) with a lagre bore
irrigation aspiration tip is the next important step prior
to insertion of an intraocular lens. The wound is checked
for integrity, and the conjunctiva replaced in position.
A 3-4 mm incision can be used in this technuqe. The
instrumentation is relatively simple. Howeve, this technique is very viscoelastic dependent. There is potential
for corneal damage. Moerover, it is a difficult technique
to master, probably not suited for hard brunescent nuclei
which are dealt with standard ECCE.
Nucleus Division with Snare
Dr Getrald Keener et al discovered a Nucleus division

technique, according to which nucleus can be divided
and conquered. Instead of using a cutting blade, he used
a fine wire that bisects the nucleus and expresses each
piece separately.
Welsch Rovert C et al reported that nucleus trisection

inside anterior chamber make the removal of lens pieces
very easy through less than 5 mm scleral tunnel incision.
FURTHER READING
1. Arrugas Olcular surgery: Mcgraw Hill Book Co.: 4: 109-15,
1962.
2. John J Alpar, Paul U Fechner: In Fechners Intraocular Lenses:
Jaypee Brothers (Indian Edn) 6-22, 1988.
3. Apple DJ, Ram Jagat, Foster A et al: Elimination of cataract
blindness: A global perspective: Entering the new millenium.
Surv of Ophthalmol 45(Suppl): 570-99, 2000.
4. Aziz Y Anis: A methodical approach to small incision cataract
surgery. In Cataract Surgery: Alternative Small Incision
Technique (1st Indian edn) Slack Inc. 139-62, 1995.
5. Blumenthal Michael: Mini Nuc Manual extra capsular
technique Highlights of ophthalmology letter, 21(5): 1993.
6. Daviels Jacques: Cited in Duke Elder, XI: 253, 1748.
7. Epstein E: History of intraocular lens implant surgery, In:
Mazzocico TR, Rajacich GH, Epstein E (Eds): Soft Implant
Lenses in Cataract Surgery, Thorogare NJ, Slock Inc: 1-10,
1986.
8. Fine IH: Infinity suture: Modified horizontal suture for 6.5
mm incisions. In Gills JP, Sanders DR (Eds): Small Incision
Cataract Surgery, Foldolde Lenses, One-stich Surgery,
Suturless Surgery, Astigmatic Keratomy. Thorofare NJ Slack
Inc: 191-96, 1990.
9. Fine IH: Architecture and construction of a self-sealing incision
for cataract surgery. J Cataract Refract Surg 17 (Suppl):
672-73, 1991.
10. Harold Ridley A: Implantation PMMA IOL in human-current
therapy. In Ophth Surg, Spaeth and Katz 135.
11. Luther L Fry: Phacosandwitch technique. In Cataract Surgery:
Alternative Small Incision Technique (1st Indian Edn) Slack
Inc: 71-110, 1995.
12. Masket S: Origin of scleral tunnel methods (letter to the Editor)
J Cataract Refract Surg 19: 812-13, 1993.
13. Peter Kansas: Phacofracture technique. In Cataract Surgery
Alternative Small Incision Technique (1st Indian Edn.) Slack
Inc: 44-70, 1995.
Sterilization
Sterilization
INTRODUCTION
When viewed upon from the broader angle however

good a surgery may have been performed should it be
complicated with infection, the result is fraught with peril.
The patient suffers ultimately and the surgeon goes
through hell. We have all had our share of infection and
its disastrous effects.
Should a surgeon say they have never had infection
spoiling their case, either they have never done surgery
or the truth lies hidden elsewhere.
Be that as it may we need to understand microorganisms in a much better manner. We need to give
this topic full attention in our hospitals and continue to
give it the importance it requires by continuing quality
checks at every interval regularly every day and in every
case.
Some basic facts of postsurgical infection in human
eyes whether cataract surgery or any intraocular surgery
is concerned, are that we need to regard all infections to
arise from the operation theatre unless proved otherwise.
The operating room is certainly the most guilty in
providing the microorganism for post-surgical infection.
It may be very easy to complain about patient compliance and dirtiness to be the cause of infection, and
sometimes that may be true, however in our hearts it is
safer and better for us to accept that this infection has
come from the operating room and then work ourselves
backwards in removing the source of the disease.
We may be able to shift blame to a tooth infection or
septic foci in the sinus, however, should we be able to
first accept the operating room to be at fault, our energies
would be directed in improving our facilities, thus averting
further mishaps from occurring.
The first rule in sterilization at least where developing
countries are concerned is not to believe any manufacturer when they claim to have sterilized their wares.
To be taken as guilty of infection unless proved otherwise.
This is true of not only suture material, disposable needles
and syringes but also of intravenous and intraocular
fluids. Many cases have been reported in India where
Sunita Agarwal
Amar Agarwal
bacteria have grown from the Ringer lactate used. A

startling study was carried out in the early 90s where
several eyes were lost due to balanced salt solution (BSS)
not being of pH 7.4, because the last rinse did not wash
of the remnant soap from the glass bottle.
What we all need to remember is that when everything is going fine nobody complains, but as soon as
there is a complication the surgeon is the first and often
the last person to be held totally responsible for all
misdemeanors on anybodys part. Thus as captain of
the ship the surgeon has to sink with his or her ship.
However, all this can be avoided by taking precautions
before entering the operating room.
HISTORY
Dating back to the time that Sushruta from 500 BC

explained the importance of washing hands and draping wounds with clean cloth, as well as having a clean
environment for surgical procedures, Indian medicine
has always kept this part of medical practice in good
stead. Practicing principles of Dhanvantri medicine a
Hindu physician-oculist wrote that surgeons should clean
their nails prior to operating, wear fresh clothing, and
spray sweet smelling vapors around the operating room.
Little did he know the importance of these instructions.
However, these were carried down through the ages by
the Vaids (Hindu physicians), now with better knowledge
there is more understanding of the topic on infection and
sterilization control.
The middle ages saw European medicine catching
ground however, sterilization tactics were still very rudimentary. Most surgeons thought it to be fashionable not
to wash hands, mayhap due to the cold climate of the
temperate zones. Thus centuries of unknown prevailed
with thousands being lost to infection and disease even
inside the operating room. It was considered hazardous
to lay a surgeons hand in the fear of losing the patient to
fever as it was called then.
However, Hieronymus Fracastorus in 1546 published
a landmark book that may have led to the discovery of
10
bacteria. His theory of contagious diseases and their

treatment sparked off the original microbe hunter, to
identify bacteria with his own saliva in 1675, using his
microscope screwed together with some lenses, Anton
van Leeuwenhoek had set about 2 centuries of hot debate
amongst the European scientists.
In 1840 Jakob Henle postulated the theory of the
contagion. This was further specified by Robert Koch in
1876 where he showed that by isolating the anthrax
bacillus and was able to infect a normal animal with the
same that the theory of contagion was true. This work
won him the Nobel Prize for medicine and physiology in
1905.
It took Louis Pasteur to bring out the emphasis of the
little beings as those responsible for disease. His paper
on the importance of washing hands before starting a
obstetrical delivery shows the utmost significance of this
one act towards a sterile atmosphere.
Throughout the 1800s pioneering technologies of
Pasteur, Nizer, Klebs, Escherich, Cohn and Ehrlich played
major roles in the evolution of discovery of pathological
germs. Today the science of microbiology and medicine
are occupied by their names forming important
landmarks in the discovery of the importance of
sterilization techniques.
Where hospital wards are concerned, making surgery
safe and banishing sepsis from hospital wards, an era of
pre-Lister and post-Lister can be demarcated. This was
the importance of Joseph Lister on surgical outcome.
He based a lot of his studies however, on Ignaz
Semmelweiss (1818-1865)who was cruelly maligned
for his theory of the origins of child-bed fever that led
him to be institutionalized and die an unhappy man.
The irony of the situation was his studies brought about
a revolution in hospital wards and the prevention of
infection by antiseptics and cleanliness reiterated by
Joseph Lister.
By the time Daimler brought out his first motor cycle
in 1884, scientists round the globe had devised the
autoclave deriving from the fact that boiling did away
with microbes. This revolutionized hospital wards and
operation theatre sepsis to a great extent. So much so
that till date some contraption of the autoclave is still
used in every operation theatre in existence in the modem
world.
By 1899 a century was going by and scientists believed
this was the ultimate and that internal sepsis was not
going to be much more advanced beyond theory and
that the field was not likely to advance further. Today
with much more information and knowledge we think
contrary, that we still know only a drop in this ocean of

knowledge against disease and infection.
Change is the spice of life and just as today changes
to another day, of more discovery and more scientific
achievements so to these pioneers were to discover much
more. Sulfanilamide first discovered by Paul Gelmo in
1908 was found to be effective on surgical wounds, by
Gerhard Domagk who first used the drug on humans in
1935. This won Domagk the Nobel Prize for Medicine
and Physiology in 1939.
Paul Ehrlich and Toju Hata discovered Salvarsan, the
arsenic derivative for the treatment of syphilis, it heralded
yet another era, that of the antibiotic.
In 1929, Alexander Fleming published his classical
work on Penicillin from London and history followed his
every achievement. Through the World Wars his
medicine was of immense use in the control of infection
and weeding out of disease. He showed first through invitro studies that a contaminant of Staphylococcus
medium, Penicillium notatum had a destructive effect on
the Staphylococcus bacteria that was growing on the agar
plate. In further experiments he showed that this mold
also had strong antibacterial activity against other
pathogenic gram-positive bacteria as well as gramnegative cocci and bacilli but was not effective against
organisms such as Escherichia coli.
While the world raged with War, yet another kind of
war was being fought for mankind inside the laboratories of HW FIorey at Oxford University. By 1940 Ernst
Chain showed the curative effects of penicillin in vivo. In
1945 by the end of the World War II, these three men
were awarded the Nobel Prize for Medicine and
Physiology. Selman Waksman discovered spates of
antibiotics in succession with streptomycin in 1944 for
tuberculosis and neomycin in 1949.
Much of todays discoveries have been dependent on
the way we see these small animalcules of
Leeuwenhoek, in 1933. Our eyes could see the destruction of the world with Hitler as the Chancellor of
Germany, and could see even greater destruction by
microbes since the invention of the first transmission
electron microscope by Ruska. Further developed to a
phase contrast microscope by 1953, by which time the
World War had ended and humanity was once again
allowed to prosper. So much so that the scanning
tunneling microscope could be developed by 1980 and
its fast developing clones that are in use today.
However, very soon the side effects of antibiotics were
noted with the classic example of chloramphenicol the
first broad-spectrum antibiotic, discovered in 1949,
Sterilization
effective against rickettsial infection, typhoid. A link was

established between severe bone marrow depression and
aplastic anemia with its use. This curtailed the use of
these eyedrops and oral regime in USA.
We owe a lot to these forefathers of modern medicine
and surgery, and todays technological advancements
have made us more wary of the microbe. It seems to be
the more we advance the more microbes we find the
cause of disease. Stress and other dietary factors were
believed to be the cause for peptic ulcers, though now
we know bacteria to be the root. In a similar manner,
there are many more diseases that still retain their shroud
of mystery.
Let us not rest on previous laurels and with the close
of this century believe that we have reached the ultimate.
In reality, we have only skimmed the surface there is
much more to be unraveled in this body beautiful of the
Homo sapiens.
Tempting to say in the words of Louis Pasteur,
Science knows no country, because knowledge
belongs to humanity, and is a torch which illuminates the world.
AREAS OF STERILIZATION
Once we enter the operating room we expect that

everything must be in order, and somebody else is in
charge, not me. However much to our utter astonishment seldom does anything go wrong, though when it
does, the blame is once again pushed on to somebody
else, not me. This is where the first principle of surgery
has to be changed and restructured. The first and only
person responsible for the whole team at work
inside an operating room is the main surgeon.
This is the person who every body in the operation theatre
must report to. This is the person who before entering
the theatre has to ensure that everything inside this pious
area is under strict control of the surgeon. This is the
person who must take responsibility if an infection should
arise in the patients eye within one week of surgery.
After carrying out so many tests and sterilization techniques I would rather believe for the benefit of all future
patients that infection in a postsurgical eye arises from
the operation theatre facilities. It is very difficult to put
infection inside a closed eyeball, though it is easy enough
while the eye coats are still open. More often than not
infection is carried into the eye by instruments themselves.
There is however a small possibility that this may not
be the case and there may be a septic foci residing in
some corner of the human body like a tooth abscess or
such. Still these occurrences are very rare and far
11
between. Moreover, it is far more beneficial to all concerned to garner our resources and give a thorough job
of the operating room than to be witch hunting on the
patients habits and dirtiness. It is my belief that even a
dirty patient cannot infect the inside of his or her eye, if
he or she has a postsurgical infection for sure it has been
carried in through the workings of the operation theatre.
Going in a methodical manner from without to within
anything entering the theatre has to be sterile. First the
operating room itself has to be sterile.
The Operating Room Air
The air we breathe can be filled with pollutants, viruses,

bacteria and irritants such as pollen, chemical gases,
odors and smog. In critical situationsmilitary command
centers and public arenasthere is also a threat of
chemical and biological agents being released into the
air. All these air-borne pollutants can be treated by using
various technologies.
We forget about the air coming into the operating
room, though however we should understand that if this
itself is clean it is much easier to retain the cleanliness
within. There are many ways of filtering clean air into
the operating room. One of the easiest and best is to first
make sure the rooms pertaining to the operation theatre
complex are sealed shut, with only one entry into the
complex. Now we need to bring in clean air into the
operating rooms.
Air-Conditioning
Ideally the whole operating area complex must be airconditioned with the units stationed well outside the
complex and only ducts bringing in fresh temperaturecontrolled air into the complex. The air-conditioning units
could be in the form of towers or split units stationed on
the terrace or window firmaments outside.
Filtration of air The ducts bringing in the clean oxygenated air need to have the air passing through filters
that can ward off bacteria which means they should be
0.2 micron filters. More often these filters need to be
changed and or cleansed on a daily pattern.
Ultraviolet radiation Ultraviolet light bulbs could be
placed in the path of the filtered air to make sure the air
is disinfected as it enters the operating rooms. Alternately
these bulbs could be left in the operating area and kept
on throughout the night, this would also ensure clean
areas the next morning after 12 hours of exposure to the
ultraviolet light.
12
Ozone treatment Another technology gaining ground

for clean air is the ozone treatment plants that generate
ozone into the air. This breaks up the microorganisms
and clean, disinfected air is ensured. One unit for 5000
cubic feet of air space is recommended.
Ozone is a reactive molecule comprising three atoms
of oxygen. Because ozone is a reactive molecule it acts
as a powerful oxidizing agent against all microbial
contaminants, organic toxins and most volatile organic
compounds (VOCs) and because of its short half-life it
rapidly reverts to water and oxygen.
When a combination of UV, moisture and ozone are
used a synergistic effect is seen. The absorption of UV
by the ozone-producing highly reactive substances that
effectively kill microorganisms including hard to kill spore
forming bacteria.
Positive pressure A positive pressure pump is maintained to make sure the air entering the operating rooms
are kept at a pressure above the rest of the area. These
pumps can be installed in the ducting and positive
pressure inside the operating areas would ensure that
the air comes only from this area and not through leaks
from windows or doors. The main door of the operating
room must function for only air escaping the operating
area and not for entering it.
Air curtain Entry points in the operating area would
do well to have automatic door closers so that the door
does not remain open unnecessarily. Also the door can
be fitted with an air curtain so that the outside air is
curtailed off from entering.
Quality Check
Quality check is ensured by every day/regularly carrying

out the PLATE TEST. This means leaving a bowl of clean
sterile water in the room to be tested for 20 minutes.
Microorganisms present in the air would settle down on
the surface of the water, a small sample is taken from
this and grown on a culture plate. If the sterilization techniques have been effective the culture should be sterile
in 24 to 48 hours. If the culture grows positive growth
remedial means have to be taken to ensure sterile cultures.
The Operating Room Water
The water coming into the operating room needs to be

free of microorganisms. After all the water with which
we are cleaning the most important area of the hospital
needs to be totally clean. If microorganisms are present
in water then they would remain on the items cleansed
and the cleaning would be bad. The water coming into
the operating room must also contain adequate amounts

of minerals.
Filtration
This still finds the safest use in bringing in clean water

into the operating area. It could be done by many
methods, ceramic is one of them. However today membrane filters seem to have replaced all else as here they
bring out the fluid bereft of bacteria. Sometimes a suction
pump is attached to the water jet so that the filtration
can take place at a faster pace.
Reverse Osmosis
A high pressure is set about in the clean water and a

system of reverse osmosis sends back the mineral content
of the water while a filtration process blocks out the
microbial content. In this way water is able to reach the
operating room withless minerals and is absolutely sterile
with no bacteria. This is also one of the techniques used
in the manufacture of bottled mineral water and can be
used very effectively in operating area complexes. This
water is now used for cleaning the operating rooms,
machines, and for surgeons while scrubbing. The water
coming from such a plant is placed in a storage drum,
preferrably made of stainless steel.
Electronic Control
Water can be made to contain low mineral counts and

no bacteria through another technique of manufacturing mineral water. This is by producing cathode and
anode electrodes on two ends of the water channel. The
anions and cations would respectively move to their
corresponding electrodes and this would clear the fluid
of mineral content. A filter present below would clear
the water of microorganisms. This is another method of
producing sterile bottled mineral water.
The Operating Room Walls, Floor,
Ceiling and Fixtures
All elements of the operating room need to be first

cleansed, then disinfected and last but not the least totally
sterile. The three steps in this process can be done by
three different fluids and chemicals.
Cleansing
This is best done with a soap and water wash. Every

surface, every table, every chair and every fixture needs
to be cleansed with a direct application of soap and water
Sterilization
13
on the surface. After cleaning with this it needs to be

cleaned with plain water.
Disinfection
Benzalkonium chloride solution 4.5 percent could be

used as a disinfectant and as a general cleaning agent
for floors.
One of the best solutions used worldwide towards the
disinfection of operation theatres and consultation suites
is the Bacillocid made by Bode from Germany. This contains 1,6 dihydroxy 2,5 dioxyhexane (chemically bound
formaldehyde) with glutaraldehyde, benzalkonium
chloride and alkyl urea derivative. A 2 percent solution
is used for the operation theatre and a 0.5 percent solution
for the consultation areas. With this solution all areas
mopped and cleansed of vegetative organisms, fungus
and viruses (Figs 3.1 to 3.3).
Fig. 3.2: Cleaning of the operation theatre

walls with Bacillocid
Fig. 3.3: Cleaning of the operation theatre

floor with Bacillocid
Fig. 3.1: Cleaning of the operation table and chair, external
surfaces of the microscope, instrument table, IV poles with
Bacillocid
Formaldehyde in the form of liquid, tablets or gas has

been used extensively in the past, however, today its use
is put to question since culture tests have proved positive
with growth even after formaldehyde sterilization.
The Operating Room Macroinstruments
All fixtures including fans, lights, air-conditioning have

to be first cleansed carefully with a dry cloth and then
mopped with Bacillocid so that they can be disinfected.
Chairs, stools, operating tables, trays have to be first
cleansed with soap water and then mopped with
Bacillocid (Fig. 3.1) and left alone for over four hours to
ensure disinfection.
Care needs to be taken on operating theatre instruments like Boyles apparatus, microscopes, phaco
machines, diathermy machines, suction machines, laser
machines. Though delicate these instruments need to
be thoroughly cleansed every day. Many a time infection
is found to be harboring in these areas and they are
difficult to clean. More sophisticated the machine more
care need to be taken in its cleanliness. This task cannot
be given to an untrained personnel and even then ideally
there should be a doctor supervising their cleaning.
Microscope
The rest of the microscope can be cleansed with soap

water as well as Bacillocid however the optics need special
care and need to cleaned only with a clean cloth preferrably silicon paper. Antifog chemical coating could be
14
given to the optics. After cleaning and before closing for

the day the optics should be ideally wrapped in its original
cloth or plastic casing and drying agents placed inside
like silicon oxide. This allows the moisture inside to be
absorbed by the chemical and with less moisture,
formation of fungus and other microorganisms on the
optics is rare.
Phaco Machines
As eye surgeons we need to be well aware of the pressure

maintained inside the eye during phacoemulsification
procedures for cataract surgery, but little do we realize
the importance of the machinery involved in giving us
this information. When the phaco probe is inside the
eye of the patient there is a continuous flow of fluid. The
fluid arises from the bottle suspended 65 cm above the
head of the patient and this produces a certain pressure
inside the eye. The Fluid then goes through the irrigation
line to the phaco tip which enters the eye and leaves the
eye through the suction tubing entering the phaco
machine. From the phaco machine another set of tubings
takes the excess fluid away into a drainage bag. What
we have overlooked is between the tubing entering
the phaco machine and exiting into the drainage
bag, it goes through a channel inside the phaco
machine. This part of the tubing is never sterilized
in the proper manner that is required before a
cataract surgery. In fact it cannot be sterilized as well.
This part of the tubing is attached to two manometers
that gauge the pressure in the tubing and give us a reading
on the panel in front. A vent exists that can release the
pressure in the tubing to atmospheric levels as soon as
our footswitch transfers from position 3 to 2 to 1. In so
doing the air from the operating room directly enters the
tubings thus if there should be bacteria in the air they
would now have an easy access to the most sterile line
that we have been trying to maintain.
These facts were not known to us for a long
time, and we had a spate of infections as Pseudomonas had managed entry into the tubings present
inside the phaco machine. None of the companies
representatives ever let us know of this tubing and its
existence and we never racked our brains hard enough
to trace the tubings, until this major catastrophy occurred.
Over a spate of 12 months we had taken out 4 intraocular lenses (IOLs) from eyes with infection. We were
able to save the eyes from blindness however rendering
them aphakic.
We first accepted that the infection came from the
operating room and now with a technology of omission
went about in a scientific manner trying to decipher where

the infection came from.
First the microsurgical instruments and tubings were
taken through the 10-step procedure as you will read
later on. Now they were tested for sterility by flowing
fluids through them and taking this fluid on a culture
plate. They were sterile, after fixing the tubings and probe
onto the phaco machine the fluids were collected from
the drainage bag and sent for culture. The second one
was positive. This told us that our sterilization techniques
were good however something was amiss.
We opened the phaco machine and found this tubing
running through it and found the vent as well. This vent
ideally should have an air filter attached to it. We sent
the tubing for culture and replaced it with a fresh sterile
piece. The culture proved to us where the culprit lay, the
Pseudomonas was grown from this tubing.
The internal tubing cannot be changed with every
case, though this would be ideal. So we have devised a
better structure for its disinfection. That is to keep the air
totally sterile and make sure no infection goes into the
tubing through the vent. This is ensured with the ozone
generator for the total operating room areas.
What we did realize through this study was that not
all cases turned up with infection even though the bacteria
must have been residing in the tubing for many a day.
The cases turned up with infection had something to do
with being the last few of the day. The cases which turned
up with infection had low immune status, either diabetes
or hypertension or such. The cases which turned up with
infection had a complication most often a posterior
capsular rupture on table thus resorting to vitrectomy.
This shows us some characters of infection that we may
already have known but not given them their due
acknowledgement.
However, what we have realized is that the phaco
machine has to be cleansed very well and air filters placed
on the vent. The tubing changed every week. And culture
tests done for every case before and after surgery (Figs
3.4 and 3.5). What this means is when the tubings and
probe are attached to the machine before starting the
case first few drops of fluid entering the drainage bag is
taken for culture (Fig. 3.6). Once again at the end of the
case this is repeated. If and when at any time a culture
should turn positive we would know the problem immediately. After these stringent measures have been installed
at our hospitals we have neither had even one infection
coming from the operating room nor had to remove any
more IOls lenses from infected eyes.
Sterilization
Fig. 3.4: Collection of Ringer lactate solution from the

aspiration tube before the operation
Fig. 3.6: Collection of Ringer lactate solution from

the front end of the internal tubing
Fig. 3.5: Collection of Ringer lactate solution from the

aspiration tube after the operation
Fig. 3.7: Ethylene oxide sterilizer
Boyles Apparatus
Regular cleaning of all parts of the machine is necessary

with spirit as this evaporates and does not leave a residue
on it. However the parts of the tubings that enter the
human system or are connected to them need to be
thoroughly cleansed, disinfected and then sterilized. The
method of choice for sterilization here is the ethylene
oxide gas chambers (Fig. 3.7). As most of the tubings
are plastic temperature of below 60C are comfortably
taken by them. Needless to say that oxygen, nitrogen
dioxide, halogen levels should be monitored on a daily
basis with every case in particular.
The Operating Room Microinstruments
Every case must be treated separately and all instruments

must be cleansed thoroughly before the next case. Once
15
a day a 10-step cleansing routine must be established.

This 10-step routine includes
1. Soap water wash with toothbrush
2. Ultrasonic cleansing with Lysol
3. Cidex cleansing and soaking for half an hour
4. Isopropyl alcohol cleansing
5. Plain sterile water cleansing
8. Boiling in sterile water
9. Ethylene oxide sterilization overnight
10. Flash autoclave sterilization three times.
Four trays are kept aside on a long side table (Fig.
3.8). Water used in this sterilization must be mineral sterile
water, as this water is totally sterile, prove it by growing
the water on a culture plate and making sure it is sterile.
16
the sterilization technique used the better would be the

results that can be achieved.
This is best done with the old soap and water wash
(Fig. 3.9). Liquid soap is used in a tray with clean sterile
mineral water. First a plain cleansing with gloved hands
is completed and then using a toothbrush into the small
crevices of instruments. This is of special importance to
instruments filled with blood and tissue. In ophthalmic
matters special reference has to be given to machines
like the automated flapper in LASIK (laser-assisted insitu keratomileusis) cases, as it is known that corneal tissue
gets clogged into the tracks and other areas of the flapper.
This can be removed much better using palmolive liquid
soap as it contains some of the safest and yet cleanest
ways to get grid out of the system.
Fig. 3.8: Four trays arranged in sequence containing carbonic
soap with mineral water, 2 percent glutaraldehyde, 70 percent
isopropyl alcohol and mineral water
Ultrasonic Cleansing
The mainstay of cleansing into crevices where the toothbrush cannot reach and this gets into the fulcrum of
forceps and scissors to clean the instruments. A chemical
solution like Lysol (Cresol and soap solution) could be
used as an adjuvant to remove the debris from clogged
surfaces. This breaks up the protein and organic matter
so that it can come clean from instrument surfaces. Most
of the fluids used in the ultrasonic cleanser need to be
antiseptics as well so they can be used as disinfectants
on the instruments cleaned.
Cidex or Glutaraldehyde 2%
Fig. 3.9: Wash all instruments in a tray of carbonic soap and

water with toothbrush
The trays are filled with the respective fluids. Each tray is
numbered and labeled so that mixing does not occur.
In each tray a toothbrush and 50 ml syringe with a
yellow tubing taken off from an IV set is kept. All microsurgical instruments are dipped in each tray periodically.
Every instrument is cleansed delicately with gloved hands
and toothbrush. When and where required every lumen
of every instrument is injected with 50 ml of the liquid
that it is dipped in. Thus the cleansing action is from the
outside as well as from the inside of every instrument.
This is specially true of probes and tubings.
Tray I with Liquid Soap and Sterile Water
The first step in sterilization of instruments is its proper

cleansing as whenever the microbial load will be less on
Once activated Cidex solution manufactured by

Johnsons & Johnsons must be used within 14 days.
Some facts like these go unnoticed in hospital
environments and the use of substandard procedures
and drugs come into play. Reiterating the fact that the
doctor has to be on top of all these activities.
Instruments are left immersed in this solution (Fig.
3.10) for 30 minutes, which is sufficient time for disinfection however for sterilization 10 hours would be needed.
Within 10 minutes at room temperature most vegetative
organisms would be destroyed, including Pseudomonas,
fungi, and viruses. The solution is very toxic to the eye
and great care has to be taken to get the solution out of
the instruments before using on humans.
Isopropyl Alcohol 70%
This is still one of the best ways of killing the microorganisms (Fig. 3.11). Instruments are soaked in the
solution for over 15 minutes and then cleansed using a
toothbrush and syringe to wash the internal elements of
probes and tubings.
Sterilization
Fig. 3.10: Wash all instruments in a tray of 2 percent

glutaraldehyde
Fig. 3.11: Wash all instruments in a tray of 70 percent

isopropyl alcohol
Fig. 3.12: Wash all instruments in a tray of mineral water
of performing this essential act of sterilization. However,

what needs to be detailed is whether the particular article
can withstand temperatures of over 100C.
After having a spate of infections and removing IOLs
from infected eyes to save the eyes, my hospital and
staff got spurned to find the cause of the infection.
Towards this a whole new regimen was set up on cleansing, disinfection and sterilization of microsurgical
instruments. After each methodology culture tests would
be taken to prove its efficacy. We did understand that
the silicon tubings had gram-positive cocci growing in
them. In a process of eliminating them we found that the
cocci inside the silicon tubing withstood many sterilization
techniques like ethylene oxide and autoclave. However
when subjected to boiling for 20 minutes the tubings
would be sterile. This once again reiterated our belief in
this age-old custom of boiling (Figs 3.13 to 3.15).
Sterile Water
Care must be taken to wash of the deleterious effects of

the above mentioned solutions. This is done effectively
by first soaking and then washing all the instruments
through three trays of sterile water (Fig. 3.12). The lumen
of the tubings must be cleansed with sterile water each
time 50 ml of the fluid passing through the probes and
tubings. Once again cleansed with sterile water
Boiling
After going through a number of tests and methods of

sterilization we still find one of the best methods remains
the age-old custom of boiling. This brings about total
death of the microorganisms. Most rudimentary of
operation theatres would still contain means and methods
17
Fig. 3.13: Diamond blades are cleaned using steam
18
Autoclave
As the last step in the sterilization cycle of instruments,

they are passed through the flash autoclave for 134C
for 5 minutes and this cycle is repeated three times in the
Statim autoclave from Canada (Fig. 3.16). It has a builtin computer that tells us of the efficiency of the cycle.
However, color indicators would also tell us of the
physical measurements reaching the desired levels.
Fig. 3.14: The external tubings, internal tubings, I/A probe

and metal knobs are boiled for 30 minutes
Fig. 3.16: Statim autoclave cassette containing the tubings and

instruments is kept in the ethylene oxide sterilizer for a period
of six hours
After doing this the instruments are laid on the

operating table and each instrument that enters the eye
is dipped in Ringer lactate before entering the eye.
The Operating Room Linen and Accessories
Fig. 3.15: The instruments are separately
boiled for 30 minutes
Ethylene Oxide Sterilization
This is not a preferred technology of sterilization for

microsurgical instruments because of the time duration
taken is over 16 hours. However, we have started using
this as one more step towards the end of the day. By the
time we finish all the cases of the day we take our instruments through this 10-step procedure ending it with a
bout of ethylene oxide where the instruments rest for the
night. However, the only aspect of this technology is that
the instruments must be cleansed of the ethylene glycol
residues that may be found over them. This is effectively
done by steam autoclave and washing intraocular instruments with ringer lactate meant for intravenous use.
All operation theatre linen and accessories must be

cleansed before entering the complex. Particular slots
should be kept ready and clean for them everyday.
Otherwise the operation theatre should be totally bereft
of any other article. Anything that is not used everyday
need not be found in the operating room. This is not the
place to keep stocks and inventory of medicines. They
could be kept in the prefunction area of the operating
room but not in the operating room itself.
Linen
Sterile operation theatre gowns, towels, gloves could be

of disposable variety, this is internationally accepted to
be the best. However, it is not practical in all kinds of
atmospheres. In India we still recycle our operating clothes
which are usually made of cloth. The methodology
Sterilization
approached towards their care is explained in the same

3-step procedure.
Cleaning This is done by taking all the sullied clothes

and first taking away all clothes coming from an infected
patient being operated or from the septic operation
theatre are treated separately than that coming from a
clean operating room. These clothes are preferrably
disposed off in an incinerator. If they cannot then they
are soaked in Dettol solution, before the cleaning process
begins.
The clothes are cleansed preferrably in a washing
machine with adequate soap being used. Then the
clothes are passed into a drying machine. Try not to leave
these clothes on the drying rope for nature to dry, because
with this outside bacteria and fungus can settle on these
clothes. Inadvertently they may fly off the clothes line
and this would also create much increase of the microbial
load for sterilization.
However, if machinary is not available these clothes
are first soaked for half an hour in hot water with soap
solution inside a large tub. A rod is taken and rotated
round and round for five minutes. This will shake off the
dirt and grind from the clothes.
After this each cloth is taken separately and washed
with hand and the clothes thrown into another tub of
hot water with a few drops of Dettol solution in it. The
clothes are left for another half an hour in this solution
and then rinsed off with plain water.
A separate enclosure should be made for the drying
of these clothes. When the clothes are placed on the
clothesline they should be pinned there as they may fly
and hit the floor picking up germs. This could be avoided.
Once dry they are picked up, folded and sealed for
sterilization.
Sterilization Clothes could be sterilized by two
methods, whichever method is used what is important is
that they be folded away keeping each procedure in
mind. That is to say if for one cataract procedure we
need three operating gowns, ten towels and six shoulder
bags, then they should be folded in such a way that these
are all kept together. One does not have to search for the
small items by opening up every item sterilized.
Autoclave This still finds the pride of place in being the
most accepted form of sterilization. However one needs
to be aware that the clothes must not come out damp.
The steam in the autoclave must be saturated but dry.
This means all the water vapor present in the air should
be gas and no droplets of water in the steam. If an
autoclave is giving out damp clothes that means
19
it is not working efficiently. The drums kept in the

autoclave must be closed immediately on removal from
the autoclave, ensuring that outside air does not enter
the drum. Once autoclaved the items can be considered
sterile for only 24 hours which means to say they need
to be reautoclaved to improve efficiency in sterilization
techniques.
Ethylene oxide sterilization With todays emphasis on

better sterilization techniques and total dependence on
them, a move has come into using the gas industrial
sterilization for hospital purposes. As there is more surety
on its efficacy this is even a preferred technology over
the autoclave. However it does have its drawbacks which
are that the hospital needs to keep a bigger inventory.
This is due to the fact that these clothing need to be
aired out for over 48 hours before they can come into
contact with human skin. Easily achieved by having four
times the number of gowns and towels one would
ordinarily keep.
The advantage of ethylene oxide sterilization for linen
over autoclave is that we never get damp clothing which
should be regarded as not sterile. Moreover the personnel
are always sure of ready stocks for operating at any time.
We do not have to start the autoclave and wait for
sterilization, we always have sterile clothing ready.
Sealing and packing In ethylene oxide sterilization
the methodology employed towards its packaging
is very important. High-grade thick plastic bags could
be used, alternately custom-designed bags are available
for ethylene oxide sterilization. However these customdesigned bags are more expensive than plain plastic bags
used commercially.
Sealing of these bags has to be immaculate as any
porthole left gaping will now allow the atmospheric air
containing microbes into the bag and once the seal is
broken the contents are not any more registered as sterile.
Sealing machines are available in the market and their
use is much better than burning the bags with a candle
and sealing them.
Ethylene oxide chamber The ethylene oxide (ETO)
gas comes compressed in gas cylinders that are attached
to the machine. These machines which use the gas
cylinder have a vacuum pump attached which first
empties the air in the ETO chamber, then we let in the
compressed ethylene oxide gas and leave it at about 50C
for over 6 to 12 hours. Now when the chamber has to
be opened, once again the vacuum pump empties the
gas out. The outlet from the machine needs to be placed
6 ft above and outside into the atmosphere. This gas is
20
toxic and its inadvertent entry inside the hospital premises

is a health hazard for personnel. Care must be taken that
the outlet tubing is placed well outside the hospital
premises, onto the terrace if possible.
Once the ETO has escaped out the atmospheric air is
let in and the chamber pressure maintained at atmospheric pressure before it is opened. The materials can
now be kept on a shelf for airing. The shelf should be
just racks with ample room on either side for the gas to
escape from its whereabouts. The linen can be now used
as sterile after 48 hours of airing.
Alternately gas ampoules are present which can be
placed inside the chamber, these ETO gas ampoules need
neither the vacuum pump nor the temperature maintenance and can be easily placed inside a big plastic bag
also prescribed by the company that manufactures the
ETO gas ampoules. All the clothing is stacked after sealing
inside the big plastic bag that occupies the whole of the
gas chamber. The ampoule is broken and this allows the
ETO gas to permeate through the whole closed plastic
bag inside the chamber. This is left so for 12 hours and
for another 14 hours when the gas escapes the chamber.
After which the contents can be taken out and placed on
airing shelves.
Medication
Parenteral
IV fluids and intraocular fluids Fluids used inside the

eye should be regarded as not sterile unless proved otherwise. Towards this exercise we sterilize all our fluids, like
Ringer lactate, saline and even 2 percent methylcellulose.
Many a surgeon in developing countries has suffered
immense loss by placing Ringer lactate into the eye
without prior sterilization. E. coli has been known to be
grown from these fluids. At the moment of an infection
occurring not just one eye will be lost, but the whole
batch of Ringer lactate would and will be used on several
eyes at a time and many losses have been reported. From
the Ringer lactate one surgeon lost over 12 eyes to
infection from the fluid. This cannot be really taken as a
mistake as we understand that fluids meant for IV therapy
must be totally sterile, however this is not always the
case.
So to protect our patients from such a malady occurring we resterilize these bottles in the autoclave. It is
preferrable to use glass bottles. Studies have shown the
plastic polymers react with the fluids and can have drastic
effects on the cornea of patients. Thus, world over glass
is a preferred carrier for use of fluids inside the eye.
Moreover, plastic bottles cannot be autoclaved as they

would melt with the over 100C needed for autoclave
sterilization.
Even when we are sterilizing these glass bottles care
has to be taken in their placement in the autoclave bins.
Autoclave indicator stickers are used on every bottle. The
bottles are placed head up, and kept in the bin with space
all around. Preferrably wrapped in some cloth towel so
that should they inadvertently break and blow up, they
would do so inside the wrapping. Care has to be taken
to let the fluids reach a level of below 80C temperature
before opening the autoclave chamber as they may blow
up on exposure to room temperature.
All fluids used inside the eye are kept at 4C for better
trauma control on the eye. As we know cold itself is an
anesthetic and controls blood vessels by constricting them
we prefer to use cold fluids inside the eye. This would
also ensure better control on the delicate tissues of the
eye and less trauma as well.
Methylcellulose 2% (VISCON) Much the same technology is used in autoclaving methylcellulose. Glass containers are once again preferred as plastic would react
with the fluids inside. The vials are kept wrapped in cloth
and placed inside the autoclave bins. Once sterile these
are shifted into a refrigerator to keep them at 4C, the
preferred temperature for methylcellulose as we know at
this temperature the viscosity is the greatest and best for
intraocular use.
All other medication These too need our undivided
attention as to their expiry. Most drugs are not re-sterilized since the methodologies used might just denature
the medication. However, place has to be kept in the
operating area complex for essential medication necessary during the course of a surgery. These medicines
should not be stocked inside the main operating room
but in prefunction area.
Care needs to be taken regularly to keep dusting and
keeping the area where medicines are kept to be clean
and free from germs. Thus to do so every day this area
must be cleaned, drawers, shelves all cleaned with plain
cloth and at least once a week with soap water and/or
Bacillocid.
Probes and Tubings
All probes and tubings are usually of disposable variety,

and they could be kept in clean shelves or drawers with
names written on the outside.
Alternately today we could recycle probes and tubings
by first cleaning them well and then passing them through
Sterilization
21
ethylene oxide sterilization. However, these tubings and

probes are usually made of plastic and for the gas
sterilization to be totally safe and non-toxic they need to
be kept on the shelf for airing for over 15 days. So the
date and time of ETO sterilization needs to be marked
on the color indicators when sterilizing these items.
A preferred methodology for sharp instruments to be
sterilized is also the ETO chamber, some of these sharp
instruments like disposable knives are also made of plastic
handles, which can withstand ETO temperatures but not
the autoclave. These too need to be kept on a shelf for
15 days before use on human tissues.
The I/A probes, the internal tubing, external tubing,

rectal knibs are all cleaned with various disinfectants (Figs
3.17 to 3.26).
Fig. 3.17: Flushing of I/A probe with 70 percent isoproppyl

alcohol passing 200 ml of alcohol into every lumen
Fig. 3.19: Flushing of the lumen of the internal tubing and the
metal knobs with 2 percent glutaraldehyde passing 200 ml of
the same into the lumen
metal knobs with carbonic soap and mineral water passing
200 ml of the same into the lumen
metal knobs with 70 percent isoproppyl alcohol passing 200
ml of alcohol into the lumen
The Operating Room Personnel
Most often surgeons like to operate in the morning,

sometimes they need to operate through the whole day,
however, it is a good exercise to see that all operating
area personnel have a regular bath first thing in the
morning before entering the operating area. All street
clothing and footwear should be removed before entering the operating area. Thus most hospitals would keep
22
metal knobs with mineral water passing 200 ml of the same
into the lumen
Fig. 3.23: Flushing of the lumen of the external tubing with 2

percent glutaraldehyde passing 200 ml of the same into the
lumen
Fig. 3.22: Flushing of the lumen of the external tubing with carbonic soap and mineral water passing 200 ml of the same into
the lumen
Fig. 3.24: Flushing of the lumen of the external tubings with 70

percent isoproppyl alcohol passing 200 ml of alcohol into the
lumen
the changing rooms as the first area of the operating area

complex.
The personnel take off their shoes and are given

alternate operating area clogs, slippers or sandals. The
operating area footwear should also undergo vigorous
cleaning procedures every day. At the end of the day, all
the footwear is taken in and washed with soap water
and cleansed with plain water and left for drying.
Footwear
Separate areas should be demarcated to keep foot-wear.

This should be kept outside the operating area complex.
However, sometimes they could be kept just inside the
door as we have seen many a surgeon goes in taking
out his or her shoes and when he or she comes back his
or her shoes are gone. This is specially true if he or she
wears lovely expensive new shoes.
Clothing
After changing the footwear all clothing needs to be

changed. A changing room has to be kept clean and with
lockers so that operating room personnel can keep their
Sterilization
23
Fig. 3.25: Flushing of the lumen of the external tubings with

mineral water passing 200 ml of same into the lumen
clothes and valuables safely. The most often used personnel clothing are pant with elasticated waist and shirts
with loose necks so that they could be slided into. It is
preferrable not to keep buttons and other such accessories on these clothing as they would get damaged in the
vigorous routine that these clothing should go through.
After the operation theatre has finished for the day
clothes from the personnel lockers are taken ideally into
a washing machine and then through the dryer and sent
for sealing and packing through ethylene oxide sterilization ready for use four days from the day of sterilization.
Towards this rigmarole the hospital would need to keep
six times the number of clothes actually required.
However, if this is not possible the clothes could be
washed by hand dried and then sent into the autoclave
for sterilization. In these clothes one is not really looking
for sterility but for disinfection and thus it is better to go
a step further and make them sterile before use.
Cap and Mask
The cap and mask need not be sterile, however they

should be clean and disinfected. Ideally the cap and mask
used can be of disposable variety since their cleaning
will then not become necessary. However, if they are not
and the hospital needs to use cloth cap and mask, they
can go through the same cycle of events like the other
clothing.
The Patient
The patient should also be made to go through a process to make him or her clean and disinfected. Ideally all
Fig. 3.26: 100 ml of Ringer lactate solution is passed through

the lumen of the internal tubings, external tubings, I/A probe
and metal knobs
patients should be told to have a bath before they go in

for elective planned surgery. This simple process does
give large benefits. Shaving where men are concerned is
essential and removal of make-up is necessary where
women are concerned.
Change of Clothes
The patient should change into operating room clothes

and take out all street clothes. Footwear has to be
removed before entering the operating room. Ideally
patients are requested to remove all their clothing
including undergarments and a patient gown given to
them. This is done in the benefit of the patient so that at
any particular time should an emergency procedure be
called for it can be applied without interference from
essential clothing. Moreover, all patients need to be monitored for their heart and blood oxygen these electrodes
are usually placed close to the heart.
However, in ophthalmic practice it is customary in a
day care surgical center that the clothes need not come
off the patient. Simple removal of shoes and shirt or dress
is sufficient. Patients are then given sterile disposable
gowns that can be worn over their undergarments. This
process is found to be satisfactory for ophthalmic patients.
All patients are also given a disposable cap so that all
hair can be placed inside the cap and not interfere in
surgical procedures.
24
Skin and Incision Site Disinfection
Many solutions are available for wound disinfection some

of the best used worldwide are povidone-iodine and
chlorhexidine gluconate 1.5 percent with cetrimide 7.5
percent. All these antiseptics will be put to better use if
they are used in conjunction with simple cleaning procedures first.
The patient's face could be washed with soap and
water and all jewellery and accessories removed. Once
the patient lies down on the operating table and is ready
for surgery, a scrubbed nurse paints povidone-iodine or
any other antiseptic on the skin. This is removed with
plain gauze.
If anesthesia is necessary it can be given now after
preliminary cleaning of the site. After injections are given
the site to be operated is once again cleansed by a scrubbed personnel with antiseptic solution.
Sterile Disposable Surgical Drape
Where the eye is concerned, in todays world the lashes

do not have to be cut for intraocular surgery. However,
whenever this is not done, then a plastic surgical disposable sterile drape is used over the eyes. This has a
gummy on the undersurface, keeping the eyes open the
surgeon places the gummy directly on the cornea and
keeps the lashes turned out so that they could stick to
the gummy surface and keep out of the surgical field.
The drape used in the ophthalmic field manufactured
by Dr Agarwals Pharma is also equipped with a drainage
bag. So, once the drape is stuck to the patients eye, the
central plastic over the palpebral fissure is cut open with
sterile scissors after the surgeon has scrubbed and
changed.
A whole 20 cc of sterile refrigerated 4C Ringer lactate
fluid is squirted over the eye, to carry out a thorough
cleaning procedure as well as to produce cryoanalgesia.
The surgery can now be started. This cleaning process is
found to be very necessary for a clean fornix and conjunctival sac.
STERILIZERS
Methods of Sterilization
For a very long time we had no idea that sterilization is

the basis of surgical correction, after all performing the
best of surgery though introducing harmful microbes
could mar the effects of surgery irreparably. With the
advent of the autoclave in 1884 we got to know a lot of
details. However, most surgical ward history can be
detailed as that before Lister and the era after Lister as

this one person was responsible in explaining antiseptic
surgery as we understand it today.
Terminology
To better understand this vast and varied aspect of

surgery, first let us understand the terms and conditions
often used.
Sterilization is a process used to achieve sterilityan

absolute term meaning the absence of all viable microorganisms.
Disinfection is a process which reduces the number of
contaminating microorganisms, particularly those liable
to cause infection, to a level which is deemed no longer
harmful to health.
Antisepsis is used to describe disinfection applied to
living tissue such as a wound.
Cleaning is a soil-removing process which removes many
microorganisms. The reduction in contamination by
cleaning processes is difficult to quantify other than
visually.
Decontamination is a general term for the treatment used
to make equipment safe to handle and includes microbiological, chemical, radioactive and other contamination.
Sterilization
An article may be regarded as sterile if it can be demonstrated that there is a probability of less than I in a million
of there being viable microorganisms on it.
Methods Five main methods are used for sterilization.

Head a widely used method needs to reach temperatures above 100C to ensure bacterial spores are killed.
Moist heat is more effective than dry as it coagulates
and denatures the protein, where water participates in
the reaction. This requires 121C for 15 min with moist
heat.
Temperatures above that of boiling water can be
attained more easily by raising the pressure in a vessel,
this is the principle of the autoclave. At sea level water
would boil and produce steam at 100C, increasing the
pressure to 2.4 bar would produce steam at 125C and
increasing to 3 bar at 134C. However, at subatmospheric
pressures this temperature would fall, thus at higher
altitudes water will boil at lower temperatures.
Sterilization
1. Quality of steam for sterilization Steam is non-toxic

and non-corrosive, though for sterilization it should
also be saturated, which means it should hold all the
water it can hold. It must also be dry, so it should not
contain water droplets. This has a greater lethal action
and is quicker in heating up the article to be sterilized.
When dry saturated steam meets a cooler surface
it condenses into a small amount of water and
liberates latent heat of vaporization. The energy
available from this latent heat is considerable. For
example, 6 liters of steam at a temperature of 134C
will condense into 10 ml of water and liberate 2162 J
of heat energy. By comparison less than 100 J of
heat energy is released by the sensible heat from air
at 134C to an article in contact with dry heat.
Steam at a higher temperature than the corresponding pressure would allow is referred to as
superheated steam and behaves like hot air. Steam
with water droplets is called wet steam and is less
efficient.
2. Types of steam sterilizers
A. Sterilizers for porous loads For linen, and wrapped
instruments, so air could get trapped in the textiles
used. Thus this type of sterilizer should have a
vacuum-assisted air removal stage to ensure that
adequate air is removed from the load before
admission of steam. The vacuum pulsing of air
also ensures that the load is dry on completion of
cycle.
B. Sterilizers for fluids in sealed containers Must have
a safety feature to ensure that the door cannot be
opened till the temperature in the glass containers
has fallen below 80C. Otherwise the thermal
stress of cold air on opening the door may cause
the bottles to explode under pressure.
C. Sterilizers for unwrapped instruments and
utensils These should not be used for wrapped
articles, recommended for dental clinics and
LASIK stations.
D. Laboratory sterilizers Culture media in containers,
laboratory glassware and equipment may be
contaminated, thus proper cleansing is necessary
before sterilization.
3. Monitoring of steam sterilizers Every load every day
every time needs monitoring of some important physical measurements.
Temperature
Pressure
Time with thermometers.
25
Detailed tests are undertaken with temperaturesensitive probes (thermocouples) inserted into standard test packs. Though most indicators show color
change on reaching particular temperatures.
Biological indicators comprising dried spore suspensions of a reference heat-resistant bacterium
Bacillus stearothermopiles, are not used for routine
testing. Although spore indicators are essential for
low-temperature gaseous processes in which the
physical measurements are very little to kill spores or
not reliable. Most often used for ethylene oxide
sterilization.
Bowie-Dick test monitors penetration of steam into
wrapped pack and detects uneven steam penetration
by a bubble of residual air in the pack.
Dry heat causes a destructive oxidation of the
essential cell constituents. Thus killing spores here
requires 160C for 2 hours. This may also cause
charring of paper, cotton, organic material.
4. Types of sterilization by dry heat
A. Incineration: Most cities around the world have
made it mandatory for most hospitals to have
incinerators in their campus for efficient waste
disposal where contaminated materials like dressings, sharp needles and other clinical wastes. The
high temperatures reached kills all organisms and
disposes by charring and burning the material.
B. Red heat: Diathermy in ophthalmic hospitals
would be done by burning a loop over a flame,
this would sterilize as well as cauterize the bleeding
vessel. However, this is still used to sterile loops,
wires, points of forceps. It is a still very much used
in emergency situations.
C. Flaming: Inoculating loops and needles are sometimes treated by immersing them in methylated
spirit and burning off the alcohol, though this does
not produce a sufficiently high temperature for
sterilization. This is also done for sterilizing drums
and trays over which sterile linen is placed. Once
again this is not totally sterile as spores may persist
over the short-term flame that is produced with
alcohol.
D. Hot and sterilizer: Oil, powders, carbon steel
instruments, and empty glassware laboratory
dishes are sterilized with hot air sterilizers, though
the over-all heating up and cooling may take
several hours.
E. Microwave sterilizer: This is the latest in roads into
sterilizers and can offer better results than hot air
26
sterilizers with shorter time spans. Within 10

minutes the material can be sterilized. However,
because of the high temperatures reached it is not
very good for organic material or plastics. Very
good for microwave transparent material like glass.
5. Factors influencing sterilization by heat would
include
A. Temperature and time: They are inversely related,
i.e. shorter time higher temperatures, holding time
is important loading and cooling time would make
the total time much longer (Table 3.1).
Table 3.1: Relationship between temperature and time
Process
Temp (inC)
Hold time (min)
Dry heat
160
170
180
120
60
30
Moist heat
121
126
134
15
10
3
B. Microbial load: The number of organisms and

spores affects the rapidity of sterilization. Thus, it
is better to go through vigorous cleaning
procedures before sterilization of products.
Ionizing radiation Both beta (electrons) and gamma

(photons) irradiation are employed industrially for the
sterilization of single use disposables.
All accelerated electrons are lethal to living cells, that
includes, g-rays, b-rays, X-rays. Bacterial spores are the
most resistant. Sterilization is achieved by the use of highspeed electrons from a machine such as a linear
accelerator or by an isotope source such as cobalt-60, a
dose of 255 kGy is generally adequate, making this an
industrial process. It is used for single use prepackaged
items like plastic syringes and catheters.
Filtration Filters are used to remove bacteria and other
larger organisms from liquids that are liable to be spoiled
by heating. Though virus can crossover they are felt to
be unimportant.
Filters using pore size of less than 0.45 microns can
render fluids free of bacteria. It is used in the preparation
of toxins and thermolabile parenteral fluids such as
antibiotic solutions, radiopharmaceuticals, and blood
products. Viruses and some bacteria like mycoplasmas
can pass through pore size of less than 0.22 microns.
Filter materials could be unglazed ceramic Chamberland filters, asbestos Seitz filters and sintered glass filters.
Though now membrane filters are usually used made of

cellulose esters or other polymers.
Sterilant gases Ethylene oxide is used for sterilization

of plastics and other thermolabile material. Formaldehyde in combination with subatmospheric steam is more
commonly used in hospitals for reprocessing thermolabile
equipment. Both processes are toxic and carry hazards
to user and patient.
1. Ethylene oxide: Highly penetrative, non-corrosive and
microcidal gas which is used to in industry for single
use, heat-sensitive medical devices such as prosthetic
heart valves and plastic catheters. Ethylene oxide
sterilization is usually carried out at temperatures
below 60C in conditions of high relative humidity.
To ensure sterility, material should be exposed to a
gas concentration of 700 to 1000 mg/l at 45 to 60C
and a relative humidity above 70 percent for about 2
hours. Care must be taken because of toxicity to
personnel, flammability and explosion risk. The
sterilized product must be aerated to remove residual
ethylene oxide before it can be safely used on the
patient, and turn round time is consequently slow.
Some recommendations for boosting infection
control as well as cut costs on EO sterilization :
Cleaning is a necessary and important activity
before sterilization. I feel that you need to adopt
standardized and effective cleaning method.
Further the items cleaned have to be dried as any
wet item will react with ethylene oxide and the
efficacy may be reduced.
The items have to be packed in one of the three
materials: linen, paper or plastic. Each has its
advantage but the limitation is the period that you
can store these sterilized items. You can use plastic
bags which are of a proper grade and store the
product up to one year after sterilization.
The sealer used for sealing packs is inappropriate
if the heating is too weak for the packaging
material used. This results in small holes in pack
after sealing. An impulse heat sealer capable of
sealing at higher temperatures.
A safe EO machine which can complete the
process of aeration within all items can be used
directly without any further handling.
Aeration is a natural process which can be hastened by installing an aerator.
2. Low temperature steam and formaldehyde A combination process of steam generated at subatmospheric
Sterilization
pressure 70 to 80C and formaldehyde gives an effective sporicidal process. It is appropriate for heatsensitive articles that can resist temperatures of 80C.
3. Propylene oxide One of the latest and new techniques is the use of propylene oxide which is a microcidal gas. It has a similar use and toxic effect like
propylene oxide.
Sterilant liquids Glutaraldehyde is generally the least

effective and most unreliable method.
Disinfection
Disinfection is applied in circumstances where sterility is

unnecessary or impractical, like bed-pans, eating utensils,
bed linen and other such items. Similarly the skin around
the site for an invasive procedure should be cleansed to
reduce chances of wound infection.
Cleaning
Thorough cleaning is a prerequisite for successful disinfection and is a process of disinfection by itself. This
can be enhanced by ultrasonic baths given to the instruments to remove dried debris.
Methods
Heat Steam or water could be used

1. Moist heat is the first method of choice, can be precisely controlled, leaves no toxic residues and does
not promote the development of resistant strains.
Washing or rinsing laundry or eating utensils in water
at 70 to 80C for a few minutes will kill most nonsporing microorganisms present. Similarly, steam
maintained at subatmospheric pressure at 73C is
used in low temperature steam disinfectors in hospitals
to disinfect thermolabile reusable equipment.
2. Boiling: Exposure to boiling water for 20 min achieves
highly effective disinfection, although this is not a
sterilization process it can be useful in emergencies if
no sterilizer is available.
Ultraviolet radiation It has limited application for disinfection of surfaces, some piped water supplies but lacks
penetrative power, however newer modifications in use
with ozone treatment plants is very effective in disinfection.
This is a low-energy, non-iodising radiation with poor
penetrating power that is lethal to microorganisms under
optimum conditions. The shorter UV rays that reach the
earths surface in quantity have a wavelength of about
27
290 nm, but even more effective radiation of 240 to 280

nm is produced by mercury lamps. It is used in the
treatment of water, air, thin films and surfaces such as
laboratory safety cabinets.
Gases Formaldehyde is used as a fumigant though it

does not have an all pervasive effect. Traditionally formaldehyde gas was used to disinfect rooms previously
occupied by patients with contagious diseases such as
smallpox. It is still used for disinfection of heat-sensitive
equipment, however its efficacy is questionable with
better products like Bacillocid available.
Filtration Air and water supplied to operation theatres
and other critical environments are filtered to remove
hazardous microorganisms, though viruses cannot
remain out altogether. However, they are considered
harmless in these environments.
A properly installed high efficiency particulate air
(HEPA) filter achieves 99.9 percent or better resistance
to particles of 0.5 microns and can produce sterile air at
the filter face.
Chemical Several chemicals with antimicrobial properties are used as disinfectants.
Antiseptic can be regarded as a special kind of
disinfectant which is sufficiently free from injurious effects
to be applied on the surface of the body, though not
suitable for systemic or oral administration.
Some would restrict the use of antiseptic preparations
applied to open wounds or abraded tissue and would
use the word skin disinfection for removal of organisms
from hands and intact skin surfaces.
1. Factors influencing the performance of chemical
disinfectants
A. The concentration of the disinfectant: The
optimum concentration required to produce a
standardized microbial effect in practice is
described as the in-use concentration. Care must
be taken in preparing accurate in-use
concentrations while diluting product. Accidental
or arbitrary over dilution may result in failure of
disinfection.
B. The number, type and location of microorganism:
The velocity of the reaction depends upon the
number and type of organisms present. In general
gram-positive bacteria are more sensitive to disinfection than gram-negative bacteria. Mycobacteria
and fungus are resistant while spores are highly
resistant, while viruses are susceptible.
Glutaraldehyde is highly active against bacteria,
viruses and spores. Other disinfectants such as
28
hexachlorophene have a relatively narrow range

of activity, predominantly against gram-positive
cocci.
C. The temperature and pH: Some disinfectants are
more active or stable at a particular pH. Though
glutaraldehyde is more stable under acidic
conditions its microbial effect is seen better when
the pH is 8.0
D. The presence of organic or other interfering
substances: Disinfectants can be inactivated by
hard tapwater, cork, plastics, blood, urine, soaps
and detergents, or other disinfectants. Information
should be sought from the manufacturer or from
reference authorities to confirm that the
disinfectant will remain active in these
circumstances.
2. Common chemicals in use
A. Alcohols: Isopropanol, ethanol, and industrial
methylated spirit have optimal bactericidal activity
in aqueous solution at concentrations of 70 to 90
percent and have little bactericidal effect outside
this range. They have limited activity against
mycobacteria and are not sporicidal. Action
against viruses is generally good. Because they
are volatile, alchohols are recommended as rapidly
drying disinfectants for skin and surfaces. However
they may not achieve adequate penetration and
kill, particularly if organic matter such as blood or
other protein-based contamination is present.
Alcohols are suitable for physically clean surfaces
such as washed thermometers or trolley tops but
not for dirty surfaces. Care must be taken when
used on the skin in conjunction with diathermy
and other instances of flammable risk. Alcohols
with chlorhexidine or povidone-iodine are good
choices for hand disinfection, they are applied to
the dry skin often with added emollient to
counteract the drying effect.
B. Aldehydes: Most aldehyde disinfectants are based
on glutaraldehyde or formaldehyde formulations,
alone or in combination. Glutaraldehyde has a
broad spectrum action against vegetative bacteria,
fungi, viruses, but acts more slowly against spores.
It is often for equipment such as endoscopes that
cannot be sterilized or disinfected by heat. It is an
irritant to the eyes, skin and respiratory mucosa,
and must be used with adequate protection of staff
and ventilation of the working environment. It
must be thoroughly rinsed after treated equipment
with sterile water to avoid carry-over of toxic
residues and recontamination. The alkaline buffered solution is claimed to remain active for several
days, but this will vary depending on the in-use
situation, including the amount of organic
material.
C. Biguanides (chlorhexidine): This is commonly
used for disinfection of skin and mucous
membranes. It is less active against gram-negative
bacteria such as Pseudomonas and Proteus sp and
in aqueous solution has limited virucidal,
tuberculocidal and negligible sporicidal activity. It
is often combined with a compatible detergent for
handwashing or with alcohol as a handrub.
Chlorhexidine has low irritancy and toxicity and
is effective even on exposed healing surfaces. It is
inactivated by organic matter, soap, anionic
detergents, hard water and some natural materials
such as cork liners or bottle closures.
D. Halogens (hypocholrites): These broad-spectrum
inexpensive chlorine-releasing disinfectants are
that of choice against viruses. For heavy spillage
such as blood, a concentration of 10,000 ppm of
available chlorine is recommended.
These are inactivated by organic matter and
corrode metals, so that contact with metallic instruments and equipment should be avoided. The
bleaching action of hypochlorites may have a
detrimental effect on fabrics and should not be
used on carpets.
Chlorine-releasing disinfectants are relatively
stable in concentrated form as liquid bleach of as
tablets (sodium dichloroisocyanurates) but should
be stored in well-sealed containers in a cool dark
place. On dilution to the required concentration
for use, activity is rapidly lost.
Hypochlorites have widespread application as
laboratory disinfectants on bench surfaces and in
discard pots. Care should be taken to remove all
chlorine-releasing agents from laboratory areas
before the use of formaldehyde fumigation to
avoid the production of carcinogenic reaction
products.
Iodine: Like chlorine, iodine is inactivated by
organic matter and has the additional disadvantage of staining and hypersensitivity. The
iodophors which contain iodine complexed with
an anionic detergent of povidone-iodine a watersoluble complex of iodine and polyvinyl pyrrolidone are less irritant and cause less staining.
Aqueous and alcohol-based povidone-iodine
Sterilization
preparations are used widely for skin and ocular

disinfection as well as other mucous membrane
disinfection.
E. Phenolics: These have been widely used as general
purpose environmental disinfectants in hospital
and laboratory practice. They exhibit broadspectrum activity and are relatively cheap. Clear
soluble phenolics have been used to disinfect
environmental surfaces and spillages if organic soil
and transmissible pathogens may have been
present. As hospital disinfection policies are rationalized, phenolics are being replaced by detergents
for cleaning and by hypochlorites for disinfection.
Most phenolics are stable and not readily inactivated by organic matter, with the exception of the
chloroxylenos (Dettol) which are also inactivated
by hard water and not recommended for hospital
use. Phenolics are incompatible with cationic
detergents. Contact should be avoided with rubber
and plastics, such as mattress covers, since they
are absorbed and may increase the permeability
of the material to body fluids. The slow release of
phenol fumes in closed environments and the
need to avoid skin contact are other reasons for
care in use of phenolics.
The bis-phenol hexachlorophane has particular
activity against gram-positive cocci, and has been
used in powder or emulsion formulations as a skin
disinfectant, notably for prophylaxis against staphylococcal infection in nurseries. There has been
some concern about the possible toxic effect of
absorption across the neonatal skin barrier on
repeated exposure. An alternative, which has been
used in the control of methicillin-resistant Staph.
aureus outbreaks is triclosan.
F. Oxidizing agents and hydrogen peroxide: Various
agents, including chlorine dioxide, peracetic acid
and hydrogen peroxide, have good antimicrobial
properties but are corrosive to skin and metals.
Hydrogen peroxide is highly reactive and has
limited application for the treatment of wounds.
G. Surface active agents: Anionic, cationic, non-ionic
and amphoteric detergents are generally used as
cleaning agents. The cationic (quaternary ammonium compounds) and amphoteric agents have
limited antimicrobial activity against vegetative
bacteria and some viruses but not mycobacteria
or bacterial spores. Quaternary ammonium compounds disrupt the membrane of microorganisms,
leading to cell lysis. Care must be taken to avoid
29
overgrowth by gram-negative contaminants and

inactivation by mixing cationic and anionic agents.
Disinfection may be enhanced by appropriate
combination of a surface active agent with disinfectant to improve contact spread and cleansing
properties.
Quality Control
Every method used must be validated to demonstrate

microbial kill. With heat and irradiation a biological test
may not be required if the physical conditions can be
proved to have reached their ultimate design.
D value The D value or the decimal reduction value is

the dose that is required to inactivate 90 percent of the
initial population. When the time required or the dose
required to reduce the population from 1 000 000 to 1
00 000 is the same as the time or dose required to reduce
the population from 1,00,000 to 10,000 the D value
remains constant over the full range of the survivor curve.
Extending treatment beyond the point where there is one
surviving cell does not give rise to fractions of a surviving
cell but rather to a statement of the probability of finding
one survivor. Thus, by extrapolation from the experimental date it is possible to determine the lethal dose
required to give a probability of less than 1 in 10,00,000
which is required to meet the pharmacopoeial definition
of sterile.
Factors Influencing Resistance
Many factors affect the ability of the microorganism to

withstand lethal procedures of sterilization. This in fact is
the reason why we need to keep updating ourselves as
to the methods of sterilization and their efficacies. This
also happens to be the reason why living creatures are
able to withstand high amounts of torture only to make
sure their breed lives on. Bacteria are not that much
different from us in this intrinsic need to propagate, grow
and leave their legacy behind. Still we need to be on top
of them to allow them to grow where we need them and
the operating room is definitely not a place we need any
of them at all. Here are some of the reasons why these
bacteria do withstand our torture.
Species or strain of microorganism As usual the spores

are more resistant than vegetative bacteria or viruses.
Though some strains of species have wide variations.
Enterobacteriaceae D values at 60C range from a few
minutes (E. coli) to 1 hour (Salmonella senftenberg). The
typical D value for Staphylococcus aureus at 70C is less
30
than I min compared with 3 min for Staph. epidermidis.

However, an unusual strain of Staph. aureus has been
isolated with a D value of 14 min at 70C. Such variable
could be attributed to the morphological and physiological changes such as alterations in cell proteins or
specific targets in the cell envelope affecting permeability.
Thus we should not understand the inactivation data
for one disease forming organism would withstand by
another. Creutzfeldt-Jakob disease is a highly resistant
agent requiring six times the normal heat sterilization cycle
(134C for 18 min).
Physiological stage Organisms grown under nutrientlimiting conditions are typically more resistant than those
grown under nutrient-rich conditions. Resistance usually
increases through the late logarithmic phase of growth
of vegetative cells and declines erratically during the
stationery phase.
Ability to form spores Bacterial endospores are more
resistant than fungal spores, some of them are used as
bacterial indicators especially for ethylene oxide sterilizers
to monitor their efficacy. Disinfection has no efficacy
where spores are concerned.
Suspending menstrum Microorganisms occluded in
salt have greatly enhanced resistance to ethylene oxide,
the presence of blood or other organic material will reduce
the effectiveness of hypochlorite solution. Thus suspended particles will alter efficacy of various techniques.
Number of microorganisms Quite obviously the initial bio-burden the more extensive must the process of
sterilization be to achieve the same assurance of sterility.
Sterilization and Disinfection Policy
All hospitals should go through a rigmarole of infection

control and agree on a particular policy to be followed
uniformly by all concerned in this infection control team.
This should be headed by the chief surgeon and each
one must report to the leader of the team everyday.
It has been noticed over centuries of medical practice
when a surgical team gets to do routine surgeries every
day for many days and years, a kind of apathy sets into
the system and somewhere someone lapses. These
instances have been the most common cause for infection. To avoid such lapses the infection control team
should meet each week to update themselves on the latest
happenings in their hospital and to bring to the notice
such lapses so that a tightening of procedures can be
applied. At each lapse the chief surgeon must be held
responsible for the actions of his or her team.
All members of the team must familiarize themselves

with the items to be sterilized and the chemicals necessary
to do so. A microbiologist should be included in this team
as they alone can monitor the efficacy of the said processes. Along with should also be a pharmaceutical
person who has full knowledge of the various chemicals
used, their action and the efficiency in said matters. It is
very instrumental to include these persons on the
infection control team of a hospital.
The hospital policy should be common and should
include:
The sources to be sterilized (equipment, skin, environment, air, water, personnel) for which a choice of
process is required to be commonly accepted by the
team for infection control.
The processes and products available for sterilization
and disinfection must be made available for all to see
and inspect. An effective policy may include a limited
number of process options, restrictions on the range
of chemical disinfectants eliminate unnecessary costs,
confusion and chemical hazards.
The category of process required for each item,
sterilization for surgical instruments and needles, heat
disinfection for laundry, crockery, bed-pans, cleaning
of floors, walls, furniture and fixtures.
The specific products and method to be used for each
item of equipment, the site of use and the staff
responsible for the procedure. These should all be
earmarked in a record so that one can get back to the
lapse when it happens.
Effective implementation of the policy requires liaison
and training of staff and updating the policy. Safety considerations for staff and patients require a careful assessment of specific procedures to minimize risks.
The staff for implementation of these processes must
wear protective gear where necessary. Gloves, aprons,
caps and masks must be included in the policy. Where
dangerous gases are used eye goggles similar to swim
goggles can be used to protect the eyes from the noxious
gases.
For proper sterilization control, it is important to go
back into every case that gets infected to try and pry and
find out what was the reason for the infection. This can
effectively be done by the weekly meeting of the infection
control team where every one tries to pitch in their inputs.
Staff should not be penalized for accepting their wrongdoings, because if they are penalized they will not accept
the cause of the infection next time it occurs. The staff
should be goaded into performing better by putting the
patients best interests in view and not for witch hunting
and blaming.
Sterilization
CULTURE RATE
The most important mechanism for the proper functioning of an operation theatre is the fact that no organism
should grow from this area. To find out whether an
organism is growing or not we need to make sure it is
present or not, that can effectively be done by growing it
on a culture media. Some of the most common culture
media used in hospitals is discussed here.
MacConkeys Agar
To make this culture plate (Fig. 3.27) is simple enough.

According to directions 51.5 gm of the powder made
available through Himedia Laboratories is dissolved in
1000 ml of distilled water. This is allowed to boil till the
powder is completely dissolved and the fluid has boiled
for over 15 minutes, thus sterilizing the fluid further. It
could be still sterilized by autoclaving though most
hospitals find 15 minutes of boiling to suffice in its
sterilization.
This culture medium contains:
Peptic digest of animal tissue
Peptone
Lactose
Bile salts
Sodium chloride
Neutral red
Agar
17 gm / lit
3
10
1.5
5
0.03
15
At a final pH at 25C of 7.1
Alternately if the ready-made powder is not available

then the following procedure can be applied to the abovementioned ingredients.
Fig. 3.27: MacConkeys blood agar culture plates
31
Base solution Dissolve agar in 500 ml of distilled water

by autoclaving at 121C for 20 minutes. Dissolve the
peptone, bile salts and sodium chloride in the remaining
500 ml of distilled water, and bring the solution to boil.
Combine the two solutions mixing thoroughly. Dissolve
the lactose and adjust the pH to 7.2. Distribute in screwcapped bottles and sterilize with autoclaving at 121C
for 15 minutes.
Dissolve 1 gm of neutral red in distilled water and
make up the volume to 100 ml. Heat the solution in
steam at 100C for 30 minutes.
Dissolve 0.1 gm of crystal violet in distilled water and
make up the volume to 100 ml. Heat the solution in
steam at 100C for 30 minutes.
To 200 ml of the base solution, melted and cooled to
about 60C add aseptically 0.6 ml of the neutral red
solution and 0.2 ml of solution with crystal violet. Mix
well and distribute into sterile Petri dishes.
Incubate the plates at 37C for 24 hours (Figs 3.28 to
3.30) and examine for contamination. Inoculate four
plates from the following stock culture Salmonella typhi,
Escherichia coli, a mixture of Salmonella typhi and E.
coli and Shigella flexneri. This will prove the efficacy of
the culture media prepared and now it can be poured
into petri dishes and refrigerated to be used on need for
culture plates. It is advisable to keep them for 24 to 48
hours and to keep making fresh batches very often.
Nutrient Agar
A general purpose medium for the cultication of microorganisms and a base for enriched or special purpose
Fig. 3.28: Culture specimen taken using sterile

swab stick from the instrument table
32
Fig. 3.29: Culture specimen taken using sterile

swab stick from the operation table head rest
Fig. 3.30: Culture specimen taken using sterile swab stick

being streaked on the MacConkeys blood agar culture plate
media. It can be made very simply by the powder available from Himedia laboratories by dissolving 28 gm of
powder in 1000 ml of distilled water and boiling for 15
minutes. This would also sterilize the medium and it is
ready for use after cooling. The powder contains:
areas sterilized or disinfected. Some of the quality checks

necessary to be carried out are
Peptic digest of animal tissue

Sodium chloride
Beef extract
Yeast extract
Agar
At 25C the pH is 7.4
5 gms/lit
5
1.5
1.5
15
Alternately if the powder is not available the separate

entities can be taken, mixed and steamed for 2 hours.
The pH should be adjusted first to 6.8 then clear the
fluid with egg albumin. Filter and bottle. Autoclave at 15
1bs pressure for 20 minutes or steaming for 30 minutes
each day on three successive days.
Blood Agar
An enriched medium for general use in routine cultivation of the more delicate microorganisms like Neisseria
meningitidis, N. gonorrhoeae and Diplococcus pneumoniae. The medium also serves as an indicator of
hemolysin production by bacteria.
It is very simple to make. Add 6 to 10 percent defibrinated blood to melted nutrient agar and cool to 45 to
60C. Pour plate or slant, incubate 24 hours to prove
sterility.
STERILIZATION CONTROL
The infection control team which consists of a microbiologist must take regular samples from the different
Plate Test
One of the easiest to perform and tells us quite a bit

about the cleaning tactics used for the particular room.
This test would not be so effective in open areas but is
quite reliable for closed areas like operating rooms.
For closed rooms Where operating rooms are concerned once we have assured ourselves there is no contaminated air coming in, with door closers, air curtains
and filtered air-conditioned ducting, cleaning the room
with detergents and disinfectants should clear the air of
all bacteria. However this does not remain so through
out the day, and it is noticed that after a few surgeries
due to human beings inside the operating rooms bacteria
do escape to contaminate the air. This can be effectively
controlled by keeping a watch on the cleaning procedures
and making sure a disinfectant mop is used after every
procedure and on every item of the operating room.
However, testing for the efficacy of the cleaning procedures is devised by the PLATE TEST. Here a sterile
bowl is used with sterile water and kept in the concerned
room for 20 minutes. Should there be bacteria in the
room they would settle down on the surface of the bowl
of water. Thus skimming the surface a few drops are taken
and placed on a Petri dish with culture media on it. This
is incubated at 38C for 48 hours and if this grows bacteria
then we know our disinfectant procedures were not
enough and we need to plough ourselves further. If it is
negative then we can proceed with the same policy. This
test should be ideally carried out every day, before every
procedure in every room of the operating area.
Sterilization
For open areas Lounges where patients wait or the

outside arenas are to be cleansed as well, if we would
like to have a tight infection control in the operating area.
After all these areas lead to the operating areathe most
pious sanctum sanctorum of the hospital edifice.
The plate test is carried out every day every few hours,
and an optimum time interval given to the hospital authorities where it can be stated that every four hours the
hospital lounges should be cleaned with disinfectant to
maintain a clean bacteria-free atmosphere. This can now
be controlled by taking plate test samples every four hours
before cleaning procedures are done and making sure
the tests remain negative for growth in all the tests taken.
If not the program needs to be revised and the hours
shortened.
This test should also be carried out in the consultation
areas and optimum time intervals for cleaning prescribed
by the microbiologist on the infection control team.
Culture Test from Walls, Floor, Fixtures, Furniture
Everyday the different areas should be taken for culture,

it is advised to take eight different areas for culture from
every room everyday. Methodology for taking culture is
to take a moist swab, by dipping a cotton tip applicator
in sterile water and rubbing it in a streak fashion on the
culture plate.
The culture plates are made in Petri dishes about 3
inches in diameter. The back surface of the Petri dish
can be stroked with a marker pen and each culture plate
divided into eight parts.
One culture plate can be ear marked for each room,
and 8 objects from the room can be cultured. It is preferrable to always include the floor, of the room however
different parts of the floor can be taken each day to ensure
proper cleaning and disinfectant use. Other objects that
can and should be cultured for are the fans, airconditioners, lights, walls, tables, chairs, stools and all
the equipment present in that particular room. Like
Boyles apparatus, phaco machines, etc.
All Fluids to be Cultured
All fluids used in the operating room must be sent for

culture tests, sometimes this becomes less possible as the
fluid is too little and necessary for parenteral application.
However, every batch of fluids used can be sent for
culture tests. This may not grow positive however its not
growing positive itself is an indication of the efficacy of
the program. This sets aside any debate that the fluid
may have contained bacteria.
33
Of special importance is fluids used for intraocular

use, or for intravenous use. As soon as each IV bottle is
opened the first few drops from the IV set can be placed
on a culture plate for incubation.
Many eye surgeons from our subcontinent have grown
E. coli from the Ringer lactate used intraocularly.
However, most often this has happened after a tragedy
of multiple eyes have succumbed to postcataract surgery
infection. Thus by performing this simple step we may
be able to thwart further mishaps.
Should any one batch of fluids be found to be positive
it is a good idea to report the matter so that others can
be forewarned and to take every bottle from that batch.
All Fluids used Parenterally to be
Checked for pH Value
Great importance should be given to the pH of fluids

inside the body especially where the eye is concerned.
We presume that all fluids marked for parenteral or
intraocular use come at the pH close to 7.4, however, it
is alarming to note the amount of times I have personally
seen surgery go wary only due to the fact that the pH
was either 5.6 or above 8. This can produce havock on
the patients cornea.
In 1992 over 300 cases were reported lost due to hazy
opaque corneas following extracapsular cataract surgery
in some states of India. This was followed by a widespread
search for the culprit. What was found was alarming to
all concerned, a balanced salt solution (BSS) was sold in
small bottles. It was learned that this solution carried an
alkaline pH, because while cleaning the glass bottles the
last rinse of soap solution (BSS) was not totally washed
out and the remaining soap solution left behind an
alkaline pH which recked havoc on the cornea producing
total blindness.
It took the investigating authorities over six months to
procure this data and cause by which time multiple
surgeries had been carried out with much devastation.
A simple technology to avoid such future catastrophies is to check out the pH on table before the surgery. A
few drops of the fluid can be dropped on a simple litmus
strip and one minute later the color change noted with a
rough estimate of the pH value noted.
This should be ideally carried out for all cases.
Specialized Equipment Cultures
Special tests are performed for special machines, like the

one available for the ethylene oxide sterilizer.
Biological chemical indicator One or more biological

chemical indicator can be placed in the steam or ethylene
34
oxide test packs and the process passed through the

sterilization cycles. If used to monitor a 270F steam
flash cycle, place a wire mesh bottom instrument tray
and then proceed.
After sterilization processing has been completed, allow
the biological chemical indicator to cool until safe to
handle and open. Remove the indicators and allow to
cool an additional 10 to 15 minutes. Observe chemical
process exposure indicator on vial label to verify color
change corresponding to sterilization cycle, i.e. ethylene
oxide turns gas process indicator to gold and steam turns
the steam process indicator to brown.
If chemical process indicator is unchanged, exposure
to the sterilization process may not have occurred. Check
the sterilization process.
If the chemical process exposure indicator on the vial
label did change to the proper color and the indicator
has cooled to touch, firmly seal the biological indicator
by pushing the cap to close till the cap reaches second
blue bar on the vial label.
Crush the inner ampoule from the outside wall of the
plastic vial to ensure that the growth medium is released
from the crushed ampoule and is in contact with the
spore disk.
Place the activated indicators in an incubator and
incubate it at 37C for EO sterilization and 55C for steam
sterilization.
If there is a color change in the medium from deep
blue to bright yellow and turbidity is evident, it means
there is a positive growth. Indicators positive for growth
will often be evident prior to maximum recommended
incubation time, but indicators not evidencing growth
mtiust be allowed to incubate for at least 24 hours (steam)
and 48 hours (ethylene oxide) to assure confidence in
the negative reading.
When, Where and Why to Use Biologicals
When?
Once a day in every sterilizer
Once a week in steam sterilizer cycle used
Every steam load with implants
Every EO load.
Three consecutive times before using new sterilizer and
after repairs.
Where?
All sterilization processes.
Why?
To challenge your sterilizers effectiveness
To assure load sterilization parameters were up to
standard.
Surgeons Hands Cultured
Right after scrubbing and ready for operation a surgeons

hands should be regularly swabbed and taken for culture
so that a close check can be carried out to the efficacy of
the cleaning and scrubbing solutions.
There are many surgeons who believe in different
technologies of scrubbing. While some would swear with
the pounding away of epithelial tissue by a brush others
would want to keep the epithelium intact at all times.
While some would swear with a last dip into alcohol,
others would keep alcohol well out of the way of surgeons
hands.
However, it has been seen that three times to lather
with soap and wash hands is a uniform tendency of most
surgeons.
Linen and Textiles Cultured
Efficacy of sterilization on the different linens and textiles

used in surgery should be tested by taking culture tests
from these items just after surgery.
Viscoelastics
Viscoelastics
iscoelastic substances are currently essential for

the successful performance of most of the
intraocular anterior segment surgery, especially
extracapsular cataract extraction and phacoemulsification
with an intraocular lens implantation. Viscoelastics substances are considered as the most important addition in
the armamentarium for microsurgery. Viscoelastic substances have revolutionised ophthalmic microsurgery
particularly cataract surgery. Balazs coined the term
viscosusrgery. Viscosurgery uses these agents to protect
tissue surfaces, to create and maintain spaces, to facilitate
intraocular tissue manipulations and to assist in
haemostasis. During the evolution of IOL surgery it was
observed that short contact between polymethyl
methacrylate of IOL and the fragile endothelial cells of
cornea could result in irreversible corneal damage leading
to persistent corneal oedema. Binkhorst et al had
recommended the air cushion technique to prevent the
danger of contact between polymethyl methacrylate
intraocular lens and the fragile endothelial cells of cornea.
Fechner reported the use of methylcellulose successfully
in intraocular lens implantations since 1976 to prevent
the rubbing of PMMA of IOL against the endothelium of
cornea. Sodium hyaluronate was used in the human eye
as a vitreous substitute for the first time in 1972. First
human studies of efficacy of hyaluronic acid were
performed by Robert Stegmann and further confirmed
and reported by Balazs et al in 1979. Ever since a variety
of viscoelastic substances have emerged.
PHYSICAL AND CHEMICAL PROPERTIES OF
VISCOELASTICS
Viscoelastic substances possess viscous and elastic

properties concomitantly. Viscoelastic substances are
excellent for protection of tissue surfaces by forming even
layers on the tissue or implant surfaces and act as ideal
coating agents. Space maintenance by viscous materials
is efficient resistance. However, the maintenance of space
with viscoelastic substances does not depend on the
outflow resistances, therefore, even effective in open
35
VP Gupta
chambers. Surface application of viscoelastic materials

maintains a stable irregular shape and is easily wiped off
when touching an obstancle. The usefulness of a
viscoelastic substance to protect tissue surfaces and for
space maintenance depends mainly on their physical
properties. The tolerance of viscoelastic substances within
the eye depends on their chemical composition. An ideal
viscoelastics substance should have the following
properties:
1. It should be inert and iso-osmotic.
2. Viscoelastic should have a high viscosity for
successful performance of various functions such as
maintenance of anatomic spaces, tissue protection,
intraocular tissue manipulations, lubrication and
haemostasis.
3. It should be free of corpuscular elements and clumps.
4. It should be sterile, non-inflammatory, non-pyogenic,
non-toxic and non-antigenic.
5. It should be reabsorbed without inflammation and
should not interfere in the wound healing.
6. It should be optically clear. Viscoelastics should not
impair the visibility inside anterior chamber.
7. Viscoelastics should possess pseudopasticity, i.e. the
ability to pass through a fine cannula, i.e. a 30 gauze
needle.
VISCOELASTIC SUBSTANCES
Currently used viscoelastics have been divided into two

broad types (a) cohesive viscoelastics having high cohesive characteristics, e.g. healon (1% NaHa), Healon GV
(1.4 Va Ha) (b) dispersive viscoelasticsThese are noncohesive viscoelastic. These materials adhere to ocular
surfaces. Dispersive viscoelastics provide a protective
coating for corneal endothelium without excessive
coakage from AC.
The following viscoelastic substances are described in
literature:
1. Hyaluronic acid
2. Methylcellulose-Hydroxypropyl methylcellulose
3. Chondroitin sulphate
36
4. Polyacrylamide
5. Collagenhuman placental collagen type IV
6. Poly TEGMATriethylene glycol monomethacrylate
Hyaluronic Acid (Sodium Hyaluronate)
It is a naturally occurring mucopolysaccharide. It consists

of a long unbranched chain of alternative N-acetyl-glucosamine and sodium gluconate. Hyaluronic acid is present
in abundance in vitreous humor and trabecular meshwork. Corneal endothelium is naturally covered with a
layer of sodium hyaluronate. It is an inert, totally transparent, non osmotic viscoelastic material composed of
98 per cent water and is highly viscous, 400,000 times
more viscous than saline. It is a viscoelastic with pseudophastic properties. It is not metazolised or degraded.
Healon(It contains sodium hyaluronate 1%) it is
derived from a natural source-rooster comb. It was the
first viscoelastic used in anterior segment surgery. Physical
properties are molecular weight 1-2 million daltons, viscosity 700000 centipoise, osmolarity 340 mOSM/kg.
storage 2-8C, pH 7.2, shelf life two years. It is available
in sterile, sealed 0.5 to 10 ml glass syringes. Blue tint
may be given to facilitate intraocular visualisation. It is
the viscoelastic most frequently used in cataract surgery
because of its characteristics and qualities during the
procedure.
DisadvantagesIt is very expensive, not available
universally and difficult to dilute hence relatively large
amount of the material may be left in the anterior chamber
and cause dangerous rise of intraocular pressure
postoperatively.
Healon GVIt is sodium hyaluronate 1.4 per cent.
The viscosity of healon GV is 10 times higher than
that of healon because of higher concentraction and
molecular weight.
AmviscIt contains sodium hyaluronate 1-1.4 per
cent. It is 20 times more viscous than chondroitin
sulfate
Amvisc plusIt is 1.6 per cent sodium hyaluronate.
Its molecular weight and viscosity is less than healon.
It is 30 per cent more viscous than amvisc.
Three per cent sodium hyaluronate (Amo vitrex)
is the highest concentration available. Its molecular weight is 0.5 million daltons and viscosity
30,000 cct, It has low cohesive properties.
Methylcellulose
Methylcellulose is a viscous, transparent, non-irritating,

water soluble compound. It is nearly inert chemically. It
is stable and can be sterilised by boiling. It does not

support the growth of micro-organisms.
Methylcellulose used for intraocular surgery is a
highly purified brand of medical use grade hydroxypropyl methylcellulose (HPMC). It is a synthetic
modification of methylcellulose. HPMC 2 per cent
is freely available commercially. The hydroxypropyl
and methyl groups replacing hydrogen groups
increase its hydrophilicity. The basic molecule is Dglucose. Two monomers of glucose combine to form
cellobiose, which differs from dextrose only in the
way the 2 monomers are stereochemically connected: in cellobiose the bonding is beta-glycosidic,
in dextrose alpha glocosodic. The human enzymes
are incapable of breaking cellobiose bonding. HPMC
is a dispersive viscoelastic agent. Its MW is 90000
Daltons. HPMC is less viscous than healon due to
low viscosity at zero shear rate 40000 PS (800020000). The dispersive nature causes better adherence of viscoelastic agent to the corneal endothelium
resulting in better protection of corneal endothelium
against fluid turbulence and lens fragments during
phacoemulsification. It lacks pseudoplastic characteristic and does not pass easily through 30 gauge
cannula. It predominantly protects tissues surfaces
against touch by implant, instruments, etc. It is a
non-physiological and non-metabolic substance consisting of large polymers.
Preparation
Preparation of 2 per cent hydroxypropyl methylcellulose

for intraocular use.
The medical use grade hydroxypropyl methylcellulose
of highest purity which is commercially available as
methocel E-4 M premium of Dow chemical corporation
is recommended. Dissolve 10 g of methocel E-4 M premium in 150 ml of boiling balanced salt solution (BSS).
Add 350 ml of icy BSS solvent. This 2 per cent HPMC
solution is stored in a refrigerator overnight at 0 to 10C
in lightly closed glass bottles. The preservatives like benzalkonium, chlorbutanol, thiomersal are not used because
of their endothelial toxic effects. However, addition of 5
mg of patent blue V (sulphan blue) has been
recommended. Next day the solution is warmed to 40C
to reduce its viscosity. The solution is now filtered through
a filter tube (pore size of 0.5 to 0.8 um). This filtration
procedure is necessary to remove crystalline complexes
which form corpuscular elements. The filtered solution is
poured into 3 ml glass vials and sealed with a rubber
Viscoelastics
stopper and aluminium cap and then sterilised by

autoclaving at 120C for 30-40 minutes. The solution is
also available in special pre-filled syringes. The main
disadvantage of pre-filled syringe is that usually great force
is applied to push later half of the solution in the anterior
chamber.
Advantages of HPMC
It is well-tolerated by corneal endothelium. It is cheap

and universally available. It can be easily prepared for
intraocular use. It can be autoclaved and resterilised.
Because of its highly hydrophilic and easily dilutable
property most of it can be easily irrigated from the eye.
The fate of the residual HPMC in the anterior chamber
after irrigation is not known. Fleming et al have shown
that methylcellulose inside the eye is harmless. According
to Fechner, if 20 per cent of what was injected into AC,
i.e. 0.5 ml of residual HPMC is left in AC, this is equivalent
to 2 mg of dry substance of methylcellulose, which is a
inert substances and did not cause any local or systemic
complication.
Contaminants/Particulate matter in HPMC
Rosen et al had raised serious concern about safety of

intraocular ocular use of hydroxypropyl methylcellulose
because of high density of particulate matter in the
solution. However, Mamose et al examined the number
of insoluble paprticles of verious sizes in one ml of 5
viscosurgical solutions and concluded that methylcellulose
solution had 10 times less particles of various sizes (1-30
mm or more in diameter) as compared to Viscoat, Amvisc
and Healon.
Systemic safety The process by which methylcellulose
is cleared from human body is till not known. However,
the doses used intraocularly are very small and most of
the solution is irrigated at the end of surgery. The residual
HPMC is clinically insignificant and unlikely to cause any
toxicity. Methylcellulose has long been used in the
preparation of injectable preparation of prednisolone
acetate and hydrocortisone acetate. Oral consumption
of large doses in soft ice creams is not known to cause
any toxicity.
Endothelial cell loss It is well-established that endothelial
cell loss with use of HPMC during IOL implantation is
lower in comparison to air. There is no statistically significant difference in the endothelial cell loss during IOL
implantation with Healon (20.7 +15.6) and 2 per cent
HPMC (18.1 +14.9%).
37
Disruption of blood aqueous barrier Fluorophotometric

studies have shown that the disruption of blood aqueous
barrier with 2 per cent HPMC in intraocular surgery is
similar to that caused by sodium chondroitin sulphate or
sodium hyaluronate.
Postoperative glaucoma Postoperative glaucoma is not
a common complication with 2 per cent HPMC. This has
been attributed to the hydrophilic nature and easy
dilutability of HPMC. However, the potential drawback
is the difficulty of completely removing HPMC due to its
dispersive nature, possibly resulting in an increased
postoperative IOP.
Chondroitin Sulphate
It is the naturally occurring glycosaminoglycan. It is a

sulphated and negatively charged viscoelastic substance.
It forms a better coating of positively charged IOL. It
reduces electrostatic interaction between IOL and
endothelial cells.
Disadvantages
1. It is not a pseudoplastic substanceextremely high

pressure is exerted for injection through a 30 G
cannula
2. Maintenance of anatomic spaces (AC depth) is poor
due to low viscosity of chondroitin sulphate 20 per
cent.
3. 50 per cent chondroitin sulphate solution damages
corneal endothelium due to hyperosmolarity
4. Its yellow colour affects transparency and visibility
through AC
ViscoatIt contains 3 per cent sodium hyaluronate
plus 4 per cent chondroitin sulphate. Its molecular
weight is 600000 daltons and viscosity at zero sheer
rate is 40000 CPS, as it is a dispersive viscoelastic
agent, it is a superior coating substance and is
superior to healon in preventing corneal
endothelial cell loss during phacoemulsificationGlasser 1989
OrcolonIt is the 4.5 per cent polyacrylamide
solution. It is a synthetic polymer. It is hydrophilic,
non-toxic and non-inflammatory. It has been
recalled from the market due to occurrence of
several cases of severe uveitis and glaucoma days
to weeks following surgery.
Poly TEGMAIt is a highly hydrophilic polymer
poly (triethylene glycol monoacrylate) a cross
linked gel. The new polymer poly TEGMA was
characterised by high biological tolerance after its
38
implantation into the anterior chamber of rabbits.

Poly TEGMA 40 per cent might be considered as
a potential viscoelastic material in humans.
Uses of Viscoelastic Substances
Viscoelastic substances are used in cataract surgery,

cornea grafting, glaucoma filteration procedures,
vitreoretinal surgery, strabismus surgery, lacrimal surgery,
evacuation of hyphaema and management of dry eye.
1. Viscoelastics in cataract surgeryUse of viscoelastics
have revolutionised the cataract surgery. Viscoelastics
have become indispensable in all forms of cataract
surgery. Viscoelastic substances are routinely used
intraoperatively in ECCE, phacoemulsification, nonphaco small incision cataract surgery and paediatric
cataract surgery with intraocular lens implantation.
Viscoelastics are also essential in secondary and scleral
fixated IOL surgery and IOL exchange or explantation
surgery. Viscosurgery uses viscoelastics to protect tissue
surfaces, to create and maintain anatomical spaces
to facilitate tissue manipulation in anterior chamber
and to assist in haemostasis. Various uses of
viscoelastics in cataract surgery are as follows:
a. Maintenance of deep anterior chamber during
surgical manipulation. Comparative studies have
demonstrated that 2 per cent HPMC, Healon,
Amvisc, and Viscoat are all effective in the maintenance of deep anterior chamber during various
stages of cataract surgery, e.g. during capsulotomy,
capsulorhexis, before nuclear expression, cortical
aspiration, insertion and manipulation of IOL,
cutting large anterior capsular flap, etc.
b. To combat vitreous upthrustall viscoelastics are
effective in controlling positive vitreous pressure.
High viscosity viscoelastics are superior in combating vitreous upthrust.
c. Facilitates in the bag insertion of IOL by inflating
the capsular bag prior to IOL insertion.
d. Viscoelastics protect the corneal endothelium from
mechanical trauma during various stages of
cataract surgeryviscoelastic substances are
injected into the AC from the beginning of cataract
surgery to facilitate anterior capsulotomy, capsulorhexis, manipulation of various instruments inside
AC and expression of nucleus. Maintenance of
deep AC with viscoelastics inflate the capsular bag
which results in easier cortical aspiration and also
prevent damage to corneal endothelium and
posterior capsule. It also helps in removing anterior
e.
f.
g.
h.
i.
j.
k.
capsule after IOL insertion following envelope

technique. Viscoelastics filled in AC and a drop of
it on the IOL optic provides complete corneal
endothelial protection during IOL implantation
and dialing of IOL. Glasser et al in a recent study
reported superior ability of viscoat to prevent
corneal endothelial cell loss during phacoemulsification with IOL implantation when compared to
Healon. This superiority has been attributed to the
presence of chondroitin sulphate in viscoat.
Chondroitin sulphate remains adherent to the
corneal endothelium.
Injection of viscoelastics into AC is of great help
during different steps of phacoemulsification and
non-phaco small incision surgery. Injection of
viscoelastic into the cleavage plane between the
lens nucleus and cortex termed as viscodissection
greatly facilitates phacoemulsification of nucleus.
The technique of nucleus removal by injecting
viscoelastic in AC after capsulorhexis during ECCE
is being practised successfully by many surgeons.
Protection of anterior hyaloid face during posterior
capsulotomy and primary posterior capsulorrhexis.
Facilitates removal of residual cortex in the presence of posterior capsule rupture. Aspiration of
lens matter is done without any irrigation in such
cases (dry aspiration)
Injection of sodium hyaluronate beneath the
subluxated lens simplifies lensectomy by elevating
the lens and prevention of total luxation.
Viscoelastics have also been used successfully to
prevent drying of corneal epithelium during
anterior segment surgery including penetrating
keratoplasty.
Management of Descemets detachment
Descemets detachment from corneal stroma is a
common complication during cataract surgery.
Sodium hyaluronate injection has been used
successfully in the repair of stripped Descemets
membrane. The tamponading effect of viscoelastic
keeps the detached Descemets membrane in the
normal anatomic position.
Viscoelastics in glaucoma filteration surgeriesThe
advantages of viscoelastics during glaucoma
filteration procedures includeto prevent shallow
anterior chamber during intraoperative and postoperative period, prevention of hyphaema, facilitates bleb formation and maintenance of permanent blebs and lower long-term postoperative IOP.
Viscoelastics
Healon (Sodium hyaluronate) has been the

most often studied viscoelastic with regard to
behaviour of viscoelastics in glaucoma filtering
surgery. It is effective in post-trabeculectomy
anterior chamber reformation. Juzych et al
reported usefulness of healon in the management
of postoperative ciliary block. There have been
reports of intraoperative use of viscoelastics to
prevent various post-trabeculectomy complications such as flat anterior chamber, detachment,
hypotony, etc. Eugene et al has recently reported
the results of a survey of members of the American
Glaucoma Society about the use of viscoelastic
materials in the post-trabeculectomy patient in the
office at the slit lamp for anterior chamber reformation 75 per cent of the respondents practised
injection of viscoelastics postoperatively at the slit
lamp in the office. Healon (60%), viscoat (17%)
and Healon GV (7%) were the three most often
used viscoelastics. Injection of viscoelastics in the
anterior chamber is not without complications. It
may cause corneal, iris or lens damage and elevation of intraocular pressure. However, Gerber et
al did not report any of these complications in a
series of 19 anterior chamber reformations. Injection of viscoelastic in an hypotonous eye with
patent sclerostomy is unlikely to cause elevated
IOP. Incidence of endophthalmitis was 1 per cent
in this survey.
l. Use of viscoelastics has been recommended for
control of intraocular bleeding, e.g. hyphaema and
suprachoroidaehaemorrhage. A technique of safe
evacuation of traumatic hyphaema using viscoelastic properties of healon has been described.
Healon maintain a deep AC, stable IOP, protects
lens, corneal endothelium and allows clear
observation.
m. Viscoelastics in vitreo-retinal surgerySodium
hyaluronate has been used as vitreous substitute.
Suprachoroidal implantation of sodium hyaluronate can be used as internal buckling procedure
in the retinal detachment surgery. Sodium hyaluronate has also been used in cases of retinal
detachment with giant retinal tears. unrolling of
giant retinal tears and approximation with
underlying retinal pigment epithelium has been
performed with use of sodium hyaluronate. The
procoagulant effect of intraocular sodium hyaluronate after phakic diabetic vitrectomy has been
reported by Pocker et al. Sodium hyaluronate has
39
also been advocated for viscodelamination of the

vitreoretinal juncture in severe diabetic eye disease.
n. viscoelastics in lacrimal surgerySodium hyaluronate has been successfully used in lacrimal sac
identification during dacryocysto-rhinostomy.
Injection of sodium hyaluronate in the lacrimal sac
helps in locating cut medial canaliculi and also
facilitates passage of lacrimal probes for repair of
lacerated canaliculi.
o. Sodium hyaluronate has been successfully used
in adjustable strabismus surgery as a biologic
sleeve. It reduces postoperative muscle adhesions
and increases the period of suture adjustability.
p. Sodium hyaluronate and chondroitin sulphate have
been used in the management of dry eye and some
ocular surface disordes. Sand BB reported marked
subjective and objective improvement
in the patients of keratoconjunctivitis sicca
Complications
Postoperative complications following intraoperative use

of viscoelastic substances are as follows:
1. Elevated intraocular pressure (IOP)
2. Corneal endothelial toxicity
3. Inflammation
4. Dilated fixed pupil
Elevated IOP postoperatively following use of viscoelastic substances remains the most common ocular toxic
effect of viscoelastic agents, It occurs with all viscoelastic
substances. It occurs 2-24 hours after surgery with a peak
at 6-8 hours. It resolves spontaneously within 72 hours.
The IOP may be elevated to dangerous levels threatening
the functioning of optic nerve and corneal endothelium.
Rise in IOP is more if viscoelastic material is not aspirated
from the anterior chamber at the end of surgery. However,
one must remember that IOP may be elevated despite
aspiration of viscoelastic substance from the anterior
chamber. The mechanism of postoperative IOP increase
is not yet fully understood. It is assumed that the
mechanical obstruction of trabecular meshwork by
viscoelastic substances decreased the outflow pathway
resulting in glaucoma. Individual variation in postoperative IOP elevation may be explained on the basis
of variation in trabecular pore size, polymer size of
hyaluronic acid, amount of fibrin, albumin, residual
viscoelastic material in AC, viscosity and molecular weight
of viscoelastic substances and inflammatory products
produced after surgery. Elevation in IOP may occur even
with administration of antiglaucoma treatment like
acetazolamide. Elevation of IOP also occurs following
ICCE with viscoelastic substances.
40
The clearance of the viscoelastic agent through the

trabecular meshwork is believed to be dependent upon
the viscosity and molecular weight. The lower the viscosity
and molecular weight of viscoelastic material, the faster
is its clearance through the trabecular meshwork. HPMC
is less viscous and has a lower molecular weight than
viscoat causes less IOP increase.
PreventionAspiration/removal of viscoelastic at the
end of surgery. Removal of viscoelastic material may be
done either by completely aspirating or by diluting the
viscoelastic substance. Aspiration of viscoelastic agent in
bulk ensures complete removal but results in loss of
anterior chamber causing more endothelial damage.
Removal by dilution of viscoelastic agent ensures maintenance of anterior chamber depth and slow removal by
irrigation and aspiration. The viscoelastic agent should
be aspirated thoroughly from the retrolental space, the
capsule fornix and the anterior chamber using an
irrigation aspiration tip. First the optic edge is titled with
a spatula and the I/A tip inserted behind the optic. After
aspiration of the central portion of viscoelastic material
the I/A tip is swept across and along the capsule equator
to capture peripheral residual viscoelastic material. The
viscoelastic agent from the AC is aspirated circumferentially from the retroiridal and preiridal spaces. The I/A
tip should always be kept away from the endothelium and the angle of AC. Despite thorough removal
of IOP both HPMC and viscoat cause a significant IOP
increase.
Postoperative monitoring of IOP is necessary after
ECCE small incision cataract surgery and administration of antiglaucoma drugs in patients with high
IOP is recommended.
Prophylactic use of antiglaucoma drugs. We routinely
administer tab acetazolamide 250 mg following ECCE
with PC IOL for two days. Timolol maleate 0.5 per
cent bid is added in appropriate cases after monitoring
IOP on first postoperative day we routinely give intravenous mannitol 1 g/kg body weight 6-8 hours following ECCE with PC IOL surgery provided there is
no contraindication. However, despite IV mannitol
and oral acetazolamide and aspiration of HPMC, we
still encounter dangerous elevations of IOP in some
cases.
Inflammatory potential and endothelial cell toxicity has
been variably reported. Intraocular inflammation and
subsequent bullous keratopathy have been reported
following the reuse of injection cannulas of healon. It has
been attributed to denatured healon by disinfectants or
autoclaving. Chondroitin sulphate being an hyperosmotic
agent can cause damage to corneal endothelium due to

dehydration because of its high osmolality. Initial
formulations of chondroitin sulphate caused several cases
of acute band keratopathy due to its high phosphate
concentration, According to recent reports toxic endothelial cell destruction syndrome occurs due to intracameral injection of toxic detergent residue due to contamination inside reusable cannula 0.2 per cent chlorhexidine digluconate has also been reported to be endothelial
toxic. The use of reusable cannula must be avoided.
Disposable cannulas should be used where-ever possible.
Author is using HPMC 2 per cent in ECCE with posterior chamber IOL for senile and paediatric cases for
last 15 years. Author has encountered severe unexpected
diffuse corneal oedema on the first postoperative day
after ECCE with posterior chamber IOL with intraoperative use of 2 per cent HPMC in 1 per cent of cases. In
some patients the corneal oedema is maximum on 2nd
postoperative day. This corneal oedema is usually
associated with ocular hypertension and dilated pupil or
decreased reactivity of pupil. This postoperative elevated
IOP developed despite routine prophylactic administration of acetazolamide 250 mg 6 hourly in all ECCE
with PC IOL implantation. Routine dilatation of pupil with
cycloplegics in early postoperative period in such cases
results in dilated fixed pupil which resists constriction with
topical pilocarpine therapy. Persistent corneal oedema
and elevated IOP have been noted in these patients.
Although mechanical trauma is usually considered to be
the most significant factor in the corneal endothelial
damage during ECCE with IOL surgery resulting in
postoperative corneal oedema. However, corneal
decompensation out of proportion to the degree of
surgical trauma may be traced to the unrecognised
preoperative endothelial dysfunction or to toxicity of
intraocular medications used during surgery.
The medications used inside AC during ECCE are 2
per cent HPMC, 0.3 ml of preservative free epinephrine
in 500 ml of BSS and diluted pilocarpine to constrict
pupil after insertion of PC IOL.
In authors opinion, viscoelastics may be implicated in
the aetiology of unexplained corneal oedema as it was
associated with elevated IOP in all such cases. Tan and
Humphry have reported that a total of 1.67 per cent of
eyes operated on using hypromellose developed a
nonreactive semidilated pupil whereas none of the eyes
from the control group developed this phenomenon. They
concluded that there is a probable link between the
intraocular use of hypromellose and abnormal pupil after
Viscoelastics
cataract surgery. Eason and Seward suggested that

sodium hyaluronate and two per cent HPMC have similar
effects on the pupil after their use in cataract surgery.
Two per cent of pupils were partially reactive in both
healon and HPMC groups
Comparative Studies Using Different Viscoelastics
Liesegang et al compared the efficacy and complications

of 2 per cent HPMC and 1 per cent sodium hyaluronate
in ECCE with PC IOL implantation in 70 patients.
although both VE agents maintained anterior chamber
and facilitated the surgery, sodium hyaluronate was
preferred. There was no excessive intraocular inflammation with either agent. Sodium hyaluronate caused
greater rise in IOP than HPMC but the difference was not
significant. Mean endothelial cell loss and corneal
thickness were also not significantly different. Intraocular
pressure doubled for the first postoperative day following
uncomplicated ICCE with AC reformed using sodium
hyaluronate with or without systemic acetazolamide.
Healon and viscoat both caused significant and
comparable elevation of intraocular pressure. Some
postoperative IOPs may be as high as 50 to 60 mm hg
despite removal of VE agent at the end of surgery. (Baren).
Fry observed that postoperative IOP rise was lower with
healon as compared to Amvisc and Viscoat. Viscoat (not
aspirated) group caused highest IOP rise. Retained Viscoat
group patients had more incidence of patients with IOP
greater than 30 mm hg. However, retained Viscoat may
have better protective effect on endothelium. In one study
although the effects of ocucoat (2% HPMC), Viscoat,
Healon and Healon GV on postoperative IOP and
endothelial cell loss after phacoemulsification were
comparable among four groups. The high molecular
weight viscoelastics (Healon and Healon GV) performed
better as viscosurgical tool during phacoemulsification.
Viscoat tended to trap nuclear fragments and air
bubbles which decreases visibility during surgery. Space
maintenance and injection case were significantly better
with Healon and Healon GV due to their high molecular
weight Huts. Kohnen et al evaluated IOP rise with healon
and healon GV in sutureless cataract surgery with foldable
IOL implantation. There was no statistically significant
difference in the highest mean IOP elevations between
both the viscoelastics but standard deviations were higher
in the Healon GV group at 6 and 24 hours groups. Both
viscoelastics can be equally removed from AC. Incidence
of high IOP using high viscosity hyaluronic acid
viscoelastics can be minimised by meticulous removal of
41
viscoelastics. Rainer et al compared IOP rise after bilateral

small incision cataract surgery using two dispersive
viscoelastic agents ocucoat (HPMC 2%) and viscoat
sodium chondroitin sulphate four per cent(sodium
hyaluronate 3%) Viscoat caused a significantly higher IOP
rise and significantly more IOP spikes than ocucoat in
the early postoperative period.
FURTHER READING
1. Barron BA, Busin M, Page C et al: Comparison of the effects
of Viscoat and Healon on postoperative intraocular pressure.
Am J Ophthalmol 100: 377-84 (Medline), 1985.
2. Brown GC, Benson WE: Use of sodium hyaluronate for repair
of giant retinal tears. Arch Ophthalmol 107: 1246, 1989.
3. Clorfeine GS, Parker WT: Use of Healon in eye muscle surgery
with adjustable sutures. Ann Ophthalmol 19: 215, 1987.
4. Eason J, Seward HC: Pupil size and reactivity following
hydroxypropyl methylcelluose and sodium hyaluronate. Br
J Ophthalmol 79: 541-43, 1995.
5. Fechner FU and Fechner MU: Methylcellulose and lens
implanatation. Br J Ophthalmol 67: 259-63, 1983.
6. Fry LL: Postoperative intraocular pressure rises: A comparison
of Healon, Amvisc, and Viscoat. J Cataract Refract Surg 15:
415-20 (Medline), 1989.
7. Gerber SL cantor LB: Slit lamp reformation of the anterior
chamber following trabeculectomy. Ophthalmic Surg 23:
784-88, 1992.
8. Glasser DB, Osborn DC, Nodeen JF et al: Endothelial
protection and viscoelastic retention during phacoemulsification and intraocular lens implantation. Arch Ophthalmol
190: 1438-40, 1991.
9. Glasser DB, Schultz RC, Hyndiuk RA: The role of
viscoelastics, cannular and irrigating solutions additives in
post-cataract surgery corneal edema: A brief reviews. Lens
Eye Toxic Res 9: 3-4, 1992.
10. Hurwitz JJ, Nik N: Lactimal sac identification for dacryocystorhinostomy. The role of sodium hyaluronate. Can J
Ophthalmol 19: 112, 1984.
11. Hutz WW, Eckhardt HB, Kothnen T: Comparison of viscoelastic substances used in phacoemulsification. J Cataract
Refract Surg 22: 955-59 (Medline), 1996.
12. Kohnen T, Von Ehr M, Schutte E et al: Evaluation of
intraocular pressure with Healon and Healon GV in sutureless
cataract surgery with foldable lens implantation. J Cataract
Refract Surg 22: 227-37, 1996.
13. Lavin MJ, Leaner PK: Sodium hyaluronate and giant retinal
tears. Arch Ophthalmol 108: 480, 1990.
14. Lerner HA, Boynton JR: Sodium hyaluronate as an adjunct
in lacrimal surgery. AM J Ophthalmol 99: 365, 1985.
15. Liesegang TJ, Bourne WM, Istrup DM: The use of hydroxypropyl methylcellulose in extracapsular cataract extraction
with intraocular lens implantation. Am J Ophthalmol 102:
723-26 (Medline), 1986.
42
16. MC Leod, James CR: Viscodelamination at the vitreoretinal

juncture in severe diabetic eye disease. Br J Ophthalmol 72:
413, 1988.
17. Mital RN, Tiwari R: Suprachoroidal injection of sodium
hyaluronate as an internal buckling procedure. Ophthalmic
Res 19: 255, 1987.
18. Momose a and Kasahara A: Methylcellulose: A better visco
surgical alaternative for intraocular lens implantation. Ind J
Ophthalmol 37: 64-66, 1989.
19. Nuyts RMMA, Boot N, V Best JA et al: Long-term 351-9
changes in corneal endothelium following toxic endothelial
cell destriction. A specular microscopic and fluorometic study.
Br J Ophthalmol 80: 15, 1996.
20. Passo MS, Emest JT, Goldstick TK: Hyaluronate increases
intraocular pressure when used in cataract extraction. Br J
Ophthalmol 69: 572-75, 1985.
21. Pocker AJ, Mc Cuess BW II, Autton WL et al: Procoagulant
effect of intraocular sodium hyaluronate after phakic diabetic
vitrectomy. A prospective randomized study. Ophthalmology
96: 1491, 1989.
22. Probst LE, Nichols BD: Corneal endothelial and intraocular
pressure changes after phacoemulsification with Amvisc Plus
and Viscoat. J Cataract Refract Surg 19: 725-30 (Medline),
1993.
23. Pruett RC, Schepens CL, Swan DA: Hyaluronic acid vitreous
substitute a six year clinical application. Arch Ophthalmol
97: 2325, 1979.
24. Rainer G, Menapace R, Findl O et al: Intraocular pressure

rise after small incision cataract surgery; a randomised
intraindividual comparison of two dispersive viscoelastic
agents. Br J Ophthalmol 85: 139-42, 2001.
25. Rainer G, Menapace R, Schmetterer K et al: Effect of
dorzolamide and latanoprost on intraocular pressure
following small incision cataract surger. J Cataract Refract
Surg 25: 1624-29 (Medline), 1999.
26. Salvo Eugene C Jr, Luntz MH, Medow Norman B: Use of
viscoelastics posttrabeculectomy: A survey of members of
American Glaucoma Society. Ophthalmic Surg Lasers 30:
271-75, 1999.
27. Sand BB, Marnerk, Norn MS: Sodium hyaluronate in the
treatment of keratoconjunctivitis sicca. a double masked
clinical trial. Acta Ophthalmol 67: 181, 1987.
28. Searl SS, Metz HS, Lindahl KJ: The use of sodium hyaluronate as a biologic sleeve in strabismus surgery. Ann Ophth
19: 215, 1987.
29. Seiff Sr, Ahn JC: Locating cut medial canaliculi by direct
injection of sodium hyaluronate into the lacrimal soc.
Ophthalmic Surgery 20: 176, 1989.
30. Tan AKK and Humphry RC: The dilated fixed pupil after
cataract surgery: Is it related to intraocular use of hypromellose. Br J Ophthalmol 77: 639-64, 1993.
31. Vitacoro AA, Vita: Coro AA hyaluronate facilitates passage
of lacrimal probes for repair of lacerated canaliculi. Arch
Ophthalmol 106: 579, 1988.
Comparison of Various ECCE Techniques
Comparison of Various
ECCE Techniques
xtracapsular cataract extraction (ECCE) can be

done by three techniques: Conventional,
Manual Phaco, Phacoemulsification (Table
5.1).
Although in all the three techniques the goal remains
the same, i.e. you have to leave behind the posterior
capsule and a part of anterior capsule. But since the
methods differ the procedure and used gadgets also vary.
Following differences can be enumerated in the three
methods.
Conjunctival Flap
The conjunctival flap is usually large in ECCE extending

from almost 2-3 Oclock to 8-9 Oclock. The conjunctival
flap is smaller in manual phaco extending from 10.30 to
1.30 Oclock, if one is very liberal in making flaps. As
one gains experience in this surgery the conjunctival flap
becomes even smaller. In conventional ECCE one can
make corneal incision only and may not need any flap.
But this flap is a must in manual phaco, because one
needs longer tunnel. In contrast to this in phacoemulsification present trend is to make a corneal tunnel
therefore, conjunctival flap is not required. Beginners still
prefer to do this surgery through scleral tunnel. Hence
they make a flap. Disadvantage of making a big flap is it
gives more astigmatism.
Cautery
Its use depends on whether surgeon has made a flap or

not. The cautery causes increase in the amount of astigmatism, which goes against the philosophy of giving least
possible astigmatism. The larger the conjunctival flap more
is the need of cautery. So, the use of cautery is maximum
in ECCE, less in manual phaco and minimum in phaco.
Cautery is not needed if corneal incision is made as in
43
Kamaljeet Singh
Vipin Bihari
Incision
This is the most important step in cataract surgery since

this gives the ultimate result of surgery. Longer the incision
more is the astigmatism; and nearer it is to limbus more
is the astigmatism. Therefore, for achieving least astigmatism surgeon should make smallest possible incision
in which, he can deliver the nucleus easily, and should
remain far from the limbus. Conventional ECCE is done
close to limbus and is the longest (10-12 mm) incision;
phacoemulsification has the minimum possible wound
(3.2 mm) if foldable lenses are used. If non-foldable lenses
are implanted the length increases to 5.5 mm taking
away the advantage of smallest incision. The incision
length in non-phaco SICS is 6 to 6.5 mm. In this regard,
both manual phaco and phacoemulsification with nonfoldable IOL are equally comparable.
Viscoelastics
It has been shown in various studies that methyl cellulose

is as good as any other viscoelastics. Methyl cellulose is
cheap and can be easily removed from anterior chamber.
This can be used both in conventional ECCE and manual phaco; though the quantity used is more in manual
phaco and less in conventional ECCE. In phacoemulsification many Indian surgeons have repeatedly shown
that methyl cellulose is as good as sodium hyaluronate,
but still the preferred viscoelastic world over is sodium
hyaluronate (healon). Its use increases the cost of surgery
immensely.
Capsulotomy
Any type of capsulotomycan-opener, envelope or

capsulorhexis can be made in conventional ECCE and
manual phaco. Whereas capsulorhexis is a must in
phacoemulsification. This is difficult to learn and makes
the learning curve longer, although trypan blue has made
life easier for surgeons.
44
Nucleus Prolapse
Sutures
This is very important step in manual phaco. Surgeon

cannot proceed further if he has not mastered this step.
It is not needed both in ECCE and phaco. If nucleus
prolapses into anterior chamber in ECCE there is no
problem as nucleus delivery becomes easier. But if it
happens in phacoemulsification most of the surgeons
advocate conversion to ECCE, though some authorities
have advocated supracapsular phaco.
Sutures are usually not needed in phaco as corneal valve

is made which automatically closes. But in case the
corneal incision has been made and there is need to
extend it for implanting even a 5.25 mm optics, suture
may be required. For scleral incision, even if the incision
is extended to 7.5 mm, sutures are not needed as the
tunnel is self-sealing. So both in phaco and manual phaco
even if the incision is large there is no need for applying
the sutures,. In contrast, ECCE needs 5 to 7 interrupted
sutures. When the sutures are applied patient has
complaints of foreign body sensation for quite long even
if 10.0 suture are used and knots are buried.
Nucleus Delivery
Nucleus delivery is easiest in ECCE since the incision is

long and single plane. It is difficult in manual phaco,
because one has to deliver the nucleus through tunnel.
Moreover, the nucleus has to be divided into smaller
pieces by some technique before delivering out. In phacoemulsification, in contrast, the nucleus delivery is through
phaco hand piece and is most difficult. The surgery is
done mostly in the bag, which depends largely on the
quality of the machine, its fluidics, holding power and
ultrasonic cutting power.
Astigmatism
There are several factors responsible for astigmatism. The

incision, suture, lens decentration, etc. but, amongst three
techniques astigmatism is maximum in ECCE. Usually
we get an astigmatism of 1.5 to 3.0 D, but surprise astigmatism up to 7.0 D has been noted. This astigmatism is
much less (0.51.5 D) in manual phaco and negligible
(0 to 1.0 D) in phacoemulsification.
Cortical Clean-up
Cortical clean-up is easiest in ECCE because nucleus

and perinucleus both are delivered out in one go.
Remaining portion is cortex only, which can be easily
washed manually with the help of Simcoe cannula.
Cleaning is slightly difficult in manual phaco because
perinucleus and cortex both remain inside AC and only
nucleus is delivered, through a small incision. Perinucleus
is hydro-extracted by keeping the Simcoe cannula at 6
Oclock and at the same time depressing the tunnel with
the same cannula, or is hydroexpressed with the help of
AC maintainer. In phacoemulsification the perinucleus
and cortical matter are aspirated by automated probe or
manually by Simcoe cannula.
Lens Implantation
Non-foldable lenses are used in ECCE and manual

phaco. The preferred optic size is 6-6.5 mm in both these
techniques, which have several advantages over small
optic lenses (used in phaco). These large size lenses do
not cause edge glare, do not decentre and do not obstruct
in retinal treatment. When foldable lenses are used in
phaco the optic size is large 6-6.5 mm. Inserting, a
foldable lens is difficult to master as newer techniques
keep on coming. Whereas, implanting a non-foldable
lens is quite easy.
Recovery
Although patient is mobile from the day one in all types

of ECCE surgeries, yet visual outcome is not that fast.
Because of the time taken for wound healing we give
glasses after 6 weeks in ECCE, whereas in manual phaco
15 days is a good period of wait for prescribing glasses.
In phaco visual recovery is almost immediate although
the glasses are prescribed after 2 weeks.
Complications
There are several complications associated with cataract

surgery. We would like to discuss the common and
dreaded complications. Corneal decompensation is rarely
seen nowadays with ECCE. When we compare, the
endothelial cell loss is slightly more in manual phaco than
in phacoemulsification, although with the use of good
amount of viscoelastics it can be reduced. Posterior
capsule rupture occurs in all the three types of surgery
but is most common in phaco, especially in the hands of
beginners. Chances of posterior dislocation of fragments
of lens and even loss in toto are much greater in phaco
than the other two techniques. Thus, when we compare
manual phaco and phacoemulsification cornea is at
greater risk in manual phaco and vitreous and retina in
phaco.
Comparison of Various ECCE Techniques
45
Table 5.1: Comparison of various ECCE techniques

ECCE
Manual Phaco
Phacoemulsification
Anaesthesia
Peribulbar
Peribulbar
No anesthesia, topical, peribulbar
Conjunctival flap size
Large if limbal
Moderate size
Small
Cautery
Required
Required
Required if flap is made, otherwise

not
Incision
10-12 mm scleral, corneal, limbal
5.5-7.5 mm scleral, tunnel
3.25.0 mm scleral or corneal

tunnel
Viscoelastics
Methyl cellulose
Methyl cellulose
Healon and /or methyl cellulose
Capsulotomy
Can-opener, envelope, capsulorhexis Can-opener, envelope, capsulorhexis Capsulorhexis must
Nucleus prolpase in AC
Not needed
Needed
Nucleus delivery
Easy
Difficult
Not needed
Quite difficult
Cortical clean-up
Manual
Manual
Automated or manual
Lens implant
Optic 6.5 mm non-foldable
Optic 5.5 to 6.5mm, nonfoldable
6.5 mm if
foldable,
Sutures
Required
Sutureless
Sutureless
Astigmatism
1.5D 4.0D
0.5 D-1.5 D
0.10D-1.0D
Recovery
6 weeks
2 weeks
1 week
Corneal decompensation Rare
Seen
Seen
PC rupture
Rare
Rare
Common
Posterior dislocation
of lens
Rare
Rare
Common
5.25 mm if
non-foldable
Complications
Hard cataract
Easily possible
Possible
Difficult
Elderly cataract
Easily possible
Possible
Difficult
Surgical skill
Average
Average
Demanding
Microscopic quality
Average will do
Average will do
Excellent depth perception with

automated focussing and zoom
Cost
Cheap
Cheap
Very costly
Type of Cataract
If the lens is hard perhaps the easiest technique is ECCE,

for soft lenses manual phaco gives excellent results and
in between these two varieties phaco is quite good.
things to learn. Whereas, any average surgeon can easily

learn ECCE both and manual phaco because no costly
gadgets but only skilled hands are required and the
surgery is not machine dependent.
Age of Patient
Microscope
In young patients the cataract is very soft hence they are

better candidates for both manual phaco and phacoemulsification. As the age advances the lens becomes
harder. Beyond 70 years as the cornea is already compromised, ECCE is the choice. There is no hard and fast
rule for this. Master surgeons can easily alter the decision.
ECCE and manual phaco can be done with any average

microscope. But for phaco the surgeon should have the
best possible microscope, as the stereopsis should be
excellent. Focussing and zoom both should ideally be
foot controlled. These two things increase the cost of
microscope immensely. In addition, the cost of phaco
machine is exorbitant, which an average surgeon from
the developing country cannot afford. Foldable lenses
and viscoelastics are also costly for phaco. Therefore, in
case the cost factor is not involved phaco would be the
choice. Otherwise, manual phaco without addition of
costly equipment is the best and safest for majority of
Indian patients and surgeons.
Surgical Skill
For any surgery surgical skill is very important but perhaps

for phaco it is most demanding. The surgeon has to use
both the hands, both feet, both ears, other than eyes.
Therefore, phaco is highly skilled job along with lot many
46
FURTHER READING
1. Amar Agarwal, Mahipal S Sachdev et al: Phacoemulsification
laser cataract surgery and foldable IOLs. Jaypee Brothers:
India. 2000.
2. Blumenthal M et al: Small incision manual extracapsular
cataract extraction using selective hydrodissection.
Ophthalmic Surg 23: 699-701, 1992.
3. Dada VK, Sandhu N: Management of cataract a revolutionary
change that occurred during last two decades. J Ind Med
Assoce. 97(8): 313-17, 1999.
4. Mathew Manual nucleo fragmentation and endothelial cell

loss. J Cat Refr Surg 23(7): 995-99, 1997.
5. Schein OD, Bass EB et al: Cataract surgical techniques:
Preferences and underlying beliefs. Arch Ophthalmol 113:
1108-12, 1995.
6. Vajpayee RB, Sabharwal S, Sharma N et al: Phaco fracture
verses phacoemulsification in eyes with age related cataract.
J Cataract Ref Surg 24: 1252-55, 1998.
7. Wright M, Chawla H, Adams A: Results of small incision
extracapsular cataract surgery using anterior chamber
maintainer without viscoelastic. BJO 83: 71-75, 1999.
Management of Diabetes in Cataract Surgery
Management
of Diabetes in
Cataract Surgery
he morbidity and mortality rates during the

perioperative period are greater in the diabetic
compared with the nondiabetic of comparable
age, for a number of reasons. Macrovascular disease is
extremely common in both type 1 and type 2 patients.
Cardiovascular complications are the major causes of
surgical mortality in diabetics (30%). In addition a high
percentage (especially in the over 50 age category) have
impaired renal function and are prone to fluid and
electrolyte imbalance, dehydration, and obtundation.
During the postoperative period, the diabetic has a higher
incidence of infection at the operative site as well as a
greater potential for urinary tract infection, pneumonia,
and other systemic infections. Wound healing may be
impaired in the setting of persistent hyperglycemia (>240
mg/dl) as a result of modified fibroblast function. This
defect, combined with infection, frequently leads to a
difficult and protracted hospitalisation and frequent
readmission. Consequently, the diabetic patient spends
30 to 50 per cent more time in the hospital than the
nondiabetic following surgery, even if the surgery proceeds without incident.
Safety and simplicity are the watchwords of the surgical
management of diabetic patients. Safety should be
ensured if the following protocols are observed. Simplicity
is essential, as surgery is frequently required in diabetic
patients and its bedside management is usually
undertaken by junior doctors who may have little or no
specialized knowledge of diabetes. Treatment regimens
should not aim for near normoglycaemia; it has been
shown that this does not improve outcome, and the risks
of hypoglycaemia are considerably increased. Sensible
and practical glycaemic targets are discussed below.
Hypoglycaemia is a major hazard of surgery, which is
particularly important to avoid, as the surgical or
47
6
Sarita Bajaj
postsurgical patient may be unaware of this or unable to

communicate.
With the use of the modern management protocols,
the major outcome measures of surgery (duration of hospital stay, morbidity and mortality) are now comparable
in diabetic and non-diabetic patients. It follows that the
skill, care and motivation with which diabetic patients
are managedideally supervised by a diabetic team
(where available) are important to the success of surgery.
PRINCIPLES OF MANAGEMENT
Management of the individual patient is determined by

the severity and nature of surgical trauma and the
duration of perioperative fasting.
Determinants of the management plan and preoperative evaluation:
1. Type of diabetestype 1 diabetes is associated with
absolute need for insulin therapy whereas type 2
diabetes is associated with increased insulin needs.
2. Treatmentdiet, oral hypoglycaemic agents (OHA)
or insulin. Subjects who are usually managed successfully without insulin need insulin only for major
surgery; otherwise, simple observation is generally
sufficient.
3. Metabolic statusreview blood glucose records and
glycosylated hemoglobin (HbA1c) values.
4. Cardiac, renal and cerebral vascular status should be
assessed.
5. Surgical details:
a. Minor or major for purposes of clarity, it is useful
to define major surgery as any procedure requiring
a general anaesthetic.
b. Type of anaesthesia.
c. Type of surgeryemergency or elective.
d. Postoperative oral intake.
48
The preoperative evaluation should be done in the

office before an elective operation or, less preferably, on
the day of admission. History of previous glycaemic
control should be reviewed and control should be
improved in symptomatic and asymptomatic patients
with sustained hyperglycaemia, reflected by a fasting
blood glucose (FBG) level higher than 200 mg/dl, high
HbA1c values (>10%), or both. Improved control during
the perioperative period (blood glucose values between
120 mg/dl and 180 mg/dl) reduces the morbidity from
fluid and electrolyte imbalance, decreases the risk of
infection, and increases the wound-healing rate. Prior
day admission is still indicated for all poorly controlled
diabetics (FBG >240mg/dl).
MINOR SURGERY
For patients posted for minor surgery, the OHA and

insulin are stopped on the day of the surgery. Once the
surgery is over and the patient permitted to resume oral
feeds the OHA is started with half the dose which the
patient was originally taking. On the second postoperative day full dose of the OHA and/or insulin is started.
SURGERY IN PATIENTS
NOT TREATED WITH INSULIN
A small subset of type 2 patients with acceptable control

(FBG < 140 mg/dl, other blood glucose values < 200
mg/dl and HbA1c of 8 to 10%) on diet or OHA may not
require insulin. Long-acting sulfonylureas (e.g. chlorpropamide) should be stopped, substituting a shorteracting sulfonylurea, if necessary.
Glycaemic control should be monitored carefully
during the period before admission. These patients
generally require only close observation. The operation
should be scheduled for the morning, if possible. Breakfast and any morning dose of OHA are omitted. Throughout the perioperative period, frequent glycaemic monitoring is required and glucose-containing infusion fluids
must be avoided. Sulfonylurea drugs, if used, should be
omitted until the first postoperative meal.
This approach is acceptable for a relatively simple and
short-lasting (less than 2 hours) surgical procedure. Poorly
controlled type 2 patients undergoing major surgery who
do not achieve the above glycaemic targets are best
managed using continuous glucose and insulin delivery
as for type 1 patients, after initial stabilization with insulin,
either in hospital or at home.
SURGERY IN INSULIN-TREATED PATIENTS

Indications for Insulin
All patients taking insulin, whether persons with type 1

or type 2 diabetes should receive insulin therapy during
the surgical procedure (Table 6.1). It is preferable to take
diabetic patients for surgery in the morning as first case.
Table 6.1: Indications for insulin therapy during surgery
Always
Sometimes
All insulin-taking diabetics

(type I and type 2)
Type 2 diabetes treated with

diet or oral hypoglycaemic
agents in acceptable control
Type 2 diabetics on diet and/or Average FBG=180 mg/dl
oral hypoglycaemic agents but
HbA1c = 10%
with chronic hyperglycaemia
surgery duration <2 hours
(i.e. FBG>180 mg/dl and
body cavity not invaded
HbA1c>10%)
food intake anticipated after
operation
Insulin Regimen
The kinetics of subcutaneous insulin absorption is unpredictable and hence not advocated. Normally, the requirement of insulin is 0.3U to metabolize 1 gm of glucose.
Continuous insulin infusion (intravenous) is the most
rational and physiologic method for perioperative
management. This approach has been shown to be safe,
effective, and flexible. Insulin infusion should be started
the night before for early morning procedures and for
patients needing improved glycaemic control. Otherwise,
the patient takes the usual evening dose of insulin or
OHA.
In all patients requiring insulin, the insulin infusion
must be started at least 2 to 3 hours before the operation
in order to titrate to the desired level of control.
There are two basic regimens for administering insulin
and glucose. The preferred method uses a separate
infusion of insulin and glucose to allow for independent
adjustments of each infusion rate. In the separate-line
system one infusion line is used to deliver 10 per cent
glucose solution at 100 ml/h, preferably using an
electronic drip-counter, while a syringe-driver pump
administers insulin through the other, usually at 2-4 U/h.
The insulin infusion can either be given into a separate
vein, or piggy-backed into the glucose line. This
approach provides flexibility and can be rapidly adjusted
depending on the hourly variation in blood glucose
values.
The alternate method is to combine insulin and
glucose as a mixture at a pre-estimated individualized
concentration. Potassium chloride (KCl) is added to the

glucose (glucose-potassium-insulin, or GKI infusion),
to counteract the risk of hypokalaemia. Table 6.2 provides
a simple protocol for managing diabetic patients (type 1
or type 2) undergoing surgery.
Table 6.2: A simple protocol for managing patients with
type 1 or type 2 diabetes undergoing surgery. These guidelines are suitable for use by junior hospital staff with limited
specialist experience of diabetes
1. Ensure satisfactory preoperative control. Operate in morning if
possible.
2. Liaise with anaesthetist.
3. Omit breakfast, and insulin or OHA on morning of surgery.
4. Non-insulin treated diabetic patients, having non-major surgery,
need observation only. Chart 2 hourly glucose by reagent strips
on day of surgery. Patients taking OHA can restart them with
next meal.
5. GKI is used in all other cases i.e. (a) all insulin-treated diabetic
patients; and (b) major surgery in non-insulin - treated diabetic
patients.
i. At 0800-0900 on morning of surgery, start GKI infusion
and infuse 5-hourly (100 ml/h):
500 ml 10% dextrose
+ 15U short-acting insulin
+ 10 mmol KCl
ii. Check blood glucose 2-hourly initially and aim for 100200 mg/dl
If > 200 mg/dl, change to GKI with 20 U insulin
If <100 mg/dl, change to GKI with 10 U insulin
Continue 5-U adjustments as necessary.
iii. Continue GKI until patients eat, then revert to usual
treatment.
The GKI regimen has gained widespread acceptance

because of its simplicity and effectiveness. To a 500-ml
bag of 10% dextrose are added 10 mmol potassium
chloride and 15U soluble insulin. This mixture is infused
over 5h. This regimen delivers similar amounts of glucose
and insulin to the separate-line system, but is considerably
simpler and, because insulin and glucose are given in
balanced proportions, the infusion rate is not so critical;
an electronic pump is therefore not essential. It also avoids
one of the main problems of giving insulin and glucose
separately, namely one of the infusions running out or
being interrupted by pump malfunction or the intravenous cannula becoming blocked or dislodged; if the
other infusion continues, dangerous hypo-or hyperglycaemia may result.
When adding insulin and potassium solutions to the
bag, it is important to use a needle that is long enough
to clear the self-sealing bung, to mix the bag well and to
label it clearly with the dosages of the additives, During
a GKI infusion, blood glucose should be monitored at
49
least hourly until insulin requirements have been determined, according to the schedule shown in Table 6.2.
The insulin delivery rate is altered by substituting a new
bag containing a different dosage, and the potassium
content is varied according to regular plasma electrolyte
measurements. Dilutional hyponatraemia may occur
when GKI infusion is prolonged. This should be treated
by additional saline infusion, and if necessary by slowing
the GKI infusion rate. In patients at risk of volume
overload, more concentrated dextrose infusions (e.g.
20%) can be given in smaller volumes, with appropriate
adjustments of insulin and potassium content.
Apart from its versatility the GKI infusion is an
acceptable method for many elective procedures, when
infusion pumps are not available and when frequent
variations in insulin needs are not anticipated.
To successfully monitor and regulate an insulin infusion
regimen, a system for the accurate measurement of blood
glucose levels at the bedside must be in place. In the
absence of rapid and accurate bedside blood glucose
monitoring with a meter, it is not safe to implement a
regimen of continuous regular insulin infusion. Furthermore, the anaesthesiologist must do blood glucose analyses every hour during the operation and adjust the
insulin infusion accordingly. The infusion is continued
until the patient is tolerating oral feeding.
POSTOPERATIVE CARE
During the reintroduction of foods such as clear liquids,

it is preferable to continue a low maintenance dose
infusion supplemented with small boluses of regular
insulin (subcutaneous) preprandially. The size of the bolus
depends on the amount of allocated carbohydrate (1U
of insulin per 10 g of carbohydrate). This is a very safe
system because the insulin dose remains adequate.
Once food tolerance is established, the infusion is
stopped and the insulin-treated diabetic may be returned
to the former dosage or may need a number of days of
frequent (premeal) doses of regular insulin The transition
regimen is developed according to the guidelines
discussed in Table 6.3. The previous days total insulin
dose is used to determine the most appropriate form of
therapy. By calculating a basic dose, with adjustments
made depending on premeal blood glucose values and
anticipated carbohydrate content, safe control can be
achieved. A small dose (10 to 15 U) of intermediateacting insulin (NPH or Lente) is added at bedtime to
provide coverage until the following morning.
Patients are continued on the above treatment plan
until postoperative complications have stabilised and
50

Table 6.3: Postoperative management of
patients with diabetes
Continue perioperative insulin infusion until food is tolerated, then

plan new regimen
Overlap (30 minutes) the initial subcutaneous dose of regular
insulin before stopping infusion
Type 2 diabetics previously treated with diet and/or OHA: prescribe
usual medication if BG <180 mg/dl. Higher BG may require
transient regular insulin every 6 hours (premeals) as per blood
glucose (bedside monitoring) sliding scale
Insulin-treated diabetics: Prescribe usual regimen or use prior
24 to 48 hours insulin dosage to develop a new basic dose regimen.
The dose selected should be 80 to 100% of the previous days
total dose. Needs may be higher during persistent stress, infection,
pain and steroids
The selected basic dose may be given premeal (breakfast [25%],
lunch [25%], and dinner [25%]), as regular insulin and NPH
given at bedtime (25%). Aim to keep BG in safe range (120-180
mg/dl).
Premeal BG (mg/dl)
Basic dose (soluble insulin)
<80
81-120
121-180
181-240
241-300
>300
4 U less
3 U less
Basic dose (no adjustment)
2 U more
3 U more
4 U more
Modify the basic dose regularly according to the sliding scale

needs. Additional doses of regular insulin may be needed at
other times (e.g. 10 PM to 2 AM)
Establish the most suitable insulin regimen or the patients
previous regimen before patient discharge
glycaemic control is satisfactory. As soon as the patient

is able to eat normally again, the usual treatment regimen
can be restarted. Frequent glycaemic monitoring is
essential because of the variable effects of surgical trauma
and other factors such as inactivity, postoperative
infection and changes in medication.
9U of intermediate acting insulin) would lower the

FBG.
2. In some type 2 patients because of insulin resistance
the blood glucose cannot be controlled with insulin
alone. Addition of small doses of OHA is recommended to overcome the resistance (half of the
previous daily dose should suffice). On the day of
the surgery the OHA is stopped.
3. Type 2 diabetics can be safely switched over to oral
drugs after a week.
4. Purified insulins are ideal for short-term use in type 2
diabetics to prevent antigenicity and insulin antibody
production.
INTRAVENOUS FLUIDS
1. Dextrose saline/normal saline is used if blood pressure

is low or normal. In patients with hypertension and
the potential for congestive cardiac failure it is safe to
use half normal saline, with central venous pressure
monitoring.
2. For normal metabolism about 50 gms glucose is
required every 8 hours for energy and to avoid ketosis.
To meet this demand at least 1000 ml of 5 per cent
glucose every 8 hours will be required.
3. In situations requiring fluid restriction 10 per cent
dextrose may be infused instead of 5 per cent dextrose
with double dose of insulin. This will take care of the
energy requirement and avoid overloading the
circulation.
4. To avoid hypokalemia, infusion of Isolyte-M or
Pharmalyte-M is alternated with dextrose/dextrose
saline particularly when insulin is added to the drip.
Electrolytes other than potassium (35 mEq/l) are
replenished by this fluid.
PRACTICALITIES OF MANAGEMENT
1. In some diabetics it may not be possible to control

the FBG with a predinner bolus of soluble insulin;
resulting in a perpetually high FBG. This cannot be
controlled by increasing the soluble insulin predinner
as it may result in nocturnal hypoglycaemia. Such a
situation requires the addition of a small dose of
intermediate-acting insulin at bedtime. For example
if the FBG is 200 mg per cent with a dose of predinner
soluble insulin of 10 IU, one may attempt to reduce
the FBG by increasing the dose to 15 U. However,
this may result in nocturnal hypoglycaemia, whereas
combining soluble insulin with intermediate-acting
insulin in the ration of 2:3 (6U of soluble insulin and
MONITORING DURING SURGERY
A vital aspect of care is adequate blood glucose monitoring. This is generally done by nursing staff at the
bedside, using glucose-oxidase reagent strips, read either
visually or by meter. During intraoperative period the
blood glucose should be monitored every hour and less
frequently as necessary thereafter. The accuracy of these
monitoring methods may be poor, and validation with
occasional laboratory measurements may be advisable.
All hospitals that use reagent strips for diabetic monitoring
should have some form of quality-control system to
ensure reasonable accuracy, and all staff involved should
be carefully trained in their use. The other alternative is
to estimate the blood sugar in the laboratory by

conventional methods. A word of caution is that the blood
should not be drawn from the arm that is connected to
the infusion line, which may show a falsely high value.
Urine glucose monitoring during surgery is not safe
particularly when the patient is on intravenous glucose.
The results of urine glucose may be strongly positive when
the blood glucose may not be high. A large dose of insulin
given based on the strongly positive urine test for glucose
may produce deleterious hypoglycaemia.
Emergency Surgery
Emergency surgery is as likely if not more likely in the

diabetic than in the nondiabetic subject. Management
will depend to a large extent on the metabolic condition
of the patient. Surgical emergencies, particularly if there
is underlying infection, can cause rapid metabolic
decompensation with dehydration, hyperglycaemia, and
ketoacidosis. Uncontrolled diabetes may also be precipitated in patients not previously known to have diabetes.
The problem necessitating surgery may have led to
metabolic decompensation; this should first be corrected
if possible, unless the operation cannot be delayed.
Diabetic patients require close attention when admitted
for an emergency operation. The first priority is to assess
glucose control, level of hydration, and acid-base status.
Preoperative management will require an aggressive
approach to correct fluid and electrolyte imbalances,
reverse acid-base disorders, and optimise blood glucose
levels. Separate insulin and fluid infusion systems are
excellent for such intercurrent management. The insulin
dose (rate per hour) and fluid needs should be tailored
to each patient according to the severity of the metabolic
decompensation and the patient response. The
management of ketoacidosis involves higher insulin
infusion rate (0.1 U per kilogram of body weight per
51
hour). The infusion is generally preceded by an

intravenous injection of regular insulin (10 U). Adjustments are then made according to hourly blood glucose
levels. Once blood glucose values return to 240 mg/dl, 5
per cent dextrose should be included in the rehydration
fluids. Adequate potassium replacement is critical, as is
close monitoring of fluid balance, acid-base status,
electrolytes, and renal function. Once the patients
condition is stable for 4 to 6 hours, the operation can
generally be performed safely. It is important to note that
following reversal of the acute stressful condition lower
insulin infusion rates will be required for a given blood
glucose level.
Our aim is to make patients safe for surgery. For this
we need an understanding teamwork between the
surgeon, anaesthetist, and the diabetologist. When the
patient is under anaesthesia, The ideal is to have diabetic
therapy supervised by a diabetic team where available
(KGMM Alberti).
FURTHER READING
1. Alberti KGMM: Diabetes and surgery. Anaesthesiology 74:
209-11, 1991.
2. Gavin LA: Perioperative management of the diabetic patient.
Endo Met Clin N Am 21: 457-75, 1992.
3. Gill GV: Surgery in patients with diabetes mellitus. In: Pickup
J and williams G (Eds): Textbook of diabetes. London:
Blackwell Science Ltd. 12.1-12.7, 1997.
4. Hirsch IB, McGill JB, Cr yer PE et al: Perioperative
management of surgical patients with diabetes mellitus.
Anaesthesiology 74: 346-59, 1991.
5. Hughes TAT, Borsey DQ: The management of diabetic
patients undergoing surgery. Pract Diabetes 1: 7-10, 1994.
6. Alberti KGMM, Gill GV, Elliott MJ: Insulin delivery during
surgery in the diabetic patient. Diabetic Care S1: 65-77, 1982.
7. Hutchison AS, Shenkir A: BM strips: how accurate are they
in general words? Diabet Med 1: 225-26, 1984.
52
Management of
Hypertension in
Cataract Surgery
INTRODUCTION
Hypertension should be well-controlled during cataract

surgery like any other surgery. Several studies have documented that patients with hypertension have higher risk
of suffering from major cardiac complications during or
shortly after non-cardiac operations than the patients who
have always been normotensive. However, most of this
increase is because of IHD (ischaemic heart disease),
chronic heart disease left ventricular dysfunction, renal
failure or other abnormalities that often occur in the
patients of hypertension.
Blood pressure should be well-controlled prior to elective surgery and anti-hypertensive medications should
be continued throughout the preoperative period. If there
is a period in which the patient is unable to receive oral
medication, topical or intravenous equivalents should be
substituted. Rapid withdrawal of beta-blocking medications is associated with adverse effect on heart rate and
blood pressure and may precipitate myocardial ischaemia.
Definition of Blood Pressure
Definition of hypertension is difficult and by necessity is

arbitrary and there is no real separation between
PC Sexena
normotension and hypertension. The higher the blood

pressures the higher the risk of stroke and coronary
events. By JNC VI (1997) and WHO (ISH 1999), the
high blood pressure has been classified in the following
categories depending upon the level of diastolic as well
as systolic blood pressure based on average of more than
two readings taken at each of two or more visits.
Among patients who are treated for hypertension,
preoperative evaluation should include review of present
medications and any history of intolerance to previous
anti-hypertensive medications, assessment of adequacy
of anti-hypertensive therapy and for evidence of target
organ damage or associated cardiovascular pathological
conditions.
Before going for cataract surgery one must assess the
effect of hypertension on retina as it carries prognostic
significance and should carry out the following minimum
investigations to assess the target organ damage.
ECGleft ventricular hypertrophy, ischaemic heart
disease.
X-ray chestheart failure.
Blood urea and serum creatinineNephropathy
Urine examination
JNC VI (Joint National Committee) Guidelines

Systolic (mm Hg)
Optimal
<120
Normal
<130
High-normal
130139
Hypertension (> 2 reading at > 2 visits after screening)
Stage 1
140159
Stage 2
160179
Stage 3
>180
Diastolic (mm Hg)

and
and
or
<80
<85
8589
or
or
or
9099
100109
>110
Isolated systolic hypertension is defined when systolic blood pressure is 160 or above and diastolic is below 80 and the staging
is done by level of systolic blood pressure.
Management of Hypertension in Cataract Surgery
Clinical examinationheart failure, stroke, TIA

(Transient Ischaemic Attack) and peripheral vascular
disease.
Management
In patients with mild to moderate hypertension diastolic

blood pressure <110 mm of Hg and systolic blood pressure < 180 mm Hg, and in non-cardiac surgeries are
generally well-tolerated. However, severe hypertension
(Diastolic blood pressure > 110 mm Hg) should be wellcontrolled prior to cataract surgery. Patient with severe
hypertension in the immediate preoperative period are
at increased risk for perioperative MI and congestive heart
failure It is neither mandatory nor desirable to delay
cataract operation (Non-cardiac operation) for weeks or
months that may be required to achieve ideal blood
pressure control in stable patients who have mild to
moderate hypertension but who have no hypertensive
end-organ damage.
Patient on anti-hypertensive therapy are at increased
risk of perioperative hypotension also.
If surgery is urgent then preoperative blood pressure
control can be achieved rapidly with the use of intravenous beta-blockers, calcium blockers, nitroglycerin or
nitroprusside. Sublingual nifedipine should not be used
as it can precipitate myocardial ischaemia or myocardial
infarction.
In management of hypertension lifestyle modification
should be practiced for mild to moderate hypertension,
e.g.:
Lose weight if overweight.
Limit alcohol intake.
Increase aerobic exercises.
Reduce sodium intake (< 100 m mol/day).
Maintain potassium intake (90 m mol/day).
Maintain calcium and magnesium intake.
Stop smoking and reduce saturated fats.
The drug therapy should be started with diuretics and
beta-blockers in uncomplicated case. The isolated systolic
hypertension in elderly, which is very common in the
53
patient of cataract, can be treated with long acting calcium

channel blockers. The hypertensive diabetic patients
going for cataract surgery should be controlled on ACE
inhibitors. A hypertensive patient with angina, the drug
of choice is beta-blockers. Thus, the drug therapy should
be individualised according to the presence of concomitant disease.
CONCLUSION
Blood pressure should be well-controlled prior to cataract

surgery and anti-hypertensive medication should be
continued through out the perioperative period. In postoperative period the blood pressure should be carefully
monitored as some patients on anti-hypertensive therapy
may have hypotension. Mild to moderate hypertension
in the absence of significant coronary or myocardial dysfunction does not add significantly to the cardiovascular
risk of cataract (Non-cardiac) surgery.
SUGGESTED READING
1. Elliott HL, Connel JMC, GT Mcinner: The year in Hypertension 2000.
2. Eugene Brawnwaid, Douglas P Ziges, Peter Libby: Heart
Disease: A Textbook of Cardiovascular Medicine, (6th ed):
2001.
3. Goldman L, Caldera DL: Risks of general anaesthesia and
elective operation in the hyper tensive patients.
Anaesthesiology 79, 50: 28592.
4. Hurst S, Valentin Fuster, R Wayne Alexander, Robert A,
O Rovrice: The heart (10th ed): 2001.
5. Hypertension control: Report of a WHO expert committee,
WHO technical report series. 862, 2000.
6. Kapllan M: Clinical hypertension: Normal (7th ed): 2000.
7. Magnussen J, Thulin T, Wernex O et al: Hemodynamic effects
of pretreatment with metoprolol in hypertensive patients
undergoing surgery: Br J Anaesth 86, 58: 25160.
8. PrysRoberts C, Meloche R, Foex P: Studies of anaesthesia
in relation to hypetension: I Cardiovascular responses of
treated and untreatede patients: Br J Anaesth 71, 43: 122.
9. Stone JG, Foex P, Sear JW et al: Risk of myocardial ischemia
during anaesthesin treated and untreated hypertensive
patients. Br J Anaesth 88, 61: 67579.
54
Preoperative
Evaluation for SICS
n all types of surgeries good preoperative evaluation

helps in giving great postoperative results and more
importantly a grateful patient. The usual pattern of
preoperative examination especially for SICS should be
following:
Detailed History
Detailed History of patient should be taken:

1 Diabetes These patients are likely to have more
incidence of postoperative uveitis, neovascularisation of iris and diabetic retinopathy. Therefore, a
diabetic should be thoroughly examined.
2. Hypertension If history of hypertension is present
it should be well-controlled, to prevent any untoward
incidence of expulsive hemorrhage.
3. Ocular history History of recurrent redness, pain,
discharge and previous treatment must be asked.
4. Refractive error Patient should be asked whether
patient is ammetropic or emmetropic at the age of
40 years. It is important from two angles:
i. IOL power calculation
ii. Scleral rigidity is low in myopic. Nucleus delivery
becomes difficult in these cases.
Examination
Detailed examination under slit lamp gives many clues.

i. Corneal endothelium can be examined by using 25x
or 40x ocular by using specular reflection, or by
using Eisner lens. By these two techniques good
assessment of corneal endothelium can be made. It
helps in excluding patients having low endothelial
cell count e.g. in Fuchs dystrophy, glaucoma, chronic iritis, trauma, old keratitis, multiple injuries and
old age. Keratic precipitates should also be looked
for.
ii. Iris pupil examination under slit lamp Any evidence
of posterior synechiae, pigments on lens, or bound
iii.
iv.
v.
vi.
vii.
Kamaljeet Singh
Sumeet Jain
down pupil can be easily assessed under slit lamp.

Pupil should also be examined after dilating it. It
will give further details for iris and also help in
knowing whether pupil dilates easily or not.
Lens examination Preoperative examination of lens
should be done by dilating pupil because it is easier
to assess the grade of hardness of cataract.
Fundus examination Fundus should be examined
by +78D lens under slit lamp. It gives a very good
view of macula even if media is hazy due to lenticular
changes. It will avoid surprise postoperative findings
of macular degeneration, diabetic maculopathy and
optic atrophy.
Hypotony Hypotonic eye is not suitable for SICS
become making a scleral tunnel in a hypotonic eye
is very difficult and there are chances of tunnel
getting ragged.
Most important aspect of SICS is expressing the
nucleus in the anterior chamber out of capsulotomy
or capsulorhexis. In a hypotonic eye prolapsing the
nucleus in AC expression of the nucleus becomes
very difficult. Hence it is advisable not to apply pinky
ball before the operation. Instead gentle massage
of the eye can be done after giving peribulbar
injection
Age of the patient As the age advances the size and
hardness of the nucleus increases. The size of the
lens at the age of 65 years is 1/3rd more than at 25
years. Hence very old patients with hard and large
nucleus are not suitable cases for SICS. This is the
preferred choice of surgery for comparatively young
patients. Therefore in older persons if we are doing
SICS, the incision should be comparatively bigger.
Small pupil Small contracted pupil makes capsulotomy or capsulorhexis very difficult. Prolapsing the
nucleus in anterior chamber becomes almost
impossible and hence it is better to do ECCE than
SICS.
Preoperative Evaluation for SICS
viii. Eyes with uveitis The patients who had recurrent

episodes of uveitis along with synechiae are not
suitable because of the following reasons.
a. Proper capsulorhexis or capsulotomy is difficult
as the pupil does not dilate fully because of the
adhesions between the capsule and iris.
b. Prolapsing the nucleus in AC is difficult.
c. There are more chances of PC rent and vitreous
prolapse as the posterior capsule is weak in these
cases.
d. Postoperative inflammation is more in patients
with uveitis.
e. There are chances of miosis, zonular weakness,
raised IOP and CME. SICS should better be
avoided in these patients or else can be done
under cover of steroids. Prednisolone one mg/
kg daily should be given one week prior to the
surgery.
ix. Patients who have undergone glaucoma filtering
surgery are not ideal for non-phaco SICS because
of hypotony.
x. Fuchs endothelial dystrophy In this, there occurs
bilateral non-inflammatory loss of endothelium.
Since in SICS the nucleus is prolapsed in the AC
55
before its expression, manipulations in AC will lead

to significant endothelial cell loss.
xi. There are few other conditions in which the technique should not be done.
a. Microphthalmos Here one has to make a very
large incision as nucleus is very large. Moreover,
there are increased chances of vitreous loss and
other congenital anomalies.
b. Extensive congenital anomalies
c. Rubella cataract
d. Rubeosis iridis
e. Subluxated lens
To summarise, the key to successful manual SICS is
proper selection of the cases for that the patients have to
be thoroughly examined, screened and planned
accordingly.
FURTHER READING
1. Natchear G: In Manual small incision cataract surgery. Arvind
Publications, India 2000.
2. Rozakis GW: In: Cataract Surgery: Alternative small incision
technique. 1st (edn): Thordofare, Inc. 1995.
3. Shah Anil: In small incision cataract surgery (Manual Phaco)
Best out of Waste Bhalani Publishing House: India. 2000.
56
Biometry
9
D Swarup
ens implantation surgery is a one-time surgery.

The refractive power of the pseudophacos is final
and the patient must live with any mistake
committed or be subjected to a very dangerous operation,
namely to the removal and replacement of the intraocular lens. Later correction is only achieved with extraocular aid in the form of glasses or contact lens.
So to ensure that our patients have the optimal
correction, the power of the lens to be implanted must
be determined individually in every case.
The problem of implant power calculation arose along
with the first ever IOL implant, when Ridley in 1949
observed in his patient a postoperative refraction of
24.0 D + 6.0 30. Ever since, various workers have
been working on this problem of implant power
estimation to obtain the best result.
The methods used to estimate implant power might
be classified in two broad heads:
1. Methods based upon primary refraction.
2. Methods based upon measurement, viz axial length,
corneal curvature, etc.
in the posterior chamber would be further away from

the retina than the natural lens.
Such lenses in which the pre and postoperative
refraction remains the same are called Idem lenses.
Depending upon the plane of placement of the optic,
the power of the IOL will vary in any given eye. The
Table 9.1 gives the power for idem lenses depending
upon the plane of placement.
Table 9.1: Rules of thumb for idem lens
Description of lens
Description of
lens in short
1. Angle supported lenses

2. Iris clip lenses
3. Iris plane lenses
4. Lens in posterior chamber close to
iris convexity of optic facing forward
5. Posterior chamber lens with nodal
point closure to the retina than with PCL
6. PCL with haptic angulated forwards and
convexity of optic towards retina
AACL
ACL
Power in
diopter
PCL
+ 17.00D
+ 18.00D
+ 19.00D
+ 20.00D
PPCL
+ 21.00D
PPPCL
+ 22.00D
(+ 22.50D)
Emmetropia Lenses
Estimation of Implant Power
Based on Primary Refraction
In the early days this method was the most used method.
The following assumption is made while adopting this
method of IOL power calculation:
1. The refractive power of the natural lens is + 23.7 D.
2. The cardinal plane of the natural lens is 6 mm
behind the corneal apex.
3. The radius of curvature of the cornea and the
distance between the lens and the retina do not vary
between patients.
If the above conditions are true, then the placement
of an IOL with a power of + 20.0 D in the posterior
chamber would result in a postoperative refraction equal
to that existing preoperatively. It explains that an IOL of
+ 20.0 D would be sufficient to mimic the natural lens
of + 23.7 D, because the cardinal plane of the IOL placed
While idem lenses are sufficient for patients who are preoperatively emmetrope, for patients with known refractive
errors, it would be more desirable to implant a lens which
would result in emmetropia postoperatively. The
following formula gives the implant power required for
emmetropia.
IOL power for emmetropia = Idem lens power + (1.25
Refractive error)
Example:
For a preoperative myopia of 2.00 D
PCL power
= 20.00 + (1.25 2.00)
= 20 2.5
= 17.5D
For a preoperative hypermetropia of + 1.00 D
ACL Power
= 18.00 + (1.25 +1)
= 18.00 + 1.25
= 19.25D
Biometry
One should remember while trying to fit emmetropising lenses, it is pertinent to note that the preoperative
glasses used by the patient need not reflect his/her real
refraction. A careful history will overcome this problem.
Limitations
Estimation of IOL power based on refraction suffers from

the basic assumption that the power of the natural lens
is + 23.7 D. Though this may be true in a majority of
cases. Postoperatively, the use of this method more than
often leads to very high refractive errors. The clarity of
an image on the retinal surface of a persons eye is determined by the sum total of:
a. The refractive power of the corneal surface
b. Power of the lens
c. The distance between the lens and retina.
Each of these factors is variable from person to person
and eye to eye. The refractive power of the corneal
surface could vary from +39 D to + 49 D, and that of
the crystalline lens from + 17 D to +27 D. The length of
eyeball, which in turn determines the distance of the lens
from the retina, varies from < 20 mm to about 28 mm.
Thus in a real situation a highly refractive corneal surface
may be compensated for by a short eye to result in
emmetropia or vice versa.
Implant Power Calculation
Based on Measurements
With the advent of keratometry and A scan sonography,

which provided accurate measurements of the radius of
curvature of the cornea and the length of the eyeball,
two important parameters required for a precise estimation of implant power.
Theoretic Formulas
It was not until 1967 when Fyodorov presented his

theoretical formula based on geometric optics utilizing
keratometry and A scan ultrasonography that implant
power calculation matured into a rational discipline.
In addition to Fyodorov and Colenbrander, Thijssen,
van der Heijde and Binkhorst published theoretical
formulas. These formulas are all based on geometric
optics as applied to schematic eye using theoretical
constants. These apparently different formulae are in fact,
identical, except for correction factors. They all can
algebraically transformed to
P=
n
L ACD
nk
n K ACD
57
Where
P = Implant power for emmetropia

n = Aqueous and vitreous refractive index
ACD = Estimated postoperative anterior chamber depth in mm
L = Axial length in mm
K = Corneal curvature in diopter
Different theoretical formulae were described by
different workers from time to time as follows:
Fyodorov
P=
Colendrander P =
Van der Heijda P =
Binkhorst
Here
P=
P=
N=
L=
K=
C=
R=
N LK
(L C) (I CK/N)
N
LC
N
LC
N
N/N C
I
I/K C/N
(NR/0.333 L)
[L C (NR/0.333 C)]
IOL power for achieving emmetropia

Refractive index of aqueous and vitreous
Axial length in mm
Keratometry in diopters
Postoperative AC depth in mm
Radius of curvature in mm.
Empiric Formula
A few workers, including Gills, Sanders, Retzlaff and Kraff

developed regression equations based on observed
clinical data relating to eye measurements and IOL power.
From these equations they developed formulae for
predicting IOL power. These formulae claim more
accuracy in predicting implant power than theoretic
formulae. These are also subject to change as more data
are incorporated into developing and regression
equations.
Among these the SRK formula developed by Sanders,
Retzlaff and Kraff has gained wide acceptance because
of its ease of use.
SRK Formula
Where
P=
P=
L=
K=
A=
A 2.5 L 0.9K
Implant power to produce emmetropia
Axial length in mm
Average keratometer reading in diopter
Specific constant for each lens type and/
or manufacturer.
58
As it can be seen from above formula, a change in the

axial length of by 1 mm results in a 2.5D change in
implant power or a change in corneal refractive power
by 1D results in a 0.9D change in implant power.
The theoretical and empiric formulae worked well for
eyes of axial length ranging from 22 to 4.5 mm. For eyes
of short or long axial length, while the theoretical
formulae predicted too high or too low emmetropia value
respectively. The SRK formula had the opposite effect.
To overcome this problem the second generation
formulae were developed. The SRK II formula was
developed where the basic SRK formula remained
unchanged but some additional computations were
necessary to suit short/long eyes.
If axial length is 20 to 21 mmadd 2 diopter to

emmetropia value
emmetropia value
Adjusting Original SRK to SRK II
Large Ammetropic Postoperative

Refraction Desired (More than 1.5D)
Average length eye No adjustment needed unless high

ametropia desired (Figs 9.1a to c).
SRK II Formula:
P = A 2.5 L 0.9 K + C
C = SRK II correction for long and short eyes.
Short Eyes (Less than 22 mm)

emmetropia value
Example The patient has a 20.73 mm axial length eye

and the original SRK formula shows 24.7 D IOL will give
emmetropia. Add 2 D to this emmetropia power 24.7 +
2 = 26.7 D for correct emmetropising power.
Long Eyes (More than 24.5 mm)
If axial length is more than 24.5 mm subtract 0.5 D from

emmetropia value.
If the postoperative refraction desired is more than

1.5 D in nonmyopic patients or more than 0.75 D in
myopic patients (Axial length greater than 24.5 mm) use
following:
IOL for desired refraction = Emmetropia power
(RF Desired refraction)
RF = 1.25 if emmetropia power greater than 14
RF = 1.00 if emmetropia power less than 14
Figs 9.1a to c: Diagram (a) showing the height of corneal dome, (b) with PC IOL showing the offset from the calculated
iris plane to optical place and (c) showing retinal thickness, ultrasonic axial length and optical axial length
Biometry
SRK/T
It is in theoretical formula developed using the non-linear

terms of physiologic optics and impirical regression
methodology for optimisation. It utilises the corneal
height formula for predicting postoperative ACD and an
axial length correction factor (Retinal thickness) which
varies with eye length.
Emmetropia should be the Goal
1. When bilateral pseudophakia is planned

2. When there is hypermetropia of 1.5 D to 2.5 D in an
useful fellow eye.
3. When there is known or suspected absence of
binocular vision
4. When senile macular choroidal degeneration is present
in both eyes
5. When a contact lens is used in an aphakic fellow eye.
59
lead to a decrease in the power of the lens by

0.75 D.
b. Meniscus optic Flipping of this lens is mechanically
difficult and is not recommended. However such a
flipping would lead to the displacement of the
principal axis posteriorly, thereby decreasing the
effective power.
c. Biconvex optic There is no change in the power if
both the surfaces are equally convex. Most IOLs have
3:1 ratio in convexity between anterior and posterior
surfaces, thus reversal of the optic would decrease
the effective power.
Apart from these, the other factors which affect the
accuracy of the implant power are differences in the
ultrasound equipment used, surgical technique, postoperative chamber depth, postoperative change in corneal curvature and manufacturing variation in implant
power labeling.
Ammetropia should be the Goal
The only indication to make the eye ammetropic exists

in unilateral pseudophakia.
Factors affecting accuracy of implant power calculation.
Axial Length Measurement
Two methods are currently used for the measurement

of the axial length. They are the applanation and
immersion technique. In the applanation method the
applanating probe is kept on the cornea, whereas in the
immersion method the probe does not come into direct
contact with the cornea but acts through an intermediary
coupling solution. In the former method there is
possibility of a slight depression of the eye leading to a
lower estimate of axial length. This is of significance in
very short eyes.
Keratometry
This is another probable source of error because in

manual keratometry, failure by the operator to calibrate
for his/her refractive error, could lead to wrong reading.
Autokeratometers are not subject to this error. It would
be better if the refractive power of the cornea is estimated
from the radius of curvature of the cornea rather than
measure the refractive power directly.
Orientation of the Implant
a. Plano convex optic The normal position is with

convex surface forward, flipping of the lens would
Surgeons Personal A Constant
Quite often differences between the expected and the

observed postoperative refraction were noted by
Sanders et al despite the use of the same style and make
of the IOL. They were able to trace this anomaly to be
due to differences between surgeons. Based on their
studies they are able to develop a method for calculating
personal A constant for each surgeon. This calculation
may be done retrospectively from records or on continual
basis. It is important to calculate separate A constant for
each style/make of the lens. The following data are
required for the same.
A1 = I + (Ra Rf) + 2.5L 0.9K C
Where A1
I
Ra
Rf
L
K
=
=
=
=
=
=
The individual A constant

Power of implant
Postoperative refraction (D)
Refraction factor
Preoperative axial length
Preoperative average keratometer
reading (D)
C = Short/long eye correction.
FURTHER READING
1. Hoffer KJ: The Hoffer Q formula: A comparison of theoretic
and regression formulas. J Cataract Refract Surg 20: 677,
1994.
2. Olsen T, Oleson H, Thim K et al: Prediction of postoperative
intraocular lens chamber depth. J Cataract Refract Surg 16:
587-90, 1990.
60
3. Retzlaff J: A new intraocular lens calculation formula. Am

Intra-ocular Implant Soc J 6: 148, 1980.
4. Retzlaff, Sanders DR, Kraff MC: Development of the SRK/T
intraocular lens implant power calculation formula. J Cataract
Refract Surg 16: 333-40, 1990.
5. Sanders DR, Kraff MC: Improvement of intraocular lens
power calculation: Regression formula. Am Intra-ocular
Implant Soc J 6: 263, 1980.
6. Sanders DR, Retzlaff J, Kraff MC: Comparison of the SRK II

formula and the other second generation formulas. J Cataract
Refract Surg 14: 136-41, 1988.
7. Sanders DR, Retzlaff J, Kraff MC et al: Comparison of the
accuracy of the Binkhorst, colenbrander and SRK implant
power prediction formulas. Am Intra-ocular Implant Soc J
7: 337-40, 1988.
Ocular Anaesthesia
Ocular Anaesthesia
10
61
Kamaljeet Singh
VK Srivastava
ost of the ocular surgeries can be performed

under local anaesthesia. However, local
anaesthesia is the best for SICS. We will describe here various types of local anaesthesia used in
cataract surgery.
Following blocks are used:
Retrobulbar
Peribulbar
Sub-Tenons
Topical
Intracameral
Retrobulbar Anaesthesia
This was the preferred anaesthesia till eighties for cataract

surgery. Its advantage is that it gives very good anaesthesia and akinesia in very small volume. 1.5 to 2.0 ml is
enough to give a very good effect. The technique is
simple. A special 4 cm long 26 gauge retrobulbar needle
is used for this purpose (Fig. 10.1). One ml xylocaine
mixed with equal amount of bupivacaine with freshly
prepared hyaluronidase (15 units per ml) is taken in a
2 cc syringe. Lower orbital margin is palpated and we go
behind the eyeball close to the orbital margin at the
junction of medial two-third and lateral one-third.
Previously it was the practice to ask the patient to look
up and in. In this position there are chances of damaging
the optic nerve sheath and the macula also comes closer
to the needle. Therefore, now the patient is just asked to
look straight or even down to prevent the injury to optic
nerve. In retrobulbar block we get two resistance. One,
while piercing the skin. Other, when we pierce the muscle
cone since our aim is to block the ciliary ganglion, which
lies within the muscle cone about 7 mm anterior to orbital
apex. Following effects are achieved with retrobulbar
block.
It causes anaesthesia
It causes akinesia
Fig. 10.1: Retrobulbar anaesthesia

Courtesy: Alcon (India)
It causes a little proptosis, which is helpful in performing the surgery.

It reduces the intraocular pressure.
It dilates the pupil
Complications
Brainstem anaesthesia This leads to respiratory arrest.

It occurs when the needle pierces the optic nerve sheath.
Through the subarachnoid space the local anaesthetic
may reach in the brain. The symptoms start within two
minutes of injection and start with confusion, cranial
nerve palsy, convulsions, hemiplegia, quadriplegia,
cardiovascular instability and even respiratory depression
and arrest. The whole episode may take 20 minutes to
set in. Although the injection into the optic nerve is
supposed to be the mechanism behind this, yet the exact
mechanism of this complication is not very clear since
some other authorities believe that hyaluronidase could
also be responsible for this.
Retrobulbar haemorrhage The orbital apex is highly
vascular structure. There are all likelihood of rupturing
the vessels, which lead to retrobulbar haemorrhage.
When it occurs there is sudden proptosis and lids become
tight. The operation in such situation is postponed after
doing a patch.
62
If the pressure is too much then the lateral canthotomy

can be done to decompress the globe. Retrobulbar
haemorrhage, in rare instances, can lead to optic atrophy.
The exact mechanism, whether it is as a result of direct
injury or because of the compression of the optic nerve
is not clear. Central retinal artery block has also been
reported due to retrobulbar haemorrhage.
Optic nerve sheath injury There are chances of hitting

the optic nerve sheath, which can lead to optic atrophy.
This can be prevented by asking the patient to look
straight rather than look up and in while injecting.
Globe perforation This can also occur while injecting.
To prevent this disaster the needle should first be directed
straight backward till you reach the equator of the eyeball.
After that it should be directed towards the occiput. If
globe perforation is suspected, wait for a while and ask
the patient to move his eyes gently. If the needle is in the
globe or in the sclera the needle will also move. The
diagnosis is made by seeing the hypotony, absence of
red glow and pain. In this case the needle should be
withdrawn and the examination by indirect
ophthalmoscope should be done. The extent of the injury
is related to the depth of perforation. If the needle
perforates only the sclera, then it heals by a simple scar.
In case it pierces the choroid, then there are chances of
choroidal haemorrhage, and if it enters the retina, then
retinal holes and detachment can occur. If the fluid is
injected inside the vitreous then there are chances of
severe reaction from the contents of the anaesthetic
used and from its preservative too. Intraocular pressure
may also rise. If intravitreal haemorrhage is present, the
patient should be referred to a vitreoretinal surgeon.
Contraindications include bleeding disorders, extreme
myopia and posterior staphyloma.
Peribulbar Anaesthesia
This is most commonly applied technique nowadays. In

retrobulbar technique we have to go in the muscle cone.
It may lead to retrobulbar haemorrhage, injury to optic
nerve and other complications enumerated above. All
these complications can be avoided in peribulbar
technique. Here the aim is to go around the eyeball. A
5cc syringe with 24 G needle is taken. In this we take 5
to 6 ml cocktail of xylocaine and sensocaine in equal
quantity and hyaluronidase in a concentration of 1.5 units
per ml. Xylocaine with adrenaline is better if it is not
contraindicated otherwise. Lower orbital margin is
palpated and at the junction of medial two-third and
lateral one-third 3 ml of already prepared cocktail is
injected around the eyeball. The remaining cocktail is

injected at a site at the junction of medial one-third and
outer two-third of upper orbital margin. One should take
care to avoid the walls of eyeball and also the conjunctiva.
Ocular massage is given for ten minutes if plain ECCE is
planned but massage should be avoided if manual phaco
is planned.
Other sites for giving the peribulbar block are:
Superior
Medial
The superior site In this technique the needle goes
through upper fornix. The patient is asked to look down
and in. The needle passes at a tangent. Since the direction
is upward there are no chances of globe rupture. It also
blocks orbicularis and superior rectus is also knocked
off. This prevents Bells phenomenon.
The medial site Here the needle passes through the
caruncle and medial canthal tendon. There is a big space
between medial orbital wall and wall of the eye. The
only vessel that can come in the close proximity is anterior
ethmoidal artery and vein which lies much above the
track of the needle. It also gives a good effect and can be
used as an adjunct.
Complications
Conjunctival chaemosis This is seen quite commonly.

While injecting, the needle passes into the conjunctiva.
The chaemosis goes off after the massage.
Globe perforation The signs and symptoms are described above. Here the emphasis is laid on the point that
the globe perforation can occur in peribulbar block also.
Initially there was an impression in the minds of the
surgeons that it does not cause globe perforation. But
the reported incidence of perforation are equal in both
peribulbar and retrobulbar anaesthesia.
Oculomotor problems The oculomotor problems associated with local block are transient diplopia extending
for one or two hours. But some cases of prolonged diplopia are reported. At times ptosis can also occur. These
complications usually resolve in due course.
The subconjunctival route It has also been tried, but
has not been widely accepted by ophthalmologists. The
injection is given at superior limbus after putting topical
xylocaine 4 per cent drops. Ocular massage is given.
Facial block is also required. This injection may also cause
accidental globe perforation. In addition, there are
chances of weakening of superior rectus. Moreover,
akinesia is not complete. Therefore this anaesthesia has
not been used commonly for ECCE, but it may prove to
be good for phacoemulsification.
Ocular Anaesthesia
Sub-Tenons block This block is favourable to both

phaco and non-phaco surgeons and can be also used in
case the patient is not ready for injection into the skin.
The site chosen is inferonasal or inferotemporal. But
inferotemporal is best avoided since inferior oblique lies
there. After instilling topical xylocaine 4 per cent drops,
a snip is given in the conjunctiva and also in the Tenons.
For assuring that the space is sub-Tenons an iris repositor
can be passed in the sub-Tenons space. Then a blunt
tipped cannula is taken and 2 cc of cocktail is injected
after reaching posterior to the equator. The advantage
of injecting posterior to the equator is that Tenons capsule
is deficient posteriorly and the fluid goes directly into the
muscle cone. Therefore excellent akinesia is obtained.
Since sensory nerves cross the Tenons capsule immediate
anaesthesia is obtained. If cannula remains anterior to
the equator there are chances of proptosis. The only disadvantage seems to be a snip into the conjunctiva and
also chances of subconjunctival haemorrhage. Therefore,
some surgeons prefer giving this block in the upper
quadrant. In case there is haemorrhage, it is covered by
the lids (Fig. 10.2).
63
Facial Nerve Blocks
Facial nerve supplies the orbicularis oculi muscle. The

action of this muscle is squeezing the lids. Its block is
essential to avoid this action. Facial nerve block is
maximally needed as an adjunct when retrobulbar block
has been used. But at times it may be of great help in
case peribulbar block does not achieve the full block of
orbicularis. Phaco and non-phaco surgeries can be done
without blocking the action of orbicularis because these
are closed chambered technique, but not the ECCE
wherein the chamber is open. It may lead to the contents
coming out of the eyeball. Several blocks have been
described but the most commonly used are being
described here.
Nadbath and Rehman Block
This block uses the anatomical fact that the facial nerve
passes below the mastoid process. The injection is given
in the triangular space below the mastoid. I have seen
Dr Momose using this technique in eighties. Usually this
technique is not used because it blocks all the branches
of facial nerve thus affecting half of the face. The vagus
nerve and the glassopharyngeal nerves lie close in this
area. Their block may lead to speech defect, drinking
and swallowing problems. Permanent facial paralysis has
also been reported.
Obrien Block
Fig. 10.2: Parabulbar or sub-Tenons anaesthesia

Topical Anaesthesia
Phacoemulsification is now commonly performed under

topical lignocaine. Paracaine is better as it does not cause
any stingy sensation. These drops instilled 5 minutes
before the surgery are very useful in anaesthetizing the
cornea. But the sensation in the iris remains. For that
intracameral lignocaine 0.5 ml can be used. It anaesthetises the iris. Thus there is no pain even if the iris is
touched by mistake. The advantage of this technique is
that there is no need of patching the eyeball and all the
complications of retro- and peribulbar are avoided. The
disadvantage is that only phaco can be done with this
technique. ECCE or nonphaco small incision should not
be done under topical.
Facial nerve crosses the neck of the mandible before

entering the parotid gland. This injection is given after
palpating the temporomandibular joint by asking the
patient to open his mouth. About half an inch below this
lies the facial nerve close to the anterior border of
mandible. Four to five ml of lignocaine is injected into
this area. The massage is must after that because nerve
lies deep. It can affect both the upper and lower branches.
Van Lint Block
With this block all the branches going to the orbicularis

can be blocked. Facial nerve gives branches to orbicularis
about 1 cm away from the lateral orbital margin in its
lateral angle. 3 to 4 ml is injected deep in this site above
the superior orbital margin, below the inferior orbital
margin and back starting from the site described above.
The only problem with this technique is its close proximity
to the operation site as it is likely to cause haematoma
formation.
There are some neuro-ophthalmic reflexes that one
needs to remember. These are as follows:
64
Oculocardiac reflex This gets precipitated when there

is pressure, torsion or pulling on the extraocular muscles.
Its signs and symptoms are sinus bradycardia, ectopic
beats or may be sinus arrest. Prophylaxis and treatment
include IM or IV atropine injection. Its pathway is through
long and short ciliary nerve to ciliary ganglion. Efferent
pathway is through vagus nerve.
reflex. Efferent are via a connection between trigeminal

sensory nucleus and pneumotaxic centre in pons and
medullary respiratory centre.
Oculorespiratory reflex Its signs and symptoms include

shallow breathing, brachypnoea or even respiratory
arrest. Its prevention and treatment include controlled
ventilation especially in children undergoing squint
surgery. Its afferent are same as that of oculo-cardiac
FURTHER READING
Oculo-metric reflex It is not well understood. It induces

vomiting and occurs as a result of pull on extraocular
muscles.
1. Jaffe Norman S: Atlas of ophthalmic surgery; JB Lippincott:

1990.
2. Amar Agarwal: Phacoemulsification, laser cataract surgery
and foldable IOLs; Jaypee Borthers, India: 2001.
Anaesthetists Role in Ocular Surgery
Anaesthetists Role in
Ocular Surgery
eneral anaesthesia in the medical armamentarium has been rightly credited for the develop-ment and progress of modern surgery. It was
called a day when on 16th Oct. 1846 WTG Morton at
Massachusetts General Hospital, USA demonstrated
successful ether anaesthesia and surgeon TC Warren
declared, Gentleman this is no humbug but a reality.
With the development of general anaesthesia, surgery
progressed but due to lack of present day technology,
advanced anaesthetic delivery equipment to maintain a
controlled blood level of anaesthetics and adjuvant drugs
to reduce unwanted effects like nausea and vomiting.
Surgeons had difficulty in operating upon eye, face, oral
cavity, etc. the area, which was already covered by anaesthetic mask. Immediate unpleasant and violent postoperative recovery associated with nausea and vomiting were
not desirable in few operations like intraocular surgery
where it might had lead to the complications like raised
intra-ocular tension and consequent possible vitreous
prolapse. Therefore, ophthalmologists were continuously
in quest of an anaesthetic technique, which would have
not interfered in consciousness and devoid of aforesaid
side-effects.
Coca leaves were believed to be gift to the Incas from
Manco Capac, son of the God Sun to suppress the agony
of mankind. Later even the operator was allowed to chew
coca leaves and trickle his saliva over the wound of the
patient to get rid of pain indicating its local analgesic
properties. But it was only Karl Koller in 1884 an associate
of famous psychoanalyst Sigmund Freud and intern in
ophthalmology in Vienna, who noted that topical use of
cocaine drops in frogs eye desensitized the cornea and
he was able to pierce it with needle without any reflex
action. He and his colleague Joseph Gartner then desensitized their own everted eyelids that gradually led to the
much-wanted present day local anaesthetic techniques
for ophthalmic operations from instillation to infiltration.
Presently many techniques from topical to nerve blocks
are available to produce local eye analgesia and akinesia,
65
11
HC Chandola
which under normal circumstances can be applied by

surgeon himself. At this juncture a simple question can
arise, Is there any need of anaesthesiologists in ophthalmic operations?
It is not only ophthalmology, but in all those field,
where the concept of minimum invasive surgery, endoscopic surgery or laser or shock wave procedures are
coming up the same question may came up spontaneously.
In reference of ophthalmic surgery following few of
the important reasons will justify the vital presence of
anaesthesiologist in ophthalmic operation theatre:
1. All operations on eye, e.g. orbit, ptosis, reconstruction with fascialata sling or team surgery requiring
help of other specialities as in rotation of graft for
aesthetic purpose cannot be performed under local
anaesthesia.
2. In cases of infants and children from simplest probing
or congenital cataract, enucleation for retinoblastoma to trauma repair general anaesthesia is
required to avoid inconvenience and mental trauma
to the patient.
3. Many of the eye ailments requiring surgical correction including cataract are aging processes and
these patients usually have other age related
problems. Such patients may have bronchial asthma
or bronchitis and any attack of cough or breathlessness during surgery may seriously effect the
outcome of surgery. Many of these patients are
diabetic, hypertensive or have ischaemic heart
disease or renal disease requiring special attention
during perioperative period. An anaesthesiologist
is fully capable of giving respiratory and cardiovascular support and managing the crisis other than
administering general anaesthetics.
Few of the patients feel disturbed or suffocated
psychologically when an eye and face cover is put
for draping purpose unless they are adequately
sedated.
66
4.
5.
6.
7.
Uncooperative, mentally confused, psychotic,

paled, severely deaf patients and those having
involuntary movements may necessitate general
anaesthesia.
If sensitivity to local analgesics is rare the overdose
toxicity either by real overdose of the drug or due to
inadvertent intravascular injection is not an uncommon happening leading to incoherent confused
behaviour, perspiration, bradycardia, etc. If left
ignored it may leave behind morbidity or even
mortality.
It is one of the most frequent demands from the
patient to remain unconscious during operation due
to fear and anxiety. Majority of the patients after
explaining the procedure get ready to be operated
under local analgesia but still a small fraction of
patients demand general anaesthesia. In the event
of an unsuccessful or partially successful block again
either deep sedation or general anaesthesia will be
required.
In case of any unforeseen life-threatening event like
the well-known oculo-cardiac reflex if anaesthesiologist is already present in operation theatre majority
of such problems can be checked to happen or
treated effectively quicker and faster as in case of
resuscitation the importance of time factor is wellrecognized.
To be guarded against medicolegal aspect the role
of an anaesthesiologist is very vital in operation
theatre irrespective of any speciality.
It is not only a dictum but also a practical reality
that no anaesthetic whether local or general should
be administered unless there is provision for artificial
ventilation. Some minimum equipments, drugs and
monitoring systems should be there for the purpose
of resuscitation in case of any eventuality.
Minimum Equipment
i. Equipment to artificially ventilate the patient, preferably an anaesthesia machine or an AMBU bag with
the provision of oxygen supplementation.
ii. Oxygen cylinder with a flow meter with provision
of connecting an oxygen delivery tube with nasal
prongs, nasal catheter, poly or ventimask. Those
patients who had history of asthma, myocardial
ischaemia or feeling of suffocation under facial
drapes should be given 2-4 litres oxygen flow per
minute via a tube with binasal prongs as unlike a
iii.
iv.
v.
vi.
vii.
mask it does not cause any tenting of drapes and

thus causing inconvenience to surgeon.
Guedels oropharyngeal airways to prevent fall back
of tongue in a sedated patient.
A suction apparatus
Magills throat cleaning forceps
Laryngoscope
Endotracheal tubes of different sizes with connectors
to ventilation equipment.
Minimum Drugs (Mostly in Injectable Form)
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
xiv.
xv.
xvi.
xvii.
xviii.
xix.
xx.
xxi.
Atropine
Adrenaline
Dopamine
Dobutamine
Preservative free 2 per cent lignocaine (Xylocard)
Ephedrine or mephenternamine
Hydrocortisone
Frusemide
Antihistaminic (Avil)
Analgesics likemorphine, fentanyl, pentrazocine
or tramadol
NSAID analgesics, e.g. diclofenac sodium
Midazolam or diazepam
Thiopentone sod. or propofol
Ketamine (intraocular surgery contraindicated)
Succinylcholine
Sodium bicarbonate (8.4 vol.%)
Sorbitrate tablets
Nitroglycerineinjections, tabs, ointments and
patches
Nitrous oxide gas
Intravenous cannulas
Adequate number of disposable syringes.
Minimum Monitoring
The following monitoring systems should be available:

i. Stethoscope
ii. Sphygmomanometer to measure blood pressure at
regular intervals preferably self-reading electronic
instrument to avoid repeated use of stethoscope.
iii. Pulse-oximeter It is one of the most valuable noninvasive monitoring systems measuring peripheral
arterial oxygen saturation (SpO2) usually with an
audible beep to monitor heart rate also, which the
operator himself can see and hear while operating.
With its ease to use it should be used in every patient.
It has a light-emitting probe which can be inserted
Anaesthetists Role in Ocular Surgery
in finger, ear lobule or palm or foot (in case of a

child) and the electronic signals are taken to the
microprocessor, which performs the necessary
calculations giving the SpO2 per cent reading on
monitor.
iv. Cardiac monitor It is again a non-invasive monitoring of electrical activity of heart using various chest
leads, especially in lead II. Arrhythmias occurring
during operation can be detected early and treated
accordingly.
67
v. Defibrillator It is the equipment, which can be used

in case of cardiac arrest to return normal rhythm of
heart by giving electrical shocks of different
intensities.
All the above monitoring systems are available
in different models either as a single system monitor
or two in one to five in one models.
vi. Dextrostix These are the enzyme-impregnated sticks
for quick measurement of blood glucose from
capillary blood by dipstick method.
68
Postoperative
Infections:
Prevention and
Management
ostoperative endophthalmitis is one of the most

devastating complications of intraocular surgery,
leading to a marked loss of vision in over 80 per
cent of cases.1 Better instrumentation, microsurgical
techniques, prophylactic antibiotics and better understanding of asepsis has significantly reduced the incidence
of this complication. Maintenance of asepsis is imperative
for ensuring safe surgery for the patient and minimizing
postoperative infection and its disastrous consequences.
The reported incidence of postoperative endophthalmitis
varies and appears to be influenced by preoperative
prophylaxis with antibiotics, the aseptic technique used
and the geographical location.
The average incidence of endophthalmitis has reduced
from approximately 10 cases per thousand prior to 1950
to the present figures of approximately one case per
thousand.2-4 Postoperative endophthalmitis may occur
clinically as an isolated event or as cluster infections in
the form of a surgical epidemic.5-7 Although in most cases,
the source of the infecting organism cannot be identified
with certainty, the most common infecting organism is
Staphylococcus epidermidis.7-9
Postoperative endophthalmitis will be discussed under
two major headings:
i. Prevention of postoperative inflammation and
endophthalmitis.
ii. Management of postoperative endophthalmitis.
PREVENTION OF POSTOPERATIVE
ENDOPHTHALMITIS
Operating Room Layout
Contemporary theatre design incorporates zoning of

areas within the operation theatre complex. 9 The
12
Jagat Ram
Gagandeep Singh Brar
important aspects of OR layout include location, design,

proper ventilation and separation of the sterile zone from
the non-sterile areas.
For strict asepsis, an eye OT should preferably be nonsharing with any other surgical discipline. The location
should preferably be on an upper floor in the building.
Contamination from a hospital construction environment
has been documented to cause an epidemic of Aspergillus
endophthalmitis.8
The major zones of an OT complex are:
a. Outer zone reception area providing access for all
persons and supplies.
b. Changing room This area is located near the entrance
of the OR complex.
c. Transfer zone This area includes a corridor for
transferring the patient.
d. Aseptic zone Scrub and gowning area, the preparation
room and the operating room (OR).
e. Operating room The OR should have one opening
towards the scrub area and another towards a sterile
zone marked for instrument packing and sterilization.
The head ends of the operating tables should be
directed away from the entrance. Floors and walls
should preferably be of non-porous material with
minimum joints to enable proper cleaning and
carbolization.
f. Disposal zone processing of used equipment supplies
and disposal of waste.
Ventilation
Air decontamination is important. High Efficiency

Particulate Air (HEPA) systems remove most microorganisms ranging in size from 0.5-5.0 .10 The principle
Postoperative Inflections: Prevention and Management
of ventilation in the OR is delivery of positive pressure

filtered air in a unidirectional vertical flow over the
operating table. The current United States Public Health
Service minimum requirement for optimum OR air is:
temperature between 18 and 24C, humidity 55-80 per
cent, and 25 changes per hour.10 Fridkins et al11 reported
4 cases, who contracted Acremonium kiliense
endophthalmitis due to defective ventilation in the OR.
In the surgical operation theatre, bacterial count of air
should not exceed 1/ft3 (35.3/m3).12 and air entering the
theatre from filters should not contain more bacteriacarrying particles than 0.5/m 3, within 30cm of the
operation site not more than 10/m3, and elsewhere in
the theatre should not exceed 20/m3.
Cleaning, Disinfection and Sterilisation of OR
The terms are independent of each other and each needs

to be clarified and understood separately. Cleaning
essentially means the removal of foreign matter (e.g. soil,
organic matter) from the concerned surface. Unless an
article is mechanically cleaned, there will not be sufficient
surface contact between it and the decontaminating
agent, and sterilisation will not be accomplished. Cleaning
is normally accomplished with water, mechanical action
and detergents. Disinfection is a process of freeing the
concerned object of all pathogenic microorganisms,
which may cause infection during its use. Sterilisation is
a process that frees the treated object of all living
organisms.13 It is impractical to attempt to sterilise the
entire OR and equipment, and the current practice
concentrates on disinfection. Instruments and drapes
need to be sterilised adequately. Sterilisation is an
absolute term, and there is no term as partial sterility.
The hundreds of compounds derived from phenol
constitute phenolic compounds. They are good
bactericides and are active against fungi.13 They are
sometimes virucidal but are not sporicidal, except at
temperatures over 100C.
This class of compounds is used for decontamination
of the OR and for noncritical medical and surgical items.
The floor and 5-6 feet of OR walls should be mopped with
phenolic solution. Similarly, wet mopping all OR tables,
mats, instrument trolleys, stools chairs and supply shelves
with phenol followed by a wipe down with 70 per cent
alcohol is an effective decontaminating regimen.13 Anaesthetic equipment like endotracheal tubes, airways and
suction apparatus should be disinfected after every use.
Formaldehyde is the most common agent used for
sterilisation of operating room. The gas is liberated by
69
spraying or heating formalin or solid paraformaldehyde.9,14-16 The efficacy of the process is however
uncertain especially at temperature below 20C and
relative humidity below 70 per cent.16 Before fumigation,
adhesive tape is applied around the edges of the door,
windows and over ventilators apertures, etc. to seal the
desired area and prevent leakage to adjacent room or
outdoors. For each 1000 cubic feet of space (28.3 m3),
500 ml of formaldehyde 40 per cent in one litre of water
is placed in an electric boiler or in a large bowl placed on
a electric hot plate with safety cut-out when boiling dry.
Switch on the boiler and leave the room and seal the
door. After fumigation the room is to be kept closed for
8-10 hours. Subsequently, ammonium solution is introduced and left in the room for a couple of hours to
neutralise the formaldehyde (1 litre ammonium solution
plus 1 litre of water for every litre of 40 per cent
formaldehyde used.)
OR Discipline
Personnel entering the OT complex should be kept to a

minimum. Anyone with overt infection should be barred
from entering the OT complex. All persons entering the
OT should change into freshly laundered clothing. Hair
and beards should be clean and be well-covered by caps
and masks. High filtration disposable masks are to be
worn at all times when within the aseptic zone. Ladies
should take special care at trimming nails and removing
jewelry when working within the theatre complex. All
persons must wash their hands thoroughly before
entering the OR. It is desirable to restrict all persons other
than the staff from the OR. In todays age of modern
electronics, it is better for students and other trainees to
be seated at a remote place and observe surgery on a
closed circuit television rather than crowd around the
surgeons table.9
Sterilisation of Instruments
Instruments need to be thoroughly cleaned after every

surgery before being subjected to sterilisation. Microsurgical instruments are best cleaned by an ultrasonic
cleaner. These contain liquids through which sound
waves pass at a frequency of 1,00,000 Hz or more.10,15
The ultrasonic waves generate submicroscopic bubbles,
which collapse and create a negative pressure on particles
in the suspension. The bacteria disintegrate and the
protein matter is coagulated by this action.15
Sterilisation can be done by physical or chemical
methods, of which the former is more reliable.
70
Physical agents Sterilisation by heat:
i. Dry heat A temperature of 160C for one hour or

180C for 20 min. will sterilise the contents by a destructive oxidation of cell constituents.15,17 The holding
period of one hour at 160C is timed as beginning
when the thermometer first shows that the air in the
oven has reached 160C. Its usefulness is limited
and some sharp instruments such as fine Vannas
scissors and blades may be damaged by dry heat.
ii. Autoclaving This method is more effective than dry
heat and requires lower temperatures in a given time.
Autoclaving at 121C for 15 minutes at 15 psi pressure effectively kills most microorganisms. A
temperature of 134C at 34 psi pressure sterilises
instruments within 3 minutes.18 Temperature sensitive detectors must always be used to ensure
adequate autoclaving. Bacillus stearothermophilus,
a thermophile that requires being cultivated at 55
to 60C is a suitable test organism; its spores are
killed at 121C in about 12 minutes. Chemical detectors show a change of color or shape after exposure
to a sterilising temperature, e.g. Bowie-Dick tape,
which is applied to packs and articles in the load,
develops diagonal lines when exposed for the correct
time to the sterilising temperature.10,18 Autoclaving
is suitable for sterilisation of most of the metal
ophthalmic instruments except sharp knife and fine
scissors. Autoclaving irrigating solutions bottles may
kill only heat labile microorganisms by action of
temperature at relatively low temperature as the
steam does not penetrate the bottle.
Flash Sterilisation
Emergency sterilisation may occasionally be required.

Perkins19 described flash sterilisation parameters as 132C
at 28 lb of pressure for three minutes for metal instruments
for gravity-displacement and prevacuum steriliser. The
recommended minimum exposure time for linen, rubber,
plastic and lumen containing items should be 10 minutes
for gravity-displacement cycle and 4 minutes for prevacuum cycles. However, the practice should be restricted
to emergency situations only, since the margin of safety
is lower.
Filtration
Use of micropore filter for FGE, intraocular air/gas

injection and intraocular antibiotic injection is a must.
Microorganisms are retained in part by the small size of
the filter pores and in part by the adsorption on the pore
walls during the passage of the fluid through the filter.
An online 0.022 micropore filter has been recommended.20,21

Chemical agents
i. Glutaraldehyde 2 per cent (Cidex) It is an effective

steriliser for instruments that cannot be autoclaved.
It is non-corrosive, does not impair the sharpness
of cutting instruments and may be used with plastic,
aluminum and rubber. It is effective against vegetative pathogens in 10 minutes and resistant pathogenic spores in 3 hours.18 It is very effective against
the tubercle bacillus.
The low surface tension allows for easy penetration to inner surfaces and it can be readily
removed by rinsing. Thorough rinsing of all sterilised
material is mandatory because residual glutaraldehyde is extremely irritating to tissues. Courtright
et al22 reported significant corneal edema developing
because of inadequate removal of of glutaraldehyde
from the small lumens of instruments.
ii. Ethylene oxide (ETO) Gas sterilisation using ethylene oxide is effective and safe for heat-labile disposable items for cost reduction. Sterilisation is
effected by a process known as alkylation in which
a hydrogen atom is replaced by a hydroxyl ethyl
radical within a protein molecule. It is advisable to
use ETO sterilised instruments after a safe aeration
period of 7-10 days to ensure that no amount of
residual ETO remains on the surface to avoid
intraocular toxicity.23
For effective sterilization, the minimum concentration required is 400-1000 mg/l. Moisture enhances
the diffusion of the ETO gas. Blood, pus and other
proteineous materials act as barriers to ETO. 1-12
hours may be required for sterilization. The double
packing of the item is done in 200 gauge thickness
polythene. The vacuum is created and loading is
done at 70 cm/Hg vacuum. ETO gas pressure is
maintained for sterilisation at 5lb/In2 for 12 hours
or 10 lb/In2 for 6 hours. The vacuum is created at
70 Ib/In2 for vacuum cleaning of the sterilised item
and then vacuum break and this cycle is repeated
3-4 times to reformation of collapsed polythene
envelope.
iii. Acetone It is a potent bactericidal agent and is useful
for routine disinfection of surfaces.24,25 Drews24 has
postulated that the poor results reported might be
due to its relative ineffectiveness in the diluted form,
and emphasised the need for using it as a concentrated solution.

Plasma Sterilisation
This new modality of sterilisation of instruments has been

introduced recently for heat sensitive medical devices. A
very small quantity of hydrogen peroxide in various
phases, including low-temperature gas plasma excited
by radio waves, is lethal to organisms on the surface of
medical devices. Hydrogen peroxide is injected into the
chamber under reduced pressure in a dry atmosphere.
Vapour diffusion occurs throughout the contents and
radio frequency energy excites H2O2 into active radicals
and reactive chemical species. The free radicals so
produced react with and destroy microorganisms present
on pre-cleaned, dry accessible surfaces. The most well
known plasma sterilisation is the Sterrad TM from
Advanced Sterilisation Products, California using
hydrogen peroxide gas plasma at low temperature
(< 50C).
Monitoring of Sterilisation Protocol
All sterilisation procedures must be monitored meticulously by appropriate means for optimum effectiveness.
Various parameters and tests like phenol coefficient,
Rideal-Walker test and Chick-Martin test may be used.
Monitoring sterilisation is difficult. Sterilisation process
indicators (e.g. temperature charts, pressure gauges) are
used to indicate inadequate process conditions. The
biological indicators come closest to an ideal monitor
because they integrate all of the sterilising parameters
involved, such as time, temperature, pressure and
packaging.
Disposal of operating room biohazardous waste Ope-
rating room biohazardous waste including infected linen,

disposable syringes, IV drip set, needles, residual IV fluids,
infected material, excised human diseased pathological
tissue is a significant hazard to public and need safe
disposal to prevent recycling of disposable and spread
of infection from infected material.
Over the last decade, the disposable of operating room
and hospital waste has received much attention. In most
of the cases it can safely be dumped in a properly
designed waste pit particularly in the developing
countries.26 Incineration has been advocated as a viable
method of disposal of OR and hospital waste.27
Sterile Surgical Protocol
1. Patient-related factors In isolated infections, patient

related factors predominate.28 Diabetic patients and
those with blepharoconjunctivitis, dry eyes or atopic
disease are at a higher risk of postoperative infections
71
as they have a higher rate of carriage of Staphylococcus aureus.28-30 Patient related preoperative risk
factors include blepharitis, conjunctivitis, dacryocystitis, lacrimal drainage abnormalities, ocular surface
disorders, host immunosuppression29,30 and even
upper respiratory tract infections in children.31
The ocular surface and adnexa is the main source
of bacteria in culture proven cases of endophthalmitis.
Using microbial DNA analysis, Speaker and coworkers
showed that the main source of infection is patients
own ocular flora.32 The importance of a scrubbing
bath of the head and face on the day of surgery should
be emphasised.
Preoperative use of topical antibiotic The role of
prophylactic antibiotics administered both topically
and subconjunctivally has been documented to reduce
postoperative infection.33,34 Topical antibiotics should
be started 24 hours before surgery and used 6-8 times
during daytime. Instillation of topical antibiotics more
than 24 hours may lead to replacement of patients
owns flora by more virulent microorganism and fungi.
2. Preoperative preparation and role of povidoneiodine Speaker and Menikoff,35 in a significant breakthrough showed that a single topical application of 5
per cent povidone-iodine solution reduced the incidence of postoperative endophthalmitis significantly.
Povidone-iodine is bactericidal in 30 seconds.35,36
Although cilia trimming was once considered helpful
in reducing postoperative infection, the present trend
is not to trim cilia for intraocular surgery. This practice
became unnecessary following widespread practice of
isolating lashes with sterile adhesive drapes. Cleaning
the lids, lid margins and adjacent skin with Povidone
iodine 5 to 10 per cent is an effective method of
eliminating microbes.37
3. Scrubbing and use of gloves It is important to use nail
brush and scrub properly. One should scrub hands
and arms below elbow. It will take 7-8 minutes to scrub
with soap. A hand dis-infection system using chlorhexidine reduces the rate of nosocomial infections
more effectively than one using alcohol and soap.38
Povidone iodine (Betadine) or Chlorhexidine scrub
(Hibiscrub ) is best for scrubbing. With povidone
iodine or chlorhexidine solution , scrubbing twice for
1-2 minutes each is adequate. After wearing sterile
gloves, it is important to wash the hand with Ringer
lactate to remove the powder from the gloves.39
4. Surgical procedure Many factors are implicated in the
occurrence of endophthalmitis including the patients
72
own immunity and the quality of surgery. Prolonged

surgery (longer than 60 minutes),40 use of prolene
haptics intraocular lenses, inadvertent ocular
penetration during extraocular surgery and vitreous
loss have been specifically documented to be risk
factors for the development of endophthalmitis.41 The
risk of developing infection is high if the integrity of
posterior capsule is lost, since it allows an easy access
for microorganisms into the vitreous cavity.37 Vitreous
loss requires introduction of additional instruments into
the eye, which contributes to the increased risk of
infection.
Postoperative risk factors include poor wound construction or closure leading to a wound leak, iris prolapse, vitreous incarceration in the wound, exposed
sutures, suture removal under inadequate aseptic conditions and the presence of a thin filtering bleb.41-43
Irrigating Fluids and Viscoelastic Agents
Contaminated fluids, tubings, intraocular lenses and

viscoelastics are known to have caused cluster infections.8,44-48 The fluids for intraocular and intravenous use
such as balanced salt solution, Ringers lactate, etc. should
be inspected for its intact packing and also for any obvious
bacterial or fungal contamination. Any visible particulate
matter should render a bottle unsafe for use even if its
sterile packing seems undisturbed. Cluster postoperative
infection usually occur as a result of breach in the OR
asepsis. Most common causes are irrigating fluids,44-48
contaminated viscoelastics,44 defective ventilation.11 In
cluster infection microbiological surveillance culture
specimens for bacterial or fungi are obtained from
environmental sites, OR floor and wall, water source,
operating room team, irrigating fluids, viscoelastics,
intraocular lenses, surgical equipments49 and autoclave
equipment.
Even with a sterile surgical technique, infection may
occur from many other sources. Studies have shown that
bacteria may be recovered from culture of anterior
chamber aspirates at the end of cataract surgery in upto
43 per cent of cases even in the presence of preoperative
antibiotic prophylaxis and aseptic techniques.50 Lacunae
in our knowledge include how many bacteria are required
to cause endophthalmitis and how low the bacterial
counts have to be in order to ensure a negligible risk of
postoperative infection. The role of antibiotics in irrigating
solutions such as balanced salt solution or Ringers lactate
is controversial.51 The antibiotic protocol is aimed at
providing protection against gram-positive bacteria,
which are the most prevalent organisms, cultured in
isolated endophthalmitis cases. For prophylaxis, half of

the maximum non-toxic dose of the antibiotic is
recommended in the infusion bottle. Vancomycin 10 mg
in a 500 ml bottle has been recommended.52 However,
there are reports that this practice makes no difference
to the incidence of postoperative endophthalmitis.53
Another concern is the emergence of vancomycinresistant coagulase negative Staphylococcus and
Enterococcus strains.53 Other considerations to be kept
in mind are the cost implications and the risk of human
error during constitution of the required solution. This is
especially true when using aminoglycosides, as inadvertent injection of toxic doses could result in macular
infarction and endothelial toxicity.
Subconjunctival Antibiotics
Subconjunctival injection of antibiotics at the end of

surgery helps in reducing postoperative infection
particularly in the setting of the developing world. A single
injection of high doses of most antibiotics maintains
therapeutic aqueous levels for 4-6 hours.54 The definite
efficacy of this practice is still questioned.55
Surgery of Infected Cases
All infected cases must be operated in a separate OR.

After performing surgery on the infected cases, the
tubings, instruments and sheets used for infected cases
must be cleaned thoroughly and sterilized adequately
before reuse. An added concern is the need for
sterilization or high level disinfection of medical devices
contaminated with blood from patients infected with HIV
or HBV, or with respiratory secretions from a patient with
pulmonary tuberculosis. Experiments have shown that
HIV, HBV, and M.tuberculosis are inactivated by
commonly used chemical germicides such as 2 per cent
glutaraldehyde, 70 per cent isopropyl alcohol, 0.3 per
cent hydrogen peroxide and 50 ppm chlorone.56
For ensuring safe surgery, each member of the OR
team must perform his/her assigned role faithfully. All
staff working in the OR should be well-versed with
sterilisation norms and techniques being followed in their
own theatre. Abiding by a few rules and ensuring OT
discipline no doubt goes a long way in providing safe
ocular surgery to patients.
MANAGEMENT OF POSTOPERATIVE
ENDOPHTHALMITIS
All patients must be examined postoperatively at the slit

lamp at least twice in the first 72 hours after surgery, at
the end of one week and finally at 4-6 weeks after surgery.
At each visit, the ophthalmologist must objectively record
visual acuity, cornea clarity, intraocular pressure and the
media clarity.
Any increasing postoperative inflammation, presence
of a hypopyon and decreasing media clarity should be
considered as infective endophthalmitis unless proved
otherwise and managed as an emergency. An USG may
be obtained if media is hazy. If the visual acuity is HM+
or better, a combination of intravitreal antibiotics such a
vancomycin 1 mg in 0.1 ml and ceftazidime 2.25 mg in
0.1 ml in separate syringes should be injected through
the pars plana. The sample should be processed for smear
and cultures for aerobic and anerobic bacteria and more
importantly, also for fungi as the incidence of postoperative fungal endophthalmitis is high in developing
countries. Most gram +ve organisms are sensitive to
vancomycin and more than 90 per cent of gram-negative
to ceftazidime. If the visual acuity is less than HM, the
patient should undergo pars plana vitrectomy, essentially
consisting of clearing of the anterior chamber of any
inflammatory exudates or fibrin and a core vitrectomy
as far as it can be comfortably done and intravitreal
injection of antibiotic is repeated at the end of surgery.
Other indications of pars plana vitrectomy include
deterioration despite initial intravitreal antibiotics, no
improvement at 48 hours, delayed onset of endophthalmitis and fungal infection.
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Sciences (2nd edn): Springfield: Charles C Thomas, 1969.
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cataract surgery. J Cataract Refract Surg 17: 385, 1991.
22. Courtright P, Lewallen S, Holland SP et al: Corneal decompensation after cataract surgery. An outbreak investigation
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23. Rutala WA: Disinfection and flash sterilization of the operating
room. J Ophthal Nur and Technol 10(3): 106-15, 1991.
24. Drews RC: Acetone sterilization in ophthalmic surgery. Ann
Ophthalmol, 9(6): 781-84, 1977.
25. Aggarwal V, Sharma S: The efficacy of acetone in the
sterilization of ophthalmic instruments. Ind J Ophthalmol 41:
20-22, 1993.
26. Basu RN: Issues involved in hospital waste management
an experience from a large teaching hospital. J Acad Hosp
Adm 7-8(2-1): 79-83, 1995-96
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27. Phillips G: Microbiological aspects of clinical waste. J Hospital

Infect 41: 1-6, 1999.
28. Wright P: Diagnosis and management of dry eyes. Trans
Ophthalmol Soc UK. 91: 119-28, 1971.
29. Johnson MW, Doft BH, Kelsey FL et al: The Endophthalmitis
Vitrectomy Study Group: Relationship between clinical
presentation and microbiologic spectrum. Ophthalmology
104: 261-72, 1997.
30. Phillips WB, Tasman WS: Postoperative endophthalmitis in
association with diabetes mellitus. Ophthalmology 101: 50818, 1994.
31. Good WV, Hing S, Irvine AR et al: Postoperative endophthalmitis in children after cataract surgery. J Paediatr
Ophthalmol Strabismus 27: 283-85, 1990.
32. Speaker MG, Milch FA, Shah MK et al: Role of external
bacterial flora in the pathogenesis of acute postoperative
endophthalmitis. Ophthalmology 98: 639-49, 1991.
33. Christy NE, Lall P: A randomized controlled comparison of
anterior and posterior periocular injection of antibiotic in the
prevention of postoperative endophthalmitis. Ophthalmic
Surg 17: 715-18, 1986.
34. Christy NE, Lall P: Postoperative endophthalmitis following
cataract surgery: Effects of sub-conjunctival antibiotics and
other factors. Arch Ophthalmol 90: 361-66, 1973.
35. Speaker MG, Menikoff JA: Prophylaxis of endophthalmitis
with povidone-iodine. Ophthalmology 98: 1769-75, 1991.
36. Boes DA, Lindquist TD, Fritsce TR et al: Effects of povidoneiodine chemical preparation and saline irrigation on the
perilimbal flora. Ophthalmology 99: 1569-74, 1992.
37. Ram J: Reducing cataract-related complications. Ind. J.
Ophthalmol 47: 153-54, 1999.
38. Doebbeling BN, Stanley GL, Sheetz CT et al: Comparative
efficacy of alternative hand-washing agents in reducing
nosocomial infections in intensive care units. N Engl J Med.
327(2): 88-93, 1992.
39. Karcioglu ZA, Aran AJ, Holmes DL et al: Inflammation due
to surgical glove powders in the rabbit eye. Arch Ophthalmol
106(6): 808-11, 1988.
40. Kresloff MS, Castellarin AA, Zarbin MA: Endophthalmitis.
Surv Ophthalmol 43(3): 193-224, 1998.
41. Menikoff JA, Speaker MG, Marmon M et al: A case control
study of risk factors for postoperative endophthalmitis.
42. Katz KJ, Cantor LB, Spaeth GL: Complications of surgery in
glaucoma. Early and late bacterial endophthalmitis after
glaucoma filtering surgery. Ophthalmology 92: 959-63, 1985.
43. Mandelbaum S, Forster RK, Gelender H et al: Late onset

endophthalmitis associated with filtering blebs. Ophthalmology 92: 964-72, 1985.
44. McCray E, Rampell N, Solomon SL et al: Outbreak of
Candida parapsilosis endophthalmitis after cataract extraction
and intraocular lens implantation. J Clin Microbiol 24: 62528, 1986.
45. Arsan AK, Adisen A, Duman S et al: Acute endophthalmitis
outbreak after cataract surgery. J Cataract Refract Surg 22:
1116-20, 1996.
46. ODay DM, Head WS, Robinson RD: An outbreak of Candida
parapsilosis endophthalmitis: Analysis of strains by enzyme
profile and antifungal susceptibility. Br J Ophthalmol 71(2):
126-29, 1987.
47. Stern WH, Tamura E, Jacob RA et al: Epidemic of postsurgical
Candida parapsilosis endophthalmitis. Clinical findings and
management of consecutive 15 cases. Ophthalmology 92:
1701-09, 1985
48. Swaddiwudhingpong W, Tangkitchot T, Silarug N: An outbreak of Pseudomonas aeruginosa postoperative endophthalmitis caused by contaminated intraocular irrigating solution.
Trans R Soc Trop Med Hyg 89: 288, 1995.
49. Zaluski S, Clayman HM, Karsenti G et al: Pseudomonas
aeruginosa endophthalmitis caused by contamination of the
internal fluid pathways of a phacoemulsifier. J Cataract
Refract Surg 25: 540-45, 1999.
50. Samad A, Solomon LD, Miller MA et al: Anterior chamber
aspirates cultures after uncomplicated phacoemulsification
and intraocular lens implantation. Am J Ophthalmol 120:
143-50, 1995.
51. Alfonso EC, Flynn HW: Controversies in endophthalmitis
prevention: The risk of emerging resistance to vancomycin.
Arch Ophthalmol 113: 1369-70, 1995.
52. Gimbel HV, Sun R, De Brof BM: Prophylactic intracameral
antibiotics during cataract surgery: The incidence of endophthalmitis and corneal endothelial loss. Eur J Implant Ref
Surg 6: 280-85, 1994.
53. Schwalbe RS, Stapleton JT, Gillign PH: Emergence of
vancomycin resistance in coagulase-negative staphylococci.
N Eng J Med 316: 927-31, 1987.
54. Aaberg TM Jr, Flynn HW Jr, Schifman J et al: Nosocomial
acute onset postoperative endophthalmitis survey.
Ophthalmology 105:1004-10, 1998.
55. Forster RK, Abbott RL, Gelender H: Management of infectious
endophthalmitis. Ophthalmology 87: 313-19, 1980.
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Regional office for South Asia, New Delhi, 52-58, 1996.
The Manual Small Incision: Surgical AspectsI
The Manual
Small Incision:
Surgical AspectsI
he scleral tunnel incision was introduced in early

eighties in an attempt to provide better wound
healing with less surgically induced astigmatism.
This became the most favoured incision technique in the
recent past for sutureless, small incision, non-phaco
cataract surgery. Although the length of external incision
in this technique varies from 5 to 8 mm still it is called
small incision cataract surgery (SICS) since the architectural design renders sutureless, selfsealing property to
this incision. This is in contrast to the standard ECCE
incision that is approximately 11-12 mm, made in posterior limbal area, which requires number of sclerocorneal
stitches.
Richard Kratz, in 1983 was the first surgeon to move
the cataract incision from the limbus to the sclera thereby
increasing the surfaces of apposed wound to produce
enhanced wound healing and less astigmatism. Girard
and Hoffman in 1984 were the pioneer to call this
posterior incision as scleral tunnel incision.
Jack A Singer in 1991 conducted a prospective clinical
trial to evaluate induced astigmatism with PMMA IOL
13
75
Mahipal S Sachdev
P Mishra
S Thanikachalam
implantation through a modified pocket incision, curved

opposite to the limbus, which was named, Frown
incision, because of its appearance to the surgeon. They
also pointed out that frown incision group consistently
had a lower standard deviation from the mean induced
astigmatism than the scleral pocket incision group.
Paul H Ernest introduced the concept of an internal
corneal lip (triplanar incision); acting as a one-way valve
and imparting self-sealing wound properties.
Surgery has evolved from being just a small incision
technique for cataract extraction to being a sutureless way
of ending the procedure, thereby causing minimal
distortion of the corneal curvature. In some cases a choice
of incision may also help in reducing a pre-existing toricity
in the cornea. So, all the vital parameters that go into the
creation of a reproducible leak proof and astigmatic
neutral incision have assumed great importance today.
The classical incision is a three-step incision, shaped
like a Z. One limb of the Z is the vertical gutter at the
external site of the incision, the second limb is the
horizontal dissection and the third limb is the angled entry
into the anterior chamber (Fig. 13.1).
Fig. 13.1: Mechanism of scleral tunnel incision
76
The vital statistics that go into the making of a manual

phaco incision include:
l. Site of the external incision.
2. Placement of the incision.
3. Style of the external incision.
4. The length of the external incision.
5. Length of the sclerocorneal tunnel.
6. Depth of tunnel dissection.
7. Size of initial opening.
8. Size of incision for IOL insertion.
9. Paracentesis opening.
Site of the External Incision
Scleral Pocket Incision (Fig. 13.2a)
In scleral pocket variety of incision, the external incision

should be based 2.00 mm posterior to the limbus.
Clear Corneal Incision
In this the corneal incision should start just anterior to

the insertion of the conjunctiva to the limbus, i.e. just
ahead of the limbal vascular arcade. If the conjunctiva
gets punctured, it may lead to massive ballooning of the
conjunctiva due to the fluid egressing from the incision.
Placement of the External Incision
The scleral tunnel incisions are usually placed at 12.00

Oclock position. Clear corneal incisions may be placed
anywhere around the limbus keeping in view the
following:
The superior limbus is usually anteriorly placed. To

make an effective corneal valve incision, the internal
opening of the incision then goes too anterior
The corneal incision is usually associated with flattening
of the meridian in which it is given, hence depending
on the pre-existing cylindrical condition of the cornea,
this side effect can be used to an advantage by placing
the incision on the steepest meridian.
Advantages and Disadvantages of
Temporal Incision
The temporal location allows greater access to the incision

than when over the brow; for the same reason the eye
does not need to be turned down, this does away with a
bridle suture and postoperative ptosis. As the iris plane is
parallel to the microscope light, the red glow is excellent
and hence visualisation is enhanced. Being furthest from
the visual axis, theoretically, it is claimed to be more
refractively stable.
Its disadvantages are a higher risk of complications
and being an uncomfortable position to work from
surgically.
Style of the External Incision
The external incision may be in the form of a straight line

or shaped like a frown. The frown incision is most stable
and is supposed to prevent sliding between the roof and
floor of the tunnel, thereby minimising astigmatic shift.
This incision is highly recommended. External incision
parallel to the limbus should be avoided.
Length of External Incision
The length of the external incision should equal the size

of the IOL that has to be introduced through it. Although
a small entry is to be made for the initial process, the
incision is opened to its full dimension for IOL implantation, or even before that while beginning the surgery.
Thickness of the Roof of the Tunnel
The thickness of the roof of the tunnel should be about

300 microns. Thickness more than this may lead
to inadvertent entry into the anterior chamber. Thin tunnel
roof may lead to buttonholing of the tunnel roof during
dissection or tearing of the thin tissue during the surgery.
Length of the Tunnel Incision
Fig. 13.2a: Scleral incision
In scleral tunnel, the tunnel length is usually between

4.0 mm (Fig. 13.2b).
77
Fig. 13.2b: Scleral tunnel
In clear corneal incision, the recommended tunnel

length is, 1.75 mm. Too long tunnel lengths compromises visibility peroperatively because of distortion of
the corneal dome. In manual phaco we prefer scleral
tunnel except in very soft cataracts when phacotrisection can be done.
Too short tunnel lengths tend to make the incision
leaky.
Size of Opening for IOL Implantation
Generally the incision needs to be extended for implantation of the IOL.
For the rigid varieties of single piece PMMA IOLs The

extension of the incision should be equal to the diameter
of the optic. Some people like to extend 0.5 mm smaller
than the size of the diameter of the IOL but the passage
of the IOL becomes tight if the length of the tunnel is
longer.
For the foldable/injectable lenses The length of the
incision depends on the type of IOL and the design of
folder/injector being used. Depending on this, the final
incision may vary between 3.5 and 4.0 mm.
Paracentesis Opening(s)
In addition to the main incision, a paracentesis opening

is required for the introduction of the second instrument
for bimanual techniques of phacoemulsification. This
opening is usually preferred on the left side of the main
incision. The incision is 0.6 to 1.0 mm in breadth and
may be in the form of a simple stab or shelved incision.
Instruments required for the incisions:

1. A 15-degree freehand (preset depth 1.300 micron)
blade for the initial groove to start the tunnel incision.
2. A 2.0 mm broad crescent blade for dissecting the
tunnel with the shaft bent at 45 degrees.
3. A suitable breadth keratome (2.5 mm, 3.0 mm, 3.2
mm, 3.4 mm) with a 90-degree angle at the tip. The
bevel should face the surgeon and the shaft of the
blade should be bent 45 degrees.
4. A 0.6 to 1.0 mm broad blade for the paracentesis
opening.
5. A blunt tipped extender blade for increasing the
incision for IOL insertion of suitable size (3.5 mm,
4.0 mm, 5.0 mm, and 5.5 mm). The bevel of the
blade should be on the undersurface. The shaft
should again be bent 45 degrees.
6. A caliper to measure the intended incision size.
Technique of Making a Incision
Scleral Tunnel (Figs 13.3a and b)
First of all the conjunctiva is reflected from the limbus

and mild bipolar cautery applied for haemostasis.
Vigorous cautery may make the scleral tissue stiff.
A caliper is used to mark the length of the incision that
is needed for IOL implantation at a suitable distance from
the limbus. A depth-preset knife (300 microns) is used to
make the initial incision into the sclera. If one intends to
make a frown incision, and intends to keep 2.0 mm
behind the limbus, then the centre of the frown should
be at the level of 2.0 mm whereas the ends of the frown
78
Fig. 13.3a: Scleral tunnel dissection with

crescent angled blade
lie more posterior.

A crescent blade is taken and the dissection is begun.
It is of utmost importance to begin dissection at the correct
depth and then to maintain the same depth throughout
the length and breadth of the incision. This is possible if
one starts the incision from one side and ends at the other
side. If you start from both sides, there is a chance of
dissecting at different levels. Multi-planer incisions create
confusion during every occasion of introduction of
instruments into the anterior chamber and must be
avoided. With experience, you get to know the depth of
dissection by the visibility of the crescent blade through
the roof of the tunnel. The roof is much more transparent
if the dissection is superficial and vice versa. Care should
be taken to preserve the continuity of the edge of the
Fig. 13.3b: Technique of scleral

tunnel incision and its extension
79
Fig. 13.3c: Extension of scleral tunnel. Courtesy: Alcon (India)
external incision. The dissection is carried forward across

the limbus into the clear corneal tissue, again maintaining
the same depth of dissection. An inadvertent opening
into the chamber at this stage may complicate matters.
The scleral incision is usually between 6.0 and 6.5 mm.
Although we have shown that even extension up to 8.0
mm does not cause any problem and does not need
any sutures. The corneal end should be dissected 2 mm
longer than the scleral incision, 1.0 mm on either side
(Fig. 13.2b).
Once the tunnel is made, paracentesis stabs are made
at the 10 O clock and the 2 O clock positions (Fig. 13.4).
It may or may not be needed and depends on the
surgeons choice.
Viscoelastic material is introduced through one incision
and the aqueous is allowed to escape from the other.
Viscoelastic is filled just enough to make the eyeball firm,
not hard.
A suitable sized keratome is taken and introduced into
the tunnel in the central position of the frown and
advanced along the dissected tunnel. Care should be

taken to prevent formation of new tracks. When the tip
of the keratome reaches the end of the tunnel, the tip is
advanced into the corneal stroma, again remaining in
the same plane. One should get this right in the first
attempt and re-entry should be avoided to prevent
formation of multiple passages.
At the intended point of entry into the anterior
chamber, the tip of the blade is dipped posteriorly and
advanced slowly until the tip of the blade just appears
inside the chamber (Figs 13.5a and b). At this point, the
direction of the tip of the blade is again turned horizontal
and the entry completed. This particular manoeuvre is
carried out to obtain a straight-line internal incision. If
the direction of the blade is not turned horizontal, the
shape of the internal incision will resemble the shape of
the tip of the keratome.
Viscoelastic present in the chamber prevents sudden
shallowing of the chamber when the keratome entry is
made, thus preventing inadvertent hitting of the lens.
Fig. 13.4: Paracentesis stabs being made. Courtesy: Alcon (India)
80
Fig. 13.5a
Clear Cornea Incision
As the name indicates, the incision is purely corneal in

nature.
There are two ways to start this incision:
By making an initial partial thickness vertical incision
Without an initial incision.
A straight partial thickness vertical incision of the
required length is made in the corneal tissue, just anterior
to the conjunctival vascular arcades. Then a keratome of
the required breadth is taken and the tip introduced into
the exposed corneal stroma just short of the full depth of
the incision. The blade is to be held parallel, relative to
the corneal surface and advanced into the corneal stroma
up to the desired length. Then the hilt of the blade is
lifted and the tip pointed towards the anterior chamber.
Pressure is applied gently for the blade tip to emerge into
the chamber, when the blade is again turned into a
horizontal direction. This is done to produce a straightline internal opening. For making a same length tunnel
every time, one has to note a reference point on the
keratome in relation to the point of entry, so that once
you are familiar with a particular keratome, you should

always get the tunnel length right. Some keratomes have
markings on them to indicate the reference point and
make this step easy.
In certain diamond keratomes, the reference point for
entry into the anterior chamber is when the shoulder of
the keratome reaches the external incision line.
Some keratomes are shaped like a trapezoid, i.e. the
tunnel they form will be just right for the phaco probe at
the internal incision, while shall be a little loose at the
external incision to facilitate easy right-left movement.
When the clear corneal incision has to be made without
an initial groove, the tip of the keratome should first dip
into the corneal tissue to the desired level before traversing
the cornea. This kind of incision should preferably be
made with a keratome with a tip angle of 90 degrees,
otherwise a tongue-shaped tag is formed at the starting
point of the roof of the corneal tunnel.
The limbal incision In order to have a longer tunnel and

valve, some surgeons advocate the initiation of the
incision from the limbus instead of the clear cornea.
Of these three described tunnel methods scleral tunnel
is the most preferred tunnel for manual SICS. The other
two methods are usually used in phacoemulsification.
The hinged wound When pressed on the posterior lip a
clear corneal paracentesis can leak. The wound can
however be made more secure and entirely self-sealing
by creating a hinge before the corneal tunnel is dissected.
The hinge can be made with both a clear corneal and a
limbus-based incision. David WI Angerman, one of the
advocates of a hinged incision creates a 600 m deep
groove that is 3.2 mm wide and then a tunnel in the
anterior one-third of the corneal stroma with a special
3.2 mm diamond keratome. The groove must be
perpendicular to the corneal curvature and the tunnel
perpendicular to the groove to obtain a totally self-sealing
wound. He has designed a single-hinge diamond knife
system for making a hinged incision (Fig. 13.6).
Advocates of this incision are convinced about its
greater safety but emphasize that what contributes to this
Figs 13.5a and b: Anterior chamber entry with angled keratome. Courtesy: Alcon (India)
81
Comparison of scleral tunnel and

corneal tunnel incisions
Scleral tunnel
Corneal tunnel
l. Indications and
contraindica
tions
Contraindicated in
bleeding diathesis,
collagen vascular
diseases, functioning bleb
2. Construction
and tissue
trauma
3. Astigmatic
control comparable
4. Risk of complications if left
sutureless (endophthalmitis/ iris
prolapse/flat
chambers)
5. Risk of
hyphaema
More difficult and

time-consuming,
more traumatic
Comparable
Indicated in functioning
filtering bleb; bleeding
diathesis, anticoagulant
medications; conjunctival
scarring; scleritis, ocular
pemphigoid and dry eye
syndromes, combined
trabeculectomy and
phacoemulsification
Less so
Comparable
Very rare
More common
Greater
Infrequent
is not just making the groove but also ensuring that it is

maintained by avoiding forceful lens insertion.
Extension of the Incision
Fig. 13.6: Creation of the special sclero-corneal pocket incision.

The anterior chamber maintainer (A) is in place, introduced
through a tunnel in clear cornea which is 1 mm wide and at
least 2 mm in length, near and parallel to the limbus (A-arrow).
The height of the BSS bottle connected to the maintainer,
controls the intraocular pressure. Two 1 mm paracentesis incisions (D) are made at 10:30 and 2:30 just anterior to the limbus,
for instrument access. The main external incision. 0.3 mm indepth and 4-5 mm long, is made 1 mm behind the limbus. A
crescent knife (C) dissects the tunnel, First 1 mm in sclera,
then 2-3 mm forward into clear cornea (1), then extending laterally (2) to produce the pockets (P) on both sides. While
performing the pockets, the crescent knife is retracted laterally
and backward (3), creating the external incision extensions (E)
on both sides. (Below) A keratome (K) enteres the anterior
chamber to accomplish the internal incision (I), curved in shape,
parallel to the limbus. The keratome must be moved in a direction
slightly away form the surgeon while moving it laterally (4-arrow).
The distance form the external to internal incision is about 3.5
to 4 mm. Internal incision (I) lengthis about 7 mm. (Courtesy:
Benjamin Boyd, MD issue No. 1, 2000 of Highlights of Ophthalmology)
The extension of the primary incision is done using a

blunt tipped extension keratome. The size of the keratome
should equal the diameter of the IOL optic that needs to
be implanted through it or the required size for a foldable
lens design. The extender keratome should have a bevel
away from the surgeon, while extending the incision; care
should be taken to prevent the edges of the incision from
being cut inadvertently by keeping the blade absolutely
horizontal and in the plane of the original incision.
Closing of the Incision
One thing that should not be forgotten about these self

sealing incisions is that their typical structure makes them
vulnerable to ingress of infectious agents to the inside of
the eye if the valve is leaky. So the closure of the incision
becomes even more important, than its making. It should
remain sutureless only as long as it does not compromise
the safety of the eye.
The corneal valve is put into function by inflating the
anterior chamber from the paracentesis opening with the
irrigating fluid. The high pressure inside the chamber
forces the two lips of the internal opening against each
other and closes them (Fig. 13.7). Depressing the posterior
82
Fig. 13.7: The corneal valve is closed by inflating the chamber

with irrigating fluid, which pushes the corneal valve shut and
seals the incision
lip of the incision should check the integrity of the incision.

The most stable wound is created in case the length of
the tunnel is equal to its width (Fig. 13.8).
If the incision is leaky, hydration of the corneal stroma
may be tried at the extreme ends of the incision. The
corneal edema pull: the tissues tight against each other
and helps in a leak proof closure.
In case the incision still leaks, a single, horizontal 10-0
nylon or 10-0 vicryl suture should do the trick. Never let
your ego come between the suture and safety.
Summing-up
In manual phaco, a good incision ensures sutureless and

astigmatically neutral closure, which is actually half the
surgical work. It is important to understand the relationship of the length of the incision and its distance from the
limbus. Small incision can be made closer to the limbus
and the longer incisions further away, with equivalent
corneal stability. The internal corneal incision actually is
the one, which affects corneal curvature. That is the
Fig. 13.8: The engineering aspects support the theory that maximum stability of the wound is achieved if length of tunnel is the
same as the width
reason why even in cases where the lateral horn of the

scleral lip gets incised during the process of extension of
the incision, one may still not find any changes in
keratometry. It is important to familiarise yourself with a
set of sharps (blades) used for fashioning the phaco
incision. Using the same design of keratomes, etc. should
help you to standardize your incision making.
Get to feel the cutting properties of different blades
with bevels on the front surface and the back surface.
The bevel positions mentioned in the text are most
recommended. It is true that diamond keratomes are very
sharp and are probably the best for making the phaco
incisions, but good quality steel keratomes carry out the
job equally well and are economical at the same time.
For the price of a single diamond blade, you can buy
hundreds of steel keratomes.
One should never compromise on the sharpness of
the blades (Fig. 13.9). Inspect every blade under the
Fig. 13.9: Various blades for making incision. Courtesy: Alcon (India)
microscope before you touch the eye. If you think it is

blunt, change it immediately. Sometimes, the blade may
look good on inspection but refuses to cut well; this
warrants immediate change of the blade.
For best results, you have to learn how to make a good
incision and then practice hard to get it right the first time,
every time!
4.
5.
6.
REFERENCES
1. Girrard LJ, Hoffman RF: Scleral tunnel to prevent induced
astigmatism. Am. J Ophthalmol 97: 450-56, 1984.
2. Kratz RP, Colvard DM, Mazzoco TR, Davidson B: Clinical
evaluation of terry surgical keratometer. Am Intraocular
Implant Soc J 6: 249-51, 1990.
3. Jack A Singer: Frown incision for minimizing induced
astigmatism after small incision cataract surgery with rigid
7.
8.
83
optic intraocular lens implantation. J. Cataract Refract Surg

17: 677-88, 1991.
Mishra P: Small incision cataract surgery (SICS) and IOL
implantation. Cyberle4ctures, www.indmedica.com/ophthal
1-4, 2000.
Kapoor Sashi, Incisions: Emmetropia. J Intraocular Implant
and Refract Society 2: 17-25, 1999.
Mishra P: Catract surgery and intraocular implantation in
children. Cyberlectures www.indmedica.com/ophthal 1-5,
2000.
Mody Kirit, Singh Gagan J: Small incision non phaco cataract
surgery. Emmetropia. J Intraocular Implant and Refract
Society 2: 9-11, 1999.
Kumar Ravindra, Small incision cataract surgery without
phacomy experience. Emmetropia, J Intraocular and Refract
Society 2: 53-55, 1999.
84
The Manual Small

Incision: Astigmatic
ConsiderationsII
very cataract surgeon knows that preoperative and

induced astigmatism is a deterrent to his aim of
making his patients emmetropic. Over the years
he has either consciously or subconsciously evolved from
doing just cataract surgery to planning astigmatic cataract
surgery. The evolution of manual phaco is largely attributable to the relative immunity the procedure provides
against large shifts in astigmatism. This immunity is not
absolute though.
One important factor, which has kept most astigmatic
cataract surgeons busy is the wound or the cataract incision. Several facts relating to incision and astigmatism
are well-established but there possibly are several yet to
be unraveled.
It is well-established that the following induce greater
astigmatism:
l. Longer incision
2. A corneal incision
3. A limbus parallel incision
4. A uniplanar incision
5. A sutured incision
TYPE
|
With the rule (WTR)
14
Mahipal S Sachdev
Pradeep Venkatesh
An obvious approach to reduce the chance of astigmatic shift would therefore be to shift to an incision that
is small (3 mm in length if corneal incision desired); that
is away from the cornea either straight or frown shaped
(to stay within the astigmatically neutral funnel); multiplanar and one that can be safely left un-sutured. Also,
wounds with a square configuration (i.e. wherein the length
and width are small and equal) are considered more.
Achieving Emmetropia
The astigmatic cataract surgeon can modify his wound

parameters to undo any undesirable preoperative astigmatism. Preoperative astigmatism could be low (0-1.0
D), moderate (1.0 to 2.0 D) or high (>2.0 D).
When the preoperative astigmatism is low, the ideal
small incision wound construction would be a straight,
clear corneal, 3 mm incision (possibly in the temporal
region). By this the surgeon aims at retaining the
preoperative sphericity. A frown incision 3 mm behind
the cornea can also achieve this goal by being within the
astigmatically neutral funnel (Fig. 14.1).
Preoperative Astigmatism
|
|
Against the rule (ATR)
|
RANGE
AIM
TECHNIQUE
|
Low (0-1D)
Retain sphericity
Clear corneal 3 mm straight

incision; or frown incision
3 mm from limbus (spherical
phaco incision profile)
|
|
Moderate (1-2.0D)
Regain sphericity
Center incision along steep

meridian, straight, thin scleral
flap, 6 mm long
|
High (> 2.0D)
Reduce sphericity
Spherical small incision profile +

Astigmatic keratotomy + Modify
IOL power (>4D astigmatism)
Fig. 14.1: Aims of cataract surgery in preoperative astigmatism
The Manual Small Incision: Astigmatic ConsiderationsII

Astigmatically Neutral Funnel
The concept of astigmatic funnel arose from two mathematical relationships; firstly, that corneal astigmatism is
directly proportional to the cube of the length of the
incision and the second, that, it is inversely related to the
distance from the limbus. Incisions made within this
funnel will be for all practical purposes, astigmatism
equivalent. Curvilinear limbus parallel incisions fall
outside this funnel and are hence unstable.
When moderate preoperative astigmatism is encountered (1.0 to 2.0 D), the small incision, surgeon in an
endeavor to regain sphericity should construct a wound
that is centered along the steep meridian, about 6 mm
with a thin scleral flap and straight in relation to the
limbus.
A combination of spherical small incision profile with
astigmatic keratotomy is needed when the aim is to
reduce preoperative sphericity that is high (>2.0 D).
Spherical small incision profile is as described under low
preoperative astigmatism. This however, is constructed
only after completing astigmatic keratotomy. A 7mm optic
zone is maintained during astigmatic keratotomy. The
depth of the incision should be 90 per cent thickness.
The length of the incision is dependent on the correction
necessary. An incision of 45 rectifies 1 D; of 60, 1.5 D
and of 90, 2.0 D. Any additional incisions made will
increase this effect by 20-30 per cent.
When preoperative astigmatism exceeds 4D, the
implant power has to be modified to counter the effect
of coupling.
In constructing the incision, the surgeon has to tailor
wound parameters to suit individual cases with one
85
important caveat, i.e. to center the wound along the meridian in which against the rule change is desired.
Thus the incision being amenable to modification as
desired by the surgeon enables him/her to achieve emmetropia. In some patients astigmatic keratotomy may be
needed for the same in addition to the tailored incision.
SUGGESTED READING
1. Buzard KA, Shearing SP: Comparison of postoperative
astigmatism with incisions of varying length closed with
horizontal sutures and with no sutures. J Cataract RefractSurg. 17(Suppl): 734-39, 1991.
2. Davison JA: Keratometric comparison of 4.0 mm and 5.5
mm scleral tunnel cataract incision. J Cataract Refract Surg.
19(1): 3-8, 1993.
3. Feil SH, Crandell AS, Olson RJ: Astigmatic decay following
small incision, self sealing cataract surgery. J Cataract Refract
Surg 20(1): 403-09, 1994.
4. Fine I Howard: The infinity suture for closing phacoemulsification incision. Symposium: In Cataract IOL and
refractive surgery. American Society of Cataract and
Refractive Surgery, 1990.
5. Gimbel HV, Sun R: Postoperative astigmatism following
phacoemulsification with sutured Vs un-sutured wounds. Can
J Ophthalmol 28(6): 258-62, 1993.
6. Masket S: Comparison of suture materials for closure of the
scleral pocket incision. J Cataract Refract Surg. 14(5): 54851, 1988.
7. Nielsen J: Induced astigmatism and its decay with a frown
incision. J Cataract Refract Surg. 19(3): 375-79, 1993.
8. Suzuki R, Tanaka K: Outcome of preoperative against the
rule astigmatism after phacoemulsification; Characteristic
change over time Part II Ophthalmologica, 204(4): 184-91,
1992.
86
Capsulotomy for
Small Incision
Cataract Surgery
apsulotomy plays a vital role in the further progress of the surgical procedure of cataract extraction by any technique. The most commonly used
techniques are (1) Can opener technique, (2) Envelope
technique, (3) Capsulorhexis. However, with a greater
appreciation of the role of symmetrical placement and
long-term maintenance of the intraocular lens,
continuous curvilinear capsulorhexis has acquired the
widest acceptance.
Can Opener Technique
In it, an irrigating cystitome or simply 26 G needle, bent

at the tip is introduced into anterior chamber and multiple
small radial cuts are made in the anterior capsule for
360 degree. The technique is same as for the conventional
extracapsular cataract extraction. It however, has the
following disadvantages:
1. Possibility of posterior extension of capsulotomy tear
during surgery.
2. Difficulty in ensuring in the bag placement of intraocular lens.
3. Escape of the haptic from the bag during IOL insertion.
4. Asymmetric fibrosis of the bag with long-term decentration of the lens.
Envelope Technique (Linear Capsulotomy)
Envelope technique became increasingly popular in

extracapsular cataract extraction as its advantage of
endothelial protection during surgery and greater surety
of in the bag placement of IOL were recognised.
Here a straight incision is made in the anterior capsule
in the upper part from two to ten Oclock position. The
rest of the capsulotomy is completed in the end after
removal of nucleus and cortex.
15
AK Grover
Pankaj Puri
Harprit Singh
However, it shares the disadvantages of possibility of

posterior extension of the tear, escape of IOL from the
bag and decentration due to long-term fibrosis.
Capsulorhexis
Continuous, curvilinear capsulorthexis (CCC) developed

by Gimbel, Neuhann and Schimizu independent of each
other in 1980s is the most preferred technique. The CCC
technique has significantly improved the safety of cataract
extraction and in the bag intraocular lens implantation.
Before we begin with discussion on capsulorhexis, a basic
understanding of the anatomy of the lens capsule is a
pre-requisite.
Anatomy of the Lens Capsule
Capsule of the lens forms a transparent homogeneous

highly elastic covering of the lens. Ultra structurally the
capsule has a laminated appearance. When out or
ruptured its edges roll out and then curl up. It is much
thicker in the front than behind and the anterior and
posterior portions are thinner towards the periphery
(equator) just within the attachment of the suspensor
ligament than at the poles (Figs 15.1 and 15.2).
The pattern of insertion of zonular fibres has an
important bearing on the size of the capsulorhexis.
Zonular fibres arise from the ciliary body and would be

divided into two groups.
First those that pass from the ciliary process to the
lens, most of which attach to the anterior or posterior
lens capsule than the equator and do not seem to cross
each other, while those that form a mesh work across
the ciliary body or extend from the pars plana to the
vitreous body to form part of the vitreous base form the
second group. As a whole the zonule forms a ring which
Capsulotomy for Small Incision Cataract Surgery
87
Fig. 15.1: Anatomy of lens capsule
Fig. 15.2: A schematic view of the lens of the eye
Fig. 15.3: Demonstrating the sheer technique for

initiating capsulorhexis
is roughly triangular on meridinal section. The base of

triangle is concave and occupies the equator and portions
of the anterior and posterior surface of the lens.
Technique: Sheer Versus RIP
The red fundus reflex produced by coaxial light of the

microscope is essential to visualise the capsule while
performing capsulorhexis. Also, high magnification,
horizontally placed eyeball and putting viscoelastic on
the wet cornea improves visibility of the anterior capsule.
Capsulorhexis can be performed by either a sheer
technique (Fig. 15.3) or by a ripping technique (Fig. 15.4).
Propagators of both the techniques have shown distinct
advantages and disadvantages of the same. However,
in our experience we feel that the sheering technique
Fig. 15.4: Demonstrating the rip technique for

initiating capsulorhexis
provides us with an advantage of an ultimate control on

the initiation and performance. Ripping the capsule is
88
less desirable than sheering because the tear tends to

extend uncontrollably even when the grasp is held
stationery. Secondly more force is generally needed to
begin a tear with ripping as opposed to that with sheering
as the force is distributed over a larger area in ripping.
This entails that a capsulorhexis performed by sheering
technique is much more under control and requires much
less energy then that performed with the ripping.
A complex physical basis of two techniques and
distribution of the force vectors in both the techniques
are being shown in Figures 15.3 and 15.4. A combination
of a sheer and rip technique can also be used to perform
a safe capsulorhexis.
Maintenance of the Anterior Chamber Depth
A deep anterior chamber which is ensured with the generous use of a viscoelastic provides us with a safe atmosphere for initiation and propagation of capsulorhexis. a
shallow anterior chamber, an indicator of a high vitreous
pressure results in the anterior displacement of lens and
zonular stress. It also leads to a more convex position of
the lens. Therefore, any stress at the sight of the capsulorhexis whilst initiation or propagation will tend to extend
towards the perphery as the force vectors then act in two
directions (Figs 15.5a and 15.5b). When the anterior
chamber is deep and viscoelastic is used to counteract
the vitreous pressure, the stress on the zonules is
neutralised (Fig. 15.5c). Thereafter, the capsular forces
work only in the direction desired. Maintaining a deep
anterior chamber during capsulorhexis is therefore highly
recommended. Learning a capsulorhexis, using a
cystitome on a visco-elastic syringe may help to compensate for any decrease in the anterior chamber depth.
Figs15.5a to c: (a) Demonstrating the upward direction of force

of vector when the anterior chamber is shallow, (b) Showing
how this force vector acts in extending the tear to the periphery,
and (c) Deepening of the anterior chamber by viscoelastic
neutralises the force vector
Initiation of Capsulorhexis
We tend to perform the capsulorhexis with the use of a

sheering technique and the technique described herewith
will follow the principle.
Capsulorhexis is often initiated with formation of a
flap. A puncture wound at the centre of the lens and the
cut is extended to a point B (Fig. 15.6). At point B
cystitome is pulled towards point C as shown in Figure
15.7. This lead to creation of a capsular flap which is
then folded over to lie on top of the intact capsule. The
direction of the horizontal cut can be towards the nasal
or temporal side of the lens or towards the site of the
incision depending on personal preference. It can then
be extended either in the clockwise or anticlockwise
direction. We prefer to perform capsulorhexis and
Fig. 15.6: Showing initiation of capsulorhexis starting from the

centre and going to the mid-periphery
continue it in an anticlockwise direction. A slight variant

of the continuous capsulotomy as popularised by Charles
Kelman may be performed by engaging the lens capsule
in the centre of the lens and then pulling the capsule
towards the incision site (Fig. 15.8). This leads to creation
of a triangular flap described as a Christmas tree flap by
Kelman.
Fig. 15.7: Showing progression of capsulorhexis

using shear technique
89
Propagation of Capsulorhexis
After initiation, as described earlier, the capsular flap is

folded upon itself. The flap is then engaged with either a
cystitome or a capsulorhexis forceps at point C and the
flap pulled in the desired direction of capsulorhexis (Fig.
15.7). While using a cystitome one has to be very cautions
that very minimum pressure is applied to engage the
capsule as too much pressure may penetrate the flap.
Also the capsule should be held or engaged somewhat
inside the peripheral edge of the flap in order to provide
a safety margin against the cystitome slipping peripherally
and damaging the intact capsule. The direction of the
force ensures correct position and extension of the
capsulorhexis. It can be seen that point of engagement
of the instrument is adjusted to stay two to three clock
hours away from the point of sheering. If the instrument
is placed closer, an artificial stress line is created which
could compromise the predictability of the capsulorhexis
and direction of sheer propagation. The direction of
capsulorhexis can be altered by changing the direction
of force as shown in Figure 15.9. The changes in direction
may be required when the capsulorhexis tends to extend
peripherally. One should be aware of the fact that if a
change in direction of the capsulorhexis is abrupt it can
induce modification of the force vectors converting sheer
to a modified rip which has a potential of peripheral
extension. A deep anterior chamber during any of these
manipulations is highly desirable for a high predictability.
Fig. 15.8: Showing a variant of continuous capsulotomy

known as Christmas Tree Flap creation
Important Factors while Initiating Capsulorhexis
1. Incision should be superficial and should involve only

the capsule.
2. Incision should be extended for just about 2 mm on
either side depending on the personal preference.
3. Aim for minimal disturbance of the lens cortical
material as this will hinder visualisation.
4. A deep anterior chamber is a pre-requisite and should
be maintained by a generous use of viscoelastics.
Fig.15.9: Showing the direction of force used for progression

of a capsulorhexis by sheer technique
The capsulorhexis is progressed gradually, the capsular

flap is engaged repeatedly and capsulotomy progressed
for about two to three clock hours at a time. Figure 15.10
shows the capsulotomy three quarters of the way through.
When coming to the end of the capsulorhexis, problems
are often entailed as there is a lot of capsule lying free,
90
impending visualisation of the capsulotomy edge.

Viscoelastic are used here to flatten the capsular flap and
to ensure good visualisation of the tear (Figs 15.11 and
15.12a and b). Also when coming to the end of the
capsulotomy an attempt should be there to bring the
capsule from outwards in, as shown in Figure 15.13. The
direction of the force is slightly modified to increase the
diameter of the capsulorhexis and then to bring the
capsular flap from out in. This modification of the
technique helps in prevention of any radial extensions
of the capsulorhexis during phacoemulsificaton.
Figs15.12a and b: A flat anterior capsule with the help of

viscoelastic enhances visualisation. Courtesy: Alcon (India)
Fig.15.10: Shows capsulorhexis finished to 3/4 of the area
Fig.15.13: Showing the direction of the capsulorhexis when

coming to the completion (coming from outwards to in)
Fig.15.11: Shows wrinking of the anterior capsule creating
problems in visualisation
Fig.15.12a
2. Radial extension of the capsulorhexis should be only

for about 2 mm.
3. The direction of the force should be in the desired
direction and shape of capsulorhexis.
4. The capsule should be grasped with the cystitome
using gentle pressure to avoid any tears or inadvertent
rupture of the capsule.
5. The point of engagement of the capsule should be
kept slightly away from the margin of the lens.
6. The capsulotomy should be progressed slowly moving
two to three clock hours at a time.
7. When nearing the end the capsule flap should be
spread evenly using a viscoelastic to enable completion of rhexis and to visualise the end of the tear.
8. Capsulorhexis should be finished from an outward in
movement of the capsule.
9. A deep anterior chamber should be maintained at all
times.
Salient Features of Capsulorhexis with

the Cystitome Using the Sheer Technique
Capsulorhexis with the Ripping Technique
1. Initiate the capsulorhexis straight in the centre puncturing just the capsule avoiding inadvertent disturbance of the cortical matter.
Performing a capsulorhexis with a ripping technique

differs from the sheering technique in the following
aspects:
1. Direction of the pull is much more towards the centre

of the capsule (Fig. 15.14).
2. The flap is engaged by pulling the instrument at a
point which is much closer to the tear.
3. A larger amount of force is required to initiate and
propagate capsulorhexis.
4. The direction of the force has to be constantly changed
to direct and propagate the capsulorhexis in a circular
manner( Fig. 15.15).
91
points at the tip directed downward to grab the anterior

capsule are now available to perform capsulotomy.
Initiation of capsulotomy in these cases is begun with a
needle puncturing the capsule in the centre making a
horizontal movement 2 mm towards the lateral side,
creating a capsular flap. The capsular flap thus created is
grasped with the forceps and the capsulorhexis may be
performed by ripping the capsule in the direction of
desired capsulorhexis. Capsulorhexis using a Utratas
forceps has been reported by some investigators to be
much easier and provides more control over the capsulorhexis then with the cystitome. However, in our experience we feel that either of the two techniques is quite
safe and predictable and use of either of the instruments
is entirely a personal preference. However, the use of a
forceps requires AC maintenance by more dense viscoelastic and methyl cellulose alone may not always suffice
(Figs 15.17 to 15.19a and b show the use of a Utratas
forceps in performing a capsulorhexis). We still prefer
the use of sheer technique in performing a capsulorhexis
even when using the Utratas forceps.
Fig.15.14: Showing the direction of the force when you are

creating a capsulorhexis with the ripping technique
Fig.15.16: Showing the use of an external light source for

visualisation of the anterior capsular flap
Fig.15.15: Shows the changing direction of force needed to

propagate the capsulorhexis in a circular manner with the ripping
technique
Shear v/s Rip
In our experience, the ripping techniques have been

shown to be more difficult to control and more likely to
inadvertently extend peripherally relative to the sheering
techniques. However, they can be combined with the
sheering technique when a change of direction of the
capsulorhexis is desirable.
Capsulorhexis Using Forceps
A number of capsulotomy forceps based on the

wonderful design of Utrata, long handled forceps with 2
Fig.15.17: Showing a Christmas Tree Flap as

advocated by Kellman
92
Capsulorhexis in Difficult Situations
Performing a capsulorhexis in eye with white cataract

and/or small pupils can occasionally present a challenging
task to the operating phaco surgeon. Absence of glow or
small pupil compromises the visualisation of the capsule
and the capsulotomy edge. However, certain modifications can be performed to perform a safe capsulorhexis
in these cases.
Capsulorhexis in Mature Cataracts
Fig.15.18: Showing initiation and progression of

capsulorhexis with forceps
The basic principle of capsulorhexis remains the same,

however certain modifications can be made in technique.
Visualisation of the capsule can be increased by maintaining a deep anterior chamber using the viscoelastic
material and also use of viscoelastic material for elevation
and manipulation of the flap torn edge after initiation of
capsulorhexis. An external light source (Fig. 15.16) can
be used on an oblique angle to help us increase visualisation of the capsular flap. Progression of capsulorhexis
in these cases should be very slow and steady and no
attempts should be made to complete capsulorhexis
rapidly.
Capsulorhexis in Hypermature Cataracts
Fig.15.19a: Showing capsulorhexis through one quadrant
In a hypermature cataract, puncturing the capsule leads

to leakage of the cortical matter obscuring the view. This
fluid matter should be aspirated or flushed from the
anterior chamber with a viscoelastic such as methyl
cellulose to clear the anterior chamber. A viscoelastic is
then injected into the lens bag to increase its volume
and the capsulotomy is performed.
A very valuable tool in improving visualisation of the
capsule has been produced by staining with dyes.
Trypan Blue Staining
Inadequate visualisation of the capsule as in mature and

hypermature cataract can be obviated by temporarily
staining the anterior capsule with any contrasting dye
for, e.g. 0.1% Trypan Blue. Staining of the anterior
capsule simplifies capsulorhexis.
Technique
Fig.15.19b: Showing near completion of

the capsulorhexis with forceps
Through the side port incision, anterior chamber is

completely filled with air. The air in the anterior chamber
causes the dye to spread over the anterior capsule,
bordered by the pupillary rim of the iris, it prevents a
direct endothelial contact. The air also prevents dilution
of the dye by the aqueous. It is observed that a large
single air bubble is essential for staining of anterior
capsule. Multiple small air bubbles cause irregular staining

of the anterior capsule.
After air is injected into the anterior chamber, with 27
G cannula, 0.2 ml of 0.1% Trypan Blue is injected. After
5 to 10 secs, the anterior chamber is thoroughly irrigated
with Balanced Salt Solution (BSS) to wash out excess of
dye. Because of blue stain of anterior capsule, the outline
of the capsulorhexis is clearly visible. This is easily
distinguished from the underlying grayish white lenticular
tissue thus simplifying capsulorhexis.
Capsulorhexis in Small Pupils
In cataracts with small pupils, the pupils can be enlarged

using either the stretching technique or using iris hooks
or by multiple sphincterotomies. Capsulotomy is performed as usual making the size of capsulorhexis equal
to just smaller to the pupillary diameter. The edge of the
capsulorhexis should be visible. Once phacoemulsifica-
93
tion is completed, the capsulotomy size can be increased

for safe introduction of the lens.
New Developments in Capsulorhexis
With technological advances a number of new aids are

now available to ensure a safe capsulorhexis. Use of a
radiofrequency probe or Erbium Yag laser are some
examples of the same.
FURTHER READING
1. Barrett Sible Phacodynamkics, Mastering the two techniques
of phacoemulsification, Second edition, Slack Incorporation,
Los Angeles California.
2. Cook Davidson, Advanced phacoemulsification technique,
Slack Incorporation California USA.
3. Paul H Cock: Mastering phacoemulsification, 4th ed, Jaypee
Brothers, New Delhi, India.
4. William F Mallony: Textbook of phacoemulsification, 1st ed,
1998.
94
Hydroprocedures
16
Subodh K Agarwal
INTRODUCTION
Epinucleus
Hydroprocedures are equally important in both the

modalities of small incision surgery-manual non-ultrasonic small incision cataract surgery as well as ultrasonic
small cincision cataract surgery or phacoemulsification.
In this chapter, when I am going to deal with hydroprocedures at length it will be in the fitness of things that
we address the subject in both its applications, i.e.
manual small incision cataract surgery and phacoemulsification.
When you have gone through this chapter you should
be armed with a wider, broad based perspective of the
subject. That day is not far off when all cataract surgeons
will have mastery over both the methods of small incision
surgery-manual and ultrasonic.
This is the semi-soft intervening zone between the soft

superficial cortex and the hard endonucleus. It can either
be expressed or aspirated.
CONCENTRIC ANATOMY OF THE LENS
The epithelial cells of the human crystalline lens are

constantly proliferating to create lens fibres. The new
fibres formed at the periphery compress the old and
deeper layers. Thus the inner core constitutes the hardest
part of the nucleus because it has been subjected to
maximum pressure for the longest duration.
The lens in cross-section comprises of a concentric
series of elliptical rings. Each ring represents laying down
of additional lens material from the epithelial cells located
on the underside of the anterior capsule.
For a cataract surgeon it is useful to consider the
crystalline lens as having three zones.
Hard Core Nucleus
The innermost central core is known as the endonucleus. The hardcore nucleus cannot be aspirated; it can
be (a) Expressed as in ECCE or (b) Fractured as in phacoemulsification or (c) Fragmented as in manual small
incision surgery.
Superficial Cortex
This is comprised of the soft lamellae lying just beneath

the capsular bag. The cortex can only be aspirated.
HISTORY
Hydrodissection was devised or invented by Michael

Blumenthal of Israel who is the father of Non-ultrasonic
manual small incision cataract surgery. Its initial aim
was to reduce the size of the nucleus to the smallest
possible hardcore endonucleus. This small endonucleus
could then easily be tipped out of the capsular bag and
then conveniently expressed out via a small self-sealing
scleral incision.
Ironically this procedure has been used as a stepping
stone in the evolution of ultrasonic small incision surgery
or modern phacoemulsification.
Terminology and Classification
Hydroprocedures
Hydrodissection
Hydrodelineation
Conventional
Manual
Cortical cleavage (Howard Fine)
Hydrosonic (Aziz Anis)
Hydro-free dissection (Gimbel)
HYDRODISSECTION
Conventional Hydrodissection
This is hydroseparation of the superficial cortex from the

epinucleus. The cardinal reason to perform hydrodissection is to enable us to rotate the nucleus. The cortical
Hydroprocedures
95
Fig. 16.1a
adhesions are broken so that the nucleus becomes freefloating in the capsular bag. We can rotate and bring
different parts of the nucleus in front of the phaco tip so
that they can be emulsified.
Basically hydrodissection is the injection of BSS under
the anterior capsular flap so that the fluid dissects around
the equator, goes below the nucleus and separates it from
its cortical attachments. If you do not see the posterior
fluid wave and the nucleus does not move anteriorly
then you have not achieved hydrodissection. The endeavour is to create a definite plane of separation between
the nucleus and cortical debris that remains attached to
the capsular bag (Figs 16.1a and b).
Figs 16.1a and b: Hydrodissection. Courtesy: Alcon (India)
Technique
First of all a good continuous curvilinear capsulorhexis

is performed. A 27 G blunt cannula is taken on a 2 ml
syringe filled with BSS (Figs 16.2 and 16.3). The cannula
Fig. 16.3: Conventional hydrodissection
enters the eye through the 2.8 mm phaco incision or the

larger incision of manual small incision surgery and the
tip is passed under the anterior capsular rim. A sufficient
amount of fluid is injected so that a posterior fluid wave
is created. Injection of excessive fluid should be avoided.
The acid test of having performed a good and complete
hydrodissection is that you should be able to rotate the
nucleus easily.
In white cataracts and in very dense cataracts the fluid
wave will not be seen but slight forward movement of
the nucleus is a good indication that a complete hydrodissection has been achieved.
Cortical Cleavage Hydrodissection
Fig. 16.2: Hydrodissection
Devised by Howard Fine this is one of the true revolutions

in cataract surgery (Fig. 16.4). It had been believed for
96
Fig. 16.4: Cortical cleavage hydrodissection
years that the cortex is naturally adherent to the capsule.

Fine observed that after doing capsulorhexis when he
removed the anterior capsule there were no adhesions
between the cortex and capsule.
In cortical cleavage hydrodissection the cannula is
lifted up, tenting the anterior capsule and then the BSS
is pushed in. This technique produces a clear cut cleavage
plane that separates all of the cortex from the capsular
bag. Some fluid gets trapped at the equator because of
dense cortical adhesions. So after the fluid wave is
completed, the nucleus is depressed with the cannula to
release all the trapped fluid into the anterior chamber.
After doing cortical cleavage hydrodissection when
phacoemulsification is performed all of the cotex comes
out with the nucleus. There is hardly any cortex left to be
removed by I/A.
Hydro-free Dissection
This is more or less the same as cortical cleavage hydrodissection. Gimbel has refined this technique-after lifting
and tenting the anterior capsule the tip of the cannula is
swept along the potential plane of cleavage; then the
fluid is injected as usual creating a cleaner cortical
cleavage.
HYDRODELINEATION OR HYDRODEMARCATION
This term stands for separation of the inner hardcore

endonucleus from the overlying epinucleus by fluid
injection (Figs 16.5 and 16.6).
Manual
There are two methods:

A. The cannula is pushed right into the body of the
nucleus. The tip passes through the soft outer nucleus
and meets with resistance when it hits the hard part of
Fig. 16.5: Hydrodelineation feel the resistance
Fig. 16.6: Hydrodelineation completed
the cataract. When fluid is injected at this point a

golden ring is formed which signals the true separation
of the nuclear layers.
B. Aspirate the superficial cortex and the epinucleus to
reach the hardcore endonucleus which cannot be
aspirated further. Hydrodelineation can now be performed by negotiating the tip of the cannula between
the endonucleus and epinucleus and then injecting a
small amount of BSS.
Separation of the inner and outer nucleus is extremely
helpful both in manual small incision surgery and in
In manual small incision surgery a small inner nucleus
is isolated and can be more easily tipped out of the bag
and then removed out via the self-sealing incision. In
phacoemulsification the shell of soft outer nucleus acts
as a very effective protective barrier for the posterior
capsule. It saves the posterior capsule from damage by
the razor sharp edges of the hard endonucleus as well as
by the sharp phaco tip.
Hydroprocedures
97
Hydrosonic Hydrodelineation
DISCUSSION
Aziz Anis (USA) devised a special hydrosonics handpiece

by which he used small bursts of ultrasound to bury the
tip deep into the hard endonucleus. Then BSS is injected
at various depths to decompact and hydrate a very hard
nucleus. This helps in easier phacoemulsification of very
hard nuclei.
The nomenclature of inner and outer nucleus or endonucleus and epinucleus is not important. The all important point is appreciation of the concept that within
the cataract there is a point where a fluid dissection can be
made isolating an inner nucleus from an outer nucleus.
The endonucleus is hard in both ways (a) Physically
the hardest part of the cataract (b) It represents the hardest
or most difficult part of cataract removal.
Hydrodissection and hydrodelineation should be
performed in every cataract procedure as far as possible.
In young and soft cataracts it is better to do hydrodissection alone. Performing hydrodelineation in such cases
leaves us with a thick outer nuclear shell which is stickly
and very difficult to manipulate. In posterior polar
cataracts it is better to do hydrodelineation alone; performing hydrodissection in such cases is catastrophic.
We should realise that mastering the techniques of
hydroprocedures should be the endeavour of all cataract
surgeons.
COMPLICATIONS OF HYDROPROCEDURES
A. Pressure generated by the fluid may lead to extension

of an irregular capsulorhexis or a can opener capsulotomy upto the equator and even beyond it. The need
for a good CCC cannot be cover emphasised both
for manual small incision surgery and phacoemulsification.
B. Injection of excessive fluid during hydroprocedures
may raise the intralenticular pressure to such a high
level that the posterior capsule may give way and the
nucleus may sink into the vitreous cavity.
C. In posterior polar cataracts even gentle hydrodissection
may lead to dehiscence of the posterior capsule in the
centre. In such cases only hydrodelineation should
be attempted
D. At times the nucleus or even the entire lens may prolapse
out of the bag into the anterior chamber. This is a
welcome development if manual small incision surgery
is attempted. If phacoemulsification is planned, the
nucleus may gently be patted back into the capsular
bag.
FURTHER READING
1. Eisner G: Eye Surgery: An Introduction to Operative
Technique (2nd ed). Springer-Verlag, Berlin: 288-95, 1990.
2. Koch, Davidson: Advanced Phacoemulsification Techniques
Slack Inc, New Jersey, 1991.
3. Seibel BS: Phacodynamics: Mastering the Tools and Techniques of Phacoemulsification Surgery (Ist ed) Jaypee
Brothers, New Delhi, 1995.
4. Sunita Agarwal et al: Phacoemulsification, Laser Cataract
Surgery and Foldable IOLs. Jaypee Brothers, New Delhi:
1998.
98
Nucleus Prolapse
from Capsular Bag
mall incision cataract surgery differs from

conventional ECCE and phacoemulsification
cataract surgery in that the nucleus needs to be
essentially prolapsed into the anterior chamber from the
capsular bag before delivering it through the incision.
Hence prolapse of nucleus in the anterior chamber is
the most important and sometimes a difficult step in
manual phaco, taking into consideration the integrity of
the capsular bag the vitreous face and corneal endothelial
damage. However, in envelope technique the nucleus is
not fully taken out of the capsular bag but is rotated in
the bag and the upper pole is brought above the iris
plane out of the capsular bag.
For prolapsing the nucleus in anterior chamber,
hydrodissection and hydrodelination are very essential
steps. Hydrodissection separates the peripheral cortex
from the capsule and makes the nucleus free in the
capsular bag, while hydrodelination separates the nucleus
from cortex and peri-nucleus thus reducing the size of
nucleus making its delivery possible through smaller
incision.
For hydrodissection the Balanced Salt Solution (BSS)
is injected through 27G cannula. The cannula is placed
about 2 mm distal to the edge of capsulotomy or
capsulorhexis and BSS injected. If red reflex is visible the
fluid wave is seen passing along the posterior capsule all
around. The visualisation of fluid wave ensures that
hydrodissection is complete. The BSS is injected in
different directions. Every time the BSS is injected the
lens should be slightly tapped posteriorly so that the fluid
does not collect posteriorly leading to posterior capsule
rupture. A good hydrodissection makes the nucleus
rotation and nucleus prolapse very easy.
After hydrodissection, hydrodelination is performed
separating the nucleus from epinucleus. For
hydrodelination the cannula is introduced deeply into
the mid-periphery of the lenticular nucleus until the hard
core of nucleus is reached. The cannula is withdrawn
17
RP Singh
BK Singh
BN Chaudhary
slightly and BSS injected creating a cleavage between

the soft fibre of the epinuclear shell and more dense
portions of the central nucleus. When a complete
hydrodelination is performed a golden ring is sometimes
observed. Hydrodelination not only reduces the size of
the nucleus but also facilitates nucleus rotation and
nucleus prolapse into AC from the capsular bag.
Nucleus Rotation and Prolapse of Nucleus
Without nucleus rotation and nucleus prolapse, manual

phaco cataract surgery can never reach its culmination.
There are various techniques described and practiced.
The few preferred ones are discussed below:
Tipping up Technique
The key to this procedure is proper tipping up of the

nucleus out of the capsular rim and above the iris plane.
The iris is retracted with a collar stud hook. Then the
capsule and iris are held with a 1.0 mm iris spatula and
the nucleus is nudged towards six Oclock with the collar
stud hook. This lowers the superior pole of the nucleus
and the equatorial rim becomes visible away from the
iris margin. The superior pole of nucleus is tipped up
with iris spatula. The viscoelastic is injected between the
nucleus and post capsule. The nucleus is then rotated
with iris spatula and is eventually prolapsed into anterior
chamber (Fig. 17.1).
Tyre Levering Technique
If the nucleus is larger than the capsulorhexis or capsulotomy, prolapsing the nucleus is quite difficult. Tyre
levering technique is useful in this difficult situation. A
7.0 mm nucleus can be removed out of 5.0 mm capsulorhexis. First of all the free rotation of nucleus is ensured
after good hydrodissection and hydrodelination. The
nucleus can be rotated with iris spatula or 30G irrigating
cannula.
Nucleus Prolapse from Capsular Bag
99
Fig. 17.1: Nucleus prolapse with the help of

lens loop/irrigating vectis
Fig. 17.2: Tipping technique to nucleus prolapse
The nucleus is nudged posteriorly towards the posterior capsule at nine Oclock equator so that the three
Oclock equator comes out of the capsular rim slightly.
The nucleus is then lifted up at three Oclock with iris
spatula and rotated out of the capsular bag as tyre is
taken out of its rim (Fig. 17.2).
endothelium. The lens lies upside down in the anterior

chamber. Ample amount of visco-elastic is now put above
and below the nucleus suspending it in a pool of viscoelastic. This separates the nucleus from the corneal
endothelium and prevents endothelial damage (Figs 17.3
and 17.4).
Tumbling of the Lens
Other Methods
In this technique the freely rotating nucleus is tumbled

along the vertical meridian by using the visco-elastic
cannula. The viscoelastic or BSS is injected under the
anterior capsular rim at nine Oclock. The viscoelastic or
BSS travel along the equator over the posterior capsule
towards the opposite side. The pooling of viscoelastic or
BSS behind the nucleus pushes the nucleus out of the
rim at three Oclock. The nucleus is further pressed at
nine Oclock, which pops the nucleus at three Oclock.
The cannula is now sweeped from nine to three Oclock
along the posterior capsule. This tumbles the lens and
brings the posterior lens surface towards the corneal
There are other methods with slight modifications, which

various surgeons are using according to their choice and
size of the nucleus, capsulotomy/capsulorhexis and
pupillary aperture.
A. In this method, a 20G irrigating cannula attached to
BSS bottle is used. The cannula is inserted facing
downward under the capsule at different places, i.e.
three Oclock, six Oclock or nine Oclock positions.
The cannula is positioned deep upto the equator. The
fluid passes between the nucleus and posterior capsule
and pressure builds up in the capsular bag. The pressure of the fluid pushes the pole of the nucleus out of
100
Fig. 17.3: Nucleus prolapse by visco-expression
the capsular rim and pupillary border. Viscoelastic is

injected under the pole of the nucleus, which further
pushes it out of the capsular rim. The nucleus is rotated
with the viscoelastic cannula and this brings whole of
the nucleus in anterior chamber.
B. This method is utilised in complicated cases where
nucleus is large or pupil is small and it is difficult to
prolapse the nucleus. With an iris retractor in the
dominant hand the iris and capsule is retracted at
twelve Oclock position and simultaneously the
posterior rim of the scleral incision is pushed slightly
downward. With the other hand, hydrodissection
cannula on an empty 2 ml syringe is passed through
two Oclock side port incision towards six Oclock
position under the rim of anterior capsule.The six
Oclock pole is pressed downward, which tumbles up
the twelve Oclock pole out of the capsule rim. The
retractor is removed and visco-elastic is injected
between the nucleus and posterior capsule at twelve
Fig. 17.4: Nucleus prolapse by using iris retractor

and hydrodissection cannula
Oclock. With the viscoelastic cannula the nucleus is

rotated out of the capsular bag in the anterior chamber.
All the above mentioned methods of nucleus prolapse
have only small differences and they are used according
to the situation. The basic principle is taking the nucleus
out at anyone of the poles and then prolapsing the rest
of the nucleus out of the capsular bag by various
methods.
Apart from incision construction, prolapse of the
nucleus in anterior chamber is the most unique and
important step of manual phaco surgery and needs to
be done meticulously and carefully, otherwise, there is
always a possibility of posterior capsular rupture and
damage to corneal endothelium.
FURTHER READING
1. Shah Anil: In Small Incision Cataract Surgery (Manual Phaco)
Bhalani Pub: India 62-67, 2000.
2. Natchiar G: Manual Small Incision Cataract Surgery. Arvind
Publications: India 21-24, 2000.
The Phaco Sandwich Technique
The Phaco
Sandwich Technique
ry is credited with the phaco sandwich technique.

This technique is simple, allows removal of lens
through a 6.06.5 mm self-sealing scleral tunnel
incision, produces much less astigmatism compared to
extracapsular cataract surgery and is sutureless. The
author has adopted this technique for over 5 years and
results have been gratifying.
101
18
Kamaljeet Singh
phrine combination and flurbiprofen eye drops. These

are instilled 1 hour before the surgery. Author suggests a
conventional ECCE if the pupil is less than 5 mm in
diameter at least in initial 50 cases. Acetazolamide one
tablet is given 2 hours prior to surgery. Some surgeons
avoid acetazolamide as it causes hypotony.
Anaesthesia
Instruments
Essentially the instruments required are similar to what

an ECCE surgeon requires. Additional instruments are.
Crescent knife
3.2 mm angled keratome
5.2 mm keratome
Irrigating vectis
Sinskey type dialer, iris repositor
AC maintainer
Preoperative Preparation
The essential thing in this surgery is wide dilatation of

pupil, which allows easy prolapse of the nucleus in anterior chamber and prevents iris entrapment during delivery
of nucleus. Pupil dilatation and its maintenance in dilated
status is achieved by instilling tropicamide and phenyle-
Fig. 18.1:Size of the conjunctival flap
A peribulbar anaesthesia with a cocktail of 3 ml of xylocaine with adrenaline and 3 ml bupivacaine mixed with
hylase is used. Superpinky ball or ocular massage for
long is not recommended as it produces hypotony.
Surgical Steps
1. After applying speculum and holding superior rectus

fornix based conjunctival flap is made (Fig. 18.1).
Careful bipolar cautery should be carried out. It gives
a bloodless field to operate and there is no
inadvertent bleeding during the making of scleral
tunnel, but overenthusiastic cautery should be
avoided as it causes astigmatism.
2. 6 to 7.5 mm partial thickness scleral tunnel incision
is made 2 mm behind limbus. Harder the nucleus
longer is the incision. In initial 25 patients longer
incision is recommended to avoid unnecessary
touch to the corneal endothelium. The scleral pocket
is made with crescent knife (Fig. 18.2). Disposable
crescent blades are the best. Their reuse might lead
to a poor tunnel. This is the single most important
step in this surgery. Therefore, no compromise
should be accepted. Scleral pocket is extended in
the corneal stroma. While making scleral tunnel
sclera induces greater resistance than the cornea.
Therefore, the surgeon should become very gentle
while entering the cornea. Otherwise it may lead to
early entry into the anterior chamber causing poor
corneal valve. The corneal tunnel should be up to
1.5 mm from the limbus and as suggested by
102
Fig. 18.2: Tunnel length with crescent blade
Fig. 18.3: Extension on other side
Fig. 18.4: Dimple at the cornea just before entering AC
Fig. 18.5: Entry into AC by 3.2 angled keratotome
Blumenthal incision should be 2 mm wider than

the scleral tunnel (Fig. 18.3). The crescent should
be swept with pressure away from anterior chamber.
3. Entry into the anterior chamber is made with an
angled 3.2 mm keratome. Angled keratome should
be sharp. Blunt keratome leads to Descemets
detachment. A dimple is seen when pressure of
keratome is applied towards anterior chamber (Fig.
18.4). The movement should be controlled otherwise
it may hit the capsule and capsulorhexis would be
difficult to make in this condition (Fig. 18.5).
4. Viscoelastic is injected into the anterior chamber (Fig.
18.8). Here the care should be taken to slightly press
the scleral side so that the aqueous can come out
and only the viscoelastic remains. It will make the
anterior capsule taut and capsulotomy becomes
easier.
5. Capsulotomy Any types of capsulotomy can be
done in SICS-can-opener, envelope or capsulorhexisall are useful (Fig. 18.9). In fact author
suggests can-opener and envelope technique in

initial few cases, because the prolapse of the nucleus
in AC becomes easier. Size is important in case one
prefers to make capsulorrhexis. 0.1 ml trypan blue
dye is injected beneath the air bubble through the
side port (Figs 18.6 and 18.7). It should not be less
than 6.5 mm and slightly eccentric on the upper
side. Both these things will help in prolapse of the
nucleus in the AC. In case the capsulorhexis is small,
whole nucleus with capsular bag can come in the
AC. Then it would be intracapsular rather than
extracapsular surgery. One should take precaution
here. Other way round too large a capsulorhexis
might extend into the periphery (Fig. 18.8).
6. Hydrodissection Aim of hydrodissection is to see that
all adhesions between cortex of lens and capsule
are broken and a free rotating nucleus is visible. The
technique of hydrodissection has been described
elsewhere. Two points need to be mentioned here.
Do not try to strain the zonules by pushing your
103
Fig. 18.6: Scleral incision with single air bubble
Fig. 18.7: Dye being injected under the

air bubble from side port
Fig. 18.8: Capsulorhexis with Trypan blue
Fig. 18.9: Extension of incision with 5.5 mm keratotome
rotating instrument too hard. If hydrodissection is

complete there is no difficulty in rotating the nucleus.
If rotation is difficult, it means incomplete hydrodissection. So, inject more fluid beneath the anterior
capsule and retry the rotation. Secondly, fluid
injection should be slow and only optimum amount
should be injected. Hydrodelineation is a must in
SICS. It helps in debulking the nucleus and delivery
of nucleus through smaller incision becomes easier.
7. The incision is enlarged with the help of 5.5 mm
angled keratome after injecting sufficient amount of
viscoelastic (Figs 18.9 and 18.10).
8. Nucleus prolapse in AC This is single important step
in a successful SICS. Nucleus prolapse is easier if
the pupil is widely dilated and a good rotation of
the nucleus is achieved after hydro-dissection. In
initial few cases it is easier to prolapse nucleus in
AC, if can-opener or envelope type of capsulotomy
has been done. The nucleus is prolapsed by rotating
the nucleus after filling the chamber with viscoelastic.
The moment, rim of nucleus is visualized, the

cannula is brought below the rim of nucleus; and
again viscoelastic is injected in between the nucleus
and perinucleus. The upper pole of nucleus will
prolapse in the AC. In small pupils one can depress
the nucleus at five Oclock with the cannula. The
upper pole at 11 Oclock, then can be seen easily.
Now the nucleus is rotated towards 12 Oclock. Thus
achieving the aim of prolapse of upper pole of
nucleus (Fig. 18.11). Once you are sure about
prolapse of nucleus in AC inject more viscoelastic
between the cornea and anterior surface of nucleus
and also behind the nucleus This maneuver requires
copious use of viscoelastic to prevent injury to the
corneal endothelial cells. Once this is achieved the
nucleus is now ready for delivery.
9. Delivery of nucleus The author uses irrigating vectis
and a Sinskey type of dialer but the difference here
is that it is like a hammer at the end and much thicker
than the dialer (Fig. 18.12). Thus it has blunt end,
104
Fig. 18.10: Enlarged incision for accomodating nucleus
Fig. 18.11: Nucleus prolapse in AC only upper pole
Fig. 18.12: Irrigating vectis and dumbel
Fig. 18.13: First enter with dumbel, on anterior surface of lens.

Second instrument is irrigating vectis, which enter behind the
nucleus
which prevents posterior capsule rupture. The author

calls it a dumble. Fluid flow through the vectis is
checked. First thing is to enter anterior chamber
through the incision with the dumble in your left
hand (Fig. 18.13). This is kept at the center of
nucleus. No pressure is applied. Then the irrigating
vectis is passed behind the posterior surface of
nucleus in such a way that the nucleus is sandwiched
between these two instruments. The pressure is
applied from below the nucleus and also on the
anterior surface of lens. At the same time the
sandwiched nucleus is brought out of the wound
(Figs 18.14 and 18.15). Two things will results. If
the lens is soft it will come out in one go. If it is hard
it may break into several pieces. A part of that will
come out sandwiched between two instruments.
Remaining pieces of nucleus are taken out by either
viscoexpression or by holding the pieces with
Mcphersons forceps. One needs to be very cautious
here as the anterior surface of nucleus or its pieces
Fig. 18.14: Nucleus sandwiched between

irrigating vectis and dumble
should always have viscoelastics in front of them.

In case one finds difficulty in delivering out the
nucleus the incision length needs to be increased.
105
Fig. 18.15: Nucleus being delivered through tunnel

sandwiched between irrigating vectis and dumbel
Fig. 18.16: Expression of perinucleus
Fig. 18.17: Cortical wash
Fig. 18.18: Perinucleus being expressed out of tunnel
Fig. 18.19: View of clean posterior capsule after cortical wash
Fig. 18.20: Conjunctiva is reposited back
This problem is normally encountered in brown hard

cataracts. Rarely in very big nucleus the tunnel has
to be abandoned and a routine ECCE is performed.
10. Remaining debris is perinucleus and cortical matter
These are removed by two-way Simcoe cannula,
which is connected to a BSS bottle by an infusion

set. Cannula is opened with full flow. Take this free
flowing cannula to 6 Oclock slight pressure on the
posterior lip of the tunnel by the cannula will
prolapse the perinucleus out of the wound. Remain-
106
ing material is cortex. A part of this will come out

with perinucleus by hydroexpression. Cortical fibres
are then aspirated (Figs 18.16 to 18.18). The details
are discussed elsewhere.
11. After the posterior capsule has been washed and
no fibres are left, intraocular lens is implanted as
usual (Figs 18.19 and 18.20).
12. Conjunctiva is reposited back by holding the
conjunctiva with two forceps. Cautery is then applied
at two ends (Fig. 18.20).
13. Gentamicin and decadron injection is instilled on the

top of conjunctiva. There is no need of giving any
subconjunctival injection.
FURTHER READING
1. Luther L Fry: The Phaco sandwich technique: In George W
Rozakis et al (Eds): Cataract Surgery Alternative SmallIncision Techniques. Thorofare Inc, 71-110, 1995 Indian
edn.
Modified Fish Hook Technique
Modified
Fish Hook Technique
or the first time the author learned this technique

in Nepal from Dr Hennig, where thousands of
cataract surgeries are performed by a simple
technique through a 26G needle. The author modified
this technique and performed several operations with
great satisfaction.
Surgical instruments required for this technique are
described below:
A. For scleral pocket incision:
Castroviego type of calipers
For Scleral groove straight blade diamond knife
with 45 degree angulation.
Under mining forward of tunnel by scleral
pocket crescent knife with 60 degree angulation.
A/C entry with 3 mm keratome.
Side port entry blade 15 degree straight.
Section enlarging blade 5.5 mm with 60 degree
angulation at shaft
B. Instruments for capsulotomy:
Utrata forceps
26 gauze needle
C. Instruments for hydroprocedures:
Hydrodissection cannula 26 gauge with 45
degree angulation with flat tip
Hydrodelineating cannula
J shaped hydrodissection cannula for 12 Oclock
D. Instrument to deliver the nucleus (Manipulation
of nucleus)
Fig. 19.1: Straight 26 G needle 1st bend to make a hook
107
19
Rajeev Vaish
A single 26 G needle is used for this purpose. 26 G

needle is bent like a hook 2 mm proximal to the bevel
edge (Fig. 19.1). The bevel edge of eye should be
facing outward. It resembles a fishhook. After that the
needle is again bent at right angle to the initial bend,
so that the hook faces right or left side (Fig. 19.2).
Angulation of this bent may be 100 to 130 degrees, it
acts like a lever while removing nucleus from the
capsular bag.
Instrument for Aspiration of Residual Cortex
Simcoe cannula regular type

Instrument for IOL Insertion
MacPherson forceps for rigid PMMA IOL implant

Inor lens folder for foldable IOL implants
Inor lens inserter.
Preoperative Clinical Examination
A thorough history and general examination is done in

following order :
1. Visual acuity examination to exclude uniocular patient
and include patient with accurate PL and PR.
2. Slit lamp microscopyAll the patients are subjected
to preoperative slit lamp microscopy on slit lamp. A
careful note of the following findings is made.
a. Pre-existing corneal scars that might interfere with
the keratometry.
Fig. 19.2: Right angle rotation of hook
2nd bend of
100-130 degree at shaft
108
3.
4.
5.
6.
7.
8.
b. Pre-existing corneal endothelial dystrophy, i.e.

Fuchs or corneal guttata that might lead to corneal decompensation.
c. A rough idea of the filtration angle by measuring
the distance between cornea and the iris.
d. Status of pupillary dilation to exclude uveitis.
e. Grading the nucleus for its toughness by noting the
colour.
f. Subluxation of lens to be reserved for plain ICCE
only.
Syringing of all selected cases.
Intraocular tension with Schitz tonometer.
Conjunctival smear to exclude any infective microbe.
Routine hemogram and complete urine examination.
Keratometry is done preoperatively in both steep and
flatter meridian to record the measured astigmatism.
A scan biometry is done in all cases to know exact
IOL power. A high axial length denotes high myopia.
A scan biometry can also exclude retinal detachment
in the cataractous eye.
Method
Lid and globe akinesia is obtained by peribulbar anaesthesia.

Lid retraction by barraquer wire low-tension speculum
and superior rectus suturing is done as usual.
Surgical Technique
A fornix based conjunctival peritomy is done between

10.30 to 1.30 Oclock position, superficial scleral blood
vessels are cauterized.
Scleral Tunnel Incision
After maintaining haemostasis, a 5.5 to 7 mm of half

thickness scleral groove, 1.5 mm behind the limbus is
made by a diamond knife. The shape of incision should
be frown or antismile.
Scleral dissection is performed by a symmetrical
biconvex dissector knife angled 60 degrees having sharp
cutting edges on both sides.
Scleral dissection is of half thickness in a given lamella
upto 1 mm of clear cornea. This creates a triplanar valve
type of self-sealing incision. At 2.30 Oclock position, the
anterior chamber is penetrated by a sharp 15 degree
angulated side port blade and viscoelastic hydroxymethyl
cellulose 2 per cent is injected in anterior chamber This
incision is used for entry of manipulation instruments
like capsulotomy needle, hydrodissection, hydrodelineation cannula and manipulation of lens.
Anterior Capsulotomy
Anterior capsulotomy is done using a 26 G needle bent

and twisted to act as a cystitome. The AC is entered
through a side port usually at about 2 Oclock position.
The AC is kept deep and formed using a viscoelastic
substance. A straight or envelope type of capsulotomy is
performed at 12 Oclock position.
Hydrodissection and Hydrodelineation
Hydrodissection is performed using a 1cc syringe and a

cannula in which the bent part is 4 mm and tip is flattened.
The cannula slides along the exposed hard core nucleus,
is inserted obliquely at 12 Oclock into the junction of
the hard core nucleus and epinucleus and 0.1-0.3 cc of
BSS is injected.
The BSS hydrodissection creates a demarcation line,
usually clearly seen by the light reflection (golden ring)
created between the nucleus and the epinucleus, or
between the epinucleus and the cortex.
Anterior Chamber Entry
Anterior chamber is entered by a keratome blade at

12 Oclock position and chamber is filled with visco
elastic. Now the section is enlarged by 5.5 mm wide section enlarging blade. The configuration of this entry
should be smile type and size varies according to the
pre-evaluated size of the nucleus.
Technique of Nucleus Delivery
Intracapsular tumbling of nucleus with (fish) hooked

extraction of nucleus.
After extending the inner incision like a smile fashion,
a 26 G needle bent like a hook in mounted on a 2 cc
viscoelastic filled syringe. We enter in the A/C injecting
visco to make it deep. A downward pressure by hook
and visco is applied at 12 Oclock position on the nucleus,
through linear capsulotomy site. By this manoeuvre the
nucleus at 12 Oclock is pushed downward and inferiorly.
Later on it will tumble inside the bag and hook goes
posteriorly to nucleus. This time we should inject 1 ml
visco inside so that the posterior capsule is pushed back.
A space is thus created to move the tip of hook anteriorly
to get embedded in mid-substance through posterior
surface of nucleus.
After hooking the nucleus we should inject more
viscoelastic that makes a positive pressure inside and this
positive pressure and a little active extracting pressure
by hook delivers the nucleus outside the bag and directly
engages it in the scleral tunnel.
Modified Fish Hook Technique
Hydrodissection and
rotation of nucleus
in the bag
Viscoelastic assisted pressure

at 12 Oclock by hook
shaped needle position
A slight more passive (visco assisted) and active (of

hook) pressure helps in extraction of nucleus from the
tunnel. It should be always kept in mind that every step
of nucleus manipulation a pre-judged amount of viscoelastic is injected gradually making nucleus tumble inside
the bag and deliver it through scleral tunnel. A well-balanced passive pressure of viscoelastic and active movement of hook is the key to success of this procedure.
The case in which difficulties are found during nuclear
manipulation should be converted into standard ECCE
by increasing the length of incision.
After thorough cleaning of capsular bag and polishing
of posterior capsule, depending on the size of incision, a
foldable silicone introaocular lens, or a 6 mm optic or a
phacolens of 5 mm optic are introduced through scleral
tunnel and placed inside capsular bag.
Intracapsular tumbling of nucleus
Hook lies behind

nucleus and extracting
it out scleral tunnel
109
Hook embedded in
the scleral tunnel
Suture Application
Scleral tunnel incisions are self-sealing incisions thats

why we apply no or a single suture according to need
and size of incision. At the end of procedure either BSS
solution or single air bubble is injected. At the same time
pressure is applied on the eye globe to check the integrity
(leakage) of wound.
Follow-up
All the patients are followed up upto two months at

weekly interval and corneal condition, Keratometry,
visual acuity and any other complications are noted and
analysed. In all visits postoperative problems and
complications like iritis and corneal oedema are observed
and treated accordingly.
110
Manual
Phaco-fracture
odern cataract surgery aims at the visual

rehabilitation of the patients in a minimally
invasive manner. The final goal is the removal
of the contents of the capsular bag through the smallest
possible incision, and the implantation of a suitable
intraocular lens into the bag. Small incision cataract
surgery has contributed immensely to accelerated wound
healing and minimization of hospital stay of the patient.
Two of the main goals of cataract surgery in recent times
are to minimize induced astigmatism and achieve rapid
visual recovery. The smaller the surgical incision, the
lesser is the residual postoperative astigmatism. With the
advent of the current technique of phacoemulsification,
and the development of todays state-of-the-ar t
phacoemulsification machines, phacoemulsification, is
today, the surgery of choice for extraction of senile
cataract. Phacoemulsification allows the removal of a
nucleus of 6-8 mm size through an incision size of 3 mm
or less. However, the expensive instrumentation and
prolonged learning curve involved with phacoemulsification are its major limitations, particularly in developing
countries.
If extracapsular cataract extraction (ECCE) is
performed through a small self-sealing incision,
postoperative visual recovery and stability can rival that
of phacoemulsification.
During late 1980s, manual fragmentation techniques
of the nucleus began to appear as an alternative to
phacoemulsification. In manual phaco-fragmentation
techniques, incision size depends on the dimensions and
hardness of the nuclear fragments to be extracted from
the anterior chamber. Usually, the nucleus is divided into
2 or 3 fragments, which is then viscoexpressed through
the incision. Soft cataract can be extracted through a 4.0
to 4.5 mm incision. With hard nuclei, it is usually
necessary to increase the wound size to avoid damaging
the iris and corneal endothelium.
20
Rajesh Sinha
Prashant Bhartiya
Rasik B Vajpayee
Small incision cataract surgery (non-phaco) is a cost

effective alternative to phacoemulsification. It combines
the advantages of small incision surgery with the low
cost of instrumentation.
Advantages of Small incision cataract surgery:
1. Less astigmatism
2. Early wound stabilization and early rehabilitation
3. Low cost of surgery
4. Shorter learning curve
There are basically two principle ways of extraction of
cataract by small incision non-phaco surgery. They are:
(1) extraction of the nucleus as a mass without
fragmentation,1,2 and (2) extraction of the nucleus after
fragmentation.3,4,5
Surgical Techniques
Various surgical techniques of small incision cataract

surgery sans phacoemulsification have been described.
The principle of small incision cataract surgery involves
reducing the size of the nucleus. This can be achieved
either by hydro-maneuvers6,7 or by breaking the nucleus
into pieces by various nucleo-fracture techniques.
Nucleo-fracture Techniques
Kansas and Sax3 initially described phaco-fragmentation

techniques. These are technically more complex than the
techniques of nucleus removal without fracture. This
involves removal of the nucleus by breaking it into smaller
chunks so as to allow their removal through a smaller
incision than that required for a conventional ECCE or a
small incision manual ECCE without nucleo-fracture.
A frown shaped scleral groove perpendicular to the
eyeball surface and of uniform depth of about half
thickness of sclera is made. The ends of the frown are
approximately 3mm from the limbus while its central
convexity is 1.5mm from the limbus. This frown incision,
which confines itself to within the astigmatic neutral zone,
Manual Phaco-fracture
provides the best results from astigmatic point of view.

The length of incision varies from 5 to 6 mm depending
upon the size of intraocular implant. This incision is then
tunneled by the use of crescent knife so that the tip of
the blade should be 1mm into the clear cornea. The
anterior chamber is entered by a 3.2mm angled
keratome. A side port is made with the microvitreoretinal
blade.
A large continuous curvilinear capsulorhexis of
approximately 7.0 mm is made using 26G needle. A large
capsulorhexis is essential for prolapsing the nucleus into
the anterior chamber. If the capsulorhexis is small, a
radiating cut to the capsulorhexis edge is made at the 12
oclock position to facilitate the prolapse of the nucleus.
Hydro-dissection and hydro-delineation are essential
for freeing the nucleus from the surrounding epinucleus
and cortex so that it can be easily prolapsed into the
anterior chamber without excessive stress. The
hydrodissection cannula is placed under the anterior
capsule, the capsule is tented and small amount of fluid
is injected. This is repeated in all the quadrants. After
every injection the nucleus is gently pressed so that fluid
seeps out and does not tear the posterior capsule.
Hydrodissection should be avoided in posterior polar
cataract. Hydro-delineation is done with a 26G cannula
by repeated strokes going deeper into the nucleus. The
end point of hydro-delineation is the appearance of a
golden ring.
The anterior chamber is deepened with viscoelastic
(sodium hyaluronate or hydroxypropyl methylcellulose)
and the nucleus is gently pushed at one end. If the hydro
procedures have been done properly and the nucleus is
free, it will lift up at one point. It is prolapsed into the
anterior chamber by repeated strokes by hydrocannula.
Viscoelastic is injected both behind the nucleus as well
as in front of the nucleus to protect the posterior capsule
and the endothelium. The whole incision is made fullthickness with a keratome. The nucleus is fractured by
using Kansas trisector (Fig. 20.1) and Kansas vectis
(Fig. 20.2). The trisector is positioned above the nucleus
and Kansas nucleus vectis placed under the nucleus. By
Fig. 20.1: Kansas trisector
Fig. 20.2: Kansas nucleus vectis
111
moving the tips of the two instruments towards each other

with a constant force, the nucleus is fractured. These
nuclear fragments are then visco-expressed and the
remaining cortical material is aspirated with a Simcoe
cannula.3,4 Maintenance of the anterior chamber is the
main surgical concern so as to avoid damage to the
corneal endothelium or the posterior lens capsule. This
is taken care either by an anterior chamber maintainer
(ACM) or by repeated injections of viscoelastic material
into the anterior chamber.
A pre-chop technique8 has been described in which
the nucleus is chopped into smaller pieces using a sharp
chopper. The fragments are then visco-expressed. Risk
of damage to the posterior capsule while using this
technique can be reduced with the use of a lens vectis or
slide behind the nucleus.
Keeners9 stainless steel loop and Quintanas10 3-0
nylon loop techniques involve snaring the nucleus and
cutting it into smaller pieces before removal.
Another technique called manual multi-phacofragmentation (MPF) with a racquet shaped nucleotome
and spatula has been described.11 A 3.2 mm clear corneal
incision was made and the spatula was placed under
and the nucleotome on top of the nucleus. The nucleus
was fragmented into 4 pieces by pressing the nucleotome
against the spatula. These pieces were extracted out using
a sandwich technique by removing the two instruments
together. Right and left manipulators were used to
displace the remaining fragments for fur ther
fragmentation and extraction. This maneuver was
repeated until the whole nucleus was fragmented.
Another instrument devised for use through a 3.2mm
incision is the Akura 5 nucleus puncher. It has the
advantage that it need not be inserted beyond the center
of the nucleus during nucleus fragmentation, can be used
safely in hard cataracts and can be used with one hand.
Pieces of the nucleus are punched out and this technique
is called the quarters extraction technique.
Epinucleus and most of the cortex can be removed
by hydro-expression. Residual cortical matter is removed
by irrigation-aspiration by a Simcoe cannula. The
intraocular lens is implanted. Stromal hydration of the
tunnel and the side port is done. This prevents the need
of any suture.
Complications
Apart from the routine surgical and postoperative

complications that can be seen during any cataract
surgery, certain specific complications can occur during
the procedure of manual nucleofracture. Here we will
112
discuss the complications that are specific to and more

commonly seen in this procedure.
sphincterotomies. An excessive manipulation of iris can

result in iridodialysis and cyclodialysis.
Intraoperative Complications
Postoperative Complications
Posterior capsular rupture Posterior capsular (PC)

rupture may occur during hydrodissection or while trying
to push the vectis between the nucleus and posterior
capsule. It can be avoided by hydroexpressing the nucleus
out of the capsular bag and then pushing the posterior
capsule well away from the nucleus by viscoelastic. If
there is a PC tear, the rent is plugged and the bag inflated
with viscoelastic. Dry aspiration of the cortical matter is
done with a Simcoe cannula. A posterior chamber lens
is implanted in the bag if the tear is small and central. In
case of a large tear, vitrectomy is performed and a
posterior chamber lens is placed over the anterior
capsular rim.
Corneal edema Central corneal edema is more commonly seen with this procedure in the immediate postoperative period. This is related to the increased endothelial loss during the surgery.
Posterior dislocation of the nucleus If further manipulation is done in the presence of a large PC rent, then
there is the risk of nucleus dropping behind in the vitreous
cavity. It is rarely seen and is appropriately managed by
a vitreoretinal surgeon in the same sitting or the wound
is closed and the patient referred to a vitreoretinal surgeon
later.
Descemets tear Tear in descemets membrane can
occur due to rubbing of large nuclear fragments against
the endothelium during delivery. It can be prevented by
keeping the anterior chamber full with viscoelastic during
nucleofracture and delivery as well as ensuring that the
direction of pull of the vectis should be in the plane of
the scleral tunnel.
Frequent shallowing of anterior chamber The anterior
chamber shallowing and collapse is quite frequently seen
owing to excessive manipulation and use of multiple
instruments in the anterior chamber. It can be avoided
by frequently injecting viscoelastic in anterior chamber
or by using an anterior chamber maintainer (ACM).
Endothelial damage Due to excessive manipulations in
the anterior chamber by multiple instruments, endothelial
damage is quite significant in this procedure. A higher
endothelial cell loss has been reported in comparison to
phacoemulsification.4
Intraoperative miosis Many a times pupil gets cons
tricted during the procedure owing to excessive
manipulation of iris. Due to this, there may be difficulty
in prolapsing the nucleus into the anterior chamber and
might warrant use of intracameral adrenaline or multiple
High intraocular pressure Intraocular pressure has been

found to be high in the immediate postoperative period
in a number of cases undergoing manual phacofracture.
This can be explained by the large amount of viscoelastic
used during the surgery. Another factor that can lead to
high postoperative intraocular pressure is the large
amount of pigment release that occurs during surgery.
Pupillary distortion Intraoperative iridodialysis or
cyclodialysis or multiple sphincterotomies if done, can
result in distortion in the pupillary size and shape.
REFERENCES
1. Blumenthal M, Ashkenazi I, Fogel R, Assia EI: The gliding
nucleus. J Cataract Refract Surg 19: 435-37, 1993.
2. Fry LL: The phacosandwich technique. In: Rozakis GW, Ed,
Cataract Surgery; Alternative Small-Incision Techniques.
Thorofare, NJ Slack, 91-110, 1990.
3. Kansas PG, Sax R: Small incision cataract extraction and
implantation surgery using a manual phacofragmentation
technique. J Cataract Refract Surg 14: 328-30, 1988.
4. Vajpayee RB, Sabharwal S, Sharma N, Angra SK: Phacofracture versus phacoemulsification in eyes with age-related
cataract. J Cataract Refract Surg 24: 1252-55, 1998.
5. Akura J, Kaneda S, Ishihara M, Matsuura K: Quarters
extraction technique for manual phacofragmentation. J
Cataract Refract Surg 26: 1281-87, 2000.
6. Blumenthal M, Ashkenazi I, Assia E, Cahane M: Smallincision manual extracapsular cataract extraction using
selective hydrodissection. Ophthalmic Surg 23: 699-701,
1992.
7. Akura J, Kaneda S, Hatta S, Matsuura K: Manual sutureless
cataract surgery using a claw vectis. J Cataract Refract Surg
26: 491-96, 2000.
8. Akahoshi T: Phaco pre-chop; manual nucleofracture prior to
p4hacoemulsification. Operative Tech Cataract Refract Surg
1: 69-91, 1998.
9. Keener GT (Jr): The nucleus division technique for small
incision cataract extraction. In: Rozakis GW, Ed, Cataract
Surgery; Alternative Small-Incision Techniques. Thorofare,
NJ Slack, 163-191, 1990.
10. Quintana M: Implantacion de LIO plegable con facosecion
manual y pequena incision. Microcirugia Ocular 6(1): 3744, 1998.
11. Gutierrez-Carmona FJ: Manual multi-phacofragmentation
through a 3.2 mm clear corneal incision. J Cataract Refract
Surg 26: 1523-28, 2000.
Microvectis Technique
Microvectis
Technique
he cataract surgery has witnessed a phenomenal

progress over the years and continues to evolve
with the addition of newer surgical techniques and
instrumentation. Michael Mc Farland first conceived the
principles of no stitch cataract surgery with phacoemulsification in 1990.1 Earlier Blumenthal in 1987
popularized the technique of Non-phaco SICS in which
he described the use of anterior chamber maintainer to
hydro-express the nucleus.2 The technique of phaco
fracture, where the nucleus is divided before its removal
was pioneered by Kansas,3,6 in 1990. In the same year,
phaco-sandwich, a bimanual technique of removal of
nucleus was described in details, by Luther Fry.4,7 Since
1995, the authors have been using a different technique
in which nucleus is expressed with the help of a
microvectis. In this technique no anterior chamber maintainer is used, as it is a cumbersome procedure and
secondly balanced salt solution (BSS) may not protect
the corneal endothelium like viscoelastics. Side port entry
is never required as a routine procedure. We recommend
this simple and effective method of delivery of nucleus
even for rock hard cataracts. The surgeons in the developing countries, particularly in India, who are dealing
with more mature and brunescent cataracts may be
benefited by this technique.
Indication
Types of cataract All types, and all grades of nuclear

cataract.
Objectives
1. To mobilize the nucleus inside the capsular bag.

2. To luxate the nucleus subsequently into the anterior
chamber.
3. To express the nucleus with the help of a microvectis /
lens loop.
21
113
P Mishra
S Thanikachalam
Wound Construction
Scleral tunnel incision, which varies from 5-8mm

depending on types of cataract.
Viscoelastics
Liberal use of low molecular viscoelastics to reform the

anterior chamber as and when required.
Instrumentation
Nuclear rotation IOL dialer/Sinskey hook or bent 26G.

needle.
Nucleus expression Microvectis (3-4 mm)/micro-lens
loop.
Anaesthesia
Non-phaco SICS can be performed under peribulbar or

topical anaesthesia. Peribulbar anaesthesia was achieved
by giving two injections, mixture of 5 cc xylocain (2%)
and 5cc bupivacaine (0.5%) by two points technique. In
selective cases proparacaine (0.5%) is used as topical
anaesthesia.
Capsulorhexis
Continuous curvilinear capsulorhexis originally described

by both Gimbel (Canada) and Neuhann (Germany), is
usually performed with a bend 26G needle or masket
capsulorhexis forceps. A rhexis of 6.5 to 7.5mm is
preferred, however, two relaxing incisions at 2 to 10
oclock is usually required to prolapse the nucleus easily
in nuclear cataracts.
Hydrodissection
Good hydrodissection should be performed to separate

the nucleus from its capsular attachment. The anterior
capsule is elevated with a 26G cannula and BSS is
injected slowly and continuously from a 2ml syringe.
114
When completed nucleus appears to move forward

following, which it must be freely rotatable within the
capsular bag.
Nucleus Expression
Although there are different techniques available for

nucleus management namely phaco-sandwich, phacofracture, hydro-expression, irrigating vectis, etc. we restrict
our discussion to removal of nucleus by microvectis
technique.
After reforming the anterior chamber with viscoelastics
the superior pole of the nucleus is engaged, lifted and
rotated with the help of an IOL dialer and prolapsed into
the anterior chamber (Figs 21.1 and 21.2). The nucleus
rotation is done either clockwise, anti-clockwise or both
to luxate the nucleus completely into anterior chamber.
Once the superior pole lifts up viscoelastics may be
injected underneath, to make nuclear rotation easy.
Viscoelastics is placed both above and below the nucleus
when it luxates into anterior chamber. This step is essential
Fig. 21.3: Microvectis is introduced below the nucleus
Fig. 21.1: Nucleus is rotated with dialer
Fig. 21.4a
Fig. 21.2: Necleus is prolapsed in AC
to avoid endothelial damage to cornea. A microvectis,

that is very small, 3-4 mm in size is introduced under the
nucleus following which the nucleus is expressed (Figs
21.3 and 21.4a and b) by applying forward pressure
gently. At the same time minimal amount of depression
of sclera, the posterior lip of wound is done by the shaft
of the vectis. The above mentioned step is carried in a
more controlled fashion under direct visualisation to
avoid trauma to cornea and iris. Sometimes the
epinucleus or portion of cortex will be sheared off by the
anterior lip of the incision without damaging the
endothelium. The remaining portion of cortex and
epinucleus can be easily rotated and removed either by
viscoexpulsion, or aspirated by Soimcoe 1/A cannula.
Microvectis Technique
115
Figs 21.4a and b: Nucleus is delivered by microvectis. Courtesy: Alcon (India)
Viscoexpulsion is achieved by injecting low molecular

viscoelastics into the anterior chamber while depressing
the posterior scleral lip simultaneously. For easy delivery
of nucleus we recommend incision of
7.5 to 8 mm for nuclear cataract (Fig. 21.5) and to 7.5
mm for cortical cataracts. The frown incision is placed 2
mm or more, posterior to limbus, i.e. wider tunnel is
fashioned to minimize postoperative astigmatism. Two
relaxing incisions over the capsule are usually required
to prolapse the nucleus into the anterior chamber and to
avoid complications like capsular tear or zonular dialysis
in hard cataracts. Similarly in these cases inner entry of
wound can be enlarged to desired length to facilitate easy
delivery of nucleus. The authors have analysed 500 cases
that underwent cataract extraction with IOL implantation
by using this technique, in two cases there were inferior
iridodialysis and hyphaema because of iris trapped
between vectis and nucleus during its delivery when the
pupil was not fully dilated. This can be avoided easily by
injecting adequate amount of viscoelastics into the
anterior chamber both above and below the nucleus.

Minimal corneal oedema was encountered in its upper
part in 5 to 6 per cent cases, which subsided within two
weeks of surgery. In paediatric cataracts as there is virtually
no nucleus; the cortex may be easily removed by viscoexpulsion or by irrigation aspiration.8 It has been observed
that endothelial loss in non-phaco SICS is between 10
and 12 per cent. The damage to the endothelium usually
occurs during nucleus expression mostly in hard cataracts.
The nuclear fragments may also touch the corneal
endothelium during irrigation aspiration. Our own
unpublished data show that the induced astigmatism is
never more than 1.50 D even for relatively large incision
in nuclear types of cataract, as these incisions are placed
more posterior to the limbus. One question that will no
doubt be asked, why not to suture such a large incision.
The logic is very simple if the tunnel is stable in 6 mm
why not in 8 mm i.e. 1 mm more on either side. In our
series of 200 cases, we have observed that the wound
remains stable (Fig. 21.5) even with 10 mm tunnel
provided the tunnel dissection is perfect and its width is
made longer (external scleral incision more posterior).
The advantages of this technique are that, it has
virtually nil learning curve. It is relatively easy to perform,
repeatable, cost effective and does not require bimanual
technique, and at the same time it gives fairly excellent
results. It is true that, despite longer incision placed for
nuclear types of cataract we could achieve watertight,
self-sealing sutureless wound in all cases (100%). Both
in terms of technique and quality this is no doubt, an
alternative to phacoemulsification in expert hands.
Practical Pearls
Fig. 21.5: AC is formed with air bubble
1. Ensure good mydriasis throughout the entire

procedure.
2. Liberal use of viscoelastics is necessitated as and
when required through out the procedure.
116
3. Good capsulorhexis is essential, but not mandatory

for easy rotation of nucleus and its luxation into
the anterior chamber. However, this technique can
be performed even with can-opener capsulotomy.
4. Relaxing incision one or two may require for hard
cataracts.
5. Internal incision, entry to anterior chamber can be
widened in accordance with the size of nucleus even
after its prolapse into anterior chamber.
6. Side port entry may be required in difficult cases
for removal of sub-incisional cortex.
7. If the capsulorhexis is small and no relaxing incisions
given, luxation of nucleus to anterior chamber
becomes traumatic and may lead to zonular
dialysis.
8. To make the rotation and subsequent luxation of
nucleus into anterior chamber easy, viscoelastics is
injected under the superior pole of the nucleus once
it is lifted up.
9. Viscoelastic must be cushioned between nucleus
and endothelium, also between nucleus and iris;
so that free floating nucleus is easily expressed out.
10. Following introduction of microvectis under the
nucleus, anterior chamber must be reformed with
viscoelastics, if it becomes flat to avoid endothelial
damage.
11. Iris should not be trapped in between the nucleus

and microvectis during delivery of nucleus.
12. As nucleus rotation is often difficult in soft cataracts,
it can be easily done with repeated irrigation and
aspiration of dislodged cortical matter.
REFERENCES
1. Mc Farland MS: Mc Farland surgical technique. In Gills JPM,
Sanders DR (Eds): Small Incision Cataract Surgery: Foldable
Lenses, One Stitch Surgery, Sutureless Surgery. Slack Inc.
Thorofare, NJ 107-16, 1990.
2. Blumenthal M, Moisseiev J: Anterior chamber maintainer
for extracapsular cataract extraction and intraocular lens
implantation. J Cataract Refract Surg 24: 160-65, 1987.
3. Kansas P: Phacofracture. In Rozakis GW (Eds): Cataract
Surgery: Alternative Small Incision Techniques. New Jersy,
USA: Slack Inc. 45-70, 1990.
4. Luther Fry: The phacosandwich technique. In Rozakis GW,
Aziz YA et al (Eds): Cataract surgeryAlternative Small
Incision Technique. Thorofare NJ, Slack Inc. 71-110, 1990.
5. Mishra P: Small incision cataract surgery (SICS). http://
.www.indmedica.com/ophthal/cyberlecture 1-4, 2000.
6. Bartovb E, Isakov I, Rock T: Nucleus fragmentation in a scleral
pocket for small incision extracapsular cataract extraction.
J cataract Refract Surg. 24(2): 160-65, 1998.
7. Bryand WR: Cataract surgery: Alternative small incision
technique. In Rozaki GW (Eds): New Jersey; Slack Inc.
Thorofare.
8. Mishra P: Cataract surgery in children. http://.www.
indmedica.com/ophthal/cyberlecture.1-5, 2000.
Modified Blumenthals Technique
Modified
Blumenthals
Technique
phthalmic surgery has seen the revolution of IOL

implantation in the last 2 decades. The focus of
attention has shifted to faster rehabilitation of
patient to his job. Phacoemulsification, a modern technique is improving everyday to make it safe technique in
all hands. Unfortunately, lack of training facilities, cost
and maintenance problem of machine has made this
procedure limited to big cities/institutions only.
Alternate small incision cataract surgery techniques are
also being practiced by many eminent surgeons of the
world. Anterior chamber maintainer assisted mininuc
technique of Professor M Blumenthal and other techniques practiced by surgeons like WR Bryant, Luther L
Fry, Peter Kansas, etc. are keeping alive the interest in
manual small incision cataract surgery.
These procedures are all the more relevant for the
developing world. Phacosurgery is expanding quite
rapidly in large cities but many government institutions
and other practitioners are still struggling to keep pace
with advancing costly techniques. Alternative small
incision cataract surgery has the advantage of low cost,
good postoperative results enabling early rehabilitation
of patients. The final aim of all surgeons should be the
sameto provide safe, early, reliable and reasonably
priced emmetropia.
Practicing steps of alternate small incision cataract
surgery will place every surgeon on a solid foundation to
switch to phaco surgery, bypassing the notoriously steep
learning curve of phaco surgery.
Preoperative Preparation and Anaesthesia
A medical clearance is obtained. Wide spectrum antibiotic

drops topically every four hours a day before surgery is
instilled. Mydriasis is achieved using cyclopentolate 1 per
cent or tropicamide 1 per cent along with phenylephrine
5-10 per cent drops. Topical 0.03 per cent flurbiprofen
117
22
KPS Malik
Ruchi Goel
or diclofenac sodium 0.1 per cent every 20 minutes thrice

will maintain intraoperative mydriasis.
Peribulbar retrobulbar/subconjunctival/sub-Tenon/
topical/intracameral preservative free xylocaine with or
without facial block can be used.
Our preferred technique is:
1. Topical xylocaine 4 per cent/Proparacaine 0.5 per cent
4-5 times.
2. 3 cc xylocaine 2% + 3 cc bupivacaine. 75 per cent as
a inferior temporal peribulbar injection. 3 cc is injected
peribulbar, needle is withdrawn, directed lateral to
lateral canthus, deep enough to inject the solution
around the branches of facial nerve. This one prick
anaesthesia should take care of every need of SICS.
No use is made of mannitol, diamox, massage, pressure or superpinky. The need is for normotensive eyeball.
Some movements of eyeball are acceptable and would
not interfere with smooth execution of the procedure.
Concept of hypotony was introduced for safe ECCE
where in surgeons made 13-15 mm corneoscleral incision.
Iris prolapse or lens extrusions were common bugbears
in absence of hypotony. Physiologically a normotensive
eyeball is the best proposition as vascular dynamics of
retinal and uveal tissue are minimally disturbed in
normotensive state . The following flow chart indicates
the advantages of maintaining a normotensive
eyeball .
Maintenance of Vascular Dynamics of Eyeball
No prostaglandin
No inflammation
No CME
No choroidal haemorrhage
Intact blood aqueous barrier
118
In small incision cataract surgery as practised by

Dr Blumenthal, AC maintainer system keeps the AC deep
and IOP at normal or higher level. This pressurised state
of eye is required for easy hydroexpression of nucleus
from the eyeball.
Hypertonic state of the eye ball also facilitates the
following:
1. Introduction of MVR for sideport entry or AC maintainer.
2. Dissection of sclerocorneal tunnel.
3. Even for curvilinear capsulorhexis the deep AC and
pressure on anterior capsule is necessary to counter
the lenticular pressure.
4. Hydroexpression of epinucleus, cortex or blood.
Sclerocorneal Pocket Tunnel Incision
Success of small incision cataract surgery depends on

efficient, smooth and functional construction of a clean
edged sclerocorneal pocket incision of suitable dimensions. The placement of initial incision posteriorly on sclera
has many advantages, namely stable section, early
healing, less induced astigmatism. It has been shown by
Trasher and Boerner that a 9 mm scleral incision will
induce astigmatism as much as that induced by a 6 mm
limbal incision. Jaffe has stated that 7 mm incision,
2 mm behind the limbus can be left unsutured.
So we have following advantages of scleral placement
of incisions:
1. Less induced postoperative astigmatism.
2. Faster stabilization of refraction.
3. Less tendency towards against the rule astigmatism.
4. Even if a suture is applied, the knot remains buried
deep in the section covered by full thickness tenon
and conjunctiva therefore there is no irritation by the
protruding ends of the suture.
Technique of making the sclerocorneal pocket tunnel
incision The incision area is prepared by detaching the
conjunctiva from limbus at 11 to 2 Oclock position. The
conjunctiva is undermined, attachment of tenon is
severed. All episcleral tissue should not be removed as it
initiates the healing. Light and minimal cautery is applied
on perforating vessels or large surface vessels. Excess cautery can lead to shrinkage of tissue and is best avoided.
Making the Groove
Site The site and shape of scleral groove will depend on
type of incision planned and AC depth. In a hypermetropic small eye with shallow AC one should not make a
groove too far behind the sclera as it will make the entry
of instruments difficult and will also pry open the section
with every manoeuvre.
Incisions can be of following shapes:
1. Straight
2. Frown
3. Inverted V, with apex pointing towards limbus.
Best instrument for initial groove is guarded diamond
knife set at a depth of 0.3 mm. Many experienced
surgeons can make brilliant grooves with blades of any
material or configuration. We use 15 number blade on
BP knife or 15 degree angled knife for making the initial
groove. Site of groove behind the limbus is dependent
on planned configuration of sclerocorneal tunnel. Three
types are shown in the Figure 22.1.
1. Straight A straight line groove is made parallel to limbus
about 5.5 to 6.5 mm in length depending on hardness
of nucleus. The groove is usually 1.5 to 2 mm behind
the limbus.
2. Frown shaped A parabolic groove convex towards
limbus is made 1.5 to 2 mm behind limbus centered
at 12 Oclock.
3. Inverted V The two arms of inverted V, AB and CB
meet at an angle of 120 degrees. A and C being 2 to
2.5 mm behind the limbus. Straight distance between
A and C being 5.5 to 6.5 mm. The point B or apex of
V falls short of touching the limbus (Fig. 22.1).
Fig. 22.1: Types of incisions
TUNNELING FORWARDS
After the initial groove has been defined with a clear cut
sharp incision, the 2.8 mm crescent blade, disposable or
diamond, is engaged in the groove. Its tip is tilted
anteriorly to follow the curve of limbus and dome of
cornea. Maintaining uniform thickness of dissection,
tunneling should be performed anteriorly upto 2 mm of
clear cornea. While dissecting the lateral area the blade
should not be moved straight but tilted downwards
following the slope of lateral cornea. The blade can be
tilted 90 degree medially or laterally to dissect pockets in
cornea and sclera. At the end of the dissection we would
have the following types of sclerocorneal pocket tunnels.
119
Fig. 22.2: Dissecting the corneoscloeral tunnel
Precautions
Not following the curve of cornea or globe can result in

premature entry into AC or buttonholing of the anterior
walls of the tunnel. Tunnel is best dissected in
normotensive eyeball. If the eye appears soft one can
inject viscoelastic to make it tight, before continuing the
dissection (Fig. 22.2).
After tunnel has been dissected, entry is made into the
anterior chamber. The capsular opening is best made
through a valvular sideport created at 10 Oclock by MVR
blade. Viscoelastic is injected to make the eyeball hypertensive (3035 mm of mercury). Small side port entry
will allow the chamber to remain deep, will have minimal
leak.
Three types of capsular openings can be made, continuous curvilinear capsulorhexis, envelope or can-op
rhexis (Fig. 22.3).
Fig. 22.3: Making curvilinear capsulorhexis
Continuous curvilinear capsulorhexis (CCC) CCC is a

landmark step in the safety of IOL surgery. CCC has
multiple advantages in phaco as well as non-phaco SICS
such as:
1.
2.
3.
4.
5.
Safe hydroprocedures.
Safe nuclear rotation and manipulation in AC.
Central IOL placement with minimal decentration.
Safer cortical clean up and posterior capsular polishing.
IOL placement on intact rhexis margin in case of
posterior capsular tear.
CCC was developed by Gimbel, Neuhann and
Shimizu, independent of each other in the mid 1980s.
Procedure
Through the sideport entry viscoelastic is injected to

deepen the AC and counter any vitreous thrust. In case
of hypermature cataracts, dyes which can stain the
anterior capsule, can be used. A suitably bent 26G
needle can be used as a cystitome. The first bent is just
near the tip at right angle and the second bent is at an
obtuse angle to allow easy manipulation in the anterior
chamber. A puncture is made in the centre of the anterior
capsule and a tongue shaped flap is lifted. This flap is
everted, flattened on the capsule and manipulated
anticlockwise (our way) or clockwise, applying shearing
force. The flap is flattened out again and again, keeping
the shearing junction in sight. Pulling far away at the
flap will have tearing effect and may result in loss of
control. The final tear is from outside to inside. If CCC
120
appears small, continue in spiral fashion all over again,

enlarging the CCC.
Precautions
1. Do not disturb the cortex otherwise visibility may be

lost.
2. Reinject the viscoelastic if chamber shallows because
the tear may go to the periphery. Stop, refill the AC,
examine and proceed. It is very important to counter
the positive pressure of vitreous.
3. CCC should not be less than 6 mm for this procedure.
Envelope Technique
Envelope technique is preferred over can-opener in cases

where CCC is difficult. In case of morgagnion, intumescent Black/brown or hypermature cataract envelope
making is an easy and excellent technique which allows
all the benefits of CCC.
A scratch mark is made at the junction of lower 2/3rd
and upper 1/3rd of capsule. Further tiny cuts are given
medially and laterally saving 1 mm of capsule on either
side, cuts are then joined by a horizontal line. This type
of capsular opening is useful for placement of IOL in the
bag. After placing the IOL in the bag the remnants of
anterior capsule are cut off by cystitome or Vannas
scissors.
Can-op Rhexis
A CCC may be given relaxing cut at 11-12 Oclock

position for nuclear manipulation out of the rigid CCC
margin in cases of hard or large nucleii. Can-op rhexis
opening will give all the benefits of CCC and allow in the
bag placement of IOL. Therefore, while performing CCC
if one loses control and part of it has to be completed by
can opener technique, it is still preferable to have some
round margin of capsular opening.
Completing the Tunnel
The prior dissected tunnel is inflated with visco to facilitate

entry of slit knife. 3.2 mm angled keratome (slit knife)
disposable, steel or diamond is introduced at 12 Oclock,
after traversing the full length of tunnel it is dipped down
in AC and knife is introduced till the elbow. It is noteworthy
that the Descemets is entered not at right angle but in
sloping fashion. Subsequent cuts are made by repeated
thrusts of the 3.2 mm knife in rest of the dissected cornea.
Conscious effort should be made to cut while going in
and not while coming out. These manoeuvres of slit knife
should be in quick succession to cover whole of
predissected area including side pockets. If chamber
shallows while cutting in the tunnel, the chamber should
be filled up with viscoelastic before reintroducing the knife.
At the end we shall get a funnel shaped sclerocorneal
pocket tunnel that is narrow outside and wider in the
cornea. It is to be noted that side pocket dissections are
akin to the bulge of the oral cavity of a snake, which can
accommodate a larger animal than its apparent mouth
size. At the time of nuclear expression a large nucleus too
can get engaged because of extraspace created by side
pockets in cornea and sclera.
Hydroprocedures
Hydroprocedures comprise of hydrodissection and

hydrodelineation. The aim is to separate the lens nucleus,
epinucleus and cortex from capsule and the lens lamella
from the cortex and its different layers. This facilitates
rotation of nucleus from its bag into the anterior chamber.
Therefore thorough hydroprocedures play a key role in
this surgery. Michael Blumenthal first described
hydroprocedures but Faust gave the term hydrodissection.
These procedures can be carried out with anterior
chamber maintainer being in on or off state.
Hydrodissection
Fixing the AC Maintainer
Fix the AC maintainer at this stage as AC is still deep with

viscoelastic. MVR entry is made at 6 O clock parallel to
limbus, away from the vascular arcade of cornea. The
AC maintainer, a hollow steel tube with 0.9 mm outer
and 0.65 mm inner diameter is entered with bevel up
and then turned 180 degrees so that the bevel faces the
iris. The AC maintainer is always inserted from the
temporal side. The tube of AC maintainer is attached to
BSS bottle suspended 60-70 cm above the patients eye.
AC is emptied of viscoelastics remaining after capsulorhexis. 1 cc Ringer lactate/BSS is loaded onto 2 cc

syringe and is injected behind the rhexis margin using a
suitably angled cannula with a blunt tip (like Healon
cannula) in different directions. The bolus of fluid injected
between anterior capsule and cortex dissects all around
the capsular bag and separates it from the nucleus. The
cortex is completely dissected from the capsule freeing
the entire lens nucleus, epinucleus, cortex from the
capsular bag thereby facilitating nuclear rotation and
manipulation out of its bag. Indication that the dissection

has occurred is a shallowing of anterior chamber,
signifying entrapment of fluid in the subcapsular layer of
the lens at one pole. Intermittent gentle tapping releases
the fluid collected behind the nucleus thereby completing
the hydrodissection (Fig. 22.4).
121
introduced between 10 and 12 Oclock positions near

the edge of the rhexis margin and passed behind the upper
pole of the nucleus. Nucleus is engaged, the hook is pulled
upwards and towards 12 Oclock. Once the bulk of the
nucleus is out, the rest is cartwheeled out clockwise or
anticlockwise into the AC.
Precautions
Hydrodelineation/Hydrodelamination/Hydrodemarcation
The fluid is injected between the epinucleus and nucleus.

The fluid wave appears as a golden ring under the surgical
microscope. The procedure is carried out using either a
straight cannula or one with 2 sideports. The final result
is a debulking of nucleus. The cannula is passed into the
nucleus until it meets resistance where the soft outer
nucleus ends and a firm inner nucleus begins. At the point
of resistance the cannula is pulled back a fraction of a
mm and fluid is injected. The fluid passes into the body
of the cataract and creates a cleavage plane. This may
be repeated at a different site. In a very hard cataract,
the inner nucleus may extend right out to the capsule
and cleavage plane may never be identified whereas in a
soft cataract multiple planes may be isolated. Thorough
hydroprocedures reduce the size of the nucleus which in
turn enable the surgeon to deliver it out of a small incision.
Nuclear Management and Delivery
Nuclear prolapse into the AC Adequately sized CCC and

thorough hydroprocedures will prolapse the nucleus in
the AC. Some of the soft cataracts have fibres firmly
adhered to each other as well as with epinucleus. These
lenses need manual manipulations or multiple hydro
procedures to finally free them out of the bag.
We use a Sinskeys hook to guide the nucleus out of
the bag. AC is filled with viscoelastic. The hook is
1. Never hold the edge of the section with forceps, hold

at the limbus or the sclera to stabilize the globe while
carrying out manoeuvres in the AC. Holding the section
will roughen the edges, delaying the healing and
leading to poor co-optation of the wound.
2. Avoid repeated entry into the section.
3. Fill up the AC with viscoelasticinject it in front and
behind the nucleus.
4. Never use rough-ended cannula in the section or you
may damage the Descemets membrane.
5. Consciously keep a watch on Descemets for any
manoeuvres in the AC.
Nuclear Delivery by Hydroexpression
This is the most important step in small incision cataract

surgery. The skill and experience of operator guides him
to make a correct size outlet depending on the hardness
of nucleus. The goal is a smooth delivery of reduced size
nucleus leaving behind other parts of the lens. AC
Maintainer, attached to a bottle of Ringer lactate/BSS,
suspended 70 cm above the patients head, is brought
into play now. Once the reduced size nucleus has been
brought out in deep AC, suspended in an ocean of
viscoelastic, a lens glide is passed from 12 o clock behind
the nucleus. Care should be taken that the glide does not
injure the iris, ciliary body or capsule during its journey
behind the nucleus. Once the glide is in position, the AC
maintainer flow is switched on fully. The tip of forceps is
used to apply a firm pressure on the lens glide, on the
scleral side of section. The nucleus will be taken up by
section and the adjacent pockets. A few intermittent taps
on the lens glide will see the nucleus delivered out,
deepening the AC. A few more taps will allow the cortex,
epinucleus to be washed out of the eye. We pull out the
AC maintainer at this stage. Simcoe cannula is further
used for cleaning up the remaining cortex.
Assisted delivery In case nucleus is stuck up in section,
lifting the bottle up will raise the pressure of fluid in
anterior chamber and help in nucleus expression. If tip of
the nucleus shows but no further progress is there, a 23
gauge needle can be held in left hand and applied at
122
Fig. 22.5: IOL placement and suturing
right angle to the axis of lens and by cartwheeling the

nucleus can be brought out. In case of large nucleus, a
part of it can be sheared off with a needle. The nucleus is
then pushed back in the AC, and rotated so that the
smaller diameter is engaged, and the nucleus is delivered.
SECTION NOT TAKING UP NUCLEUSCAUSES
1.
2.
3.
4.
5.
Small section
Irregular section
Hypotony
Leaking AC
Iris prolapse before nucleus is engaged.
Solution
1. Re-evaluate the adequacy of section and enlarge with

keratome if needed.
2. Raise the pressure of AC by lifting the irrigating fluid
bottle higher.
A thin iris repositor and even a 3.2 mm keratome can
be used on place of lens glide for nuclear delivery.
Cortical Clean-up
We disconnect the AC maintainer at this stage and do

cortical clean-up with cimcoe cannula.
IOL Placement
IOL is held by straight lens holding forceps at the junction of 1/3rd and 2/3rd of optic. The lower haptic and
optic is guided into the bag at 6 Oclock position. Same
forceps can rotate the upper haptics into the bag or a Y
shaped dialer can be used to place the upper haptic into
the bag. McPherson forceps is not a very good instrument for placing the IOL in the lower fornix of the bag
(Fig. 22.5).
Closure of Section
A well-constructed inverted V or frown shaped incision

can be left unsutured. Fluid is injected from sideport to
see the leakage of section. If doubt about safety of the
section exists, an (infinity) shaped suture, taking deep
bites in the scleral bed, is applied. Sideport site and AC
maintainer site can be hydrated by injecting a few drops
of BSS in the stroma (Fig. 22.5).
FURTHER READING
1. Feil SH, Crandall AS, Oslon RJ: Astigmatic Decay following
small incision, self-sealing cataract surgery: One year follow
up, J Cataract Refract Surg 21: 433-36, 1995.
2. Jaffe N: Cataract surgery and its complications. CV Mosby
Co.: St Louis; 6th ed. 1990.
3. Rainer G, Vass C, Menapace R et al: Long-term course of
surgically induced astigmatism after a 5.0 mm sclerocorneal
valve incision. J Cataract Refract Surg 27(12): 1642-46,
1998.
4. Rozakis GW: Cataract surgery: Alternative small incision
techniques. Jaypee Brothers: India.
5. Shephard JR: Induced astigmatism in small incision cataract
surgery. J Cataract Refract Surg 15(1): 85-88, 1989.
6. Singer JA: Frown incision for minimizing induced astigmatism
after small incision cataract surgery with rigid optic intraocular
lens implantation. J Cataract Refract Surgery 17(Suppl):
677-88, 1991.
7. Steinert RF, Brint SF, White SM et al: Astigmatism after small
incision cataract surgery. Ophthalmology 93(4): 417-23,
1991.
8. Uusitalo RJ, Tarkkanen A: Outcomes of small incision cataract
surgery. J Cataract Refract Surgery 24(2): 212-21, 1998.
9. Wright M, Chawla H, Adams A: Results of small incision
extra-capsular cataract surgery using the anterior chamber
maintainer without viscoelastic. Br J Ophthalmol 83(1): 7175, 1999.
Small Incision Manual Phaco-section Using the Anterior Chamber Maintainer
Small Incision Manual

Phaco-section
Using the Anterior
Chamber Maintainer
mall incision cataract extraction without phacoemulsification has many advantages.
1. It is elegant.
2. It is not dependent on expensive and frequently
capricious equipment.
3. The visual results compare favourably with those of
any other available technique.
4. The cell count of the corneal endothelium, after
surgery also compares favourably with that of other
techniques.
5. It is virtually impossible to drop the nucleus into the
vitreal cavity.
6. The continual inflow of Balanced Salt Solution (BSS)
through the Anterior Chamber Maintainer (ACM)
reduces the risk of infection.
7. The same flow militates against expulsive haemorrhage and eliminates the need for any other kind of
irrigation.
My method combines elements of manual phacosection as made popular by Peter Kansas and the socalled mini-nuc approach of Michael Blumenthal. The
procedure starts with three self-sealing paracentesis
openings, made in the peripheral cornea with a 1.15 mm
stiletto knife. The first, lower temporal, angles obliquely
to point towards the inferior pole of the lens.
The other two enter at ten Oclock and two Oclock,
angled to point just above the centre of the lens.
The lower canal will hold the ACM (first described by
Lewicky) and must be precisely the width of the knife.
Any sideways movement of the blade, particularly during
withdrawal, will produce an incision too large and likely
to permit leakage around the ACM.
123
23
Hector Bryson Chawla
Inserting the ACM
The tubing must be full of BSS and free of air bubbles. A

three way tap, proximal to the ACM tubing allows control
of the fluid flow into the eye without the sudden surges
that occur with an automated foot switch.
The 20 gauge ACM is held, bevel downwards, at right
angles to the surface of the cornea. The tip of the bevel is
then insinuated into the paracentesis. Continued pressure
at right angles engages the ACM in the corneal tunnel. At
this point, it is moved into the line of the tunnel and, with
an oscillating rotatory action can be moved into its final
position with the tip of the ACM inside the anterior
chamber (AC).
The bevel of the ACM must be rotated to direct the
fluid flow away from the corneal endothelium (Fig. 23.1).
Fig. 23.1: (Chawla) Wound and paracentesis incisions
124
The ACM must be at least 20 gauge. Some manufacturers produce ACMs whose too small bore does not
allow an adequate flow of fluid. The use of such products
might well have led to a distrust of the ACM technique.
Irrigation
BSS is obligatory to maintain corneal clarity. The bottle

height should be as low as is compatible with the maintenance of the AC. A height of fourteen inches corresponds to an Intraocular Presssure (IOP) of 26 mm/Hg.
The surgeon should be aware of the fluctuations in
IOP created by changing the bottle height.
Incision
The corneo-scleral incision must be self-sealing of the

ACM is to be allowed to maintain a constant AC depth.
I use a 15 blade, a crescent knife and a 3.2 mm keratome. For the dextrous, it is possible to make all these
incisions with the 15 blade-again reducing the cost.
An external incision, 5.2 mm long is made just behind
the limbus to be between one-third and one-half of the
scleral depth.
A scleral pocket is created and extended 1.5 mm into
the cornea with the crescent knife.
The AC is entered from the anterior end of this pocket
with a 3.2 mm keratome. The internal edge of this wound
is parallel to the limbus and is made by cutting in one
direction only-not with a saw-like movement. Making the
internal wound slightly wider than the external creates a
natural birth canal to collect lenticular fragments for
smooth delivery.
Fig. 23.2: Rotation of nucleus
If the combined nuclei threaten to be too large for the

capsulorhexis then one should endeavour to isolate and
dislocate the endonucleus (Figs 23.2 and 23.3a to c).
There is no hard and fast rule about this but in my
experience, removing the epinucleus from the capsular
bag is easier when it is still attached to the nucleus. When
it is on its own, it can sometimes be a reluctant passenger.
But that is still a safer alternative to sacrificing an intact
capsulorhexis.
Capsulorhexis
At this point the fluid to the ACM is turned off at the three
way tap and visco-elastic is introduced into the AC
through a cystotome. Creating a continuous curvilinear
capsulorhexis calls for a skill that is common to all cataract
techniques but here the diameter must be slightly bigger
than standard in order to allow delivery of the endonucleus or the combined endo-and epi-nuclei into the
AC. If the capsulorhexis is thought to be too small then
as a last resort, it can be relaxed by oblique incisions with
long Vannas scissors at three and nine Oclock.
Trying to achieve the desired shape of the capsulorhexis
under BSS calls for a skill that is denied to most of us.
Nuclear Dislocaton
BSS through a Rycroft cannula is directed into the

capsular bag, to separate the cortex from the capsule and
the combined nuclei from the cortex.
Figs 23.3a to c: Technique of dislocation of endonucleus
125
Nuclear Bisection
The instruments essential for this technique are1. The solid vectis-a flat plate attached to a handle not
unlike a hockey stick with the blade pointing
upwards.
2. The nuclear bisector-a firm cutting implement similar
in shape to a lens dialler but without the angled tip.
Once the endo-nucleus or the combined nuclei are
isolated they can be dialled into the AC. The space
between them and the corneal endothelium is filled with
visco-elastic through a Rycroft cannula. Now is the time
to divide the nucleus in two between the solid vectis and
the nuclear bisector. The critical point of all these manoeuvres is that every time one enters the anterior chamber,
one must precede this entry with visco-elastic. No matter
how much is used, its use will be fully repaid by a crystal
cornea the next day and a gentle reminder that this
operation is still significantly cheaper than phacoemulsification.
The aim is to insinuate the solid vectis between the
nucleus and the capsular bag and the bisector between
the nucleus and the cornea. The technique is to begin
with the bisector and then tease the solid vectis into
position whilst advancing the tip of the bisector until it is
pointing from eleven or one Oclock towards six Oclock.
As with golf clubs, the right handed and the left handed
operator can be accommodated (Fig. 23.4a and b).
Figs 23.5a and b: Fragments of nucleus being

removed by Arruga forceps
Although the temptation might be to press the bisector

down towards the iris, the secret is to keep the bisector
firm whilst pressing up, away from the iris with the solid
vectis, to split the nucleus easily into two.
The half nuclei are now ready for removal. There are
several methods for achieving this end but I have found
the best is to modify the tips of the standard Arruga
intracapsular capsule forceps (Figs 23.5a and b). If one
thinks of them in their natural state as being tipped with
teaspoons then we must convert these into a soup
spoon shape.
Again preceding every move with visco-elastic to the
AC, one dials the half nucleus so that it lies directly in line
with its proposed line of removal. The forceps are slid
into the AC and the trick is to lay them nearer the iris so
that the fragment appears to be nipped upwards rather
than grasped directly. It is the simplest matter now to slide
it out, remembering always that the leading pole must be
elevated so as not to catch on the wrong side of the scleral
tunnel.
Removal of Epi-nucleus
Figs 23.4a and b: Insertion of dissecting instruments
At this point the ACM can be turned on again whilst

depression of the posterior lip of the scleral wound, allows
126
any floating fragments to be swept into the tunnel and

out of the eye. A nucleus, too soft for bisection can be
removed in the same way.
Cortex Aspiration
A cortex extractor with a 0.4 mm port attached to a 5 ml

syringe easily removes the remaining cortex through one
or other of the side port incisions.
Lens Insertion
The implant can be dialled into the capsular bag in the

standard way under visco-elastic which must be removed
afterwards.
Closing the Wound
The wound can be left sutureless but in my experience

this will produce up to three dioptres of astigmatism. A
10/0 Mersilene suture in the style of the St. Andrews cross
goes a long way to minimise postoperative astigmatism.
So fine a gauge of suture material cannot be tied against
resistance without breaking. Such resistance can be
elegantly and briefly eliminated by having the assistant
squeeze the inflow tubing to the ACM. With the wound
edges in the correct position and the second throw of the
knot about to be drawn tight, the tubing is released and a
gentle tide of BSS rises to meet the counter pressure of
the completing knot.
obstruction be insurmountable, then excision of the

offending iris is often the only recourse.
Occasionally partial closure of the three way tap can
reduce the tide of BSS flowing through the wound.
A third possibility is to conduct as much of the operation as possible under visco-elastic, thus minimises
damage to the iris.
After this operation is complete, in such circumstances,
the iris sometimes defies all atempts to replace it where it
belongs. At this point the cortex extractor can be turned
to another use and, through one of the side ports, can,
by suction, pull the iris out of the wound and into an
approximation of a round pupil.
Extra sutures can help to keep it in place but it must be
remembered that every time a susture is inserted into a
leaking wound with the three way tap of BSS open, the
iris will be swept out again remorselessly.
Failed Capsulorhexis
The surgical dilemma is common to all techniques. If the

integrity of the posterior capsule is felt to be threatened,
then the flow of BSS must be carefully monitored during
cortex extraction.
Even with an intact capsulorhexis, it is sometimes
possible to capture the posterior capsule in the port of
the cortex extractor. The risisng stress lines cannot be
mistaken and reversal of the flow almost always saves
the capsule and the reputation of the surgeon.
Removal of the ACM
No great complexity is required to disengage the ACM

from its corneal tunnel, or to realise that the AC will
shallow somewhat during this manoeuvre.
Sealing the Paracenteses
BSS from a syringe can be injected through a Rycroft

cannula into the walls of the tunnels, producing opaque
blanching of the stroma and restoring the AC depth as
deemed appropriate.
With the pressure being high in the syringe a little
foresight will make sure that the Rycroft cannula does
not turn into a bullet leaving a trail of devastation across
the anterior segment.
Too Small Capsulorhexis
The temptation here is to preserve the continuous

curvilinear state at all costs. To succumb to this temptation
risks converting to the operation we have all abandonedthe intracapsular cataract extraction.
The endo-nucleus refuses to float on a sea of BSS out
of the capsular bag because the exit to the AC is too
small. A search for the nuclear margin will almost certainly
find the capsule instead and the sudden case with which
everything enters the AC tells again the story of the road
to perdition being paved with good intentions. An intact
posterior capsule which can be achieved often, with a
little extra care is worth the sacrifice of the curvilinear
edge.
Pitfalls
Corneo-scleral Tunnel not Self-sealing
Reluctant Epi-nucleus
The flow of BSS constantly drives the iris into the tunnel,
obstructing any attempt at surgical elegance. If the
Occasionally the epi-nucleus defies all attempts to tease

it out of the capsular bag. The simplest way to overcome
its reluctance, is to reduce the inflow of BSS where upon

the semi solid rolls and layers of epi-nucleus will rise into
the AC sufficiently to allow the tip of the cortex extractor,
without suction, to dial the remainder out of the capsular
bag rather like a mollusc out of its shell.
127
Postoperative Care
This differs in no way from any other technique and the

eye is optically stable almost from the outset.
Anatomically Shallow Anterior Chamber
It would be self evident that endothelial protection can

only be achieved by increased use of visco-elastic.
128
Manual Multiphacofragmentation: A
New Technique for
Cataract Surgery
24
Francisco J Gutirrez-Carmona
INTRODUCTION
Current surgical techniques used in cataract surgery have

two fundamental objectives: (i) to induce the minimum
postoperative astigmatism, and (ii) to achieve rapid
recuperation of the patients sight after surgery.
To meet these objectives, it is necessary to perform
cataract surgery using a small incision. It has been shown
that the smaller the surgical incision, the smaller the
residual postoperative astigmatism.
Of all the techniques described for cataract operations,
phacoemulsification is the one that allows working with
smaller incisions. However, it is a technique which requires
a long learning curve, with expensive and complicated
instrumentation and equipment.
Our manual multiphacofragmentation (MPF) technique allows cataract surgery through 3.2 mm clearcorneal or 3.5 mm scleral-tunnel incisions. In this method
the nucleus is fragmented into multiple tiny pieces of
22 mm.
The method enables cataract surgery in soft and hard
nuclei. The results obtained in postoperative astigmatism
are similar to those obtained with phacoemulsification,
but with a shorter learning curve and less financial outlay.
On the other hand, our method is an ideal back-up
after discontinuation of emulsification when complications arise in phacosurgery, since with the help of our
instrument set, we can conclude the surgery without
enlarging the incision.
We designed an instrument set, manufactured by John
Weiss and Son Ltd in England, which consist of:
A racquet-shaped nucleotome 8 mm long and 2 mm
wide, divided along its short axis by 3 thin transverse
bars 2 mm apart , set at 45 degrees to a long straight
handle (Fig. 24.1).
Fig. 24.1: Nucleotome with a racquet-shaped end
A spatula 8 mm long by 2 mm wide the same shape

as the nucleotome, used as a support during the
fragmentation (Fig. 24.2).
Two straight-handled manipulators, right and left,
used to collect the nuclear fragments (Fig. 24.3).
SURGICAL TECHNIQUE
This technique can be carried out with the use of retrobulbar or peribulbar anesthesia, topical or topical +
intracameral anesthesia.
Manual Multiphacofragmentation: A New Technique for Cataract Surgery
129
Incision
The surgery can be performed with a 3.2 mm clearcorneal (Fig. 24.4), or 3.5 mm scleral-tunnel incision
(Fig. 24.5).
The clear-corneal incision is performed at 12 Oclock
with a 45 stab incision knife and with the help of a
disposable angled crescent knife. The scleral-tunnel
incision is made after carrying out a fornix-based conjunctival miniflap about 2 mm posterior to the cornealscleral limbus with the help of a disposable angled
crescent knife, without penetrating the AC.
Fig. 24.2: Saptula with an end the same size

as the nucleotome
Fig. 24.4: The 3.2-mm clear-corneal incision is

performed at 12 O'clock
Fig. 24.3: Manipulators, right and left
To perform MPF it is important to have good pharmacological mydriasis, since the pupil could contract
during surgery.
High density viscoelastic is injected into the anterior

chamber (AC) through a superior and temporal paracentesis, and a capsulorhexis is performed with a
cystotome. It should be sufficiently wide (6.0 - 6.5 mm)
to allow an easy luxation of the nucleus into the AC.
Fig. 24.5: The 3.5-mm scleral-tunnel incision is made with the

help of an angled crescent knife
130
Hydrodissection and Luxation of the Nucleus
After entering the AC with a 3.2 mm phaco knife,

balanced salt solution (BSS) is injected through the
incision with a Binkhorst cannula between the anterior
capsule and the cortex at 12 Oclock, or with a straight
Rycroft cannula. The BSS must be injected slowly and
continuously until the wave of dissection is visible on
the posterior capsule.
The injection of BSS is continued until luxation of the
nucleus in the AC is partial. Then, it can be completed
by rotating the nucleus with a cannula, cystotome
or spatula.
Nuclear Fragmentation
Once the nucleus has been luxated into the AC, highdensity viscoelastic (Viscoat, Amvisc Plus, etc.) is injected
into the surrounding area to fill the AC. The nucleus is
then fragmented by placing the spatula beneath and the
nucleotome on top of the nucleus (Fig. 24.6). Pressure is
then created by slowly pressing the nucleotome against
the spatula, until this section of the nucleus is fragmented
into four pieces which remain within the nucleotome,
and which, with the help of the spatula, are extracted
from the AC with a sandwich technique (Fig. 24.7).
This maneuver is repeated until all the nucleus is
fragmented.
During nuclear fragmentation it is important to fill the
AC with high-density viscoelastic, as needed, to protect
the corneal endothelium and to facilitate safe
manipulation during surgery.
Fig. 24.7: The nuclear fragments within the nucleotome are

extracted with a sandwich technique
Fig. 24.8: Right manipulator displacing a nuclear fragment

towards the center of the anterior chamber
Manipulation of Nuclear Fragments
The right and left manipulators are used to displace the

remaining fragments of the nucleus to the center of the
AC for further fragmentation and extraction (Fig. 24.8).
Extraction of the Cortex and Remains of Nucleus
Fig. 24.6: Pressing the nucleotome (on top) against the
spatula (beneath) the nucleus is fragmented
The lens cortex is aspirated with an I/A Simcoe cannula.

If tiny pieces of the nucleus are left in the AC, it is
sometimes possible to remove them using only the
Manual Multiphacofragmentation: A New Technique for Cataract Surgery
Fig. 24.9: A foldable lens is implanted in the

capsular bag
nucleotome. Otherwise they can be extracted by the

nucleotome and spatula, by aspiration with a Simcoe or
Charleux cannula, or by gentle irrigation of the AC with
BSS using a Rycroft cannula while simultaneously
depressing the posterior lip of the incision.
IOL Implantation and Wound Closure
High-density viscoelastic is injected into the capsular bag

and a foldable IOL is implanted (Fig. 24.9). The viscoelastic material is then aspirated with an irrigating/
aspirating cannula. Closure of the incision is performed
with stromal hydration, or with a single cross-stitch (Fig.
24.10).
We recommend to ophthalmologists who are new to
this technique that they initially practise it using incisions
of more than 3.2 or 3.5 mm and thereafter reduce the
incision size once they have mastered the technique.
Lately I have been performing some steps of my
technique with the help of an anterior chamber
maintainer (ACM)model Lewicky 20 G from Katena
or the ACM 20 G from John Weiss Ref. 0185061.
The ACM works by producing a constant irrigation
flow of BSS into the AC. This flow generates a positive
intraocular pressure (IOP) that stabilizes the AC depth
during some steps of the surgery. On the other hand,
with the ACM the quantity of viscoelastic material used
per surgery is reduced, diminishing the financial outlay.
131
Fig. 24.10: A single cross-stitch is

enough to close the wound
The ACM is used:

During the capsulorhexis
In order to aspirate the anterior cortex and epinucleus
in soft and medium hard nuclei before the
hydrodissection/hydrodelineation
For the aspiration of cortical debris
For the extraction of tiny nuclear fragments, by depressing the posterior incision lip with a straight cannula.
The maneuvers of nuclear multi-fragmentation and
IOL implantation are carried out with the help of high
density viscoelastic material.
REFERENCES
1. Uusitalo RJ, Ruusuvaara P, Jarvinen E et al: Early rehabilitation after small incision cataract surgery. Refract Corneal
Surg 9:67-70, 1993.
2. Shepherd JR: Induced astigmatism in small incision cataract
surgery. J Cataract Refract Surg 15:85-88, 1989.
3. Cristobal JA, Minguez E, Ascaso J et al: Size of incision and
induced astigmatism in cataract surgery. J Fr Ophtalmol 16:
311-14, 1993.
4. Gutierrez-Carmona FJ: Manual technique allows for small
incision cataract surgery. Ocular Surgery News: Surgical
Maneuvers 15(21):14-15, 1997.
5. Gutierrez-Carmona FJ: Manual technique allows for small
incision cataract surgery. Ocular Surgery News: Surgical
Maneuvers (Internat ed) 9(2):10-11, 1998.
6. Gutirrez-Carmona FJ: Nueva tcnica e instrumental de facofragmentacin manual para incisiones esclerales tunelizadas
de 3.5 mm. Arch Soc Esp Oftalmol 74:181-86, 1999.
132
The New
Method of Manualphacofragmentation
(Phaco-drainage)
hacoemulsification offers the advantages of rapid

wound healing and early visual rehabilitation.
However, economic constraints in developing
countries place phacoemulsification beyond the reach
of many ophthalmic surgeons.
The manual phacofragmentation is the alternative
technique to solve many problems. So, we created a new
method called Phacodrainage. I have used this
technique since 1998 and have done more than 100
operations by this technique.
25
Amporn Jongsareejit
Idea Concept
1. Crack the nucleus into small pieces

2. Remove the pieces of nucleus through 3.5 mm long
corneal wound.
3. Use passiveaspiration force to remove the pieces of
nucleus.
Preoperative Assessment
Cataract with nucleus grading I-III and no weakness of

zonules are selected. Complete ocular examination,
endothelial cell counts and IOP are measured in every
case. Three special instruments are required:
1. Anterior chamber maintainer
2. Aspiration cannula and
3. Nucleus removal tube (Amporntube)
Fig. 25.2: Corneal wound is made
Fig. 25.1: Nucleus removal tube (Amporn-tube)
After peribulbar anaesthesia is given, I perform

paracentesis at 2 sites at 6 and 12 Oclock. Six Oclock is
used for inserting A/C maintainer and 12 Oclock for
viscoelastic injection. After viscoelastic injection, make a
3.5 mm long corneal wound at temporal site. A large
The New Method of Manual-phacofragmentation (Phaco-drainage)
133
Fig. 25.4: Crack the nucleus into 4 pieces
Fig. 25.5: Insert the nucleus removal tube
capsulorhexis (5.56.5 mm) is performed. Hydrodissection and hydrodelineation are carried out.
Cracking the nucleus into 4 pieces in the capsular bag
with capsulorhexis forceps and Sinskey hook (very similar
to prechop technique). The advantage of this technique
is reduced corneal endothelium trauma.
Insert the nuclear removal tube through corneal
wound (3.5 mm) for removing the pieces of nucleus by
this tube. The advantages are reduced wound size and
wound trauma.
Open the infusion line, BSS goes into the anterior
chamber via A/C maintainer. When I open the valve, (at
handle of the nuclear removal tube) passive aspiration

force occurs; and when I close the valve, the passive force
is stopped. That means I can control passive aspiration
force by closing and opening the valve. The advantage is,
I do not need any machines for suction force , decrease
chance of A/C collapse , and decrease turbulence flow.
We can increase the passive aspiration force by
increasing the height of bottle. Almost the height 6070
cm is enough for creating the passive aspiration force.
If the pieces of nucleus are too large, two Sinskey hooks
are used to crack it into smaller pieces again. So that
they it can pass through the tube.
134

IOP H Passive aspiration 1/Fluid loss
Fig. 25.6: Passive aspiration force
Fig. 25.7: Crack the pieces of nucleus by Sinskey hook
Intraoperative parameters
Average viscoelastic substance
Average irrigating fluid
Average time to manage nucleus
0.5+/0.2 ml/case
178+/13 ml/case
5.75+/1.77 min
Postoperative endothelial cell count and

loss at 3 months
Fig. 25.8: Remove the remaining cortex
After removal of all nuclear pieces, I clean the remaining cortex by aspiration cannula.
Turn off BSS line and reinject the viscoelastic substance
into anterior chamber. Next, insert the foldable IOL as
regular method.
Result
On first postoperative day, the central corneas were

clear and cells or flasre were minimal (no difference from
phacoemulsification).
Preoperative mean count (Cell/mm2)

Postoperative mean cell loss (Cell/mm2)
Mean loss (%)
Postoperative BCVA (at 3 months)
2338.92+/245.08
1973.94+/399.69
16.46+/5.29
0.8
No serious complications are seen. A few cases of iris

trauma and corneal wound oedema in the early period
are found.
Advantages
1. No ultrasoundNo heat.
2. Cheap (do not need complicated machine).
3. Less wound trauma (because pieces of nucleus pass
through tube and not through corneal wound).
The New Method of Manual-phacofragmentation (Phaco-drainage)
135
Fig. 25.9: Insert the foldable IOL
Disadvantages
1. Selected cases (NS grade 1+ to 3+).
2. More total operation time (average 30-40 min./case).
3. Need learning period.
4. Need special instruments (The nuclear removal tube).
CONCLUSION
Fig. 25.10: First postoperative day
4. Minimal turbulence flow (decreased BSS to be used).

5. Can be inserted the foldable IOL.
I can perform cataract surgery with small incision without

phacomachine in normal cataract cases (NS 1+ 3+),
Improving the quality of nuclear removal tube is recommended for improving the efficacy of operation (The nuclear removal tube is handmade , and the reusable tube
is not of good quality).
136
Temporal Tunnel
Incision in SICS
he concept of surgically induced astigmatism has

added an entirely unique dimension to cataract
surgery with emphasis more focussed on the
refractive aspect of the surgery in present era.
Over the years, the better understanding of various
preoperative and intraoperative determinants of surgically induced astigmatism has made it possible to actually
plan out the surgical intervention and their modifications
according to preoperative state of astigmatism of the
patient in order to achieve minimum possible or nil postoperative astigmatism.
Incision being the first and the most important determinant of postoperative astigmatism which can be modified
in various ways in terms of size, site, shape, axis, etc. to
reduce the degree of postoperative astigmatism. Placement of incision temporally along the vertical meridian
is one modification to minimise the high pre-existing
against the rule (ATR) astigmatism, thereby improving
the visual outcome.
Besides, a temporal incision has other advantages too,
it induces less amount of astigmatism as compared to
superior one and has a better wound strength due to
minimal separational force of lid pressure and gravity.
The temporal limbus being farther from visual axis it
causes less distortion of central corneal curvature,
particularly in cases of secondary IOL implantation or in
eyes with previous surgery at 12 Oclock position
A temporal incision offers a distinct advantage of
avoidance of incision being placed over the compromised
scar tissue or preservation of functioning filtering bleb in
previous glaucoma surgery. The incision on temporal
side is also preferable in deeply seated eyes of operational
case and in cases of coloboma of iris.
ADVANTAGE OF TEMPORAL INCISION
Reduction against the Rule (ATR) Astigmatism
With the rule (WTR) astigmatism was found in 90 per

cent of population which shifts to against the rule (ATR),
26
MK Rathore
as the age advances, so that incidence of ATR is 5 to 6

times higher in age above 50 years (Duke Elder, 1969).
Jaffe (1975) observed prevalence of astigmatism as
WTR 30 per cent, ATR 42.5 per cent and oblique in 17
per cent in preoperative cases and similar observation by
Singh and Kumar (1976) ATR 45 per cent, WTR 30 per
cent and oblique in 15 per cent.
Cornea flattens over any incision and this effect
increases as incision approaches near the visual axis thus
superior incision results in postoperative ATR. This effect
in terms of visual gain is beneficial to preoperative WTR
case, but unfavourable visual results in cases having high
ATR preoperatively.
Therefore, the property of cornea to flatten along the
incision can be used to flatten the steeper horizontal meridian in cases of preoperative ATR astigmatism by placing
temporal incision.
For many years the superior site has been favourable
approach in most of intraocular surgical procedure and
it continues to be favoured location even today. In 1993,
Joel C performed surgery of cataract by lateral incision
and found net reduction of ATR by 0.72Dstatistically
a significant amount. Thereafter, many other workers
advocated this approach to reduce or nullify ATR astigmatism (Nelson PJ, 1995; Haberle H et al, 1995; Volkmer
C, 1996; Weindler J 1996; Antoni HJ, 1997; Lyhne N et
al, 1998; Schuler 1998).
Bohm B et al (1997) reported lateral approach with
scleral tunnel to be safe procedure and suggested it to be
used routinely in all patient having preoperative ATR
astigmatism.
Useful in Secondary and Combined Procedure
Masket S (1986) in his study on secondary IOL implantation demonstrated overall reduction or corneal cylinder
from modest flattening of surgical axis with a temporally
oriented scleral pocket incision and found it water tight
stable wound with astigmatic control.
Temporal Tunnel Incision in SICS
Gayton JL (1996) found a substantially greater

number of cases receiving a temporal cataract incision
with a superonasal trabeculectomy.
Caprioli J et al (1997) and Rossetti L et al (1997) also
found the temporal incision advantageous in cases where
superior limbus used for glaucoma surgery. It not only
preserves the functioning bleb, but also minimises the
ATR astigmatism resulted from previous surgery.
Stable Incision
Cravy TV (1991) found a statistically significant and

prolonged stabilisation of keratometric astigmatism in
planned ECCE via a lateral approach as compared to
identical surgery performed in vertical meridian.
Vazquez LA et al (1993) concluded that horizontal
5 mm sutureless scleral tunnel incision showed less
induced astigmatism with most rapid stable refraction.
Similar observation by Wong HC et al (1994) and Haberle
H (1995).
Zheng et al (1997) found a 3 mm temporal pocket
incision tube astigmatically neutral. Simsek S et al (1998)
concluded that upper lid pressure on superior corneal
incision led to fluctuating ATR astigmatism. Wollensack J
et al (1995) and Anders N et al (1997) reported scleral
tunnel incision has highest wound stability as compared
to incision at 12 Oclock.
137
Surgeon is required to perform the surgery from the

side and hence instead of sitting towards the head of
the patient, sits by his corresponding side
Operating microscope needs to be positioned accordingly
As there is no support for the surgeons wrist, some
kind of support (e.g. in the form of two cushions) has
to be used
Bridle suture is passed underneath the lateral rectus
muscle instead of superior rectus suture (optional)
All the steps of the surgery are the same as those being
performed from 12 Oclock position, but the incision
has to be bevelled more anteriorly as the temporal
limbus is away as compared to the superior limbus
Lastly, performing the surgery from temporal aspect
changes the functional angle, to which the surgeon
has to adjust himself initially. But after some practice
this position becomes less awkward and tedious
(Fig. 26.1).
Corneal Topographic Changes
Vass C and Menapace RJ (1994) have reported in their

computerised statistically analysis of corneal topography
for changes after temporal incision resulted in mean
flattening of 0.4 to 1.4 D in temporal region but no
significant vertical steepening or nasal flattening noticed,
hence less effect on visual axis.
Hoffer KJ (1994) has reported that the temporal
incision induced minimal central endothelial cell loss
compared to a superior incision group since superior
cornea is closer to central cornea.
Fig. 26.1: Temporal incision: extending the incision
SURGICAL STEPS
COMPLICATIONS
There is no more difference in surgical steps of temporal

tunnel as compared to small incision cataract surgery
from superior incision. Before considering surgery
through a temporal incision, certain modifications of the
surgical set-up and adjustments are necessary.
Complications are few and manageable and are similar

to SICS preformed from superior sector, but once the
technique is mastered, it is very safe and rewarding.
Intraoperative complications in our series of first 100 cases
were noticed as:
138
Premature anterior chamber entry 7.5 per cent, iridodialysis 7.5 per cent, posterior capsular rent 2.5 per cent.
Postoperative complications includes-striate keratopathy 45 per cent on 1st day which is always reversible,
fibrinoid reaction in 10 per cent, which responds quickly
to subconjunctival steroids + antibiotics injection. Pigment dispersion in 5 per cent cases. Conjunctival flap
retraction was more common 10 per cent as compared
to SICS for superior site as the conjunctival flap has no
support of lid pressure and gravity force.
Postoperative astigmatic control in our series of 100
initial cases 70 per cent was astigmatism upto 0.5 D and
rest 30 per cent upto 1.0D.
Thus showing a significant and favourable postoperative refractive condition, which gives an edge over other
surgical site.
There is WTR shift in temporal tunnel sutureless surgery. A 6 mm to 6.5 mm temporal incision produced a
mean surgically induced astigmatism (SIA) was 0.6 D
while same size of incision superiorly produces mean
astigmatism 0.98 D ATR (Similar observation by Neilson
PJ (1995), Ullern M (1997) Chou JC (1997), Huang F
(1998).
Thus significantly minimum produced astigmatism has
always resulted in better unaided visual acuity. The basic
principle of Incision causing flattening along the meridian in which it is placed has been utilized for management of moderate to high degree of preoperative astigmatism. The temporal incision was a neutralising effect on
preoperative ATR.
CONCLUSION
Preoperatie determinants form a major factor in final

visual outcome following cataract surgery a meticulous
work-up of preoperative astigmatism is necessary in order
to reduce it, by suitable plan.
Entire surgical set-up and adjustment of surgeons positions, support to wrist, etc. are necessary before proceeding to surgery from temporal side.
Incision has to be bevelled more anteriorly as temporal
limbus is farther from visual axis. Due to change in functional angle this approach of surgery may require little
practice.
Mean surgically induced astigmatism was 0.6 D. There
is WTR shift in all cases of temporal incision. Confirming
this technique as add to refractive surgery while performing SICS, apart from this the temporal wound was
found to be more stable. This is a incision of choice in all
cases who have undergone previous surgery from 12
Oclock position.
A simple modification in incision placement produced

comparable results to other sophisticated procedure and
hence offers a way to attain better surgical outcome with
limited resources available in most of the set-up.
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1. Anders N et al: Postoperative astigmatism and relative
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2. Antoni HJ et al: 3 years experience with ECCE with tunnel
incision. Ophthalmologe 94(1): 12-15, 1997.
3. Bohm B et al: 7 mm tunnel incision with lateral approach as
routine intervention in cataract surgery. Ophthalmologe
94(1): 3-5 1997.
4. Caprioli J et al: Temporal corneal phacoemulsification in
filtered glaucoma patients. Trans Am Ophthalmol Soc 95:,
153-67; Discussion 167-70 1997.
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phacoemulsification with foldable intraocular lens. Chung
Hua I. Hsuch Tsa Chih (Taipei) (Taiwan), 60(4): 195-98,
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6. Cravy TV: Routine use of a lateral approach to cataract extraction to achieve rapid and sustained stabilization of postoperative astigmatism. J Cataract Refract Surg 17(4): 41523, 1991.
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London: 5: 95-102 274-80, 370-76, 1959.
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Cataract Refract Surg 20: 308, 1994.
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incision. J Cataract Refract Surg 24(4): 477-81, 1998.
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and Co: St. Louis 111-12, 127, 246-53, 1984.
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17. Lyhne N: Relationship between preoperative axis of
astigmatism and postoperative astigmatic changes after
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Temporal Tunnel Incision in SICS

18. Masket S: Temporal incision for astigmatic control in
secondary implantation. J Cataract Refract Surg 12(2): 17981, 1986.
19. Nielson PJ: Prospective evaluation of surgically induced
astigmatism and astigmatic kerototomy effects of various self
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20. Simsek S et al: Effect of superior and temporal clear corneal
incisions on astigmatism after sutureless phacoemulsification.
J Cataract Refract Surg 24(4): 515-18, 1998.
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extraction. BJO 60: 638-41, 1976.
22. Vazquez LA et al: Surgically induced astigmatism: A
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23. Volkmer C et al: Minimising astigmatism by controlled

localization of cataract approach with the no stitch technique:
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100-04, 1996.
24. Weindler J et al: Is cranial corneoscleral 6 mm no-stitch tunnel incision contraindicated in against-the-rule astigmatism?
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25. Wong HC et al: Corneal astigmatism induced by superior
versus temporal corneal incisions for extra-capsular cataract
extraction. Aust NZ J Ophthalmol 22(4): 237-41, 1994.
26. Zheng L et al: Astigmatism and visual recovery after large
incision extracapsular cataract surgery and small incision
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140
Cortical Clean-up
elivery of the nucleus either in one piece or in

fragments marks the beginning of cortical
aspiration. The cortex is also referred to as soft
lens matter and its adequate removal is a very important
step in present day cataract surgery, be it a conventional
extracapsular cataract extraction, phacoemulsification or
small incision cataract surgery. Ability to ensure its complete removal distinguishes the modern cataract surgery
from its earlier version. Successful cortical clean-up
involves adequate cortical removal while preserving the
capsular bag, suspensory ligaments of the lens (no
zonular dialysis) and the integrity of corneal endothelium.
Complete removal of the cortex goes a long way in
restoring quicker and better visual acuity. It also reduces
the chances of uveitis, posterior capsular opacification
and IOL decentration. It also greatly enhances the
visibility of the posterior segment in the event of any
posterior segment pathology like retinal detachment,
diabetic retinopathy, etc.
For the removal of the cortex, coaxial retroillumination
is invaluable. However, with proper regard for the
macula, this illumination must be used for as short a
time as possible. This type of illumination should end as
soon as the lens is implanted by either turning the eye
away from the upward direction by tightening the
superior rectus bridle suture or by changing to oblique
illumination or by both.
Cortical removal can be accomplished using either
the automated systems or manual irrigation aspiration
(I/A) devices depending upon the preference of the
surgeon or the demands of the situation. Each method
has got its merits and demerits. No single technique is
suitable in all circumstances. Each surgeon has got his
own likes and dislikes and selects a technique that suits
him the best. Even for those surgeons who are using an
automated system for irrigation aspiration, it is imperative
that instruments for manual cortex removal be at hand
since a machine can fail. Familiarity with instruments for
manual cortex removal is also essential. If the surgeon is
unprepared for machine failure and it occurs in an eye
27
RN Misra
TN Vyas
with small pupil and stringy cortex (which is difficult to

aspirate by any technique) then the patient is in serious
jeopardy. Every surgeon without a back-up I/A unit must
master a manual cortical aspiration technique (Fig. 27.1).
Fig 27.1: I/A of cortex technique by simcoe
The main advantages of automated I/A system include

removal of the cortex in a tightly closed anterior chamber
as a result anterior chamber remains deep, fornices
remains open and easily accessible. There is no forward
movement of the vitreous and posterior capsule and less
chances of choroidal effusion or haemorrhage. Chances
of endothelial damage are less as the anterior chamber
remain deep all the time. The automated system however,
is not free from certain disadvantages like it is a difficult
procedure, requires prior setting and it lacks the instantaneously variable intraoperative control by the surgeon.
In a tightly closed chamber, a sudden surge of machine
controlled infusion pressure can rupture the posterior
capsule. Outflow around a cannula in a less tightly closed
chamber decreases the chances of rupture but increases
irrigation volume requirement and causes more endothelial damage. Conversely, manual cortical clean-up can
be easily mastered ensures self-reliance, and offers greater
safety, sensitivity, flexibility and reliability.
Cortical Clean-up
With patience a surgeon can gradually learn to apply

a degree of suction appropriate to the quality of cortical
matter to be aspirated. The cortical material in the fornix
has a very dense and mucoid consistency and therefore
needs a higher level of aspiration which is immediately
administered by a thumb pull. In the case of granular
cortical material, less suction is required and a more
delicate pull is used. With experience one gets to know
almost intuitively how much suction to apply to each of
the cortical presentations. There is no machine that can
produce the delicate control of cortical aspiration that
the human brain, coordinating with a hand, can sustain.
Therefore, we strongly favour manual aspiration as
opposed to the insensitive machine aspiration in small
incision cataract surgery.
The present chapter is designed to help define manual
cortical removal technique. It may also stir interest in
surgeons who are married to the machine to stimulate
them to try something new. Some surgeons may even
be converted to the manual technique.
Cortical aspiration in small incision cataract surgery is
much different than cortical aspiration in extracapsular
cataract extraction procedure. For one thing, there is
much less cortex to remove. Some of it was washed away
with the hydrodissection, and some of it came out with
the outer nucleus. Secondly the closed chamber
technique in small incision cataract surgery also helps to
maintain the depth of the anterior chamber and that
makes it easier to get out the cortex. Deep anterior
chamber also helps to avoid corneal endothelial damage
from instruments or excessive irrigation as well as capsule
or vitreous injury. If a continuous curvilinear capsulorhexis has been done instead of a can-opener capsulotomy it makes the cortical aspiration much more easier
because it eliminates the capsular flaps that may interfere
with the aspiration. Subincisional cortex is however most
difficult to remove in small incision cataract surgery.
A large variety of manual irrigation aspiration cannula
are available in the market, but the most commonly used
one is Simcoe cannula. It is a small calibre (thin wall 23
gauge) twin barrel I/A unit, one for aspiration and another
for irrigation. Aspiration port is situated anteriorly where
as infusion port is situated on the side. Simcoe cannula
are available in various gauges from 21 to 24, but 23
gauge is probably the best, because port size is such that
it is occluded by one tissue at a time either cortex, capsule
or vitreous. Its port size is large enough for quick and
safe cortical aspiration.
Irrigation aspiration in Simcoe cannula is independently variable: control is sensitive, instantaneous, and
141
immediately reversible. This inexpensive, autoclavable

unit can be reused for a large number of times.
Simcoe cannula is of two typesdirect and reverse
depending on the mode of infusion aspiration. In Simcoe
reverse cannula aspiration is bimanual and infusion is
either through a separate syringe connected to the
cannula by a silastic tubing and held by an assistant or
through a gravity infusion, in which silastic tubing of the
cannula is connected by a drip set to the infusion bottle
held high-up in a drip set stand. Infusion rate in the later
veriety is controlled by a stop attached with the drip set.
In Simcoe direct type surgeon holds the cannula in one
hand (right hand for a right handed person) and aspiration is through the adjacent twin cannula connected by
silastic tubing to a syringe isolated in the other hand.
Infusion in this type is either from a silastic squeeze bulb
or directly through an infusion bottle connected to the
cannula by a dripset. Infusion through a silastic squeeze
bulb is directly under the control of the surgeon, as a
result it is gentle, minimal and just sufficient to replace
the aspirated volume thereby avoiding turbulence in the
anterior chamber. On the other hand gravity infusion
lacks the sensitive, variable control of the bulb.
The syringe used for cortical aspiration has to be
capable of providing proper suction. Leaking plungers,
tight syringes too large or too small syringes do not work
properly.
Once the surgeon has got the instruments of his liking
the process of cortical clean-up begins. Curved Simcoe
cannula is gently slipped into the anterior chamber and
the loose cortical material floating in the anterior chamber
is gently aspirated. Remove as much large cortical
material as possible before turning to fine cortical remnants. Because in the event of vitreous loss fine cortical
remnants in the vitreous will get absorbed, where as larger
cortical fragments can lead to a very severe inflammatory
response. Once the free floating cortical material has been
aspirated, cannula is placed beneath the margin of the
anterior capsule and the cortical mater is engaged by
applying gentle suction through the syringe and by a
combination of rotation and translation pulled and
brought into the centre of the pupil before finally aspirating it (Fig. 27.2). Aspiration always proceeds from
periphery to the centre of the pupil, never in the reverse
direction. Only material that is clearly visible should be
aspirated. Tissue in the blind, under the iris, should be
moved to the pupillary area before the aspiration is done.
While aspirating the porthole must be visible, i.e. it must
face vertically upwards. This technique exploits the fact
142
that the cortical lens fibres are arranged radially, and are
therefore easiest to aspirate in this direction. When pulling
cortex from behind the iris, use gentle to and fro movements in order to loosen the material from the capsule at
the equator. Thereby one obtains more material with less
suction and so reduces the danger of collapse of anterior
chamber.
The posterior capsule must be watched for different
lines, (curved or straight). The former indicates that the
cortex is still present whereas later indicates that the
capsule has been caught in the suction port. The
recognition of these lines, particularly the straight ones
radiating out from the suction port indicating that the
posterior capsule is incorporated in the aspiration port
are very important because any further aspiration or
movement while it is impacted will lead to the rupture of
the posterior capsule. Engagement of the posterior
capsule in the port mandates immediate cessation of
suction and reflux to disengage it (Fig. 27.3). Otherwise,
the capsule will be ruptured and vitreous will be lost.
Avoid the build-up of high intraocular pressure, sudden
large amplitude movements of the iris, capsule and
hazardous intraocular movement of the cannula. Use as
little irrigating fluid as possible.
A collapsing bag is a feature of zonule dehiscence and
makes removal of the cortical matter very difficult.
Continued aspiration of the cortex tends to exacerbate
the problem, and a capsular tension ring should be
considered.
Cortical aspiration should ideally start from 6 Oclock
position and gradually proceed towards 5, 4, 3, 2, Oclock
position and 7, 8, 9, 10 Oclock position or vice versa
depending upon the preference of the surgeon or the

demands of the situation.
The cortex situated at 11 to 1 Oclock position or the
sub incisional cortex is the most difficult to aspirate. There
are various ways to aspirate it. Most commonly employed
technique is by making one or two side port incisions,
about 70 to 90 away from the primary incision and
aspirating the subincisional cortex by a Simcoe cannula.
Another method, which can be used, is by J shaped or
U shaped cannula (Fig. 27.4). In this technique cannula
is inserted into the incision sideways, and then rotated
to place the tip under the anterior capsule and cortex is
aspirated. If capsulorhexis has been done, IOL can be
placed in the bag and then rotated by 180, haptics of
the IOL could dislodge the superior cortex, which can
then be easily aspirated. This technique works very well
specially if there is a lot of cortex left. However, if rhexis
has not been performed and IOL is to be placed in the
ciliary sulcus, this technique is of no use. A gentle massage
of the iris by the irrigation aspiration cannula at the 12
Oclock position can dislodge the subincisional cortex,
which then can be aspirated. Disadvantages of this
technique include damage to zonules and iris. It can also
constrict the pupil thereby making cortical clean-up
further more difficult. Small amount of cortical material
can be left in the subincisional area, rather than to struggle
and cause a posterior capsular rent or zonular dialysis.
Fig 27.2: Engaging the cortical matter with aspiration port

beneath the anterior capsule rim
Fig 27.3: Radial stress lines in posterior capsule on

adherence with suction port
Posterior Capsule Polishing
It can be done by gently rubbing the posterior capsule

by the Simcoe cannula itself. Apart from this several
instruments are available to polish the posterior capsule.
Cortical Clean-up
143
Fig 27.5: Capsular polishing. Courtesy: Alcon (India)

Fig 27.4: Cortical wash through J shaped cannula
Kratz scratcher is one instrument quite commonly used.

It is nothing but a curved irrigating needle roughened
up by sand blasting, hydrohoning or coating with particles
of diamond dust. It is used by attaching it to cystitome
handle. Blunt air injection cannula or an olive tipped
needle can also be used for capsular polishing. It should
be rubbed gently against the posterior capsule to remove
the fine lens matter adherent to the posterior capsule
(Fig. 27.5). As the polisher touches the posterior capsule,
a halo reflex appears around the scratcher. Pressure
applied through the scratcher or polisher must be
sufficient enough to produce a halo of about 4 mm.
Excessive pressure may result in stress lines.
The effectiveness of the posterior capsule cleaning
often depends on the physical characteristics of the
capsule. A thin, floppy posterior capsule is the most dangerous. It is difficult to slide the tip of the polisher along
it without dragging it into folds that can rupture. A thick,
taught capsule is easiest to clean. Not infrequently, a
plaque may be present on the posterior capsule. It can
sometimes be scratched away by a fine tip of a bent
needle or picked away by a Mcpherson forceps. One

should not be too aggressive with residual plaques as an
opening in the posterior capsule can be made at a later
date with Nd: YAG laser.
Cortical Clean-up in PC Rent
If the posterior capsular tear occurs at the time of cortical

clean-up, cannula should be withdrawn from the anterior
chamber immediately. Anterior chamber should be filled
with the viscoelastic, so as to push the vitreous face back
and distent the capsular bag. If vitreous is not in the
anterior chamber, i.e. vitreous face is intact, then the area
of posterior capsular tear is left alone and cortex from
other areas is removed, preferably with dry aspiration
(filling the anterior chamber with viscoelastic repeatedly
and aspirating the cortex). Cortex should be aspirated
towards the tear and never away from it, otherwise it
may pull the vitreous. With dry aspiration almost all the
cortex can be removed without disturbing the vitreous.
If the cortex has got mixed with the vitreous and vitreous
is present in the angle or the wound an anterior vitrectomy
should be performed.
144
Intraocular
Lenses
he evolution of the cataract surgery with the

introduction of intraocular lens implantation has
been one of the major achievements of modern
medicine. The intraocular lenses provide a precise
pseudophakic optical rehabilitation with minimal magnification and excellent optical properties. The advent of
small incision surgery made possible by phacoemulsification and foldable IOLs represents another major
milestone in cataract surgery. It is important for the
ophthalmologists to have an in-depth knowledge of the
basic design and optical features of the various IOLs
currently in use.
Classification of IOLs
1. Site of implantation
i. Posterior chamber IOLs
ii. Iris plane IOLs
iii. Anterior chamber IOLs
iv. Scleral fixated IOLs.
2. Flexibility of lenses
i. Rigid IOLsPMMA
ii. Foldable IOLssilicone, hydrogel, acrylic,
collamer.
3. Material of optic
i. Polymethyl methacrylate (PMMA) optic
ii. Silicone optic
iii. Hydrogel or hydrophilic acrylic
iv. Hydrophobic acrylic
v. Thermoset (memory lens)
vi. Collamer.
4. Combination of optic and haptic material
i. Single piece IOLhaptic and optic made of same
material, e.g. all PMMA single piece IOL, all
acrylic single piece IOL.
ii. Three piece IOLwhere optic and haptic are
made of different materials, e.g. three piece
PMMA IOL (optic made of PMMA and haptics
of polypropylene), acrysol IOL (optic made of
hydrophobic acrylic and haptics of PMMA.
28
Tanuj Dada
Harinder Sethi
OPTIC MATERIALS FOR IOLs
An ideal IOL material should have following properties:

High optical quality
High index of refraction
Light weight
Durable, resistant to mechanical stress
Easy fabrication
Non antigenic/non-allergic
Non carcinogenic
Sterilization easy
Lack of inflammatory reaction, foreign body reaction,
or tissue chaffing
Blocking UV radiation
Implantable through a small incision.
Polymethylmethacrylate (PMMA)
It is an inert polymer of methyl methacrylate monomer.

It is manufactured through addition polymerization of
methacrylic acid methylester, which is derived from
acrylic acid. It was the first material to be used for intraocular implants by Harold Ridley. The idea of this material
being used for IOLs came from the fact that it had been
noticed that during World War II, intraocular fragments
of PMMA in the eyes of the pilots (which came from the
shattered canopies of fighter aircrafts), demonstrated inert
properties. This material is light, hard and transparent
and transmits a broader spectrum of light than the human
lens, thereby allowing the transmission of UV rays. Hence
UV absorbing materials have been incorporated as
covalently bonded or entrapped chromophores to prevent retinal damage. The agents commonly used as UV
absorbers are benzotriazoles and benzophenones. The
material is hydrophobic and may damage corneal endothelium on contact. The main disadvantage of PMMA
lenses is that they are non-flexible and have to be inserted
through a larger incision. The specific gravity of PMMA
is 1.19 and the refractive index of 1.497. PMMA has the
longest track record as an intraocular lens material and
has given an excellent optical performance till date.
Intraocular Lenses
Surface modification by heparin and other chemicals can

be done to reduce the deposits over the IOL and
opacification.
Silicone
It is composed of repeating chains of cross-linked dimethyl siloxane. The major advantages of this material are
the autoclavibility and decreased trauma to the intraocular structures. Silicone has affinity for proteins, which
may account for the build up of the surface proteins on
to the IOL optic. The material has a low tensile strenth
and must be handled carefully to avoid tearing. It is compressible and has an excellent memory (the ability to
return to original shape after deformation). The refractive index is 1.411.46 and specific gravity is 1.011.06.
Due to low refractive index, their relative thickness is more
for the same dioptric power and hence high power silicone lenses are thick and cumbersome to handle with
an uncontrolled opening inside the eye. Discoloration to
145
a tan brown colour had been reported in the first generation lenses and these lenses cannot be used in the presence of silicone oil within the eye as it chemically adheres
to these lenses.
Recently second generation silicone material has been
introduced which has a higher refractive index and is
increasingly becoming popular. The Pharmacia-Upjohn
CeeOn Edge 911 IOL represents the second generation
silicone IOLs. The edge of the optic is square or truncated
and it uses polyvinylidine fluoride haptic material with a
well-designed Cap C haptic configuration design providing an excellent memory.
Hydrogel
The optic of hydrogel lenses is made up poly-hydoxyethylmethacrylate (HEMA) with a 38 per cent water content and bonded with an UV absorber. They are lathe
cut in the dry state and require polishing. They are rigid
in the dehydrated state and become soft and rubbery on
Three Piece Silicone Intraocular Lenses

Properties
Elastimide IOL
SI 30 NB
SI 40 NB
SI 55 NB
Array SA 40 N
Design
3 piece
silicone-IOL
3 piece
silicone-IOL
3 piece
silicone-IOL
3 piece
silicone-IOL
3 piece
silicone-IOL
Model
AQ-1016/AQ
2010/AQ
2003
SI 30 NB
SI 40 NB
SI 55 NB
SA 40 N
Manufacturer
Staar Surgical, Inc. Allergan Inc.
Allergan Inc.
Allergan Inc.
Allergan Inc.
Overall diameter
(mm)
13.5/13.5/12.5
13.0
13.0
13.0
13.0
Optic diameter
(mm)
Biconvex 6.3
Biconvex 6.0
Biconvex 6.0
Biconvex 5.5
Biconvex 6.0
Optic diameter
Silicone polymer
Silicone polymer
Silicone polymer
Silicone polymer
Silicone polymer
Water content
< 1%
< 1%
< 1%
< 1%
< 1%
Refractive index
NA
1.46
1.46
1.46
1.46
Haptic material
Polyimide
Polypropylene
PMMA
PMMA
PMMA
Haptic angulation
10 deg
10 deg
10 deg
10 deg
10 deg
A constant
119
117.4
118
118
118
ACD (mm)
5.55
4.4
4.7
4.7
4.7
Diopter (range)
+14.5 to +28.5
+6.0 to +30
+6.0 to +30
+6.0 to +30
+16.0 to +24
Incision (mm)
NA
NA
NA
2.6
3.0
146

Properties
CeeOn 912
CeeOn Edge 911
Design
3 piece silicone IOL
3 piece silicone-IOL
Model
CeeOn 912
CeeOn 912
Manufacturer
Pharmacia-Upjohn, Inc.
Pharmacia-Upjohn, Inc.
Overall diameter (mm)
12.0
12.0
Optic diameter (mm)
Biconvex 6.0
Biconvex 6.0
Optic diameter
Silicone polymer
Silicone polymer
Water content
< 1%
< 1%
Refractive index
1.43
1.46
Haptic material
PMMA
PVDG (polyvinylidene fluoride)
Haptic angulation
6 deg
6 deg
A constant
117.8
118.3
ACD (mm)
4.6
4.9
Diopter (range)
+10 to +30.0
+12.0 to +28.0
Incision (mm)
NA
NA
hydration. Since they are hydrophilic, they are less

damaging to the corneal endothelium on contact. These
lenses have a low tensile strength and can get torn on
insertion. This IOL material may accumulate protein
deposits and can be deformed by tissue pressures, leading
to optical changes and changes in effective power. Their
refractive index is 1.47 and specific gravity is 1.19. This
group of polymers resembles the living tissue in their

physical properties more than any other class of materials
and are the easiest to insert as they are pre-rolled and
open up inside the eye gradually with hydration.
However, many lenses made from this material are
required to be maintained in a cold chain which is a
major disadvantage with these lenses.
Memory Thermoset IOL

Properties
Memory Lens
Design
3-piecehydrogel-IOL
Model
Memory Lens U940A
Manufacturer
Ciba Vision, Inc.
Overall diameter (mm)
130
Optic diameter (mm)
6.0
Optic material
Hydrogel polymer
Water content
20 %
Refractive index
1.47
Haptic material
Polypropylene
Haptic angulation
10 deg
A constant
119
ACD (mm)
5.6
Diopter (range)
N/A
Intraocular Lenses
Acrylic
Flexible acrylic is a co-polymer of phenylethylacrylate

and phenylethylmethacrylate. The cross-linking imparts
it a good three-dimensional stability and temperture
dependent viscoelasticity. Lenses made of this material
are softer and more easily foldable at body temperature
than room temperature. Unfolding is much slower and
more controlled than silicone lenses. It has high refractive
index of 1.55 making it the thinnest lens possible. Its has
a unique surface characteristic, i.e. tackiness (tendency
to adhere to surgical instruments and posterior capsule.
These are available as single piece (all acrylic) and 3piece lenses (PMMA haptics) and are currently the most
popular foldable lens materials with the minimum incidence of posterior capsular opacification. The decreased
rate of posterior capsular opacification (PCO) has been
attributed to the square edge design of the lens optic,
which has a barrier effect on proliferating lens epithelial
cells.
The Alcon AcrySof is the most popular IOL in this
group. It has an optic made up of flexible acrylic available in 2 diameters of 5.5 mm (MA30BA) and 6 mm
(MA60BM) and open loop haptics made of PMMA. The
overall diameter of the IOL is 12.5 mm (smaller optic)
and 13 mm (larger optic). Recently single piece AcrySof
lenses have also been introduced in the market which
have both the optic and haptic made up of acrylic.

Various studies have documented that PCO rates are
least with the Acrysof lenses which has been related to
the good biocompatibility of this IOL. This is due to the
sticky characteristic of the IOL and its close adherence
with both the anterior and posterior capsules and the
the square truncated optic edge.
HAPTIC MATERIALS FOR IOLs
Nylon (polyamide)
These are fibre polymers with repeating amide

(-CONH-) groups. They are named according to the
number of carbon atoms in the monomer subunits. The
commonly used ones are nylon 6 (Perlon, Supramid)
and nylon 66.
It has a tendency to slowly hydrolyse with gradual
water absorption and to be broken down at amide sites
by proteolytic enzymes. Hence they have gone into
disuse. Polyimide material is similar to polyamide, but
with greater heat resistance and has been used with glass
and silicon optic.
Polymethylmethacrylate (PMMA)
The advantage of PMMA haptics is the total lack of degradation in vivo. Since they are stiffer than polypropylene,
Acrylic Foldable IOLs

Design
3 piece acrylic- IOL
3 piece acrylic- IOL
Model
AcrySof MA30BA (5.5mm optic),

MA60BM (6.0mm optic).
AR-40
Alcon Laboratories, Inc.
Allergan, Inc.
Manufacturer
147
Overall diameter (mm) 12.5 and 13.0
13.0
Optic Diameter (mm)
Biconvex 5.5 and 6.0
Biconvex 6.0
Optic diamter
Hydrophobic acrylic polymer
Hydrophobic acrylic polymer
Water content
< 0.5%
NA
Refractive index
1.55
1.47
Haptic material
PMMA
PMMA
Haptic angulation
5 and 10 deg
5 deg
A constant
118.9
118.4
ACD (mm)
5.49
5.2
Diopter (range)
+ 10.0 to + 30 MA30BA
+ 10.0 to +30
Incision (mm)
+6
to + 30 MA60BM
3.0 to 3.5 and 3.5 to 4.0
3.2
148
they can be easily dialed in the bag. Moreover, they have

better memory than polypropylene, with better fixation
and centration. Three-piece silicone IOL with polypropylene haptics have a higher incidence of decentration,
pigment adherence and capsule opacification compared
with PMMA haptics. Single piece all-PMMA exhibit the
best loop memory. It is currently the most popular haptic
material. An angulation of the haptics 10 degrees anterior
to the optic is done to minimize pupillary capture and
iris chaffing.
Polypropylene (Prolene)
It is polymer derived from propane. Its chief advantage

is its hydrophobic nature making it very resistant to
hydrolysis. However a full spectrum UV light irradiation
leads to loss of tensile strenth. It is commonly used in the
three-piece lenses because of its biological compatibility,
resistance to biodegradation, flexibility and tensile
strength. It is usually dyed blue or purple for better visibility. A tendency to loose memory with time when
deformed by tissue is noted, with higher incidence of
decentration. Prolene loops are more flexible making

insertion easier. The main disadvantage of these haptics
is that they activate the complement pathway leading to
neutrophil chemotaxis with more postoperative inflammation. Bacteria also adhere better to polypropylene and
this leads to a greater risk of endophthalmitis. Hence this
material is no longer used for making IOL haptics.
Polyvinylidene fluoride (PVDF)
This is the latest IOL haptic material that has recently

been introduced with some of the new generation silicone
lenses. It provides a good memory and very stable
fixation.
Haptic Design
There are basically three types of haptic designs currently

in use:
1. Open loop (such as modified C loop design).
2. Plate haptic (Chiron C10UB and C11UB)
3. Mini loop plate haptic design (Medevec VS2)
Plate Haptic Lenses

Small Hole Plate Silicone Plate Lens
Large Hole Plate Silicone Lens
Properties
Bausch and Lomb

Surgical, Inc.
Staar Surgical, Inc.
Bausch and Lomb

Surgical, Inc.
Design
Model
C10 UB
(small holes 0.3 mm)
AA-4203V
(Small holes 0.3 mm)
C11 UB
(large holes 1.15 mm)
AA-4203 VF
(large holes 1.15 mm)
Manufacturer
Bausch and Lomb

Surgical ,Inc
(Formerly Chiron Vision)c
Bausch and Lomb

Surgical ,Inc
(Formerly Chiron Vision)c
Overall diameter
(mm)
10.5
10.5
10.5
10.5
Optic diameter
(mm)
Biconvex 6.0 mm
Biconvex 6.0 mm
Biconvex 6.0 mm
Biconvex 6.0 mm
Optic material
Silicone polymer
Silicone polymer
Silicone polymer
Silicone polymer
Water content
< 1%
< 1%
< 1%
< 1%
Refractive index
1.413
1.413
1.413
1.413
Haptic material
Silicone
Silicone
Silicone
Silicone
Haptic angulation
0 deg
0 deg
0 deg
0 deg
A constant
119
118.5
119
118.5
ACD (mm)
5.59
5.26
5.59
5.26
Diopter (range)
+4 to +31
+14.5 to +28.5
+4 to +31
+14.5 to +28.5
Incision (mm)
3.2
3.5
3.2
3.2
Intraocular Lenses
BASIC PRINCIPLES OF IOL MANUFACTURE
Lathe Cutting
The PMMA is taken as large block and a lathe with a tip

is used to cut the optic to the predetermined size, shape
and radius of curvature. The lens formed has rough edges
and surface, requiring polishing by a tumbling process
(lens is placed in a vertically rotating drum where in it
tumbles repeatedly with polishing compounds) or
specialized rotating rods (moved over the lens to make it
smooth). The residual polishing compound is thoroughly
removed.
149
used. These lenses are essentially one-piece PMMA

implants with either of two kinds of optic design, round
or oval. The round optic lenses have a diameter ranging
from 5.0 to 5.5 mm, while the oval optic lenses have a
horizontal diameter of 5.0 mm and a vertical diameter
of 6.0 mm. The overall diameter of these lenses ranges
from 11.5 to 12.5 mm, approximately the diameter of
the empty capsular sac. The oval lens optic is no longer
used as they are more prone to decentration and an
increased incidence of postoperative glare and diplopia
has been reported with these lenses (Fig. 28.1)
Injection Molding
The PMMA block or pellet is heated and forced at high

pressure through a steel mould which is designed to
provide a proper shape, size, and power of the lens. Later
the material softens and takes the shape of the mould.
Thereafter the mould is removed and lens is polished.
Injection moulded lenses have a tendency to wrap with
time and produce optical distortion. A higher susceptibility to damage by Nd: YAG laser is also reported.
Compression Molding
It is a hybrid process of lathe cutting and injection molding. The PMMA is first lathe cut and the rough version is
placed in the mold of the specific shape and power. It is
then subjected to high temperature and pressure and later
polished.
Cast Molding
It is similar to injection molding except that preformed

PMMA is not used. The resin that is purified and distilled
from the methylmethacrylate monomer is mixed with a
catalyst and poured into the injection mold. The actual
polymerization of the PMMA occurs inside the mold. The
process allows more accuracy and reproducibility. Moreover, the UV absorber can be added prior to polymerisation giving better bonding.
PROFILE OF RIGID IOLs USED FOR
SMALL INCISION CATARACT SURGERY
Conventionally an optic size of 6.5 mm and an overall

diameter of 13 mm has been used for cataract surgery
with IOL implantation in the ciliary sulcus. With the
advent of small incision cataract surgery and capsulorhexis it has become possible to place the lenses within
the capsular bag and hence smaller lenses are now being
One-Piece
Fig. 28.1: Diagrammatic representation of the most

commonly used posterior chamber IOls.
The main disadvantage of using these lenses is that

since they are rigid, implantation of these lenses requires
an enlargement of the incision size equal to optic
diameter. Once the incision is enlarged to 5-5.5 mm it
no longer remains astigmatically neutral and there is an
increased chance of postoperative leakage from the
wound if left unsutured. Even if there is no leakage of
fluid after applying pressure on the cornea/sclera at the
operating table one should always apply a suture. This
is important because there can be a long-term slippage
of the wound lip and progressive against the rule
astigmatism in such cases. Therefore, one must apply
atleast one 10-0 monofilament nylon suture when rigid
150
IOLs are used for small incision cataract surgery. Another

problem with these lenses is that due to the smaller optic
size, there can be problems of glare/diplopia in patients
with large pupils and during night vision. There is also a
higher incidence of posterior capsular opacification and
decentration. These lenses should not be used if the
capsulorhexis has been torn or if there is a large posterior
capsular rupture such that the lens has to be placed over
the margin of the capsulorhexis. Currently these are the
most popular lenses used for small incision cataract
surgery in our country due to the low cost.
FOLDABLE IOLs
These lenses mark a major landmark in history of IOLs

and as the name suggests these lenses can be folded
and thus inserted from small incisions in cataract surgery.
Advantages
1. Require a small incision (2.5-3.5 mm) for insertion.

2. This decreases postoperative astigmatism, increases
wound stability and allows rapid visual rehabilitation.
3. These lenses have a decreased incidence of risk of
posterior capsular opacification and cellular precipitates on the lens surface as compared to PMMA
lenses.
4. These lenses are relatively easy to explant due to
decreased perilenticular fibrosis with these lenses. In
addition due to a soft lens material the optic can be
cut into two and easily removed.
5. Currently used foldable lenses also have a better NdYAG laser compatibility and put decreased strain on
the zonules because of their reduced weight.
Disadvantages
1. Foldable lenses have a shorter track record and their

long-term biocompatibility within the ocular tissues
has not been fully evaluated.
2. These lenses have a low tensile strength and are thus
more prone to damage during implantation. Permanent fold marks and creases from holding, folding and
inserting these lenses may produce disturbances in
vision. In a cold temperature acrylic lenses may even
crack when folded.
3. Some of the foldable IOLs such as the Memory require
a cold chain to be maintained in a foldable form.
4. Lens discoloration has been reported with silicone
IOLs.
5. It is difficult to use a foldable IOL in the presence of a
posterior capsular rent.
6. If vitreoretinal surgery is required in an eye with a silicone implant, silicone oil cannot be used as a vitreous
substitute.
7. Currently foldable lenses are also much more expensive than rigid PMMA lenses.
Surgical Considerations in the
Insertion of Foldable IOLs
There are two basic techniques for foldable IOL insertion.

These IOLs can be inserted into the capsular bag by using
a passport/insertor/injector system or a holder-folder
system. The former system requires the smallest incision
size for IOL implantation. The holder-folder method is
the most popular method for IOL insertion.
The IOL can be folded by using either of the two
principles.
1. Horizontal or longitudinal principle which allows for
a two-step implantation technique ensuring control
and safety. This is folding along the 6 to 12 Oclock
meridian such that the haptics form a moustache.
The anterior haptic goes in first under the capsulorhexis
margin while the posterior haptic stays outside the
wound. After the IOL is released inside the capsular
bag, the posterior optic is dialled into the capsular
bag.
2. Vertical or transverse principle which allows the lens
to be placed in the bag in one manoeuvre. This is
folding along the 3 to 9 Oclock meridian such that
both haptics are placed together in the capsular bag
and do not need to be dialed after the lens opens up
in the capsular bag.
It is important to remember that silicone IOLs should
be dry before handled with the holder/folder, while acrylic
lenses should be wet when folded.
In the event of a zonular dialysis the IOL should be
inserted after putting an endocapsular ring (ECR) made
of PMMA to stabilise the capsular bag.
The injector systems use a disposable cartridge
wherein the IOL is placed. There is usually drawing of
the IOL outlined on the cartridge, which tells the surgeon
as to which direction the IOL should be placed. The IOL
is placed in the cartridge coated with a viscoelastic, the
cartridge is then closed and inserted into the injector.
The screw of the injector is slowly turned and one can
visualize the haptic of the IOL coming into the nozzle of
the cartridge. The nozzle is then placed inside the capsular
bag which has already been filled with viscoelastic and
the screw of the injector turned further to release the IOL
into the capsular bag.
Intraocular Lenses
Problems Encountered during Foldable IOL Insertion

i. The optic may slip if it is wet, especially if it is a
silicone IOL.
ii. Flipping out of the IOL may result from inappropriate
instruments and technique.
iii. Breakage of the haptic can occur from incorrect
tucking of the haptic during insertion.
iv. Tearing of the optic can occur if the handling is not
gentle, especially during the use of hydrogel IOLs.
v. The optic may crack when folded. This is usually
seen with acrylic IOLs if they are used in a cold
environment.
vi. The IOL may unfold with a sudden jerk within the
capsular bag. This can lead to a loss of capsular
integrity and a posterior capsular tear.
vii. Delayed unfolding may be seen during the insertion
of AcrySof or Memory lens.
viii. The IOL optic may be indented/damaged by pressure from the holding/folding instrument.
ix. Incomplete opening of the holder may occur and
the IOL may not be released into the capsular bag.
In such cases the IOL needs to be disengaged from
the holder with the help of a Sinskey hook
introduced from the side port incision.
x. Detachment of the Descemets membrane may
occur during IOL insertion.
MULTIFOCAL INTRAOCULAR LENSES
The intraocular lenses commonly in use have a fixed

focus which can be adjusted by adjusting the IOL power
to serve for near, intermediate or distance vision. It is
not possible to see near and distant objects clearly with
these lenses and thus patients are always dependent on
spectacles. Over the past decade, a variety of multifical
intraocular lenses (MIOLs) have been introduced and
enjoyed a widespread clinical use. Both refractive and
diffractive models have been shown to be effective in
allowing each eye to achieve quality, uncorrected distance
and near acuity after cataract surgery. The major concerns with the use of these lenses are the loss of contrast
sensitivity and the inducement of glare and halos from
light sources during night vision. All MIOLs require careful
attention to IOL power calculations and the creation of a
relatively planospherical result after surgery.
151
by a distance optical power. A new model made of silicone with PMMA haptics has shown surprisingly good
clinical results despite the potential for visual blur with
pupillary miosis. The NuVueTM is considered to be a near
dominant, MIOL and some surgeons use it in a monovision capacity for the near eye.
Three-zone MIOL A variety of three-zone MIOLs providing distance and near vision by using a near annulus
at various distance from the central distance component
have been popular. The Storz True VistaTM and the
Domilens Progress ThreeTM are examples of this style.
Normal pupil patients do enjoy both near and distance
vision but smaller pupils can obstruct the near component
with some three-zone MIOLs. One advantage of this lens
design is that even though there is pupil dependency,
distance vision is always preserved despite the loss of
near acuity with miosis.
Spherical Curve MIOL The AMO ArrayTM SA40N MIOL
is a lens designed with five zones of near and distance
powers on the anterior surface of the optic. These power
rings help to reduce pupillary dependency. The ArrayTM
is considered a distance dominant lens and provides
near acuities without correction in the J-3 range or better,
offering good midrange and near acuity for most tasks.
Some patients will prefer the addition of a bifocal add
for finer print and especially under low-light conditions.
The AMO ArrayTM is available in a foldable silicone
material with PMMA haptics. A new injectable delivery
system allows for greater ease of insertion. The AMO
ArrayTM lens is currently the most popular multifocal IOL
in current use.
DIFFRACTIVE MIOLs
Diffractive optics multifocal technology is slowly gaining

wide acceptance. The major advantage of this lens is
less pupil dependency and the ability to provide an even
distribution of near and distance vision. However,
manufacturing techniques are more difficult and critical
with these lenses due to difficulties with making of the
diffractive plate. Pharmacia has developed a diffractive
MIOL, the CeeonTM 811E. Addition of a diffractive
component to the popular AcrysofTM acrylic IOL is also
under consideration.
REFRACTIVE MIOLs
ACCOMMODATING INTRAOCULAR LENS
Target or Centre Surround MIOL
TM
The Chiron NuVue is an example of an MIOL with the

central near add in the middle of the optic surrounded
The ability to implant a new lens within the original

capsular bag of the crystalline lens and restore the physiologic accommodation is a concept being investigated by
152
many research workers all over the globe. Kamman and

Cumming have modifed the traditional plate haptic
silicon IOL to allow for movement of the IOL within the
capsular bag after insertion. This intriguing design has
demonstrated initial success in restoring presbyopic
accommodation. Accommodative amplitudes of approximately 2 to 3 diopters have been observed. However,
long-term studies have to be done before the clinical
efficacy of these lenses is established.
TORIC INTRAOCULAR LENSES
The plate haptic IOL design has been modified to

produce a toric IOL with the correction cylinder added
along the long axis of the IOL. This is marked on the
surface of the lens optic. For the toric design to be effective, the lens should not rotate within the eye after implantation. Rotation is relatively unusual but can occur during
the first 4 to 6 weeks after implantation, prior to fibrosis
around the lens and through the large positioning holes.
After this 4 to 6-week period the lens fixates in the
capsular bag via the fibrosis through the positioning holes
and fusion of the anterior and posterior capsules. This
helps to prevent long-term rotation as well as decentration
and dislocation of the IOL.
PIGGYBACK INTRAOCULAR LENSES
This concept involves the use of two intraocular lenses

placed one on top of the other (piggyback). This may be
done as a primary procedure to obtain an optimal
refractive result in highly ametropic eyes (e.g. high
hypermetropia) where sufficiently high power in a single
IOL may not be available. The second IOL can also be
implanted at a later date as a secondary procedure to
correct for a poor refractive result of the previous cataract
surgery. Both the lenses can be placed in the capsular
bag or one can be placed in the bag and the second IOL
in the ciliary sulcus. The main complication with use of
piggyback lenses is interlenticular opacification or
interpseudophakic opacification of polypseudophakia
(opacification between the two IOLs) which may require
both IOLs to be explanted.
COMPLICATIONS OF
FOLDABLE INTRAOCULAR LENSES
Descemets Membrane Detachment Caused by

IOL during Insertion
When inserting an IOL the lower edge of the optic can

cause a Descemets membrane detachment. This
Descemets membrane detachment is likely to occur if

IOL is inserted just parallel to the scleral tunnel incision
and where a detached scroll of membrane is already
present. In such cases the membrane can be repositioned
through the injection of air or expanding gas into the
anterior chamber.
Posterior Capsular Rupture during IOL Insertion
The posterior capsule can be ruptured during IOL

insertion and a if there is a pre-existing tear in the posterior
capsule, it can extend. Such a complication can occur if
adequate quantity of viscoelastic has not been inserted
in the bag or there is considerable leakage of viscoelastic
substance during IOL insertion. The use of a passport
system with plate haptic lenses is more likely to cause
this problem. If there is a tear in the posterior capsule
prior to IOL insertion, the injector/passport system should
not be used at all. If a tear occurs during IOL insertion,
the IOL may be left in the bag if the tear is small and the
viscoelastic removed manually with a Simcoe cannula
or using bimanual irrigation-aspiration. However if there
is a large tear then the IOL should be placed on the
margin of the capsulorhexis.
IOL Damage during Insertion
The haptics may be damaged during IOL insertion

through a small wound and one of the haptics may be
broken. In such cases it is essential to remove and replace
the IOL. During insertion care should be taken to
adequately extend the incision so as not to force the IOL
through a small and tight wound. Special caution is
warranted when a high power IOL is injected. Use of a
wrong forceps for holding the IOL may cause compression marks on the IOL optic and may even crack the
IOL requiring explantation of the IOL.
Bag Sulcus Fixation
During insertion of the IOL, the lower haptic may be

placed in the bag and the upper haptic may lie in the
ciliary sulcus. This can lead to IOL decentration and the
haptic may also cause a chronic uveitis/pigment
dispersion by rubbing on the iris tissue. Asymmetric loop
placement can also cause the windshield wiper syndrome
with the superior loop and optic shifting position with
eye movements and causing damage to the corneal
endothelium. To avoid this complication the upper loop
of the IOL should be carefully dialed in the bag and the
surgeon should check that both haptics are in the bag
before concluding the surgery.
Intraocular Lenses
153
Capsular Bag Distension Syndrome
Silicone Oil Adherence to IOL
This problem arises when a small capsulorhexis completely covers the optic and thereby seals the capsular bag.
There is sequestration of fluid secreted from the remnant
epithelial cells within the capsular bag and a progressive
inflation of the capsular bag. Retained viscoelastic
material behind the IOL can also lead to this condition
by creating an osmotic gradient and drawing more fluid
from across the capsule. This creates to an anterior shift
of the IOL and progressive myopia. The condition can
be prevented by performing a large capsulorhexis. The
treatment of this capsular distension syndrome is done
by doing a Nd-YAG laser capsulotomy of the anterior
capsule. A nick is created at the edge of the capsulorhexis
at 2/3rd locations, which allows fluid trapped within the
capsular bag to escape into the anterior chamber.
Irreversible silicone oil adhesion to the optic of a silicone

foldable IOL may occur during vitreoretinal surgery. The
silicone oil droplets condense on to the optic of the IOL
and lead to a severe degradation of the optics of the
IOL. This condition can be avoided by not implanting
silicone IOLs in eyes with present or potential vitreoretinal disease.
IOL Decentration
Implanting a small diameter IOL (which is meant to go

in the capsular bag) in the ciliary sulcus can lead to a
severe decentration of the IOL. This is especially seen
when a rent in the posterior capsule occurs and the small
diameter IOL is placed over the margin of the capsulorhexis by the surgeon. It is important to remember that
plate haptic lenses which do not have open loops should
never be placed over the capsulorhexis. The surgeon
should always have a large diameter (6.5 mm optic, overall diameter 13 mm) IOL available for implanting in the
ciliary sulcus in the event of a large posterior capsular
rupture. In cases of zonular dehiscence, a PMMA endocapsular ring should be implanted within the capsular
bag and then the IOL inserted, to prevent decentration
of the IOL.
Lens Dislocation
Complete lens dislocation into the vitreous is a rare

complication. It may occur due to the presence of an
unrecognized zonular dialysis during surgery or the presence of pre-existing zonular deficiency such as in posttraumatic eyes or eyes that have undergone previous
vitreoretinal surgery. Such a complication has also been
reported after YAG capsulotomy, especially with plate
haptic lenses. A pars plana vitrectomy is necessary for
removal of lenses dislocated into the vitreous and the
intraocular lens may then be repositioned with iris or
scleral suturing or substituted with an anterior chamber
IOL.
Capsular Contracture Syndrome
The anterior capsulorhexis can undergo a progressive

contracture leading to a capsular phimosis with obscuration of the visual axis and decentration of the IOL.
This occurs due to a fibrous metaplasia of the residual
lens epithelial cells and is aggravated if the original
capsulorhexis is small. This complication is most
frequently seen with the silicone plate haptic lenses. The
contracture can be relieved by performing a YAG
capsulotomy at the margin of the anterior capsule.
Uveitis
Polypropylene haptics can activate complement and

induce white cell chemotaxis and thus incite an inflammatory reaction. IOLs with polypropylene haptics are
also a risk factor for endophthalmitis with a risk 4 times
that of all PMMA posterior chamber lenses.
Endophthalmitis
Delayed onset endophthalmitis, which has a delayed

onset and an indolent course, has been described in eyes
with intraocular lenses. The most common responsible
organism is Staphylococcus epidermidis. A more indolent
from caused by Propionibacterium acnes may present
as chronic granulomatous uveitis with white plaques on
the posterior capsule. This infection appears to be
enhanced by localized entrapment of organisms within
the capsule and has been reported only in eyes with intraocular lenses. Adherence of organisms to lenses may play
some role. If Propionibacterium is suspected vancomycin
is the treatment of choice, although some cases may not
respond to medical management and require an IOL
explantation with excision of the involved capsule.
IOL Discolouration
IOL discolouration has been reported with the first

generation silicone IOLs. The discolouration of the optic
varies from light tan to a brown colour and appears from
154
15 months to 5 years after implantation. It can also be

seen in the IOLs in vitro if the lenses have not been used
for a long time. Although this colouration does not affect
the visual acuity, it can cause a fall in the contrast
sensitivity.
IOL Glistenings
This complication has been reported with the AcrySof

IOL especially if AcryPak packaging has been used
instead of the traditional wagon wheel packaging. These
glistenings are basically microvacuole formation within
the lens optic and are influenced by temperature changes.
This can cause a significant decrease in the contrast sensitivity and induce glare.
Glare
Use of small optics (<5.5 mm) can cause an edge glare,

especially during conditions of decreased illumination,
which cause a pupillary dilatation. This is a serious problem with square edge lenses such as the AcrySof with a
5.5 mm optic. It can cause a significant visual disability
to the patients, especially during night driving. A trial of
0.5-1 per cent pilocarpine may be done to decrease the
symptoms in such patients, although the IOL may even
have to be explanted due to this problem.
Posterior Capsule Opacification
Posterior capsular opacification (PCO) is currently the

most important issue in modern day cataract surgery.
Residual lens epithelial cells at the equator and the
anterior capsule proliferate and cause an opacification
of the posterior capsule after cataract surgery. This leads
to a decrease in the visual acuity, contrast sensitivity and
causes glare. Silicone and PMMA lenses have higher rates
of PCO as compared to acrylic lenses. A YAG laser
capsulotomy has to be performed in such cases but it
can cause damage to the optic of the IOL and opening
up of the posterior capsule increases the risk of a
subsequent retinal detachment. PCO can be reduced by
the following factors:
1. Adequate hydrodissection for facilitating a complete
cortical clean up.
2. An in-the-bag fixation of the IOL.
3. Diameter of the capsulorhexis slightly smaller than the
optic (seals the bag).
4. High biocompatibility of the IOL.
5. Maximal IOL optic-posterior capsule contact.
6. Square truncated edge of the IOL optic.
7. Primary posterior capsulorhexis with optic capture in
pediatric cases.
The Technique of IOL Implantation in SICS
The Technique of
IOL Implantation
in SICS
t is a foregone conclusion that, if the surgery has been

uneventful till this stage, there are unlikely to be many
hiccups on your way to successfully completing
sutureless cataract extraction with IOL implantation.
Probably that is why there is so little literature available
on techniques of IOL implantation.
Nevertheless, a few pertinent points need to be elicited
here, for the benefit of the beginner, or for those converting from conventional ECCE to SICS.
The peculiarities of IOL implantation in SICS arise
out of the specific nature of the passageway. At 3.5 to
4.5 mm, the sclerocorneal tunnel of SICS is the longest
passageway the IOL must traverse before being implanted. By comparison, the passageway in conventional
ECCE is barely 1.5 mm, and even the clear corneal tunnel, favoured by todays phaco surgeons, is a mere 2 to
2.5 mm (Fig. 29.1). Also, the SICS tunnel traverses two
different tissues, the sclera, and the cornea. Therefore,
certain differences exist in the technique of implantation
of the IOL in SICS, vis a vis the conventional ECCE, or
the phacoemulsification.
155
29
Nikhilesh Trivedi
Within the SICS also, there are some subtle differences.

While most of the SICS techniques involve the use of
viscoelastics, the Blumenthal technique (my technique
of choice) uses BSS itself to keep the AC formed for
implantation. This gives rise to another set of problems
which unfold as you proceed with implantation. As the
IOL is pushed through the tunnel, due to positive pressure
in the AC, the leading haptic tends to bend strongly. On
entering the AC, this haptic springs free suddenly. At this
stage, the AC tends to become shallow, with the escaping
of the BSS. So if you continue pushing the IOL, you
may be trying to introduce it into the bag when the
posterior capsule may be convex, and not concave. The
consequences are well-imaginable. Even with the IOL in
the AC, and the leading haptic in the bag, introducing
any instrument through the tunnel to manipulate the
upper haptic into the bag also results in a shallowing of
the AC. Though mostly harmless, this is alarming enough
to induce tachycardia in the surgeon.
After 4 incidents of near disaster, I changed my
technique of IOL implantation, from Push and Dial, to
Pull and Dial. This has saved me from many an anxious
moment since then. I will now describe both the
techniques, step by step.
The Technique
Step 1
Fig. 29.1: Comeoscleral tunnel for SICS
This will apply to those SICS techniques where viscoelastic is used. Fill the AC and the capsular bag with
visco. Preferably, introduce your visco cannula through
the main tunnel, and not the side port. Keep injecting
visco as you withdraw your cannula after filling the AC
and the bag. Make sure that you inject some visco in the
tunnel also. This will keep the tunnel slightly gaping, as
well as act as a lubricant for the passage of a rigid IOL.
156
Step 2
Here it is presumed that rigid IOLs are being used. The

use of foldable IOLs in SICS is unnecessary and unwarranted, since the tunnel is at least 5.5 mm wide, and can
accommodate most of the rigid lenses.
Hold the IOL with McPhersons forceps near the upper
dialing hole. Alternatively, the vertical Daljeet Singh IOL
forceps could be used to grasp the lens longitudinally.
This would be useful for the push and dial, but not for
the pull and dial technique.
Step 3
Push and Dial Introduce the leading haptic into the
tunnel. As you see the leading haptic enter the AC, tilt
the lens downwards so that the haptic is directed towards
the six Oclock pole. Keep pushing the lens till the leading
haptic is completely in the bag, and the lower dialing
hole is also at the pupillary border at six Oclock. Gently
release the IOL and withdraw the forceps. You may now
introduce the Sinskey hook from the side port, or the
main tunnel, and dial the IOL into the bag. Alternatively,
you may grasp the upper haptic with McPhersons
forceps, and rotate the lens as you tuck the upper haptic
under the edge of the capsule or the pupillary border. At
any stage, if the AC becomes shallow, cease, and reform
the AC with more viscoelastic. Once the IOL is in place
and well-centered, removing the viscoelastic, and corneal
hydration of the sideports if any, will complete the last
steps of a successful SICS.
Sinskey hook from the side port with your first hand.
The lower dialing hole should be visible at the internal
(corneal) incision. Engage this hole with the hook and
drag or pull the lens into the AC, directing the lower
haptic into the bag at six Oclock (Fig. 29.2). The upper
haptic may sometimes tend to snag in the tunnel at this
stage, but can be easily guided with the plane forceps in
the other hand. When the leading haptic is safely in the
bag, you may disengage the Sinskey hook from the lower
dialing hole and engage it in the upper dialing hole (Fig.
29.3). By this time, the entire IOL is in the AC, and the
tunnel is sealed, giving you a deep AC. You can now
easily dial the upper haptic into the bag.
Step 4
Pull and Dial This is an excellent procedure for the
Blumenthal technique where hydrostatic pressure is used
to form the AC and fill the capsular bag for implantation.
When you start implanting, the tunnel is tightly closed
due to the BSS flowing into the AC through the Anterior
Chamber Maintainer. Hence the leading haptic bends
dangerously (and may even break!) when you push the
IOL into the tunnel. As the lens enters the AC and you
keep pushing the lens, the haptic suddenly springs free.
This is accompanied by a slight shallowing of the AC as
the BSS gushes out of the tunnel. Push the IOL a little
more till the main body of the lens is blocking the tunnel,
and the gush of BSS diminishes. As you now release the
IOL from the McPhersons forceps, use the other hand
with a plane micro-forceps, to hold the upper haptic and
to tilt the lens slightly downwards. Now introduce a
Fig. 29.2: Implantation technique
CONCLUSION
This modification of the technique for Blumenthal

becomes necessary as the AC shallows as soon as you
introduce any instrument or the IOL through the tunnel
into the AC. If you try to introduce much of the IOL
into the AC as you did in the Push and Dial technique,
the risk of traumatizing the posterior capsule or the
corneal endothelium is high. Hence it is better to Pull
and Dial, rather than Push and Dial, for the Blumenthal
technique.
The Technique of IOL Implantation in SICS
157
An uneven tunnel, or a rough floor of the tunnel, can

cause much difficulty, particularly in the implantation of
the IOL.
At no stage should you try to continue pushing the
IOL if the AC has shallowed. You must cease, but need
not withdraw the IOL. Rather, deepen the chamber by
pushing more viscoelastic from the side port, over the
IOL. Then you can carry on from where you left the
IOL.
The dictum Better Safe Than Sorry would be a useful
one to memorise and recall.
REFERENCES
Fig. 29.3: Implantation technique drawing the lens

downwards from upper hole
CARE TO BE TAKEN
For any SICS procedure, a good and clean tunnel is an

absolute must. The importance of using a sharp (or new)
crescent knife for each case cannot be overemphasised.
1. Thomas R, Kuriakose T, George R: Efficient small-incision

cataract surgery, Indian J Ophthalmol 48: 145-51, 2000.
2. Blumenthal M, Askenazi I, Fogel R et al: The Gliding Nucleus,
3. Lahane TP: The incision-structural principles, Opthalmology
Today 2: 93-95, 2001.
4. Blumenthal M: Surgical principles and techniques for small
incision ECCE. Mini Highlights of Ophthalmology 21: 5(18), 1993.
158
Wound
Closure
he main function of a tunnel incision is to provide

watertight self-sealing valved wound. By pressing
against the dome of cornea and on the limbus
one can check the integrity of wound. Sealing can be
done by hydration of corneal stroma, which is achieved
by injecting irrigating fluid into the external tip of the
side port wound. The integrity is tested by applying
pressure with a sponge against the posterior lip of the
wound to make the incision leak. In the absence of leak,
the incision is covered with the conjunctival flap.Suturing
is required if:
a. There is a leaking tunnel.
b. Tunnel is more than 6.5 mm in length, even if it is
self-sealing in order to avoid against the rule astigmatism.
c. Premature entry.
d. Triple procedure has been done.
e. Paediatric cataract (due to thin sclera).
Suturing techniques can be divided into:
1. Appositional/Radial/Vertical sutures.
2. Horizontal.
Both can be either interrupted, figure of eight or continuous. Interrupted sutures give better control through
individual suture cutting while continuous suture equalises the tension across the wound.
30
MP Tandon
TN Vyas
Horizontal Sutures
They are less likely to disturb the alignment of internal

entry incision so as to cause less astigmatism than radial
sutures. They make the incision watertight by flattening
the scleral tunnel types of horizontal sutures.
1. Shepherds single horizontal suture This suture was
introduced by shepherd primarily for closure of scleral
tunnel of 5 mm width, which were weak. This consists
of a single bite starting at one end of the wound
entering the roof and floor of pocket vertically, passing
it horizontally to the other end along the floor of the
pocket and then bringing it externally through the roof
of the pocket on the other side of the tunnel. The
externalised sutures are then tied, thus closing the
incision. But this technique was not appropriate for
longer incisions, besides it resulted in an externalised
knot, and passage of suture through the deep layer of
the scleral pocket cannot be seen (Figs 30.1a to e).
Vertical Sutures
They appose the external lip of the wound, which results

in internal separation of the corneal lip because of pulling
of the sclera and cornea. They are separated by the
normal physiological gape, and this pulling of external
wound creates a new un-physiological position. The
internal entry site, which is the true astigmatism control
site is separated and disturbed. This can be reduced by
taking deep bites in the scleral bed, which brings proper
apposition of the scleral bed to the superficial flap.
Fig. 30.1a: Enter roof and floor of the

pocket vertically at one end
2. Horizontal anchor suture was introduced by Masket

for incisions between 4.0 to 7.0 mm in length to allow
direct visualisation of the horizontal suture within the
Wound Closure
159
Fig. 30.1b: Pass the suture horizontally to the

other end along the floor
Figs 30.1d and e: The suture being tied closes the incision
Fig. 30.1c: Bring out the suture through the
roof of pocket on the other end and tie it
anterior placement of the external layer of the scleral

pocket and the induction of an against-the-rule
astigmatic change (Figs 30.2a to h).
deep layer of scleral pocket. It also had the advantage

to close the incisional Dead space, to prevent internal
wound gape and fish-mouthing, to bury the knot
within the pocket, to provide a central anchor against
Fig. 30.2c: Externalize the suture through the roof of incision
Figs 30.2a and b: Take a miniradial bite towards the cornea
Fig. 30.2d: Bring it horizontally through one extreme of incision

and enter the incision through its roof and run horizontally in
the floor
160
Fig. 30.2e: Make a safety loop over the initial miniradial pass
Fig. 30.2g: Bring it out through the roof, run horizontally again
enter through the roof just before the centre of incision matching
the initial miniradial suture
Fig. 30.2f: Run deep in the floor of inicsion horizontally to

reach the other end of the incision
The technique consists of applying the suture in the

deep bed of the pocket with a miniradial bite taken
towards the cornea and externalised through the outer
layer of the pocket. The suture then passed horizontally
to the right extreme of the pocket and pierced through
the outer layer or roof of the pocket to enter the wound
space. The horizontal or circumferential portion of suture
continued from right to left under direct visualisation
in two bites, creating a safety loop over the initial
mini-radial pass. The extreme left of the deep layer or
floor of the pocket is reached, the suture then brought
externally and carried to the centre of the incision where
it was passed through the roof of the pocket into the
floor of the bed under the safety loop, matching the
original mini-radial bite and completing the suture course.
The knot is buried within the scleral pocket to prevent
conjunctival irritation.
Fig. 30.2h: The knot is burried in the scleral pocket,

preventing conjunctival irritation
Fig. 30.3a: Enter the tunnel through the roof
Fines Infinity Sutures
Resembles mathematical symbol for infinity in cross

section. It was introduced for closure of tunnel of 6.5
mm. It consists of two loops each covering approximately
40 per cent of tunnel width. The first loop enters the
wound space through the roof, pierces the floor of the
pocket and is their passed horizontally along the floor of
the pocket. It thin exits just left of the midline, through
the roof in the pocket. The second loop is similarly made
at the other end of the incision, again exiting just right to
the midline. The two ends of the sutures are tied externally
closing the incision (Figs 30.3a to i).
Fig. 30.3b: Pass the suture horizontally along the floor of

tunnel and take it out just to the other side of midline
Wound Closure
161
Fig. 30.3c: Take out the suture through the roof of tunnel
Fig. 30.3f: Take out the suture through the roof of the tunnel
Fig. 30.3d: Make the 2nd loop
Fig. 30.3g: Tie the suture externally
Fig. 30.3e: Run the suture along the floor of tunnel and take
out just beyond the midline
Alternatively the second bite of the suture can be taken

with the second needle of a double-armed suture, just to
the right of the exit point of the first bite and advancing
the needle from right to left.
Figs 30.3h and i: In cross-section this suture resembles the

mathematical symbol for infinity
162
Fig. 30.4a: Radial sutures reapproximate the edges of external

incision, pulling the cornea and sclera to a new, unphysiological
position, disturbing the internal entry site which is the true
astigmatism control site
Fig. 30.4b: Horizontal sutures flatten the tunnel creating a more

physiological closure of internal incision, thus decreasing the
degree of astigmatism
SUGGESTED READING
The comparison of horizontal vs vertical sutures are

shown in Figures 36.4a and b. In the end we can advice,
if you are in doubt that the tunnel incision is not selfsealing do not feel nicer in applying suture, never depend
on nature because nature may be against you, as it is
rightly said that a stitch in time save a nine.
1. Fiche H: Infinity suture: Modified horizontal suture for 6.5

mm incisions in Gills JP, Sanders DR (Eds): SICS Me Stitch
Surgery: Thordfare, NJ Slack, 191-96, 1990.
2. Manual small incision cataract surgery: an alternative technique to instrumental phaco-emulsification publisher Arvind
Publications, Madurai, India 33-34, 2000.
3. Masket S : Horizontal anchor suture closure method for SICS.
J Cat Refr Surg (Suppl.) 689-95, 1991.
When and How to Convert?
When and
How to Convert?
he ultimate goal of the surgeon and the patient

both is achieving good vision. Keeping this in mind
the surgeon should never mind converting to
conventional Extra Capsular Cataract Extraction (ECCE).
While operating, if there is insistence of completing the
surgery through small incision, bad results are sure to
occur. Postoperatively the results can even make you
think against the choice of this surgery. It is always better
to learn from others experience and faults. Followings
are the pearls for the beginners:
Preoperative assessment should be immaculate
because some cases are difficult to manage by this
technique especially for the beginners. Elder the patients
more are chances of large nucleus and also poor
endothelial cells count. These patients should be avoided
initially. Patients with Fuchs Endothelial Dystrophy, small
pupils, old uveitis, hypotony, and black cataracts are good
for conventional ECCE. Selection of softer cataracts in
younger patients (less than 55 years) is excellent to begin
with and patients between 55 to 60 years are good
candidates. Beyond this age surgeons skill and hardness
of cataract will come into play.
31
Kamaljeet Singh
consequently nucleus prolapse in anterior chamber

will not be possible, and cortical cleanup will also be
difficult. During delivery of nucleus the iris starts
coming out first. So it is better not to plan manual
phaco. But in case the pupil becomes small during
the surgery one should convert to conventional
incision of ECCE.
b. Incision size I can make an incision as large as 7.5
mm if the need arises, e.g. in black hard cataract there
is no point keeping length of incision at 5.5 mm as
described in the standard textbooks. If I find slightest
difficulty in delivering the nucleus out, I am ready to
increase the length of incision (Fig. 31.1), or to convert
WHEN TO CONVERT?
It is important to keep in mind that our aim is to give

vision to the patient. Beginners may stick to the original
plan despite facing complications. I have seen most
successful and experienced cricketers change their stance
on the quality of balling attack. Sachin is a great player
because he can adjust to the all kinds of balling techniques. These may be spin, medium pace or fast balling.
Similarly the experienced surgeons change their
technique depending upon the difficulties encountered.
Following points need to be taken care of:
a. Small pupil Manual phaco is difficult to manage in
small pupils. Small pupil can be present preoperatively.
In this case it is better not to plan manual phaco,
because large capsulorhexis is not possible,
163
Fig. 31.1: The incision should be extended

as long as in conventional ECCE
164
Fig. 31.2a: Nucleus delivery difficult through small incision
Fig. 31.2b: Enlargement of incision makes delivery easy
to conventional ECCE. As a beginner I used to deliver

the nucleus out through smaller incisions and faced
the music as I got white cornea the next day. So moral
of the story is never hesitate in increasing the length
of incision or converting to conventional ECCE in hard
cataracts.
c. Tunnel If the tunnel is not nicely made, you are sure
to land into trouble. Premature entry into anterior
chamber will lead to iris prolapse during procedures
like delivery of nucleus and washing of cortical matter.
Hyphaema and even iridodialysis may occur. In this
situation it is better to convert.
d. Difficulty in nucleus prolapse If the nucleus prolapse
is not possible by a few manoeuvres. One should convert. The factors responsible for difficulty in nucleus
prolapse are small capsulorhexis and hypotony. If
capsulorhexis is small one can give relaxing incisions
at ten and two Oclock position. One more trial should
be given for prolapsing the nucleus. Still if it is not
possible to prolapse the nucleus conversion is the best
answer. Hypotony causes maximum hindrance in
prolapse of the nucleus. If hypotony is too much the
surgeon will feel as if there is a vacuum pump inside
the eye, which is pulling the lens back. In this case
also the author suggests conversion to conventional
ECCE.
e. Posterior capsule rupture After the delivery of nucleus
during cortical cleanup at first sight of posterior capsule
rupture, the mind should be set for conversion because
the complications can be dealt with easily when you

are in the midst of your well-recognised surgery. So
converting to conventional ECCE is advised. Although
this complication can be managed nicely in closed
chamber. Vitrectomy if vitreous has come in anterior
chamber, removal of the cortical matter, and implantation, all are possible within the chamber.
So, to conclude to my mind small pupil, unexpected
large nucleus, iris prolapsing through the tunnel, difficulty
in prolapsing the nucleus and posterior capsule rupture
are the main culprits and one should not hesitate in
converting.
HOW TO CONVERT?
Conversion is very simple. The scleral incision is extended

towards the limbus with the help of corneal section
enlarging scissors. Then the incision is extended on the
limbus on both temporal and nasal sides. The incision is
extended to the usually performed ECCE length so that
there is no undue pressure required for extraction of the
nucleus (Figs 31.2a and b).
SUGGESTED READING
1. Bhattacharjee H, Singh S, Deka S: Small incision cataract
surgery (SICS) In Printers and Publishers. 133-91, 1998.
2. G Natchiar: Manual Small Incision Cataract Surgery. Arvind
Publishers: Madurai, India 67- 68, 2000.
3. Jaffe NS, JaffeMS, Jaffe GF: Surgical techniques in cataract
surgery and its complications. Mosby 65-131, 1997.
Current Status of Medications in Cataract Surgery
Current Status of
Medications in
Cataract Surgery
reoperative use of medication varies from place

to place and surgeon to surgeon. In some centres
too many drugs are used and at others too few.
Moreover, there is always addition to the existing list of
availability of medicines. Antibiotics, steroids, povidone
iodine and non-steroidal anti-inflammatory drugs are the
mainstays of the pre, intra and postoperative treatment
available today. In this article we will discuss the present
scenario of their usage under following heads:
l. Antibiotics
2. Corticosteroids
3. Non-steroidal anti-inflammatory drugs.
Antibiotics
It is very clear now that most important source of postoperative infection is patients own flora. Therefore preoperative antibiotics eye drops are used commonly. These
days commonly used preoperative antibiotic drops are
ciprofloxacin, tobramycin and ofloxacin. The question
is which antibiotic is the best amongst the presently available medicines. In a study: by Durmazetal1 to compare
the aqueous humour concentrations of topically applied
ciprofloxacin, ofloxacin and tobramycin in 30 patients
undergoing cataract or trabecullectomy surgery. These
eye drops were used for six times at an interval of 15
minutes beginning 90 minutes before the surgery. The
mean aqueous humour level of ciprofloxacin was 0.02+/
-0.077 microgram/ml, ofloxacin 0.964+/0.693 microgram/ml. Tobramycin did not reach the concentration
that could be detected by the applied method. The study
concluded that aqueous humour levels of ofloxacin and
ciprofloxacin were more than the minimum inhibitory
concentration (M1C) levels for most of the pathogens
that may cause postoperative endophthalmitis. In another study by Akkan et al 2 comparison of 0.3 per cent
165
32
Kamaljeet Singh
Shweta Pandey
Monika Joshi
ciprofloxacin, 0.3 per cent ofloxacin and 0.3 per cent

norfloxacin was done. Topical ofloxacin achieved a significantly higher mean level in aqueous humour than ciprofloxacin, and both were higher than norfloxacin. These
MICs were good enough to combat most of ocular pathogens that may cause postoperative endophthalmitis. For
the above three antibiotics another study was carried
out by Von Keyserlingk et al.3 They concluded that these
antibiotics achieved higher concentration for majority of
the gram-negative bacteria but these are not prophylactically effective against Streptococcus pneumonie or
Pseudomonas aeruginosa. It seems that of the currently
available antibiotics for preoperative topical use ofloxacin
is the best antibiotic but may not be prophylactically very
effective against Streptococcus pneumonie or Pseudomonas aeruginosa.
Povidone iodine five per cent, an iodine-releasing
polymer has shown to destroy bacteria in 30 seconds
and its efficacy being equal to 3-day antibiotic eye drops
containing polymixin, gentamicin and neomycin. It has
antibiotic, antifungal and antiviral properties. When
antibiotic drops and povidone iodine both are instilled
together the effect achieved is additive and further
decrease in antimicrobial load results. Povidoneiodine
five per cent should be practiced as a routine before
cataract surgery. It has also been found that when IOLs
are implanted they carry some microbials with them due
to contact with the bulbar conjunctiva. Povidoneiodine
applied before the surgery can be very useful in this aspect
as well.
Subconjunctival injections of antibiotic: Bacteria have been isolated from the anterior chamber after
the surgery despite above measures. Luckily the body
resistance is such that these are taken care of. But still
this provides enough evidence of the use of antibiotics
by sub-conjunctival route.4 There are two schools of
166
thought for their usage through this route. One school

does not subscribe to the idea of use of subconjunctival
injection and the other does. The first says that
endophthalmitis developed despite injection being given
and organism being sensitive to the antibiotic used. This
school argues that there are chances of globe perforation.
The other school recommends subconjunctival injection
of antibiotic and most commonly used antibiotic for this
purpose is gentamicin.
Intracameral Use of Antibiotic
This method of use of antibiotic is also an important

method. Frequently used antibiotics by this method are
gentamicin and vancomycin. Antibiotics are injected into
the infusion bottle in the hope that the incidence of
postoperative endophthalmitis will reduce. But this aspect
is also controversial. Greatest problem with wide spread
usage of the antibiotics is development of resistance. In
addition, there are chances of toxicity to the retina if they
are not properly used. The Endophthalmitis Vitrectomy
Study found that systemic antibiotics were not required
in addition to intravitreal antibiotics for the treatment of
postoperative endophthalmitis. This paper5 also suggests
the reason for this; eighteen patients with postoperative
endophthalmitis were studied, following intravenous
injection of 1g of vancomycin in 14 patients and intravitreal injection of 1mg in four patients. The concentration
of vancomycin in the vitreous ranged from 0.4-4.5 mg
per ml in the patients who had received intravenous
injections, which was lower than the minimal inhibitory
concentrations (MICs) required for the causative bacteria
isolated from the same samples. In contrast, the concentration of vancomycin in the four patients who received
intravitreal injection varied from 25-182 mg per ml. Also
of note is that the vancomycin was still present upto 72
hours from the time of the intravitreal injection. There is
little need to add intravenous administration to an intravitreal injection of vancomycin. Vancomycin is very effective against the gram-positive cocci that are likely to be
responsible for more than 90 per cent of confirmed cases
of bacterial endophthalmitis. It is worrying; therefore, that
many cataract surgeons are using low-dose vancomycin
in their infusion fluids as a prophylactic, which is probably
not reaching the MICs required and may in fact be
encouraging resistance to this extremely useful, low
toxicity drug. Several studies have been done to prove
or disprove the above point. Adenis et al6 recommend
the use of vancomycin on the basis that the concentration
achieved after the surgery were quite effective. Shimuzu
and Shimuzu observed that their incidence of
endophthalmitis reduced from .08% to .05% by intracameral use of carbapenem and imipenen in 2160 cases.
OBrien7 reported that intracameral use of antibiotic
polymixin and bactracin in both in vitro and in vivo rabbit
models results in statistically significant reduction in
bacterial colonisation. Other authors like Feys et al8 found
that addition vancomycin had no effect on the occurrence
of intraocular contamination. Lehman9 reports that
intracameral gentamicin is cleared so fast from the
antibiotic the bactericidal effects are difficult to reach in
that short time. Ferro et al10 are also of the opinion that
the intracameral use of antibiotic may not be of much
help. The Center for Disease Control11 has issued a warning to limit the use of vencomycin because of the reported
development of resistance. Thus exact recommendation
of intracameral use is still lacking.
Non-steroidal Anti-inflammatory Agents
Several non-steroidal anti-inflammatory agents like

flurbiprofen, indomethacin, diclofenac, ketorolac are used
preoperatively for maintenance of pupillary dilatation
postoperatively to reduce the reaction after cataract surgery. Many studies have been done on the above drugs
comparing their effects with each other and with steroids
as well. Recently voltaren has been introduced and
several studies reported its beneficial effect over other
anti-inflammatory eye drops. In a study conducted by
Ostrov et al12 no significant difference was found between
ketorolac, prednisolone acetate, and dexamethasone in
the postoperative period in the cells and flare in aqueous.
In fact incidence of postoperative cystoid macular
oedema was less common in patients who used ketorolac
eye drops. Another study conducted by Schmidt et al13
showed that the reduction in anterior chamber flare as
measured by laser flare meter was significantly greater
with flurbiprofen or with indomethacin. In a double
masked conducted by Butt et al14 comparison of the effect
of voltaren-gentamycin combination with dexamethasone-neomycin-polymixin combination no statistically
significant difference was found in anterior chamber after
the extracapsular cataract surgery. Similarly other authors
Rowen et al and Roberts et al15 found voltaren to be
very effective in preventing postoperative reaction and
almost as effective as steroid and better than other nonsteroidal anti-inflammatory agents.
Corticosteroids
Corticosteroids are commonly used anti-inflammatory

agents after cataract surgery. Their anti-inflammatory
Current Status of Medications in Cataract Surgery
effect is considered more superior than the non-steroidal

anti-inflammatory agents, but the greatest problem with
their use is rise in the intraocular pressure. Commonly
used corticosteroids are dexamethasone, prednisolone,
fluromethalone. Intraoperatively used method is by
subconjunctival route. Many surgeons prefer to use this
route others do not. In order to lay this controversy to
rest Nakamura et al15 conducted a study comparing this
route with those who did not receive intraoperative
injection. Weijtens et al16 differ and showed that a subconjunctival injection of steroid resulted in significant
aqueous and vitreous concentrations. In 50 patients
undergoing vitrectomy for various indications, 2.5 mg
of dexamethasone was injected subconjunctivally after
topical anaesthesia, and aqueous, vitreous and serum
samples were taken at the beginning of surgery. There
was no control peribulbar steroid group; instead the
aqueous and vitreous concentrations were compared with
those from previous studies of peribulbar dexamethasone
injections. High aqueous concentrations of dexamethasone were found, and the mean peak vitreous concentration was found to be 12 and 3 times higher than after
oral and peribulbar administration, respectively. The
authors of the paper feel that these results warrant a
randomised trial to establish whether subconjunctival
corticosteroids administration, particularly for delivering
dexamethasone to the posterior segment.
The other route is by intraocular use. Chang et al17
report in their study that the use of an intraocular biodegradable polymer dexamethasone drug delivery
system (DEX DDS), placed between the iris and anterior
surface of the intraocular lens at the time of cataract
surgery, in reducing postoperative inflammation. This was
a randomised, double-masked, parallel group study
comparing two dose levels of the preparation with
placebo and no-treatment groups. Animal studies have
shown that dexamethasone is released for 7-10 days,
after which levels become undetectable. The anterior
chamber (AC) cells and AC flare were assessed for 60
days postoperatively using slit-lamp examination. The
number of patients in each group requiring additional
anti-inflammatory medication was also noted. At week
two, 80% of the controls required additional topical
steroid medication compared with seven per cent of those
with the DEX DDS. By month 2, 12% of the DEX DDS
patients required topical steroid, compared with 83% of
those in the control placebo group. There were no
significant complications from the intraocular steroid; in
particular, there was no elevation of intraocular pressure.
The rebound inflammation at 7-10 days, when the
167
intraocular steroid preparation would no longer be active,

was seen only infrequently. DEX DDS may prove useful
in postoperative treatment regimens where antibiotic
drops are not given either, for it means that the patient
does not need to use postoperative drops at all.
Rimexolone and loteprednol are two recently introduced steroids in USA. In studies done by Leibowitz
et al18 and Novack et al19 it has been reported that
loteprednol is less likely to cause postoperative rise of
intraocular pressure than prednisolone and has equal
effect in anterior chamber flare after the surgery
CONCLUSIONS
Ofloxacin and ciprofloxacin are good antibiotics because

of better bioavailabiltiy in aqueous humour. They may
be used both preoperatively and postoperatively.
Voltaren, a non-steroidal anti-inflammatory agent can
be used safely for preventing intraoperative miosis and
can also be used in place of steroids in postoperative
period for reducing the anterior chamber reaction and
for prevention of cystoid macular oedema.
Subconjunctival injection of antibiotic and steroids
remains a controversial subject. Intracameral use of
antibiotic also remains a controversial topic. Intraocular
use of steroid is a new method of delivery.
REFERENCES
1. Durmaz B, Marol S, Durmaz R et al: Aqueous humour
concentration of topically applied ciprofloxacin, ofloxacin and
tobramycin. Arzneimitt for Schung 47: 413-15, 1997.
2. Akkan AG, Mutlu I, Ozyazgan S et al: Penetration of topically
applied ciprofloxacin, norfloxacin and ofloxacin into the
aqueous humor of the uninflamed human eye. J Chemother
9: 257-62, 1997.
3. von Keyserlingk J, Beck R, Fischer U et al: Penetration of
ciprofloxacin, norfloxacin and ofloxacin into the aqueous
humours of patients by different topical application modes.
EurJ CLh Pharmacol 53: 251-55, 1997.
4. Ferencz JR, Assia EL, Diamantstein L et al: Meir vancomycin
concentration in the vitreous after intravenous arid intravitreal
administration for postoperative endophthalmitis I-losp, Kfar
Saba Israil Arch Ophthalmil 117: 1023-27, l999.
5. Adenis JP, Robert PY, Mounier M et al: Anterior chamber
concentrations of vancomycin in the irrigating solution at
the end of cataract surgery. J Cataract Refract Surg 23: 11114, 1997.
6. OBrian TP, Kirn KB, Barequet I: Effect of intracameral
antibiotic supplementation at the end of cataract surgery:
An experimental model (abstract). Invest Ophthalmol Vis Sci
38: S1-4, 1997.
7. Feys J, Salvanet-Bouccara A, Emond JP et al: Vancomycin
prophylaxis and intraocular contamination during cataract
surgery. J Cataract Refract Surg 23: 891-97, 1997.
168
8. Lehmann OJ, Roberts CJ, Ikram K et al: Association between

non-administration of subconjunctival cefuroxime and
postoperative endophthalmitis. J Cataract Refract Surg 23:
889-93, 1997.
9. Ferro JF, de-Pablos M, Logrono MJ et al: Postoperative
contamination after using vancomycin and gentamicin during
phacoemulsification. Arch Ophthalmol 115:165-70, 1997.
10. Hospital Infection Control Practices Advisory Committee
(NICPAC): Recommendations for preventing the spread of
vancomycin resistance. Infect Control hosp Epidemiol 16:
105-13, 1995.
11. Ostrov CS, Sirkin SR, Deutsch WE et al: Ketorolac, prednisolone, and dexamethasone for postoperative inflammation.
Clin Ther 19: 259-72, 1997.
12. Schmidi B, Mester U, Diestelhorst M et al: Laser flare
measurement with 3 different non-steroidal anti-inflammatory
drugs after phacoemulsification with posterior chamber lens
implantation. Ophthalmology 94: 33-37, 1997.
13. Butt Z, Fsadni MG, Sunder RP: Diclofenac-gentamicin
combination eye drops compared with corticosteroid
14.
15.
16.
I7.
18.
antibiotic combination eye drops after cataract surgery. Clin

Drug lnvest, 15: 229-34, 1998.
Roberts CW: Pretreatment with topical diclofenac sodium to
decrease postoperative inflammation. Ophthalmology
103(15): 636-39, 1996.
Weijtens O, Feron EJ, Schoemaker RC et al: High concentration of dexamethasone in aqueous and vitreous after
subconjunctival injection. Rotterdam Eye Hosp, Rotterdam,
The Netherlands. Am J Ophthalmol 128: 192-97, 1999.
Chang DF, Garcia IH, Hunkeler JD et al: Phase II results of
an intraocular steroid delivery system for cataract surgery.
Altos Eye Physicians, Los Allos, CA, USA. Ophthalmologica
106(1): 1 172-77, 1999.
Leibowitz IM, Bartlett JD, Rich R et al: Intraocular pressureraising potential of 1 .0% rimexolone in patients responding
to corticosteroids. Arch Ophthalmol 14(1): 933-37, 1996.
Novack GD, Towes J, Crockett RS et al: Change in intraocular
pressure during chronic use of loteprednol etabonate. J
Glaucoma 7: 266-69, 1998.
Complications of Manual Phaco
Complications of
Manual Phaco
169
33
Kamaljeet Singh
ajority of the complications associated with

phacoemulsification and extracapsular surgery
are common to manual phaco. We shall discuss
here the specific complications of manual phaco. The
complications of manual phaco can be divided into
following subheads.
INTRAOPERATIVE COMPLICATIONS
1.
2.
3.
4.
Complications associated with wound construction.

Complications associated with AC maintenance.
Complications associated with capsulotomy.
Complications associated with nucleus prolpase in
AC.
5. Complications associated with delivery of nucleus.
6. Complications associated with debris clean-up.
7. Complications associated with implantation.
Complications Associated with
Wound Construction
It is the most significant step in any sutureless surgery,

whether in phaco or in manual phaco, or even in
conventional ECCE. Proper wound construction and
tunnel formation is most important in manual phaco
because wound is bigger and tunnel should have more
length to keep it self-sealing. Most common complication
associated with this step is premature entry into the
anterior chamber. This causes iris prolapse during various
manoeuvres (Fig. 33.1) and increases the chances of
Descemets tears. Other common complication is button
holing of the sclera if the depth in the scleral tunnel is too
shallow. Deeper dissection can also be a problem as
superficial sclera may disinsert from the deeper sclera.
This is called scleral disinsertion. Excessive bleeding may
occur while constructing the wound as the incision here
is given about 2 mm behind the limbus, which has more
capillaries. Bleeding can be taken care of by doing careful
bipolar cautery.
Fig. 33.1: Iris prolapse through the wound

due to premature entry
Management Keeping the crescent blade in one plane

can prevent premature entry. If it occurs immediately the
dissection should be abandoned. Begin dissecting from
the other end of the tunnel, or one can choose other site,
or dissection from other plane should be started. This
wound is likely to leak. Therefore, it will need suturing.
Button holing can be prevented by avoiding dissection
at shallow plane while doing scleral dissection. If small
hole is there, then second plane at deeper site may be
selected, If the hole is large the site of incision needs to
be changed.
Avoiding deep dissection can prevent scleral disinsertion. If it occurs, radial sutures are applied to secure the
wound. If Descemets detachment occurs we have to
inject air (Fig. 33.2).
Complications Associated with AC Maintainer
Problem most frequently seen with AC maintainer isit

comes out from the wound, if the tunnel for AC
maintenance is wide. In contrast, if it is too tight the AC
170
periphery. If smaller capsulorhexis is done the ECCE may

turn to ICCE while prolapsing the nucleus. Capsulorhexis
is not a must here as in phacoemulsification. The simplest
and best is to make an envelope type capsulotomy. In
those technique where two instruments are used, like in
sandwich, phacosection or phacofragmentation anterior
capsule also gets sandwiched between two instruments
and can lead to zonular disinsertion in inferior position.
Here the surgeon should keep other instruments under
direct supervision. This complication does not occur
when capsulorhexis or Beer can-opener technique is
used.
Fig. 33.2: Detachment of Descemets membrane-injecting air

bubble is enough for reattachment
maintainer enters in AC with a bang and may injure iris.

Author once entered in AC with such force that it caused
subluxation and the surgery was abandoned. Therefore,
one should make a tunnel about 2 mm long and entry
should not have great resistance. The AC maintainer
should be of 20G as advocated by Blumenthal.
Complications during Capsulotomy
If surgeon chooses to do this surgery with capsulorhexis,

it should be not less than 6.5 mm. Making a large
capsulorhexis is difficult because it may extend in the
Management Small capsulorhexis can be turned to beer

can-opener in the upper aspect from 11 to 1 Oclock by
applying several cuts on the margin of capsulorhexis.
Several cuts should be made. Only one cut may extend
in the periphery while prolapsing the nucleus (Fig. 33.3).
Zomular disinsertion necessitates implantation in ciliary
sulcus (Fig. 33.4).
Complications Associated with
Hydrodissection and Hydrodelineation
Two problems can occur during these procedures. The

hydrodissection may be insufficient to cause rotation.
More hydrodissection is required in this case. Keep doing
hydrodissection till rotation is achieved. Secondly, there
can be posterior capsular rupture. This occurs due to
too much fluid going in a bolus, or fluid getting stuck in
between posterior capsule and nucleus. For avoiding this
complication, one can inject fluid and then should
Fig. 33.3: Small capsulorhexis makes delivery of nucleus difficult multiple cuts in
superior positions can make the delivery of nucules easier
Complications of Manual Phaco
Fig. 33.4: Zonular distinsertion-Implantation in ciliary sulcus
depress the nucleus so that the fluid may not remain

there at one point and fluid may move. If this is not
carried, there are chances of even posterior dislocation
of nucleus.
Complications During Nuclear Prolapse in AC
The beginner faces biggest problem in prolapsing the

nucleus in AC. This difficulty occurs when there is
hypotony, pupil is small, capsulorhexis is small, or nucleus
is soft. Therefore, this step should be practiced in canopener technique, as the prolapse is easiest in this
method. Diamox or pinky ball should not be applied as
it causes hypotony. If hypotony is too much and nucleus
does not prolapse, one may have to convert to ECCE. A
few cases of capsular dialysis have been reported during
accidental dialing of capsulorhexis edge in place of
nucleus. If the pupil is small one can do a sector
iridectomy and proceed or convert to ECCE. In case the
nucleus is soft and does not rotate, one can wash the
cortical matter. Now the nucleus view will be better and
prolapse will be possible. Actually in this case for rotation
the surgeon does not go deep enough and remains in
the cortex and the perinuclear plane.
Complications during Delivery of Nucleus
Several techniques of delivering of nucleus have been

described in this book. One problem of transient corneal
oedema is common in all the techniques, due to nucleus
touch to the endothelium. This touch should be avoided
and the delivery should be made easy. As during the
delivery of a child episiotomy is given, similarly if delivery
of nucleus becomes difficult one should increase the
length of the incision. If corneal valve remains formed,
171
Fig. 33.5: Dialysis of iris
incision up to 8 mm long can safely remain sutureless. In

techniques where two instruments are used to handle
the nucleus, there are chances of iridodialysis at the site
of entry. This may occur when the viscoelastics are scanty
in the AC and it is not deep. Care should be taken to
displace the anterior capsule inferiorly if envelope type
capsulotomy has been made when sandwich technique
is used. Otherwise it may lead to disinsertion of zonules
in the inferior position while delivering the nucleus out.
Complications Associated with Debris Cleanup
Posterior capsule rupture can occur which should be

managed by doing vitrectomy, if vitreous has came into
the anterior chamber. If there is small repture, which is
detected early IOL can be easily implanted in the bag
(Fig. 33.6). Any cortical matter left should be aspirated
by dry suction method. The issue is described in detail
elsewhere. Subincisional cortical matter is difficult to
clean. For this J shaped cannula can be used or separate
entry at 7 Oclock should be made. The cortex can also
be disengaged while dialing the IOL.
Complications Associated with Implantation
The biggest problem is implanting the lens in the bag,

because we are implanting lens through a tunnel. The
tilted lens cannot go in the inferior side, as the tunnel is
horizontally long. The inferior haptic in this case, may
be left on anterior surface of iris. The superior haptic is
then implanted in the bag and inferior haptic is dialed
into the bag. The other complication occurs when the
chamber is not filled with viscoelastics. The IOL
implantation can cause endothelial touch.
172
not, then hypertonic saline should be added to the

treatment regimen.
Endophthalmitis
Posterior capsular opacification
Table 33.1: Authors experience with complications in
250 consecutive patients including initial cases:
1.
2.
3.
4.
5.
6.
Fig. 33.6: Small posterior capsular suplure with no disturbance

of anterior hyaloid face in the bag implantation can be done
POSTOPERATIVE COMPLICATIONS
Shallow AC It can be seen if the surgeon has not tested

the corneal valve by depressing the upper sclera
behind the incision. This complication can be tackled
by applying a suture and reviewing the wound. If
postoperatively chamber is shallow the patient should
be taken to operation theatre for re-suturing.
Corneal Oedema Postoperative corneal oedema is
usually transient. It disappears in 2-3 days. If it does
Button holing
Premature entry into AC
Iridodialysis
PC rupture
Transient corneal oedema
Pseudophakic bullous keratopathy
1
2
3
1
15
3
FURTHER READING
1. Drews RC: Management of complications during posterior
chamber implantation. Implants in Ophthalmology 2: 17576,1998.
2. Skuta GL et al: Zonular dialysis during extracapsular cataract
extraction in pseudoexfoliation syndrome. Arch Ophthalmol
105: 632-34, 1987.
3. Ulreche Demeler Management of intraoperative
complications. In Piers Percival (Ed): A Colour Atlas of Lens
Implantation Wolfe Publishing Ltd: 1991.
4. Shah Anil: Complications in Small Incision Cataract Surgery
Bhalani Publishing House, India: 2000.
5. Duch Mestres: Intraoperative complications of ECCE/SICS J
Cat Ref Surg 25: 1275-79, 1999.
Management of Posteriorly Dislocated Lenses
34
Management
of Posteriorly
Dislocated Lenses
he aim of every cataract surgeon is to ensure a

safe removal of the cataractous lens. In addition
there is an overpowering desire by the patient to
be rehabilitated early. This is matched by an equally
sincere effort by the surgeon to provide the same. Sometimes, however, the surgeon encounters a scenario of
having either the crystalline lens or pseudophakos
dislocated posteriorly into the vitreous. This undesirable
situation may occur during conventional cataract surgery
as well as phacoemulsification. Such a mishap not only
compromises restoration of the patients vision but also
the surgeons confidence, particularly so in the case of
novice surgeons. Today however, the surgeon may take
solace in the fact that the situation is not beyond salvage
if the management is appropriately planned. Planning
must be individualised taking several factors into
consideration such as the following questions: What
happens if the dislocated components are left to stay? Is
prognosis affected? When must one intervene? Who
should intervene and how?
Clinical Situations
Broadly, posteriorly dislocated crystalline lens or a

pseudophakos can have a typical or an atypical presentation, an immediate or delayed presentation and an
uncomplicated or complicated presentation (Chart 34.1).
In a typical case the history itself is diagnostic. Atypical
cases are those in which a history is lacking and the
patient presents with features of endophthalmitis (read
case 1), vitreous hemorrhage or other complications such
as aphakic glaucoma (read case 2). Another atypical
presentation is a patient with an anterior chamber IOL
found alongwith a dislocated posterior chamber IOL
(often detected incidentally). This latter situation we designate as a new entity called the Double IOL syndrome
(read case 3). Only a thorough clinical evaluation and
173
Lalit Verma
P Venkatesh
HK Tiwari
also a degree of suspicion can identify the atypical cases.

The following three case descriptions as encountered by
us highlight these atypical presentations.
Typical
Atypical
Immediate
Uncomplicated
Complicated
Delayed
Chart 34.1: Presentation in sunk phakos and pseudophakos
Case 1: Endophthalmitis
An elderly male with a subluxated lens was meant to

undergo an intracapsular cataract surgery. His discharge
summary read OD/OS ICCE done. This patient presented to the emergency on the third postoperative day
with features of endophthalmitis. Indirect ophthalmoscopy was not performed. Ultrasonography reported the
presence of focal low to medium reflectivity lesion, as
possible exudates due to the presence of other point like
and pseudomembranous vitreous opacities. Indirect
ophthalmoscopy done at a later date however, revealed
a dislocated lens. Evidently this had been fallaciously
interpreted by USG as possible exudates. The short
coming here was an incomplete discharge summary but
complete clinical evaluation.
Case 2: Aphakic Glaucoma
This was again a male patient. He was being managed

as a case of aphakic glaucoma. Fundus could not be
visualised due to a small pupil with synechiae and media
opacification. A careful history was re-elicited and this
174
pointed towards the possibility of an attempt at

implantation having been made. In this case ultrasonography was conclusive in that a dislocated IOL was
identified in the inferior vitreous. This case emphasises
the need to approach some atypical cases with a degree
of suspicion.
that these patients may need is a close follow-up and

visual rehabilitation by contact lenses, spectacles or
secondary AC-IOL. (creating a double IOL syndrome
in a relatively safe eye) depending on the compatibility
of the ocular structures (e.g. angle) and fellow eye status.
Case 3: The Double IOL Syndrome
We had a patient with subtotal retinal detachment, a welldefined primary break in the superotemporal quadrant
and without PVR. In association with this was a not so
easily discernible PC IOL dislocated into the anterior midvitreous inferiorly. As the retinal detachment did not
appear to be directly related to the dislocated IOL a conventional RD surgery with subretinal fluid drainage was
undertaken. The retina settled with an uneventful postoperative course. He had a best corrected visual acuity
of 6/36. At a second stage, AC IOL implantation was
undertaken as the dislocated IOL was fixed. Thereby
a double IOL syndrome was created considering this
eye to be relatively safe. Until the last follow-up he has
had no complications and has retained 6/24 vision.
It is clearly self evident that with the possibility of the
above enumerated complications a conservative
approach to managing these cases is ill-suited in most.
Preoperatively however, intraocular inflammation and
raised intraocular pressure should be controlled by
medical treatment.
Non-surgical management may be considered in a
quiet eye with small retained lens fragments or wherein
the entire lens with its capsule intact (as in couching) has
dislocated. Time is a great healer in some patients who
have less than one quarter of the lens material dislocated.
This may be well tolerated and eventually may get
resorbed after a variable length of time. Gilliland et al
however, reported that even small fragments may be
associated with significant macular oedema, persistent
uveitis and glaucoma on long-term follow-up. A careful
follow-up of such cases wherein conservative management has been planned is therefore important.
In all cases of dislocated lens or its fragments and in
dislocated artiphakic lenses, the essential cause is a breach
in the integrity of the capsular bag during several surgical
steps ranging from capsulotomy, nucleus delivery or
phacoemulsification to irrigation-aspiration of lens
remnants. In a situation wherein the cataract surgeon
sees a dislocating nucleus what should he do? when
should he make an effort at removing it himself/herself
and when should he take the expertise of a vitreoretinal
surgeon?
The cataract surgeon may make an attempt at removal
when the dislocated lens material is seen to be lying on
We had a patient referred to our retina services with a

diagnosis of pseudophakos (AC-IOL) with retinal
detachment. During a repeat indirect ophthalmoscopy
in the clinic a posteriorly dislocated PC IOL was detected.
Conventional retinal detachment (RD) surgery was
planned in this patient with the double IOL syndrome
for two reasons -firstly the posteriorly dislocated IOL was
relatively fixed and secondly, removal of the PC IOL
following a vitreoretinal surgery would entail more significant anterior segment trauma because of the AC IOL.
An immediate or delayed presentation in such cases
has a bearing not only on the visual prognosis but also
on the surgical plan. In those presenting early, the surgeon
will have to specially consider the corneoscleral incision
parameters. A large or small section, the wound architecture and wound integrity will have a bearing on the
surgical approach.
Any nucleus or artiphakia dislocated posteriorly and
associated with the following, either singly or in combination falls into the complicated category (Chart 34.2).
The complications could be vitreous haemorrhage, retinal
detachment, severe inflammatory reaction, glaucoma or
the double IOL syndrome. In cases with retinal detachment distinction has to be made as to its relation with
the dislocated lens. The answer to the question is the
IOL directly responsible for the RD? will determine the
surgical approach in some cases. (case 4) Patients with a
dislocated IOL of longstanding duration and one that is
fixed by fibrosis and without the above mentioned
complications fall into an entirely separate category. All
Severe
inflammatory
reaction
Vitreous
haemorrhage
Secondary
glaucoma
Double-IOL
syndrome
Retinal detachment
IOL related
IOL independent
Chart 34.2: The complicated dislocation
Case 4: Is IOL Directly Responsible for the RD?
the anterior hyaloid membrane. In such cases use of lens

loop, wire vectis and cryoprobe have been reported to
be effective. Injection of visco-elastic posterior to nucleus
can be tried with the aim of floating the nucleus anteriorly
and removing it subsequently from the limbal section.
Once the nucleus or lens remnants migrate posteriorly
these methods rarely succeed and infact may worsen the
situation. Panic attempts involving excessive surgical
manipulation and invasion of the vitreous with scoops,
cryoprobes or excessive irrigation only complicates things
further. Associated with these manoeuvres may be
subsequent retinal break formation and retinal detachment. The essence in preventing further complications
is to the treat the vitreous with care. Mishandling this
vital component leads to untold problems. It should never
be pulled out, no matter how gently. The safest way of
handling the vitreous is to cut, aspirate; cut and aspirate.
Sponge and scissors vitrectomy is an unsafe method of
approaching vitreous complication.
In the above scenario the cataract surgeon can perform
a good anterior vitrectomy using not weck cell sponge
and Vannas scissors but a functioning vitreous probe.
The wound should be closed properly without any
attempt at an intraocular implantation. Having done so
the patient should be referred to a vitreoretinal surgeon.
The other option is to let a vitreoretinal surgeon take
over at the same sitting. The latter approach is possible
only if a vitreoretinal surgeon is immediately available.
All cataract surgeons would do well to have atleast a
standby functioning vitrectomy set at hand (Chart 34.3).
Dislocating nucleus/fragment
On anterior hyaloid
|
May attempt removal
In posterior vitreous
Take over by
VR surgeon
Good probe anterior

vitrectomy and wound
closure; No IOL
|
Referral to VR surgeon
for its strengthening and preplanning any surgical incision

that may need to be made while removing a large nucleus
or IOL. Corneal endothelial cell count and gonioscopy
would indicate if an AC IOL is going to be compatible if
ever desired by the surgeon. Pupillary dilation should
also be evaluated. Elevated intraocular pressure and
inflammation should be controlled by medical treatment.
The status of retina, the mobility or fixity of the dislocated
component should be properly assessed. In the presence
of an opaque media ultrasonography may help to
localise, confirm or detect a retinal detachment. Bright
flash ERG and VER may help in predicting status of retina
and optic nerve conduction.
Having taken a decision to operate, the visual prognosis should be explained to the patient and an informed
written consent obtained.
Surgical steps should be preplanned and modified as
needed preoperatively. Factors to be considered during
this planning process are the need for a preplaced corneoscleral groove, actual incision site taking astigmatism
also into consideration. The nucleus density should be
assessed if possible. The need for an encirclage and/or
buckle placement as also that of a long-term vitreous
substitute like silicone oil or gas should be assessed. A
combined approach vitreous surgery may be safer in
certain situations. The necessity of having to use
perfluorocarbon liquids should also be pre-evaluated.
The subsequent approaches available to a vitreoretinal
surgeon are many. The final approach would depend
largely on the hardness of the dislocated nucleus and
the individual surgeons preference and experience.
(Chart 34.4) Simple pars plana vitrectomy with cutting
and aspiration alone may suffice when the dislocated
component is only cortical matter, a soft nucleus or a
small nuclear piece. In the presence of a large nucleus
resistant to cutting and aspiration the technique of
impalement of nucleus using an MVR blade can be tried
Intravitreal
Phacoemulsification
Intravitreal
Phacofragmentation
Chart 34.3: Dislocating nucleus/fragment
Cases that have been referred for later surgery need

to be carefully evaluated preoperatively. This would
include determining the potential visual acuity of the
involved eye and the fellow eye status. On this would
depend the plan of visual rehabilitation. Wound
architecture as well as integrity will determine the need
175
Combination of
different techniques
Modified 25-27 G needle

PPV in
dislocated
nucleus
(options)
Mechanical crushing/
cutting and aspiration
Endocryo probe
(with insulated sleeve)
MVR blade
delivery
Chart 34.4: Perfluorocarbon liquids
176
PPV
Resistant nucleus identified
Impale with MVR blade
Endoilluminator acts as support
Tilt MVR knife with the
impaled nucleus
into the anterior chamber
Can constrict pupil
(with Pilocarpine chelate)
Complete preplaced corneal
groove (6-8 mm)
(by surgeon/assistant)
Express nucleus
Chart 34.5: Dislocated nucleus-surgical algorithm
successfully in significant percentage of cases (Chart

34.5). The disadvantages of this technique are probability
of greater tissue trauma and the possibility of the impaled
nucleus falling back into the vitreous. The use of
perfluorocarbon liquids prevents this risk and reduces
tissue trauma. Cost of PFCLs is an overbearing factor.
For removal of lost lens fragments Weinstein et al have
reported a new surgical technique using the Machemer
lens. In a recent report Rover claims good results of
phacoemulsification in the mid-vitreous cavity for dislocated lenses in 15 patients. Phacoemulsification was
preceded by pars plana vitrectomy. No perfluorocarbon
liquids were used in the study. The author concludes
that the procedure is safe and easy, has no retinal side
effects and reduces the intraoperative risks of alternate
methods by avoiding a large opening into the anterior
chamber and ocular hypotony. The approach seems
agressive and we advocate that extreme caution is necessary while performing phacoemulsification in the vitreous
even by the most experienced surgeons.
In our experience the two approaches which can be
employed successfully in patients with a dislocated
nucleus are (1) Use of perfluorocarbon liquids (2) MVR
blade impalement and delivery through the limbal route.
About PFCLs, we again re-emphasise that although
expensive, it makes surgery safer and causes less tissue
trauma. It should be made use of wherever possible.
One sentence of caution: PFCL is no magic liquid, it
makes surgery atraumatic and successful provided it is
injected only after a thorough vitrectomy. PFCL should
never be injected without prior vitrectomy. A problem

that may arise while using PFCL is entrapment of some
nuclear remnants in the depths of the convex PFCL
meniscus and the ocular coat anywhere around the
periphery and beyond the surgeons view. In case of
doubt gentle depression will make them evident,
following which they can be removed. If this precaution
is not undertaken the surgeon may be surprised to find a
few remnants following PFCL removal and an
unnecessary prolongation of surgical time ensues.
Layering the PFCL above with visco-elastic has been
reported to facilitate removal of such fragments trapped
in the periphery.
The management of intraocular lenses dislocated into
the vitreous cavity is different surgically from that described above for dislocated nucleus. Peroperative evaluation and surgical planning are however similar. In addition
the surgeon should decide whether to explant the IOL
and leave the eye aphakic to explant the dislocated IOL
and replace a new PC IOL or AC IOL or to reimplant the
same dislocated IOL. The latter can be achieved by
placing the IOL onto the capsulolenticular remnants or
by scleral fixation. Several methods of removing a
dislocated implant have been described but central to all
these is a good pars plana vitrectomy. Unlike in surgery
for removing a dislocated nucleus, PFCL is not as
indispensable during surgery for a dislocated IOL.
Three kinds of approaches to surgery for management
of a dislocated IOL can be used. These are a limbal
approach, a pars plana approach or a combined limbal
and pars plana approach.
The limbal approach is to be preferred when the dislocated implant is in the anterior or mid-vitreous and
easily visible under the microscope without the need for
an endoilluminator. Pars plana approach is generally
preferred when the luxated IOL is in the posterior vitreous
cavity, is lying on the retinal surface or is associated with
complications such as severe vitreous reaction, retinal
detachment, etc.
In both approaches no effort should be made at pulling
on the implant prematurely. A complete vitrectomy is a
must even before trying to grip the IOL. Perilenticular
adhesions have to be carefully cut with Vannas scissors
(limbal approach) or intravitreal scissors or probe and
the IOL dissected completely free. The free IOL can only
then be safely picked up using intravitreal forceps or other
less desirable methods like a modified iris hook, etc. It is
better to grip the optic and push the IOL up rather than
grip the haptic and pull on it. The latter approach risks
IOL lying in
anterior/mid vitreous
177
IOL in posterior vitreous/

lying on retinal surface
No RD
RD present
PPV
Hold IOL with
intravitreal forceps
Can use PFCL
Explant the IOL
via limbus
Limbal approach
(Anterior vitrectomy
and explant the IOL)
No IOL (aphakic)
Internal
scleral
fixation of IOL
without taking
it out
PVR absent
Two stage
Buckling reattachment
surgery
Defer IOL for 2nd
procedure
Single stage
VR surgery
Placement of IOL on capsulo-lenticular remnants
A C IOL
PVR present
VR surgery
with use of PFCL
and removal of IOL
No attempt at
re-implantation
Scleral fixation (same/new IOL)
Chart 34.6: Approach to management of sunk IOL luxated IOL in vitreous cavity.
Depending on: fellow eye status, visual potential, etc.
breakage of the haptic with the IOL subsequently falling

back onto the retina. Here again use of PFCL makes
surgery relatively safer by preventing this possibility.
To have the eye aphakic or implant the same or a new
IOL will depend on factors previously discussed and also
on those shown in Chart 34.6. Internal scleral fixation
techniques described for reimplanting the dislocated IOL
are time consuming and cause more tissue trauma in the
learning phase at least. Chang and colleagues have
devised a new 25-guage forceps that they found useful
for anterior segment application during vitreous surgery.
This forceps has a curved shaft, a tip with a distal platform
for grasping a suture and a proximal groove for gripping
a haptic. These forceps facilitate manipulations such as
fastening a suture loop around a haptic, repositioning an
intraocular lens at the ciliary sulcus or repairing inadvertent
or pre-existing iridodialysis.
Use of PFCL becomes mandatory if proliferative
vitreoretinopathy is present or the surgeon has decided
to manage both the dislocated implant and retinal detachment or to reimplant the same lens.
Visual Prognosis
Several reports are available in literature that compare

visual results with the timing of surgery. Gilliland et al
did not find any statistical difference between the timing
of vitrectomy and incidence of glaucoma. In contrast
Fastenberg et al reported that delayed vitrectomy (9-50
days) was associated with a better visual acuity but an
increased incidence of glaucoma.
Blodi and associates report that vitrectomy performed
within 3 weeks of cataract surgery had a lower incidence
of glaucoma, compared to that undertaken beyond 3
weeks (18 percent to 60 percent). In this study 63 percent
of those subjected to early vitrectomy had a vision of 6/
60 or better. All patients undergoing vitrectomy at later
stage had a vision of only finger counting.
Kim et al in 1994 reported no significant difference in
final visual acuity or incidence of glaucoma following
early (within 7 days) and late vitrectomy groups. However, visual outcome was better and complications minimised when the case was immediately taken over by a
vitreoretinal surgeon. Seventy-five percent of such
178
patients had a visual acuity of 20/40 or better in comparison to 67 percent in all others.
Factors that probably would improve success of the
surgery are three preoperative factors, three peroperative
factors and three postoperative factors. Proper and
complete clinical evaluation, controlling intraocular pressure and inflammation medically and preplanning
surgical steps are the preoperative factors. Peroperative
factors are constituted by patient anaesthesia (general
anaesthesia or adequately prepared local anaesthesia),
modifying and executing the preplanned steps and finally
good instrumentation and co-ordinated assistance. Postoperative regime, patient positioning and augmentation
(e.g. laser), if needed, constitute the postoperative factors.
To conclude it may be said that all lenses (crystalline
or artificial) can sink easily in a complicated cataract
surgery and it is only with an effort that they can be
removed. Falling back of the lens nucleus or IOL is
analogous to sliding down a slope, while retrieving them
is analogous to climbing up the slope. A team effort with
good co-ordination makes the climb not only easier but
also less hazardous.
Post-surgical Endophthalmitis
Post-surgical
Endophthalmitis
INCIDENCE AND AETIOLOGY
Postoperative endophthalmitis is a catastrophic

complication of intraocular surgery. Although its reported
incidence has decreased significantly in the present era
from 1% to about 0.05-0.1%. It still remains a source of
dread for all eye specialists. Despite improvements in
asepsis and sterilization, infectious endophthalmitis
continues to persist as one of the most important sight
threatening condition.
The incidence of post-surgical endophthalmitis is
dependent on the type of surgery, the criteria used for
diagnosis (clinical/ laboratory culture) and the duration
of follow up. In the series reported by Kattan et al (30,002
cases), the incidence of culture positive endophthalmitis
following cataract surgery, secondary IOL implantation,
penetrating keratoplasty, filtering surgery for glaucoma
and pars plana vitrectomy was 0.072%, 0.30%, 0.11%,
0.061% and 0.051% respectively. The risk seems higher
following penetrating keratoplasty because of the donor
cornea being potentially contaminated and in secondary
implant surgery due to a lack of compartmentalization.
Other less common situations wherein endophthalmitis
may occur are, following removal of sutures and after
laser capsulotomy.
Postoperative endophthalmitis can present within a
few days to weeks (early endophthalmitis) or after several
months to years (delayed endophthalmitis). Depending
on the severity and clinical course the infection can be
acute or chronic. In delayed onset endophthalmitis it is
important to distinguish between cases that occur
following a delayed entry of the organism (e.g. bleb
related/wound dehiscence) from those due to a delayed
manifestation. In the former situation the etiologic agent
is usually highly virulent and manifests acute clinical
symptoms and signs while in the latter situation, the
infecting agent has a low virulence and tends to follow
an indolent course.
35
179
Lalit Verma
Pradeep Venkatesh
HK Tiwari
Although all groups of bacteria can produce endophthalmitis, the predominant form is gram-positive
organisms. Gram-positive organisms are responsible for
90 to 95 per cent of all post-surgical endophthalmitis. In
the Endophthalmitis Vitrectomy Study (EVS), gramnegative isolates on culture were obtained in only 6% of
endophthalmitis cases following cataract surgery. Despite
this low prevalence of gram-negative infection they are
important to recognize early, as these organisms are
highly virulent, produce endotoxins and rapidly begin
to colonize the vitreous cavity. They need a more vigorous
management approach and early vitrectomy may also
become necessary. Fungal endophthalmitis following
intraocular surgery is seen in about 3% of patients. EVS
did not include any case suspected of being fungal in
origin into its study.
Gram-positive organisms that have been isolated in
cases of post-surgical endophthalmitis have been
Staphylococcus epidermides, Staphylococcus aureus,
Streptococcus pneumoniae, Streptococcus viridans,
Streptococcus pyogenes, Peptostreptococci and
Corynebacterium. Of these, Staphylococcus epidermides
is the predominant isolate in 20 to 50 per cent cases.
Propionibacterium acnes and Actinomyeces are grampositive organisms capable of producing a slow grade
endophthalmitis. Staphylococcus epidermides also has
this ability. Clostridium, a positive anaerobe, is an
extremely rare cause unlike in post-traumatic cases.
Gram-negative organisms known to cause bacterial
endophthalmitis are Pseudomonas aeruginosa (most
common isolate), Proteus mirabilis, Klebsiella pneumoniae, Haemophilus influenzae, Escherichia coli and
enterococci. Post-surgical fungal endophthalmitis has
been reported with the following organisms, Aspergillus,
Candida, Cephalosporium, Penicillium and Paecilomyces.
Interestingly, several studies have shown that most
cases of endophthalmitis are caused by organisms that
180
normally inhabit the conjunctival sac either as

saprophytes or opportunistic pathogens. Staphylococcus
epidermides has been isolated from the conjunctival sac
in 69% and Staphylococcus aureus in about 33% of
normal eyes. H. influenzae and rarely fungi may also be
present as normal microflora. Accumulating evidence has
shown that in the majority of post-surgical endophthalmitis, the causative organism is derived from the patients
own periocular microbial flora. More recent studies have
infact shown using plasmid typing, restriction endonuclease analysis, southern blot hybridization and pulsed
field electrophoresis, that isolates obtained from the
conjunctival sac and from intraocular aspirates are
genetically indistinguishable. This reflects on how
important it is to ensure topical asepsis and sterility during
all intraocular procedures. This also shows the need to
defer intraocular surgery until conditions such as
dacryocystitis, lid infection and blepharitis have been
adequately treated.
POST-SURGICAL BACTERIAL ENDOPHTHALMITIS
Clinical Features
In the majority of cases with post-surgical bacterial

endophthalmitis the clinical presentation is very classical
and causes little problems in diagnosis. However, a not
so infrequent occurrence is the presence of subtle signs
in the early stages that keeps the surgeon wondering
whether it is an infectious endophthalmitis or a sterile
inflammation. This is most likely to be seen in the early
follow up period after surgery. In such situations
observation over the next 6-24 hours is very critical to
make a definitive diagnosis. During this period of
observation, the patient is started on adequate doses of
topical and systemic anti-inflammatory agents (mainly
corticosteroids). Endophthalmitis of an infectious origin
usually progresses significantly while a sterile
inflammation either remains stable or shows a minimal
worsening. When uncertainty still prevails it is better to
err on the side of an infectious endophthalmitis and start
appropriate treatment.
Three forms of endophthalmitis are recognized based
on the clinical profile. The fulminant variety occurs within
about 4 days and is usually caused by gram-negative
bacteria, streptococci or Staphylococcus aureus. The
acute form develops between 5-7 days and is most likely
to be caused by S. epidermides or coagulase negative
cocci (rarely by fungi). Chronic type of endophthalmitis
usually develops one to several months after the surgery
and organisms involved are fungi, Propionibacterium
acnes or S. epidermides.
The cardinal symptoms of post-surgical bacterial

endophthalmitis revolve around the attributes of vision
and pain. In the early postoperative period, pain more
than anticipated is a common symptom but is not present
universally in all cases. The grade of pain may vary from
absent to mild to severe. In the EVS report, 26 per cent
of patients had no pain at all. Hence, the absence of
pain should not be taken as a factor against the likelihood
of infectious endophthalmitis. When a decrease in pain
is the usual course in the days following surgery, its
worsening is however, an ominous symptom. A nonimprovement in vision to the anticipated degree, when
accompanied by an unexpected inflammatory reaction,
is a more frequently observed presentation in early postoperative endophthalmitis. Blurring was the presenting
symptom in 94% of patients studied in the EVS and so
may be considered as the most common symptom. There
may be an associated mucopurulent discharge.
Acute bacterial endophthalmitis occurring later on has
a very classical presentation. Most patients complain of
a sudden onset and a rapid worsening of pain accompanied by a significant decrease in vision. Other symptoms that may be present are discharge, excessive tearing,
increased sensitivity to normal light (photophobia),
increase in redness of the eye and blepharospasm.
On examination the visual acuity is less than anticipated and may even be hand motions or only light
perception in fulminant cases and when the presentation
to an ophthalmologist is delayed. In the EVS study, hand
movements were tested at a distance of 60 cm and light
projection from 90 cm. A normal range of ocular motility
makes the likelihood of panophthalmitis unlikely. The
conjunctiva shows a variable degree of hyperemia and
chaemosis and there is marked circumcorneal congestion.
Corneal involvement is variable, ranging from a relatively
clear cornea to one that is grossly oedematous and hazy.
A limbal ring abscess, suture abscess, wound dehiscence
are other signs that may be present. The anterior chamber
shows a significant degree of flare and cells, the reaction
sometimes being frankly fibrinous. The presence of a
hypopyon is considered by most as a cardinal sign of
infectious endophthalmitis. The hypopyon is dependent
and in early cases may be confined to the angle alone
when it may be missed. The iris pattern is lost, appears
muddy and boggy and is resistant to dilation. There is a
tendency to form posterior synechiae early. Pupillary
response to light is absent or sluggish. In less fulminant
cases one may be able to appreciate a retrolenticular
flare and cells. In more severe cases, a dense discrete or
confluent, yellowish vitreous exudation is evident. The
intraocular pressure is usually on the lower side of normal

but may be elevated in the early stages of endophthalmitis. Most cases have some degree of digital tenderness.
Clarity of the media in endophthalmitis is graded (as
adopted by EVS) depending on the visibility of the retinal
details on indirect ophthalmoscopy and is as under:
Grade 1
More than 20/40 (6/12) view of the retina.
Grade 2
Second order retinal vessels visible.
Grade 3
Some vessels visible but not second order.
Grade 4
No retinal vessels visible.
Grade 5
No red reflex.
In any patient with suspected endophthalmitis and
where retinal details are not visible it is mandatory to
undertake ultrasonography whenever it is available,
before instituting any form of invasive, diagnostic or
therapeutic interventions. This is to rule out the possibility
of conditions that may mimic endophthalmitis such as
dislocated nucleus and also to detect the presence of a
choroidal detachment, retinal detachment and the degree
of vitreous exudation and posterior vitreous detachment.
Ultrasonography thus is a useful aid in establishing the
diagnosis, prognostication, planning surgery and
sometimes in follow up. Other investigations like visual
evoked potential and electroretinography have no role
in either the management or the prognostication in
endophthalmitis and so are not indicated.
Confirmation of Diagnosis
Although it is prudent to follow the dictum that all

unexpected inflammatory response be considered endophthalmitis unless proven otherwise, it is nevertheless
important to confirm the diagnosis by culturing the
organism from intraocular samples obtained in the
laboratory. This raises several issues such as which ocular
sample to culture, on what media to culture and when to
interpret the growth as positive or otherwise.
In the recent past there was an emphasis that in
patients with endophthalmitis discharge from the
conjunctival sac and lid margin should be sent for culture.
This is no longer recommended because of several
reasons such as poor yield, culture of an unrelated
organism and wasteful expenditure. If however, a suture
abscess or infected suture tract is present, the removed
suture must be cultured.
The most important samples to culture are aspirates
from the aqueous and vitreous cavity. Although the
possibility of isolating an organism is 56-70 per cent from
181
vitreous samples and only 36-40 per cent from aqueous

samples, there have been reports when the latter was
positive and the former negative. For this reason it is
necessary to culture specimen obtained from both
aqueous and vitreous. If an aspirate has been obtained
into a syringe and the laboratory can be reached
immediately, then the specimens are best sent to the
laboratory with the original syringe with a cap on the
needle to prevent contamination.
Aqueous tap is obtained by a paracentesis using a
25-27 gauge, half inch needle mounted on a tuberculin
syringe with its plunger on. About 0.1 ml of fluid is
aspirated in a controlled manner by gently withdrawing
the plunger. The needle may be directly inoculated into
the culture media. A part of the aspirate is ideally plated
directly on to the culture media while any remaining
aspirate is used to prepare slides for Gram stain and
Giemsa stain.
A sample of the vitreous is the most important source
to know the organism producing the endophthalmitis. It
is sometimes recommended that the vitreous sample may
be obtained using a 23 gauge needle introduced through
the pars plana just before injecting the intravitreal
antibiotics. This is said to provide an undiluted specimen
and also create space for the antibiotic drugs to be
subsequently injected. Although aspiration of vitreous
may appear simpler it is fraught with a risk of producing
vitreous traction particularly when the vitreous is formed.
Aspiration may also not provide adequate sample for
analysis as in endophthalmitis the vitreous is denser and
usually contains inflammatory membranes. Infact it is
possible that most retinal detachments following
intravitreal injection are a result of vitreous aspiration
rather than the injection. For aspiration of vitreous a 22
gauge needle should be used. In an aphakic patient
without an intact posterior capsule and in the absence of
a limbal infiltrate or abscess, one may aspirate vitreous
through the anterior chamber itself. If the vitreous is fluid,
0.2-0.3 ml of fluid is gently aspirated.
The safest method to obtain vitreous sample is by
vitreous biopsy. Vitreous biopsy not only enables an adequate volume of sample to be obtained but also prevents
vitreous traction by cutting the strands rather than pulling
on it. Vitreous biopsy can be obtained by one of two
methods: with an infusion line and without an infusion
line. The former has the disadvantages of diluting the
specimen obtained and the need for an additional
sclerotomy to be made. For obtaining an undiluted
specimen by vitreous biopsy, the suction line on the
vitreous cutter (which is usually connected to an
182
automated suction during routine vitrectomy) is replaced

by a shorter tubing (about 2.5 cm in length) carrying at
its one end a tuberculin syringe to enable manual suction.
The vitreous cutter is placed in the anterior vitreous and
cutting is actuated. Simultaneously, an assistant begins
to withdraw the piston on the tuberculin syringe so as to
induce suction. The procedure is stopped after 0.2 to
0.3 ml of sample has been obtained. The lost volume
may be replaced by injecting saline (if no further
vitrectomy has been planned) or by opening the preplaced infusion line when a vitrectomy has already been
planned.
Whenever pars plana vitrectomy has been undertaken
in a patient with endophthalmitis, the irrigating fluid
admixed with the vitreous present in the cassette may
also be sent in a sterile manner to the laboratory. The
fluid can also be suctioned with aseptic precautions across
a 0.45 millipore filter and the filter sent. In the laboratory
the filter should be divided into fragments each of which
is then transferred onto separate culture media. If the
culture medium is solid, then care must be used to ensure
that the filtered organisms are on the top surface and
not trapped between the filter and the agar. An alternative
method is to concentrate the vitreous by centrifugation.
The ideal recommended handling of samples obtained
has been:
Placing one drop of fluid on a blood agar plate,
streaking carefully with a needle and incubating at
37C.
Placing one drop of fluid on chocolate agar plate,
streaking carefully and incubating at 37C in a 4 to
10 per cent CO2 enriched environment.
Inoculating one drop into Sabourauds medium
without any inhibitors and maintaining this at room
temperature.
Inoculate one drop onto thioglycolate broth and mix
with the deeper, thicker portion of the broth with sterile
cotton tipped applicator. This media is incubated at
37C and it supports growth of anaerobes and
microaerophilic organisms such as P. acnes.
Place one drop on each of two clean glass slides for
Gram and Giemsa stain. The smear made should
neither be too thin nor too thick. The former tends to
disperse the microbes and cells making microscopic
study difficult and the latter takes up heavy staining
making it impossible to detect organisms. Ideally the
drop should be gently spread on a scrupulously clean
glass slide using a clean bacteriological loop. The
smear is then allowed to air dry. Heat fixation is to be
avoided and absolute methanol used instead for
fixation. Centrifugal cytology has been reported as

being superior but is not always necessary to
undertake.
Additional fluid available may be inoculated into
brain-heart infusion or cooked meat broth.
A summary about the laboratory confirmation of
diagnosis in endophthalmitis including the criteria for
laboratory confirmed growth is given in Appendix 1.
Since most cases of postoperative endophthal mitis
occur in the early days following surgery, one has to pay
adequate attention to the integrity of the wound before
undertaking procedures like aqueous or vitreous aspiration and intravitreal injection. Most cases need a facial
block and either topical anaesthesia or retrobulbar
anaesthesia. General anaesthesia is recommended for
children, un-cooperative patients and those with profuse
congestion of the orbital tissue.
Treatment of Postoperative Bacterial Endophthalmitis
Having made a diagnosis of endophthalmitis, the patient

is told about the diagnosis and the therapeutic interventions that may be necessary. He is also informed about
the guarded visual prognosis and consent is obtained.
Endophthalmitis can be managed as a daycare, outpatient emergency provided patient understands the need
for frequent evaluation. Out-station patients and oneeyed patients may need to be admitted.
The three most important determinants in the outcome
following endophthalmitis are:
Time duration between presentation of symptoms,
diagnosis of endophthalmitis and the initiation of
appropriate treatment. In our country, late presentation of patients to their specialists is a frequent
occurrence particularly in rural circumstances and this
decreases any chances of visual recovery. In experimental animals it has been shown that intravitreal
antibiotics are not able to salvage an eye when given
24 hours or later after introducing an innoculum of
an infective organism into the vitreous cavity. It has
also been reported that when intravitreal antibiotics
are injected more than 48 hours after the infection is
established the efficacy of the drug in eradicating the
infection is poor.
Virulence and load of the causative organism. Higher
the organismal load entering the eye and greater the
virulence of the organism, greater is the risk of developing endophthalmitis. However, the actual number
of organisms necessary to incite endophthalmitis in
humans is yet to be determined. The most virulent
organisms responsible for post-surgical endophthalmitis are the gram-negative bacilli (Pseudomonas,
Klebsiella, Escherichia, Proteus) and gram-positive

organisms like Staphylococcus aureus and
streptococci.
Pharmacokinetics and spectrum of activity of the intravitreal drugs: The goal in endophthalmitis management is to rapidly obtain adequate concentrations of
the anti-microbial agent and maintain this for a
sufficient period of time in the vitreous cavity without
causing any toxic effect. This depends on several
factors concerning both the drug (original dose, route
of egress from the eye, pH, ionization, molecular size,
protein binding) and the ocular tissue (surgical status
of the eye: presence or absence of the lens and
vitreous, degree of breakdown of the blood retinal
barrier).
At presentation, it would be useful to grade the
severity of endophthalmitis as severe or not severe. Endophthalmitis is considered to be severe in the presence of
the following: vision of inaccurate light projection, afferent
pupillary defect, no fundus glow, limbal ring infiltrate
(abscess) and cases that have not responded to
appropriate intravitreal therapy. Some consider a vision
of 20/400 and above as mild cases. However they also
caution that vision may not be that useful a parameter
to classify the severity of endophthalmitis as some patients
may have poorer vision compared to the other milder
clinical signs.
The primary objective in endophthalmitis treatment
is to rapidly eradicate the colonization of the infecting
organism within the vitreous cavity and also to prevent
toxin and inflammation mediated damage to vital
structures like the optic nerve (nerve fiber layer) and
retina. The secondary objectives are to provide symptomatic relief, prevent synechia formation in miosis, remove
any opaque membranes in the media (pupillary/vitreous).
The ultimate objective is to maximize visual recovery.
When the visual potential seems unlikely, one should
atleast aim to sustain the structural integrity of the globe
so as to prevent cosmetic disfigurement. The follow up
of patients with endophthalmitis should be atleast every
12 hours initially and not any longer.
The mainstay of treatment in post-surgical endophthalmitis is administration of broad-spectrum intravitreal antibiotics. Vitrectomy is indicated in a highly
selective category of patients and is discussed in detail
later on. For a better understanding, the management
options in post-surgical endophthalmitis include:
Antimicrobial therapy (Intravitreal therapy, topical and
systemic therapy); Anti-inflammatory therapy (Intravitreal, topical and systemic corticosteroids and NSAIDs);
183
Supportive therapy (cycloplegics, anti-glaucoma medication, etc.) and Surgical therapy (Vitrectomy).
ANTIMICROBIAL THERAPY
Earlier on, the most useful route for administering antibiotics to treat intraocular infections used to be very
controversial. It is however, now unequivocally established that most antibiotics given systemically do not
reach the minimum inhibitory concentrations necessary
within the vitreous cavity. This is true despite the presence
of a compromised blood ocular barrier in patients with
endophthalmitis. Some present day antibiotics (Ciprofloxacin, Sparfloxacillin, and Pefloxacillin) have been
shown to achieve significant concentrations in the
vitreous cavity following systemic administration.
However, the destruction progresses so rapidly in bacterial endophthalmitis that the concentrations may still
be inadequate to rapidly curtail further growth of the
organisms. The only route that is capable of achieving
this objective is the direct administration of antibiotics
into the vitreous cavity. Intravitreal route of administration
however, has its own limitations and risks.
Intravitreal Antibiotics in Post-surgical Endophthalmitis
It would be most ideal to identify the causative agent,

determine its antibiotic sensitivity and then administer
specific antibiotics. This is not practical in treating
endophthalmitis because the above process takes time
and any time delay in these patients worsens the prognosis rapidly. Hence, the most important criterion while
deciding on the choice of antibiotic for intravitreal
administration is its spectrum of activity against the most
common organisms known to produce endophthalmitis
and also its known toxicity. The recommendation that
one should administer a broad spectrum antibiotic does
not mean that obtaining intraocular specimens,
laboratory culture and determination of antibiotic
sensitivity are no longer necessary. Contrarily, these
measures become most important whenever there is a
lack of response to the broad-spectrum antibiotic administered empirically at the start of treatment. Today, the
preferred intravitreal antimicrobial therapy in postsurgical endophthalmitis is with a combination of two
drugs, one having a broad spectrum of activity against
gram-positive organisms and the other against gramnegative organisms (preferred combinations are mentioned subsequently). It is important however, that the
two drugs to not have any antagonistic tendency. Two
drug regimen is the preferred modality of treatment
184
because there is as yet no single drug that is highly effective against both gram-positive and gram-negative organisms and also has an adequate half life in the vitreous
cavity.
Before giving an intravitreal injection any infected
sutures or suture abscess should be removed. It is again
emphasized that it is necessary to pay adequate attention
to the wound integrity and the status of the lens (aphakic/
pseudophakic or phakic). The latter decides the site of
pars plana entry and in a aphakic patient with a broken
vitreous face, a translimbal route may be adopted. If
obvious vitreous herniation or incarceration into the
wound is present, then a limited anterior vitrectomy and
wound revision may also be planned along with the
intravitreal injection. Attention should also be paid to
ensure that the intraocular pressure before the injection
is not high and there is no pre-existing retinal or choroidal
detachment (ultrasonography).
Intravitreal injection should be undertaken with all
aseptic precautions by an experienced person or under
guidance. The operating room Incharge and sisters
should be informed and requested to arrange a trolley
with the necessary instruments. It is always useful to have
an assistant during the injection. The drugs to be given
intravitreally should be prepared afresh by the eye
surgeon himself, again with aseptic precautions. This is
necessary to ensure proper dosage of the drug. While
inadequate concentrations can lead to treatment failure,
an excess dose can cause toxic effects on the retina. An
informed consent is a must before giving an intravitreal
injection.
The choice of anaesthesia should be decided
beforehand taking into consideration factors mentioned
earlier. In our view a facial block decreases the risk of
vitreous upthrust by contraction of the orbicularis oculi
during the actual injection of intravitreal drugs and should
be used as a routine in all cases with an early postoperative endophthalmitis following conventional cataract
surgery. Topical anaesthesia suffices in a large majority
of cases with a healthy wound and retrobulbar injection
is required less frequently. Peribulbar anaesthesia should
be avoided, as it tends to increase orbital volume and
pressure over the globe. No digital massage or other forms
of mechanical pressure over the globe should be used. If
needed, intraocular pressure may be lowered before the
injection by giving the patient acetazolamide tablets. This
is only rarely necessary as aspiration of intraocular fluids
before intravitreal injection for culture and sensitivity
serves to decrease the intraocular pressure.
The periocular region is painted with povidone-iodine

and the cul-de-sac also washed with a solution of the
same. Visualization of the operative site should be
adequate. The injection is given transconjunctivally and
no peritomy is necessary (if vitreous biopsy is not planned). It is important to choose the quadrant of injection
(usually one that increases the ease of injection) and then
measure and mark the distance from the limbus (3.0 mm
if aphakic, 3.5 mm if pseudophakic and 4.0 mm if phakic)
at which the injection is to be given. Aqueous and vitreous
samples are then obtained as described earlier. Before
actual injection of the drugs, the globe should be stabilized
in an atraumatic manner. Use of fixation forceps is fraught
with the danger of tearing of the inflammed conjunctiva
and haemorrhage in a large number of patients. In
cooperative patients, it is often possible to obtain
adequate stability of the globe by placing a cotton-tipped
applicator in the opposite quadrant. The surgeon then
gradually inserts the 26-30 gauge needle on the tuberculin
syringe containing the prepared drug, at the previously
marked site. The bevel of the needle should be facing
upwards towards the surgeon and the direction of
penetration should be towards the direction of the
anterior or mid-vitreous. The drug should then be injected
slowly in a drop by drop manner (achieved by rotating
the plunger) and avoiding jet formation. It is prudent to
avoid making multiple entries into the eye and so the
second injection should be given through the initial
needle. The syringe can be carefully replaced with the
one containing the second drug by asking the assistant
to stabilize the needle by gripping its hub using a forceps.
The intraocular pressure is checked at the end of the
procedure. Subconjunctival injection of antibiotics is
given and the eye patched. There is no need for a
prolonged bandaging. Administration of topical drugs
may be begun as early as one hour after the procedure.
It has been suggested by some that reclining the patient
with the head up immediately after the procedure may
decrease the risk of the drug settling on the macula and
preventing its toxic damage.
In the past, several drugs were used for intravitreal
injection and several of these are rarely recommended
today. The presently recommended combination therapy
of choice in post-surgical bacterial endophthalmitis is:
First choice
Injection Vancomycin
Injection Ceftazidime
: 1000 g in 0.1 ml plus

: 2.25 mg in 0.1 ml
Second choice*
Injection Vancomycin
Injection Amikacin
: 1000 g in 0.1 ml plus

: 400 g in 0.1 ml
Third choice
Injection Vancomycin : 1000 g in 0.1 ml plus
Injection Gentamicin : 200 g in 0.1 ml
* This was the preferred antibiotic combination in EVS
study.
Preparation of the most frequently and less commonly
used intraocular drugs in the management of postsurgical endophthalmitis is shown in Appendix 2A and
Appendix 2B respectively.
Vancomycin is a macrolide antibiotic that is highly
effective against most gram-positive organisms including
methicillin and cephalosporin resistant strains as well as
coagulase negative staphylococci. It has been found to
be safe when given even in a dose of 2 mg in 0.1 ml and
also has a synergistic effect when used in combination
with amikacin. In vitro, vancomycin when combined with
ceftazidime in the same syringe is known to produce a
precipitate and so they should be injected from separate
syringes.
Ceftazidime is a third generation cephalosporin that
has been found to have a bactericidal effect against a
wide range of gram-negative organisms including pseudomonas. Unlike with aminoglycosides no drug resistance has so far been reported, no retinal toxicity has
been found in the recommended intravitreal dose and it
has been found more effective in acidic and hypoxic
conditions. It has no activity against gram-positive
organisms.
Amikacin is the preferred aminoglycoside because it
is effective against gram-negative organisms resistant to
other aminoglycosides and its retinal toxicity is four times
less than that with gentamicin. Since ceftazimide has a
similar bactericidal effect and no retinal toxicity exists,
many now prefer this drug to amikacin in the first line
management of postoperative bacterial endophthalmitis.
Gentamicin is only rarely recommended because of the
increased likelihood of macular infarction and also
because of a high degree of drug resistance.
Quinolones such as ciprofloxacin have also been
evaluated as a single drug treatment regimen in postoperative endophthalmitis. However, they suffer from the
disadvantage that their half-life in the vitreous cavity is
less and so a repeat injection becomes necessary within
12-24 hours in order to obtain a therapeutic response.
Penicillins, erythromycin and even the first and second
generation cephalosporins are no longer recommended
as the first line drugs in the management of endophthalmitis because of the existence of a significant degree of
drug resistance and their limited range of anti-bacterial
activity.
Intravitreal treatment carries with it a risk of the following complications: elevated intraocular pressure,
185
intraocular hemorrhage (including hyphema), drug

induced retinal toxicity and retinal detachment. In phakic
eyes an added risk is that of cataract due to contact by
the needle.
Intravenous Antibiotics in
Post-surgical Bacterial Endophthalmitis
Even though it is possible that the vitreous levels of

antimicrobial drugs given systemically may increase in
endophthalmitis because of the associated inflammation
and resultant breakdown of the blood-retinal barrier, the
role of Intravenous antibiotics alone in the management
of endophthalmitis, is at best, supportive and not primary.
This is supported by several observations:
Animal studies have found poor intraocular penetration of most parenterally administered antibiotics.
Exceptions are some newer antibiotics like imipenem,
cephazolin, ciprofloxacin and sparfloxacin and
pefloxacin. Aminoglycosides in particular have very
poor intraocular penetration following parenteral
administration.
73 per cent of 103 patients with endophthalmitis did
not regain any useful vision after conventional
treatment (systemic antibiotics alone)
Study by Pavan et al showed good results with the
use of only intravitreal drugs without parenteral
antibiotics
Conclusion from EVS study that whether or not
systemic antibiotics are used there is no difference in
final visual acuity
Added to the above observations, systemic administration of antibiotics also has the disadvantages of cost
effectiveness and potential for systemic adverse drug
reactions. Another concern with the irrational use of
newer antibiotics parenterally is the risk of encouraging
drug resistance. Despite these facts however, a large
majority of eye specialists involved in treating endophthalmitis still prefer to use parenteral antibiotics in
addition to intravitreal injection, as it is possible that it
may help in augmenting and sustaining an adequate
concentration of the antibiotics in the vitreous cavity for
a more prolonged period. The recommended dose of
antibiotics for systemic administration in endophthalmitis
is given in Appendix 3A.
Topical and Subconjunctival Antibiotics in
Post-surgical Bacterial Endophthalmitis
For topical medication in endophthalmitis, a combination

of two drugs is preferred, one having a predominant effect
on the gram-positive organisms and the other against
186
gram-negative organisms. The frequency of administration is every hour (with each drug used alternately) in
the initial phases of treatment. This is modified depending
on the response to overall measures. In the presence of
a corneal ulcer or wound abscess, fortified eyedrops are
recommended. The antibiotic drugs used in the EVS
study were vancomycin (50 mg/ml) and amikacin (20
mg/ml). The method of preparing fortified eyedrops is
given in Appendix 3B.
In a patient complaint to the regimen of topical medication prescribed, subconjunctival antibiotic injection
may have only a limited role. Subconjunctival injection
is not routinely used by us in managing patients with
endophthalmitis. In addition to patient discomfort, tearing
of conjunctiva and subconjunctival hemorrhage, there
is also a risk of intraocular injection of the drug this procedure. The recommended dose of commonly used
antibiotics for subconjunctival injection is shown in
Appendix 3C.
ANTI-INFLAMMATORY THERAPY:
ROLE OF CORTICOSTEROIDS
One of the major causes of tissue damage in bacterial

endophthalmitis is the release of inflammatory mediators
in large quantities. This occurs because of invasion by
the organisms and also because of several endotoxins
released by them. These have an ability to stimulate the
complement pathway and also the arachidonic pathway
releasing both leukotrienes and prostaglandins. These
inflammatory mediators have chemotactic properties and
so attract polymorphonuclear leukocytes and macrophages into the vitreous cavity. Proteolytic and collagenolytic enzymes released from leukocytes are also harmful
to the highly sensitive intraocular tissues.
Corticosteroids decrease the risk of tissue damage
resulting from the above mechanism by inhibiting both
the lipo-oxygenase and cyclo-oxygenase pathways of
arachidonic acid metabolism. Corticosteroids remain the
most potent anti-inflammatory agents known. For being
most useful they have to be given early and in adequate
doses. They should however not be used whenever a
fungal infection is suspected as they enhance fungal
growth by decreasing the defense mechanisms within
the body.
In post-surgical bacterial endophthalmitis, corticosteroids may be given systemically, injected into the
vitreous cavity and also used as topical drops and for
subconjunctival injection. The use of systemic corticosteroids is well-accepted but there is a persisting
controversy regarding the necessity and role of intravitreal
corticosteroids in improving the visual results in endo-
phthalmitis. In addition, it is not known if oral or intravenous administration is as effective as intravitreal

injection.
The disadvantages of intravitreal corticosteroids is the
possibility that it may reduce the ability of the eye to
sterilize the innoculum of microorganisms it has encountered. They have been found to have little effect on the
damaging effect of bacterial toxins on the retina. Infact,
one experimental study on S. aureus endophthalmitis,
has shown increase in inflammation, retinal necrosis and
corneal opacification following intravitreal injection of
steroids. In contrast to the above findings, there are
reports in literature which show clearing of the vitreous
in 9 of 20 patients given 1200 g of corticosteroids
intravitreally.
Hence, the use of intravitreal injection of steroids
remains a decision left to the discretion of the surgeon.
The recommended dose of corticosteroids in bacterial
endophthalmitis for intravitreal, systemic and subconjunctival injection is given in Appendix 4.
SUPPORTIVE THERAPY
Certain medications act as adjuncts in the management

of patients with endophthalmitis. These include
cycloplegics and drugs to lower any elevation of
intraocular pressure that may be seen in some patients.
Cycloplegics are an important part of the treatment and
as a general guideline, the strongest cycloplegic is to be
prescribed in severe cases of endophthalmitis. We use
atropine 1% ointment 8 hourly initially and then change
to either, homatropine 2% drops 4-8 hourly or to a
combination of atropine and prednisolone eyedrops 6
hourly. Apart from enabling control of inflammation and
relieving ciliary spasm, cycloplegics prevent synechia
formation in miosis and increase the chances of having
a dilated pupil. Presence of a dilated pupil not only
enables better clinical evaluation but also becomes an
asset if a need for performing a vitrectomy arises.
In patients with elevated intraocular pressure, drugs
such as oral acetazolamide and timolol may be
prescribed. A vitreous tap before giving an intravitreal
injection may also help to lower the intraocular pressure
at least transiently in some patients.
VITRECTOMY IN POST-SURGICAL
ENDOPHTHALMITIS
Vitrectomy is the second line of management approach

in endophthalmitis with specific and definite indications.
It is technically more demanding, needs experience and
has a potential to lead to complications, particularly
retinal detachment. Also, it may not always be rewarding
in terms of the functional outcome. Vitrectomy for

endophthalmitis may be necessary at two stages, primary,
during the acute infection or secondary in the resolved
phase for vitreous opacification or membranes. Vitrectomy in the later stage is less demanding and less likely
to cause complications in comparison to vitrectomy the
primary, acute stage of endophthalmitis.
The timing When to do vitrectomy in endophthalmitis is difficult to decide and a controversial issue because
choosing a time that is neither too late nor too early is
subjective, usually based on the surgeons past experiences and also because the benefit versus safety window
for this procedure is very narrow.
The advantages of vitrectomy are that it decreases the
infectious, toxic and inflammatory load; provides
adequate undiluted specimen for culture studies;
increases antibiotic concentration within the eye and by
removing media opacities enables a more rapid visual
recovery. In reality however the functional outcome may
be less than that theoretically possible because of a
surgical bias in undertaking vitrectomy only in the more
severe and advanced cases. As a result of this bias not
only does the surgery become more difficult but also the
risk of complications like retinal detachment increases
and so also the possibility of a relapse.
Peroperative problems that a surgeon faces during
vitrectomy for endophthalmitis are a poor visualization
due to an edematous cornea or IOL membranes, a ring
abscess around the limbus that makes any attempted
suturing of an incision here impossible, an absent and
often adherent and Sticky vitreous without PVD, an
inflamed or necrotic retina which is easily liable to develop
tears and the risk of operating in the presence of
congested choroidal vasculature.
During surgery, a 6 mm infusion cannula should be
preferred, the MVR blade used for making the sclerotomies must be sharp and the cutter must not cause a drag
on the vitreous fibrils. The three cardinal principles to be
remembered while doing vitrectomy for endophthalmitis
are: Use maximal cutting rate, minimal suction and do
not attempt to induce a PVD if it is not already present.
No attempt should be made to go very close to the retina.
At the end of vitrectomy, it is generally recommended
that intravitreal antibiotic injections be given (1/10th of
normal recommended dose).
The indications recommended in literature for
undertaking immediate vitrectomy are severe cases, cases
in which gram-negative organisms are seen on a smear
examination of the vitreous aspirate and in cases showing
187
no response to medical treatment (intravitreal injection).

A severe case has been defined as one in which there is
a total absence of red reflex, an inaccurate projection of
light, an afferent pupillary defect, a corneal ring infiltrate
and a patient worsening 24-48 hours after an intravitreal
injection.
The most common approach that mostly decides the
time that vitrectomy should be undertaken is a worsening
despite a proper intravitreal injection or a lack of response
to two repeat intravitreal injections. This is also the
approach adopted at our centre.
The only prospective randomized controlled evaluation of intravitreal and vitrectomy procedures for endo
phthalmitis is the endophthalmitis vitrectomy study.
Details of this study are discussed in the subsequent
section. The goal of pars plana vitrectomy in the EVS
was to remove at least 50 per cent of vitreous gel in eyes
with no vitreous separation.
The EVS did not answer the question of when to
undertake vitrectomy, however, it clearly answered the
question of when to undertake additional surgery be it a
repeat intravitreal or repeat vitrectomy. According to this
study a repeat intervention should be undertaken in eyes
doing poorly 36-60 hours after the first intervention
(vitrectomy or intravitreal). At 3-9 months after the interventions, when they assessed the visual acuity and media
clarity in the various groups, they found that:
If initial vision is hard movements or better there was
no difference in the outcome between immediate
vitrectomy and intravitreal injection groups.
However, if the initial vision was only light perception,
the final visual acuity and media clarity was substantially better in patients undergoing vitrectomy.
This study indirectly indicates that one very certain
indication to immediately undertake pars plana vitrectomy in patients with postoperative (post-cataract
surgery) endophthalmitis is when the initial vision is light
perception only.
ENDOPHTHALMITIS VITRECTOMY STUDY
Endophthalmitis Vitrectomy Study (EVS) was a multicentric study undertaken in the United States and
involving 420 patients who had developed bacterial
endophthalmitis within 6 weeks of cataract surgery or
secondary IOL implantation. The primary objective of
the study was to determine the role of early pars plana
vitrectomy in comparison to intravitreal injection alone
(TAP) in patients with endophthalmitis and also to identify
the role of systemic antibiotic treatment in these cases.
188
The main objective outcome measures determined were

improvement in visual acuity and improvement in media
clarity at the end of 3-9 month follow-up.
The other criteria for inclusion in the study was a visual
acuity of at least or more than light perception and less
than 20/50 and with a relatively clear cornea and anterior
chamber. Patients with a history of other intraocular
surgeries, presentation after 6 weeks, fungal endophthalmitis, trauma and age below 18 years were not
included in the study. Other exclusion criteria included
previous intraocular antibiotic administration, other
causes of poor vision, presence of retinal or choroidal
detachment and drug sensitivity to lactams.
The patients were randomly categorized into four
groups: PPV with systemic antibiotics, PPV without
systemic antibiotics, TAP with systemic antibiotics and
TAP without systemic antibiotics.
An important factor during this study was in the
assessment of vision when it was less than finger counting
at 1m. As mentioned earlier light projection was tested
at a distance of 90 cm with the strongest intensity of light
from an indirect ophthalmoscope. Hand movements
vision was tested at a distance of 60 cm with a light source
from behind the patient. The stimulus of hand movements was presented five times and the response was
recorded as positive if four of these were correctly identified. Media clarity was graded as indicated earlier.
Patients were only admitted for management when it
was felt that topical medication may not be administered
regularly, in presence of transportation difficulties and
whenever pars plana surgery was contemplated.
The most common symptoms at presentation was
blurred vision (94%) followed by pain (74%). The mean
interval between surgery and onset of symptoms was 4
days and visit to a vitreous surgeon, 6 days. Treatment
was initiated in all patients within 6 hours of presentation
and after having obtained diagnostic samples from the
eyelid, anterior chamber (0.1 ml using 25-27 gauge
needle) and vitreous (0.2 ml by aspiration or biopsy).
These specimens were cultured on chocolate agar (37C
in CO2), fresh enriched thioglycolate (37C) and fresh
Sabourauds dextrose agar (25C). Laboratory confirmed
growth was defined as mentioned earlier. and using this
definition, no growth was obtained in 18 per cent cases,
equivocal growth was seen in 13 per cent and positive
growth in 69 per cent. The breakup of those with a
positive culture was: gram-positive, coagulase negative
species in 47 per cent, other gram positive organisms in
16 per cent, gram-negative in four per cent and more
than one species in three per cent cases. When culture
growth was co-related with the final visual acuity it was

found that in patients with a gram-positive, coagulase
negative organismal growth, 62 per cent achieved more
than 20/50 vision while only 55 per cent did so in patients
with no growth on culture.
The intravitreal drugs used in this study were
vancomycin (1000 g in 0.1 ml) and amikacin (400 g
in 0.1 ml). No intravitreal corticosteroids were given. For
systemic (parenteral) administration the chosen drugs
were ceftazidime (2 gm every 8 hourly) and amikacin
(7.5 mg/kg initially and then 6 mg/kg every 12 hours). In
those allergic to lactams, ciprofloxacin 750 mg orally twice
daily was used as an alternative. Systemic medication
was given for a period of 5-10 days and left to the treating
physicians discretion.
For subconjunctival injection the drugs chosen were
vancomycin (25 mg/0.5 ml), ceftazidime (100 mg/0.5
ml) and dexamethasone 6 mg/ 0.25 ml. Topical antibiotic
medications included vancomycin (50 mg/ml) and
amikacin (20 mg/ml) given every 4 hourly routinely or
alternately every 1 hourly if wound leak or infection was
present.
The surgical interventions performed were vitreous
tap and intravitreal injection or vitreous biopsy and intravitreal injection or pars plana vitrectomy and intravitreal
injection. The goal of vitrectomy in eyes with no obvious
vitreous separation was to remove atleast 50 per cent of
the vitreous gel.
Additional surgery (re-vitrectomy, re-vitreous tap or
vitrectomy) was undertaken in eyes doing poorly 36-60
hours after the first intervention. Signs of worsening were
an absent red reflex or increasing opacification, a 1 mm
increase in the height of hypopyon, development of a
corneal ring infiltrate and worsening pain.
The major conclusions of the EVS study were:
If initial vision is hand motions or better then there is
no difference in outcome between immediate
vitrectomy or intravitreal antibiotics
If initial vision is only light perception then final visual
acuity and media clarity are substantially better in
patients undergoing vitrectomy and intravitreal
injection as compared to intravitreal injection alone
Whether or not systemic antibiotics are used there is
no difference in final visual acuity
In subsequent reports from the EVS group other
important observations were made. These include:
The vitreous is a richer source of laboratory confirmed
growth
Gram stain should not determine the choice of
antibiotic drugs
Vitrectomy with culture of vitrectomy cassette fluid

did not produce significantly more positive cultures
than vitreous tap or biopsy material and so the
procedure (i.e. vitrectomy) should not be performed
solely to improve the microbiological yield.
Secondary or anterior chamber IOL implantation was
associated with a possible shift in the spectrum of
organisms isolated towards gram-positive organisms
other than coagulase negative micrococci.
Vancomycin was active against all gram-positive
isolates tested; amikacin and ceftazidime showed
equivalent activity against gram-negative isolates
A positive Gram stain or infection with species other
than gram-positive, coagulase negative micrococci is
significantly associated with poorer visual outcomes.
Although visual prognosis is strongly associated with
the type of infecting organism and Gram stain
positivity, presenting visual acuity remains more
powerful than microbiologic factors in predicting
visual outcome and favorable response to vitrectomy.
POST-SURGICAL FUNGAL ENDOPHTHALMITIS
Clinical Features
Patients may present either with a blurring or decrease

in vision associated with some degree of redness or with
complaints of floaters. Most cases of fungal
endophthalmitis following intraocular surgery usually
appear several weeks to months later. The characteristic
feature is a relative lack of symptoms compared to the
signs on examination of the eye. The presentation is that
of chronic endophthalmitis with indolent inflammation.
The anterior chamber may show a fixed hypopyon and
a fibrinous mesh-like exudation. There is variable degree
of corneal oedema, the intraocular pressure is frequently
elevated and the vitreous may show snow balls and fluffy
opacities. Infrequently the fungal colonies may be
misdiagnosed as retained lens matter and prescribed
steroids. Fundus glow is variable but vision may be less
than expected. Clinically it may be sometimes difficult to
distinguish fungal endophthalmitis from P. acnes
endophthalmitis.
Confirmation of Diagnosis
Material for culture in fungal endophthalmitis is as for

post-surgical bacterial endophthalmitis. However it may
be more difficult to aspirate as the colonies are usually
tenacious. The routinely used culture media for fungal
growth is Sabourauds dextrose agar. Although colonies
may begin to appear within a few days, it should be
189
observed for atleast 2 weeks before reporting it as

negative. If Sabourauds media is unavailable or the
specimen is inadequate, the laboratory may be told to
hold the blood agar plate for 3 weeks and observe for
fungi.
MANAGEMENT OF POSTOPERATIVE
FUNGAL ENDOPHTHALMITIS
The objectives of treatment in fungal endophthalmitis

remains the same as that in bacterial endophthalmitis.
However, the results are not gratifying because of several
factors like delayed diagnosis, lack of non-toxic fungicidal
drugs and the inadequacy of intravitreal injection alone
in the treatment. The only agreement is that steroids in
form are absolutely contraindicated in fungal endophthalmitis.
Systemic Antifungal Therapy
Unlike metastatic endophthalmitis caused by fungi,

postoperative fungal endophthalmitis poses a peculiar
problem in deciding the route of drug administration. In
the former, there is an associated fungaemia and usually
extraocular sites of fungal colonization, hence, systemic
antifugal therapy is easily justified. This is not so in the
case of postoperative fungal endophthalmitis wherein the
fungal colonization is limited to the intraocular cavities.
Since most anti-fungal drugs have the potential to cause
significant adverse effects, the role of systemic therapy
in such a situation may seem questionable. Moreover,
not all of these drugs have a good enough penetration
into the intraocular cavities. The problem has been solved
to a certain degree by the discovery of certain anti-fungal
drugs causing fewer systemic adverse effects and also
having a better intraocular penetration.
Exact management guidelines for the management
of exogenous fungal endophthalmitis are not available
in literature. The relative paucity of controlled studies on
the treatment approach in this form of endophthalmitis
is possibly related to the infrequent occurrence of fungal
endophthalmitis in comparison to bacterial endophthalmitis after intraocular surgery.
There are three major groups of anti-fungal drugs
available in the market and it is important for us to know
their limitations, advantages and potential for toxicity.
These three groups are: Polyenes (Amphotericin B),
Azoles (Ketoconazole, Miconazole, Fluconazole, Itraconazole) and Fluocytosine.
Amphotericin-B Parenteral amphotericin-B has been
considered the treatment of choice in intraocular fungal
190
infections. However, this form of treatment has several

disadvantages such as poor intraocular penetration and
the potential for both systemic adverse effects and retinal
toxicity.
Amphotericin-B may be fungistatic or fungicidal
depending on the concentration of the drug within the
tissues and the susceptibility of the fungi. It destroys fungi
by causing changes in the permeability of their cell
membranes. It is recommended that before starting
patients on systemic amphotericin-B, a test dose be given.
This is usually with 1mg of the drug in 20 ml of 5 per
cent dextrose (not normal saline) given intravenously
over half an hour. Therapy should not be undertaken if
the patient develops serious side effects like hypotension
or cardiac arrhythmias with the test dose. In the absence
of any adverse effects, treatment can be started one hour
later with a dose of 0.7 mg/kg of amphotericin in 500 ml
of 5 per cent dextrose by slow intravenous infusion over
2-6 hours. Although more rapid administration (within
1-2 hours) have been advocated, it may carry a greater
risk. Previously the subsequent approach was to increase
the dose gradually (5-10 mg) each day. However may
be better to try and achieve the maximum dose of 0.71.0 mg/kg/day as early as possible. No treatment response
is usually seen in the first week. Subsequently, the
inflammation begins to gradually subside. Treatment
should be continued until the inflammation and any
chorioretinal lesions present, show complete resolution.
Toxic adverse effects known to occur with intravenous
administration of amphotericin-B are anaphylaxis,
convulsions, phlebitis, chills, fever, headache, anaemia
and thrombocytopenia. Hypotension and cardiac arrhythmias are other serious side effects. The most common
and significant adverse effect is nephrotoxicity. This is
reported to occur in 80 per cent of patients and so
constant monitoring of renal parameters is a must during
treatment with parenteral amphotericin-B treatment.
Azole derivatives These newer group of drugs have the
advantages of adequate systemic absorption following
oral administration, better penetration into the intraocular
cavities (fluconazole>ketoconazole>itraconazole) and
lesser risk of serious adverse effects. To be effective
however, they have to be given early. The only drug
shown to be effective in reducing fungal counts when
given after 7 days of fungal inoculation in experimental
animals has been ketoconazole.
The disadvantage of azole derivatives are that they are
not as effective as amphotericin B, resistance to the drug
may develop rapidly and they have a significant antagonistic effect when combined with amphotericin-B.
Moreover, they only have a fungistatic effect. In comparative studies with amphotericin-B and fluoconazole in
experimental animals it was seen that the initial response
(for the first 17 days) to treatment was identical in both the
groups. From the 21st day onwards however, the fluconazole group began to again worsen probably because of
the development of drug resistance. As combined therapy
with amphotericin-B and azole derivatives has been shown
to increase the risk of developing resistance to amphotericin
B, the use of this form of combination therapy is not
recommended.
The usual dose of the usually preferred azole derivatives in the treatment of intraocular fungal infections is:
Ketoconazole (400 mg/day in a single or two divided
doses) and Fluconazole (200 mg/day in a single or two
divided doses).
If azole derivatives are chosen as the first line of
treatment in the management of fungal endophthalmitis,
it would be probably prudent to not persist with the
treatment if no response is observed within the first 7 to
10 days. This is also probably necessary if the condition
begins to worsen after an initial response as seen in the
experimental study mentioned earlier. Under both these
circumstances one should change to treatment with
amphotericin B despite its known adverse effects.
Constant interaction with an internist to monitor for toxic
effects and modify dosage of the drug accordingly
however, becomes very essential.
An important part of the management is to remember
that corticosteroids by any route are absolutely contraindicated in the management of fungal endophthalmitis.
Flucytosine Treatment with drug alone in the management of fungal infections is not recommended because
of the rapid development of drug resistance. However, it
may be used in combination treatment with amphotericin
B when the intraocular inflammation is severe and resistant to initial treatment. Fluocytosine is given orally in a
dose of 50-100 mg/kg/day in four divided doses. This
drug can cause hematologic, renal and hepatic toxicity.
Dose of various anti-fungal agents for systemic
administration is shown in Appendix 5A.
INTRAVITREAL ANTIFUNGAL THERAPY
Unlike in postoperative bacterial endophthalmitis where

the mainstay of treatment is intravitreal administration,
in fungal endophthalmitis, this mode of drug administration acts only as an adjunct to systemic medication.
This is because, fungi unlike bacteria multiply less rapidly
and correspondingly treatment of fungal endophthalmitis
requires a prolonged duration (in weeks and not days)
of adequate concentrations of the anti-fungal agent within

the vitreous cavity. This objective cannot be achieved
with intravitreal administration. A probably more
efficacious way of achieving this objective in future could
be the development of sustained release intraocular
devices similar to those presently in use to treat patients
with cytomegalovirus retinitis (e.g. Ganciclovir intraocular
deviceGIOD).
The method of injection and the precautions while
administering an intravitreal injection is the same as those
described under postoperative bacterial endophthalmitis.
However, the follow-up guidelines (e.g. when to repeat
the injection/how long to wait before vitrectomy, etc.)
following this injection are not clearly defined. Steroids
are absolutely contraindicated.
Preparation of Amphotericin-B for intravitreal injection
is given in Appendix 5B.
Vitrectomy in Fungal Endophthalmitis
The only differences with regard to vitrectomy for bacterial

and fungal endophthalmitis are that in the latter it is
generally recommended that it be performed early and
an antifungal injection (usually Amphotericin B) given
into the vitreous at the end of the surgery.
At our center, in cases of fungal endophthalmitis, we
prefer to initially give a trial of azole derivatives (Fluconazole/Ketoconazole) for 10-14 days. If this fails, we subject
them to vitrectomy and continue with the above drugs.
If still the exudation reappears an intravitreal injection of
Amphotericin-B 5 g is given. In general the prognosis
has not been very satisfactory in patients with postoperative fungal endophthalmitis.
PROPIONIBACTERIUM ACNES ENDOPHTHALMITIS
In patients with chronic postsurgical endophthalmitis,

Propionibacterium acnes has been reported to be the
most common isolate. Propionibacterium acnes is an
anaerobic, gram-positive bacillus that is normally present
in the conjunctival sac as a commensal. Though considered to have no pathogenic potential a few decades
ago, this organism is now known to a frequent cause of
chronic bacterial endophthalmitis. A few cases of
endophthalmitis by Propionibacterium granulosum have
also been reported.
Propionibacterium acnes has an ability to stimulate
the immune system but being resistant to killing by the
polymorphs and monocytes, it remains intracellularly
after phagocytosis by macrophages. The organism
probably acts as an adjuvant in stimulating an immune
191
response against soft lens matter remaining after cataract

surgery.
Propionibacterium acnes endophthalmitis presents as
a low grade, smoldering type of intraocular inflammation
following cataract surgery. Because of this pattern of
inflammation, it tends to be missed in its early stages.
The inflammation may show an initial response to
steroids but subsequently begins to recur. Endophthalmitis caused by P. acnes has certain classical clinical
features such as the presence of whitish plaques in relation
to the capsular bag, history of unexpected inflammation
after YAG capsulotomy and the frequent tendency to
relapse following initial response. The whitish plaques
are composed of colonies of P. acnes. Laboratory confirmation of the diagnosis is also difficult and often delayed
because the organism begins to show up on anaerobic
culture media only after about 2 weeks. The whitish
plaques are formed by both sequestered colonies of the
organism as well as inflammatory cells.
Acute cases of endophthalmitis caused by P. acnes
infection have also been reported. These cases are few
and they differ from the chronic form in showing a
gratifying response to treatment. Recurrences are not
known to occur following acute infection with P. acnes
infection. This is probably because the organisms have
not become sequestered within the capsular bag.
For laboratory confirmation of P. acnes infection, the
organism should be cultured on anaerobic media and
observed for growth for atleast 14 days.
Management of endophthalmitis caused by P. acnes
poses a peculiar challenge. Although the virulence of
the organism is low and it does not usually produce a
severe inflammatory response, it is difficult to eradicate
because it can remain sequestered within the capsular
bag. It would probably not be possible for the antibiotics
to reach these spaces and remain there at the needed
concentrations for a sufficient duration of time.
Controversies exist in the management approach in this
form of endophthalmitis due to clinical variables such as
the severity of infection.
Treatment approaches that have been indicated in
literature are intravitreal antibiotics alone in mild cases,
to vitrectomy, total capsulectomy and IOL explantation
along with intraocular and systemic antibiotics in very
severe cases. Intravitreal injection for P. acne endophthalmitis has to be given into the capsular bag to be of
some value. The objective of total capsulectomy and IOL
explantation is to eradicate colonies of P. acnes sequestered within the confines of the capsular bag. Surgical
measure like partial capsulectomy and retaining of the
IOL may provide only transient respite. The antibiotic of
192
choice in treating endophthalmitis caused by Propionibacterium acnes is vancomycin in the same dose recommended for other forms of bacterial endophthalmitis
(1000 g in 0.1 ml).
STERILE ENDOPHTHALMITIS
(POSTOPERATIVE INFECTION VS INFLAMMATION)
Though infection is the most serious and probably the

most common cause of unexpected postoperative inflammation, it is not the only cause. Other factors incriminated
in the genesis of postoperative inflammation include
retained lens matter, residual chemicals from sterilization,
toxicity of residual monomers on PMMA lenses,
mechanical irritation of the iris and ciliary body by the
lens and rarely inadvertent injection of xylocaine or
antibiotics containing high concentration of these drugs.
Inflammation caused by these agents are sometimes
termed sterile postoperative endophthalmitis.
The dictum that all unexpected postoperative reaction
should be considered as infective until proven otherwise
is useful. However, there are certain clinical features that

may aid in making this critical differentiation. These are
summarized in Table 35.1.
Table 35.1: Infection vs inflammation
Parameter
Infection
Inflammation
Focal infiltrate
Fundus glow
Vitreous cavity
Color of exudates
IOP
Commonly present
Poor/Absent
Haze ++
Yellowish
Low
Rare
OK/ Mildly poor
Clear/ Mild Haze
White
Normal
Visual prognosis In the EVS study, the rates of achieving

a final visual acuity of 20/100 or more in relation to the
organism producing endophthalmitis was as follows:
gram-positive, coagulase negative micrococci (84%),
Staphylococcus aureus (50%), streptococci (30%), enterococci (14%) and gram-negative organisms (56%). It was
found that a positive Gram stain or infection with species
other than gram-positive, coagulase negative micrococci
is significantly associated with poorer visual outcomes.
APPENDIX 1
Summary of Laboratory Confirmation of
Diagnosis in Endophthalmitis
Direct plating is better than sending the sample in transportation

media
If direct plating is not possible, then the sample should be sent
at the earliest for plating in the laboratory and immediate Gram
and Giemsa staining performed
Lid margin and conjunctival swab cultures are no longer
recommended
Culture of suture removed in the presence of a suture abscess
or infected suture track is a must
Samples from both aqueous and vitreous must be cultured
Aqueous and vitreous samples must be obtained with sterile
precautions
Plating should be on all three culture media: aerobic, anaerobic

and fungal
The preferred culture media are:
Chocolate agar ( 37C in CO2 )
Fresh enriched thioglycolate ( 37C )
Fresh Sabourauds dextrose agar ( 25C )
No culture should be considered negative until two weeks of
observation for growth
Laboratory confirmed growth is defined as:
1. Atleast semiconfluent growth on solid media
2. Any growth on more than or equal to 2 media
3. Growth on one media supported by a positive Gram stain.
APPENDIX 2A
Preparation of Commonly Recommended Intravitreal
Drugs in Postoperative Bacterial Endophthalmitis
1. Vancomycin hydrochloride (1000 g in 0.1 ml): The drug is
available as a powder in a strength of 500 mg. Reconstitute
this with 10 ml of sterile solution of injection or saline. This
gives a strength of 50 mg in 1.0 ml and hence 10 mg in 0.2
ml. 0.2 ml of the drug is drawn into a tuberculin syringe and
this is further diluted with 0.8 ml of sterile saline to give a
strength of 10 mg in 1.0 ml and hence 1000 g (1 mg) in
0.1 ml.
2. Ceftazidime hydrochloride (2.25 mg in 0.1 ml): The drug is

available as a powder in a strength of 500 mg. Reconstitute
this with 2 ml of sterile solution for injection to give a strength
of 250 mg in 1 ml (has 225 mg of active ingredient) and 25
mg (22.5 mg) in 0.1 ml. 0.1 ml of the drug is drawn into a
tuberculin syringe and diluted further with 0.9 ml of sterile
solution to give a strength of 2 5 mg (22.5 mg) in 1.0 ml and
hence 2.25 mg in 0.1 ml.
3. Cefazolin hydrochloride (2.25 mg in 0.1 ml): The drug is
available as a powder in a strength of 500 mg. The required
concentration is achieved by following the same steps of
dilution indicated above for ceftazidime hydrochloride.
4. Ciprofloxacin hydrochloride (150 g in 0.1 ml): The drug is
available as a 100 ml bottle containing 200 mg of ciprofloxacin.
0.15 ml is withdrawn into a tuberculin syringe and this is mixed
with 0.1 ml ringer lactate. 0.1 ml of this mixture contains
150 g of ciprofloxacin
5. Amikacin sulfate (400 g in 0.1 ml): The drug is available as a
solution in a strength of 100 mg in 2 ml vial (50 mg in 1 ml)
193
and 10 mg in 0.2 ml. 0.2 ml of the drug is drawn into a tuberculin syringe and diluted further with 2.3 ml of sterile solution
to give a strength of 10 mg in 2.5 ml and hence 400 g in
0.1 ml.
6. Gentamicin sulfate (200 g in 0.1 ml): The drug is available
as a solution of 80 mg in 2 ml vial (40 mg in 1 ml) and 4 mg in
0.1 ml. 0.1 ml of the drug is drawn into a tuberculin syringe
and diluted further with 1.9 ml of sterile solution to give a
strength of 4 mg in 2 ml (2 mg in 1 ml) and hence 200 g in
0.1 ml.
APPENDIX 2B
Preparation of Less Commonly Recommended Intravitreal
Drugs in Postoperative Bacterial Endophthalmitis
1. Chloramphenicol (2000 g in 0.1 ml): The drug is available
as a powder in a strength of 1000 mg. Reconstitute this with
10 ml of sterile solution for injection to give a strength of 100
mg in 1 ml and 10 mg in 0.1 ml. Draw 0.1 ml into a tuberculin
syringe and dilute further with 0.4 ml of sterile solution to give
a strength of 10 mg in 0.5 ml and hence 2 mg (2000 g) in
0.1 ml.
2. Clindamycin (1000 g in 0.1 ml): The drug is available as a

solution in a strength of 300 mg in 2 ml vial (150 mg in 1 ml)
and 15 mg in 0.1ml. Draw 0.1 ml into a tuberculin syringe and
dilute further with 1.4 ml of sterile solution to give a strength
of 15 mg in 1.5 ml and hence 1 mg (1000 g) in 0.1 ml.
APPENDIX 3A
Recommended Dose of Commonly Used Antibiotics in Supportive
Management of Post-surgical Endophthalmitis
1. Vancomycin
: 1 g IV q 12 hr
(30 mg/kg/day)
2. Ciprofloxacin*
: 750 mg PO q 12 hr
400 mg IV q 12hr
9. Amikacin
: 240 mg q 8 hr
(15 mg/kg/day)
3. Ceftazidime
: 2 g IV q 8 hr
(100 mg/kg/day)
10. Tobramycin
: 80 mg q 8 hr
(5 mg/kg/day)
(5 mg/kg/day)
8. Chloramphenicol : 1 g IV q 8 hr
(50 mg/kg/day)
4. Ceftriaxone
: 2 g IV q 8 hr
(100 mg/kg/day)
11. Gentamicin
: 80 mg q 8 hr
5. Cefazolin
: 1.5 g IV q 6 hr
(~75 mg/kg/day)
12. Ofloxacin
: 200 mg PO q12 hr
6. Imipenem
: 1 g IV q 12 hr
500 mg PO q 8 hr
7. Cephalothin
: 1 g IV q 4 hr
(100 mg/kg/day)
* Avoid in children below 12 years and in pregnant and lactating

mothers
APPENDIX 3B
Recommended Concentrations of Antibiotics
for Subconjunctival Injection
1.
2.
3.
4.
Vancomycin
Ceftazidime
Cefazolin
Ceftriaxone
: 25 mg/0.5 ml
: 100 mg/0.5 ml
: 100 mg/0.5 ml
: 100 mg/0.5 ml
5.
6.
7.
8.
Tobramycin
Gentamicin
Chloramphenicol
Clindamycin
: 20 mg/0.5 ml
: 20 mg/0.5 ml
: 100 mg/0.5 ml
: 150 mg/0.5 ml
194
APPENDIX 3C
Preparation of Commonly Used
Fortified EyeDrops*
1. Cefuroxime (50 mg/ml): An injection vial of 1000 mg
cefuroxime is diluted with 2.5 ml sterile water. Of this dilution,
2.5 ml is then added to 12.5 ml of artificial tears. This is stable
at room temperature for 24 hours and in the refrigerator for
96 hours.
2. Tobramycin (15 mg/ml): Add 2 ml of parenteral tobramycin
containing 80 mg of the drug into a commercially available
5 ml vial of tobramycin eyedrops (0.3%)
3. Gentamicin (15 mg/ml): Add 2 ml of parenteral gentamicin

containing 80 mg of the drug into a commercially available
5 ml vial of gentamicin eyedrops (0.3%).
* Fortified eyedrops in endophthalmitis is not recommended
routinely but only if there is a concurrent corneal ulcer or
suture abscess and in bleb associated endophthalmitis.
APPENDIX 4
Recommended Dose of Corticosteroids in
Bacterial Endophthalmitis
A. Intravitreal Dexamethasone (400 g in 0.1 ml): The drug is
available as a solution in a strength of 8 mg in 2 ml vial (4 mg
in 1 ml) and hence 0.4 mg (400 g) in 0.1 ml. 0.1 ml of the
drug may be withdrawn directly into a tuberculin syringe
without any further dilution.
B. Systemic Corticosteroids (Equivalent Doses):

1. Prednisolone
: 1-2 mg/kg/day PO
2. Betamethasone :
3. Dexamethasone :
C. Subconjunctival Dexamethasone: 1 mg in 0.25 ml
APPENDIX 5A
Recommended Dose of Systemic Anti-fungal
Agents for Fungal Endophthalmitis
1. Amphotericin B : 0.7-1.0 mg/kg/day (given slow IV over 2-6
hours after a test dose)
2. Fluconazole
: 200 mg/day PO in single or two divided
doses
3. Ketoconazole
4. Itraconazole
5. Flucytosine
: 400 mg/day in single or two divided doses

: 200 mg/ day in single or two divided doses
: 50-100 mg/kg/day
APPENDIX 5B
Preparation of Intravitreal Drugs in
Fungal Endophthalmitis
1. Amphotericin B (5 g): Amphotericin B available as 50 mg
powder in a vial. Reconstitute this with 10 ml of dextrose 5%
(not normal saline) to give a concentration of 5 mg/ml and
500 g in 0.1 ml. Take 0.1 ml into a tuberculin syringe and

dilute further with 9.9 ml of dextrose 5% to give a concentration
of 500 g in 10 ml and 50 g /ml and 5 g in 0.1 ml.
Posterior Segment Disorders and SICS
Posterior Segment
Disorders and SICS
mall incision cataract surgery and

phacoemulsification have revolutionized the
management of cataract surgery. The main
advantages of these procedures over conventional extracapsular cataract extraction (ECCE) with intraocular
lens (IOL) implantation are a consequence of the reduced
size of the wound required for delivery of the nucleus.
Consequently the surgery can be performed in a closed
system with out significant alterations in the intraocular
pressure (IOP). Furthermore the smaller size of the wound
imparts it with greater stability and minimises
postoperative morbidity and especially postoperative
astigmatism. Today more than ever before, cataract
extraction by small incision cataract surgery is being
performed as an outpatient office procedure permitting
early rehabilitation with minimal to no morbidity. It is
therefore important for all small incision cataract surgeons
to have a sound knowledge of the posterior segment
complications of small incision cataract surgery. In
comparison to conventional cataract surgery, especially
regarding posterior segment disorders which might occur
either during small incision surgery or in the postoperative
period and compromise the final visual outcome.
Pathophysiology of Posterior Segment Disorders
Posterior segment affections in patients undergoing small

incision cataract surgeries can be described along four
major subheads.
A. Posterior segment surgical complications of small
incision surgery.
B. Posterior segment disorders which arise de novo
following the surgery in the postoperative period, i.e.
cystoid macular oedema.
C. Previously existing disorders which can be aggravated
following small incision cataract surgery, i.e. diabetic
retinopathy.
D. Associated independent retinal pathologies, i.e. retinal
detachment or macular degeneration.
36
195
Dinesh Talwar
Mool Chand
Gopal S Pillai
Posterior Segment Surgical Complications
Preoperative Complications These include complications

relating to ocular anaesthesia, i.e.:
Accidental globe perforation
Central retinal artery occlusion following long time
use of superpinky
Intraoperative complications
Expulsive haemorrhage
Vitreous loss
Posterior dislocated nucleus
Dislocated IOL
Postoperative complications
Endophthalmitis
Late retrobulbar haemorrhage
ACCIDENTAL GLOBE PERFORATION
Accidental globe perforations during local anaesthesia

are a well documented, but rare complication in
experienced hands. The incidence of needle perforations
during retrobulbar anaesthesia varies from study to study
with figures of 1 in 12000 to 3 in 4000 cases reported by
different authors. The incidence is much lower in patients
who receive peribulbar blocks. However, accidental globe
perforation has been reported following peribulbar
injections as well. The possibility of carrying out a small
incision cataract surgery and especially a phacoemulsification under topical anaesthesia or without anaesthesia
raises the important possibility of total prevention of this
complication during this procedure. It is however likely
that the use of peribulbar or retrobulbar blocks will
continue even in patients undergoing phacoemulsification as topical phaco is likely to be possible only in
patients who are extremely co-operative. Further more a
peribulbar or retrobulbar block is likely to be used in all
patients undergoing a small incision cataract surgery.
196
Clinical Features
The most important predisposing factors for the

occurence of this complication are large myopic eyes and
very uncooperative patients. Varying clinical
presentations may occur in patients who have had
accidental perforations of the globe depending upon the
sequence of events that have happened i.e.
1 The needle penetrates the globe and the drug is
injected into the globe
2 The needle penetrates the globe, and is then retracted
and the drug is injected into the orbital cavity.
3 The needle penetrates the eye anteriorly and then
again posteriorly and the drug is injected into the
orbital cavity.
In situation one, If the drug is accidentally injected into
the globe, the IOP rises to extremely high levels, and the
patient may complain of severe pain as the drug is being
injected. The cornea becomes hazy and the anterior
chamber may become shallow. In situations two and three,
the condition is diagnosed when there is sudden hypotony
or pupillary constriction, a characteristic poking through
sensation and loss of the red reflex and pain may be
complained by the patient at the time of perforation.
Management
Further management of this complication depends upon

the situation. The factors, which influence decision making in this situation, are extent of the cataract, the IOP,
media clarity including the clarity of the cornea, presence
or absence of vitreous haemorrhage, and presence of a
retinal detachment.
If the cataract is total and if the IOP is within normal
limits, it is best to go ahead with the cataract extraction
in the same sitting. If however the site of the perforation
can be visualized due to a moderate or mild cataract,
one should ask a retinal surgeon to seal the break with
cryopexy or laser photocoagulation using a laser indirect
ophthalmoscope before the patient is taken up for
cataract extraction. Furthermore it is preferable to wait
for 3 to 4 weeks after the prophylactic treatment before
going in for the cataract extraction. It is therefore mandatory to do an indirect ophthalmoscopy in all suspected
cases of occult perforation.
In patients who have very high IOP, it is probably best
to defer surgery to the next operating day to permit the
IOP to come down to normal. But immediate paracentesis may be required to prevent permanent visual
loss due to central retinal artery occlusion (CRAO)
because of very high IOP. The visualization of sponta-
neous or induced central retinal artery pulsations in a

clear media and high IOP is a sign of impending CRAO.
Patients who have a vitreous haemorrhage with a hazy
media or in cases who have retinal detachments would
need to be taken up for prompt vitreous surgery in
addition to the cataract surgery.
Since cataract surgery will be needed in most of the
cases even to manage the posterior segment pathology,
the cataract should be removed in the first sitting if it can
be safely done so. The decision to insert an IOL should
then be based on the condition of the posterior segment
of the eye after nucleus removal and cortical aspiration.
If the media is clear and no retinal detachment is present,
an IOL may be inserted. If however the media is very
hazy and / or a retinal detachment is present, it is best to
avoid inserting an IOL. A flow diagram outlining the
management of accidental globe perforation is given in
Figure 36.1.
Accidental globe perforation: Approach to management
Indirect ophthalmoscopy (If globe perforation is suspected

Media clear enough
To visualize perforation site
Media hazy
No RD
Perforation site
With overlying
Vitreous haemorrhage
RD
Laser/ Cryo
Vitreoretinal surgery
Fig. 36.1
CENTRAL RETINAL ARTERY OCCLUSION
Central retinal artery occlusion has been reported rarely

following peribulbar anaesthesia. This is likely to occur
when the superpinky has been kept at high pressure for
a long time. The compressing effect of the superpinky
could raise the intraocular pressure when it is on and
thereby precipitate a central retinal artery occlusion.
Hence it is important not to keep the superpinky at too
high a pressure. It is even more important to release the
superpinky at timely intervals. Generally the pressure
exerted by a pressure lowering devise on the eye should
be lesser than 30 mm of Hg. This pressure should not be
exerted for over 15 minutes at a time. It is important to
remember that once central retina artery gets obstructed,
we might not be able to diagnose the condition until the
postoperative phase when treatment modalities are not
likely to be effective in successfully managing the
condition.

EXPULSIVE HAEMORRHAGE
Introduction
Expulsive choroidal haemorrhage is a dreaded complication of ocular surgery. Its incidence has been quoted
to be 0.05 to 0.5 per cent during cataract surgery by
different authors. The incidence of this complication is
likely to be lower in patients undergoing phacoemulsification since a closed intraocular cavity is maintained at
a near constant intraocular pressure through out the
procedure. Whether the risk of this complication is less
in patients undergoing small incision cataract surgery is
open to question.
It has been shown that axial length > 25.8 mm, a
history of glaucoma, preoperative intraocular pressure
> 18 mm of Hg, and intraoperative pulse rate >85 beats
per minute are all associated with higher risk of expulsive
haemorrhage. Long-standing hyper tension and
arteriosclerosis are also predisposing factors.
The site of haemorrhage is probably a sclerotic
choroidal arteriole where the vessel crosses the suprachoroidal space from the scleral canal. It has been
postulated that the sudden hypotony following surgical
penetration of the globe causes a bending and then a
rupture of the arteriole.
Clinical Features
This complication can be diagnosed when in a case,

sudden wound gape, iris prolapse, self-delivery of lens
and loss of red reflex begin to occur in quick succession.
Finally this might even lead to expulsion of the whole
intraocular contents. Capsular rent during extension of
section and a spontaneous prolapse of a PC IOL into
AC in a previously well formed anterior chamber are
other early signs of suprachoroidal haemorrhage.
(personal experience)
Management
It is quite evident that this complication has to be

recognized early and prompt measures taken to reduce
the tension and close the wound immediately in order
to successfully salvage the eye in these cases. Prompt
closure of the wound is the most important step in the
management as it can help to salvage the eye and even
the vision in a number of patients. The quickest technique
to close a wound, which has just begun to gape, is one
which has been described by Dr Daljit Singh. A set of 6
or 7 8-0 needles which have been left over after suturing
of previous cataract surgeries must always be kept handy
on one side of the OT trolley so as to facilitate closure. In
197
case one suspects impending choroidal haemorrhage,

these needles are quickly passed through the corneal and
scleral ends of the wound and kept in place till formal
suturing can be completed. The needles should be passed
as quickly as possible even if iris incarceration into the
wound occurs since this can be managed once the wound
is secure.
In many cases, the occurence of choroidal
haemorrhage is recognized late when the IOP has risen
to dangerously high levels. At this time, the technique
described previously will no longer work. In this situation,
it is best to use a 4-0 or a 6-0 vicryl or silk suture for
wound closure since finer sutures are likely to give way
due to the high pressure. It is imperative that the wound
be closed as quickly as possible in this situation even if
iris gets incarcerated in the wound. If the surgeon feels
that the tension has to be controlled further, a posterior
sclerotomy can be done 4 to 4.5 mm posterior to the
limbus. Some surgeons have also advocated retrovitreal
fluid aspiration through the pars plana route if possible.
Personally we feel that this may not prove to be feasible
during the acute crisis confronting the surgeon at that
time.
In case the acute event has been successfully managed,
the possibility of salvaging the eye and its vision increases
significantly. The patient is managed conservatively with
all the efforts directed at the control of IOP and intraocular
inflammation. Choroidal haemorrhages often regress
spontaneously in 2-3 weeks. If kissing choroidal
haemorrhagic detachments form it may become
necessary to drain them on the 5th to 7th day. The
procedure may need to be combined with a vitrectomy
for clearing of vitreous haemorrhage. The management
of a kissing choroidals is best left to an expert vitreoretinal
surgeon to whom the patient should be referred as soon
as the condition is detected.
Some times, choroidal haemorrhage develops during
the postoperative period in elderly patients with arteriosclerosis, especially those patients who have been
engaging in Valsalva maneuvers such as straining at stool
or coughing. The possibility of this complication should
be explained to the patient and he or she should be
warned against coughing or severe straining in the early
postoperative period.
VITREOUS LOSS
Vitreous loss is one complication that all cataract surgeons

have experienced at one time or the other. This complication occurs even in the best of hands and hence all
198
cataract surgeons should be well versed with its

management. The incidence has been reported to vary
from 2 to 5 per cent by different authors. The incidence
of posterior capsular tears and vitreous loss is high in the
early phases of the learning curve of small incision
cataract surgery. The incidence is probably higher during
the learning curve of the phaco surgeon than it is of
manual small incision cataract surgeon. Vitreous loss most
commonly occurs during the nucleotomy and lens matter
aspiration.
Clinical Features
The capsule rupture may not be readily visible at times.

In this situation, we might have to rely on subtle signs
like the inability to aspirate cortex despite adequate
suction, a peaked pupil, or posterior movement of lens
remnants. Sudden deepening of the anterior chamber
and a brightening of the red glow may also be noticed. A
cellulose sponge kept at the wound and rolled will show
the vitreous strands if there is vitreous in the wound. These
clinical features will be more over similar in cases of
vitreous loss occurring in small incision manual cataract
surgeries and in phacoemulsification.
Management
It is important that all the vitreous is removed from the

anterior chamber and the wound as it can lead to traction
and later complications. The vitreous at the wound can
be cleared by a scissors or by an automated vitrectomy
probe (preferred method). Instilling viscoelastic material
into the bag may reposit the vitreous if the tear is small
and there is only a limited vitreous bulge. If a significant
amount of vitreous is present in the anterior chamber,
and certainly if it is present in the wound, an automated
vitrectomy should be performed using high cutting rates
of upto 600 cuts per minute and low aspiration pressures
and low irrigation. The endpoint of vitrectomy is a round
central pupil with a deep anterior chamber with a
posteriorly curved iris surface. Infusion for the vitrectomy
should be provided either in the full function vitrectomy
probe or through a 20 or 22-gauge cannula attached to
the infusion bottle suspended 2 feet above the patients
head. The infusion should then be used judiciously as
excessive infusion could hydrate the gel vitreous, thereby
prolonging the vitrectomy. Finally a vitreous sweep is
used to move vitreous stands away from the wound and
into the pupillary space.
The management of cases with vitreous loss associated
with nucleus drop is dealt with elsewhere. It is quite
important to understand that once a lens has sunk down,

no fishing of the lens should be done from the anterior
route as it will increase the traction on the vitreoretinal
interface.
CHOROIDAL DETACHMENT
When serous fluid accumulates in the suprachoroidal

space choroidal detachment can occur. The shunting of
fluid into this space is generally precipitated by low IOP,
causing hydrostatic pressure to decrease in the anterior
uveal veins. The plasma proteins add an osmotic force
that draws more fluid into the space, increasing the
detachment. Low IOP following cataract surgery can
result from a wound leak or ciliary body shutdown. The
possibility of this complication is low in cases, which have
undergone small incision cataract surgery or
phacoemulsification unless the corneal or scleral valve
has been made in a faulty manner. Attention to the
creation of a good corneal or scleral valve is thus essential
in all cases undergoing small incision cataract surgery.
Care should also be taken to hydrate or close the sideport
which may be a more common cause of leakage . Many
a time this is ignored thinking that the opening is very
small.
Clinical Features
The characteristic clinical signs are smooth dome like

brownish elevations of the peripheral choroid and retina.
As a consequence, the ora serrata becomes easily visible
in the affected area with an indirect ophthalmoscope.
These mounds appear very solid but vary in extent. The
differential diagnoses include retinal detachment and
retinal mass lesions.
Management
Under most circumstances, a choroidal detachment is

managed conservatively. If the anterior chamber is well
formed and if the choroidal detachments are small to
moderate in size, it is recommended that the patient be
maintained on a strong cycloplegic agent, such as
atropine ointment, 3-4 times per day or homatropine
eye drops 8 times a day along with a topical steroid one
hourly, i.e. 16 to 18 times daily. Systemic steroids may
be added to this treatment regime if needed. If the cause
of the hypotony is from a wound leak, then it must be
resutured.

CYSTOID MACULAR OEDEMA (CME)
Introduction and Epidemiology
The accumulation of fluid in the macula resulting in the

formation of cystic spaces, after cataract surgery, is referred to as Irvine-Gass syndrome. The fluid may be
extracellular in the outer plexiform and inner nuclear
layers of the retina, or intracellular causing Muller cell
degeneration with intracellular vacuolation. CME is more
often seen in association with complicated cataract
surgery and is more commonly seen in patients with
rupture of the posterior capsule with vitreous loss, vitreous
incarcerated in the surgical wound, or in those with a
poorly positioned intraocular lens.
The incidence of angiographically documented CME
is approximately 50 per cent after intracapsular cataract
extraction, 20 per cent after extracapsular cataract extraction and 10 per cent after phacoemulsification surgery.
However, studies have reported that the occurrence of
clinically significant macular edema varies between 1.52.3 per cent and is probably lesser in patients who have
undergone phacoemulsification as compared to those
who have undergone conventional ECCE and IOL.
There is a paucity of studies, which have evaluated the
incidence of this disorder in patients undergoing small
incision cataract surgery.
It is important to differentiate clinically diagnosed
cystoid macular edema based on biomicroscopic
examination, from angiographic cystoid macular edema
based on fluorescein angiography since angiographic
CME does not necessarily affect visual acuity. Persistent
macular edema may however result in foveal receptor
damage and macular degeneration.
The common risk factors for the development of CME
following cataract surgery are rupture of the posterior
capsule, vitreous loss, or insertion of a flexible open-loop
anterior chamber IOL. Other causes are secondary lens
implantation, intraocular lens exchange, old age, preexisting uveitis and YAG capsulotomy.
Clinical Features
The usual clinical presentation is a history of blurring of

vision 2-6 weeks following cataract surgery. The problem
of cystoid macular edema comes up earlier in the era of
small incision cataract surgery as most patients have
begun to gain a very good visual acuity soon after surgery
due to minimum astigmatism in comparison to routine
ECCE and IOL where sutures are removed only after six
weeks. Thus these patients can experience the visual loss
caused by CME quite early in their postoperative
199
course.The patient usually presents with gradually

decreasing vision usually in the range of 6/18 and 6/60.
Direct ophthalmoscopy reveals the absence of foveal
reflex with the presence of cystic spaces in the macular
region, the inner walls of which are not appreciable. The
pathology can be visualised with greater clarity using a
slitlamp biomicroscopy with a 90-D lens, which reveals
the characteristic cystic spaces in the foveal region.
Evidence of cells or flare may be present in some cases.
In most cases, fluorescein angiography reveals parafoveal
retinal capillary leakage In the early and mid phases of
the angiogram where as a petaloid pattern of leakage in
the macula and leakage on or around the optic disc
occurs in the late phases of the angiogram. (Fig. 36.2)
However, the visual acuity is not related to the amount
of leakage.
Fig. 36.2: Fluosescein angiogram of a patient with cystoid

macular oedema demonstrahng a petalloid form of dye leakage
in the late phase
Management
Prostaglandin release has been implicated in the

disruption of the inner blood-retinal barrier after ocular
surgery and as a cause of CME. Non steroidal antiinflammatory drugs and topical, periocular or oral
corticosteroids are of proven benefit in reducing the
immediate postoperative inflammation that presumably
contributes to the development of CME. In patients in
whom there is a significant visual loss, the first line of
management should probably consist of periocular or
systemic steroids (Injection kenocort ( triamcinolone) 0.5
cc in the subtenons space or tablet prednisolone 1 mg/
kg/ day) orally after breakfast along with an antacid or
an H1 blocking agent to prevent gastritis. Topical
200
diclofenac sodium 4 times daily can be added to this

regimen. In case there is evidence of improvement over
the following 2 to 3 weeks, the subtenons kenocort
injection can be repeated after 3 weeks and slowly tapered
off by increasing the duration between the doses. Some
authors have also used acetazolamide one tablet twice
daily in the management of CME.
The problem with most of the therapies is the high
incidence of recurrence following the withdrawal of the
treatment. It is therefore necessary to continue the
treatment for long enough duration to prevent relapses.
The Vitrectomy-Aphakic Cystoid Macular Edema
Study showed that pars plana vitrectomy to release
vitreous attachments to the surgical wound was beneficial,
significantly improving visual acuity in patients with
postoperative CME associated with vitreous incarceration. YAG vitreolysis has also been selectively used
to divide vitreous strands adherent to the surgical wound.
This is however, possible only if the strand is very localised. Other factors like a poorly positioned lens should
also be managed appropriately. Local oxygen therapy
using goggles for 6 hours a day for 3 weeks has been
shown to have utility in 80 to 90 per cent of patients
though we have no personal experience with this mode
of treatment. It is important to remember that the
successful treatment of chronic CME requires persistence
on the part of the treating ophthalmologist and the
patient.
Photic Maculopathy
The light of the operating microscope can cause macular

damage. Operating microscope maculopathy was seen
in 7 per cent of 135 consecutive patients undergoing
cataract extraction according to one study.
The greatest risk of photic injury occurs following
insertion of an IOL, which focuses the light of the microscope onto the retina. The photic retinopathy of operating
microscopes is probably due to shorter-wavelength visible
light (blue and blue-green). The probability of operating
microscope damage can be reduced by using the lowest
illumination needed for a particular procedure, and by
filtering out light at wavelengths below 450 nm. The
duration of a patients exposure to coaxial illumination
should be minimised by using an occluder or by using
paraxial illumination whenever coaxial illumination is not
essential. As the operating time decreases with phacoemulsification and small incision cataract surgery, the
incidence of these complications are also bound to
decrease.
DIABETIC RETINOPATHY AND CATARACT
Cataract surgery in diabetic patients is more unpredictable

due to many factors like difficulty in fundus visualisation,
increased incidence of cystoid macular edema, and
increased risk of progression of the retinopathy and
anterior segment neovascularisation. A history of prior
photocoagulation can also influence the clinical course
of these patients.
The approach to management is based on adequate
visualisation of the fundus and a proper diagnosis of the
stage of retinopathy. An indirect ophthalmoscopy and a
fluorescein angiography must be included in the
preoperative work up of these patients. Preoperative
assessment of the magnitude of visual loss caused by
cataract is often difficult in the diabetic patient, and a
laser interferometry should be performed in such cases
to know how much improvement is likely to be achievable
with a cataract surgery alone. Even in cases in which the
retina is normal, the patient should be warned of the risk
of development of diabetic retinopathy following surgery,
which could hamper his vision. The variables affecting
the progression of diabetic retinopathy after cataract
surgery include the stage of the diabetic retinopathy, type
of cataract surgery, occurrence of surgical complications
and previous laser surgery.
Epidemiology
Those patients, in whom there is no evidence of diabetic

retinopathy have minimal risk of progression following
cataract extraction. Deterioration of diabetic retinopathy
occurs following cataract surgery in 30 to 40 per cent of
diabetics. if they had significant pre-existing diabetic
retinopathy prior to the surgery. In cases with pre-existing
diabetic maculopathy, the progression of maculopathy
is seen in 20 to 30 per cent of patients. These patients
have a higher than normal incidence of cystoid macular
edema also. Pre-existing proliferative diabetic retinopathy
is associated with an increase in the risk of vitreous
haemorrhage
Approach to Management
The approach to management is based on the sufficient

visualisation of the fundus. In mild nonproliferative
diabetic retinopathy, no active intervention is done preoperatively for the retinopathy (Fig. 36.3a) Only
postoperative observation is needed in such patients. In
moderate to severe nonproliferative diabetic retinopathy,
pre-operative panretinal photocoagulation should be
considered as a management option, especially in India

since the risk of patients being lost during the follow-up
is high. In patients with pre-existing proliferative diabetic
retinopathy, panretinal photocoagulation should be done
to whatever extent is possible preoperatively and completion of the same must be done in the early post-operative period (Fig. 36.3b). Maculopathy detected preoperatively will not only deteriorate, but is also associated
with the risk of development of cystoid macular edema
in the postoperative period. If focal macular laser is
possible, then the same should be carried out and cataract
surgery should be carried out 4 to 6 weeks later. However,
the role of prophylaxis with nonsteroidal anti-inflammatory drugs in the pre-operative period to prevent the
occurrence of CME is still debated.
Fig. 36.3a: Fluorescein angiography of a patient with early

non-proliferetive diabetic retinopathy
It is important that the patients glycaemic status is

checked before he is taken up for cataract surgery. It is
known that the chances of infection in a diabetic eye are
no higher than in the normal population, but in cases
where infection has occurred, the course is more severe.
IOLs are not contraindicated in diabetics. Surgery as
such should be directed so as to insert a larger IOL (6mm
optic), which is surface modified and which will help in
the early postoperative visualisation of the fundus and
laser treatment if necessary. Steps like posterior capsule
polishing should be taken to prevent the development
of aftercataract. An inferior sphincterotomy may help in
increasing the pupil size in the otherwise rigid pupil. It is
important that the integrity of posterior capsule be
maintained during the surgery. Extra sutures should be
applied in patients undergoing small incision nonphaco
cataract surgery to permit photocoagulation in the early
201
Fig. 36.3b: Fluorescein angiography of a patient with

proliferative diabetic retinopathy
The rate of progression of retinopathy is higher
following intracapsular cataract extraction (ICCE) than
with ECCE. Progression to the stages of rubeosis iridis,
vitreous haemorrhage and diabetic maculopathy are
known. There is no significant difference in the rate of
progression of diabetic retinopathy between
uncomplicated ECCE and ECCE and IOL.
The advantage of phacoemulsification in such cases
is the watertight compartment formed and the higher
wound strength that it offers in the immediate
postoperative period, which not only makes it possible
to do a vitreous surgery with the cataract surgery in the
same sitting if needed, but also makes the laser treatment
in early postoperative period easier. This advantage is
partially negated if the wound size is large. In advanced
cataracts, where the posterior segment cannot be assessed
for diabetic changes, it is advisable to carry out an indirect
ophthalmoscopy on the operating table following cataract
extraction and evaluate the retinal status prior to insertion
of the IOL. In cases, which require vitreous surgery, it is
best to leave the patient aphakic after the cataract
extraction. In these cases, after the completion of the
retinal surgery, an IOL can be inserted if needed. In case
an IOL is planned, a silicone IOL is best avoided in cases
where we contemplate the possibility of a vitreous surgery
at a later date.
There is a higher incidence of iris neovascularisation
reported following capsular rupture during the surgery.
Risk of neovascularisation also increases following YAG
capsulotomy. Preoperative photocoagulation can help
to reduce the incidence of cystoid macular edema
following cataract surgery. The progression of diabetic
202
retinopathy is still possible postoperatively in lasered

patients and it depends on the stage of diabetic
retinopathy and the status of retina in these cases.
RETINAL DETACHMENT
FOLLOWING CATARACT SURGERY
Introduction and Epidemiology
Eyes with aphakia or pseudophakia account for more

than 40 per cent of the total retinal detachments operated
at any large referral centre. The incidence of retinal
detachment is 2 to 5 percent after intracapsular cataract
extraction and 0 to 1.4 percent after extracapsular cataract
extraction. However, the incidence may approach 20
percent in cases with vitreous loss. YAG capsulotomy is
risky in that the chances of retinal detachment increase
threefold after the capsulotomy. The incidence of
postoperative detachment is substantially increased in
myopic eyes. 50 per cent of retinal detachments occur
within the first year after cataract surgery. Retinal
detachment may be present preoperatively in an eye
undergoing cataract extraction or it may develop in the
Approach to Management
In all cases of cataract, where the fundus is poorly visualised by an indirect ophthalmoscope, it is imperative to
get an ultrasound of the posterior segment done so as to
rule out a retinal detachment. In case a retinal detachment
is detected on the ultrasound, it is best to refer the case
for a vitreoretinal surgery. Alternatively the case may be
considered for a small incision cataract surgery (phaco
or manual). Extracapsular cataract extraction should be
avoided in such situations since the integrity of the corneal
wound is not established for atleast 4 to 6 weeks following
the surgery. A phacoemulsification has the advantage of
permitting scleral buckling or primary vitreoretinal surgery
in the same sitting or soon after the cataract surgery as
the wound integrity is well maintained. A similar advantage exists to a lesser extent following a small incision
manual cataract surgery. Retinal detachments detected
preoperatively in a patient who needs cataract surgery
are best handled with a primary vitreous surgery if fundus
visualisation is poor or by an indirect ophthalmoscopy
after removing the cataract (but prior to insertion of the
IOL). In case the vitreoretinal surgeon concludes that
the retinal detachment is relatively fresh and amenable
to a scleral buckling procedure, one could consider
insertion of a large diameter 6 mm IOL (not of silicone)
If however, the retinal detachment is old or with
proliferative vitreoretinopathy (PVR), it is better not to

insert an IOL.
Retinal detachments following cataract extraction
typically have small flap tears along the posterior margin
of the vitreous base. The retinal detachments are usually
more extensive and often involve the macula. Multiple
breaks are found in more than 50 percent of retinal
detachments that occur following cataract extraction. The
progression to proliferative vitreoretinopathy is also faster
in such cases. These cases are managed like all other
rhegmatogenous retinal detachments, with a scleral
buckling surgery. In some cases it is difficult to find the
break in cases of post cataract surgery retinal detachment,
even with indentation because apart from the fact that
the breaks are small and peripherally located, visualisation is also often difficult in many cases due to the
presence of peripheral capsular opacification, and reflexes
from the IOL edge.
The intra-operative visualisation of the fundus may
also be hampered by the IOL edge or posterior capsule
opacification, The corneal wound may need strengthening before starting the retinal detachment surgery.
Even corneal/ scleral valves need to be strengthened most
of the times, as they are not watertight under higher
pressures, which are often reached when the eyeball is
being manipulated. It is also important for the anterior
segment surgeons to know that the possibility of
subluxation or dislocation of the IOL always exists during
a scleral buckling or vitreous surgery.
Prognosis following aphakic or pseudophakic RD
surgery is at best fair. Patients with anterior chamber IOLs
have a lower probability of reattachment after one
procedure than do patients with posterior chamber
IOLs. In recent times, anatomic success rates of upto 85
to 90 per cent are being claimed following RD surgery in
post cataract surgery patients. The visual outcome in
these patients may be subsequently occasionally complicated by cystoid macular edema, which further jeopardises the final visual acuity obtained by these patients.
POSTCATARACT SURGERY ANTERIOR
ISCHAEMIC OPTIC NEUROPATHY (AION)
Anterior ischemic optic neuropathy was first described

in 1951. Towne first reported four cases of optic
neuropathy after uncomplicated cataract extraction. In
1973, Carroll reported the occurrence of AION with visual
loss 4 weeks to 15 months after cataract surgery. In 1980,
Hayreh described visual loss after cataract surgery that
was thought to be secondary to ION. Risk factors for the
development of nonarteritic ION include hypertension,

diabetes, smoking, and a crowded disk with a small cup,
especially if the patient had a crowded disk in both eyes.
Pathogenesis
Hypotheses to explain the infarctive processes associated

with both the anterior and posterior forms of optic
neuropathy (AION and PION) involve anatomical factors
peculiar to the optic nerve. The peripapillary choroid
supplies blood to both the nerve head and retrolaminar
region of the optic nerve. In the presence of hypotension
leading to compensatory mechanisms involving chemical
mediators such as angiotensin II, peripapillary choroidal
vasoconstriction results in anterior optic nerve ischemia.
Most likely, patients who have visual loss weeks to
months following surgery represent cases of spontaneous
nonarteritic ION unrelated to the cataract surgery;
however, those with visual loss in the immediate postoperative period represent a separate clinical entity. In
these patients, the exact pathogenesis remains unclear.
Hayreh proposes elevated IOP or fall in blood pressure
as the possible mechanism. Others suggest possible
structural abnormalities in the optic disc.
Clinical Features and Management
Patients present with diminution of vision in the

immediate postoperative period or weeks or months
following the surgery. The anterior form of ION is
characterised by pale optic disc edema involving all or
part of the disc with or without splinter haemorrhages in
the acute stage. Gradual atrophic changes develop over
approximately two months with resolution of the edema.
This contrasts with acute posterior ischemic optic
neuropathy, wherein theres a normal disc and fundus
at onset, gradually giving way to disc atrophic changes
over the next two months. No successful treatment has
been found though the use of pulse steroid therapy in
the acute phase has shown some promises.
Most studies cite an occurrence of ION in the fellow
eye in 30 to 50 per cent of patients. These series were
reported before topical anaesthesia was introduced, and
these patients had retrobulbar or general anaesthesia. It
is not known whether topical anaesthesia is associated
with the same risk.
Outer Retinal Ischaemic Infarction
This is a peculiar syndrome occurring as a complication

of cataract extraction. Gass first reported a case in 1982.
The syndrome is characterised initially by acute loss of
central and paracentral vision, which is usually discovered
203
on the first postoperative day. Fundus examination in

these cases revealed that the posterior pole is stippled by
diffuse and patchy whitening of the outer retinal layers.
Fluorescein angiography shows normal angiographic
retinal and choroidal appearance and circulation time,
but a peculiar polygonal pattern of fluorescein staining
of the pigment epithelium and outer retina is present in
the area of retinal whitening. Later the mottling and
whitening of the retina disappears with partial recovery
of the central visual field. The optic disc and retinal
vascular calibre are maintained. Prolonged elevation of
the intraocular pressure sufficient to obstruct choroidal
blood flow occurring during the use of intraocular
volume-reducing devices before surgery, during phacoemulsification is postulated as the major cause of this
complication. No beneficial treatment options are
available till now.
Age Related Macular Degeneration and Cataract
Age related macular degeneration (ARMD) is the leading

cause of visual morbidity among the elderly population
in the west and is speedily catching up as an important
problem in India also. The most important determinant
in the prevalence of ARMD is age as shown by the
Framingham Eye Survey. The prevalence of clinically
significant ARMD was 1.6 percent of persons aged 52 to
64, 11.0 percent of persons between the ages of 65 and
74, and 27.9 percent of persons 75 to 85 years showing
clearly the importance of age in the development of
ARMD. Thus it goes without saying that a lot of elderly
patients who have cataract are also likely to have ARMD.
In all cases where the visual loss is not explainable by
cataract alone, we should have a detailed examination
of the macular area to rule out any changes of ARMD. It
is important to keep in mind that there are two important
clinical forms of age related macular degeneration : a)
Dry age related macular degeneration, which accounts
for 90 per cent of patients with this condition, but causes
only 10 per cent of the total blindness attributable to this
disorder and b) wet (exudative ARMD) which accounts
for 105 of the patients, but 90 per cent of the blindness
caused by this disorder. Manifestaions of dry ARMD
include macular drusen, pigmnetary changes and geographic atrophy. Drusen do not persay result in visual
loss. Pigmentary changes and geographic atrophy can
result in mild to moderate visual loss. Dry ARMD usually
presents with a raised lesion, which may be a serous
detachment, retinal pigment epithelial detachment or a
disciform subretinal scar. The presence of subretinal blood
and/or exudates is a hallmark of exudative age related
204
macular degeneration. This can result in severe visual

loss (less than or equal to 5/200) though the visual acuity
may be preserved for a few weeks or months in the early
stages of the disease process. Patients with severe age
related macular degeneration often give a history of loss
of colour perception. The presence of this history in a
patient with cataract which is too extensive to permit
fundus evaluation should warn the surgeon of the
possibility of this disorder. Patients with ARMDshould
be explained regarding the disorder and should be kept
on regular follow-ups. Preoperative evaluation should
include a laser interferometry or potential visual acuity
meter for predicting the possible visual outcome. A
fluorescein angiography should be obtained preoperatively if the fundus is visible. If it is not visible, then an
angiography should be arranged postoperatively.
During surgery, it is possible to give the patient an
advantage of magnification by using Gallelian telescopic
system. Undercorrection of the IOL power and positive
correction given outside will give the patient more magnification than with his correct power of IOL. Such a course
may be worthwhile in a patient who is likely to have
significant visual defects due to ARMD. A good refraction
and low visual aids are to be offered to the patient. Postoperatively the patient should be assessed properly for
the ARMD with a fluorescein angiography and should
be followed up regularly with an Amslers grid.
Distortion on the Amslers grid testing is an early
indication of development of exudative ARMD in a
patient who is previously suffering from the dry form of
the disease. Recent studies have indicated that high doses

of anti-oxidants ( Vitamin C 500 mg, vitamin E 400 IU
and beta-carotene) along with 80 mg of zinc and 2 micrograms of copper per day can significantly bring down
the risk of both moderate and severe visual loss in patients
with age related macular degeneration.
Patients who develop the exudative form of the disease
would need to be treated by argon laser (If the lesion is
greater than 200 micrometer away from the fovea or by
Photodynamic therapy or Transpupillary thermotherapy
if the lesion is juxta-or subfoveally located. Both these
therapies have shown promise for the management of
patients with exudative age related macular degeneration
involving the fovea. The role of photodynamic therapy
with verteporfrin in the management of subfoveal
exudative ARMD has been validated by a number of
double masked placebo controlled trials. Both Photodynamic therapy and Transpupillary thermotherapy
therapies are now available in a number of centres in
India.
The conditions described above represent some of the
commoner and more important posterior segment
disorders that a small incision cataract surgeon is likely
to encounter in his practice. Quite obviously, the list is
not exhaustive and does not purport to be complete.
The objective of the authors was to provide a small
incision cataract surgeon with information regarding basic
practical approach to management of the more important
posterior segment disorders seen in clinical ophthalmic
practice.
Glaucoma and SICS
37
Glaucoma and
SICS
oexistence of cataract and glaucoma in the same

eye is frequently encountered in elderly population. The surgeon should consider the option
of performing cataract and glaucoma surgeries in two
stages or to combine in one sitting that is more appropriate for the individual depending on the visual status
and condition of the eye. Over the past decade combined
cataract extraction and glaucoma filtration surgery has
been shown to be an effective procedure for the patients
having glaucoma with visually significant cataract.
Phacotrab, phacoemulsification combined with trabeculectomy is widely acclaimed procedure for these cases,
but it is not so popular in the developing countries
because of its cost factor and long learning curve. In this
chapter we would like to discuss an alternate procedure,
non-phaco SICS and trabeculectomy which is very simple
to perform (easy learning curve) and cost effective.
The anatomic and physiologic alterations occurring
in glaucomatous eyes are protean. Corneal decompensation seen after otherwise uncomplicated cataract
extraction is common in-patients having sustained a
severe attack of ACG and all attempts to prevent corneal
trauma is ensured during cataract surgery. Patients with
pseudoexfoliation syndrome have abnormal zonules and
capsules, which might predispose to capsular rent,
pigment dispersion, break of aqueous barrier, hyphaema
etc. The lenses of patients with long-standing glaucoma
and advanced cataract often subluxate, if not fully, has
to be kept in mind and to be managed more cautiously.
So as the atonic pupil that follows after an acute attack
of ACG is fixed and dilated requires a large IOL optic to
prevent glare and monocular diplopia. Recognizing these
factors preoperatively remains the key for the sucessful
visual outcome in combined surgery.
Indication
Presence of visually significant cataract with glaucoma is

considered for non-phaco SICS trabeculectomy, and
other indications are:
1.
2.
3.
4.
205
P Mishra
S Thanikachalam
Inadequate control of IOP

Medical intolerance/poor compliance
Mild to moderate optic nerve damage
Advanced glaucoma.
Instrumentation
26-G needle
Hydrodissection cannula
Crescent knife/ Diamond knife, round type blade with
4 mm long sharp sides
Angled keratome, 2.65 mm
Microvectis (micro lens loop)
Simcoe cannula
Weckcell sponges
9-0, 10-0 nylon suture
Punch forceps or Scleral trephine(1.5, 2 mm).
Surgical Techniques
Anaesthesia
Combined surgery is most safely performed with peribulbar anaesthesia. The anaesthetic solution consists of
mixture of 2 per cent lidocaine and 0.5 per cent bupivacaine. It is injected into the anterior orbit by two points
technique. The 26-G needle introduced below the supraorbital notch and advanced to a mid orbit depth, the
second incision site is given above the inferior orbital
rim near lateral canthus.
Conjunctival Flap
There have been conflicting reports regarding the safety

and efficacy of the limbus-based vs the fornix-based
conjunctival flaps in combined surgery of cataract and
glaucoma.1,2 The fornix-based conjunctival flap in this
combined procedure has the advantages of better
exposure of the surgical site, less handling of the
conjunctival flap and more posterior development of the
conjunctival filtering bleb. For the above reasons we
206
Fig. 37.1: Scleral tunnel formation with crescent
always prefer a fornix-based conjunctival flap (Fig. 37.1),

which is closed by suturing one or both ends of the flap
to the limbus with 9-0 nylon suture for a tight limbal
closure. Sometimes watertight closure is achieved by
suturing the flap with peripheral cornea with 10-0 nylon.
The conjunctival flap is usually dissected in the superior
quadrant and the width of the conjunctival dissection
should be slightly larger than anticipated scleral tunnel
incision for better exposure. The conjunctival reflection
should be made as posterior as possible, at least 8-10
mm posterior to the limbus. Haemostasis of episcleral
blood vessels is achieved by bipolar diathermy.
Scleral Incision
A three-stage (triplanar) scleral tunnel incision is made

with the initial external frown incision given approximately 2-3 mm posterior to the limbus. It is given either
with a diamond knife or a stainless steel blade. The
second incision is intrascleral dissection (Fig. 37.1) and
the third oblique entry into anterior chamber through
clear cornea. The scleral dissection is kept half the thickness and the anterior entry wound should not extend
too anterior else it will cause striae formation in the
posterior cornea, which prevents adequate visualisation
of the anterior segment. A low molecular viscoelastic substance is injected to reform the anterior chamber once
its entry is made with angled micro-keratome. From one
end of the incision another radial incision is given which
is extended to the limbus (Fig. 37.2). This step is essential
for trabeculectomy, which may be given after completion
of the cataract surgery and lens implantation.
Fig. 37.2: Frown incision and a radial incision at

one end for trabeculectomy
is often limited by small pupil or poor dilation in glaucoma

patients on long-standing medical therapy. Inability to
dilate pupil sufficiently or small rhexis may cause vitreous
loss due to zonular dialysis during nucleus management.
All necessary steps to be undertaken for management of
small pupil. When necessary, multiple partial sphincterotomies or stretching of pupil with Sinskey hook may be
done to enlarge the pupil. Rhexis can be performed very
easily in mature/advanced cataracts by using Trypan blue,
which enhances the visualisation by staining the anterior
capsule. Whenever the rhexis is small, two relaxing
incisions at 2 and 10 Oclock are usually required to luxate
the nucleus easily in to anterior chamber in nuclear
cataracts.
Hydrodissection
It is a crucial step to be performed in all the cases, which

separates the nucleus from its capsular attachments. The
anterior capsule is elevated with a 26 G cannula attached
to a 2 ml syringe filled with BSS and the fluid is injected
slowly and continuously beneath the edge of capsulorhexis to create a fluid wave that passes across the red
reflex. The fluid wave is not visible in dense cataracts. In
such cases, when hydrodissection is completed, the
nucleus appears to move forward following which it must
rotate freely inside the capsular bag.
Nucleus Management
Capsulorhexis
Continuous curvilinear capsulorhexis is performed using

26G needle or rhexis forceps. The size of capsulorhexis
Nucleus delivery with conventional large incision surgery

is dangerous in uncontrolled glaucoma, because of the
positive vitreous pressure. The small incision technique
Glaucoma and SICS
offers distinct advantage over it with safe removal of the

nucleus. The nucleus is luxated into the anterior chamber
with Sinskey hook or bent 26-G needle. This is usually
done by rotating the nucleus either clockwise, anticlockwise or both following reforming the anterior
chamber with viscoelastics. Once it is in the anterior
chamber the nucleus is gently expressed through the
scleral tunnel using a microvectis. This is our preferred
technique for nucleus removal over the last 5 years. The
residual cortex is aspirated with Simcoe cannula.
Complete cortical removal, with sclerostomy site free of
capsule, cortex, blood or vitreous is extremely important
for the success of combined surgery. The posterior
capsule may be polished, if necessary. The viscoelastics
is placed in the capsular bag to distend sufficiently enough
for lens implantation. IOL implantation is performed by
using any preferred technique. Pupil is restored to round
and small size by gently stroking the iris, even intracameral pilocarpine can be used for intraoperative miosis,
which should be thoroughly washed away from the
anterior chamber.
tion that is sufficient for good flap is about half the thickness of sclera. Once IOL implantation is over anterior
chamber is reformed with either air (Fig. 37.3) or
viscoelastics, another radial incision from one end of
scleral groove (frown incision) is given upto the limbus
(Fig. 37.2). A triangular flap is fashioned (Fig. 37.4); it
should be handled with fine forceps to avoid injury to it.
The dissection is continued anteriorly into the cornea so
that scleral spur can be identified through deep scleral
lamella and 1 mm of cornea anterior to the spur is seen.
When the scleral flap is retracted towards the pupil by
the assistant a blade breaker knife or Bard Parker knife
with 11-G blade is used to make two radial (Fig. 37.5)
incisions about 1.5 mm apart extending for about 2 mm
from corneolimbal junction to the sclerolimbal. A third
incision is made parallel to the limbus at the corneolimbal
junction. The free edge of block tissue is grasped with
Pierse Hoskins forceps and rotated posteriorly allowing
the angled vannas scissors to cut horizontally at the scleral
spur.
Antimetabolites
If antimetabolites are used for intractable glaucoma it

should be applied under the conjunctival/scleral flap. It
is useful in high-risk cases where chances of failure of
trabeculectomy are high; it may effectively limit fibrosis,
scarring and bleb failure. MMC offers a beneficial effect
on combined filtration surgery without having the corneal
toxicity of 5 FU.5,6 Excess concentration of the drug may
cause conjunctival necrosis with underlying scleral
melting, bleb leak, hypotony and even endophthalmitis.
The preferred method is, a 5 5 mm sponge soaked in
mitomycin C with a concentration of 0.25 mg/ml is
applied to the filtered area for about two minutes with
the conjunctiva and tenons draped over it. Care was
taken to avoid contact between the sponge and the edge
of the flap by holding conjunctiaval flap edge away from
the sponge with tying forceps.6,7 The site is then irrigated
with BSS to remove residual drug.
Fig. 37.3: IOL implanted with air bubble in AC
Scleral Flap
Dissection of scleral flap (Fig. 37.1) is vital step for successful wound closure. If scleral flap is too thin it will lead to
button holing or tear formation resulting in excessive
filtration with postoperative hypotony and the situation
is made even worse with use of MMC. If the flap is made
too thick it may lead to premature entry into the anterior
chamber with subsequent iris prolapse. The ideal dissec-
207
Fig. 37.4: Dissection of triangular flap at

one end of frown incision
208
Fig. 37.5: Radial incision over the trabecular meshwork
Fig. 37.7: Deep scleral flap visible, iridectomy done
Alternatively Kelly punch is used to excise trabecular

tissue; the third option is, to use 1.5 or 2 mm scleral
trephine to remove a circular piece of trabecular meshwork to create filtration fistula. The block of tissue
removed (Fig. 37.6) should contain anterior scleral spur,
Schlemms canal, trabecular meshwork, Schwalbes line
and peripheral cornea. A peripheral iridectomy (Fig. 37.7)
is performed and the anterior chamber reformed with
BSS. The scleral flap is closed with single 9-0 nylon suture
at the apex of the flap, where the radial incision was
initiated.
Conjunctival Closure
The fornix based conjunctival flap is closed by suturing

its one or both ends to the limbus with 9-0 nylon suture
for a tight limbal closure. Some times the conjunctival
wound is closed with peripheral cornea by running 10-0
nylon suture for a watertight closure.8 The anterior
chamber is filled with air for wound stability (Fig. 37.8).
Fig. 37.8: Conjunctiva is closed
Postoperative Medications
Topical corticosteroids are administered generously in

the immediate postoperative period to inhibit
inflammation and to decrease scar tissue, which is tapered
slowly within 2-3 weeks. Cyclopentolate (1%) is used
whenever there is severe iritis for few days. Digital
massage over cornea through the lids is applied whenever
necessary during early postoperative period, particularly
when the IOP is greater than 20 mm Hg8. Drugs that
decrease secretion of aqueous, acetazolamide should not
be used unless indicated. Persistent flat anterior chamber
in the postoperative period should be diagnosed by
Siedels test and managed accordingly.
Conclusions
Fig. 37.6: Removal of trabecular meshwork with
exposure of iris, trabeculectomy completed
Combined surgery attempts to manage cataract and

glaucoma in single surgical procedure, performed in the
Glaucoma and SICS
same site. The procedure employing non-phaco scleral

tunnel small incision surgery for cataract extraction also
provides access for filtration surgery simultaneously with
improved success and safety without the need for second
surgical procedure. It does not require longec learning
curve, greater skill, and at the same time gives fairly
excellent results. No doubt, this can be considered as a
low cost alternative to phacotrabeculectomy in the
developing countries.
REFERENCES
1. Mc Cartney DL, Memmen JE, Stark WJ et al: The efficacy
and safety of combined trabeculectomy, cataract extraction
and intraocular lens implantation. Ophthalmology 95: 75463, 1988.
2. Simmons ST, Litoff D, Nichols DA et al: Extracapsular cataract
extraction and posterior chamber intraocular lens
3.
4.
5.
6.
7.
8.
209
implantation combined with trabeculectomy in patients with

glaucoma. Am J Ophthalmol 104: 465-70, 1987.
Hurvitz LM: Combined surgery for cataract and glaucoma.
Curr Opinions Ophthalmol 4(2): 73, 1993.
Lyle WA, Jin JC: Comparison of a 3 and 6 mm incision in
combined phacoemulsification and trabeculectomy. Am J
Ophthalmol 111: 189-96, 1991.
Costa VP, Moster MR, Wilson RP et al: Effects of topical
mitomycin C on primary trabeculectomies and combined
procedures. Br J Ophthalmol 77: 693, 1993.
Wong P, Goldenfeld M, Ruderman J et al: 5 Flurouracil (5FU)
after primary combined filteration surgery: A prospective,
randomised study. Invest ophthalmol Vis Sci 34: 727, 1993.
Wyse T, Meyer M, Ruderman JM et al: Combined trabeculectomy and phacoemulsification: A one site vs two site
approach. Am J Ophthalmol 125(3): 334-39, 1988.
Lemon LC, Shin DH, Kim C et al: Limbus based vs fornix
based conjunctival flap in combined Glaucoma and cataract
surgery with adjunctive mitomycin C. Am J Ophthalmol
125(3): 340, 1998.
210
Paediatric Cataract:
My Experiences
38
Daljit Singh
he whole question of a large, medium, small and

mini incisions is concerned with the removal of
the harder part of the cataract- the nucleus. The
rest can be removed by irrigation/aspiration. In most of
the paediatric patients, the size and the hardness of the
nucleus permit the performance of the lens removal and
intraocular lens implantation manoeuvres through a relatively small incision. However, the presentation of the
paediatric patients shows a great variation and the
response of the ocular tissues during and after the surgery
are different from the adults. The surgical approach to
the lens removal and the type of lens implantation is
extremely varied and full of controversies.
The purpose of small incision surgery in paediatric
patients.
In the adults, the main purpose of a small incision
surgery is to minimise postoperative astigmatism. In the
paediatric cases, it is to ensure greater safety during the
conduct of the surgery and to minimise operative and
postoperative problems peculiar to this group. Keeping
the incision line suture less is not mandatory.
Clinical situations requiring cataract and implant
surgery:
1. Congenital cataract.
2. Dislocated lens.
3. Traumatic cataract.
4. Secondary cataract.
5. Secondary lens implantation.
Congenital Cataract
There are more varieties of congenital cataract (Fig. 38.1)

than meet the eye or are described in the literature. From
the surgical point of view, the following observations are
important:
1. The integrity of the capsular bag About 10 per cent
of congenital cataracts have a pre-existing rent/
opening/dehiscence/absence of the posterior capsule in a small or a large area of the posterior
capsule.
Fig. 38.1: Congenital cataract
2. The physical state of the cataractous lens The

consistency of the cataract may vary to milky fluid
like to hard rock like, with all the intermediate
stages.
3. The anterior capsule Since an extracapsular surgery
is being performed, an important component of
success is formed by excellence obtained in the
capsulotomy step. The anterior capsule varies in
many characters like its consistency, uniformity,
fragility, support from the underlying cortex and
the pull of the zonular fibres.
Surgical approach to congenital cataract:
Only Lens Extraction
The lens may be removed through:

a. Small limbal incision/incisions.
b. Pars plana lensectomy. In my opinion a pars plana
approach is riskier, since it unnecessarily cuts through
important vitreous cisterns, produces fibrotic reactions,
and is likely to cause some vitreous-lens mix. A number
of vitreoretinal problems can arise as a result.
c. The anterior route: This is the one described below.
Paediatric Cataract: My Experiences

The Anterior Route Approach to
Congenital Cataract
If an intraocular lens implantation is desired, then the

minimum size of the incision shall take in to consideration
the widest diameter of the intraocular lens optic. My
approach is described below which can be modified to
suit the needs of an individual surgeon.
Incisions
a. Two side port pocket incisions 1 mm wide, 180 degrees

apart. The pocket depth may be kept at about 1 mm.
First a 0.3 mm deep vertical groove is made, which is
followed by horizontal pocket section.
b. The anterior chamber is filled with a visco-elastic
material, like HPMC. The eye should feel firm at this
point which will help the next step.
c. A 4.25 mm wide vertical groove is made at the upper
limbus. This is followed by the making of a pocket
section, the depth being about 2 mm.
The incisions are best made with diamond knives.
However, good quality disposable steel blades are
also available for the purpose.
The purpose of making pocket incisions is manifold.
They help to maintain the depth of the anterior
chamber during surgery. They minimise the tendency
of the iris to prolapse through incisions. They prevent
the formation of peripheral anterior synechiae. The
anterior chamber should be kept deep throughout the
procedure either by irrigation or by keeping HPMC in
it. A flat anterior chamber invites the formation of fibrin
during the surgery, which can be quite troublesome.
The younger the patient, the greater is the need to
take observe this precaution. Lastly, if and when
suturing is necessary, it can be done easily.
d. The anterior chamber is once again filled with HPMC.
Anterior capsulectomy /capsulotomy is an important step.

The following types of anterior capsulectomies are
possible:
CCC This is done with a capsulotomy needle through
the side port alone or assisted by a forceps through
the upper larger incision. The anterior capsule in the
paediatric patients is sometimes so elastic that the
capsulotomy can run into the periphery. This spoils
the ground for in the bag implantation, if so planned.
Can opener capsulotomy of a very large size can be
done with a view to destroy most if not all the anterior
capsule cells. However, the equatorial cells still remain.
211
A subtotal anterior capsulectomy makes it very easy

to remove the cortex from the fornices.
Kloti needle This bipolar cautery needle gives more
control on the size and shape of anterior capsulotomy.
It takes about 30 to 40 seconds to perform a good
capsulectomy. The capsule seems to stick to the needle
as it is cut.
Fugo blade The blade tip is in the form of a 100 micron
filament, which when activated gets covered with a
30 micron wide column of plasma. The plasma has
great cutting properties. It cuts without any resistance.
A capsulotomy can be performed in 5 to 10 seconds.
It may be performed in parts, which are then united
by retouching. The cut edge made with plasma energy
becomes strong and resists tearing, something that
does not happen with other capsulotomies. Fugo blade
capsulotomy is done in a deep anterior chamber.
Cataract Removal
The cataract removal in uncomplicated cases have soft

consistency cortex and nucleus can be performed in the
following way:
Irrigation/aspiration with any of the well known
cannulas. My preference for my own design (made
by Indo-German) is due to the fact in this cannula,
the irrigation port is on the under surface and the
aspirating port is on the anterior surface. With the
irrigation on, one can not tear the posterior capsule,
since the capsule is pushed away by the fluid pressure.
The irrigating fluid gets into the fornices and pushes
out the cortical matter, making it easy to attract it to
the aspirating port. The aspiration is done with a 1 ml
disposable syringe. The removal of the cortex under
the pocket incision is difficult. For this reason the 12
O clock cortex is loosened by irrigation from the side
port incisions.
Irrigation/aspiration with the help of phaco or nonphaco irrigation/aspiration machines. The procedure
is quicker, since the fluid movement is fast and
aspiration can be done at a higher vacuum pressure.
Dry aspiration: Little or no saline is used in this
technique. A 22-gauge cannula attached to the syringe
is used to suck out the lens. Each aspiration is followed
by injecting HPMC in the bag to loosen more of the
lens. Care is taken not to aspirate near the posterior
capsule, so as not to produce a tear.
I do dry aspiration as follows. From the side port incisions and from the top, I inject HPMC under the cut
edge of the anterior capsule. As the lens matter rises, I
212
push HPMC close to the posterior capsule. Practically

the whole of the lens mass rises anteriorly and the
chamber becomes deep. At this stage the HPMC cannula
is introduced through the upper incision. This results in
the raised lens mass passing out of the top incision.
Further HPMC push into the lens fornices is done to raise
and deliver the remaining lens masses. At the end, if so
needed, a small saline irrigation/ aspiration is done. The
technique described above seems to work best if capsulotomy has been done with a Fugo blade, since this
capsulotomy allows the big lens mass to be delivered
without tearing. It is pertinent to mention that Fugo blade
helps make much bigger intact capsulotomy than by other
procedures, which is an advantage.
Lens Implantation
The choice of an intraocular lens is surgeons preference.

I use an artisan lens (earlier called iris-claw lens for the
following reasons. This lens avoids the angle of the
anterior chamber, the corneal endothelium, the reactive
space behind the iris (which I call Pandoras box), every
part of the lens and the tissues in contact can be examined
in the follow-up examinations, posterior capsulotomy is
easy to perform afterwards, the lens can be explanted or
exchanged atraumatically, if ever a need arises. The lens
is well-tolerated as our 22-year experience shows.
Many surgeons have other choicesin the bag lens
implantation with or without a posterior capsulotomy,
anterior vitrectomy and optic capture. The sulcus fixation
is however much more risky for fear of ciliary body
erosion and related problems.
times the process of iris pulling will cause a tear at the iris
root resulting in iris bleeding. The bleeding can be reduced by raising the pressure inside the anterior chamber
with saline or HPMC and waiting for a sufficient length
of time. In the end the anterior chamber is washed clean.
Air Bubble
The two sides of the pocket section come together only

if the anterior chamber is well-formed at the end of the
operation, either with saline or with air or a combination
of the two. Make sure that there is no leakage from any
incision. Look at the possibility of a leakage when the
patient is out of anaesthesia. If in doubt, it is better to
apply a couple of sutures and provide security to the
incisions (Fig. 38.2).
The above description suffices for a patient of say 3
to 5 years suffering from a textbook type of zonular
cataract without any other complicating factor. Obviously
the conditions are going to be different if the patient is
much younger, say of about 3 months of age or much
older, say around 17 years.
Peripheral Iridectomy
It is good to do peripheral iridectomy in most young

patients even if an in the bag lens implantation has been
done. The reason is that any postoperative reaction is
likely to cause synechia formation and iris bombe. True,
you can overcome this with a laser Peripheral Iridotomy
(PI). But laser PIs are highly unpredictable in black eyes
and are likely to get closed soon. In young infants, I have
seen large iridectomies and even complete iridectomies
closed with tissue growth, even without a sign of
inflammation.
How to do a peripheral iridectomy through a pocket
incision? It is not possible to hold the periphery of the
iris. The other alternative is to hold the iris close to the
inner opening of the incision, pull the iris downwards
and cut it inside the eye with a scissors (normally we are
used to cutting the iris by pulling it out). A number of
Fig. 38.2: Look of the eye after surgery
Dislocated Lenses
Dislocated lenses are more difficult to manage for obvious

reasons (Fig. 38.3). The following approaches are
practiced:
1. Pars plana lensectomy and vitrectomy, with or
without lens implantation. The intraocular lens
fixation is in the sulcus, over some of the retained
lens capsule. Or it can be a scleral fixated intraocular lens.
2. Anterior approach: A capsular tension ring
followed by in the bag intraocular lens. If the
crystalline lens is considerably off centre, then a
loop of the intraocular lens may be scleral fixated.
Paediatric Cataract: My Experiences
213
Traumatic Cataract
Fig. 38.3: Subluxated lens
3. Lensectomy by one of the many ways, followed

by angle supported lens.
4. Anterior route lens extraction followed by artisan
lens implantation.
The size of the incision will vary with the technique
adopted. For the last technique that I employ, the size
and position of the incision remains the same as for
routine congenital cataract cases. The lens extraction is
done by one of the following ways:
1. Manual capsulotomy, dry aspiration of the lens and
artisan lens implant.
2. Automated capsulotomy with Fugo blade. The
beauty with this device is that the capsular bag
does not move during the cutting process and the
cut edge is stronger than we get by manual means.
HPMC is injected into the capsular bag to deliver
most of the lens while the rest is removed by dry
aspiration assisted by HPMC. The use of this
instrument minimises disturbance to the vitreous,
since it becomes possible to preserve the zonular
fibres that are present at the start of the procedure.
3. A dislocated lens with little or no zonular supported
is manoeuvred into the anterior chamber, the pupil
is contracted and the lens is removed by dry aspiration, the capsular bag being removed at the end.
A small anterior vitrectomy is done after artisan
lens implantation.
4. In adults with dislocated opaque lens, a small incision cataract surgery is highly risky. In some cases
a 180 incision and cryo-extraction is a sensible
procedure. In a rare case, the lens might need
removal by lensectomy or phaco-fragmentation
through pars plana route.
In most cases, it is possible to use the same basic pocket

incisions to deal with most of the trauma situations, at
the end of which an intraocular lens may or may not be
implanted. For any kind of lens implantation, it will be
necessary to create a favourable anatomical situation for
the lens to be fixed. Synechia need to be broken and the
space behind the iris cleared, before a lens can go into
the sulcus. The iris needs to be freed from adhesions
before an artisan lens can be fixed. Whenever anterior
vitrectomy becomes necessary to deal with disturbed
vitreous or to clear the visual axis, It is important to suture
the incision line, else a satisfactory closure of the incision
line is not possible.
Secondary Cataract
After cataract or secondary cataract formation is common

after ECCE and lens implantation in paediatric patients.
It may not form if the cataract was membranous, milkbag or one that had a pre-existing posterior capsular
opening (and needed anterior vitrectomy). It may or may
not form if a subtotal anterior capsulectomy was done
during operation. Its formation in Marfan cases is not
ruled out if the posterior capsule has been saved during
lens extraction.
In subtotal anterior capsulectomy cases it has been
observed that unless there is an element of inflammation,
the secondary cataract is thin and can be easily cut with
Yag laser or with a capsulotomy needle.
Sometimes the secondary cataract is thick and has
dense synechia with the intraocular lens or with the uveal
tissues. A manual capsulotomy in these cases can produce a traction on the vitreous and retina or the uveal
tissues. For this reason it is necessary to adopt alternate
approaches, which are:
Make a pocket incision. Reach the membrane with
the tip of a knife and stab it. Introduce a vitrectomy
probe and cut the membrane if it can be held by
suction. If it does not succeed, a Vannas scissors can
be used to cut the membrane, with as little pull as
possible. HPMC is used liberally to protect endothelium and to create space for the scissors to work.
Erbium laser Erbium laser energy can easy cut a thick
secondary cataract. A 1.5 mm incision is enough for
the purpose. The broken up material is irrigated out.
Fugo blade can cut a dense membrane without any
resistance. It can also be introduced through a 1.5 mm
incision. The membrane can be cut in two ways. Go
round the membrane, cut it and then pull out the
214
separated piece. The other way is to keep touching

the membrane again and again with the plasma blade
tip. The touched point just disappears in the plasma
field.
Secondary Lens Implantation
Secondary lens implantation in paediatric patients is an

important field. Aphakia results from the surgery on
congenital cataract, traumatic cataract after blunt or perforating trauma and after PP lensectomy for endophthalmitis resulting from perforating injuries. The presentations
are extremely varied and each case merits individual
assessment and an appropriate surgical approach. The
surgical approach has the following ingredients:
The incision is made in an anatomically undisturbed
part of the limbus.
The peripheral anterior synechia are broken if they
are likely to interfere with secondary lens implantation.
The synechia in the pupillary area are cut. Synechia
between the posterior surface of the iris and the
capsular membrane are separated and sufficient space
is created, if a posterior chamber lens is to be inserted.
The anterior chamber is cleared of vitreous and any
strands going to the limbal or the injury site.
The synechia can be cut with the tip of a disposable
27-gauge needle, with erbium laser or with Fugo plasma
knife. The advantage with plasma knife is that the cutting
is done without any bleeding.
The surgical and post-surgical problems connected
with secondary lens implantation depend upon the type
of lens selected (angle supported, sulcus supported, in

the bag and scleral fixated), the ease with which a space
has been created where to fix the lens and the amount
of trauma that is suffered by the tissues, especially uveal.
Artisan lens implantation seems to be the least traumatic
procedure in most cases, especially the ones that have
no posterior capsule.
The most difficult cases are the ones in which pars
plana vitrectomy has been done. The moment the anterior chamber is opened the eyeball seems to collapse. If
a lens is introduced in the anterior chamber and is left
un-held with a forceps, it call pass through the pupil and
get lost in the vitreous cavity (without vitreous). A Sheet
glide is a reliable tool to prevent such a mishap. Even a
sheet glide can fall into the vitreous, if care is not taken.
It is best to fashion a glide (it has to be made by the
surgeon himself) such that its outer end is much larger
than the incision line. In all cases of pars plana vitrectomy,
it is important to suture all incision lines, howsoever, small,
else the eyeball will tend to collapse in the postoperative
period.
To Sum up
In paediatric cataract cases, the incisions are always small.

But the construction of the incision line should be such
that it allows the performance of all surgical steps,
prevents collapse of the anterior chamber during surgery,
allows perfect closure of the incision line at the end of
the surgery and prevents the formation of peripheral
anterior synechiae.
SICS in Paediatric Cataracts
SICS in
Paediatric Cataracts
ataract surgery has undergone great refinement

in recent years. Small incision cataract surgery,
has become the technique of choice, because of
early visual and functional rehabilitation. Self-sealing
sutureless wound construction has recently achieved great
success and popularity in adult cataract surgery but its
use in paediatric cataract management is still gaining
popularity and is not well established.1,2
SelfSealing Sutureless Wound Construction
Since the self-sealing sutureless wound construction has

achieved great success in adult cataract surgery, it was
also applied to children, 3 but with mixed success.
Although one study has documented secure self sealing
sutureless wound following ECCE with IOL implantation
in children, other surgeons found the need for suturing
the wound at the conclusion of surgery because of
aqueous leakage.4,5 In a prospective study investigating
the role of sutureless wound construction in children,
the wound leak was reported in 100% of eyes of children
below 11 years of age who underwent ECCE with PPC
with AV + IOL.6 The incidence of wound leak was only
33% in eyes of same age group that had an intact
posterior capsule at the end of surgery. No leaks were
observed in eyes of the patients above 11 years of age.
The wound leak is probably because of low scleral rigidity
in children causing fish mouthing of the internal aspect
of the wound, with inadequate apposition of the corneal
flap to overlying stroma. So, suturing of such wounds
are required to ensure proper apposition of corneal flap.7
We suture such wounds as a routine practice in children
below 11 years of age.
Capsulorhexis
Manual Continuous Curvilinear Capsulorhexis
Anterior capsulotomy shape, size, and edge integrity are

important for long-term centration of a capsular fixated
IOLs. Since manual continuous curvilinear capsulorhexis
39
215
Kuldeep Kr Srivastava
P Vijayalakshmi
has become a standard anterior capsulotomy technique

in adult, it was naturally also applied to children but with
mixed success.8 The paediatric lens capsule is more elastic
than in adults and requires more force before it tears.
Reduced scleral rigidity in children results in posterior
vitreous upthrust when the eye is entered. The vitreous
pressure pushes the lens anteriorly and keeps the anterior
lens capsule taut which causes difficulty in completing
the rhexis resulting in the so called run away rhexis. In
addition, a small rhexis may end up much larger than
intended, because of marked elasticity of anterior capsule
in children. CCC can be applied on very young eyes but
its successful application needs paediatric experience and
modification of technique.4
For the successful completion of continuous curvilinear
capsulorhexis (CCC) in children following points are
helpful.9
Use high molecular weight viscoelastics to push the
anterior capsule back and deepen the anterior
chamber. This will create laxity in anterior capsule and
counter the effect of vitreous up thrust caused by globe
collapse.
Aim to make slightly smaller CCC in children than
adults.
While creating the CCC, frequently release the capsular
flap and inspect the size, shape and direction of tear.
Regrasp near the site of continuous tear and re-adjust
the direction of pull as needed to keep the capsulotomy
on the planned courses.
Tractional forces must be directed centripetally at all
times, rather than circumferentially in order to avoid
extention of the CCC out to the equator.
Additional viscoelastic should be injected as needed
to keep the anterior capsule lax during the tearing.
Lenticular content may leak into the anterior chamber
during CCC as a result of increased intralenticular
pressure from vitreous upthrust. If this happens,
aspiration of a portion of lens contents may be needed
before completing the CCC.
216
Vitrectorhexis
A mechanized, vitrector-cut anterior capsulotomy has

compared favourably to manual CCC in a direct comparison using very fresh paediatric autopsy eyes.8 The
mechanized capsulotomy, referred to vitrectorhexis is
easier to perform and resists tearing during IOL placement. According to M Edward Wilson who performed
vitrectorhexis in more than 150 children, after an initial
learning curve, radial tears are very rare when using this
technique.9
When performing a vitrectorhexis, the following
surgical caveats are offered.9
Use a vitrector supported by a venturi pump. Peristaltic
pump system will not cut anterior capsule easily.
Use an infusion sleeve or a separate infusion port,
but with either approach, maintain a snug fit of the
instrument in the incision through which they are
placed. The anterior chamber of these eyes will collapse readily if leakage occurs around the instrument
thereby making vitrectorhexis more difficult to
complete.
Vitrectorhexis begins by placing the vitrector with its
cutting port positioned posteriorly, on the centre of the
intact anterior capsule. The cutter is turned on and suction
is increased till the anterior capsule is engaged and
opened. It usually begins with cutting rates of 150 to
300 cuts per minute and an aspiration maximum of 150
to 250 mm Hg. With the cutting port facing posteriorly
against the capsule, the capsular opening is enlarged to
the desired shape and size. Although vitrectorhexis is less
than ideal when compare to CCC,it is next to CCC.
Bipolar Radiofrequency Capsulotomy
Radiofrequency diathermy capsulotomy, first described

by Kloti in 1984 and then by Gassman and Coauthors
in 1988,has been used as an alternative to CCC for
intumescent adult cataracts and for cataract surgery in
children.10,11,12 The Kloti device cuts the anterior capsule
with a platinum alloy tipped probe using a high frequency
current of 500 KHz. The probe tip is heated to about
160C and produces a thermal capsulotomy as it is
moved in a circular path across the anterior capsule. Even
when performed perfectly, a diathermy cut capsulotomy
can be seen to have coagulated capsular debris along
the circular edge. In addition, the edge has been shown
experimentally to be less elastic than a manual CCC
edge.13 Since the stretching force needed to break the
edge of a diathermy cut capsulotomy is much less
compared to a CCC edge, the surgical manipulation
needed to remove a cataract and place an IOL may result

in a radial tear when the diathermy is used. However,
Comer et al12 reported no radial tear when using the
diathermy cut capsulotomy in children where the mean
age was 23 months.
Posterior Capsular Opacification (PCO)
The posterior capsular opacification, which is not a major

concern in adults, remains a significant concern in
children particularly below two years of age. According
to a study in children, PCO occurs an average of two
years after surgery regardless of the age.14 Experience
with Nd: Yag capsulotomy in children has shown mixed
results, with recurrence of opacification requiring repeated
laser treatment and sometimes surgical membranectomy
as a secondary procedure.15,16
Prevention of Posterior Capsular Opacification
In order to prevent PCO, various techniques have been

in practice. Some of them are as follows:
1. Extracapsular cataract extraction with primary posterior
capsulotomy/capsulorhexis with anterior vitrectomy
(ECCE + PPC/PCCC + AV) Because of high incidence
of PCO in children, PPC/PCCC should be considered
in children who are not expected to be a candidate
for Yag capsulotomy within 18 months of surgery.14
The PPC and AV is combined with ECCE in order to
avoid the need for Yag capsulotomy and secondary
surgical membranectomy after ECCE, while retaining
a capsular bag that is suitable for IOL implantation. It
is more effective than procedures, which leaves
vitreous undisturbed (ECCE +PPC) in preventing
reopacification of posterior capsule. Although
technically challenging when IOL implantation is
planned, this approach has shown encouraging early
results as a means of maintenance of a clear visual
axis.16,17
2. Posterior capture of IOL optic by posterior continuous
curvilinear capsulorhexis (PCCC) A new technique
developed by Gimbel 18 consists of in the bag IOL
placement followed by PCCC and capture of the IOL
optic by the PCCC. This approach was premised on
the belief that 360 apposition of the anterior and
posterior capsular leaflets would lead for formation of
a Sommerings ring configuration anterior to IOL and
that lens epithelial cells would be kept in anterior
chamber, where they would be carried away with
aqueous fluid. Gimbels preliminary results appear to
support this view.
3. IOL Modification A square edge intraocular lens has

been proposed to prevent PCO.19
Management of PCO
a. YAG capsulotomy Cystoid macular edema (CME),

which is an important complication of YAG capsulotomy in adults, is not of a major concern in children.
It can be done even on the table at the completion of
the surgery or weeks after surgery without a significant
risk of CME.
b. Surgical membranectomy In certain situations like
thick PCO, uncooperative patient, recurrence of PCO
after YAG capsulotomy or soft after-cataract, YAG
capsulotomy may not clear the visual axis and surgical
membranectomy with anterior vitrectomy is required.
IOL Implantation in Children
The advantage of using IOL for aphakic correction in

children is its ability to provide continuous, optically
optimal refractive correction, immediately following
surgery without dependence on compliance by the
patient and family. Although IOLs were first tried in
children in the late 1950s, 20 paediatric usage has lagged
far behind implantation in adults because of the basic
conservatism of most paediatric ophthalmologist who
wanted to see ample, confirmation of the safety and
efficacy of IOLs in adults before subjecting children to
their widespread uses. Recent reports in the literature
indicate very encouraging short to intermediate term
results following childhood cataract surgery with IOL
implantation and have considerably decreased the
controversy surrounding it.3,4,13,21,22 Presently the major
controversy of IOL implantation in children is the problem
of its application in infants. The small dimension of infant
eye, the many significant difference between its tissue
and those of the mature eye, the magnitude of changes
it will undergo during completion of development, and
its tendency to react intensively to the presence of an
intraocular foreign body, are the major limitations of IOL
implantation in infants.
Choice of IOL
Of available lens materials, only PMMA has so far stood

the test of time adequately to be considered appropriate
for implantation in eyes with life expectancy of many
decades. Presently foldable IOLs (silicon and acrysoft)
and heparin surface modified IOLs are also being
implanted with short-term encouraging results.23,24 Single
piece, biconvex modified C loop designs have been
the choice of most paediatric cataract surgeon in recent
217
years.25 The lens size of 12 mm is generally suitable for

posterior chamber implantation in eyes more than two
years old, with capsule fixation.26 The lens size of 10
mm is reccomonded for children less than two years of
age. Optic diameter and designs are not very important.
IOL Power
Selection of IOL power has been one of the most controversial topics relating to paediatric cataract management.
It is well known that the power required for aphakic
correction declines rapidly during first year of life and to
a considerable degree further during the childhood. Thus,
a pseudophakic eye that is emmetropic at age of one
year may become 510 diopters myopic at maturity.
Furthermore, if an eye is rendered significantly hypermetropic at early age, it will need supplemental refractive
correction to ensure optimal visual development negating
much of the advantage of IOL.
Gordon and Donzis, in their study on the growth of
the eye after birth, demonstrated that approximately 90%
of the growth of the eyeball is complete during the first
18 months after birth.27 Since the overall increase in axial
length from 18 months of age to 11 years is about 2mm,
many surgeons today attempt towards making the eye
hypermetropic by two diopters in children between two
and four years of age.27
Some of the currently prevalent approaches are
outlined below:
Vasavada and Chauhan (1994), recommended 60%
under correction for infant eyes. Using modified SRK
II formula 1.0 D is added for every 1mm decrease in
axial length instead of standard 2.50 D, taking 23.0
mm as an average adult axial length and 22 .0D as
standard IOL power.3 This approach results in 60%
undercorrection. Based on a similar modification,
Dahan and Salmenson (1990) aim for 80% undercorrection in children below 18 months of age.28
Dahan et al (1997) suggested the guidelines for IOL
power calculation as below 29
<2 years : Do Biometry and undercorrect by 20%
or
Use axial length only
Axial Length (mm)
IOL Power (D)
17
28.0
18
27.0
19
26.0
20
24.0
21
22.0
2-8 years : Do Biometry and undercorrect by 10%
Same power as calculated with SRK II formula is
implanted in children over 8 years of age.
218
With the above methods of IOL power calculation,

child is left with residula hypermetropia which is
amblyogenic and needs supplemental correction. To
avoid this problem, Piggyback intraocular lenses have
been proposed wherein one IOL of adult power is
implanted in the bag (permanent lens) and another
foldable acrylic lens of 7-14D is implanted in sulcus
(temporary lens) at the same sitting.30 Temporary lens is
removed later when an adult refraction is achieved.
IOL Placement
Since the uveal tissue in the children is highly reactive,

in the bag placement of IOL is highly desirable. The
significantly lowered incidence of severe postoperative
uveitis described in several recent reports in paediatric
IOL implantation seems largely attributed to improved
success in in the bag implantation.3,4 In eyes that lack
sufficient capsular bag for in the bag implantation, ciliary
sulcus placement is considered an alternative site of lens
placement.23 Majority of the surgeons do not consider
anterior chamber IOL placement in children even in
absence of adequate capsule support.23
A new technique developed by H.V. Gimbal consist
of in the bag placement of IOL followed by posterior
CCC and capture of the IOL optic by PCCC.18 This
technique claims to maintain clear visual axis for longer
time and preliminary results appears to support this
view.18
REFERENCES
1. McFarland MS: McFarland surgical technique. In Gills JP,
Sanders DR (Eds): SmallIncision Cataract Surgery: Foldable
Lenses, OneStitch Surgery, Sutureless Surgery, Astigmatic
Keratotomy. Slack Inc, Thorofare, NJ 107-16, 1990.
2. Th.Pfleger, Scholz U, Skorpik Ch: Postoperative astigmatism
after no-stitch, small incision cataract surgery with 3.5 mm
and 4.5 mm incisions. J Cataract Refract Surg 20: 400-05,
1994.
3. Vasavada AR, Chauhan H: Intraocular lens implantation in
infants with congenital cataracts. J Cataract Refract Surg 20:
592-98, 1994.
4. Gimbel HV, Ferensowicz M, Raannan M et al: Implantation
in children. J Pediatr Opthalmol Strabismus 30: 69-79, 1993.
5. Zetterstrom C, Kugelberg U, Oscarson C: Cataract surgery
in children with capsulorhexis of anterior and posterior
capsules and heparinsurfacemodified intraocular lenses.
6. Basti S, Krishnamachary M, Guptha S: Results of sutureless
wound construction in children undergoing cataract
extraction. J Paediatr Ophthalmol Strabismus 33(1): 52-54,
1996.
7. Gimbel HV, Sun R, DeBroff BM: Recognition and management of internal wound gape. J Cataract Refract Surg 21:
121-24, 1995.
8. Wilson ME, Bluestein EC, Wang XH et al: Comparision of
mechanized anterior capsulotomy and manual continuous
capsulorhexis in pediatric eyes. J Cataract Refract Surg. 20:
602-06, 1994.
9. Edward Wilson M: Anterior Capsule Management for Pediatric Intraocular Lens Implantation. J Paediatr Ophthalmol
Strabismus 36: 314-19, 1999.
10. Gassmann F, Schimmelpfennig B, Kloti R: Anterior
Capsulotomy by means of bipolar radiofrequency
endodiathermy. J Cataract Refract Surg. 14: 673-76, 1988.
11. Delcoigne CD, Hennekes R: Circular continuous anterior
capsulotomy with high frequency diathermy. Bull Soc Belg
Ophthalmol 249: 6772, 1993.
12. Comer RM, Abdulla N, O Keefe M: Radiofrequency diathermy capsulorhexis of the anterior and posterior capsules
in pediatric cataract surgery: priliminary studies. J Cataract
Refract Surg 23: 641-44, 1997.
13. Luck J, Brahma AK, Noble BA: A comparative study of the
elastic properties of continuous tear curvilinear capsulorhexis
versus capsulorhexis produced by radiofrequency endodiathermy. Br J Ophthalmol. 78: 39296, 1994.
14. David A Plager, Stephen N Lipsky, Stephen K Snyder et al:
15. Atkinson CS, Hiles DA: Treatment of secondary posterior
capsular membranes with the Nd: YAG laser in a pediatric
population. Am J Ophthalmol 118: 496-501, 1994.
16. Surendra Basti, Uma Ravishankar, Satish Gupta. Results of
prospective evaluation of three methods of management of
paediatric cataracts. Ophthalmology 103: 713-20, 1996.
17. Mackool RJ, Chattiawala H: Pediatric cataract surgery and
intraocular lens implantation: a new technique for preventing
or excising postoperative secondary membranes. J Cataract
Refract Surg 17: 62-68, 1991.
18. Gimbel HV, DeBroff BM: Posterior capsulorhexis with optic
capture: Maintaining a clear visual axis after pediatric cataract
surgery. J Cataract Refract Surgery 20: 658-64,1994
19. Nishi O, Nishi K: Preventing posterior capsular opacification by creating a discontinuous sharp bend in the capsule.
20. Choyce DP: Correction of uni-ocular aphakia by means of
anterior chamber acrylic implants. Trans Ophthalmol Soc UK.
78: 459-70, 1958.
21. Dahan E, Salmenson BD: Pseudophakia in children. J
Cataract Refract Surg 16: 75-82,1990.
22. Sinskey RM, Stoppel J, Amin P: Long term results of intraocular lens implantation in pediatric patients. J Cataract
Refract Surg 19: 405-08, 1993.
23. Sima Pavlovic, Felix K Jakobil, Mickeal Graef et al: Cataract
Refract Surg 26: 88-95, 2000.
24. Surendra Basti, Murali K Aasuri, Madhukar K Reddy et al:
Cataract Refract Surg 25: 782-87, 1999.
25. Apple DJ, Mamalis N, Brady SE et al: Biocompatibility of
implant materials: A review and scanning electron

microscopic study. Am Intraocular Implant Soc J 10: 53
66, 1984.
26. Wilson ME, Apple DJ, Bluestein EC et al:, Intraocular lenses
for pediatric implantation: Biomaterials, designs and sizing.
27. Gordon RA, Donzis PB: Refractive development of the
human eye. Arch Ophthalmol 103: 785-89, 1985.
219
28. Dahan E, Salmenson BD: Psedophakia in children. J Cataract

Refract Surg 16: 75-82, 1990
29. Dahan E, Matthias UH, Drusedau: Choice of lens and dioptric
power in paediatric pseudophakia. J Cataract Refract Surg
23: 618-623, 1997.
30. Edward Wilson JI: Paed Ophthal and Strabismus 36: 28186, 1999.
220
Posterior Capsule
Opacification
40
Jagat Ram
Gagandeep S Brar
osterior capsule opacification (PCO) and posterior

chamber intraocular lens (PCIOL) decentration
(Fig. 40.1) still remain two major complications of
extracapsular cataract surgery (ECCE) or phacoemulsification.1-6 Ridley, who performed the first intraocular lens implantation in 1949, himself noted these
complications in his earliest patients.7 In his initial publications, he described lens decentration, and remarking
that apparently, the most difficult problem was to retain
the lens in position. He also recognized the problem of
PCO and designated it as the principal complication
that is not easy to treat, and which requires division of
posterior capsule, i.e surgical posterior capsulotomy.8,9
Control of decentration and PCO is becoming more
necessary now that IOL implantation is emerging as a
refractive procedure that mandates almost a perfect
optical rehabilitation as opposed to the former goal of
simply removing the opaque lens material and achieving
safe but less than optimal visual rehabilitation.2-5 As the
cataract operation continues to be perfected, major goal
is to eliminate these complications.
Clinical studies have noted an incidence varying
between 10-50 per cent of posterior capsule opacification
following ECCE or phacoemulsification with PC IOL
implantation.1-3,12-25 Schaumberg et al conducted an
important metanalysis of published articles on PCO and
generated pooled estimate of eyes developing PCO over
three postoperative points: 1,3 and 5 years. They noted
that even today the rate of PCO remains unexpectedly
and unacceptably high-still over 25 per cent during the
5-year postoperative period. 1 Furthermore, adverse
clinical sequelae may be associated with Nd:YAG laser
posterior capsulotomy. Last but not the least, there are
very significant and compelling financial reasons to
eliminate the necessity to do Nd:YAG laser capsulotomy.
Nd:YAG laser posterior capsulotomy now ranks as the
second most expensive surgical cost to the US health
care system, second only to the cost of the original
cataract operation.13
Fig. 40.1: Slit lamp photograph of left eye of a 65 years old

woman, status postcataract surgery (ECCE); with marked
upward decentration of a bag-sulcus fixated all-PMMA IOL. Note
VS-PCO in the visual axis and sutures are also seen at the
incision
The reported Nd:YAG laser posterior capsulotomy rate

ranged from 30 to 50 per cent in the 1980s.2,3,11 More
recent reports document an additional decrease in PCO
and Nd: YAG laser capsulotomy rates.5, 11,14-17 With the
use of modern surgical techniques and IOLs, posterior
capsule opacification and Nd: YAG laser posterior capsulotomy rate is decreasing to less than 10 per cent.18-23
In a recent study by Apple et al17 comparing foldable
versus rigid designs, the foldable IOLs were associated
with a much lower Nd: YAG laser posterior capsulotomy
rate (14.1% vs. 31.1%). Surgical tools and IOLs are now
available to bring these rates down to single digits. Careful
application and use of these tools by surgeons can
genuinely lead in the direction of virtual eradication of
secondary cataract, the second most common cause of
visual loss worldwide.

Pathogenesis of Posterior Capsule Opacification
Most secondary cataracts are caused by proliferation of

equatorial lens epithelial cells, forming the pearl form of
posterior capsule opacification. 26 Posterior capsule
plaques or fibrous plaque detected in patients after ECCE
are not uncommon in the developing countries27 and
such plaques are rarely seen in the industrialized world.
The epithelium of the lens consists of anterior epithelial cells known as A-cells which is single continuous
cell line. These cells are continuous with the cells of the
equatorial lens bow. The cells of equatorial lens bow are
the E-cells, which comprise the germinal cells undergoing
mitosis as they peel off from the equator. They continuously form peripheral cortical fibers. A-cells tends to
remain in place and not migrate and are prone to change
toward fibrous tissue (fibrous tissue metaplasia) when
disturbed. In contrast E-cells of equatorial lens bow tends
to migrate along the posterior capsule and form pearls
form of posterior capsule opacification (Fig. 40.2). These
equatorial cells are the primary source of classical
secondary cataract especially the pearl form of posterior
capsule opacification.26 Fibrous form of posterior capsule
opacification occurs as result of either posterior
proliferation of A-cells or may result from a fibrous
metaplasia of posteriorly migrating E cells.
Fig. 40.2: A slit lamp photograph of eye in a 58 years old female

with sulcus-sulcus fixated all PMMA IOL after an ECCE showing
posterior capsule opacification (epithelial pearls) in the visual
axis
Clinical appearance of PCO may also be caused by a

postoperative localized endophthalmitis, a condition
which has been recognized as a cause of persistent,
221
usually low grade uveitis.28-30 Meisler and associates28

were first to recognize the role of Propionibacterium acnes
as an offending organism. Piest and associates29 and
Apple and associates30 were the first to emphasize the
concept of a post-ECCE localized infectious process
caused by sequestrated organism within the capsular bag.
Clinically, it is important to be aware of the fact that
clinical picture of PCO may be produced by localized
endophthalmitis. The use of Nd: YAG laser capsulotomy
to treat the posterior capsule thickening in this condition
may lead to precipitation of severe inflammation.
Evaluation Techniques for
Methods of evaluation are important to measure the

progress of posterior capsule opacification. Most of the
studies evaluate posterior capsule opacification after
ECCE/phacoemulsification after full dilatation of pupil
using slit lamp biomicroscopy. PCO is defined as
opacification of the posterior capsule in the visual axis
that is observed on slit lamp biomicroscopy which
includes Soemmerings ring (PCO peripheral to the IOL
optic), Elschnigs pearls and fibrous opacification behind
the IOL optic. The degree of opacification is assessed
using distant direct ophthalmoscopy, direct visualisation
by slit lamp biomicroscopy, and decrease in best corrected
visual acuity after surgery. Visually significant posterior
capsular opacification is defined as a decrease in the best
corrected postoperative vision by two Snellen lines. Tetz
described a photographic image analysis system that
can morphologically score posterior capsule opacification without dependence on visual acuity testing.31
Standardised slit lamp retroillumination photographs are
analysed. Posterior capsule opacification score is
calculated by multiplying the density of opacification and
graded from 1-4 by the fraction of capsule area behind
the IOL optic that is opacified. This technique shows good
inter- and intra-observer reliability. Pande et al reported
a more sophisticated system of retroillumination imaging of the posterior capsule using a computerized high
resolution digital system that can produce excellent
images for objective documentation and quantitative
measurement of posterior capsule opacification.32 Apple
et al utilised Miyake-Apple posterior photographic
technique (Fig. 40.3) for analyzing commonly used IOL
model in eyes obtained postmortem to evaluate PCO
and whether or not an eye had an Nd: YAG laser
capsulotomy.17
222

Prevention of Posterior Capsule Opacification
Fig. 40.3. Miyake-Apple view of a pseudophakic eye obtained

postmortem, implanted with all-PMMA IOL. The visual axis is
clear following Nd: YAG laser capsulotomy. Note peripheral
residual cortical material an example of inadequate cortical
clean up (Courtesy: David J Apple, MD, Charleston, USA)
Management of Posterior Capsule Opacification
In the past, invasive surgical posterior capsulotomy was

the primary treatment of posterior capsule opacification
and it is still performed where Nd: YAG laser facility is
not available or in cases with very dense or fibrotic membrane particularly in children.33 The treatment of choice
for clinically significant posterior capsule opacification is
Nd: YAG laser posterior capsulotomy.34-36 It is an effective
modality in the management of posterior capsule
opacification.
There are several disadvantages of Nd: YAG laser
capsulotomy:
There are several vision-threatening complications
such as damage to IOL optic, postoperative intraocular
pressure elevation, cystoid macular oedema, retinal
detachment, IOL subluxation or dislocation and exacerbation of localized endophthalmitis. Nd:YAG laser posterior capsulotomy significantly increases the overall cost
of cataract surgery beside being a burden on the health
care.
Keeping in view several vision-threatening complication of Nd: YAG laser capsulotomy or surgical capsulotomy, peeling or removal of epithelial cells from the
posterior capsule in eyes with pearl type of PCO with
automated irrigation mode or capsule vacuuming mode
or using two-ways Simcoe cannula is recommended
particularly in patients with high myopia where incidence
of retinal detachment increases several fold after Nd: YAG
laser or surgical posterior capsulotomy.
Although all the steps of cataract surgery are important

in reducing this entity, six factors are particularly
important in relation to eliminating or at least delaying
posterior capsule opacification.
First, very essential step in reducing PCO is the
reduction of formation of postoperative Soemmerings
ring, which is a precursor of PCO. This can be reduced
not only by excellent hydrodissection enhanced cortical
clean up but also by use of a highly biocompatible IOLs
that reduce stimulation of cellular proliferation.2,3,5,13,26
The six factors influencing PCO formation are described
below:
1. Hydrodissection-enhanced cortical clean-up First
formal publication on this procedure was by Faust37
in 1984 and later on in 1992. Howard Fine 38 perfected
the technique of subcapsular fluid injection and coined
the term cortical cleavage hydrodissection. Cortical
clean-up hydrodissection is used by many surgeons
to facilitate lens substance removal and enhance the
safety of surgery. The goal of hydrodissection is to
remove equatorial cells and cortex, as opposed to
removal of the single layer of anterior epithelium that
does not migrate.13,26
2. In-the bag fixation of IOL The obvious advantage
of in-the-bag fixation is accomplishment of good
centration and more important advantage that is
not often appreciated is reduction in incidence of
PCO. 2,3,5,13,26,39,40 The hydrodissection enhanced
cortical clean-up and in-the-bag fixation of IOL are
two most important surgical factors in reducing PCO.
In-the-bag fixation of IOL functions primarily enhances
the IOL-optic barrier effect. When the IOL optic is fully
in the capsular bag, its contact is maximum with the
posterior capsule and the barrier effect is functional
(Figs 40.4 and 40.5). When one or both of the haptics
are out-of-the-bag , a potential space exists that allows
ingrowth of cells towards the visual axis.41,42
3. Capsulorhexis edge on the IOL surface A significant
factor which helps in reducing PCO is creation of a
capsulorhexis with a diameter slightly smaller than that
of IOL optic, so that the anterior capsulorhexis edge
rests on the IOL optic (Fig. 40.5). This helps to provide
a tight fit (analogous to a shrink-wrap ) of the capsule
around the optic.26,43-45
4. Biocompatibility of IOL In general, the amount of PCO
depends in part on the biocompatibility of the IOL.
The less the cell proliferation, the less the chance of
posterior capsule thickening. The amount of PCO
depends on many factors such as the quality of
223
Fig. 40.4: Close-up of an eye of a 52-year male with bag-bag

fixated PMMA IOL with clear visual axis after phacoemulsification. Note anterior capsule opacification
Fig. 40.5: Close-up of an eye of a 52-year male with bag-bag

fixated acrylic IOL with clear visual axis after phacoemulsification
surgery, duration of implant in the eye and biocompatibility of IOL material. It has been reported that
acrylic IOLs display the lowest amount of cell proliferation, and hence are the most biocompatible.46-49
5. Maximum IOL optic posterior capsule contact In-thebag fixation of IOL helps to maintain a tight contact
between the IOL optic and posterior capsule and helps
to inhibit the migration of cells across the visual
axis.10,14,47,50-54 Posterior angulation of IOL haptics
and a posterior convexity of IOL optic also contribute
significantly in maintaining this maximum posterior
capsule contact. Still another factor, which appears to
contribute, is related to stickiness of IOL biomaterial,
which in turn might create an adhesion of the capsule
and IOL optic.
6. Barrier effect of IOL optic The IOL optic barrier effect
comes into play as a second line of defence against
PCO.55-58 Implanting IOL in the capsular bag enhances
the barrier effect. It has been shown that optic with
round edges might have negative influence by allowing
some of the cells to migrate under the tapered edge of
the optic onto the posterior capsule. A truncated optic
edge appears to create an abrupt and effective block
to cells growing onto the posterior capsule. Examples
of square edge optic IOLs are Alcon AcrySof,
Pharmacia Cee On 911, etc.
perhaps be effective in reducing PCO.2,5965 The various

pharmacological studied till date are caffeic acid
phenethyl ester in a rabbit model, hypo-osmolar drugs
(sterile water), and antimetabolites. Antimetabolites that
have been studied are daunomycin, methotrexate, 5fluoro-uracil and colchicine. The rationale for use of these
agents is to inhibit lens epithelial cell mitosis while
avoiding toxic effects to non-mitotic cells. Some
investigators are studying immunological agents such as
monoclonal antibodies targeted to lens epithelial cells.
Pharmacological Techniques and

Immunological Inhibitors of PCO
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Pharmacological techniques which could accomplish the

reduction or destruction of lens epithelial cells would
A New Entity: Interlenticular Opacification (ILO) or

Opacification of Piggyback IOL
The use of piggyback IOL, i.e use of paired IOLs in one

eye is becoming more and more common for correcting
residual refractive error after IOL surgery or as primary
procedure in high refractive error.66-72 Opacification
between two-implanted IOL has been termed as
Interlenticular opacification or interpseudophakos
Elschnig pearls. In contrast to PCO, this entity occurs
as a result of pearls formation or opacification between
the two IOLs, undoubtedly due to ingrowth of cells from
the equatorial lens bow. Werner et al70 have suggested
implanting the posterior IOL in the capsular bag and
anterior IOL in the sulcus to reduce this complication
besides all the factors listed for preventing PCO.
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50. Holladay JT: Evaluating the intraocular lens optic. Survey
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Index
A
Accidental globe perforation 195
clinical features 196
management 196
Advantages of temporal incision 136
corneal topographic changes 137
reduction against the rule (ATR)
astigmatism 136
stable incision 137
useful in secondary and combined
procedure 136
Age related macular degeneration and
cataract 203
Amphotericin-B 189
Anterior chamber maintainer 123
Anterior ischaemic optic neuropathy
(AION) 202
Anti-inflammatory therapy 186
Antifungal therapy 189
Antimetabolites 207
Antimicrobial therapy 183
Aphakic glaucoma 173
Areas of sterilization 11
medication 20
parenteral 20
probes and tubings 20
operating room air 11
air curtain 12
air-conditioning 11
filtration of air 11
ozone treatment 12
positive pressure 12
quality check 12
ultraviolet radiation 11
operating room linen and accessories
18
linen 18
operating room macroinstruments 13
Boyles apparatus 15
microscope 13
phaco machines 14
operating room microinstruments 15
autoclave 18
boiling 17
cidex of glutaraldehyde 16
ethylene oxide 18
isopropyl alcohol 16
sterile water 17
tray l with liquid soap and sterile
water 16
ultrasonic cleansing 16
operating room personnel 21

cap and mask 23
clothing 22
footwear 22
operating room walls, floor, ceiling
and fixtures 12
cleansing 12
disinfection 13
operating room water 12
electronic control 12
filtration 12
reverse osmosis 12
patient 23
changes of clothes 23
skin and incision site disinfection
24
sterile disposable surgical drape 24
Astigmatism 44
Azole derivatives 190
B
Bag sulcus fixation 152
Biometry 56
Blood pressure
definition 52
joint national committee guidelines 52
management 53
Brainstem anaesthesia 61
C
Capsular contracture syndrome 153
Capsulorhexis 88, 92, 93, 124, 206
in difficult situations 92
in hypermature cataracts 92
in mature cataracts 92
in small pupils 93
initiation of 88
new developments in capsulorhexis
93
propagation 89
trypan blue staining 92
using forceps 91
with the ripping technique 90
Capsulotomy 43, 86
can opener technique 86
capsulorhexis 86
envelope technique (linear
capsulotomy) 86
Cautery 43
Central retinal artery occlusion 196
Choroidal detachment
management 198
Clear corneal incision 76, 80
Congenital cataract 210, 211
air bubble 212
anterior capsulotomy 211
cataract removal 211
incisions 211
lens implantation 212
peripheral iridectomy 212
Conjunctival
chaemosis 62
closure 208
flap 43, 205
Corneoscleral tunnel 155
Cortex aspiration 126
Cortical clean-up 44, 140
cortex technique by simcoe 140
in PC rent 143
posterior capsule polishing 142
Cystoid macular oedema
epidemiology 199
management 199
photic maculopathy 200
D
Diabetic retinopathy and cataract
approach to management 200
epidemiology 200
Diffractive MIOLs 151
Dislocated lenses 212
Double IOL syndrome 174
E
Emmetropia 84
Emmetropia lenses 56
Endophthalmitis 153, 173, 179
post-surgical 179
incidence and aetiology 179
post-surgical bacterial 180
confirmation of diagnosis 181
treatment 182
post-surgical fungal 189
confirmation of diagnosis 189
management 189
propionibacterium acnes 191
228
Endophthalmitis vitrectomy study 187

Epinucleus 94
Expulsive haemorrhage 197
management 197
External incision 76
Extracapsular cataract extraction 43
F
Facial nerve blocks 63
Fish hook technique 107
method 108
preoperative clinical examination 107
surgical instruments 107
surgical technique 108
anterior chamber entry 108
hydrodelineation 108
hydrodissection 108
scleral tunnel incision 108
technique of nucleus delivery 108
Fuchs endothelial dystrophy 163
G
Globe perforation 62
H
Hard core nucleus 94
Human lens
microscopic structure 1
anterior epithelium 2
capsule 1
cement substance of amorphous
material 2
ciliary zonule 2
cilio-equatorial fibres 2
cilio-posterior capsular 2
lens fibres 2
orbiculoanterior capsular 2
orbiculoposterior capsular 2
surgical anatomy 2
Hydrodelineation or hydrodemarcation
96
hydrosonic 97
manual 96
Hydrodissection 94, 206
conventional 94
technique 95
cortical cleavage 95
hydro-free dissection 96
Hydroprocedures 94
Hypertension 52
Hypotony 54
I
Implant power calculation 57
adjusting original SRK to SRK II 58
ammetropia 59
axial length measurement 59
biconvex optic 59
emmetropia 59
keratometry 59
meniscus optic 59
empiric formula 57
SRK formula 57
surgeons personal A constant 59
theoretic formulas 57
Incision 43, 124
Insertion of foldable IOLs
surgical considerations 150
Insulin
regimen 48
therapy 48
Intraocular lens 144, 151
accommodating 151
classification of 144
haptic materials 147
haptic design 148
nylon (polyamide) 147
polymethylmethacrylate 147
polypropylene (prolene) 148
polyvinylidene fluoride 148
optic materials 144
acrylic 147
hydrogel 145
polymethylmethacrylate 144
silicone 145
Intravitreal antifungal therapy 190
IOL
decentration 153
discolouration 153
glistenings 154
IOL implantation 4, 77
size of opening for 77
paracentesis opening(s) 77
technique of making a incision 77
K
Kansas
nucleus vectis 111
trisector 111
L
Lathe cutting 149
Lens 44, 56, 86, 153, 210
dislocation 153
extraction 210
implantation 44
implantation surgery 56
Lens capsule
anatomy 86
Limbus
anterior limbal border 3
midlimbal line 3
posterior limbal border 3
Local anaesthesia 61
peribulbar 62
complications 62
retrobulbar 61
complications 61
topical 63
M
Macrovascular disease 47
Manual multiphacofragmentation
surgical technique 128
extraction of the cortex and
remains of nucleus 130
hydrodissection and luxation of the
nucleus 130
incision 127
IOL implantation and wound
closure 131
manipulation of nuclear fragments
130
nuclear fragmentation 130
Manual phaco 169
postoperative complications 172
corneal oedema 172
shallow AC 172
preoperative complications 169
associated with debris cleanup 171
associated with hydrodissection and
hydrodelineation 170
associated with implantation 171
associated with wound construction
169
during capsulotomy 170
during delivery of nucleus 171
during nuclear prolapse in AC 171
with AC maintainer 169
Manual phaco-fracture 110
complications 111
corneal edema 112
Descemets tear 112
endothelial damage 112
high intraocular pressure 112
intraoperative miosis 112
posterior capsular rupture 112
posterior dislocation of the nucleus
112
pupillary distortion 112
shallowing of anterior chamber
112
Index
surgical techniques 110
nucleo-fracture techniques 110
Manual phaco incision 76
Manual phacofragmentation
preoperative assessment 132
Medications in cataract surgery
antibiotics 165
intracameral use 166
povidone iodine 165
subconjunctival injections 165
corticosteroids 166
non-steroidal anti-inflammatory agents
166
Microvectis technique
anaesthesia 113
capsulorhexis 113
hydrodissection 113
indication 113
instrumentation 113
nucleus expression 114
practical pearls 115
viscoelastics 113
Modified Blumenthals technique
completing the tunnel 120
continuous curvilinear capsulorhexis
119
envelope technique 120
hydrodissection 120
hydroprocedures 120
making the groove 118
nuclear management and delivery
121
preoperative preparation and anaesthesia 117
sclerocorneal pocket tunnel incision
118
tunneling forwards 118
Molding
cast 149
compression 149
injection 149
N
Nadbath and Rehman block 63
Neutral funnel 85
Nuclear bisection 125
Nuclear dislocation 124
Nuclear extraction
manual small incision techniques 7
blumenthal 7
nucleus division with snare 8
phacofracture 7
phacosandwich 7
Nucleus 7, 44, 98, 206
delivery 44
hardness 7
management 206
prolapse 44
rotation and prolapse of nucleus 98
other methods 99
tipping up technique 98
tumbling of the lens 99
tyre levering technique 98
O
Obrien block 63
Oculomotor problems 62
Ophthalmic surgery 65
minimum drugs 66
minimum equipment 66
minimum monitoring 66
Optic nerve sheath injury 62
Outer retinal ischaemic infarction 203
P
Paediatrics cataracts 215
bipolar radiofrequency capsulotomy
216
capsulorhexis 215
posterior capsular opacification 216
self-sealing sutureless wound construction 215
vitrectorhexis 216
Patients with diabetes 50
postoperative management 50
emergency surgery 51
intravenous fluids 50
monitoring during surgery 50
Perfluorocarbon liquids 175
Phaco sandwich technique
instruments 101
preoperative preparation 101
surgical steps 101
capsulotomy 102
conjunctiva 106
conjunctival flap 101
delivery of nucleus 103
entry into the anterior chamber
102
hydrodissection 102
nucleus prolapse 103
posterior capsule 106
remaining debris 105
scleral tunnel incision 101
viscoelastic 102
Phaco-drainage 132
Posterior capsule opacification 154, 220
evaluation techniques 221
immunological inhibitors of 223
interlenticular opacification 223
management of 222
229
opacification of piggyback 223

pathogenesis of 221
pharmacological techniques 223
prevention of 222
Posterior segment disorders
complications 195
pathophysiology 195
Postoperative endophthalmitis 68
cleaning, disinfection and sterilisation
of OR 69
filtration 70
flash sterilisation 70
OR discipline 69
sterilisation of instruments 69
irrigating fluids and viscoelastic agents
72
monitoring of sterilisation protocol 71
sterile surgical protocol 71
operating room layout 68
surgery of infected cases 72
ventilation 68
Preoperative astigmatism 84
R
Removal of epi-nucleus 125
Retinal detachment following cataract
surgery 202
Retrobulbar haemorrhage 61
S
Scleral flap 207
Scleral incision 206
Scleral tunnel 77
Scleral tunnel incision 75
mechanism of 75
Secondary cataract 213
Secondary lens implantation 214
Small incisions
evolution of 5
extracapsular cataract surgery 6
Sterilization 9, 24
cleaning 27
disinfection 27
factors influencing 26
history 9
methods 24
quality control 29
terminology 24
Sterilization and disinfection policy 30
blood agar 32
MacConkeys agar 31
nutrient agar 31
Sterilization control 32
culture test from walls, floor, fixtures,
furniture 33
linen and textiles cultured 34
230
specialized equipment cultures 33

surgeons hands cultured 34
plate test 32
Sub-Tenons block 63
Superficial cortex 94
Sutures 44, 158
fines infinity 160
horizontal 158
horizontal anchor 158
Shepherds single 158
vertical 158
T
Temporal incision 76
Temporal tunnel incision 136
Traumatic cataract 213
Tunnel incision 76
U
Uveitis 153
V
Van Lint block 63
Various ECCE techniques 45
Viscoelastic substances
chemical properties 35
complications 39
types 35
chondroitin sulphate 37
hyaluronic acid (sodium hyaluronate) 36
methylcellulose 36
uses 38
cataract surgery 38
control of intraocular bleeding 39

in lacrimal surgery 39
in vitreo-retinal surgery 39
maintenance of deep anterior
chamber 38
management of Descemets
detachment 38
management of dry eye 39
strabismus surgery 39
Viscoelastics 43
Vitrectomy 186
Vitreous loss 197
management 198
W
Wound closure 158
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