Professional Documents
Culture Documents
Principles of
Phacoemulsification
4r
AYPEE. HIGHTIGHTS
#r MEDICAL PUBLISHERS, INC.
T
Hssential Princ{ples
of
Phacoemulstficattdln
Editor
Pascal W. Hasler, MD
d;4
T IAYPEE. HIGHTICHTS
@,
i
l
4t l
PRODUCTION
Editor in Chief: Samuel Boyd, MD
Production Director: Kayra Mejia
Dig¡tal Composition: Laura Duran, Erick Navarro
Art Director: Eduardo Chandeck
lnternationaI Communications: Joyce 0rtega
MARKETING
Director Sates & Marketing Latin America: Srinivas Chaubey
Customer Service: MirosLava Bonitla
Sales Manager: Tomas Martinez
97 B-99 62- 67 B- 61 -B
Pascal W. Hasler, MD
Fettow of the European Board
of 0phtha[motogy IFEB0)
Depa rtment of 0phtha[motogy,
University HospitaI of BaseL,
Base[, Switzerland
rr
FOREWORD
First you have to know that I am a vitreoretinaI surgeon and
lwas rea[ty disappointed about my cataract surgery skitLs. I decided
to change that and found an exceltent and very experienced cataract
surgeon and teacher from lndia, Nirav PateL. The initiaL idea was
to put down in writing the knowtedge of Dr. Nirav Patel, in order to
remember at[ the imporiant steps of phacoemuLsification cataract
surgery during my time as a feltow at the "Advanced Eye Care Ctinic"
in Vadodara, lndia. After coming back to Switzertand I started to draw
important steps and pitfaLLs of the procedure in order to visuaIize the
topic. Dr. Patel showed the first draft to his trainees and he reatized
how they improved faster. lt finatty reached the size of the handbook
that you have in your hands now.
The question rises- why shoutd there be another book on
cataract surgery? WeLt, this handbook is quite different than most of
the other ones. There are a lot of practicaI tips and tricks a cataract
surgeon beginner as we[[ as a more experienced cataract surgeon can
benefit from. The idea was to make the topic straight forward and not
to oversize the content with information which is not of any practicaI
use. Most of the information taken f or this handbook has been given by
Dr. Nirav Patet. Besides, I was abte to compite additionaI information
on cataract surgery from other books, DVD's and homepages which
hel.ped me to write this book. You wil'tfind the list of the references at
the end of the book.
The sentences are short and concise and may sometimes
sou nd even [ike a com mand. Some of this i nf ormation is very im portant,
so I repeat it severaItimes in order not to be forgotten. Dr. Patel and
I decided to offer this handbook to at[ fetlows at the "Advanced Eye
Care Ctrnic" as a help and a guide for phacoemutsification surgery. I
reatty hope it wil.t help you to improve your skiLts!
lwant to thank Nirav Patet, MD who helped me to become a
better cataract surgeon and Frank Sens, who arranged the contact
with him. ldo atso want to thank my surgical teachers Chrisiian
Prünte, Joergen ViLtumsen, Ole Mark Jensen, Sebastian Wotf , Se[im
0rgü1, ULrike Schneider and Jürg Messerli. I want to thank atso Josef
FLammer for the support of ihis advanced cataract surgery training
in lndia. Last but not Least I dedicate the book to my famity, my wife
Deborah and my chitdren Sven and Mira.
PascaI W. HasLer, MD
v
CONTENTS
HydrodissectionandHydrodetineation........... . ...35
VI Grooving.... ........45
vil. Divide & Conquer. .......................57
vilt. Chip&F1ip............ . . .. ...ó5
tx. Stop & Chop.......... .....................69
X, Phaco Chop.......... ..... .. . ..75
References ..,...,...,.107
1ndex......... .......,.....109
v,'l
llllllllllillliiiiiillilliiililiiriiiliiiilllrilllillililiillllilillliliillrililiiiiiiiliiiiliiiiililiiiliiiiiiilliiillllilrll n
Phace S4ethsds and
Devire Settings
1. Divide ú Conguer
4. Phaco Chop
l;i
phacoemursirication
illlliillllilllliilil Essentiarpirncipres or iiilliililllllillllillllilililililllllilllililillli
> You do not have to take over these settings. Use the safest settings
in your hands, but something must happen white you are working
in the eye. Too safe settings witl increase your working time in the
For chopping you need high vacuum power in order to hotd the
[ens. Therefore you may need to adapt the settings.
:=l==:::::t
i,::::...=:..:::=:
, il irli ti r1r 11irtll1iltilii,o"upt"' r:
phaco Methods and Device Settinss iitiiliiiiiliiiiliili
],]l]lii
power.
> To scutpt the nucteus you need low outftow rate and just Littte
VACU U M.
High outfl,ow rate does not increase the speed of nucteus remova[,
but rather creates turbutence and high flow rate through the eye
and since you are not occtuding the phaco tip, you can use low
vacuum white grooving.
The outflow rate is the ftow rate at which the ftuid leaves the eye
through the aspirating instrument Iml'/MinJ.
Remember: the bottLe height has no inftuence on the outflow rate
in peristattic pumps Iin venturi pumps there is a retationship: the
higher the pump, the higher the ftow.'.).
The bottLe height has to be adapted to the ftow since the chamber
shoutd stay stabte during work.
The outftow of fLuid cools down the phaco tip whiLe working' Using
onty the phacoemutsification mode wit[ create a corneaI burn "
As soon as you use the operating pump, ftuid witL ftow out of the
eye and the loP wiLt lower down. Look at the anterior chamber
depth white working in the eye. You may have to adapt the bottte
heig ht. ,l
it
3' ir:
. ,l¡
:l EssentialPrinciples of Phacoemulsification' iiilril r,' il il!
> Vacuum is buitding up when the phaco tip is occtuded. You do not
have a vacuum effect without occtusion... f Figure 11.
vacuum wiLt buiLd up in an occtuded tip. The higher the ftow, the
faster you wit[ buiid up vacuum IFigure 11.
is not the same as vacuum. You only have vacuum while the tip
"Flcw
is cccluded. Think about that when you are wo*ing with phaco."."
Fignge I
Vacuum is not important white sculpting the nucteus, but gets
important if you are eating the lens pieces. That's why some
surgeons have two or more programs of vacuum and pump action
during one phaco.
For a given amount of uttrasound power per time unit, more
volume of nuctear material wilt be aspirated white the tip is
occtuded. Therefore using occtusion during phaco is more time
and energy eff icient then without occtusion.
To hotd a piece of nucteus you need high vacuum. First grab it with
aspiration and create a short phaco power in order to get into the
piece and create tip occtusion for vacuum.
4
iiiiiliiilliiiiliiiiil1chapter I: Phaco
Methods and Device Settinss
iif iiljillliiiiilif
o .s\
r TT
.You have to leam to occlude tfte tip of the phaco
ptobe' You u¡¡ll then
be abls to uss the vac{¡um porsr. ln sofrer cataract you t4'ill need
less phaco power to eal lfie lens..."
Figure 2
Do not press with the phaco tip on the incision. compression of the
incision Lips with the working phaco tip wit[ create a corneat burn.
Especialty the anterior tip is in danger white scutpting deep'
As soon as you have vacuum buitding up, you know then that you
have occtuded the tip. But be aware of the fact that you wilt then
not have ftow cooting the phaco tip...
Do not use phaco power for tong time otherwise you have a corneal
burn.
'itl
I
principres or
1ii tiiiititliiiiii;t Essentiat
Figure 3
6
i|iiiijiiiiliiii iiiiirii ffiffi
Fcstttmmümg, S4ácr*scffiptr,
Fhacmdymermirs eruC
rn&ye
Each step ofthe procedure has a lot of influence on the next steps.
A problem at the end of the operation may have the reason at the
beginning of the operation.
,: t,l
7l I
I
lli lliiif iliiii essenttal Principles or Phacoemulsrfication
With a temporaI approach you avoid the brow. You have a better
access to the eye.
You can atso start with a superior approach, but this is a littte more
difficuLt to start with. lt is important to choose your patients and
not to start with these "deep" eyes.
Right foot for the phaco pedaI and left for the microscope or the
other way round. Learn to use both feetl Adapt to the way it is done
at your ctinic.
lf possibLe take your dominant foot for the phaco pedaI and the
non-dominant foot for the microscope footswitch.
Do not start cataract operations at your cLinic with a lot of speciaI
and new stuff onty for you. You have to adapt to the situation and
watch others. Your co-workers witl appreciate that.
First: check if the eye/the face are horizontaL to the microscope.
Often you have to ask the patient to put his chin up.
Then check if the head is not titted to the other eye. The f tuid shoul.d
fLow down away to the temporatside from the operation fietd and
not coLtecting around the operated eye and towards the nose.
you have atso a smatl. fietd of vision and a bad depth of fietd. With
a low magnification you wit[ not see detaits. Choose the best
magnif ication for your work, but do not use too high magnification.
B
illi]ilo."p."' ir: positionins, Microscope, phacodynamics and more lii]i]f f ljiliilil]i]il
> Whenever you reatize that the eye presents with too much pressure
from behind then check first the lid specutum position.
correctty. lf you have had problems during the draping, you witl
have problems later.
> You have to take away the lashes from the operation fietd since
they are a major source of bacteria.
Start the irrigation for the phaco tip or l/A-tip before you enter the
eye Ikick the pedal, first horizontaLl.y to the teft or the way you have
programmed your phaco device).
Enter the eye always with infusion on. First, because you witl. have
less air bubbtes in the anterior chamber and second, because the
anterior chamber wiLt fiLt more contro[[ed.
You can program your foot pedaI as you want. Here is an exampte
with four positions: Position 0 - everything is off, Position 1 -
irrigation is on Iremember to start the infusion before you enter
the eye!), no pump, no uttrasound. Position 2 - irrigation is on,
pump is on, no u[trasound. Position 3 - irrigation is on, pump is on,
and uttrasound is on.
> You may atso program your phaco device differentty, but you have
to know exactly what is going on while you are pressing the foot
peda l.
9-,
phacoemursirication
illlllliliiiillllllj Essentiar Friircipres or lllilllllllllliiilliliillliiiiiilililliiiiiiliiillll
It is not a sign of weakness if you feet not being the right surgeon
for this eye. Better be [ore before the operation than be stumped
during and after the operation.
The goaI of phacoemulsification is to remove [ens with minimaI
ultrasound power to reduce damage io the cornea, but safe phaco
does not mean low power. Appropriate phaco power is demanded.
Stop phaco power if you are not working ctose to the [ens!
surgeryl
lf visualization gets poor during cataract surgery something is
wrong. You have to analyze the prob[em. Stop, look, anatyze and
act!
lf you do not have red ref tex then check the microscope parameters.
lf you stitt not have a red reftex then you have a white or btack
cataract, a vitreous hemorrhage or a totaI retinaI detachment, a
[arge retinaI tumor or a [arge retinaI hemorrhage. Better color
the lens capsute before doing capsutorhexis in these cases.
,,,,1O
l
iillrlliliillitillilr
tl iirllirliiil,liii;i
I
> A sma[[ pupiL is nothing for a cataract surgeon beginner' You have
to ditate this pupiL or if not possibte ask an experienced surgeon to
take over [Figure /*1.
Figure 4
lf the pupiL is smatl you are in troubte, since it may not get bigger
during ihe whote procedure. First try to ditate it with OVD and
additionat topicat mydriatic drops. You may atso put adrenatin in
the anterior chamber. Wait for severaI minutes untiI you see an
effect. lf the pupiL is stitL too smatI you need mechanicaI entargers
Like iris hooks or a Matyugin ring.
lf you trembte too much with your hands during the cataract
surgery, better remove the instruments of the eye and try to calm
down for several minutes and then continue. Don't let you be
siressed by others! You may atso drink coffee after the operation
instead of before.
11
ljiliiiiiliiililiiji Essentiar Fii¡cipres or phacoemursincation iiliiliiilliijiiiiliiillllilllllllliilllllllliiiiii
perform a stow, but safe procedure than a fast and dangerous one.
The speed of operation witl come after more experience.
certain situations.
in troubte even before the operation, then ask a cottege that you
may need his hel.p.
ffiT
Corneal Wounds
15 ]i :
illiiiilliiiillliiii Essentiar
principres of phacoemursification iiiiliiilliliiiillliiijlijillliiirliiiiiliiliilllliiii
You need to pass through the totaI thickness of the cornea white
creating the paracentesis or the tunne[. Especiatty you shoutd pass
the [argest part of the blade through the endotheLium (Figure 71.
Figure 7
¡;: l;:¡¡.:$¡f[
-_
Figure 8
>- Avoid extreme etevation of the phaco tip or the l/A hand piece
during intraocuLar maneuve[s. you are stretching the wound and
it may not be sel'f -seaLing any more...
Perform the ctear corneaI incision as peripheraI as possibte. You
wit[ have less astigmatism thereafter and witl. be abte to work in
the eye with betier visuatization f Figure 9f .
Figure 9
meridian. The more centraI you put the ctear corneaI incision the
more you have astigmatism.
:16
Chapter III: Corneal Wounds
Stabil.ize the eye white performing the incisions, but don't press
too much on the gtobe. Better hotd it with a forceps for exampte
IFigure 10].
Fixating the eye during ctear corneal incision is safer. You can
use a cotton tip, a fixation ring or even the finger opposite to the
incision side IFigure 10).
Figure 10
Do not use extensive pressure to hotd the eye with the second
instrument. lt is better to hold it with a forceps then.
Take care not to create the paracentesis or the tunnel too ftat. You
may hit the endothetium after coming into the eye.
Figure 11
lf you loose a cannuta f rom the syringe whil.e injecting OVD or BSS,
then remember to tighten it better next time...
lfyou nick the [ens capsute during paracentesis or tunneI
preparation, then remember to include the nick during
capsutorhexis, Use it as the starting point of the rhexis...
lf you nick the iris, do not worry. This is usualty not a big deat.
lf you put the paracentesis at the wrong ptace, then make another
one... IFigure 81.
Figure tz
lf you know that you have to deat with a rock-hard cataract then
put the phaco tunne[ backwards, meaning that you do not perform
a cLear cornea incision, but a sctero-corneaI incision. The cornea
witl. benefit from this position since corneaI burns may occur due
to excessive phaco power.
Check the eye pressure before you enter the eye! EspeciaLty after
having performed a retrobutbar injection or in eyes with known
high intraocutar pressure. lf the lOP is too high then first press
on the eye for 1-2 minutes. lf stitL too high then do it again. lf stitL
too high you may even use intravenous mannitoL to lower down
the pressure Itnot working wel.t in vitrectomized eyes...), and check
with anesthesioLogist, if patient is abLe to take mannitoU.
lf you know that you have a high intraocutar pressure before the
operation, give carboanhydrase inhibitors preoperativeLy. This
is also a good idea if you have a patient with shattow anterior
cha mber.
19
KW
Cnpsutnrhexis
lf you do not want to work with the cystotome, you may pinch
the capsute on purpose during the paracentesis or tunneting
procedure. lt is easier then to grab the borderwith the forceps.
You may directty inject the dye through the paracentesis Ibefore
OVD!) or you may f irst inject an air bubbte in the anterior chamber
and then put in the dye. Afterwards you need to ftush the anterior
chamber severattimes untityou have a clear view.
Capsutorhexis must be around 5mm, not too big and not too sma[t,
but better a Iittte too big then too smat[.
2t
___-...-.-tl
Figure'15
Must be curvitinear and round. The correct name for the good
capsu[orhexis is CCC for "continuous curvitinear capsu[orhexis".
Just do it Like the name says f Figure 141.
:ZE
continuous curvil¡near capsulorhexis...
"CCc =
Figure L4
Figure 15
23
l,rtililiiii;i;;ill Essentiar
principres of phacoemursification
lillillilliilliliiliiiiililliillllllllllliilllllllillll
> As a beginner, use two hands during this procedure. The dominant
hand is hotding the rhexis instrument and the other one hetps to
guide it.
Figure 16
forceps not...
Do not push too much down on the cornealwound white doing the
rhexis. OVD may come out and the chamber wit[ ftatten and you
may atso experience fotds in the cornea with reduced visibil,ity.
t7
Ftgure 18
: :, .taalf
¿5,, .. l'ili
i: l' i:: l:ii,'
The ripping technique consists in putl.ing the fLap more towards
the center of the capsute. You have to pul.t the ftap at a point much
ctoser to the tear than with the shearing technique f Figure 191.
With the ripping technique you putl the tear more towards the
center of the pupil. IFigure 19].
re 19
....,26t.
,,Stop pullingl The ¡hexis is run*ing cut.
Stay calñ, and ftrst flll in OWO..."
- "'Figur€'.,,!Q.:',;i:
inject 0VD over the tear, and then use the forceps to make a sharp
turn inwards to prevent radiatization: grab the end of the ftap right
where the rhexis is heading out and then put[ inwards, somehow in
the direction in between radiaItowards the center and tangentiat!
And stay atways on the surface of the [ensl f Figure 211.
> To redirect the tear you have to act on the ftap ctose to the
evatuating tear lFigure 211.
,lo Jtrp th€ l€ff rlnilifiS out, yc! h¿ve td ritsck th¿ flig slore tü the Aát
¿nd pq,l th€ fláp parsc¿ntÉlly,,. snd dó rot forg€t OWD-állinÍ bsfofe..."
Figure 21
':t
¿
Essential Principles of Phacoemulsification llllllllllllllllllillllllillllli'iliiil'illi1ii lll
lf you have difficul.ties to identify the border of the flap then inject
OVD towards the probable direction of the running flap' lf you stiLl
cannot see the fLap margin then use capsular scissors to create a
new tear or use the etectro-capsutorhexis device.
L-
,,4 positivr vitreous pressur€ creaies ananterior disBlacemeñt of the lens
with zonular stress. The anterior capsule is under teñ5ioñ too,
Capsulorhexis will always run out in this situation,.."
Figure 22
> A shattowing anterior chamber results in an anterior displacement
of the lens and therefore zonuLar stress. These forces are creating
tension on the anterior Lens capsute. Performing capsutorhexis
under these circumstances wi[[ lead to peripherat propagation of
the tear IFigure 22).
>= You need atways OVD ready to inject white performing the rhexis
f Figure 231.
Figure 23
29
t
ii iiiiilliiiliilililil Essentiar?iincipres or phacoemursincation liiiiiiliiiiilliiillllilililljlllliiiillllilillliliiliililllill
towards the periphery, then never ever tet the anterior chamber
fLatten. Put ViscoeLastic even before exiting the chamber with the
irrigation instrument Iphaco tip or l/A-t¡p).
>= Use needLe first, as [ong as possibte. lf rhexis is going out, then
refiLt the anterior chamber and then use the forceps. PutL the
rhexis margin directty at its end, ftat on the surface of the Lens,
towards the center and a littte in the direction the ftap shoutd go.
This witL redirect the f Lap IFigure 21).
pinch the anterior capsute with the cystotome [or even directty
with the forceps) and then continue with forceps.
the fLap, otherwise your rhexis wiLI run out f Figure 241.
>" The most difficuLt part of the rhexis is the 12 o'clock position (if
you work with the main incision approachl since corneaIstriae are
often produced by wound distortion. You can avoid this diff icutty by
changing from the main incision to a paracentesis.
3L ,"i',
.:i
princrpres or phacoemursirication iliilliilililliilllliiiiiilililiiiliillililllillllllllllllll
tiltnittiittttltl Essentiar
ii
t0L.
issue...You may have the [ens coming out of the bag during
hydrodissection and you wiLt have to put it back in the back
afterwards. At the end of the surgeryyou wittthen have to be sure
that the haptics are both in the bag. lf the l0L shows a tendency to
put[ forward, use a miotic agent in order to keep the l0L where it
shoutd stay.
lf ftuid is coming out of the bag, continue with the forceps [since
there is a ftuid fitLed bag, the need[e has no contra-pressure and
needle rhexis does not work properl,y). Try to perform a very smat[
[the rhexis wiL[ always try to run out!] and quickty performed
forceps rhexis. This wil.t give you a normaI sized rhexis. lf, after
initiaL puncture of the capsute, there is no fLuid coming out, then
i=
needte rhexis is possibte, but perform it quick and atways fiLt the
chamber with OVD.
::,:. .32
liillllilllllilillliiiiilililililllltilllliiiillillilllililliiliiilliilliililillliiliiliiiiiliii chapter IV: capsu,orhexis liiililiiiililiiiiii rl
Remember: in a tense bag the rhexis wit[ atways try to run out.
Atways deepen the anterior chamber and be quick!!! lf you are to
s[ow, the rhexis may run out without doing anything... I think you
remember the Argentinean ftag sign...
lf there is evidence of zonutar l.axity during the case, then consider
ptacing iris hooks to stabitize the capsutar bag. You do not have
to place 4 iris hooks, but just enough to ho[d the bag at the place
where zonuta support is gone.
Do not overinf late the anterior chamber with OVD white putting the
iris retractors. You wit[ have probtems to reach the pupiL margin
since it is way back.
:\'
33 !.
ll:'
ffiydrmffiámmwmt'&mryru /
Mydrmdm&ümmm&ámm
shoutd know how the lens is built. From outside you have first the
Lens capsu[e, then the cortex, the epinucteus and [ast the nucteus.
You have to understand the anatomy in order to realize what you
are doing f Figure 25).
35
iiliililiiliillljilij Essential
principres or phacoemursirication,
iljlijjjllllljiljllliliillillllliiiilijjjiiillillillll
lf you drop a piece of nucteus into the posterior chamber you may
probabLy have to ask a vitreoretinaL IVRJ surgeon to remove it f rom
there. A cortex loss is usualty less of a probtem. Therefore it is
safer f irst to perform hydrodetineation in cases where you expect
to have a posterior capsutar weakness in order to remove the
nuc[eus.
Put the infusion cannuta between [ens capsu[e and cortex 1mm
from the border of the rhexis towards outside and flush relatively
quick fFigure 2ó1.
Figure ,26,,
36
Chapter V: Hydrodissection / Hydrodelt"eatto" iiiiii I il
Figure 27
may btowout the posterior capsuLe... But if you push the syringe
too Iittte, nothing wiLt happen f Figure 28).
Figure 28
37
[,,,,,,'',,,,"',,,,,,
You may start to inject fLuid just before entering the subcapsutar
space during hydrodissection. Push then the cannu[a forward and
continue to inject fluid until. you see the wave passing to the other
side.
Figure 29
Push the lens back in the back after every injection phase. First,
to avoid protapse of the [ens in the anterior chamber, especialty
in [arge capsu[orhexis. Second, to avoid high pressure in the
posterior between [ens and bag due to compartment syndrome
[you may break the posterior capsuteJ f Figure 301.
q'-*** _J
-Iig*rs f9*_**_
Figure 31
forward in the [ens untityou see the tens moving sl"ightLy. You wit[
be then at the right position to inject f Luid. Look for the gotden ring
sign creation during fl,uid injection f Figure 321.
Figure 52
Chapter v: Hydrodissection / Hydrodelineation IiiIif Iiiiii Iiiiiiii
the bag! Rotating the lens ensures that the job is done" lf the tens
does not rotate then you witL not be able to perform the cataract
extraction niceLy f Figure 331"
>' A [ens that dropped out of the bag during hydrodissection shouLd
be pushed back if possib[e. You do not have to rotate it thereafter
since it is aIready free...
Figure 33
put ftuid in the eye and the fLuid shoutd have no problems to get
out of the eye IFigure 31].
ts Look for a ftuid wave passing behind the Lens. Do not stop injecting
as soon you can see it. Continue untiI it reaches the other side
IFiqure 30].
4L
iliiillii]illiill]]liiiiljj rssentiar Principres or Phacoemursiricationy lilliiiilliiiiilliiiiiillrrllllririlliilliiillililillli
After each try, push the [ens back into his bag. With this maneuver
you break the firm equatoriaI cortico-capsu[ar adhesions and
the [ens gets free. Otherwise you just push more BSS behind the
lens creating high pressure there and risking a posterior capsutar
rupture IFigure 28).
With a very soft cataract it is diff icutt or even impossibte to put the
[ens back in the bag. Therefore do not overdue the dissection.
42
Chapter V: Hydrodissection / Hydrodelineation , i ,i i li,,ii i I
than with the cannutal. You shoul.d clearl.y see that the lens is
turning IFigure 331.
43
Wffi
Grooving
lf you do not use the phaco tip property, it is more a weapon in the
eye than a hetp for you IFigure 341.
,,Ne asp¡ration ior phakc power) in this situation. You do not have
fluid corning in the eye afld th€ anterior chamber will coltapse..."
Figure 34
45 ' ,:'.,11
lil iliilililiiliiiillil Essentiat princip,es or phacoemursincation liiliiillliilillliiiiillllrllililllliiillllliliiliillllilll
use the phaco tip through a smat[ incision and thereafter entarge it
for l0L imptantation. But be carefuLbecause of the corneaI burns
since the sleeve can easier be occtuded in smatI wounds. And you
can etevate the infusion bottLe if you have performed a good and
tight incision. A teaky incision witI otherwise increase the flow in
the eye and create turbutences.
ctose to the rhexis rim, ctose to the iris, ctose to the endothetium,
or close to the posterior capsute and at the inferior nuctear rim
f Figure 351.
.,Avo¡d th€ proximal and distal iris during aspiratiün ánd ph¿ko power...
Figure 55
phaco tip moves in the eye. Learn to use the incision as a futcrum.
Otherwise you witL encounter corneaI striae with a bad visuatization
and a leaky wound tFigure 3ó1.
46
,,Try ta p¡vst the phakc probe in the incision. You will have less
ccrneal folds and a better vision..."
Figure 36
Atways futt speed at the beginning in the safe you
want to make a race and the tights turn green: with
Phaco-1 program IFigure 37).
From the border of the proximaI rhexis to the other one. That's
your race distance [Figure 371.
Figure 37
4V
t--
I
il I i i i i lil f i I i i i i i I Essential Principles of Phacoemulsification
Figure 38
The groove wiLt be deeper opposite to the tunnel. But do not forget
to groove the proximaI part atso...
48
Chapter VI: Grooving
the len$ is movins lsrward during grooving, you push too much on lhe lens.
"lf
You are pulli¡g on the zonüles. Move slower andlor increase phako power..."
Figure 39
You may occtude the steeve the deeper you groove and wi[[ then
have reduced irrigation f Figure 401.
,,A n¿rrow grouv€ wlll obstruct the silicone sleeve, ssp€cially ln the periphery.."
Figure 40
:.i
':'ll
::.3
4ei j
I
.l
'I¡
Essentiar princrpres or phacoemursirication liliiiililillllililllilf lliliilliliilliiiilliliilf
f ilillllll
The deeper you get, the more you have red reftex. The red reftex
shou[d shine l.ike a down going sun. Then you are deep enough
IFigure 411.
Figure 41
As soon as the groove get's quite deep, you shoutd not go futl
power any more...
lf you have to attack the centraI deep f ibers, then dividing is easier.
But remember to stay always on the safe side. Too deep is too
deep...
Figure 42
Figure 43
51
Essential Principles of Phacoemulsification 11lil1;ill11liliiiiiiliiiiiiiiiiiii.i
lf the center of the nucteus is not thin enough you wiLl not be
successfuI in dividing IFigure 42).
Figure 44
The Lens should not move much during grooving. Optimal. grooving
is achieved when the [ens nearty does not move. This impticates
that in hard nucteus you have to increase the phaco power. lf the
Lens stitl moves then go fu[[ power, but stowty. lf the Lens stiLt
moves, then do not groove with the tip comptetety embedded in
the nucleus IFigure 39).
As a beginner try the divide and conquer technique f irst. You witL of
course have to learn at[ four techniques at the end to be a comptete
cataract surgeon.
Turn the nucleus either with the second instrument or with the
phaco tip untiI you have it in the optimaI position. Use the wat[of
the groove as a counter bearing to turn (Figure 451.
\*l
,,Don 't be lazy. Turn the lens 90 degree for the second groove...''
Figure 45
53
r lriiiiiliiiiilriiiiii
Essential Principles of Phacoemuisification iiiliiiiiiiiiiiliiriilliiiiiiiliiiiiiiiiiiiiiiiiiiiiii
G1 cataract you may have to groove once or twice with fu[[ power
to be through the nucteus, in G2 twice orthree times, in G3 and G/+
more than three times.
Try, if not working then you have to stop & chop or even chip & ftip.
Adapt to the situation !l!
not pushing on the posterior wal.[ of the tunnet. You are creating a
lot of outftow white pushing on the wound lFigure 4ó1.
.,tf the ¿nteriar ihamber is getting flat, yüu have to know why" Here due to
manipulation with the phakc tip or a toa lar6e incision, you have a wound leaking...'
Figure 46
54
iiiiiliiiiiliiiiiiilii
that you are not pressing on any wound. You may even have to
remove the other instrument and stay in the eye onty with the
phaco tip f Figure 471.
,,lf the anterior chamber flaüens, then check the wounds for leackage...'-
Figure 47
on the wounds, then increase the bottLe height, check the tubing
and fLuid Level. and decrease the ftow. lf the corneaI wounds are
leaking then consider suturing the leaky wound or just one end of
the wound.
55
'
.l
:a:i
.Wffiffi
ffi*wa$e & ffimwkqe#ffitr
at atLl!!
> After 2 deep grooves in the nucleus put the phaco tip deep in the
center and the Nagahara chopper in front of it Inot beside!), push
first down and then to the side to divide IFigure 43).
Put the instruments as deep as possibLe within the groovel
lf you try to divide the [ens in his center or above, you compress the
ftoor of the [ens instead of dividing it f Figure 481.
Figure 48
57
Essential Frincipres of phacoemulsification llllllllillllliillliilllliillillilllllllllllllllllllllll
Push the [ens first down and then to the side! [Figure 43).
lf you try to crack the nucteus but you act not deep enough then
you may separate the two watts of the nuc[eus, but the posterior
part of the nucteus witL be more compressed instead of being
cracked IFigure 48).
Be sure that the cracking is comptete. You may have to crack
severaI times... WeLt, the centraI part or the very peripheraI part is
sometimes not wet[ cracking f Figure 491.
58
llff I fi ii i cr,upt"r.VII Divide I conquer
Figure 50
t- :, Yr":_:1_ _J
59
i
j
grooving then groove deeper, especiatty in the center and try again
cracking.
nucteus Ino watls any more from the grooving), then change to the
chip and ftip strategy. Take one ha[f out of the bag into the anterior
chamber and then chop it vertica[ty.
Figure 52
60
opening sf thc phako tip shoirld never
"The
ever be directed lcwards the capsule..."
Figure 53
last pieces too aggressivety with phaco power towards the capsute
f Figure 541.
61 '':,
t
I
and then Lift it up in the aspiration mode towards a safer zone for
phacoemutsif ication f Figure 551.
Iigure 55
Stay in the center of the anterior chamber with the phaco tip
whi[e eating the pieces. Do not put[ out the tip whi[e doing phaco
power or aspiration, otherwise the anterior wit[ cottapse since the
infusion is located behind the tip opening and may get out of the
eye (the posterior capsute is in danger...J
lfyou are ab[e to perform a crack in soft to very soft cataract, then
continue in divide and conquer [groove deeper and try atso the 90o
groove). lf stitl. not possibte to crack, then skip to chip and ftip.
Try first to get the sma[[ pieces out in the anterior chamber after
cracking. lt is easier thereafter to get out the bigger one...
lf there are some nuc[ear fragments that want to come out. So let
them come out of the capsul.ar bag and eat themlTake the easier
one f irst. The others wi[[ then come easier...
To takethe nucteus fragments out you have to adjust the phaco tip
opening to the piece. Turn the opening to the side or tiLt it a tittte
.62
''..,
'. Chapter VII: Divide I Conquer i
As soon as you have one piece of nucteus left in the bag, you may
change the phaco machine settings from phaco-2 into phaco-1.
You reduce the vacuum and therefore are in safer settings for the
posterior capsute.
lf you get out a quite big piece in relativety soft cataract then try to
hoLd ii on one side Inot in the center]. You witL probabty be abte to
eai it up easier tike that. ln harder cataract you take them out in
the center and then chop them.
lf one piece is too big and [ies in the anterior chamber, then make
it smatler, especiatty in hard cataracts, meaning that you have to
chop it horizontatty. Otherwise the corneaLendotheLium suffers.
63
liilriilrlliiiiliiiiii
Essential Piinciples of Phacoemulsification iliiiiiiiiiiiiiiiiiiiiiiiiitiiiiiiiiiiiliilililillllllll
then search it! They are often difficul.t to find in eyes with wel.t-
estabtished arcus senitis or with smat[ pupits. You may ftush the
side ports and the main incision to find them f Figure 5ó1.
Figure 56
Never leave a nucleus piece in the eyelYou wit[ have probtems after
the surgery with pro[onged inftammation and high intraocutar
p ress u re.
lf you have an epinucteus cup left after taking out the nucteus, try
to aspirate it on side and fl.ip it.0therwise use a b[unt instrument
to push it towards your phaco tip and eat it, white taking care of the
posterior capsute fFigure 571.
57
64
i.i..ii..i.ri.riiiii.riiiiriti.urirr'.iririi.i.liif Wffi Kffi
ffi$atp S
Ft*p
,,Chip & Flip: the first way. You bowl out the lens""."
Figure 58
65
iiiiliiililliliilliliiii Essentiar
princip,es of phacoemu,sification iliiliiiilliililliililliiiiiiiiiilliiiililliillliiillllllill
deep groove centraI and then divide the nucteus Like in divide &
conquer, thereafter you bowl out the nucleus f Figure 591.
,,Ship & flip; the s€cond way. You perform a nice and deep groove and theñ divide...'
Figure 59
v -u
,,Chip & Flip: that's the way ycu turn the epinucleus.
Aspirate ihe border of the cup and then pull it away in occlusion
mode. lt is rsally a kind o{fl¡pp¡ng out of the bag..."
Ftgwe 60
66
=.
?:
y- Take care of the capsute white chipping... lFigure ó11.
fl.ip. Then you have to hotd it with the phaco tip. Use just LittLe
phaco power to emu[sify the nucleus.
lf you are ab[e to divide the nucteus once in soft cataracts, you can
also chip one ha[f out of the bag and finishing it and then the other
one. lt is realty a nice method to deaIwith softer cataracts.
The chip & tip method is a nice method safety variant if you
destroyed your wat[s in divide & conquer method and you are not
abl.e to crack the nucteus any more. Changing to the ctassicaI chip
& f tip is a perfect way to comptete your cataract operation in these
cases.
irliliiliiiililillilrirlllirritrrrrrrlrrlrririiiiiiiriirllrlrrlrrrirrlrliiilliii mW
Stwp &
thwp
A good method to avoid stress towards the zonutes"
p rog ra m)
You perform one deep groove and then divide the nucteus in two
pieces by cracking it. You stop the divide & conquer method at this
point and start chopping fFigure ó21.
,,Stop & chop starts like good-old divide and coñguer rnethod:
you perform a nice and deep groove and then divide..."
Figure 62
69
Essentiai'Principles of Phacoemulsification
:,:i ¡1: i : t:; i'll::,:ll ;i
First perform a deep groove. You may eventuaL[y turn the [ens 180'
to groove a[so in the otherdirection. Then crack it and turn 90o and
Letthe phaco tip work his way in the centraL nucteus with some
power. Then hotd the nucLeus hatf with vacuum and chop either
horizontaI or verticat.
To attack the nucLeus with the chopper it is better to remove the
epinucteus first.
Stop the nucteus from moving with pLanting the phaco tip deep in
the nucteus [first give a tittte phaco power, then hoLd the nucteus
with vacuum).
Remember: you cannot hoLd the nucteus white you are using phaco
powerl The phaco power is to get deep in the nucteus.
To prepare for chopping you have to bring the phaco tip at least in
the middte of the nucteus and keep it there. You may impaLe the
tip into the nucleus with first a tittte phaco action and then hoLd it
with aspiration, but you don't need atways to hotd the phaco tip in
aspiration mode. Adapt to the situation!
VQt,,
]]rrr]li]rlti]iiiiiii
,,Stop & Chóp: horl¡ontal chcpping. Place the chopping instrurnent between
epinucleus and nucleus in the distal periphery of the lens.
Then slide towards the phako tip...'
Figure 63
between the epinucteus and the nucleus white stiLt being in contact
with the nucteus. lt is easier to reach the periphery if you titt your
instrument paratLetto the iris ptane and rotate it back as you reach
the equator IFigure ó4i.
nucteus whi[e you are moving the chopper towards the phaco tip.
Towards the center the [ens is getting bigger f Figure ó41.
7L
Essential Principles of Phacoemulsification
After removing the epinucleus to the capsulürhtxi$ border you rotsts the
choppa ¡n order to slip b€tter in belween epinudeus and nucleus and
a$ you reach ihe periphery you rotatelle instrument back. Then
move lhe t¡p deep towards the phako tip..."
Figure 64
IS
hoLding the nucteus with vacuum and the second instrument is
pLanted deep in front of it and pulted to the side fFigure ó51.
,,stqp & Chop: vertical rhcpplng. Plant th* chopping instrilment aboüt
o*e millimeter antcrlor to the phacs tip, Do nüt put it rnore di$tal
since you will break the o*clu$¡on sf the tip due to vectsr forces.,."
72
I
l, :,, r, Chapter lX: Stop S Chop
73
Phaco Chsp
with the phaco tip and then chop as much as you can.
Regarding chopping techniques see atso chapter lX. Stop & Chop.
Probabty the fastest method Iin the hand of an experienced
surgeon- you reat[y have to know a [ot about cataracts before you
can deaI with itJ.
ii;
al
73 I
i
l':
rl:
Essential Principles of Phacoemulsification lii l
Figure 66
67
There are one hand and two hand l/A tips. Both are usefut, but
both have to be used a Litt[e different.
Stay atways in the middte of the capsute with the irrrgation tip in
two hand l/A f Figure ó81.
Figure 68
77
t
,,Go under the antér¡or rhexis in tns périphery, as$rafe wn;b me opeil¡ng
sf the aspirat¡ón t¡p shorjld be upwards, try to get ocslu$ion añd tneil püll
towards th6 cÉnter of the bag" ...'"
Figure 69
side to side [this wi[[ [oosen the cortex therel and then putt under
aspiration towards the center lFigure 701.
are sure that you did not have caught the rhexis margin or the
posterior capsu[e. Eventuatty you have to pu[[ out the l/A content
lFigure 711.
,,lf you aspirate the posterior capsule ánd then stap asp¡ralion,
ths poslericr capsular w¡ll be released..."
Figure 71
v- Sticky cortex needs patience...
'1+ The most difficutt part of lens cortex removal is the superior
subincisionaI area. An angutated one hand l/A tip hetps to get to
this area. ln two hand l/A instruments you may have to perform
a third paracentesis at ó o'ctock to reach the area or remove the
cortex with bimanual. l/A (Figure 72!.
79
L ,lir'. .,,
,'
,li ;i il,l ll;i Essenttal Principles of Phacoemulsification iliiiiiiliilillilliltiiillliliililiilllllliitililiilllilll
rotationaI movement from left to right [or the other way roundJ
and turn during that movement the opening first downwards and
then upwards again.
> Another point regarding subincisionaI cortex removaI for the two
hand tips is that the paracentesis shoutd not be too ctose to the
phaco tunne[. You better access the cortex if the paracenteses are
positioned away from the main incision.
be sure that you have not engaged the rhexis border. ln doubt,
stop the suction immediatety and leave the l/A tip where it was. To
panic now is not the right moment...
the cortex you have engaged the posterior capsute in the tip. You
are now tearing on the capsute and the zonutes... Stay ca[m, stop
aspirating and leave the tip there. Don't move! Now you can use
reftux or the capsute witL be free since you stopped aspiration
f Figure 731.
,,See the small starfolds in the ptrster¡or capsular ba6? Stcp aspirating
and ds, nst move the aspiration tip.""
Figure 73
:i..,:.1¡8$.,
Chapter XI: Cortex Removai
>-' lf you move the aspiration tip white you have engaged the posterior
capsute, you wit[ create a tear f FigureTl*1.
,,lt you aspiratr the pósterior capsule and thÉn pull back, you will have a
74
you are not moving the tipl Therefore release the foot pedaI and
even push the ref Lux IFigure 71).
81
l-
I
princrpres or phacoemursincation
ili Essential
j]
ii ili i] if l il if iiiiiiiliiiiliiriiilliiiiiiiiiiliiiliiiiliiliiiiiiiiii iliiiilüilil
il i I
out with the irrigation and you have time to think... lf no vitreous
i
is present and the ho[e is sma[[ then put the lens in the bag. Do
not use too much aspiration white taking out the OVD... Check for
vitreous in the corneaI wounds. lf you have vitreous in the anterior
chamber protapsing from the hole then you have to perform
anterior vitrectomy. But remember: never try to put[ the vitreous.
You may puLL the retina with it..." Vitreous has to be cut away or
released f rom the corneaI wounds (Figure 7ó1.
,,lf you $ee a ps$teriür e*psular te*r; you h¿ve to $eal it with
OWO ¡s soon á$ Bossible. But nevér removÉ thc irrigatiün
canula ort of the eye until OWD is in th€ éye..."
Figure 76
fl*
,,Let the lens fragrnent csrne to you.
The flow wlll work for you..."
Figure 77
lf you have a rhexis tear or in very thin and mobite capsute, then try
to get out as much cortex as possibte and eventuatty teave smat[
cortex amounts. You can either take them out while the lens is
in the bag or leave it there. A YAG-capsutotomy is safer than a
ruptured posterior capsute during phaco surgery...
A ftaccid posterior capsute is difficutt and dangerous to poLish.
Put some pressure with a finger on the sctera in order to increase
the pressure from the posteriorsegment and you wi[[ have a taut
posterior capsute that is easier to potish...
Do not overdo the posterior capsu[e potishing. A YAG-capsul.otomy
[ater is sti[[ better than a capsutar tear...
Do not potish the posterior capsute too much. you may potish
vitreous at the end...
. .'..:' :
:: :il
:.::
83,,,,.
XffiX
üealtng wtth Vitrepus tn
the Anterior Chamher
lf you deaI with vitreous in the anterior chamber then you have to
think about the cause. This may guide your surgicatway of treating
the probtem and may hetp you to decide where to put the IOL tater
f Figure 781.
Figure 78
,,,¡ ]
,: rlil
. '."'''rlll
$9,": ll
'. ,',,','rli.|i
"' ' "'tril
I
Basics of Phacoemulsification Cataract Surgery
Figure 79
lf [ens pieces sink to the back of the eye you definitively know that
you are in troubte...
Figure 80
86
crrapter Xil: Dealing with vitreous in the Anterior chamber ¡ li i ll
ijii ' t
the anterior chamber, then you may be lucky, or do not see the
vitreous... lf there is real.ty no vitreous, seaI the capsu[ar wound
with OVD and continue the phacoemulsification or the l/A or
whereveryou are. But do it in a stow manner, reduce the flowand
work away from the tear, that's safer IFigure 7ó).
:.
87 rr
Basics of Phacoemulsification Cataract Surgery
I
lfyou knowthat you have vitreous proLapse in the anterior chamber,
then first stop phaco/aspiration in l/A, but keep the instruments in I
the eye!!! Use your other hand to put in dispersive Inot cohesive!]
OVD in the anterior chamber and then you can come out. You wiLL
seaI the wound and press the vitreous back IFigure 7ó].
Never ever putt too much on vitreous. You may pul.t the retina too...
"You have to cut the vitreous!!!". Use scissors or use a vitreous
cutter. Whil.e using the scissors you have to cut fast, severaI times.
Put the irrigation just in the eye and put the cutter deeper. You
create a pressure gradient downwards towards the cutter. lf you
irrigate in the area of the cutter you may push the vitreous away
from the cutter and even worse more anterior toward the wound.
88
Chapter Dealing with Vitreous in the Anterior Chamber
the vitrous with the cutter under thc capsul* and towards th*
"Cut
center of the vitreous absut U4 ta Ll3 of the p$ster¡ür
thamb*r deep."."
Figure 81
eye. The cutter shou[d be taken out of the eye in the fast cutting
mode and no aspiration. Put again some dispersive OVD and
check the wounds for vitreous protapse [using a cotton tip or a
triangular tipl. ln doubt you have to check the wound from the
opposite paracentesis with a spatuta instrument, especiatty look
for incarcerated vitreous in the tunnet f Figure 92f .
,,Check always the wounds for v¡tréous strands" Vitreou$ is
trañsparent, you have to search it".."
Figure 82
To visuatize the vitreous, you can use triamcinoLone. But this can
make the overview of the situation even worse, especiatly if you
put a lot of triamcinotone...
=.:¡¡;.$Q,¡
l r:::.¡¡::,::::r:
i]iliiillliii]iiiiiii chapter: XII: Dealins with vitreous in the Anterior chamber
,,lf you trkÉ out an instrument while yau hav* a caps*:lar tear;
you mty pull the vitresus with you.","
Figure 83
,,Vitresus has always the tendency to get o$i of the eye since it follows
Pressure gradients" Furtherrnofe it behaves like glue and you cün nüt
Suck it away. You have to cut it. PleasE check the i*cisions for vitrecus..."
Figure 84
9t
foolws always pressure gradiÉnts. Where ffuid ccmes out
"¡Vitreous
of the eye, yoü may encountar vitr€ous also,.."
Figure 85
lf you think that you have cteaned the anterior chamber of vitreous,
then perform one [ast step: create a miosis with topicaI drops or
better intracameraIand look for unusuaLcorners in the pupiL. The
vitreous may stit[ be around f Figure 8ó1.
,After hav¡ng placed the lens in the bagy'sulcus {if pos$ble), create a mioris
and look for the pupillary marg¡n. ¡fthere is sr there are corners th€n
you haw süll vilreous around... Vi$eous is trá¡s¡arent...'
Figure 86
92
iiiiiijriiiiijijjjjiiiiiiiiiiiiiiiiiiiiiiiiiiiiitjiiiiiiijriiiijjitiiiiiijiiiiiiiiiiiiiiiiiiliiijjjiliiiijiiijjjjj
Kfitr[
Xnsertimvn c¡f tkre lffiL
shou[d know the size of you tunnel br.ade and then just check what
kind of [ens you want to imptant.
Figure 87
93
Ii ll
j j
iiiIiiii iII iii i Essential FÍinciples of Phacoemulsification iiiiliiiiiiiii r rlllirililiiiiiiiiiiiiiiiirlrlirliliiillli
During entargement you have to be sure that you stay in the tunneI
and then go stowty under the anterior capsute [compteteLy - the
[argest diameter shoutd pass the corneaLendothelium].
White coming out with the btade, open a littte more towards one
side of the port. This witl make it easier to introduce the [ens.
ln smatl capsutar tears you stitl can put the lOL in the bag. ln
larger tears better p[ace it in the sutcus if you sti[[ have enough
support by the zonutes fFigure 881.
AA
]- 7\
,,ln srnall posterior capsular rupture. you still can put the lens in the bag.
ln larger one, you should put the haptics in the sulcus ..."
Figure 88
94
Chapter XIil. Insertion of the IOL
,.ln larger posterior capsular rupture, you shouid put the hapdcs ín the sulcus,
but you still can put the ophc in the bag. You will then have a rhexis fixated lens..."
re' CompLetety fiLt the anterior chamber and the bag with OVD before
putting in the lOL. Be sure that the tunnel is atso fitLed with 0VD
Then, the IOL or the shooter stips better into the eye f Figure 901"
,,While filling the bag with OVD, check for the OVD propagation line
deep in the bag {called the,,Orgül wave"}..."
Figure 90
95
lf you put it in the bag the first haptic shoutd be in the bag from the
beginning (Figure 911.
,,lf yos want to put the IOL in the bag, put the first haptic in the bag while
you are still psshing in ths lOL,.."
Figure 91
s
tu
,,,fr5;Ey-,,
lot in the sulcus, you have to put the first haptic
,,lf you want to put the
between thé irir a¡d the zofiulesllens capsute""."
Figure 92
96
chapter Xrrr rnsertion of the rol I l]lliiliiii l
,,lf you want to put the IOL in the sulcus, prepare the lscaüon by injecting
OVD between the iris and ttre ronules/lens capsule..."
Ftgure 93
> The IOL shoutd go ín forming a"Z" with the haptics side Inot an
"S"... which woutd mean "stop", do not imptant Like thatl. lnstead
of "2" you may prefer another acronym Like "7-0-L-even" which
is the same... This design is actuatty for right-handed surgeons
in order to easity rotate the haptics in the bag Ictock-wise)
IFigure 941.
Jhe lüL should go in the eye fcrming a ,,2*'with the haptic$ and not a,,S"
,,5" would mean stop and turn the lCIL!".."
Figure 94
97
ilr ]iiii Essential principles of Phacoemulsificarion iiliiiiiiiiiiiiiii r
lf you put in the t0L the wrong way, then you have three possibil.ities.
First ftip it within the eye [better for more experienced surgeonsl,
second leave itas it is Iit is nota catastrophe, butyou mayencounter
more posterior capsute opacification and the l0L power may not
be adequate) and third, you take out the [ens and put it in correctly.
lf you are not shooting the lOL, but inserting it with a [arge wound,
put the first haptic directty in the bag and the optic shou[d have
passed the corneaI endotheLium with the [arger diameter. Then
press the optic [with the Y-instrument] first down untiI hatf of the
optic is over the rhexis margin [and in the bagl and then turn the
haptic ctockwise. This wil.t put both haptics in the bag f Figure 951.
,,lf one hapüc is in the bag and the sther is still outside, then push the optic
forward in tht bag, press the lens d*wn and turn the IOL clockwi$e there.
The IOL will be in the bag then...'
Figure 95
l0L. Be sure that the first l0L haptic is going in the sutcus. lf it
turns out to be in the bag and you stitL push the l0L in the eye, you
may need a vitreoretinaI surgeon (Figure 9ó1.
98
chapter Xrrr: rnsertron of the rol ijijjiijijiijjijjiiji
,,lf you want to put the fOL in the sulcus {in targe posterior capsular rupture!
and you put the first haptic in the bag wlile still pushing in the tü! yóu may
loose the IOL ¡ilta th€ post€rior {hamber..."
Figure 96
lf you are in doubt whether the haptics are in the bag, then check
with Nagahara chopper or Y-instrument: push iris at the pupiil.ary
margin out and [ook for the haptics. Eventuatty the [ens has to be
turned in the bag to visualize both haptics.
Both haptics in the bag or both in the sutcus is OK, but never leave
one in and the other oui. The l0L wit[ decenter towards the haptic
in the su[cus. This by the way is the most common reason for IOL
decenteri ng.
lf the l0L is just a littte decentered, then leave it or rotate the IOL
carefutty for better centering.
lf the l0L doesn't center then check the haptics Itocated both in
the sutcus or in the bag? lf so, then put them in correctty), look for
zonular diatysis Iif so, then put a capsutar tension ring if tess than
5 ctock hours diatysis, otherwise put [ens in sutcusJ, check wounds
for vitreous lwith cotton tip or miotic agent injection), check for
haptic damage [you may have to reptace the lOL...).
gg,,' :ii
parts away f rom the tear.
lf you have just a sma[[ posterior capsutar tear in the center, then
put the lens in the bag. lf the tear is going towards the periphery
then put the [ens in the sutcus.
lf you have a rupture of the zonutes of less than 5 clock hours with
unstab[e capsute, then put a capsutar ring, if you have more than
5 hours, then put the [ens in the sulcus.
Even with the lens in the sutcus due to unstabte zonutes, a capsutar
ring heIps to stabitize the eye.
ln zonutar diaLysis the lens shoutd be imptanted in the axis of
the diatysis, meaning that the [ens haptic is pushing towards the
diatysis.
lf you use a capsu[ar ring then try to put it in the direction of the
diaLysis. According to the position of the unstabte zonutes you may
use a paracentesis to inject it.
Put in the capsu[ar ring with an injector orwith two forceps. 0ne
forceps guides the capsutar ring and the other one pushes forward.
lf you have to put the lens in the sutcus then decrease the IOL
power of about 0.75-1 dpt! {PLacement in the sutcus creates about
a 0.75 D myopic shift in g[asses).
Remove the OVD over and behind the lOL f Figure 971.
-ii .
+1",'100
jijjiiiiiiiiilijiiljiiiiiiiiiiiiijiiliiiiiiiiiiiiiiiiiiiiiiiiiiiiiiji Chapter XIII: Insertion of the IOL
Figure 97
ln [arger tunneI incision [for exampte more than 5 mmJ you may
have to suture the cornea with 1 to 3 stitches (Nyton 10-01. But
remember that a nicety performed tunneL witt be tight even if
larger than 5 mm.
Better sutu re the tu n neI if you th in k that it is not tig ht or the patient
witt rub his eyes after surgery.
chamber wit[ stay deep and the cornea witt benef it f Figure 981.
A\
ffi@
,,4 positive vitreous pressure creater afi anterior displacement ofthe loL and may luxate
it orrt of the bag. Create coi¡nt€rpressure with an air bubble ¡n thE anterior chamber snd
check your wounds. They are probably not water thight...'
Figure 98
to3
ll,, essenttal Principles of Phacoemulsification
Take out the OVD after having ptaced the [ens. The dispersive OVD is
harder to remove lshort molecutes don't stick together during l/A,
but short motecutes create less post op l0P spike...). The cohesive
OVD is easier to remove lLonger motecules stick together], but
these Longer motecutes bLock the trabecutar meshwork resulting
in big l0P spikes.
Use intracameraI antibiotics after cataract operation, but avoid
giving aminogtycoside antibiotics in the eye since they are
retin otoxic.
Postoperative tan*
TetL the patient that he shoutdn't rub or put pressure on the eye
after cataract operation.
The patient shouLd wear a protective eye shietd during the night
for one to two weeks after cataract operation.
lnstruct the patient that he shoutd avoid sptashing water directty
in the operated eye during the first days after operation.
Body bath, meaning washing betow the neck, is altowed, but the
patient shoutd not take a bath or go in the swimming pootfor two
weeks.
fa?.
treatment.
lnstruct your patient how to put the eye drops.
lnstruct the patient to wash his hands before apptying the eye
d rops.
The cornea is not heaLed, but the IOL is more stabte in the eye after
some days.
A ctear cornea the first day after surgery, i.e. a cornea with onty
a Littl,e amount of edema/endotheliaL fotds, is a good sign after
surgery.
1CI3
xtw
ileeüsimn Thking in
tataract üperatücns
3. Hydrodissection? Good: push [ens back and turn the [ens in the
bag. lncomptete: repeat at another point, if not working then
hydrodetineation (see 2.1.
105
Ii iif iI i ii iii ii] iiii I Essentiar Piincipres or Phacoemursirication iiiiiiiiiiiiiiillliriiiiiiiiiiiiiiiiiiilriliiiliiirilillll
8. OVD removat and finishing: Comptete: are you sure that there
is no OVD behind the Lens? EventuaLty press a littte on the lens
or go behind the [ens. Then check the wounds. Tight wounds?:
lf not then hydrate the paracentesis or suture the wound with
Nyton 10-0.
106
¡lirlliriill1iiiiiiiiitliltlrrlr1rlrlrrlrrrlr;iilr;iiliitiiiiiiliiiiiliiiiiiiiiiiiiiiii
ffim#mw#Kruffiffis
xo8
iliiiijiiiiiiiiiiljiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiijiiiijjiiitiliiiliiiiiiiilliiiliiiiliilillliliiiiitiliiililiiiji
XNMHX
Anesthesia 9
Antibiotics 102
Astigmatism 16,19
n
Batanced sa[t solution [see BSS)
Battooning [see conjunctivat bal.tooningl
BSS Ibatanced salt sotution] 18,28,30, /.
Burn [see corneaI burnJ
Bottte height 3, 55, 87
1ü9
I i I
j
] i i I i I I I i
j
I i I I i i i Essentiar Piincipres or Phacoemursirication ilililiiiiiliiiiiililililiiiiillliiiiiiiiilillilriillilillli
t¡
FI
Lid specutum 9
Magnification B
Mannito[ 19
Marfan's syndrome 10
Misdirection syndrome [see inf usion misdirection syndrome]
Retinitispigmentosa 28
Ring lsee capsutar ring or ring signl
Ring sign [see gotden ring sign)
Rupture 38, 39, 42,81,83, 89, 95, 98, 100, 103
I Essential Principles or Phacoemulsirication
j
ii ii ii ii il iii ii iii
Scissors 28,32,33, 88
Settings 1,2, 63
Shearing 24,25,26
Spatuta 30,48, 8ó, 89, 100
Specutum [see iid specutum)
SubchoroidaI hemorrhage 5, ó
Sutcus 33,87,89, 90, 94,95,96,98,99, 100, 10ó
Suture 1 8, 88, 101, 102,1 03, 1 0ó
TI
Tenon 18
Trauma 10, 3ó, 42,102
Triamcinoton 90, 100
tt
v l
tsBN 978-9962-678-61-8
4-
AYPEE. HIGHTIGHTS
$r MEDICAL PUBTISHERS, INC.
ilililililJilt|[ilffiil[
Ava i I able onl i ne at wwwjph med ical.com