VALUTAZIONE DEL PZ.

CATARATTOSO
Consider Is the cataract causing the visual decline?
Is the cataract secondary to a systemic or ocular condition?
Could the eye/patient survive cataract surgery if indicated?

SINTOMI DELLA CATARATTA

Visual gradual decline, although w/ post subcapsular cataract (PSCC) VA can
acuity decline over days
Often Near VA decline is greater than far VA decline in PSCC
Glare night driving problems, halos, especially with PSCC and cortical
Myopic "second sight", especially in nuclear sclerotic cataract
shift
Diplopia monocular, especially in PSCC

INDICAZIONI PER LA CHIRURGIA DELLA CATARATTA

Functional, Document difficult with reading, driving, glare, recognizing faces
Read: US Dept. of Health and Human Services Practice Clinical Guideline
#4
Cataract in Adults: Management of Functional Impairment
In Iowa must document functional decline with patient's signature for medicare
Elsewhere: Best corrected Visual Acuity <= 20/50 at far or near acceptable to
VA, Medicare, etc..
Best corrected Visual Acuity > 20/40
mandatory to document functional disability
eg. monocular diplopia, glare, occupational impairment...

Uncommon lens induced disease, eg. glaucoma

indications: medical need to visualize the fundus, eg. diabetes

CARATTERISTICHE DEL BUON PZ. DA OPERARE

Good vision in the fellow eye, bad vision in cataractous eye
Big pupil
Prominent eyes, shallow forehead -- allows for easy access to the superior limbus
Patients that can lie still, eg. general anesthesia is perfect for first case if justified eg.
claustrophobia
Patients whose other eye was done by a neophyte surgeon

VALUTAZIONE PRE-OPERATORIE:
HPI functional visual decline
PMH DM, asthma, COPD, CHF, problems with bleeding, allergies
Meds Coumadin, ASA (is their blood esp thick or do they have a medical problem)
SH Occupation that requires special visual powers
Can they tolerate the post operative care, eg put in drops, monocular
POH h/o glaucoma, steroid response, h/o RD, h/o macular edema, h/o sugery other eye
Read current glasses -- especially important to know spherical equivalent of fellow eye
Eye exam: RAPD -- very important when the vision remains
VA Streak or MR for best poor after cataract extraction
corrected visual acuity in dim Undilated pupil size -- useful when selecting among
and bright light IOL optic diameters, esp young pts
When vision is poor - doc no Dilated pupil Size - useful when selecting among
improvement with up to an surgeons
addition of -3.00 If the pupil dosen't dilate - have a plan, eg.
Retractors, stretch, sphincterotomy
CVF LP in all four quadrants in dense cataracts
Keratometer readings of both eyes -- do prior to other
K manipulations
External abnormal tear fcn, malposition,
blepharitis/spasm
Prom brow/deep socket think temporal or
schedule next resident
SLE Mainly look at the cornea -- any edema or
guttata, beware if thicker than 620 µm lens
hardness, phacodynesis, PXF
Gonioscopic exam of hyperopes, diabetics, and
patients with h/o trauma
 Dilated not mandatory if you have looked
examination back recently (w/in month)
does the poor view match the poor
vision
look carefully at pts with DM,
consider preop focal, FFA
document normal macula, ON,
PVD if present
Special laser interferometry - diffraction pattern on
Tests: retina to estimate VA potential
potential acuity meter - projects a teeny
Snellen chart around lens opacity
neither test is that helpful in my opinion
Consider echography when you have no view
Axial Eye length (AEL) measurement
Specular microscopy of the endo cell to determine
cells/mm2 in special cases eg. Fuchs
Body Exam History and physical is brief: can they lie flat and still;
if not why not?

CONSENSO
Most important part of pre-operative visit
Talk them through the procedure briefly -- use the words: shot, cut, and stitches in your
discussion
Tell them: we can usually place a plastic lens in the eye.
no we don't use the laser (much confusion about the Yag for secondary
cataract)
we will patch their eye overnight following the surgery
we will see them at 1 day, 1 week, and 6 weeks post op if all goes well
we will prescribe new glasses when they are stable -- usually 2 mos. post op
Benefits: 90 % better than 20/40, 96% better vision than pre-op (DesMoines ECCE data)
I lower these percents with increasing retinal disease
Risks: 3% vision worse than pre-op (DesMoines ECCE data)
use the death (<1:100,000), loss of eye (<1:10,000), irregular pupil
words: (1:10)
after cataract (1:5 requiring laser in 2 years

CHIRURGIA DELLA CATARATTA

ICCE intracapsular cataract surgery - lens with capsule removed
ECCE lens removed and much of lens capsule left in place
Manual or planned ECCE done with expression of nucleus through large incision
Phacoemulsification uses ultrasound energy to break up the nucleus through small
 incision
Pars plana lensectomy (PPLx) posterior approach by retinal surgeons often at time of vitrectomy
Method Indications Advantages Disadvantages
ICCE Poor zonular No risk of secondary cataract High risk vitreous loss (20%)
support Little instrumentation needed Astigmatism
Delayed visual rehabilitation
Contraindicated in children
Only ant chamber or sulcus fixated
IOL
ECCE Very hard lens Less instrumentation needed Astigmatism
Poor K Easy on corneal endothelium Delayed visual rehabilitation
endothelium Allows post chamber IOL
Phaco Most cataracts Fast visual rehabilitation Expensive instrumentation
Ultrasound is hard on corneal
endothelium
PPLx Poor zonlular Right surgeon present if lens Expensive instrumentation
support goes south May loose all zonular support
During vitrectomy

ICCE
Indications rarely indicated today - I have only seen/done one case
Unstable lenses with severe zonular laxity
Contraindications
absolute: children, traumatic capsular rupture
relative: high myopia, Marfans, vitreous presenting around
lens
Pre-op orbital massage or osmotic agents to reduce vitreous pressure
Anesthesia Retrobulbar and lid block
Rarely general anesthesia, eg: claustrophobia, dementia, tremor
Procedure Superior bridle suture
May need a scleral support ring in high myopes
Peritomy of about 170 degrees
Limbal incision of about 170 degrees chord length in the 10 mm range
Safety sutures are preplaced - usually 7-O vicryl
Small peripheral iridotomy is placed
Alpha-chymotrypsin is placed through the PI into posterior chamber to degrade
zonules
Anterior surface of the lens is dried with a cellulose sponge
Cryo probe is placed on mid-periphery of the lens and frozen
Lens is removed with a side to side motion through incision
Wound is closed with safety sutures
Vitreous is attended to if needed
Anterior chamber lens is placed
 Wound is closed with 10-O nylon
Post-op: Similar to ECCE

ECCE (con espressione del nucleo)

Indications Still indicated today - Dr. Cohen's first case in pvt practice ECCE
Hard lenses with tenative corneal endothelium
Contraindications poor zonular support
Pre-op orbital massage or osmotic agents to reduce vitreous pressure
Anesthesia Retrobulbar and lid block
Rarely general anesthesia, eg: claustrophobia, dementia, tremor
Procedure (See appendix for details)
Superior bridle suture
Peritomy of about 170 degrees
Initial limbal groove in sclera with a chord length in the 9 mm range
Initial entry into anterior chamber to allow capsulotomy (3 mm)
Instill viscoelastic (see appendix 2)
Remove anterior capsule (usually with can opener approach)
Mobilize lens (physically with cystitome or with hydrodissection)
Extend initial incision to full length of groove (with scissors or knife)
Safety sutures are preplaced usually 7-O vicryl
Lens removed by lens loop or with counter pressure technique
Wound is closed with safety sutures
Cortical material is removed using I/A device (either automated or manual)
Instill viscoelastic
Lens is placed in the posterior chamber
Wound is closed with 10-O nylon
Post-op exam RAPD, VFF to CF
Day #1 VA in op eye w and w/o PH -- expect
about 20/100 w/PH
SLE expect corneal edema and 3-4+ cell
and flare
don't waste time with refraction or
keratometry
Seidel test of wound
applanation if < 8 look hard for
tension leak
if > 30 start with beta
blockers
usually can see fundus without dilation
document no RD or choroidal
plan
drops pred forte 1% i gtt qid (more
with severe inflammation)
ocuflox i gtt qid (any antibiotic
will do)
cyclogyl 1% i gtt bid
f/u usually one week later
next day with wound leak, big corneal
 abrasion, etc...
give a post operative instruction sheet
Post-op Day #7 exam RAPD, VFF to CF
VA w/ and w/o PH -- expect about 20/50 w/PH
keratometry for fun -- expect about 7.1 diopters at 90 (DesMoines data)
don't waste time with refraction
SLE expect little corneal edema and 1-2+ cell and flare
usually can see fundus without dilation document no RD, CME, or
choroidal
plan d/c antibiotic (tell pt. to keep bottle in refrigerator for suture removal)
d/c cyclogyl if inflammation is less than 1+; o/w, continue for 1 more
week
taper Pred forte, i gtt qid for 7 more days,
e.g.: then
i gtt tid for 7 days, then
i gtt bid for 7 days, then
i gtt qd for 7 days, then
discontinue
f/u usually 5 weeks later at 6 wks p/o (allows time to begin suture removal)
with any problem e.g.more inflammation see sooner
Post-op Week exam RAPD, VFF to CF
#6 VA w and w/o PH -- expect about 20/50 w/PH
keratometry
expect about 5.4 diopters at 90 (DesMoines data)
don't get confused and read backwards
eg. for 5.4 at 90: left dial could read 40 right dial reads 45.4
MR (start either with streak or 2/3 of cylinder from K's and adjust SE to
-1.0)
SLE look at the wound and decide which sutures look tight

lysis Indicated when cyl is >= 2 diopt. on MR or <= 3 on K's (if you did not
do MR)
if it's less than 2 on MR, stop, high fives, don't cut anything
remove tightest suture at axis of cylinder on k's
only cut one suture at week 6-8 visits
can cut two beyond week 8
if tight axis is between sutures cut both (if beyond week 8)

plan full activity

antibiotic drop i gtt qid for 4 days (following each suture removal)
f/u if no sutures need to be removed (will never happen)
give glasses -- usually +2.5 add with MR
f/u 6 mos.
otherwise return every 1-2 weeks for additional suture lysis

Post-op Month you really have about three three choices (don't stall):
#6
 1. pull a stitch (i.e. cyl at axis of stitch is greater than 2 on MR)
2. give glasses (i.e. no stitch to pull or cylinder is less than 2 on MR)
3. get FFA because you suspect CME

don't waste time thinking about other possibilities

not everybody is going to be 20/20. we only promise that 90% will be 20/40
or better

FACOEMULSIFICAZIONE
Indications Most common method of cataract removal
Contraindications poor zonular support, extremely hard lens, hypermature lens
Pre-op: orbital massage sometimes used - Honan baloon, super pinky
Anesthesia Topical +/- intracameral non preserved lidocaine
Retrobulbar and lid block

Potential Complications What to do about it

Retrobulbar hemorrhage Delay case and consider cantholysis
Inject/perf eye ball Delay case and cryo/laser area/pray

Rarely general anesthesia, eg: claustrophobia, dementia, tremor

Procedure Fantastic Book - must read - P.S. Koch Simplifying Phacoemulsification

1) Rarely superior bridle suture (when performing superior tunnel)

Potential Complications What to do about it

Drive into vitreous Delay case and cryo/laser area

2) Paracentesis with #75 blade, or some other sharp knife, mark

knife w/marker ink to see
Fixation with 0.12 forceps or with fixation ring

Potential Complications What to do about it

Put in wrong place Make another
Too small Make another
Too big Suture later
Nick capsule Include in removed capsule w/rhexis
Nick iris Forget about it

3) If topical instill lidocaine (1% non-preserved in TB syringe

w/ Troutman 27 or 30 g)
Some debate about loss of endothelial cells with lidocaine
Patients will note some sting - can buffer by diluting 4% lido to 1% w/ BSS+
Potential Complications What to do about it
Put in preserved lidocaine Wash out AC and pray

4) Place viscoelastic (see appendix 2)

Arshinoff shell technique: 1st dispersive (eg. viscoat), then cohesive (eg.
healon)
Allows dispersive to coat cornea and protect from ultrasound energy
Allows cohesive to maintain chamber during the first part of procedure
Or use just one. Healon is cheapest at the University

Potential Complications What to do about it

Shoot loose canula into Tighten it better next time
eyeball Suck out the air with an air syringe or place the
Air bubbles viscoelastic distal and force out

5) Wound

Style Advantages Disadvantages

Limbal Easy to convert to ECCE
Phaco Tip doesn't distort cornea
Similar to ECCE wound
Scleral Rarely induces astigmatism
Seals nicely
Cornea Doesn't induce astigmatism
No cautery
No conjunctival manipulation
Eye is white after surgery
Induces astigmatism
Always requires suture
Requires cautery
Requires conj manipulation
Eye is red after surgery
Hard to convert to ECCE
Technically difficult
Cautery
Conjunctival manipulation
Phaco Tip distorts cornea
Eye is red after surgery
Hard to convert to ECCE
Technically difficult
Phaco Tip distorts cornea
? increased endopthalmitis

Limbal
Peritomy of 4-7 mm depending on IOL size
Cauterize sclera
1/2 depth groove into limbus with crescent blade or 64 beaver
enter eye with keratome (sized for phaco needle eg 2.8 mm for Alcon micro)

Potential Complications What to do about it

Groove too deep into Limbus Usually no big deal
Groove/enter posterior W/iris prolapse move elsewhere
Nick capsule Include w/removed cap w/rhexis
Nick iris Forget about it
Scleral tunnel
Peritomy of 4-7 mm depending on IOL size
Cauterize sclera
1/2 depth groove into sclera with crescent blade
tunnel at 1/2 depth through sclera into cornea with crescent blade
enter eye with keratome (sized for phaco needle eg 2.8 mm for Alcon micro)

Potential Complications What to do about it

Groove too deep into uvea
Shred scleral flap
Enter AC posterior
Enter AC w/crescent too wide
Nick capsule
Nick iris
Close wound and move elsewhere
Tunnel further into clear cornea
W/iris prolapse close and move
Partial suture to maintain AC
Include w/removed cap w/rhexis
Forget about it

Corneal
1/2 depth cut into cornea near limbus with guarded diamond or steel crescent
1/3 depth tunnel into cornea with either crescent or keratome
enter eye with keratome (sized for phaco needle eg 2.8 mm for Alcon micro)

Potential Complications What to do about it

Groove too deep into cornea Suture at end like limbal
Shred flap Longer corneal tunnel
Tunnel too long distorting view Re-enter w/keratome but shorter
Nick capsule Include w/removed cap w/rhexis
Nick iris Forget about it

6) Capsulorhexis
Most important part of the procedure
Anterior chamber must be filled with viscoelastic
3 basic techniques
cystitome - intial cut and control of tear with cystitome
combo - initial cut with cystitome, most of tear with forceps
forceps- sharp forceps cut and then grab capsule to complete tear
goal is a central circular opening slightly small than the optic diamter

7) Hydrodissection
Second most important of procedure
Balanced salt solution in 3 cc syringe with troutman 27 g or similar
Inject fluid just under cpasule to cleave cortex from capsule
Must see a fluid wave. Don't stop till you get enough, Don't stop till you get
enough
May prolapse lens with a large capsulorhexis - can be a good thing.

8) Phacoemulsification
Goal is to remove lens with the minimum U/S time
 Trend is to use increasing vacuum and decreasing u/s power to remove
nucleus
Phaco can be done:
Endocapsular - keeping the lens in bag during phaco
Supracapsular - prolapsing nucleus into sulcus during phaco
In anterior chamber - prolapsing usually shelled out nucleus into AC
"lollipop" - tipping nucleus on side 1/2 in bag; 1/2 in AC.
Many ways to disassemble nucleus (must see Alcon tape -- 7 ways to frag
nucleus)
Sculpting out a bowl
Divide and conquer
Chopping

9) Cortical Aspiration
Aspiration is used to grab and peel the cortex off not suck it up
Dangerous procedure - most common time for Vitreous loss
Sub-incisional removal is most difficult esp with small rhexis

10) Fill Bag with viscoelastic

Arshinof shell technique: 1st cohesive (eg. healon), then dispersive (eg.
viscoat)
Allows cohesive to mainain bag and force it open
Allows dispersive to seal the wound during lens insertion
Or use just one. Healon is cheapest at the University

11) Wound is extended to allow placement of the lens

PMMA lenses need slightly more than optic size
Folded 6.0 mm acrylic needs about 3.5 mm more for high power lenses
Silicon unfolder needs only about 3.0 mm

12) Lens is placed into capsular bag

Make sure the lens is right side up
Usually you initially place leading haptic into bag
Trailing haptic is dialed into bag w/sinsky or placed in bag wih kelman
forceps
Use miotic eg. Miochol if lens is in sulcus

13) Sutures are preplaced

Preplace while viscoelastic maintains chamber
Usually need 2 interrupted or one X suture with 6 mm scleral tunnel
Usually need 3 interrupted sutures with 6 mm limbal wound
Usually need no sutures with 3-4 mm wound of cornea or sclera

14) Viscoelastic is removed with I/A device

15) Sutures are tied

3/1/1 for 10-O nylon

16) Other
Consider subconjuntival antibiotics
Alternative is to d/c patch 6 hours after block and start drops
 Patch if retrobulbar was used

Post-op exam
Day #1 RAPD, VFF to CF
VA expect about 20/40 better w/PH
SLE expect corneal edema proportional to
ultrasound time
1-2+ cell and flare
IOP if < 8 look hard for leak with Seidel test
if > start with beta blockers, assume
30 viscoelastic retention
bleed aqueous/viscoelastic through
paracentesis
if > suppress aueous and bleed until
40 pressure is stable in 20-30 range
may take several hours -- Be
especially wary of CRAO w/DM
usually can see fundus without dilation document
no RD or choroidal
plan tobradex i gtt qid (or any
antibiotic with steroid or
NSAID)
f/u one week later
next day with wound leak, big
corneal abrasion, etc...
give a post operative instruction sheet
Post-op exam RAPD, VFF to CF
Week #1 VA expect about 20/30 PH 20/20
SLE expect little corneal edema and trace to 1+
cell and flare
Check fundus at either 1 or six week visit
document no RD, CME, or choroidal
plan
taper i gtt tid for 7 more
Tobradex: days, then
i gtt bid for 7
days, etc..
f/u usually 3-4 weeks later
Post-op Week #4 exam RAPD, VFF to CF
VA expect about 20/25 PH 20/20
MR - consider suture induced astigmatism as in ECCE
plan give glasses
f/u 6 months or do other eye
 LENTE INTRAOCULARE
History Harold Ridley placed first lens in 1949 -PMMA
1950s rigid anterior chamber lenses were used with ECCE and ICCE bullous
keratopathy was common
chronic inflammation led to CME and glaucoma
lens which were too small would decenter and too long would hurt
Later pupil or iris fixation lenses were used to avoid contact with the angle
Some would suture onto the iris and other would clip on
These lenses would frequently dislocate
Closed loop flexible anterior chamber lens were next
These kept corneal transplant surgeons in business for years

Today Modern open loop flexible anterior chamber lenses have been a great success
The development of viscoelastics to allow safe placement is most important
Posterior chamber lenses are most commonly used today with ECCE-phaco
Most lenses are biconvex - so optically they are equivalent upside down
But most lens have haptics which are angled to push optic
posterior
3 basic materials - PMMA, acrylic, silicone
PMMA is the time tested material but requires a large incision
Use the largest optic that can fit incision eg 6.5 or 7 for ECCE
Be careful cheeting down on optic size to allow smaller incision in
phaco
Esp. in young light can get around optic w/pupil dilation at
night
Acrylic and silicone lenses are very popular

Lens Material Advantages Disadvantages

PMMA Time tested Wound size > optic diameter
Cost
Little inflammation
Acrylic Foldable Cost
Little inflammation
Silicone Foldable Cost
Injectable A bit more inflammation
Makes silicon oil Vx difficult

Multifocal lens are now approved by the FDA

Allow for decent uncorrected near and far vision
Increase problems with glare and contrast

SCELTA DEL POTERE DELLA LENTE INTRAOCULARE (IOL)

Ridley's post op refraction in 1949 was -24.0 +6.0 x30 - your patients will expect better
Four things you need to know to calculate correct IOL power:

1) Desired postoperative SE
Usually -0.5 to -1.00 is the plan. Why?
if you are left myopic post op. someplace in front of your head is in focus
-1.00 gets you about 20/40 at far and you can see well at mid distance
A spectacle overcorrection of -1.00 will nearly eliminate induced IOL mag.
Sometimes however you may not want a SE of -1.00
if the other eye is stable (post op or no cataract) and you want to match it
patient prefers to have 20/20 at far without correction (good luck)

2) The length of the eye

AEL device uses ultrasound to estimate the length of the eye
Measure both eyes
Remeasure greater than 0.3 mm difference between eyes
if
AEL < 22 or > 25
Full of potential error, pushing too hard, not axial, etc...
Error on device at VA can be, as high as +/- 0.5 mm. according to Dr. Ossoinig
With AEL < 22 or > 25 consider sending to echo for immersion beware of
staphyloma

3) The power of the cornea

Keratometric measurement of both eyes -- should be about the same
Remeasure greater than 1 diopter difference between eyes
if
K ave < 40 or > 47
mires are irregular

4) The post operative position of the IOL

The more anterior the IOL is placed the less power the IOL needs for emmetropia
Goal is to place a posterior chamber (PC) lens
These can end up in the bag (best) or sulcus (anterior to ant. capsule)
Inadvertent placement in the sulcus creates a 0.75 d myopic shift
Always plan to have available anterior chamber (AC) lenses
These are placed anterior to the iris w/haptics that settle into the angle
These are used when the posterior capsule is not agreeable to holding an IOL
When too small they can tilt and when too large they can hurt

Estimating the IOL power for emmetropia:

Formulas started with a theoretical model by Fydorov, Collenbrander et all, 1970s

Based on geometric optics
Power = N/(AEL-ACD) - N/(N/K-ACD)
where: Power is the expected power of IOL for emmetropia post op
N is the aqueous and vitreous refractive index
ACD is the post operative depth of the IOL
AEL is the axial eye length as measured via an ultrasound
device
Ave-K is average of the two keratometric axes
 But you don't know the ACD or post operative depth of the lens pre op!

Useful Formulas use regression analysis or other tricks to estimate ACD

1) SRK
Power = A-constant - 2.5(AEL) - 0.9(Ave-K)

Classic regression formula develped in 1980 by Sanders, Retzlaff, and Kraff

where: A-constant is a parameter of the type of lens and ACD
eg. PC lens -- Alcon acrysoft A constant of 118.9
AC lens -- Alcon MTA series A constant of
115.3

note that an error of x in axial eye length results in an error of 2.5x in IOL power
falls apart in predictive value with eyes w/AEL < 22 and > 24.5

2) Other algorithms
AEL device has many algorithms to choose from to give power for both PC and
AC lenses
Some also use ant chamber depth to estimate IOL power
Error is greatest with with high myopes and high hyperopes
Estimate the power for both the AC and the PC lens compare several formulas
High myopes end up more myopic and high hyperopes end up more hyperopic post op
than predicted

Selecting the IOL power for your patient

The SRK computes the lens power for emmetropia; but, you probably want -1.00
you can use the AEL device printout to find the lens for any desired post op. SE
roughly a change of the IOL from the emmetropic value of 1.4 results in SE change
of 1.0
eg. SRK gives 19 diopters for emmetropia, about 20.5 will give -1.00 SE post op.

If your estimated IOL power is unusual you are probably wrong

Double check your calculations and when applicable look at experience with other
eye's IOL
ask yourself was the patient very myopic or hyperopic as a young person (eg in the
big war)
then if convinced that the calculations are right, make sure the lens is stocked

Pre-operative scut for the day of the operation

Always have dilation and numbing drops in your pocket
Retrobulbar, peribulbar, +/- modified Obrien facial nerve block
You will need to collect a posterior chamber and 3 anterior chamber lens prior to surgery
 The PC lens power that you selected preop
You need 3 AC lenses as these come in 3 diameters: 12.5, 13.0, and 13.5 mm.
AC lens is sized at surgery by adding 1mm to the "white to white" horiz limbal
diameter
Chart buffing: operative note, post operative orders
Fill out Rx or call in post op drops Tobradex i gtt qid (many other choices - no one is
eg: right)
Add cyclogyl 1% i gtt bid with ECCE
tape your mask or coat your spectacles so they don't fog
Adjust the operating microscope
Are you operating from a superior or temporal approach (ECCE/ICCE always
superior)
put assistant's eyepiece on proper side of microscope
adjust prior to prepping patient so you don't inadvertently touch the field
set interpupillary distance of scope
align focus into neutral position with foot pedal and adjust height manually before
locking

Your position is 1) adjust bed height to allow your feet under bed on
important pedals
2) adjust micorscope into focus
3) adjust chair height to get eyes comfortably into oculars

Appendix 1
Detailed ECCE Procedure
1) place lid speculum

Goals Keep lashes and lids out of the way

Big potential screw-ups: Abrade cornea
Direct lashes the wrong way

2) bridle suture
Goals Keep eye in infraduction
allow access to superior limbus
Big potential screw-ups: driving 4-0 silk into vitreous
assistant: holds eye in infraduction and says "bridle suture"
you: left: O'Brien forceps 8 mm superior to limbus wide grasp of Sup Rectus tendon
right: 4-0 Silk suture passing needle just under forceps through tendon
you: tie the silk and secure to drape with hemostat

3) make the cystitome it's really a capsulotome as you are going to cut the capsule with it
Goals save money for VA by making it youself
Big potential screw-ups: hard to screw this part up
making the cystitome too big ("it's so big")
assistant: "so far all is going well, cystitome"
you: left: take TB syringe and 5/8" long 25 gauge needle
right: use needle driver to bend tip of needle 90 degrees
4) peritomy
Goals Get the conjunctiva out of the way
Big potential screw-ups: Shredding the sclera
Removing pieces of conjunctiva
assistant: "so far all is going well, cystitome"
you: left: 0.12 forceps grab and tent up the conjunctiva and tenons 2 mm sup limbus
right: w/ Wescott scissors cut through conjunctiva and tenons to sclera at 10:00
Continue with blunt dissection to clear a tunnel from about 10 to 2 o'clock
With one blade inside tunnel/one out, cut off the conjunctiva at the limbus
relaxing incision to expose the sclera at 2:00

assistant: "calipers at 11 mm" and shows you how much to clean at the limbus
you: left: 0.12 forceps on sclera controlling the globe
right: Gill knife to scrape away the remaining episcleral tissue

assistant: dabs away blood with Weck cell sponge

you: left: still with the 0.12 on sclera controlling globe -- get used to it
right: bipolar cautery to control bleeding
keep the tips barely separated and stay on the sclera and off the conjunctiva

5) groove
Goals Carve a groove into limbus to guide cut later
Big potential screw-ups: Entering the anterior chamber prematurely
Groove posterior to limbus resulting in iris
prolapse during later phases of operation
assistant: shows you 11 mm again with the calipers
you: left: on the sclera with the 0.12 forceps controlling the globe
right: #64 beaver blade starting at 2 o'clock on limbus to 10 o'clock (11 mm)
Hold blade using Taylor technique (roll with thumb and first finger)
partial thickness about 1/3 depth in one smooth slow stroke
handle is perpendicular to the eye and blade stays tangential to limbus

6) entering the eye

Goals Cut a slit at limbus to allow instruments in
Small enough cut to help maintain chamber
Big potential screw-ups: Slice up the iris as you enter
you: left: on the sclera with 0.12 controlling the globe
right: with keritome enter anterior chamber through groove at 11:30
keep blade parallel to iris plane

7) anterior capsulotomy
Goals Form the chamber with Healon (viscoelastic)
Cut out the anterior lens capsule
Big potential screw-ups: Pulling and not cutting the capsule
(resulting in zonular dehiscence)
Cutting too peipheral through the zonules
assistant: "Healon and side lights down, coaxial lights up, and room lights off"
you: left: secure Healon syringe and direct cannula into anterior chamber
right: depress plunger to fill anterior chamber (from inferior to superior)
 assistant: "cystitome"
you: both enter eye with cystitome point parallel to iris
rotate cystitome with tip now pointing to the anterior capsule
puncture the capsule at the 6 o'clock position
move the tip circumferentially cutting the capsule to about 6:30 o'clock
lift the tip and repuncture at 6:30 o'clock and repeat until you get to 12:00
go back to 6:00 again and now go circumferentially to the left
complete casulotomy to 12:00 and exit eye with cystitome
you: right: enter anterior chamber with closed Kellman McPherson forceps
open forceps over anterior capsule
move forceps down over the capsule and close to grasp the capsule
remove the capsule from the eye

8) freeing the nucleus

Goals Separate the nucleus from cortex
Position the nucleus for easy expression
Big potential screw-ups: Breaking zonules by being too rough
you: both enter the eye with the cystitome as before
gently jam the point of the cystitome into the lens nucleus at 9:00 o'clock
gently rock the lens nucleus away from the cortex
repeat at 3:00, 6:00, and lastly at 12:00
spin the nucleus a bit for fun to ensure its free from cortex
if possible leave the nucleus tipped so that the inferior aspect is posterior
assistant: "gently doctor"

9) enlarging the wound

Goals Get the wound big enough to express nucleus
Big potential screw-ups: Cutting the iris along with the wound
Stripping Descemet's membrane
Getting out of the groove as you cut
assistant: "castro's to the left"
you: left: 0.12 forceps on sclera to control globe
right: put one blade of Castroviejos into eye keeping away from iris
guide the outside blade onto groove and cut along groove its full extent
watch the blade tip inside the eye and stay up and away from the iris
assistant: "castros to the right"
you: right: same maneuver to the other side (some use the other hand)

10) Safety sutures

Goals Pre place sutures to allow quick closure
Big potential screw-ups: Place them too close to each other
(so that later the lens can't pass between them)
assistant: "7-0 vicryl/calipers at 7 mm" and shows you where to put two safety sutures
you: left: use 0.12 forceps to grab cornea at caliper mark at around 1:30
right: drive 7-0 vicryl through 2/3 depth cornea and through adjacent sclera
assistant: cuts suture long

you: reload needle and repeat at the other caliper mark around 10:30

you right grab the vicryl between cornea and sclera and pull out loop of slack
 allows for expansion of the corneoscleral wound during lens expression

11) Nucleus expression

Goals Get out the nucleus and leave the rest intact
Big potential screw-ups: Expressing vitreous
Not recognizing the wound is too small
you right 0.12 forceps grasping the posterior lip of the wound at 12 o'clock
press gently down on the posterior lip of the would
rotate the 0.12 forceps more parallel with the iris to make a lens ramp
left if needed gently press at 6:00 o'clock with a muscle hook

assistant uses a needle to spear the nucleus as it exits the wound

your first thought if the lens doesn't come should be to expand the wound

12) Securing the chamber

Goals Grossly closing the wound
Big potential screw-ups: Just close the wound
you both use large tying instruments to secure the two safety sutures
left 0.12 forceps grasping cornea at 12 o'clock
right place another 7-0 vicryl this time at 12 o'clock
both use large tying instruments to tie last safety suture

13) Aspiration of cortical material

Goals Removing the remaining lens cortical material
Big potential screw-ups: Aspirating and tearing the posterior capsule
Aspirating and tearing the anterior capsule
assistant "room lights off and set up the McIntyre"
you both enter with McIntyre cannula between sutures at 1 o'clock
aspiration port should always be looking at you (anterior)
engage cortex by slipping port under iris (and anterior capsule)
assistant will provide appropriate suction with syringe to tug on cortex
once engaged pull cortex slowly to the middle and assistant will aspirate
change position of entry to get cortex close to 12 o'clock
never aspirate unless you have cortex engaged
watch for "spiders" (posterior capsule tension lines)

14) Lens placement

Goals Putting the lens in the bag or sulcus
Big potential screw-ups: Placing one haptic in bag and one in sulcus
Rupturing capsule during placement
Putting in the wrong power of lens
assistant "open the posterior chamber lens" and cuts safety suture at 12 o'clock
you both fill the anterior chamber with Healon
right hold IOL container and verify lens power
left use straight tying instrument to hold inferior haptic of IOL
(inferior haptic should always point left)
raise IOL above container
right grasp inferior haptic and optic with Kelman forceps
left 0.12 forceps lift cornea
right with Kelman forceps place IOL through wound into anterior chamber
 direct inferior haptic posterior into the capsular bag
left stabilize IOL optic with side of 0.12 forceps (do not grasp)
right release IOL and gently remove Kelman forceps from eye
right grasp superior haptic with Kelman forceps at tip (supinate)
gently advance tip of superior haptic
twist (pronate) to bend "knee" of haptic inferior under iris
release haptic under iris to place entire IOL into position
right rotate the lens if needed with a Sinsky hook

15) Closure
Goals Water tight closure
Minimal astigmatism
Big potential screw-ups: Wound Leak or gape post op
Suturing the iris along with the cornea
Demonstrating that you have not practiced at all
assistant "10-0 please and room lights on"
you left 0.12 forceps to present tissue to the needle driver
right drive 10-O nylon with bite to about 2/3 corneal depth
start at the 12:00 o'clock position (where safety suture used to be)
same depth through the sclera
try to keep them radial with equal tension
slow and deliberate is better than fast with lots of rework
you both place about 7
tie with micro tying instruments with 3 throws, then 1 and 1 throw
assistant cuts suture ends for you long
you remove remaining two vicryl safety sutures
assistant "McIntyre please" and assists with aspiration
you both direct the McIntyre port over the IOL facing you as always
assistant will aspirate the remaining Healon and cortical debris cleanup
you complete closure as needed
assistant/you check wound with Weck cell sponge pressing on posterior edge
you left straight tying instrument grab long end of 10-O
right trim ends with #75 super sharp

16) Completing the case

Goals Injections of antibiotic and steroid
Patching
Big potential screw-ups: Injecting into the vireous cavity
"didn't know he was allergic to gentamicin"
Patching the eye open
assistant "injections please"
you left tent up inferior conjunctiva with 0.12 forceps
right before injecting ask yourself: "any allergies?"
with bevel down inject Ancef and decadron
place into subconjuctival space avoiding vessels
both remove lid speculum and drapes
place ointment (eg. tobradex)
double patch with benzoin
 Appendix 2
Viscoelastic
Two basic kinds:

Cohesive: high molecular weight, high surface tension, eg:

healon
Big, bulky, and likes itself

Dispersive: low molecular weight, low surface tension, eg:

viscoat
Smooth and likes to coat others

More of a Ocucoat Most

continuum Viscoat dispersive

Provisc
Amvisc
Amvisc
plus
Healon

Healon GV Most Cohesive

Different jobs demand different viscoelastics

1. Maintain space: eg. AC during rhexis cohesive best
bag during IOL insertion

2. Create space: eg. Creating sulcus cohesive best

presenting lens material

3. Sealing off: eg. Sealing capsular tear dispersive best

keeping iris fragment at bay

4. Coating: eg. Protect corneal endothelium dispersive best

lubricate cornea w/o asst.

Removal Dispersive harder to remove but post op IOP spike less of a problem

Cohesive is easier to remove because of high surface tension

Surgical Cohesive Dispersive

Step
Capsulorhexis 1) Easy to maintain deep chamber 1) Must completely fill
2) Can suddenly lose a large amount of chamber to maintain
material through wound
Phaco Goes away with first vacuum 1) Stays on endothelium
2) Attract particles to
 endothelium
3) increased risk of burn
IOL insertion Easy to open/maintain bag Hard to remove residual
Easy to remove material material