SURGICAL TECHNIQUES FOR CATARACT

EXTRACTION
 1.Intracapsular cataract extraction ( ICCE )
 2.Extracapsular cataract extraction ( ECCE )
-Conventional ECCE
-Manual small incision cataract surgery
-Phacoemulsification

• Local or general anesthesia

• Local anesthesia preferred
Intracapsular cataract extraction
 Presently – not performed
 Entire cataractous lens along with the intact capsule is removed.
 Large incision of 10-12mm .
 Only indication: markedly sublaxated and dislocated lens.
 Pre- requisite : weak and degenerated zonules
Surgical steps of the ICCE technique :
 A) Superior rectus (bridle ) suture
 B)Conjuctival flap ( fornix based )
 C) Partial thickness groove or gutter
 D) Cornoscleral section
 E)Peripheral iridectomy
 F) methods of lens delivery : smith Indian method,
cryoextraction, capsule forceps method, irisophake method,
wire vectis method
 . Formation of anterior chamber
- after lens delivery , iris is reposited in anterior chamber and
sterile air or balanced salt solution is injected.
G) , H) Anterior chamber IOL
I) Closure of incision using 5-7 interrupted sutures
J) Conjunctival flap is reposited and secured by wet field
cautery
K) Subconjunctival inj. Of dexamethasone0.25ml and
gentamicin 0.5ml is given.
L )Patching of eye is done with a pad and sticking plaster
or a bandage is applied.
 ECCE
(Extracapsular Cataract
Extraction)
• DEFINITION
Removal of major portion of anterior capsule with
epithelium, nucleus and cortex leaving behind the
intact posterior capsule.
INDICATIONS FOR ECCE-
All adulthood and childhood cataracts

CONTRAINDICATION FOR ECCE-

Markedly subluxated or dislocated lens (indication of ICCE)
with weak and degenerated ciliary zonules
TECHNIQUES OF ECCE

CONVENTIONAL PHACOEMULSIFICATION
ECCE MANUAL SICS
(SMALL
INCISION
CATARACT
SURGERY)
CONVENTIONAL ECCE- SURGICAL STEPS

Superior rectus suture/bridle suture

fix the eye in downward gaze

Fornix based conjunctival flap

conjunctiva and Tenon’s capsule is dissected at limbus
and hemostasis achieved by wet field cautery
Partial thickness groove or gutter with razor blade
length: 10 to 2 O’ clock ; depth: 2/3rds of anterior limbal area

Entry into anterior chamber

(with razor blade or 3.2mm keratome)

Viscoelastic substance injected into anterior chamber

(to prevent collapse of anterior chamber)
egs: 2% methylcellulose, 1% sodium hyaluronate
 Anterior capsulotomy

Can-opener’s Linear Continuous circular

Technique capsulotomy capsulorrhexis

• Can-opener’s Technique- multiple radial cuts with cystitome

• Linear - single linear cut at upper portion of capsule
• Continuous circular - circular tearing of capsule with cystitome
 Removal of anterior capsule
(with Kelman-McPherson forceps)

Completion of cornoscleral section

Length: 10 to 2 O’ clock ; with enlarging scissors or 5.2mm blunt
keratome
 Hydrodissection
(separation of corticonuclear mass from capsule by injection of BSS- balanced salt solution)

Removal of nucleus

Pressure and counterpressure Irrigating wire vectis method:

Method: posterior pressure at 12 o clock position loop of wire passed below nucleus and then lifted out
with corneal forceps or lens spatula of eye
counterpressure at 6 o clock position with lens
hook
 Aspiration of cortex
(using two way irrigation and aspiration cannula)

Injection of viscoelastic

IOL Implantation
(PMMA post chamber IOL implanted in capsular bag)
 Corneo-scleral suturing
(3-5 interrupted or continuous 10-0 nylon sutures)

Removal of viscoelastic substance and BSS injection

(using two way cannula before closing last suture)
(removal of viscoelastic substance to avoid secondary glaucoma)
 Secure conjunctival flap
(by wet field cautery)

Subconjuctival injections
dexamethasone 0.25 ml gentamicin 0.5 ml

Patching of eye
CONVENTIONAL ECCE

ADVANTAGES OVER SICS DISADVANTAGES OVER SICS

• EASY TO LEARN • LONGER INCISION OF 12mm
• MULTIPLE SUTURES SO INCREASED
CHANCE OF INFECTION ON
REMOVAL(SUTURE ABSCESS)
• GREATER RISK OF
 VITREOUS AND IRIS PROLAPSE
 EXPULSIVE CHOROIDAL HEMORRHAGE
 POSTOPERATIVE ASTIGMATISM
 ANTERIOR CHAMBER SHALLOWING
MANUAL SMALL INCISION CATARACT
SURGERY
Differences between SICS and Conventional ECCE, in SICS-
• Bridle suture can be done on lateral rectus in patients with against
the rule astigmatism and rest of the surgery done on the temporal
quadrant.
• Conjunctival flap made from 10 to 2 O’ clock position for a length of
4mm.
• Sclerocorneal tunnel incision done as 3 components-
1)External scleral incision-length-5.5 mm to 7.5mm
depth-1.5 mm to 7.5mm
shape-straight/frown shaped/chevron
 2)Sclerocorneal tunnel-depth:1-1.5 mm into cornea with crescent
knife
3)Internal corneal incision- with 3.2mm angled keratome
• Side-port entry- 1.5 mm incision at 9 o’clock for injection of BSS after
IOL implantation
• Nuclear removal – rotation done with Sinskey’s hook
• Nuclear delivery methods -1)Irrigating wire Vectis method
2)Blumenthals technique
3)Fishhook technique
• Corneoscleral suturing is not done and sclerocorneal tunnel is sealed
by Ringer’s lactate injection due to valve effect.
• Rarely if required a single infinity suture is done.
MANUAL SICS
ADVANTAGES OVER
PHACOEMULSIFICATION
• Applicable for grade 4 and 5
hard cataracts
• Easier to learn
• Not machine dependent
• Less serious complications
(nuclear drop)
• Less time required
• Cost is less
DISADVANTAGES OVER
PHACOEMULSIFICATION
• Larger Incision (6mm compared
to 3.2mm),greater chance of
astigmatism
• Delayed healing and visual
rehabilitation
• Postop tenderness and hyphema
PHACOEMULSIFICATION
 Most popular surgical technique today
 Principle: Nucleus emulsified by a phacoemulsifier and lens
matter removed by suction.
 Foldable posterior chamber IOL is implanted
 Physiological aqueous substitute called BSS (Balanced Salt
Solution) replaces the evacuated fluid
 Small incision and surgery is sutureless
STEPS OF PHACOEMULSIFICATION
1. INCISION 2. CONTINUOUS CURVILINEAR
Clear corneal incision (3mm) with a keratome. CAPSULORRHEXIS (CCC) of 4-6mm
One or two side ports/stab incisions for Injection of viscoelastic material in anterior
bimanual control chamber
Anterior capsule torn off in a continuous
curvilinear fashion
3. HYDRODISSECTION
Separation of capsule from the cortex by injecting fluid exactly
between the two
Hydrodelineation can also be done
4. EMULSIFICATION OF NUCLEUS AND ASPIRATION

Phacoemulsification probe : Hollow titanium needle (1 mm)

vibrates at ultrasonic speed of 40,000 times per second
Phacoemulsifier machine provides energy for emulsification
and creates a vacuum for aspirating the cortex.
Irrigation sleeve: BSS circulation to avoid heat transmission.
 Techniques for nucleotomy
a. Chip and flip technique
b. Divide and conquer technique (4 quadrant cracking)
c. Stop and chop technique
d. Direct phaco chop technique

5. IRRIGATION AND ASPIRATION

Of remaining cortical lens matter
5. IOL IMPLANTATION
Foldable IOL inserted with injector is ideal
Phacoprofile rigid IOL can also be used if incision is enlarged.

6. REMOVAL OF VISCOELASTIC MATERIAL AND WOUND CLOSURE

MICROINCISION CATARACT SURGERY (MICS)
 Phacoemulsification performed through microincision
(<2 mm)
 No surgically induced astigmatism

TECHNIQUES
1. Microincision coaxial phocoemulsification- Stab incision
(2 mm)
2. Bimanual microphacoemulsification- 2 limbal incisions
3. Phaconit – By Prof Amar Agarwal for Bimanual Micro
Phaco done with a Needle Incision Technique (<1mm)
FEMTOSECOND LASER ASSISTED
CATARACT SURGERY (FLACS)
A MICS in which few steps are done
by femtosecond laser (FSL)

 Post FSL surgical steps

 Steps with FSL
1. Corneal incision opened up with
1. Capsulorrhexis fine iris repositor
2. Lens fragmentation 2. Anterior chamber –viscoelastic
3. Clear corneal incision material
3. Capsulorrhexis flap removed
4. Arcuate corneal incision
4. Lens fragments phocoaspirated
5. Foldable IOL placed
Merits and Demerits of
Phacoemulsification over SICS
 MERITS  DEMERITS
1. Topical anesthesia sufficient 1. Learning curve difficult
2. Post op congestion minimal 2. Complications are unforgiving
3. Small incision 3. Machine dependent
4. Less corneal complications 4. High cost
5. Visual rehabilitation 5. Difficult to tackle grade IV
6. Post op astigmatism AND V cataracts

Conclusion: In spite of demerits it is popular as complications are few in expert

hands and early visual rehabilitation is possible
video
POST OPERATIVE MANAGEMENT

1. Lie quietly for 2-3 hrs, nill oral

2. Diclofenac sodium for post op pain injection
3. Eye patch removed and inspected next morning
4. Antibiotic drops [4 times, 10 to 14 days]
5. Topical steroids [3-4 times per day, 6-8 weeks]
6. Topical ketorolac [NSAIDS- 3 times, 4 weeks]
7. Topical timolol [twice daily for 4 weeks]
8. Topical cycloplegic mydriatric [OD for 10-14 days]
9. Suture removal if needed
10. Final spectacles given [8 weeks after SICS, 3-4 weeks after phaco]
COMPLICATIONS OF CATARACT SURGERY
 Cataract surgery has become one of the most widely performed
surgeries in the world. Though as all surgeries do they have
certain complications.

 They are split into 5 major categories:

1. Preoperative complications
2. Operative complications
3. Early postoperative complications
4. Delayed post operative complications
5. IOL related complications
COMPLICATIONS:

 Haemorrhage – posterior segment

 Vitreous loss
 Retinal detachment
 Cystoid macular oedema
 Herniation in anterior chamber
 Pupillary block
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