Small incision cataract surgery presentation

1. Small Incision Cataract
Surgery
Kumar Vaibhav
3rd Year MD Ophthalmology Resident
BPKLCOS, TUTH
1

2. Layout
• Preparation & Draping
• Bridle Suture
• Peritomy
• Sclerocorneal Tunnel
• Capsulotomy
• Hydroprocedures
• Nucleus management
• Iol insertion
2

3. Anaesthesia
Retrobulbar injection
3
Site: Junction of medial 2/3rd and lateral 1/3rd of
lower lid adjacent and parallel to orbital floor
Peribulbar block:
8-10ml
Retrobulbar block: 2-4ml
Lignocaine 2% with Adrenaline 1:000000
Bupivacaine 0.5%
Hyaluronidase 1500 IU to 20ml bottle of lignocaine
Administering an eye anaesthetic: principles, techniques, and complications Ahmed Fahmi and Richard Bowman
Community Eye Health. 2008 Mar; 21(65): 14–17.

4. Preparation & Draping
• Betadine
• Start centrally and move peripherally
• Do not return back to eye
• Betadine is allowed to dry for upto 2 minutes
• Dry eyelashes and periorbital area so that drape sticks
• Elevate superior eyelid and place drape directly over
eye
• Get all eyelashes under drape
• Tuck lashes back under lids while placing eye speculum
4

5. Bridle Suture
• To maneouvre globe
• Also provides counter-traction force during
Nucleus extraction
• Double angulated forceps
• Angulated tip measures 7.7
mm to grasp the superior
rectus from the limbus
• It is held with tip pointing
face down towards
conjunctiva, and superior
rectus is fixed through
intact conjunctiva and held
with help of toothed
forceps
5

6. • Move the muscle from
side to side, test hold of
muscle and make sure
the globe moves
accordingly
• 4–0 silk suture is passed
under area held by
forceps
Kalt’s needle holder
Hold like a raquet
6

7. Superior rectus muscle
grasped
Suture passed under
the muscle
Globe steadied by
pulling and clamping
suture
7

8. Complications
• Globe Perforation!!
• Pass needle exactly under the area of muscle grasp and
lift the forceps holding the muscle while doing so
• Keep the tip of needle upwards after the initial pass and
take a small bite
• Bleeding
• Avoid larger vessels of conjunctiva while taking bite
• Muscle Injury (Laceration, Avulsion)
• Failed Bridle Suture
• Post Op Ptosis
8

9. Conjuctival Peritomy
• The opening of conjunctival flap
• Forceps (Colibri/Pierce Hoskin) in non-dominant hand and
conjunctival scissors in dominant hand
• The flap is based toward the fornix
• Initiate at 10 o’clock
Westcott conjunctival scissors: slightly blunted
points to avoid globe injury. Spring action
ensures minimum pressure required
only to close the tip and guards against
excessive opening of the blade.
9

10. • Grasp conjunctiva just behind limbus with forceps and a
firm vertical traction to create a conjunctival fold so that
conjuctiva and tenon’s can be held together
• Cut from conjunctival scissors should be vertical with
limbs of scissors perpendicular to scleral surface
Conjunctival/tenon
opening with exposure
of underlying sclera
10

11. • Blunt dissection of conjunctiva is carried by inserting blades
(closed) beneath tenon capsule. The tip has to be directed
toward limbus & blades opened to separate tenons from
underlying sclera
11

12. • The conjunctiva is then cut at limbus.
12

13. • An ideal conjunctival peritomy exposes the blue limbal
zone without any overhanging conjunctival epithelium
• Peritomy of approx 8mm in length and 4mm in width is
often sufficient in size
• A proper blunt dissection would have ensured that there
is bare sclera at the bed without any islets of tenons
13

14. Cautery
• Wet-field bipolar cautery
• Allows visualization of instrument during tunnel creation
• Prevent/minimises bleed into anterior chamber intra and
post-operatively
• Disadvantages of sclera cautery:
• Scleral thinning and scleral necrosis can occur
• Poor wound healing
14

15. • Tips:
• Apply point cautery to scleral bleeders only
• Cautery of limbal “blue zone bleeders” has to be
avoided
• Cauterized tenons is difficult to separate from sclera
• Cautery should not be applied after sclera incision and
tunneling
15

16. Limbal Paracentesis Port*
• Side port
• Keratome
• 1-2 clock hours away from internal corneal incision
• Helps in
• AC depth maintainance
• Staining Anterior Capsule
• Cortical clean up
16

17. Staining Anterior Capsule*
• Air is pushed in AC
• Trypan blue is used to stain the anterior capsule
• Trypan blue is washed out
• AC maintained with viscoelastics
17

18. Scleral Incision
• Introduced by Paul Ernest
• Self sealing cataract incision, Corneal valve incision
• Components of Scleral incision
• External sclera incision – constructed by blade/surgical knife
• Sclerocorneal tunnel – constructed by tunnel blade/crescent
knife
• Internal corneal incision – created by keratome
18

19. External Scleral Incision
• 1 to 2 mm posterior to limbus
19

20. • Length: Titrate according to density of lens nucleus, but
minimum being 6.5mm
• Instruments:
• Colibri forceps in non dominant hand grasp the scleral
tissue and blade/crescent knife in dominant hand mark
Incision
Castroviejo Colibri Forceps
Crescent Bevel Up
20

21. • Koch described, seal-sealing incisions were astigmatically
neutral
Koch PS. Structural analysis of cataract incision construction. J Cataract Refract Surg 1991;17 (Suppl.):661–667.
Imaginary pair of curved lines, incision made
within them will be astigmatically neutral and
the more anterior the incision is made the
higher will be the astigmatism
21

22. • Shapes:
Frown incisionStraight incisionSmile incision
Inverted batwing incisionChevron incision
22

23. The Incision Depth
• Optimal depth: ½to ¾ of scleral thickness
23

24. Sclerocorneal Tunnel Construction
• Initiation – Finding right plane
• Propagation – Maintaining the plane and widening of
tunnel
• Keratotomy – Entry into AC to create a third plane for the
valve effect
• Extension – Extending the inner corneal lip
24

25. • Sweep the incision with tip of crescent blade (bevel up) to
make incision smooth, nonragged, and of uniform depth
• Judge the depth of incision by looking at the blade trans-
sclerally
• Propagate the blade with swiveling action
25

26. 26

27. • Lateral swiping movements to be done so that tilt of
blade is along and equal to contour of globe
• Direct the tip of blade towards a higher plane at limbus to
match Corneal curvature
Button
Hole!!
Pre
mature
entry!!
27

28. • Extend the tunnel upto 1.5mm in clear cornea
• Use a bevel down keratome and dimple- down technique
to enter AC and create a third plane gives for valved effect.
• Once AC is entered, keep keratome parallel to plane of iris
and extend tunnel with forward cutting movement
28

29. 29

30. Complications
• Irregular incision
• Buttonhole
• Premature entry
• Descemet’s membrane detachment
30

31. CAPSULAR OPENING
• Opening the anterior capsule
• Stable enough to prevent anterior capsular tears from
continuing to posterior capsule.
• It should be of adequate size
CAN OPENER
TECHNIQUE
ENVELOPE
CAPSULOTOMY
CONTINOUS
CURVILINEAR
CAPSULORRHEXIS
31

32. Instruments
• Pierse Hoskin/Colibri Forceps
• Bent Cystotome Needle
• Capsulorrhexis Forceps
• Viscoelastics
32

33. Can opener Technique
33

34. The Good:
Easy to learn
High number of
tears share forces
thus reducing
chances of
radialisation
The Bad:
Capsular tags are
difficult to
differentiate from
cortex, during
cortical clean up
34

35. Continuous Curvilinear Capsulorrhexis
• A puncture is made in central anterior capsule
• Puncture is directed peripherally either in a clockwise or
counterclockwise fashion
• Tear is led in a circular fashion
• Control is achieved by grasping about 2 clock hours away
from free flap edge closest to leading fold of capsule
Leading tear aroundInitiation with puncture Turning the flap over
35

36. 37

37. The Good:
• Easier cortical clean up
• Promotes stability and
centration of IOL
• Resists anterior
capsular radial tears
• Safe hydrodissection
and in-the-bag lens
rotation
The Bad:
• More experience to
master
• Large CCC may
promote IOL
dislocation from bag
• Small CCC will have
difficulty in prolapse of
lens into anterior
chamber
• Requires excellent
visualisation
38

38. Envelope Technique
39

39. Hydroprocedures
Hydrodissection
1. Conventional
2. Cortical cleavage
Hydrodelineation
40

40. Conventional: separation
of superficial cortex from
epinucleus
Separation of cortex from
capsule
41

41. AC is emptied of viscoelastic
26G blunt cannula is guided
1mm behind the rhexis margin
in the subcapusular plane
Anterior capsule is tented up
BSS is pushed – posterior fluid
wave is seen, which passes
circumferentially in the zone 42

42. This cleaves the cortex from the
posterior capsule in most
locations
The entire lens bulges forward
because of the fluid that is trapped
posteriorly within the capsular bag
The capsule is decompressed by
depressing the central portion of
the lens with cannula
43

43. LOOK FOR
• Advancement of
fluid
• Anterior movement
of nucleus
• Stretching of CCC
• Deepening of
anterior chamber
44

44. Difficulty in
tracking the
capsular margin
Hydro through
side port in a
visco filled eye
Less fluid
injection:
Incomplete Hydro
More fluid
injection:
Chances of PCR
Mistakes
45

45. Hydrodelineation
• Separating outer epinuclear shell from central
compact mass of inner nuclear material, the
endonucleus, by the forceful irrigation of fluids
(balanced salt solution) into the mass of the
nucleus
• Performed in cases of Posterior polar cataract
46

46. Nucleus management:
2 maneuvers
Nucleus prolapse from capsular
bag
Nucleus delivery
47

47. Adequate capsulorrhexis
and good hydrodissection
One pole of nucleus
tilts forward
hydrocannula/viscocannula
carefully maneuvered under the
rhexis margin to go underneath
the edge of nucleus
Inject fluid/visoelastic
to dislodge equatorial
edge out of capsular
bag
Whole nucleus is rotated
into the AC
48

48. Prolapsed lateral
pole of nucleus
Nucleus prolapse
with Sinskey hook
49

49. Wire Vectis
50

50. Viscoexpression
51

51. Fish Hook Technique
• “Lahan technique” or “Hennig technique”
• Introduced in 1997 by Dr. Albrecht Hennig in Lahan Eye
Hospital in Nepal
Fish hook made
from 30 G needle
Hydrodissection,
upper pole of
nucleus brought in
AC
Hook inserted between
nucleus and posterior
capsule, tip turned so
that it inserts into the
central lower nucleus
52

52. Cortex Removal
• Simcoe cannula
• Tackle most accessible parts first, such as inferior
and nasal parts
Two small hollow metal tubes
Each tube has a hub for attachment
Infusion line goes in infusion hub
Syringe in the needle hub
Tip of the cannula is blunt
53

53. Cortical material floating in the
anterior chamber is gently
aspirated.
Cannula placed beneath anterior
capsular margin, Cortex is
engaged and brought into
centre of pupil and aspirated
When pulling cortex from
behind iris, to & fro movement
is done to loosen the cortex
from capsule at equator 54

54. Sub Incisional Cortex
J or U Shaped
Simcoe Cannula
Aspiration through
side port
55

55. IOL Insertion
• PMMA lens
56

56. S means STOP!!
57

57. Fill the AC and the capsular bag
with viscoelastics
Hold IOL with Mc Pherson’s
forcep near upper dialing hole
Introduce the leading haptic
into the tunnel
After leading haptic enters AC,
tilt it downward and direct
towards 6 o’ clock 58

58. Keep pushing till leading haptic
is completely in the bag and
lower dialing hole at pupillary
border at 6 o’clock
Gently release the IOL and
withdraw the forcep
Grasp the trailing haptic with
McPherson’s forceps, and rotate
the lens as you tuck the trailing
haptic under edge of capsule 59

59. 60

60. • To confirm whether the IOL is in bag look for these:
• Appearance of stretch lines in center of the posterior capsule
• To visualize shiny appearance of anterior capsular rim over
haptic
61

61. • Wash the viscoelastics
• Checking the Wound Integrity: Gently tap on dome of
cornea or at limbus opposite to wound with hydro-
cannula.
• Hydro the side port
62

62. • Intracameral antibiotics
• Cefuroxime 1mg per 0.1ml
• 0.1% Moxifloxacin (0.5% moxifloxacin add 4ml BSS)
• Vancomycin 1mg per 0.1ml
63

63. • Check the wound again
• Indications for suturing:
• A leaking tunnel
• Premature entry or button-hole
• Pediatric patient
• Posterior capsular rent with vitreous disturbance
• Vertical sutures
Cross suturesVertical sutures
64

64. • Sub conjunctival injection
• Remove speculum
• Recheck the eye
• Apply ointment
• Keep an eye pad
65

65. References:
• Manual Small Incision Cataract Surgery Second
Edition by Aravind Eye Care System
• Manual Small Incision Cataract Surgery First Edition
Bonnie An Henderson. Springer Publication
• Small incision cataract surgery: Mini-review by
Parikshit M Gogate Published in Indian J
Ophthalmol. 2009 Jan-Feb; 57(1): 45–49.
• Small incision cataract surgery: tips for avoiding
surgical complications article by Reeta Gurung and
Albrecht Hennig Published in Community Eye
Health. 2008 Mar; 21(65): 4–5.
• Internet sources
66

66. THANK
YOU
67

67. Sleepless
nights
68
Descemet membrane detachment Nucleus drop & IOL Drop
PCR With Vitreous Loss
Argentina
Flag sign
Zonular dehiscence Retrobulbar hemorrhage
Decentered IOL
Iridodialysis