1. Management of cataract (non-pharmacology)
Mainstay of cataract surgery isnow phacoemulsification:
 throughsmall corneal incisions,combinedwiththe use of foldable intraocularlenses
insertedthroughthese smallincisionstocorrector minimizeastigmatism.
Usedprimarily as secondline procedure:
 techniquesof large incision extracapsularsurgeryand intracapsular surgeryare to correct
unusual intraoperative problem
 Example:nuclearscleroticcataractstoo dense forphacoemulsification
Surgical treatment has 2 types:
1. Intracapsular lens extraction ( ICCE)
2. Extracapsular lens extraction (ECCE)
Intracapsular lensextraction ( ICCE)
 incisionof 12–14 mm around the limbus
 involve the removal of lensandsurroundinglenscapsule
General technique:
 a speculumisinsertedtoretractthe lidswithoutpressure beingappliedtothe globe after
anesthetized
 An incisionismade large enoughforlensdelivery
 One or two iridectomiesare necessarytopreventpupil block thatleadtoirisadhesion,
incarceration,orprolapse throughthe wound.
 Alpha-chymotrypsin(if necessaryandif available) isintroducedthroughacannulatopass
behindthe lowerpupil border
 Approximately0.3mL of fluidisinjectedoverthe zonuletothe sidesandbelow it
(Functionof fluid: toweakenthe zonule,prove the patencyof the iridotomy,andirrigate
small amountsof bloodor iris pigmentfromthe anteriorchamber)
 Thisenablesremoval of the lenswithoutzonulartractiononthe peripheralretina
 The lenscan be heldbycapsule forceps,bysuction,or byfreezingwithacryoprobe and the
lastis the mostreliable.
Specifictechniques:
 IRISMANAGEMENT
 Evenwitha large cataractous lens,the pupil issufficientlyelastictopermititsextraction
 If the irisisinelastic,aradial iridotomy(keyholeiridotomy - fromperipheral iridectomy
to pupil) mustbe performed
 A suture can be pre-placedbeforelensextractionsothatthe radial iridotomycanbe
repairedafterlensextraction
 VITREOUSPRESENTATION OR PROLAPSE
- vitreousvolumeisreducedduringpreparationandanestheticadministrationandby
preventingexternalpressureonthe globe toavoidprolapsed

2. - If vitreousprolapsesthroughthe pupil,itisessential topreventitsincarcerationby
sufficientanteriorvitrectomy
 INTRAOCULARLENS
-Because the capsularbag hasbeenremoved,the choice of IOLsupportislimitedtothe
angle,the iris,orto the ciliarysulcussupport(fixatedbysuture).
-Aniris-supportedlensismore stable whenplacedinanobliquedirectionandprevented
fromrotatingby suturingthe hapticto the midperipheral irisstroma
Extracapsular lensextraction
 involve the removal of almostthe entire natural lenswhilethe elasticlenscapsule leftintact
to allowintraocularlensimplantation
 replace bysyntheticintraocularlens
 hole ismade incrystalline lensincentral position
1.Anterior capsulectomy
 “CAN-OPENER” CAPSULECTOMY
 pinpointperforationsare createdinacentral,circulartract inthe anteriorcapsule
 Centripetal tractionisplacedonthe central piece of capsule tocreate a tear alongthe
perforations
 loose piece isthen carefullyremoved
 LINEAR CAPSULECTOMY(CAPSULORRHEXIS) AND INTERCAPSULAR TECHNIQUES
 curvilinearincisionismade inthe upperthirdof the anteriorlenscapsule tocreate a slit
or envelope openingintothe lenscapsularbag
 can be insertedintothe remainingcapsularbagaftercortical material removal
 CAPSULORRHEXIS
 easytechnique foranteriorcapsule removal
 initial capsulotomycanbe made centrallywith:
- cystotome or
- a bentneedle or
- byusingthe tip of the capsulorrhexisforceps.
 a piece of anteriorcapsule isgraspedandtorn ina circularmanner to achieve the round
opening
 NUCLEAR EXPRESSION
 scleral lipof the incisionshouldbe depressedtoallow the leadingpole of the nucleusto
present
 Gentle pressure atthe 180° opposinglimbus thenexpressesthe nucleus byusingsquint
hook
 space betweennucleusandposteriorcapsule/cortex isopen
 CORTICALWASHOUT
 Partial closure of the woundandirrigationproduce a deepandsafe anteriorchamber
withinwhichtowork
 Cleaningof the posteriorcapsule andremoval of remainingresistantcortical remnants
by aspirationusingafine cannulawithapolishedtip
 INTRAOCULAR LENS INSERTION
 Insertionof the IOLis performedbybycirculardialingof the IOLor bydirectplacement
usingfine forceps

3. 2. Small Incision Nuclear Expression Surgery (Mininuc Technique)
 ANTERIORCHAMBER MAINTAINER
 isinsertedthroughclearcorneato the anteriorchamberbetweenthe 4o’clockand8
o’clockpositions,parallel toandnearthe limbus
 CAPSULORRHEXIS
 IOPis increasedto40 mmHg (5.3 kPa).
 pressure pushesthe lensbackwardwhichpreventsaccidental radial capsuleteartothe
periphery
 5–6 mmcapsulorrhexisispreferred
 SCLEROCORNEALPOCKETTUNNEL
 Scleraentrance incisionis5mm longand isplaced1 mm behindthe limbus
 bothendsof the incision,perpendicularbackwardincisionsis1mm
 The tunnel isdissectedanteriorlyfor3–4 mm (1 mm inthe sclera,1 mm inthe limbus
tissue,and2 mm inclear cornea)
 The pockettunnel facilitatesnucleusexpression.
 NUCLEUS MANIPULATION
 Hydrodissectionisperformedin2 separate parts:
- justunderthe capsule: partiallymovesthe nucleustothe anteriorchamberatthe 12
o’clockposition
- betweenthe hard-core nucleusandthe epinucleus
 hydrodissectorcannulaislodgedperpendicularlyaroundthe equatorof the nucleusand
thenmovedbehindthe nucleus
 hard-core small nucleusisbeingseparatedfromthe epinucleusandcortex
 nucleusisreadyforexpression
 NUCLEUS EXPRESSION
 A plasticglide (4mm wide,0.2mm thick) isintroducedthroughthe tunnel underthe
nucleus.
 Slightpressure isinducedonthe glide atthe innerlimbal area,whichisusedtoguide
the nucleusthatis to be engagedinthe sclerocorneal pockettunnel
 pocketismade to accommodate the nucleusat thisstage
 CORTEX REMOVALAND INTRAOCULARIMPLANTATION
 facilitatedbythe deepanteriorchamberformationinducedbythe anteriorchamber
maintainersystem
 DuringIOL implantationandaspiration,capsularbagisinflated

4. Cataract surgery in complicated eyes
Preoperative evaluation
 Important to evaluate status of zonules for those with eye disease history
 Patient who don’t have adequate support from zonules may experience
postoperative IOL decentration or dislocation.
 Zonular integrity evaluated by looking at presence of phacodonesis
 Patient should examine for iridodialysis when have ocular trauma history
 Patient also evaluated for uveitis because uveitis and corticosteroid treatment can
cause visual disabling cataract
 In uveitis used heparin surface modified polymethyl methacrylate (PMMA)
 Avoid using IOL in uveitic patient because it can cause inflammation
Specific techniques
1.Zonular Dehiscence
 A large capsulorrhexis (5.5mm) made to facilitate removal nuclear fragment with
minimal zonular stress
 Careful hydrodissection done so nucleus can rotate easily within the capsular bag
 If phacoemulsification need to be done within capsular bag:
-phaco needle tip should be handle skilfully to create trough toward dehiscence area
so that len s nucleus pushed toward weakened area which preserved zonule
 Capsular fixation hooks use to stabilize the capsular bag because no zonules to offer
resistance to tearing forces
 Capsular edge gently retract with hook to the direction of dehiscence
 Phacoemulsification and hydrodissection are performed
 Cortical cleanup must be performed delicately and completely
 After remove cataract, IOL must be selected
 IntracapsularIOL placementwithoutacapsulartensionsegmentorringmay be appropriate
for patientswhohave upto 6 clock hoursof zonulardehiscence
 can alsobe managedbya PMMA capsularfixationsegmenttoallow fixationtothe scleral
wall witha prolene suture
 the fixationalsoiskeepingthe lensimplantfrommigratingawayfromareasof zonular
dehiscence
2.Uveitis
 Cataract extraction with IOL is difficult to do
 Should not be operated until uveitis has been inactive for 6 month to a year

5.  Uveitic patient receive oral prednisone 10 mg/kg daily up to 1 week prior to surgery
and tapering about 2-3 week
 Phacoemulsification is usually being chosen in this case
 uveiticpatients,itisbesttoavoidanteriorchamberlenses,iris-supportedPCLs,andsulcus-
supportedPCLsas theyhave a tendencytocause postoperative inflammation
3. Compromised epithelium
 Trauma of intraocular surgery may lead to endothelial cell loss which cause
prolonged and irreversible, cornea edema.
 Pachymetry and specular microscopy should be done towards suspected person with
corneal edema
 making the incision by more posterior,scleral tunnel approach.
 A dispersive ophthalmic viscosurgical device will be more protective to the corneal
endothelium
 Phacoemulsificationenergyandtime shouldbe kepttoaminimum
 nuclear fragments should be emulsified as posteriorly as possible with the tip of the
phaco handpiece aimed away from the cornea

6. PHACOEMULSIFICATION
Handpieces and tip:
 Phaco handpiece converts electrical energy into mechanical vibratory energy
 Standard handpieces couple the crystal to the phacotip by moves forward and
backward when crystal deform
 But now, there are hanpiece cause the tipto tort or twistwhenthe crystalsdeform

Power modulation

Pumps and fluidics
 Function of phaco pump : to hold nucleus on tip & to remove debris on tip
 There are 2 pump principles:
1. Flow-driven
2. Vacuum-driven
 Flow bases (peristaltic)


Postocclusion surge
 In an unmodulatedsystem: whenthe occlusionbreaks,fluidrushesintothe tubing
