Intra capsular cataract extraction (ICCE) was an early surgical technique for removing cataracts but had high complication rates. Extra capsular cataract extraction (ECCE) was developed to address these issues by leaving the posterior capsule intact. ECCE became the standard technique with improvements in microscopes, irrigation/aspiration systems, and intraocular lenses. Phacoemulsification, an ECCE variant using ultrasonic fragmentation, further reduced complications through smaller incisions allowing faster recovery.

1. Intra capsular cataract extraction (ICCE)
ICCE
 ICCE evolved into a very successful operation
 Preferred surgical technique before the refinement of
modern ECCE surgery
 However there remained 5% rate of potentially
blinding complications including:




Infection
Hemorrhage
RD
CME

2. Intra capsular cataract extraction (ICCE)
 ECCE has replaced ICCE, almost entirely in most
parts of the world:
1. Better operating microscopes
2. More sophisticated surgical aspiration systems
3. More sophisticated IOL implants

3. Techniques (ICCE)
 Smith’s method
 Arruga’s method
 Erysiphakes
 Cryo surgery
 Chemical dissolution of zonular fibers

4. Smith’s technique
 Smith used external pressure with muscle hook to
mechanically break the inferior zonules
 Expelled the lens through the limbal incision
 The lens would “Tumble”, I.e. the inferior pole would
exit the eye before the superior pole

5. Arruga’s method
 Toothless forceps (Arruga’s) used to grasp
the lens capsule and then gently pulled
from the eye using side-to-side motion that
broke the zonules

6. Arruga’s Forceps

7. Erysiphakes technique
 Suction cuplike devices
were used to
remove the
lens with
traction

8. Cryo surgery
 Cryprobe: Hollow metal-tipped probe, cooled by liquid
nitrogen, that is touched to the lens surface
 As the temperature of the probe tip falls below
freezing, an ice ball forms and the lens adheres to it
 This instrument forms an ice ball, fusing the lens
capsule, cortex, and nucleus
 Lessening the risk of capsular rupture as the cataract
is removed

9. Chemical dissolution of zonular fibers
 The enzyme is irrigated into posterior chamber to
dissolve the zonular fibers in order to facilitate ICCE
surgery
 Enzyme alpha-chymotrypsin enhances the safety of
ICCE by increasing the ease of lens removal

10. Extra capsular cataract extraction (ECCE)
 Shift from ICCE to modern ECCE
 To decrease the rate of potentially blinding:
 Complications
 To facilitate the placement of PC IOLs
 By leaving the PC intact, the surgeon could
decrease the risk of:
 Vitreous loss and
 Complications like RD, CME, and Bullous Keratopathy

11. Extra capsular cataract extraction (ECCE)
 Key to the development of modern ECCE
technique were the growing use of:
 Operating microscopes for increased
magnification &
 Improved methods of cortical removal

12. Extra capsular cataract extraction (ECCE)
 Charles Kelman in 1967 developed phacoemulsification
 This new type of ECCE:
 Ultrasonically emulsified the lens nucleus,
 Allowing the operation to be performed through a small
incision
 This method has continued to grow in popularity as:
 Techniques &
 Instrumentation

13. Indications of ICCE
 Operating microscopes not available
 Unstable / luxated cataracts
 Week zonular support

14. Advantages of ICCE
• Entire lens removed with no capsule left behind to:
• Opacify or
• Require additional surgery
• Less sophisticated instrumentation required
• Non automated extraction devices:
Cryoprobes
Capsular forceps
Erysiphakes
Allow this procedure
To be performed
Under most conditions

15. Disadvantages of ICCE
• Large ICCE incision 12 – 14 mm (160° - 180°)


Delayed healing
Iris incarceration
 Delayed visual rehabilitation
 Vitreous incarceration
• Postoperative wound leaks with inadvertent filteration
• Endothelial cell loss > following ICCE than ECCE
• Corneal / endothelial cell trauma from lifting / folding
of the cornea (lens delivery / cryprobe)
• Cystoid macular edema (transient 50%, persistent 2%
- 4%)

16. Disadvantages of ICCE (cont’d)
 Vitreous complications:
In young patients PC is firmly adherent to anterior
hyaloid; attempted ICCE will usually result in vitreous loss
 Intact vitreous face may opacify and ↓ vision
 Adherence to corneal endothelium (corneal edema)
 Adherence to iris (pupillary block glaucoma)
 Broken vitreous face may incarcerate in the wound
with vitreous traction causing:
 RD
 CME

Vitreous in AC causing open angle glaucoma

17. Disadvantages of ICCE
(cont’d)
 IOL implantation problematic since posterior capsular
support missing
 IOL choices include:

ACL /Sutured PC IOL (Iris fixation IOLs no longer available)
 These significant disadvantages and risks led to loss
of popularity of ICCE

18. Patient preparation

Pharmacologic pupillary dilation with topical
mydriatic and cycloplegic agents to facilitate
lens removal (iris retractors intraoperatively)

Anaesthesia

19. Patient preparation

(cont’d)
Orbital massage / osmotic agents (manitol,
glycerine, isosorbide) before surgery
1. Intermittent digital pressure on closed eye lids or
2. Occulopressive device (honann baloon, mercury bag,
sponge ball, strap)
3. Massage helps to:

Distribute the anaesthetic agent within orbit

↓ Orbital volume

↓ Pressure on the globe

↓ IOP

20. Patient preparation
(cont’d)
Orbital massage (cont’d)
4. Minimizes vitreous prolapse during cataract
extraction and facilitates an angle supported
IOL
5. Osmotic agents are used less frequently:

Volume load in patients with heart and kidney
failure

Nausea (Occasional)

Urinary urgency during surgery

21. Patient preparation
(cont’d)
 Procedure
 Postoperative course
VA should be consistent with:
1.
Refractive state of the eye
2.
Clarity of the cornea
3.
Clarity of the media
4.
Visual potential of the retina and optic nerve

22. Patient preparation
(cont’d)
 ECCE

ECCE involves removal of the nucleus and
cortex through an opening in the anterior
capsule (anterior capsulotomy), leaving the
posterior capsule in place.

23. Patient preparation
(cont’d)
ECCE (cont’d)
Methods
1. Nucleus expression (manual)
2. Phacoemulsification (Ultrasonic fragmentation)

24. Patient preparation
(cont’d)
ECCE (cont’d)
Methods

Preferred method of routine cataract
surgery

Selection of technique for nucleus removal
depends upon:

Instrumentation available

Surgeon’s level of experience with each technique

25. Advantages of ECCE surgery (cont’d)
 Smaller incision
 Less traumatic to corneal endothelium
 Eliminates complications (short and long
term) associated with vitreous adherent to:
 Incision wound
 Iris
 Cornea

26. Advantages of ECCE surgery (cont’d)
 Intact posterior capsule allows better anatomical
position for IOL fixation
 Intact posterior capsule ↓ incidence of:
 CME
 RD
 Corneal edema

27. Advantages of ECCE surgery (cont’d)
 Intact posterior capsule ↓ ability of bacteria,
introduced into eye, to gain access to vitreous cavity
and cause endophthalmitis




2ndry IOL implantation
Filtration surgery
Corneal Transplantation
Wound rapair
Technically easier
and safer when
intact PC is
present

28. Contraindications (ECCE)
 Zonular weakness
 ECCE requires zonular integrity for selective
removal of nucleus and cortical material
 Therefore when zonular support appears
insufficient to allow safe removal of the cataract
through ECCE surgery, ICCE or Pars Plana
Lensectomy should be considered

29. Instrumentation (ECCE)
 A wide range of instruments is available
for each step of ECCE:
 Opening the anterior capsule
 Dissecting and removing the nucleus
 Removing the lens cortex
 Polishing PC

30. Cystotome
 Used for anterior capsulotomy (opening in the
anterior of the lens)
 Fashioned from 25 gauge needles by bending at its
hub and beveled tip
 Prefabricated cystotomes also commercially available
 The needle tip is used to puncture and tear the
anterior capsule

31. Irrigation and aspiration system
coaxial, double-lumen blunt cannulas
 One lumen irrigates BSS into the AC
 Second lumen aspirates lens material out of the AC
 Irrigation is gravity fed from a solution bottle
 Fluid flow is regulated with adjustment of bottle height
 The flow may be constant, or the surgeon can
employ a foot control connected to a pinch valve

32. Irrigation and aspiration system coaxial,
double-lumen blunt cannulas (cont’d)
Aspiration:
 Syringe connected to the cannula
 Elaborate pump system controlled by a
foot switch

33. Lens nucleus
Removed by a variety of techniques, each
with its own set of instruments:

Lens expressor

Lens loop

Spoon, Vectis

34. Procedure ECCE
 Pupillary dilation
 Critical to the success of ECCE esp.
phacoemulsification
 Cycloplegic / mydriatic drops
 NSAID (topical/oral) these agents help to
maintain dialation during surgery

35. Procedure ECCE
(cont’d)
 Incision
 Incision: Mid limbal, chord length 8 – 12 mm,
which is smaller than for ICCE
 The initial incision consists of a limbal groove
 Some surgeons prefer more posterior incision
with anterior dissection creating a flap of tunnel
 A stab incision is made into AC
 AC depth stabilized by viscoelastic agents, air
bubble, or continuous fluid irrigation
 Cystotome is inserted for anterior capsulotomy

36. Procedure ECCE
 Capsulotomy
 Christmas tree
 Can-opener
 Capsulorrhexis
(cont’d)

37. Procedure
ECCE
(cont’d)
Capsulotomy (cont’d)
Christmas tree
 With cystotome anterior capsule punctured
inferiorly and
 The flap of the capsule drawn toward the wound
and cut with scissors

38. Procedure
ECCE
(cont’d)
Capsulotomy (cont’d)
Can-Opener
 Cystotome used to make a series of connected
punctures or small tears in circle

39. Procedure ECCE
(cont’d)
 Capsulorrhexis
 Continuous tear anterior capsulotomy popular in
phacoemulsification, can be performed with either:
 Csytotome or
 Capsulorrhexis forceps
 First a small tear is created,
 The edge this tear is then grasped with cytotome
tip/forceps, and
 A smooth tear is created, removing a circular
portion of anterior capsule

41. Procedure ECCE
(cont’d)
 Capsulorrhexis (cont’d)
 This technique provides:
 Structural integrity for the lens capsule
 Maintain implant stability
 Centeration

42. Nuclear expression
 Manual
1. Whole (Lens loop, spoon, vectis, irrigation)
2. Fragmentation with forceps/nuclear splitter)
 Ultrasonic fragmentation

43. Lens cortex aspiration
1. Syringe connected to cannula
2. Pump system controlled by foot switch

44. Posterior capsular polishing
 Abrasive tipped irrigation cannula / low
vacuum clean using low aspiration
remove epithelial and cortical particles
from the capsular surface

45. IOL implantation





AC filled with viscoelastic / BBS / air
Viscoelastic most reliable AC maintainer
It also protects corneal endothelial
IOL inserted in the ciliary sulcus / capsular bag
Sulcus fixation:
 Requires greater IOL diameter (>12.5 mm)
 Large diameter optic (6 mm)
 More forgiving in case of postoperative decentration
 Bag fixation:
 IOL diameter <12.5 mm
 Optic diameter 5.00 mm

46. Wound suturing
 10/0 Nylon
 Proper suture tension ↓ postoperative Astigmatism
 Loose sutures – Against-the-rule
Astigmatism
 Tight sutures – With-the rule
Astigmatism

47. Postoperative course ECCE
 As with ICCE, VA on the first
postoperative day should be consistent
with:
 Refractive state of the eye
 Clarity of the cornea
 Clarity of the media
 Visual potential of the retina and optic nerve

48. Postoperative course ECCE
 Lid: Mild eye lid edema and erythema may occur
 Conjunctiva: May be injected and boggy
 Cornea: Should be clear and free of striate / edema
 AC: Should be of normal depth and mild cellular
reaction typical

49. Postoperative course ECCE
(cont’d)
 Posterior capsule: Should be clear and intact
 Implant: Should be well positioned and stable
 Red reflex: Should be strong and clear
 IOP: Elevations may be associated with retained
viscoelastic

50. Postoperative course ECCE
Antibiotics and Corticosteroids:
 Topical antibiotic and corticosteroids are used for first
few weeks
Vision:
 Steady improvement in vision and comfort, as
inflammation subsides

51. Postoperative course ECCE
(Cont’d)
Refraction:
 Refraction stable by 6th – 8th weeks,
 Glasses may then be prescribed
Astigmatism:
 If significant astigmatism along the axis of incision,
selective sutures removed by 6th week, according to
keratometry corneal topography

52. Phacoemulsification

Phacoemulsification is an ECCE technique that
differs from “standard ECCE with nuclear
expression” by the:
1. Size of incision required
2. Method of nucleus removal

This technique uses ultrasonically driven needle
(phaco tip) to fragment the nucleus and aspirate the
lens substance through a needle port

53. Phacoemulsification (cont’d)
Advantages


Lower incidence of wound related complications

Faster healing

Rapid visual rehabilitation

AC depth controlled during surgery and
providing safeguards against positive vitreous
pressure and choroidal haemorrhage (closed
system)

54. Phacoemulsification (cont’d)

Instrumentation
 Ultrasound
 Irrigation system
 Aspiration system

55. Phacoemulsification (cont’d)

Ultrasound

The phacoemulsification hand piece contains
a piezoelectic crystal that vibrates at
frequency of 24000 – 56000 Hz

The vibration is transmitted to the head which
is attached to the phaco tip

56. Phacoemulsification (cont’d)
 Aspiration

The aspiration system of phacoemulsification
machine varies according to the pump design:
1. Peristaltic
Pump
2. Diaphragm
Pump
3. Venture
Pump

57. Phacoemulsification (cont’d)

Aspiration (cont’d)

Peristaltic Pump
 Consists of set of rollers that move along a
flexible tubing, forcing fluid through the
tubing and creating a relative vacuum at
the aspiration port of phacoemulsification
needle

58. Phacoemulsification (cont’d)

Aspiration (cont’d)

Diaphragm Pump
 Flexible diaphragm overlying a fluid
chamber with one-way valves at the inlet
and outlet

59. Phacoemulsification (cont’d)
Aspiration (cont’d)


Venturi Pump

Creates a vacuum based on the venturi principle:- That
a flow of gas across a port creates a vacuum
proportional to the rate of the gas

60. Phacoemulsification

Irrigation
 Fluid dynamics of phacoemulsification
requires constant irrigation through the
irrigation sleeve around the ultrasound
tip
 Constant irrigation:
 Maintains AC depth
 Cools the phacoemulsification probe
 Prevents heat buildup and adjacent
tissue damage