Surgery: Phacoemulsification with Limbal Relaxing Incisions

This video demonstrates phacoemulsification with limbal relaxing incisions to reduce the astigmatism. The nucleus was removed using divide and conquer technique and an IOL was implanted

Surgery location: on-board the Orbis Flying Eye Hospital in Trujillo, Peru

Surgeon: Dr. Stephen Lane, University of Minnesota


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Dr. Stephen Lane: This is a patient with relatively high astigmatism that’s against the rule at 170 degrees.

So I start up by making two paracenteses.

You can see that I’ve pre-placed two purple marks to mark and delineate the three and nine o’clock positions where the limbal relaxing incisions will be placed and I usually do that toward the end of the case. So we’ll make our typical incision. And now I’ll use some trypan blue. And then hydrodissection.

And so you can see that this turns very easily.

So for a little bit more viscoat in to protect the endothelium I think this is a very dense lens. So
now will do in terms of a divide and conquer and we’ll do it in four across type fashion. And so we’ll go ahead and just make a groove.

And see we’re going wider and this is a very dense lens.

Go on phaco power, go up to 50 percent please. So I’m adding some linear power to the torsional and then will turn. We can use the second instrument to help turn it. And you can see how dense the lense is. So I just need to be patient and then we’ll turn it again.

And remember this is the most dense part of the lense is in the center. And then we’ll turn it again.
And then we will go back to the original one. You can see how it’s getting thinner, I hope you can see that on the TV screen.

And I think we’re getting close to being able to crack it. You don’t want to push down, you want the machine to do the work.

Now we’ll just break. So there is a break. We can still go even a little deeper centrally. So we’re just trying to break this into four pieces.

[And even though we’ve used quite a bit of energy, it’s all in the back. Now what we’ll do is we’ll turn this to the side and we can just come in and grab the piece, kind of burrow in and just pull it up into the front and here if you want to, you can go ahead and chop this. And again, you try and keep the phaco tip in the center of the pie.

You can let the machine do the work. And again you just bring this up, you engage it and just pull it out of the bag. You can break it into pieces if you can.

Now we’re starting to see a red reflex, I guess one of the reasons we didn’t have a very good red reflex is because the lens was so dense. Try and work more or less in the center of the eye. And
so you can see even with very dense lenses, you can do this four quadrant divide and conquer. You just have to be very patient.

So you can see that it takes longer to do that than the chopping technique. But this was a good demonstration, I think that it can be done even with very dense lenses, if you remain patient.
And I think that it still is a good technique, one in which is a good place to start because you can see even after I broke it into four pieces, I was still chopping it afterwards to break it up even into smaller pieces. So the one thing about very dense lenses is that they typically don’t have a lot of cortex.

And then will come underneath the capsule and polish the underside of the capsule.
I believe that allows us to do and achieve a less inflammation after surgery.
Now we’re going to put in the visco elastic to deepen the capsular bag.

So you don’t have to go all the way into the eye, you can use the incision as part of the tunnel as I’ve done here. Now we’re going to do the astigmatic keratotomy incisions. So we’re going to just make the wounds a little bit more watertight. And we’ll come back in and take out the viscoelastic.

This is a guarded knife, so this is 500 microns as you can see. I am going to go ahead and do sort of a maximal limbal relaxing incision. Astigmatism as you remember was at 170. She’s got about two and a half diopters at 170 and so that’s where we will make the incision.

Question: How much astigmatism do you correct with those incisions?
Dr. Lane: You know I would expect that we might get about one and a half diopters with these maybe.
And so we just started just inside the limbus and just go right around. And then we can incorporate the incision that we had already here, that’s already full thickness, we’ll just extend it.

And there we go. So that’s all there is to it. Always make sure that the diamond is set back to zero.

And so now we’ll remove the viscoelastic and once again just kind of nudge the lens, come underneath it, visualize the opening and then remove the other viscoelastic.

You won’t catch anything if you’re underneath the lens with the port up. And some BSS now on the syringe and so will just hydrate the wounds.

August 21, 2017

Last Updated: October 31, 2022

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