Surgery: Basics of Phacoemulsification: Incisions (Part 1/6)

00:00
Hi this is Dr. Wyche Coleman dictating on the cataract surgery basics. This is video one of six on incisions. So basically I have 10 videos from a random surgery day, these are all standard on laser cases, cut out only the incisions the paracentesis in the main to give you a series of 10 just focusing on one part and we’ll break it up into the six steps of cataract surgery. When I talk to you this not in the order, it’s happening on the screening of a watch that on your own, but one step at a time as it occurs. So the first step is the paracentesis.

00:41
Number one I stabilize the out with point one twos, they’re nice, because you can always grasp the concept, the Limbus, if you need to, I use a 15 degree male aid that’s a little bit more versatile than MVR to me, because you can make an incision slightly wider if you need to, like about one millimeter, but you can always go a little bit bigger or a little bit smaller for things like iris hooks.

00:59
So whenever you’re using the 15 degree knife, it’s important not to have it rotated, you want it real flat, as it goes into the Iris plane rotationally and in the Z axis. So I looked at the base of the blade, where the blade hooks to the plastic to see if I have it rotated. So the best way to see it because if you focus on the tip, which is typically where you’re looking when you’re inserting it into the cornea, you can’t really tell if there’s rotation present.

01:28
So I go about one half to two thirds away, and that’s about a one millimeter wound maybe slightly more, come straight out. We’re using shugarcaine on every case. Our argument there is that you could get a better dilated pupil, you’ll need myostat a lot less at the time and the only argument that we can find against shugarcaine in every case is that myostat doesn’t work too good, but as long as you use it a lot less and you have good pupil dilation, I think it’s a good trade off.

01:56
So after the paracentesis is made, lidocaine is injected, followed by viscoelastic. We want to make sure that cannula tips all the way in the eye we don’t want to detect off corneal epithelium with lidocaine or especially viscoelastic, will come all the way across the eye. That way, if we have bubbles, we’ll be burping them back out the paracentesis get the off fairly firm. And I’m going to stabilize with my point one two is I believe one of these cases the patient’s is belzing, is not cooperative and fixating. And in that case, I can just grab the conjunctiva at the Limbus. And so I don’t have to change instruments in order to be able to complete my wound.

02:35
If you were using a Connard or second instrument to do the paracentesis ,you’d have to switch to something if you wanted to grasp the conj and also don’t like torque 90 degrees away from where you’re making the incisions. For me in a comfort level, it’s optimal to make the incisions 90 degrees apart, it also helps me mechanically, to have an advantage to crack and divide and conquer the nucleus, which we’ll see the technique on that in the next video, or maybe two videos away.

03:02
So this was a small pupil and I injected the viscoelastic more centrally, to try to give some more pupil dilation. I noticed that after the fact that sort of a subtle technique that I’m just learning by watching my own videos, that I think I do subconsciously. Now I do puncture the capsule with the microkeratome, that’s a 2.4 single bevel microkeratome by Alcon. If you have a blade that has bevels on the side edge of it, that’s not safe to do. I think it’s important to note that for paracentesis wounds you always want the bevel facing superior towards the top of the patient’s head. That way if they have a Bell’s reflex, you don’t make a large, several o’clock hour incision in the cornea.

03:39
So you’ll see in these videos, you’ll have alternating bevel facing up, bevel facing right, bevel facing left. That’s just a function of which eye we are in. So if we’re in the left eye, the bevel is gonna face right and if we’re on the left eye, the bevel is going to face left and that’s to keep it always facing superior towards the top of the patient’s head.

04:03
Now make us two step main incision I used to make a three step but I think a two step is adequate, so I’m basically in cornea plane, then iris plane and pushing down slightly as I enter into the eyes, so I’m controlling the length of the incision. A paracentesis incision basically should be Iris plane flat and you see I’m grasping the conj here. I’ve got the point one twos ready to go, so I have to change instruments to do it. Somewhat uncooperative patient, you saw the light go out and like go back on. Sometimes when people can’t fixate on the light, you can turn it off then turn it back on and that’ll help them find it and fixate. In this case not helping much and we’re just going to have to suffer through this one. I think the patient gets a little more sedation does better

04:50
We got lidocaine, follow that with the viscolastic. I think it’s important to note the location of the wounds, where you’re starting the wounds they should be about point five millimeters into clear cornea, I think that’s the ideal place to start. So if you get too anterio,r that’s really a problem with the main wound, even more so than the paracentesis. So I’m going to start about a half a millimeter into clear cornea for both of the incisions. You’ll see I’m pretty consistent in this location, and the depth and basically, the whole technique seems to be pretty consistent from patient to patient even with different levels of patient cooperation.

05:24
Now, on your main incision, if you make it too far anterior, it will torture you the whole case and it could get close to the visual axis. You don’t want it to be anterior because it’s initiated too anterior or because it’s too long. And I think about a 2.5 millimeter length is about right. So you’ll see the length here, there is a mark on this blade, I like the two four care tone because it gives you a guide on when you should go ahead and penetrate into the anterior chamber. If you make it too posterior, it will track back into the conjunctiva, it’s important not to push down. As you’re initially making your cut, you can push down to enter the anterior chamber, but do not push down as you initiate the wound. Because that will cause the edges of the blade to track posteriorly into the conjunctiva. You can get conjunctiva bubbling from BSS getting trapped underneath it, and that can cause a heck of a problem for your view and some discomfort for the patient afterwards.

06:15
To get the eye fairly firm, I’ve seen people use many methods to stabilize the eye, fingers, Connors in the paracentesis wound, you know every time I try something new I end up back with a point one twos, I like less instruments in my set, I like less passing of instruments and that helps me to be pretty versatile and do whatever I need to do.

06:37
So we’ll talk through these last few, half a millimeter anterior, one half to two thirds the way in. I’m going to get the cannula tip all the way into the anterior chamber before I started major injection. You can inject a little bit but you want to make sure that your ends you don’t disect away into helium. A little pain with the Lidocaine, be ready for that movement. I’m injecting a little viscoelastic because that was a little another dab of shugaircaine to make sure we got a good numb.

07:07
Okay, here comes the viscoelastic, we’re going to inject a little bit and then come all the way across the eye and bring the fluid way back towards the paracentesis and that way if we have any bubbles, they burp right out of the eye and they don’t obstruct our view, when we move on to the next step, which is to capsulorhexis.

07:28
90 degrees apart on the wounds again. And I will start a half millimeter anterior about 2.5 millimeters in length, puncture the anterior capsule. That puncture is going to be our starting point for our capsularhexis. I really liked that technique. We’ll talk about it more in the next video. So hope this series helps everybody. I like to break it down for those interested in time and efficiency, the incision portion, if you take this eight minute and 17 second video divided by 10, that’s 48 seconds on average, to complete a paracentesis.

08:00
Inject sugarcaine, inject viscoelastic and complete a main wound and puncture the anterior capsule. And that just gives me a starting point and rather than having to drag a somewhat blunt instrument across the surface of the capsule, I can go ahead and just go in with my tips closed together on utratas, lift up and begin the capsulorhexis. Okay, be sure and watch the next one. Thanks for watching this one.