This video demonstrates a routine phacoemulsification surgery in a 50-year-old man with soft cataract with a 1 piece foldable lens implantation.
Surgeon: Dr. Michael Vrabec, University of Wisconsin, Appleton, Wisconsin, USA
DR VRABEC: This patient is 50 plus years old and we’re going to be doing cataract surgery on him, small incision phacoemulsification with insertion of a posterior chamber intraocular lens. This is a ring speculum with a ring forceps or a Thornton fixation ring that will hold the eye for my initial incision. These tips are blunt, to avoid damage to the conjunctiva and bleeding. So, we want a three step corneal incision. So initially down to half stroma, now 50% stroma for about two to two and a half millimeters.
Now back into the cornea, so there’s my incision, that should self-seal. So, if this was topical, I would put in intracameral lidocaine, but since it’s a block, I will not use intracameral lidocaine. This is Provisc, I’ll put a little bit outside the eye to clear any air bubbles. So just enough viscoelastic to maintain anterior chamber shape.
This is a 75 blade that I’ll use for my second incision. This incision is parallel to the iris in only about a millimeter. Now we’ll start to capsulorhexis, using 0.12 forceps to hold the conjunctiva. My initial rhexis starts centrally and moves out several millimeters and then I begin the tear. And this is you Utrata forceps for the rhexis. I want the rhexis, maybe about five and a half millimeters in size. And I take several grabs of the capsule to keep it short. Capsulorhexis is complete now.
This is a soft nucleus with a dense posterior subcapsular cataract. So, we’ll hydro dissect just under the lip of the anterior capsule and I’m going to try to flip this. So, we have a flip. There’s a tendency for the iris to prolapse so I will use some viscoelastic to put it back. Now we’ll begin the phaco, I’ll use the 0.12 forceps to introduce the phaco needle.
So, this is a soft lens.
There’s a little piece of nucleus trapped in the wound. Let’s get that right away.
Now we can set it on cortex. All right now we’ll begin the I&A.
We are always very gentle; we don’t want to push anything.
So, what I’ll do now is switch to my 90 degree, irrigation and aspiration cannula. And this is very good for sub incisional cortex.
We can open the lens, let’s have the BSS on the 27-gauge cannula. So, what I want to do is just do a little bit of polishing of the capsule. I’m very careful not to hurt the capsule. Now we’ve opened the capsular bag, not too much just enough.
I inspected to make sure there’s no scratches or defects. The cartridge is filled with viscoelastic, we can see the icon of the implant. We match the haptic with the haptic to make sure the implant is not inserted upside down. Next, I’ll start a flex of the leading haptic. Gently push the implant into the cartridge, then we have to press down on the implant.
Noptic.ow we’re tucking the trailing haptic over the optic.
And then gently pushing on the edge of the optic to advance the implant down the cartridge. This is called a monarch injector and it fits in, it snaps into place. Now I want to make sure that the injector paddle engages the implant properly and does not ride over or under the implant. Now we’ll begin to turn the screws.
And we’re advancing the implant, just before the tip of the injector. We don’t want any portion of the implant exposed outside the tip. So I’m going to use the Bechert nucleus rotator, in order to provide counter traction to the eye when I insert the IOL. I slowly advance the implant into the eye.
Now we need to insert the implant into the capsular bag. We start by ensuring that the leading haptic is in the capsular bag. Very carefully we place the optic in the capsular bag. We make sure that the trailing haptic gets into the capsular bag.
So now the implant is in the capsular bag. And we want to make sure that the haptics spring out and make contact with the sulcus of the bag.
Now it’s very important that we remove all of the viscoelastic.
Now I’ll have some BSS. I’ll use the BSS for two purposes. One is to do an irrigation of the anterior chamber to confirm there is no retained cortex. We can see that quite a bit in patients who take Tamsulosin. The second reason for the irrigation is to hydrate the wound to ensure that it is watertight.
Wound hydration both above and below. I’m careful not to hydrate under Descemet’s membrane because that could cause a Descemet’s membrane detachment.
I confirm that the implant is centered. I will now check to confirm that the wound is watertight without suture. And the wound is watertight without sutures, both the primary and secondary wounds. I do not push on the sclera to check wound integrity. I just gently touch the wound with no pressure.
Pupil is round, IOL is centered. The wound is watertight, chamber is deep. And so, we are done and I will put some drops in the eyes.