Surgery: Phacoemulsification and Canaloplasty

[Wyche] This is a Dr. Wyche Coleman for Cybersight. This is a mature cataract in a patient with coexisting glaucoma. We’ll make our paracentesis about a half a millimeter anterior to the limbus. Shugarcaine, which I use in every one. We can use the same cannula to draw air, and fill the anterior chamber with air, prior to using trypan blue to stain the capsule. We’ll burp out with our viscoelastic the remaining trypan blue to get a good view. I like to puncture the capsule with my keratome to create a very definite point to begin my capsulorhexis. On these dense cataracts, we have to make sure that it doesn’t tear out, a lot of times it has a tendency to, this one seems to be fairly well controlled. And I made it a slightly bit larger than I normally would in preparation to use to the miLOOP. I think that helps bring a dense lens into the anterior chamber slightly easier.

Some people say do not hydrodissect a mature cataract, but I think it is safe if you use very low pressure and very low volume. It’s a low flow situation. If you create high pressure, you are at risk of blowing out the posterior capsule before the nucleus is removed. If you’re going to do it, do it carefully. I do think it helps get the lasso around the lens when you use the miLOOP.

I like to place the miLOOP with the loop facing left, it’s more natural to me being right handed. You can see the black mark on the miLOOP and that’s about where you need to place it in the wound to get the correct placement around the lens without shifting the lens and stretching zonules. I rotate slightly beyond where I’d like the wire to be, straight down and then come back.

We have to hold the lens down with our second instrument as the miLOOP cuts through the nucleus to keep it from pulling into the anterior chamber. You can see we got a clean slice of a very dense cataract. And we completely pull the loop in to remove it from the eye.
Here we’re in procedure two on the Centurion for a divide-and-conquer. I use, essentially, the same technique of breaking the lens into a quadrant whether I groove it with the phaco or whether I crack it in half with the miLOOP. You can see we break off what is almost a perfect quarter. I believe this is the most efficient way that I’ve found to remove the nucleus in a real consistent way whether it’s a dense lens or whether it’s a very soft lens.

We’ll bring the second quadrant up into the anterior chamber and actually break it into a slightly smaller piece since the lens is extremely dense. It’s important to note here that you still have a heminucleous in the capsular bag that’s protecting the posterior capsule. It’s not particularly important to hold your second instrument deep. That gets progressively more important as you remove more of the nucleus and there’s less to hold the capsular bag from touching the phaco tip.

Now we have a heminucleous remaining, we’ll bring it into the anterior chamber. Use the Connor and the phaco tip to crack it into even quarters, as even as possible. Now’s the time that we have to think about protecting deep with the Connor wand. Connor is my second instrument of choice. But whatever you have, make sure it’s something not sharp at this point so you that you can hold the capsule back and very efficiently phaco without worrying about it coming forward.

You can see this is a very dense lens. Even with the miLOOP, the CDE’s getting up around 16 before the case is done. You can safely say that without the miLOOP, it would be in the 20’s, at least. I believe the miLOOP probably takes about five off of your CDE in any given case with a very dense lens.

As usual in this case, with a dense cataract, there’s not hardly any cortex remaining. We’d be real gentle with removing it and sometimes they posterior capsule is brittle. It can be more prone to rupture when a nucleus is that dense. Take a little Provisc through the paracentesis wound to make sure that there were no remaining fragments there. If there were, I’d rather find them now rather than when I hydrate the wound at the end of the case. Now that the lens is inserted, we’ll place it in the bag, get ready for intraoperative gonioscopy. We’ll plate the anterior chamber with some more Provisc, try to open up the space that the anterior chamber angle with the Provisc.

Get good visualization with the gonioprism. I love the NGENUITY, particularly for these cases, because visualization with the anterior chamber angle is basically unparalleled. I’ve never gotten a better view than I do with the NGENUITY. This is the Omni device for goniotomy canaloplasty. It’s important to point up slightly, but not too much, because we want this to get in Schlemm’s canal and not dive posteriorly into the suprachoroidal space. We like to visualize it passing through Schlemm’s canal just below the T.M. Now we’ll rotate the Omni to the other direction in preparation for 180 degree goniotomy. At this point there’s no viscoelastic left in the cannula and we’ll fully extend it and then pull it back through the trabecular meshwork to perform approximately 180 degree goniotomy.

Remove the viscoelastic, I always go behind the lens by sliding it over slightly. You can see even that’s little tiny fragment of a very dense nucleus doesn’t come out well with the I and A. You have to be careful to get as much of it as we can prior to I and A. Hydrate, check wounds, beautiful case, the patient did very well.