Surgery: Phacoemulsification in Dense Cataract

This video demonstrates a phacoemulsification surgery using stop and chop technique for nucleus removal.

Surgery Location: on-board the Orbis Flying Eye Hospital, Accra, Ghana
Surgeon: Dr. Roberto Pineda, Harvard Medical School, Boston, USA


DR PINEDA: I think we’re going to try to do a stop and chop technique for this patient. So we’ll start with the standard central groove, but then we’re gonna switch to horizontal chopping, and this is just to show how we transition to that technique, which is good for denser lenses, and useful in high myopia cases. We’ll be doing a clear corneal incision for this. I like to keep the forceps open to stabilize the globe. And we’re gonna go ahead and put in some viscoelastic. So we’re gonna go in here. We’re gonna deepen the chamber. And we’ll use the keratome to stabilize the globe with our paracentesis. Enter a little vertically. Then flatten it out. Moving forward here. Just wiggling a little bit for maximum control. And we’ll get a little further. We can dimple down in, and again, just wiggle it in through Bowman’s, and flatten it out. Standard size capsulorrhexis. Relatively centered. Push out in a straight line. Lift up. Turning over that edge. We’re gonna go ahead and use the capsulorrhexis forceps. And again, I like to pull about 2 to 3 clock hours and let go, for maximum control. And again, I’m keeping this turned over. Again, sticking it a little bit centrally. I’m just gonna free it up. And again, we’re gonna go — keep going around. And we have a nice round rhexis. When we do the hydrodissection, our goal is to not go 180 degrees across, but about 90 degrees away. Where we can see the edge of the capsule very well. Going under the edge here. I’m lifting up, and I’m pushing. I already saw the fluid wave. I see the lens rising already. I’m gonna stop. I’m already getting a little iris to the wound. I want to press down. And I’m gonna add just a little bit more here. I’m getting some iris prolapse, which is not good. So I’m letting some fluid out of here. See, it’s viscoelastic. I’m just pressing down on the wound now. Remember, we talked during the lecture to let some fluid out of the paracentesis. Okay. Now we should be soft enough, I should be able to allow that to go back in. So now we’re gonna try to turn. We do the subincisional. So here the lens easily turns. Again, I can turn it. Yep. So we’re all ready. So again, we’re gonna go inside here. And here. Good. Now, again, there’s a prechop setting. This is just to get rid of some of the viscoelastic and some of the cortex on the surface. Just within the capsulorrhexis. Just make it easier to perform your surgery. That’s what we’re doing here. We’re gonna advance it. To sculpt. We’re gonna start superior enough. And it’s a little dense, which we know. And we’re not occluding the whole tip. Only about 50%. So that’s pretty good. Now you can crack this. Or try to. So we’re just gonna try to crack. Which it did. Now we’re gonna do our stop and chop. So we can turn this. Now, what we’re gonna do is go to the chop setting. Okay. So this is a different setting. We’re gonna engage the nucleus. We’re gonna pull it towards us, and we’re gonna put this chopper underneath. This is a horizontal chopper. You can see it’s blunt at the end. We’re gonna engage the center. So we engage. And you get behind it. And you bring it toward you. And you chop the piece. You can take the piece right out. Sometimes people keep the fragments in place, or keep some of the fragments in place. Again, we’re gonna — you have to phaco into the piece. Pull it toward you. Okay. And then bring it toward you. We’re gonna rotate again. Again, you want to phaco right in kind of the center area. Oh, this one’s already partially cracked. And pull it out. You can go around. And separate it. Last piece — it’s a little big. You can hold it. You can bring the chopper around. You want to separate it. Sometimes not so easy. Then we’re just keeping this in the center. You see, I’m not really moving my tip around. I rotate it a little bit. And I’m keeping my second instrument close by. Below my phaco tip. And again, we just rotate. Remember, we’re using our fluidics here. And I’ve got a little cortex here. I’m not sure I’m gonna get rid of that. It actually came out. Okay. And we’re all done. We’ll put the chopper back and remove the cortex. There’s not lots of cortex here. You can see this tangential stripping. Sometimes you have to go a little bit further. He has some sticky cortex. It’s not coming off as easily as we’d like. And so the lens is bigger. So sometimes the cortex can be — the bag can be a little bit more floppy. And of course, the subincisional is the toughest. So that’s very good. We have a little bit of subincisional cortex. So here there’s just a little bit of cortex. I can’t quite get it out. So this is the kind of cortex that you just decide sometimes it’s safer to leave than to try to remove. So we’re gonna inflate the capsular bag. When we have a little iris prolapse, we don’t want to overinflate, but we want to get under the capsule. Sometimes we remove the cells on the back of the anterior capsule. From a clinically scientific standpoint, I don’t know that it’s been shown to make a difference. In any of those studies. So I do it in cases where there’s pseudoexfoliation, retinitis pigmentosa, cases of uveitis, cases where we know these patients are at risk for anterior capsular phimosis. Again, this one — we’re just rotating into position. But in general, I don’t think it makes a difference. So here we’ve got the lens in the bag. We’ve got a little iris to the wound. I’m gonna let a little visco out to try to control that. And then we’ll go back to the I/A. Again, I have a little bit of debris under the lens. I’m just gonna lift the lens up here. And that’s just to get rid of some of that. It makes it look a little — just for a second. And I go back and I hold it down. To get all the viscoelastic out from the bag. Sometimes I go to each quadrant, just tapping, as I am here. And going all the way around. Now we see the iris near the wound wants to prolapse. Doesn’t it? Wants to come out. So what did we do about that? Well, what we do is we actually do what we call just a dry removal of the I/A. So when I’m done I/A-ing, I’m gonna take my foot off the pedal. I’m gonna actually let some fluid out. And then I’m gonna come out. See, the iris already wants to come out. I’m trying to let some fluid out. If you’re having iris prolapse that you can’t control, you really need to put a suture in. Putting a miotic in to help bring down the pupil can sometimes be very helpful. Sometimes I just sweep under the subincisional area, to make sure the iris is out of the way. Sometimes there’s very small iris strands that you can’t really see or appreciate. So we’re gonna go ahead and hydrate the wound. Yeah. Okay. Good. We’re all done.

3D Version

December 1, 2019

Last Updated: October 31, 2022

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