Surgery: Phacoemulsification in Posterior Subcapsular Cataract

We have this gentleman for phacoemulsification, as you can see. There’s a little bit of cortical opacity anteriorly there. With a little fibrosis in that edge. And there’s posterior capsular opacification. So this is a reasonably soft cataract. And you do go in. Keep the blade not tilted like that, but almost horizontal. And press down a little bit before initiation, and gently push the blade through, until you come up to the mark. And once you reach that mark, then you depress it down a little bit, and then smoothly enter. Now, the next step here is because this is topical. We need to make sure that we get a little bit of lignocaine in. So I’m just going to inject a little bit, and then I’m going to use the VisionBlue. Now, we can use air to make sure the stain is more, but usually I don’t use that. I just wash it off almost immediately with the lignocaine itself. And then I’m going to inject the viscoelastic, and that’s the viscoelastic going in. So that’s Viscoat. Now, this is the side port incision. Again, it’s very controlled. And I go there. Then we’re going to do another one. And so we’re going in gently. I’m going to make a slight depression. You can see that depression nicely. And then I’m going to lift up a small flap. Once I do that, I’m going to start tearing this. It is always easy to follow to the margin of the pupil, when doing the rhexis. That way, it becomes easier to size it, and also to get a central rhexis. So it is very controlled, slow, grasp and regrasp. Pick it up again. Without trying to do — and make sure the anterior chamber is deep. If the anterior chamber depth is reduced for any reason, then you need to go in and deepen it before proceeding with the rhexis. Otherwise, there is a risk of runoff. So go in. Depress. Go under the anterior capsule, and gently inject, and you can see the fluid wave slowly traveling right across. Once that is done, test to see whether the rotation is there. If not, the procedure may have to be repeated. So I’m just going to repeat this again on this side as well. Now it is free and it is rotatable. I’m going to start the phaco, and then I go into full pedal position 1, and I’m just going to go in very gently. You can see I’m having the tip turned sideways. And then I’m just going to remove some of the viscoelastic to enable flow to occur. Because if there is no flow, it’s going to heat up, and you can get an incisional burn. So this is a fairly soft cataract. And let me see whether I can get the — yes. It is possible to crack this nucleus. So I’m just going to crack it into two. So I can see the posterior capsule now. So we are in quadrant now. And the vacuum is more. So I’m just going to hold it. And then I’m going to grasp it and pull it towards the center. Make sure when you tumble the quadrant, not to allow it to touch the corneal endothelium. Very important. So very controlled. I usually use the second instrument above the quadrant to make sure that it doesn’t come up and hit the endothelium. So you can see that still — I tumbled it, but I’m still controlling it. I’m keeping that for as long as possible, the subincisional quadrant. You can go through cases very fast. But still the patient’s safety is paramount, and each step has to be done very purposefully. So it is possible to use very low levels of energy dissipated. So there are advantages of keeping the amount of energy that is expended. Cumulative dissipated energy levels low. So I’m using bimanual again, like all my cases, and I’m going with the infusion first. Make sure that the anterior chamber is deep. Because otherwise, it is possible to cause a Descemet’s tear, which I was talking about. Descemet’s detachment. And if you do get a Descemet’s detachment, the main thing is to recognize it early. So again, cortical removal in a radial fashion. Grasp the anterior skirt, rather than the posterior one. And then pull towards the center. So if there is a little dense cortical matter, you just nudge it in with the second instrument. So the advantage of bimanual is that you can really place the second incision sites at very comfortable positions. Because the instruments are curved, and any part of the subincisional area is totally accessible. So I’m just going to start doing that last part, which is removal of the cortex for which I have switched hands. You have to be very careful. We can see here that the posterior capsule — it’s bulging up. It has a convex upwards, so very, very important. You have to be extremely careful when polishing it, because the vitreous pressure is a little bit on the high side. So I’m going to leave that and change hands again. There’s a little bit of cortical matter there, which I need to deal with. Okay. The rest I’m gonna deal after I get the lens in. So this is Provisc. This is to inject the lens. Again, I’m very careful. I’m just gonna start injecting before I really enter the anterior chamber, to open up the lips of the incision. And then I’m going in, and I’m going to inject into the bag. Open up the bag very nicely. There is the lens. Again, lift the superior lip upwards, and then start gently injecting it. Tilt the lens downwards, as it goes in. So then it goes directly into the bag. And you can just push it down. Take the viscoelastic out. I’m just going under the lid. And trying to clean up a little bit on this side. Okay. So the anterior capsule, I think… It’s not a step that a lot of people do. But I like to do this routinely. So I clean up a little bit, or as much as possible. So this patient, you can see, has a little bit of fibrosis for whatever reason. So that’s a little tricky, because the vitreous pressure is a little high in this patient. I’m just going to leave the haptic here. Because if the fibrosis progresses later on, it can cause a shift of the lens. So the haptic will give some protection. I’m just going to tuck it in under that area of fibrosis, and keep it like that. I’m going to reduce the pressure by loosening up the speculum. So that the pressure on the eye itself is reduced. And you can see that when I do that, the anterior chamber forms very well. I need to nudge that lens back into position, which I will do. You can see we’ve got nice color. I’m just going to seal the wounds, test its integrity, and then close up.