Surgery: Phacoemulsification in Posterior Subcapsular Cataract

This video demonstrates a phacoemulsification surgery in a 54-year-old male who presented with posterior subcapsular cataract. After the capsulorhexis, a prechop was done and the nucleus was removed using a divide and conquer technique. An IOL was implanted in the bag and the wounds were hydrated.

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



54-year-old with a PSC cataract. You can see the pupil’s fairly well dilated. Relatively strong red reflex. When you start with the paracentesis, you really need a second instrument. I like to hold the second instrument against the globe here as a countertraction. Now we’re gonna put in some air here. Now, that’s always a little troubling, having those small bubbles. I like to make sure I have enough air. The issue with Trypan is people put too much in. And so I just put a few drops in the center, if possible. And I actually paint it on the surface. So I just wipe it across the surface. That’s it. And then it doesn’t need to be there very long. Just irrigate until the blue is gone. The bubble is gonna keep us from hitting the capsule. So I go all the way across. And then I slowly fill up. I usually move it back and forth to get the bubble to come out uniformly. And then we have a nice deep chamber. Here I go relatively vertically, to the surface. Once I get in, I flatten it out. I wiggle forward. About halfway along here. Then I go vertical again, and anterior. So I like to start in the center. And I like to go radial. So we enter here in the center. Go radial. And then lift up a little bit to get that turned over. And now we go to our Utrata forceps. I like to regrab every two to three clock hours. So I pull a few clock hours. You see how I keep this turned over? I’m not grabbing here, right next to it. I grab about a millimeter away. Now, see how this is actually not coming with the rest of the capsule? I usually free this up. And then I regrab again. Leaving it turned over the whole time. And again, I’m regrabbing. You can turn your flap around. Now, when we go to the hydrodissection, you want to lift up on the capsule. Go in. Lift up. Push hard. You can see we’re getting… There it goes. The lens is now pushing up against the capsule. I want to decompress it. So I decompress it at the edge. Do you see that? It just decompressed. Now we want to rotate the lens. And make sure it spins. So here we’re gonna spin it. It didn’t spin so easily. I’m gonna try again. So then I switch direction. Okay. There it goes. So now it’s rotating. So we have a prephaco setting. Prechop here. And we’re gonna go in first with our second instrument. This is our chopper. And here we go. So we’re all set here. We’re gonna do the prephaco. Just remove this material on top. So now we’re ready for sculpting. Again, just keep this still here. Okay. And again, we’re gonna go until we’re looking for a color change, or we feel we’re at least 3 down. So that’s pretty deep. I usually push the nucleus peripherally and rotate. I’m just using one instrument. I’m not doing two. Some people do a two-instrument spin. I’m gonna push this out and rotate. So usually when I do three, I like to see if I can crack. It saves time. So we’re good there. It’s cracked on that one. So I’m gonna rotate. If you have a good depth and good length, you can usually crack. So these are all cracking very well. And I’ll do the last one here. Okay. So now they’ve all cracked. We’re gonna move to the next quadrant removal. And what we’re gonna do is — again, we’re gonna look for the smaller piece. So I’m gonna grab it and wiggle it out. See, I’m wiggling it out. This breaks the cortical fibers. And then we rotate. Just get rid of those pieces. Move to the next piece. Same thing. Wiggle it out. Okay. We’ve got one piece left. Again, not much cortex. So you usually just turn your tip to change the fluidics. So this patient had asteroid hyalosis. We can see that now. Asteroid hyalosis is very deceptive, because it makes it hard to judge depth. So we’re gonna make a separate paracentesis site for our bimanual. Ideally we would want to do this ahead of time. So I want to be a little careful. So we have our irrigation on. This is our I and A now. So again, with this, you can really do a great job of doing tangential removal. Sometimes we remove the cells on the back of the anterior capsule. Doing it here. Usually we take this out first. And then we take this out. So very nice. We’ll go ahead and put viscoelastic into the anterior chamber. Usually I try to get under the bag here before I inflate it. The asteroid makes it very hard to appreciate the posterior capsule. It’s already hard enough to see. But now it’s very hard to see. Again, I want to hold the injector vertically. See how vertical it is? Then you can just push straight down. You twist it in. As soon as it’s in, you can flatten it out a little bit. And then inject the lens. You can use anything. But again, we want to rotate this in. I like the haptics a little zonule. It prevents or reduces negative dysphotopsias for the patient. So again, we want to go in our little paracentesis here. We want to remove that viscoelastic. Which you can easily do now. For this case, again, we want to first hydrate the paracentesis we created. See how tangential I’m doing my wound hydration? Have it pointing directly into the stroma. You get much better hydration. And now we’re gonna check our wound. Again, remember, we don’t want the needle ever pointing at the eyeball. Line it up like this. Inject below. Thank you.

3D Version

November 21, 2019

Last Updated: October 31, 2022

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