Surgery: Phacoemulsification using Divide and Conquer Technique

Dr. Suhas Haldipurkar: Well, this patient is a 65-year-old male. Came for a right cataract. Side ports should be on either side. Not too far away from the mine incision. I prefer to do rhexis on the staining. If initially I did my rhexis with Visicort, which is a dispersive, because I wanted a little bit of the scholiastic to stay in the eye file the phaco procedure is on. But that’s the only thing that really protects me from damage to the endothelium.
The rhexis should not be too big. I would aim for 5, 5.25. And that’s the ideal size. Because you want proper adequate overlap. Not too little overlap, and not too much. If the adequate overlap doesn’t exist, there’s always a chance for the optic to slightly tilt sometimes leading to —
Now, that’s a beautiful rhexis. And I appreciate you putting back in OVD —
Yes.
How ponder do you think a hydridized section is? Do you think that’s a very important step?
Well, I would do minimal hydro. Enough for me to see the hydro vein crossing across and then just rub the nucleus. And this is kind of enough for me. Most of the peripheral regions are broken. And then I fill the eye with little viscoelastic. This time I’m using healon.
And I appreciate that you’re doing pre- phaco now, not only to remove some of the OVDs to avoid a burn, but also to clear some working space.
Yes. So, now I have cleared the endonuclear part of the loose cortex, the nucleus is cleared. And I’m ready to take on. I would prefer to do a full cordon here.
I think divide and conquer is always a safe technique.
Yes.
You can do it in every case.
Yes.
And one of the things you can help us with is, how do you gauge the depth of your trench?
Well, one thing, I purely go by the change in the color.
Yes, sir.
Keeping eyes on either side of the walls to be quite vertical and very straight. But very often if you make too wide a tunnel, at times it’s difficult to crack them. In this case it’s adequately deep enough and I have seen the beginning of change of color. And after the first round of trench is complete, I decide if I want to go through another round or continue with cracking.
Now, at this stage, since the rhexis is well-centered —
Yes, sir.
I can do the pickle crisscross.
Yes.
Normally when you make your trench, the distal part really gets deeper. The proximal part needs to be treated again.
This is where your hydro really comes in. You have such good lens mobility. You’re not putting any stress on the zonules. I really appreciate your excellent hydro.
And now I come to the depth of the trench. And with the two instruments properly placed, I try and crack it. If I don’t get a proper crack, that’s an indication that I still need to go deeper. I normally strive for a clean cut which —
Yes, sir.
Sometimes you get. In this particular case I have not got it. It doesn’t really matter because the nucleus is not very hard.
Now, there’s a full crack. I know that back home what is your — do you do stop and shop or phaco chop?
I prefer to do phaco chop.
Yes, sir.
Simply it saves on the amount of energy that you’ll be using.
Yeah.
And number two, it’s also quicker, so when you use a technique which is quicker, there’s less amount of fluid that’s going through the eye.
And do you find that the first quadrant is always the most difficult? Once you get that, you have more mobility and more space?
Yes. Yes.
And I like how you bring the — a quadrant to the central safe zone where you have the most depth and you’re further away from the posterior capsule.
You always bring them in the center and use your second instrument to cut it further into another smaller pieces. Where the chop is holding back the piece. The front piece, you emulsify so you don’t have pieces floating into the chamber. And your phaco tip is not making much movement. It stays in the center all throughout. And most of the mobility is done with your second instrument.
With the last piece, do you like to sometimes go to epi-nucleus? Or at least you recommend that for starting doctors to go to epi just to protect from the bag?
No, I would keep the same set with the parameters lowered. But at this stage, sometimes when you have small chunks left, I go to epi-nucleus. Can I have epi-nucleus, please? But then it’s safer for a beginner —
Yes, sir.
Not to dabble with this. It’s safer that you go to eye and do it. Sometimes when your second sight portal is big, and your iris has a tendency of floppiness. The iris tends to come into the sight port.
And are you going to put in OVD? Or do you go straight to IA now?
I push it on just to protect the endothelium and then go with the IA.
You were talking about interoperative myosis.
Yes.
And I know during your side port you had a little bit of the iris prolapse.
Yes.
If we were having iris constriction right now, what would you be doing so that you could have good view of the case and be able to get the eye wall in.
If I can still see for the of my rhexis, I would not bother to dilate it, because most of my cortical wash is already done.
Yes, sir.
So, I just have to get the lens into the back. This is a time when ID use my visco to do Viscoelastic. But very often if I still had to do a bit of cortical wash left, or if I’m planning to put a toric lens, then this is the time I use intracameral epitrate. And try and dilate it and it’s very effective in dilating. But very often I’ll see some of these pupils, which are constricted, when you go with your irrigation, you know, the pressure of fluid is sometimes slightly dilated. Enough to carry on with the function. But the problem comes when you put a toric and the pupil has really come down, because you want to see those marks on the toric. Sometimes I may have used one of the devices if it’s already important.
Right. So, you just got to my point about why this step is sometimes critically important with small pupil is during a toric case. And especially with your toric lenses, it’s important to remove the OVD from behind the lens.
Yes.
How do you do that? What technique do you do? Do you rock and roll? What do you do to remove OVD from behind the lens?
First, I remove it from the interior.
Yes, sir.
And then I go with the single IA, the suggested irrigation.
Okay.
And that I’ll demonstrate just now. Now, it’s not difficult there because the pupil is dilated. But still, what I do is I stop the irrigation a bit. Try and pass the lens down. And here I go under and start the irrigation. This I do as routine in all the cases because I realize that some of this coalescence still stays behind and always has to be taken out. And now most of the viscoelastic from the eye is out. And what I need to do is just hydrate the float of my wound so it gives me some amount of closure. And then go for hydration of the side ports.
realized one thing. Phaco is such that each step leads to some problem in the next. Like, in this case, to start with, my tunnel was slightly short. In this I would like to say that your side port should be as limited as possible, especially the left one. Because that’s where a lot of leakage happens that goes unnoticed.
Yes. Thank you again, sir.
Yes. Thank you so much.