The objective of this lecture is to familiarize and learn to overcome complications during phacoemulsification. Dr. Haldipurkar also speaks about how to minimize the damage to the rest of the eye and when to call for expert opinion or vitreo-retinal intervention.

Lecture location: on-board the Orbis Flying Eye Hospital in Chittagong, Bangladesh

Lecturer: Dr. Suhas Haldipurkar, Laxmi Eye Institute, Mumbai, India

Transcript

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Dr. Suhas Haldipurkar: Good morning. Let’s look at what causes complications. How can you alleviate the complication so that your phaco route becomes clear. The best part of phaco is that phaco has got clear-cut seven steps. The first step, obviously, is selecting the right patient and assessing them. Because you have to know what kind of cataract, what kind of personality, what kind of diseases that come from so you know how the cataract is going to behave.
So much so today that when you see a patient who is more than 60, 65 years old, you have to take a history of, do you have any difficulty in urinating? Especially if he is male. If he has, you’ll naturally ask him, do you take any type of medications for that problem? Because with the usage of UroMAXX is being so good that when some patient has prosthetic problems and difficulty urinating and he’s put on UroMAXX and tamsulosin isn’t, they do very well, and they don’t want to be away from it.
In spite of urologists knowing that this can — oh, I’m so sorry. I’m so sorry. So, that means last fives were all clean slate. Or did you hear something? It’s too hard, you see, to hold it level. Yeah.
So, because that drug is so good, so a urologist doesn’t want to get rid of it. And if that patient is on that, and you’re not aware that patient is on UroMAXX, and unfortunately, he is one — but not everyone on UroMAXX will be a floppy iris. Some of them will have. In fact, they say it’s all of them. Like, someone was on UroMAXX, they’ll stop it eight months back, they’ll still get that. Someone who is on it right now and still may not get it. You want to say something? No.
So, what — if the patient does UroMAXX, you stop the tablet. If that patient’s pupil doesn’t dilate, and there’s no obvious reason, tell me one obvious reason for a pupil not dilating in an adult? Anyone? Diabetes. Good. What else? Anybody else? Residents. Pupil not dilating well in an adult.
Yes. That’s a secondary reason. Huh? Come again?
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>> One at a time. Yeah. That’s also used. Anything else? Huh? That’s too far away. Huh? Okay. Yeah. So — and sometimes you check for a reason and you don’t find a reason. And then you look into this history. There is a history, there is no history. But just — it’s safer — unless atropine is contraindicated to have the patient on atropine eye drops three days before. Sometimes you’re worried. Atropine may not give you full dilation. It doesn’t really matter. It’s always better to have a semi-dilating pupil than a pupil which dilates well and halfway comes down.
Now, with atropine, I will be talking about small pupil management. I will be talking — it’s an absolutely, you know, a proper way in which a known floppy iris can be managed. Now, let’s keep that aside and let’s go to the topic proper. And those are the reasons why I thought it’s better that we have some idea of complications before we — as a first stop.
So, all these talks like you experienced yesterday are going to come with objectives. Now, the objective is going to be to familiarize and learn to overcome complications with minimal damage to the rest of the eye and to know when to call for expert opinion or VR intervention.
Now, if you are fortunate enough to have some amount of vitreoretinal knowledge, it help use. If you are working in an institute where you have a VR backup, it helps you. You know, it helps you to a certain extent. Even last week I had a patient who, for unknown reasons — you know that patient had intimate contact with very high pressure and absolutely flat AC. So, I told my surgeon, I said — I mean, in the past I have done that. Since he was there in the next year, I told him, do you mind doing posterior sclerotomy and reduce some vitreous so that the eye will become soft? And he promptly did that.
But in an intimas eye, the lens is so tense, that when he went back to do it, he broadly opened up the posterior capsule. And here, the eye was sore, the moment I started and did the rhexis and started doing phaco, the whole nucleus fell in. So, nucleus drop is one dreaded complication that can occur to anybody at any stage. Now, in this patient, I didn’t have to talk a word with the patient. I just had to shift him — because we have those tables that have Vs. I shifted him into the next theater. He carried on with the work. He finished. The patient was wheeled back. I put the lens. It just said the surgeon would have taken him ten minutes, took him 35 minutes. But I didn’t have to give him an explanation. The most I had to tell him, he was in for some posterior capsular problems, and I had to have the posterior surgeon intervene.
Remember one thing. If you have complications, always, always mention it. For him to listen from surgeon’s mouth on the same day is 100 times better than your competitor telling him. And then he feels the doctor was hiding something from me. We, as beginners, we feel, oh, my god, if I say that, it’ll affect my reputation. But these are short-term worries. In the long-term, it helps you. It always helps. It pays if you are absolutely true to your patient.
Now, complications. Complications proper. Now, I was talking about five to seven steps. Right? Now, they’re absolutely clear-cut steps. The surgical steps start with tunnel cut section, obviously. Then next is rhexis. Next is hydrodissection. Next is nucleus management. Then is cortical cleanup, and the lensing foundation. Now, you’re going to agree with me, each step has an effect on the next one. Yeah?
So, spend all your time on the first step. So then, if I know I can do a good tunnel, and if I quickly do it, there are possibilities it may be big, it may be small, it may be long, it may be short. And all of them can cause you problems. Yeah? All of them can cause you problems. So, we know that it has to be around 1.8 to 2 millimeter. If it’s longer, then sometimes the external repairs, sometimes you get an or locking. Sometimes it comes into the cornea and your visibility is disturbed. So, there are a lot of these things.
So, each complication, like I said, is potentially dangerous for the health of the eye and can have cascading effects. Now, when I say “Potentially dangerous,” can you tell me, what do you mean by “potentially dangerous”? Yeah, yeah. All right. Anyone else want to say? Potentially dangerous. One step. If there’s a complication, it becomes potentially dangerous to the health. When you say that, what exactly do you mean?
In an eye, for under phaco, what can be a potential danger? Obviously — come again? No, no, no. That is — the potentially dangerous thing is hurting the endothelium. Yes. Hurting the endothelium. Yeah? Hurting the endothelium is most potential. Number two, the PC can rupture and it can go. Number three, anything, iris can tear. You can get dialysis, all those things.
So, the complications can be classified into various things. They could be wound-related. They could be rhexis-related. They could be hydrated section-related. They could be nucleus related. Each step will have related complications.
Let’s take — now you participate in telling me. We’ll start with Tamina. Short wound. What can short wound cause? These are wound-related complications. Each of you remember one complication related to a particular step. Anybody can raise a hand and say it with regards to this, this can happen. With regards to wound, this can happen. Short wound. What would short wound do?
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>> Yes. Short wound is —
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>> No, no. What — if you have a short wound, what exactly happens? Huh? Iris spread. What can iris lead to? In addition to the iris, it gives you small pupil. Shaloid. Repeated Shaloid, yeah? Once you start getting a small pupil, that’s the end of the surgery for the novice, because you’re not adept enough to do phaco on a small pupil.
Long wound. Just now we spoke.
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>> Yes. Manipulation. Yes. That means manipulating the figure. Then you can have overlocking. Then you can have — see the manipulation itself decides most of the other good things. Then a tight wound. One complication of tight wound?
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>> Wound burn. What causes wound burn?
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>> Why power causes wound burn? Why high power causes wound burn?
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>> So, with — we know, when you say high power, you say you’re 100% power. Right? But today we have something called cold phaco. You heard of cold phaco? Cold phaco means what? Can anybody tell me, what is cold phaco? You’ve not heard of cold phaco?
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>> Yes. Cold phaco means, in short it is — the fluid. You play with the fluid. See, in phaco, what happens, phaco of two types. One is a longitudinal, traditional longitudinal [inaudible], and the other one is torsional. In longitudinal, you have something called continuous phaco. There the needle is all the time vibrating. Then you have Sunalp phaco, what it vibrates 50% of the times. And 50% of the times it’s off.
So, it gets 50% of the time to cool down. Right? Now, when you change this 50% to 40% or 30%, you are changing it — huh?
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>> So, when you change its ratio, you give more time for it to get cool. So, let’s say you are at continuous hold and use it for one minute. And then you keep it on pulse mode and use it for one minute, you are using 50% less energy. Then you keep it on micro-pulses at 25% on and 75% off. In one minute, only 15 seconds it will be on. So, that way the needle can be avoided from getting heated up. See, what happens in phaco, because of thermal energy and rotational energy, a lot of heat is generated. And that’s the reason you have the tip, which is bathing in fluid.
Now, if the fluid is all the time there, and cooling the tip, the tip will not heat it up. So, when you get a wound burn, what exactly happens is that a tight wound will prevent the fluid from going in. Or fluid from coming out. And that is how the tip gets heated up. The tip — otherwise it will get heated up, but it is cooled by the fluid. And here there is no fluid because the wound is tight and the sleeve is malleable. Right.
Then loose wound. Now, tell me, a loose wound. Why it is a complication?
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>> Loose wound. Yeah?
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>> No, no, no. Inflection is later. At the time of surgery.
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>> Huh?
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>> Yeah. So, if you have a loose wound, you have leakage. How do you counter that? If you started your surgery. You realize that you have leakage. What do you do to —
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>> All right. So, you add to the fluid. That means you use an AC maintainer. Simpler than that. Huh? Stitch when you have too big a leak. Lesson in that. That is where you need to know your fluidics. In phaco fluidics, there are four — four components. Can you tell me the components? Number one, irrigation. Irrigation, aspiration — aspiration fluoride, vacuum, or — see, the four are — vacuum, aspiration fluoride, fourth is [inaudible]. All right? Fourth. And there’s actually a fifth one which comes into play which many people do not realize and that is? The posterior with disk pressure. Now, the importance of that you come to know when you operate on a vitrectomized eye and then you open it in a normal light.
When you open it in a vitrectomized eye, there is no pressure from behind. So, the whole game is different. If you operate on a normal eye, vitreous is giving that much of burst. You know, it totally changes the dynamics. So as far as that is concerned. Then, when you have a loose wound, if you raise the bottle, more and more fluid will come in. So it will counter the amount of leakage. If it is still not enough, you will decrease the fluoride. Aspiration fluid. And it will — — the eye. So, if you reduce the aspiration fluoride, that shallowing will become less. The importance of this is, when you’re operating on a myo, the moment you put a phaco in, the AC becomes deep, right? Why AC becomes deep in a myo?
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>> So?
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>> Because pressure is low, sclera visibility is less. What else? In a high myo, the zonals are also weak. The eyeball is big. The bag is big. There?
tried to reduce the aspiration, increase the aspiration. You — yeah? Think about the high and low. Increase the aspiration fluid so the AC becomes shallower. Or you reduce the vacuum also. So, here you exactly do the opposite.
The centered rhexis. Right? Can someone tell me — tell me you can tell me, small rhexis. What can be the problem of a small rhexis? You have a choice. You can tell me about a small rhexis or a large rhexis. And then the opposite. You will say about large rhexis or a small rhexis. One of you will be ready with the rhexis. Either small or big. You can say either.
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>> Small rhexis. All right. In SICS. You do small or big? In SICS, do you make a small rhexis or a big rhexis? Big. Why?
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>> You want a whole new place to come out. Easily. So, exactly opposite reason you do small. Not very small. Smaller. You don’t want the nucleus to come out. Why don’t you want the nucleus to come out? Because when you’re doing phaco, a rhexis works like a current. We don’t realize that. Now, imagine when the phaco was started by Charles Kelman in ’67. And then by ’71, some of the American surgeons did pick it up. And I call them the true inventors, or pioneers, of phaco. Originally the inventer is Kelman. But these people were daring enough to do it. Imagine the time when the rhexis concept was not there. When there was no viscoelastic. There was no linearity of phaco. When there was no linearity of phaco.
It’s all or none. Cut or no cut. Do you understand? That means there’s a sure recipe for endothelial decompensation. In such situations, they dared to do it. Yeah? But all the time the rhexis came. All the time the viscoelastics came. And today you all are working on a — you know, it’s called a cake walk. It’s so simple to do. It’s so simple to do. So, when you have a smaller rhexis, it kind of prevents the nucleus coming forward. If the nucleus comes into the AC, it will hit that endothelium, which you don’t want. But, if it’s too small, you can manually go inside there. Because most of the phaco we try to do within the bag. In the bag phaco. Why do you want to do in the bag phaco? Because you want to stay away from the endothelium. Why do you want to stay away from the endothelium? During phaco, that’s the most major thing you want to prevent getting damaged, yeah?
Then we go to big rhexis. Big rhexis. It’s simple. Exactly opposite. The moment of big rhexis, it keeps on coming forward, and then you lose that and honestly having to do phaco in the interior is part of the viscoelastic, is a disaster as well as the endothelium is concerned. Yeah? Incomplete rhexis, same reason. Decentered rhexis is also not good because later on when you want to put your lens in, the lens also tends to get decentered and there are so many issues with that.
Now, let’s look at how do I — now, this is a very simple, very straightforward case. And imagine what happens. Now, this is a forceps column up. Look at that. Now, this case is done at a topical. I’ll go back on this. Absolutely straightforward. Patient has been told to keep the eye steady. And a slight movement. Now, what happened is, the tear has gone here. So, now it’s totally different way you have to do it. What I do is, I use the forceps and complete it. Now, it’s become a small decentered rhexis.
But I don’t stop there. Because I can’t do phaco within this much. So I went from here with the microscissors and made a small nick. And I’m converting that into a circular one. And now I told her, please, for heaven’s sake, don’t move your eye. Sometimes if the patient is alert, they don’t follow you. You can’t really soft pedal — I say — no. Sometimes you’re literally in a — will you please shut up? You know? You know, I love that. But you’re doing it with love. So, it doesn’t really hurt your conscience. This, all of us know.
What is it called?
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>> Yeah. Argentinian sign. Why is it called Argentinian sign?
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>> Their flag looks something like that. You know, view strips and circular with their flag. And when you want to do a staining, first it is always better that you inject air. Now, my practice is, I tried to aspirate the liquid — the liquefied portion. But in spite of that, and then what I do is I inject viscoelastic to flatten. Now, this well tell you that it is slightly curved. That means they are still not — I unnecessarily did it a little too in a hurry. So, what I do next is elevate — once it has gone in, you can’t retrieve it. You go and make a small cut.
And then, of course — now, this is one thing you should remember if you’re using a forceps. Sometimes it overshoots. So, you have to use another instrument. Remember one thing, if you want to be a good phaco surgeon, two hands are essential. If you ask me to do a rhexis with my left hasn’t, I won’t be able to do it.
All of us have to be ambidextrous. So, how do you become ambidextrous? You will say, I will write with my left hand. It doesn’t help much. You will say, I’ll do my, you know, brush my teeth. It may help you a little. If you tell me, I’ll paint with my left hand, that will help you more. You know, some of the strokes that we use while painting, they are the ones that you want. That means, in short, when you want to do phaco, your hands have to be absolutely equally efficient in both hands. And more important, your wrist has to be loose.
Very often when a person learns his phaco for the first time, his wrists are tight. Many unconsciously, they’re very tight. The moment you hold your instrument tight, it cannot move. Meaning I tell them to, you know, it has to be so much free. And you cannot become free here unless you get a command from here, you know? What happens if you said a command — so, from here to your other hand, it becomes tight. Your command to your hand should be, let loose. And the hand, because there’s nothing that can be done. It’s all very capable. To do delicate work, you have to be absolutely [inaudible]. To do [inaudible], there has to come first, solid pull from up. Meaning forceful relaxation. Also, the relaxation of the hands.
If you want to do an efficient work, then your fingers — your wrist has to be free. And then you can do most of this, you know, and you think it’s easy.
Now, this is a case — it’s a very interesting case. A patient comes with chronic uveitis. And what happens in chronic uveitis? If it’s an early one, or if it’s a minimal one, you get posterior synechia. You get posterior synechia. But if it’s been a very bad, very chronic uveitis case, the entire iris gets plastered on the endo capsule. And sometimes even your visco dissection may not separate it.
One slip that I did — normally I expect the evidence to be very minimal. So I find a gap, put my spatula, and just sweep it. That spatula will separate all of the regions that you have there. Unfortunately in this case, the areas were so tight that when I start, I immediately realized that the capsule has slightly torn. And once you have a capsule that tears — so far were good. And then I realized that not — everything is not okay. Especially here. Here, all right. Here I see. But then, if you are not stained, you really can’t make up.
So, halfway through the surgery, I stain it. Why do I stain it? Why do I stain it? You stain a capsule so that you can see it better. Here. If you don’t have a globe, because it’s a white cataract, and you’re not stained, then you’re in for a disaster. And after I stain it, I use a cutter. Can someone tell me, why did I use cutters so early in this case?
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>> Yes.
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>> Yes.
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>> Hold it close.
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>> You can start from the beginning.
>> During the — the separation of the iris, you can use the endocapsule.
>> Yes.
>> So you can make —
>> Yes.
>> To make it — [ Away from microphone ] — that’s why you use it.
>> You use it the cutter so that all the tags can be cut. If the tags remain, they can get pulled into your phaco tip later. So, you cut those tags and try to give it some kind of a semblance of a circularity. Because in an open gap, to make a circular gap is difficult. Good.
Now, you also see this. Yeah? And then, I also use two wide hooks to stretch it. It’s called stretch pupilloplasty. I was talking about this iris knuckle. I can easily push it back. But the experience tells you that the more you cut, the more you push, it’s going to come out. So, at the first instance, I made a small iridectomy. I would have preferred to make the iridectomy as earlier as possible, but in this case, it was difficult. But still, it is better to have a little central iridectomy than not to do it. If I didn’t do it, then half my surgery would be obstructed.
And now that I see the capsule better, now the advantage I had in this case was that the nucleus was not very hard. And when the nucleus is not hard, the phaco doesn’t use much energy. And here, because the pupil is small, very often the cortex can stay under the iris and you may not see it. So, it’s always better to use a second instrument or your irrigator to just lift it up to see the cortex to get it out.
Then I put a lens — you just now watched me use a lens. Now, that was a three-piece lens, yeah? Did you notice? The lens I used was three-piece. Can the resident tell me what’s the basic difference between a three-piece and a single-piece lens? Structurally we know. Single piece and three-piece. Or multi-piece. But why did I use a three-piece — or a multi-piece — instead is of single piece. Single piece is something that we always use. What you use a three-piece to counter the reaction? Is that the reason? What has less angulation. Three-piece lens has angulation. And the reason for angulation is, you know? It has to stay in the bag, ideally. Or, wherever it stays, not necessarily in the bag, wherever it stays, because of the poor angulation, the optics should push back. So that there’s no optic capture. The iris is not closer to the lens because of that angulation.
And if you put it in the bag, or otherwise, because it is posteriorly pressed, it presses against the posterior capsule. Single piece have no angulation. Single piece is meant for in the bag. Single piece is never put in the cell case because the haptics are too thick and they can cause a lot of reaction if they have to be put in the cell case. Number three, single piece is a smaller lens. In the cell case, the lens can shift. And even if I see the bag and put it, once the rhexis is open, once the capsular bag is open, you can be rest assured that even if you have a lens in the bag today, tomorrow it’s going to rotate and come into the cell case. So, it’s safer to put a three-piece. Once you put a three-piece, you always have the worry that haptics will get stuck in the peripheral iris, so you [inaudible] so the haptics are gone into the cell case properly. Now you have a choice to either suture that by using the ring pupilloplasty to hold, or you may just leave it.
In this case I decided to just let it pass. Well, with regards to iris hooks. Well, iris hooks are used to dilate the pupil. You dilate the pupil when it’s to the possible to carry on with the phaco. Or you want to do a rhexis, and in a small pupil, you cannot. Or, you want to put a toric lens. Unless the pupil is well-dilated, you cannot see the exact angle of placement. But in this case, doing phaco was easy because I was doing central phaco, and the nucleus was soft.
Now, if I had to put an iris hook, I could have easily made it simpler. But what is of more benefit of putting an iris hook, in this case? Yes. I exactly get your point. Iris hook makes phaco much simpler. Yes. Yes. I fully agree with you. At every possibility that you get, and when you feel that your phaco is going to be a troublesome thing or a difficult thing, it is made simpler by using iris hooks.
Well, well, every step when you learn for the first time is difficult. Because — but iris hook is not so difficult. It will be difficult if the AC is extremely shallow. Here, either talk about it right at the beginning or after this?
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>> No, no. In that case, before you put iris hook, you have to — in fact, in this case, I was planning to use a ring also. But to use it — to use the ring or a hook, you have to first separate the iris from the capsule. No. Because the iris was stuck on the posterior capsule.
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>> But — but then by that time the capsule had all torn. And then — then I used vitrectomy to cut over the capsular tags. So, then, at that stage, iris hooks had lesser value than when you use it as an original case to open up. Very often, you want to last stage a phaco, after the completion of phaco, also we use iris hooks — I’ll show you another case — where you have a problem and you want to get into the bag. You can’t see the bag. You are about to put a lens. At the time you can also use an iris hook. Iris hook can be used at various stages. I’ll just show you. But it’s a good question. Now, this is a very important film.
Now, you only wish that it doesn’t occur to anybody. Watch it carefully. I’m sure you see it. Can you guess what it is?
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>> Huh? It’s one of those 1,000 cases that you get if you’re unfortunate enough. The case looked absolutely normal. There was nothing that suspected — that I could suspect. Let’s see it again. See, if you see before, there’s no reason why that posterior capsule should give way. Yes, sir?
>> We have two questions from our global audience.
>> Yes.
>> The question is, should we start —
>> The burst typically has come because burst isn’t one burst. You keep it at a higher set, and then when you want to get into the nucleus to chop it, that’s when you go into burst.
>> Right.
>> But in sculpting, what you want is an absolute smooth flow through that groove. And to make it, in fact you sat down and bring down your vacuum and keep your moderate forward, but always in pulse mode and never in the burst mode. If you have a pupil that is small to begin with, we know there are various ways of innovation we can manage it. One, a known small pupil can always be done the way I said. You can start with atropine pre-op. Before the surgery, you can always use a combination of Pontocaine, or Xylocaine with tropical — plus and Adenoline to be mixed together and use it to prepare a drop. But that’s not my preferred technique.
What I use is I use topical C plus three times. Use atropine before. And as soon as I open the eye, I’ll use a visco adaptive to open up the pupil. If that is enough, then I’m fine with that. Otherwise I’ll go through two side pores, use two Y-hooks and do stretch pupilloplasty, and that will give me a sufficiently-sized pupil. If that doesn’t work for me, I will use one of those halogens or a VX ring and I may use — if I’m not comfortable with that, and if I’m very familiar with using hooks, I’ll use four iris hooks to open up the back.
Now, the question is, what happens when halfway through the surgery you get the pupil down? If that happens, very often one in 1,000 dilution of intracameral epidemeologicity trait I’ll use. That normally gives you a nice opening. If it doesn’t give you, I have no hesitation to stain the bag if at all, you know, rhexis margin cannot be made out. And then I’ll use hooks or a ring. But the hooks or ring can be used at any stage of the surgery. Ring preferably at the beginning of surgery. But after putting the scleritic and separating the iris from underneath, you can use hooks segmentally, or in all four quadrants to open up the bag to your desired size to carry on with.
So, it’s available as intracameral atropine. So, that is what we normally prefer to use. All right. So, now you saw this. In this particular case, as I progress, I know that the capsule has given way. Ideally what I will — what I should be doing — is stop here. Stop at this stage. Inject dispersive, a scelastic, to block the vitreous and give a buffer or a cushion for the nucleus to stay. But it was not to be. And the nucleus, two fragments, fell in. And then the case had to be shifted. But then these nuclear fragments were softened. So what I did was I completed the cortical wash. Implanted the lens in the cell case and shifted them, and called the VR surgeon immediately and he took over. Because the nuclear fragments were soft. And it was easily removable with fragmatome or a cutter. So, in this case, when you have a rhexis intact, and posterior capsule absent, the choice — the ideal choice for lens is three-piece. Which is put and if possible, you also do an optic capture like you have done an optic capture here. You do optic capture because you want the optics to be well-centered. And to do that, you have to have the rhexis, which is circular and centered.
And the reason you do optic capture is to ensure that even if the lens tends to decenter a bit, at least the optic is in the center and unless the lens is in the center, the visual rehabilitation may not be as good.
Now, nucleus–related, there can be so many nucleus-related complications. If it’s too soft or too hard, a nucleus, it can cause problems. Too hard, or too big a nucleus. Especially when you have long-had standing, you know, hard brown leathery cutters. They are so big. They are occupying the entire space within the capsular bag. There’s hardly any capsular or cortical cushion. Epinucleus cushion. And they’ll definitely cause an issue. And because they are long-standing, the capsular bag is also stretched. So, especially when you reach the last fragment, there’s always a tendency for the capsule, you know, to get aspirated into the phaco tip. You have problems with leathery, hypermature, intumescent cataract because it’s difficult to crack them. You tend to use a lot of energy — use a lot of energy. And sometimes phaco tips getting blocked with viscoelastic will get you raising the feed and wound burns. And with, of course, unstable bag or if the pupil starts coming down as it was very often with a lot of turbulence in the anterior chamber. Or your chopper touching the iris. The iris gets irritated. The pupil comes down. And then it further complicates the matter. So, it’s always better to remember your phaco dynamics. Play with your fluid, fluid level, so that you’re safe within the chamber and proceed.
Now, there’s something called safe phaco and unsafe phaco. Now, this is a classic example of unsafe phaco. A resident, what he does, he’s not fully aware that what can be the consequence? And this is a typical consequence. And I’ll repeat it. Everyone has to see how this happens. See, there’s no reason, you know, when you see an iris so close — this is very typical. And it doesn’t stop there. It is not the iris alone which is cut.
The rhexis under it is also cut. So, sometimes you can get the rhexis there. Sometimes you can get posterior capsular there. But it becomes an eventful surgery. The whole idea in phaco is to have uneventful surgery. And this — here you are working at very high vacuum. So, there’s a good possibility that nucleus is managed well after the surgery — after this complication — but the damage is already done. So, you can see the damage after the nucleus has come off.
You can see those folds. Now, those folds are sinister. They tell you that there’s some tear there. Remember one thing. Let’s say you have set your phaco. Vacuum is set at 400. Now, 400, for a beginner, is very high. So, you, when you start your phaco, the safe parameters would be you would work at 300 vacuum. You would work at 20, 25 fluid. Because at 25, nothing can happen suddenly. The whole process is slow. And the power will depend only on the hardness of the nucleus. The harder the nucleus, if you think your power cannot manage it, you may raise it. But, again, the power will change from machine to machine. Like, the Centurion that I’m using today would probably work at a lower power because it’s more efficient and we’re using torsional technology. And you know torsional technology, unlike traditional longitudinal phaco, even if we use it more, it doesn’t get heated up, so it doesn’t really matter. All of us, when we start, you all, you are working at bigger institutes. You all would start with a more compact and a smaller machine which are all longitudinal phaco port. Even the high-ended signature, or some of the other companies like Berkeley, they all are working on longitudinal. Longitudinal was equally efficient. But today we are going to work on centurion. Centurion works on torsional technology. Torsional technology, in simple words, is, unlike longitudinal traditional, where the phaco tip moves longitudinally, here the needle moves as a rotation — as a, you know, side-to-side rotation movement. But the side-to-side movement has its own problem. Especially when you have a hard cataract, the tip gets clogged.
And so, as to avoid it, they always added longitudinal phaco in the form of IP. Intelligent phaco. That mean when is your phaco tip is about to get blocked, that mean when is your vacuum reaches a pre-set level, about 90% of pre-set level is reached, suddenly the traditional phaco is started and it kind of pushes away. Because traditional phaco, the hallmark is, because of its hammer effect and its forward movement, it pushes the fragments of it, vacuum and fluoride, pull it towards. So, there is an attraction and repulsion. And you have to create a balance between them to get a good — within the anterior chamber to do a good, smooth, uneventful phaco.
So, coming back to this case, I have set, at this stage, very high vacuum so that I get good purchase on the nuclear fragment and the sense of phaco is your phaco tips should always be occluded. If your tip is occluded, then the phaco works more efficiently. Now, like I told you, these are the sinister signs of capsular rupture.
So, we come to — furthermore, more common phaco complications in which posterior capsular rupture. Remember one thing, all of us will get busier and we’ll continue to get busier because very rarely you’re supercautious and you work on low parameters. You can get into PC ruptures. And one should all the time try and ensure you don’t get PCR. Because otherwise PCR is very common. And among the newcomers, getting posterior capsular rupture is very common. I’ll show you what can cause posterior capsular rupture is. Then you can get nucleus dislocation. We saw one. You can get intraocular trauma. We saw that. And very often if the nucleus is very hard, or there’s a huge rent or the zonals have torn, you may not be able to complete and you have to convert it.
Now, this is a classic case of what can happen if your parameters were not set properly. Now, look at that. It’s a very soft cataract. There is no reason for anything to happen. Soft, white cataract. Now, we just observe that, again. In slow motion. You know? Suddenly something gives way. And you have to notice it immediately. And now you can see this here. So, even before your phaco comes out, you inject viscoelastic from the side port.
There’s a clear-cut punched out circular opening. And before your phaco tip comes out, you take your second instrument out and inject viscoelastic. Now, viscoelastics are of two types, cohesive and dispersive. Now, both of them have two different functions. Cohesive is more for creating a space, separations, and when you want to do your rhexis, you want a stable, well-formed chamber. Your cohesive helps you. If you want to disperse something, you want to push back something, you want something to stay there when you’re doing your phaco, that is when you have to use a dispersive.
Now, this is an occasion for you to use dispersive. And dispersive viscoelastics are chondroitin and sulfate or there is another medium called visco adoptive which is sodium Hydronic in a concentrated form. So sodium Hydronic with Abbott, or Johnson & Johnson now, is available as healon, healon V, and healon V. Healon V is a viscoelastic which has a function similar to sodium chondroitin sulfate, which is Visco. Now, at this stage, through the side port, I inject dispersive viscoelastic. Why do you inject? Because you want to push back the vitreous.
Unless you push back the vitreous, you cannot complete your phaco, because otherwise that just gets mixed up. And once it gets into your phaco tip, you are in for a mess. Watch carefully. See, this you are able to aspirate because — and now the reason for doing this is that you want to do vitrectomy and try and convert this air into a hole. Circular hole. Can anyone tell me why would you like to convert your posterior capsular rupture into a hole? Can anyone tell me?
More valid reason. That you can do by doing straight vitrectomy through it. But after doing vitrectomy, you would like to look at the tag and convert it into a hole. Stable. The tear will not extend. What is a — yes. Huh? If you prevent the extension, but more importantly, because you want to put a lens in the bag. Meaning, when you do phaco, your attempts should always be to put the lens in the bag. Because the proper place for a lens is in the bag.
So, you don’t to want miss on that. So, how will you do it? So, the principle here you should understand is that if there is vitreous mixed up into the viscoelastic, and when you are holding your capsular tag, you cannot tear it. So, first do vitrectomy, clear the vitreous from behind the capsule. Inject viscoelastic to push back the vitreous so there is viscoelastic behind the capsule, in front of the capsule so you have a clear edge which you can, you know, hold it with the forceps and convert it into a tear. And remember, it is much easier to do a posterior capsular rhexis than interior capsular rhexis because posterior capsule is very thin. But then it becomes difficult with this vitreous.
So, we’ll see it once uninterrupted and then go to the next — it’s not a long film. Just watch that. It suddenly gives. And the reason for that is, probably the settings were for a hard cataract. And this was a soft cataract. Presuming I had set it — see, now, those are old videos. Now, look at the tip. Now, that’s a classic standard tip. Standard tip was used in those days for 2.8 incision. Even if you use 2.8 incision, we use micro flow tips. We only changed the sleeve. In those days the sleeves were standard with the tip was very big. When the tip is big, what happens is, you have to set your parameters very low. Otherwise suddenly fluid gushes in.
Maybe this — it may be a problem with the film. Let’s see. So, in this case, the power was set too high. Vacuum was probably meant for a hard cataract. It does not reset. So, the lesson that I learned from this is, all of us before we start looking at the hardness of the nucleus, looking at what you plan to do, you have to reset your parameters. And resetting parameters and customize them for cases are extremely important. Otherwise we end up with problems. And then what I do is, that’s a — hydrophilic lens that I used to use in those days. Since I could make a circular opening, it was easy to put the lens into the bag and, like I said, putting the lens in the bag has all the advantages.
Now, let’s see about this. Now, watch this case. Now, this is also a very important case. Again, a resident doing it in a hurry. Little recklessly. What he does, you know, when you have such — look at that. Now, this is very common. This is extremely common. And there’s no business why it should occur. And it will occur if you’re not careful. Now, what happened is, there was a last piece left. When the last piece is left, you have to reset your parameters and ensure that your phaco tip is never left unexposed. When you are close to the PC, if your phaco is on and you’re close to it, you can’t expect anything other than this. But the question is, how do you manage it?
Now, the piece is not very soft. The hole, luckily, is not very big. The vitreous has come. You have already injected viscoelastic to push it back. And you don’t want vitreous to get mixed up with the cortex. And because the dispersive, the viscoelastic is pushed back, your vitreous is not present. So your IA can be done comfortably. But you’re still left with the fragment. And believe me, with all the experience, if you are to get rid of this fragment by phaco, you are bound to disturb the vitreous.
So, I think of something else. I mean, this is not difficult. Even a beginner can do it. But at least for a beginner, it gives you an idea of what are the possibilities. And in this case, I wanted to show because we were discussing about rhexis, I mean, iris hooks. What did I do now?
>> [ Away from microphone ]
>> Now, triamcinolone is one thing that can identify the vitreous. So, once — once the triamcinolone is put, you use your cutter and you be careful at that rent. Because you want to keep that rent circumcised and as small as possible. Because if possible, you want to put the lens in the back. So, as god help you, luckily this is a punched out opening again. If it’s a small circular punched out opening, you can go under. Ideally — ideally — you should go past plana, do vitrectomy, take back the vitreous from behind. But if you are not, you know, very available for that, this is what we normally do.
Now, having ensured that there’s no vitreous and there’s no cortex, I think of a slight lateral pinking. I decide to put a lens into the cell case. With the fragment there. Which we call a scaffolding. And once the lens is blocking your rent, you can safely do your vitrectomy, I mean, you can basically do your phaco. And what I want to show is — not this — but, how do you go after this? This is now easy because nuclear fragments can never drop. Having done it, you can’t stop it because a single piece is never meant for cell case fixation. Never.
Sometimes you may be lucky. But it is not meant for it. Because its haptics are thick. So, I want to get the lens in the back. But what’s happening is, one haptic is somehow refusing to get in. So, at this late stage, I decide to put two hooks. Why I want to put hooks? Because I want that rhexis opening to be visible. And once you have used a hook, getting the lens into the bag is a simple job. It’s a small step that I want to do. But for that purpose, you use a hook.
Get the hook out after the purpose is done. And you have the lens comfortably sitting there. Now, the purpose of showing this is, now, these are small, small times when you should not go, now it’s too late. Can I put the rhexis — I mean, hooks. Yes. You can put it for any purpose as long as it’s solving your purpose.
So, implant-related complications. Well, there’s a big bunch of implanted-related complications that can occur. Implant can break in the wound, in the eye. Sometimes it can have cracks. Very bad cracks. And sometimes the cracks can be seen in the optic area. You probably want to change it. Sometimes because of PC rupture you have to do reverse, you know, vault. Sometimes a lens can get stuck in the wound. I mean, that’s something, you know, when you have — very often it can happen. If you use a 2.2 and try to push, half the lens is inside, half the lens is in the wound, and it’s extremely difficult. Then you have to open the wound and pull it out. But there are ways in which one can become expert. And thank you so much.

 

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December 14, 2017

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