Surgery: Phacoemulsification

This video demonstrates a routine phacoemulsification surgery with detailed narration for each step. The surgeon used stop and chop technique for the nuclear removal and an IOL was implanted in the bag.

Surgery Location: on-board the Orbis Flying Eye Hospital, Kingston, Jamaica
Surgeon: Dr. Sherif El-Defrawy, University of Toronto

Transcript

DR EL-DEFRAWY: So I like to use a 0.12 to start my wound. And I’m going to be making a temporal or maybe just a little bit supratemporal wound. I really like the temporal approach, and I like it for several reasons. One, this is the farthest point from the visual axis. So if you go superiorly, you are closer to the visual axis than if you go temporally. And then the other reason is that if I go temporally, then my glaucoma colleagues just love me. Because I spare all this superior conj for them. So should the patient need any glaucoma surgery in the future, you’ve got good conjunctiva available. Now, of course, with clear cornea, you still spare the conj, but here you have no problems at all for them to make their flaps and make their corneal tunnels. I like to grab where I’m gonna make my main incision. There are many ways to do this. I’m gonna just show you mine. And then I like my stab incision, my paracentesis port, about 90 degrees or 70 to 90 degrees. And I like to go pretty flat. And just at the limbus, and I’ll enter, and I’ll go straight in. I’m looking at my internal diameter right here. And gauging a diameter that’s gonna allow me passage of my cannulas comfortably. And that will be very suitable. The other thing is that I will look to markings. Because sometimes it’s very hard to know where this is. So I will look to markings on the conj. If you get a little bit of bleeding, that tells you where your site is, because sometimes it’s very hard to find. Now we’re gonna put in some VisionBlue. We’re gonna go through our stab incision here. And we’re gonna inject VisionBlue. We used to inject an air bubble because of epithelial toxicity, but we found with the small amount of Trypan blue that we’re putting in, and the quick irrigation, the epithelium tolerates this just fine. So we put in a little bit of VisionBlue. And now we’re gonna irrigate that VisionBlue out. I’m gonna prime my viscoelastic, and I’m using Viscoat here. And this is gonna give us some viscodilation and open the chamber. If there’s an air bubble, I try to get beyond it and either express it to the side port or around where my main wound is going to be. I tend to fill the chamber tight, and then I will grab onto my side port for control. So I like the 0.12s, and I’ll just use the single tooth, just inside the side port wound. I’m not grabbing endothelium. And I will score epithelium just at the limbus. And that gives me an initial placing for my keratome. A lot of these keratomes are marked, and you can see the mark on this keratome, and it shows you where you have to advance into cornea before turning the corner and entering the anterior chamber. And that gives you a biplanar effect. Now, here I could use a cystotome, but what I’m gonna do is redirect my knife, and I’m gonna enter directly into the anterior capsule. I’m gonna come back to the same plane, so I don’t extend my wound any more, and that way I don’t need a cystotome, and I’ll take the capsulorrhexis forceps. You can see this clearly. I’m just gonna inject some viscoelastic behind it, to clear it. You notice I like to grab the wound. You don’t need to grab the wound, but I do like to grab it, to give me some control over the eye. I will make my anterior capsulectomy with the cystotome, instead of my knife here, and then what you do is just go underneath the capsule, you do this with your cystotome if you’re using a cystotome. We’re gonna lift up the flap, and we’ll lift it up to about the diameter that we want, and we can start our CCC. And the key thing of the flap is grabbing about a millimeter to 2 millimeters away, keeping that fold. That fold is a critical part. And it’s that fold that gives you control, right there. And keeping that fold all the way around. And subincisionally, at about 11:00, you want to grab, and you want to take it all the way around to the other side, and often there’s an opportunity to regrab that side as well. And you can finish off your capsulorrhexis. You don’t have to take the flap out of the eye. And of course, the next step is hydrodissection. But you want to make some room in the anterior chamber before you hydrodissect. There are people that will grab or hang on to the sclera or conj here and depress the eye to force some viscoelastic out. I like to just irrigate the anterior chamber in the center of the chamber, while pressing down on the bottom lip, and you can see a little bit of that viscoelastic evacuating and giving me room in the eye to hydrodissect. I hold my cannula horizontally. I just get underneath the capsule. And then just to the pupillary edge. Once I’m at the pupillary edge, I’ll infuse, and I’ll look for the wave. And if you notice, I’m also decompressing that eye. And here it’s gonna be hard to see the wave, because of the cortical nature of this cataract. But I’m constantly decompressing, because you don’t want to create a situation of an anterior capsular block. This is where fluid gets behind the lens, pushes the lens up against the capsulorrhexis edge, and then when you infuse more fluid, you get a rupture of the posterior capsule. And here we’re infusing this other side. And now we’re gonna see if this lens rotates. And I always tell my trainees: Hold the lens. Hold the cannula like a pencil. And start from the left and try to rotate to the right. If that doesn’t work, go the other way. And we have some rotation there. I don’t know if you can appreciate that. But I can see rotation. If there wasn’t, I would just continue to hydrodissect until I got rotation. And so nuclear disassembly now depends on the type of cataract. And here I have a Kelman tip, and it’s got a 45-degree angle, and I like to start in prephaco. Prephaco gives me a vacuum of 400, an aspiration flow of 30, but I have no ultrasound power. How do you enter? I like to enter on the side. Some people will invert the phaco tip to enter, and then I rotate once I get inside. I also like to hang on to the side port, again. This side port — it will not affect the way this side port heals. What are the downsides of grabbing the side port? Well, you can get some fluid egress and control, loss of control of the anterior chamber. But I don’t find that to be the case. So now in prephaco, I’m just gonna aspirate some of this cortex. I’m cautious about approaching the capsular border. And I’m just gonna aspirate a ways, and I’m gonna introduce the chopper here. If you want, you can try to rotate a bit as well, and get some of this. So now we’re ready to begin disassembling the nucleus. What I’m gonna do for this, this case, is a stop and chop, to demonstrate that technique. So I’m gonna groove here. I’m gonna chop and then fracture the lens into two halves. And then I will chop the two halves, to disassemble and remove. So I’m in sculpt now. And I’m gonna start at one end of the capsulorrhexis. I’m gonna go straight across to the other end of the capsulorrhexis. I’m gonna widen it just a little bit. Remember that the lens is shaped like a bowl. And so we’ve got to go down into the bowl and then come up the other wall of the bowl. And I’m looking down at the base of that lens. To see my depth. And I can actually see some of the retinal reflection coming through. And that gives me a little gauge on how deep I am. Now, I have pretty reasonable depth here. I’m gonna put my phaco tip right down in the base. I’m gonna put my chopper in front of my phaco tip. And I’m gonna separate. And I should be able to tease that lens apart. Then I can use some crossed sword technique here, just to push the other half off, and we have a nice fracture of the lens into two halves. And so now I can rotate that lens. Maybe I could have hydrodissected a bit more. And now we can go to chop. And I’m gonna use a horizontal chopping technique. And so I’m going to use some vacuum, a little bit of phaco to adhere, I can hear the vacuum going up, I’m gonna slide underneath the anterior capsule, get behind it, bring the chopper in towards the phaco tip, and then separate to the side. And that gives us two quadrants there. And I like, since I’m right here, I can take this piece out, bring it up to the capsular plane. You notice, because it’s a Kelman, I’ve rotated my Kelman, so I’m not down in the bag, but I’m about at the iris plane. And I’m gonna eat that piece there. And I’m gonna continue, piece by piece, like this. I’m still in chop. And I’m not so worried about the bag coming up to my tip, because I’ve got this big cataract holding it back. And in fact, I can grab this piece and pull it into the anterior chamber. And here I’m just gonna be able to chop it in half, to have two pieces. And I can disassemble. You can see that my chamber is… I’m losing a bit of chamber maintenance, because of my chop. And I’m gonna go to quad. And now my quad is not as high a vacuum. We can adhere this. I’ll bring it up. We can chop that. And actually, it’ll actually just come. What I tell my trainees always is that here is the midline. And I don’t want them to be eating the pieces beyond the midline. And I don’t want them in the bag. I want them at the level of the capsular plane. So you can go into the bag, grab a piece, bring it up to about the midline, above the capsulorrhexis, and that’s where we should be doing our breaking up of the nuclear fragments. So now we’ve got the nucleus disassembled and removed, and we’re gonna go to cortical clean-up. So now we’re gonna go to the irrigation and aspiration. And I’m going to my cortex setting. And with my cortex setting, I have a vacuum of 500, aspiration flow of 40, so it’s high vac, high flow. And we’re gonna start the irrigation, and go into the eye. Again, I like to hold onto my side port, because it allows me maneuverability. The downside is some people say that it does some damage to the side port. I don’t see that. And some people say that you get loss of fluid from the side port and less of a chamber, and that is true, but I find that I cope well with it. Here what we’re gonna do is go underneath the capsulorrhexis, adhere some of the cortex, bring it past the capsulorrhexis, and then I’m gonna give it maximum aspiration. When you have an epinuclear plate, you want to try to bring that whole plate forward. So I’m pulling the different sides. And with a big epinuclear plate like this, if you can get underneath it, that makes a difference. And often the epinuclear setting of your phaco tip is very handy to remove that, but sometimes if you don’t know the thickness of the plate, you don’t feel so comfortable going in to pull these pieces out with the phaco tip. Now, it’s a bit of a floppy bag, but it’s gonna be fine for this lens. And so as we talked about this morning briefly, we have some lens epithelial cells here, and while they’re important for forming the seal around that bag, sometimes they can lead to capsular phimosis, and so I do a little bit of lens epithelial cell clean-up, because I know that they’re important, but I don’t want too many of them remaining. With a polish technique, I’m at a vacuum of 50 and an aspiration rate of 12, so it’s low vac, low flow. And it’s quite a safe technique. So that should be very good to put in the lens now. For lens insertion, we’re gonna use a cohesive viscoelastic that’s gonna allow easy removal. We’re aiming for plano for this woman. I like to use my 0.12s as countertraction. And I just place my 0.12s into the side port for countertraction, and then I can put this lens in. It’s a big cartridge, and that’s why it’s a tight squeeze. And we’re just on top of the capsular bag, and now I’m just inserting the lens. And I can actually see it underneath the bag. And then I’ll use the Sinskey hook to ensure that the lens is into the bag. And you always want to make sure that the haptics are off the optic. I’m gonna use the irrigation and aspiration tip to remove the viscoelastic, and again, sometimes just putting the tip in and irrigating — look at all the viscoelastic starting to come out just from the irrigation. And then we’ll aspirate. I do like to see if I can get underneath the lens. And here I’m underneath the lens, removing the viscoelastic from underneath. And as long as you can appreciate my port is facing the endothelium, as long as my port is facing the endothelium, I’m safe. I’m not gonna get that bag. And so we’ve removed the viscoelastic. And now the last step is we’re gonna hydrate the wound. I like to hydrate only the edges of the wound, and I use BSS on a cannula. And just with a little bit of pressure, I’ll infuse fluid to see the cornea develop some edema as it swells. And as it swells, it seals that lens closed. And then I will just hydrate. Often just one side of the side port is enough to close it. I’m happy with these wounds, and so I don’t often check the wounds. I will go in and center the lens to make sure that that lens is nice and centered on the capsulorrhexis. And I’ll adjust the pressure, when I’m in there. And then check the pressure afterwards. That’s a pretty nice pressure. And we have nicely sealed wounds, and so that’s the end of the operation. Thank you.

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May 29, 2019

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