Surgery: Phacoemulsification combined with Goniotomy using the Kahook Dual Blade

This patient here is a 60-year-old male who has open-angle glaucoma, previously treated in the right eye with a phaco trabectome procedure, with good results. Low pressure, off medications. Currently low 20, maybe 20 to 22, on multiple medications on the left eye, with the cataract. So since it seemed like good success with angle-based surgery on the right eye, we thought this was a good opportunity to attempt angle-based surgery on the left eye. And the procedure today will be phacoemulsification with intraocular lens and Kahook dual blade. We’ll see if we’ll be able to attempt it. Because as you can see here, we have a pretty large little subconj hemorrhage after the block. So first, I like to do the cataract surgery before the angle surgery. So I’m gonna start here with our paracentesis. So we’re gonna use the intracameral preservative-free lidocaine. So usually I use 1% preservative-free, or 2%. You can also drip some on the cornea and do some intracamerally. Next, I will use a dispersive viscoelastic like Viscoat. And DuoVisc. This will help coat the endothelium. So really well dilated. So now we’ll do the keratome. So let’s start back here. Usually I do a little scratch incision. Tunnel up into the cornea. Make a little bit longer tunnel today. Come all the way in there. Straight in and out. So really square edges. Long tunnel is ideal. Next we’re gonna use cystotome to do capsulorrhexis. So come out nice and far to the side. Pull down. You can go counterclockwise. Clockwise. You should be familiar with going different ways. You can stick with the cystotome. Just trying to get a nice circular rhexis. I like to use Utrata. So remember to not make it too large. So you have good optic overlap. All right. So there we completed the rhexis. Now we’ll do some hydrodissection. This is a flat cannula. So you want to kind of tug under. So you can see the fluid wave went around the back. I should see if the lens is mobile. Okay. So for prechopping, you kind of want to get down to the nuclear portion. So usually what I do is I blow away a bunch of the lens there. The cortical portion. Kind of dive in here a little bit. You need to have good zonules for this. See, you can do some presplitting there. So just clean out all this cortex initially. Get a better view to see what kind of pieces you’ve cracked. So just sort of stay in the middle. Do all your phaco in the center there. Once you debulk a piece, that’s helpful. Okay. So there I got some rotation there. Maybe there’s just some cortical adhesions or something. Just kind of debulk the large piece here. Once it flips over, that’s a good sign. Okay. So I’ll switch over to IA. So now I take the Provisc. Now we’re gonna fill up the eye here. See that deepen all the way. Now you’ve got room for the lens. So I’d like to do a thorough removal for glaucoma cases. Remove all the viscoelastic to try to prevent first day post-op pressure spike. So don’t just remove the Provisc, but make sure all the Viscoat is gone too. Do a very good sweep of the anterior chamber. Okay. Now I’m just gonna take the Healon GV. So I like to use GV for molecular weight. For doing the angle-based surgery. For doing angle-based surgery, I recommend using this lens. You can see here it’s called the Glaukos left hand — if you’re using the left hand. For a right-handed surgeon, it’s called open access. And that’s because this part right here allows you to get inside through your wounds, in order to do manipulation in the angle. So the first thing we need to do is rotate the head. Because to get into direct view of gonioscopy, you must turn to the opposite side. So I’m gonna rotate his head all the way to the right. And now we’re gonna tilt the scope. So we need to tilt the scope. At least around 30 to 45 degrees. So now you can see the TM, hopefully. Maybe even some little heme reflex in there. You see the scleral spur. And then basically ciliary body is right at the iris margin right now. So this is basically like a fixation ring. Disposable. You attach it on there. Snap it on. So this allows you more control of the eye. So that’s a very useful instrument. Okay. Let look at what the Kahook dual blade looks like. So basically this is a dual blade, because on the top and the bottom are both cutting sides, and the sharp point is in the center. I’m pointing to it right here. So you’re kind of going into the middle of the eye first. Okay. So the next thing is you get centered. Now you’ve got the instrument in the eye. You can see… So what I’m doing is I’m coming across. Following the curve of the TM. You want to see some heme. That’s really good. That shows you that you’re in the right spot. You see that white line now? So that’s TM split open there. So sometimes you can see the little leftover TM piece. Some people cut it off. Some people leave it. It’s this thing right over here. You see that little strap left over? You’ll see it curl up like a scroll postoperatively. So it’ll just hang out in the periphery. No big deal. Some people try to go in the other direction to get it even bigger. I think for these purposes, he had a pretty good response to trabectome. We don’t have to be that aggressive to get it much larger. So it’s basically what was started probably at an angle like this, going in, coming across, to about right here. So that’s probably only about this far along, I would say. They might have a little microhyphema tomorrow. It’s normal. It’s a good sign. If it’s an eye full of blood, then obviously… Anticoagulated pupil, and they can have large hyphemas that you occasionally need to wash out. I use Miochol sometimes. Bring the pupil down. Get it away from the wound. Just one little more washout, and then we’re done. We usually use intracameral antibiotics at the end of the case. Just giving some antibiotic-steroid combo here.