This video demonstrates a routine phacoemulsification surgery in a dense nuclear cataract. Dr. Lehmann used the divide and conquer technique for nuclear removal and he explains all the steps in detail.
Surgery location: on-board the Orbis Flying Eye Hospital in Trujillo, Peru
Surgeon: Dr. James Lehmann, San Antonio, USA
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Dr. James Lehmann: Hi, my name is Dr. Lehmann, and I’m going to be narrating this video of a phacoemulsification I performed in Trujillo, Peru. It’s a pretty standard-type cataract down there. Pretty dense nuclear cataract, probably in the 20, 50-2070 range. This place has nice dilation. And we’re going to pick it up after making the paracentesis and injecting the vision blues. I’ve put in the viscoelastic there, and it brought out the rest of the vision blue. And we have a good red reflex there, and we’re going to use the 2.65-millimeter keratome to construct a temporal wound.
You want to make about a 2-3 millimeter tunnel there. Almost like a rectangle to a square-type shape. That tells you that it’s long enough. Of course, if an incision is too short, you’re going to get iris prolapse. And if it’s too long, you’re going to have distortion of the wound and poor visualization of the rest of the case.
So, here is the beginning of the rhexis. I use a pre-made cystotome and create a little slice across the anterior capsule. And then make the first turn with that. I prefer using Utrata forceps to using the cystotome for the whole rhexis because I feel there’s more control. We aim for a 4-6 millimeter rhexis, and you always kind of want to be leading it with the edge of the rhexis folded over as you can see there. You never to want pull outward. And you always want to re-grasp about 2 millimeters from the site of the tear. That keeps you in control. And it’s like leading a dog. You’re kind of telling it where you want to do next.
So, we’ve made the rhexis there. It’s about 5-6 millimeters, a little bit eccentric, perhaps, but still good. And now we’re putting some BSS in the anterior chamber to bring out the rest of the anterior capsule and we’re going to do hydrodissection at this point. It’s good to see kind of a fluid wave, I’m not sure we’re going to see that here. But after you inject some fluid, you always have to blot and push down on the nucleus so that any fluid is released so you don’t blow out the capsule.
There you can see some viscoelastic come out of the eye and the lens come up. That tells you got some fluid around there. But I didn’t see a fluid wave, so I keep pushing. On these dense cataracts, sometimes you don’t see a fluid wave. So, it’s always good to verify prior to continuing with the phaco that you can rotate the nucleus. Again, I couldn’t say that enough. I would keep doing hydrodissection and keep blotting down the pressure until you can confirm that you can rotate the nucleus. That’s the safest way for a beginning phaco surgeon to handle this situation. So, there I got another cannula of V SS. I’m trying to turn it right here. Oh, I can turn it already. That tells me the zonules are good. And then I can proceed with phaco.
So, the next thing would be to get the phaco hand piece. And I like to insert it upside down so that I don’t use the sharp end down by the iris or the capsule. And then once it’s in the eye I rotate it 180 degrees. So, I use continuous irrigation into the AC, rotate 180 degrees, and then begin the divide and conquer technique by providing a central groove. What you should see is being able to cut with minimal moving or distortion of the wound or moving of the nucleus. And now, people always say, how wide should that central groove be? About 1.5-2 phaco tips would be reasonable. And then, of course, the $10,000 question is always, how deep does it need to be? Well, my answer to that is that about 80% is the right answer. So, once you start to see some horizontal lines, that tells you you’re getting in the right layer of the epinucleus there. So, and I think I’m pretty happy with the depth there. So, I’m going to insert my second instrument. And both of these go in the kind of periphery there. And you can see. And we’re just going to gently rotate them like that so that you crack that nucleus. And then using the second instrument, like pushing on a door, we’re going to rotate.
The more peripherally you push, the less pressure you have to use. Just like pushing a door is easier the farther away from the hinge that you are. And here we’re making another groove. Now, the depth is easy now because we know what’s the full thickness. So, you want to go about 80% and then crack that. All right. And then you can either keep rotating. That’s what we’re going to do. Okay. So, we’re going to make all four quadrants. Same thing. After that first groove, you have a very good idea of what depth you should be at. There I could see it was almost already fractured, so I don’t have to go deep at all. And then we’re going to make the last two quadrants here. And, of course, you can take quadrants out as you go. I think I’m just demonstrating a classic divide and conquer technique here.
It’s easier to do that last heminucleus with the other quadrants in the eye, otherwise it has a tendency to kind of move around on you. So, now we moved over to quadrant mode, which is obviously more vacuum, and we’re going to bring the quadrant. So, this begs the question, what’s the proper way to bring a quadrant up into the anterior chamber? And where should you bring it up? Well, the iris plane is always the reference point. You want to be outside the bag in the iris plane. You saw there I removed my second instrument. Oftentimes that stabilized the chamber more because there’s no fluid egress from the paracentesis. And, so, here we’re on quadrant mode. We’re eating it up. You know, minimal manipulation of the phaco tip is needed. Especially on the newer machines. The nucleus just bounces and dances on the tip. You don’t want to be up by the endothelium and you don’t want to be in the bag so that you avoid any surge or nick in the capsule.
Now, where do you grab? You always want to grab across from the incision. See how I moved the nucleus there? You don’t want to be rotating that nucleus and trying to grab things sub-incisionally. You want to go across the eye. And you go on just under the anterior capsule and grab in a safe place there. You never to want grab posteriorly by the tip of the pie piece. You always want to grab it by the crust, as it were. So, we’re bringing that fragment up and we are eating the iris plane.
People talk about the different phaco techniques. You can do stop and chop, et cetera. And I think that you’ll find the one that you like and that works with your technique. After ten years of private practice, I still do the divide and conquer. And can also sometimes leave the final heminucleus in place and chop it in the AC. Any way you slice it, the case doesn’t take maybe but eight to ten minutes.
And so, that’s good. So, instead of going to grab the piece right there, I’m going to rotate it away from me so that I can have more control and know my depth in the eye better. So, now I can go grab that top of the pie crust and bring it up into the iris plane and eat. And so, always on my last piece, and I haven’t removed my second instrument, I would remove it at this point. And that gives a lot of stability.
Modern phaco machines have very little surge, but you want to err on the side of more anteriorly eating that last piece so the posterior capsule doesn’t trampoline. All right. So, we’re done with the phaco part. There seems to be somewhat of an epinucleus and, of course, cortex remaining. The INA tip I used is 45-degree with a silicone tip. It makes things very settle and very easy with low risk of damaging the posterior capsule. When I entered the eye there, you saw me reach under the iris. I think there was some deepening of the AC. That can happen in myopic eyes and I wanted to break up that anterior capsule iris block there.
And this is pretty friendly cortex. It looks like it’s coming to the tip easy. I’m getting all the little remnants there.
There I’m doing vacuuming of the capsule and it looks clear. The posterior capsule looks clear and there doesn’t some to be any remaining cortex. Everything is going smoothly. We’re going to fill the anterior chamber with viscoelastic. This would be Provox. And you want to put a big, firm fill of the eye. Especially when you’re starting, you would rather have too much than too little. This is the monarch injector. And we’re going to be injecting the SA-60AT lens with the wound assist. So, put it in. Rotate the screw on the injector. And then the lens comes in nicely, gently, without real aggressive haptic unfolding. And I use a Sinskey hook here to put it in the vascular bag. And if the haptics are stuck to the optic, you just free them up a little by nudging them where they want to go. It’s not terribly important, the orientation of the haptics, but if your rhexis is not 100% overlapping on the optic, you want to center it as well as you can and perhaps put the haptic in the area where there’s not as much capsule overlying the optic.
All right. Getting all the viscoelastic out of the eye here. And then it looks like I’m getting enough capsular overlap here. And here I’m going to even go underneath the optic to make sure all the viscoelastic is gone. This is fairly easy to do with a silicone hand piece. And it looks like we have good rhexis coverage there. So, I’m trying to get the lens in good position there. And then the last step, of course, is stromal hydration of the main wound and of the paracentesis and any intracameral antibiotics you would inject. These days I’m injecting moxifloxacin at the end of the case. But there’s always sub conjunctival antibiotics. You do what you can with what you have. And just getting the lens centered little better. Trying to get as much overlap on the optic. Looks like we have 100% on the optic coverage there. And we’re just filling up the AC. Touching it, making sure it’s a good pressure. And that would conclude the case.
Well, I thought the case was over. But apparently the wound was leaking. So, the decision was made to put in a suture. And so, I’m quick to do this if I can’t get that wound to close with stromal hydration. And it will just be a 10-0 nylon passed through the wound there with a 3-1-1 closure. And that helps you to have you sleep well the night after surgery. So peace of mind is worth it. Rotate the numbered, of course, and then do the same things. Recenter the lens. So, we want to verify that we have good pressure. And now I think we’re done. Thanks.
January 29, 2018