This video demonstrates a phacoemulsification surgery in a dense nuclear cataract, using a four-quadrant divide and conquer technique with bimanual cortical clean-up.

Surgery Location: on-board the Orbis Flying Eye Hospital, Mandalay, Myanmar
Surgeon: Dr. Charith Fonseka, Nawaloka Hospital, Colombo, Sri Lanka


Dr. Fonseka: So this is a reasonably dense cataract, both cortical and posterior subcapsular. I’m using a 2.75 blade here, so I would make a temporal incision because in my hands that is the best for controlling surgically induced astigmatism. So just going to give a touch of intracameral lidocaine, the eye is blocked very well. And this is a viscoat which I’m injecting and I’m just going to inject a little bit at the wound edge. So I’m just going to fill the entire anterior chamber with viscoat. And now I’m going to make two side port incisions. Having the second instrument in, enables me to control the position of the eyes. I’ve initiated the rhexis and I’m going to go around slowly trying to get nice round rhexis.
That’s the completion of the rhexis. And this is the hydro dissection, these sort of the outside limit of, where I would be able to do the rhexis without staining because there’s really no good red reflex. So now I’m going to start the phacoemulsification and I’m going to go in with the infusion on. So this is a reasonably hard cataract. I’m going to make a small groove here because that is also one way in which it can be done. And yesterday I did horizontal chops. So this is a vertical one. It’s very important to try and disassemble the nucleus prior to commencing its removal. And I’m just demonstrating this, I’ve disassembled it into four pieces, four quadrants, and this one is the largest. So I’m just going to leave that alone and I’m going in and taking this smaller one out.
It doesn’t really matter for this case, but in some circumstances, it may be important not to stress the capsule out too much. So this, the density’s more, especially the central density is quite high. So they don’t get chewed up that easily. I need to apply a fair amount of energy. And this is the last part. Now, at this point I can switch to a lower mode or just continue, but I need to be very watchful because this is the last quadrant, this is the time the posterior capsule can come up. So as I do this, I sort of take my foot off the pedal so that there is no instability of the anterior chamber at all.
Now I’m going to go into bimanual. There is a little sandblasting at the edge which can be used to polish the capsule. So go in and they have a nice curve to enable access to any part of the subcapsular area. You remove the cortical material through a radial incision and I’m just going to polish this as well. There is a little bit of fibrosis there, just leave that alone. It’s not going to cause any problem. Now I’m going to fill the eye with Provisc. So the lens is nicely loaded for me, just going in, open up the lips and generally inject it downwards, so that the leading haptics go into the capsular bag.
You can use the bimanual itself to nudge the lens in and sometimes this method may be necessary. So always go in with the infusion first and then take this out. We just clean the subcapsular area a little bit. It’s always nice to have a clean capsule. Visualization of the retina is better when the capsule is polished. So it’s always good to always inflate it a little bit, but remember, at the end, you need to tap it so that the intraocular pressure is not high because that causes two problems. It causes pain to the patient postoperatively as the block wears out, and also it will endanger the optic nerve. So the last part is to give in some intracameral vigamox, which I always do. It’s just a little bit is enough, and some on the cornea.

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February 29, 2020

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