This is a routine phacoemulsification surgery in a 57-year-old lady with posterior sub capsular cataract. A phaco flip technique was used and the lens which was soft, was then aspirated. An IOL with aspheric design was implanted in the capsule.
Surgeon: Dr. Sherif El-Defrawy, University of Toronto
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DR EL-DEFRAWAY: Okay. So we have a 57-year-old lady with primarily a posterior subcapsular cataract. She has pseudoex, as you can see, but she dilates very nicely in spite of the pseudoex. And so we’re gonna do a phaco. And because she’s young, and this is primarily a posterior subcapsular, we’ll probably do a phaco flip technique. But we’ll see how dense the nucleus is when we get in there. So the first thing that I’ll do is mark where my main wound would be. And I tend to do this — I like temporal approaches. I will do this with my pickup, my 0.12 forceps. And this is about where my wound is gonna be. I like my side port incision about 90 degrees to that wound. And so everyone is different with respect to this. But this kind of guides me for my side port. It’s very important to hold your side port blade flat, and go in perfectly flat. It should be a straight in and a straight out. And I’m using some VisionBlue, not because we need it in this case. We had pretty good visualization of the capsule. Only to help demonstrate our techniques here. You’ll notice that I didn’t put in an air bubble to protect the endothelium, and the reason is that we found that the commercial product that we buy is pretty safe, and not endotheliotoxic. But we know that Trypan blue can be, and so if you’re unsure, put in an air bubble, underneath the VisionBlue. And now I’m putting in my viscoelastic, to fill the AC. And I like my AC full. I will often grab the side port wound very gingerly, to give me a little bit of control of the eye. And we’ll make our main wound incision. For the main wound, I like to mark the epithelium. So I’ll make a little mark on the epithelium. And that’ll start my three-point incision. You know, usually the design of these keratomes are designed to give you a biplanar incision. With marking the epithelium, you theoretically make the initial cut through the epithelium, and try to get more of a triplanar incision. In this case, I’m gonna slide up to — I actually have a little mark on the blade, to allow me to know how deep I am. That’s about the right thickness. I’ll rotate and enter into the AC. And change my path to give me a triplanar incision. With my cystotome, I’ll make sure that as I enter, I don’t do any cutting of the wound. And I’ll rotate it in the right position. We’ll make a cut, and push up to lift up our flap for us. And you can either use the cystotome to do your entire capsulorrhexis, or you can use capsulorrhexis forceps. With the capsulorrhexis forceps, I’ll stand up the capsule, to be able to regrab, and one of the nice things of grabbing onto the side port incision is that I can use that as a countertraction to allow me to rotate the eye. We want the capsulorrhexis to be about 0.5 millimeters smaller than the diameter of the lens we’re putting in to form a nice seal. And then I’m going to go just underneath the capsule and hydrodissect. At the same time, you’ll notice that I’m gonna depress the bottom of the wound, and that is gonna allow the viscoelastic to escape, as there is an increase in pressure around. I’m gonna hydrodissect again from the other side now. Because this is a soft lens, I’m going to flip it up into the anterior chamber. Because it’s going to be mostly aspiration. It’s not gonna be a whole lot of phaco. So I’m gonna go to the other side, and with a little bit of force, I’m gonna do some more hydrodissection and flip the lens in the anterior chamber. So now I have the lens hydrodissected and flipped. Now, in this case, I’m going to do things in a different order. I’m going to put in my chopper first. And the reason I’m going to put in the chopper first is I don’t want the lens to fall back in the bag when I put in my phaco. Now I can put in my phaco. And now I’m going to start phacoing. And so what I’m gonna do is just aspirate the top of the lens here. And now I’ve got the lens up and down, I’m gonna try to do a vertical crack and split the lens in two. And we’re gonna continue aspirating the rest of the lens. It’s gonna be relatively soft. And the rest we’re gonna do with the IA. It’s just mostly the membrane in the back of the posterior subcapsule. And we have the IA now. And so what we’re gonna do, once again: I do like to hang onto my side port, very gingerly. And we’re gonna just aspirate out the cortex. I have a little bit of epinucleus here with this cortical material. And we have a little bit of subincisional cortex here. I’m gonna need to go to bimanual to get this out. I’m just gonna enlarge my side port just a little bit to allow the bimanual. And we have all the cortex out. Now, there is some material — you’ll notice there’s some material on the anterior capsular face. And some people try to vacuum the anterior capsule to get rid of that material. You don’t want to do that. These cells that are located on the anterior capsule will actually help form a very nice, tight seal around the lens, and prevent lens epithelial cell migration. So you don’t really want to be vacuuming the anterior capsule. I use my side port as a little bit of countertraction to get my injector in. You want to ensure that the haptics are off the optic. We’ll irrigate — this was an Alcon SN60 lens, so it has an aspheric design. This is a younger patient in cataract standards, and will benefit more from an aspheric design, because potentially her pupil will be a little bit bigger in scotopic conditions. Very important to hydrate. And we’ll hydrate the edges of the wounds well. This will seal our wound very nicely. We want to make sure that the wound is well sealed, because we have seen that pressure does drop a few hours after surgery, and you can get a sucking wound effect if it’s not closed well. You don’t want to irrigate the superior aspect of your wound, because you risk peeling Descemet’s, and we want a reasonable pressure inside the eye, and this feels pretty good. So we have good overlap and well-sealed wounds.
July 14, 2017