Surgery: Manual Small Incision Cataract Surgery in Hypermature Cataract

This video demonstrates a manual small incision cataract surgery in a hypermature cataract. A watertight wound was constructed and the nucleus was delivered using the visco-expression technique. An IOL was implanted in the capsular bag and the wound was checked for the integrity.

Surgery Location: on-board the Orbis Flying Eye Hospital, Addis Ababa, Ethiopia
Surgeon: Dr. Rishi Swarup, Swarup Eye Centre, Hyderabad, India


So this is a white hyper mature cataract. It’s intumescent, we are going to stain the capsule with vision Blue. Methylcellulose, always inject from the opposite side of the anterior chamber and come back filling the anterior chamber. Healon GV, this I’m additionally giving to flatten the anterior capsule. So you can see the little gush of fluid, but the healon is keeping the capsule back in its place. It’s fragile, as you can see. It’s cutting easily. So I have to be delicate. So I’m going to be close to the cutting edge and making it a little centripetal.

So that’s a fairly larger size rhexis, which is what I wanted. And even though it’s tending to run out, we are able to control it to a large extent. Again, it’s tending to run out, so I’m going to put it a little centripetally. So this is tending to run out, so I’m just going to pull it in, with a micro capsular rhexis forceps that can be used through a parasynthesis. So I’m just pulling it centripetally now and managed to complete rhexis safely. This patient has a bit of a deep set eye, so making the radial incision on the conjunctival epithelium and trying to do a scissor dissection with westcott scissors, along with the tenons. Cut the conjunctiva along the limbus to get a fornix based flap and then radial extension at the other end. So this is about 1.5 millimeters behind.

So a good idea to use a caliper in the beginning stages. So that’s about 5.5, and I’m going to make a back cut about 1.5. The crescent blade is introduced from the depth of the scleral incision, riggling movements till it reaches about one millimeter or 1.5 millimeters into the cornea. And then as we withdraw the crescent blade, we make circular movements on either side to dissect the scleral tunnel. It’s important to make these side pockets so that the nucleus comes out easily. This is a fairly large nucleus, so the side pockets will become all the more important. So this side is done. Now we’re going to do the same thing on this side.
So that’s a good pocket. So we have a fairly good tunnel now. We can see that the pupil has come down a little bit. I’m just introducing the tip of the keratome sidewards and then I will turn it in, ensuring that it’s not itching either the roof or the floor of the tunnel. Now we’re just going to create a dimple, enter inside, and then horizontalize, so that we cut on the downstroke. Make sure that the cut extends still the limbus on both sides. When you’re entering, please make sure you don’t depress the internal wound. Otherwise you can have the viscoelastic flowing out and the anterior shallowing, the iris popping out through the main wound.

So I’m just going to go through the main wound, under the pupil. Since I can’t see the rhexis edge, I’m going to just dig into the cortex a little bit and hydro dissect. And you can see the pole has already popped out. So I’m trying to go under the pole and turn it. So I’m just putting in some viscoleastic. So the pupil is small, one of the tricks is to insert viscoleastic on top of the iris and turn the iris around the nucleus, like this. Just trying to bring the equator out, so now we have more than 50% of the nucleus out. That’s good enough to deliver. I’m giving counter pressure at six o’clock, and this is a kelman McPherson. I’m going to go into the wound just short of the internal lip, open it up, depress. Hopefully the nucleus should come out nicely. So this is getting a bit stuck in the wound. but I feel it is going to come out, you can give a little bit of pressure, counter pressure like so, and then have the whole thing come out like that. The rest of the epi nucleus can be visco expressed like this, so you just inject some viscoelastic behind it and depress the wound. And most of that also comes out.

So I’m just going to remove the cortex using bimanual. So you can see the pupil has really come down now. We now have some intracameral adrenaline. Hopefully that should dilate the pupil a little bit. So it’s dilated. Just a little bit more, not too much. We should be able to manage. So again, I’m being very tentative, because I can’t see what I’m doing. My aspiration is very low. If I see some cortex coming, then I’ll increase the vacuum. So now I see something, so I’ll go back again. Bigger challenge for me in this case was the deep set eye, especially if you’re doing a superior incision, it really sometimes can trouble you. Using a superior rectus would probably be something helpful. In this particular case, it would help turn your eye down and make your life a little easier. So it’s tending to go into the anterior chamber. We’ll just direct it with a synskey Hook. There’s a bit of pigment release from the iris. We’ll just wash that off. And just making sure that the lens is gone into the bag. You can see the whole blob of healon came out in toto, which is one of the advantages of cohesive viscoelastic. It comes out as easily as it goes in, so it saves you some time and you don’t have to spend too much time on irrigation aspiration later.

3D Version:

Last Updated: March 13, 2024

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