cataract surgery knowledge for optometrist, ophthalmic assistant & OT staff orparaclinicals etc........

1. DIFFERENT TYPES OF CATARACT
EXTRACTION
Presented by:
Dr. Sandeepkumar

2. TYPES OF CATARACT SURGERY
• Intra Capsular Cataract Extraction (ICCE)
• Extra Capsular Cataract Extraction (ECCE)
• Small Incision Cataract Surgery (SCIS)
• Phacoemulsification
ECCE
ICCE

3. Intra Capsular Cataract Extraction (ICCE)

4. Extra Capsular Cataract Extraction (ECCE)

5. Small Incision Cataract Surgery (SCIS)

6. Phacoemulsification

7. DETAILS OF EACH TECHNIQUE
• ICCE
• ECCE
• SICS
• PHACO
• PHACONIT
• FEMTO LASER CATARACT EXTRACTION

8. Intra capsular cataract extraction (ICCE)
ICCE
 ICCE evolved into a very successful operation
 Preferred surgical technique before the refinement of modern ECCE surgery
 However there remained 5% rate of potentially blinding complications including:
 Infection
 Hemorrhage
 RD
 CME

9.  ECCE has replaced ICCE, almost entirely in most parts of the world:
1. Better operating microscopes
2. More sophisticated surgical aspiration systems
3. More sophisticated IOL implants
Intra capsular cataract extraction (ICCE)

10. Techniques (ICCE)
 Smith’s method
 Arruga’s method
 Erysiphakes
 Cryo surgery
 Chemical dissolution of zonular fibers

11. Smith’s technique
 Smith used external pressure with muscle hook to mechanically break the inferior
zonules
 Expelled the lens through the limbal incision
 The lens would “Tumble”, I.e. the inferior pole would exit the eye before the
superior pole

12. Arruga’s method
 Toothless forceps (Arruga’s) used to grasp the lens capsule and
then gently pulled from the eye using side-to-side motion that
broke the zonules

13. Arruga’s Forceps

14. Cryo surgery
 Cryprobe: Hollow metal-tipped probe, cooled by liquid nitrogen, that is touched
to the lens surface
 As the temperature of the probe tip falls below freezing, an ice ball forms and the
lens adheres to it
 This instrument forms an ice ball, fusing the lens capsule, cortex, and nucleus
 Lessening the risk of capsular rupture as the cataract is removed

15. Extra capsular cataract extraction (ECCE)
 Shift from ICCE to modern ECCE
 To decrease the rate of potentially blinding:
 Complications
 To facilitate the placement of PC IOLs
 By leaving the PC intact, the surgeon could decrease the risk of:
 Vitreous loss and
 Complications like RD, CME, and Bullous Keratopathy

16. Extra capsular cataract extraction (ECCE)
 Key to the development of modern ECCE technique were the
growing use of:
 Operating microscopes for increased magnification &
 Improved methods of cortical removal

17. Extra capsular cataract extraction (ECCE)
 Charles Kelman in 1967 developed phacoemulsification
 This new type of ECCE:
 Ultrasonically emulsified the lens nucleus,
 Allowing the operation to be performed through a small incision
 This method has continued to grow in popularity as:
 Techniques &
 Instrumentation

18. Indications of ICCE
 Operating microscopes not available
 Unstable / luxated cataracts
 Week zonular support

19. Advantages of ICCE
Cryoprobes
Capsular forceps
Erysiphakes
Allow this procedure
To be performed
Under most conditions
• Entire lens removed with no capsule left behind to:
• Opacify or
• Require additional surgery
• Less sophisticated instrumentation required
• Non automated extraction devices:

20. Disadvantages of ICCE
 Delayed healing
 Iris incarceration
 Delayed visual rehabilitation
 Vitreous incarceration
• Large ICCE incision 12 – 14 mm (160 - 180)
• Postoperative wound leaks with inadvertent filteration
• Endothelial cell loss > following ICCE than ECCE
• Corneal / endothelial cell trauma from lifting / folding
of the cornea (lens delivery / cryprobe)
• Cystoid macular edema (transient 50%, persistent 2%
- 4%)

21.  Vitreous complications:
In young patients PC is firmly adherent to anterior
hyaloid; attempted ICCE will usually result in vitreous loss
 Intact vitreous face may opacify and  vision
 Adherence to corneal endothelium (corneal edema)
 Adherence to iris (pupillary block glaucoma)
 Broken vitreous face may incarcerate in the wound with vitreous traction
causing:
 RD
 CME
 Vitreous in AC causing open angle glaucoma
Disadvantages of ICCE (cont’d)

22.  IOL implantation problematic since posterior capsular support missing
 IOL choices include:
 ACL /Sutured PC IOL (Iris fixation IOLs no longer available)
 These significant disadvantages and risks led to loss of popularity of ICCE
Disadvantages of ICCE (cont’d)

23. Patient preparation
 Pharmacologic pupillary dilation with topical mydriatic and cycloplegic
agents to facilitate lens removal (iris retractors intraoperatively)
 Anaesthesia

24. Patient preparation
 Orbital massage / osmotic agents (manitol, glycerine, isosorbide) before surgery
1. Intermittent digital pressure on closed eye lids or
2. Occulopressive device (honann baloon, mercury bag, sponge ball, strap)
3. Massage helps to:
 Distribute the anaesthetic agent within orbit
  Orbital volume
  Pressure on the globe
  IOP
(cont’d)

25. Patient preparation
Orbital massage (cont’d)
4. Minimizes vitreous prolapse during cataract extraction and facilitates an angle supported IOL
5. Osmotic agents are used less frequently:
 Volume load in patients with heart and kidney failure
 Nausea (Occasional)
 Urinary urgency during surgery
(cont’d)

26.  Procedure
 Postoperative course
VA should be consistent with:
1. Refractive state of the eye
2. Clarity of the cornea
3. Clarity of the media
4. Visual potential of the retina and optic nerve
Patient preparation (cont’d)

27.  ECCE
 ECCE involves removal of the nucleus and cortex through an opening in the
anterior capsule (anterior capsulotomy), leaving the posterior capsule in
place.
Patient preparation (cont’d)

28. ECCE (cont’d)
Methods
1. Nucleus expression (manual)
2. Phacoemulsification (Ultrasonic fragmentation)
Patient preparation (cont’d)

29. ECCE (cont’d)
Methods
 Preferred method of routine cataract surgery
 Selection of technique for nucleus removal depends upon:
 Instrumentation available
 Surgeon’s level of experience with each technique
Patient preparation (cont’d)

30. Advantages of ECCE surgery
 Smaller incision
 Less traumatic to corneal endothelium
 Eliminates complications (short and long term) associated with
vitreous adherent to:
 Incision wound
 Iris
 Cornea
(cont’d)

31. Advantages of ECCE surgery
 Intact posterior capsule allows better anatomical position for IOL fixation
 Intact posterior capsule  incidence of:
 CME
 RD
 Corneal edema
(cont’d)

32. Advantages of ECCE surgery
 Intact posterior capsule  ability of bacteria, introduced into eye, to gain access to vitreous cavity and
cause endophthalmitis
 2ndry IOL implantation
 Filtration surgery
 Corneal Transplantation
 Wound rapair
Technically easier and safer when
intact PC is present
(cont’d)

33. Contraindications (ECCE)
 Zonular weakness
 ECCE requires zonular integrity for selective removal of nucleus and cortical material
 Therefore when zonular support appears insufficient to allow safe removal of the
cataract through ECCE surgery, ICCE or Pars Plana Lensectomy should be considered

34. Instrumentation (ECCE)
 A wide range of instruments is available for each step of ECCE:
 Opening the anterior capsule
 Dissecting and removing the nucleus
 Removing the lens cortex
 Polishing PC

35. Cystotome
 Used for anterior capsulotomy (opening in the anterior of the lens)
 Fashioned from 25 gauge needles by bending at its hub and beveled tip
 Prefabricated cystotomes also commercially available
 The needle tip is used to puncture and tear the anterior capsule

36. Irrigation and aspiration system coaxial, double-lumen
blunt cannulas
 One lumen irrigates BSS into the AC
 Second lumen aspirates lens material out of the AC
 Irrigation is gravity fed from a solution bottle
 Fluid flow is regulated with adjustment of bottle height
 The flow may be constant, or the surgeon can employ a foot control connected to
a pinch valve

37. Irrigation and aspiration system coaxial, double-lumen blunt
cannulas (cont’d)
Aspiration:
 Syringe connected to the cannula
 Elaborate pump system controlled by a foot switch

38. Lens nucleus
Removed by a variety of techniques, each
with its own set of instruments:
 Lens expressor
 Lens loop
 Spoon, Vectis

39. Procedure ECCE
 Pupillary dilation
 Critical to the success of ECCE esp. phacoemulsification
 Cycloplegic / mydriatic drops
 NSAID (topical/oral) these agents help to maintain dialation during surgery

40. Procedure ECCE
 Incision
 Incision: Mid limbal, chord length 8 – 12 mm, which is smaller than for ICCE
 The initial incision consists of a limbal groove
 Some surgeons prefer more posterior incision with anterior dissection creating a flap of tunnel
 A stab incision is made into AC
 AC depth stabilized by viscoelastic agents, air bubble, or continuous fluid irrigation
 Cystotome is inserted for anterior capsulotomy
(cont’d)

41. Procedure ECCE
 Capsulotomy
 Christmas tree
 Can-opener
 Capsulorrhexis
(cont’d)

42. Procedure ECCE
Capsulotomy (cont’d)
Christmas tree
 With cystotome anterior capsule punctured inferiorly and
 The flap of the capsule drawn toward the wound and cut with scissors
(cont’d)

43. Procedure ECCE
Capsulotomy (cont’d)
Can-Opener
 Cystotome used to make a series of connected punctures or small tears in circle
(cont’d)

44. Procedure ECCE
 Capsulorrhexis
 Continuous tear anterior capsulotomy popular in phacoemulsification, can be performed with either:
 Csytotome or
 Capsulorrhexis forceps
 First a small tear is created,
 The edge this tear is then grasped with cytotome tip/forceps, and
 A smooth tear is created, removing a circular portion of anterior capsule
(cont’d)

46. Procedure ECCE
 Capsulorrhexis (cont’d)
 This technique provides:
 Structural integrity for the lens capsule
 Maintain implant stability
 Centeration
(cont’d)

47. Nuclear expression
 Manual
1. Whole (Lens loop, spoon, vectis, irrigation)
2. Fragmentation with forceps/nuclear splitter)
 Ultrasonic fragmentation

48. Lens cortex aspiration
1. Syringe connected to cannula
2. Pump system controlled by foot switch

49. Posterior capsular polishing
 Abrasive tipped irrigation cannula / low vacuum clean using low
aspiration remove epithelial and cortical particles from the capsular
surface

50. IOL implantation
 AC filled with viscoelastic / BBS / air
 Viscoelastic most reliable AC maintainer
 It also protects corneal endothelial
 IOL inserted in the ciliary sulcus / capsular bag
 Sulcus fixation:
 Requires greater IOL diameter (>12.5 mm)
 Large diameter optic (6 mm)
 More forgiving in case of postoperative decentration
 Bag fixation:
 IOL diameter <12.5 mm
 Optic diameter 5.00 mm

51. Wound suturing
 10/0 Nylon
 Proper suture tension  postoperative Astigmatism
 Loose sutures – Against-the-rule Astigmatism
 Tight sutures – With-the rule Astigmatism

52. Postoperative course ECCE
 As with ICCE, VA on the first postoperative day should be consistent
with:
 Refractive state of the eye
 Clarity of the cornea
 Clarity of the media
 Visual potential of the retina and optic nerve

53. Postoperative course ECCE
 Lid: Mild eye lid edema and erythema may occur
 Conjunctiva: May be injected and boggy
 Cornea: Should be clear and free of striate / edema
 AC: Should be of normal depth and mild cellular
reaction typical

54. Postoperative course ECCE (cont’d)
 Posterior capsule: Should be clear and intact
 Implant: Should be well positioned and stable
 Red reflex: Should be strong and clear
 IOP: Elevations may be associated with retained
viscoelastic

55. Postoperative course ECCE
Antibiotics and Corticosteroids:
 Topical antibiotic and corticosteroids are used for first few weeks
Vision:
 Steady improvement in vision and comfort, as inflammation subsides

56. Postoperative course ECCE (Cont’d)
Refraction:
 Refraction stable by 6th – 8th weeks,
 Glasses may then be prescribed
Astigmatism:
 If significant astigmatism along the axis of incision, selective sutures removed by 6th week, according to
keratometry corneal topography

57. Phacoemulsification
 Phacoemulsification is an ECCE technique that differs from “standard ECCE
with nuclear expression” by the:
1. Size of incision required
2. Method of nucleus removal
 This technique uses ultrasonically driven needle (phaco tip) to fragment the
nucleus and aspirate the lens substance through a needle port

58. Phacoemulsification (cont’d)
 Advantages
 Lower incidence of wound related complications
 Faster healing
 Rapid visual rehabilitation
 AC depth controlled during surgery and providing safeguards against positive vitreous pressure and
choroidal haemorrhage (closed system)

59. Phacoemulsification (cont’d)
 Instrumentation
 Ultrasound
 Irrigation system
 Aspiration system

60. Phacoemulsification (cont’d)
 Ultrasound
 The phacoemulsification hand piece contains a piezoelectic crystal that vibrates at frequency
of 24000 – 56000 Hz
 The vibration is transmitted to the head which is attached to the phaco tip

61. Phacoemulsification(cont’d)
 Aspiration
 The aspiration system of phacoemulsification machine varies according to the pump design:
1. Peristaltic Pump
2. Diaphragm Pump
3. Venture Pump

62. Phacoemulsification(cont’d)
 Aspiration (cont’d)
 Peristaltic Pump
 Consists of set of rollers that move along a flexible tubing, forcing fluid through the tubing
and creating a relative vacuum at the aspiration port of phacoemulsification needle

63. Phacoemulsification(cont’d)
 Aspiration (cont’d)
 Diaphragm Pump
 Flexible diaphragm overlying a fluid chamber with one-way valves at the inlet and outlet

64. Phacoemulsification(cont’d)
 Aspiration (cont’d)
 Venturi Pump
 Creates a vacuum based on the venturi principle:- That a flow of gas across a port
creates a vacuum proportional to the rate of the gas

65. Phacoemulsification
 Irrigation
 Fluid dynamics of phacoemulsification requires constant
irrigation through the irrigation sleeve around the
ultrasound tip
 Constant irrigation:
 Maintains AC depth
 Cools the phacoemulsification probe
 Prevents heat buildup and adjacent tissue damage