Do’s and Don’ts in Phaco Surgery: Text and Atlas Navneet Toshniwal
INDEX
ABCDEFHIKLMNOPRSTVWZ
A
Air bubble 56, 147, 166
removal of 57
Anterior chamber 148, 149, 178
B
Bimanual irrigation-aspiration cannulas 145
Blunt instrument, use of 4
C
Cannula 49
aspiration port of 150
distal end of 46
hitting iris 17
tip of 16
Capsular bag 145, 163
Capsule 31
anterior 23, 32
center 33
edge of 30, 40
important 23
injury to 2
open 30
touching of 23
Capsulorhexis 15, 23, 33, 37, 38, 39, 43
Capsulorhexis 5
controlled 43
feel of 15
in one case 41
needle and forcep 24
preparation for 15
procedure 28
through main port 35
through side port 28
Toshniwal microcapsulorhexis forcep 26
Utrata forcep 23
Cartridge 164
Chop near left side port incision 107
Chopper
acute angulation of 119
and dialer 72
correlation of 98
direction of 69, 108, 109, 161
free movement of 119
handling of 98
placement of 132
pressure of 141
round surface of 162
side port incision 71
to phaco tip 111
Cornea 2, 3, 32, 62, 74, 76, 132, 134
burn 56, 58, 61
chances of injury 108
folds on 165
injury to 37, 7, 13, 122
Corneal lamellae with cannula 15
Corneal touch 6
Cortex, remove 148
Crescent 10
D
Descemet's membrane 6, 16, 36, 52, 165, 167, 159
Dialer 173, 178
and chopper 84, 89, 94
division by 68
movement of 69
superficial 76
E
Energy 181
Epinucleus 152, 158
and cortex, remove 162
near incision 148
Eye ball 140, 150
distorted 119
hypotony of 6
F
Fibers, stretching of 151
Fluid, irrigation of 53
Foldable intraocular lens 163
H
Haptic of IOL 169
Hardness of nucleus 52
Hold and chop 183
case series of 114
different situations 118
Hydrodelamination 44, 49
Hydrodelineation procedure 49
Hydrodissection cannula 44
Hydroprocedures 44, 50
Hyphema 14
I
Incision 1
edge of 44
long length of 8
plane of 163
quality of 1
side port 12
Injector system on incision 163
Intraocular lens 8, 168, 172, 173
implantation 163, 179
procedure for 163, 177
manipulation of 178
Iridodialysis 14, 40
Iris 74, 164
and cornea 74
hitting of 145
injury to 14, 18, 40, 109, 164
prolapse 51
stucked 143
Irrigating fluid 57
Irrigation-aspiration cannula 147–149
plane of 159
K
Keratome 1
direction of 8
entry visualization of 1
instruments used 1
size 167
L
Lens, hard part of 145
Limbal incision 10
M
Mass
bulk of 106
vicinity of 117
McPherson forcep 173
Micro lens holding forcep 173
Micro scissors 15
Microcapsulorhexis forcep 33
help of 43
N
Nuclear mass 133
Nucleus 183
big mass of 121, 125
bulk of 142
central trench of 67
chop small piece of 122
deeper plane of 73
division of 68
edge of 102
management 5
steps of 98, 180
mass 107, 123, 133
pulling of 114
rubbing of 134
piece 120
lifting of 102
orientation of 138
proper plane of 119
removal of 131
round mass of 114, 117
size of 137
small pieces of 186
soft part of 64, 133
vicinity of 101
O
Onquer technique in nucleus management 52
P
Periphery, minimum energy for 181
Phaco
fluidics 131, 140, 144
important for 1
procedure 44
surgery 5, 10
crucial step in 68
important steps in 15
step of 1
Phaco tip 8, 9, 52, 53, 100, 130, 139
and chopper 128
anteroposterior 108
division by 83
angulation 98
degree of 167
directed downward 133
direction of 127, 135
entry of 54
in hold and chop 98, 104
part of 56
pressure of 140
superficial 100
use of straight 61
Phacoemulsification surgery, final step of 163
Posterior capsule 153
design of 155
rupture 63, 99, 136, 140, 145, 147, 155
Prechopper 78
blade, placement of 80
dividing nucleus 79
Pupil 18, 142
constriction of 47, 55, 145
triangular shape of 136
R
Refraction, change in 173
S
Segal optiks 15
Shallow anterior chamber 77
Shallow trench, case series of 89
Soft cataract 103
Soft tissue 147, 157
fibers of 150
Sticky soft tissue, removal of 162
Subincisional cortex, removal of 155
Sunayana surgicals 15
Surgical media center 180
T
Toshniwal microcapsulorhexis forcep 26
Trench 52, 180
correlate, graphs of 181
effective shape of 181
superficial 80
V
Vacuum 180, 183
and flow rate, understanding of 98
Vannas scissors 15
Visco cannula 38, 145, 178
force of 171
position of 171
Viscoelastic 5, 19, 30
aspiration of 147
mix with trypan blue 19
solution 166
W
Wound, leakage of 140
Z
Zonular dialysis 75, 140, 145, 162, 172, 174
Zonular pull, chances of 158
Zonules pressure on 60, 72, 75, 80
×
Chapter Notes

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IncisionCHAPTER 1

 
INTRODUCTION
  • First important step of phaco surgery.
  • Excellent incision architecture is important for phaco fluidics.
  • Quality of incision depends on use of good blades.
  • Instruments used are keratome blade, 15 degree blade, curved 19G or 20G MVR blade, crescent, and 15 no. blade.
 
KERATOME
 
Observation (Figs. 1A and B)
Air bubble is obscuring visualization of keratome entry.
zoom view
Fig. 1.1A:
2
zoom view
Fig. 1B:
 
Results
  • Injury to cornea can occur.
  • Injury to anterior capsule can occur.
Do's
  • Air bubble is often present in anterior chamber.
  • With keratome entry air bubble comes out, for further smooth entry.
 
Observations (Figs. 2A to C)
  • Fingers are seen in the microscopic view during incision.
  • Placement of fingers near the tip of keratome.
zoom view
Fig. 2A:
3
zoom view
Figs. 2B and C:
 
Results
  • More pressure during keratome entry can cause injury to anterior capsule.
  • Eyeball can move inferiorly which makes procedure difficult.
Do's
One should hold keratome at proper site of handle, i.e. away from the tip of keratome.
 
Observation (Figs. 3A and B)
Folds on cornea seen during keratome entry.
4
zoom view
Figs. 3A and B:
 
Results
  • Use of blunt instrument is noticed.
  • Descemet's membrane can get detached.
Do's
Always use sharp instruments.
 
Observation (Figs. 4A and B)
Keratome entry is far away from limbus.
5
zoom view
Figs. 4A and B:
 
Result
Phaco surgery can be difficult to perform, mainly capsulorhexis, nucleus management, and irrigation aspiration.
Do's
Keratome entry should be near to limbus for better instrument manipulation.
 
Observations (Figs. 5A and B)
  • Difficulty to pass keratome.
  • This situation generally occurs in hypotony.
  • Big air bubble is seen which means that anterior chamber is not formed fully with viscoelastics.
6
zoom view
Figs. 5A and B:
 
Results
  • Descemet's membrane can get detached.
  • More pressure is needed to complete the entry of keratome which can injure anterior capsule.
Do's
Hypotony of eyeball should be converted to normotensive eyeball by filling with viscoelastics.
 
Observations (Figs. 6A and B)
  • Keratome is coming out after completion of incision.
  • Corneal touch with keratome tip is noticed.
  • Anterior chamber is collapsed.
7
zoom view
Figs. 6A and B:
 
Result
Injury to cornea, iris or anterior capsule can occur.
Do's
  • This situation happens due to slow movement of keratome while coming out.
  • Adequate speed is mandatory after completion of incision.
 
Observation (Fig. 7)
Length of incision is more in the layers of cornea without anterior chamber entry.8
zoom view
Fig. 7:
 
Result
Long length of incision will interfere with entry and movement of instruments like phaco tip, irrigating/aspirating cannula, intraocular lens (IOL) injector, etc.
Do's
Length of incision in the layers of cornea should be adequate so that incision should be near square shaped.
 
Observations (Figs. 8A and B)
  • Keratome has been passed fully almost near to 6 o'clock position.
  • Direction of keratome is away from center.
zoom view
Fig. 8A:
9
zoom view
Fig. 8B:
 
Results
  • More pressure can cause injury to cornea, iris, and anterior capsule.
  • Wrong direction may lead to difficulty to pass phaco tip toward center.
Do's
  • Direction of keratome should be towards center.
  • Avoid force while passing keratome.
  • Such type of force is due to use of blunt instruments, so avoid use of blunt instruments.
 
Observation (Figs. 9A and B)
Main incision and side port incision is closer to each other.
zoom view
Fig. 9A:
10
zoom view
Fig. 9B:
 
Results
  • During phaco surgery, leaking of solution occurs through side port.
  • Anterior chamber can get collapsed.
  • Phaco fluidics can get hampered.
Do's
Distance between main incision and side port incision should be adequate.
 
CRESCENT
 
Observations (Fig. 10)
  • This is limbal incision.
  • Crescent is blunt as folds on cornea seen.
zoom view
Fig. 10:
11
 
Result
  • Difficulty to do the procedure.
Do's
Crescent should be adequately sharp.
 
Observation (Figs. 11A to D)
Crescent is used in tilted fashion during limbal (Figs. 11A and B) and clear corneal incision (Figs. 11C and D).
zoom view
Figs. 11A and B:
12
zoom view
Figs. 11C and D:
 
Results
  • Injury to cornea can occur.
  • Some time incision can split in vertical fashion.
Do's
Plane of crescent should be parallel to layers of cornea.
 
SIDE PORT INCISION
 
Observation (Fig. 12)
Blade is blunt as pressure on cornea is noticed.13
zoom view
Fig. 12:
 
Result
Difficulty to do incision.
Do's
Instruments should be sharp.
 
Observation (Fig. 13)
MVR blade is used for right side port incision in tilted fashion.
zoom view
Fig. 13:
 
Result
Injury to cornea can occur.14
Do's
MVR blade should be parallel to layers of cornea.
 
Observation (Figs. 14A and B)
Curved MVR blade is hitting iris.
zoom view
Figs. 14A and B:
 
Results
  • Injury to iris can occur in mechanical way or iridodialysis.
  • Constriction of pupil can occur which leads to difficulty in further steps.
  • Hyphema can occur.
Do's
MVR blade should pass parallel to the iris plane.