prepared during lens session

1. Cataract extraction (Manual)
and cataract surgery in special
situation
Bipin Bista
Resident
Ophthalmology

2. Introduction
 Invaluable management of certain crystalline lens and zonular pathologies inappropriate for phaco.
 Choice of procedure based on a spectrum of factors and operative experience.
 Provides excellent rehabilitation of blindness from cataract .

3. Manual (Large incision) Cataract Surgery
 8-12 mm of arc length around limbus.
 Incisional position may vary in accordance to astigmatism.
 Sutures must not be overtightened

4. Suture removal criteria
 After 1 month, if wound dehiscence is required to correct cylindrical error (3-6 Diopters)
 After 2 months,if minor dehiscence is required.
 At 3-6 months to resume preop cylinder
 After 6 months to maintain surgically induced cylindrical correction.

5. Intracapsular Cataract Extraction
 Iris Management
 Vitreous presentation or prolapse
 Intraocular lenses.

6. Extracapsular Cataract Extraction
 Entails more steps than ICCE
 Anterior capsulectomy : Can-opener capsulectomy,linear capsulectomy & intercapsular techniques,
capsulorrhexis
 Nuclear expression
 Cortical wash-out
 Intraocular lens insertion

7. Extracapsular Cataract Extraction -
Indication
 For greater margin of safety.
 Compromised corneal clarity
 Poor pupil dilatation
 Posterior synechiae
 Zonular dehiscence ?
 Likelihood of capsule rupture with ?vitreous loss

8. ECCE - Preparation
 Aseptic preparation by applying betadine 10% solution , drying the lid margin with sponges, apply a
large plastic drape to the open lid and incise.

9. ECCE – Conjunctival Incision
 Fornix based flap to expose the limbus using 7 mm peritomy with oblique relaxing incisions
extending from the limbus about 3 mm posteriorly .
 Obliterate all visible surface vessels posterior to the anterior limbus.

10. ECCE – Scleral Incision
 Measure 10 mm by calipers, 3 mm posterior to limbus.
 Partially penetrating incision using 300 disposable steel microsurgical blade.
 Parallel groove with the limbus.
 Perpendicular to the groove.
 Lamellar dissection using Crescent Blade.
 Anterior dissection being careful with depressing the heel of Crescent to avoid premature
penetration
 Dissection should be about 4 mm till the point of AC entry.
 Use of keratome/phaco blade for AC entry parallel with iris.

11. Anterior Capsulectomy
 Fully inflate the AC with a viscoelastic
 Use of 27-gauze needle with a micro-hook at its tip (Cystotome) for 6-7 mm capsulectomy.
 ‘can opener’ : simplest type of capsular opening, closed , pinpoint perforations are created in a
central, circular tract in anterior capsule. Centripetal traction is given. Better in cases of small pupil
and poor visibility.
 Linear capsulectomy & intercapsular techniques : curvilinear incision made in the upper third of
anterior lens to create a slit or envelope opening.
 Capsulorrhexis : quick and once learned easy technique for anterior capsule removal, best security
for the IOL within the capsular bag. Should be parallel to the pupillary margin. Diameter of 6 mm

12. Removal of the nucleus
 Following hydrodissection, Nucleus is separated from cortex/capsule.
 Prolapse the superior lens nucleus into the AC.
 Pass the irrigating vectis or McIntyre 26-gauze cannula (Fishhook)
 Move the tip to the 2 o’clock position and slide beneath the margin of the anterior capsular leaflet
 Retract the leaflet firmly so that cannula will pass beyond the equator
 Maintain posterior pressure against the scleral wound while holding the shaft of instrument parallel with
plane of iris to bring nucleus forward.
 Slowly there will be cleavage of nucleus from posterior capsule.
 Commonly a rumpled shell of epinuclear cortex strips away and remains adjacent to the wound lip.

13. Removal of cortex
 Use of Simcoe’s I/A cannula
 Insertion through 2.5 mm wound segments.
 Insert tip gently beneath the iris and into the capsular fornix
 Ensure the tip around into the pupillary space.
 Increase the aspiration vacuum, once the aspiration tube is free of other content and is aspirating
cortex.
 Polish the posterior capsule with Kratz scratcher, if residual fibrotic material is hard to come away
then plan for YAG laser capsulotomy.

14. Implantation of the Lens
 Inflate the AC with Visco.
 Additional visco beneath the anterior capsular flap to inflate the capsule for “in the bag” insertion.
 In case of sulcus implantation, visco should be used to flatten the residual anterior capsular flap against
the posterior capsule to permit inflation of the space of the ciliary sulcus.
 Hold lens with lens insertion forceps and slide into the anterior chamber and tilt it to position the haptic in
capsular bag.
 Rotating the haptic 7 o’ clock or 8 o’ clock.
 Proper placement & rotation using iris hook.
 Superior haptic is flexed sufficiently to rotate into a horizontal position.
 Minimise manipulation of the lens to avoid dislocation of haptic from capsular bag into sulcus.

15. Cataract surgery in special condition
 Psychological consideration
 Systemic consideration
 External ocular abnormalities
 Corneal condition
 Compromised visualisation of lens
 Altered lens and zonular anatomy
 Extremes in axial length
 Glaucoma and cataract
 Uveitis
 Retinal condition
 Following pars plana vitrectomy
 Ocular trauma

16. Psychological consideration
 Claustrophia “vocal local”
 Dementia or other mental disabilities : toleration of sedation, GA,

17. Systemic Consideration
 Medical Status : Hypertension and diabetes.
 In case of diabetic patient are asked to fast after
midnight before surgery, with adjustment of
hypoglycemic.
 Keep patient in revesed Trendelburg position to
reduce venous congestion to head and neck
and lessen the risk of VH & choroidal
haemorrhage.
 Scleritis & uveitis should be minimised / control.
 Extreme challenge in cases of arthritis / cervical
sponditis/ ankylosing spondylitis

18. Anticoagulant therapy or Bleeding
Disorders
 Special consideration in cases on chronic anticoagulation therapy.
 TIA, CVA, MI, PE & failure of bypass grafts.
 Risk of ocular complications : Suprachoroidal haemorrhage, RB haemorrhage, & hyphaema .
 Retrobulbar haemorrhage is 3 times higher in patient receiving anti-coagulants.
 Discontinuation of the anti-coagulant should be decided by the prescribing physician.
 Should be asked regarding use of medications like aspirin , vitamin E & K.
 Look for chronic liver disease, bone marrow suppression, clotting factor deficiency & malabsorption
syndrome.

19. External ocular abnormalities
 Blepharitis & Acne Rosacae : control is necessary to prevent from endophthalmitis, go for hot
compression and eyelid scrubs, plugging of the meibomian gland and by foaminess and vascularisation
of the eyelid margin. Systemic tetracycline is the mainstay as it saponifies inspissated meibomian
secretion.
 Keratoconjunctivitis Sicca : optimising dry eye prior to surgery improves the visual outcomes. Aqueous
layer supportive treatment, intraoperative desiccation of the corneal epithelium can be prevented by
irrigating solution or by coating the cornea with viscoelastic.
 Close observation in patient under post operative steroid as it may cause collagenase activation.
 Bandage (Therapeutic) contact lens , tarsorrhapy, or amniotic membrane transplant for persistent
epithelial defects with stromal loss.
 Pemphigoid : causes severe dryness d/t scarring of meibomian glands & accessory lacrimal glands &
occlusion of lacrimal gland orifices. Gentle speculum should be kept to avoid traction on globe.

20. Corneal conditions
 Important refracting element
 Identification is important.
 Dry eye, blepharitis, and epithelial basement dystrophy
 Corneal irregularities interfere with accurate keratometry & leads to incorrect lens power.
 Wait for at least 6-8 weeks for smoothening & stabilisation
 Corneal stromal opacities are unlikely to reduce VA.
 If cornea is too opaque, combined surgery – PK/EK.

21. Cataract following keratoplasty
 Cataract may be due trauma , prolonged corticosteroid use to prevent graft rerjection.
 Scleral tunnel is approached .
 Post-operative graft failure is reduced by graft evaluation , protection of endothelium with a
viscoelastic agent.
 Delayed until all PK sutures are removed, contour are stable, and accurate keratometric readings
can be obtained for IOL power selection.
 Preferable is PCIOL because they minimise contact, in cases of any inadequate capsular support
then PCIOL is sutured to the sclera or iris

22. Cataract following refractive surgery
 IOL power calculation & visual outcome are less predicitive.
 Clinical must thoroughly inform the patient about the limits of precision in power calculation.
 Postoperative hyperopia is more commonly encountered after cataract surgery.
 There will be post-operative corneal swelling thereby flattening the cornea and inducing hyperopia,
this swelling may require more than 3 months to resolve.
 Corneal cataract incision should be placed between RK incisions.
 Incisional violation may lead to destabilisation of wound.
 LASIK require 1 month to resolve the swelling.

23. Compromised visualisation of the lens
 Small pupil : Bimanual pupil stretching
(Kugler/Lester hooks) or tethering the iris with
hooks or pupil expansion devices. Extensive
manipulation may lead to increased post-
operative inflammation. Use of Visco is
another method.
 Poor red reflex : difficult to discriminate the
capsular edge, thereby increasing the chance
for incomplete capsulorrhexis. Corneal
scarring also make surgery
treacherous.Easier staining with Tryphan Blue

24. Altered lens & zonular anatomy.
 Advanced cataract
 Intumescent cataract
 Iris coloboma and correctopia
 Posterior polar cataract
 Zonular dehiscence with lens subluxation or dislocation
 Exfoliation syndrome
 Cataract in aniridia

25. Advanced cataract
 Surgical manipulation increases the chance for iris trauma, zonular tearing, capsular rupture,
vitreous loss & dropping of lens fragments into the posterior segment.
 Increased Ultrasonic power may lead to increase the risk of endothelial trauma & wound burn.
 Helpful to create larger capsulorrhexis.
 Excessive mechanical force may lead to excessive mechanical force on a nucleus.
 Mechanical separation of nucleus decreases total ultrasound time when divides into small pieces.

26. Intumescent cataract
 Cataract has become swollen and enlarged with cortical material that often envelops a hard
nucleus floating inside capsular bag.
 These cataracts have weak zonular fibers and fragile capsules.
 Creates postitive pressure in the capsular bag, so the initial capsular entry may extend outward
toward the lens periphery.
 High viscosity OVD exerts pressure on anterior capsule and maintains chamber depth.

27. Iris coloboma & corectopia
 Commonly associates with zonular
dehiscence or absence.
 Revealed by pharmacologic dilatation.
 Iris hooks, capsular tension ring – helps to
stabilise and serve as an artificial iris
diaphragm.
 Surgeron has also option to repair the
coloboma with suture.

28. Posterior polar cataract
 High risk of capsular rupture in case of absent or weak area of posterior lens capsule .
 Surgeon should avoid creating excessive pressure.
 Small volumes of fluid are directed around the cortex upto but not cross the opacity.
 Gentle hydrodelineation is carried out, leaving a generous amount of epinuclear bowl.
 AC depth should be maintained & fluctuation in IOP should be controlled.
 Adherent posterior polar opacity is treated by laser capsulotomy.

29. Zonular dehiscence with lens subluxation
or dislocation.
 Iridodonesis / Phacodonesis detected at the slit
lamp may be the initial findings .
 Sometimes remaining zonular fibers may tether
the lens within the anterior vitreous which seems
upright in slit but tilts backward on supine and is
outreached for AS surgeons.
 Determine zonular status by observing lens
equator or by use of a goniolens to visualise
zonular fibers .
 If zonular disruption encompasses greater than
1200 go for ECCE/ICCE
 If weakness is less than 1200 use capsular
hooks/capsular tension ring.

30. References
Ophthalmology : yanoff and duker : 4th Edition
American academy of ophthalmology : section 11 : 2014-2015

31. THANK YOU