Intra capsular cataract extraction (ICCE) was an early surgical technique for removing cataracts but had high complication rates. Extra capsular cataract extraction (ECCE) was developed to address these issues by leaving the posterior capsule intact. ECCE became the standard technique with improvements in microscopes, irrigation/aspiration systems, and intraocular lenses. Phacoemulsification, an ECCE variant using ultrasonic fragmentation, further reduced complications through smaller incisions allowing faster recovery.
Bangalore Call Girl Whatsapp Number 100% Complete Your Sexual Needs
Cataract surgery
1. 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
2. Intra capsular cataract extraction (ICCE)
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
3. Techniques (ICCE)
Smith’s method
Arruga’s method
Erysiphakes
Cryo surgery
Chemical dissolution of zonular fibers
4. 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
5. 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
8. 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
9. Chemical dissolution of zonular fibers
The enzyme is irrigated into posterior chamber to
dissolve the zonular fibers in order to facilitate ICCE
surgery
Enzyme alpha-chymotrypsin enhances the safety of
ICCE by increasing the ease of lens removal
10. 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
11. 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
12. 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
13. Indications of ICCE
Operating microscopes not available
Unstable / luxated cataracts
Week zonular support
14. Advantages of ICCE
• Entire lens removed with no capsule left behind to:
• Opacify or
• Require additional surgery
• Less sophisticated instrumentation required
• Non automated extraction devices:
Cryoprobes
Capsular forceps
Erysiphakes
Allow this procedure
To be performed
Under most conditions
15. Disadvantages of ICCE
• Large ICCE incision 12 – 14 mm (160° - 180°)
Delayed healing
Iris incarceration
Delayed visual rehabilitation
Vitreous incarceration
• 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%)
16. Disadvantages of ICCE (cont’d)
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
17. Disadvantages of ICCE
(cont’d)
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
19. Patient preparation
(cont’d)
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
20. Patient preparation
(cont’d)
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
21. Patient preparation
(cont’d)
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
22. Patient preparation
(cont’d)
ECCE
ECCE involves removal of the nucleus and
cortex through an opening in the anterior
capsule (anterior capsulotomy), leaving the
posterior capsule in place.
25. Advantages of ECCE surgery (cont’d)
Smaller incision
Less traumatic to corneal endothelium
Eliminates complications (short and long
term) associated with vitreous adherent to:
Incision wound
Iris
Cornea
26. Advantages of ECCE surgery (cont’d)
Intact posterior capsule allows better anatomical
position for IOL fixation
Intact posterior capsule ↓ incidence of:
CME
RD
Corneal edema
27. Advantages of ECCE surgery (cont’d)
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
28. 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
29. 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
30. 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
31. 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
32. 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
33. Lens nucleus
Removed by a variety of techniques, each
with its own set of instruments:
Lens expressor
Lens loop
Spoon, Vectis
34. 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
35. Procedure ECCE
(cont’d)
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
39. Procedure ECCE
(cont’d)
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
40.
41. Procedure ECCE
(cont’d)
Capsulorrhexis (cont’d)
This technique provides:
Structural integrity for the lens capsule
Maintain implant stability
Centeration
44. Posterior capsular polishing
Abrasive tipped irrigation cannula / low
vacuum clean using low aspiration
remove epithelial and cortical particles
from the capsular surface
45. 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
47. 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
48. 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
49. 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
50. 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
51. 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
52. 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
53. 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)
60. 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