Surgery: Phacoemulsification in a Dense Cataract

Dr. Fonseka: So she’s a 62 years, we’ve got a reasonably dense cataract here. I’m going to use 2.75 blade, and I was telling about the Mark on the keratome knife. So we know that this is roughly the length that is required for the main incision. That’s a brilliant blue, I’m washing that out. I love viscoat because it gives a lot of protection to the corneal endothelium, and especially in these cases where the cataract density is high. Slight depression on the center of the capsule, and then I raise it up, fold it over, grasp and regrasp, follow the edge of the pupil.
Now I’m going to do the hydrodissection and I’m going to use both my hands for this because I want a very controlled hydrodissection, just raise the capsule a little bit and inject, I can see the fluid wave. I hope you saw that went right through. I’ll just do it on this side as well. Can see that the nucleus is rotating freely. This is a 30 degree Kelman going sideways with the infusion on and aspirate a little bit of the viscoelastics to ensure there is flow. That’s a stop and shop, and then again, it’s a horizontal chop.
So we got four quadrants now. I just want to make sure it doesn’t come up and hit the endothelium. So I’m just going to use my second instrument to control these fragments. As you can see, I’ve left the last quadrant in the sub incisional area. At this quadrant, I’m going to be very careful, just going to come off the foot pedal frequently. So all the nuclear material is gone. So I go in with the infusion on, regrasp that and pull it to the center, so that’s in a radial fashion. There is a little bit of epinucleus here. If there is a fragment, which does not go in, you can always nudge it in with the infusion cannula. I am pulling it radially towards the center. And that part is clean.
So we got a little bit of fluff there. I’m going to now fill the anterior chamber and open up the capsular bag. Now it’s very important to make sure that the endothelium again is not damaged in any way. You need to be really very watchful about the endothelium. If the capsular bag is nicely opened up, then it’s possible for the lens to be implanted very easily into the capsular bag. We really don’t want these single piece IOLs anywhere else, except in the capsular bag. Usually the leading haptic goes in nicely. And if at all, you need to nudge the trailing haptic a bit. Once the viscoelastic is removed, it centers itself. And it’s very, very important to ensure that the anterior capsule covers the periphery of the optic. So there was a little bit of a plaque there.
I really didn’t want to do anything till I have the lens in. So again, as I said earlier, very, very important to make sure that the wounds are well-hydrated. If there is a wound leak, fluid from the forneces can ingress into the anterior chamber, and that’s deadly. And that has been nicely demonstrated in various papers. Q: You know, I love looking at your corneas postop day one, cause they’re so clear. Dr. Fonseka: As I said, I use a good viscoelastic like viscoat always and then make very, very sure that the endothelium is protected at all times. A lot of us are paranoid about the posterior capsule and sometimes we do forget about the importance of the endothelium and I cannot emphasize it enough.