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1. Cataract Surgeries Roxanne Kanga

2. Overview & History Couching first cataract surgery introduced by Sushutra from India in 600 BC cataractous lens was pushed into the vitreous cavity crude extracapsular cataract extraction introduced in 1745 became unpopular due to marked complications Intracapsular cataract extraction (ICCE) was introduced in 19th century. It has stood the test of time and had been widely employed for about 100 years over the world (1880-1980).

3. Extracapsular cataract extraction (ECCE) The surgical techniques of ECCE presently, in vogue are: Conventional extracapsular cataract extraction (ECCE) Manual small incision cataract surgery (SICS), Phacoemulsification. Femtosecond laser assisted cataract surgery (FLACS).

4. Advantages of ECCE >>> ICCE 1. ECCE is a universal operation and can be performed at all ages, except when zonules are not intact, whereas ICCE cannot be performed below 40 years of age. 2. Posterior chamber IOL can be implanted after ECCE, while it cannot be implanted after ICCE 3. Postoperative vitreous related problems ( such as herniation in anterior chamber, pupillary block and vitreous touch syndrome) associated with ICCE are not seen after ECCE 4. Incidence of postoperative complications such as endophthalmitis, cystoid macular oedema and retinal detachment are much less after ECCE as compared to that after ICCE 5 . Postoperative astigmatism is less with ECCE techniques, as the incision is smaller. 6. Prognosis for subsequent glaucoma filtering or corneal transplantation (if required) is much improved with ECCE. 7. Incidence of secondary rubeosis in diabetics is reduced after ECCE.

5. Demerits of con ventional ECCE over SICS Long incision (10 to 12 mm). Multiple sutures are required. Open chamber surgery with high risk of vitreous prolapse, intraoperative hard eye and expulsive choroidal haemorrhage. High incidence of postoperative astigmatism . Postoperative suture-related problems like irritation and suture abscess , etc. Postoperative wound-related problems such as wound leak, shallowing of anterior chamber and iris prolapse. Needs suture removal, during which infection may occur.

6. SICS vs Phaecoemulsification Universal applicability. all types of cataracts including hard cataracts (grade IV and V) Learning curve- much easier to learn as compared to phacoemulsification. Not machine dependent - thus can be practised anywhere. Less surgical complications - Disastrous complication like nuclear drop into vitreous cavity is much less than in phacoemulsification technique. Cost effective

7. Surgical procedure: ICCE

8. Sup erior rectus bridle suture Conjunctival flap Partial thickness groove or gutter Corneoscleral section Iridectomy Lens delivery Smith indian method Cryoextraction Capsule forceps method Wire vectis method Formation of anterior chamber Implantation of ACIOL closure of incision Conjunctival flap Subconjunctival injection Patching of eye

9. Surgical procedure: conventional ECCE

10. 1. Superior rectus (bridle) suture – to rotate the globe and maintain control 2. Conjunctival flap – usually fornix-based, to expose sclera/limbus 3. Haemostasis – control bleeding using cautery 4. Partial-thickness groove (gutter) – at the limbus, facilitating entry. 5. Corneoscleral (or limbal) section – to open the wound. 6. Injection of viscoelastic – to maintain the anterior chamber and protect the endothelium. 7. Anterior capsulotomy, via techniques such as Can-opener, L inear (envelope), C ontinuous curvilinear capsulorrhexis (CCC). 8. Removal of anterior capsule – using forceps (e.g., Kelman–McPherson). 9. Completion of corneoscleral section – enlarging the entrance enough for nucleus delivery. 10. Hydrodissection – to separate nucleus from cortex.

11. 11. Nucleus delivery – by: Pressure–counterpressure method, or Irrigating wire vectis technique. 12. Aspiration of the cortex – using irrigation–aspiration cannula (e.g., Simcoe's). 13. Implantation of posterior chamber IOL – often PMMA, into the capsular bag. 14. Closure of incision – with multiple interrupted or continuous 10-0 nylon sutures. 15. Removal of viscoelastic substance – aspirated before final suturing. 16. Repositing conjunctival flap – securing it, frequently with wet-field cautery. 17. Subconjunctival injection – typically dexamethasone + gentamicin, followed by eye patching.

12. Manual small inc ision cataract surgery Superior rectus bridle suture Downward gaze for fixation of globe Countertraction force during delivery of nucleus Conjunctival flap Sharp tipped scissors Along limbus 10-2 o clock Conjunctiva separated from sclera → 4 mm strip of sclera along entire incision length exposed Hemostasis Wet field cautery

13. SCLEROCORNEAL TUNNEL Triplanar Self sealing Funnel shaped

14. Cresent knife

15. Sharp tip 3.2 mm keratome

16. Side port entry 1.5 mm corneal inc ision 9 o clock position Aspiration of cortex, deepening anterior chamber

17. Capsultotomies Can opener method Envelope method

18. CCC By a bent 26 G needle - cystitome Hydro dissection Separating nucleus from cortex

19. Nuclear mana gement Irrigating wire vectis Visco expression → push visco through 6 o clock position Sandwich method Blumenthal Fish hook method Phacofracture

20. Aspiration of cortex By Simcoe’s 2 way irrigation and aspiration cannula IOL implantation By McPherson’s IOL holding forceps Removal of viscoelastic material Simcoe's Wound closure Anterior chamber deepened by salt solution/ RL Conjunctival flap - uniplanar → stromal ligation of side port

21. PHAECOEMULSIFICATION

22. Complications Intraoperative Posterior capsule rupture. Vitreous loss. Zonular dialysis. Suprachoroidal hemorrhage. Early Post-op Corneal edema, raised IOP, hyphema, endophthalmitis. Late Post-op Cystoid macular edema. Posterior capsular opacification (after-cataract).

23. Self-sealing scleral tunnel incision (5–6 mm). Continuous curvilinear capsulorrhexis (CCC). Hydrodissection + nucleus delivery (viscoexpression / vectis). Cortical cleanup with Simcoe cannula/I&A. IOL implantation in capsular bag or sulcus. Advantages: Low cost, no advanced machines. Diadvantage: Larger incision → astigmatism. Surgical procedure: manual SICS

24. Clear corneal incision (2.8–3.2 mm). Capsulorrhexis + hydrodissection. Nucleus fragmented & emulsified with ultrasound probe. Cortical cleanup with I/A. Foldable IOL inserted with injector. Advantages: Small incision, less astigmatism, faster recovery. Disadvantage: Expensive, requires technology. Surgical procedure: Phaecoemulsification

25. Intraocular Lens Types Material: PMMA (rigid), Acrylic, Silicone (foldable). Optics: Monofocal, Multifocal, Toric, EDOF. Position: Posterior chamber (bag/sulcus), Anterior chamber, Iris-fixated. Techniques of Implantation Preferred: In-the-bag (best stability). Sulcus placement (if bag compromised). ACIOL (if no capsular support).

26. Postoperative management Medications : Antibiotic drops (5–7 days). Steroids (4–6 weeks, taper). NSAIDs (prevent CME). Lubricants. Care : Eye shield at night × 1 week. Avoid rubbing, water, dust. Follow-up : Day 1, Week 1, 4–6 weeks (final refraction).