PHACO STEP.pptx

phacoemulsifikasi surgery step

1. PHACOEMULSIFICATION SURGERY STEPS

2. Site Marking and Time Out the surgeon, uses marking pens or stickers to identify the operative eye to prevent errors in surgical site Information typically reviewed during the time-out includes patient name, patient date of birth, procedure, operative eye, and type and power of the intraocular lens (IOL).

3. Exposure of the Globe After the anesthesia has been administered and the eye has been prepared and draped in sterile the eyelids are held apart with an eyelid speculum

4. Clear cornea incision for the main incision  2.2-3.2 mm wide, biplanar or multiplanar incision Create stable and watertight incision (minimize wound leakage and endophthalmitis) Length of the wound should permit optimal visualization Too long  surgeon may have problem manipulating phaco tip to AC Too short  incision may not seal properly Clear cornea incision

5. Biplanar self-sealing biplanar incision. A beveled blade is flattened against the eye created with beveled , trapezoidal diamond blades The blade is oriented parallel to the iris, and the tip is placed at the start of the clear cornea The blade is tilted up and the heel down so that the blade is angled 10° from the iris plane

6. Triplanar a diamond or metal blade is used to create a 0.3-mm-deep groove perpendicular to the corneal surface Another blade is inserted into the groove, and its tip is then directed tangentially to the corneal surface C reating a tunnel through clear cornea into the anterior chamber.

7. Paracentesis paracentesis incision : insertion of a second instrument, introduction of intracameral additives, and placement of iris hooks. Using A small sharp blade, such as a 15° blade A straight entry plane is made parallel to the iris or at a slight downward angle The operating microscope’s light reflecting off the paracentesis blade can be used to ensure that the blade is parallel to the iris plane.

8. Continous Curvilinier Capsulorrhexis (CCC) Advantages of CCC : Allows the surgeon to choose from a wide range of phacoemulsification techniques Resists radial anterior capsule tears that could extend around and open the posterior capsule Stabilizes the lens nucleus, allowing maneuvers to disassemble it within the capsular bag (thereby reducing trauma to the corneal endothelium)

9. Continous Curvilinier Capsulorrhexis (CCC) begins a CCC with a central, radial cut in the anterior capsule using a cystotome needle or capsulorrhexis forceps the end of the radial cut, the needle is either pushed or pulled in the direction of the desired tear then engages the free edge with either forceps or the cystotome needle T he flap is carried around in a circular manner (Courtesy of Lisa Park, MD.) . AAO BCSC 13. Lens and Catarct

10. Hydrodissection is performed to separate the peripheral and posterior cortex from the underlying posterior lens capsule Places a bent, blunt-tipped 25-to 30-gauge cannula or flattened hydrodissection cannula attached to a 3-to 5-mL syringe under the anterior capsule flap Hydrodissection Gentle irrigation continues until a wave of fluid moving under the nucleus and across the red reflex

11. This separates the harder endonucleus from the softer epinucleus Hydrodelinitation In less brunescent cataracts, a fluid wave can be seen separating the endonucleus from the epinucleus and producing the “golden ring” sign.

12. Difficulty in rotation may suggest : inadequate hydrodissection loose zonular fibers posterior capsule rupture Nucleus Rotation Nucleus Disassembly and Removal steps: S culpting Cracking Chopping Grasping E mulsifying

13. Two main modes or settings are used during phacoemulsification: Sculpt (if using a “divide and conquer” technique) or chop (if using a chopping technique) Segment removal

14. Location of Emulsification Posterior Chamber Iris Plane Anterior Chamber Techniques of Nucleus Disassembly Phaco fracture “ divide and conquer ” technique Chopping techniques Horizontal phaco chop technique Stop and chop Vertical chopping techniques

15. The phaco tip lifts while the chopper depresses P lace the chopper under the capsular rim and around the equatorial nucleus.

16. Irigation & Aspiration Once phacoemulsification of the nucleus has been completed, a plate of soft epinucleus or transitional cortex may rest on the posterior capsule. phaco needle used to accomplish irrigation and aspiration (I/A) without ultrasound reduced vacuum and flow settings can be employed to aspirate this material from the capsular fornix or posterior capsule.

17. Irigation & Aspiration The I/A functions may also be separated using a bimanual technique A spiration port is introduced through the paracentesis incision while irrigation through a second paracentesis maintains the anterior chamber. A dvantage of this technique is that it allows the surgeon to more easily reach the subincisional cortex. D isadvantage is that the anterior chamber may become unstable if the flow rate through the aspiration handpiece out- paces the influx of fluid through the separate irrigation handpiece.

18. IOL Insertion In uncomplicated cataract surgery, the goal is generally to place an IOL into the capsular bag The surgeon must determine whether the support structures within the eye are adequate to maintain IOL centration and stability With posterior capsule rupture, sufficient anterior capsule support may allow a 3-piece PCIOL to be safely placed in the ciliary sulcus Complete lack of capsular support warrants placement of an anterior chamber lens (ACIOL) or a scleral-or iris-fixated posterior chamber lens.

19. After IOL Insertion removes the OVD from the anterior segment to minimize the risk of increased postoperative IOP To reproduce physiologic IOP, balanced salt solution is instilled via the paracentesis incision to reform the anterior chamber. Hydration of the corneal incision : temporary stromal swelling and increases the wound apposition Courtesy of Professor Uday Devgan MD is a Los Angeles Cataract Surgeon who authors CataractCoach.com

20. Thank You