SICS

Small incision cataract surgery presentation

1. Small Incision Cataract Surgery Kumar Vaibhav 3 rd Year MD Ophthalmology Resident BPKLCOS, TUTH 1

2. Layout Preparation & Draping Bridle Suture Peritomy Sclerocorneal Tunnel Capsulotomy Hydroprocedures Nucleus management Iol insertion 2

3. Anaesthesia Retrobulbar injection 3 Site: Junction of medial 2/3rd and lateral 1/3rd of lower lid adjacent and parallel to orbital floor Peribulbar block: 8-10ml Retrobulbar block: 2-4ml Lignocaine 2 % with Adrenaline 1:000000 Bupivacaine 0.5 % Hyaluronidase 1500 IU to 20ml bottle of lignocaine Administering an eye anaesthetic: principles, techniques, and complications Ahmed Fahmi and Richard Bowman Community Eye Health. 2008 Mar; 21(65): 14–17 .

4. Preparation & Draping Betadine S tart centrally and move peripherally Do not return back to eye Betadine is allowed to dry for upto 2 minutes Dry eyelashes and periorbital area so that drape sticks Elevate superior eyelid and place drape directly over eye Get all eyelashes under drape Tuck lashes back under lids while placing eye speculum 4

5. Bridle Suture To maneouvre globe Also provides counter-traction force during Nucleus extraction D ouble angulated forceps A ngulated tip measures 7.7 mm to grasp the superior rectus from the limbus It is held with tip pointing face down towards conjunctiva, and superior rectus is fixed through intact conjunctiva and held with help of toothed forceps 5

6. Move the muscle from side to side, test hold of muscle and make sure the globe moves accordingly 4–0 silk suture is passed under area held by forceps Kalt’s needle holder Hold like a raquet 6

7. Superior rectus muscle grasped Suture passed under the muscle Globe steadied by pulling and clamping suture 7

8. Complications Globe Perforation!! Pass needle exactly under the area of muscle grasp and lift the forceps holding the muscle while doing so Keep the tip of needle upwards after the initial pass and take a small bite Bleeding Avoid larger vessels of conjunctiva while taking bite Muscle Injury (Laceration, Avulsion) Failed Bridle Suture Post Op Ptosis 8

9. Conjuctival Peritomy The opening of conjunctival flap Forceps ( Colibri/Pierce Hoskin ) in non-dominant hand and conjunctival scissors in dominant hand The flap is based toward the fornix Initiate at 10 o’clock Westcott conjunctival scissors: slightly blunted points to avoid globe injury. Spring action ensures minimum pressure required only to close the tip and guards against excessive opening of the blade. 9

10. Grasp conjunctiva just behind limbus with forceps and a firm vertical traction to create a conjunctival fold so that conjuctiva and tenon’s can be held together Cut from conjunctival scissors should be vertical with limbs of scissors perpendicular to scleral surface Conjunctival/tenon opening with exposure of underlying sclera 10

11. Blunt dissection of conjunctiva is carried by inserting blades (closed) beneath tenon capsule. The tip has to be directed toward limbus & blades opened to separate tenons from underlying sclera 11

12. The conjunctiva is then cut at limbus. 12

13. An ideal conjunctival peritomy exposes the blue limbal zone without any overhanging conjunctival epithelium Peritomy of approx 8mm in length and 4mm in width is often sufficient in size A proper blunt dissection would have ensured that there is bare sclera at the bed without any islets of tenons 13

14. Cautery Wet-field bipolar cautery Allows visualization of instrument during tunnel creation Prevent/minimises bleed into anterior chamber intra and post-operatively Disadvantages of sclera cautery: Scleral thinning and scleral necrosis can occur Poor wound healing 14

15. Tips: Apply point cautery to scleral bleeders only Cautery of limbal “blue zone bleeders” has to be avoided Cauterized tenons is difficult to separate from sclera Cautery should not be applied after sclera incision and tunneling 15

16. Limbal Paracentesis Port* Side port Keratome 1-2 clock hours away from internal corneal incision Helps in AC depth maintainance Staining Anterior Capsule Cortical clean up 16

17. Staining Anterior Capsule* Air is pushed in AC Trypan blue is used to stain the anterior capsule Trypan blue is washed out AC maintained with viscoelastics 17

18. Scleral Incision Introduced by Paul Ernest Self sealing cataract incision, Corneal valve incision Components of Scleral incision External sclera incision – constructed by blade/surgical knife Sclerocorneal tunnel – constructed by tunnel blade/crescent knife Internal corneal incision – created by keratome 18

19. External Scleral Incision 1 to 2 mm posterior to limbus 19

20. Length : Titrate according to density of lens nucleus, but minimum being 6.5mm Instruments: Colibri forceps in non dominant hand grasp the scleral tissue and blade/crescent knife in dominant hand mark Incision Castroviejo Colibri Forceps Crescent Bevel Up 20

21. Koch described, seal-sealing incisions were astigmatically neutral Koch PS. Structural analysis of cataract incision construction . J Cataract Refract Surg 1991;17 (Suppl .):661–667. Imaginary pair of curved lines, incision made within them will be astigmatically neutral and the more anterior the incision is made the higher will be the astigmatism 21

22. Shapes: Frown incision Straight incision Smile incision Inverted batwing incision Chevron incision 22

23. The Incision Depth Optimal depth: ½ to ¾ of scleral thickness 23

24. Sclerocorneal Tunnel Construction Initiation – Finding right plane Propagation – Maintaining the plane and widening of tunnel Keratotomy – Entry into AC to create a third plane for the valve effect Extension – Extending the inner corneal lip 24

25. Sweep the incision with tip of crescent blade (bevel up) to make incision smooth, nonragged, and of uniform depth Judge the depth of incision by looking at the blade trans-sclerally Propagate the blade with swiveling action 25

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27. Lateral swiping movements to be done so that tilt of blade is along and equal to contour of globe Direct the tip of blade towards a higher plane at limbus to match Corneal curvature Button Hole!! Pre mature entry!! 27

28. Extend the tunnel upto 1.5mm in clear cornea Use a bevel down keratome and dimple- down technique to enter AC and create a third plane gives for valved effect . Once AC is entered, keep keratome parallel to plane of iris and extend tunnel with forward cutting movement 28

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30. Complications Irregular incision Buttonhole Premature entry Descemet’s membrane detachment 30

31. CAPSULAR OPENING Opening the anterior capsule Stable enough to prevent anterior capsular tears from continuing to posterior capsule. It should be of adequate size CAN OPENER TECHNIQUE ENVELOPE CAPSULOTOMY CONTINOUS CURVILINEAR CAPSULORRHEXIS 31

32. Instruments Pierse Hoskin/Colibri Forceps Bent Cystotome Needle Capsulorrhexis Forceps Viscoelastics 32

33. Can opener Technique 33

34. The Good: Easy to learn High number of tears share forces thus reducing chances of radialisation The Bad: Capsular tags are difficult to differentiate from cortex, during cortical clean up 34

35. Continuous Curvilinear Capsulorrhexis A puncture is made in central anterior capsule Puncture is directed peripherally either in a clockwise or counterclockwise fashion Tear is led in a circular fashion Control is achieved by grasping about 2 clock hours away from free flap edge closest to leading fold of capsule Leading tear around Initiation with puncture Turning the flap over 35

36. 36 Shearing force T earing force or Ripping Force

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38. The Good: Easier cortical clean up Promotes stability and centration of IOL Resists anterior capsular radial tears Safe hydrodissection and in-the-bag lens rotation The Bad: More experience to master Large CCC may promote IOL dislocation from bag Small CCC will have difficulty in prolapse of lens into anterior chamber Requires excellent visualisation 38

39. Envelope Technique 39

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41. Conventional: separation of superficial cortex from epinucleus Separation of cortex from capsule 41

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44. LOOK FOR Advancement of fluid Anterior movement of nucleus Stretching of CCC Deepening of anterior chamber 44

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46. Hydrodelineation Separating outer epinuclear shell from central compact mass of inner nuclear material, the endonucleus, by the forceful irrigation of fluids (balanced salt solution) into the mass of the nucleus P erformed in cases of Posterior polar cataract 46

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49. Prolapsed lateral pole of nucleus Nucleus prolapse with Sinskey hook 49

50. Wire Vectis 50

51. Viscoexpression 51

52. Fish Hook Technique “Lahan technique” or “Hennig technique” Introduced in 1997 by Dr. Albrecht Hennig in Lahan Eye Hospital in Nepal Fish hook made from 30 G needle Hydrodissection, upper pole of nucleus brought in AC Hook inserted between nucleus and posterior capsule, tip turned so that it inserts into the central lower nucleus 52

53. Cortex Removal Simcoe cannula Tackle most accessible parts first, such as inferior and nasal parts Two small hollow metal tubes Each tube has a hub for attachment Infusion line goes in infusion hub Syringe in the needle hub Tip of the cannula is blunt 53

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56. IOL Insertion PMMA lens 56

57. S means STOP!! 57

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61. To confirm whether the IOL is in bag look for these: A ppearance of stretch lines in center of the posterior capsule To visualize shiny appearance of anterior capsular rim over haptic 61

62. Wash the viscoelastics Checking the Wound Integrity: Gently tap on dome of cornea or at limbus opposite to wound with hydro-cannula. Hydro the side port 62

63. Intracameral antibiotics Cefuroxime 1mg per 0.1ml 0.1 % Moxifloxacin (0.5 % moxifloxacin add 4ml BSS) Vancomycin 1mg per 0.1ml 63

64. Check the wound again Indications for suturing: A leaking tunnel Premature entry or button-hole Pediatric patient Posterior capsular rent with vitreous disturbance Vertical sutures Cross sutures Vertical sutures 64

65. Sub conjunctival injection Remove speculum Recheck the eye Apply ointment Keep an eye pad 65

66. References: Manual Small Incision Cataract Surgery Second Edition by Aravind Eye Care System Manual Small Incision Cataract Surgery First Edition Bonnie An Henderson. Springer Publication Small incision cataract surgery: Mini-review by Parikshit M Gogate Published in Indian J Ophthalmol. 2009 Jan-Feb; 57(1): 45–49 . Small incision cataract surgery: tips for avoiding surgical complications article by Reeta Gurung and Albrecht Hennig Published in Community Eye Health. 2008 Mar; 21(65): 4–5 . Internet sources 66

67. THANK YOU 67