Phacoemulsification some Basic Ideas… Khalid M. Al-Arfaj, MD Dammam University.
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Transcript of Phacoemulsification some Basic Ideas… Khalid M. Al-Arfaj, MD Dammam University.
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Phacoemulsification some Basic Ideas…
Khalid M. Al-Arfaj, MDDammam University
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3-Vedio …
1-Quiz …
2- lecture …
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Case selection …
Anesthesia …
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Antibiotics
• Control blepharitis well before surgery (endophthalmitis usually results from lid flora)!
• Fluoroquinolones
Povidone-iodine• inexpensive• extremely broad-spectrum• irritating to eye in undiluted (10%)
solution; dilute to 5%• irrigate fornices with solution• paint, do not scrub, eyelashes
when prepping
Pre-operative Eyedrops
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History of small incisions
1977: Scleral tunnel1990: Sclerocorneal1991: Clear corneal1991-present: Variations in clear corneal
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Conjunctival peritomyDissection through Tenon’s fasciaCauteryScleral groove 1-2 mm posterior to the limbusScleral tunnelKeratome to enter the AC
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Advantages:Wound can be safely enlarged for conversion to ECCEConjunctiva covers the woundPotentially less endothelial damageAstigmatically neutral
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Disdvantages:Surgical exposure
Sunken eyeballProminent brow
Potential damage to ciliary bodyIris prolapseFiltering blebs and scarring make it difficult
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Keratome to tunnel and enter the eye .
Clear cornea
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Advantages:Can use topical anesthesiaFasterBetter surgical exposureFiltering blebs and scarring irrelevantNo subconjunctival hemorrhages
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Disadvantages:Pre-existing corneal problems a relative contraindication:
FuchsPrevious PK
Possible higher rate of endophthalmitis in unsutured casesBallooning of conjunctiva if incision too posteriorConversion to ECCE more problematic
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AstigmatismPre-existing ocular disease:
PterygiaFiltering blebsTubesEndothelial disease
Wound location
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Tunnel lengthGoal to be self-sealing“Square” incision
Depends on widthGenerally want at least 2.0-2.5 mm long
Sharp entry through Descemet’s membrane
Wound architecture
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External incisionToo anterior or too posterior
Internal incisionToo anterior or too posterior
TunnelToo long or too short
Incision widthToo narrow or too wide
Problems with the wound
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Wound Final Thoughts
The wound may be one of the easiest steps of cataract surgery, but it sets the stage for the entire caseEveryone may have a different phaco woundPrinciples the same
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Capsulorrhexis
Continuous curvilinear capsulorrhexis (CCC)It is a continuous tear capsulotomy.It can be made in the anterior capsule or both anterior and posterior capsules.It confines the IOL to the capsular bag.It assures long-term centration of the IOL.
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Technique
Completely fill the anterior chamber with viscoelastic agent.Flatten the dome of the anterior lens capsulePuncture the anterior capsule with a bent 30-gauge needle or sharp-tipped capsulorhexis forceps.Start a flap that flops over toward the incision.
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Technique
Grasp the flap with capsulorrhexis forceps (Utrata forceps).Spiral out to the desired diameter.Tear tangentially all the way around (no radial forces).Regrasp the flap as necessary.Keep an equal distance from the pupil margin while tearing.
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Hydrodissection & Hydrodelineation
Goals
Nucleus rotation
Epinucleus rotation
Loosen cortex
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Used to separate lens nucleus from surrounding cortex and capsule
Creates a freely mobile nucleusFacilitates nucleus rotation during phacoemulsification
Hydrodissection
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Used to separate epinucleus from harder nuclear material
Creates an epinuclear bowl that protects lens capsule during phacoemulsification
Hydrodelineation
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Hydrodissection cannula25- to 30- gauge
Flattened tip with angled or curved shaft
Facilitates placement under anterior capsule
J-shaped cannula may be used for sub-incisional area
Background
Technique …
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Complete several fluid waves to ensure adhesions to capsule broken
Proceed to hydrodelineationInject fluid into edge of nucleus“Golden ring” sign indicates epinuclear separation
Confirm that nucleus rotates
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Lens nucleus occludes capsulorhexis
Trapped BSS expands posterior capsule, AC shallows
Posterior capsule may rupture
Intraoperative Capsular Block Syndrome
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PHACODYNAMICS
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Two Basic Elements
US → Emulsify the CataractFluid circuit → cooling and remove the Emulsified Cataract
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Three Main Machine
Functions USFlowIrrigation
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Fluidics
IrrigationFlowVacuum
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Fluidics
Flow → peristaltic → vacuum only at occlusionVacuum → venture → continuous vacumBOTH → millennium
Flow control mode Vacuum control
mode
Type of Pumps
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Irrigation
Amount of fluid that enters the eye Depend on: Bottle
height pressure on
the eye
flow from the eye
Tip diameterWound leak
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Flow
Fluid leaving the eye ml/minSpeed with which the material is sucked to the tipControl pump speedNo-occlusion → current and attraction forceWith occlusion → rise time (time for maximum preset vacum)Flow rate
Surge Vacum riseSafety
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Vacuum
Holding power With occlusion → No flow
but pump will continue → negative pressure at aspiration line → vacum → Stop pump at maximum preset vacum
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Good Fluidics
Irrigation Wound Leak
Aspiration (flow)
Vacum
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Surge
Sudden ↓ of A/C pressure → collapse
Dynamic ↓ of vacum by surgeon by deocclusion
Bottle height Machine complianceVacum and flow rateTip diameter → resistance
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Flow
Flow depends on pump speed
not on bottle height
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US Power
mode of delivery
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USSafest phaco is with appropriate power not with the lower power
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Mechanism of Action
Jackhammer → direct contactCavitation → with cavitational bubblesSonic wave
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Mode = US Delivery
Continuous Pulse Burst
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Pulse
Fixed interval but linear power Fixed duty cycle
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Burst Mode
Fixed power of linear intervalVariable duty cycle
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Repulsion
Chatter → flaying of peace away from the PHACO tip
Mode - ↓ by Pulse , Burst and WS