6/7/2011
Phacoemulsification
The Jorge N. Buxton, M.D.
Microsurgical Education Center Video
WELCOME RESIDENTS Robert Block, M.D.
STOP BEFORE YOU START SET-
PHACO MACHINE SET-UP
TIME-OUT !
TIME-
PRE-OP CHECKLIST
Learn how to set-up your phaco machine
yp y
Verify patient identity
Learn how to assemble phaco handpiece
Verify proper procedure
Learn how to tune and prime the phaco
Verify proper operative site
handpiece
Verify implant power
SET-
MICROSCOPE SET-UP Instrument Tray
Have all instruments ready before you begin
15 blade
Cystitome
Keratome
Cannulas
Zero and clean objectives and optics Second Instrument
Trypan Blue Capsule Dye
Make certain foot pedal is operational
Viscoelastics
Iris Hooks
Lens Insertion Device and Cartridge
Lens Implants
Topography Maps
1
6/7/2011
Block the correct eye Position the Patient
p g
Position head to optimize surgical access
Verify operative site
Chin-up !
Topical, peri- or retro-bulbar block
Tape head with chin up
Prep and Drape Patient Before you scrub....
Micturate and Evacuate BEFORE you
Irrigate with Povodine Iodine
operate...
Scrub Draping Patient
Drape lids and lashes with Tegaderm
Irrigate ith B l d S lt S l ti
I i t eye with Balanced Salt Solution
Consider taping face mask before you scrub (BSS) before placing speculum to avoid
corneal abrasion
Gently place eyelid speculum
2
6/7/2011
Sit Down Focus Microscope
Adjust table to proper height Position scope over eye
Adjust your stool to proper height Zoom to high power
Keep your back straight and chin up Gross focus, then fine focus
Focus microscope Zoom to low power
Fixate Eye Side-
Create Side-port Incision
Use 15-degree blade, MVR blade, diamond
Thornton Ring
blade, or Stiletto blade
Wide Clot Forceps placed opposite
Wid open Cl t F l d it
Place incision about 22 degrees away from
incision
phaco incision at limbus
0.12 Forceps (can cause subconjunctival
Watch internal ostium and tip of blade enter
hemorrhage)
the anterior chamber!
Side-
Create Side-port Incision Side-
Side-Port “Second Incision”Blades
Do not pierce anterior lens capsule with
blade
WATCH THE TIP OF THE BLADE AS IT
ENTERS THE ANTERIOR CHAMBER
3
6/7/2011
Cannulation Trypan Blue Capsule Staining
Follow the vector of the side-port incision
with the cannula p
Cannulate side port incision
Having trouble ? Inject air bubble into anterior chamber
Retract and press cannula down and toward Inject trypan blue into anterior chamber
the pupil
Trypan Blue Capsule Staining Trypan Blue Anterior Capsule Staining
Trypan Blue Removal Viscoelastic Fill
Bleed viscoelastic cannula to remove any
Place Balanced Salt Solution (BSS) cannula bubbles
g p
through side-port incision
Place viscoelastic cannula into anterior
Inject BSS and gape incision at the same chamber
time to allow fluid egress/flush out
“BACKFILL” the chamber with viscoelastic
DO NOT OVERFILL CHAMBER
Withdraw viscoelastic cannula
4
6/7/2011
Phaco Incision Keratome
y
Fixate eye g
Single Bevel vs. Double Bevel
Place Keratome at limbus Steel Blade vs. Diamond Blade
Create Clear Corneal Incision Blade Size (mm): 1.8, 2.2, 2.5, 2.65, 2.75
Keratome Keratome
Incision Construction Incision Construction
“Clear Corneal” vs. “Near- Clear Corneal”
“Tri-Planar” vs. “Simple Stab”
5
6/7/2011
Continuous Curvilinear Capsulorrhexis Continuous Curvilinear Capsulorrhexis
Tearing a circular opening in the anterior
capsule
Howard Gimbel, M.D.
Continuous Curvilinear Capsulorrhexis Continuous Curvilinear Capsulorrhexis
Initiate capsulorrhexis with cystitome
Place cystitome on viscoelastic syringe for
chamber refilling
Inspect the “beak” of the cystitome
Continuous Curvilinear Capsulorrhexis Continuous Curvilinear Capsulorrhexis
“Start in the center, and make me a nice
clock arm” - John M. Aljian, MD Drag the cystitome across from the center,
don’t dig into the cortex !
6
6/7/2011
Continuous Curvilinear Capsulorrhexis Continuous Curvilinear Capsulorrhexis
Back-up cystitome 1mm, sneak beak under
capsule, and lift up capsule to create dog ear Lift that flap
flap Lead your flap
Continuous Curvilinear Capsulorrhexis Continuous Curvilinear Capsulorrhexis
Capsulorrhexis “Utrata” Forceps
Continuous Curvilinear Capsulorrhexis Continuous Curvilinear Capsulorrhexis
Walk that ‘rrhexis around the eye
7
6/7/2011
Continuous Curvilinear Capsulorrhexis Continuous Curvilinear Capsulorrhexis
Pull up the flap- so that it stands up in the
HOLD ON !! DO NOT LET GO OF THE FLAP chamber
WHEN YOU NEED TO RE-GRAB IT !! It will then be easy to re-grasp
Continuous Curvilinear Capsulorrhexis Continuous Curvilinear Capsulorrhexis
AVOID RE-GRASPING UNDER THE INCISION
Stand up the capsule flap in the chamber
Let go RE-GRASP BEFORE YOU TRAVERSE UNDER
Then re-grasp the capsule THE INCISION
Hydro-dissection
Hydro-dissection
Hydro-
Gently tuck tip of hydro-dissection cannula
under anterior capsule rim
Gently irrigate, watch for “fluid wave”
8
6/7/2011
Hydro-
Hydro-dissection You have to “Spin to Win”
Consider re-positioning cannula if fluid wave
not achieved Gently k l “di l l
G tl rock nucleus, or “dial nucleus” t ” to
Bevel the cannula tip anteriorly or make certain it is free from its attachments
posteriorly while gently irrigating to find to the lens capsule.
cleavage plane
Pre-Phaco
Pre- Pre-
Pre-Phaco
Irrigate/Flush Phaco handpiece
Check silicone sleeve position for phaco tip Start with machine set to “Sculpt Mode”
exposure Enter eye in “Foot Pedal Position 1”
Check handpiece tubing connections
Phaco Foot Pedal Phaco Foot Pedal
REFLUX “Spit it out” : Treadle to the left
g
Irrigation: Position 1
Cautery
Aspiration/Vacuum: Position 2
Phaco Mode Change
Phacoemulfsification: Position 3
Change Irrigation Bottle Height
9
6/7/2011
Pre-
Pre-Phaco Pre-
Pre-Phaco
Engage upper lip of wound with 0.12
p
forceps and lift Gently remove the cortex from area inside
Insert Phaco tip into eye with a downward your capsulorrhexis
vector towards pupil “Take the icing off the top of the cake”
Do not engage Descemet’s Membrane
Clearing Surface Cortex Clearing Surface Cortex
Removes some viscoelastic from eye and
avoids phaco tip overheating
Exposes the anterior surface of the lens
nucleus
The “Second Instrument” The “Second Instrument”
Start with a blunt paddle or ball tip DO NOT DRIFT
Advance to Chopper DO NOT ENGAGE ENDOTHELIUM
10
6/7/2011
Nuclear Irrigation / Aspiration
Deconstruction Without Complications
Ken Rosenthal, M.D. Jonathan Ellant, M.D.
11