Cataract Extraction with Phacoemulsification and Posterior Chamber Intraocular Lens

Anesthesia

1. Pre-op holding
1. Intravenous sedation - Remifentanil
2. Peribulbar block with 50/50 mix of 2% lidocaine and 0.75%
2. Honan balloon is placed for 5-10 minutes
1. Intraoperative
2. Intravenous midazolam

Patient Positioning

3. Patient is transferred to surgical eye bed and placed in supine position
4. Surgical site is prepped with 5% povidone-iodine. A drop is placed on the ocular surface and the periocular skin and lids are prepped

Exposure

5. Aperture drape placed over operative eye
6. Small Tegaderm cut in half to drape eye lashes of the upper and lower lid
7. Lid retraction with angled wire Lieberman speculum
8. Balanced salt solution for irrigation throughout the case to maintain surgical view

Surgical Approach

9. Paracentesis
1. 1.1-mm side port blade (1.1-mm Clearport-Sharpoint) is used to create paracentesis tract parallel to iris plane approximately 3-4 clock hours from the main incision
2. Intracameral injection of dispersive viscoelastic (Viscoat-Alcon) to pressurize eye
10. Temporal clear corneal incision
1. 2.5-mm keratome (2.5-mm angled slit, bevel up keratome blade-Sharpoint) is used to create a triplanar corneal incision just anterior to the surgical limbus
11. Capsulotomy
1. 27 gauge cystotome on cohesive viscoelastic is used to create the initial capsulotomy and capsular flap
2. The purpose of the cohesive viscoelastic is to control the tear if needed. If the capsular tear is going radially toward the equator of the lens, some viscoelastic injected over the tear can immediately gain control of the radial tear and allow the surgeon to recover the capsulotomy
3. The anterior capsule is punctured centrally
4. The capsular tear is propagated toward the 9 o'clock direction with a slight “smile” configuration that helps to facilitate a controlled flap toward the 12 o'clock direction
12. Continuous curvilinear capsulorhexis
1. Utrata forceps are then used to grasp the capsular flap, and in a clockwise fashion, complete a continuous curvilinear capsulorhexis
2. The clockwise direction of the tear allows for completion of approximately 75% of the capsulorhexis before reaching the sub-incisional capsule. This technique allows for a significant amount of capsule to be available to help facilitate the capsulorhexis through the sub-incisional space
13. Hydrodissection and hydrodelineation
1. Balanced salt solution on a flat cannula is injected under the anterior capsule to separate the cortex from the epinucleus and nucleus of the cataract
2. This step is critical in allowing free rotation of the lens nucleus for nuclear disassembly
3. A fluid wave should be visible as the BSS separates the nucleus from the cortex and capsule
4. Hydrodelineation is seen here as well. This creates another separation between the epinucleus and nucleus. The golden ring sign can be seen. The epinuclear shell can be another barrier of protection for the posterior capsule during nuclear disassembly.
5. The BSS cannula is used to rotate the lens nucleus to confirm mobility
14. Phacoemulsification
1. Phacoemulsification handpiece (30-degree mini-flared Kelman ABS tip) is then placed through the temporal corneal incision
2. Minimal central cortical cleanup is performed. This will leave longer cortical tags. This will be useful during cortex removal later in the case
3. Phacoemulsification in scolpt is used to create a central groove essentially demarcating 2 heminuclei. The groove should be deepest where the cataract is largest in anterior posterior dimension. Care should be taken not to groove deeply in the periphery as the A/P dimension of the lens is less, and the posterior capsule can be more easily encountered
4. Grayson Nucleus manipulator is then placed through the paracentesis deep into the groove along with the phaco tip. Using minimal pressure posteriorly to keep the instruments at the base of the groove, the Grayson and phaco tip are separated, splitting the nucleus into 2 heminuclei
5. Lens nucleus is rotated with the Grayson, and the heminucleus is grooved and cracked in similar fashion. This is repeated with the second heminucleus
6. Quadrant removal settings are then used to remove the 4 lens quadrants
7. Phaco is performed at the iris plane, which provides a safe distance from both the capsular bag and the corneal endothelium
8. Epinucleus is removed with the phaco handpiece
15. Cortical removal
1. Cortical remnants are removed with coaxial irrigation/aspiration handpiece (silicone sleeve straight I/A tip).  Linear aspiration instead of fixed aspiration allows for controlled purchase of the cortical material, especially sub-incisional
2. Sub-incisional cortex is the first to be removed. This is where leaving a cortical tag allows for easier removal of cortex. Straight I/A tip is rotated with aspiration port rotated posteriorly to purchase the cortical tags sub-incisionally. This is done with minimal wound distortion. After purchase of the cortical tag, the aspiration port is rotated anteriorly into the central safe zone to complete aspiration of that cortical material
3. The remaining cortex can be removed with the aspiration port placed under the anterior capsular edge, again polling towards the central safe zone
16. Capsular polish
1. Nightingale capsular polisher is used to clear the posterior capsule of any residual lens epithelium
2. This is inserted through the temporal incision while the capsular bag is deflated
3. This allows for the Nightingale to rub off any adherent lens debris
17. Inflation of capsular bag
    1. Cohesive viscoelastic is injected into the capsular bag to create space for injection of the IOL
    2. Injection of posterior chamber IOL
    3. Wound-assisted technique using the Platinum 1 injector
    4. The IOL is injected with the leading haptic aimed into the capsular bag
    5. Trailing haptic is placed into the capsular bag with a Kuglen hook
    6. The haptics are left in the 3- and 9-o'clock position
18. Removal of viscoelastics
    1. Irrigation-aspiration handpiece is used to aspirate the viscoelastic in the capsular bag and anterior chamber
    2. Reform the anterior chamber with balanced salt solution
    3. BSS is injected in the temporal incision while hydrating the corneal stroma
    4. This helps to seal the corneal incision
    5. Paracentesis is also hydrated
    6. The eye is left with intraocular pressure of about 15-20 mmHg

Check Incisions

19. Gentle pressure is placed at the posterior wound edge to test for wound stability and leakage
20. Suture if necessary
    1. If the wounds are not water tight, then interrupted 10-0 nylon suture is placed in the wound. Knot is rotated and buried
21. Remove lid speculum
22. Immediate postoperative care
23. Dress eye with antibiotic/steroid ointment, soft eye patch and hard shield

Postoperative Care

24. Topical antibiotic, non-steroidal, and steroid eye drop 4 times a day for 1 week, then non-steroidal and steroid eye drop twice a day for 3 weeks.
25. Eye shield at bedtime for 1 week
26. Limited physical activity for 1-2 weeks
27. Follow-up appointments at 1 day, 1 week, and 1 month post-op
28. Post-op refraction at 1 week