Cataract Surgery: Simple techniques help avoid common pitfalls in manual small-incision surgery
In a previous article in Ocular Surgery News Europe/Asia-Pacific Edition, I described a technique that I call topical manual small-incision cataract surgery.
Surgeons who are transitioning from either extracapsular cataract extraction or phacoemulsification to topical manual small-incision cataract surgery may encounter a few small roadblocks. This article offers simple techniques to help avoid some of the common problems that can occur during the learning stage of topical manual small-incision cataract surgery.
Tips to overcome common pitfalls
Assess the nucleus size and hardness preoperatively. Always perform a good preoperative assessment of the nucleus because the nucleus size and hardness will influence the size of the incision. Patients with good peripheral red-orange reflex require only a 5.5-mm to 6-mm frown incision, while those with no red-orange reflex need a longer incision. Brunescent cataracts are better handled with ECCE.
In addition, note the texture of the nucleus equator after it has been subluxated into the anterior chamber. Some cataracts with good red-orange reflex actually are already quite hardened and dense, and for these types of cataracts, the wound should always be widened slightly.
Decide what type of capsulotomy to use. If you are an ECCE surgeon who is used to doing a can-opener capsulotomy, you can stick to that during the transition period. However, a continuous curvilinear capsulorrhexis is ideal, and switching to capsulorrhexis facilitates easier cortical cleanup and in-the-bag IOL implantation. I usually perform a continuous curvilinear capsulorrhexis in all of my cases. For slightly dense cataracts, I make four relaxing cuts in the capsulorrhexis to ensure that the lens can be easily subluxated and brought forward.
Perform meticulous hydrodissection to subluxate and bring the lens forward. Meticulous hydrodissection is essential, just as when doing phaco. Press down slightly on the nucleus in the mid-equatorial area so that it tilts. The nucleus edge then can usually be tilted over the iris and the turn movement done with the hydrodissection needle. If any difficulty is encountered, perform hydrodissection again. If it is still difficult, fill the chamber with viscoelastic and turn the nucleus with the chopper.
Use an adequately sized incision to deliver the nucleus. Most beginning surgeons are under the impression that they have to deliver the nucleus using the smallest opening possible. I always tell them to replace the word “smallest” with the word “safest” because ultimately a safe, smooth delivery produces the best result.
To deliver the nucleus safely, always perform a last-minute assessment of the wound size. If there is any doubt, widen the incision a little. It will take only a few seconds to throw in one closure stitch with 10-0 nylon. If a possibly hard nucleus is encountered, extend the incision to the edge of the nucleus equator on both sides, and the nucleus will then slide out easily.
Complete cortical cleanup through two side ports. An analysis of our cases revealed that most posterior capsular tears occurred during cortical cleanup, not during nucleus delivery. The main culprit was the habit of doing cortical cleanup through the main incision. This incision acts is a tri-planar valve, so any pressure on the wound causes the valve to open and the chamber to collapse. Instead of using the main incision, make two clear-corneal side ports at 3 o’clock and 9 o’clock, and complete manual cortical cleanup through these ports.
Learn to manage posterior capsular tears with vitreous loss. A posterior capsular tear with vitreous loss is a problem no surgeon wants to see, but sometimes it is unavoidable during cataract surgery. A future article will address the management of vitreous loss with manual instrumentation.
I hope these pearls will encourage more eye surgeons to try topical manual small-incision cataract surgery.
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- Miguel Tomas S. Sarabia, MD, is medical director of the Tony Chan Memorial Eye Center, West Visayas, Philippines.