Tips MSICS 2016

Tips in MSICS
Anuchit Poonyathalang, Ramathibodi Hospital,
Petchrada Ung-aram,
Buriram Hospital,
Thanapol Liratpong,
Hospital
General Police
Cataract Surgery Volunteers Group Princess Mother Medical
Volunteers Foundation (PPMVF) www.pmmv.or.th [email protected] : www.rcopt.org
The Royal College of Ophthalmologists of Thailand
Patient selection
โหงวเฮ้ง
• Good exposure: Canthotomy
• Aware Zonules & Iris: PXS
• Wound Design
• Temporal approach has less astigmatism
than superior
Peritomy Reverse L shape
To reduce wound hemorrhage and post
op Hyphema
- Cauterize blood vessels at distal end not
the bleeding spot
- big vessel usually in conjunctiva
- Cauterize blood vessel not the sclera
itself , avoid wound shrinkage, post op
pain and scleral melting
-Cauterize
beyond
groove for
possible
extension
Scleral incision and tunnel
- curvilinear most easy
- Depth 50 – 60 %
- Width 7–8 mm, dark brown or nigra 11-12
mm.
SCLERAL GROOVE
‘curvilinear most easy
‘Depth 50 – 60 % ‘Width yellow 7–8 mm, dark
brown or nigra 11-12 mm
‘If bleeding from inside
groove cauterize root of
vessel.
Moving crescent
knife in first block
like a catfish, then
extend as windshield
wiper with forward
direction
designed length
intrascleral 2 mm.
intracorneal 1 mm.
- If there is big blood vessel in mid sclera
please move tunnel more in to the cornea
to avoid intratunnel bleeding
- Inner bigger than outer ( trapezoid
shape )
Fully dilated pupil by adding
Intracameral medicaine 0.2cc.+ BSS 0.3cc
Intracameral adrenaline 0.1+ BSS 0.4cc
Before CCC
• Zonule condition
• Stain anterior capsule with Tryphan blue
for
– White cataract
– Anterior capsular cataract with scar
– Black brown cataract , vitreous
hemorrhage
( no axial light reflex )
J Cataract Refract Surg. 2008 Aug;34(8):
1367-73. doi: 10.1016/j.jcrs.2008.03.041.
Effect of trypan blue on the elasticity of
the human anterior lens capsule.
Dick HB1, Aliyeva SE, Hengerer F.
Trypan blue staining
affected the biomechanical
properties of the human lens
capsule and led to a
significant reduction in
elasticity and an increase in
stiffness.
Timing of staining :
live cells possess intact cell
membranes that exclude
trypan blue
Capsular opening CCC circular curvilinear capsulorhexis
Mild cataract 8 mm.
Brown cataract 10 mm. +/- relax
Nigra 10 mm. with relax
Relaxing incision
: symmetrical 180 to each other
: 4 to 16 points depend on size of nucleus
and
CCC
-
CCC in white cataract
Tryphan blue
Center piercing
aspirate milky cortex as much as possible
Inject viscoelastic in anterior chamber
and capsular bag
• CCC : MSICS Ruit PMMV/ Petchrada
• Not success every case
•
•
•
•
CCC in Nigra
Complication
• Capsulorhexis tear-out rescue
- Backward traction on the capsule flap
Brian C Little, et.al J cataract Refract Surg 2006;
32:1420-2
- Unfold to flat capsule, use capsule forceps
pull to opposite direction
- Then pull toward center
- Then pull back to the normal CCC
Nuclear expression
• Hydrodissection by dragging anterior
capsule to equator
• At that moment use the blunt ended of the
viscoelastic needle bring up the nucleus
equator while injecting balance salt solution
under the nucleus
• ( Heavy nucleus use viscoelastic )
• ( Two handed one push one lift “ use spatula
push nucleus down to opposite end the
proximal end will automatic lifted )
2 handed technique and viscoelastic
push iris down ( Dr. Vitoon )
Nuclear extraction
• Now a part of nucleus is on one side on iris
• Use needle, hook or simcoe rotate nucleus up
in oblique direction until whole nucleus is on
the iris
• Some occasion pupil became constrict,
do not try to drag or pull nucleus up with
force it may cause iris root tear and hyphema
post operative can be found,
if nucleus do not come up use viscoelastic
push
iris down under nucleus.
Nuclear extraction
• Now nucleus is in anterior chamber and is on
the iris
• Check size of wound again if nucleus is big or
thick please extend wound
• Left hand : use corneal forceps to firmly
grasp the left side of sclera for beginner test
the firmness by move the eye back and forth
• Right hand : use Ruit corrugated simcoe to
fill anterior chamber with BSS, water
pressure will push nucleus to the wound
Nuclear extraction
• Left hand grasp sclera firmly in primary
position while Right hand move tip of
simcoe sideway along iris surface and swing
the curved part of simcoe under nucleus.
( Do not put tip of simcoe straight direct
under nucleus it may rupture capsule. )
• Then let BSS fill in anterior chamber and
hold nucleus in its palm
• Use corneal forceps on left hand move eye
to nasal side while right hand use simcoe to
press down sclera and pull the nucleus out ,
slowly
1
2
3
Cortex aspiration
• Because the wound is bigger than normal
anterior chamber tends to leak
: Fold the cornea inward to decrease wound
length
• Subincision cortex is difficult to aspirate
: use simcoe with aspiration hole up and do
the aspiration while moving tips left to right,
or use simcoe tips to polish posterior capsule
then aspirate the cortex or create a side port.
IOL insertion
• In stable anterior chamber, IOL can be inserted
under BSS with simcoe
• In rather flat chamber insert IOL under
viscoelastic
• Anterior chamber wash out
• Check wound with cotton bud or weck-cel
sponge
• If there is fluid leakage put 10-0 nylon. Wound
hydration usually not helpful.
• Cauterize conjunctiva, a little more than
approximation to press the tunnel watertight.
Thank you
Nuclear extraction
• Hydrodissection by dragging anterior capsule to
equator. At that very moment use the blunt
ended of the viscoelastic needle bring up the
nucleus equator while injecting balance salt
solution under the nucleus ( if nucleus is heavy
inject viscoelastic to open space between lens
equator and capsule )
• Or: Use simcoe to flush one side of nucleus up
• Or: Two handed technique : Use the Sinskey
Lens Hook push nucleus at the other end of
wound entrance, nasal nucleus now sink down
the proximal end will be lifted.
FAILED EXTRACTION
Calm down
Inadequate incisional size
Wrong position simcoe
Incomplete subluxation
Obstruction of surgical exist ( double tunnel )
Increase water influx