Small Incision Cataract Surgery

Small Incision
Cataract Surgery
(Manual Phaco)
basmala blog (always original)
Small Incision
Cataract Surgery
(Manual Phaco)
Kamaljeet Singh MS
Associate Professor
Department of Ophthalmology
MLN Medical College
and
Consultant Ophthalmologist
State Institute of Ophthalmology
Allahabad, India
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Small Incision Cataract Surgery (Manual Phaco)
© 2002, Kamaljeet Singh
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First Edition: 2002
Publishing Director: RK Yadav
ISBN 81-7179-932-9
Typeset at JPBMP typesetting unit

Printed at Lordson Publishers (P) Ltd., C-5/19, RP Bagh, Delhi 110 007
To
My respected parents
Pitaji, Late S Amar Singh Saluja
and
Mataji, Smt Ram Rakhi Saluja
Contributors
AK Grover MD Gagandeep Singh Brar MD
Senior Consultant Assistant Professor
Ganga Ram Hospital Department of Ophthalmology
New Delhi, India Postgraduate Institute of Medical
Education and Research
Amar Agarwal MS FRCS FRCOphth (Lon)
Chandigarh, India
Medical Director
Agarwal's Eye Hospital Gopal S Pillai
13 Cathedral Road Senior Resident
Chennai, India Dr RP Centre for Ophthalmic Sciences
All India Institute of Medical Sciences
Amporn Jongsareejit MD
New Delhi, India
Mettapracharak (Raikhing) Hospital
Sampran Nakornpathom HC Chandola MD
Thailand Associate Professor
BK Singh MS Department of Anaesthesiology
Eye Surgeon MLN Medical College
State Institute of Ophthalmology Allahabad, India
Allahabad, India HK Tiwari MD
BN Chaudhary MBBS Professor and Chief
Senior Divl Medical Officer (NE Rly) Dr RP Centre for Ophthalmic Sciences
Junior Resident All India Institute of Medical Sciences
Department of Ophthalmology New Delhi, India
MLN Medical College
Harinder Sethi MD
Dr RP Centre for Ophthalmic Sciences
Allahabad, India
D Swarup MS New Delhi, India
Medical Superintendent Harpreet Singh
State Institute of Ophthalmology Registrar
Allahabad, India Ganga Ram Hospital
Daljit Singh MS New Delhi, India
Consultant Ophthalmologist Hector Bryson Chawla FRCS
Amritsar, India Consultant Ophthalmic Surgeon
Dinesh Talwar MD Royal Infirmary
Addl Professor Edinburgh, UK
Dr RP Centre for Ophthalmic Sciences Jagat Ram MD
All India Institute of Medical Sciences Department of Ophthalmology
New Delhi, India Postgraduate Institute of Medical Education
and Research, Chandigarh, India
Francisco J Gutiérrez-Carmona MD PhD
Department of Ophthalmology KS Kathait MS
Hospital General de Segovia Eye Surgeon
Segovia, Spain Jaunpur, India
viii Small Incision Cataract Surgery (Manual Phaco)
KPS Malik MD P Mishra MS

Head, Department of Ophthalmology Professor and Head
Safdarjung Hospital RMMCH, Annamalai University
New Delhi, India Annamalainagar
Tamil Nadu, India
Kamaljeet Singh MS
Associate Professor P Venkatesh MD
Department of Ophthalmology Lecturer
MLN Medical College and Dr RP Centre for Ophthalmic Sciences
Consultant Ophthalmologist All India Institute of Medical Sciences
State Institute of Ophthalmology New Delhi, India
Allahabad, India
P Vijayalakshmi MS DO
Kuldeep Kr Srivastava MS Arvind Eye Hospital and
Arvind Eye Hospital and Postgraduate Institute of Ophthalmology
Postgraduate Institute of Ophthalmology 1, Anna Nagar
1, Anna Nagar, Madurai, India
Madurai, India
PC Saxena MD DM (Card)
Lalit Verma MD
Head and Professor
Additional Professor
Department of Cardiology
MLN Medical College
Allahabad, India
New Delhi, India
Pankaj Puri MD
MK Rathore MS Senior Registrar
Head and Professor of Ophthalmology Ganga Ram Hospital
Rewa Medical College New Delhi, India
Rewa, India
Prashant Bhartiya MD
MP Tandon MS Senior Registrar
Associate Professor Dr RP Centre for Ophthalmic Sciences
Department of Ophthalmology All India Institute of Medical Sciences
MLN Medical College New Delhi, India
Allahabad, India RN Misra MS
Ex-Director, Professor
Mahipal S Sachdev MD
Medical Director
MLN Medical College
New Delhi Centre for Sight
New Delhi, India
Allahabad, India
Monika Joshi
Senior Resident RP Singh MS
Department of Ophthalmology Senior Eye Surgeon
Lady Harding Medical College State Institute of Ophthalmology
New Delhi, India Allahabad, India
Mool Chand Rajesh Sinha MD DNB

Senior Resident Senior Registrar
Dr RP Centre for Ophthalmic Sciences Dr RP Centre for Ophthalmic Sciences
All India Institute of Medical Sciences All India Institute of Medical Sciences
New Delhi, India New Delhi, India
Nikhilesh Trivedi MS Rajiv Vaish MS
Ophthalmic Surgeon Consultant Ophthalmologist
Balaghat, India Allahabad, India
Contributors ix
Rasik B Vajpayee MS Sunita Agarwal MS
Professor of Ophthalmology Consultant Ophthalmology
Dr RP Centre for Ophthalmic Sciences Agarwal's Eye Hospital
All India Institute of Medical Sciences Bangalore, India
New Delhi, India
TN Vyas MS
Ruchi Goel MD Department of Ophthalmology
Department of Ophthalmology MLN Medical College
Safdarjung Hospital State Institute of Ophthalmology
New Delhi, India Allahabad, India
S Thanikachalam MD
Tanuj Dada MD
Lecturer in Ophthalmology
Lecturer
RMMCH, Annamalai University
Annamalainagar
Tamil Nadu, India
New Delhi, India
Sarita Bajaj MD DM (Endo)
Department of Medicine VK Srivastava MS

MLN Medical College Senior Eye Surgeon
Allahabad, India State Institute of Ophthalmology
Allahabad, India
Shweta Pandey MS
Ex-Resident VP Gupta MS
Allahabad, India Vipin Bihari MS
Director, Professor
Subodh K Agarwal MS Department of Ophthalmology
Consultant Ophthalmologist MLN Medical College
Lucknow, India State Institute of Ophthalmology
Sumeet Jain MBBS Allahabad, India
Junior Resident
MLN Medical College
Allahabad, India
Foreword
T
he aim of quality modern cataract surgery is to achieve an optimal visual result by the
removal of a reduced nucleus through a small incision without inflicting irreparable
damage on the corneal endothelium.
Contrary to fashionable belief, expensive equipment is no obligatory, indeed, particularly if
not well maintained, it can be a positive hindrance. It certainly raises the cost at the outset and can
often increase the possibility of things going wrong at any time later.
Manual phaco is relevant to both the developing and the developed world and DrKamaljeet
Singh and his co-authors have succeeded admirably in their attempt to cover the subject in all its
aspects. Each chapter gives step by step instruction that will delight the converted and tempt
those not yet persuaded of its importance.
From the start of my career I have tried not to be dependent on complicated equipment except
where necessity commands and not only is manual phaco-section my chosen approach to the
cataract of others, it would also be to my own, where surgery ever to be necessary.
Hector Bryson Chawla FRCS (Ed.)

Consultant Ophthalmic Surgeon
Royal Infirmary, Edinburgh
Scotland
Preface
T
he sense of sight, according to Sydney Smith, is indeed the highest bodily privilege, the
purest physical pleasure, which man has derived from his Creator. The onus of maintaining
this wonderful gift throughout life rests on the skills of an ophthalmic surgeon. Through the
period of time these surgical skills have undergone many innovations and advances. The journey
of cataract surgery has evolved from the eighteenth century Jacques Daviel’s extracapsular surgery
to the present-day extracapsular surgery of phacoemulsification with foldable lenses. Modern day
phacoemulsification with foldable intraocular lenses is being practiced in almost ninety percent of
the patients in the developed countries of the world. The surgery has improved to a level where
surgeons are implanting intraocular lenses through less than 1mm incision, giving patients almost
instant vision. Today Indian surgeons are marching shoulder to shoulder with their Western
counterparts in the progress made in the world of ophthalmology. Many surgeons in India have
proved beyond doubt that they are highly skilled and given the opportunity they can perform
equally well if not better than the more fortunate Western ophthalmologists.
Unfortunately, the benefits of improved technology and technique in phacoemulsification are
being availed by a fortunate, comparatively wealthy few in the developing world. Majority of the
masses has to go through the ordeal of intracapsular surgery with its attendant hazards of aphakic
spectacles. In recent times at least ECCE IOL has been made available to the teeming millions of
the developing world, thanks to the untiring efforts of the WHO. But sutures, astigmatism and
complications like posterior capsular opacification and decentration accompany this surgery.
Therefore, on one end of the spectrum we have phaco surgery with foldable lenses practiced by
the resourceful surgeons and availed by the wealthy few. While on the other, patients coming from
the lower strata of society have to bear with aphakic spectacles. In fact, in a developing country like
India, our primary goal should be to strive hard to provide all the benefits to the common man at
minimum possible costs. In achieving this goal, manual phaco or the non-phaco small incision
cataract surgery (SICS) can be extremely helpful. It has almost all the advantages of
phacoemulsification, namely, less astigmatism, early mobility, less decentration and at the same
time, is as inexpensive as ECCEIOL. This book has been written precisely with the above-mentioned
goal in mind. The main purpose of this book is to explain the various surgical manouvers with
diagrams, photographs and a detailed text. Simple steps, explained in easy language, are the
hallmark of this book. It is hoped that this may stimulate the reader towards this surgery, which
may prove to be significant for easy transition. An attempt has been made to acquaint the reader
with almost all the subjects of IOL surgery by this technique so that he does not feel the need to
turn to any other book.
The book begins with the history of cataract surgery, which is so important to understand as the
technique has evolved tremendously in a very short span of time. Preoperative evaluation and
various anesthetic techniques are very significant in giving good surgical results. Subjects like diabetes
and hypertension management have been specially included in the book as they have become so
widespread that their effective management must be clear to all the surgeons. An effort has been
made to describe all the techniques of nucleus delivery to achieve the same objective, that is, a
sutureless anastigmatic result. Readers are requested to go through each chapter with care and
form their own impression of the benefits and risks involved in each technique. It is advisable to
follow the systemic approach of one step and one technique at a time. Postoperative complications
and their management pertaining to this particular surgery have also been dealt with exhaustively.
Management of endophthalmitis, posterior dislocation of lens and posterior capsular opacification
xiv Small Incision Cataract Surgery (Manual Phaco)
form separate chapters in this book due to their significance in obtaining good surgical outcome.
Paediatric cataract surgery through tunnel—a complicated subject has also been extensively covered.
Eminent surgeons, of national and international repute, who have a vast experience and
knowledge in this particular field of surgery, have contributed in this book. They are confident of
this surgery, have provided excellent results and through their concisely written chapters, with
photographs and diagrams, have provided substance to this book. I am extremely grateful to them
for giving their best in the shortest possible time. Finally, this book would be considered successful
only if the reader could deliver the objective of providing good vision at economical cost to maximum
number of patients.
Kamaljeet Singh
Contributors xv
Acknowledgements
I
n presenting this work I have been supported by several friends, teachers, colleagues and family
members. I am deeply indebted to my friends Dr Mahipal S Sachdev and Dr Amar Agarwal
who mainly motivated me to write this book. I am immensely thankful to Prof RN Misra who
encouraged me to initiate this work and has been a constant source of inspiration for me. I am also
grateful to Prof Vipin Bihari for permitting me to use the existing facilities in the department.
I am indebted to many colleagues and residents in the department who have not only drawn
the diagrams but also painstakingly read the proofs for which I especially acknowledge Dr Sanjay
Sharma, Dr Sumeet Jain, Dr Pawan Kumar and Dr Riyaz Khan. I also thank Dr JD Jain and Dr AK
Chadha for their valuable suggestions.
I extend my gratitude to my two special residents—Dr BN Chowdhary and Dr KS Kathait, who
have worked with me for over three years and have suggested several improvements in the technique
of manual small incision cataract surgery.
My thanks are also extended to Alcon Labs (India) for providing beautiful illustrations as well as
to the Journal Survey of Ophthalmology (Elsevier) and The Highlights of Ophthalmology for their
copyright permission for the Table No and Figure No.
I also wish to express my gratitude to Mr Jitendar Vij and the staff of Jaypee Brothers who never
got ruffled by my regular urgent calls for preparation of this manuscript. Mr Vinod and Mr Vivek
Naithani of Allahabad, the father and son team, did the typing work with meticulous accuracy, to
them I am highly obliged.
I will fail in my duty if I do not thank my wife Dr Anuja for her help and timely suggestions, as
also for calming me in my moments of anxiety while I was preparing this book.
My special appreciation to Anuja, my daughter Manika and my son Pranav, for patiently bearing
the loss of special moments in the preparation of this mammoth task.
I am extremely grateful to Dr Hector Bryson Chawla, who despite his busy schedule always gave
me a helping hand and never disappointed for any demand. I am also thankful to Dr Jongsareejit
for his timely response.
Contents
1. .Anatomy of the Lens ......................................................................................... 1
BN Chaudhary, Kamaljeet Singh
2. .History of Cataract Surgery ............................................................................... 4
Kamaljeet Singh, KS Kathait
3. .Sterilization ...................................................................................................... 9
Sunita Agarwal, Amar Agarwal
4. .Viscoelastics ................................................................................................... 35
VP Gupta
5. .Comparison of Various ECCE Techniques ....................................................... 43
Kamaljeet Singh, Vipin Bihari

6. .Management of Diabetes in Cataract Surgery .................................................. 47
Sarita Bajaj
7. .Management of Hypertension in Cataract Surgery ........................................... 52
PC Saxena
8. .Preoperative Evaluation for SICS .................................................................... 54
Kamaljeet Singh, Sumeet Jain
9. .Biometry ......................................................................................................... 56
D Swarup
10. Ocular Anaesthesia ......................................................................................... 61
Kamaljeet Singh, VK Srivastava
11. Anaesthetist's Role in Ocular Surgery ............................................................. 65
HC Chandola
12. Postoperative Infections: Prevention and Management .................................... 68
Jagat Ram, Gagandeep Singh Brar
13. The Manual Small Incision: Surgical Aspects—I ............................................. 75
Mahipal S Sachdev, P Mishra, S Thanikachalam
14. The Manual Small Incision: Astigmatic Considerations—II ............................. 84
Mahipal S Sachdev, Pradeep Venkatesh
15. Capsulotomy for Small Incision Cataract Surgery ........................................... 86
AK Grover, Pankaj Puri, Harpreet Singh
16. Hydroprocedures ............................................................................................ 94
Subodh K Agarwal
17. Nucleus Prolapse from Capsular Bag .............................................................. 98
RP Singh, BK Singh, BN Chaudhary
18. The Phaco Sandwich Technique .................................................................... 101
Kamaljeet Singh
19. Modified Fish Hook Technique...................................................................... 107
Rajiv Vaish
20. Manual Phaco-fracture .................................................................................. 110
Rajesh Sinha, Prashant Bhartiya, Rasik B Vajpayee
xviii Small Incision Cataract Surgery (Manual Phaco)
21. Microvectis Technique .................................................................................. 1 1 3

P Mishra, S Thanikachalam
22. Modified Blumenthal's Technique ................................................................. 1 1 7
KPS Malik, Ruchi Goel
23. Small Incision Manual Phaco-section Using the
.Anterior Chamber Maintainer ....................................................................... 1 2 3
Hector Bryson Chawla
24. Manual Multiphacofragmentation: A New Technique for Cataract Surgery .... 1 2 8
Francisco J Gutiérrez-Carmona
25. The New Method of Manual-phacofragmentation (Phaco-drainage) ................ 1 3 2
Amporn Jongsareejit
26. Temporal Tunnel Incision in SICS ................................................................. 1 3 6
MK Rathore
27. Cortical Clean-up ......................................................................................... 1 4 0
RN Misra, TN Vyas
28. Intraocular Lenses ........................................................................................ 1 4 4

Tanuj Dada, Harinder Sethi
29. The Technique of IOL Implantation in SICS .................................................. 1 5 5
Nikhilesh Trivedi
30. Wound Closure ............................................................................................. 1 5 8
MP Tandon, TN Vyas
31. When and How to Convert? ........................................................................... 1 6 3
Kamaljeet Singh
32. Current Status of Medications in Cataract Surgery ........................................ 1 6 5
Kamaljeet Singh, Shweta Pandey, Monika Joshi
33. Complications of Manual Phaco .................................................................... 1 6 9
Kamaljeet Singh
34. Management of Posteriorly Dislocated Lenses ............................................... 1 7 3
Lalit Verma, Pradeep Venkatesh, HK Tiwari
35. Post-surgical Endophthalmitis ...................................................................... 1 7 9
Lalit Verma, Pradeep Venkatesh, HK Tiwari
36. Posterior Segment Disorders and SICS ......................................................... 1 9 5
Dinesh Talwar, Mool Chand, Gopal S Pillai
37. Glaucoma and SICS ..................................................................................... 2 0 5
P Mishra, S Thanikachalam
38. Paediatric Cataract: My Experiences ............................................................. 2 1 0
Daljit Singh
39. SICS in Paediatric Cataracts ........................................................................ 2 1 5
Kuldeep Kr Srivastava, P Vijayalakshmi
40. Posterior Capsule Opacification ................................................................... 2 2 0
Jagat Ram, Gagandeep Singh Brar
Index ............................................................................................................................. 227

Anatomy of
the Lens
1 BN Chaudhary
Kamaljeet Singh
T
he adult human lens is an asymmetrical spheroid, disappear when zonules are loose during accommo-
which does not possess nerves, vessels or con- dation.
nective tissue. It is located behind the iris and pupil

in the anterior compartment of the eye (Fig. 1.1). Microscopic Structure of the Lens
• The diameter of the lens is 9-10 mm and thickness 4- The lens consists of:
5 mm, which varies greatly as the eye accommodates i. Capsule
for near and distant vision ii. The anterior epithelium
• The lens has anterior and posterior surfaces and the iii. The cement substance of amorphous material
border where the two meet is known as the equator iv. The lens fibres.
• The anterior surface is less convex than the posterior,
radius of curvature being about 9 mm, while that of Capsule The capsule forms a transparent structure-less
posterior surface is 5.5 mm highly elastic envelope, which encapsulates the lens
• The posterior surface lies in a fossa lined by the hyaloid material. The anterior capsule is much thicker than
membrane in front of the vitreous. It is separated from posterior. The anterior and posterior capsules are thicker
the vitreous by a slight space filled with primitive at the equator than at the poles, where the suspensary
vitreous ligaments are attached. The thickest region up to 23 μ is
• The equator of the lens forms a circle lying 0.5 mm located close to the equator on both the anterior and
within the cilliary processes. The equator is not smooth posterior surfaces. The posterior pole is the thinnest
but shows a number of dentations, which correspond region (4 μ) while at the equator (17 μm) and anterior
to the attachment of zonular fibres. These dentations pole (9-14 μ) is of intermediate thickness.
Fig. 1.1: Anatomy of the adult human lens

2 Small Incision Cataract Surgery (Manual Phaco)
The anterior epithelium This is a single layer of cubical The colour of the lens also changes with age. In the
cells beneath the anterior capsule (There is no corres- infant and young, it is quite colourless. After about 35
ponding posterior epithelium). This layer is responsible years the central portion develops yellow tinge and
for all the metabolic and mitotic activity of the lens. This gradually becomes darker and more extensive with age.
layer produces the lens fibres. In the older people the lens has amber colour.
The cubical cells of the anterior epithelium gradually Sometimes the lens appears gray in old people when
become columnar and elongate towards the equator and seen by indirect illumination and can be mistaken as
are eventually converted into lens fibres. cataract by the beginners.
As these cells elongate into lens fibres, the part, which
Ciliary Zonule The ciliary zonules consist of fibres
is in contact with the capsule becomes the posterior part
arising from the ciliary body to the lens. It holds the lens
of lens fibres, while the opposite end grows into the
in position and enables the ciliary muscles to act on it.
anterior portion of the lens fibre.
The zonular fibres are attached at the equator and the
The cement substance of amorphous material The anterior and posterior capsule near the equator.
various elements forming the lens are bound together The zonular fibres can be classified in two groups: Main
by an amorphous substance. The cement substance glues and Auxillary fibres.

the various fibres to each other. A. Main fibres consists of following fibres:
It is found at following sites: i. Orbiculoposterior capsular They originate from the
1. Beneath the capsule both in front and behind. ora serrata and are inserted into the posterior
2. A thin layer deep to the anterior epithelium. capsule.
3. The central strand. ii. Orbiculoanterior capsular They are the thickest
The central strand occupies the axis of the lens from and strongest of the zonular fibres. They originate
anterior to posterior pole. Extending towards the equator
from the pars plana of ciliary body and inserted
from this axial collection the amorphous material is
into the anterior capsule of the lens.
collected in the form of Y. The anterior Y is vertical and
iii. The cilio-posterior capsular fibres They are the
posterior is inverted (λ). The lens fibres get inserted into
most numerous fibres. They arise from the valleys
these.
and sides of the ciliary processes. They are directed
The lens fibres Each lens fibre is a long, prismatic six- posteriorly and cross the anteriorly directed fibres
sided band. Lens fibre is a collection of albuminoid and are inserted into the posterior capsule.
material enclosed in a pseudo-membrane. The iv. The cilio-equatorial fibres They are present only
membrane is called pseudo because it is composed of in youthful eyes, originate from ciliary valleys and
the same material as its contents but is denser. inserted to the equator of the lens. With age these
During embryonic development the first lens fibres fibres disappear.
arise from posterior epithelium, which run from the back B. The auxillary fibres Some of these fibres strengthen
to the front of the vesicle. The later fibres are derived the main fibres and help to anchor the individual
from the equatorial portion of the anterior epithelium. portions of the zonule, while others hold the ciliary
The newer fibres are laid external to the deep older fibres body together. These are very fine and run from
and this give the lens a laminated structure.
without inwards and forward.
New lens fibres are laid on throughout life and as the
It is noteworthy that in old age a large number of zon-
central portion, which corresponds to the keratin layer
ular fibres disappear but some fibres also get thickened.
of the skin cannot be shed, the lens keeps on growing.
However, the growth is not proportional to the number Surgical Anatomy of the Lens
of fibres, because the deeper older fibres get shrunken.
The lens at the age of 65 years is one-third larger than at For the purpose of cataract surgery lens can be anato-
the age of 25 years. Hence, we can anticipate bigger mically divided into:
nucleus and may need bigger incision while performing i. Capsular bag with sub-capsular epithelium.
surgery in older persons. ii. Superficial cortex, i.e. soft lens matter that can be
The consistency of the lens varies and superficial cortex aspirated.
is softer than central part of nucleus. The nucleus increases iii. Immediate epinucleus with semi-soft lens matter that
in size with age and this becomes flatter with age. However, can be expressed out.
the refractive power of lens is retained by an increase in iv. Deep nucleus or a hard core that can be expressed
the refractive index of the nucleus. fractured, fragmented or phacoemulsified.
Anatomy of the Lens 3
Fig. 1.2: Surgical anatomy of limbus
The capsular bag encapsulates the lens substance. It the cornea, which creates a prominent ridge. This
is highly elastic and hence a big nucleus can be expressed ridge overlies the termination of Bowman’s
out from a comparatively small capsulotomy or membrane.
capsulorhexis. ii. The midlimbal line When the conjunctiva is sepa-
The capsular bag provides support to the IOL within rated from the limbus a bluish transluscent zone 1
the bag allowing for good haptic placement. The anterior to 1.2 mm wide is seen posterior to the anterior
epithelium consisting of cubical cells beneath the anterior limbal border. Posterior to this bluish zone is the
capsule is responsible for all the metabolic and mitotic white sclera. The line formed at the junction of bluish
activity of the lens. The cells migrate and elongate towards zone and white sclera is called midlimbal line and it
equator and produce lens fibres. After extra-capsular overlies the Schwalbe’s line (which is the termination
cataract extraction the remaining lens epithelium of Descemet’s membrane).
especially those in the equator region undergo metaplasia iii. Posterior limbal border It lies 1 mm behind the mid-
and migrate towards posterior capsule and lead to limbal line and can be seen only with the use of
posterior capsule opacification. sclerotic scatter illumination. Posterior limbal border
The zonules are inserted into the capsule in a lies approximately over the scleral spur.
continuous fashion at the equator, anteriorly 2-2.5 mm The width of the blue limbal zone varies in different
into the capsule and 1-1.25 mm into the posterior quadrants. Maximum width is in the superior quadrant
capsule. Hence only a 5-6 mm of zonular free zone of about 1mm. In the temporal and nasal quadrant it is
capsule is left for capsulorhexis or capsulotomy. 0.4 mm and in the inferior quadrant 0.8 mm wide. The
The lens nucleus has a configuration with a well- width of the white limbal zone remains constant through-
defined hard inner nucleus surrounded by semi-soft out.
epinucleus and soft cortical matter. During hydro- The midlimbal line is a very important landmark,
delineation the nucleus is separated from epinucleus and which overlies the Schwalbe’s line and we can remem-
this reduces the size of the overall nucleus which can be ber this by the phrase, “where the white meets the blue
expressed out from a smaller incision. The epinucleus Schwalbe’s line waits for you.”
also forms a cushion beneath the nucleus during But the difficulty is that this landmark is frequently
phacoemulsification. indistinct. Anterior limbal line can be easily distinguished
in a limbus based conjunctival flap, but in a fornix-based
Surgical Anatomy of the Limbus flap it is frequently irregular and is not a helpful landmark.
Limbus is an important structure from surgical point of FURTHER READING
view as all the surgery for cataract and glaucoma is
2. Gholam Peyman (Ed): Principles of Ophthalmology Jaypee
performed at the limbus. The external landmarks of the
Brothers; 489-91, 532-33, 1987.
surgical limbus are (Fig. 1.2): 1. Wolf’s Anatomy of the Eye 5: 138-42, 1961.
i. The anterior limbal border It is identified by the 3. Yanoff M, Duker JS (Ed): Ophthalmology Mosby International
insertion of conjunctiva and Tenon’s capsule into Ltd: 4-(1.1-1.4), 1999.
History of
Cataract Surgery
2 Kamaljeet Singh
KS Kathait
H
istorians suggest that Egyptians, Greeks and surgery by making a corneal incision and pressing the
Romans performed operations. Sushruta is lower limbus with the end of a strabismus hook.
considered to be the father of cataract surgery, Despite these techniques, most of the ophthalmologists
who used to push the lens towards the retina, by a needle. performed extracapsular technique. Intracapsular tech-
This technique, called couching was mastered by Indians nique was fraught with complications due to non-avail-
and is still being practiced at some remote areas. ability of anaesthesia. It was only in 1919 that Willard
With certainty only this can be said that Arabians for the first time described the akinesia of orbicularis,
performed cataract surgery by reclination or depression. later Tochat in 1920 published his work. Later Van Lint’s
Daviel extracted the lens in recent times in 1745. He (1920) and O’Brien’s (1929) facial block techniques
made a section in the limbus with a triangular knife. The became popular and are being still practiced world over.
cut was enlarged with a scissors or small knife having a In 1930, Elschnig and Arruga advocated the retrobulbar
dull point. The cornea was then raised and cataract anaesthesia.
removed with a Lancet, which pierced the pupil. The Jacquina Barraaquer used alphachymotrypsin in 1958
surgery remained in abeyance since infections used to for destroying the zonules for removing the cataract by
occur and eyes were lost due to this. It was only after intracapsular technique to avoid undue pressure by the
1870, when the antisepsis was discovered, that cataract zonules. This enzyme remained in use for long dissolving
surgery became popular and all the ophthalmologists the zonules for intracapsular surgery especially in the
started performing this technique. von Graefe (1865) young patients.
used a knife for making the cornea scleral incision. This
knife has been used till eighties by many surgeons IOL Implantation
especially in camp surgery. Graefe also advocated
iridectomy for the first time. Till this time, interestingly Casanova has mentioned in his memoirs that he met
the surgery was extracapsular and sutureless, Williams Tadini in 1766, who showed him a box with small spheres
started sutures in 1967. that were well-polished and looked like beautiful crystals.
The technique remained extracapsular for long. The oculist then had remarked, “One may put such
Pagenstecher (1877) tried intracapsular surgery by globes under the cornea in place of crystalline lens.”
pressing the lower corneal limbus with a fixation forceps Casanova although doubted that Tadini used to perform
and depressing the scleral border by introducing a spatula such operations, but he can be said to be the first person,
behind the lens through the incision. Stoever in 1902, who probably mentioned the possibility of lens
presented technique of removing the lens by creating a implantation.
vacuum through a cupping device joined to a rubber Casaamata, the Count Eye Doctor of Dresden, in 1795
bulb, called erisophake. This technique gained popularity used to perform cataract operations and also implanted
only when Barraquer (1917) presented his cannula cup an artificial lens. Münchow (1964) cited a book, named
and suction apparatus. Forceps removal of lens was first Schiferli (1797) in his study “About the History of Intra-
time advocated by Staneuleann but became popular only ocular Correction of Aphakia.” It states, ‘Casaamata
after publication of his results by Elschnig (1924). performed the procedure by inserting a glass lens through
Smith’s technique was published in 1910 for perform- the wound of the cornea into the eye. He realised, how-
ing the intracapsular cataract operation. He did the ever, that the glass lens could not substitute for the natural
History of Cataract Surgery 5
produced the iritis, glaucoma and hyphaema due to its
lens because during the experiment, the glass fell into designs. Later several modifications by these two
the bottom of the eye. Therefore, Casaamata can be said ophthalmologists and by Fyodorov also appeared.
to be first surgeon to attempt an intraocular correction Fyodorov’s sputnik lens became quite popular.
of aphakia.
Fourth generation lenses Since the Binkhorst’s lenses
But so far as the history of modern lens implantation
loops were tying in front and back of iris he was not too
goes Harold Ridley of London is considered as father of
happy and produced a design in which posterior loops
intraocular lens implantation. Ridley (1952) mentions in
would be placed in the capsular bag. These lenses were
British Journal of Ophthalmology that while he was
called Binkhorst’s iridocapsular lenses. Worst, came up
performing a cataract operation in 1949 a medical
with another idea of fixing lens with iris by applying sut-
student asked why he did not replace the sick lens with a
ures. These lenses were called Worst’s Madallion lenses.
new one. This initiated Ridley to implant the first lens.
Worst used steel sutures for fixing these lenses. In India,
Thus, the first lens was implanted into the capsular bag
Dr Daljit Singh is the pioneer, who used iris-claw lenses
following extracapsular cataract extraction at St. Thomas
in thousands with excellent results.
Hospital in London on November 28, 1949 and the

second on August 23, 1950 (Ridley, 1951). Both of these Fifth generation lenses Pearce and Simocoe in 1977
lenses had too high a refractive power and patients had used the posterior chamber lenses by modifying the
high myopic error (– 20.0D and – 15.0D). This gave an Binkhorst’s four-loop lenses. They sacrificed the posterior
idea to Ridley to measure the radius of curvature. He loops of these lenses and placed in the back after during
operated 750 patients with new lenses. But later in 1959 ECCE. He sutured these lenses with the iris or capsule in
gave up implantation because there were lots of the superior position.
complications. These lenses, weighed 110 mg, were made These lenses gave an idea to Shearing who introduced
of acrylic. Acrylic was used because it was found that J-loop lenses, which was basically the lens, being used
during World War II, some members of the British Air by Barraquer also. Barraquer used to place these lenses
Force sustained perforating eye injuries from airplane in the anterior chamber, whereas Shearing placed them
canopies. Those were made of acrylic glass, it was noticed behind the iris after ECCE. The haptic made its own
by the ophthalmologists, that it did not cause any irritation place on the ciliary body, which he called ciliary lenses.
to the eyes. This was, in fact, the beginning of true PCIOLs, which
Second generation lenses, which were supported in were excellent and reduced the incidence of corneal de-
the angle of anterior chamber. These were called, second compensation, iritis and glaucoma. Later came the
generation lenses (Strampelli, 1954). Many Simcoe’s ‘C’ α modified ‘C’ lenses.
ophthalmologists around the world implanted these generation VI lenses In the early nineties the era of
intraocular lenses with their own designs, but they PC-IOLs through can-opener technique started ending.
produced complications like corneal decompensation, The main drawbacks of canopener technique with
glaucoma and iritis and fell into disrepute. The problem ciliary sulcus fixated lenses are IOL instability and
was basically of the manufacturing designs and decentration. Posterior capsular opacification was
sterilization. Amongst these second generation lenses another problem seen in 50% of the cases. Now came
Choyce produced several designs, ultimately Choyce the era of surgery within in the bag implantation through
Mark VIII lens was perfectly designed and was used by envelope or capsulorhexis. The extracapsular surgery
several surgeons from 1963 until 1978. with long incision and in the bag placement of one
Third generation lenses Epstein and Binkhorst pro- piece IOLs is included in Generation VIA. When the
duced the iris fixed lenses, which caused iritis in many same surgery is done by phacoemulsification technique
patients. Later they produced iris plane lenses or pupillary with capsulorhexis and in the bag placement of single
lenses. These lenses were used in USA for quite a long piece or foldable IOL it is included in Generation VIB
period from 1968 until 1980s, but these implants used (Table 2.1).
to cause chronic irritation and cystoid macular oedema.
Evolution of Small Incisions
During this time Binkhorst produced four-loop iris clip
lenses. It had two clips anterior to iris and two behind With the advent of phacoemulsification, Kelman pre-
the iris and they did not reach the angle. These lenses dicted that incisions 3 mm wide be astigmatism-neutral
Table 2.1: Evolution of extracapsular cataract surgery*

1977 1982 1987 1992 2000
Pre-capsular Surgery, Generation V Capsular Surgery, Generation VI
V-a V-b VI-a VI-b
Beginning phase Transitional period Large incision Small incision
1. No viscoelastic 1. Use viscoelastic
2. Can-opener anterior 2. Continuous curvilinear
capsulotomy Capsulorhexis (CCC) or
Envelop (intercapsular)
technique, (especially for
large hard nuclei)
3. No hydrodissection This period combined one or 3. hydrodissection-enhanced Same as generation VI-a, but
more elements of generation V-a cortical clean-up with increased use of phaco-
with one or more of the advances emulsification and foldable IOLs
leading to generation VI-a inserted through a small incision
4. “Simple” ECCE 4. Advanced ECCE or phaco

5. IOL Fixation with one or 5. Consistent in-the-bag Complications rare
both haptics out-of-the-bag (capsular) haptic fixation
(precapsular fixation)
6. Early 3-piece PC-IOLs, 6. High quality PC-IOLs, espe-
often poor designs and cially one-piece all-PMMA
manufacture (capsular designs)
Complications were common, Few complications
especially:
1. Decentration
2. PCO
3. Zonular capsular ruptures
*Capsular in-the-bag
(Reprinted from: Survery of Ophthalmology, Vol 45, David J Apple et al: Cataract surgery with regid and foldable PCIOLs, ECCE and
phacoemulsification 77, 2000, with permission from Elsevier Science)
because of their reduced size. However, within a very implantation. The achievement of astigmatism neutrality
short time after the introduction of phacoemulsification, was impressive. Others rapidly recognized that the
intraocular lens (IOL) implants became more common compressive force of the single horizontal suture was
place. This necessitated enlargement of the phacoemulsi- tangential to the limbus and therefore exerted no force
fication incision to 6.5 to 7 mm for lens implantation. on the cornea, which would alter its curvature. As a result
Kratz is generally credited as the first surgeon to move variations of the Shepherd single stitches were soon
from the limbus posteriorly to the sclera, increasing developed for closure of incision 5 to 7 mm wide, includ-
appositional surfaces to enhance wound healing and ing the fine infinity suture, Masket’s horizontal anchor
attempt to exert less traction on the cornea, thereby suture and Fishkind’s horizontal overlap suture.
controlling surgically induced astigmatism. Girard and In 1989, McFarland in Pine Bluff, Arkansas introduced
Hoffman were the first to call the posterior incision a an incision architecture that allowed the phaco-
‘scleral tunnel incision’ and were perhaps the first to make emulsification and implantation of lenses without the
a point of actually entering the anterior chamber from a need for suturing. This involved lengthening the scleral
slightly corneal location. tunnel and in his early attempts, creating partial thickness
With the availability of small incision lenses that could grooves in the floor of the scleral tunnel parallel to the
be introduced through incisions of 4 mm or less; the stage long axis of the tunnel so that the incision could be
was set for the development of technique that resulted reversibly stretched to admit a foldable lens.
in the achievement of both relative astigmatism neutrality Ernest observed McFarland’s surgery and recognized
and self-sealing incisions. In 1989, Shepherd introduced that McFarland’s long scleral tunnel incision terminated
the single horizontal suture, which was actually a vertical in a decidedly corneal entrance and that the posterior
mattress suture, for the closure of 4 mm scleral tunnel lip of the incision, the so called corneal lip, acted as a
incisions in phacoemulsification and foldable lens one way valve imparting to this incision its self-sealing
History of Cataract Surgery 7
characteristic. Koch in Warwick, Rhode island described Table 2.2: Classification of nucleus hardness
what he called the incisional tunnel, indicating that there Diameter as seen in Degree of
were certain characteristics of self-sealing incisions with operating microscope nuclear hardness
respect to length and configuration that imparted not Less than 1 mm 0
only self-sealability but also astigmatism neutrality to 1-2 mm 1
these incisions. 3-4 mm 2
Self-sealing scleral tunnel incisions have varied with 5-6 mm 3
respect to width and the configuration of the groove 7 mm or more 4
(which represents the external or scleral incision as
opposed to the internal or corneal portion of the incision). forceps to crack the nucleus. For safety reasons, this tech-
The groove has varied from circumlimbal to straight to nique was abandoned is favour of the nuclear prolopse
frown or chevron-shaped. method.
The rebirth of extracapsular cataract extraction in its
modern, refined microsurgical version has brought with Blumenthal Technique
it the need for an adequate technique for anterior Blumenthal technique is an ingenious method of cataract
capsulectomy. That’s why in 1984, Gimbel in Calgary, surgery introduced by Blumenthal of lsrael, and is the
Alberta and Neuhann in Munich developed a technique preferred form of manual SICS. Its essential feature is
that essentially consisted of tearing rather than cutting hydrodissection and hydrodelineation of the core nucleus
out, a central anterior capsular window. Neuhann termed followed by its dislocation into the anterior chamber. The
it capsulorhexis. nucleus delivery is by hydrodynamic expression.
While SICS is certainly possible with linear and can- The advantages of this technique are that the AC is
opener type capsulotomy, it is the continuous curvilinear formed at all times, it is not viscoelastic dependent and
capsulorhexis (CCC) that has made modern techniques there are no instruments used within the AC for nucleus
of endolenticular phacoemulsification possible. delivery. Moreover, no sophisticated instrumentation is
Capsulorhexis leaves a capsular bag with mechanical and required; it can be used with all tyes of nuclei and with
structural integrity, in spite of an opening large enough all types of capsulotomies, thus, increasing its universal
to deliver the lens. appeal.
The ‘hydrodissection method’ was first described by
Micheal Blumenthal but the term ‘hydrodissection’ was Phacosandwich Technique
given by Faust. Luther Fry et al introduced Phacosandwich technique.
In hydrodissection the infusion fluid is injected exactly He discovered that nucleus can be captured between
between the anterior capsule and the cortex so that the two instruments and moulded through a 7.5 mm incision
fluid wave dissects all around the capsular bag and sepa- with ease.
rates it. This facilitates nucleus rotation and manipulation Luther Fry first attempted to cut the nucleus in two
during phaco and non-phaco techniques. and remove the pieces separately through the same
Hydrodelineation was a concept introduced by Aziz incision in 1985 (unaware that Gerald Keener had deve-
Y Anis. In hydrodelineation, the infusion fluid is injected loped a nucleus bisection technique two years ago). He
between the epinucleus and nucleus. This fluid wave found it difficult to do what he attempted but in the process
appears as a golden ring under the surgical microscope. discovered that by squeezing the nucleus between a lens
A reliable classification of nuclear hardness based on spatula and lens loop, it could be extracted through a
the diameter of the smallest circle delineated is listed in smaller incision, leaving the softer peripheral nuclear and
Table 2.2. cortical matter to be aspirated. Today, almost a decade
Measuring the diameter of the delineated circle is later, Luther Fry uses this technique in almost 70 per cent
reasonable by comparing it to the measured limbal of his planned ECCE cases with an incision of 7.5 mm
incision. size. Gills a few years later, described a similar method
where a lens loop alone is used to extract the nucleus.
Nuclear Extraction in
Manual Small Incision Techniques Phacofracture Technique
The concept of fracturing or cracking the nucleus is This technique pioneered by Kansas and designed by
not new. As far back as 1967, Kelman used Ringberg Francisco J, Gutierrez C accomplishes nucleus removal
in the following way. After CCC or can-opener capsulo- Welsch Rovert C et al reported that nucleus trisection
tomy, hydrodelineation of the nucleus is performed and inside anterior chamber make the removal of lens pieces
the nucleus is prolapsed into the AC. Viscoelastic was very easy through less than 5 mm scleral tunnel incision.
used to protect the endothelium and needs to be
replenished as liberally as required. A solid curved vectis FURTHER READING
is introduced under the nucleus and a special instrument 1. Arruga’s Olcular surgery: Mcgraw Hill Book Co.: 4: 109-15,
called the nucleotome is introduced above the nucleus. 1962.
The nucleus is sandwiched between these two 2. John J Alpar, Paul U Fechner: In Fechner’s Intraocular Lenses:
instruments. The nucleotome is manoeuvred towards the Jaypee Brothers (Indian Edn) 6-22, 1988.
3. Apple DJ, Ram Jagat, Foster A et al: Elimination of cataract
nucleus till it comes in contant with the vectis. Keping blindness: A global perspective: Entering the new millenium.
nucleotome in place, a spatula is introduced, and using Surv of Ophthalmol 45(Suppl): 570-99, 2000.
it and the nucleotome the cleavage is confirmed and the 4. Aziz Y Anis: A methodical approach to small incision cataract
pieces of the nucleus separated. Viscoelastic is replenished surgery. In Cataract Surgery: Alternative Small Incision
and a special nucleus forceps with 9 mm jaws, each with Technique (1st Indian edn) Slack Inc. 139-62, 1995.
5. Blumenthal Michael: Mini Nuc Manual extra capsular

a double row of teeth, is introduced into the AC. Nuclear
technique Highlights of ophthalmology letter, 21(5): 1993.
fragments were then positioned in the axis of the wound 6. Daviels Jacques: Cited in Duke Elder, XI: 253, 1748.
and removed. Removal of cortical debris mixed with 7. Epstein E: History of intraocular lens implant surgery, In:
viscoelastic (viscoelastic sludge) with a lagre bore Mazzocico TR, Rajacich GH, Epstein E (Eds): Soft Implant
irrigation aspiration tip is the next important step prior Lenses in Cataract Surgery, Thorogare NJ, Slock Inc: 1-10,
to insertion of an intraocular lens. The wound is checked 1986.
8. Fine IH: Infinity suture: Modified horizontal suture for 6.5
for integrity, and the conjunctiva replaced in position. mm incisions. In Gills JP, Sanders DR (Eds): Small Incision
A 3-4 mm incision can be used in this technuqe. The Cataract Surgery, Foldolde Lenses, One-stich Surgery,
instrumentation is relatively simple. Howeve, this tech- Suturless Surgery, Astigmatic Keratomy. Thorofare NJ Slack
nique is very viscoelastic dependent. There is potential Inc: 191-96, 1990.
for corneal damage. Moerover, it is a difficult technique 9. Fine IH: Architecture and construction of a self-sealing incision
for cataract surgery. J Cataract Refract Surg 17 (Suppl):
to master, probably not suited for hard brunescent nuclei
672-73, 1991.
which are dealt with standard ECCE. 10. Harold Ridley A: Implantation PMMA IOL in human-current
therapy. In Ophth Surg, Spaeth and Katz 135.
Nucleus Division with Snare 11. Luther L Fry: Phacosandwitch technique. In Cataract Surgery:
Alternative Small Incision Technique (1st Indian Edn) Slack
Dr Getrald Keener et al discovered a Nucleus division Inc: 71-110, 1995.
12. Masket S: Origin of scleral tunnel methods (letter to the Editor)
technique, according to which nucleus can be divided
J Cataract Refract Surg 19: 812-13, 1993.
and conquered. Instead of using a cutting blade, he used 13. Peter Kansas: Phacofracture technique. In Cataract Surgery
a fine wire that bisects the nucleus and expresses each Alternative Small Incision Technique (1st Indian Edn.) Slack
piece separately. Inc: 44-70, 1995.
Sterilization 9
Sterilization 3 Sunita Agarwal

Amar Agarwal
INTRODUCTION bacteria have grown from the Ringer lactate used. A

startling study was carried out in the early 90s where
When viewed upon from the broader angle however
several eyes were lost due to balanced salt solution (BSS)
good a surgery may have been performed should it be
not being of pH 7.4, because the last rinse did not wash
complicated with infection, the result is fraught with peril.
of the remnant soap from the glass bottle.
The patient suffers ultimately and the surgeon goes

What we all need to remember is that when every-
through hell. We have all had our share of infection and
thing is going fine nobody complains, but as soon as
its disastrous effects.
there is a complication the surgeon is the first and often
Should a surgeon say they have never had infection
the last person to be held totally responsible for all
spoiling their case, either they have never done surgery
misdemeanors on anybody’s part. Thus as captain of
or the truth lies hidden elsewhere.
the ship the surgeon has to sink with his or her ship.
Be that as it may we need to understand micro-
However, all this can be avoided by taking precautions
organisms in a much better manner. We need to give
before entering the operating room.
this topic full attention in our hospitals and continue to
give it the importance it requires by continuing quality
HISTORY
checks at every interval regularly every day and in every
case. Dating back to the time that Sushruta from 500 BC
Some basic facts of postsurgical infection in human explained the importance of washing hands and drap-
eyes whether cataract surgery or any intraocular surgery ing wounds with clean cloth, as well as having a clean
is concerned, are that we need to regard all infections to environment for surgical procedures, Indian medicine
arise from the operation theatre unless proved otherwise. has always kept this part of medical practice in good
The operating room is certainly the most guilty in stead. Practicing principles of Dhanvantri medicine a
providing the microorganism for post-surgical infection. Hindu physician-oculist wrote that surgeons should clean
It may be very easy to complain about patient comp- their nails prior to operating, wear fresh clothing, and
liance and dirtiness to be the cause of infection, and spray sweet smelling vapors around the operating room.
sometimes that may be true, however in our hearts it is Little did he know the importance of these instructions.
safer and better for us to accept that this infection has However, these were carried down through the ages by
come from the operating room and then work ourselves the Vaids (Hindu physicians), now with better knowledge
backwards in removing the source of the disease. there is more understanding of the topic on infection and
We may be able to shift blame to a tooth infection or sterilization control.
septic foci in the sinus, however, should we be able to The middle ages saw European medicine catching
first accept the operating room to be at fault, our energies ground however, sterilization tactics were still very rudi-
would be directed in improving our facilities, thus averting mentary. Most surgeons thought it to be fashionable not
further mishaps from occurring. to wash hands, mayhap due to the cold climate of the
The first rule in sterilization at least where developing temperate zones. Thus centuries of unknown prevailed
countries are concerned is not to believe any manu- with thousands being lost to infection and disease even
facturer when they claim to have sterilized their wares. inside the operating room. It was considered hazardous
To be taken as guilty of infection unless proved otherwise. to lay a surgeons hand in the fear of losing the patient to
This is true of not only suture material, disposable needles “fever” as it was called then.
and syringes but also of intravenous and intraocular However, Hieronymus Fracastorus in 1546 published
fluids. Many cases have been reported in India where a landmark book that may have led to the discovery of
bacteria. His theory of contagious diseases and their contrary, that we still know only a drop in this ocean of
treatment sparked off the original microbe hunter, to knowledge against disease and infection.
identify bacteria with his own saliva in 1675, using his Change is the spice of life and just as today changes
microscope screwed together with some lenses, Anton to another day, of more discovery and more scientific
van Leeuwenhoek had set about 2 centuries of hot debate achievements so to these pioneers were to discover much
amongst the European scientists. more. Sulfanilamide first discovered by Paul Gelmo in
In 1840 Jakob Henle postulated the theory of the 1908 was found to be effective on surgical wounds, by
contagion. This was further specified by Robert Koch in Gerhard Domagk who first used the drug on humans in
1876 where he showed that by isolating the anthrax 1935. This won Domagk the Nobel Prize for Medicine
bacillus and was able to infect a normal animal with the and Physiology in 1939.
same that the theory of contagion was true. This work Paul Ehrlich and Toju Hata discovered Salvarsan, the
won him the Nobel Prize for medicine and physiology in arsenic derivative for the treatment of syphilis, it heralded
1905. yet another era, that of the antibiotic.
It took Louis Pasteur to bring out the emphasis of the In 1929, Alexander Fleming published his classical
“little beings” as those responsible for disease. His paper work on Penicillin from London and history followed his
on the importance of washing hands before starting a every achievement. Through the World Wars his
obstetrical delivery shows the utmost significance of this medicine was of immense use in the control of infection
one act towards a sterile atmosphere. and weeding out of disease. He showed first through in-
Throughout the 1800s pioneering technologies of vitro studies that a contaminant of Staphylococcus
Pasteur, Nizer, Klebs, Escherich, Cohn and Ehrlich played medium, Penicillium notatum had a destructive effect on
major roles in the evolution of discovery of pathological the Staphylococcus bacteria that was growing on the agar
germs. Today the science of microbiology and medicine plate. In further experiments he showed that this mold
are occupied by their names forming important also had strong antibacterial activity against other
landmarks in the discovery of the importance of pathogenic gram-positive bacteria as well as gram-
sterilization techniques. negative cocci and bacilli but was not effective against
Where hospital wards are concerned, making surgery organisms such as Escherichia coli.
safe and banishing sepsis from hospital wards, an era of While the world raged with War, yet another kind of
pre-Lister and post-Lister can be demarcated. This was war was being fought for mankind inside the laborat-
the importance of Joseph Lister on surgical outcome. ories of HW FIorey at Oxford University. By 1940 Ernst
He based a lot of his studies however, on Ignaz Chain showed the curative effects of penicillin in vivo. In
Semmelweiss (1818-1865)—who was cruelly maligned 1945 by the end of the World War II, these three men
for his theory of the origins of child-bed fever that led were awarded the Nobel Prize for Medicine and
him to be institutionalized and die an unhappy man. Physiology. Selman Waksman discovered spates of
The irony of the situation was his studies brought about antibiotics in succession with streptomycin in 1944 for
a revolution in hospital wards and the prevention of tuberculosis and neomycin in 1949.
infection by antiseptics and cleanliness reiterated by Much of today’s discoveries have been dependent on
Joseph Lister. the way we see these small “animalcules”’ of
By the time Daimler brought out his first motor cycle Leeuwenhoek, in 1933. Our eyes could see the destruc-
in 1884, scientists round the globe had devised the tion of the world with Hitler as the Chancellor of
autoclave deriving from the fact that boiling did away Germany, and could see even greater destruction by
with microbes. This revolutionized hospital wards and microbes since the invention of the first transmission
operation theatre sepsis to a great extent. So much so electron microscope by Ruska. Further developed to a
that till date some contraption of the autoclave is still phase contrast microscope by 1953, by which time the
used in every operation theatre in existence in the modem World War had ended and humanity was once again
world. allowed to prosper. So much so that the scanning
By 1899 a century was going by and scientists believed tunneling microscope could be developed by 1980 and
this was the ultimate and that internal sepsis was not its fast developing clones that are in use today.
going to be much more advanced beyond theory and However, very soon the side effects of antibiotics were
that the field was not likely to advance further. Today noted with the classic example of chloramphenicol the
with much more information and knowledge we think first broad-spectrum antibiotic, discovered in 1949,
Sterilization 11
effective against rickettsial infection, typhoid. A link was between. Moreover, it is far more beneficial to all con-
established between severe bone marrow depression and cerned to garner our resources and give a thorough job
aplastic anemia with its use. This curtailed the use of of the operating room than to be witch hunting on the
these eyedrops and oral regime in USA. patients habits and dirtiness. It is my belief that even a
We owe a lot to these forefathers of modern medicine dirty patient cannot infect the inside of his or her eye, if
and surgery, and today’s technological advancements he or she has a postsurgical infection for sure it has been
have made us more wary of the microbe. It seems to be carried in through the workings of the operation theatre.
the more we advance the more microbes we find the Going in a methodical manner from without to within
cause of disease. Stress and other dietary factors were anything entering the theatre has to be sterile. First the
believed to be the cause for peptic ulcers, though now operating room itself has to be sterile.
we know bacteria to be the root. In a similar manner,
there are many more diseases that still retain their shroud The Operating Room Air
of mystery.
Let us not rest on previous laurels and with the close The air we breathe can be filled with pollutants, viruses,
bacteria and irritants such as pollen, chemical gases,
of this century believe that we have reached the ultimate.

In reality, we have only skimmed the surface there is odors and smog. In critical situations—military command
much more to be unraveled in this body beautiful of the centers and public arenas—there is also a threat of
Homo sapiens. chemical and biological agents being released into the
Tempting to say in the words of Louis Pasteur, air. All these air-borne pollutants can be treated by using
“Science knows no country, because knowledge various technologies.
belongs to humanity, and is a torch which illumi- We forget about the air coming into the operating
nates the world.” room, though however we should understand that if this
itself is clean it is much easier to retain the cleanliness
AREAS OF STERILIZATION within. There are many ways of filtering clean air into
the operating room. One of the easiest and best is to first
Once we enter the operating room we expect that
make sure the rooms pertaining to the operation theatre
everything must be in order, and somebody else is in
complex are sealed shut, with only one entry into the
charge, not me. However much to our utter astonish-
complex. Now we need to bring in clean air into the
ment seldom does anything go wrong, though when it
operating rooms.
does, the blame is once again pushed on to somebody
else, not me. This is where the first principle of surgery
Air-Conditioning
has to be changed and restructured. The first and only
person responsible for the whole team at work Ideally the whole operating area complex must be air-
inside an operating room is the main surgeon. conditioned with the units stationed well outside the
This is the person who every body in the operation theatre complex and only ducts bringing in fresh temperature-
must report to. This is the person who before entering controlled air into the complex. The air-conditioning units
the theatre has to ensure that everything inside this pious could be in the form of towers or split units stationed on
area is under strict control of the surgeon. This is the the terrace or window firmaments outside.
person who must take responsibility if an infection should
Filtration of air The ducts bringing in the clean oxy-
arise in the patient’s eye within one week of surgery.
genated air need to have the air passing through filters
After carrying out so many tests and sterilization tech-
that can ward off bacteria which means they should be
niques I would rather believe for the benefit of all future
0.2 micron filters. More often these filters need to be
patients that infection in a postsurgical eye arises from
changed and or cleansed on a daily pattern.
the operation theatre facilities. It is very difficult to put
infection inside a closed eyeball, though it is easy enough Ultraviolet radiation Ultraviolet light bulbs could be
while the eye coats are still open. More often than not placed in the path of the filtered air to make sure the air
infection is carried into the eye by instruments themselves. is disinfected as it enters the operating rooms. Alternately
There is however a small possibility that this may not these bulbs could be left in the operating area and kept
be the case and there may be a septic foci residing in on throughout the night, this would also ensure clean
some corner of the human body like a tooth abscess or areas the next morning after 12 hours of exposure to the
such. Still these occurrences are very rare and far ultraviolet light.
Ozone treatment Another technology gaining ground the operating room must also contain adequate amounts
for clean air is the ozone treatment plants that generate of minerals.
ozone into the air. This breaks up the microorganisms
and clean, disinfected air is ensured. One unit for 5000 Filtration
cubic feet of air space is recommended.
This still finds the safest use in bringing in clean water
Ozone is a reactive molecule comprising three atoms
into the operating area. It could be done by many
of oxygen. Because ozone is a reactive molecule it acts
methods, ceramic is one of them. However today mem-
as a powerful oxidizing agent against all microbial
brane filters seem to have replaced all else as here they
contaminants, organic toxins and most volatile organic
bring out the fluid bereft of bacteria. Sometimes a suction
compounds (VOC’s) and because of its short half-life it
pump is attached to the water jet so that the filtration
rapidly reverts to water and oxygen.
can take place at a faster pace.
When a combination of UV, moisture and ozone are
used a synergistic effect is seen. The absorption of UV
Reverse Osmosis
by the ozone-producing highly reactive substances that
effectively kill microorganisms including hard to kill spore A high pressure is set about in the clean water and a
forming bacteria. system of reverse osmosis sends back the mineral content
of the water while a filtration process blocks out the
Positive pressure A positive pressure pump is main-
microbial content. In this way water is able to reach the
tained to make sure the air entering the operating rooms
operating room withless minerals and is absolutely sterile
are kept at a pressure above the rest of the area. These
with no bacteria. This is also one of the techniques used
pumps can be installed in the ducting and positive
in the manufacture of bottled mineral water and can be
pressure inside the operating areas would ensure that
used very effectively in operating area complexes. This
the air comes only from this area and not through leaks
water is now used for cleaning the operating rooms,
from windows or doors. The main door of the operating
machines, and for surgeons while scrubbing. The water
room must function for only air escaping the operating
coming from such a plant is placed in a storage drum,
area and not for entering it.
preferrably made of stainless steel.
Air curtain Entry points in the operating area would
do well to have automatic door closers so that the door Electronic Control
does not remain open unnecessarily. Also the door can
Water can be made to contain low mineral counts and
be fitted with an air curtain so that the outside air is
no bacteria through another technique of manufactu-
curtailed off from entering.
ring mineral water. This is by producing cathode and
Quality Check anode electrodes on two ends of the water channel. The
anions and cations would respectively move to their
Quality check is ensured by every day/regularly carrying corresponding electrodes and this would clear the fluid
out the PLATE TEST. This means leaving a bowl of clean of mineral content. A filter present below would clear
sterile water in the room to be tested for 20 minutes. the water of microorganisms. This is another method of
Microorganisms present in the air would settle down on producing sterile bottled mineral water.
the surface of the water, a small sample is taken from
this and grown on a culture plate. If the sterilization tech- The Operating Room Walls, Floor,
niques have been effective the culture should be sterile Ceiling and Fixtures
in 24 to 48 hours. If the culture grows positive growth
remedial means have to be taken to ensure sterile cultures. All elements of the operating room need to be first
cleansed, then disinfected and last but not the least totally
The Operating Room Water sterile. The three steps in this process can be done by
three different fluids and chemicals.
The water coming into the operating room needs to be
free of microorganisms. After all the water with which
Cleansing
we are cleaning the most important area of the hospital
needs to be totally clean. If microorganisms are present This is best done with a soap and water wash. Every
in water then they would remain on the items cleansed surface, every table, every chair and every fixture needs
and the cleaning would be bad. The water coming into to be cleansed with a direct application of soap and water
Sterilization 13
on the surface. After cleaning with this it needs to be
cleaned with plain water.
Disinfection
Benzalkonium chloride solution 4.5 percent could be
used as a disinfectant and as a general cleaning agent
for floors.
One of the best solutions used worldwide towards the
disinfection of operation theatres and consultation suites
is the Bacillocid made by Bode from Germany. This con-
tains 1,6 dihydroxy 2,5 dioxyhexane (chemically bound
formaldehyde) with glutaraldehyde, benzalkonium
chloride and alkyl urea derivative. A 2 percent solution
is used for the operation theatre and a 0.5 percent solution
for the consultation areas. With this solution all areas Fig. 3.2: Cleaning of the operation theatre
mopped and cleansed of vegetative organisms, fungus walls with Bacillocid
and viruses (Figs 3.1 to 3.3).
Fig. 3.3: Cleaning of the operation theatre

floor with Bacillocid
Fig. 3.1: Cleaning of the operation table and chair, external
Care needs to be taken on operating theatre instru-
surfaces of the microscope, instrument table, IV poles with
Bacillocid ments like Boyles apparatus, microscopes, phaco
machines, diathermy machines, suction machines, laser
Formaldehyde in the form of liquid, tablets or gas has machines. Though delicate these instruments need to
been used extensively in the past, however, today its use be thoroughly cleansed every day. Many a time infection
is put to question since culture tests have proved positive is found to be harboring in these areas and they are
with growth even after formaldehyde sterilization. difficult to clean. More sophisticated the machine more
care need to be taken in its cleanliness. This task cannot
The Operating Room Macroinstruments be given to an untrained personnel and even then ideally
All fixtures including fans, lights, air-conditioning have there should be a doctor supervising their cleaning.
to be first cleansed carefully with a dry cloth and then
Microscope
mopped with Bacillocid so that they can be disinfected.
Chairs, stools, operating tables, trays have to be first The rest of the microscope can be cleansed with soap
cleansed with soap water and then mopped with water as well as Bacillocid however the optics need special
Bacillocid (Fig. 3.1) and left alone for over four hours to care and need to cleaned only with a clean cloth pre-
ensure disinfection. ferrably silicon paper. Antifog chemical coating could be
given to the optics. After cleaning and before closing for went about in a scientific manner trying to decipher where
the day the optics should be ideally wrapped in its original the infection came from.
cloth or plastic casing and drying agents placed inside First the microsurgical instruments and tubings were
like silicon oxide. This allows the moisture inside to be taken through the 10-step procedure as you will read
absorbed by the chemical and with less moisture, later on. Now they were tested for sterility by flowing
formation of fungus and other microorganisms on the fluids through them and taking this fluid on a culture
optics is rare. plate. They were sterile, after fixing the tubings and probe
onto the phaco machine the fluids were collected from
Phaco Machines the drainage bag and sent for culture. The second one
As eye surgeons we need to be well aware of the pressure was positive. This told us that our sterilization techniques
maintained inside the eye during phacoemulsification were good however something was amiss.
procedures for cataract surgery, but little do we realize We opened the phaco machine and found this tubing
the importance of the machinery involved in giving us running through it and found the vent as well. This vent
this information. When the phaco probe is inside the ideally should have an air filter attached to it. We sent
eye of the patient there is a continuous flow of fluid. The the tubing for culture and replaced it with a fresh sterile
fluid arises from the bottle suspended 65 cm above the piece. The culture proved to us where the culprit lay, the
head of the patient and this produces a certain pressure Pseudomonas was grown from this tubing.
inside the eye. The Fluid then goes through the irrigation The internal tubing cannot be changed with every
line to the phaco tip which enters the eye and leaves the case, though this would be ideal. So we have devised a
eye through the suction tubing entering the phaco better structure for its disinfection. That is to keep the air
machine. From the phaco machine another set of tubings totally sterile and make sure no infection goes into the
takes the excess fluid away into a drainage bag. What tubing through the vent. This is ensured with the ozone
we have overlooked is between the tubing entering generator for the total operating room areas.
the phaco machine and exiting into the drainage What we did realize through this study was that not
bag, it goes through a channel inside the phaco all cases turned up with infection even though the bacteria
machine. This part of the tubing is never sterilized must have been residing in the tubing for many a day.
in the proper manner that is required before a The cases turned up with infection had something to do
cataract surgery. In fact it cannot be sterilized as well. with being the last few of the day. The cases which turned
This part of the tubing is attached to two manometers up with infection had low immune status, either diabetes
that gauge the pressure in the tubing and give us a reading
or hypertension or such. The cases which turned up with
on the panel in front. A vent exists that can release the
infection had a complication most often a posterior
pressure in the tubing to atmospheric levels as soon as
capsular rupture on table thus resorting to vitrectomy.
our footswitch transfers from position 3 to 2 to 1. In so
This shows us some characters of infection that we may
doing the air from the operating room directly enters the
already have known but not given them their due
tubings thus if there should be bacteria in the air they
would now have an easy access to the most sterile line acknowledgement.
that we have been trying to maintain. However, what we have realized is that the phaco
These facts were not known to us for a long machine has to be cleansed very well and air filters placed
time, and we had a spate of infections as Pseudo- on the vent. The tubing changed every week. And culture
monas had managed entry into the tubings present tests done for every case before and after surgery (Figs
inside the phaco machine. None of the companies’ 3.4 and 3.5). What this means is when the tubings and
representatives ever let us know of this tubing and its probe are attached to the machine before starting the
existence and we never racked our brains hard enough case first few drops of fluid entering the drainage bag is
to trace the tubings, until this major catastrophy occurred. taken for culture (Fig. 3.6). Once again at the end of the
Over a spate of 12 months we had taken out 4 intra- case this is repeated. If and when at any time a culture
ocular lenses (IOL’s) from eyes with infection. We were should turn positive we would know the problem imme-
able to save the eyes from blindness however rendering diately. After these stringent measures have been installed
them aphakic. at our hospitals we have neither had even one infection
We first accepted that the infection came from the coming from the operating room nor had to remove any
operating room and now with a technology of omission more IOls lenses from infected eyes.
Sterilization 15
Fig. 3.4: Collection of Ringer lactate solution from the Fig. 3.6: Collection of Ringer lactate solution from
aspiration tube before the operation the front end of the internal tubing
Fig. 3.5: Collection of Ringer lactate solution from the

Fig. 3.7: Ethylene oxide sterilizer
aspiration tube after the operation
Boyles Apparatus
a day a 10-step cleansing routine must be established.
Regular cleaning of all parts of the machine is necessary This 10-step routine includes
with spirit as this evaporates and does not leave a residue 1. Soap water wash with toothbrush
on it. However the parts of the tubings that enter the 2. Ultrasonic cleansing with Lysol
human system or are connected to them need to be 3. Cidex cleansing and soaking for half an hour
thoroughly cleansed, disinfected and then sterilized. The 4. Isopropyl alcohol cleansing
method of choice for sterilization here is the ethylene 5. Plain sterile water cleansing
oxide gas chambers (Fig. 3.7). As most of the tubings 6. Plain sterile water cleansing
are plastic temperature of below 60°C are comfortably 7. Plain sterile water cleansing
taken by them. Needless to say that oxygen, nitrogen 8. Boiling in sterile water
dioxide, halogen levels should be monitored on a daily 9. Ethylene oxide sterilization overnight
basis with every case in particular. 10. Flash autoclave sterilization three times.
Four trays are kept aside on a long side table (Fig.
The Operating Room Microinstruments
3.8). Water used in this sterilization must be mineral sterile
Every case must be treated separately and all instruments water, as this water is totally sterile, prove it by growing
must be cleansed thoroughly before the next case. Once the water on a culture plate and making sure it is sterile.
the sterilization technique used the better would be the

results that can be achieved.
This is best done with the old soap and water wash
(Fig. 3.9). Liquid soap is used in a tray with clean sterile
mineral water. First a plain cleansing with gloved hands
is completed and then using a toothbrush into the small
crevices of instruments. This is of special importance to
instruments filled with blood and tissue. In ophthalmic
matters special reference has to be given to machines
like the automated flapper in LASIK (laser-assisted in-
situ keratomileusis) cases, as it is known that corneal tissue
gets clogged into the tracks and other areas of the flapper.
This can be removed much better using palmolive liquid
soap as it contains some of the safest and yet cleanest
ways to get grid out of the system.

Fig. 3.8: Four trays arranged in sequence containing carbonic
soap with mineral water, 2 percent glutaraldehyde, 70 percent Ultrasonic Cleansing
isopropyl alcohol and mineral water
The mainstay of cleansing into crevices where the tooth-
brush cannot reach and this gets into the fulcrum of
forceps and scissors to clean the instruments. A chemical
solution like Lysol (Cresol and soap solution) could be
used as an adjuvant to remove the debris from clogged
surfaces. This breaks up the protein and organic matter
so that it can come clean from instrument surfaces. Most
of the fluids used in the ultrasonic cleanser need to be
antiseptics as well so they can be used as disinfectants
on the instruments cleaned.
Cidex or Glutaraldehyde 2%
Once activated Cidex solution manufactured by
Johnsons & Johnsons must be used within 14 days.
Some facts like these go unnoticed in hospital
Fig. 3.9: Wash all instruments in a tray of carbonic soap and environments and the use of substandard procedures
water with toothbrush and drugs come into play. Reiterating the fact that the
doctor has to be on top of all these activities.
The trays are filled with the respective fluids. Each tray is Instruments are left immersed in this solution (Fig.
numbered and labeled so that mixing does not occur. 3.10) for 30 minutes, which is sufficient time for disinfec-
In each tray a toothbrush and 50 ml syringe with a tion however for sterilization 10 hours would be needed.
yellow tubing taken off from an IV set is kept. All micro- Within 10 minutes at room temperature most vegetative
surgical instruments are dipped in each tray periodically. organisms would be destroyed, including Pseudomonas,
Every instrument is cleansed delicately with gloved hands fungi, and viruses. The solution is very toxic to the eye
and toothbrush. When and where required every lumen and great care has to be taken to get the solution out of
of every instrument is injected with 50 ml of the liquid the instruments before using on humans.
that it is dipped in. Thus the cleansing action is from the
outside as well as from the inside of every instrument. Isopropyl Alcohol 70%
This is specially true of probes and tubings. This is still one of the best ways of killing the micro-
organisms (Fig. 3.11). Instruments are soaked in the
Tray I with Liquid Soap and Sterile Water
solution for over 15 minutes and then cleansed using a
The first step in sterilization of instruments is its proper toothbrush and syringe to wash the internal elements of
cleansing as whenever the microbial load will be less on probes and tubings.
Sterilization 17
Fig. 3.12: Wash all instruments in a tray of mineral water

Fig. 3.10: Wash all instruments in a tray of 2 percent
glutaraldehyde
of performing this essential act of sterilization. However,
what needs to be detailed is whether the particular article
can withstand temperatures of over 100°C.
After having a spate of infections and removing IOLs
from infected eyes to save the eyes, my hospital and
staff got spurned to find the cause of the infection.
Towards this a whole new regimen was set up on clean-
sing, disinfection and sterilization of microsurgical
instruments. After each methodology culture tests would
be taken to prove its efficacy. We did understand that
the silicon tubings had gram-positive cocci growing in
them. In a process of eliminating them we found that the
cocci inside the silicon tubing withstood many sterilization
techniques like ethylene oxide and autoclave. However
when subjected to boiling for 20 minutes the tubings
Fig. 3.11: Wash all instruments in a tray of 70 percent would be sterile. This once again reiterated our belief in
isopropyl alcohol this age-old custom of boiling (Figs 3.13 to 3.15).
Sterile Water
Care must be taken to wash of the deleterious effects of
the above mentioned solutions. This is done effectively
by first soaking and then washing all the instruments
through three trays of sterile water (Fig. 3.12). The lumen
of the tubings must be cleansed with sterile water each
time 50 ml of the fluid passing through the probes and
tubings. Once again cleansed with sterile water
Boiling
After going through a number of tests and methods of
sterilization we still find one of the best methods remains
the age-old custom of boiling. This brings about total
death of the microorganisms. Most rudimentary of
operation theatres would still contain means and methods Fig. 3.13: Diamond blades are cleaned using steam
Autoclave
As the last step in the sterilization cycle of instruments,
they are passed through the flash autoclave for 134°C
for 5 minutes and this cycle is repeated three times in the
Statim autoclave from Canada (Fig. 3.16). It has a built-
in computer that tells us of the efficiency of the cycle.
However, color indicators would also tell us of the
physical measurements reaching the desired levels.
Fig. 3.14: The external tubings, internal tubings, I/A probe

and metal knobs are boiled for 30 minutes
Fig. 3.16: Statim autoclave cassette containing the tubings and

instruments is kept in the ethylene oxide sterilizer for a period
of six hours
After doing this the instruments are laid on the

operating table and each instrument that enters the eye
is dipped in Ringer lactate before entering the eye.
The Operating Room Linen and Accessories

Fig. 3.15: The instruments are separately All operation theatre linen and accessories must be
boiled for 30 minutes cleansed before entering the complex. Particular slots
should be kept ready and clean for them everyday.
Ethylene Oxide Sterilization Otherwise the operation theatre should be totally bereft
This is not a preferred technology of sterilization for of any other article. Anything that is not used everyday
microsurgical instruments because of the time duration need not be found in the operating room. This is not the
taken is over 16 hours. However, we have started using place to keep stocks and inventory of medicines. They
this as one more step towards the end of the day. By the could be kept in the prefunction area of the operating
time we finish all the cases of the day we take our instru- room but not in the operating room itself.
ments through this 10-step procedure ending it with a
Linen
bout of ethylene oxide where the instruments rest for the
night. However, the only aspect of this technology is that Sterile operation theatre gowns, towels, gloves could be
the instruments must be cleansed of the ethylene glycol of disposable variety, this is internationally accepted to
residues that may be found over them. This is effectively be the best. However, it is not practical in all kinds of
done by steam autoclave and washing intraocular instru- atmospheres. In India we still recycle our operating clothes
ments with ringer lactate meant for intravenous use. which are usually made of cloth. The methodology
Sterilization 19
approached towards their care is explained in the same it is not working efficiently. The drums kept in the
3-step procedure. autoclave must be closed immediately on removal from
the autoclave, ensuring that outside air does not enter
Cleaning This is done by taking all the sullied clothes
the drum. Once autoclaved the items can be considered
and first taking away all clothes coming from an infected
sterile for only 24 hours which means to say they need
patient being operated or from the septic operation
to be reautoclaved to improve efficiency in sterilization
theatre are treated separately than that coming from a
techniques.
clean operating room. These clothes are preferrably
disposed off in an incinerator. If they cannot then they Ethylene oxide sterilization With todays emphasis on
are soaked in Dettol solution, before the cleaning process better sterilization techniques and total dependence on
begins. them, a move has come into using the gas industrial
The clothes are cleansed preferrably in a washing sterilization for hospital purposes. As there is more surety
machine with adequate soap being used. Then the on its efficacy this is even a preferred technology over
clothes are passed into a drying machine. Try not to leave the autoclave. However it does have its drawbacks which
these clothes on the drying rope for nature to dry, because are that the hospital needs to keep a bigger inventory.
with this outside bacteria and fungus can settle on these This is due to the fact that these clothing need to be
clothes. Inadvertently they may fly off the clothes line aired out for over 48 hours before they can come into
and this would also create much increase of the microbial contact with human skin. Easily achieved by having four
load for sterilization. times the number of gowns and towels one would
However, if machinary is not available these clothes ordinarily keep.
are first soaked for half an hour in hot water with soap The advantage of ethylene oxide sterilization for linen
solution inside a large tub. A rod is taken and rotated over autoclave is that we never get damp clothing which
round and round for five minutes. This will shake off the should be regarded as not sterile. Moreover the personnel
dirt and grind from the clothes. are always sure of ready stocks for operating at any time.
After this each cloth is taken separately and washed We do not have to start the autoclave and wait for
with hand and the clothes thrown into another tub of sterilization, we always have sterile clothing ready.
hot water with a few drops of Dettol solution in it. The
Sealing and packing In ethylene oxide sterilization
clothes are left for another half an hour in this solution
the methodology employed towards its packaging
and then rinsed off with plain water.
is very important. High-grade thick plastic bags could
A separate enclosure should be made for the drying
be used, alternately custom-designed bags are available
of these clothes. When the clothes are placed on the
for ethylene oxide sterilization. However these custom-
clothesline they should be pinned there as they may fly
designed bags are more expensive than plain plastic bags
and hit the floor picking up germs. This could be avoided.
used commercially.
Once dry they are picked up, folded and sealed for
Sealing of these bags has to be immaculate as any
sterilization.
porthole left gaping will now allow the atmospheric air
Sterilization Clothes could be sterilized by two containing microbes into the bag and once the seal is
methods, whichever method is used what is important is broken the contents are not any more registered as sterile.
that they be folded away keeping each procedure in Sealing machines are available in the market and their
mind. That is to say if for one cataract procedure we use is much better than burning the bags with a candle
need three operating gowns, ten towels and six shoulder and sealing them.
bags, then they should be folded in such a way that these
Ethylene oxide chamber The ethylene oxide (ETO)
are all kept together. One does not have to search for the
gas comes compressed in gas cylinders that are attached
small items by opening up every item sterilized.
to the machine. These machines which use the gas
Autoclave This still finds the pride of place in being the cylinder have a vacuum pump attached which first
most accepted form of sterilization. However one needs empties the air in the ETO chamber, then we let in the
to be aware that the clothes must not come out damp. compressed ethylene oxide gas and leave it at about 50°C
The steam in the autoclave must be saturated but dry. for over 6 to 12 hours. Now when the chamber has to
This means all the water vapor present in the air should be opened, once again the vacuum pump empties the
be gas and no droplets of water in the steam. If an gas out. The outlet from the machine needs to be placed
autoclave is giving out damp clothes that means 6 ft above and outside into the atmosphere. This gas is
toxic and its inadvertent entry inside the hospital premises Moreover, plastic bottles cannot be autoclaved as they
is a health hazard for personnel. Care must be taken that would melt with the over 100°C needed for autoclave
the outlet tubing is placed well outside the hospital sterilization.
premises, onto the terrace if possible. Even when we are sterilizing these glass bottles care
Once the ETO has escaped out the atmospheric air is has to be taken in their placement in the autoclave bins.
let in and the chamber pressure maintained at atmos- Autoclave indicator stickers are used on every bottle. The
pheric pressure before it is opened. The materials can bottles are placed head up, and kept in the bin with space
now be kept on a shelf for airing. The shelf should be all around. Preferrably wrapped in some cloth towel so
just racks with ample room on either side for the gas to that should they inadvertently break and blow up, they
escape from its whereabouts. The linen can be now used would do so inside the wrapping. Care has to be taken
as sterile after 48 hours of airing. to let the fluids reach a level of below 80°C temperature
Alternately gas ampoules are present which can be before opening the autoclave chamber as they may blow
placed inside the chamber, these ETO gas ampoules need up on exposure to room temperature.
neither the vacuum pump nor the temperature main- All fluids used inside the eye are kept at 4°C for better
tenance and can be easily placed inside a big plastic bag trauma control on the eye. As we know cold itself is an
also prescribed by the company that manufactures the anesthetic and controls blood vessels by constricting them
ETO gas ampoules. All the clothing is stacked after sealing we prefer to use cold fluids inside the eye. This would
inside the big plastic bag that occupies the whole of the also ensure better control on the delicate tissues of the
gas chamber. The ampoule is broken and this allows the eye and less trauma as well.
ETO gas to permeate through the whole closed plastic
bag inside the chamber. This is left so for 12 hours and Methylcellulose 2% (VISCON) Much the same techno-
for another 14 hours when the gas escapes the chamber. logy is used in autoclaving methylcellulose. Glass con-
After which the contents can be taken out and placed on tainers are once again preferred as plastic would react
airing shelves. with the fluids inside. The vials are kept wrapped in cloth
and placed inside the autoclave bins. Once sterile these
Medication are shifted into a refrigerator to keep them at 4°C, the
preferred temperature for methylcellulose as we know at
Parenteral this temperature the viscosity is the greatest and best for
intraocular use.
IV fluids and intraocular fluids Fluids used inside the
eye should be regarded as not sterile unless proved other- All other medication These too need our undivided
wise. Towards this exercise we sterilize all our fluids, like attention as to their expiry. Most drugs are not re-steri-
Ringer lactate, saline and even 2 percent methylcellulose. lized since the methodologies used might just denature
Many a surgeon in developing countries has suffered the medication. However, place has to be kept in the
immense loss by placing Ringer lactate into the eye operating area complex for essential medication neces-
without prior sterilization. E. coli has been known to be sary during the course of a surgery. These medicines
grown from these fluids. At the moment of an infection should not be stocked inside the main operating room
occurring not just one eye will be lost, but the whole but in prefunction area.
batch of Ringer lactate would and will be used on several Care needs to be taken regularly to keep dusting and
eyes at a time and many losses have been reported. From keeping the area where medicines are kept to be clean
the Ringer lactate one surgeon lost over 12 eyes to and free from germs. Thus to do so every day this area
infection from the fluid. This cannot be really taken as a must be cleaned, drawers, shelves all cleaned with plain
mistake as we understand that fluids meant for IV therapy cloth and at least once a week with soap water and/or
must be totally sterile, however this is not always the Bacillocid.
case.
So to protect our patients from such a malady occur- Probes and Tubings
ring we resterilize these bottles in the autoclave. It is All probes and tubings are usually of disposable variety,
preferrable to use glass bottles. Studies have shown the and they could be kept in clean shelves or drawers with
plastic polymers react with the fluids and can have drastic names written on the outside.
effects on the cornea of patients. Thus, world over glass Alternately today we could recycle probes and tubings
is a preferred carrier for use of fluids inside the eye. by first cleaning them well and then passing them through
Sterilization 21
ethylene oxide sterilization. However, these tubings and The I/A probes, the internal tubing, external tubing,
probes are usually made of plastic and for the gas rectal knibs are all cleaned with various disinfectants (Figs
sterilization to be totally safe and non-toxic they need to 3.17 to 3.26).
be kept on the shelf for airing for over 15 days. So the
date and time of ETO sterilization needs to be marked The Operating Room Personnel
on the color indicators when sterilizing these items. Most often surgeons like to operate in the morning,
A preferred methodology for sharp instruments to be sometimes they need to operate through the whole day,
sterilized is also the ETO chamber, some of these sharp however, it is a good exercise to see that all operating
instruments like disposable knives are also made of plastic area personnel have a regular bath first thing in the
handles, which can withstand ETO temperatures but not morning before entering the operating area. All street
the autoclave. These too need to be kept on a shelf for clothing and footwear should be removed before enter-
15 days before use on human tissues. ing the operating area. Thus most hospitals would keep
Fig. 3.17: Flushing of I/A probe with 70 percent isoproppyl Fig. 3.19: Flushing of the lumen of the internal tubing and the
alcohol passing 200 ml of alcohol into every lumen metal knobs with 2 percent glutaraldehyde passing 200 ml of
the same into the lumen
Fig. 3.18: Flushing of the lumen of the internal tubing and the Fig. 3.20: Flushing of the lumen of the internal tubing and the
metal knobs with carbonic soap and mineral water passing metal knobs with 70 percent isoproppyl alcohol passing 200
200 ml of the same into the lumen ml of alcohol into the lumen
Fig. 3.21: Flushing of the lumen of the internal tubing and the Fig. 3.23: Flushing of the lumen of the external tubing with 2
metal knobs with mineral water passing 200 ml of the same percent glutaraldehyde passing 200 ml of the same into the
into the lumen lumen
Fig. 3.22: Flushing of the lumen of the external tubing with carbo- Fig. 3.24: Flushing of the lumen of the external tubings with 70
nic soap and mineral water passing 200 ml of the same into percent isoproppyl alcohol passing 200 ml of alcohol into the
the lumen lumen
the changing rooms as the first area of the operating area The personnel take off their shoes and are given
complex. alternate operating area clogs, slippers or sandals. The
operating area footwear should also undergo vigorous
Footwear cleaning procedures every day. At the end of the day, all
Separate areas should be demarcated to keep foot-wear. the footwear is taken in and washed with soap water
and cleansed with plain water and left for drying.
This should be kept outside the operating area complex.
However, sometimes they could be kept just inside the
Clothing
door as we have seen many a surgeon goes in taking
out his or her shoes and when he or she comes back his After changing the footwear all clothing needs to be
or her shoes are gone. This is specially true if he or she changed. A changing room has to be kept clean and with
wears lovely expensive new shoes. lockers so that operating room personnel can keep their
Sterilization 23
Fig. 3.25: Flushing of the lumen of the external tubings with

mineral water passing 200 ml of same into the lumen
clothes and valuables safely. The most often used per-

sonnel clothing are pant with elasticated waist and shirts
Fig. 3.26: 100 ml of Ringer lactate solution is passed through
with loose necks so that they could be slided into. It is the lumen of the internal tubings, external tubings, I/A probe
preferrable not to keep buttons and other such acces- and metal knobs
sories on these clothing as they would get damaged in the
vigorous routine that these clothing should go through. patients should be told to have a bath before they go in
After the operation theatre has finished for the day for elective planned surgery. This simple process does
clothes from the personnel lockers are taken ideally into give large benefits. Shaving where men are concerned is
a washing machine and then through the dryer and sent essential and removal of make-up is necessary where
for sealing and packing through ethylene oxide sterili- women are concerned.
zation ready for use four days from the day of sterilization.
Towards this rigmarole the hospital would need to keep Change of Clothes
six times the number of clothes actually required. The patient should change into operating room clothes
However, if this is not possible the clothes could be and take out all street clothes. Footwear has to be
washed by hand dried and then sent into the autoclave removed before entering the operating room. Ideally
for sterilization. In these clothes one is not really looking patients are requested to remove all their clothing
for sterility but for disinfection and thus it is better to go including undergarments and a patient gown given to
a step further and make them sterile before use. them. This is done in the benefit of the patient so that at
any particular time should an emergency procedure be
Cap and Mask called for it can be applied without interference from
The cap and mask need not be sterile, however they essential clothing. Moreover, all patients need to be moni-
should be clean and disinfected. Ideally the cap and mask tored for their heart and blood oxygen these electrodes
are usually placed close to the heart.
used can be of disposable variety since their cleaning
However, in ophthalmic practice it is customary in a
will then not become necessary. However, if they are not
day care surgical center that the clothes need not come
and the hospital needs to use cloth cap and mask, they
off the patient. Simple removal of shoes and shirt or dress
can go through the same cycle of events like the other
is sufficient. Patients are then given sterile disposable
clothing.
gowns that can be worn over their undergarments. This
process is found to be satisfactory for ophthalmic patients.
The Patient
All patients are also given a disposable cap so that all
The patient should also be made to go through a pro- hair can be placed inside the cap and not interfere in
cess to make him or her clean and disinfected. Ideally all surgical procedures.
Skin and Incision Site Disinfection detailed as that before Lister and the era after Lister as
this one person was responsible in explaining antiseptic
Many solutions are available for wound disinfection some
of the best used worldwide are povidone-iodine and surgery as we understand it today.
chlorhexidine gluconate 1.5 percent with cetrimide 7.5
Terminology
percent. All these antiseptics will be put to better use if
they are used in conjunction with simple cleaning proce- To better understand this vast and varied aspect of
dures first. surgery, first let us understand the terms and conditions
The patient's face could be washed with soap and often used.
water and all jewellery and accessories removed. Once
Sterilization is a process used to achieve sterility—an
the patient lies down on the operating table and is ready
absolute term meaning the absence of all viable micro-
for surgery, a scrubbed nurse paints povidone-iodine or
organisms.
any other antiseptic on the skin. This is removed with
plain gauze. Disinfection is a process which reduces the number of
If anesthesia is necessary it can be given now after contaminating microorganisms, particularly those liable
preliminary cleaning of the site. After injections are given to cause infection, to a level which is deemed no longer
the site to be operated is once again cleansed by a scrub- harmful to health.
bed personnel with antiseptic solution.
Antisepsis is used to describe disinfection applied to
Sterile Disposable Surgical Drape living tissue such as a wound.
Where the eye is concerned, in todays world the lashes Cleaning is a soil-removing process which removes many
do not have to be cut for intraocular surgery. However, microorganisms. The reduction in contamination by
whenever this is not done, then a plastic surgical dis- cleaning processes is difficult to quantify other than
posable sterile drape is used over the eyes. This has a visually.
gummy on the undersurface, keeping the eyes open the Decontamination is a general term for the treatment used
surgeon places the gummy directly on the cornea and to make equipment safe to handle and includes micro-
keeps the lashes turned out so that they could stick to biological, chemical, radioactive and other conta-
the gummy surface and keep out of the surgical field. mination.
The drape used in the ophthalmic field manufactured
by Dr Agarwal’s Pharma is also equipped with a drainage Sterilization
bag. So, once the drape is stuck to the patient’s eye, the
central plastic over the palpebral fissure is cut open with An article may be regarded as sterile if it can be demons-
sterile scissors after the surgeon has scrubbed and trated that there is a probability of less than I in a million
changed. of there being viable microorganisms on it.
A whole 20 cc of sterile refrigerated 4°C Ringer lactate Methods Five main methods are used for sterilization.
fluid is squirted over the eye, to carry out a thorough
cleaning procedure as well as to produce cryoanalgesia. Head a widely used method needs to reach tempera-
The surgery can now be started. This cleaning process is tures above 100°C to ensure bacterial spores are killed.
found to be very necessary for a clean fornix and con- Moist heat is more effective than dry as it coagulates
junctival sac. and denatures the protein, where water participates in
the reaction. This requires 121°C for 15 min with moist
STERILIZERS heat.
Temperatures above that of boiling water can be
Methods of Sterilization
attained more easily by raising the pressure in a vessel,
For a very long time we had no idea that sterilization is this is the principle of the autoclave. At sea level water
the basis of surgical correction, after all performing the would boil and produce steam at 100°C, increasing the
best of surgery though introducing harmful microbes pressure to 2.4 bar would produce steam at 125°C and
could mar the effects of surgery irreparably. With the increasing to 3 bar at 134°C. However, at subatmospheric
advent of the autoclave in 1884 we got to know a lot of pressures this temperature would fall, thus at higher
details. However, most surgical ward history can be altitudes water will boil at lower temperatures.
Sterilization 25
1. Quality of steam for sterilization Steam is non-toxic Detailed tests are undertaken with temperature-
and non-corrosive, though for sterilization it should sensitive probes (thermocouples) inserted into stan-
also be saturated, which means it should hold all the dard test packs. Though most indicators show color
water it can hold. It must also be dry, so it should not change on reaching particular temperatures.
contain water droplets. This has a greater lethal action Biological indicators comprising dried spore sus-
and is quicker in heating up the article to be sterilized. pensions of a reference heat-resistant bacterium
When dry saturated steam meets a cooler surface Bacillus stearothermopiles, are not used for routine
it condenses into a small amount of water and testing. Although spore indicators are essential for
liberates latent heat of vaporization. The energy low-temperature gaseous processes in which the
available from this latent heat is considerable. For physical measurements are very little to kill spores or
example, 6 liters of steam at a temperature of 134°C not reliable. Most often used for ethylene oxide
will condense into 10 ml of water and liberate 2162 J sterilization.
of heat energy. By comparison less than 100 J of Bowie-Dick test monitors penetration of steam into
heat energy is released by the sensible heat from air wrapped pack and detects uneven steam penetration
at 134°C to an article in contact with dry heat. by a bubble of residual air in the pack.
Steam at a higher temperature than the correspon- Dry heat causes a destructive oxidation of the
ding pressure would allow is referred to as essential cell constituents. Thus killing spores here
superheated steam and behaves like hot air. Steam requires 160°C for 2 hours. This may also cause
with water droplets is called wet steam and is less charring of paper, cotton, organic material.
efficient.
4. Types of sterilization by dry heat
2. Types of steam sterilizers A. Incineration: Most cities around the world have
A. Sterilizers for porous loads For linen, and wrapped made it mandatory for most hospitals to have
instruments, so air could get trapped in the textiles incinerators in their campus for efficient waste
used. Thus this type of sterilizer should have a disposal where contaminated materials like dres-
vacuum-assisted air removal stage to ensure that sings, sharp needles and other clinical wastes. The
adequate air is removed from the load before high temperatures reached kills all organisms and
admission of steam. The vacuum pulsing of air disposes by charring and burning the material.
also ensures that the load is dry on completion of B. Red heat: Diathermy in ophthalmic hospitals
cycle. would be done by burning a loop over a flame,
B. Sterilizers for fluids in sealed containers Must have this would sterilize as well as cauterize the bleeding
a safety feature to ensure that the door cannot be vessel. However, this is still used to sterile loops,
opened till the temperature in the glass containers wires, points of forceps. It is a still very much used
has fallen below 80°C. Otherwise the thermal in emergency situations.
stress of cold air on opening the door may cause C. Flaming: Inoculating loops and needles are some-
the bottles to explode under pressure. times treated by immersing them in methylated
C. Sterilizers for unwrapped instruments and spirit and burning off the alcohol, though this does
utensils These should not be used for wrapped not produce a sufficiently high temperature for
articles, recommended for dental clinics and sterilization. This is also done for sterilizing drums
LASIK stations. and trays over which sterile linen is placed. Once
D. Laboratory sterilizers Culture media in containers, again this is not totally sterile as spores may persist
laboratory glassware and equipment may be over the short-term flame that is produced with
contaminated, thus proper cleansing is necessary alcohol.
before sterilization. D. Hot and sterilizer: Oil, powders, carbon steel
3. Monitoring of steam sterilizers Every load every day instruments, and empty glassware laboratory
every time needs monitoring of some important phy- dishes are sterilized with hot air sterilizers, though
sical measurements. the over-all heating up and cooling may take
• Temperature several hours.
• Pressure E. Microwave sterilizer: This is the latest in roads into
• Time with thermometers. sterilizers and can offer better results than hot air
sterilizers with shorter time spans. Within 10 Though now membrane filters are usually used made of
minutes the material can be sterilized. However, cellulose esters or other polymers.
because of the high temperatures reached it is not
very good for organic material or plastics. Very Sterilant gases Ethylene oxide is used for sterilization
good for microwave transparent material like glass. of plastics and other thermolabile material. Formalde-
hyde in combination with subatmospheric steam is more
5. Factors influencing sterilization by heat would commonly used in hospitals for reprocessing thermolabile
include equipment. Both processes are toxic and carry hazards
A. Temperature and time: They are inversely related, to user and patient.
i.e. shorter time higher temperatures, holding time 1. Ethylene oxide: Highly penetrative, non-corrosive and
is important loading and cooling time would make microcidal gas which is used to in industry for single
the total time much longer (Table 3.1). use, heat-sensitive medical devices such as prosthetic
heart valves and plastic catheters. Ethylene oxide
Table 3.1: Relationship between temperature and time
sterilization is usually carried out at temperatures
Process Temp (in°C) Hold time (min) below 60°C in conditions of high relative humidity.
Dry heat 160 120 To ensure sterility, material should be exposed to a
170 60 gas concentration of 700 to 1000 mg/l at 45 to 60°C
180 30 and a relative humidity above 70 percent for about 2
Moist heat 121 15 hours. Care must be taken because of toxicity to
126 10 personnel, flammability and explosion risk. The
134 3 sterilized product must be aerated to remove residual
ethylene oxide before it can be safely used on the
B. Microbial load: The number of organisms and patient, and turn round time is consequently slow.
spores affects the rapidity of sterilization. Thus, it Some recommendations for boosting infection
is better to go through vigorous cleaning control as well as cut costs on EO sterilization :
procedures before sterilization of products. • Cleaning is a necessary and important activity
Ionizing radiation Both beta (electrons) and gamma before sterilization. I feel that you need to adopt
(photons) irradiation are employed industrially for the standardized and effective cleaning method.
sterilization of single use disposables. • Further the items cleaned have to be dried as any
All accelerated electrons are lethal to living cells, that wet item will react with ethylene oxide and the
includes, g-rays, b-rays, X-rays. Bacterial spores are the efficacy may be reduced.
most resistant. Sterilization is achieved by the use of high- • The items have to be packed in one of the three
speed electrons from a machine such as a linear materials: linen, paper or plastic. Each has its
accelerator or by an isotope source such as cobalt-60, a advantage but the limitation is the period that you
dose of 255 kGy is generally adequate, making this an can store these sterilized items. You can use plastic
industrial process. It is used for single use prepackaged bags which are of a proper grade and store the
items like plastic syringes and catheters. product up to one year after sterilization.
• The sealer used for sealing packs is inappropriate
Filtration Filters are used to remove bacteria and other if the heating is too weak for the packaging
larger organisms from liquids that are liable to be spoiled material used. This results in small holes in pack
by heating. Though virus can crossover they are felt to after sealing. An impulse heat sealer capable of
be unimportant. sealing at higher temperatures.
Filters using pore size of less than 0.45 microns can • A safe EO machine which can complete the
render fluids free of bacteria. It is used in the preparation process of aeration within all items can be used
of toxins and thermolabile parenteral fluids such as directly without any further handling.
antibiotic solutions, radiopharmaceuticals, and blood • Aeration is a natural process which can be has-
products. Viruses and some bacteria like mycoplasmas tened by installing an aerator.
can pass through pore size of less than 0.22 microns.
Filter materials could be unglazed ceramic Chamber- 2. Low temperature steam and formaldehyde A combi-
land filters, asbestos Seitz filters and sintered glass filters. nation process of steam generated at subatmospheric
Sterilization 27
pressure 70 to 80°C and formaldehyde gives an effec- 290 nm, but even more effective radiation of 240 to 280
tive sporicidal process. It is appropriate for heat- nm is produced by mercury lamps. It is used in the
sensitive articles that can resist temperatures of 80°C. treatment of water, air, thin films and surfaces such as
laboratory safety cabinets.
3. Propylene oxide One of the latest and new tech-
niques is the use of propylene oxide which is a micro- Gases Formaldehyde is used as a fumigant though it
cidal gas. It has a similar use and toxic effect like does not have an all pervasive effect. Traditionally for-
propylene oxide. maldehyde gas was used to disinfect rooms previously
occupied by patients with contagious diseases such as
Sterilant liquids Glutaraldehyde is generally the least smallpox. It is still used for disinfection of heat-sensitive
effective and most unreliable method. equipment, however its efficacy is questionable with
better products like Bacillocid available.
Disinfection
Filtration Air and water supplied to operation theatres
Disinfection is applied in circumstances where sterility is
and other critical environments are filtered to remove
unnecessary or impractical, like bed-pans, eating utensils,
hazardous microorganisms, though viruses cannot

bed linen and other such items. Similarly the skin around
remain out altogether. However, they are considered
the site for an invasive procedure should be cleansed to
harmless in these environments.
reduce chances of wound infection. A properly installed high efficiency particulate air
(HEPA) filter achieves 99.9 percent or better resistance
Cleaning
to particles of 0.5 microns and can produce sterile air at
Thorough cleaning is a prerequisite for successful dis- the filter face.
infection and is a process of disinfection by itself. This
Chemical Several chemicals with antimicrobial proper-
can be enhanced by ultrasonic baths given to the instru-
ties are used as disinfectants.
ments to remove dried debris.
Antiseptic can be regarded as a special kind of
disinfectant which is sufficiently free from injurious effects
Methods
to be applied on the surface of the body, though not
Heat Steam or water could be used suitable for systemic or oral administration.
1. Moist heat is the first method of choice, can be pre- Some would restrict the use of antiseptic preparations
cisely controlled, leaves no toxic residues and does applied to open wounds or abraded tissue and would
not promote the development of resistant strains. use the word skin disinfection for removal of organisms
Washing or rinsing laundry or eating utensils in water from hands and intact skin surfaces.
at 70 to 80°C for a few minutes will kill most non- 1. Factors influencing the performance of chemical
sporing microorganisms present. Similarly, steam disinfectants
maintained at subatmospheric pressure at 73°C is A. The concentration of the disinfectant: The
used in low temperature steam disinfectors in hospitals optimum concentration required to produce a
to disinfect thermolabile reusable equipment. standardized microbial effect in practice is
2. Boiling: Exposure to boiling water for 20 min achieves described as the in-use concentration. Care must
highly effective disinfection, although this is not a be taken in preparing accurate in-use
sterilization process it can be useful in emergencies if concentrations while diluting product. Accidental
no sterilizer is available. or arbitrary over dilution may result in failure of
disinfection.
Ultraviolet radiation It has limited application for dis- B. The number, type and location of microorganism:
infection of surfaces, some piped water supplies but lacks The velocity of the reaction depends upon the
penetrative power, however newer modifications in use number and type of organisms present. In general
with ozone treatment plants is very effective in dis- gram-positive bacteria are more sensitive to disin-
infection. fection than gram-negative bacteria. Mycobacteria
This is a low-energy, non-iodising radiation with poor and fungus are resistant while spores are highly
penetrating power that is lethal to microorganisms under resistant, while viruses are susceptible.
optimum conditions. The shorter UV rays that reach the Glutaraldehyde is highly active against bacteria,
earth’s surface in quantity have a wavelength of about viruses and spores. Other disinfectants such as
hexachlorophene have a relatively narrow range residues and recontamination. The alkaline buffe-
of activity, predominantly against gram-positive red solution is claimed to remain active for several
cocci. days, but this will vary depending on the in-use
C. The temperature and pH: Some disinfectants are situation, including the amount of organic
more active or stable at a particular pH. Though material.
glutaraldehyde is more stable under acidic C. Biguanides (chlorhexidine): This is commonly
conditions its microbial effect is seen better when used for disinfection of skin and mucous
the pH is 8.0 membranes. It is less active against gram-negative
D. The presence of organic or other interfering bacteria such as Pseudomonas and Proteus sp and
substances: Disinfectants can be inactivated by in aqueous solution has limited virucidal,
hard tapwater, cork, plastics, blood, urine, soaps tuberculocidal and negligible sporicidal activity. It
and detergents, or other disinfectants. Information is often combined with a compatible detergent for
should be sought from the manufacturer or from handwashing or with alcohol as a handrub.
reference authorities to confirm that the Chlorhexidine has low irritancy and toxicity and
disinfectant will remain active in these is effective even on exposed healing surfaces. It is
circumstances. inactivated by organic matter, soap, anionic
2. Common chemicals in use detergents, hard water and some natural materials
A. Alcohols: Isopropanol, ethanol, and industrial such as cork liners or bottle closures.
methylated spirit have optimal bactericidal activity D. Halogens (hypocholrites): These broad-spectrum
in aqueous solution at concentrations of 70 to 90 inexpensive chlorine-releasing disinfectants are
percent and have little bactericidal effect outside that of choice against viruses. For heavy spillage
this range. They have limited activity against such as blood, a concentration of 10,000 ppm of
mycobacteria and are not sporicidal. Action available chlorine is recommended.
against viruses is generally good. Because they These are inactivated by organic matter and
are volatile, alchohols are recommended as rapidly corrode metals, so that contact with metallic instru-
drying disinfectants for skin and surfaces. However ments and equipment should be avoided. The
they may not achieve adequate penetration and bleaching action of hypochlorites may have a
kill, particularly if organic matter such as blood or detrimental effect on fabrics and should not be
other protein-based contamination is present. used on carpets.
Alcohols are suitable for physically clean surfaces Chlorine-releasing disinfectants are relatively
such as washed thermometers or trolley tops but stable in concentrated form as liquid bleach of as
not for dirty surfaces. Care must be taken when tablets (sodium dichloroisocyanurates) but should
used on the skin in conjunction with diathermy be stored in well-sealed containers in a cool dark
and other instances of flammable risk. Alcohols place. On dilution to the required concentration
with chlorhexidine or povidone-iodine are good for use, activity is rapidly lost.
choices for hand disinfection, they are applied to Hypochlorites have widespread application as
the dry skin often with added emollient to laboratory disinfectants on bench surfaces and in
counteract the drying effect. discard pots. Care should be taken to remove all
B. Aldehydes: Most aldehyde disinfectants are based chlorine-releasing agents from laboratory areas
on glutaraldehyde or formaldehyde formulations, before the use of formaldehyde fumigation to
alone or in combination. Glutaraldehyde has a avoid the production of carcinogenic reaction
broad spectrum action against vegetative bacteria, products.
fungi, viruses, but acts more slowly against spores. Iodine: Like chlorine, iodine is inactivated by
It is often for equipment such as endoscopes that organic matter and has the additional disad-
cannot be sterilized or disinfected by heat. It is an vantage of staining and hypersensitivity. The
irritant to the eyes, skin and respiratory mucosa, iodophors which contain iodine complexed with
and must be used with adequate protection of staff an anionic detergent of povidone-iodine a water-
and ventilation of the working environment. It soluble complex of iodine and polyvinyl pyr-
must be thoroughly rinsed after treated equipment rolidone are less irritant and cause less staining.
with sterile water to avoid carry-over of toxic Aqueous and alcohol-based povidone-iodine
Sterilization 29
preparations are used widely for skin and ocular overgrowth by gram-negative contaminants and
disinfection as well as other mucous membrane inactivation by mixing cationic and anionic agents.
disinfection. Disinfection may be enhanced by appropriate
E. Phenolics: These have been widely used as general combination of a surface active agent with dis-
purpose environmental disinfectants in hospital infectant to improve contact spread and cleansing
and laboratory practice. They exhibit broad- properties.
spectrum activity and are relatively cheap. Clear
soluble phenolics have been used to disinfect Quality Control
environmental surfaces and spillages if organic soil Every method used must be validated to demonstrate
and transmissible pathogens may have been microbial kill. With heat and irradiation a biological test
present. As hospital disinfection policies are ratio- may not be required if the physical conditions can be
nalized, phenolics are being replaced by detergents
proved to have reached their ultimate design.
for cleaning and by hypochlorites for disinfection.
Most phenolics are stable and not readily inacti- D value The D value or the decimal reduction value is
vated by organic matter, with the exception of the the dose that is required to inactivate 90 percent of the
chloroxylenos (Dettol) which are also inactivated initial population. When the time required or the dose
by hard water and not recommended for hospital required to reduce the population from 1 000 000 to 1
use. Phenolics are incompatible with cationic 00 000 is the same as the time or dose required to reduce
detergents. Contact should be avoided with rubber the population from 1,00,000 to 10,000 the D value
and plastics, such as mattress covers, since they remains constant over the full range of the survivor curve.
are absorbed and may increase the permeability Extending treatment beyond the point where there is one
of the material to body fluids. The slow release of surviving cell does not give rise to fractions of a surviving
phenol fumes in closed environments and the cell but rather to a statement of the probability of finding
need to avoid skin contact are other reasons for one survivor. Thus, by extrapolation from the experi-
care in use of phenolics. mental date it is possible to determine the lethal dose
The bis-phenol hexachlorophane has particular required to give a probability of less than 1 in 10,00,000
activity against gram-positive cocci, and has been which is required to meet the pharmacopoeial definition
used in powder or emulsion formulations as a skin of sterile.
disinfectant, notably for prophylaxis against stap-
hylococcal infection in nurseries. There has been Factors Influencing Resistance
some concern about the possible toxic effect of
Many factors affect the ability of the microorganism to
absorption across the neonatal skin barrier on
withstand lethal procedures of sterilization. This in fact is
repeated exposure. An alternative, which has been
the reason why we need to keep updating ourselves as
used in the control of methicillin-resistant Staph.
to the methods of sterilization and their efficacies. This
aureus outbreaks is triclosan.
also happens to be the reason why living creatures are
F. Oxidizing agents and hydrogen peroxide: Various
able to withstand high amounts of torture only to make
agents, including chlorine dioxide, peracetic acid
sure their breed lives on. Bacteria are not that much
and hydrogen peroxide, have good antimicrobial
different from us in this intrinsic need to propagate, grow
properties but are corrosive to skin and metals.
and leave their legacy behind. Still we need to be on top
Hydrogen peroxide is highly reactive and has
of them to allow them to grow where we need them and
limited application for the treatment of wounds.
the operating room is definitely not a place we need any
G. Surface active agents: Anionic, cationic, non-ionic
of them at all. Here are some of the reasons why these
and amphoteric detergents are generally used as
bacteria do withstand our torture.
cleaning agents. The cationic (quaternary ammo-
nium compounds) and amphoteric agents have Species or strain of microorganism As usual the spores
limited antimicrobial activity against vegetative are more resistant than vegetative bacteria or viruses.
bacteria and some viruses but not mycobacteria Though some strains of species have wide variations.
or bacterial spores. Quaternary ammonium com- Enterobacteriaceae D values at 60°C range from a few
pounds disrupt the membrane of microorganisms, minutes (E. coli) to 1 hour (Salmonella senftenberg). The
leading to cell lysis. Care must be taken to avoid typical D value for Staphylococcus aureus at 70°C is less
than I min compared with 3 min for Staph. epidermidis. All members of the team must familiarize themselves
However, an unusual strain of Staph. aureus has been with the items to be sterilized and the chemicals necessary
isolated with a D value of 14 min at 70°C. Such variable to do so. A microbiologist should be included in this team
could be attributed to the morphological and physio- as they alone can monitor the efficacy of the said pro-
logical changes such as alterations in cell proteins or cesses. Along with should also be a pharmaceutical
specific targets in the cell envelope affecting permeability. person who has full knowledge of the various chemicals
Thus we should not understand the inactivation data used, their action and the efficiency in said matters. It is
for one disease forming organism would withstand by very instrumental to include these persons on the
another. Creutzfeldt-Jakob disease is a highly resistant infection control team of a hospital.
agent requiring six times the normal heat sterilization cycle The hospital policy should be common and should
(134°C for 18 min). include:
• The sources to be sterilized (equipment, skin, envi-
Physiological stage Organisms grown under nutrient- ronment, air, water, personnel) for which a choice of
limiting conditions are typically more resistant than those process is required to be commonly accepted by the
grown under nutrient-rich conditions. Resistance usually
team for infection control.

increases through the late logarithmic phase of growth • The processes and products available for sterilization
of vegetative cells and declines erratically during the and disinfection must be made available for all to see
stationery phase. and inspect. An effective policy may include a limited
Ability to form spores Bacterial endospores are more number of process options, restrictions on the range
resistant than fungal spores, some of them are used as of chemical disinfectants eliminate unnecessary costs,
bacterial indicators especially for ethylene oxide sterilizers confusion and chemical hazards.
to monitor their efficacy. Disinfection has no efficacy • The category of process required for each item,
where spores are concerned. sterilization for surgical instruments and needles, heat
disinfection for laundry, crockery, bed-pans, cleaning
Suspending menstrum Microorganisms occluded in of floors, walls, furniture and fixtures.
salt have greatly enhanced resistance to ethylene oxide, • The specific products and method to be used for each
the presence of blood or other organic material will reduce item of equipment, the site of use and the staff
the effectiveness of hypochlorite solution. Thus sus- responsible for the procedure. These should all be
pended particles will alter efficacy of various techniques. earmarked in a record so that one can get back to the
Number of microorganisms Quite obviously the ini- lapse when it happens.
tial “bio-burden” the more extensive must the process of Effective implementation of the policy requires liaison
sterilization be to achieve the same assurance of sterility. and training of staff and updating the policy. Safety consi-
derations for staff and patients require a careful assess-
Sterilization and Disinfection Policy ment of specific procedures to minimize risks.
The staff for implementation of these processes must
All hospitals should go through a rigmarole of infection wear protective gear where necessary. Gloves, aprons,
control and agree on a particular policy to be followed caps and masks must be included in the policy. Where
uniformly by all concerned in this infection control team. dangerous gases are used eye goggles similar to swim
This should be headed by the chief surgeon and each goggles can be used to protect the eyes from the noxious
one must report to the leader of the team everyday. gases.
It has been noticed over centuries of medical practice For proper sterilization control, it is important to go
when a surgical team gets to do routine surgeries every back into every case that gets infected to try and pry and
day for many days and years, a kind of apathy sets into find out what was the reason for the infection. This can
the system and somewhere someone lapses. These effectively be done by the weekly meeting of the infection
instances have been the most common cause for infec- control team where every one tries to pitch in their inputs.
tion. To avoid such lapses the infection control team Staff should not be penalized for accepting their wrong-
should meet each week to update themselves on the latest doings, because if they are penalized they will not accept
happenings in their hospital and to bring to the notice the cause of the infection next time it occurs. The staff
such lapses so that a tightening of procedures can be should be goaded into performing better by putting the
applied. At each lapse the chief surgeon must be held patients best interests in view and not for witch hunting
responsible for the actions of his or her team. and blaming.
Sterilization 31
CULTURE RATE Base solution Dissolve agar in 500 ml of distilled water
by autoclaving at 121°C for 20 minutes. Dissolve the
The most important mechanism for the proper function-
peptone, bile salts and sodium chloride in the remaining
ing of an operation theatre is the fact that no organism
should grow from this area. To find out whether an 500 ml of distilled water, and bring the solution to boil.
organism is growing or not we need to make sure it is Combine the two solutions mixing thoroughly. Dissolve
present or not, that can effectively be done by growing it the lactose and adjust the pH to 7.2. Distribute in screw-
on a culture media. Some of the most common culture capped bottles and sterilize with autoclaving at 121°C
media used in hospitals is discussed here. for 15 minutes.
Dissolve 1 gm of neutral red in distilled water and
MacConkey’s Agar make up the volume to 100 ml. Heat the solution in
steam at 100°C for 30 minutes.
To make this culture plate (Fig. 3.27) is simple enough. Dissolve 0.1 gm of crystal violet in distilled water and
According to directions 51.5 gm of the powder made make up the volume to 100 ml. Heat the solution in
available through Himedia Laboratories is dissolved in steam at 100°C for 30 minutes.
1000 ml of distilled water. This is allowed to boil till the To 200 ml of the base solution, melted and cooled to
powder is completely dissolved and the fluid has boiled about 60°C add aseptically 0.6 ml of the neutral red
for over 15 minutes, thus sterilizing the fluid further. It solution and 0.2 ml of solution with crystal violet. Mix
could be still sterilized by autoclaving though most well and distribute into sterile Petri dishes.
hospitals find 15 minutes of boiling to suffice in its Incubate the plates at 37°C for 24 hours (Figs 3.28 to
sterilization. 3.30) and examine for contamination. Inoculate four
This culture medium contains: plates from the following stock culture Salmonella typhi,
Peptic digest of animal tissue 17 gm / lit Escherichia coli, a mixture of Salmonella typhi and E.
Peptone 3 coli and Shigella flexneri. This will prove the efficacy of
Lactose 10
the culture media prepared and now it can be poured
Bile salts 1.5
into petri dishes and refrigerated to be used on need for
Sodium chloride 5
culture plates. It is advisable to keep them for 24 to 48
Neutral red 0.03
hours and to keep making fresh batches very often.
Agar 15
At a final pH at 25°C of 7.1 Nutrient Agar
Alternately if the ready-made powder is not available A general purpose medium for the cultication of micro-
then the following procedure can be applied to the above- organisms and a base for enriched or special purpose
mentioned ingredients.
Fig. 3.28: Culture specimen taken using sterile

Fig. 3.27: MacConkey’s blood agar culture plates swab stick from the instrument table
Fig. 3.29: Culture specimen taken using sterile Fig. 3.30: Culture specimen taken using sterile swab stick
swab stick from the operation table head rest being streaked on the MacConkey’s blood agar culture plate
media. It can be made very simply by the powder avail- areas sterilized or disinfected. Some of the quality checks
able from Himedia laboratories by dissolving 28 gm of necessary to be carried out are
powder in 1000 ml of distilled water and boiling for 15
minutes. This would also sterilize the medium and it is Plate Test
ready for use after cooling. The powder contains: One of the easiest to perform and tells us quite a bit
Peptic digest of animal tissue 5 gms/lit
about the cleaning tactics used for the particular room.
Sodium chloride 5 This test would not be so effective in open areas but is
Beef extract 1.5 quite reliable for closed areas like operating rooms.
Yeast extract 1.5 For closed rooms Where operating rooms are concer-
Agar 15 ned once we have assured ourselves there is no con-
At 25°C the pH is 7.4 taminated air coming in, with door closers, air curtains
Alternately if the powder is not available the separate and filtered air-conditioned ducting, cleaning the room
entities can be taken, mixed and steamed for 2 hours. with detergents and disinfectants should clear the air of
The pH should be adjusted first to 6.8 then clear the all bacteria. However this does not remain so through
fluid with egg albumin. Filter and bottle. Autoclave at 15 out the day, and it is noticed that after a few surgeries
1bs pressure for 20 minutes or steaming for 30 minutes due to human beings inside the operating rooms bacteria
each day on three successive days. do escape to contaminate the air. This can be effectively
controlled by keeping a watch on the cleaning procedures
Blood Agar and making sure a disinfectant mop is used after every
procedure and on every item of the operating room.
An enriched medium for general use in routine cultiva-
However, testing for the efficacy of the cleaning pro-
tion of the more delicate microorganisms like Neisseria
cedures is devised by the PLATE TEST. Here a sterile
meningitidis, N. gonorrhoeae and Diplococcus pneu-
bowl is used with sterile water and kept in the concerned
moniae. The medium also serves as an indicator of
room for 20 minutes. Should there be bacteria in the
hemolysin production by bacteria. room they would settle down on the surface of the bowl
It is very simple to make. Add 6 to 10 percent defibri- of water. Thus skimming the surface a few drops are taken
nated blood to melted nutrient agar and cool to 45 to and placed on a Petri dish with culture media on it. This
60°C. Pour plate or slant, incubate 24 hours to prove is incubated at 38°C for 48 hours and if this grows bacteria
sterility. then we know our disinfectant procedures were not
enough and we need to plough ourselves further. If it is
STERILIZATION CONTROL
negative then we can proceed with the same policy. This
The infection control team which consists of a micro- test should be ideally carried out every day, before every
biologist must take regular samples from the different procedure in every room of the operating area.
Sterilization 33
For open areas Lounges where patients wait or the Of special importance is fluids used for intraocular
outside arenas are to be cleansed as well, if we would use, or for intravenous use. As soon as each IV bottle is
like to have a tight infection control in the operating area. opened the first few drops from the IV set can be placed
After all these areas lead to the operating area—the most on a culture plate for incubation.
pious sanctum sanctorum of the hospital edifice. Many eye surgeons from our subcontinent have grown
The plate test is carried out every day every few hours, E. coli from the Ringer lactate used intraocularly.
and an optimum time interval given to the hospital autho- However, most often this has happened after a tragedy
rities where it can be stated that every four hours the of multiple eyes have succumbed to postcataract surgery
hospital lounges should be cleaned with disinfectant to infection. Thus by performing this simple step we may
maintain a clean bacteria-free atmosphere. This can now be able to thwart further mishaps.
be controlled by taking plate test samples every four hours Should any one batch of fluids be found to be positive
before cleaning procedures are done and making sure it is a good idea to report the matter so that others can
the tests remain negative for growth in all the tests taken. be forewarned and to take every bottle from that batch.
If not the program needs to be revised and the hours
All Fluids used Parenterally to be

shortened. Checked for pH Value
This test should also be carried out in the consultation
areas and optimum time intervals for cleaning prescribed Great importance should be given to the pH of fluids
by the microbiologist on the infection control team. inside the body especially where the eye is concerned.
We presume that all fluids marked for parenteral or
Culture Test from Walls, Floor, Fixtures, Furniture intraocular use come at the pH close to 7.4, however, it
is alarming to note the amount of times I have personally
Everyday the different areas should be taken for culture, seen surgery go wary only due to the fact that the pH
it is advised to take eight different areas for culture from was either 5.6 or above 8. This can produce havock on
every room everyday. Methodology for taking culture is the patient’s cornea.
to take a moist swab, by dipping a cotton tip applicator In 1992 over 300 cases were reported lost due to hazy
in sterile water and rubbing it in a streak fashion on the opaque corneas following extracapsular cataract surgery
culture plate. in some states of India. This was followed by a widespread
The culture plates are made in Petri dishes about 3 search for the culprit. What was found was alarming to
inches in diameter. The back surface of the Petri dish all concerned, a balanced salt solution (BSS) was sold in
can be stroked with a marker pen and each culture plate small bottles. It was learned that this solution carried an
divided into eight parts. alkaline pH, because while cleaning the glass bottles the
One culture plate can be ear marked for each room, last rinse of soap solution (BSS) was not totally washed
and 8 objects from the room can be cultured. It is preferr- out and the remaining soap solution left behind an
able to always include the floor, of the room however alkaline pH which recked havoc on the cornea producing
different parts of the floor can be taken each day to ensure total blindness.
proper cleaning and disinfectant use. Other objects that It took the investigating authorities over six months to
can and should be cultured for are the fans, air- procure this data and cause by which time multiple
conditioners, lights, walls, tables, chairs, stools and all surgeries had been carried out with much devastation.
the equipment present in that particular room. Like A simple technology to avoid such future catastrop-
Boyles apparatus, phaco machines, etc. hies is to check out the pH on table before the surgery. A
few drops of the fluid can be dropped on a simple litmus
All Fluids to be Cultured strip and one minute later the color change noted with a
All fluids used in the operating room must be sent for rough estimate of the pH value noted.
culture tests, sometimes this becomes less possible as the This should be ideally carried out for all cases.
fluid is too little and necessary for parenteral application. Specialized Equipment Cultures
However, every batch of fluids used can be sent for
culture tests. This may not grow positive however its not Special tests are performed for special machines, like the
growing positive itself is an indication of the efficacy of one available for the ethylene oxide sterilizer.
the program. This sets aside any debate that the fluid Biological chemical indicator One or more biological
may have contained bacteria. chemical indicator can be placed in the steam or ethylene
oxide test packs and the process passed through the When, Where and Why to Use Biologicals
sterilization cycles. If used to monitor a 270°F steam When?
“flash” cycle, place a wire mesh bottom instrument tray • Once a day in every sterilizer
and then proceed. • Once a week in steam sterilizer cycle used
After sterilization processing has been completed, allow • Every steam load with implants
the biological chemical indicator to cool until safe to • Every EO load.
handle and open. Remove the indicators and allow to Three consecutive times before using new sterilizer and
cool an additional 10 to 15 minutes. Observe chemical after repairs.
process exposure indicator on vial label to verify color
Where?
change corresponding to sterilization cycle, i.e. ethylene All sterilization processes.
oxide turns gas process indicator to gold and steam turns
the steam process indicator to brown. Why?
If chemical process indicator is unchanged, exposure • To challenge your sterilizer’s effectiveness
• To assure load sterilization parameters were up to
to the sterilization process may not have occurred. Check
standard.
the sterilization process.
If the chemical process exposure indicator on the vial Surgeons Hands Cultured
label did change to the proper color and the indicator
Right after scrubbing and ready for operation a surgeon’s
has cooled to touch, firmly seal the biological indicator
hands should be regularly swabbed and taken for culture
by pushing the cap to close till the cap reaches second
so that a close check can be carried out to the efficacy of
blue bar on the vial label.
the cleaning and scrubbing solutions.
Crush the inner ampoule from the outside wall of the There are many surgeons who believe in different
plastic vial to ensure that the growth medium is released technologies of scrubbing. While some would swear with
from the crushed ampoule and is in contact with the the pounding away of epithelial tissue by a brush others
spore disk. would want to keep the epithelium intact at all times.
Place the activated indicators in an incubator and While some would swear with a last dip into alcohol,
incubate it at 37°C for EO sterilization and 55°C for steam others would keep alcohol well out of the way of surgeon’s
sterilization. hands.
If there is a color change in the medium from deep However, it has been seen that three times to lather
blue to bright yellow and turbidity is evident, it means with soap and wash hands is a uniform tendency of most
there is a positive growth. Indicators positive for growth surgeons.
will often be evident prior to maximum recommended
incubation time, but indicators not evidencing growth Linen and Textiles Cultured
mtiust be allowed to incubate for at least 24 hours (steam) Efficacy of sterilization on the different linens and textiles
and 48 hours (ethylene oxide) to assure confidence in used in surgery should be tested by taking culture tests
the negative reading. from these items just after surgery.
Viscoelastics 35
Viscoelastics 4 VP Gupta
V
iscoelastic substances are currently essential for chambers. Surface application of viscoelastic materials
the successful performance of most of the maintains a stable irregular shape and is easily wiped off
intraocular anterior segment surgery, especially when touching an obstancle. The usefulness of a
extracapsular cataract extraction and phacoemulsification viscoelastic substance to protect tissue surfaces and for
with an intraocular lens implantation. Viscoelastics subs- space maintenance depends mainly on their physical
tances are considered as the most important addition in properties. The tolerance of viscoelastic substances within
the armamentarium for microsurgery. Viscoelastic subs- the eye depends on their chemical composition. An ideal
tances have revolutionised ophthalmic microsurgery viscoelastics substance should have the following
particularly cataract surgery. Balazs coined the term properties:
viscosusrgery. Viscosurgery uses these agents to protect 1. It should be inert and iso-osmotic.
tissue surfaces, to create and maintain spaces, to facilitate 2. Viscoelastic should have a high viscosity for
intraocular tissue manipulations and to assist in successful performance of various functions such as
haemostasis. During the evolution of IOL surgery it was maintenance of anatomic spaces, tissue protection,
observed that short contact between polymethyl intraocular tissue manipulations, lubrication and
methacrylate of IOL and the fragile endothelial cells of haemostasis.
cornea could result in irreversible corneal damage leading 3. It should be free of corpuscular elements and clumps.
to persistent corneal oedema. Binkhorst et al had 4. It should be sterile, non-inflammatory, non-pyogenic,
recommended the air cushion technique to prevent the non-toxic and non-antigenic.
danger of contact between polymethyl methacrylate 5. It should be reabsorbed without inflammation and
intraocular lens and the fragile endothelial cells of cornea. should not interfere in the wound healing.
Fechner reported the use of methylcellulose successfully 6. It should be optically clear. Viscoelastics should not
in intraocular lens implantations since 1976 to prevent impair the visibility inside anterior chamber.
the rubbing of PMMA of IOL against the endothelium of 7. Viscoelastics should possess pseudopasticity, i.e. the
cornea. Sodium hyaluronate was used in the human eye ability to pass through a fine cannula, i.e. a 30 gauze
as a vitreous substitute for the first time in 1972. First needle.
human studies of efficacy of hyaluronic acid were
performed by Robert Stegmann and further confirmed VISCOELASTIC SUBSTANCES
and reported by Balazs et al in 1979. Ever since a variety Currently used viscoelastics have been divided into two
of viscoelastic substances have emerged. broad types (a) cohesive viscoelastics having high cohe-
sive characteristics, e.g. healon (1% NaHa), Healon GV
PHYSICAL AND CHEMICAL PROPERTIES OF
(1.4 Va Ha) (b) dispersive viscoelastics—These are non-
VISCOELASTICS
cohesive viscoelastic. These materials adhere to ocular
Viscoelastic substances possess viscous and elastic surfaces. Dispersive viscoelastics provide a protective
properties concomitantly. Viscoelastic substances are coating for corneal endothelium without excessive
excellent for protection of tissue surfaces by forming even coakage from AC.
layers on the tissue or implant surfaces and act as ideal The following viscoelastic substances are described in
coating agents. Space maintenance by viscous materials literature:
is efficient resistance. However, the maintenance of space 1. Hyaluronic acid
with viscoelastic substances does not depend on the 2. Methylcellulose-Hydroxypropyl methylcellulose
outflow resistances, therefore, even effective in open 3. Chondroitin sulphate
4. Polyacrylamide is stable and can be sterilised by boiling. It does not

5. Collagen—human placental collagen type IV support the growth of micro-organisms.
6. Poly TEGMA—Triethylene glycol monomethacrylate Methylcellulose used for intraocular surgery is a
highly purified brand of medical use grade hydroxy-
Hyaluronic Acid (Sodium Hyaluronate) propyl methylcellulose (HPMC). It is a synthetic
It is a naturally occurring mucopolysaccharide. It consists modification of methylcellulose. HPMC 2 per cent
of a long unbranched chain of alternative N-acetyl-gluco- is freely available commercially. The hydroxypropyl
samine and sodium gluconate. Hyaluronic acid is present and methyl groups replacing hydrogen groups
in abundance in vitreous humor and trabecular mesh- increase its hydrophilicity. The basic molecule is D-
work. Corneal endothelium is naturally covered with a glucose. Two monomers of glucose combine to form
layer of sodium hyaluronate. It is an inert, totally trans- cellobiose, which differs from dextrose only in the
parent, non osmotic viscoelastic material composed of way the 2 monomers are stereochemically con-
98 per cent water and is highly viscous, 400,000 times nected: in cellobiose the bonding is beta-glycosidic,
more viscous than saline. It is a viscoelastic with pseudo- in dex–trose alpha glocosodic. The human enzymes
phastic properties. It is not metazolised or degraded. are incapable of breaking cellobiose bonding. HPMC
Healon—(It contains sodium hyaluronate 1%) it is is a dispersive viscoelastic agent. Its MW is 90000
derived from a natural source-rooster comb. It was the Daltons. HPMC is less viscous than healon due to
first viscoelastic used in anterior segment surgery. Physical low viscosity at zero shear rate 40000 PS (8000-
properties are molecular weight 1-2 million daltons, vis- 20000). The dispersive nature causes better adher-
cosity 700000 centipoise, osmolarity 340 mOSM/kg. ence of viscoelastic agent to the corneal endothelium
storage 2-8°C, pH 7.2, shelf life two years. It is available resulting in better protection of corneal endothelium
in sterile, sealed 0.5 to 10 ml glass syringes. Blue tint against fluid turbulence and lens fragments during
may be given to facilitate intraocular visualisation. It is phacoemulsification. It lacks pseudoplastic charac-
the viscoelastic most frequently used in cataract surgery teristic and does not pass easily through 30 gauge
because of its characteristics and qualities during the cannula. It predominantly protects tissues surfaces
procedure. against touch by implant, instruments, etc. It is a
Disadvantages—It is very expensive, not available non-physiological and non-metabolic substance con-
universally and difficult to dilute hence relatively large sisting of large polymers.
amount of the material may be left in the anterior chamber
and cause dangerous rise of intraocular pressure Preparation
postoperatively. Preparation of 2 per cent hydroxypropyl methylcellulose
• Healon GV—It is sodium hyaluronate 1.4 per cent. for intraocular use.
The viscosity of healon GV is 10 times higher than The medical use grade hydroxypropyl methylcellulose
that of healon because of higher concentraction and of highest purity which is commercially available as
molecular weight. methocel E-4 M premium of Dow chemical corporation
• Amvisc—It contains sodium hyaluronate 1-1.4 per is recommended. Dissolve 10 g of methocel E-4 M pre-
cent. It is 20 times more viscous than chondroitin mium in 150 ml of boiling balanced salt solution (BSS).
sulfate Add 350 ml of icy BSS solvent. This 2 per cent HPMC
• Amvisc plus—It is 1.6 per cent sodium hyaluronate. solution is stored in a refrigerator overnight at 0 to 10°C
Its molecular weight and viscosity is less than healon. in lightly closed glass bottles. The preservatives like benzal-
It is 30 per cent more viscous than amvisc. konium, chlorbutanol, thiomersal are not used because
• Three per cent sodium hyaluronate (Amo vitrex)— of their endothelial toxic effects. However, addition of 5
is the highest concentration available. Its mole- mg of patent blue V (sulphan blue) has been
cular weight is 0.5 million daltons and viscosity— recommended. Next day the solution is warmed to 40°C
30,000 cct, It has low cohesive properties. to reduce its viscosity. The solution is now filtered through
a filter tube (pore size of 0.5 to 0.8 um). This filtration
Methylcellulose
procedure is necessary to remove crystalline complexes
Methylcellulose is a viscous, transparent, non-irritating, which form corpuscular elements. The filtered solution is
water soluble compound. It is nearly inert chemically. It poured into 3 ml glass vials and sealed with a rubber
Viscoelastics 37
stopper and aluminium cap and then sterilised by Disruption of blood aqueous barrier Fluorophotometric
autoclaving at 120°C for 30-40 minutes. The solution is studies have shown that the disruption of blood aqueous
also available in special pre-filled syringes. The main barrier with 2 per cent HPMC in intraocular surgery is
disadvantage of pre-filled syringe is that usually great force similar to that caused by sodium chondroitin sulphate or
is applied to push later half of the solution in the anterior sodium hyaluronate.
chamber.
Postoperative glaucoma Postoperative glaucoma is not
a common complication with 2 per cent HPMC. This has
Advantages of HPMC
been attributed to the hydrophilic nature and easy
It is well-tolerated by corneal endothelium. It is cheap dilutability of HPMC. However, the potential drawback
and universally available. It can be easily prepared for is the difficulty of completely removing HPMC due to its
intraocular use. It can be autoclaved and resterilised. dispersive nature, possibly resulting in an increased
Because of its highly hydrophilic and easily dilutable postoperative IOP.
property most of it can be easily irrigated from the eye.
The fate of the residual HPMC in the anterior chamber Chondroitin Sulphate
after irrigation is not known. Fleming et al have shown It is the naturally occurring glycosaminoglycan. It is a
that methylcellulose inside the eye is harmless. According sulphated and negatively charged viscoelastic substance.
to Fechner, if 20 per cent of what was injected into AC, It forms a better coating of positively charged IOL. It
i.e. 0.5 ml of residual HPMC is left in AC, this is equivalent reduces electrostatic interaction between IOL and
to 2 mg of dry substance of methylcellulose, which is a endothelial cells.
inert substances and did not cause any local or systemic
complication. Disadvantages
Contaminants/Particulate matter in HPMC 1. It is not a pseudoplastic substance—extremely high

pressure is exerted for injection through a 30 G
Rosen et al had raised serious concern about safety of cannula
intraocular ocular use of hydroxypropyl methylcellulose 2. Maintenance of anatomic spaces (AC depth) is poor
because of high density of particulate matter in the due to low viscosity of chondroitin sulphate 20 per
solution. However, Mamose et al examined the number cent.
of insoluble paprticles of verious sizes in one ml of 5 3. 50 per cent chondroitin sulphate solution damages
viscosurgical solutions and concluded that methylcellulose corneal endothelium due to hyperosmolarity
solution had 10 times less particles of various sizes (1-30 4. Its yellow colour affects transparency and visibility
mm or more in diameter) as compared to Viscoat, Amvisc through AC
and Healon. • Viscoat—It contains 3 per cent sodium hyaluronate
Systemic safety The process by which methylcellulose plus 4 per cent chondroitin sulphate. Its molecular
is cleared from human body is till not known. However, weight is 600000 daltons and viscosity at zero sheer
the doses used intraocularly are very small and most of rate is 40000 CPS, as it is a dispersive viscoelastic
the solution is irrigated at the end of surgery. The residual agent, it is a superior coating substance and is
HPMC is clinically insignificant and unlikely to cause any superior to healon in preventing corneal
toxicity. Methylcellulose has long been used in the endothelial cell loss during phacoemulsification-
preparation of injectable preparation of prednisolone Glasser 1989
acetate and hydrocortisone acetate. Oral consumption • Orcolon—It is the 4.5 per cent polyacrylamide
of large doses in soft ice creams is not known to cause solution. It is a synthetic polymer. It is hydrophilic,
any toxicity. non-toxic and non-inflammatory. It has been
recalled from the market due to occurrence of
Endothelial cell loss It is well-established that endothelial several cases of severe uveitis and glaucoma days
cell loss with use of HPMC during IOL implantation is to weeks following surgery.
lower in comparison to air. There is no statistically signi- • Poly TEGMA—It is a highly hydrophilic polymer
ficant difference in the endothelial cell loss during IOL poly (triethylene glycol monoacrylate) a cross
implantation with Healon (20.7 +15.6) and 2 per cent linked gel. The new polymer poly TEGMA was
HPMC (18.1 +14.9%). characterised by high biological tolerance after its
implantation into the anterior chamber of rabbits. capsule after IOL insertion following envelope
Poly TEGMA 40 per cent might be considered as technique. Viscoelastics filled in AC and a drop of
a potential viscoelastic material in humans. it on the IOL optic provides complete corneal
endothelial protection during IOL implantation
Uses of Viscoelastic Substances and dialing of IOL. Glasser et al in a recent study
Viscoelastic substances are used in cataract surgery, reported superior ability of viscoat to prevent
cornea grafting, glaucoma filteration procedures, corneal endothelial cell loss during phacoemulsi-
vitreoretinal surgery, strabismus surgery, lacrimal surgery, fication with IOL implantation when compared to
evacuation of hyphaema and management of dry eye. Healon. This superiority has been attributed to the
1. Viscoelastics in cataract surgery—Use of viscoelastics presence of chondroitin sulphate in viscoat.
have revolutionised the cataract surgery. Viscoelastics Chondroitin sulphate remains adherent to the
have become indispensable in all forms of cataract corneal endothelium.
surgery. Viscoelastic substances are routinely used e. Injection of viscoelastics into AC is of great help
intraoperatively in ECCE, phacoemulsification, non- during different steps of phacoemulsification and
phaco small incision cataract surgery and paediatric non-phaco small incision surgery. Injection of
cataract surgery with intraocular lens implantation. viscoelastic into the cleavage plane between the
Viscoelastics are also essential in secondary and scleral lens nucleus and cortex termed as viscodissection
fixated IOL surgery and IOL exchange or explantation greatly facilitates phacoemulsification of nucleus.
surgery. Viscosurgery uses viscoelastics to protect tissue The technique of nucleus removal by injecting
surfaces, to create and maintain anatomical spaces viscoelastic in AC after capsulorhexis during ECCE
to facilitate tissue manipulation in anterior chamber is being practised successfully by many surgeons.
and to assist in haemostasis. Various uses of f. Protection of anterior hyaloid face during posterior
viscoelastics in cataract surgery are as follows: capsulotomy and primary posterior capsulorrhexis.
a. Maintenance of deep anterior chamber during g. Facilitates removal of residual cortex in the pre-
surgical manipulation. Comparative studies have sence of posterior capsule rupture. Aspiration of
demonstrated that 2 per cent HPMC, Healon, lens matter is done without any irrigation in such
Amvisc, and Viscoat are all effective in the main- cases (dry aspiration)
tenance of deep anterior chamber during various h. Injection of sodium hyaluronate beneath the
stages of cataract surgery, e.g. during capsulotomy, subluxated lens simplifies lensectomy by elevating
capsulorhexis, before nuclear expression, cortical the lens and prevention of total luxation.
aspiration, insertion and manipulation of IOL, i. Viscoelastics have also been used successfully to
cutting large anterior capsular flap, etc. prevent drying of corneal epithelium during
b. To combat vitreous upthrust—all viscoelastics are anterior segment surgery including penetrating
effective in controlling positive vitreous pressure. keratoplasty.
High viscosity viscoelastics are superior in com- j. Management of Descemet’s detachment—
bating vitreous upthrust. Descemet’s detachment from corneal stroma is a
c. Facilitates in the bag insertion of IOL by inflating common complication during cataract surgery.
the capsular bag prior to IOL insertion. Sodium hyaluronate injection has been used
d. Viscoelastics protect the corneal endothelium from successfully in the repair of stripped Descemet’s
mechanical trauma during various stages of membrane. The tamponading effect of viscoelastic
cataract surgery—viscoelastic substances are keeps the detached Descemet’s membrane in the
injected into the AC from the beginning of cataract normal anatomic position.
surgery to facilitate anterior capsulotomy, capsulo- k. Viscoelastics in glaucoma filteration surgeries—The
rhexis, manipulation of various instruments inside advantages of viscoelastics during glaucoma
AC and expression of nucleus. Maintenance of filteration procedures include—to prevent shallow
deep AC with viscoelastics inflate the capsular bag anterior chamber during intraoperative and post-
which results in easier cortical aspiration and also operative period, prevention of hyphaema, facili-
prevent damage to corneal endothelium and tates bleb formation and maintenance of perma-
posterior capsule. It also helps in removing anterior nent blebs and lower long-term postoperative IOP.
Viscoelastics 39
Healon (Sodium hyaluronate) has been the also been advocated for viscodelamination of the
most often studied viscoelastic with regard to vitreoretinal juncture in severe diabetic eye disease.
behaviour of viscoelastics in glaucoma filtering n. viscoelastics in lacrimal surgery—Sodium hyalu-
surgery. It is effective in post-trabeculectomy ronate has been successfully used in lacrimal sac
anterior chamber reformation. Juzych et al identification during dacryocysto-rhinostomy.
reported usefulness of healon in the management Injection of sodium hyaluronate in the lacrimal sac
of postoperative ciliary block. There have been helps in locating cut medial canaliculi and also
reports of intraoperative use of viscoelastics to facilitates passage of lacrimal probes for repair of
prevent various post-trabeculectomy complica- lacerated canaliculi.
tions such as flat anterior chamber, detachment, o. Sodium hyaluronate has been successfully used
hypotony, etc. Eugene et al has recently reported in adjustable strabismus surgery as a biologic
the results of a survey of members of the American sleeve. It reduces postoperative muscle adhesions
Glaucoma Society about the use of viscoelastic and increases the period of suture adjustability.
materials in the post-trabeculectomy patient in the p. Sodium hyaluronate and chondroitin sulphate have
office at the slit lamp for anterior chamber reforma- been used in the management of dry eye and some
tion 75 per cent of the respondents practised ocular surface disordes. Sand BB reported marked
injection of viscoelastics postoperatively at the slit subjective and objective improvement
lamp in the office. Healon (60%), viscoat (17%) in the patients of keratoconjunctivitis sicca
and Healon GV (7%) were the three most often Complications
used viscoelastics. Injection of viscoelastics in the
anterior chamber is not without complications. It Postoperative complications following intraoperative use
may cause corneal, iris or lens damage and eleva- of viscoelastic substances are as follows:
tion of intraocular pressure. However, Gerber et 1. Elevated intraocular pressure (IOP)
al did not report any of these complications in a 2. Corneal endothelial toxicity
series of 19 anterior chamber reformations. Injec- 3. Inflammation
tion of viscoelastic in an hypotonous eye with 4. Dilated fixed pupil
Elevated IOP postoperatively following use of visco-
patent sclerostomy is unlikely to cause elevated
elastic substances remains the most common ocular toxic
IOP. Incidence of endophthalmitis was 1 per cent
effect of viscoelastic agents, It occurs with all viscoelastic
in this survey.
substances. It occurs 2-24 hours after surgery with a peak
l. Use of viscoelastics has been recommended for
at 6-8 hours. It resolves spontaneously within 72 hours.
control of intraocular bleeding, e.g. hyphaema and
The IOP may be elevated to dangerous levels threatening
suprachoroidaehaemorrhage. A technique of safe
the functioning of optic nerve and corneal endothelium.
evacuation of traumatic hyphaema using visco-
Rise in IOP is more if viscoelastic material is not aspirated
elastic properties of healon has been described. from the anterior chamber at the end of surgery. However,
Healon maintain a deep AC, stable IOP, protects one must remember that IOP may be elevated despite
lens, corneal endothelium and allows clear aspiration of viscoelastic substance from the anterior
observation. chamber. The mechanism of postoperative IOP increase
m. Viscoelastics in vitreo-retinal surgery—Sodium is not yet fully understood. It is assumed that the
hyaluronate has been used as vitreous substitute. mechanical obstruction of trabecular meshwork by
Suprachoroidal implantation of sodium hyaluro- viscoelastic substances decreased the outflow pathway
nate can be used as internal buckling procedure resulting in glaucoma. Individual variation in post-
in the retinal detachment surgery. Sodium hya- operative IOP elevation may be explained on the basis
luronate has also been used in cases of retinal of variation in trabecular pore size, polymer size of
detachment with giant retinal tears. unrolling of hyaluronic acid, amount of fibrin, albumin, residual
giant retinal tears and approximation with viscoelastic material in AC, viscosity and molecular weight
underlying retinal pigment epithelium has been of viscoelastic substances and inflammatory products
performed with use of sodium hyaluronate. The produced after surgery. Elevation in IOP may occur even
procoagulant effect of intraocular sodium hyalu- with administration of antiglaucoma treatment like
ronate after phakic diabetic vitrectomy has been acetazolamide. Elevation of IOP also occurs following
reported by Pocker et al. Sodium hyaluronate has ICCE with viscoelastic substances.
The clearance of the viscoelastic agent through the agent can cause damage to corneal endothelium due to
trabecular meshwork is believed to be dependent upon dehydration because of its high osmolality. Initial
the viscosity and molecular weight. The lower the viscosity formulations of chondroitin sulphate caused several cases
and molecular weight of viscoelastic material, the faster of acute band keratopathy due to its high phosphate
is its clearance through the trabecular meshwork. HPMC concentration, According to recent reports toxic endo-
is less viscous and has a lower molecular weight than thelial cell destruction syndrome occurs due to intra-
viscoat causes less IOP increase. cameral injection of toxic detergent residue due to conta-
Prevention—Aspiration/removal of viscoelastic at the mination inside reusable cannula 0.2 per cent chlorhexi-
end of surgery. Removal of viscoelastic material may be dine digluconate has also been reported to be endothelial
done either by completely aspirating or by diluting the toxic. The use of reusable cannula must be avoided.
viscoelastic substance. Aspiration of viscoelastic agent in Disposable cannulas should be used where-ever possible.
bulk ensures complete removal but results in loss of Author is using HPMC 2 per cent in ECCE with pos-
anterior chamber causing more endothelial damage. terior chamber IOL for senile and paediatric cases for
Removal by dilution of viscoelastic agent ensures main- last 15 years. Author has encountered severe unexpected
tenance of anterior chamber depth and slow removal by diffuse corneal oedema on the first postoperative day
irrigation and aspiration. The viscoelastic agent should after ECCE with posterior chamber IOL with intraopera-
be aspirated thoroughly from the retrolental space, the tive use of 2 per cent HPMC in 1 per cent of cases. In
capsule fornix and the anterior chamber using an some patients the corneal oedema is maximum on 2nd
irrigation aspiration tip. First the optic edge is titled with
postoperative day. This corneal oedema is usually
a spatula and the I/A tip inserted behind the optic. After
associated with ocular hypertension and dilated pupil or
aspiration of the central portion of viscoelastic material
decreased reactivity of pupil. This postoperative elevated
the I/A tip is swept across and along the capsule equator
IOP developed despite routine prophylactic adminis-
to capture peripheral residual viscoelastic material. The
tration of acetazolamide 250 mg 6 hourly in all ECCE
viscoelastic agent from the AC is aspirated circumferen-
with PC IOL implantation. Routine dilatation of pupil with
tially from the retroiridal and preiridal spaces. The I/A
cycloplegics in early postoperative period in such cases
tip should always be kept away from the endothe-
results in dilated fixed pupil which resists constriction with
lium and the angle of AC. Despite thorough removal
of IOP both HPMC and viscoat cause a significant IOP topical pilocarpine therapy. Persistent corneal oedema
increase. and elevated IOP have been noted in these patients.
• Postoperative monitoring of IOP is necessary after Although mechanical trauma is usually considered to be
ECCE small incision cataract surgery and adminis- the most significant factor in the corneal endothelial
tration of antiglaucoma drugs in patients with high damage during ECCE with IOL surgery resulting in
IOP is recommended. postoperative corneal oedema. However, corneal
• Prophylactic use of antiglaucoma drugs. We routinely decompensation out of proportion to the degree of
administer tab acetazolamide 250 mg following ECCE surgical trauma may be traced to the unrecognised
with PC IOL for two days. Timolol maleate 0.5 per preoperative endothelial dysfunction or to toxicity of
cent bid is added in appropriate cases after monitoring intraocular medications used during surgery.
IOP on first postoperative day we routinely give intra- The medications used inside AC during ECCE are 2
venous mannitol 1 g/kg body weight 6-8 hours fol- per cent HPMC, 0.3 ml of preservative free epinephrine
lowing ECCE with PC IOL surgery provided there is in 500 ml of BSS and diluted pilocarpine to constrict
no contraindication. However, despite IV mannitol pupil after insertion of PC IOL.
and oral acetazolamide and aspiration of HPMC, we In authors opinion, viscoelastics may be implicated in
still encounter dangerous elevations of IOP in some the aetiology of unexplained corneal oedema as it was
cases. associated with elevated IOP in all such cases. Tan and
Inflammatory potential and endothelial cell toxicity has Humphry have reported that a total of 1.67 per cent of
been variably reported. Intraocular inflammation and eyes operated on using hypromellose developed a
subsequent bullous keratopathy have been reported nonreactive semidilated pupil whereas none of the eyes
following the reuse of injection cannulas of healon. It has from the control group developed this phenomenon. They
been attributed to denatured healon by disinfectants or concluded that there is a probable link between the
autoclaving. Chondroitin sulphate being an hyperosmotic intraocular use of hypromellose and abnormal pupil after
Viscoelastics 41
cataract surgery. Eason and Seward suggested that viscoelastics. Rainer et al compared IOP rise after bilateral
sodium hyaluronate and two per cent HPMC have similar small incision cataract surgery using two dispersive
effects on the pupil after their use in cataract surgery. viscoelastic agents ocucoat (HPMC 2%) and viscoat
Two per cent of pupils were partially reactive in both sodium chondroitin sulphate four per cent—(sodium
healon and HPMC groups hyaluronate 3%) Viscoat caused a significantly higher IOP
rise and significantly more IOP spikes than ocucoat in
Comparative Studies Using Different Viscoelastics the early postoperative period.
Liesegang et al compared the efficacy and complications FURTHER READING
of 2 per cent HPMC and 1 per cent sodium hyaluronate
in ECCE with PC IOL implantation in 70 patients. 1. Barron BA, Busin M, Page C et al: Comparison of the effects
although both VE agents maintained anterior chamber of Viscoat and Healon on postoperative intraocular pressure.
Am J Ophthalmol 100: 377-84 (Medline), 1985.
and facilitated the surgery, sodium hyaluronate was
2. Brown GC, Benson WE: Use of sodium hyaluronate for repair
preferred. There was no excessive intraocular inflam- of giant retinal tears. Arch Ophthalmol 107: 1246, 1989.
mation with either agent. Sodium hyaluronate caused
3. Clorfeine GS, Parker WT: Use of Healon in eye muscle surgery

greater rise in IOP than HPMC but the difference was not with adjustable sutures. Ann Ophthalmol 19: 215, 1987.
significant. Mean endothelial cell loss and corneal 4. Eason J, Seward HC: Pupil size and reactivity following
thickness were also not significantly different. Intraocular hydroxypropyl methylcelluose and sodium hyaluronate. Br
pressure doubled for the first postoperative day following J Ophthalmol 79: 541-43, 1995.
uncomplicated ICCE with AC reformed using sodium 5. Fechner FU and Fechner MU: Methylcellulose and lens
hyaluronate with or without systemic acetazolamide. implanatation. Br J Ophthalmol 67: 259-63, 1983.
Healon and viscoat both caused significant and 6. Fry LL: Postoperative intraocular pressure rises: A comparison
of Healon, Amvisc, and Viscoat. J Cataract Refract Surg 15:
comparable elevation of intraocular pressure. Some
415-20 (Medline), 1989.
postoperative IOPs may be as high as 50 to 60 mm hg
7. Gerber SL cantor LB: Slit lamp reformation of the anterior
despite removal of VE agent at the end of surgery. (Baren). chamber following trabeculectomy. Ophthalmic Surg 23:
Fry observed that postoperative IOP rise was lower with 784-88, 1992.
healon as compared to Amvisc and Viscoat. Viscoat (not 8. Glasser DB, Osborn DC, Nodeen JF et al: Endothelial
aspirated) group caused highest IOP rise. Retained Viscoat protection and viscoelastic retention during phacoemulsi-
group patients had more incidence of patients with IOP fication and intraocular lens implantation. Arch Ophthalmol
greater than 30 mm hg. However, retained Viscoat may 190: 1438-40, 1991.
have better protective effect on endothelium. In one study 9. Glasser DB, Schultz RC, Hyndiuk RA: The role of
although the effects of ocucoat (2% HPMC), Viscoat, viscoelastics, cannular and irrigating solutions additives in
post-cataract surgery corneal edema: A brief reviews. Lens
Healon and Healon GV on postoperative IOP and
Eye Toxic Res 9: 3-4, 1992.
endothelial cell loss after phacoemulsification were
10. Hurwitz JJ, Nik N: Lactimal sac identification for dacryo-
comparable among four groups. The high molecular cystorhinostomy. The role of sodium hyaluronate. Can J
weight viscoelastics (Healon and Healon GV) performed Ophthalmol 19: 112, 1984.
better as viscosurgical tool during phacoemulsification. 11. Hutz WW, Eckhardt HB, Kothnen T: Comparison of visco-
Viscoat tended to trap nuclear fragments and air elastic substances used in phacoemulsification. J Cataract
bubbles which decreases visibility during surgery. Space Refract Surg 22: 955-59 (Medline), 1996.
maintenance and injection case were significantly better 12. Kohnen T, Von Ehr M, Schutte E et al: Evaluation of
with Healon and Healon GV due to their high molecular intraocular pressure with Healon and Healon GV in sutureless
weight Huts. Kohnen et al evaluated IOP rise with healon cataract surgery with foldable lens implantation. J Cataract
Refract Surg 22: 227-37, 1996.
and healon GV in sutureless cataract surgery with foldable
13. Lavin MJ, Leaner PK: Sodium hyaluronate and giant retinal
IOL implantation. There was no statistically significant tears. Arch Ophthalmol 108: 480, 1990.
difference in the highest mean IOP elevations between 14. Lerner HA, Boynton JR: Sodium hyaluronate as an adjunct
both the viscoelastics but standard deviations were higher in lacrimal surgery. AM J Ophthalmol 99: 365, 1985.
in the Healon GV group at 6 and 24 hours groups. Both 15. Liesegang TJ, Bourne WM, Istrup DM: The use of hydroxy-
viscoelastics can be equally removed from AC. Incidence propyl methylcellulose in extracapsular cataract extraction
of high IOP using high viscosity hyaluronic acid with intraocular lens implantation. Am J Ophthalmol 102:
viscoelastics can be minimised by meticulous removal of 723-26 (Medline), 1986.
16. MC Leod, James CR: Viscodelamination at the vitreoretinal 24. Rainer G, Menapace R, Findl O et al: Intraocular pressure
juncture in severe diabetic eye disease. Br J Ophthalmol 72: rise after small incision cataract surgery; a randomised
413, 1988. intraindividual comparison of two dispersive viscoelastic
17. Mital RN, Tiwari R: Suprachoroidal injection of sodium agents. Br J Ophthalmol 85: 139-42, 2001.
hyaluronate as an “internal” buckling procedure. Ophthalmic 25. Rainer G, Menapace R, Schmetterer K et al: Effect of
Res 19: 255, 1987. dorzolamide and latanoprost on intraocular pressure
18. Momose a and Kasahara A: Methylcellulose: A better visco following small incision cataract surger. J Cataract Refract
surgical alaternative for intraocular lens implantation. Ind J Surg 25: 1624-29 (Medline), 1999.
Ophthalmol 37: 64-66, 1989. 26. Salvo Eugene C Jr, Luntz MH, Medow Norman B: Use of
19. Nuyts RMMA, Boot N, V Best JA et al: Long-term 351-9 viscoelastics posttrabeculectomy: A survey of members of
changes in corneal endothelium following toxic endothelial American Glaucoma Society. Ophthalmic Surg Lasers 30:
cell destriction. A specular microscopic and fluorometic study. 271-75, 1999.
Br J Ophthalmol 80: 15, 1996. 27. Sand BB, Marnerk, Norn MS: Sodium hyaluronate in the
20. Passo MS, Emest JT, Goldstick TK: Hyaluronate increases treatment of keratoconjunctivitis sicca. a double masked
intraocular pressure when used in cataract extraction. Br J clinical trial. Acta Ophthalmol 67: 181, 1987.
Ophthalmol 69: 572-75, 1985. 28. Searl SS, Metz HS, Lindahl KJ: The use of sodium hyaluro-
21. Pocker AJ, Mc Cuess BW II, Autton WL et al: Procoagulant nate as a biologic sleeve in strabismus surgery. Ann Ophth
effect of intraocular sodium hyaluronate after phakic diabetic 19: 215, 1987.
vitrectomy. A prospective randomized study. Ophthalmology 29. Seiff Sr, Ahn JC: Locating cut medial canaliculi by direct
96: 1491, 1989. injection of sodium hyaluronate into the lacrimal soc.
22. Probst LE, Nichols BD: Corneal endothelial and intraocular Ophthalmic Surgery 20: 176, 1989.
pressure changes after phacoemulsification with Amvisc Plus 30. Tan AKK and Humphry RC: The dilated fixed pupil after
and Viscoat. J Cataract Refract Surg 19: 725-30 (Medline), cataract surgery: Is it related to intraocular use of hypro-
1993. mellose. Br J Ophthalmol 77: 639-64, 1993.
23. Pruett RC, Schepens CL, Swan DA: Hyaluronic acid vitreous 31. Vitacoro AA, Vita: Coro AA hyaluronate facilitates passage
substitute a six year clinical application. Arch Ophthalmol of lacrimal probes for repair of lacerated canaliculi. Arch
97: 2325, 1979. Ophthalmol 106: 579, 1988.
Comparison of Various ECCE Techniques 43
Comparison of Various
ECCE Techniques
5 Kamaljeet Singh
Vipin Bihari
E
xtracapsular cataract extraction (ECCE) can be Incision
done by three techniques: • Conventional, This is the most important step in cataract surgery since
• Manual Phaco, • Phacoemulsification (Table
this gives the ultimate result of surgery. Longer the incision

5.1). more is the astigmatism; and nearer it is to limbus more
Although in all the three techniques the goal remains is the astigmatism. Therefore, for achieving least astig-
the same, i.e. you have to leave behind the posterior matism surgeon should make smallest possible incision
capsule and a part of anterior capsule. But since the in which, he can deliver the nucleus easily, and should
methods differ the procedure and used gadgets also vary. remain far from the limbus. Conventional ECCE is done
Following differences can be enumerated in the three close to limbus and is the longest (10-12 mm) incision;
methods. phacoemulsification has the minimum possible wound
(3.2 mm) if foldable lenses are used. If non-foldable lenses
Conjunctival Flap are implanted the length increases to 5.5 mm taking
away the advantage of smallest incision. The incision
The conjunctival flap is usually large in ECCE extending length in non-phaco SICS is 6 to 6.5 mm. In this regard,
from almost 2-3 O’clock to 8-9 O’clock. The conjunctival both manual phaco and phacoemulsification with non-
flap is smaller in manual phaco extending from 10.30 to foldable IOL are equally comparable.
1.30 O’clock, if one is very liberal in making flaps. As
one gains experience in this surgery the conjunctival flap Viscoelastics
becomes even smaller. In conventional ECCE one can
make corneal incision only and may not need any flap. It has been shown in various studies that methyl cellulose
But this flap is a must in manual phaco, because one is as good as any other viscoelastics. Methyl cellulose is
needs longer tunnel. In contrast to this in phacoemulsi- cheap and can be easily removed from anterior chamber.
fication present trend is to make a corneal tunnel This can be used both in conventional ECCE and man-
therefore, conjunctival flap is not required. Beginners still ual phaco; though the quantity used is more in manual
prefer to do this surgery through scleral tunnel. Hence phaco and less in conventional ECCE. In phacoemulsi-
they make a flap. Disadvantage of making a big flap is it fication many Indian surgeons have repeatedly shown
that methyl cellulose is as good as sodium hyaluronate,
gives more astigmatism.
but still the preferred viscoelastic world over is sodium
hyaluronate (healon). Its use increases the cost of surgery
Cautery
immensely.
Its use depends on whether surgeon has made a flap or
not. The cautery causes increase in the amount of astig- Capsulotomy
matism, which goes against the philosophy of giving least Any type of capsulotomy—can-opener, envelope or
possible astigmatism. The larger the conjunctival flap more capsulorhexis can be made in conventional ECCE and
is the need of cautery. So, the use of cautery is maximum manual phaco. Whereas capsulorhexis is a must in
in ECCE, less in manual phaco and minimum in phaco. phacoemulsification. This is difficult to learn and makes
Cautery is not needed if corneal incision is made as in the learning curve longer, although trypan blue has made
phacoemulsification. life easier for surgeons.
Nucleus Prolapse Sutures

This is very important step in manual phaco. Surgeon Sutures are usually not needed in phaco as corneal valve
cannot proceed further if he has not mastered this step. is made which automatically closes. But in case the
It is not needed both in ECCE and phaco. If nucleus corneal incision has been made and there is need to
prolapses into anterior chamber in ECCE there is no extend it for implanting even a 5.25 mm optics, suture
problem as nucleus delivery becomes easier. But if it may be required. For scleral incision, even if the incision
happens in phacoemulsification most of the surgeons is extended to 7.5 mm, sutures are not needed as the
advocate conversion to ECCE, though some authorities tunnel is self-sealing. So both in phaco and manual phaco
have advocated supracapsular phaco. even if the incision is large there is no need for applying
the sutures,. In contrast, ECCE needs 5 to 7 interrupted
Nucleus Delivery sutures. When the sutures are applied patient has
complaints of foreign body sensation for quite long even
Nucleus delivery is easiest in ECCE since the incision is
if 10.0 suture are used and knots are buried.
long and single plane. It is difficult in manual phaco,
because one has to deliver the nucleus through tunnel.

Astigmatism
Moreover, the nucleus has to be divided into smaller
pieces by some technique before delivering out. In phaco- There are several factors responsible for astigmatism. The
emulsification, in contrast, the nucleus delivery is through incision, suture, lens decentration, etc. but, amongst three
phaco hand piece and is most difficult. The surgery is techniques astigmatism is maximum in ECCE. Usually
done mostly in the bag, which depends largely on the we get an astigmatism of 1.5 to 3.0 D, but surprise astig-
quality of the machine, its fluidics, holding power and matism up to 7.0 D has been noted. This astigmatism is
ultrasonic cutting power. much less (0.5–1.5 D) in manual phaco and negligible
(0 to 1.0 D) in phacoemulsification.
Cortical Clean-up
Recovery
Cortical clean-up is easiest in ECCE because nucleus
and perinucleus both are delivered out in one go. Although patient is mobile from the day one in all types
Remaining portion is cortex only, which can be easily of ECCE surgeries, yet visual outcome is not that fast.
washed manually with the help of Simcoe cannula. Because of the time taken for wound healing we give
Cleaning is slightly difficult in manual phaco because glasses after 6 weeks in ECCE, whereas in manual phaco
perinucleus and cortex both remain inside AC and only 15 days is a good period of wait for prescribing glasses.
nucleus is delivered, through a small incision. Perinucleus In phaco visual recovery is almost immediate although
is hydro-extracted by keeping the Simcoe cannula at 6 the glasses are prescribed after 2 weeks.
O’clock and at the same time depressing the tunnel with
the same cannula, or is hydroexpressed with the help of Complications
AC maintainer. In phacoemulsification the perinucleus There are several complications associated with cataract
and cortical matter are aspirated by automated probe or surgery. We would like to discuss the common and
manually by Simcoe cannula. dreaded complications. Corneal decompensation is rarely
seen nowadays with ECCE. When we compare, the
Lens Implantation endothelial cell loss is slightly more in manual phaco than
Non-foldable lenses are used in ECCE and manual in phacoemulsification, although with the use of good
phaco. The preferred optic size is 6-6.5 mm in both these amount of viscoelastics it can be reduced. Posterior
techniques, which have several advantages over small capsule rupture occurs in all the three types of surgery
optic lenses (used in phaco). These large size lenses do but is most common in phaco, especially in the hands of
not cause edge glare, do not decentre and do not obstruct beginners. Chances of posterior dislocation of fragments
in retinal treatment. When foldable lenses are used in of lens and even loss in toto are much greater in phaco
phaco the optic size is large 6-6.5 mm. Inserting, a than the other two techniques. Thus, when we compare
foldable lens is difficult to master as newer techniques manual phaco and phacoemulsification cornea is at
keep on coming. Whereas, implanting a non-foldable greater risk in manual phaco and vitreous and retina in
lens is quite easy. phaco.
Comparison of Various ECCE Techniques 45
Table 5.1: Comparison of various ECCE techniques
ECCE Manual Phaco Phacoemulsification
Anaesthesia Peribulbar Peribulbar No anesthesia, topical, peribulbar
Conjunctival flap size Large if limbal Moderate size Small
Cautery Required Required Required if flap is made, otherwise
not
Incision 10-12 mm scleral, corneal, limbal 5.5-7.5 mm scleral, tunnel 3.2–5.0 mm scleral or corneal
tunnel
Viscoelastics Methyl cellulose Methyl cellulose Healon and /or methyl cellulose
Capsulotomy Can-opener, envelope, capsulorhexis Can-opener, envelope, capsulorhexis Capsulorhexis must
Nucleus prolpase in AC Not needed Needed Not needed

Nucleus delivery Easy Difficult Quite difficult
Cortical clean-up Manual Manual Automated or manual
Lens implant Optic 6.5 mm non-foldable Optic 5.5 to 6.5mm, nonfoldable 6.5 mm if 5.25 mm if
foldable, non-foldable
Sutures Required Sutureless Sutureless
Astigmatism 1.5D – 4.0D 0.5 D-1.5 D 0.10D-1.0D
Recovery 6 weeks 2 weeks 1 week
Complications
Corneal decompensation Rare Seen Seen
PC rupture Rare Rare Common
Posterior dislocation Rare Rare Common
of lens
Hard cataract Easily possible Possible Difficult
Elderly cataract Easily possible Possible Difficult
Surgical skill Average Average Demanding
Microscopic quality Average will do Average will do Excellent depth perception with
automated focussing and zoom
Cost Cheap Cheap Very costly
Type of Cataract things to learn. Whereas, any average surgeon can easily
If the lens is hard perhaps the easiest technique is ECCE, learn ECCE both and manual phaco because no costly
for soft lenses manual phaco gives excellent results and gadgets but only skilled hands are required and the
surgery is not machine dependent.
in between these two varieties phaco is quite good.
Age of Patient Microscope
In young patients the cataract is very soft hence they are ECCE and manual phaco can be done with any average
better candidates for both manual phaco and phaco- microscope. But for phaco the surgeon should have the
emulsification. As the age advances the lens becomes best possible microscope, as the stereopsis should be
harder. Beyond 70 years as the cornea is already compro- excellent. Focussing and zoom both should ideally be
foot controlled. These two things increase the cost of
mised, ECCE is the choice. There is no hard and fast
microscope immensely. In addition, the cost of phaco
rule for this. Master surgeons can easily alter the decision.
machine is exorbitant, which an average surgeon from
Surgical Skill
the developing country cannot afford. Foldable lenses
and viscoelastics are also costly for phaco. Therefore, in
For any surgery surgical skill is very important but perhaps case the cost factor is not involved phaco would be the
for phaco it is most demanding. The surgeon has to use choice. Otherwise, manual phaco without addition of
both the hands, both feet, both ears, other than eyes. costly equipment is the best and safest for majority of
Therefore, phaco is highly skilled job along with lot many Indian patients and surgeons.
FURTHER READING 4. Mathew Manual nucleo fragmentation and endothelial cell

loss. J Cat Refr Surg 23(7): 995-99, 1997.
1. Amar Agarwal, Mahipal S Sachdev et al: Phacoemulsification 5. Schein OD, Bass EB et al: Cataract surgical techniques:
laser cataract surgery and foldable IOLs. Jaypee Brothers: Preferences and underlying beliefs. Arch Ophthalmol 113:
India. 2000. 1108-12, 1995.
2. Blumenthal M et al: Small incision manual extracapsular 6. Vajpayee RB, Sabharwal S, Sharma N et al: Phaco fracture
cataract extraction using selective hydrodissection. verses phacoemulsification in eyes with age related cataract.
Ophthalmic Surg 23: 699-701, 1992. J Cataract Ref Surg 24: 1252-55, 1998.
3. Dada VK, Sandhu N: Management of cataract a revolutionary 7. Wright M, Chawla H, Adams A: Results of small incision
change that occurred during last two decades. J Ind Med extracapsular cataract surgery using anterior chamber
Assoce. 97(8): 313-17, 1999. maintainer without viscoelastic. BJO 83: 71-75, 1999.
Management of Diabetes in Cataract Surgery 47
Management
of Diabetes in
6
Cataract Surgery Sarita Bajaj
T
he morbidity and mortality rates during the postsurgical patient may be unaware of this or unable to
perioperative period are greater in the diabetic communicate.
compared with the nondiabetic of comparable With the use of the modern management protocols,
age, for a number of reasons. Macrovascular disease is the major outcome measures of surgery (duration of hos-
extremely common in both type 1 and type 2 patients. pital stay, morbidity and mortality) are now comparable
Cardiovascular complications are the major causes of in diabetic and non-diabetic patients. It follows that the
surgical mortality in diabetics (30%). In addition a high skill, care and motivation with which diabetic patients
percentage (especially in the over 50 age category) have are managed—ideally supervised by a diabetic team
impaired renal function and are prone to fluid and (where available) are important to the success of surgery.
electrolyte imbalance, dehydration, and obtundation.
During the postoperative period, the diabetic has a higher PRINCIPLES OF MANAGEMENT
incidence of infection at the operative site as well as a Management of the individual patient is determined by
greater potential for urinary tract infection, pneumonia, the severity and nature of surgical trauma and the
and other systemic infections. Wound healing may be duration of perioperative fasting.
impaired in the setting of persistent hyperglycemia (>240 Determinants of the management plan and pre-
mg/dl) as a result of modified fibroblast function. This operative evaluation:
defect, combined with infection, frequently leads to a 1. Type of diabetes—type 1 diabetes is associated with
difficult and protracted hospitalisation and frequent absolute need for insulin therapy whereas type 2
readmission. Consequently, the diabetic patient spends diabetes is associated with increased insulin needs.
30 to 50 per cent more time in the hospital than the 2. Treatment—diet, oral hypoglycaemic agents (OHA)
nondiabetic following surgery, even if the surgery pro- or insulin. Subjects who are usually managed succes-
ceeds without incident. sfully without insulin need insulin only for major
Safety and simplicity are the watchwords of the surgical surgery; otherwise, simple observation is generally
management of diabetic patients. Safety should be sufficient.
ensured if the following protocols are observed. Simplicity 3. Metabolic status—review blood glucose records and
is essential, as surgery is frequently required in diabetic glycosylated hemoglobin (HbA1c) values.
patients and its bedside management is usually 4. Cardiac, renal and cerebral vascular status should be
undertaken by junior doctors who may have little or no assessed.
specialized knowledge of diabetes. Treatment regimens 5. Surgical details:
should not aim for near normoglycaemia; it has been a. Minor or major— for purposes of clarity, it is useful
shown that this does not improve outcome, and the risks to define major surgery as any procedure requiring
of hypoglycaemia are considerably increased. Sensible a general anaesthetic.
and practical glycaemic targets are discussed below. b. Type of anaesthesia.
Hypoglycaemia is a major hazard of surgery, which is c. Type of surgery—emergency or elective.
particularly important to avoid, as the surgical or d. Postoperative oral intake.
The preoperative evaluation should be done in the SURGERY IN INSULIN-TREATED PATIENTS

office before an elective operation or, less preferably, on Indications for Insulin
the day of admission. History of previous glycaemic
control should be reviewed and control should be All patients taking insulin, whether persons with type 1
improved in symptomatic and asymptomatic patients or type 2 diabetes should receive insulin therapy during
with sustained hyperglycaemia, reflected by a fasting the surgical procedure (Table 6.1). It is preferable to take
blood glucose (FBG) level higher than 200 mg/dl, high diabetic patients for surgery in the morning as first case.
HbA1c values (>10%), or both. Improved control during Table 6.1: Indications for insulin therapy during surgery
the perioperative period (blood glucose values between Always Sometimes
120 mg/dl and 180 mg/dl) reduces the morbidity from
• All insulin-taking diabetics • Type 2 diabetes treated with
fluid and electrolyte imbalance, decreases the risk of (type I and type 2) diet or oral hypoglycaemic
infection, and increases the wound-healing rate. Prior agents in acceptable control
day admission is still indicated for all poorly controlled • Type 2 diabetics on diet and/or • Average FBG=180 mg/dl
diabetics (FBG >240mg/dl). oral hypoglycaemic agents but – HbA1c = 10%
with chronic hyperglycaemia – surgery duration <2 hours

(i.e. FBG>180 mg/dl and – body cavity not invaded
MINOR SURGERY HbA1c>10%) – food intake anticipated after
operation
For patients posted for minor surgery, the OHA and
insulin are stopped on the day of the surgery. Once the
Insulin Regimen
surgery is over and the patient permitted to resume oral
feeds the OHA is started with half the dose which the The kinetics of subcutaneous insulin absorption is unpre-
patient was originally taking. On the second postopera- dictable and hence not advocated. Normally, the require-
tive day full dose of the OHA and/or insulin is started. ment of insulin is 0.3U to metabolize 1 gm of glucose.
Continuous insulin infusion (intravenous) is the most
SURGERY IN PATIENTS rational and physiologic method for perioperative
NOT TREATED WITH INSULIN management. This approach has been shown to be safe,
effective, and flexible. Insulin infusion should be started
A small subset of type 2 patients with acceptable control the night before for early morning procedures and for
(FBG < 140 mg/dl, other blood glucose values < 200 patients needing improved glycaemic control. Otherwise,
mg/dl and HbA1c of 8 to 10%) on diet or OHA may not the patient takes the usual evening dose of insulin or
require insulin. Long-acting sulfonylureas (e.g. chlor- OHA.
propamide) should be stopped, substituting a shorter- In all patients requiring insulin, the insulin infusion
acting sulfonylurea, if necessary. must be started at least 2 to 3 hours before the operation
Glycaemic control should be monitored carefully in order to titrate to the desired level of control.
during the period before admission. These patients There are two basic regimens for administering insulin
generally require only close observation. The operation and glucose. The preferred method uses a separate
should be scheduled for the morning, if possible. Break- infusion of insulin and glucose to allow for independent
fast and any morning dose of OHA are omitted. Through- adjustments of each infusion rate. In the ‘separate-line’
out the perioperative period, frequent glycaemic moni- system one infusion line is used to deliver 10 per cent
toring is required and glucose-containing infusion fluids glucose solution at 100 ml/h, preferably using an
must be avoided. Sulfonylurea drugs, if used, should be electronic drip-counter, while a syringe-driver pump
omitted until the first postoperative meal. administers insulin through the other, usually at 2-4 U/h.
This approach is acceptable for a relatively simple and The insulin infusion can either be given into a separate
short-lasting (less than 2 hours) surgical procedure. Poorly vein, or ‘piggy-backed’ into the glucose line. This
controlled type 2 patients undergoing major surgery who approach provides flexibility and can be rapidly adjusted
do not achieve the above glycaemic targets are best depending on the hourly variation in blood glucose
managed using continuous glucose and insulin delivery values.
as for type 1 patients, after initial stabilization with insulin, The alternate method is to combine insulin and
either in hospital or at home. glucose as a mixture at a pre-estimated individualized
concentration. Potassium chloride (KCl) is added to the least hourly until insulin requirements have been deter-
glucose (‘glucose-potassium-insulin’, or ‘GKI’ infusion), mined, according to the schedule shown in Table 6.2.
to counteract the risk of hypokalaemia. Table 6.2 provides The insulin delivery rate is altered by substituting a new
a simple protocol for managing diabetic patients (type 1 bag containing a different dosage, and the potassium
or type 2) undergoing surgery. content is varied according to regular plasma electrolyte
measurements. Dilutional hyponatraemia may occur
Table 6.2: A simple protocol for managing patients with when GKI infusion is prolonged. This should be treated
type 1 or type 2 diabetes undergoing surgery. These guide-
by additional saline infusion, and if necessary by slowing
lines are suitable for use by junior hospital staff with limited
specialist experience of diabetes the GKI infusion rate. In patients at risk of volume
1. Ensure satisfactory preoperative control. Operate in morning if overload, more concentrated dextrose infusions (e.g.
possible. 20%) can be given in smaller volumes, with appropriate
2. Liaise with anaesthetist. adjustments of insulin and potassium content.
3. Omit breakfast, and insulin or OHA on morning of surgery. Apart from its versatility the GKI infusion is an
4. Non-insulin treated diabetic patients, having non-major surgery, acceptable method for many elective procedures, when
need observation only. Chart 2 hourly glucose by reagent strips infusion pumps are not available and when frequent
on day of surgery. Patients taking OHA can restart them with
variations in insulin needs are not anticipated.
next meal.
5. GKI is used in all other cases i.e. (a) all insulin-treated diabetic To successfully monitor and regulate an insulin infusion
patients; and (b) major surgery in non-insulin - treated diabetic regimen, a system for the accurate measurement of blood
patients. glucose levels at the bedside must be in place. In the
i. At 0800-0900 on morning of surgery, start GKI infusion absence of rapid and accurate bedside blood glucose
and infuse 5-hourly (100 ml/h): monitoring with a meter, it is not safe to implement a
500 ml 10% dextrose
+ 15U short-acting insulin regimen of continuous regular insulin infusion. Further-
+ 10 mmol KCl more, the anaesthesiologist must do blood glucose ana-
ii. Check blood glucose 2-hourly initially and aim for 100- lyses every hour during the operation and adjust the
200 mg/dl insulin infusion accordingly. The infusion is continued
If > 200 mg/dl, change to GKI with 20 U insulin until the patient is tolerating oral feeding.
If <100 mg/dl, change to GKI with 10 U insulin
Continue 5-U adjustments as necessary.
iii. Continue GKI until patients eat, then revert to usual POSTOPERATIVE CARE
treatment. During the reintroduction of foods such as clear liquids,
it is preferable to continue a low maintenance dose
The GKI regimen has gained widespread acceptance infusion supplemented with small boluses of regular
because of its simplicity and effectiveness. To a 500-ml insulin (subcutaneous) preprandially. The size of the bolus
bag of 10% dextrose are added 10 mmol potassium depends on the amount of allocated carbohydrate (1U
chloride and 15U soluble insulin. This mixture is infused of insulin per 10 g of carbohydrate). This is a very safe
over 5h. This regimen delivers similar amounts of glucose system because the insulin dose remains adequate.
and insulin to the separate-line system, but is considerably Once food tolerance is established, the infusion is
simpler and, because insulin and glucose are given in stopped and the insulin-treated diabetic may be returned
balanced proportions, the infusion rate is not so critical; to the former dosage or may need a number of days of
an electronic pump is therefore not essential. It also avoids frequent (premeal) doses of regular insulin The transition
one of the main problems of giving insulin and glucose regimen is developed according to the guidelines
separately, namely one of the infusions running out or discussed in Table 6.3. The previous day’s total insulin
being interrupted by pump malfunction or the intra- dose is used to determine the most appropriate form of
venous cannula becoming blocked or dislodged; if the therapy. By calculating a basic dose, with adjustments
other infusion continues, dangerous hypo-or hyper- made depending on premeal blood glucose values and
glycaemia may result. anticipated carbohydrate content, safe control can be
When adding insulin and potassium solutions to the achieved. A small dose (10 to 15 U) of intermediate-
bag, it is important to use a needle that is long enough acting insulin (NPH or Lente) is added at bedtime to
to clear the self-sealing bung, to mix the bag well and to provide coverage until the following morning.
label it clearly with the dosages of the additives, During Patients are continued on the above treatment plan
a GKI infusion, blood glucose should be monitored at until postoperative complications have stabilised and
Table 6.3: Postoperative management of 9U of intermediate acting insulin) would lower the
patients with diabetes FBG.
• Continue perioperative insulin infusion until food is tolerated, then 2. In some type 2 patients because of insulin resistance
plan new regimen
the blood glucose cannot be controlled with insulin
• Overlap (30 minutes) the initial subcutaneous dose of regular
insulin before stopping infusion alone. Addition of small doses of OHA is recom-
• Type 2 diabetics previously treated with diet and/or OHA: prescribe mended to overcome the resistance (half of the
usual medication if BG <180 mg/dl. Higher BG may require previous daily dose should suffice). On the day of
transient regular insulin every 6 hours (premeals) as per blood the surgery the OHA is stopped.
glucose (bedside monitoring) sliding scale
• Insulin-treated diabetics: Prescribe usual regimen or use prior
3. Type 2 diabetics can be safely switched over to oral
24 to 48 hours insulin dosage to develop a new basic dose regimen. drugs after a week.
The dose selected should be 80 to 100% of the previous day’s 4. Purified insulins are ideal for short-term use in type 2
total dose. Needs may be higher during persistent stress, infection, diabetics to prevent antigenicity and insulin antibody
pain and steroids production.
The selected basic dose may be given premeal (breakfast [25%],
lunch [25%], and dinner [25%]), as regular insulin and NPH

given at bedtime (25%). Aim to keep BG in safe range (120-180 INTRAVENOUS FLUIDS
mg/dl).
1. Dextrose saline/normal saline is used if blood pressure
Premeal BG (mg/dl) Basic dose (soluble insulin) is low or normal. In patients with hypertension and
<80 4 U less the potential for congestive cardiac failure it is safe to
81-120 3 U less use half normal saline, with central venous pressure
121-180 Basic dose (no adjustment)
monitoring.
181-240 2 U more
241-300 3 U more 2. For normal metabolism about 50 gms glucose is
>300 4 U more required every 8 hours for energy and to avoid ketosis.
To meet this demand at least 1000 ml of 5 per cent
• Modify the basic dose regularly according to the sliding scale
glucose every 8 hours will be required.
needs. Additional doses of regular insulin may be needed at
other times (e.g. 10 PM to 2 AM) 3. In situations requiring fluid restriction 10 per cent
• Establish the most suitable insulin regimen or the patient’s dextrose may be infused instead of 5 per cent dextrose
previous regimen before patient discharge with double dose of insulin. This will take care of the
energy requirement and avoid overloading the
glycaemic control is satisfactory. As soon as the patient circulation.
is able to eat normally again, the usual treatment regimen 4. To avoid hypokalemia, infusion of Isolyte-M or
can be restarted. Frequent glycaemic monitoring is Pharmalyte-M is alternated with dextrose/dextrose
essential because of the variable effects of surgical trauma saline particularly when insulin is added to the drip.
and other factors such as inactivity, postoperative Electrolytes other than potassium (35 mEq/l) are
infection and changes in medication. replenished by this fluid.
PRACTICALITIES OF MANAGEMENT
MONITORING DURING SURGERY
1. In some diabetics it may not be possible to control
the FBG with a predinner bolus of soluble insulin; A vital aspect of care is adequate blood glucose moni-
resulting in a perpetually high FBG. This cannot be toring. This is generally done by nursing staff at the
controlled by increasing the soluble insulin predinner bedside, using glucose-oxidase reagent strips, read either
as it may result in nocturnal hypoglycaemia. Such a visually or by meter. During intraoperative period the
situation requires the addition of a small dose of blood glucose should be monitored every hour and less
intermediate-acting insulin at bedtime. For example frequently as necessary thereafter. The accuracy of these
if the FBG is 200 mg per cent with a dose of predinner monitoring methods may be poor, and validation with
soluble insulin of 10 IU, one may attempt to reduce occasional laboratory measurements may be advisable.
the FBG by increasing the dose to 15 U. However, All hospitals that use reagent strips for diabetic monitoring
this may result in nocturnal hypoglycaemia, whereas should have some form of quality-control system to
combining soluble insulin with intermediate-acting ensure reasonable accuracy, and all staff involved should
insulin in the ration of 2:3 (6U of soluble insulin and be carefully trained in their use. The other alternative is
to estimate the blood sugar in the laboratory by hour). The infusion is generally preceded by an
conventional methods. A word of caution is that the blood intravenous injection of regular insulin (10 U). Adjust-
should not be drawn from the arm that is connected to ments are then made according to hourly blood glucose
the infusion line, which may show a falsely high value. levels. Once blood glucose values return to 240 mg/dl, 5
Urine glucose monitoring during surgery is not safe per cent dextrose should be included in the rehydration
particularly when the patient is on intravenous glucose. fluids. Adequate potassium replacement is critical, as is
The results of urine glucose may be strongly positive when close monitoring of fluid balance, acid-base status,
the blood glucose may not be high. A large dose of insulin electrolytes, and renal function. Once the patient’s
given based on the strongly positive urine test for glucose condition is stable for 4 to 6 hours, the operation can
may produce deleterious hypoglycaemia. generally be performed safely. It is important to note that
following reversal of the acute stressful condition lower
Emergency Surgery insulin infusion rates will be required for a given blood
Emergency surgery is as likely if not more likely in the glucose level.
diabetic than in the nondiabetic subject. Management Our aim is to make patients safe for surgery. For this
will depend to a large extent on the metabolic condition we need an understanding teamwork between the
of the patient. Surgical emergencies, particularly if there surgeon, anaesthetist, and the diabetologist. When the
is underlying infection, can cause rapid metabolic patient is under anaesthesia, “The ideal is to have diabetic
decompensation with dehydration, hyperglycaemia, and therapy supervised by a diabetic team where available”
ketoacidosis. Uncontrolled diabetes may also be precipi- (KGMM Alberti).
tated in patients not previously known to have diabetes.
The problem necessitating surgery may have led to FURTHER READING
metabolic decompensation; this should first be corrected
1. Alberti KGMM: Diabetes and surgery. Anaesthesiology 74:
if possible, unless the operation cannot be delayed.
209-11, 1991.
Diabetic patients require close attention when admitted 2. Gavin LA: Perioperative management of the diabetic patient.
for an emergency operation. The first priority is to assess Endo Met Clin N Am 21: 457-75, 1992.
glucose control, level of hydration, and acid-base status. 3. Gill GV: Surgery in patients with diabetes mellitus. In: Pickup
Preoperative management will require an aggressive J and williams G (Eds): Textbook of diabetes. London:
approach to correct fluid and electrolyte imbalances, Blackwell Science Ltd. 12.1-12.7, 1997.
reverse acid-base disorders, and optimise blood glucose 4. Hirsch IB, McGill JB, Cr yer PE et al: Perioperative
levels. Separate insulin and fluid infusion systems are management of surgical patients with diabetes mellitus.
Anaesthesiology 74: 346-59, 1991.
excellent for such intercurrent management. The insulin
5. Hughes TAT, Borsey DQ: The management of diabetic
dose (rate per hour) and fluid needs should be tailored patients undergoing surgery. Pract Diabetes 1: 7-10, 1994.
to each patient according to the severity of the metabolic 6. Alberti KGMM, Gill GV, Elliott MJ: Insulin delivery during
decompensation and the patient response. The surgery in the diabetic patient. Diabetic Care S1: 65-77, 1982.
management of ketoacidosis involves higher insulin 7. Hutchison AS, Shenkir A: BM strips: how accurate are they
infusion rate (0.1 U per kilogram of body weight per in general words? Diabet Med 1: 225-26, 1984.
Management of
Hypertension in
7
Cataract Surgery PC Sexena
INTRODUCTION normotension and hypertension. The higher the blood

Hypertension should be well-controlled during cataract pressures the higher the risk of stroke and coronary
surgery like any other surgery. Several studies have docu- events. By JNC VI (1997) and WHO (ISH 1999), the
mented that patients with hypertension have higher risk high blood pressure has been classified in the following
of suffering from major cardiac complications during or categories depending upon the level of diastolic as well
shortly after non-cardiac operations than the patients who as systolic blood pressure based on average of more than
have always been normotensive. However, most of this two readings taken at each of two or more visits.
increase is because of IHD (ischaemic heart disease), Among patients who are treated for hypertension,
chronic heart disease left ventricular dysfunction, renal preoperative evaluation should include review of present
failure or other abnormalities that often occur in the medications and any history of intolerance to previous
patients of hypertension. anti-hypertensive medications, assessment of adequacy
Blood pressure should be well-controlled prior to elec- of anti-hypertensive therapy and for evidence of target
tive surgery and anti-hypertensive medications should organ damage or associated cardiovascular pathological
be continued throughout the preoperative period. If there conditions.
is a period in which the patient is unable to receive oral Before going for cataract surgery one must assess the
medication, topical or intravenous equivalents should be effect of hypertension on retina as it carries prognostic
substituted. Rapid withdrawal of beta-blocking medica- significance and should carry out the following minimum
tions is associated with adverse effect on heart rate and investigations to assess the target organ damage.
blood pressure and may precipitate myocardial ischaemia. • ECG–left ventricular hypertrophy, ischaemic heart
disease.
Definition of Blood Pressure
• X-ray chest–heart failure.
Definition of hypertension is difficult and by necessity is • Blood urea and serum creatinine—Nephropathy
arbitrary and there is no real separation between • Urine examination
JNC VI (Joint National Committee) Guidelines

Systolic (mm Hg) Diastolic (mm Hg)
Optimal <120 and <80
Normal <130 and <85
High-normal 130–139 or 85–89
Hypertension (> 2 reading at > 2 visits after screening)
Stage 1 140–159 or 90–99
Stage 2 160–179 or 100–109
Stage 3 >180 or >110
Isolated systolic hypertension is defined when systolic blood pressure is 160 or above and diastolic is below 80 and the staging
is done by level of systolic blood pressure.
Management of Hypertension in Cataract Surgery 53
• Clinical examination–heart failure, stroke, TIA patient of cataract, can be treated with long acting calcium
(Transient Ischaemic Attack) and peripheral vascular channel blockers. The hypertensive diabetic patients
disease. going for cataract surgery should be controlled on ACE
inhibitors. A hypertensive patient with angina, the drug
Management of choice is beta-blockers. Thus, the drug therapy should
be individualised according to the presence of con-
In patients with mild to moderate hypertension diastolic comitant disease.
blood pressure <110 mm of Hg and systolic blood pres-
sure < 180 mm Hg, and in non-cardiac surgeries are
CONCLUSION
generally well-tolerated. However, severe hypertension
(Diastolic blood pressure > 110 mm Hg) should be well- Blood pressure should be well-controlled prior to cataract
controlled prior to cataract surgery. Patient with severe surgery and anti-hypertensive medication should be
hypertension in the immediate preoperative period are continued through out the perioperative period. In post-
at increased risk for perioperative MI and congestive heart operative period the blood pressure should be carefully
failure It is neither mandatory nor desirable to delay monitored as some patients on anti-hypertensive therapy
cataract operation (Non-cardiac operation) for weeks or may have hypotension. Mild to moderate hypertension
months that may be required to achieve ideal blood in the absence of significant coronary or myocardial dys-
pressure control in stable patients who have mild to function does not add significantly to the cardiovascular
moderate hypertension but who have no hypertensive risk of cataract (Non-cardiac) surgery.
end-organ damage.
Patient on anti-hypertensive therapy are at increased SUGGESTED READING
risk of perioperative hypotension also. 1. Elliott HL, Connel JMC, GT Mcinner: The year in Hyper-
If surgery is urgent then preoperative blood pressure tension 2000.
control can be achieved rapidly with the use of intra- 2. Eugene Brawnwaid, Douglas P Ziges, Peter Libby: Heart
venous beta-blockers, calcium blockers, nitroglycerin or Disease: A Textbook of Cardiovascular Medicine, (6th ed):
nitroprusside. Sublingual nifedipine should not be used 2001.
as it can precipitate myocardial ischaemia or myocardial 3. Goldman L, Caldera DL: Risks of general anaesthesia and
infarction. elective operation in the hyper tensive patients.
Anaesthesiology 79, 50: 285–92.
In management of hypertension lifestyle modification
4. Hurst S, Valentin Fuster, R Wayne Alexander, Robert A,
should be practiced for mild to moderate hypertension, O’ Rovrice: The heart (10th ed): 2001.
e.g.: 5. Hypertension control: Report of a WHO expert committee,
• Lose weight if overweight. WHO technical report series. 862, 2000.
• Limit alcohol intake. 6. Kapllan M: Clinical hypertension: Normal (7th ed): 2000.
• Increase aerobic exercises. 7. Magnussen J, Thulin T, Wernex O et al: Hemodynamic effects
• Reduce sodium intake (< 100 m mol/day). of pretreatment with metoprolol in hypertensive patients
• Maintain potassium intake (90 m mol/day). undergoing surgery: Br J Anaesth 86, 58: 251–60.
8. Prys–Roberts C, Meloche R, Foex P: Studies of anaesthesia
• Maintain calcium and magnesium intake.
in relation to hypetension: I Cardiovascular responses of
• Stop smoking and reduce saturated fats. treated and untreatede patients: Br J Anaesth 71, 43: 122.
The drug therapy should be started with diuretics and 9. Stone JG, Foex P, Sear JW et al: Risk of myocardial ischemia
beta-blockers in uncomplicated case. The isolated systolic during anaesthesin treated and untreated hypertensive
hypertension in elderly, which is very common in the patients. Br J Anaesth 88, 61: 675–79.
Preoperative
Evaluation for SICS
8 Kamaljeet Singh
Sumeet Jain
I
n all types of surgeries good preoperative evaluation down pupil can be easily assessed under slit lamp.
helps in giving great postoperative results and more Pupil should also be examined after dilating it. It
will give further details for iris and also help in
importantly a grateful patient. The usual pattern of

preoperative examination especially for SICS should be knowing whether pupil dilates easily or not.
following: iii. Lens examination Preoperative examination of lens
should be done by dilating pupil because it is easier
Detailed History to assess the grade of hardness of cataract.
iv. Fundus examination Fundus should be examined
Detailed History of patient should be taken: by +78D lens under slit lamp. It gives a very good
1 Diabetes These patients are likely to have more view of macula even if media is hazy due to lenticular
incidence of postoperative uveitis, neovasculari- changes. It will avoid surprise postoperative findings
sation of iris and diabetic retinopathy. Therefore, a of macular degeneration, diabetic maculopathy and
diabetic should be thoroughly examined. optic atrophy.
2. Hypertension If history of hypertension is present v. Hypotony Hypotonic eye is not suitable for SICS
it should be well-controlled, to prevent any untoward become making a scleral tunnel in a hypotonic eye
incidence of expulsive hemorrhage. is very difficult and there are chances of tunnel
3. Ocular history History of recurrent redness, pain, getting ragged.
discharge and previous treatment must be asked. Most important aspect of SICS is expressing the
4. Refractive error Patient should be asked whether nucleus in the anterior chamber out of capsulotomy
patient is ammetropic or emmetropic at the age of or capsulorhexis. In a hypotonic eye prolapsing the
40 years. It is important from two angles: nucleus in AC expression of the nucleus becomes
i. IOL power calculation very difficult. Hence it is advisable not to apply pinky
ii. Scleral rigidity is low in myopic. Nucleus delivery ball before the operation. Instead gentle massage
becomes difficult in these cases. of the eye can be done after giving peribulbar
injection
Examination
vi. Age of the patient As the age advances the size and
Detailed examination under slit lamp gives many clues. hardness of the nucleus increases. The size of the
i. Corneal endothelium can be examined by using 25x lens at the age of 65 years is 1/3rd more than at 25
or 40x ocular by using specular reflection, or by years. Hence very old patients with hard and large
using Eisner lens. By these two techniques good nucleus are not suitable cases for SICS. This is the
assessment of corneal endothelium can be made. It preferred choice of surgery for comparatively young
helps in excluding patients having low endothelial patients. Therefore in older persons if we are doing
cell count e.g. in Fuch’s dystrophy, glaucoma, chro- SICS, the incision should be comparatively bigger.
nic iritis, trauma, old keratitis, multiple injuries and vii. Small pupil Small contracted pupil makes capsulo-
old age. Keratic precipitates should also be looked tomy or capsulorhexis very difficult. Prolapsing the
for. nucleus in anterior chamber becomes almost
ii. Iris pupil examination under slit lamp Any evidence impossible and hence it is better to do ECCE than
of posterior synechiae, pigments on lens, or bound SICS.
Preoperative Evaluation for SICS 55
viii. Eyes with uveitis The patients who had recurrent before its expression, manipulations in AC will lead
episodes of uveitis along with synechiae are not to significant endothelial cell loss.
suitable because of the following reasons. xi. There are few other conditions in which the tech-
a. Proper capsulorhexis or capsulotomy is difficult nique should not be done.
as the pupil does not dilate fully because of the a. Microphthalmos Here one has to make a very
adhesions between the capsule and iris. large incision as nucleus is very large. Moreover,
b. Prolapsing the nucleus in AC is difficult. there are increased chances of vitreous loss and
c. There are more chances of PC rent and vitreous other congenital anomalies.
prolapse as the posterior capsule is weak in these b. Extensive congenital anomalies
cases. c. Rubella cataract
d. Postoperative inflammation is more in patients d. Rubeosis iridis
with uveitis. e. Subluxated lens
e. There are chances of miosis, zonular weakness, To summarise, the key to successful manual SICS is
raised IOP and CME. SICS should better be proper selection of the cases for that the patients have to
avoided in these patients or else can be done be thoroughly examined, screened and planned
under cover of steroids. Prednisolone one mg/ accordingly.
kg daily should be given one week prior to the
surgery. FURTHER READING
ix. Patients who have undergone glaucoma filtering
1. Natchear G: In Manual small incision cataract surgery. Arvind
surgery are not ideal for non-phaco SICS because
Publications, India 2000.
of hypotony. 2. Rozakis GW: In: Cataract Surgery: Alternative small incision
x. Fuch’s endothelial dystrophy In this, there occurs technique. 1st (edn): Thordofare, Inc. 1995.
bilateral non-inflammatory loss of endothelium. 3. Shah Anil: In small incision cataract surgery (Manual Phaco)
Since in SICS the nucleus is prolapsed in the AC Best out of Waste Bhalani Publishing House: India. 2000.
Biometry 9 D Swarup
L
ens implantation surgery is a one-time surgery. in the posterior chamber would be further away from
The refractive power of the pseudophacos is final the retina than the natural lens.
and the patient must live with any mistake Such lenses in which the pre and postoperative
committed or be subjected to a very dangerous operation, refraction remains the same are called Idem lenses.
namely to the removal and replacement of the intra- Depending upon the plane of placement of the optic,
ocular lens. Later correction is only achieved with extra- the power of the IOL will vary in any given eye. The
ocular aid in the form of glasses or contact lens. Table 9.1 gives the power for idem lenses depending
So to ensure that our patients have the optimal upon the plane of placement.
correction, the power of the lens to be implanted must
Table 9.1: Rules of thumb for idem lens
be determined individually in every case.
Description of Power in
The problem of implant power calculation arose along Description of lens lens in short diopter
with the first ever IOL implant, when Ridley in 1949
observed in his patient a postoperative refraction of 1. Angle supported lenses AACL + 17.00D
24.0 D + 6.0 × 30°. Ever since, various workers have 2. Iris clip lenses ACL + 18.00D
been working on this problem of implant power 3. Iris plane lenses + 19.00D
estimation to obtain the best result. 4. Lens in posterior chamber close to PCL + 20.00D
iris convexity of optic facing forward
The methods used to estimate implant power might
5. Posterior chamber lens with nodal PPCL + 21.00D
be classified in two broad heads:
point closure to the retina than with PCL
1. Methods based upon primary refraction.
6. PCL with haptic angulated forwards and PPPCL + 22.00D
2. Methods based upon measurement, viz axial length,
convexity of optic towards retina (+ 22.50D)
corneal curvature, etc.
Emmetropia Lenses
Estimation of Implant Power
Based on Primary Refraction While idem lenses are sufficient for patients who are pre-
operatively emmetrope, for patients with known refractive
In the early days this method was the most used method. errors, it would be more desirable to implant a lens which
The following assumption is made while adopting this would result in emmetropia postoperatively. The
method of IOL power calculation: following formula gives the implant power required for
1. The refractive power of the natural lens is + 23.7 D. emmetropia.
2. The cardinal plane of the natural lens is 6 mm IOL power for emmetropia = Idem lens power + (1.25
behind the corneal apex. × Refractive error)
3. The radius of curvature of the cornea and the Example:
distance between the lens and the retina do not vary For a preoperative myopia of –2.00 D
between patients. PCL power = 20.00 + (1.25 × –2.00)
If the above conditions are true, then the placement = 20 – 2.5
of an IOL with a power of + 20.0 D in the posterior = 17.5D
chamber would result in a postoperative refraction equal For a preoperative hypermetropia of + 1.00 D
to that existing preoperatively. It explains that an IOL of ACL Power = 18.00 + (1.25 × +1)
+ 20.0 D would be sufficient to mimic the natural lens = 18.00 + 1.25
of + 23.7 D, because the cardinal plane of the IOL placed = 19.25D
Biometry 57
One should remember while trying to fit emmetro- Where P = Implant power for emmetropia
pising lenses, it is pertinent to note that the preoperative n = Aqueous and vitreous refractive index
glasses used by the patient need not reflect his/her real ACD = Estimated postoperative anterior cham-
refraction. A careful history will overcome this problem. ber depth in mm
L = Axial length in mm
Limitations K = Corneal curvature in diopter
Estimation of IOL power based on refraction suffers from Different theoretical formulae were described by
the basic assumption that the power of the natural lens different workers from time to time as follows:
is + 23.7 D. Though this may be true in a majority of N – LK
cases. Postoperatively, the use of this method more than Fyodorov P=
– (L – C) (I – CK/N)
often leads to very high refractive errors. The clarity of
an image on the retinal surface of a person’s eye is deter-
N N
mined by the sum total of: Colendrander P = –
a. The refractive power of the corneal surface L–C N/N – C
b. Power of the lens

c. The distance between the lens and retina. N I
Van der Heijda P = –
Each of these factors is variable from person to person L–C I/K – C/N
and eye to eye. The refractive power of the corneal
surface could vary from +39 D to + 49 D, and that of (NR/0.333 – L)
Binkhorst P=
the crystalline lens from + 17 D to +27 D. The length of [L – C (NR/0.333 – C)]
eyeball, which in turn determines the distance of the lens
Here P= IOL power for achieving emmetropia
from the retina, varies from < 20 mm to about 28 mm.
N= Refractive index of aqueous and vitreous
Thus in a real situation a highly refractive corneal surface
L= Axial length in mm
may be compensated for by a short eye to result in
K= Keratometry in diopters
emmetropia or vice versa.
C= Postoperative AC depth in mm
Implant Power Calculation R= Radius of curvature in mm.
Based on Measurements
Empiric Formula
With the advent of keratometry and A scan sonography,
which provided accurate measurements of the radius of A few workers, including Gills, Sanders, Retzlaff and Kraff
curvature of the cornea and the length of the eyeball, developed regression equations based on observed
two important parameters required for a precise esti- clinical data relating to eye measurements and IOL power.
mation of implant power. From these equations they developed formulae for
predicting IOL power. These formulae claim more
Theoretic Formulas accuracy in predicting implant power than theoretic
formulae. These are also subject to change as more data
It was not until 1967 when Fyodorov presented his are incorporated into developing and regression
theoretical formula based on geometric optics utilizing equations.
keratometry and A scan ultrasonography that implant Among these the SRK formula developed by Sanders,
power calculation matured into a rational discipline. Retzlaff and Kraff has gained wide acceptance because
In addition to Fyodorov and Colenbrander, Thijssen, of its ease of use.
van der Heijde and Binkhorst published theoretical
formulas. These formulas are all based on geometric SRK Formula
optics as applied to schematic eye using theoretical
constants. These apparently different formulae are in fact, P= A – 2.5 L – 0.9K
identical, except for correction factors. They all can Where P= Implant power to produce emmetropia
algebraically transformed to L= Axial length in mm
K= Average keratometer reading in diopter
n n×k A= Specific constant for each lens type and/
P= –
L – ACD n – K × ACD or manufacturer.
As it can be seen from above formula, a change in the • If axial length is 20 to 21 mm—add 2 diopter to
axial length of by 1 mm results in a 2.5D change in emmetropia value
implant power or a change in corneal refractive power • If axial length is 10 to 20 mm—add 3 diopter to
by 1D results in a 0.9D change in implant power. emmetropia value
The theoretical and empiric formulae worked well for
eyes of axial length ranging from 22 to 4.5 mm. For eyes Example The patient has a 20.73 mm axial length eye
of short or long axial length, while the theoretical and the original SRK formula shows 24.7 D IOL will give
formulae predicted too high or too low emmetropia value emmetropia. Add 2 D to this emmetropia power 24.7 +
respectively. The SRK formula had the opposite effect. 2 = 26.7 D for correct emmetropising power.
To overcome this problem the second generation
formulae were developed. The SRK II formula was Long Eyes (More than 24.5 mm)
developed where the basic SRK formula remained If axial length is more than 24.5 mm subtract 0.5 D from
unchanged but some additional computations were emmetropia value.
necessary to suit short/long eyes.
Adjusting Original SRK to SRK II Large Ammetropic Postoperative

Refraction Desired (More than 1.5D)
Average length eye No adjustment needed unless high
ametropia desired (Figs 9.1a to c). If the postoperative refraction desired is more than
SRK II Formula: 1.5 D in nonmyopic patients or more than – 0.75 D in
P = A – 2.5 L – 0.9 K + C myopic patients (Axial length greater than 24.5 mm) use
C = SRK II correction for long and short eyes. following:
IOL for desired refraction = Emmetropia power –
Short Eyes (Less than 22 mm) (RF × Desired refraction)
• If axial length is 21 to 22 mm—add 1 diopter to RF = 1.25 if emmetropia power greater than 14
emmetropia value RF = 1.00 if emmetropia power less than 14
Figs 9.1a to c: Diagram (a) showing the height of corneal dome, (b) with PC IOL showing the offset from the calculated
iris plane to optical place and (c) showing retinal thickness, ultrasonic axial length and optical axial length
Biometry 59
SRK/T lead to a decrease in the power of the lens by
0.75 D.
It is in theoretical formula developed using the non-linear
terms of physiologic optics and impirical regression b. Meniscus optic Flipping of this lens is mechanically
methodology for optimisation. It utilises the corneal difficult and is not recommended. However such a
height formula for predicting postoperative ACD and an flipping would lead to the displacement of the
axial length correction factor (Retinal thickness) which principal axis posteriorly, thereby decreasing the
varies with eye length. effective power.
Emmetropia should be the Goal

c. Biconvex optic There is no change in the power if
both the surfaces are equally convex. Most IOLs have
1. When bilateral pseudophakia is planned 3:1 ratio in convexity between anterior and posterior
2. When there is hypermetropia of 1.5 D to 2.5 D in an surfaces, thus reversal of the optic would decrease
useful fellow eye. the effective power.
3. When there is known or suspected absence of Apart from these, the other factors which affect the
binocular vision accuracy of the implant power are differences in the

4. When senile macular choroidal degeneration is present ultrasound equipment used, surgical technique, post-
in both eyes operative chamber depth, postoperative change in cor-
5. When a contact lens is used in an aphakic fellow eye. neal curvature and manufacturing variation in implant
power labeling.
Ammetropia should be the Goal
The only indication to make the eye ammetropic exists Surgeon’s Personal A Constant
in unilateral pseudophakia. Quite often differences between the expected and the
Factors affecting accuracy of implant power calcu- observed postoperative refraction were noted by
lation. Sander’s et al despite the use of the same style and make
of the IOL. They were able to trace this anomaly to be
Axial Length Measurement due to differences between surgeons. Based on their
Two methods are currently used for the measurement studies they are able to develop a method for calculating
of the axial length. They are the applanation and personal A constant for each surgeon. This calculation
immersion technique. In the applanation method the may be done retrospectively from records or on continual
applanating probe is kept on the cornea, whereas in the basis. It is important to calculate separate A constant for
immersion method the probe does not come into direct each style/make of the lens. The following data are
contact with the cornea but acts through an intermediary required for the same.
coupling solution. In the former method there is A1 = I + (Ra × Rf) + 2.5L – 0.9K – C
possibility of a slight depression of the eye leading to a
lower estimate of axial length. This is of significance in Where A1 =
The individual A constant
very short eyes. I =
Power of implant
Ra =
Postoperative refraction (D)
Keratometry Rf =
Refraction factor
L =
Preoperative axial length
This is another probable source of error because in
manual keratometry, failure by the operator to calibrate K =
Preoperative average keratometer
for his/her refractive error, could lead to wrong reading. reading (D)
Autokeratometers are not subject to this error. It would C = Short/long eye correction.
be better if the refractive power of the cornea is estimated
from the radius of curvature of the cornea rather than FURTHER READING
measure the refractive power directly. 1. Hoffer KJ: The Hoffer Q formula: A comparison of theoretic
and regression formulas. J Cataract Refract Surg 20: 677,
Orientation of the Implant 1994.
2. Olsen T, Oleson H, Thim K et al: Prediction of postoperative
a. Plano convex optic The normal position is with intraocular lens chamber depth. J Cataract Refract Surg 16:
convex surface forward, flipping of the lens would 587-90, 1990.
3. Retzlaff J: A new intraocular lens calculation formula. Am 6. Sanders DR, Retzlaff J, Kraff MC: Comparison of the SRK II
Intra-ocular Implant Soc J 6: 148, 1980. formula and the other second generation formulas. J Cataract
4. Retzlaff, Sanders DR, Kraff MC: Development of the SRK/T Refract Surg 14: 136-41, 1988.
intraocular lens implant power calculation formula. J Cataract 7. Sanders DR, Retzlaff J, Kraff MC et al: Comparison of the
Refract Surg 16: 333-40, 1990. accuracy of the Binkhorst, colenbrander and SRK implant
5. Sanders DR, Kraff MC: Improvement of intraocular lens power prediction formulas. Am Intra-ocular Implant Soc J
power calculation: Regression formula. Am Intra-ocular
7: 337-40, 1988.
Implant Soc J 6: 263, 1980.
Ocular Anaesthesia 61
Ocular Anaesthesia 10 Kamaljeet Singh

VK Srivastava
M
ost of the ocular surgeries can be performed
under local anaesthesia. However, local
anaesthesia is the best for SICS. We will des-
cribe here various types of local anaesthesia used in

cataract surgery.
Following blocks are used:
• Retrobulbar
• Peribulbar
• Sub-Tenon’s
• Topical Fig. 10.1: Retrobulbar anaesthesia
• Intracameral Courtesy: Alcon (India)
Retrobulbar Anaesthesia • It causes a little proptosis, which is helpful in per-

forming the surgery.
This was the preferred anaesthesia till eighties for cataract • It reduces the intraocular pressure.
surgery. Its advantage is that it gives very good anaes- • It dilates the pupil
thesia and akinesia in very small volume. 1.5 to 2.0 ml is
enough to give a very good effect. The technique is Complications
simple. A special 4 cm long 26 gauge retrobulbar needle
Brainstem anaesthesia This leads to respiratory arrest.
is used for this purpose (Fig. 10.1). One ml xylocaine
It occurs when the needle pierces the optic nerve sheath.
mixed with equal amount of bupivacaine with freshly
Through the subarachnoid space the local anaesthetic
prepared hyaluronidase (15 units per ml) is taken in a
may reach in the brain. The symptoms start within two
2 cc syringe. Lower orbital margin is palpated and we go
minutes of injection and start with confusion, cranial
behind the eyeball close to the orbital margin at the
nerve palsy, convulsions, hemiplegia, quadriplegia,
junction of medial two-third and lateral one-third.
cardiovascular instability and even respiratory depression
Previously it was the practice to ask the patient to look
and arrest. The whole episode may take 20 minutes to
up and in. In this position there are chances of damaging set in. Although the injection into the optic nerve is
the optic nerve sheath and the macula also comes closer supposed to be the mechanism behind this, yet the exact
to the needle. Therefore, now the patient is just asked to mechanism of this complication is not very clear since
look straight or even down to prevent the injury to optic some other authorities believe that hyaluronidase could
nerve. In retrobulbar block we get two resistance. One, also be responsible for this.
while piercing the skin. Other, when we pierce the muscle
cone since our aim is to block the ciliary ganglion, which Retrobulbar haemorrhage The orbital apex is highly
lies within the muscle cone about 7 mm anterior to orbital vascular structure. There are all likelihood of rupturing
apex. Following effects are achieved with retrobulbar the vessels, which lead to retrobulbar haemorrhage.
block. When it occurs there is sudden proptosis and lids become
• It causes anaesthesia tight. The operation in such situation is postponed after
• It causes akinesia doing a patch.
If the pressure is too much then the lateral canthotomy injected around the eyeball. The remaining cocktail is
can be done to decompress the globe. Retrobulbar injected at a site at the junction of medial one-third and
haemorrhage, in rare instances, can lead to optic atrophy. outer two-third of upper orbital margin. One should take
The exact mechanism, whether it is as a result of direct care to avoid the walls of eyeball and also the conjunctiva.
injury or because of the compression of the optic nerve Ocular massage is given for ten minutes if plain ECCE is
is not clear. Central retinal artery block has also been planned but massage should be avoided if manual phaco
reported due to retrobulbar haemorrhage. is planned.
Other sites for giving the peribulbar block are:
Optic nerve sheath injury There are chances of hitting • Superior
the optic nerve sheath, which can lead to optic atrophy. • Medial
This can be prevented by asking the patient to look The superior site In this technique the needle goes
straight rather than look up and in while injecting. through upper fornix. The patient is asked to look down
Globe perforation This can also occur while injecting. and in. The needle passes at a tangent. Since the direction
To prevent this disaster the needle should first be directed is upward there are no chances of globe rupture. It also
straight backward till you reach the equator of the eyeball. blocks orbicularis and superior rectus is also knocked
After that it should be directed towards the occiput. If off. This prevents Bell’s phenomenon.
globe perforation is suspected, wait for a while and ask The medial site Here the needle passes through the
the patient to move his eyes gently. If the needle is in the caruncle and medial canthal tendon. There is a big space
globe or in the sclera the needle will also move. The between medial orbital wall and wall of the eye. The
diagnosis is made by seeing the hypotony, absence of only vessel that can come in the close proximity is anterior
red glow and pain. In this case the needle should be ethmoidal artery and vein which lies much above the
withdrawn and the examination by indirect track of the needle. It also gives a good effect and can be
ophthalmoscope should be done. The extent of the injury used as an adjunct.
is related to the depth of perforation. If the needle Complications
perforates only the sclera, then it heals by a simple scar.
In case it pierces the choroid, then there are chances of Conjunctival chaemosis This is seen quite commonly.
choroidal haemorrhage, and if it enters the retina, then While injecting, the needle passes into the conjunctiva.
retinal holes and detachment can occur. If the fluid is The chaemosis goes off after the massage.
injected inside the vitreous then there are chances of Globe perforation The signs and symptoms are des-
severe reaction from the contents of the anaesthetic cribed above. Here the emphasis is laid on the point that
used and from its preservative too. Intraocular pressure the globe perforation can occur in peribulbar block also.
may also rise. If intravitreal haemorrhage is present, the Initially there was an impression in the minds of the
patient should be referred to a vitreoretinal surgeon. surgeons that it does not cause globe perforation. But
Contraindications include bleeding disorders, extreme the reported incidence of perforation are equal in both
myopia and posterior staphyloma. peribulbar and retrobulbar anaesthesia.
Oculomotor problems The oculomotor problems asso-
Peribulbar Anaesthesia
ciated with local block are transient diplopia extending
This is most commonly applied technique nowadays. In for one or two hours. But some cases of prolonged dip-
retrobulbar technique we have to go in the muscle cone. lopia are reported. At times ptosis can also occur. These
It may lead to retrobulbar haemorrhage, injury to optic complications usually resolve in due course.
nerve and other complications enumerated above. All The subconjunctival route It has also been tried, but
these complications can be avoided in peribulbar has not been widely accepted by ophthalmologists. The
technique. Here the aim is to go around the eyeball. A injection is given at superior limbus after putting topical
5cc syringe with 24 G needle is taken. In this we take 5 xylocaine 4 per cent drops. Ocular massage is given.
to 6 ml cocktail of xylocaine and sensocaine in equal Facial block is also required. This injection may also cause
quantity and hyaluronidase in a concentration of 1.5 units accidental globe perforation. In addition, there are
per ml. Xylocaine with adrenaline is better if it is not chances of weakening of superior rectus. Moreover,
contraindicated otherwise. Lower orbital margin is akinesia is not complete. Therefore this anaesthesia has
palpated and at the junction of medial two-third and not been used commonly for ECCE, but it may prove to
lateral one-third 3 ml of already prepared cocktail is be good for phacoemulsification.
Ocular Anaesthesia 63
Sub-Tenon’s block This block is favourable to both Facial Nerve Blocks
phaco and non-phaco surgeons and can be also used in
Facial nerve supplies the orbicularis oculi muscle. The
case the patient is not ready for injection into the skin. action of this muscle is squeezing the lids. Its block is
The site chosen is inferonasal or inferotemporal. But essential to avoid this action. Facial nerve block is
inferotemporal is best avoided since inferior oblique lies maximally needed as an adjunct when retrobulbar block
there. After instilling topical xylocaine 4 per cent drops, has been used. But at times it may be of great help in
a snip is given in the conjunctiva and also in the Tenon’s. case peribulbar block does not achieve the full block of
For assuring that the space is sub-Tenon’s an iris repositor orbicularis. Phaco and non-phaco surgeries can be done
can be passed in the sub-Tenon’s space. Then a blunt without blocking the action of orbicularis because these
tipped cannula is taken and 2 cc of cocktail is injected are closed chambered technique, but not the ECCE
after reaching posterior to the equator. The advantage wherein the chamber is open. It may lead to the contents
of injecting posterior to the equator is that Tenon’s capsule coming out of the eyeball. Several blocks have been
is deficient posteriorly and the fluid goes directly into the described but the most commonly used are being
muscle cone. Therefore excellent akinesia is obtained. described here.
Since sensory nerves cross the Tenon’s capsule immediate

anaesthesia is obtained. If cannula remains anterior to Nadbath and Rehman Block
the equator there are chances of proptosis. The only dis- This block uses the anatomical fact that the facial nerve
advantage seems to be a snip into the conjunctiva and passes below the mastoid process. The injection is given
also chances of subconjunctival haemorrhage. Therefore, in the triangular space below the mastoid. I have seen
some surgeons prefer giving this block in the upper Dr Momose using this technique in eighties. Usually this
quadrant. In case there is haemorrhage, it is covered by technique is not used because it blocks all the branches
the lids (Fig. 10.2). of facial nerve thus affecting half of the face. The vagus
nerve and the glassopharyngeal nerves lie close in this
area. Their block may lead to speech defect, drinking
and swallowing problems. Permanent facial paralysis has
also been reported.
O’brien Block
Facial nerve crosses the neck of the mandible before
entering the parotid gland. This injection is given after
palpating the temporomandibular joint by asking the
patient to open his mouth. About half an inch below this
Fig. 10.2: Parabulbar or sub-Tenon’s anaesthesia lies the facial nerve close to the anterior border of
Courtesy: Alcon (India) mandible. Four to five ml of lignocaine is injected into
this area. The massage is must after that because nerve
Topical Anaesthesia lies deep. It can affect both the upper and lower branches.
Phacoemulsification is now commonly performed under
Van Lint Block
topical lignocaine. Paracaine is better as it does not cause
any stingy sensation. These drops instilled 5 minutes With this block all the branches going to the orbicularis
before the surgery are very useful in anaesthetizing the can be blocked. Facial nerve gives branches to orbicularis
cornea. But the sensation in the iris remains. For that about 1 cm away from the lateral orbital margin in its
intracameral lignocaine 0.5 ml can be used. It anaes- lateral angle. 3 to 4 ml is injected deep in this site above
thetises the iris. Thus there is no pain even if the iris is the superior orbital margin, below the inferior orbital
touched by mistake. The advantage of this technique is margin and back starting from the site described above.
that there is no need of patching the eyeball and all the The only problem with this technique is its close proximity
complications of retro- and peribulbar are avoided. The to the operation site as it is likely to cause haematoma
disadvantage is that only phaco can be done with this formation.
technique. ECCE or nonphaco small incision should not There are some neuro-ophthalmic reflexes that one
be done under topical. needs to remember. These are as follows:
Oculocardiac reflex This gets precipitated when there reflex. Efferent are via a connection between trigeminal
is pressure, torsion or pulling on the extraocular muscles. sensory nucleus and pneumotaxic centre in pons and
Its signs and symptoms are sinus bradycardia, ectopic medullary respiratory centre.
beats or may be sinus arrest. Prophylaxis and treatment
Oculo-metric reflex It is not well understood. It induces
include IM or IV atropine injection. Its pathway is through
vomiting and occurs as a result of pull on extraocular
long and short ciliary nerve to ciliary ganglion. Efferent
muscles.
pathway is through vagus nerve.
Oculorespiratory reflex Its signs and symptoms include FURTHER READING
shallow breathing, brachypnoea or even respiratory 1. Jaffe Norman S: Atlas of ophthalmic surgery; JB Lippincott:
arrest. Its prevention and treatment include controlled 1990.
ventilation especially in children undergoing squint 2. Amar Agarwal: Phacoemulsification, laser cataract surgery
surgery. Its afferent are same as that of oculo-cardiac and foldable IOLs; Jaypee Borthers, India: 2001.
Anaesthetist’s Role in Ocular Surgery 65
Anaesthetist’s Role in
Ocular Surgery
11 HC Chandola
G
eneral anaesthesia in the medical armamen- which under normal circumstances can be applied by
tarium has been rightly credited for the develop- surgeon himself. At this juncture a simple question can
arise, ‘Is there any need of anaesthesiologists in ophthal-
-ment and progress of modern surgery. It was

called a day when on 16th Oct. 1846 WTG Morton at mic operations?’
Massachusetts General Hospital, USA demonstrated It is not only ophthalmology, but in all those field,
successful ether anaesthesia and surgeon TC Warren where the concept of minimum invasive surgery, endo-
declared, “Gentleman this is no humbug” but a reality. scopic surgery or laser or shock wave procedures are
With the development of general anaesthesia, surgery coming up the same question may came up sponta-
progressed but due to lack of present day technology, neously.
advanced anaesthetic delivery equipment to maintain a In reference of ophthalmic surgery following few of
controlled blood level of anaesthetics and adjuvant drugs the important reasons will justify the vital presence of
to reduce unwanted effects like nausea and vomiting. anaesthesiologist in ophthalmic operation theatre:
Surgeons had difficulty in operating upon eye, face, oral 1. All operations on eye, e.g. orbit, ptosis, reconstruc-
cavity, etc. the area, which was already covered by anaes- tion with fascialata sling or team surgery requiring
thetic mask. Immediate unpleasant and violent postope- help of other specialities as in rotation of graft for
rative recovery associated with nausea and vomiting were aesthetic purpose cannot be performed under local
not desirable in few operations like intraocular surgery anaesthesia.
where it might had lead to the complications like raised 2. In cases of infants and children from simplest probing
intra-ocular tension and consequent possible vitreous or congenital cataract, enucleation for retino-
prolapse. Therefore, ophthalmologists were continuously blastoma to trauma repair general anaesthesia is
in quest of an anaesthetic technique, which would have required to avoid inconvenience and mental trauma
not interfered in consciousness and devoid of aforesaid to the patient.
side-effects. 3. Many of the eye ailments requiring surgical cor-
Coca leaves were believed to be gift to the Incas from rection including cataract are aging processes and
Manco Capac, son of the God Sun to suppress the agony these patients usually have other age related
of mankind. Later even the operator was allowed to chew problems. Such patients may have bronchial asthma
coca leaves and trickle his saliva over the wound of the or bronchitis and any attack of cough or breath-
patient to get rid of pain indicating its local analgesic lessness during surgery may seriously effect the
properties. But it was only Karl Koller in 1884 an associate outcome of surgery. Many of these patients are
of famous psychoanalyst Sigmund Freud and intern in diabetic, hypertensive or have ischaemic heart
ophthalmology in Vienna, who noted that topical use of disease or renal disease requiring special attention
cocaine drops in frog’s eye desensitized the cornea and during perioperative period. An anaesthesiologist
he was able to pierce it with needle without any reflex is fully capable of giving respiratory and cardio-
action. He and his colleague Joseph Gartner then desen- vascular support and managing the crisis other than
sitized their own everted eyelids that gradually led to the administering general anaesthetics.
much-wanted present day local anaesthetic techniques Few of the patients feel disturbed or suffocated
for ophthalmic operations from instillation to infiltration. psychologically when an eye and face cover is put
Presently many techniques from topical to nerve blocks for draping purpose unless they are adequately
are available to produce local eye analgesia and akinesia, sedated.
Uncooperative, mentally confused, psychotic, mask it does not cause any tenting of drapes and
paled, severely deaf patients and those having thus causing inconvenience to surgeon.
involuntary movements may necessitate general iii. Guedel’s oropharyngeal airways to prevent fall back
anaesthesia. of tongue in a sedated patient.
4. If sensitivity to local analgesics is rare the overdose iv. A suction apparatus
toxicity either by real overdose of the drug or due to v. Magill’s throat cleaning forceps
inadvertent intravascular injection is not an uncom- vi. Laryngoscope
mon happening leading to incoherent confused vii. Endotracheal tubes of different sizes with connectors
behaviour, perspiration, bradycardia, etc. If left to ventilation equipment.
ignored it may leave behind morbidity or even
mortality. Minimum Drugs (Mostly in Injectable Form)
5. It is one of the most frequent demands from the i. Atropine
patient to remain unconscious during operation due ii. Adrenaline
to fear and anxiety. Majority of the patients after iii. Dopamine
explaining the procedure get ready to be operated iv. Dobutamine

under local analgesia but still a small fraction of v. Preservative free 2 per cent lignocaine (Xylocard)
patients demand general anaesthesia. In the event vi. Ephedrine or mephenternamine
of an unsuccessful or partially successful block again vii. Hydrocortisone
either deep sedation or general anaesthesia will be viii. Frusemide
required. ix. Antihistaminic (Avil)
6. In case of any unforeseen life-threatening event like x. Analgesics like–morphine, fentanyl, pentrazocine
the well-known ‘oculo-cardiac reflex’ if anaesthesio- or tramadol
logist is already present in operation theatre majority xi. NSAID analgesics, e.g. diclofenac sodium
of such problems can be checked to happen or xii. Midazolam or diazepam
treated effectively quicker and faster as in case of xiii. Thiopentone sod. or propofol
resuscitation the importance of time factor is well- xiv. Ketamine (intraocular surgery contraindicated)
recognized. xv. Succinylcholine
7. To be guarded against medicolegal aspect the role xvi. Sodium bicarbonate (8.4 vol.%)
of an anaesthesiologist is very vital in operation xvii. Sorbitrate tablets
theatre irrespective of any speciality. xviii. Nitroglycerine–injections, tabs, ointments and
It is not only a dictum but also a practical reality patches
that no anaesthetic whether local or general should xix. Nitrous oxide gas
be administered unless there is provision for artificial xx. Intravenous cannulas
ventilation. Some minimum equipments, drugs and xxi. Adequate number of disposable syringes.
monitoring systems should be there for the purpose
of resuscitation in case of any eventuality. Minimum Monitoring
The following monitoring systems should be available:
Minimum Equipment
i. Stethoscope
i. Equipment to artificially ventilate the patient, prefer- ii. Sphygmomanometer to measure blood pressure at
ably an anaesthesia machine or an AMBU bag with regular intervals preferably self-reading electronic
the provision of oxygen supplementation. instrument to avoid repeated use of stethoscope.
ii. Oxygen cylinder with a flow meter with provision iii. Pulse-oximeter It is one of the most valuable non-
of connecting an oxygen delivery tube with nasal invasive monitoring systems measuring peripheral
prongs, nasal catheter, poly or ventimask. Those arterial oxygen saturation (SpO2) usually with an
patients who had history of asthma, myocardial audible beep to monitor heart rate also, which the
ischaemia or feeling of suffocation under facial operator himself can see and hear while operating.
drapes should be given 2-4 litres oxygen flow per With its ease to use it should be used in every patient.
minute via a tube with binasal prongs as unlike a It has a light-emitting probe which can be inserted
Anaesthetist’s Role in Ocular Surgery 67
in finger, ear lobule or palm or foot (in case of a v. Defibrillator It is the equipment, which can be used
child) and the electronic signals are taken to the in case of cardiac arrest to return normal rhythm of
microprocessor, which performs the necessary heart by giving electrical shocks of different
calculations giving the SpO2 per cent reading on intensities.
monitor. All the above monitoring systems are available
iv. Cardiac monitor It is again a non-invasive moni- in different models either as a single system monitor
toring of electrical activity of heart using various chest or two in one to five in one models.
leads, especially in lead II. Arrhythmias occurring vi. Dextrostix These are the enzyme-impregnated sticks
during operation can be detected early and treated for quick measurement of blood glucose from
accordingly. capillary blood by dipstick method.
Postoperative
Infections:
12
Prevention and
Management
Jagat Ram
Gagandeep Singh Brar
P
ostoperative endophthalmitis is one of the most important aspects of OR layout include location, design,
devastating complications of intraocular surgery, proper ventilation and separation of the sterile zone from
leading to a marked loss of vision in over 80 per the non-sterile areas.
cent of cases.1 Better instrumentation, microsurgical For strict asepsis, an eye OT should preferably be non-
techniques, prophylactic antibiotics and better under- sharing with any other surgical discipline. The location
standing of asepsis has significantly reduced the incidence should preferably be on an upper floor in the building.
of this complication. Maintenance of asepsis is imperative Contamination from a hospital construction environment
for ensuring safe surgery for the patient and minimizing has been documented to cause an epidemic of Aspergillus
postoperative infection and its disastrous consequences. endophthalmitis.8
The reported incidence of postoperative endophthalmitis The major zones of an OT complex are:
varies and appears to be influenced by preoperative a. Outer zone reception area providing access for all
prophylaxis with antibiotics, the aseptic technique used persons and supplies.
and the geographical location. b. Changing room This area is located near the entrance
The average incidence of endophthalmitis has reduced of the OR complex.
from approximately 10 cases per thousand prior to 1950 c. Transfer zone This area includes a corridor for
to the present figures of approximately one case per transferring the patient.
thousand.2-4 Postoperative endophthalmitis may occur d. Aseptic zone Scrub and gowning area, the preparation
clinically as an isolated event or as cluster infections in room and the operating room (OR).
the form of a surgical epidemic.5-7 Although in most cases, e. Operating room The OR should have one opening
the source of the infecting organism cannot be identified towards the scrub area and another towards a sterile
with certainty, the most common infecting organism is zone marked for instrument packing and sterilization.
Staphylococcus epidermidis.7-9 The head ends of the operating tables should be
Postoperative endophthalmitis will be discussed under directed away from the entrance. Floors and walls
two major headings: should preferably be of non-porous material with
i. Prevention of postoperative inflammation and minimum joints to enable proper cleaning and
endophthalmitis. carbolization.
ii. Management of postoperative endophthalmitis. f. Disposal zone processing of used equipment supplies
and disposal of waste.
PREVENTION OF POSTOPERATIVE
ENDOPHTHALMITIS
Ventilation
Operating Room Layout
Air decontamination is important. High Efficiency
Contemporary theatre design incorporates zoning of Particulate Air (HEPA) systems remove most micro-
areas within the operation theatre complex. 9 The organisms ranging in size from 0.5-5.0 μ.10 The principle
Postoperative Inflections: Prevention and Management 69
of ventilation in the OR is delivery of positive pressure spraying or heating formalin or solid paraformal-
filtered air in a unidirectional vertical flow over the dehyde.9,14-16 The efficacy of the process is however
operating table. The current United States Public Health uncertain especially at temperature below 20°C and
Service minimum requirement for optimum OR air is: relative humidity below 70 per cent.16 Before fumigation,
temperature between 18 and 24°C, humidity 55-80 per adhesive tape is applied around the edges of the door,
cent, and 25 changes per hour.10 Fridkins et al11 reported windows and over ventilators apertures, etc. to seal the
4 cases, who contracted Acremonium kiliense desired area and prevent leakage to adjacent room or
endophthalmitis due to defective ventilation in the OR. outdoors. For each 1000 cubic feet of space (28.3 m3),
In the surgical operation theatre, bacterial count of air 500 ml of formaldehyde 40 per cent in one litre of water
should not exceed 1/ft3 (35.3/m3).12 and air entering the is placed in an electric boiler or in a large bowl placed on
theatre from filters should not contain more bacteria- a electric hot plate with safety cut-out when boiling dry.
carrying particles than 0.5/m 3, within 30cm of the Switch on the boiler and leave the room and seal the
operation site not more than 10/m3, and elsewhere in door. After fumigation the room is to be kept closed for
the theatre should not exceed 20/m3. 8-10 hours. Subsequently, ammonium solution is intro-
duced and left in the room for a couple of hours to

Cleaning, Disinfection and Sterilisation of OR neutralise the formaldehyde (1 litre ammonium solution
The terms are independent of each other and each needs plus 1 litre of water for every litre of 40 per cent
to be clarified and understood separately. Cleaning formaldehyde used.)
essentially means the removal of foreign matter (e.g. soil,
OR Discipline
organic matter) from the concerned surface. Unless an
article is mechanically cleaned, there will not be sufficient Personnel entering the OT complex should be kept to a
surface contact between it and the decontaminating minimum. Anyone with overt infection should be barred
agent, and sterilisation will not be accomplished. Cleaning from entering the OT complex. All persons entering the
is normally accomplished with water, mechanical action OT should change into freshly laundered clothing. Hair
and detergents. Disinfection is a process of freeing the and beards should be clean and be well-covered by caps
concerned object of all pathogenic microorganisms, and masks. High filtration disposable masks are to be
which may cause infection during its use. Sterilisation is worn at all times when within the aseptic zone. Ladies
a process that frees the treated object of all living should take special care at trimming nails and removing
organisms.13 It is impractical to attempt to sterilise the jewelry when working within the theatre complex. All
entire OR and equipment, and the current practice persons must wash their hands thoroughly before
concentrates on disinfection. Instruments and drapes entering the OR. It is desirable to restrict all persons other
need to be sterilised adequately. Sterilisation is an than the staff from the OR. In today’s age of modern
absolute term, and there is no term as partial sterility. electronics, it is better for students and other trainees to
The hundreds of compounds derived from phenol be seated at a remote place and observe surgery on a
constitute phenolic compounds. They are good closed circuit television rather than crowd around the
bactericides and are active against fungi.13 They are surgeon’s table.9
sometimes virucidal but are not sporicidal, except at
temperatures over 100°C. Sterilisation of Instruments
This class of compounds is used for decontamination Instruments need to be thoroughly cleaned after every
of the OR and for noncritical medical and surgical items. surgery before being subjected to sterilisation. Micro-
The floor and 5-6 feet of OR walls should be mopped with surgical instruments are best cleaned by an ultrasonic
phenolic solution. Similarly, wet mopping all OR tables, cleaner. These contain liquids through which sound
mats, instrument trolleys, stools chairs and supply shelves waves pass at a frequency of 1,00,000 Hz or more.10,15
with phenol followed by a wipe down with 70 per cent The ultrasonic waves generate submicroscopic bubbles,
alcohol is an effective decontaminating regimen.13 Anaes- which collapse and create a negative pressure on particles
thetic equipment like endotracheal tubes, airways and in the suspension. The bacteria disintegrate and the
suction apparatus should be disinfected after every use. protein matter is coagulated by this action.15
Formaldehyde is the most common agent used for Sterilisation can be done by physical or chemical
sterilisation of operating room. The gas is liberated by methods, of which the former is more reliable.
Physical agents Sterilisation by heat: An online 0.022μ micropore filter has been recom-
i. Dry heat A temperature of 160°C for one hour or mended.20,21
180°C for 20 min. will sterilise the contents by a des-
Chemical agents
tructive oxidation of cell constituents.15,17 The holding
i. Glutaraldehyde 2 per cent (Cidex®) It is an effective
period of one hour at 160°C is timed as beginning
steriliser for instruments that cannot be autoclaved.
when the thermometer first shows that the air in the
It is non-corrosive, does not impair the sharpness
oven has reached 160°C. Its usefulness is limited
of cutting instruments and may be used with plastic,
and some sharp instruments such as fine Vannas
scissors and blades may be damaged by dry heat. aluminum and rubber. It is effective against vege-
ii. Autoclaving This method is more effective than dry tative pathogens in 10 minutes and resistant patho-
heat and requires lower temperatures in a given time. genic spores in 3 hours.18 It is very effective against
Autoclaving at 121°C for 15 minutes at 15 psi pres- the tubercle bacillus.
sure effectively kills most microorganisms. A The low surface tension allows for easy pene-
temperature of 134°C at 34 psi pressure sterilises tration to inner surfaces and it can be readily
instruments within 3 minutes.18 Temperature sensi- removed by rinsing. Thorough rinsing of all sterilised
tive detectors must always be used to ensure material is mandatory because residual glutaral-
adequate autoclaving. Bacillus stearothermophilus, dehyde is extremely irritating to tissues. Courtright
a thermophile that requires being cultivated at 55 et al22 reported significant corneal edema developing
to 60°C is a suitable test organism; its spores are because of inadequate removal of of glutaraldehyde
killed at 121°C in about 12 minutes. Chemical detec- from the small lumens of instruments.
tors show a change of color or shape after exposure ii. Ethylene oxide (ETO) Gas sterilisation using ethy-
to a sterilising temperature, e.g. Bowie-Dick tape, lene oxide is effective and safe for heat-labile dis-
which is applied to packs and articles in the load, posable items for cost reduction. Sterilisation is
develops diagonal lines when exposed for the correct effected by a process known as alkylation in which
time to the sterilising temperature.10,18 Autoclaving a hydrogen atom is replaced by a hydroxyl ethyl
is suitable for sterilisation of most of the metal radical within a protein molecule. It is advisable to
ophthalmic instruments except sharp knife and fine use ETO sterilised instruments after a safe aeration
scissors. Autoclaving irrigating solutions bottles may period of 7-10 days to ensure that no amount of
kill only heat labile microorganisms by action of residual ETO remains on the surface to avoid
temperature at relatively low temperature as the intraocular toxicity.23
steam does not penetrate the bottle. For effective sterilization, the minimum concen-
tration required is 400-1000 mg/l. Moisture enhances
Flash Sterilisation
the diffusion of the ETO gas. Blood, pus and other
Emergency sterilisation may occasionally be required. proteineous materials act as barriers to ETO. 1-12
Perkins19 described flash sterilisation parameters as 132°C hours may be required for sterilization. The double
at 28 lb of pressure for three minutes for metal instruments packing of the item is done in 200 gauge thickness
for gravity-displacement and prevacuum steriliser. The polythene. The vacuum is created and loading is
recommended minimum exposure time for linen, rubber, done at 70 cm/Hg vacuum. ETO gas pressure is
plastic and lumen containing items should be 10 minutes maintained for sterilisation at 5lb/In2 for 12 hours
for gravity-displacement cycle and 4 minutes for pre- or 10 lb/In2 for 6 hours. The vacuum is created at
vacuum cycles. However, the practice should be restricted 70 Ib/In2 for vacuum cleaning of the sterilised item
to emergency situations only, since the margin of safety and then vacuum break and this cycle is repeated
is lower. 3-4 times to reformation of collapsed polythene
envelope.
Filtration iii. Acetone It is a potent bactericidal agent and is useful
Use of micropore filter for FGE, intraocular air/gas for routine disinfection of surfaces.24,25 Drews24 has
injection and intraocular antibiotic injection is a must. postulated that the poor results reported might be
Microorganisms are retained in part by the small size of due to its relative ineffectiveness in the diluted form,
the filter pores and in part by the adsorption on the pore and emphasised the need for using it as a concen-
walls during the passage of the fluid through the filter. trated solution.
Plasma Sterilisation as they have a higher rate of carriage of Staphylo-
coccus aureus.28-30 Patient related preoperative risk
This new modality of sterilisation of instruments has been
factors include blepharitis, conjunctivitis, dacryo-
introduced recently for heat sensitive medical devices. A
cystitis, lacrimal drainage abnormalities, ocular surface
very small quantity of hydrogen peroxide in various
disorders, host immunosuppression29,30 and even
phases, including low-temperature gas plasma excited
upper respiratory tract infections in children.31
by radio waves, is lethal to organisms on the surface of
The ocular surface and adnexa is the main source
medical devices. Hydrogen peroxide is injected into the
of bacteria in culture proven cases of endophthalmitis.
chamber under reduced pressure in a dry atmosphere.
Using microbial DNA analysis, Speaker and coworkers
Vapour diffusion occurs throughout the contents and
radio frequency energy excites H2O2 into active radicals showed that the main source of infection is patient’s
and reactive chemical species. The free radicals so own ocular flora.32 The importance of a scrubbing
produced react with and destroy microorganisms present bath of the head and face on the day of surgery should
on pre-cleaned, dry accessible surfaces. The most well be emphasised.
known plasma sterilisation is the Sterrad TM from Preoperative use of topical antibiotic The role of
Advanced Sterilisation Products, California using prophylactic antibiotics administered both topically
hydrogen peroxide gas plasma at low temperature and subconjunctivally has been documented to reduce
(< 50°C). postoperative infection.33,34 Topical antibiotics should
be started 24 hours before surgery and used 6-8 times
Monitoring of Sterilisation Protocol during daytime. Instillation of topical antibiotics more
than 24 hours may lead to replacement of patients
All sterilisation procedures must be monitored meti- owns flora by more virulent microorganism and fungi.
culously by appropriate means for optimum effectiveness.
Various parameters and tests like ‘phenol coefficient,’ 2. Preoperative preparation and role of povidone-
Rideal-Walker test and Chick-Martin test may be used. iodine Speaker and Menikoff,35 in a significant break-
Monitoring sterilisation is difficult. Sterilisation process through showed that a single topical application of 5
indicators (e.g. temperature charts, pressure gauges) are per cent povidone-iodine solution reduced the inci-
used to indicate inadequate process conditions. The dence of postoperative endophthalmitis significantly.
biological indicators come closest to an ideal monitor Povidone-iodine is bactericidal in 30 seconds.35,36
because they integrate all of the sterilising parameters Although cilia trimming was once considered helpful
involved, such as time, temperature, pressure and in reducing postoperative infection, the present trend
packaging. is not to trim cilia for intraocular surgery. This practice
became unnecessary following widespread practice of
Disposal of operating room biohazardous waste Ope-
isolating lashes with sterile adhesive drapes. Cleaning
rating room biohazardous waste including infected linen,
the lids, lid margins and adjacent skin with Povidone
disposable syringes, IV drip set, needles, residual IV fluids,
iodine 5 to 10 per cent is an effective method of
infected material, excised human diseased pathological
eliminating microbes.37
tissue is a significant hazard to public and need safe
disposal to prevent recycling of disposable and spread 3. Scrubbing and use of gloves It is important to use nail
of infection from infected material. brush and scrub properly. One should scrub hands
Over the last decade, the disposable of operating room and arms below elbow. It will take 7-8 minutes to scrub
and hospital waste has received much attention. In most with soap. A hand dis-infection system using chlor-
of the cases it can safely be dumped in a properly hexidine reduces the rate of nosocomial infections
designed waste pit particularly in the developing more effectively than one using alcohol and soap.38
countries.26 Incineration has been advocated as a viable Povidone iodine (Betadine®) or Chlorhexidine scrub
method of disposal of OR and hospital waste.27 (Hibiscrub ®) is best for scrubbing. With povidone
iodine or chlorhexidine solution , scrubbing twice for
Sterile Surgical Protocol 1-2 minutes each is adequate. After wearing sterile
1. Patient-related factors In isolated infections, patient gloves, it is important to wash the hand with Ringer
related factors predominate.28 Diabetic patients and lactate to remove the powder from the gloves.39
those with blepharoconjunctivitis, dry eyes or atopic 4. Surgical procedure Many factors are implicated in the
disease are at a higher risk of postoperative infections occurrence of endophthalmitis including the patient’s
own immunity and the quality of surgery. Prolonged isolated endophthalmitis cases. For prophylaxis, half of
surgery (longer than 60 minutes),40 use of prolene the maximum non-toxic dose of the antibiotic is
haptics intraocular lenses, inadvertent ocular recommended in the infusion bottle. Vancomycin 10 mg
penetration during extraocular surgery and vitreous in a 500 ml bottle has been recommended.52 However,
loss have been specifically documented to be risk there are reports that this practice makes no difference
factors for the development of endophthalmitis.41 The to the incidence of postoperative endophthalmitis.53
risk of developing infection is high if the integrity of Another concern is the emergence of vancomycin-
posterior capsule is lost, since it allows an easy access resistant coagulase negative Staphylococcus and
for microorganisms into the vitreous cavity.37 Vitreous Enterococcus strains.53 Other considerations to be kept
loss requires introduction of additional instruments into in mind are the cost implications and the risk of human
the eye, which contributes to the increased risk of error during constitution of the required solution. This is
infection. especially true when using aminoglycosides, as inad-
Postoperative risk factors include poor wound cons- vertent injection of toxic doses could result in macular
truction or closure leading to a wound leak, iris pro- infarction and endothelial toxicity.
lapse, vitreous incarceration in the wound, exposed

sutures, suture removal under inadequate aseptic condi- Subconjunctival Antibiotics
tions and the presence of a thin filtering bleb.41-43 Subconjunctival injection of antibiotics at the end of
surgery helps in reducing postoperative infection
Irrigating Fluids and Viscoelastic Agents
particularly in the setting of the developing world. A single
Contaminated fluids, tubings, intraocular lenses and injection of high doses of most antibiotics maintains
viscoelastics are known to have caused cluster infec- therapeutic aqueous levels for 4-6 hours.54 The definite
tions.8,44-48 The fluids for intraocular and intravenous use efficacy of this practice is still questioned.55
such as balanced salt solution, Ringer’s lactate, etc. should
be inspected for its intact packing and also for any obvious Surgery of Infected Cases
bacterial or fungal contamination. Any visible particulate All infected cases must be operated in a separate OR.
matter should render a bottle unsafe for use even if its After performing surgery on the infected cases, the
sterile packing seems undisturbed. Cluster postoperative tubings, instruments and sheets used for infected cases
infection usually occur as a result of breach in the OR must be cleaned thoroughly and sterilized adequately
asepsis. Most common causes are irrigating fluids,44-48 before reuse. An added concern is the need for
contaminated viscoelastics,44 defective ventilation.11 In sterilization or high level disinfection of medical devices
cluster infection microbiological surveillance culture contaminated with blood from patients infected with HIV
specimens for bacterial or fungi are obtained from or HBV, or with respiratory secretions from a patient with
environmental sites, OR floor and wall, water source, pulmonary tuberculosis. Experiments have shown that
operating room team, irrigating fluids, viscoelastics, HIV, HBV, and M.tuberculosis are inactivated by
intraocular lenses, surgical equipments49 and autoclave commonly used chemical germicides such as 2 per cent
equipment. glutaraldehyde, 70 per cent isopropyl alcohol, 0.3 per
Even with a sterile surgical technique, infection may cent hydrogen peroxide and 50 ppm chlorone.56
occur from many other sources. Studies have shown that For ensuring safe surgery, each member of the OR
bacteria may be recovered from culture of anterior team must perform his/her assigned role faithfully. All
chamber aspirates at the end of cataract surgery in upto staff working in the OR should be well-versed with
43 per cent of cases even in the presence of preoperative sterilisation norms and techniques being followed in their
antibiotic prophylaxis and aseptic techniques.50 Lacunae own theatre. Abiding by a few rules and ensuring OT
in our knowledge include how many bacteria are required discipline no doubt goes a long way in providing safe
to cause endophthalmitis and how low the bacterial ocular surgery to patients.
counts have to be in order to ensure a negligible risk of
postoperative infection. The role of antibiotics in irrigating
MANAGEMENT OF POSTOPERATIVE
solutions such as balanced salt solution or Ringer’s lactate
ENDOPHTHALMITIS
is controversial.51 The antibiotic protocol is aimed at
providing protection against gram-positive bacteria, All patients must be examined postoperatively at the slit
which are the most prevalent organisms, cultured in lamp at least twice in the first 72 hours after surgery, at
the end of one week and finally at 4-6 weeks after surgery. 8. Tabbara KF, al Jabarti AL: Hospital construction associated
At each visit, the ophthalmologist must objectively record outbreak of ocular aspergillosis following cataract surgery.
visual acuity, cornea clarity, intraocular pressure and the Ophthalmology 105: 522-26, 1998.
9. Ram J, Kaushik S, Brar GS et al: Prevention of postoperative
media clarity.
infections in ophthalmic surgery. Ind J Ophthalmol 49: 59-
Any increasing postoperative inflammation, presence 69, 2001.
of a hypopyon and decreasing media clarity should be 10. Laufman H: The operating room. In Benett JV, Brachman
considered as infective endophthalmitis unless proved PS (Eds): Hospital Infections. Boston: Little Brown and Co.,
otherwise and managed as an emergency. An USG may 315-24, 1986.
be obtained if media is hazy. If the visual acuity is HM+ 11. Fridkin SK, Kremer FB, Bland LA et al: Acremonium kiliense
or better, a combination of intravitreal antibiotics such a endophthalmitis that occurred after cataract extraction in an
ambulator y surgical center and was traced to an
vancomycin 1 mg in 0.1 ml and ceftazidime 2.25 mg in
environmental reservoir. Clin Infect Dis 22(2): 222-27, 1996.
0.1 ml in separate syringes should be injected through 12. Senior BW: Examination of water, milk, food and air. In
the pars plana. The sample should be processed for smear Collee JG, Fraser AG, Marmion BP et al (Eds): Mackie and
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importantly, also for fungi as the incidence of post- Livingston, New York, London 204-39, 1989.
operative fungal endophthalmitis is high in developing 13. Rutala WA: APIC guidelines for selection and use of
countries. Most gram +ve organisms are sensitive to disinfectants. Am J Infect Control 18: 99-117, 1990.
vancomycin and more than 90 per cent of gram-negative 14. Kramer SG, Char D: Microscope sterility system. Trans Am
Acad Ophthalmol Otolaryngol 83(5): 869-71, 1977.
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15. Gupta M, Gupta AK: Modern ophthalmic operation theatre.
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Am J Ophthalmol 93(4): 518-19, 1982.
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Medical Microbiology: A Guide to the Laboratory Diagnosis
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glaucoma. Early and late bacterial endophthalmitis after HBV and other infections in the health care setting. WHO
glaucoma filtering surgery. Ophthalmology 92: 959-63, 1985. Regional office for South Asia, New Delhi, 52-58, 1996.
The Manual Small Incision: Surgical Aspects–I 75
The Manual
Small Incision:
13 Mahipal S Sachdev
P Mishra
Surgical Aspects–I S Thanikachalam
T
he scleral tunnel incision was introduced in early implantation through a modified pocket incision, curved
eighties in an attempt to provide better wound opposite to the limbus, which was named, “Frown
healing with less surgically induced astigmatism. incision”, because of its appearance to the surgeon. They
This became the most favoured incision technique in the also pointed out that frown incision group consistently
recent past for sutureless, small incision, non-phaco had a lower standard deviation from the mean induced
astigmatism than the scleral pocket incision group.
cataract surgery. Although the length of external incision
Paul H Ernest introduced the concept of an internal
in this technique varies from 5 to 8 mm still it is called
corneal lip (triplanar incision); acting as a one-way valve
small incision cataract surgery (SICS) since the archi-
and imparting self-sealing wound properties.
tectural design renders sutureless, selfsealing property to
Surgery has evolved from being just a small incision
this incision. This is in contrast to the standard ECCE technique for cataract extraction to being a sutureless way
incision that is approximately 11-12 mm, made in poste- of ending the procedure, thereby causing minimal
rior limbal area, which requires number of sclerocorneal distortion of the corneal curvature. In some cases a choice
stitches. of incision may also help in reducing a pre-existing toricity
Richard Kratz, in 1983 was the first surgeon to move in the cornea. So, all the vital parameters that go into the
the cataract incision from the limbus to the sclera thereby creation of a reproducible leak proof and astigmatic
increasing the surfaces of apposed wound to produce neutral incision have assumed great importance today.
enhanced wound healing and less astigmatism. Girard The classical incision is a three-step incision, shaped
and Hoffman in 1984 were the pioneer to call this like a Z. One limb of the Z is the vertical gutter at the
posterior incision as scleral tunnel incision. external site of the incision, the second limb is the
Jack A Singer in 1991 conducted a prospective clinical horizontal dissection and the third limb is the angled entry
trial to evaluate induced astigmatism with PMMA IOL into the anterior chamber (Fig. 13.1).
Fig. 13.1: Mechanism of scleral tunnel incision

The vital statistics that go into the making of a manual • The superior limbus is usually anteriorly placed. To
phaco incision include: make an effective corneal valve incision, the internal
l. Site of the external incision. opening of the incision then goes too anterior
2. Placement of the incision. • The corneal incision is usually associated with flattening
3. Style of the external incision. of the meridian in which it is given, hence depending
4. The length of the external incision. on the pre-existing cylindrical condition of the cornea,
5. Length of the sclerocorneal tunnel. this side effect can be used to an advantage by placing
6. Depth of tunnel dissection. the incision on the steepest meridian.
7. Size of initial opening.
8. Size of incision for IOL insertion. Advantages and Disadvantages of
9. Paracentesis opening. Temporal Incision
Site of the External Incision The temporal location allows greater access to the incision
than when over the brow; for the same reason the eye
Scleral Pocket Incision (Fig. 13.2a) does not need to be turned down, this does away with a
In scleral pocket variety of incision, the external incision bridle suture and postoperative ptosis. As the iris plane is
should be based 2.00 mm posterior to the limbus. parallel to the microscope light, the red glow is excellent
and hence visualisation is enhanced. Being furthest from
Clear Corneal Incision the visual axis, theoretically, it is claimed to be more
refractively stable.
In this the corneal incision should start just anterior to Its disadvantages are a higher risk of complications
the insertion of the conjunctiva to the limbus, i.e. just and being an uncomfortable position to work from
ahead of the limbal vascular arcade. If the conjunctiva surgically.
gets punctured, it may lead to massive ballooning of the
conjunctiva due to the fluid egressing from the incision.
Style of the External Incision
Placement of the External Incision The external incision may be in the form of a straight line
or shaped like a frown. The frown incision is most stable
The scleral tunnel incisions are usually placed at 12.00
and is supposed to prevent sliding between the roof and
O’clock position. Clear corneal incisions may be placed
floor of the tunnel, thereby minimising astigmatic shift.
anywhere around the limbus keeping in view the
This incision is highly recommended. External incision
following:
parallel to the limbus should be avoided.
Length of External Incision

The length of the external incision should equal the size
of the IOL that has to be introduced through it. Although
a small entry is to be made for the initial process, the
incision is opened to its full dimension for IOL implan-
tation, or even before that while beginning the surgery.
Thickness of the Roof of the Tunnel

The thickness of the roof of the tunnel should be about
300 microns. Thickness more than this may lead
to inadvertent entry into the anterior chamber. Thin tunnel
roof may lead to buttonholing of the tunnel roof during
dissection or tearing of the thin tissue during the surgery.
Length of the Tunnel Incision

• In scleral tunnel, the tunnel length is usually between
Fig. 13.2a: Scleral incision 4.0 mm (Fig. 13.2b).
Fig. 13.2b: Scleral tunnel
• In clear corneal incision, the recommended tunnel Instruments required for the incisions:
length is, 1.75 mm. Too long tunnel lengths compro- 1. A 15-degree freehand (preset depth 1.300 micron)
mises visibility peroperatively because of distortion of blade for the initial groove to start the tunnel incision.
the corneal dome. In manual phaco we prefer scleral 2. A 2.0 mm broad crescent blade for dissecting the
tunnel except in very soft cataracts when phaco- tunnel with the shaft bent at 45 degrees.
trisection can be done. 3. A suitable breadth keratome (2.5 mm, 3.0 mm, 3.2
Too short tunnel lengths tend to make the incision mm, 3.4 mm) with a 90-degree angle at the tip. The
leaky. bevel should face the surgeon and the shaft of the
blade should be bent 45 degrees.
Size of Opening for IOL Implantation
4. A 0.6 to 1.0 mm broad blade for the paracentesis
Generally the incision needs to be extended for implan- opening.
tation of the IOL. 5. A blunt tipped extender blade for increasing the
For the rigid varieties of single piece PMMA IOLs The incision for IOL insertion of suitable size (3.5 mm,
extension of the incision should be equal to the diameter 4.0 mm, 5.0 mm, and 5.5 mm). The bevel of the
of the optic. Some people like to extend 0.5 mm smaller blade should be on the undersurface. The shaft
than the size of the diameter of the IOL but the passage should again be bent 45 degrees.
of the IOL becomes tight if the length of the tunnel is 6. A caliper to measure the intended incision size.
longer.
Technique of Making a Incision
For the foldable/injectable lenses The length of the
incision depends on the type of IOL and the design of Scleral Tunnel (Figs 13.3a and b)
folder/injector being used. Depending on this, the final First of all the conjunctiva is reflected from the limbus
incision may vary between 3.5 and 4.0 mm. and mild bipolar cautery applied for haemostasis.
Vigorous cautery may make the scleral tissue stiff.
Paracentesis Opening(s) A caliper is used to mark the length of the incision that
In addition to the main incision, a paracentesis opening is needed for IOL implantation at a suitable distance from
is required for the introduction of the second instrument the limbus. A depth-preset knife (300 microns) is used to
for bimanual techniques of phacoemulsification. This make the initial incision into the sclera. If one intends to
opening is usually preferred on the left side of the main make a frown incision, and intends to keep 2.0 mm
incision. The incision is 0.6 to 1.0 mm in breadth and behind the limbus, then the centre of the frown should
may be in the form of a simple stab or shelved incision. be at the level of 2.0 mm whereas the ends of the frown
lie more posterior.

A crescent blade is taken and the dissection is begun.
It is of utmost importance to begin dissection at the correct
depth and then to maintain the same depth throughout
the length and breadth of the incision. This is possible if
one starts the incision from one side and ends at the other
side. If you start from both sides, there is a chance of
dissecting at different levels. Multi-planer incisions create
confusion during every occasion of introduction of
instruments into the anterior chamber and must be
avoided. With experience, you get to know the depth of
dissection by the visibility of the crescent blade through
the roof of the tunnel. The roof is much more transparent
if the dissection is superficial and vice versa. Care should
Fig. 13.3a: Scleral tunnel dissection with

crescent angled blade be taken to preserve the continuity of the edge of the
Fig. 13.3b: Technique of scleral

tunnel incision and its extension
Courtesy: Alcon (India)
Fig. 13.3c: Extension of scleral tunnel. Courtesy: Alcon (India)
external incision. The dissection is carried forward across advanced along the dissected tunnel. Care should be
the limbus into the clear corneal tissue, again maintaining taken to prevent formation of new tracks. When the tip
the same depth of dissection. An inadvertent opening of the keratome reaches the end of the tunnel, the tip is
into the chamber at this stage may complicate matters. advanced into the corneal stroma, again remaining in
The scleral incision is usually between 6.0 and 6.5 mm. the same plane. One should get this right in the first
Although we have shown that even extension up to 8.0 attempt and re-entry should be avoided to prevent
mm does not cause any problem and does not need
formation of multiple passages.
any sutures. The corneal end should be dissected 2 mm
At the intended point of entry into the anterior
longer than the scleral incision, 1.0 mm on either side
chamber, the tip of the blade is dipped posteriorly and
(Fig. 13.2b).
Once the tunnel is made, paracentesis stabs are made advanced slowly until the tip of the blade just appears
at the 10 O’ clock and the 2 O’ clock positions (Fig. 13.4). inside the chamber (Figs 13.5a and b). At this point, the
It may or may not be needed and depends on the direction of the tip of the blade is again turned horizontal
surgeon’s choice. and the entry completed. This particular manoeuvre is
Viscoelastic material is introduced through one incision carried out to obtain a straight-line internal incision. If
and the aqueous is allowed to escape from the other. the direction of the blade is not turned horizontal, the
Viscoelastic is filled just enough to make the eyeball firm, shape of the internal incision will resemble the shape of
not hard. the tip of the keratome.
A suitable sized keratome is taken and introduced into Viscoelastic present in the chamber prevents sudden
the tunnel in the central position of the frown and shallowing of the chamber when the keratome entry is
made, thus preventing inadvertent hitting of the lens.
Fig. 13.4: Paracentesis stabs being made. Courtesy: Alcon (India)

you are familiar with a particular keratome, you should

always get the tunnel length right. Some keratomes have
markings on them to indicate the reference point and
make this step easy.
In certain diamond keratomes, the reference point for
entry into the anterior chamber is when the shoulder of
the keratome reaches the external incision line.
Some keratomes are shaped like a trapezoid, i.e. the
tunnel they form will be just right for the phaco probe at
the internal incision, while shall be a little loose at the
external incision to facilitate easy right-left movement.
When the clear corneal incision has to be made without
an initial groove, the tip of the keratome should first dip
into the corneal tissue to the desired level before traversing
the cornea. This kind of incision should preferably be

made with a keratome with a tip angle of 90 degrees,
otherwise a tongue-shaped tag is formed at the starting
Fig. 13.5a
point of the roof of the corneal tunnel.
Clear Cornea Incision The limbal incision In order to have a longer tunnel and
valve, some surgeons advocate the initiation of the
As the name indicates, the incision is purely corneal in incision from the limbus instead of the clear cornea.
nature. Of these three described tunnel methods scleral tunnel
There are two ways to start this incision: is the most preferred tunnel for manual SICS. The other
• By making an initial partial thickness vertical incision two methods are usually used in phacoemulsification.
• Without an initial incision.
The hinged wound When pressed on the posterior lip a
A straight partial thickness vertical incision of the
clear corneal paracentesis can leak. The wound can
required length is made in the corneal tissue, just anterior
however be made more secure and entirely self-sealing
to the conjunctival vascular arcades. Then a keratome of
by creating a hinge before the corneal tunnel is dissected.
the required breadth is taken and the tip introduced into
The hinge can be made with both a clear corneal and a
the exposed corneal stroma just short of the full depth of limbus-based incision. David WI Angerman, one of the
the incision. The blade is to be held parallel, relative to advocates of a hinged incision creates a 600 μm deep
the corneal surface and advanced into the corneal stroma groove that is 3.2 mm wide and then a tunnel in the
up to the desired length. Then the hilt of the blade is anterior one-third of the corneal stroma with a special
lifted and the tip pointed towards the anterior chamber. 3.2 mm diamond keratome. The groove must be
Pressure is applied gently for the blade tip to emerge into perpendicular to the corneal curvature and the tunnel
the chamber, when the blade is again turned into a perpendicular to the groove to obtain a totally self-sealing
horizontal direction. This is done to produce a straight- wound. He has designed a single-hinge diamond knife
line internal opening. For making a same length tunnel system for making a hinged incision (Fig. 13.6).
every time, one has to note a reference point on the Advocates of this incision are convinced about its
keratome in relation to the point of entry, so that once greater safety but emphasize that what contributes to this
Figs 13.5a and b: Anterior chamber entry with angled keratome. Courtesy: Alcon (India)
Comparison of scleral tunnel and
corneal tunnel incisions
Scleral tunnel Corneal tunnel
l. Indications and Contraindicated in Indicated in functioning
contraindica bleeding diathesis, filtering bleb; bleeding
tions collagen vascular diathesis, anticoagulant
diseases, function- medications; conjunctival
ing bleb scarring; scleritis, ocular
pemphigoid and dry eye
syndromes, combined
trabeculectomy and
phacoemulsification
2. Construction More difficult and Less so
and tissue time-consuming,
trauma more traumatic
3. Astigmatic Comparable Comparable
control compar-
able
4. Risk of compli- Very rare More common
cations if left
sutureless (endo-
phthalmitis/ iris
prolapse/flat
chambers)
5. Risk of Greater Infrequent
hyphaema
is not just making the groove but also ensuring that it is

maintained by avoiding forceful lens insertion.
Extension of the Incision

The extension of the primary incision is done using a
blunt tipped extension keratome. The size of the keratome
should equal the diameter of the IOL optic that needs to
be implanted through it or the required size for a foldable
Fig. 13.6: Creation of the special sclero-corneal pocket incision. lens design. The extender keratome should have a bevel
The anterior chamber maintainer (A) is in place, introduced away from the surgeon, while extending the incision; care
through a tunnel in clear cornea which is 1 mm wide and at
should be taken to prevent the edges of the incision from
least 2 mm in length, near and parallel to the limbus (A-arrow).
The height of the BSS bottle connected to the maintainer, being cut inadvertently by keeping the blade absolutely
controls the intraocular pressure. Two 1 mm paracentesis inci- horizontal and in the plane of the original incision.
sions (D) are made at 10:30 and 2:30 just anterior to the limbus,
for instrument access. The main external incision. 0.3 mm in- Closing of the Incision
depth and 4-5 mm long, is made 1 mm behind the limbus. A
One thing that should not be forgotten about these self
crescent knife (C) dissects the tunnel, First 1 mm in sclera,
then 2-3 mm forward into clear cornea (1), then extending late- sealing incisions is that their typical structure makes them
rally (2) to produce the pockets (P) on both sides. While vulnerable to ingress of infectious agents to the inside of
performing the pockets, the crescent knife is retracted laterally the eye if the valve is leaky. So the closure of the incision
and backward (3), creating the external incision extensions (E) becomes even more important, than its making. It should
on both sides. (Below) A keratome (K) enteres the anterior remain sutureless only as long as it does not compromise
chamber to accomplish the internal incision (I), curved in shape, the safety of the eye.
parallel to the limbus. The keratome must be moved in a direction The corneal valve is put into function by inflating the
slightly away form the surgeon while moving it laterally (4-arrow).
The distance form the external to internal incision is about 3.5
anterior chamber from the paracentesis opening with the
to 4 mm. Internal incision (I) lengthis about 7 mm. (Courtesy: irrigating fluid. The high pressure inside the chamber
Benjamin Boyd, MD issue No. 1, 2000 of Highlights of Ophthal- forces the two lips of the internal opening against each
mology) other and closes them (Fig. 13.7). Depressing the posterior
Fig. 13.7: The corneal valve is closed by inflating the chamber

with irrigating fluid, which pushes the corneal valve shut and
seals the incision Fig. 13.8: The engineering aspects support the theory that maxi-
mum stability of the wound is achieved if length of tunnel is the
lip of the incision should check the integrity of the incision.
same as the width

The most stable wound is created in case the length of
the tunnel is equal to its width (Fig. 13.8). reason why even in cases where the lateral “horn” of the
If the incision is leaky, hydration of the corneal stroma scleral lip gets incised during the process of extension of
may be tried at the extreme ends of the incision. The the incision, one may still not find any changes in
corneal edema pull: the tissues tight against each other keratometry. It is important to familiarise yourself with a
and helps in a leak proof closure. set of “sharps” (blades) used for fashioning the phaco
In case the incision still leaks, a single, horizontal 10-0 incision. Using the same design of keratomes, etc. should
nylon or 10-0 vicryl suture should do the trick. Never let
help you to standardize your incision making.
your ego come between the suture and safety.
Get to feel the cutting properties of different blades
with bevels on the front surface and the back surface.
Summing-up
The bevel positions mentioned in the text are most
In manual phaco, a good incision ensures sutureless and recommended. It is true that diamond keratomes are very
astigmatically neutral closure, which is actually half the sharp and are probably the best for making the phaco
surgical work. It is important to understand the relation- incisions, but good quality steel keratomes carry out the
ship of the length of the incision and its distance from the job equally well and are economical at the same time.
limbus. Small incision can be made closer to the limbus For the price of a single diamond blade, you can buy
and the longer incisions further away, with equivalent hundreds of steel keratomes.
corneal stability. The internal corneal incision actually is One should never compromise on the sharpness of
the one, which affects corneal curvature. That is the the blades (Fig. 13.9). Inspect every blade under the
Fig. 13.9: Various blades for making incision. Courtesy: Alcon (India)
microscope before you touch the eye. If you think it is optic intraocular lens implantation. J. Cataract Refract Surg
blunt, change it immediately. Sometimes, the blade may 17: 677-88, 1991.
look good on inspection but refuses to cut well; this 4. Mishra P: Small incision cataract surgery (SICS) and IOL
warrants immediate change of the blade. implantation. Cyberle4ctures, www.indmedica.com/ophthal
For best results, you have to learn how to make a good 1-4, 2000.
incision and then practice hard to get it right the first time, 5. Kapoor Sashi, Incisions: Emmetropia. J Intraocular Implant
every time! and Refract Society 2: 17-25, 1999.
6. Mishra P: Catract surgery and intraocular implantation in
REFERENCES children. Cyberlectures www.indmedica.com/ophthal 1-5,
2000.
1. Girrard LJ, Hoffman RF: Scleral tunnel to prevent induced
astigmatism. Am. J Ophthalmol 97: 450-56, 1984. 7. Mody Kirit, Singh Gagan J: Small incision non phaco cataract
2. Kratz RP, Colvard DM, Mazzoco TR, Davidson B: Clinical surgery. Emmetropia. J Intraocular Implant and Refract
evaluation of terry surgical keratometer. Am Intraocular Society 2: 9-11, 1999.
Implant Soc J 6: 249-51, 1990. 8. Kumar Ravindra, Small incision cataract surgery without
phaco–my experience. Emmetropia, J Intraocular and Refract
3. Jack A Singer: Frown incision for minimizing induced

astigmatism after small incision cataract surgery with rigid Society 2: 53-55, 1999.
The Manual Small

Incision: Astigmatic
14
Considerations–II Mahipal S Sachdev
Pradeep Venkatesh
E
very cataract surgeon knows that preoperative and An obvious approach to reduce the chance of astig-
induced astigmatism is a deterrent to his aim of matic shift would therefore be to shift to an incision that
making his patients “emmetropic”. Over the years is small (3 mm in length if corneal incision desired); that
he has either consciously or subconsciously evolved from is away from the cornea either straight or frown shaped
doing just cataract surgery to planning astigmatic cataract (to stay within the astigmatically neutral funnel); multi-
surgery. The evolution of manual phaco is largely attri- planar and one that can be “safely” left un-sutured. Also,
butable to the relative immunity the procedure provides wounds with a square configuration (i.e. wherein the length
against large shifts in astigmatism. This immunity is not and width are small and equal) are considered more.
absolute though.
Achieving Emmetropia
One important factor, which has kept most astigmatic
cataract surgeons busy is the wound or the cataract inci- The astigmatic cataract surgeon can modify his wound
sion. Several facts relating to incision and astigmatism parameters to undo any undesirable preoperative astig-
are well-established but there possibly are several yet to matism. Preoperative astigmatism could be low (0-1.0
be unraveled. D), moderate (1.0 to 2.0 D) or high (>2.0 D).
It is well-established that the following induce greater When the preoperative astigmatism is low, the ideal
astigmatism: small incision wound construction would be a straight,
l. Longer incision clear corneal, 3 mm incision (possibly in the temporal
2. A corneal incision region). By this the surgeon aims at retaining the
3. A limbus parallel incision preoperative sphericity. A “frown” incision 3 mm behind
4. A uniplanar incision the cornea can also achieve this goal by being within the
5. A sutured incision astigmatically neutral funnel (Fig. 14.1).
Preoperative Astigmatism
|
| |
TYPE With the rule (WTR) Against the rule (ATR)
| |
| | |
RANGE Low (0-1D) Moderate (1-2.0D) High (> 2.0D)
↓ ↓ ↓
AIM Retain sphericity Regain sphericity Reduce sphericity
↓ ↓ ↓
TECHNIQUE Clear corneal 3 mm straight Center incision along steep Spherical small incision profile +
incision; or frown incision meridian, straight, thin scleral Astigmatic keratotomy + Modify
3 mm from limbus (spherical flap, 6 mm long IOL power (>4D astigmatism)
phaco incision profile)
Fig. 14.1: Aims of cataract surgery in preoperative astigmatism

The Manual Small Incision: Astigmatic Considerations–II 85
Astigmatically Neutral Funnel important caveat, i.e. to center the wound along the meri-
The concept of astigmatic funnel arose from two mathe- dian in which against the rule change is desired.
matical relationships; firstly, that corneal astigmatism is Thus the incision being amenable to modification as
directly proportional to the cube of the length of the desired by the surgeon enables him/her to achieve emme-
incision and the second, that, it is inversely related to the tropia. In some patients astigmatic keratotomy may be
distance from the limbus. Incisions made within this needed for the same in addition to the tailored incision.
funnel will be for all practical purposes, astigmatism
equivalent. Curvilinear limbus parallel incisions fall SUGGESTED READING
outside this funnel and are hence unstable.
1. Buzard KA, Shearing SP: Comparison of postoperative
When moderate preoperative astigmatism is encoun- astigmatism with incisions of varying length closed with
tered (1.0 to 2.0 D), the small incision, surgeon in an horizontal sutures and with no sutures. J Cataract Refract-
endeavor to regain sphericity should construct a wound Surg. 17(Suppl): 734-39, 1991.
that is centered along the steep meridian, about 6 mm 2. Davison JA: Keratometric comparison of 4.0 mm and 5.5
with a thin scleral flap and straight in relation to the mm scleral tunnel cataract incision. J Cataract Refract Surg.
limbus. 19(1): 3-8, 1993.

A combination of spherical small incision profile with 3. Feil SH, Crandell AS, Olson RJ: Astigmatic decay following
astigmatic keratotomy is needed when the aim is to small incision, self sealing cataract surgery. J Cataract Refract
Surg 20(1): 403-09, 1994.
reduce preoperative sphericity that is high (>2.0 D).
4. Fine I Howard: The infinity suture for closing phaco-
Spherical small incision profile is as described under “low” emulsification incision. Symposium: In Cataract IOL and
preoperative astigmatism. This however, is constructed refractive surgery. American Society of Cataract and
only after completing astigmatic keratotomy. A 7mm optic Refractive Surgery, 1990.
zone is maintained during astigmatic keratotomy. The 5. Gimbel HV, Sun R: Postoperative astigmatism following
depth of the incision should be 90 per cent thickness. phacoemulsification with sutured Vs un-sutured wounds. Can
The length of the incision is dependent on the correction J Ophthalmol 28(6): 258-62, 1993.
necessary. An incision of 45° rectifies 1 D; of 60°, 1.5 D 6. Masket S: Comparison of suture materials for closure of the
and of 90°, 2.0 D. Any additional incisions made will scleral pocket incision. J Cataract Refract Surg. 14(5): 548-
51, 1988.
increase this effect by 20-30 per cent.
7. Nielsen J: Induced astigmatism and its decay with a frown
When preoperative astigmatism exceeds 4D, the
incision. J Cataract Refract Surg. 19(3): 375-79, 1993.
implant power has to be modified to counter the effect 8. Suzuki R, Tanaka K: Outcome of preoperative against the
of coupling. rule astigmatism after phacoemulsification; Characteristic
In constructing the incision, the surgeon has to “tailor” change over time Part II Ophthalmologica, 204(4): 184-91,
wound parameters to suit individual cases with one 1992.
Capsulotomy for
Small Incision
15 AK Grover
Cataract Surgery Pankaj Puri

Harprit Singh
C
apsulotomy plays a vital role in the further pro- However, it shares the disadvantages of possibility of
gress of the surgical procedure of cataract extrac- posterior extension of the tear, escape of IOL from the
tion by any technique. The most commonly used bag and decentration due to long-term fibrosis.
techniques are (1) Can opener technique, (2) Envelope
technique, (3) Capsulorhexis. However, with a greater Capsulorhexis
appreciation of the role of symmetrical placement and Continuous, curvilinear capsulorthexis (CCC) developed
long-term maintenance of the intraocular lens, by Gimbel, Neuhann and Schimizu independent of each
continuous curvilinear capsulorhexis has acquired the other in 1980’s is the most preferred technique. The CCC
widest acceptance. technique has significantly improved the safety of cataract
extraction and in the bag intraocular lens implantation.
Can Opener Technique Before we begin with discussion on capsulorhexis, a basic
In it, an irrigating cystitome or simply 26 G needle, bent understanding of the anatomy of the lens capsule is a
at the tip is introduced into anterior chamber and multiple pre-requisite.
small radial cuts are made in the anterior capsule for
Anatomy of the Lens Capsule
360 degree. The technique is same as for the conventional
extracapsular cataract extraction. It however, has the Capsule of the lens forms a transparent homogeneous
following disadvantages: highly elastic covering of the lens. Ultra structurally the
1. Possibility of posterior extension of capsulotomy tear capsule has a laminated appearance. When out or
during surgery. ruptured its edges roll out and then curl up. It is much
2. Difficulty in ensuring in the bag placement of intra- thicker in the front than behind and the anterior and
ocular lens. posterior portions are thinner towards the periphery
3. Escape of the haptic from the bag during IOL insertion. (equator) just within the attachment of the suspensor
4. Asymmetric fibrosis of the bag with long-term decen- ligament than at the poles (Figs 15.1 and 15.2).
tration of the lens. The pattern of insertion of zonular fibres has an
important bearing on the size of the capsulorhexis.
Envelope Technique (Linear Capsulotomy)
Zonular fibres arise from the ciliary body and would be
Envelope technique became increasingly popular in divided into two groups.
extracapsular cataract extraction as its advantage of First those that pass from the ciliary process to the
endothelial protection during surgery and greater surety lens, most of which attach to the anterior or posterior
of ‘in the bag’ placement of IOL were recognised. lens capsule than the equator and do not seem to cross
Here a straight incision is made in the anterior capsule each other, while those that form a mesh work across
in the upper part from two to ten O’clock position. The the ciliary body or extend from the pars plana to the
rest of the capsulotomy is completed in the end after vitreous body to form part of the vitreous base form the
removal of nucleus and cortex. second group. As a whole the zonule forms a ring which
Capsulotomy for Small Incision Cataract Surgery 87
Fig. 15.1: Anatomy of lens capsule
Fig. 15.3: Demonstrating the sheer technique for

initiating capsulorhexis
Fig. 15.2: A schematic view of the lens of the eye
is roughly triangular on meridinal section. The base of
triangle is concave and occupies the equator and portions
of the anterior and posterior surface of the lens.
Technique: Sheer Versus RIP

The red fundus reflex produced by coaxial light of the
microscope is essential to visualise the capsule while
performing capsulorhexis. Also, high magnification,
horizontally placed eyeball and putting viscoelastic on
the wet cornea improves visibility of the anterior capsule.
Capsulorhexis can be performed by either a sheer
technique (Fig. 15.3) or by a ripping technique (Fig. 15.4). Fig. 15.4: Demonstrating the rip technique for
Propagators of both the techniques have shown distinct initiating capsulorhexis
advantages and disadvantages of the same. However, provides us with an advantage of an ultimate control on
in our experience we feel that the sheering technique the initiation and performance. Ripping the capsule is
less desirable than sheering because the tear tends to

extend uncontrollably even when the grasp is held
stationery. Secondly more force is generally needed to
begin a tear with ripping as opposed to that with sheering
as the force is distributed over a larger area in ripping.
This entails that a capsulorhexis performed by sheering
technique is much more under control and requires much
less energy then that performed with the ripping.
A complex physical basis of two techniques and
distribution of the force vectors in both the techniques
are being shown in Figures 15.3 and 15.4. A combination
of a sheer and rip technique can also be used to perform
a safe capsulorhexis.
Maintenance of the Anterior Chamber Depth

A deep anterior chamber which is ensured with the gene-
rous use of a viscoelastic provides us with a safe atmos-
phere for initiation and propagation of capsulorhexis. a
shallow anterior chamber, an indicator of a high vitreous
pressure results in the anterior displacement of lens and
zonular stress. It also leads to a more convex position of
the lens. Therefore, any stress at the sight of the capsu-
lorhexis whilst initiation or propagation will tend to extend
towards the perphery as the force vectors then act in two
directions (Figs 15.5a and 15.5b). When the anterior
chamber is deep and viscoelastic is used to counteract
the vitreous pressure, the stress on the zonules is
neutralised (Fig. 15.5c). Thereafter, the capsular forces
work only in the direction desired. Maintaining a deep Figs15.5a to c: (a) Demonstrating the upward direction of force
anterior chamber during capsulorhexis is therefore highly of vector when the anterior chamber is shallow, (b) Showing
recommended. Learning a capsulorhexis, using a how this force vector acts in extending the tear to the periphery,
cystitome on a visco-elastic syringe may help to compen- and (c) Deepening of the anterior chamber by viscoelastic
sate for any decrease in the anterior chamber depth. neutralises the force vector
Initiation of Capsulorhexis
We tend to perform the capsulorhexis with the use of a
sheering technique and the technique described herewith
will follow the principle.
Capsulorhexis is often initiated with formation of a
flap. A puncture wound at the centre of the lens and the
cut is extended to a point B (Fig. 15.6). At point B
cystitome is pulled towards point C as shown in Figure
15.7. This lead to creation of a capsular flap which is
then folded over to lie on top of the intact capsule. The
direction of the horizontal cut can be towards the nasal
or temporal side of the lens or towards the site of the
incision depending on personal preference. It can then
be extended either in the clockwise or anticlockwise Fig. 15.6: Showing initiation of capsulorhexis starting from the
direction. We prefer to perform capsulorhexis and centre and going to the mid-periphery
continue it in an anticlockwise direction. A slight variant Propagation of Capsulorhexis
of the continuous capsulotomy as popularised by Charles After initiation, as described earlier, the capsular flap is
Kelman may be performed by engaging the lens capsule folded upon itself. The flap is then engaged with either a
in the centre of the lens and then pulling the capsule cystitome or a capsulorhexis forceps at point C and the
towards the incision site (Fig. 15.8). This leads to creation flap pulled in the desired direction of capsulorhexis (Fig.
of a triangular flap described as a Christmas tree flap by 15.7). While using a cystitome one has to be very cautions
Kelman. that very minimum pressure is applied to engage the
capsule as too much pressure may penetrate the flap.
Also the capsule should be held or engaged somewhat
inside the peripheral edge of the flap in order to provide
a safety margin against the cystitome slipping peripherally
and damaging the intact capsule. The direction of the
force ensures correct position and extension of the
capsulorhexis. It can be seen that point of engagement
of the instrument is adjusted to stay two to three clock

hours away from the point of sheering. If the instrument
is placed closer, an artificial stress line is created which
could compromise the predictability of the capsulorhexis
and direction of sheer propagation. The direction of
capsulorhexis can be altered by changing the direction
Fig. 15.7: Showing progression of capsulorhexis of force as shown in Figure 15.9. The changes in direction
using shear technique may be required when the capsulorhexis tends to extend
peripherally. One should be aware of the fact that if a
change in direction of the capsulorhexis is abrupt it can
induce modification of the force vectors converting sheer
to a modified rip which has a potential of peripheral
extension. A deep anterior chamber during any of these
manipulations is highly desirable for a high predictability.
Fig. 15.8: Showing a variant of continuous capsulotomy

known as “Christmas Tree Flap” creation
Important Factors while Initiating Capsulorhexis

1. Incision should be superficial and should involve only Fig.15.9: Showing the direction of force used for progression
the capsule. of a capsulorhexis by sheer technique
2. Incision should be extended for just about 2 mm on The capsulorhexis is progressed gradually, the capsular
either side depending on the personal preference. flap is engaged repeatedly and capsulotomy progressed
3. Aim for minimal disturbance of the lens cortical for about two to three clock hours at a time. Figure 15.10
material as this will hinder visualisation. shows the capsulotomy three quarters of the way through.
4. A deep anterior chamber is a pre-requisite and should When coming to the end of the capsulorhexis, problems
be maintained by a generous use of viscoelastics. are often entailed as there is a lot of capsule lying free,
impending visualisation of the capsulotomy edge.

Viscoelastic are used here to flatten the capsular flap and
to ensure good visualisation of the tear (Figs 15.11 and
15.12a and b). Also when coming to the end of the
capsulotomy an attempt should be there to bring the
capsule from outwards in, as shown in Figure 15.13. The
direction of the force is slightly modified to increase the
diameter of the capsulorhexis and then to bring the
capsular flap from out in. This modification of the Figs15.12a and b: A flat anterior capsule with the help of
technique helps in prevention of any radial extensions viscoelastic enhances visualisation. Courtesy: Alcon (India)
of the capsulorhexis during phacoemulsificaton.
Fig.15.10: Shows capsulorhexis finished to 3/4 of the area
Fig.15.13: Showing the direction of the capsulorhexis when

coming to the completion (coming from outwards to in)
Fig.15.11: Shows wrinking of the anterior capsule creating 2. Radial extension of the capsulorhexis should be only
problems in visualisation for about 2 mm.
3. The direction of the force should be in the desired
direction and shape of capsulorhexis.
4. The capsule should be grasped with the cystitome
using gentle pressure to avoid any tears or inadvertent
rupture of the capsule.
5. The point of engagement of the capsule should be
kept slightly away from the margin of the lens.
6. The capsulotomy should be progressed slowly moving
two to three clock hours at a time.
7. When nearing the end the capsule flap should be
spread evenly using a viscoelastic to enable comple-
tion of rhexis and to visualise the end of the tear.
8. Capsulorhexis should be finished from an outward in
Fig.15.12a movement of the capsule.
9. A deep anterior chamber should be maintained at all
times.
Salient Features of Capsulorhexis with
the Cystitome Using the Sheer Technique Capsulorhexis with the Ripping Technique
1. Initiate the capsulorhexis straight in the centre punc- Performing a capsulorhexis with a ripping technique
turing just the capsule avoiding inadvertent distur- differs from the sheering technique in the following
bance of the cortical matter. aspects:
1. Direction of the pull is much more towards the centre points at the tip directed downward to grab the anterior
of the capsule (Fig. 15.14). capsule are now available to perform capsulotomy.
2. The flap is engaged by pulling the instrument at a Initiation of capsulotomy in these cases is begun with a
point which is much closer to the tear. needle puncturing the capsule in the centre making a
3. A larger amount of force is required to initiate and horizontal movement 2 mm towards the lateral side,
propagate capsulorhexis. creating a capsular flap. The capsular flap thus created is
4. The direction of the force has to be constantly changed grasped with the forceps and the capsulorhexis may be
to direct and propagate the capsulorhexis in a circular performed by ripping the capsule in the direction of
manner( Fig. 15.15). desired capsulorhexis. Capsulorhexis using a Utrata’s
forceps has been reported by some investigators to be
much easier and provides more control over the capsu-
lorhexis then with the cystitome. However, in our experi-
ence we feel that either of the two techniques is quite
safe and predictable and use of either of the instruments
is entirely a personal preference. However, the use of a

forceps requires AC maintenance by more dense visco-
elastic and methyl cellulose alone may not always suffice
(Figs 15.17 to 15.19a and b show the use of a Utrata’s
forceps in performing a capsulorhexis). We still prefer
the use of sheer technique in performing a capsulorhexis
even when using the Utrata’s forceps.
Fig.15.14: Showing the direction of the force when you are
creating a capsulorhexis with the ripping technique
Fig.15.16: Showing the use of an external light source for

visualisation of the anterior capsular flap
Fig.15.15: Shows the changing direction of force needed to

propagate the capsulorhexis in a circular manner with the ripping
technique
Shear v/s Rip

In our experience, the ripping techniques have been
shown to be more difficult to control and more likely to
inadvertently extend peripherally relative to the sheering
techniques. However, they can be combined with the
sheering technique when a change of direction of the
capsulorhexis is desirable.
Capsulorhexis Using Forceps

A number of capsulotomy forceps based on the Fig.15.17: Showing a “Christmas Tree Flap” as
wonderful design of Utrata, long handled forceps with 2 advocated by Kellman
Capsulorhexis in Difficult Situations

Performing a capsulorhexis in eye with white cataract
and/or small pupils can occasionally present a challenging
task to the operating phaco surgeon. Absence of glow or
small pupil compromises the visualisation of the capsule
and the capsulotomy edge. However, certain modifica-
tions can be performed to perform a safe capsulorhexis
in these cases.
Capsulorhexis in Mature Cataracts

The basic principle of capsulorhexis remains the same,
however certain modifications can be made in technique.
Visualisation of the capsule can be increased by main-
taining a deep anterior chamber using the viscoelastic

Fig.15.18: Showing initiation and progression of material and also use of viscoelastic material for elevation
capsulorhexis with forceps and manipulation of the flap torn edge after initiation of
capsulorhexis. An external light source (Fig. 15.16) can
be used on an oblique angle to help us increase visuali-
sation of the capsular flap. Progression of capsulorhexis
in these cases should be very slow and steady and no
attempts should be made to complete capsulorhexis
rapidly.
Capsulorhexis in Hypermature Cataracts

In a hypermature cataract, puncturing the capsule leads
to leakage of the cortical matter obscuring the view. This
fluid matter should be aspirated or flushed from the
anterior chamber with a viscoelastic such as methyl
cellulose to clear the anterior chamber. A viscoelastic is
then injected into the lens bag to increase its volume
and the capsulotomy is performed.
Fig.15.19a: Showing capsulorhexis through one quadrant A very valuable tool in improving visualisation of the
capsule has been produced by staining with dyes.
Trypan Blue Staining

Inadequate visualisation of the capsule as in mature and
hypermature cataract can be obviated by temporarily
staining the anterior capsule with any contrasting dye
for, e.g. 0.1% Trypan Blue. Staining of the anterior
capsule simplifies capsulorhexis.
Technique
Through the side port incision, anterior chamber is
completely filled with air. The air in the anterior chamber
causes the dye to spread over the anterior capsule,
bordered by the pupillary rim of the iris, it prevents a
direct endothelial contact. The air also prevents dilution
Fig.15.19b: Showing near completion of of the dye by the aqueous. It is observed that a large
the capsulorhexis with forceps single air bubble is essential for staining of anterior
capsule. Multiple small air bubbles cause irregular staining tion is completed, the capsulotomy size can be increased
of the anterior capsule. for safe introduction of the lens.
After air is injected into the anterior chamber, with 27
G cannula, 0.2 ml of 0.1% Trypan Blue is injected. After New Developments in Capsulorhexis
5 to 10 secs, the anterior chamber is thoroughly irrigated With technological advances a number of new aids are
with Balanced Salt Solution (BSS) to wash out excess of now available to ensure a safe capsulorhexis. Use of a
dye. Because of blue stain of anterior capsule, the outline radiofrequency probe or Erbium Yag laser are some
of the capsulorhexis is clearly visible. This is easily examples of the same.
distinguished from the underlying grayish white lenticular
tissue thus simplifying capsulorhexis. FURTHER READING
1. Barrett Sible Phacodynamkics, Mastering the two techniques
Capsulorhexis in Small Pupils of phacoemulsification, Second edition, Slack Incorporation,
Los Angeles California.
In cataracts with small pupils, the pupils can be enlarged 2. Cook Davidson, Advanced phacoemulsification technique,
using either the stretching technique or using iris hooks Slack Incorporation California USA.
or by multiple sphincterotomies. Capsulotomy is per- 3. Paul H Cock: Mastering phacoemulsification, 4th ed, Jaypee
formed as usual making the size of capsulorhexis equal Brothers, New Delhi, India.
to just smaller to the pupillary diameter. The edge of the 4. William F Mallony: Textbook of phacoemulsification, 1st ed,
capsulorhexis should be visible. Once phacoemulsifica- 1998.
Hydroprocedures 16 Subodh K Agarwal
INTRODUCTION Epinucleus
Hydroprocedures are equally important in both the This is the “semi-soft” intervening zone between the soft
modalities of small incision surgery-manual non-ultra- superficial cortex and the hard endonucleus. It can either
sonic small incision cataract surgery as well as ultrasonic be expressed or aspirated.
small cincision cataract surgery or phacoemulsification.
In this chapter, when I am going to deal with hydro- Superficial Cortex
procedures at length it will be in the fitness of things that This is comprised of the soft lamellae lying just beneath
we address the subject in both its applications, i.e. the capsular bag. The cortex can only be aspirated.
manual small incision cataract surgery and phacoemulsi-
fication. HISTORY
When you have gone through this chapter you should Hydrodissection was devised or “invented” by Michael
be armed with a wider, broad based perspective of the Blumenthal of Israel who is the father of “Non-ultrasonic
subject. That day is not far off when all cataract surgeons manual small incision cataract surgery.” Its initial aim
will have mastery over both the methods of small incision was to reduce the size of the nucleus to the smallest
surgery-manual and ultrasonic. possible hardcore endonucleus. This small endonucleus
could then easily be tipped out of the capsular bag and
CONCENTRIC ANATOMY OF THE LENS then conveniently expressed out via a small self-sealing
scleral incision.
The epithelial cells of the human crystalline lens are
Ironically this procedure has been used as a stepping
constantly proliferating to create lens fibres. The new
stone in the evolution of ultrasonic small incision surgery
fibres formed at the periphery compress the old and
or modern phacoemulsification.
deeper layers. Thus the inner core constitutes the hardest
part of the nucleus because it has been subjected to Terminology and Classification
maximum pressure for the longest duration.
Hydroprocedures
The lens in cross-section comprises of a concentric
series of elliptical rings. Each ring represents laying down
of additional lens material from the epithelial cells located Hydrodissection Hydrodelineation
on the underside of the anterior capsule.
– Conventional – Manual
For a cataract surgeon it is useful to consider the
– Cortical cleavage (Howard Fine) – Hydrosonic (Aziz Anis)
crystalline lens as having three zones.
– Hydro-free dissection (Gimbel)
Hard Core Nucleus
HYDRODISSECTION
The innermost central core is known as the endonuc-
Conventional Hydrodissection
leus. The hardcore nucleus cannot be aspirated; it can
be (a) Expressed as in ECCE or (b) Fractured as in phaco- This is hydroseparation of the superficial cortex from the
emulsification or (c) Fragmented as in manual small epinucleus. The cardinal reason to perform hydrodissec-
incision surgery. tion is to enable us to rotate the nucleus. The cortical
Hydroprocedures 95
Fig. 16.1a
adhesions are broken so that the nucleus becomes free-

floating in the capsular bag. We can rotate and bring

different parts of the nucleus in front of the phaco tip so
that they can be emulsified.
Basically hydrodissection is the injection of BSS under
the anterior capsular flap so that the fluid dissects around Figs 16.1a and b: Hydrodissection. Courtesy: Alcon (India)
the equator, goes below the nucleus and separates it from
its cortical attachments. If you do not see the posterior
fluid wave and the nucleus does not move anteriorly
then you have not achieved hydrodissection. The endea-
vour is to create a definite plane of separation between
the nucleus and cortical debris that remains attached to
the capsular bag (Figs 16.1a and b).
Technique
First of all a good continuous curvilinear capsulorhexis
is performed. A 27 G blunt cannula is taken on a 2 ml
syringe filled with BSS (Figs 16.2 and 16.3). The cannula
Fig. 16.3: Conventional hydrodissection
enters the eye through the 2.8 mm phaco incision or the

larger incision of manual small incision surgery and the
tip is passed under the anterior capsular rim. A sufficient
amount of fluid is injected so that a posterior fluid wave
is created. Injection of excessive fluid should be avoided.
The acid test of having performed a good and complete
hydrodissection is that you should be able to rotate the
nucleus easily.
In white cataracts and in very dense cataracts the fluid
wave will not be seen but slight forward movement of
the nucleus is a good indication that a complete hydro-
dissection has been achieved.
Cortical Cleavage Hydrodissection

Devised by Howard Fine this is one of the true revolutions
Fig. 16.2: Hydrodissection in cataract surgery (Fig. 16.4). It had been believed for
Fig. 16.4: Cortical cleavage hydrodissection Fig. 16.5: Hydrodelineation feel the resistance
years that the cortex is naturally adherent to the capsule.

Fine observed that after doing capsulorhexis when he
removed the anterior capsule there were no adhesions
between the cortex and capsule.
In cortical cleavage hydrodissection the cannula is
lifted up, tenting the anterior capsule and then the BSS
is pushed in. This technique produces a clear cut cleavage
plane that separates all of the cortex from the capsular
bag. Some fluid gets trapped at the equator because of
dense cortical adhesions. So after the fluid wave is
completed, the nucleus is depressed with the cannula to
release all the trapped fluid into the anterior chamber.
After doing cortical cleavage hydrodissection when
phacoemulsification is performed all of the cotex comes
out with the nucleus. There is hardly any cortex left to be Fig. 16.6: Hydrodelineation completed
removed by I/A.
the cataract. When fluid is injected at this point a
Hydro-free Dissection golden ring is formed which signals the true separation
This is more or less the same as cortical cleavage hydro- of the nuclear layers.
B. Aspirate the superficial cortex and the epinucleus to
dissection. Gimbel has refined this technique-after lifting
reach the hardcore endonucleus which cannot be
and tenting the anterior capsule the tip of the cannula is
aspirated further. Hydrodelineation can now be per-
swept along the potential plane of cleavage; then the
formed by negotiating the tip of the cannula between
fluid is injected as usual creating a cleaner cortical
the endonucleus and epinucleus and then injecting a
cleavage.
small amount of BSS.
Separation of the inner and outer nucleus is extremely
HYDRODELINEATION OR HYDRODEMARCATION
helpful both in manual small incision surgery and in
This term stands for separation of the inner hardcore phacoemulsification.
endonucleus from the overlying epinucleus by fluid In manual small incision surgery a small inner nucleus
injection (Figs 16.5 and 16.6). is isolated and can be more easily tipped out of the bag
and then removed out via the self-sealing incision. In
Manual phacoemulsification the shell of soft outer nucleus acts
There are two methods: as a very effective protective barrier for the posterior
A. The cannula is pushed right into the body of the capsule. It saves the posterior capsule from damage by
nucleus. The tip passes through the soft outer nucleus the razor sharp edges of the hard endonucleus as well as
and meets with resistance when it hits the hard part of by the sharp phaco tip.
Hydroprocedures 97
Hydrosonic Hydrodelineation DISCUSSION
Aziz Anis (USA) devised a special hydrosonics handpiece The nomenclature of inner and outer nucleus or endo-
by which he used small bursts of ultrasound to bury the nucleus and epinucleus is not important. The all impor-
tip deep into the hard endonucleus. Then BSS is injected tant point is appreciation of the concept that within
at various depths to decompact and hydrate a very hard the cataract there is a point where a fluid dissection can be
nucleus. This helps in easier phacoemulsification of very made isolating an inner nucleus from an outer nucleus.
hard nuclei. The endonucleus is hard in both ways (a) Physically
the hardest part of the cataract (b) It represents the hardest
or most difficult part of cataract removal.
COMPLICATIONS OF HYDROPROCEDURES
Hydrodissection and hydrodelineation should be
A. Pressure generated by the fluid may lead to extension performed in every cataract procedure as far as possible.
of an irregular capsulorhexis or a can opener capsulo- In young and soft cataracts it is better to do hydrodis-
tomy upto the equator and even beyond it. The need section alone. Performing hydrodelineation in such cases
for a good CCC cannot be cover emphasised both leaves us with a thick outer nuclear shell which is stickly
and very difficult to manipulate. In posterior polar

for manual small incision surgery and phacoemulsi-
cataracts it is better to do hydrodelineation alone; per-
fication.
forming hydrodissection in such cases is catastrophic.
B. Injection of excessive fluid during hydroprocedures
We should realise that mastering the techniques of
may raise the intralenticular pressure to such a high
hydroprocedures should be the endeavour of all cataract
level that the posterior capsule may give way and the surgeons.
nucleus may sink into the vitreous cavity.
C. In posterior polar cataracts even gentle hydrodissection FURTHER READING
may lead to dehiscence of the posterior capsule in the 1. Eisner G: Eye Surgery: An Introduction to Operative
centre. In such cases only hydrodelineation should Technique (2nd ed). Springer-Verlag, Berlin: 288-95, 1990.
be attempted 2. Koch, Davidson: Advanced Phacoemulsification Techniques
D. At times the nucleus or even the entire lens may prolapse Slack Inc, New Jersey, 1991.
out of the bag into the anterior chamber. This is a 3. Seibel BS: Phacodynamics: Mastering the Tools and Tech-
niques of Phacoemulsification Surgery (Ist ed) Jaypee
welcome development if manual small incision surgery
Brothers, New Delhi, 1995.
is attempted. If phacoemulsification is planned, the 4. Sunita Agarwal et al: Phacoemulsification, Laser Cataract
nucleus may gently be patted back into the capsular Surgery and Foldable IOL’s. Jaypee Brothers, New Delhi:
bag. 1998.
Nucleus Prolapse
from Capsular Bag
17 RP Singh
BK Singh
BN Chaudhary
S
mall incision cataract surgery differs from slightly and BSS injected creating a cleavage between
conventional ECCE and phacoemulsification the soft fibre of the epinuclear shell and more dense
cataract surgery in that the nucleus needs to be portions of the central nucleus. When a complete
essentially prolapsed into the anterior chamber from the hydrodelination is performed a golden ring is sometimes
capsular bag before delivering it through the incision. observed. Hydrodelination not only reduces the size of
Hence prolapse of nucleus in the anterior chamber is the nucleus but also facilitates nucleus rotation and
the most important and sometimes a difficult step in nucleus prolapse into AC from the capsular bag.
manual phaco, taking into consideration the integrity of
the capsular bag the vitreous face and corneal endothelial Nucleus Rotation and Prolapse of Nucleus
damage. However, in envelope technique the nucleus is Without nucleus rotation and nucleus prolapse, manual
not fully taken out of the capsular bag but is rotated in phaco cataract surgery can never reach its culmination.
the bag and the upper pole is brought above the iris There are various techniques described and practiced.
plane out of the capsular bag. The few preferred ones are discussed below:
For prolapsing the nucleus in anterior chamber,
hydrodissection and hydrodelination are very essential Tipping up Technique
steps. Hydrodissection separates the peripheral cortex
The key to this procedure is proper tipping up of the
from the capsule and makes the nucleus free in the
nucleus out of the capsular rim and above the iris plane.
capsular bag, while hydrodelination separates the nucleus
The iris is retracted with a collar stud hook. Then the
from cortex and peri-nucleus thus reducing the size of
capsule and iris are held with a 1.0 mm iris spatula and
nucleus making its delivery possible through smaller
the nucleus is nudged towards six O’clock with the collar
incision.
stud hook. This lowers the superior pole of the nucleus
For hydrodissection the Balanced Salt Solution (BSS)
and the equatorial rim becomes visible away from the
is injected through 27G cannula. The cannula is placed
iris margin. The superior pole of nucleus is tipped up
about 2 mm distal to the edge of capsulotomy or
capsulorhexis and BSS injected. If red reflex is visible the with iris spatula. The viscoelastic is injected between the
fluid wave is seen passing along the posterior capsule all nucleus and post capsule. The nucleus is then rotated
around. The visualisation of fluid wave ensures that with iris spatula and is eventually prolapsed into anterior
hydrodissection is complete. The BSS is injected in chamber (Fig. 17.1).
different directions. Every time the BSS is injected the Tyre Levering Technique
lens should be slightly tapped posteriorly so that the fluid
does not collect posteriorly leading to posterior capsule If the nucleus is larger than the capsulorhexis or capsulo-
rupture. A good hydrodissection makes the nucleus tomy, prolapsing the nucleus is quite difficult. Tyre
rotation and nucleus prolapse very easy. levering technique is useful in this difficult situation. A
After hydrodissection, hydrodelination is performed 7.0 mm nucleus can be removed out of 5.0 mm capsu-
separating the nucleus from epinucleus. For lorhexis. First of all the free rotation of nucleus is ensured
hydrodelination the cannula is introduced deeply into after good hydrodissection and hydrodelination. The
the mid-periphery of the lenticular nucleus until the hard nucleus can be rotated with iris spatula or 30G irrigating
core of nucleus is reached. The cannula is withdrawn cannula.
Nucleus Prolapse from Capsular Bag 99
Fig. 17.1: Nucleus prolapse with the help of Fig. 17.2: Tipping technique to nucleus prolapse
lens loop/irrigating vectis
The nucleus is nudged posteriorly towards the poste- endothelium. The lens lies upside down in the anterior
rior capsule at nine O’clock equator so that the three chamber. Ample amount of visco-elastic is now put above
O’clock equator comes out of the capsular rim slightly. and below the nucleus suspending it in a pool of visco-
The nucleus is then lifted up at three O’clock with iris elastic. This separates the nucleus from the corneal
spatula and rotated out of the capsular bag as tyre is endothelium and prevents endothelial damage (Figs 17.3
taken out of its rim (Fig. 17.2). and 17.4).
Tumbling of the Lens Other Methods

In this technique the freely rotating nucleus is tumbled There are other methods with slight modifications, which
along the vertical meridian by using the visco-elastic various surgeons are using according to their choice and
cannula. The viscoelastic or BSS is injected under the size of the nucleus, capsulotomy/capsulorhexis and
anterior capsular rim at nine O’clock. The viscoelastic or pupillary aperture.
BSS travel along the equator over the posterior capsule A. In this method, a 20G irrigating cannula attached to
towards the opposite side. The pooling of viscoelastic or BSS bottle is used. The cannula is inserted facing
BSS behind the nucleus pushes the nucleus out of the downward under the capsule at different places, i.e.
rim at three O’clock. The nucleus is further pressed at three O’clock, six O’clock or nine O’clock positions.
nine O’clock, which pops the nucleus at three O’clock. The cannula is positioned deep upto the equator. The
The cannula is now sweeped from nine to three O’clock fluid passes between the nucleus and posterior capsule
along the posterior capsule. This tumbles the lens and and pressure builds up in the capsular bag. The pres-
brings the posterior lens surface towards the corneal sure of the fluid pushes the pole of the nucleus out of
Fig. 17.4: Nucleus prolapse by using iris retractor

and hydrodissection cannula
Fig. 17.3: Nucleus prolapse by visco-expression
O’clock. With the viscoelastic cannula the nucleus is
the capsular rim and pupillary border. Viscoelastic is
rotated out of the capsular bag in the anterior chamber.
injected under the pole of the nucleus, which further
All the above mentioned methods of nucleus prolapse
pushes it out of the capsular rim. The nucleus is rotated
have only small differences and they are used according
with the viscoelastic cannula and this brings whole of
to the situation. The basic principle is taking the nucleus
the nucleus in anterior chamber.
out at anyone of the poles and then prolapsing the rest
B. This method is utilised in complicated cases where
of the nucleus out of the capsular bag by various
nucleus is large or pupil is small and it is difficult to
methods.
prolapse the nucleus. With an iris retractor in the
Apart from incision construction, prolapse of the
dominant hand the iris and capsule is retracted at
nucleus in anterior chamber is the most unique and
twelve O’clock position and simultaneously the
important step of manual phaco surgery and needs to
posterior rim of the scleral incision is pushed slightly
be done meticulously and carefully, otherwise, there is
downward. With the other hand, hydrodissection
always a possibility of posterior capsular rupture and
cannula on an empty 2 ml syringe is passed through
damage to corneal endothelium.
two O’clock side port incision towards six O’clock
position under the rim of anterior capsule.The six FURTHER READING
O’clock pole is pressed downward, which tumbles up 1. Shah Anil: In Small Incision Cataract Surgery (Manual Phaco)
the twelve O’clock pole out of the capsule rim. The Bhalani Pub: India 62-67, 2000.
retractor is removed and visco-elastic is injected 2. Natchiar G: Manual Small Incision Cataract Surgery. Arvind
between the nucleus and posterior capsule at twelve Publications: India 21-24, 2000.
The Phaco Sandwich Technique 101
The Phaco
Sandwich Technique
18 Kamaljeet Singh
F
ry is credited with the phaco sandwich technique. phrine combination and flurbiprofen eye drops. These
This technique is simple, allows removal of lens are instilled 1 hour before the surgery. Author suggests a
through a 6.0–6.5 mm self-sealing scleral tunnel conventional ECCE if the pupil is less than 5 mm in
incision, produces much less astigmatism compared to diameter at least in initial 50 cases. Acetazolamide one
extracapsular cataract surgery and is sutureless. The tablet is given 2 hours prior to surgery. Some surgeons
author has adopted this technique for over 5 years and avoid acetazolamide as it causes hypotony.
results have been gratifying.
Anaesthesia
Instruments
A peribulbar anaesthesia with a cocktail of 3 ml of xylo-
Essentially the instruments required are similar to what caine with adrenaline and 3 ml bupivacaine mixed with
an ECCE surgeon requires. Additional instruments are. hylase is used. Superpinky ball or ocular massage for
• Crescent knife long is not recommended as it produces hypotony.
• 3.2 mm angled keratome
• 5.2 mm keratome Surgical Steps
• Irrigating vectis
1. After applying speculum and holding superior rectus
• Sinskey type dialer, iris repositor
• AC maintainer fornix based conjunctival flap is made (Fig. 18.1).
Careful bipolar cautery should be carried out. It gives
Preoperative Preparation a bloodless field to operate and there is no
inadvertent bleeding during the making of scleral
The essential thing in this surgery is wide dilatation of
tunnel, but overenthusiastic cautery should be
pupil, which allows easy prolapse of the nucleus in ante-
avoided as it causes astigmatism.
rior chamber and prevents iris entrapment during delivery
2. 6 to 7.5 mm partial thickness scleral tunnel incision
of nucleus. Pupil dilatation and its maintenance in dilated
is made 2 mm behind limbus. Harder the nucleus
status is achieved by instilling tropicamide and phenyle-
longer is the incision. In initial 25 patients longer
incision is recommended to avoid unnecessary
touch to the corneal endothelium. The scleral pocket
is made with crescent knife (Fig. 18.2). Disposable
crescent blades are the best. Their reuse might lead
to a poor tunnel. This is the single most important
step in this surgery. Therefore, no compromise
should be accepted. Scleral pocket is extended in
the corneal stroma. While making scleral tunnel
sclera induces greater resistance than the cornea.
Therefore, the surgeon should become very gentle
while entering the cornea. Otherwise it may lead to
early entry into the anterior chamber causing poor
corneal valve. The corneal tunnel should be up to
Fig. 18.1:Size of the conjunctival flap 1.5 mm from the limbus and as suggested by
Fig. 18.2: Tunnel length with crescent blade Fig. 18.3: Extension on other side
Fig. 18.4: Dimple at the cornea just before entering AC Fig. 18.5: Entry into AC by 3.2 angled keratotome
Blumenthal incision should be 2 mm wider than suggests can-opener and envelope technique in
the scleral tunnel (Fig. 18.3). The crescent should initial few cases, because the prolapse of the nucleus
be swept with pressure away from anterior chamber. in AC becomes easier. Size is important in case one
3. Entry into the anterior chamber is made with an prefers to make capsulorrhexis. 0.1 ml trypan blue
angled 3.2 mm keratome. Angled keratome should dye is injected beneath the air bubble through the
be sharp. Blunt keratome leads to Descemet’s side port (Figs 18.6 and 18.7). It should not be less
detachment. A dimple is seen when pressure of than 6.5 mm and slightly eccentric on the upper
keratome is applied towards anterior chamber (Fig. side. Both these things will help in prolapse of the
18.4). The movement should be controlled otherwise nucleus in the AC. In case the capsulorhexis is small,
it may hit the capsule and capsulorhexis would be whole nucleus with capsular bag can come in the
difficult to make in this condition (Fig. 18.5). AC. Then it would be intracapsular rather than
4. Viscoelastic is injected into the anterior chamber (Fig. extracapsular surgery. One should take precaution
18.8). Here the care should be taken to slightly press here. Other way round too large a capsulorhexis
the scleral side so that the aqueous can come out might extend into the periphery (Fig. 18.8).
and only the viscoelastic remains. It will make the 6. Hydrodissection Aim of hydrodissection is to see that
anterior capsule taut and capsulotomy becomes all adhesions between cortex of lens and capsule
easier. are broken and a free rotating nucleus is visible. The
5. Capsulotomy Any types of capsulotomy can be technique of hydrodissection has been described
done in SICS-can-opener, envelope or capsulo- elsewhere. Two points need to be mentioned here.
rhexis—all are useful (Fig. 18.9). In fact author Do not try to strain the zonules by pushing your
Fig. 18.6: Scleral incision with single air bubble Fig. 18.7: Dye being injected under the
air bubble from side port
Fig. 18.8: Capsulorhexis with Trypan blue Fig. 18.9: Extension of incision with 5.5 mm keratotome
rotating instrument too hard. If hydrodissection is The moment, rim of nucleus is visualized, the
complete there is no difficulty in rotating the nucleus. cannula is brought below the rim of nucleus; and
If rotation is difficult, it means incomplete hydro- again viscoelastic is injected in between the nucleus
dissection. So, inject more fluid beneath the anterior and perinucleus. The upper pole of nucleus will
capsule and retry the rotation. Secondly, fluid prolapse in the AC. In small pupils one can depress
injection should be slow and only optimum amount the nucleus at five O’clock with the cannula. The
should be injected. Hydrodelineation is a must in upper pole at 11 O’clock, then can be seen easily.
SICS. It helps in debulking the nucleus and delivery Now the nucleus is rotated towards 12 O’clock. Thus
of nucleus through smaller incision becomes easier. achieving the aim of prolapse of upper pole of
7. The incision is enlarged with the help of 5.5 mm nucleus (Fig. 18.11). Once you are sure about
angled keratome after injecting sufficient amount of prolapse of nucleus in AC inject more viscoelastic
viscoelastic (Figs 18.9 and 18.10). between the cornea and anterior surface of nucleus
8. Nucleus prolapse in AC This is single important step and also behind the nucleus This maneuver requires
in a successful SICS. Nucleus prolapse is easier if copious use of viscoelastic to prevent injury to the
the pupil is widely dilated and a good rotation of corneal endothelial cells. Once this is achieved the
the nucleus is achieved after hydro-dissection. In nucleus is now ready for delivery.
initial few cases it is easier to prolapse nucleus in 9. Delivery of nucleus The author uses irrigating vectis
AC, if can-opener or envelope type of capsulotomy and a Sinskey type of dialer but the difference here
has been done. The nucleus is prolapsed by rotating is that it is like a hammer at the end and much thicker
the nucleus after filling the chamber with viscoelastic. than the dialer (Fig. 18.12). Thus it has blunt end,
Fig. 18.10: Enlarged incision for accomodating nucleus Fig. 18.11: Nucleus prolapse in AC only upper pole
Fig. 18.12: Irrigating vectis and dumbel Fig. 18.13: First enter with dumbel, on anterior surface of lens.
Second instrument is irrigating vectis, which enter behind the
nucleus
which prevents posterior capsule rupture. The author
calls it a dumble. Fluid flow through the vectis is
checked. First thing is to enter anterior chamber
through the incision with the dumble in your left
hand (Fig. 18.13). This is kept at the center of
nucleus. No pressure is applied. Then the irrigating
vectis is passed behind the posterior surface of
nucleus in such a way that the nucleus is sandwiched
between these two instruments. The pressure is
applied from below the nucleus and also on the
anterior surface of lens. At the same time the
sandwiched nucleus is brought out of the wound
(Figs 18.14 and 18.15). Two things will results. If
the lens is soft it will come out in one go. If it is hard
it may break into several pieces. A part of that will Fig. 18.14: Nucleus sandwiched between
come out sandwiched between two instruments. irrigating vectis and dumble
Remaining pieces of nucleus are taken out by either
viscoexpression or by holding the pieces with should always have viscoelastics in front of them.
Mcpherson’s forceps. One needs to be very cautious In case one finds difficulty in delivering out the
here as the anterior surface of nucleus or its pieces nucleus the incision length needs to be increased.
Fig. 18.15: Nucleus being delivered through tunnel Fig. 18.16: Expression of perinucleus
sandwiched between irrigating vectis and dumbel
Fig. 18.17: Cortical wash Fig. 18.18: Perinucleus being expressed out of tunnel
Fig. 18.19: View of clean posterior capsule after cortical wash Fig. 18.20: Conjunctiva is reposited back
This problem is normally encountered in brown hard which is connected to a BSS bottle by an infusion
cataracts. Rarely in very big nucleus the tunnel has set. Cannula is opened with full flow. Take this free
to be abandoned and a routine ECCE is performed. flowing cannula to 6 O’clock slight pressure on the
10. Remaining debris is perinucleus and cortical matter posterior lip of the tunnel by the cannula will
These are removed by two-way Simcoe cannula, prolapse the perinucleus out of the wound. Remain-
ing material is cortex. A part of this will come out 13. Gentamicin and decadron injection is instilled on the
with perinucleus by hydroexpression. Cortical fibres top of conjunctiva. There is no need of giving any
are then aspirated (Figs 18.16 to 18.18). The details subconjunctival injection.
are discussed elsewhere.
11. After the posterior capsule has been washed and
FURTHER READING
no fibres are left, intraocular lens is implanted as
usual (Figs 18.19 and 18.20). 1. Luther L Fry: The Phaco sandwich technique: In George W
12. Conjunctiva is reposited back by holding the Rozakis et al (Eds): Cataract Surgery Alternative Small-
conjunctiva with two forceps. Cautery is then applied Incision Techniques. Thorofare Inc, 71-110, 1995 Indian
at two ends (Fig. 18.20). edn.
Modified Fish Hook Technique 107
Modified
Fish Hook Technique
19 Rajeev Vaish
F
or the first time the author learned this technique • A single 26 G needle is used for this purpose. 26 G
in Nepal from Dr Hennig, where thousands of needle is bent like a hook 2 mm proximal to the bevel
cataract surgeries are performed by a simple edge (Fig. 19.1). The bevel edge of eye should be
technique through a 26G needle. The author modified facing outward. It resembles a fishhook. After that the
this technique and performed several operations with needle is again bent at right angle to the initial bend,
great satisfaction. so that the hook faces right or left side (Fig. 19.2).
Surgical instruments required for this technique are Angulation of this bent may be 100 to 130 degrees, it
described below: acts like a lever while removing nucleus from the
A. For scleral pocket incision: capsular bag.
• Castroviego type of calipers Instrument for Aspiration of Residual Cortex
• For Scleral groove straight blade diamond knife
with 45 degree angulation. • Simcoe cannula regular type
• Under mining forward of tunnel by scleral
Instrument for IOL Insertion
pocket crescent knife with 60 degree angulation.
• A/C entry with 3 mm keratome. • MacPherson forceps for rigid PMMA IOL implant
• Side port entry blade 15 degree straight. • Inor lens folder for foldable IOL implants
• Section enlarging blade 5.5 mm with 60 degree • Inor lens inserter.
angulation at shaft
B. Instruments for capsulotomy: Preoperative Clinical Examination
• Utrata forceps A thorough history and general examination is done in
• 26 gauze needle following order :
C. Instruments for hydroprocedures: 1. Visual acuity examination to exclude uniocular patient
• Hydrodissection cannula 26 gauge with 45 and include patient with accurate PL and PR.
degree angulation with flat tip 2. Slit lamp microscopy—All the patients are subjected
• Hydrodelineating cannula to preoperative slit lamp microscopy on slit lamp. A
• J shaped hydrodissection cannula for 12 O’clock careful note of the following findings is made.
D. Instrument to deliver the nucleus (Manipulation a. Pre-existing corneal scars that might interfere with
of nucleus) the keratometry.
Fig. 19.2: Right angle rotation of hook → 2nd bend of

Fig. 19.1: Straight 26 G needle → 1st bend to make a hook 100-130 degree at shaft
b. Pre-existing corneal endothelial dystrophy, i.e. Anterior Capsulotomy

Fuch’s or corneal guttata that might lead to cor-
Anterior capsulotomy is done using a 26 G needle bent
neal decompensation.
and twisted to act as a cystitome. The AC is entered
c. A rough idea of the filtration angle by measuring
through a side port usually at about 2 O’clock position.
the distance between cornea and the iris.
The AC is kept deep and formed using a viscoelastic
d. Status of pupillary dilation to exclude uveitis. substance. A straight or envelope type of capsulotomy is
e. Grading the nucleus for its toughness by noting the performed at 12 O’clock position.
colour.
f. Subluxation of lens to be reserved for plain ICCE Hydrodissection and Hydrodelineation
only.
3. Syringing of all selected cases. Hydrodissection is performed using a 1cc syringe and a
4. Intraocular tension with Schiötz tonometer. cannula in which the bent part is 4 mm and tip is flattened.
5. Conjunctival smear to exclude any infective microbe. The cannula slides along the exposed hard core nucleus,
6. Routine hemogram and complete urine examination. is inserted obliquely at 12 O’clock into the junction of
the hard core nucleus and epinucleus and 0.1-0.3 cc of
7. Keratometry is done preoperatively in both steep and

flatter meridian to record the measured astigmatism. BSS is injected.
8. A scan biometry is done in all cases to know exact The BSS hydrodissection creates a demarcation line,
IOL power. A high axial length denotes high myopia. usually clearly seen by the light reflection (golden ring)
created between the nucleus and the epinucleus, or
A scan biometry can also exclude retinal detachment
between the epinucleus and the cortex.
in the cataractous eye.
Anterior Chamber Entry
Method
Anterior chamber is entered by a keratome blade at
Lid and globe akinesia is obtained by peribulbar anaes-
12 O’clock position and chamber is filled with visco
thesia.
elastic. Now the section is enlarged by 5.5 mm wide sec-
Lid retraction by barraquer wire low-tension speculum
tion enlarging blade. The configuration of this entry
and superior rectus suturing is done as usual.
should be smile type and size varies according to the
pre-evaluated size of the nucleus.
Surgical Technique
A fornix based conjunctival peritomy is done between Technique of Nucleus Delivery
10.30 to 1.30 O’clock position, superficial scleral blood Intracapsular tumbling of nucleus with (fish) hooked
vessels are cauterized. extraction of nucleus.
After extending the inner incision like a smile fashion,
Scleral Tunnel Incision
a 26 G needle bent like a hook in mounted on a 2 cc
After maintaining haemostasis, a 5.5 to 7 mm of half viscoelastic filled syringe. We enter in the A/C injecting
thickness scleral groove, 1.5 mm behind the limbus is visco to make it deep. A downward pressure by hook
made by a diamond knife. The shape of incision should and visco is applied at 12 O’clock position on the nucleus,
be frown or antismile. through linear capsulotomy site. By this manoeuvre the
Scleral dissection is performed by a symmetrical nucleus at 12 O’clock is pushed downward and inferiorly.
biconvex dissector knife angled 60 degrees having sharp Later on it will tumble inside the bag and hook goes
cutting edges on both sides. posteriorly to nucleus. This time we should inject 1 ml
Scleral dissection is of half thickness in a given lamella visco inside so that the posterior capsule is pushed back.
upto 1 mm of clear cornea. This creates a triplanar valve A space is thus created to move the tip of hook anteriorly
type of self-sealing incision. At 2.30 O’clock position, the to get embedded in mid-substance through posterior
anterior chamber is penetrated by a sharp 15 degree surface of nucleus.
angulated side port blade and viscoelastic hydroxymethyl After hooking the nucleus we should inject more
cellulose 2 per cent is injected in anterior chamber This viscoelastic that makes a positive pressure inside and this
incision is used for entry of manipulation instruments positive pressure and a little active extracting pressure
like capsulotomy needle, hydrodissection, hydrode- by hook delivers the nucleus outside the bag and directly
lineation cannula and manipulation of lens. engages it in the scleral tunnel.
Modified Fish Hook Technique 109
Hydrodissection and Viscoelastic assisted pressure Intracapsular tumb- Hook lies behind Hook embedded in
rotation of nucleus at 12 O’clock by hook ling of nucleus nucleus and extracting the scleral tunnel
in the bag shaped needle position it out scleral tunnel
A slight more passive (visco assisted) and active (of Suture Application
hook) pressure helps in extraction of nucleus from the Scleral tunnel incisions are self-sealing incisions that’s
tunnel. It should be always kept in mind that every step why we apply no or a single suture according to need
of nucleus manipulation a pre-judged amount of visco- and size of incision. At the end of procedure either BSS
elastic is injected gradually making nucleus tumble inside solution or single air bubble is injected. At the same time
the bag and deliver it through scleral tunnel. A well-bal- pressure is applied on the eye globe to check the integrity
anced passive pressure of viscoelastic and active move- (leakage) of wound.
ment of hook is the key to success of this procedure.
The case in which difficulties are found during nuclear
Follow-up
manipulation should be converted into standard ECCE
by increasing the length of incision. All the patients are followed up upto two months at
After thorough cleaning of capsular bag and polishing weekly interval and corneal condition, Keratometry,
of posterior capsule, depending on the size of incision, a visual acuity and any other complications are noted and
foldable silicone introaocular lens, or a 6 mm optic or a analysed. In all visits postoperative problems and
phacolens of 5 mm optic are introduced through scleral complications like iritis and corneal oedema are observed
tunnel and placed inside capsular bag. and treated accordingly.
Manual
Phaco-fracture
20 Rajesh Sinha
Prashant Bhartiya
Rasik B Vajpayee
M
odern cataract surgery aims at the visual Small incision cataract surgery (non-phaco) is a cost
rehabilitation of the patients in a minimally effective alternative to phacoemulsification. It combines
invasive manner. The final goal is the removal the advantages of small incision surgery with the low
of the contents of the capsular bag through the smallest cost of instrumentation.
possible incision, and the implantation of a suitable Advantages of Small incision cataract surgery:
intraocular lens into the bag. Small incision cataract 1. Less astigmatism
surgery has contributed immensely to accelerated wound 2. Early wound stabilization and early rehabilitation
healing and minimization of hospital stay of the patient. 3. Low cost of surgery
Two of the main goals of cataract surgery in recent times 4. Shorter learning curve
are to minimize induced astigmatism and achieve rapid There are basically two principle ways of extraction of
visual recovery. The smaller the surgical incision, the cataract by small incision non-phaco surgery. They are:
lesser is the residual postoperative astigmatism. With the (1) extraction of the nucleus as a mass without
advent of the current technique of phacoemulsification, fragmentation,1,2 and (2) extraction of the nucleus after
and the development of today’s state-of-the-ar t fragmentation.3,4,5
phacoemulsification machines, phacoemulsification, is
Surgical Techniques
today, the surgery of choice for extraction of senile
cataract. Phacoemulsification allows the removal of a Various surgical techniques of small incision cataract
nucleus of 6-8 mm size through an incision size of 3 mm surgery sans phacoemulsification have been described.
or less. However, the expensive instrumentation and The principle of small incision cataract surgery involves
prolonged learning curve involved with phacoemulsi- reducing the size of the nucleus. This can be achieved
fication are its major limitations, particularly in developing either by hydro-maneuvers6,7 or by breaking the nucleus
countries. into pieces by various nucleo-fracture techniques.
If extracapsular cataract extraction (ECCE) is
performed through a small self-sealing incision, Nucleo-fracture Techniques
postoperative visual recovery and stability can rival that Kansas and Sax3 initially described phaco-fragmentation
of phacoemulsification. techniques. These are technically more complex than the
During late 1980s, manual fragmentation techniques techniques of nucleus removal without fracture. This
of the nucleus began to appear as an alternative to involves removal of the nucleus by breaking it into smaller
phacoemulsification. In manual phaco-fragmentation chunks so as to allow their removal through a smaller
techniques, incision size depends on the dimensions and incision than that required for a conventional ECCE or a
hardness of the nuclear fragments to be extracted from small incision manual ECCE without nucleo-fracture.
the anterior chamber. Usually, the nucleus is divided into A frown shaped scleral groove perpendicular to the
2 or 3 fragments, which is then viscoexpressed through eyeball surface and of uniform depth of about half
the incision. Soft cataract can be extracted through a 4.0 thickness of sclera is made. The ends of the frown are
to 4.5 mm incision. With hard nuclei, it is usually approximately 3mm from the limbus while its central
necessary to increase the wound size to avoid damaging convexity is 1.5mm from the limbus. This frown incision,
the iris and corneal endothelium. which confines itself to within the astigmatic neutral zone,
Manual Phaco-fracture 111
provides the best results from astigmatic point of view. moving the tips of the two instruments towards each other
The length of incision varies from 5 to 6 mm depending with a constant force, the nucleus is fractured. These
upon the size of intraocular implant. This incision is then nuclear fragments are then visco-expressed and the
tunneled by the use of crescent knife so that the tip of remaining cortical material is aspirated with a Simcoe
the blade should be 1mm into the clear cornea. The cannula.3,4 Maintenance of the anterior chamber is the
anterior chamber is entered by a 3.2mm angled main surgical concern so as to avoid damage to the
keratome. A side port is made with the microvitreoretinal corneal endothelium or the posterior lens capsule. This
blade. is taken care either by an anterior chamber maintainer
A large continuous curvilinear capsulorhexis of (ACM) or by repeated injections of viscoelastic material
approximately 7.0 mm is made using 26G needle. A large into the anterior chamber.
capsulorhexis is essential for prolapsing the nucleus into A pre-chop technique8 has been described in which
the anterior chamber. If the capsulorhexis is small, a the nucleus is chopped into smaller pieces using a sharp
radiating cut to the capsulorhexis edge is made at the 12 chopper. The fragments are then visco-expressed. Risk
o’clock position to facilitate the prolapse of the nucleus. of damage to the posterior capsule while using this
Hydro-dissection and hydro-delineation are essential technique can be reduced with the use of a lens vectis or
for freeing the nucleus from the surrounding epinucleus slide behind the nucleus.
and cortex so that it can be easily prolapsed into the Keener’s9 stainless steel loop and Quintana’s10 3-0
anterior chamber without excessive stress. The nylon loop techniques involve snaring the nucleus and
hydrodissection cannula is placed under the anterior cutting it into smaller pieces before removal.
capsule, the capsule is tented and small amount of fluid Another technique called manual multi-phaco-
is injected. This is repeated in all the quadrants. After fragmentation (MPF) with a racquet shaped nucleotome
every injection the nucleus is gently pressed so that fluid and spatula has been described.11 A 3.2 mm clear corneal
seeps out and does not tear the posterior capsule. incision was made and the spatula was placed under
Hydrodissection should be avoided in posterior polar and the nucleotome on top of the nucleus. The nucleus
cataract. Hydro-delineation is done with a 26G cannula was fragmented into 4 pieces by pressing the nucleotome
by repeated strokes going deeper into the nucleus. The against the spatula. These pieces were extracted out using
end point of hydro-delineation is the appearance of a a sandwich technique by removing the two instruments
golden ring. together. Right and left manipulators were used to
The anterior chamber is deepened with viscoelastic displace the remaining fragments for fur ther
(sodium hyaluronate or hydroxypropyl methylcellulose) fragmentation and extraction. This maneuver was
and the nucleus is gently pushed at one end. If the hydro repeated until the whole nucleus was fragmented.
procedures have been done properly and the nucleus is Another instrument devised for use through a 3.2mm
free, it will lift up at one point. It is prolapsed into the incision is the Akura 5 nucleus puncher. It has the
anterior chamber by repeated strokes by hydrocannula. advantage that it need not be inserted beyond the center
Viscoelastic is injected both behind the nucleus as well of the nucleus during nucleus fragmentation, can be used
as in front of the nucleus to protect the posterior capsule safely in hard cataracts and can be used with one hand.
and the endothelium. The whole incision is made full- Pieces of the nucleus are punched out and this technique
thickness with a keratome. The nucleus is fractured by is called the ‘quarters extraction technique’.
using Kansas trisector (Fig. 20.1) and Kansas vectis Epinucleus and most of the cortex can be removed
(Fig. 20.2). The trisector is positioned above the nucleus by hydro-expression. Residual cortical matter is removed
and Kansas nucleus vectis placed under the nucleus. By by irrigation-aspiration by a Simcoe cannula. The
intraocular lens is implanted. Stromal hydration of the
tunnel and the side port is done. This prevents the need
of any suture.
Fig. 20.1: Kansas trisector Complications

Apart from the routine surgical and postoperative
complications that can be seen during any cataract
surgery, certain specific complications can occur during
Fig. 20.2: Kansas nucleus vectis the procedure of manual nucleofracture. Here we will
discuss the complications that are specific to and more sphincterotomies. An excessive manipulation of iris can
commonly seen in this procedure. result in iridodialysis and cyclodialysis.
Intraoperative Complications Postoperative Complications
Posterior capsular rupture Posterior capsular (PC) Corneal edema Central corneal edema is more com-
rupture may occur during hydrodissection or while trying monly seen with this procedure in the immediate post-
to push the vectis between the nucleus and posterior operative period. This is related to the increased endo-
capsule. It can be avoided by hydroexpressing the nucleus thelial loss during the surgery.
out of the capsular bag and then pushing the posterior High intraocular pressure Intraocular pressure has been
capsule well away from the nucleus by viscoelastic. If found to be high in the immediate postoperative period
there is a PC tear, the rent is plugged and the bag inflated in a number of cases undergoing manual phacofracture.
with viscoelastic. Dry aspiration of the cortical matter is This can be explained by the large amount of viscoelastic
done with a Simcoe cannula. A posterior chamber lens used during the surgery. Another factor that can lead to
is implanted in the bag if the tear is small and central. In high postoperative intraocular pressure is the large
case of a large tear, vitrectomy is performed and a amount of pigment release that occurs during surgery.
posterior chamber lens is placed over the anterior
Pupillary distortion Intraoperative iridodialysis or
capsular rim.
cyclodialysis or multiple sphincterotomies if done, can
Posterior dislocation of the nucleus If further manipu- result in distortion in the pupillary size and shape.
lation is done in the presence of a large PC rent, then
there is the risk of nucleus dropping behind in the vitreous REFERENCES
cavity. It is rarely seen and is appropriately managed by 1. Blumenthal M, Ashkenazi I, Fogel R, Assia EI: The gliding
a vitreoretinal surgeon in the same sitting or the wound nucleus. J Cataract Refract Surg 19: 435-37, 1993.
is closed and the patient referred to a vitreoretinal surgeon 2. Fry LL: The phacosandwich technique. In: Rozakis GW, Ed,
later. Cataract Surgery; Alternative Small-Incision Techniques.
Thorofare, NJ Slack, 91-110, 1990.
Descemet’s tear Tear in descemet’s membrane can 3. Kansas PG, Sax R: Small incision cataract extraction and
occur due to rubbing of large nuclear fragments against implantation surgery using a manual phacofragmentation
technique. J Cataract Refract Surg 14: 328-30, 1988.
the endothelium during delivery. It can be prevented by
4. Vajpayee RB, Sabharwal S, Sharma N, Angra SK: Phaco-
keeping the anterior chamber full with viscoelastic during fracture versus phacoemulsification in eyes with age-related
nucleofracture and delivery as well as ensuring that the cataract. J Cataract Refract Surg 24: 1252-55, 1998.
direction of pull of the vectis should be in the plane of 5. Akura J, Kaneda S, Ishihara M, Matsuura K: Quarters
the scleral tunnel. extraction technique for manual phacofragmentation. J
Cataract Refract Surg 26: 1281-87, 2000.
Frequent shallowing of anterior chamber The anterior 6. Blumenthal M, Ashkenazi I, Assia E, Cahane M: Small-
chamber shallowing and collapse is quite frequently seen incision manual extracapsular cataract extraction using
owing to excessive manipulation and use of multiple selective hydrodissection. Ophthalmic Surg 23: 699-701,
1992.
instruments in the anterior chamber. It can be avoided
7. Akura J, Kaneda S, Hatta S, Matsuura K: Manual sutureless
by frequently injecting viscoelastic in anterior chamber cataract surgery using a claw vectis. J Cataract Refract Surg
or by using an anterior chamber maintainer (ACM). 26: 491-96, 2000.
8. Akahoshi T: Phaco pre-chop; manual nucleofracture prior to
Endothelial damage Due to excessive manipulations in p4hacoemulsification. Operative Tech Cataract Refract Surg
the anterior chamber by multiple instruments, endothelial 1: 69-91, 1998.
damage is quite significant in this procedure. A higher 9. Keener GT (Jr): The nucleus division technique for small
endothelial cell loss has been reported in comparison to incision cataract extraction. In: Rozakis GW, Ed, Cataract
phacoemulsification.4 Surgery; Alternative Small-Incision Techniques. Thorofare,
NJ Slack, 163-191, 1990.
Intraoperative miosis Many a times pupil gets cons– 10. Quintana M: Implantacion de LIO plegable con facosecion
tricted during the procedure owing to excessive manual y pequena incision. Microcirugia Ocular 6(1): 37-
44, 1998.
manipulation of iris. Due to this, there may be difficulty 11. Gutierrez-Carmona FJ: Manual multi-phacofragmentation
in prolapsing the nucleus into the anterior chamber and through a 3.2 mm clear corneal incision. J Cataract Refract
might warrant use of intracameral adrenaline or multiple Surg 26: 1523-28, 2000.
Microvectis Technique 113
Microvectis
Technique
21 P Mishra
S Thanikachalam
T
he cataract surgery has witnessed a phenomenal Wound Construction
progress over the years and continues to evolve Scleral tunnel incision, which varies from 5-8mm
with the addition of newer surgical techniques and depending on types of cataract.
instrumentation. Michael Mc Farland first conceived the

principles of no stitch cataract surgery with phaco- Viscoelastics
emulsification in 1990.1 Earlier Blumenthal in 1987
Liberal use of low molecular viscoelastics to reform the
popularized the technique of Non-phaco SICS in which
anterior chamber as and when required.
he described the use of anterior chamber maintainer to
hydro-express the nucleus.2 The technique of phaco Instrumentation
fracture, where the nucleus is divided before its removal
was pioneered by Kansas,3,6 in 1990. In the same year, Nuclear rotation IOL dialer/Sinskey hook or bent 26G.
phaco-sandwich, a bimanual technique of removal of needle.
nucleus was described in details, by Luther Fry.4,7 Since Nucleus expression Microvectis (3-4 mm)/micro-lens
1995, the authors have been using a different technique loop.
in which nucleus is expressed with the help of a
Anaesthesia
microvectis. In this technique no anterior chamber main-
tainer is used, as it is a cumbersome procedure and Non-phaco SICS can be performed under peribulbar or
secondly balanced salt solution (BSS) may not protect topical anaesthesia. Peribulbar anaesthesia was achieved
the corneal endothelium like viscoelastics. Side port entry by giving two injections, mixture of 5 cc xylocain (2%)
is never required as a routine procedure. We recommend and 5cc bupivacaine (0.5%) by two points technique. In
this simple and effective method of delivery of nucleus selective cases proparacaine (0.5%) is used as topical
even for rock hard cataracts. The surgeons in the deve- anaesthesia.
loping countries, particularly in India, who are dealing
with more mature and brunescent cataracts may be Capsulorhexis
benefited by this technique. Continuous curvilinear capsulorhexis originally described
by both Gimbel (Canada) and Neuhann (Germany), is
Indication usually performed with a bend 26G needle or masket
capsulorhexis forceps. A rhexis of 6.5 to 7.5mm is
Types of cataract All types, and all grades of nuclear preferred, however, two relaxing incisions at 2 to 10
cataract. o’clock is usually required to prolapse the nucleus easily
in nuclear cataracts.
Objectives
1. To mobilize the nucleus inside the capsular bag. Hydrodissection
2. To luxate the nucleus subsequently into the anterior Good hydrodissection should be performed to separate
chamber. the nucleus from its capsular attachment. The anterior
3. To express the nucleus with the help of a microvectis / capsule is elevated with a 26G cannula and BSS is
lens loop. injected slowly and continuously from a 2ml syringe.
When completed nucleus appears to move forward

following, which it must be freely rotatable within the
capsular bag.
Nucleus Expression
Although there are different techniques available for
nucleus management namely phaco-sandwich, phaco-
fracture, hydro-expression, irrigating vectis, etc. we restrict
our discussion to removal of nucleus by microvectis
technique.
After reforming the anterior chamber with viscoelastics
the superior pole of the nucleus is engaged, lifted and
rotated with the help of an IOL dialer and prolapsed into
the anterior chamber (Figs 21.1 and 21.2). The nucleus
rotation is done either clockwise, anti-clockwise or both

to luxate the nucleus completely into anterior chamber. Fig. 21.3: Microvectis is introduced below the nucleus
Once the superior pole lifts up viscoelastics may be
injected underneath, to make nuclear rotation easy.
Viscoelastics is placed both above and below the nucleus
when it luxates into anterior chamber. This step is essential
Fig. 21.1: Nucleus is rotated with dialer Fig. 21.4a
to avoid endothelial damage to cornea. A microvectis,

that is very small, 3-4 mm in size is introduced under the
nucleus following which the nucleus is expressed (Figs
21.3 and 21.4a and b) by applying forward pressure
gently. At the same time minimal amount of depression
of sclera, the posterior lip of wound is done by the shaft
of the vectis. The above mentioned step is carried in a
more controlled fashion under direct visualisation to
avoid trauma to cornea and iris. Sometimes the
epinucleus or portion of cortex will be sheared off by the
anterior lip of the incision without damaging the
endothelium. The remaining portion of cortex and
epinucleus can be easily rotated and removed either by
Fig. 21.2: Necleus is prolapsed in AC viscoexpulsion, or aspirated by Soimcoe 1/A cannula.
Microvectis Technique 115
Figs 21.4a and b: Nucleus is delivered by microvectis. Courtesy: Alcon (India)
Viscoexpulsion is achieved by injecting low molecular anterior chamber both above and below the nucleus.
viscoelastics into the anterior chamber while depressing Minimal corneal oedema was encountered in its upper
the posterior scleral lip simultaneously. For easy delivery part in 5 to 6 per cent cases, which subsided within two
of nucleus we recommend incision of weeks of surgery. In paediatric cataracts as there is virtually
7.5 to 8 mm for nuclear cataract (Fig. 21.5) and to 7.5 no nucleus; the cortex may be easily removed by visco-
mm for cortical cataracts. The frown incision is placed 2 expulsion or by irrigation aspiration.8 It has been observed
mm or more, posterior to limbus, i.e. wider tunnel is that endothelial loss in non-phaco SICS is between 10
fashioned to minimize postoperative astigmatism. Two and 12 per cent. The damage to the endothelium usually
relaxing incisions over the capsule are usually required occurs during nucleus expression mostly in hard cataracts.
to prolapse the nucleus into the anterior chamber and to The nuclear fragments may also touch the corneal
avoid complications like capsular tear or zonular dialysis endothelium during irrigation aspiration. Our own
in hard cataracts. Similarly in these cases inner entry of unpublished data show that the induced astigmatism is
wound can be enlarged to desired length to facilitate easy never more than 1.50 D even for relatively large incision
delivery of nucleus. The authors have analysed 500 cases in nuclear types of cataract, as these incisions are placed
that underwent cataract extraction with IOL implantation more posterior to the limbus. One question that will no
by using this technique, in two cases there were inferior doubt be asked, “why not to suture such a large incision.”
iridodialysis and hyphaema because of iris trapped The logic is very simple if the tunnel is stable in 6 mm
between vectis and nucleus during its delivery when the why not in 8 mm i.e. 1 mm more on either side. In our
pupil was not fully dilated. This can be avoided easily by series of 200 cases, we have observed that the wound
injecting adequate amount of viscoelastics into the remains stable (Fig. 21.5) even with 10 mm tunnel
provided the tunnel dissection is perfect and its width is
made longer (external scleral incision more posterior).
The advantages of this technique are that, it has
virtually nil learning curve. It is relatively easy to perform,
repeatable, cost effective and does not require bimanual
technique, and at the same time it gives fairly excellent
results. It is true that, despite longer incision placed for
nuclear types of cataract we could achieve watertight,
self-sealing sutureless wound in all cases (100%). Both
in terms of technique and quality this is no doubt, an
alternative to phacoemulsification in expert hands.
Practical Pearls
1. Ensure good mydriasis throughout the entire
procedure.
2. Liberal use of viscoelastics is necessitated as and
Fig. 21.5: AC is formed with air bubble when required through out the procedure.
3. Good capsulorhexis is essential, but not mandatory 11. Iris should not be trapped in between the nucleus
for easy rotation of nucleus and its luxation into and microvectis during delivery of nucleus.
the anterior chamber. However, this technique can 12. As nucleus rotation is often difficult in soft cataracts,
be performed even with can-opener capsulotomy. it can be easily done with repeated irrigation and
4. Relaxing incision one or two may require for hard aspiration of dislodged cortical matter.
cataracts.
REFERENCES
5. Internal incision, entry to anterior chamber can be
widened in accordance with the size of nucleus even 1. Mc Farland MS: Mc Farland surgical technique. In Gills JPM,
Sanders DR (Eds): Small Incision Cataract Surgery: Foldable
after its prolapse into anterior chamber.
Lenses, One Stitch Surgery, Sutureless Surgery. Slack Inc.
6. Side port entry may be required in difficult cases Thorofare, NJ 107-16, 1990.
for removal of sub-incisional cortex. 2. Blumenthal M, Moisseiev J: Anterior chamber maintainer
7. If the capsulorhexis is small and no relaxing incisions for extracapsular cataract extraction and intraocular lens
given, luxation of nucleus to anterior chamber implantation. J Cataract Refract Surg 24: 160-65, 1987.
3. Kansas P: Phacofracture. In Rozakis GW (Eds): Cataract
becomes traumatic and may lead to zonular
Surgery: Alternative Small Incision Techniques. New Jersy,

dialysis. USA: Slack Inc. 45-70, 1990.
8. To make the rotation and subsequent luxation of 4. Luther Fry: The phacosandwich technique. In Rozakis GW,
nucleus into anterior chamber easy, viscoelastics is Aziz YA et al (Eds): Cataract surgery–Alternative Small
injected under the superior pole of the nucleus once Incision Technique. Thorofare NJ, Slack Inc. 71-110, 1990.
5. Mishra P: Small incision cataract surgery (SICS). http://
it is lifted up. .www.indmedica.com/ophthal/cyberlecture 1-4, 2000.
9. Viscoelastic must be cushioned between nucleus 6. Bartovb E, Isakov I, Rock T: Nucleus fragmentation in a scleral
and endothelium, also between nucleus and iris; pocket for small incision extracapsular cataract extraction.
so that free floating nucleus is easily expressed out. J cataract Refract Surg. 24(2): 160-65, 1998.
10. Following introduction of microvectis under the 7. Bryand WR: Cataract surgery: Alternative small incision
technique. In Rozaki GW (Eds): New Jersey; Slack Inc.
nucleus, anterior chamber must be reformed with Thorofare.
viscoelastics, if it becomes flat to avoid endothelial 8. Mishra P: Cataract surgery in children. http://.www.
damage. indmedica.com/ophthal/cyberlecture.1-5, 2000.
Modified Blumenthal’s Technique 117
Modified
Blumenthal’s
22
Technique KPS Malik
Ruchi Goel
O
phthalmic surgery has seen the revolution of IOL or diclofenac sodium 0.1 per cent every 20 minutes thrice
implantation in the last 2 decades. The focus of will maintain intraoperative mydriasis.
attention has shifted to faster rehabilitation of Peribulbar retrobulbar/subconjunctival/sub-Tenon/
patient to his job. Phacoemulsification, a modern tech- topical/intracameral preservative free xylocaine with or
nique is improving everyday to make it safe technique in without facial block can be used.
all hands. Unfortunately, lack of training facilities, cost Our preferred technique is:
and maintenance problem of machine has made this 1. Topical xylocaine 4 per cent/Proparacaine 0.5 per cent
procedure limited to big cities/institutions only. 4-5 times.
Alternate small incision cataract surgery techniques are 2. 3 cc xylocaine 2% + 3 cc bupivacaine. 75 per cent as
also being practiced by many eminent surgeons of the a inferior temporal peribulbar injection. 3 cc is injected
world. Anterior chamber maintainer assisted mininuc peribulbar, needle is withdrawn, directed lateral to
technique of Professor M Blumenthal and other tech- lateral canthus, deep enough to inject the solution
niques practiced by surgeons like WR Bryant, Luther L around the branches of facial nerve. This one prick
Fry, Peter Kansas, etc. are keeping alive the interest in anaesthesia should take care of every need of SICS.
manual small incision cataract surgery. No use is made of mannitol, diamox, massage, pres-
These procedures are all the more relevant for the sure or superpinky. The need is for normotensive eyeball.
developing world. Phacosurgery is expanding quite Some movements of eyeball are acceptable and would
rapidly in large cities but many government institutions not interfere with smooth execution of the procedure.
and other practitioners are still struggling to keep pace Concept of hypotony was introduced for safe ECCE
with advancing costly techniques. Alternative small where in surgeons made 13-15 mm corneoscleral incision.
incision cataract surgery has the advantage of low cost, Iris prolapse or lens extrusions were common bugbears
good postoperative results enabling early rehabilitation in absence of hypotony. Physiologically a normotensive
of patients. The final aim of all surgeons should be the eyeball is the best proposition as vascular dynamics of
same–to provide safe, early, reliable and reasonably retinal and uveal tissue are minimally disturbed in
priced emmetropia. normotensive state . The following flow chart indicates
Practicing steps of alternate small incision cataract the advantages of maintaining a normotensive
eyeball .
surgery will place every surgeon on a solid foundation to
switch to phaco surgery, bypassing the notoriously steep Maintenance of Vascular Dynamics of Eyeball
↓
learning curve of phaco surgery. No prostaglandin
↓
Preoperative Preparation and Anaesthesia No inflammation
A medical clearance is obtained. Wide spectrum antibiotic ↓
No CME
drops topically every four hours a day before surgery is
↓
instilled. Mydriasis is achieved using cyclopentolate 1 per No choroidal haemorrhage
cent or tropicamide 1 per cent along with phenylephrine ↓
5-10 per cent drops. Topical 0.03 per cent flurbiprofen Intact blood aqueous barrier
In small incision cataract surgery as practised by groove too far behind the sclera as it will make the entry
Dr Blumenthal, ‘AC maintainer system’ keeps the AC deep of instruments difficult and will also pry open the section
and IOP at normal or higher level. This pressurised state with every manoeuvre.
of eye is required for easy hydroexpression of nucleus Incisions can be of following shapes:
from the eyeball. 1. Straight
Hypertonic state of the eye ball also facilitates the 2. Frown
following: 3. Inverted V, with apex pointing towards limbus.
1. Introduction of MVR for sideport entry or AC main- Best instrument for initial groove is guarded diamond
tainer. knife set at a depth of 0.3 mm. Many experienced
surgeons can make brilliant grooves with blades of any
2. Dissection of sclerocorneal tunnel.
material or configuration. We use 15 number blade on
3. Even for curvilinear capsulorhexis the deep AC and
BP knife or 15 degree angled knife for making the initial
pressure on anterior capsule is necessary to counter groove. Site of groove behind the limbus is dependent
the lenticular pressure. on planned configuration of sclerocorneal tunnel. Three
4. Hydroexpression of epinucleus, cortex or blood. types are shown in the Figure 22.1.
1. Straight A straight line groove is made parallel to limbus

Sclerocorneal Pocket Tunnel Incision about 5.5 to 6.5 mm in length depending on hardness
Success of small incision cataract surgery depends on of nucleus. The groove is usually 1.5 to 2 mm behind
efficient, smooth and functional construction of a clean the limbus.
edged sclerocorneal pocket incision of suitable dimen- 2. Frown shaped A parabolic groove convex towards
sions. The placement of initial incision posteriorly on sclera limbus is made 1.5 to 2 mm behind limbus centered
has many advantages, namely stable section, early at 12 O’clock.
3. Inverted V The two arms of inverted V, AB and CB
healing, less induced astigmatism. It has been shown by
meet at an angle of 120 degrees. A and C being 2 to
Trasher and Boerner that a 9 mm scleral incision will
2.5 mm behind the limbus. Straight distance between
induce astigmatism as much as that induced by a 6 mm
A and C being 5.5 to 6.5 mm. The point B or apex of
limbal incision. Jaffe has stated that 7 mm incision,
V falls short of touching the limbus (Fig. 22.1).
2 mm behind the limbus can be left unsutured.
So we have following advantages of scleral placement
of incisions:
1. Less induced postoperative astigmatism.
2. Faster stabilization of refraction.
3. Less tendency towards against the rule astigmatism.
4. Even if a suture is applied, the knot remains buried
deep in the section covered by full thickness tenon
and conjunctiva therefore there is no irritation by the
protruding ends of the suture. Fig. 22.1: Types of incisions
Technique of making the sclerocorneal pocket tunnel TUNNELING FORWARDS

incision The incision area is prepared by detaching the
After the initial groove has been defined with a clear cut
conjunctiva from limbus at 11 to 2 O’clock position. The
sharp incision, the 2.8 mm crescent blade, disposable or
conjunctiva is undermined, attachment of tenon is
diamond, is engaged in the groove. It’s tip is tilted
severed. All episcleral tissue should not be removed as it
anteriorly to follow the curve of limbus and dome of
initiates the healing. Light and minimal cautery is applied
cornea. Maintaining uniform thickness of dissection,
on perforating vessels or large surface vessels. Excess cau-
tunneling should be performed anteriorly upto 2 mm of
tery can lead to shrinkage of tissue and is best avoided.
clear cornea. While dissecting the lateral area the blade
should not be moved straight but tilted downwards
Making the Groove
following the slope of lateral cornea. The blade can be
Site The site and shape of scleral groove will depend on tilted 90 degree medially or laterally to dissect pockets in
type of incision planned and AC depth. In a hypermetro- cornea and sclera. At the end of the dissection we would
pic small eye with shallow AC one should not make a have the following types of sclerocorneal pocket tunnels.
Fig. 22.2: Dissecting the corneoscloeral tunnel
Precautions Continuous curvilinear capsulorhexis (CCC) CCC is a

Not following the curve of cornea or globe can result in landmark step in the safety of IOL surgery. CCC has
premature entry into AC or buttonholing of the anterior multiple advantages in phaco as well as non-phaco SICS
walls of the tunnel. Tunnel is best dissected in such as:
normotensive eyeball. If the eye appears soft one can 1.Safe hydroprocedures.
inject viscoelastic to make it tight, before continuing the 2.Safe nuclear rotation and manipulation in AC.
dissection (Fig. 22.2). 3.Central IOL placement with minimal decentration.
After tunnel has been dissected, entry is made into the 4.Safer cortical clean up and posterior capsular polishing.
anterior chamber. The capsular opening is best made
5.IOL placement on intact rhexis margin in case of
through a valvular sideport created at 10 O’clock by MVR
posterior capsular tear.
blade. Viscoelastic is injected to make the eyeball hyper-
tensive (30–35 mm of mercury). Small side port entry CCC was developed by Gimbel, Neuhann and
will allow the chamber to remain deep, will have minimal Shimizu, independent of each other in the mid 1980’s.
leak.
Three types of capsular openings can be made, conti- Procedure
nuous curvilinear capsulorhexis, envelope or can-op
rhexis (Fig. 22.3). Through the sideport entry viscoelastic is injected to
deepen the AC and counter any vitreous thrust. In case
of hypermature cataracts, dyes which can stain the
anterior capsule, can be used. A suitably bent 26G
needle can be used as a cystitome. The first bent is just
near the tip at right angle and the second bent is at an
obtuse angle to allow easy manipulation in the anterior
chamber. A puncture is made in the centre of the anterior
capsule and a tongue shaped flap is lifted. This flap is
everted, flattened on the capsule and manipulated
anticlockwise (our way) or clockwise, applying shearing
force. The flap is flattened out again and again, keeping
the shearing junction in sight. Pulling far away at the
flap will have tearing effect and may result in loss of
Fig. 22.3: Making curvilinear capsulorhexis control. The final tear is from outside to inside. If CCC
appears small, continue in spiral fashion all over again, Completing the Tunnel
enlarging the CCC.
The prior dissected tunnel is inflated with visco to facilitate
Precautions entry of slit knife. 3.2 mm angled keratome (slit knife)
disposable, steel or diamond is introduced at 12 O’clock,
1. Do not disturb the cortex otherwise visibility may be after traversing the full length of tunnel it is dipped down
lost. in AC and knife is introduced till the elbow. It is noteworthy
2. Reinject the viscoelastic if chamber shallows because that the Descemet’s is entered not at right angle but in
the tear may go to the periphery. Stop, refill the AC, sloping fashion. Subsequent cuts are made by repeated
examine and proceed. It is very important to counter thrusts of the 3.2 mm knife in rest of the dissected cornea.
the positive pressure of vitreous. Conscious effort should be made to cut while going in
3. CCC should not be less than 6 mm for this procedure. and not while coming out. These manoeuvres of slit knife
should be in quick succession to cover whole of
Envelope Technique predissected area including side pockets. If chamber
Envelope technique is preferred over can-opener in cases shallows while cutting in the tunnel, the chamber should
where CCC is difficult. In case of morgagnion, intume- be filled up with viscoelastic before reintroducing the knife.
scent Black/brown or hypermature cataract envelope At the end we shall get a funnel shaped sclerocorneal
making is an easy and excellent technique which allows pocket tunnel that is narrow outside and wider in the
all the benefits of CCC. cornea. It is to be noted that side pocket dissections are
A scratch mark is made at the junction of lower 2/3rd akin to the bulge of the oral cavity of a snake, which can
and upper 1/3rd of capsule. Further tiny cuts are given accommodate a larger animal than it’s apparent mouth
medially and laterally saving 1 mm of capsule on either size. At the time of nuclear expression a large nucleus too
side, cuts are then joined by a horizontal line. This type can get engaged because of extraspace created by side
of capsular opening is useful for placement of IOL in the pockets in cornea and sclera.
bag. After placing the IOL in the bag the remnants of
anterior capsule are cut off by cystitome or Vannas Hydroprocedures
scissors. Hydroprocedures comprise of hydrodissection and
hydrodelineation. The aim is to separate the lens nucleus,
Can-op Rhexis
epinucleus and cortex from capsule and the lens lamella
A CCC may be given relaxing cut at 11-12 O’clock from the cortex and its different layers. This facilitates
position for nuclear manipulation out of the rigid CCC rotation of nucleus from its bag into the anterior chamber.
margin in cases of hard or large nucleii. Can-op rhexis Therefore thorough hydroprocedures play a key role in
opening will give all the benefits of CCC and allow in the this surgery. Michael Blumenthal first described
bag placement of IOL. Therefore, while performing CCC hydroprocedures but Faust gave the term hydrodissection.
if one loses control and part of it has to be completed by These procedures can be carried out with anterior
can opener technique, it is still preferable to have some chamber maintainer being in on or off state.
round margin of capsular opening.
Hydrodissection
Fixing the AC Maintainer
AC is emptied of viscoelastics remaining after capsu-
Fix the AC maintainer at this stage as AC is still deep with lorhexis. 1 cc Ringer lactate/BSS is loaded onto 2 cc
viscoelastic. MVR entry is made at 6 O’ clock parallel to syringe and is injected behind the rhexis margin using a
limbus, away from the vascular arcade of cornea. The suitably angled cannula with a blunt tip (like Healon
AC maintainer, a hollow steel tube with 0.9 mm outer cannula) in different directions. The bolus of fluid injected
and 0.65 mm inner diameter is entered with bevel up between anterior capsule and cortex dissects all around
and then turned 180 degrees so that the bevel faces the the capsular bag and separates it from the nucleus. The
iris. The AC maintainer is always inserted from the cortex is completely dissected from the capsule freeing
temporal side. The tube of AC maintainer is attached to the entire lens nucleus, epinucleus, cortex from the
BSS bottle suspended 60-70 cm above the patient’s eye. capsular bag thereby facilitating nuclear rotation and
manipulation out of it’s bag. Indication that the dissection introduced between 10 and 12 O’clock positions near
has occurred is a shallowing of anterior chamber, the edge of the rhexis margin and passed behind the upper
signifying entrapment of fluid in the subcapsular layer of pole of the nucleus. Nucleus is engaged, the hook is pulled
the lens at one pole. Intermittent gentle tapping releases upwards and towards 12 O’clock. Once the bulk of the
the fluid collected behind the nucleus thereby completing nucleus is out, the rest is cartwheeled out clockwise or
the hydrodissection (Fig. 22.4). anticlockwise into the AC.
Precautions
1. Never hold the edge of the section with forceps, hold
at the limbus or the sclera to stabilize the globe while
carrying out manoeuvres in the AC. Holding the section
will roughen the edges, delaying the healing and
leading to poor co-optation of the wound.
2. Avoid repeated entry into the section.
3. Fill up the AC with viscoelastic–inject it in front and

behind the nucleus.
4. Never use rough-ended cannula in the section or you
may damage the Descemet’s membrane.
5. Consciously keep a watch on Descemet’s for any
Fig. 22.4: Hydrodissection
manoeuvres in the AC.
Nuclear Delivery by Hydroexpression

Hydrodelineation/Hydrodelamination/Hydrodemarcation
This is the most important step in small incision cataract
The fluid is injected between the epinucleus and nucleus.
surgery. The skill and experience of operator guides him
The fluid wave appears as a golden ring under the surgical
to make a correct size outlet depending on the hardness
microscope. The procedure is carried out using either a of nucleus. The goal is a smooth delivery of reduced size
straight cannula or one with 2 sideports. The final result nucleus leaving behind other parts of the lens. AC
is a debulking of nucleus. The cannula is passed into the Maintainer, attached to a bottle of Ringer lactate/BSS,
nucleus until it meets resistance where the soft outer suspended 70 cm above the patient’s head, is brought
nucleus ends and a firm inner nucleus begins. At the point into play now. Once the reduced size nucleus has been
of resistance the cannula is pulled back a fraction of a brought out in deep AC, suspended in an ocean of
mm and fluid is injected. The fluid passes into the body viscoelastic, a lens glide is passed from 12 ‘o clock behind
of the cataract and creates a cleavage plane. This may the nucleus. Care should be taken that the glide does not
be repeated at a different site. In a very hard cataract, injure the iris, ciliary body or capsule during its journey
the inner nucleus may extend right out to the capsule behind the nucleus. Once the glide is in position, the AC
and cleavage plane may never be identified whereas in a maintainer flow is switched on fully. The tip of forceps is
soft cataract multiple planes may be isolated. Thorough used to apply a firm pressure on the lens glide, on the
hydroprocedures reduce the size of the nucleus which in scleral side of section. The nucleus will be taken up by
turn enable the surgeon to deliver it out of a small incision. section and the adjacent pockets. A few intermittent taps
on the lens glide will see the nucleus delivered out,
Nuclear Management and Delivery deepening the AC. A few more taps will allow the cortex,
Nuclear prolapse into the AC Adequately sized CCC and epinucleus to be washed out of the eye. We pull out the
thorough hydroprocedures will prolapse the nucleus in AC maintainer at this stage. Simcoe cannula is further
the AC. Some of the soft cataracts have fibres firmly used for cleaning up the remaining cortex.
adhered to each other as well as with epinucleus. These Assisted delivery In case nucleus is stuck up in section,
lenses need manual manipulations or multiple hydro– lifting the bottle up will raise the pressure of fluid in
procedures to finally free them out of the bag. anterior chamber and help in nucleus expression. If tip of
We use a Sinskey’s hook to guide the nucleus out of the nucleus shows but no further progress is there, a 23
the bag. AC is filled with viscoelastic. The hook is gauge needle can be held in left hand and applied at
Fig. 22.5: IOL placement and suturing

right angle to the axis of lens and by cartwheeling the Closure of Section
nucleus can be brought out. In case of large nucleus, a
part of it can be sheared off with a needle. The nucleus is A well-constructed inverted V or frown shaped incision
then pushed back in the AC, and rotated so that the can be left unsutured. Fluid is injected from sideport to
smaller diameter is engaged, and the nucleus is delivered. see the leakage of section. If doubt about safety of the
section exists, an ∞ (infinity) shaped suture, taking deep
SECTION NOT TAKING UP NUCLEUS–CAUSES bites in the scleral bed, is applied. Sideport site and AC
1. Small section maintainer site can be hydrated by injecting a few drops
2. Irregular section of BSS in the stroma (Fig. 22.5).
3. Hypotony
4. Leaking AC FURTHER READING
5. Iris prolapse before nucleus is engaged. 1. Feil SH, Crandall AS, Oslon RJ: Astigmatic Decay following
small incision, self-sealing cataract surgery: One year follow
Solution
up, J Cataract Refract Surg 21: 433-36, 1995.
1. Re-evaluate the adequacy of section and enlarge with 2. Jaffe N: Cataract surgery and its complications. CV Mosby
keratome if needed. Co.: St Louis; 6th ed. 1990.
2. Raise the pressure of AC by lifting the irrigating fluid 3. Rainer G, Vass C, Menapace R et al: Long-term course of
surgically induced astigmatism after a 5.0 mm sclerocorneal
bottle higher.
valve incision. J Cataract Refract Surg 27(12): 1642-46,
A thin iris repositor and even a 3.2 mm keratome can 1998.
be used on place of lens glide for nuclear delivery. 4. Rozakis GW: Cataract surgery: Alternative small incision
techniques. Jaypee Brothers: India.
Cortical Clean-up 5. Shephard JR: Induced astigmatism in small incision cataract
surgery. J Cataract Refract Surg 15(1): 85-88, 1989.
We disconnect the AC maintainer at this stage and do
6. Singer JA: Frown incision for minimizing induced astigmatism
cortical clean-up with cimcoe cannula.
after small incision cataract surgery with rigid optic intraocular
lens implantation. J Cataract Refract Surgery 17(Suppl):
IOL Placement 677-88, 1991.
IOL is held by straight lens holding forceps at the junc- 7. Steinert RF, Brint SF, White SM et al: Astigmatism after small
tion of 1/3rd and 2/3rd of optic. The lower haptic and incision cataract surgery. Ophthalmology 93(4): 417-23,
1991.
optic is guided into the bag at 6 O’clock position. Same
8. Uusitalo RJ, Tarkkanen A: Outcomes of small incision cataract
forceps can rotate the upper haptics into the bag or a Y surgery. J Cataract Refract Surgery 24(2): 212-21, 1998.
shaped dialer can be used to place the upper haptic into 9. Wright M, Chawla H, Adams A: Results of small incision
the bag. McPherson forceps is not a very good instru- extra-capsular cataract surgery using the anterior chamber
ment for placing the IOL in the lower fornix of the bag maintainer without viscoelastic. Br J Ophthalmol 83(1): 71-
(Fig. 22.5). 75, 1999.
Small Incision Manual Phaco-section Using the Anterior Chamber Maintainer 123
Small Incision Manual

Phaco-section
23
Using the Anterior
Chamber Maintainer Hector Bryson Chawla
S
mall incision cataract extraction without phaco- Inserting the ACM
emulsification has many advantages. The tubing must be full of BSS and free of air bubbles. A
three way tap, proximal to the ACM tubing allows control
1. It is elegant. of the fluid flow into the eye without the sudden surges
2. It is not dependent on expensive and frequently that occur with an automated foot switch.
capricious equipment. The 20 gauge ACM is held, bevel downwards, at right
3. The visual results compare favourably with those of angles to the surface of the cornea. The tip of the bevel is
any other available technique. then insinuated into the paracentesis. Continued pressure
4. The cell count of the corneal endothelium, after at right angles engages the ACM in the corneal tunnel. At
surgery also compares favourably with that of other
this point, it is moved into the line of the tunnel and, with
techniques.
an oscillating rotatory action can be moved into its final
5. It is virtually impossible to drop the nucleus into the
position with the tip of the ACM inside the anterior
vitreal cavity.
chamber (AC).
6. The continual inflow of Balanced Salt Solution (BSS)
The bevel of the ACM must be rotated to direct the
through the Anterior Chamber Maintainer (ACM)
fluid flow away from the corneal endothelium (Fig. 23.1).
reduces the risk of infection.
7. The same flow militates against expulsive haemor-
rhage and eliminates the need for any other kind of
irrigation.
My method combines elements of manual phaco-
section as made popular by Peter Kansas and the so-
called mini-nuc approach of Michael Blumenthal. The
procedure starts with three self-sealing paracentesis
openings, made in the peripheral cornea with a 1.15 mm
stiletto knife. The first, lower temporal, angles obliquely
to point towards the inferior pole of the lens.
The other two enter at ten O’clock and two O’clock,
angled to point just above the centre of the lens.
The lower canal will hold the ACM (first described by
Lewicky) and must be precisely the width of the knife.
Any sideways movement of the blade, particularly during
withdrawal, will produce an incision too large and likely
to permit leakage around the ACM. Fig. 23.1: (Chawla) Wound and paracentesis incisions
The ACM must be at least 20 gauge. Some manu-

facturers produce ACMs whose too small bore does not
allow an adequate flow of fluid. The use of such products
might well have led to a distrust of the ACM technique.
Irrigation
BSS is obligatory to maintain corneal clarity. The bottle
height should be as low as is compatible with the main-
tenance of the AC. A height of fourteen inches corres-
ponds to an Intraocular Presssure (IOP) of 26 mm/Hg.
The surgeon should be aware of the fluctuations in
IOP created by changing the bottle height.
Incision
The corneo-scleral incision must be self-sealing of the Fig. 23.2: Rotation of nucleus
ACM is to be allowed to maintain a constant AC depth.
I use a 15 blade, a crescent knife and a 3.2 mm kera- If the combined nuclei threaten to be too large for the
tome. For the dextrous, it is possible to make all these capsulorhexis then one should endeavour to isolate and
incisions with the 15 blade-again reducing the cost. dislocate the endonucleus (Figs 23.2 and 23.3a to c).
An external incision, 5.2 mm long is made just behind There is no hard and fast rule about this but in my
the limbus to be between one-third and one-half of the experience, removing the epinucleus from the capsular
scleral depth. bag is easier when it is still attached to the nucleus. When
A scleral pocket is created and extended 1.5 mm into it is on its own, it can sometimes be a reluctant passenger.
the cornea with the crescent knife. But that is still a safer alternative to sacrificing an intact
The AC is entered from the anterior end of this pocket capsulorhexis.
with a 3.2 mm keratome. The internal edge of this wound
is parallel to the limbus and is made by cutting in one
direction only-not with a saw-like movement. Making the
internal wound slightly wider than the external creates a
natural birth canal to collect lenticular fragments for
smooth delivery.
Capsulorhexis
At this point the fluid to the ACM is turned off at the three
way tap and visco-elastic is introduced into the AC
through a cystotome. Creating a continuous curvilinear
capsulorhexis calls for a skill that is common to all cataract
techniques but here the diameter must be slightly bigger
than standard in order to allow delivery of the endo-
nucleus or the combined endo-and epi-nuclei into the
AC. If the capsulorhexis is thought to be too small then
as a last resort, it can be relaxed by oblique incisions with
long Vannas scissors at three and nine O’clock.
Trying to achieve the desired shape of the capsulorhexis
under BSS calls for a skill that is denied to most of us.
Nuclear Dislocaton
BSS through a Rycroft cannula is directed into the
capsular bag, to separate the cortex from the capsule and
the combined nuclei from the cortex. Figs 23.3a to c: Technique of dislocation of endonucleus
Nuclear Bisection
The instruments essential for this technique are-
1. The solid vectis-a flat plate attached to a handle not
unlike a hockey stick with the blade pointing
upwards.
2. The nuclear bisector-a firm cutting implement similar
in shape to a lens dialler but without the angled tip.
Once the endo-nucleus or the combined nuclei are
isolated they can be dialled into the AC. The space
between them and the corneal endothelium is filled with
visco-elastic through a Rycroft cannula. Now is the time
to divide the nucleus in two between the solid vectis and
the nuclear bisector. The critical point of all these mano-
euvres is that every time one enters the anterior chamber,
one must precede this entry with visco-elastic. No matter

how much is used, its use will be fully repaid by a crystal
cornea the next day and a gentle reminder that this
operation is still significantly cheaper than phaco-
emulsification.
The aim is to insinuate the solid vectis between the
nucleus and the capsular bag and the bisector between
the nucleus and the cornea. The technique is to begin
with the bisector and then tease the solid vectis into
position whilst advancing the tip of the bisector until it is
Figs 23.5a and b: Fragments of nucleus being
pointing from eleven or one O’clock towards six O’clock. removed by Arruga forceps
As with golf clubs, the right handed and the left handed
operator can be accommodated (Fig. 23.4a and b). Although the temptation might be to press the bisector
down towards the iris, the secret is to keep the bisector
firm whilst pressing up, away from the iris with the solid
vectis, to split the nucleus easily into two.
The half nuclei are now ready for removal. There are
several methods for achieving this end but I have found
the best is to modify the tips of the standard Arruga
intracapsular capsule forceps (Figs 23.5a and b). If one
thinks of them in their natural state as being tipped with
“teaspoons” then we must convert these into a “soup”
spoon shape.
Again preceding every move with visco-elastic to the
AC, one dials the half nucleus so that it lies directly in line
with its proposed line of removal. The forceps are slid
into the AC and the trick is to lay them nearer the iris so
that the fragment appears to be nipped upwards rather
than grasped directly. It is the simplest matter now to slide
it out, remembering always that the leading pole must be
elevated so as not to catch on the wrong side of the scleral
tunnel.
Removal of Epi-nucleus
At this point the ACM can be turned on again whilst
Figs 23.4a and b: Insertion of dissecting instruments depression of the posterior lip of the scleral wound, allows
any floating fragments to be swept into the tunnel and obstruction be insurmountable, then excision of the
out of the eye. A nucleus, too soft for bisection can be offending iris is often the only recourse.
removed in the same way. Occasionally partial closure of the three way tap can
reduce the tide of BSS flowing through the wound.
Cortex Aspiration A third possibility is to conduct as much of the opera-
A cortex extractor with a 0.4 mm port attached to a 5 ml tion as possible under visco-elastic, thus minimises
syringe easily removes the remaining cortex through one damage to the iris.
or other of the side port incisions. After this operation is complete, in such circumstances,
the iris sometimes defies all atempts to replace it where it
Lens Insertion belongs. At this point the cortex extractor can be turned
The implant can be dialled into the capsular bag in the to another use and, through one of the side ports, can,
standard way under visco-elastic which must be removed by suction, pull the iris out of the wound and into an
afterwards. approximation of a round pupil.
Extra sutures can help to keep it in place but it must be
Closing the Wound remembered that every time a susture is inserted into a
leaking wound with the three way tap of BSS open, the
The wound can be left sutureless but in my experience
iris will be swept out again remorselessly.
this will produce up to three dioptres of astigmatism. A
10/0 Mersilene suture in the style of the St. Andrew’s cross
Failed Capsulorhexis
goes a long way to minimise postoperative astigmatism.
So fine a gauge of suture material cannot be tied against The surgical dilemma is common to all techniques. If the
resistance without breaking. Such resistance can be integrity of the posterior capsule is felt to be threatened,
elegantly and briefly eliminated by having the assistant then the flow of BSS must be carefully monitored during
squeeze the inflow tubing to the ACM. With the wound cortex extraction.
edges in the correct position and the second throw of the Even with an intact capsulorhexis, it is sometimes
knot about to be drawn tight, the tubing is released and a possible to capture the posterior capsule in the port of
gentle tide of BSS rises to meet the counter pressure of the cortex extractor. The risisng stress lines cannot be
the completing knot. mistaken and reversal of the flow almost always saves
the capsule and the reputation of the surgeon.
Removal of the ACM
No great complexity is required to disengage the ACM Too Small Capsulorhexis
from its corneal tunnel, or to realise that the AC will The temptation here is to preserve the continuous
shallow somewhat during this manoeuvre. curvilinear state at all costs. To succumb to this temptation
risks converting to the operation we have all abandoned-
Sealing the Paracenteses the intracapsular cataract extraction.
BSS from a syringe can be injected through a Rycroft The endo-nucleus refuses to float on a sea of BSS out
cannula into the walls of the tunnels, producing opaque of the capsular bag because the exit to the AC is too
blanching of the stroma and restoring the AC depth as small. A search for the nuclear margin will almost certainly
deemed appropriate. find the capsule instead and the sudden case with which
With the pressure being high in the syringe a little everything enters the AC tells again the story of the road
foresight will make sure that the Rycroft cannula does to perdition being paved with good intentions. An intact
not turn into a bullet leaving a trail of devastation across posterior capsule which can be achieved often, with a
the anterior segment. little extra care is worth the sacrifice of the curvilinear
edge.
Pitfalls
Corneo-scleral Tunnel not Self-sealing Reluctant Epi-nucleus
The flow of BSS constantly drives the iris into the tunnel, Occasionally the epi-nucleus defies all attempts to tease
obstructing any attempt at surgical elegance. If the it out of the capsular bag. The simplest way to overcome
its reluctance, is to reduce the inflow of BSS where upon Postoperative Care
the semi solid rolls and layers of epi-nucleus will rise into
This differs in no way from any other technique and the
the AC sufficiently to allow the tip of the cortex extractor,
eye is optically stable almost from the outset.
without suction, to dial the remainder out of the capsular
bag rather like a mollusc out of its shell. Anatomically Shallow Anterior Chamber
It would be self evident that endothelial protection can
only be achieved by increased use of visco-elastic.
Manual Multiphaco-
fragmentation: A
24
New Technique for
Cataract Surgery Francisco J Gutiérrez-Carmona
INTRODUCTION
Current surgical techniques used in cataract surgery have
two fundamental objectives: (i) to induce the minimum
postoperative astigmatism, and (ii) to achieve rapid
recuperation of the patient’s sight after surgery.
To meet these objectives, it is necessary to perform
cataract surgery using a small incision. It has been shown
that the smaller the surgical incision, the smaller the
residual postoperative astigmatism.
Of all the techniques described for cataract operations,
phacoemulsification is the one that allows working with
smaller incisions. However, it is a technique which requires
a long learning curve, with expensive and complicated
instrumentation and equipment.
Our manual multiphacofragmentation (MPF) tech-
nique allows cataract surgery through 3.2 mm clear-
corneal or 3.5 mm scleral-tunnel incisions. In this method
the nucleus is fragmented into multiple tiny pieces of
2×2 mm.
The method enables cataract surgery in soft and hard
nuclei. The results obtained in postoperative astigmatism
are similar to those obtained with phacoemulsification,
Fig. 24.1: Nucleotome with a racquet-shaped end
but with a shorter learning curve and less financial outlay.
On the other hand, our method is an ideal back-up • A spatula 8 mm long by 2 mm wide the same shape
after discontinuation of emulsification when complica- as the nucleotome, used as a support during the
tions arise in phacosurgery, since with the help of our fragmentation (Fig. 24.2).
instrument set, we can conclude the surgery without • Two straight-handled manipulators, right and left,
enlarging the incision. used to collect the nuclear fragments (Fig. 24.3).
We designed an instrument set, manufactured by John
Weiss and Son Ltd in England, which consist of: SURGICAL TECHNIQUE
• A racquet-shaped nucleotome 8 mm long and 2 mm
wide, divided along its short axis by 3 thin transverse This technique can be carried out with the use of retro-
bars 2 mm apart , set at 45 degrees to a long straight bulbar or peribulbar anesthesia, topical or topical +
handle (Fig. 24.1). intracameral anesthesia.
Manual Multiphacofragmentation: A New Technique for Cataract Surgery 129
Incision
The surgery can be performed with a 3.2 mm clear-
corneal (Fig. 24.4), or 3.5 mm scleral-tunnel incision
(Fig. 24.5).
The clear-corneal incision is performed at 12 O’clock
with a 45° stab incision knife and with the help of a
disposable angled crescent knife. The scleral-tunnel
incision is made after carrying out a fornix-based con-
junctival miniflap about 2 mm posterior to the corneal-
scleral limbus with the help of a disposable angled
crescent knife, without penetrating the AC.
Fig. 24.2: Saptula with an end the same size

as the nucleotome
Fig. 24.4: The 3.2-mm clear-corneal incision is

performed at 12 O'clock
Fig. 24.3: Manipulators, right and left

To perform MPF it is important to have good phar-
macological mydriasis, since the pupil could contract
during surgery.
Anterior Capsulotomy
High density viscoelastic is injected into the anterior
chamber (AC) through a superior and temporal para-
centesis, and a capsulorhexis is performed with a
cystotome. It should be sufficiently wide (6.0 - 6.5 mm) Fig. 24.5: The 3.5-mm scleral-tunnel incision is made with the
to allow an easy luxation of the nucleus into the AC. help of an angled crescent knife
Hydrodissection and Luxation of the Nucleus

After entering the AC with a 3.2 mm phaco knife,
balanced salt solution (BSS) is injected through the
incision with a Binkhorst cannula between the anterior
capsule and the cortex at 12 O’clock, or with a straight
Rycroft cannula. The BSS must be injected slowly and
continuously until the “wave of dissection” is visible on
the posterior capsule.
The injection of BSS is continued until luxation of the
nucleus in the AC is partial. Then, it can be completed
by rotating the nucleus with a cannula, cystotome
or spatula.
Nuclear Fragmentation
Once the nucleus has been luxated into the AC, high-
density viscoelastic (Viscoat, Amvisc Plus, etc.) is injected Fig. 24.7: The nuclear fragments within the nucleotome are
into the surrounding area to fill the AC. The nucleus is extracted with a sandwich technique
then fragmented by placing the spatula beneath and the
nucleotome on top of the nucleus (Fig. 24.6). Pressure is
then created by slowly pressing the nucleotome against
the spatula, until this section of the nucleus is fragmented
into four pieces which remain within the nucleotome,
and which, with the help of the spatula, are extracted
from the AC with a “sandwich” technique (Fig. 24.7).
This maneuver is repeated until all the nucleus is
fragmented.
During nuclear fragmentation it is important to fill the
AC with high-density viscoelastic, as needed, to protect
the corneal endothelium and to facilitate safe
manipulation during surgery.
Fig. 24.8: Right manipulator displacing a nuclear fragment

towards the center of the anterior chamber
Manipulation of Nuclear Fragments

The right and left manipulators are used to displace the
remaining fragments of the nucleus to the center of the
AC for further fragmentation and extraction (Fig. 24.8).
Extraction of the Cortex and Remains of Nucleus

The lens cortex is aspirated with an I/A Simcoe cannula.
Fig. 24.6: Pressing the nucleotome (on top) against the If tiny pieces of the nucleus are left in the AC, it is
spatula (beneath) the nucleus is fragmented sometimes possible to remove them using only the
Manual Multiphacofragmentation: A New Technique for Cataract Surgery 131
Fig. 24.9: A foldable lens is implanted in the Fig. 24.10: A single cross-stitch is
capsular bag enough to close the wound
nucleotome. Otherwise they can be extracted by the

The ACM is used:
nucleotome and spatula, by aspiration with a Simcoe or • During the capsulorhexis
Charleux cannula, or by gentle irrigation of the AC with • In order to aspirate the anterior cortex and epinucleus
BSS using a Rycroft cannula while simultaneously in soft and medium hard nuclei before the
depressing the posterior lip of the incision. hydrodissection/hydrodelineation
• For the aspiration of cortical debris
IOL Implantation and Wound Closure • For the extraction of tiny nuclear fragments, by depre-
High-density viscoelastic is injected into the capsular bag ssing the posterior incision lip with a straight cannula.
and a foldable IOL is implanted (Fig. 24.9). The visco- The maneuvers of nuclear multi-fragmentation and
elastic material is then aspirated with an irrigating/ IOL implantation are carried out with the help of high
aspirating cannula. Closure of the incision is performed density viscoelastic material.
with stromal hydration, or with a single cross-stitch (Fig. REFERENCES
24.10).
1. Uusitalo RJ, Ruusuvaara P, Jarvinen E et al: Early rehabi-
We recommend to ophthalmologists who are new to
litation after small incision cataract surgery. Refract Corneal
this technique that they initially practise it using incisions Surg 9:67-70, 1993.
of more than 3.2 or 3.5 mm and thereafter reduce the 2. Shepherd JR: Induced astigmatism in small incision cataract
incision size once they have mastered the technique. surgery. J Cataract Refract Surg 15:85-88, 1989.
Lately I have been performing some steps of my 3. Cristobal JA, Minguez E, Ascaso J et al: Size of incision and
induced astigmatism in cataract surgery. J Fr Ophtalmol 16:
technique with the help of an anterior chamber
311-14, 1993.
maintainer (ACM)—model Lewicky 20 G from Katena 4. Gutierrez-Carmona FJ: Manual technique allows for small
or the ACM 20 G from John Weiss Ref. 0185061. incision cataract surgery. Ocular Surgery News: Surgical
The ACM works by producing a constant irrigation Maneuvers 15(21):14-15, 1997.
flow of BSS into the AC. This flow generates a positive 5. Gutierrez-Carmona FJ: Manual technique allows for small
incision cataract surgery. Ocular Surgery News: Surgical
intraocular pressure (IOP) that stabilizes the AC depth
Maneuvers (Internat ed) 9(2):10-11, 1998.
during some steps of the surgery. On the other hand, 6. Gutiérrez-Carmona FJ: Nueva técnica e instrumental de faco-
with the ACM the quantity of viscoelastic material used fragmentación manual para incisiones esclerales tunelizadas
per surgery is reduced, diminishing the financial outlay. de 3.5 mm. Arch Soc Esp Oftalmol 74:181-86, 1999.
The New
Method of Manual-
25
phacofragmentation
(Phaco-drainage) Amporn Jongsareejit
P
hacoemulsification offers the advantages of rapid Idea Concept
wound healing and early visual rehabilitation. 1. Crack the nucleus into small pieces
However, economic constraints in developing 2. Remove the pieces of nucleus through 3.5 mm long
countries place phacoemulsification beyond the reach corneal wound.
of many ophthalmic surgeons. 3. Use passive–aspiration force to remove the pieces of
The manual phacofragmentation is the alternative nucleus.
technique to solve many problems. So, we created a new
method called “Phaco–drainage”. I have used this
technique since 1998 and have done more than 100
operations by this technique.
Preoperative Assessment
Cataract with nucleus grading I-III and no weakness of
zonules are selected. Complete ocular examination,
endothelial cell counts and IOP are measured in every
case. Three special instruments are required: Fig. 25.2: Corneal wound is made
1. Anterior chamber maintainer
2. Aspiration cannula and
3. Nucleus removal tube (Amporn–tube)
Fig. 25.3: Hydrodissection

After peribulbar anaesthesia is given, I perform
paracentesis at 2 sites at 6 and 12 O’clock. Six O’clock is
used for inserting A/C maintainer and 12 O’clock for
viscoelastic injection. After viscoelastic injection, make a
Fig. 25.1: Nucleus removal tube (Amporn-tube) 3.5 mm long corneal wound at temporal site. A large
The New Method of Manual-phacofragmentation (Phaco-drainage) 133
Fig. 25.4: Crack the nucleus into 4 pieces
Fig. 25.5: Insert the nucleus removal tube
capsulorhexis (5.5–6.5 mm) is performed. Hydrodis- handle of the nuclear removal tube) passive aspiration
section and hydrodelineation are carried out. force occurs; and when I close the valve, the passive force
Cracking the nucleus into 4 pieces in the capsular bag is stopped. That means I can control passive aspiration
with capsulorhexis forceps and Sinskey hook (very similar force by closing and opening the valve. The advantage is,
to pre–chop technique). The advantage of this technique I do not need any machines for suction force , decrease
is reduced corneal endothelium trauma. chance of A/C collapse , and decrease turbulence flow.
Insert the nuclear removal tube through corneal We can increase the passive aspiration force by
wound (3.5 mm) for removing the pieces of nucleus by increasing the height of bottle. Almost the height 60–70
this tube. The advantages are reduced wound size and cm is enough for creating the passive aspiration force.
wound trauma. If the pieces of nucleus are too large, two Sinskey hooks
Open the infusion line, BSS goes into the anterior are used to crack it into smaller pieces again. So that
chamber via A/C maintainer. When I open the valve, (at they it can pass through the tube.
IOP α H α Passive aspiration α 1/Fluid loss
Fig. 25.6: Passive aspiration force

Fig. 25.7: Crack the pieces of nucleus by Sinskey hook
Intraoperative parameters
Average viscoelastic substance 0.5+/–0.2 ml/case
Average irrigating fluid 178+/–13 ml/case
Average time to manage nucleus 5.75+/–1.77 min
Postoperative endothelial cell count and

loss at 3 months
Preoperative mean count (Cell/mm2) 2338.92+/–245.08
Postoperative mean cell loss (Cell/mm2) 1973.94+/–399.69
Fig. 25.8: Remove the remaining cortex Mean loss (%) 16.46+/–5.29
Postoperative BCVA (at 3 months) 0.8
After removal of all nuclear pieces, I clean the remain-
ing cortex by aspiration cannula. No serious complications are seen. A few cases of iris
Turn off BSS line and reinject the viscoelastic substance trauma and corneal wound oedema in the early period
into anterior chamber. Next, insert the foldable IOL as are found.
regular method.
Advantages
Result 1. No ultrasound—No heat.
On first postoperative day, the central corneas were 2. Cheap (do not need complicated machine).
clear and cells or flasre were minimal (no difference from 3. Less wound trauma (because pieces of nucleus pass
phacoemulsification). through tube and not through corneal wound).
The New Method of Manual-phacofragmentation (Phaco-drainage) 135
Fig. 25.9: Insert the foldable IOL

Disadvantages
1. Selected cases (NS grade 1+ to 3+).
2. More total operation time (average ≈ 30-40 min./case).
3. Need learning period.
4. Need special instruments (The nuclear removal tube).
CONCLUSION
I can perform cataract surgery with small incision without

phaco–machine in normal cataract cases (NS 1+ – 3+),
Improving the quality of nuclear removal tube is recom-
Fig. 25.10: First postoperative day
mended for improving the efficacy of operation (The nuc-
4. Minimal turbulence flow (decreased BSS to be used). lear removal tube is handmade , and the reusable tube
5. Can be inserted the foldable IOL. is not of good quality).
Temporal Tunnel
Incision in SICS
26 MK Rathore
T
he concept of surgically induced astigmatism has as the age advances, so that incidence of ATR is 5 to 6
added an entirely unique dimension to cataract times higher in age above 50 years (Duke Elder, 1969).
surgery with emphasis more focussed on the Jaffe (1975) observed prevalence of astigmatism as
refractive aspect of the surgery in present era. WTR 30 per cent, ATR 42.5 per cent and oblique in 17
Over the years, the better understanding of various per cent in preoperative cases and similar observation by
preoperative and intraoperative determinants of surgi- Singh and Kumar (1976) ATR 45 per cent, WTR 30 per
cally induced astigmatism has made it possible to actually cent and oblique in 15 per cent.
plan out the surgical intervention and their modifications Cornea flattens over any incision and this effect
according to preoperative state of astigmatism of the increases as incision approaches near the visual axis thus
patient in order to achieve minimum possible or nil post- superior incision results in postoperative ATR. This effect
operative astigmatism. in terms of visual gain is beneficial to preoperative WTR
Incision being the first and the most important determi- case, but unfavourable visual results in cases having high
nant of postoperative astigmatism which can be modified ATR preoperatively.
in various ways in terms of size, site, shape, axis, etc. to Therefore, the property of cornea to flatten along the
reduce the degree of postoperative astigmatism. Place- incision can be used to flatten the steeper horizontal meri-
ment of incision temporally along the vertical meridian dian in cases of preoperative ATR astigmatism by placing
is one modification to minimise the high pre-existing temporal incision.
against the rule (ATR) astigmatism, thereby improving For many years the superior site has been favourable
the visual outcome. approach in most of intraocular surgical procedure and
Besides, a temporal incision has other advantages too, it continues to be favoured location even today. In 1993,
it induces less amount of astigmatism as compared to Joel C performed surgery of cataract by lateral incision
superior one and has a better wound strength due to and found net reduction of ATR by 0.72D—statistically
minimal separational force of lid pressure and gravity. a significant amount. Thereafter, many other workers
The temporal limbus being farther from visual axis it advocated this approach to reduce or nullify ATR astig-
causes less distortion of central corneal curvature, matism (Nelson PJ, 1995; Haberle H et al, 1995; Volkmer
particularly in cases of secondary IOL implantation or in C, 1996; Weindler J 1996; Antoni HJ, 1997; Lyhne N et
eyes with previous surgery at 12 O’clock position al, 1998; Schuler 1998).
A temporal incision offers a distinct advantage of Bohm B et al (1997) reported lateral approach with
avoidance of incision being placed over the compromised scleral tunnel to be safe procedure and suggested it to be
scar tissue or preservation of functioning filtering bleb in used routinely in all patient having preoperative ATR
previous glaucoma surgery. The incision on temporal astigmatism.
side is also preferable in deeply seated eyes of operational
case and in cases of coloboma of iris. Useful in Secondary and Combined Procedure
ADVANTAGE OF TEMPORAL INCISION Masket S (1986) in his study on secondary IOL implan-
tation demonstrated overall reduction or corneal cylinder
Reduction against the Rule (ATR) Astigmatism
from modest flattening of surgical axis with a temporally
With the rule (WTR) astigmatism was found in 90 per oriented scleral pocket incision and found it water tight
cent of population which shifts to against the rule (ATR), stable wound with astigmatic control.
Temporal Tunnel Incision in SICS 137
Gayton JL (1996) found a substantially greater • Surgeon is required to perform the surgery from the
number of cases receiving a temporal cataract incision side and hence instead of sitting towards the head of
with a superonasal trabeculectomy. the patient, sits by his corresponding side
Caprioli J et al (1997) and Rossetti L et al (1997) also • Operating microscope needs to be positioned accor-
found the temporal incision advantageous in cases where dingly
superior limbus used for glaucoma surgery. It not only • As there is no support for the surgeon’s wrist, some
preserves the functioning bleb, but also minimises the kind of support (e.g. in the form of two cushions) has
ATR astigmatism resulted from previous surgery. to be used
• Bridle suture is passed underneath the lateral rectus
Stable Incision muscle instead of superior rectus suture (optional)
• All the steps of the surgery are the same as those being
Cravy TV (1991) found a statistically significant and performed from 12 O’clock position, but the incision
prolonged stabilisation of keratometric astigmatism in has to be bevelled more anteriorly as the temporal
planned ECCE via a lateral approach as compared to limbus is away as compared to the superior limbus
identical surgery performed in vertical meridian. • Lastly, performing the surgery from temporal aspect
Vazquez LA et al (1993) concluded that horizontal changes the functional angle, to which the surgeon
5 mm sutureless scleral tunnel incision showed less has to adjust himself initially. But after some practice
induced astigmatism with most rapid stable refraction. this position becomes less awkward and tedious
Similar observation by Wong HC et al (1994) and Haberle (Fig. 26.1).
H (1995).
Zheng et al (1997) found a 3 mm temporal pocket
incision tube astigmatically neutral. Simsek S et al (1998)
concluded that upper lid pressure on superior corneal
incision led to fluctuating ATR astigmatism. Wollensack J
et al (1995) and Anders N et al (1997) reported scleral
tunnel incision has highest wound stability as compared
to incision at 12 O’clock.
Corneal Topographic Changes
Vass C and Menapace RJ (1994) have reported in their

computerised statistically analysis of corneal topography
for changes after temporal incision resulted in mean
flattening of 0.4 to 1.4 D in temporal region but no
significant vertical steepening or nasal flattening noticed,
hence less effect on visual axis.
Hoffer KJ (1994) has reported that the temporal
incision induced minimal central endothelial cell loss
compared to a superior incision group since superior
cornea is closer to central cornea. Fig. 26.1: Temporal incision: extending the incision
SURGICAL STEPS COMPLICATIONS

There is no more difference in surgical steps of temporal Complications are few and manageable and are similar
tunnel as compared to small incision cataract surgery to SICS preformed from superior sector, but once the
from superior incision. Before considering surgery technique is mastered, it is very safe and rewarding.
through a temporal incision, certain modifications of the Intraoperative complications in our series of first 100 cases
surgical set-up and adjustments are necessary. were noticed as:
Premature anterior chamber entry 7.5 per cent, irido- A simple modification in incision placement produced
dialysis 7.5 per cent, posterior capsular rent 2.5 per cent. comparable results to other sophisticated procedure and
Postoperative complications includes-striate kerato- hence offers a way to attain better surgical outcome with
pathy 45 per cent on 1st day which is always reversible, limited resources available in most of the set-up.
fibrinoid reaction in 10 per cent, which responds quickly
to subconjunctival steroids + antibiotics injection. Pig- BIBLIOGRAPHY
ment dispersion in 5 per cent cases. Conjunctival flap
1. Anders N et al: Postoperative astigmatism and relative
retraction was more common 10 per cent as compared
strength of tunnel incision: A prospective clinical trial. J
to SICS for superior site as the conjunctival flap has no Cataract Refract Surg 23(3): 332-36, 1997.
support of lid pressure and gravity force. 2. Antoni HJ et al: 3½ years experience with ECCE with tunnel
Postoperative astigmatic control in our series of 100 incision. Ophthalmologe 94(1): 12-15, 1997.
initial cases 70 per cent was astigmatism upto 0.5 D and 3. Bohm B et al: 7 mm tunnel incision with lateral approach as
rest 30 per cent upto 1.0D. routine intervention in cataract surgery. Ophthalmologe
Thus showing a significant and favourable postope- 94(1): 3-5 1997.
rative refractive condition, which gives an edge over other 4. Caprioli J et al: Temporal corneal phacoemulsification in
filtered glaucoma patients. Trans Am Ophthalmol Soc 95:,
surgical site.
153-67; Discussion 167-70 1997.
There is WTR shift in temporal tunnel sutureless sur- 5. Chou JC et al: Cornea refractive changes after clear cornea
gery. A 6 mm to 6.5 mm temporal incision produced a phacoemulsification with foldable intraocular lens. Chung
mean surgically induced astigmatism (SIA) was 0.6 D Hua I. Hsuch Tsa Chih (Taipei) (Taiwan), 60(4): 195-98,
while same size of incision superiorly produces mean 1997.
astigmatism 0.98 D ATR (Similar observation by Neilson 6. Cravy TV: Routine use of a lateral approach to cataract extrac-
PJ (1995), Ullern M (1997) Chou JC (1997), Huang F tion to achieve rapid and sustained stabilization of post-
(1998). operative astigmatism. J Cataract Refract Surg 17(4): 415-
23, 1991.
Thus significantly minimum produced astigmatism has
7. Duke-Elder WS: System of Ophthalmology, Henry Kempton
always resulted in better unaided visual acuity. The basic London: 5: 95-102 274-80, 370-76, 1959.
principle of “Incision causing flattening along the meri- 8. Gayton JL et al: Combined cataract and glaucoma
dian in which it is placed” has been utilized for manage- procedures using temporal cataract surgery. J Cataract Refract
ment of moderate to high degree of preoperative astigma- Surg 22(10): 1485-91, 1996.
tism. The temporal incision was a neutralising effect on 9. Haberle H et al: Induced astigmatism in extracapsular cataract
preoperative ATR. extraction with tunnel incision and various wound closures.
Klin Monatsbl Augenheilkd 207(3): 176-79, 1995.
10. Heider W et al: Corneal topography after cataract surgery
CONCLUSION
with tunnel incision on a steeper meridian in inverse and
Preoperatie determinants form a major factor in final oblique astigmatism. Ophthalmologe 1997.
visual outcome following cataract surgery a meticulous 11. Hoffer KJ: Cell loss with temporal and superior incisions. J
work-up of preoperative astigmatism is necessary in order Cataract Refract Surg 20: 308, 1994.
12. Huang FC et al: Comparison of surgically induced astigma-
to reduce it, by suitable plan.
tism after sutureless temporal clear corneal and scleral frown
Entire surgical set-up and adjustment of surgeon’s posi- incision. J Cataract Refract Surg 24(4): 477-81, 1998.
tions, support to wrist, etc. are necessary before proce- 13. Jaffe N: Cataract Surgery and its Complications. CV Mosby
eding to surgery from temporal side. and Co: St. Louis 111-12, 127, 246-53, 1984.
Incision has to be bevelled more anteriorly as temporal 14. Joel C Axt et al: Reduction of postoperative against-the-rule
limbus is farther from visual axis. Due to change in func- astigmatism by lateral incision technique. J Cataract Refract
tional angle this approach of surgery may require little Surg 19(3): 380-86, 1993.
practice. 15. Lee T Nordan: The surgical rehabilitation of vision: An
Mean surgically induced astigmatism was 0.6 D. There integrated approach to anterior segment surgery. Gower
Medical Publishing: London, 23, 1992.
is WTR shift in all cases of temporal incision. Confirming
16. Liekfeld A et al: Self-closing corneoscleral tunnel incision in
this technique as “add” to refractive surgery while per- cataract surgery. Ophthalmologe 93(1): 8-11, 1996.
forming SICS, apart from this the temporal wound was 17. Lyhne N: Relationship between preoperative axis of
found to be more stable. This is a incision of choice in all astigmatism and postoperative astigmatic changes after
cases who have undergone previous surgery from 12 superior scleral incision phacoemulsification. J Cataract
O’clock position. Refract Surg 24(7): 435-39, 1998.
Temporal Tunnel Incision in SICS 139
18. Masket S: Temporal incision for astigmatic control in 23. Volkmer C et al: Minimising astigmatism by controlled
secondary implantation. J Cataract Refract Surg 12(2): 179- localization of cataract approach with the no stitch technique:
81, 1986. A prospective study. Klin Monatsbl Augenheilkd 209(2-3):
19. Nielson PJ: Prospective evaluation of surgically induced 100-04, 1996.
astigmatism and astigmatic kerototomy effects of various self 24. Weindler J et al: Is cranial corneoscleral 6 mm ‘no-stitch’ tun-
sealing small incision. J Cataract Refract Surg 27(1): 43-48, nel incision contraindicated in against-the-rule astigmatism?
1995.
Klin Monatsbl Augenheilkd 208(6): 428-30, 1996.
20. Simsek S et al: Effect of superior and temporal clear corneal
25. Wong HC et al: Corneal astigmatism induced by superior
incisions on astigmatism after sutureless phacoemulsification.
J Cataract Refract Surg 24(4): 515-18, 1998. versus temporal corneal incisions for extra-capsular cataract
21. Singh D, Kumar K: Keratometric changes after cataract extraction. Aust NZ J Ophthalmol 22(4): 237-41, 1994.
extraction. BJO 60: 638-41, 1976. 26. Zheng L et al: Astigmatism and visual recovery after ‘large
22. Vazquez LA et al: Surgically induced astigmatism: A incision’ extracapsular cataract surgery and ‘small’ incision
comparison of different cataract incision and closures PK for phacoemulsification. Trans Am Ophthalmol Soc 95: 387-
Health Sci J 12(2): 99-103, 1993. 410, Discussion 410-15, 1997.
Cortical Clean-up 27 RN Misra

TN Vyas
D
elivery of the nucleus either in one piece or in with small pupil and stringy cortex (which is difficult to
fragments marks the beginning of cortical aspirate by any technique) then the patient is in serious
aspiration. The cortex is also referred to as soft jeopardy. Every surgeon without a back-up I/A unit must
lens matter and its adequate removal is a very important master a manual cortical aspiration technique (Fig. 27.1).
step in present day cataract surgery, be it a conventional

extracapsular cataract extraction, phacoemulsification or
small incision cataract surgery. Ability to ensure its comp-
lete removal distinguishes the modern cataract surgery
from its earlier version. Successful cortical clean-up
involves adequate cortical removal while preserving the
capsular bag, suspensory ligaments of the lens (no
zonular dialysis) and the integrity of corneal endothelium.
Complete removal of the cortex goes a long way in
restoring quicker and better visual acuity. It also reduces
the chances of uveitis, posterior capsular opacification
and IOL decentration. It also greatly enhances the
visibility of the posterior segment in the event of any
posterior segment pathology like retinal detachment,
diabetic retinopathy, etc.
For the removal of the cortex, coaxial retroillumination Fig 27.1: I/A of cortex technique by simcoe
is invaluable. However, with proper regard for the
macula, this illumination must be used for as short a The main advantages of automated I/A system include
time as possible. This type of illumination should end as removal of the cortex in a tightly closed anterior chamber
soon as the lens is implanted by either turning the eye as a result anterior chamber remains deep, fornices
away from the upward direction by tightening the remains open and easily accessible. There is no forward
superior rectus bridle suture or by changing to oblique movement of the vitreous and posterior capsule and less
illumination or by both. chances of choroidal effusion or haemorrhage. Chances
Cortical removal can be accomplished using either of endothelial damage are less as the anterior chamber
the automated systems or manual irrigation aspiration remain deep all the time. The automated system however,
(I/A) devices depending upon the preference of the is not free from certain disadvantages like it is a difficult
surgeon or the demands of the situation. Each method procedure, requires prior setting and it lacks the instanta-
has got its merits and demerits. No single technique is neously variable intraoperative control by the surgeon.
suitable in all circumstances. Each surgeon has got his In a tightly closed chamber, a sudden surge of machine
own likes and dislikes and selects a technique that suits controlled infusion pressure can rupture the posterior
him the best. Even for those surgeons who are using an capsule. Outflow around a cannula in a less tightly closed
automated system for irrigation aspiration, it is imperative chamber decreases the chances of rupture but increases
that instruments for manual cortex removal be at hand irrigation volume requirement and causes more endo-
since a machine can fail. Familiarity with instruments for thelial damage. Conversely, manual cortical clean-up can
manual cortex removal is also essential. If the surgeon is be easily mastered ensures self-reliance, and offers greater
unprepared for machine failure and it occurs in an eye safety, sensitivity, flexibility and reliability.
Cortical Clean-up 141
With patience a surgeon can gradually learn to apply immediately reversible. This inexpensive, autoclavable
a degree of suction appropriate to the quality of cortical unit can be reused for a large number of times.
matter to be aspirated. The cortical material in the fornix Simcoe cannula is of two types—direct and reverse
has a very dense and mucoid consistency and therefore depending on the mode of infusion aspiration. In Simcoe
needs a higher level of aspiration which is immediately reverse cannula aspiration is bimanual and infusion is
administered by a thumb pull. In the case of granular either through a separate syringe connected to the
cortical material, less suction is required and a more cannula by a silastic tubing and held by an assistant or
delicate pull is used. With experience one gets to know through a gravity infusion, in which silastic tubing of the
almost intuitively how much suction to apply to each of cannula is connected by a drip set to the infusion bottle
the cortical presentations. There is no machine that can held high-up in a drip set stand. Infusion rate in the later
produce the delicate control of cortical aspiration that veriety is controlled by a stop attached with the drip set.
the human brain, coordinating with a hand, can sustain. In Simcoe direct type surgeon holds the cannula in one
Therefore, we strongly favour manual aspiration as hand (right hand for a right handed person) and aspira-
opposed to the insensitive machine aspiration in small tion is through the adjacent twin cannula connected by
incision cataract surgery. silastic tubing to a syringe isolated in the other hand.
The present chapter is designed to help define manual Infusion in this type is either from a silastic squeeze bulb
cortical removal technique. It may also stir interest in or directly through an infusion bottle connected to the
surgeons who are “married to the machine” to stimulate cannula by a dripset. Infusion through a silastic squeeze
them to try something new. Some surgeons may even bulb is directly under the control of the surgeon, as a
be converted to the manual technique. result it is gentle, minimal and just sufficient to replace
Cortical aspiration in small incision cataract surgery is the aspirated volume thereby avoiding turbulence in the
much different than cortical aspiration in extracapsular anterior chamber. On the other hand gravity infusion
cataract extraction procedure. For one thing, there is lacks the sensitive, variable control of the bulb.
much less cortex to remove. Some of it was washed away The syringe used for cortical aspiration has to be
with the hydrodissection, and some of it came out with capable of providing proper suction. Leaking plungers,
the outer nucleus. Secondly the closed chamber tight syringes too large or too small syringes do not work
technique in small incision cataract surgery also helps to
properly.
maintain the depth of the anterior chamber and that
Once the surgeon has got the instruments of his liking
makes it easier to get out the cortex. Deep anterior
the process of cortical clean-up begins. Curved Simcoe
chamber also helps to avoid corneal endothelial damage
cannula is gently slipped into the anterior chamber and
from instruments or excessive irrigation as well as capsule
the loose cortical material floating in the anterior chamber
or vitreous injury. If a continuous curvilinear capsulo-
is gently aspirated. Remove as much large cortical
rhexis has been done instead of a can-opener capsulo-
material as possible before turning to fine cortical rem-
tomy it makes the cortical aspiration much more easier
because it eliminates the capsular flaps that may interfere nants. Because in the event of vitreous loss fine cortical
with the aspiration. Subincisional cortex is however most remnants in the vitreous will get absorbed, where as larger
difficult to remove in small incision cataract surgery. cortical fragments can lead to a very severe inflammatory
A large variety of manual irrigation aspiration cannula response. Once the free floating cortical material has been
are available in the market, but the most commonly used aspirated, cannula is placed beneath the margin of the
one is Simcoe cannula. It is a small calibre (thin wall 23 anterior capsule and the cortical mater is engaged by
gauge) twin barrel I/A unit, one for aspiration and another applying gentle suction through the syringe and by a
for irrigation. Aspiration port is situated anteriorly where combination of rotation and translation pulled and
as infusion port is situated on the side. Simcoe cannula brought into the centre of the pupil before finally aspir-
are available in various gauges from 21 to 24, but 23 ating it (Fig. 27.2). Aspiration always proceeds from
gauge is probably the best, because port size is such that periphery to the centre of the pupil, never in the reverse
it is occluded by one tissue at a time either cortex, capsule direction. Only material that is clearly visible should be
or vitreous. Its port size is large enough for quick and aspirated. Tissue in the blind, under the iris, should be
safe cortical aspiration. moved to the pupillary area before the aspiration is done.
Irrigation aspiration in Simcoe cannula is indepen- While aspirating the porthole must be visible, i.e. it must
dently variable: control is sensitive, instantaneous, and face vertically upwards. This technique exploits the fact
that the cortical lens fibres are arranged radially, and are depending upon the preference of the surgeon or the
therefore easiest to aspirate in this direction. When pulling demands of the situation.
cortex from behind the iris, use gentle to and fro move- The cortex situated at 11 to 1 O’clock position or the
ments in order to loosen the material from the capsule at sub incisional cortex is the most difficult to aspirate. There
the equator. Thereby one obtains more material with less are various ways to aspirate it. Most commonly employed
suction and so reduces the danger of collapse of anterior technique is by making one or two side port incisions,
chamber. about 70 to 90° away from the primary incision and
The posterior capsule must be watched for different aspirating the subincisional cortex by a Simcoe cannula.
lines, (curved or straight). The former indicates that the Another method, which can be used, is by J shaped or
cortex is still present whereas later indicates that the U shaped cannula (Fig. 27.4). In this technique cannula
capsule has been caught in the suction port. The is inserted into the incision sideways, and then rotated
recognition of these lines, particularly the straight ones to place the tip under the anterior capsule and cortex is
radiating out from the suction port indicating that the aspirated. If capsulorhexis has been done, IOL can be
posterior capsule is incorporated in the aspiration port placed in the bag and then rotated by 180°, haptics of
are very important because any further aspiration or the IOL could dislodge the superior cortex, which can
movement while it is impacted will lead to the rupture of then be easily aspirated. This technique works very well
the posterior capsule. Engagement of the posterior specially if there is a lot of cortex left. However, if rhexis
capsule in the port mandates immediate cessation of has not been performed and IOL is to be placed in the
suction and reflux to disengage it (Fig. 27.3). Otherwise, ciliary sulcus, this technique is of no use. A gentle massage
the capsule will be ruptured and vitreous will be lost. of the iris by the irrigation aspiration cannula at the 12
Avoid the build-up of high intraocular pressure, sudden O’clock position can dislodge the subincisional cortex,
large amplitude movements of the iris, capsule and which then can be aspirated. Disadvantages of this
hazardous intraocular movement of the cannula. Use as technique include damage to zonules and iris. It can also
little irrigating fluid as possible. constrict the pupil thereby making cortical clean-up
A collapsing bag is a feature of zonule dehiscence and further more difficult. Small amount of cortical material
makes removal of the cortical matter very difficult. can be left in the subincisional area, rather than to struggle
Continued aspiration of the cortex tends to exacerbate and cause a posterior capsular rent or zonular dialysis.
the problem, and a capsular tension ring should be
considered. Posterior Capsule Polishing
Cortical aspiration should ideally start from 6 O’clock It can be done by gently rubbing the posterior capsule
position and gradually proceed towards 5, 4, 3, 2, O’clock by the Simcoe cannula itself. Apart from this several
position and 7, 8, 9, 10 O’clock position or vice versa instruments are available to polish the posterior capsule.
Fig 27.2: Engaging the cortical matter with aspiration port Fig 27.3: Radial ‘stress lines’ in posterior capsule on
beneath the anterior capsule rim adherence with suction port
Cortical Clean-up 143
Fig 27.5: Capsular polishing. Courtesy: Alcon (India)

Fig 27.4: Cortical wash through J shaped cannula
Courtesy: Alcon (India)
needle or picked away by a Mcpherson forceps. One
Kratz scratcher is one instrument quite commonly used. should not be too aggressive with residual plaques as an
opening in the posterior capsule can be made at a later
It is nothing but a curved irrigating needle roughened

up by sand blasting, hydrohoning or coating with particles date with Nd: YAG laser.
of diamond dust. It is used by attaching it to cystitome
handle. Blunt air injection cannula or an olive tipped Cortical Clean-up in PC Rent
needle can also be used for capsular polishing. It should If the posterior capsular tear occurs at the time of cortical
be rubbed gently against the posterior capsule to remove clean-up, cannula should be withdrawn from the anterior
the fine lens matter adherent to the posterior capsule chamber immediately. Anterior chamber should be filled
(Fig. 27.5). As the polisher touches the posterior capsule, with the viscoelastic, so as to push the vitreous face back
a halo reflex appears around the scratcher. Pressure and distent the capsular bag. If vitreous is not in the
applied through the scratcher or polisher must be anterior chamber, i.e. vitreous face is intact, then the area
sufficient enough to produce a halo of about 4 mm. of posterior capsular tear is left alone and cortex from
Excessive pressure may result in stress lines. other areas is removed, preferably with dry aspiration
The effectiveness of the posterior capsule cleaning (filling the anterior chamber with viscoelastic repeatedly
often depends on the physical characteristics of the and aspirating the cortex). Cortex should be aspirated
capsule. A thin, floppy posterior capsule is the most dan- towards the tear and never away from it, otherwise it
gerous. It is difficult to slide the tip of the polisher along may pull the vitreous. With dry aspiration almost all the
it without dragging it into folds that can rupture. A thick, cortex can be removed without disturbing the vitreous.
taught capsule is easiest to clean. Not infrequently, a If the cortex has got mixed with the vitreous and vitreous
plaque may be present on the posterior capsule. It can is present in the angle or the wound an anterior vitrectomy
sometimes be scratched away by a fine tip of a bent should be performed.
Intraocular
Lenses
28 Tanuj Dada
Harinder Sethi
T
he evolution of the cataract surgery with the OPTIC MATERIALS FOR IOLs
introduction of intraocular lens implantation has An ideal IOL material should have following properties:
been one of the major achievements of modern • High optical quality
medicine. The intraocular lenses provide a precise • High index of refraction

pseudophakic optical rehabilitation with minimal magni- • Light weight
fication and excellent optical properties. The advent of • Durable, resistant to mechanical stress
small incision surgery made possible by phacoemulsi- • Easy fabrication
fication and foldable IOLs represents another major • Non antigenic/non-allergic
milestone in cataract surgery. It is important for the • Non carcinogenic
ophthalmologists to have an in-depth knowledge of the • Sterilization easy
basic design and optical features of the various IOLs • Lack of inflammatory reaction, foreign body reaction,
currently in use. or tissue chaffing
• Blocking UV radiation
Classification of IOLs • Implantable through a small incision.
1. Site of implantation
i. Posterior chamber IOLs Polymethylmethacrylate (PMMA)
ii. Iris plane IOLs It is an inert polymer of methyl methacrylate monomer.
iii. Anterior chamber IOLs It is manufactured through addition polymerization of
iv. Scleral fixated IOLs. methacrylic acid methylester, which is derived from
2. Flexibility of lenses acrylic acid. It was the first material to be used for intra-
i. Rigid IOLs–PMMA ocular implants by Harold Ridley. The idea of this material
ii. Foldable IOLs–silicone, hydrogel, acrylic, being used for IOLs came from the fact that it had been
collamer. noticed that during World War II, intraocular fragments
3. Material of optic of PMMA in the eyes of the pilots (which came from the
i. Polymethyl methacrylate (PMMA) optic shattered canopies of fighter aircrafts), demonstrated inert
ii. Silicone optic properties. This material is light, hard and transparent
iii. Hydrogel or hydrophilic acrylic and transmits a broader spectrum of light than the human
iv. Hydrophobic acrylic lens, thereby allowing the transmission of UV rays. Hence
v. Thermoset (memory lens) UV absorbing materials have been incorporated as
vi. Collamer. covalently bonded or entrapped chromophores to pre-
4. Combination of optic and haptic material vent retinal damage. The agents commonly used as UV
i. Single piece IOL–haptic and optic made of same absorbers are benzotriazoles and benzophenones. The
material, e.g. all PMMA single piece IOL, all material is hydrophobic and may damage corneal endo-
acrylic single piece IOL. thelium on contact. The main disadvantage of PMMA
ii. Three piece IOL–where optic and haptic are lenses is that they are non-flexible and have to be inserted
made of different materials, e.g. three piece through a larger incision. The specific gravity of PMMA
PMMA IOL (optic made of PMMA and haptics is 1.19 and the refractive index of 1.497. PMMA has the
of polypropylene), acrysol IOL (optic made of longest track record as an intraocular lens material and
hydrophobic acrylic and haptics of PMMA. has given an excellent optical performance till date.
Intraocular Lenses 145
Surface modification by heparin and other chemicals can a tan brown colour had been reported in the first gene-
be done to reduce the deposits over the IOL and ration lenses and these lenses cannot be used in the pre-
opacification. sence of silicone oil within the eye as it chemically adheres
to these lenses.
Silicone Recently second generation silicone material has been
introduced which has a higher refractive index and is
It is composed of repeating chains of cross-linked dime- increasingly becoming popular. The Pharmacia-Upjohn
thyl siloxane. The major advantages of this material are CeeOn Edge 911 IOL represents the second generation
the autoclavibility and decreased trauma to the intra- silicone IOLs. The edge of the optic is square or truncated
ocular structures. Silicone has affinity for proteins, which and it uses polyvinylidine fluoride haptic material with a
may account for the build up of the surface proteins on well-designed Cap C haptic configuration design provid-
to the IOL optic. The material has a low tensile strenth ing an excellent memory.
and must be handled carefully to avoid tearing. It is com-
pressible and has an excellent memory (the ability to Hydrogel
return to original shape after deformation). The refrac-

tive index is 1.41–1.46 and specific gravity is 1.01–1.06. The optic of hydrogel lenses is made up poly-hydoxy-
Due to low refractive index, their relative thickness is more ethylmethacrylate (HEMA) with a 38 per cent water con-
for the same dioptric power and hence high power sili- tent and bonded with an UV absorber. They are lathe
cone lenses are thick and cumbersome to handle with cut in the dry state and require polishing. They are rigid
an uncontrolled opening inside the eye. Discoloration to in the dehydrated state and become soft and rubbery on
Three Piece Silicone Intraocular Lenses

Properties Elastimide IOL SI 30 NB SI 40 NB SI 55 NB Array SA 40 N
Design 3 piece 3 piece 3 piece 3 piece 3 piece

silicone-IOL silicone-IOL silicone-IOL silicone-IOL silicone-IOL
Model AQ-1016/AQ SI 30 NB SI 40 NB SI 55 NB SA 40 N
–2010/AQ
–2003
Manufacturer Staar Surgical, Inc. Allergan Inc. Allergan Inc. Allergan Inc. Allergan Inc.
Overall diameter 13.5/13.5/12.5 13.0 13.0 13.0 13.0

(mm)
Optic diameter Biconvex 6.3 Biconvex 6.0 Biconvex 6.0 Biconvex 5.5 Biconvex 6.0
(mm)
Optic diameter Silicone polymer Silicone polymer Silicone polymer Silicone polymer Silicone polymer
Water content < 1% < 1% < 1% < 1% < 1%
Refractive index NA 1.46 1.46 1.46 1.46
Haptic material Polyimide Polypropylene PMMA PMMA PMMA
Haptic angulation 10 deg 10 deg 10 deg 10 deg 10 deg
A– constant 119 117.4 118 118 118
ACD (mm) 5.55 4.4 4.7 4.7 4.7
Diopter (range) +14.5 to +28.5 +6.0 to +30 +6.0 to +30 +6.0 to +30 +16.0 to +24
Incision (mm) NA NA NA 2.6 3.0

Properties CeeOn 912 CeeOn Edge 911

Design 3 piece silicone– IOL 3 piece silicone-IOL
Model CeeOn 912 CeeOn 912
Manufacturer Pharmacia-Upjohn, Inc. Pharmacia-Upjohn, Inc.
Overall diameter (mm) 12.0 12.0
Optic diameter (mm) Biconvex 6.0 Biconvex 6.0
Optic diameter Silicone polymer Silicone polymer
Water content < 1% < 1%
Refractive index 1.43 1.46
Haptic material PMMA PVDG (polyvinylidene fluoride)
Haptic angulation 6 deg 6 deg
A– constant 117.8 118.3

ACD (mm) 4.6 4.9
Diopter (range) +10 to +30.0 +12.0 to +28.0
Incision (mm) NA NA
hydration. Since they are hydrophilic, they are less group of polymers resembles the living tissue in their
damaging to the corneal endothelium on contact. These physical properties more than any other class of materials
lenses have a low tensile strength and can get torn on and are the easiest to insert as they are pre-rolled and
insertion. This IOL material may accumulate protein open up inside the eye gradually with hydration.
deposits and can be deformed by tissue pressures, leading However, many lenses made from this material are
to optical changes and changes in effective power. Their required to be maintained in a cold chain which is a
refractive index is 1.47 and specific gravity is 1.19. This major disadvantage with these lenses.
Memory Thermoset IOL

Properties Memory Lens
Design 3-piece–hydrogel-IOL
Model Memory Lens U940A
Manufacturer Ciba Vision, Inc.
Overall diameter (mm) 130
Optic diameter (mm) 6.0
Optic material Hydrogel polymer
Water content 20 %
Refractive index 1.47
Haptic material Polypropylene
Haptic angulation 10 deg
A– constant 119
ACD (mm) 5.6
Diopter (range) N/A
Acrylic have both the optic and haptic made up of acrylic.
Various studies have documented that PCO rates are
Flexible acrylic is a co-polymer of phenylethylacrylate least with the Acrysof lenses which has been related to
and phenylethylmethacrylate. The cross-linking imparts the good biocompatibility of this IOL. This is due to the
it a good three-dimensional stability and temperture “sticky” characteristic of the IOL and its close adherence
dependent viscoelasticity. Lenses made of this material with both the anterior and posterior capsules and the
are softer and more easily foldable at body temperature the square truncated optic edge.
than room temperature. Unfolding is much slower and
more controlled than silicone lenses. It has high refractive HAPTIC MATERIALS FOR IOLs
index of 1.55 making it the thinnest lens possible. Its has
a unique surface characteristic, i.e. tackiness (tendency Nylon (polyamide)
to adhere to surgical instruments and posterior capsule.
These are available as single piece (all acrylic) and 3- These are fibre polymers with repeating amide
piece lenses (PMMA haptics) and are currently the most (-CONH-) groups. They are named according to the
popular foldable lens materials with the minimum inci- number of carbon atoms in the monomer subunits. The
dence of posterior capsular opacification. The decreased commonly used ones are nylon 6 (Perlon, Supramid)
rate of posterior capsular opacification (PCO) has been and nylon 66.
attributed to the square edge design of the lens optic, It has a tendency to slowly hydrolyse with gradual
which has a barrier effect on proliferating lens epithelial water absorption and to be broken down at amide sites
cells. by proteolytic enzymes. Hence they have gone into
The Alcon AcrySof is the most popular IOL in this disuse. Polyimide material is similar to polyamide, but
group. It has an optic made up of flexible acrylic avail- with greater heat resistance and has been used with glass
able in 2 diameters of 5.5 mm (MA30BA) and 6 mm and silicon optic.
(MA60BM) and open loop haptics made of PMMA. The
overall diameter of the IOL is 12.5 mm (smaller optic) Polymethylmethacrylate (PMMA)
and 13 mm (larger optic). Recently single piece AcrySof The advantage of PMMA haptics is the total lack of degra-
lenses have also been introduced in the market which dation in vivo. Since they are stiffer than polypropylene,
Acrylic Foldable IOLs

Design 3 piece acrylic- IOL 3 piece acrylic- IOL
Model AcrySof MA30BA (5.5mm optic),
MA60BM (6.0mm optic). AR-40
Manufacturer Alcon Laboratories, Inc. Allergan, Inc.
Overall diameter (mm) 12.5 and 13.0 13.0
Optic Diameter (mm) Biconvex 5.5 and 6.0 Biconvex 6.0
Optic diamter Hydrophobic acrylic polymer Hydrophobic acrylic polymer
Water content < 0.5% NA
Refractive index 1.55 1.47
Haptic material PMMA PMMA
Haptic angulation 5 and 10 deg 5 deg
A– constant 118.9 118.4
ACD (mm) 5.49 5.2
Diopter (range) + 10.0 to + 30 MA30BA + 10.0 to +30
+6 to + 30 MA60BM
Incision (mm) 3.0 to 3.5 and 3.5 to 4.0 3.2
they can be easily dialed in the bag. Moreover, they have decentration. Prolene loops are more flexible making
better memory than polypropylene, with better fixation insertion easier. The main disadvantage of these haptics
and centration. Three-piece silicone IOL with polypro- is that they activate the complement pathway leading to
pylene haptics have a higher incidence of decentration, neutrophil chemotaxis with more postoperative inflam-
pigment adherence and capsule opacification compared mation. Bacteria also adhere better to polypropylene and
with PMMA haptics. Single piece all-PMMA exhibit the this leads to a greater risk of endophthalmitis. Hence this
best loop memory. It is currently the most popular haptic material is no longer used for making IOL haptics.
material. An angulation of the haptics 10 degrees anterior
to the optic is done to minimize pupillary capture and Polyvinylidene fluoride (PVDF)
iris chaffing.
This is the latest IOL haptic material that has recently
Polypropylene (Prolene) been introduced with some of the new generation silicone
lenses. It provides a good memory and very stable
It is polymer derived from propane. Its chief advantage fixation.
is its hydrophobic nature making it very resistant to
hydrolysis. However a full spectrum UV light irradiation Haptic Design

leads to loss of tensile strenth. It is commonly used in the
three-piece lenses because of its biological compatibility, There are basically three types of haptic designs currently
resistance to biodegradation, flexibility and tensile in use:
strength. It is usually dyed blue or purple for better visi- 1. Open loop (such as modified C loop design).
bility. A tendency to loose memory with time when 2. Plate haptic (Chiron C10UB and C11UB)
deformed by tissue is noted, with higher incidence of 3. Mini loop plate haptic design (Medevec VS2)
Plate Haptic Lenses

Small Hole Plate Silicone Plate Lens Large Hole Plate Silicone Lens
Properties Bausch and Lomb Staar Surgical, Inc. Bausch and Lomb Staar Surgical, Inc.
Surgical, Inc. Surgical, Inc.
Design 1– piece silicone IOL 1– piece silicone IOL 1– piece silicone IOL 1– piece silicone IOL
Model C10 UB AA-4203V C11 UB AA-4203 VF
(small holes 0.3 mm) (Small holes 0.3 mm) (large holes 1.15 mm) (large holes 1.15 mm)
Manufacturer Bausch and Lomb Staar Surgical, Inc. Bausch and Lomb Staar Surgical, Inc.
Surgical ,Inc Surgical ,Inc
(Formerly Chiron Vision)c (Formerly Chiron Vision)c
Overall diameter 10.5 10.5 10.5 10.5
(mm)
Optic diameter Biconvex 6.0 mm Biconvex 6.0 mm Biconvex 6.0 mm Biconvex 6.0 mm
(mm)
Optic material Silicone polymer Silicone polymer Silicone polymer Silicone polymer
Water content < 1% < 1% < 1% < 1%
Refractive index 1.413 1.413 1.413 1.413
Haptic material Silicone Silicone Silicone Silicone
Haptic angulation 0 deg 0 deg 0 deg 0 deg
A– constant 119 118.5 119 118.5
ACD (mm) 5.59 5.26 5.59 5.26
Diopter (range) +4 to +31 +14.5 to +28.5 +4 to +31 +14.5 to +28.5
Incision (mm) 3.2 3.5 3.2 3.2
BASIC PRINCIPLES OF IOL MANUFACTURE used. These lenses are essentially one-piece PMMA
implants with either of two kinds of optic design, round
Lathe Cutting
or oval. The round optic lenses have a diameter ranging
The PMMA is taken as large block and a lathe with a tip from 5.0 to 5.5 mm, while the oval optic lenses have a
is used to cut the optic to the predetermined size, shape horizontal diameter of 5.0 mm and a vertical diameter
and radius of curvature. The lens formed has rough edges of 6.0 mm. The overall diameter of these lenses ranges
and surface, requiring polishing by a tumbling process from 11.5 to 12.5 mm, approximately the diameter of
(lens is placed in a vertically rotating drum where in it the empty capsular sac. The oval lens optic is no longer
tumbles repeatedly with polishing compounds) or used as they are more prone to decentration and an
specialized rotating rods (moved over the lens to make it increased incidence of postoperative glare and diplopia
smooth). The residual polishing compound is thoroughly has been reported with these lenses (Fig. 28.1)
removed.
Injection Molding
The PMMA block or pellet is heated and forced at high

pressure through a steel mould which is designed to
provide a proper shape, size, and power of the lens. Later
the material softens and takes the shape of the mould.
Thereafter the mould is removed and lens is polished.
Injection moulded lenses have a tendency to wrap with
time and produce optical distortion. A higher suscepti-
bility to damage by Nd: YAG laser is also reported.
Compression Molding
It is a hybrid process of lathe cutting and injection mold-
ing. The PMMA is first lathe cut and the rough version is
placed in the mold of the specific shape and power. It is
then subjected to high temperature and pressure and later
polished.
Cast Molding
It is similar to injection molding except that preformed One-Piece
PMMA is not used. The resin that is purified and distilled
from the methylmethacrylate monomer is mixed with a Fig. 28.1: Diagrammatic representation of the most
catalyst and poured into the injection mold. The actual commonly used posterior chamber IOls.
polymerization of the PMMA occurs inside the mold. The The main disadvantage of using these lenses is that
process allows more accuracy and reproducibility. More- since they are rigid, implantation of these lenses requires
over, the UV absorber can be added prior to polymeri- an enlargement of the incision size equal to optic
sation giving better bonding. diameter. Once the incision is enlarged to 5-5.5 mm it
no longer remains astigmatically neutral and there is an
PROFILE OF RIGID IOLs USED FOR
increased chance of postoperative leakage from the
SMALL INCISION CATARACT SURGERY
wound if left unsutured. Even if there is no leakage of
Conventionally an optic size of 6.5 mm and an overall fluid after applying pressure on the cornea/sclera at the
diameter of 13 mm has been used for cataract surgery operating table one should always apply a suture. This
with IOL implantation in the ciliary sulcus. With the is important because there can be a long-term slippage
advent of small incision cataract surgery and capsulo- of the wound lip and progressive against the rule
rhexis it has become possible to place the lenses within astigmatism in such cases. Therefore, one must apply
the capsular bag and hence smaller lenses are now being atleast one 10-0 monofilament nylon suture when rigid
IOLs are used for small incision cataract surgery. Another 6. If vitreoretinal surgery is required in an eye with a sili-
problem with these lenses is that due to the smaller optic cone implant, silicone oil cannot be used as a vitreous
size, there can be problems of glare/diplopia in patients substitute.
with large pupils and during night vision. There is also a 7. Currently foldable lenses are also much more expen-
higher incidence of posterior capsular opacification and sive than rigid PMMA lenses.
decentration. These lenses should not be used if the
capsulorhexis has been torn or if there is a large posterior Surgical Considerations in the
capsular rupture such that the lens has to be placed over Insertion of Foldable IOLs
the margin of the capsulorhexis. Currently these are the
most popular lenses used for small incision cataract There are two basic techniques for foldable IOL insertion.
surgery in our country due to the low cost. These IOLs can be inserted into the capsular bag by using
a passport/insertor/injector system or a holder-folder
FOLDABLE IOLs system. The former system requires the smallest incision
size for IOL implantation. The holder-folder method is
These lenses mark a major landmark in history of IOLs the most popular method for IOL insertion.
and as the name suggests these lenses can be folded The IOL can be folded by using either of the two
and thus inserted from small incisions in cataract surgery. principles.
1. Horizontal or longitudinal principle which allows for
Advantages a two-step implantation technique ensuring control
1. Require a small incision (2.5-3.5 mm) for insertion. and safety. This is folding along the 6 to 12 O’clock
2. This decreases postoperative astigmatism, increases meridian such that the haptics form a “moustache”.
wound stability and allows rapid visual rehabilitation. The anterior haptic goes in first under the capsulorhexis
3. These lenses have a decreased incidence of risk of margin while the posterior haptic stays outside the
posterior capsular opacification and cellular preci- wound. After the IOL is released inside the capsular
pitates on the lens surface as compared to PMMA bag, the posterior optic is dialled into the capsular
lenses. bag.
4. These lenses are relatively easy to explant due to 2. Vertical or transverse principle which allows the lens
decreased perilenticular fibrosis with these lenses. In to be placed in the bag in one manoeuvre. This is
addition due to a soft lens material the optic can be folding along the 3 to 9 O’clock meridian such that
cut into two and easily removed. both haptics are placed together in the capsular bag
5. Currently used foldable lenses also have a better Nd- and do not need to be dialed after the lens opens up
YAG laser compatibility and put decreased strain on in the capsular bag.
the zonules because of their reduced weight. It is important to remember that silicone IOLs should
be dry before handled with the holder/folder, while acrylic
Disadvantages lenses should be wet when folded.
1. Foldable lenses have a shorter track record and their In the event of a zonular dialysis the IOL should be
long-term biocompatibility within the ocular tissues inserted after putting an endocapsular ring (ECR) made
has not been fully evaluated. of PMMA to stabilise the capsular bag.
2. These lenses have a low tensile strength and are thus The injector systems use a disposable cartridge
more prone to damage during implantation. Perma- wherein the IOL is placed. There is usually drawing of
nent fold marks and creases from holding, folding and the IOL outlined on the cartridge, which tells the surgeon
inserting these lenses may produce disturbances in as to which direction the IOL should be placed. The IOL
vision. In a cold temperature acrylic lenses may even is placed in the cartridge coated with a viscoelastic, the
crack when folded. cartridge is then closed and inserted into the injector.
3. Some of the foldable IOLs such as the Memory require The screw of the injector is slowly turned and one can
a cold chain to be maintained in a foldable form. visualize the haptic of the IOL coming into the nozzle of
4. Lens discoloration has been reported with silicone the cartridge. The nozzle is then placed inside the capsular
IOLs. bag which has already been filled with viscoelastic and
5. It is difficult to use a foldable IOL in the presence of a the screw of the injector turned further to release the IOL
posterior capsular rent. into the capsular bag.
Problems Encountered during Foldable IOL Insertion by a distance optical power. A new model made of sili-
i. The optic may slip if it is wet, especially if it is a cone with PMMA haptics has shown surprisingly good
silicone IOL. clinical results despite the potential for visual blur with
ii. Flipping out of the IOL may result from inappropriate pupillary miosis. The NuVueTM is considered to be a “near
instruments and technique. dominant”, MIOL and some surgeons use it in a mono-
iii. Breakage of the haptic can occur from incorrect vision capacity for the near eye.
tucking of the haptic during insertion.
iv. Tearing of the optic can occur if the handling is not Three-zone MIOL A variety of three-zone MIOLs pro-
gentle, especially during the use of hydrogel IOLs. viding distance and near vision by using a near annulus
v. The optic may crack when folded. This is usually at various distance from the central distance component
seen with acrylic IOLs if they are used in a cold have been popular. The Storz True VistaTM and the
environment. Domilens Progress ThreeTM are examples of this style.
vi. The IOL may unfold with a sudden jerk within the Normal pupil patients do enjoy both near and distance
capsular bag. This can lead to a loss of capsular vision but smaller pupils can obstruct the near component
with some three-zone MIOLs. One advantage of this lens
integrity and a posterior capsular tear.

vii. Delayed unfolding may be seen during the insertion design is that even though there is pupil dependency,
of AcrySof or Memory lens. distance vision is always preserved despite the loss of
viii. The IOL optic may be indented/damaged by pres- near acuity with miosis.
sure from the holding/folding instrument. Spherical Curve MIOL The AMO ArrayTM SA40N MIOL
ix. Incomplete opening of the holder may occur and is a lens designed with five zones of near and distance
the IOL may not be released into the capsular bag. powers on the anterior surface of the optic. These power
In such cases the IOL needs to be disengaged from rings help to reduce pupillary dependency. The ArrayTM
the holder with the help of a Sinskey hook is considered a “distance dominant” lens and provides
introduced from the side port incision. near acuities without correction in the J-3 range or better,
x. Detachment of the Descemet’s membrane may offering good midrange and near acuity for most tasks.
occur during IOL insertion. Some patients will prefer the addition of a bifocal add
for finer print and especially under low-light conditions.
MULTIFOCAL INTRAOCULAR LENSES
The AMO ArrayTM is available in a foldable silicone
The intraocular lenses commonly in use have a fixed material with PMMA haptics. A new injectable delivery
focus which can be adjusted by adjusting the IOL power system allows for greater ease of insertion. The AMO
to serve for near, intermediate or distance vision. It is ArrayTM lens is currently the most popular multifocal IOL
not possible to see near and distant objects clearly with in current use.
these lenses and thus patients are always dependent on
spectacles. Over the past decade, a variety of multifical DIFFRACTIVE MIOLs
intraocular lenses (MIOLs) have been introduced and
Diffractive optics multifocal technology is slowly gaining
enjoyed a widespread clinical use. Both refractive and
wide acceptance. The major advantage of this lens is
diffractive models have been shown to be effective in
less pupil dependency and the ability to provide an even
allowing each eye to achieve quality, uncorrected distance
distribution of near and distance vision. However,
and near acuity after cataract surgery. The major con-
cerns with the use of these lenses are the loss of contrast manufacturing techniques are more difficult and critical
sensitivity and the inducement of glare and halos from with these lenses due to difficulties with making of the
light sources during night vision. All MIOLs require careful diffractive plate. Pharmacia has developed a diffractive
attention to IOL power calculations and the creation of a MIOL, the CeeonTM 811E. Addition of a diffractive
relatively planospherical result after surgery. component to the popular AcrysofTM acrylic IOL is also
under consideration.
REFRACTIVE MIOLs
ACCOMMODATING INTRAOCULAR LENS
Target or Centre Surround MIOL
The ability to implant a new lens within the original
TM capsular bag of the crystalline lens and restore the physio-
The Chiron NuVue is an example of an MIOL with the
central near add in the middle of the optic surrounded logic accommodation is a concept being investigated by
many research workers all over the globe. Kamman and Descemet’s membrane detachment is likely to occur if
Cumming have modifed the traditional plate haptic IOL is inserted just parallel to the scleral tunnel incision
silicon IOL to allow for movement of the IOL within the and where a detached scroll of membrane is already
capsular bag after insertion. This intriguing design has present. In such cases the membrane can be repositioned
demonstrated initial success in restoring presbyopic through the injection of air or expanding gas into the
accommodation. Accommodative amplitudes of approxi- anterior chamber.
mately 2 to 3 diopters have been observed. However,
long-term studies have to be done before the clinical Posterior Capsular Rupture during IOL Insertion
efficacy of these lenses is established. The posterior capsule can be ruptured during IOL
insertion and a if there is a pre-existing tear in the posterior
TORIC INTRAOCULAR LENSES capsule, it can extend. Such a complication can occur if
The plate haptic IOL design has been modified to adequate quantity of viscoelastic has not been inserted
produce a toric IOL with the correction cylinder added in the bag or there is considerable leakage of viscoelastic
along the long axis of the IOL. This is marked on the substance during IOL insertion. The use of a passport
surface of the lens optic. For the toric design to be effec- system with plate haptic lenses is more likely to cause
tive, the lens should not rotate within the eye after implan- this problem. If there is a tear in the posterior capsule
tation. Rotation is relatively unusual but can occur during prior to IOL insertion, the injector/passport system should
the first 4 to 6 weeks after implantation, prior to fibrosis not be used at all. If a tear occurs during IOL insertion,
around the lens and through the large positioning holes. the IOL may be left in the bag if the tear is small and the
After this 4 to 6-week period the lens fixates in the viscoelastic removed manually with a Simcoe cannula
capsular bag via the fibrosis through the positioning holes or using bimanual irrigation-aspiration. However if there
and fusion of the anterior and posterior capsules. This is a large tear then the IOL should be placed on the
helps to prevent long-term rotation as well as decentration margin of the capsulorhexis.
and dislocation of the IOL.
IOL Damage during Insertion
PIGGYBACK INTRAOCULAR LENSES The haptics may be damaged during IOL insertion
This concept involves the use of two intraocular lenses through a small wound and one of the haptics may be
placed one on top of the other (piggyback). This may be broken. In such cases it is essential to remove and replace
done as a primary procedure to obtain an optimal the IOL. During insertion care should be taken to
refractive result in highly ametropic eyes (e.g. high adequately extend the incision so as not to force the IOL
hypermetropia) where sufficiently high power in a single through a small and tight wound. Special caution is
IOL may not be available. The second IOL can also be warranted when a high power IOL is injected. Use of a
implanted at a later date as a secondary procedure to wrong forceps for holding the IOL may cause compres-
correct for a poor refractive result of the previous cataract sion marks on the IOL optic and may even crack the
surgery. Both the lenses can be placed in the capsular IOL requiring explantation of the IOL.
bag or one can be placed in the bag and the second IOL
in the ciliary sulcus. The main complication with use of Bag Sulcus Fixation
piggyback lenses is interlenticular opacification or During insertion of the IOL, the lower haptic may be
interpseudophakic opacification of polypseudophakia placed in the bag and the upper haptic may lie in the
(opacification between the two IOLs) which may require ciliary sulcus. This can lead to IOL decentration and the
both IOLs to be explanted. haptic may also cause a chronic uveitis/pigment
dispersion by rubbing on the iris tissue. Asymmetric loop
COMPLICATIONS OF placement can also cause the windshield wiper syndrome
FOLDABLE INTRAOCULAR LENSES with the superior loop and optic shifting position with
eye movements and causing damage to the corneal
Descemet’s Membrane Detachment Caused by
IOL during Insertion
endothelium. To avoid this complication the upper loop
of the IOL should be carefully dialed in the bag and the
When inserting an IOL the lower edge of the optic can surgeon should check that both haptics are in the bag
cause a Descemet’s membrane detachment. This before concluding the surgery.
Capsular Bag Distension Syndrome Silicone Oil Adherence to IOL
This problem arises when a small capsulorhexis comp- Irreversible silicone oil adhesion to the optic of a silicone
letely covers the optic and thereby seals the capsular bag. foldable IOL may occur during vitreoretinal surgery. The
There is sequestration of fluid secreted from the remnant silicone oil droplets condense on to the optic of the IOL
epithelial cells within the capsular bag and a progressive and lead to a severe degradation of the optics of the
inflation of the capsular bag. Retained viscoelastic IOL. This condition can be avoided by not implanting
material behind the IOL can also lead to this condition silicone IOLs in eyes with present or potential vitreo-
by creating an osmotic gradient and drawing more fluid retinal disease.
from across the capsule. This creates to an anterior shift
of the IOL and progressive myopia. The condition can Capsular Contracture Syndrome
be prevented by performing a large capsulorhexis. The
The anterior capsulorhexis can undergo a progressive
treatment of this capsular distension syndrome is done
contracture leading to a capsular phimosis with obs-
by doing a Nd-YAG laser capsulotomy of the anterior
curation of the visual axis and decentration of the IOL.
capsule. A nick is created at the edge of the capsulorhexis

This occurs due to a fibrous metaplasia of the residual
at 2/3rd locations, which allows fluid trapped within the
lens epithelial cells and is aggravated if the original
capsular bag to escape into the anterior chamber.
capsulorhexis is small. This complication is most
frequently seen with the silicone plate haptic lenses. The
IOL Decentration contracture can be relieved by performing a YAG
Implanting a small diameter IOL (which is meant to go capsulotomy at the margin of the anterior capsule.
in the capsular bag) in the ciliary sulcus can lead to a
severe decentration of the IOL. This is especially seen Uveitis
when a rent in the posterior capsule occurs and the small Polypropylene haptics can activate complement and
diameter IOL is placed over the margin of the capsu- induce white cell chemotaxis and thus incite an inflam-
lorhexis by the surgeon. It is important to remember that matory reaction. IOLs with polypropylene haptics are
plate haptic lenses which do not have open loops should also a risk factor for endophthalmitis with a risk 4 ½ times
never be placed over the capsulorhexis. The surgeon that of all PMMA posterior chamber lenses.
should always have a large diameter (6.5 mm optic, over-
all diameter 13 mm) IOL available for implanting in the Endophthalmitis
ciliary sulcus in the event of a large posterior capsular
Delayed onset endophthalmitis, which has a delayed
rupture. In cases of zonular dehiscence, a PMMA endo-
onset and an indolent course, has been described in eyes
capsular ring should be implanted within the capsular
with intraocular lenses. The most common responsible
bag and then the IOL inserted, to prevent decentration
organism is Staphylococcus epidermidis. A more indolent
of the IOL.
from caused by Propionibacterium acnes may present
as chronic granulomatous uveitis with white plaques on
Lens Dislocation the posterior capsule. This infection appears to be
Complete lens dislocation into the vitreous is a rare enhanced by localized entrapment of organisms within
complication. It may occur due to the presence of an the capsule and has been reported only in eyes with intra-
unrecognized zonular dialysis during surgery or the pre- ocular lenses. Adherence of organisms to lenses may play
sence of pre-existing zonular deficiency such as in post- some role. If Propionibacterium is suspected vancomycin
traumatic eyes or eyes that have undergone previous is the treatment of choice, although some cases may not
vitreoretinal surgery. Such a complication has also been respond to medical management and require an IOL
reported after YAG capsulotomy, especially with plate explantation with excision of the involved capsule.
haptic lenses. A pars plana vitrectomy is necessary for
IOL Discolouration
removal of lenses dislocated into the vitreous and the
intraocular lens may then be repositioned with iris or IOL discolouration has been reported with the first
scleral suturing or substituted with an anterior chamber generation silicone IOLs. The discolouration of the optic
IOL. varies from light tan to a brown colour and appears from
15 months to 5 years after implantation. It can also be Posterior Capsule Opacification

seen in the IOLs in vitro if the lenses have not been used
Posterior capsular opacification (PCO) is currently the
for a long time. Although this colouration does not affect
most important issue in modern day cataract surgery.
the visual acuity, it can cause a fall in the contrast
sensitivity. Residual lens epithelial cells at the equator and the
anterior capsule proliferate and cause an opacification
IOL Glistenings of the posterior capsule after cataract surgery. This leads
to a decrease in the visual acuity, contrast sensitivity and
This complication has been reported with the AcrySof
causes glare. Silicone and PMMA lenses have higher rates
IOL especially if AcryPak packaging has been used
of PCO as compared to acrylic lenses. A YAG laser
instead of the traditional wagon wheel packaging. These
capsulotomy has to be performed in such cases but it
glistenings are basically microvacuole formation within
can cause damage to the optic of the IOL and opening
the lens optic and are influenced by temperature changes.
up of the posterior capsule increases the risk of a
This can cause a significant decrease in the contrast sensi-
tivity and induce glare. subsequent retinal detachment. PCO can be reduced by
the following factors:

Glare 1. Adequate hydrodissection for facilitating a complete
cortical clean up.
Use of small optics (<5.5 mm) can cause an edge glare,
2. An in-the-bag fixation of the IOL.
especially during conditions of decreased illumination,
which cause a pupillary dilatation. This is a serious prob- 3. Diameter of the capsulorhexis slightly smaller than the
lem with square edge lenses such as the AcrySof with a optic (seals the bag).
5.5 mm optic. It can cause a significant visual disability 4. High biocompatibility of the IOL.
to the patients, especially during night driving. A trial of 5. Maximal IOL optic-posterior capsule contact.
0.5-1 per cent pilocarpine may be done to decrease the 6. Square truncated edge of the IOL optic.
symptoms in such patients, although the IOL may even 7. Primary posterior capsulorhexis with optic capture in
have to be explanted due to this problem. pediatric cases.
The Technique of IOL Implantation in SICS 155
The Technique of
IOL Implantation
29
in SICS Nikhilesh Trivedi
I
t is a foregone conclusion that, if the surgery has been Within the SICS also, there are some subtle differences.
uneventful till this stage, there are unlikely to be many While most of the SICS techniques involve the use of
hiccups on your way to successfully completing viscoelastics, the Blumenthal technique (my technique
sutureless cataract extraction with IOL implantation. of choice) uses BSS itself to keep the AC formed for
Probably that is why there is so little literature available implantation. This gives rise to another set of problems
on techniques of IOL implantation. which unfold as you proceed with implantation. As the
Nevertheless, a few pertinent points need to be elicited IOL is pushed through the tunnel, due to positive pressure
here, for the benefit of the beginner, or for those con- in the AC, the leading haptic tends to bend strongly. On
verting from conventional ECCE to SICS. entering the AC, this haptic springs free suddenly. At this
The peculiarities of IOL implantation in SICS arise stage, the AC tends to become shallow, with the escaping
out of the specific nature of the passageway. At 3.5 to of the BSS. So if you continue pushing the IOL, you
may be trying to introduce it into the bag when the
4.5 mm, the sclerocorneal tunnel of SICS is the longest
posterior capsule may be convex, and not concave. The
passageway the IOL must traverse before being implan-
consequences are well-imaginable. Even with the IOL in
ted. By comparison, the passageway in conventional
the AC, and the leading haptic in the bag, introducing
ECCE is barely 1.5 mm, and even the clear corneal tun-
any instrument through the tunnel to manipulate the
nel, favoured by today’s phaco surgeons, is a mere 2 to
upper haptic into the bag also results in a shallowing of
2.5 mm (Fig. 29.1). Also, the SICS tunnel traverses two
the AC. Though mostly harmless, this is alarming enough
different tissues, the sclera, and the cornea. Therefore, to induce tachycardia in the surgeon.
certain differences exist in the technique of implantation After 4 incidents of near disaster, I changed my
of the IOL in SICS, vis a vis the conventional ECCE, or technique of IOL implantation, from Push and Dial, to
the phacoemulsification. Pull and Dial. This has saved me from many an anxious
moment since then. I will now describe both the
techniques, step by step.
The Technique
Step 1
This will apply to those SICS techniques where visco-
elastic is used. Fill the AC and the capsular bag with
visco. Preferably, introduce your visco cannula through
the main tunnel, and not the side port. Keep injecting
visco as you withdraw your cannula after filling the AC
and the bag. Make sure that you inject some visco in the
tunnel also. This will keep the tunnel slightly gaping, as
Fig. 29.1: Comeoscleral tunnel for SICS well as act as a lubricant for the passage of a rigid IOL.
Step 2 Sinskey hook from the side port with your first hand.
The lower dialing hole should be visible at the internal
Here it is presumed that rigid IOLs are being used. The
use of foldable IOLs in SICS is unnecessary and unwar- (corneal) incision. Engage this hole with the hook and
ranted, since the tunnel is at least 5.5 mm wide, and can drag or pull the lens into the AC, directing the lower
accommodate most of the rigid lenses. haptic into the bag at six O’clock (Fig. 29.2). The upper
Hold the IOL with McPherson’s forceps near the upper haptic may sometimes tend to snag in the tunnel at this
dialing hole. Alternatively, the vertical Daljeet Singh IOL stage, but can be easily guided with the plane forceps in
forceps could be used to grasp the lens longitudinally. the other hand. When the leading haptic is safely in the
This would be useful for the push and dial, but not for bag, you may disengage the Sinskey hook from the lower
the pull and dial technique. dialing hole and engage it in the upper dialing hole (Fig.
29.3). By this time, the entire IOL is in the AC, and the
Step 3 tunnel is sealed, giving you a deep AC. You can now
easily dial the upper haptic into the bag.
Push and Dial Introduce the leading haptic into the
tunnel. As you see the leading haptic enter the AC, tilt
the lens downwards so that the haptic is directed towards
the six O’clock pole. Keep pushing the lens till the leading
haptic is completely in the bag, and the lower dialing
hole is also at the pupillary border at six O’clock. Gently
release the IOL and withdraw the forceps. You may now
introduce the Sinskey hook from the side port, or the
main tunnel, and dial the IOL into the bag. Alternatively,
you may grasp the upper haptic with McPherson’s
forceps, and rotate the lens as you tuck the upper haptic
under the edge of the capsule or the pupillary border. At
any stage, if the AC becomes shallow, cease, and reform
the AC with more viscoelastic. Once the IOL is in place
and well-centered, removing the viscoelastic, and corneal
hydration of the sideports if any, will complete the last
steps of a successful SICS.
Step 4
Pull and Dial This is an excellent procedure for the

Blumenthal technique where hydrostatic pressure is used
to form the AC and fill the capsular bag for implantation.
When you start implanting, the tunnel is tightly closed
due to the BSS flowing into the AC through the Anterior Fig. 29.2: Implantation technique
Chamber Maintainer. Hence the leading haptic bends
dangerously (and may even break!) when you push the CONCLUSION
IOL into the tunnel. As the lens enters the AC and you This modification of the technique for Blumenthal
keep pushing the lens, the haptic suddenly springs free. becomes necessary as the AC shallows as soon as you
This is accompanied by a slight shallowing of the AC as introduce any instrument or the IOL through the tunnel
the BSS gushes out of the tunnel. Push the IOL a little into the AC. If you try to introduce much of the IOL
more till the main body of the lens is blocking the tunnel, into the AC as you did in the Push and Dial technique,
and the gush of BSS diminishes. As you now release the the risk of traumatizing the posterior capsule or the
IOL from the McPherson’s forceps, use the other hand corneal endothelium is high. Hence it is better to Pull
with a plane micro-forceps, to hold the upper haptic and and Dial, rather than Push and Dial, for the Blumenthal
to tilt the lens slightly downwards. Now introduce a technique.
The Technique of IOL Implantation in SICS 157
An uneven tunnel, or a rough floor of the tunnel, can
cause much difficulty, particularly in the implantation of
the IOL.
At no stage should you try to continue pushing the
IOL if the AC has shallowed. You must cease, but need
not withdraw the IOL. Rather, deepen the chamber by
pushing more viscoelastic from the side port, over the
IOL. Then you can carry on from where you left the
IOL.
The dictum ‘Better Safe Than Sorry’ would be a useful
one to memorise and recall.
REFERENCES
1. Thomas R, Kuriakose T, George R: Efficient small-incision

cataract surgery, Indian J Ophthalmol 48: 145-51, 2000.
Fig. 29.3: Implantation technique drawing the lens
downwards from upper hole 2. Blumenthal M, Askenazi I, Fogel R et al: The Gliding Nucleus,
J Cataract Refract Surg 19: 435-37, 1993.
CARE TO BE TAKEN 3. Lahane TP: The incision-structural principles, Opthalmology
Today 2: 93-95, 2001.
For any SICS procedure, a good and clean tunnel is an 4. Blumenthal M: Surgical principles and techniques for small
absolute must. The importance of using a sharp (or new) incision ECCE. Mini Highlights of Ophthalmology 21: 5(1-
crescent knife for each case cannot be overemphasised. 8), 1993.
Wound
Closure
30 MP Tandon
TN Vyas
T
he main function of a tunnel incision is to provide Horizontal Sutures
watertight self-sealing valved wound. By pressing They are less likely to disturb the alignment of internal
against the dome of cornea and on the limbus entry incision so as to cause less astigmatism than radial
one can check the integrity of wound. Sealing can be sutures. They make the incision watertight by flattening
done by hydration of corneal stroma, which is achieved the scleral tunnel types of horizontal sutures.
by injecting irrigating fluid into the external tip of the 1. Shepherd’s single horizontal suture This suture was
side port wound. The integrity is tested by applying introduced by shepherd primarily for closure of scleral
pressure with a sponge against the posterior lip of the tunnel of 5 mm width, which were weak. This consists
wound to make the incision leak. In the absence of leak, of a single bite starting at one end of the wound
the incision is covered with the conjunctival flap.Suturing entering the roof and floor of pocket vertically, passing
is required if: it horizontally to the other end along the floor of the
a. There is a leaking tunnel. pocket and then bringing it externally through the roof
b. Tunnel is more than 6.5 mm in length, even if it is of the pocket on the other side of the tunnel. The
self-sealing in order to avoid against the rule asti- externalised sutures are then tied, thus closing the
gmatism. incision. But this technique was not appropriate for
c. Premature entry. longer incisions, besides it resulted in an externalised
d. Triple procedure has been done. knot, and passage of suture through the deep layer of
e. Paediatric cataract (due to thin sclera). the scleral pocket cannot be seen (Figs 30.1a to e).
Suturing techniques can be divided into:
1. Appositional/Radial/Vertical sutures.
2. Horizontal.
Both can be either interrupted, figure of eight or conti-
nuous. Interrupted sutures give better control through
individual suture cutting while continuous suture equa-
lises the tension across the wound.
Vertical Sutures
They appose the external lip of the wound, which results

in internal separation of the corneal lip because of pulling
of the sclera and cornea. They are separated by the
normal physiological gape, and this pulling of external
Fig. 30.1a: Enter roof and floor of the
wound creates a new un-physiological position. The pocket vertically at one end
internal entry site, which is the true astigmatism control
site is separated and disturbed. This can be reduced by 2. Horizontal anchor suture was introduced by Masket
taking deep bites in the scleral bed, which brings proper for incisions between 4.0 to 7.0 mm in length to allow
apposition of the scleral bed to the superficial flap. direct visualisation of the horizontal suture within the
Wound Closure 159
Fig. 30.1b: Pass the suture horizontally to the

other end along the floor
Figs 30.1d and e: The suture being tied closes the incision
anterior placement of the external layer of the scleral

Fig. 30.1c: Bring out the suture through the
pocket and the induction of an “against-the-rule”
roof of pocket on the other end and tie it
astigmatic change (Figs 30.2a to h).
deep layer of scleral pocket. It also had the advantage
to close the incisional “Dead space”, to prevent internal
wound gape and “fish-mouthing”, to bury the knot
within the pocket, to provide a central “anchor” against
Fig. 30.2c: Externalize the suture through the roof of incision
Fig. 30.2d: Bring it horizontally through one extreme of incision

and enter the incision through its roof and run horizontally in
Figs 30.2a and b: Take a miniradial bite towards the cornea the floor
Fig. 30.2e: Make a safety loop over the initial miniradial pass Fig. 30.2g: Bring it out through the roof, run horizontally again
enter through the roof just before the centre of incision matching
the initial miniradial suture
Fig. 30.2f: Run deep in the floor of inicsion horizontally to

reach the other end of the incision
The technique consists of applying the suture in the Fig. 30.2h: The knot is burried in the scleral pocket,
deep bed of the pocket with a miniradial bite taken preventing conjunctival irritation
towards the cornea and externalised through the outer
layer of the pocket. The suture then passed horizontally
to the right extreme of the pocket and pierced through
the outer layer or roof of the pocket to enter the wound
space. The horizontal or circumferential portion of suture
continued from right to left under direct visualisation
in two bites, creating a safety loop over the initial
mini-radial pass. The extreme left of the deep layer or
floor of the pocket is reached, the suture then brought
externally and carried to the centre of the incision where
it was passed through the roof of the pocket into the
floor of the bed under the safety loop, matching the
original mini-radial bite and completing the suture course.
Fig. 30.3a: Enter the tunnel through the roof
The knot is buried within the scleral pocket to prevent
conjunctival irritation.
Fines Infinity Sutures
Resembles mathematical symbol for infinity in cross

section. It was introduced for closure of tunnel of 6.5
mm. It consists of two loops each covering approximately
40 per cent of tunnel width. The first loop enters the
wound space through the roof, pierces the floor of the
pocket and is their passed horizontally along the floor of
the pocket. It thin exits just left of the midline, through
the roof in the pocket. The second loop is similarly made
at the other end of the incision, again exiting just right to
the midline. The two ends of the sutures are tied externally Fig. 30.3b: Pass the suture horizontally along the floor of
closing the incision (Figs 30.3a to i). tunnel and take it out just to the other side of midline
Wound Closure 161
Fig. 30.3c: Take out the suture through the roof of tunnel Fig. 30.3f: Take out the suture through the roof of the tunnel
Fig. 30.3d: Make the 2nd loop Fig. 30.3g: Tie the suture externally
Fig. 30.3e: Run the suture along the floor of tunnel and take
out just beyond the midline
Alternatively the second bite of the suture can be taken

with the second needle of a double-armed suture, just to
the right of the exit point of the first bite and advancing Figs 30.3h and i: In cross-section this suture resembles the
the needle from right to left. mathematical symbol for infinity
Fig. 30.4a: Radial sutures reapproximate the edges of external Fig. 30.4b: Horizontal sutures flatten the tunnel creating a more
incision, pulling the cornea and sclera to a new, unphysiological physiological closure of internal incision, thus decreasing the
position, disturbing the internal entry site which is the true degree of astigmatism
astigmatism control site
SUGGESTED READING
1. Fiche H: Infinity suture: Modified horizontal suture for 6.5
The comparison of horizontal vs vertical sutures are mm incisions in Gills JP, Sanders DR (Eds): SICS Me Stitch
shown in Figures 36.4a and b. In the end we can advice, Surgery: Thordfare, NJ Slack, 191-96, 1990.
2. Manual small incision cataract surgery: an alternative tech-
if you are in doubt that the tunnel incision is not self-
nique to instrumental phaco-emulsification publisher Arvind
sealing do not feel nicer in applying suture, never depend Publications, Madurai, India 33-34, 2000.
on nature because nature may be against you, as it is 3. Masket S : Horizontal anchor suture closure method for SICS.
rightly said that “a stitch in time save a nine.” J Cat Refr Surg (Suppl.) 689-95, 1991.
When and How to Convert? 163
When and
How to Convert?
31 Kamaljeet Singh
T
he ultimate goal of the surgeon and the patient consequently nucleus prolapse in anterior chamber
both is achieving good vision. Keeping this in mind will not be possible, and cortical cleanup will also be
the surgeon should never mind converting to difficult. During delivery of nucleus the iris starts
coming out first. So it is better not to plan manual
conventional Extra Capsular Cataract Extraction (ECCE).

While operating, if there is insistence of completing the phaco. But in case the pupil becomes small during
surgery through small incision, bad results are sure to the surgery one should convert to conventional
occur. Postoperatively the results can even make you incision of ECCE.
think against the choice of this surgery. It is always better b. Incision size I can make an incision as large as 7.5
to learn from other’s experience and faults. Followings mm if the need arises, e.g. in black hard cataract there
are the pearls for the beginners: is no point keeping length of incision at 5.5 mm as
Preoperative assessment should be immaculate described in the standard textbooks. If I find slightest
because some cases are difficult to manage by this difficulty in delivering the nucleus out, I am ready to
technique especially for the beginners. Elder the patients increase the length of incision (Fig. 31.1), or to convert
more are chances of large nucleus and also poor
endothelial cells count. These patients should be avoided
initially. Patients with Fuch’s Endothelial Dystrophy, small
pupils, old uveitis, hypotony, and black cataracts are good
for conventional ECCE. Selection of softer cataracts in
younger patients (less than 55 years) is excellent to begin
with and patients between 55 to 60 years are good
candidates. Beyond this age surgeon’s skill and hardness
of cataract will come into play.
WHEN TO CONVERT?
It is important to keep in mind that our aim is to give
vision to the patient. Beginners may stick to the original
plan despite facing complications. I have seen most
successful and experienced cricketers change their stance
on the quality of balling attack. Sachin is a great player
because he can adjust to the all kinds of balling tech-
niques. These may be spin, medium pace or fast balling.
Similarly the experienced surgeons change their
technique depending upon the difficulties encountered.
Following points need to be taken care of:
a. Small pupil Manual phaco is difficult to manage in
small pupils. Small pupil can be present preoperatively.
In this case it is better not to plan manual phaco, Fig. 31.1: The incision should be extended
because large capsulorhexis is not possible, as long as in conventional ECCE
Fig. 31.2a: Nucleus delivery difficult through small incision Fig. 31.2b: Enlargement of incision makes delivery easy
to conventional ECCE. As a beginner I used to deliver the complications can be dealt with easily when you
the nucleus out through smaller incisions and faced are in the midst of your well-recognised surgery. So
the music as I got white cornea the next day. So moral converting to conventional ECCE is advised. Although
of the story is never hesitate in increasing the length this complication can be managed nicely in closed
of incision or converting to conventional ECCE in hard chamber. Vitrectomy if vitreous has come in anterior
cataracts. chamber, removal of the cortical matter, and implan-
c. Tunnel If the tunnel is not nicely made, you are sure tation, all are possible within the chamber.
to land into trouble. Premature entry into anterior So, to conclude to my mind small pupil, unexpected
chamber will lead to iris prolapse during procedures large nucleus, iris prolapsing through the tunnel, difficulty
like delivery of nucleus and washing of cortical matter. in prolapsing the nucleus and posterior capsule rupture
Hyphaema and even iridodialysis may occur. In this are the main culprits and one should not hesitate in
situation it is better to convert. converting.
d. Difficulty in nucleus prolapse If the nucleus prolapse
is not possible by a few manoeuvres. One should con- HOW TO CONVERT?
vert. The factors responsible for difficulty in nucleus Conversion is very simple. The scleral incision is extended
prolapse are small capsulorhexis and hypotony. If towards the limbus with the help of corneal section
capsulorhexis is small one can give relaxing incisions enlarging scissors. Then the incision is extended on the
at ten and two O’clock position. One more trial should limbus on both temporal and nasal sides. The incision is
be given for prolapsing the nucleus. Still if it is not extended to the usually performed ECCE length so that
possible to prolapse the nucleus conversion is the best there is no undue pressure required for extraction of the
answer. Hypotony causes maximum hindrance in nucleus (Figs 31.2a and b).
prolapse of the nucleus. If hypotony is too much the
surgeon will feel as if there is a vacuum pump inside SUGGESTED READING
the eye, which is pulling the lens back. In this case
1. Bhattacharjee H, Singh S, Deka S: Small incision cataract
also the author suggests conversion to conventional
surgery (SICS) In Printers and Publishers. 133-91, 1998.
ECCE. 2. G Natchiar: Manual Small Incision Cataract Surgery. Arvind
e. Posterior capsule rupture After the delivery of nucleus Publishers: Madurai, India 67- 68, 2000.
during cortical cleanup at first sight of posterior capsule 3. Jaffe NS, JaffeMS, Jaffe GF: Surgical techniques in cataract
rupture, the mind should be set for conversion because surgery and its complications. Mosby 65-131, 1997.
Current Status of Medications in Cataract Surgery 165
Current Status of
Medications in
32 Kamaljeet Singh
Shweta Pandey
Cataract Surgery Monika Joshi
P
reoperative use of medication varies from place ciprofloxacin, 0.3 per cent ofloxacin and 0.3 per cent
to place and surgeon to surgeon. In some centres norfloxacin was done. Topical ofloxacin achieved a signi-
too many drugs are used and at others too few. ficantly higher mean level in aqueous humour than cipro-
Moreover, there is always addition to the existing list of floxacin, and both were higher than norfloxacin. These
availability of medicines. Antibiotics, steroids, povidone MICs were good enough to combat most of ocular patho-
iodine and non-steroidal anti-inflammatory drugs are the gens that may cause postoperative endophthalmitis. For
mainstays of the pre, intra and postoperative treatment the above three antibiotics another study was carried
available today. In this article we will discuss the present out by Von Keyserlingk et al.3 They concluded that these
scenario of their usage under following heads: antibiotics achieved higher concentration for majority of
l. Antibiotics the gram-negative bacteria but these are not prophy-
2. Corticosteroids lactically effective against Streptococcus pneumonie or
3. Non-steroidal anti-inflammatory drugs. Pseudomonas aeruginosa. It seems that of the currently
available antibiotics for preoperative topical use ofloxacin
Antibiotics is the best antibiotic but may not be prophylactically very
effective against Streptococcus pneumonie or Pseudomo-
It is very clear now that most important source of post- nas aeruginosa.
operative infection is patient’s own flora. Therefore pre- Povidone iodine five per cent, an iodine-releasing
operative antibiotics eye drops are used commonly. These polymer has shown to destroy bacteria in 30 seconds
days commonly used preoperative antibiotic drops are and its efficacy being equal to 3-day antibiotic eye drops
ciprofloxacin, tobramycin and ofloxacin. The question containing polymixin, gentamicin and neomycin. It has
is which antibiotic is the best amongst the presently avail- antibiotic, antifungal and antiviral properties. When
able medicines. In a study: by Durmazetal1 to compare antibiotic drops and povidone iodine both are instilled
the aqueous humour concentrations of topically applied together the effect achieved is additive and further
ciprofloxacin, ofloxacin and tobramycin in 30 patients decrease in antimicrobial load results. Povidoneiodine
undergoing cataract or trabecullectomy surgery. These five per cent should be practiced as a routine before
eye drops were used for six times at an interval of 15 cataract surgery. It has also been found that when IOLs
minutes beginning 90 minutes before the surgery. The are implanted they carry some microbials with them due
mean aqueous humour level of ciprofloxacin was 0.02+/ to contact with the bulbar conjunctiva. Povidoneiodine
-0.077 microgram/ml, ofloxacin 0.964+/–0.693 micro- applied before the surgery can be very useful in this aspect
gram/ml. Tobramycin did not reach the concentration as well.
that could be detected by the applied method. The study Subconjunctival injections of antibiotic: Bacte-
concluded that aqueous humour levels of ofloxacin and ria have been isolated from the anterior chamber after
ciprofloxacin were more than the minimum inhibitory the surgery despite above measures. Luckily the body
concentration (M1C) levels for most of the pathogens resistance is such that these are taken care of. But still
that may cause postoperative endophthalmitis. In an- this provides enough evidence of the use of antibiotics
other study by Akkan et al 2 comparison of 0.3 per cent by sub-conjunctival route.4 There are two schools of
thought for their usage through this route. One school endophthalmitis reduced from .08% to .05% by intra-
does not subscribe to the idea of use of subconjunctival cameral use of carbapenem and imipenen in 2160 cases.
injection and the other does. The first says that O’Brien7 reported that intracameral use of antibiotic
endophthalmitis developed despite injection being given polymixin and bactracin in both in vitro and in vivo rabbit
and organism being sensitive to the antibiotic used. This models results in statistically significant reduction in
school argues that there are chances of globe perforation. bacterial colonisation. Other authors like Feys et al8 found
The other school recommends subconjunctival injection that addition vancomycin had no effect on the occurrence
of antibiotic and most commonly used antibiotic for this of intraocular contamination. Lehman9 reports that
purpose is gentamicin. intracameral gentamicin is cleared so fast from the
antibiotic the bactericidal effects are difficult to reach in
Intracameral Use of Antibiotic that short time. Ferro et al10 are also of the opinion that
This method of use of antibiotic is also an important the intracameral use of antibiotic may not be of much
method. Frequently used antibiotics by this method are help. The Center for Disease Control11 has issued a warn-
gentamicin and vancomycin. Antibiotics are injected into ing to limit the use of vencomycin because of the reported
the infusion bottle in the hope that the incidence of development of resistance. Thus exact recommendation
postoperative endophthalmitis will reduce. But this aspect of intracameral use is still lacking.
is also controversial. Greatest problem with wide spread
Non-steroidal Anti-inflammatory Agents
usage of the antibiotics is development of resistance. In
addition, there are chances of toxicity to the retina if they Several non-steroidal anti-inflammatory agents like
are not properly used. The Endophthalmitis Vitrectomy flurbiprofen, indomethacin, diclofenac, ketorolac are used
Study found that systemic antibiotics were not required preoperatively for maintenance of pupillary dilatation
in addition to intravitreal antibiotics for the treatment of postoperatively to reduce the reaction after cataract sur-
postoperative endophthalmitis. This paper5 also suggests gery. Many studies have been done on the above drugs
the reason for this; eighteen patients with postoperative comparing their effects with each other and with steroids
endophthalmitis were studied, following intravenous as well. Recently voltaren has been introduced and
injection of 1g of vancomycin in 14 patients and intra- several studies reported its beneficial effect over other
vitreal injection of 1mg in four patients. The concentration anti-inflammatory eye drops. In a study conducted by
of vancomycin in the vitreous ranged from 0.4-4.5 mg Ostrov et al12 no significant difference was found between
per ml in the patients who had received intravenous ketorolac, prednisolone acetate, and dexamethasone in
injections, which was lower than the minimal inhibitory the postoperative period in the cells and flare in aqueous.
concentrations (MICs) required for the causative bacteria In fact incidence of postoperative cystoid macular
isolated from the same samples. In contrast, the concen- oedema was less common in patients who used ketorolac
tration of vancomycin in the four patients who received eye drops. Another study conducted by Schmidt et al13
intravitreal injection varied from 25-182 mg per ml. Also showed that the reduction in anterior chamber flare as
of note is that the vancomycin was still present upto 72 measured by laser flare meter was significantly greater
hours from the time of the intravitreal injection. There is with flurbiprofen or with indomethacin. In a double
little need to add intravenous administration to an intra- masked conducted by Butt et al14 comparison of the effect
vitreal injection of vancomycin. Vancomycin is very effec- of voltaren-gentamycin combination with dexame-
tive against the gram-positive cocci that are likely to be thasone-neomycin-polymixin combination no statistically
responsible for more than 90 per cent of confirmed cases significant difference was found in anterior chamber after
of bacterial endophthalmitis. It is worrying; therefore, that the extracapsular cataract surgery. Similarly other authors
many cataract surgeons are using low-dose vancomycin
Rowen et al and Roberts et al15 found voltaren to be
in their infusion fluids as a prophylactic, which is probably
very effective in preventing postoperative reaction and
not reaching the MICs required and may in fact be
almost as effective as steroid and better than other non-
encouraging resistance to this extremely useful, low
steroidal anti-inflammatory agents.
toxicity drug. Several studies have been done to prove
or disprove the above point. Adenis et al6 recommend
Corticosteroids
the use of vancomycin on the basis that the concentration
achieved after the surgery were quite effective. Shimuzu Corticosteroids are commonly used anti-inflammatory
and Shimuzu observed that their incidence of agents after cataract surgery. Their anti-inflammatory
Current Status of Medications in Cataract Surgery 167
effect is considered more superior than the non-steroidal intraocular steroid preparation would no longer be active,
anti-inflammatory agents, but the greatest problem with was seen only infrequently. DEX DDS may prove useful
their use is rise in the intraocular pressure. Commonly in postoperative treatment regimens where antibiotic
used corticosteroids are dexamethasone, prednisolone, drops are not given either, for it means that the patient
fluromethalone. Intraoperatively used method is by does not need to use postoperative drops at all.
subconjunctival route. Many surgeons prefer to use this Rimexolone and loteprednol are two recently in-
route others do not. In order to lay this controversy to troduced steroids in USA. In studies done by Leibowitz
rest Nakamura et al15 conducted a study comparing this et al18 and Novack et al19 it has been reported that
route with those who did not receive intraoperative loteprednol is less likely to cause postoperative rise of
injection. Weijtens et al16 differ and showed that a sub- intraocular pressure than prednisolone and has equal
conjunctival injection of steroid resulted in significant effect in anterior chamber flare after the surgery
aqueous and vitreous concentrations. In 50 patients
undergoing vitrectomy for various indications, 2.5 mg CONCLUSIONS
of dexamethasone was injected subconjunctivally after Ofloxacin and ciprofloxacin are good antibiotics because
topical anaesthesia, and aqueous, vitreous and serum of better bioavailabiltiy in aqueous humour. They may
samples were taken at the beginning of surgery. There be used both preoperatively and postoperatively.
was no control peribulbar steroid group; instead the Voltaren, a non-steroidal anti-inflammatory agent can
aqueous and vitreous concentrations were compared with be used safely for preventing intraoperative miosis and
those from previous studies of peribulbar dexamethasone can also be used in place of steroids in postoperative
injections. High aqueous concentrations of dexame- period for reducing the anterior chamber reaction and
thasone were found, and the mean peak vitreous concen- for prevention of cystoid macular oedema.
tration was found to be 12 and 3 times higher than after Subconjunctival injection of antibiotic and steroids
oral and peribulbar administration, respectively. The remains a controversial subject. Intracameral use of
authors of the paper feel that these results warrant a antibiotic also remains a controversial topic. Intraocular
randomised trial to establish whether subconjunctival use of steroid is a new method of delivery.
corticosteroids administration, particularly for delivering
dexamethasone to the posterior segment. REFERENCES
The other route is by intraocular use. Chang et al17 1. Durmaz B, Marol S, Durmaz R et al: Aqueous humour
report in their study that the use of an intraocular bio- concentration of topically applied ciprofloxacin, ofloxacin and
degradable polymer dexamethasone drug delivery tobramycin. Arzneimitt for Schung 47: 413-15, 1997.
system (DEX DDS), placed between the iris and anterior 2. Akkan AG, Mutlu I, Ozyazgan S et al: Penetration of topically
surface of the intraocular lens at the time of cataract applied ciprofloxacin, norfloxacin and ofloxacin into the
aqueous humor of the uninflamed human eye. J Chemother
surgery, in reducing postoperative inflammation. This was
9: 257-62, 1997.
a randomised, double-masked, parallel group study 3. von Keyserlingk J, Beck R, Fischer U et al: Penetration of
comparing two dose levels of the preparation with ciprofloxacin, norfloxacin and ofloxacin into the aqueous
placebo and no-treatment groups. Animal studies have humours of patients by different topical application modes.
shown that dexamethasone is released for 7-10 days, EurJ CLh Pharmacol 53: 251-55, 1997.
after which levels become undetectable. The anterior 4. Ferencz JR, Assia EL, Diamantstein L et al: Meir vancomycin
chamber (AC) cells and AC flare were assessed for 60 concentration in the vitreous after intravenous arid intravitreal
days postoperatively using slit-lamp examination. The administration for postoperative endophthalmitis I-losp, Kfar
Saba Israil Arch Ophthalmil 117: 1023-27, l999.
number of patients in each group requiring additional 5. Adenis JP, Robert PY, Mounier M et al: Anterior chamber
anti-inflammatory medication was also noted. At week concentrations of vancomycin in the irrigating solution at
two, 80% of the controls required additional topical the end of cataract surgery. J Cataract Refract Surg 23: 111-
steroid medication compared with seven per cent of those 14, 1997.
with the DEX DDS. By month 2, 12% of the DEX DDS 6. O’Brian TP, Kirn KB, Barequet I: Effect of intracameral
patients required topical steroid, compared with 83% of antibiotic supplementation at the end of cataract surgery:
those in the control placebo group. There were no An experimental model (abstract). Invest Ophthalmol Vis Sci
38: S1-4, 1997.
significant complications from the intraocular steroid; in
7. Feys J, Salvanet-Bouccara A, Emond JP et al: Vancomycin
particular, there was no elevation of intraocular pressure. prophylaxis and intraocular contamination during cataract
The rebound inflammation at 7-10 days, when the surgery. J Cataract Refract Surg 23: 891-97, 1997.
8. Lehmann OJ, Roberts CJ, Ikram K et al: Association between antibiotic combination eye drops after cataract surgery. Clin
non-administration of subconjunctival cefuroxime and Drug lnvest, 15: 229-34, 1998.
postoperative endophthalmitis. J Cataract Refract Surg 23: 14. Roberts CW: Pretreatment with topical diclofenac sodium to
889-93, 1997. decrease postoperative inflammation. Ophthalmology
9. Ferro JF, de-Pablos M, Logrono MJ et al: Postoperative 103(15): 636-39, 1996.
contamination after using vancomycin and gentamicin during 15. Weijtens O, Feron EJ, Schoemaker RC et al: High concen-
phacoemulsification. Arch Ophthalmol 115:165-70, 1997. tration of dexamethasone in aqueous and vitreous after
10. Hospital Infection Control Practices Advisory Committee subconjunctival injection. Rotterdam Eye Hosp, Rotterdam,
(NICPAC): Recommendations for preventing the spread of
The Netherlands. Am J Ophthalmol 128: 192-97, 1999.
vancomycin resistance. Infect Control hosp Epidemiol 16:
16. Chang DF, Garcia IH, Hunkeler JD et al: Phase II results of
105-13, 1995.
an intraocular steroid delivery system for cataract surgery.
11. Ostrov CS, Sirkin SR, Deutsch WE et al: Ketorolac, predni-
solone, and dexamethasone for postoperative inflammation. Altos Eye Physicians, Los Allos, CA, USA. Ophthalmologica
Clin Ther 19: 259-72, 1997. 106(1): 1 172-77, 1999.
12. Schmidi B, Mester U, Diestelhorst M et al: Laser flare I7. Leibowitz IM, Bartlett JD, Rich R et al: Intraocular pressure-
measurement with 3 different non-steroidal anti-inflammatory raising potential of 1 .0% rimexolone in patients responding
drugs after phacoemulsification with posterior chamber lens to corticosteroids. Arch Ophthalmol 14(1): 933-37, 1996.
implantation. Ophthalmology 94: 33-37, 1997. 18. Novack GD, Towes J, Crockett RS et al: Change in intraocular
13. Butt Z, Fsadni MG, Sunder RP: Diclofenac-gentamicin pressure during chronic use of loteprednol etabonate. J
combination eye drops compared with corticosteroid Glaucoma 7: 266-69, 1998.
Complications of Manual Phaco 169
Complications of
Manual Phaco
33 Kamaljeet Singh
M
ajority of the complications associated with
phacoemulsification and extracapsular surgery
are common to manual phaco. We shall discuss
here the specific complications of manual phaco. The

complications of manual phaco can be divided into
following subheads.
INTRAOPERATIVE COMPLICATIONS
1. Complications associated with wound construction.
2. Complications associated with AC maintenance.
3. Complications associated with capsulotomy.
4. Complications associated with nucleus prolpase in
AC.
5. Complications associated with delivery of nucleus.
6. Complications associated with debris clean-up. Fig. 33.1: Iris prolapse through the wound
7. Complications associated with implantation. due to premature entry
Complications Associated with Management Keeping the crescent blade in one plane
Wound Construction can prevent premature entry. If it occurs immediately the
It is the most significant step in any sutureless surgery, dissection should be abandoned. Begin dissecting from
whether in phaco or in manual phaco, or even in the other end of the tunnel, or one can choose other site,
conventional ECCE. Proper wound construction and or dissection from other plane should be started. This
tunnel formation is most important in manual phaco wound is likely to leak. Therefore, it will need suturing.
because wound is bigger and tunnel should have more Button holing can be prevented by avoiding dissection
length to keep it self-sealing. Most common complication at shallow plane while doing scleral dissection. If small
hole is there, then second plane at deeper site may be
associated with this step is premature entry into the
selected, If the hole is large the site of incision needs to
anterior chamber. This causes iris prolapse during various
be changed.
manoeuvres (Fig. 33.1) and increases the chances of
Avoiding deep dissection can prevent scleral disinser-
Descemet’s tears. Other common complication is button
tion. If it occurs, radial sutures are applied to secure the
holing of the sclera if the depth in the scleral tunnel is too
wound. If Descemet’s detachment occurs we have to
shallow. Deeper dissection can also be a problem as
inject air (Fig. 33.2).
superficial sclera may disinsert from the deeper sclera.
This is called scleral disinsertion. Excessive bleeding may Complications Associated with AC Maintainer
occur while constructing the wound as the incision here
is given about 2 mm behind the limbus, which has more Problem most frequently seen with AC maintainer is—it
capillaries. Bleeding can be taken care of by doing careful comes out from the wound, if the tunnel for AC
bipolar cautery. maintenance is wide. In contrast, if it is too tight the AC
periphery. If smaller capsulorhexis is done the ECCE may

turn to ICCE while prolapsing the nucleus. Capsulorhexis
is not a must here as in phacoemulsification. The simplest
and best is to make an envelope type capsulotomy. In
those technique where two instruments are used, like in
sandwich, phacosection or phacofragmentation anterior
capsule also gets sandwiched between two instruments
and can lead to zonular disinsertion in inferior position.
Here the surgeon should keep other instruments under
direct supervision. This complication does not occur
when capsulorhexis or Beer can-opener technique is
used.
Management Small capsulorhexis can be turned to beer
can-opener in the upper aspect from 11 to 1 O’clock by
applying several cuts on the margin of capsulorhexis.

Several cuts should be made. Only one cut may extend
Fig. 33.2: Detachment of Descemet’s membrane-injecting air
in the periphery while prolapsing the nucleus (Fig. 33.3).
bubble is enough for reattachment Zomular disinsertion necessitates implantation in ciliary
sulcus (Fig. 33.4).
maintainer enters in AC with a bang and may injure iris.
Author once entered in AC with such force that it caused Complications Associated with
subluxation and the surgery was abandoned. Therefore, Hydrodissection and Hydrodelineation
one should make a tunnel about 2 mm long and entry
Two problems can occur during these procedures. The
should not have great resistance. The AC maintainer
hydrodissection may be insufficient to cause rotation.
should be of 20G as advocated by Blumenthal.
More hydrodissection is required in this case. Keep doing
hydrodissection till rotation is achieved. Secondly, there
Complications during Capsulotomy
can be posterior capsular rupture. This occurs due to
If surgeon chooses to do this surgery with capsulorhexis, too much fluid going in a bolus, or fluid getting stuck in
it should be not less than 6.5 mm. Making a large between posterior capsule and nucleus. For avoiding this
capsulorhexis is difficult because it may extend in the complication, one can inject fluid and then should
Fig. 33.3: Small capsulorhexis makes delivery of nucleus difficult multiple cuts in
superior positions can make the delivery of nucules easier
Complications of Manual Phaco 171
Fig. 33.4: Zonular distinsertion-Implantation in ciliary sulcus

Fig. 33.5: Dialysis of iris
depress the nucleus so that the fluid may not remain
there at one point and fluid may move. If this is not incision up to 8 mm long can safely remain sutureless. In
carried, there are chances of even posterior dislocation techniques where two instruments are used to handle
of nucleus. the nucleus, there are chances of iridodialysis at the site
of entry. This may occur when the viscoelastics are scanty
Complications During Nuclear Prolapse in AC in the AC and it is not deep. Care should be taken to
displace the anterior capsule inferiorly if envelope type
The beginner faces biggest problem in prolapsing the capsulotomy has been made when sandwich technique
nucleus in AC. This difficulty occurs when there is is used. Otherwise it may lead to disinsertion of zonules
hypotony, pupil is small, capsulorhexis is small, or nucleus in the inferior position while delivering the nucleus out.
is soft. Therefore, this step should be practiced in can-
opener technique, as the prolapse is easiest in this Complications Associated with Debris Cleanup
method. Diamox or pinky ball should not be applied as Posterior capsule rupture can occur which should be
it causes hypotony. If hypotony is too much and nucleus managed by doing vitrectomy, if vitreous has came into
does not prolapse, one may have to convert to ECCE. A the anterior chamber. If there is small repture, which is
few cases of capsular dialysis have been reported during detected early IOL can be easily implanted in the bag
accidental dialing of capsulorhexis edge in place of (Fig. 33.6). Any cortical matter left should be aspirated
nucleus. If the pupil is small one can do a sector by dry suction method. The issue is described in detail
iridectomy and proceed or convert to ECCE. In case the elsewhere. Subincisional cortical matter is difficult to
nucleus is soft and does not rotate, one can wash the clean. For this ‘J’ shaped cannula can be used or separate
cortical matter. Now the nucleus view will be better and entry at 7 O’clock should be made. The cortex can also
prolapse will be possible. Actually in this case for rotation be disengaged while dialing the IOL.
the surgeon does not go deep enough and remains in
the cortex and the perinuclear plane. Complications Associated with Implantation
Complications during Delivery of Nucleus The biggest problem is implanting the lens in the bag,
Several techniques of delivering of nucleus have been because we are implanting lens through a tunnel. The
described in this book. One problem of transient corneal tilted lens cannot go in the inferior side, as the tunnel is
oedema is common in all the techniques, due to nucleus horizontally long. The inferior haptic in this case, may
touch to the endothelium. This touch should be avoided be left on anterior surface of iris. The superior haptic is
and the delivery should be made easy. As during the then implanted in the bag and inferior haptic is dialed
delivery of a child episiotomy is given, similarly if delivery into the bag. The other complication occurs when the
of nucleus becomes difficult one should increase the chamber is not filled with viscoelastics. The IOL
length of the incision. If corneal valve remains formed, implantation can cause endothelial touch.
not, then hypertonic saline should be added to the

treatment regimen.
• Endophthalmitis
• Posterior capsular opacification
Table 33.1: Author’s experience with complications in
250 consecutive patients including initial cases:
1. Button holing 1
2. Premature entry into AC 2
3. Iridodialysis 3
4. PC rupture 1
5. Transient corneal oedema 15
6. Pseudophakic bullous keratopathy 3
Fig. 33.6: Small posterior capsular suplure with no disturbance FURTHER READING
of anterior hyaloid face in the bag implantation can be done
1. Drews RC: Management of complications during posterior
chamber implantation. Implants in Ophthalmology 2: 175-
POSTOPERATIVE COMPLICATIONS 76,1998.
2. Skuta GL et al: Zonular dialysis during extracapsular cataract
• Shallow AC It can be seen if the surgeon has not tested extraction in pseudoexfoliation syndrome. Arch Ophthalmol
the corneal valve by depressing the upper sclera 105: 632-34, 1987.
behind the incision. This complication can be tackled 3. Ulreche Demeler Management of intraoperative
by applying a suture and reviewing the wound. If complications. In Piers Percival (Ed): A Colour Atlas of Lens
Implantation Wolfe Publishing Ltd: 1991.
postoperatively chamber is shallow the patient should 4. Shah Anil: Complications in Small Incision Cataract Surgery
be taken to operation theatre for re-suturing. Bhalani Publishing House, India: 2000.
• Corneal Oedema Postoperative corneal oedema is 5. Duch Mestres: Intraoperative complications of ECCE/SICS J
usually transient. It disappears in 2-3 days. If it does Cat Ref Surg 25: 1275-79, 1999.
Management of Posteriorly Dislocated Lenses 173
Management
of Posteriorly
34 Lalit Verma
Dislocated Lenses
P Venkatesh
HK Tiwari
T
he aim of every cataract surgeon is to ensure a also a degree of suspicion can identify the atypical cases.
safe removal of the cataractous lens. In addition The following three case descriptions as encountered by
there is an overpowering desire by the patient to us highlight these atypical presentations.
be rehabilitated early. This is matched by an equally
sincere effort by the surgeon to provide the same. Some-
times, however, the surgeon encounters a scenario of
having either the crystalline lens or pseudophakos
Typical Atypical Uncomplicated Complicated
dislocated posteriorly into the vitreous. This undesirable
situation may occur during conventional cataract surgery
as well as phacoemulsification. Such a mishap not only
compromises restoration of the patient’s vision but also Immediate Delayed
the surgeon’s confidence, particularly so in the case of
Chart 34.1: Presentation in sunk phakos and pseudophakos
novice surgeons. Today however, the surgeon may take
solace in the fact that the situation is not beyond salvage
Case 1: Endophthalmitis
if the management is appropriately planned. Planning
must be individualised taking several factors into An elderly male with a subluxated lens was meant to
consideration such as the following questions: What undergo an intracapsular cataract surgery. His discharge
happens if the dislocated components are left to stay? Is summary read “OD/OS ICCE done”. This patient pre-
prognosis affected? When must one intervene? Who sented to the emergency on the third postoperative day
should intervene and how? with features of endophthalmitis. Indirect ophthalmo-
scopy was not performed. Ultrasonography reported the
Clinical Situations presence of focal low to medium reflectivity lesion, as
Broadly, posteriorly dislocated crystalline lens or a possible exudates due to the presence of other point like
pseudophakos can have a typical or an atypical presen- and pseudomembranous vitreous opacities. Indirect
tation, an immediate or delayed presentation and an ophthalmoscopy done at a later date however, revealed
uncomplicated or complicated presentation (Chart 34.1). a dislocated lens. Evidently this had been fallaciously
In a typical case the history itself is diagnostic. Atypical interpreted by USG as possible exudates. The short
cases are those in which a history is lacking and the coming here was an incomplete discharge summary but
patient presents with features of “endophthalmitis” (read complete clinical evaluation.
case 1), vitreous hemorrhage or other complications such
as “aphakic glaucoma” (read case 2). Another atypical Case 2: Aphakic Glaucoma
presentation is a patient with an anterior chamber IOL
found alongwith a dislocated posterior chamber IOL This was again a male patient. He was being managed
(often detected incidentally). This latter situation we desig- as a case of aphakic glaucoma. Fundus could not be
nate as a new entity called the “Double IOL syndrome” visualised due to a small pupil with synechiae and media
(read case 3). Only a thorough clinical evaluation and opacification. A careful history was re-elicited and this
pointed towards the possibility of an attempt at that these patients may need is a close follow-up and
implantation having been made. In this case ultrasono- visual rehabilitation by contact lenses, spectacles or
graphy was conclusive in that a dislocated IOL was secondary AC-IOL. (creating a “double IOL” syndrome
identified in the inferior vitreous. This case emphasises in a relatively “safe” eye) depending on the compatibility
the need to approach some atypical cases with a degree of the ocular structures (e.g. angle) and fellow eye status.
of suspicion.
Case 4: Is IOL Directly Responsible for the RD?
Case 3: The Double IOL Syndrome We had a patient with subtotal retinal detachment, a well-
We had a patient referred to our retina services with a defined primary break in the superotemporal quadrant
diagnosis of pseudophakos (AC-IOL) with retinal and without PVR. In association with this was a not so
easily discernible PC IOL dislocated into the anterior mid-
detachment. During a repeat indirect ophthalmoscopy
vitreous inferiorly. As the retinal detachment did not
in the clinic a posteriorly dislocated PC IOL was detected.
appear to be directly related to the dislocated IOL a con-
Conventional retinal detachment (RD) surgery was
ventional RD surgery with subretinal fluid drainage was
planned in this patient with the double IOL syndrome
undertaken. The retina settled with an uneventful post-

for two reasons -firstly the posteriorly dislocated IOL was operative course. He had a best corrected visual acuity
relatively fixed and secondly, removal of the PC IOL of 6/36. At a second stage, AC IOL implantation was
following a vitreoretinal surgery would entail more signi- undertaken as the dislocated IOL was “fixed”. Thereby
ficant anterior segment trauma because of the AC IOL. a “double IOL” syndrome was created considering this
An immediate or delayed presentation in such cases eye to be relatively safe. Until the last follow-up he has
has a bearing not only on the visual prognosis but also had no complications and has retained 6/24 vision.
on the surgical plan. In those presenting early, the surgeon It is clearly self evident that with the possibility of the
will have to specially consider the corneoscleral incision above enumerated complications a conservative
parameters. A large or small section, the wound archi- approach to managing these cases is ill-suited in most.
tecture and wound integrity will have a bearing on the Preoperatively however, intraocular inflammation and
surgical approach. raised intraocular pressure should be controlled by
Any nucleus or artiphakia dislocated posteriorly and medical treatment.
associated with the following, either singly or in combi- Non-surgical management may be considered in a
nation falls into the complicated category (Chart 34.2). quiet eye with small retained lens fragments or wherein
The complications could be vitreous haemorrhage, retinal the entire lens with its capsule intact (as in couching) has
detachment, severe inflammatory reaction, glaucoma or dislocated. Time is a great healer in some patients who
the double IOL syndrome. In cases with retinal detach- have less than one quarter of the lens material dislocated.
This may be well tolerated and eventually may get
ment distinction has to be made as to its relation with
resorbed after a variable length of time. Gilliland et al
the dislocated lens. The answer to the question “is the
however, reported that even small fragments may be
IOL directly responsible for the RD”? will determine the
associated with significant macular oedema, persistent
surgical approach in some cases. (case 4) Patients with a uveitis and glaucoma on long-term follow-up. A careful
dislocated IOL of longstanding duration and one that is follow-up of such cases wherein conservative manage-
fixed by fibrosis and without the above mentioned ment has been planned is therefore important.
complications fall into an entirely separate category. All In all cases of dislocated lens or its fragments and in
dislocated artiphakic lenses, the essential cause is a breach
in the integrity of the capsular bag during several surgical
steps ranging from capsulotomy, nucleus delivery or
Severe Vitreous Secondary Double-IOL phacoemulsification to irrigation-aspiration of lens
inflammatory haemorrhage glaucoma syndrome remnants. In a situation wherein the cataract surgeon
reaction sees a dislocating nucleus what should he do? when
Retinal detachment
should he make an effort at removing it himself/herself
and when should he take the expertise of a vitreoretinal
IOL related IOL independent surgeon?
The cataract surgeon may make an attempt at removal
Chart 34.2: The complicated dislocation when the dislocated lens material is seen to be lying on
the anterior hyaloid membrane. In such cases use of lens for its strengthening and preplanning any surgical incision
loop, wire vectis and cryoprobe have been reported to that may need to be made while removing a large nucleus
be effective. Injection of visco-elastic posterior to nucleus or IOL. Corneal endothelial cell count and gonioscopy
can be tried with the aim of floating the nucleus anteriorly would indicate if an AC IOL is going to be compatible if
and removing it subsequently from the limbal section. ever desired by the surgeon. Pupillary dilation should
Once the nucleus or lens remnants migrate posteriorly also be evaluated. Elevated intraocular pressure and
these methods rarely succeed and infact may worsen the inflammation should be controlled by medical treatment.
situation. Panic attempts involving excessive surgical The status of retina, the mobility or fixity of the dislocated
manipulation and invasion of the vitreous with scoops, component should be properly assessed. In the presence
cryoprobes or excessive irrigation only complicates things of an opaque media ultrasonography may help to
further. Associated with these manoeuvres may be localise, confirm or detect a retinal detachment. Bright
subsequent retinal break formation and retinal detach- flash ERG and VER may help in predicting status of retina
ment. The essence in preventing further complications and optic nerve conduction.
is to the treat the vitreous with care. Mishandling this Having taken a decision to operate, the visual prog-
vital component leads to untold problems. It should never nosis should be explained to the patient and an informed
be pulled out, no matter how gently. The safest way of written consent obtained.
handling the vitreous is to cut, aspirate; cut and aspirate. Surgical steps should be preplanned and modified as
Sponge and scissors vitrectomy is an unsafe method of needed preoperatively. Factors to be considered during
approaching vitreous complication. this planning process are the need for a preplaced corneo-
In the above scenario the cataract surgeon can perform scleral groove, actual incision site taking astigmatism
a good anterior vitrectomy using not weck cell sponge also into consideration. The nucleus density should be
and Vannas scissors but a functioning vitreous probe. assessed if possible. The need for an encirclage and/or
The wound should be closed properly without any buckle placement as also that of a long-term vitreous
attempt at an intraocular implantation. Having done so substitute like silicone oil or gas should be assessed. A
the patient should be referred to a vitreoretinal surgeon. combined approach vitreous surgery may be safer in
The other option is to let a vitreoretinal surgeon take certain situations. The necessity of having to use
over at the same sitting. The latter approach is possible perfluorocarbon liquids should also be pre-evaluated.
only if a vitreoretinal surgeon is immediately available. The subsequent approaches available to a vitreoretinal
All cataract surgeons would do well to have atleast a surgeon are many. The final approach would depend
standby functioning vitrectomy set at hand (Chart 34.3). largely on the hardness of the dislocated nucleus and
the individual surgeon’s preference and experience.
Dislocating nucleus/fragment (Chart 34.4) Simple pars plana vitrectomy with cutting
and aspiration alone may suffice when the dislocated
On anterior hyaloid In posterior vitreous component is only cortical matter, a soft nucleus or a
| small nuclear piece. In the presence of a large nucleus
May attempt removal resistant to cutting and aspiration the technique of
impalement of nucleus using an MVR blade can be tried
Take over by Good “probe” anterior
VR surgeon vitrectomy and wound Intravitreal
closure; No IOL Phacoemulsification Modified 25-27 G needle
| PPV in
Referral to VR surgeon Intravitreal dislocated Mechanical crushing/
Phacofragmentation nucleus cutting and aspiration
Chart 34.3: Dislocating nucleus/fragment (options)
Combination of Endocryo probe
Cases that have been referred for later surgery need different techniques (with insulated sleeve)
to be carefully evaluated preoperatively. This would
include determining the potential visual acuity of the MVR blade
involved eye and the fellow eye status. On this would delivery
depend the plan of visual rehabilitation. Wound
architecture as well as integrity will determine the need Chart 34.4: Perfluorocarbon liquids
PPV never be injected without prior vitrectomy. A problem

that may arise while using PFCL is entrapment of some
Resistant nucleus identified
nuclear remnants in the depths of the convex PFCL
Impale with MVR blade meniscus and the ocular coat anywhere around the
periphery and beyond the surgeon’s view. In case of
Endoilluminator acts as support
doubt gentle depression will make them evident,
Tilt MVR knife with the following which they can be removed. If this precaution
impaled nucleus is not undertaken the surgeon may be surprised to find a
into the anterior chamber few remnants following PFCL removal and an
unnecessary prolongation of surgical time ensues.
Can constrict pupil
(with Pilocarpine chelate)
Layering the PFCL above with visco-elastic has been
reported to facilitate removal of such fragments trapped
Complete preplaced corneal in the periphery.
groove (6-8 mm) The management of intraocular lenses dislocated into
(by surgeon/assistant) the vitreous cavity is different surgically from that des-
cribed above for dislocated nucleus. Peroperative evalua-
Express nucleus
tion and surgical planning are however similar. In addition
Chart 34.5: Dislocated nucleus-surgical algorithm the surgeon should decide whether to explant the IOL
and leave the eye aphakic to explant the dislocated IOL
successfully in significant percentage of cases (Chart and replace a new PC IOL or AC IOL or to reimplant the
34.5). The disadvantages of this technique are probability same dislocated IOL. The latter can be achieved by
of greater tissue trauma and the possibility of the impaled placing the IOL onto the capsulolenticular remnants or
nucleus falling back into the vitreous. The use of by scleral fixation. Several methods of removing a
perfluorocarbon liquids prevents this risk and reduces dislocated implant have been described but central to all
tissue trauma. Cost of PFCLs is an overbearing factor. these is a good pars plana vitrectomy. Unlike in surgery
For removal of lost lens fragments Weinstein et al have for removing a dislocated nucleus, PFCL is not as
reported a new surgical technique using the Machemer indispensable during surgery for a dislocated IOL.
lens. In a recent report Rover claims good results of Three kinds of approaches to surgery for management
phacoemulsification in the mid-vitreous cavity for dis- of a dislocated IOL can be used. These are a limbal
located lenses in 15 patients. Phacoemulsification was approach, a pars plana approach or a combined limbal
preceded by pars plana vitrectomy. No perfluorocarbon and pars plana approach.
liquids were used in the study. The author concludes The limbal approach is to be preferred when the dis-
that the procedure is safe and easy, has no retinal side located implant is in the anterior or mid-vitreous and
effects and reduces the intraoperative risks of alternate easily visible under the microscope without the need for
methods by avoiding a large opening into the anterior an endoilluminator. Pars plana approach is generally
chamber and ocular hypotony. The approach seems preferred when the luxated IOL is in the posterior vitreous
agressive and we advocate that extreme caution is neces- cavity, is lying on the retinal surface or is associated with
sary while performing phacoemulsification in the vitreous complications such as severe vitreous reaction, retinal
even by the most experienced surgeons. detachment, etc.
In our experience the two approaches which can be In both approaches no effort should be made at pulling
employed successfully in patients with a dislocated on the implant prematurely. A complete vitrectomy is a
nucleus are (1) Use of perfluorocarbon liquids (2) MVR must even before trying to grip the IOL. Perilenticular
blade impalement and delivery through the limbal route. adhesions have to be carefully cut with Vannas scissors
About PFCLs, we again re-emphasise that although (limbal approach) or intravitreal scissors or probe and
expensive, it makes surgery safer and causes less tissue the IOL dissected completely free. The free IOL can only
trauma. It should be made use of wherever possible. then be safely picked up using intravitreal forceps or other
One sentence of caution: PFCL is no magic liquid, it less desirable methods like a modified iris hook, etc. It is
makes surgery atraumatic and successful provided it is better to grip the optic and push the IOL up rather than
injected only after a thorough vitrectomy. PFCL should grip the haptic and pull on it. The latter approach risks
IOL lying in
anterior/mid vitreous IOL in posterior vitreous/
lying on retinal surface
No RD RD present
• PPV
• Hold IOL with
intravitreal forceps
• Can use PFCL
Explant the IOL Internal PVR absent PVR present

via limbus scleral • VR surgery
Limbal approach fixation of IOL with use of PFCL
(Anterior vitrectomy without taking and removal of IOL

and explant the IOL) it out • No attempt at
re-implantation
Two stage Single stage

• Buckling reattachment VR surgery
surgery
• Defer IOL for 2nd
procedure
No IOL (aphakic) Placement of IOL on capsulo-lenticular remnants A C IOL Scleral fixation (same/new IOL)
Chart 34.6: Approach to management of sunk IOL luxated IOL in vitreous cavity.
Depending on: fellow eye status, visual potential, etc.
breakage of the haptic with the IOL subsequently falling Visual Prognosis
back onto the retina. Here again use of PFCL makes Several reports are available in literature that compare
surgery relatively safer by preventing this possibility. visual results with the timing of surgery. Gilliland et al
To have the eye aphakic or implant the same or a new did not find any statistical difference between the timing
IOL will depend on factors previously discussed and also of vitrectomy and incidence of glaucoma. In contrast
on those shown in Chart 34.6. Internal scleral fixation Fastenberg et al reported that delayed vitrectomy (9-50
techniques described for reimplanting the dislocated IOL days) was associated with a better visual acuity but an
are time consuming and cause more tissue trauma in the increased incidence of glaucoma.
learning phase at least. Chang and colleagues have Blodi and associates report that vitrectomy performed
devised a new 25-guage forceps that they found useful within 3 weeks of cataract surgery had a lower incidence
for anterior segment application during vitreous surgery. of glaucoma, compared to that undertaken beyond 3
This forceps has a curved shaft, a tip with a distal platform weeks (18 percent to 60 percent). In this study 63 percent
for grasping a suture and a proximal groove for gripping of those subjected to early vitrectomy had a vision of 6/
a haptic. These forceps facilitate manipulations such as 60 or better. All patients undergoing vitrectomy at later
fastening a suture loop around a haptic, repositioning an stage had a vision of only finger counting.
intraocular lens at the ciliary sulcus or repairing inadvertent Kim et al in 1994 reported no significant difference in
or pre-existing iridodialysis. final visual acuity or incidence of glaucoma following
Use of PFCL becomes mandatory if proliferative early (within 7 days) and late vitrectomy groups. How-
vitreoretinopathy is present or the surgeon has decided ever, visual outcome was better and complications mini-
to manage both the dislocated implant and retinal detach- mised when the case was immediately taken over by a
ment or to reimplant the same lens. vitreoretinal surgeon. Seventy-five percent of such
patients had a visual acuity of 20/40 or better in com- good instrumentation and co-ordinated assistance. Post-
parison to 67 percent in all others. operative regime, patient positioning and augmentation
Factors that probably would improve success of the (e.g. laser), if needed, constitute the postoperative factors.
surgery are three preoperative factors, three peroperative To conclude it may be said that all lenses (crystalline
factors and three postoperative factors. Proper and or artificial) can sink easily in a complicated cataract
complete clinical evaluation, controlling intraocular pres- surgery and it is only with an effort that they can be
sure and inflammation medically and preplanning removed. Falling back of the lens nucleus or IOL is
surgical steps are the preoperative factors. Peroperative analogous to sliding down a slope, while retrieving them
factors are constituted by patient anaesthesia (general is analogous to climbing up the slope. A team effort with
anaesthesia or adequately prepared local anaesthesia), good co-ordination makes the climb not only easier but
modifying and executing the preplanned steps and finally also less hazardous.
Post-surgical Endophthalmitis 179
Post-surgical
Endophthalmitis
35 Lalit Verma
Pradeep Venkatesh
HK Tiwari
INCIDENCE AND AETIOLOGY Although all groups of bacteria can produce endo-
phthalmitis, the predominant form is gram-positive
Postoperative endophthalmitis is a catastrophic
organisms. Gram-positive organisms are responsible for

complication of intraocular surgery. Although its reported
90 to 95 per cent of all post-surgical endophthalmitis. In
incidence has decreased significantly in the present era
the Endophthalmitis Vitrectomy Study (EVS), gram-
from 1% to about 0.05-0.1%. It still remains a source of
negative isolates on culture were obtained in only 6% of
dread for all eye specialists. Despite improvements in
endophthalmitis cases following cataract surgery. Despite
asepsis and sterilization, infectious endophthalmitis
this low prevalence of gram-negative infection they are
continues to persist as one of the most important sight
important to recognize early, as these organisms are
threatening condition.
highly virulent, produce endotoxins and rapidly begin
The incidence of post-surgical endophthalmitis is to colonize the vitreous cavity. They need a more vigorous
dependent on the type of surgery, the criteria used for management approach and early vitrectomy may also
diagnosis (clinical/ laboratory culture) and the duration become necessary. Fungal endophthalmitis following
of follow up. In the series reported by Kattan et al (30,002 intraocular surgery is seen in about 3% of patients. EVS
cases), the incidence of culture positive endophthalmitis did not include any case suspected of being fungal in
following cataract surgery, secondary IOL implantation, origin into its study.
penetrating keratoplasty, filtering surgery for glaucoma Gram-positive organisms that have been isolated in
and pars plana vitrectomy was 0.072%, 0.30%, 0.11%, cases of post-surgical endophthalmitis have been
0.061% and 0.051% respectively. The risk seems higher Staphylococcus epidermides, Staphylococcus aureus,
following penetrating keratoplasty because of the donor Streptococcus pneumoniae, Streptococcus viridans,
cornea being potentially contaminated and in secondary Streptococcus pyogenes, Peptostreptococci and
implant surgery due to a lack of compartmentalization. Corynebacterium. Of these, Staphylococcus epidermides
Other less common situations wherein endophthalmitis is the predominant isolate in 20 to 50 per cent cases.
may occur are, following removal of sutures and after Propionibacterium acnes and Actinomyeces are gram-
laser capsulotomy. positive organisms capable of producing a slow grade
Postoperative endophthalmitis can present within a endophthalmitis. Staphylococcus epidermides also has
few days to weeks (early endophthalmitis) or after several this ability. Clostridium, a positive anaerobe, is an
months to years (delayed endophthalmitis). Depending extremely rare cause unlike in post-traumatic cases.
on the severity and clinical course the infection can be Gram-negative organisms known to cause bacterial
acute or chronic. In delayed onset endophthalmitis it is endophthalmitis are Pseudomonas aeruginosa (most
important to distinguish between cases that occur common isolate), Proteus mirabilis, Klebsiella pneumo-
following a delayed entry of the organism (e.g. bleb niae, Haemophilus influenzae, Escherichia coli and
related/wound dehiscence) from those due to a delayed enterococci. Post-surgical fungal endophthalmitis has
manifestation. In the former situation the etiologic agent been reported with the following organisms, Aspergillus,
is usually highly virulent and manifests acute clinical Candida, Cephalosporium, Penicillium and Paecilo-
symptoms and signs while in the latter situation, the myces.
infecting agent has a low virulence and tends to follow Interestingly, several studies have shown that most
an indolent course. cases of endophthalmitis are caused by organisms that
normally inhabit the conjunctival sac either as The cardinal symptoms of post-surgical bacterial
saprophytes or opportunistic pathogens. Staphylococcus endophthalmitis revolve around the attributes of vision
epidermides has been isolated from the conjunctival sac and pain. In the early postoperative period, pain more
in 69% and Staphylococcus aureus in about 33% of than anticipated is a common symptom but is not present
normal eyes. H. influenzae and rarely fungi may also be universally in all cases. The grade of pain may vary from
present as normal microflora. Accumulating evidence has absent to mild to severe. In the EVS report, 26 per cent
shown that in the majority of post-surgical endophthal- of patients had no pain at all. Hence, the absence of
mitis, the causative organism is derived from the patients pain should not be taken as a factor against the likelihood
own periocular microbial flora. More recent studies have of infectious endophthalmitis. When a decrease in pain
infact shown using plasmid typing, restriction endo- is the usual course in the days following surgery, its
nuclease analysis, southern blot hybridization and pulsed worsening is however, an ominous symptom. A non-
field electrophoresis, that isolates obtained from the improvement in vision to the anticipated degree, when
conjunctival sac and from intraocular aspirates are accompanied by an unexpected inflammatory reaction,
genetically indistinguishable. This reflects on how is a more frequently observed presentation in early post-
important it is to ensure topical asepsis and sterility during operative endophthalmitis. Blurring was the presenting
all intraocular procedures. This also shows the need to symptom in 94% of patients studied in the EVS and so
defer intraocular surgery until conditions such as may be considered as the most common symptom. There
dacryocystitis, lid infection and blepharitis have been may be an associated mucopurulent discharge.
adequately treated. Acute bacterial endophthalmitis occurring later on has
a very classical presentation. Most patients complain of
POST-SURGICAL BACTERIAL ENDOPHTHALMITIS a sudden onset and a rapid worsening of pain accom-
Clinical Features panied by a significant decrease in vision. Other symp-
toms that may be present are discharge, excessive tearing,
In the majority of cases with post-surgical bacterial increased sensitivity to normal light (photophobia),
endophthalmitis the clinical presentation is very classical increase in redness of the eye and blepharospasm.
and causes little problems in diagnosis. However, a not On examination the visual acuity is less than antici-
so infrequent occurrence is the presence of subtle signs
pated and may even be hand motions or only light
in the early stages that keeps the surgeon wondering
perception in fulminant cases and when the presentation
whether it is an infectious endophthalmitis or a sterile
to an ophthalmologist is delayed. In the EVS study, hand
inflammation. This is most likely to be seen in the early
movements were tested at a distance of 60 cm and light
follow up period after surgery. In such situations
projection from 90 cm. A normal range of ocular motility
observation over the next 6-24 hours is very critical to
makes the likelihood of panophthalmitis unlikely. The
make a definitive diagnosis. During this period of
observation, the patient is started on adequate doses of conjunctiva shows a variable degree of hyperemia and
topical and systemic anti-inflammatory agents (mainly chaemosis and there is marked circumcorneal congestion.
corticosteroids). Endophthalmitis of an infectious origin Corneal involvement is variable, ranging from a relatively
usually progresses significantly while a sterile clear cornea to one that is grossly oedematous and hazy.
inflammation either remains stable or shows a minimal A limbal ring abscess, suture abscess, wound dehiscence
worsening. When uncertainty still prevails it is better to are other signs that may be present. The anterior chamber
err on the side of an infectious endophthalmitis and start shows a significant degree of flare and cells, the reaction
appropriate treatment. sometimes being frankly fibrinous. The presence of a
Three forms of endophthalmitis are recognized based hypopyon is considered by most as a cardinal sign of
on the clinical profile. The fulminant variety occurs within infectious endophthalmitis. The hypopyon is dependent
about 4 days and is usually caused by gram-negative and in early cases may be confined to the angle alone
bacteria, streptococci or Staphylococcus aureus. The when it may be missed. The iris pattern is lost, appears
acute form develops between 5-7 days and is most likely muddy and boggy and is resistant to dilation. There is a
to be caused by S. epidermides or coagulase negative tendency to form posterior synechiae early. Pupillary
cocci (rarely by fungi). Chronic type of endophthalmitis response to light is absent or sluggish. In less fulminant
usually develops one to several months after the surgery cases one may be able to appreciate a retrolenticular
and organisms involved are fungi, Propionibacterium flare and cells. In more severe cases, a dense discrete or
acnes or S. epidermides. confluent, yellowish vitreous exudation is evident. The
intraocular pressure is usually on the lower side of normal vitreous samples and only 36-40 per cent from aqueous
but may be elevated in the early stages of endophthal- samples, there have been reports when the latter was
mitis. Most cases have some degree of digital tenderness. positive and the former negative. For this reason it is
Clarity of the media in endophthalmitis is graded (as necessary to culture specimen obtained from both
adopted by EVS) depending on the visibility of the retinal aqueous and vitreous. If an aspirate has been obtained
details on indirect ophthalmoscopy and is as under: into a syringe and the laboratory can be reached
immediately, then the specimens are best sent to the
Grade 1 More than 20/40 (6/12) view of the retina.
laboratory with the original syringe with a cap on the
Grade 2 Second order retinal vessels visible. needle to prevent contamination.
Aqueous tap is obtained by a paracentesis using a
Grade 3 Some vessels visible but not second order.
25-27 gauge, half inch needle mounted on a tuberculin
Grade 4 No retinal vessels visible. syringe with its plunger on. About 0.1 ml of fluid is
Grade 5 No red reflex. aspirated in a controlled manner by gently withdrawing
In any patient with suspected endophthalmitis and the plunger. The needle may be directly inoculated into
where retinal details are not visible it is mandatory to the culture media. A part of the aspirate is ideally plated
undertake ultrasonography whenever it is available, directly on to the culture media while any remaining
before instituting any form of invasive, diagnostic or aspirate is used to prepare slides for Gram stain and
therapeutic interventions. This is to rule out the possibility Giemsa stain.
of conditions that may mimic endophthalmitis such as A sample of the vitreous is the most important source
dislocated nucleus and also to detect the presence of a to know the organism producing the endophthalmitis. It
choroidal detachment, retinal detachment and the degree is sometimes recommended that the vitreous sample may
of vitreous exudation and posterior vitreous detachment. be obtained using a 23 gauge needle introduced through
Ultrasonography thus is a useful aid in establishing the the pars plana just before injecting the intravitreal
diagnosis, prognostication, planning surgery and antibiotics. This is said to provide an undiluted specimen
sometimes in follow up. Other investigations like visual and also create space for the antibiotic drugs to be
evoked potential and electroretinography have no role subsequently injected. Although aspiration of vitreous
in either the management or the prognostication in may appear simpler it is fraught with a risk of producing
endophthalmitis and so are not indicated. vitreous traction particularly when the vitreous is formed.
Aspiration may also not provide adequate sample for
Confirmation of Diagnosis
analysis as in endophthalmitis the vitreous is denser and
usually contains inflammatory membranes. Infact it is
Although it is prudent to follow the dictum that all possible that most retinal detachments following
unexpected inflammatory response be considered endo- intravitreal injection are a result of vitreous aspiration
phthalmitis unless proven otherwise, it is nevertheless rather than the injection. For aspiration of vitreous a 22
important to confirm the diagnosis by culturing the gauge needle should be used. In an aphakic patient
organism from intraocular samples obtained in the without an intact posterior capsule and in the absence of
laboratory. This raises several issues such as which ocular a limbal infiltrate or abscess, one may aspirate vitreous
sample to culture, on what media to culture and when to through the anterior chamber itself. If the vitreous is fluid,
interpret the growth as positive or otherwise. 0.2-0.3 ml of fluid is gently aspirated.
In the recent past there was an emphasis that in The safest method to obtain vitreous sample is by
patients with endophthalmitis discharge from the vitreous biopsy. Vitreous biopsy not only enables an ade-
conjunctival sac and lid margin should be sent for culture. quate volume of sample to be obtained but also prevents
This is no longer recommended because of several vitreous traction by cutting the strands rather than pulling
reasons such as poor yield, culture of an unrelated on it. Vitreous biopsy can be obtained by one of two
organism and wasteful expenditure. If however, a suture methods: with an infusion line and without an infusion
abscess or infected suture tract is present, the removed line. The former has the disadvantages of diluting the
suture must be cultured. specimen obtained and the need for an additional
The most important samples to culture are aspirates sclerotomy to be made. For obtaining an undiluted
from the aqueous and vitreous cavity. Although the specimen by vitreous biopsy, the suction line on the
possibility of isolating an organism is 56-70 per cent from vitreous cutter (which is usually connected to an
automated suction during routine vitrectomy) is replaced fixation. Centrifugal cytology has been reported as
by a shorter tubing (about 2.5 cm in length) carrying at being superior but is not always necessary to
its one end a tuberculin syringe to enable manual suction. undertake.
The vitreous cutter is placed in the anterior vitreous and • Additional fluid available may be inoculated into
cutting is actuated. Simultaneously, an assistant begins brain-heart infusion or cooked meat broth.
to withdraw the piston on the tuberculin syringe so as to A summary about the laboratory confirmation of
induce suction. The procedure is stopped after 0.2 to diagnosis in endophthalmitis including the criteria for
0.3 ml of sample has been obtained. The lost volume ‘laboratory confirmed growth’ is given in Appendix 1.
may be replaced by injecting saline (if no further Since most cases of postoperative endophthal mitis
vitrectomy has been planned) or by opening the pre- occur in the early days following surgery, one has to pay
placed infusion line when a vitrectomy has already been adequate attention to the integrity of the wound before
planned. undertaking procedures like aqueous or vitreous aspira-
Whenever pars plana vitrectomy has been undertaken tion and intravitreal injection. Most cases need a facial
in a patient with endophthalmitis, the irrigating fluid block and either topical anaesthesia or retrobulbar
admixed with the vitreous present in the cassette may anaesthesia. General anaesthesia is recommended for
also be sent in a sterile manner to the laboratory. The children, un-cooperative patients and those with profuse
fluid can also be suctioned with aseptic precautions across congestion of the orbital tissue.
a 0.45 μ millipore filter and the filter sent. In the laboratory Treatment of Postoperative Bacterial Endophthalmitis
the filter should be divided into fragments each of which
is then transferred onto separate culture media. If the Having made a diagnosis of endophthalmitis, the patient
culture medium is solid, then care must be used to ensure is told about the diagnosis and the therapeutic interven-
that the filtered organisms are on the top surface and tions that may be necessary. He is also informed about
not trapped between the filter and the agar. An alternative the guarded visual prognosis and consent is obtained.
method is to concentrate the vitreous by centrifugation. Endophthalmitis can be managed as a daycare, out-
The ideal recommended handling of samples obtained patient emergency provided patient understands the need
has been: for frequent evaluation. Out-station patients and one-
• Placing one drop of fluid on a blood agar plate, eyed patients may need to be admitted.
streaking carefully with a needle and incubating at The three most important determinants in the outcome
37°C. following endophthalmitis are:
• Placing one drop of fluid on chocolate agar plate, • Time duration between presentation of symptoms,
streaking carefully and incubating at 37°C in a 4 to diagnosis of endophthalmitis and the initiation of
appropriate treatment. In our country, late presen-
10 per cent CO2 enriched environment.
tation of patients to their specialists is a frequent
• Inoculating one drop into Sabourauds medium
occurrence particularly in rural circumstances and this
without any inhibitors and maintaining this at room
decreases any chances of visual recovery. In experi-
temperature.
mental animals it has been shown that intravitreal
• Inoculate one drop onto thioglycolate broth and mix
antibiotics are not able to salvage an eye when given
with the deeper, thicker portion of the broth with sterile 24 hours or later after introducing an innoculum of
cotton tipped applicator. This media is incubated at an infective organism into the vitreous cavity. It has
37°C and it supports growth of anaerobes and also been reported that when intravitreal antibiotics
microaerophilic organisms such as P. acnes. are injected more than 48 hours after the infection is
• Place one drop on each of two clean glass slides for established the efficacy of the drug in eradicating the
Gram and Giemsa stain. The smear made should infection is poor.
neither be too thin nor too thick. The former tends to • Virulence and load of the causative organism. Higher
disperse the microbes and cells making microscopic the organismal load entering the eye and greater the
study difficult and the latter takes up heavy staining virulence of the organism, greater is the risk of deve-
making it impossible to detect organisms. Ideally the loping endophthalmitis. However, the actual number
drop should be gently spread on a scrupulously clean of organisms necessary to incite endophthalmitis in
glass slide using a clean bacteriological loop. The humans is yet to be determined. The most virulent
smear is then allowed to air dry. Heat fixation is to be organisms responsible for post-surgical endophthal-
avoided and absolute methanol used instead for mitis are the gram-negative bacilli (Pseudomonas,
Klebsiella, Escherichia, Proteus) and gram-positive Supportive therapy (cycloplegics, anti-glaucoma medi-
organisms like Staphylococcus aureus and cation, etc.) and Surgical therapy (Vitrectomy).
streptococci.
• Pharmacokinetics and spectrum of activity of the intra- ANTIMICROBIAL THERAPY
vitreal drugs: The goal in endophthalmitis manage- Earlier on, the most useful route for administering anti-
ment is to rapidly obtain adequate concentrations of
biotics to treat intraocular infections used to be very
the anti-microbial agent and maintain this for a
controversial. It is however, now unequivocally estab-
sufficient period of time in the vitreous cavity without
lished that most antibiotics given systemically do not
causing any toxic effect. This depends on several
reach the minimum inhibitory concentrations necessary
factors concerning both the drug (original dose, route
within the vitreous cavity. This is true despite the presence
of egress from the eye, pH, ionization, molecular size,
of a compromised blood ocular barrier in patients with
protein binding) and the ocular tissue (surgical status
endophthalmitis. Some present day antibiotics (Cipro-
of the eye: presence or absence of the lens and
floxacin, Sparfloxacillin, and Pefloxacillin) have been
vitreous, degree of breakdown of the blood retinal
shown to achieve significant concentrations in the
barrier).
vitreous cavity following systemic administration.
At presentation, it would be useful to grade the
However, the destruction progresses so rapidly in bac-
severity of endophthalmitis as severe or not severe. Endo-
terial endophthalmitis that the concentrations may still
phthalmitis is considered to be severe in the presence of
be inadequate to rapidly curtail further growth of the
the following: vision of inaccurate light projection, afferent
organisms. The only route that is capable of achieving
pupillary defect, no fundus glow, limbal ring infiltrate
this objective is the direct administration of antibiotics
(abscess) and cases that have not responded to
into the vitreous cavity. Intravitreal route of administration
appropriate intravitreal therapy. Some consider a vision
however, has its own limitations and risks.
of 20/400 and above as mild cases. However they also
caution that vision may not be that useful a parameter
Intravitreal Antibiotics in Post-surgical Endophthalmitis
to classify the severity of endophthalmitis as some patients
may have poorer vision compared to the other milder It would be most ideal to identify the causative agent,
clinical signs. determine its antibiotic sensitivity and then administer
The primary objective in endophthalmitis treatment specific antibiotics. This is not practical in treating
is to rapidly eradicate the colonization of the infecting endophthalmitis because the above process takes time
organism within the vitreous cavity and also to prevent and any time delay in these patients worsens the prog-
toxin and inflammation mediated damage to vital nosis rapidly. Hence, the most important criterion while
structures like the optic nerve (nerve fiber layer) and deciding on the choice of antibiotic for intravitreal
retina. The secondary objectives are to provide sympto- administration is its spectrum of activity against the most
matic relief, prevent synechia formation in miosis, remove common organisms known to produce endophthalmitis
any opaque membranes in the media (pupillary/vitreous). and also its known toxicity. The recommendation that
The ultimate objective is to maximize visual recovery. one should administer a broad spectrum antibiotic does
When the visual potential seems unlikely, one should not mean that obtaining intraocular specimens,
atleast aim to sustain the structural integrity of the globe laboratory culture and determination of antibiotic
so as to prevent cosmetic disfigurement. The follow up sensitivity are no longer necessary. Contrarily, these
of patients with endophthalmitis should be atleast every measures become most important whenever there is a
12 hours initially and not any longer. lack of response to the broad-spectrum antibiotic adminis-
The mainstay of treatment in post-surgical endo- tered empirically at the start of treatment. Today, the
phthalmitis is administration of broad-spectrum intra- preferred intravitreal antimicrobial therapy in post-
vitreal antibiotics. Vitrectomy is indicated in a highly surgical endophthalmitis is with a combination of two
selective category of patients and is discussed in detail drugs, one having a broad spectrum of activity against
later on. For a better understanding, the management gram-positive organisms and the other against gram-
options in post-surgical endophthalmitis include: negative organisms (preferred combinations are men-
Antimicrobial therapy (Intravitreal therapy, topical and tioned subsequently). It is important however, that the
systemic therapy); Anti-inflammatory therapy (Intra- two drugs to not have any antagonistic tendency. Two
vitreal, topical and systemic corticosteroids and NSAIDs); drug regimen is the preferred modality of treatment
because there is as yet no single drug that is highly effec- The periocular region is painted with povidone-iodine
tive against both gram-positive and gram-negative orga- and the cul-de-sac also washed with a solution of the
nisms and also has an adequate half life in the vitreous same. Visualization of the operative site should be
cavity. adequate. The injection is given transconjunctivally and
Before giving an intravitreal injection any infected no peritomy is necessary (if vitreous biopsy is not plan-
sutures or suture abscess should be removed. It is again ned). It is important to choose the quadrant of injection
emphasized that it is necessary to pay adequate attention (usually one that increases the ease of injection) and then
to the wound integrity and the status of the lens (aphakic/ measure and mark the distance from the limbus (3.0 mm
pseudophakic or phakic). The latter decides the site of if aphakic, 3.5 mm if pseudophakic and 4.0 mm if phakic)
pars plana entry and in a aphakic patient with a broken at which the injection is to be given. Aqueous and vitreous
samples are then obtained as described earlier. Before
vitreous face, a translimbal route may be adopted. If
actual injection of the drugs, the globe should be stabilized
obvious vitreous herniation or incarceration into the
in an atraumatic manner. Use of fixation forceps is fraught
wound is present, then a limited anterior vitrectomy and
with the danger of tearing of the inflammed conjunctiva
wound revision may also be planned along with the
and haemorrhage in a large number of patients. In

intravitreal injection. Attention should also be paid to cooperative patients, it is often possible to obtain
ensure that the intraocular pressure before the injection adequate stability of the globe by placing a cotton-tipped
is not high and there is no pre-existing retinal or choroidal applicator in the opposite quadrant. The surgeon then
detachment (ultrasonography). gradually inserts the 26-30 gauge needle on the tuberculin
Intravitreal injection should be undertaken with all syringe containing the prepared drug, at the previously
aseptic precautions by an experienced person or under marked site. The bevel of the needle should be facing
guidance. The operating room Incharge and sisters upwards towards the surgeon and the direction of
should be informed and requested to arrange a trolley penetration should be towards the direction of the
with the necessary instruments. It is always useful to have anterior or mid-vitreous. The drug should then be injected
an assistant during the injection. The drugs to be given slowly in a drop by drop manner (achieved by rotating
intravitreally should be prepared afresh by the eye the plunger) and avoiding jet formation. It is prudent to
surgeon himself, again with aseptic precautions. This is avoid making multiple entries into the eye and so the
necessary to ensure proper dosage of the drug. While second injection should be given through the initial
inadequate concentrations can lead to treatment failure, needle. The syringe can be carefully replaced with the
an excess dose can cause toxic effects on the retina. An one containing the second drug by asking the assistant
informed consent is a must before giving an intravitreal to stabilize the needle by gripping its hub using a forceps.
injection. The intraocular pressure is checked at the end of the
The choice of anaesthesia should be decided procedure. Subconjunctival injection of antibiotics is
beforehand taking into consideration factors mentioned given and the eye patched. There is no need for a
earlier. In our view a facial block decreases the risk of prolonged bandaging. Administration of topical drugs
vitreous upthrust by contraction of the orbicularis oculi may be begun as early as one hour after the procedure.
It has been suggested by some that reclining the patient
during the actual injection of intravitreal drugs and should
with the head up immediately after the procedure may
be used as a routine in all cases with an early postope-
decrease the risk of the drug settling on the macula and
rative endophthalmitis following conventional cataract
preventing its toxic damage.
surgery. Topical anaesthesia suffices in a large majority
In the past, several drugs were used for intravitreal
of cases with a healthy wound and retrobulbar injection injection and several of these are rarely recommended
is required less frequently. Peribulbar anaesthesia should today. The presently recommended combination therapy
be avoided, as it tends to increase orbital volume and of choice in post-surgical bacterial endophthalmitis is:
pressure over the globe. No digital massage or other forms
of mechanical pressure over the globe should be used. If First choice
needed, intraocular pressure may be lowered before the Injection Vancomycin : 1000 μg in 0.1 ml plus
injection by giving the patient acetazolamide tablets. This Injection Ceftazidime : 2.25 mg in 0.1 ml
is only rarely necessary as aspiration of intraocular fluids Second choice*
before intravitreal injection for culture and sensitivity Injection Vancomycin : 1000 μg in 0.1 ml plus
serves to decrease the intraocular pressure. Injection Amikacin : 400 μg in 0.1 ml
Third choice intraocular hemorrhage (including hyphema), drug
Injection Vancomycin : 1000 μg in 0.1 ml plus induced retinal toxicity and retinal detachment. In phakic
Injection Gentamicin : 200 μg in 0.1 ml eyes an added risk is that of cataract due to contact by
* This was the preferred antibiotic combination in EVS the needle.
study.
Preparation of the most frequently and less commonly Intravenous Antibiotics in
used intraocular drugs in the management of post- Post-surgical Bacterial Endophthalmitis
surgical endophthalmitis is shown in Appendix 2A and
Appendix 2B respectively. Even though it is possible that the vitreous levels of
Vancomycin is a macrolide antibiotic that is highly antimicrobial drugs given systemically may increase in
effective against most gram-positive organisms including endophthalmitis because of the associated inflammation
methicillin and cephalosporin resistant strains as well as and resultant breakdown of the blood-retinal barrier, the
coagulase negative staphylococci. It has been found to role of “Intravenous antibiotics alone” in the management
be safe when given even in a dose of 2 mg in 0.1 ml and of endophthalmitis, is at best, supportive and not primary.
This is supported by several observations:
also has a synergistic effect when used in combination

with amikacin. In vitro, vancomycin when combined with • Animal studies have found poor intraocular pene-
ceftazidime in the same syringe is known to produce a tration of most parenterally administered antibiotics.
precipitate and so they should be injected from separate Exceptions are some newer antibiotics like imipenem,
syringes. cephazolin, ciprofloxacin and sparfloxacin and
Ceftazidime is a third generation cephalosporin that pefloxacin. Aminoglycosides in particular have very
has been found to have a bactericidal effect against a poor intraocular penetration following parenteral
wide range of gram-negative organisms including pseu- administration.
domonas. Unlike with aminoglycosides no drug resis- • 73 per cent of 103 patients with endophthalmitis did
tance has so far been reported, no retinal toxicity has not regain any useful vision after conventional
been found in the recommended intravitreal dose and it treatment (systemic antibiotics alone)
has been found more effective in acidic and hypoxic • Study by Pavan et al showed good results with the
conditions. It has no activity against gram-positive use of only intravitreal drugs without parenteral
organisms. antibiotics
Amikacin is the preferred aminoglycoside because it • Conclusion from EVS study that whether or not
is effective against gram-negative organisms resistant to systemic antibiotics are used there is no difference in
other aminoglycosides and its retinal toxicity is four times final visual acuity
less than that with gentamicin. Since ceftazimide has a Added to the above observations, systemic adminis-
similar bactericidal effect and no retinal toxicity exists, tration of antibiotics also has the disadvantages of cost
many now prefer this drug to amikacin in the first line effectiveness and potential for systemic adverse drug
management of postoperative bacterial endophthalmitis. reactions. Another concern with the irrational use of
Gentamicin is only rarely recommended because of the newer antibiotics parenterally is the risk of encouraging
increased likelihood of macular infarction and also drug resistance. Despite these facts however, a large
because of a high degree of drug resistance. majority of eye specialists involved in treating endo-
Quinolones such as ciprofloxacin have also been phthalmitis still prefer to use parenteral antibiotics in
evaluated as a single drug treatment regimen in postope- addition to intravitreal injection, as it is possible that it
rative endophthalmitis. However, they suffer from the may help in augmenting and sustaining an adequate
disadvantage that their half-life in the vitreous cavity is concentration of the antibiotics in the vitreous cavity for
less and so a repeat injection becomes necessary within a more prolonged period. The recommended dose of
12-24 hours in order to obtain a therapeutic response. antibiotics for systemic administration in endophthalmitis
Penicillins, erythromycin and even the first and second is given in Appendix 3A.
generation cephalosporins are no longer recommended
as the first line drugs in the management of endophthal-
Topical and Subconjunctival Antibiotics in
mitis because of the existence of a significant degree of Post-surgical Bacterial Endophthalmitis
drug resistance and their limited range of anti-bacterial
activity. For topical medication in endophthalmitis, a combination
Intravitreal treatment carries with it a risk of the follow- of two drugs is preferred, one having a predominant effect
ing complications: elevated intraocular pressure, on the gram-positive organisms and the other against
gram-negative organisms. The frequency of administra- phthalmitis. In addition, it is not known if oral or intra-
tion is every hour (with each drug used alternately) in venous administration is as effective as intravitreal
the initial phases of treatment. This is modified depending injection.
on the response to overall measures. In the presence of The disadvantages of intravitreal corticosteroids is the
a corneal ulcer or wound abscess, fortified eyedrops are possibility that it may reduce the ability of the eye to
recommended. The antibiotic drugs used in the EVS sterilize the innoculum of microorganisms it has encoun-
study were vancomycin (50 mg/ml) and amikacin (20 tered. They have been found to have little effect on the
mg/ml). The method of preparing fortified eyedrops is damaging effect of bacterial toxins on the retina. Infact,
given in Appendix 3B. one experimental study on S. aureus endophthalmitis,
In a patient complaint to the regimen of topical medi- has shown increase in inflammation, retinal necrosis and
cation prescribed, subconjunctival antibiotic injection corneal opacification following intravitreal injection of
may have only a limited role. Subconjunctival injection steroids. In contrast to the above findings, there are
is not routinely used by us in managing patients with reports in literature which show clearing of the vitreous
endophthalmitis. In addition to patient discomfort, tearing in 9 of 20 patients given 1200 μg of corticosteroids
of conjunctiva and subconjunctival hemorrhage, there intravitreally.
is also a risk of intraocular injection of the drug this pro- Hence, the use of intravitreal injection of steroids
cedure. The recommended dose of commonly used remains a decision left to the discretion of the surgeon.
antibiotics for subconjunctival injection is shown in The recommended dose of corticosteroids in bacterial
Appendix 3C. endophthalmitis for intravitreal, systemic and subcon-
junctival injection is given in Appendix 4.
ANTI-INFLAMMATORY THERAPY:
ROLE OF CORTICOSTEROIDS SUPPORTIVE THERAPY
One of the major causes of tissue damage in bacterial Certain medications act as adjuncts in the management
endophthalmitis is the release of inflammatory mediators of patients with endophthalmitis. These include
in large quantities. This occurs because of invasion by cycloplegics and drugs to lower any elevation of
the organisms and also because of several endotoxins intraocular pressure that may be seen in some patients.
released by them. These have an ability to stimulate the Cycloplegics are an important part of the treatment and
complement pathway and also the arachidonic pathway as a general guideline, the strongest cycloplegic is to be
releasing both leukotrienes and prostaglandins. These prescribed in severe cases of endophthalmitis. We use
inflammatory mediators have chemotactic properties and atropine 1% ointment 8 hourly initially and then change
so attract polymorphonuclear leukocytes and macro- to either, homatropine 2% drops 4-8 hourly or to a
phages into the vitreous cavity. Proteolytic and collageno- combination of atropine and prednisolone eyedrops 6
lytic enzymes released from leukocytes are also harmful hourly. Apart from enabling control of inflammation and
to the highly sensitive intraocular tissues. relieving ciliary spasm, cycloplegics prevent synechia
Corticosteroids decrease the risk of tissue damage formation in miosis and increase the chances of having
resulting from the above mechanism by inhibiting both a dilated pupil. Presence of a dilated pupil not only
the lipo-oxygenase and cyclo-oxygenase pathways of enables better clinical evaluation but also becomes an
arachidonic acid metabolism. Corticosteroids remain the asset if a need for performing a vitrectomy arises.
most potent anti-inflammatory agents known. For being In patients with elevated intraocular pressure, drugs
most useful they have to be given early and in adequate such as oral acetazolamide and timolol may be
doses. They should however not be used whenever a prescribed. A vitreous tap before giving an intravitreal
fungal infection is suspected as they enhance fungal injection may also help to lower the intraocular pressure
growth by decreasing the defense mechanisms within at least transiently in some patients.
the body.
In post-surgical bacterial endophthalmitis, cortico- VITRECTOMY IN POST-SURGICAL
steroids may be given systemically, injected into the ENDOPHTHALMITIS
vitreous cavity and also used as topical drops and for Vitrectomy is the second line of management approach
subconjunctival injection. The use of systemic cortico- in endophthalmitis with specific and definite indications.
steroids is well-accepted but there is a persisting It is technically more demanding, needs experience and
controversy regarding the necessity and role of intravitreal has a potential to lead to complications, particularly
corticosteroids in improving the visual results in endo- retinal detachment. Also, it may not always be rewarding
in terms of the functional outcome. Vitrectomy for no response to medical treatment (intravitreal injection).
endophthalmitis may be necessary at two stages, primary, A severe case has been defined as one in which there is
during the acute infection or secondary in the resolved a total absence of red reflex, an inaccurate projection of
phase for vitreous opacification or membranes. Vitrec- light, an afferent pupillary defect, a corneal ring infiltrate
tomy in the later stage is less demanding and less likely and a patient worsening 24-48 hours after an intravitreal
to cause complications in comparison to vitrectomy the injection.
primary, acute stage of endophthalmitis. The most common approach that mostly decides the
The timing “When to do vitrectomy” in endophthal- time that vitrectomy should be undertaken is a worsening
mitis is difficult to decide and a controversial issue because despite a proper intravitreal injection or a lack of response
choosing a time that is neither too late nor too early is to two repeat intravitreal injections. This is also the
subjective, usually based on the surgeon’s past expe- approach adopted at our centre.
riences and also because the benefit versus safety window The only prospective randomized controlled evalua-
for this procedure is very narrow. tion of intravitreal and vitrectomy procedures for endo–
The advantages of vitrectomy are that it decreases the phthalmitis is the endophthalmitis vitrectomy study.
infectious, toxic and inflammatory load; provides Details of this study are discussed in the subsequent
adequate undiluted specimen for culture studies; section. The goal of pars plana vitrectomy in the EVS
increases antibiotic concentration within the eye and by was to remove at least 50 per cent of vitreous gel in eyes
removing media opacities enables a more rapid visual with no vitreous separation.
recovery. In reality however the functional outcome may The EVS did not answer the question of when to
be less than that theoretically possible because of a undertake vitrectomy, however, it clearly answered the
surgical bias in undertaking vitrectomy only in the more question of when to undertake additional surgery be it a
severe and advanced cases. As a result of this bias not repeat intravitreal or repeat vitrectomy. According to this
only does the surgery become more difficult but also the study a repeat intervention should be undertaken in eyes
risk of complications like retinal detachment increases doing poorly 36-60 hours after the first intervention
and so also the possibility of a relapse. (vitrectomy or intravitreal). At 3-9 months after the inter-
Peroperative problems that a surgeon faces during ventions, when they assessed the visual acuity and media
vitrectomy for endophthalmitis are a poor visualization clarity in the various groups, they found that:
due to an edematous cornea or IOL membranes, a ring • If initial vision is hard movements or better there was
abscess around the limbus that makes any attempted no difference in the outcome between immediate
suturing of an incision here impossible, an absent and vitrectomy and intravitreal injection groups.
often adherent and “Sticky” vitreous without PVD, an • However, if the initial vision was only light perception,
inflamed or necrotic retina which is easily liable to develop the final visual acuity and media clarity was substan-
tears and the risk of operating in the presence of tially better in patients undergoing vitrectomy.
congested choroidal vasculature. This study indirectly indicates that one very certain
During surgery, a 6 mm infusion cannula should be indication to immediately undertake pars plana vitrec-
preferred, the MVR blade used for making the scleroto- tomy in patients with postoperative (post-cataract
mies must be sharp and the cutter must not cause a drag surgery) endophthalmitis is when the initial vision is light
on the vitreous fibrils. The three cardinal principles to be perception only.
remembered while doing vitrectomy for endophthalmitis
are: Use maximal cutting rate, minimal suction and do ENDOPHTHALMITIS VITRECTOMY STUDY
not attempt to induce a PVD if it is not already present. Endophthalmitis Vitrectomy Study (EVS) was a multi-
No attempt should be made to go very close to the retina. centric study undertaken in the United States and
At the end of vitrectomy, it is generally recommended involving 420 patients who had developed bacterial
that intravitreal antibiotic injections be given (1/10th of endophthalmitis within 6 weeks of cataract surgery or
normal recommended dose). secondary IOL implantation. The primary objective of
The indications recommended in literature for the study was to determine the role of early pars plana
undertaking immediate vitrectomy are severe cases, cases vitrectomy in comparison to intravitreal injection alone
in which gram-negative organisms are seen on a smear (TAP) in patients with endophthalmitis and also to identify
examination of the vitreous aspirate and in cases showing the role of systemic antibiotic treatment in these cases.
The main objective outcome measures determined were growth was co-related with the final visual acuity it was
improvement in visual acuity and improvement in media found that in patients with a gram-positive, coagulase
clarity at the end of 3-9 month follow-up. negative organismal growth, 62 per cent achieved more
The other criteria for inclusion in the study was a visual than 20/50 vision while only 55 per cent did so in patients
acuity of at least or more than light perception and less with no growth on culture.
than 20/50 and with a relatively clear cornea and anterior The intravitreal drugs used in this study were
chamber. Patients with a history of other intraocular vancomycin (1000 μg in 0.1 ml) and amikacin (400 μg
surgeries, presentation after 6 weeks, fungal endo- in 0.1 ml). No intravitreal corticosteroids were given. For
phthalmitis, trauma and age below 18 years were not systemic (parenteral) administration the chosen drugs
included in the study. Other exclusion criteria included were ceftazidime (2 gm every 8 hourly) and amikacin
previous intraocular antibiotic administration, other (7.5 mg/kg initially and then 6 mg/kg every 12 hours). In
causes of poor vision, presence of retinal or choroidal those allergic to lactams, ciprofloxacin 750 mg orally twice
detachment and drug sensitivity to lactams. daily was used as an alternative. Systemic medication
The patients were randomly categorized into four was given for a period of 5-10 days and left to the treating
groups: PPV with systemic antibiotics, PPV without physicians discretion.

systemic antibiotics, TAP with systemic antibiotics and For subconjunctival injection the drugs chosen were
TAP without systemic antibiotics. vancomycin (25 mg/0.5 ml), ceftazidime (100 mg/0.5
An important factor during this study was in the ml) and dexamethasone 6 mg/ 0.25 ml. Topical antibiotic
assessment of vision when it was less than finger counting medications included vancomycin (50 mg/ml) and
at 1m. As mentioned earlier light projection was tested amikacin (20 mg/ml) given every 4 hourly routinely or
at a distance of 90 cm with the strongest intensity of light alternately every 1 hourly if wound leak or infection was
from an indirect ophthalmoscope. Hand movements present.
vision was tested at a distance of 60 cm with a light source The surgical interventions performed were vitreous
from behind the patient. The stimulus of hand move- tap and intravitreal injection or vitreous biopsy and intra-
ments was presented five times and the response was vitreal injection or pars plana vitrectomy and intravitreal
recorded as positive if four of these were correctly identi- injection. The goal of vitrectomy in eyes with no obvious
fied. Media clarity was graded as indicated earlier. vitreous separation was to remove atleast 50 per cent of
Patients were only admitted for management when it the vitreous gel.
was felt that topical medication may not be administered Additional surgery (re-vitrectomy, re-vitreous tap or
regularly, in presence of transportation difficulties and vitrectomy) was undertaken in eyes doing poorly 36-60
whenever pars plana surgery was contemplated. hours after the first intervention. Signs of worsening were
The most common symptoms at presentation was an absent red reflex or increasing opacification, a 1 mm
blurred vision (94%) followed by pain (74%). The mean increase in the height of hypopyon, development of a
interval between surgery and onset of symptoms was 4 corneal ring infiltrate and worsening pain.
days and visit to a vitreous surgeon, 6 days. Treatment The major conclusions of the EVS study were:
was initiated in all patients within 6 hours of presentation • If initial vision is hand motions or better then there is
and after having obtained diagnostic samples from the no difference in outcome between immediate
eyelid, anterior chamber (0.1 ml using 25-27 gauge vitrectomy or intravitreal antibiotics
needle) and vitreous (0.2 ml by aspiration or biopsy). • If initial vision is only light perception then final visual
These specimens were cultured on chocolate agar (37°C acuity and media clarity are substantially better in
in CO2), fresh enriched thioglycolate (37°C) and fresh patients undergoing vitrectomy and intravitreal
Sabourauds dextrose agar (25°C). Laboratory confirmed injection as compared to intravitreal injection alone
growth was defined as mentioned earlier. and using this • Whether or not systemic antibiotics are used there is
definition, no growth was obtained in 18 per cent cases, no difference in final visual acuity
equivocal growth was seen in 13 per cent and positive In subsequent reports from the EVS group other
growth in 69 per cent. The breakup of those with a important observations were made. These include:
positive culture was: gram-positive, coagulase negative • The vitreous is a richer source of laboratory confirmed
species in 47 per cent, other gram positive organisms in growth
16 per cent, gram-negative in four per cent and more • Gram stain should not determine the choice of
than one species in three per cent cases. When culture antibiotic drugs
• Vitrectomy with culture of vitrectomy cassette fluid observed for atleast 2 weeks before reporting it as
did not produce significantly more positive cultures negative. If Sabourauds media is unavailable or the
than vitreous tap or biopsy material and so the specimen is inadequate, the laboratory may be told to
procedure (i.e. vitrectomy) should not be performed hold the blood agar plate for 3 weeks and observe for
solely to improve the microbiological yield. fungi.
• Secondary or anterior chamber IOL implantation was
associated with a possible shift in the spectrum of MANAGEMENT OF POSTOPERATIVE
organisms isolated towards gram-positive organisms FUNGAL ENDOPHTHALMITIS
other than coagulase negative micrococci. The objectives of treatment in fungal endophthalmitis
• Vancomycin was active against all gram-positive remains the same as that in bacterial endophthalmitis.
isolates tested; amikacin and ceftazidime showed However, the results are not gratifying because of several
equivalent activity against gram-negative isolates factors like delayed diagnosis, lack of non-toxic fungicidal
• A positive Gram stain or infection with species other drugs and the inadequacy of intravitreal injection alone
than gram-positive, coagulase negative micrococci is in the treatment. The only agreement is that steroids in
significantly associated with poorer visual outcomes. form are absolutely contraindicated in fungal endo-
• Although visual prognosis is strongly associated with phthalmitis.
the type of infecting organism and Gram stain
positivity, presenting visual acuity remains more Systemic Antifungal Therapy
powerful than microbiologic factors in predicting
visual outcome and favorable response to vitrectomy. Unlike metastatic endophthalmitis caused by fungi,
postoperative fungal endophthalmitis poses a peculiar
POST-SURGICAL FUNGAL ENDOPHTHALMITIS problem in deciding the route of drug administration. In
the former, there is an associated fungaemia and usually
Clinical Features extraocular sites of fungal colonization, hence, systemic
Patients may present either with a blurring or decrease antifugal therapy is easily justified. This is not so in the
in vision associated with some degree of redness or with case of postoperative fungal endophthalmitis wherein the
complaints of floaters. Most cases of fungal fungal colonization is limited to the intraocular cavities.
endophthalmitis following intraocular surgery usually Since most anti-fungal drugs have the potential to cause
appear several weeks to months later. The characteristic significant adverse effects, the role of systemic therapy
feature is a relative lack of symptoms compared to the in such a situation may seem questionable. Moreover,
signs on examination of the eye. The presentation is that not all of these drugs have a good enough penetration
of chronic endophthalmitis with indolent inflammation. into the intraocular cavities. The problem has been solved
The anterior chamber may show a fixed hypopyon and to a certain degree by the discovery of certain anti-fungal
a fibrinous mesh-like exudation. There is variable degree drugs causing fewer systemic adverse effects and also
of corneal oedema, the intraocular pressure is frequently having a better intraocular penetration.
elevated and the vitreous may show snow balls and fluffy Exact management guidelines for the management
opacities. Infrequently the fungal colonies may be of exogenous fungal endophthalmitis are not available
misdiagnosed as retained lens matter and prescribed in literature. The relative paucity of controlled studies on
steroids. Fundus glow is variable but vision may be less the treatment approach in this form of endophthalmitis
than expected. Clinically it may be sometimes difficult to is possibly related to the infrequent occurrence of fungal
distinguish fungal endophthalmitis from P. acnes endophthalmitis in comparison to bacterial endoph-
endophthalmitis. thalmitis after intraocular surgery.
There are three major groups of anti-fungal drugs
Confirmation of Diagnosis available in the market and it is important for us to know
their limitations, advantages and potential for toxicity.
Material for culture in fungal endophthalmitis is as for
These three groups are: Polyenes (Amphotericin B),
post-surgical bacterial endophthalmitis. However it may
Azoles (Ketoconazole, Miconazole, Fluconazole, Itracona-
be more difficult to aspirate as the colonies are usually
zole) and Fluocytosine.
tenacious. The routinely used culture media for fungal
growth is Sabourauds dextrose agar. Although colonies Amphotericin-B Parenteral amphotericin-B has been
may begin to appear within a few days, it should be considered the treatment of choice in intraocular fungal
infections. However, this form of treatment has several Moreover, they only have a fungistatic effect. In compara-
disadvantages such as poor intraocular penetration and tive studies with amphotericin-B and fluoconazole in
the potential for both systemic adverse effects and retinal experimental animals it was seen that the initial response
toxicity. (for the first 17 days) to treatment was identical in both the
Amphotericin-B may be fungistatic or fungicidal groups. From the 21st day onwards however, the flucona-
depending on the concentration of the drug within the zole group began to again worsen probably because of
tissues and the susceptibility of the fungi. It destroys fungi the development of drug resistance. As combined therapy
by causing changes in the permeability of their cell with amphotericin-B and azole derivatives has been shown
membranes. It is recommended that before starting to increase the risk of developing resistance to amphotericin
patients on systemic amphotericin-B, a test dose be given. B, the use of this form of combination therapy is not
This is usually with 1mg of the drug in 20 ml of 5 per recommended.
cent dextrose (not normal saline) given intravenously The usual dose of the usually preferred azole deriva-
over half an hour. Therapy should not be undertaken if tives in the treatment of intraocular fungal infections is:
the patient develops serious side effects like hypotension Ketoconazole (400 mg/day in a single or two divided
or cardiac arrhythmias with the test dose. In the absence doses) and Fluconazole (200 mg/day in a single or two
of any adverse effects, treatment can be started one hour divided doses).
later with a dose of 0.7 mg/kg of amphotericin in 500 ml If azole derivatives are chosen as the first line of
of 5 per cent dextrose by slow intravenous infusion over treatment in the management of fungal endophthalmitis,
2-6 hours. Although more rapid administration (within it would be probably prudent to not persist with the
1-2 hours) have been advocated, it may carry a greater treatment if no response is observed within the first 7 to
risk. Previously the subsequent approach was to increase 10 days. This is also probably necessary if the condition
the dose gradually (5-10 mg) each day. However may begins to worsen after an initial response as seen in the
be better to try and achieve the maximum dose of 0.7- experimental study mentioned earlier. Under both these
1.0 mg/kg/day as early as possible. No treatment response circumstances one should change to treatment with
is usually seen in the first week. Subsequently, the amphotericin B despite its known adverse effects.
inflammation begins to gradually subside. Treatment Constant interaction with an internist to monitor for toxic
should be continued until the inflammation and any effects and modify dosage of the drug accordingly
chorioretinal lesions present, show complete resolution. however, becomes very essential.
Toxic adverse effects known to occur with intravenous An important part of the management is to remember
administration of amphotericin-B are anaphylaxis, that corticosteroids by any route are absolutely contra-
convulsions, phlebitis, chills, fever, headache, anaemia indicated in the management of fungal endophthalmitis.
and thrombocytopenia. Hypotension and cardiac arrhy- Flucytosine Treatment with drug alone in the manage-
thmias are other serious side effects. The most common ment of fungal infections is not recommended because
and significant adverse effect is nephrotoxicity. This is of the rapid development of drug resistance. However, it
reported to occur in 80 per cent of patients and so may be used in combination treatment with amphotericin
constant monitoring of renal parameters is a must during B when the intraocular inflammation is severe and resis-
treatment with parenteral amphotericin-B treatment. tant to initial treatment. Fluocytosine is given orally in a
Azole derivatives These newer group of drugs have the dose of 50-100 mg/kg/day in four divided doses. This
advantages of adequate systemic absorption following drug can cause hematologic, renal and hepatic toxicity.
oral administration, better penetration into the intraocular Dose of various anti-fungal agents for systemic
cavities (fluconazole>ketoconazole>itraconazole) and administration is shown in Appendix 5A.
lesser risk of serious adverse effects. To be effective
INTRAVITREAL ANTIFUNGAL THERAPY
however, they have to be given early. The only drug
shown to be effective in reducing fungal counts when Unlike in postoperative bacterial endophthalmitis where
given after 7 days of fungal inoculation in experimental the mainstay of treatment is intravitreal administration,
animals has been ketoconazole. in fungal endophthalmitis, this mode of drug adminis-
The disadvantage of azole derivatives are that they are tration acts only as an adjunct to systemic medication.
not as effective as amphotericin B, resistance to the drug This is because, fungi unlike bacteria multiply less rapidly
may develop rapidly and they have a significant anta- and correspondingly treatment of fungal endophthalmitis
gonistic effect when combined with amphotericin-B. requires a prolonged duration (in weeks and not days)
of adequate concentrations of the anti-fungal agent within response against soft lens matter remaining after cataract
the vitreous cavity. This objective cannot be achieved surgery.
with intravitreal administration. A probably more Propionibacterium acnes endophthalmitis presents as
efficacious way of achieving this objective in future could a low grade, smoldering type of intraocular inflammation
be the development of sustained release intraocular following cataract surgery. Because of this pattern of
devices similar to those presently in use to treat patients inflammation, it tends to be missed in its early stages.
with cytomegalovirus retinitis (e.g. Ganciclovir intraocular The inflammation may show an initial response to
device—GIOD). steroids but subsequently begins to recur. Endo-
The method of injection and the precautions while phthalmitis caused by P. acnes has certain classical clinical
administering an intravitreal injection is the same as those features such as the presence of whitish plaques in relation
described under postoperative bacterial endophthalmitis. to the capsular bag, history of unexpected inflammation
However, the follow-up guidelines (e.g. when to repeat after YAG capsulotomy and the frequent tendency to
the injection/how long to wait before vitrectomy, etc.) relapse following initial response. The whitish plaques
following this injection are not clearly defined. Steroids are composed of colonies of P. acnes. Laboratory confir-
are absolutely contraindicated. mation of the diagnosis is also difficult and often delayed
Preparation of Amphotericin-B for intravitreal injection because the organism begins to show up on anaerobic
is given in Appendix 5B. culture media only after about 2 weeks. The whitish
plaques are formed by both sequestered colonies of the
Vitrectomy in Fungal Endophthalmitis organism as well as inflammatory cells.
Acute cases of endophthalmitis caused by P. acnes
The only differences with regard to vitrectomy for bacterial infection have also been reported. These cases are few
and fungal endophthalmitis are that in the latter it is and they differ from the chronic form in showing a
generally recommended that it be performed early and gratifying response to treatment. Recurrences are not
an antifungal injection (usually Amphotericin B) given known to occur following acute infection with P. acnes
into the vitreous at the end of the surgery. infection. This is probably because the organisms have
At our center, in cases of fungal endophthalmitis, we not become sequestered within the capsular bag.
prefer to initially give a trial of azole derivatives (Flucona- For laboratory confirmation of P. acnes infection, the
zole/Ketoconazole) for 10-14 days. If this fails, we subject organism should be cultured on anaerobic media and
them to vitrectomy and continue with the above drugs. observed for growth for atleast 14 days.
If still the exudation reappears an intravitreal injection of Management of endophthalmitis caused by P. acnes
Amphotericin-B 5 μg is given. In general the prognosis poses a peculiar challenge. Although the virulence of
has not been very satisfactory in patients with post- the organism is low and it does not usually produce a
operative fungal endophthalmitis. severe inflammatory response, it is difficult to eradicate
because it can remain sequestered within the capsular
PROPIONIBACTERIUM ACNES ENDOPHTHALMITIS bag. It would probably not be possible for the antibiotics
to reach these spaces and remain there at the needed
In patients with chronic postsurgical endophthalmitis, concentrations for a sufficient duration of time.
Propionibacterium acnes has been reported to be the Controversies exist in the management approach in this
most common isolate. Propionibacterium acnes is an form of endophthalmitis due to clinical variables such as
anaerobic, gram-positive bacillus that is normally present the severity of infection.
in the conjunctival sac as a commensal. Though con- Treatment approaches that have been indicated in
sidered to have no pathogenic potential a few decades literature are intravitreal antibiotics alone in mild cases,
ago, this organism is now known to a frequent cause of to vitrectomy, total capsulectomy and IOL explantation
chronic bacterial endophthalmitis. A few cases of along with intraocular and systemic antibiotics in very
endophthalmitis by Propionibacterium granulosum have severe cases. Intravitreal injection for P. acne endo-
also been reported. phthalmitis has to be given into the capsular bag to be of
Propionibacterium acnes has an ability to stimulate some value. The objective of total capsulectomy and IOL
the immune system but being resistant to killing by the explantation is to eradicate colonies of P. acnes seques-
polymorphs and monocytes, it remains intracellularly tered within the confines of the capsular bag. Surgical
after phagocytosis by macrophages. The organism measure like partial capsulectomy and retaining of the
probably acts as an adjuvant in stimulating an immune IOL may provide only transient respite. The antibiotic of
choice in treating endophthalmitis caused by Propioni- is useful. However, there are certain clinical features that
bacterium acnes is vancomycin in the same dose recom- may aid in making this critical differentiation. These are
mended for other forms of bacterial endophthalmitis summarized in Table 35.1.
(1000 μg in 0.1 ml). Table 35.1: Infection vs inflammation
Parameter Infection Inflammation
STERILE ENDOPHTHALMITIS
(POSTOPERATIVE INFECTION VS INFLAMMATION) Focal infiltrate Commonly present Rare
Fundus glow Poor/Absent OK/ Mildly poor
Though infection is the most serious and probably the Vitreous cavity Haze ++ Clear/ Mild Haze
most common cause of unexpected postoperative inflam- Color of exudates Yellowish White
mation, it is not the only cause. Other factors incriminated IOP Low Normal
in the genesis of postoperative inflammation include
retained lens matter, residual chemicals from sterilization, Visual prognosis In the EVS study, the rates of achieving
toxicity of residual monomers on PMMA lenses, a final visual acuity of 20/100 or more in relation to the
mechanical irritation of the iris and ciliary body by the organism producing endophthalmitis was as follows:
lens and rarely inadvertent injection of xylocaine or gram-positive, coagulase negative micrococci (84%),
antibiotics containing high concentration of these drugs. Staphylococcus aureus (50%), streptococci (30%), entero-
Inflammation caused by these agents are sometimes cocci (14%) and gram-negative organisms (56%). It was
termed ‘sterile postoperative endophthalmitis’. found that a positive Gram stain or infection with species
The dictum that all unexpected postoperative reaction other than gram-positive, coagulase negative micrococci
should be considered as infective until proven otherwise is significantly associated with poorer visual outcomes.
APPENDIX 1
Summary of Laboratory Confirmation of

Diagnosis in Endophthalmitis
• Direct plating is better than sending the sample in transportation • Plating should be on all three culture media: aerobic, anaerobic
media and fungal
• If direct plating is not possible, then the sample should be sent • The preferred culture media are:
at the earliest for plating in the laboratory and immediate Gram • Chocolate agar ( 37°C in CO2 )
and Giemsa staining performed • Fresh enriched thioglycolate ( 37°C )
• Lid margin and conjunctival swab cultures are no longer • Fresh Sabourauds dextrose agar ( 25°C )
recommended • No culture should be considered negative until two weeks of
• Culture of suture removed in the presence of a suture abscess observation for growth
or infected suture track is a must • Laboratory confirmed growth is defined as:
• Samples from both aqueous and vitreous must be cultured 1. Atleast semiconfluent growth on solid media
• Aqueous and vitreous samples must be obtained with sterile 2. Any growth on more than or equal to 2 media
precautions 3. Growth on one media supported by a positive Gram stain.
APPENDIX 2A
Preparation of Commonly Recommended Intravitreal

Drugs in Postoperative Bacterial Endophthalmitis
1. Vancomycin hydrochloride (1000 μg in 0.1 ml): The drug is 2. Ceftazidime hydrochloride (2.25 mg in 0.1 ml): The drug is
available as a powder in a strength of 500 mg. Reconstitute available as a powder in a strength of 500 mg. Reconstitute
this with 10 ml of sterile solution of injection or saline. This this with 2 ml of sterile solution for injection to give a strength
gives a strength of 50 mg in 1.0 ml and hence 10 mg in 0.2 of 250 mg in 1 ml (has 225 mg of active ingredient) and 25
ml. 0.2 ml of the drug is drawn into a tuberculin syringe and mg (22.5 mg) in 0.1 ml. 0.1 ml of the drug is drawn into a
this is further diluted with 0.8 ml of sterile saline to give a tuberculin syringe and diluted further with 0.9 ml of sterile
strength of 10 mg in 1.0 ml and hence 1000 μg (1 mg) in solution to give a strength of 2 5 mg (22.5 mg) in 1.0 ml and
0.1 ml. hence 2.25 mg in 0.1 ml.
3. Cefazolin hydrochloride (2.25 mg in 0.1 ml): The drug is and 10 mg in 0.2 ml. 0.2 ml of the drug is drawn into a tuber-
available as a powder in a strength of 500 mg. The required culin syringe and diluted further with 2.3 ml of sterile solution
concentration is achieved by following the same steps of to give a strength of 10 mg in 2.5 ml and hence 400 μg in
dilution indicated above for ceftazidime hydrochloride. 0.1 ml.
4. Ciprofloxacin hydrochloride (150 μg in 0.1 ml): The drug is
6. Gentamicin sulfate (200 μg in 0.1 ml): The drug is available
available as a 100 ml bottle containing 200 mg of ciprofloxacin.
as a solution of 80 mg in 2 ml vial (40 mg in 1 ml) and 4 mg in
0.15 ml is withdrawn into a tuberculin syringe and this is mixed
0.1 ml. 0.1 ml of the drug is drawn into a tuberculin syringe
with 0.1 ml ringer lactate. 0.1 ml of this mixture contains
and diluted further with 1.9 ml of sterile solution to give a
150 μg of ciprofloxacin
5. Amikacin sulfate (400 μg in 0.1 ml): The drug is available as a strength of 4 mg in 2 ml (2 mg in 1 ml) and hence 200 μg in
solution in a strength of 100 mg in 2 ml vial (50 mg in 1 ml) 0.1 ml.
APPENDIX 2B
Preparation of Less Commonly Recommended Intravitreal

Drugs in Postoperative Bacterial Endophthalmitis
1. Chloramphenicol (2000 μg in 0.1 ml): The drug is available 2. Clindamycin (1000 μg in 0.1 ml): The drug is available as a
as a powder in a strength of 1000 mg. Reconstitute this with solution in a strength of 300 mg in 2 ml vial (150 mg in 1 ml)
10 ml of sterile solution for injection to give a strength of 100 and 15 mg in 0.1ml. Draw 0.1 ml into a tuberculin syringe and
mg in 1 ml and 10 mg in 0.1 ml. Draw 0.1 ml into a tuberculin dilute further with 1.4 ml of sterile solution to give a strength
syringe and dilute further with 0.4 ml of sterile solution to give of 15 mg in 1.5 ml and hence 1 mg (1000 μg) in 0.1 ml.
a strength of 10 mg in 0.5 ml and hence 2 mg (2000 μg) in
0.1 ml.
APPENDIX 3A
Recommended Dose of Commonly Used Antibiotics in Supportive

Management of Post-surgical Endophthalmitis
1. Vancomycin : 1 g IV q 12 hr (30 mg/kg/day) 8. Chloramphenicol : 1 g IV q 8 hr (50 mg/kg/day)

2. Ciprofloxacin* : 750 mg PO q 12 hr 400 mg IV q 12hr 9. Amikacin : 240 mg q 8 hr (15 mg/kg/day)
3. Ceftazidime : 2 g IV q 8 hr (100 mg/kg/day) 10. Tobramycin : 80 mg q 8 hr (5 mg/kg/day)
4. Ceftriaxone : 2 g IV q 8 hr (100 mg/kg/day) 11. Gentamicin : 80 mg q 8 hr (5 mg/kg/day)
5. Cefazolin : 1.5 g IV q 6 hr (~75 mg/kg/day) 12. Ofloxacin : 200 mg PO q12 hr
6. Imipenem : 1 g IV q 12 hr 500 mg PO q 8 hr * Avoid in children below 12 years and in pregnant and lactating
7. Cephalothin : 1 g IV q 4 hr (100 mg/kg/day) mothers
APPENDIX 3B
Recommended Concentrations of Antibiotics

for Subconjunctival Injection
1. Vancomycin : 25 mg/0.5 ml 5. Tobramycin : 20 mg/0.5 ml

2. Ceftazidime : 100 mg/0.5 ml 6. Gentamicin : 20 mg/0.5 ml
3. Cefazolin : 100 mg/0.5 ml 7. Chloramphenicol : 100 mg/0.5 ml
4. Ceftriaxone : 100 mg/0.5 ml 8. Clindamycin : 150 mg/0.5 ml
APPENDIX 3C
Preparation of Commonly Used

Fortified EyeDrops*
1. Cefuroxime (50 mg/ml): An injection vial of 1000 mg 3. Gentamicin (15 mg/ml): Add 2 ml of parenteral gentamicin
cefuroxime is diluted with 2.5 ml sterile water. Of this dilution, containing 80 mg of the drug into a commercially available
2.5 ml is then added to 12.5 ml of artificial tears. This is stable 5 ml vial of gentamicin eyedrops (0.3%).
at room temperature for 24 hours and in the refrigerator for * Fortified eyedrops in endophthalmitis is not recommended
96 hours. routinely but only if there is a concurrent corneal ulcer or
2. Tobramycin (15 mg/ml): Add 2 ml of parenteral tobramycin suture abscess and in bleb associated endophthalmitis.
containing 80 mg of the drug into a commercially available
5 ml vial of tobramycin eyedrops (0.3%)
APPENDIX 4
Recommended Dose of Corticosteroids in

Bacterial Endophthalmitis
A. Intravitreal Dexamethasone (400 μg in 0.1 ml): The drug is B. Systemic Corticosteroids (Equivalent Doses):
available as a solution in a strength of 8 mg in 2 ml vial (4 mg 1. Prednisolone : 1-2 mg/kg/day PO
in 1 ml) and hence 0.4 mg (400 μg) in 0.1 ml. 0.1 ml of the 2. Betamethasone :
drug may be withdrawn directly into a tuberculin syringe 3. Dexamethasone :
without any further dilution. C. Subconjunctival Dexamethasone: 1 mg in 0.25 ml
APPENDIX 5A
Recommended Dose of Systemic Anti-fungal

Agents for Fungal Endophthalmitis
1. Amphotericin B : 0.7-1.0 mg/kg/day (given slow IV over 2-6 3. Ketoconazole : 400 mg/day in single or two divided doses
hours after a test dose) 4. Itraconazole : 200 mg/ day in single or two divided doses
2. Fluconazole : 200 mg/day PO in single or two divided 5. Flucytosine : 50-100 mg/kg/day
doses
APPENDIX 5B
Preparation of Intravitreal Drugs in

Fungal Endophthalmitis
1. Amphotericin B (5 μg): Amphotericin B available as 50 mg 500 μg in 0.1 ml. Take 0.1 ml into a tuberculin syringe and
powder in a vial. Reconstitute this with 10 ml of dextrose 5% dilute further with 9.9 ml of dextrose 5% to give a concentration
(not normal saline) to give a concentration of 5 mg/ml and of 500 μg in 10 ml and 50 μg /ml and 5 μg in 0.1 ml.
Posterior Segment Disorders and SICS 195
Posterior Segment
Disorders and SICS
36 Dinesh Talwar
Mool Chand
Gopal S Pillai
S
mall incision cataract surgery and Posterior Segment Surgical Complications
phacoemulsification have revolutionized the Preoperative Complications These include complications
management of cataract surgery. The main relating to ocular anaesthesia, i.e.:

advantages of these procedures over conventional extra- • Accidental globe perforation
capsular cataract extraction (ECCE) with intraocular
• Central retinal artery occlusion following long time
lens (IOL) implantation are a consequence of the reduced
use of superpinky
size of the wound required for delivery of the nucleus.
Consequently the surgery can be performed in a closed Intraoperative complications
system with out significant alterations in the intraocular • Expulsive haemorrhage
pressure (IOP). Furthermore the smaller size of the wound • Vitreous loss
imparts it with greater stability and minimises • Posterior dislocated nucleus
postoperative morbidity and especially postoperative • Dislocated IOL
astigmatism. Today more than ever before, cataract
extraction by small incision cataract surgery is being Postoperative complications
performed as an outpatient office procedure permitting • Endophthalmitis
early rehabilitation with minimal to no morbidity. It is • Late retrobulbar haemorrhage
therefore important for all small incision cataract surgeons
to have a sound knowledge of the posterior segment ACCIDENTAL GLOBE PERFORATION
complications of small incision cataract surgery. In
comparison to conventional cataract surgery, especially Accidental globe perforations during local anaesthesia
regarding posterior segment disorders which might occur are a well documented, but rare complication in
either during small incision surgery or in the postoperative experienced hands. The incidence of needle perforations
period and compromise the final visual outcome. during retrobulbar anaesthesia varies from study to study
with figures of 1 in 12000 to 3 in 4000 cases reported by
Pathophysiology of Posterior Segment Disorders different authors. The incidence is much lower in patients
Posterior segment affections in patients undergoing small who receive peribulbar blocks. However, accidental globe
incision cataract surgeries can be described along four perforation has been reported following peribulbar
major subheads. injections as well. The possibility of carrying out a small
A. Posterior segment surgical complications of small incision cataract surgery and especially a phacoemulsi-
incision surgery. fication under topical anaesthesia or without anaesthesia
B. Posterior segment disorders which arise de novo raises the important possibility of total prevention of this
following the surgery in the postoperative period, i.e. complication during this procedure. It is however likely
cystoid macular oedema. that the use of peribulbar or retrobulbar blocks will
C. Previously existing disorders which can be aggravated continue even in patients undergoing phacoemulsi-
following small incision cataract surgery, i.e. diabetic fication as topical phaco is likely to be possible only in
retinopathy. patients who are extremely co-operative. Further more a
D. Associated independent retinal pathologies, i.e. retinal peribulbar or retrobulbar block is likely to be used in all
detachment or macular degeneration. patients undergoing a small incision cataract surgery.
Clinical Features neous or induced central retinal artery pulsations in a

clear media and high IOP is a sign of impending CRAO.
The most important predisposing factors for the
Patients who have a vitreous haemorrhage with a hazy
occurence of this complication are large myopic eyes and
media or in cases who have retinal detachments would
very uncooperative patients. Varying clinical
need to be taken up for prompt vitreous surgery in
presentations may occur in patients who have had
addition to the cataract surgery.
accidental perforations of the globe depending upon the
Since cataract surgery will be needed in most of the
sequence of events that have happened i.e.
cases even to manage the posterior segment pathology,
1 The needle penetrates the globe and the drug is
the cataract should be removed in the first sitting if it can
injected into the globe
be safely done so. The decision to insert an IOL should
2 The needle penetrates the globe, and is then retracted
then be based on the condition of the posterior segment
and the drug is injected into the orbital cavity.
of the eye after nucleus removal and cortical aspiration.
3 The needle penetrates the eye anteriorly and then
If the media is clear and no retinal detachment is present,
again posteriorly and the drug is injected into the
an IOL may be inserted. If however the media is very
orbital cavity.
hazy and / or a retinal detachment is present, it is best to

In situation one, If the drug is accidentally injected into
avoid inserting an IOL. A flow diagram outlining the
the globe, the IOP rises to extremely high levels, and the management of accidental globe perforation is given in
patient may complain of severe pain as the drug is being Figure 36.1.
injected. The cornea becomes hazy and the anterior
chamber may become shallow. In situations two and three, Accidental globe perforation: Approach to management
the condition is diagnosed when there is sudden hypotony
or pupillary constriction, a characteristic “poking through” Indirect ophthalmoscopy (If globe perforation is suspected
sensation and loss of the red reflex and pain may be
complained by the patient at the time of perforation. Media clear enough Media hazy
To visualize perforation site
Management
No RD RD Perforation site
With overlying
Further management of this complication depends upon Vitreous haemorrhage
the situation. The factors, which influence decision mak-
ing in this situation, are extent of the cataract, the IOP, Laser/ Cryo Vitreoretinal surgery
media clarity including the clarity of the cornea, presence
or absence of vitreous haemorrhage, and presence of a Fig. 36.1
retinal detachment.
CENTRAL RETINAL ARTERY OCCLUSION
If the cataract is total and if the IOP is within normal
limits, it is best to go ahead with the cataract extraction Central retinal artery occlusion has been reported rarely
in the same sitting. If however the site of the perforation following peribulbar anaesthesia. This is likely to occur
can be visualized due to a moderate or mild cataract, when the superpinky has been kept at high pressure for
one should ask a retinal surgeon to seal the break with a long time. The compressing effect of the superpinky
cryopexy or laser photocoagulation using a laser indirect could raise the intraocular pressure when it is on and
ophthalmoscope before the patient is taken up for thereby precipitate a central retinal artery occlusion.
cataract extraction. Furthermore it is preferable to wait Hence it is important not to keep the superpinky at too
for 3 to 4 weeks after the prophylactic treatment before high a pressure. It is even more important to release the
going in for the cataract extraction. It is therefore manda- superpinky at timely intervals. Generally the pressure
tory to do an indirect ophthalmoscopy in all suspected exerted by a pressure lowering devise on the eye should
cases of occult perforation. be lesser than 30 mm of Hg. This pressure should not be
In patients who have very high IOP, it is probably best exerted for over 15 minutes at a time. It is important to
to defer surgery to the next operating day to permit the remember that once central retina artery gets obstructed,
IOP to come down to normal. But immediate para- we might not be able to diagnose the condition until the
centesis may be required to prevent permanent visual postoperative phase when treatment modalities are not
loss due to central retinal artery occlusion (CRAO) likely to be effective in successfully managing the
because of very high IOP. The visualization of sponta- condition.
EXPULSIVE HAEMORRHAGE case one suspects impending choroidal haemorrhage,
Introduction
these needles are quickly passed through the corneal and
scleral ends of the wound and kept in place till formal
Expulsive choroidal haemorrhage is a dreaded compli- suturing can be completed. The needles should be passed
cation of ocular surgery. Its incidence has been quoted as quickly as possible even if iris incarceration into the
to be 0.05 to 0.5 per cent during cataract surgery by wound occurs since this can be managed once the wound
different authors. The incidence of this complication is is secure.
likely to be lower in patients undergoing phacoemulsi- In many cases, the occurence of choroidal
fication since a closed intraocular cavity is maintained at haemorrhage is recognized late when the IOP has risen
a near constant intraocular pressure through out the to dangerously high levels. At this time, the technique
procedure. Whether the risk of this complication is less described previously will no longer work. In this situation,
in patients undergoing small incision cataract surgery is it is best to use a 4-0 or a 6-0 vicryl or silk suture for
open to question. wound closure since finer sutures are likely to give way
It has been shown that axial length > 25.8 mm, a due to the high pressure. It is imperative that the wound
history of glaucoma, preoperative intraocular pressure be closed as quickly as possible in this situation even if
> 18 mm of Hg, and intraoperative pulse rate >85 beats iris gets incarcerated in the wound. If the surgeon feels
per minute are all associated with higher risk of expulsive that the tension has to be controlled further, a posterior
haemorrhage. Long-standing hyper tension and sclerotomy can be done 4 to 4.5 mm posterior to the
arteriosclerosis are also predisposing factors. limbus. Some surgeons have also advocated retrovitreal
The site of haemorrhage is probably a sclerotic fluid aspiration through the pars plana route if possible.
choroidal arteriole where the vessel crosses the supra-
Personally we feel that this may not prove to be feasible
choroidal space from the scleral canal. It has been
during the acute crisis confronting the surgeon at that
postulated that the sudden hypotony following surgical
time.
penetration of the globe causes a bending and then a
In case the acute event has been successfully managed,
rupture of the arteriole.
the possibility of salvaging the eye and its vision increases
Clinical Features significantly. The patient is managed conservatively with
all the efforts directed at the control of IOP and intraocular
This complication can be diagnosed when in a case, inflammation. Choroidal haemorrhages often regress
sudden wound gape, iris prolapse, self-delivery of lens spontaneously in 2-3 weeks. If kissing choroidal
and loss of red reflex begin to occur in quick succession. haemorrhagic detachments form it may become
Finally this might even lead to expulsion of the whole necessary to drain them on the 5th to 7th day. The
intraocular contents. Capsular rent during extension of procedure may need to be combined with a vitrectomy
section and a spontaneous prolapse of a PC IOL into for clearing of vitreous haemorrhage. The management
AC in a previously well formed anterior chamber are of a kissing choroidals is best left to an expert vitreoretinal
other early signs of suprachoroidal haemorrhage. surgeon to whom the patient should be referred as soon
(personal experience) as the condition is detected.
Some times, choroidal haemorrhage develops during
Management
the postoperative period in elderly patients with arterio-
It is quite evident that this complication has to be sclerosis, especially those patients who have been
recognized early and prompt measures taken to reduce engaging in Valsalva maneuvers such as straining at stool
the tension and close the wound immediately in order or coughing. The possibility of this complication should
to successfully salvage the eye in these cases. Prompt be explained to the patient and he or she should be
closure of the wound is the most important step in the warned against coughing or severe straining in the early
management as it can help to salvage the eye and even postoperative period.
the vision in a number of patients. The quickest technique
to close a wound, which has just begun to gape, is one VITREOUS LOSS
which has been described by Dr Daljit Singh. A set of 6
or 7 8-0 needles which have been left over after suturing Vitreous loss is one complication that all cataract surgeons
of previous cataract surgeries must always be kept handy have experienced at one time or the other. This compli-
on one side of the OT trolley so as to facilitate closure. In cation occurs even in the best of hands and hence all
cataract surgeons should be well versed with its important to understand that once a lens has sunk down,
management. The incidence has been reported to vary no fishing of the lens should be done from the anterior
from 2 to 5 per cent by different authors. The incidence route as it will increase the traction on the vitreoretinal
of posterior capsular tears and vitreous loss is high in the interface.
early phases of the learning curve of small incision
cataract surgery. The incidence is probably higher during CHOROIDAL DETACHMENT
the learning curve of the phaco surgeon than it is of
manual small incision cataract surgeon. Vitreous loss most When serous fluid accumulates in the suprachoroidal
commonly occurs during the nucleotomy and lens matter space choroidal detachment can occur. The shunting of
aspiration. fluid into this space is generally precipitated by low IOP,
causing hydrostatic pressure to decrease in the anterior
Clinical Features uveal veins. The plasma proteins add an osmotic force
The capsule rupture may not be readily visible at times. that draws more fluid into the space, increasing the
In this situation, we might have to rely on subtle signs detachment. Low IOP following cataract surgery can
like the inability to aspirate cortex despite adequate result from a wound leak or ciliary body shutdown. The
suction, a peaked pupil, or posterior movement of lens possibility of this complication is low in cases, which have
remnants. Sudden deepening of the anterior chamber undergone small incision cataract surgery or
and a brightening of the red glow may also be noticed. A phacoemulsification unless the corneal or scleral valve
cellulose sponge kept at the wound and rolled will show has been made in a faulty manner. Attention to the
the vitreous strands if there is vitreous in the wound. These creation of a good corneal or scleral valve is thus essential
clinical features will be more over similar in cases of in all cases undergoing small incision cataract surgery.
vitreous loss occurring in small incision manual cataract Care should also be taken to hydrate or close the sideport
surgeries and in phacoemulsification. which may be a more common cause of leakage . Many
a time this is ignored thinking that the opening is very
Management small.
It is important that all the vitreous is removed from the
anterior chamber and the wound as it can lead to traction Clinical Features
and later complications. The vitreous at the wound can
be cleared by a scissors or by an automated vitrectomy The characteristic clinical signs are smooth dome like
probe (preferred method). Instilling viscoelastic material brownish elevations of the peripheral choroid and retina.
into the bag may reposit the vitreous if the tear is small As a consequence, the ora serrata becomes easily visible
and there is only a limited vitreous bulge. If a significant in the affected area with an indirect ophthalmoscope.
amount of vitreous is present in the anterior chamber, These mounds appear very solid but vary in extent. The
and certainly if it is present in the wound, an automated differential diagnoses include retinal detachment and
vitrectomy should be performed using high cutting rates retinal mass lesions.
of upto 600 cuts per minute and low aspiration pressures
and low irrigation. The endpoint of vitrectomy is a round Management
central pupil with a deep anterior chamber with a
posteriorly curved iris surface. Infusion for the vitrectomy Under most circumstances, a choroidal detachment is
should be provided either in the full function vitrectomy managed conservatively. If the anterior chamber is well
probe or through a 20 or 22-gauge cannula attached to formed and if the choroidal detachments are small to
the infusion bottle suspended 2 feet above the patients moderate in size, it is recommended that the patient be
head. The infusion should then be used judiciously as maintained on a strong cycloplegic agent, such as
excessive infusion could hydrate the gel vitreous, thereby atropine ointment, 3-4 times per day or homatropine
prolonging the vitrectomy. Finally a vitreous sweep is eye drops 8 times a day along with a topical steroid one
used to move vitreous stands away from the wound and hourly, i.e. 16 to 18 times daily. Systemic steroids may
into the pupillary space. be added to this treatment regime if needed. If the cause
The management of cases with vitreous loss associated of the hypotony is from a wound leak, then it must be
with nucleus drop is dealt with elsewhere. It is quite resutured.
CYSTOID MACULAR OEDEMA (CME) course.The patient usually presents with gradually
Introduction and Epidemiology
decreasing vision usually in the range of 6/18 and 6/60.
Direct ophthalmoscopy reveals the absence of foveal
The accumulation of fluid in the macula resulting in the reflex with the presence of cystic spaces in the macular
formation of cystic spaces, after cataract surgery, is refer- region, the inner walls of which are not appreciable. The
red to as Irvine-Gass syndrome. The fluid may be pathology can be visualised with greater clarity using a
extracellular in the outer plexiform and inner nuclear slitlamp biomicroscopy with a 90-D lens, which reveals
layers of the retina, or intracellular causing Muller cell the characteristic cystic spaces in the foveal region.
degeneration with intracellular vacuolation. CME is more Evidence of cells or flare may be present in some cases.
often seen in association with complicated cataract In most cases, fluorescein angiography reveals parafoveal
surgery and is more commonly seen in patients with retinal capillary leakage In the early and mid phases of
rupture of the posterior capsule with vitreous loss, vitreous the angiogram where as a petaloid pattern of leakage in
incarcerated in the surgical wound, or in those with a the macula and leakage on or around the optic disc
poorly positioned intraocular lens. occurs in the late phases of the angiogram. (Fig. 36.2)
The incidence of angiographically documented CME However, the visual acuity is not related to the amount
is approximately 50 per cent after intracapsular cataract of leakage.
extraction, 20 per cent after extracapsular cataract extrac-
tion and 10 per cent after phacoemulsification surgery.
However, studies have reported that the occurrence of
clinically significant macular edema varies between 1.5-
2.3 per cent and is probably lesser in patients who have
undergone phacoemulsification as compared to those
who have undergone conventional ECCE and IOL.
There is a paucity of studies, which have evaluated the
incidence of this disorder in patients undergoing small
incision cataract surgery.
It is important to differentiate clinically diagnosed
cystoid macular edema based on biomicroscopic
examination, from angiographic cystoid macular edema
based on fluorescein angiography since angiographic
CME does not necessarily affect visual acuity. Persistent
macular edema may however result in foveal receptor
damage and macular degeneration. Fig. 36.2: Fluosescein angiogram of a patient with cystoid
The common risk factors for the development of CME macular oedema demonstrahng a petalloid form of dye leakage
in the late phase
following cataract surgery are rupture of the posterior
capsule, vitreous loss, or insertion of a flexible open-loop
anterior chamber IOL. Other causes are secondary lens Management
implantation, intraocular lens exchange, old age, pre- Prostaglandin release has been implicated in the
existing uveitis and YAG capsulotomy. disruption of the inner blood-retinal barrier after ocular
surgery and as a cause of CME. Non steroidal anti-
Clinical Features
inflammatory drugs and topical, periocular or oral
The usual clinical presentation is a history of blurring of corticosteroids are of proven benefit in reducing the
vision 2-6 weeks following cataract surgery. The problem immediate postoperative inflammation that presumably
of cystoid macular edema comes up earlier in the era of contributes to the development of CME. In patients in
small incision cataract surgery as most patients have whom there is a significant visual loss, the first line of
begun to gain a very good visual acuity soon after surgery management should probably consist of periocular or
due to minimum astigmatism in comparison to routine systemic steroids (Injection kenocort ( triamcinolone) 0.5
ECCE and IOL where sutures are removed only after six cc in the subtenon’s space or tablet prednisolone 1 mg/
weeks. Thus these patients can experience the visual loss kg/ day) orally after breakfast along with an antacid or
caused by CME quite early in their postoperative an H1 blocking agent to prevent gastritis. Topical
diclofenac sodium 4 times daily can be added to this DIABETIC RETINOPATHY AND CATARACT
regimen. In case there is evidence of improvement over
the following 2 to 3 weeks, the subtenons kenocort Cataract surgery in diabetic patients is more unpredictable
injection can be repeated after 3 weeks and slowly tapered due to many factors like difficulty in fundus visualisation,
off by increasing the duration between the doses. Some increased incidence of cystoid macular edema, and
authors have also used acetazolamide one tablet twice increased risk of progression of the retinopathy and
daily in the management of CME. anterior segment neovascularisation. A history of prior
The problem with most of the therapies is the high photocoagulation can also influence the clinical course
incidence of recurrence following the withdrawal of the of these patients.
treatment. It is therefore necessary to continue the The approach to management is based on adequate
treatment for long enough duration to prevent relapses. visualisation of the fundus and a proper diagnosis of the
The Vitrectomy-Aphakic Cystoid Macular Edema stage of retinopathy. An indirect ophthalmoscopy and a
Study showed that pars plana vitrectomy to release fluorescein angiography must be included in the
vitreous attachments to the surgical wound was beneficial, preoperative work up of these patients. Preoperative
assessment of the magnitude of visual loss caused by
significantly improving visual acuity in patients with

postoperative CME associated with vitreous incar- cataract is often difficult in the diabetic patient, and a
ceration. YAG vitreolysis has also been selectively used laser interferometry should be performed in such cases
to divide vitreous strands adherent to the surgical wound. to know how much improvement is likely to be achievable
This is however, possible only if the strand is very loca- with a cataract surgery alone. Even in cases in which the
lised. Other factors like a poorly positioned lens should retina is normal, the patient should be warned of the risk
also be managed appropriately. Local oxygen therapy of development of diabetic retinopathy following surgery,
using goggles for 6 hours a day for 3 weeks has been which could hamper his vision. The variables affecting
shown to have utility in 80 to 90 per cent of patients the progression of diabetic retinopathy after cataract
though we have no personal experience with this mode surgery include the stage of the diabetic retinopathy, type
of treatment. It is important to remember that the of cataract surgery, occurrence of surgical complications
successful treatment of chronic CME requires persistence and previous laser surgery.
on the part of the treating ophthalmologist and the
patient. Epidemiology
Those patients, in whom there is no evidence of diabetic
Photic Maculopathy retinopathy have minimal risk of progression following
cataract extraction. Deterioration of diabetic retinopathy
The light of the operating microscope can cause macular occurs following cataract surgery in 30 to 40 per cent of
damage. Operating microscope maculopathy was seen diabetics. if they had significant pre-existing diabetic
in 7 per cent of 135 consecutive patients undergoing retinopathy prior to the surgery. In cases with pre-existing
cataract extraction according to one study. diabetic maculopathy, the progression of maculopathy
The greatest risk of photic injury occurs following is seen in 20 to 30 per cent of patients. These patients
insertion of an IOL, which focuses the light of the micro- have a higher than normal incidence of cystoid macular
scope onto the retina. The photic retinopathy of operating edema also. Pre-existing proliferative diabetic retinopathy
microscopes is probably due to shorter-wavelength visible is associated with an increase in the risk of vitreous
light (blue and blue-green). The probability of operating haemorrhage
microscope damage can be reduced by using the lowest
illumination needed for a particular procedure, and by
Approach to Management
filtering out light at wavelengths below 450 nm. The
duration of a patient’s exposure to coaxial illumination The approach to management is based on the sufficient
should be minimised by using an occluder or by using visualisation of the fundus. In mild nonproliferative
paraxial illumination whenever coaxial illumination is not diabetic retinopathy, no active intervention is done pre-
essential. As the operating time decreases with phaco- operatively for the retinopathy (Fig. 36.3a) Only
emulsification and small incision cataract surgery, the postoperative observation is needed in such patients. In
incidence of these complications are also bound to moderate to severe nonproliferative diabetic retinopathy,
decrease. pre-operative panretinal photocoagulation should be
considered as a management option, especially in India
since the risk of patients being lost during the follow-up
is high. In patients with pre-existing proliferative diabetic
retinopathy, panretinal photocoagulation should be done
to whatever extent is possible preoperatively and comp-
letion of the same must be done in the early post-opera-
tive period (Fig. 36.3b). Maculopathy detected pre-
operatively will not only deteriorate, but is also associated
with the risk of development of cystoid macular edema
in the postoperative period. If focal macular laser is
possible, then the same should be carried out and cataract
surgery should be carried out 4 to 6 weeks later. However,
the role of prophylaxis with nonsteroidal anti-inflam-
matory drugs in the pre-operative period to prevent the
occurrence of CME is still debated. Fig. 36.3b: Fluorescein angiography of a patient with
proliferative diabetic retinopathy
postoperative period.
The rate of progression of retinopathy is higher
following intracapsular cataract extraction (ICCE) than
with ECCE. Progression to the stages of rubeosis iridis,
vitreous haemorrhage and diabetic maculopathy are
known. There is no significant difference in the rate of
progression of diabetic retinopathy between
uncomplicated ECCE and ECCE and IOL.
The advantage of phacoemulsification in such cases
is the watertight compartment formed and the higher
wound strength that it offers in the immediate
postoperative period, which not only makes it possible
to do a vitreous surgery with the cataract surgery in the
Fig. 36.3a: Fluorescein angiography of a patient with early same sitting if needed, but also makes the laser treatment
non-proliferetive diabetic retinopathy in early postoperative period easier. This advantage is
partially negated if the wound size is large. In advanced
It is important that the patient’s glycaemic status is cataracts, where the posterior segment cannot be assessed
checked before he is taken up for cataract surgery. It is for diabetic changes, it is advisable to carry out an indirect
known that the chances of infection in a diabetic eye are ophthalmoscopy on the operating table following cataract
no higher than in the normal population, but in cases extraction and evaluate the retinal status prior to insertion
where infection has occurred, the course is more severe. of the IOL. In cases, which require vitreous surgery, it is
IOLs are not contraindicated in diabetics. Surgery as best to leave the patient aphakic after the cataract
such should be directed so as to insert a larger IOL (6mm extraction. In these cases, after the completion of the
optic), which is surface modified and which will help in retinal surgery, an IOL can be inserted if needed. In case
the early postoperative visualisation of the fundus and an IOL is planned, a silicone IOL is best avoided in cases
laser treatment if necessary. Steps like posterior capsule where we contemplate the possibility of a vitreous surgery
polishing should be taken to prevent the development at a later date.
of aftercataract. An inferior sphincterotomy may help in There is a higher incidence of iris neovascularisation
increasing the pupil size in the otherwise rigid pupil. It is reported following capsular rupture during the surgery.
important that the integrity of posterior capsule be Risk of neovascularisation also increases following YAG
maintained during the surgery. Extra sutures should be capsulotomy. Preoperative photocoagulation can help
applied in patients undergoing small incision nonphaco to reduce the incidence of cystoid macular edema
cataract surgery to permit photocoagulation in the early following cataract surgery. The progression of diabetic
retinopathy is still possible postoperatively in lasered proliferative vitreoretinopathy (PVR), it is better not to
patients and it depends on the stage of diabetic insert an IOL.
retinopathy and the status of retina in these cases. Retinal detachments following cataract extraction
typically have small flap tears along the posterior margin
RETINAL DETACHMENT of the vitreous base. The retinal detachments are usually
FOLLOWING CATARACT SURGERY more extensive and often involve the macula. Multiple
Introduction and Epidemiology breaks are found in more than 50 percent of retinal
detachments that occur following cataract extraction. The
Eyes with aphakia or pseudophakia account for more progression to proliferative vitreoretinopathy is also faster
than 40 per cent of the total retinal detachments operated in such cases. These cases are managed like all other
at any large referral centre. The incidence of retinal rhegmatogenous retinal detachments, with a scleral
detachment is 2 to 5 percent after intracapsular cataract buckling surgery. In some cases it is difficult to find the
extraction and 0 to 1.4 percent after extracapsular cataract break in cases of post cataract surgery retinal detachment,
extraction. However, the incidence may approach 20 even with indentation because apart from the fact that
percent in cases with vitreous loss. YAG capsulotomy is the breaks are small and peripherally located, visuali-
risky in that the chances of retinal detachment increase sation is also often difficult in many cases due to the
threefold after the capsulotomy. The incidence of presence of peripheral capsular opacification, and reflexes
postoperative detachment is substantially increased in from the IOL edge.
myopic eyes. 50 per cent of retinal detachments occur The intra-operative visualisation of the fundus may
within the first year after cataract surgery. Retinal also be hampered by the IOL edge or posterior capsule
detachment may be present preoperatively in an eye opacification, The corneal wound may need streng-
undergoing cataract extraction or it may develop in the thening before starting the retinal detachment surgery.
postoperative period. Even corneal/ scleral valves need to be strengthened most
of the times, as they are not watertight under higher
Approach to Management
pressures, which are often reached when the eyeball is
In all cases of cataract, where the fundus is poorly visua- being manipulated. It is also important for the anterior
lised by an indirect ophthalmoscope, it is imperative to segment surgeons to know that the possibility of
get an ultrasound of the posterior segment done so as to subluxation or dislocation of the IOL always exists during
rule out a retinal detachment. In case a retinal detachment a scleral buckling or vitreous surgery.
is detected on the ultrasound, it is best to refer the case Prognosis following aphakic or pseudophakic RD
for a vitreoretinal surgery. Alternatively the case may be surgery is at best fair. Patients with anterior chamber IOLs
considered for a small incision cataract surgery (phaco have a lower probability of reattachment after one
or manual). Extracapsular cataract extraction should be procedure than do patients with posterior chamber
avoided in such situations since the integrity of the corneal IOLs. In recent times, anatomic success rates of upto 85
wound is not established for atleast 4 to 6 weeks following to 90 per cent are being claimed following RD surgery in
the surgery. A phacoemulsification has the advantage of post cataract surgery patients. The visual outcome in
permitting scleral buckling or primary vitreoretinal surgery these patients may be subsequently occasionally compli-
in the same sitting or soon after the cataract surgery as cated by cystoid macular edema, which further jeo-
the wound integrity is well maintained. A similar advant- pardises the final visual acuity obtained by these patients.
age exists to a lesser extent following a small incision
manual cataract surgery. Retinal detachments detected POSTCATARACT SURGERY ANTERIOR
preoperatively in a patient who needs cataract surgery ISCHAEMIC OPTIC NEUROPATHY (AION)
are best handled with a primary vitreous surgery if fundus
visualisation is poor or by an indirect ophthalmoscopy Anterior ischemic optic neuropathy was first described
after removing the cataract (but prior to insertion of the in 1951. Towne first reported four cases of optic
IOL). In case the vitreoretinal surgeon concludes that neuropathy after uncomplicated cataract extraction. In
the retinal detachment is relatively fresh and amenable 1973, Carroll reported the occurrence of AION with visual
to a scleral buckling procedure, one could consider loss 4 weeks to 15 months after cataract surgery. In 1980,
insertion of a large diameter 6 mm IOL (not of silicone) Hayreh described visual loss after cataract surgery that
If however, the retinal detachment is old or with was thought to be secondary to ION. Risk factors for the
development of nonarteritic ION include hypertension, on the first postoperative day. Fundus examination in
diabetes, smoking, and a crowded disk with a small cup, these cases revealed that the posterior pole is stippled by
especially if the patient had a crowded disk in both eyes. diffuse and patchy whitening of the outer retinal layers.
Fluorescein angiography shows normal angiographic
Pathogenesis retinal and choroidal appearance and circulation time,
Hypotheses to explain the infarctive processes associated but a peculiar polygonal pattern of fluorescein staining
with both the anterior and posterior forms of optic of the pigment epithelium and outer retina is present in
neuropathy (AION and PION) involve anatomical factors the area of retinal whitening. Later the mottling and
peculiar to the optic nerve. The peripapillary choroid whitening of the retina disappears with partial recovery
supplies blood to both the nerve head and retrolaminar of the central visual field. The optic disc and retinal
region of the optic nerve. In the presence of hypotension vascular calibre are maintained. Prolonged elevation of
leading to compensatory mechanisms involving chemical the intraocular pressure sufficient to obstruct choroidal
mediators such as angiotensin II, peripapillary choroidal blood flow occurring during the use of intraocular
vasoconstriction results in anterior optic nerve ischemia. volume-reducing devices before surgery, during phaco-
Most likely, patients who have visual loss weeks to emulsification is postulated as the major cause of this
months following surgery represent cases of spontaneous complication. No beneficial treatment options are
nonarteritic ION unrelated to the cataract surgery; available till now.
however, those with visual loss in the immediate post-
operative period represent a separate clinical entity. In Age Related Macular Degeneration and Cataract
these patients, the exact pathogenesis remains unclear. Age related macular degeneration (ARMD) is the leading
Hayreh proposes elevated IOP or fall in blood pressure cause of visual morbidity among the elderly population
as the possible mechanism. Others suggest possible in the west and is speedily catching up as an important
structural abnormalities in the optic disc. problem in India also. The most important determinant
in the prevalence of ARMD is age as shown by the
Clinical Features and Management Framingham Eye Survey. The prevalence of clinically
Patients present with diminution of vision in the significant ARMD was 1.6 percent of persons aged 52 to
immediate postoperative period or weeks or months 64, 11.0 percent of persons between the ages of 65 and
following the surgery. The anterior form of ION is 74, and 27.9 percent of persons 75 to 85 years showing
characterised by pale optic disc edema involving all or clearly the importance of age in the development of
part of the disc with or without splinter haemorrhages in ARMD. Thus it goes without saying that a lot of elderly
the acute stage. Gradual atrophic changes develop over patients who have cataract are also likely to have ARMD.
approximately two months with resolution of the edema. In all cases where the visual loss is not explainable by
This contrasts with acute posterior ischemic optic cataract alone, we should have a detailed examination
neuropathy, wherein there’s a normal disc and fundus of the macular area to rule out any changes of ARMD. It
at onset, gradually giving way to disc atrophic changes is important to keep in mind that there are two important
over the next two months. No successful treatment has clinical forms of age related macular degeneration : a)
been found though the use of pulse steroid therapy in Dry age related macular degeneration, which accounts
the acute phase has shown some promises. for 90 per cent of patients with this condition, but causes
Most studies cite an occurrence of ION in the fellow only 10 per cent of the total blindness attributable to this
eye in 30 to 50 per cent of patients. These series were disorder and b) wet (exudative ARMD) which accounts
reported before topical anaesthesia was introduced, and for 105 of the patients, but 90 per cent of the blindness
these patients had retrobulbar or general anaesthesia. It caused by this disorder. Manifestaions of dry ARMD
is not known whether topical anaesthesia is associated include macular drusen, pigmnetary changes and geo-
with the same risk. graphic atrophy. Drusen do not persay result in visual
loss. Pigmentary changes and geographic atrophy can
Outer Retinal Ischaemic Infarction
result in mild to moderate visual loss. Dry ARMD usually
This is a peculiar syndrome occurring as a complication presents with a raised lesion, which may be a serous
of cataract extraction. Gass first reported a case in 1982. detachment, retinal pigment epithelial detachment or a
The syndrome is characterised initially by acute loss of disciform subretinal scar. The presence of subretinal blood
central and paracentral vision, which is usually discovered and/or exudates is a hallmark of exudative age related
macular degeneration. This can result in severe visual the disease. Recent studies have indicated that high doses
loss (less than or equal to 5/200) though the visual acuity of anti-oxidants ( Vitamin C 500 mg, vitamin E 400 IU
may be preserved for a few weeks or months in the early and beta-carotene) along with 80 mg of zinc and 2 micro-
stages of the disease process. Patients with severe age grams of copper per day can significantly bring down
related macular degeneration often give a history of loss the risk of both moderate and severe visual loss in patients
of colour perception. The presence of this history in a with age related macular degeneration.
patient with cataract which is too extensive to permit Patients who develop the exudative form of the disease
fundus evaluation should warn the surgeon of the would need to be treated by argon laser (If the lesion is
possibility of this disorder. Patients with ARMDshould greater than 200 micrometer away from the fovea or by
be explained regarding the disorder and should be kept Photodynamic therapy or Transpupillary thermotherapy
on regular follow-ups. Preoperative evaluation should if the lesion is juxta-or subfoveally located. Both these
include a laser interferometry or potential visual acuity therapies have shown promise for the management of
meter for predicting the possible visual outcome. A patients with exudative age related macular degeneration
fluorescein angiography should be obtained preopera- involving the fovea. The role of photodynamic therapy
tively if the fundus is visible. If it is not visible, then an with verteporfrin in the management of subfoveal
angiography should be arranged postoperatively. exudative ARMD has been validated by a number of
During surgery, it is possible to give the patient an double masked placebo controlled trials. Both Photo-
advantage of magnification by using Gallelian telescopic dynamic therapy and Transpupillary thermotherapy
system. Undercorrection of the IOL power and positive therapies are now available in a number of centres in
correction given outside will give the patient more magni- India.
fication than with his correct power of IOL. Such a course The conditions described above represent some of the
may be worthwhile in a patient who is likely to have commoner and more important posterior segment
significant visual defects due to ARMD. A good refraction disorders that a small incision cataract surgeon is likely
and low visual aids are to be offered to the patient. Post- to encounter in his practice. Quite obviously, the list is
operatively the patient should be assessed properly for not exhaustive and does not purport to be complete.
the ARMD with a fluorescein angiography and should The objective of the authors was to provide a small
be followed up regularly with an Amsler’s grid. incision cataract surgeon with information regarding basic
Distortion on the Amsler’s grid testing is an early practical approach to management of the more important
indication of development of exudative ARMD in a posterior segment disorders seen in clinical ophthalmic
patient who is previously suffering from the dry form of practice.
Glaucoma and SICS 205
Glaucoma and
SICS
37 P Mishra
S Thanikachalam
C
oexistence of cataract and glaucoma in the same 1. Inadequate control of IOP
eye is frequently encountered in elderly popu- 2. Medical intolerance/poor compliance
lation. The surgeon should consider the option 3. Mild to moderate optic nerve damage
of performing cataract and glaucoma surgeries in two 4. Advanced glaucoma.

stages or to combine in one sitting that is more appro-
priate for the individual depending on the visual status Instrumentation
and condition of the eye. Over the past decade combined • 26-G needle
cataract extraction and glaucoma filtration surgery has • Hydrodissection cannula
been shown to be an effective procedure for the patients • Crescent knife/ Diamond knife, round type blade with
having glaucoma with visually significant cataract. 4 mm long sharp sides
Phacotrab, phacoemulsification combined with trabe- • Angled keratome, 2.65 mm
culectomy is widely acclaimed procedure for these cases, • Microvectis (micro lens loop)
but it is not so popular in the developing countries • Simcoe cannula
because of its cost factor and long learning curve. In this • Weckcell sponges
chapter we would like to discuss an alternate procedure, • 9-0, 10-0 nylon suture
non-phaco SICS and trabeculectomy which is very simple • Punch forceps or Scleral trephine(1.5, 2 mm).
to perform (easy learning curve) and cost effective.
The anatomic and physiologic alterations occurring Surgical Techniques
in glaucomatous eyes are protean. Corneal decompen-
sation seen after otherwise uncomplicated cataract Anaesthesia
extraction is common in-patients having sustained a Combined surgery is most safely performed with peri-
severe attack of ACG and all attempts to prevent corneal bulbar anaesthesia. The anaesthetic solution consists of
trauma is ensured during cataract surgery. Patients with mixture of 2 per cent lidocaine and 0.5 per cent bupi-
pseudoexfoliation syndrome have abnormal zonules and vacaine. It is injected into the anterior orbit by two points
capsules, which might predispose to capsular rent, technique. The 26-G needle introduced below the supra-
pigment dispersion, break of aqueous barrier, hyphaema orbital notch and advanced to a mid orbit depth, the
etc. The lenses of patients with long-standing glaucoma second incision site is given above the inferior orbital
and advanced cataract often subluxate, if not fully, has rim near lateral canthus.
to be kept in mind and to be managed more cautiously.
So as the atonic pupil that follows after an acute attack
Conjunctival Flap
of ACG is fixed and dilated requires a large IOL optic to
prevent glare and monocular diplopia. Recognizing these There have been conflicting reports regarding the safety
factors preoperatively remains the key for the sucessful and efficacy of the limbus-based vs the fornix-based
visual outcome in combined surgery. conjunctival flaps in combined surgery of cataract and
glaucoma.1,2 The fornix-based conjunctival flap in this
Indication combined procedure has the advantages of better
Presence of visually significant cataract with glaucoma is exposure of the surgical site, less handling of the
considered for non-phaco SICS trabeculectomy, and conjunctival flap and more posterior development of the
other indications are: conjunctival filtering bleb. For the above reasons we
Fig. 37.1: Scleral tunnel formation with crescent
always prefer a fornix-based conjunctival flap (Fig. 37.1), Fig. 37.2: Frown incision and a radial incision at
which is closed by suturing one or both ends of the flap one end for trabeculectomy
to the limbus with 9-0 nylon suture for a tight limbal
is often limited by small pupil or poor dilation in glaucoma
closure. Sometimes watertight closure is achieved by
patients on long-standing medical therapy. Inability to
suturing the flap with peripheral cornea with 10-0 nylon.
dilate pupil sufficiently or small rhexis may cause vitreous
The conjunctival flap is usually dissected in the superior
quadrant and the width of the conjunctival dissection loss due to zonular dialysis during nucleus management.
should be slightly larger than anticipated scleral tunnel All necessary steps to be undertaken for management of
incision for better exposure. The conjunctival reflection small pupil. When necessary, multiple partial sphinctero-
should be made as posterior as possible, at least 8-10 tomies or stretching of pupil with Sinskey hook may be
mm posterior to the limbus. Haemostasis of episcleral done to enlarge the pupil. Rhexis can be performed very
blood vessels is achieved by bipolar diathermy. easily in mature/advanced cataracts by using Trypan blue,
which enhances the visualisation by staining the anterior
Scleral Incision capsule. Whenever the rhexis is small, two relaxing
A three-stage (triplanar) scleral tunnel incision is made incisions at 2 and 10 O’clock are usually required to luxate
with the initial external frown incision given approxi- the nucleus easily in to anterior chamber in nuclear
mately 2-3 mm posterior to the limbus. It is given either cataracts.
with a diamond knife or a stainless steel blade. The
second incision is intrascleral dissection (Fig. 37.1) and Hydrodissection
the third oblique entry into anterior chamber through
It is a crucial step to be performed in all the cases, which
clear cornea. The scleral dissection is kept half the thick-
separates the nucleus from its capsular attachments. The
ness and the anterior entry wound should not extend
anterior capsule is elevated with a 26 G cannula attached
too anterior else it will cause striae formation in the
to a 2 ml syringe filled with BSS and the fluid is injected
posterior cornea, which prevents adequate visualisation
of the anterior segment. A low molecular viscoelastic sub- slowly and continuously beneath the edge of capsulor-
stance is injected to reform the anterior chamber once hexis to create a fluid wave that passes across the red
its entry is made with angled micro-keratome. From one reflex. The fluid wave is not visible in dense cataracts. In
end of the incision another radial incision is given which such cases, when hydrodissection is completed, the
is extended to the limbus (Fig. 37.2). This step is essential nucleus appears to move forward following which it must
for trabeculectomy, which may be given after completion rotate freely inside the capsular bag.
of the cataract surgery and lens implantation.
Nucleus Management
Capsulorhexis
Nucleus delivery with conventional large incision surgery
Continuous curvilinear capsulorhexis is performed using is dangerous in uncontrolled glaucoma, because of the
26G needle or rhexis forceps. The size of capsulorhexis positive vitreous pressure. The small incision technique
offers distinct advantage over it with safe removal of the tion that is sufficient for good flap is about half the thick-
nucleus. The nucleus is luxated into the anterior chamber ness of sclera. Once IOL implantation is over anterior
with Sinskey hook or bent 26-G needle. This is usually chamber is reformed with either air (Fig. 37.3) or
done by rotating the nucleus either clockwise, anti- viscoelastics, another radial incision from one end of
clockwise or both following reforming the anterior scleral groove (frown incision) is given upto the limbus
chamber with viscoelastics. Once it is in the anterior (Fig. 37.2). A triangular flap is fashioned (Fig. 37.4); it
chamber the nucleus is gently expressed through the should be handled with fine forceps to avoid injury to it.
scleral tunnel using a microvectis. This is our preferred The dissection is continued anteriorly into the cornea so
technique for nucleus removal over the last 5 years. The that scleral spur can be identified through deep scleral
residual cortex is aspirated with Simcoe cannula. lamella and 1 mm of cornea anterior to the spur is seen.
Complete cortical removal, with sclerostomy site free of When the scleral flap is retracted towards the pupil by
capsule, cortex, blood or vitreous is extremely important the assistant a blade breaker knife or Bard Parker knife
for the success of combined surgery. The posterior with 11-G blade is used to make two radial (Fig. 37.5)
capsule may be polished, if necessary. The viscoelastics incisions about 1.5 mm apart extending for about 2 mm
is placed in the capsular bag to distend sufficiently enough from corneolimbal junction to the sclerolimbal. A third
for lens implantation. IOL implantation is performed by incision is made parallel to the limbus at the corneolimbal
using any preferred technique. Pupil is restored to round junction. The free edge of block tissue is grasped with
and small size by gently stroking the iris, even intra- Pierse Hoskins forceps and rotated posteriorly allowing
cameral pilocarpine can be used for intraoperative miosis, the angled vannas scissors to cut horizontally at the scleral
which should be thoroughly washed away from the spur.
anterior chamber.
Antimetabolites
If antimetabolites are used for intractable glaucoma it
should be applied under the conjunctival/scleral flap. It
is useful in high-risk cases where chances of failure of
trabeculectomy are high; it may effectively limit fibrosis,
scarring and bleb failure. MMC offers a beneficial effect
on combined filtration surgery without having the corneal
toxicity of 5 FU.5,6 Excess concentration of the drug may
cause conjunctival necrosis with underlying scleral
melting, bleb leak, hypotony and even endophthalmitis.
The preferred method is, a 5× 5 mm sponge soaked in
Fig. 37.3: IOL implanted with air bubble in AC
mitomycin C with a concentration of 0.25 mg/ml is
applied to the filtered area for about two minutes with
the conjunctiva and tenons draped over it. Care was
taken to avoid contact between the sponge and the edge
of the flap by holding conjunctiaval flap edge away from
the sponge with tying forceps.6,7 The site is then irrigated
with BSS to remove residual drug.
Scleral Flap
Dissection of scleral flap (Fig. 37.1) is vital step for succes-
sful wound closure. If scleral flap is too thin it will lead to
button holing or tear formation resulting in excessive
filtration with postoperative hypotony and the situation
is made even worse with use of MMC. If the flap is made
too thick it may lead to premature entry into the anterior Fig. 37.4: Dissection of triangular flap at
chamber with subsequent iris prolapse. The ideal dissec- one end of frown incision
Fig. 37.5: Radial incision over the trabecular meshwork

Fig. 37.7: Deep scleral flap visible, iridectomy done

Alternatively Kelly punch is used to excise trabecular
tissue; the third option is, to use 1.5 or 2 mm scleral
trephine to remove a circular piece of trabecular mesh-
work to create filtration fistula. The block of tissue
removed (Fig. 37.6) should contain anterior scleral spur,
Schlemm’s canal, trabecular meshwork, Schwalbe’s line
and peripheral cornea. A peripheral iridectomy (Fig. 37.7)
is performed and the anterior chamber reformed with
BSS. The scleral flap is closed with single 9-0 nylon suture
at the apex of the flap, where the radial incision was
initiated.
Conjunctival Closure
The fornix based conjunctival flap is closed by suturing
its one or both ends to the limbus with 9-0 nylon suture
for a tight limbal closure. Some times the conjunctival
wound is closed with peripheral cornea by running 10-0
Fig. 37.8: Conjunctiva is closed
nylon suture for a watertight closure.8 The anterior
chamber is filled with air for wound stability (Fig. 37.8). Postoperative Medications
Topical corticosteroids are administered generously in
the immediate postoperative period to inhibit
inflammation and to decrease scar tissue, which is tapered
slowly within 2-3 weeks. Cyclopentolate (1%) is used
whenever there is severe iritis for few days. Digital
massage over cornea through the lids is applied whenever
necessary during early postoperative period, particularly
when the IOP is greater than 20 mm Hg8. Drugs that
decrease secretion of aqueous, acetazolamide should not
be used unless indicated. Persistent flat anterior chamber
in the postoperative period should be diagnosed by
Siedel’s test and managed accordingly.
Conclusions
Fig. 37.6: Removal of trabecular meshwork with Combined surgery attempts to manage cataract and
exposure of iris, trabeculectomy completed glaucoma in single surgical procedure, performed in the
same site. The procedure employing non-phaco scleral implantation combined with trabeculectomy in patients with
tunnel small incision surgery for cataract extraction also glaucoma. Am J Ophthalmol 104: 465-70, 1987.
3. Hurvitz LM: Combined surgery for cataract and glaucoma.
provides access for filtration surgery simultaneously with Curr Opinions Ophthalmol 4(2): 73, 1993.
improved success and safety without the need for second 4. Lyle WA, Jin JC: Comparison of a 3 and 6 mm incision in
surgical procedure. It does not require longec learning combined phacoemulsification and trabeculectomy. Am J
curve, greater skill, and at the same time gives fairly Ophthalmol 111: 189-96, 1991.
excellent results. No doubt, this can be considered as a 5. Costa VP, Moster MR, Wilson RP et al: Effects of topical
mitomycin C on primary trabeculectomies and combined
low cost alternative to phacotrabeculectomy in the
procedures. Br J Ophthalmol 77: 693, 1993.
developing countries. 6. Wong P, Goldenfeld M, Ruderman J et al: 5 Flurouracil (5FU)
after primary combined filteration surgery: A prospective,
REFERENCES randomised study. Invest ophthalmol Vis Sci 34: 727, 1993.
7. Wyse T, Meyer M, Ruderman JM et al: Combined trabecu-
1. Mc Cartney DL, Memmen JE, Stark WJ et al: The efficacy lectomy and phacoemulsification: A one site vs two site
and safety of combined trabeculectomy, cataract extraction approach. Am J Ophthalmol 125(3): 334-39, 1988.
and intraocular lens implantation. Ophthalmology 95: 754- 8. Lemon LC, Shin DH, Kim C et al: Limbus based vs fornix
63, 1988. based conjunctival flap in combined Glaucoma and cataract
2. Simmons ST, Litoff D, Nichols DA et al: Extracapsular cataract surgery with adjunctive mitomycin C. Am J Ophthalmol
extraction and posterior chamber intraocular lens 125(3): 340, 1998.
Paediatric Cataract:
My Experiences
38 Daljit Singh
T
he whole question of a large, medium, small and
mini incisions is concerned with the removal of
the harder part of the cataract- the nucleus. The
rest can be removed by irrigation/aspiration. In most of

the paediatric patients, the size and the hardness of the
nucleus permit the performance of the lens removal and
intraocular lens implantation manoeuvres through a rela-
tively small incision. However, the presentation of the
paediatric patients shows a great variation and the
response of the ocular tissues during and after the surgery
are different from the adults. The surgical approach to
the lens removal and the type of lens implantation is
extremely varied and full of controversies.
The purpose of small incision surgery in paediatric
patients. Fig. 38.1: Congenital cataract
In the adults, the main purpose of a small incision
surgery is to minimise postoperative astigmatism. In the
2. The physical state of the cataractous lens The
paediatric cases, it is to ensure greater safety during the
consistency of the cataract may vary to milky fluid
conduct of the surgery and to minimise operative and
like to hard rock like, with all the intermediate
postoperative problems peculiar to this group. Keeping
stages.
the incision line suture less is not mandatory.
3. The anterior capsule Since an extracapsular surgery
Clinical situations requiring cataract and implant
is being performed, an important component of
surgery:
success is formed by excellence obtained in the
1. Congenital cataract.
capsulotomy step. The anterior capsule varies in
2. Dislocated lens.
many characters like its consistency, uniformity,
3. Traumatic cataract.
fragility, support from the underlying cortex and
4. Secondary cataract.
the pull of the zonular fibres.
5. Secondary lens implantation.
Surgical approach to congenital cataract:
Congenital Cataract
Only Lens Extraction
There are more varieties of congenital cataract (Fig. 38.1)
than meet the eye or are described in the literature. From The lens may be removed through:
the surgical point of view, the following observations are a. Small limbal incision/incisions.
important: b. Pars plana lensectomy. In my opinion a pars plana
1. The integrity of the capsular bag About 10 per cent approach is riskier, since it unnecessarily cuts through
of congenital cataracts have a pre-existing rent/ important vitreous cisterns, produces fibrotic reactions,
opening/dehiscence/absence of the posterior cap- and is likely to cause some vitreous-lens mix. A number
sule in a small or a large area of the posterior of vitreoretinal problems can arise as a result.
capsule. c. The anterior route: This is the one described below.
Paediatric Cataract: My Experiences 211
The Anterior Route Approach to A subtotal anterior capsulectomy makes it very easy
Congenital Cataract to remove the cortex from the fornices.
If an intraocular lens implantation is desired, then the • Kloti needle This bipolar cautery needle gives more
control on the size and shape of anterior capsulotomy.
minimum size of the incision shall take in to consideration
It takes about 30 to 40 seconds to perform a good
the widest diameter of the intraocular lens optic. My
capsulectomy. The capsule seems to stick to the needle
approach is described below which can be modified to
as it is cut.
suit the needs of an individual surgeon.
• Fugo blade The blade tip is in the form of a 100 micron
filament, which when activated gets covered with a
Incisions
30 micron wide column of plasma. The plasma has
a. Two side port pocket incisions 1 mm wide, 180 degrees great cutting properties. It cuts without any resistance.
apart. The pocket depth may be kept at about 1 mm. A capsulotomy can be performed in 5 to 10 seconds.
First a 0.3 mm deep vertical groove is made, which is It may be performed in parts, which are then united
followed by horizontal pocket section. by retouching. The cut edge made with plasma energy
b. The anterior chamber is filled with a visco-elastic becomes strong and resists tearing, something that
material, like HPMC. The eye should feel firm at this does not happen with other capsulotomies. Fugo blade
point which will help the next step. capsulotomy is done in a deep anterior chamber.
c. A 4.25 mm wide vertical groove is made at the upper
limbus. This is followed by the making of a pocket Cataract Removal
section, the depth being about 2 mm.
The incisions are best made with diamond knives. The cataract removal in uncomplicated cases have soft
However, good quality disposable steel blades are consistency cortex and nucleus can be performed in the
also available for the purpose. following way:
The purpose of making pocket incisions is manifold. • Irrigation/aspiration with any of the well known
They help to maintain the depth of the anterior cannulas. My preference for my own design (made
chamber during surgery. They minimise the tendency by Indo-German) is due to the fact in this cannula,
of the iris to prolapse through incisions. They prevent the irrigation port is on the under surface and the
the formation of peripheral anterior synechiae. The aspirating port is on the anterior surface. With the
anterior chamber should be kept deep throughout the irrigation on, one can not tear the posterior capsule,
procedure either by irrigation or by keeping HPMC in since the capsule is pushed away by the fluid pressure.
it. A flat anterior chamber invites the formation of fibrin The irrigating fluid gets into the fornices and pushes
during the surgery, which can be quite troublesome. out the cortical matter, making it easy to attract it to
The younger the patient, the greater is the need to the aspirating port. The aspiration is done with a 1 ml
take observe this precaution. Lastly, if and when disposable syringe. The removal of the cortex under
suturing is necessary, it can be done easily. the pocket incision is difficult. For this reason the 12
d. The anterior chamber is once again filled with HPMC. O’ clock cortex is loosened by irrigation from the side
port incisions.
Anterior Capsulotomy • Irrigation/aspiration with the help of phaco or non-
Anterior capsulectomy /capsulotomy is an important step. phaco irrigation/aspiration machines. The procedure
The following types of anterior capsulectomies are is quicker, since the fluid movement is fast and
possible: aspiration can be done at a higher vacuum pressure.
• CCC This is done with a capsulotomy needle through • “Dry aspiration”: Little or no saline is used in this
the side port alone or assisted by a forceps through technique. A 22-gauge cannula attached to the syringe
the upper larger incision. The anterior capsule in the is used to suck out the lens. Each aspiration is followed
paediatric patients is sometimes so elastic that the by injecting HPMC in the bag to loosen more of the
capsulotomy can run into the periphery. This spoils lens. Care is taken not to aspirate near the posterior
the ground for in the bag implantation, if so planned. capsule, so as not to produce a tear.
• Can opener capsulotomy of a very large size can be I do dry aspiration as follows. From the side port inci-
done with a view to destroy most if not all the anterior sions and from the top, I inject HPMC under the cut
capsule cells. However, the equatorial cells still remain. edge of the anterior capsule. As the lens matter rises, I
push HPMC close to the posterior capsule. Practically times the process of iris pulling will cause a tear at the iris
the whole of the lens mass rises anteriorly and the root resulting in iris bleeding. The bleeding can be red-
chamber becomes deep. At this stage the HPMC cannula uced by raising the pressure inside the anterior chamber
is introduced through the upper incision. This results in with saline or HPMC and waiting for a sufficient length
the raised lens mass passing out of the top incision. of time. In the end the anterior chamber is washed clean.
Further HPMC push into the lens fornices is done to raise
Air Bubble
and deliver the remaining lens masses. At the end, if so
needed, a small saline irrigation/ aspiration is done. The The two sides of the pocket section come together only
technique described above seems to work best if capsu- if the anterior chamber is well-formed at the end of the
lotomy has been done with a Fugo blade, since this operation, either with saline or with air or a combination
capsulotomy allows the big lens mass to be delivered of the two. Make sure that there is no leakage from any
without tearing. It is pertinent to mention that Fugo blade incision. Look at the possibility of a leakage when the
helps make much bigger intact capsulotomy than by other patient is out of anaesthesia. If in doubt, it is better to
procedures, which is an advantage. apply a couple of sutures and provide security to the
incisions (Fig. 38.2).

Lens Implantation The above description suffices for a patient of say 3
to 5 years suffering from a textbook type of zonular
The choice of an intraocular lens is surgeon’s preference. cataract without any other complicating factor. Obviously
I use an artisan lens (earlier called iris-claw lens for the the conditions are going to be different if the patient is
following reasons. This lens avoids the angle of the much younger, say of about 3 months of age or much
anterior chamber, the corneal endothelium, the reactive older, say around 17 years.
space behind the iris (which I call Pandora’s box), every
part of the lens and the tissues in contact can be examined
in the follow-up examinations, posterior capsulotomy is
easy to perform afterwards, the lens can be explanted or
exchanged atraumatically, if ever a need arises. The lens
is well-tolerated as our 22-year experience shows.
Many surgeons have other choices–in the bag lens
implantation with or without a posterior capsulotomy,
anterior vitrectomy and optic capture. The sulcus fixation
is however much more risky for fear of ciliary body
erosion and related problems.
Peripheral Iridectomy
It is good to do peripheral iridectomy in most young
patients even if an in the bag lens implantation has been Fig. 38.2: Look of the eye after surgery
done. The reason is that any postoperative reaction is
likely to cause synechia formation and iris bombe. True, Dislocated Lenses
you can overcome this with a laser Peripheral Iridotomy Dislocated lenses are more difficult to manage for obvious
(PI). But laser PIs are highly unpredictable in black eyes reasons (Fig. 38.3). The following approaches are
and are likely to get closed soon. In young infants, I have practiced:
seen large iridectomies and even complete iridectomies 1. Pars plana lensectomy and vitrectomy, with or
closed with tissue growth, even without a sign of without lens implantation. The intraocular lens
inflammation. fixation is in the sulcus, over some of the retained
How to do a peripheral iridectomy through a pocket lens capsule. Or it can be a scleral fixated intra-
incision? It is not possible to hold the periphery of the ocular lens.
iris. The other alternative is to hold the iris close to the 2. Anterior approach: A capsular tension ring
inner opening of the incision, pull the iris downwards followed by in the bag intraocular lens. If the
and cut it inside the eye with a scissors (normally we are crystalline lens is considerably off centre, then a
used to cutting the iris by pulling it out). A number of loop of the intraocular lens may be scleral fixated.
Paediatric Cataract: My Experiences 213
Traumatic Cataract
In most cases, it is possible to use the same basic pocket
incisions to deal with most of the trauma situations, at
the end of which an intraocular lens may or may not be
implanted. For any kind of lens implantation, it will be
necessary to create a favourable anatomical situation for
the lens to be fixed. Synechia need to be broken and the
space behind the iris cleared, before a lens can go into
the sulcus. The iris needs to be freed from adhesions
before an artisan lens can be fixed. Whenever anterior
vitrectomy becomes necessary to deal with disturbed
vitreous or to clear the visual axis, It is important to suture
the incision line, else a satisfactory closure of the incision
Fig. 38.3: Subluxated lens line is not possible.
3. Lensectomy by one of the many ways, followed Secondary Cataract

by angle supported lens. After cataract or secondary cataract formation is common
4. Anterior route lens extraction followed by artisan after ECCE and lens implantation in paediatric patients.
lens implantation. It may not form if the cataract was membranous, milk-
The size of the incision will vary with the technique bag or one that had a pre-existing posterior capsular
adopted. For the last technique that I employ, the size opening (and needed anterior vitrectomy). It may or may
and position of the incision remains the same as for not form if a subtotal anterior capsulectomy was done
routine congenital cataract cases. The lens extraction is during operation. Its formation in Marfan cases is not
done by one of the following ways: ruled out if the posterior capsule has been saved during
1. Manual capsulotomy, dry aspiration of the lens and lens extraction.
artisan lens implant. In subtotal anterior capsulectomy cases it has been
2. Automated capsulotomy with Fugo blade. The observed that unless there is an element of inflammation,
beauty with this device is that the capsular bag the secondary cataract is thin and can be easily cut with
does not move during the cutting process and the Yag laser or with a capsulotomy needle.
Sometimes the secondary cataract is thick and has
cut edge is stronger than we get by manual means.
dense synechia with the intraocular lens or with the uveal
HPMC is injected into the capsular bag to deliver
tissues. A manual capsulotomy in these cases can pro-
most of the lens while the rest is removed by dry
duce a traction on the vitreous and retina or the uveal
aspiration assisted by HPMC. The use of this
tissues. For this reason it is necessary to adopt alternate
instrument minimises disturbance to the vitreous,
approaches, which are:
since it becomes possible to preserve the zonular • Make a pocket incision. Reach the membrane with
fibres that are present at the start of the procedure. the tip of a knife and stab it. Introduce a vitrectomy
3. A dislocated lens with little or no zonular supported probe and cut the membrane if it can be held by
is manoeuvred into the anterior chamber, the pupil suction. If it does not succeed, a Vannas scissors can
is contracted and the lens is removed by dry aspira- be used to cut the membrane, with as little pull as
tion, the capsular bag being removed at the end. possible. HPMC is used liberally to protect endo-
A small anterior vitrectomy is done after artisan thelium and to create space for the scissors to work.
lens implantation. • Erbium laser Erbium laser energy can easy cut a thick
4. In adults with dislocated opaque lens, a small inci- secondary cataract. A 1.5 mm incision is enough for
sion cataract surgery is highly risky. In some cases the purpose. The broken up material is irrigated out.
a 180° incision and cryo-extraction is a sensible • Fugo blade can cut a dense membrane without any
procedure. In a rare case, the lens might need resistance. It can also be introduced through a 1.5 mm
removal by lensectomy or phaco-fragmentation incision. The membrane can be cut in two ways. Go
through pars plana route. round the membrane, cut it and then pull out the
separated piece. The other way is to keep touching of lens selected (angle supported, sulcus supported, in
the membrane again and again with the plasma blade the bag and scleral fixated), the ease with which a space
tip. The touched point just disappears in the plasma has been created where to fix the lens and the amount
field. of trauma that is suffered by the tissues, especially uveal.
Artisan lens implantation seems to be the least traumatic
Secondary Lens Implantation
procedure in most cases, especially the ones that have
Secondary lens implantation in paediatric patients is an no posterior capsule.
important field. Aphakia results from the surgery on The most difficult cases are the ones in which pars
congenital cataract, traumatic cataract after blunt or perfo- plana vitrectomy has been done. The moment the ante-
rating trauma and after PP lensectomy for endophthal- rior chamber is opened the eyeball seems to collapse. If
mitis resulting from perforating injuries. The presentations a lens is introduced in the anterior chamber and is left
are extremely varied and each case merits individual un-held with a forceps, it call pass through the pupil and
assessment and an appropriate surgical approach. The get lost in the vitreous cavity (without vitreous). A Sheet
surgical approach has the following ingredients: glide is a reliable tool to prevent such a mishap. Even a
• The incision is made in an anatomically undisturbed sheet glide can fall into the vitreous, if care is not taken.
part of the limbus. It is best to fashion a glide (it has to be made by the
• The peripheral anterior synechia are broken if they surgeon himself) such that its outer end is much larger
are likely to interfere with secondary lens implantation. than the incision line. In all cases of pars plana vitrectomy,
it is important to suture all incision lines, howsoever, small,
• The synechia in the pupillary area are cut. Synechia
else the eyeball will tend to collapse in the postoperative
between the posterior surface of the iris and the
period.
capsular membrane are separated and sufficient space
is created, if a posterior chamber lens is to be inserted.
To Sum up
• The anterior chamber is cleared of vitreous and any
strands going to the limbal or the injury site. In paediatric cataract cases, the incisions are always small.
The synechia can be cut with the tip of a disposable But the construction of the incision line should be such
27-gauge needle, with erbium laser or with Fugo plasma that it allows the performance of all surgical steps,
knife. The advantage with plasma knife is that the cutting prevents collapse of the anterior chamber during surgery,
is done without any bleeding. allows perfect closure of the incision line at the end of
The surgical and post-surgical problems connected the surgery and prevents the formation of peripheral
with secondary lens implantation depend upon the type anterior synechiae.
SICS in Paediatric Cataracts 215
SICS in
Paediatric Cataracts
39 Kuldeep Kr Srivastava
P Vijayalakshmi
C
ataract surgery has undergone great refinement has become a standard anterior capsulotomy technique
in recent years. Small incision cataract surgery, in adult, it was naturally also applied to children but with
has become the technique of choice, because of mixed success.8 The paediatric lens capsule is more elastic
early visual and functional rehabilitation. Self-sealing than in adults and requires more force before it tears.
sutureless wound construction has recently achieved great Reduced scleral rigidity in children results in posterior
success and popularity in adult cataract surgery but its vitreous upthrust when the eye is entered. The vitreous
use in paediatric cataract management is still gaining pressure pushes the lens anteriorly and keeps the anterior
popularity and is not well established.1,2 lens capsule taut which causes difficulty in completing
the rhexis resulting in the so called “run away rhexis”. In
Self–Sealing Sutureless Wound Construction addition, a small rhexis may end up much larger than
intended, because of marked elasticity of anterior capsule
Since the self-sealing sutureless wound construction has in children. CCC can be applied on very young eyes but
achieved great success in adult cataract surgery, it was its successful application needs paediatric experience and
also applied to children, 3 but with mixed success. modification of technique.4
Although one study has documented secure self – sealing For the successful completion of continuous curvilinear
sutureless wound following ECCE with IOL implantation capsulorhexis (CCC) in children following points are
in children, other surgeons found the need for suturing helpful.9
the wound at the conclusion of surgery because of • Use high molecular weight viscoelastics to push the
aqueous leakage.4,5 In a prospective study investigating anterior capsule back and deepen the anterior
the role of sutureless wound construction in children, chamber. This will create laxity in anterior capsule and
the wound leak was reported in 100% of eyes of children counter the effect of vitreous up thrust caused by globe
below 11 years of age who underwent ECCE with PPC
collapse.
with AV + IOL.6 The incidence of wound leak was only
• Aim to make slightly smaller CCC in children than
33% in eyes of same age group that had an intact
adults.
posterior capsule at the end of surgery. No leaks were
• While creating the CCC, frequently release the capsular
observed in eyes of the patients above 11 years of age.
flap and inspect the size, shape and direction of tear.
The wound leak is probably because of low scleral rigidity
Regrasp near the site of continuous tear and re-adjust
in children causing fish mouthing of the internal aspect
the direction of pull as needed to keep the capsulotomy
of the wound, with inadequate apposition of the corneal
on the planned courses.
flap to overlying stroma. So, suturing of such wounds
• Tractional forces must be directed centripetally at all
are required to ensure proper apposition of corneal flap.7
times, rather than circumferentially in order to avoid
We suture such wounds as a routine practice in children
extention of the CCC out to the equator.
below 11 years of age.
• Additional viscoelastic should be injected as needed
Capsulorhexis to keep the anterior capsule lax during the tearing.
• Lenticular content may leak into the anterior chamber
Manual Continuous Curvilinear Capsulorhexis during CCC as a result of increased intralenticular
Anterior capsulotomy shape, size, and edge integrity are pressure from vitreous upthrust. If this happens,
important for long-term centration of a capsular fixated aspiration of a portion of lens contents may be needed
IOLs. Since manual continuous curvilinear capsulorhexis before completing the CCC.
Vitrectorhexis needed to remove a cataract and place an IOL may result

in a radial tear when the diathermy is used. However,
A mechanized, vitrector-cut anterior capsulotomy has
Comer et al12 reported no radial tear when using the
compared favourably to manual CCC in a direct com-
diathermy cut capsulotomy in children where the mean
parison using very fresh paediatric autopsy eyes.8 The
age was 23 months.
mechanized capsulotomy, referred to vitrectorhexis is
easier to perform and resists tearing during IOL place-
Posterior Capsular Opacification (PCO)
ment. According to M Edward Wilson who performed
vitrectorhexis in more than 150 children, after an initial The posterior capsular opacification, which is not a major
learning curve, radial tears are very rare when using this concern in adults, remains a significant concern in
technique.9 children particularly below two years of age. According
When performing a vitrectorhexis, the following to a study in children, PCO occurs an average of two
surgical caveats are offered.9 years after surgery regardless of the age.14 Experience
• Use a vitrector supported by a venturi pump. Peristaltic with Nd: Yag capsulotomy in children has shown mixed
pump system will not cut anterior capsule easily. results, with recurrence of opacification requiring repeated
• Use an infusion sleeve or a separate infusion port, laser treatment and sometimes surgical membranectomy
but with either approach, maintain a snug fit of the as a secondary procedure.15,16
instrument in the incision through which they are
placed. The anterior chamber of these eyes will col- Prevention of Posterior Capsular Opacification
lapse readily if leakage occurs around the instrument In order to prevent PCO, various techniques have been
thereby making vitrectorhexis more difficult to in practice. Some of them are as follows:
complete.
1. Extracapsular cataract extraction with primary posterior
Vitrectorhexis begins by placing the vitrector with its
capsulotomy/capsulorhexis with anterior vitrectomy
cutting port positioned posteriorly, on the centre of the (ECCE + PPC/PCCC + AV) Because of high incidence
intact anterior capsule. The cutter is turned on and suction of PCO in children, PPC/PCCC should be considered
is increased till the anterior capsule is engaged and in children who are not expected to be a candidate
opened. It usually begins with cutting rates of 150 to for Yag capsulotomy within 18 months of surgery.14
300 cuts per minute and an aspiration maximum of 150 The PPC and AV is combined with ECCE in order to
to 250 mm Hg. With the cutting port facing posteriorly avoid the need for Yag capsulotomy and secondary
against the capsule, the capsular opening is enlarged to surgical membranectomy after ECCE, while retaining
the desired shape and size. Although vitrectorhexis is less a capsular bag that is suitable for IOL implantation. It
than ideal when compare to CCC,it is next to CCC. is more effective than procedures, which leaves
vitreous undisturbed (ECCE +PPC) in preventing
Bipolar Radiofrequency Capsulotomy reopacification of posterior capsule. Although
Radiofrequency diathermy capsulotomy, first described technically challenging when IOL implantation is
by Kloti in 1984 and then by Gassman and Coauthors planned, this approach has shown encouraging early
in 1988,has been used as an alternative to CCC for results as a means of maintenance of a clear visual
intumescent adult cataracts and for cataract surgery in axis.16,17
children.10,11,12 The Kloti device cuts the anterior capsule 2. Posterior capture of IOL optic by posterior continuous
with a platinum alloy tipped probe using a high frequency curvilinear capsulorhexis (PCCC) A new technique
current of 500 KHz. The probe tip is heated to about developed by Gimbel 18 consists of ‘in the bag’ IOL
160°C and produces a thermal capsulotomy as it is placement followed by PCCC and capture of the IOL
moved in a circular path across the anterior capsule. Even optic by the PCCC. This approach was premised on
when performed perfectly, a diathermy cut capsulotomy the belief that 360° apposition of the anterior and
can be seen to have coagulated capsular debris along posterior capsular leaflets would lead for formation of
the circular edge. In addition, the edge has been shown a Sommering’s ring configuration anterior to IOL and
experimentally to be less elastic than a manual CCC that lens epithelial cells would be kept in anterior
edge.13 Since the stretching force needed to break the chamber, where they would be carried away with
edge of a diathermy cut capsulotomy is much less aqueous fluid. Gimbel’s preliminary results appear to
compared to a CCC edge, the surgical manipulation support this view.
3. IOL Modification A square edge intraocular lens has years.25 The lens size of 12 mm is generally suitable for
been proposed to prevent PCO.19 posterior chamber implantation in eyes more than two
years old, with capsule fixation.26 The lens size of 10
Management of PCO mm is reccomonded for children less than two years of
a. YAG capsulotomy Cystoid macular edema (CME), age. Optic diameter and designs are not very important.
which is an important complication of YAG capsulo-
IOL Power
tomy in adults, is not of a major concern in children.
It can be done even on the table at the completion of Selection of IOL power has been one of the most contro-
the surgery or weeks after surgery without a significant versial topics relating to paediatric cataract management.
risk of CME. It is well known that the power required for aphakic
correction declines rapidly during first year of life and to
b. Surgical membranectomy In certain situations like
a considerable degree further during the childhood. Thus,
thick PCO, uncooperative patient, recurrence of PCO
a pseudophakic eye that is emmetropic at age of one
after YAG capsulotomy or soft after-cataract, YAG
year may become 5–10 diopters myopic at maturity.
capsulotomy may not clear the visual axis and surgical
Furthermore, if an eye is rendered significantly hyper-

membranectomy with anterior vitrectomy is required.
metropic at early age, it will need supplemental refractive
IOL Implantation in Children correction to ensure optimal visual development negating
much of the advantage of IOL.
The advantage of using IOL for aphakic correction in Gordon and Donzis, in their study on the growth of
children is its ability to provide continuous, optically the eye after birth, demonstrated that approximately 90%
optimal refractive correction, immediately following of the growth of the eyeball is complete during the first
surgery without dependence on compliance by the 18 months after birth.27 Since the overall increase in axial
patient and family. Although IOLs were first tried in length from 18 months of age to 11 years is about 2mm,
children in the late 1950s, 20 paediatric usage has lagged many surgeons today attempt towards making the eye
far behind implantation in adults because of the basic hypermetropic by two diopters in children between two
conservatism of most paediatric ophthalmologist who and four years of age.27
wanted to see ample, confirmation of the safety and Some of the currently prevalent approaches are
efficacy of IOLs in adults before subjecting children to outlined below:
their widespread uses. Recent reports in the literature • Vasavada and Chauhan (1994), recommended 60%
indicate very encouraging short to intermediate term under correction for infant eyes. Using modified SRK
results following childhood cataract surgery with IOL II formula 1.0 D is added for every 1mm decrease in
implantation and have considerably decreased the axial length instead of standard 2.50 D, taking 23.0
controversy surrounding it.3,4,13,21,22 Presently the major mm as an average adult axial length and 22 .0D as
controversy of IOL implantation in children is the problem standard IOL power.3 This approach results in 60%
of its application in infants. The small dimension of infant undercorrection. Based on a similar modification,
eye, the many significant difference between its tissue Dahan and Salmenson (1990) aim for 80% under-
and those of the mature eye, the magnitude of changes correction in children below 18 months of age.28
it will undergo during completion of development, and • Dahan et al (1997) suggested the guidelines for IOL
its tendency to react intensively to the presence of an power calculation as below 29
intraocular foreign body, are the major limitations of IOL <2 years : Do Biometry and undercorrect by 20%
implantation in infants. or
Use axial length only
Choice of IOL
Axial Length (mm) IOL Power (D)
Of available lens materials, only PMMA has so far stood 17 28.0
the test of time adequately to be considered appropriate 18 27.0
for implantation in eyes with life expectancy of many 19 26.0
decades. Presently foldable IOLs (silicon and acrysoft) 20 24.0
and heparin surface modified IOLs are also being 21 22.0
implanted with short-term encouraging results.23,24 Single 2-8 years : Do Biometry and undercorrect by 10%
piece, biconvex modified ‘C’ loop designs have been • Same power as calculated with SRK II formula is
the choice of most paediatric cataract surgeon in recent implanted in children over 8 years of age.
With the above methods of IOL power calculation, 7. Gimbel HV, Sun R, DeBroff BM: Recognition and manage-
child is left with residula hypermetropia which is ment of internal wound gape. J Cataract Refract Surg 21:
amblyogenic and needs supplemental correction. To 121-24, 1995.
8. Wilson ME, Bluestein EC, Wang XH et al: Comparision of
avoid this problem, Piggyback intraocular lenses have
mechanized anterior capsulotomy and manual continuous
been proposed wherein one IOL of adult power is capsulorhexis in pediatric eyes. J Cataract Refract Surg. 20:
implanted in the bag (permanent lens) and another 602-06, 1994.
foldable acrylic lens of 7-14D is implanted in sulcus 9. Edward Wilson M: Anterior Capsule Management for Pedia-
(temporary lens) at the same sitting.30 Temporary lens is tric Intraocular Lens Implantation. J Paediatr Ophthalmol
removed later when an adult refraction is achieved. Strabismus 36: 314-19, 1999.
10. Gassmann F, Schimmelpfennig B, Kloti R: Anterior
IOL Placement Capsulotomy by means of bipolar radiofrequency
endodiathermy. J Cataract Refract Surg. 14: 673-76, 1988.
Since the uveal tissue in the children is highly reactive, 11. Delcoigne CD, Hennekes R: Circular continuous anterior
‘in the bag’ placement of IOL is highly desirable. The capsulotomy with high frequency diathermy. Bull Soc Belg
significantly lowered incidence of severe postoperative Ophthalmol 249: 67–72, 1993.
uveitis described in several recent reports in paediatric 12. Comer RM, Abdulla N, O’ Keefe M: Radiofrequency dia-
IOL implantation seems largely attributed to improved thermy capsulorhexis of the anterior and posterior capsules
in pediatric cataract surgery: priliminary studies. J Cataract
success in ‘in the bag’ implantation.3,4 In eyes that lack
Refract Surg 23: 641-44, 1997.
sufficient capsular bag for ‘in the bag’ implantation, ciliary 13. Luck J, Brahma AK, Noble BA: A comparative study of the
sulcus placement is considered an alternative site of lens elastic properties of continuous tear curvilinear capsulorhexis
placement.23 Majority of the surgeons do not consider versus capsulorhexis produced by radiofrequency endo-
anterior chamber IOL placement in children even in diathermy. Br J Ophthalmol. 78: 392–96, 1994.
absence of adequate capsule support.23 14. David A Plager, Stephen N Lipsky, Stephen K Snyder et al:
A new technique developed by H.V. Gimbal consist Ophthalmology 104: 600-07, 1997.
15. Atkinson CS, Hiles DA: Treatment of secondary posterior
of in the bag placement of IOL followed by posterior
capsular membranes with the Nd: YAG laser in a pediatric
CCC and capture of the IOL optic by PCCC.18 This population. Am J Ophthalmol 118: 496-501, 1994.
technique claims to maintain clear visual axis for longer 16. Surendra Basti, Uma Ravishankar, Satish Gupta. Results of
time and preliminary results appears to support this prospective evaluation of three methods of management of
view.18 paediatric cataracts. Ophthalmology 103: 713-20, 1996.
17. Mackool RJ, Chattiawala H: Pediatric cataract surgery and
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6. Basti S, Krishnamachary M, Guptha S: Results of sutureless 24. Surendra Basti, Murali K Aasuri, Madhukar K Reddy et al:
wound construction in children undergoing cataract Cataract Refract Surg 25: 782-87, 1999.
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1996. implant materials: A review and scanning electron
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66, 1984. Refract Surg 16: 75-82, 1990
26. Wilson ME, Apple DJ, Bluestein EC et al:, Intraocular lenses 29. Dahan E, Matthias UH, Drusedau: Choice of lens and dioptric
for pediatric implantation: Biomaterials, designs and sizing. power in paediatric pseudophakia. J Cataract Refract Surg
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Posterior Capsule
Opacification
40 Jagat Ram
Gagandeep S Brar
P
osterior capsule opacification (PCO) and posterior
chamber intraocular lens (PCIOL) decentration
(Fig. 40.1) still remain two major complications of
extracapsular cataract surgery (ECCE) or phaco-

emulsification.1-6 Ridley, who performed the first intra-
ocular lens implantation in 1949, himself noted these
complications in his earliest patients.7 In his initial publi-
cations, he described lens decentration, and remarking
that apparently, the most difficult problem was to retain
the lens in position. He also recognized the problem of
PCO and designated it as “the principal complication”
that is not easy to treat, and which requires division of
posterior capsule, i.e surgical posterior capsulotomy.8,9
Control of decentration and PCO is becoming more
necessary now that IOL implantation is emerging as a
refractive procedure that mandates almost a perfect
optical rehabilitation as opposed to the former goal of Fig. 40.1: Slit lamp photograph of left eye of a 65 years old
simply removing the opaque lens material and achieving woman, status postcataract surgery (ECCE); with marked
upward decentration of a bag-sulcus fixated all-PMMA IOL. Note
safe but less than optimal visual rehabilitation.2-5 As the VS-PCO in the visual axis and sutures are also seen at the
cataract operation continues to be perfected, major goal incision
is to eliminate these complications.
Clinical studies have noted an incidence varying
between 10-50 per cent of posterior capsule opacification The reported Nd:YAG laser posterior capsulotomy rate
following ECCE or phacoemulsification with PC IOL ranged from 30 to 50 per cent in the 1980s.2,3,11 More
implantation.1-3,12-25 Schaumberg et al conducted an recent reports document an additional decrease in PCO
important metanalysis of published articles on PCO and
and Nd: YAG laser capsulotomy rates.5, 11,14-17 With the
generated pooled estimate of eyes developing PCO over
use of modern surgical techniques and IOLs, posterior
three postoperative points: 1,3 and 5 years. They noted
capsule opacification and Nd: YAG laser posterior cap-
that even today the rate of PCO remains unexpectedly
and unacceptably high-still over 25 per cent during the sulotomy rate is decreasing to less than 10 per cent.18-23
5-year postoperative period. 1 Furthermore, adverse In a recent study by Apple et al17 comparing foldable
clinical sequelae may be associated with Nd:YAG laser versus rigid designs, the foldable IOLs were associated
posterior capsulotomy. Last but not the least, there are with a much lower Nd: YAG laser posterior capsulotomy
very significant and compelling financial reasons to rate (14.1% vs. 31.1%). Surgical tools and IOLs are now
eliminate the necessity to do Nd:YAG laser capsulotomy. available to bring these rates down to single digits. Careful
Nd:YAG laser posterior capsulotomy now ranks as the application and use of these tools by surgeons can
second most expensive surgical cost to the US health genuinely lead in the direction of virtual eradication of
care system, second only to the cost of the original secondary cataract, the second most common cause of
cataract operation.13 visual loss worldwide.
Posterior Capsule Opacification 221
Pathogenesis of Posterior Capsule Opacification usually low grade uveitis.28-30 Meisler and associates28
Most secondary cataracts are caused by proliferation of were first to recognize the role of Propionibacterium acnes
equatorial lens epithelial cells, forming the pearl form of as an offending organism. Piest and associates29 and
posterior capsule opacification. 26 Posterior capsule Apple and associates30 were the first to emphasize the
plaques or fibrous plaque detected in patients after ECCE concept of a post-ECCE localized infectious process
are not uncommon in the developing countries27 and caused by sequestrated organism within the capsular bag.
such plaques are rarely seen in the industrialized world. Clinically, it is important to be aware of the fact that
The epithelium of the lens consists of anterior epi- clinical picture of PCO may be produced by localized
thelial cells known as A-cells which is single continuous endophthalmitis. The use of Nd: YAG laser capsulotomy
cell line. These cells are continuous with the cells of the to treat the posterior capsule thickening in this condition
equatorial lens bow. The cells of equatorial lens bow are may lead to precipitation of severe inflammation.
the E-cells, which comprise the germinal cells undergoing
mitosis as they peel off from the equator. They conti- Evaluation Techniques for
nuously form peripheral cortical fibers. A-cells tends to Posterior Capsule Opacification
remain in place and not migrate and are prone to change Methods of evaluation are important to measure the
toward fibrous tissue (fibrous tissue metaplasia) when progress of posterior capsule opacification. Most of the
disturbed. In contrast E-cells of equatorial lens bow tends studies evaluate posterior capsule opacification after
to migrate along the posterior capsule and form pearls ECCE/phacoemulsification after full dilatation of pupil
form of posterior capsule opacification (Fig. 40.2). These using slit lamp biomicroscopy. PCO is defined as
equatorial cells are the primary source of classical opacification of the posterior capsule in the visual axis
secondary cataract especially the pearl form of posterior that is observed on slit lamp biomicroscopy which
capsule opacification.26 Fibrous form of posterior capsule includes Soemmering’s ring (PCO peripheral to the IOL
opacification occurs as result of either posterior optic), Elschnig’s pearls and fibrous opacification behind
proliferation of A-cells or may result from a fibrous the IOL optic. The degree of opacification is assessed
metaplasia of posteriorly migrating E cells. using distant direct ophthalmoscopy, direct visualisation
by slit lamp biomicroscopy, and decrease in best corrected
visual acuity after surgery. Visually significant posterior
capsular opacification is defined as a decrease in the best
corrected postoperative vision by two Snellen lines. Tetz
described a photographic image analysis system that
can morphologically score posterior capsule opacifica-
tion without dependence on visual acuity testing.31
Standardised slit lamp retroillumination photographs are
analysed. Posterior capsule opacification score is
calculated by multiplying the density of opacification and
graded from 1-4 by the fraction of capsule area behind
the IOL optic that is opacified. This technique shows good
inter- and intra-observer reliability. Pande et al reported
a more sophisticated system of retroillumination imag-
ing of the posterior capsule using a computerized high
resolution digital system that can produce excellent
Fig. 40.2: A slit lamp photograph of eye in a 58 years old female
images for objective documentation and quantitative
with sulcus-sulcus fixated all PMMA IOL after an ECCE showing
posterior capsule opacification (epithelial pearls) in the visual measurement of posterior capsule opacification.32 Apple
axis et al utilised Miyake-Apple posterior photographic
technique (Fig. 40.3) for analyzing commonly used IOL
Clinical appearance of PCO may also be caused by a model in eyes obtained postmortem to evaluate PCO
postoperative localized endophthalmitis, a condition and whether or not an eye had an Nd: YAG laser
which has been recognized as a cause of persistent, capsulotomy.17
Prevention of Posterior Capsule Opacification
Although all the steps of cataract surgery are important

in reducing this entity, six factors are particularly
important in relation to eliminating or at least delaying
posterior capsule opacification.
First, very essential step in reducing PCO is the
reduction of formation of postoperative Soemmering’s
ring, which is a precursor of PCO. This can be reduced
not only by excellent hydrodissection enhanced cortical
clean up but also by use of a highly biocompatible IOLs
that reduce stimulation of cellular proliferation.2,3,5,13,26
The six factors influencing PCO formation are described
below:
1. Hydrodissection-enhanced cortical clean-up First
formal publication on this procedure was by Faust37

Fig. 40.3. Miyake-Apple view of a pseudophakic eye obtained
in 1984 and later on in 1992. Howard Fine 38 perfected
postmortem, implanted with all-PMMA IOL. The visual axis is
clear following Nd: YAG laser capsulotomy. Note peripheral the technique of subcapsular fluid injection and coined
residual cortical material an example of inadequate cortical the term cortical cleavage hydrodissection. Cortical
clean up (Courtesy: David J Apple, MD, Charleston, USA) clean-up hydrodissection is used by many surgeons
to facilitate lens substance removal and enhance the
safety of surgery. The goal of hydrodissection is to
Management of Posterior Capsule Opacification remove equatorial cells and cortex, as opposed to
In the past, invasive surgical posterior capsulotomy was removal of the single layer of anterior epithelium that
the primary treatment of posterior capsule opacification does not migrate.13,26
and it is still performed where Nd: YAG laser facility is 2. In-the bag fixation of IOL The obvious advantage
not available or in cases with very dense or fibrotic mem- of in-the-bag fixation is accomplishment of good
brane particularly in children.33 The treatment of choice centration and more important advantage that is
for clinically significant posterior capsule opacification is not often appreciated is reduction in incidence of
Nd: YAG laser posterior capsulotomy.34-36 It is an effective PCO. 2,3,5,13,26,39,40 The hydrodissection enhanced
modality in the management of posterior capsule cortical clean-up and in-the-bag fixation of IOL are
opacification. two most important surgical factors in reducing PCO.
There are several disadvantages of Nd: YAG laser In-the-bag fixation of IOL functions primarily enhances
capsulotomy: the IOL-optic barrier effect. When the IOL optic is fully
There are several vision-threatening complications in the capsular bag, it’s contact is maximum with the
such as damage to IOL optic, postoperative intraocular posterior capsule and the barrier effect is functional
pressure elevation, cystoid macular oedema, retinal (Figs 40.4 and 40.5). When one or both of the haptics
detachment, IOL subluxation or dislocation and exacer- are out-of-the-bag , a potential space exists that allows
bation of localized endophthalmitis. Nd:YAG laser pos- ingrowth of cells towards the visual axis.41,42
terior capsulotomy significantly increases the overall cost 3. Capsulorhexis edge on the IOL surface A significant
of cataract surgery beside being a burden on the health factor which helps in reducing PCO is creation of a
care. capsulorhexis with a diameter slightly smaller than that
Keeping in view several vision-threatening compli- of IOL optic, so that the anterior capsulorhexis edge
cation of Nd: YAG laser capsulotomy or surgical capsulo- rests on the IOL optic (Fig. 40.5). This helps to provide
tomy, peeling or removal of epithelial cells from the a tight fit (analogous to a “shrink-wrap” ) of the capsule
posterior capsule in eyes with pearl type of PCO with around the optic.26,43-45
automated irrigation mode or capsule vacuuming mode 4. Biocompatibility of IOL In general, the amount of PCO
or using two-ways Simcoe cannula is recommended depends in part on the biocompatibility of the IOL.
particularly in patients with high myopia where incidence The less the cell proliferation, the less the chance of
of retinal detachment increases several fold after Nd: YAG posterior capsule thickening. The amount of PCO
laser or surgical posterior capsulotomy. depends on many factors such as the quality of
Fig. 40.4: Close-up of an eye of a 52-year male with bag-bag Fig. 40.5: Close-up of an eye of a 52-year male with bag-bag
fixated PMMA IOL with clear visual axis after phacoemulsi- fixated acrylic IOL with clear visual axis after phacoemulsi-
fication. Note anterior capsule opacification fication
surgery, duration of implant in the eye and biocom- perhaps be effective in reducing PCO.2,59–65 The various
patibility of IOL material. It has been reported that pharmacological studied till date are caffeic acid
acrylic IOLs display the lowest amount of cell proli- phenethyl ester in a rabbit model, hypo-osmolar drugs
feration, and hence are the most biocompatible.46-49 (sterile water), and antimetabolites. Antimetabolites that
5. Maximum IOL optic posterior capsule contact In-the- have been studied are daunomycin, methotrexate, 5-
bag fixation of IOL helps to maintain a tight contact fluoro-uracil and colchicine. The rationale for use of these
between the IOL optic and posterior capsule and helps agents is to inhibit lens epithelial cell mitosis while
to inhibit the migration of cells across the visual avoiding toxic effects to non-mitotic cells. Some
axis.10,14,47,50-54 Posterior angulation of IOL haptics investigators are studying immunological agents such as
and a posterior convexity of IOL optic also contribute monoclonal antibodies targeted to lens epithelial cells.
significantly in maintaining this maximum posterior
capsule contact. Still another factor, which appears to A New Entity: Interlenticular Opacification (ILO) or
contribute, is related to stickiness of IOL biomaterial, Opacification of Piggyback IOL
which in turn might create an adhesion of the capsule The use of piggyback IOL, i.e use of paired IOLs in one
and IOL optic. eye is becoming more and more common for correcting
6. Barrier effect of IOL optic The IOL optic barrier effect residual refractive error after IOL surgery or as primary
comes into play as a second line of defence against procedure in high refractive error.66-72 Opacification
PCO.55-58 Implanting IOL in the capsular bag enhances between two-implanted IOL has been termed as
the barrier effect. It has been shown that optic with “Interlenticular opacification” or “interpseudophakos
round edges might have negative influence by allowing Elschnig pearls.” In contrast to PCO, this entity occurs
some of the cells to migrate under the tapered edge of as a result of pearls formation or opacification between
the optic onto the posterior capsule. A truncated optic the two IOLs, undoubtedly due to ingrowth of cells from
edge appears to create an abrupt and effective block the equatorial lens bow. Werner et al70 have suggested
to cells growing onto the posterior capsule. Examples implanting the posterior IOL in the capsular bag and
of square edge optic IOLs are Alcon AcrySof®, anterior IOL in the sulcus to reduce this complication
Pharmacia Cee On 911, etc. besides all the factors listed for preventing PCO.
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53. Sterling S, Wood TO: Effect of intraocular lens convexicity 71. Shugar JK, Keeler S: Interpseudophakos intraocular lens
on posterior capsular opacification .J Cataract Refract Surg surface opacification as a late complication of piggyback
12: 655, 1986. acrylic posterior chamber lens implantation. J Cataract Refract
54. Linnola RJ: Sandwich theory: Bioactivity-based explanation Surg 26(3): 448-55, 2000.
for posterior capsule opacification. J Cataract Refract Surg 72. Shugar JK, Schwartz T: Interpseudophakos Elschnig pearls
23: 1539-42, 1997. associated with late hyperopic shift: A complication of
55. Nagata T, Minakata A, Watanabe I: Adhesiveness of AcrySof piggyback posterior chamber intraocular lens implantation.
to a collagen film. J Cataract Refract Surg 23: 1254-59, 1997. J Cataract Refract Surg 25(6): 863-67, 1999.
Index
A operating room personnel 21 Choroidal detachment
cap and mask 23 clinical features 198
Accidental globe perforation 195
clothing 22 management 198
clinical features 196
footwear 22 Clear corneal incision 76, 80
management 196
operating room walls, floor, ceiling Congenital cataract 210, 211
Advantages of temporal incision 136
and fixtures 12 air bubble 212
corneal topographic changes 137
cleansing 12 anterior capsulotomy 211
reduction against the rule (ATR)
disinfection 13 cataract removal 211
astigmatism 136
operating room water 12 incisions 211
stable incision 137
electronic control 12 lens implantation 212
useful in secondary and combined
filtration 12 peripheral iridectomy 212
procedure 136
reverse osmosis 12 Conjunctival
Age related macular degeneration and
patient 23 chaemosis 62
cataract 203
Amphotericin-B 189 changes of clothes 23 closure 208
Anterior chamber maintainer 123 skin and incision site disinfection flap 43, 205
Anterior ischaemic optic neuropathy 24 Corneoscleral tunnel 155
(AION) 202 sterile disposable surgical drape 24 Cortex aspiration 126
Anti-inflammatory therapy 186 Astigmatism 44 Cortical clean-up 44, 140
Antifungal therapy 189 Azole derivatives 190 cortex technique by simcoe 140
Antimetabolites 207 in PC rent 143
Antimicrobial therapy 183 B posterior capsule polishing 142
Aphakic glaucoma 173 Bag sulcus fixation 152 Cystoid macular oedema
Areas of sterilization 11 Biometry 56 clinical features 199
medication 20 Blood pressure epidemiology 199
parenteral 20 definition 52 management 199
probes and tubings 20 joint national committee guidelines 52 photic maculopathy 200
operating room air 11 management 53
air curtain 12 Brainstem anaesthesia 61 D
air-conditioning 11
Diabetic retinopathy and cataract
filtration of air 11 C approach to management 200
ozone treatment 12
Capsular contracture syndrome 153 epidemiology 200
positive pressure 12
Capsulorhexis 88, 92, 93, 124, 206 Diffractive MIOLs 151
quality check 12
in difficult situations 92 Dislocated lenses 212
ultraviolet radiation 11
in hypermature cataracts 92 Double IOL syndrome 174
operating room linen and accessories
18 in mature cataracts 92
E
linen 18 in small pupils 93
operating room macroinstruments 13 initiation of 88 Emmetropia 84
Boyle’s apparatus 15 new developments in capsulorhexis Emmetropia lenses 56
microscope 13 93 Endophthalmitis 153, 173, 179
phaco machines 14 propagation 89 post-surgical 179
operating room microinstruments 15 trypan blue staining 92 incidence and aetiology 179
autoclave 18 using forceps 91 post-surgical bacterial 180
boiling 17 with the ripping technique 90 clinical features 180
cidex of glutaraldehyde 16 Capsulotomy 43, 86 confirmation of diagnosis 181
ethylene oxide 18 can opener technique 86 treatment 182
isopropyl alcohol 16 capsulorhexis 86 post-surgical fungal 189
sterile water 17 envelope technique (linear clinical features 189
tray l with liquid soap and sterile capsulotomy) 86 confirmation of diagnosis 189
water 16 Cautery 43 management 189
ultrasonic cleansing 16 Central retinal artery occlusion 196 propionibacterium acnes 191
Endophthalmitis vitrectomy study 187 I Lens capsule

Epinucleus 94 anatomy 86
Implant power calculation 57
Expulsive haemorrhage 197 Limbus
adjusting original SRK to SRK II 58
clinical features 197 anterior limbal border 3
ammetropia 59
management 197 midlimbal line 3
axial length measurement 59
External incision 76 posterior limbal border 3
biconvex optic 59
Extracapsular cataract extraction 43 Local anaesthesia 61
emmetropia 59
peribulbar 62
keratometry 59
F complications 62
meniscus optic 59 retrobulbar 61
Facial nerve blocks 63 empiric formula 57 complications 61
Fish hook technique 107 SRK formula 57 topical 63
method 108 surgeon’s personal A constant 59
preoperative clinical examination 107 theoretic formulas 57 M
surgical instruments 107 Incision 43, 124
Macrovascular disease 47
surgical technique 108 Insertion of foldable IOLs
Manual multiphacofragmentation
anterior capsulotomy 108 surgical considerations 150
surgical technique 128
anterior chamber entry 108 Insulin
anterior capsulotomy 127
hydrodelineation 108 regimen 48

extraction of the cortex and
hydrodissection 108 therapy 48
remains of nucleus 130
scleral tunnel incision 108 Intraocular lens 144, 151
hydrodissection and luxation of the
technique of nucleus delivery 108 accommodating 151
nucleus 130
classification of 144
Fuch’s endothelial dystrophy 163 incision 127
haptic materials 147
IOL implantation and wound
haptic design 148
G closure 131
nylon (polyamide) 147
manipulation of nuclear fragments
Globe perforation 62 polymethylmethacrylate 147
130
polypropylene (prolene) 148
nuclear fragmentation 130
H polyvinylidene fluoride 148
Manual phaco 169
optic materials 144 postoperative complications 172
Hard core nucleus 94 acrylic 147
Human lens corneal oedema 172
hydrogel 145 shallow AC 172
microscopic structure 1 polymethylmethacrylate 144
anterior epithelium 2 preoperative complications 169
silicone 145 associated with debris cleanup 171
capsule 1 Intravitreal antifungal therapy 190 associated with hydrodissection and
cement substance of amorphous IOL hydrodelineation 170
material 2 decentration 153 associated with implantation 171
ciliary zonule 2 discolouration 153 associated with wound construction
cilio-equatorial fibres 2 glistenings 154 169
cilio-posterior capsular 2 IOL implantation 4, 77 during capsulotomy 170
lens fibres 2 size of opening for 77 during delivery of nucleus 171
orbiculoanterior capsular 2 paracentesis opening(s) 77 during nuclear prolapse in AC 171
orbiculoposterior capsular 2 technique of making a incision 77 with AC maintainer 169
surgical anatomy 2 Manual phaco-fracture 110
Hydrodelineation or hydrodemarcation K
complications 111
96 Kansas corneal edema 112
hydrosonic 97 nucleus vectis 111 Descemet’s tear 112
manual 96 trisector 111 endothelial damage 112
Hydrodissection 94, 206 high intraocular pressure 112
conventional 94 L intraoperative miosis 112
technique 95 Lathe cutting 149 posterior capsular rupture 112
cortical cleavage 95 Lens 44, 56, 86, 153, 210 posterior dislocation of the nucleus
hydro-free dissection 96 dislocation 153 112
Hydroprocedures 94 extraction 210 pupillary distortion 112
Hypertension 52 implantation 44 shallowing of anterior chamber
Hypotony 54 implantation surgery 56 112
Index 229
surgical techniques 110 hardness 7 opacification of piggyback 223
nucleo-fracture techniques 110 management 206 pathogenesis of 221
Manual phaco incision 76 prolapse 44 pharmacological techniques 223
Manual phacofragmentation rotation and prolapse of nucleus 98 prevention of 222
preoperative assessment 132 other methods 99 Posterior segment disorders
Medications in cataract surgery tipping up technique 98 complications 195
antibiotics 165 tumbling of the lens 99 pathophysiology 195
intracameral use 166 tyre levering technique 98 Postoperative endophthalmitis 68
povidone iodine 165 cleaning, disinfection and sterilisation
subconjunctival injections 165 O of OR 69
corticosteroids 166 filtration 70
O’brien block 63
non-steroidal anti-inflammatory agents flash sterilisation 70
Oculomotor problems 62
166 OR discipline 69
Ophthalmic surgery 65
Microvectis technique sterilisation of instruments 69
minimum drugs 66
anaesthesia 113 irrigating fluids and viscoelastic agents
minimum equipment 66
72
capsulorhexis 113 minimum monitoring 66
monitoring of sterilisation protocol 71
hydrodissection 113 Optic nerve sheath injury 62
sterile surgical protocol 71
indication 113 Outer retinal ischaemic infarction 203
operating room layout 68

instrumentation 113
surgery of infected cases 72
nucleus expression 114 P
ventilation 68
practical pearls 115
Paediatrics cataracts 215 Preoperative astigmatism 84
viscoelastics 113
bipolar radiofrequency capsulotomy
Modified Blumenthal’s technique
216 R
completing the tunnel 120
capsulorhexis 215
continuous curvilinear capsulorhexis Removal of epi-nucleus 125
posterior capsular opacification 216
119 Retinal detachment following cataract
self-sealing sutureless wound construc-
envelope technique 120 surgery 202
tion 215
hydrodissection 120 Retrobulbar haemorrhage 61
vitrectorhexis 216
hydroprocedures 120 Patients with diabetes 50
making the groove 118 S
postoperative management 50
nuclear management and delivery emergency surgery 51 Scleral flap 207
121 intravenous fluids 50 Scleral incision 206
preoperative preparation and anaes- monitoring during surgery 50 Scleral tunnel 77
thesia 117 Perfluorocarbon liquids 175 Scleral tunnel incision 75
sclerocorneal pocket tunnel incision Phaco sandwich technique mechanism of 75
118 instruments 101 Secondary cataract 213
tunneling forwards 118 preoperative preparation 101 Secondary lens implantation 214
Molding surgical steps 101 Small incisions
cast 149 capsulotomy 102 evolution of 5
compression 149 conjunctiva 106 extracapsular cataract surgery 6
injection 149 conjunctival flap 101 Sterilization 9, 24
delivery of nucleus 103 cleaning 27
N entry into the anterior chamber disinfection 27
102 factors influencing 26
Nadbath and Rehman block 63 hydrodissection 102 history 9
Neutral funnel 85 nucleus prolapse 103 methods 24
Nuclear bisection 125 posterior capsule 106 quality control 29
Nuclear dislocation 124 remaining debris 105 terminology 24
Nuclear extraction scleral tunnel incision 101 Sterilization and disinfection policy 30
manual small incision techniques 7 viscoelastic 102 blood agar 32
blumenthal 7 Phaco-drainage 132 MacConkey’s agar 31
nucleus division with snare 8 Posterior capsule opacification 154, 220 nutrient agar 31
phacofracture 7 evaluation techniques 221 Sterilization control 32
phacosandwich 7 immunological inhibitors of 223 culture test from walls, floor, fixtures,
Nucleus 7, 44, 98, 206 interlenticular opacification 223 furniture 33
delivery 44 management of 222 linen and textiles cultured 34
specialized equipment cultures 33 U control of intraocular bleeding 39

surgeons hands cultured 34 in lacrimal surgery 39
plate test 32 Uveitis 153 in vitreo-retinal surgery 39
Sub-Tenon’s block 63 maintenance of deep anterior
V
Superficial cortex 94 chamber 38
Sutures 44, 158 Van Lint block 63 management of Descemet’s
fines infinity 160 Various ECCE techniques 45 detachment 38
horizontal 158 Viscoelastic substances management of dry eye 39
horizontal anchor 158 chemical properties 35 strabismus surgery 39
Shepherd’s single 158 complications 39 Viscoelastics 43
vertical 158 types 35 Vitrectomy 186
chondroitin sulphate 37 Vitreous loss 197
T hyaluronic acid (sodium hyaluro- clinical features 198
Temporal incision 76 nate) 36 management 198
Temporal tunnel incision 136 methylcellulose 36
W
Traumatic cataract 213 uses 38
Tunnel incision 76 cataract surgery 38 Wound closure 158
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Small Incision

• 4-2-1067/1-3, Ist Floor, Balaji Building

Small Incision Cataract Surgery (Manual Phaco)

© 2002, Kamaljeet Singh

All rights reserved. No part of this publication should be reproduced, stored in a

First Edition: 2002

Publishing Director: RK Yadav

Typeset at JPBMP typesetting unit

KPS Malik MD P Mishra MS

Mool Chand Rajesh Sinha MD DNB

Department of Medicine VK Srivastava MS

Hector Bryson Chawla FRCS (Ed.)

Kamaljeet Singh, Vipin Bihari

21. Microvectis Technique .................................................................................. 1 1 3

28. Intraocular Lenses ........................................................................................ 1 4 4

Index ............................................................................................................................. 227

nective tissue. It is located behind the iris and pupil

Fig. 1.1: Anatomy of the adult human lens

by an amorphous substance. The cement substance glues and Auxillary fibres.

Fig. 1.2: Surgical anatomy of limbus

Hospital in London on November 28, 1949 and the

Table 2.1: Evolution of extracapsular cataract surgery*

4. “Simple” ECCE 4. Advanced ECCE or phaco

5. Blumenthal Michael: Mini Nuc Manual extra capsular

Sterilization 3 Sunita Agarwal

INTRODUCTION bacteria have grown from the Ringer lactate used. A

The patient suffers ultimately and the surgeon goes

of this century believe that we have reached the ultimate.

Fig. 3.3: Cleaning of the operation theatre

Fig. 3.5: Collection of Ringer lactate solution from the

the sterilization technique used the better would be the

ways to get grid out of the system.

Fig. 3.12: Wash all instruments in a tray of mineral water

Fig. 3.14: The external tubings, internal tubings, I/A probe

Fig. 3.16: Statim autoclave cassette containing the tubings and

After doing this the instruments are laid on the

The Operating Room Linen and Accessories

Fig. 3.25: Flushing of the lumen of the external tubings with

clothes and valuables safely. The most often used per-

hazardous microorganisms, though viruses cannot

team for infection control.

Fig. 3.28: Culture specimen taken using sterile

All Fluids used Parenterally to be

4. Polyacrylamide is stable and can be sterilised by boiling. It does not

Contaminants/Particulate matter in HPMC 1. It is not a pseudoplastic substance—extremely high

3. Clorfeine GS, Parker WT: Use of Healon in eye muscle surgery

this gives the ultimate result of surgery. Longer the incision

Nucleus Prolapse Sutures

because one has to deliver the nucleus through tunnel.

Nucleus prolpase in AC Not needed Needed Not needed

Age of Patient Microscope

FURTHER READING 4. Mathew Manual nucleo fragmentation and endothelial cell

The preoperative evaluation should be done in the SURGERY IN INSULIN-TREATED PATIENTS

with chronic hyperglycaemia – surgery duration <2 hours

lunch [25%], and dinner [25%]), as regular insulin and NPH

INTRODUCTION normotension and hypertension. The higher the blood

JNC VI (Joint National Committee) Guidelines

importantly a grateful patient. The usual pattern of

b. Power of the lens

Adjusting Original SRK to SRK II Large Ammetropic Postoperative

Emmetropia should be the Goal

binocular vision accuracy of the implant power are differences in the

Ocular Anaesthesia 10 Kamaljeet Singh