Intra capsular cataract extraction (ICCE)

ICCE
ICCE evolved into a very successful operation
Preferred surgical technique before the refinement
of modern ECCE surgery
However there remained 5% rate of potentially
blinding complications including:
Infection
Hemorrhage
RD
CME
Intra capsular cataract extraction (ICCE)

ECCE has replaced ICCE, almost entirely in most parts

of the world:

1. Better operating microscopes

2. More sophisticated surgical aspiration systems

3. More sophisticated IOL implants

Techniques (ICCE)

Smiths method

Arrugas method

Erysiphakes

Cryo surgery

Chemical dissolution of zonular fibers

Smiths technique

Smith used external pressure with muscle hook to

mechanically break the inferior zonules

Expelled the lens through the limbal incision

The lens would Tumble, I.e. the inferior pole would

exit the eye before the superior pole

Arrugas method

Toothless forceps (Arrugas) used to grasp

the lens capsule and then gently pulled
from the eye using side-to-side motion
that broke the zonules
Arrugas Forceps
Erysiphakes technique
Suction cup-
like devices
were used to
remove the
lens with
traction
Cryo surgery
Cryprobe: Hollow metal-tipped probe, cooled by
liquid nitrogen, that is touched to the lens surface
As the temperature of the probe tip falls below
freezing, an ice ball forms and the lens adheres to it
This instrument forms an ice ball, fusing the lens
capsule, cortex, and nucleus
Lessening the risk of capsular rupture as the cataract
is removed
Chemical dissolution of zonular fibers

The enzyme is irrigated into posterior chamber to

dissolve the zonular fibers in order to facilitate ICCE

surgery

Enzyme alpha-chymotrypsin enhances the safety of

ICCE by increasing the ease of lens removal

Extra capsular cataract extraction (ECCE)

Shift from ICCE to modern ECCE

To decrease the rate of potentially blinding:
Complications
To facilitate the placement of PC IOLs

By leaving the PC intact, the surgeon could

decrease the risk of:
Vitreous loss and
Complications like RD, CME, and Bullous Keratopathy
Extra capsular cataract extraction (ECCE)

Key to the development of modern ECCE

technique were the growing use of:

Operating microscopes for increased

magnification &

Improved methods of cortical removal

Extra capsular cataract extraction (ECCE)

Charles Kelman in 1967 developed phacoemulsification

This new type of ECCE:
Ultrasonically emulsified the lens nucleus,
Allowing the operation to be performed through a small
incision
This method has continued to grow in popularity as:
Techniques &
Instrumentation
Indications of ICCE

Operating microscopes not available

Unstable / luxated cataracts

Week zonular support

Advantages of ICCE
Entire lens removed with no capsule left behind to:
Opacify or
Require additional surgery
Less sophisticated instrumentation required
Non automated extraction devices:
Cryoprobes Allow this procedure
Capsular forceps To be performed
Erysiphakes Under most conditions
Disadvantages of ICCE
Large ICCE incision 12 14 mm (160 - 180)
Delayed healing Delayed visual rehabilitation
Iris incarceration Vitreous incarceration

Postoperative wound leaks with inadvertent filteration

Endothelial cell loss > following ICCE than ECCE
Corneal / endothelial cell trauma from lifting / folding
of the cornea (lens delivery / cryprobe)
Cystoid macular edema (transient 50%, persistent 2%
- 4%)
Disadvantages of ICCE (contd)
Vitreous complications:
In young patients PC is firmly adherent to anterior
hyaloid; attempted ICCE will usually result in vitreous loss
Intact vitreous face may opacify and vision
Adherence to corneal endothelium (corneal edema)
Adherence to iris (pupillary block glaucoma)
Broken vitreous face may incarcerate in the wound
with vitreous traction causing:
RD
CME
Vitreous in AC causing open angle glaucoma
Disadvantages of ICCE (contd)

IOL implantation problematic since posterior capsular

support missing

IOL choices include:

ACL /Sutured PC IOL (Iris fixation IOLs no longer available)

These significant disadvantages and risks led to loss

of popularity of ICCE
Patient preparation

Pharmacologic pupillary dilation with topical

mydriatic and cycloplegic agents to facilitate

lens removal (iris retractors intraoperatively)

Anaesthesia
Patient preparation (contd)

Orbital massage / osmotic agents (manitol,

glycerine, isosorbide) before surgery
1. Intermittent digital pressure on closed eye lids or
2. Occulopressive device (honann baloon, mercury bag,
sponge ball, strap)
3. Massage helps to:
Distribute the anaesthetic agent within orbit
Orbital volume
Pressure on the globe
IOP
Patient preparation (contd)

Orbital massage (contd)

4. Minimizes vitreous prolapse during cataract
extraction and facilitates an angle supported
IOL
5. Osmotic agents are used less frequently:
Volume load in patients with heart and kidney
failure
Nausea (Occasional)
Urinary urgency during surgery
Patient preparation (contd)

Procedure
Postoperative course
VA should be consistent with:
1. Refractive state of the eye
2. Clarity of the cornea
3. Clarity of the media
4. Visual potential of the retina and optic nerve
Patient preparation (contd)

ECCE
ECCE involves removal of the nucleus and

cortex through an opening in the anterior

capsule (anterior capsulotomy), leaving the

posterior capsule in place.

Patient preparation (contd)

ECCE (contd)

Methods

1. Nucleus expression (manual)

2. Phacoemulsification (Ultrasonic fragmentation)

Patient preparation (contd)

ECCE (contd)
Methods
Preferred method of routine cataract
surgery
Selection of technique for nucleus removal
depends upon:
Instrumentation available
Surgeons level of experience with each technique
Advantages of ECCE surgery (contd)

Smaller incision
Less traumatic to corneal endothelium
Eliminates complications (short and long
term) associated with vitreous adherent to:
Incision wound
Iris
Cornea
Advantages of ECCE surgery (contd)

Intact posterior capsule allows better anatomical

position for IOL fixation

Intact posterior capsule incidence of:

CME

RD

Corneal edema
Advantages of ECCE surgery (contd)

Intact posterior capsule ability of bacteria,

introduced into eye, to gain access to vitreous cavity
and cause endophthalmitis

2ndry IOL implantation

Filtration surgery Technically easier
Corneal Transplantation and safer when
intact PC is present
Wound rapair
Contraindications (ECCE)
Zonular weakness
ECCE requires zonular integrity for selective
removal of nucleus and cortical material

Therefore when zonular support appears

insufficient to allow safe removal of the
cataract through ECCE surgery, ICCE or Pars
Plana Lensectomy should be considered
Instrumentation (ECCE)
A wide range of instruments is available
for each step of ECCE:
Opening the anterior capsule

Dissecting and removing the nucleus

Removing the lens cortex

Polishing PC
Cystotome
Used for anterior capsulotomy (opening in the
anterior of the lens)
Fashioned from 25 gauge needles by bending at its
hub and beveled tip
Prefabricated cystotomes also commercially available
The needle tip is used to puncture and tear the
anterior capsule
Irrigation and aspiration system
coaxial, double-lumen blunt cannulas

One lumen irrigates BSS into the AC

Second lumen aspirates lens material out of the AC
Irrigation is gravity fed from a solution bottle
Fluid flow is regulated with adjustment of bottle
height
The flow may be constant, or the surgeon can
employ a foot control connected to a pinch valve
Irrigation and aspiration system coaxial,
double-lumen blunt cannulas (contd)

Aspiration:
Syringe connected to the cannula

Elaborate pump system controlled by a

foot switch
Lens nucleus

Removed by a variety of techniques, each

with its own set of instruments:
Lens expressor
Lens loop
Spoon, Vectis
Procedure ECCE
Pupillary dilation
Critical to the success of ECCE esp.

phacoemulsification

Cycloplegic / mydriatic drops

NSAID (topical/oral) these agents help to

maintain dialation during surgery

Procedure ECCE (contd)

Incision
Incision: Mid limbal, chord length 8 12 mm,
which is smaller than for ICCE
The initial incision consists of a limbal groove
Some surgeons prefer more posterior incision
with anterior dissection creating a flap of tunnel
A stab incision is made into AC
AC depth stabilized by viscoelastic agents, air
bubble, or continuous fluid irrigation
Cystotome is inserted for anterior capsulotomy
Procedure ECCE (contd)

Capsulotomy
Christmas tree

Can-opener

Capsulorrhexis
Procedure ECCE (contd)

Capsulotomy (contd)
Christmas tree
With cystotome anterior capsule punctured
inferiorly and
The flap of the capsule drawn toward the wound
and cut with scissors
Procedure ECCE (contd)

Capsulotomy (contd)
Can-Opener
Cystotome used to make a series of connected

punctures or small tears in circle

Procedure ECCE (contd)

Capsulorrhexis
Continuous tear anterior capsulotomy popular in
phacoemulsification, can be performed with
either:
Csytotome or
Capsulorrhexis forceps
First a small tear is created,
The edge this tear is then grasped with cytotome
tip/forceps, and
A smooth tear is created, removing a circular
portion of anterior capsule
Procedure ECCE (contd)

Capsulorrhexis (contd)
This technique provides:

Structural integrity for the lens capsule

Maintain implant stability

Centeration
Nuclear expression

Manual
1. Whole (Lens loop, spoon, vectis, irrigation)

2. Fragmentation with forceps/nuclear splitter)

Ultrasonic fragmentation
Lens cortex aspiration

1. Syringe connected to cannula

2. Pump system controlled by foot switch

Posterior capsular polishing

Abrasive tipped irrigation cannula / low

vacuum clean using low aspiration
remove epithelial and cortical particles
from the capsular surface
IOL implantation
AC filled with viscoelastic / BBS / air
Viscoelastic most reliable AC maintainer
It also protects corneal endothelial
IOL inserted in the ciliary sulcus / capsular bag
Sulcus fixation:
Requires greater IOL diameter (>12.5 mm)
Large diameter optic (6 mm)
More forgiving in case of postoperative decentration
Bag fixation:
IOL diameter <12.5 mm
Optic diameter 5.00 mm
Wound suturing
10/0 Nylon

Proper suture tension postoperative Astigmatism

Loose sutures Against-the-rule Astigmatism

Tight sutures With-the rule Astigmatism

Postoperative course ECCE
As with ICCE, VA on the first
postoperative day should be consistent
with:
Refractive state of the eye

Clarity of the cornea

Clarity of the media

Visual potential of the retina and optic nerve

Postoperative course ECCE

Lid: Mild eye lid edema and erythema may occur

Conjunctiva: May be injected and boggy

Cornea: Should be clear and free of striate / edema

AC: Should be of normal depth and mild cellular

reaction typical
Postoperative course ECCE (contd)
Posterior capsule: Should be clear and intact

Implant: Should be well positioned and stable

Red reflex: Should be strong and clear

IOP: Elevations may be associated with retained

viscoelastic
Postoperative course ECCE

Antibiotics and Corticosteroids:

Topical antibiotic and corticosteroids are used for first

few weeks

Vision:

Steady improvement in vision and comfort, as

inflammation subsides
Postoperative course ECCE (Contd)

Refraction:

Refraction stable by 6th 8th weeks,

Glasses may then be prescribed

Astigmatism:

If significant astigmatism along the axis of incision,

selective sutures removed by 6th week, according to
keratometry corneal topography
Phacoemulsification
Phacoemulsification is an ECCE technique that
differs from standard ECCE with nuclear
expression by the:
1. Size of incision required
2. Method of nucleus removal
This technique uses ultrasonically driven needle
(phaco tip) to fragment the nucleus and aspirate
the lens substance through a needle port
Phacoemulsification (contd)
Advantages
Lower incidence of wound related complications
Faster healing
Rapid visual rehabilitation
AC depth controlled during surgery and
providing safeguards against positive vitreous
pressure and choroidal haemorrhage (closed
system)
Phacoemulsification (contd)
Instrumentation

Ultrasound

Irrigation system

Aspiration system
Phacoemulsification (contd)
Ultrasound
The phacoemulsification hand piece contains

a piezoelectic crystal that vibrates at

frequency of 24000 56000 Hz

The vibration is transmitted to the head which

is attached to the phaco tip

Phacoemulsification (contd)

Aspiration
The aspiration system of phacoemulsification
machine varies according to the pump design:

1. Peristaltic Pump

2. Diaphragm Pump

3. Venture Pump
Phacoemulsification (contd)

Aspiration (contd)
Peristaltic Pump
Consists of set of rollers that move along a
flexible tubing, forcing fluid through the
tubing and creating a relative vacuum at
the aspiration port of phacoemulsification
needle
Phacoemulsification (contd)

Aspiration (contd)
Diaphragm Pump
Flexible diaphragm overlying a fluid
chamber with one-way valves at the inlet
and outlet
Phacoemulsification (contd)

Aspiration (contd)
Venturi Pump
Creates a vacuum based on the venturi principle:- That
a flow of gas across a port creates a vacuum
proportional to the rate of the gas
Phacoemulsification
Irrigation
Fluid dynamics of phacoemulsification
requires constant irrigation through the
irrigation sleeve around the ultrasound
tip
Constant irrigation:
Maintains AC depth
Cools the phacoemulsification probe
Prevents heat buildup and adjacent
tissue damage