TEKNIK OPERASI

KATARAK
ECCE
(Extracapsular Cataract Extraction)
Indication
• Subluxated lens
• Significant zonule loss (e.g., pseudoexfoliation)
• Traumatic cataract
• Mature cataracts (brunescent internal)
• Large posterior capsule tear at beginning of planned phaco
surgery
Preoperative
• Preoperative Preparation
• Consent
• Intraocular lens  biometry
• Operative site identification
• Adequate pupillary dilation or prepare for pupil stretch 
midric/midriatyl
• Patient position
• Anesthesia
• Retrobulbar block (injectional anesthesia: including peribulbar or
subtenon’s techniques)
• Eliminate Posterior Pressure – This is extremely important in ECCE
and should be done for approximately 10 minutes unless there is a
known zonular problem.
• Manual – Apply pressure for a few seconds and then release for a few
seconds
• Honan Balloon – Use a 30 mmHg Honan and be careful that it is
positioned properly on the globe
Bridle suture –jahitan kendali
• Rotate globe inferiorly with a muscle hook
• Grasp superior rectus (SR) with 0.3 to 0.5 toothed forceps
approximately 10 mm posterior to the limbus and lift the
muscle off the globe
• Pass 4-0 silk suture with a tapered needle under the SR
tendon (needle should be flat with the globe to avoid
penetration)
• Cut off needle and clamp the suture to the drape with a
hemostat to rotate the globe down.
Conjunctival Peritomy
• Use blunt Wescotts to make a radial incison at the 10:00
position, 2 mm posterior to the limbus (Tenon’s capsule
inserts 1.5 mm posterior to the limbus)
• Use blunt dissection to remove Tenon’s and conjunctiva from
globe
• Keep scissor blades parallel to the limbus, insert one blade
into the conjunctival pocket, pull blades gentle toward the
cornea and cut
• Repeat until the conjunctival peritomy measures
approximately 12 mm (cord length)
Cautery
• Verify correct power setting on the machine. If using bipolar
tips, keep tips approximately 0.5 mm apart
• Use a sweeping motion over the sclera and start posteriorly
approximately 2-3 mm from the limbus.
Incision
• Groove
• Measure the length of the desired wound by marking the sclera with
the caliper tips set at 10.5 mm.
• Use 0.12 forceps to grasp sclera at approximately the 11:00 position
to stabilize the globe.
• Hold the blade handle perpendicular to the globe and make the
incision from left to right approximately 1 mm posterior to the blue
line.
• Consider making the grove more anterior in a blue iris to prevent
early entry and iris prolapse.
• The depth of the groove should be approximately ½ to 1/3 scleral
depth.
• The length of the groove should be 10.5 mm, beginning at the 10:30
position and ending at approximately the 2:30 position.
• Attempt to make the groove in one continuous motion by rotating
the blade within your fingertips.
Incision
• Enter anterior chamber
• Elevate the anterior lip of the wound with the 0.12 forceps,
exposing the apex of the flap, and enter the anterior chamber
with the 75 blade parallel to the iris plane
• Make a 3 mm incision either to the right side of the wound (right-
handed surgeon) or to the left (left-handed surgeon).
• Capsular dye injection (trypan blue)

• Viscoelastic injection
• Inject the viscoelastic primarily at the 6:00 position first to push
the aqueous out of the eye, while filling the entire anterior
chamber.
• Cystotome
• Use a pre-bent cystotome or use a hemostat to bend a 25-guage
needle
 Capsulotomy
• Can-opener
• Hold the cystotome with both hands to stabilize and penetrate the
anterior capsule at the 6:00 position and sweep to the side.
• Continue making small punctures circumferentially to complete a 6-7
mm capsulotomy. With each puncture the surgeon will sweep to the
right while going up the left side and to the left while going up the
right side.
• Continuous
• If a continuous capsulorhexis is performed, radial tears must be
made to facilitate nucleus removal.
• Removal of anterior capsule
• Use an angled instrument to grasp the central anterior capsule.
• Ensure that the anterior capsule is free from the peripheral capsule
by pulling the capsule gently in all directions
• Remove the anterior capsule from the eye.
Enlarging the wound
• Use corneoscleral scissors and enter the anterior chamber
with lower jaw of the scissors and cut toward the opposite
side of the wound.
• Push gently toward the 6:00 position as you cut to ensure that
you enlarge the wound at the most anterior aspect of the
tunnel.
• Maintain scissor blades in the groove and keep blades parallel
to the iris plane.
Nucleus removal
• Manual Expression
• This is achieved by applying external, posterior pressure with
forceps or the irrigating lens loop 2 mm posterior to the limbus at
the 12:00 position and using an assistant to elevate the anterior
lip of the wound.
• When the nucleus begins to prolapse, counterpressure is applied
with a muscle hook at the 6:00 position to facilitate removal of
the nucleus. Once the nucleus is partially out of the eye, any
pointed instrument may be used to completely rotate the
remainder of the lens out of the eye.
Nucleus removal
• Lift and extract
• Either hydrodissection or manual rotation should be performed
to elevate the 12:00 lens into the anterior chamber.
• To manually rotate the nucleus, use a Sinskey hook, cannula or
cystotome to gently rock the lens in a dialing/circumferential
manner and then lift and rotate.
• Once the superior portion of the lens is elevated, an irrigating
lens loop may be inserted under the lens.
• The irrigating lens loop is then flattened parallel to the iris plane,
lifted toward the cornea, and removed from the eye with the
nucleus.
Suture Placement
• To maintain the anterior chamber during cortical removal, it is
beneficial to place 2 or 3 10-0 nylon sutures at the 10:00,
12:00 and 2:00 positions.
• If the iris is light-colored or there is a tendency for iris
prolapse, additional sutures may be placed.
Cortex removal
• Manual or Automated
• The cortex may be removed by using either a manual aspirating
cannula (i.e. Simcoe cannula) or an automated
irrigating/aspirating system.
• This technique is similar to phacoemulsification, however, with a
can-opener capsulotomy, care should be taken not to accidently
grasp the anterior capsule leaflets.
• Strip the cortex toward the center of the pupil and aspirate more
aggressively only when the port is fully occluded with cortex.
IOL Implantation
• The capsular bag is reformed with viscoelastic prior to implantation of
the IOL.
• It is important to reform the capsular bag and not just deepen the anterior
chamber.
• This is achieved by directing the viscoelastic under the anterior capsular leaf
of the capsular bag at the 6 o’clock position.
• If sutures were placed prior to cortical removal, one or more will need
to be removed in order to insert a non-foldable lens.
• To insert a non-foldable lens, grasp the lens approximately ½ to 1/3 onto the
optic of the IOL with long-angled forceps (i.e. Kelman).
• Hold the anterior lip of the wound and ease the IOL into the bag by tilting the
lens down and pushing the leading haptic into the 6:00 position.
• When the majority of the IOL is in the capsular bag, the anterior wound is
released and the trailing haptic is grasped to prevent extrusion of the IOL
when the optic is released.
• Tap the IOL further into the bag with closed Kelman forceps until the optic is
completely behind the pupil.
• Place or rotate the trailing haptic into the capsular bag as you would with
phacoemulsification.
Wound closure
• Place enough 10-0 nylon sutures to ensure adequate wound
closure.
• With proper wound construction, 4-5 sutures should be
adequate.
Removal viscoelastic
• Tapping posteriorly on the anterior surface of the IOL will
facilitate removal of the viscoelastic retained behind the IOL.
Injections
• Pupillary contriction with either intracameral Miochol or
Miostat is prudent in ECCE to reduce the risk of optic pupillary
capture.
• Subconjunctival Antibiotics and Steroids
phacoemulsification
Clear cornea incision
• Temporal side
• Planes:
• 3 plane
• 2 plane
• 1 plane
• Insert trypan blue
• Insert viscoelastic
• Perform Continuous curvolinear capsulorhexis
CCC
Hydrodissection
• Using BSS
• 2 sides: 2 o’clock
position and 10
o’clock position
• Ensure the cortex is
separated from the
capsule
Phacoemulsification
• Techniques:
• Divide & conquer
• Phaco chop/ quick chop
• Stop & chop
DIVIDE AND CONQUER

• The maneuver of fracturing the lens

• 1985  divide and conquer technique by HV Gimbel
• 1990  Shepherd’s phaco fracture technique
PHACO CHOP TECHNIQUE

• 1993  Kunihiro Nagahara

• The main benefits of the technique are
twofold:
• reduction of total ultrasound energy and
phacoemulsification time and
• decreased stress on the zonules
STOP AND CHOP
• Koch and Katzen, modified the phaco-chop technique to provide space
for tissue separation, nucleus manipulation, and aid ease of removal.
• I/A cortex
• Viscoelastic insertion
• IOL insertion
• Insert Myostat
• Wound closure:
• Suture (if needed)
• Stromal hydration
• Antibiotic intracameral injection
• Seidel test
Thank you