Phacoemulsification in subluxated cataracts is a challenging situation for the phaco surgeon due to lot of variables like management of the subluxation, management of the cataract, vitreous etc. Here are the top ten Pearls for Phaco in subluxated Cataracts.
1 Pre-Op Assessment
Careful slit-lamp examination for
a) Extent of Subluxation
b) The density of the cataract
c) Presence or absence of vitreous in Anterior chamber
d) Status of the corneal endothelium
e) Age of the patient
2 Devices & Instrumentation
a) Capsular Tension Ring (CTR)
size 10 – 12 mm
size 11 – 13 mm
b) CIONNI Ring (1 or 2 eyelets)
c) CT Segment (Ahmed Segment)
d) Capsular Hooks
e) Iris Hooks
f) Micro Surgical instrumentation like Microrhexis forceps etc.
3 Proper Surgical Planning
Zonule loss less than 1 quadrant: Place 3 piece IOL in the axis of the Zonular loss
1 to 2 quadrants: CTR Standard
2 to 3 quadrants: CIONNI 1 or 2 or CT segment (Ahmed)
More than 3 quadrants: Above or scleral fixated IOL
4 Surgical Plan
Site of incision: Opposite to the Zonular loss area
Capsulorhexis: Trypan Blue, Keep Microrhexis forcep with you
Optical Viscoelastic Device: Apply Softshell technique
Viscoat (Dispersive)
Healon (Cohesive)
5 Surgical Plan :
Circumferential stability of the bag
a) CTR – When to use
As early as you want
As late as you can
b) Size
Normal: 10 – 12 mm
Myopic: 11 – 13 mm
c) Radial stability of the bag
Iris hooks for the capsular bag
Capsular Hooks
Beware of iris hooks for the capsular bag, they can rip open the capsulorhexis margin.
6) Management of Vitreous In Anterior Chamber
Vitreous to be managed prior to phacoemulcification.
Use Viscoat.
Preservative free Tricort (TRIAMCINOLONE ACETONIDE)
Limbal or PARS PLANA VITRECTOMY.
7 Phaco Technique
a) Direct Chop Technique
b) Lower parameters (Reduced Vaccum, Aspiration Flow Rate)
c) Viscoat
D) Inject OVD into to Anterior Chamber every time you come out of the eye
8 Sequence of Surgery
A) INCISION
B) RHEXIS
C) HYDRODISSECTION
D) CTR
E) IRIS HOOKS OR CAPSULAR HOOKS
F) NUCLEUS MANAGEMENT
G) CORTEX REMOVAL
H) IOL IMPLANTATION IN THE BAG (PREFERABLY 3 PIECE IOL)
9 Use of Femto (CATALYS)
Ideal for subluxated cataracts
a) INCISION
b) RHEXIS
c) NUCLEUS FRAGMENTATION
10 Bail Out Options
a) ECCE
b) ICCE
c) Scleral fixated (Sutured) IOL
d) Glued IOL
e) Yamane Technique
f) Retro iris fixated IOL
SUMMARY
Loose zonules pose a significant challenge knowledge of anatomy of eye is important. Attention to surgical principles is a must scleral fixated IOL remains a bail-out option.
Always have Plan A, Plan B, Plan C before you start the Surgery on Subluxated Cataracts.