Phacoemulsification

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NCM 1o4

• form of cataract removal • is a cataract surgery in which an ultrasonic device is used to break up and then remove a cloudy lens, or cataract, from the eye to improve vision. • Involves removing the eye's natural lens while leaving in place the back of the capsule, which holds the lens in place.

first lens is the cornea, a clear membrane that covers the front of the eye.

second lens is the eye's natural crystalline lens, which is held in place by a capsule located behind the pupil

The eye works like a camera with two lenses.

• When the natural lens becomes cloudy, usually because of the aging process, it keeps light rays from passing through or diffuses the light in such a way that vision becomes fuzzy or hazy.

• Cataracts also can occur anytime because of injury, exposure to toxins, or diseases such as diabetes. Congenital cataracts are caused by genetic defects or developmental problems, or exposure to some contagious diseases during pregnancy.

• Phacoemulsification, or phaco, as surgeons refer to it, is used to restore vision in patients whose vision has become cloudy from cataracts. In the first stages of a cataract, people may notice only a slight cloudiness as it affects only a small part of the lens, the part of the eye that focuses light on the retina. As the cataract grows, it blocks more light and vision becomes cloudier. As vision worsens, the surgeon will recommend cataract surgery, usually phaco, to restore clear vision. With advancements in cataract surgery such as the IOL (intraocular lens) patients can sometimes

• The technique of phacoemulsification utilizes a small incision. The tip of the instrument is introduced into the eye through this small incision. Localized high frequency waves are generated through this tip to break the cataract into very minute fragments and pieces, which are then sucked out through the same tip in a controlled manner. A thin 'capsule' or shell is left behind after cleaning up of the entire opaque cataract. • The incision size for phacoemulsification is approximately 3.0 millimeters in width. If a lens implant that can be folded is used following removal of the cataract, this incision may not have to be enlarged. If a

Disposable keratome. This instrument is designed for clear corneal phacoemulsification. The width of the wound created will allow the entry of the phaco tip without it being too narrow or too wide.

Cystotome needle. This needle is designed with for easy manipulation in the anterior chamber. The sharp bent tip is used to tear the anterior capsule and initiate the capsulorrhexis.

Utrata forceps. This forceps has bent sharp tips. It can be used instead of cystotome needle for capsulorrhexis. Alternatively, it can be used to pick up the anterior capsular flap created by the cystotome needle to complete the capsulorrhexis.

Phacoemulsification probe. The phaco needle is used to emulsify the nucleus. The sleeve is placed over the needle during phacoemulsification. The sleeve is incompressible and serves as an insulator. Water which flows between the sleeve and the needle acts as a coolant and avoids burnt to the cornea.

Nucleus rotator. used to divide the nucleus. with the help of the phaco tip

Simcoe irrigation-aspiration cannula. This instrument is used to remove any cortical material left after phacoemulsification. It has two ports: one for irrigation to maintain the anterior chamber and the other for aspiration. It can also be used to remove viscoelastic material at the end of the surgery.

Folding forceps. This instrument is designed to fold the lens at right angle and implant it into the capsular bag.

Sinskey hooks. Straight and bent. The hook is used to dial the haptic into the capsular bag.

Intraocular lens (IOL)

Phaco probe

• In phacoemulsification cataract surgery, the surgeon makes a very small incision -- about 1/8th of an inch -- in the white of the eye near the outer edge of the cornea. A small ultrasonic probe is inserted through this opening and, oscillating at 40,000 cycles per minute, is used to break up (emulsify) the cataract into tiny pieces. The emulsified material is simultaneously suctioned from the eye by the open tip of the same instrument. The hard central core of the cataract (the nucleus) is removed first, followed by extraction of the softer, peripheral cortical fibers that make up the remainder of the lens. The front (anterior) section of the lens capsule is removed along with the fragments of the natural lens. The back (posterior) portion of the capsule is left in place to hold and maintain the correct position for the implanted intraocular lenses. • After removal of the cataract, a prescription intraocular lens, or IOL, is permanently implanted in the lens capsule to replace the natural crystalline lens of the eye that was removed during the surgery. This lens is rolled inside a tiny hollow tube and inserted through the same incision that was used to remove the cataract. The folded lens is pushed out of the tube by a tiny plunger and, as it unfolds, is positioned by the surgeon in the center of the lens

1. The process begins with the creation of a micro incision with a diamond knife.

2. A round opening is then made in the skin of the natural lens, which is like a grape, with a skin and a softer interior.

3. Next, using a special probe with suction, the interior of the natural lens is removed, leaving only the skin. This technique is called phacoemulsification and uses ultrasound to remove the cataract. Lasers are not used to remove the cataract but may be used after the surgery.

4. The lens capsule is carefully cleaned and polished, providing a natural location for the new lens (the intraocular lens) that will be inserted into the eye to correct vision. The lens is flexible and actually fits through the tiny initial incision, opening inside the eye into the "skin" of the natural lens. Over time, the capsule contracts, "shrink-wrapping" the lens in place and making it a permanent part of the eye.

5. The new lens becomes so well integrated into the eye that even severe trauma will not dislodge it.

• Complications are unlikely, but can occur. Patients may experience spontaneous bleeding from the wound and recurrent inflammation after surgery. Flashing, floaters, and double vision may also occur a few weeks after surgery. The surgeon should be notified immediately of these symptoms. Some can easily be treated, while others such as floaters may be a sign of a retinal detachment. • Retinal detachment is one possible serious complication. The retina can become detached by the surgery if there is any weakness in the retina at the time of surgery. This complication may not occur for weeks or months. • Infections are another potential complication, the most serious being endophthalmitis, which is an infection in the eyeball. This complication, once widely reported, is much more uncommon today because of newer surgery techniques and antibiotics. • Patients may also be concerned that their IOL might become displaced, but newer designs of IOLs also have limited reports of intraocular lens dislocation.

• Immediately following surgery, the patient is monitored in an outpatient recovery area. The patient is advised to rest for at least 24 hours, until he or she returns to the surgeon's office for follow-up. Only light meals are recommended on the day of surgery. The patient may still feel drowsy and may experience some eye pain or discomfort. Usually, over-the-counter medications are advised for pain relief, but patients should check with their doctors to see what is recommended. Other side effects such as severe pain, nausea, or vomiting should be reported to the surgeon immediately. • There will be some changes in the eye during recovery. Patients may see dark spots, which should disappear a few weeks after surgery. There also might be some discharge and itching of the eye. Patients may use a warm, moist cloth for 15 minutes at a time for relief and to loosen the matter. All matter should be gently cleared away with a tissue, not a fingertip. Pain and sensitivity to light are also experienced after surgery. Some patients may also have slight drooping or bruising of the eye which will improve as the eye heals.

• Patients have their first postoperative visit the day after surgery. The surgeon will remove the eye shield and prescribe eye drops to prevent infections and control intraocular pressure. These eye drops are used for about a month after surgery. • Patients are advised to wear an eye shield while sleeping, and refrain from rubbing the eye for at least two weeks. During that time, the doctor will give the patient special tinted sunglasses or request that he or she wear current prescription eyeglasses to prevent possible eye trauma from accidental rubbing or bumping. Unlike other types of cataract extraction, patients can resume normal activity almost immediately after phaco. • Subsequent exams are usually at one week, three weeks, and six to eight weeks following surgery. This can change, however, depending on any complications or any unusual postoperative symptoms. • After the healing process, the patient will probably need new corrective lenses, at least for close vision. While IOLs can remove the need for myopic correction, patients will probably need new lenses for close work.