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Premium member Presentation Transcript PHACO BASICS: PROCEDURE Dr.Kaivan Shah Dr.Smita Praveen: PHACO BASICS: PROCEDURE Dr.Kaivan Shah Dr.Smita Praveen1.Incision & Wound construction: 1.Incision & Wound construction Be clear about: a) Anatomy of surgical limbus:3 borders & 2 zones b) Astigmatic neutral funnel: mouth 3-3.5 mm at limbus & flares out as moves posterior 3 shapes: Frown, smile & straight c) Self sealing valve mechanism: inner corneal lip should be 1.75 mm all along & should be smooth, not raggedTypes:: Types: Main Port : 2 types 1. Scleral incision : should be square, self sealing, 1/3 to 1/2 thickness(300-500micron) adv. : less chances of endophthalmitis disadv. : not possible under topical & temporal section,more bleeding,difficult instrumentation 2. Clear Corneal incision : superior or temporal depending on keratometry reading Temporal better b’coz, less induced astigmatism less pooling of fluid in deep set eyes Tunnel interferes less with visibility as HD>VD by 1 mmPowerPoint Presentation: Types: uni,bi and tiplanar, hinged Adv. : done under topical, no bleeding, ease of instrumentation Disadv.: more chances of endophthalmitis Limbal approach is good compromise between two. Side port : Site - 2-3 clock hours from main port 180 deg apart, corneal not Scleral Size - 1.5*1.5mm2. CCC:: 2. CCC: Prerequisite for phaco as intact CCC strengthens capsule withstand IOP fluctuations,allows post.chamber phaco Ideal size : 5-6mm,should cover o.25mm of IOL circumferentially Needs : firm eyeball, well-formed A/C with flat ant.capsule, moderate to good dilatation, red fundal reflex Physics : ripping & shearing forces Site : main port- easy maneuverability, more leakage side port- stable A/C, difficult to stabilize eyePowerPoint Presentation: Method : needle/cystitome Vs forceps Forceps CCC : ( Utratta ) Adv : good grip on flap, easy to change direction Useful in fibrotic, atrophic capsule, in intumescent cataracts with high I/L pressure for posterior CCC Disadv: wound leak & corneal distortion Dye assisted : use of trypan blue in mat.cat.3. Hydroprocedures:: 3. Hydroprocedures: Aim: convert lens in 3 parts: 1.capsule with cortex, 2.epinucleus, 3.endonucleus Adv: facilitates rotation, epinuclear plate gives cushion during phaco & protect PC & reduce energy, enables prolapse of small nucleus out of rhexis margin in CSZ instruments:2cc syr,26-30G cannula,27G idealPowerPoint Presentation: 2 components: 1. Hydrodissection : separation of lens from capsule by fluid wave. Remove visco first to avoid inadvertent increase in IOP Do it from main port, tenting of margin Inject beyond 2-3mm of margin Watch for : fluid wave, loss of glow, pop up nucleus Compression hydro dissection Careful in: small/large CCC, post.polarPowerPoint Presentation: 2. Hydrodelineation : create smallest possible nucleus & thickest epinuclear plate Watch for Golden ring Always do rotation of nucleus after completion of hydroprocedures. Difficult rotation causes: incomplete hydro, adhesions with capsule, dialysis of bag, soft cataract4.PHACOEMULSIFICATION:: 4.PHACOEMULSIFICATION: Aim : remove central core nucleus with minimum phacoenergy by diff.techniques Understand posterior curvature of lens & hardness of nucleus Instruments : phaco tip & chopper Before starting phaco fill A/C with visco & remove ant.epinuclear plate & cortex Different techniques used: “stop & chop”,”divide & conquer”,”phaco chop”PowerPoint Presentation: Different steps used: trenching, splitting of nucleus & phaco aspiration. Depending upon step, phaco parameters are modified. 1. Trenching : first step in stop-chop & divide-conquer method, width 2 tip diameters, length up to ring, depth 2-3 tip deep(glow should be seen) Settings: low flow, low/nil vacuum, high power 2. Splitting : with 2 instruments Push method / pull methodPowerPoint Presentation: 3. Chopping : piece of nucleus after splitting are aspirated by this technique Settings: medium flow,high vacuum, medium energy Control over footpedal & familiarity with machine sounds of utmost importance Method: bury tip in nucleus with short burst energy, hold with vacuum & aspirate it with intermittent use of energy Careful while aspirating last piece Chattering & Surge occurs while this step Horizontal chop Vs Vertical Chop5.Epinucleus Removal:: 5.Epinucleus Removal: 3 parts: anterior, equatorial & posterior Instruments: Phaco tip & iris repositor settings: high flow,medium vacuum,low power Method: “flip & chip” Catch equatorial part with vacuum,pull in CSZ & aspirate with small burst of energy Keep Repositor below tip to prevent catching PC Hydro.can be done to separate it from capsule6.Cortex Aspiration: 6.Cortex Aspiration Includes removal of cortex & PC polishing Important to prevent PCO & uveitis Cortical removal : 1.Coaxial I/A system : tip is straight/angulated(45/90 degree) Aspiration orifice in front of tip-o.2 to 0.7m Tip covered by silicone sleeve 2.Bimanual I/A system : 1 irrigation(2 holes) & 1 aspiration cannula Method: catch beneath CCC pull towards centre & aspirate in CSZPowerPoint Presentation: Parameters: high flow & vacuum Capsule polishing : to reduce PCO formation Very low vacuum & flow High magnification with focus on PC Stretch PC by filling A/C with visco,no folds in PC should be present Instruments: sand blasted aspiration cannula/rounded iris repositor Beginners don’t try7. IOL insertion : 7. IOL insertion Visco filled eye & adequate wound size Nonfoldable IOL: with 2 forceps with/without dialer Foldable IOL: holder-folder method & injector method Ensure in the bag placement8.Visco Wash: 8.Visco Wash Visomet washed with I/A mode Ensure all viscomet is washed to prevent postop glaucoma Tap over centre of IOL to release visco trapped in the bag9.Wound Closure: 9.Wound Closure Adequate hydrate wound Check water tightness of wound If necessary air can be put Take suture if in doubt about integrity/corneal wound burn in c/o corneal tunnelPowerPoint Presentation: Thank you You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
phaco basics procedure kaivanshah247 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Copy Does not support media & animations WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 670 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: July 19, 2012 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript PHACO BASICS: PROCEDURE Dr.Kaivan Shah Dr.Smita Praveen: PHACO BASICS: PROCEDURE Dr.Kaivan Shah Dr.Smita Praveen1.Incision & Wound construction: 1.Incision & Wound construction Be clear about: a) Anatomy of surgical limbus:3 borders & 2 zones b) Astigmatic neutral funnel: mouth 3-3.5 mm at limbus & flares out as moves posterior 3 shapes: Frown, smile & straight c) Self sealing valve mechanism: inner corneal lip should be 1.75 mm all along & should be smooth, not raggedTypes:: Types: Main Port : 2 types 1. Scleral incision : should be square, self sealing, 1/3 to 1/2 thickness(300-500micron) adv. : less chances of endophthalmitis disadv. : not possible under topical & temporal section,more bleeding,difficult instrumentation 2. Clear Corneal incision : superior or temporal depending on keratometry reading Temporal better b’coz, less induced astigmatism less pooling of fluid in deep set eyes Tunnel interferes less with visibility as HD>VD by 1 mmPowerPoint Presentation: Types: uni,bi and tiplanar, hinged Adv. : done under topical, no bleeding, ease of instrumentation Disadv.: more chances of endophthalmitis Limbal approach is good compromise between two. Side port : Site - 2-3 clock hours from main port 180 deg apart, corneal not Scleral Size - 1.5*1.5mm2. CCC:: 2. CCC: Prerequisite for phaco as intact CCC strengthens capsule withstand IOP fluctuations,allows post.chamber phaco Ideal size : 5-6mm,should cover o.25mm of IOL circumferentially Needs : firm eyeball, well-formed A/C with flat ant.capsule, moderate to good dilatation, red fundal reflex Physics : ripping & shearing forces Site : main port- easy maneuverability, more leakage side port- stable A/C, difficult to stabilize eyePowerPoint Presentation: Method : needle/cystitome Vs forceps Forceps CCC : ( Utratta ) Adv : good grip on flap, easy to change direction Useful in fibrotic, atrophic capsule, in intumescent cataracts with high I/L pressure for posterior CCC Disadv: wound leak & corneal distortion Dye assisted : use of trypan blue in mat.cat.3. Hydroprocedures:: 3. Hydroprocedures: Aim: convert lens in 3 parts: 1.capsule with cortex, 2.epinucleus, 3.endonucleus Adv: facilitates rotation, epinuclear plate gives cushion during phaco & protect PC & reduce energy, enables prolapse of small nucleus out of rhexis margin in CSZ instruments:2cc syr,26-30G cannula,27G idealPowerPoint Presentation: 2 components: 1. Hydrodissection : separation of lens from capsule by fluid wave. Remove visco first to avoid inadvertent increase in IOP Do it from main port, tenting of margin Inject beyond 2-3mm of margin Watch for : fluid wave, loss of glow, pop up nucleus Compression hydro dissection Careful in: small/large CCC, post.polarPowerPoint Presentation: 2. Hydrodelineation : create smallest possible nucleus & thickest epinuclear plate Watch for Golden ring Always do rotation of nucleus after completion of hydroprocedures. Difficult rotation causes: incomplete hydro, adhesions with capsule, dialysis of bag, soft cataract4.PHACOEMULSIFICATION:: 4.PHACOEMULSIFICATION: Aim : remove central core nucleus with minimum phacoenergy by diff.techniques Understand posterior curvature of lens & hardness of nucleus Instruments : phaco tip & chopper Before starting phaco fill A/C with visco & remove ant.epinuclear plate & cortex Different techniques used: “stop & chop”,”divide & conquer”,”phaco chop”PowerPoint Presentation: Different steps used: trenching, splitting of nucleus & phaco aspiration. Depending upon step, phaco parameters are modified. 1. Trenching : first step in stop-chop & divide-conquer method, width 2 tip diameters, length up to ring, depth 2-3 tip deep(glow should be seen) Settings: low flow, low/nil vacuum, high power 2. Splitting : with 2 instruments Push method / pull methodPowerPoint Presentation: 3. Chopping : piece of nucleus after splitting are aspirated by this technique Settings: medium flow,high vacuum, medium energy Control over footpedal & familiarity with machine sounds of utmost importance Method: bury tip in nucleus with short burst energy, hold with vacuum & aspirate it with intermittent use of energy Careful while aspirating last piece Chattering & Surge occurs while this step Horizontal chop Vs Vertical Chop5.Epinucleus Removal:: 5.Epinucleus Removal: 3 parts: anterior, equatorial & posterior Instruments: Phaco tip & iris repositor settings: high flow,medium vacuum,low power Method: “flip & chip” Catch equatorial part with vacuum,pull in CSZ & aspirate with small burst of energy Keep Repositor below tip to prevent catching PC Hydro.can be done to separate it from capsule6.Cortex Aspiration: 6.Cortex Aspiration Includes removal of cortex & PC polishing Important to prevent PCO & uveitis Cortical removal : 1.Coaxial I/A system : tip is straight/angulated(45/90 degree) Aspiration orifice in front of tip-o.2 to 0.7m Tip covered by silicone sleeve 2.Bimanual I/A system : 1 irrigation(2 holes) & 1 aspiration cannula Method: catch beneath CCC pull towards centre & aspirate in CSZPowerPoint Presentation: Parameters: high flow & vacuum Capsule polishing : to reduce PCO formation Very low vacuum & flow High magnification with focus on PC Stretch PC by filling A/C with visco,no folds in PC should be present Instruments: sand blasted aspiration cannula/rounded iris repositor Beginners don’t try7. IOL insertion : 7. IOL insertion Visco filled eye & adequate wound size Nonfoldable IOL: with 2 forceps with/without dialer Foldable IOL: holder-folder method & injector method Ensure in the bag placement8.Visco Wash: 8.Visco Wash Visomet washed with I/A mode Ensure all viscomet is washed to prevent postop glaucoma Tap over centre of IOL to release visco trapped in the bag9.Wound Closure: 9.Wound Closure Adequate hydrate wound Check water tightness of wound If necessary air can be put Take suture if in doubt about integrity/corneal wound burn in c/o corneal tunnelPowerPoint Presentation: Thank you