Phaco surgery and its challenging situations
by Albrecht Hennig, Lila Raj Puri, Sanjay Kumar Singh

Jaypee’s Video Atlas of Phaco Instruction Course

by Albrecht Hennig
About Video

This video demonstrates and discusses challenging situations and its management, specially related to phaco surgery. This first surgery deals with the management of a subluxated lens, which became only visible at the beginning of the surgery. Here special care needs to be taken to not further increase this situation. This means very careful maneuvers with CCC, hydrodissection, hydro­delineation and mobilizing the nucleus. Before entering the phaco tip into the eye, the bottle height should be reduced to 60-70 cm and low phaco power applied. This is quite a soft nucleus and most of it can be removed in irrigation/aspiration mode. Therefore, the phaco time was only 0.3 seconds. The desired foldable IOL could be inserted without problems. The 45-old-man next surgery is on a traumatic white cataract. The anterior capsule is partly fibrosed and, therefore, the CCC is much more difficult to perform. For fibrosed capsules, fine scissors are often helpful. The nucleus is very soft and all lens content can be removed in irrigation/aspiration mode without any ultrasound. With the next surgery, the CCC is difficult to perform and runs out at the side of the incision. To get a new beginning, a part of the capsule is opened with scissors and then the anterior capsule opening completed. Catch the capsule flap always close to the tear. Also the phacoemulsification process is more difficult because the central posterior nucleus is difficult to separate. All steps need to be done with special care because, in this case, there is an incomplete CCC. A PMMA lens is carefully inserted in such a way that the haptic is not located at the side of the CCC defect. In intumescent lenses, special care needs to be taken that the CCC will not run out. The nucleus cannot be broken in two halves, but only in pieces. A PMMA IOL is inserted into the capsular bag, you can check the in-the-bag position of the IOL by pulling the haptic and observing the CCC edge. In this white, mature cataracts with HM vision are also suitable for phaco, when a quite soft nucleus can be expected. The visual acuity or the density of the cataract is no criteria whether suitable for phaco or not, but only the hardness of the nucleus. Young patients with intumescent lenses often have pre-existing posterior opacities or plaques, which are difficult to remove.

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