PHACOEMULSIFICA TION IN THE ANTERIOR CHAMBER CHARLES
D.
THE first paper on phacoemulsification appeared in the American Journal of Ophthalmology in 1967. This article described the animal research and technique for phacoemulsification and envisioned bringing the lens nucleus into the anterior chamber for greater access. Subsequent work was done emulsifying the lens in situ. After much experience with both methods, I felt that emulsification in the anterior chamber was and is the method of choice. The lens can be emulsified, liquefied, or fragmented either in its capsule from an anterior route (through the limbus) or through a posterior route (pars plana), which in my opinion adds numerous complications, such as mixing of lens material with vitreous to the procedure. ADVANTAGES OF EMULSIFYING IN THE ANTERIOR CHAMBER
KELMAN,
MD
in congenital cataracts, and can be simply aspirated, this is not a serious problem. The tip gently moves behind the iris and the lens being soft in nature follows itself into the tip. In adult and senile cataracts, however, this is not the case. The emulsifier tip must actually bore holes and penetrate the lens for any action to take place. With the pupil constricted, it is far too easy to puncture the posterior capsule and to continue the emulsification not knowing that the posterior capsule has been punctured. The surgeon soon finds that the lens is gone, but it has gone into the vitreous, not into the emulsifier. Trauma to the iris and, therefore, postoperative iritis and possibly cystoid macular edema are greatly minimized by emulsifying in the anterior chamber-again, because of the improved visualization of the placement of the tip of the emulsifier.
With the nucleus in the anterior chamber it is possible for the surgeon to emulsify the lens with no The possible disadvantage to emulconcern about the pupil constrict- sification in the anterior chamber ing as it often does during the emul- lies with the corneal endothelium. sification. Conversely, emulsifica- It is imperative that the surgeon tion behind the iris can be danger- does not rub the emulsifier or the ous. If the pupil constricts during lens against the endothelium. By the emulsification, visualization of refraining from sudden and rapid the lens and the tip is greatly re- motions of the emulsifier within the duced. If the lens is soft, as it is eye, the surgeon need not compromise the corneal endothelium. With the prolapse of the lens in the anterior chamber, it is also important Submitted for publication Oct 26, 1978. that the surgeon does not touch the Reprint requests to 150 E 58th St, New York, NY instrument or the lens against the 10022. 1980
VOLUME 86 NOVEMBER 1979
:VHACOEMULSIFICATION
endothelium. This can be accomplished by keeping the chamber deep with irrigation during the prolapse. TECHNIQUE OF PHACO-NUCLEAR PROLAPSE
Prolapsing the lens into the anterior chamber is simple provided that (1) the capsule has been widely opened and (2) the pupil is widely dilated. The capsule can be widely opened by several techniques. The one I favor is the "Christmas tree" technique, wherein a large wedge of capsule is removed with a cystotome and then peripheral openings are added. Other techniques such as peripheral multiple perforations followed by an anterior capsulectomy have been described and are also effective. If the surgeon opens the capsule widely without disturbing the zonules, prolapse of the nucleus will be facilitated. With a widely dilated pupil, it is easy for the surgeon to bring the lens into the anterior chamber before the pupil constricts, as it often does. If the pupil constricts, it is advisable to perform either a planned extracapsular extraction through a larger incision or a peripheral iridectomy and a sphincterotomy. This will allow the surgeon to bring the lens into the anterior chamber through a small pupil. If the patient is young, suturing of the sphincter with one nylon suture will be required at the end of the procedure. The lens is rocked into the chamber with the vertical seesaw technique or, with a softer lens, the lateral technique. In each case it is
1981
necessary to bring the edge of the lens to the midline. If a vertical seesaw technique is being performed, the lower edge of the lens must be brought to the 3 o'clock - 9 o'clock position. This will assure the surgeon that the lens is actually out of the capsule below, and then, when the nucleus is released, it will snap into position in front of the the iris. The most common fault in prolapsing the nucleus is the timidity of this first maneuver. TECHNIQUE OF ANTERIOR CHAMBER EMULSIFICATION
With the lens in the anterior chamber, the emulsification of the lens is quite simple. The surgeon must learn not to press the lens against the endothelium but merely to touch the lens with the emulsifier tip, allowing the lens to come into the tip. Care must also be taken not to press the lens against the posterior capsule and, of course, not to touch the posterior capsule or the cornea with the vibrating tip. There are two basic approaches to emulsification of the lens. 1. Carousel Technique-The lens is attacked from the periphery first leaving the nucleus until the end. The edge of the lens is engaged and the lens slowly rotates into the emulsifier. With this maneuver, care must be taken not to let the lens rapidly spin, as this spinning could remove endothelial cells. 2. Croissant Technique-The nucleus is attacked first, sculptured away and hollowed out, and then the peripheral cortical material is easily removed. All through the emulsification the surgeon should be aware of heat
1982
CHARLES D. KELMAN
OPHTH AAO
build-up. This can be readily seen ASPIRATION OF REMAINING CORTICAL MATERIAL first by an innocuous clouding in the anterior chamber. This cloudiUsing the irrigation/ aspiration ness represents emulsified lens particles that have been freed but not handpiece, the surgeon can easily aspirated. Since they were not as- remove the rest of the cortical mapirated, it means that a piece of the terial. Care must be taken not to lens is plugging the tip. The emul- turn the lumen of the tip down to sifier should be removed· and the the posterior capsule since this blockage remedied. Toward the end might engage it. If this does occur, of the emulsification, one must lower releasing the foot switch will release the power of the instrument to pre- the posterior capsule. The most comvent chattering of small lens parti- mon mistake during the aspiration cles against the endothelium and of the cortical material is attemptalso to a void engaging the poste- ing to grasp the peripheral fragrior capsule with the emulsifier. ments of cortex rather than placing Vitreous loss must be handled m the irrigation/aspiration handpiece under the iris in the very fornix the following manner: of the capsule to get the root of the 1. If nucleus is present in the material. anterior chamber at the time of vitreous loss, the eye must be opened up to 180° and the nucleus spooned POSTERIOR CAPSULE out of the eye. At this time, a shallow anterior vitrectomy is performed, When an instrument is placed on removing any cortical material as the posterior capsule, a halo appears well. If only a small piece of nucleus around the instrument. This permits is left when the vitreous face is rup- the surgeon to know when he is tured, careful examination of the touching the posterior capsule so remaining pieces may be attempted that he can clean off any remainwithout opening the eye. ing cells. These cells should be removed if possible, even if the poste2. Mter the nucleus has been re- rior capsule is going to be opened, moved and before all of the cortex since it will reduce fibrosis of the has been removed: Once the nucleus peripheral fragments of posterior has been removed it is no longer capsule. Mter the incision is closed, necessary to open the eye ·if there a Ziegler knife is passed adjacent to is vitreous loss. A simple vitrec- the suture and the capsule is gently tomy including any remaining cor- depressed with the knife; as the tical material will suffice to clear knife is swept to the side, the postethe eye and to give a good visual rior capsule opens, leaving the vitresult. reous face intact.
D.
THE first paper on phacoemulsification appeared in the American Journal of Ophthalmology in 1967. This article described the animal research and technique for phacoemulsification and envisioned bringing the lens nucleus into the anterior chamber for greater access. Subsequent work was done emulsifying the lens in situ. After much experience with both methods, I felt that emulsification in the anterior chamber was and is the method of choice. The lens can be emulsified, liquefied, or fragmented either in its capsule from an anterior route (through the limbus) or through a posterior route (pars plana), which in my opinion adds numerous complications, such as mixing of lens material with vitreous to the procedure. ADVANTAGES OF EMULSIFYING IN THE ANTERIOR CHAMBER
KELMAN,
MD
in congenital cataracts, and can be simply aspirated, this is not a serious problem. The tip gently moves behind the iris and the lens being soft in nature follows itself into the tip. In adult and senile cataracts, however, this is not the case. The emulsifier tip must actually bore holes and penetrate the lens for any action to take place. With the pupil constricted, it is far too easy to puncture the posterior capsule and to continue the emulsification not knowing that the posterior capsule has been punctured. The surgeon soon finds that the lens is gone, but it has gone into the vitreous, not into the emulsifier. Trauma to the iris and, therefore, postoperative iritis and possibly cystoid macular edema are greatly minimized by emulsifying in the anterior chamber-again, because of the improved visualization of the placement of the tip of the emulsifier.
With the nucleus in the anterior chamber it is possible for the surgeon to emulsify the lens with no The possible disadvantage to emulconcern about the pupil constrict- sification in the anterior chamber ing as it often does during the emul- lies with the corneal endothelium. sification. Conversely, emulsifica- It is imperative that the surgeon tion behind the iris can be danger- does not rub the emulsifier or the ous. If the pupil constricts during lens against the endothelium. By the emulsification, visualization of refraining from sudden and rapid the lens and the tip is greatly re- motions of the emulsifier within the duced. If the lens is soft, as it is eye, the surgeon need not compromise the corneal endothelium. With the prolapse of the lens in the anterior chamber, it is also important Submitted for publication Oct 26, 1978. that the surgeon does not touch the Reprint requests to 150 E 58th St, New York, NY instrument or the lens against the 10022. 1980
VOLUME 86 NOVEMBER 1979
:VHACOEMULSIFICATION
endothelium. This can be accomplished by keeping the chamber deep with irrigation during the prolapse. TECHNIQUE OF PHACO-NUCLEAR PROLAPSE
Prolapsing the lens into the anterior chamber is simple provided that (1) the capsule has been widely opened and (2) the pupil is widely dilated. The capsule can be widely opened by several techniques. The one I favor is the "Christmas tree" technique, wherein a large wedge of capsule is removed with a cystotome and then peripheral openings are added. Other techniques such as peripheral multiple perforations followed by an anterior capsulectomy have been described and are also effective. If the surgeon opens the capsule widely without disturbing the zonules, prolapse of the nucleus will be facilitated. With a widely dilated pupil, it is easy for the surgeon to bring the lens into the anterior chamber before the pupil constricts, as it often does. If the pupil constricts, it is advisable to perform either a planned extracapsular extraction through a larger incision or a peripheral iridectomy and a sphincterotomy. This will allow the surgeon to bring the lens into the anterior chamber through a small pupil. If the patient is young, suturing of the sphincter with one nylon suture will be required at the end of the procedure. The lens is rocked into the chamber with the vertical seesaw technique or, with a softer lens, the lateral technique. In each case it is
1981
necessary to bring the edge of the lens to the midline. If a vertical seesaw technique is being performed, the lower edge of the lens must be brought to the 3 o'clock - 9 o'clock position. This will assure the surgeon that the lens is actually out of the capsule below, and then, when the nucleus is released, it will snap into position in front of the the iris. The most common fault in prolapsing the nucleus is the timidity of this first maneuver. TECHNIQUE OF ANTERIOR CHAMBER EMULSIFICATION
With the lens in the anterior chamber, the emulsification of the lens is quite simple. The surgeon must learn not to press the lens against the endothelium but merely to touch the lens with the emulsifier tip, allowing the lens to come into the tip. Care must also be taken not to press the lens against the posterior capsule and, of course, not to touch the posterior capsule or the cornea with the vibrating tip. There are two basic approaches to emulsification of the lens. 1. Carousel Technique-The lens is attacked from the periphery first leaving the nucleus until the end. The edge of the lens is engaged and the lens slowly rotates into the emulsifier. With this maneuver, care must be taken not to let the lens rapidly spin, as this spinning could remove endothelial cells. 2. Croissant Technique-The nucleus is attacked first, sculptured away and hollowed out, and then the peripheral cortical material is easily removed. All through the emulsification the surgeon should be aware of heat
1982
CHARLES D. KELMAN
OPHTH AAO
build-up. This can be readily seen ASPIRATION OF REMAINING CORTICAL MATERIAL first by an innocuous clouding in the anterior chamber. This cloudiUsing the irrigation/ aspiration ness represents emulsified lens particles that have been freed but not handpiece, the surgeon can easily aspirated. Since they were not as- remove the rest of the cortical mapirated, it means that a piece of the terial. Care must be taken not to lens is plugging the tip. The emul- turn the lumen of the tip down to sifier should be removed· and the the posterior capsule since this blockage remedied. Toward the end might engage it. If this does occur, of the emulsification, one must lower releasing the foot switch will release the power of the instrument to pre- the posterior capsule. The most comvent chattering of small lens parti- mon mistake during the aspiration cles against the endothelium and of the cortical material is attemptalso to a void engaging the poste- ing to grasp the peripheral fragrior capsule with the emulsifier. ments of cortex rather than placing Vitreous loss must be handled m the irrigation/aspiration handpiece under the iris in the very fornix the following manner: of the capsule to get the root of the 1. If nucleus is present in the material. anterior chamber at the time of vitreous loss, the eye must be opened up to 180° and the nucleus spooned POSTERIOR CAPSULE out of the eye. At this time, a shallow anterior vitrectomy is performed, When an instrument is placed on removing any cortical material as the posterior capsule, a halo appears well. If only a small piece of nucleus around the instrument. This permits is left when the vitreous face is rup- the surgeon to know when he is tured, careful examination of the touching the posterior capsule so remaining pieces may be attempted that he can clean off any remainwithout opening the eye. ing cells. These cells should be removed if possible, even if the poste2. Mter the nucleus has been re- rior capsule is going to be opened, moved and before all of the cortex since it will reduce fibrosis of the has been removed: Once the nucleus peripheral fragments of posterior has been removed it is no longer capsule. Mter the incision is closed, necessary to open the eye ·if there a Ziegler knife is passed adjacent to is vitreous loss. A simple vitrec- the suture and the capsule is gently tomy including any remaining cor- depressed with the knife; as the tical material will suffice to clear knife is swept to the side, the postethe eye and to give a good visual rior capsule opens, leaving the vitresult. reous face intact.
