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SURGICAL TECHNIQUES FOR CATARACT EXTRACTION
1. INTRACAPSULAR CATARACT EXTRACTION (ICCE)
Status: OBSOLETE - sparingly performed worldwide; historically used for ~100 years.
Surgical Steps (12 steps):
| Step | Detail |
|---|---|
| 1. Superior rectus (bridle) suture | Fixes eye in downward gaze |
| 2. Conjunctival flap (fornix-based) | Exposes limbus; haemostasis by wet field or heat cautery |
| 3. Partial thickness groove/gutter | 2/3 depth of anterior limbal area, 9:30 to 2:30 O'clock (150°), razor blade knife |
| 4. Corneoscleral section | AC opened with razor blade / 3.2 mm keratome; completed with sclerocorneal scissors |
| 5. Iridectomy | Peripheral iridectomy with iris forceps + de Wecker's scissors - prevents pupil block glaucoma |
| 6. Lens delivery (methods below) | See below |
| 7. Formation of anterior chamber | Iris reposited; chamber formed with sterile air or BSS |
| 8. ACIOL implantation | Anterior chamber IOL (Figs 9.24G, H) |
| 9. Closure of incision | 5-7 interrupted sutures (8-0, 9-0, or 10-0 nylon) |
| 10. Conjunctival flap reposited | Secured by wet-field cautery |
| 11. Subconjunctival injection | Dexamethasone 0.25 mL + Gentamicin 0.5 mL |
| 12. Patching of eye | Pad + sticking plaster / bandage |
Methods of Lens Delivery in ICCE:
i. Smith Indian Method
- Lens delivered by tumbling technique
- Pressure on limbus at 6 O'clock + counterpressure at 12 O'clock using lens expressor and spatula
- Lower pole delivered first
ii. Cryoextraction (presently in vogue for adult cataracts)
- Cornea lifted with swab, iris in vogue for ECCE
- Cryoprobe applied on anterior surface of lens in upper quadrant
- Freezing at -40°C creates adhesion between lens and probe
- Zonules ruptured by gentle rotatory movements
- Upper pole of lens extracted first (sliding movements)
iii. Capsule Forceps Method
- Arruga's capsule holding forceps introduced into AC
- Anterior capsule caught at 6 O'clock
- Zonules ruptured; lens extracted with gentle sliding movements
iv. Irisophake Method - Obsolete, not in use
v. Wire Vectis Method
- Used for subluxated/dislocated lenses only
- Loop of wire vectis slid below subluxated lens; lifted out
2. EXTRACAPSULAR CATARACT EXTRACTION (ECCE)
Surgical Techniques for Adult Cataracts:
- Conventional ECCE
- Manual Small Incision Cataract Surgery (MSICS)
- (Phacoemulsification - mentioned earlier in text)
High-Yield Exam Points:
- ICCE = whole lens (with capsule) removed
- ECCE = nucleus + cortex removed, posterior capsule left intact
- Cryoprobe temperature in ICCE = -40°C
- Incision size in ICCE = 150° (9:30 to 2:30)
- Iridectomy in ICCE prevents = pupil block glaucoma
- Post-op injection = Dexamethasone + Gentamicin subconjunctival
- MSICS = sutureless, low cost, wider applicability, easier learning curve than phaco
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