Manual of Practical Cataract Surgery

Manual of
Practical Cataract Surgery

Manual of
Practical Cataract Surgery
R Sundararajan MS DO
Professor Emeritus in Ophthalmology
The Tamilnadu Dr MGR Medical University, Chennai
Consulting Surgeon, Madurai City Hospital
Madurai, Tamil Nadu, India
Formerly
Professor and HOD in Ophthalmology
Madurai Medical College, Madurai
Professor of Ophthalmology
Vinayaka Medical College, Salem
PG Institute of Ophthalmology
Dr Joseph’s Eye Hospital, Trichy
Tamil Nadu, India
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

• New Delhi • Ahmedabad • Bengaluru • Chennai • Hyderabad
Kochi • Kolkata • Lucknow • Mumbai • Nagpur • St Louis (USA)
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357
Registered Office
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021
+91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683
e-mail: jaypee@jaypeebrothers.com, Website: www.jaypeebrothers.com
Branches
 2/B, Akruti Society, Jodhpur Gam Road Satellite
Ahmedabad 380 015, Phones: +91-79-26926233, Rel: +91-79-32988717
Fax: +91-79-26927094, e-mail: ahmedabad@jaypeebrothers.com
 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East
Bengaluru 560 001, Phones: +91-80-22285971, +91-80-22382956, 91-80-22372664
Rel: +91-80-32714073, Fax: +91-80-22281761 e-mail: bangalore@jaypeebrothers.com
 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road
Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089
Fax: +91-44-28193231 e-mail: chennai@jaypeebrothers.com
 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road,
Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498
Rel:+91-40-32940929, Fax:+91-40-24758499 e-mail: hyderabad@jaypeebrothers.com
 No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road
Kochi 682 018, Kerala, Phones: +91-484-4036109, +91-484-2395739
+91-484-2395740 e-mail: kochi@jaypeebrothers.com
 1-A Indian Mirror Street, Wellington Square
Kolkata 700 013, Phones: +91-33-22651926, +91-33-22276404
+91-33-22276415, Rel: +91-33-32901926, Fax: +91-33-22656075
e-mail: kolkata@jaypeebrothers.com
 Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar
Lucknow 226 016 Phones: +91-522-3040553, +91-522-3040554
e-mail: lucknow@jaypeebrothers.com
 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel
Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532,
Rel: +91-22-32926896, Fax: +91-22-24160828
e-mail: mumbai@jaypeebrothers.com
 “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road
Nagpur 440 009 (MS), Phone: Rel: +91-712-3245220, Fax: +91-712-2704275
e-mail: nagpur@jaypeebrothers.com
USA Office
1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA,
Ph: 001-636-6279734
Manual of Practical Cataract Surgery
© 2009, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval
system, or transmitted in any form or by any means: electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and author
will not be held responsible for any inadvertent error(s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition: 2009

ISBN: 978-81-8448-605-6
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset & Packagings Ltd New Delhi
To
My Father
whose life-long ambition to make me
a well-educated individual...
and
My Mother
whose life-long prayers till her death
to provide me excellent education...
Have provided me the strength to bring out this work
Preface
Though many books are already available in the market,

I am introducing this book, with a view to simplify the
procedures so that beginners can easily learn doing Manual
Phaco (SICS). For high volume surgeries, this procedure is
the usual choice as it requires minimum instruments and
minimum time.
When I had an opportunity to visit some Eye Hospitals,
I saw students doing planned ECCE with IOL and have
either not done or scared to do Manual Phaco.
All beginners of cataract surgery are bound to commit
mistakes causing complications which can either be easily
rectified or the eye is lost.
An attempt has been made to avert complications by
making the beginners to understand how each and every
step produces the desired or undesired effect.
To master the technique of Manual Phaco procedure,
one has to be thoroughly oriented with the planned ECCE
(Extra Capsular Cataract Extraction) with IOL. This is why
this section is also incorporated in this book. In addition,
capsulorhexis procedure is explained with the help of easy
drawings. In case, the Rhexis is smaller or irregular, a
rectifying method of the procedure is also furnished in an
easily understandable magnified drawings. SICS is a poor
man’s Phaco emulsification procedure.
If one is thorough with this capsulorhexis and other
basic procedures, it would be easy for the individual to start
the phaco emulsification procedures and Micro Phaco
procedure, which requires costly equipments and more of
an institutional procedures.
viii Manual of Practical Cataract Surgery
Though various lectures and CME (Continuing Medical

Education) techniques and other methods had been
instituted at various centres, I have made this contribution
which will be useful to understand still more in detail on
seeing the drawings.
Similarly, a topic on Squint is also incorporated though
not inter-related. Most of the Ophthalmologists are
interested in mastering the basic techniques of cataract
surgeries only, giving least importance to Squint.
An attempt has been made in this book to make the
beginners understand Squint easily.
R Sundararajan
Acknowledgements
The main portion of this subject was gathered from the files
I maintained from my own surgeries and management of
complications after IOL surgeries.
I am immensely grateful to Dr Rajasekaran, Chairman,
Dr Joseph’s Eye Hospitals, for the great opportunity
provided to me to handle plenty of cases of orbit and IOL
cases.
I am grateful to Dr Nelson Jesudasan, Director, PG
Institute JEH, Trichy, for the valuable permission and
encouragement to bring out this small book.
My grateful thanks are due to my friendly colleagues,
Dr Rajmohan, Dr Ramalingam and Dr Shibu, who used to
come forward to help me at the time of distress.
I am thankful to my close friend Prof K Kannan, who
permitted me to use his printing instruments and also his
staff Mrs Ramiza for typing. The preliminary drawings were
done by me.
I am indebted to Shri Jitendar P Vij (Chairman and
Managing Director), Mr Tarun Duneja (Director-Publishing),
Mr KK Raman (Production Manager) and Ms Samina Khan
(PA to Director-Publishing) of M/s Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi for publishing the book. I am
also thankful to Mr Jayanandan, Senior Author Coordinator
(Chennai Branch) who encouraged me a lot to finish my
work by his frequent contacts.
Contents
1. How to Prevent Complications in

Manual Phaco? ............................................................ 1
2. How to Prevent Complications in Planned

ECCE and PCIOL? .................................................... 45
3. Posterior Capsular Rupture—Rent ........................ 65
4. Capsulorhexis in Detail ........................................... 79
5. Understanding the Basics of Strabismus ............. 91
Index ........................................................................... 121

How to Prevent Complications in Manual Phaco?
CHAPTER 1
1
How to Prevent Complications
in Manual Phaco?
COMPLICATIONS IN MANUAL PHACO (SICS)

The following are the usual complications seen during
manual phaco (SICS) procedures:
1. Exccentric position of the globe due to incorrect eye
fixation (Bridle sutures) (Superior Rectus fixation).
2. Scleral bleeding due to fixation with colibri forceps.
3. Endothelial and epithelial damage or perforation during
tunnel making.
4. Iris prolapse during side port incision.
5. Posterior capsular rupture during BSF injection.
6. Vitreous disturbances.
7. Nucleus sinking or drop.
8. Iridodialysis.
9. IOL drop into vitreous.
“Prevention is better than cure” is the usual proverb
which everybody knows. Hence, the operative procedures
are adopted keeping in mind the proverb.
MANUAL PHACO—SICS (SMALL INCISION SURGERY)

—HOW TO PREVENT COMPLICATIONS?
Though manual phaco is not a difficult surgery in principle,
one has to be very careful enough to face the complications
which are difficult to tackle and hence, there is a need to
form certain basic principles to prevent the same.
2 Manual of Practical Cataract Surgery
Pre-Requisites
• A good microscope with an excellent illuminations.
• A well trained assistant.
• A sharp unmovable crescent knife.
• A good straight fixation forceps or straight colibri.
• A free visco elastic substance in a freely flowing syringe-
(preferably glass syringe).
• Sharp blade or No. 1 - Baud parker knife.
• A good wet field cautery.
• A well dilated pupil with Tropicamide and Phenyle-
phrine combined drug.
• Keep the preferred IOL ready with correct power
calculation.
• A spare Anterior chamber IOL also with correct power.
ANESTHESIA AND ANALGESIA

Peribulbar block with an excellent massage of eyeball by
balancing weight or super pinky ball.
The purpose is that the eyeball should be made very
soft and immovable. This appears to be safe, ideal and
satisfactory method for a successful surgery, though there
are other methods.
Procedure
• When the eye is perfectly blocked, painting of the eye by
povidone and instill the same drops into the conjuctival
sac.
• Wash with BSF after a few minutes.
• Speculum is placed.
How to Prevent Complications in Manual Phaco? 3
SUPERIOR RECTUS FIXATION; BRIDLE SUTURE

(FIG. 1.1)
This is one of the important steps in surgery.
• Correct placement of bridle suture is mandatory. When
this is correctly done, the eye is depressed and that an
ample working space is available for conjunctival
cautery, incision and mainly to create a tunnel by the
angled crescent knife comfortable.
• If right half of SR is caught, eye will deviate to right side
and similarly into the left side.
• If superior oblique muscle is also caught, eye will plunge
eccentrically making the produre difficult.
• If conjunctiva is caught, there may be a tear of conjuctiva
and the eye will be in the primary position. The working
space for tunneling with crescent knife will be reduced
leading on to the following complications.
• Faulty incision —'Unnecessary bleeding while making
incision and tunneling.
• Insufficient space for tunnel making, followed by all
difficulties like:
• A. Premature entry:
• B. Iris prolapse or ciliary body prolapse, Iridodialysis,
damage to upper zonules of lens.
• C. Vitreous disturbance.
Fig. 1.1: Bridle suture well including spare

conjunctiva on either side
CONJUCTIVAL INCISION
Figs 1.2A to C: Conjuctional Incision
The fornix based conjuctival flap with radial cut at

temporal side on right side or nasal side in left eye is made
as shown in the figure 1.2.
It is better to do always on Right side even for left eye-
for a comfortable approach. From radial cut, extend with
conjunctival scissors upto 1 or 2 O'clock.
A minimal cautery on the sclera is applied, where you
are going to make incision (Fig. 1.3). It is better to avoid
using cautery at the limbus to preserve the Stem cells.
It is also essential to preserve the Tensons capsule while
cauterising, as the same may be useful to catch and fix the
eye while performing tunnelling.
The cautery with wet field cautery is always better.
Fig. 1.3
SCLERAL INCISION : (UNDER LOWER MAGNIFICATION)

(LIMBAL INCISION) 0.4 X OR 0.6 X.
There are three types of incisions.
1. Curvilinear incision (Parallel to limbus).
Figs 1.4A and B: Curvilinear incision
2. Horizontal or Linear incision
Figs 1.5A and B: Horizontal or linear incision
3. Frown incision
Fig. 1.6: Frown incision

For the beginners the First Incision is better whereas
frown incision is better for experienced surgeons.
TUNNEL MAKING
• The basic principle is step incision which acts as a valve.
Fig. 1.7
• Make a slight vertical incision first, with ordinary blade.
Fig. 1.8
• Then, incision which is parallel to the layers of stroma
with side to side movement of crescent knife to separate
the stromal bundles is done.
• Some do more oblique incision by holding the blade as
we catch a pen during writing so as to reach the stromal
portion of the sclera, leading on to the stromal tissue of
cornea upto 1-2 mm inside the cornea then by elevating
the first incision by crescent knife and then introduce
crescent knife to separate to layers.
Figs 1.9A and B

In hypermetropia, the sclera is thick. In myopia, the
sclera is thin. Though, it is difficult to know on the table, it
can be approximately understood by the following
methods.
1. The effective IOL power is below 20 for PC after careful

IOL calculation. It may be a myopic eye.
2. When the AP diameter is high in 'A' scan picture.
3. In old and healed case of scleritis especially intercalary
staphyloma the sclera may be thin.
4. Remember the eyeball is a round globe over which we
have another dome of cornea. So the movement of the
crescent knife blade should be parallel to the curvature
of the sclera, limbus and cornea into the stroma tissue.
Figs 1.10A and B

• After making a vertical incision catch hold of the outer
lip of sclera towards limbus, insert the crescent knife into
the stromal tissues, separate the stromal bundles parallel
to the surface of the dome of cornea by side to side
movement of crescent knife upto 1-2 mm into cornea.
• While doing this, be careful enough not to deviate the
curvature of dome, otherwise there will be button holeing
either through the endothelium or epithelium.
• Further one can always expect that there will always be
an up and down movement of the head of the patient due
to poor co-operation which creates the same problem.
Sometimes, there will be descemets detachment.
• While making crescent knife tunnelling, there will be
movement of the head and eye normally. So it is
necessary to fix the eye.
• Fixing the eye with the colibri on the sclera will produce
unnecessary bleeding.
Fig. 1.11
• So it is better to catch either the tenons capsule near the
superior rectus with a collibri forceps or press the globe
with the dry cotton bud which will absorb the blood at
2 O'clock.
• When the bud becomes wet, the grip slips away. Always
use a fresh dry buds and proceed side to side movement
of tunnelling.
• Start the tunnelling incision from left side first with side
to side movement of sharp crescent knife upto right side
and finish off this procedure at left side again. This is for
operational convenience.
Figs 1.12A to C
• Do this procedure as quickly as possible keeping in mind
about dome curvature of the cornea.
Fig. 1.13
• Another operational convenience is to make the major
portion of the Tunnelling incision in the right side of the
eye.
Fig. 1.14
• Temporal side incision is also practiced by sitting on the
temporal side of patient.
Fig. 1.15
SIDE PORT INCISION

This incision can be made at any place.
• If incision is made at limbus, there is an immediate gush
of aqueous out, making the anterior chamber shallow
subsequently producing iris prolapse.
• In case without our knowledge the incision is deep, there
is a chance of iridodialysis, tear of zonules, leading on to
disturbance to vitreous face.
• Prefereably in case, the side port incision is made at 6

O'clock position of limbus, it makes the further procedure
difficult by iris prolapse. Whether it is at limbus on inside
cornea.
Fig. 1.16A and B

• So, it is better to make S.P.I (Side port incision) at 8 or 9
O'clock position 1 mm inside the limbus i.e., in the cornea.
• This S.P.I also should be a step incision to act as a valve
and self-sealing.
Figs 1.17A and B

• When we are using a big angled keratome, the breadth
of the incision is more and so there is a chance of leak of
aqueous once the surgery is over.
• So, it is better to make an incision smaller so as to admit
the tip of 26 G needle for injection of air or Trypan blue
dye.
• In case a pterygium is present, it is preferable to avoid
and make S.P.I below the margin of pterygium.
Fig. 1.18
• When you make a S.P.I, it is better to catch the opposite,
side limbus or sclera and fix it with toothed forceps or
colibri and then introduce S.P.I blade or angled keratome.
Fig. 1.19: Fix at opposite side.

The purpose of S.P.I is to aspirate the 12 O'clock
position cortex, through this hole.
When once the S.P.I is done, anterior chamber becomes
shallow. Fill the anterior chamber immediately with air or
Viscomet with blunt 26 G needle.
While introducing the needle for air injection, there is
always a chance of damage to anterior capsule. So the
procedure should be quick and damage free.
Figs 1.20A to C
Once the air bubble is injected into anterior chamber

and A/c is formed, the trypan blue dye may be injected
under the air bubble and smear the anterior capsule with
the dye. BSF wash is subsequently given to wash the dye
and then fill the chamber again with the Viscomet to push
the air out.
Fig. 1.21
If you are confident of washing 12 O'clock cortex
without S.P.I, you can skip this procedure and similarly the
dye also. Once the surgery is over, S.P.I can be closed by
injecting intralamellar BSF, if necessary.
Now the surgeon can open the sclerocorneal incision
and open incision at 10 - 12 O'clock position to make
anterior capsulotomy. Inject viscomet immediately to fill
and to prevent shallowing of anterior chamber.
CAPSULORHEXIS; (UNDER HIGH MAGNIFICATION) 1.0X

OR 1.5X
Bend the 26 G needle a little bigger than suggested in
planned ECCE where it is ½ mm
45° - 60°
Fig. 1.22
Here the purpose of bending the needle is not only to

cut the anterior capsule but also to push the capsule
towards the center while making a 5 mm size circular
incision with the tip of the bent needle. The dyed anterior
capsule appears blue.
Fig. 1.23: This portion of anterior capsule

is elevated and separated.
Inject viscomet into anterior chamber. Now, introduce
the bent needle through the sclerocorneal incision,
horizontally to avoid damage to endothelium of cornea or
anterior capsule of lens and then rotate anti, clockwise.
Start from the centre i.e., tear the capsule at the centre
in a curved fashion. With the tip of the needle, push the
capsular free edge, close to the junction and tear. Make a
gentle pushing with the direction towards the centre, slowly
millimeter by mellimeter till you achieve a circular rhexis
with clear border. This can also be achieved using
Mcpherson forceps or Utratas forceps by simple tearing
circularly the free elevated end of capsule.
Make a oblique C-shaped incision at the centre of lens
capsule.
The elastic capsule recoils as shown in the picture. The
curvature 'C' is to create circular linear tear and to create a
free border of capsule to fold. Fold the free edge of the
capsule.
CAPSULORHEXIS
Figs 1.24A to H: Capsulorhexis
CAPSULORHEXIS WITH 26 G NEEDLE (BENT)

MAGNIFIED.
Figs 1.25A to H: Capsulorhexis with 26G needle

Then, slightly elevate the capsule and push the folded

border of the free end of the capsule in such a way to create
a circular tear as shown in the figure.
The difficulty arises when the bent needle pushes the
anterior lens capsule to tear at left side - 3 O'clock position.
The problem can be solved by meticulous, patient handling.
The ideal way to learn is by practicing the same with a
red tomato or sapota fruit (chippu).
You are at liberty to make a can-opener method and
proceed, instead of rhexis. The advantage of this rhexis is
to avoid the unnecessary tags of capsule.
Big or wide rhexis is always better for manual phaco
procedure.
In small rhexis, when the BSF is injected under the
capsule for hydrodissection the BSF stays in the posterior
pole to form a pool and finds it difficult to create a wayout
and so it creates a posterior capsular rent followed by
vitreous disturbances.
Fig. 1.26
In case you make a bigger rhexis, fluid easily finds its
way out and does not pool in the posterior capsule.
Fig. 1.27
HYDRODISSECTION
Inject 1 cc of BSF under the cut edge of anterior capsule at
the periphery at 6 O'clock to 9 O'clock. This produces the
separation of posterior capsule from the cortical fibers and
raises the nucleus slightly above and floats.
Figs 1.28A and B
EXTENTION OF INCISION
After filling the Anterior Chamber A/c with Viscomet the
small wound in the corneo-scleral incision at 11-12 O'clock
position may be extended with the help of wound extension
blade or angled keratome on either side of the wound so as
to allow the easy delivery of nucleus. For this, the wound
extendor is comfortable.
Fig. 1.29
As the incision is small the wound may be extended
inside only on either side, the inner C.S opening should be
bigger than the outer side C.S opening.
Figs 1.30A and B
MANUAL ROTATION OF NUCLEUS
Fig. 1.31
In each and every step of the procedure, you should
not fail to notice the anterior chamber becoming shalow.
When it becomes shallow, it produces endothelial
damage, so you have to inject then and there sufficient
Viscomet to prevent endothelial damage to cornea.
Now, inject BSF under anterior capsule after a
successful Rhexis at 5-6-7-8 O'clock position to raise the
nucleus above pupil.
NUCLEUS DELIVERY
Fig. 1.32
Once the hydrodissection is done, inject viscomet into
anterior chamber with the help of nucleus dialor (IOL
Dialor) engage the tip of dialor a 7 to 8 O'clock position of
periphery of nucleus near the dilated margin or pupil.
Fig. 1.33
Rotate the nucleus in a clockwise pattern while
gradually raising and elevating the nucleus, so that the
equator of the nucleus is tilted up and appears well into
the anterior chamber.
After having seen the equator or nucleus in anteiror
chamber the nucleus is slightly tilted.
Fig. 1.34
Now engage the under surface of the nucleus near the
equator and rotate in an anti, clockwise manner, till the
entire nucleus comes into anterior chamber.
Figs 1.35A to C
No, inject viscomet both above in anterior chamber and
below the nucleus.
Fig. 1.36
During the entire procedure, inject viscomet,
sufficiently to keep anterior chamber well formed.
During the first clockwise rotation procedure, if the
nucleus does not appear into anterior chamber easily, or if
you see that the nucleus recoils back into its original
position, it signifies that there is an
1. Adhesion or
2. Small pupil (undilated).
3. Small rhexis.
Adhesions
Fig. 1.37
In case, you are not able to locate the cause of recoil,
i.e., the site of adhesion, it is better to avoid unnecessary
venture, do the well practiced procedure, planned ECCE
and nucleus delivery by squeezing the equator of the
nucleus out.
– If insufficiently dilated pupil = there is posterior synechia.
– If you notice a dimple at the centre of iris, there is
adhesion at the mid position of iris.
– If recoils or a pull is noticed at the pheriphery, then there
is adhesion at the periphery.
– If you are able to locate the posterior synechia release
with iris repositor.
– Otherwise, you are likely to rupture the posterior capsule
and allow the nucleus to sink.
Caution
It is always better not to allow the nucleus to sink into
vitreous.
SMALL RHEXIS
This may also be due to small rhexis. The diameter of normal
rhexis is 5 mm. If you make a slightly wider rhexis, (about 6
mm) the nucleus rotation and nuclear delivery also is easy,
(The reason behind is already mentioned)
Once small rhexis is already done, the relaxing incision
of anterior lens capsule will be helpful.
Make an incision at ALC at 5 and 8 O'clock position or
at 12 O'clock position alone.
Figs 1.38A and B

ALC - Anterior lens capsule.
SMALL PUPIL (UNDIALATED)

In Px syndrome or iris adhesions due to uveitis, pupil may
not dilate.
Under such conditions, try to release the synaechia, by
sweeping with iris repositor all around through the pupil.
Or do a key hole iridectomy (i.e., make a P.I, at 12 O'clock
posistion. Then by introducing one edge of scissors though
the P.I upto pupil and cut it.
Fig. 1.39
Now dial up the nucleus into anterior chamber after
making the nucleus to enter into anterior chamber fully, it
is your duty now to deliver the nucleus out.
NUCLEUS DELIVERY
Inject plenty of viscomet under the nucleus and above the
nucleus. Now by introducing the viscomet needle upto
6 O'clock position, inject viscomet, more and allow the
nucleus to be drifted out automatically by slightly depressing
the posterior lip of sclera.
Figs 1.40A and B

If the corneo, scleral incision is slightly bigger the
nucleus automatically finds its way out by the viscomet
pressure.
If the C.S incision appears small inject some viscomet
then extend the inner incision on either side slightly and
try the same procedure or do any one of the following

method.
Figs 1.41A and B

a. Sandwich method.
b. Irrigating Vectis method.
c. Cut the nucleus into two and deliver each bit separately.
Sandwich Method
Inject viscomet under the nucleus and above the nucleus
into anterior chamber. Pass the vectis below the nucleus and
nucleus rotator above the iris upto 6 O'clock position till the
equator is engaged in vectis.
The nucleus rotator should be placed over the anterior
nuclear border near 6 O'clock position of equator of lens.
The hook portion should be placed horizontally so that it
does not touch the endothelium of the cornea.
Fig. 1.42
And sandwiching the nucleus on either side. Now,

gradually drag the nucleus out, so that it does not touch
the endothelium at any point in a curved fashion, gradually
pulling out and up towards the surgeon.
Fig. 1.43
If the C.S tunnel is slightly bigger try injecting viscomet
at 6 O'clock postion of anterior chamber, allow the entire
nucleus to be drifted out automatically, depressing the
posterior lip of tunnel with the same viscomet cannula.
During the delivery of nucleus, it is likely, without the
surgeons knowledge, that the surgeon may introduce vectis
under the iris through the pupillary border at 6 O'clock
position and pull the iris also out, along with the nucleus -
i.e., either partial or total iridodialysis.
So to avoid, carefully see that the vectis is passed under
the nucleus through the transparent semi-cataractous
nucleus. This is visible in microscope.
Or even at 12 O'clock position by creating a partial
dialysis at 12 O'clock position.
Figs 1.44A and B
IRRIGATING VECTIS METHOD

There is another method of delivery of the nucleus. the
device is called Irrigating vectis. This consists of three small
holes at the vectis portion of the syringe needle. The needle
tube extends all around the vectis (Figs 1.45A and B).
Figs 1.45A and B

The needle is attached to BSF fluid tube directly or the
tube needle directly mounted on the syringe loaded with
BSF fluid (Fig. 1.4.5). This depends on the convenience of
the surgeon.
Figs 1.46A and B

The Method
After the hydrodissection, and once the nucleus is rotated
and brought out into anterior chamber. Fill the anterior
chamber with viscomet (Viscoelastic fluid ) both above and
below the nucleus. The posterior capsule is situated under
the iris diaphragm.
Fig. 1.47
Now, introduce the irrigating vectis through the limbal
opening, without the flow of fluid, under the nucleus into
the anterior chamber, so that the concave surface of the
vectis engages the under surface of nucleus upto the
equatorial position.
Fig. 1.48
Now, open the valve in the BSF dripset, so that the BSF
flows well into the anterior chamber. The fluid pressure
pushes the nucleus out and simultaneously drag the
nucleus out.
1. Fluid pressure pushes nucleus out.
2. Hook the nucleus out.
3. Depress the posterior scleral lip so that nucleus comes
out easily.
Fig. 1.49
The precautions to be taken are:
The freely flowing BSF fluid should not be directed
towards the posterior capsule, as this procedure may
rupture the posterior capsule and the anterior vitreous face
causing vitreous disturbance.
Fig. 1.50
While introducing the irrigating vectis, with the BSS
fluid flow is on, may hit the endothelium of the cornea and
damage the endothelial cells.
Fig. 1.51
Fig. 1.52
While introducing the vectis there is a chance of
Descemets detachment when the anterior chamber is
shallow. So fill the anterior chamber with visc first, making
anterior chamber well formed and then start the procedure.
Fig. 1.53
The following are the expected complications:
1. When the nucleus is densely cataractous, it may obstruct
the view of irrigating vectis passing under it. As a result,
there is a chance of the vectis passing under the iris
diapharagm upto the root of iris. In this manoeuvre, there
is a chance of creating irido dialysis at 6 O'clock position.
Figs 1.54A to C
2. In case direction of the irrigating vectis is more oblique

and tilted towards 6 O'clock position, there is a chance
of the irrigating fluid to flash through the posterior
capsule and anterior vitreous face and disturbing the
vitreous.
Fig. 1.55
3. While introducing the vectis, if the fluid has already
started flowing, there is a chance of damaging the
endothelium of the cornea, when fluid hits against it.
Figs 1.56A to H
1. Fluid pressure pushes nucleus out.

2. Hook the nucleus out.
3. Depress the posterior scleral lip so that nucleus comes
out easily.
EPINUCLEUS DELIVERY
After the nucleus delivery, there will always be a bulk of
epinucleus left over at the anterior chamber, which will be
seen as a hazy media.
This can be cleared by injecting viscomet again into
Anterior chamber introducing the viscomet cannula at
6 O'clock position of the periphery and see that the
remaining epinucleus is drifted out, by pushing viscomet.
Remember to depress the posterior lip of wound by the
same cannula, so that the epinucleus finds its way out
easily. Some surgeons prefer to syringe out using BSF in
the cannula.
Fig. 1.57
In my experience the injection of viscomet does a good
clearing.
When once this procedure is over, the media appears
still slightly hazy, due to the remaining cortex.
This can be well washed with BSF in the 21 G cannula
or 22 G needle and aspirate.
For the Beginners

It is better to use the 22 G cannula needle to aspirate this
thin cortex. This takes a little time to aspirate.
For a quick washing of cortex use of 21 G needle
Cannula with BSF is better. This is possible only with some
experienced surgeons. The method of syringing the cortex
has already been discussed.
INSERTION OF IOL
Fill the anterior chamber once again with viscomet.
Introduce the IOL of your choice into the anterior
chamber and then in between the anterior and posterior
capsule at 6 O'clock position in such a way that the dialor,
when engaged, can rotate the IOL clockwise, i.e. the lower
haptic curvature should be facing left side.
Fig. 1.58
Before doing this procedure perform the following
procedure.
a. Catch the upper haptic with the Mcpherson or IOL lens
holder.
Figs 1.59A to D
b. Remember the possibility of creating a damage to the
surface of the optic when engaging the IOL with
Mcpherson or lens holder.
c. Wash the IOL with distilled water on both the sides and
then smear the IOL with viscomet on both sides to avoid
damage to endothelium of cornea.
After having placed the IOL in position, wash the IOL
with BSF and the anterior chamber.
Closure
As the incision is smaller, the approximation of both the
corneal lip and scleral lip is perfect as it is a step incision.
This does not require suturing.
CONJUNCTIVAL CLOSURE
Bring the conjunctiva to its original position. Catch the both
ends (vertical) as shown in the picture and using wet field
cautery, inside BSF and cauterise.
Figs 1.60A to C
While cauterising, catch the base (lower) position of
conjunctival flap and cauterise under BSF.
Fig. 1.61
INTRAOPERATIVE COMPLICATIONS AND HOW TO

TACKLE IT
Iridodialysis
1. If it occurs at 6 O'clock position inject viscomet in anterior
chamber to push the flap back. When you see that the
flap is nearing limbus, carefuly catch the free end of iris,
start suturing, take the first bite at 6 O'clock position at
the limbus as shown in the picture. 2nd bite at the root
of iris. 3rd bite at 6 O'clock position of the cornea and
suture with 8 or 10 suture.
Figs 1.62A to C
If necessary two more sutures, one on either side.
Fig. 1.63
2. When the iridodialysis is at 11-2 O'clock position take
the 1st bite at sclera take out, then 2nd bite at root of iris,
take out and then 3rd bite at the cornea and suture or
vice versa.
Figs 1.64A to D
Nucleus Sinking
This should not be allowed to happen - this is a dreaded
complication.
In case nucleus starts sinking, put a stab puncture at
pars plana with 24 G needle at 7 O'clock position or at a
suitable position, push in the needle under the nucleus,

make the nucleus float. Ask your assistant to push up the
nucleus carefully, quickly introduce the Macpherson, catch
either the haptic or optic or nucleus and pull out.
Figs 1.65A and B

After having removed the nucleus out, have a look at
the pupil to find out where the vitreous is peeping out.
Pupil will be peaking at one place as shown in picture.
Figs 1.66A and B
HALF NUCLEUS DELIVERY

Vectis should be passed under the nucleus upto the equator
and the nucleus dialor should also be at the same place
engaged similarly to bring out in full.
Sometimes, if you engage the nucleus at the centre with
both the vectis and the dialor, it is likely that only one half
of the nucleus alone comes out breaking the nucleus into
half.
Fig. 1.67
The remaining half of the nucleus will be retained in
the anterior chamber. In such circumstances, it is better to
inject viscomet at 6 O'clock position of anterior chamber
which forces the remaining nucleus to be drifted out.
In case it is not possible, engage the nucleus again with
vectis and nucleus dialor and pull out. Now introduce
Vannas scissors cut the vitreous at the pupillary border,
make the pupil round or circular or inject pilocar or
acetylcholine to make it round and reconstricted. Inject air
to reform the anterior chamber put in anterior chamber
IOL. Do peripheral iridectomy and close.
When once the nucleus is sunk. Abandon the surgery
and leave it to retinal surgeon.
Figs 1.68A and B

Catching the IOL at the optic surface will produce
scratches or rough surface on IOL.
It is always better to catch the haptics.
DESCEMETS DETACHMENT IN SICS

There is a chance of descemets and endothelial detachment
and hanging into the anterior chamber giving a false
impression. When any instrument is introduced through the
step incision. At this circumstances the surgeon has to
understand that the descemets -endothelium complex in the
scleral side is projecting, whereas the same in corneal side is
far behind, concealed and out of direct view. Anterior
chamber may be shallow.
The surgeon has to be more careful and deal without
excitement. It is better, he removes the nucleus quickly by
some uncomplicated method and insert the IOL, wash with
BSF to remove cortex. The purpose is to proceed without
complicating it anymore.
Now fill in air in the anterior chamber to push back the
descemets and endothelium complex in its original position.
Reform anterior chamber and if necessary, limbal suture
may be placed to keep the descemets complex well
reapproximated in the post operative period.
Fig. 1.69
Remove nucleus quickly, wash the cortex.
Fig. 1.70
WHEN THE PUPIL IS NOT DILATED.

As in pseudoexfoliation syndrome or in iritis.
Sweep the iris with iris-repositor through the pupil all
around. Break the synechia.
Some surgeons dilate the pupil by dialors by keeping
it in opposite direction and dilate, sometimes tear occurs.
Fig. 1.71
Some make one cut at 5 O'clock and 8 O'clock position
at pupillary border which is not sufficient.
Fig. 1.72
My opinion is to make a peripheral iridectomy at 12
O'clock position then vertical cut make a keyhole
iridectomy. This produces sufficient dialatation, pull out iris
at 12 O'clock position, suture the pigmentary epithelium
side and put it back (after introducing the IOL).
Fig. 1.73
IN DIABETES AND OLD AGE

There is always a possibility of iritis and choroiditis, posterior
synechia. Under such condition, dialing or rotating the
nucleus is not possible. In our attempt to dial, the nucleus
becomes suddenly vertical, producing posterior capsular
rent.
Find out where the rent is?

Find out whether the vitreous is above or below the nucleus,
use a cotton bud and pull, see whether the pupil distorts. In
such circumstances, cut the vitreous at the pupillary margin
and prevent sinking of nucleus by passing 24 G needle at
pars plana below the nucleus, lift the nucleus up with the
help of Mcpherson forceps-remove the nucleus.
For a beginner the success of the surgery depends on
1. Correct superior rectus fixation
2. The sufficient pupillary dilatation, and
3. A procedure to prevent sinking of the nucleus by any
means.
WHEN WILL YOU INJECT VISCOMET INTO ANTERIOR

CHAMBER?
The principle is
• To avoid injury to the endothelium of the cornea.
• To clear the hazyness of the cornea put a drop on the
cornea.
• When anterior chamber is opened inadverdantly or
without our knowledge during surgery.
• During incision when anterior chamber is opened.
• Side port incision (S.P.I) immediate gush of aqueous
inject viscomet to reform anterior chamber or if you want
to inject dye, inject air.
• After injecting trypan blue dye-inject viscomet to reform
anterior chamber.
• When C. S incision opened aquous comes out. Inject
viscomet to reform anterior chamber.
• Before making anterior capsulotomy- inject viscomet.
• After making anterior capsulotomy - inject viscomet.
• Before injecting BSF under anterior capsule to separate.
• Before using dialor for nuclear rotation.
• When rotating the under surface of the nucleus at its
equator.
• When once nucleus comes out into anterior chamber.
• Inject at 6 O'clock position of anterior chamber to drift
out nucleus when incision is bigger simultaneously
depressing the posterior lip of sclera.
• Before introducing the vectis under the nucleus and
dialor above. Inject viscomet both above and below the
nucleus.
• After the nucleus is out reform anterior chamber with
viscomet and also at 6 O'clock position to push the
epinucleus out.
• Before aspirating the remaining cortex.
• Before introducing the IOL.
SUMMARY FOR MANUAL PAHCO
Conjunctival incision
Side port Incision
Figs 1.74A to Q
Figs 1.75A to K
NUCLEUS ROTATION
Figs 1.76A to E
NUCLEUS DELIVERY
Figs 1.77A to C
Figs 1.78A to D
Figs 1.79A to C
How to Prevent Complications in Planned ECCE ... 45
CHAPTER
2
How to Prevent Complications
in Planned ECCE with PCIOL?
This portion is specially included for-this method is still

practiced in most of the centres and is also a basic for the
advanced procedures. Secondly, in case of failures in manual
phaco or micro phacos one can quickly change over or
convert it to this method to restore the vision rather than
dealing unnecessarily with complications. So it becomes
absolutely essential to master this basic method to restore
vision to the patient.
COMPLICATIONS
The following are the usual complications that can occur
during surgery:
1. Retrobulbar hemorrhage.
2. Wound gaping.
3. IRIS prolapse and infection.
4. Descemets detachment
5. Endothelial damage—leading to striate Keratitis in the
post-operative period.
Retrobulbar Haemorrhage
For local analgesia-peribulbar analgesia followed by
massage by placing a balanced weight or with or without
facial analgesia.
Retrobulbar injection of 2% xylocaine, adrenaline and

hyalase with 2.5 cm length or 2.0 cm length needles is likely
to tear either the blood vessels or pierce into meningeal
sheath or damage to optic nerve by entry of the needle. Or
double puncture of the globe, in myopic eyes or big eyes.
In case, the analgesia expires prematurely, it is
advisable to give an injection of ½ to 1 ml of 2% Xylocaine-
subconjuntivally at 6 O'clock or fornix. During the middle
of surgery. To avoid infection it is preferable to use a fresh
2 ml disposable syringe and fresh sterile bottle of 2%
Xylocaine.
HOW TO PREVENT COMPLICATIONS IN PLANNED ECCE

WITH PCIOL?
Now, it has become inevitable that all cases who are getting
operated should face "SUCCESS" otherwise we are getting
into troubles with consumers problems. As such, each step
of surgery has become important so that we can be cautious
about the possible complications.
This is helpful for beginners though it is not much useful
for surgeons who performs "small incision surgeries".
Basically, the microscope should have excellent
illumination, wide field coverage, with good optics. All
aseptic precautions should be strictly followed. Including
general like dental sepsis, otitis media, ulcers, etc.
First exclude diabetes, hypertension, dacryocystitis and
glaucoma mainly.
Dilate the pupil with Tropicamide and Phenylephrine
combined drug.
Proper preoperative/Eyelash cutting.
Betadine painting, instillation in eye followed by
washing.
Before starting the surgery when the patient is on the

table, focus the microscope -with 1.6 magnification bringing
the optics on the headside towards the surgeon to bend the
26 guage needle first i.e., 0.5 mm at the tip (small enough
to raise only the anterior capsule).
Big needle bend ruptures posterior capsule.
Viscoelastic substances loaded in advance and kept
ready without -air bubbles.
BSF or Ringer lactate solution with patent cannula
ready.
Posterior capsule is thin by 1/5 of the anterior capsule.
Tip bending should be small.
If it is Long, posterior capsule will rupture.
Figs 2.1A to I
SMALL SCLERAL SIDE CAPSULOTOMY IS BETTER.

If more central scleral side capsulotomy nucleus has to find
a longer way to sweep and come out.
In this process nucleus becomes vertical and so
damages endothelium of cornea and posterior capsule.
Excessive depression with central incision of anterior
capsule may itself press and tear posterior capsule causing
vitrous disturbance.
Perfectly sharp blade (blunt blade produces ragged
incision-followed by descemets detachment) should be
used.
Fig. 2.2
UNDER LOW MAGNIFICATION

After applying the speculum-take a wider bunch of
conjunctiva on either side of the superior rectus muscle-
passing the curved needle under the muscle (since partial
bite of superior rectus deviates the position of the eye, to an
unwanted position ) by depressing the lower fornix.
Conjunctiva is reflected from right side to left side with
radial cut at 10 O'clock close to limbus (limbal based ) and
extended to 2-3 O'clock left side.
Fig 2.3
Figs 2.4A and B

I always prefer to do step incision of the limbus starting
at the posterior limbus (towards surgeron). Vertical incision,
then horizontal, in the stroma and finaly oblique entry into
a/c (vertical entry into a/c may pull down descemets
membrance and detachment).
Figs 2.5A and B

The horizontal incision is made with the center portion
of the blade following the curvature as it produces
separation of bundles of stroma - Tip incision may tear the
bundles.
Figs 2.6A and B

Step incision acts as valve and avoids iris prolapse,
wound gaping and less number of sutures are enough.
Center position
Tip
|
↓
Figs 2.7A and B

Now, open anterior chamber obliquely with tip of blade
at 10.30 O'clock to 11.30 O'clock position -at Pre-descemets
level.
Fig. 2.8
Once the aquous starts coming, introduce the Visco-
elastic needle with syringe and inject it. Otherwise anterior
chamber becomes shallow introduction of instruments will
separate descemets membrance.
Figs 2.9A to C
If air bubbles are present, push the needle tip upto 6

O'clock position of anterior chamber and inject viscomet
(viscoelastic) till the air bubbles are drifted away through
the limbal opening at 11 O'clock position.
Fig. 2.10
UNDER HIGH MAGNIFICATION

Carefully Watch the Anterior Capsulotomy Margin
Introduce the tip of the needle so that bent tip is horizontally
introduced parallel to the surface of iris, then tilt vertically
down.
I prefer to do anterior capsulotomy in "Smiling face
technique" - as I find it useful, because-in case a rent at 12
O'clock position occurs, you can notice it easily when the
pupil becomes slightly oval or a pull - distorted, after
removal of nucleus.
Figs 2.11A to D
The anterior capsulotomy should be done towards the

scleral side of the capsule.
Instead of making anterior capsulotomy by 26 G
needle, Smiling face technique, the same can be done with
the tip of the blade on a handle to create a linear border.
Fig. 2.12
This incision can be made after fully opening the
anterior chamber, subsquently filling the chamber with
Viscoelastic substance.
The needle anterior capsulotomy produces capsular
tags which may disturb the surgeon during aspiration of
cortex at 12 O'clock position.
By doing knife blade incision, the incision borders are
clear cut and there is no capsular tags.
Figs 2.13A to C
Aspiration of capsular tags sometimes produces
extension into posterior capsule.
Figs 2.14A and B

Smaller scleral side flap is always better, for sliding

delivery of the nucleus.
Figs 2.15A and B

Even if anterior capsulotomy is smaller in one stroke,
you can extend the same during hydrodissection. Do not
repeat.
Bigger scleral side flap will take a longer way to sweep
the nucleus to come out of capsule. It will produce nucleus
becoming vertical, producing damage to endothelium of
cornea.
Figs 2.16A to C
Hard nucleus may rupture of posterior capsule and
disturbance to patellar fossa and vitreus. Posterior capsule
is 1/5 th of the thickness of anterior capsule.
Inject viscomet at 10 O'clock position to make it deeper
to avoid injury to iris. (Shallow anterior chamber produces
cut of iris and sometimes lens matter also).
Fig. 2.17
Extend the incision on either side with curved scissors.
Figs 2.18A to E
Enlarging the incision at limbus will be difficult with
scissors. So enlarge incision on either side with end of the
blade on blade holder from inside out (anterior chamber
should be deeper with viscomet-otherwise whallow
anterior chamber may produce cut and shaving of
endothelium).
Fig. 2.19
Now, hydrodissection-In multiple injections under the
anterior capsules in smaller amounts in different directions.
Fig. 2.20
(The bulk injection or 1 cc or 2 cc of BSF fluid may
rupture the very thin posterior capsule at the centre)
Fig. 2.21
Deliver the nucleus making pressure at 6 O'clock
position with either wire vectis or depressor about 1-2 mms
above the limbus in cornea and counter pressure to
unsleeve the anterior capsule at 12 O'clock position for easy
squeezing and sliding delivery of the nucleus from the
equatorial position.
Figs 2.22A and B

Making pressure at the centre of the cornea will depress
the central cornea followed by pushing the nucleus down
to tear the posterior capsule.
Figs 2.23A and B

Gentle counter-pressure at 12 O'clock position of sclera
can be done with another wire vectis or spatula.
Pass the cannula with aspiration port above.
Fig. 2.24
Pass the cannula parallel to the surface of the iris, then
slightly dip to enter under the anterior capsule and again
raise up so that fluid speed is not directed towards posterior
capsule.
Figs 2.25A and B

The flow of BSF is sufficient to float the cortex and
aspirate from periphery to the center.
Figs 2.26A and B

Speed should be adjusted so that anterior chamber

should never be made shallow, as it may suck the centre
of the cornea, as well as the posterior capsule creating
rupture vitreus disturbance. Fluid speed either moderate
or a little faster.
If bulk of epinucleus is present, depress the scleral side
opening' inject viscomet at 6 O'clock position of anterior
chamber to push out (kindly refer the topic on posterior
capsular rent).
Keep always the pupil well dialated to have clear views
of the procedure what you are doing. In pseudo exfoliation
syndrome, old uveitis with posterior synechia patients,
pupil will not dialate. Under such condition, key-hole
iridectomy should be done to have a clear view.
Fig. 2.27
One or two drops of adreneline in BSF solution in a
2 ml syringe, if injected may dilate the pupil.
Nuclear cataract (brown cataract) will be bigger and
harder. So bigger incision and liberal use of viscoelastic
material will be needed to protect the cornea.
Inject viscomet under anterior capsule and raise it. Fill
in anterior chamber.
Figs 2.28A and B

When cortex is cleared, IOL should be introduced as

per the calculations made by SRK formula under anterior
capsule.
Catch haptic IOL with Mcpherson forceps with the
(angled bent) to the right and the lower haptic to the left
so that if introduced, it should rotate clockwise as shown
in the figure.
Figs 2.29A and B

If corretly done-and rotated, anterior capsule will be
lying over the IOL and raise it with viscomet.
Fig. 2.30
Cut anterior capsule obliquely or curved at 3 and
9 O'clock position - and peel off capsule in the form of
rhexis with Mcpherson.
Figs 2.31A and B

Wash anterior chamber with BSF
Inject Air and then suture.
Take full thickness bite, (as the corneal lip contains only
Epithelium, stroma) and then another bite at the step-in
scleral side with correct approximation.
Fig. 2.32
Needle holder should catch the centre position of the
10.0 suture needle. (If the needle is caught at 1/3 rd end of
either side of needle-it may straighten)
Figs 2.33A to C
My Suggession to "Smiling Face Technique" Is This

Even if a small rent is noticed, vitreous can be raised with
cotton bud. Cut with scissors-all around the pupil, put in
air - the PC lens can be placed above the Anterior capsule -
ciliary sulcus IOL.
• Yag laser can be applied at a later date if necessary.
If nucleus becomes vertical during delivery, inject
viscomet both anterior and posterior to lens flatten with iris
spatula.
If cortex is present at 12 O'clock postion, pull out iris
at 12 O'clock position ' aspirate cortex.
Cortex should be aspirated - in opposite direction.
Fig. 2.34
At the time of irrigation and aspiration at the periphery
-carefully introduce the cannula in between anterior and
posterior capsule upto periphery with a slight tilt upwards
to make cortex float-aspirate. In case you include posterior
capsule -dehiscence occurs. Now discontinue. Inject
viscomet-flatten, posterior capsule carefully introduce PC
IOL.
Fig. 2.35
If analgesia wears off and patient is restless, inject 2%

xylocaine ' subconjunctivally at 6 O'clock to relieve pain.
Bend the cystitome with the base of needle holder,
otherwise the needle holder will get spoiled.
Fig. 2.36
In Can Opener Method
Fig. 2.37
Start anterior capsulotomy at 9 O'clock position and
proceed in anticlockwise method as shown in figure.
Fig. 2.38
For safer removal of capsule make multiple vertical and
horizontal incisions make it into multiple smaller bits.
Aspirate with infusion with cannula.
1. When the pupil is not round → Iris is caught by the haptic
somewhere. So rotate-reverse-sometimes vitreous
prolapse can also distort the pupil.
2. When there is froth in anterior chamber with air → There
is still some viscomet present.
Brown Membranous Congenital Posterior

black cataract cataract in capsular
cataract children opacity
Hard big Clear with 7 shape GA with good a/c ------

nucleus (small horizontally forming.
placed incision)
So incision Needle-scrape Good relaxation No sclerosis

should be big make it thin
Hard nucleus Do it with PC rhexis is better Good anterior

may produce viscomet and insinuate capsulotomy.
damage to HAPTIC below
PC rhexis
Endothelium Do posterior (optic capture) Extract clear

inject plenty of capsulo rhexis IOL power heparin nucleus.
viscomet over if needed treated IOL is
the nucleus. better
Deliver the -- -- Layer of

nucleus by clear cortex
sliding method. may come in.
If anterior Wash and

capsulotomy allow cortex
is not enough to peel of thin
give a cut like layer of cortex
this.
CAPSULOTOMY OR
OR posterior capsulotomy.
Figs 2.39A to C
Do caneopener Rhexis is better
method and anterior vitrectomy.
Scleral side
Capsulotomy
should be small.
In Pseudo- Immature Myopic eye

cataract exfoliation cataract cataract
Figs 40A and B
Lens if deep Posterior capsule There will be a Sclera is thin

incision or fragile and do key thin slice of cortex So when you
repeat hole iridectomy or lying over the make a vert-
Incision Pupillary margin posterior capsule cal incision
damages cut one or two run the fluid, raise -> invariably
the cortex → the ciliary body
aspirate is seen give
So dialate pupil peribul bar
Well with block after
adrenaline raising the
globe with the
tip of your
finger and
supra orbital
Raise the Fig. 41 block after
anterior capsule depressing the
with small bent globe.
needle→extend
the incision→
infusion.
Wisk awy the When IOL

hard nucleus power is low it
with horizon- is myopic put
tally forward no deep
pushing stimul- incision
taneous capsulo- Fig. 42
tomy irrigation
and aspiration
with tast fluid
flow. Anterior-
capsulotomy
Fig. 43
Central SK Peripheral SK Descemet’s

(Striate Karatitis) folds
Causes Causes Causes

1. If canula hole up→ 1. While introducing 1. Ragged incision by
fluid hits endothelium instruments without blunt blade→lifts the
viscomet. descemets membrane.
Fig. 44
2. Nucleus-hard
(brown) if delivered 2. Tip of the hapatic 2. Shallow a/c when
without scraping. And during introduction
of needle→chance of
separation decemets.
3. Vertical turning of 3. Blunt blade-ragged 3. This leads into
nucleus incision. Lamellar injection of
viscomet.
Fig. 45
4. Instruments touching —— 4. So slanting endothelial
the back of the cornea. incision with sharp blade
at 10 to 11o’clock position
is better.
5. A/c shallow → 5. Immediately aspiration
causes suction of endo- puncture—gush of
thelium after endo- acquous→inject viscomet
thelial of cornea- star to prevent shallow a/c
folds.
6. IOL-opti border 6. DELAY-makes
touching the centre of the a/c shallow→the cycle
endotheliumà IOL- repeats.
haptic. Scratching if
viscomet is not admi-
nistered and a/c is
shallow.
Broken capsulotomy bent

Needle→if used for air
injection rough edge
touches the endothelium.
CHAPTER Posterior Capsular Rupture—Rent 65
3
Posterior Capsular
Rupture—Rent
After having gone through the journals, attending

conferences, I understand that some of our Ophthalmic
practitioners are facing some problems in ECCE of IOL
surgeries. I am writing this article when most of us are
striving hard to practice small incision surgeries and phaco
and Microphaco.
This will be Useful for Beginners.

The following are the common complications Iris prolapses,
posterior capsular rent and vitreous loss, endothelial
damage, endoophthalmitis, zonular dehiscences and etc.
In this section, I am making an attempt in relation to
the causation of PC rupture and how to prevent the same.
I am confining myself only to planned ECCE with
routine IOL surgeries excluding small incision surgeries.
As we all know, PC rupture is a dreaded complication
for the surgeon as his ambition to do a better PC. IOL is
simply shattered throwing us in the lurch and to redecide
the alternate ways to complete.
The following are the circumstances, where in the PC
rent or rupture can occur during.
I Incision II Anterior III Hydro Dissection

Capsulotomy
1. Limbal incision 2. Illumination 10. Not a bolus and
with sharp blade 3. Magnification 11. Multiple small amounts
in myopic eyes. 4. Dialatation in different positions
5. Big needle tip under the anterior capsule
6. Scleral side flap if big.
7. A/c flat
8. Surgeon should have
excellent visual control.
9. Repeating the capsulotomy
(digging in the same groove)
may produce PC tear.
IV During irrigation V. Delivery of nucleus VI Implantation

12. A/c should be 18. Small scleral side flap 25. Introducing lower haptic
always full and of anterior capsulotomy with pressure on the PC
never flat. sliding delivery.
13. Moderate fluid 19. Pressure should not 26. Sharp edge of the optic
-fast be at the centre of when the A/c is shallow.
cornea.
14. Pupils should be 20. Adequate side of
fully dialated opening of anterior
(if small dialate capsulotomy.
with adrenaline 21. Adequate limbal open
or other methods). ing for easy delivery of
15. Speed- the fluid nucleus.
speed should not 22. Pupil should be fully
directly hit on the dialated.
posterior capsule.
16. Aspiration needle 23. Pressure should not
should be smooth- be on the zonules.
spicule may tear.
17. Aspiration needle 24. It should be on the
tip should not equatorial part of
pierce the PC or anterior capsule-to
plunge.
1. Incision:
Making deep limbal incision with sharp blade in a myopic
eye, can produce iridodialyses, zonular tear and disturbance
to vitreous as the sclera is thinner than normal.
Posterior Capsular Rupture—Rent 67
Fig. 3.1
2. Ilumination:
Should be good enough, to see every step in surgery, what
exactly is going on while working inside the globe. Dim
illumination ( in the microscope or focusing lamp ) will lead
to un-understanding of the procedure in the surgery.
3. Magnification:
The surgeon should immmediately change to higher
magnification (from 0.6 to 1 or 1.6) and do the anterior
capsulotomy with an excellent visual control. It is always
better to do anterior capsulotomy under higher magnification.
4. Dialation:
Pupil should be fully dialated to see what is happening in
each step of surgery. If pupil is small, try to dialate the pupil
with adrenaline - BSF Mixture. If undialating pupil as in PX
F syndrome, it is better to do keyhole iridectomy and do
anterior capsulotomy. Once IOL insertion is over, pigment
epithelium of iris may be brought out and sutured with 10.0
suture with closely cut knot left inside. Some prefer to do
sphin, cterotomy either at 12 O'clock position only or in two
places one at 11 O'clock and 1 O'clock position.
5. Small needle tip:
For this a recollection of the brief anatomy of the anterior
segment - LENS.
Figs 3.2A and B

Lens is a bispherical sphero base in prism, wherein,
apex of the cone is the equator which is rounder, when the
accommodation is paralysed the diameter is 9-10 mm
(1-2 mm shorter than the diameter of the cornea).
Thickness at the centre is 4-5 mm. At the periphery -
about 1-2 mm. Posterior capsule is 1/5 of thickness than that
of anterior capsule. Capsule at the equator is also thicker.
Figs 3.3A to D
Needle Measurement
26 G needle 12 mm long-bevelled edge measures 2 mm,
wherein hole is situated there is a tip of 0.5 mm which is
flat.
Fig. 3.4
Regarding Needle
The 26 G needle is used for anterior capsulotomy. We
surgeons are bending the needle atleast 1.5-2 mm at the tip
for capsulotomy.
We always choose to do 5-6 mm diameter of anterior
capsulotomy leaving 1.5-2 mm periphery. At the place
where we do anterior capsulotomy the thickness of lens
may be about 1.5-3 mm, so with big bend of the needle
there is every chance that we may injure the posterior
capsule and anterior vitreous face.
Figs 3.5A to E
This is more so, when we are dealing with patient with
deep A/c's. So why not we make a smallest bend i.e., at
the edge which measure ½ mm to ¼ mm at the flat sharp
edge and prevent the possible damage to posterior capsule.
For this, we need a magnification of the optics. Move the
optics, well to the temporal side of the eye, increase the
magnification from 0.6 to 1.0 or 1.6 and comfortably bend
the needle before the start of the surgery-after all, our
purpose is to deal with the anterior capsule only.
Fig. 3.6
Sometimes, when we have doubt about our perfectness
in anterior capsulotomy, we try digging in the same groove
to ensure perfectness. In out attempt to do this procedure
we invariably, are likely to damage the posterior capsule
and anterior vitreous face. This procedure can be avoided,
provided we have a best visual control of the procedure
under magnification during first time anterior capsulotomy.
In Morgagnian cataract, where the cortex is fluid in
nature the fluid (milky white) cortex excudes out
immediately and the capsule is adherent to nucleus and
closer to posterior capsule. Here the chances of PC rupture
is much more.
Figs 3.7A and B
Scleral side of the Anterior capsulotomy

Should be small, so that on pressure at 6 O'clock position,
the 12 O'clock portion of nucleus tilts up and gets unsleeved,
provided the sclera at 12 O'clock position is adequately
pressed,with sustained pressure at 6 O'clock portion of
capsule the nucleus is squeezed out.
Fig. 3.8
Whereas if the scleral side anterior capsulotomy is big

enough, on pressure at 6 O'clock position of capsule, the
nucleus has to undergo a big sweep -it becomes vertical.
This produces rupture of posterior capsule, disturbance of
anterior vitreous face and disturbance. In addition, the thick
hard nucleus as in brown cataract produces endothelial
damage of the cornea.
Figs 3.9A and B
Shallow Anterior Chamber

The anterior chamber should not be allowed to become
shallow and flat. Shallow anterior chamber allows the
anterior vitreous face and posterior capsule to rise up, along
with flat cornea. In such a situation, aspiration sucks the
endothelium of cornea or posterior capsule which depends
on the situation.
Fig. 3.10
Excellent Visual Control

With adequate magnification, surgeon should see what
happens in each step.
Repeating the capsulotomy

Some surgeons with a doubt about the perfectness of the
capsulotomy, may try digging in the same groove may result
in rupture as the thickness in the periphery is small and
tapering.
Fig. 3.11
Hydrodissection
This is usually done with either BSF fluid or ringer lactate
injecting under the anterior capsule with a bolus of one or 2
cc's fastly may result in perforation of the central part of
posterior capsule which is 1/5 of the thickness compared to
the anterior capsule.
Fig. 3.12
Instead multiple injection in various directions like

3,5,7,9 O'clock position in small quantities can avoid such
mishappenings.
Figs 3.13A and B
During irrigation and aspiration

The purpose of this is to maintain the eye. IOP and shape,
and to make the cortex float for easy aspiration. By doing so
with BSF fluid or ringer lactate, we are likely to create hole
or tear by the following ways.
1. Fast speed of the fluid may hit on the posterior capsules,
which is 1/5 th of the thickness of anterior capsules.
Fig. 3.14
2. Tip of the cannula itself can cause tear when you plunge.
Fig. 3.15
3. Irregular surface or small spicule in the under surface of

cannula can tear, posterior capsule.
To avoid this, ensure that the under surface of the
cannula is smooth prior to surgery. While doing irrigation,
introduce the cannula parallel to the surface of the iris and
slightly tilt down and immediately go under the anterior
capsule upto the priphery. Make sure, that the fluid flows
straight to hit only the area 1 mm above the equator i.e., at
the anterior capsule of the periphery and never at the
centre. Engage the cortex, bring to the centre from all
around and then aspirate. If you ensure this, the fluid can
be allowed to run faster to maintain anterior chamber.
Fig. 3.16A and B
The tip of the cannula should never be allowed to touch

the posterior capsule.
Make sure that anterior chamber does not become
shallow, as it may produce central hole during aspiration.
During this procedure, the pupil should be kept well
dilated. If the pupil constricts dilate it either with adrenaline
BSF mixture or other methods. If the pupil is persistently
small as in PX syndrome- a keyhole iridectomy followed
by resuturing at the end is mandatory. Irrigation and
aspiration in small pupil is not advised.
During delivery of Nucleus

As described earlier, anatomically, when we press with lens
hook at 6 O'clock position of the limbus, we create invariably
dehiscence of zonules, as the diameter of the lens is smaller
than the corneal diameter by 1-2 mm. This can be seen when
we aspirate a broad based tag with cortex.
Fig. 3.17
Instead if we press about 1-2 mm above in the cornea
with a slender vectis we are actually pressing at the edge
of the capsule which result in squeezing out of the nucleus,
provided the pupil is well dialated, adequate capsulotomy,
and corneoscleral section to dispel the nucleus.
Fig. 3.18
Using vectis is better than the sturdy lens hook which
is often used as cautery in some centers.
Fig. 3.19
In case we press at the middle of the cornea, the
nucleus exerts pressure on the posterior capsule and
anterior vitreous face which results in PC rupture and
vitreous disturbance of drifting forwards.
Fig. 3.20
During Implantation
When the anterior chamber is shallow with small pupil, even
the introduction of lower haptics blindly with a little force
may result in PC rupture
Summary for how to prevent Complications in Planned
ECCE and IOL
Another methods
Corneoscleral Incision
Extension of incision
Figs 3.21A to X
Figs 3.22A to L
CHAPTER Capsulorhexis in Detail 79
4
Capsulorhexis in Detail
Capsulorhexis is one of the methods by which the anterior

capsulotomy is done to deliver the Lens, wash the cortex,
and finally introduce the IOL inside the bag.
This ensures a clear cut margin-border of the anterior
capsulotomy which appears cosmetically good.
Also, during the procedure of aspiration of cortex, the
risk of aspiration of tags of anterior capsule without our
knowledge is averted.
This type of risk is very common during the can opener
method of anterior capsulotomy.
Here during the aspiration of cortex, the tags of anterior
capsule creates a tear extending radially to the posterior
capsule which is thinner by five times than the anterior
capsule.
This creates in disturbance to anterior vitreus face. This,
in turn, results in vitreous disturbance along with excentric
position of the pupil. This produces an inability to place the
IOL in position inside the capsular bag.
Types of Capsulotomy
1. Anterior Capsulotomy.
2. Posterior Capsulotomy.
POSTERIOR CAPSULOTOMY
This is done in the centre or axial portion of posterior capsule.
The usual size of posterior capsulotomy is 4mm. This is
carefully done under the microscope with the magnification
to create a punched out hole which is smaller than the size
of the Optic of IOL. So that it does not disturb the anterior
vitreous face.
ANTERIOR CAPSULOTOMY
This is the primary procedure to create a circular rent at the
centre in the axial portion with a clear-cut border to deliver
the nucleus comfortably, aspirate the cortex without any
complication and to introduce the IOL inside the capsular
bag.
The usual diameter of the anterior capsulotomy is
5-6 mm.
USES OF CAPSULOTOMY
In anterior capsulotomy
The tags produced as a result of irregular can-opener method
or any other methods is carefully prevented as this method
of anterior capsulorhexis -produces a clear-cut border (like
a punched out border) and that the chances of creating a tag
is not possible.
This produces an acceptably (though not cosmetically)
good, regular and clear-cut and circular margin in the axial
portion of the globe.
In posterior capsulorhexis
The chances of formation and creation of posterior capsular
opacity (as a result of failed attempt in the formation of new
Capsulorhexis in Detail 81
lens fibers) in young patients is carefully prevented,

provided an associated anterior vitrectomy is also done.
Procedures
Capsulorhexis consists of an initial puncture of anterior
capsule at the center, in the axial portion, to create a free
fold of the capsule followed by a circular tear of the same
flap either by utratas forceps or by any other forceps of
surgeons choice, and by pulling the freely hanging flap to
create a circular rent or by carefull pushing of the same flap
from the attached portion of the whole capsule near the
junction between the attached portion of the lens capsule
and the origin of the free flap, to deliver the nucleus out and
to introduce the PC IOL.
Here the pushing of the free flap from the junction is
done circularly with an axis at the center.
For initial puncture, any sharp needle is enough. Once
this is done, the tension in the capsule is released, which
creates a gap.
Fig. 4.1
This gap creates a useful free flap with a scope to create
a linear circular tear with an axis at the center of the anterior
capsule starting from the lower arm.
This is achieved when the initial puncture is a slanting
C, in which the lower arm is directed to create an anti-
clockwise circular tear either by a pull of the free flap or a
push of the same from the original anterior capsule.
If the initial puncture is a reverse slanting C, the lower

arm of C is directed to create a clockwise movement of the
free flap (by a forceps or a bent needle ) with an axis at the
center.
The purpose is to make a circular rent with a diameter
of 5 mm, upto 6mm. The lower half of free arm of C should
be directed in such a way to create a circular tear or rent.
The size of the rhexis can also be 4mm in diameter.
This is usefull in the posterior capsule which is thinner by
5 times than that of anterior capsule. This is useful to
introduce the optic portion of the IOL behind the posterior
capsule when the haptic portion is left inside. The capsular
bag and vice-versa, to avoid the subsequent development
of posterior capsular proliferation of new lens fibers leaving
an opacity (posterior capsular opacity) especially in children
and young people.
Just try to raise the flap, fold it, and from the base of
the flap one can, with the tip of a cystitome, push the free
flap circularly with the axis at the center or pull the flap
circularly with the tip of the needle. Usually most of the
surgeons use a 90 degree bent needle to push or pull. But
when using a 90 degree bent needle, it usually punctures
the free flap and jeopardizes the further procedures,
creating tension to the surgeon during surgery.
The surgeons can do this rhexis by pulling the free
anterior capsular flap. In a circular fashion to create a
circular clear-cut rent with the tip of a cystitome just below
the junction.
The symbol C, is to direct the line of tear in the free
flap of anterior capsule to go circularly in an anti clockwise
pattern on the right side. Otherwise our attempt to create
a circular tear gets spoiled. Figures 4.2 and 4.3.
Anterior capsulorhexis
Starting from right side ⎯⎯→ Anticlockwise magnified
movement magnified
Push the flap as indicated above at the junction of free and attached
portion of anterior capsule with the tip of the needle
Figs 4.2A to H
Anterior capsulorhexis
Starting from right side ⎯⎯→ Anticlockwise
movement — Magnified
Gently pull the free flap as indicated with the tip of needle
Figs 4.3A to H
REVERSE C
The anterior capsulotomy can also be made using a reverse
C in which the lower arm of the reverse C is directed upto
create a free flap. Here the free flap can be directed to tear as
circular rent in a clockwise pattern with an axis at the center.
Figure 4.4 and 4.5.
REPEAT CAPSULORHEXIS
In case the rhexis is not successful, small, irregular and not
satisfactory, a repeat capsulorhexis can be done around the
Anterior capsulorhexis — Starting from left side — Clockwise

movement (roation of flap) — Reverse — C method magnified
Push the free flap at the junction with the tip of the needle at the
periphery
Figs 4.4A to H
Anterior Capsulorhexis — Starting from left side — Clockwise

roation of flap) — Reverse ‘C’ = ‘C’ method magnified
Gently Pull the free flap all around with the tip of the needle at the
periphery
Figs 4.5A to H
failed 5 mm rhexis making it into a 6–7 mm rhexis. For this

the lower arm of regular C or reverse C or U-shaped incision
can be done around the failed one. This is useful in anterior
capsulotomy only as the size is bigger.
In Regular type
The lower arm of C or U-shaped flap can be raised with the
help of a cystitome outside the failed flap at 9 O’clock
position the flap can be raised and pushed at an
anticlockwise pattern circularly to create a clear cut border.
Or the lower arm of C or U-shaped nick can be made
outside the failed one at 3 O’clock position, raise the flap
with the cystitome and pull or push as per the necessity,
to create a circular rent or capsulotomy. Figures 4.6 and 4.7.
METHOD- 2
Some surgeons prefer to peal the border circularly outside
the original capsulotomy to make it into a 6-7mm
capsulotomy with a clear - cut border. The beginner can learn
and practice this on a red tomato.
METHOD-3
To admit the IOL inside the capsular bag, in case the
diameter of capsule-rhexis is small, one can make 2 radial
cuts from the clear-cut border of the rhexis - one at 10 O’clock
position, another at 2 O’clock position. Instead, the surgeon
can do this at 5 O’clock and 8 O’clock position of the border.
PURPOSE OF MAKING IT BIGGER

The purpose of making the rhexis bigger is to admit the IOL
easily inside. The capsular bag and to deliver the nucleus
easily from inside the capsular bag.
Anterior Capsulorhexis from right side anticlockwise rotation of

flap – Magnified
For small irregular
Make a small side incision raise the flap → pull the free flap all
around from the existing
Figs 4.6A to I
PURPOSE OF CAPSULORHEXIS
In case of can - opener method, the inner border of the rhexis
is irregular with the tags projecting. The tags, during the
aspiration of cortex, by a cannula mounted on a syringe
Repeat capsulorhex is from left side — Clockwise Rotation Flap

magnified
Make a small side incision raise the flap → pull the free flap all
around from the existing
Figs 4.7A to I
gets extended sometimes creating a tear at posterior capsule

producing vitreous disturbance and nucleus or IOL drop.
Creation of Cystitome
The routine practice of bending the needle (26 gauge) to 45
to 60 degree can be followed and done as usual.
Tip of the needle is bent at 90 degree either at the hub

of the beveled edge or at the base.
The 90 degree bent - tip of the needle, if used to fold
the flap and to push the anterior capsular flap to create a
circular capsulorhexis with a clear-cut margin, it usually
creates a puncture of the flap and tears jeopardizing the
procedure.
Instead, if the tip is bent for 45 to 60 degrees and used
carefully, to push or pull the flap, with the help of the slope
in the tip, puncturing and tearing can very well be
prevented.
COMPLICATIONS
The beginners while doing capsulorhexis, they fail to achieve
the satisfactory size, of the hole and the shape.. Sometimes
it becomes irregular.
In order to rectify this unfortunate attempt, the
surgeon can re-create a circular rhexis, starting from the
edge of it at 3 or 9 O’clock positions or at any suitable
position of surgeons choice. and convenience, by creating
a free flap from the edge of failed rhexis by doing a U
shaped or lower half of C and develop a circular rhexis -
as suggested in the picture.
This can also be done with the same needle or utrtas
forceps.
For a capsulorhexis using a forceps ( for beginners)

Catch hold of the free flap (after an initial puncture) of
anterior capsule at or near the peripheral edge with the
forceps of surgeons choice and tear carefully round,
millimeter by millimeter carefully, till you complete a
circular tear.
The same principle is applicable to other methods also
(Follow the legends already available).
CHAPTER Understanding the Basics of Strabismus 91
5
Understanding the
Basics of Strabismus
PREFACE TO STRABISMUS
As everybody is interested in learning phaco and microphaco,
and the concentration is diverted towards that line, only a
little interest is shown to squint or strabismus
Infact, in some centres, the subject is totally eliminated.
Hence, I have made an attempt to simplify the subject
and express the importance so that everybody can easily
understand the subject.
It is not my intention to deal elaborately about the
details of each and every part of this subject as it is an
annexe part of the origional manual phaco.
For further detailed knowledge about this subject, the
readers are requested to refer appropriate text books and
other referances to update their knowledge.
The Author
Squint or Strabismus
Causes of Eso deviation Exo deviation
1. Increased accommodation- 1. Decreased accommodation due
as in bilateral hypermetropia to bilateral aquired myopia
(superable).
2. Increased convergence as in 2. Decreased convergence as in
bilateral congenital myopia. recession of near point in
presbyopia.
3. Superable hypermetropia which 3. decreased accommodation in
sees at all distances whatever the one eye -decreased convergence
refraction of the other eye, (super- (as in myopia-hypermetropic
able hypermetropia that anisometropia).
can be overcome by sustainable
accommodation in order to give
clear vision).
ANATOMICAL FACTORS
Abnormal or relative due to abnormal bony defects.
– Congenital – Acquired
– Low IPD – High IPD
– Trauma – Trauma
– Displacement of visual axis – Displacement of visual
axis.
– Due to lesion in nerve supply – Same to muscles
PHYSIOLOGICAL FACTORS
– Excessive application of – Esophoria
close works
Dissociation Factors;
a) Prolonged uniocular actvity as in watch makers,
repairers. Microscopists accompanied by neglect or
suppression.
Understanding the Basics of Strabismus 93
6. Organic nervous or muscles – Disease as an

palsies early sign
Cerebral tumours – Palsies
Cerebrovascular diseases
Neurosyphillis
Disseminated sclerosis
Myasthenia gravis
6th nerve Palsies
4th nerve palsies
7. Precipitation factors
Bodily ill-health – Prolonged
Ocular fatique
Mental illhealth,
Advancing age
Certain occupations-specific
Age Factors
Eye blind from birth or blinded within – Eye becomes
first few weeks of life an eye which blind from
becomes blind between infancy and adolescence-
adolescence- DIVERGENCE
– CONVERGES
On reading the above classification, the reader or the student
will understand that there is definitely a relationship between
refractive error, accommodation, and convergence.
Basic
• Eso means deviation of the eye towards the nose.
• Exo means deviation of the eye towards the earlobe.
• Phorias means a tendency of the eye to deviate.

• Tropias means already deviated, developed, established,
manifested.
Deviation
Hypermetropia
Hypermetropic astigmatism if untreated->sustained contrac-
tion of ciliary muscles (changes
the lens curvature)
(Accommodation)
Convergence.
= refractive errors(hypermetropia) → accommodation →
convergence.
One dioptre of hypermetropia produces one diopter of
accommodation which in turn produces two meter angles
of convergence.
The refractive error namely hypermetropia (if
uncorrected) produces sustained contraction of ciliary
muscles (accommodation) which is also always associated
with a determined amount of convergence.
This is due to a simultaneous stimulation of the the
visual cortex whenever the accommodation reflex is
stimulated i.e., accommodative stimulus acts as a trigger
mechanism->stimulates->convergence.
ACCOMMODATION
Is a process by which the lens changes its focus from distance
to near and vice- versa. The ciliary muscles through its
zonules are attached to the equator of the lens. There are
three types of muscles viz., circular, longitudinal and
meridional (oblique) muscles.
The rays or objects from infinite are parallel rays when
accommodation is at rest, falls on the light sensitive layers
of the retina after converging by the lens. When the object

comes closer and closer, the rays becomes divergent. And
so they fall behind the light sensitive layers of retina. One
diopter of hypermetropia creates one diopter of
accommodation, which in turn creates two meter angles of
convergence--one meter angle for each eye. Although the
incident-infinite distant rays(objects) are parallel, the
emergent rays from the eyes should have a wider field in
each eye having an overlaping of the two fields producing
binocular single vision.
This binocular single vision consists of three processes viz.
1. Simultaneous perception.
2. Fusion.
3. Stereopsis (depth perception)
For this, both eyes should have an acceptably good
vision, having a simultaneous perception,to fuse the two
objects having stereopsis (depth perception).
The process of accommodation varies as the child
grows old. At the age of 10 yrs the accommodation is at 7
inches, which recedes to 22 inches at the age of 40, and
recedes more and more as the age advances.
In case the individual is hypermetropic, even for dis-
tance (infinite), the ciliary muscles are in a state of sustained
contraction, producing pain, headache, and eye-strain.
If circular muscles are acting, there will be pain around
the eye. When radial or longitudinal muscles are acting, the
pain will be radiating to the back of the head. Possibly there
may be a relationship of oblique muscles to that of
astigmatism. This is an unauthorised deduction. There is an
associated convergence in relation to the accommodation.
Accommodation and convergence are both reflex
processes which has the control at the area no. 17 to 19.of
visual cortex.
Nerve Pathways
Accommodation and convergence have different nerve
pathways. This is also important to know where the level of
lesion is.
The accommodation may fail, paralyse, or may become
insufficient in certain conditions and similarly spasm of
accommodation may also occur.
Cycloplegia or Paralysis of Accommodation

The following are the conditions where it occurs:
a. Cycloplegic drugs -may be unilateral or bilateral.
b. 3rd nerve paralysis or paresis.
c. Alcoholism, diabetes, neurological disorders.
d. Sexually transmitted diseases
e. Diphtheria, syphillis etc.
f. Myopia - defect is not noticed.
g. Hypermetropia -both distance and near vision are affected.
h. Emmetropia-only near vision alone is affected.
Insufficiency of accommodation is seen in presbyopia
due to normal physiologically related conditions, ageing,
glaucoma, eye strain, due to excessive near work. Spasm of
accommodation may occur due to use of miotic drugs.
Uncorrected refractive errors, insufficient illumination,
anxiety, and tension. Use of drugs-atropine, can abolish the
spasm of accommodation and pain also.
HETEROPHORIA
Phorias may be eso, exo, hyper, hypo, and cyclo. The causes
of—
Esophoria Exophoria
Purely anatomical anomoly(motor obstacle)which is insufficient

to cause manifest deviation.
1. Orbital asymmetry. Orbital asymmetry
2. Abnormality in IPD (Narrow) Wide IPD.
3. Slight degree of ocular muscle Medial rectus palsy.
paresis. Early degree of 6th
nerve palsy (Lateral rectus palsy).
ACCOMMODATION AND CONVERGENCE FACTORS
Demand for increased accomm- Demand for decreased accomm-

odation as in superable odation as in acquired myopia
hypermetropia. decreased convergence as in
(OR) presbyopia.
Demand for increased conver-
gence as in congenital myopia.
Excessive use of eyes for close works
Bodily ill-health or mental ill-health
Ocular or general fatique, advancing age.
Certain occupations which require
prolonged ocular activity and mental
concentrations.
TYPES
There are four types:
1. Convergence excess type: 1. Convergence weakness type:
Maddox wing reading is Maddox wing reading is
larger than obtained in larger than obtained in
maddox rod. maddox rod.
2. Divergence weakness type: 2. Divergence excess type:
Maddox Rod reading is Maddox rod reading is
larger than seen in larger than obtained in
wing maddox wing.
SYMPTOMS
Depends on decompensation.
Sometimes larger phorias may not produce symptoms. But
smaller phorias can cause severe symptoms. People who do
more close works may produce more symptoms than others
like farmers.
Symptoms in uncompensated phorias patients may produce:

1. Symptoms of muscles fatigue like headache or aching
pains, which disappears on closing one eye.
2. Difficulty in changing focus- near to distance and vice
versa.
3. Photophobia- which disappears using dark glasses or
relieved by closing one eye.
Symptoms due to difficulty to maintain binocular vision:

1. Blurring of letters.
2. Intermittant diplopia (due to temporary deviation of visual
axis).
3. Intermittant squint which is noticed by friends.
Symptoms due to defective postural sensations:

• Transmitted from ocular muscles due to alteration of
muscles.
• Tones-like landing of aircrafts or during playing games.
Eye Examinations
1. Vision(both distance and near vision) in both eyes.
2. Cycloplegic refraction and correction with spectacles.
Hypermetropia must be fully corrected as this is closely
related to accommodation and convergence, though

myopia may be undercorrected.
As the spasm of accommodation is the cause for headache,
(even for distance ) Hypermetropia has to be fully corrected.
3. Ocular movements in nine cardinal positions should be
done. Diplopia chart testing is a useful examination.
4. To find out the angle of deviation
a. Corneal reflex testing (hirschberg test) in infants.
Fig. 5.1
Cover Test
Is to find out "recovery movement" to resume binocular fixation.
There are three tests in this:
• Cover test for -Tropias.
• Cover and uncover test -for phorias.
• Alternate cover test - for phorias and tropias.
• Prism bar cover test - to quantitatively measure the total
deviation.
• Prisms are placed with the apex pointng towards
deviation.
• When prisms are being changed, always make sure that
the other eye is covered.
• Base-in or out prism - placed appropriately in front of
one eye and then perform alternate cover test, until there
is no refixation movement.
6. Measurement of ange of deviation.

• Perimetry method.
• By Synaptophore method and measure the angle of
deviation.
• By Maddox rod and maddox wing test.
• With the help of maddox rod at a distance of 6 meters in
one eye and look for the streek of light producing crossed
diplopia (right side streek crossing to the left side.-
Exophoria) or uncrossed diplopia -Esophoria.
The amount of separation can be measured by a prism-
bar to find out the amount of angle of deviation. The
Maddox wing test is for near (33 cm).
7. Measurement of accommodation by RAF ruler.
8. Measurement of convergence by RAF ruler.
9. Diplopia tests.
10. Worths Four-dot tests.
11. State of binocular vision-an assesment to be done.
Figs 5.2A to E (For color version see Plate 1)

Figs 5.3A to C (For color version see Plate 2)




Maddox Rod tests one fullpage
• Ask the patient to see a pen torch

light.
• Maddox Rod to be placed in one
eye, other eye — normal.
→ Esophoria
• Correct with base out prism.
→ No horizontal phoria.
→ Exophoria
• Correct with base in prism.
Figs 5.7A to D
TREATMENT OF PHORIAS
a. Refractive errors are to be corrected. Hypermetropia even
for distance should be fully corrected to relieve the
sustained contraction of ciliary muscles (accommodation),
astgmatism and myopia also should be corrected.
b. Orthoptic treatment --This is mainly useful in convergence
insufficiency and also in exophorias by doing fusional
exercises.to improove fusional reserve.
c. Prismatic spectacles - this is only a temporary arrangement
in elderly patients and not a cure in this condition.
d. Improvement of general health. This is an important
measure as most of the patients suffer due to serious
diseases of physical and mental conditions.
e. Surgery if necessary and in selective cases.
Flow Chart
• The Macular fixation develops in 2 to 3months after birth.

• Convergence and accommodation reflexes develop 2 to 3
months after birth. These reflex center is situated in the
occipital cortex areas No. 17 to 19.
We have already dealt with heterophorias
HETEROTROPIAS
The types of tropias are:
a. Intermittant-here the deviation is not continuously present.
b. Uniocular- in one eye only.
c. Alternating- in this the vision in each eye is almost the
same. But at a time, only one eye is fixing while the other
is deviating and vice versa.
d. Constant- here the deviation is always present.
e. Infantile esotropia.
f. Accommodative esotropia.
g. Non-accommodative and partially accommodative.
Qualitative Types
Esotropia, exotropia, hypertropia, hypotropia etc.

The causes of esotropias and exotropias are;-
Convergent Squint-(Concomitant)–Esotropia
1. High hypermetropia producing the over action of
accommodation (ciliary muscles) as result of synergic
action of accommodation and convergence leads to over
action of convergence initially and then for distance.
2. Abnormal physiological incooperation of accommoda-
tion and convergence. In case of high hypermetropia
in children of 2-3 years,if uncorrected may produce
Intermittant squint which becomes constant sub-
sequently.
3. Congenital myopia: The new -born child with congenital
myopia does not have a stimulus to see distant object but
fixes only the near object- the mother. Because the medial
rectus is more powerful, it remains convergent
4. Congenital Paresis:
Due to some unknown reasons, there may be some
paralysis or paresis of one or two ocular muscles of eye
producing squint. As the macular fixation develops 2-3
months after birth, it is either noticed or not. The same
paresis or palsy may also occur as a result of serious
illness to the child at this age. The palsy may be in
horizontal, vertical or oblique muscles.
5. Dissociation of the eye as a result of uncorrected refractive
errors producing hazy unacceptable vision- even if
corrected. The corrected power may be under or
insufficient. Sometime the astigmatic correction could be
incorrect. Extended patching of one eye. Due to congenital
aquired macular defect leading to defective fixation.
6. If visual pathways are defective due to some lesion.
7. General ill-health conditions.
Divergent Squint: (concomitant) Exotropia

1. Due to Neuro-muscular inco-ordination of unknown
reasons at the age of 3 - 5 years divergent squint occurs as
intermittant first, ending as constant in the following
types:
a. Divergent excess types -for distance.
b. Convergence insufficiency type for near (maddox
wing)
2. Unilateral myopia-uncorrected, producing divergent
squint of the myopic eye. In bilateral myopia, if untreated
- produce alternating type of divergent squint.
3. As a result of some serious pathology in the eye producing
loss of eye presents as divergent squint.
4. Overcorrection in convergent squint.
5. Medial rectus paralysis in 3rd nerve palsy.
6. General ill-health, etc.
Points to remember in Esotropia

a. High hypermetropia ->overaction of ciliary muscles->
overaction of convergence for near first->Squint.
b. Uncorrected high hypermetropia (due to inco-ordination
between accommodation and convergence)->deviation
intermittant first, below 3 years.
c. Myopia from birth->in infants -> esotropia persists.
d. in infants ->paralysis or paresis ->tropia of all types.
e. uncorrected and under corrected refractive errors ->
unequal vision and clarity.
f. Macular pathology in infancy-or anywhere in visual
pathology.
g. Defective general health.
Points to remember in Exotropia

a. Neuromuscular inco-ordination->after 3 years -
>intermittant->constant-primary-not appear to be related
to refractive errors.
b. Unilateral myopia or myopic astigmatism -> one eye-
>divergent.
c. Bilateral myopia-> alternating squint.
d. Eye with no vision->Exotropia.
Symptoms
1. In early cases there will be diplopia, subsequently
followed by absence of diplopia ->supression.
2. Cosmetically defective appearance.-deviation of one or
both eyes as noticd by parents or relatives.
3. In school children it is noticed.
4. In children, if is noticed along with yellow or white reflex
of pupils (one should exclude the various causes of
pseudoglioma mainly retinoblastoma in children).
Eye Examination--routine
1. Inspection:
• To find out whether convergent or divergent squint.
• To find out small degree, moderate or severe degree
pseudosquint or true squint.
• Sudden onset or gradual onset.
• Intermittant or constant type (an observer can notice)
family history.
2. Vision- aquity.
3. Ocular motility:
• To find out whether it is a paralytic or non-paralytic
each eye should be tested separately.
4. Pupillary reflexes:
• To rule out the other causes of peudoglioma especially
retinoblastoma.
5. Cycloplegic refraction to find out the refractive errors.
6. Cover test -in children, using a torch light one can find
out approximatively the angle of deviation in degrees.
• Cover one eye and look for recovery movements.
Though this tests is not much useful in obvious squint,
it is an important test to find out whether the child is
fixing uniocularly or bilaterally. The co-operation of
the child is difficult.
7. To find out the angle of deviation:
a. Corneal reflex test -useful in children as mentioned.
b. Perimeter test -The number of degrees on the arc will
give a clue to the angle of deviation.
c. Prism and cover test – By changing the increasing
strength of prisms (base-in or base out for convergent
or divergent squint) till the recovery movement is
abolished one can find out the correct amount of
deviation.
d. Maddox wing and maddox rod test. This test is not

usefull but may be usefull in some cases.
Bagolinis striated lens test interpretation
Figs 5.8A to D
8. Binocular Function test:

a. Simultaneus perception test: In synaptophore, by
using slides of two dissimilar objects the patient may
be asked to see slides like -lion and cage and asking
them to put the lion in the cage.
b. Fusion: In this, there will be two slides of dissimilar
pictures but incomplete, like cat or rabbit holding
flowers. By asking the patients to fuse both into one
complete picture (super-imposed) the patient has the
ability to fuse. In case it does not, but simply comes
and goes -it may be taken as suppresion.
c. Stereopsis(depth perception): In this, there are slides
of two dissimilar objects. The patient is asked to
appreciate the depth by superimposeing both.
TREATMENT
This consists of the following:
a. Correction of refractive errors by spectacles.
b. In case the patient has developed amblyopia -
occlusion of the fixing eye should be done, followed
by stimulation of the affected-amblyopic eye. If
exccentric fixation has developed, the occlusion of the
affected eye should be done. To make the unsteady
fixation into steady fixation.Then follow the previous
procedure.
c. Orthoptic procedures, if necessary to create binocular
vision.
d. Surgery as a cosmatic correction in some patients.
CONVERGENCE
Convergence is a process by which the visual axis of both the
eyes are directed towards the nose by synchronous adduction
of both the medial recti muscles.
Types of Convergence: Convergence may be voluntary

or reflexes. It is initiated in the visual cortex.
The reflex convergence is analysed in 4 components:
1. Tonic convergence.
2. Accommodative convergence.
3. Fusional convergence.
4. Proximal convergence.
Tonic Convergence
This depends on the tone of the muscles and occurs in the
absence of any stimulation to accommodation. In cases of
convergence-excess type, a non-accommodative esotropia is
seen.
Treatment
By drugs
Accommodative Convergence
Normally when accommodation is exerted, an estimated
amount of convergence is also exerted.
Treatment
This can be corrected by correcting refractive errors.
Fusional Convergence
Normally a certain amount of convergence is present for a
normal accommodation. For finer adjustments necessary for
binocular fixation -> this fusional convergence is required.
This is involuntary.
Proximal Convergence:
An awareness of near object or subject creates an appropriate
degree of convergence.
Flow Chart: Treatment of concomitant squint in a child

Flow Chart: Treatment of concomitant squint in an adult

Amblyopia
Amblyopia can be discussed in the following types:
1. Stimulus deprivation amblyopia.
2. Strabismic amblyopia.
3. Anisometropic amblyopia.
4. Anisoconic amblyopia.
5. Ametropic amblyopia.
Treatment
1. Treatment of the cause of amblyopia.
2. Patching or occlusion of the normal eye so that the affected
eye can be made to see and be stimulated by some methods.
Eccentric Fixation
The following are the types:
1. Fovial fixation.
2. Perifovial fixation.
3. Parafovial fixation.
Treatment
1. Occlusion or Patching of the affected eye so that the normal
eye which is unsteady can be made to become steady.
2. Once the eye becomes steady, the regular treatment for
amblyopia can be started. which is given above.
PARALYTIC SQUINT
Causes of paralysis of external ocular muscles
1. Any type of lesion in any one of the muscles or the nerve
which supplies the same muscle starting from the
nucleus of origin upto the place of insertion in the eye,
like congenital anomolies, infection, inflammation, benign

or malignant conditions, trauma, toxins, vascular or space-
occupying conditions can paralyse the function of the
muscles producing the deviation of the eye-paralytic
squint.
a. Superior rectus, inferior rectus.
b. Medial rectus, lateral rectus.
c. Superior oblique, inferior oblique muscles.
Lateral rectus muscle is supplied by 6th nerve (abducent
nerve). Superior oblique muscle is supplied by 4th nerve
(trochlear nerve) superior rectus, inferior rectus, medial
rectus and inferior oblique --3rd nerve.
2. Sequelae of the affected muscles will be
a. Overaction of the contralateral synergist.
b. Contracture of the ipsilateral antagonist.
c. Secondary palsy of the contralateral antagonist.
The examples are:
a. For right lateral rectus palsy-the sequela are -overaction
of left medial rectus, contracture of right medial rectus
and secondary palsy of left lateral rectus.
b. For left superior oblique palsy-sequela are -overaction
of right inferior rectus, contracure of the left inferior
oblique and secondary palsy of right superior rectus.
3. Clinically the signs and symptoms are:
a. Diplopia(immediate) if the eye is having vision.
b. Due to this diplopia, the patient will have headache,
nausea, vertigo, and other discomforts which gets
cleared on closing the affected eye.
c. Defective movement of the affected eye.
d. Compensatory head posture and chin position.
Investigations
a. Diplopia chart to find out which specific side muscle is
affected.
b. Clinical demonstration of restriction of movement of the

particular muscle. Each affected muscle has different
diplopia charting, compensatory headposture and chin
position to avoid the discomforts of the diplopia.
Treatment
1. Treatment of the cause, if possible and curable.
2. Occlusion of the affected eye by some means to eliminate
the discomfort for diplopia.
3. Temporary prismatic spectacles if available.
4. Appropriate surgical procedures to tackle the problem
towards the improvement of the situation as it is difficult
in most of the conditions.
Diagnostic features of palsy of extrinsic muscles

Muscle Ocular Defective Diplopia Greatest Usual comp
and posture movement Type separation -ensatory
nerve of images head
supply postures
Lateral Eye Outwards horizontal on abdu- Face turned

Rectus turned in (abduction) homonymous ction towards
affected side
Sixth side(also chin
Cerebral may be
lowered)
Medial Eye turned Inwards Horizontal On addu- Face turne

Rectus out (adduction) crossed ction towards nor-
mal side (also
Third chin may be
Cerebral raised
Superior Eye Upwards Vertical, upper On elevation Chin raised

rectus turned when the (false) image outwards and head
downwards eye is belonging to usually turned
Third (and abducted affected eye; and tilted
cerebral slightly also intorsional towards
outwards) and corssed affected side
Inferior Eye turned Downwards Vertocal, upper On de- Chin lowered

Rectus upwards when the (False) image pression and face
(and slightly eye is abduc- belonging to outwards usually turned
outwards) ted affected eye; towards
Third affected side
cerebral and head tilted
towards the
normal side
Superior Eye Downwards vertical, lower On depress- Chin lowered

oblique turned up- when the eye (false) image ion outw- and head tilted
wards (and is adducted belonging to ards ad turned to-
slightly affected eye; wards normal
Fourth inwards) also intors- side
cerebral ional crossed
Inferior Eye turned Upwards Vertical, upper On Chin raised

Oblique downwards when the (false) image elevation and face turned
(and slightly eye is belonging to inwards towards nor-
inwards) adducted affected eye; mal side and
also extorsional head tilted to-
and crossed wards affected
side
Index
A Complications in planned
Accommodation 94 ECCE 46
cycloplegia 96 Concomitant squint 115
nerve pathways 96 Conjunctival incision 4
paralysis 96 Conjunctival closure 32
Accommodation and Convergence 113
convergence accommodative 114
factors 97 treatment 114
Amblyopia 117 fusional 114
treatment 117 proximal 114
tonic 114
B treatment 114
Bagolinis striated lens test Cover test 99
interpretation 112 D
Basics of strabismus 91
anatomical factors 92 Delivery of nucleus 74
physiological factors 92 Descemet ’s detachment in
Bridle suture 3 SICS 37
C E
Capsulorhexis 12, 79 Eccentric fixation 117
complications 90 treatment 117
purpose 79 Epinucleus delivery 30
Capsulotomy 79 Esophoria 97
procedures 81 Excellent visual control 72
types 79 Exophoria 97
anterior 80 Extention of incision 16
posterior 80 F
uses 80 Frown incision 5
in anterior
H
capsulotomy 80
in posterior Half nucleus delivery 35
capsulorhexis 80 Heterophoria 96
Heterotropias 108 Paralytic squint 117

qualitative types 108 causes 117
convergent squint 108 investigations 118
divergent squint 109 treatment 119
High magnification 51 Posterior capsular rupture 65
Hydrodissection 16, 72 dialation 67
Hypermetropia 99 illumination 67
incision 66
I magnification 67
Implantation 76 small needle tip 67
Insertion of IOL 31 R
Iridodialysis 33
Repeat capsulorhexis 84
Irrigating vectis method 25
Irrigation and aspiration 73 S
L Scleral incision 5
Scleral side of anterior
Linear incision 5 capsulotomy 70
Low magnification 48 Shallow anterior chamber 71
M Side port incision 9
Small pupil 21
Maddox rod test 112
Small rhexis 21
Maddox wing 112
Small scleral side
Manual phaco 1 capsulotomy 48
complications 1 Smiling face technique 60
prevention 1 Superior rectus fixation 3
Manual rotation of nucleus
T
17
McPherson forceps 58 Treatment of phorias 107
Morgagnian cataract 70 Tunnel making 6
N U
Nucleus 18, 22, 34, 43 Undialated pupil 21
Utratas forceps 90
delivery 18, 22
Uveitis 21
rotation 43
sinking 34 V
P Vectis method 25
Palsy of extrinsic muscles 120 W
diagnostic features 120 Worth’s four dot test 100

Manual of Practical Cataract Surgery

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Manual of Practical Cataract Surgery

Uploaded by

Copyright:

Available Formats

Manual of

Practical Cataract Surgery

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

First Edition: 2009

Though many books are already available in the market,

Though various lectures and CME (Continuing Medical

1. How to Prevent Complications in

2. How to Prevent Complications in Planned

3. Posterior Capsular Rupture—Rent ........................ 65

4. Capsulorhexis in Detail ........................................... 79

5. Understanding the Basics of Strabismus ............. 91

Index ........................................................................... 121

COMPLICATIONS IN MANUAL PHACO (SICS)

MANUAL PHACO—SICS (SMALL INCISION SURGERY)

ANESTHESIA AND ANALGESIA

SUPERIOR RECTUS FIXATION; BRIDLE SUTURE

Fig. 1.1: Bridle suture well including spare

Figs 1.2A to C: Conjuctional Incision

The fornix based conjuctival flap with radial cut at

SCLERAL INCISION : (UNDER LOWER MAGNIFICATION)

Figs 1.4A and B: Curvilinear incision

2. Horizontal or Linear incision

Figs 1.5A and B: Horizontal or linear incision

Fig. 1.6: Frown incision

Figs 1.9A and B

1. The effective IOL power is below 20 for PC after careful

Figs 1.10A and B

SIDE PORT INCISION

• Prefereably in case, the side port incision is made at 6

Fig. 1.16A and B

Figs 1.17A and B

Fig. 1.19: Fix at opposite side.

Once the air bubble is injected into anterior chamber

CAPSULORHEXIS; (UNDER HIGH MAGNIFICATION) 1.0X

Here the purpose of bending the needle is not only to

Fig. 1.23: This portion of anterior capsule

Figs 1.24A to H: Capsulorhexis

CAPSULORHEXIS WITH 26 G NEEDLE (BENT)

Figs 1.25A to H: Capsulorhexis with 26G needle

Then, slightly elevate the capsule and push the folded

Figs 1.28A and B

Figs 1.30A and B

MANUAL ROTATION OF NUCLEUS

Figs 1.38A and B

SMALL PUPIL (UNDIALATED)

Figs 1.40A and B

try the same procedure or do any one of the following

Figs 1.41A and B

And sandwiching the nucleus on either side. Now,

Figs 1.44A and B

IRRIGATING VECTIS METHOD

Figs 1.45A and B

Figs 1.46A and B

2. In case direction of the irrigating vectis is more oblique

1. Fluid pressure pushes nucleus out.

For the Beginners

INTRAOPERATIVE COMPLICATIONS AND HOW TO

If necessary two more sutures, one on either side.

suitable position, push in the needle under the nucleus,

Figs 1.65A and B

Figs 1.66A and B

HALF NUCLEUS DELIVERY

Figs 1.68A and B

DESCEMETS DETACHMENT IN SICS