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Principles Of Cataract surgery

Anaesthesia
Local anaesth General anaesth A) Local anaesthesia: 1) Retrobulbar block: to block oculomotor nerve before it reaches the recti muscles Agents used: bupivacaine 0.5% plus lidocaine 2% plus hyaluronidase 150u Site : just above the inf orbital rim bet temporal limbus and lateral canthus

2) Peribulbar block: to instill the local anesthetic


outside the muscle cone and avoid proximity to the optic nerve. Location: inferotemporal lower orbital margin, midway between the lateral canthus and the lateral limbus 3) Sub-Tenon's Block: conjunctiva is anesthetized first using drops of local anesthetic. bridle suture is placed around the superior rectus muscle. Then the capsule is incised under sterile conditions at a point 78?mm from the corneal limbus, between the 1 o'clock and 2 o'clock positions. specially designed needle is with the correct curved radius of 30mm is passes beyond the equator mixture of lidocaine 2% (5ml) plus bupivacaine 0.5% (5ml) plus 1500U hyaluronidase

3) Facial block: to block facial nerve or its zygomatic


branches to paralyze orbicularis mus Aim is to prevent the closure n squeezing of eye lids during surgery - O Briens tech: approx 5 ml of the anaest agent infiltered at neck of mandible just infront of tragus - Van lint method: needle is introduced 1mm behind the lat canthus and sol is infiltered along sup and inferolateral orbital margins in V shaped manner

4) Surface anaesthesia: 0.5% proparacaine


installed topically.depth and duration of topical anesthesia are dose-dependent. maximal effect may last 5 to 20 minutes

Hydrodissection/ hydrodelineation:
hydrodissection of the lamellar planes To separate the nucleus from the surrounding cortex. Fluid flows around the equator of the lens, peripheral to the cortex, into the posterior aspect of the lens capsule. it continues forward and reaches the dense adhesions between the capsule and the cortex at the equator.

Hydrodelineation is performed by injection of the fluid into the substance of the nucleus. tract is made midway between the center of the anterior surface of the nucleus and the equator. The cannula is advanced toward the central plane of the nucleus until the nucleus starts to move.

Fluid flows along the path of least resistance, which is the junction between the soft epinucleus and the hard endonuclear mass; this results in the formation of a golden ring or dark circle at that junction. This completes the circumferential division of the nucleus. In about 70% of cases, the cortex is evacuated with the epinuclear removal.

Nucleus Removal In conventional surgery and in scleral small incision surgery


scleral supression: Pressure is exerted at both the 6 o'clock (at the inferior limbal border) and the 12 o'clock (1 or 2 mm posterior to the incision superiorly) meridians with blunt instruments. A lens loop is typically used superiorly, and another blunt instrument such as a forceps or a muscle hook is used inferiorly. As pressure against the globe is alternated between the two instruments, the nucleus begins to pass through the incision at the superior limbus.it is a controlled process. prolapse in ant chamber

Phacoemulsification:
Nucleus is removed by various techniques All of them are based on sculpting (central crating or grooving), fracturing the nucleus into several segments while rotating it within the bag, and then emulsifying each fragment. start the emulsification at a lower power than is anticipated for the specific nucleus Nucleofracture and emulsification are usually done with high irrigation (high bottle), 50% emulsification power, and moderate aspiration. The power may be increased to 75% for hard nucleus.

Techniques A. Carousel B. Chip-and-flip (Fine) C. Phacofracture 1. Divide-and-conquer (Gimbel) 2. Four-quadrant pregrooved (Shepherd) 3. Nonstop chop (Nagahara) 4. Stop-and-chop (Koch) 5. Double chop (Kammann)

The cracked nucleus is emulsified. Location A. Anterior chamber B. Iris plane C. Posterior chamber Cortex is removed PCIOL lens is implanted, foldable or nonfoldable Sutures are applied