Chapter 3 - Old School
Old School Cataract Surgery Techniques

[CLICK ON TABLE FOR LARGER VIEW]
ICCE – [view video]
Indications: rarely indicated today - I have only done five cases. Unstable lenses with severe zonular laxity.
Be Careful: children, capsular rupture, high myopia, Marfans, vitreous present.
Pre-op: orbital massage or osmotic agents to reduce vitreous pressure.
Anesthesia: Retrobulbar and lid block. Rarely general anesthesia, e.g., claustrophobia, dementia, tremor.
Procedure:
Planned ECCE (with nucleus expression) – [VIEW VIDEO]
Indications: Still indicated today. Hard lenses with tentative corneal endothelium (weak indication).
Contraindications: poor zonular support.
Pre-op: consider orbital massage or osmotic agents to reduce vitreous pressure
Anesthesia: Retrobulbar and lid block, sub-tenon's block, or rarely general anesthesia, e.g., claustrophobia, dementia, tremor.
Procedure:
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- intracapsular cataract extraction (ICCE) - lens with capsule removed [VIEW VIDEO]
- extracapsular cataract extraction (ECCE) - lens removed and much of lens capsule left in place. Can be done via two approaches: manual or planned ECCE done with expression of nucleus through large; or, phacoemulsification ultrasound device breaks up nucleus through small incision. [VIEW VIDEO]
- Pars plana lensectomy (PPLx) is an approach by retinal surgeons often at time of vitrectomy.
Comparison of Cataract Surgery Techniques

[CLICK ON TABLE FOR LARGER VIEW]
ICCE – [view video]
Indications: rarely indicated today - I have only done five cases. Unstable lenses with severe zonular laxity.
Be Careful: children, capsular rupture, high myopia, Marfans, vitreous present.
Pre-op: orbital massage or osmotic agents to reduce vitreous pressure.
Anesthesia: Retrobulbar and lid block. Rarely general anesthesia, e.g., claustrophobia, dementia, tremor.
Procedure:
- Superior bridle suture
- May need a scleral support ring in high myopes
- Peritomy of about 170 degrees
- Limbal incision of about 170 degrees chord length in the 11-12 mm range
- Safety sutures are preplaced - usually 7-O Vicryl
- Small peripheral iridotomy is placed
- Alpha-chymotrypsin was placed to degrade zonules (no longer available)
- Anterior surface of the lens is dried with a cellulose sponge
- Cryo probe is placed on mid-periphery of the lens and frozen
- Lens is removed with a side to side motion through incision
- Wound is closed with safety sutures
- Vitreous is attended to if needed
- Anterior chamber lens is placed
- Wound is closed with 10-O nylon
Planned ECCE (with nucleus expression) – [VIEW VIDEO]
Indications: Still indicated today. Hard lenses with tentative corneal endothelium (weak indication).
Contraindications: poor zonular support.
Pre-op: consider orbital massage or osmotic agents to reduce vitreous pressure
Anesthesia: Retrobulbar and lid block, sub-tenon's block, or rarely general anesthesia, e.g., claustrophobia, dementia, tremor.
Procedure:
- Procedure Superior bridle suture
- Peritomy of about 170 degrees
- Initial limbal groove in sclera with a chord length in the 11mm range
- Initial entry into anterior chamber to allow capsulotomy (3 mm)
- Instill viscoelastic (see appendix 2)
- Remove anterior capsule (usually with can opener approach)
- Mobilize lens (physically with cystitome or with hydrodissection--be careful)
- Extend initial incision to full length of groove (with scissors or knife)
- Safety sutures are preplaced usually 7-O vicryl
- Lens removed with lens loop or with counter pressure technique
- Wound is closed with safety sutures
- Cortical material is removed using I/A device (either automated or manual)
- Instill ophthalmic viscoelastic device (OVD)
- Lens is placed in the posterior chamber
- Wound is closed with 10-O nylon
- OVD is removed
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