Cataract Surgery Techniques

Cataract Surgery Techniques - Setting the Stage

• Preoperative Evaluation:
  • History: Systemic (DM), ocular (glaucoma, uveitis).
  • Visual assessment: BCVA, glare testing.
  • Slit-lamp: Cataract grade (e.g., LOCS III), PCO, pseudoexfoliation, phacodonesis.
  • Fundoscopy: Rule out retinal co-pathology (ARMD, DR).
  • Biometry: A-scan (ultrasound) or Optical (IOLMaster, Lenstar) for axial length (AL), keratometry (K), anterior chamber depth (ACD).
• IOL Power Calculation:
  • Key inputs: AL, K-readings, ACD.
  • Formulas: SRK/T, Hoffer Q, Holladay 1 & 2, Barrett Universal II.
  • Target: Emmetropia or planned residual refraction.

  ⭐ A 1 mm error in axial length measurement typically results in a ~2.5-3.0 D postoperative refractive error.

• Anesthesia Choices:
  • Topical: Proparacaine, Lignocaine 2% jelly.
  • Injectable: Peribulbar, Sub-Tenon's. Retrobulbar (less common).
  • General Anesthesia: Indicated for children, uncooperative patients.

Cataract Surgery Techniques - Hands On Healing

• Intracapsular Cataract Extraction (ICCE):
  • Entire lens & capsule removed.
  • Large incision (~10-12mm); requires sutures.
  • Aphakic glasses or ACIOL needed. Rarely performed now.
• Extracapsular Cataract Extraction (ECCE):
  • Nucleus removed, posterior capsule (PC) preserved.
  • Smaller incision than ICCE (~8-10mm).
  • Allows PCIOL implantation in capsular bag.
• Manual Small Incision Cataract Surgery (MSICS/SICS):
  • ECCE variant; self-sealing sclero-corneal tunnel (~5.5-7mm).
  • No/minimal sutures; quicker visual recovery.
  • Cost-effective, ideal for mature/hard cataracts.

  ⭐ SICS is the preferred manual technique in India, offering rapid visual rehabilitation without expensive phacoemulsification machinery.

Cataract Surgery Techniques - Ultrasound & Laser

• Phacoemulsification (Phaco): Gold standard.
  • Uses ultrasonic vibrations to emulsify the lens nucleus.
  • Small incision (typically 2.2-2.8 mm).
  • Steps: Incision → Capsulorhexis → Hydrodissection → Phacoemulsification → IOL Implantation.
  • Advantages: Faster visual recovery, less astigmatism.
• Femtosecond Laser-Assisted Cataract Surgery (FLACS):
  • Laser automates key steps: corneal incisions, anterior capsulotomy, lens fragmentation.
  • Aims for ↑ precision & ↓ phaco energy.
  • Potential for better IOL centration.

⭐ FLACS can create highly precise and reproducible capsulotomies, potentially improving IOL stability and effective lens position.

Cataract Surgery Techniques - Lenses & Aftercare

• Intraocular Lenses (IOLs):
  • Types: Monofocal (standard), Multifocal (distance/near), Toric (astigmatism), EDOF (Extended Depth of Focus).
  • Materials: PMMA (rigid), Foldable (Acrylic - widely used, Silicone).
  • Power Calculation: Biometry formulas (e.g., SRK/T, Hoffer Q).
• Post-operative Aftercare:
  • Medications: Topical antibiotic, steroid (tapered dose), NSAID.
  • Schedule: Follow-up Day 1, Week 1, Month 1.
  • Monitor for:
    • Endophthalmitis (⚠️ severe intraocular infection).
    • Posterior Capsular Opacification (PCO).
    • Cystoid Macular Edema (CME).
    • Corneal edema, IOL malposition.
  • Advice: Eye shield (nightly), avoid eye rubbing, limit heavy lifting.

⭐ Posterior Capsular Opacification (PCO) is the most common late complication after cataract surgery, treated with Nd:YAG laser capsulotomy.

High‑Yield Points - ⚡ Biggest Takeaways

• Phacoemulsification: Gold standard; ultrasonic fragmentation via small incision; foldable IOL.
• SICS: Manual, sutureless alternative; larger self-sealing tunnel; good for hard cataracts & high volume.
• ECCE: Larger incision (8-10mm), sutures needed; nucleus expressed; less common.
• FLACS: Femtosecond laser for precise capsulorhexis, corneal incisions, & lens fragmentation.
• PCO: Most common late complication (after-cataract); treated with Nd:YAG laser capsulotomy.
• Endophthalmitis: Rare but severe infection; requires urgent intravitreal antibiotics.