1) Rarely superior bridle suture (when performing superior tunnel)

2) Paracentesis with #75 blade, or some other sharp knife, mark
    knife w/marker ink to see

Fixation with 0.12 forceps or with fixation ring

3) If topical instill lidocaine (1% non-preserved in TB syringe
    w/ Troutman 27 or 30 g)

Some debate about loss of endothelial cells with lidocaine

Patients will note some sting - can buffer by diluting 4% lido to 1% w/ BSS+

4) Place viscoelastic (see appendix 2)

Arshinoff shell technique: 1st dispersive (eg. viscoat), then cohesive (eg. healon)

Allows dispersive to coat cornea and protect from ultrasound energy

Allows cohesive to maintain chamber during the first part of procedure

Or use just one. Healon is cheapest at the University

Limbal

Peritomy of 4-7 mm depending on IOL size

Cauterize sclera

1/2 depth groove into limbus with crescent blade or 64 beaver

enter eye with keratome (sized for phaco needle eg 2.8 mm for Alcon micro)

Potential Complications	What to do about it
Groove too deep into Limbus Groove/enter posterior Nick capsule Nick iris	Usually no big deal W/iris prolapse move elsewhere Include w/removed cap w/rhexis Forget about it

Scleral tunnel

Peritomy of 4-7 mm depending on IOL size
Cauterize sclera
1/2 depth groove into sclera with crescent blade
tunnel at 1/2 depth through sclera into cornea with crescent blade
enter eye with keratome (sized for phaco needle eg 2.8 mm for Alcon micro)

Potential Complications	What to do about it
Groove too deep into uvea Shred scleral flap Enter AC posterior Enter AC w/crescent too wide Nick capsule Nick iris	Close wound and move elsewhere Tunnel further into clear cornea W/iris prolapse close and move Partial suture to maintain AC Include w/removed cap w/rhexis Forget about it

Corneal

1/2 depth cut into cornea near limbus with guarded diamond or steel crescent
1/3 depth tunnel into cornea with either crescent or keratome
enter eye with keratome (sized for phaco needle eg 2.8 mm for Alcon micro)

Potential Complications	What to do about it
Groove too deep into cornea Shred flap Tunnel too long distorting view Nick capsule Nick iris	Suture at end like limbal Longer corneal tunnel Re-enter w/keratome but shorter Include w/removed cap w/rhexis Forget about it

6) Capsulorhexis

Most important part of the procedure
Anterior chamber must be filled with viscoelastic
3 basic techniques

cystitome - intial cut and control of tear with cystitome
combo - initial cut with cystitome, most of tear with forceps
forceps- sharp forceps cut and then grab capsule to complete tear

goal is a central circular opening slightly small than the optic diamter

7) Hydrodissection

Second most important of procedure
Balanced salt solution in 3 cc syringe with troutman 27 g or similar
Inject fluid just under cpasule to cleave cortex from capsule
Must see a fluid wave. Don't stop till you get enough, Don't stop till you get enough
May prolapse lens with a large capsulorhexis - can be a good thing.

8) Phacoemulsification

Goal is to remove lens with the minimum U/S time
Trend is to use increasing vacuum and decreasing u/s power to remove nucleus
Phaco can be done:

Endocapsular - keeping the lens in bag during phaco
Supracapsular - prolapsing nucleus into sulcus during phaco
In anterior chamber - prolapsing usually shelled out nucleus into AC
"lollipop" - tipping nucleus on side 1/2 in bag; 1/2 in AC.

Many ways to disassemble nucleus (must see Alcon tape -- 7 ways to frag nucleus)

Sculpting out a bowl
Divide and conquer
Chopping

9) Cortical Aspiration

Aspiration is used to grab and peel the cortex off not suck it up
Dangerous procedure - most common time for Vitreous loss
Sub-incisional removal is most difficult esp with small rhexis

10) Fill Bag with viscoelastic

Arshinof shell technique: 1st cohesive (eg. healon), then dispersive (eg. viscoat)

Allows cohesive to mainain bag and force it open

Allows dispersive to seal the wound during lens insertion

Or use just one. Healon is cheapest at the University

11) Wound is extended to allow placement of the lens

PMMA lenses need slightly more than optic size
Folded 6.0 mm acrylic needs about 3.5 mm more for high power lenses
Silicon unfolder needs only about 3.0 mm

12) Lens is placed into capsular bag

Make sure the lens is right side up
Usually you initially place leading haptic into bag
Trailing haptic is dialed into bag w/sinsky or placed in bag wih kelman forceps
Use miotic eg. Miochol if lens is in sulcus

13) Sutures are preplaced

Preplace while viscoelastic maintains chamber
Usually need 2 interrupted or one X suture with 6 mm scleral tunnel
Usually need 3 interrupted sutures with 6 mm limbal wound
Usually need no sutures with 3-4 mm wound of cornea or sclera

14) Viscoelastic is removed with I/A device

15) Sutures are tied

3/1/1 for 10-O nylon

16) Other

Consider subconjuntival antibiotics
Alternative is to d/c patch 6 hours after block and start drops
Patch if retrobulbar was used