| Goals | Keep lashes and lids out of the way |
| Big potential screw-ups: | Abrade cornea Direct lashes the wrong way |
| Goals | Keep eye in infraduction allow access to superior limbus |
| Big potential screw-ups: | driving 4-0 silk into vitreous |
| assistant: | holds eye in infraduction and says "bridle suture" | |
| you: | left: | O'Brien forceps 8 mm superior to limbus wide grasp of Sup Rectus tendon |
| right: | 4-0 Silk suture passing needle just under forceps through tendon | |
| you: | tie the silk and secure to drape with hemostat | |
| Goals | save money for VA by making it youself |
| Big potential screw-ups: | hard to screw this part up making the cystitome too big ("it's so big") |
| assistant: | "so far all is going well, cystitome" | |
| you: | left: | take TB syringe and 5/8" long 25 gauge needle |
| right: | use needle driver to bend tip of needle 90 degrees | |
| Goals | Get the conjunctiva out of the way |
| Big potential screw-ups: | Shredding the sclera Removing pieces of conjunctiva |
| assistant: | "so far all is going well, cystitome" | |
| you: | left: | 0.12 forceps grab and tent up the conjunctiva and tenons 2 mm sup limbus |
| right: | w/ Wescott scissors cut through conjunctiva and tenons to sclera at 10:00 Continue with blunt dissection to clear a tunnel from about 10 to 2 o'clock With one blade inside tunnel/one out, cut off the conjunctiva at the limbus relaxing incision to expose the sclera at 2:00 |
|
| assistant: | "calipers at 11 mm" and shows you how much to clean at the limbus | |
| you: | left: | 0.12 forceps on sclera controlling the globe |
| right: | Gill knife to scrape away the remaining episcleral tissue | |
| assistant: | dabs away blood with Weck cell sponge | |
| you: | left: | still with the 0.12 on sclera controlling globe -- get used to it |
| right: | bipolar cautery to control bleeding keep the tips barely separated and stay on the sclera and off the conjunctiva |
|
| Goals | Carve a groove into limbus to guide cut later |
| Big potential screw-ups: | Entering the anterior chamber prematurely Groove posterior to limbus resulting in iris prolapse during later phases of operation |
| assistant: | shows you 11 mm again with the calipers | |
| you: | left: | on the sclera with the 0.12 forceps controlling the globe |
| right: | #64 beaver blade starting at 2 o'clock on limbus to 10 o'clock (11 mm) Hold blade using Taylor technique (roll with thumb and first finger) partial thickness about 1/3 depth in one smooth slow stroke handle is perpendicular to the eye and blade stays tangential to limbus |
|
| Goals | Cut a slit at limbus to allow instruments in Small enough cut to help maintain chamber |
| Big potential screw-ups: | Slice up the iris as you enter |
| you: | left: | on the sclera with 0.12 controlling the globe |
| right: | with keritome enter anterior chamber through groove at 11:30 keep blade parallel to iris plane |
| Goals | Form the chamber with Healon (viscoelastic) Cut out the anterior lens capsule |
| Big potential screw-ups: | Pulling and not cutting the capsule (resulting in zonular dehiscence) Cutting too peipheral through the zonules |
| assistant: | "Healon and side lights down, coaxial lights up, and room lights off" | |
| you: | left: | secure Healon syringe and direct cannula into anterior chamber |
| right: | depress plunger to fill anterior chamber (from inferior to superior) | |
| assistant: | "cystitome" | |
| you: | both | enter eye with cystitome point parallel to iris rotate cystitome with tip now pointing to the anterior capsule puncture the capsule at the 6 o'clock position move the tip circumferentially cutting the capsule to about 6:30 o'clock lift the tip and repuncture at 6:30 o'clock and repeat until you get to 12:00 go back to 6:00 again and now go circumferentially to the left complete casulotomy to 12:00 and exit eye with cystitome |
| you: | right: | enter anterior chamber with closed Kellman McPherson forceps open forceps over anterior capsule move forceps down over the capsule and close to grasp the capsule remove the capsule from the eye |
| Goals | Separate the nucleus from cortex Position the nucleus for easy expression |
| Big potential screw-ups: | Breaking zonules by being too rough |
| you: | both | enter the eye with the cystitome as before gently jam the point of the cystitome into the lens nucleus at 9:00 o'clock gently rock the lens nucleus away from the cortex repeat at 3:00, 6:00, and lastly at 12:00 spin the nucleus a bit for fun to ensure its free from cortex if possible leave the nucleus tipped so that the inferior aspect is posterior |
| assistant: | "gently doctor" | |
| Goals | Get the wound big enough to express nucleus |
| Big potential screw-ups: | Cutting the iris along with the wound Stripping Descemet's membrane Getting out of the groove as you cut |
| assistant: | "castro's to the left" | |
| you: | left: | 0.12 forceps on sclera to control globe |
| right: | put one blade of Castroviejos into eye keeping away from iris guide the outside blade onto groove and cut along groove its full extent watch the blade tip inside the eye and stay up and away from the iris |
|
| assistant: | "castros to the right" | |
| you: | right: | same maneuver to the other side (some use the other hand) |
| Goals | Pre place sutures to allow quick closure |
| Big potential screw-ups: | Place them too close to each other (so that later the lens can't pass between them) |
| assistant: | "7-0 vicryl/calipers at 7 mm" and shows you where to put two safety sutures | |
| you: | left: | use 0.12 forceps to grab cornea at caliper mark at around 1:30 |
| right: | drive 7-0 vicryl through 2/3 depth cornea and through adjacent sclera | |
| assistant: | cuts suture long | |
| you: | reload needle and repeat at the other caliper mark around 10:30 | |
| you | right | grab the vicryl between cornea and sclera and pull out loop of slack allows for expansion of the corneoscleral wound during lens expression |
| Goals | Get out the nucleus and leave the rest intact |
| Big potential screw-ups: | Expressing vitreous Not recognizing the wound is too small |
| you | right | 0.12 forceps grasping the posterior lip of the wound at 12 o'clock press gently down on the posterior lip of the would rotate the 0.12 forceps more parallel with the iris to make a lens ramp |
| left | if needed gently press at 6:00 o'clock with a muscle hook | |
| assistant uses a needle to spear the nucleus as it exits the wound
your first thought if the lens doesn't come should be to expand the wound |
||
| Goals | Grossly closing the wound |
| Big potential screw-ups: | Just close the wound |
| you | both | use large tying instruments to secure the two safety sutures |
| left | 0.12 forceps grasping cornea at 12 o'clock | |
| right | place another 7-0 vicryl this time at 12 o'clock | |
| both | use large tying instruments to tie last safety suture |
| Goals | Removing the remaining lens cortical material |
| Big potential screw-ups: | Aspirating and tearing the posterior capsule Aspirating and tearing the anterior capsule |
| assistant | "room lights off and set up the McIntyre" | |
| you | both | enter with McIntyre cannula between sutures at 1 o'clock aspiration port should always be looking at you (anterior) engage cortex by slipping port under iris (and anterior capsule) assistant will provide appropriate suction with syringe to tug on cortex once engaged pull cortex slowly to the middle and assistant will aspirate change position of entry to get cortex close to 12 o'clock never aspirate unless you have cortex engaged watch for "spiders" (posterior capsule tension lines) |
| Goals | Putting the lens in the bag or sulcus |
| Big potential screw-ups: | Placing one haptic in bag and one in sulcus Rupturing capsule during placement Putting in the wrong power of lens |
| assistant | "open the posterior chamber lens" and cuts safety suture at 12 o'clock | |
| you | both | fill the anterior chamber with Healon |
| right | hold IOL container and verify lens power | |
| left | use straight tying instrument to hold inferior haptic of IOL (inferior haptic should always point left) raise IOL above container |
|
| right | grasp inferior haptic and optic with Kelman forceps | |
| left | 0.12 forceps lift cornea | |
| right | with Kelman forceps place IOL through wound into anterior chamber direct inferior haptic posterior into the capsular bag |
|
| left | stabilize IOL optic with side of 0.12 forceps (do not grasp) | |
| right | release IOL and gently remove Kelman forceps from eye | |
| right | grasp superior haptic with Kelman forceps at tip (supinate) gently advance tip of superior haptic twist (pronate) to bend "knee" of haptic inferior under iris release haptic under iris to place entire IOL into position |
|
| right | rotate the lens if needed with a Sinsky hook | |
| Goals | Water tight closure Minimal astigmatism |
| Big potential screw-ups: | Wound Leak or gape post op Suturing the iris along with the cornea Demonstrating that you have not practiced at all |
| assistant | "10-0 please and room lights on" | |
| you | left | 0.12 forceps to present tissue to the needle driver |
| right | drive 10-O nylon with bite to about 2/3 corneal depth start at the 12:00 o'clock position (where safety suture used to be) same depth through the sclera try to keep them radial with equal tension slow and deliberate is better than fast with lots of rework |
|
| you | both | place about 7 tie with micro tying instruments with 3 throws, then 1 and 1 throw |
| assistant | cuts suture ends for you long | |
| you | remove remaining two vicryl safety sutures | |
| assistant | "McIntyre please" and assists with aspiration | |
| you | both | direct the McIntyre port over the IOL facing you as always assistant will aspirate the remaining Healon and cortical debris cleanup |
| you | complete closure as needed | |
| assistant/you | check wound with Weck cell sponge pressing on posterior edge | |
| you | left | straight tying instrument grab long end of 10-O |
| right | trim ends with #75 super sharp | |
| Goals | Injections of antibiotic and steroid Patching |
| Big potential screw-ups: | Injecting into the vireous cavity "didn't know he was allergic to gentamicin" Patching the eye open |
| assistant | "injections please" | |
| you | left | tent up inferior conjunctiva with 0.12 forceps |
| right | before injecting ask yourself: "any allergies?" with bevel down inject Ancef and decadron place into subconjuctival space avoiding vessels |
|
| both | remove lid speculum and drapes place ointment (eg. tobradex) double patch with benzoin |
|