ECCE (with nucleus expression)
Indications Still indicated today - Dr. Cohen's first case in pvt practice ECCE
Hard lenses with tenative corneal endothelium
Contraindications poor zonular support
Pre-op orbital massage or osmotic agents to reduce vitreous pressure
Anesthesia Retrobulbar and lid block
Rarely general anesthesia, eg: claustrophobia, dementia, tremor
Procedure (See appendix for details)
Superior bridle suture
Peritomy of about 170 degrees
Initial limbal groove in sclera with a chord length in the 9 mm 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)
Extend initial incision to full length of groove (with scissors or knife)
Safety sutures are preplaced usually 7-O vicryl
Lens removed by 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 viscoelastic
Lens is placed in the posterior chamber
Wound is closed with 10-O nylon
Post-op Day #1 exam RAPD, VFF to CF
VA in op eye w and w/o PH -- expect about 20/100 w/PH
SLE expect corneal edema and 3-4+ cell and flare
don't waste time with refraction or keratometry
Seidel test of wound
applanation tension       if < 8 look hard for leak
if > 30 start with beta blockers
usually can see fundus without dilation document no RD or choroidal
plan
drops       pred forte 1% i gtt qid (more with severe inflammation)
ocuflox i gtt qid (any antibiotic will do)
cyclogyl 1% i gtt bid
f/u usually one week later
next day with wound leak, big corneal abrasion, etc...
give a post operative instruction sheet
Post-op Day #7 exam RAPD, VFF to CF
VA w/ and w/o PH -- expect about 20/50 w/PH
keratometry for fun -- expect about 7.1 diopters at 90 (DesMoines data)
don't waste time with refraction
SLE expect little corneal edema and 1-2+ cell and flare
usually can see fundus without dilation document no RD, CME, or choroidal
plan d/c antibiotic (tell pt. to keep bottle in refrigerator for suture removal)
d/c cyclogyl if inflammation is less than 1+; o/w, continue for 1 more week
taper Pred forte, e.g.:       i gtt qid for 7 more days, then
i gtt tid for 7 days, then
i gtt bid for 7 days, then
i gtt qd for 7 days, then
discontinue
f/u usually 5 weeks later at 6 wks p/o (allows time to begin suture removal)
with any problem e.g.more inflammation see sooner
Post-op Week #6 exam
RAPD, VFF to CF
VA w and w/o PH -- expect about 20/50 w/PH
keratometry
expect about 5.4 diopters at 90 (DesMoines data)
don't get confused and read backwards
eg. for 5.4 at 90: left dial could read 40 right dial reads 45.4
MR (start either with streak or 2/3 of cylinder from K's and adjust SE to -1.0)
SLE look at the wound and decide which sutures look tight
lysis
Indicated when cyl is >= 2 diopt. on MR or <= 3 on K's (if you did not do MR)
if it's less than 2 on MR, stop, high fives, don't cut anything
remove tightest suture at axis of cylinder on k's
only cut one suture at week 6-8 visits
can cut two beyond week 8
if tight axis is between sutures cut both (if beyond week 8)
plan full activity
antibiotic drop i gtt qid for 4 days (following each suture removal)
f/u
if no sutures need to be removed (will never happen)
give glasses -- usually +2.5 add with MR
f/u 6 mos.
otherwise return every 1-2 weeks for additional suture lysis
Post-op Month #6 you really have about three three choices (don't stall):
  1. pull a stitch (i.e. cyl at axis of stitch is greater than 2 on MR)
  2. give glasses (i.e. no stitch to pull or cylinder is less than 2 on MR)
  3. get FFA because you suspect CME
don't waste time thinking about other possibilities
not everybody is going to be 20/20. we only promise that 90% will be 20/40 or better


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