e c c e handout

8/10/2019 E C C E handout

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Extracapsular Cataract Extraction:Nonphacoemulsification Large and Small

Incision Approach

ASCRS 2012Bonnie An Henderson MD, Thomas A Oetting MD, Maria M Aaron MD, Preston H

Blomquist MD, Eduardo C Alfonso MD, Samar Basak MBBS, Christine Ament MD,Surendra Basti MD, Venkatesara V Mootha MD, A!ha" #aghukant Vasa$ada MBBS

%#CS, Mohammed Shehena& MBBS, Brian # Sulli$an MD, Amar Agaral MBBS,

Athi"a Agaral MBBS, Ash$in Agaral MBBS, Adil Agaral MBBS, Anosh AgaralMBBS, Hari'ri"a Ara$ind, MBBS, Dianna ( Bordei)k MD, De!asish Bhatta)har"a,

MBBS

Course !"ecti#es

At the conclusion of the course $ou should !e a!le to:

1. To understand the indications for primary ECCE and for conversion to ECCEsurgery

2. To understand how to competently perform the steps of primary ECCE andconversion to ECCE surgery

3. To become familiar with and understand how to deal with complications ofECCE surgery

Introduction%h$ are &e doing this course'

As small incision phacoemulsification surgery becomes the standard of care, trainees are oftennot being taught how to perform ECCE surgery. e believe primary and conversion to ECCEsurgery still plays an important role in certain cases. !nowing how to perform this surgerycompetently is crucial when faced with complications during phacoemulsification surgery. ECCEsurgery is widely practiced internationally where access to e"pensive phacoemulsificatione#uipment is limited.

%ho are the Lecture Instructors'

a$ %r. &onnie An 'enderson is a partner at (phthalmic Consultants of &oston and anassistant clinical professor at 'arvard. )he was previously the %irector of theComprehensive (phthalmology )ervice at *assachusetts Eye and Ear +nfirmary where

she was one of the main surgical attendings for the residents. )he received the 'arvard*edical )chools Teacher of the -ear award and nominated for 'arvards E"cellence inTeaching award. )he currently is a surgical preceptor at Tufts )chool of *edicine.bahenderson/eyeboston.com$

b$ %r. *aria Aaron is an Associate 0rofessor of (phthalmology, Emory niversity )chool of*edicine. )he has been the esidency 0rogram %irector at Emory for 1 years and hastrained and mentored over 4 residents and 25 medical students during this tenure. )heis the past60resident of the 0rogram %irectors Council of the Association of niversity0rofessors of (phthalmology and serves as the 7ice6Chair of the (phthalmology C
mailto:[email protected]:[email protected]


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for the AC8*E. )he has received an Achievement Award from the AA( and is an A&(e"aminer for the (ral &oards.

c$ %r. Thomas A. (etting is a leader in ophthalmic education. 'e is the 0rogram %irectorand a Clinical 0rofessor of (phthalmology at the niversity of +owa. 'e is Chief of theEye )ervice and %eputy %irector of )urgery for the 7A*C in +owa City. 'e hassupervised over 3, resident cataract cases. 'e won the resident teaching award in2, 21, 22, and 25. 'e serves on the A&(9AA( Anterior )egment !nowledge&ase tas: force and serves on the Cataract Committee for the 24 AA( annualmeeting. thomas6oetting/uiowa.edu$

d$ %r. 8eoffrey Tabin is 0rofessor of (phthalmology ; 7isual )ciences and %irector of the%ivision of +nternational (phthalmology at the epalese counterparts directing Tilganga EyeCentres efforts to provide an international standard of eye care and participating in theoutreach programs.

(rimar$ ECCE

* Primar" ECCE Surger"+ Maria Aaron MD

- *ndi)ations

a- Brunes)ent lens !- Su!+lu.ated lens+ &onule loss

)- Traumati) )atara)t d- Missions o$erseas

/- (earning Pearls

a- Dilating dro's !- *n)isions

)- Ca'sulorhe.is

d- Suturing

e- 0et la!1- Surgi)al Te)hnique+ (arge *n)ision

a- *n)isions + lim!al $s tunnel !- Ca'sulorhe.is methods )- Basi) te)hniques of lens e.tra)tion

d- Corte. remo$al

2- 0et (a!+Onl" realisti) 'la)e to learn ell a- Basi) et la!

!- Video of e.tra)a' te)hnique using 'ig e"e

(rimar$ ECCE ) Small Incision Cataract Surger$ *SICS+

** Primar" ECCE ith Small in)ision 3S*CS4 5 6eoffre" Ta!in M-D-

- *ndi)ationsa- Same as large in)ision

!- Benefits of small in)ision 5 less astigmatism, less suturing and

'osto' suture )utting, et)-)- 7se around the orld

/- Surgi)al te)hnique

a- Videos +Ste' !" ste' instru)tion, dis)uss te)hniques!- *nstrumentation 5 i-e- *rrigating lens loo'
mailto:[email protected]:[email protected]:[email protected]


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/- Steinert #% Cataract Surgery: Technique Complications Management/nded-

Saunders, Philadel'hia PA, /==2

1- Henderson BA,Essentials of Cataract Surgery, Sla)k *n), Thorofare 8;, /==>2- Oetting, TA, Cataract Surgery for Greenhorns, A$aila!le at

htt'?@@medrounds-org@)atara)t+surger"+greenhorns- a))essed Se'tem!er , /==>

- Chang D%, Oetting TA, :im T, Curbside Consultations in Anterior SegmentSurgery, Sla)k *n), Thorofare 8;, /==>
http://medrounds.org/cataract-surgery-greenhorns.%20accessed%20September%209http://medrounds.org/cataract-surgery-greenhorns.%20accessed%20September%209


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IPrimary Extracapsular Cataract ExtractionMaria Aaron, MD

De'artment of O'hthalmolog"Emor" 7ni$ersit" S)hool of Medi)ine

A- *ndi)ations

Su!lu.ated lens

Signifi)ant &onule loss 3e-g-, 'seudoe.foliation4

Traumati) )atara)t

Mature )atara)ts 3!runes)ent internal4

(arge 'osterior )a'sule tear at !eginning of 'lanned 'ha)o surger"

O$erseas Missions

B- Preo'erati$e Pre'aration

Consent

*ntrao)ular lens

O'erati$e site identifi)ation

Adequate 'u'illar" dilation or 're'are for 'u'il stret)h

Patient 'osition

C- Anesthesia

#etro!ul!ar !lo)k 3ine)tional anesthesia? in)luding 'eri!ul!ar or

su!tenon


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)ornea and )ut- #e'eat until the )onun)ti$al 'eritom" measures

a''ro.imatel" / mm 3)ord length4

)- Cauter" + Verif" )orre)t 'oer setting on the ma)hine- *f using !i'olarti's, kee' ti's a''ro.imatel" =- mm a'art- 7se a see'ing motion o$er

the s)lera and start 'osteriorl" a''ro.imatel" /+1 mm from the lim!us-

d- *n)ision 6roo$e

Measure the length of the desired ound !" marking the s)lera ith the )ali'er ti's

set at =- mm- 7se =-/ for)e's to gras' s)lera at a''ro.imatel" the ?== 'ositionto sta!ili&e the glo!e- Hold the !lade handle 'er'endi)ular to the glo!e and make the

in)ision from left to right a''ro.imatel" mm 'osterior to the !lue line- Consider

making the gro$e more anterior in a !lue iris to 're$ent earl" entr" and iris 'rola'se-

The de'th of the groo$e should !e a''ro.imatel" to @1 s)leral de'th- The lengthof the groo$e should !e =- mm, !eginning at the =?1= 'osition and ending at

a''ro.imatel" the /?1= 'osition- Attem't to make the groo$e in one )ontinuous

motion !" rotating the !lade ithin "our fingerti's-

Tunnel + 7se either a or !lade to make a s)leral tunnel into the)ornea- 7se a )ir)ular motion ith the !lade to enlarge the tunnel for

the entire length of the gro$e-

Enter anterior )ham!er

Ele$ate the anterior li' of the ound ith the =-/ for)e's, e.'osing the a'e. of the

fla', and enter the anterior )ham!er ith the > !lade 'arallel to the iris 'lane- Make

a 1 mm in)ision either to the right side of the ound 3right+handed surgeon4 or to theleft 3left+handed surgeon4-

e- Vis)oelasti) ine)tion

*ne)t the $is)oelasti) 'rimaril" at the ?== 'osition first to 'ush the

aqueous out of the e"e, hile filling the entire anterior )ham!er-

f- C"stotome 7se a 're+!ent )"stotome or use a hemostat to !end a /+guage needle

g- Ca'sulotom"

Can+o'ener 5 Hold the )"stotome ith !oth hands to sta!ili&e and

'enetrate the anterior )a'sule at the ?== 'osition and see' to theside- Continue making small 'un)tures )ir)umferentiall" to )om'lete

a +> mm )a'sulotom"- 0ith ea)h 'un)ture the surgeon ill see' to

the right hile going u' the left side and to the left hile going u' theright side-

Continuous 5 *f a )ontinuous )a'sulorhe.is is 'erformed, radial tears

must !e made to fa)ilitate nu)leus remo$al-

#emo$al of anterior )a'sule 5 7se an angled instrument to gras' the

)entral anterior )a'sule- Ensure that the anterior )a'sule is free from

the 'eri'heral )a'sule !" 'ulling the )a'sule gentl" in all dire)tions-

#emo$e the anterior )a'sule from the e"e-h- Enlarge ound

7se )orneos)leral s)issors and enter the anterior )ham!er ith loer

a of the s)issors and )ut toard the o''osite side of the ound-


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Push gentl" toard the ?== 'osition as "ou )ut to ensure that "ou

enlarge the ound at the most anterior as'e)t of the tunnel- Maintain

s)issor !lades in the groo$e and kee' !lades 'arallel to the iris 'lane-i- 8u)leus #emo$al

Manual E.'ression

This is a)hie$ed !" a''l"ing e.ternal, 'osterior 'ressure ith for)e's or the irrigatinglens loo' / mm 'osterior to the lim!us at the /?== 'osition and using an assistant to

ele$ate the anterior li' of the ound- 0hen the nu)leus !egins to 'rola'se,

)ounter'ressure is a''lied ith a mus)le hook at the ?== 'osition to fa)ilitateremo$al of the nu)leus- On)e the nu)leus is 'artiall" out of the e"e, an" 'ointed

instrument ma" !e used to )om'letel" rotate the remainder of the lens out of the e"e-

(ift and e.tra)t

Either h"drodisse)tion or manual rotation should !e 'erformed to ele$ate the /?==lens into the anterior )ham!er- To manuall" rotate the nu)leus, use a Sinske" hook,

)annula or )"stotome to gentl" ro)k the lens in a dialing@)ir)umferential manner and

then lift and rotate- On)e the su'erior 'ortion of the lens is ele$ated, an irrigating

lens loo' ma" !e inserted under the lens- The irrigating lens loo' is then flattened'arallel to the iris 'lane, lifted toard the )ornea, and remo$ed from the e"e ith the

nu)leus-

- Suture Pla)ement

To maintain the anterior )ham!er during )orti)al remo$al, it is

!enefi)ial to 'la)e / or 1 =+= n"lon sutures at the =?==, /?== and

/?== 'ositions- *f the iris is light+)olored or there is a tenden)" for iris'rola'se, additional sutures ma" !e 'la)ed-

k- Corte. #emo$al

Manual or Automated 5 The )orte. ma" !e remo$ed !" using either a

manual as'irating )annula 3i-e- Sim)oe )annula4 or an automated

irrigating@as'irating s"stem- This te)hnique is similar to'ha)oemulsifi)ation, hoe$er, ith a )an+o'ener )a'sulotom", )are

should !e taken not to a))identl" gras' the anterior )a'sule leaflets-

Stri' the )orte. toard the )enter of the 'u'il and as'irate moreaggressi$el" onl" hen the 'ort is full" o))luded ith )orte.-

l- *O( *m'lantation

The )a'sular !ag is reformed ith $is)oelasti) 'rior to im'lantation of

the *O(- *t is im'ortant to reform the )a'sular !ag and not ust dee'en

the anterior )ham!er- This is a)hie$ed !" dire)ting the $is)oelasti)

under the anterior )a'sular leaf of the )a'sular !ag at the o


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*O( hen the o'ti) is released- Ta' the *O( further into the !ag ith

)losed :elman for)e's until the o'ti) is )om'letel" !ehind the 'u'il-

Pla)e or rotate the trailing ha'ti) into the )a'sular !ag as "ou ouldith 'ha)oemulsifi)ation-

m- 0ound Closure

Pla)e a )orneal light shield to 'rote)t the ma)ula from 'hototo.i)it"-Pla)e enough =+= n"lon sutures to ensure adequate ound )losure-

0ith 'ro'er ound )onstru)tion, 2+ sutures should !e adequate-

n- #emo$al of Vis)oelasti)

One suture should !e left untied to allo entr" ith the automated or

manual irrigation@as'iration instrument to )om'letel" remo$e the

$is)oelasti)- Ta''ing 'osteriorl" on the anterior surfa)e of the *O(

ill fa)ilitate remo$al of the $is)oelasti) retained !ehind the *O(-o- *ne)tions

Pu'illar" )ontri)tion ith either intra)ameral Mio)hol or Miostat is

'rudent in ECCE to redu)e the risk of o'ti) 'u'illar" )a'ture-

Su!)onun)ti$al Anti!ioti)s and Steroids


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II. Small Incision Cataract Surgery in Underdeveloped Countries

Geoffrey Tabin M..

Evolution of t!e "ptimal Surgical #pproac! to Cataracts in t!e eveloping

$orld

Catara)ts are the leading )ause of !lindness orldide ith the maorit" of )ases in

de$elo'ing nations- Of the 1F million )ases of !lindness 3$isual a)uit" less than/=@2==4, an estimated million are )aused !" age+related )atara)ts- *n 8e'al alone

the 'er)entage of )ura!le !lindness resulting from )atara)ts is more than F= 'er)ent,

and in *ndia 1-F million 'eo'le de$elo' )atara)t !lindness "earl"- As the orld


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The e$ening !efore surger" the 'atients< fa)es are $igorousl" ashed and anti!ioti)

dro's and ointment are instilled- Prior to surger" the e"elashes are )losel" )ro''edand flouroquinolone e"e dro's are instilled at the time of dilation- The e"e is then

're''ed ith Betadine and a retro!ul!ar anestheti) is administered !" an anestheti)

te)hni)ian, after hi)h, a Betadine soaked gau&e is held o$er the e"e- At the start ofthe )ase the surgeon 'erforms a final Betadine 're' ith instillation of a small

amount of G Betadine into the forni. of the e"e- This 'reo'erati$e )leaning and

sterili&ation regimen leads to a lo infe)tion rate- Effi)ien)" of 'atient turno$er isma.imi&ed? as the surgeon is 're''ing and dra'ing the e"e the s)ru! nurse is

arranging a ne instrument set and surger" 'ro)eeds ith a t"'i)al dela" of less than

three minutes !eteen )ases-

Surgical Tec!ni%ue

Surgeon Positioning and Maximizing Surgical Field Exposure

0e generall" ad$o)ate that !eginning surgeons learn S*CS from a su'erior a''roa)hhoe$er, man" S*CS surgeons o'erate from a tem'oral a''roa)h-

Temporal vs. Superior Surgical Approach

0hile a su'erior a''roa)h has long !een the standard of )are hen 'erforming

ECCE, e routinel" 'erform 3FG of )ases4 ECCE using a tem'oral surgi)al

a''roa)h as there is a signifi)ant differen)e !eteen the amount of 'ost+o'erati$eastigmatism indu)ed !" the to te)hniques- The mean indu)ed astigmati) )hange is

-> dio'ters 3D4 folloing a su'erior surgi)al a''roa)h due to the effe)ts of gra$it"

and motion of the e"elids on the ound, hile, =-> D of astigmatism is indu)edfolloing a tem'oral surgi)al a''roa)h-

A su'erior a''roa)h has remained the mainstream te)hnique of )hoi)e gi$en thefolloing ad$antages? %irst, the u''er e"elid )o$ers the e.ternal ound folloing the

o'eration hen a su'erior a''roa)h is used, 'ro$iding good ound 'rote)tion-

Se)ond, surgeon 'ositioning at the head of the o'erating ta!le 'ro$ides for a more

streamlined flo of 'atients through the o'erating suite- Mi)ros)o'e heads, )hair'ositions, and instrument ta!les need not !e re'ositioned !eteen )ases-

%ortunatel", most of these limitations ha$e !een o$er)ome- The rate of 'ost+o'erati$einfe)tion is equi$alent hen using either a su'erior or a tem'oral a''roa)h hoe$er,

it is )riti)al to )lose the )onun)ti$a o$er the e.ternal s)leral ound ith )auteri&ation

at the )om'letion of the tem'oral a''roa)h surger"- 0e ha$e also de$elo'ed ano'erating ta!le hi)h fa)ilitates 'atient flo hen o'erating tem'orall"- *t allos

the surgeon to !e seated at one side 'atients are then 'ositioned ith their feet

'er'endi)ular to the surgeon


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Access the Anterior Chamber (AC b! Creating a Sclerocorneal Tunnel

A su'erior re)tus tra)tion suture ma" !e used if o'erating su'eriorl" to enhan)e

e.'osure- A forni.+!ased )onun)ti$al 'eritom" to s)lera is 'erformed su'eriorl"

from = to / o


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fluid from the )annula ill engage the nu)leus into the internal mouth of the

s)lero)orneal tunnel- H"drostati) 'ressure 'lus gentle lifting and retra)tion ith the

ti' of the Sim)oe )annula ill for)e the nu)leus further into the tunnel- O'en thee.ternal foramen of the tunnel ith gentle donard 'ressure using the heel of the

Sim)oe )annula and deli$er the entire nu)leus 3%igure 24-

PC %&' Placement

The Sim)oe )anula is then used in the standard fashion to remo$e all nu)lear and)orti)al de!ris from the AC and )a'sular !ag- 8e.t, air is ine)ted into the anterior

)ham!er using the #")roft )annula and a PMMA 3'ol"meth"lmetha)r"late4 PC *O( is

inserted into the )a'sular !ag- Alternati$el", the *O( )an !e inserted after filling the

AC and e.'anding the )a'sular !ag ith $is)oelasti)- The a'e. of the V+sha'ed)a'sulotom" tear should also !e folded !a)kards during this maneu$er so that the

fla' lies on to' of the anterior )a'sule- During insertion of the leading ha'ti), the

anterior li' of the )ornea is folded inard hi)h 'rote)ts the )orneal endothelium

during lens im'lantation- The leading ha'ti) is then 'assed into the )a'sular !aginferiorl", !ehind the !ase of the triangular )a'sulotom" 3%igure 4- The folded

anterior )a'sule fla' at the !ase of the triangular )a'sulotom" ser$es as an easil"identifia!le landmark and fa)ilitates )orre)t PC *O( 'la)ement-The trailing ha'ti) is

then 'assed into the )a'sular !ag and )orre)t 'la)ement of the PC *O( ithin the

)a'sular !ag is )onfirmed !" o!ser$ing 'osterior )a'sule stret)h lines that form'er'endi)ular to the )onta)ts !eteen the *O( ha'ti)s and the )a'sule-

Capsulectom!

*f a triangular )a'sulotom" as 'erformed, the anterior )a'sular fla' is remo$ed to

're$ent o!s)uration of the $isual a.is- A small in)ision is made in the anterior

)a'sule at the edge of the !ase of the triangular fla' ith fine Vannas s)issors hilemaintaining the AC de'th ith an irrigating Sim)oe )annula- The )a'sular fla' is

engaged ith as'iration using the Sim)oe )annula 3using lo flo irrigation4 and

used to gentl" tear the fla' entirel" a)ross its !ase hi)h then should !e remo$edfrom the AC 3%igure 4-

Closure

The Sim)oe )annula is used to irrigate and as'irate residual air or $is)oelasti) in the

AC and intrao)ular 'ressure is restored- The 1+'laned s)lero)orneal tunnel ill self+

seal hi)h is )onfirmed !" a''l"ing gentle 'ressure to the glo!e ith an instrumentand o!ser$ing for ound leakage- %eer than G of our ounds require suture

'la)ement for adequate )losure- A su!)onun)ti$al ine)tion of anti!ioti) and steroid

is gi$en ust su'erior to the )onun)ti$al ound hi)h !alloons the )onu)ti$a andmo$es it o$er the lim!us to )o$er the s)leral ound- *n the instan)e of a tem'oral

surgi)al a''roa)h the )onun)ti$a is )losed o$er the s)leral ound ith )auteri&ation

at the ound edges-


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After remo$ing the sterile dra'es anti!ioti) ointment is a''lied to the e"e hi)h is

then 'at)hed and shielded- Steroid and anti!ioti) dro's are instilled e$er" to hours

for the first 'ost+o'erati$e da" and then four times 'er da" for three eeks-

Surgical "utcomes

7tili&ing intrao)ular lenses manufa)tured in *ndia or 8e'al and lo)al 'harma)euti)als

the )ost 'er surger" is less than tent" dollars 'er )ase- Moreo$er, e.'erien)ed

surgeons routinel" 'erform more than fift" )ases 'er da" ith an a$erage o'eratingtime of fi$e minutes 'er surger"- The results of a 'ros'e)ti$e, randomi&ed )lini)al

trial in 8e'al )om'aring our manual sutureless e.tra)a'sular surgi)al te)hnique ith

'ha)oemulsifi)ation ere 'u!lished in the ;anuar" /==> Ameri)an ;ournal of

O'hthalmolog"- *t as an IE.'ert TrialJ ith Professor Da$id Chang o'erating itha 'ha)o+)ho' 3'ha)o4 te)hnique and Dr- Sanduk #uit doing the tem'oral a''roa)h

small in)ision ECCE 3S*CS4- Both te)hniques a)hie$ed e.)ellent and equi$alent

results- At si. months FG of the S*CS 'atients had an un)orre)ted $isual a)uit"

37CVA4 of /=@= or !etter and FG had a !est+)orre)ted a)uit" 3BCVA4 of /=@= or!etter this out)ome as equi$alent to the $isual a)uit" out)omes of the 'ha)o

'atients 3%igure >4- %urthermore, S*CS is signifi)antl" faster, less e.'ensi$e and lesste)hnolog" de'endent than 'ha)oemulsifi)ation and ma" !e the more a''ro'riate

surgi)al 'ro)edure for the treatment of ad$an)ed )atara)ts in the de$elo'ing orld-

&eferences

Brilliant 6E, ed- The E'idemiolog" of Blindness in 8e'al? #e'ort of the F

8e'al Blindness Sur$e"- Chelsea, Mi)h? Se$a %oundation FF?+/2-

#uit S, #o!in A(, Pokhrel #P, Sharma A, Defaller ;, Maguire PT- (ong+term

results of e.tra)a'sular )atara)t e.tra)tion and 'osterior )ham!er intrao)ular lens

insertion in 8e'al- Tr- Am- O'hth- So)- Vol (KKK*K +>- #uit S-, Ta!in, 6- Chang, D- A Pros'e)ti$e #andomi&ed Clini)al Trial of

Pha)oemulsifi)ation $s- Manual Sutureless Small+*n)ision E.tra)a'sular Catara)tSurger" in 8e'al, Ameri)an ;ournal of O'hthalmolog"- Vol 21 8o- ;an /==>

1/+1F-

#uit et al, O'hthalmolog" =?FF>+/

#uit et al, Clini)al and E.'erimental O'hthalmolog" /=== /F, />2+


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*** Conversion to ECCE+ Thomas A Oetting MS MD

Con$ersion to ECCE often )omes at a diffi)ult time- The lens is a!out to fall south, the$itreous has 'rola'sed and the surgeon is stressed- 7nderstanding the ste's and 'ro)ess

of )on$ersion to ECCE is essential and stud" !efore the )risis ill hel' soothe the stress

hen this ine$ita!le 'ro)ess o))urs- 0e ill )o$er se$eral areas? identif"ing 'atients atrisk for the need for )on$ersion to ECCE, indi)ations for )on$ersion, )on$ersion from

to'i)al to su!+tenon


16/29

Table )

ifficulty (actors3modified from Oetting, Catara)t Surger" for 6reenhorns, htt'?@@medrounds-org@)atara)t+surger"+greenhorns4

%a)tor Time Equi'ment@Anesth-

9onular (a.it" Dou!le *ris retra)tors a$aila!le to hold )a'sule

Ca'sular #ing 3CT#4

#ead" for sutured *O(#ead" for *CCE, eg )r"o

Consider #B

Consider Su' lim!al ound

#o)k Hard (ens Add =G Consider 'lanned ECCE

Consider su' lim!al ound @PEConsider #B

Small Pu'il Add =G Stret)h Pu'il 3onl" @o %loma.4Consider *ris retra)tors

Consider #B

%loma. Add =G Strongl" )onsider *ris retra)torsConsider single iris retra)tor

Consider #B

Poor #ed #efle. Add =G Tr"'an Blue

Consider #B

Consider su' lim!al ound

Big Bro Add /G Consider su'@inf- !ridal sutures

Consider #B to gi$e 'ro'tosis

8arro Angle Add /G Ma" need iris hooks for 'rola'se

Consider smaller 'ha)oti'

%requent dis'ersi$e OVD

Predis'osition

Cornealde)om'ensation

=G BSS 'ha)o )ho'

Arshinoff shell @OVDConsider )on$ersion to ECCE

E.isting Tra! =G A$oid %i.ation ringA$oid Con mani'ulation

Ala"s suture

Past PPV. =G Possi!le CT#

Careful during *@A

Cannot (a" flat =G Consider general or at least monitored

Anti)oag- =G To'i)al to a$oid ine)tion risk

Mono)ular =G To'i)al for faster reha!ilitationTr" to forget a!out it
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17/29

Indications for conversion Con$ersion to ECCE is indi)ated hen 'ha)oemulsifi)ation

is failing- Sometimes this is due to a $er" hard lens hi)h does not su!mit to ultrasound

or a lens that is hard enough that the surgeon is )on)erned that the required ultrasoundenerg" ill harm a tentati$e )ornea, e-g- %u)hs< endothelial d"stro'h" or 'osterior

'ol"mor'hous d"stro'h" 3PPMD4- Sometimes one ill )on$ert to ECCE hen an errant

)a'sulorhe.is goes radial es'e)iall" ith a hard )r"stalline lens hen the surgeon is)on)erned that the risk of dro''ing the lens is too great ith )ontinued

'ha)oemulsifi)ation- #arel" no ith Tr"'an Blue d"e, a surgeon ill )hoose to )on$ert

to ECCE hen the anterior )a'sule is hard to see and )a'sulorhe.is must !e )om'letedith the )an o'ener te)hnique- More often the )on$ersion is indi)ated hen the

)r"stalline lens is loose from eak &onules or a 'osterior )a'sule tear hi)h make

'ha)oemulsifi)ation less safe than e.tending the ound and remo$ing the residual lens

material- *ndi)ations for )on$ersion to ECCE in)lude?

Hard )r"stalline lens or unsta!le endothelium

#adial tear in anterior )a'sule ith hard lens

Poor $isuali&ation des'ite Tr"'an d"e Posterior )a'sular tear

9onular dial"sis

Converting to subtenon-s anest!esia- Often e )on$ert )ases from to'i)al )lear )orneal

to ECCE- 0hile the ECCE )an !e done under to'i)al it is usuall" more )omforta!le and

safer to gi$e additional anestheti) hi)h is t"'i)all" a su! tenon


18/29

(igure )

%or)e's holding o'en 'osterior fla' of disse)tion into su!tenons

s'a)e- (a)rimal )anula ith gentle )ur$e a''ro.imating the )ur$eof the glo!e read" to insert lo)al anestheti)

Converting t!e $ound The maor ste' toard )on$erting to ECCE is to either e.tendthe e.isting ound or )lose and make another- The ECCE ill require a large in)ision of

from +/ mm hi)h is )losed ith suture- The de)ision to e.tend the e.isting ound or

make a ne ound hinges on se$eral fa)tors? lo)ation of the original ound, si&e of the!ro, 'ast surgi)al histor", and 'ossi!le need for future surger"-

"riginal

ound

#dvantages of ma'ing ne

ound for ECCE

#dvantages of extending

ound for ECCE

Temporal Allos lim!al in)ision su'eriorAllos lids to )o$er suture

Should iris damage o))ur it ill

!e su'eriorSim'le to start fresh

Prote)ts e.isting tra!A$oids !ig !ro

Sup Temporal

/eft eye

none Alread" ha$e su' in)ision

8o need to )hange 'osition

Inf Temporal

&ig!t Eye

Allos lim!al in)ision su'erior

Allos lids to )o$er sutureShould iris damage o))ur it ill

!e su'erior

Sim'le to start fresh

Prote)ts e.isting tra!

A$oids !ig !ro

Superior none Alread" ha$e su' in)ision

8o need to )hange 'osition


19/29

Ma'ing a ne incisionduring )on$ersion is identi)al to that for a 'lanned ECCE- The

original in)ision is )losed ith a =+O n"lon suture- The surgeon and mi)ros)o'e are

rotated as the surgeon should sit su'erior- The ste's to make a ne su'erior in)ision are?

Conun)ti$al 'eritom" of a!out >= degrees

7se 2 or )res)ent !lade to make lim!al groo$e ith a )hord length of mm Bi'olar )auter" for hemostasis

7se keratome to make initial in)ision starting in groo$e into AC

E.tend initial in)ision to full length of groo$e 3ith s)issors or knife4

Safet" sutures are 're'la)ed usuall" >+O $i)r"l

Extending an existing incision)an !e tri)k" and the te)hnique is different for s)leral

tunnels )om'ared to )lear )orneal in)isions- Hoe$er in !oth )ases the original

e.tension is !rought to the lim!us- *n the )ase of an original s)leral in)ision the in)isionis !rought anterior to oin the lim!us on either end !efore e.tending along the lim!us for

a )hordlength of a!out mm- *n the )ase of an e.isting )orneal in)ision the )orneal

in)ision is !rought 'osterior toard the lim!us !efore e.tending the ound along the

lim!us for a )hord length of a!out mm- 0hen iris hooks are !eing used in a diamond)onfiguration the ound )an !e e.tended to 'reser$e the su!+in)isional hook and the

large 'u'il/-

Conun)ti$al 'eritom" of a!out >= degrees

7se 2 or )res)ent !lade on either side of the e.isting ound to make a lim!al

groo$e ith a )hord length of mm

Bi'olar )auter" for hemostasis

7se Cres)ent to !ring e.isting s)leral ound anterior or e.isting )orneal ound'osterior to oin lim!us

E.tend initial in)ision to full length of groo$e 3ith s)issors or knife4

Safet" sutures are 're'la)ed usuall" >+O $i)r"l

&emoving t!e lensOne has to !e far more )areful hen remo$ing the nu)leus during the

t"'i)al )on$ersion to ECCE hi)h )omes along ith $itreous loss- %irst the anterior

)a'sule must !e large enough to allo the nu)leus to e.'ress hi)h ma" require rela.ingin)isions in some )ases- 0hen the &onules are eak or the 'osterior )a'sule is torn the

lens )annot !e e.'ressed ith fluid or e.ternal 'ressure as is often done ith a 'lanned

ECCE ith inta)t )a'sule@&onlules- After an" $itreous is remo$ed 3see !elo4, the lens

must !e )arefull" loo'ed out of the anterior )ham!er ith minimal 'ressure on the glo!e-*f the 'osterior )a'sule and &onlues are in ta)t than the lens )an !e e.'ressed as des)ri!ed

ith a 'lanned ECCE-

&emoving /ens it! intact capsule complex

mo!ili&e lens 3'h"si)all" ith )"stitome or ith h"drodisse)tion++!e )areful4

(ens remo$ed @ lens loo' or @ )ounter 'ressure te)hnique


20/29

0ound is )losed ith safet" sutures and additional )entral $i)r"l suture

Corti)al material is remo$ed using *@A de$i)e 3either automated or manual4

*nstill o'hthalmi) $is)oelasti) de$i)e 3OVD

(ens is 'la)ed in the 'osterior )ham!er

0ound is )losed ith =+O n"lon and $i)r"l sutures are remo$ed-

OVD is remo$ed

&emoving /ens it! vitreous present

mo!ili&e lens ith $is)oat )anulla ++ ti' lens so that ound side is anterior4

sli' lens loo' under lens, toe u', remo$e lens

0ound is )losed ith safet" sutures and additional )entral $i)r"l suture

Anterior $itre)tom" 3see !elo4

Corti)al material is remo$ed using dr" te)hnique or anterior $itre)tor

instill o'hthalmi) $is)oelasti) de$i)e 3OVD

(ens is 'la)ed in the sul)us or in the anterior )han!er

0ound is )losed ith =+O n"lon and $i)r"l sutures are remo$ed

OVD is remo$ed

Placement of t!e I"/ *O( sele)tion ith ECCE )on$ersion de'ends on the residual

)a'sular )om'le.1,2- The ke" to *O( )entration is to get !oth of the ha'ti)s in the same

'la)e? either !oth in the !ag or !oth in the sul)us-

0hen the 'osterior )a'sule is inta)t folloing a )on$ersion to ECCE the anterior

)a'sular o'ening is usuall" 'oorl" defined hi)h )an make !ag 'la)ement

diffi)ult- *f the anterior )a'sule and thus the !ag is ell defined, then 'la)e asingle 'ie)e a)r"li) *O( ithout folding it dire)tl" and gentl" into the !ag using

kelman for)e's-

0hen the 'osterior )a'sule is inta)t and the anterior )a'sule is 'oorl" defined

then 'la)e a 1 'ie)e *O( in the sul)us su)h as a large sili)one *O( or the MA=

a)r"li) !" 'la)ing these dire)tl" and unfolded into the sul)us ith kelman for)e's-

Make sure that !oth ha'ti)s are in the sul)us-

0hen the 'osterior )a'sule is damaged, if enough anterior )a'sule and 'osterior

)a'sule is left to su''ort the *O(, define the sul)us ith $is)oat and 'la)e the *O(dire)tl" in the sul)us- Make sure !oth ha'ti)s are in the sul)us- *f the *O( does

not seem sta!le then 'la)e M)Cannel sutures to se)ure the *O( to the iris or

remo$e and re'la)e ith an AC *O( 3don


21/29

limiting indu)ed astigmatism- Often the )are is $er" similar to that of a 'lanned ECCE

ith a!out 1 'ost o'erati$e $isits one the same da" or ne.t, one a eek later, and one

a!out + eeks later- De'ending on the amount of astigmatism the 'atient ma" requirese$eral $isits to sequentiall" remo$e sutures hile eliminating indu)ed astigmatism-

(irst post operative visit Often on the same afternoon 2+ hours folloing surger" orne.t morning ith the 'rimar" em'hasis to )he)k the *OP, look for ound leaks and s)an

for residual lens material or $itreous in the anterior )ham!er- Most ound leaks should

!e sutured !ut if the AC is not formed )losing these is mandator"- #esidual nu)learmaterial should !e remo$ed in the ne.t fe da"s if 'resent !ut residual )orti)al material

ill often dissol$e aa" ith little inflammation- Lou ould e.'e)t 'oor $ision in the

/=@/== range due to astigmatism and edema- The anterior )ham!er should !e formed and

t"'i)all" has moderate )ell 3=+/= )ells@h'f ith =-/ mm !eam4- *f the *OP is less than= sear)h hard for a leak using Siedel testing- *f the *OP is in the =+/ range all is

'ro!a!l" O: unless the 'atient is a $as)ulo'ath and then the u''er limit of *OP toleran)e

should !e loered- *f the *OP is in the 1=+1 range )onsider aqueous su''ression- *f the

*OP is 2= than )onsider aqueous su''ression and !leeding don the *OP ith the'ara)entesis or anterior )ham!er ta'- The *OP should !e re)he)ked =+= minutes later

to ensure su))ess ith "our treatment- (ook at the fundus and rule out retinal deta)hmentand )horoidal effusion or hemorrhage- T"'i)all" 'atients are 'la)ed on 'rednisolone

a)etate G i dro' 2 times a da", )")log"l G i dro' / times a da", and an anti!ioti) i dro'

2 times a da" for the ne.t eek-

$ee' ) post operative visit The $ision and 'ressure should dramati)all" im'ro$e in

'atients o$er the ne.t eek here "ou ha$e )on$erted to ECCE- The $ision should !e

in the /=@== range ith an im'ro$ement ith 'in hole to /=@=- The $ision is usuall"limited !" residual edema and astigmatism- *n a stud" of our ECCE e found a!out >

dio'ters of )"linder at the one eek $isit- Lou should e.'e)t $er" little inflammation and

do)ument that no #D e.ists- Sear)h for residual lens material in the anterior segment and'osterior 'ole- Lou )an dis)ontinue the )")log"l and the anti!ioti)- Slol" ta'er the

'rednisolone a)etate like i gtt qid for > more da"s, then i gtt tid for > da"s, then gtt !id

for > da"s, then i gtt qd for > da"s, then dis)ontinue- *f the 'atient is at risk for CME 3eg$itreous loss4 than kee' on 'rednisolone qid and start a non steroidal like a)ular * gtt qid

until the ne.t $isit 2 + eeks later-

$ee' 0 post operative visit The $ision should )ontinue to im'ro$e as the astigmatismsettles and the )ornea )lears further- The e"e should !e )omforta!le- The $ision should

!e in the /=@F= range ith an im'ro$ement to /=@2= ith 'in hole- *n our stud" the

astigmatism indu)ed !" ECCE sutures as a!out -= dio'ters at the in)ision- Theanterior segment should !e quiet and the *OP normal 3unless the 'atient is a steroid

res'onder4- Consider CME as a 'ossi!ilit" in 'atients here )on$ersion as required as

these )ases are often long and )an in$ol$e $itreous loss ith OCT, %%A, or )lini)al e.am-

But the main issue is astigmati) )ontrol ith suture remo$al- 7se keratometr", refra)tion,

streak retinos)o'", or to'ogra'h" to guide in suture remo$al- *f the keratometr" is 2-==

at =, and 2=-== at F= then look for tight sutures at around = degrees 3/ o)lo)k4 that


22/29

are )ausing dio'ters of )"linder- Lou )an take onl" one suture at eeks, then )an take

ma"!e / at a time !" F eeks- The 'lan is to remo$e a suture and see ho the )ornea

settles- 0hen the astigmatism is less than a!out -= to - dio'ters "ou should sto'- 7seanti!ioti) dro's for a fe da"s after suture remo$al- After this $isit "ou should )onsider

the folloing )hoi)es ith ea)h $isit 3don


23/29

Cut lo@*rrigate high

*n general the !ottle height should !e lo 5 ust high enough to kee' the AC formed andnot so high to 'ush fluid and 'ossi!l" $itreous out from the e"e- The )utting rate should

!e as high as 'ossi!le hen )utting $itreous and lo hen )utting )orti)al lens material-

0e ill se'aratel" dis)uss earl", mid, and late )ase $itreous loss !elo-

1itreous Presenting early in case 3!ile most of crystalline lens is in eye This is the

orst time for $itreous to 'rola'se and one should strongl" )onsider )on$erting to ECCE-The ste's to )onsider are outlined !elo-

*f to'i)al do su!tenons ine)tion 3as des)ri!ed a!o$e4

Consider )losing the tem'oral in)ision ith =+= and make se'arate in)ision

ith 'eritom" su'eriorl" es'e)iall" 3as dis)ussed a!o$e4

7se dis'ersi$e $is)oelasti) to lift lens u' near the ound and to dis'la)e

$itreous more 'osterior-

Ma" need e)k )ell $itre)tom" to )lean u' if the $itreous is $er" 'rola'sed

7se lens loo' to remo$e lens 3as des)ri!ed a!o$e4

Ha$e 0es)ott s)issors read" hen loo'ing out lens to )ut $itreous

Close ith 1 >+= $i)r"l safet" sutures one at )enter and one on either side 1

mm aa" 3allos remo$al of )enter suture to 'la)e mm *O(

Ma" need to add some =+O n"lon at ound edges to get atertight

Anterior $itre)tom" 3as dis)ussed a!o$e se'arate as'@)utter from irrigator4

Dr" remo$al of residual )orti)al material ith s"ringe on /> gauge )annula

7se ;+)annula or 'ara)entesis if needed for su!+in)isional material

Consider staining ith :enalog 3see !elo4

Pla)e *O( if 'ossi!le in sul)us 3adust 'oer4 or use an AC *O( 3don


24/29

Dr" remo$al of residual )orti)al material ith s"ringe on /> gauge )annula

7se ;+)annula or 'ara)entesis if needed for su!in)isional material

Consider staining ith kenalog 3see !elo4

Pla)e *O( if 'ossi!le in sul)us or AC 3if AC don


25/29

Pla)e a // gauge needle on the distal end of the filter

Dra / ml of BSS into the s"ringe through the filter to resus'end the :enalog

The :enalog 3no ithout 'reser$ati$e and dilute =?4 ill stain $itreous

strands hite

&eferences

- Oetting, TA, Cataract Surgery for Greenhorns, A$aila!le at

htt'?@@medrounds-org@)atara)t+surger"+greenhorns- a))essed Se'tem!er , /==>/- Du''s 0; Oetting TA, Diamond iris retra)tor )onfiguration for small+'u'il

e.tra)a'sular or intra)a'sular )atara)t surger"- ; Catara)t #efra)t Surg Vol

1=3/4?/2>1+/2>

1- Chang D%, Oetting TA, :im T, Curbside Consultations in Anterior Segment

Surgery, Sla)k *n), Thorofare 8;, /==>

2- Henderson BA,Essentials of Cataract Surgery, Sla)k *n), Thorofare 8;, /==>

- Burk SE, Da Mata AP, Sn"der ME, S)hneider S, Osher #H, Cionni #;-Visuali&ing $itreous using :enalog sus'ension ; Catara)t #efra)t Surg- /==1

A'r/324?2+
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26/29

*V- COMP(*CAT*O8S 5 Bonnie An Henderson M-D-

). Intraoperative

A- Su'ra)horoidal hemorrhage

$is%s:0ith large in)ision surger", the risk of a hemorrhage in)reases as ell as the risk of a

)atastro'hi) out)ome- The knon risks in)lude in)reased age ith mature lenses,

'ree.isting u$eitis, glau)oma, s"stemi) h"'ertension, high m"o'ia, and 'atients onanti)oagulation medi)ations-

&iagnosis:

Patient ma" )om'lain of se$ere 'ain- The surgeon ma" noti)e )ham!er shalloing, lossof red refle., and hardening of the e"e- *ndire)t o'hthalmos)o'" is ne)essar" to assess

the fundus- *f una$aila!le, a handheld lens ith the o'erating mi)ros)o'e 3Osher

Panfundus lens4 )an !e used to qui)kl" $ie the fundus-

Treatment:

%irst and foremost is )losure of the e"e to 're$ent further e.'ulsion of the o)ular tissues-*f the e"e )annot !e )losed ith sutures, the in)ision )an !e held )losed ith dire)t

'ressure hile *V Mannitol is gi$en- On)e the e"e is se)ured ith sutures, an"

'rola'sing u$eal tissue )an !e re'ositioned- *f the e"e )annot !e )losed, the )horoidalhemorrhage )an !e drained !" 'la)ing a 'osterior s)lerotom" 1- to 2-= mm 'osterior to

the lim!us- Hoe$er, man" retina surgeons do not re)ommend attem'ting to drain an

a)ute hemorrhage unless it is done ith the goal of )losing the e"e- *f the e"e has !een

su))essfull" )losed, it is 'rudent to refer to a retinal s'e)ialist for 'ossi!le drainage at alater time, if needed- The )om'lete remo$al of )orti)al material or im'lantation of the

*O( is se)ondar" to the 'rimar" goal of sta!ili&ing the e"e- Prom't referral to a retina

s'e)ialist is re)ommended-

B- Vitreous (oss

This has !een )o$ered in Dr- Oetting


27/29

in)ision or using a s'atula through the 'ars 'lana to su''ort and ele$ate the lens- *f the

lens fragment is too 'osterior or not easil" a))essi!le, it is ala"s safer to )lose the e"e

and refer the dro''ed lens to a retinal surgeon- *f the 'atient needs additional retinalsurger" to remo$e the dro''ed fragment, it is im'ortant to )onsider the 'ros and )ons of

'la)ing the *O(- *f the lens fragment is large and hard, the retina surgeon ma" need to

'rola'se the fragment anteriorl"- Therefore, it ma" !e !enefi)ial to lea$e the 'atienta'haki) until after the fragment has !een remo$ed-

D- *ris Prola'se?$is%s:

0ith a large in)ision, iris 'rola'se is )ommon e$en in an un)om'li)ated ECCE- A 'oorl"

)onstru)ted uni'lanar ound ith a 'osterior entr" ill in)rease the risk of iris 'rola'se-

The use of al'ha adrenergi) !lo)kers su)h as Tamsulosin 3%loma.4 )an )ause the iristissue to !e flo''" and also in)rease the likelihood of 'rola'se during surger"- Ele$ating

the intrao)ular 'ressure ith e.)essi$e ine)tion of fluid or $is)oelasti)s )an )ause iris

'rola'se-

Continued iris 'rola'se during surger" )an )ause 'u'il irregularities, iris damage,

inflammation, !leeding, and 'eri'heral anterior s"ne)hiae-

Treatment:

*ntra)ameral mioti) should !e used to )onstri)t the 'u'il to assist in redu)ing the iris'rola'se- *f the iris 'rola'se is mild, gentle re'ositioning of the iris ith a !lunt

instrument su)h as a )annula or s'atula )an !e effe)ti$e- *f the iris )annot !e

re'ositioned, a small 'eri'heral iride)tom" )an !e 'erformed- On)e the iris has !een

re'ositioned !a)k in the e"e, !e )areful not to o$erl" inflate the e"e hi)h ma" )ause theiris to 'rola'se again-

6. Postoperative

A- 0ound leak

$is%s:

*n )om'li)ated )ases ith 'osterior )a'sular tears, $itreous or iris tissue ma" !ein)ar)erated in the ound and hindering ound )losure- *f this is sus'e)ted, )arefull"

e.amine for 'eaked 'u'ils or $itreous strands to the ound- *f iris tissue has 'rola'sed

through the ound, the !luish )olor of the u$ea )an !e seen in the ound under the

)onun)ti$a-

&iagnosis:

*f the anterior )ham!er is flat or the intrao)ular 'ressure is lo, ala"s test the ound forleakage- 7sing a )on)entrated fluores)ein stri' or dro', 'la)e on the ound and e$aluate

for dilution of the stain !" leaking aqueous humor-

Treatment:

*f the )ause of the ound leak is in)ar)erated $itreous or iris, the 'atient must ha$e a

ound re$ision in the o'erating room- A $itre)tom" should !e 'erformed if $itreous is

found- *f there is no 'osterior )a'sular tear or $itreous 'resenting, !ut iris tissue is


28/29

'rola'sing, intra)ameral mioti) )an !e gi$en to 'ull the iris out of the ound- 6entle

re'osition of the iris )an !e 'erformed- The ound should !e re+sutured to 're$ent

further leaking-

*f the ound leak is not due to the a!o$e reasons, it ma" !e suffi)ient to follo the

'atient medi)all" for a fe da"s- A !andaged )onta)t lens )an !e 'la)ed and an aqueoushumor su''ressor )an !e gi$en to'i)all"- Be sure to 'la)e the 'atient on to'i)al

anti!ioti)s in the 'resen)e of an" ound leak- *f the ound leak does not resol$e after

se$eral da"s, the ound should !e re+sutured-

B- High Astigmatism@Suture Cutting

$is%s:The e$olution of )atara)t surger" is toards smaller and smaller in)isions-

Therefore, )atara)t surgeons and those in training are suturing less often- 0hen suturesare not 'la)ed in a 'ro'er manner, the result )an !e an as"mmetri) ound )losure-

Sutures 'la)ed ith different tensions and different orientations )an )ause high

astigmatism 'osto'erati$el"- This is often true in )ases here an ECCE as un'lanned-

&iagnosis:

*ntrao'erati$el", the indu)ed )orneal astigmatism )an !e measured using a handheld'orta!le keratometer or 'hotokeratos)o'e- *f there is a large amount of astigmatism from

a tight suture, the suture should !e re'la)ed-

Posto'erati$el", the $ision ill !e 'oor ith high un)orre)ted astigmatism- :eratometr"

measurements, manifest refra)tion, )orneal to'ogra'h" are all useful in e$aluating the

amount and lo)ation of the astigmatism-

Treatment:

0hen and ho to remo$e large in)ision sutures is )ontro$ersial- The sooner the sutures

are )ut, the greater the effe)t of rela.ing the stee'ness in that meridian- Hoe$er, thetiming must !e !alan)ed to ensure 'ro'er ound healing hile )onsidering the

effe)ti$eness of astigmatism )ontrol- Most 'h"si)ians agree to ait at least 1+2 eeks

!efore )utting sutures in a large ECCE in)ision- Some 'h"si)ians ill ait until after theto'i)al steroid dro's ha$e !een sto''ed !efore )utting sutures-

Ho man" sutures to )ut at one time is also )ontro$ersial- Some 'h"si)ians ill onl"

remo$e one suture at a time and ha$e the 'atient return in +/ eeks to re)he)k theastigmatism- Others ill )ut man" at the same time rela. the )orneal astigmatism- Ea)h

)ase should !e )onsidered indi$iduall" and the sta!ilit" of the ound should !e

)onsidered hen )hoosing the num!er of sutures to )ut-

0hen )utting sutures, the goal is to minimi&e 'ulling an" e.'osed suture through the e"e

during the remo$al 'ro)edure- Therefore, )ut the suture )losest to the )orneal edge and'ull the end out of the s)leral side so the e.terior 'ortion of the suture 3la"ing on to' of

the s)lera4 is not 'ulled through the e"e, onl" the interior 'ortion is 'ulled out of the e"e-

Ala"s use a dro' of to'i)al anti!ioti)s !efore and after the suture remo$al- Some

surgeons ill )ontinue the to'i)al anti!ioti)s u' to one eek after suture remo$al-


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C- Medi)ations

Preo'erati$el", if an ECCE is 'lanned, anti)oagulants in)luding as'irin and 8SA*Dsshould !e dis)ontinued if 'ossi!le- Consult ith the 'rimar" )are 'h"si)ian and dis)uss

'ossi!le dis)ontinuation-

Patient ho are undergoing a 'rimar" ECCE or )on$ersion to an ECCE should ha$e an

ine)ted 3'eri!ul!ar or retro!ul!ar4 anestheti)- To'i)al, intra)ameral, and su!tenon

e c c e handout

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