Step by step through phacoemulsification
- Pre-operative anesthetic drops and dilating drops
- Additional anesthetic drops
- Surgical prep using betadine
- Creation of a paracentesis
- Injection of preservative-free lidocaine into the anterior chamber
- Injection of a thick, dispersive ophthalmic viscoelastic device (OVD) into the anterior chamber to provide a working space and protect the inner surface (endothelial layer) of the cornea
- Creation of a clear corneal incision site (typically a tri-planar wound to promote self-seal)
- Capsulorhexis (CAP-su-lo-REX-is) is the creation of an opening in the anterior capsule to gain access to the cortex and nucleus. Most of the capsule is left intact to provide a pouch for insertion of the IOL. First, an angular tab is made in the capsule. This tab is then pulled in a curvilinear motion to create a circular opening. This is a very important surgical step since mistakes can make the removal of the natural lens and intraocular lens (IOL) insertion very difficult.
- The cortex is dissociated from the overlying capsule by injecting a balanced salt solution (BSS) between the cortex and capsule (hydrodissection). The surgeon may then spin or rotate the lens to ensure it is freely mobile.
- Hydrodelineation may similarly be performed to separate the endonucleus from the epinucleus. The purpose is to leave the epinuclear shell to protect the posterior capsule during the first stages of phacoemulsification and removal of the endonucleus, but this step is often not performed and the entire nucleus is instead removed at once.
- A probe uses ultrasonic energy to break up the lens nucleus. A vacuum attached to the same probe removes the nucleus fragments that are generated. Several approaches may be used, including a “divide and conquer” approach whereby the nucleus is first divided into two main pieces. Other techniques use a chopper as a second instrument to fragment the nucleus into multiple pieces which are then emulsified by the phaco-hand piece.
- The cortex is aspirated and pulled away from the capsule. Care must be taken to avoid tearing the capsule and allowing vitreous leakage into the anterior chamber.
- The capsular bag is filled with a cohesive OVD (this is a less viscous OVD than was used to fill the anterior chamber), creating a space in which to inject the lens.
- Placement of the intraocular lens (IOL). The lens itself has the optic and two haptics (arms). The lens is inserted into the capsular bag through a tube and uncurls automatically. The haptics extend outward into the periphery of the capsular bag to maintain the optic within the center of the capsular bag. If the optic is right side up, the haptics form the shape of a number “2”, and an optic placed upside down will look like an “s.”
- Removal of OVD from the capsular bag and anterior chamber.
- Hydration of the corneal incision with BSS, which causes local corneal epithelial cells to expand and compress each other and allows for wound closure without sutures.
- Assessment for leakage by drying the wound area with a weck-cell tip and gently pressing down on the cornea.
- Application of topical antibiotic eye drops, as well as a topical steroid (intracameral antibiotic injections during surgery may also be used and reduce the incidence of endophthalmitis relative to topical antibiotics). Sometimes topical drops are also used to lower eye pressure.
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