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Phacoemulsification of Nuclear Cataract and Intraocular Lens Implantation

Cataract surgery is an appropriate option to consider when a patient’s visual function is no longer able to support their desired activities or when it becomes a detriment to their health and quality of life. Phacoemulsification with intraocular lens implantation is the most common procedure used to restore vision in patients with cataracts; it has been shown to restore vision to 20/40 or better in over 95% of cases [2] . The procedure uses an ultrasonic handpiece to fragment, emulsify, and aspirate an opacified lens all through a small incision in the cornea. A new intraocular lens made of acrylic is inserted into the remaining lens capsule and replaces the cataract. This outpatient surgery is typically sutureless and completed in 10-20 minutes.

This case highlights a patient with a nuclear sclerotic cataract who elected for phacoemulsification extraction with intraocular lens implantation. The video showcases the proper placement of cataract removal instruments and phaco handpiece, completion of the most critical step of the procedure—the capsulorhexis and highlights proper placement of the intraocular lens.

Authors

Adam Neuhouser, Medical Student, University of Arkansas for Medical Sciences, ajneuhouser@uams.edu.

Victoria Ly, Medical Student, University of Arkansas for Medical Sciences, vly@uams.edu.

Ahmed A. Sallam, M.D., Ph.D. Department of Ophthalmology, Jones Eye Institute. asallam@uams.edu

This video shows phacoemulsification cataract extraction with intraocular lens implantation in a patient with a nuclear sclerotic cataract. The video documents all key points of the procedure and highlights classic techniques including paracentesis, placement of ophthalmic viscoelastic device, continuous curviliniear capsulorhexis, hydrodissection with BSS, phacoemulsification, cortical irrigation and aspiration, IOL injection, and incision closure [1].
-Functional decline in vision (e.g. difficulty reading, driving, recognizing faces, diplopia) with best-corrected visual acuity of 20/40 or worse. -Blurred vision and glare. -Clinically significant anisometropia in the presence of a cataract. -Lens opacity inhibits management of posterior segment disease. -Lens causing inflammation, angle-closure, or medically unmanageable open-angle glaucoma.
-Relatively hard lens which should be managed with manual large-incision cataract surgery (extracapsular cataract extraction). -No/minimal zonular support of lens. -Current inflammation, infection, corneal scars, macular or retinal deterioration, optic nerve disease, or other ophthalmic pathology are associated with poorer outcomes.
Standard intraocular surgery set-up and sterility prep. Orbital anesthesia via sub-Tenon’s block. Lid speculum was used to retract eyelids.
-Preoperative workup includes a full ophthalmic history and physical exam and specific testing for intraocular lens selection. Testing includes: keratometric readings, ultrasound axial length of the eye (A-scan), and a calculation of implant power requirements. -In some circumstances, other preoperative tests include: corneal endothelial cell counts, corneal pachymetry, B-scan ultrasonographic scanning of the posterior segment, potential visual acuity (PVA) testing, ophthalmic photography, and corneal topographic scanning [3]. -The risks, benefits and alternatives to phacoemulsification with IOL are also explained to the patient prior to the procedure.
The lens sits behind the iris and is suspended by zonular fibers. The zonules attach the equator of the lens to the surrounding ciliary body. The iris divides the anterior chamber from the posterior chamber. The lens itself consists of three basic structures: the outermost layer is the capsule, followed by the cortex, and inner nucleus.
Advantages: -Small incision which usually does not require sutures, and associated with reduced postoperative inflammation, patient discomfort after surgery, and reduces recovery period relative to extracapsular cataract extraction. -Low risk of serious sight-threatening complications. -Potential for correction of myopic or hyperopic vision with insertion of monofocal or multifocal lens. Disadvantages: -Potentially expensive. -Higher incidence of surgical complications like corneal damage in unskilled hands in comparison to conventional cataract surgery. -Requires a cooperative patient who will not move their head during the operation, and must be able to lay flat for 30-60 minutes.
Potential for ptosis, endophthalmitis, corneal decompensation, retinal detachment, CME, and suprachoroidal hemorrhage, irregular pupil, and intraoperative floppy iris syndrome.
The authors declare no conflict of interest.
N/A
1. Oetting TA (2012) Cataract Surgery for Greenhorns. 2. Powe NR, Schein OD, Gieser SC, Tielsch JM, Luthra R, Javitt J, Steinberg EP. Arch Ophthalmol. (1994) Synthesis of the literature on visual acuity and complications following cataract extraction with intraocular lens implantation. Cataract Patient Outcome Research Team;112(2):239. 3. Hagan JC 3rd, Wyatt B. J Ophthalmic Nurs Technol. (1993) Preoperative evaluation and workup of the cataract and intraocular lens implant patient;12(3):123-8.

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