Learning Learning PhacoemulsificationPhacoemulsification forfor TremorTremor SurgeonsSurgeons

GedeGede PardiantoPardianto

Dr. Gede Pardianto. SMEC Jakarta Jl Pemuda 36 Rawamangun Jakarta

Timur. Sumatera Eye Center Jl Iskandar Muda 278

Medan. Tel 628155000300.

GraduateGraduate– Doctor of Medicine Doctor of Medicine Universitas Universitas

AirlanggaAirlangga– Ophthalmologist Ophthalmologist Universitas AirlanggaUniversitas Airlangga

OfficeOffice– Sumatera Eye Center, MedanSumatera Eye Center, Medan– Dr Komang Makes Naval Hospital, Dr Komang Makes Naval Hospital,

BelawanBelawan– Universitas Sumatera Utara, Medical Universitas Sumatera Utara, Medical

SchoolSchool

MemberMember– IOAIOA– InaSCRSInaSCRS– ESCRSESCRS– ASCRSASCRS

No Financial InterestNo Financial Interest

Gede Gede PardiantoPardianto

Phaco surgeryPhaco surgery

Phaco surgery Phaco surgery only a little thing only a little thing we dowe do

All of our time All of our time we practice we practice Practice makes perfectPractice makes perfect

PhacosurgeryPhacosurgery

MicrosurgeryMicrosurgery Advanced surgeryAdvanced surgery Refractive surgeryRefractive surgery

Tremor surgeonsTremor surgeons

Tend to failTend to fail High ‘mortality’ in learning process High ‘mortality’ in learning process But possibly to success But possibly to success don’t be don’t be

surrender or giving up easilysurrender or giving up easily Being gentle and carefully Being gentle and carefully patient’s patient’s

sight is everythingsight is everything Know the pitfall and limitationKnow the pitfall and limitation Know what should do and do notKnow what should do and do not Learn more, practice moreLearn more, practice more

PhacoPhaco

Same proper procedure in entire Same proper procedure in entire process of surgery with ‘little bit’ process of surgery with ‘little bit’ pressure in a view techniquepressure in a view technique

Pre phacoPre phaco Peri phacoPeri phaco During phacoDuring phaco Post phacoPost phaco

Pre-phacoPre-phaco

Patient selectionPatient selection Optical biometry scanned immature Optical biometry scanned immature

cataractcataract

Peri-phacoPeri-phaco

Adjust your microscope Adjust your microscope reset reset Adjust your seatAdjust your seat Adjust your patient’s positionAdjust your patient’s position Protect the fellow eyeProtect the fellow eye Place your drape properlyPlace your drape properly Cut to open your drape properlyCut to open your drape properly Place your speculum properlyPlace your speculum properly Now place your hand gently firmNow place your hand gently firm

Better but you don’t have toBetter but you don’t have to

General or local anesthesia General or local anesthesia Fixing the eye ballFixing the eye ball

Microscope (again)Microscope (again)

Your foot please Your foot please stay on pedal stay on pedal PDPD IlluminationIllumination MagnificationMagnification FocusFocus Reset (again)Reset (again)

During phacoDuring phaco IncisionIncision CCCCCC HydrodissectionHydrodissection SculptingSculpting CrackingCracking Segment RemovalSegment Removal Epi-nucleus removalEpi-nucleus removal Capsule polishCapsule polish Irrigation/AspirationIrrigation/Aspiration Lens InsertionLens Insertion Wound closureWound closure

IncisionIncision Second IncisionSecond Incision

– Proper two- or three- Proper two- or three- planed incisionplaned incision

– Optimum size Optimum size – Direction controlledDirection controlled

Main IncisionMain Incision– Proper two- or three-Proper two- or three-

planed incisionplaned incision– Precise sizePrecise size

‘‘Third’ IncisionThird’ Incision– Minimum sizeMinimum size Mahatme V, 2005

Incision: PitfallIncision: Pitfall Early anterior capsule Early anterior capsule

teartear ‘‘Not enough’ portNot enough’ port Leaking portLeaking port Leaking wound Leaking wound

shallow ACDshallow ACD Iris prolapseIris prolapse

– More limbalMore limbal– Direct one-planedDirect one-planed

Post operative Post operative astigmatism astigmatism positionposition

Mahatme V, 2005

OVDOVD

Right OVDRight OVD Tight anterior chamberTight anterior chamber Space Space StructureStructure

CCCCCC Fixed eye ballFixed eye ball Stained capsule Stained capsule

compulsorycompulsory Tight anterior chamberTight anterior chamber Curve tearCurve tear Gently movementGently movement

– PosteriorlyPosteriorly– Toward centerToward center

Keep alertKeep alert Proper sizeProper size

Mahatme V, 2005

Mahatme V, 2005

CCC: PitfallCCC: Pitfall

EscapeEscape Too largeToo large Too smallToo small Weak Weak

Hydrodissection: PitfallHydrodissection: Pitfall

Inadequate Inadequate Difficult to rotateDifficult to rotate Early drop nucleusEarly drop nucleus

HydrodissectionHydrodissection

Direction of canuleDirection of canule Position of hand, Position of hand,

syringe and needlesyringe and needle Amount of waterAmount of water Power of pressurePower of pressure Speed of injectionSpeed of injection Time of injectionTime of injection

Mahatme V, 2005

Mahatme V, 2005

HydrodelineationHydrodelineation

Traumatic cataractTraumatic cataract Posterior pole Posterior pole

cataractcataract Post vitrectomy Post vitrectomy

cataractcataract Hard brown Hard brown

cataract cataract

Mahatme V, 2005

Rotating the nucleusRotating the nucleus

Be sure Be sure nucleus nucleus movable movable

Beware of zonular Beware of zonular weaknessweakness

Use two toolsUse two tools

Mahatme V, 2005

During phaco: PitfallDuring phaco: Pitfall

Wound burnWound burn Endothelial burnEndothelial burn SurgeSurge Broken CCCBroken CCC PCRPCR Drop nucleus or segmentDrop nucleus or segment Iris damageIris damage

Sculpting and CrackingSculpting and Cracking

Nearest areaNearest area Position of phaco tipPosition of phaco tip Direction of tip’s bevelDirection of tip’s bevel Position and direction of chopperPosition and direction of chopper Make sure those in right handling, right Make sure those in right handling, right

place, right setting, right maneuver of place, right setting, right maneuver of hands and feethands and feet

Beware of the edge of CCCBeware of the edge of CCC

Sculpting and CrackingSculpting and Cracking

Mahatme V, 2005 Mahatme V, 2005

Mahatme V, 2005

Segment removalSegment removal

Smaller segment Smaller segment easier to removeeasier to remove

Position of phaco tipPosition of phaco tip– Center Center center of iris center of iris

plane areaplane area– Irrigating controlledIrrigating controlled

Direction of bevelDirection of bevel Mind your foot on Mind your foot on

pedalpedal Mind you second Mind you second

instrumentinstrument

Mahatme V, 2005

Last pieces and epinucleus Last pieces and epinucleus removalremoval

Mind your irrigationMind your irrigation Bevel-up Bevel-up Mind your second Mind your second

instrumentinstrument Mind your foot on Mind your foot on

pedalpedal Don’t hesitate to add Don’t hesitate to add

OVD OVD lift epinucleus lift epinucleus anteriorlyanteriorly

Don’t to fast move to Don’t to fast move to I/A modeI/A mode

Mahatme V, 2005

Irrigation/Aspiration and Irrigation/Aspiration and Capsule PolishCapsule Polish

Mind your illuminationMind your illumination Mind the posterior capsuleMind the posterior capsule Always from equator or edge areaAlways from equator or edge area Venting controlledVenting controlled Stop without moveStop without move

PitfallPitfall

SurgeSurge Bitten capsuleBitten capsule PCRPCR

Mahatme V, 2005

Inserting the IOLInserting the IOL

Zoom outZoom out Gently loading IOL from pack to Gently loading IOL from pack to

cartridgecartridge Zoom in, focusedZoom in, focused Inserting the IOLInserting the IOL Mind the edge of CCC aheadMind the edge of CCC ahead Firm your hand Firm your hand no retread no retread Under OVD or hydro-insertionUnder OVD or hydro-insertion

Inserting the IOLInserting the IOL

Wound closureWound closure

Direction of needleDirection of needle Amount of waterAmount of water Speed of injectionSpeed of injection

Wound closure: PitfallWound closure: Pitfall

InadequateInadequate Loss of fluidLoss of fluid Fast overload anterior chamberFast overload anterior chamber

Post phacoPost phaco

Release the speculumRelease the speculum Release eye drapeRelease eye drape Instill some eye dropsInstill some eye drops Place eye shieldPlace eye shield

Sail of the 150 years of Gold Rush in California USA, 1999

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