Extracapsular Cataract Extraction:

Nonphacoemulsification Large and Small

Incision Approach
ASCRS 2012
Bonnie 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, Venkateswara V Mootha MD, Abhay Raghukant Vasavada MBBS
FRCS, Mohammed Shehenaz MBBS, Brian R Sullivan MD, Amar Agarwal MBBS,
Athiya Agarwal MBBS, Ashvin Agarwal MBBS, Adil Agarwal MBBS, Anosh Agarwal
MBBS, Haripriya Aravind, MBBS, Dianna L Bordewick MD, Debasish Bhattacharya,
MBBS
Course Objectives
At the conclusion of the course you should be able to:
1. To understand the indications for primary ECCE and for conversion to ECCE
surgery
2. To understand how to competently perform the steps of primary ECCE and
conversion to ECCE surgery
3. To become familiar with and understand how to deal with complications of
ECCE surgery
Introduction
Why are we doing this course?
As small incision phacoemulsification surgery becomes the standard of care, trainees are often
not being taught how to perform ECCE surgery. We believe primary and conversion to ECCE
surgery still plays an important role in certain cases. Knowing how to perform this surgery
competently is crucial when faced with complications during phacoemulsification surgery. ECCE
surgery is widely practiced internationally where access to expensive phacoemulsification
equipment is limited.
Who are the Lecture Instructors?
a) Dr. Bonnie An Henderson is a partner at Ophthalmic Consultants of Boston and an
assistant clinical professor at Harvard. She was previously the Director of the
Comprehensive Ophthalmology Service at Massachusetts Eye and Ear Infirmary where
she was one of the main surgical attendings for the residents. She received the Harvard
Medical Schools Teacher of the Year award and nominated for Harvards Excellence in
Teaching award. She currently is a surgical preceptor at Tufts School of Medicine.
(bahenderson@eyeboston.com)
b) Dr. Maria Aaron is an Associate Professor of Ophthalmology, Emory University School of
Medicine. She has been the Residency Program Director at Emory for 10 years and has
trained and mentored over 60 residents and 25 medical students during this tenure. She
is the past-President of the Program Directors Council of the Association of University
Professors of Ophthalmology and serves as the Vice-Chair of the Ophthalmology RRC

for the ACGME. She has received an Achievement Award from the AAO and is an ABO
examiner for the Oral Boards.
c) Dr. Thomas A. Oetting is a leader in ophthalmic education. He is the Program Director
and a Clinical Professor of Ophthalmology at the University of Iowa. He is Chief of the
Eye Service and Deputy Director of Surgery for the VAMC in Iowa City. He has
supervised over 3,000 resident cataract cases. He won the resident teaching award in
2000, 2001, 2002, and 2005. He serves on the ABO/AAO Anterior Segment Knowledge
Base task force and serves on the Cataract Committee for the 2006 AAO annual
meeting. (thomas-oetting@uiowa.edu )
d) Dr. Geoffrey Tabin is Professor of Ophthalmology & Visual Sciences and Director of the
Division of International Ophthalmology at the John A Moran Eye Center, University of
Utah. He is the co-director of the Himalayan Cataract Project and spends at least three
months per year in Asia working with his Nepalese counterparts directing Tilganga Eye
Centres efforts to provide an international standard of eye care and participating in the
outreach programs.
Primary ECCE

I Primary ECCE Surgery- Maria Aaron MD

1. Indications
a. Brunescent lens
b. Sub-luxated lens- zonule loss
c. Traumatic cataract
d. Missions overseas
2. Learning Pearls
a. Dilating drops
b. Incisions
c. Capsulorhexis
d. Suturing
e. Wet lab
3. Surgical Technique- Large Incision
a. Incisions - limbal vs tunnel
b. Capsulorhexis methods
c. Basic techniques of lens extraction
d. Cortex removal
4. Wet Lab-Only realistic place to learn well
a. Basic wet lab
b. Video of extracap technique using pig eye
Primary ECCE - Small Incision Cataract Surgery (SICS)

II Primary ECCE with Small incision (SICS) Geoffrey Tabin M.D.

1. Indications
a. Same as large incision
b. Benefits of small incision less astigmatism, less suturing and
postop suture cutting, etc.
c. Use around the world
2. Surgical technique
a. Videos -Step by step instruction, discuss techniques
b. Instrumentation i.e. Irrigating lens loop

c. International use
Conversion to ECCE

III. Conversion to ECCE Surgery Thomas Oetting M.D.

1. Indications
a. Non-continuous capsulorrhexis
b. Posterior capsular tear
c. Zonular dialysis
d. Poor visualization
2. Considerations
a. Timing of conversion
b. Anesthesia supplementation
c. Patient factors blood pressure, brow
3. Surgical Technique
a. Converting a clear corneal vs scleral tunnel wound
-New wound location
-Considerations for original wound
b. Lens fragment removal techniques
c. Viscoelastic choices- when and which one to choose
d. Sheets glide
e. Expressing lens in the presence of a posterior capsule tear
3. Vitrectomy
a. Settings
b. Techniques for lens removal
c. Techniques for cortex removal
d. How much to do
e. Use of Kenalog
Complications

IV. Complications Bonnie An Henderson M.D.

1. Intraoperative
a.Suprachoroidal hemorrhage
b. Vitreous loss
c. Dropped lens fragment
d. Iris prolapse
2. Postoperative
a. Wound leak
b. High astigmatism
c. Suture cutting techniques and guidelines
d. Medications
Resources

1. Albert and Jakobiecs Principles and Practice of Ophthalmology 2nd edition (3rd
edition coming soon)

2. Steinert RF Cataract Surgery: Technique Complications Management 2nd ed.

Saunders, Philadelphia PA, 2004
3. Henderson BA, Essentials of Cataract Surgery, Slack Inc, Thorofare NJ, 2007
4. Oetting, TA, Cataract Surgery for Greenhorns, Available at
http://medrounds.org/cataract-surgery-greenhorns. accessed September 9, 2007
5. Chang DF, Oetting TA, Kim T, Curbside Consultations in Anterior Segment
Surgery, Slack Inc, Thorofare NJ, 2007

I Primary Extracapsular Cataract Extraction

Maria Aaron, MD
Department of Ophthalmology
Emory University School of Medicine
A. Indications
Subluxated lens
Significant zonule loss (e.g., pseudoexfoliation)
Traumatic cataract
Mature cataracts (brunescent internal)
Large posterior capsule tear at beginning of planned phaco surgery
Overseas Missions
B. Preoperative Preparation
Consent
Intraocular lens
Operative site identification
Adequate pupillary dilation or prepare for pupil stretch
Patient position
C. Anesthesia
Retrobulbar block (injectional anesthesia: including peribulbar or
subtenons techniques)
Eliminate Posterior Pressure This is extremely important in ECCE and
should be done for approximately 10 minutes unless there is a known
zonular problem.
Manual Apply pressure for a few seconds and then release for a
few seconds
Honan Balloon Use a 30 mmHg Honan and be careful that it is
positioned properly on the globe
Mercury Bag
D. Position Surgeon and Microscope
E. Procedure
a. Bridle Suture - Rotate globe inferiorly with a muscle hook. Grasp superior
rectus (SR) with 0.3 to 0.5 toothed forceps approximately 10 mm posterior
to the limbus and lift the muscle off the globe. Pass 4-0 silk suture with a
tapered needle under the SR tendon (needle should be flat with the globe
to avoid penetration). Cut off needle and clamp the suture to the drape
with a hemostat to rotate the globe down.
b. Conjuntival Peritomy - Use blunt Wescotts to make a radial incison at the
10:00 position, 2 mm posterior to the limbus (Tenons capsule inserts 1.5
mm posterior to the limbus). Use blunt dissection to remove Tenons and
conjunctiva from globe. Keep scissor blades parallel to the limbus, insert
one blade into the conjunctival pocket, pull blades gentle toward the

cornea and cut. Repeat until the conjunctival peritomy measures

approximately 12 mm (cord length)
c. Cautery - Verify correct power setting on the machine. If using bipolar
tips, keep tips approximately 0.5 mm apart. Use a sweeping motion over
the sclera and start posteriorly approximately 2-3 mm from the limbus.
d. Incision
Groove
Measure the length of the desired wound by marking the sclera with the caliper tips
set at 10.5 mm. Use 0.12 forceps to grasp sclera at approximately the 11:00 position
to stabilize the globe. Hold the blade handle perpendicular to the globe and make the
incision from left to right approximately 1 mm posterior to the blue line. Consider
making the grove more anterior in a blue iris to prevent early entry and iris prolapse.
The depth of the groove should be approximately to 1/3 scleral depth. The length
of the groove should be 10.5 mm, beginning at the 10:30 position and ending at
approximately the 2:30 position. Attempt to make the groove in one continuous
motion by rotating the blade within your fingertips.
Tunnel - Use either a 66 or 69 blade to make a scleral tunnel into the
cornea. Use a circular motion with the blade to enlarge the tunnel for
the entire length of the grove.
Enter anterior chamber
Elevate the anterior lip of the wound with the 0.12 forceps, exposing the apex of the
flap, and enter the anterior chamber with the 75 blade parallel to the iris plane. Make
a 3 mm incision either to the right side of the wound (right-handed surgeon) or to the
left (left-handed surgeon).
e. Viscoelastic injection
Inject the viscoelastic primarily at the 6:00 position first to push the
aqueous out of the eye, while filling the entire anterior chamber.
f. Cystotome
Use a pre-bent cystotome or use a hemostat to bend a 25-guage needle
g. Capsulotomy
Can-opener Hold the cystotome with both hands to stabilize and
penetrate the anterior capsule at the 6:00 position and sweep to the
side. Continue making small punctures circumferentially to complete
a 6-7 mm capsulotomy. With each puncture the surgeon will sweep to
the right while going up the left side and to the left while going up the
right side.
Continuous If a continuous capsulorhexis is performed, radial tears
must be made to facilitate nucleus removal.
Removal of anterior capsule Use an angled instrument to grasp the
central anterior capsule. Ensure that the anterior capsule is free from
the peripheral capsule by pulling the capsule gently in all directions.
Remove the anterior capsule from the eye.
h. Enlarge wound
Use corneoscleral scissors and enter the anterior chamber with lower
jaw of the scissors and cut toward the opposite side of the wound.

Push gently toward the 6:00 position as you cut to ensure that you
enlarge the wound at the most anterior aspect of the tunnel. Maintain
scissor blades in the groove and keep blades parallel to the iris plane.
i. Nucleus Removal
Manual Expression
This is achieved by applying external, posterior pressure with forceps or the irrigating
lens loop 2 mm posterior to the limbus at the 12:00 position and using an assistant to
elevate the anterior lip of the wound. When the nucleus begins to prolapse,
counterpressure is applied with a muscle hook at the 6:00 position to facilitate
removal of the nucleus. Once the nucleus is partially out of the eye, any pointed
instrument may be used to completely rotate the remainder of the lens out of the eye.
Lift and extract
Either hydrodissection or manual rotation should be performed to elevate the 12:00
lens into the anterior chamber. To manually rotate the nucleus, use a Sinskey hook,
cannula or cystotome to gently rock the lens in a dialing/circumferential manner and
then lift and rotate. Once the superior portion of the lens is elevated, an irrigating
lens loop may be inserted under the lens. The irrigating lens loop is then flattened
parallel to the iris plane, lifted toward the cornea, and removed from the eye with the
nucleus.
j. Suture Placement
To maintain the anterior chamber during cortical removal, it is
beneficial to place 2 or 3 10-0 nylon sutures at the 10:00, 12:00 and
2:00 positions. If the iris is light-colored or there is a tendency for iris
prolapse, additional sutures may be placed.
k. Cortex Removal
Manual or Automated The cortex may be removed by using either a
manual aspirating cannula (i.e. Simcoe cannula) or an automated
irrigating/aspirating system. This technique is similar to
phacoemulsification, however, with a can-opener capsulotomy, care
should be taken not to accidently grasp the anterior capsule leaflets.
Strip the cortex toward the center of the pupil and aspirate more
aggressively only when the port is fully occluded with cortex.
l. IOL Implantation
The capsular bag is reformed with viscoelastic prior to implantation of
the IOL. It is important to reform the capsular bag and not just deepen
the anterior chamber. This is achieved by directing the viscoelastic
under the anterior capsular leaf of the capsular bag at the 6 oclock
position.
If sutures were placed prior to cortical removal, one or more will need
to be removed in order to insert a non-foldable lens. To insert a nonfoldable lens, grasp the lens approximately to 1/3 onto the optic of
the IOL with long-angled forceps (i.e. Kelman). Hold the anterior lip
of the wound and ease the IOL into the bag by tilting the lens down
and pushing the leading haptic into the 6:00 position. When the
majority of the IOL is in the capsular bag, the anterior wound is
released and the trailing haptic is grasped to prevent extrusion of the

IOL when the optic is released. Tap the IOL further into the bag with
closed Kelman forceps until the optic is completely behind the pupil.
Place or rotate the trailing haptic into the capsular bag as you would
with phacoemulsification.
m. Wound Closure
Place a corneal light shield to protect the macula from phototoxicity.
Place enough 10-0 nylon sutures to ensure adequate wound closure.
With proper wound construction, 4-5 sutures should be adequate.
n. Removal of Viscoelastic
One suture should be left untied to allow entry with the automated or
manual irrigation/aspiration instrument to completely remove the
viscoelastic. Tapping posteriorly on the anterior surface of the IOL
will facilitate removal of the viscoelastic retained behind the IOL.
o. Injections
Pupillary contriction with either intracameral Miochol or Miostat is
prudent in ECCE to reduce the risk of optic pupillary capture.
Subconjunctival Antibiotics and Steroids

II. Small Incision Cataract Surgery in Underdeveloped Countries

Geoffrey Tabin M.D.
Evolution of the Optimal Surgical Approach to Cataracts in the Developing
World
Cataracts are the leading cause of blindness worldwide with the majority of cases in
developing nations. Of the 38 million cases of blindness (visual acuity less than
20/400), an estimated 16 million are caused by age-related cataracts. In Nepal alone
the percentage of curable blindness resulting from cataracts is more than 80 percent,
and in India 3.8 million people develop cataract blindness yearly. As the worlds
population ages the incidence of cataract in developing nations will continue to rise
and with no improvement in current practices, the World Health Organization
estimates a doubling of blindness rates by 2020. Projections show that to eliminate
this rapidly growing backlog within the next 25 years, the annual global number of
cataracts operated on must increase from 7 to 32 million by the year 2020. There is
clearly a pressing need for faster, less-expensive, and more effective delivery of high
quality cataract surgery.
New surgical techniques have minimized the use of expensive consumables and
optimized efficiency while preserving the highest level of quality in visual outcomes
and minimizing complications (Ruit, 1991). Three steps have dramatically improved
the speed and efficiency with which we are able to deliver high quality suture-less,
small incision, cataract surgery (SICS). The first is a well constructed scleral tunnel
with a larger internal opening than the external scleral incision which relies upon
intraocular pressure to close the internal lip of the wound, thereby creating a selfsealing wound and eliminating post-operative suture-induced astigmatism. The
second is a triangular capsulotomy technique which eliminates the need for capsular
staining with even the most mature cataracts. Finally, our lens delivery technique
relies on use of fluidics and eye positioning to irrigate the nucleus through our funnelshaped wound and out of the eye. Finally, the once cost-prohibitive intraocular lenses
(IOLs) and other consumables such as viscoelastic, have become affordable due to
high-quality production in developing countries including Nepal and India. It has
become increasingly clear that the modified version of extracapsular cataract
extraction (ECCE) with posterior chamber (PC) IOL placement described in this
chapter is the preferred approach to cataract surgery in the developing world.
Preoperative Management
Preoperative management begins with the surgeon examining patients who have been
pre-screened for vision and relative afferent pupillary defects by ophthalmic
assistants. As the majority of our patients have mature cataracts with no view to the
posterior segment, when available, the patients undergo B-scan ultrasound at the time
of their biometry measurements.

The evening before surgery the patients faces are vigorously washed and antibiotic
drops and ointment are instilled. Prior to surgery the eyelashes are closely cropped
and flouroquinolone eye drops are instilled at the time of dilation. The eye is then
prepped with Betadine and a retrobulbar anesthetic is administered by an anesthetic
technician, after which, a Betadine soaked gauze is held over the eye. At the start of
the case the surgeon performs a final Betadine prep with instillation of a small
amount of 5% Betadine into the fornix of the eye. This preoperative cleaning and
sterilization regimen leads to a low infection rate. Efficiency of patient turnover is
maximized: as the surgeon is prepping and draping the eye the scrub nurse is
arranging a new instrument set and surgery proceeds with a typical delay of less than
three minutes between cases.
Surgical Technique
Surgeon Positioning and Maximizing Surgical Field Exposure
We generally advocate that beginning surgeons learn SICS from a superior approach;
however, many SICS surgeons operate from a temporal approach.
Temporal vs. Superior Surgical Approach
While a superior approach has long been the standard of care when performing
ECCE, we routinely perform (98% of cases) ECCE using a temporal surgical
approach as there is a significant difference between the amount of post-operative
astigmatism induced by the two techniques. The mean induced astigmatic change is
1.75 diopters (D) following a superior surgical approach due to the effects of gravity
and motion of the eyelids on the wound, while, 0.75 D of astigmatism is induced
following a temporal surgical approach.
A superior approach has remained the mainstream technique of choice given the
following advantages: First, the upper eyelid covers the external wound following the
operation when a superior approach is used, providing good wound protection.
Second, surgeon positioning at the head of the operating table provides for a more
streamlined flow of patients through the operating suite. Microscope heads, chair
positions, and instrument tables need not be repositioned between cases.
Fortunately, most of these limitations have been overcome. The rate of post-operative
infection is equivalent when using either a superior or a temporal approach; however,
it is critical to close the conjunctiva over the external scleral wound with cauterization
at the completion of the temporal approach surgery. We have also developed an
operating table which facilitates patient flow when operating temporally. It allows
the surgeon to be seated at one side; patients are then positioned with their feet
perpendicular to the surgeons line of sight, facing in either direction depending on
the eye to be operated upon (Figure 1).

Access the Anterior Chamber (AC) by Creating a Sclerocorneal Tunnel

A superior rectus traction suture may be used if operating superiorly to enhance
exposure. A fornix-based conjunctival peritomy to sclera is performed superiorly
from 10 to 2 oclock to bare sclera. Light cauterization is used to control bleeding and
blanch episcleral vessels over the incision site. A straight to slightly frown shaped
incision centered at 12 oclock is carried to 30-50% scleral depth tangential to the
limbus for 6-7 mm and approximately 1.5-2 mm from the limbus. This incision can
be made with a razor blade fragment or crescent blade, the former helping with cost
containment. The crescent blade is then used to create a lamellar scleral corneal
tunnel from the initial incision in a single plane approximately 1-1.5 mm into the
clear cornea and parallel to the ocular surface. The dissected pocket should extend
nasally and temporally to the limbus so that the transverse extent is much greater in
the cornea than in the sclera (Figure 2).
Triangular Capsulotomy vs. Continuous Curvilinear Capsulorrhexis (CCC)
Triangular capsulotomy
In the developing world mature, hypermature and Morgagnian cataracts are common;
the anterior capsules associated with such dense cataracts are often tough and
leathery, and there are frequently adhesions between the anterior capsule and the lens
nucleus. Furthermore, poor surgical visibility is common due to corneal scars,
pterygium, climatic keratopathy, sub-optimal surgical microscopes. Under these
circumstances, capsulorrhexis types of capsulotomies are difficult to complete and
can lead to incomplete or inadequate capsular openings or tears in unexpected
directions, increasing the risk of posterior capsular rupture.
Triangular capsulotomy has many advantages which make it a superb option in such
sub-optimal surgical settings. First, it utilizes a straight needle, which facilitates entry
into the AC and allows easy control of AC depth because the sclerocorneal tunnel has
not yet been completed. Second, visibility is optimized as opaque lens material can be
readily removed from the AC by aspiration or irrigation. Third, the capsulotomy is
cut, not torn, creating a reliably triangular shape, minimizing the number of capsular
tags. Fourth, a triangular capsular flap provides clear visibility of the boundaries of
the capsular bag, facilitating IOL placement.
Continuous Curvilinear Capsulorrhexis (CCC)
We often employ a CCC for less advanced cataracts by using a 27-gauge needle
introduced into the AC through a separate puncture site immediately adjacent to the
external wound of the sclerocorneal tunnel. Viscoelastic is instilled prior to insertion
of the needle into the anterior chamber. This capsular opening needs to be
approximately 5-6 mm in diameter, substantially larger than that utilized during
phacoemulsification, as the entire lens must be expressed through this capsular
window.

Triangular Capsulotomy
The triangular capsulotomy is performed before the sclerocorneal tunnel is completed
so that the depth of the AC is maintained. A straight 26-guage needle attached to a 1
ml syringe filled with balance saline solution is passed through the scleral tunnel with
the entry point into the AC in sclera, not the more rigid corneal tissue. Using the
beveled tip of the needle, the linear cut in the capsule is made from 4 oclock to
twelve oclock and then from 8 oclock to twelve oclock so the two incisions meet at
12 oclock. Thus, a triangular, or V-shaped flap of anterior lens capsule still attached
at its base is created (Figure 3). Each point of the triangular flap should be
approximately 3mm from the center of the pupil. The apex of the capsulotomy is
then lifted with the needle tip and peeled towards 6 oclock to ensure the capsular
cuts are complete. If the chamber shallows a small amount of fluid may be irrigated
through the needle to re-deepen the chamber.
Following capsulotomy, the sclerocorneal tunnel is then completed using a keratome
blade to enter the anterior chamber. The sides of the blade are used to open the
cornea from the temporal to the nasal aspects of the wound. The wound should be
internally flared to encourage the nucleus to engage the tunnel at the time of
expression. Viscoelastic may be placed in the AC to facilitate wound creation.
Nucleus Delivery into the Anterior Chamber
The lens nucleus is displaced from the capsular bag into the AC using both
hydrostatic and gentle mechanical pressure. Irrigating under the displaced triangular
anterior capsule flap as well as under the temporal and nasal edges of the flap with a
flowing Simcoe cannula will mobilize the lens nucleus and delaminate the lens
components by hydrodissection. The nucleus is then gently directed inferiorly within
the capsular bag while intermittently directing irrigation posterior to the nucleus, until
the superior nuclear pole emerges from the capsular bag into the AC, forming a new
cleavage plane between the nucleus and the iris. This newly formed cleavage between
the nucleus and the iris is then accentuated by directing flow between the iris and the
nucleus with the Simcoe cannula until the lens is entirely delivered into the AC. It is
important not to force the nucleus in any one direction too strongly as this will strain
and possibly compromise the zonules.
Extraction of the Nucleus from the Anterior Chamber
The lens nucleus is now removed from the eye. While several potential protocols are
available for nucleus removal we recommend avoiding procedures that require
sectioning or fragmentation of the nucleus, as these may traumatize the corneal
endothelium. We recommend the following technique.
The vigorously flowing Simcoe cannula is passed posterior to the nucleus until the tip
is fully visible beyond the distal pole of the nucleus. The eye is then gently rotated
downward with toothed forceps held in the other hand. The accumulating irrigation

fluid from the cannula will engage the nucleus into the internal mouth of the
sclerocorneal tunnel. Hydrostatic pressure plus gentle lifting and retraction with the
tip of the Simcoe cannula will force the nucleus further into the tunnel. Open the
external foramen of the tunnel with gentle downward pressure using the heel of the
Simcoe cannula and deliver the entire nucleus (Figure 4).
PC IOL Placement
The Simcoe canula is then used in the standard fashion to remove all nuclear and
cortical debris from the AC and capsular bag. Next, air is injected into the anterior
chamber using the Rycroft cannula and a PMMA (polymethylmethacrylate) PC IOL is
inserted into the capsular bag. Alternatively, the IOL can be inserted after filling the
AC and expanding the capsular bag with viscoelastic. The apex of the V-shaped
capsulotomy tear should also be folded backwards during this maneuver so that the
flap lies on top of the anterior capsule. During insertion of the leading haptic, the
anterior lip of the cornea is folded inward which protects the corneal endothelium
during lens implantation. The leading haptic is then passed into the capsular bag
inferiorly, behind the base of the triangular capsulotomy (Figure 5). The folded
anterior capsule flap at the base of the triangular capsulotomy serves as an easily
identifiable landmark and facilitates correct PC IOL placement. The trailing haptic is
then passed into the capsular bag and correct placement of the PC IOL within the
capsular bag is confirmed by observing posterior capsule stretch lines that form
perpendicular to the contacts between the IOL haptics and the capsule.
Capsulectomy
If a triangular capsulotomy was performed, the anterior capsular flap is removed to
prevent obscuration of the visual axis. A small incision is made in the anterior
capsule at the edge of the base of the triangular flap with fine Vannas scissors while
maintaining the AC depth with an irrigating Simcoe cannula. The capsular flap is
engaged with aspiration using the Simcoe cannula (using low flow irrigation) and
used to gently tear the flap entirely across its base which then should be removed
from the AC (Figure 6).
Closure
The Simcoe cannula is used to irrigate and aspirate residual air or viscoelastic in the
AC and intraocular pressure is restored. The 3-planed sclerocorneal tunnel will selfseal which is confirmed by applying gentle pressure to the globe with an instrument
and observing for wound leakage. Fewer than 1% of our wounds require suture
placement for adequate closure. A subconjunctival injection of antibiotic and steroid
is given just superior to the conjunctival wound which balloons the conjuctiva and
moves it over the limbus to cover the scleral wound. In the instance of a temporal
surgical approach the conjunctiva is closed over the scleral wound with cauterization
at the wound edges.

After removing the sterile drapes antibiotic ointment is applied to the eye which is
then patched and shielded. Steroid and antibiotic drops are instilled every two hours
for the first post-operative day and then four times per day for three weeks.
Surgical Outcomes
Utilizing intraocular lenses manufactured in India or Nepal and local pharmaceuticals
the cost per surgery is less than twenty dollars per case. Moreover, experienced
surgeons routinely perform more than fifty cases per day with an average operating
time of five minutes per surgery. The results of a prospective, randomized clinical
trial in Nepal comparing our manual sutureless extracapsular surgical technique with
phacoemulsification were published in the January 2007 American Journal of
Ophthalmology. It was an Expert Trial with Professor David Chang operating with
a phaco-chop (phaco) technique and Dr. Sanduk Ruit doing the temporal approach
small incision ECCE (SICS). Both techniques achieved excellent and equivalent
results. At six months 89% of the SICS patients had an uncorrected visual acuity
(UCVA) of 20/60 or better and 98% had a best-corrected acuity (BCVA) of 20/60 or
better; this outcome was equivalent to the visual acuity outcomes of the phaco
patients (Figure 7). Furthermore, SICS is significantly faster, less expensive and less
technology dependent than phacoemulsification and may be the more appropriate
surgical procedure for the treatment of advanced cataracts in the developing world.
References
Brilliant GE, ed. The Epidemiology of Blindness in Nepal: Report of the 1981
Nepal Blindness Survey. Chelsea, Mich: Seva Foundation; 1988:115-241.
Ruit S, Robin AL, Pokhrel RP, Sharma A, Defaller J, Maguire PT. Long-term
results of extracapsular cataract extraction and posterior chamber intraocular lens
insertion in Nepal. Tr. Am. Ophth. Soc. Vol LXXXIX 59-76.
Ruit S., Tabin, G. Chang, D. A Prospective Randomized Clinical Trial of
Phacoemulsification vs. Manual Sutureless Small-Incision Extracapsular Cataract
Surgery in Nepal, American Journal of Ophthalmology. Vol 143 No.1 Jan 2007
32-38.
Ruit et al, Ophthalmology 1999; 106:1887-92;
Ruit et al, Clinical and Experimental Ophthalmology 2000 28, 274-9

III Conversion to ECCE - Thomas A Oetting MS MD

Conversion to ECCE often comes at a difficult time. The lens is about to fall south, the
vitreous has prolapsed and the surgeon is stressed. Understanding the steps and process
of conversion to ECCE is essential and study before the crisis will help soothe the stress
when this inevitable process occurs. We will cover several areas: identifying patients at
risk for the need for conversion to ECCE, indications for conversion, conversion from
topical to sub-tenons, wound preparation, expressing the lens material, closure of the
wound, placement of the IOL, post operative issues and a brief section on anterior
vitrectomy.
Patients at risk for conversion to ECCE. One of the most important parts of the preoperative process for cataract patients is to assess the difficulty factors that may lead to
conversion to ECCE or otherwise complicate the procedure. You may want to add
operative time to your schedule or ask for additional equipment. You may want to
change to a superior limbal wound which facilitates conversion to an ECCE rather than a
temporal clear corneal incision. You may want to do a retrobulbar block rather than
topical anesthesia as the case may last longer or is more likely to become complicated.
Or you may want someone more experienced to do the case.
Difficulty Factors1 (in decreasing order of importance):

Zonular Laxity (PXF, h/o trauma, marfans )

Rock Hard Lens (red or black lens)
Pupil size (why is it small? PXF, DM s/p laser, CPS, floppy from Flomax)
Cannot lay flat for very long, eg. COPD, claustrophobia, tremor, severe obesity
Big brow limiting superior access
Narrow angle limiting AC space
Predisposition to corneal decompensation: e.g. guttata, PPMD, hard nucleus
Poor red reflex white/black cataract making CCC difficult
Past surgery such as existing trab or past PPVx
Predisposition to exposure: eg: botox, past lid trauma, DM
Anticoagulants e.g., coumadin, ASA
Monocular

Table 1
Difficulty Factors
(modified from Oetting, Cataract Surgery for Greenhorns, http://medrounds.org/cataract-surgery-greenhorns 1)

Factor
Zonular Laxity

Time
Double

Rock Hard Lens

Add 50%

Small Pupil

Add 50%

Flomax

Add 50%

Poor Red Reflex

Add 50%

Big Brow

Add 25%

Narrow Angle

Add 25%

Predisposition
Corneal
decompensation
Existing Trab

0%

Past PPVx

0%

Cannot Lay flat

Anticoag.
Monocular

0%
0%
0%

0%

Equipment/Anesth.
Iris retractors available to hold capsule
Capsular Ring (CTR)
Ready for sutured IOL
Ready for ICCE, eg cryo
Consider RB
Consider Sup limbal wound
Consider planned ECCE
Consider sup limbal wound w/PE
Consider RB
Stretch Pupil (only w/o Flomax)
Consider Iris retractors
Consider RB
Strongly consider Iris retractors
Consider single iris retractor
Consider RB
Trypan Blue
Consider RB
Consider sup limbal wound
Consider sup/inf. bridal sutures
Consider RB to give proptosis
May need iris hooks for prolapse
Consider smaller phacotip
Frequent dispersive OVD
BSS+; phaco chop
Arshinoff shell w/OVD
Consider conversion to ECCE
Avoid Fixation ring
Avoid Conj manipulation
Always suture
Possible CTR
Careful during I/A
Consider general or at least monitored
Topical to avoid injection risk
Topical for faster rehabilitation
Try to forget about it

Indications for conversion Conversion to ECCE is indicated when phacoemulsification

is failing. Sometimes this is due to a very hard lens which does not submit to ultrasound
or a lens that is hard enough that the surgeon is concerned that the required ultrasound
energy will harm a tentative cornea, e.g. Fuchs endothelial dystrophy or posterior
polymorphous dystrophy (PPMD). Sometimes one will convert to ECCE when an errant
capsulorhexis goes radial especially with a hard crystalline lens when the surgeon is
concerned that the risk of dropping the lens is too great with continued
phacoemulsification. Rarely now with Trypan Blue dye, a surgeon will choose to convert
to ECCE when the anterior capsule is hard to see and capsulorhexis must be completed
with the can opener technique. More often the conversion is indicated when the
crystalline lens is loose from weak zonules or a posterior capsule tear which make
phacoemulsification less safe than extending the wound and removing the residual lens
material. Indications for conversion to ECCE include:

Hard crystalline lens or unstable endothelium

Radial tear in anterior capsule with hard lens
Poor visualization despite Trypan dye
Posterior capsular tear
Zonular dialysis

Converting to subtenons anesthesia. Often we convert cases from topical clear corneal
to ECCE. While the ECCE can be done under topical it is usually more comfortable and
safer to give additional anesthetic which is typically a sub tenons injection of
bupivicaine and lidocaine. This will provide some akinesia and additional anesthesia.
There is usually subconjunctival hemorrhage and if the injection is made too anterior it
can cause chemoisis and ballooning of the conjunctiva. The steps of the sub tenons
injection are outlined below1:

Prepare 3cc syringe with equal pars of 2% lidocaine/0.75% bupivacaine

Place lacrimal canula (or Masket canula) with gentle curve to approximate that of
the globe
Pick a quadrant for the block (best to go for a lateral quadrant to avoid oblique
mm)
Have the patient look away from the chosen quadrant to increase exposure
Use .12 forceps to retract conjuctiva
Make small incision down to sclera with Wescott scissors
Redirect Wescott scissors with curve down and bluntly dissect through quadrant
Dissect past the equator (similar to using stevens tenotomy scissors in peds/retina)
Use .12 Forceps for counter traction
Place canula through incision and direct past the equator before injecting
The local anesthetic should flow easily and cause little chemosis -- If not redissect
with the wescott scissors to get more posterior
Use 2-3 cc of the local mixture

Figure 1
Forceps holding open posterior flap of dissection into subtenons
space. Lacrimal canula with gentle curve approximating the curve
of the globe ready to insert local anesthetic
Converting the Wound The major step toward converting to ECCE is to either extend
the existing wound or close and make another. The ECCE will require a large incision of
from 9-12 mm which is closed with suture. The decision to extend the existing wound or
make a new wound hinges on several factors: location of the original wound, size of the
brow, past surgical history, and possible need for future surgery.
Original
wound
Temporal

Sup Temporal
Left eye
Inf Temporal
Right Eye

Superior

Advantages of making new

wound for ECCE
Allows limbal incision superior
Allows lids to cover suture
Should iris damage occur it will
be superior
Simple to start fresh
none
Allows limbal incision superior
Allows lids to cover suture
Should iris damage occur it will
be superior
Simple to start fresh
none

Advantages of extending
wound for ECCE
Protects existing trab
Avoids big brow

Already have sup incision

No need to change position
Protects existing trab
Avoids big brow

Already have sup incision

No need to change position

Making a new incision during conversion is identical to that for a planned ECCE. The
original incision is closed with a 10-O nylon suture. The surgeon and microscope are
rotated as the surgeon should sit superior. The steps to make a new superior incision are:

Conjunctival peritomy of about 170 degrees

Use 64 or crescent blade to make limbal groove with a chord length of 11mm
Bipolar cautery for hemostasis
Use keratome to make initial incision starting in groove into AC
Extend initial incision to full length of groove (with scissors or knife)
Safety sutures are preplaced usually 7-O vicryl

Extending an existing incision can be tricky and the technique is different for scleral
tunnels compared to clear corneal incisions. However in both cases the original
extension is brought to the limbus. In the case of an original scleral incision the incision
is brought anterior to join the limbus on either end before extending along the limbus for
a chordlength of about 11mm. In the case of an existing corneal incision the corneal
incision is brought posterior toward the limbus before extending the wound along the
limbus for a chord length of about 11mm. When iris hooks are being used in a diamond
configuration the wound can be extended to preserve the sub-incisional hook and the
large pupil2.

Conjunctival peritomy of about 170 degrees

Use 64 or crescent blade on either side of the existing wound to make a limbal
groove with a chord length of 11mm
Bipolar cautery for hemostasis
Use Crescent to bring existing scleral wound anterior or existing corneal wound
posterior to join limbus
Extend initial incision to full length of groove (with scissors or knife)
Safety sutures are preplaced usually 7-O vicryl

Removing the lens One has to be far more careful when removing the nucleus during the
typical conversion to ECCE which comes along with vitreous loss. First the anterior
capsule must be large enough to allow the nucleus to express which may require relaxing
incisions in some cases. When the zonules are weak or the posterior capsule is torn the
lens cannot be expressed with fluid or external pressure as is often done with a planned
ECCE with intact capsule/zonlules. After any vitreous is removed (see below), the lens
must be carefully looped out of the anterior chamber with minimal pressure on the globe.
If the posterior capsule and zonlues are in tact than the lens can be expressed as described
with a planned ECCE.
Removing Lens with intact capsule complex

mobilize lens (physically with cystitome or with hydrodissection--be careful)

Lens removed w/ lens loop or w/ counter pressure technique

Wound is closed with safety sutures and additional central vicryl suture
Cortical material is removed using I/A device (either automated or manual)
Instill ophthalmic viscoelastic device (OVD
Lens is placed in the posterior chamber
Wound is closed with 10-O nylon and vicryl sutures are removed.
OVD is removed

Removing Lens with vitreous present

mobilize lens with viscoat canulla -- tip lens so that wound side is anterior)
slip lens loop under lens, toe up, remove lens
Wound is closed with safety sutures and additional central vicryl suture
Anterior vitrectomy (see below)
Cortical material is removed using dry technique or anterior vitrector
instill ophthalmic viscoelastic device (OVD
Lens is placed in the sulcus or in the anterior chanber
Wound is closed with 10-O nylon and vicryl sutures are removed
OVD is removed

Placement of the IOL IOL selection with ECCE conversion depends on the residual
capsular complex3,4. The key to IOL centration is to get both of the haptics in the same
place: either both in the bag or both in the sulcus.

When the posterior capsule is intact following a conversion to ECCE the anterior
capsular opening is usually poorly defined which can make bag placement
difficult. If the anterior capsule and thus the bag is well defined, then place a
single piece acrylic IOL without folding it directly and gently into the bag using
kelman forceps.
When the posterior capsule is intact and the anterior capsule is poorly defined
then place a 3 piece IOL in the sulcus such as a large silicone IOL or the MA50
acrylic by placing these directly and unfolded into the sulcus with kelman forceps.
Make sure that both haptics are in the sulcus.
When the posterior capsule is damaged, if enough anterior capsule and posterior
capsule is left to support the IOL, define the sulcus with viscoat and place the IOL
directly in the sulcus. Make sure both haptics are in the sulcus. If the IOL does
not seem stable then place McCannel sutures to secure the IOL to the iris or
remove and replace with an AC IOL (dont forget to place a PI with vitrector).
When the capsule is severly damaged and cannot support an IOL then place the
IOL in the anterior chamber. Use kelman forceps to place the IOL, then secure
the chamber, and use a sinsky hook to place the AC IOL into its final position.
(dont forget to place a PI with vitrector).

Post operative issues. Postoperative care for patients following conversion from phaco
to ECCE is a bit more complicated and focuses on preventing cyctoid macular edema and

limiting induced astigmatism. Often the care is very similar to that of a planned ECCE
with about 3 post operative visits one the same day or next, one a week later, and one
about 5-6 weeks later. Depending on the amount of astigmatism the patient may require
several visits to sequentially remove sutures while eliminating induced astigmatism.
First post operative visit Often on the same afternoon 4-6 hours following surgery or
next morning with the primary emphasis to check the IOP, look for wound leaks and scan
for residual lens material or vitreous in the anterior chamber. Most wound leaks should
be sutured but if the AC is not formed closing these is mandatory. Residual nuclear
material should be removed in the next few days if present but residual cortical material
will often dissolve away with little inflammation. You would expect poor vision in the
20/200 range due to astigmatism and edema. The anterior chamber should be formed and
typically has moderate cell (10-20 cells/hpf with 0.2 mm beam). If the IOP is less than
10 search hard for a leak using Siedel testing. If the IOP is in the 10-29 range all is
probably OK unless the patient is a vasculopath and then the upper limit of IOP tolerance
should be lowered. If the IOP is in the 30-39 range consider aqueous suppression. If the
IOP is >40 than consider aqueous suppression and bleeding down the IOP with the
paracentesis or anterior chamber tap. The IOP should be rechecked 60-90 minutes later
to ensure success with your treatment. Look at the fundus and rule out retinal detachment
and choroidal effusion or hemorrhage. Typically patients are placed on prednisolone
acetate 1% i drop 4 times a day, cyclogyl 1% i drop 2 times a day, and an antibiotic i drop
4 times a day for the next week.
Week 1 post operative visit The vision and pressure should dramatically improve in
patients over the next week where you have converted to ECCE. The vision should be
in the 20/100 range with an improvement with pin hole to 20/50. The vision is usually
limited by residual edema and astigmatism. In a study of our ECCE we found about 7
diopters of cylinder at the one week visit. You should expect very little inflammation and
document that no RD exists. Search for residual lens material in the anterior segment and
posterior pole. You can discontinue the cyclogyl and the antibiotic. Slowly taper the
prednisolone acetate like i gtt qid for 7 more days, then i gtt tid for 7 days, then gtt bid
for 7 days, then i gtt qd for 7 days, then discontinue. If the patient is at risk for CME (eg
vitreous loss) than keep on prednisolone qid and start a non steroidal like acular I gtt qid
until the next visit 4 -6 weeks later.
Week 5 post operative visit The vision should continue to improve as the astigmatism
settles and the cornea clears further. The eye should be comfortable. The vision should
be in the 20/80 range with an improvement to 20/40 with pin hole. In our study the
astigmatism induced by ECCE sutures was about 5.0 diopters at the incision. The
anterior segment should be quiet and the IOP normal (unless the patient is a steroid
responder). Consider CME as a possibility in patients where conversion was required as
these cases are often long and can involve vitreous loss with OCT, FFA, or clinical exam.
But the main issue is astigmatic control with suture removal. Use keratometry, refraction,
streak retinoscopy, or topography to guide in suture removal. If the keratometry is 45.00
at 90, and 40.00 at 180 then look for tight sutures at around 90 degrees (12 oclock) that

are causing 5 diopters of cylinder. You can take only one suture at 5 weeks, then can take
maybe 2 at a time by 8 weeks. The plan is to remove a suture and see how the cornea
settles. When the astigmatism is less than about 1.0 to 1.5 diopters you should stop. Use
antibiotic drops for a few days after suture removal. After this visit you should consider
the following choices with each visit (dont waste too much time thinking about other
possibilities and remember not everybody is going to be 20/20.
:
1. pull a stitch (i.e. cyl at axis of stitch is greater than 1 on MR)
2. give glasses (i.e. no stitch to pull or cylinder is less than 1 on MR)
3. get FFA or OCT because you suspect CME
Anterior Vitrectomy. Converting to ECCE is almost always accompanied by vitreous.
Sometimes the conversion comes when the lens is too hard and the capsule is intact but
most often it seems conversion comes when the zonules or capsule releases the vitreous
into the reluctant hands of the anterior segment surgeon. We will cover the causes and
signs of vitreous prolapse and the principals of anterior vitrectomy in various situations.
Causes of vitreous prolapse. The vitreous either comes around the zonules or through a
tear in the posterior capsule. Posterior capsular tears are caused commonly by: anterior
tear extending posteriorly most common, posterior tear secondary to phaco needle
being too deep too deep, a chopper or from the I/A instrument, or a pre-existing injury
( eg. posterior polar cataract iatrogenic from PPVx, or from penetrating lens trauma).
Zonular problems are often pre-existing such as from trauma, PXF, or Marfans but can
also be iatrogenic from forceful rotation of the lens or pulling on the capsule during I/A.
Signs of vitreous prolapse. The first sign of vitreous prolapse is denial. Something
seems wrong but you cant quite pin point the issue. At first you deny that an issue
exists but soon it becomes clear. More tell tale signs of vitreous prolapse include: the
chamber deepens, the pupil widens, lens material no longer centered, particles no longer
come to phaco or I/A, and the lens no longer rotates freely. When you suspect vitreous
prolapse you should place dispersive OVD into the eye before removing the phaco needle
or I/A and can check the wound with a Weck sponge for vitreous.
Basic Principles of anterior vitrectomy. The key to a successful anterior vitrectomy is
to control the fluidics of the eye. The first step is to close the chamber. This is often
hard when you have converted to an ECCE as the wound is large. However you must
close the wound so that the only exit point for fluid is the aspiration/cutting device.
Separate the irrigation device from the aspiration/cutting device so that you can create a
pressure differential such that the vitreous is encouraged to go to the aspiration/cutter.
The final important point is to cut low and irrigate high. If you can place the irrigation
device in the anterior chamber above the aspiration/cutter down near the plane of the
posterior capsule than the vitreous will leave the anterior chamber.

Close the chamber

Separate irrigation and cutter

Cut low/Irrigate high

In general the bottle height should be low just high enough to keep the AC formed and
not so high to push fluid and possibly vitreous out from the eye. The cutting rate should
be as high as possible when cutting vitreous and low when cutting cortical lens material.
We will separately discuss early, mid, and late case vitreous loss below.
Vitreous Presenting early in case while most of crystalline lens is in eye This is the
worst time for vitreous to prolapse and one should strongly consider converting to ECCE.
The steps to consider are outlined below1.

If topical do subtenons injection (as described above)

Consider closing the temporal incision with 10-0 and make separate incision
with peritomy superiorly especially (as discussed above)
Use dispersive viscoelastic to lift lens up near the wound and to displace
vitreous more posterior.
May need weck cell vitrectomy to clean up if the vitreous is very prolapsed
Use lens loop to remove lens (as described above)
Have Wescott scissors ready when looping out lens to cut vitreous
Close with 3 7-0 vicryl safety sutures one at center and one on either side 3
mm away (allows removal of center suture to place 6 mm IOL
May need to add some 10-O nylon at wound edges to get watertight
Anterior vitrectomy (as discussed above separate asp/cutter from irrigator)
Dry removal of residual cortical material with syringe on 27 gauge cannula
Use J-cannula or paracentesis if needed for sub-incisional material
Consider staining with Kenalog (see below)
Place IOL if possible in sulcus (adjust power) or use an AC IOL (dont forget
peripheral iridotomy)
Miochol to bring pupil downseats sulcus IOL, peaked pupil helps to detect
vitreous

Vitreous Presenting mid case while removing cortical material. This seems to be
the most common time for vitreous loss. Often one will get the posterior capsule just as
the last nuclear fragment is taken. Of course there is no reason to convert to ECCE in
this case. The following steps are useful1

Place viscoat in area of tear or dialysis before removing instruments

Make separate 1 or 1.5 mm incision for anterior vitrectomy
Separate irrigation (through paracentesis) and asp/cutter (through larger
paracenetesis)
May need to suture original wound to keep chamber formed
Irrigate high and cut/suck low creates a pressure gradient to push the V back
Settings low vacuum 100 range, low bottle height 50 range, max cut rate
Try to get some of the residual cortical material

Dry removal of residual cortical material with syringe on 27 gauge cannula

Use J-cannula or paracentesis if needed for subincisional material
Consider staining with kenalog (see below)
Place IOL if possible in sulcus or AC (if AC dont forget peripheral iridotomy)
Miochol to bring pupil down

How to deal with Vitreous Presenting late in the case while placing IOL This is the
least problematic and least common time to loose vitreous. The main issue is to make
sure the IOL is stable while attending to the vitreous and then to secure a proper IOL in
either the AC, sulcus, or bag1.
Place viscoat in area of tear or dialysis before removing instruments
Make separate 1 or 1.5 mm incision for anterior vitrectomy
Separate irrigation (through paracentesis) and asp/cutter (through larger
paracenetesis)
May need to suture original wound to keep chamber formed
Irrigate high and cut/suck low creates a pressure gradient to push the V back
Settings low vacuum 100 range, low bottle height 50 range, max cut rate
If the sulcus can support an IOL, then
o Move existing 3 piece IOL into sulcus
o Replace existing single piece IOL with 3 piece in sulcus
o Consider anterior capsule capture of optic if CCC is round and
centered
If the tear in the posterior capsule is round and secure
o Place viscoat in hole
o Gently place single piece IOL into the bag (be very careful with 3
piece in bag)
Miochol to bring pupil down
Staining the Vitreous with Kenalog. Scott Burk at Cincinatti Eye described using
Kenalog off label to stain vitreous that had prolapsed into the anterior chamber5. As
Kenalog is not approved by the FDA for this indication and as some retnal surgeons have
had sterile and even infectious endophthalmitis from using Kenalog its use is
controversial. However it is a very useful adjunct to anterior vitrectomy. The method for
mixing the Kenalog to dilute 10:1 and to wash off the preservative follows:

TB syringe to withdrawn 0.2 ml of well shaken Kenalog (40mg/ml)

Remove the needle and replace with a 5 (or 22) micron syringe filter (Sherwood
Medical)
Force the suspension through the filter and discard the preservative filled vehicle
The Kenalog will be trapped on the syringe side of the filter
Transfer the filter to a 5 ml syringe filled with balanced salt solution (BSS)
Gently force the BSS through the filter to further rinse out preservative
Repeat rinsing a few times

Place a 22 gauge needle on the distal end of the filter

Draw 2 ml of BSS into the syringe through the filter to resuspend the Kenalog
The Kenalog (now without preservative and dilute 10:1) will stain vitreous
strands white

References
1. Oetting, TA, Cataract Surgery for Greenhorns, Available at
http://medrounds.org/cataract-surgery-greenhorns. accessed September 9, 2007
2. Dupps WJ Oetting TA, Diamond iris retractor configuration for small-pupil
extracapsular or intracapsular cataract surgery. J Cataract Refract Surg Vol
30(12):2473-2475
3. Chang DF, Oetting TA, Kim T, Curbside Consultations in Anterior Segment
Surgery, Slack Inc, Thorofare NJ, 2007
4. Henderson BA, Essentials of Cataract Surgery, Slack Inc, Thorofare NJ, 2007
5. Burk SE, Da Mata AP, Snyder ME, Schneider S, Osher RH, Cionni RJ.
Visualizing vitreous using Kenalog suspension J Cataract Refract Surg. 2003
Apr;29(4):645-51

IV. COMPLICATIONS Bonnie An Henderson M.D.

1. Intraoperative
A. Suprachoroidal hemorrhage
Risks:
With large incision surgery, the risk of a hemorrhage increases as well as the risk of a
catastrophic outcome. The known risks include increased age with mature lenses,
preexisting uveitis, glaucoma, systemic hypertension, high myopia, and patients on
anticoagulation medications.
Diagnosis:
Patient may complain of severe pain. The surgeon may notice chamber shallowing, loss
of red reflex, and hardening of the eye. Indirect ophthalmoscopy is necessary to assess
the fundus. If unavailable, a handheld lens with the operating microscope (Osher
Panfundus lens) can be used to quickly view the fundus.
Treatment:
First and foremost is closure of the eye to prevent further expulsion of the ocular tissues.
If the eye cannot be closed with sutures, the incision can be held closed with direct
pressure while IV Mannitol is given. Once the eye is secured with sutures, any
prolapsing uveal tissue can be repositioned. If the eye cannot be closed, the choroidal
hemorrhage can be drained by placing a posterior sclerotomy 3.5 to 4.0 mm posterior to
the limbus. However, many retina surgeons do not recommend attempting to drain an
acute hemorrhage unless it is done with the goal of closing the eye. If the eye has been
successfully closed, it is prudent to refer to a retinal specialist for possible drainage at a
later time, if needed. The complete removal of cortical material or implantation of the
IOL is secondary to the primary goal of stabilizing the eye. Prompt referral to a retina
specialist is recommended.
B. Vitreous Loss
This has been covered in Dr. Oettings lecture above.
C. Dropped Lens Fragment
Risks:
With any posterior capsular tear, there is a risk of dislocating a lens fragment. Often the
posterior capsular tear goes undetected and is discovered when a fragment suspiciously
appears to be too posterior. The causes of dropped lens fragments in the presence of a
capsule tear are a history of a vitrectomy or excessive infusion.
Treatment:
If the lens fragment is in the anterior vitreous, a high molecular weight viscoelastic can
be injected posterior to the fragment to elevate it anteriorly. This can be done through the
anterior cataract wound if the fragment is anterior and easily accessible. If the fragment
is not in the anterior vitreous or if the fragment fails to elevate, a posterior assisted
levitation (PAL) can be performed by injecting viscoelastic solution via a pars plana

incision or using a spatula through the pars plana to support and elevate the lens. If the
lens fragment is too posterior or not easily accessible, it is always safer to close the eye
and refer the dropped lens to a retinal surgeon. If the patient needs additional retinal
surgery to remove the dropped fragment, it is important to consider the pros and cons of
placing the IOL. If the lens fragment is large and hard, the retina surgeon may need to
prolapse the fragment anteriorly. Therefore, it may be beneficial to leave the patient
aphakic until after the fragment has been removed.
D. Iris Prolapse:
Risks:
With a large incision, iris prolapse is common even in an uncomplicated ECCE. A poorly
constructed uniplanar wound with a posterior entry will increase the risk of iris prolapse.
The use of alpha adrenergic blockers such as Tamsulosin (Flomax) can cause the iris
tissue to be floppy and also increase the likelihood of prolapse during surgery. Elevating
the intraocular pressure with excessive injection of fluid or viscoelastics can cause iris
prolapse.
Continued iris prolapse during surgery can cause pupil irregularities, iris damage,
inflammation, bleeding, and peripheral anterior synechiae.
Treatment:
Intracameral miotic should be used to constrict the pupil to assist in reducing the iris
prolapse. If the iris prolapse is mild, gentle repositioning of the iris with a blunt
instrument such as a cannula or spatula can be effective. If the iris cannot be
repositioned, a small peripheral iridectomy can be performed. Once the iris has been
repositioned back in the eye, be careful not to overly inflate the eye which may cause the
iris to prolapse again.
2. Postoperative
A. Wound leak
Risks:
In complicated cases with posterior capsular tears, vitreous or iris tissue may be
incarcerated in the wound and hindering wound closure. If this is suspected, carefully
examine for peaked pupils or vitreous strands to the wound. If iris tissue has prolapsed
through the wound, the bluish color of the uvea can be seen in the wound under the
conjunctiva.
Diagnosis:
If the anterior chamber is flat or the intraocular pressure is low, always test the wound for
leakage. Using a concentrated fluorescein strip or drop, place on the wound and evaluate
for dilution of the stain by leaking aqueous humor.
Treatment:
If the cause of the wound leak is incarcerated vitreous or iris, the patient must have a
wound revision in the operating room. A vitrectomy should be performed if vitreous is
found. If there is no posterior capsular tear or vitreous presenting, but iris tissue is

prolapsing, intracameral miotic can be given to pull the iris out of the wound. Gentle
reposition of the iris can be performed. The wound should be re-sutured to prevent
further leaking.
If the wound leak is not due to the above reasons, it may be sufficient to follow the
patient medically for a few days. A bandaged contact lens can be placed and an aqueous
humor suppressor can be given topically. Be sure to place the patient on topical
antibiotics in the presence of any wound leak. If the wound leak does not resolve after
several days, the wound should be re-sutured.
B. High Astigmatism/Suture Cutting
Risks: The evolution of cataract surgery is towards smaller and smaller incisions.
Therefore, cataract surgeons and those in training are suturing less often. When sutures
are not placed in a proper manner, the result can be an asymmetric wound closure.
Sutures placed with different tensions and different orientations can cause high
astigmatism postoperatively. This is often true in cases where an ECCE was unplanned.
Diagnosis:
Intraoperatively, the induced corneal astigmatism can be measured using a handheld
portable keratometer or photokeratoscope. If there is a large amount of astigmatism from
a tight suture, the suture should be replaced.
Postoperatively, the vision will be poor with high uncorrected astigmatism. Keratometry
measurements, manifest refraction, corneal topography are all useful in evaluating the
amount and location of the astigmatism.
Treatment:
When and how to remove large incision sutures is controversial. The sooner the sutures
are cut, the greater the effect of relaxing the steepness in that meridian. However, the
timing must be balanced to ensure proper wound healing while considering the
effectiveness of astigmatism control. Most physicians agree to wait at least 3-4 weeks
before cutting sutures in a large ECCE incision. Some physicians will wait until after the
topical steroid drops have been stopped before cutting sutures.
How many sutures to cut at one time is also controversial. Some physicians will only
remove one suture at a time and have the patient return in 1-2 weeks to recheck the
astigmatism. Others will cut many at the same time relax the corneal astigmatism. Each
case should be considered individually and the stability of the wound should be
considered when choosing the number of sutures to cut.
When cutting sutures, the goal is to minimize pulling any exposed suture through the eye
during the removal procedure. Therefore, cut the suture closest to the corneal edge and
pull the end out of the scleral side so the exterior portion of the suture (laying on top of
the sclera) is not pulled through the eye, only the interior portion is pulled out of the eye.
Always use a drop of topical antibiotics before and after the suture removal. Some
surgeons will continue the topical antibiotics up to one week after suture removal.

C. Medications
Preoperatively, if an ECCE is planned, anticoagulants including aspirin and NSAIDs
should be discontinued if possible. Consult with the primary care physician and discuss
possible discontinuation.
Patient who are undergoing a primary ECCE or conversion to an ECCE should have an
injected (peribulbar or retrobulbar) anesthetic. Topical, intracameral, and subtenons
anesthesia does not provide sufficient anesthesia or akinesia for large incision surgery. If
the injection is being given during a conversion with an open eye, place temporary
sutures and inject a smaller volume than would normally be injected in a primary ECCE.
Since direct pressure with a Honan balloon cannot be used with an open eye, the surgeon
should wait for the injected anesthetic to diffuse behind the eye before attempting to
proceed.
Postoperatively, the topical medication regimen should also be altered. Since larger
incisions take longer to heal and have more inflammation, the antibiotics and steroid
duration is often longer. Although there are no set guidelines for postoperative
medications, many surgeons will continue the topical antibiotics for several weeks. The
steroids may also be used longer before tapering if there was significant iris manipulation
or a posterior capsular tear. NSAIDs are also useful to decrease inflammation and risk of
cystoid macular edema.