SEP 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: https://digital.eyeworld.org/i/82503

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Page 20 of 103

September 2012 Tools & techniques Cortical cleaving hydrodissection by I. Howard Fine, M.D. F oward Fine, M.D., has confided in me that one of his biggest disap- pointments in ophthalmology has been his difficulty in adequately teaching cortical cleaving hydrodissection. This technique is one of the simplest but most powerful methods of adding safety to routine cases and especially challenging eyes with compromised zonules. The first time you successfully perform cortical cleaving hydrodissection and look down at a pristine capsular bag devoid of cortex— without having used an I/A handpiece—it will be difficult to suppress a big smile. In this month's column, we have the H honor of having Dr. Fine describe his corti- cal cleaving hydrodissection technique in a detailed step-by-step approach that should be clear to any surgeon. His description of the anatomy of cortical capsular connec- tions and the mechanical explanation of how the method works should give us all a better understanding of the complexity of cortical capsular structure and the ingenious simplicity of his technique. I encourage all cataract surgeons who do not perform cortical cleaving hydrodissection to give it a try. Richard Hoffman, M.D., Tools & techniques editor ollowing the completion of a capsulorhexis through a side-port incision, we perform gentle cortical cleaving hydrodissection.1 Hydrodissection of the nucleus in cataract surgery has traditionally been perceived as the injection of fluid into the cortical layer of the lens under the lens capsule to sepa- rate the lens endonucleus and epin- ucleus from the cortex and capsule.2 With increased use of continuous curvilinear capsulorhexis and pha- coemulsification in cataract surgery, hydrodissection became a very im- portant step to mobilize the nucleus within the capsule for disassembly and removal.3-6 Following nuclear removal, cortical cleanup proceeded as a separate step, using an irrigation and aspiration handpiece. I first described cortical cleaving hydrodissection, which is a hydrodissection technique designed to cleave the cortex from the lens capsule and thus leave the cortex attached to the epinucleus.1 If cortical cleaving hydrodissection is performed correctly, it lyses the con- nections between the cortex and the equator of the lens capsule resulting in greater ability to rotate the cataract and dramatically facilitates cortical clean-up. In fact, cortical cleaving hydrodissection frequently eliminates the need for cortical clean-up as a separate step in cataract surgery thereby eliminating the risk of capsular rupture during cortical clean-up. In a large percent- age of cases with 19 gauge tips, less frequently with 20 gauge tips, cortical clean-up is not necessary as a separate step in that during the mobilization of the epinucleus, the cortex is mobilized at the same time. We generally hyrdodissect in two aliquots: one through each of two side-port incisions with decompres- sion following the injection of each aliquot. We then try to rotate the lens within the capsular bag. A small capsulorhexis, 5-5.5 mm, optimizes the procedure. The large anterior capsular flap makes this type of hydrodissection easier to perform. The anterior capsular flap is elevated away from the cortical material with a 26-gauge blunt can- nula (e.g., Katena, K7-5150) prior to hydrodissection. The cannula maintains the anterior capsule in a tented-up position at the injection site near the lens equator. Irrigation prior to elevation of the anterior capsule should be avoided because it will result in transmission of a fluid wave circumferentially within the cortical layer, hydrating the cortex continued on page 22 EW NEWS & OPINION 21 0.06% TRYPAN BLUE OPHTHALMIC SOLUTION VisionBlueTM is indicated for use as an aid in ophthalmic surgery by staining the anterior capsule of the lens.1 VisionBlueTM is intended to be applied directly on the anterior lens capsule, staining any portion of the capsule which comes in contact with the dye. It is recommended that after injection all excess VisionBlueTM be immediately removed from the eye by thorough irrigation of the anterior chamber. The dye does not penetrate the capsule, permitting visualization of the anterior capsule in contrast to the non stained lens cortex and inner lens material.1 VisionBlueTM is contraindicated Rx Only Please see adjacent page for brief prescribing information. when a non-hydrated (dry state), hydrophilic acrylic intraocular lens (IOL) is planned to be inserted into the eye because the dye may be absorbed by the IOL and stain the IOL. Adverse reactions reported following use of VisionBlueTM include D.O.R.C. International B.V. Scheijdelveweg 2 3214 VN Zuidland The Netherlands Phone: +31 181 45 80 80 Fax: +31 181 45 80 90 E-mail: sales@dorc.nl inadvertent staining of the posterior lens capsule or vitreous face. Staining of the posterior lens capsule or vitreous face is generally self limited, lasting up to one week. ORDER INFORMATION VisionBlueTM of 10 syringes of 0.5ml/box Dutch Ophthalmic USA 10 Continental Drive Bldg 1, Exeter, NH 03833, U.S.A. Phone: +1 800-75-DUTCH or +1 603-778-6929 Fax: +1 603-778-0911 E-mail: sales@dutchophthalmicusa.com Call: (800) 75-DUTCH or (603) 778-6929 E-mail: sales@dutchophthalmicusa.com 1 Melles GJR, de Waard PWT, Pameyer JH, Houdijn Beekhuis W, Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refractive Surgery 1999; 25:7-9 is available in sterile packs

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