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aspiration handpiece with changeable tips for cortex removal in small incision phacoemulsification
Irrigation/aspiration handpiece with changeable tips for cortex removal in small incision phacoemulsification John C. Hagan III, M.D.
instruments and notes
Phacoemulsification cataract extraction and insertion of a posterior chamber intraocular lens (IOL) through a small incision is a major trend in contemporary cataract surgery. Cortex removal, especially at the 12 o'clock position, is more difficult with phacoemulsification and small incisions than with planned extracapsular cataract extraction (ECCE). One approach to the 12 o'clock cortex is aspiration through a separate side-port incision. Another is the use of multiple irrigation/ aspiration (1/A) handpieces with a variety of tip configurations for cortex removal. Recently an 1/A handpiece with interchangeable tips, which is compatible with most phacoemulsification units, became commercially available (Figure 1). Six different tip configurations are provided (Figure 2). A study of the effectiveness of this instrument for cortex removal when used with phacoemulsification and small incision posterior
The author has no financial or proprietary interest in the instrument described in this report. Reprint requests to John C. Hagan III, M.D., Midwest Eye Institute of Kansas City, 2700 Hospital Drive, Fifth Floor, North Kansas City, Missouri 64116. 318
J CATARACT REFRACT SURG-VOL 18, MAY 1992
Fig. 1.
(Hagan) The irrigation/aspiration handpiece.
chamber IOL surgery was designed and the results are reported.
SUBJECTS AND METHODS A form for evaluating the extent of cortex removal during phacoemulsification and small incision posterior chamber IOL implantation was devised . If any cortex other than wisps remained after cortex removal the amount was quantitated by the number of clock hours visible cortex covered. Operative complications were recorded. Cortex not visible intraoperatively but which became visible postoperatively was quantitated and recorded. The cases were a consecutive, unselected series of phacoemulsification and posterior chamber IOL insertions performed by me from 1/1/91 until 8/31/91. Phacoemulsification, which I had been performing for two years, was done in all cases unless the combination of small pupil, lens hardness, and corneal dystrophy was such that ECCE
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was felt to be safer. Triple procedures were excluded. Pupils were dilated preoperatively with 1 % tropicamide, 2.5% phenylephrine, and 1 % cyclopentolate. Flurbiprofen was also used preoperatively. A Honan eye compressor was applied 30 minutes before surgery, and a peribulbar injection through a 23-gauge Alcon Thornton needle was given using 5 cc to 7 cc of 0.75% marcaine and 2% xylocaine in a 1:1 mixture with hyaluronidase. A small fornixbased flap was raised superiorly and a 5 mm partial thickness scleral incision was made 1.5 mm to 3.0 mm posterior to the limbus. Through a 3.1 mm keratome puncture, the anterior chamber was filled with chondroitin sulfate-sodium hyaluronate (Viscoat®) and a continuous curvilinear capsulorhexis was made with forceps. Hydrodissection was done with balanced salt solution. A side-port incision was made if the nucleus appeared hard. An Alcon Series 10,000 Master phacoemulsifier was used with a 45-degree phaco tip in all but five cases. In those five cases the Storz Premier phaco emulsifier was used. The nucleus was removed intercapsularly with a one-handed phacoemulsification technique. In very hard lenses a two-handed minimal lift technique was used. The cortex was removed with the Rhein 1/A handle and the supplied tips. The 90-degree tip was used to remove the 12 o'clock cortex first and the curved tip was used to remove the inferior, nasal, and lateral cortex. If the superior cortex was difficult to remove, the 45-degree and' Binkhorst tips were used; the straight and Simcoe tips were not used. After cortex removal the capsular bag was filled with Viscoat, the incision enlarged to 5.1 mm, and a 5 X 6 mm, surface-modified, poly(methyl methacrylate), 14.0 mm lens with polypropylene loops was placed in the capsular bag. The Viscoat was re-
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Fig. 2.
(Hagan) Six interchangeable tips for the handpiece.
Simcoe
/"'IF.rt?$!!!!! J CATARACT REFRACT SURG-VOL 18, MAY 1992
319
moved, intracameral carbacol instilled, and the wound closed with a single 10-0 nylon X-type suture or left sutureless. All patients were seen one day, one week, and five weeks after surgery. No patients were lost to follow-up.
surgical re-operations. In none of the tabulated cases did cortex that was not seen intraoperatively become visible postoperatively. Only the Rhein I/A instruments were used. No handpiece or tip failure or other mechanical problems were encountered.
RESULTS
DISCUSSION
Two hundred eighty-eight phacoemulsification with posterior chamber lens implantation cases were included in the study. Twenty-three cases of ECCE and one intracapsular cataract extraction with an anterior chamber implant done on a subluxated lens were excluded. No phacoemulsification was converted to ECCE. Phacoemulsification was done in 93 % of the total cases. There were two operative complications with phacoemulsification: a capsular tear and vitreous loss occurred with nuclear rotation on a very hard lens, and a patient with pseudoexfoliation had zonular dialysis, capsular tear, and vitreous loss during cortex removal. These two cases were excluded from the residual cortex summary. The overall incidence of capsular tear/vitreous loss in phacoemulsification cases was 0.69%. No complications occurred during the planned ECCE cases. Residual cortex obscuring one clock hour at the 12 0' clock position occurred in six (2.1 %) cases and obscuring two or more clock hours in no cases. In two of these residual cases the cortex was removed by aspiration through the side-port incision using a cannula of my design. 1 Visible residual cortex in the remaining four cases (1.4 %) resisted removal attempts and was left. It did not cause any clinically significant problems. There were no cases of prolonged inflammation, infections, or secondary
320
The Rhein 1/A handpiece with interchangeable tips was effective in removing cortex in this phacoemulsification series. Only four tips were used; most cases were completed with the 90-degree tip and the curved tip. No clinically significant cortex was left in any of the 288 cases. One of two cases of capsular tears, which was a case of pseudoexfoliation with a dialysis, occurred during cortical removal. It was not felt the instrument contributed to this complication. There were no mechanical problems with the instrument and after many procedures by multiple surgeons the tips fit securely. Operative time was reduced since it is faster switching tips than changing complete 1/A handpieces. The tip is economical in that it replaces six different handpieces. Although not summarized in this report, the instrument was used in 23 cases of ECCE in this series. Cortex was removed completely in all cases. The Rhein 1/A handpiece with changeable tips is an effective and economical instrument for removing cortex in phacoemulsification and small incision posterior chamber IOL surgery. REFERENCE 1. Hagan IC III. A new cannula for removal of 12 o'clock cortex through a sideport corneal incision. Ophthalmic Surg 1992; 23: 62-63
J CATARACT REFRACT SURG-VOL 18, MAY 1992
instruments and notes
Phacoemulsification cataract extraction and insertion of a posterior chamber intraocular lens (IOL) through a small incision is a major trend in contemporary cataract surgery. Cortex removal, especially at the 12 o'clock position, is more difficult with phacoemulsification and small incisions than with planned extracapsular cataract extraction (ECCE). One approach to the 12 o'clock cortex is aspiration through a separate side-port incision. Another is the use of multiple irrigation/ aspiration (1/A) handpieces with a variety of tip configurations for cortex removal. Recently an 1/A handpiece with interchangeable tips, which is compatible with most phacoemulsification units, became commercially available (Figure 1). Six different tip configurations are provided (Figure 2). A study of the effectiveness of this instrument for cortex removal when used with phacoemulsification and small incision posterior
The author has no financial or proprietary interest in the instrument described in this report. Reprint requests to John C. Hagan III, M.D., Midwest Eye Institute of Kansas City, 2700 Hospital Drive, Fifth Floor, North Kansas City, Missouri 64116. 318
J CATARACT REFRACT SURG-VOL 18, MAY 1992
Fig. 1.
(Hagan) The irrigation/aspiration handpiece.
chamber IOL surgery was designed and the results are reported.
SUBJECTS AND METHODS A form for evaluating the extent of cortex removal during phacoemulsification and small incision posterior chamber IOL implantation was devised . If any cortex other than wisps remained after cortex removal the amount was quantitated by the number of clock hours visible cortex covered. Operative complications were recorded. Cortex not visible intraoperatively but which became visible postoperatively was quantitated and recorded. The cases were a consecutive, unselected series of phacoemulsification and posterior chamber IOL insertions performed by me from 1/1/91 until 8/31/91. Phacoemulsification, which I had been performing for two years, was done in all cases unless the combination of small pupil, lens hardness, and corneal dystrophy was such that ECCE
~
M,
$tr.T'JP
~?:;":·#mnI$5f ,'~~'<
_ _
,,'_ 0
;
was felt to be safer. Triple procedures were excluded. Pupils were dilated preoperatively with 1 % tropicamide, 2.5% phenylephrine, and 1 % cyclopentolate. Flurbiprofen was also used preoperatively. A Honan eye compressor was applied 30 minutes before surgery, and a peribulbar injection through a 23-gauge Alcon Thornton needle was given using 5 cc to 7 cc of 0.75% marcaine and 2% xylocaine in a 1:1 mixture with hyaluronidase. A small fornixbased flap was raised superiorly and a 5 mm partial thickness scleral incision was made 1.5 mm to 3.0 mm posterior to the limbus. Through a 3.1 mm keratome puncture, the anterior chamber was filled with chondroitin sulfate-sodium hyaluronate (Viscoat®) and a continuous curvilinear capsulorhexis was made with forceps. Hydrodissection was done with balanced salt solution. A side-port incision was made if the nucleus appeared hard. An Alcon Series 10,000 Master phacoemulsifier was used with a 45-degree phaco tip in all but five cases. In those five cases the Storz Premier phaco emulsifier was used. The nucleus was removed intercapsularly with a one-handed phacoemulsification technique. In very hard lenses a two-handed minimal lift technique was used. The cortex was removed with the Rhein 1/A handle and the supplied tips. The 90-degree tip was used to remove the 12 o'clock cortex first and the curved tip was used to remove the inferior, nasal, and lateral cortex. If the superior cortex was difficult to remove, the 45-degree and' Binkhorst tips were used; the straight and Simcoe tips were not used. After cortex removal the capsular bag was filled with Viscoat, the incision enlarged to 5.1 mm, and a 5 X 6 mm, surface-modified, poly(methyl methacrylate), 14.0 mm lens with polypropylene loops was placed in the capsular bag. The Viscoat was re-
>' _- ':
"¢~
Fig. 2.
(Hagan) Six interchangeable tips for the handpiece.
Simcoe
/"'IF.rt?$!!!!! J CATARACT REFRACT SURG-VOL 18, MAY 1992
319
moved, intracameral carbacol instilled, and the wound closed with a single 10-0 nylon X-type suture or left sutureless. All patients were seen one day, one week, and five weeks after surgery. No patients were lost to follow-up.
surgical re-operations. In none of the tabulated cases did cortex that was not seen intraoperatively become visible postoperatively. Only the Rhein I/A instruments were used. No handpiece or tip failure or other mechanical problems were encountered.
RESULTS
DISCUSSION
Two hundred eighty-eight phacoemulsification with posterior chamber lens implantation cases were included in the study. Twenty-three cases of ECCE and one intracapsular cataract extraction with an anterior chamber implant done on a subluxated lens were excluded. No phacoemulsification was converted to ECCE. Phacoemulsification was done in 93 % of the total cases. There were two operative complications with phacoemulsification: a capsular tear and vitreous loss occurred with nuclear rotation on a very hard lens, and a patient with pseudoexfoliation had zonular dialysis, capsular tear, and vitreous loss during cortex removal. These two cases were excluded from the residual cortex summary. The overall incidence of capsular tear/vitreous loss in phacoemulsification cases was 0.69%. No complications occurred during the planned ECCE cases. Residual cortex obscuring one clock hour at the 12 0' clock position occurred in six (2.1 %) cases and obscuring two or more clock hours in no cases. In two of these residual cases the cortex was removed by aspiration through the side-port incision using a cannula of my design. 1 Visible residual cortex in the remaining four cases (1.4 %) resisted removal attempts and was left. It did not cause any clinically significant problems. There were no cases of prolonged inflammation, infections, or secondary
320
The Rhein 1/A handpiece with interchangeable tips was effective in removing cortex in this phacoemulsification series. Only four tips were used; most cases were completed with the 90-degree tip and the curved tip. No clinically significant cortex was left in any of the 288 cases. One of two cases of capsular tears, which was a case of pseudoexfoliation with a dialysis, occurred during cortical removal. It was not felt the instrument contributed to this complication. There were no mechanical problems with the instrument and after many procedures by multiple surgeons the tips fit securely. Operative time was reduced since it is faster switching tips than changing complete 1/A handpieces. The tip is economical in that it replaces six different handpieces. Although not summarized in this report, the instrument was used in 23 cases of ECCE in this series. Cortex was removed completely in all cases. The Rhein 1/A handpiece with changeable tips is an effective and economical instrument for removing cortex in phacoemulsification and small incision posterior chamber IOL surgery. REFERENCE 1. Hagan IC III. A new cannula for removal of 12 o'clock cortex through a sideport corneal incision. Ophthalmic Surg 1992; 23: 62-63
J CATARACT REFRACT SURG-VOL 18, MAY 1992