Cataract Surgeon and Ophthalmologist, Robert Cykiert, M.D.

0:00 Hi, it's Doctor Robert Seikert. Welcome to Episode #24 of the Doctor Podcast Show. Today I'm going to be talking about cataract surgery and actually be performing the surgery. Here's the patient in the operating room with their eye open. I have what's called a wire lid speculum holding the eyelids open so that the patient can close their eye. I just applied some anesthetic to the eye. It's called 4% lidocaine, which numbs the eye. Now if you're squeamish, don't watch this because I'm about to put in a 1mm blade into the cornea, on the cornea, on the bottom of the eye and also on the top of the eye.

0:40 This is known as a paracentesis incision. It's approximately 1mm wide and allows me access into the eye during the surgery. Later on in the case you can see that the patient is awake and moving their eye. What I'm doing now is injecting a gel into the inside of the eye, what's called an anterior chamber. You can see it's a thick gel and the purpose of this is to inflate the eye. I now just squirted the eye with some saline solution to keep the cornea moist so that it doesn't dry out. Next step is I use a 2.4mm blade, a very sharp blade called a keratome and I basically inserted into the cornea.

1:24 I'm holding onto the eye with a small forceps on the white part of the eyes so that the patient doesn't move their eye during this delicate incision. Next step that I do is to actually make an incision into the cataract using this very sharp needle point which you can see cataract is about the same size and shape as an M&M. The purpose of this is for me to create an opening on the surface of the cataract and the cataract sits right behind the pupil and the pupil is very dilated in this patient, which gives us excellent access to the cataract.

2:05 Cataract, as I mentioned, is the size and shape of an M&M. What I'm doing here is removing a part of the candy shell so that I can get out all of the chocolate from the M&M without ruining or cracking the rest of the candy shell. What I do now, after making that initial incision in what's called the anterior capsule of the cataract, is I'm inserting a forceps. This is called a eutrata forceps. And as you can see, I'm actually tearing this capsule, the candy shell of the M&M, very carefully and trying to make a perfect circular tear.

2:45 This is a very delicate procedure. This is probably the most critical part of cataract surgery. It has to be done perfectly. If it's not done perfectly, the rest of the procedure is often much more complicated. You can see I'm just about finished tearing the entire anterior capsule and I'm going to remove it from the eye. And just to demonstrate, I put it on the surface of the cornea there. So now I created a circular opening in the M&M shell and I have access to the chocolate inside the M&M. What I'm about to do, after putting some more numbing drops on the eye of course, which I do every two or three minutes during the surgery, is I'm going to inject a saline solution with this device called a cannula.

3:36 This is a saline solution that I inject into the cataract. What this does is it goes all around and separates the cataract from the rest of this capsule that I mentioned to you earlier. The capsule is extremely thin. It's about 15 microns if you can imagine there's 1000 microns in a millimeter. This capsule is 15mm thick. It's extremely delicate. What I've done there is irrigated or squirted this solution around the entire cataract, and now I'm going to put in a little hook and you can see I am able to rotate the cataract inside this very delicate, very thin capsule.

4:21 That tells me that I've separated the cataract from the capsule. I'm now going to insert a device called a faco emulsification tip. This squirts fluid into the eye while simultaneously vibrating at extremely high speeds, and what I'm doing is emulsifying the cataract. I'm converting the dense solid cataract into a liquid and then I'm vacuuming out through the opening of this vibrating metal tip. And then I rotate the cataract approximately 90° and I make another groove or incision. This is called sculpting of the cataract.

5:04 It's removing the chocolate from the M&M without damaging the candy shell. I now rotate the cataract another 90° and I make another groove or incision. More sculpting and when I'm in approximately 90% depth of the cataract, I stop because I don't want to tear the capsule in the back of the cataract. I don't want to break the shell of the M&M. Now I have an XX marks the spot and I'm going to post this on x.com so it all makes sense. So I have a perfect X. Now it's a groove. It's about 90% thick through the cataract.

5:48 I'm injecting that gel now to basically deepen the eye and inflate the eye so it does not deflate. Now I can't get out the whole cataract which is about 12mm wide through a 6mm incision that I made in the capsule. So what I'm going to do is crack or split the cataract into approximately 4 equal pieces using these two devices. One is a called a sinsky hook, the other one is called a cyclodialysis spatula. I rotate the lens at 90° increments. I then crack the lens because I was able to make that groove about 90% thickness so it'll crack easily for me now that I have 4 equal pieces.

6:31 Think of it as a pizza pie with four slices. I hope I'm not making you too hungry with the M&M and pizza pie analogy. And there were some more numbing drops over there. So now I split this cataract or the chocolate into 4 equal pieces. I then reinsert the fake O emulsification device, and now I can take out these individual chunks or quadrants of the cataract with this fake O emulsification, which liquefies the cataract with vibrations and simultaneously vacuums it out of the eye. I rotate each of those quadrants so that I can access them.

7:10 I have to be extremely careful not to touch the cornea, not to touch the dilated pupil, not to touch the rest of the capsule of the cataract, because those structures are critical for the rest of the procedure, as you'll see. So now I've removed 100% of the what's called a nucleus or the dense core of the cataract. What remains in the periphery or edges of the cataract is called cortex. I just applied some more numbing drops. The cortex is like a soft chocolate. Imagine an M&M that has a very dense, thick chocolate in the center, but very soft chocolate in the periphery of the edges.

7:49 I'm inserting what's called an irrigation aspiration device, and I'm gently sucking out those very soft pieces of what's called cataract cortex that sit in the periphery. These are attached to the capsule, which is 15 microns thick, So I have to be extremely careful not to touch that capsule. And as you can see, I've gotten all of it out at this point. So that now I've evacuated the entire cataract from its capsule. I've evacuated all of the chocolate out of the M&M. All that remains is a candy shell.

8:30 So what do I do at this point? I want to delineate the anterior capsule with this hook. You can see it. It's a almost a perfect circle there that I created in the beginning of the procedure. What I'm going to do now is basically inflate the eye with that gel like substance. You can see it's like a thick gel and I'm going to inject that in there to inflate the front part of the eye. And I'm also going to inflate the capsule, the M&M candy shell with this thick gel. Because the gel is very thick, it stays inside the eye and it basically gives me space to work in.

9:09 Keep in mind everything is about 3 or 4mm apart. Next thing is I'm going to put a lens implant inside the eye. My current favorite lens implant is made by Alcon. It's a CNAOTO and the power is plus 21.0. This lens comes prepackaged in a delivery system and you'll be able to see in a moment that the delivery system is like a syringe. I'm actually pressing a button now which is advancing the yellow colored lens implant. It's called an intracer lens. It's made out of plastic. I'm now inserting that which is about 2.4 millimeters into my original 2.4mm incision.

9:56 I now press a button and this lens, which was scrolled up inside this little syringe device, unfolds inside the eyeball in the capsular bag where the M CMM chocolate used to be and it has a memory so it unfolds. You can see the lens is made out of three parts. The center part is the optics of the lens, almost like a contact lens, and the edges of the lens have what's called haptics. These haptics hold the lens in perfect position and centration. I'm now nudging the lens, haptics and optic into perfect centered position in the center of the pupil in the capsule or bag.

10:38 What I do now is I insert a device which I used previously to remove the soft part of the cataract to remove all of the gel from inside the eye. You can see the lens implant is is bumping around and jumping around a little bit because this gel is very thick and as it comes out of the eye because I'm suctioning it out, it actually moves the implant. I'm now moving my irrigation aspiration device around to get all the gel out of the eye. Because if you leave the gel in the eye, the patient will have very high pressure the next day, which is not a good thing.

11:12 So we want to remove all the gel. Next thing I do is I inflate the eye with saline solution, which is similar to the liquid that's inside the eye. I'm squirting that in through the original tiny incisions that I made with the 1mm blade. What I'm doing now is hydrating the cornea where I made my initial incision. I'm squirting saline solution into what's called a corneal stroma. The cornea is like a sponge. It absorbs this fluid. It turns white as it absorbs the fluid. What's happening is the cornea is swelling by swelling.

11:48 It's self sealing the original 2.4mm incision that I made to enter the eye. This seals the incision and therefore I don't need any stitches when I do cataract surgery because the incision self seals by injecting the saline solution into the cornea and as you can see the lens implant or intracer lens is perfectly centered and now I'm going to inject some additional solution. This is called myocol. What this does is it shrinks the pupil a little bit. I have a very large pupil to do the surgery. It helps me to access the cataract easily.

12:29 At the end of the surgery I want to shrink the pupil a little bit. You can see the pupil is shrinking. What I want to do now is make sure that all my incisions are completely sealed so there's no leakage of fluid from inside the eye. So I'm using this triangular sponge to press on the incisions that I initially made just to make sure that there's no fluid leaking out of the eye when I press on the eye. Keep in mind, the patient does not feel any of this because the eye is completely numb with those lidocaine drops that I've been applying every two or three minutes during the entire procedure.

13:04 What I'm doing now is just irrigating some antibiotic and steroid solution on the eye to prevent infection and reduce inflammation. I'm now squirting some more of the numbing drops and now what I'm going to do is remove that wire lid speculum that kept the patient's eyes open. I'm also going to remove these little plastic drapes from the patient and we are done. Thanks for watching this episode of Doctor Podcast #24. We hope to see you soon for more episodes. If you enjoyed this episode, as usual, please subscribe to Doctor podcasts and also please press like and repost and comment on the episodes that you like.

13:52 Thank you very much.