Complex cataract surgery, with ophthalmologist Robert Cykiert, M.D.

Hi, thanks for tuning into a new episode of the Doctor Podcast Show. I'm your host, Doctor Robert Seikart. Today we have a very interesting episode. About six months ago, I posted an episode where I actually did cataract surgery and posted it online to show you what it looks like. Today I'm doing another cataract operation, but this time it's a complex cataract surgery. Previously, I posted a routine cataract surgery in an older patient who developed cataracts from aging. This current patient is very different.

The patient had what's called an acute glaucoma attack with an extremely high pressure in the eye, which is very painful and cause loss of vision. The patient had emergency laser iridotomy treatment by another ophthalmologist and then was referred to me because he developed a very advanced cataract such that he was only able to see light and dark in the eye, could not read the eye chart at all, and could not see anything else. If you look at the video screen now, you'll see I have a picture of what this cataract looks like.

In the upper left hand corner. You'll see the previous case that I posted online, which was a routine cataract, and you can see that there's a red pupil. That's because the light from the microscope that I used to do the surgery is reflecting off the retina and the retina has a reddish color. So you get this what's called a red reflex. This allows us to do the cataract surgery and allows us to visualize the different parts of the cataract. In this patient, you can see that the cataract is white.

There is no red reflex. Because this cataract is extremely advanced. It's called a hyper mature cataract and therefore we lose some of the landmarks during cataract surgery and I'll show you how I use special techniques and instruments to bypass that problem and still get a good result. Additionally, during this video segment, you'll see that from time to time I will post on the left upper corner elements of the previous cataract surgery that I did so you can compare the two. So let's start by watching the video.

You can see in the center of the screen here we have a white cataract and you can see the pupil is partially dilated. The pupil did not dilate fully because the iris and pupil were damaged by the glaucoma attack. I just put some numbing drops, 4% lidocaine on the eye, on the cornea to numb the eye. I do that repeatedly during the surgery so that the patient has no discomfort and no pain at all. During the surgery Surgery you can see that patients eye is moving. I don't inject any medications and you can see now I'm using a very sharp razor blade to create small incisions in the eye through the cornea.

These are called paracentesis incisions. This is done with a approximately 1mm very sharp surgical blade. In this patient, I have to make six of these incisions. I'm now doing this with my right hand and with the left hand I'm holding onto the eye by grasping the conjunctival membrane. So now I've done three of these with my right hand and now I'm going to switch hands. It helps to be ambidextrous when doing cataract surgery. You can see now that I'm grasping the eye with my right hand and the forcep, and now I'm making these small paracentesis incisions with the small blade, which is called a super blade, by the way.

Now, this is very difficult to do in this patient because this patient has what's called a very shallow anterior chamber because of the dense cataract and because he had a condition called narrow angles before he developed the glaucoma attack. So this has to be done very carefully so that I don't accidentally nick the iris or the pupil or the cataract. Otherwise I'm going to run into some serious complications during the surgery. Now, once I've made all of these six incisions with the Sharp superblade, what I'm going to do is inject some lidocaine, 1% lidocaine preservative free, into the anterior Chamber of the eye.

This is done to numb the internal parts of the eye so that the patient has no discomfort when I remove the cataract or manipulate the iris and pupil during the surgery. Now, because this pupil would not dilate fully because the pupil muscles and the iris muscles were damaged by the acute glaucoma attack, what I need to do is put in these very tiny hooks into the eye through the paracentesis incisions that I made, and that allows me to dilate the pupil more fully so that I can access the cataract during the surgery.

As you see, I've put in two hooks so far. I'm putting in a third one. Now. There's also a small air bubble in the eye which occasionally gets in while I'm doing these maneuvers. The air bubble is inconsequential and does not interfere in any way with the surgery and either gets evacuated from the eye or gets dissolved in the eye. So now I have 3 hooks that I've put in to the eye. You can see I've dilated the pupil and now I'm putting in this 4th hook. These hooks are made out of a very thin nylon plastic which is flexible but sturdy enough so that I can manipulate the pupil.

This also has to be done extremely carefully because I can't damage the iris or pupil while doing this or cause any tears in the iris or pupil, otherwise I'll get bleeding in the eye. You can see in the upper left corner now I'm using a 2.4mm keratome, which is a very sharp knife to enter the anterior chamber. This has to be done very carefully and delicately so that I don't injure the iris, the pupil or the cataract. Because the anterior chamber is very shallow here and there's very little space, it's very difficult to work inside this cataract, as opposed to the routine cataract which you saw in the upper left corner of the screen.

Now what I'm going to do now is inject some blue dye into the eye. It's called Tripan blue. What this does is it colors the anterior capsule or front part of the cataract in a very blue vivid color. Since I don't have that red reflex because this cataract is extremely advanced, what I'm doing is using this dye to actually turn the front of the cataract, the anterior capsule, into a blue color so I can visualize it better. Without this, it would be nearly impossible to remove the cataract safely.

If you watch my previous video, you know that the cataract is approximately the size and shape of an M&M candy, and the anterior capsule is like the candy shell surrounding the chocolate of an M&M. What I do now is gently rub the cornea so that I'm distributing this tripan blue dye inside the eye, and while I'm doing that, it's actually staining the cataract. Interestingly, it doesn't stain other parts of the eye, it just stains the cataract. I'm now irrigating some saline solution into the eye to remove the excess tripan blue fluid and you can see that the front of the cataract they enter capsule of the cataract is staining a very pretty blue color.

Actually this allows me to visualize the inter capsule of the cataract which I need to remove. It's like removing part of the candy shell of an M&M candy and now I'm injecting what's called viscoelastic, which is a thick gel like fluid to deepen the front part of the eye. If you look at the upper left hand corner, I use a very fine needle to create a cut in the anterior capsule. But in this eye, which is now coloured blue, I don't have the luxury of the red reflex. So fortunately I have this blue stain of the capsule.

You can see I'm making an incision into the capsule using this very sharp needle tip, which is called a cystotome. And what I do is I create a microscopic flap in the anterior capsule of this mature cataract. I now insert Eutrata forceps which grabs this. And what I try to do now is make a very circular cut by tearing this flap, which is colored blue, and slowly creating what's called an anterior capsulotomy or a capsulorexis. It's also known as this is a critical part of the procedure. It has to be done very carefully.

You have to make this as close to a perfect circle as possible in the upper left corner. You can see me doing that on the routine cataract, but I have the luxury of the red reflex helping me to see the capsule. In this case, I have now the luxury of the Tripan blue dye, which allows me to visualize this capsule. So now I've done the capsulotomy, I've taken it out, I'm putting it on the cornea to visualize it, and I don't need that anymore. So basically I get rid of it. What I'm doing now is injecting some saline solution known as BSS solution under the anterior capsule of the cataract.

What I'm doing is trying to create a fluid stream under the body of the cataract or think of it as the chocolate of the M&M, to try to separate the cataract from the rest of the capsule or the capsular bag. And this allows me to later remove the cataract successfully without injuring any other parts of the eye. Now to make sure that I fully separated the cataract from the capsule, I inserted an instrument called a Sinsky hook and you can see that I'm actually rotating the bulk of the cataract inside the capsular bag.

It's almost like rotating the chocolate inside an M&M but leaving the capsule or candy shell intact. What I'm doing now, both in the upper left corner in the routine cataract and in this cataract, is I inserted what's called a faco emulsification handpiece, or faco. This is a metal tube that's vibrating at thousands of times per minute, and what it's doing is converting the hard cataract into a liquid state and then I'm vacuuming the cataract out. This has to be done very carefully and gently so that I don't injure the iris, the pupil, or the capsular bag that the cataract is in.

As I'm doing this, the facial emulsification handpiece is also irrigating a saline solution into the eye so that the eye does not collapse, because if I'm removing fluid, I have to replace the fluid. You just watch me rotate the cataract approximately 90° and now I'm making another groove into the cataract. You can see I'm doing similarly in the upper left hand corner in the routine cataract, but there I have the red reflex to guide me. Here I don't have a red reflex because this cataract is very advanced and hyper mature, and as a result I just have to look at this very carefully through the microscope, which is in approximately 15 power.

So I'm seeing everything magnified. Now I need to go and make these grooves as deep as possible into the cataract, yet not go too deep so that I accidentally break the posterior capsule or the candy shell at the back of the M&M. So I go about 80% depth and this is done by visualization alone. There is no sensation of touch. And once I feel this groove is about 80% of the depth of the cataract, I rotate the cataract again about 90° and I create another groove. These grooves allow me to crack the cataract into four individual pieces, which I can then more easily remove through the opening that I made in the anterior capsule.

And you can see now I have a four part groove and I've split the cataract into approximately 4 parts and it looks like an XX marks the spot here. I'm going a little deeper in one of the incisions. Now what I do now is inject some of that viscoelastic fluid, that gel fluid which allows me to inflate the eye so that the eye does not collapse. And what I'm going to do now is insert two instruments into the eye to actually crack or break this cataract into four pieces. By the way, I put some more numbing drops there, as you noted, so that patient has no sensation of this at all.

Patient has no pain or discomfort. What I'm doing now is gently cracking the cataract into four individual pieces, almost like a pizza pie with four slices. This has to be done very carefully because if I crack too hard then and I will rip the capsule. The capsule is extremely thin. It's about 15 microns thick. Think of it as Saran wrap or plastic wrap, but much much thinner than that. A red blood cell of a human is about 7 or 8 microns in diameter. This capsule is about twice the thickness of two red blood cells aligned.

Now, once I've broken the cataract into four individual pieces, I tried to get those pieces out individually by applying suction, which allowed me to pull out that slice of the pizza pie, so to speak. You can see in the upper left hand corner I'm doing that as well, but my visualization is much better there because I have that red reflex to allow me to identify anatomic parts of the eye. Here I'm removing another slice of the pizza pie or another piece of the cataract. You can see this cataract has a dark amber color, which means it's very hard and it's very difficult to emulsify it and turn it into a liquid.

The cataract has now mostly come out of the capsular bag. I'm applying this facial emulsification vibration energy, which by the way is control with a foot pedal. When I press on the foot pedal, it irrigates fluid into the eye. If I press down a little further, it aspirates or vacuums out, and if I press a little further then it vibrates and actually liquefies the cataract. What I'm doing here is injecting some more viscoelastic fluid into the eye to allow me to position the cataract fragments in a way so that it's easier to access with this fake old emulsification handpiece.

So again, with my right hand, I'm controlling the vibrating facial emulsification handpiece. With the left hand, I'm holding onto the eye and the conjunctiva so that the eye doesn't move and is stabilized. And with my foot, I am controlling the pedal that controls the facial emulsification probe. Additionally, with my left foot, I occasionally will adjust the microscope focusing or microscope zoom power. So we use both hands and both feet to do cataract surgery. You now see that I have a red reflex because I've removed this very, very dense cataract and now I inserted what's called an irrigation aspiration handpiece into the eye.

This removes parts of the cataract that are called the cortex, and you can see in the upper left hand corner. I'm doing that as well on the routine cataract. Once I've removed all the cortex from the eye, I inject the viscoelastic gel like substance into the front part of the eye to inflated the anterior chamber. I'm also injecting it into the capsular bag which you can see the outline of. It's still a little blue in color from the Tri pan blue dye that I injected. What I'm doing now is getting my intraocular lens implant ready.

It sits inside this capsule plastic capsule which is made by a company called Alcon, and now I'm inserting that into my 2.4mm incision. With my right hand, I'm pressing a button which extrudes the intraocular lens into the eye. The lens is wrapped up like a Taco inside of this capsule structure. Inside the plastic handpiece, I've now dimmed some of the lights so you can see the intracer lens implant a little bit better. Similarly, in the upper left hand corner, I've also inserted the intracer lens.

Now I have to position this intracer lens perfectly inside the capsular bag or the remaining candy shell of the M&M. So I'm using an instrument called Asinski hook, which allows me to manipulate this implant so that I get it perfectly centered in the middle of the capsular bag, which you can see I've accomplished now and you can still see some of the residual blue anterior capsule. Now I need to remove these iris hooks, which I do very carefully and delicately. I don't want to accidentally rip the iris or pupil when I remove these hooks.

These hooks have done their job. They kept the pupil people dilated for me during this very intense, delicate, detailed surgery, and now I'm taking them out one hook at a time. This is done again under the microscope with about 10 to 15 power of magnification, so I can see exactly what I'm doing. And now I've taken out or I'm about to take out the third hook. Sometimes these hooks can get caught up in the iris or the pupil and you have to play with them a little bit and manipulate them a little bit so that you can get them out safely and not rip the iris, the pupil, or the anterior capsule of the cataract.

And now I'm about to take out the 4th hook. Now I have this gel like substance in the eye called viscoelastic which I need to remove because if you leave it inside the eye it can cause severe pressure elevations after the surgery. So I'll be taking that out. I'm also irrigating some saline solution with a very fine cannula into the little holes that I made. The reason I'm doing this is I want to make sure there are no strands or shreds of iris. Stuck in the incisions that I made, we don't want to leave those in there because they potentially could cause inflammation in the eye.

Now I'm inserting that handpiece again that I used to clean out the cortex material, and I'm actually aspirating or vacuuming out the viscoelastic material. And you can see the lens implant jumps around a little bit because this material is very thick and dense. And sometimes when it comes out, it'll push the lens a little bit. I'm doing that similarly in the upper left hand corner in the routine cataract that I posted about six months ago. Once I've removed all this viscoelastic material, you can see the pupil is beginning to shrink.

Some of the iris has now actually gotten stuck in the incision that I made. So I'm using a very fine instrument of fine cannula to basically reinsert the iris back into the eye. I'm also irrigating some saline solution fluid into the cornea at the same time to try to close that wound. The cornea is like a sponge. If you inject fluid into it, it will absorb it and it will thicken like a sponge thickens when you expose it to water and that allows me to seal the incision. Now I'm injecting some more saline solution into what's called the corneal stroma, which again thickens the cornea and it basically self seals the incision that I made, the 2.4mm incision.

This temporarily turns the cornea white, but overnight this fluid will be reabsorbed by the cornea and the cornea will clear up there as well. So now I've completed that maneuver. What I'm noticing now is that part of the pupil is actually stuck in the back of my corneal wound that I created. So I'm inserting this Sinski hook through one of the incisions that I previously made and I'm actually grasping the pupil with that hook and pulling it out of my corneal incision. You can't have any iris or pupil stuck in your incision because you will have a lot of post operative inflammation and also problems with inflammation in the retina and possibly increased pressure.

What I'm doing now is using a sponge which is triangular shaped to press on the wound to make sure that there's no fluid leaking out of the eye. You can also see that the pupil has shrunken nicely and is now round which tells me that none of the iris or pupil is stuck in the wound anymore. I'm now pressing on all my other incisions that I made to make sure they are all watertight and that no fluid escapes. And that's the end of this complex cataract surgery procedure. I hope you enjoyed watching it.

Thank you.

In this episode