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 Table of Contents  
SURGICAL CORNER
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 189-193

A new technique of phacoemulsification without hydroprocedures


1 Department of Cataract and Cornea Services, Chandraprabha Eye Hospital, Jorhat, Assam, India
2 Department of Ophthalmology, JIPMER Hospital, Puducherry, India

Date of Submission06-Mar-2021
Date of Decision08-Mar-2021
Date of Acceptance09-Mar-2021
Date of Web Publication21-Aug-2021

Correspondence Address:
Dr. Sandip Sarkar
Senior Resident, Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Gorimedu, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_60_21

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  Abstract 


Purpose: We describe a new technique where phacoemulsification can be safely performed without doing hydroprocedure. Materials and Methods: We conducted a prospective, nonrandomized, noncomparative, single-center study where Group A had undergone phacoemulsification without hydroprocedure and Group B had undergone conventional phacoemulsification. After capsulorhexis, we insert the phacoemulsification tip into the eye without doing any hydroprocedure. First shaving of the cortex and epinucleus is done within the capsulorhexis area. Then, the tip is buried into the center of the nucleus and an anteroposterior crack is fashioned. Then, the tip is placed at 8 o'clock position to chop away a piece of nucleus and emulsified. A similar maneuver is done at 4 o'clock position. The phacoemulsification tip and the chopper are now positioned at the cracked site of the lower fragments. Using the two instruments, the fragments are pushed to the opposite direction and emulsified. Results: The mean age of the patients of Group A was 65.7 ± 8.16 years and Group B was 68.9 ± 9.85 years (P = 0.127). The mean best-corrected visual acuity in Group A improved from 0.92 ± 0.49 logarithm of the minimum angle of resolution (logMAR) to 00.01 ± 0.02 logMAR at 3 months postoperatively. The mean endothelial cell loss was 145 ± 123 cells/mm2 at 3 months postoperatively. There was no significant difference in postoperative outcomes between both the groups. Conclusion: The technique can be safely applied in all cataracts, especially posterior polar cataract and white mature cataract where hydrodissection is contraindicated.

Keywords: Chopping, cortical cleavage hydrodissection, hydroprocedure, phacoemulsification


How to cite this article:
Bardoloi N, Sarkar S. A new technique of phacoemulsification without hydroprocedures. Kerala J Ophthalmol 2021;33:189-93

How to cite this URL:
Bardoloi N, Sarkar S. A new technique of phacoemulsification without hydroprocedures. Kerala J Ophthalmol [serial online] 2021 [cited 2021 Nov 30];33:189-93. Available from: http://www.kjophthal.com/text.asp?2021/33/2/189/324199




  Introduction Top


Hydrodissection of the nucleus in cataract surgery has been defined by Faust in 1984 as the injection of fluid into the cortical layer of the lens under the lens capsule to separate the nucleus from the cortex and capsule.[1] The original hydrodissection technique described by Faust was a way to express the nucleus out of the bag in extracapsular cataract extraction (ECCE) surgery. When modern phacoemulsification technique evolved, hydrodissection was more used to facilitate the rotation of the nucleus initially for the divide and conquer technique and later for chopping techniques. Fine described cortical cleaving hydrodissection technique in 1992 where he lifted the anterior capsular flap and injected fluid with a 26G blunt cannula to break the cortical capsular adhesions from the nucleus.[2]

Since its inception, hydrodissection has been an integral part of all types of cataract surgical techniques, namely phacoemulsification, manual small incision cataract surgery, and age-old ECCE. The purpose of doing the hydroprocedure in phacoemulsification is to facilitate easy nuclear rotation and better emulsification.[3] However, the procedure is not always safe as it seems. There have been published reports of posterior capsular rupture (PCR) following hydroprocedure.[4],[5] Dislocation of lens nucleus into the vitreous cavity after standard hydrodissection is not very uncommon. Intraoperative capsule block syndrome is a well-known complication of hydroprocedure which finally results in PCR and dropping of the nucleus into the vitreous cavity.[6] Hydrodissection cannula-related zonular dialysis is also reported.[7] Phacoemulsification without hydrodissection is a technique which we have developed to prevent hydrodissection-related complications. Two techniques of phacoemulsification without hydroprocedure have been described in the literature. We are describing a new technique, which is very simple, safe, does not need any special maneuvers, reproducible, can be applied in all types of cataracts, and will be especially beneficial in posterior polar cataract or white mature cataract where hydrodissection is better avoided.


  Materials and Methods Top


We have been doing phacoemulsification without hydrodissection since 2008 (a film and a paper presented at ASCRS conference at Boston in 2010 and San Diego in 2011, respectively). We conducted a prospective, nonrandomized, noncomparative, single-center, clinical interventional study from January 2019 to December 2019 in a tertiary eye care center of Northeast India. The study protocol was approved by the institutional ethics committee, and it adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all the participants after explaining them study. All patients with age-related cataract requiring phacoemulsification surgery and those who gave informed consent for the study were enrolled. Complete ophthalmic evaluation including medical and ophthalmic history, preoperative uncorrected visual acuity, best-corrected visual acuity (BCVA), the slit-lamp examination to grade the lens and assess the anterior segment, intraocular pressure (IOP) with Goldmann applanation tonometry, and dilated fundus evaluation with indirect ophthalmoscopy was done. Grading of the cataract was done using the Lens Opacities Classification System III (LOCS III).[8] In cases of a dense cataract, B-scan ultrasonography was performed. Biometry was performed with intraocular lens (IOL) Master-500 (Zeiss, Jena, Germany) using partial coherence laser interferometry. In cases of hazy, the axial length was obtained by immersion A-scan and the data were put on IOL Master-500 and the IOL power was calculated. All the enrolled patients were categorized into two groups; in one Group A, phacoemulsification was done without hydroprocedure, while in Group B, conventional phacoemulsification with hydroprocedure was performed.

Surgical technique

All surgeries were performed by a single experienced surgeon (NB) under topical anesthesia (proparacaine 0.5% drops). Two 1-mm side-port incisions were made at 2 o'clock and 9 o'clock position using a microvitreoretinal blade (Alcon Laboratories, Inc.). The irrigating cannula of the bimanual irrigation and aspiration (I/A) apparatus was inserted in continuous irrigation mode to form a stable chamber. A 5.5-mm continuous curvilinear capsulorhexis was performed under irrigation using a 30G cystitome. A temporal limbal incision was made with a 2.2-mm single-bevel keratome (Alcon Laboratories, Inc.). At first, sodium hyaluronate 1.0% (Healon) was injected to form the anterior chamber (AC) and then chondroitin sulfate 4.0%–sodium hyaluronate 3.0% (Viscoat, Alcon Laboratories, Inc.) was injected to coat the endothelium.

All eyes had undergone torsional phacoemulsification (Centurion Vision System, Alcon Laboratories, Inc.) using the active fluidics system with balanced tip. The parameters were set as follows: 60% Ozil, vacuum 400 mmHg, flow rate 30 cc/min, and the IOP being kept at 50 mmHg.

The first step is known as shaving. The bevel of the phaco tip is placed sideways toward the left side instead of the usual bevel-up position. In this step, the cortex and epinucleus within the capsulorhexis boundaries are grasped by the phaco tip and aspirated without using any phaco power [Figure 1]a. In the next step, the phaco tip is buried deep into the center of the nucleus. The nucleus is hold with phacoemulsification probe with adequate vacuum and anterior posterior crack is initiated using chop in situ technique [Figure 1]b.[9] In hard, big, and leathery nucleus, a crater is made initially, and then, the chopping is done to crack the nucleus into two halves. Here, step-by-step chopping with lateral separation technique is done to facilitate the crack.[10] After the crack, the phaco tip is placed at 8 o'clock position at the same parameter. The tip holds the nuclear half, slightly lifts it, and pulls little toward the center. Chopping is done at this position to fashion a crack and to take out a triangular piece of the nucleus and subsequently emulsified [Figure 1]c. The tip is now placed at 4 o'clock position to chop and emulsify another triangular piece of the nucleus using a similar technique [Figure 1]d. There remain the last two pieces lying at the incision end. These two pieces were cracked during the first step. Most of the time, they remain adhered loosely. The phaco tip and the chopper are now positioned at the cracked site of these two lower fragments [Figure 1]e. The phaco tip holds the right-hand fragment steady, and the chopper pulls away from the left-hand fragment up toward 6 o'clock position. This fragment is then emulsified. The fourth fragment now lying unattached can quickly be mobilized to 6 o'clock position to complete the emulsification [Figure 1]f. The epinucleus usually comes out along with the nuclear fragment in most of the times. The cortical matter was removed with bimanual I/A. A foldable hydrophobic acrylic single-piece IOL is injected into the capsular bag using the hydroimplantation technique [[Figure 2] and Video 1].[11] Intracameral preservative-free moxifloxacin (0.5 ml) was injected into the AC. The main incision and side-port incision were sealed with stromal hydration. The intraoperative parameters such as cumulative dissipated energy, ultrasound time (US time), and fluid loss (ml) was noted at the end of the surgery from the video overlay.
Figure 1: (a) Shaving of the cortex within capsulorhexis margin, (b) Cracking of the nucleus into two halves done, (c) Chopping at 8 o'clock position of the nucleus with removal of a piece of nucleus, (d) Chopping at 4 o'clock position of the nucleus with removal of a triangular piece of the nucleus, (e) The phaco tip and the chopper are now positioned at the cracked site of the lower fragments. Using the two instruments, the fragments are pushed to the opposite direction and are easily taken out one after the other, (f) Last nuclear piece mobilized to 6 o'clock position and emulsified

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Figure 2: Animated diagrams showing the steps of phacoemulsification without hydroprocedure

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  Results Top


We conducted a prospective, randomized, comparative study to evaluate the outcomes of phacoemulsification without hydrodissection. [Table 1] shows the baseline demographics of all the patients. The mean age of the patients of Group A was 65.7 ± 8.16 years and Group B was 68.9 ± 9.85 years. Nucleus hardness was 3.22 ± 0.78 in Group A and 3.55 ± 0.45 in Group B (P = 0.122) (the grading of cataract was done according to the LOCS III). The nucleus was successfully cracked by direct chopping method in majority of the cases. In rest of the cases, a small central crater was made before direct chopping being done. Rotation of the nucleus was attempted in all cases after the emulsification of the second fragment. In most of the cases, the nuclear fragments rotated on the first attempt. In remaining cases, a third chopping was done at 2 O'clock position to fashion another piece of the nucleus. After that, the fragments moved freely to be emulsified as in conventional phaco.
Table 1: Baseline characteristics of the patients

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[Table 2] shows the mean values of intraoperative parameters. In none of the cases, hydrodissection was performed. Nucleus rotation was successful in 100% of cases. PCR was noticed in two cases during last piece removal; we did anterior vitrectomy and implanted the three-piece hydrophobic IOL over sulcus.
Table 2: Phacoemulsification parameters of the patients

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[Table 3] shows postoperative parameters following phacoemulsification after 3 months. There was no significant difference in BCVA, endothelial cell loss, and IOP between both the groups.
Table 3: Postoperative parameters after 3 months

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  Discussion Top


The significant gain in our technique is that we have been able to avoid the hydroprocedure-related complications such as PCR, capsular block syndrome, and cannula-related zonulolysis. Another benefit of this technique, the epinucleus came out along with the nuclear fragments. This eliminated the need for going to the epinucleus mode. The scanty cortex left at the end of the nucleus removal is another gain. This makes cortex removal and easy and quick.

The primary purpose of doing hydrodissection is to facilitate rotation of the nucleus during phacoemulsification. In our technique, nucleus rotation was not necessary up to Stage 4, i.e. till the 4 o'clock nuclear fragment was not emulsified. After that, the remaining nuclear fragments can be so easily rotated as if somebody has done an excellent cortical cleaving hydrodissection beforehand. Hence, we could have achieved the advantage of nuclear rotation as done in normal hydrodissection without doing so. In our practice, we do not look for corticocapsular adhesion (CCA) in routine preoperative evaluation. Presuming that there were cases of CCA, we operated with the nonhydrodissection procedure; we can say that they did not create any difficulty since we did not have the problem of rotation in any of the cases.

In this technique, we take advantage of a phenomenon called natural hydrodissection.[11] The first step of this phaco procedure, the shaving, allows enough balanced salt solution to pass naturally beneath the anterior capsule to do some hydrodissection. In the second step, when the nucleus is held and lifted little, some more fluid goes around the subcapsular space. In the third step, when the nuclear half is held, lifted, and pulled toward the center at 4 o'clock, one can notice fluid passing through the lateral subcapsular space separating the nuclear epinuclear portion from that of the capsule and cortex. A similar maneuver at the 8 o'clock position separates the other nuclear half free of adhesions. That is why after the removal of the second fragment, the remaining fragments become adhesion free and can easily be rotated. In manual hydrodissection, there may be an error in finding the right path of the fluid. In natural hydrodissection, the fluid finds its path naturally, thus eliminating any error.

Masuda and Tsuneoka described a technique of hydrodissection-free phacoemulsification in which they apply mechanical sweeping movements to break the CCAs.[12] This technique of mechanical sweeping may cause stress on the zonules and cause zonular dialysis. Hence, is it not a suitable technique in cases of zonular weakness, subluxated cataract?

In semi-crater and split technique by Soda and Yaguchi, a wall is sculpted perpendicular to the center of the nucleus and the nucleus is split into two sections. In the next step, multiple pie-shaped sections or L-shaped fractures are created, facilitating rotation and removal of the nuclear pieces.[13] In this technique, the authors themselves have admitted that this technique is not suitable for hard, brown cataracts.

Compared to these two techniques, our technique can be applied safely in all types of cataracts including cataracts with weak zonules and any type of hard, brown and even in leathery cataracts. Our technique hardly differs from the conventional phacoemulsification technique, except that the chopping at 4 o'clock and 8 o'clock is little unconventional as most of the phaco surgeons like to do chopping in the area around 6 o'clock.

In our study, we have performed this technique in cases with pseudoexfoliation syndrome, posterior polar cataract, brunescent, white cataract, small pupil, shallow AC, long axial length, postvitrectomy, and intraoperative floppy iris, which are categorized as high-risk cases.[14]

In respect to the teaching point of view, in our hospital, all our resident surgeons are encouraged to perform the hydrodissection-free phacoemulsification. Initially, we teach them to divide and conquer technique[15] for initial few days, but once they got the hangover of phacoemulsification, then we shift them to hydrodissection-free phacoemulsification and they have been performing with favorable outcomes. We have not included their performed cases in the study, but a comparative study between an experienced surgeon and a resident surgeon will be very beneficial.


  Conclusion Top


Vigorous hydrodissection can cause many complications such as PCR, nucleus drop, and zonular dialysis. Two techniques of phacoemulsification have been described in the literature to overcome this problem.[12],[13] This nonhydroprocedure technique of phacoemulsification holds good in the 1442 cases that we have operated at our hospital. The experience of these cases makes us believe that this technique can be easily apply to overcome those problems and can be a major technique in posterior polar cataract where hydroprocedure is contraindicated.

Declaration of the patient consent

Informed consent was obtained from all individual participants included in the study. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Faust KJ. Hydrodissection of soft nuclei. J Am Intraocul Implant Soc 1984;10:75-7.  Back to cited text no. 1
    
2.
Fine IH. Cortical cleaving hydrodissection. J Cataract Refractive Surg 1992;18:508-12.  Back to cited text no. 2
    
3.
Vasavada AR, Singh R, Apple DJ, Trivedi RH, Pandey SK, Werner L. Effect of hydrodissection on intraoperative performance: Randomized study. J Cataract Refract Surg 2002;28:1623-8.  Back to cited text no. 3
    
4.
Yeoh R. The 'pupil snap' sign of posterior capsule rupture with hydrodissection in phacoemulsification. Br J Ophthalmol 1996;80:486.  Back to cited text no. 4
    
5.
Kershner RM. Capsular rupture at hydrodissection. J Cataract Refractive Surg 1992;18:423.  Back to cited text no. 5
    
6.
Miyake K, Ota I, Ichihashi S, Miyake S, Tanaka Y, Terasaki H. New classification of capsular block syndrome. J Cataract Refract Surg 1998;24:1230-4.  Back to cited text no. 6
    
7.
Munshi V, Sampat V, Pagliarini S. Zonular dialysis and vitreous loss with a J-shaped hydrodissection cannula during phacoemulsification. J Cataract Refract Surg 2005;31:450-1.  Back to cited text no. 7
    
8.
Chylack LT, Wolfe JK, Singer DM, Leske MC, Bullimore MA, Bailey IL, et al. The lens opacities classification system III. Arch Ophthalmol 1993;111:831-6.  Back to cited text no. 8
    
9.
Vasavada AR, Desai JP. Stop, chop, chop, and stuff. J Cataract Refract Surg 1996;22:526-9.  Back to cited text no. 9
    
10.
Singh R, Vasavada AR, Janaswamy G. Phacoemulsification of brunescent and black cataracts. J Cataract Refract Surg 2001;27:1762-9.  Back to cited text no. 10
    
11.
Bardoloi N, Sarkar S, Pilania A, Das H. Pure phaco: Phacoemulsification without ophthalmic viscosurgical devices. J Cataract Refract Surg 2020;46:174-8.  Back to cited text no. 11
    
12.
Masuda Y, Tsuneoka H. Hydrodissection-free phacoemulsification surgery: Mechanical cortical cleaving dissection. J Cataract Refract Surg 2014;40:1327-31.  Back to cited text no. 12
    
13.
Soda M, Yaguchi S. Phacoemulsification without hydrodissection: Semi-crater and split technique. J Cataract Refract Surg 2015;41:1132-6.  Back to cited text no. 13
    
14.
Gupta A, Singh J, Dhillon B. Cataract classification system for risk stratification in surgery. J Cataract Refract Surg 2011;37:1363-4.  Back to cited text no. 14
    
15.
Gimbel HV. Divide and conquer nucleofractis phacoemulsification: Development and variations. J Cataract Refract Surg 1991;17:281-91.  Back to cited text no. 15
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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