Non-routine Supplies needed on the table:Diamond sideport for scleral windows
25 gauge needle
VISCOELASTIC ON TABLE: 1 Dispersive (Viscoat or Duovsic), 2 COHESIVE (Provisc or GV), 1 Supervisco (Healon V)
Kuglen Hook for pupil stretch, synechiolysis
Bimanual Vitrector for LPI / Iridozonulohyaloidectomy (could do a little PPV for a few seconds)
10-0 Nylon or 10-0 Vicryl suture to close main wound(or Bimanual IA)
IV MANNITOL. 12.5 grams vial. 1 vial per 70 kg. 1 or 2 vials. 20% 20 Minutes prior to phaco. Shrink vitreous and create space with less positive pressure
SCLEROTOMY or small scleral window (i or ii, 1 to 2 mm in size) (DO 1 infero temporal)will avoid Suprachoroidal hemorrhage & Choroidal effusions
Early Intra-Op. 4 mm back, 2 mm long horizontal to limbus, remove block of sclera 1-2 mm wide coming anteriorly.
<19 mm eyes ... do Choroidal Percolating Windows, 4 mm back in 1 or 2 quadrants Inferonasal and infero temporal sclera flaps to percolate and drain fluid. with slits. End of case they will start to percolate.
NEVER LET CHAMBER SHALLOW - Place visco in bag/AC before coming out slowly. Small incisions with corneal wounds .... 2.2 mm blade, 21 gauge phaco. Dispersive visco, then cohesive visco, then main wound (good tunnel length is important), then superviscous visco Healon V. Kuglen hook to release posterior synechiae. 5 mm rhexis under Healon V, even if you have to run it under iris margin a bit. Burp a little visco, then VERY GENTLE Chang hydrodissection. Hemi-crack nucleus. Place Cohesive Visco (Healon GV, or Provisc) into bag before coming out after Phaco, & after IA
IRIDOZONULOHYALOIDECTOMY for Unicameral Eye & avoid malignant glaucoma. IKE AHMED. Place IOL in bag. Stroke iris to bring pupil down to lower risk of malignant glaucoma. Suture wound tight with double throw Z suture Healon V. Make 1 mm LPI at peripheral Iris with Vitrector or IA Cut with very low aspiration. Go through LPI into zonules & hyaloid blindly, aim posteriorly. Chamber will deepen much better and easier. LPI will avoid IOP spikes, pupillary block, ACG. Cohesive Visco into eye before removing vitrector.
REMOVE FINAL VISCO MANUALLY with BSS CANNULA in SIDEPORTS.
SUTURE CONJ CLOSED
SUBCONJUNTIVAL STEROID INJECTION