CONVENTIONAL EXTRACAPSULAR CATARACT EXTRACTION

Surgical steps of conventional ECCE are :
1. Superior rectus (bridle) suture is passed to fix the
eye in downward gaze (Fig. 8.17A).
2. Conjunctival flap (fornix based) is prepared to
expose the limbus (Fig. 8.17B) and haemostasis is
achieved by wet field cautery. Many surgeons do
not make conjunctival flap.
3. Partial thickness groove or gutter is made through
about two-thirds depth of anterior limbal area from 10
to 2 O’clock (120o) with the help of a razor blade knife
(Fig. 8.17C).
4. Corneoscleral section. The anterior chamber is
opened with the razor blade knife or with 3.2-mm
keratome.
5. Injection of viscoelastic substance in anterior
chamber. A viscoelastic substance such as 2%
methylcellulose or 1% sodium hyaluronate is injected
into the anterior chamber. This maintains the anterior
chamber and protects the endothelium.
6. Anterior capsulotomy. It can be performed by any
of the following methods:
i. Can-opener's technique. In it, an irrigating
cystitome (or simply a 26 gauge needle, bent at
its tip) is introduced into the anterior chamber
and multiple small radial cuts are made in the
anterior capsule for 360o (Fig. 8.18A).
ii. Linear capsulotomy (Envelope technique). Here
a straight incision is made in the anterior capsule
(in the upper part) from 2-10 O'clock position.
The rest of the capsulotomy is completed in the
end after removal of nucleus and cortex.
iii. Continuous circular capsulorrhexis (CCC).
Recently this is the most commonly performed
procedure. In this the anterior capsule is torn in
a circular fashion either with the help of an
irrigating bent-needle cystitome or with a
capsulorrhexis forceps (Fig. 8.20B).
7. Removal of anterior capsule. It is removed with
the help of a Kelman-McPherson forceps (Fig. 8.18B).
8. Completion of corneoscleral section. It is
completed from 10 to 2 O’ clock position either with
the help of corneo-scleral section enlarging scissors
or 5.2-mm blunt keratome (Fig. 8.18C).
9. Hydrodissection. After the anterior capsulotomy,
the balanced salt solution (BSS) is injected under the
peripheral part of the anterior capsule. This
manoeuvre separates the corticonuclear mass from
the capsule.
10. Removal of nucleus. After hydrodissection the
nucleus can be removed by any of the following
techniques:
i. Pressure and counter-pressure method. In it the
posterior pressure is applied at 12 O’clock
position with corneal forceps or lens spatula and
the nucleus is expressed out by counter-pressure
exerted at 6 O'clock position with a lens hook
(Fig. 8.18D).
ii. Irrigating wire vectis technique. In this method,
loop of an irrigating wire vectis is gently passed
below the nucleus, which is then lifted out of the
eye.
11. Aspiration of the cortex. The remaining cortex is
aspirated out using a two-way irrigation and
aspiration cannula (Fig. 8.18E).
12. Implantation of IOL. The PMMA posterior
chamber IOL is implanted in the capsular bag after
inflating the bag with viscoelastic substance (Figs.
8.18 G & H).
13. Closure of the incision is done by a total of 3 to
5 interrupted 10-0 nylon sutures or continuous sutures
(Fig. 8.18I).
14. Removal of viscoelastic substance. Before tying
the last suture the visco-elastic material is aspirated
out with 2 way cannula and anterior chamber is filled
with BSS.
15. Conjunctival flap is reposited and secured by
wet field cautery.
16. Subconjunctival injection of dexamethasone 0.25
ml and gentamicin 0.5 ml is given.
17. Patching of eye is done with a pad and sticking
plaster or a bandage is applied.