|Year : 1957 | Volume
| Issue : 1 | Page : 6-10
Atraumatic intracapsular extraction of cataract
Tulsi Das, MC Maudgal
Department of Ophthalmology & Otolaryngology, Medical College, Amritsar, India
|Date of Web Publication||9-May-2008|
Department of Ophthalmology & Otolaryngology, Medical College, Amritsar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das T, Maudgal M C. Atraumatic intracapsular extraction of cataract. Indian J Ophthalmol 1957;5:6-10
Cataract Surgery with the least trauma should be characterised by the following : -
- No disturbance in the normal lie of the structures.
- No advancement of the anterior face of vitreous forwards.
- Even if the vitreous face has advanced forwards a little. a gentle pressure as detailed below should restore it hack to its normal position.
- Minimum operation time possible.
- Least instrumentation of the eye.
- Least instrumentation of the interior of the eye.
- Precise control of vitreous.
- Accurate judgement of pressure.
- Fullest confidence of the surgeon without any self-consciousness.
- Minimum post-operative complications.
The ideal operation for the removal of catarctous lens is intracapsular extraction. Intracapsular surgery has its own fascination and always gives the best results provided the technique robs it of its complications. Whether we have evolved such a faultless technique so far is for others to judge. Intracapsular surgery is being practised all over the world with various techniques and with varying degrees of success. Every surgeon has his own modification of intracapsular extraction of the lens. meaning thereby that no single method is foolproof. Going through the literature one finds in the last two decades (1933-55) any number of modifications proposed by different surgeons all with a purpose. not to disturb the anterior face of the vitreous. The ideal technique. would obviously be one which would cause the least disturbance to the natural lie of the structures of the eye and which ensures an operative success of 100% i.e. without any vitreous disturbance and with the minimum post-operative complications.
Disturbance of the anterior vitreous face is the main bugbear. Vitreous prolapse should be considered a gross complication. It was Col. Henry Smith, who, during routine upright delivery of the lens, noticed that the incidence of vitreous prolapse was much less in cases where incidentally the lower pole of the lens presented first in the corneal wound. This procedure was then universally acknowledged and adopted as an essential step in many of the different methods of the intracapsular surgery evolved during the last two decades (1935-55), i.e. forceps, erisiphake etc.
The method evolved in our clinic, where about two thousand cataract operations are done every year, promises to be the least traumatic operation with a 99-100% of operative success. It is most suitable for a hard lens. This operation has been styled as "Ledge. Lever and Tumble" i.e. the three essential steps needed for the extraction of the lens. The technique of the operation is as follows:
After the usual preoperative preparation (ensuring proper sterilization and cleanliness, central sedation achieved by a ncmbutal capsule of 100 mgm. or phenergan. one hour before the operation). the patient is brought to the operation theatre. Facial block, supplemented with van Lint's anaesthesia and locally surface anaesthesia by anethaine 1% drops and retrobulbar novocaine injection 4% give the optimum control of the eyeball and the patient.
It is very much desired that the tension should not be allowed to become very low: as this does not allow a good leverage. To achieve this, instillation of 1% anethaine with adrenaline hydrochloride (1 in 1000, 20 drops to an ounce), is done, one drop every 2 minutes: the fourth drop is put in when the patient is on the table and a retrobulbar injection of 4% novocaine ½-¾. is given. At the eighth minute the operation is begun. If the operation is delayed longer, the tension may fall below the optimum for this operation (15 mm. Hg. (Schiotz) is the optimum).
The first step is the regular knife incision, usually with a narrow von Graef's knife, through the upper half of the cornea, extending from limbus to limbus although a bit smaller incision will not be a disadvantage, provided one is not dealing with a black cataract. A button-hole iridectomy follows. Iris forceps is thus the only instrument that need be introduced into the anterior chamber and that too only just at the extreme periphery.
If stitches are to be applied, one or more are placed now. They arc first passed through the sclera, then through the cut bevelled surface of the corneal lip to the polished anterior surface of the cornea. This avoids slipping of the needle as would occur if tile suturing is done first through the cornea. Tile loops are held aside and the extraction begun.
In our part of the country, especially in the Punjab the limbus is hardly ever avascular. It has always some degree of Pannus.
The convex surface of the lens spatula is held over the upper lip of the wound till the handle comes to form an angle of 80' to the eyeball, [Figure - 1]A and gentle pressure is exerted backwards and downwards towards the optic nerve, thus pushing the upper Dole of the lens backwards and downwards. while the lower pole rotates on its horizontal axis upwards and forwards. This causes a little bulge (ledge). at the lower limbus of the cornea. The point of the lens hook is placed just below this bulge. [Figure - 1]B and thus one grasps the lens between the spatula and the hook. With a gentle movement of the point of the hook forwards and upwards and the spatula backwards and downwards lever action) the suspensory ligament breaks in the lower half; and the lower pole of the lens presents in the wound and tumbles forwards and upwards (tumbling). Usually this manoeuvre takes just 2 or 3 seconds. The lens is still in the grip of the hook and spatula and levering is stopped. The spatula and the hook applied at the upper and lower pole respectively, act in a see-saw manner. The upper pressure with the spatula is lessened and the point of hook tucks the cornea against the advancing lower pole of the lens [Figure l]C. When most of the lens has come out, cornea is insinuated further beneath the lens either with the point of the hook or its head. A last gentle sweep of the hook breaks the remaining upper suspensory ligament and the completely freed lens is taken out. [Figure - 1]D.
The chief consideration all along is to demonstrate the bulge and to hold the lens between the hook and the spatula and keep the lens in intimate contact with the cornea below and the upper lip of the wound above. There should literally be no space between the two lips of the wound and the lens. This precaution is absolutely essential for the safe delivery of the lens. which avoids the main bugbear of the cataract surgery. i.e. advancement or breach in the anterior face of vitreous. After the extraction one must be in a position to demonstrate that not only the anterior face of the vitreous has not broken, but also it has not even advanced forwards. This is quite easy to see and appreciate if there is a deep cup in the cornea after extraction of the lens by this method.
The iris if it has come forward over the lip of the wound, is gently reposited and the lower corneal lip is lifted up and adjusted to lie over its corneo-scleral counter-part, one bevelled surface lying against the other, and its temporary sealing is done by placing the cotton wool swab for a minute over the apposed lips of the wound. If stitches are used, they are tied before the swab is placed.
The stitches are removed on the eighth day and are not allowed to remain longer as they maintain irritation and gather discharge. The patient is discharged on the ninth day.
This, in our view, is the ideal atraumatic operation with no complication on the table and therefore very rare post-operative complications. If the iris has been saved, too much pressure avoided, and vitreous shown the proper courtesy the post-operative recovery will invariably he uneventful and the wound would heal by first intention. There is minimum possibility of iris prolapse. The greatest advantage of this operation is that the surgeon can assert with confidence that the capsule will no burst, the anterior face of the vitreous will not break. the lower pole of the lens will invariably present in the wound and that the delivery will be the speediest and therefore the safest. Delivery by erisiphake is sometimes as quick but then there is no control over the vitreous which is maximum by the method detailed above.
The main precaution is not to be over enthusiastic, if with three attempts. usually with one, the lens does not start tumbling, the technique should be abandoned and the lens taken out either by forceps or by extracapsular method. The dilatation of pupil is effected by the instilled drops and retrobulbar anaesthesia, and no other mydriatic is dropped. In case the iris is tough and fibrous, complete iridectomy is done and the lens taken out by the ledge, lever and tumble method.
| Comments|| |
- This is not the method of Smith where pressure is exerted on the vitreous. Just sufficient pressure is applied to the upper pole of the lens to cause a bulge at the lower pole. From this point onwards the expressor glides along the anterior face of the vitreous, between it and the posterior lens surface. The point of the hook is pointing more forwards towards the posterior lens surface and not backwards towards the vitreous. The usual criticism against the method of Smith cannot therefore apply to this method.
- The complete sealing of the wound by the emerging cataract all through the delivery is proof against vitreous prolapse and infection. Where several operations are to be done daily, this method surpasses all other methods in its simplicity, safety and percentage of success.
- It appears to approach the near ideal in intracapsular extraction of lens. It has given excellent results in our hands for a number of years, even in the hands of beginners at our hospital. 
| Summary|| |
- A new variation of intracapsular surgery is presented for hard and mature cataracts. The technique is described as the ledge, lever and tumble operation and is the least traumatic of cataract operations.
- It is the safest, speediest and the most controlled Intracapsular Operation
| References|| |
Duke-Elder, W. S. (1940). Textbook of Ophthalmology. Vol. 3. Henry Kimpton. London. (St. Louis, Mosby.) p. 3115.
Dutt, K. C. (1938). Cataract operations in the prehistoric age. Arch. of Ophthalmology, 20 : 1.
Kirby, D. B. (1950). Surgery of Cataract. Philadelphia. J. B. Lippincott Co., pp. 1-35.
McNamara. M. C. Quoted by Smith in 6, p. 207.
Molroney. Quoted by Smith in 6.. p. 209.
Smith, H. (1928). The treatment of Cataract. Butterworth & Co., Calcutta, (India). pp. 99-123.
[Figure - 1]