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Manual phacocracking yields good results
The small-incision technique is simple, has few complications and does not require use of a phaco machine, a surgeon says.
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Manual phacocracking is a small-incision cataract extraction technique that yields good results in eyes with soft to moderate nuclear sclerosis. The technique is performed using easy surgical maneuvers with minimal instrumentation. This article reports our experience with the technique.
Manual phacocracking requires only a 21-gauge needle to crack the lens into two pieces. Its principles are adapted from tunnel cracking in phacoemulsification. I use the 21-gauge needle like the tip of a phaco handpiece to penetrate about half the thickness of the lens, then use a Sinskey hook to embed above the needle to crack the lens into two pieces.
We have experienced few complications with the technique.
Surgical technique
I performed manual phacocracking in 108 eyes in Prapokklao Hospital, Thailand, from September 2001 to April 2003.
Anesthesia was done with retrobulbar block, and topical anesthesia was required only in some cases. Paracentesis was performed at 12 o’clock and 7 o’clock (relative to the right eye), with the 7 o’clock incision larger than the 12 o’clock incision. A temporal clear corneal incision was made using a 3.2-mm keratome. Capsulorrhexis of 6 mm to 7 mm was performed using forceps.
Hydrodissection and hydrodelamination were performed until the core nucleus was loosened. The lens was tilted slightly into the anterior chamber. Viscoelastic was injected behind and in front of the lens to protect the endothelial cells and the posterior capsule.
The 21-gauge needle was bent in the manner of a capsulotomy needle (Figure 1) and placed bevel-down. The needle was inserted through the 7 o’clock paracentesis, and a Sinskey hook was inserted at 12 o’clock. The needle was inserted to about half the thickness of the lens in the center of the lens, and then the Sinskey hook was used to push against the needle. The Sinskey hook was embedded above the needle to perform cracking in a manner similar to tunnel cracking. This separated the lens into two pieces (Figures 2 and 3). A spatula and Sinskey hook were used in situations where the lens did not initially separate completely (Figure 4).
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The incision was extended to 6 mm wide and viscoelastic was injected to protect the endothelial cells and the posterior capsule. The Sinskey hook was used to pull each of the lens pieces out of the eye, and a spatula was placed behind the lens pieces to guide them to the incision (Figure 5).
The lens cortex was irrigated using a Simcoe cannula. The IOL was then implanted into the capsular bag. The incision was sutured with 10-0 nylon sutures. The viscoelastic was removed using the Simcoe cannula, and the anterior chamber was flushed with balanced salt solution.
Results
Follow-ups were at weeks 1, 2 and 4 and then at 1-month intervals. The mean length of follow-up was 24.8 weeks (4 to 80 weeks). Postop visual acuity was 20/20 in 26 eyes (24.08%), 20/30 to 20/40 in 64 eyes (59.26%) and less than 20/60 in 18 eyes (16.06%).
The only intraoperative complication was posterior capsule rupture in two eyes. Postop complications included transient corneal edema in 11 eyes. This is the most common postop complication in small-incision manual cataract extraction. Corneal edema improved by a few days postop. In this study, corneal edema was found in eyes with hard nuclear sclerosis that were difficult to crack.
For Your Information:
- Praputsorn Kosakarn, MD, can be reached at Prapokklao Hospital, Chanthaburi, Thailand; +66-39-324-97580 ext. 1450; e-mail: praputk@yahoo.com.