Forceps hook technique aids in globe fixation

Pressure from the keratome incision is equalized, immobilizing the globe. The epithelium is untouched.

Issue: April 1, 2002

ByJames E. Lusk, MD

Hook maneuver provides counter-traction during the keratome incision.	“Hooking” helps stabilize during capsulorrhexis using either arm of the forceps.
Hooking enables a lifting of the primary incision with insertion of the phaco tip.	Hooking also enables a lifting of the primary incision to facilitate IOL insertion.
Center pressure during IOL insertion is provided using hooking.

Clear corneal cataract surgery and topical anesthesia are widely adopted advances in surgical technique. We use Rand-Stein analgesia and rarely use block anesthesia for small-incision surgery.

Along with these advances comes a new set of tactical problems. Fixation of the globe during the keratome incision can be challenging. If one grasps conjunctiva, then a hemorrhage results. Fixation rings cause pressure and pain, which can raise the patient’s anxiety at the outset of the case. Inserting forceps deep in the side port incision can cause chamber collapse. Grasping the corneal edge of the side port or keratome incision results in scarring, epithelial basement changes or even avulsion of a sliver of cornea, all of which can lead to a chronic foreign body sensation.

We now use a “hooking” technique with a 0.12 forceps that avoids these pitfalls and is always successful at providing counterpressure to our keratome incision. This permits a controlled incision, avoiding short or long tracks and epithelial abrasions.

For the right-handed surgeon, the left arm of the Colibri 0.12 forceps (in the left hand) is inserted just inside the side port incision and is pressed toward the keratome (in the right hand) at a 45° angle. I usually initiate the keratome incision first, then engage the side port with the lower arm of the 0.12.

The forceps are not closed, otherwise the superior teeth would damage surface epithelium over the side port, resulting in chronic irritation. The usual tendency is to insert the right arm (the wrong arm) of the forceps in the side port, which requires one to push away from the keratome with the 0.12 forceps, resulting in loss of control.

With proper technique, the only fixation points on the cornea are inside the side port with the forceps and in the incision with the keratome. Using these counterforces, the globe can be immobilized in the topical anesthesia case in which the patient could move his eye at the wrong time, resulting in a short incision or worse.

Using this technique, we have almost eliminated the foreign-body sensation that afflicts many clear corneal incision patients. Epithelium is never touched using this maneuver. The same forceps fixation technique can be used during the rhexis, lens implant insertion or insertion of the handpieces.

For IOL insertion, the right arm of the forceps lifts the main incision but never grasps it. The lens injector is inserted. Then the left arm is “hooked” in the side port for countertraction during the lens injection. The goal is to leave a pristine epithelium and a pain-free patient on postop day 1.

For Your Information:

James E. Lusk, MD, is an assistant clinical professor at the LSU-Shreveport Medical Center and is in private practice. He can be reached at Lusk Eye Specialists, 1860 Fairfield Ave., Shreveport, LA 71101; (318) 222-5555; fax: (318) 222-6414; e-mail: jazzmo49@yahoo.com.