Pearls can lead to improved phaco techniques

Tetracaine drops, pre-loading patients with anti-inflammatories, supracapsular procedures can make phaco more efficient.

KOLOA, Hawaii — Using tetracaine drops in the eye before administering dilating drops is one of many pearls on how to improve phaco techniques offered here by Richard L. Lindstrom, MD. He also described his modified supracapsular nucleus-removal technique.

In a presentation at Hawaii 2001, the Royal Hawaiian Eye Meeting, sponsored by Ocular Surgery News in conjunction with the New England Eye Center, Dr. Lindstrom outlined suggestions that have helped make phacoemulsification an efficient procedure in his hands.

“Put a drop of tetracaine in the eye prior to putting your dilating drops in,” he said. “It’s more comfortable, and the drugs penetrate better. You can break down the epithelial barrier function and get much better penetration of your Neo-Synephrine (phenylephrine HCl, Sanofi Pharmaceuticals) and Cyclogyl (cyclopentolate HCl, Alcon).”

Steroids and anesthetic

Dr. Lindstrom likes to pre-load patients with the same topical antibiotic steroid and non-steroidal anti-inflammatory drugs that the patient will use postoperatively.

“It doesn’t cost anything and so I go Neo, Cyclo and in my case, you can put in TobraDex (tobramycin dexamethasone, Alcon) and Voltaren (diclofenac sodium, Novartis). Or you can use Ocuflox (ofloxacin, Allergan), Acular (ketorolac tromethamine, Allergan) and Lotemax (loteprednol etabonate, Bausch & Lomb) or whatever you’d like,” he said.

Dr. Lindstrom mainly uses Xylocaine (lidocaine HCl, AstraZeneca) as his topical anesthetic.

“I do mainly topical anesthesia, and I don’t find that I miss the retrobulbar block, but I do sometimes find that I have patients with a lot of blepharospasm. If I use a speculum that holds the lids open, they squeeze so hard sometimes they shallow the chamber. If I use a flexible speculum, sometimes the lids close,” he said.

While working with difficult eyes, Dr. Lindstrom said he does a little facial nerve block, using 2% Xylocaine.

“It decreases the squeeze a little bit, and it only lasts a few minutes if there is no epinephrine in the block and it wears off. You don’t have to put on a patch; they have a good blink reflex by the time they go home.”

Another technique Dr. Lindstrom uses is putting 1 cc of heparin in a 500 cc bottle of irrigation fluid to eliminate fibrin.

“If you’re a veterinary ophthalmologist you put heparin in the bottle on every case because there is so much fibrin that outpours in an animal eye that it’s basically required to do the surgery,” he said. “The same things occur in some human patients as well, where you get that little fibrin plug postop.”

Modified supracapsular technique

Dr. Lindstrom said he prefers to operate on left eyes from the nasal side.

“I do a right eye temporal, move over 2 inches and do the left nasally,” he said. “It’s actually very easy to enter the eye just right over the low point of the bridge of the nose. It’s actually much easier than superior and much less awkward than trying to crank all the way around and getting to the temporal side in the left eye.”

Dr. Lindstrom said he does a larger anterior capsulectomy than others because he likes to have the capsule cover the IOL optic. Less subcapsular epithelium, inflammation and posterior capsular opacity are the among the benefits of a larger anterior capsulectomy, he said.

“The bottom line is it just makes the operation easier and it allows me to do what I call tilt and tumble, or a modified supracapsular technique,” he said.

When doing this style of phaco, Dr. Lindstrom prefers to use vacuum pump machines.

“You don’t really need really high vacuum when you’re doing the outside-in supracapsular type technique,” he said. “The real key to be able to do this is to get the nucleus to tilt up. In the modern era it’s ‘back to Kratz,’ and if you simply continue to hydrodissect after you see the fluid wave, in 90% of the patients, the nucleus will just tilt up on its own.”

If there is trouble getting the nucleus to tilt up, Dr. Lindstrom said doing a viscodissection with a little viscoelastic under the lens will always produce the desired result.

“Once the nucleus is sitting up (above the capsule), it’s very easy to do phacoemulsification for basically anyone,” Dr. Lindstrom said. “It’s a real quick, easy phaco, outside-in. You can either rotate the nucleus or it will follow right in depending on the consistency. It’s very quick and very safe to the posterior capsule. So you emulsify basically outside in and just stabilize the nucleus. When half of it is gone, you can tumble it upside down or you can rotate, whatever you like.”

For Your Information:

• Richard L. Lindstrom, MD, can be reached at 710 E. 24th St., Suite 106, Minneapolis, MN, 55404; (612) 813-3633; fax: (612) 813-3660; e-mail: rllindstrom@worldnet.att.net.