This is a manual small incision cataract surgery. And you can see that we've already placed the superior rectus bridle suture. And we're starting to make the peritomy with Westcott scissors, and Colibri forceps. We'll make 120 degree peritomy superiorly and we'll make sure that we're removing tenons as well as conjunctiva. We'll make a relaxing incision to keep the conjunctiva out of our workspace. And then we'll use wet field cautery to maintain hemostasis. We'll measure two millimeters posterior to the limbus for the beginning of our frown shaped incision. And then the ends of our frown shaped incision will extend three millimeters posterior to the limbus, and the wound will be six millimeters in length. After we've marked our wound, we use our crescent blade to draw the frown shape incision and this is the first incision of our triplanar incision. We then turn our crescent blade upwards, and use the toe to really define that first layer of the triplanar incision. The second layer of the triplanar incision is, your tunnel. And you're going to tunnel carefully, all the way up to anterior to the limbal vessels. And you have to change the way your crescent blade is Is aiming when you get to the cornea, because the curve of the cornea is steeper than the curve of the sclera. So, you want to put your heel down and your toe up when you enter that limbal space. And you can see here that the sclera pockets are much wider and that internal lip of the incision is going to be much wider than that external six millimeter lip of the incision. Because the diameter of the nucleus is too big to fit through that small six millimeter incision, without widening it on the inside. Next we use our 75 15 blade, to make our side port incision well away from our deep scleral pockets we've created internally, and we fill the anterior chamber with viscoelastic. Next we use the ceratome blade to wiggle through our tunnel. Making sure we're in the same plane and not creating a new tunnel all the way to the edge of the tunnel, and then we aim the toe of our ceratome parallel to the plane of the iris and enter into the interior chamber, and that makes the third portion of our tri-planar incision. We then turn our attention to using the cysotome, to making the capsulorhexis. And we need to make an eight to nine millimeter capsulorhexis so that when we hydroprolapse the lens from the capsular bag we do not cause a posterior capsular rent from the pressure of the fluid being caught inside that bag from too small of a rhexis. When we get stuck with the rexus from the superior incision. We can use the side port incision to help get us around the corner. And you can change between the utratas and the cystotome. To help redirect the rexus. The rhexis is being completed with the utrata forceps. Then we're going to use the chain cannula to tent up the capsulorrhexis and try and hydroprolapse the nucleus into the anterior chamber. And you can see that the inferior pole of the nucleus has been prolapsed over the plane in the iris. We'll then use a Sinskey hook, to dial the lens out of the capsular bag. And the motion is up, and out. And dialing the lens. Now we're going to put more viscoelastic , between the lens and the cornea. And between the lens and capsular bag, and we can use the viscoelastic to also try and prolapse the lens better into the anterior chamber. The lens is almost completely into the anterior chamber. We're going to use the Sinskey hook to dial it a little bit more to make sure it is completely free of the iris. Usually we would have used our ceratome already to enlarge the interior incision, before we dialed the lens out of the bag. But, at this point, we realized that we needed to enlarge that incision and we made sure to enlarge it and enlarge the sclera pockets all the way to the very edge of that incision. So, the internal incision is about 180 degrees, whereas the external incision is only six milimeters. We're going to put more viscoelastic underneath the lens to protect the iris, so that we don't sandwich the iris and the lens together as we slide our irrigating vectis into the anterior chamber underneath the lens, making sure we can visualize all the edges of our irrigating vectis. And then we're going to take the bridle suture. In our thumb in our second finger and use our pointer finger to depress the irrigating vectis to depress the posterior lip of the incision through the irrigating vectis and then push on the irrigating vectis and use your other hand to irrigate and. Remove the lens from the anterior chamber. We then will use the irrigation aspiration to remove the residual cortical material, fill the bag with viscoelastic, and then use the lens forceps to place a three piece lens and then use a Sinsky hook to dial the lens into the bag. And ensure that the haptics are well placed within the capsular bag. We'll then use irrigation aspiration to remove the residual viscoelastic material. We'll check our wound and you notice that it was well constructed enough that it does not leak yet we will put a single suture, a 10 0 nylon interrupted through the incision and we'll then close the conjunctiva with cautery. After that we'll use subconjunctival dexamethasone and cephalexin and the case will come to an end.
