Presbyopic Implant
Video Transcript
Hi, I’m Lori um i am a sports official. I work basketball and more recently volleyball. Um i’ve worked basketball for over 12 years. First doing rec league children’s then about 10 11 years ago i started officiating high school basketball and and now for about three plus years i’ve been officiating adult mainly men’s leagues and then within the last couple years i started officiating volleyball.
I just wanted to let everybody know that getting the pie procedure so far has been a blessing i’ve had prk surgeries and by far um this is the best ever with prk i’m telling you there’s there’s pain and discomfort and with prk if you have any doubts don’t have the doubts minimal discomfort, minimal pain, so far great results.
I’m not quite a weak post-op and um i’m loving it. I started out as a child and grew into like a negative eight nearsightedness and as time has gone on got hard lenses gas permeables and then because of the thin corneas my only choice was prk and i had both my eyes done with prk.
I’m glad i did it but it’s a painful long process and again pie is so worth it. I highly recommend it Dr Khanna is great his staff is great do it.
Is Presbyopic Implant Surgery (PIE) Better Than PRK
Presbyopic Implant Surgery | Pie Surgery Toric (Surgery View)
Video Transcript
Hi this is Dr Rajesh Khanna. You guys call me iii doc and i’m going to talk to you about the various steps in the procedure we have termed presbyopic implant in eye or pi so this is the first step making a wound to enter into the eye so this has to be constructed very carefully so our instruments can go in but at the end there should be no leak that is fluid should not leak out or nor should bugs go in so this one we just made a paracentesis and we will make one more parasynthesis the difference between the main wound and paracentesis is
main wound is 2.2 millimeter.Now we are going to put the specially crafted drops these are the magic drops which numb the eye from inside and made up of phenylephrine and xylocaine lidocaine preservative free. Now we put in some jelly uh which will coat the endothelium and prevent any trauma to it during the surgery this is followed by an optic zone marker where i’m centering on the line of sight by asking the patient to look at the three lights from the microscope this is going to play a very important role for two reasons.
One is in the capsular axis which we are going to begin now and then towards the end when we are centering the lens exam exactly towards the line of sight so this is the initial opening made with the assisted dome not with the 400 000 laser but with a 20 cent needle crafted specially this is a
robotic mic micro forceps called capsular excess forceps.Which is going to make a circum uh circumferential opening in the natural lens the this again as you see is a piece of r and the size has to be very well controlled and for which we had made use the oc marker which was around six five point seven millimeter. So we keep within it and get a very good rexes and then we remove the capsule anterior capsule.
Even if we don’t remove it comes out when the jelly comes out and when we go in and remove the lens fibers till now the light patient can see and i keep it very low lights not to bother them.
Now we use bss fluid waves to separate the natural lens capsule from the cortical material and this is a very important point what we are doing is rotating the lens from the capsular back and separating it.
Alot of people call presbyopic implant deny as lens exchange this point shows it’s not true. We are separating the covering of the entire lens from its contents and we’re only going to remove the contents not the entire lens and this is the faco machine which uses sound waves that’s it sound waves to dissolve the natural lens and aspiration to suck it out.
That’s why we are able to do it all through a small wound less than an inch and we spend enough time to do things carefully as the patient is awake monitoring them making sure they’re not having pain and i talk to the patients i tell them what i’m doing and as when the lights will be bright when i need their help and when i don’t.
Now i’m waiting to put in the second instrument because that takes the control of the eye in my hand because when only one instrument is there patient can still move their eyes around but with two instruments it becomes more steady and i removing the central core of the nucleus of the lens first this is the hardest part uh like the most form and so it’s better to remove it in centrally and go deep so to keep away from the cornea and away from the lens capsule.
Now we bring in the second instrument and this is a variation because believe it or not sometimes we have to adjust according to the instruments available and this time i remember one of the sterilizers broke down and so a regular naga hara chopper or cyber choppers were not available so we started with the sweeper that instrument believe it or not we just call it sweeper to move the lens around and provide stability.
But then hey we discovered that it’s ready and this is the cybill chopper so very carefully we are putting it through the anterior cortical layers and the lens and the right hand which has the faecal provides the vacuum to stabilize the lens and left high hand goes from periphery to center and splits the lens.
Now that we have split the lens into pieces just like pizza pie the more pieces you split the easier the smaller they are to grasp and take them out. The less energy we put into the eye the more comfortable it is for the patient and for the eye that translates to quicker healing.
So but we have to all times be careful not to injure the posterior capsule that means the capsule behind the natural lens and that’s again making a point if you do the whole lens exchange you’re damaging everything and then your presbyopic implant will have not a place to sit in that’s why this procedure is called presbyopic implant deny and not clear lens exchange not refractive lens exchange.
We are not exchanging the entire lens just eliminating the contents so and we have different settings now we’ve got a gone on epi nucleus setting which removes the thinner epinucleus. Now some fibers are left and where we feel it’s safer to remove this with just cortical aspiration where there’s no feco involved the reason we don’t want fecal because it can hit the posterior capsule.
I like to hydrate the paracentesis wounds at this time so to keep the chamber well formed and now we are going to go with the special instrument, i use it’s called a transformer because it can transform from one-handed like we are beginning now and also go to two-handed an air bubble sneaked in but we’ve got rid of it.
Now we’ve converted it to two-handed to remove the air bubble and uh allow us to reach places which one hand it can’t.
So previously i star had started like two decades ago with one-handed then switched to only two-handed and each one had its own benefits and advantages but the transformer for last five years i’ve been using has been godsend because it gives me the benefits of both techniques.
So i can reach anywhere in the eye without enlarging the wounds so this used to be the traditionally difficult area to reach under our handpiece and we can reach from left side and having it one-handed or by the irrigation flow from the bigger port allows the eye and the capsular back
to remain well formed, so we don’t grab it by mis mistake.The tips are also very special they are a special poly amide so they are less prone to one grab the capsules they’re very smooth polish so they don’t injured and believe it or not they’re disposable now as you see there’s a leak from the side wound, so i’m using just a cut of excel to hydrate the wound so we can keep the chamber well from the capsular bag well form so we can grab just the cortex and not the anterior capsule which will tear it up.
Speed is good but that should not be our only motivation um because this is for lifetime we are doing and an
extra minute or two spend achieving perfection is what i believe in and i’m sure if you’re a patient you’ll want perfection then uh olympic race to the finish, which we know is coming to Tokyo this year.So when we do the soft lenses for presbyopic implants unlike old people’s cataracts the fibers are usually very sticky and they take more time to come out so as you had seen the central part was very easy to do with fecal but these ones end up sticking and some we have to use judiciously so i’m going to use a technique i learned from my mentor Dr Schneider out of cincinnati around 25 years ago.
Where i’m going to use the implant itself to free the last fibers so this will go out of view because the lens big lens is going through a small wound and it’s called patient assisted delivery because i’m asking the patient to look towards me when i’m putting the implant.
Now the implant is in i’m putting a little viscoelastic to push it down and now i’m going to be rotating it the rotating motion is going to scrape against the capsules uh without and liberate the cortical fibers, without damaging the capsule so as you had seen we had folded the lens input so we have to wait for the arms known as the haptics to open up.
So it’s like the wings of the bird they open up and we are using those wings to move the cortex as you can see the cortex has got freed now and even if it hadn’t got freed we can go from the side port and remove it you might ask why we are removing it after putting in the lens than before because the lens acts like a tampon against the posterior capsule so there’s less chance or very little chance of damaging the posterior capsule when the lens is in so we can’t grab it.
And we can be a little bit more aggressive as you can see this is a multifocal presbyopic implant we can see the rings on it even though they’re not traditional rings but height modifications you can see the capsular outline of the anterior capsule we’re removing all the jelly because if we leave the jelly behind it’s going to block the drainage pathways and cause high pressure spike.
At the end of the case what we like to see i like to even touch it with my finger. Oh this is an important part uh since
this is a toric presbyopic implant we are making sure it’s aligned along our predetermined axis which in this case is around 180 degrees. So i was saying how should the ib and the end the pupil should be around the optic zone we had determined in the beginning the lens should be well centered and again we asked the patient to look at the light so the light center of light is right in the center of the lens.Hydrating all the wounds make sure there’s no jelly in the eye the pressure is good it’s not too soft the chamber shouldn’t collapse, the wound shouldn’t leak and we are just testing the wounds making sure they’re not leaking and also with my finger i can palpate and see the pressure because you know 25, 27 years ago when we started that’s how we learned we didn’t have all the sophisticated instruments but that has come to play an advantage today.
So we like to leave the pressure around 20 25 or 15 somewhere in there we don’t want the pressure too low because then wound will allow fluid from outside to go in.
In the end we put in intra camera antibiotics that was what you saw just go inand now the procedure is over and we’reall done.
Presbyopic Implant Surgery | Pie Surgery Toric (Surgery View)
