This clip shows a straightforward PP Lensectomy. Note the following steps:
1. The fragmentor is ALWAYS brought in from the superotemporal sclerotomy. The size of the fragmentor handle makes it difficult to bring in nasally over the patient's nose.
2. This clip shows all ports as 20 gauge. A small gauge infusion can be placed. If a 25+ infusion is placed, be cautious not to overcome the infusion with the large bore of the 20 ga frag.
3. It is helpful, as shown in this clip, to infuse INTO the lens directly, rather than use the infusion from the cannula. In fact, infusing into the vitreous will help force vitreous up into the lens capsule, thus exerting traction on the peripheral vitreous base. Here a 20 ga needle is connected to the infusion line (the infusion to the cannula was clamped with a hemostat and disconnected). The needle can also be helpful to rotate and manipulate pieces of the nucleous as it is being removed.
4. Begin by fragmenting through the center of the lens. Frag on the way through, and come off the power on the way back. Core a vertical path through the lens, and then use the frag and infusion needle to crack it apart into two pieces. The pieces can be rotated and divided into quarters as well.
5. Once the nucleous has been removed, switch to the vitrectomy probe. Note in this clip that a piece of nucelus had been dislocated into the vitreous and needed to be later removed. Make sure that an anterior vitrectomy has been done before starting the lensectomy whenever possible. This helps prevent grabbing anterior vitreous when using the vitrectomy probe to strip away the residual cortex from the undersurface of the capsule.
6. Try if possible to preserve the anterior lens capsule intact. The final step is to polish the intact lens capsule free of lens epithelial cells. The best way to do this is to use the endoilluminator to illuminate the undersurface of the capsule, and to turn off the light of the microscope. The epithelial cells become very easy to see. Turn off the cutting mode, and use the vitrectomy probe to aspirate and "scrape" away the cells with a back and forth motion. If a hole or tear in the capsule exists, aspirate toward the hole, but not away from it, so as to avoid enlarging the hole. The capsule can be left for later support of an IOL in the sulcus. Also, it is beneficial to keep silicone oil in the posterior segment. This technique was reported by our group in 2002 ncbi.nlm.nih.gov/pubmed/11825819