Cataract Surgery

Instruments
Presenter - Dr. Sneha S.
Pakhale
Moderator - Dr. Varsha
Mangiraj
• A surgical instrument is a specially
designed tool or device which is used to
perform a few specific actions during a
surgical procedure.

• Sharps: These include scissors, blades,

knives, needles.

• Blunts: These include speculum, needle

holders, retractors, spatulas, cannulas,
hooks, and forceps.
Describing an instrument-
• Full Name (inventor/developer’s name)

• Material (stainless steel, titanium, plastic, fibre)

• Parts (handle, shaft, joint, blade/tips, retaining

system)

• Special part or design if any

• Action & Uses

• Method of sterilization
Parts of an instrument
Barraquer’s Needle Holder
Castroviejo’s NeedleHolder

• Small pointed straight or curved tips with

serrations. Short shaft with grips,
interlocking leaf handle.

• Uses:
• To hold fine gauge needles
• Used mainly for passing sutures in the
conjunctiva, cornea, sclera
• To suture extraocular muscles in squint
surgery
Kalt needle holder:

• Thick blunt tip, stout shaft with grip, with

a locking-self retaining mechanism.

• Uses:
• To hold heavy gauge needles (thicker than
6-0)
• Oculoplasty surgeries, Lid surgery
• Passing bridle suture under superior
rectus muscle during cataract surgery.
• Skin and muscle suturing
Arruga’s Needle Holder :
Bard Parker Handle With 11 no. Blade
• Stainless steel BP handle. Sharp edged
blade with a pointed tip for stab incisions.

• Uses:
• For making accurate stab incisions.
• In chalazion surgery.
• For making precise incision planes for
removal of very small lesions
• Making corneo-scleral incision for cataract
surgery.
Bard Parker handle with 15 no.
blade
• Sharp edged blade with curved tip for longer incisions

• Uses:
• For skin incision in upper lid blepharoplasty.
• For debridement of corneal epithelium in corneal ulcer.
• For scraping of corneal infiltrate for microbiological
examination.
• For making corneo-sceral incision for cataract surgery.
• For dissecting scleral flaps in retinal detachment surgery.
• Scraping off epithelium to improve visualization prior to
certain surgries-
• Retinal detachment, goniotomy for Congenital glaucoma,
in DSEK surgery.
• Universal wire speculum

a. Barraquer eye speculum with

fenestrated blade

b. Barraquer eye speculum with solid

blade

• Stainless steel
• Thin and lightweight
• Less pressure on intraocular structures
• Can be used for both sides/eyes hence
universal
c. Weiss eye speculum

d. Self retaining universal eye

speculum

• Stainless-steel
• Stouter shaft and tips
• Spring mechanism or locking screw to
increase the area of exposure.
• Self retaining.
• May contribute to intraocular pressure.
• Uses:
• To keep the eyelids apart and keep lashes away
from operating field, during any ocular surgery
• Any extraocular surgery e.g., squint surgery,
pterygium surgery
• Intraocular surgeries- cataract, glaucoma, retinal
• Enucleation and evisceration operation
• Removal of conjunctival and corneal foreign bodies
• Examination in un co-operative patients and
children.
• Examination of the eye in a patient with
blepharospasm.
• Can be used to perform fundus examination using
+20D lens and mobile devices
• Difficulty in keeping the lids open during
Pediatric eye speculum:

• Stainless steel, thin wires and small

curved wire loops at business end.

• Uses:
• Hold the lid apart without applying
excessive pressure.
• EUA
• ROP examination and lasers
• Pediatric surgeries.
Castroviejo’s Caliper:
• Stainless-steel instrument. Pointed stout tips. Lap joint. Shaft
with a locking screw and a graduated millimeter scale which
can be used to adjust the distance between the tips.

• Used to take measurements during squint, ptosis, pterygium,

scleral buckling, and corneal surgeries

• Squint surgery
Calipers set at a predetermined amount are used to mark the
distance for muscle resections and recessions.

• Ptosis surgery
To measure the conjunctiva–Müller’s muscle to be excised in
fasanella servat procedure.
• To measure incision length in cataract surgery.

• Retinal detachment and pars plana vitrectomy

surgery to mark the ports.
• To mark site for intravitreal injections

• To measure and mark corneal diameter in

penetrating keratoplasty to trephine the host
corneal button.
• To measure size of graft in pterygium surgery.

• To measure corneal diameter in EUA

Castroviejo’s Corneo-Scleral Scissors:
• Stainless steel scissors. Interlocking leaf handle, small sharp
angled tips, separate for right and left side.

• Uses:

• To enlarge corneal or corneoscleral incision in intracapsular

and extracapsular cataract surgery.

• To cut corneo-scleral rim during tissue harvesting in a

postmortem eye.

• To enlarge corneal incision in keratoplasty operation.

• To cut the scleral and trabecular tissue in trabeculectomy

Cystitome:

• Double Bent 26 or 27 gauge hypodermic

needle. Angulation at hub is 60 degrees
and angulation at tip is 90 degrees

• Uses-
• For doing anterior capsulotomy or
capsulorhexis during cataract surgery
Dastoor’s Superior Rectus Holding Forceps:

• Stainless steel curved toothed forceps. With stout handle with

serrations for grip. 45 degrees angled tip measuring 10mm in
length. And 7.7 mm length of horizontal part. (corresponding
to the distance of insertion of SR from limbus)

• Uses:
• To hold the superior rectus tendon while passing a bridle
suture under it.

• To stabilize the eyeball during any operation such as cataract

surgery, glaucoma surgery, corneal surgery, etc.

• Traction suture in various surgeries.

Ball point cautery
• Stainless steel handle shaft and tip
• Solid copper ball few millimeters away from
the tip.

• Uses-
• Thermal cautery of bleeding vessels during
intraocular surgery.

• Disadvantages-
• Causes charring of tissues if excessive heating
done. Less control over cauterization
Electrocautery Probe :
• A fine non-toothed forceps attached to a electric source.
• Upon grasping the tissue an electrical current generated
between the tips of the cautery probe. Coagulation and
hemostasis.
• Thus it is a non-thermal electrocoagulation.

• Advantages-
• Can be combined with irrigation
• More precise and controlled cauterization
• Minimal damage and charring of surrounding tissues

• Uses:
• To cauterize episcleral and conjunctival blood vessels before
making sclerocorneal tunnel in small incision cataract
surgery, phaco-emulsification surgery
Halsted artery forceps
• Stainless steel forceps with a stout ring handle.
Ratchet for locking ( 3 step lock to regulate the
pressure within tips). Long shaft. Box joint and stout
curved blades with inner serrations for firm grip.

• Uses:
• To hold betadine swab for painting the operating field.
• To hold bridle stuture to the drape during cataract
surgery.
• To catch the bleeding vessels during operations of the
lids and lacrimal sac, other oculoplasty procedures.
Hartman’s Mosquito Forceps:

• Stainless steel forceps. Ring handle and 2

step ratchet. very short shaft. And short
straight or curved tips with serrations.
Barraquer Iris Spatula (repositor) :

• Stainless steel round handle with a flat

curved blunt blade.

• Uses:
• To gently reposit the iris in the anterior
chamber in case it prolapses out during
any intraocular surgery
• To break synechiae at the pupillary
margin
Aspiration Cannula:

• Uses:
• In the presence of anterior chamber
maintainer.
• It is used to aspirate cortical matter
remnants following nucleus delivery in
small incision cataract surgery
Lewicky Anterior Chamber Maintainer:

• Uses:
• Silicone tube is connected to an
irrigation-infusion line.
• The tip is in the anterior chamber to
ensure the anterior chamber is well
infused with fluid to maintain its depth
during surgery.
Simcoe 2 way Irrigation-
Aspiration Cannula:
• Stainless steel metal [Link] two ports for irrigation
and aspiration. A continuous irrigation line attached to
the main hub and a side port connects to the aspiration
cannula with a tubing.
• Reverse simcoe the direction of irrigation and aspiration
are reversed.

• Uses:
• For manual aspiration of the lens cortex in cataract
surgery with dual function of irrigation and aspiration
• For aspiration of hyphema or exudates from the anterior
chamber
• To remove viscoelastic material at the end of the surgery
J Shaped Irrigation Aspiration Cannula

• Uses:
• To remove subincisional cortex after
nucleus delivery in cataract surgery.

• To direct the hydrodissection to the cortex

beneath the scleral incision to achieve
better mobilization of the cortex in this
area
Keratome blade

• Sharp tipped bevel side up blade.

• 45 degrees angled, triangular tip
• Available in 2.2, 2.4 and 2.8 mm, 3.2mm
• Used for making valvular, phaco
emulsification incision
• Limbal, clear corneal, or near clear corneal
incision, which can be biplanar, or three-
step incision
• Helps to make the incision with lesser
force and minimizes wound leakage.
Crescent blade
• Stainless steel, blunt-tipped, sharp edged, bevel
side up blade. 2.5mm
• Blade is curved and mounted on a plastic handle.
• Splitting action and sharp edges on both sides

• Uses-
• To make corneal scleral tri-planar tunnel in
MSICS.
• To dissect partial thickness scleral flap in
trabeculectomy surgery.
• For making scleral pockets in VR surgery.
15 Degrees Side port or lance blade
• Fine straight knife with a pointed tip.
• Cutting edge on one side.

• Uses-
• For making small valvular, clear corneal,
self sealing incisions (side ports) in any
intraocular surgery.
Lewis Lens Loop (wire vectis):

• Stainless steel instrument with a stout flat

handle and a round looped tip at a slight angle.

• Uses:
• To apply pressure on the sclera superiorly to
depress the posterior lip of the wound which
facilitates lens delivery by tumbling or sliding
technique in ICCE.
• Nucleus delivery by sliding technique in ECCE
and SICS.
• To remove dislocated or subluxated lens
Lim’s Corneoscleral Forceps:

• Slender stainless steel forceps.

• Serrated handle for grip
• Very thin, curved, fine, toothed tips

• Uses:
• To hold the cornea or scleral edge (of
incision) for suturing during cataract,
glaucoma surgery
• Repair of corneal and/or scleral tears.
Sinskey IOL manipulating hook (Dialer):

• Stainless steel instrument with corrugations or serrations all over

the handle for grip
• Thin slender angled tip, with small hook at the end of tip.

• Uses:
• Rotation and manipulation of nucleus prior to delivery.

• To dial and rotate the IOL for proper positioning in the capsular bag
or ciliary sulcus.

• Nucleus manipulation in phacoemulsification.

• May be in the form of nucleus rotation in the capsular bag,
cracking of the nucleus and feeding of the nuclear fragments into
the phaco tip.
 Smith lens expressor:
• Stainless steel handle, thinner curved tip with 90 degrees
angle.

• Uses:
• To apply gentle pressure at the limbus at the 6 O'clock
position during the delivery of lens in intracapsular cataract
extraction (tumbling technique).

• To express the nucleus in extracapsular cataract extraction.

• It can also be used as muscle hook if the latter is not

available.

• Also used along with wire vectis to extract out the

dislocated lens.
Jamson Muscle Hook :
Kelmann - Mc pherson’s Forceps:

• Small short stainless steel or titanium

forceps
• With thin curved tips. Non-toothed

• Uses:
• To hold the superior haptic of IOL during
its placement
• To tear off the anterior capsular flap in
ECCE
• Can be used for tying 8-0 and 10-0
Arruga’s capsular forceps
• Stainless steel forceps with a short shaft.
• Angled. blunt blades.
• Characteristic cup/spoon shaped tips with
a hollow within the tips.

• Uses-
• For cupping and extracting the capsular
flaps.
• For removing cortical/nuclear fragments.
Phacoemulsification Probe:

• Uses:

• For sculpting and emulsifying the nucleus

and epinucleus during cataract surgery.
• The tip angulation- 0 to 60 degrees.
• Covered with a sleeve for a snug fit and
localise the phaco energy at the tip.
Phaco sleeves

• Silicon sleeve to cover over the phaco tip

• It has two holes on the side, 180 degrees apart for
irrigation outlet.
• Comes in a wide variety of sizes and colors based
on tip configuration
• Sizes: 19G, 20G, 21G, and 23G
• Autoclaved or ETO sterilized
• Helps to keep the phaco energy localized at the tip
• Prevents leakage from corneal wound
• Improves nuclear followability
Bimanual Irrigation-Aspiration
Cannula:
• Uses:
• Along with the phacoemulsification machine for
automated irrigation and aspiration of cortical
matter.
• Used to remove cortical matter to prior to
implantation of IOL
• Remove excess visco-elastic before end of
surgery.
• To polish the posterior capsule
• 19G, 20G, 21G, 23G, 25G.
Westcott tenotomy scissors(conjunctival scissors):

• Small slender stainless steel scissors.

• Leaf interlocking handle and small sharp
curved blade (12-15mm)

• Uses:
• For cutting and undermining conjunctiva
and tenons in various operations such as
small incision cataract surgery,
phacoemulsification surgery, evisceration
• For cutting sutures
Vanna’s Scissors :
• Very small stainless steel scissors. Similar to wescott
scissors but very short sharp blades (7mm) with pointed
tips.
• Uses:
• For cutting anterior capsule of the lens in extracapsular
surgery.
• For performing iridectomy, spincterotomy.
• For cutting vitreous strands in anterior manual
vitrectomy.
• For cutting fine sutures such as 10-0 nylon
• For cutting inner scleral flap in trabeculectomy
• For cutting pupillary membrane
• For cutting lamellar corneal tissue
• For harvesting limbal stem cells
De Wecker’s Iris Scissors:
• Uses:
• It is used to perform iridectomy, iridotomy
and iris abcission.
• To cut the prolapsed vitreous and
pupillary membrane
Micro-Capsulotomy
scissors:
• For cutting delicate structures like lens
capsule with high precision.
Micro-Capsulorrhexis
Forceps
• Uses:
• To grasp the anterior lens capsule and
perform continuous curvilinear
capsulorrhexis.
Mendez Degree Gauge:
• Uses:
• It is used along with the axis marker to
create marks on the cornea for accurate
placement of incision or toric IOLs in the
desired axis.
Jones Towel Clip:
• Uses:
• To hold sterile drapes in place
Towel Clamp:
• Use:
• To hold sterile drapes in place
Cionni’s Capsular tension rings
modified CTR and
Ahmed tension segments

• C-shaped, Open flexible PMMA rings.

• Sizes 10, 11, 12, 13, 14 mm. upon insertion futher expand the capsular
bag.
• Simple ring with eyelets (CTR)
• C-shaped Ring with a single or double loop. (modified CTR)
• Can be sutures to sclera for additional support in larger ZDs.
• Injected into capsular bag with help of special injector.

• Indications in zonular dialysis–

• Less than 3 clock hrs- simple CTR
• 3 to 5 clock hours- modified CTR single or double loops or ahmed
segments
• 6 to 8 clock hours – modified CTR with double loops, with capsular hooks.
Intracameral Cefuroxime :
• Time-dependent bactericidal effect via inhibition of
cell wall synthesis.

• Broad-spectrum, covers both gram-positive and

gram-negative organisms with notable exceptions of
methicillin-resistant Staphylococcus aureus (MRSA)
and multidrug-resistant Enterococci.

• Recommended dose - 1.0 mg/0.1 mL.

• Five-fold reduction in postoperative

endophthalmitis
Intracameral Moxifloxacin :

• Concentration dependent bactericidal killing via

selective bacterial topoisomerase II and IV
inhibition.

• Coverage for gram-negative and atypical

pathogens.
• Proposed dose - 150ug/ml to 500ug/ml

• Four-fold decrease in postoperative

endophthalmitis.
Intracameral Vancomycin :

• Bactericidal antibiotic that works by blocking

cell wall synthesis and bacteriostatic for at least
first 6 hours.

• Good coverage of gram-positive organisms, but it

is ineffective against gram-negative pathogens.

• Excellent coverage of MRSA

• Recommended dose of 1.0 mg/0.1 mL.

Summary of Current Intracameral
Antibiotics Usage

Single-use Other Available

Antibiotics Dose Suggested
Form Forms
50mg power 750mg powder
Cefuroxime 1.0mg/0.1mL
(Aprokam) form
5mg/mL single-
0.5% Vigamox 0.15-0.5mg/
Moxifloxacin use vial
solution 0.1mL
(Imprimis Rx)
500mg powder
Vancomycin Not available 1.0mg/0.1mL
form
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