Los Angeles, CA | Dr. Brad Elkins, MD: Topical Clear Cornea | Opthalmology Associates of the Valley

Dr. Brad Elkins narrates Topical Clear Cornea, Cataract Extractions.


Dr. Brad Elkins, MD: Ophthalmology Associates of the Valley is the oldest and largest ophthalmology practice in the San Fernando Valley. We are nationally recognized as leaders in innovative and advanced eye surgery. We hope that you find the following eye surgery as incredible as we do. This is a topical, clear corneal cataract extraction videotape where we're going to remove the cataract and then implant in and drop the lens. This particular lens is going to be a crystal lens, which is a accommodating interocular lens, which gives patients a distance vision simultaneously with near vision. This surgery is done under topical anesthesia and the patient cannot feel anything being done here. That's a diamond knife that just made a small little incision here into the eye.

Dr. Brad Elkins, MD: A little bit of fluid is injected in the eye. This is a topical anesthetic which goes inside the eye, which helps numb the eye up even further. This is a jelly being injected in the eye. It's called a viscoelastic and it maintains the shape of the eye. Next, you're going to see the incision being fashioned with two different types of diamond knives. The reason for the diamond knives is they make a very precise and clean incision and the goal here is to make this self-sealing, meaning that we don't need to put any stitches at the end of the surgery to keep the eye watertight.

Dr. Brad Elkins, MD: The patient cannot feel any of this being done. They are awake, often talking to me during the surgery, but they're not having any discomfort or any sensation. This is a special type of needle, which is going to make a small little tear in the front part of the lens called the anterior capsule. As you can see, the tear is being extended down towards the bottom. Next, an instrument's going to go in the eye, which is going to make this into a continuous curvilinear fashion.

Dr. Brad Elkins, MD: It's a basically a circular opening in the front surface of the lens. The goal here is to give ourselves access to this lens structure, which is quite a large and thick structure sitting inside of the eye. This whole structure here is the lens and it's very thick. What we're doing now as you can see it being peeled back is this, we're trying to create this circular opening within the front part of the lens so that another instrument can go inside the lens and remove the contents of it.

Dr. Brad Elkins, MD: A little bit of fluid is going to be injected inside the lens capsule to free up what we call the nucleus, which is the part of the lens that, as you can see there, it's almost popping forward, so the nucleus needs to be freed so it can be easily moved with instruments during the surgery. This is called phacoemulsification. This is about the size of a pen tip and the front part of of the phacoemulsification instrument, this metal part is like a little jackhammer. It moves back and forth very rapidly, as well as rotationally from side to side and it creates a sound wave bursts which break the lens up into small little fragments.

Dr. Brad Elkins, MD: As you can see, I'm making a little groove here and now it's going to be cracked. We're going to crack the lens in half, which is being done now. The lens is then rotated and we once again make these small grooves within the lens deeper and deeper. And then it will be cracked in the four different pieces. As you can see, the lens fragments are freed and now they're going to be removed. And these are large quadrants we call them. And as you can see, the instrument sucks out the quadrant, cracks it into small little pieces and then vacuums them into the inside of this little needle tip, which has a hollow hole within it so the fragments can be efficiently removed.

Dr. Brad Elkins, MD: Notice how yellowish brown the lens fragment is. This is what obstructs the light from getting inside the eye and makes the patient's vision blurry. Miraculously, once again, these patients are not feeling any of these manipulations or maneuvers. You can probably notice how much brighter the red reflex or the reflective light is with the cataract having been removed. These little wisp-like structures you're seeing here are called cortical fibers, which are going to be removed now with a separate instrument which basically aspirates the fibers off the lens capsule. The best way to describe what a cataract is is if you took a water balloon, filled it with water and then froze it. The ice within that water balloon is basically being removed during cataract surgery. We're leaving the water balloon intact except for this small circular hole in the front part, which gives us access to the ice.

Dr. Brad Elkins, MD: And as you can see, the ice has almost been completely removed now. But at the same time, we've left the water balloon in place. And now we're going to get ready to implant the interocular lens into that capsular bag or that water balloon, which will keep the lens implant intact and safe. Notice how nice and clear the structures are. And then once again, you can see the edges of this circular hole within the capsular bag. The anterior, the front part of the eye, and the bag itself are going to be filled with this viscoelastic, again, to maintain its shape and structure.

Dr. Brad Elkins, MD: You're then going to notice the injector, which is going to insert this interocular lens. There are different types of interocular lenses. This one particular lens is called a crystal lens and it's major advantages that it can give patients near vision. It accommodates, it moves slightly forward and backwards to accomplish good distance vision and good reading vision. It's going to go through this small three millimeter incision here and then it will unfold inside of the eye. And the advantage of foldable lenses are that they can be put through a very tiny incision and minimizing any astigmatism creation and any chance of having wound leaks postoperatively and thereby eliminating the infection risk. The lens is being folded and prepared at this present time.

Dr. Brad Elkins, MD: Now the cartridge is being inserted and you'll see the lens here being pushed forward and you'll see these little hooks called haptics, which are going to be the first thing to come out. And the haptics, these hooks, keep the lens in place within the capsular bag. As you can see that the haptics are out and now the lens is going to pop out. And it's difficult for it to pop out that quickly. This is the lens, the interocular lens optic. And as you can see, these haptics here are attached to a hinge-like device, which makes the crystal lens unique. This is what enables the crystal lens to focus back and forth. As you can see, there's a little hinge here and there's a hinge up in here as well. There's a hinge on this side of the lens as well as on this side of the lens.

Dr. Brad Elkins, MD: And that hinge is what enables the lens to move forward and back. The lens is being positioned in the correct orientation to achieve maximal accommodation. The jelly-like viscoelastic is being removed now from the eye as the lens is being centered well. And you can see how nicely the center of the lens is. Once again, this is the optic, almost like a contact lens. Here's one hinge and here's the other hinge. And this lens is able to move back and forth as the patient makes muscle movements to achieve a combination.

Dr. Brad Elkins, MD: The wound is being hydrated both here and here with a little bit of fluid. And this fluid creates a watertight structure which prevents any leakage from the eye. Once again, no stitches are needed in this type of surgery because of the diamond knives, the small incision, as well as some of the modern surgical techniques that we're using. The eye will be checked for leaks. I often push on the eye with both my finger and other instruments to make sure that the fluid is not going to leak from the eye.

Dr. Brad Elkins, MD: And once again, this is a check to make sure the lens is staying in a backward position. We don't want the lens to come forward. There I am checking the eye to make sure it's watertight and not going to leak. This is difficult to achieve from this dimension, but the lens is sitting posteriorly or backwards, which is the correct position during the surgery.