2

On the publication
Kensaku Miyake
President, Japan Ophthalmologists Association
Chairman of the Board of Executives
/Director Shozankai Miyake Ophthalmologic Hospital

There are many textbooks on surgery. However, those that provide easy-to-understand and systematic
descriptions of the basic physical principles, or basic mechanics, of various procedures are limited.
Augenchirurgie by G. Eisner and Phacodynamics by B.S. Seibel are among the few such textbooks.
If phacoemulsification/aspiration is compared to a guide to writing, a characteristic of this book is that
it begins by explaining the grammar, and then systematically describes techniques to complete excellent
pieces of writing. This clear concept permeates the entire book.
This book consists of 3 chapters. Chapter 1 touches on the basic techniques, basic surgical procedures
and instrumentation, and important knowledge about them. Chapter 2 deals with basic training using a
model eye with a few drills. Chapter 3 describes specific manipulations in ultrasound cataract surgery
based on information provided in the previous chapters. Specific surgical manipulations are provided
with some variations, as might be expected, and are all described in plain language.
Chapter 1, which describes important knowledge on surgical techniques and the basics of
instrumentation, typically embodies the concept of this book. It gives plain explanations of important
points including principles of the use of linear and angled instruments for different situations,
intraocular instrumentation with the eye position always directed to the optic axis, instrumentation
with vector dynamics in mind, differential employment of open and closed fragmentation, and causes of
surges and methods for their prevention. This essence is reflected systematically in the contents of
Chapters 2 and 3.
This book was coauthored by more than 30 frontline ophthalmologists representing Japan today, but
it is free from inconsistencies in writing, which are likely to occur under coauthorship. This was the
result of the strong leadership of 3 editors, who meticulously ironed out the stylistic unevenness among
the coauthors.
This book is planned to be marketed as a set with KITARO, a model eye for practicing cataract surgery.
Both of them were proposed and developed in the Project for Reinforcing the Ophthalmologic Service
System in Nepal initiated jointly by the Association for Ophthalmic Cooperation in Asia (AOCA) and
JICA in 2007 under the initiative of Mr. Junske Akura, an editor of this book, and others.
I strongly recommend this book for the following 2 reasons: Today, reform of the Congress of Japan
Clinical Ophthalmology, Congress of the Japanese Ophthalmological Society, and Japanese Society of
Ophthalmic Surgeons is in progress, and the most important theme of this movement is the education of
ophthalmologists. This book has contents that can serve as an excellent model for education in surgery,
which is a characteristic field with special difficulties in physician education. The other reason is that
the coauthors of this book include those who are eager to prevent blindness and promote surgical
education in developing countries, as is Mr. Junske Akura mentioned above, reminding us
ophthalmologists of developed countries that we must more enthusiastically address these problems in
developing countries. I believe that this book can help achieve these objectives, and sincerely wish that
it is read by many people.

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A textbook prepared by integrating
teaching methods
-- Differences compared with conventional textbooks --
Junske Akura
Clinical Professor, Tottori University School of Medicine
Chairman of the Board of Directors, Association for Ophthalmic Cooperation in Asia

Acquire important and essential knowledge first

A considerable amount of knowledge is necessary to perform surgery safely and efficiently. However,
knowledge truly necessary for an ophthalmologist who first learns surgery is limited. While many
important points are mentioned in the textbooks written by our seniors, miscellaneous information is
squeezed into them, making it difficult for novices to selectively acquire core information. In this book,
unlike conventional textbooks, techniques are not explained procedure by procedure, but basic
information essential for developing surgical skills is arranged in the order that it should be learned.
The essence that brings you to real mastery is packed in the first 10 points of key knowledge and 30
points.

Masters intuitive manipulations are scientifically analyzed and described

Surgical manipulations by masters of surgery are truly impressive. They perform such smooth
manipulations based on innate intuition and the accumulation of experience, often without being
conscious of them. In this book, such intuitive manipulations are analyzed from scientific viewpoints
and described in plain words. For example, Point 2 of Key Knowledge 1 says, Angled and linear
instruments should be manipulated differently. With an angled instrument, the tip should be moved by
rotating the handle held with the fingers. This manipulation is very important in preparing CCC using
a cystome or treating the nucleus with a hook, but has not been mentioned in the existing textbooks to
my knowledge (except that Dr. Yamagishi, an ophthalmic microsurgeon, slightly touched on it). All
masters of surgery perform this unconsciously, but the conscious manipulation of angled instruments, as
this book advises, helps novices improve rapidly. In addition to the manipulation of angled instruments,
this book also describes many unconscious (intuitive) manipulations not mentioned in conventional
textbooks to facilitate the acquisition of masters skills over a short period.

Learn by doing it there and then

Nothing is more absurd than attempting an operation without first acquiring the necessary
knowledge. However, as one never improves in playing tennis or the piano no matter how many times
one may read a textbook, knowledge obtained solely by reading is impractical. Knowledge can be
effective only when it is put into practice. Surgical skills can also be improved by practicing them daily.
However, on-the-job learning is extremely difficult today, when the disclosure of information is a
requirement and medical lawsuits are frequent. Practicing surgery using porcine eyes involves
sanitation problems, and it is difficult to simulate treatments of the nucleus or anterior capsule in the
human eye. In addition, surgical disposables are expensive, making repeat practice difficult. We,
therefore, developed KITARO, a model eye for practicing cataract surgery. It allows the simulation of
most surgical manipulations including CCC, nuclear splitting, IOL insertion, and the suturing of an
incision as many times as the learner wishes. A learner should read this book with KITARO on his/her
desk and perform the manipulations described in the book there and then. It is clear which is more
effective, only reading, understanding, and imagining something or actually performing it. The
simultaneous use of this book and KITARO enhances the efficiency of learning 100 times!!

The profits from the book are used as ophthalmologic aid for developing countries
Lastly, in compiling this book, the coeditors Drs. Kunihiro Nagahara and Yoshihiro Tokuda helped
considerably. Also, the coauthors kindly provided their manuscripts free of charge. We editors
mercilessly cut, modified, and supplemented their manuscripts, which they so elaborately prepared. We
did so to make the book consistent, but, to the authors, this may have seemed disrespectful. We would
like to take this opportunity to express our sincere thanks and apologies. The editors also owe much to
Mr. Yuji Tsuchikawa, who drew wonderful illustrations by calculating the dimensions of actual
ophthalmic tissues and instruments, many business firms including Apply Inc., and persons in charge of
this publication who so generously cooperated to bring KITARO and this textbook into existence.
This textbook is an offshoot of the educational activities in cataract surgery conducted by the
Association for Ophthalmic Cooperation in Asia in Nepal, India, and China. Should this book yield any
profit, we will gratefully use it for the support of developing countries. It is our sincere hope that many
young doctors throughout the world will study using this textbook, grow into master ophthalmic
surgeons, and bring light and delight to many patients.

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Gods gift

Kunihiro Nagahara
Director of Seibo Eye Clinic

I am the second director of Seibo Eye Clinic. The first director was my mother. Forty years have
passed since she opened an ophthologic clinic in Sakaide, and 15 years have passed since this initial
clinic was renewed as the present Seibo Eye Clinic. When I was a child, I remember that my mother
simply washed eyes day after day in a small treatment room. In those days, my parents were
determined for me to become a doctor and take over the clinic, and so they pushed me to study by
putting me in a school for supplementary lessons and hiring a private tutor even in my elementary
school days.

However, I was never very good at study. I took the entrance examination of a respected junior high
school in another prefecture at the behest of my father, but I failed, and went to a local junior high school.
In my junior high school days, I suddenly became interesting in being good at study (rather than the
studies themselves), probably due to the lingering effect of studying for the entrance exam, and, at one
time, read all the study-aid books and completed all the drill books I found at bookstores in my town.
However, after I entered high school, my passion turned to motorbikes and playing in a band, and my
school records were way below the level necessary for medical school. When studying for the entrance
examination for a medical school overwhelmed me, I wondered Why do I have to go to a medical school
to wash peoples eyes? However, perhaps through Gods mischief, I passed the exam and entered a
medical school.

When I graduated from medical school, I decided to join an ophthalmologic department simply
because I was from a family of ophthalmologists. I have not conducted research on a particular subject
or written a doctoral thesis, and I have not had any specialty until very recently.

I have been clever with my hands since childhood, and making plastic models used to be my hobby.
After I entered the ophthalmologic department, I began to take an interest in microscopic surgery, in
which I could rely on my dexterity. I happened to become particularly interested in cataract surgery, and
it became my specialty before I knew it. In those days (about 25 years ago), a person who was talented in
surgery and exhibited excellent surgical skills would at best be praised for his/her dexterity, and, as
there was no system for public acknowledgment of the skill, they would not be given a doctors degree or
be promoted to a professor or associate professor no matter how splendidly they performed surgery. (On
the contrary, when I exhibited my skill as a member of the department, I was deprived of opportunities
to perform operations, perhaps to avoid upsetting the balance with other members of the department.)

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 In addition, I did not think I had so much talent in ophthalmic surgery, and I did not like being
described as gifted. One day, however, a businessman came from the United States to observe my
surgery and, on leaving, handed me a note scribbled on a small piece of paper. The letter said, Dr.
Nagahara, you have a wonderful God-given gift. Please, cherish it. God-given gift. When I saw this, I
was, for the first time, truly delighted at being praised for my skill.

Each person has such a gift; no one is denied. However, these gifts differ from one person to another.
We do not know the gift each of us is endowed with, and may end our lives without ever knowing. Maybe,
I just happened to realize my gift.

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 Contributors

Chikako Suto M.D. Yoshiaki Kiuchi M.D. Yoshihiro Tokuda M.D.

Assistant Professor Professor Vice-director Inoue Eye hospital
Tokyo Women's Medical Hiroshima University Tokyo, Japan
University, Hiroshima, Japan
Tokyo , Japan

Mikio Inamura M.D. Shinichi Arai M.D. Kiichiro Mitani M.D.

Director Nigata University Director

Inamura Eye clinic Nigata, Japan Mitani Eye clinic

Yokohama , Japan Hyogo, Japan

Yoshiyuki Hara M.D. Hiroyuki Matsushima M. D. Basant Sharma M.D

Clinical Professor Associate Professor Associate Professor
OsakaUniversity Dokkyo University Rana-Ambika Lumbini Eye Institute
Osaka, Japan Tochigi, Japan Bhairawa, Nepal

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 Contents

Chapter 1 Key knowledge and basic instrument manipulations one must learn first
The essence of key knowledge and instrument manipulations, without which one can never hope for
improvement, are summarized into 10 items
Key knowledge 1 Basic intraocular instrument manipulations as the basis of all small incision
surgery
Key knowledge 2 Intraocular instrument manipulations that control the eye position
Key knowledge 3 Intraocular instrument manipulations based on vector dynamics
Key knowledge 4 Local anatomy and intraocular instrument manipulations that one must learn to
avoid intraoperative complications
Key knowledge 5 Functions of phaco machines and intraocular instrument manipulations that one
must learn to perform safe and efficient surgery
Key knowledge 6 Intraoperative complications due to specific functions of phaco machines and
methods for their prevention
Key knowledge 7 Preparation of side ports and intraocular instrument manipulations in
consideration of differences in hook shape
Key knowledge 8 Intraocular instrument manipulations and incision in consideration of the
structure of self-sealing incision and eyelid height
Key knowledge 9 Facts to learn about the preparation of self-sealing incisions
Key knowledge 10 Points for the mastery of continuous circular capsulorrhexis (CCC)

Chapter 2 Description of specific techniques used in phacoemulsification

Important points of each step and management of difficult situations are explained practically
Technique 1 Anesthesia
Technique 2 Sclerocorneal incision
Technique 3 Continuous circular capsulorrhexis (CCC)
Technique 4 Hydroprocedures
Technique 5 Nuclear manipulation 1: Stop & chop technique
Technique 6 Nuclear manipulation 2: Phaco chop technique
Technique 7 Removal of epinucleus
Technique 8 Cortical aspiration
Technique9 IOL Implantation and Wound Closure

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10
 Chapter 1

Key knowledge and basic instrument

manipulations one must learn first

The essence of key knowledge and instrument manipulations, without which one
can never hope for improvement, are summarized into 10 items

Everyone who wants to perform surgery desires Without knowledge and skill in instrument
to become skillful and hopes to avoid problems manipulations described in this chapter, one can
during surgery. To achieve this, there are basic never improve or avoid problems during surgery,
instrument manipulations based on key no matter how well one may learn specific
knowledge that every surgeon must learn. techniques of phacoemulsification.

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 Key Knowledge 1
Basic intraocular instrument manipulations as the
basis of all small incision surgery
Mastery of these basic instrument manipulations must precede that of all other techniques for
Point 1
In small incision surgery, all intraocular instrument
movements are combinations of pendular
movements with the incision as the pivot and
insertion and retraction along the incision.
To smoothly perform pendular movements
with the incision as the pivot, it is important
to pay attention to moving the handle of the
instrument widely, to move its tip slightly,
and to change the direction of the instrument
with the incision as the center.
The instrument manupilation accompanied
with insertion and retraction through the
wound is laying the instrument while
incerting it to opposit side and standing it
while retracting it to wound side.
An unskilled surgeon would move the entire
instrument inserted through an incision into the
eye laterally to the left (or right), with the
intention to move its tip in that direction, thereby
applying unnecessary force to the eye and tilting
it or distorting the cornea. A skilled surgeon
moves the rear end of the instrument to the left
(or right) to move its tip to the right (or left) and
upward (or downward) to move its tip downward
(or upward) (Fig. 1). By always pivoting the
instrument around the incision, the surgeon need
not apply unnecessary force to the eye and can
perform surgery by always positioning the eye
along the optic axis without wrinkling the cornea.
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improvement in surgical skills
At this time, it must be noted that these
instrument movements around the incision are
not limited to the lateral direction but are also
vertical, i.e., three-dimensional. Vertical
movements are made by standing and laying the
instrument.
Also, it must be noted that, in performing lateral
and vertical pendular movements with the
incision as the center (pivot), one must move the
rear end of the instrument widely over a few
centimeters in order to move its tip slightly over a
few millimeters in the eye, because the
intraocular part of the instrument is much
shorter than the extraocular part, while, in linear
manipulations along the incision, the distance of
tip movement is equal to that of hand movement.
Inexperienced surgeons pay attention only to the
tip of the instrument and cannot perform such
pendular movements with the incision as the
pivot. Therefore, they should rather direct their
attention to moving the rear end of the
instrument. Another key to smoothly
performing pendular movement with the incision
as the canter is paying attention to changing the
direction of the instrument with the incision at
the center.
Practical small incision cataract surgery is the
combinations of pendular movements with the
incision as the pivot and insertion and retraction
along incision. This instrument manupilation
accompanied with insertion and retraction
through the wound is the movement of laying it while retracting it to wound side.
while incerting it to opposit side and standing it

a. Pendular movements with the incision b. Pendular movements with the incision

as the pivot in a lateral direction as the pivot in a vertical direction

A key to smoothly performing lateral (a) and vertical (b) pendular movements with the

incision as the center (pivot) is paying attention to turning the instrument with the incision

at the center and moving the rear end of the instrument in the direction opposite to the

intended movement of the tip.

The instrument manipulation accompanied with insertion and

retraction through the incision are laying (incling) the instrument

while inserting deeper regions and standing (raising) it while

withdrawing to the incision site.

Fig. 1: In small incision surgery, all intraocular instrument manipulations are

combinations of pendular movements centering around the incision and

insertion and retraction along the incision.

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