Cataract Art - Science - PDF

I
This book was created and written by

Professor Boyd at Miramar Plaza Towers,
overlooking the Panama Canal, the Pacific
OUTLINE OF MAJOR SUBJECTS
Ocean and the city of Panama.
Project Director: Andres Caballero, Ph.D

Production Manager: Kayra Mejia
Page Design and
Typesetting: Kayra Mejia
Laura Duran
Art Design: Eduardo Chandeck Chapter 1: Surgical Anatomy of the Human Lens
Spanish Translation: Cristela F. Aleman, M.D.
Medical Illustrations: Stephen F. Gordon, B.A.
Trina Fennell, M.S. Chapter 2: Indications and Preoperative Evaluation
Samuel Boyd, M.D.
Sales Manager: Tomas Martinez
Marketing Manager: Eric Pinzon
Chapter 3: IOL Power Calculation In Standard
Customer Service
Manager: Miroslava Bonilla and Complex Cases - Preparing for Surgery
International
Communications: Joyce Ortega
Chapter 4: Preventing Infection and Inflammation
Chapter 5: Proceeding with the Operation
ISBN Nº 9962-613-03-5
©Copyright, English Edition, 2001. Chapter 6: Phacoemulsification - Why So Important?

Highlights of Ophthalmology Int'l
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Chapter 7: Preparing for the Transition
Clayton, Bldg. 207
Panama, Rep. of Panama Chapter 8: Instrumentation and Emulsification Systems
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The Advanced, Late Breaking Techniques
All rights reserved and protected by
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Chapter 11: Complications of Phacoemulsification
Printed: Bogota, Colombia
South America
Intraoperative - Postoperative
Chapter 12: Cataract Surgery in Complex Cases
Chapter 13: Manual Extracapsular Techniques of Choice
Planned ECCE - Small Incision ECCE
Chapter 14: The New Cataract Surgery Developments
II
ACKNOWLEDGMENTS
All the text in this Volume has been written by the author. I am very much indebted
to the Master Consultants and to all Guest Experts who are listed in this Front Section
of the ATLAS. They are all highly recognized, prestigious authorities in their fields and
provided me with most valuable information, perspectives and insights.
The production of this ATLAS is a major enterprise. In addition to our dedicated

staff at HIGHLIGHTS, three of my most valuable collaborators have been vital to its
success: Robert C. Drews, M. D., as Co-Editor of the English Edition; Cristela
Ferrari de Aleman, M.D., an expert in phacoemulsification who advised me in all the
technical stages of the step-by-step small incision surgical procedures and Samuel
Boyd, M.D., for his strong support, valuable advice derived from his expertise in all the
vitreoretinal techniques related to cataract surgery.
Among my closest collaborators in HIGHLIGHTS, Andres Caballero, Ph.D., the

Project Director and Kayra Mejia, my editorial right hand Production Manager of many
years have gone the extra mile to accomplish a very difficult task in production of this
work.
To each person mentioned in this page, on behalf of the thousands of readers of

HIGHLIGHTS, I express my profound recognition and gratitude.
III
D EDICATION
This 25th Volume of the Atlas and Textbooks of HIGHLIGHTS is
dedicated to my colleagues in 106 nations worldwide who faithfully read the
HIGHLIGHTS in seven major languages.
May "THE ART AND THE SCIENCE OF CATARACT SURGERY"

contribute to your further understanding of what is best for your patients.
May it also help you to master the "state of the art" techniques in your
continuous quest for the right answers. May it provide you with insights in
your efforts to rehabilitate vision to millions of people who are still blind
from cataract, a curable disease.
"The Art and the Science of Cataract Surgery" is also dedicated to the
countless ophthalmic surgeons who, through combined efforts with leaders
and scientists in industry, have made of modern cataract surgery the safest
and most effective major operation in the field of medicine.
And, by all means, to the great innovators each of whom developed a

new era for cataract surgery in their time. Symbolically, IGNACIO
BARRAQUER, M.D., whose innovation of intracapsular extraction by
mechanized suction in 1917 resulted in the first practical and efficient
method to remove a cataract without vitreous loss. To JOAQUIN
BARRAQUER, M.D., for his pioneering work in rendering ophthalmic
surgery under the microscope a feasible and practical new method leading
to the era of microsurgery. To CHARLES KELMAN, M.D., who, by
providing us with phacoemulsification, started the new era of small incision
surgery. And to HAROLD RIDLEY, M.D., the symbol of intraocular lens
implantation.
The recognition to the great innovators is for their ingenuity and for
their courage. All innovators stimulate opposition. They all encountered
strong opposition but they overcame it through their courage and results.
BENJAMIN F. BOYD, M.D., F.A.C.S.
IV
AUTHOR AND
EDITOR-IN-CHIEF
BENJAMIN F. BOYD, M.D., D.Sc. (Hon), F.A.C.S.
Doctor Honoris Causa

Immediate Past President, Academia Ophthalmologica Internationalis
Honorary Life Member, International Council of Ophthalmology
Recipient of the Duke-Elder International Gold Medal Award (Interna-

tional Council of Ophthalmology), the Barraquer Gold Medal (Barcelona),
the First Benjamin F. Boyd Humanitarian Award and Gold Medal for the
Americas (Pan American), the Leslie Dana Gold Medal and the National
Society for Prevention of Blindness Gold Medal (United States), Moacyr
Alvaro Gold Medal (Brazil), the Jorge Malbran Gold Medal (Argentina),
the Favaloro Gold Medal (Italy).
Recipient of The Great Cross Vasco Nuñez de Balboa Panama's Highest

National Award.
Founder and Chief Consultant, Ophthalmology Center of Clinica Boyd, Panama,

R.P.; Editor-in-Chief, Highlights of Ophthalmology's ten Editions (Brazilian, Chinese,
English, German, Indian, Italian, Japanese, Middle East and Spanish); Author, Highlights of
Ophthalmology's Atlas and Textbooks (25 Volumes); Diplomate, American Board of
Ophthalmology; Past-President (1985-1987) and Executive Director ((1960-1985) Pan
American Association of Ophthalmology; Fellow, American Academy of Ophthalmology;
Fellow, American College of Surgeons; Guest of Honor, American Medical Association,
1965; Guest of Honor, American Academy of Ophthalmology, 1978 and Barraquer Institute
in Barcelona, 1982 and 1988; Doctor Honoris Causa of Five Universities; Recipient of the
Great Cross of Christopher Columbus, Dominican Republic's highest award, for "Contribu-
tions to Humanity"; Founding Professor of Ophthalmology, University of Panama School of
Medicine (1953-1974); Former Dean and Chief, Department of Surgery, University of
Panama School of Medicine (1969-1970); O'Brien Visiting Professor of Ophthalmology,
Tulane University School of Medicine, New Orleans, 1983; Honorary Professor of Ophthal-
mology at Four Universities; Past-President, Academy of Medicine and Surgery of Panama;
Honor Member, Ophthalmological Societies of Argentina, Bolivia, Brazil, Canada, Colom-
bia, Costa Rica, Chile, Dominican Republic, Guatemala, Mexico, Paraguay, Peru; Recipient
of the Andres Bello Silver Medal from the University of Chile for "Extraordinary
Contributions to World Medical Literature."
V
MASTER CONSULTANTS
JOAQUIN BARRAQUER, M.D., F.A.C.S., Director and Chief Surgeon,

Barraquer Ophthalmology Center; Barcelona, Spain. Professor of Ophthalmology,
Autonomous University of Barcelona, Spain. Chair, Academia Ophthalmologica
Internationalis.
MICHAEL BLUMENTHAL, M.D., Director, Ein Tal Eye Center, Israel.
Professor of Ophthalmology, Sidney A. Fox Chair in Ophthalmology, Tel Aviv
University. Past President, European Society of Cataract and Refractive Surgery.
EDGARDO CARREÑO, M.D., Assistant Professor of Ophthalmology,
University of Chile; Director, Carreño Eye Center, Santiago, Chile.
VIRGILIO CENTURION, M.D., Chief of the Institute for Eye Diseases, Sao
Paulo, Brazil.
JACK DODICK, M.D., Chief, Department of Ophthalmology, Manhattan Eye
and Ear Hospital, New York. Clinical Professor of Ophthalmology, Columbia
University College of Physicians and Surgeons, New York.
CRISTELA FERRARI ALEMAN, M.D., Associate Director, Cornea and

Anterior Segment, Boyd Ophthalmology Center. Clinical Professor, University
of Panama School of Medicine, Panama, Rep. of Panama.
I. HOWARD FINE, M.D., Clinical Associate Professor of Ophthalmology,
Oregon Health Sciences University. Founding Partner, Oregon Eye Surgery
Center.
HOWARD V. GIMBEL, M.D., MPH, FRCSC, Professor and Chairman,
Department of Ophthalmology, Loma Linda University, California; Clinical
Assistant Professor, Department of Surgery, University of Calgary, Alberta,
Canada; Clinical Professor, Department of Ophthalmology, University of California,
San Francisco, California; Founder and Director, Gimbel Eye Centre in Calgary,
Albert, Canada.
RICHARD LINDSTROM, M.D., Medical Director, Phillips Eye Center for
Teaching and Research. Clinical Professor,, University of Minnesota, Minneapolis.
MAURICE LUNTZ, M.D., Chief of Glaucoma Service, Manhattan Eye and Ear
Hospital, New York. Clinical Professor of Ophthalmology, Mt. Sinai School of
Medicine, New York.
OKIHIRO NISHI, M.D., Director of Jinshikai Medical Foundation, Nishi Eye
Hospital, Osaka, Japan.
MIGUEL A. PADILHA, M.D., Professor and Chairman, Department of
Ophthalmology, School of Medical Sciences of Volta Redonda, Rio de Janeiro.
Professor, Graduate Course of the Brazilian Society of Ophthalmology and
Director, Central Department of Ophthalmology, Brazilian College of Surgeons.
Former President, Brazilian Society of Cataract and Intraocular Implants.
VI
CO-EDITOR
ENGLISH EDITION
Robert C. Drews, M.D., F.A.C.S., F.R.C.Ophth.
Professor Emeritus of Clinical Ophthalmology, Washington University School of

Medicine, St. Louis, Missouri.
President Elect of the American Ophthalmological Society
Gold Medal of Pan-American Association of Ophthalmology; Rayner Medal, United

Kingdom Intraocular Implant Society; Binkhorst Medal, American Intraocular
Implant Society; Gold Medallion of the National Academy of Science of Argentina;
The Montgomery Medal, Irish Ophthalmological Society; Gold Medal of the
University of Rome; Gold Medal of the Missouri Ophthalmological Society.
Former Chief of Surgery, Bethesda General Hospital, St. Louis, Missouri, and
Former Chief of the Section of Ophthalmology, Bethesda General Hospital, St. Louis and
St. Luke's Hospital, St. Louis, Missouri. Past Chairman of the Council of the American
Ophthalmological Society, Former member of the American Board of Ophthalmology,
and of the Board of Trustees, Washington University in St. Louis. Past President of the
Pan American Association of Ophthalmology, International Ophthalmic Microsurgery
Study Group, International Intraocular Implant Club, American Intra-Ocular Implant
Society, Southern Medical Association, Section on Ophthalmology, Missouri
Ophthalmological Society, Missouri Association of Ophthalmology, St. Louis
Ophthalmological Society, St. Louis Society for the Blind, Past Vice President, American
Academy of Ophthalmology.
Named Lectures: the Luedde Memorial Lecturer, St. Louis University School of
Medicine; Rayner Lecture, United Kingdom Intraocular Implant Society; Binkhorst
Lecture, American Intraocular Implant Society; C. Dwight Townes Memorial Lecture,
Louisville Kentucky; The Montgomery Lecture, Dublin, Irish Ophthalmological Society;
Boberg-Ans Lecture, Copenhagen, Denmark, ESCRS; G. Victor Simpson Lecture,
Washington DC; Gradle Lecture, PAAO; Joseph P. Bryan Glaucoma Lecture, Durham,
North Carolina.
VII
GUEST EXPERTS
EVERARDO BAROJAS, M.D., Dean, Prevention of Blindness and Rehabilitation

of Sight Society, Mexico, D.F.
PROF. RUBENS BELFORT JR., M.D., Professor and Chairman, Department

of Ophthalmology, Federal University of São Paulo (Escola Paulista de Medicina-
Hospital São Paulo), Brazil; Chair, Academia Ophthalmologica Internationalis.
RAFAEL CORTEZ, M.D., Director, Ophthalmic Surgery Center (CECOF),

Caracas, Venezuela.
FRANCISCO GUTIERREZ C., M.D., Ph.D, Anterior Segment Surgery and

Pediatric Ophthalmologist Specialist, Department of Ophthalmology, Hospital
General de Segovia, Spain. Former Fellow of Ramon Castroviejo, M.D.
FRANCISCO MARTINEZ CASTRO, M.D., Associate Professor of

Ophthalmology, Autonomous University of Mexico. Consultant in Uveitis, Institute
of Ophthalmology "Conde de Valenciana" and Seguro Social Medical Center,
Mexico, D.F.
JUAN MURUBE, M.D., Professor of Ophthalmology, University of Alcala and

Chairman, Department of Ophthalmology, Hospital Ramon y Cajal, Madrid, Spain.
DAVID McINTYRE, M.D., Head, McIntyre Clinic and Surgical Center, Bellevue,
Washington.
CARLOS NICOLI, M.D., Associate Professor of Ophthalmology, University of

Buenos Aires, Argentina. Director, "Oftalmos" Institute.
FELIX SABATES, M.D., Professor and Chairman, Department of Ophthalmology,

University of Missouri, Kansas City School of Medicine, Missouri.
JUAN VERDAGUER, M.D., Academic Director, Los Andes Ophthalmological

Foundation, Santiago, Chile; Professor of Ophthalmology, University of Chile;
Professor of Ophthalmology, University of Los Andes; Past President, Pan American
Association of Ophthalmology.
LIHTEH WU, M.D., Associate Surgeon in Vitreoretinal Diseases, Instituto de

Cirugia Ocular, San Jose, Costa Rica. Consultant in Vitreoretinal Diseases,
Department of Ophthalmology, Hospital Nacional de Niños, San Jose, Costa Rica.
VIII
CONTENTS
FOCUSING AND OVERVIEW OF WHAT IS BEST

Tackling the Challenges
Role of Small Incision Manual Extracapsulars
IOL's of Choice
The Best Phaco Techniques
CHAPTER 1
SURGICAL ANATOMY OF THE HUMAN LENS

CLINICAL APPLICATIONS
Behaviour of Different Cataracts 5
Anatomical Characteristics of Different Types of Cataract 7
How Cataracts Respond Differently 7
Incidence and Pathogenesis 8
CHAPTER 2
INDICATIONS FOR SURGERY -

PREOPERATIVE EVALUATION
INDICATIONS 11
Role of Quality of Life 11
The Role of Visual Acuity 11
Contrast Sensitivity and Glare Disability 12
Contrast Sensitivity Characteristics 13
Relation of Glare to Type of Cataract 14
Evaluation of Macular Function 15
PREOPERATIVE GUIDELINES IN COMPLEX CASES 21
How to Proceed in Patients with Retinal Disease 21
The Importance of Pre-Op Fundus Exam 21
Cataract Surgery in Diabetic Patients 21
Evaluating Diabetics Prior to Cataract Surgery 21
Importance of Maintaining the Integrity of the Lens Capsule 24
Significant Increase in Complications Following Cataract Surgery 24
Appropriate Laser Treatment 25
Main Options in Management of Co-existing Diabetic 27
Retinopathy and Cataract
Cataract Surgery and Age-Related Macular Degeneration 28
RETINAL BREAKS AND RETINAL DEGENERATIONS 28
PRIOR TO CATARACT SURGERY
Cataract Surgery in Patients with Uveitis 31
Method of Choice 32
Diagnosing the Type of Uveitis in the Pre-Operative Phase 32
Preoperative Management 32
The Intraocular Lens 33
Cataract Surgery in Adult Strabismus Patients 33
Preoperative Judgment 33
IX
CHAPTER 3
PREPARING FOR SURGERY 37
Making Patients Confident 37

Patients Encounter with the Physician 37
Ingredients of a Strong Relationship 38
Evaluating the Patient's Cataract 38
Approaching the Day of Surgery 39
Patient's Expectations 39
IOL POWER CALCULATION IN STANDARD 39

AND COMPLEX CASES
Postop Refractive Errors No Longer Admissible 40
The Challenge of the Complex Cases 43
The Most Commonly Used Formulas 44
Main Causes of Errors 44
Targeting Post-Op Refraction 45
Monocular Correction 45
Binocular Correction 46
Good Vision in the Non-Operated Eye 46
When Cataracts in Both Eyes 46
IOL POWER CALCULATION IN COMPLEX CASES 47
Specific Methods to Use in Complex Cases 47
Practical Method for Choosing Formulas in Complex Cases 47
High Hyperopia 47
The Use of Piggyback Lenses in Very High Hyperopia 48
High Myopia 49
DETERMINING IOL POWER IN PATIENTS WITH 49
PREVIOUS REFRACTIVE SURGERY
Methods Most Often Used 52
The Clinical History Method 52
The Trial Hard Contact Lens Method 53
Example as Provided by Holladay 53
The Corneal Topography Method 54
THE IMPORTANCE OF DETECTING IRREGULAR 54
ASTIGMATISM
IOL POWER CALCULATION IN PEDIATRIC CATARACTS 54
Different Alternatives 55
Alternatives of Choice 55
IOL POWER CALCULATION FOLLOWING VITRECTOMY 57
CHAPTER 4
PREVENTING INFECTION AND INFLAMMATION

Use of Antiseptics, Antibiotics and Antiinflammatory Agents 63
Effective Preoperative Antibiotic Treatments 63
Regimens Recommended 64
Gills Formulas to Prevent Infection 64
1) For High Volume Cataract Surgery 64
2) Non-Complex, Effective and Safe Alternative for 65
Prevention of Infection
X
CHAPTER 5
PROCEEDING WITH THE OPERATION
PREPARATION, SEDATION AND ANESTHESIA 71

Preparation of Patient 71
Sedation 71
Pupillary Dilation 72
ANESTHESIA 72
Topical 72
Selection of Anesthetic Method 72
Unassisted Topical Anesthesia 74
The Anesthetic Procedure of Choice 75
Technique for Irrigation of Lidocaine in AC 75
Injection of Viscoelastic 75
What Can be Done with the Combined Anesthesia 75
Side Effects of the Combined Anesthesia 75
How to Manage Patients Who Feel Pain and Discomfort 75
PHOTOTOXICITY IN CATARACT SURGERY 75
CHAPTER 6
PHACOEMULSIFICATION - WHY SO IMPORTANT?
COMPARING PLANNED EXTRACAPSULAR WITH 83

PHACO EXTRACAPSULAR
ADVANTAGES OF THE PHACO TECHNIQUE 83
MAIN TECHNICAL DIFFERENCES ASSOCIATED WITH PHACO 84
LIMITATIONS OF PHACOEMULSIFICATION 86
CHAPTER 7
PREPARING FOR THE TRANSITION
GENERAL OVERVIEW AND STEP BY STEP CONSIDERATIONS 93

Equipment - Dependent and Phase-Dependent Technique 93
Mental Attitude 93
UNDERSTANDING THE PHACO MACHINE 94
Becoming Familiar with the Equipment 94
Two Hands, Two Feet and Special Sounds 95
Main Elements of Phaco Machines - Their Action on Fluid Dynamics 95
COMPARISON OF SURGICAL TECHNIQUES FOR 96
TRANSITION VS EXPERIENCED SURGEONS
Techniques Which Are the Same for the Transition and for 96
Advanced Surgeons
Techniques that Vary According to the Skill of the Surgeon 96
XI
SURGICAL TECHNIQUE IN THE TRANSITION 97
Anesthesia 97
The Incision 97
How to Make a Safe Transition from Large to Small Incision 97
Role of Conjunctival Flap 101
Anterior Capsulorhexis 102
Hydrodissection 104
THE MECHANISM OF THE PHACO MACHINE 106
Getting Ready to Use Phaco During Transition 106
Optimal Use of the Phaco Machine 106
The Rationale Behind It - Main Functions 106
Parameters of the Phaco Machine 112
How to Program the Machine for Optimal Use 114
Fluid Dynamics During Phaco 114
Fluidics and Physics of Phacoemulsification 116
Importance of and Understanding the Surge Phenomenon 119
Lessening Intraoperative 121
Complications from the Surge 121
NUCLEUS REMOVAL - APPLICATION OF PHACO 123
FRACTURE AND EMULSIFICATION 123
The Divide and Conquer Technique 124
Emulsification of the Nuclear Fragments 126
FINAL STEPS 126
Aspiration of the Epinucleus 126
Aspiration of the Cortex 126
Intraocular Lens Implantation 128
Removal of Viscoelastic 128
Closure of the Wound 129
What to Do if Necessary to Convert 130
Testing the Wound for Leakage 131
Immediate Postoperative Management 131
CHAPTER 8
INSTRUMENTATION AND EMULSIFICATION SYSTEMS
INSTRUMENTATION 137
Eye Speculum 137
Fixation Ring 137
Knives and Blades 137
Hydrodissection Cannula 140
Cystotomes or Capsulorhexis Forceps 141
Nuclear Manipulators or Choppers (Second Instrument) 142
Forceps and Cartridge Injector Systems for Insertion of 144
Foldable Intraocular Lenses
THE PHACO PROBES AND TIPS 147
Phaco Tips 148
Surgical Principles Behind the Different Phaco Tips 149
PHACOEMULSIFICATION SYSTEMS 150
The Alcon Legacy 150
The Allergan Sovereign 150
The Bausch & Lomb - Storz Millennium 150
XII
The Pulse and Burst Modes 151
Differences Between Them 151
Clinical Applications of the Pulse Mode 152
Clinical Applications of the Burst Mode 154
Its Role in Transition to Chopping 154
Advances with the Sovereign Phaco System 154
CHAPTER 9
MASTERING PHACOEMULSIFICATION
General Considerations 159

Trauma-Free Phacoemulsification 159
Faster Operations 160
Do They Sacrifice Patient Care? 160
Readiness and Know-How to Become Efficient 160
THE ADVANCED, LATE-BREAKING TECHNIQUES 160
Anesthesia 160
Fixation of the Globe 161
THE INCISIONS 161
The Primary Incision 161
Essential Requirements for a Self-Sealing Corneal Incision 162
Position of the Clear Cornea Tunnel Incision 162
Reservations About the Clear Corneal Incision 164
Advantages to the Temporal Approach 164
Importance of the Length of the Tunnel 166
Placing and Making the Primary Incision 166
Surgeon's Position 167
Controversy Over the Strength and Safety of the Wound 167
Testing the Wound for Leakage 167
Closing a Leaking Wound Without Sutures 167
THE ANCILLARY INCISION 169
ANTERIOR CAPSULORHEXIS 169
Key Role 169
Technique for Performing a First Class CCC 170
Size of the Capsulorhexis 170
STAINING THE ANTERIOR CAPSULE IN WHITE CATARACTS 172
HYDRODISSECTION - HYDRODELAMINATION 175
Technique of Hydrodissection 175
Hydrodelamination 175
MANAGEMENT OF THE NUCLEUS 176

Concepts Fundamental to All Techniques 176
The Essential Principles 177
THE ENDOCAPSULAR TECHNIQUES 177
THE HIGH ULTRASOUND ENERGY AND LOW VACUUM GROUP 177

THE GROOVING AND CRACKING METHODS 177
XIII
The Divide and Conquer Four Quadrant Nucleofractis Technique 177
Principles of the Divide and Conquer Techniques 180
The Role of D & C Techniques in Cataracts of 180
Different Nucleus Consistency
Present Role of Original Four Quadrant Divide and Conquer 181
THE LOW ULTRASOUND ENERGY AND HIGH VACUUM GROUP 181
THE CHOPPING TECHNIQUES 183
Main Instruments Used 183
Surgical Principles of the Original Phaco Chop 184
Chopping Techniques Presented in this Volume 184
THE STOP AND CHOP TECHNIQUE 184
Surgical Principles 184
Absolute Requirements to Perform the Stop and Chop 188
Importance of the Phaco Chopper 188
Highlights of the Stop and Chop Technique 189
FUNDAMENTAL DIFFERENCES BETWEEN CHOPPING 190
AND DIVIDE AND CONQUER (D & C) TECHNIQUES
THE CRATER PROCEDURES 191
The Crater Divide and Conquer (Mackool) 191
The Crater Phaco Chop for Dense, Hard Nuclei 191
THE NUCLEAR PRE-SLICE OR NULL PHACO CHOP 194
TECHNIQUE
Disassembling the Nucleus 194
How Is the Null-Phaco Chop Done 194
Potential Complications 198
Contributions of this Technique 198
THE CHOO-CHOO CHOP AND FLIP 198
PHACOEMULSIFICATION TECHNIQUE
Origin of the Name “Choo-Choo” 199
Comparison With Other Techniques 202
Fine's Parameters 202
THE TRANSITION TO CHOPPING TECHNIQUES 204
REMOVAL OF RESIDUAL CORTEX AND EPINUCLEUS 205
INTRAOCULAR LENS IMPLANTATION 207
The Increased Interest in Foldable IOL's 207
The Most Frequently Used IOL's 207
MONOFOCAL FOLDABLE LENSES 208
THE FOLDABLE ACRYLIC IOL'S 208
THE FOLDABLE MONOFOCAL SILICONE IOL's 209
OTHER MONOFOCAL LENSES 210
The Hydrogel, Foldable Monofocal IOL 210
The Foldable Toric Lens 210
Bitoric Lens But Not Foldable 210
THE FOLDABLE MULTIFOCAL IOL 211
The Array Multifocal Silicone Lens 211
How Does the Array Foldable Multifocal Lens Work? 212
Quality of Vision with Array Multifocal 212
Patient Selection and Results 212
XIV
Specific Guidelines for Implanting the Array Lens 213
Special Circumstances for Array Implantation 213
Need for Spectacle Wear PostOp 214
Halos at Night and Glare 214
SURGICAL PRINCIPLES AND GUIDELINES FOR 214
IOL IMPLANTATION
PREFERRED METHODS OF IOL IMPLANTATION 214
Use of Forceps vs Injectors 214
Advantages and Disadvantages 214
New Trends for Folding and Insertion of IOL's 214
Guidelines for Insertion of Different Types of Lenses 218
Surgical Technique with Array Lens 218
Carreño's Technique of Acrylic IOL Implantation 218
Through a 2.75 mm Incision
Dodick's AcrySof's Implantation Technique 220
Implantation Technique for Silicone Foldable IOL's 222
Using Cartridge-Injector System
TESTING THE WOUND FOR LEAKAGE 223
CHAPTER 10
FOCUSING PHACO TECHNIQUES ON THE

HARDNESS OF THE NUCLEUS
MULTIPLICITY OF TECHNIQUES 229

The Essential Criteria for Success 229
DIFFERENT NUCLEUS CONSISTENCY - 229
TECHNIQUES OF CHOICE
Representative Experts 230
LINDSTROM'S PROCEDURES OF CHOICE 230
Advantages of the Supracapsular 231
Disadvantages of the Supracapsular 232
Contraindications of Supracapsular 232
HIGHLIGHTS OF THE SUPRACAPSULAR 233
IRIS PLANE TECHNIQUE
CENTURION'S TECHNIQUES RELATED 234
TO NUCLEUS CONSISTENCY
CARREÑO'S NUCLEAR EMULSIFICATION TECHNIQUE 237
OF CHOICE (PHACO SUB 3)
Adjusting the Equipment Parameters to Remove Cataracts 237
of Various Nuclear Density
Three Sets of Values Programmed Into Memory 237
Technique of Choice and Consistency of Cataract 238
NISHI'S TECHNIQUES OF CHOICE FOR 245
NUCLEI OF DIFFERENT CONSISTENCIES
XV
CHAPTER 11
COMPLICATIONS OF PHACOEMULSIFICATION
INTRAOPERATIVE COMPLICATIONS 249-268

Main Intraoperative Complications 249
Incidence 249
Facing the Challenges 250
COMPLICATIONS WITH THE INCISION 250
COMPLICATIONS RELATED TO ANTERIOR 254
CAPSULORHEXIS
COMPLICATIONS WITH HYDRODISSECTION 258
COMPLICATIONS DURING NUCLEUS REMOVAL 259
COMPLICATIONS DURING REMOVAL OF THE CORTEX 260
COMPLICATIONS DURING FOLDABLE IOL's IMPLANTATION 260
COMPLICATIONS WITH POSTERIOR CAPSULE RUPTURE 262
Pars Plana Vitrectomy for Dislocated Nucleus 266
POSTOPERATIVE COMPLICATIONS 269-290
MEDICAL 269
Cystoid Macular Edema 269
Diabetes and Cystoid Macular Edema 273
PHOTIC MACULOPATHY 273
AMINOGLYCOSIDE TOXICITY 275
POSTERIOR CAPSULE OPACIFICATION 277
Overview 277
Role of IOL in PCO 277
Role of Continuous Curvilinear Capsulorhexis in PCO 278
Main Factors that Reduce PCO 278
PERFORMING THE POSTERIOR CAPSULOTOMY 279
Size of Capsulotomy 279
Posterior Capsulotomy Laser Procedure 279
Complications Following Nd:YAG Posterior Capsulotomy 281
POSTOPERATIVE ASTIGMATISM IN CATARACT PATIENTS 281
MANAGEMENT 281
Procedure of Choice 282
Highlights of AK Procedure 283
EXPLANTATION OF FOLDABLE IOL'S 284
RETAINING THE BENEFIT OF THE SMALL INCISION 284
RETINAL DETACHMENT 286
POSTOPERATIVE ENDOPHTHALMITIS 286
INTRAOCULAR LENS DISLOCATION 288
XVI
CHAPTER 12
CATARACT SURGERY IN COMPLEX CASES
Aims of this Chapter 295

Broadening of Indications 295
Complex Cases Already Discussed in Previous Chapters 296
FOCUSING ON THE MAIN COMPLEX CASES 296
THE DIFFERENT TYPES OF VISCOELASTICS 296
Their Specific Roles 296
Cohesive and Dispersive Viscoelastics 296
The Cohesive VES - Specific Properties 296
The Dispersive VES- Specific Properties 297
PHACOEMULSIFICATION AFTER PREVIOUS 298
REFRACTIVE SURGERY
PHACOEMULSIFICATION IN HIGH MYOPIA 298
CHALLENGES OF PHACOEMULSIFICATION IN HYPEROPIA 299
REFRACTIVE CATARACT SURGERY 299
Why and When Do Refractive Cataract Surgery 299
TECHNIQUE FOR REFRACTIVE CATARACT SURGERY 300
CATARACT AND GLAUCOMA 302
Overview - Alternative Approaches 302

COMBINED CATARACT SURGERY AND 303
TRABECULECTOMY
Indications 303
Evolution of the Incision for Combined Cataract Extraction 303
and Trabeculectomy
A. Extracapsular Cataract Extraction with Trabeculectomy 304
B. Phacoemulsification with Trabeculectomy 308
Intraocular Lens Implants 308
Preoperative Preparation 308
SURGICAL TECHNIQUES STEP BY STEP 310
ECCE and Trabeculectomy With Single, Unbroken Tunnel Incision 310
Phacoemulsification With Trabeculectomy 315
Antimetabolites in Combined Procedures 318
Results of Combined Cataract Surgery and Trabeculectomy 320
PHACOEMULSIFICATION IN DISEASED CORNEAS 322
PHACOEMULSIFICATION AND IOL IMPLANTATION 322

IN THE PRESENCE OF OPAQUE CORNEA
Overview 322
Padilha’s Timing and Technique 322
Specific Recommendations 324
PHACOEMULSIFICATION, IOL IMPLANTATION 325
AND FUCHS’ DYSTROPHY
Preoperative Evaluation 325
Special Precautions During Phacoemulsification 325
XVII
PHACOEMULSIFICATION IN SMALL PUPILS 328
Pharmacological Mydriasis 328

Mechanical Dilatation with Viscoelastics 328
Mechanical Strategies 328
TRAUMATIC CATARACTS 333
Overview 333
Assessment of the Injured Eye 333
Highlights of Examination 333
Diagnostic Imaging 333
Combined Injuries of Anterior and Posterior Segment 334
Traumatic Cataracts in the Presence of Anterior 334
Segment Penetrating Wounds
MANAGEMENT OF TRAUMATIC CATARACT 334
HIGHLIGHTS OF SURGICAL TECHNIQUE 334
The Incision 334
Anterior Capsulorhexis 334
Lens Removal 334
Role of Intracapsular Tension Ring in Traumatic Cataracts 335
Removal of Cortex 336
Selection of IOL 339
IOL Implantation 339
Selection of Viscoelastic in Traumatic Cataracts 339
Phacoemulsification Advantages in Traumatic Cataract 340
PHACOEMULSIFICATION IN SUBLUXATED CATARACTS 340

Strategic Management 340
MANAGEMENT DEPENDING ON SIZE OF 340
ZONULAR DIALYSIS
Special Precautions with Subluxated Cataracts 342
Increasing the Safety of Posterior Lens Implantation in 344
Extensive Zonular Disinsertion
Fixation of the Anterior Capsule to the Ciliary Sulcus 345
CATARACT SURGERY IN CHILDHOOD 347

Previous Controversies Now Resolved 347
1) Age and Timing for Surgery 347
Bilateral Cataracts 347
Unilateral Cataracts 347
Preoperative Evaluation 348
History 348
Examination 349
The Special Case of Lamellar Cataracts 350
Rubella Cataracts 350
The Need for Close Monitoring 350
Preoperative Considerations 350
The Decision to Implant IOL’s in Children with Cataract Surgery 351
Surgical Technique 351
The Posterior Approach to Cataract Extraction in Children 355
CATARACT SURGERY IN UVEITIS 355
XVIII
CHAPTER 13
THE PRESENT ROLE OF MANUAL EXTRACAPSULARS
Overview 359
PERFORMING A FLAWLESS PLANNED EXTRACAPSULAR 361
CATARACT EXTRACTION (with an 8 mm Incision and
Posterior Chamber IOL Implantation)
General Anesthesia 361
Local Anesthesia 362
Technique for Extracapsular Cataract Extraction 364
with an 8 mm Incision (ECCE)
THE MANUAL, SMALL INCISION EXTRACAPSULARS 375
THE MINI-NUC TECHNIQUE 375

SURGICAL TECHNIQUE 376
Anesthesia, Paracentesis, ACM 376
Capsulorhexis 377
Conjunctiva 377
Sclerocorneal Pocket Primary Incision and Tunnel 378
Hydrodissection and Nucleus Dislocation 378
Nucleus Expression Using Glide and High IOP 381
Epinucleus and Cortex Extraction 383
IOL Implantation 384
Pupil Enlarged by Increased IOP 386
Advantages of the Continuous Flow of BSS 387
during Manual ECCE
Complications 387
THE SMALL INCISION PHACO SECTION 389

MANUAL EXTRACAPSULAR TECHNIQUE
Overview 389
Evolution of Technique 389
Indications 389
PHACO SECTION MOST IMPORTANT FEATURES 389
Capsulorhexis 390
Completing the Tunnel Incision 390
Anterior Chamber Maintainer 391
Aspiration of the Anterior Cortex and Epinucleus 392
Phacosection 393
Transition from Extracapsular Extraction to Phacosection 395
THE SMALL INCISION MANUAL PHACOFRAGMENTATION 400
Benefits of (MPF) 400

Experiences with Other Phaco Fragmentation Techniques 400
Why Use Gutierrez' Technique? 400
Surgical Technique 402
Complications 405
XIX
CHAPTER 14
THE NEW CATARACT SURGERY DEVELOPMENTS

Overview 409
DODICK’S PHOTOLYSIS SYSTEM 409
THE CATAREX SYSTEM 411
Aziz PhacoTmesis 411
Water Jet Technology 411
XX
Fo c u s i n g a n d O v e r v i ew o f W h a t i s B e s t
FOCUSING AND OVERVIEW OF WHAT IS BEST
Modern cataract surgery is definitely re- Role of Small Incision Manual

lated to lens removal through small, short, Extracapsular
valve like incisions and implantation of fold-
able intraocular lenses implanted through these Although we provide special emphasis
short incisions. on how to master phacoemulsification and
foldable IOL implantation, including an in-
Tackling the Challenges depth analysis of how to prevent and manage
intraoperative and postoperative complications,
In this Volume we present what is best we also present to you the small incision manual
for our patients and how to tackle the chal- extracapsular techniques of proven and lasting
lenges with vigor. We present the new devel- value. For those surgeons who are prevented
opments in preoperative evaluation, the ex- by practical considerations, or who simply
pansion of the indications as the outcomes prefer to not take the significant step of enter-
have improved, the new, sometimes complex ing into small incision surgery, the chapter on
problems brought by refractive and how to perform a flawless planned extracapsu-
vitreoretinal surgery in calculating IOL power. lar with 8 mm incision and its merits is superbly
And we illustrate the steps that remain rather as presented by one of the world's master sur-
constant and which apply either to the surgeon geons.
in the process of transition or the experienced
small incision surgeon, vs the methods that do IOL's of Choice
change and require the skill of an experienced
surgeon. In modern cataract surgery it is essential
We also present the anesthetic methods to discuss the IOL's of choice and their merits.
of choice, the understanding of the phaco Selecting the correct lens implant (size of optic,
machine, how it works and what the rationale chemical material, foldable vs non-foldable,
is behind its optimal use. How to undergo the mono vs multifocal) may play a more impor-
safe and successful transition from planned tant role in the final patient's final visual out-
extracapsular to phaco. The incisions of come and satisfaction than the specific tech-
choice for most surgeons, the methods that nique used for phacoemulsification of the
enhance the performance of capsulorhexis in nucleus.
complex cases, the modern techniques of
hydrodissection, hydrodelineation and cortex The Best Phaco Technique
removal that have stood the test of time and the
advantages and disadvantages of the different The best phacoemulsification tech-
methods of nucleus removal in phacoemulsifi- nique to use is based on the relation of the type
cation.
1
T H E A R T A N D THE S C I E N C E OF C ATA R A C T S U R G E R Y
of cataract to a specific method of nucleus operation, to management of traumatic cata-

removal for that specific stage of cataract. The racts and cataract surgery in patients with cor-
divide and conquer in four quadrants continues neal dystrophies.
to be the procedure of choice for the beginner Pediatric cataracts have not been resolved
in the transition period or for the surgeon who with the improved management options and
does not have a large volume of cataract sur- almost risk-free capabilities of the magnitude
gery. The technique for nucleus removal with that we have available in adult patients. This,
one hand continues to be fundamental for each in part, may be related to the fact that the
phaco surgeon to learn. We will also present postoperative care depends more on the par-
the phaco sub-3, phaco chop, phaco pre-chop, ents than on the surgeon. The previously
choo-choo chop and flip and the phaco burst, highly controversial point of implanting in-
all of which are techniques for the more traocular lenses in children has shifted to a
advanced or experienced surgeons. Each has positive decision on the part of most surgeons
its merits, effectiveness and limitations. who now agree to implant IOL's in children
when the selection of cases has been done
The Complex Cases prudently.
Let us now proceed to discuss each one
Small incision cataract surgery has sig- of the highlights of modern cataract surgery.
nificantly changed the approach and manage- The field is exciting and a source of great
ment of the complex cases. It is the most satisfaction to the surgeon who does it well and
important contribution made in years to a suc- with full dedication to the benefit of his or her
cessful and safe combined glaucoma-cataract patients.
2
C h a p t e r 1: S u r g i c a l A n a t o m y o f t h e H u m a n L e n s
SURGICAL ANATOMY OF THE HUMAN LENS
Clinical Applications - Behaviour distinguish what is really anterior capsule, what

of Different Cataracts is cortex and where the posterior capsule is.
When removing the cortex, we must keep
Understanding the three-dimensionality in mind that its substance is three dimensional
and concentric anatomy of the lens as origi- (Fig. 1). As described in this figure, the nucleus
nally conceived by Henry Clayman, M.D. for is the pit of the avocado. The pit in the avocado
HIGHLIGHTS is fundamental for having a does not drop out because it is held in by
clear picture of some of the main steps in adhesions between the flesh of the avocado and
performing phaco. I refer to the dissection of the pit. Figure 1 also shows that the cortex (C)
the different structures of the nucleus with adheres to the epinucleus and the nucleus. In
fluid, that is, hydrodissection of the anterior order to remove the nucleus by whatever tech-
and posterior capsule from the cortex, separa- nique you prefer, these nuclear-cortical adhe-
tion of the nucleus and epinucleus with fluid sions have to be broken and out comes the
and the different tissue reactions to the forces nucleus, whether by phacoemulsification or by
presented during phacoemulsification of the planned extracapsular.
nucleus. The residual cortex, which is the flesh of
The normal crystalline lens is an avascu- the avocado, is wrapped around, three dimen-
lar structure. As pointed out by Howard sionally, inside the skin of the avocado, which
Gimbel, M.D., lens fibers are surrounded by is the capsule (Fig. 1). When aspirating the
the lens capsule which is the basement mem- cortex, it is prudent not to attack the cortex right
brane of the lens epithelial cells (Fig. 1). Lens on but to get a free edge, which you may attract
epithelial cells are located just inside the cap- to the aspiration port, and peel from its capsule
sule and exist as a single layer. The epithelial support.
cells can differentiate into lens fibers, and this In Fig. 1 you may see a conceptual cross
process occurs in an area just posterior to the section of the anterior globe, with all the struc-
lens equator. As new lens fibers are formed, the tures of the human lens involved in the maneu-
central fibers are compacted, forming the vers hereby described. The capsule is like the
nucleus of the lens. The surrounding densely skin of an avocado, both anterior (A) and
packed fibers form the cortex (Fig. 1). Due to posterior (P). The flesh of the avocado is
the anatomical arrangement of cells and fibers, comparable to the cortex (Fig. C). The pit of
the Y sutures are formed within the lens the avocado is comparable to the lens epi-
nucleus. nucleus and nucleus (Fig. E-N). In (1) the
For a surgeon not experienced in small cortex (C), epinucleus (E) and nucleus (N) are
incision extracapsular techniques, there may shown removed from the capsule. (2) Shows
be difficulties recognizing the hidden anatomy the cortex (C) removed from the nucleus and
of the morbid cataract. It may be difficult to epinucleus (E and N). The nuclear-cortical
5
Figure 1: Three-Dimensionality of the Lens - Clinical Applications
Figure 1 presents a conceptual cross section of the anterior globe and the three dimensional nature of the lens
anatomy, with all the structures of the human lens involved in the surgical maneuvers. Think of the lens as if it were
an avocado. The capsule is like the skin of an avocado, both anterior (A) and posterior (P). The flesh of the avocado
is comparable to the cortex (Fig. C). The pit of the avocado is comparable to the lens epinucleus and nucleus (Fig.
E-N). The pit in the avocado does not drop out because it is held in by adhesions between the flesh of the avocado
and the pit. The cortex (C) adheres to the epinucleus (E) and the nucleus (N). The residual cortex, which is the flesh
of the avocado, is wrapped around, three dimensionally, inside the skin of the avocado, which is the capsule (Fig. A-
P). When aspirating the cortex, it is prudent not to attack the cortex directly but to get a free edge, which you may attract
to the aspiration port, and peel it from its capsule support. In (1) the cortex (C), epinucleus (E) and nucleus (N) are
shown removed from the capsule. (2) Shows the cortex (C) removed from the nucleus and epinucleus (E and N). The
nuclear-cortical adhesions have to be broken down before the nucleus can come out (2 and 3). In (E) the epinucleus
is shown as an entity distinct from the nuclear core. This figure allows us to better understand the anatomical basis
for the formation of grooves across the nucleus skillfully utilized by the surgeon in the technique of
phacoemulsification.
6
C h a p t e r 1: S u r g i c a l A n a t o m y o f t h e H u m a n L e n s
adhesions have to be broken down before the moisture. Medium to firm-density cataracts
nucleus can come out (2 and 3). In (E) the have concentric lamellae of tissue that are
epinucleus is shown as an, entity distinct from densely packed together, packed so tight that
the nuclear core. This figure allows us to better there is no room for moisture between lamel-
understand the anatomical basis for the lae.
formation of grooves across the nucleus skill-
fully utilized by the surgeon in the technique of How Cataracts Respond Differently
phacoemulsification. Paul Koch, M.D. emphasizes that each
Anatomical Characteristics of one of these different types of cataracts re-
sponds differently, so surgical forces need to
Different Types of Cataract be applied differently. In breaking the nucleus
The lens in cross section is made up of a the surgeon needs to individualize the opera-
concentric series of elliptical rings. Each one tion to take advantage of the natural tendencies
of these rings represents growth of the lens and of each type of cataract. Soft to medium
the laying down of additional lens material density cataracts are malleable and compli-
from the epithelial cells located on the under- ant. We can hold them in the capsular bag and
side of the anterior capsule. In soft to medium squeeze them from between neighboring pieces.
density cataracts, the concentric lamellae of Medium to firm density cataracts are more
cataract tissue are not densely packed, so much like rocks. They have rigid form and are much
of the space inside the cataract is taken up by more demanding of the surgeon's skill. If we
Figure 2: Dense, Nuclear Brunescent

Cataract
In dense, nuclear brunescent

cataracts, as shown in Fig. 2, there is less
water content, the capsule is dehydrated
and there is a significant increase in the
density and opacity of the nucleus (C).
These nuclei are more like rocks, and are
the hardest to manage with phacoemulsi-
fication in the transitional stage or by
surgeons inexperienced in phaco. Diffi-
culties during surgery may arise that can
be characteristic in this type of cataract
such as difficulty in identifying the
capsulorhexis or with the hydrodissection.
7
rub them against the capsule, the capsule can BIBLIOGRAPHY

break. If we pull them up into the anterior
chamber, the capsulotomy may split. If they Assia, EI., Legler, UFC., Apple, DJ.: The capsular
touch the corneal endothelium, they abrade it. bag after short and long term fixation of intraocular
Understanding this surgical anatomy of lenses. Ophthalmology, 1995; 102:1151-7.
the lens and its clinical applications helps sig-
Boyd, BF.: Cataract/IOL Surgery. World Atlas
nificantly in recognizing that each type of cata-
Series of Ophthalmic Surgery, published by
ract acts differently and that our approach
HIGHLIGHTS, Vol. II, 1996; 5:5-13.
should vary depending on the individual pa-
tient (Fig. 2). Boyd, BF.: Cataract/IOL Surgery. World Atlas
Series of Ophthalmic Surgery, published by
INCIDENCE AND HIGHLIGHTS,Vol. II, 1996; 5:34-38.
PATHOGENESIS Boyd, BF.: New developments for small incision
cataract surgery. Highlights of Ophthalm. Jour-
It is widely known that cataracts consti- nal, Volume 27, Nº 4, 1999;45-46.
tute the major source of curable blindness world-
wide. Not only do they seriously affect large Gimbel, HV., Anderson Penno, EE: Cataracts:
segments of the population in developing or Pathogenesis and treatment. Canadian Journal of
less economically fortunate regions but also Clinical Medicine, September 1998.
the peri-urban areas of large and developed
cities which are equipped with highly trained Koch, PS.: Simplifying Phacoemulsification, 5th
ophthalmologists and the latest technology. ed., published by Slack; 1997; 7:85-86.
For psychological or social reasons difficult to
Lens and Cataract, Basic and Clinical Science
understand, many blind or almost blind per-
Course, Section 11. American Academy of Oph-
sons living in these peri-urban "belts" do not thalmology, 1998-99.
seek medical advice and treatment when easily
available. This is one of the mysteries of
people whose quality of life is significantly
limited by partial or complete opacification of
the crystalline lens. Figure 2 shows a
brunescent, advanced, hard cataract which be-
comes sometimes very difficult to treat by
phaco, even in skillful hands. Many patients
allow their cataracts to become this much ad-
vanced even if they live near medical facilities
that may provide proper care at a much more
advantageous time.
As pointed out by Howard Gimbel, M.D.,
there are a variety of causes and types of
cataracts. By definition, all cataracts share the
common feature of opacification of some por-
tion of the crystalline lens which, if within the
to cataract formation.
8
Chapter 2: I n d i c a t i o n s a n d P re o p e r a t i v e Ev a l u a t i o n
INDICATIONS AND PREOPERATIVE EVALUATION
INDICATIONS come increasingly difficult to perform surgery

if the lens becomes extremely dense or
To date there is no established medical brunescent.
treatment for the prevention or treatment of Waiting too long may require that the
cataract formation and thus the treatment of surgeon operate on dense nuclear cataracts,
cataracts remains surgical. Contrary to the which increases the risk of posterior capsule
commonly held belief that cataracts must reach tears, whether we perform planned extracapsu-
a certain degree of density or become "ripe" lar or a phacoemulsification. This complica-
prior to considering cataract surgery, today the tion may lead to other rather serious problems
crystalline lens can be removed at virtually any such as dislocated nucleus, retinal detachment,
stage. In fact, refractive lensectomy in which macular edema, bullous keratopathy and in-
the clear crystalline lens is removed may be flammation.
used to surgically eliminate or significantly
reduce the need for glasses in patients with The Role of Visual Acuity
very high myopia or hyperopia. In the latter
condition, this may be achieved by implanting There are very few strict criteria for rec-
several piggyback lenses within the capsular ommending cataract surgery. In the United
bag following clear lensectomy. States, however, many professional review
organizations have indicated that the reduction
Role of Quality of Life of Snellen distance acuity to 20/40 or worse as
a result of cataract is sufficient indication in
Cataract/IOL surgery improves quality and of itself for cataract surgery. This is
of life better than any other medical procedure generally the minimum standard for driving. In
known to mankind. Cataract surgery is indi- some of the advanced, developed countries,
cated when the patient's quality of life is being being unable to obtain a driver's license may
affected by visual impairment, when there is a seriously affect a person's life because he/she
diminution in vision if the patient is exposed to may be disqualified to drive to the market or
light or at night, and when the preoperative shop to purchase food and other materials es-
evaluation indicates that the potential for resto- sential to daily existence. However, in many
ration of sight is good. How much a patient's cases surgery may be indicated without reduc-
quality of life is impaired from a cataract is tion of visual acuity to the level of 20/40 if the
relative, varying with the patient's occupation patient has difficulty performing activities of
and age. The key factor is not to wait until a daily living. Because patients have varying
nuclear cataract becomes hard. With time, the occupational and recreational needs, some pa-
lens fiber density becomes a hard nuclear tients may need cataract surgery prior to having
brunescent cataract (Fig. 2) . With most mod- their vision reduced to 20/40 by standard tests.
ern phacoemulsification techniques it may be- In addition, near vision in some cases may be
11
compromised more than distance acuity par- increasingly aware that diminished contrast
ticularly in the case of central posterior subcap- sensitivity which interferes with sharp vision
sular cataracts. The trend toward early re- under different color backgrounds or target
moval of cataract offers the advantage of luminance, is an essential element of sight and
operating on a younger age group, many of a highly limiting factor in the presence of
whom are still productive members of society. cataract. This is perceived by the patient for
Their need for early return to their usual life- example when he or she is unable to read a
style is extremely important. The older popu- computer screen at the airport if the back-
lation, often living alone, also benefits from ground is light blue and the print is light yellow
early visual recovery. These high expectations even though visual acuity in the physician's
and needs require that the ophthalmic surgeon refracting lane was 20/30 or 20/25. The same
perform superior surgery to obtain excellent for disabling glare.
postoperative visual acuity and early visual These are two additional very important
rehabilitation. issues in determining when the cataract should
As emphasized by Gimbel, symptoms of be removed. For many years this judgment has
cataracts include complaints of a yellowing of been based on Snellen visual acuity. But a
vision, glare, halos, decreased night vision, and patient can score quite well on Snellen acuity
generally blurred vision in adults. Nuclear while suffering in real life. Posterior subcap-
sclerosis which is a typical form of age-related sular cataracts are notorious for interfering
cataracts may also induce a myopic shift and with reading, even when distance vision is
patients may give a history of having changed good, and may induce a great deal of glare.
their glasses several times within a short period Snellen acuity may be 20/20 or 20/25, but
of time. In children cataracts may present as against oncoming headlights while driving at
leukocoria and may result in strabismus and/or night, for instance, the glare may diminish the
amblyopia if not treated promptly. functional vision to 20/100 or even 20/200.
People with nuclear sclerosis, the most com-
Contrast Sensitivity and Glare mon form of cataract, tend to be bothered by
Disability decreased contrast sensitivity rather than glare.
Although glare disability and contrast
In evaluating a patient with cataract and sensitivity are distinctly different, the terms
in the process of deciding when that person often are erroneously interchanged. The test-
requires cataract/IOL surgery, it is fundamen- ing characteristics of each, however, may over-
tal to keep always in mind that standard Snellen lap, and a reduction in one function often leads
acuity measurements do not give any informa- to a diminution in the other, further adding to
tion with regard to symptoms of disabling the confusion of their differences. As clarified
glare. As a matter of fact, very good visual by Samuel Masket, M.D., glare disability is
acuity with the Snellen chart in the physician's a light-induced visual symptom. Contrast
examining room may lead the ophthalmologist sensitivity testing is a means of vision analysis,
to making the wrong decision and recommen- analogous to a markedly expanded form of
dations unless he or she takes other factors into Snellen acuity evaluation at varied amounts of
consideration. In later years, we have become target luminance.
12
Contrast Sensitivity A patient who has a reduction in contrast

Characteristics sensitivity might perceive the small, highly
contrasted targets on a Snellen test line but be
Like audiometry, which measures the incapable of identifying larger objects at re-
sensitivity of the hearing apparatus to stimuli at duced contrast. There are alterations in the
different audio frequencies, contrast sensitiv- visual system that can cause visual loss that are
ity analysis determines the ability of the visual not detected by the determination of Snellen
system to perceive objects of differing con- visual acuity but may be evaluated by testing of
trasts as well as sizes. contrast sensitivity function. This is unlike
Figure 3 B (below right): Contrast Sensitivity

Recording Chart
The contrast sensitivity recording chart pro-

vides four (4) rows of wave gratings. At the recom-
mended test distance of 8 ft (2.5 meters), these
gratings test the spatial frequencies of 3, 6, 12 and
18 cycles/degree. This chart provides a full con-
trast sensitivity curve. The functional acuity is de-
termined by the lowest level of contrast sensitivity
(gray band) that can be detected by the patient. The
functional acuity score is shown in a bracket next
to the contrast sensitivity score.
Figure 3 A (above left): Importance of Testing for

Contrast Sensitivity
The Contrast Sensitivity Test is used clinically

to evaluate cataracts, glaucoma, diabetic eye disease,
contact lens performance and refractive surgery. In the
presence of cataract the clouding of the lens causes
light scatter on the retina. This reduces image contrast
and causes dimness of vision. One of the more difficult
problems in evaluating how a cataract is affecting the
patient's visual function is that many cataract patients
preserve good visual acuity as tested in the refracting
lane (Snellen chart) but complain about their visual
disability. The true “real-world” vision of cataract pa-
tients can be established as a functional acuity score
using contrast sensitivity and glare testing.
13
disabling glare, which determines the effect of may have severely lower visual function dur-
extraneous light on visual performance. Con- ing daylight driving although they do well with
trast sensitivity evaluation is a measurement the Snellen acuity chart. In essence, the Snellen
of the resolving power of the eye at varied chart evaluates quantity of vision. Contrast
contrasts between image and background sensitivity tests evaluate quantity and quality
(Fig. 3 A-B). of vision. The equipment to perform the test is
A number of useful contrast and glare accessible and inexpensive. It is basically a
sensitivity testing methods have been devised chart about 0.3 meters in size and it costs about
(Fig. 3 A-B). They are accessible and inexpen- US$200.00
sive. Unfortunately, standardization of these
techniques has not yet been achieved. It is
essential that the clinician be fully aware of
Preoperative Considerations
these two factors that may impinge on the
patient's real vision or quality of vision, in In addition to determining visual acuity
addition to the Snellen acuity test. by the Snellen chart, contrast sensitivity and
glare disability testing as outllined, all patients
with cataracts should have a thorough history
Relation of Glare to Type of
taken including any systemic or ocular medica-
Cataract tions being used and any systemic disease for
which they receive treatment. A family history
Neumann et al. have determined that is also included. The ophthalmologic exami-
nuclear cataract is more likely to be associ- nation should include intraocular pressure
ated with nighttime glare disability, while cor- (IOP) measurements, keratometry, pupil exam,
tical cataract formation is associated with routine motility testing, and dilated slit-lamp
daylight glare, and posterior subcapsular cata- and funduscopic examinations including indi-
racts may induce glare disability associated rect ophthalmoscopy to examine the central
with bright, direct sunlight or bright central and peripheral retina. Ancillary testing such as
light sources. Cortical cataracts seem more visual fields, topography, specular microscopy
likely to cause glare symptoms than nuclear for endothelial cell counts, and fluorescein
cataracts. Masket points out that frequently, angiography should be considered in selected
patients with dense central posterior subcapsu- cases. There are many causes for decreased
lar cataracts frequently retain excellent dis- vision and ,especially in older patients, these
tance Snellen acuity as measured in the refract- causes may exist concurrently. Age-related
ing lane, yet they perform poorly on any of the macular degeneration is possibly the most im-
available glare testing devices. Such patients portant and difficult to detect because of the
existing opacity of the cataract.
14
Evaluation of Macular Function Any well trained ophthalmologist can

diagnose major lesions of the optic nerve or
The main preoperative tests to determine retina preoperatively. The major problem is
with the subtle lesions that nevertheless limit
central visual acuity are: 1) the Potential
the patient's capacity to read or distinguish
Visual Acuity Meter (PAM) and 2) the Super
clear images at distance postoperatively.
Pinhole. They permit evaluation of the macu-
One of the most important tests for
lar function in patients in whom examination
evaluating macular function in the presence of
of the macula is difficult due to media opaci-
a lens opacity dense enough to make our clini-
ties. They are more useful when they are
cal examination of the macula unreliable is the
integrated into the total evaluation of the pa-
Guyton-Minkowski Potential Visual Acuity
tient.
Meter (PAM).
One of the major problems that all of us
The Super Pinhole developed by David
confront as clinical ophthalmologists is that of
McIntyre, M.D., is another highly practical
patients with cataracts who correct to 20/100 or
and useful method to evaluate macular func-
20/200 and on whom we are planning to
tion. The Laser Interference-Fringe Method
operate but cannot see the fundus, particularly
has also been previoulsy used but it is less
the macula. This is aggravated when the pa-
practical. Most clinical ophthalmologists pre-
tient has a few old small corneal opacities. The
ever-present question is: what is the visual fer the PAM test or the Super Pinhole.
prognosis if we operate, either by a cataract
extraction or combined with a corneal trans- The PAM
plant? What can we anticipate for the patient or
his/her family about future, postoperative vi- The Potential Acuity Meter (PAM) is an
sion even if we do not have any significant instrument which attaches to a slit lamp. It
operative or postoperative complications? Ul- serves as a virtual pinhole by projecting a
trasonography and clinical tests will give us regular Snellen visual acuity chart through a
only a partial and limited answer. very tiny aerial pinhole aperture about one-
Since we cannot see the state of the tenth of a millimeter (0.1 mm) in diameter. The
macula or papilla, we are limited as to the light carrying the image of the visual acuity
prognosis. Sometimes we have the pleasant chart narrows to a fine 0.1 mm beam and is
surprise of obtaining more vision postopera- directed through clearer areas in cataracts (or
tively than we predicted; in other cases, we face corneal disease), allowing the patient to read
the unpleasant reality of finding macular de- the visual acuity chart as if the cataract or
generation or other lesions in the macula or corneal disease were not there (Figs. 4 and 5A
optic nerve that result in poor central vision in and B). The PAM is taken from its stand and
spite of a beautifully performed operation. placed directly onto the slit lamp in the same
15
Figure 4 : Concept of the Guyton-Minkowski Potential Acuity Meter With Cataractous Lens (PAM)
The beam (arrow) of the projected Snellen chart is shown passing through a cataract (C) and forming the image
of the chart on the retina (R). The beam of light can only strike the retina when the beam is able to pass through the
lens, between opacities. With the chart successfully projected onto the retina, the patient can respond and we can
determine the potential visual acuity as if the cataract were not there. The PAM serves as a superpinhole by projecting
the regular Snellen chart along a tiny beam 0.1 mm in diameter.
manner as the detachable type of Goldmann can avoid the light scattering produced by the
tonometer. The examination takes from two to opacities. It is this light scattering which washes
five minutes per eye, depending on the density out the retinal image and decreases vision be-
of the cataract. hind cataracts. By projecting the image of the
As pointed out by Guyton, for the PAM visual acuity chart through one tiny area, we
to work adequately, there must be some small avoid that scattering effect, and the patient can
hole in the cataract for the light beam to pass see the chart (Figs. 6 A-B and 7 A-B).
through. You may find such a hole even in How is the instrument operated by the
cataracts which have media clouding of up to clinician or an assistant? The device is mounted
20/200 and better. When you find it, then you on a slit lamp so that the operator can see
16
Figure 5 A (above left): Concept of the

Potential Acuity Meter (PAM) in Cases
of Corneal Opacities and Cataract
In Fig. 5-A the tiny beam of light

(arrow) of the projected Snellen chart is
shown striking a corneal opacity and failing
to penetrate the cornea.
Figure 5 B (below right): Concept of the

Potential Acuity Meter (PAM) in Cases
of Corneal Opacities and Cataract
In Fig.5-B, by moving the beam to

a point between the corneal opacities, the
projected Snellen chart can pass on through
the cornea and onto the retina (arrow) so
that the patient can see it and we can
determine the visual acuity. The test as
shown in Figs. 4-A and 4-B is particularly
important if we are considering a com-
bined cataract extraction and penetrating
keratoplasty.
17
exactly where the light beam is passing. The It is sometimes difficult to find a small
light beam is directed to various parts of the hole in a cataract with density greater then
pupil (Fig. 4, 6-A, 6-B, 7-A, 7-B). It can be 20/200, although holes have been found in
focused in between lens opacities. It is easy to counting-fingers cataracts. If you obtain good
see when the beam is going in because it vision behind any cataract, you have the infor-
practically disappears (Fig. 6-B). When it hits mation you need. As to the visual prognosis
an opacity, you can see the opacity light up behind very dense cataracts, if you cannot
(Fig. 6-7). When you move the beam with the obtain a good reading, you still do not know
slit lamp control to lucent, non-opaque areas, quite where you are.
you see the beam pierce through (Figs. 6-B and The instrument is best operated in a dark-
7-B). It is valuable to observe this because if ened room because it is easier to see the light
you know you are getting the beam through beam. The best results are obtained with a
and the patient still reads poorly, you can be dilated pupil because you have a better chance
fairly confident that there will be a poor of finding an appropriate hole in the cataract.
result after surgery. If you are not sure Ninety percent of patients whose best correct-
whether the beam is penetrating and the patient able vision is 20/200 and better preoperatively,
reads poorly, results of surgery will be uncer- achieve the predicted vision or within two lines
tain. So, the slit lamp monitoring of the light
beam is important.
Figure 6-A: How the PAM

Works - Slit Lamp View
In Fig. 6-A the ophthal-

mologist directs the small beam of
light through different parts of the
dilated pupil in a patient with lens
opacities. One can see here that
the beam of light (arrow) is hitting
a lens opacity. This light is strongly
scattered by the opacity, lighting
up the opacity, leaving little or no
light remaining to penetrate on
through to the retina.
18
Figure 6-B: How the PAM Works

- Slit Lamp View
In Fig. 6-B the beam (ar-

row) is successfully penetrating the
lens at a point where no lens opaci-
ties are present, and the beam dis-
appears into the vitreous cavity (V).
As the light beam broadens out,
passing into the vitreous, it is no
longer visible to the doctor. The
examiner thus can be certain that
the light beam of the projected
Snellen chart is getting in to the
retina. With the beam successfully
projecting the Snellen chart image
on the retina, the patient can re-
spond accordingly so that the ex-
aminer can determine the potential
visual acuity irrespective of the len-
ticular opacities.
than the predicted vision after surgery. When potential vision than the patient can achieve
the preoperative visual acuity is worse than 20/ with best refractive correction postoperatively.
200, only about 60% achieve vision within No single test of visual function, how-
three lines of the vision predicted by the PAM. ever, is sufficient to mandate surgery. Instead,
The vision obtained after surgery is it is the visual needs of the patient in combina-
generally equal to, or better than the vision tion with careful estimation of the potential for
predicted with the Potential Acuity Meter. False the return of visual function after surgery that
positives occur in 10-15% of cases. When the finally serves as the basis for the ophthalmolo-
test is done in cases of cystoid macular edema, gist to decide whether surgery is indicated and
the instrument occasionally indicates better useful.
19
Figure 7 A: How the PAM Works -

Cross Section View
Figures 7 A and 7 B demon-

strate in cross-section the views shown
in Figs. 6 A-B. In (A), the light beam
(arrow) can be seen striking a lens opac-
ity (C) and thus does not penetrate the
lens. The patient in this case cannot see
the projected Snellen chart.
Figure 7 B: How the PAM Works -

Cross Section View
In Fig. 7-B the light beam is

directed to another part of the pupil
where it is focused between lens
opacities so that the projected Snellen
chart passes to the posterior pole.
Hence the patient will see the chart
and respond so that we can determine
the effective potential visual acuity.
20
PREOPERATIVE GUIDELINES FOR CATARACT SURGERY IN

COMPLEX CASES
HOW TO PROCEED IN PATIENTS Diabetic patients are very predisposed to

WITH RETINAL DISEASE developing cataracts. This is especially true of
younger diabetic patients, who are also highly
predisposed to developing diabetic retinopathy
The Importance of Pre-Op Fundus (diabetes Type I). In a series of diabetic retin-
Exam opathy and maculopathy patients 15 years
after laser treatment, only 22% of the eyes
Thorough peripheral retinal examination maintained clear lenses (Figs. 10 and 11).
should be done before cataract extraction. We Cataracts will often form following vitrectomy
are all proud to be first class clinical ophthal- surgery for diabetic retinopathy.
mologists and not think of cataract surgery Rarely retinopathy can cause cataracts.
only as a mechanical, technical procedure. As An example would be prolonged vitreous
patients live longer, they are apt to have more cavity hemorrhage that results in a partial
preoperative diseases sometimes difficult to opacification of the lens. (Very high risk pro-
diagnose unless we are on the alert for them. liferative diabetic retinopathy - Fig. 12)
Because the patient with an even moderate
degree of cataract has reduced clarity of vision, Evaluating Diabetics Prior to
it is easily possible that recent abnormalities
Cataract Surgery
may not have been observed or reported by the
patient. This is particularly the case with
retinal diseases. Clinically significant macular edema
(CSME) and less obvious macular changes in
CATARACT SURGERY IN non-proliferative retinopathy may be the cause
of decreased vision in addition to the cataract
DIABETIC PATIENTS (Fig. 13).
It is important to listen to the patient's
Because of the increasing importance history when evaluating the cause of visual
of diabetic retinopathy, both in incidence and deterioration. This can be helpful in deciding
severity, we provide special emphasis to this how much of the visual loss may be due to
disease in considering cataract surgery in com- cataract as opposed to visual damage caused by
plex cases. Cataract and retinovascular com- retinovascular conditions.
plications often co-exist in diabetic patients. A good fundus examination through a
The combination can present problems in de- dilated pupil is essential. In diabetic patients as
termining the cause of decreased vision. Cata- in all patients, cataract should be removed
ract surgery can also result in rapid pro- when a patient's visual function does not meet
gression of diabetic retinopathy that may his/her visual needs and the visual loss is con-
need treatment with photocoagulation sistent with the cataract. It is very rare that
(Figs. 8 and 9)..
21
Figure 8 : Scatter Photocoagulation to Ischemic Retinal Area Invaded by Vessels in Diabetic Retinopathy
Cataract extraction does not cause retinopathy to develop when it was not present before cataract removal, but it
definitely may worsen pre-existent retinopathy, particularly if there is a proliferative retinopathy already present. This figure
shows an ischemic area of the retina being treated with scatter photocoagulation. Please observe the large nets of vessels. (Photo
courtesy of Prof. Rosario Brancato, M.D., from Milan, Italy, reproduced from "Practical Guide to Laser
Photocoagulation", Italian Edition by Brancato, Coscas and Lumbroso, published by SIFI).
Figure 9: Significant Regression of Retinal Neovascularization Following Scatter Photocoagulation
You may observe that the large nets of vessels shown in Fig. 8 have regressed following treatment with scatter
photocoagulation of the proliferative neovascularization existing before cataract surgery. You may observe the laser burns. If
the fundus is adequately visible in spite of the cataract, it is preferable to perform photocoagulation before doing cataract surgery.
(Photo courtesy of Prof. Rosario Brancato, M.D., from Milan, Italy, reproduced from "Practical Guide to Laser Photocoagu-
lation", Italian Edition by Brancato, Coscas and Lumbroso, published by SIFI).
22
Figure 10 (above right): Focal Photo-

coagulation for Diabetic Maculopathy
Previous to Cataract Surgery
The laser applications are di-

rected to the microvascular alterations
responsible for chronic, leaking fluid
which gives rise to macular edema. (Photo
courtesy of Prof. Rosario Brancato,
M.D., from Milan, Italy, reproduced from
"Monografie della Societa Oftalmologica
Italiana", Italian Edition by Brancato and
Bandello, published by ESAM).
Figure 11 (below left): Grid Treatment with Photocoagulation for Diabetic Maculopathy
Ophthalmoscopic appearance after grid pattern treatment of the macula in which

diffuse rather than focal leakage is identified on the fluorescein angiogram. Only 22% of
these eyes maintain clear lenses 15 years after laser treatment, particularly younger diabetics.
(Photo courtesy of Prof. Rosario Brancato, M.D., from Milan, Italy, reproduced from
"Monografie della Societa Oftalmologica Italiana", Italian Edition by Brancato and Bandello,
published by ESAM).
23
cataracts need to be removed so that treatment when the lens capsule and zonular integrity
of the diabetic retinopathy can be performed. are sacrificed by the cataract surgery such
Occasionally, cataracts need to be removed as with rupture of the posterior capsule.
when performing vitrectomy. Retained lens material may produce increased
It is important that we consider various inflammation, which may further accelerate
diabetic factors in planning cataract surgery this process. While it is important to maintain
because the retinopathy can influence the an intact posterior lens capsule, it is equally
result. We may see increased bleeding and important to have an easily dilatable pupil and
fibrin formation, especially in the younger pa- a clear capsule to allow a good fundus view
tients with active retinopathy and compromised through which laser treatment can be performed.
retinal perfusion.
Significant Increase in Complications
Importance of Maintaining the Following Cataract Surgery
Integrity of the Lens Capsule
The progression of retinopathy follow-
Cataract surgery may not only result in ing cataract surgery may take several forms.
rapid progression of diabetic retinopathy, but We may see a patient with non-proliferative
it may also complicate its management and retinopathy rapidly develop macular edema
treatment. Rapid deterioration often occurs (CSME) (Figs. 10, 11 and 13). Macular edema
Figure 12: Severe, Advanced Proliferative

Diabetic Retinopathy, Very High-Risk - A
Prolongued Vitreous Cavity Hemorrhage
May Result in Partial Opacification of Lens
Artistic rendition of severe, advanced,

proliferative, very high risk diabetic retinopa-
thy. (A) Shows a fundus view of a severe case
of proliferative diabetic retinopathy. There are
preretinal hemorrhages (H) in several loca-
tions. Note the extensive active fibrovascular
proliferation causing a traction detachment (D)
nasally due to traction from the fibrovascular
tissue (A) on the retina. There is also active
fibrovascular proliferation along the retinal
vessel arcade (V) with detachment of the macu-
lar area. Note the active fibrovascular stalk (S)
which obscures the optic nerve. (B) Shows the
same eye with the surgeon's view as seen through
the pupil, and accompanying cross section view
of the tissue pathology. Note hemorrhage (H),
traction (arrows) of the posterior hyaloid (C),
traction detachment of the retina (D), and ac-
tive fibrovascular stalk (S) on the optic nerve.
24
Figure 13: Diabetic Macular Edema
(A) Shows the fundus view of diabetic

macular edema. Notice thickening of the macu-
lar area (F). From the oblique cross section (B),
an area of the retina and choroid is magnified in
(C) to show its relationship to the clinical oph-
thalmoscopic fundus view above. In (C), there is
pooling of fluid (D) within the inner layers of the
retina. This fluid is trapped between the gan-
glion cell layer (G) and the outer plexiform layer
(P). Notice there is almost complete loss of the
intermediary neurons (N) in this area.
may progress from being diffuse to being cys- significant macular edema (Figs. 13 and 14)
tic. Rafael Cortez, M.D., has observed that should receive focal or grid laser treatment
diabetic patients with proliferative retinopathy (Figs. 10, 11 and 14) to seal the leakage which
(Fig. 12), or non-proliferative retinopathy is detectable through fluorescein angiography.
(Fig. 13) or even without retinopathy, have a Eyes with severe, non-proliferative (pre-pro-
higher risk of developing a vitreous hemor- liferative) diabetic retinopathy (Fig. 15) and
rhage, rubeosis of the iris and neovascular proliferative retinopathy (Fig. 16) should
glaucoma postoperatively. This risk is particu- receive panretinal laser photocoagulation
larly high in those patients with proliferative (Fig. 17) before cataract surgery. This treat-
retinopathy (Fig. 12). ment will reduce additional proliferation and
deterioration.
Appropriate Laser Treatment Even with a cataract, laser treatment can
usually be performed with good pupillary dila-
Most diabetic retinopathy complications tation. Krypton red wavelengths are often
can be prevented by appropriate laser treat- successful in penetrating somewhat dense
ment before cataract surgery. Eyes with non- nuclear sclerotic lenses (Fig. 14). Retrobulbar
proliferative retinopathy that have clinically anesthesia may be necessary.
25
Figure 14 (above right): Prevention of Dia-

betic Retinopathy Complications by Laser
Treatment before Cataract Surgery
Most diabetic retinopathy complications

can be prevented by appropriate laser treatment
before cataract surgery. Eyes with non-prolif-
erative retinopathy that have retinal thickening
from edema near the macula should receive
focal treatment of the macular aneurysms to
erase fluorescein leakage. As shown in this
figure, even with a cataract, krypton red wave-
lengths are often successful in penetrating fairly
dense nuclear sclerotic lenses. Laser treatment
must be performed with good pupillary dilata-
tion.
Figure 15 (center): Severe Non-Proliferative Dia-

betic Retinopathy (Pre-Proliferative).
This photo shows a characteristic severe, non-

proliferative diabetic retinopathy, previously known
as pre-proliferative. Please observe prominent soft
exudates, dot blot hemorrhages, venous beading, and
microaneurysms. (Photo courtesy of Lawrence A.
Yannuzzi, M.D., selected from his extensive retinal
images collection with the collaboration of Kong-
Chan Tang, M.D.)
Figure 16 (below right): Proliferative Diabetic

Retinopathy
This photo shows the next stage in severity

of the disease. Please observe a large subretinal
hemorrhage surrounding soft cotton exudates at the
lower temporal arcade. There are also multiple
intraretinal hemorrhages with neovascularization
elsewhere (NVE), which is defined as a proliferative
retinopathy anywhere in the retina which is greater
than 1 disc diameter from the optic disc margin. The
macula is not shown. (Photo courtesy of Samuel
Boyd, M.D., Clinica Boyd, Panama).
26
Figure 17 (above right): Panretinal Laser Photocoagula-

tion Before Cataract Surgery
In treating diabetic retinopathy, panretinal photoco-

agulation covers all of the periphery and mid-periphery of the
retina from the ora serrata to the vascular arcades, sparing only
the posterior pole. (Photo courtesy of Prof. Rosario Brancato,
M.D., from Milan, Italy, reproduced from "Practical Guide to
Laser Photocoagulation", Italian Edition by Brancato, Coscas
and Lumbroso, published by SIFI.
Main Options in Management of may need to combine the cataract removal with
Co-existing Diabetic Retinopathy and a vitrectomy (Fig. 18).
Cataract Intraocular lenses do not present a prob-
lem when a patient is going to have a vitrec-
The first and most successful is to defer tomy. The visual results of pseudophakic eyes
the cataract surgery until laser treatment can be with diabetic retinopathy complications that
performed. If there is extensive vitreous hem- have vitrectomy surgery are essentially identi-
orrhage or traction retinal detachment, you cal to those of phakic eyes.
Figure 18: Need to Combine Cataract Removal

with Vitrectomy (Vitreous Hemorrhage and
Traction Retinal Detachment)
The first indication for vitrectomy in the

case of proliferative diabetic retinopathy is the
presence of vitreous hemorrhage (H). This is
conditional, however, depending on several factors
such as status of retinopathy, visual loss, adequacy
of previous photocoagulation, frequency of
hemorrhage, vision in the fellow eye, advancing iris
neovascularization, response to vitreous surgery in
fellow eye, and systemic factors. In general, surgery
for retinopathy is more likely to be indicated with
hemorrhage in the presence of active fibrovascular
proliferation or traction retinal detachment. This is
the second indication for vitrectomy, namely a
traction retinal detachment, but only when the macula
(M) is detached as shown. Note contraction (arrows)
of posterior hyaloid (P) causing a non-rhematogenous
retinal detachment (D) due to traction from the
fibrovascular tissue (A) on the retina.
27
CATARACT SURGERY AND RETINAL BREAKS AND RETINAL DE-

AGE-RELATED MACULAR GENERATIONS PRIOR TO CATARACT
SURGERY
DEGENERATION
Felix Sabates, M.D., has best outlined The preoperative treatment of these reti-
the precautions we must take when considering nal lesions has traditionally come into consid-
extracapsular extraction or phacoemulsifica- eration as a possible means of preventing reti-
tion in eyes with already present age-related nal detachments after cataract extraction, espe-
macular degeneration already present. These cially in myopes. I refer only to those periph-
principles are: 1) It is important to study the eral retinal degenerations which can be clini-
macular area in detail prior to cataract surgery cally defined and identified, and which have
to detect the presence of age-related macular statistically been linked with retinal detach-
degeneration. 2) If cataract surgery is per- ment following posterior vitreous detachments.
formed in the presence of age-related macular This, therefore, excludes senile retinoschisis,
degeneration, special care should be taken to which has a higher prevalence in the general
reduce the possibility of inflammation even population than among patients with a retinal
if it would require immediate use of anti- detachment. What needs to be clarified is the
inflammatory drugs. 3) Cystoid macular edema effect of cataract surgery on the risk retinal
should be aggressively treated, with careful breaks and degenerations present and what
follow-up emphasized. 4) Cataract surgery recommendations should be given in regard to
should not be performed on the patient with their management prior to cataract surgery.
active "wet" macular degeneration (Fig. 19) This requires therapeutic proof that prophylac-
until it has been brought to a dry stage (Fig. 20). tic treatment significantly lowers this risk be-
If there is bleeding from a neovascular mem- low that which the natural course of untreated
brane, cataract surgery should be postponed lesions would present. There is an increasing
until at least six (6) months after the blood has tendency to support the concept that retinal
completely reabsorbed and there has been detachments generally are associated with re-
no recurrence of the bleeding has been present. cent, not old, retinal breaks. At the present time
5) In patients with macular scars (Fig. 20) and the picture is not clear. We lack solid reports
opaque cataracts, surgical removal of the opaci- supporting the prophylactic treatment of pre-
fied lens with intraocular lens implantation existing retinal breaks prior to cataract surgery.
may be of benefit in recovering some degree of What happens to an eye with lattice de-
pericentral or peripheral vision. The smaller generation when cataract extraction is per-
the macular scar, the better the prognosis. No formed? Again, we face a lack of valid reports
cataract surgery should be performed unless in the literature to support preventive treatment
the cataract is opaque enough so that when it is prior to cataract surgery. About 90% of eyes
removed, the patient will probably perceive the with lattice degeneration do not detach after
benefit of the operation. small incision cataract extraction even when
28
Figure 19 (above right): Anatomy and Pathology of

Exudative, ("Wet") Macular Degeneration with
Extrafoveal Neovascularization
Cataract surgery should not be performed in

these cases. Wait until it has been brought to dry stage as
shown in Fig. 20. Fundus view (A) shows an example of
exudative "wet" macular degeneration with an extrafoveal
neovascular membrane (N) and limited subretinal
hemorrhage (H) just at the margin of the paramacular
retinal vessels surrounding the fovea (F). From the
oblique cross section (B), an area is magnified in (C) to
show the direct relationship between clinical
ophthalmoscopic fundus view above and its corresponding
cellular pathology. Pathology reveals that the retina is
slightly elevated over a neovascular membrane (N). Note
vessels emanating from the choriocapillaris (J), into the
neovascular membrane (N) and into the sub-RPE and
subretinal spaces, passing through small breaks (T) in the
retinal pigment epithelial cell layer (E). There is some
atrophy of photoreceptors in this area (P). Subretinal
blood (H) is seen to either side of the neovascular
membrane. Large choroidal vessels (K).
Figure 20 (below left)): Anatomy and Pathology of

Non-Exudative, Geographic ("Dry") Macular
Degeneration
In these patients, surgical removal of the opacified
lens with IOL implantation may be of benefit in recovering
some degree of peripheral vision. Fundus view (A) shows
an example of non-exudative, geographic atrophic "dry"
macular degeneration where atrophy of the retinal pigment
epithelium predominates. The smaller the macular scar,
the better the prognosis for cataract surgery. Notice the
clinical signs of drusen (D) which can appear as discrete
subretinal bodies, confluent masses or hard glinting lesions,
usually yellowish in color. Darker intraretinal pigment (I)
may or may not be present. Retinal pigment epithelium
atrophy (E) is identified by prominence of the underlying
choroidal vessels. From the oblique cross section (B), an
area is magnified in (C) to show the direct relationship
between the clinical ophthalmoscopic fundus view above
and its corresponding cellular pathology. Pathology
includes subretinal drusen (D) and atrophy of the RPE (E).
Compare the disorganized RPE cell layer at (E) on the
right to the more normal configuration at (N) on the left.
Most importantly, though not clinically visible, there is
definite loss of photoreceptors (P) in the area of
degeneration (compare with normal photoreceptor layer
on the left). Other anatomy: inner limiting membrane (L),
choriocapillaris (J) and large choroidal vessels (K).
29
YAG laser capsulotomy is later performed. may preclude the use of laser. The type of tear
Those that do develop a retinal detachment present and other factors including the location
frequently do not detach from retinal breaks of the tear and the existence of high myopia
adjacent to or within the lattice lesions, but would influence the ophthalmologist's judg-
from unrelated areas which previously looked ment in deciding when to treat. Fig. 21 shows
clinically normal. This has now been observed the typical retinal tear that he treats, sealed
by numerous investigators. with cryotherapy.
Sabates thinks that each case must be Since seven to eight percent of the popu-
individualized. If a patient has a history of lation has lattice degeneration, it is obvious that
retinal detachment in one eye and lattice not all patients with lattice degeneration should
degeneration with retinal holes in the other eye, be treated. Regardless of whether the patient is
he performs cryosurgery or laser surgery and treated prior to cataract surgery, those patients
closes those holes in the second eye. Usually should be followed closely with careful exami-
cryosurgery is required because the cataract nation of the peripheral retina postoperatively
following cataract removal.
Figure 21: Creating the Chorioretinal Ad-

hesion of Retinal Tear with Cryotherapy
Before Performing Cataract Surgery
This figure presents the treatment with

cryotherapy of a retinal tear that needs to be
sealed prior to cataract surgery. The freezing
and defrosting is observed with the indirect
ophthalmoscope. (A conceptual slit beam has
been added to this illustration to enhance the
3-dimensional nature of the view).
30
CATARACT SURGERY IN PATIENTS

WITH UVEITIS
Rubens Belfort Jr.,M.D., in Sao Paulo,

Brazil and Martinez Castro in Mexico have
conducted extensive research on these patients.
Cataracts develop frequently in patients with
uveitis, either as a result of inflammation, the
treatment of inflammation or both. There has
been much controversy as to what to do, how
to do it and when to operate in patients with
cataract and uveitis, and whether intraocular
lenses should be implanted in these patients.
Professor Rubens Belfort Jr. consid-
ers that uveitis is one of the last categories
for which surgeons have advised «don’t do it»
when cataract surgery is considered. Cataract
surgery has been regarded as contraindicated
because of the initial bad results with in- Figure 22: Uveitic Cataract
traocular lenses (IOLs) in patients with uvei-
tis. Until about 10 years ago, most surgeons Cataracts caused by an inflammatory uveitic process
generally occur with pigment deposits (P) on the anterior cap-
avoided cataract surgery with or without IOL sule of the lens (C) related to anterior synechiae that can im-
implantation in these patients. mobilize the pupillary sphincter. The intensive use of topical
There was concern about superim- steroids for the management of the uveitis can hasten the for-
mation of such cataracts. Cataracts are the major cause of
posing IOL implantation, with the inflamma- loss of vision in patients with chronic uveitis. Current tech-
tion which used to accompany it in many niques for small incision surgery, new types of IOL's and ad-
cases, on a seriously compromised and al- vances in management of uveitis enable their removal where
previously this was contraindicated.
ready inflamed eye. This concept has now
changed. The development of current tech-
niques for small incision cataract surgery,
new types of IOLs, and advances in the
management of patients with uveitis have
changed the prognosis. The change is fortu-
nate because cataracts are the major cause of
loss of vision in patients with chronic uveitis
(Fig. 22). Moreover, cataracts are potentially
dangerous for patients with uveitis because
they interfere with visualization of the fun-
dus, denying the ophthalmologist the op-
portunity to identify macular lesions and
to treat them adequately. When these pa-
31
tients finally undergo long-postponed sur- instance, patients with ocular sarcoid have a
gery, usually with good anatomic success, much worse postoperative course than other
central vision may not be recovered because patients. Therefore, a patient with sarcoidosis
of irreversible macular damage that had and uveitis, even in the absence of important
developed from chronic cystoid macular uveitis, must be approached more carefully
edema. Therefore it is critical for both the than patients with other types of uveitis.
surgeon and the patient with uveitis to realize Other types of uveitis that can be effectively
there is another reason for cataract surgery in managed are Fuchs’ heterochromic cyclitis,
addition to improving vision as much as intermediate uveitis, and posterior uveitis as
possible. Removal of the cataract enables the well as most of the anterior essential uveities.
the ophthalmologist to examine and treat the Behcet’s disease and other vascular inflam-
macula in order to forestall damage. mations, which in the past were considered to
have a bad prognosis, have shown much
Method of Choice better results with current techniques.
In theory, removal of the lens as a Preoperative Management

whole (intracapsular) could lead to less
inflammation. In fact, careful extracapsular In general, the less inflamed the eye at
surgery with adequate cleaning of the lens the time of surgery, the better the prognosis.
material during surgery usually provides a Ideally, every patient should be operated only
better outcome. Most surgeons now prefer after being inflammation-free for at least 3
phacoemulsification to a classic extracapsu- months, although this is not possible in many
lar extraction of the cataract even in patients cases. Uveitis is chronic, no matter what dose
with uveitis. Belfort believes phacoemulsifi- of steroids is used, and many patients must be
cation leads to faster results and less operated even in the presence of some active
inflammation, and he advocates phaco- uveitis. The goal is to have the eye as little
emulsification with or without an IOL. inflamed as possible. Preoperative steroids, as
Intracapsular technique is no longer used eyedrops or even systemically, as well as
except in some rare cases of lens-induced immunosuppressive drugs have to be used in
uveitis, in which inflammation is caused by more severe cases. In patients who do not
the leakage of protein material from the lens. respond to steroids alone, Belfort uses sys-
temic oral cyclosporin and oral prednisone
Diagnosing the Type of Uveitis in the therapy. In 20% of patients the use of an
IOL is not advisable. This includes patients
Pre-Operative Phase
with granulomatous uveitis such as sarcoid,
Vogt-Koyanagi-Harada syndrome, and sym-
Belfort emphasizes that in the preop-
pathetic ophthalmia. Belfort also advises
erative phase, it is very important for the
against using IOLs in patients with juvenile
surgeon to determine the exact type of uveitis
rheumatoid arthritis, who tend to have a
the patient has in order to better predict the
chronic disease and may develop long-term
surgical outcome and minimize reaction. For
complications.
32
The Intraocular Lens traction has been done first, followed later by a
surgical correction of strabismus. As a matter
Currently, IOLs can be used in at least of fact, we may even hesitate to remove a
80% of patients with both uveitis and cata- cataract in a patient who has had a deviated eye
ract. Selecting the right type of IOL is very for a long period for two reasons: First, cataract
important. Although PMMA lenses are well removal may result in postoperative diplopia,
tolerated by the eye with uveitis, they may and second, it is difficult to predict whether
lead to more posterior capsule opacification amblyopia may be present in the deviated eye,
than other lenses. Belfort recommends not leaving us with a questionable prognosis.
using silicone in cases of uveitis because Successful combined cataract and stra-
silicone lenses by themselves can cause bismus surgery is highly feasible. The ideal
uveitis and may aggravate previous intraocu- patient for a combined approach must fill cer-
lar inflammation, especially in heavily pig- tain prerequisites: one, he or she must have a
mented people. Belfort therefore prefers to congenital strabismus rectifiable by surgery on
use acrylic lenses in these patients. We do a single muscle in each eye. Second, the patient
not yet have clinical trials or studies that must have an alternating deviation and equal
establish conclusively the superiority of one fusion potential in each eye, determined either
lens material over another. Results appear not by knowing the patient's vision before the onset
to be better with heparin-coated IOLs than of the cataracts or by the results of the potential
with PMMA lenses in patients with uveitis. acuity meter (PAM) that should be about equal
Considering that heparin-coated lenses are in both eyes (see figures 3 through 7). An equal
also more expensive, Belfort does not advo- potential acuity meter measurement in both
cate using them in uveitis. eyes would seem to exclude amblyopia, thereby
improving the chances for an optimal visual
CATARACT SURGERY IN ADULT outcome.
STRABISMUS PATIENTS During combined cataract and strabis-
mus surgery, if the patient continues to blink or
squeeze the eyelids following the combined
Preoperative Judgment topical and intracameral anesthesia, you can
obtain anesthetic control this a sub-Tenon's
The treatment of co-existing cataract and
injection of lidocaine as illustrated in Figs. 33
strabismus traditionally has been managed with
and 34. The effect is almost instantaneous, and
separate operations. Usually the cataract ex-
surgery can continue without delay.
33
BIBLIOGRAPHY
Boyd, BF.: Cataract Surgery in Diabetic Patients.

World Atlas Series of Ophthalmic Surgery, pub-
lished by HIGHLIGHTS,Vol. IV, 1999; 9:153-54.
Boyd, BF.: Undergoing cataract surgery with a

master surgeon: A personal experience. Highlights
of Ophthalm. Journal, Vol. 27, Nº 1, 1999;2-3.
Charlton, Judie: Cataract surgery and lens implan-

tation. Editorial Overview, Current Opinion in
Ophthalmology, 2000, 11:1-2.
Fine, IH.: Cataract surgical problem: Consultation

section. J Cataract Refractive Surg, 1997; 23:704.
Gimbel, HV., Anderson Penno, EE: Cataracts:

Pathogenesis and treatment. Canadian Journal of
Clinical Medicine, September 1998.
Gimbel HV., Basti S., Ferensowicz MA., DeBroff

BM: Results of bilateral cataract extraction with
posterior chamber intraocular lens implantation in
children. Ophthalmology, 1997; 104:1737-1743.
John K., Fenzl R.: Preoperative Workup. Cataract

Surgery: The State of the Art. Edited by Gills, JP.,
Slack; 1998; 1:1-8.
Lacava, AC., Caballero, JC., Medeiros, OA., Cen-

turion, V.: Biometria no alto miope. Rev Bras de
Oft. 1995;54:619-622.
Masket S.: Preoperative evaluation of the patient

with visually significant cataract. Atlas of Cata-
ract Surgery, Edited by Masket S. & Crandall AS,
published by Martin Dunitz Ltd., 1999, 1:3-5.
Neumann D., Weissmann OD., Isenberg SJ., et al:

The effectiveness of daily wear contact lenses for
correction of infantile aphakia. Arch Ophthalmol.
1993;111:927-9.
34
C h a p t e r 3: IOL Power Calculation in Standard and Complex Cases - Preparing for Surgery
IOL POWER CALCULATION

IN STANDARD AND COMPLEX CASES
PREPARING FOR SURGERY

Making Patients Confident Patients Encounter with the
Physician
From the minute the patient considers
undergoing surgery, fear is present. There is And in the encounter with the physician
fear of the unknown and fear of someone oper- patients should feel respected and important.
ating on your eye. Jack Dodick, M.D., from Even though the waiting room is busy, every-
New York, believes in the important influence thing should seem unhurried when the pa-
of office personnel and environment on mak- tient is sitting in the chair across from the
ing patients confident and comfortable. Dodick physician. The ophthalmologist should con-
strongly advocates hiring and training high- vey the impression that, at this time, the
level professional staff. When patients interact patient is the most important person.
with highly competent staff at every encounter, The physician’s ability to project a con-
they tend to conclude that the doctor must be fident manner is also critical to success.
very good because he has selected and trained Dodick believes it is an art to convey this
his staff so well. Many doctors pay too little confidence and professionalism to patients. It
attention to the impressions staff make on their is partly done through certain inflections in
patients. They are tempted to cut corners by the voice; perhaps it is easier to explain in
hiring clerks at low pay if they fail to realize reverse. Sometimes the doctor who does not
that patients’ impressions of staff are integral feel totally secure in his ability to produce
to their impressions of their physician. results may become a little defensive, and
In addition, the office environment give more emphasis to potential complica-
should be tasteful. The impression patients tions than the real positive benefits of the
have when they enter the office influences operation. “Well, you have a cataract. As you
their feelings about their physician. An office know, you can have it operated on or not, and
that is dirty and cluttered reflects poorly on there are some complications that sometimes
the practice. Dodick believes that once pa- occur. For example. . .” Although potential
tients feel respected and comfortable with the complications are in fact true, the chance that
expertise of the physician and his/her staff, these complications will occur is minimal.
they relax and decide they have come to the Dodick does not dwell on these rare potential
right place. complications. Instead, he emphasizes the
37
very high probability of positive results when patients decide they are unhappy with
communicating with patients. He retains a their vision. Most people understand this, but
position of objectivity in order that his own often Dodick hears the question, “What
perspective will not unduly influence the pa- would you do in my position?” Dodick
tient. The patient must be informed of poten- handles this by looking the patient in the eye
tial risks but with modern small incision and responding: “This is a very simple ques-
cataract surgery, they are very unusual. tion. If I were very happy with my vision
right now, I would do nothing. If I were
Ingredients of a Strong Rela- unhappy, I would decide in a minute to have
tionship cataract surgery.” Then patients fully realize
that cataract surgery is truly an elective proce-
The physician’s ability to instill confi- dure.
dence and trust in patients, and an ability to
articulately convey his confidence through Evaluating the Patient's Cataract
the spoken word are the basic ingredients of a
strong relationship between physician and Of course, giving patients this choice is
patient. predicated upon the fact that the ophthal-
A fundamental question is how should mologist has conducted a thorough examina-
the ophthalmologist approach patients who tion. With slit lamp biomicroscopy posterior
measure well on Snellen acuity, but still subcapsular cataracts which strongly inter-
complain about their vision because of the fere with vision by inducing a great deal of
very important factors of contrast sensitivity glare are very easy to evaluate, whereas
and glare we have already discussed. Dodick nuclear sclerotic cataracts are often difficult
follows these basic steps. He first listens to to evaluate on the slit lamp. People with
the patient and tries to make a historical posterior subcapsular cataracts can measure
determination about how happy or incapaci- 20/20 or 20/25 on Snellen acuity because they
tated they are because of their vision. If are really looking through the little pinholes
patients claim to be very happy with their of the posterior subcapsular cages (Fig. 23-
vision, Dodick goes no further. He merely A-B). The minute they see oncoming head-
instructs them that they, like everyone over lights while driving at night, for instance, the
50, have some lens changes. He explains the glare may diminish their functional vision
basic anatomy of the human eye (Fig. 1-A), to 20/100 or even 20/200. On the other hand,
with its clear windows inside and outside, and people with nuclear sclerosis, the most com-
the tendency of the inside window to become mon form of cataract, tend to complain about
cloudy. The treatment, of course, is to replace contrast sensitivity rather than glare (Fig. 23-
the cloudy window with a clear window and C-D).
thereby restore their vision. Over the years Dodick has found that a
In approaching the question of when a good way to evaluate lenticular or media
cataract should be removed, Dodick rein- changes is to examine the red reflex of the
forces the concept that in nearly all condi- patient by holding an ophthalmoscope about
tions, cataract surgery is 100% elective. The 12 to 14 inches from the eye and determining
time to remove a cataract is the time that whether it is a bright red reflex, a gray reflex,
38
Figure 23 A-D: Posterior Subcapsular Cataract (top, left and right). Cataract with Nuclear Sclerosis (bottom, left and
right)
Figures 23 A and B are three dimensional photographs of a characteristic posterior subcapsular cataract, seen with the
slit lamp (top-left) and with indirect illumination also using the slit lamp (top-right). Patients with posterior subcapsular
cataracts can measure 20/20 or 20/25 on the Snellen visual acuity chart in the examining room, because they are seeing through
the little pinholes of the posterior subcapsular cages. When they are exposed to oncoming headlights while driving at night,
the glare may diminish their functional vision to 20/100 or even 20/200.
Figures 23 C and D are three dimensional photos of nuclear sclerotic cataract, viewed with diffuse illumination (left)
and with the slit lamp beam (right). This is the most common form of cataract. Patients tend to be hindered more by loss of
contrast sensitivity rather than glare. (Reproduced with permission from AAO's Basic and Clinical Science Course, Lens and
Cataract, 1999, pp.42, 48, enhanced by HIGHLIGHTS).
39
or a dark black reflex. This provides a good out glasses, by all means do not sacrifice their
indicator of opacity. In some circumstances a near vision just for providing 20/20.
nuclear cataract can be better evaluated with The availability of foldable multifocal
this technique than with the slit lamp. Dodick IOL's makes this surgeon-patient understand-
does not rely on tests for contrast sensitiv- ing even more critical so that the visual
ity when evaluating cataracts. Although advantages of these lenses need to be fully
conditions of glare can be simulated in a appreciated versus the disadvantages which
clinical setting, Dodick relies on the exist but may be less significant. A similar
patient’s real life test experience instead. situation presents with the alternative of
monovision. If the surgeon contemplates
Approaching the Day of using this method, which is a good alterna-
Surgery tive for many patients, it is important to make
sure the patient understands how this works
Once Dodick and his patient have and be enthusiastic with this alternative. Fi-
reached the mutual understanding that cata- nal visual satisfaction with these methods,
ract surgery may be beneficial, the patient is multifocal IOL's and monovision, will de-
in essence turned over to a series of highly pend a great deal on the selection by the
trained, dedicated, professional staff who surgeon of the right patient for these alterna-
work closely with him. The next person the tives. With multifocal IOL's patients are
patient sees is a highly trained technician. The happier with bilateral implantation. With
technician explains that a measurement is monocular implantation, it is preferable not to
needed to determine the correct lens to im- delay surgery in the fellow eye unless there is
plant into the eye, and they undergo an a major reason, because most patients feel
ultrasonography scan. When the test is com- very insecure with monocular vision and hav-
pleted, the patient is turned over to the surgi- ing only one eye operated.
cal counselor, who has become a master at
making patients comfortable and ready to DETERMINING IOL
approach the day of cataract surgery.
POWER (BIOMETRY)
Patient's Expectations
Ocular biometry must be performed
It is essential to clarify to the patient prior to cataract surgery. There is no
what he/she may expect and what not to question that when well selected and prop-
expect. Postoperative patient satisfaction is erly done the ultrasonic methods afford us
based on this pre-op surgeon-patient commu- the best way of achieving the desired postop-
nication and understanding. What are the erative refraction. Determination of intraocu-
patient's daily needs and what final uncor- lar lens power through meaningful keratom-
rected visual acuity for distance and near he eter readings and axial length measurement
would prefer? Does he want to read without through A-Scan ultrasonography has be-
glasses? If so, then he must know he would come a "standard of care". It is a challenging
not see perfectly clearly for distance. If he/ technique and crucial to the visual result and
she are myopes and consequently read with- patient satisfaction.
40
Postop Refractive Errors No no longer admissible. In small incision tech-

Longer Admissible niques, cataract surgery has attained the status
of refractive surgery. Therefore, exact deter-
This is particularly true considering the mination of the IOL power to end up with the
high patient's expectations and the minimal specific planned postoperative refraction is
astigmatism created by small incision cataract essential. The advent of multifocal foldable
surgery, particularly phacoemulsification. IOL's makes this even more of an important,
Patients look forward to wearing spectacles though complex subject, as well as operating
postoperatively only under special circum- on eyes with different axial lengths: normal
stances. As emphasized by Centurion and (Fig. 24), short as in hyperopia (Fig. 25 A-B),
Zacharias, postoperative refractive errors are long as in myopia (Fig. 26).
Figure 24: Determination of IOL Power in

Patients with Normal Axial Length (Nor-
mal Eyes) - Mechanism of How Ultrasound
Measures Distances and Determines Axial
Length
The use of ultrasound to calculate the

intraocular lens power takes into account the
variants that may occur in the axial diameter
of the eye and the curvature of the cornea. The
ultrasound probe (P) has a piezoelectric crys-
tal that electrically emits and receive high
frequency sound waves. The sound waves
travel through the eye until they are reflected
back by any structure that stands perpendicu-
larly in their way (represented by arrows).
These arrows show how the sound waves
travel through the ocular globe and return to
contact the probe tip. Knowing the speed of
the soundwaves, and based on the time it takes
for the sound waves to travel back to the probe
(arrows), the distance can be calculated. The
speed of the ultrasound waves (arrows) is
higher through a dense lens (C) than through
a clear one. Soft tipped transductors (P) are
recommended to avoid errors when touching
the corneal surface (S). The ultrasound equip-
ment computer can automatically multiply the
time by the velocity of sound to obtain the
axial length. Calculations of intraocular lens
power are based on programs such as SRK-II,
SRK-T, Holladay or Binkhorst among others,
installed in the computer.
41
Figure 25 A (above right): IOL Power

Calculation in Patients With Very Short
Axial Length (Hyperopia)
In eyes with short or very short

axial lengths as shown in Fig. 25 the third
generation formulas such as Holladay 2
and Hoffer-Q seem to provide the best
results. Holladay has discovered that the
size of the anterior and posterior segments
is not proportional in extremely short eyes
(<20.0 mm). Only 20% of short eyes
present a small anterior segment
(nanophthalmic eyes); 80% present a nor-
mal anterior segment and it is the posterior
segment that is abnormally short as shown
here. (P) represents probe, (S) represents
corneal surface.
Figure 25-B (below left): Concept of the

Piggyback High Plus Intraocular Lenses
In cases of very high hyperopia, a

clear lens extraction may be done combined
with the use of piggyback high-plus
intraocular lenses. One (A), or two (B) or,
some surgeons suggest, three or more
intraocular lenses can be implanted inside
the capsular bag (C). This piggyback
implantation technique may solve the
problems of having to implant a lens of over
+30 diopters with its consequent optical
aberrations, but the procedure may give rise
to postoperative complications. Some
prestigious surgeons have their reservations
(see text).
42
The Challenge of the Complex (Fig. 32) frequently in Europe and infre-
Cases quently in the U.S., also add unique and
different difficult challenges, in performing
The use of refractive surgery on the an exact biometry in every individual
cornea using a variety of techniques: excimer patient's condition. When using ultrasound,
(Fig. 27), RK (Fig. 28), Intracorneal Ring axial length is determined by measurement of
Segments (INTACS - Fig. 29) makes ocular the reflection of the eye tissue interfaces with
biometry even more complex. These refrac- the ultrasonic beam (Fig. 24 - arrows). The
tive corneal refractive techniques change the A-scan must be carefully calibrated and the
parameters in these special cases as compared beam velocity must correspond to whether or
with those we use for normal eyes and make not the patient is phakic, pseudophakic, or
these special cases. Computerized aphakic and may need to be modified in the
videokeratography provides additional im- special cases previously described. The ultra-
portant data. sound probe (T) has a piezoelectric crystal
The current acceptance of implanting that electro-mechanically emits and receives
IOL's in children following pediatric cata- high frequency sound waves. The sound
ract surgery (Fig. 31) and the frequent use waves travel through the eye until they are
of vitrectomy with the use of silicone oil reflected back by any structure that stands in
Figure 26: IOL Power Calculation in High Myopia
In high myopia with axial lengths higher

than 27.0 mm the use of the SRK II formula with
an individual surgeon's factor has shown good pre-
dictability of the refractive target. Probe (P), cor-
neal surface (S).
43
their way (represented by arrows). Assuming constant used, but also the estimated anterior
the average velocity of the sound waves in the chamber depth (depending on the formula),
eye being measured, and based on the time it preop refraction and age must be taken into
takes for the sound waves to travel back to account. Adjustments can also be made for a
the probe (arrows), a distance can be calcu- specific surgeon's technique.
lated. The ultrasound equipment's computer In the search for continuous refinement
can automatically multiply the time by the and accuracy of results, new methods based
velocity of sound to obtain the axial length. on laser interferometry may replace ultra-
At least three scans should be obtained which sonography in the future.
are within 0.15 mm of each other. Gimbel
recommends that the A-scan should be mea- Main Causes of Errors
sured twice by independent technicians if the
axial length is unusually short (Fig. 25) (hy- Zacharias and Centurion have pointed
peropia) or long (Fig. 26) (myopia) (<22 mm out that most postoperative refraction errors
or >25 mm), or if the difference between the occur not due to errors in the formulas but to
two eyes is more than 0.3 mm, if the axial imprecise preoperative measurements. For
length measurement does not correlate with each millimeter of error in biometry there is
the refraction or the patient has difficulty with a -2.5 diopter error in the calculation of the
keeping the eyes open or with fixation. IOL power. If more than one error occurs in
the same examination there may be signifi-
The Most Commonly Used For- cant postoperative refractive errors.
mulas Keratometry in both eyes should be repeated
when:
The most commonly used IOL formula • corneal curvature is less than 40.00 D
was developed by Sanders, Retzlaff and Kraff or more than 47.00 D;
and is known as the SRK formula, where • the difference of the corneal cylinder
p = A - 2.5L - 0.9K. "P" refers to lens implant is more than 1.00 D between both eyes;
power to produce emmetropia, "L" refers to • the corneal cylinder correlates poorly
axial length, "K" refers to average with the refraction cylinder.
keratometric readings in diopters and "A" is a During the examination, the patient sits
constant that is specific to the lens implant in front of the skilled technician performing
that is to be used. Several second and third the ultrasound test. He/she is asked to fixate
generation lens power calculation formulas at a point straight ahead. The ultrasound soft
have been developed including the SRK2 and probe is positioned axially, touching the cor-
SRK/T, Hoffer Q, and the Holladay 2 formu- neal epithelium as lightly as possible so as not
las. Gimbel emphasizes that to avoid errors to compress and thereby shorten the eye. It is
in lens power calculations not only must the useful to visualize the procedure laterally to
biometry be accurate and the correct "A" make sure that the cornea is not being com-
pressed (Fig. 24).
44
Targeting Post-Op Refraction group, these visual acuities are adequate with
no additional glasses required. At times when
This parameter is the only one that the they might need finer acuity, they can wear
physician must decide upon by himself and regular bifocals, which will correct them for
feed into the computer. All the other param- distance and near.
eters are measured or assumed values over In older, more sedentary patients, two
which he has no control. When selecting a lens diopters of myopia may be a better goal. For
implant power Gimbel generally recommends these patients reading without glasses may be
that the surgeon target mild myopia and thus preferred to distance vision without glasses.
avoid inadvertent postoperative hyperopia. A The second reason for targeting the post-
patient who is hyperopic postoperatively will op refraction to approximately -1.00 to -1.50,
need spectacles for clear vision at any range, sometimes -2.00 diopters, is that, statistically,
whereas a patient who is slightly myopic will between 70% and 90% of patients will fall
have a range of clear vision corresponding to within + or -1.00 diopter error of this desired
the degree of myopia. In all cases the patient postoperative refraction. The errors, as men-
must be counselled with regard to expectations tioned previously, are primarily a result of our
of refractive changes and they should be coun- inability to make exact measurements on the
selled that they will generally need reading living eye.
glasses or bifocals postoperatively as the im- Therefore, the patient will fall between
plant has no power of accommodation, unless plano and -2.00 diopters 90% of the time. This
the patient's targeted postop refraction is around will assure most patients of useful vision with-
-2.00 on purpose. out glasses. Hence, the error of the ultrasound
measurement is best handled by choosing the
Monocular Correction postoperative refraction of -1.00. On the other
hand, if we target for plano, which is the target
that some physicians try to obtain, 90% of the
Holladay has pointed out that with mo-
patients will be between -1.00 and +1.00 diopt-
nocular correction, there are two major consid-
ers. When the patient's refraction is on the +1
erations for determining what would be the
side, he has less useful vision at any distance
best postoperative refraction for any patient. If
because he is hyperopic and does not have the
we are only considering one eye (i.e., the other
ability to accommodate.
eye is amblyopic), targeting the postoperative
Consequently, because it is very unde-
refraction for approximately -1.00 to -1.50
sirable to have a hyperopic correction, tar-
diopters is probably the best choice.
geting for -1.00 not only optimizes the best
This is usually best because most people
vision at all distances but also minimizes the
have visual needs for both distance and near;
chance for hyperopia that can result from the
that is, they want to be able to drive and to read
inaccuracies of ultrasonic measurements.
without having to wear glasses. If we target the
Holladay's recommendation for choos-
patient's post-op refraction for -1.00 to -1.50,
ing -1.00 to -1.5 as the postoperative refraction
the patient will have 20/20 vision at approxi-
is based on one eye only, i.e. monocular condi-
mately 2 to 3 feet, 20/30 vision in the distance,
tions. When the vision in the other eye is good,
and 20/30 at 14 inches. With a normal size
its refraction must be considered for binocular
pupil of approximately 3 mm in the cataract age
vision.
45
Binocular Correction -8.00. We have limited the difference in the

spectacle lenses to a two diopter difference in
In patients with Binocular Correction: the final prescription. Again, we are advised to
one overriding rule when choosing an IOL target for a two diopter difference, not a three
power is that one should never aim for spec- diopter difference, because there is approxi-
tacles which give the patient a difference in the mately a one diopter tolerance in the accuracy
power between the right and left lens greater of the ultrasonic measurement.
than three diopters. The reason for this is that
even though the patient may have 20/20 vision When Cataracts in Both Eyes
in primary gaze, when the patient looks up or
down, the induced vertical prism difference in If the operation on the second eye is to be
the two eyes is so large that it will create double done shortly after the first, the IOL calculation
vision. Therefore, avoid anisometropia. is made as if he were monocular, as in our
previous discussion.
Good Vision in the Non-Operated Eye For example, with a patient +5 in both
eyes, if the second eye is cataractous and it is
In a patient who has good vision in the planned that the patient would also need cata-
non-operative eye, one must target the in- ract surgery in that second eye within a short
traocular lens power for a refraction within period of time, it would be wise to target for
two diopters of his/her present prescription in -1 in the first eye. When the vision in the
the non-operative eye. This measurement operated eye exceeds the vision in the other
should be two diopters, not three, due to our 1 eye, -1 lenses in both should be prescribed until
diopter A-scan variability. For example, if we the second eye is operated. Soon. This is not
have a patient who is hyperopic and has +5 only true with intraocular lens surgery; it is true
diopters correction in each eye, we cannot in all forms of refraction. The patient needs to
target the intraocular lens for a postoperative understand what we are doing and to be a part
refraction of -1 diopter because this would of the decision process. One should never give
produce a 6 diopter difference between the two a patient more than a three diopter difference in
lenses, resulting in double vision or confusion. his/her spectacles unless he has previously
Holladay recommends selecting the worn such a prescription. One exception is a
intraocular lens power to obtain a refraction child who is under five or six years of age and
which is approximately two diopters less than who can adjust to this difference by turning his
the non-operative eye. Consequently, on our head rather than moving his eyes. Another is
patient who is +5 diopters in both eyes, we the patient with an alternating strabismus.
should target the postoperative refraction in the We must continue in our efforts to avoid
eye with the cataract for +3, so ther e is a creating astigmatism by our surgery. If the
90% probability that there will be less than a patient is already astigmatic, try to avoid too
3 diopter difference. much astigmatic imbalance (high plus at 90º in
In contrast, if the patient were highly one eye and high minus at 90º in the other). This
myopic in each eye, for example, -10.00 in both results in a vertical prism effect in reading and
eyes, we should target the intraocular lens the need for prescribing a slab off prism. This
power to produce refraction of approximately problem has fortunately been significantly di-
minished with small incision surgery, particu-
46
larly phaco, and with the application of refrac- advantages of modern technology, the small
tive cataract surgery by placing the incision in incision extracapsulars and careful inspection
the correct axis at the time of cataract surgery. of the peripheral retina allow us to perform a
This we will discuss under the major heading of safe lens removal and provide an IOL implan-
"The Incision." tation with a sufficiently desirable power to
provide a specific patient with the very high
IOL POWER CALCULATION quality of vision that we must demand of our-
selves for the benefit of our patients.
IN COMPLEX CASES
Practical Method for Choosing
Specific Methods to Use in Formulas in Complex Cases
Complex Cases
From a practical standpoint, if several
Considering that there are no specific formulas are available to the clinician, the first
methods on which there is full agreement as to choice as recommended by Zacharias and
what to do in these patients, and after consult- Centurion are as follows:
ing different authorities in this field, we hereby • short eyes: L <22.00 mm: Holladay 2 or
recommend the use of third generation formu- Hoffer Q. These constitute 8% of cases.
las, preferably more than one and that the • L (axial length) between 22.00 and
highest resulting IOL power should be used for 24.50 mm; 72% of the cases: mean of the three
the implant. These formulas are preferably the formulas: Hoffer, Holladay and SKR/T.
Holladay 2, the SRK/T or the Hoffer formulas. • L between 24.50 mm and 26.00 mm;
Do not use a regression formula (e.g., SRK I or 15% of the cases: Holladay 2 or SRK/T
SRK II). We also recommend that you use • L higher than 26.00 mm; 5% of the
central topography's flattest curve as a cases: SRK/T
keratometric method unless you are fortunate
to have all the information needed in order to High Hyperopia
use the "historical method." This reading is
fed to the computer utilizing the selected for- In eyes with short or very short axial
mulas. The computer will then provide you lengths (Fig. 25) the third generation formulas
with the power of the IOL to use. such as Holladay 2 and Hoffer-Q seem to
The modern formulas hereby recom- provide the best results. Observing high refrac-
mended are already available in most of the tive errors in extremely short eyes (<20.0 mm),
computers available today to calculate IOL Holladay has discovered that the size of the
power. You just select the formulas you be- anterior and posterior segments is not propor-
lieve adequate which should be present within tional, and has devised certain measurements
your equipment. to be used to calculate the parameters in these
The reason behind all these sophisticated eyes. Assembling data from 35 international
and very careful IOL calculations in highly researchers Holladay concluded that only 20%
myopic patients with cataract is, of course, of short eyes present a small anterior segment
that although the cataract removal by itself can (nanophthalmic eyes); 80% present a normal
somewhat compensate for the high myopia, the anterior segment and it is the posterior segment
47
that is abnormally short. This means that the proved optical quality because there are fewer
formulas that predict a small anterior segment spherical aberrations than with very high di-
in a short eye provoke an 80% error margin, as opter lenses.
they will predict an abnormally shallow ante- Measuring the position of piggyback
rior chamber which, in turn, can lead to hyper- lenses, Holladay observed that contrary to
opic errors of up to 5 diopters. The Holladay 2 what he supposed -- that the anterior lens would
formula comprises the seven parameters previ- occupy a more anterior position -- what effec-
ously described for IOL calculation: axial tively happens is that the anterior lens pre-
length, keratometry, ACD (anterior chamber serves its normal position while the posterior
depth), lens width, white-to-white corneal hori- lens moves backwards because of the disten-
zontal diameter, preoperative refraction, and sible nature of the capsular bag. The latter may
age. This new formula has reduced 5 D errors accommodate more than two IOLs and there
to less than 1 D in eyes with high hyperopia. are cases of patients with four piggyback lenses
Although biometry is easy to perform, in the same eye.
most errors in hyperopic patients occur be- Holladay's recommendation for calcu-
cause of probe compression. Zacharias and lating the power of lenses with the piggyback
Centurion emphasize that only the corneal procedure in high hyperopic patients is to add
epithelium should be touched, without any 3 diopters to the total value of the pre-op IOL
resulting indentation (Fig. 25-A). power calculation and divide the total by 3,
placing 2/3 of the power in the posterior lens
The Use of Piggyback Lenses in and 1/3 in the anterior lens. This facilitates
Very High Hyperopia the replacement of the anterior lens, if neces-
sary, as it is the thinnest lens. The 3 diopters
For very short eyes (<22.00 mm in added to the total value are meant to roughly
length) even though the Holladay 2 or the compensate the hyperopic error resulting from
Hoffer Q formulas are a significant advance in the space behind the posterior lens. This is
calculating the IOL power needed, we do not calculated more precisely with the Holladay 2
have IOLs easily available with a power higher formula.
than +34 diopters because a higher diopter lens Joaquin Barraquer, M.D., in Barcelona,
would have a marked, almost spherical curva- who often attends very complex anterior seg-
ture, that would cause major optical aberra- ment diseases referred to him from different
tions. Such lenses can be customized but still parts of the world, has observed a substantial
may cause undesirable optical aberrations. In increase in depth of focus with the piggyback
these cases the piggyback method is employed, procedure as compared to the implantation of a
i.e., the implantation of more than one IOL in single custom made lens. He has done both
a single eye, dividing the total power among procedures. Barraquer as well as I. H. Fine,
the different lenses, placing 2/3 of the power in M.D., another master surgeon, are still cau-
the posterior lens and 1/3 in the anterior lens tious about the piggyback method. They
(Fig. 25-B). feel that it is not yet clear how Elschnig pearls
Gayton (1994) was the first to place two between the lenses will behave in the postop-
lenses in a single eye. He observed that placing erative period if there is progressive capsular
multiple lenses in a single eye produces im- fibrosis. Recently, John Gayton, David
48
Apple et al described the presence of without the use of a personalized correction

interlenticular opacification in two pairs of factor have yet to be developed. Zacharias and
piggyback lenses that had to be explanted from Centurion emphasize that there are technical
2 patients with significant visual loss related to difficulties in performing the echobiometry of
opacification between the optics. They were patients with high myopia, especially when
submitted for pathological analysis. Gross and they have a posterior staphyloma. In those
histopathological examinations were per- cases they obtain extremely irregular retinal
formed, and photomicroscopy was used to docu- echoes that cannot provide certainty in terms
ment the results. of really correct results of the IOL calculation.
Gross examination showed accumula- In addition, a posterior staphyloma may not
tion of a membrane-like white material be- always coincide with the macula, so the higher
tween the lenses. Histopathological examina- measurement is not necessarily the correct one,
tion revealed that the tissue consisted of re- as is the case with normal eyes.
tained/proliferative lens epithelial cells (blad- In these patients it is useful to perform B
der cells or pearls) mixed with lens cortical type ultrasound to identify the existence of a
material. staphyloma and its relation with the macula.
They recommended three surgical means Equally important is to have an ultrasound
that may help prevent this complication: me- probe with a fixation light. The patient is asked
ticulous cortical cleanup, especially in the equa- to fixate at the light -- which he will do with the
torial region; creation of a relatively large con- macula -- facilitating the measurement.
tinuous curvilinear capsulorhexis to sequester Lacava and Centurion studied 27 myo-
retained cells peripheral to the IOL optic within pic eyes with an axial length of more than
the equatorial fornix; insertion of the posterior 26.50 mm, and found that 88% of the patients
IOL in the capsular bag and the anterior IOL, in with whom they used the SRK/T formula were
the ciliary sulcus to isolate retained cells from within the emmetropic criteria established by
the interlenticular space. George Waring.
Echobiometry in highly hyperopic eyes,
especially microphthalmic and nanophthalmic DETERMINING IOL POWER
eyes, is still far from desirable.
IN PATIENTS WITH PREVI-
High Myopia OUS REFRACTIVE SURGERY
According to Zacharias and Centurion's Patients who have undergone excimer

experience, results of cataract surgery in highly laser procedures, radial keratotomy or INTACS
myopic eyes with axial lengths higher than have had modifications to their corneal curva-
31.0 mm with implantation of low or negative tures (Figs. 27, 28, 29). Accurate keratometric
power IOLs may be successful, without any readings are fundamental in calculating IOL
more operative or postoperative complications power. IOL power calculation for cataract
than normal eyes. The use of the SRK II surgery in patients previously submitted to
formula with an individual surgeon's factor refractive surgery by modification of the
showed good predictability of the refractive corneal curvature is a new challenge for the
target (Fig. 26). However, better formulas cataract surgeon basically because of two
49
Figure 27: IOL Power Calculation in

Patients After Excimer Laser Procedure
In this group of patients even with

the most advanced ultrasonic equipment,
there is a degree of variation in the results
of the IOL power calculation. This is the
result of the varying modification in the
curvature of the cornea after the excimer
laser ablation (A). There is no universally
accepted formula to calculate these pa-
tients' IOL power accurately. The standard
methods used in normal eyes are inad-
equate in these patients. For alternative
methods, consult text.
Figure 28: IOL Power Calculation in

Patients After Radial Keratotomy
Patients operated with radial

keratotomy undergo corneal curvature
changes that cannot be measured reli-
ably with the standard methods. The
data of the corneal curvature obtained
from corneal topography are fed into a
computer using third generation formu-
las to establish a more dependable calcu-
lation of the intraocular lens power. This
illustration shows the correct way of
using the ultrasound transducer (P) on
the cornea placing it on the optical
center midway between the corneal
incisions (RK). For alternative methods
of calculation see text.
50
Figure 29: IOL Power Calculation After an Intracorneal Ring Segment Procedure
As with other refractive procedures on the cornea, this technique for correction of low myopia also modifies the
central corneal curvature (arrows). Due to the limited correction power the INTACS can handle (miopias up to -2.5 D),
it is presumed that the variability in the reduction of the central corneal curvature should not be very significant.
Topography determines the present corneal curvatures. The surgeon uses the flattest keratometric reading as a
reference in cases where the pre-refractive procedure keratometry cannot be obtained. This data is fed into the
computer and with the use of the programs outlined in the text the power of the intraocular lens is determined. In this
illustration we can see the ultrasound transducer (P) on the central cornea inside the area in which the intracorneal
rings (IC) are placed.
features. 1) Patients who previously decided to errors if used for IOL calculations. Therefore,
undergo refractive surgery are more standard keratometry readings should not be
phychologically resistant to using spectacles to used for IOL calculations in these patients. If
correct residual ametropia. Consequently, their done, the standard IOL power-predictive for-
expectations for cataract surgery are unusually mulas based on such readings commonly result
high. 2) So far there is no universally ac- in substantial undercorrection with postopera-
cepted formula to calculate these patients' tive hyperopic refraction or anisometropia both
IOL power accurately. Routine keratometry of which are very undesirable.
readings do not accurately reflect the true cor- Jack Holladay, M.D., a recognized
neal curvature in these cases and may result in authority on IOL power calculations and in all
51
optical-refractive subjects in ophthalmology, raphy method. Holladay believes that the

considers that accurate determination of the calculation or "clinical history" method and the
corneal power in these patients is difficult and hard contact lens trial are the two more reliable
is usually the determining factor in the accu- of the three, because the corneal topography
racy of the predicted refraction following cata- instruments presently available do not provide
ract surgery. Providing this group of patients accurate central corneal power following PRK,
with the same accuracy of intraocular lens LASIK and RKs with optical zones of 3 mm or
power calculations as we have provided our less. In RKs with larger optical zones, the
standard cataract patients presents an espe- topography instruments become more reliable.
cially difficult challenge. The great majority of cases, however, have had
RK with an optimal zone larger than 3 mm, so
Methods Most Often Used they should also qualify for this method.
There are three methods to determine the The Clinical History Method
effective power of the cornea in these complex
cases: 1) the clinical history method, also The "clinical history" method is the most
termed by Holladay "the calculation method"; often used. In the "historical or calculation
2) the contact lens method; and 3) the topog- method", however, the keratometry reading
Figure 30: Posterior Capsulorhexis in Pediatric Patients
Following the conventional steps of phacoemulsification, an appropriate intraocular lens for children
is inserted (IOL) with the required power in compliance with the criteria of the practitioner following the
guidelines in the text. Once the intraocular lens is located in the bag, and properly protecting the tissues with
viscoelastics, a cystotome (C) is introduced through the limbal incision (I), and directed behind the IOL to
perform a posterior capsule tear or posterior capsulorhexis (PC). This opening in the posterior capsule at the
time of the phaco procedure can provide permanent improved vision to the child.
52
and refraction before refractive surgery must cases, calculation is complicated by the pro-
be known along with an accurate postoperative gressive flattening that occurs in about 25% of
refraction which is not often the case. It is also RK patients. It is nearly impossible to separate
important to keep in mind that at present, far these two factors and determine the impact of
more patients have had RK than PRK and each on the refraction before cataract surgery.
LASIK combined. Also, our long-term fol-
low-up of RK patients is much greater. The The Trial Hard Contact Lens
long-term studies of RK patients reveal that Method
some have hyperopic shifts in their refraction
and develop progressive against-the-rule astig- The second method often used, which is
matism which may complicate the final vision the trial hard contact lens method, requires a
of the patient operated for cataract, unless plano hard contact lens with a known base
detected at the time of preoperative evaluation curve and is limited to patients whose cataract
and corrected. The long-term refractive changes does not prevent them from being refracted to
in PRK and LASIK are unknown, except for approximately +0.50 D. This usually requires
the regression effect following attempted PRK a visual acuity of better than 20/80. The patient's
corrections exceeding 8 D. Whichever proce- spheroequivalent refraction is determined by
dure the patient has had, the stability or insta- standard refraction. The refraction is then
bility of the refraction must be determined. repeated with the hard contact lens in place. If
When using the "clinical history or calculation the spheroequivalent refraction does not change
method" a subtraction of the spherical equiva- with the contact lens, then the patient`s cornea
lent (SEQ) change after refractive surgery from must have the same power as the base curve of
the original K-reading is done to determine the the plano contact lens, since the base curve and
new "accurate" corneal curve. This, however, front curve are the same in a plano contact lens.
is not information easily found. It is useful and If the patient has a myopic shift in the refraction
can be applied whenever refraction and the K- with the contact lens, then the base curve of the
reading before the keratorefractive procedure contact lens is stronger than the cornea by the
are available to cataract surgeons. If this amount of the shift. If there is a hyperopic shift
information is not available, which is not in the refraction with the contact lens, then the
unusual, we recommend that the base curve of the contact lens is weaker than the
keratometry be measured with corneal to- cornea by the amount of the shift.
pography and use the flattest curve of this
reading as the new corneal curve to feed the Example as Provided by Holladay
computer that will then automatically provide
us with the IOL power to use. The patient has a current spheroequivalent
Another downfall of the history method refraction of +0.25 D. When a plano hard
is that cataracts frequently cause induced myo- contact lens with a base curve of 35.00 D is
pia. This method, however, requires an accu- placed on the cornea, the spherical refraction
rate and stabilized refraction after the changes to -2.00 D. Since the patient had a
keratorefractive procedure and at the time we myopic shift with the contact lens, the cornea
are contemplating cataract surgery. In many must be weaker than the base curve of the
53
contact by 2.25 D. Therefore, the cornea must nize any patients with low cell counts from the
be 32.75 D (35.00 - 2.25), which is slightly previous surgery who may be at higher risk for
different from the value obtained by the histori- corneal decompensation or prolonged visual
cal or calculation method. This method is recovery.
limited by the accuracy of the refractions, which The potential acuity meter (PAM), super
may be limited by the cataract. pinhole and hard contact lens trial are often
helpful as secondary tests in determining the
The Corneal Topography respective contribution to reduced vision by
Method the cataract and the corneal irregular astigma-
tism. The patient should be informed that only
Current corneal topography instruments the glare from the cataract will be eliminated.
provide greater accuracy, compared to Any glare from the keratorefractive procedure
keratometers, in determining the power of cor- will essentially remain unchanged.
neas with irregular astigmatism. The computer
in topography instruments provides a very IOL Power Calculation in
accurate determination of the anterior surface
of the cornea. The limitation of this method is Pediatric Cataracts
that the computer in corneal topography pro-
vides no information about the posterior sur- How to optically correct patients with
face of the cornea. In order to accurately bilateral congenital cataracts and monocular
determine the total power of the cornea, the congenital cataract has been a major subject of
power of both surfaces must be known. controversy for many years. Some distin-
guished ophthalmic surgeons 20 years ago were
The Importance of Detecting strongly against performing surgery in mo-
Irregular Astigmatism nocular congenital cataract followed by treat-
ment of amblyopia with a contact lens. Visual
Holladay has strongly recommended that results were so bad that children with this
biomicroscopy, retinoscopy, corneal topog- problem must be amblyopic by nature, they
raphy and endothelial cell counts be per- thought, and the psychological damage to the
formed in all of these complex cases. The first children and the parents by forcing such treat-
three tests are primarily directed at evaluating ment was to be condemned.
the amount of irregular astigmatism. This Surgery of bilateral congenital cataracts
determination is extremely important preop- at a very early age followed by correction with
eratively because the irregular astigmatism spectacles and sometimes with contact lenses
may be contributing to the reduced vision as usually ended with no better than 20/60 vision
well as the cataract. The irregular astigma- bilaterally. This was again a source for belief
tism may also be the limiting factor in the that congenital cataracts either unilateral or
patient's vision following cataract surgery. The bilateral were by nature associated with am-
endothelial cell count is necessary to recog- blyopia, profound in cases of monocular cases
and fairly strong in bilateral cataracts.
54
When posterior chamber IOL implanta- Different Alternatives

tion in adults became established as the proce-
dure of choice, strong influences within oph- The limitations in calculating these lenses
thalmology were adamantly opposed to their powers (Fig. 31) is due to the fact that the eye
use in children for the following reasons: 1) the grows after cataract surgery and therefore re-
eye grows in length with consequent signifi- fraction will change. Two main methods of
cant change in refraction. It was considered choosing an IOL power for pediatric patients
impossible to predict such change and conse- are available: 1) Make the eye emmetropic at
quently, the accurate IOL power adequate for the time of surgery and thereby treat amblyopia
each child. 2) There was opacification of immediately taking advantage of a much better
posterior capsule in most cases. This required visual acuity. This is followed later by an IOL
a second operation for posterior capsulotomy exchange because of increasing myopia
and the presence of an IOL would impede (growth of the eye).
proper surgical maneuvers. Even though there are more practical and
You will not find this concise history in efficient techniques for IOL exchange, as de-
any other book. I lived through it and therefore vised by Jack Dodick, M.D., this alternative is
share it with you. second choice.
The situation has now significantly 2) Proceed with incomplete overcorrec-
changed. The previous failures with spec- tion of the eye at the time of surgery (treated
tacles and contact lenses, the new develop- with glasses or contact lenses) taking advan-
ments in technology and surgical techniques tage of the trend toward emmetropization
and the fresh insight of surgeons of a new which will occur as the eye grows. By "in-
generation has led us to discard the previous complete" we mean leaving the eyes hyper-
thinking and very definitely implant posterior opic. As the eye grows in length with age (axial
chamber IOL's in children. This has been made growth), the myopization that takes place in an
possible from the surgical point of view by the eye artificially rendered hyperopic will lead to
following developments: new medications that emmetropia or close to normal refraction. This
effectively prevent and/or control inflamma- measure avoids myopic anisometropia that may
tion; the introduction of posterior capsule lead to an undesirable change of IOL surgi-
capsulorhexis introduced by Gimbel in cally. In the meantime, the temporary hypero-
North America promptly followed by pia is managed with standard spectacles or
Everardo Barojas in Mexico and Latin contact lenses.
America (Fig. 30); high viscosity viscoelastics
to facilitate intraocular surgery in smaller eyes; Alternatives of Choice
new, more appropriate IOL's for children and
implantation in their capsular bag; more re-
In the IOL power calculation in children
fined technology that leads to a less difficult
younger than 1 year, keratometry is difficult
calculation of the IOL power.
and fortunately less important because the
55
Figure 31: IOL Power Calculation in Pediatric

Cataract
The growth of the ocular globe is

ecographically registered until 18 years of age. How-
ever, the lens continues growing throughout the life of
the individual. In normal conditions, anterior cham-
ber (A) depth is reduced as the lens increases in size.
In pathological conditions such as the presence of cata-
racts the opposite may happen: the anterior chamber
depth may increase due to reduction in the volume of
the lens (C). In this illustration we can see the changes
in the size of the globe through the shaded images that
outline the growth of the eye by stages. At birth the
axial diameter in the normal patient may measure ap-
proximately 17.5 mm, at three years of age it may
measure 21.8 mm (X), at ten years 22.5 mm identi-
fied in (Y) and in normal adulthood nearly 24 mm
(Z). In selecting the lens power to be used, some sur-
geons choose to make the child hyperopic (arrows) with
the intention that his growth will compensate hypero-
pia with the passage of time and will be eventually
closer to achieving an emmetropic eye. Others prefer
to calculate an intraocular lens closer to emmetropia
with the intention of keeping the child emmetropic
during his growing years and prescribing eyeglasses
in the future.
values change very rapidly during the first six frequently suffer from a unilateral traumatic
months. Thus keratometry may be replaced by cataract, overcorrect them by +1.00 D.
the mean adult average keratometry value of 3) A new method of management in
44.00 D. Children less than two years old may pediatric cataracts is to render the eyes
be incompletely corrected +3.00 D to even emmetropic from the very start and when axial
+4.00 D; between three and four years old length grows and makes the eye myopic,
incompletely correct them +3.00 D in those proceed to implant a second IOL with negative
closer to three and +2.50 D in those closer to or minus power utilizing the piggyback tech-
four. In children closer to six or seven, who nique and placing the new IOL in front of the
have little chance of recovering from any am- primary IOL (Fig. 25- B).
blyopia present but who are the ones that more
56
IOL Power Calculation the calculation of an intraocular lens implant

in a silicone filled eye (Fig. 32). They recom-
Following Vitrectomy mend: (1) the use of a modified ultrasound
velocity in silicone oil in the calculation of
For the most part, IOL power calcula-
axial length, (2) the use of convexoplano
tion in eyes that develop a cataract following
IOL's, and (3) the addition of a constant to
vitrectomy is straightforward. The intravitreal
compensate for the refractive index of sili-
gas is reabsorbed and slowly replaced by
cone oil.
aqueous. If silicone oil was used instead of
The velocity of sound in a medium is
perfluorocarbons, when the oil is removed,
inversely related to the medium’s refractive
aqueous fills the vitreous cavity. Since the
index. Since silicone oil has a higher index of
refractive indices of aqueous and vitreous are
refraction than vitreous, it slows down sound
identical (1.336), no corrections are needed in
velocity. For instance, sound velocity in sili-
the calculation of the IOL power.
cone oil is 986 m/s compared to 1532 m/s in
But what if silicone oil is present in
aqueous. If we recall, the velocity of sound is
the vitreous cavity? Lihteh Wu, M.D., has
preset in the computer in the ultrasound
pointed out that anywhere from 60% to 100%
machine. If no modification is made, the eye
of eyes have been reported to develop cata-
appears to be longer than it actually is. Conse-
ract following silicone oil tamponade. Up to
quently, the wrong IOL may be implanted.
25% of eyes with silicone oil tamponade,
Drs. Meldrum, Aaberg, Patel, and
especially those with retinal detachment sec-
Davis also explain why the choice of IOL is
ondary to necrotizing retinitis, will require
important. When convexoplano lenses are
permanent tamponade. Several authors
used, the anterior surface of the lens is solely
have reported unpredictable refractions fol-
responsible for the refractive power of the
lowing cataract extraction in silicone-filled
lens. Thus the presence of silicone oil in the
eyes when traditional formulas are used. In
vitreous cavity has no effect on the refractive
one study the axial length was measured prior
power of the IOL. On the other hand, when
to silicone oil tamponade, and the IOL power
biconvex lenses are used, the posterior sur-
was calculated using the traditional formulas.
face also contributes to the refractive power
In these eyes the average postoperative re-
of the lens. The refractive power of the poste-
fraction was about +4.00 diopters (with a
rior surface depends on the difference be-
range of +2 to +6 D). These results were
tween the refractive indices of the IOL and
more hyperopic than had been predicted and
the vitreous or vitreous substitute. Since sili-
the change is associated with the different
cone oil has a higher index of refraction than
refractive index of silicone oil. If the silicone
vitreous, the posterior refractive power of the
oil was later removed then the postoperative
lens is reduced. The use of a biconvex lens
refraction was only off by 0.5 to 1 D.
requires further correction.
Drs. Melissa Meldrum, Tom
Meldrum, Aaberg, Patel, and Davis
Aaberg, Anil Patel, and Janet Davis have
make the following recommendations.
described and proposed correction factors for
57
• Measure the axial length using the velocity of oil. For a convexoplano lens no additional
sound in silicone oil. correction factor is required.
• Calculate the IOL power to achieve emmetro- For instance, let us suppose that a patient
pia using the traditional formulas. To this IOL requires indefinite intraocular tamponade with sili-
power, a correction factor must be added to cone oil and develops a cataract. Using the tradi-
obtain the IOL power to achieve emmetropia tional formulas, assuming that the IOL power is
in silicone oil. The correction factors range calculated to be 22 D based on a measured axial
from 2.79 D to 3.94 D, for axial lengths from length of 23 mm. To this 22D we must add a
20 mm to 30 mm. correction factor of 3.64D (Meldrum et al) to cor-
• Choose a convexoplano IOL if possible. If rect for the axial length. Thus, for this patient a 25.5
another type of le1ns is used, another correc- D convexoplano lens should be implanted in order
tion factor must be added to obtain the total to achieve emmetropia in the presence of silicone
power of the IOL in the presence of silicone oil. No additional correction factor for the IOL
design is necessary.
Figure 32: IOL Power Calculation in Pa-

tients After Vitrectomy Procedure With
Silicone
If the patient is in the process of

undergoing this procedure it is recom-
mended to calculate the intraocular lens
before using silicone in the vitreous cavity
(V) and extracting the lens (C).
Polymethylmethacrylate lenses (PMMA)
are recommended. Silicone foldable IOL's
are not recommended because the silicone
oil in the vitreous cavity sticks to the
intraocular lens and sometimes causes
opacities. In the calculation of these lens
powers there may be differences in excess
of 5-7 diopters. Errors can be frequent
because if the vitreous cavity (V) is not
filled completely with silicone (S), the
movement of the bubble can induce errors
in the calculation of the lens. In addition, in
the eye filled with silicone, the ultrasound
waves travel slower (arrows). This affects
the axial diameter measurement during IOL
power calculation. For alternative methods
of IOL power calculation, see text.
58
RECOMMENDED READING Grinbaum A., Treister G., Moisseiev J.: Predicted and
actual refraction after intraocular lens implantation in
eyes with silicone oil. J Cataract Refract Surg, 1996;
Mendicute J, Cadarso L, Lorente R., Orbegozo J, 22:726-729.
Soler JR: Facoemulsificación, 1999. Grusha YO., Masket, S., Miller, KM: Phacoemulsifica-
tion and lens implantation after pars plana vitrectomy.
BIBLIOGRAPHY Ophthalmology 1998;105:287-294.
Holladay, JT: Intraocular lens power in difficult cases.

Boyd, BF.: Undergoing cataract surgery with a master
Atlas of Cataract Surgery, Edited by Masket & Crandal,
surgeon: a personal experience. Highlights of Ophthalm.
Published by Martin Dunitz, 1999, 19:147-158.
Bi-monthly Journal, Volume 27, Nº 1,1999;3.
Brady, KM., Atkinson, CS., Kilty, LA., Hiles, DA: Holladay JT., Gills, JP., Leidlein, J., Cherchio, M.:
Cataract surgery and intraocular lens implantation in Achieving emmetropia in extremely short eyes with two
children. Am J. Ophthalmol, 1995;120:1-9. piggyback posterior chamber intraocular lenses. Oph-
thalmology, 1996; 103:1118-1123.
Buckley, EG., Klombers, LA., Seaber, JH., et al: Man-
agement of the posterior capsule during intraocular lens Hoffer, KJ: Intraocular lens power calculation for eyes
implantation. Am J Ophthalmol, 1993;115:722-8. after refractive keratotomy. J Refract Surg,
1995;11:490-3.
Dahan, E., Drusedan, MUH.: Choice of lens and dioptric
power in pediatric pseudophakia. J Cataract Refract Hoffer, KJ.: The Hoffer Q formula: A comparison of
Surg, 1997;23:618-23. theoretic and regression formulas. J Cataract Surg.,
1993; 19:700-711.
Gayton, JL.: Implanting two posterior chamber intraocu-
lar lenses in microphthalmos. Ocular Surgery News,
Hoffer, KJ: Ultrasound velocities for axial length mea-
1994:64-5.
surement. J Cat Refract Surg, 1994;20:554-562.
Gayton JL., Apple DJ., Peng Q., Visessook N., Sanders
V., Werner L., Pandey SK., Escobar-Gomez, M., Kora, Y., Shimizu, K., Inatomi, M., et al: Eye growth
Hoddinott D., Van Der Karr M.: Interlenticular opacifi- after cataract extraction and intraocular lens implanta-
cation: Clinicopathological correlation of a complication in children. Ophthalmic Surg, 1993;24:467-75.
tion of posterior chamber piggyback intraocular lenses.
J Cataract Refract Surg, 2000; 26:300-336 ©ASCRS Lacava AC., Centurion, V.: Cataract surgery after re-
and ESCRS. fractive surgery, Faco Total, Editora Cultura Medica,
2000;269-276.
Gimbel, HV: Posterior continuous curvilinear
capsulorhexis and optic capture of the intraocular lens to Lyle WA, Jin GJC.: Intraocular lens power prediction in
prevent secondary opacification in pediatric cataract patients who undergo cataract surgery following
surgery. J Cataract Refract Surg, 1997;23:652-656. previous radial keratotomy. Arch Ophthalmol 1997;
115:457-61.
Gimbel, HV., Basti, S., Ferensowicz, MA., DeBroff,
BM.: Results of bilateral cataract extraction with poste- McCartney, DL., Miller, KM., Stark, WJ., et al: In-
rior chamber intraocular lens implantation in children. traocular lens style and refraction in eyes treated with
Ophthalmology, 1997; 104:1737-1743. silicone oil. Arch Ophthalmol 1987; 105:1385-1387.
59
Meldrum, LM., Aaberg, TM., Patel A, Davis, JL.:Cataract

extraction after silicone oil repair of retinal detachments
due to necrotizing retinitis. Arch Ophthalmol
1996;114:885-892.
Olsen T., Thim K., Corydon L.,:Theoretical versus SRK

I and SRK II calculation of intraocular lens power. J.
Cataract Refract Surg, 1990;16:217-225.
Sanders DR, Retzlaff J, Kraff MC, Gimbel, H., Raanan,

M.: Comparison of the SRK/T formula and other
theoretinal and regression formulas. J Cataract Refract
Surg., 1990; 16(3):341-346.
Wu, L: IOL power calculation after vitrectomy. Guest

Expert, Boyd’s, BF, The Art and the Science of Cataract
Surgery, HIGHLIGHTS OF OPHTHALMOLOGY,
2001.
Zacharias W., Centurion, V.: Biometry and the IOL

calculation for the cataract surgeon: Its importance.
Faco Total, 2000; 66-88.
60
C h a p t e r 4: P rev e n t i n g I nf e c t i o n and Inflammation
PREVENTING INFECTION
AND INFLAMMATION
dure of choice for a large number of surgeons

Use of Antiseptics, Antibiotics well trained in phaco, the key factors to con-
and Antiinflammatory Agents sider are that most infections come from the
patient's own flora. Consequently, we must
Endophthalmitis following cataract sur- effectively kill bacteria in the skin, lids and
gery is a rare complication. When it occurs, ocular surface before making an incision in the
however, it becomes the most serious postop- eye itself. For this purpose, you may place 5%
erative complication. We will discuss its pre- Betadine solution inside the fornix and leave it
vention in this chapter and its management in there for 2 minutes before washing it out of the
the chapter on Complications from Cataract eye. This is followed by painting the lids with
Surgery. 10% povidone-iodine solution.
The use of preoperative, intraoperative Peter McDonnell, MD., has pointed out
and postoperative antibiotics and antiinflam- that endophthalmitis is difficult to study scien-
matory agents and the very careful cleaning of tifically, because it occurs so rarely. Al
the lids are generally accepted as the standard Sommer, M.D., the Dean of the School of
of care in patients undergoing cataract surgery. Public Health at Johns Hopkins University,
has emphasized that to do a prospective, ran-
domized trial in order to prove that a specific
Effective Preoperative Antibiotic
management lowers the risk of endophthalmi-
Treatments tis, is close to impossible. There are almost no
scientific data proving that various strategies
There is no agreement as to which is the clearly reduce the risk of this complication.
most effective type of antibiotic as well as the Such data are even harder to obtain now be-
dosage and route of administration to prevent cause, as incision sizes have gotten smaller, the
postoperative infectious endophthalmitis. We risk of endophthalmitis has dropped. But as
do know, however, that aminoglycosides are incision sizes have dropped, so has the time
toxic to the healing cornea while that it takes for surgery. This, of course,
fluoroquinolones are not. The former have reduces the risk.
also gaps in the antibacterial spectrum of activ- Henry Perry, M.D., has also brought
ity and the latter (i.e. ciprofloxacin and out another important point: In patients where
ofloxacin) are more potent for a wide spectrum the posterior capsule breaks or there is need for
of bacteria with less toxicity. a vitrectomy, those patients should be treated
With regard to prophylaxis in an era of with extra antibiotics because the risk for infec-
increasing use of small incision cataract sur- tion significantly increases depending on
gery where corneal incision without conjuncti- whether it is just the capsule that has ruptured
val protection over it is becoming the proce- or whether you actually had to do a vitrectomy.
63
nology ocular surgery, Gills outline is an excel-

Regimens Recommended lent measure to follow. The following is his
step by step procedure.
Considering that there are so many alter- 1) Gills considers that filtering all the
native regimens for minimizing the develop- irrigating solutions through a 0.2 micron
ment of infection, depending on the personal millipore filter is a major step forward in
choices of different successful surgeons, I am minimizing infection, particularly endoph-
hereby presenting what I consider two alterna- thalmitis. Following his use of filtration, the
tives that appear to be effective and safe. incidence of endophthalmitis at Gills Institute
has significantly reduced from 1-2 per 1000,
Gills Formulas to Prevent Infec- which was the same as the national average in
tion the U.S. to an overall incidence of 1 in 8000 to
10,000.
2) After years of successfully using
1) For High Volume Cataract antibiotics (gentamicin and vancomycin) in the
Surgery irrigating solution, Gills has changed to what
he considers maximum security, which is as
As proposed by James Gills, M.D., after follows:
years of profound clinical analysis of this sub- A) Preoperatively, 15 minutes prior to
ject on many thousands of his own patients. transfer to the operating room:
Gills' regime is complex particularly when it a) Neosynephrine 10% one drop.
comes to the preparation of two antibiotic mix- b) Ocuflox 0.3% mixed with Indocin,
tures with two antiinflammatory agents one drop.
(NSAIDS) for injection into the anterior cham- This combination of Ocuflox (a
ber at the end of the operation. The accurate fluoroquinolone) and Indocin (a non-steroidal)
preparation, mixture and exact dilution of a is prepared as follows: Reconstitute 1 mg of
variety of medications that needs to be done Indocin with Ocuflox. Reinject into Ocuflox
with absolute accuracy and in very small doses bottle and use one drop of this mixture.
for injection routinely into the anterior cham-
ber is a big step forward in minimizing endoph- B) In the Operating Room
thalmitis, based on Gills' extensive experi- a) Tetracaine: 0.5% 1 gtt x 3 (3 min.
ence. The disadvantage is, however, that such apart with final drop instilled just prior to
multiple steps of preparing these mixtures by beginning).
operating paramedical personnel in some large b) Betadine BSS: 1 gtt x 3 (2 gtts at the
institutions where not only ophthalmic surgery beginning of the case, 1 gtt at the end).
is performed may be somewhat risky. A small Preparation: Draw up into the syringe
human error is feasible, particularly on the side 5 cc of BSS followed by 5 cc of Betadine
of mistakenly applied larger doses, which may solution 10%.
lead to toxicity of the ocular tissues. In large Change needle to 18 gauge filter needle
private eye centers, where the paramedical wil filter and inject into sterile empty vial. Use
personnel is exclusively dedicated to high tech- the drops on the eye as outlined above but
obtained from this prepared mixture.
64
c) Cyloxan (antibiotic): Instill one drop they cannot enter the soft eyes that may occur
at the end of the operation. within the first hour after surgery. During this
d) Intraocular anesthesia (Intracam- critical period it is important to make sure that
eral): Irrigated inside the anterior chamber the eye is clear and clean.
(see Chapter 6).
Gills no longer uses antibiotics in the C) Oral Medications: These are in-
irrigating solution. Instead, he feels there is a stilled before the antibiotic ointment.
more effective control by using a combination Ibuprofen 200 mg ÷ tablet given pre-op
of antibiotics and antiinflammatory drugs di- and ÷ tablet postop unless contraindicated.
rectly injected into the anterior chamber at the
end of the operation. This combination of 2) Non-Complex, Effective and
drugs is obtained as follows: Safe Alternative for Prevention of In-
f) Post-op Anterior Chamber Injec-
fection
tion of Indomethacin, Solucortef and Two
Antibiotics
The regimen that follows is practical and
• Draw up 14.4 ml BSS into a syringe and
effective, one which every ophthalmic surgeon
inject 12.4 ml of this BSS into an empty sterile
may use with excellent results.
bottle.
• Use the remaining 2 ml to reconstitute 1) Asepsis
two 1 mg vials of Indomethacin. Follow the same routine previously
• Add both of the 1 ml vials of In- outlined for thorough cleaning of lids and skin
domethacin solution to the 12.4 ml bottle con- with soap and 10% povidone iodine solutions.
taining BSS making 14.4 ml of total volume. The same applies for use of 5% Betadine 1 drop
• Add 8 gtts of Solucortef 125 mg/ml topically, Betadine 5% solution inside the
(8 minims using TB syringe), 0.06 fornix leaving it there for 2 minutes before
Cephtazidime 50 mg/ml. washing it out of the eye.
• 0.1 ml Vancomycin 500 mg/10 ml to 2) Preop antibiotics: none.
the 14.4 ml bottle of Indomethacin solution. 3) Filtration of irrigating solution
• Dosage per patient: 0.50 ml of this If the micropore filter is available,
mixture is injected into the anterior chamber at by all means use it as recommended by Gills.
the end of the operation. 4) Intracameral irrigation at end of
g) Recovery Room: Polytracin oint- operation
ment x 1. Yes. Irrigate the anterior chamber with
In doses higher than those described in an effective mixture of:
this outline, Vancomycin and Cephtazidime A) One antibiotic and one steroidal anti-
would interact and precipitate out of solution. inflammatory mixture containing:
Gills states that he has no problems with the a) Gentamicin 0.5 ml drawn from
minute concentrations used for intraocular in- a vial containing 40 mg / ml.
jection. At the end of the operation, topical b) Prednisoloneacetate (Depomedrol)
Betadine® drops are instilled in the eye. 0.5 ml solution from a vial containing 40 mg /
Betadine eliminates flora in the cul-de-sac so ml.
65
This combination is easy to use, it pro- recommended. Both of these antibiotics are
vides very little risk of confusion and is most very effective. You may use one or the other.
effective. They may be instilled immediately following
surgery and started four times a day within one
5) Topical instillation after intracam- hour of surgery.
eral irrigation Antimicrobials should be used only for
the shortest period of time needed to obtain the
In cataract surgery there are many ways desired effect and should never be tapered
to reduce the ocular surface flora which is the but simply discontinued. Do not prescribe
main source of contamination that may lead to them at a frequency of less than four times
endophthalmitis. It is also quite clear the daily.
usefulness of Povidone-Iodine as an antiseptic Antibiotics in the first seven days may be
in the skin and lids and Betadine gtts topically used in combination with a steroid. However,
preoparatively as outlined previously. The use once you discontinue the topical application of
of preoperative antibiotics has never been a the antibiotic within seven days, if everything
subject of consensus essentially because there looks well, the patient has to continue with
is no fundamental evidence that they really steroids.
contribute to minimize the risk of infection.
Most Frequently Used Anti-in-
Antibiotics Most Commonly Used flammatory Agents
As to the use of postoperative antibiotics The most frequently used antiinflamma-

which is the subject we discuss here, the sub- tory agents applied topically are Prednisolone
conjunctival injection of antibiotics is not Acetate 1%, commercially known as Prednefrin
recommended by the majority of experts. Forte by Allergan or Econopred by Alcon.
The general consensus, however, is that imme- These may be started promptly following sur-
diately following cataract surgery, the postop- gery, so that the medication starts its effects
erative use of antibiotics and antiinflammatory immediately and continued depending on the
agents applied topically is an important com- clinical findings and the surgeon's individual
ponent of the formula for successful results. preference.
Antibiotic ointment used immediately at the In cataract surgery, there is an inherent
end of surgery is certainly the preference of difficulty in establishing consensus guidelines.
most surgeons. Those outlined above are the most generally
The antibiotics most commonly used to- accepted by advanced surgeons. It is important
day in the form of drops are Ciprofloxacine that the antibiotics, particularly the
(Ciloxan from Alcon) or Ofloxacine (Ocuflox fluoroquinolone family, which are indeed very
in some countries or Oslox in others , manufac- effective as an antimicrobial medication, be
tured by Allergan). The routine use of antibi- used no more than seven days, unless there is a
otic drops q.i.d. for seven days is the dosage specific indication to continue the antibiotic.
66
Antibiotics in Irrigating Solutions Postoperative Antiinflammatory

Agents
The previously widely used practice of
using antibiotics in irrigating solutions are of We already described the use of antiin-
questionable value. Their use has not been flammatory agents by irrigation into the ante-
proven to be effective, mainly because the rior chamber immediately following the op-
concentration and the duration or the exposure eration. Gills uses a combination of non-
of the antibiotic to the bacteria is insufficient to steroidal antiinflammatory agents (Indometha-
achieve a killing effect. A much better proce- cin) and a steroidal medication within the ante-
dure is to instill within the anterior chamber a rior chamber, mixed with two antibiotics. In
combination of antibiotic and antiinflamma- the other more simple and very effective alter-
tory agent as outlined previously. There also native which we have outlined, 0.5 ml of Pred-
seems to be a general consensus not to use nisolone Acetate (Depomedrol) combined with
Vancomycin in the irrigating solutions or for 0.5 ml of antibiotic (Gentamycin) are irrigated
irrigation of the anterior chamber immediately intracamerally immediately following the op-
following surgery. Prospective studies seem to eration.
indicate some potential toxicity particularly a Postoperatively, the most effective anti-
clinical significant cystoid macular edema and inflammatory agents is a combination of Pred-
decreased best corrected visual acuity in cata- nisolone Acetate 1% q.i.d. gradually tapered
ract patients receiving Vancomycin in the irri- over eight weeks and a non-steroidal antiin-
gating solutions as compared with controls. flammatory drug such as Voltaren® q.i.d. for
This is not a proven fact but it is a potential for two weeks. Either Voltaren or Acular® are two
concern that has been expressed by the Centers commonly used and effective medications. It
of Disease Control in the United States. is also known that topical diclofenac can re-
duce pain, burning and inflammation. It may
Patching also be effective in reducing photophobia after
pupil dilation. The mechanism is not known.
Following phacoemulsification, patch- However, the use of diclofenac alone is not
ing is not used unless the patient lives very far sufficient to eradicate all inflammation. Supple-
away and may be at risk for trauma during his mental topical steroid is necessary to com-
trip back home. Practically all patients today pletely control inflammation.
are operated in outpatient surgical centers or This combination of postoperative medi-
eye clinics that have their own operating room cations applied topically not only contribute to
and they go home without patching and start the prevention of inflammation and infection
using the topical antibiotics and antiinflamma- but also significantly contribute in the patient's
tory agents immediately after getting home so postoperative comfort.
that the medication will start with their effect
immediately.
67
BIBLIOGRAPHY
Boyd, BF.: Cataract/IOL Surgery, Section V-A,

World Atlas Series of Ophthalmic Surgery, High-
lights of Ophthalmology, Vol. II, 1996; 5:17.
Chitkara DK., Jayamanne DGR., Griffiths PG.,

Fsadni, MG.: Effectiveness of topical diclofenac in
relieving photophobia after pupil dilation. J Cata-
ract Refract Surg 1997; 23:740-744.
Gills, JP.: Pharmacodynamics of cataract surgery,

Cataract Surgery: The State of the Art. Slack;
1998; 3:19-22.
Lane, S., et al: Antibiotic prophylaxis in oph-

thalmic surgery, Ocular Surgery News, Special
Supplement, Jan. 2000.
O'Brien, TP, et al: Antibiotic update, current treat-

ment modalities in ophthalmic surgery, Ocular
Surgery News, Special Supplement, May 1998.
Perry, HD., Hoffman, J. et al: Choosing an antibi-

otic for perioperative use, Ocular Surgery News,
Supplement on Antibiotics, July 1998.
68
C h a p t e r 5: P ro c e e d i ng W i t h t h e O p e r a t i o n
PROCEEDING WITH THE OPERATION
PREPARATION, SEDATION agents which vary according to the

AND ANESTHESIA anesthesiologist's and surgeon's choice. In
the holding area, Jack Dodick, M.D. in New
York, applies a prudent amount of ocular
Preparation of Patient compression to the eye and orbit for 10-15
minutes. He finds this very beneficial in
Unless the patient is scheduled for gen- lowering the intraocular pressure. This ma-
eral anesthesia or is likely to be operated under neuver lowers the volume of the fluid inside
very heavy sedation (non-airway supported) it of the eye and orbits thereby leading to a
is unnecessary to keep these usually older, hypotensive eye. This creates a more favor-
fragile patients fasting for a large number of able surgical environment. This maneuver
hours. This only contributes to fatigue and was previously done using Honan's ballon in
anxiety. It is also contraindicated to have the conjunction with peribulbar or retrobulbar
patients remove all their clothes. This inter- injection of local anesthetic, procedures no
feres with the patient's sense of privacy and longer used in small incision cataract surgery.
contributes to further anxiety as to what is to The patient is made comfortable in the re-
come. clining chair which is very much like a first
The patient is made comfortable in the class seat on an airplane that reclines in an
holding area, where he or she is met by the almost 180 degree position. Other surgeons
attending nurse, who then explains what is prefer to place the patient on an operating
going to transpire. Presurgical checks are table specially adapted to their needs and
conducted, and the nurse instills whether they operate from above or on the
Neosinephrine 10% and tropicamide 1% two side.
drops each in order to dilate the pupil and one
drop of antibiotic and of Betadine solution, Sedation
depending on the surgeon's preference. This
subject is discussed in Chapter 4. Long What sedation to administer depends on
acting pupillary dilating agents such as the individual patient's emotional profile,
cyclopentolate, atropine, homatropine or sco- which the surgeon should have detected dur-
polamine have no role in today`s small ing his preoperative evaluation. In most
incision surgery. cases, 5 mg of Valium per mouth on arrival to
The patient is then transported to an- the clinic leads to sufficient relaxation so that
other holding area in the operating room suite he or she feels comfortable during surgery.
either by walking or on a lounge chair on Dodick prefers for the anesthetist to adminis-
wheels. There the patient is met by the anes- ter a small dose, 1 mg, of Versed intrave-
thesiologist, who explains that an intravenous nously. Versed, like Valium, is a member of
line will be started and administers sedative the benzodiazepine family, but it has a much
71
shorter half-life. Whereas valium takes up to 1) Blocks by Injection Anesthesia

24 hours to be metabolized by the liver, with Sharp Metal Needles
Versed is totally out of the body in less than 2
hours. The patient is totally sedated for about a) Retrobulbar: no longer used except
10 minutes and the patient is wide awake in exceptional cases.
and alert after 10-15 minutes, which is the b) Peribulbar: no longer used.
time the operation lasts. The drug is gone c) Parabulbar: no longer used.
from the system within 2 hours. With valium, d) Van Lint, O'Brien, Nadbath for
on the other hand, patients sometimes feel controlling lid contraction: no longer used.
groggy for a day or two. e) Hyaluronidase: after many years of
recommending its use, it has been finally
Pupillary Dilation shown that hyaluronidase is not an important
factor in obtaining akinesia more promptly or
Pupillary dilation is critical to the suc- having a more lasting effect.
cess of ECCE, especially phacoemulsifica-
tion. Cycloplegic/mydriatic drops, adminis- 2) Sub- Tenon's with a Flexible
tered preoperatively, effectively dilate the pu-
Needle
pil, while topical nonsteroidal antiinflamma-
tory drops can help to maintain dilation dur-
This is a highly effective anesthesia
ing surgery. These medications are instilled
mostly used in combination with topical anes-
topically at the time of preparation of the
thesia by surgeons who are either beginning
patient before entering the operating room.
or already are in the transition period of
ECCE to phacoemulsification. This combi-
ANESTHESIA nation is also the procedure of choice by
surgeons who perform extracapsular extrac-
Topical tion or small incision manual extracapsular.
Prospective, randomized studies have con-
All patients have two or three drops of cluded that single-quadrant, direct sub-
proparacaine or tetracaine instilled in the eye, Tenon`s injection of anesthetic is as rapid and
regardless of the type of anesthesia the effective as retrobulbar injection for cataract
surgeon decides to use. One drop every surgery (Figs. 33 and 34). It provides better
minute x 3 is a standard protocol (Fig. 35). anesthesia with comparable akinesia.
The most common complications are
Selection of Anesthetic Method chemosis and subconjunctival hemorrhage,
but no major complications are encountered.
There are a variety of anesthetic meth- The dispersion of anesthetic fluid under
ods known to all of you. We will list them Tenon's is effective enough to substantially
here and proceed to identify those that no diminish lid discomfort. For these reasons,
longer have a place in small incision cataract Sub-Tenon's anesthesia using a flexible can-
surgery. They are: nula has replaced retrobulbar and peribulbar
except in very unusual cases.
72
Figure 33 (above right): Sub-Tenon's

Local Anesthesia with Flexible Can-
nula - Surgeon´s View
Forceps (F) lift the conjunctiva-

Tenon´s capsule in the inferior nasal or
inferior temporal quadrants between the
rectus muscles 3 mm from the limbus. A
small 1 mm buttonhole is cut with scissors
(not shown). A Greenbaum flexible can-
nula (C) is advanced (arrow) through the
buttonhole until conjunctiva and Tenon´s
fits snugly over the hub of the syringe. 2.5
cc of local anesthetic is infused quickly,
creating a gush of fluid using the "bolus"
technique. If additional anesthesia/akine-
sia is needed during surgery, the cannula
may be re-introduced.
Figure 34 (below left): Sub-Tenon's

Local Anesthesia with Flexible Cannula
- Cross Section View
This cross section view of the left

eye shows the position of the flexible
Greenbaum cannula during infusion of an-
esthetic. The cannula (C) is directed poste-
riorly and fluid infused (white arrow) in the
sub-Tenon´s space. Inset 1 shows the flex-
ible nature (black arrow) of the cannula
which provides virtually no risk of globe
perforation or retrobulbar hemorrhage. In-
set 2 shows the rounded, blunt tip with D-
shaped port of the half-round cannula.
73
Technique for Performing Sub- wider popularity of the clear corneal tunnel
Tenon's incision as first emphasized by I. Howard
Fine, M.D., (Oregon, USA).
When performing a Sub-Tenon's local Most surgeons who use this incision
anesthesia, 1.5 ml of lidocaine is injected. now do it from the temporal side, which
Under topical anesthesia, a small incision is requires a series of readjustments in the
made in the fused conjunctiva/Tenon's cap- operating room. This procedure requires
sule 3 mm from the limbus (Fig. 33). If the the use of a foldable IOL. A corneal tunnel
surgeon is right handed, it is easier to perform sutureless valve incision no larger than
the incision at the inner lower quadrant be- 3.0 mm is recommended. Otherwise, corneal
tween the rectus muscles in the right eye and complications may arise and the incision would
at the lower temporal quadrant in the left eye. not be self-sealing.
If the surgeon is left handed, it would be the
opposite. The surgical plane of Tenon's at- Advantages of Unassisted Topical
tachment to the sclera is carefully dissected Anesthesia
and the cannula is advanced through this
apperture (Fig. 34). It is very important This term refers to the use only of anes-
that the cannula is always in sub-Tenon's thetic drops to obtain sufficient anesthesia to
plane. Otherwise, if it is only under the perform the cataract operation. Edgardo
conjunctiva, the flushed anesthetic solution Carreño, M.D., Professor of Ophthalmology
will backflush or will infiltrate all throughout at the Funcacion Los Andes, Santiago, Chile
the subconjunctival space, where it becomes and a phacoemulsification expert, considers
ineffective and creates chemosis. that the use of topical anesthesia using a clear
The cannula is advanced under Tenon's corneal tunnel self-sealing valve incision is a
until the conjunctiva/Tenon's fits snugly over significant advance in cataract surgery. With
the hub of the 3 cc syringe. 1.5 cc of the topical anesthesia, visual recovery is immedi-
local anesthetic is infused using the "bolus" ate. Other advantages as outlined by Carreño:
technique. The anesthetic is infused quickly 1) It prevents the well-known complica-
creating a gush of fluid that spreads through- tions of retrobulbar and peribulbar injections
out the retro and parabulbar spaces (Fig. 34). 2) It lowers the time of operating room
use thereby lowering costs.
Unassisted Topical Anesthesia 3) There is no immediate postoperative
ptosis, which with retrobulbar or peribulbar
Most ophthalmic surgeons, when using and Van-Lint-O'Brien infiltrations lasts from
unassisted topical anesthesia, in which 6-8 hours due to temporary akinesia of the lids
only drops are administered, use it only when (as contrasted with the late postoperative pto-
performing phacoemulsification and IOL im- sis which is related to the bridle suture on the
plantation through a clear cornea tunnel superior rectus). It provides for immediate
incision. The increased acceptance of topical postoperative visual recovery which, again, is
anesthesia is directly related to the somewhat its main advantage.
74
Disadvantages of Unassisted Topi- 4) The presence of a very opaque cata-

cal Anesthesia ract is a contraindication to the use of topical
anesthesia (Fig. 1-B). This is because the
Many surgeons who have performed surgeon depends on the patient's capacity to
cataract surgery utilizing "unassisted" topical visually concentrate on the operating micro-
anesthesia, that is, topical drops alone, agree scope light in order to avoid eye movement
with Paul S. Koch, M.D., that pure, unassisted during the operation. If he/she cannot fixate
topical anesthesia is fairly disappointing. He well on the microscope light and maintain that
estimates that one out of four patients have fixation, the eye will move. This may lead to
some sensation during the operation. Some- complications.
times, patients feel pressure build up in the eye In essence, adequate selection of patients
during injection of viscoelastic. Some feel iris is fundamental when considering the use of
manipulation. Others are aware of the sensa- topical anesthesia.
tion of the lens being implanted into the eye.
Koch found that he felt uncomfortable operat- The Anesthetic Procedure of
ing on these people, because he never knew in Choice
advance who would be comfortable and who
would not. It is the general consensus today among
Other disadvantages and limitations as surgeons experienced with phacoemulsifica-
outlined by Carreño are: tion that a combination of topical anesthesia
1) Only a highly experienced surgeon (proparacaine 1% or tetracaine 1%) and 0.5 cc
should operate with topical anesthesia. The of 1% unpreserved lidocaine irrigated into the
eye can move, which makes the operation more anterior chamber through a 30-gauge cannula
difficult. If the eye movement occurs while (Figs. 35 and 36) is the anesthetic procedure of
capsulorhexis is being done, an undesirable choice for small incision cataract surgery, par-
capsular tear may take place leading to failure ticularly phacoemulsification. This important
of this important stage of the operation. breakthrough in ophthalmic anesthesia was
2) The most controversial argument introduced by James Gills, M.D. in 1997.
against topical anesthesia is an intraoperative
complication. Consequently, the surgeon must Technique for Irrigation of Lidocaine
be highly skilled so as to:
in AC
a) expect as few intraoperative com-
plications as possible. b) be able to convert to
Dodick first makes a clear cornea inci-
another method of anesthesia during the intra-
sion using a 2.7 mm diamond knife. He believes
operative stage. Topical anesthesia by itself
that the non-preserved lidocaine irrigated into
may be insufficient for the surgeon to ad-
the anterior chamber anesthetizes the nerves
equately handle intraoperative complications.
of the iris and the ciliary body. The pressure
3) Topical anesthesia is not indicated in
waves that ensue during irrigation and aspira-
all patients. This is particularly true in
tion in the midst of the phaco operation can
anxious, stressed patients, people with hearing
sometimes impinge upon those nerve fibers
limitations, children and very young patients.
and lead to discomfort. In addition, Dodick has
75
Figure 35: Topical Anesthesia
Unaided topical anesthesia is now

a commonly used method in small inci-
sion cataract surgery because it is user
friendly and comfortable for the patient.
Only expert small incision surgeons
should use it without the aid of another
method. Most surgeons prefer to use topi-
cal anesthesia combined with intracam-
eral anesthesia (Fig. 36) in small incision
cataract surgery. This illustration shows
the use of anesthetic drops (A) such as
proparacaine or tetracaine, one drop ev-
ery 10 minutes, 30-45 minutes preopera-
tively.
observed that this anesthesia inside the eye number of patients and by different surgeons.
helps dull the patient’s sensitivity to the bright In papers published based on monitoring pa-
light of the microscope by temporarily block- tient discomfort, not by a subjective
ing some photoreceptor cells. The rest of the questionaire, but by objectively measuring vi-
operation is continued through the same clear tal signs during surgery. the data support the
cornea incision. conclusion that patients operated with anterior
Intraocular unpreserved lidocaine irri- chamber irrigation of unpreserved lidocaine
gated into the anterior chamber as outlined has feel comfortable during the procedure, despite
been proven safe and convenient. having had no intravenous sedation and re-
Even though a few researchers (i.e. Gillow gardless of sex or age and dismiss the subjective
et al, Boulton et al) have concluded that the nature of postoperative questioning patients
routine use of intracameral lidocaine as a supple- concerning discomfort. In view of the small
ment to topical anesthesia in routine controversy existing, we must rely on the proven
phacoemulsification does not have a clinically extensive experience of well known, presti-
useful role, these experiences constitute a sig- gious, cataract surgeons such as James Gills,
nificant minority and are based on postoperative M.D., and Paul Koch, M.D., here presented.
questioning of patients concerning discomfort An alternative technique for intracam-
or by well documented trials but in medium eral irrigation of 0.5 cc of 1% lidocaine is the
76
Figure 36: Use of Intracameral Anesthesia done with the aid of fine toothed forceps (F)
in the contralateral side of the ancillary inci-
After instilling anesthetic drops on the sion acting as counterpressure. One dose of
conjunctiva and cornea (Fig. 35) the surgeon en- 0.5 ml of 1% unpreserved lidocaine is irri-
ters the anterior chamber through the ancillary gated into the anterior chamber. The prelimi-
incision (I) (Fig. 41-A) using an insulin syringe nary marking of the main incision is shown
with a 30 gauge cannula (C). This maneuver is in (A).
one proposed by Paul S. Koch, M.D (Fig. 36). 30-gauge cannula (Fig. 36). Most of the time,
He uses a 15º blade in his left hand and .12 the patient does not feel anything, but some-
forceps in the right hand. The blade is placed times, either because of intraocular pressure
where he wants the sideport entry incision and changes or the effect of direct flow onto the iris,
the forceps 180º away from that, resting on the the patient may feel a little discomfort. This is
peripheral cornea (Fig. 36). The forceps are not a matter of concern because in a matter of
only pressed against the cornea. They do not seconds the discomfort dissapears.
grab it, because the purpose of the forceps is Koch squirts the little extra lidocaine
only to provide counter pressure for the inci- that remains in the syringe on the surface of the
sion. The blade is then used to make an incision cornea, providing additional topical effect. The
approximately 1 mm wide and 1 mm long, eye is not paralyzed, and an occasional patient
beginning in the peripheral clear cornea. may move it, but this is not nearly the problem
That incision is completely comfortable, that it is with topical anesthesia. The lack of
because it is no more than a corneal manipula- discomfort makes it unnecessary for the patient
tion, and the cornea is still anesthetized from to want to move the eye, and Koch as well as
the original drops given in the holding unit. Gills have found that cooperation in keeping
Then, 0.5 cc of 1% unpreserved lidocaine the eye still is excellent.
is irrigated into the anterior chamber through a
77
Injection of Viscoelastic operation. This clinical observation may sup-

port Koch's hypothesis, because in the absence
The eye anesthetizes quickly, and the of a posterior capsule the lidocaine could dif-
fuse back toward the retina that much more
anesthesia is very profound. Usually in less
easily. As the lidocaine wears off, the visual
than 10 seconds, the eye is already anesthe-
acuity and contrast sensitivities recover.
tized, and the viscoelastic injection is performed
quite comfortably.
How to Manage Patients Who Feel
Pain and Discomfort
What Can be Done with the Com-
bined Anesthesia If the patient continues to blink or squeeze
the eyelids following the combined topical and
Because the combination of topical and intracameral anesthesia, you can control this
intracameral irrigation anesthesia is so effec- with the sub-Tenon's injection of lidocaine as
tive, the surgeon can perform cataract surgery, illustrated in Figs. 33 and 34. The effect is
lens implantation, iris manipulation, and even almost instantaneous, and surgery can con-
vitrectomy if a complication arises usually tinue without delay.
without any further injection of anesthetic. If a
patient does feel some discomfort, a second PHOTOTOXICITY IN
irrigation may be performed. Patients with
mental retardation and those with deafness CATARACT SURGERY
have been successfully operated with this anes-
thetic combination as long as the surgeon takes Since all cataract surgery is done
the time to explain prior to surgery that he under the microscope, we should clarify here
wanted them to look at the light and keep the practical and clinical aspects of light or
phototoxicity from the surgical microscope. It
looking at the light.
has been demonstrated that in some patients
and under specific circumstances, toxicity from
Side Effects of the Combined the light of the microscope can affect the macula.
Anesthesia This is seen with fluorescein angiography,
which shows an area of pigment abnormality
Lidocaine has an effective duration of up usually below the fovea. The visual field in
to 4 hours. Patients may not see very well these patients shows that in this area there is
immediately after the operation, but then a few severe to moderate phototoxic damage to the
hours later the vision really improves. Koch photoreceptors. Without these tests,
has concluded that patients have a temporary, phototoxicity can be difficult to determine and
neuro-sensory, retinal blockade causing tran- to see.
sient blurring of vision following the operation. The major factors involved with
He has postulated that the anesthetic may dif- phototoxicity are the time of exposure, the
fuse back to the retina and perhaps has a direct tilt and the illumination intensity. (It is
effect on the ganglion cells. Gills had a patient important to realize how hard it is to get away
with an open posterior capsule who had signifi- from the macular area if we are centered over
cant vision loss for about 24 hours after the the pupil).
78
The microscope has three light sources: BIBLIOGRAPHY

the two side lights and the coaxial beam. Each
of these light sources produces a focal point of Anders, N., Heuermann, T., Ruther K., Hartman,
illumination on the retina. It is not the time C: Clinical and electrophysiologic results after in-
length of the operation that is important. It is tracameral lidocaine 1% anesthesia. Ophthalmol-
ogy 1999; 106:1863-1868.
the time the light is focused on one particu-
lar area of the retina which is critical.
Boulton JE., Lopatatzidis A., Luck J., Baer RM.:
In addition, within the period which any A randomized controlled trial of intracameral
one operation lasts, sequential light exposure lidocaine during phacoemulsification under topical
to the same retinal area is additive. If we turn anesthesia. Ophthalmology, 2000; 107:68-71.
on the light on one spot for three minutes, turn
it off and then turn it on that same spot for Boyd, BF.: Cataract/IOL Surgery. World Atlas
another four minutes, the effects of those expo- Series of Ophthalmic Surgery, HIGHLIGHTS OF
sures are additive. If, in a certain patient and OPHTHALMOLOGY, Vol. II, 1996; 5:21-22.
with a certain intensity of light from the micro-
scope, we expose one macular area during Boyd, BF: Significant developments in local anes-
thesia. Highlights of Ophthalmol. Bi-Monthly Jour-
three minutes, we may have no lesion whatso-
nal, Vol. 23, Nº 6, 1995 Series, pp 55-62.
ever but if the total exposure extends to seven
and a half to eight minutes, a lesion may occur. Carreño E.: Phacoemulsification Sub-3 technique.
In the human eye, with the standard surgical Guest Expert, Boyd’s BF., The Art and the Science
microscopes on maximum intensity of light, of Cataract Surgery, Highlights of Ophthalmol-
it probably only takes four to eight minutes ogy, 2001.
to produce a retinal lesion. Most phototoxic
burns are seen in the inferior part of the fovea. Fichman RA: Use of topical anesthesia alone in
We should leave the light source on the cataract surgery. J Cataract Refract Surg, 1996;
lowest setting. 22:612-614.
The potential for trouble related to
Gillow T., Scotcher SM., Deutsch J., While A.,
phototoxicity in cataract surgery is not often
Quinlan MP: Efficacy of supplementary intracam-
recognized. The patient may have 20/25 vision
eral lidocaine in routine phacoemulsification under
postoperatively and still complain that he does topical anesthesia. Ophthalmology, 1999; 106:2173-
not see adequately. Only after fluorescein 2177.
angiography and a visual field can we then
explain why these patients complain. Even the Gills JP., Cherchio M., Raanan MG.: Unpreserved
most experienced of us need to be aware of the lidocaine to control discomfort during cataract sur-
potential for phototoxicity and take the steps to gery using topical anesthesia. J Cataract Refract
avoid it. Surg. 1997; 23:545-550.
Gills JP., Martin RG., Cherchio M.: Topical anes-

thesia and intraocular lidocaine. Cataract Surgery:
The State of the Art, Slack; 1998; 2:9-17.
Koch, PS.: Anesthesia. Simplifying Phacoemulsi-

fication, 5th ed., Slack; 1997; 2:12-26.
79
Koch, PS.: Anterior chamber irrigation with

unpreserved lidocaine 1% for anesthesia during
cataract surgery. J Cataract Refract Surg. 1997;
551-554.
Koch, PS.: Preoperative and postoperative medica-

tions of anesthesia. Current Opinion in Ophthal-
mology 1998; 9;1:5-9.
Koch, PS.: Preoperative Preparation . Simplifying

Phacoemulsification, 5th ed., Slack; 1997; 1:1-11.
Masket S.: Ocular anesthesia for small incision

cataract surgery. Atlas of Cataract Surgery, Edited
by Masket-Crandall, Published by Martin Dunitz
Ltd., 1999; 15:111-114.
Naor J., Slomovic AR.: Anesthesia modalities for

cataract surgery. Current Opinion in Ophthalmol-
ogy, Vol. 11 Nº 1, Feb. 2000.
Tseng SH., Chen FK: A randomized clinical trial of

combined topical-intracameral anesthesia in cata-
ract surgery. Ophthalmology 1998; 105:2007-2011.
80
C h a p t e r 6: P h a c o e m u l s i f i c a t i o n - W hy S o I mp o r t a n t ?
PHACOEMULSIFICATION
WHY SO IMPORTANT?
Phacoemulsification is the "state of the visual recovery takes place slowly through a
art" operation of choice for cataract surgery in period of 5 to 6 weeks.
academic institutions and private eye centers In small incision manual
worldwide. Ophthalmologists in training (Resi- extracapsulars such as with Blumenthal's
dencies and Fellowships) receive training in MINI NUC and Gutierrez manual
phacoemulsification first and manual extra- phacofragmentation, a foldable IOL may be
capsular as a second choice. implanted. Both of these procedures are fully
presented in the Section on Manual Extracap-
COMPARING PLANNED sular Extraction in this same Volume follow-
EXTRACAPSULAR WITH PHACO ing Phacoemulsification. Visual recovery is
EXTRACAPSULAR much more rapid.
With planned extracapsular extraction ADVANTAGES OF THE PHACO

an 8-9 mm limbal incision is performed, TECHNIQUE
preceded by a conjunctival flap (either limbal
based or fornix based). The anterior capsule is The phacoemulsification technique of-
usually opened with a "can opener" fers the following benefits and advantages over
capsulorhexis technique. Some surgeons have planned extracapsular as outlined by Edgardo
developed the expertise to do a continuous Carreño: 1) it is performed through an inci-
circular capsulorhexis. The nucleus is then sion 3mm or less in size which is self-sealing
expressed with gentle pressure inferiorly such and watertight thereby improving safety dur-
that the lens is subluxated in its entirety into the ing the procedure. 2) It is significantly less
anterior chamber and out of the eye through a invasive thereby leading to much less ocular
superior limbal incision (Fig. 37). Aspiration trauma and consequently less postoperative
is used to remove the remaining cortex from inflammation. 3) It results in minimal or no
the capsular bag and viscoelastic is irrigated induced astigmatism. 4) It provides much
into the anterior chamber and capsular bag more rapid visual and physical recovery and
(Fig. 38). A PMMA intraocular lens im- prompt refractive stability. The visual recov-
plantation is performed (Fig. 39) and the ery is immediate if topical anesthesia is used.
wound is sutured. All these advantages lead to an important in-
In planned extracapsular, which is still crease in the patient's quality of life. In addi-
ably and successfully performed by a signifi- tion, a smaller incision also may reduce the risk
cant number of ophthalmic surgeons, the final of endophthalmitis.
83
Figure 37: Planned Extracapsular
With planned extracapsular, the anterior

capsule is opened with a "can opener"
capsulorhexis technique. The nucleus is ex-
pressed with gentle pressure inferiorly. Pressure
(black arrow) is applied on the posterior wound
lip. The nucleus (N) is slid out of the eye (white
arrow). The incision shown here is medium in
size (5-6 mm) and allows implantation of a PMMA
IOL. A full incision extracapsular is 8-9 mm in
arc.
MAIN TECHNICAL DIFFERENCES Removal of the lens by phacoemulsifica-

ASSOCIATED WITH PHACO tion is followed by placement of a posterior
chamber foldable intraocular lens implant
The opening of the anterior capsule is through a 3 mm incision. The wound may
done as a continuous curvilinear capsulorhexis require one or no sutures. Variations of
(CCC) as described by Gimbel et al (see Figs. technique may involve a superior limbal inci-
43, 44, 45). An ultrasonic probe (Figs. 50-A sion with dissection of a sclero corneal tunnel
and B) is used to emulsify the nucleus and to form a self-sealing valve incision, a clear
draw it out of the eye through an aspiration corneal incision with corneal tunnel and self-
port (Chapter 8). This allows the removal of a sealing valve incision (with experienced sur-
10 mm cataract through a 3 mm incision (or geons) and the scleral tunnel incision which is
less). Because the integrity of the anterior used increasingly less but is a safe procedure
chamber is maintained throughout the proce- for difficult cases (Figs. 40, 41, 42). The limbal
dure, the intraocular pressure is subject to less and the corneal incision are either placed at 12
fluctuation and poses much less of a risk for o'clock or in the superior temporal quadrant.
suprachoroidal hemorrhage. The limbal incision and tunnel is the proce-
84
Figure 38 (above right): Irrigation with

Viscoelastic
Before insertion of the intraocular

lens, fluid in the anterior chamber and within
the capsular bag is replaced with a vis-
coelastic liquid. A cannula (C) is placed
into the capsular bag at position (B) and
viscoelastic (V) injected (arrows). The can-
nula is inserted across the anterior chamber
to a position (A) and as the cannula is
withdrawn, viscoelastic (V) is injected (ar-
rows). Replaced fluid (F) flows out through
the incision. The viscoelastic will help to
protect corneal endothelium, posterior cap-
sule and iris during insertion and intraocular
manipulation of the lens implant.
Figure 39 (below left): IOL Implantation in

Planned Extracapsular
Following aspiration of the remain-

ing cortex from the capsular bag and deepening the
anterior and posterior chambers with viscoelastic
as shown in Fig. 38, the intraocular lens is inserted
into the capsular bag. The inferior loop is directed
into the capsular bag inferiorly (arrow). The supe-
rior loop shown here is then inserted into the
superior capsular bag.
85
dure of choice for surgeons in the transition tion is equipment and instrument-dependent as
stage or who do not have a large cataract well as team-dependent, because the team as-
surgical volume because it allows conversion sisting with surgery must fully understand all
into extracapsular if necessary. Enlargement of the steps of the operation and, by all means,
a corneal incision in order convert to an extra- how the phaco machine works.
capsular extraction, often results in intolerable
postoperative astigmatism. The Importance of Mental Attitude
Both standard polymethylmethacrylate
(PMMA) or foldable (acrylic, silicone or hy- Understanding the workings of the phaco
drophilic) intraocular lenses may be used. A machine requires a complete change in mental
foldable lens allows for an even smaller inci- attitude and the undergoing of a rigorous train-
sion and less risk of postoperative astigmatism ing not only in the surgical technique, but
as a result of wound construction. Because of learning to use two feet (microscope and
the watertight wound construction of this pedal) instead of one (microscope). The sur-
method and the stability of the anterior cham- geon must also be attentive to the perception of
ber during phacoemulsification, this technique different sounds emitted by the machine, each
is amenable to topical anesthesia in a coopera- one signaling a different function and param-
tive patient (Fig. 35) or a combined topical and eters which in turn the surgeon must act upon.
sub-Tenon's local anesthesia, (Figs. 33, 34) or It is essential for the physician to understand
a combined topical and intracameral anesthe- exactly how to obtain the optimal use of the
sia ( Fig. 36) advised by Gills. The choice machine, the rationale behind it, the fluid and
mainly depends on the experience and skill of phacodynamic processes within the machine
the surgeon , but there may be special consid- and the eye and how to manage safely the
erations such as difficulty in communication equipment, safely, including the various
with the patient and in cases complicated by a handpieces and, of course, the phaco power,
patient's poor general health. and the irrigation and aspiration (see Figs. 49-
A through 65).
LIMITATIONS OF
PHACOEMULSIFICATION Motivation to Undertake this Task
Surgeons who have a successful clinical This is not an easy task. The multiple
practice, ample experience and well earned mechanical functions of the equipment are not
prestige and are using planned extracapsular "friendly" to those physicians who , althoufh
are understandably reticent and apprehensive excellent surgeons, are not mechanically
about shifting from a technique they already minded. Only the knowledge that such a
master to one which depends a great deal on the change, if successfully done, will be best for
understanding of how the phaco machine func- his/her patients can serve as the motivation to
tions. 50% of the success in doing phacoemul- undertake such a significant step.
sification depends on the proper use of the For all these reasons, many excellent
equipment at each stage of the operation. Oph- surgeons decide not to enter into phaco, and
thalmic surgeons are used to depend on their many others have the equipment available in
surgical skill. It is part of their self-esteem. As their eye center or hospital but allow it to
emphasized by Centurion, phacoemulsifica- remain idle.
86
In order to overcome these negative as- The significant economical savings to

pects of phacoemulsification, it is fundamental the patient from lost working hours with ECCE
to have a smooth transition into phaco. In order vs almost immediate recovery with phaco and
to achieve it, it is essential that you read and re- the improved quality of life with phaco are
read the next chapter (Chapter 7), which pre- other major important contributions. All these
sents the very best ways to achieve a successful are important features to consider when the so-
transition with little stress or apprehension. called expenses for both operations are taken
into account.
Comparison of Costs - Phaco vs ECCE
Phaco's Progressively Decreasing
One of the strong limitations of phaco Investment
has been the cost of not only the phaco equip-
ment but also the supplies related to its use. What about the high expenses with phaco
This is important for a significant number of equipment? There was a time when the equip-
ophthalmologists when operating on patients ment or phaco machine required a significant
who are not economically advantaged. investment. The supplies or tubing needed for
each patient was also a heavy expense when
Fixed Costs with ECCE performing several cases. All this has changed
due, in great part, to the ingenuity and under-
Let us analyze, however, the updated standing by the industry that these high ex-
situation related to costs of performing pha- penses and initial investment were a signifi-
coemulsification, and compare it with the costs cant barrier which prevented more ophthalmic
of the supplies needed to perform extracapsu- surgeons from adopting phaco.
lar extraction. With the latter, there is the cost At present, most of the companies that
of very fine sutures, which are unnecessary in manufacture phaco units are helping physi-
phaco; there is the cost of local anesthesia cians and hospitals to acquire the equipment
involved with either a retrobulbar or a paraocular and supplies. The equipment is made available
injection versus phaco in which only topical at much more reasonable prices than their real
sometimes with intracameral anesthesia is uti- sales cost, with the understanding that there
lized. The cost of the postoperative injection of will be a monthly utilization by the surgeon of
steroid in the fornix often done following ext- the phaco supplies of that particular manufac-
racapsular is also unnecessary with phaco al- turer. In addition, the manufacturer provides
though the trend now is to inject steroid in the advice and hands-on-training by experts to the
anterior chamber (see Chapter 5). The cost of surgeon so that he/she will be able to enter into
even a fairly short stay in the recovery room the transition period (Chapter 7) utilizing his/
following the often used sedation needed with her own personal equipment acquired from
an extracapsular extraction for anxiety is higher that manufacturer.
than in patients with phacoemulsification who The "tubing" which previously had to be
have had only topical anesthesia without seda- discarded after each operation is no longer a
tion and walk to their home within a few problem cost-wise. Now it may be used for as
minutes following surgery. many as 60 cases in the same day. No re-
87
sterilization is needed. The tubing may be This is important information that needs
used without replacement for a complete day to be appreciated by cataract surgeons through-
of phaco surgery. Upon completion of all the out the world interested not only in the progress
phaco cases in one day, the tubing must be of the technology of our profession but also in
discarded. Therefore, by programming the the humanitarian aspects of what we do best
surgeon´s cases accordingly, a great deal of which is ophthalmology.
savings can be made.
All of this makes the phaco technique It is also of great interest as outlined by
more accessible to a larger number of surgeons. Contreras that the number of phaco opera-
We still have to cope, however, with the needs tions being performed has increased in those
of surgeons in countries in which the gross countries with the highest gross national prod-
national product is very low. uct per person. In countries where earnings by
patients are low, phaco is still behind. In many
Major Limitations in Non-Eco- countries, only 5 to 10% of the population can
nomically Advantaged Countries afford phacoemulsification in spite of the fa-
cilities that we have outlined. Of the rest,
Experts in programs for rehabilitation of thirty percent of the population has a mid-level
sight in large numbers of indigent patients-- of income, 30% are very poor, and 30% of the
such as Francisco Contreras, M.D. in Peru, population are in extreme poverty.
Everardo Barojas, M.D. in Mexico, Juan As we continue to progress in the technological
Batlle, M.D. in the Dominican Republic, developments of ophthalmology, which is a
Newton Kara, M.D., in Brazil,-- all of whom blessing, we also need to be aware of the
are magnificent surgeons with a large private limitations existing in the populations of many
practice but also do a great deal of service to the countries throughout the world.
communities, have stated that most patients in An exemplary case is that achieved by
this category earn no more than US$1.00 (one Professor Arthur Lim, M.D., in Singapore,
dollar) a day and that the maximum that can be who has put together significant funds from
charged to a patient for a cataract operation private organizations and has trained large num-
should be what that particular patient earns in bers of young ophthalmologists to learn these
one month. modern techniques to combat blindness in South
East Asia and China.
88
BIBLIOGRAPHY
Centurion V: Importance of mental attitude and

motivation in phacoemulsification. Faco Total,
pp. 57.
Centurion, V.: The transition to phaco: a step by

step guide. Ocular Surgery News, Slack, 1999.
Carreño E.: Phacoemulsification Sub-3 technique.

Guest Expert, Boyd’s BF., The Art and the Science
of Cataract Surgery, Highlights of Ophthalmol-
ogy, 2001.
Drews, RC: Medium-sized and small incision ext-

racapsular extraction without phaco. World Atlas
Series of Ophthalmic Surgery of Highlights, by
Boyd, BF, Vol. II, 1995; 5:54-56.
Gimbel, H: Posterior Continuous Curvilinear Cap-

sulorhexis (PCCC). World Atlas Series of Oph-
thalmic Surgery of Highlights, by Boyd, BF, Vol.
II, 1995; 5:96-97.
89
90
C h a p t e r 7: P re p a r i n g f o r t h e Tr a n s i t i o n
PREPARING FOR THE TRANSITION
GENERAL OVERVIEW AND STEP tion and proper training to perform each phase
BY STEP CONSIDERATIONS of the transition well.
Outlining the steps necessary in the
Complete comprehension of what is transition from extracapsular surgery to pha-
presented in this chapter is essential for the coemulsification, we will present you a de-
successful undertaking of phacoemulsification. tailed picture of what it really takes to enter
Before you read it, we strongly recommend into the transition and to master the learning
that you first read Chapter 6 which refers not curve. We will describe and fully illustrate
only to the unquestionable advantages of phaco each one of the steps in sequence.
but to its limitations, most of which are related For young ophthalmologists who enter
to the challenge of understanding how the directly into phacoemulsification in their train-
phaco machine works and how to attain its ing, this "bitter pill" of changing from planned
optimal use. extracapsular to phaco is an experience they
will fortunately miss. But when they later
Equipment - Dependent and teach others who have not been trained in
Phase-Dependent Technique phaco, but learned and have spent their career
doing extracapsular instead, they need to rec-
The transition from planned extracapsu- ognize - as we do in this presentation - the
lar extraction to phacoemulsification funda- difficulties their colleagues face, and teach
mentally refers to the gradual change that the accordingly. Extracapsular surgeons still con-
ophthalmic surgeon who already masters the stitute the majority of ophthalmologists world-
planned extracapsular must undertake in order wide.
to dominate the new technique of phaco, which
is equipment-dependent. This transition should Mental Attitude
be progressive and atraumatic. As the surgeon
advances step by step, he or she should never The surgeon must be absolutely con-
go on to the following step if he has not vinced that changing from planned extracapsu-
dominated the previous step. This operation lar to phacoemulsification will be best for his
is also a phase-dependent technique, as em- patients, particularly because of a very rapid
phasized by Centurion. Each phase must be visual recovery and physical rehabilitation back
completed with the precision of a watch maker. into normal life. As long as the surgeon is not
If you pass on to the following step without completely persuaded of the reasons why he
mastering the previous step, complications may wants to take this crucial step in his profes-
arise with consequent failure and grief. This sional development, he will never attain a
learning curve is achieved with effort, dedica- positive experience during the transition with
93
maximum safety, low risk and high benefits for operations in the field of medicine. Once the
the patient and minimal stress for him/herself. decision is made, it must be followed through
The fact that phaco also significantly shortens with firmness and resolve.
the waiting period for cataract surgery in the
second eye, that it has 50% fewer complica- UNDERSTANDING THE PHACO
tions than ECCE and that the operation can be MACHINE
done while the cataract is still in its early stages
(20/40 vision, lowered contrast sensitivity and A successful phacoemulsification de-
glare intolerance) should be another strong pends essentially on two factors: 1) the surgeon's
incentive to adopt phaco (See Chapter 6). The skill; 2) the surgeon's and his team's under-
usual reasoning that the planned extracapsular standing of how the phaco machine works.
surgeon assumes are thoughts like: "If I do so It is fundamental for the surgeon to have
well with planned extracapsular, why change?". a thorough and practical knowledge regarding
This is particularly true when your practice is the specific equipment that he is using and how
mostly composed of private patients, some of the technology of phaco machines in general
them important persons in the community and operates.
no risks can be taken. The successful extracap-
sular surgeon continues to find reasons for not Becoming Familiar with the
making the change, such as: "I have very little
Equipment
postoperative astigmatism with planned extra-
capsular, so why get into the problem of oper-
Becoming first familiar with the phaco
ating with a smaller incision and the difficulties
machine in an experimental laboratory first, is
that may arise?" "The visual recovery compar-
the best way to learn and understand how the
ing the two techniques after several weeks is
equipment works. This has been reemphasized
about the same; I am not in a hurry for my
once and again by Virgilio Centurion M.D.,
patient to attain a prompt visual result as long
one of the world's best cataract surgeons who
as the final visual recovery will be the same."
has dedicated a great deal of his valuable time
"It is better for the patient to have a good
to teach the transition through courses and
planned extracapsular than a bad phaco." "I
publications. His recommendation is to prac-
know that with planned extracapsular I will
tice first in the laboratory the use of both hands
have practically no complications, but I am not
and the four positions of the phaco machine
so sure that such will be the case with phaco,
foot pedal so as to become familiar, comfort-
particularly in the early cases."
able, and adept with the parameters of the
In essence, the surgeon has to make his/
machine (Figs. 52, 53). For more sensitive
her decision rationally and on his or her own
control of the phaco machine foot pedal, use a
initiative. This will provide the stimulus and
shoe with a thin sole (keep it in the operating
the perseverance in order to enter into the
room) and use your dominant foot (equivalent
learning curve and the perseverance to eventu-
to the dominant hand). Control the surgical
ally master what is considered one of the best
microscope with the non-dominant foot.
94
Practice using both hands can be attained While learning to use the machine's foot
with pig eyes and synthetic eyes in synthetic pedal you must also perceive the significance
heads, often coached by the company repre- of the sounds of the machine which vary
sentative from whom you acquired the phaco depending on the surgical step or stage, such as
machine and equipment. The surgeon can also the balance of flow when the phaco tip is not
practice with a human ocular globe supplied by occluded (Figs. 57, 58), and the sounds alerting
large Eye Banks or with pig eyes removed soon the surgeon to changed in fluid dynamics when
after the animal is sacrificed. These globes there is occlusion of the tip. In each instance,
should be refrigerated, not frozen, with the the surgeon receives a sonic feedback, con-
cornea protected with a sponge. When placed stantly informing him about the state of the
in a 700 W microwave oven for 4 seconds, the fluid dynamics in the eye (Figs. 59, 60). So the
lens develops a subcapsular cataract. After 9 surgeon must learn to use both hands, both feet,
seconds, 50% of the lens will be opaque and and to listen to the phaco machine.
hard. In essence, experimental training first in
the laboratory is the best investment the sur-
Two Hands, Two Feet and Special geon can make to shorten and successfully
Sounds transverse the learning curve. It is a necessary
experience to learn the workings of the equip-
The surgeon should dedicate appropri- ment fully. Its main aim is not that of learning
ately extensive time in the laboratory towards the surgical technique at this stage. That comes
acquiring complete self-assurance in the use of later. We must not improvise or try to learn
the machine, coordinating his or her hands and the use of a phaco machine in the operating
the two foot pedals. Additional time may be room. The surgeon should not begin learning
used to practice how to make the new, smaller the use of the machine directly on a patient's
incision, the capsulorhexis and other surgical seeing eye.
steps. Phaco is mostly a two-handed tech-
nique, so you must become trained and develop Main Elements of Phaco Machines -
reflexes to use both of your hands and both of Their Action on Fluid Dynamics
your feet, together.
During training in the laboratory, the In this chapter we will thoroughly dis-
surgeon grasps how the machine works during cuss the optimal use of the phaco machine and
each step of the operation, learns the method the rationale behind it, the three elements of
for introduction of the phaco tip and the most most phaco systems (irrigation, aspiration and
comfortable position in which to place the ultrasonic energy), fluidics and phacodynam-
handpiece; why and when to elevate or lower ics, the importance of and understanding of the
the height of the fluid bottle, when to increase Surge Phenomenon. The rationale behind high
or decrease the flow of fluid or the vacuum and vacuum - low ultrasound power technology,
when to increase or decrease the power of the the new technology of the peristaltic pump,
phaco. These parts of the learning curve are particularly in the three main equipment sources
mastered in the laboratory so as to really available such as the Alcon's Legacy 2000,
understand and become fully adept with the Allergan's Prestige (and the Sovereign) and
functions of the equipment before entering the Storz Millennium and some useful informa-
patient's eye.
95
tion about the new phaco tips and their contri- Hydrodissection and Hydrodelin-
bution toward a better operation. eation
These techniques remain essentially the
COMPARISON OF SURGICAL
same for the transition and in advanced sur-
TECHNIQUES FOR TRANSITION geons (Figs. 46, 47, 48).
VS EXPERIENCED SURGEONS
Epinucleus Removal
There are several techniques in pha-
This technique does not vary substan-
coemulsification that remain practically the
tially in the transition from that used by ad-
same for the surgeon who is undergoing the
vanced surgeons (Fig. 69).
transition and those who are more experienced.
On the other hand, there are stages of the
operation in which there are definite variations
Cortex Removal
for the experienced surgeon, some of them The technique is the same for both groups
minor, others moderate and others major. (Figs. 70, 71). It is important not to feel overconfi-
We have divided the subjects into two dent at this stage and by all means avoid being
(2) groups: 1) those that are the same for all aggressive.
surgeons and 2) those that vary depending on
the skill of the surgeon for this particular opera- Techniques that Vary According
tion. to the Skill of the Surgeon
Techniques Which Are the Same Anesthesia
for the Transition and for In the transition, the surgeon may use
Advanced Surgeons parabulbar or Sub-Tenon's (flush) anesthesia
using Greenbaum's cannula (Figs. 33, 34), par-
Capsulorhexis ticularly because conversion to ECCE may be
needed. It is only advanced surgeons who may
use topical anesthesia alone or combined with
These parts of the technique are practi- intracameral irrigation anesthesia (Figs. 35,
cally the same for both groups, with slight 36).
individual variations (Figs. 43, 44, 45). The
main feature that may vary is the size of the
Fixation of the Globe
capsulorhexis. Some very advanced surgeons
do a small capsulorhexis, while in the transi- In the transition, the surgeon does need
tion a somewhat larger capsulorhexis is advis- to fixate the globe, passing a suture through the
able, depending on the size of the IOL to be superior rectus, versus the experienced sur-
implanted. geon who does not need to do so.
96
The Incision Type of IOL
Sclero corneal tunnel, limbal tunnel, cor- Foldable lenses should only be used
neal tunnel: these three types of incisions de- by advanced surgeons. PMMA oval lenses
pend on the skill and experience of the surgeon. 5.0 x 6.0 mm are the standard in the transition
In the transition it is important to use the (Fig. 72-A).
stepped incision starting at the limbus and
performing a sclero corneal tunnel based on a Nucleus Removal
limbal incision, in case there is need to revert
to a ECCE. During the transition, it is always
There are many different techniques that
important for the surgeon to know that he/she
may be utilized by advanced surgeons. They
may revert to ECCE whenever they feel un-
will be discussed in a separate chapter. For the
comfortable with the surgery at any specific
transition, the basic technique to use when
stage. Only more advanced surgeons should do
beginning phaco is the "divide and conquer"
the corneal incision and tunnel (Figs. 40, 41,
into four quadrants. "Divide and conquer" is
42).
usually done with two hands (Fig. 56). The
surgeon must also learn, however, how to per-
form this technique with one hand.
SURGICAL TECHNIQUE IN THE TRANSITION
Anesthesia you consult Chapter 5 on this important aspect

of the operation.
During the transition it is advisable that
the surgeon utilize the type of anesthesia with The Incision
which he/she feels more safe and in better
control (Figs. 33, 34). It is unnecessary to add How to Make a Safe Transition from
a new source of stress or immediate change at Large to Small Incision
this stage of the procedure. Nevertheless, when
the surgeon is in charge of the situation and
masters the phaco technique, it is ideal to use Role of the Ancillary Incision
topical anesthesia because of its ability to pro-
vide immediate visual recovery. The com- This is an important step in performing
bined use of topical anesthesia and intracam- phacoemulsification. Although there are tech-
eral anesthesia is more effective than topical niques to perform it with only one hand, phaco
anesthesia alone and should be tried before the is fundamentally a two-handed procedure.
surgeon attempts to operate using topical anes- The ancillary incision is made before the
thesia alone (Figs. 35, 36). I recommend that main incision is performed. As shown in
97
Fig. 41, this incision serves as an entry for a fidence. The surgeon may start with a small
second instrument which is necessary for ma- stepped limbal valvulated incision slightly
neuvers to remove the nucleus (Fig. 56). This larger than the phaco tip (Fig. 42) even though
wound is also utilized in irrigation of the he knows that he plans to convert to his usual
anterior chamber with intracameral local anes- planned extracapsular. It is not advisable to
thetic as explained in Chapter 5 and illustrated start the transition with a corneal incision
in Fig. 36, and for the insertion of viscoelastic because, upon enlarging it, the resulting astig-
previous to making the main incision and dur- matism may be severe. The more anteriorly
ing several other steps of the operation. How- located the incision, the more astigmatism the
ever, some advanced phaco surgeons do not patient may end up with. By starting the
perform hydrodelamination and remove the transition with a limbal incision, the surgeon
epinucleus usually during the emulsification will use the same area for the incision that he is
of the nucleus. accustomed to use in his planned extracapsular
At the end of surgery, the ancillary inci- but will make the incision valvulated (stepped)
sion also serves to inject fluid into AC to test for and smaller than th e usual extracapsular
leaks in the wound (Fig. 73). (Figs. 40, 41, 42). The surgeon must master the
technique of the small incision valve like inci-
The Main Incision sion at the limbus, so that it can be part of his
armamentarium in the future (Fig. 40-C). Once
the surgeon is certain that he will not need to
During the early stages of the transition, convert from phaco to planned extracapsular
the surgeon should plan to start the operation and therefore will not need to enlarge the inci-
as a phaco but learn how to convert to the sion, he may choose to make a corneal incision
planned extracapsular he or she is accustomed if he wishes, but not before (Fig. 40-C). This
to do successfully if this becomes necessary. is what we refer to as a safe transition from a
This will provide additional comfort and con- large to a small incision, a transition that must
Figure 40 A-C (See Facing Page 101): Phacoemulsification Incisions - Surgeon’s and Cross Section Views
Figure A - Limbal Incision (left, above and below): The incision of choice during the transition period and which may continue
to be utilized successfully by the surgeon is a stepped limbal incision, slightly larger than the size of the phaco tip, (L-above left). The
incision is placed in this location so that if the surgeon feels uncomfortable with the surgery at any stage of the transition into phaco,
the limbal incision may be extended to convert to ECCE in his/her first steps of transition without complications. The cross section
view below, left, shows the stepped limbal tunnel incision, valvulated and self-sealing. Unless it is made larger, no suture may be needed
or perhaps one suture. The three steps to make a valvulated incision starting at the limbus are the same than those shown in Fig. B below
for the scleral tunnel incision, except that the length of point 2 in the second plane or tunnel is shorter.
Figure B - Scleral Tunnel Incision (center above and below): The scleral tunnel incision involves a three step entry into the
anterior chamber creating a 5.5 mm long valvulated self-sealing wound. The first step (1) is a straight or “frown” shaped vertical
groove scleral incision at about 1.5 mm posterior to the limbus. The second plane of the incision (2) is dissected at constant depth (300
98
microns) toward and into the clear cornea for about 1 mm. The blade should be parallel to the iris plane. The third step
is a penetrating incision into the anterior chamber (3) with the blade obliquely to the iris plane. This type of incision
is no longer frequently used. It used to be the most popular incision, but then we learned that the self-sealing valvulated
action of the incision is not related to the length of the tunnel outside of the cornea but within the cornea.
Figure C - Corneal Tunnel Sutureless Incision (above right): The 3.2 mm long corneal tunnel incision (C) also
creates a valve which is self-sealing. As seen in the cross section (below right) a vertical groove (1) is made in the clear
cornea followed by a second plane incision (2) approximately oblique to the iris plane. This corneal incision should
not be used in the transition period but can be used advantageously by more experienced surgeons whose ability to
perform each step of phacoemulsification adequately practically assures that there will not be any need to convert to
an ECCE. If a corneal incision as shown in (C) is made and the surgeon has to convert, the enlargement of the corneal
incision to finish the operation as an extracapsular may lead to major astigmatism.
Figure A (limbal) and C (corneal tunnel) are either performed at 12 o'clock as shown in this plate or
located in the superior right quadrant. This is preferred by many surgeons who feel that this location facilitates
their surgical manipulations.
99
Figure 41-A: Making the Ancillary

Incision
This is a most important stage of

phacoemulsification since the operation
itself is mainly a two-handed technique.
The steps involved are: 1) First, mark the
limbal area (A) where the limbal stepped
main incision will be made (Figs. 41 B
and 42) between 9 and 12. In the
transition it is recommended to place the
stepped incision at 12 o'clock as shown
here. 2) Make the ancillary incision (I)
always at 3 o'clock. This is performed
with a special 15 º blade designed for
paracentesis (K). 3) Proceed to perform
the limbal valvulated stepped incision
and enter the anterior chamber, as shown
in Figs. 41-B and 42 (surgeon's views).
The ancillary incision serves to intro-
duce a second instrument as shown in
Fig. 67, inject intracameral local anes-
thesia as shown in Fig. 36 and irrigate
viscoelastic into the anterior chamber.
Figure 41 B: Initial Stages of Self-

Sealing, Stepped, Valvulated Tunnel
Incision at the Limbus - Surgeon's View
This surgeon's view shows the

Crescent knife blade (K) entering the first
incision (1) just at the limbus. The blade
is advanced (red arrow) for some distance
in the plane of the cornea, and a tunnel
(blue arrows) is created. This forms the
second step (2) in the three-step incision.
The knife does not enter the anterior cham-
ber at this stage.
100
Figure 42: Final Step of Self-Sealing, Stepped, Valvulated Tunnel Incision at

the Limbus Performed with the Diamond Knife - Surgeon's View
A diamond knife blade (D) enters the first incision (1), the second tunnel
incision (2), and is then directed slightly oblique to the iris plane and advanced
(arrow) into the anterior chamber. This forms the internal aspect of the incision into
the chamber (A). This is the third sted (3) in the three-step self-sealing incision.
be undertaken step by step as the surgeon Role of Conjunctival Flap

progresses in his learning curve (Figs. 40, 41,
42). In the early stages of the transition, the
Later, as he progresses and learns to surgeon may prefer to start with a small fornix
master phacoemulsification, the surgeon is based conjunctival flap from 10:00 to 2:00
ready to make two significant changes in the o'clock, and place light cautery under each
technique: 1) Operate from an oblique position edge of the flap. If the limbal incision is
and make the incision in the upper right quad- extended because one of the initial phaco steps
rant, temporally as shown in Figs. 41-B and 42; becomes a source of problem and there is need
2) Perform a corneal incision (Fig. 40-C) infor conversion to ECCE, there will be less
stead of a limbal incision (Figs. 40-A, 41-B, 42 bleeding.
101
Figure 43: Continuous Curvilinear Anterior

Capsulorhexis with Cystotome - Step 1
Anterior capsulorhexis is one of the steps

of phacoemulsification that is practically the
same both for the surgeon beginning with the
transition or the more advanced surgeon, with
the exception that some advanced surgeons pre-
fer to do a smaller capsulorhexis. The technique
shown here is the initial step performed with the
cystotome-needle (see Fig. 97). In the transition,
it is recommended that it be continued with
forceps as shown in figures 44 and 45. With an
irrigating cystotome, the center of the anterior
capsule is punctured creating a horizontal V-
shaped tear. The tear is extended toward the
periphery and continued circumferentially in
the direction of the arrow. In the surgeon's
transition stage, the cystotome is introduced
through a 3.5 to 4.0 mm limbal incision. The
initial puncture of the anterior capsule with the
cystotome needle shown here as made in the mid
periphery is the technique initially utilized by
the pioneers of capsulorhexis and is shown here
in this form for historical reasons. The present
method has been modified to start the puncture
in the center, as a frontal incision shown in Fig.
98. This leads to better results and facilitates the
maneuver.
Anterior Capsulorhexis ous circular capsulorhexis is larger than the

wound or paracentesis required to simply in-
This again is a vital step in the transition. troduce a cystotome and perform a can opener
Changing from the can opener capsulotomy capsulotomy.
(Fig. 37) to the anterior continuous circular It is highly recommended to make the
capsulorhexis (CCC) is one of the fundamental capsulorhexis under sufficient viscoelastic .
steps in the transition (Figs. 43, 44, 45). The The latter should be injected into the anterior
surgeon must learn first by practicing chamber as a first measure before trying the
capsulorhexis on the skin of a grape or by using capsulorhexis (Fig. 2). It is also fundamental
a very thin sheet of plastic wrap such as the one not to begin with dense, hard cataracts where
that covers some chocolate candies. Once the it is difficult to see the edge of the capsulorhexis.
surgeon understands the concept of the tech- It is prudent to try performing this procedure
nique and can do it in the laboratory, he or she over and over again in cataracts that are less
may begin to use it for the patient. dense until the surgeon is able to perform them
The surgeon must keep in mind that the in eyes with poor visualization of the edge of
space needed to adequately maneuver the cys- the capsule.
totome (Fig. 43) or the capsulorhexis forceps Because the surgeon, in the initial stages
(Figs. 44, 45) in order to do a proper continu- that we are discussing here, will most probably
102
Figure 44 (above right):Continuous Curvilin-

ear Anterior Capsulorhexis with Forceps-
Step 2
After having made the initial tear of the

anterior capsule with an irrigating cystotome in
the center of the anterior capsule, the tear is ex-
tended toward the periphery in a circular direction,
this time utilizing forceps as shown in this figure.
The tear is extended toward the periphery and
continues circumferentially in a continuous man-
ner for the remaining 180 degrees, as initially
described by Gimbel.
Figure 45 (below right): Continuous Curvilin-

ear Anterior Capsulorhexis with Forceps -
Step 3
The flap of the capsule is flipped over on

itself. The forceps engage the underside of the
capsule. The tear is continued toward its radial
segment. In the transition, beginning surgeons are
encouraged to use forceps as shown in figures 44
and 45 in order to perform the continuous circular
capsulorhecis (CCC). Viscoelastic is essential in
this maneuver. The correct size of the CCC is 5.5
mm to 6.0 mm. A larger CCC, would be
undesirable because the nucleus may come out of
the bag too quickly, forcing the surgeon to do
emulsification in the anterior chamber which may
lead to endothelial damage. For the early steps of
the transition, when the surgeon may have to
convert to ECCE, it is important to perform two
relaxing incisions radially at 10 and 2 o'clock in the
anterior capsule, in order to facilitate the removal of
the complete nucleus in an ECCE if necessary.
103
need to convert to ECCE, it is important that he capsules from the cortex (Figs. 46, 47) and the
perform two relaxing incisions radially in the nucleus from the epinucleus (Fig. 48). When
anterior capsule at 10 and 12 o'clock following this is achieved, the nucleus is liberated so that
the CCC, in order to facilitate the removal of it will be free for the ensuing maneuvers of
the complete nucleus with a planned manual rotation, fracture and emulsification, all of
extracapsular. If these relaxing incisions in the which will come as the next steps in the
anterior capsule are not done, the surgeon may procedure (Figs. 55, 56). As long as the
confront serious problems in removing the surgeon is not sure that the nucleus has been
nucleus (Fig. 37). freed of its attachments through the
hydrodissection and will rotate easily, he should
Hydrodissection not proceed to try to rotate it mechanically
because this may lead to rupture of the zonules.
Once the surgeon is able to perform a Also, if the nucleus is not separated from the
circular continuous capsulorhexis (CCC) with- cortex by hydrodissection (Fig. 48), the sur-
out problems, he is ready to go into the next geon should not proceed to apply the phaco
step, which is hydrodissection (Figs. 46, 47, ultrasound to the nucleus because he or she
48). This step should not be undertaken before may well meet with complications by extend-
mastering the capsulorhexis. If not, tears in the ing the effects of ultrasound not only to the
anterior capsule may extend towards the equa- nucleus but peripherally to the cortex. This can
tor when performing the injection with fluid to lead to the feared rupture of the posterior cap-
do the hydrodissection. The surgeon should sule. Instead, the surgeon should decide to
have clearly in mind the anatomy of the crystal- convert to a ECCE. Although Fig. 47 shows
line lens and what is it that he is after with hydrodissection through a corneal tunnel
hydrodissection (Fig. 1). With this maneuver, (surgeon's view), keep in mind that all maneu-
by using waves of liquid (Figs. 46, 47, 48) we vers during the transition are done with a
wish to separate the anterior and posterior limbal incision, as shown in Figs. 40 A, 41, 42.
Figure 46 : Hydrodissection - Stage 1

- Separation of the Anterior and Pos-
terior Capsule from the Cortex -
Cross Section View
A 25 gauge cannula is placed

through the continuous circular
capsulorhexis under the anterior lens
capsule (A). Fluid is infused as
shown by the pink arrows in order to
separate the anterior capsule from the
cortex. A wave of fluid shown by the
pink arrows and identified as (W) ex-
tends along the posterior capsule, sepa-
rating the posterior capsule (P) from
cortex (C).
104
Figure 47 (above left): Hydrodissection of

the Lens Capsule from the Cortex During
Phacoemulsification - Surgeon's View
This is a surgeon's view of what is

shown in figure 46 in cross section view.
Following circular curvilinear anterior
capsulorhexis, a cannula (C) is inserted into the
anterior chamber. The cannula tip is placed
between the anterior capsule and the lens cor-
tex at the various locations shown in the ghost
views. BSS is injected at these locations (ar-
rows) to separate the capsule from the cortex as
shown in Fig. 46. The resultant fluid waves (W)
can be seen against the red reflex. These waves
continue posteriorly to separate the posterior
capsule from the cortex.
Figure 48 (below right): Hydrodissection -

Stage 2 - Separation of Nucleus and Epi-
nucleus and the Cortex
In this stage, the cannula is advanced

beneath the cortex (C) and the infusion with
BSS is started in order to separate the nucleus
(N) from the epinucleus (E). The pink arrows
between these two structures, nucleus (N) and
epinucleus (E), show the flow of fluid. The
gold "ring" of fluid separating the nucleus
from the epinucleus is here identified as (GR).
105
THE MECHANISM OF THE patients. It must be achieved first in an

experimental laboratory before attempting to
PHACO MACHINE operate on humans with seeing eyes, as empha-
sized by Centurion.
Getting Ready to Use Phaco Optimal Use of the Phaco

During Transition Machine
We have already emphasized the crucial The Rationale Behind It -

importance of understanding how the phaco Main Functions
machine works in order for the surgeon to
perform phacoemulsification successfully. This Edgardo Carreño, M.D., one of South
is a task every cataract surgeon must undertake America's top phaco surgeons and teacher,
when contemplating the use of phaco in his/her describes the three main functions of the
Figure 49-A: The Principles of How the

Phaco Machine Works
This conceptual view shows the three

main elements of most phaco systems. (1)
The irrigation (red): Intraocular pressure is
maintained and irrigation is provided by the
bottle of balanced salt solution (B) connected
via tubing to the phaco handpiece (F). It is
controlled by the surgeon. Irrigation enters
the eye via an infusion port (H) located on the
outer sleeve of the bi-tube phaco probe. Height
of the bottle above the eye is used to control
the inflow pressure. (2) Aspiration (blue):
(I) enters through the tip of the phaco probe,
passes within the inner tube of the probe,
travels through the aspiration tubing and is
controlled by the surgeon by way of a vari-
able speed pump (J). The peristaltic type
pump is basically a motorized wheel exerting
rotating external pressure on a portion of the
flexible aspiration line which physically
forces fluid through the tubing. Varying the
speed of the rotating pump controls rate of
aspiration. Aspirated fluid passes to a drain
(L). (3) Ultrasonic energy (green) is pro-
vided to the probe tip via a connection (M) to
the unit. All three of these main phaco
functions are under control of the surgeon by
way of a multi-control foot pedal (N).
106
Figure 49-B (previa Fig. 1-1, p.3 libro Seibel on Phacodynamics): The Rationale Behind the Phaco Machine
In this diagramatic figure from Seibel's excellent book on Phacodynamics, you can clearly observe the mechanical
workings and rationale behind the function of the phaco machine, as explained in Fig. 49-A, its figure legend and the text.
The ultrasound energy coming from the handpiece emulsifies the cataract (Fig. 50-B) so that a 10 mm cataract may be
removed by the aspiration port and line through a 3 mm or smaller incision. A fluidic circuit counteracts the heat build up
caused by the ultrasonic needle and removes the fragmented or "emulsified" lens material via the aspiration port and
aspiration line while maintaining the anterior chamber. The fluid is supplied via the irrigation port and line by the elevated
irrigating bottle, which is controlled by the surgeon elevating it or lowering it. This fluid circuit is regulated by the aspiration
pump. (After Seibel, B.S., Phacodynamics, 3rd Ed., 1999, p. 3, Slack, as modified by HIGHLIGHTS).
phaco machine: 1) irrigation; 2) aspiration; phaco tip of the hand piece (Figs. 50-A and
and 3) fragmentation of nucleus. This is 50-B). Many types of phaco tip shapes have
clearly shown in Figs. 49-A and 49-B. Irri- been created to more efficiently handle
gation is done with the irrigation bottle, nuclear extraction, as shown in Fig. 51. A
aspiration with the aspiration pump and command pedal, which is controlled by the
fragmentation with ultrasonic energy surgeon’s foot, guides the machine into the
through the titanium needle present in the following four positions: 0 (zero) which is at
107
Figure 50 A (above left): The Phaco Handpiece
This diagramatic figure clearly shows the

different components of the phacoemulsification
handpiece. The phaco needle is manufactured with
various degrees of bevel, angulations and shapes, as
shown in Fig. 51. The probe tip is hollow with the
distal opening functioning as the aspiration port.
Irrigation fluid flows through two ports located
180º apart on the silicone irrigation sleeve. The
irrigation sleeve hub shown here in blue threads the
sleeve onto the handpiece body outer casing. The
phaco needle threads directly into the internal mecha-
nism of the handpiece containing the ultrasound
generator. The ultrasound power oscillates be-
tween 25.000 and 60.000 times a second (Hz). This
energy is transmitted along the handpiece into the
phaco needle in such a way that the primary oscil-
lation is axial.(After Seibel, B.S., Phacodynamics,
3rd Ed., 1999, p. 99, Slack, as modified by HIGH-
LIGHTS).
Figure 50 B (below right): Mechanism of Action

of Phacoemulsification Probe Tip
Phacoemulsification involves the use of a

probe tip (T) which vibrates very rapidly and acts
as a jackhammer and emits heat to break up lens
material (L) into fragments (F). Fragments are
aspirated from the eye via the center of this probe
tip which is hollow (black arrow). An outer sleeve
(S) provides for passage of infusion fluid. Fluid
enters the eye (white arrow) via infusion ports (P)
in this outer sleeve. The infusion fluid constantly
replaces any aspirate removed from the eye to
maintain a stable intraocular pressure.
108
Figure 51: New Phaco Tips
Many types of phaco tip shapes have been created in an attempt to more
efficiently handle nuclear extraction. Different types include various degrees of
bevel, angulations, and shapes of the tip. Examples include: A-straight round tip,
B- 15º bevel, C-30º bevel, D-45º bevel, E-bent 45º tip, F-rectangular tip, G-
enlarged bevel tip, and H-another enlarged bevel tip. The beveled tips provide an
oval shaped aspiration opening with gradually increasing areas of contact (areas
shown in blue) to nuclear material. Angled or bent tips attempt to allow access
of the tip to more peripheral locations within the capsular bag.
rest; position 1 for irrigation, position 2 for chamber depends on the height of the bottle,
irrigation-aspiration and position 3 for irriga- the diameter of the tubing and the pressure
tion, aspiration and phacoemulsification already existing in the anterior chamber
(Figs. 52 and 53). (Figs. 49-A, 49-B, 54). The flow rate into the
The first function (irrigation) con- eye is determined by the balance of the
trolled by the foot pedal is provided by a pressure in the tubing - regulated by the
bottle with BSS. The liquid flows by gravity. height of the bottle, and the back pressure in
The amount of liquid that reaches the anterior the anterior chamber. When the two are
109
Figure 52 (above left): Basic Phaco Foot

Pedal Functions
The foot pedal controls inflow, out-

flow, and ultrasonic rates. With the foot
pedal in the undepressed position, the inflow
valve is closed, the outflow pump is station-
ary, and there is no ultrasonic energy being
delivered to the phaco tip. With initial de-
pression of the pedal (1), the irrigation line
from the raised infusion bottle is opened.
Further depression of the pedal (2), starts
and gradually increases the flow rate of the
aspiration pump to a maximum amount
preset by the surgeon. Further depression of
the pedal (3) turns on increasing ultrasonic
power to the phaco tip for lens fragmenta-
tion.
Figure 53 (below right): New Dual Linear-

Lateral Pedal Control
A new pedal control separates the in-

flow-outflow and ultrasonic power functions.
The inflow (1) - outflow (2) function is con-
trolled by pedal depression, with increasing
outflow availability incurred with increasing
pedal depression. Inflow will match outflow
rates. Increasing ultrasonic power is applied by
doing a lateral rotation of the foot pedal (3). The
lateral rotation of the foot pedal (3) is shown in
the ghost view. Separating these functions al-
lows the surgeon to apply varying amounts of
ultrasonic power with varying inflow-outflow
rates. With the depression only type pedal,
ultrasonic power is only engaged with maxi-
mum inflow and outflow. There are
phacoemulsification maneuvers when this is not
desirable. A low inflow-outflow rate, for in-
stance, may be desired when engaging
ultrasound.
110
equal, there is no flow. If there is leakage or Figure 54: Irrigating Bottle Height Related to Flow Rate -
Hydrostatic and Hydrodynamic Stages
aspiration of fluid from the anterior chamber,
the pressure there drops, and fluid in the Bottle height (C) has the important function of provid-
tubing flows in to restore the pressure in the ing constant chamber pressure during all phases of surgery,
including during times of sudden changes in outflow rates.
AC, and, indirectly thereby, the volume. The Maintenance of safe intraocular pressure is important in both
tubing is purposely made wide enough so that "hydrostatic" (A - no fluid moving within the fluidic circuit)
it impedes the flow of the BSS only slightly and "hydrodynamic" situations (B - fluid moving within the
circuit). A bottle height of 45cm above the eye will provide an
under normal rates of flow. It does limit approximate 30mmHg of intraocular pressure (I) when no
maximum flow - during anterior chamber fluid is moving in the circuit (hydrostatic state A) when there
collapse for example, unfortunately, however. is no aspiration taking place and the aspiration pump (E) is off.
When the aspiration pump (J-arrows) is turned on, (hydrody-
namic state B), the intraocular pressure (M) will go down, for
example to 20mmHg, depending on the outflow rate. Arrows
depict fluidic inflow (red) and outflow (blue) in the system.
This is because the intraocular pressure decreases proportion-
ally as the flow rate increases (Bernoulli's equation). Therefore
it is important to maintain a constant IOP, to increase the bottle
height when using a high phaco outflow rate. Likewise, the
bottle height should decrease when the aspiration (outflow)
rate is decreased. The black arrows on the tube (J) indicates
drainage.
111
The second function, which is aspira- It is precisely the anteroposterior oscillation

tion, is provided by a pump, which creates a of the phaco tip which produces the emulsi-
difference in pressure between the aspiration fication (Figs. 50-B, 55, 56, 67, 68).
line and the anterior chamber. The pumps
may be a peristaltic pump, a Venturi pump, a Parameters of the Phaco Machine
diaphragm pump, a rotary vane pump, or a
scroll pump. The peristaltic pump has What are the phacoemulsification ma-
become the most widely known and used. chine parameters? How are they utilized?
Many feel it is safer. Just like inflow, a base These parameters need to be set and reset
level of suction occurs whenever the pump is depending on the type of cataract: soft,
activated, depending on how hard the pump is medium-hard, very hard, (as shown in
working. When there is occlusion of the tip Fig. 2); the stage of the operation; and also,
with the foot pedal in the aspiration position importantly, the various situations which the
(position 2), the pump will continue to pump surgeon must solve. These parameters are:
and crate more and more suction until the 1) the amount of ultrasonic energy
material which is provoking the occlusion is applied to the nuclear material for its emulsi-
aspirated, or until the suction in the tubing fication. It is expressed as a percentage of the
reaches the maximum that the surgeon has phaco machine’s available power and it deter-
preset on the control panel (Figs. 59, 60, 61). mines the turbulence which is generated in
This latency period before reaching maxi- the anterior chamber during surgery. It is
mum suction level provides a greater security ideal to use the least amount of power
margin allowing the surgeon to take immedi- possible during the operation. This is pos-
ate action in case the tip grasps (and sucks in) sible by combining other functions of the
the iris or the posterior capsule instead of machine and maneuvers within the nucleus to
grasping the lens mass. In order to perceive facilitate fracture and emulsification of the
what happens to the fluid dynamics when the lens. The use of excess phaco energy may
phaco tip is not occluded, please see Figs. 57, result in damage to structures beyond the
58. The reason for limiting the maximum nucleus, such as the posterior capsule and the
suction pressure is to limit the rush of fluid endothelium.
out of the eye the moment the fragment which 2) The aspiration flow rate. This
occluded the tip is aspirated. This provides measures the amount of liquid aspirated from
the surgeon the opportunity to stop aspiration the anterior chamber per unit of time. In
and avoid collapse of the anterior chamber. practical terms, this determines the speed
The third function of the phaco ma- with which the lens material is sucked in into
chine - the production of ultrasonic vibra- the phaco tip. This is synonymous with the
tions leading to fragmentation of the lens - power of "attraction" or suction of the lens
is carried out by a crystal transducer located fragments into the irrigation-aspiration hand-
in the handpiece, which transforms high fre- piece (Fig. 61). High maximum flow rates
quency electrical energy into high (ultra- may result in collapse of the anterior chamber
sonic) frequency mechanical energy. The if the irrigation cannot keep up.
crystal drives the titanium tip of the phaco 3) The third parameter measures the
unit to oscillate in its anterior-posterior axis. vacuum or negative pressure created in the
112
Figure 55: Varying Ultrasonic Settings While Proceeding Through a Nucleus of Varying Density During the Creation of a
Furrow or Groove
Under surgeon control via the foot pedal, the ultrasonic power can be varied during creation of a trans nuclear groove to
accommodate the varying density of the nucleus encountered at each location. For example, when beginning the furrow (A) 30% power
is all that is required initially in the low density peripheral portion of the nucleus (P). Note slight depression (arrow) of the foot pedal
(1) to obtain this power setting. As the phaco tip is progressed toward the central nucleus, ultrasonic power may be increased to 60%
as it encounters more dense epinuclear material (E). Note increased foot pedal depression (arrow) to increase power (2). When the phaco
enters the densest central portion of the nucleus (N), ultrasonic power may be increased up to 90-100% by further depression (arrow)
of the foot pedal (3). As the phaco tip again encounters less dense material on the distal side of the nucleus near the epinucleus (E),
ultrasonic power is again reduced to perhaps 60% to efficiently remove that material. The foot pedal depression is reduced to lower
the power (4). Varying the power to just the minimum level required at each stage avoids excessive intraocular ultrasonic power,
provides for a safer extraction, and avoids possible abrupt engagement of the tip with epinucleus and nearby the posterior capsule.
113
aspiration line and actually determines the in order to keep the nucleus fragments close
force with which the material is fixated onto to the phaco tip and prevent the vibrating
the orifice in the phaco tip. This is known as effect from repelling the fragments from the
fixation power or grasp and depends on the tip opening. We need a higher flow of aspira-
aspiration force (Figs. 59-60, 61). The tion to bring the fragments of the nucleus to
higher the aspiration pressure, the more rapid the tip of the handpiece and make the proce-
the aspiration flow, and the less the amount dure faster.. In this Memory 2, we also need
of time it takes to obtain the maximum higher vacuum since here we need to have
vacuum power. If the occlusion at the tip is good grasping power to hold the fragments
broken or interrupted, due to the negative against the phaco tip so that we can proceed
pressure in the aspiration line, fluid is to emulsify them. Memory 2 is the memory
rapidly sucked out of the eye. This may lead for fragment mobilization and emulsification.
to collapse of the anterior chamber with risk In Memory 3: removal of epinucleus,
of damage to the corneal endothelium as well all the parameters are lowered considering
as the posterior capsule. This is known as the that the epinucleus is soft. Memory 3 is
Surge Phenomenon (Figs. 61-65). specifically for the epinucleus, whenever it
exists.
How to Program the Machine for
Fluid Dynamics During Phaco
Optimal Use
Michael Blumenthal, M.D., has made
We have already discussed the phaco- profound studies on this most important sub-
emulsificator’s settings which include the ul- ject. Its understanding really makes a differ-
trasonic power, the aspiration flow, which is ence between success and failure in small
the power of attraction and the vacuum, incision cataract surgery, particularly in pha-
which is the grasping power. coemulsification. There are two factors
In order to perform a rational phaco, specifically involved: 1) the amount of in-
we must know how to program or calibrate flow and 2) the amount of outflow during
the "memory" of the machine. There are any given period of the surgery. Fluid dy-
three memories in the machine. Memory 1 is namics are responsible for the following in-
for sculpting the nucleus( Figs, 55, 56), traocular conditions during surgery: a) fluc-
Memory 2 is for fragmentation, mobilization tuation in the anterior chamber depth; b)
and emulsification of the nuclear fragments turbulence; c) intraocular pressure.
(Figs, 67, 68) and Memory 3 is for removal Blumenthal has pointed out numerous
of the epinucleus, when this exists (Fig. 69). times that zero fluctuation is the target to be
In Memory 1: nuclear sculpting, we achieved in surgery, insuring that intraocular
need high ultrasound power with low flow manipulations are most effective and accu-
and low vacuum since at this stage we do not rately performed as well as keeping steady
need any fixation or attraction power. In and natural the intraocular architecture
Memory 2: nuclear fragmentation, how- and relationship between various tissues
ever, we need low ultrasound or phaco power (Figs. 57-60).
114
Figure 56: Use of Different Phacomachine Parameters to Sculpt the Nucleus for Making Quadrants -
Memory 1 - Divide and Conquer Technique
A linear vertical furrow is made in the nucleus from 6 to 12 o'clock. A second furrow in the lens is made
perpendicular to the first using the phacoemulsifier probe. The phaco probe (P) and manipulator (M) engage
opposite sides of the furrow inferiorly. Force is applied with the instruments in opposing directions (arrows) to
crack (C) the nucleus along the length of the furrow. Additional manipulations of this type further lengthes and
deepens the crack. The lens is rotated 90 degrees within the capsular bag and a crack is made in the second furrow
in the same manner (not shown). (The incision during transition should be limbal based. Corneal incision shown
here is for advanced surgeons.) The parameters of the machine used to create the furrows in the lens are shown
in the figures within the rectangular table immediately above this figure. At this stage, the surgeon uses Memory
1 which is shown digitally in the machine as 1. The digital figure under U.S. refers to the ultrasound power utilized
at this stage in order to create the furrows in the nucleus. ASP refers to the aspiration flow rate, and the VAC
shown on the machine refers to the amount of vacuum. These parameters are identified in the rectangle next to
Fig. 56.
By cracking the lens furrows at their base, the surgeon creates four separate quadrants of nuclear material.
Manipulation of each quadrant for individual removal is carefully guided by use of flow and vacuum. Flow is used
to move a quadrant to the phaco tip (P). Once engaged, vacuum is used to impale and manipulate the quadrant
for safe removal.
115
Fluctuation in the anterior chamber most complete study on the physics on pha-
depth is the consequence of the following coemulsification and the fluid dynamics in-
conditions: the amount of outflow exceeds volved. This must reading for anyone who
the amount of inflow in a given period. As a wants to delve more deeply into this subject.
result, the anterior chamber is reduced in Seibel points out that phacoemulsifica-
depth or collapses (Figs. 62 and 63). When tion surgery is essentially the integration of
the amount of outflow is reduced below the two basic elements: 1) you use ultrasound
amount of inflow, the anterior chamber depth energy in order to emulsify the nucleus; 2)
is recovered (Fig. 65). This phenomenon, you utilize a fluidic circuit in order to remove
when repeating itself, increases fluctuation. the emulsified material through a small inci-
When fluctuation occurs abruptly, as in the sion while maintaining the anterior chamber
sudden release of blockage of the phaco tip in depth integrity. This fluidic circuit is pro-
aspiration, this is called Surge (Figs. 61-65). vided by an elevated bottle of BSS that
produces not only the volume of fluid within
Fluidics and Physics of the circuit but also provides the pressure in
order to maintain the anterior chamber hydro-
Phacoemulsification
dynamically and hydrostatically. When out-
flow and inflow are balanced, the pressure of
Barry S. Seibel, M.D., in his classic the anterior chamber is proportional to the
book Phacodynamics, presents perhaps the height of the bottle (Figs. 49-A, 49-B).
Figure 57 : Fluid Dynamics - Balance

of Flow When the Phaco Tip Is
Unoccluded - Hydrodynamic Bal-
anced System
When the phaco tip is

unoccluded (D), the outflow rate of
fluid from the eye (blue arrows) is
determined by the rate (G) of pumping
action of the peristaltic pump (F) under
surgeon control. In the unoccluded
"hydrodynamic" balanced system, in-
flow (red arrows) from the infusion
bottle (B) will replace (C) the aspirated
fluid at the same rate, to maintain the
constant intraocular pressure deter-
mined by the height of the bottle above
the eye. In this unoccluded case, the
rates of inflow and outflow are equal.
116
This fluidic circuit is regu-

lated by a pump which not only
washes the emulsified substances
but also provides a highly useful
clinical purpose. When the tip of
the phaco handpiece is not oc-
cluded, the pump produces certain
currents within the anterior cham-
ber, which are measured in millili-
ters per minute, which are respon-
sible for attracting the nuclear frag-
ments towards the phaco tip. When
a fragment completely occludes the
phaco tip, the pump provides a
vacuum which is measured in mm
Hg, which holds the fragments
firmly against the phaco tip (Figs.
57-60).
There are two main types of
pumps utilized during phaco: The
Flow pump and the Vacuum pump.
Figure 58: Fluid Dynamics - Balance of Inflow and
The Flow pump, responsible for the direct
Outflow During Phacoemulsification - Tip
control of flow, physically regulates the fluid Unoccluded - Hydrodynamic Balanced System
within the aspiration line by direct contact
This view is a close-up complement of what is
between the fluid and the mechanism of the illustrated in Fig. 57. The anterior chamber during
pump. Even though the scroll pump is the phacoemulsification is a closed system in which there
latest type of flow pump, the one traditionally is both intake and output of liquid and where the pressure
must be controlled. With nothing occluding the tip of the
known as the peristaltic pump is the more phaco handpiece (P), vacuum pressure is zero (table
commonly utilized. One of its important point 1), At this point, the inflow (green arrow) equals
characteristic is the capacity to control the the outflow (red arrow) of the phacoemulsification probe,
and the pressure in the eye is maintained and constant
flow of fluid as well as the vacuum. This (table levels 2 and 3).
allows the aspiration flow to be independent
of the height of the bottle of fluid. Neverthe-
less, it is dependent on the degree of occlu-
sion of the phaco tip. Aspiration flow
diminishes when the degree of occlusion at
the phaco tip increases and aspiration stops
completely when the occlusion at the phaco tionally regulates the flow of aspiration when
tip is total (Figs. 59, 60). the port of aspiration is not occluded. When
These pumps have in common a the port of aspiration is occluded, the flow
drainage cassette adapted to the aspiration ceases and the suction is transferred to the
line. The pumps are connected to the cassette cassette by means of the aspiration line to the
and produce a suction which in turn propor- occluded tip (Figs. 57-60).
117
Figure 59 (above left): Fluid Dynamics - Balan-

ce of Flow When the Phaco Tip Is Occluded
with Lens Material - Hydrostatic Closed System
When a piece of nuclear material (N) is

drawn to and blocks (occludes) the aspiration port
of the phaco tip, fluid balance is still maintained
within the eye. Although the pump (F) is still
running, it can no longer providing fluid outflow
(D) because the system is blocked, but it is now
providing vacuum pressure, holding the occlud-
ing fragment. In the balanced "hydrostatic" closed
system, inflow (C) ceases at the same time since it
now has nowhere to move. Controlled intraocular
pressure is maintained via the inflow line to the
level determined by the height of the bottle (B)
above the eye. Equal zero rates of inflow and
outflow is revealed by no drainage (G) from the
occluded yet balanced system.
Figure 60 (below right): Fluid Dynamics -

Balance of Inflow and Outflow During
Phacoemulsification - Tip Occluded With Lens
Material - Hydrostatic Closed System
This view is a close-up complement of the

fluid dynamics shown in Fig. 59. When the tip of
the phacoemulsification probe is occluded with
nuclear material (L), the vacuum pressure rises to
a level to which the machine is set (table - arrow
- 1), and the inflow and outflow rates go down
(table 2 and 3 - green and red arrows). With the
aspiration port occluded, no fluid can enter or exit
the eye.
118
Importance of and Understand- thereby giving rise to a sudden elevation of

ing the Surge Phenomenon the output of fluid from the anterior chamber
(Fig. 61). The output of fluid suddenly
The Surge phenomenon occurs when a becomes larger than the input of fluid. This
fragment of nuclear material is suddenly dis- differential results in sudden collapse of the
placed from occlusion through the aspiration anterior chamber and can lead to serious
tip at the handpiece of the phaco machine, complications (Figs. 62, 63).
Figure 61: Mechanism of the

Undesirable Surge Phenomenon
One problem area of the
closed phaco system occurs dur-
ing abrupt dislodging of an oc-
cluding piece of lens material so
othat it no longer occluds the
aspiration port of the phaco tip. A
sudden drop in intraocular pres-
sure occurs as the fluid rate into
the eye fails to immediately match
the sudden fluid rate out of the eye.
This is known as the Surge Phe-
nomenon. (A) Shows a piece of
lens material occluding the aspira-
tion port of the phaco tip and is
held in place by vacuum pressure
created by the operating pump (D).
(Note there is no drainage (E) from
the blocked system.) Infusion from
the irrigating bottle (C) has ceased,
but is still providing controlled
intraocular pressure due to its el-
evated position above the eye.
With sufficient vacuum pressure
from the pump and/or emulsifica-
tion from the ultrasonic energy,
the nuclear piece will abruptly
enter the aspiration port and the
fluid system will once again open
(B). Because the plastic infusion/
aspiration lines and the eye walls
are flexible in absorbing the sud-
den inflow-outflow pressure dif-
ferential, there occurs a moment
when the infusion fluid (G-small
arrow) does not effectively enter
the eye fast enough to replace the fluid suddenly moving out of the unblocked system (F-large arrow). Outflow rate from
the force of the pump is momentarily greater than the replacing infusion rate. This out of balance system (out of balance
in not providing constant intraocular pressure) in which the eye momentarily absorbs the inflow/outflow rate differential,
may traumatically collapse the eye for a short period. (See Figs. 62 and 63).
119
Figure 62 (above left): Physical Problems

Caused by Surge
During the Surge Phenomenon when a

nuclear piece (F) is abruptly aspirated from the
eye, the anterior chamber may collapse due to
a sudden loss of intraocular fluid. The cornea
(C) may cave in, resulting in possible endothe-
lial cell damage if it comes near the phaco
probe. The posterior capsule (D) may also be
damaged from anterior displacement toward
the instrument. The fluid outflow rate must be
brought under control, and the inflow rate (small
red arrow) and outflow rate (large blue arrow)
are again equalized with the eye repressurized,
to reestablish a balanced system with constant,
controlled intraocular pressure is not maintained.
Figure 63 (below right): Problem of Surge

During Phacoemulsification
This view is a close-up complement of

what is shown in Figs. 61 and 62 and explained
in their respective figure legends. Here we
perceive more clearly the complications within
the eye caused by the outflow surge
phenomenon. Surge may occur after a
fragmented piece of lens nuclear material is
suddenly no longer occluding the aspiration
port. Aspiration occurs abruptly and the vacuum
usually goes to 0 (table point 1 - blue arrow).
This sudden aspiration of too much liquid from
the eye (large red arrow within the a.c.) is
greater than the rate at which the inflow can
replace the liquid aspirated (small green arrow
in phaco probe). Notice that the table shows
the outflow rate is large at this stage (table -
point 3 red cube and arrow) and the inflow rate
(table - point 2 green cube and arrow) has not
caught up with it. This differential causes the
posterior capsule to move forward (E) and the
corneal endothelium to move inward (D), which
can result in severe complications.
120
When the phaco tip is not occluded, the anterior chamber than the inflow, the
excess vacuum is zero (0), (Fig. 58) but the chamber collapses with possible rupture of
flow of aspiration is very high with a large the posterior capsule and damage to the en-
quantity of flow going in and out from the dothelium (Figs. 61-65).
anterior chamber. Note the distinction be-
tween the normal suction, or vacuum, pres- Lessening Intraoperative
sure which always exists in Positions 2 & 3, Complications from the Surge
and which must exist to produce the normal
aspiration flow we speak of, with the extra As emphasized by Centurion, the latest
"vacuum" pressure which builds up when generation of phacoemulsification machines
there is tip occlusion. When the phaco tip is make surge control possible (Figs. 64, 65).
occluded with nuclear material, the outflow With these machines it is possible to work
of fluid stops and the vacuum rises to the with a high vacuum of more than 300 mm
maximum level to which the machine was while maintaining a steady flow rate. When
originally calibrated and which we previously the last part of the nuclear material goes
described (Fig. 60). This high vacuum aids through the phaco tip, a sensor located at the
the rapid emulsification of the nuclear frag- aspiration line signals a micro processor to
ment with or without ultrasound. When there slow the rate of the pump. Sometimes there is
is much more sudden outflow of fluid from some reflux in the process of maintaining the
Figure 64: Technical Solution to Prevent

the Undesirable Surge Phenomenon
One technical solution for eliminat-

ing the surge phenomenon involves the use
of a high-tech microprocessor. (Fig. A)
When a nuclear piece (F) occludes the aspi-
ration port and then suddenly (B) is aspi-
rated (F-arrow) by the vacuum pressure of
the pump (P), a sensor (E) located on the
aspiration line signals a microprocessor (G)
in the unit that an abrupt surge in aspiration
flow has begun to take place. Within milli-
seconds, the microprocessor directs the motor
of the pump (P) to slow down. The reduc-
tion in aspiration rate resulting from the
slowed pump occurs before the eye can
collapse from any volume differential en-
countered between sudden inflow and out-
flow rates. The potentially dangerous surge
phenomenon is avoided. This elimination
of the surge phenomenon allows the surgeon
to safely use higher vacuum rates (necessary
in some situations) with a reduction in the
need to use potentially damaging high ultra-
sonic power settings. Surgery becomes safer
and faster.
121
same intraocular pressure. This high speed The surge phenomenon is more of a
mechanism insures that the pressure is always concern when you utilize a conventional tip
the same inside the eye. with the 0.9 port with high vacuum and flow
As emphasized by Barry Seibel, the of aspiration. It is less of a problem when you
surge phenomenon occurs in positions 2 or 3 utilize the irrigation-aspiration tip with the
of the foot pedal when a nuclear fragment smaller opening (0.3 mm). In addition, it is
totally occludes totally the phaco tip. possible to diminish the propensity for surge
Vacuum builds up in the aspiration line, the during phaco by utilizing a more resistant
lens material is emulsified sufficiently so that type of tip such as the Microflow or the
it is quickly drawn within the phaco tip, the Microseal or with the systems ABS which we
occlusion is broken, and there is a sudden describe in Chapter 8, (Fig. 84).
surge of aspiration, emptying the anterior
chamber.
Figure 65: Advances in Equipment Technology to Prevent the Surge During Phaco
This is a close-up view of the anterior segment showing what is illustrated and explained in Fig. 64 and its figure legend. The
latest generation of phacoemulsification machines make surge control possible. During the problem period when the last part of the
nuclear material is aspirated through the phaco tip, a sensor signals a microprocessor to slow the rate of the vacuum pump. As a
consequence, when the nuclear material no longer occludes the phaco tip and the sensor detects that the vacuum pressure is dropping
suddenly (table point 1 blue arrow and block), the sensor instantly sends a signal to the pump to slow the outflow rate (broken red arrow
next to phaco tip). The outflow rate (table point 3 - broken red arrow and block) is thereby moderated to allow the inflow rate time
to catch up (table point 2 green arrow and block ). This control of the pump action allows inflow and outflow rates increase together
in a more equal fashion during this moment of potential negative surge. This makes surgery much safer, quicker and easier.
122
NUCLEUS REMOVAL has been able to successfully perform all the

previous steps over and over again in different
APPLICATION OF PHACO patients. This experience will serve the sur-
geon as the requisite basis for success in the
FRACTURE AND EMULSIFICATION emulsification and removal of the nucleus in
the present patient.
This is really when the surgeon begins to In removing the nucleus the surgeon first
utilize the ultrasound energy in the phaco attempts to divide the nucleus by fragmenting
machine and apply it within the patient's eye. it into smaller portions that in due time will
During the transition period, this is a step that then be emulsified individually (Figs. 55, 56,
should be preceded by a good number of hours 66, 67, 68). If the fracture or division of the
of practice in the experimental laboratory until nucleus has been incomplete and has resulted
the surgeon is confident in the application of in large pieces or incomplete fractures, the
the ultrasound energy. It implies that he or she surgeon will not be able to perform the pha-
Figure 66: The Role of Cavitation in

Breaking the Cataract Inside the Bag
There are two forces involved in

emulsifying a cataract. One is the
mechanical force of the ultrasound as
shown in Figs. 55 and 56 and explained in
their respective figure legends; and 2.) the
mechanism of cavitation. The magnified
section of cataract presented here shows
that as the phaco tip makes its tiny
ultrasonic movements, the energy releases
bubbles (B) inside the nucleus creating
cavities (C). The build-up of bubbles inside
the nucleus creates new hollow spaces (C)
in the lens structure, the phenomenon of
cavitation. This cavitation facilitates the
break-up and destruction of the cataract.
Some of the new phaco tips as
shown in Fig. 51 are designed to produce
more cavitation. The one shown in this
figure is one of the best, designed by
Kelman for the Alcon phaco machines. It
has a very thin tip with a 30 degree bend.
It is particularly effective in hard nuclei
because of its enhanced cavitation.
123
coemulsification successfully or he will need without having to push them against the poste-
to use so much ultrasound energy that there rior capsule than it is to emulsify a large,
may be endothelial damage. Present tech- cumbersome nucleus.
niques of phacoemulsification are precisely The nuclear fracturing techniques devel-
geared to avoiding the use of large amounts of oped by Gimbel are in part possible because of
ultrasound energy. the CCC (capsulorhexis) technique that Gimbel
There are different techniques for the and Neuhann originated. The mechanical
fracture of the nucleus. In the end, the surgeon fracturing of the lens causes extra physical
will decide which one he prefers or feels more stress within the capsule, and that cannot be
secure with. Often, it depends on the type and done without great risks of tears extending
maturity of the cataract. At this stage of the around posteriorly unless you have a proper
transition, when the surgeon is only beginning CCC. There is almost an interdependence of
in his experience in fracturing and dividing the these two methods. The fracturing techniques
lens to apply the ultrasound, the most recom- have not only provided more efficiency in
mended procedure is to divide it into four phacoemulsification in routine cases; they have
quadrants, the well known "divide and con- also made phacoemulsification in difficult
quer" first presented by Gimbel (Fig. 56). cases safer and more feasible.
Later, the surgeon will be able to utilize other Gimbel clarifies that not only are there
modern techniques which also use high vacuum lamellar cleavage planes corresponding to the
and low phaco but which may be too difficult different zones of the lens, but also there are
in the transition. radial fault lines corresponding to the radial
At this stage of division or fracturing of orientation of the fibers, as first described by
the lens in the transition, it is recommended Drews. Until the development of these nuclear
that the surgeon use Memory 1 of the phaco fracturing techniques we had not taken advan-
machine (Fig. 56) which implies a discretely tage of this construction (Figs. 55,56,67,68).
high amount of ultrasound, low or no vacuum, The lens fractures quite readily in radial or pie-
low aspiration and the conventional height of shaped segments (Fig. 67). To accomplish this
the bottle (65-72 cms). radial fracturing, the surgeon must sculpt deeply
into the center of the nucleus and push out-
The Divide and Conquer Technique wards (Fig. 56). Sculpting is used to create a
trench or trough in the nucleus. Then the
In the "divide and conquer" technique, surrounding part is divided into two
the phacoemulsification instrument is used to hemisections. The separation must occur in the
create a deep tunnel in the center or the upper thickest area of the lens located at the center of
part of the nucleus. The nucleus is split into the nucleus (Figs. 103 and 104).
halves, sometimes fourths, and even occasion- An additional consideration with these
ally into eighths. Splitting the nucleus is safer types of nuclear fractures is whether the seg-
for the endothelium and easier to learn, espe- ments should be left in place until all the
cially for the less experienced ophthalmologist fracturing is complete or whether they should
converting from planned extracapsular surgery be broken off and emulsified as soon as they are
to phacoemulsification. It is easier to keep separated. With a lax capsule and particularly
smaller particles away from the endothelium with a dense, or brunescent nucleus (Fig. 2),
124
Figure 67 (above left): Emulsification of Lens

Fragments
This surgeon's view shows the

management of the lens quadrants. The apex of
each of the four loose quadrants is lifted, the
ultrasound phaco tip is embedded into the poste-
rior edge of each and by means of aspiration the
surgeon centralizes each quadrant for
emulsification.
Fig. 68 (below right): Emulsification

of Lens Fragments
In this cross-section view you

can see the loose quadrants ready for
emulsification by phaco as illustrated
through a surgeon's view in Fig. 67.
Here you see a viscoelastic (V) being
injected via a cannula (C) into the
cleavage created by hydrodissection of
the posterior nucleus from the posterior
cortex and epinucleus as shown in Fig.
47 (blue arrow). The "viscoelastic sand-
wich" helps protect the posterior
capsule to prevent its rupture when the
nucleus is undergoing manipulation and
emulsification. Note viscoelastic liquid
filling the anterior chamber (blue arrow).
The parameters of the phaco machine
at this stage of emulsification of lens
quadrants with aspiration-
fragmentation of the nucleus are shown
within the rectangular table immediately
above this figure. Memory 2 is shown
digitally in the machine and by sound as
2. U.S. refers to the ultrasound power
used. ASP is identified as the flow rate and VAC as the amount of vacuum, all specifically at this stage.
125
Gimbel considers that it is safer to leave the tion. This is due to his lack of familiarity with
segments in place to keep the posterior capsule handling large fragments of epinucleus and
protected. The segments are easier to fracture cortex since in the planned extracapsular ex-
if they are held loosely in place by the rest of traction he is accustomed to remove a large and
the already fractured segments still in the bag complete nucleus that includes all the epi-
(Fig. 105). nucleus and a significant amount of cortex.
During the transition, the surgeon has to man-
Emulsification of the Nuclear age safely the irrigation-aspiration handpiece.
Fragments Later, when he masters the technique, he may
aspirate the epinucleus and cortex by maintain-
If the surgeon has been successful in the ing the aspiration with the tip of the phaco
fragmentation of the nucleus, the next step is to handpiece. For this stage of the aspiration of
emulsify the pieces of segments of the divided the epinucleus, the surgeon will use Memory 3
nucleus. He may do this with the linear con- which means very low or no ultrasound power,
tinuous mode or with the pulse mode. The a moderate to high vacuum, and high flow of
latter done during the transition provides more aspiration, with the bottle of fluid maintained at
security for the surgeon and allows him to use the conventional height (Fig. 69).
less ultrasound which is the definite tendency
at present. Aspiration of the Cortex
The surgeon may later slowly begin to
utilize other more specialized techniques known This step is closely related to the previ-
as the different "chop" techniques which we ous one (Figs. 70, 71). There can also be a
will discuss later. These techniques facilitate larger incidence of posterior capsule rupture
much more the emulsification of the segments during this stage since the surgeon does not
or pieces of the fractured nucleus than the have the epinucleus as a barrier which up to a
divide and conquer but they are a little more few seconds before was protecting the poste-
complex. During this step of emulsification of rior capsule. The surgeon should use a larger
the nuclear fragments, the surgeon may use quantity of viscoelastic whenever required with
Memory 2 in the machine which delivers low the purpose of protecting the posterior capsule.
ultrasound, high vacuum, and a larger flow of During the transition period, he may help his
aspiration, with a conventional height of the maneuvers by using the Simcoe cannula with
bottle of fluid (Figs. 67, 68). which the planned extracapsular surgeon usu-
ally feels safe. This cannula may be introduced
FINAL STEPS through the ancillary incision. The Simcoe
cannula has the disadvantage, though, that the
aspiration hole or aperture is smaller than that
Aspiration of the Epinucleus of the irrigation-aspiration handpiece of the
phaco machine. Consequently, the aspiration
It is during this specific step that there is
of the masses of cortex may become more
a higher incidence of rupture of the posterior
difficult and slow. During this stage, the sur-
capsule for the surgeon in the period of transi-
126
Figure 69 (right): Epinucleus Removal
Once the nucleus has been extracted,

similar flow and vacuum presets are used to
remove the epinucleus. Moderated control of
flow, then vacuum are essential to a successful
and safe removal as identified in the parameters
above this figure. Higher flow and vacuum
rate are inappropriate for engaging the
epinucleus located so close to the posterior
capsule (R) and iris. Too low a flow and
vacuum will fail to engage the epinucleus. A
moderate flow rate is used to draw (arrow) the
distal epinucleus (C) to the phaco tip (P) without
pulling in the capsule or iris. Once the phaco
has engaged the epinucleus, moderate vacuum
is used to maintain its grip on the epinucleus to
remove it as a whole, as centrally in the pupil
as possible. Too high a vacuum may abruptly
break away a piece of the epinucleus and
penetrate the epinuclear bowl and threaten the
posterior capsule beneath. Too low a vacuum
setting during removal may lose its grip on the
epinucleus and lengthens surgery. During the
transition stage, use a limbal incision. The
corneal incision in this figure is for experienced
surgeons. During epinuclear removal use
Memory 3, as shown.
Figure 70 (left): Phacoemulsification - Re-

moval of Residual Cortex in Transition
The ultrasound tip is exchanged for an

irrigation-aspiration tip (I/A), which is smaller
and finer than the ultrasound tip. The anterior edge
of cortex is engaged at the 6 o’clock position. The
instrument peels cortex from the posterior capsule
and removes it using the Memory 4 setting. The
parameters are shown in the rectangle above this
figure. Please observe that the vacuum is signifi-
cantly increased and the aspiration and flow rate
are moderately higher than the step shown in Fig.
69.
This figure shows (for didactic purposes) a
larger amount of cortex than the experienced sur-
geon has to deal with. This mass of cortex is what
may be seen during the transition phase which is
the step of the operation we discuss in this chapter.
The experienced surgeon performs a more
effective hydrodissection and frequently does not
need to perform irrigation/aspiration because little
cortex remains. He/she remove the epinucleus
usually during the emulsification process.
127
Figure 71: Phacoemulsification - Irrigation/

Aspiration of Residual Cortex
Residual cortex (C) is removed from the

capsular bag using curved Irrigation/Aspiration
probes. A slightly curved tip is used to gently
aspirate residual cortex nasally and temporally.
Residual cortex located in the hard-to-reach as-
pects of the superior capsular bag are reached
with a very curved I/A probe tip. The machine
parameters used at this stage are shown with Fig.
70, and correspond to Memory 4. The corneal
incision shown here is for surgeons experienced
enough that no conversion to extracapsular is
expected. For surgeons in their transition period,
a limbal incision is more prudent.
geon should use Memory 4 in the setting of the to 5.2 mm. A 5.2 mm knife blade will do this
machine which means zero phaco power, maxi- most accurately. In extending the arc of the
mum vacuum and the highest flow of aspira- incision, the surgeon must maintain the valve-
tion as compared with all the previously men- like, auto-sealing characteristics present in the
tioned memories. The fluid bottle is main- original small incision. The PMMA IOL im-
tained at the conventional height. plantation is performed as shown in Fig. 72-B.
After this stage has been mastered, the surgeon
Intraocular Lens Implantation may then change to implantation of the fold-
able lenses but this must be done only after the
For the surgeon in the stage of transition, surgeon is completely satisfied with his phaco
it is advisable to begin by implanting PMMA technique.
IOLs either of the ovoid shape (Fig. 72-A) or
with round optics of a fairly small diameter. Removal of Viscoelastic
The ovoid 5 x 6 lens shown in Fig. 72-A is just
Throughout the different stages of this
right.
procedure, the presence of viscoelastic in the
anterior chamber is always a measure to keep
Enlarging the Incision and Im- in mind in order to prevent or minimize damage
planting the Lens to the surrounding structures during surgical
maneuvers, particularly the corneal endothe-
In order to accomplish this the surgeon needs to lium. When removing viscoelastic from the
extend the small incision with which he started, anterior chamber, the phaco machine must be
128
in zero phaco or ultrasound, high vacuum, very Closure of the Wound

low aspiration and the bottle of fluid should be
significantly lower. After all the surgical steps If a good incision has been made, valve-
have been accomplished, it is important, as we like, auto-sealing and waterproof, no suture
all know, to remove the viscoelastic in order to will be absolutely necessary even in those
avoid a high intraocular pressure postopera- cases where the wound has been extended to an
tively, with subsequent corneal edema, blurred arc of 5.2 mm for the PMMA IOL implantation
vision and pain during the first postoperative as shown in Figs. 72-A and B. As long as these
days. two requisites are met, that is, extending the
Even though this measure of removing incision to 5.2 mm with a special knife blade of
all the viscoelastic has been emphasized over that size and maintaining a valve-like, auto-
and over again in lectures and published pa- sealing incision, there is little danger of com-
pers, there are still surgeons who are not fully plications without sutures. Nevertheless, if
aware of the importance of taking this step and the surgeon is not sure he has made a valvulated
the consequent complications.
Figure 72 A: The Ovoid PMMA IOL for

Implantation During the Transition
During the transition period, the limbal

incision is enlarged to 5.5 mm size and a 5 x
6 mm ovoid PMMA lens (Fig. 72-A) is
implanted through this incision. The optical
zone should not be smaller.
129
Figure 72 B: PMMA IOL Implantation in

Transition Period
Before implanting the PMMA IOL,

the surgeon should irrigate, with machine
parameters of U.S. zero power, ASP 50 and
VAC 500. After irrigation, the surgeon intro-
duces viscoelastic in the A.C. and bag before
IOL implantation. Lubricate the lips of the
incision with viscoelastic first. The use of
foldable IOL's introduced through a clear
corneal incision is a goal to be tried and attained
later, when the surgeon feels more comfortable
with his surgical technique.
incision from the beginning (3 steps - enlarged to one side and 2 or 3 sutures are
Fig. 40-A and 42 A-B), even a 3 mm incision placed (pre or post placed). The incision is
with no sutures will leak. If so, to leave the completed to the other side and 2 or 3 more
patient without any sutures would be to take an sutures are put in place (pre or post placed ).
unnecessary risk. It is more prudent to place The two superior sutures are placed at either
two or three 10-0 nylon sutures in the wound end of the "valve incision", so that irrigation-
and they may be removed early in the postop- aspiration (I + A) can be performed unhin-
erative stage. This decision really depends on dered at that site. These two sutures are tied
the ability of the surgeon to create a valve-like, with a slip knot prior to I & A, and then
self sealing incision. loosened to place the IOL. The other sutures
are tied and knots buried before I & A. At the
What to Do if Necessary to Convert end of the operation an additional suture can
be placed if the incision is not secure. To
When the surgeon decides to convert reduce risks, the surgeon may preplace the 3
from phaco to extracapsular,, viscoelastic is 10-0 nylon sutures across a grove on each side
placed in the anterior chamber. The incision is first, before enlarging the incision.
130
Testing the Wound for Leakage incision. The small conjunctival flap is then
advanced over the incision.
Before considering that the surgery is Immediate Postoperative
over, it is important to be sure that no leakage
Management
exists either through the main incision or
through an ancillary incision, under the micro- After instilling antibiotic ointment and
scope. This is done by cleaning and drying the topical antiinflammatory drops, the eye may be
incision with a Weck-cell sponge, removing patched if local anesthesia such as retrobulbar,
the viscoelastic and slightly overfilling the peribulbar or sub-Tenon's were used. If only
anterior chamber with BSS after the viscoelas- topical anesthesia or topical combined with
tic is removed and exerting mild pressure over intracameral irrigation anesthesia was used
the cornea with the sponge (Fig. 73) or using (Figs, 35, 36), you may leave the patient with-
fine forceps to lightly "dance on" the cornea. out any patch. This facilitates the postopera-
At this time one can observe if there is any tive use of antiinflammatory drops by the
wound leak (Fig. 73). If the surgeon finds that patient.
there is a leak, the best way to solve it is by The use of subconjunctival or parabul-
injecting BSS into the lips of the incision to bar injection of antibiotics and steroids imme-
hydrate the tissues and force the incision closed. diately following surgery, is no longer accepted
This works even better for the small ancillary as necessary, as was outlined in Chapter 4.
Figure 73: Evaluation of Leak Proof

Incision
This figure shows the surgeon

checking to test if the incision is really leak
proof, by doing the following: 1) after drying
the lips of the incision, exhert light pressure
over the cornea with Weck sponge. The
"shadow" image represents the sponge
delicately "dancing" over the cornea. Look
for any fluid escaping through the wound.
2) inject fluid through the paracentesis and
observe if any drops of fluid come out through
the previous incision. If a leak is found, the
surgeon must suture the wound.
131
RECOMMENDED READINGS
Seibel, BS: Phacodynamics: Mastering the Tools

and Techniques of the Phacoemulsification Surgery,
Third Edition, 1999.
BIBLIOGRAPHY
Barojas, E: Importance of hydrodissection in phaco.

Guest Expert, Boyd’s BF The Art and the Science
of Cataract Surgery of HIGHLIGHTS, 2001.
Benchimol, S., Carreño, E: The transition from

planned extracapsular surgery to phacoemulsifica-
tion. Highlights of Ophthalmol. International En-
glish Ed., Vol. 24, 1996, Nº 3.
Carreño, E.: From can opener to capsulorhexis: the

crucial step in the phaco transition. Course on How
to shift successfully from mannual ECCE to ma-
chine-assisted small incision cataract. AAO, Oct.
1999.
Carreño, E.: Hydrodissection and hydrodelineation.

Guest Expert, Boyd’s BFThe Art and the Science
of Cataract Surgery of HIGHLIGHTS, 2001.
Centurion, V.: The transition to phaco: a step by

step guide. Ocular Surgery News, Slack, 1999.
Drews, RC.: YAG laser demonstration of the

anatomy of the lens nucleus. Ophthalmic Surgery
1992. 23:822-824.
Koch, PS: Hydrodissection. Simplifying Pha-

coemulsification. Fifth Edition, Slack, 1997, 8:87-
98.
132
133
134
C h a p t e r 8: Instrumentation and Emulsification Systems
INSTRUMENTATION AND
EMULSIFICATION SYSTEMS
INSTRUMENTATION Fixation Ring

Phacoemulsification uses many of the Its use is optional but it may be quite
same instruments that are used in conventional helpful during the construction of the limbal or
extracapsular cataract surgery. We will not the clear cornea tunnel incision because it pro-
refer to them in this chapter because every duces fixation of the globe throughout the
cataract surgeon is fully familiar with such circumference of the ring. The most popular
instruments. fixation ring is the Fine-Thornton (Fig. 75). If
This chapter is exclusively focused to- the surgeon prefers not to use the fixation ring,
ward those instruments especially created for the globe may be fixed with very fine 0.12
phacoemulsification surgery or those that may toothed forceps.
have common features for both techniques,
extracapsular and phaco, but that have required Knives and Blades
modifications for the surgeon to undertake
successful phacoemulsification surgery. There are two options for the knives and
There are multiple variations of each blades (Figs. 76-77): 1) utilize stainless steel
type of instrument. Consequently, rather than disposable knives (Fig. 76); 2) use diamond
referring to the instruments by the name of their knives which can be re-sterilized (Fig. 77).
creators or proponents, we will focus here on Both types of knives and blades have their
the specific characteristics needed for phaco advantages and disadvantages. The selection
surgery. These instruments are: really depends on the preference of the sur-
geon. The disposable stainless steel blades and
Eye Speculum knives have reached a very high level of quality
and precision. They may be re-sterilized for a
It is very important to have the right eye small number of cases, certainly no more than
speculum (Fig. 74). Since topical anesthesia is four or five. They require a lower initial
utilized by most experienced phaco surgeons, investment and less care when handling by the
the speculum must have a lock to prevent the nurses and assistants. Nevertheless, when we
lids from closing and squeezing during sur- are going to make a clear corneal incision and
gery. tunnel, it is recommended to use a diamond
The speculum should not interfere with knife which can be calibrated (Fig. 77). Those
the surgeon's movements and instrumentation knives and blades can be manufactured with
when operating in the upper temporal quad- different parameters. Those for paracentesis
rant, which is the approach mostly utilized (Fig. 76 B) have an angulation of 30 degrees.
today.
137
Figure 74 (left): Eye Speculum
Phaco surgery using topical anesthesia

requires that the eye speculum design offer suffi-
cient aperture for operating from the side, which is
always done from 9 to 12 o’clock, whether right or
left eye. The speculum has a lock and strong arms
to keep the eye open in case that the patient
squeezes the lids.
Figure 75 (right): The Fine-Thornton

Fixation Ring
Some surgeons find this fixation

ring useful, particularly during the con-
struction of the limbal or the clear cornea
tunnel incision. Other surgeons prefer to
fixate the globe with a forceps.
138
Crescent knives (Fig. 76-C) have a rounded Consequently, for surgeons who do a major
point which is fundamental in the construction amount of surgery, the diamond knife may be,
of the tunnel in the incision as shown in Fig. 41- in the end, economically more efficient.
B, Chapter 8. The disposable knives with sharp In Fig. 77 you may see diamond knives
points range from 2.6 to 3.2 mm (Fig. 76-A). designed for various purposes, 77-A for para-
They are particularly useful in the small inci- centesis or side port incision (also shown dur-
sions when utilizing different sized phaco ing surgery in Fig. 41-A); Fig. 77-B for a
probes and tips as shown in Figs. 82 A and B. 3.2 mm incision or slightly smaller as in
The 5.2 mm blunt point blades as shown Carreño's Phaco Sub-3 technique, also shown
in Figs. 76-D may be highly useful to enlarge in Fig. 40 C. Fig. 77-C shows the crescent type
the incision in case of PMMA 5.5 mm of knife, also seen in the surgical steps in
intraocular lens implantation or larger as Fig. 41-B and Fig. 42. Very narrow sharp
shown in Fig. 72 A. There is, however, an pointed blades are being developed to
increasing tendency to utilize diamond knives perform the 1 (one) mm incisions to be used
because the surgeon is able to obtain a perfect with Dodick's PhotoLysis recently ap-
incision. The knives also last for a long time. proved by the FDAusing a special ND-YAG
laser.
Figure 76: Stainless Steel Disposable

Knives for Phacoemulsification
(A) Knife to make a 3.2 mm

primary incision. (B) Blade with a 30
degrees angulation for paracentesis or
sideport incision to allow introduction
of the second instrument (manipulator
or chopper) and other purposes such as
viscoelastic injection. (C) Crescent knife.
The rounded point is fundamental in the
construction of the tunnel incision. (D)
This 5.2 mm blunt point blade may be
highly useful to enlarge the incision in
case of PMMA 5.0 x 6.0 mm optics as
the one shown in Fig. 72-A intraocular
lens implantation or larger .
139
Figure 77 (left): Diamond Knives
(A) Utilized for side port or paracentesis

incision (also shown during surgery in Fig. 41-A).
(B) This blade is used for 3.2 mm incision or
slightly smaller as in Carreño's Phaco Sub-3. This
knife is also shown in Fig. 42. (C) Crescent dia-
mond knife with rounded point fundamental in the
construction of the tunnel incision( also shown in
Figs. 41-B and 42).
Figure 78 A (right): Hydrodissection Can-

nula Under the Anterior Capsule.
For this purpose it is recommended to

use a 25 G flat tip cannula. Observe how the
cannula enters below the edge of the
capsulorhexis performed on the anterior cap-
sule. The surgeon then injects the BSS to sepa-
rate the capsule with the cortex from the nucleus.
Hydrodissection Cannula
This special cannula is shown

in Fig. 78-A and in Figs. 46 - 48. These
cannulas are especially made with a rect-
angular and 27 G diameter that facili-
tates the injection of liquid to separate
the anterior capsule from the cortex. They
are re-sterilizable. They should be con-
nected to a 3 or 5 cc syringe to allow a
better effect from dispersion of liquid.
For hydrodissection, there are also other
special cannulas in the form of "J" which
may be useful for specific maneuvers as
shown in Fig. 47.
140
Cystotomes or Capsulorhexis Forceps As to the capsulorhexis forceps (Fig. 78

B-C) there is a large variety and types of
There are several alternatives to the se- designs. The best known is the Utratta-Kershner
lection of cystotomes. One group is already forceps (Fig. 78-B left). The main characteris-
designed and manufactured for this purpose, tic of all capsulorhexis forceps is that they
with 25, 27 and 30 G calibers. Some surgeons have very fine, resistant arms and tips that
prefer to bend the tip of an insulin needle, prevent trapping of the iris. Curved ends are
which provides a very sharp point. The main highly useful so that the surgeon can manipu-
characteristic of the cystotome is that it must be late more comfortably within the anterior cham-
very sharp to facilitate the creation of the first ber. In any case, they must be easily connected
capsular flap during capsulorhexis and enable to a syringe that contains air or balance salt
the surgeon to continue performing a curvilin- solution for injection in addition to the conven-
ear capsulorhexis. These cystotomes must be tional viscoelastic, when the surgeon feels it is
easily adjustable to the needs and comfort of needed. There are other very useful
the surgeon in his/her maneuvers. capsulorhexis forceps such as the ones de-
signed by Gimbel (Fig. 78 C), the Masket,
the Corydon and several designed by Buratto.
Figure 78 B-C: Capsulorhexis Forceps
(A) The Utratta-Kershner's forceps. (B) The

Gimbel's forceps. All capsulorhexis forceps have very
fine, resistant arms and the end of the tips are slightly
curved (see inset) that will prevent trapping of the iris.
Please observe the special design that is highly useful
to manipulate more comfortably within the anterior
chamber. Other popular capsulorhexis forceps carry
the name of Masket, Corydon and Buratto.
141
Nuclear Manipulators or Choppers or the chopper shown in Fig. 80, is to facilitate

(Second Instrument) the bimanual maneuvering and rotation of the
nucleus, as well as allowing the chopping of it
intofragments that are going to be emulsified.
These ancillary instruments are abso-
In Fig. 79 we show two well known lens
lutely essential in order to adequately perform
manipulators: 79-A is the Lester instrument
the maneuvers necessary to remove the nucleus,
and Fig. 79-B is the Osher. In Fig. 80, you may
as described and illustrated in Chapter 9. There
see different types of choppers: 80-A the
is a large variety of types and designs. These
Fukasaku chopper and 80-B the Dodick-
instruments are introduced into the anterior
Kamman chopper.
chamber through the ancillary or side port
Some of these instruments have a blunt
incision. The purpose of this second instru-
tip, some longer or shorter length tips. All of
ment, either the manipulator shown in Fig. 79
them must have angulation as a common char-
Figure 79: Nuclear Manipulators
(A) Shows the Lester nuclear manipula-

tor. (B) The Osher manipulator. These are two of
the most popularly used ancillary instruments es-
sential to perform the bimanual maneuvers to
remove the nucleus, as described in Chapter 9.
These nuclear manipulators are essentially used in
the non-chopping techniques.
142
Figure 80: Choppers
In this illustration you may see two of the

most popularly used choppers (second or ancil-
lary instruments) ustilized by the surgeon in the
bimanual technique of removal of the lens nucleus
with the chopping method as described in Chap-
ter 9. (A) Shows the Fukasaku chopper. (B)
shows the Dodick-Kamman chopper. Please
observe that all the tips have a small diameter
angulation (0.25 - 0.50 mm). they have a blunt tip
which is able to cut or slice the nucleus. They
must have sufficient strength in the tip to create
and lead the forces of traction and rotation of the
nucleus. All surgeons have available both types
of ancillary instruments, the nuclear manipula-
tors and the choppers, to use in the procedure that
he/she decides for a specific patient.
acteristic, with the angulated tip being of very although the surgeon has his procedure of
small diameter (0.25 - 0.50 mm). The tip is able choice, he/she is not bound to rigorously follow
to cut or slice the nucleus. They must have that same procedure in all cataracts. The sur-
sufficient strength or resistance in the tip to geon has to adapt to different circumstances
create and lead the forces of traction and rota- and situations.
tion of the nucleus and they must be smooth and Other commonly known choppers are
blunt on the posterior surface in order to avoid those of Seibel, Nagahara, Nichamin. There
damage to the surrounding tissues. Some sur- are some hooks that are specifically utilized for
geons have available both types of instru- rotation of the nucleus. They need to be
ments, manipulators and choppers, depending angulated and have the shape of a shirt button.
on the type of surgery they are doing, because The best known is the Lester.
143
Forceps and Cartridge Injector Sys- standing cataract surgeons for this purpose
tems for Insertion of Foldable In- (Fig. 81) or by a combination of instruments
designed by the manufacturer to facilitate fold-
traocular Lenses
ing and insertion known as cartridge injector
systems. Examples of often used forceps are
Small incremental advancements con- shown in Fig. 81 and injectors in Fig. 82.
tinue to take place for placement of foldable Dodick prefers to use forceps to implant
IOL’s through small incisions. There is a Alcon's AcrySof (acrylic foldable IOL). Other
definite trend toward the development of sepa- very popular and useful forceps are the Fine
rate instruments for folding and inserting IOL’s Universal III forceps (Rhein Medical, Tampa,
rather than using the insertion device to fold the Fla.) and the Buratto insertion forceps (Ameri-
IOL. can Surgical Instruments. Westmont, Illinois).
The majority of foldable lenses are in- The latter is used specifically for the acrylic
serted either by forceps designed by out- lens.
Figure 81: Forceps for Insertion of Foldable

IOL's
There is a large variety of instruments

designed for this purpose. The right design is
related to the type of IOL you will be using. Here
we present the Osher-Seibel folding forceps (A)
with a curved design to easily fold most soft
intraocular lenses. For the insertion, we shows the
Blaydes angled lens forceps (B) that will help the
surgeon to gently insert the IOL in the bag.
144
Figure 82 AB (right): Injectors for Insertion of Foldable

IOL's
(A) The Allergan Unfolder. Sapphire Series Fold-

able IOL Implantation System: With very soft tip and
design, the Unfolder Sapphire offers excellent control during
the implantation of Allergan’s acrylic foldable intraocular
lens. In this surgeon´s view we are presenting the Sapphire
model for the acrylic IOL. Once the IOL is unfolding inside the
capsular bag, the cartridge should be rotated with the tip
aperture facing down to permit a smoth ejection of the IOL.
(B) The Alcon Monarch Model. Foldable IOL Im-
plantation System: The Monarch system´s design allows the
acrylic foldable IOL to blossom out of the tip aperture in a
safe, controlled way with no haptic harm. The injector tip is
introduced through the phaco incision asobserved here, ro-
tated and advanced to the center of the capsular bag were the
lens is slowly injected and unfolded on one plane into the
bag. Alcon is also continuing to develop finer injection through
its high technology capabilities.
Figure 82 C (left): Alcon’s Acrylic System to Fold IOL's
This special device allows the surgeon to carefully

fold the acrylic IOL previous to its insertion. The IOL is posi-
tioned in the top center of the Acrypack. The optics of the
IOL is shown here. Once in position the two arms of the
Acrypack are slightly compressed and allow the surgeon to
fold the IOL like a Mexican “taco” or a cigar. With the help of
the insertion forceps (Fig. 81) you may then catch the lens not
halfway but slightly closer to the folded part of the lens.
145
Cartridge Injector Systems Allergan's foldable three piece silicone

lens (monofocal or multifocal - AMO Array)
Some of the newest advances in lens with PMMA haptics may be implanted with
insertion technology surround the use of car- AMO's Unfolder Phacoflex injector system.
tridge injector systems. Fine, Lewis and Allergan's acrylic foldable IOL (Sensar and
Hoffman believe that there are many perceived Clariflex lenses) may be implanted with a new
advantages of implanting foldable IOLs with injector now available and known as the
injector systems, as compared with folding Unfolder Sapphire, as described by Centu-
forceps. These advantages include the possi- rion (Fig. 82-A). These injectors are re-
bility of greater sterility, ease of folding and sterilizable (as are the forceps, of course).
insertion, and implantation through smaller Alcon’s popular 5.5 mm AcrySof IOL
incisions. may be implanted with one of its injectors such
Greater sterility with injector systems is as the Monarch (Fig. 82) or with a standard
believed to occur because the IOL is brought cartridge through a 3.0 mm incision. Some
directly from its sterile package to its sterile have reported injecting this lens through a 2.8
cartridge and inserted into the capsular bag mm incision. Many surgeons use Alcon’s
without ever touching the external surface of Acrypack (Fig. 82) when implanting the
the eye, as is the case for lenses in folding AcrySof lenses. The Acrypack serves to first
forceps. Although this advantage would sug- fold the IOL. The surgeon then uses a forceps
gest a lower rate of endophthalmitis with injec- (Fig. 81) to implant the already folded IOL.
tor systems, recent clinical studies have shown The Alcon AcrySof lens, which requires
no significantly different rate of bacterial con- 3.5 to 4.0 mm incisions for 6.0 mm optics and
tamination of the anterior chamber after im- 3.2 to 3.5 mm incisions for 5.5 mm optics, is
plantation of silicone lenses with a forceps now packaged in a wagon wheel dispenser.
versus an injector. The easiest folding instrument to use for these
Perhaps the most appealing advantage of lenses is the Rhein folder, because its tips have
injector systems is that the lens can be loaded been extended to make it easier to remove the
by a nurse or technician without the use of an lens from the wagon wheel package. The
operating microscope, further streamlining the forceps can be turned with the tips down in the
procedure. In addition, inserting foldable lenses nondominant hand. The tips go into the slots on
with a cartridge device is generally felt to be both sides of the optics, so that the lens can be
easier than insertion with forceps, and these picked up and placed on a drop of viscoelastic.
lenses can usually be implanted through a The forceps are then turned so that the tabs are
smaller incision when delivered by means of an down. The lens is grasped and folded, and then
injector, compared with an insertion forceps. the insertion device in the dominant hand is
used to insert the lens.
146
Figure 83: Phaco Probe and Tip - Diverse Design and Diameters
Here we may observe and compare a standard phaco tip (A) with 3.2 mm in diameter
and a 3.5 mm incision width usually employed in scleral or limbal tunnel incisions. In (B)
we present the angled Kelman phaco tip attached to a finer phaco probe inserted through
a 2.6 mm corneal tunnel incision.This tip allows a smaller incision with less peri-incisional
fluid escape. It also gives rise to less heat transmission to the lips of the wound.
THE PHACO PROBES AND TIPS phaco tip emits more heat which could harm
the corneal lips. The phaco probe and tip,
In Fig. 83 you can see two different types shown in Fig. 83 (right), is narrower and can,
of phaco probes and tips. In Fig. 83 (left), there therefore, be utilized in smaller corneal inci-
is a larger caliber probe with a straight tip. sions such as the 2.6 mm shown in Fig. 83
This is particularly used when the incision is (right). The popular angled Kelman tip shown
predominantly limbal. The incision is slightly here has a high capacity to cut the tissues and is
larger than the one mostly utilized today which very useful in more dense cataracts. It allows
is the corneal incision shown in Fig. 83 (right). the use of a finer probe because there is less
The probe in Fig. 83 (left) using a standard contact with the lips of the wound and less heat
damage.
147
Figure 84: The Phaco Probe and Tips - Several Models

for Different Uses
The phacoemulsification probe and its components is

shown in detail to the left. Standard Tip (T). The Standard
tip (T), attached to it, is employed in cataracts with
moderately dense nucleus. Its large diameter (5.2 mm)
requires a wider incision. Probe’s Aspiration port (AP),
Irrigation port (IP), silicone Sleeve (S), Handpiece (H),
Irrigation line (I), Aspiration line (AL) and the Ultrasound
line (U). It is important to understand its mechanism in
order to manipulate this instrument with extreme accuracy.
To the right you find several phaco tips for different
purposes related to the type of cataract and the technique
utilized.
The Micro-Flow Tip (A) has some spiral grooves that
always provides cool fluid that flows around the needle,
thereby diminishing the heat around the incision. The
Mackool-Kelman tip (B), has a teflon coat to diminish the
heat that could harm the cornea. This is one of the latest
generation phaco instruments. The transformation of en-
ergy always involves some dispersion which generates
some heat.
The Aspiration Bypass System (ABS) shown in (C),
is also a new model 3.2 mm in diameter with a 0.25 mm side
hole (encircled in red) which contributes to prevent the
collapse of the anterior chamber (this micro-hole also aids
in controlling the temperature diminishing the heat over the
structures in the anterior chamber). The Surge phenomenon or A.C. collapse might be produced with larger aperture side holes
(0.85 mm) in the tip. This does hot happen with these new devices. The Flare tip (D) was designed to perform faster and better
contact with the nucleus while making the groove (D & C procedures) and the chopping techniques. The broader angle of
contact between this tip and the nucleus is more effective in softer nucleus. The Kelman angled phaco tip (E), optimizes the
ultrasound effect during the procedure and permits a better cavitation. It is more efficient in hard nuclei. The curved tip model
allows more contact with the tissues (internally and externally) and less possibilities of traction to the zonule.
Phaco Tips variety of them as shown in Figs. 51 and 84.

Depending on the surgeon’s technique and
The different components of the phaco circumstances of the case, they all can contrib-
probe are shown in Fig. 84 left . Please observe ute to better control in maneuvering of the
the standard tip (T). The probe is also shown in nucleus.
detail in Figs. 50-A and 50-B in Chapter 7. In figure 84 (right) and Fig. 51, you may
With the advent of chopping techniques in see the most important tips. Fig. 84 A is the
phacoemulsification, there has been increasing Microflow tip, 84 B is the Mackhool-Kelman
interest in the development of new tips for phaco tip, 84 C is the Aspiration Bypass
different uses and purposes. There is a large System (ABS), 84 D the flare head phaco tip,
variety of phaco tips, and each one has its and 84 E is the popular Kelman angled phaco
reason for being. Chopping procedures are tip. Their specific features are presented in the
facilitated by selecting the right tips from a caption of Fig. 84.
148
Surgical Principles Behind the they offer more safety and control. The most
Different Phaco Tips popular are:
The different uses for each of these 1) Kelman's Turbosonics and

different tips are described in the caption of Miniturbosonics
Fig. 84.
The main variations in phaco tips are These tips have a curved shape that at-
related to :1) Angulation. 2) Shape. 3) Size and tains larger contact with tissue surface, internal
4) Thickness. And 5) The existence or not of a and external, leading to more cavitation even
protective insulated cover that facilitates cool- though the ultrasound energy used may be the
ing so as to minimize the transfer of heat to the same as compared when using the standard tip.
surrounding tissues, essentially the corneal lips Higher cavitation allows destruction of the
of the wound. nucleus beyond the area of touch.
The miniturbosonics is essentially the
The Importance of Angulation and same style of tip but with lesser diameter.
Beveling The main advantages of these tips are: 1)
US energy is optimized leading to increased
The more beveled is the tip the larger the cavitation. 2) Better cutting and slicing of
cutting surface and the larger the area which tissues in very hard nuclei.
must be occluded at the tip. Those ranging
from 0º to 15º do not cut much but they occlude 2) Micro Tips
more easily. They are, therefore, ideal for soft
cataracts and for some chopping techniques in They all have smaller internal and exter-
which a maximum capacity for occlusion and nal diameters as compared with conventional
high vacuum is necessary. tips. Main Advantages: You can work with
Tips with more angulation and bevel smaller incisions and attain greater stability of
such as 45 degrees have a high capacity to cut the anterior chamber because these tips have
the tissues and are very useful for the maneu- more resistance to the passing of lens frag-
vers of phacofracture in dense cataracts and in ments leading to less risk of the Surge phenom-
the Divide and Conquer techniques. enon. They do require, however, more vacuum
Nevertheless,these tips offer a higher risk of in order to obtain similar tissue fixation than
posterior capsule rupture precisely because they when using a conventional tips.
are so sharp and highly cutting. These micro tips are the ones indicated
for use with the Mackool cassette system that
Importance of Shape and Size by definition has tubes with narrower inner
New developments are oriented to surfaces and thicker outer surfaces, facilitating
microtips and the Mackool system because the use of higher vacuum and reducing Surge.
149
PHACOEMULSIFICATION SYSTEMS
Figure 85: Shown above are the three most advanced phacoemulsification machines and
systems. (A) the well known Alcon Legacy 20,000. (B) Allergan’s Sovereign, that is now
their “top of the line” and most efficient equipment. (C) Storz Millennium, which delivers
all the advances described in this Chapter.
In the past three years, there have been These systems are able to provide much
dramatic improvements in the technology of more reproduceable energy at each power
phacoemulsification, involving every aspect setting regardless of the mass and density of
of phaco systems. These range from the phaco the nuclear material at the phaco tip. Since this
probes and tips all the way down to the foot load is continually changing, the system must
pedal. Improvements in the generation and be able to adjust. If not, the efficiency of the
control of ultrasonic power, fluidics, handpieces equipment is immediately affected.
and tips have been made which are extremely The main systems available today for
advantageous to the cataract surgeon. We are phacoemulsification are provided by the major
all indebted to the manufacturers of our instru- players in industry and have very advanced
ments and equipments who have invested technology. These systems are the well known
heavily in financing this research and have Alcon Surgical LEGACY 20,000 equipment
attracted the best designers and engineers to (Fig. 85-A), the AMO (Allergan) Sovereign
carry on these developments. (Fig. 85-B) and the Bausch & Lomb - Storz
150
Millennium (Fig. 85-C). Allergan's Sovereign as auto pulse phaco, burst mode phaco and
is the top of the line at Allergan. The equipment occlusion mode phaco which are most impor-
known as Diplomax made available for several tant in modern phacoemulsification surgery.
years by Allergan is still a useful machine,
more portable and of lower price than the The Pulse and Burst Modes
Sovereign.
Differences Between Them
How to Select the Right
Equipment for You This is one of the most important techno-
logical advances in phaco systems, as empha-
In answer to the many questions that we sized by I. Howard Fine, M.D., in the U.S. as
receive from colleagues throughout the world well as by Edgardo Carreño, M.D., one of
as to which machine or equipment to purchase, South America’s top phaco surgeons. When
we strongly recommend that the first priority you contemplate acquiring a new machine, be
should be to select one of these three, but based certain that it offers these two modalities.
on the quality and availability of service and What is the difference between them? In
technical support that you will be able to Pulse Mode we have linear power for a
obtain in your community. It is useless to fixed interval of the application of that power
have a superb phaco machine if that particular (Fig. 86). In Burst Mode, we have fixed
manufacturer provides inadequate technical power with a variable interval in the applica-
support in the area where you practice. Each tion of that power (Fig. 87). Therefore, Pulse
one of these three major systems makes avail- is a fixed short interval, Burst is a variable
able power modulations and advantages such interval.
Figure 86: Concept of Pulse Mode in Phacoemul-

sification
Pulse mode provides a great advantage in

mobilizing and removing tissue. In pulse mode,
the ultrasonic energy can be increased while the
pulse rate or application rate of the energy remains
constant. One chooses a certain number of pulses
per second (P), say 2 pulses per second, which re-
mains fixed during the surgeon's ability to increase
the ultrasonic energy level as the foot pedal (F) is
depressed in position 3. Note the constant pulse
rate (P) as depicted by two pulses shown in front
of each tip. Note increasing energy which can be
applied, as represented by the enlarging size of the
phaco tip and arrow (E), as the foot pedal (F) is
depressed. Graph A (Pulse Rate - P/S) shows that
pulse rate remains constant (horizontal line) dur-
ing increased depression of the foot pedal. Graph
B (Energy Level) shows that energy application (E)
increases in a linear fashion, to a preset maximum,
with depression of the foot pedal. Burst Mode, as
displayed in the next illustration, is the reverse of
Pulse Mode.
151
Figure 87: Concept of Burst Mode in Pha-

coemulsification
Burst Mode provides more control of

the ultrasonic energy level, which is advan-
tageous during certain maneuvers. In burst
mode, one chooses the ultrasonic energy level
desired on the control panel, and it remains
fixed. As you depress the foot pedal in posi-
tion 3, the pause between bursts of the fixed
energy decreases from intermittent bursts to
more frequent bursts, toward ultimately con-
tinuous phaco. Note the constant energy level
(E) as represented by the constant size of the
phaco tip and arrow. Note increasing burst
rate (P) as depicted by the increasing num-
ber of bursts shown in front of each tip, as
the pedal (F) is depressed. Graph A (Pulse
Rate - P/S ) shows that burst rate increases
during increased depression of the foot pedal.
Graph B (Energy Level) shows that energy
level (E) remains constant (horizontal line),
with depression of the foot pedal.
Clinical Applications of the Pulse on the phaco tip. The vacuum provides sub-
stantial control for holding the tissue between
Mode applications of phaco power, with almost no
potential for chattering. (Editor's Note: chat-
Pulse mode provides a great advantage in tering refers to when the nucleus bounces
mobilizing and removing tissue (Fig. 86). In against the phaco tip at a high rate of speed
the chopping techniques (Chapter 9), at a fixed without emulsifying it as desired, like when
pulse rate of 2 pulses per second, the surgeon one’s teeth chatter when cold - Fig. 89).
chops by stabilizing the nucleus with the chop When using the LEGACY 20,000 equip-
instrument in the golden ring. Fine likes to ment, for instance, Fine can specifically cus-
pull to the side of the phaco needle rather than tomize the application of the parameters of
to the top of the needle so that after the second phaco power based on differences in the
chop, the initial tissue segment is already density and type of cataract tissue he is
lolipopped. (Editor's Note: lolipopped refers removing. This technological advance is also
to securely engulfing the tip of the phaco into available in the other outstanding equipment
the nucleus, like a lollipop or candy sucker on already mentioned, particularly Allergan's Sov-
a stick. The phaco tip is analogous to the stick ereign and Storz (Bausch & Lomb) Millen-
and the nucleus is the round candy portion - nium.
Fig. 88) He does not have to search for the The power levels used by Fine are very
nucleus, or manipulate it: it’s already engaged low -- very frequently in the low teens. It is rare
152
Figure 88 (right): Concept of

"Lollipopping" the Nucleus
Lollipopping the nucleus refers to se-

curely engulfing the tip of the phaco into the
nucleus, like a candy sucker on a stick. The
phaco tip (P) is analogous to the stick and
the nucleus (N) is the round candy portion.
This technique provides a secure, controlled
hold on the nucleus during the chopping and
other maneuvers.
Figure 89 (left): Concept of "Chattering"

during Application of Phaco Power
(Top) An undesirable condition during

phacoemulsification is when the phaco tip
bounces (arrows) against the nucleus or lens
piece when attempting to emulsify it. This
condition wastes time and presents unneeded
ultrasonic energy into the eye with no result-
ing emulsification and extraction. The chat-
tering effect is represented by a bouncing ball
against the ground. (Below) Increased vacuum
can provide the additional control for holding
the tissue between applications of phaco power,
so that chattering does not occur. Here the tis-
sue is efficiently extracted (arrow) as repre-
sented by the smoothly rolling ball.
153
for him to have an effective phaco time greater such as fluidics, ultrasonics, footpedal, and
than 20 seconds and an average phaco power of bottle height.
more than 20 percent. Meanwhile, the vacuum With respect to fluidics, the Sovereign
is high, 340 mmHg. He minimizes power and has a digital peristaltic pump that, because of
allows high vacuum to do the job. its sophistication, is capable of mimicking ev-
ery other pump system. Its highly developed
Clinical Applications of the Burst responsive fluidics monitoring system, called
the Intellesis, monitors the fluidics 50 times
Mode per second. There is a sensitive control of what
is happening to the vacuum in the anterior
Its Role in Transition to Chopping chamber. It also has the ability to respond
rapidly because the pump can reverse, in addi-
Fine believes the easiest way for sur- tion to move forward, slow, and stop. An inor-
geons to make the transition to chopping (Chap- dinately stable anterior chamber can be
ter 9) is to use the burst mode set for single- achieved, with a reduced tendency for vaulting
bursts with the panel control (Fig. 87). He of the capsule or fluctuations in chamber depth
prefers a burst of 150 ms with vacuum of 400 (See Chapter 7 - Figs. 62, 63, 65). This new
mmHg. Also, by using Burst mode and a level of control offers optimum safety.
BiModal sub-mode, Fine can use a higher The foot pedal has an on-board com-
aspiration flow rate to attract the epinuclear puter and is capable of multiple functions
ring out of the capsular fornix. (Figs. 52, 53, 55, Chapter 7). The foot pedal
can be used with either the toe or heel depend-
ing on the surgeon's height. Using the foot
Advances with the Sovereign Phaco pedal, even remote parameters such as bottle
System height, can be changed.
Another important feature is the ultra-
Just as there are significant advances and sonics which has expanded from a two-crystal
technological contributions with the prestigious to a four-crystal handpiece. This four-crystal
LEGACY 20,000 machine manufactured by handpiece is adaptable to technology from
Alcon Surgical, Allergan has recently brought manufacturers other than Allergan. Many
into the market its Sovereign. This is really the machines are not designed to use tips from
top of the line for Allergan in this type of companies other than the parent company. Fine
surgery. It takes into consideration and actu- likes to use a Kelman bent tip for certain
ally participates in what all surgeons want cases and he can use it with the Sovereign
which is better and more predictable surgical (Figs. 83-B and 84-E.)
dynamics for their cataract patients. This The ophthalmologist acquiring a new
equipment has superb fluidics and capacity for unit is naturally concerned whether the Sover-
programming and provides increasing ease of eign can be programmed and used without
cataract removal. extensive study and training in the system. Of
The Sovereign utilizes very effectively course, every surgeon must understand the
the micro-processor controls and an on-board fundamentals of how phaco machines in gen-
computer regulation of all the components, eral work, as presented in Chapter 7. Accord-
154
ing to Fine, extensive study is not required vacuum is constant, one advantage of power
because there is a sensor that monitors the modulation is that nuclear material tends to be
delivery of ultrasound energy. It is difficult to kept at the tip. Nuclear material seldom chat-
keep a system that has a changing mass, shape, ters (Fig. 89) and almost never shoots into the
and density of material at the tip at its resonance anterior chamber, where it can threaten the
frequency. But this system monitors, through endothelium. Fine feels that the Sovereign
its microprocessors, 50 different functions that represents a new level of finesse and control
are impacting resonance frequency, 500 times that leads to safety and ease of operation.
a second, and changes and corrects them Fine’s Phacoemulsification Parameters
automatically. including the Pulse and Burst Modes for Alcon’s
Legacy 20,000, Allergan’s Sovereign and Storz
Pulse and Burst Modes on the Millennium, are presented in specially designed
Sovereign Tables in pages 202-203.
Edgardo Carreño’s Adjustable Burst
We have already outlined the great sig- Mode Parameters using Alcon’s Legacy 20,000
nificance and importance of the Pulse and are presented in this page.
Burst Modes applicable with Alcon's LEGACY In essence, we have a wonderful new
20,000 equipment, which is a superb machine menu of remarkably sophisticated, helpful
(Figs. 86, 87). Fine often combines Pulse and phaco instrument choices. Each surgeon will
Burst modes also when using the Sovereign. need to make his or her own decision, remem-
Because the power is intermittent and the bering to consider local service and support.
155
RECOMMENDED READINGS
Seibel, B.: New phaco tips. Phacodynamics -
Mastering the Tools & Techniques of Phacoemul-
Buratto, L: Phacoemulsification: Principles and sification Surgery, Third Edition, Section One:104-
Techniques, 1998. 111.
Mendicute, J., Cadarso, L., Lorente, R., Orbegozo, Technical advances in phacoemulsification sys-
J., Soler, JR: Facoemulsificación, 1999. tems, Ocular Surgery News, Feb. 2000.
Seibel, BS: Phacodynamics: Mastering the Tools

and Techniques of Phacoemulsification Surgery,
Third Edition, 1999.
BIBLIOGRAPHY
Davidson J.: A comparison of technologically ad-

vanced ultrasonic tips. Advances in Technique &
Technology, Alcon Surgical - April 1999, Part 2 of
2.
Fine, IH., Lewis JS, Hoffman, RS: New techniques

and instruments for lens implantation, Current
Opinion in Ophthalmology 1998, 9:20-25.
Fine, IH., Lewis JS, Hoffman, RS: Recent advances

in phacoemulsification systems. Cataract Surgery:
The State of the Art, Edited by Gills, H., Slack,
1998.
Fine, IH.: Total control phaco chop. Advances in

Technique & Technology - Alcon Surgical, Part 2
of 2, April 1999.
Koch, PS.:Blades. Simplifying Phacoemulsifica-

tion, Fifth Edition, Slack, 1997, 3:21-26.
Piovella M., Camesasca, F.: New phaco tips and

handpieces. Atlas of Cataract Surgery, Masket &
Crandall, 1999, 5:42-47.
Salvitti, E.R: Flared tip technology. Advances in

Technique & Technology, Alcon Surgical - April
1999, Part 2 of 2.
156
C h a p t e r 9: Mastering Phacoemulsification - The Advanced, Late Breaking Techniques
MASTERING PHACOEMULSIFICATION
General Considerations Now let us consider fundamental con-

cepts, measures, methods and techniques nec-
We have presented the step-by-step tech- essary to follow in order to master phacoemul-
nique of phaco during the transition including sification.
the fundamental understanding of how the phaco
machine works (Chapter 7). The specific in- Trauma-Free
strumentation, equipments and best systems Phacoemulsification
used for phacoemulsification are discussed in
Chapter 8. Considering that this procedure is very
Regarding instruments and use of equip- much device-dependent, Centurion establishes
ment, it is essential to keep in mind that we a tripod: physician-technician-machine. By
should first train in order to thoroughly under- individually organizing and interrelating the
stand and command the subtleties of our physician's role, his/her technician's important
phacoemulsifier before its clinical use. As input and coordination, the functioning of the
frequently emphasized by Centurion, we will machine and the technique, we are able to
not be able to improvise or try to master it in the perform the procedure free of trauma to our
surgical suite. patients and less stress to the surgeon. This
may be accomplished without changing the
Advantages of Phaco Operating Center's routine.
In this "trauma-free phaco," it is also
It is also generally accepted that the main important to achieve the following: 1) no
reasons why phacoemulsification has stimu- delays of patients, anesthesiologists or the sur-
lated so much interest is because of the follow- gical team. 2) Perform a limited number of
ing advantages, all of which improve results: daily procedures with predictable results more
1. Less ocular trauma induced. days in the week which is preferable to a
2. Less postoperative inflammation. schedule of longer but less frequent operating
3. Astigmatism induced is minimal or nil. days with a much larger volume of operations
4. Postoperative refraction is more promptly in one single day.
stabilized. Perform 4 (four) cataract surgeries in
5. Less risk of endophthalmitis. one hour is as much as we should aim for. The
6. Topical anesthesia can be effectively used. objective is not to operate quickly but to take
7. Immediate physical and visual rehabilita- advantage of the results of a well-trained team
tion is attained. that has adapted well to this system.
159
Faster Operations cataract operation itself. There are a series of

steps to make the process flow efficiently.
I. Howard Fine, M.D., has pointed out
Do They Sacrifice Patient Care? that there is an emphasis today of cataract
surgery being likened to a foot race. Some
If the operating team is really effi- surgeons show videos with stopwatches. Just
cient, speed should not necessarily lead looking at their hands reflects how they rush
to lesser results. The key lies in the rather than doing maneuvers that are appropri-
adroitness and perfect coordination among ate for working inside the eye. Racing the
Centurion's "tripod: surgeon-technician-ma- clock is definitely not good for the patient.
chine". Making an operation safe and effective In our teaching, it is important to convey
should be our primary goal. It is important to that endothelial cell loss, iris trauma, incisions
balance time, speed and safety, because in the that do not heal, or broken capsules, may result
end we all should aim for safe operations. because of a desire to do faster procedures. As
a matter of fact, complications should be less
Readiness and Know-How to Become because of the advanced technology we cur-
Efficient rently possess. If you have one or two operat-
ing rooms, efficiency is more connected to the
Stephen Lane, M.D., has very posi- turnover, not necessarily the individual case.
tively emphasized that if you want to go faster, The most practical method to obtain speed with
ignore what is happening inside the eye and efficiency is the one recommended by Centu-
concentrate on what is happening in the oper- rion: use two operating rooms with exactly the
ating room (OR). Make sure that the OR staff same equipment disposition -- they are cloned
is proficiently getting the cases in and out and rooms. This saves time because it is not
moving the patients with readiness. If the necessary to change equipment; provides sav-
surgeon is only working in one room, there is ings in maintenance and, most important: op-
more time wasted moving a patient from one erating room staff can concentrate on the
room to another, getting a room cleaned up, and needs of the patient and the surgical team.
getting the next patient in, than during the
THE ADVANCED, LATE-BREAKING TECHNIQUES
Anesthesia type of anesthesia has the great advantage of

enabling the surgeon to operate without any
Advanced or experienced phaco surgeons intense emotional involvement or requiring the
may use topical anesthesia alone or combined more active cooperation needed with topical
with intracameral irrigation anesthesia (Figs. anesthesia. It is very comfortable to arrive at
35, 36). You may find as in-depth discussion the operating room where two or three patients
of this subject in Chapter 5. The other alterna- are already anesthetized and ready to begin
tive, of course, is to have the assistant or anes- surgery.
thesiologist use peribulbar anesthesia, gener- The advantages of topical combined with
ally Xylocaine 2% + Marcaine 0.50%. This intracameral vs peribulbar are amply discussed
160
in Chapter 5. For experienced surgeons, the THE INCISIONS

combined topical-intracameral approach is
much preferred because of immediate visual
Phacoemulsification is a two-handed pro-
recovery.
cedure in most cases. Consequently there are
two incisions done:
Fixation of the Globe 1) The Primary Incision.
2) The Ancillary Incision.
The experienced surgeon does not need
to fixate the globe with sutures. Fixation by The Primary Incision
grasping the superior rectus muscle with for-
ceps and placing a 6-0 silk suture through it,
For experienced surgeons, the procedure
repeating the same maneuver with the inferior
of choice is a self-sealing clear corneal, stepped
rectus, is completely outmoded for phacoemul-
valvulated incision, performed temporally
sification. Besides, it leads to postoperative
(Figs. 90-95). This incision is self-sealing and
ptosis in a good number of cases.
heals without sutures. It is shown in Figs. 90
Many surgeons utilize the Fine-Thornton
and 91 (surgeon's view). Most surgeons do a
fixation ring (Fig. 75 - Chapter 8), particularly
two-step clear corneal tunnel incision as shown
during the construction of the limbal or the
in Fig. 92, cross section view. Others prefer the
clear cornea tunnel incision. Other surgeons
three step corneal tunnel incision because they
prefer to fixate the globe with a forceps.
feel i t may add a factor of safety (shown in
Figure 90: Initial Stages of Self-Sealing,

Corneal, Stepped, Valvulated Tunnel
Incision - Surgeon's View
This surgeon's view shows the Crescent

knife blade (K) entering the first incision (1) just
at the limbus. The blade is advanced (red arrow)
for some distance in the plane of the cornea, and
a tunnel (blue arrows) is created. This forms the
second step (2) in the three-step incision. The
knife does not enter the anterior chamber at this
stage.
161
Fig. 93, cross section view). When performing viscoelastic or saline solution through this side
a two-step incision, the length of the tunnel is incision. Then he proceeds to perform the
slightly larger to ensure that the incision will be primary self-sealing corneal incision, as shown
self-sealing. A short tunnel may not self-seal in Figs. 90-93. The two-incision process, the
(Fig. 92). sharpness and precision of the diamond knife
and even the stainless steel blades, and the
Essential Requirements for a Self- presence of viscoelastic in the pressurized eye
Sealing Corneal Incision make it possible for a valve-like self-sealing
incision to be made in the cornea without
To be safely performed, the clear cornea damaging its structure.
tunnel incision must be done with a sharp
diamond knife (Figs. 77, 90, 91, 92, 93) Position of the Clear Cornea Tunnel
although the presently available stainless Incision
steel disposable knives are also very sharp
and useful (Fig. 76, Chapter 8). Sergio The trend today is to make the clear
Benchimol, M.D., in Brazil, who was one of cornea incision on the temporal side as intro-
the first surgeons to popularize this incision in duced by I. Howard Fine and Kimiya Shimizu,
South America, starts the surgery with a self- although Shimizu is inclined to perform a single
sealing, small, 1 mm paracentesis side port plane incision, which is not generally accepted
incision (Fig. 41) and pressurizes the eye with but he was a pioneer in the introduction of the
clear cornea incision.
Figure 91: Final Step of Self-Sealing,

Corneal, Stepped, Valvulated Tunnel
Incision Performed with the Diamond
Knife - Surgeon's View
A diamond knife blade (D) enters

the first incision (1), the second tunnel
incision (2), and is then directed in a slightly
oblique direction to the iris plane and
advanced into the anterior chamber (ar-
row). This forms the internal aspect of the
incision into the chamber (A). This is the
third step (3) in a three-step self-sealing
incision.
162
Figure 92 (above left): The Two Step Clear

Cornea Tunnel Incision - Cross Section View
This cross section shows the location,

direction and length of the two step clear cornea
tunnel incision. (1) The incision is started in
clear cornea just inside the limbus. (2) It ex-
tends through the stroma for 1.75 to 2.0 mm
before entering the anterior chamber. This
length of tunnel is important to ensure that the
incision will be self-sealing. A short tunnel, by
comparison (dotted line), may not self seal.
Figure 93 (below right): The Three Step Cor-

neal Tunnel Incision - Cross Section View
The three step corneal tunnel incision

begins (1) with a perpendicular corneal incision
1 mm inside the corneo-scleral limbus (L). This
3.0 mm long first pass incision is made to a depth
of about 300 microns. (2) The second pass
consists of an incision made parallel to the cor-
nea which tunnels for 1.75 mm to 2.00 mm. (3)
The third step enters into the anterior chamber.
This will form the internal lip of the incision just
like the internal valve lip of a traditional corneal-
scleral tunnel incision.
163
Reservations About the Clear Advantages to the Temporal Approach

Corneal Incision
1) The approach to the anterior chamber
Some surgeons have reservations about the is easier, especially in patients with a narrow
clear-cornea incision, particularly because of palpebral fissure (Fig. 94).
postoperative astigmatism and endophthalmi- 2) As inferior duction of the eyeball is not
tis. These used to be two major complications required with the temporal approach, the iris
of clear cornea incisions. These problems have plane is always kept at right angles to the
been almost solved by making the wound as microscope to provide good visibility.
small as 3.2 mm or less at the temporal site and 3) As pointed out by Kimiya Shimizu,
by using intracameral antibiotics as discussed the cornea is oval and the optical center of the
in Chapter 4. cornea deviates to the nasal area from the
Figure 94: Advantages of the Temporal Ap-

proach Corneal Incision
There are several advantages to the tem-

poral approach. First, the optic center (C) is
slightly further away from the temporal limbus
(distance E) as compared to the 12 o'clock
limbus (distance D). Therefore, a temporal
cataract incision is farther away from the optic
center of the eye, and any resulting post-op
corneal edema around the incision is less likely
to affect the immediate visual rehabilitation.
Second, by utilizing a temporal approach there
is no restriction of instrument movement caused
by the speculum, as does exist with the 12
o'clock approach. Note portion of speculum (S)
at 12, and none temporally (T). Third, the
eyebrow and somewhat more protruding su-
praorbital rim can restrict instrument movement
using the 12 o'clock approach. Compare poste-
riorly directed arrow at 12 (representing
instrument approach) to temporal arrow (T),
(representing unrestricted instrument approach
in the plane of the iris). Therefore, more easeof
access to the anterior chamber structures, along
with the unrestricted movement of instruments,
is gained using the temporal approach.
164
anatomic center. Therefore, in the temporal Although patients do not report having much
approach, the incision's, the distance is about 1 pain, they do report a greater sense of aware-
mm more from the optical center as compared ness or discomfort for at least a week or so
with a superior incision (Fig. 94). Thus, the after the scleral tunnel procedure. With the
operative invasion to the corneal center is mini- clear cornea incision, on the other hand, the
mal in the temporal incision. As a result, epithelium regenerates within 24 hours, much
surgically induced astigmatism is small and like it does after a corneal abrasion. Those
recovery of visual acuity is fast. In addition, patients who undergo a clear cornea incision
when working on clear cornea at the 12 o'clock report awareness of a sandy sensation which is
position (closer to the optical axis than the virtually gone within 24 hours as the corneal
temporal position) if there is a small amount of epithelium is reepithelialized.
edema near the edge of the incision, being In many cases Dodick and many sur-
closer to the optic center of the cornea, may geons have done a scleral tunnel operation that
temporarily interfere with the immediate vi- turns out perfectly with 20/20 vision, and the
sual recovery aimed at with topical anesthesia patient still complains months and maybe even
and clear corneal incision. years later of an awareness or irritation in that
4) The wound will not separate when eye. Creating a scleral tunnel wound leaves a
blinking. The temporal incision, therefore, scar at or near the limbus (Fig. 40), which
facilitates good adaptation of the wound. Dodick believes interferes with tear film distri-
5) In addition, there is more space for bution. Eventhough it heals beautifully, the
the surgeon's hands. The temporal approach interference with tear flow leaves patients with
makes the phacoemulsification itself easier a vague awareness or irritation in the eye.
because the eyebrow is not a barrier, and freer With a clear cornea incision, the limbus
movements are possible. is never invaded, and a vascular scar is never
created. Therefore, tear film distribution is
Additional Patient's Comfort with never disturbed. The final reason Dodick
Corneal Incision chooses the clear corneal tunnel is that it is a
much more cosmetic procedure. With the
Jack Dodick definitely prefers to do a scleral tunnel incision, patients often have a red
clear cornea incision rather than the scleral eye. No change is apparent in patients who
tunnel procedure. Although he considers that have had the clear cornea incision just a few
both incisions are excellent and lead to the hours after the operation.
same outcome, patients tend to be more com- A postoperative photograph showing the
fortable and satisfied with the clear cornea barely visible scar of the corneal tunnel inci-
incision. sion on the temporal side is shown in Fig. 95.
Using the scleral tunnel procedure, the In Edgardo Carreño's experience,
surgeon cuts into the sclera, conjunctiva, phaco through clear cornea is less traumatic,
Tenon's membrane, and some blood vessels, considering that there is no need for conjuncti-
which takes perhaps 1 to 2 weeks to heal. val dissection nor the use of cautery related to
scleral tunnel dissection. There is also no
possibility of hyphema and there is less postop-
165
Figure 95: Minimal Scar Following Clear

Corneal Temporal Incision
With slit lamp retroillumination we

can see the very fine scar in the postoperative
stage after performing phacoemulsification
utilizing a clear corneal incision done on the
temporal side of the left eye. With daylight or
even a pen light frontal illumination, this scar
is barely seen. Please also observe that the
scar is very regular, almost like drawn on
paper. This, of course, leads to practically no
astigmatism postopertaively. (Courtesy of
Edgardo Carreño, M.D.)
erative inflammation because there is less corneal endothelium becomes shorter. Thus,
trauma. when the surgeon performs a corneal incision
The postoperative cosmetic appearance for the first time, it is recommended to make
of the globe is better, the eye looks as if never a rather shorter tunnel and to place 11-0 nylon
touched (Fig. 95). The patient feels more single knot without being concerned with self-
comfortable because there are no sutures, no sealing.
cautery has been done and there is no pain. The
intraoperative time is less because several tra- Placing and Making the Primary
ditional stages of the operation have been elimi- Incision
nated. Therefore, the cost is reduced.
As emphasized by Kimiya Shimizu, the
Importance of the Length of the proper placement of the incision is important.
Tunnel If it is too anterior, the corneal tunnel becomes
shorter, and the self-sealing effect is decreased.
Ideally, the part of the corneal tunnel In contrast, if it is too posterior, conjunctival
itself should be about 1.75 mm (Fig. 93). A bleeding and/or chemosis sometimes occur.
shorter tunnel (dotted line in Fig. 92) decreases So, before incising the cornea, dry the
the self-sealing rate, although the surgeon's incision site, make the vertical first step just
visibility becomes better. Too long of a tunnel anterior to the terminal conjunctival vessels,
increases the self-sealing, but corneal folds then insert and advance the keratome straight
sometimes disturb surgeon's visibility. Cor- about 1.75 mm into the corneal stroma. Next,
neal endothelial damage also becomes greater direct the keratome slightly downwards in the
as the distance between the phaco tip and iris plane to perforate Descemet's membrane.
166
When the tip of the keratome appears in the conclusion of surgery and remains sealed, the
anterior chamber, remove the Merocel sponge time before complete healing of the incision is
and release the counterpressure. After that, accomplished is almost irrelevant, especially
advance the keratome, swinging it to both right since there is still a 6-day period in which
and left sides. By doing this, the incision may limbal incisions are not healed. An analogy
be conducted safely without causing the col- can be drawn to the sealing that takes place
lapse of the anterior chamber. The length of the during LASIK, in which there is no fibrovascu-
corneal tunnel is usually 1.75 mm, but if it is a lar healing of the clear corneal interface, which
complicated or hard nucleus case, it should be has little effect on the strength, effectiveness,
shorter. On the other hand, when the patient or safety of the wound, and, in fact, is an
has good mydriasis or a shallow anterior cham- advantage by limiting scarring and an inflam-
ber, the incision site should be a little anterior, matory healing response.
and the corneal tunnel should be longer to Clear corneal cataract incisions are be-
prevent iris damage and/or iris prolapse. coming a more popular option for cataract
extraction and IOL implantation throughout
Surgeon's Position the world. Through the use of clear corneal
incisions and topical and intracameral anesthe-
When the operator is right-handed and sia, we have achieved surgery that is the least
he/she is operating the right eye, sit at the 10.30 invasive of any kind in the history of cataract
position. When operating on the left eye, sit at surgery with visual rehabilitation that is almost
4:00. immediate. Clear corneal incisions have had a
proven record of safety with relative astigmatic
Controversy Over the Strength and neutrality utilizing the smaller incision sizes.
In addition, corneal incisions result in an excel-
Safety of the Wound
lent cosmetic outcome.
One of the most controversial criticisms

Testing the Wound for Leakage
of clear corneal incisions has been their relative
strength compared to limbal or scleral inci-
There are several methods to test the seal
sions. Mackool has demonstrated that once the
of the incision. For the most practical one, we
incision width is 3.5 mm or less and the length
refer you to Fig. 73, Chapter 7, and the explana-
of the tunnel 1.75 to 2 mm, there is an equal
tory text in the same page under this title.
resistance to external deformation in clear cor-
neal incisions as compared to scleral tunnel
incisions. Ernest work as well has revealed Closing a Leaking Wound
that as incision sizes get increasingly smaller, Without Sutures
3mm or less, the force required to cause failure
of these incisions becomes very similar for Professor Juan Murube, M.D.
limbal and clear corneal incisions. This further (Madrid), has demonstrated the effectiveness
documents the safety of corneal incisions. of a very comfortable maneuver in order to
The real issue for these various inci- close-shut a leaking wound instead of having to
sions is not healing but sealing. Fine feels suture it. Although a self-sealing, stepped
that as long as an incision is sealed at the valvulated corneal tunnel incision, 3.0 mm or
167
less in size, is very unlikely to leak, there is a Honan balloon over the eye for 30 minutes at
always the possibility for this to occur. The 35 mm Hg pressure. At the same time, the
main causes are related to making the corneal patient is administered orally one tablet of 250
incision larger than 3.0 mm and excessive mg of Acetazolamide (Diamox). The way this
trauma to the lips of the wound during surgery works is that the significant intraocular
particularly with the phaco probe. These fac- hypotony produced by the combined use of the
tors may give rise to a continuous loss of Honan balloon and Diamox results in the
aqueous humor. This may be detected the production of a significantly reduced amount
following day by means of a positive Seidel of aqueous humor that is produced with suffi-
test in which several drops of fluorescein are cient continuity to reform the anterior chamber
instilled over the wound and examination is but not in sufficient quantity to seep through
performed with ultraviolet light. the wound. After a few minutes, the walls of
Because the aqueous humor escapes the wound have had a chance to adhere to each
through the wound continuously, the wound is other, thereby sealing the wound. No further
kept open. Unless this is corrected immedi- positive Seidel test is observed even though the
ately, the surgeon may have to suture the wound. normal intraocular pressure is reestablished.
The very comfortable and effective ma- This maneuver is innocuous and simple as well
neuver recommended by Professor Murube in as highly effective (Fig. 96).
order to close-shut a leaking wound is to place
Figure 96: Murube's Method of Seal-

ing a Leaking Wound with Honan's
Balloon
The combined use of Honan

Balloon’s compression for 30 minutes at
35 mg Hg pressure and one 250 mg tablet
orally of Acetazolamide lead to sealing of
the leaking wound.
168
THE ANCILLARY INCISION ANTERIOR

This is an important step in performing CAPSULORHEXIS
phacoemulsification. Although there are tech-
niques to perform phaco with only one hand,
Key Role
phacoemulsification is fundamentally a two-
handed procedure. This procedure is also presented in
The ancillary or side-port incision is made Chapter 7 for the transition period and illus-
before the main incision. It serves as an entry trated in Figs. 43, 44 and 45. It is generally
for a second instrument which is necessary for agreed that a well performed anterior continu-
maneuvers to remove the nucleus, either nuclear ous capsulorhexis is an essential step for the
manipulators (fig. 79) or choppers (Fig. 80). success of phacoemulsification. The key rea-
The location and technique of making the an- sons for being so important is that capsulorhexis
cillary incision is shown in Fig. 41 A. prevents IOL decentration. In cotrast with the
In addition to serving as the mode of extracapsular extraction and can opener capsu-
entry for the essential second instrument the lotomy, even when the surgeon was sure that
ancillary incision is utilized in irrigation of the he/she placed the IOL within the bag during
anterior chamber with intracameral local anes- surgery, sometimes 30 to 40% of cases after
thetic as presented in Chapter 6 and illustrated two or three months would have one of the lens
in Fig. 36. It is also the route for the insertion loops protruding out of the capsular bag and
of viscoelastic previous to making the primary reaching to the sulcus, thereby leading to
incision. decentration. On the other hand, by perform-
At the end of surgery, the ancillary inci- ing the continuous circular capsulorhexis fol-
sion is used to inject fluid into the anterior lowed by implantation of the lens within the
chamber to test for leaks in the wound, as bag, the IOL will permanently remain well
shown in Fig. 73. centered within the capsular bag. This has been
emphasized time and again by Everardo
Barojas, M.D., one of Mexico's most presti-
Making the Ancillary Incision
gious cataract surgeons and a good number of
other experts on the subject.
The steps involved in performing the
ancillary incision are:
1) First, mark the corneal location where
The Role of Viscoelastic in CCC
the clear corneal stepped main incision would
be made, which is always between 9 and 12, as One of the key steps in achieving a first
shown in Figs. 41 B and 42. This measure class capsulorhexis is to do it with viscoelastic
serves the surgeon for orientation as to exactly in the anterior chamber rather than with BSS.
where to place the two incisions. The high density viscoelastic is used not only to
2) Make the ancillary incision at 3 o'clock. protect the endothelium and other surrounding
This is performed with a special 15 degrees tissues but also serves as a third hand that
blade designed for paracentesis (Figs. 76 and amplifies the working space and facilitates the
77). maneuvers of the surgeon's manuevers. It also
169
helps to flatten the anterior capsule. This last It is important for the surgeon to see the under-
measure facilitates the correct performance of side surface of the anterior capsular flap as
the procedure. shown in Fig. 98.
Some surgeons find that in order to per-
Technique for Performing a First form the procedure more safely, upon finishing
Class CCC each one of the circular tears with the Uttrata
forceps and before completing the circle, in-
Beginning surgeons should be encour- stead of leaving the capsulorhexis folded, take
aged to use forceps as shown in Figs. 44 and 45. it back to the way it was, that is, unfolded. This
All cases should be performed with injection of makes the next step easier to perform, that is the
viscoelastic material in the anterior chamber. anterior capsule, easier to grasp in order to
The experienced surgeon may perform the pro- engage and disengage to provide the best con-
cedure with a cystotome-needle which is a No. trol for creation of a circular opening (Figs. 99,
26 needle with the tip bent into a square angle 100).
as shown in Fig. 97.
The CCC utilizing the cystotome needle Size of the Capsulorhexis
and viscoelastic is more safely and effectively
performed using the central punch technique. For experienced surgeons mastering pha-
This makes the first incision in the center, as coemulsification, it is generally advisable to
shown in Fig. 98 and not in the periphery, as use a 5.5 mm central and completely enclosed
was the tendency when the procedure was rhexis. This is close to the ideal phacoemulsi-
developed (shown in Fig. 43). Using the fication technique performed safely within the
central punch technique, there are fewer possi- capsular bag.
bilities that a tear will spread to the periphery. The size of the capsulorhexis, however,
The continuation of the capsulorhexis tear, may be better determined by the type of in-
once the central punch is done, may be done traocular lens model to be implanted. Carreño
clockwise or counter clockwise, as is more emphasizes that upon using Alcon's foldable
comfortable for the surgeon. Usually, it is acrylic implant with a 5.5 mm optic, he prefers
continued in a circular fashion in a counter a 4.5 mm or 5.0 mm rhexis so that the edge of
clockwise direction as shown in Fig. 99, care- the optic is completely covered by the ante-
fully completing a circle from outwards inward rior capsule. This helps in preventing fibrosis
obtaining a completely closes rhexis (Fig. 100). which may be produced when both capsules
It is fundamental to advance the capsular come into contact. It is also helpful in reducing
tear in a well controlled manner. This is achieved glare especially in younger patients who have
by placing the cystotome-needle against the more of a tendency for pupillary dilation at
surface of the anterior capsule and re-grasping night or in the darkness.
the tear as many times as necessary to continue On the other hand, upon using the
the circular teaar until completing the circle. silicone foldable lenses, Carreño prefers a
A very important part of the first step in 5.0 mm to 5.5 mm rhexis to prevent contraction
CCC is to be able to obtain the flipping of the of the capsular sac, which may accompany this
resultant capsular flap once the cystotome- type of implant when the diameter of the
needle engages the anterior capsule centrally. capsulorhexis is smaller.
170
Figure 97 (above left): Cystotome - Needle

Adjusted for CCC
The experienced surgeon often prefers

to perform CCC with a cystotome-needle. Many
surgeons use a 26 gauge needle with the tip bent
into a square angle. Others use a 23 gauge
needle. The needle is prepared with two separate
bending motions as follows: 1) the tip of a
straight 26 or 23 gauge needle (N) is grasped
with a needle bender (B). 2) The tip of the needle
is bent downward 90º in a vertical motion (ar-
row).
Figure 98 (center): Continuous Curvilinear Anterior Cap-

sulorhexis Performed with the Cystotome-Needle (Step 1)
The first step is to engage the cystotome-needle into

the central region of the anterior capsule superiorly at the X and
flip the resultant capsular flap over. Please observe that the
surgeon can see the underside of the capsular flap (C). The
cystotome-needle (N) engages the underside of the capsular
flap (C) and moves it in the direction of the blue arrow which
in this case is counter clockwise in order to produce a circular
tear in the capsule (red arrows). A fixation forceps provides
stability which is essential during the performance of the CCC.
Figure 99 (below left): Continuous Cur-

vilinear Anterior Capsulorhexis
Performed with the Cystotome-Needle
(Step 2)
After injection of viscoelastic, the

surgeon starts with the puncture of the cap-
sule and proceeds to make the first small
flap. When this first flap is turned over, the
tint is clearly seen because the color is de-
tected in the internal face of the capsule and
not in the epithelium.
171
Figure 100: Continuous Curvilinear Anterior Capsulorhexis Performed

with the Cystotome-Needle (Step 3)
The cystotome needle continues to be engaged on the underside of the

flipped anterior capsular flap and is moved in a direction (blue arrow) to
complete the circular tear (red arrow). The capsular flap is then removed from
the eye.
Another factor which influences the size microscope to provide the red reflex of the
of the capsulorhexis, is the degree of hardness fundus. Over this red reflex the anterior cap-
of the cataract. In cases where the nucleus is sule and the border of the progressively per-
too hard, Carreño feels that it is more prudent formed continuous circular capsulorhexis can
to perform a rhexis which is not too small, be very well visualized. This allows the comple-
certainly no less than 5.0 mm in diameter, to tion of the circle (Fig. 100) under adequate
ease performing the phaco chop techniques, visual control. On the other hand, when the
which are the most highly recommended for surgeon is dealing with white, hypermature
treating hard nucleus. cataracts that have either been allowed to get
into that advanced stage or have been produced
STAINING THE ANTERIOR by trauma, the details and border of the CCC
cannot be well visualized because this white
CAPSULE IN WHITE CATARACTS
cataract interferes with fundus reflex . Conse-
quently, the step by step progress in the perfor-
As shown in Figs. 98, 99 and 100, a well
mance of the CCC is not well visualized.
performed CCC allows the coaxial light of the
Accidentally, the edge of the anterior capsule
172
flap could be displaced toward the periphery opment of a very effective technique to control
and the lens equator. From here, upon perform- the performance of the CCC in white cataracts.
ing the maneuvers inherent to phacoemulsifi- It consists in staining the anterior capsule of the
cation, damage to the posterior capsule could lens in order to adequately visualize the details
be inflicted thereby allowing passage of the during the performance of the CCC (Fig. 101).
vitreous to the anterior chamber or a luxation of Without the dye it is nearly impossible to
the nucleus into the vitreous or a displacement see the anterior capsule. These cataracts are
of the intraocular lens once inserted. These risky. It is very difficult to distinguish the
important considerations have led to the devel- anterior capsule from the underlined cortex.
Figure 101 (above right): Murube's Technique

of Staining the Anterior Capsule in White Cata-
racts to Perform Adequate CCC
White cataracts (L) present a problem be-

cause the red reflex is not present making the
capsulorhexis quite difficult and risky. A vis-
coelastic is first injected into the anterior chamber
immediately followed by the injection of a bubble
of air which partially displaces the viscoelastic
from the anterior chamber. This leaves the corneal
endothelium lubricated with the viscoelastic.
A hydrodissection cannula (H) is intro-
duced through the corneal incision over the anterior
capsule (C). Two drops of Trypan Blue are in-
stilled. Wait for ten seconds.
Figure 102 (below left): Anterior Capsule

Stained with Trypan Blue in White Cataracts
to Facilitate Performance of Adequate CCC -
Murube's Technique
After waiting for ten seconds, the ante-

rior capsule in the white cataract is fully stained.
Viscoelastic is then injected into the anterior
chamber to remove the air (air exchange). The
anterior capsule is a little blue. The surgeon can
now proceed with the capsulorhexis now that he/
she sees the capsule clearly.
173
Staining Substances and Methods Methylene Blue, if used, should be a 1% solu-

tion while Gentian Violet should be at one part
There is a variety of staining substances per thousand. The new research by the Japa-
and methods of how to perform the staining. nese in Nagoya refers to the use of 0.05%
They have been presented by prestigious oph- Indocyanine Green solution. The problem
thalmologists since 1998: in Japan through with the latter is that it is very costly. The
Nagoya University School of Medicine; in Trypan Blue solution is being currently mar-
Spain, Oscar Asis, M.D.; in Holland, Jerritm keted as a nontoxic stain.
Melles, M.D.; in the U.S., Thomas Oetting
and Rick Nearhing. The most practical and Technique for Injection of Stain-
effective method now being popularized is the ing Solutions
one presented by Prof. Juan Murube (Madrid).
The different staining substances analyzed by Murube first irrigates a viscoelastic into
Murube are the following: the anterior chamber. This is immediately
1) Fluorescein 2%. This is obtained by and partially displaced by an air bubble in
mixing 1 ml of 10% fluorescein for intravenous the anterior chamber in order to leave the
use with 2 ml of BSS. corneal endothelium slightly lubricated and
2) Indocyanine Green (ICG): This is protected by the viscoelastic. A cannula is
obtained by mixing 25 mg of ICG in 0.5 ml of inserted through the corneal incision as shown
an aqueous solvent which might be obtained in Fig. 101 and two drops of Trypan Blue are
from Akorn in Buffalo Grove, Illinois. This deposited over the anterior capsule. The sur-
mixture is then diluted in 4.5 ml of BSS. geon waits ten seconds. This is followed by
3) Trypan Blue: Prepared by mixing 1 ml injection again of viscoelastic in order to elimi-
of trypan blue 0.4% (obtained from Life Tech- nate the air bubble from the anterior chamber,
nology, Grand Island, New York) in 3 ml of the so-called "air exchange". At this time
BSS. tinting is not yet detected until the first flap of
4) Gentian Violet: solution at 0.01 con- the rhexis is done because the tissue absorbing
centration diluted with BSS. the tint is not the capsular epithelium but the
5) Methylene Blue: solution at 0.01 mixed internal face of the capsule, visible enough for
with BSS. the surgeon to see the capsule very clearly and
to proceed to perform the capsulorhexis ad-
Murube's research has led him to select equately. Utilizing this technique, when per-
Trypan Blue as the staining solution of choice. forming the capsulorhexis (Figs. 98, 99, 100)
This has been confirmed through the clinical the surgeon can see that the epithelium behind
research of Carlos Nicoli, M.D., in Argentina, the anterior capsule is selectively stained. It is
one of South America's top phacoemulsifica- important to keep in mind that the epithelium is
tion surgeons. Nicoli emphasizes that Methyl- behind the anterior capsule. When the surgeon
ene Blue and Gentian Violet are very difficult lifts the flap gently, he/she can see the epithe-
to prepare because they must have very spe- lium perfectly stained so he/she may safely
cific concentrations. It is fundamental that the proceed to complete the capsulorhexis.
stain used not be toxic to the corneal endothe- This technique is considered of great
lium. Therefore, it should be prepared at ex- value, a breakthrough in this step of phacoemul-
actly the right concentration. For instance, sification.
174
HYDRODISSECTION - to where hydrodissection was begun. After this

maneuver, the surgeon attempts to rotate the
HYDRODELAMINATION nucleus. If the nucleus was released by com-
plete hydrodissection, it will rotate freely. If
This next step is of great importance. Its there is no rotation, try a new hydrodissection
objective is to separate the capsule from the located opposite the site of the initial one.
cortex and the cortex from the nucleus (Figs. Centurion recommends that after the nucleus
46, 47, 48). Its significance is related to the is released, it be rotated four or five times 360º.
liberation of the adherences which attach the This releases possible cortex or epinucleus or
nucleus to the cortex or the cortex to the cap- capsule adherence. Thus, at the end of nucleus
sule, facilitating aspiration (Figs. 1, 46, 47, 48). emulsification there is practically no need to
The hydric chamber created with aspirate cortical remains.
hydrodissection also plays a role in the protec- Following hydrodissection, it is essential
tion of the posterior chamber and the posterior to confirm that the nucleus is completely sepa-
capsule during the phacoemulsification ma- rated from the cortex before proceeding with
neuvers. the next step, which is management of the
nucleus with the different phaco techniques.
Technique of Hydrodissection (For the do's and particularly don'ts related to
hydrodissection, it is important to read the text
Using a 3 ml syringe with a maximum of on this subject in Chapter 7, next to Figs. 46, 47,
1.5 ml infusion fluid, a 25 G flat tip cannula is 48).
introduced underneath the capsulorhexis (Fig.
78-A). Following Fine and Centurion's rec- Hydrodelamination
ommendations, the anterior capsule is raised
and BSS is infused with light pressure. The Hydrodelamination is the separation of
fluid will distribute itself along the posterior the nucleus from the soft epinucleus (Fig. 48).
capsule and will drain through the opposite This technique is done after completing
side. The liquid wave can be seen in the center hydrodissection. The same needle (Fig. 78-A)
of the red reflex (Fig. 46, 47). This process is is introduced beneath the cortex and into the
repeated at 6, 3 and 9 o'clock keeping in mind lens stroma while infusing BSS, which will
that after infusing, we should press the cataract delaminate sheets of cataracts, isolating the
against the capsule to avoid elevation of pres- nucleus from the epinucleus, forming the golden
sure within the capsular bag. ring (Fig. 48 GR).
After the liquid wave reaches the area of With present techniques, many surgeons
the pupillary opening, the syringe is with- do not used to perform hydrodelamination fol-
drawn and the center of the nucleus is com- lowing a very well done hydrodissectgion.
pressed in an attempt to release the adherences They remove the epinucleus usually during the
of the cortex to the capsule on the side opposite emulsification of the nucleus.
175
MANAGEMENT OF THE NUCLEUS
General Considerations choo chop and flip technique presented in Figs.

122- 126), some form of ultrasound is used for
At this stage, we proceed with the culmi- chopping.
nating phase of the operation. The previous All modern techniques are oriented to-
methods of emulsification of the nucleus first ward breaking up or disassembling the nucleus
within the anterior chamber and later in the iris to facilitate its removal from the eye. These
plane are somewhat outmoded with the excep- techniques, which rely on mechanical energy,
tion of the supracapsular otherwise known as have been developed to reduce the amount of
the “tilt and tumble” iris plane technique, which ultrasound energy necessary to break up the
is still Lindstrom’s first choice. It is less hard part of the lens nucleus. In addition,
demanding. At present, though, the most often disassembling the nucleus removes it from the
used phacoemulsification techniques in han- capsular recesses of the bag, thereby facilitat-
dling the nucleus are performed in the posterior ing its removal with the phaco probe.
chamber within the capsular bag. These are Nuclear disassembling techniques use
all identified as endocapsular techniques. some ultrasound at the beginning of the proce-
They have the advantage of reduced risk of dure to create multiple troughs or grooves. A
damaging the endothelium. They also enable second instrument such as a spatula or chopper
the surgeon to work with a larger opening in the can then be used to crack or break the nucleus.
capsulorhexis which is definitely useful in pa- In this chapter we present the three groups
tients whose pupillary dilatation is not ad- of techniques mostly used in advanced pha-
equate. These methods have the disadvantage coemulsification methods for nucleus removal.
that nucleus manipulation is done closer to the You will find the fundamental concepts which
posterior capsule and more stress is placed on are applicable to all methods and a descrip-
the zonular fibers, to their consequent risk. tion of the principles that make these methods
The almost universal use of endocapsu- highly successful, all of which have been de-
lar phacoemulsification has been made pos- veloped by highly prestigious cataract sur-
sible because of innovations in technique and geons. It is by understanding these concepts
equipment. that the surgeon will be able to develop one or
two essential techniques and use them as the
Concepts Fundamental to All methods of choice adapting his/her chosen
Techniques procedure to virtually any situation and the
different types of cataract encountered, either
Surgical Principles soft, standard or medium-density and the very
Almost every contemporary cataract sur- hard cataract.
geon uses some form of chopping, and all The surgeon will find in this Volume
surgeons who perform chopping use some form precisely what he needs to understand and to
of ultrasound to facilitate the chop. Whether it adopt the method which he feels more comfort-
be a groove-and-chop, divide and conquer, or a able with and most suitable for his patients. If
technique like Fine's quick chop (the choo- a more complete description of the techniques
176
available is desired, we suggest that you refer ticles away from the endothelium without hav-
to the carefully selected, short list of recom- ing to push them against the posterior capsule.
mended books and bibliography presented at These essential principles are illustrated in Fig.
the end of the chapter for the method's origina- 103 (The Cracking Effect), Fig. 104 (The Di-
tors and proponents. viding Effect through Opposing Forces), Fig.
105 (The Slicing Process) and Fig. 106 (the
The Essential Principles Dividing Process).
2) Smooth sculpting which avoids
1) A general principle for all techniques nuclear movement and zonular stress is criti-
to remove the nucleus in phacoemulsification, cal to all methods. Well-controlled deep and
either the original four quadrants divide and central sculpting facilitates cracking in seg-
conquer and its derivative divide and conquer mentation methods and rim removal in one and
(D & C) methods, and the relatively recent two-handed methods. By using just enough
chopping techniques is that it is first essential to ultrasound power to embed the phaco tip and
debilitate the core of the nucleus so that the then backing off to the I/A position (standard
nucleus can be split into halves, sometimes pedal position 2), the nucleus can be positively
fourths (Figs. 67, 103 through 106) and occa- engaged for rotation and manipulation. This
sionally into eighths. This allows emulsifi- versatility of the phaco tip is especially impor-
cation and aspiration of nucleus segments tant for one-handed techniques as well as chop-
(Fig. 105) instead of attempting to carve the ping techniques.
entire nucleus without a planned strategy. This The principles of mechanical advan-
splitting of the nucleus is safer for the endothe- tage apply to all methods; safety is maxi-
lium because it is easier to keep smaller par- mized by using the minimum force and move-
ment required to accomplish a given task.
THE ENDOCAPSULAR TECHNIQUES

THE HIGH ULTRASOUND ENERGY AND LOW VACUUM GROUP
THE GROOVING AND CRACKING The classical and less complicated technique
METHODS of this first group is the Four Quadrants
"Divide and Conquer" described in 1987 by
Howard Gimbel. The principles of this method
The Divide and Conquer Four are presented and described in figures 56 and
Quadrant Nucleofractis 67 in Chapter 7. In order to debilitate and
remove the nucleus, a linear vertical sulcus or
Technique groove is done in the nucleus from 6:00 to
12:00 o'clock and a second groove perpendicu-
lar to the first is done, both using the pha-
The first group of endocapsular opera- coemulsifier probe. The carving of these fur-
tions was based on the principle of utilizing rows results in the nucleus being seen with a
large amounts of phaco energy and low vacuum. cross as shown in Figs. 56 and 67. A second
177
instrument known as the "manipulator" which sulcus (Figs. 103 and 104) Both must be
is introduced through the ancillary or side port positioned beyond half the depth of the groove.
incision engages the opposite side of the groove The sulcus should have been carved with a
inferiorly (Figs. 67 and 79). The phaco tip is width equal to 1.5 diameters of the phaco
impaled on one side of the already deep groove sleeve. The depth at which the phaco tip is
and the manipulator on the opposite side of the impaled is 1.5 times the width of the phaco tip
(Fig. 103).
Figure 103 (above right): Pha-

coemulsification - Cracking Effect
Once the desired thinning of

the nucleus core is done (a furrow or a
crater), a second instrument, a chopper
or a manipulator is used to divide (ar-
rows) the nucleus in half pulling the
instrument from periphery to the cen-
ter. The phaco tip is impaled on one
side of the already deep groove and the
manipulator in the equator of the
nucleus, adjacent to the tip. The depth
at which the phaco tip is impaled is 1.5
times the width of the phaco tip.
Figure 104 (below left): Phacoemulsifi-

cation - Dividing Effect
Opposing force (arrows) is applied

to both sides of the cracking with the phaco
probe and the help of the chopper. Divid-
ing the nucleus in small pieces will facilitate
its removal with the phacoemulsifier em-
ploying less ultrasound and higher vacuum.
178
Cracking the Nucleus the four loose quadrants is lifted with the ma-
nipulator and the ultrasound phaco tip is em-
Force is applied with the instruments in bedded into the posterior edge of each segment
opposing directions in order to crack the nucleus (Fig. 105). By means of aspiration the surgeon
along the length of the groove (Figs. 103, 104, centralizes each quadrant into the phaco tip
106 below). Additional manipulations of this and proceeds to emulsify each piece, which
type further lengthen and deepen the cracks. requires the use of a somewhat high amount of
The lens is rotated 90º within the capsular bag ultrasound power. When operating on a softer
and a crack is made in the second groove in the cataract, these fractured pieces are reasonably
same manner. The need to rotate the lens 90º, large, perhaps several clock hours in diameter,
which is done in all techniques of phaco, is and as they are broken free they are emulsified
because the maneuvering by the surgeon is immediately.
always done in the lower half of the field. In very dense cataracts, the pieces
Doing such maneuvering in the upper half is should be much smaller. These pieces are
technically very difficult and cumbersome. left in place until the surgeon has worked all
In the Divide and Conquer technique, the the way around the nucleus, so that as the rim
maneuver of rotating the nucleus 90º is re- is manipulated and spun around, the capsular
peated three times until the nucleus becomes bag will stay fully expanded as the nuclear rim
divided in four sections (Figs. 67 and 105). is manipulated and spun around. Only after
After this is done, the lens fragments are emul- the last piece is broken are they removed by
sified as shown in Fig. 67. The apex of each of emulsification.
Figure 105: Phacoemulsification - Slicing Pro-

cess
This cross section view shows the pha-

coemulsification probe removing the nucleus
fragments within the capsular bag. Note the apex
of one of the fragments created in the nucleus
being lifted with the second instrument (arrow)
and the ultrasound tip embedded into the posterior
edge of each segment ready for emulsification.
The epinucleus and cortex will then be removed
during the phaco process. If we operate on a softer
cataract, the freed fractured pieces are emulsified
immediately.
179
Relation Between Divide and Con- within the capsular bag. There are actually two
quer and the Continuous Circular Cap- subdivisions: the trench Divide & Conquer and
the crater Divide & Conquer, but they both
sulorhexis
follow two very simple principles:
1) Weaken the radii of the nucleus. This
As pointed out by Paul Koch, M.D., the
creates a space in the middle of the cataract in
nuclear fracturing divide and conquer tech-
which other instruments can be introduced to
niques developed initially by Gimbel and all
force (crack) apart the sections of the nucleus
the phacoemulsification techniques that are
(Figs. 56, 67, 103, 104, 106).
designed to move the nucleus through the cap-
2) Break apart the nuclear parts including
sulorhexis are in part possible because of the
the rim of the nucleus (Figs. 104, 105, 106).
development of the continuous circular capsu-
Koch has pointed out that the distinction
lorhexis that Gimbel and Neuhann originated
between a trench and a crater is not clear-cut.
individually (Figs. 43-45, 98, 99, 100). The
There is actually a continuum extending from
CCC made nearly obsolete all the existing
true trench to true crater.
phacoemulsification procedures, because each
of them required that the nucleus be prolapsed
out of the capsular bag for each removal, either The Role of D & C Techniques in
in the iris plane or in the anterior chamber Cataracts of Different Nucleus
(although the iris-plane tilt and tumble tech- Consistency
nique is still used by Lindstrom with signifi-
cant success - Editor). Now that the capsular Softer Cataracts (Trench D & C)
bag could be kept intact with a very strong form
of capsulotomy, new techniques were needed Softer cataracts need preservation of
to get the nucleus out of the bag. The mechani- firm tissue so that the cataract can be manipu-
cal fracturing of the lens causes extra physical lated. If we remove much of the central nucleus,
stress within the capsule and cannot be done all of the firm tissue would be removed, and
without great risk of tears of the anterior cap- any attempt to manipulate it would be difficult.
sule extending around posteriorly unless we The instruments we use would go like through
have a proper CCC. There is an interdepen- cheese in the remaining soft tissue. Some of the
dence of these techniques. relatively hard central core is necessary to
resist the instruments, give them something to
press against, and, ultimately, something to
Principles of the Divide and Conquer manipulate. Recognizing this, Gimbel recom-
Techniques mended the creation of a trench that is really a
narrow pass down the middle of the cataract.
Gimbel developed the Divide & Con- This freed up a little space, but preserved walls
quer techniques to meet the challenge and the of central nucleus for manipulation. The trench
opportunity created by the CCC: to operate D & C is indicated for softer cataracts.
180
Dense Cataracts (Crater D & C) below the level of the anterior capsule into
which the rim tissue can be pulled for emulsi-
In these cases the strategy is entirely fication. (Editor’s Note: this technique is not
different. We want to remove as much of the to be confused with the original crater-bowl
hard center core of the cataract as possible procedure used years ago).
during this sculpting phase, leaving only a thin
and soft nuclear rim for later removal. For Steps Following the Trench or the
these cataracts, a crater Divide and Conquer is
Crater D & C
recommended when using D & C techniques.
The nucleus is held in place firmly in the
Once the nucleus is prepared with either
bag. We can sculpt into the cataract with the
the trench or the crater, the nuclear rim is
ultrasound energy and remove all of the hard,
broken apart using a unique and clever method
dense nuclear core without the cataract mov-
of fracturing it. The phacoemulsification tip is
ing. That keeps the phaco tip and all of the
driven into the remaining broad nuclear rim
debris far away from the endothelium and
and held there with aspiration. A Barraquer
allows safe and extensive nucleus removal. It
spatula or manipulator (Fig. 79) is placed next
also allows us to stay away from the posterior
to the phaco tip and poked into the rim right
capsule.
next to it (Fig. 67). The two instruments are
As pointed out by Paul Koch, M.D., we
separated, breaking the rim apart (Fig. 104).
can judge the depth of the sculpting from fairly
The nucleus is rotated around a bit, reengaged
distinctive changes in the red reflex. The first
with th e phaco tip and the Barraquer spatula,
clue to depth is the color of the cataract. We
and broken again (Fig. 106 below).
normally begin with a red reflex, but as soon as
we start emulsifying the epinucleus, the reflex
changes and becomes either burgundy or gray. Present Role of Original Four
As we sculpt down toward the middle of the Quadrant Divide and Conquer
cataract, we reach the gray center, and as we get
through that, the reflex starts turning burgundy The original, four quadrant "Divide and
again (Fig. 69). Once we reach the posterior Conquer Technique" illustrated in Figs. 56 and
epinucleus, the color is back to red. 67, 103, 104 and 106 below is now the tech-
If we monitor the color changes as we nique of choice for those surgeons who are less
sculpt, we can work our way very deep into the experienced and are converting from planned
catarac t without the risk of cutting the poste- extracapsular surgery to phacoemulsification.
rior capsule. We slow down as the color It is the easiest method. The debilitation of the
brightens. nucleus is achieved by high doses of ultrasound
The primary goal of crater creation is energy and the "eating" or emulsification of the
to remove the very dense nuclear core, leaving quadrants also requires high ultrasound en-
only a much softer nuclear rim, thereby con- ergy. For this reason we included this tech-
verting the cataract from a dense one into a soft nique as the one of choice in Chapter 7 that
one. The secondary goal is to create a space covers the stage of Transition.
181
The original four quadrant divide and development of the chopping techniques, be-
conquer technique has the significant impor- ginning with Nagahara's Phaco Chop. The
tance of having served as the basis for the latter, though, are based on different prin-
proliferation of many variations of the divide ciples and constitute the group of low ultra-
and conquer. Many of them are still useful. It sound energy - high vacuum procedures
also provided the insight needed for the which at present are the techniques of choice.
Figure 106: Phacoemulsification - Dividing

Process Chopping vs Divide and Conquer
(Top) The opposing forces in the chop-

ping techniques are shown in vertical arrows.
Please observe the chopper (Fig. 80) biting the
nucleus fibers from the periphery towards the
center, with phaco tip deeply impaled creating
fixation and steadiness of the nucleus. This is
sincronized move of the phaco probe and the
chopper. (Below) Shows the opposing forces
(arrows) cracking the nucleus after the deep
groove has been made with the ultrasound
(D & C technique). In this stage, the movement
is from the center to the periphery (arrows).
182
THE LOW ULTRASOUND ENERGY AND

HIGH VACUUM GROUP
The techniques described in the first group sharp needles to engage and cut nuclear mate-
are known as the grooving and cracking meth- rial. The aspiration mode played a secondary
ods. Now it is important for the surgeon to role, after the material had been emulsified.
evolve into the second group, which are the The trend now is the opposite, that is, to
chopping methods, because chopping enables use low ultrasound power and high vacuum.
you to reduce ultrasound energy in the eye by These chopping techniques emphasize the as-
using greater mechanical forces - mechanical piration aspect while the ultrasound power is
forces that will not harm the eye. I. Howard utilized as an aid to fragment the hard portions
Fine, M.D., emphasizes that the easier we can of the nucleus and to facilitate aspiration of the
make it to help surgeons transition to chopping, nuclear material. This is a significant advance
the better we will be serving our patients. which allows much more control by the sur-
Innovations in technique have under- geon.
gone a rapid and important evolution driven by In all modern techniques, the surgeon
advances in technology. At the time when the uses only sufficient but very small amounts of
initial four quadrant technique was introduced ultrasound power to fragment the nuclear ma-
by Gimbel in 1987, the early phacoemulsifica- terial that is occluding the tip of the phaco
tion machines vibrated at a constant power needle. The advances in technology that have
with constant aspiration requiring the use of a made this possible are presented in Chapter 8,
large amount of ultrasound power in order to under “Emulsification System,” and illus-
obtain rapid sculpting of the nucleus using trated in Fig. 85.
THE CHOPPING TECHNIQUES
They are all based on the concept of the Main Instruments Used
Phaco Chop technique initially devised by
Nagahara in 1993. Since then a multiplicity In the chopping techniques, two instru-
of techniques that stem from the principles of ments are utilized: 1) the phaco chopper intro-
the phaco chop have been developed but are duced through the ancillary or side port inci-
less complex than the original Phaco Chop. sion, which serves as an ax (Fig. 80). The
The lens substance, including the nucleus, phaco tip serves as a chopping block (Fig. 106
has a concentric lamellar and radial structure. above). The nucleus is easily fractured with the
It can be fractured along the direction of the phaco chop technique. The latter is more effec-
lens fibers that run from one side of the equator tive for standard to moderately hard nuclei than
towards the opposite side, passing through the a soft one.
center of the nucleus (Fig. 106 above).
183
Surgical Principles of the Original Chopping Techniques Presented

Phaco Chop in this Volume
The surgical principle of the original From the large variety of chopping tech-
phaco chop technique is first, after hydrodis- niques now available, we have chosen five for
section, the phaco tip is placed into the eye and presentation in Chapters 9 and 10. They were
touches the nucleus as far superiorly as pos- all originated by highly prestigious, experi-
sible, inside the limits of the capsulotomy. enced phacoemulsification experts and repre-
Using a quick burst of phaco energy the tip is sent the direction in which this surgery is ori-
buried securely into the nucleus. ented. These procedures are: 1) The Stop and
The chopper is inserted through the side- Chop (Paul Koch); 2) The Crater Phaco
port incision, and placed on the nucleus as far Chop (MacKool); 3) The Null Phaco Chop
inferiorly as possible, again right inside the also referred to as Pre-Slice (Jack Dodick); 4)
capsulotomy. It is buried right into the cataract The Choo-Choo Chop and Flip (I. Howard
and then pulled up toward the phaco tip, divid- Fine). 5) The Stop and Karate Chop Tech-
ing the cataract . This technique, which was the nique as advocated by Edgardo Carreño, one
basis for all chopping techniques that later of the top phaco surgeons in South America.
developed, presented two problems: unlike His insights are somewhat different than the
previous experiences with Divide & Conquer top surgeons in North America.
and In-Situ Fracture, there was no space in the
middle of the cataract for manipulation. When
the surgeon finished chopping the four quarters
THE STOP AND CHOP
and was ready to emulsify one of them, he had TECHNIQUE
no room to allow it to slide toward the phaco
tip. It was wedged in place in the capsular bag Surgical Principles
and did not move easily.
The surgeon had to engage the fragment This is the main variation of the phaco
and pull it into the anterior chamber for re- chop technique. It is widely used, and was
moval, converting the case from one that was popularized by Paul Koch. Its most important
purely endocapsular, to one that was three- contribution is that it facilitates one of the
quarters endocapsular and one-quarter ante- significant difficulties encountered with the
rior chamber phaco. original phaco chop which is the fragmenting
The surgeon had divided the nucleus of the first half of the nucleus and removal of
into fragments, but had no space for maneuver- the first fragment.
ability in order to remove them. A superior quality CCC and a good
Even though the Phaco-Chop technique hydrodissection are fundamental before man-
of Nagahara initiated a new era in phacoemul- aging the nucleus, as in all other phaco opera-
sification, the original procedure had to be tions. After the hydrodissection is completed
modified in order to overcome the problems (Figs. 46-48, 78-A), Koch usually does not
here outlined. perform hydrodelineation for this procedure,
184
Figure 107: Stop and Chop Technique -

Stage 1 - Sculpting the One Central Groove
After instillation of viscoelastic, the

phaco probe is introduced through the primary
incision size (3.2 mm) at 10.30 o'clock and the
chopper at 3 o'clock. This side view shows
how the phato tip is impaled in the lens sub-
stance, sculpting a central groove as if we were
doing the classical nucleofractures but only
one groove is done and not the classical cross.
This creates a space in the center which is
essential for nucleus manipulation. The groove
(G) is extended toward the periphery of the
nucleus with the phaco probe (P). This maneu-
ver debilitates the central core of the lens
permitting its easier fracturing with the chop-
per.
because he is able to chop the nucleus into bite- cataracts, a center crater is done instead of a
sized pieces. Because he constantly pulls pieces furrow.
into the middle of the capsular bag, he does not The deep nuclear sculpting is performed
need the cushion of epinucleus. All he would from 12 o'clock to 6 o'clock, creating a vertical
be doing if he created one would be adding one trough (Fig. 107). A second instrument de-
more step at the end -- removal of epinucleus. signed for phaco chop (chopper) is inserted
Koch's method is to sculpt a central through the ancillary incision (Figs. 108, 80).
groove as if we were doing the classical Nucle- The chopper is inserted underneath the
ofractis or divide and conquer technique but anterior capsular edge in the lower right quad-
only one groove is done and not the classical rant (Fig. 108), advanced out to the periphery
cross. This creates a space in the center (Figs. of the capsule (Fig. 109), embedded in the
107, 108) which is essential for nucleus ma- peripheral nucleus (Fig. 110), and pulled back
nipulation. In softer cataracts, the surgeon to the central groove. This creates a small free
does a lighter furrow or trench while in the wedges of nucleus, which are easily emulsified
standard two to three plus or even four plus and aspirated (Fig. 111).
185
Figure 108 (above right): Stop and Chop Tech-

nique - Stage 2 - Insertion and Role of Second
Instrument
Once the groove has been sculpted deep

enough (half the diameter of the phaco probe) in the
12 o'clock to 6 o'clock direction, the second instru-
ment (chopper) is inserted through the ancillary
incision and placed underneath the anterior capsu-
lar edge in the right lower quadrant. It is then
advanced out to the periphery of the capsule, em-
bedded in the peripheral nucleus and pulled back to
the central groove, creating small free wedges of
nucleus which are emulsified.
Figure 109 (center): Stop and Chop

Technique - Stage 3 - Rotation of the
Nucleus
A space had been produced for

the ultrasound tip and the ancillary chop-
per to fracture the nucleus. The surgeon
stops, rotates the nucleus through 90 de-
grees, fixates the lower half of the nucleus
with the ultrasound tip and creates a crack
with the hook exherting traction in the
opposite direction.
Figure 110 (above right): Stop and Chop Tech-

nique - Stage 4 - Creating Free Wedges of Nucleus
The same piece of nucleus is again stabi-

lized with the phaco tip while the chopper is
advanced out to the periphery and pulled centrally.
The surgeon uses the chopper (C) to crack the
rotated nucleus in small pieces starting at the pe-
riphery. Observe how the chopper is pulled from
the 6 o'clock position under the capsulorhexis to-
wards the center while the phaco probe (P) maintains
the nucleus in a fixed position for firm support.
186
Fracturing of the Nucleus hook, exerting force toward the ultrasound tip
(Figs. 111, 106 above). The same piece of
The ultrasound tip and the ancillary chop- nucleus is again stabilized with the phaco tip,
per fracture the nucleus into two parts by while the phaco chop instrument is advanced
exerting force toward each other. The surgeon out to the periphery and pulled centrally
holds the ultrasound tip steady, which serves as (Figs. 110, 111), creating another small free
the firm block holding the nucleus and the wedge of nucleus for emulsification and aspi-
chopper slices the nucleus from the periphery ration. The process is repeated until the entire
towards the center of the nucleus. Numerous first nuclear half is removed. The other nuclear
bites are performed with the choopper creating half is rotated into the inferior capsular bag,
small free wedges to be emulsified (Fig. 111). and the entire process is repeated (Figs. 108
through 111).
Fixating, Rotating and Creating From these four initial fragments, which
can be easily mobilized from the capsular bag,
Small Free Wedges of Nucleus for
each piece is further divided into smaller pieces
Emulsification and Aspiration and eaten with the ultrasound. Thereby, the
importance of the burst action in the phaco
At this point, the surgeon stops, rotates machine, because the surgeon cuts small pieces
the nucleus through 90 degrees (Figs. 108, 109, and emulsifies, again cuts small pieces and
110). He fixates the lower half of the nucleus emulsifies them (See Chapter 8 for Burst Mode
with the ultrasound tip and cracks it with a and Pulse Mode). The whole procedure occurs
with no sculpting .
Figure 111: Stop and Chop Technique

- Stage 5 - Chopping and Emulsifica-
tion
At this point the inferior half of

the nucleus has been cracked and begins
to be emulsified. With the chopper the
surgeon pulls from the periphery toward
the center to divide and create additional
small free wedges of nucleus which are
then emulsified and aspirated. The pro-
cess is repeated until the entire remaining
nuclear half is removed.
187
This is the essence of the stop and chop, nipulator or chopper, he should attempt to
one of the most important of the advanced fracture the nucleus (Figs. 103, 104, 106 above).
techniques. It is easy to split the nucleus into two parts
because the chopper or manipulator does a
Absolute Requirements to better job separating the nucleus halves than
the olive tip spatula previously used for this
Perform the Stop and Chop purpose. If there are difficulties and the frac-
ture line is not seen, the initial groove in the
Although this technique is much less center of the nucleus can be deepened but the
complex than the original phaco chop, in order surgeon must pay great attention to the color of
for it to be successful, the following principles the red reflex to be sure he/she is not too close
must be attained: to the posterior capsule.
1) Hydrodissection: this stage of the The fracture of the nucleus into two parts
procedure must be very well done (Figs. 46-48, first is the key to the success of the operation.
78-A). A great deal of the success of this Only after this will the surgeon be allowed to
technique depends on the ability to easily proceed making smaller free segments or
mobilize the nucleus (Figs. 108-110). We wedges by additionally fracturing with the chop-
must be sure that the nucleus can be completely per (Fig. 111).
rotated before beginning its phacoemulsifica- Fracturing with the chopper depends
tion. The ease with which the nucleus can be largely on the instrument insertion depth. Nor-
rorated depends on a very well done hydro- mally, the phaco probe and tip as well as the
dissection. Before beginning phacoemulsifi- chopper should be inserted at a depth about
cation of the nucleus, the surgeon should ro- 2/3 the diameter of the phaco tip. Once the
tate the nucleus two or three times inside the nuclear fragments have been made, the proce-
bag. If the rotation is not easy, then there was dure is continued with the usual maneuvers
a failure in the hydrodissection maneuver. The (Figs. 105 - 111). At the end of nuclear re-
surgeon must not attempt to mobilize the moval, there is a small quantity of residual
nucleus mechanically or by force. material which is then aspirated.
2) The Initial Groove: done to create
the space inside the nucleus for it to be
fractured (Figs. 107 - 108). This groove must Importance of the Phaco
be well done to be useful. It allows the Chopper
surgeon to free the two sectors easily (Fig. 106
above). This ancillary instrument is absolutely
3) Fracturing the Nucleus: when the essential to perform the chopping technique.
surgeon has reached a good depth with the two There is a large variety of these phaco chop-
instruments, that is, the phaco tip and the ma- pers. They all look like a golf club and the most
188
effective ones have a somewhat sharp point absorbed by the external cortex and the separa-
1.5 mm in length (Fig. 80). In figures 103 tion induced through hydrodissection
through 121 you may observe the chopper 3) How useful is this procedure is in
being used in different techniques. The chop- cataracts of different nuclear consistency
per is inserted through the side port or ancil- depends on the ability of the surgeon to adapt
lary incision. The hook or chopper is posi- his technique to the type of cataract he/she is
tioned at 6:00 o'clock underneath the anterior operating. The size of the nuclear wedges
capsule as far peripheral and deep as possible created can vary based on nuclear consistency.
(Figs. 105, 110, 111). The shape of the point This technique is even useful in hard nuclei
is most important. We can chop a soft nucleus using less ultrasound and more aspiration. Hard
using a sharp point; a wedge shaped tip facili- nuclei require smaller wedges while softer
tates chopping of a hard nucleus. nuclei can yield with larger wedges.
The stop and chop technique is useful in
Highlights of the Stop and Chop most cataracts with different consistency:
in hard nuclei, in soft and in cataracts with
Technique nuclei of standard consistency. It is a method
that lends itself to wide use. There is greater
1) It provides excellent stabilization of ease in dealing with very hard nuclei as
the nucleus by fixation with the phaco tip and compared with most other techniques.
slicing and biting with the chopper. The latter 4) The advantages of this procedure over
has more of an active role in the procedure than the conventional divide and conquer methods
the ancillary instruments in other endocapsular include reduced stress on the capsular bag and
techniques. The surgeon uses the two hands in zonular fibers because the use of the chopper
harmony during the entire phaco nuclear re- simplifies the fracture.
moval. 5) The operation decreases phaco time.
This also means that the surgeon should 6) It creates less turbulence and conse-
pay very close attention to the chopper, which quent complications.
needs as much control as the ultrasound tip. 7) Any remaining epinucleus and cortex
2) Throughout the entire procedure, the is removed in standard fashion.
ultrasound energy transmitted to the nucleus is 8) By dividing the nucleus in two halves,
not transmitted to the epinucleus and the cor- the stop and chop technique facilitates the more
tex. Therefore, it is not passed on to the difficult maneuvering encountered by the sur-
posterior capsule and the zonules because it is geon in phaco chop.
189
FUNDAMENTAL DIFFERENCES BETWEEN CHOPPING

TECHNIQUES AND DIVIDE AND CONQUER (D & C) TECHNIQUES
The two main groups of techniques uti- Finally, chopping is a more time produc-
lized in modern, endosacular advanced meth- tive method than cracking in that a segmenting
ods for managing of the nucleus in phacoemul- chop can be made with a single instrument
sification are the chopping techniques and its movement (Figs. 104 above, 111) as opposed
derivatives and the cracking techniques (divide to multiple ultrasonic sculpting passes required
and conquer and its derivatives). There are for a groove (Figs. 56, 67). Also, the smaller
fundamental differences in regards to their chopped fragments are more readily emulsi-
surgical principles. fied with less repositioning required as com-
Chopping tends to stabilize the nucleus pared to larger quadrants.
between the phaco tip and the chopping instru- In the chopping techniques, the chop-
ment. Furthermore, mechanical force is di- ping direction is from the equator to the center
rected centripetally as the chopping instrument (Fig. 104 above). In the divide and conquer
cleaves the nucleus (Fig. 106 above). There- procedures, the cracking is from the center
fore, minimal force is directed outward toward the equator (Fig. 104 below). There-
against the capsule periphery. This is in fore, in the divide and conquer procedures, the
contrast to cracking methods, during which surgeon must begin sculpting the center of the
the nuclear periphery is pushed outward nucleus and debilitating the nucleus at that
against the capsule by the cracking instruments stage, making a trench or a crater with ultra-
(Figs. 104, 106 below). As a consequence, any sound to start the cracking from the center,
defect in the capsulorhexis is at greater risk and as shown in Figs. 106 below, and 104. In the
may have a tendency to extend to the periphery chopping techniques, the surgeon sticks the
and posteriorly with cracking as opposed to phaco tip into the nucleus and insert the phaco
chopping. chopper into the space between the equator and
Chopping is also a more productive the capsule at the 6 o'clock position (Figs. 105,
method than cracking with respect to the need 110, 111). Then the phaco chopper is drawn to
to use ultrasound power because chopping uses the phaco tip to crack the nucleus. There is no
mechanical force for nuclear segmentation as need of sculpting during this stage of the proce-
opposed to sculpting grooves which are done dure which is the reason why the phaco energy
with ultrasound, even though modified D & C can be significantly reduced.
techniques do allow the use of low total ultra- Sculpting with the ultrasound energy is
sound energy because it is not used continu- the easiest and safest step of the operation and
ously. that is why we recommend the divide and
Ultrasound is used more efficiently dur- conquer original four quadrant technique for
ing chopping because it is applied in the more the transition. There is no ultrasound sculpting
effective occlusion mode. in the stop and chop.
190
THE CRATER PROCEDURES Instead, a small, central crater is sculpted

with controlled amounts of ultrasound energy,
The Crater Divide and Conquer leaving a dense peripheral rim (Fig. 112). After
(Mackool) the central core of the nucleus is removed, the
maneuvering of fracturing can be accomplished
This procedure is based on Gimbel's by first placing the chopping instrument under
Divide and Conquer surgical principles. It is the anterior capsule at the 6 o'clock position
a modification of the original four quadrant (Fig. 113). Keeping the phaco tip placed into
divide and conquer. Because it is used mostly the bulkhead of the nuclear rim (Fig. 113), the
for hard nuclei, the center of the nucleus is vacuum of the tip is used to stimulate division
weakened in the shape of a small crater by of the nucleus. No ultrasound is used. The
applying ultrasound energy and proceeding to chopping instrument which has been intro-
crack the nucleus in two halves. This is fol- duced through the ancillary incision pulls to-
lowed by further cracking into four pieces ward the incision (arrow), slightly away from
using the ultrasound energy with the help of the the phaco tip and gently towards the posterior
ancillary instrument. The pieces are then emul- capsule. This results in a fracture through the
sified. nuclear rim and any remaining thin nuclear
plate (Figs. 114). The nucleus is then rotated in
The Crater Phaco Chop for Dense, order to accomplish additional fracturing of
Hard Nuclei small segments (Figs. 114, 115). Fracturing is
done with much less ultrasound energy than in
The crater phaco chop is essentially used the D & C Crater Procedure.
in harder, more dense and brunescent cataracts In the Crater Chop technique, again we
(Fig. 2) in which a trench or trough or groove initially debilitate the nuclear core with ultra-
cannot be used because it does not weaken the sound energy. When weakened, the phaco tip
entire lens nucleus sufficiently to easily frac- is impaled or firmly buried in the central nucleus
ture the nucleus. The resulting segments would (Figs. 113, 114). Multiple wedges are created
be too large to manage safely. This is because by the continuous process of biting tissue using
the epinucleus of a hard nucleus is thin and a the chopper. These small pieces are then
hard nucleus has a dual structure consisting of emulsified (Fig. 116).
an outer soft and inner hard nucleus or core. This Crater Chop technique is not to be
Also, a hard nucleus is thicker than a soft identified as the Crater-Bowl procedure de-
nucleus and the posterior part is harder and scribed previously in which a substantial amount
more elastic. In these lenses, the phaco chop of of ultrasound energy was used to debilitate the
Nagahara or even the stop and chop of Koch central tissue.
may not be sufficient.
191
Figure 112 (above left): Crater Chop

Technique - Stage 1 - Creation of the
Small Crater
The central epinucleus and ante-

rior cortex are removed. The phaco tip
(P) is used for sculpting at the center. A
small central crater is sculpted with con-
trolled amounts of ultrasound energy,
leaving a dense peripheral rim. This
creates a thin central nucleus suitable to
easier fracturing with the chopper.
Figure 113 (center): Crater Chop Tech-

nique - Stage 2 - Fracturing the Nucleus
With coordinated movements the

phaco probe (P) is impaled and buried
through the thickness of the dense pe-
riphery. At that time the chopoper (C) is
employed to start the fracture deeply and
vertically from the periphery to the cen-
ter toward the phaco tip in the direction
of the primary incision.
Figure 114 (below left): Crater Chop

Technique - Stage 3 - Slicing the
Nucleus into Small Wedges
Small, controlled and smooth

movements are required to slice por-
tions of the nucleus into wedges without
tearing the posterior capsule. Portions
of the nucleus are attracted and rotated
toward the center with the phaco probe
(P) in ultrasound mode, fracturing the
wedges into small pieces with the help
of the chopper (C) and rendering them
for emulsifiction and aspiration.
192
When to Remove Nuclear Seg-

ments Immediately vs When Leave
them in Place
The entire lens is fractured before any

pieces are removed, maintaining the disten-
tion of the capsule which helps to prevent
an inadvertent capsule rupture, as shown in
Fig. 115). With a dense or brunescent nucleus,
it is safer to leave the segments in place to
maintain the shape of the bag, without the
potential for collapse. The segments are easier
to fracture if they are held loosely in place by
the rest of the segments still in the bag.
Figure 115 (above ): Crater Chop Technique - Stage

4 - Fracturing and Chopping Process
During the fracturing process, the phaco tip is

buried in the dense nuclear periphery while the continu-
ous action of the chopper bites the nucleus into pieces
bringing them to the center. Here we may observe this
combined maneuver using the chopper (C) and the
phaco probe (P) for rotation and cutting of fragments.
Figure 116 (below): Crater Chop Technique - Stage 5

- Attacking the Final Quadrant
The phaco tip is brought in contact with the last

fragment. Tip occlusion is maintained using short bursts
of low energy ultrasound. While keeping the tip oc-
cluded the fragment is advanced toward the center of the
capsular bag with the help of the chopper (C) for com-
plete aspiration with the phaco probe (P).
193
THE NUCLEAR PRE-SLICE OR NULL actual breaking up of the lens uses no ultra-
PHACO CHOP TECHNIQUE sound at all.
In this technique, Dodick sections the
This technique has been devised by Jack nucleus into four parts with no ultrasound
Dodick, M.D., from New York, one of the using two specially designed hooks (Figs. 117
world's experts in cataract surgery. Almost - 121). It is as safe as any phaco chop, and takes
every contemporary cataract surgeon uses some an equal amount of time.
form of chopping, and all surgeons who per-
form chopping use some form of ultrasound to How Is the Null-Phaco Chop Done
facilitate the chop. Whether it be a groove-and-
chop, divide and conquer, or a technique like The procedure uses two elongated
Howard Fine's quick chop (the choo-choo chop Sinskey hooks, which have a 2 mm bend
and flip technique presented later in this chap- with a round polished ball at the end
ter), some form of ultrasound is used for chop- neatly shown in Figs. 119 and 120. The
ping. anterior cortex is vacuumed, and viscoelastic
is placed in the eye. The first hook is intro-
Disassembling the Nucleus duced through the paracentesis incision paral-
lel to the lens until it is in the capsular bag.
Importance in Modern Techniques Dodick always does the phacoemulsification
at the 11:00 position, which means the para-
All modern techniques are oriented to- centesis incision is at about 2:30 (Fig. 117).
ward breaking up or disassembling the nucleus The hook enters the capsular bag and is
to facilitate its removal from the eye. These rotated 90 degrees so that it engages the
techniques, which rely on mechanical energy, equator of the nucleus. The first hook is now
have been developed to reduce the amount of in place and is pointing toward the optic
ultrasound energy necessary to break up the nerve.
hard part of the lens nucleus. In addition, Then the second hook is introduced
disassembling the nucleus removes it from the through the phacoemulsification incision,
capsular recesses of the bag, thereby facilitat- again parallel to the lens (Fig. 117). It en-
ing its removal with the phaco probe. gages the capsular bag and enters it. The
Nuclear disassembling techniques use surgeon then rotates the hook 90 degrees so
some ultrasound at the beginning of the proce- that the tip faces the optic nerve and engages
dure to create multiple troughs or grooves. A the equator of the nucleus below. The hooks
second instrument such as a spatula or chopper should be about 180 degrees apart. Taking
can then be used to crack or break the nucleus. great care, the surgeon moves the hooks to
Dodick now routinely uses the nuclear pre- bring the tips together (Fig. 118). This pro-
slice or null-phaco chop technique except in cess will not tear the posterior capsule, but it
hardened, black cataracts. This procedure re- is important not to place the hooks in the
duces the amount of ultrasound needed to re- sulcus. As the two hooks are brought to-
move cataracts by phacoemulsification. The gether, they bisect the nucleus (Fig. 118).
194
Figure 117: Dodick’s Null-Phaco Chop

Technique - Stage 1 - Insertion and
Placement of Hooks
Two identical elongated hooks (H)

which have a 2 mm bend with a round
polished ball at the end serve as the chop-
pers. The first hook is introduced through
the ancillary incision at 2 - 3 o'clock and
the other one through the primary incision.
The hooks are positioned opposite one
another. They enter the capsular bag and
are rotated 90 degrees so that they engage
the equator of the lens. The hooks are 180
degrees apart.

Technique - Stage 2 - Bissecting the Nucleus
Thesurgeon pulls on the hooks to

bring them together and bisect the nucleus.
195
After the first crack a second crack of

each half is easily made. The 11:00 hook is
moved toward 6:00, and placed in the
capsular bag while the second hook is left in
the trough or groove (Fig. 119). The two
hooks are brought together resulting in a
trisection. At this point the lens has been cut
into three parts (Fig. 119). The procedure can
be repeated by splitting the next half in a
similar fashion (Fig. 120). Upto this point no
ultrasound has been used.
Once the quadrants are each broken up
into three or four parts, they are removed with
bevel down phaco, with high vacuum of 300
mm Hg to 500 mm Hg. This is in a peristaltic
system, with a high flow rate of 30cc to 40 cc
per minute. The amount of energy needed is
Figure 119 (above): Dodick’s Null-
Phaco Chop Technique - Stage 3 - Frac-
extremely low.
turing the Inferior Half of the Cataract
The 11 o’clock hook is moved

toward 6 o’clock and placed in the capsu-
lar bag. The second hook is left in the
groove. The two hooks are brought to-
gether resulting in a trisection (this part
of lens is cut into three parts).
Figure 120 (below): Dodick’s Null-

Phaco Chop Technique - Stage 4 -
Fracturing the Superior Half of the
Cataract
Once the inferior half is di-

vided, the surgeon proceeds with the
superior half in a similar manner. The
hooks or choppers are placed at 11
o’clock and centrally and drawn to-
gether toward the visual axis to com-
plete the disassembling of the entire
cataract.
196
Dodick disassembles some 1+ 2+ Learning and Adjustment

lenses with little or no ultrasound, because
this maneuver not only sections the nucleus Performing this technique does require
into four parts, it actually dislodges these some learning and adjustment. The learning
parts quite well from the recesses of the curve required for this technique is to master
capsular bag (Figs. 120, 121). He brings the the placement of the two hooks nd to prevent
last two quadrants into the pupillary plane rotation of the nucleus while it is being
and is able to break them up further with the divided. Great care must be exercised in the
aid of a Sinskey hook through the paracente- placement of the hooks into the capsular bag.
sis incision. When he needs ultrasound in 3+ There is a tendency for the nucleus to rotate,
or 4+ cataracts, he rarely goes above 30 % but you soon develop a proprioceptive-like
ultrasound because the lens is already broken sense of placing those hooks. If you see or
into four parts (Fig. 121). feel internal rotation of the nucleus about to
begin, you simply adjust the hooks.

Technique - Stage 5 - Cataract Fractured
in Four Fragments
Once fractured, the four fragments of

the cataract are removed using mainly
vacuum and aspiration. Once mastered, this
technique is highly reproducible and takes no
longer than any other chop technique and re-
duces the amount of ultrasound energy intro-
duced into the eye.
197
Once mastered, this technique is highly amount of energy necessary to evacuate the
reproducible, it takes no longer than any lens. The technique Dodick describes is one
other chop technique, and reduces the amount method of nuclear disassembly. These meth-
of ultrasound energy introduced into the eye. ods in general dramatically reduce the
It may be a very good alternative procedure amount of energy to break up the nucleus,
for experienced phaco surgeons. leading to clearer corneas and quicker reha-
bilitation of the patient after surgery.
Potential Complications
To critics, this technique appears dan-

THE CHOO-CHOO CHOP AND
gerous. The belief is that the capsular bag FLIP PHACOEMULSIFICATION
can be dislocated. However, Dodick has not TECHNIQUE
found this to be a problem if the recesses of
the capsular bag are identified by vacuuming This special technique devised by
of the anterior cortical material and the hooks I. Howard Fine, M.D., head of the Oregon
are carefully placed in the capsular bag and Eye Institute in Eugene, Oregon and Clinical
not in the sulcus. Critics may point out that Professor at the Oregon Health Science Uni-
the tip is back toward the posterior capsule, versity in Portland, is a chopping technique
and the two hooks brought across the nucleus that uses power modulations and high
might rip the posterior capsule. This, accord- vacuum along with specific maneuvers to
ing to Dodick, does not happen. minimize the amount of ultrasound energy in
On the contrary, he thinks that this can the eye and maximize safety and control. It is
actually be a safer procedure, especially in effective in all types of cataracts and allows
eyes with weak zonules and hardened nuclei to be removed safely in the
pseudoexfoliation. Rather than sculpting and presence of a compromised endothelium.
applying pressure toward the zonules, the This procedure facilitates the achieve-
vector forces from the special hooks pull ment of two goals: minimally invasive cata-
toward the center, reducing stress on the ract surgery and maximally rapid visual reha-
zonules. bilitation. It is designed to take maximum
For more dense cataracts (e.g. 3+), he advantage of various new technologies avail-
does use low ultrasound, perhaps 15%, maxi- able, mainly the Alcon 20,000 Legacy, the
mum 30%, and again high vacuum, 300 to AMO Sovereign (Allergan) and the Storz
400 mmHg, and a high flow rate. To mini- Millennium phacoemulsification systems
mize the effect of surge, he uses the (Fig. 85). These technologies include high
MAXVAC high vacuum tubing and the aspi- vacuum cassettes and tubing, multiple pro-
ration bypass ABS tip. grammable features on all systems, as well as
the Mackool Micro Tip (Fig. 84) with the
Contributions of this Technique Legacy and burst mode and occlusion mode
capabilities with the Sovereign (Figs. 86, 87).
Dodick's procedure shows that using The result is enhanced efficiency, control, and
mechanical energy to break up the lens in safety. The procedure is done as shown and
place of ultrasound is helpful in reducing the described in Figs. 122, 123, 124, 125, and
126.
198
Origin of the Name “Choo-Choo” The short bursts or pulses of ultrasound

energy continuously reshape the pie-shaped
Fine uses high vacuum and short segments which are kept at the tip, allowing
bursts, or pulses, of phaco ultrasonic power. for occlusion and extraction by the vacuum.
The name “choo-choo” arises from the re- The size of the pie-shaped segments is cus-
sulting sound of the pulse mode (Fig. 125). tomized to the density of the nucleus with
The nucleus is continually rotated so that pie- smaller segments for denser nuclei. Phaco in
shaped segments can be scored and chopped, burst mode (Fig. 125) or at this low pulse rate
and then removed by high vacuum assisted by (Fig. 86) sounds like “choo-choo-choo-
short bursts or pulses of phaco. (Editor’s choo”; this is the reason behind the name of
Note: scoring the nucleus in this instance this technique. (Editor’s Note: for a precise
means using the wedge-shaped edge of the description and illustration of the pulse and
chopper instrument to groove and then cut the burst modes, and their clinical applications,
nucleus in half against the countering resis- see pages 151-156, and Figs. 86, 87).
tance of the phaco tip which has been se- The term “flip” refers to management
curely engulfed in the opposite side of the of the epinucleus (Fig. 126). Fine considers
nucleus.) it important not to remove the epinucleus too
Figure 122: Choo-Choo Chop Technique -

Stage 1
Following instillation of high density,

cohesive viscoelastic, cortico cleaving, circu-
lar capsulorhexis (C), hydrodissection and
hydrodelineation of the nucleus are performed.
The exposed epinucleus (E) exposed by the
CCC is aspirated. To chop the nucleus into
two hemispheres, a Fine/Nagahara chopper
(F) introduced through a side port incision
engages the distal nuclear margin at the golden
ring (G) and stabilizes the endonucleus. Si-
multaneously, the 30 degree bevel-down
phaco tip (P) introduced through a clear cor-
neal incision “lollipops” the proximal nucleus.
The nucleus is scored by bringing the chop-
per proximally (red arrow) to the side of the
phaco tip, which provides a countering force
(blue arrow).
199
Figure 123 (above): Choo-Choo Chop Tech-

nique - Stage 2
This figure shows the resting positions

of the instruments just following completion
of the nuclear chop (arrow). The chopper (F)
has been brought proximally and slightly to
the side of the phaco tip and the phaco (P) has
been held stationary. The hands are then sepa-
rated - the chop instrument moving to the left
and slightly down (1), and the phaco tip to
the right and slightly up (2).
Figure 124 (below): Choo-Choo Chop

Technique - Subsequent Chopping of Nu-
cleus
In a similar manner to the first chop,

the phaco (P) and chopper (F) are used in com-
bination to score and chop the heminuclei.
First the nucleus is rotated into position as
shown. Here the chopper is directed from
position 1 to position 2 toward the side of the
bevel-down phaco tip to score (3 - arrow) the
hemisphere. These smaller pieces can then
more easily be extracted from the eye with
reduced use of ultrasonic power by using
power modulations. The second nuclear
hemisphere (H) is dealt with in the same fash-
ion.
200
Figure 125 (above left): Choo-Choo Chop

Technique - Use of Burst Mode Ultrasonic
Power
The chopper (F) is used to assist in

holding the nuclear pie-shaped segments
against (arrow) the phaco (P) aspiration port.
Using high vacuum and short bursts, or pulses,
of phaco ultrasonic power (thus the name
“choo-choo” from the resulting sound of the
pulse mode), the nuclear material is frag-
mented and aspirated with minimal or no chat-
tering of the piece against the phaco tip. This
makes for a more efficient and timely removal
of the nucleus.
Figure 126 (below right): The Epinuclear

Flip Technique
Following removal of the endonucleus,

the rim of the distal epinucleus (E) is engaged
with the phaco tip (P) in the bevel-up position.
The chopper (F) is used to assist in flipping (ar-
row) the epinucleus. In this more centrally lo-
cated position, the entire epinuclear rim and
floor can be evacuated from the eye safely and
completely. This is followed by foldable IOL
implantation and removal of viscoelastic and
any residual cortex.
201
early, to avoid leaving a large amount of ultrasound energy (grooving) to further disas-
residual cortex after evacuation of the epi- semble the nucleus.
nucleus. The epinuclear rim of the fourth High vacuum is utilized to remove
quadrant is utilized as a handle to flip the nuclear material rather than utilizing ultra-
remaining epinucleus. sound energy to convert the nucleus to an
emulsate that is evacuated by aspiration.
Comparison With Other Techniques
Fine's Parameters
The choo-choo chop and flip technique
utilizes the same hydro forces to disassemble The parameters used by Fine for this
of the nucleus as in cracking techniques, but technique and applied to the three main pha-
substitutes mechanical forces (chopping) for coemulsification equipments are the follow-
ing:
202
These Parameters are adjusted depending on the hardness of the nucleus. They can be pro-
grammed in the corresponding “Memory” of the equipment.
203
THE TRANSITION TO tion with fewer factors to worry about.

For mobilizing the nuclear tissue, Fine
CHOPPING TECHNIQUES likes a burst width of 80 milliseconds in
surgeon control (Fig. 87). Once again, you
In the transition to chopping, Fine rec- can customize your options to control what
ommends the following steps: happens at the tip. If things are moving along
Impale the nucleus on the phaco tip rapidly, you can depress the foot pedal to foot
superiorly. If you have not lollipoped the position 3 and decrease the interval between
probe tip deep enough (Fig. 88), return to bursts. Or if you feel like things are a little
position 2 and then go back into position 3. precarious or there is a very hard piece of
(Editor’s Note: lollipoping refers to securely nucleus and you want to avoid chattering, you
engulfing the tip of the phaco into the can back off a little bit. (Editor’s Note:
nucleus, like a lollipop or candy sucker on a chattering is when the nucleus bounces
stick. The phaco tip is analogous to the stick against the phaco tip at a high rate of speed
and the nucleus is the round candy portion.) without being emulsified as desired, like
A burst takes place each time you enter when ones teeth chatter when cold - Fig. 89)
position 3. The material will be held very firmly at
When you have lollipoped deeply the tip with no chatter, and will not emerge
enough (Fig. 88), score the nucleus. (Editor’s into the anterior chamber. This affords a
Note: scoring the nucleus means using the much greater level of safety when dealing
wedge-shaped edge of the chopper instrument with a hard cataract in the presence of endot-
to groove the nucleus deeply, against the helial disease.
countering resistance from the lollipoped Once you have taken care of the
phaco on the opposite side of the nucleus.) endonucleus, you can employ the Bimodal fea-
Place the chop instrument in the golden ring ture using the pedal to vary your aspiration flow
(Fig. 75), go from foot position 2 into foot rate in foot position 2. This helps you to mo-
position 3 and floor it (Editor’s Note: push- bilize and bring the epinuclear roof out of the
ing the pedal fully all the way to the bottom capsular fornix and position it in such a way
setting, as when applying full gas pedal pres- that you can trim it. Fine trims the rim of the
sure in a car). You can chop the nucleus epinucleus in three different quadrants and uses
without having to worry about what your foot the rim in the remaining quadrant to flip the
is doing because your foot is on the floor — rest of the epinucleus (Fig. 126). He brings
the vacuum will hold the nucleus as you the handpiece central and then trims the epi-
manipulate the chop instrument. nucleus. Once he goes into foot position 3 the
Then break the nucleus in half by tip clears. As the rim of the epinuclear shell is
separating the two instruments while depress- removed, the aspiration flow rate causes the
ing the chopper and slightly elevating the residual cortex to flow over the floor of the
phaco needle. You will not have to worry epinuclear plate.
about what your foot is doing because you are Fine does not usually have to remove
already in control of the nucleus — you will the cortex as a separate step of phacoemulsifi-
not have to manipulate your foot at all. This cation. In 70 percent of these cases, he has no
technique will allow you a much easier transi- cortex remaining.
204
These types of maneuvers can be done REMOVAL OF RESIDUAL

because there is a stable anterior chamber
with a very low tendency for surge. CORTEX AND
The new technology in these advanced EPINUCLEUS
machines and new software allows the sur-
geon to put into effect the important advance
The surgeon who is learning this tech-
in performing phacoemulsification, which is
nique usually has more cortex to aspirate and
fundamentally cutting power. The surgeon
needs to follow a specific technique for re-
really has little worry about cutting power
moval of the epinucleus. This is discussed in
himself because the new software provides
depth and illustrated in Figs. 69, 70 and 71,
him/her so many more options. With these
Chapter 7. If not cautiously done, there is a
recent advances in phacoemulsification sys-
higher incidence of rupture of the posterior
tems, the surgeon has indeed a total control
capsule.
phaco chop. The new type of software de-
The situation differs for the experienced
scribed in Chapter 8, Fig. 85, will advance
surgeon. Due to the importance attributed to
phacoemulsification in regions of the world
a well-performed hydrodissection and rota-
where there is a preponderance of hard cata-
tion of the nucleus at the end of it, generally
ract with diseased endothelium.
the epinucleus and the residual cortex are
Figure 127: Irrigation/Aspiration of Residual Cortex Inferiorly
Following emulsification of the nucleus, the ultrasound tip is replaced by the

irrigation/aspiration tip (A). The tip is placed into the anterior chamber through the
primary incision and inserted under the anterior capsule in the inferior sector to remove
the small amounts of residual cortex. It is important not to be aggressive nor attempt to
vacuum clean. This is risky and may result in posterior capsule rupture.
205
Figure 128: Irrigation/Aspiration of Residual

Cortex Superiorly
In superior areas where it is difficult to

maneuver with the irrigation/aspiration tip (ghost
view - A), particularly at 12 o’clock, we may re-
move the residual cortex located superiorly using a
manual aspiration technique with a curved irriga-
tion/aspiration cannula or a standard Simcoe can-
nula (S). Here the Simcoe cannula is inserted infe-
riorly through an additional paracentesis (P) which
is a third incision performed between 6 and 7
o’clock. It is moved superiorly to remove the re-
sidual cortex under the anterior capsule leaves.
Manual technique allows more accurate control.
Another method to attain this is following the pro-
cedure shown in figure 71. Again, it is important
not to be aggressive.
aspirated together with the nucleus segments. little barbs or sharp spots that could rupture or
The aspiration of cortical remains becomes tear the posterior capsule. The Chip and Flip
unnecessary because they were partially or technique advocated by Fine may be very
totally eliminated during nucleus emulsifica- useful in this phase (Fig. 126). The entire
tion. If this does not happen, the tip of the epinuclear rim and floor can be evacuated
phaco emulsifier aspirates the free epinucleus safely and completely.
with the pedal on position 2, with the help of If some cortical material remains, par-
the nucleus manipulator (Figs. 69 and 126). ticularly in the hard-to-reach superior capsu-
Once the nucleus has been removed and lar bag underneath the anterior capsule
the surgeon proceeds to irrigate/aspirate leaves, the surgeon proceeds to remove this
whatever cortex remains, he/she may become residual cortex as shown in Figs. 127 and
over-confident thinking that the operation is 128. It is very important not to be aggres-
practically finished. It is, if the cortex and sive. Do not attempt to clear the very last bit
epinucleus are then removed with special of cortex remaining because this could lead to
care. Always be certain to check the tip of the accidental rupture of the posterior capsule.
I/A phaco tip preoperatively to detect any
206
3) Foldable IOL technology has signifi-

INTRAOCULAR LENS cantly improved associated with the use of
IMPLANTATION non-toxic, highly biocompatible chemicals
and polymers of which the foldable IOL`s are
made. This is particularly important with the
The Increased Interest in Fold- development of second generation silicone
lenses which have been proven to be non-toxic,
able IOL's non-inflammatory, non-sensitizing, inert and
available at lower costs.
Present trends point to an increasing use
of foldable IOL's for the following reasons: The Most Frequently Used IOL's
1) Small incision cataract surgery con-
tinues to be on the rise. Patients who are in the
Even though there is a distinct trent to-
financial, social, business and professional lev-
wards foldable lenses, PMMA IOL's continue
els to afford phacoemulsification look forward
to be the most frequently implanted intraocular
to a very prompt visual rehabilitation. This can
lenses throughout the world, (except in the
be made possible only by a successful phaco
U.S). PMMA IOL’s are used more commonly
with a small, valvulated, self-sealing 3 mm
even in Europe, although to an ever-decreas-
average incision which requires a first class
ing extent, as has been pointed out by Tobias
foldable IOL (Figs. 90, 91).
Neuhann, M.D., of Germany, in a classic
Surgeons, therefore, no longer accept
study he made of new foldable IOL's (see
the previous methods of performing a cataract
bibliography).
extraction through a small incision followed by
The still preponderant use of PMMA
an enlargement of the wound in order to insert
lenses is related to the unquestionable reality
a 6.0 mm optic PMMA lens. As a consequence,
that, for a variety of reasons, extracapsular
industry rose to this challenge and has devel-
surgery is still the cataract operation mostly
oped high quality foldable IOL's .
used throughout the globe. More than 60% of
2) Through the significant clinical and
very good ophthalmic surgeons perform ECCE
laboratory research made by R. Lindstrom,
in the majority of patients even though they
I.H. Fine, Ernest and Neuhann, Langernman
may recognize that phacoemulsification is a
and other prestigious colleagues, refractive
better operation especially for of very prompt
cataract surgery was developed as a standard
visual rehabilitation.
procedure by: a) placing the corneal cataract
incision in the right place. b) developing the
right architectural design of a small self-seal- Special Indications for PMMA
ing, valvulated, corneal tunnel incision that can Lenses
result in 1.00 D or less of postoperative astig-
matism (Figs. 92, 93). This has stimulated the Richard Lindstrom, M.D. uses fold-
use of foldable monofocal and multifocal IOL's. able lens implants in most cataract operations.
207
Figure 129: Insertion of PMMA Anterior

Chamber Lens in Aphakia - Gonioscopic View
A gonioscopic mirror is used to check the

position of the proximal footplates, and to ensure
that there is no iris tuck. The distal footplates are
also checked again with the gonio prism to ensure
that they have not been displaced during place-
ment of the proximal haptics.
Nevertheless, he considers that there still are The most widely accepted, major groups
indications for the standard PMMA lenses, for of foldable lenses are made of either acrylic or
example the secondary anterior chamber lens second generation silicone (PDMDPS). Each
implant (Fig. 129). He also uses standard group has advantages and disadvantages. Other
PMMA intraocular lenses when performing a monofocal lenses creating interest are the
triple procedure that includes a penetrating Memory lens, the hydrogel lenses and the toric
keratoplasty. In these patients there is no lens made by STAAR.
reason to use a foldable lens. He may use a
7 mm optic modified C loop PMMA lens. THE FOLDABLE ACRYLIC IOL'S
MONOFOCAL FOLDABLE These lenses have a very high refractive

LENSES index providing crystal clear vision. Chemi-
cally they are closely related to the still gener-
ally favored PMMA. Mechanically they are
An extensive variety of excellent
best described as pliable rather than elastic.
monofocal foldable lenses are produced by
This is clinically important because acrylic
manufacturers in the US, Germany, France,
lenses are comsidered by many surgeons as
Belgium, Switzerland and other countries. They
somewhat bulky when folded and, conse-
use the finest technology and front-line engi-
quently, difficult to implant through an inci-
neers, biochemists and designers.
208
sion less than 3.5 mm. We have presented Disadvantages of Acrylic

Carreño's technique in which he describes Foldables
how to insert the AcrySof lens through a 2.8
mm incision in Chapter 8. The most widely Foldable acrylic lenses come in a 5.5 and
used foldable acrylic lenses are the popular a 6 mm optic size. Lindstrom and some other
Alcon AcrySof lens model MA30BA, which surgeons prefer the 6 mm optic because the
has a 5.5 mm optic and PMMA haptics and the 5.5 mm optic lenses may have problems with
Allergan Sensar AR40 with a 6.0 mm optic. edge glare and unwanted visual images.
They both come with very practical folding and Another limitation with acrylic lenses, accord-
injector systems, the "Acrypack" for Alcon's ing to Lindstrom, is that none of the foldable
AcrySof and the "Unfolder Saphire" for acrylic lenses will go through an incision smaller
Allergan's Sensar. than 3.5 mm. (they are pliable but not elastic -
Editor) In his experience, you have to make
Specific Advantages of Acrylic one of two compromises if you use an acrylic
Foldables lens. Either you make the incision larger or
make the optic smaller. 3.5 mm instead of 3.2
In addition to providing a very high or 3.0 mm is not a large difference but still,
refractive index, they are also the first choice with a clear corneal incision, Lindstrom thinks
lenses to use in higher risk cases such as the smaller the incision the safer it is as far as
patients with diabetic retinopathy (Figs. 8-17), sealing of the wound. And if you go to a smaller
chronic uveitis or any candidates for future optics then you get more symptoms of edge
vitrectomy with silicone oil. glare, particularly with younger patients who
Another advantage seems to be that have larger pupils.
acrylic lenses have a "tacky" surface. Edgardo Carreño, M.D., on the other
According to Tobias Neuhann, M.D., a hand, has developed a technique by which he
positive consequence of this tackiness is a implants the foldable acrylic Alcon AcrySof
mechanical adhesiveness between lens capsule lens 5.5 mm optic through a 2.75 mm incision.
and IOL, which, in turn, may lead to reduction Carreño's technique is described in this book
of secondary cataract (posterior capsule opaci- in Chapter 8.
fication).
A disadvantage of this tackiness, how-
ever, is that a multitude of small particles may THE FOLDABLE MONOFOCAL
stick to the lens surface and be pressed into the SILICONE IOL's
material with the implantation instruments,
where they remain forever, since they are not Second generation silicones are gain-
absorbed. For these reasons, injector implanta- ing in popularity because they are inert and do
tion or disposable implantation forceps are not give rise to inflammatory reactions. This
gaining increasing importance in handling these second generation silicone polymer is identi-
lenses (Fig. 82 B and C). fied as the PDMDPS.
209
There was a time when the silicone lenses OTHER MONOFOCAL LENSES
caused more inflammation or capsular fibroses
but the newer silicones do not do that at least The Hydrogel, Foldable Monofocal
based on the studies made by Lindstrom and
IOL
others. Many surgeons like silicone lenses
because they go through an incision smaller These lenses swell in water. Their me-
than other lenses thereby allowing a larger chanical properties are pliable rather than elas-
optic. The favorite lenses are those with 6.0 tic. Their properties are close to PMMA but
mm optic or larger. have a hydrophilic surface and may be folded
There are now two companies that have and inserted through small incisions.
a 6.3 mm optic silicone lens. One of them is
Staar and the other is Bausch & Lomb. Most The Foldable Toric Lens
other companies have 6 mm optic silicone
lenses. The most popular monofocal foldable
The STAAR toric IOL (AA4203T) com-
silicone lenses are Allergan's SI 40 NV and
bines recent toric technology with a flexible
Bausch & Lomb's LI 61 both of which have a
optic. The toric optic offers three cylindrical
6 mm optic. The Bausch & Lomb LI 63
powers (2.5 D, 3.5 D, 4.0 D) as well as
silicone lens has a 6.3 mm optic. Silicone
spherical (+14D to +26 D) values, and the plate
lenses have more elasticity. When the lens is
haptic possesses large fenestrations designed
implanted through an injector, it stretches. So
for lens fixation in the capsular bag.
it can go through a smaller incision. The
The results of this product are encourag-
Allergan SI 40 NV that has a 6.00 mm optic and
ing and appear to be stable. This implant
the Bausch & Lomb LI 63 with a 6.3 mm optic
extends the range of refractive lens surgery,
will go through a 3 mm incision with the proper
especially in cases where high ametropia is
injector nd cartridge made available by
combined with astigmatism.
the manufacturer for those spe cific lenses
(Fig. 132). This gives you a 6.3 mm or 6.0 mm
optic through a 3 mm incision. The open
Bitoric Lens But Not Foldable
modified C loop silicone lenses are better ac-
cepted by the surgeon than the plate haptic Although we here emphasize essentially
lenses because of less decentration. the trends towards the increasing use of fold-
able lenses, it is important to bring out the
development of the bitoric IOL although it is
The Importance of Cost
not foldable. This lens has been developed by
H.R. Koch and manufactured by Dr. Schmidt
An additional advantage of the silicone
Intraokularlinsen in Germany. The disk-
lenses is that because many companies make
shaped PMMA implant consists of two toric
them, they tend to be less expensive. And so,
lenses of the same power, both with one
if you are in an environment where cost is an
planar and one toric side, which counter-rotate
issue, which is just about anywhere in the
to produce a variable degree of astigmatic
world, the new second generation, high quality
power. The direction of the haptic defines the
silicone lenses on the average can be purchased
position of the cylindrical axis, and two addi-
for maybe half the price of foldable lenses of
tional lines in the optical periphery allow an
other materials.
210
exact intraocular positioning. The range of this ing the quality of life following cataract sur-
6 mm toric IOL is outstanding: spherical power gery. I. Howard Fine, M.D., and Richard
between -3.0 D and +30 D combined with Hoffman, Javitt and colleagues in the U.S.
cylindrical power from +1.0 D to +12.0 D. It is and Virgilio Centurion, M.D. in Brazil have
12.5 or 13.4 mm in diameter; done extensive clinical research on the perfor-
mance of this foldable multifocal lens and the
THE FOLDABLE benefits of high quality multifocal vision in
their patients. Having used different kinds
MULTIFOCAL IOL of multifocal IOLs in the past, Centurion is
familiar with the complications in their design.
The Array Multifocal Silicone This new multifocal lens, however, is a refrac-
Lens tive molded lens instead of a diffractive lens
(Figs. 130, 131). Its use is recommended by
This is one of the most important devel- Centurion for surgeons who are confident
opments in rehabilitation of sight and improv- with phacoemulsification and small incision
techniques.
Figure 130 (left): How the Multifocal Array In-

traocular Lens Works - Frontal View
The new multifocal Array intraocular lens

has five refractive zones on the anterior surface. Be-
tween each of them there is a narrow aspheric transition
zone. Zones 1, 3 and 5 (red) dominate for distance
vision, and zones 2 and 4 (yellow) dominate for near
vision. The optical mechanism of these zones is
shown in Fig. 131.
Figure 131 (right): How the Multifocal Array In-

traocular Lens Works - Cross Section View
This cross section shows how the steeper areas of

the lens (yellow zones 2 and 4) are of higher power and
focus on near objects (N). The flatter areas of the lens (red
zones 1, 3, and 5) are of lower power and focus far objects
(F). Light rays from a distant object (O) which refract
through zones 2 and 4 (yellow rays) focus at (N). Light
rays from a distant object which refract through zones 1, 3
and 5 (red rays) focus at (F). Zones 2 and 4 have smooth
transitions to adjacent zones, and focus light at intermedi-
ate distances. These aspheric transitions between the
optical zones greatly reduce the halo effect which was
sometimes bothersome using older diffractive designs.
211
How Does the Array Foldable Multi- Quality of Vision with Array Multi-
focal Lens Work? focal
The lens is manufactured by Allergan Refractive multifocal IOLs, such as the

Medical Optics. It has a foldable silicone optic Array, have been found to be superior to
that is 6.0 mm in diameter with haptics made of diffractive multifocal IOLs by demonstrating
polymethylmethacrylate and a haptic diameter better contrast sensitivity and less glare dis-
of 13 mm (Fig. 130). The lens can be inserted ability. The Array does produce a small
through a clear corneal or scleral tunnel inci- amount of contrast sensitivity loss equivalent
sion that is 2.8 mm wide, using the Unfolder to the loss of 1 line of visual acuity at the 11%
injector system manufactured by AMO contrast level using Regan contrast sensitivity
(Allergan) (Fig. 82 A). charts. This loss of contrast sensitivity at low
There are five zones on the anterior levels is present only when the Array is
surface. Between each of them there is a placed monocularly. This has not been dem-
narrow aspheric transition zone. The 5 domi- onstrated with bilateral placement and bin-
nant zones provide the following: 1) a clear ocular testing. In addition to relatively nor-
image for distance (2 zones); 2) one zone for mal contrast sensitivity, good random-dot ste-
intermediate distance, and 3) two zones for reopsis and less distance and near aniseikonia
near. The Allergan Array Lens differs from were present in patients with bilaterally
the older diffractive lens designs not only in placed implants as compared to those with
having classical optics for the definitive unilateral implants.
zones, but in having aspheric transition zones In a study by Javitt and colleagues,
which, according to Centurion, provide the 41% of bilateral Array subjects were found
patient with a smooth transition between the never to require spectacles, as compared to
images for distance, intermediate, and near 11.7% of monofocal controls. Overall, sub-
vision, greatly reducing the halo effect which jects with bilateral Array IOLs reported better
was sometimes so bothersome with older overall vision, less limitation in visual func-
designs. Even those patients who may com- tion, and less use of spectacles than did
plain of some halos after surgery seldom monofocal controls.
report them 2 or 3 months later. Studies in different parts of the world
Fine and Hoffman describe the lens as report that more than 85% of patients have
having an aspherical component and thus 20/40 or better vision without correction after
each zone repeats the entire refractive se- implantation with this lens. All of the 456
quence corresponding to distance, intermedi- patients in the US Clinical Study have J3 or
ate, and near foci. This results in vision over better, and more than 60% are J2 or J1
a range of distances. The lens uses 100% of without correction. About half are 20/20
the incoming available light and is weighted without correction.
for optimum light distribution. With typical
pupil sizes, approximately half of the light is Patient Selection and Results
distributed for distance, one-third for near
vision, and the remainder for intermediate Fine and Hoffman emphasize that the
vision. advantages of astigmatically neutral clear
212
corneal cataract surgery have allowed for the Holladay II formula and the Holladay II
increased utilization of multifocal technology back-calculation to yield accurate and consis-
in both cataract and clear lens replacement tent results.
surgery. Careful attention to patient selec-
tion, preoperative lens power calculations, in Specific Guidelines for Implanting
addition to meticulous surgical technique, the Array Lens
will allow surgeons to offer multifocal tech-
nology to their patients with great success. Fine and Hoffman have used the Array
Researchers working with this lens multifocal IOL over the last 2.5 years exten-
have the clinical impression that depth of sively, in approximately 30% of their cataract
focus and quality of vision are improved if patients and in the majority of their clear lens
the surgeon does a bilateral implantation replacement refractive surgery patients. As a
and implants the second eye within 4 weeks result of their experience, they have devel-
of the first implantation. The results seem to oped specific guidelines with respect to the
be improved if there is a very short interval selection of candidates and surgical strategies
between the first and second eye. (If the that enhance outcomes with this IOL.
cataract merits removal in both eyes. This is AMO recommends using the Array
usually the case when modern small incision multifocal IOL for bilateral cataract patients
cataract surgery is performed. - Editor). whose surgery is uncomplicated and whose
Of the 350 multifocal lens implanta- personality is such that they are not likely
tions Centurion has done, about half were to fixate on the presence of minor visual
bilateral, and half were monocular. The mo- aberrations such as halos around lights. Ob-
nocular implantations involved traumatic or viously, a broad range of patients would be
inflammatory cataracts rather than senile acceptable candidates. Relative or absolute
cataracts . He has not yet used multifocal contraindications include the presence of
IOLs in patients with congenital cataracts, but ocular pathological processes (other than
they work well for monocular implantation cataracts) that may degrade image formation
when a patient has one normal eye. Gener- or may be associated with less than ad-
ally patients do not depend upon glasses equate visual function postoperatively de-
much for near vision after the implantation. spite visual improvement after surgery.
With bilateral implantation, the quality of Contraindications are age-related macular de-
vision and quality of life of patients improve generation, uncontrolled diabetes or diabetic
considerably. Sometimes they only need retinopathy, uncontrolled glaucoma, recur-
glasses to drive at night and to read very rent inflammatory eye disease, retinal detach-
small print. ment risk, and corneal disease or previous
Fine and Hoffman point out that the refractive surgery in the form of radial kerato-
most important assessment for successful tomy, photorefractive keratectomy, or laser-
multifocal lens use, other than patient selec- assisted in situ keratomileusis.
tion, involves precise preoperative measure- Fine and Hoffman also avoid the use of
ments of axial length in addition to accurate these lenses in patients who complain exces-
lens power calculations. They have found sively, are highly introspective and fussy, or
applanation techniques in combination with obsessed over body image and symptoms.
213
They are conservative when evaluating pa- compare the vision between the two eyes and
tients with occupations that involve frequent refer to the differences existing, even though
night driving or that put high demands on they may have good visual acuity in both. 2)
vision and near work (e.g., engineers and Yes, the multifocal IOL does fullfil its optical
architects). Such patients need to demon- purpose both for distance and near. Although
strate a strong desire for relative spectable it does not completely prevent the wearing of
independence in order to be considered for spectacles, it does diminish the dependency
Array implantation. on glasses. Clarify this to the patient preop-
In their practice, they have reduced eratively. 3) Select the patient according to
patient selection to a very rapid process. his/her visual needs. 4) Do a very precise
Once they determine that someone is a candi- preoperative biometry; 5) Perfect your cata-
date for either cataract extraction or clear lens ract surgery to end up with less than 1.00 D
replacement, they ask the patient two ques- astigmatism.
tions: First, "If we could put an implant in
your eye that would allow you to see both Special Circumstances for Array Im-
distance and near without eyeglasses, under plantation
most circumstances, would that be an advan-
tage?" Approximately 50% of their patients There are special circumstances in
say no directly or indirectly. Negative re- which implantation of a multifocal IOL
sponses may include, "I don't mind wearing should be strongly considered. Alzheimer's
glasses," "My grandchildren wouldn't recog- patients frequently lose or misplace their
nize me without glasses," "I look terrible spectacles, and thus they might benefit from
without glasses," or "I've worn glasses all the full range of view that a multifocal IOL
mylife." These patients receive monofocal provides without spectacles. Patients with
IOls. Of the 50% who say it would be an arthritis of the neck or other conditions with
advantage, they ask a second question: "If limited range of motion of the neck may
the lens is associated with halos around lights benefit from a multifocal IOL rather than
at night, would its placement still be an multifocal spectacles, which require changes
advantage?" Approximately 60% of this in head position. Patients with a monocular
group of patients say that they do not think cataract who have successfully worn
they would be bothered by these symptoms, monovision contact lenses should be consid-
and they receive a multifocal IOL. ered possible candidates for monocular im-
Centurion also emphasizes that these plantation. The same is true for certain
lenses should not be used in patients with a professionals such as photographers who
basic astigmatism of more than 1.50 diopters. want to alternate focusing through the camera
Prof. Luis Fernandez Vega in Spain and adjusting imaging parameters on the
recommends a series of important guidelines camera without spectacles. In these patients,
in order to be successful with advanced tech- the focusing eye could have a monofocal IOL
nology multifocals: 1) Do only bilateral and the nondominant eye a multifocal IOL.
multifocal implantations in adults. Do not Fine and Hoffman almost always use the
place a monofocal IOL in one eye and a Array for traumatic cataracts in young adults
multifocal in the other. Otherwise, patients in order to facilitate binocularity at near,
214
especially if the fellow eye has no refractive geographical and cultural regions. They have
error or is corrected by contact lenses. provided HIGHLIGHTS with the pearls of
the methods that lead them to successful
Need for Spectacle Wear PostOp implantation. They are: Jack Dodick, M.D.,
from New York, I. Howard Fine, M.D.,
Prior to implanting an Array lens, they from Oregon, and Richard Lindstrom,
inform all candidates of the lens's statistics to M.D., from Minnesotta, three different areas
ensure that they understand that spectacle of the United States. And Edgardo Carreño,
independence is not guaranteed. Approxi- M.D., from South America (Chile).
mately 41% of patients implanted with bilat- First, you will find the present status of
eral Array IOLs will never need to wear the preferred methods of lens implantation,
eyeglasses, 50% wear glasses on a limited forceps vs injectors, their pros and cons.
basis (such as driving at night or during Second, the techniques of implantation of 1)
prolonged reading), 12% will always need to the Array Multifocal Foldable Lens
wear glasses for near work, and approxi- (Allergan). 2) The acrylic monofocal lens, in
mately 8% will need to wear spectacles on a this case the AcrySof Lens (Alcon). 3) The
full-time basis for distance and near correc- silicone monofocal foldable lens (STAAR).
tion.
PREFERRED METHODS OF IOL
Halos at Night and Glare IMPLANTATION
15% of patients were found to have

difficulty with halos at night, and 11% had
Use of Forceps vs Injectors
difficulty with glare, as compared to 6% and
1%, respectively, in monofocal patients. Advantages and Disadvantages
SURGICAL PRINCIPLES AND GUIDE- Many surgeons like to use forceps to
LINES FOR IOL IMPLANTATION implant the foldable lens, others use injectors.
Lindstrom reminds us that the original in-
Just as there are a large number of struments available for foldable lenses were
methods to disassemble the nucleus there is a all forceps. Consequently, those surgeons
wide variety of techniques to implant the that used foldable lenses early on got used to
IOL's, particularly the foldable lenses. What the forceps insertion method (Figs. 133,
counts is the results and the feasibility to 134). But there is a disadvantage to the for-
achieve a successful implantation. ceps approach. It adds some mass to the
We present here the surgical principles amount of material you are putting into the
and guidelines for implantation of the most eye (Fig. 132) thereby requiring a slightly
commonly used types of foldable lenses. We larger incision. Another disadvantage of us-
have chosen the principles followed by ing forceps is that you may touch the lens to
highly respected, skilled phaco surgeons who the conjuntiva or sclera before placing it into
do a great deal of teaching in addition to the incision. Several studies have shown that
having a large, solid practice in different the lens picks up bacteria and mucus and
215
other debris from the surface of the eye when Cartridge Injector Systems
you use the typical cross action forceps (Fig.
133). This may increase the risk of post- Fine, Lewis and Hoffman believe that
operative inflammation or infection. For there are many perceived advantages of im-
these reasons, Lindstrom now prefers the planting foldable IOLs with injector systems,
injectors, because you take a sterile lens out as compared with folding forceps. These ad-
of a sterile package, put it into a sterile vantages include the possibility of greater ste-
injector and place the lens directly inside the rility, ease of folding and insertion, and im-
eye. With the injector you also have less plantation through smaller incisions as empha-
bulk, thereby requiring a slightly smaller inci- sized by Lindstrom (Fig. 132).
sion (Fig. 132-A). Greater sterility with injector systems is
The reason a good number of surgeons believed to occur because the IOL is brought
do not like the injectors is: 1) they got used directly from its sterile package to its sterile
to folding with forceps, (Figs. 132-B, 133) cartridge and inserted into the capsular bag
which are convenient and they are used to without ever touching the external surface of
them. 2) All the injectors have a small failure the eye, as is the case for lenses in folding
rate. It is very annoying when you load a forceps. Although this advantage would sug-
lens into the injector and then after placing it gest a lower rate of endophthalmitis with injec-
inside the eye, the optic is torn or one of the tor systems, recent clinical studies have shown
lens loops is bent or damaged. Some sur- no significantly different rate of bacterial con-
geons do not use injectors because they do tamination of the anterior chamber after im-
not like the lens failures that occassionally plantation of silicone lenses with a forceps
occur with them. The newer injectors of the versus an injector.
better companies, however, are performing Perhaps the most appealing advantage of
very well now. injector systems is that the lens can be loaded
by a nurse or technician without the use of an
New Trends for Folding and operating microscope, further streamlining the
Insertion of IOL's procedure. In addition, inserting foldable lenses
with a cartridge device is generally felt to be
The majority of lenses are still folded easier than insertion with forceps.
and inserted with forceps (Figs. 132-B, 133). There are no irregular surfaces as may
Nevertheless, there is a definite trend toward occur between the surface of the forceps and
the development of separate instruments for the lens. The IOL is lodged inside the cartridge
folding and inserting IOL’s rather than using and injector system.
the insertion device to fold the IOL. The Allergan's foldable three piece silicone
combination of instruments designed by the lens (monofocal or multifocal - AMO Array)
manufacturers to facilitate folding and inser- with PMMA haptics may be implanted with
tion is known as cartridge injector systems AMO's Unfolder Phacoflex injector system.
which are then used to implant the IOL. Allergan's acrylic foldable IOL (Sensar and
Clariflex lenses) may be implanted with a new
216
Figure 132: Insertion of Foldable IOL - Forceps vs Injector - Comparative Incision Size
The insertion of a foldable intraocular lens may well be done either with forceps or with injectors.
There is a difference between the two regarding the size and architecture of the incision.
When injectors are used (A) we may maintain the small size primary incision of 2.8 mm (red arrow).
On the contrary, when we use forceps for the insertion of the IOL (B), the diamond blade needs to be
extended fully (yellow arrow) in order to enlarge the incision from 2.8 mm to 3.0 mm to accommodate the
silicone IOL insertion and 3.4 mm with acrylic IOL’s . This is due to the added bulk relation of lens and
forceps. With the injector, there is no additional bulk.
injector now available and known as the 3.2 to 3.5 mm incisions for 5.5 mm optics,
Unfolder Sapphire, as described by Centu- when implanted with forceps is now packaged
rion (Fig. 82-A). These injectors are rein a wagon wheel dispenser. The easiest fold-
sterelizable (as are the forceps, of course). ing instrument to use for these lenses is the
Alcon’s popular 5.5 mm AcrySof IOL Rhein folder, as recommended by Fine be-
may be implanted with one of its injectors such cause the tips have been extended to make it
as the Monarch (Fig. 82) or with a standard easier to remove the lens from its wagon wheel
cartridge through a 3.4 mm incision. Carreño packaging. The forceps can be turned with the
reports injecting this lens through a 2.8 mm tips down in the nondominant hand. The tips
incision (Fig. 132). Many surgeons use Alcon’s go into the slots on both sides of the optics, so
Acrypack (Fig. 82) when implanting the that the lens can be picked up and placed on a
AcrySof lenses. The Acrypack serves to first drop of viscoelastic. The forceps are then
fold the IOL. The surgeon then uses a forceps turned so that the tabs are down. The lens is
(Fig. 81) to implant the already folded IOL. grasped and folded, and then the insertion
The Alcon AcrySof lens, which requires device is used to insert the lens using the
3.5 to 4.0 mm incisions for 6.0 mm optics and surgeon’s dominant hand.
217
Guidelines for Insertion of Dif- nately degrade visual acuity in Array pa-
tients. Because of these phenomena, patients
ferent Types of Lenses implanted with Array lenses will require YAG
laser posterior capsulotomies earlier than will
Surgical Technique with Array Lens patients with monofocal IOLs.
Minimally invasive surgery is key.
Fine and Hoffman consider it very im- Techniques that utilize effective phacoemulsi-
portant that incision construction be appropri- fication powers of 10% or less are highly
ate with respect to size and location because the advantageous and can best be achieved with
multifocal Array works best when the final power modulations (burst mode or two pulses
postoperative refraction has less than 1 D of per second) rather than continuous phacoemul-
astigmatism. They favor a clear corneal inci- sification modes (Figs. 86-89, Chapter 8). The
sion at the temporal periphery that is 3 mm or Management of Complications with the Array
less in width and 2 mm long (Fig. 91). Each Lens is discussed in Chapter 11 (Complica-
surgeon should be aware of his or her usual tions).
amount of surgically induced astigmatism by
vector analysis. The surgeon must also con- Carreño's Technique of Acrylic
sider the best meridian in the cornea to place the IOL Implantation Through a
incision considering the existing preoperative
astigmatism in order to end up with minimum 2.75 mm Incision
postop astigmatism. We discuss this subject
under "Refractive Cataract Surgery" in Chap- Because it is generally considered that
ter 12 (Complex Cases). acrylic lenses require a somewhat larger inci-
In preparation for phacoemulsifiction, sion (3.4 mm) to be introduced into the anterior
the capsulorhexis must be round (Figs. 44, 45) chamber without harming the lips of the wound,
and its size should be sufficient so that there is we present Carreño's technique by which he
a small margin of anterior capsule overlapping implants the AcrySof lens (acrylic, Alcon)
the optic circumferentially. This is important through a 2.75 mm incision. This is one stage
in order to guarantee in-the-bag placement of of the Phaco Sub 3 method which he advocates.
the IOL and prevent anteroposterior alter- Carreño from Chile, is a highly skilled cata-
ations in location that would affect the final ract surgeon.
refractive status. Hydrodelineation and cor- Carreño emphasizes that in order to
tical-cleaving hydrodissection are crucial in introduce the acrylic intraocular lens through
all patients because they facilitatelens disas- very small incisions, as is the case in Phaco Sub
sembly and complete cortical cleanup. 3, using adequate technique and equipment is
Taking the time and care to perform a imperative. Otherwise, the implantation could
careful and effective cortical cleanup as shown cause severe trauma to the corneal margins of
in Figs. 127 and 128, without being aggressive, the wound and the endothelium as well as
may reduce the incidence of posterior cap- leading to an undesired increase in the size of
sule opacification, the presence of which, the incision. Before implantation, a generous
even in very small amounts, will inordi- amount of viscoelastic should be injected into
the capsular bag and the anterior chamber.
218
Foldable Acrylic Lens of Choice of the AcrySof MA30BA through a 2.75mm

corneal incision without complications.
Carreño's experience is based on the use Before completing the insertion of the
of Alcon's AcrySof lens model MA30BA optic, which should be very controlled so as not
(5.5mm optic, total length 12.5mm, PMMA to penetrate abruptly into the anterior chamber
haptics). and risking the integrity of the posterior cap-
sule, the surgeon puts the haptic under the edge
Implantation Technique of the capsulorhexis so it can be placed in the
capsular bag.
The lens is folded with forceps (paddle), placed Once the optic is in the anterior chamber,
parallel to the haptics (longitudinal implanta- the Buratto forceps are rotated 90 degrees in
tion technique). The implantation forceps this position, and they are released so the lens
(Buratto) are used to grasp the lens so that the unfolds (Fig. 133). Due to the thin incision, the
haptics are perfectly parallel to the fold, going lens tends to be trapped in the claws of the
through the center line of the optic, and reach- forceps. To release it, the surgeon pushes gen-
ing the edge. tly downward with the spatula. Now the for-
Correctly grasping the Buratto forceps may be withdrawn, and the lens continues
ceps is critical to penetration with the to gradually unfold (Fig. 133). The second
AcrySof through a 2.75mm incision. If the haptic is immediately grasped with Kelman-
lens fold is not completely symmetrically, an McPherson forceps to introduce it into the
edge is produced that impedes its introduction. anterior chamber. Aided by the spatula, using a
If the jaws of the forceps are at an angle to the bimanual maneuver, the implantation is com-
lens fold, a separation is created between the pleted by placing the lens optic first and then
faces, which may make the lens impossible to the second haptic into the capsular bag (Fig.
introduce through a small incision. 134).
The surgeon proceeds with the Buratto Implantation of the AcrySof MA30BA
forceps placed in such a way that the lens fold lens through a 2.75mm corneal incision is not
stays on the left. It is very important that the easy, but Carreño emphasizes that if the
first haptic enters the anterior chamber before described technique is followed step by step,
the optic. Otherwise, the lens may be damaged the surgeon can perform it without injuring
if the haptic is trapped with the optic inside the corneal tissues. However, when dealing with
corneal tunnel. Then the surgeon inserts the AcrySof MA30BA lenses stronger than 24
optic by exerting pressure and using slight diopters, Dr. Carreño prefers to use a slightly
lateral movements along the corneal tunnel. larger incision (3.0mm) because the greater
The spatula, introduced through the lateral thickness of these lenses may make them diffi-
paracentesis, exerts firm and constant cult or impossible to implant through a 2.75mm
counterpressure. (In order to exert adequate incision. (Editor's Note: as pointed out at the
counterpressure, the lateral paracentesis must beginning when describing the acrylic IOL's
be placed 60 degrees from the main incision.) implantation, most expert surgeons find it very
This pressure and counterpressure maneuver is difficult or unfeasible to implant an acrylic lens
another key aspect of successful implantation through a 3.0 mm incision using forceps with-
out harming the lips of the wound - Fig. 132).
219
Once the implantation is complete, the could conceivably interfere with visual acu-
viscoelastic is carefully removed from the an- ity.
terior chamber and from the capsular bag. The A second measure taken by Dodick to
surgeon must take care not to leave viscoelastic facilitate this lens' entry into the wound after
material behind the intraocular lens. (It is nec- folding and holding it with forceps is to pinch
essary to push the implant optic gently back- the lead edge of the lens with a second
ward with the cannula to force the evacuation forceps, to make the "nose" conform into a
of the viscoelastic through the capsulorhexis bullet or missile shape. This facilitates entry
opening.) into the eye. Once the nose enters into the
Finally, balanced saline solution is in- eye, the rest of the lens follows with great
jected through the lateral paracentesis to en- facility (Fig. 133).
sure that the incision is perfectly self-sealing. Dodick uses folding and insertion
forceps to insert the lens. They must be very
Dodick's AcrySof's Implantation fine folding forceps so as to add very little
bulk to the combination of lens and forceps
Technique that have to enter through the small wound
(Fig. 132).
Special Features About
AcrySof´s Implantation Dodick's Three Stage Implanta-
tion
When handling the lens, it is important
to keep in mind that especially in high powers Dodick likes to divide the implantation
up to 30 diopters, this is a thick lens. This of the lens into three stages once it is in the
makes folding more difficult. Jack Dodick, anterior chamber. First, when the lead haptic is
M.D., has found that pre-warming the lens in the capsular bag, the lens is allowed to
dramatically facilitates the ease of the fold. unfold. Stage two is the implantation only of
This is done at his institution (Manhattan Eye the optic. Stage three, once the optic is im-
and Ear Hospital) by placing it in a warm planted the surgeon inserts the superior haptic
environment such as on top of a sterilizer that by rotating it in with the Lester hook or placing
has an ambient temperature between 100 and it with a Kelman-McPherson forceps. Dodick
105 degrees. This seems to soften the material considers that a common mistake when im-
and facilitates the gentle folding of the lens, planting any soft foldable IOL, is to implant
making it much easier to implant especially it in only two stages. Once the inferior haptic is
for high diopter lenses which are more diffi- placed into the capsular bag, some surgeons
cult to fold. proceed immediately to try to place the optic
It is also important to keep in mind that and the superior haptic in one second stage. His
if the surgeon performs rapid folding of a experience has taught him that implantation
cold lens, this may leave striae in the lens that becomes simpler and more controlled by divid-
ing it into the three stages described.
220
Fig. 133 (right): Foldable Intraocular Lens

Implantation Through a Corneal Incision
Using Forceps - Final Unfolded Position
The lens holding forceps are slowly

opened and the lens is gently unfolded (ar-
rows) inside the capsular bag as shown. Widely
used cross-action forceps presented in this
figure (Buratto’s forceps not shown).
Figure 134 (left): Foldable Intraocular Lens

Implantation Through a Corneal Incision Using
Forceps - Final Unfolded Position
This view shows the final unfolded position

of the foldable intraocular lens and its haptics within
the capsular bag. Please observe the final appear-
ance of the corneal incision (C).
221
Implantation Technique for tridge is then closed and placed in the injec-
tor. In order not to enlarge the incision,
Silicone Foldable IOL's Using Carreño considers that it is essential to intro-
Cartridge-Injector System duce the tip of the cartridge a few millimeters
into the anterior chamber, as its thickness in-
Lindstrom prefers to implant these lenses creases towards the back (Fig. 132-A). With
with a cartridge injector system. Since the the injector in place, the lens is advanced through
second generation silicone lenses are very flex- the cartridge. Once it begins to unfold in the
ible, they stretch when implanted through a anterior chamber, it is guided with the first
cartridge-injector system, providing the sur- haptic under the edge of the capsulorhexis and
geon with the advantage of inserting the lens placed in the capsular bag. Once it is unfolded,
through a smaller incision (Fig. 132-A). the empty cartridge is removed. Using a spatula
Carreño's technique for implantation of introduced through the lateral paracentesis, the
silicone foldable lenses starts with the injection second haptic is gently pushed downward and
of viscoelastic in the anterior chamber, the backward to be placed in the capsular bag as
capsular bag and into the cartridge. Once vis- well.
coelastic has been injected into the cartridge, For you to have a mental picture of the
the lens is loaded carefully so that both sides are concept of foldable lens implantation, we refer
inserted into the lateral channels. The car- you to Fig. 135.
Figure 135: Concept of Foldable Intraocular Lens Implantation
This cross section view shows the movement of the foldable intraocular lens during insertion. Folding forceps
removed for clarity. (1) Folded lens outside the eye. (2) Folded lens passing through small incision. (3) Folded lens
placed posteriorly into the capsular bag through anterior capsule opening and then rotated 90 degrees. (4) Lens slowly
unfolded in the bag. (5) Final unfolded position of lens within the capsular bag.
222
TESTING THE WOUND FOR BIBLIOGRAPHY

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225
226
C h a p t e r 10: Focusing Phaco Techniques on the Hardness of the Nucleus
FOCUSING PHACO TECHNIQUES ON

THE HARDNESS OF THE NUCLEUS
MULTIPLICITY OF surgeon has developed a technique with which

TECHNIQUES he/she feels comfortable, that works best for
him/her and that fills the essential criteria of
Visiting prestigious eye centers and not damaging the posterior capsule, the
through personal communications with a iris and/or the corneal endothelium.
number of expert consultants throughout the
world, it is interesting to observe how many DIFFERENT NUCLEUS
different techniques and modifications of the
basic phacoemulsification procedures have CONSISTENCY -
been developed. They all work well, if used TECHNIQUES OF CHOICE
in skilled hands. In addition, watching videos
of phaco procedures performed by outstand- In Chapter 9, in discussing the Manage-
ing cataract surgeons from different regions, ment of Disassembling the Nucleus, we pre-
cultures, races and economic status of their sented the surgical principles of the major,
countries, surgeons who perform a thou- late-breaking techniques mostly used now,
sand or more cataract operations a year, showing how they work and how they
we find them using techniques that are quite are performed. These can be classified as:
different from each other. Some use low 1) Divide and Conquer (D & C) techniques
vacuum, others use high vacuum, one uses a and 2) the chopping procedures based on
60º phaco tip while the next one uses a 0 (zero) modifications of the Phaco Chop of Nagahara
degree tip for the same type of cataract. One (Japan). Most of the now extensively used
would do a supracapsular while the other techniques that we present in Chapter 9 have
emphasizes the need to do all cataracts using been developed by pioneers and distinguished
an endocapsular technique. Some are crack- surgeons from North America (Gimbel from
ing, some are chopping. Canada; and Paul Koch, MacKool, Dodick,
and I. Howard Fine, from the U.S.). Many
The Essential Criteria for Success other prestigious surgeons from all continents
have made substantial contributions to render
The revealing experience is that the great this step of the operation more effective and
majority of their cases have very good results less risky.
and the operated eyes look very well. What Now let us try to get into the crucial
we learn from this experience is that each subject that most ophthalmic surgeons want
229
to know: What are the procedures of choice has performed many thousand phacoemulsi-
when we need to remove nuclei of different fication procedures. They are highly success-
consistencies? ful and their concepts are solid. What we
The answer is that this is not a math- present in this Chapter is how each one of
ematical formula whereupon the techniques these five (5) prestigious surgeons perform
can be categorized based exclusively on how phaco, with emphasis on nucleus removal
hard a nucleus we are going to operate. But the when faced with the five types of cataracts that
subject is sufficiently clear to allow us to we are all familiar with, based on different
present highly useful guidelines, based on the nucleus consistency.
extensive experience of highly recognized sur- You may observe that each one of them
geons. This is what we are providing you here. has a different procedure of choice. I will
In Chapter 9, you can find the guidelines confirm that they are all successful. This
and surgical principles of the techniques most experience may serve the ophthalmic surgeon
surgeons use now and what consistency of as guidelines within which to select the tech-
cataracts do better in general with the major nique he/she feels more comfortable with and
techniques such as D & C operations, the Stop that may serve the patients best. A great deal
and Chop, the Crater Chop, the Null-Phaco depends on where you practice, what equip-
Chop and the Choo-Choo Chop and Flip. A ment and facilities you have and the type of
variety of other procedures not described in cataracts you mostly do.
Chapter 9 are modifications of the fundamen-
tal techniques and carry the name of the sur- LINDSTROM'S PROCEDURES
geon who sponsors the procedure.
OF CHOICE
Representative Experts
1) For Soft and Medium Density (stan-
dard) Cataract: the supracapsular iris-plane
Confronting Nuclei of Different procedure (Figs. 136-139).
Hardness The supracapsular operation is popu-
larly known as the "tilt and tumble" technique.
Now let us focus more specifically on It is performed on the iris plane and is not
the procedures of choice of some highly repre- endocapsular.
sentative experts from different regions of the 2) Posterior capsular cataract or the
world regarding the operation they use when cataract in a young patient with relatively
confronting nuclei of different consisten- soft nucleus without much ultrasound power
cies. These surgeons are: Richard needed: the supracapsular iris plane technique.
Lindstrom, M.D., from the U.S.; Lucio 3) For Very Hard Nuclei: the Stop and
Buratto, M.D., from Europe (Italy); Okihiro Chop (an endocapsular technique) described
Nishi, M.D., from Japan, Edgardo in Figs. 107-111).
Carreño, M.D., (Chile) and Virgilio Lindstrom considers that a clear cor-
Centurion, M.D., (Brazil) the latter two rep- nea incision is not indicated when doing the
resenting different regions and cultures of stop and chop in very hard nuclei. He uses a
South America. Each one of these surgeons corneo-scleral incision and larger amounts of
230
viscoelastic. More ultrasound energy is needed geon to bring a part of the nucleus or the whole
to disassemble these very hard nuclei with nucleus in front of the anterior capsular ridge
more danger of wound burn and endothelial (Figs. 136-137).
damage. The sclera is more resistant to the In addition, Lindstrom considers that
heating up of the wound than is the cornea. In with the endocapsular techniques the number
addition, by moving back to the sclera you are of posterior capsular tears with or without
farther away from the corneal endothelium vitreous loss is higher for most surgeons be-
with less risk of damage, particularly in pa- cause they are working inside the capsular
tients with borderline corneas. bag. With a supracapsular technique the
nucleus is up closer to the anterior chamber so
Advantages of the Supracapsular the incidence of posterior capsule tears is re-
duced. It is also a very easy technique to learn.
Lindstrom notes that supracapsular For a beginning surgeon the endocapsular tech-
techniques enjoy increasing popularity. A niques are more difficult to teach and need a
slightly larger anterior capsulorhexis (5.5 to longer learning curve and more time to per-
6.0 mm), is necessary. This allows the sur- form (see Chapters 7 and 9).
Figure 136: Lindstrom’s Supracapsular

(“Tilt and Tumble”) Technique
Following clear corneal temporal

incision (T), superior limbal counterpunc-
ture for secondary instrumentation (S), and
5.5 or 6.0 mm circular capsulorhexis (C), a
Pearce hydrodissection cannula (H) is in-
troduced between the nucleus (N) and cap-
sule. Slow continuous hydrodissection is
performed with BSS (blue arrow) beneath
the anterior capsular rim until a fluid wave
(W) is seen. Irrigation is continued until
the nucleus tilts up on one side (red arrow),
out of the capsular bag. This is the “tilt”
portion of the “Tilt and Tumble Phaco Tech-
nique.” Viscoelastic is introduced beneath
the nucleus and into the chamber (not
shown).
231
Figure 137: Phacoemulsification of the First

Half of the Nucleus - Lindstrom’s Supra-
capsular (“Tilt and Tumble”)
With the nucleus (N) tilted toward the

main incision, the phaco probe (P) emulsifies
and removes one half of the nucleus using an
outside-in approach. During this removal, the
nucleus is supported by a second instrument,
such as a nucleus rotator (R) introduced
through the secondary counterpuncture (S).
Disadvantages of the Supracapsular bevel anterior, bevel to the side, bevel down
or bevel close to you. There is a little spray
The disadvantage of the supracapsular that comes out of the phaco tip when you are
technique is that you are working much closer doing the surgery. We want that spray to go
to the corneal endothelium. The surgeon must away from the corneal endothelium so it is
be very careful in his technique and should not important to place the bevel to the side or the
perform it on a very hard nucleus. With the bevel down technique in using supracapsular
modern technology available in the phaco technique.
machines (Chapter 8) and the adequate use of
viscoelastic we have another margin of secu- Contraindications of Supracapsular
rity to protect the endothelium.
Another measure that helps a good deal Lindstrom performs the supracapsular
to protect the endothelium is to do the pha- technique in all cataracts except: 1) Patients
coemulsification with the bevel of the tip down who have cornea guttata, Fuchs' dystrophy or
or to the side. You have the alternative of low endothelial counts. 2) Very hard cata-
placing the phaco instrument in the eye with the racts.
232
HIGHLIGHTS OF THE prior to tumbling the nucleus in a supracapsular

SUPRACAPSULAR IRIS PLANE approach. Rather than completing the tum-
bling of the entire nucleus, Lindstrom sup-
TECHNIQUE
ports the nucleus in the plane of the iris and
anterior capsular leaflet and then emulsifies
The main steps are illustrated and ex-
half of it (Figs. 136-137). With a much smaller
plained in Figs. 136-139. The surgeon needs
nuclear remnant, he tumbles the remaining one
to become quite adept at hydrodissecting until
half upside down and completes the emulsifi-
the nucleus is lifted, which is the first step
cation (Figs. 138-139).
Figure 138 (left): Tumbling the Remaining

Half of the Nucleus - Lindstrom’s Supra-
capsular (“Tilt and Tumble”)
One half of the nucleus has been re-

moved, the remaining half is tumbled upside
down (arrow) with the secondary instrument
(R). This brings the nucleus into a position to
be attacked from the opposite pole with the
phaco probe (P).
Figure 139 (right): Phacoemulsification

of the Second Half of the Nucleus -
Lindstrom’s Supracapsular (“Tilt and
Tumble”)
The remaining nuclear half is

emulsified and removed with the phaco
from an outside edge-in direction. Again,
the nucleus is supported in the iris plane
by the secondary instrument (R) during
phacoemulsification.
233
In this operation, it is important to make 3) For hard nucleus (+ + + and above)

a slightly larger anterior CCC (5.5 to 6.0 mm). Centurion's favorite technique is the Phaco
If a small anterior capsulorhexis is done, the Quick Chop, as developed by Pfeifer. The
hydrodissection step where the nucleus is tilted parameters he prefers are based on the differ-
can be dangerous and rupture the posterior ent machines that he uses and are presented.
capsule during hydrodissection could be pos- The main difference between this tech-
sible. If a small anterior capsulectomy is nique and other phaco chop procedures are:
inadvertently created, Lindstrom favors con- 1) The placement of the chopper is in the
verting to an endocapsular phacoemulsifica- center of the lens, and not under the anterior
tion technique or enlarging the capsulorhexis. capsule. 2) The movement of the chopper is
If he is unable to tilt the nucleus with either vertical, instead of horizontal as in other
hydrodissection or manual technique, he will phaco chop techniques.
also convert to an endocapsular approach.
Occasionally the entire nucleus will Highlights of Other Steps in
subluxate into the anterior chamber. In this Centurion's Technique
setting, if the cornea is healthy, the anterior
chamber roomy, and the nucleus soft, he will Anesthesia: For routine cases he recom-
often complete the phacoemulsification in the mends topical anesthesia. Peribulbar is used
anterior chamber keeping the nucleus away for special situations, such as subluxated lens,
from the corneal endothelium. The nucleus white cataract, combined cataract- glaucoma
can also be pushed back inferiorly over the surgery and so on.
capsular bag to allow the iris plane tilt and The Ancillary Incision: Usually, he
tumble technique to be completed. sits at the head of the patient, performing
first the ancillary incision and injecting a
CENTURION'S TECHNIQUES viscoelastic substance. This incision is
RELATED TO NUCLEUS placed 80º away from the primary incision,
CONSISTENCY which is usually located between 10 and 11
o’clock (Fig. 41).
1) For soft nucleus (+) Centurion's The Primary Incision: Is a one step
procedure of choice is the flip and chip (Fine incision between 10 and 11 o'clock per-
- see Figs. 122-126). formed with the 3.0 mm clear path (Asico)
2) For intermediate nucleus (++) (those diamond knife (Figs. 41, 42).
not hard enough to be chopped), Centurion Capsulorhexis: He refills the anterior
performs the classical divide and conquer chamber with more viscoelastic and per-
(Figs. 56, 67, 103, 104, 206 below). forms a 5.5 mm capsulorhexis, with a cysto-
Because Centurion does not perform tome.
hydrodelamination, he usually removes the Hydrodissection: The next step is the
epinucleus during emulsification of the cortical cleaving hydrodissection, as de-
nucleus. If the hydrodissection was well done, scribed by Fine. The nucleus must be totally
usually irrigation-aspiration (I/A) will not be or completely free inside the capsular bag. At
necessary. this time, he rotates the nucleus once or twice
clockwise or anti-clockwise.
234
IOL Implantation: he injects vis- It is not necessary to enlarge the incision

coelastic. For routine cases Centurion uses during the implantation. In his experience,
foldable IOLs. He has been working with with the acrylic lens it is necessary to enlarge
silicone IOL's for many years and is very to 3.5 mm to implant the Sensar (Allergan)
confident with the implantation technique and 3.75 mm with the AcrySof (Alcon).
using the unfolder through 3.0 mm incision.
235
236
CARREÑO'S NUCLEAR Three Sets of Values

EMULSIFICATION TECHNIQUE Programmed Into Memory
OF CHOICE (PHACO SUB 3)
Carreño uses the following criteria:
For the latest concepts on surgery re- three sets of values programmed into the
lated to density of cataracts, I also refer you memory in the Legacy 20,000. These param-
to page 7. Carreño's Phaco Sub 3 is a eters are set according to the degree of
phacoemulsification procedure performed hardness of the cataract. They are:
through an incision of 3 mm or less. There
are other modifications of the phaco tech- • Memory 1: Use high ultrasound power
nique also identified as "Phaco Sub 3." His to enable a quick (continuous mode) nuclear
goal is to make it as uninvasive as possible. sculpt or chisel and lower levels of vacuum
He follows all the parameters appropriate and aspiration flow (Fig. 56). There is no
for the entire spectrum of nuclear density need for great grasping or fixation power, or
that have proven to be efficient, safe, and power of attraction in this stage of the tech-
replicable by other surgeons. Obviously, in nique.
order to achieve good surgical results, it is • Memory 2: For capture, mobilization
imperative that the phaco machine settings and emulsification of nuclear fragments
are perfectly adjusted to the needs of each (pulse mode) (Figs. 67, 68) it is necessary to
type of nucleus and to the requirements of have high vacuum levels and aspiration flow
each step of the technique. Carreño uses in order to achieve considerable grasp and
the Legacy 20,000 equipment (Alcon). fixation power. It is also necessary to have
little ultrasound power so that the nuclear
Adjusting the Equipment fragments that are free are not propelled from
the phaco tip by excessive vibration.
Parameters to Remove • Memory 3: Is intended for the removal
Cataracts of Various Nuclear of soft material like the epinucleus, and uses
Density much lower values in all settings, in pulse
mode (Fig. 69).
Height of the bottle (infusion): 75 cm to
It is important to keep in mind that the 85 cm.
basic parameters of the phacoemulsifier are Phaco tip: Kelman type (curved) ABS Micro
the ultrasound power, the vacuum, and the Tip with a 30-degree tip (Fig. 84).
aspiration flow. These are amply discussed If a good hydrodissection is performed
and beautifully illustrated in pages 112-114, with the cortical cleaving technique, it is
119-122 and Figs. 83, 84, 61-65. possible to remove the epinucleus along with
237
the nuclear material in the majority of me- of the phaco tip and to provide protection to
dium hard cataracts and in virtually all hard the corneal endothelium.
cataracts.
Working with well-programmed Technique of Choice and

memories is a great advantage when using
the Phaco Sub 3 Technique. By eliminating
Consistency of Cataract
filtration through the surgical wound, the
smaller incision directs the flow of liquid SOFT CATARACTS (grade 1 - 2
and nuclear fragments towards the micro tip nucleus)
for aspiration, making the phacoemulsifica-
tion procedure more efficient. That is, there Carreño recommends Fine’s Chip
is no competition between the flow of liquid and Flip because the nuclei are not very
toward the surgical incision and the flow hard and generally cannot be fractured (Figs.
toward the phaco tip, which can occur with 122-126). With this technique, it is impor-
larger, leaking incisions. Also, the more tant to use hydrodissection and
hermetic incision of Phaco Sub 3 reduces the hydrodelamination maneuvers. Hydrodis-
amount of liquid circulating in the eye dur- section makes free nuclear rotation within
ing surgery and maintains a deeper and more the capsular sac easier, and
stable anterior chamber. This helps preserve hydrodelamination clearly outlines the sepa-
the integrity of the corneal endothelium and ration between the harder inner nucleus and
the posterior capsule, which, undoubtedly, the softer epinucleus that surrounds it. The
confers greater safety to the technique. gold hydrodelamination ring denotes the
(Editor’s Note: see Chapter 7 for a very limit to which it is possible to emulsify the
well illustrated presentation of the fluidics of nucleus without risking capsular damage
phacoemulsification). (Fig. 48).
While performing Phaco Sub 3 it is First Step (“memory 1”: vacuum 0
very important to keep in mind that a lateral to 10 mm Hg, aspiration flow 18 cc/min,
movement of the micro tip must be avoided U/S power 60%).
so as not to enlarge the incision during With a manipulator introduced
surgery. It is therefore necessary to always through the lateral paracentesis, the nucleus
keep the micro tip working from 12 is gently moved toward 12 o’clock to allow
o’clock to 6 o’clock without lateral move- the micro tip, maintained in a central posi-
ment. This explains the great importance of tion, to emulsify the inner nucleus ring at 6
a second instrument (manipulator or chop- o’clock without the risk of reaching the
per), introduced through the lateral paracen- capsular fornix. Then, with the manipulator,
tesis to facilitate rotation, mobilization ma- the nucleus is rotated in order to place other
neuvers, and nuclear fracture. nuclear fragments in position to be emulsi-
Before beginning nuclear emulsifica- fied. The microtip must not be advanced
tion, regardless of the technique used, the past the gold hydrodelamination ring. This
surgeon should always inject viscoelastic in maneuver is repeated until the entire inner
the anterior chamber to ease the penetration nuclear ring is completely removed.
238
Second Step (“memory 2”: vacuum level of safety it provides. The nucleus is
200 mm Hg, aspiration flow 25 cc/min, U/S soft enough to allow quick sculpting with
power 40%, 6 - 8 pulses/sec). low ultrasound. At the same time it is hard
The manipulator is inserted into the enough for the surgeon to create fractures
cleavage plane obtained through without difficulty (keep in mind that soft
hydrodelamination and is passed behind the grade 1 (+) cataracts cannot be fractured).
residual nuclear fragment (chip). The chip is Furthermore, with grade 2-3 nuclei, no ex-
lifted and taken to the center of the capsular cessive pull is exerted on the zonule while
sac. It is here that the chip may be emulsi- the fragments are sculpted, which can occur
fied with greater safety. with harder nuclei.
Third Step (“memory 3”: vacuum In general, all of the nuclear fracture
100 mm Hg, aspiration flow 20 cc/min, U/S techniques (Fig. 106) aim to divide the
power 30%, 6 - 8 pulses/sec). nucleus in multiple fragments to allow their
The center of the epinucleus is pushed removal through the small circular aperture
toward 6 o’clock with the manipulator. Slid- of the capsulorhexis and also to make pha-
ing the epinucleus out of the upper capsular coemulsification more efficient inside the
fornix, the microtip can pull the epinucleus capsular bag (Fig. 105). Phacoemulsifica-
up toward the main incision using aspiration tion of small fragments of nuclear material
only (phaco pedal in position 2). The epi- is faster than emulsification of an entire
nucleus is then folded over itself top-down nucleus. The procedure is therefore quicker,
(flip), using the spatula and the microtip. and the ultrasound time is reduced. The
This moves the nucleus away from the pos- fragments are mobilized more easily within
terior capsule. Once the flip maneuver is the capsular bag and it is possible to take
completed, the epinucleus is removed safely them to the center without much difficulty
by simple aspiration or using low power (Fig.111). This allows them to be removed
ultrasound (Figs. 122 – 126). in a safe zone, eliminating the risk of injury
to the posterior capsule or the corneal endot-
helium.
MEDIUM DENSITY In Quadrant Nuclear Fracture, the
nucleus is divided into four parts, which are
CATARACTS (grade 2 - 3 nucleus)
then moved individually toward the central
safe zone to be emulsified (Fig. 105).
For cataracts with a medium-hard
nucleus, Carreño prefers to use Shepherd’s
First Step (“memory 1”: vacuum 10
Quadrant Nuclear Fracture technique, to 20 mm Hg, aspiration flow 25 cc/min,
which is a variation of Gimbel’s original U/S power 70%):
“Divide and Conquer” procedure (Fig. 67) A manipulator is introduced through
which is a grooving and cracking method. the side port incision to rotate the nucleus
Carreño considers that Shepherd’s tech- (Figs. 56 and 67). Moving the microtip
nique has become the nuclear fracture from 12 o’clock to 6 o’clock, thin and deep
technique most widely used by phaco sur- grooves are carved until a cross is formed
geons because of its simplicity and the high (Fig. 67). Ideally, these grooves should
239
extend almost to the edge of the safety, the surgeon may first lift the corner
capsulorhexis (to avoid the peripheral cap- of the quadrant with the spatula to distance
sule), and should be deeper in the middle it from the posterior capsule. With harder
than in the periphery (to respect the curve of cataracts, sometimes simple aspiration is not
the posterior capsule) (Figs. 103, 104). They enough to occlude the opening of the
should also be slightly thicker than the ultra- microtip. Apply a few ultrasound bursts
sound tip (including the silicone sheath) and (phaco pedal in position 3) to grasp the
should be 80%-90% of the depth of the nuclear material and generate occlusion
nucleus (Fig. 103). The visualization of the (Figs. 52, 53). Once occlusion is achieved
red reflex at the bottom of the groove indi- and the phaco pedal is again in position 2,
cates adequate depth to the surgeon. the surgeon should wait until the vacuum
Second Step: reaches the aspiration line. This makes it
Once the cross is formed (Fig. 67), the possible to hold the quadrant firmly on the
nucleus is divided into four quadrants. The opening of the tip. At this precise moment,
phaco tip and the manipulator are placed at relying on good grasping force, the surgeon
the bottom of the groove at 6 o’clock and are can pull the quadrant toward the central safe
pushed in opposite directions (with a direct zone. The quadrant should be completely
or crossed maneuver) (Fig. 104). The separa- controlled by the manipulator in order to
tion results in a fracture line, which extends avoid turbulence and contact. Then the
from the periphery to the center of the poste- quadrant is emulsified with the machine in
rior nuclear wall (Fig. 104). After the pulse mode (Fig. 86). With large and hard
nucleus is rotated 90 degrees, fractures are fragments, it is useful to use chop maneu-
performed until the nucleus is divided into vers (with the same chopper or secondary
four fragments (Fig. 105). The fracture instrument) in order to divide the quadrant
should include all the nuclear material; all the into smaller fragments, to make the surgery
fragments must be separated in order to quicker and easier (Figs. 105, 106). The
ensure a good result. Before continuing to the procedure described is repeated for the other
next step, the surgeon should mobilize the quadrants until the entire nucleus is emulsi-
quadrants with the spatula in the capsular bag fied.
to ensure that there are no connections be- HARD CATARACTS (grade 3-4
tween them (Fig. 105). nucleus)
Third Step (“memory 2”: vacuum
300 mm Hg, aspiration flow 35 cc/min, U/S With hard cataracts, Carreño prefers
power 50%, 6 - 8 pulses/sec) (Fig. 67) to use chopping techniques. They offer
The microtip is directed toward 6 clear advantages over the divide and con-
o’clock, and the phaco pedal is in position 2 quer procedures in the management of this
(irrigation/aspiration without ultrasound). type of nucleus (See pages 177-182). As a
The first quadrant is captured by plac- method of nuclear fragmentation, the chop-
ing the tip in contact with nuclear material to ping techniques derived from Nagahara’s
generate occlusion (Figs. 59, 60). For greater original “Phaco Chop” considerably reduce
240
the power and total time of phacoemulsifica- original “Phaco Chop,” offers a greater ad-
tion, thereby reducing the tension on the vantage by confining the chop to the central
zonules and the posterior capsule and con- region within the limits of the capsulorhexis.
fining the entire phacoemulsification proce- This means the surgeon avoids the need to
dure to the central 3 mm of the pupil (Fig. reach dangerously with the chopper under the
183). anterior capsule, toward the lens equator, to
Three important features of the chop- create the fracture.
ping techniques are important to emphasize: The “Stop and Karate Chop” technique
1. Chopping is a completely differ- basically consists of three steps, which are
ent method than nuclear fracture. It basically the sculpting or chiseling of the central sul-
consists of making cuts following the natu- cus (Fig. 107, page 185) in order to fracture
ral cleavage of the lens ( similar to cutting a the nucleus in two halves, the chopping of
log with ax blows) (see page 183). the two hemi-nuclei, (Fig. 106, page 182)
2. In order to lend itself well to the and the mobilization and ulterior emulsifica-
chop maneuver, the nucleus must have a tion of the nuclear fragments (Fig. 111).
firm consistency. (Editor's Note: from the practical point of
3. The conservation of energy gained view, these are the same principles of the
by not carving grooves (D & C) makes Stop and Chop (pages. 184-188), except that
chopping particularly indicated for the man- the direction of the cut in the “Phaco Chop”
agement of hard nuclei. technique goes from the equator towards the
center of the nucleus, while the “Karate
The Stop and Karate Chop Chop” goes from the anterior pole to the
posterior pole).
Carreño’s preferred chopping tech- First Step (“memory 1”: vacuum
nique is the “Stop and Karate Chop”, which 20 mm Hg to 30 mm Hg, aspiration flow
is a combination of Koch’s “Stop and Chop 30 cc/min, U/S power 80%):
and Nagahara’s “Karate Chop.” He finds it The procedure is initiated by chiseling
is a very safe procedure combining the ad- a central sulcus with the microtip toward 6
vantages of both techniques. o’clock (as if it were nuclear fracture in four
Without a doubt, Koch’s “Stop and quadrants) (Fig. 107). The chiseling is com-
Chop” noticeably simplifies Nagahara’s pleted toward the other extreme after rotating
original “Phaco Chop” technique by creating the nucleus 180 degrees aided by the chopper
an initial groove (Fig. 107) which, in turn, introduced through the side port incision
creates a space in the nucleus, making the (Fig. 109). Once the desired depth is ob-
chopping maneuvers, mobilization, and tained, the nucleus is divided into two halves.
nuclear fragment emulsification much It is fractured with the phaco tip, and the
easier. This explains its great popularity as a chopper is placed in the bottom of the sulcus.
chop technique (page 184). At the same The surgeon must ensure that the halves are
time, “Karate Chop,” which corresponds to a completely separated (Fig. 106). From this
modification introduced by Nagahara to his time on, no more sculpting or cracking is
241
done, and the chopping maneuvers are the “Phaco Chop,” is what prompted
initiated. (Hence, the “Stop and Chop” des- Nagahara to call this modification of his
ignation by Paul Koch). technique the “Karate Chop.”
Second Step (“memory 2”: vacuum Third Step (“memory 2” is main-
400 mm Hg, aspiration flow 40 cc/min, U/S tained: vacuum 400 mm Hg, aspiration flow
power 60%, 6 to 8 pulses/sec): 40 cc/min, U/S power 60%, 6 to 8 pulses/
The nucleus is rotated 90 degrees so sec):
that it is in a horizontal position to ease the Once the nuclear division is complete,
grasp of the distal hemi-nucleus with the the quadrants are mobilized. They are cap-
microtip. The phaco pedal is in position 2 tured with the microtip and pulled to the
(irrigation-aspiration), the microtip is placed central safety zone, where they are emulsi-
against the wall of the sulcus in its central fied. In order to capture the quadrants, the
portion while ultrasonic pulses (phaco pedal surgeon grasps the nuclear material by ap-
in position 3) are applied, and the nuclear plying some ultrasonic pulses (Fig. 105)
material is grasped. Once occlusion is (phaco pedal in position 3). Once occlusion
reached, the pedal is returned to pedal posi- is achieved, the vacuum is increased (phaco
tion 2 in order to increase the vacuum and pedal in position 2) to ensure grasp at the
obtain good fixation at the microtip. Now microtip. The maneuver is repeated until all
the choopper is sunk into the nuclear mate- fragments are removed. As with Shepherd’s
rial slightly in front of the microtip. By “Quadrant Nuclear Fracture,” any large
pulling the instruments in opposite direc- nuclear fragments present should be divided
tions (the chopper towards the left and the using chopping maneuvers to speed the pro-
microtip toward the right), the surgeon frac- cedure.
tures the distal hemi-nucleus into two halves The presence of a central sulcus plays
(Fig. 111, page. 189). The nucleus is then a fundamental part in the development of the
rotated 180 degrees, and the procedure is “Stop and Karate Chop” technique, as space
repeated so as to fracture the other hemi- is created within the nucleus (Fig. 107).
nucleus in two halves as well. The nucleus With the occlusion of the tip, it is easier to
ends up divided into four quadrants. perform the chop, to move the nucleus poste-
Carreño prefers not to remove the quad- riorly, and to remove the fragments.
rants immediately. Keeping all the pieces
within the capsular bag stabilizes the second VERY HARD CATARACTS
hemi-nucleus at the moment the chop is (4-5 grade nucleus):
performed, making the maneuver easier. It
is very important to ensure that all four In these extremely hard nuclei (rubra
quadrants are completely independent of and nigra cataracts), that represent a great
each other. Introducing the chopper directly challenge for the phaco surgeon, Carreño’s
into the nucleus, without having to reach the technique of choice is “Crater and Karate
periphery to carry out the fracture, as with Chop,” which is a combination of Gimbel’s
242
“Crater Divide and Conquer” with position 3). The nuclear material is impaled.
Nagahara’s previously mentioned “Karate Once occlusion is reached, the pedal is
Chop.” The key to success with these very placed in position 2 to increase the vacuum
hard nuclei lies in reducing the nuclear vol- in the aspiration line and firmly attach the
ume as much as possible while maintaining a nucleus to the opening of the microtip. The
peripheral nuclear ring firm enough to per- chopper is then introduced into the nuclear
form chopping maneuvers geared to creating edge in front of the microtip (“Karate Chop”
the fractures (See pages. 191-193 for refer- technique, without taking the chopper to the
ence of the very similar Crater Phaco Chop equator underneath the anterior capsule.)
Technique - Editor). The instruments are pulled apart to complete
The basic steps for the “Crater and the first fracture. The nucleus is rotated, and
Karate Chop” technique are the sculpting of the maneuver is repeated in order to make
a very deep central crater, the chopping of the second fracture, creating the first frag-
the peripheral nuclear ring to create multiple ment. The process continues until the
fragments, and finally, the mobilization and nucleus is divided into multiple fragments
emulsification of these fragments (Fig. 112- (five or more). The surgeon must ensure that
116 for reference). there are no connections between them. The
First Step (“memory 1”: vacuum 20 harder the nucleus, the smaller and more
mm to 30 mm Hg, aspiration flow 30 cc/min, numerous the fragments must be in order to
U/S power 90%): make them more manageable. While mak-
Directing the microtip always towards ing subsequent chopping maneuvers, it is
6 o’clock, the surgeon sculpts a crater in the useful to leave the fragments in place to
central nuclear zone, using rotation maneu- keep the capsular bag well-distended. This
vers to facilitate and deepen it. (The use of reduces the possibility of an inadvertent cut
ultrasound for a prolonged amount of time into the posterior capsule with the phaco tip.
during this step of the technique is not risky Third Step (uses “memory 2”:
because the nuclear sculpting is performed vacuum 400 mm Hg, aspiration flow
inside the capsular sac, far away from the 40 cc/min, U/S power 70%, 6 to 8 pulses/
corneal endothelium.) In order to fracture, it sec):
is necessary to centrally sculpt very deeply Once the nucleus is fragmented,
(until the red reflex appears in the bottom) Carreño proceeds to move each individual
while maintaining enough dense material in fragment toward the center to emulsify it.
the nuclear periphery. (Because very hard fragments are involved,
Second Step (“memory 2”: vacuum it is advisable to inject viscoelastic to protect
400 mm Hg, aspiration flow 40 cc/min, U/S the corneal endothelium). The tip is placed
power 70%, 6 to 8 pulses/sec): against the nuclear fragment at 6 o’clock,
The microtip is placed against the wall and ultrasonic pulses are applied (phaco
of the central crater at 6 o’clock, and ultra- pedal in position 3) to capture the fragment.
sound pulses are applied (phaco pedal in Then the vacuum is allowed to increase
243
(phaco pedal in position 2) to reach a firm is then rotated in order to place another
grasp at the microtip opening. The fragment fragment at 6 o’clock. The procedure is re-
is then pulled toward the center, into the peated until all the fragments are completely
safety zone, to be emulsified. The nucleus removed.
244
NISHI'S TECHNIQUES OF BIBLIOGRAPHY

CHOICE FOR NUCLEI OF Buratto, L: Buratto's elective techniques for pha-
DIFFERENT CONSISTENCIES coemulsification according to grades of hardness of
nuclei. Phacoemulsification: Principles and Tech-
Nishi uses two different techniques niques by Lucio Buratto, 1998; 6:166-170.
depending on nucleus consistency.
1) Soft (+), Standard (++): Carreño, E.: Nuclear emulsification technique of choice
(Phaco Sub 3). Guest Expert The Art and the Science of
In these groups, Nishi uses a modifi- Cataract Surgery of HIGHLIGHTS, 2001.
cation of the Divide and Conquer procedure
(Figs. 56 and 67) and sometimes Fine's Centurion, V.: Centurion's technique related to nucleus
Choo-Choo Chop and Flip technique (Figs. consistency. Guest Expert The Art and the Science of
122-126) using high vacuum and low ultra- Cataract Surgery of HIGHLIGHTS, 2001.
sound energy from the very beginning Lindstrom, R.: Lindstrom's procedures of choice. Guest
(vacuum 170 mm Hg, energy up to 60% Expert The Art and the Science of Cataract Surgery of
using Allergan's Diplomax phaco machine). HIGHLIGHTS, 2001.
High energy is not necessary for those nu-
clei, and it is cumbersome for the surgeon to Lindstrom, R: Tilt and tumble phacoemulsification.
Clear Cornea Lens Surgery, edited by I. Howard Fine,
switch on from high vacuum-low energy to Slack, 1999;9:99-119.
low vacuum-high energy.
2) Moderately Hard to Hard Lindstrom, R: Tilt and tumble phacoemulsification.
Operative Techniques in Cataract and Refractive Sur-
Nucleus (+++): gery. Vol. 1, Nº 2 (June), 1998: pp. 95-102.
In cases with moderately hard and
hard nucleus, higher energy up to 80% Nishi, O: Nishi's technique of choice related to nucleus
(even 100%) is used for rock-hard nucleus, of different consistency. Guest Expert The Art and the
taking care not to burn the wound. This Science of Cataract Surgery of HIGHLIGHTS, 2001.
high energy is combined with low vacuum
for making a groove or a cross. For making
a groove, the tip is never occluded and high
vacuum is not needed. After the nucleus is
divided into 2 or 4 parts, the next step is
emulsification. The machine is switched to
high vacuum low energy, unless higher en-
ergy is needed for emulsifying the fractured
quadrants. High vacuum is now needed,
because the nucleus fragments must be
pulled towards the center by occluding the
tip opening.
3) Hard (++++) or Very Hard
Nuclei (+++++):
Nishi uses a chopping technique
(Figs. 103, 106, 107-111). Care is taken to
stay away from the corneal endothelium.
245
246
C h a p t e r 11: Complications of Phacoemulsification - Intraoperative and Postoperative
INTRAOPERATIVE COMPLICATIONS
General Considerations Main Intraoperative

Complications
Even in the most experienced hands com-
The main complications are related
plications occur. The best management of
to the following phases of the operation:
complications is to avoid them. When
1) complications related to the incision.
unpreventable, a well thought out, carefully
2) Those associated with anterior capsulorhexis.
executed plan can give very good visual re-
3) Complications consequent upon rupture of
sults.
the posterior capsule. 4) Complications re-
When using topical anesthesia, the pa-
lated to emulsification and removal of the
tient is an active participant in the procedure.
nucleus through different techniques. We also
Complications can occur when patients move
need to confront the complications related to
their head, body, or eye, cough, or squeeze their
hydrodissection and/or hydrodelineation, those
eyelids. Consequently, they should be fully
that occur during the process of aspiration of
educated and carefully selected. We should
the cortex, intraocular lens implantation and
provide proper education in advance about
the difficulties of the operation when the pupil
what will be experienced so that the level of
is small.
anxiety will be low. When speaking with the
patient, the surgeon should sound calm and in
control. If patients sense the surgeon's anxiety Incidence
they may become more anxious, further limit-
ing their ability to cooperate. When patients As pointed out by Howard Gimbel,
become over sedated they may fall asleep and M.D., the incidence of intraoperative compli-
might awake disoriented. The best way to keep cations will vary to some degree with the
patients from waking up suddenly is to keep surgeon’s experience and the type of proce-
them from falling asleep. dure performed as, for instance, when a sclero
In cases under topical anesthesia, exces- corneal tunnel is performed versus a clear
sive globe movement can impair the safe corneal incision. It will also vary depending
completion of the operation. If the patient is on the anatomic characteristics of the indi-
unable to hold the eye steady, or if they are vidual eye as in small pupils and hypermature
perceiving discomfort from the surgery, aug- cataracts. Intraoperative complications are
menting the anesthesia with a subtenon, peribul- also related to the type of anesthesia utilized
bar, or retrobulbar block may be helpful. This but this has been significantly diminished by
can be accomplished quite safely when a self- combining topical and intracameral local an-
sealing wound is done. esthesia which is used in most cases, or using
this combination with sub-Tenon’s anesthe-
249
sia when desired (Chapter 5). Since retrobul- (Fig. 140). Or else, he makes the incision a
bar or peribulbar anesthesia are practically no little bit too large. If it is too shallow or
longer used in phacoemulsification, even by beveled, it will become a non self-sealing, non-
those who are starting in the transition period, valvulated wound. If it is too large, a persistent
the risks of globe perforation or retrobulbar iris prolapse may occur. You may try to ignore
hemorrhage have practically disappeared. it but it keeps coming back.
With a superficial, shallow incision, you
Facing the Challenges may manage it as shown in Fig. 140. Simply
abort the superficial tunnel, go back to the first
Virgilio Centurion, M.D. from Sao or initial vertical groove of the incision (300
Paulo, Brazil, one of Latin America’s most microns depth) corresponding to 1/2 the cor-
experienced and didactic anterior segment sur- neal thickness and place the blade deeper,
geons, has dedicated years of research and forming a second tunnel with the correct depth
teaching on how to master phacoemulsifica- located below the first or superficial tunnel
tion. This includes being prepared for the (Fig. 140).
challenges of the intraoperative complications, If you are having a very difficult time
which are different than those we were accus- with an incision, the best thing to do is to close
tomed to face with planned extracapsular. that incision with one or two vicryl sutures
Centurion emphasizes that each cataract op- which will eventually dissolve and move over
eration presents its own challenges, and that to another nearby spot and start over. With a
even though we have reached a very advanced clear corneal incision, starting over only takes
level of safety and predictability with pha- a short additional time (Fig. 141).
coemulsification, it is important that we keep
in mind the complications that may arise so as Problems from Incorrect Place-
to minimize situations that may bring the level ment and Performance of Incision
of stress to a peak in the operating room.
In Fig. 142 you may see a summary of
COMPLICATIONS WITH THE the problems in creating the sclero corneal,
INCISION limbal and corneal tunnel incisions. The
correct placement and structure of each inci-
sion is presented in Fig. 40. A key element
Too Short and Shallow or Too in the success of phacoemulsification is to
Large obtain a good internal valve incision.
As Centurion has emphasized, it is
Lindstrom points out that the most fre- only by experience and extreme care that we
quent complication he has with the clear develop a sense of «feeling» of the ideal
corneal incision is that he either makes the depth, that is, the one which will not endanger
width of the incision a little bit too short, or the intraocular tissues and will ensure a good
the dissection too shallow or too beveled tunnel protection.
250
Figure 140 (left): Complications while Mak-

ing a Clear Corneal Incision - Too Shallow
and Short
The corneal tunnel incision should be

self-sealing and valvulated, at about 300 mi-
crons depth. That is approximately half the
corneal thickness. Here we observe that the
first incision was too superficial (red) not
permitting a proper valve to function. Thereby,
the wound is not self-sealing. One solution
for this is to abort this tunnel and start again
from the initial incision, go deeper forming a
second tunnel (arrows) below the first super-
ficial tunnel.
Figure 141 (right): Problems From Incor-

rect Placement of Tunnel Incisions
The correct placement and performance

of the sclero corneal tunnel, limbal or corneal
incision is extremely important. In case of the
sclero-corneal, a 5 mm external incision (E) is
made 1-3 mm from the limbus to a depth corre-
sponding to 1/2 to 2/3 thickness of the sclera. A
scleral tunnel (T) between 2 to 3 mm in length is
made. With blade directed toward and in a paral-
lel path to the pupil, the internal valve (V) opening
is created. Common placement errors are shown
by blue lines. Also shown is a detachment of
Descemet’s membrane (D), another common er-
ror that can be avoided by use of abundant
viscoelastic. (Original illustration by HIGH-
LIGHTS, based on principles from Virgilio
Centurion's book titled "Complicações Durante
a Facoemulsificação".)
251
Figure 142: Complications during Incision - Closing of the Im-

proper Incision and Making a New One
If the elected incision site is too superficial and short or too

large (A) so that it may not provide correct sealing, it is advisable to
close the first incision with vicryl sutures and perform a new and
correct incision next to the first one (B). The surgeon may choose the
horizontal (S) or radial sutures according to his/her experience.
Detachment of Descemet's lubricating the tunnel with viscoelastic and by

Membrane very careful folding of the IOL and lubrication
either of forceps or the injector, in order to
An occasional but important complica- attain a non-traumatic introduction and im-
tion is detachment of Descemet’s membrane, plantation of the IOL.
as shown in Fig. 143. The main causes are: 1) Important: During the dissection of
ocular hypotension while dissecting the tunnel the internal step of the incision which leads to
or while constructing the internal part of the the formation of the internal valve (V), the
tunnel to make the valve-like incision. The intraocular pressure must be either normal or
injection of viscoelastic through the side port slightly high and the tip of the blade must be
of the incision before performing the primary directed towards the pupil and follow a
incision can prevent this from happening. 2) parallel path toward the pupil as shown in
The introduction of the blade in the wrong Figs. 140, 142 and 143. Use abundant vis-
direction when constructing the internal part of coelastic in order to keep Descemet’s mem-
the incision (Figs. 140, 142 and 143). 3) The brane where it belongs until the conclusion of
forced introduction of the phaco tip or foldable the surgery.
lenses in a tight incision. This may be avoided A detachment of Descemet’s membrane
by being very careful during entry of the tip, by discovered postop, is an important complica-
252
tion when it occurs because it may be incision for the extracapsular at the limbus.
followed by corneal edema and even The nucleus and cortex are removed and the
inflammation. If it occurs, topical antiinflam- IOL implanted. When suturing, it is important
matory medications are sometimes useful. to close the wound by placing the interrupted
If the detachment is significant, however, sutures radially. When you get to the junction
(Fig. 143) there may be corneal decompensa- between the part of the incision where the
tion progressing to bullous keratopathy which tunnel was started and the limbus, suture it as
may eventually require a penetrating graft. shown in Fig. 144. The arrow shows conver-
sion when the initial incision was a sclerocor-
Precautions with Closure of the neal tunnel. Unless properly sutured, the valve
Incision Upon Conversion may leak at this site.
Conversion to extracapsular is not infre- Heating the Wound

quent when you start in the transition period
and may be necessary even in the hands of a Very occasionally, if one is not careful,
more experienced surgeon upon the develop- you can heat the wound. It looks like you
ment of complications. If the incision is cor- cauterized the cornea. That is not such a
neal, move to the limbus. Other surgeons problem during the surgery but this wound
prefer the scleral tunnel incision or the tunnel may well leak. If that occurs, at the end of the
starting at the limbus or about 1 to 1.5 mm operation, the surgeon has to close the wound
from the limbus. When converting, enlarge the by suturing but will not be able to perfectly
Figure 143: Complications with the Tun-

nel Incision - Detachment of Descemet's
Membrane
A detachment of Descemet's mem-

brane (D) may be observed during con-
struction of the valvulated incision, ma-
nipulation of the incision with the phaco
probe in a tight incision or from insertion of
the intraocular lens. This complication
happens more frequently when making the
incision in a hypotensive eye, or the wrong
maneuver when introducing the knife.
253
approximate the edges of the incision because constantly being produced and was causing
this may induce a large astigmatism. The most the positive Seidel) remain in the anterior
practical approach is to suture the anterior chamber. The anterior chamber has the op-
edges of the tunnel to the posterior surface of portunity to reform. After a few minutes,
the wound using a mattress suture. A little when the intraocular pressure returns to nor-
gap will remain in almost every setting but you mal, the walls of the incision have come
can create a sealing incision. You should together and adhered, without any further
expect a small to moderate amount of astigma- positive Seidel. This ingenious maneuver is
tism, but the good news is that it will go away simple and avoids having to re-suture the
with time. It is only a temporally induced patient.
astigmatism. The difficulty is to get that
incision to seal. COMPLICATIONS RELATED TO
ANTERIOR CAPSULORHEXIS
Management of Leaking
Incisions with a Positive Seidel It is generally agreed that this is the
procedure of choice to open the anterior cap-
Infrequently, a clear cornea incision or a sule. In most cases, it allows the phaco
scleral tunnel incision larger than 3 mm in technique to be performed within the capsular
width may show leaking of fluid one day bag and, consequently, the maneuvering and
postoperatively. This is either secondary to an instrumentation does not affect the surround-
incision larger than planned and not sutured, or ing tissues particularly the corneal endothe-
by too much trauma in the lips of the wound lium. Capsulorhexis also allows an almost
usually by the phaco tip. perfect positioning of the intraocular lens. As
When this leaking occurs, it may be emphasized by Centurion, when the surgeon
immediately detected by instilling a drop of dominates the technique of capsulorhexis, cases
fluorescein and observing the patient under of decentration, capture and/or subluxation of
ultraviolet light. The problem with these the IOL are rare.
patients is that the constant escape of aqueous
humor keeps the wound open and may re- Main Complications
quire suturing of the incision which certainly
is a nuisance. The main complications may be related
Prof. Juan Murube, M.D., from to: 1) the size of the capsulorhexis. It may be
Madrid recommends a very ingenious maneu- either too large or too small. This is due to a
ver in order to close the leaking wound technical mistake either in the judgment of the
without having to re-suture the incision. He surgeon or in performing the technique. The
places a Honan balloon (Fig.96) over the eye ideal diameter of capsulorhexis ranges from
for 30 minutes at a pressure of 35 mm Hg and 5 to 6 mm. Centurion advises that, when there
at the same time administers 1 tablet of is doubt, check the diameter of the capsulo-
acetazolamide, 250 mg orally (Diamox). The tomy by holding a compass over the cornea.
hypotony produced when the Honan balloon When the capsulorhexis is too small, less than
is removed makes the aqueous humor (that is 5 mm (Fig. 145), problems may arise during the
manipulation of the nucleus and the IOL im-
254
Figure 144: Precautions with Clo-

sure of the Incision Upon Conver-
sion
The wound is closed with in-

terrupted sutures radially. When you
get to the junction between the part of
the incision where the tunnel was
started and the limbus, you must place
the suture as shown in this figure. Oth-
erwise, the valve may leak. (Courtesy
of Virgilio Centurion, M.D., from his
book titled “Complicaçoes Durante a
Facoemulsificaçao”.)
Figure 145: Complications Related to

Anterior Capsulorhexis - Too Small
When the anterior capsulorhexis

(C) is rather small (less than 5 mm), the
manipulation of the nucleus may present
problems that might compromise the suc-
cessful results of surgery, and IOL implan-
tation may be more difficult.
255
plantation may be more difficult to the extent of that occurs, Lindstrom goes back to the
compromising the final result of the surgery. beginning, makes a little cut with Vannas
If it is considered to be small, perform a scissors at the edge of the rhexis (Fig. 146) in
small lateral cut in the capsulorhexis with the other direction from where the extension
Vannas scissors at 10 o'clock (Fig. 146). into the zonules occurred and enlarges the
Afterwards, perform a second and wider ante- rhexis around the opposite way (Fig. 147). In
rior capsulorhexis with the Uttrata forceps at these cases, the surgeon may have to pre-
12 o'clock which will prevent or eliminate sume that there was a little radial tear to start
the likelihood of stenosis of the opening and must be very careful with the next step,
(Fig. 147). This is also a good option on what the hydrodissection, because most probably
to do if there is some discomtinuity or small there is a weak spot in the anterior capsule.
tear identified in the anterior capsulorhexis. In that case you should probably not use a
When the capsulorhexis is too large plate haptic lens.
(Fig. 148), larger than 6 mm, some difficul-
ties may arise in stabilizing the nucleus after Preventing Rhexis Complications by
hydrodissection with a tendency for the Tinting
nucleus to move into the anterior chamber.
Thic could possibly endanger the corneal One of the major advances in performing
endothelium and other surrounding structures circular continuous capsulorhexis (CCC) in
and emulsification would need to be done in hypermature cataracts which are either totally
the anterior chamber. Maintain sufficient white or very dark is the tinting of the anterior
viscoelastic between the lens and the endot- capsule. In these eyes, the fundus reflex
helium. cannot be seen by the coaxial light of the
Lindstrom considers that if the microscope. When the reflex is not present, it
capsulorhexis is really large (Fig. 148) it is is extremely difficult to see in order to com-
not a major problem although there is a plete the circular capsulorhexis. Tinting of the
tendency to develop a higher rate of capsular anterior capsule through various substances
opacity because the border of the such as Fluorescein 2%, Indocyanine Green,
capsulorhexis is not placed over the edge of Trypan Blue, Gentian Violet, or Methylene
the posterior capsule. Blue is a new development to improve the
Another problem that Lindstrom has visibility of the anterior capsule during CCC.
commonly encountered is the chamber will Professor Juan Murube, M.D., in Madrid and
shallow as you are doing the capsulorhexis, Professor Carlos Nicoli, M.D., in Buenos
particularly in younger eyes. The way to Aires both definitely prefer the use of Trypan
avoid this is that as you see the chamber Blue as the best coloring substance for this
shallowing, put more viscoelastic in it and purpose. They place the tinting substance over
put it more centrally in the younger eye. the anterior capsule when the anterior chamber
Another complication is that the is full of air as advised by Murube. The tech-
capsulorhexis will tear into the zonules. If nique is shown in (Figs. 101, 102, page 173).
256
Figure 146 (above): Management of Small

Anterior Capsulorhexis
If it is considered to be small, perform a

small lateral cut in the capsulorhexis with Vannas
scissors at 10 o'clock.
Figure 147 (center): Enlarging a Small Capsulorhexis -

Managing a Discontinuity of the Rhexis
Perform a second and wider anterior capsulorhexis

with the Uttrata forceps which will prevent or eliminate the
likelihood of stenosis of the opening. This figure also serves to
show what to do when there is a discontinuity or small tear
identified in the anterior capsulorhexis (C). The best option
first is the injection of viscoelastic. Next, try with the forceps
(F) to perform a second anterior capsulorhexis (arrow) leaving
a regular surface with no weak points in order not to alter the
correct evolution of the surgery. The white arrow identifies the
small discontinuity of the rhexis which is being repaired.
Figure 148 (below): Complications Related to

Anterior Capsulorhexis - Too Large
The ideal size ranges from 5 to 6 mm. In

this surgeon's view you may observe a large
capsulorhexis (C). This may induce tears of the
posterior capsule during the stage of phacoemul-
sification or a tendency for the nucleus to move to
the anterior chamber during the operation.
257
COMPLICATIONS WITH areas until one is sure the nucleus is loose and
HYDRODISSECTION will rotate. Having a loose nucleus by
hydrodissection is one of the keys to success
What we try to accomplish with with the endocapsular technique. If the
hydrodissection is that by irrigating with a surgeon does not get the nucleus loose it leads
stream of BSS immediately under the anterior to complications in the next step.
capsule, we produce a separation of the rest of Centurion emphasizes that if the nucleus
the lens from the anterior capsule, including the does not spin freely within the capsular bag it
nucleus and cortex, and separation of the is due to incomplete hydrodissection. It is
cortex from the epinucleus. important not to try to rotate the nucleus me-
If you are doing an endocapsular tech- chanically at this stage but, instead, repeat the
nique, sometimes it is difficult to get the nucleus hydrodissection maneuver and/or introduce in
loose by hydrodissection. Sometimes surgeons the anterior chamber a Sinskey hook through
will stop because they find it is taking them the main incision and another hook through an
longer than they expected and are not sure how ancillary incision as shown in Fig. 149. The
to proceed. If the surgeon stops to the extent of hooks are fixed at opposite sides of the nucleus.
discontinuing hydrodissection, this makes the In Fig. 149 the arrows indicate the direction of
rest of the operation much more difficult and the spin of the nucleus when a slight traction is
risky. Lindstrom emphasizes that one should applied but this is done after a repeat
continue to hydrodissect and do so in different hydrodissection. For this procedure, the ante-
rior chamber should be filled with viscoelastic.
Figure 149: Freeing a Fixed Nucleus After

Ineffective Hydrodissection
Under viscoelastic, a Sinskey hook (1)

is introduced in the anterior chamber through
the main incision and another hook (2)
through the ancillary incision. The hooks are
fixed at opposite sides of the nucleus (N).
Arrows indicate the direction of spin of the
nucleus when a slight traction is applied.
258
Figure 150: Proper Depth of the Lens

Groove for “Divide and Conquer” Tech-
nique
As indicated, the depth of the lens

groove should be 1 1/2 to 2 times the
diameter of the tip of the phacoemulsifier
(P). Arrows show the direction of oppos-
ing forces applied to both sides of the
groove to fracture the nucleus.
Centurion emphasizes not to proceed too shallow a groove within the lens, not deep
to the next stage, which is nucleus removal enough to allow fracturing of the remaining
through phaco, without being sure that the nuclear bed.
nucleus is free. In traumatic or congenital If the surgeon is using the "Divide and
cataracts be particularly careful when per- Conquer" technique, the reliable point of ref-
forming hydrodissection due to the possible erence when performing the groove, is the tip
fragility of the posterior capsule. of the phacoemulsifier as shown in Fig. 150.
The tip of the phacoemulsifier should pen-
etrate the central region of the nucleus 1 1/2
COMPLICATIONS DURING to 2 times the diameter of the tip of the
NUCLEUS REMOVAL phacoemulsifier (Fig. 150). The arrows in
this figure show the direction of opposing
Before proceeding with phacoemulsifi- forces applied to both sides of the groove in
cation of the nucleus, it is assumed that the order to fracture the nucleus. As this pro-
surgeon has performed correctly all the previ- ceeds, the red reflex becomes redder (Also
ous phases of the operation. Upon entering see Figs. 104 page 178, and 106 page 182).
this crucial stage of the operation, the surgeon The most serious complication of nucleus
may have difficulty in fracturing the nucleus. removal is rupture of the posterior capsule,
That usually is caused by having performed which we address separately in this chapter.
259
Surgeon's Fatigue cluded and it is time to relax. Not so. An

unpleasant rupture of the posterior capsule
Lindstrom points out that another pre- may occur during the following step, which is
ventive measure to avoid complications dur- removal of the cortex.
ing nucleus removal is that in the more Lindstrom emphasizes that for most
difficult eyes, the surgeon fatigues, or gets people removing the cortex is "easy" but many
tired. When this happens, he stops and rests. of the series in the world literature will show
The minute you think you do not seem totally that as many posterior capsules are torn during
comfortable and your movements get a little cortical removal as are during the nucleus re-
awkward he recommends stopping and put moval. The hard part is over but do not loose
some viscoelastic in the eye. Use two instru- concentration. Slow down, and make sure you
ments to rotate the nucleus into a more favor- do this step properly. The cortex usually is
able position (Fig. 149) and then start again. quite easy to remove but most of the difficulty
In some difficult eyes Lindstrom may restart and risk occurs when trying to vacuum clean
and stop even two or three times. Maybe that the posterior capsule. Lindstrom is not con-
means the case took four minutes longer but vinced that it makes any difference to vacuum
this is not important. In those really difficult clean the posterior capsule because this is not
eyes it can mean the difference between suc- where the source of the eventual opacification
cess and failure. In some complications of the posterior capsule. He discourages
symposia, if you observe the live surgery aggressive vacuuming of the posterior capsule.
you can see the tremors of some surgeon's If you are going to do it be very certain that
hands when it is taking them a long time in there is no barb or sharp point on the tip of the
difficult cases, and they get awkward and I/A. He has seen many capsules torn by a little
uncomfortable, they just cannot get the barb or sharp tip on the I/A tip particularly
nucleus into the right position. In those cases during the vacuum cleaning.
Lindstrom thinks if you just stop and rest for
a minute, put a little viscoelastic, take your COMPLICATIONS DURING
time and be patient until being able to rotate FOLDABLE IOL's IMPLANTA-
the nucleus (or other difficult maneuvers) you TION
can save yourself and the patient a great deal
of problems.
Wrong IOL Power and
COMPLICATIONS DURING Decentration
REMOVAL OF THE CORTEX
To prevent complications, the key is to
get the lens symmetrically into the capsular
After the nucleus has been removed, it is
bag or symmetrically into the ciliary sulcus if
important that the surgeon remain concentrated
for some reason the surgeon feels insecure
on proceeding with skill and attention to every
about the capsular bag being intact. This re-
detail to the end stages of the operation. It is
quires being very observant that there is a good
natural for some surgeons to consider that
capsular rim and certain that you are placing
immediately after removing the nucleus, the
the complete lens at the bottom of the capsule.
main steps of the operation have been con-
260
Also, be sure you have the correct lens because they are not within the central zone;
and correct lens power. Surgeons who receive and 2) others have suffered significant tears
many referrals from other colleagues consider and have had to be removed during surgery,
that the most common reasons they have to requiring that a new lens be inserted. These
operate in order to change an IOL are: 1) error tears might have been due to the lack of lubri-
in lens power calculation during the previous cation with viscoelastic or because the sur-
operation and 2) late decentration or sublux- geon did not use the proper technique of inser-
ation. tion.
Asymmetric Capsulorhexis Importance of Warming Acrylic

IOL's
Sometimes, a decentration of the IOL
occurs because there is an asymmetric Upon using acrylic lenses, they should
capsulorhexis. The margins of the rhexis are be warmed before folding and implantation.
not over the optic on all sides. Consequently, This measure provides easier folding and a
one side gets underneath the lens, it fibroses slower unfolding. If we attempt to fold and
and pushes the lens aside. If for some specific implant an acrylic IOL at room temperature,
reason the haptics were placed in the sulcus, the lens presents resistance to folding and a
sometimes the sulcus can be very large, as in certain resistance to unfolding.
myopes, and there can be an area of disinser-
tion. Management of Complications
with Array Multifocals
Deficient Intraoperative Handling
As emphasized by Fine and Hoffman,
Carlos Nicoli, M.D., one of Argentina's in situations in which the first eye has already
most prestigious cataract surgeons, finds that received an Array lens implant, complications
the intraoperative complications with foldable management must be directed toward finding
IOL`s are not significant but we do have to be the way to implant an Array IOL in the second
alert as to problems arising from intraoperative eye. Under most circumstances, capsule
handling of the lenses, the instruments used to rupture will still allow for implantation of
fold the lenses, the injectors and the forceps. an Array lens as long as there is an intact
Heavy or high density viscoelastics placed capsulorhexis. Under these circumstances,
within the plastic injectors have led to breakage the lens haptics are implanted in the sulcus, and
of the injector at the time of insertion. In the optic is prolapsed posteriorly through the
addition, if the surgeon does not have enough anterior capsulorhexis. This is facilitated by a
experience with the injectors, he may scratch capsulorhexis that is slightly smaller than the
the lens optic. Also, if we grasp the lenses with diameter of the optic (Fig. 145) in order to
forceps without a stop at the tip, the optics can capture the optic in essentially an in-the-bag
be scratched at the time of folding. location. If full sulcus implantation is used,
Nicoli points out that tears may occur in then an appropriate change in the IOL power
lenses at the time of insertion. They may be: will have to be made to compensate for the
1) partial tears where vision is not affected more anterior location of the IOL within the
261
eye. When vitreous loss occurs, a meticulous Higher Risks for Posterior
vitrectomy with clearing of all vitreous strands Capsule Tear
must be performed.
Iris trauma must be avoided because the Carlos Nicoli, M.D., points out that
pupil size and shape may affect the visual posterior capsular tears have an incidence of
function of a multifocal IOL postoperatively. approximately 3%. This is the maximum
If the pupil measures less than 2.5 mm impair- acceptable. There is a much lower incidence
ment of near visual acuity may ensue owing to with surgeons of considerable experience.
the location of the lens rings serving near visual Above 3%, we must investigate what we are
acuity (Figs. 130, 131). doing wrong.
For patients with small postoperative Nicoli emphasizes that there are also
pupil diameters affecting near vision, a mydri- situations which we should detect at the time
atic pupilloplasty may be tried successfully of preoperative evaluation because they favor
using the Argon laser. a high risk of posterior capsule tear. The
most important are: 1) patients with history
COMPLICATIONS WITH of trauma who may have zonular dialysis;
POSTERIOR CAPSULE 2) patients with pseudoexfoliation; 3) hard
cataracts with large nuclei; 4) patients with
RUPTURE larger axial length; 5) posterior subcapsular
cataracts have an inherent weakness of the
posterior capsule. In the latter group, one
Maintaining the integrity of the posterior must be very careful not to perform
capsule is a must because the incidence of hydrodissection and delamination techniques
retinal complications is higher when there is because they might stimulate the formation
posterior capsular disruption. We specifically of a capsule tear not perceived by the sur-
refer to cystoid macular edema and retinal geon.
detachment.
The disruption of the posterior capsule Capsule Rupture Early
may occur at any stage of the operation, at the
beginning, in the mid stage upon removing When it occurs early, at the beginning
the nucleus and in the late stage when aspirat- of nucleus phacoemulsification, it does so
ing the cortex. Adequate management can more frequently with soft nuclei. The sur-
provide satisfactory vision. geon miscalculates his maneuvers, is very
A tear in the posterior capsule is most stressed, applies too much phaco power or a
frequent for surgeons who are beginning in disproportional vacuum all of which lead to
the process of transition or who are doing fast aspiration and emulsification of part or
their first cases. It mostly occurs when the whole nucleus, epinucleus and cortex.
finishing the nucleus and epinucleus removal The posterior capsule comes along with all
and during the phase of aspiration of the these structures.
residual cortex. The tear is usually located at Another cause for capsule rupture early
12 o’clock or nearby.
262
is that the surgeon has sculpted deeply in a Capsule Rupture During More
soft nucleus. By and large, tears occur in the Advanced Stages of Nucleus Removal
central region and in a circular or oval shape
(Fig. 151). In order to manage this complica- When using the «divide and conquer»
tion, Centurion advises to stop everything, or the chopping techniques, if there is a
do a so-called "dry vitrectomy" in which no capsular tear during phacoemulsification of
infusion is used or a limited vitrectomy with one of the nucleus quadrants, the tear in
very low flow system. It is also essential to the posterior capsule may or may not be
use small amounts of viscoelastic under the perceived by the surgeon. If the
nucleus fragments to push the vitreous and phacoemulsifier’s efficiency is reduced to the
lens fragments away from the posterior cap- extent that aspiration no longer occurs, we
sule tear (Fig. 151). Nevertheless, if vitre- must always be suspicious that we have a tear
ous is already prolapsed, this must be solved in the posterior capsule and vitreous blocking
first. The experienced surgeon may then the port. In these cases, Centurion again
proceed with phacoemulsification decreasing recommends to stop, inject viscoelastic, by
significantly the phaco power, or convert to all means identify the site and the size of the
an extracapsular (Fig. 144). If this complica- tear, perform anterior vitrectomy, inject vis-
tion happens during the transition, the wisest
decision is to convert.
Figure 151: Complications with Posterior Capsule

Rupture
A disruption of the posterior capsule (H) is

the most severe intraoperative complication. If no
immediate action is taken, luxation of nucleus mate-
rial (N) to the vitreous and retina may occur. If
vitreous prolapse is present and it mixes with nucleus
fragments, the vitreous should be addressed first. To
solve this complication the surgeon must stop the
maneuvers of nucleus removal. Proceed immediately
to inject viscoelastic (V) under the nucleus fragments
to push the vitreous and lens fragments away from the
posterior capsule tear. In this figure, only a "trickle"
of viscoelastic (V) is seen between the tear and the
nucleus fragments. The rest of the viscoelastic is
underneath the nucleus attempting to push it away
from the tear. At this time it is indicated to perform
a well controlled anterior "dry vitrectomy" in which
no infusion is used or one with a very low flow
system. If abundant nuclear material still remains
after these measures are taken, the surgeon may
choose between converting to ECCE or very care-
fully continuing with phacoemulsification decreas-
ing significantly the phaco power. It depends on the
surgeon's experience.
263
coelastic again, and proceed to luxation of the sound energy. Then immediately proceed to
remaining parts of the nucleus into the ante- clean the anterior chamber from all nucleus
rior chamber with a bimanual maneuver (Fig. fragments present. If the nucleus or frac-
152). If the tear is fairly large and not tions of it are free or connected to capsular
sufficient posterior capsular support remains, residues and present in the anterior third of
an IOL may be placed in the sulcus if the the vitreous chamber, viscoelastic may be
anterior capsule is intact. placed behind them for support and an ante-
In case the surgeon does not feel safe rior vitrectomy performed using a vitrectomy
enough to proceed with phacoemulsification, instrument plus viscoelastic, trying to pull the
he can always convert to extracapsular as nucleus into the anterior chamber and then
long as the incision has been made in the finish the phacoemulsification. On the other
limbus and not in the cornea. He may also hand, if the nucleus is in a deeper location
enlarge the limbal incision to remove the rest within the vitreous cavity (Fig. 155), it is
of the nuclear pieces (Fig. 144). strongly advised to perform only an anterior
In the presence of a large tear of the vitrectomy for removal of the fragments
posterior capsule, it may be unrealistic and present in the anterior third of the vitreous
risky to implant an IOL completely within cavity, remove the cortex and implant an
the bag. As a matter of fact, some of the more intraocular lens as shown in Figs. 152, 153,
frequent cases of tears result in partial ab- 156. Refer the patient to a posterior seg-
sence of the upper half of the capsular bag. In ment surgeon. Do not attempt to remove a
such cases, after infusion of viscoelastic and nucleus which has fallen into the vitreous
vitrectomy and being sure that the anterior yourself unless you have experience with
capsule is intact, you may implant a PMMA vitreoretinal surgery. The surgeon must see
IOL by securing the superior haptic in the what he does and certainly doing attempts «in
sulcus by a single suture as shown in Fig. 153 the dark» may lead to very severe and irre-
and utilizing the remaining inferior part of versible vitreoretinal lesions that definitely
the capsular bag as a support for the inferior jeopardize the outcome.
haptics (Fig. 153). Some surgeons prefer to
implant both loops symmetrically in the sul- Capsule Rupture During Cortex
cus in such cases. Removal
Nuclear Fragments Dislocated Rupture of the posterior capsule while
Into Vitreous removing the cortex is frequently at 12
o’clock and may be due to the use of very
A non perceived or inadvertent major high aspiration parameters, usually 400 to
tear of the posterior capsule or of the zonule 500 mm Hg (Figs. 71 and 128).
when beginning to manage the nucleus or half If the capsule is ruptured during the
way through the nucleus removal may lead aspiration of cortex and vitreous enters the
to having pieces of nucleus or the entire anterior chamber, the first step is to perform a
nucleus fall into the vitreous. The most "dry anterior vitrectomy" or an anterior vit-
important measure is to identify the loca- rectomy with very low flow system and
tion of the rupture and discontinue ultra- proceed to implant the intraocular lens which
264
Figure 152 (left): Posterior Capsule Rupture

- Surgeon Luxates a Lens Fragment into
Anterior Chamber
In the presence of a large posterior

capsule rupture, an anterior vitrectomy is per-
formed. Viscoelastic is infused in the anterior
chamber. One alternative is for the lens frag-
ments (F) to be moved or luxated by the surgeon
to the anterior chamber with a bimanual maneu-
ver. An IOL (I) is placed in the sulcus to shield
the defect. Safe phacoemulsification (P) may
continue with very low ultrasound energy. The
surgeon may decide not to continue with the
phaco technique and convert to ECCE.
Figure 153 (right): Lens Placement over

Large Capsular Disruption.
A large capsular disruption has

occurred resulting in partial absence of
the upper half of the capsular bag. One
alternative is for the surgeon to implant
the IOL (L) with one haptic in the sulcus
(S) above, and the other haptic within
the remaining part of the capsular bag
(C). The haptic in the sulcus above is
secured by a single suture.
265
may serve as a shield protecting the posterior Pars Plana Vitrectomy for
capsule defect (Fig. 154). Aspirating the cor-
tical residues at 12 o’clock is technically
Dislocated Nucleus
difficult (Fig. 128), but may be more difficult
if there has been an incomplete Significant Factors Related to
hydrodissection or a small capsulorhexis Outcome
(Fig. 145). In Fig. 154, you may see that the
surgeon is aspirating the cortical residues Lihteh Wu, M.D., after reviewing the
after a posterior capsule rupture with an IOL world literature, reports that immediate pars
placed to protect the posterior capsule defect plana vitrectomy offers no visual advantage
as a shield so that aspiration can continue. over delayed vitrectomy. As a matter of fact,
Then the cortical residues at the 12 o’clock sometimes it is necessary to wait for the
position are aspirated with a curved cannula. intraocular pressure to be controlled and for
In order to prevent posterior capsule the corneal edema to resolve. Borne,
rupture during the stage of cortex I/A, it is Tasman et al in a classic paper published in
essential not to be aggressive in attempting to "Ophthalmology" in June 1996 in a retrospec-
remove all the remaining cortex and not to do tive review of 121 eyes that underwent pars
the "vacuum cleaning" process. This is risky plana vitrectomy for removal of retained lens
and does not constitute the main source of fragments as a result of phacoemulsification
posterior capsule opacification postopera-
tively.
Figure 154: Aspiration of Cortical Resi-

due after Posterior Capsule Rupture.
The IOL (L) is placed to shield the

posterior capsule defect (D) so that very
low flow aspiration can continue. Cortical
residues (R) at the 12:00 position are being
aspirated with a curved cannula (C).
266
Figure 155: Complications of Posterior Capsule Rupture - Luxation of the Nucleus

Into the Vitreous Cavity
When the nucleus (C) or fragments are dislocated into the vitreous cavity (V), a pars
plana vitrectomy is usually indicated for the extraction of lens nuclear fragments to avoid
future complications. The surgical technique consists of a pars plana vitrectomy with three
ports. The endoiluminator (E), the vitrectomy probe or the ultrasonic fragmentation probe
(F) are inserted through pars plana sclerotomies. The infusion cannula (I) is inserted through
a third sclerotomy to obtain a stable intraocular pressure during the procedure.
Perfluorocarbon liquids (P) are sometimes used in the vitreous cavity to raise the nucleus for
extraction.
referred to the Wills Eye Hospital concluded sion (Fig. 155). However, the risk of retinal
that the timing of vitrectomy does not have a detachment (RD) is increased, and visual
statistically significant impact on visual out- outcome may be adversely affected if RD
come. Neither the type of intraocular lens nor occurs.
the timing of lens implantation significantly The Wills Eye Hospital team also em-
altered the final visual acuity. Most eyes with phasized that during cataract surgery, the sur-
retained lens fragments do well after vitrec- geon must avoid aspirating (without cutting)
tomy, with the majority recovering good vi- any presenting vitreous gel. Attempts to
267
Figure 156: Complications from Posterior Capsule Rupture - Implantation of the

Intraocular Lens
The intraocular lens may be implanted depending on the situation: 1) In the
capsular bag if sufficient posterior capsule remains to serve as partial support, as long as
the anterior capsule is intact. This is shown in Figs. 152, 153, 154. 2) The second
alternative is to fixate the IOL in the sulcus or even sutured (S) to the sclera (IOL). In this
figure, the IOL is shown sutured to the sclera at the level of the ciliary sulcus on both sides,
following vitrectomy. After the vitrectomy is completed, it is recommended to keep the
infusion cannula (I) in place during the fixation of the intraocular lens and remove it at the
end of the entire procedure. This will reassure a stable intraocular pressure during these
maneuvers. IOL implantation at the time of vitrectomy is another alternative when the IOL
was not implanted after anterior vitrectomy and the anterior segment surgeon decided it was
better to do it later. The IOL is sutured to the sclera at the level of the ciliary sulcus, as
shown in "S".
retrieve any lens fragments that have started tures should be confirmed at the time of
to dislocate posteriorly should be made only wound closure. Last, indirect ophthalmos-
with vitrectomy handpieces. The use of lens copy with scleral depression should be per-
loops, forceps, and other instruments that formed at the end of the procedure or by a
have the potential to engage and pull on retinal specialist to identify any retinal tears
vitreous gel should not be used. A complete because these will require at least laser or
limbal vitrectomy should be performed be- cryo retinopexy.
fore any lens placement and the absence of Figure 156 represents an IOL fixated to
vitreous to the wound or other anterior struc- the sulcus after vitrectomy.
268
POSTOPERATIVE COMPLICATIONS
Despite the technological advances and related complications typical of the tran-
that have made cataract surgery an operation sition period from extracapsular to pha-
with such a high rate of success, postopera- coemulsification. If vitreous loss occurs, the
tive complications still occur although less incidence of clinically significant CME in-
frequently. For didactic purposes, we have creases up to 8%.
divided them into medical and surgical com- CME remains a significant cause of
plications. unexpected poor visual acuity after un-
eventful, uncomplicated cataract surgery.
MEDICAL
Pathogenesis
Cystoid Macular Edema Characteristically, fluorescein angiog-
raphy demonstrates leakage from the
Incidence parafoveal retinal capillaries and from optic
nerve capillaries. If the patient is examined
Professor Juan Verdaguer, M.D., from right after fluorescein angiography, dye leak-
Chile points out that the incidence of this age into the aqueous humor can be easily
complication has decreased due to improved seen; consequently, there is evidence of a
surgical techniques and better management of generalized increased ocular vascular perme-
complications. ability. Histopathological studies have dem-
Although the incidence of angiographic onstrated expansion of the extracellular space
CME has been estimated in about 20% in in the outer plexiform layer of the fovea
pseudophakic patients, clinically significant (Henle fibers), giving rise to cystoid spaces
macular edema with reduced visual acuity (Fig. 175 A). There may be also some degree
occurs approximately in 1% of cases under- of subretinal fluid.
going uncomplicated extracapsular cataract The pathogenesis of aphakic and
surgery. pseudophakic CME is not known. Inflam-
CME is more common following com- mation of the iris is considered an important
plicated extracapsular and phacoemulsifi- factor in the pathogenesis; the irritated iris
cation procedures, particularly if the poste- releases a number of inflammatory mediators
rior capsule was ruptured, with vitreous loss that may be involved in CME. Inflammatory
and implantation of an anterior chamber lens mediators, such as prostaglandins, diffuse
269
into the vitreous cavity and into the retina, the hyperfluorescent spaces are separated by
causing the disruption of the blood-retinal a dark hypofluorescent stellate figure. The
barrier at the macular and optic nerve capil- angiographists should be aware of the prob-
laries. ably diagnosis to avoid missing the later
Chronic iris irritation by entrapment of frames that will show this characteristic peta-
iris to the wound with a peaked pupil, vitre- loid or floral pattern (Fig. 157 B).
ous adherence to the wound with iris traction, Late leakage of optic nerve capillaries
anterior chamber intraocular lenses and iris is also demonstrable in the late frames; how-
clip lenses may trigger the release of these ever optic nerve swelling is usually not no-
inflammatory mediators. ticeable ophthalmoscopically.
Fluorescein angiography may be the
Clinical Findings only means of making the diagnosis of CME
if the media is hazy.
The patient may complain of blurred
vision four to six weeks after surgery, or Clinical Course
much later in the postoperative period. In a
patient who has undergone uncomplicated Most patients will experience sponta-
cataract surgery, the surgeon will be sur- neous recovery of visual acuity and resolution
prised by an unexpected and uncorrectable of CME during the first year after surgery
reduced visual acuity, in the range of 20/30 - (Fig. 158). Patients with persistent CME
20/60. Most patients will have a white eye after 6 months may develop permanent
and only a few will show some mild form of loss of vision ("chronic CME"). These
anterior segment irritation. A few patients patients may develop a lamellar macular hole
may show some vitreous inflammatory cells. or pigment epithelial changes.
Clinically, CME may be easily over-
looked, unless the macular area is carefully Treatment
examined at the slit lamp with a Goldman
contact lens or similar. The macula appears Verdaguer clarifies that current thera-
thickened, with intraretinal cystoid spaces, in peutic intervention for prophylaxis and treat-
a honeycomb pattern; the foveal reflex is lost ment of CME are based on blocking the
(Figs. 157 A, B, C). A few patients show inflammatory mediators that may be in-
evidence of epiretinal membrane formation, volved in CME, mainly the prostaglandins.
with cellophane-like reflexes. Prostaglandins are synthesized from
Fluorescein angiography is diagnostic. arachidonic acid released from cell mem-
Early phases demonstrate a very slow leakage branes by phospholipase A 2. Cyclo-oxyge-
from the parafoveal retinal capillaries. In the nase converts arachidonic acid to cyclic inter-
later frames, the dye fills the cystoid spaces; mediates and then to prostaglandins.
270
Figure 157: Cystoid Macular Edema after Complicated Cataract Surgery with
Rupture of the Posterior Capsule and Anterior Chamber IOL
(A) Cystoid spaces at the macula and soft exudate inferonasal to the macula.
(B) Late filling of cystoid spaces with fluorescein, in a petalloid pattern. Leakage
from optic nerve capillaries. (C) Late frame of fluorescein angiography after 6
months of topical treatment (sodium diclofenac + prednisolone acetate 1%) shows
marked improvement. (Courtesy of Prof. Juan Verdaguer, M.D.)
271
Figure 158: Cystoid Macular Edema after Uncomplicated Extracapsular

Cataract Surgery
(A) Four months after surgery, visual acuity 20/100. (B) Three years
after surgery, visual acuity 20/25. Spontaneous improvement. (Courtesy of
Prof. Juan Verdaguer, M.D.)
Corticosteroids prevent the release of Treatment of Chronic CME

arachidonic acid from cell membranes, by
blocking phospholipase A 2. Non steroidal Pooled data from randomized clinical
antiinflammatory drugs are cyclo-oxygenase trials indicate a treatment benefit in terms of
inhibitors, blocking the synthesis of prostag- improving final visual acuity by two or more
landins. lines. These studies report the efficacy of a
combination of corticosteroid and cyclo-
Prophylactic Treatment oxygenase inhibitors (COI, or NSAID's). In
all but one trial, COI was tested alone with
A randomized clinical trial by Flach et good results. Since there might be a synergis-
al demonstrated that cyclo-oxygenase inhibi- tic effect, the following approach is sug-
tors (COI) alone used prophylactically re- gested:
duced the incidence of CME after cataract 1. Topical corticosteroids, prednisone ac-
surgery. Ketorolac tromethamine 0.5% oph- etate 1% four times daily + topical COI
thalmic solution was administrated three (diclofenac sodium 0.1% or flurbiprofen so-
times daily beginning one day before surgery dium 0.03% or ketorolac tromethamine 0.5%)
and continued for 19 days postoperatively. four times daily. The treatment is maintained
Given the relatively low incidence of CME in at least for two months, with careful monitor-
uncomplicated cataract surgery, prophylactic ing of the intraocular pressure. If the patient
treatment is seldom used. has a steroid pressure response, treatment
272
should be limited to topical COI. In case of at the macula, and disc leakage, will have a
favorable response, the regime is tapered very predominantly postsurgical CME.
slowly. If there is no response at two months,
the following interventions could be consid- Treatment Recommendations
ered, without discontinuing the initial treat-
ment. 1. Optimize medical treatment.
2. Periocular steroid injections limited (metabolic control, arterial hypertension,
to a maximum of three. dislipidemia, anemia).
3. Carbonic anhidrase inhibitors may 2. Use topical steroids and COI, to
work in a few patients but may be poorly treat the presumed pseudophakic CME.
tolerated. 3. Laser photocoagulation, focal or
4. Surgery should be considered only in grid, if there are leaking microaneurysms or
patients with surgical complications that have diffuse leakage, with lipid exudation and reti-
modified the anatomy of the anterior segment nal hemorrhages.
and only if a well conducted pharmacological
therapeutic trial has failed. PHOTIC MACULOPATHY
In patients with vitreous incarceration
in the wound, Nd:YAG vitreolysis may be
The intense illumination system of
tried, but is difficult. An anterior vitrectomy,
modern operating microscopes may induce
with repair of vitreous adhesion to the wound
photochemical retinal injury. The first cases
or iris may be the procedure of choice in these
of phytotoxicity after uneventful cataract sur-
cases. More extensive surgery may be re-
gery were described by McDonald and Irvine
quired if there is significant lens malposition.
(1983).
Diabetes and Cystoid Macular
Photochemical vs Photothermal
Edema
Damage
Verdaguer is an authority on diabetic
Verdaguer clarifies that photochemical
retinopathy. He emphasizes once again that
injury is different from photothermal damage
patients with preexisting diabetic macular
(photocoagulation). Photocoagulation occurs
edema are at substantial risk for worsening of
after brief and intense light exposure; photo-
the macular edema following cataract sur-
chemical injuries develops after prolonged
gery. Moreover, diabetics are probably more
exposure at intensity too low to induce photo-
susceptible to pseudophakic CME. The two
coagulation. Photocoagulation induces an
conditions, diabetic macular edema and post-
immediate visible reaction; photochemical
surgical CME may, in fact, coexist in a given
damage is not immediately recognizable.
diabetic patient. Patients with lipidic exu-
In photochemical injuries, light activa-
dates, retinal hemorrhages, perifoveal
tion of cell molecules generates oxygen sin-
microaneurysms, diffuse or focal leakage at
glets (free oxygen radicals). These are very
angiography will have a predominantly dia-
toxic and induce oxidation and damage of cell
betic macular edema. Patients without these
components.
characteristics, a petaloid pattern of leakage
273
Shorter wavelengths carry most energy to the center of the fovea. If the eye is
(UV and blue visible light) and are more infraducted by a superior rectus suture, the
likely to produce photochemical damage. lesion will be located below the macula.
Fluorescein angiography will show in-
Incidence tense staining of the oval plaque. Cicatricial
changes are apparent within the first week,
Juan Verdaguer points out that the with pigmentary mottling and athropic
incidence of photoretinal injuries during ext- changes of the pigment epithelium within a
racapsular cataract surgery has been esti- sharply demarcated oval area. The lesion
mated at 7 to 28% in different series. Photic shows a highly characteristic leopard-skin
retinal injury did not develop after pha- appearance.
coemulsification in one series, with careful The scotoma fades rapidly and the
limiting of coaxial exposure time and micro- visual acuity may improve, unless the lesion
scope irradiance. is large and involves the macula. Fluorescein
angiography will reveal changes restricted to
Risk Factors the oval scar, with window defects and
blocked fluorescence corresponding to the
The main risk factors associated with areas of hyperpigmentation (Fig. 159).
photochemical damage are duration of the
exposure (longer surgery time) and intensity Preventive Measures
of the operating microscope illumination.
Longer surgery times have been associ- The illuminating light should not be
ated with increased incidence of retinal pho- brighter than necessary and the cornea
tochemical injuries. However, the complica- should be covered whenever the surgeon is
tion has occurred in short, uneventful proce- not working intraocularly. A finger blocking
dures. Therefore, the skilled, rapid, experi- the light may suffice.
enced surgeon, should not disregard the dan- Indirect illumination, instead of co-
gers of photoxicity. axial illumination should be used during
closure of surgical wound in extracapsular
Clinical Findings procedures, since the risk is maximal follow-
ing implantation of the lens, with the light
The patient may complain of a scotoma
clearlu focused directly on the retina.
that may be central or paracentral, in corre-
Tilting the microscope toward the sur-
spondence to the retinal injury location. A
geon and infraduction of the globe may
few patients may give a history of postopera-
displace the light below the fovea.
tive erithropsia. In other cases the main
Small incision phacoemulsification
complaint may be unexpected poor visual
technique is less likely to induce light toxic-
acuity, if the injury is near the fovea.
ity, since the instruments remain in the visual
Visible changes at the retina will be
axis most of the time and operating times are
apparent 24 to 48 hours following exposure.
reduced in the hands of experienced sur-
In the early postoperative period the lesion
geons. There is no treatment for this
appears a subtle creamy deep, pale oval le-
complication.
sion, usually just below or above or temporal
274
Figure 159: Photic Maculopathy after Extracapsular Cataract

Surgery - Cicatricial Stage
(A) Pigmentary mottling and cicatricial changes within an

oval scar. (B) Typical leopard-skin appearance at angiography.
(Courtesy of Prof. Juan Verdaguer, M.D.)
Photosensitizing agents, such as 1) Intravitreal injections in endoph-

hidroxchloroquine,phenotiazines, allopurinal, thalmitis treatment regimes. Toxicity may
etc., should be discontinued before surgery, follow administration of gentamicin at rec-
since they may potentiate photic damage to ommended doses. Verdaguer has seen this
the retina. complication after intravitreal injection of
0.15 mg of gentamicin, a dose previously
AMINOGLYCOSIDE considered safe.
Treatment of post surgical endoph-
TOXICITY thalmitis should include the intravitreous in-
Aminoglycosides have been widely jection of an antibiotic which acts effectively
used in the prophylaxis and treatment of against gram-positive organisms (vancomy-
ocular infections. Macular infarction is a cin) and one that is effective against gram
severe complication that has been mainly negatives, since gram-negative endoph-
associated with the administration of gen- thalmitis is much more common. Given the
tamicin, but has also been reported after use very narrow safe therapeutic window of
of amikacin and tobramycin. aminoglycosides, a good choice would be a
Juan Verdaguer emphasizes that cephalosporin such as ceftazidime. If the
aminoglycoside toxicity may be related to: surgeon is confronted with an acute postsurgi-
275
cal endophthalmitis and ceftazidime is not macular area. (Intravitreal aminoglycosides

available, an aminoglycoside should be intend to settle on the posterior pole in the
cluded in the intravitreous injection, at the supine position). Examination reveals milky
lowest effective dose (100 mg of gentamicin white opacification of the retina, a cherry red
or 400 mg of amikacin). Even at these doses, spot and a few blot retinal hemorrhages. The
toxicity cannot be ruled out. appearance is similar to that seen in central
2) Prophylactic intravitreous injec- retinal artery occlusion, but limited to the
tions in severe trauma cases. Verdaguer posterior pole. It also differs from branch
has seen this complication after a prophylac- retinal arterial occlusion, since the infarction
tic intravitreous tobramycin injection. involves the retina both above and below the
Aminoglycosides should not be used macula. Fluorescein angiography reveals
intravitreally for prophylactic purposes. sharply demarcated central area of occlusion
Endophthalmitis is a treatable disease and of the retinal vessels and some perivascular
aminoglycoside toxicity is not. leakage (Fig. 160).
(Campochiaro et at).
3) Following uncomplicated subcon-
junctival injection after routine cataract sur-
gery. Although this has been reported in the
literature, Verdaguer has never seen a case.
The complication is believed to be associated
with leakage of the antibiotic into the eye
through the cataract wound (with or without
sutures). The tunnelled, non-sutured wounds, Figure 160: Aminoglycoside Toxicity 2 Months after
Intravitreous Injection of Gentamicin
create a one way valve, allowing subconjunc-
tival antibiotics and access into the anterior Vascular occlusion involving the temporal ves-
chamber. Subconjunctival antibiotic injec- sels (Macular infarction). (Courtesy of Prof. Juan
Verdaguer, M.D.)
tions, if used, should be placed in the quad-
rant opposite to the wound.
4) Dilution errors in intravitreal injec-
tions.
5) Inadvertent intraocular injection due
to confusion with miochol or other sub-
stances. If the mistake is discovered dur-
ing surgery, profuse anterior segment lavage
should be done, immediately. Immediate
vitrectomy has also been recommended.
Clinical Findings
Vision is profoundly affected the day

following surgery or the intravitreal injection.
Usually, the retinal infarction affects the
276
The condition is untreatable and irre- How LECs Invade the Posterior
versible. Optic atrophy and atrophic and Capsule
pigmentary retinal changes develop later.
Nishi has pointed out that residual
POSTERIOR CAPSULE LECs proliferate at the pre-equatorial germi-
OPACIFICATION native zone and migrate posteriorly onto the
posterior capsule postoperatively. In addi-
tion, when the anterior capsule comes into
Overview contact with the posterior capsule, the LECs
underneath the anterior capsule also mi-
Okihiro Nishi, M.D., is a renowned grate onto the posterior capsule abun-
authority on this subject because of his exten- dantly, before the two capsules adhere and
sive research and revealing findings. Nishi grow together. The apposition of the anterior
has emphasized that posterior capsule opaci- capsule and the posterior capsule can induce
fication (PCO) is the most frequent postop- fibrotic PCO.
erative complication associated with de-
creased vision in cataract surgery. Itoccurs Role of IOL in PCO
with an incidence of up to 50% within 5 years
after surgery.
When the IOL is in the capsular bag
Various mechanical, pharmaceutical
the optic can separate both capsules, and
and immunologic techniques have been ap-
interferes with the LEC migration from the
plied in attempts to prevent PCO by removing
anterior capsular edge onto the posterior cap-
or killing residual lens epithelial cells
sule. The inhibition of migrating LECs and
(LECs), but none has been confirmed to be
the separation of the capsules by the IOL
satisfactorily practical, effective and safe for
optic are the main reasons why the incidence
routine clinical practice. Nishi emphasizes
of PCO is significantly lower in eyes with
that the most effective approach to reduce or
an IOL than in those without one.
delay the incidence of PCO is by inhibiting
the migration of LECs and not by killing the
cells. Specific Features of the AcrySof
and PCO
Main Causes of PCO
Nishi points out that the AcrySof IOL
Recent clinical, pathological and ex- reportedly has a significant low incidence of
perimental studies have emphasized that PCO PCO. His recent studies indicate that this
is usually secondary to a proliferation and effect may be due to the sharp and rectangular
migration of residual lens epithelial cells. edge design of the AcrySof IOL. His histo-
(LECs). pathologic findings of the lens capsule con-
277
taining an AcrySof IOL in rabbits disclose Role of Continuous Curvilinear

that the lens capsule wrapped the IOL so
firmly that it conformed faithfully to the
Capsulorhexis in PCO
rectangular sharp optic edge of the IOL
and that migrating LECs were apparently Nishi emphasizes that continuous cur-
inhibited at this capsular bend or angle vilinear capsulorhexis (CCC) can contribute
created by the sharp edge and posterior to reduce PCO because it facilitates the im-
capsule by contact. The creation of such a plantation of an IOL symmetrically in the
bend or angle in the posterior capsule re- capsular bag maintaining it there without
quires a well-centered CCC, smaller than decentration. It is extremely important to
the IOL optic, so that the CCC edge is in create a well-centered CCC of the correct size
apposition to the optic. for the prevention of migrating LECs. The
On the other hand, the role of this lens CCC edge should be smaller than the IOL
may be dependent not only on the rectangular optic and cover its margin (Fig. 145). A
edge design but also on the features of the decentered, oversized CCC or incomplete
IOL acrylic material, such as adhesiveness. CCC with a radial tear (Fig. 146) may result
The AcrySof IOL has triple the adhesiveness in the apposition of both capsules. Even
to a collagen film compared to a PMMA IOL. though the defective area lies in a very lim-
The adhesiveness may also help to facilitate ited circumference, the LECs migrate from
the creation of the bend. Moreover, the the edge of the anterior capsule onto the
acrylic material itself may have effects on the posterior capsule, causing PCO.
inhibition of migrating LECs. This adhesive-
ness property of the acrylic lens, which we Main Factors that Reduce PCO
described as "tackiness" in Chapter 9 under
"Advantages and Properties of Acrylic Nishi clarifies that there are three key
Lenses" merits further investigation. This factors that play an important role in reducing
"tackiness" or adhesiveness seems to play a the incidence of PCO: 1) the design of the
role in the positive effects of the AcrySof IOL, which results in the creation of a sharp
lens. If so, then this might be a factor of bend in the capsule. The discontinuous,
particular importance for the use of acrylic rectangular bend or angle in the posterior
lenses and designs of future IOL's. capsule interferes with the proliferation of
From the analysis provided here, it is LECs. 2) The material of the IOL, which
clear that the preventive effect on PCO of an points to the benefits of some acrylic because
AcrySof IOL may be both design and mate- of its adhesive properties and
rial dependent. biocompatibility (less fibrosis). 3) The surgi-
cal technique which emphasizes a perfectly
278
centered CCC of smaller size than the IOL Nevertheless, there are important
optic. contraindications to making a small capsulo-
In addition, Nishi strongly recom- tomy. The most important are: 1) Difficulties
mends a NSAID for 3 months postopera- in the evaluation of the retinal fundus. 2) The
tively, in order to reduce postoperative in- center of the capsulotomy may be clear fol-
flammation with conversion of mononuclear lowing treatment but the rest of the capsule
cells into fibroblasts, and possibly prolifera- remains opaque, and sometimes with a crys-
tion of residual LECs. talloid appearance. Patients with macular
degeneration, for example, may see better
Visual Loss from PCO - when the capsulotomy is wide enough to
Differential Diagnosis prevent contrast reducing haze from the re-
sidual hazy peripheral capsule. In those cases
It is often a rather difficult clinical it is better to dilate the pupil 4-5 mm preop-
judgment to determine if the capsule opacity eratively in order perform a more effective
is in fact responsible for the patient`s de- treatment.
creased vision. The principal misdiagnosis is Dodick generally makes a capsule
to believe that the capsule is responsible for opening the size of a normal pupil, 3-4 mm at
the problem when, in fact, the patient has the most.
developed a cystoid macular edema which
may be difficult to detect because of the Posterior Capsulotomy Laser
posterior capsular opacity. When in doubt, a Procedure
pre-capsulotomy fluorescein angiography is
appropriate to determine if macular edema is Timing
present.
Alice McPherson, M.D., was one of
PERFORMING THE POSTERIOR the first retina specialists to demonstrate that
CAPSULOTOMY retinal detachment could be precipitated by
early YAG laser posterior capsulotomy. She
Size of Capsulotomy has advised waiting approximately 4-6
months after cataract surgery to perform a
Some prestigious anterior segment sur- YAG laser posterior capsulotomy. The prior
geons have advocated not dilating the pupil dictum to wait one year, was done to be sure
for performing a YAG posterior capsulotomy. all inflammation was finished, in order to
Many patients' pupillary openings are not avoid cystoid macular edema.
located in the exact anatomical center of the McPherson has pointed out that once a
iris. Once the pupil is dilated, it can be capsulotomy is performed, the pseudophakic
difficult to identify where the true pupillary eye is actually like an aphakic eye. Keeping
opening was located. the patient`s posterior lens capsule in place as
279
Figure 161: Nd:YAG Laser Cruciate Pattern in Posterior Capsulotomy
For laser posterior capsulotomy, leave the pupil undilated because

many pupils are not in the exact anatomical center of the iris. Leaving the
pupil undilated allows the surgeon to open the capsule in exactly the correct
location. Use a cruciate pattern as shown here to avoid pits in the center of the
intraocular lens.
long as possible can reduce the tendency for adequate opening can be made with 10 laser
vitreous traction on the periphery. After the applications or less, depending on how
YAG capsulotomy is done, any predisposing taught the capsule is. A cruciate pattern is
factor can increase the potential for a retinal recommended, starting in the periphery at 12
detachment or cystoid macular edema. o'clock, working down across the center of
the capsule toward 6 o'clock, and complete
Technique the cross from 3 to 9 o'clock (Fig. 161). The
capsule will usually retract further after com-
Use the lowest level energy pulse that pleting the capsulotomy.
will open the capsule, usually 1 mJ. An
280
Complications Following Nd:YAG lotomy or a disruption of the anterior hyaloid

Posterior Capsulotomy might produce posterior retinal traction, an-
other possible cause for CME. Thus, a poten-
tial relationship does exist. In suspicious
Intraocular Pressure Elevation
cases only a fluorescein angiogram after the
treatment may provide the answer.
The most common complication is a
transient pressure elevation. This must be
anticipated and treated prophylactically. The POSTOPERATIVE
most effective method is to instill one drop of ASTIGMATISM IN
brinzolamide or dorzolamide 30 minutes be- CATARACT PATIENTS
fore and one drop following the laser proce-
dure. Patients at higher risk of developing
With present advances in small incision
transient elevation of the intraocular pressure
cataract surgery, particularly with clear cor-
are those that have anterior chamber intraocu-
neal incisions, postoperative astigmatism fol-
lar lenses and patients with pre-existing glau-
lowing phacoemulsification should be mini-
coma.
mal. A well trained surgeon creates an astig-
matically neutral incision to prevent an in-
Retinal Detachment duced astigmatism.
If astigmatism is present preoperatively,
A higher percentage of pseudophakic the surgeon addresses the problem at the
detachments occurs in cases with a history of time of cataract surgery. By placing the
fellow eye detachment, preexisting retinal corneal incision in the indicated axis, preex-
disease such as lattice degeneration and reti- isting astigmatism and cataract surgery are
nal holes, or in eyes with axial lengths above performed simultaneously. This latter subject
25 mm. Retinal detachments associated with which we term "Refractive Cataract Surgery"
Nd:YAG laser posterior capsulotomy occur is addressed at the beginning of Chapter 12
most often within the first 6 months following (Cataract Surgery in Complex Cases).
capsulotomy.
MANAGEMENT
Cystoid Macular Edema
Astigmatism, either preexisting that
It is not well-known yet whether was not fully corrected or induced may be
Nd:YAG laser capsulotomy can induce the managed after cataract surgery either with
formation of cystoid macular edema (CME) incisional refractive surgery (astigmatic kera-
in a quiet eye. Anterior segment inflamma- totomy) or with excimer laser (LASIK or
tion can occur after laser capsulotomy, and PRK).
inflammation has been identified as an etio-
logic factor for CME especially if laser treat- How to Proceed
ment has been more intensive than the param-
eters already established. In addition, pro- Wait a minimum of three months fol-
lapse of vitreous anteriorly through the capsu- lowing surgery in order to deal with a stable
281
astigmatism and do the adequate evaluation.

The patient is examined with refraction,
keratometry and corneal topography.
Techniques
The surgeon may perform either an

excimer laser procedures (Fig. 162 A-B) or an
astigmatic keratotomy (AK) (Fig. 162-C) in
order to either enhance the effects of the
cataract incision on any remaining astigma-
tism or correct an astigmatism induced during
the cataract operation, which is usually re-
lated to large incision, planned extracapsular.
How These Techniques Work
LASIK or PRK may either flatten the

steep meridian or steepen the flat meridian.
On the other hand, AK incisions work by
flattening the steep axis. Tough not as accu-
rate as when treating spherical corrections,
myopic astigmatism treatment has been in-
creasingly successful, on the order of 80% of
intended correction.
Procedure of Choice
Most surgeons prefer using astigmatic

keratotomy (AK) because: 1) it is highly
effective; 2) costs are much lower than
excimer laser procedures.
If the astigmatism is larger than 1.5 D
Figure 162: Correcting Astigmatism Following Cataract
against the rule, paired with-the-rule inci- Surgery
sions are done because they can augment the
astigmatism-reducing effect (Fig. 162-C) Figures 162 A and B show the use of excimer laser in
postoperative astigmatism. The actual surgical procedure for
Oshika et al in Japan reported a pro- astigmatism, either LASIK or PRK, is the same as for
spective evaluation of predictability and ef- spherical ametropias. In LASIK, when treating simple or
fectiveness of arcuate keratotomy treating compound myopic astigmatism, the excimer beam (L) also
flattens the steep axis. Figure C shows the additional relaxing
corneal astigmatism after cataract surgery in incisions that can be used in the postoperative period with
astigmatic keratotomy (AK). The AK technique is the same
as described for congenital or idiopathic astigmatism, al-
though not as predictable.
282
104 eyes. They concluded that astigmatic choice is a 7 mm optical zone to avoid
keratotomy in pseudophakic eyes is less pre- visual aberrations with a smaller optical
dictable than that in eyes with idiopathic zone. The effect of these arcuate relaxing
astigmatism, but the procedure is sufficiently incisions is titrated by the length of the inci-
effective in reducing the residual astigmatism sions (Fig. 164).
after cataract surgery. Individual nomograms
are necessary for astigmatic keratotomy in Highlights of AK Procedure
eyes with naturally occurring and postsurgi-
cal astigmatism. In figure 164 we present Anesthetize the eye with the topical
Richard Lindstrom's nomograms. anesthetic of your choice. The center of the
pupil is marked with the tip of a .12 mm
Key Factors in the Effects of forceps which has been painted with Gentian
Astigmatic Keratotomy violet. A 7 mm (or the diameter selected)
optical zone marker (Fig. 163) is centered
These are related to the diameter of the over the pupil and pressed down. The axis of
optical zone utilized (Fig. 163), and the the steepest meridian is identified with two
length and depth of the incisions. In correct- marks, 180º apart, over the 7 mm optical
ing postoperative astigmatism a common zone previously marked.
Figure 163: Marking the Central Optical

Zone in Astigmatic Keratotomy
Following the marking of the visual

axis (V), and steep meridian, the optical zone,
which will remain free of any incisions, is
delineated with this optical clear zone marker.
The size of the optical zone (T) is determined
by the data specific to each patient's required
correction (Nomogran in Fig. 164).
283
Find patient age group, then move right to find a result closest to refractive cylinder.
To calculate the size of the transverse incision (when indicated) as compared to the
amount of degrees of the Arcuate Keratotomies outlined above, you may use the
following equivalents:
30º arc= 2.0 mm 45º arc= 2.5 mm 60º arc= 3.0 mm 90º arc= 3.5 mm
Make one or two arcuate incisions Dodick, M.D., and Susan Batlan, M.D.,
(Fig. 162-C) in the 7 mm zone according to recently developed a technique to solve this
the nomogram (Fig. 164). The wound is situation.
inspected and irrigated.
The Most Common Indications
EXPLANTATION OF for Explantation
FOLDABLE IOL'S
The most common indications for ex-
plantation are dislocation or improper fixa-
RETAINING THE BENEFIT OF tion, chronic inflammation, anisometropia,
THE SMALL INCISION improperly oriented haptics, a defective in-
traocular lens, and haptic breakage.
The problem arises once a flexible Flexible intraocular lenses, which are
IOL has been implanted and there is need being used with increasing frequency with
to remove it. How can we proceed to small incision cataract surgery, are introduced
explant the IOL while retaining the benefits into the eye through a 3.0 to 3.4 mm wound.
of small incision cataract surgery? Jack Explantation without enlarging the wound is
284
certainly desirable in order to retain the ben- purpose of small incision cataract surgery
efit of the small incision. because the original wound needs to be en-
larged from 5.0 to 6.0 mm to facilitate in-
Problems Presented by traocular lens removal.
Traditional Techniques Description of New Technique
Explantation has usually been a delicate Because the average central anterior
problem to handle. The techniques suggested chamber depth is usually 3.0 mm it is difficult
for this purpose have been technically diffi- to invert the intraocular lens to properly reori-
cult and risk compromising the corneal endot- ent the haptics. Further, removal of the
helium and posterior lens capsule. intraocular lens in one piece is not possible
Most procedures for intraocular lens without enlarging the wound size, even if it is
explantation have included enlarging the a flexible IOL.
wound and extruding the unfolded intraocular Dodick and Batlan first deepen the
lens in one piece or bisecting the intraocular anterior chamber and expand the lens capsule
lens under viscoelastic with Vannas scissors with a superior quality viscoelastic. They
before removal through the wound. The need then incise the IOL optic along its radius with
to enlarge the wound, however, defeats the Gills' capsulotomy scissors (Fig. 165). This
Figure 165: Explantation of Foldable

IOL While Maintaining a Small Incision -
Stage 1
The small incision size can be main-

tained in cases where it is necessary to re-
move a foldable intraocular lens. First, the
anterior chamber is deepened with viscoelas-
tic. Gills capsulotomy scissors (S) are used
to partially incise the intraocular lens optic
(L), along its radius. This radial incision
extends from the periphery of the optic to the
center of the optic, as shown by the position
of the scissors in the illustration. The half-
bisected optic will then hinge at the center
when explanted (see Fig. 166).
285
maneuver allows the lens to be folded in half, presence of rupture of the posterior capsule
and creates a lens with no part greater than particularly when lens fragments are mixed
3 mm in width. The superior haptic is then with the vitreous. What to do and what not to
grasped with Kelman-McPherson forceps and do is addressed in this same chapter under
the intraocular lens, with the optic folded in Intraoperative Complications of Pha-
half, is gently pulled through the incision. coemulsification - Posterior Capsule Rup-
The elastic properties of the flexible IOL ture. This is an uncommon complication but
enable the surgeon to deform the optic and it does occur in the initial stages of the
remove the intraocular lens in one piece learning curve during the transition from
(Fig. 166) ECCE to phacoemulsification.
By utilizing this technique for explanta-
tion of a foldable IOL following small inci- Clinical Course of RD
sion cataract surgery, the surgeon does not
compromise the integrity of the original Patients typically complain of photopsias,
wound, posterior lens capsule, or corneal floaters, scotomas and blurry vision. Previous
endothelium. reports have emphasized the poorer outcome
of surgery for RRD in pseudophakic eyes as
RETINAL DETACHMENT compared to phakic eyes. These authors expe-
rience is that peripheral capsular opacifica-
Risk Factors tion, lenticular remnants and the optical ef-
fects induced by the rim of the IOL impair
Cataract extraction is a well-known visualization of the small peripheral retinal
risk factor for the development of a breaks by indirect ophthalmoscopy, thereby
rhegmatogenous retinal detachment (RRD). interfering with the vitreoretinal surgeon's
Anywhere from 20% to 40% of RRD occur in best performance.
eyes that have undergone cataract surgery In the present practice of clinical oph-
(Fig. 167). thalmology, repair of retinal detachment is
routinely referred by the cataract surgeon to a
Incidence vitreoretinal surgeon.
The incidence of RRD following POSTOPERATIVE

ECCE and PCIOL implantation has been ENDOPHTHALMITIS
reported to be between 0.25% and 1.7%. The
incidence of retinal detachment is less in By definition, endophthalmitis refers
patients with uncomplicated phacoemulsifi- to the presence of an inflammatory reaction in
cation because this procedure is performed both the anterior and posterior segments of
through a self-sealing, watertight small inci- the eye. Its etiology may be infectious or
sion with improved safety during the proce- noninfectious. The infectious nature of en-
dure. It is also significantly less invasive. dophthalmitis is one of major concern to
The rate of RD associated with ophthalmic surgeons. Fortunately, it has be-
phacoemulsification greatly increases in the come a highly infrequent complication.
286
Figure 166 (left): Explantation of Foldable IOL

While Maintaining a Small Incision - Stage 2
The superior haptic (H) is then grasped with

Kelman-McPherson forceps (F) and the incised IOL
is gently pulled through (arrow) the small 3.2 mm
incision. The greatest width of the half-incised 6.0
mm optic is now 3.0 mm and therefore will fit
through the maintained small incision.
Figure 167 (right): Difference Between Phakic

and Pseudophakic Detachments
Classic pseudophakic retinal detachments

differ from phakic retinal detachments in two
major ways. Retinal detachments (R) with an
intraocular lens (L) following cataract surgery are
usually associated with more anteriorly located
multiple breaks (M) along the posterior margin
of the vitreous base (dotted line). Also with
pseudophakos, these types of breaks tend to be in
multiple quadrants. On the other hand, phakic
detachments often tend to involve a single quad-
rant with one tear. The second major difference
between phakic and pseudophakic detachments is
in the reduced ability of the surgeon to see the
peripheral retina in the case of pseudophakos (not
shown).
287
The causes of infectious endoph- Management and Visual

thalmitis include bacterial and fungal organ- Outcome
isms. Depending on its time course, endoph-
thalmitis may be further classified as acute or The management of acute postopera-
chronic. The speed with which the patient tive bacterial endophthalmitis has been influ-
develops symptoms is directly proportional to enced by the results of the Endophthalmitis
the virulence of the organism. Vitrectomy Study. This study provides es-
sential information for the understanding of
Relative Virulence of Organ- how to proceed in the care of patients with
isms this potentially devastating complication. Its
guidelines are as follows: 1) A vitreous
Highly virulent organisms that are specimen needs to be obtained for culture
commonly isolated include Staphylococcus and sensitivity as soon as possible (Fig. 168).
aureus, Streptococci and Gram negative 2) Intravitreal amikacin (0.4 mg / 0.1 mL)
rods. Staphylococcus epidermidis is a little and vancomycin (1.0 mg / 0.1 mL) must
less virulent and happens to be the most be injected after the specimen is obtained
common organism isolated. Propionibacte- (Fig. 168). 3) If the initial visual acuity was
rium acnes and fungi present in a more hands motion or better, study results suggest
indolent manner. Noninfectious causes in- that the visual outcome is the same whether
clude retained lens fragments. According to or not immediate pars plana vitrectomy is
Professor Juan Verdaguer, the most com- done. 4) Vitrectomy is indicated in those
mon endophthalmitis is the one produced by eyes with initial visual acuity of light percep-
gram-negative organisms. tion or worse. Systemic antibiotics did not
affect the visual outcome of patients in the
Clinical Findings and Source study. 5) The visual outcome was better in
of Infection those eyes with better visual acuity at presen-
tation, underscoring the need for early di-
In acute cases, the patient often com- agnosis.
plains of progressive worsening of vision, In the cases where fungal or P. acnes
redness, ocular discharge and increasing ocu- endophthalmitis is suspected, a vitrectomy is
lar pain. Examination often reveals eyelid usually indicated with the injection of
edema, chemosis, corneal edema, intense cell intravitreal antibiotics or antifungals.
and flare, iris hyperemia, vitritis and hy-
popyon. Visual loss is often secondary to the INTRAOCULAR LENS
release of toxins and the inflammatory reac-
tion. The main sources of infection are the
DISLOCATION
normal bacterial flora in the lids and conjunc-
tiva. Scrubbing the lids with povidone 5% Posterior dislocation of an IOL is an
just prior to surgery is an effective way of uncommon complication of cataract surgery.
reducing the bacterial load. Its frequency appears to have increased in the
288
Figure 168: Technique of Vitreous Tap

in Diagnosis and Intravitreal Adminis-
tration of Antibiotics
A Ziegler knife (or equivalent) is

inserted 3 mm posterior to the limbus to
create a tract into the vitreous. The knife
is directed toward the mid-vitreous cav-
ity. The knife is removed and a 22 gauge
needle attached to a small syringe is
inserted through the tract made by the
knife. A vitreous specimen is obtained
for culture and sensitivity studies. An-
other syringe is attached to the needle and
amikacin (0.4 mg / 0.1 mL) and vanco-
mycin (1.0 mg / 0.1 mL) are injected
intravitreally immediately after the vitre-
ous specimen is obtained.
past few years as more surgeons enter into the floater. Posterior capsular rupture or zonular
inevitable steep learning curve of phacoemul- dialysis are usually present. The IOL may be
sification in which posterior capsule ruptures freely mobile in the vitreous cavity, may be
may occur. The great emphasis given to the fixed to the retina, or may be seen hanging
Transition into Phaco in Chapter 7 of this with one haptic attached to the posterior
Volume is precisely oriented toward facilitat- capsule, iris or ciliary body.
ing a successful and comfortable approach to
this procedure. Management
Symptomatology Observation can be recommended if the
IOL is not mobile and there are no retinal
The patient with intraocular lens dislocation complications, but this would defeat the pur-
often complains of sudden loss of vision due poses of the operation. We can not expect the
to the uncorrected aphakia. If complications patient to be satisfied with aphakic spectacle
such as retinal detachment, cystoid macular correction or contact lenses.
edema or vitreous hemorrhage occur, the pa- Several surgical options are available.
tient may also complain of loss of vision. If These include removal, exchange or reposi-
the IOL is mobile in the vitreous cavity, it tioning of the IOL. Repositioning of the IOL
may be observed by the patient as a huge into the ciliary sulcus or over posterior capsu-
289
lar remnants with less than a total of 6 clock BIBLIOGRAPHY

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change (removal of the dislocated IOL and
Borne, MJ., Tasman W., Regillo, C., Malecha, M.,
placement of a flexible open loop anterior
Sarin, Lou: Outcomes of vitrectomy for retained
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should be considered if adequate capsular Centurion.
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soon available. (The Nu-Vita phakic anterior thalmology, 1992 Jan; 99(1):51-57.
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Endoophthalmitis Vitrectomy Study Group. Re-
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it alone and implant a second IOL. tomy and of intravenous antibiotics for the treat-
ment of post-operative bacterial endophthalmitis.
The Role of Silicone Plate IOL's Arch Ophthalmol 1995; 113:1479-1496.
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rectomy with placement of an open-loop, flesible tion technique for dislocated posterior chamber
anterior chamber lens. Ophthalmology 1998; intraocular lens implants [letter]. Arch Ophthalmol
105(6):1011-1014. 1998 Jul; 116(7):967.
Nishi, O: Prevention of posterior capsule opacifi- Smiddy WE, Ibanez GV, Alfonso E, et al: Surgical
cation after cataract surgery: theoretical and prac- management of dislocated intraocular lenses. J
tical solutions. Atlas of Cataract Surgery, Edited Cataract Refract Surg 1995 Jan; 21(1):64-69.
by Masket S. & Crandall AS, published by Martin
Dunitz Ltd., 1999, 24:205-212. Wilkinson CP: Pseudophakic retinal detachments.
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Nishi, O: Removal of lens epithelial cells by ultra-
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Nishi O, Nishi K, Fujiwara T, Shirasawa E: Effects

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21:461-5.
Oshika T, Shimazaki J, Yoshitomi F, Oki K, Sakabe

I, Matsuda S, Shiwa T, Fukuyama M, Hara Y:
Arcuate keratotomy to treat corneal astigmatism
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predictability and effectiveness. Ophthalmology,
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Powe NR, Schein OD, Gieser SC, et al: Synthesis

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291
292
C h a p t e r 12: Cataract Surgery in Complex Cases
CATARACT SURGERY
IN COMPLEX CASES
In previous chapters we have discussed Aims of this Chapter

in depth how to evaluate the patient preop-
eratively (Chapter 2), how to calculate the Based on the tools and concepts pro-
correct IOL power in standard and complex vided in Chapters 1-11, in this Chapter we
cases (Chapter 3), prevent major complica- carefully consider, in depth, powerful tech-
tions such as infection (Chapter 4), and how niques available today which allow the use of
to proceed with the operation by using phacoemulsification in the management of
adequate, modern anesthesia and to make the complex, and more challenging cases.
operating room efficient (Chapter 5). Why
phacoemulsification is so important (Chapter
6), how to make the transition from ECCE to Broadening of Indications
phacoemulsification with minimum risk to
the patient while minimizing mental and As emphasized by Miguel Angelo
emotional trauma to the surgeon (Chapter 7), Padilha, M.D., F.B.C.S., one of Brazil’s
what are the best instruments and equipments most prestigious anterior segment surgeons,
to use in phacoemulsification (Chapter 8), are the progressive mastering of phacoemulsifi-
all essential experiences and information for cation (Chapter 9) by an increasing number of
the modern cataract surgeon. In addition, you surgeons in various parts of the world allows
may also find the state of the art phacoemul- indications for this procedure to broaden rap-
sification techniques and facilitate your idly extending to the complex cases that were
understanding of each group of procedures so previously considered a contraindication to
that you can establish a basis for your own phaco. Patients with very hard cataracts,
selection of the procedure that will lead you classified as “rock hard cataracts”, eyes with
to master phacoemulsification (Chapters 9 shallow anterior chamber, pseudoexfoliation,
and 10). Finally, a discussion of the most subluxated cataracts, cornea guttata, corneal
important complications you may encounter dystrophies, corneal transparency alterations,
in phacoemulsification and in planned as well as small pupils, were previously con-
extracapsulars and how to manage them suc- sidered contraindications to the use of this
cessfully is presented in Chapter 11. technique.
295
In this chapter, we intend to provide the viscoelastics years ago as his «third assis-
cataract surgeon with practical clinical tant.» Viscoelastics are very important for
observations, strategies and surgical cataract surgery, whether in routine or com-
techniques leading to safe and efficient plex cases. Their main uses are for maintain-
management of cataract surgery in special ing the anterior chamber depth, protecting the
situations that we refer to as «the Complex endothelium, as aids during capsulorhexis,
Cases.» Although much of the focus is on hydrodissection, phacoemulsification, with
phacoemulsification, many of the approaches I/A, maintaining the capsular bag fully open
to complex cases here presented are also a intraocular lens during insertion, unfolding,
applicable to manual extracapsular. and positioning of the IOL.
They have a special place in this chap-
Complex Cases Already Discussed in ter because their adequate use has become
even more valuable and indispensable in the
Previous Chapters management of complex cases.
They are: 1) Cataract surgery in Cohesive and Dispersive

patients with diabetic retinopathy (pages
21-27, Figs. 8-18). 2) In age-related
Viscoelastics
macular degeneration (pages 28-29, Figs.
In the past few years, industry has
19-20). 3) In the presence of retinal breaks
refined viscoelastics, and made their proper-
(pages 28-30, Fig. 21). 4) In uveitis (pages
ties more specific so that we now have avail-
31,33, Fig. 22). 5) In adult strabismus with
able two main groups, each type better than
partial amblyopia (page 33). 6) Determining
the other for specific functions. As clarified
IOL power in complex cases (pages 48-58,
by Buratto, these groups are: 1) cohesive,
Figs. 24-32).
2) dispersive.
FOCUSING ON THE The Cohesive VES -

Specific Properties
MAIN COMPLEX
CASES The better known cohesives are those
with high viscosity, such as Healon GV,
Healon, Provisc, Amvisc Plus, Amvisc, and
THE DIFFERENT TYPES OF Biolon. They are very useful in creating
space and stabilizing the tissues, increasing
VISCOELASTICS mydriasis, supporting the nucleus during
capsulorhexis, deepening the anterior cham-
Their Specific Roles ber, separating synechiae, opening the capsu-
lar bag and maintaining this space during
For years we have generally referred to implantation of the IOL.
viscoelastics (VES) as highly valuable pro- The cohesive viscoelastics maintain
tective and space-maintaining substances. space really well because the molecules hold
Joaquin Barraquer, M.D., referred to themselves together. They are also quite easy
296
to remove. If you are trying to create a space each particular case. Each surgeon must be
such as when opening the capsular bag, or sufficiently trained to choose the most appro-
deepening the anterior chamber, then the co- priate substance for the individual patient and
hesive viscoelastics are going to work better. the specific technique.
The Dispersive VES- PHACOEMULSIFICATION

Specific Properties AFTER PREVIOUS
The dispersive VES are those with REFRACTIVE SURGERY
lower viscosity and lower cohesiveness.
They break up easily when injected into the The primary challenge in operating on
eye and therefore disperse in small frag- patients who have already had radial kerato-
ments. This group includes Viscoat (Alcon), tomy (RK) or excimer laser surgery is selec-
Vitrax (Allergan) and the methylcellulose tion of the appropriate lens power. As the
products. These substances form a layer that corneal curvature is altered, the usual predic-
will adhere and coat the posterior surface of tive formulas have also been altered. Stan-
the cornea to protect the endothelium during dard ultrasound A-scan technology and cor-
phacoemulsification, or from other instru- neal curvature are still used to estimate the
mentation during manual ECCE. They help in appropriate lens implant for reaching the tar-
capturing nuclear fragments. They are also get refraction. In addition, if the fellow eye
valuable if the phacoemulsification tip acci- has not had refractive surgery, that eye is also
dentally catches the iris, in zonular disinser- measured.
tion and rupture of the posterior capsule. We have already discussed this subject
The dispersive viscoelastics are ex- in practical and specific terms for the clini-
cellent coaters. If you aim to reduce the cian in pages 50-54 and presented the meth-
friction between the intraocular lens optic and ods and formulas most often used. Since
the injector, so you are less likely to tear the there is no universally accepted formula to
intraocular lens, Lindstrom uses a dispersive calculate these patient’s IOL power accu-
viscoelastic. Or, if you are operating on an rately, we present here the method used by a
eye with a dry or somewhat opaque surface, master cataract surgeon to solve this problem.
placing a few drops of the dispersive vis- Jack Dodick, M.D., has found the
coelastic on the surface clears the view sig- following procedure quite effective. He im-
nificantly. If you tear the posterior capsule, plants a specifically designated lens under
but have not lost vitreous yet, if you again topical anesthesia with sutureless clear cor-
inject a dispersive viscoelastic, it can stay in neal wound. Following the operation, the
the eye over the tear and the capsule, to hold patient is taken to an autorefractor just min-
vitreous back and protect the capsule while utes after surgery. If there is a high ametropia
you carefully remove the nuclear remnants or present, the patient returns to the table, the
a little cortex. That can be very helpful. eye is again prepped, the lens is removed and
But the dispersives are a little more replaced with one of the appropriate power. In
difficult to remove and they do not maintain patients with high myopia, for example, the
space as well. Consequently, the choice of surgeon’s best judgment about lens implant
VES varies with the surgical requirements of power can be considerably off target because
297
of untoward circumstances like a staphyloma. PHACOEMULSIFICATION

In patients who have had RK, surgeons tend
to underestimate the power of the lens im-
IN HIGH MYOPIA
plant.
In patients with high myopia, pha-
Removing the lens does not present a
coemulsification is somewhat more challeng-
major problem. The challenge is to remove
ing than in other eyes. Patients with high
the lens without enlarging the small incision
myopia have globes that are superelongated
and implant another through the same small
and sclera that is thinned out. The minute
incision . If the original 6 mm or 5.5 mm optic
the phaco probe is inserted and the infusion
has been implanted through a 3.2 mm inci-
starts, the chamber deepens dramatically
sion by folding; it is important to remove the
(Fig. 169). The probe must reach deep into
lens without sacrificing the length of the
the eye to access the nucleus because the lens
wound. This is done quite simply by bisecting
iris diaphragm may have moved considerably
the optic with Gills’ capsulotomy scissors
back. Dodick has sought to overcome this
under viscoelastic and removing the hinged
problem by lowering the bottle height and
two halves through the small incision. This
reducing the flow, so that the lens is unlikely
technique for removing the foldable lens is
to move to such a posterior location. Even
presented in Figs. 165 and 166, Chapter 11.
when this occurs, it is still quite possible with
Figure 169: Special Conditions of Pha-

coemulsification in Patients with High
Myopia
Phacoemulsification in patients
with high myopia presents additional chal-
lenges. Patients with high myopia have
globes which are elongated (green arrows)
and have thinner sclera. As the phacoemul-
sification probe (P) is introduced into such
eyes, the lens (red arrow) and iris (blue
arrow) move posteriorly by a considerable
amount. The probe must then reach deeper
into the eye for lens extraction. High
vacuum and sectioning of the nucleus into
pieces can allow the surgeon to bring the
nucleus more anteriorly for easier removal.
298
high vacuum to bring the nucleus up into the REFRACTIVE CATARACT

pupillary plane earlier than with a normal or
emmetropic eye. Phaco chop helps further by SURGERY
cutting the nucleus in several pieces and
bringing these pieces up into the pupillary Why and When Do Refractive
plane with high vacuum. Cataract Surgery
The challenges in calculating the cor-
rect IOL power in high myopia are discussed
Richard Lindstrom, M.D. has be-
on page 50.
come an advocate of what he calls «refractive
cataract surgery», by which we mean trying
CHALLENGES OF to improve the patient’s astigmatism at the
PHACOEMULSIFICATION time of cataract surgery.
IN HYPEROPIA In his extensive research and clinical
experience, about 70% of the cataract patients
that he operates have less than one diopter of
The challenge in hyperopia is some-
astigmatism preoperatively and about 30%
what different. Dodick refers to these as
have more than one. He does not make any
crowded eyes because all of the small ana-
astigmatic corrections in those that have less
tomical structures are in a smaller, confined
than one diopter. That is good enough for
space. Positive pressure is more likely to
20/30 uncorrected visual acuity. Lindstrom
occur. Dodick makes two fundamental ad-
becomes somewhat more aggressive with
justments in technique when dealing with an
astigmatism when there are two diopters or
extremely hyperopic eye. First, he dehydrates
more before the cataract operation. His goal
the vitreous with an osmotic agent such as
is to reduce it to one diopter; not to try to
Mannitol. Secondly, he tries to compress the
correct it all, just to get it down into a
eye and to express some of the unbound
reasonable range. He advises making the
water in the vitreous with a compressive
combined operation for cataract and astigma-
device like an Honan balloon (Fig. 96). He
tism only when performing phacoemulsifi-
leaves this Honan balloon on at about 35 to
cation.
40 mm Hg for 20 to 30 minutes. These two
As a matter of fact, he advises against
preparatory steps help reduce the volume of
it if the phacoemulsification incision, is
the eye and soften the eye prior to nucleus
enlarged to place a 6.5 or 7 millimeter optic
removal.
PMMA IOL or when a planned ECCE is
The challenges in calculating the cor-
performed. In such cases, he recommends,
rect IOL power in high hyperopia are pre-
doing the cataract surgery, see what you get,
sented on page 48. The pros and cons of
and then fix it later if there is a problem.
piggyback lenses in very high hyperopia are
Most patients adapt to glasses. This is be-
discussed on page 49.
299
cause with an incision of this size, it is almost principles of astigmatic keratotomy at the
impossible to plan the refractive operation. time of surgery. He does this very conserva-
The range of effect on astigmatism with such tively. The cataract wound becomes one
incisions is significant. With a planned extra- astigmatic keratotomy. On the opposite side,
capsular wound one patient might change a at a 7 mm optical zone, he will make a small
diopter and another might change four diopt- 2 mm corneal incision to correct 1 diopter or
ers. a 3 mm long incision to correct 2 diopters of
astigmatism in the cataract age group. This
TECHNIQUE FOR becomes a second astigmatic keratotomy
(Fig. 170).
REFRACTIVE CATARACT If the patient preoperatively has 3
SURGERY diopters of astigmatism, Lindstrom places
the 3 mm cataract/IOL incision again on the
Surgical Principles steeper meridian. This brings the astigmatism
down to 2-1/2. If he wants the patient to end
Lindstrom’s surgical principles and up with 1/2 diopters instead of 2 1/2 diopters
technique are as follows: of astigmatism, he makes a small 3 mm, non-
1) Move the cataract 3 mm tunnel perforating corneal incision with a diamond
incision to the steeper meridian (Fig. 170). knife on the opposite side of the cataract
He thinks of this small wound as an astig- incision at a 7 mm optical zone (Fig. 170).
matic keratotomy. This will reduce the
present astigmatism by 0.50 diopters. If the
patient has 1 diopter of plus cylinder at axis Surgical Procedure
90, and a 3 mm cataract incision is made at
axis 90, he/she will end up with only a 1/2 Lindstrom sets the depth of the dia-
diopter of cylinder. If they have +1 diopter at mond blade at 600 microns. In that area on
180 and the 3 mm cataract/IOL incision is the average the cornea is about 650 microns
moved over to the temporal side where the thick so it is a very safe setting so as not to
steeper meridian is located, they will end up perforate the cornea. This incision can be
with only +1/2 diopter of astigmatism at 180º done at the very beginning of the surgery.
which is good enough for 20/20 vision uncor- The first thing to do is make this little tiny
rected. Lindstrom’s approach is to make cut. The other alternative is to complete the
them better, not to correct all the astigmatism. cataract operation, firm up the eye, and make
If they have 1.5 diopters, they will end up that tiny cut at the end, but that may be more
with 1 diopter cylinder and that is acceptable. difficult.
But if they have 2 diopters to begin with, they The exact location of this cut in the
will end up with 1.5 diopters and that is cornea is 3.5 mm from the center of the
outside his goal. Lindstrom’s outcome goal cornea. By using a 7 mm optical zone, the
is 1 diopter astigmatism or less. cut is really 3.5 mm from the center of the
2) If more than 1.0 diopter of astigma- cornea. The diameter of the cornea is 12 mm.
tism would remain, Lindstrom applies the The limbus is 6 mm from the center.
300
Why Straight Cuts Instead of

Arcuate
Lindstrom uses a 7 mm optical zone

marker that has little marks on it for 30, 45,
60 and 90 degrees. At a 7 mm zone a 30
degree arcuate cut is equivalent to a 2 mm
straight cut and a 45 degree arcuate cut is
equivalent to a 3 mm straight cut (Fig. 171).
Lindstrom finds that it is safer and easier
Figure 171 (below): Length of Straight Corneal

Incision Related to Arcuate Incision
At the 7 mm optical zone (dotted line), a 30º

arcuate cut is equivalent to a 2 mm straight cut
(A). At the 7 mm optical zone, a 45º arcuate
cut is equivalent to a 3 mm straight cut (B).
Dr. Lindstrom finds that it is safer and easier to
make such small incisions straight rather than
Figure 170 (above)): Technique for Refractive Cata- arcuate.
ract Surgery
Dr. Lindstrom places the 3 mm cataract tunnel

incision (C) in the steeper meridian to reduce pre-op
astigmatism when present in a cataract patient. Further
reduction of astigmatism may be obtained with a
corneal incision (A) placed opposite the cataract inci-
sion in the same axis at the 7 mm optical zone
(dotted line). The example shows a patient with pre-op
3 diopters of plus cylinder at axis 145º (inset). The
corneal cataract incision is placed in this axis and may
reduce the pre-op astigmatism by 0.50 diopters. The 3
mm straight corneal incision placed opposite the cata-
ract incision in the same axis at the 7 mm optical zone
should reduce astigmatism further by 2.0 diopters. The
two together will reduce astigmatism a total of 2.5
diopters.
301
just to make these small incisions straight has not observed any major complications
instead of arcuate. With this technique he such as poor wound healing, infection or
tries to make things safe and better for the perforation.
patient, not perfect, and without doing any
harm. This means trying to bring a patient Full Refractive Correction of
from 3.5 diopters of astigmatism down to the Cataract Patient
one, in order to improve the quality of his/her
vision. He finds that he can enhance the By selecting the correct IOL power
results to the point now where about 85% to even in complex cases as outlined in pages
90% of the patients will have 1 diopter or less 45-54, correcting the preexisting astigmatism
of astigmatism. as discussed here and further enhancement
Lindstrom finds that these tiny inci- with the use of toric foldable IOL’s if neces-
sions programmed as outlined here are a very sary (see Chapter 9), we have the means to
powerful tool and seem to be very safe. He create in our patients the truly refractive
cataract operation.
CATARACT AND GLAUCOMA
Age related cataract and primary with laser trabeculoplasty or filtration sur-
open-angle glaucoma or chronic angle clo- gery. Luntz believes that this approach has
sure glaucoma often coexist in the older its drawbacks. Medical therapy for glaucoma
population. With increasing longevity this is may necessitate miotics, which tend to reduce
becoming more prevalent. The management visual acuity regardless of preexisting lens
of such cases has been controversial because opacities, and may encourage an acceleration
medical or surgical therapy of one condition of cataract progression. Surgical therapy of
often affects the other. glaucoma may be associated with increased
Most of the concepts and techniques lens opacification, especially if the surgery is
presented in this chapter are based on the complicated by inadvertent lens trauma but
experiences and observations of Maurice H. even in the absence of lens trauma. Subse-
Luntz, M.D., Chief of the Glaucoma Service quent cataract extraction, even if a function-
at the Manhattan Eye and Ear Hospital in ing bleb and good drainage are obtained,
New York. results in loss of the bleb in approximately
10% of eyes, and inability to restore control
Overview - Alternative of the glaucoma.
When the indications for cataract ex-
Approaches traction are present but the glaucoma is con-
trolled medically, the most common approach
When cataract and glaucoma coexist has been to remove the cataract and continue
but the glaucoma is uncontrolled or poorly medical management of the glaucoma. In-
controlled, one approach is to give priority to traocular pressure is more easily controlled in
control of the glaucoma either with addi- some eyes after lens extraction but a signifi-
tional medication or if this is not possible, cant number of these patients will require
302
glaucoma surgery as early as 3-6 months after 174, 175, the combined extracapsular ex-
standard cataract extraction . The patient then traction with trabeculectomy step by step in
faces a second surgical procedure with its Figs. 176 through 181, and phacoemulsifica-
attendant risks soon after the first operation. tion combined with trabeculectomy step by
An alternative approach is combined step in Figs. 182 through 187.
cataract and glaucoma surgery. Most sur-
geons are now oriented toward this approach. Indications
Excellent results are reported with extracap-
sular cataract extraction and trabeculectomy The indications based on Luntz’s ob-
(Luntz and Stein, 1988; Simmons, 1992) and servations are: 1) Any eye with open angle
phacoemulsification with trabeculectomy. glaucoma and cataract in which surgery is
The combined procedure is used in those required for the cataract, even if the glaucoma
patients in whom IOP runs above the upper can be medically controlled but requires more
limit of the target IOP for that patient, or in than two medications to do so. If combined
whom good control of IOP necessitates the surgery is not done, many of these eyes will
use of three or more different drugs. In those require glaucoma surgery at a later date,
patients in whom IOP is well controlled using exposing the patient to two surgical proce-
no more than two different drugs, phacoemul- dures where one would have sufficed. An
sification alone will generally maintain ad- exception to this are those patients in whom
equate postoperative control. IOP with three medications runs in the very
low teens (10-11mm Hg).
COMBINED CATARACT 2) Eyes with uncontrolled glaucoma
SURGERY AND requiring glaucoma surgery and significant
cataract with corrected vision of 20/40 or less,
TRABECULECTOMY reading 6-pt. print or less or with poor glare
tolerance.
In this chapter, we will first present
the evolution of the different types of Com-
bined Procedures for Cataract Extraction and Evolution of the Incision for
Trabeculectomy as described by Luntz, to Combined Cataract Extraction
provide you with an instant mental picture of and Trabeculectomy
the different approaches to this problem, the
latest being combining phacoemulsification The combined operation for cataract
with a tunnel incision and trabeculectomy. and glaucoma constitutes two procedures per-
Considering that this Volume covers all ma- formed at the same surgical session. The
jor, widely accepted cataract surgery proce- technique for each procedure remains un-
dures, we present the advanced techniques in changed but the surgical incision needs to be
combined surgery for glaucoma with pha- modified using either separate incisions for
coemulsification as well as with planned ext- each procedure (Fig. 172) or combining the
racapsular. The evolution of the different incisions for each operation into one com-
types of combined cataract extraction-trab- pound incision (Figs. 173, 174, 175).
eculectomy is presented in Figs. 172, 173,
303
A. Extracapsular Cataract intracapsular surgery or of a nuclear extrac-

tion for extracapsular surgery, thus facilitat-
Extraction with Trabeculectomy
ing their removal. This allows the use of an
incision of smaller cord length - namely, 9.5
1. Separate Incisions mm instead of the usual 11 mm chord length
(Fig. 173).
The cataract and trabeculectomy inci- Luntz points out that a matter of
sions are made separately at different sites. great importance in the architecture of this
The cataract incision is made in the cornea and compound incision is that the continuity of
is a single 11 mm chord length corneal cataract the limbal scleral incision for the cataract
incision. A 3 mm x 3 mm lamellar scleral removal is broken in the center by the intru-
trabeculectomy flap is made separately in the sion of the trabeculectomy flap with its two
upper nasal quadrant in the sclera under fornix radial incisions which are placed 3 mm apart.
or limbus based conjunctival flap (Fig. 172). By breaking the continuity of the limbal
This approach has the disadvantage that it scleral incision (the cataract portion of the
necessitates a corneal cataract wound for incision) we introduce an element of instabil-
extracapsular surgery. This type of incision is ity into the incision. Part of the incision is
no longer popular because of its tendency parallel to the limbus (the cataract incision)
toward higher levels of astigmatism in the and part of the incision is radial to the limbus
early postoperative phase before the corneal (the trabeculectomy incision). Where the two
sutures are removed. This approach is a good meet at each side of the trabeculectomy
technique for those surgeons using a small scleral flap the incision, when stressed post-
corneal incision for phacoemulsification com- operatively (for example by squeezing of the
bined with trabeculectomy (Fig. 187). eyelid or distortion of the globe) they can
shift horizontally, vertically or obliquely,
2. Compound Incision causing postoperative oblique or against the
rule astigmatism. The ability of the incision
By the term «compound incision» we mean to shift vertically is magnified if the cataract
that the surgeon combines a limbal 2-plane and trabeculectomy incisions meet at the lim-
cataract incision of 9.5 mm or 10 mm chord bus at a 90º angle. To minimize this effect,
length with a 3 mm x 3 mm 1/2 thickness Luntz recommends that the cataract incision
lamellar scleral flap for the trabeculectomy should be curved into the trabeculectomy
(Fig. 173). Luntz prefers to place a trab- incision forming a convex curve on each side
eculectomy flap in the center of the cataract of the cataract trabeculectomy incision junc-
incision and this is a generally favored tech- tion (Fig. 173). This curving of the incision
nique (Fig. 173). When the trabeculectomy reduces any tendency for vertical shift. This
flap is placed in the center of the cataract can be enhanced by careful attention to place-
incision and the cornea-scleral trabeculectomy ment of the interrupted sutures at the time of
block measuring (2 mm x 2 mm) is removed suturing the incision. Additional stability is
from the scleral bed before removing the imparted to the incision by placing the inter-
cataract, the total surface area of the cataract rupted 10-0 nylon sutures radially in the
incision is increased at the site of maximum cataract portion of the incision, and by plac-
thickness of the lens during extraction for ing the sutures in the curved junction between
304
Figure 172 A (left): Evolution of Types of

Combined Cataract Extraction-Trabeculec-
tomy Surgery - Type 1- Individual Surgical
Sites - Surgeon’s View
The first method of combined cataract

extraction with trabeculectomy involves two
separate surgical sites. The cataract surgery is
performed through a corneal incision (C). The
trabeculectomy is performed by a standard tech-
nique at the limbus. Note separate 3 mm by 3
mm scleral flap (F) and 2 mm by 2 mm trab-
eculectomy window (W). Iridectomy (I). Lim-
bus based conjunctival flap.
Figure 172 B (right): Evolution of

Types of Combined Cataract Extrac-
tion-Trabeculectomy Surgery - Type
1- Individual Surgical Sites - Cross
Section View
In this cross-section view, you
can instantly identify the anatomical
structures involved in the combined pro-
cedure when using two individual surgi-
cal sites. Note the scleral trabeculec-
tomy flap (F) separate from corneal cata-
ract incision (C). Trabeculectomy win-
dow (W). Iridectomy (I). Limbus based
conjunctival flap.
305
the cataract and trabeculectomy portions at

45º to the incision line (Fig. 173).
Although this is a relatively stable
compound incision, it is not as stable as a
single unbroken incision and will induce
more astigmatism, particularly oblique and
against the rule astigmatism, than would be
expected with a simple, unbroken cataract
incision. An unbroken incision can be
achieved by making the incision for the cata-
ract surgery separate from the trabeculectomy
(Fig. 172) or by using a large scleral bevel
and combining both the trabeculectomy and
the cataract wound within the unbroken inci-
sion (Figs. 174, 175).
Figure 173 A (above) : Evolution of Types of

Combined Cataract Extraction-Trabeculectomy
- Type 2- Combined Incision - Surgeon’s View
A combination of the cataract extraction

and trabeculectomy incisions is seen in this
surgeon’s view. Note the limbus based two-plane
cataract incision (C) with cord length of 9.5 mm
and centrally placed 3 mm by 3 mm scleral flap (F).
Note the 2 mm by 2 mm trabeculectomy window
(W). The junction of the cataract incision and
scleral flap is convex in shape (arrow) for a more
stable wound closure. Iridectomy (I). Fornix based
conjunctival flap.
Figure 173 B (below): Evolution of Types of Com-

bined Cataract Extraction-Trabeculectomy - Type 2-
Combined Incision - Cross Section View
This cross section view allows prompt identifica-

tion of the tissues and technique involved as explained in
Fig. 173 A. Compare the site of the cataract incision
(limbus-based) and the combined scleral flap (F) with
cataract incision in contrast with the individual surgical
sites incision shown in Fig. 172 B.
306
Figure 174 A (left): Evolution of Types of

Combined Extracapsular Cataract Extrac-
tion-Trabeculectomy - Type 3- Single, Unbro-
ken Tunnel Incision - Surgeon’s View
Development of the scleral tunnel inci-

sion for phacoemulsification has simplified the
incision for combined extracapsular cataract ex-
traction and trabeculectomy. A 9.5 mm to 10 mm
cord length, 1/2- scleral thickness groove (S) is
placed 1.5 mm posterior to the surgical limbus. A
scleral tunnel is dissected to the limbus, penetrat-
ing into the anterior chamber in the center of the
groove incision and widened on each side over
the full 10 mm length of the groove using a
crescent knife and corneo-scleral scissors (C)
(See Fig.178). The resulting scleral flap (F) is
reflected. A trabeculectomy window (W) is per-
formed under this scleral flap, contained within
the scleral bed. Iridectomy (I) shown in Fig. 174-
B. Fornix based conjunctival flap.
Figure 174 B (right): Evolution of Types of

Combined Extracapsular Cataract Extraction-
Trabeculectomy - Type 3- Single, Unbroken
Tunnel Incision - Cross Section View
The angled view of the structures involved

in the tunnel incision shows the difference in this
surgical approach to the two previous types of
incision (Figs. 172-B and 173-B). The anatomical
structures and technique of incision are explained
in figure legend of Fig. 174 A.
307
3. Combining the cataract- lens a 5.5 or 6 mm chord length incision

trabeculectomy into a single, would be used.
The trabeculectomy block is removed
unbroken incision
from the scleral bevel within the incision as
described previously in Figs. 179, 180. (For
Instead of making the cataract por-
details of the surgical technique see Pha-
tion of the incision at the limbus, the cataract
coemulsification Cataract Incision with Trab-
incision is moved posteriorly to a position
eculectomy later in this chapter, Figs. 182,
1.5 mm or 2 mm posterior and parallel to the
187.
limbus. This is the preferred incision for
extracapsular cataract surgery with trab-
eculectomy (Fig. 174). Intraocular Lens Implants
A trabeculectomy block of 2 mm
x 2 mm can be excised out of this scleral- Luntz considers that the indications
corneal bevel (Figs. 179, 180) without the for implanting an intraocular lens are the
necessity of cutting a separate trabeculectomy same in glaucoma patients as in non-glau-
flap in the sclera (Fig. 173). The end result is coma patients. The posterior chamber in-
a trabeculectomy block dissected within the traocular lens is preferable. Anterior chamber
scleral cataract incision which is a simple, lenses (Kelman-Multiflex - Editor) have been
unbroken incision (Fig. 180) adding signifi- successfully used where a posterior chamber
cantly to the stability of the scleral incision lens cannot be safely used, for example,
and reducing the amount of postoperative where the anterior and posterior capsule have
astigmatism. been extensively torn and will not support a
posterior chamber intraocular lens in the bag
B. Phacoemulsification with or in the sulcus. (This subject is discussed in
detail in pages 118-123 - Editor).
Trabeculectomy
Preoperative Preparation
This is presently the preferred tech-
nique for those with experience in pha-
Pilocarpine drops should be stopped
coemulsification surgery. It results in the
24-48 hours before surgery in order to facili-
least level of postoperative astigmatism and
tate pupillary dilatation at the time of surgery.
rapid visual rehabilitation.
If preoperative intraocular pressure is high it
The most popular incision is similar
should be reduced prior to surgery with intra-
to the one shown in Fig. 177 except that the
venous Mannitol (1.5 g./kg. body weight) or
pocket incision is made to a chord length
with oral glycerine 75 cc. Topical steroids
between 3.1 mm and 6 mm rather than the
(Prednisolone 1% q.i.d.) and topical nonste-
10 mm chord length incision used for extra-
roidal antiinflammatory drops are given 24-
capsular extraction. The chord length of this
hours before surgery and continued for 1 to 2
incision will depend on the size and type of
weeks after surgery. This reduces postopera-
intraocular lens used. Thus, for a foldable
tive inflammation and may diminish the inci-
silicone or acrylic IOL, a 3.5 or 4 mm chord
dence of cystoid macular edema.
length will be used; whereas, for a PMMA
308
Figure 175 A (right): Evolution of Types of Com-

bined Cataract Extraction-Trabeculectomy - Type
4 - Tunnel Incision for Phacoemulsification and
Trabeculectomy
A 1/2- scleral thickness, 6 mm cord length

groove (S) is made 1.5 mm posterior to the limbus. A
scleral tunnel (T) (its margins denoted by dotted lines)
is dissected to the limbus. The corneal incision for
introduction of the phacoemulsification probe and
trabeculectomy window (W) are located within the
resulting scleral bed. Iridectomy (I). Fornix based
conjunctival flap.
Figure 175 B (left): Evolution of Types of

Combined Cataract Extraction-Trab-
eculectomy - Type 4 - Tunnel Incision
for Phacoemulsification and Trabeculec-
tomy - Section View
Compare this cross section view

with the one shown in Fig. 174 B. The
scleral tunnel flap is much smaller. The
cataract incision (C) in Fig. 174 B is much
larger. This figure shows in cross section
what is described in the surgeon’s view in
Fig. 175 A.
309
SURGICAL TECHNIQUES 4) The fornix-based conjunctiva flap

adheres and scars at the limbus. As a result,
STEP BY STEP the bleb forms posteriorly producing a dif-
fuse, well-vascularized «low-profile» bleb
The following is a summary of the well behind the limbus. There is less possi-
two main procedures step-by-step as recom- bility of developing a thin «high-profile»
mended by Luntz. avascular anterior bleb which overhangs the
cornea, which has the added risk of micro-
ECCE and Trabeculectomy scopic perforations of hypoxic conjunctiva
With Single, Unbroken Tunnel and possible intraocular infection.
5) The posteriorly situated bleb and
Incision the scar at the limbus allow safe and early
contact lens fitting if a contact lens is re-
Conjunctival - Tenon’s Flap quired.
(Fornix-based) (5x-7x Magnification) 6) Tenon’s fascia is minimally trau-
matized.
If Mitomycin is to be used Luntz
prefers to apply it to the conjunctival surface Scleral-Corneal Incision
before raising the conjunctival-Tenon’s flap (7x-10x Magnification)
(see section on antimetabolites further in this
chapter). A 1/2-thickness scleral groove is cut
A superior rectus bridal suture is op- in the exposed sclera using a diamond knife
tional. The fornix-based conjunctival-Tenon’s blade or a crescent knife blade 1.5 mm poste-
flap with a 12 mm cord length is raised at the rior to the surgical limbus, extending for 9.5
superior limbus. The flap is dissected posteri- to 10 mm cord length parallel to the limbus
orly to further expose the sclera. Adequate (Fig. 176). At the center point of the incision
hemostasis and clearing of the sclera is ob- (12:00 o’clock position) a crescent knife
tained. blade is used to dissect a scleral tunnel just
Luntz considers that the fornix-based anterior to the corneal vascular arcade which
conjunctival flap has many advantages com- is then dissected to each side across the cord
pared to a limbus-based flap: length of the incision (Fig. 176). A 3.1 mm
1) There is better exposure and visual- keratome is introduced into the «tunnel» at 12
ization of the operative field. o’clock and advanced to the anterior limit of
2) The possibility of damaging the the tunnel in the cornea (Fig. 176). Pressing
conjunctival flap during dissection, particu- the point of the keratome downward toward
larly producing a «buttonhole» is eliminated. the iris, the keratome is advanced and pen-
3) A fornix-based flap is technically etrates the cornea into the anterior chamber
easier to dissect than a limbus-based flap, with the tip of the keratome 45º to the iris
especially when operating in an area of plane (Fig. 177). At this point, the direction
scarred conjunctiva, either from previous sur- of the keratome tip is changed to run parallel
gery or trauma. It also offers better exposure to the iris surface and the keratome is ad-
of the surgical area. vanced fully into the anterior chamber to
310
complete the 3.1 mm incision (Fig. 177).

The keratome is removed and the anterior
chamber filled with viscoelastic. Using a
Superblade, a paracentesis incision is made at
the 9:00 o’clock and 3:00 o’clock meridians.
Figure 177 (below): Combined Extracap-

sular Cataract Extraction - Trabeculec-
tomy Procedure With Single, Unbroken
Tunnel Incision - Step 3
A 3.1 mm keratome (K) is introduced

into the tunnel at the 12 o’clock position and
advanced to the anterior limit of the tunnel in
the cornea (inset - 1). The tip of the keratome
is depressed and advanced into the anterior
chamber. At this point, the direction of the
keratome tip is changed to run parallel to the
iris surface and the keratome is fully ad-
vanced into the anterior camber (inset -2 ) to
complete the 3.1 mm incision. The keratome
Figure 176 (above): Combined Extracapsular
is removed and the anterior chamber is filled
Cataract Extraction - Trabeculectomy Proce-
with viscoelastic.
dure With Single, Unbroken Tunnel Incision
- Steps 1 and 2
A 12 mm cord length, fornix based

conjunctival flap (C) is reflected. A 1/2 thickness
vertical scleral groove incision (S) is made with
a diamond knife or crescent knife (not shown),
1.5 mm posterior to the limbus for a cord length
of 9.5 to 10 mm, parallel to the limbus. At the
center the groove (12 o’clock position), a cres-
cent knife blade (K), is used to dissect a scleral
tunnel to just anterior to the corneal vascular
arcade. The sclera is then dissected to each side
across the length of the groove (arrows - dotted
lines).
311
Anterior Capsulotomy incision into the anterior chamber with a 1.5 -

(10x Magnification) 2 mm wide scleral-corneal bevel (Fig. 174).
A 27-gauge needle with the tip bent to Trabeculectomy

90º is introduced into the anterior chamber (10x Magnification)
and a can-opener capsulotomy or preferably
a large capsulorhexis, depending on the The anterior chamber is filled with
surgeon’s preference is performed. viscoelastic . A 2 mm x 2 mm block of tissue
is excised from the scleral-corneal bevel at
Completion of Sclero-Corneal the 12:00 o’clock position using a Luntz-
Incision (10x Magnification) Dodick microsurgical punch (Katena). The
posterior limit of the excised scleral-corneal
The scleral flap is lifted and microsurgi- block reaches to the scleral spur (Figs. 179,
cal corneal-scleral scissors are introduced 180).
into the scleral-corneal incision cutting to the The trabeculectomy opening located in
left and right, completing the incision into the the center of the scleral-corneal incision re-
anterior chamber for the entire cord length of duces resistance of the scleral bevel to pas-
the original scleral groove (Fig. 178). The sage of the lens nucleus from the eye and
final result is a 9.5 to 10 mm cord length facilitates its removal.
Figure 178: Combined Extracapsular Cataract Ex-

traction - Trabeculectomy Procedure - Step 4
After an anterior capsulotomy or

capsulorhexis has been performed, the scleral flap (F)
is lifted and corneal-scleral scissors (D) are intro-
duced into the previous 3.1 mm incision. The cataract
incision is extended to the left and right (arrow) using
the scissors. This produces a 9.5 to 10 mm cord length
incision into the anterior chamber with a 2mm-wide
scleral-corneal bevel. The anterior chamber is then
filled with viscoelastic.
312
Figure 179 (left): Combined Extracapsular

dure - Step 5
This cross section shows the scleral-corneal

bevel (T). An approximately 2 by 2mm block of
tissue is excised from the scleral-corneal bevel
(T) at the 12 o’clock position using a Kelly
Descemets punch (P) or Vannas scissors. The
posterior limit of the excised block reaches to
the scleral spur (arrow).
Figure 180 (right): Combined Extracapsu-

lar Cataract Extraction - Trabeculectomy
Procedure - Step 6
This surgeon’s view shows the initial

1/2-thickness scleral groove incision (S), the
completed 9.5 to 10mm scleral-corneal bevel
incision (C), the approximately 2mm by 2mm
trabeculectomy window (W) and reflected
scleral flap (F). (See Figure 174 B for
corresponding cross section view). The sur-
geon then performs an extracapsular cataract
extraction and IOL insertion using his/her pre-
ferred technique. A peripheral iridectomy
under the trabeculectomy is essential.
313
Figure 181: Combined Extracapsular Cataract

Extraction - Trabeculectomy Procedure - Step 7
This surgeon’s view shows closure of the

incision with two interrupted 10-0 nylon sutures
placed through the full thickness of the scleral flap at
the limbus and through the posterior scleral incision
on each side of the trabeculectomy opening (dotted
line). A running uninterrupted 10-0 Nylon suture
closes the conjunctival incision (not shown).
Removal of the Lens Nucleus midway across the iris from the right side
and Cortex. Insertion of IOL with a Vannas or DeWecker scissors, and then
moving the iris to the right and completing
The surgeon proceeds with extracapsu- the iridectomy cut.
lar cataract extraction and insertion of an IOL
using his/her preferred technique. Closure of the Cataract-Trabeculec-
tomy Incision (5x Magnification)
Iridectomy (10x Magnification)
Closure is achieved using interrupted
Following insertion of the IOL a pe- 10-0 nylon sutures, one interrupted suture on
ripheral iridectomy is made within the trab- either side of the trabeculectomy opening
eculectomy opening ensuring that the base of leaving the trabeculectomy opening and adja-
the iridectomy is wider than the trabeculec- cent scleral bevel unsutured (Fig. 181). The
tomy opening (Fig. 173-A). This is achieved interrupted sutures are placed through the
by grasping the iris near its root at the center full thickness of the scleral flap at the limbus
of the trabeculectomy opening, bringing it out and through the posterior scleral incision
of the eye and moving to the left, cutting (Fig. 181). The sutures are not tightly tied,
314
but tied to achieve tissue apposition without used it is applied before raising the conjuncti-
«crimping» the scleral flap and are «buried» val flap.
in the sclera. It is desirable to inflate the
anterior chamber with balanced salt solution Scleral-Corneal Incision (7x-10x
to achieve a good positive intraocular pres- Magnification)
sure before tying these sutures.
An alternative is to use one horizontal Luntz performs a 1/2-thickness vertical
suture through the scleral flap and scleral- scleral groove, 5.5 mm or 6.0 mm cord
corneal bevel on either side of the trabeculec- length, depending on the diameter of the IOL
tomy opening. to be used, or 3.5 mm cord length if a foldable
IOL is used, which is cut in the exposed
Closure of the Conjunctivo-Tenons’ sclera in the superior half of the globe,
Flap (5X Magnification) 1.5 mm posterior to the limbus using a cres-
cent blade or diamond blade (Fig.182). The
An uninterrupted 10-0 nylon suture crescent knife then dissects under the anterior
running from the limbal sclera to conjunctiva lip of the groove to within the corneal vascu-
closes the conjunctival incision. These sular arcade extending the dissection on either
tures should be tightly tied, particularly if an side to the limits of the incision (Fig. 182).
antimetabolite is used. Using a Superblade, a paracentesis inci-
sion is made at the 9:00 o’clock and 3:00
Phacoemulsification With o’clock meridians.
A 2.5 mm keratome is inserted into the
Trabeculectomy scleral-corneal incision at the 12:00 o’clock
meridian advancing the keratome to the edge
This procedure is shown in Figs. 182 of the incision just anterior to the corneal
through 187. vascular arcade (Fig. 183). The tip of the
keratome is pushed toward the anterior
Conjunctivo-Tenons’ Flap chamber, it is withdrawn slightly and the
(5x-7x Magnification) anterior chamber is penetrated with the
keratome tip 45º to the iris plane. At this
A 6 mm fornix-based flap is raised in point, the keratome tip is raised so that the
the same way as described previously for the keratome advances fully into the anterior
combined extracapsular extraction and trab- chamber parallel to the iris plane producing a
eculectomy. Luntz’ technique when using 2.5 mm «tunnel» incision (Figs. 183, 177
antimetabolites is that if mitomycin is to be Insets).
315
Figure 182 (left): Combined Phacoemulsifica-

tion Cataract Extraction - Trabeculectomy Pro-
cedure - Steps 1 and 2
A 6mm cord length fornix based conjuncti-

val flap is reflected. A 1/2 thickness vertical scleral
groove incision is made with a diamond knife or
crescent knife (not shown) at 1.5mm posterior and
parallel to the limbus for a cord length of 6mm for
a 5.5 or 6.0mm diameter IOL, or 3.5mm if a
foldable IOL is used (Fig. 40 B). At the center of
the groove incision (12 o’clock position), a cres-
cent knife blade (K) is used to dissect a scleral
tunnel to just anterior to the corneal vascular ar-
cade. The sclera is then dissected to each side
across the length of the groove (arrows).
Figure 183 (right): Combined Phacoemulsifi-

cation Cataract Extraction - Trabeculectomy
Procedure - Step 3
A 2.5mm keratome (K) is introduced into

the tunnel at the 12 o’clock position and advanced
to the anterior limit of the tunnel in the cornea
(See Fig. 177, inset 1). The tip of the keratome is
depressed and advanced into the anterior cham-
ber. At this point, the direction of the keratome tip
is changed to run parallel to the iris surface and
the keratome is fully advanced into the anterior
chamber (See Fig. 177, inset 2) to complete the
2.5mm incision. The keratome is removed and the
anterior chamber is filled with viscoelastic. The
cataract is then removed.
316
Corneal «Tunnel» Incision and Trabeculectomy is not performed prior

Separate Trabeculectomy to lens removal in order to maintain a water-
tight «tunnel» incision for the phacoemulsifi-
(7x-10x Magnification) cation.
The 2.5 mm tunnel incision is enlarged
to a 6 mm incision for insertion of a 6 mm
For cataract and glaucoma surgery the
IOL. If a 5 mm IOL is used, a 5 mm incision
3.0 - 3.5 mm tunnel intracorneal incision
is made; and if a foldable lens is used the
placed in the temporal cornea can be used
incision can be reduced to 3.5 mm.
with a trabeculectomy performed separately
and superiorly (Fig. 187).
Trabeculectomy (10x-15x
Capsulorhexis, Phacoemulsifi- Magnification)
cation, Nucleofractis, Infusion/ As-
Following insertion of the IOL the ante-
piration and IOL Insertion (10x-15x rior chamber is filled with viscoelastic and a
Magnification) trabeculectomy is made within the scleral
bevel of the tunnel incision using the same
Using the scleral corneal tunnel inci- technique as described in Figs. 175 and 179.
sion (Fig. 184), the surgeon performs the The next step is an iridectomy insuring that
above procedures according to his/her pre- the iridectomy base is wider than the trab-
ferred method. eculectomy opening, as previously described
(Fig. 184).
Figure 184: Combined Phacoemulsification

dure - Step 4
This figure shows the final configuration of the

combined Phacoemulsification Cataract Extrac-
tion - Trabeculectomy incision. (See Figure 175
B for the corresponding cross section view).
The scleral-corneal incision has been extended
for its full length. In this figure, a cord length of
6mm is illustrated. The IOL is then inserted.
Trabeculectomy (W) is performed by removing
an approximately 2mm by 2mm block of the
scleral-corneal bevel down to the scleral spur
(see Figure 179). Iridectomy is performed (I).
The sclera is shown lifted here to reveal the
scleral tunnel (T) (its margins denoted by dotted
lines). Initial scleral groove incision (S).
317
Closure of the Incision the cornea is horizontal to the limbus

(5x Magnification) (Fig. 186). The free end of this nylon suture
entering into the posterior lip of the scleral
An interrupted 10-0 nylon suture is incision is held with tying forceps. Three
placed through the scleral incision on either throws are made, and the tying forceps then
side of the trabeculectomy as described in engages the portion of the suture that is
Fig. 185. The trabeculectomy and adjoining exteriorized between the anterior lip of the
scleral-corneal bevel is left open without su- scleral incision and the limbus. This portion
tures. The knots should be buried. The of the suture is then pulled through the three
scleral flap can also be left unsutured but loops held in the other tying forceps, and a
Luntz has found a high incidence of postop- bow knot is tightened, apposing the two lips
erative bleeding and hyphema in these eyes. of the scleral incision. The free end of the
The 3.5mm incision or the 6 mm scleral flap nylon suture from the bow tie is cut, and the
are left unsutured only if the surgeon antici- free end of the nylon suture on the cornea is
pates that freer drainage of aqueous through cut. The radial and horizontal suture in the
the trabeculectomy opening will be required cornea eliminates a free end of nylon suture
early in the postoperative period. However, on the cornea behaving as a windshield wiper.
the disadvantage of an unsutured scleral flap, Two such releasable nylon sutures are placed
particularly the 6 mm scleral flap, is that the in the incision at the same locations as shown
anterior chamber may be shallow or flat in the for the interrupted sutures in Fig. 185. (The
immediate postoperative period. To overcome above technique is the method described by
this problem, one or two releasable 10-0 Allan E. Kolker, M.D.).
nylon sutures should be used (Figs. 186 A-B).
These have the advantage that the anterior Conjunctival Closure
chamber is very unlikely to shallow postop- (5x Magnification)
eratively, because the scleral incision is par-
tially sutured, and, at the same time, the The conjunctiva is closed with an
sutures can be easily removed in the postop- uninterrupted 10-0 nylon suture as previously
erative period if and when more drainage described.
through the filtering procedure is required. (Editor’s Note: in patients with glau-
The releasable sutures are placed as follows: coma and cataract, one of the most difficult
the 10-0 nylon suture (Luntz prefers a CU-5 problems to deal with is the management of
needle) is loaded backwards in the needle the small pupil. This important subject is
holder. The suture is placed through the discussed separately in this same chapter.)
posterior lip of the scleral incision and then
through the anterior lip of the incision (poste- Antimetabolites in Combined
rior lip of the trabeculectomy flap) and exteri-
orized through the anterior lip. A second bite
Procedures
is taken at the limbus and into adjacent cornea
in a radial direction and is exteriorized. A Luntz believes that antimetabolites
third bite is then taken at the point where the should be used routinely in combined cataract
suture exits from the cornea, and this bite in and trabeculectomy as the result is better.
318
Figure 185 (left): Combined Phacoemulsifi-

cation Cataract Extraction - Trabeculectomy
Procedure - Step 5
This surgeon’s view shows closure of

the 6mm incision with two interrupted 10-0
nylon sutures placed through the full thickness
of the scleral flap at the limbus and through the
posterior scleral incision on each side of the
trabeculectomy opening (dotted line). If prop-
erly valvulated to prevent loss of the anterior
chamber, the 6mm scleral flap can be left
unsutured, which will result in a bigger drop in
intraocular pressure. A running uninterrupted
10-0 Nylon suture closes the conjunctival inci-
sion (not shown).
Figure 186 A-B (right): Technique for

Placement of Releasable Sutures
(A) The 10-0 nylon suture is

passed through both lips of the scleral flap,
through the limbus radially into the cornea
and then through the cornea parallel to the
limbus (to prevent the “windshield wiper”
effect of a radial suture. Figure (B) shows
the technique for tying the bow. The
portion of suture between the anterior lip
of the scleral flap and the limbus is pulled
up into a bow and tied to the free end of the
suture at the posterior lip of the scleral
flap. (This technique was introduced by
Alan Kolker, M.D., and is reproduced
with his permission).
319
Choice of Antimetabolite Results of Combined Cataract

Surgery and Trabeculectomy
Surgeons in general will vary in their
choice of an appropriate antimetabolite de-
In Luntz’ experience, the results of
pending on the age of the patient and their
combined cataract surgery and trabeculec-
own personal experience. For the combined
tomy have been consistently good. In a study
cataract and trabeculectomy procedure, Luntz
combining extracapsular cataract extraction
uses mitomycin-C routinely, as the results of
with posterior chamber intraocular lens im-
the procedures are better with the use of an
plant and trabeculectomy, 38 eyes were fol-
antimetabolite. There is a remote possibility
lowed for up to 46 months, with a mean of
of teratogenesis and the development of can-
16.4 months. The average preoperative in-
cer many years following application of this
traocular pressure was 20.5 mm Hg and the
drug. For this reason, and particularly so in
average postoperative pressure was 14.5 mm
children, an informed consent is required
Hg, a statistically significant change. The
before Mitomycin-C is applied.
mean number of medications preoperatively
When using Mitomycin, Luntz’ pre-
was 2.3 and postoperatively at the end of the
ferred technique is to soak a Weck cell sponge
follow-up period this had still dropped to a
into a solution of 0.4% Mitomycin-C. The
mean of 1.42.
soaked Weck cell sponge is placed on the
conjunctival surface at the site selected for There was no significant change in the
surgery. It is held on the conjunctiva for one- visual field graded from the preoperative to
minute and then replaced with a freshly the postoperative level. Visual acuity,
soaked Weck cell sponge for a further one- which averaged 20/120 preoperatively,
minute, and this is repeated a third or fourth improved to an average of 20/50
time giving a total application time of three or postoperatively.
four minutes. Following this, the conjuncti- Simmons et al (1992), have also re-
val surface is vigorously lavaged with bal- ported good results with few complications
anced salt solution to remove all traces of the using extracapsular cataract extraction with
drug. posterior chamber intraocular lens and trab-
Some surgeons have used a topical eculectomy (as well as phacoemulsification
application of 5-FU intraoperatively with a and trabeculectomy -Editor).
Weck cell sponge soaked in the drug, In Luntz’ studies, the complications
similar to the way Mitomycin-C is used. associated with combined ECCE and trab-
The effectiveness of this method is still eculectomy (and (phacoemulsification and
undecided. trabeculectomy) were surprisingly few and of
no greater severity than would have been
320
expected from the cataract surgery or the level of postoperative iritis. None of the
glaucoma surgery alone. Intraoperative com- patients had shallow or flat anterior chambers
plications specific to the combined operation postoperatively, which can be attributed to
were not observed. The complications that good apposition and closure of the cataract
were seen were similar to those associated wound.
with a trabeculectomy or extracapsular cata- When using antimetabolites, if a sig-
ract extraction alone. nificant leak from the conjunctival wound
Immediate postoperative problems does occur this will in most cases require
consisted of corneal edema of mild degree surgical repair. Surgical repair entails re-
which rapidly resolved, and iritis which suturing the incision. In severely affected
caused no long-term problems. Contrary to eyes, the conjunctiva at the site of the leak
what was anticipated, the performance of a becomes friable and normal conjunctiva is
radial iridectomy and its repair by suturing rotated from the fornix or moved across as a
the iris when this procedure was chosen by flap from the adjacent temporal or nasal
the surgeon did not cause an increase in the conjunctiva.
Figure 187 : An Alternative Technique of Pha-

coemulsification Using “Tunnel” Intracorneal
Incision Combined with Separate Trabeculec-
tomy
In cases of combined phako and glaucoma

surgery, a 3.0 - 3.5mm “tunnel” intracorneal
incision (C) is placed in the temporal cornea to
perform the phacoemulsification and foldable lens
implantation. Trabeculectomy is performed in the
standard manner separately and superiorly with
3mm by 3mm scleral flap (F) and 2mm by 2mm
trabeculectomy window (W).
321
PHACOEMULSIFICATION
IN DISEASED CORNEAS
PHACOEMULSIFICATION described above: a corneal trephining first,

followed by open sky extracapsular extrac-
AND IOL IMPLANTATION tion, intraocular lens implantation and sutur-
IN THE PRESENCE OF ing the donor cornea to the recipient’s cornea
OPAQUE CORNEA to complete the operation.
If the cornea is reasonably transpar-
ent, allowing the surgeon to visualize the
Overview structures of the anterior chamber (Fig. 188)
Most of the concepts and techniques Padilha’s procedure of choice is removal of
presented on this subject are based on the the cataract by phacoemulsification first
extensive clinical experience and research of which is a pressurized, much safer system,
Professor Miguel Angel Padilha, of Brazil. continued by IOL implantation and last, com-
For many years, a triple procedure involving pleting the penetrating graft, as first recom-
a corneal transplant, cataract extraction and mended by Enrique Malbran, M.D., from
intraocular lens implantation regularly en- Argentina in 1995.
tailed an open sky extracapsular cataract ex- Step 1: Incomplete trephining of the
traction. This technique exposed the open moderately opaque cornea reaching half
eye for a long period of time, while the depth (Fig. 188). Step 2: Viscoelastic is
surgeon performed the anterior capsulotomy, injected into the anterior chamber through a
extraction of the cataract nucleus, aspiration side port incision. A Valvulated self-sealing
of the cortical material and the implantation scleral tunnel incision 2 mm posterior to the
of the intraocular lens. Only then is the limbus, is performed, as shown in Fig. 40-B.
donor’s cornea placed and adequately su- Step 3: CCC with a bent needle used as a
tured. During this period, the eye is subjected cystotome and long Kelman-McPherson for-
to considerable risk, including the greatly ceps, preceded by injection of viscoelastic
feared complication of expulsive hemor- (Figs. 97, 44, 45). Step 4: The remaining
rhage. phases of phacoemulsification are completed
in a routine way, followed by the implantation
of an PMMA or foldable intraocular lens,
Padilha’s Timing and Technique depending on the experience of the surgeon
(Fig. 189). A miotic agent is injected
When the cornea is opaque to the intracamerally. Step 5: Padilha checks the
extent of preventing visualization of the ante-
hermetic closure of the sclero-corneal tunnel.
rior chamber, no other alternative is left than
The wound may or may not be closed with a
to proceed with the surgical timing and steps
horizontal suture depending on how sure the
322
Figure 188: Phacoemulsification in Opaque

Corneas - Stage 1
The surgeon first proceeds to do an

incomplete trephining of the affected cornea
with the trephine gauged to enter only 1/2 the
corneal depth (T). Next, the surgeon proceeds
with the injection of viscoelastic (V) through an
ancillary incision (A). Through a scleral-
corneal tunnel incision, a valvulated self-seal-
ing wound 2 mm posterior from the limbus
(W), a circular capsulorhexis (C) is performed.
The remaining phases of phacoemulsification
are completed in a routine way.
Figure 189: Phacoemulsification in

Opaque Corneas - IOL Insertion -
Stage 2
Following phacoemulsification,
and I/A of the cortical remains, the ante-
rior chamber is again filled with vis-
coelastic. The next step is the implanta-
tion of a PMMA or a foldable intraocu-
lar lens (L), depending on the preference
of the surgeon. Tunnel incision (W).
323
surgeon is of its complete sealing. He pro- 2) The technique of phacoemulsifica-

ceeds with the removal of the opaque corneal tion must be endocapsular, within the capsu-
button using a disposable Beaver knife and lar bag, using the surgeon’s procedure of
Castroviejo’s scissors (Fig. 190). The sur- choice for management and disassembling
geon completes the procedure by bringing the nucleus. This is with the purpose of
together the edges of the donor and recipient preventing additional damage to the corneal
corneas, using 16 interrupted 10.0 nylon endothelium. If necessary, the nucleus may
monofilament sutures. This approach un- be dislocated into the anterior chamber where
doubtedly reduces the long period of time it can be removed or into the iris plane
during which the eye remains exposed, thus (using Lindstrom’s iris-plane techniques -
making surgery much safer. Figs. 136-139, Chapter 10). But repeatedly
lubricating the cornea with dispersive vis-
Specific Recommendations coelastic.
3) If corneal edema deriving from the
1) Padilha strongly recommends that corneal disease itself is present and interferes
the phaco procedure not be done using a clear with visualization of the intraocular maneu-
cornea incision. Complications or difficulties vers, the corneal epithelium may be com-
may arise at the time of performing the pletely removed to facilitate the surgeon’s
penetrating graft. Consequently, use the adequate view of surgical maneuvers and
sclero-corneal tunnel incision shown in Fig. instrumentation. (Editor’s Note: placing dis-
40-B. persive viscoelastic over the cornea will fur-
ther facilitate the inner view by the surgeon).
Figure 190: Phacoemulsification in Opaque

Corneas - Completing the Penetrating
Keratoplasty - Stage 3
Following the IOL implantation (L),

through the tunnel incision (W), the surgeon
completes the trephining of the cornea and pro-
ceeds with the removal of the corneal button (T)
with a disposable knife and Castroviejo or
Barraquer scissors (S). The surgeon completes
the procedure by placing 16 radial interrupted
10-0 nylon sutures in the donor recipient.
324
PHACOEMULSIFICATION, If there is considerable corneal edema,

with an endothelial cell count of less than
IOL IMPLANTATION AND 500/mm2 and a central pachymetry up to 610
FUCHS’ DYSTROPHY micra, the procedure of choice is performing
combined surgery consisting of penetrating
Preoperative Evaluation keratoplasty, cataract extraction and IOL
implantation.
These patients demand a meticulous
preoperative evaluation before cataract sur- Special Precautions During
gery. This should not be limited to a good Phacoemulsification
biomicroscopic examination with the slit
lamp. Specular microscopy and corneal
pachymetry may provide additional informa- 1) The presence of cornea guttata or
tion of value to decide if a cataract extraction Fuchs’ dystrophy is not a contraindication to
is sufficient or if a triple procedure is the most phacoemulsification, but it does require
appropriate. These diagnostic examinations additional specific precautions. The surgeon
should be made if the equipment is available. must significantly decrease turbulence and
In the majority of patients, however, a maintain the anterior chamber with a
detailed biomicroscopy may be sufficient to sufficient quantity of BSS and viscoelastic to
determine the amount of guttata and the ex- prevent contact between the nuclear
tension of the corneal edema. fragments and the endothelium, particularly
at the stage of aspiration of cortical remnants.
2) In corneas with Fuchs’ dystrophy, it
Role of Specular
is very important to use dispersive
Biomicroscopy and Pachymetry viscoelastic for better adherence to and
protection of the diseased endothelium. Be
In performing specular biomicros- attentive in case the viscoelastic comes out
copy, counting the endothelial cells is not through the wound. This makes it necessary
sufficient to guarantee that an eye with cor- to reintroduce it fairly often during the
neal disease will withstand surgical trauma surgical procedure. This should be done
without developing further corneal edema, through the sideport incision (Fig. 191). The
or even worse, bullous keratopathy in the phaco or the I/A tip should be kept
future. Analysis of the cell morphology pro- functioning within the anterior chamber
vides important additional information for avoiding its removal and reinsertion back and
predicting the nature of postoperative compli- forth through the main incision. This could
cations after phacoemulsification or any other lead to additional trauma.
intraocular surgery. 3) During phacoemulsification, the
Pachymetry offers a dynamic maneuvers should be very delicate, using
evaluation of these same corneas. Repetitive techniques that reduce the time and power of
measures of the thickness of the diseased the ultrasound. Padilha considers that the
cornea may demonstrate how well its fluid phaco fracture or “divide-and-conquer”
system functions. techniques, are the most indicated. When
325
emulsifying the last quadrant the surgeon ar fragments attached to the titanium tip and
must prevent fragments from moving into set in motion the pulse system of the
the anterior chamber and touching the equipment. If such fragments should move
endothelium (Fig. 192). The ideal into the anterior chamber, dispersive
procedure is to maintain a high vacuum viscoelastic substance should be used to
power (150 mmHg or higher), keeping nucle- prevent their touching the endothelium
(Fig. 192).
Figure 191 (left): Phacoemulsification in

Fuchs’ Dystrophy - Use of Viscoelastic
In such altered corneas it is very

important to use dispersive viscoelastics (V)
for better adherence to and protection of the
diseased corneal endothelium. The lateral
paracentesis or sideport incision (L) should
be used for the intracameral injection of
viscoelastic. The phaco tip introduced
through the primary incision is not to be
reinserted in and out, back and forth (T)
for intraocular maneuvers . This could add
trauma.
Figure 192 (right): Phacoemulsification

in Fuchs’ Dystrophy - Ideal Procedure
During phacoemulsification, the

maneuvers should be very delicate, de-
creasing the power of ultrasound to the
minimum desirable, and using techniques
that reduce the time of ultrasound. The
ideal procedure is to maintain a high
vacuum power (150 mmHg or more), keep-
ing lens fragments attached to the phaco tip
(P), and use the pulse system of the equip-
ment. If such fragments should tend to
move into the anterior chamber (white ar-
row), the dispersive viscoelastic (V) should
be once more irrigated into the anterior
chamber to protect the endothelium.
326
Figure 193: Phacoemulsification in Fuchs’ Dystrophy -

IOL Implantation
At the time of IOL implantation (L) the first step

should be the introduction of viscoelastic in the anterior
chamber and the capsular bag (C) as presented in Fig. 191 to
keep the bag well distended, especially if a foldable lens is to
be implanted.
4) At the time of lens implantation, At the end of surgery, the aspiration of

the first step should be the introduction of a the cohesive VE will be easier and faster than
cohesive viscoelastic (VE) inside the the dispersive VE. In order to protect the
capsular bag to maintain the posterior cornea from any damage, the dispersive VE
capsule well distended, especially if a should not be removed aggressively although
foldable lens is to be implanted (Fig. 193). all VES should be removed. Administration
The next step is to lubricate the injector with of carbonic anhydrase inhibitors and
dispersive viscoelastic to facilitate the betablockers during the immediate
delivery of the lens from inside the injector postoperative period is always recommended
with the bag. to inhibit elevation of intraocular pressure,
especially in cases with some corneal
disease.
327
PHACOEMULSIFICATION IN SMALL PUPILS
Pharmacological Mydriasis Mechanical Strategies
Phacoemulsification requires that the In patients who have a certain degree of

pupil be well dilated. Adequate exposure iris atrophy that may be related to advanced
of the lens and the anterior capsule is senility, post uveitis, trauma or the long term
essential. Padilha first tries to obtain a use of miotics in glaucomatous eyes, the
pharmacological mydriasis. He uses a following options are available to obtain ad-
combination of Phenylephrine 10%, equate exposure of the lens and the anterior
Tropicamide 1% ( Mydriacyl R ), and a capsule.
prostaglandin inhibitor such as
Indomethacin or Flurbiprofen 0.03% 1. Stretching the Pupil
(Ocufen R ), which is administered every 15
minutes during 1 hour before surgery. The pupil in most patients can be
Among the two inhibitors, Padilha prefers stretched to an adequate dilatation using two
Ocufen R, for better maintenance of Kuglin hooks as advocated by Maurice
the mydriasis. This pharmacological Luntz, M.D. One Kuglin hook is inserted
combination is administered if, of course, no into a preformed temporal paracentesis and
cardiovascular contraindications exist. advanced to the opposite nasal pupil margin
If this combination of medications is where the Kuglin hook engages the pupil
not effective, unpreserved adrenaline 1:1000 margin (Fig. 194). The second Kuglin hook
diluted in 10 ml of BSS may be injected into enters the anterior chamber through a pre-
the anterior chamber at the beginning of formed nasal paracentesis, is advanced across
surgery. the anterior chamber to the opposite temporal
pupillary edge, which it engages (Fig. 194).
Both Kuglin hooks are now pushed toward
Mechanical Dilatation with the limbus, stretching the pupil horizon-
Viscoelastics tally until maximal stretching is achieved.
There will inevitably be some small sphincter
In the presence of iris adhesions to the tears.
anterior lens capsule, Luntz mechanically Both Kuglin hooks are now removed
separates them using a viscoelastic passed from the anterior chamber and re-entered into
through a cannula. Once the synechiae have the anterior chamber through two preformed
been separated, intracameral Epinephrine keratome incisiona one at 12 o’clock and the
(adrenaline) is injected and in many instances other at 6 o’clock (Fig. 195). One Kuglin
the pupil will dilate adequately. hook is advanced across the anterior chamber
to engage the pupil margin at 6 o’clock, and
328
Figure 194 (left): Stretching the Pupil

Horizontally with Two Kuglin Hooks
One Kuglin hook is inserted through a

temporal paracentesis and advanced to the
opposite nasal pupil margin and engages the
pupil margin. The second Kuglin hook enters
the anterior chamber through a nasal paracen-
tesis, and is advanced across the anterior
chamber to the opposite temporal pupillary
edge, which it engages. Both Kuglin hooks
are now pushed toward the limbus, stretch-
ing the pupil horizontally until maximal
stretching is achieved.
Figure 195 (right): Stretching the Pupil Verti-

cally with Two Kuglin Hooks
Both Kuglin hooks are now re-positioned

through keratome incisions at 12 and 6 o’clock.
One Kuglin hook is advanced across the anterior
chamber to engage the pupil margin at 6 o’clock,
and the second Kuglin hook engages the pupil
margin at 12 o’clock. Both Kuglin hooks are
pushed toward the limbus facing each other
thereby stretching the pupil vertically. Once
the maximal vertical extension is achieved, the
Kuglin hooks are removed.
329
the second Kuglin hook engages the pupil 2) Mechanical Pupillary Dilators
margin at 12 o’clock. Both Kuglin hooks are
again pushed toward the limbus, facing each In those cases in which the pupil
other, at 6 and 12 o’clock, thereby stretching margin is fibrosed or very spastic, one of the
the pupil vertically (Fig. 195). Once the maxi- following procedures may be necessary.
mal vertical extension is achieved, the Kuglin
hooks are retracted. Intracameral epinephrine
A) Plastic Iris Hooks (Alcon-
is injected, followed by intracameral vis-
Grieshaber) are inserted through four para-
coelastic. In those eyes in which the pupil
centesis incisions in the cornea (Fig. 196) as
margin in not significantly fibrosed and not
advocated by Luntz as well as Padilha. The
too spastic, this maneuver can achieve a
hooks engage the pupil margin at the 10:00
sufficiently dilated pupil to proceed with pha-
o’clock, 2:00 o’clock, 4:00 o’clock and 8:00
coemulsification. The technique using
o’clock meridians, and the pupil is forcibly
Kuglin hooks has also been advocated by
enlarged by pulling the hooks outward and
Miguel Padilha, M.D.
fixing their positions. Metal hooks are also
available but Luntz considers that plastic
hooks are less traumatic to the pupil.
Figure 196: Alcon-Grieshaber Flexible Iris Re-

tractor for Small Pupil
The flexible iris retractor is a safe alternative

for temporary iris fixation in cases where dilatation
cannot be achieved pharmacologically and when the
pupil is not fibrosed and can be stretched. The
retractor is made of prolene and a flexible tab (H)
made of nylon holds the hook in position once in the
eye. Four self-sealing 0.5 mm stab paracentesis
incisions are made in the peripheral cornea at the
10:00, 2:00, 4:00 and 8:00 o’clock meridians. The
hooks (H) are inserted through the paracentesis inci-
sions (P) and engage the iris at the pupil margin
(arrow - 1). The pupil is forcibly enlarged by pulling
the hooks outward (arrow - 2). The final position of
the hooks is fixed by adjusting the flexible nylon tab
toward the eye (arrow - 3). Inset shows surgeon’s
view of the final configuration of the retractors and
the resulting pupil shape.
330
Figure 197: Phacoemulsification in Small Pupils -

Beehler’s Pupil Dilator
The Beehler’s pupil dilator (B) allows dilation in

three directions with only one maneuver. Three arms (A)
extend from inside the instrument and exert distention on the
margins of the pupil. The same instrument also stimulates a
discrete retraction of the iris in the direction of the corneal or
scleral tunnel incision (T).
When the pupil margins are heavily with viscoelastic to facilitate the introduction
fibrosed this method will not achieve ad- of the other two.
equate pupil dilation, or the pupil margin may
be severely traumatized. B) The Beehler Pupil Dilator
Padilha considers that, of all the avail-
able mechanical resources, the one that has Padilha uses this instrument when the
contributed the most safety and satisfaction in other options outlined above have not been
the management of small pupils is the flexible effective. This dilator, made by Moria, in
iris retractor (Alcon-Grieshaber) (Fig. 196). France, allows dilatation in three directions
These retractors are extremely useful, even if with only one maneuver (Fig. 197). More-
placing them requires extra time. After the over, it provokes a discrete retraction of the
placement of the first or the second retractor, iris in the direction of the corneal or scleral
the anterior chamber may need to be refilled tunnel incision.
331
C) The Silicone Expander Ring Padilha emphasizes that stretching

maneuvers using mechanical dilators may
In more severe cases, Padilha uses a induce a certain degree of iris atony. This
silicone ring with an indentation, which fits predisposes the iris margins to insinuate into
all along the edge of the pupil. This presents the titanium tip, during the phaco maneuvers,
some advantages. Using this technique the leading to injury of the sphincter and the iris
iris fits like a tire around the ring, which is tissue. The same can occur with sector iridec-
like an iron wheel (Fig. 198). Among its tomies, which can also predispose the iris to
disadvantages is the fact that it can loosen the development of synechiae to the anterior
itself easily with intraocular maneuvers dur- capsule during the postoperative period, re-
ing the phaco procedure. Known as quiring the administration of miotic drops for
Graether’s pupil expander (EagleVision some time.
#1540) it has three components: the pre-
loaded expander, a disposable insertor and a
glide retractor of the iris. (The use of this ring
is controversial - Editor).
Figure 198: Phacoemulsification in Small Pupils -

Adjustment of the Silicone Expander Ring
Once the silicone expander ring (E) is in

position, Padilha slides out the iris retractor glide
(not shown) and adjusts the final placement of the
silicone expander using two Sinskey hooks (H).
332
TRAUMATIC CATARACTS
Overview Highlights of Examination

The complex repair of an eye injury is The ophthalmologist must examine the
best when a team which shares anterior and patient carefully. The examination should
posterior segment skills work together in begin with an assessment of the visual
primary and secondary management. function, if there is light perception or light
Almost all bad results following ocular projection. The prognosis is better if there is
trauma occur in injuries involving the poste- good light projection. Then the eye should
rior segment, particularly when the lens is be examined in the usual way with the direct
also damaged ophthalmoscope and the slit lamp. In many
cases the fundus cannot be visualized be-
Assessment of the Injured Eye cause of the presence of opaque media: cor-
nea, lens, and vitreous hemorrhage. The
The circumstances of the injury and the presence of a foreign body must be definitely
early clinical assessment give important in- excluded. It is important to search for ana-
formation that will determine the early man- tomically related trauma. Individual in-
agement and help to predict complications. traocular structures are not often damaged
As pointed out by Michael Roper- alone.
Hall, M.D., an accurate history is essential. In severe injuries, the full extent of
This can be very helpful in indicating the damage is obscured by blood or opacities in
nature and extent of injury. The true history the media . Special assessment is needed
is sometimes elusive, especially when chil- before planning surgery to establish the ex-
dren are involved, or there is potential for tent of damage and the visual potential.
litigation. There may be no light perception in the
The injuries that cause traumatic cata- presence of a complete vitreous hemorrhage -
ract occur not only from serious penetrating until the hemorrhage clears. In such cases
trauma, but also from blunt injury. Most diagnostic imaging is invaluable.
blunt injuries are not severe enough to cause
rupture of the sclera. In evaluating and Diagnostic Imaging
managing all blunt injuries, it is important to
recognize that each ocular tissue, from the B-scan ultrasonography should be
cornea to the posterior choroid, may have used to identify the presence of a foreign
been damaged by the impact. Therefore, body and where is it precisely located, the
management is based on identifying the af- amount of vitreous hemorrhage present and
fected tissues, understanding the pathophysi- the condition of the retina. Ultrasound imag-
ology of events that can occur after a blunt ing also demonstrates changes in lens posi-
injury, and anticipating possible secondary tion; posterior rupture of the lens; cyclitic
complications.
333
membrane; hemorrhage into the vitreous; defect either from a blunt rupture or a sharp
separation of the vitreous from the retina; and laceration.
retinal detachment, which are obscured to
direct examination (Fig. 199).
MANAGEMENT OF
Combined Injuries of Anterior and TRAUMATIC CATARACT
Posterior Segment
Robert Stegmann, M.D., has very ex-
A damaged lens mixed with blood and tensive experience in trauma cases. He be-
vitreous needs prompt and adequate surgery. lieves that the prognosis for a traumatic cata-
Failure to remove this debris encourages ract can be the same as for a routine senile
fibrosis with a cyclitic membrane causing cataract if the traumatic cataract is handled
ciliary body detachment and hypotony even- properly. This excludes cases in which there
tually leading to retinal detachment and ph- is damage to the posterior segment, the vitre-
thisis bulbi. ous has become cloudy, or the retina is dam-
aged from the same trauma, or where infec-
Traumatic Cataracts in the tion has occurred.
Presence of Anterior Segment Small Wounds in Anterior

Penetrating Wounds Capsule
Main Objectives In many cases a penetrating wound in
the cornea and lens is small, the lens material
In anterior segment injuries the initial still remains within the capsule and, even
objectives are watertight repair of the corneal though cloudy, it may not escape through the
wound, restoring normal depth to the anterior tiny capsular tear (Fig. 200). Prof. Giora
chamber, intensive antibiotic treatment to Treister from Israel recommends that in such
prevent infection and intense antiinflamma- cases, the lens be left alone during the first
tory therapy from the very start. The further surgical intervention. He repairs the primary
goals are to manage the cataract adequately, wound and goes no further at this time
reduce secondary damage by minimizing ex- because generally these are the worst condi-
cessive corneal scarring; assuring a clear, tions for operating on the eye. The tissues are
adequately sized and cosmetically and opti- swollen and irritated, and perhaps even in-
cally desirable pupillary opening; and pre- fected. The trauma may have occurred at
venting further damage to the anterior cham- night. In case of unexpected complications,
ber angle that could result in glaucoma. the most experienced surgeons are not on
Often all of these objectives can be duty.
achieved at the time of initial wound repair If it is not absolutely necessary to go
although in some cases further surgical further with the initial procedure, Treister
procedures are needed. The traumatic injury recommends that it will suffice to close the
may have caused a lens anterior capsular primary wound and to concentrate on proper
reconstruction later.
334
Figure 199 (above): Importance of Diagnostic Imaging in

Traumatic Cataracts
In addition to studying the cataract itself, B-scan

ultrasonography demonstrates changes in lens position; pos-
terior rupture of the lens; cyclitic membrane; hemorrhage
into the vitreous; separation of the vitreous from the retina;
and retinal detachment, which are obscured to direct exami-
nation. Figure 199 shows a polaroid photo of a B-scan
ultrasound.
Figure 200 (below): Traumatic Cataract from Small Penetrating Wound in the
Cornea and Lens
This cross section of the anterior segment of the eye shows a damaged lens
with an anterior capsular tear (T). The lens is cloudy but lens material has still not
escaped through the capsular tear. In such cases, Dr. Treister repairs the primary
corneal wound (W) at this time and goes no further (assuming that the posterior
segment of the eye is not involved in the trauma). A few days later when the eye is
less irritated, lens extraction and IOL insertion can be performed.
335
If Anterior Capsule More Widely Timing for Primary Lens

Damaged Extraction
If the anterior capsule is more widely John Alpar, M.D., who has extensive
damaged and lens material is present in the experience with traumatic cataracts, consid-
anterior chamber, (Fig. 201) Treister re- ers that a primary lens extraction should
moves all the lens material during the first occur any time the lens is so damaged that its
surgical intervention and examines the poste- particles are mixed with anterior chamber or
rior segment with the indirect ophthalmo- vitreous material. The lens should also be
scope. If the trauma is confined to the anterior removed in cases of subluxated lens follow-
segment, the vitreous is clear, the retina is ing trauma. The advantages of a primary
attached without retinal tears and no foreign operation in these cases are that postopera-
body is seen, a posterior chamber lens is tive inflammation is reduced, rehabilitation
implanted . time is faster, and later examinations, includ-
ing the evaluation of the retina, are easier to
perform.
Figure 201: Traumatic Cataract with Anterior Capsule Widely

Damaged
Lens material is present in the anterior chamber. Viscoelastic has

been injected into the anterior chamber. The AC is irrigated (blue arrow)
with BSS and the debris, pigment residues, fibrin and lens material (D) are
washed out of the eye (red arrow). Lens damage shown in (L).
336
The most important indications for ary glaucoma and might need a filtering
primary operation are signs that point to the operation at a later date.
likelihood of a ruptured posterior capsule
with vitreous already entering the chamber. Anterior Capsulorhexis
More Extensive Damage In many cases the anterior capsule has
Affecting Posterior Capsule been perforated. A CCC may be quite diffi-
cult and sometimes risky. Paul Koch has
In case of perforation of the lens with advocated that a better way to open the
an opening also in the posterior capsule, unsupported part of the anterior capsule rup-
Treister as well as Stegmann in South tured zonules is to use capsule scissors. A
Africa remove the vitreous from the anterior puncture can be made in the anterior capsule,
chamber (if present) with a vitrector to- scissors introduced with one blade through
gether with the lens material but try to pre- the puncture, and a snip capsulotomy per-
serve the posterior lens capsule, or part of it, formed. Koch points out that pulling inward
for sulcus-placed posterior IOL implantation. to create a capsulorhexis with a needle or
forceps could be dangerous, dislocating the
Specific Problems with lens beyond the point of recovery.
Traumatic Cataracts Other parts of the capsule, where the
zonules are intact, may be opened in the usual
Paul Koch, M.D., points out that fashion.
zonules are often torn and there may be The circular anterior capsulotomy
significant risk of collapse of the posterior should be made large enough so that the
capsule as well as vitreous prolapse around nucleus can be floated out of the bag with
the equator of the lens. Consequently, in the hydrodissection. Typically this occurs easily
preoperative evaluation with the slip lamp, because the nucleus is white, soft and fluffy.
look carefully for evidence of zonulysis. In performing the anterior capsulotomy,
if the cataract is white, the use of Trypan Blue
as shown in Figs. 101 and 102, page 173 may
increase the possibility for performing a
HIGHLIGHTS OF
successful capsulotomy.
SURGICAL TECHNIQUE
Lens Removal
The Incision
In the presence of traumatic cataract,
A sclero-corneal tunnel (Fig. 40-B) is phacoemulsification is done in the anterior
definitely the incision to be used. A corneal chamber. Once the nucleus enters the anterior
tunnel incision is contraindicated. The chamber, viscoelastic can be placed above
conjunctiva must be treated very delicately. and below it, protecting the cornea and push-
Some of these patients may develop second- ing the flaccid capsule as far posteriorly as
337
Figure 202: Concept of Intracapsular

Tension Ring in Traumatic Cataracts and
Subluxated Lenses
(A) The intracapsular tension ring

(R) is an open circular PMMA ring inserted
(arrows) into the capsular bag (C) via an
injector (I) through a 3.5 mm incision. Both
ends have a small eyelet (E) for better
maneuverability with a hook during implan-
tation. The ring lies at the equator of the
capsular bag and so maintains the capsular
bag shape. An IOL can then be implanted
into the capsular bag with the ring in place.
(B) Shows an isolated view of the entire
capsular bag with the ring (R) and IOL (L)
in place, with haptics of the IOL (H) prop-
erly positioned within the distended bag.
The intracapsular ring distributes the forces
(arrows) inside the capsular bag, thereby
making it possible to work safely. Asym-
metrical collapse of the bag and
decentration of the IOL is prevented.
possible. In a young patient the nucleus is recent development, as advocated by Robert

usually very soft and is amenable to many J. Cionni, M.D., in the U.S. and Okihiro
different options. For a patient with an intact Nishi, M.D., in Japan. This device maintains
capsulorhexis, phaco-aspiration of the the shape of the bag during and following
nucleus is safe and effective. If an anterior or extracapsular surgery or phacoemulsification
posterior capsular tear is present, then manual in traumatic cases or in patients with sublux-
aspiration with a Simcoe-style cannula af- ation or pseudoexfoliation. It has important
fords greater control. «Dry» aspiration of the implications in terms of preventing IOL dislo-
soft nucleus under viscoelastic material offers cation, decentration, tilting, further zonular
excellent control, especially in the most com- dehiscence, and posterior capsule opacifica-
plicated cases, as advocated by Snyder and tion. The capsular tension ring (or
Osher. intracapsular ring), is an open circular
PMMA haptic (Fig. 202). It can distribute the
Role of Intracapsular Tension forces inside the capsular bag, thereby mak-
Ring in Traumatic Cataracts ing it possible to perform surgery safer, and
decentration of the IOL is prevented.
In the management of traumatic cata-
This is an important advance in
racts, the ring is placed in the bag for support,
cataract surgery. The ring is a relatively
338
provided that there is an intact anterior capsu- the IOL in the capsular bag is indicated and
lotomy and posterior capsular bag. In some desirable. If an intracapsular ring is not
cases it will be easy to place it prior to available and only a small area of zonular
emulsification of the nucleus, while in other dehiscence is present, slowly unfolding the
patients it is better to place it prior to cortical implant or very gently placing a rigid lens
aspiration. This will stabilize the capsule and with soft loops will minimize the stress on the
support the areas lacking zonules. Once the intact remaining zonules.
capsule is secure, the cortex can be removed Ciliary sulcus placement of a posterior
and the implant placed. If necessary the ring chamber implant is still possible in the setting
can be sutured transsclerally.. of a posterior capsular tear or zonular dialysis
(Figs, 153, 154, 156). If the anterior
capsulorhexis is intact, yet a severe posterior
Removal of Cortex capsule break exists, the haptics should be
After nucleus removal, before proceed- placed in the sulcus. It may be possible to
ing with cortical aspiration, inspect the poste- capture the lens optic posteriorly into the
rior capsule carefully to be sure that there are capsulorhexis. This will provide adequate
no tears as a result of the injury, particularly a support and will prevent the lens from subse-
blunt injury, where tears might be hidden. quently dislocating.
If the capsule is intact, proceed as usual, If the capsulorhexis is incompetent or
following the principles and techniques out- larger than the implant optic, sulcus fixation
lined in Figs. 127 and 128. In case of doubt with a large diameter implant can be utilized.
about the effects of automated irrigation-
aspiration, you may use the manual aspiration Selection of Viscoelastic in
with the Simcoe-type cannula, as shown in Traumatic Cataracts
Fig. 128. This allows a greater degree of
control.
In those eye centers where the two main
types of viscoelastics are available (disper-
Selection of IOL sive and cohesive), the following are good
choices as advocated by Snyder and Osher:
Traumatic cataracts may be associ-
1) When the hyaloid face is partly exposed, a
ated at a late date with some vitreoretinal
highly retentive (dispersive) viscoelastic
complications. PMMA and acrylic lenses are
agent such as Viscoat (Alcon) or Vitrax
well tolerated by the eye and preferred by the
(Allergan), may tamponade the vitreous and
vitreoretinal surgeons. Since traumatic cata-
keep it back. The dispersive agents also
racts are not uncommonly associated with
protect the endothelium well. This may be
some degree of traumatic mydriasis, a 6.0
particularly important in cases in which the
mm or larger diameter IOL optic is a prudent
endothelial cell density has been reduced by
choice.
the trauma. 2) On the other hand, the space
retaining qualities and ease of removal typical
IOL Implantation of highly cohesive viscoelastic agents, such
as Healon GV (Pharmacia & Upjohn), make
With the support and stability of an these agents more appropriate for the lens
intracapsular tension ring, the placement of implantation stage of the procedure.
339
Phacoemulsification Advan- cation reduces the risk of expulsive hemor-

rhage. In addition, a closed system allows
tages in Traumatic Cataract compartmentalization within the anterior seg-
ment. If the posterior capsule is broken or if a
Traumatized eyes with potentially zonular dehiscence is present, viscoelastic
weakened zonules are at greater risk for su- tamponade of the vitreous can be best main-
prachoroidal hemorrhage. Maintaining a tained in the setting of a closed system.
closed system as provided by phacoemulsifi-
PHACOEMULSIFICATION IN
SUBLUXATED CATARACTS
Strategic Management extend to more than 45º of the crystalline
lens circumference, and we can see an
Phacoemulsification is performed in a excellent red retinal reflex, it is almost
totally closed system, where the ultrasound certain that a phacoemulsification can be
tip blocks the incision, allowing the volume accomplished safely.
of aspirated masses to equal the volume of The hydrodissection must separate the
liquid injected into the anterior chamber, thus lens capsule from the cortex by injecting
maintaining stable intraocular pressure balanced salt solution (BSS) under the ante-
throughout the surgery. The space available rior capsule, and the hydrodelamination must
for disassembling the cataract is extremely attain consistent detachment of the nucleus
small, limited anteriorly by the corneal from the epinucleus (Fig. 203).
endothelium and, posteriorly, by the posterior The sharp separation of these structures
capsule. will significantly reduce the tension on the
If the zonules sustaining the crystal- fragile zonules during disassembling of the
line lens are weak, broken or nonexistent, in nucleus and aspiration of the residual cortex.
part or totally, or when the posterior capsule 2. a) If the damage to the zonular fibers
is ruptured, a delicate and risky situation may extends to more than 45º and the cataract has
arise unless we are ready to manage it effec- a hard nucleus with a retinal reflex turning
tively. brown, or b) the dialysis extends to 180º,
the insertion of an intracapsular tension ring
MANAGEMENT DEPENDING ON (Fig. 202) will be extremely useful to better
SIZE OF ZONULAR DIALYSIS support the crystalline bag throughout the
surgical procedure, reducing the chances of
When confronted with a zonular dislocation of the cataract into the vitreous.
rupture, Padilha recommends adopting the This is true even in cases of soft cataract. The
following strategies: 1) If during use of the intracapsular tension ring is also
biomicroscopy at the office, under mydriasis valid for cases with pseudoexfoliation and
and with a slit lamp, a small or moderate ectopia lentis – as in the Marfan syndrome
zonular dialysis is detected, which does not and others.
340
3. On the other hand, if there is a cially in cases of hard cataracts. In these

very extensive damage to the zonular fibers patients, Padilha advocates performing an
with a dialysis of more than 180º, Padilha intracapsular extraction associated with a
considers that phacoemulsification or even a Kelman anterior chamber implant, or a
planned extracapsular extraction may not be posterior chamber lens fixated to the sclera
sufficiently safe, even with the help of the (Fig. 156). He considers this to be a more
intracapsular tension ring (Fig. 202), espe- prudent solution.
Figure 203: Subluxated Cataracts - Hydrodissection
The cannula (C) is positioned under the anterior capsule (A) and the BSS is
injected separating the cortex from the nucleus and epinucleus. This maneuver is
repeated in order to create a clear cleavage plane. Too much irrigation must be
avoided. Otherwise, it may produce a dangerous blocking of the nucleus against the
margins of the anterior capsulotomy. This could give rise to a sudden dislocation of
the cataract into the vitreous (V) by creating a tear of the posterior capsule (P).
341
Special Precautions with properties, with another of dispersive

properties, which scatters and adheres to in-
Subluxated Cataracts struments or tissues. While the latter will
protect the damaged zonular area, by adher-
Padilha points out that some important ing to adjacent tissues of that region and
issues should be considered when subluxated helping prevent an eventual escape of the
cataracts are approached. vitreous, the cohesive viscoelastic will press
down upon the anterior face of the crystalline
Anterior Capsulotomy lens, transforming it into a convex surface,
and facilitate making the CCC. Such convex-
Anterior capsulotomy should be ity will help channel the zonular tear in the
performed as a continuous curvilinear direction of the center of the capsule and
capsulorhexis (CCC). The surgeon needs to not toward the periphery because of the cen-
use extreme caution starting with a bent trifugal force generated above the surface
needle and completing it with this same (Fig. 204). (Editor’s Note: A very clear
instrument or with the Uttrata’s or similar definition of the qualities of the cohesive and
forceps. the dispersive viscoelastics, and how they
If any problem arises at the time of differ from one another, is presented at the
the anterior capsule perforation with the cys- beginning of this Chapter).
totome (bent-needle) the surgeon may begin
the capsulorhexis with a pinch-type forceps Additional Measures to Reduce
such as the Kershner capsulorhexis cysto-
Risks
tome-forceps (Rhein Medical). The maneu-
vers should be executed very carefully and
1) Padilha recommends that the pha-
smoothly so as to prevent further damage to
coemulsification incision, whether in clear
the zonules. The diameter of this capsulo-
cornea or a scleral tunnel, should be placed
tomy should not be very large. Reaching the
as far away (circumferentially) as possible
equatorial region must be avoided at all costs.
from the damaged zonular region. This is to
(Editor’s Note: I also refer you to the discus-
prevent extension of the zonular dialysis by
sion of Traumatic Cataracts complicated by
the insertion and withdrawal of instruments in
some zonular dialysis, in which Paul Koch
the interior of the eye precisely in the most
recommends using scissors to perform the
affected area. If the zonular rupture is located
anterior capsulotomy so as to not exhert
in the superior quadrants a superior temporal
further pressure on the weakened zonules
incision will make surgery more demanding
with the maneuvers of a standard
and risky.
capsulorhexis.)
2) To further reduce risks, Padilha
Characteristics of Viscoelastics advises the use of disposable plastic flexible
Used iris retractors, which will help sustain and
Another important issue involves the stabilize the crystalline bag. The flexible
use of viscoelastic substances. It is important hooks are anchored in the borders of the
to combine one viscoelastics with cohesive CCC, in exactly the way we use them in
342
Figure 204 (left): Subluxated Cataracts - Use of

Dispersive Viscoelastic
An important issue involves the use of vis-

coelastic substances. These substances should have
characteristics such as viscosity, pseudoplasticity,
coatability and elasticity, which will allow various
maneuvers during the surgical procedure. This view
shows a cannula (C) inserted under the iris (I) in the
region where a zonular dialysis (ZD) is present,
injecting a dispersive viscoelastic, closing the dam-
aged zonular area and lessening the chances of an
eventual vitreous escape.
Figure 205 (right): Subluxated Cataracts - Help-

ing Support of Capsular Bag with Flexible Iris
Retractors
To provide more support to the capsular bag,

flexible iris retractors (F) are fastened to the borders
of the anterior capsulotomy (C). The retractors are
inserted through four opposite ancillary incisions.
Once the retractors are in position (F), the
capsulorhexis (C) is carefully put on stretch, without
much traction. Then the surgeon may proceed with
phacoemulsification using very low parameters such
as vacuum less than 150 mmHg, low irrigation and
reduced ultrasound power (less than 70%). Phaco
probe (P).
343
order to dilate small pupils (Figs. 205 and Increasing the Safety of
196) except that the retractors are placed in
the margins of the anterior capsulotomy
Posterior Lens Implantation in
instead of the margins of the pupil. Extensive Zonular Disinsertion
3) During disassembling of the nucleus,
maneuvers to rotate the nucleus should be In those cases where a more extensive
reduced to a minimum. In order to prevent the zonular disinsertion is present, it is important
need for these maneuvers, hydrodissection to create safer conditions to implant a lens in
and hydrodelamination should done carefully the posterior chamber. Variations and con-
but thoroughly. stant improvements of this technique have
4) Padilha recommends that the been presented at various meetings and pub-
intracapsular tension ring be introduced after lications by many authors, especially Drs.
the hydrodelamination is completed and Jorge Villar-Kuri, from Mexico, Robert
before emulsification (Fig. 202). This is an- Osher, from the United States, Yoshihiro
other very important measure to provide sup- Tokuda, from Japan, Charlotta Zetterstrom,
port to the capsular bag. Usually the ring is from Sweden, among others.
held by a long Kelman-McPherson forceps Some guidelines are basic and very
and introduced clockwise. When operating on important in these extreme situations,
the right eye using a superior sclero- corneal including cases of Marfan’s syndrome. The
tunnel incision, the ring is moved 1 hour in surgeon should always opt for a small
the direction of 3 o’clock and 6 o’clock. A capsulorhexis using a bent needle, and carry
spatula—preferably Koch’s spatula—is used out the hydrodissection very carefully.
to facilitate the insertion of the ring in the Padilha considers there are at least
correct position inside the bag. These rings three options in order to increase the safety
come in different sizes. They are produced of the posterior chamber lens implantation.
by Morcher GmbH, Germany, and Corneal, The first consists in totally removing the
France, and will be commercially available capsular bag following removal of the
through Alcon in the near future. cataract. This could be indicated in certain
If an accidental cataract subluxation situations where the lens is too dislocated
occurs during a conventional cataract sur- either superiorly or inferiorly, and vitreous
gery, the surgery must be interrupted and the loss is present. Following a generous anterior
ring should be introduced as described above. vitrectomy using an automated vitrector,
In these cases, Padilha prefers to implant a the intraocular lens is sutured to the sclera,
one-piece intraocular lens, all PMMA, inside (Fig. 156).
the capsular bag and to make its length coin-
cide with the meridian where the zonular
rupture occurred.
344
Figure 206 (above): Subluxated Cataracts

- Fixation of the Anterior Capsule to the
Ciliary Sulcus - Stage 1
Once the capsular bag is filled with

viscoelastic, the anterior capsulotomy (C) is
enlarged to the left and right using Vannas
scissors (V). This allows the capsule to
distend and allow more space for the
insertion of the IOL.
Figure 207 (below): Subluxated Cata-

racts - Fixation of the Anterior Capsule
to the Ciliary Sulcus - Stage 2
A prolene 10-0 suture (P) is care-

fully inserted in the anterior chamber and
through the anterior capsule flap (C) that
has been created with the scissors, in a
curved “U”. Take care to ensure that the
endothelium is not touched. Scleral flap
in the inferior part of the globe for final
fixation of sutures (F).
Fixation of the Anterior Capsule to This technique involves making two incisions
the Ciliary Sulcus in the anterior capsule, through the small
CCC (Fig. 206), as in the intercapsular tech-
The second option to increase the nique advocated some years ago by Sourdille
safety of the posterior lens implantation and and Galand. The borders of the free edge of
to prevent it from dislocating is to actually the capsule should be folded and sutured to
suture the anterior capsule to the ciliary sul- the sclera at the opposite side of the luxation,
cus. This is done so that when the IOL is as suggested by Villar-Kuri . The step-by-
sutured and implanted, it will remain in place. step technique is shown in Figs. 206-210.
345
Figure 208 (above): Subluxated Cataracts - Fixa-

tion of the Anterior Capsule to the Ciliary Sulcus -
Stage 3
Viscoelastic is reinjected in the anterior cham-

ber. Through an inferior triangular scleral flap (F), 2.0
mm from the limbus, the surgeon introduces a straight,
long, 25 gauge needle (N), emerging through the
primary incision (M), with its bevel up. Into its bore
the surgeon inserts the C7 needle (magnified inset),
and slowly pulls the long needle until it goes out of the
globe through the inferior scleral flap.
Figure 209 (center): Subluxated Cataracts -

Fixation of the Anterior Capsule to the Ciliary
Sulcus - Stage 4
The suture is used to pull up the anterior
capsule (C) to the inferior scleral bed (S). The
knot is buried inside the sclera, closing the
scleral flap (F) with a 10-0 nylon suture (N).
Figure 210 (below): Subluxated Cataracts - Fixa-

tion of the Anterior Capsule to the Ciliary Sulcus -
Last Stage
At this point the anterior capsule (C) is fixed to

the ciliary sulcus to permit more space and safety for
the IOL insertion. Finally, the IOL of the surgeon’s
choice (L) is implanted, placing it in a position perpen-
dicular to the disinsertion. The primary incision is
closed with a horizontal 10-0 nylon suture (N).
346
CATARACT SURGERY IN CHILDHOOD
Previous Controversies Now procedure in bilateral cases. This requires

changing all instruments and sterile clothing
Resolved of the surgeon, nurse and patient between
eyes. Patching is not indicated. General
Cataract surgery in the pediatric patient anesthesia is used in all cases.
and the post op management of these children
is still a complex problem, but significantly Unilateral Cataracts
less than up to five years ago. The difficult
controversies previously existing regarding Unilateral congenital cataract presents a
finding solutions for their visual recovery more challenging problem, since even a mild
have been solved in most cases. These con- cataract will cause irreversible deep amblyo-
troversies are: pia in one eye if not treated. Treatment is
based on surgery within two months of life,
1) Age and Timing for Surgery prompt optical correction with intraocular
lens implantation and aggressive occlusion
Bilateral Cataracts therapy with frequent follow-up have been
successful in several series.
It is now generally agreed that early
cataract surgery in bilateral cataracts and Preconditions to be Met for
immediate optical correction can prevent Useful Vision
otherwise irreversible deprivation amblyopia
in the child born with dense cataracts. Un- In cases of unilateral cataracts, if
less this is done, children with bilateral cata- cataract surgery with IOL implantation is not
racts who undergo surgery later in childhood done very early in life, the chances of
or in their teens recover only limited visual achieving good vision are slim. It is possible
acuity, usually an average of no better than to achieve useful vision in some children
20/60. Optimum optical correction following with monocular congenital cataracts provided
surgery is more effectively done today with certain important preconditions are met. The
IOL implantation. most important is the age at which the surgery
In infants with bilateral cataracts, de- is undertaken along with equally important
spite an increased complication rate, surgery immediate optical correction and occlusion
must be performed within the first months of therapy as emphasized by Noel Rice, M.D.
age to avoid irreversible amblyopia. at Moorfields Eye Hospital in London and
Cataract surgery in children over the Eugene Helveston, M.D. in the U.S. years
age of 1 year is less complex with a higher ago. These preconditions continue to be
success rate and with fewer complications in valid. It is essential first to provide a focused
the postoperative period. It is best to perform image and second, eliminate suppression.
surgery in both eyes at the same «sitting». This «triumverate» or «troika» of
Sterility must be maintained during the whole treatment is the key to success. To a great
347
extent, the ophthalmologist depends on other that the implications of asymmetrical input
professionals who determine when the cata- into the visual system are vitally important,
ract is identified and referral takes place. If particularly in relation to unilateral congeni-
the child does not present to the ophthalmolo- tal cataracts.
gist within the optimal period for surgery and
optical rehabilitation, clearly the ophthalmic When Should We Not Operate?
surgeon is considerably constrained in the
quality of care he/she can provide. Timing is Any unilateral lenticular opacity that is
absolutely the key. If the surgeon decides to moderately severe will cause amblyopia. If
operate on a unilateral cataract, the family management as here described is not pos-
needs to expect the very high likelihood of sible very early in life, it may be best if we
only a helper eye, and not an eye that will advise against it. Very mild unilateral len-
have very good vision. It is important to ticular opacity, may be best left alone. Re-
acknowledge this limitation. moving a small unilateral cataract that causes
a small degree of amblyopia creates aphakia,
Role of Parents which may lead to even more amblyopia,
unless we implant the adequate IOL and
Their role is absolutely essential for undertake aggressive occlusion therapy.
achieving a good result. The surgeon would
be wise to take this factor into consideration Preoperative Evaluation
before undertaking treatment. Parents who
do not understand what they and the child
History
need to go through for pre and postoperative
management to prevent and «conquer» am-
In the workup of a child with cataract,
blyopia, become the first contraindication to
a detailed history is necessary. It is impor-
surgery. This is particularly important in
tant to determine whether the cataract is
unilateral cataracts in which prolonged am-
progressive, particularly in older children.
blyopia treatment is essential.
Contrary to some earlier teaching, we now
know that bilateral cataracts are often pro-
Importance of Asymmetrical gressive. Frequently, in children from ages
Visual Input 3 to 6 and even of high school age, vision is
gradually diminished bilaterally because of
The period of sensitivity of the visual progressive congenital cataracts.
system and its responsiveness to the develop- As pointed out by Charlotta
ment of vision through having a good visual Zetterstrom, M.D., PhD, of Stockholm,
input in humans is still not precisely deter- Sweden, in a clinically healthy child, an
mined, but we know that it is most respon- extensive preoperative evaluation to establish
sive during early infancy, and it falls off the cause for the cataract is not routinely
rapidly during the first year of life. The necessary. Congenital cataracts are fre-
clinical research made by Rice at Moorfields quently inherited as an autosomal dominant
and Von Noorden in the U.S. determined trait but a recessive inheritance also occurs.
348
It is important, to rule out metabolic disor- at the age of 2-3 months generally indicates a
ders, genetically transmitted syndromes, in- poor visual prognosis.
trauterine infections and ocular conditions Complete examination of infants with
with associated anomalies. dilated pupils often requires sedation or gen-
eral anesthesia and can be performed during
Examination the same anesthesia as the surgery although,
if possible, days before surgery, so that the
The workup of the congenital cataract surgeon can be better informed to enable
patient continues with the office examina- him/her to make adequate decisions, and to
tion. Infants with congenital cataracts gener- inform the parents properly.
ally resist having their eyes examined, and Measurement of the corneal diameter,
do not cooperate with the examining physi- intraocular pressure using a handheld tonom-
cian. This causes considerable stress in the eter, type and density of the cataract by
family. The ophthalmologist must use spe- photography, are all part of a good examina-
cial examination techniques. First, the light tion in these patients. Zetterstrom empha-
should be turned down to low levels of sizes that when the clarity of the media
illumination, which causes the eyes to open permits, indirect ophthalmoscopy may reveal
immediately. Direct illumination is used to persistent fetal vessels or other posterior seg-
determine the extent of the opacity. ment abnormalities that may have an impact
The red reflex should first be deter- on the visual outcome. A-scan measurement
mined by direct ophthalmoscopy with the of the axial length, and keratometer readings
pupil undilated. The cataract is often most are done. These are essential measurements
dense in the central part of the lens and after for contact lens and IOL power calculation.
dilatation it seems to be less significant. Newborn eyes with congenital cataract are
While the newborn child is awake it is also shorter and have a smaller corneal diameter
important to assess visual function, if pos- compared to controls (Fig. 31 and text pages
sible, with a Teller acuity card. Watch for the 54-56).
ability to fix and follow with an object that A B-scan ultrasound is also performed
attracts attention. Clarify with the parents in cases in which visualization of the retina is
whether they have had any visual interaction impossible, in order to determine whether
with the child. there are retinal abnormalities, masses, or the
Children with significant bilateral con- presence of hypoplastic primary vitreous.
genital cataracts may seem to have delayed Helveston considers it important to deter-
development as well as obviously impaired mine the intraocular pressure because there is
visual behavior. Children with monocular a significant relationship between reduced
cataracts often present with strabismus, corneal diameter, intraocular pressure, and
which however may not develop until severe the presence of glaucoma. One of the most
irreparable visual loss has occurred. Chil- serious problems in the management of con-
dren with monocular cataract are almost al- genital cataracts, particularly bilateral con-
ways detected much later than cases with genital cataracts, is the glaucoma that may
bilateral cataract. The presence of nystagmus occur 5 to 10 years after successful cataract
349
surgery treatment. This glaucoma resembles through the peripheral lens, there is no indi-
chronic simple glaucoma in the adult patient. cation for precipitous and early surgery.
While the intraocular pressure may show Such cases can be treated very conserva-
only a modest increase, glaucoma in children tively.
can be extremely resistant to successful treat- These patients often have vision suffi-
ment. If not controlled, it can cause the same ciently reduced in primary and early second-
type of atrophy in the optic nerve that occurs ary school years to benefit from cataract
in chronic simple glaucoma. removal and IOL implantation between ages
5 and 15 or even a little earlier.
The Special Case of Lamellar
Cataracts Rubella Cataracts
Saunders, the founder of Moorfield’s These cataracts used to be an important

Eye Hospital, determined 200 years ago that source of blindness. Rubella cataracts tend to
lamellar cataracts often do not interfere at all be bilateral and progressive and result in a
or at a rather insignificant level with visual membranous type of partially resolved cata-
development. The lamellar cataract looks ract, posterior synechiae, and chronic uveitis.
central and quite dense on retroillumination, For the past 25 years, since rubella immuni-
but is revealed under slit-lamp illumination zation has been available, rubella cataracts
as definitely lamellar. Children with lamellar have been virtually nonexistent. The key
cataracts usually achieve very good vision if point in managing these rubella cataracts is
these cataracts are operated on much later in not to aspirate them incompletely because
life, even late in childhood or the teens or eventually the eyes are lost. The process of
twenties. Patients do not usually develop aspiration reactivates the virus.
nystagmus and often achieve normal or near
normal vision. The corollary is that there is The Need for Close Monitoring
no need to operate on these children in early
infancy. The prognosis is better if operated These children should be closely moni-
when older, when visual development is tored. This includes evaluating visual devel-
complete. An accurate calculation of IOL opment to be sure it is proceeding in a
power can be made, with a better visual satisfactory manner. The surgeon’s responsi-
result. bility is to both nurture the process of sight
In his clinical research, Rice observed and to help prevent amblyopia. Otherwise,
that in many children with lamellar cataracts, the outcome will be poor because of insuffi-
if ophthalmoscopy is undertaken even with a cient attention to the anti-amblyopia treat-
reasonably dilated pupil, the view of the ment.
fundus is often extremely obscured; in fact,
there may not even be any red reflex. If eyes Preoperative Considerations
are examined fully, however, it can always
be seen that there is clear cortex. If there is a The most important relates to the cal-
reasonable view of the peripheral fundus culation and selection of the type of IOL to
350
be used and its correct power. The method and consequently, the accurate IOL power
and the considerations relating to IOL power adequate for each child. 2) There was
calculation in pediatric cataracts is amply and opacification of the posterior capsule in most
clearly presented in pages 54, 55, 56 and Fig. cases. This required a second operation for
31, page 56. posterior capsulotomy and the presence of an
IOL would impede proper surgical maneu-
The Decision to Implant IOL’s vers.
The situation has now significantly
in Children with Cataract changed. The previous failures with spec-
Surgery tacles and contact lenses, the new develop-
ments in technology and surgical techniques
How to optically correct patients with and the fresh insight of surgeons of a new
bilateral congenital cataracts and monocular generation have led us to discard the previous
congenital cataract has been a major subject thinking and to consider the implantation of
of controversy for many years. Some distin- posterior chamber IOL’s a very positive de-
guished ophthalmic surgeons 20 years ago velopment in children. This has been made
were strongly against performing surgery in possible by the following developments: 1)
monocular congenital cataract followed by new medications that effectively prevent and/
treatment of amblyopia with a contact lens. or control inflammation. 2) The introduction
Visual results were so bad that children with of posterior capsule capsulorhexis by
this problem must be amblyopic by nature, Gimbel in North America promptly fol-
they thought, and the psychological damage lowed by Everardo Barojas in Mexico and
to the children and the parents by forcing Latin America (Fig. 30). 3) High viscosity
such treatment was to be condemned. viscoelastics to facilitate intraocular surgery
Surgery of bilateral congenital cata- in smaller eyes. 4) New, more appropriate
racts at a very early age followed by correc- IOL’s for children and implantation in the
tion with spectacles and sometimes with capsular bag. 5) Refined technology that
contact lenses usually ended with no better leads to a more precise calculation of the IOL
than 20/60 vision bilaterally. This was again power.
a source for the belief that congenital cata-
racts either unilateral or bilateral were by A «Major» Controversy No More
nature associated with amblyopia, profound
in cases of monocular cases and fairly strong The controversy as to whether to im-
in bilateral cataracts. plant IOL’s or not in the management of
When posterior chamber IOL implanta- cataract surgery in children has been almost
tion in adults became established as the resolved. At present, most surgeons place
procedure of choice, strong influences within intraocular lenses, whether treating congeni-
ophthalmology were adamantly opposed to tal cataracts or traumatic cataracts, following
their use in children for the following rea- evidence that they can be safely tolerated in
sons: 1) the eye grows in length with conse- most children. The informed consent discus-
quent significant change in refraction. It was sion with the parent or guardian, however,
considered impossible to predict such change should include the fact that intraocular lenses
351
have still not been approved by the FDA for points out that the anterior capsule is thick
use in children. This is a matter of particular and elastic in children and a capsular tear can
importance in the U.S. easily extend out to the equator.
The previously existing controversy of A central puncture is made with a cysto-
the timing of the IOL implantation in chil- tome and the leading edge of the capsule is
dren has also been resolved as a conse- grasped with forceps. Several repeated
quence of experience. Intraocular lens im- grasps are recommended to avoid extension
plantation may be significantly easier at the to the equator and to assure maximal control.
time of cataract extraction than at a later date, The capsulorhexis should be kept small be-
since iridocapsular adhesions and fusion of cause it usually enlarges due to the inherent
the anterior and posterior capsular flaps make elasticity of the capsule. (See figures 97, 98,
a subsequent secondary implant procedure 99, 100 for CCC with cystotome and 45, 46
more challenging. with forceps).
Surgical Technique Nucleus Removal
The Incision After an appropriate hydrodissection,

the removal of the nucleus and cortex in the
A sclero-corneal tunnel 3.5 to 3.8 mm majority of cases can be performed using an
wide is the procedure of choice (Fig. 40-B). I/A probe with a 0.5 mm orifice, because for
Manage the conjunctiva very carefully in the most part the congenital cataract is usu-
case the patient develops secondary glaucoma ally very soft. Occasionally the cataract is
later in life. Because the sclera is soft and hard and has to be disassembled and re-
elastic in children, it is hard to achieve a self- moved. All the lens cortical material must be
sealing incision. Consequently, the incision aspirated in order to reduce postoperative
should be sutured. inflammation (Fig. 128, page 206). Prolifera-
tion of cells leading to a secondary cataract
formation is more aggressive in the younger
The Anterior Chamber and Pupil
child.
High-viscosity viscoelastic material is
used because the anterior chamber is shallow Posterior Capsulorhexis
in these small eyes. If the pupil is small,
stretching the pupil with flexible iris retrac- In children a posterior capsulorhexis
tors (Alcon-Grieshaber) can be very helpful combined with an anterior vitrectomy are
(Fig. 198). They are placed before the con- necessary to produce a clear optical axis and
tinuous anterior capsulorhexis is performed. reduce the need for a secondary operation.
The diameter of the posterior capsulorhexis
must be at least 3.5 to 4.0 mm or it will tend
Anterior Capsulorhexis
to close. Moreover, the anterior and poste-
rior capsules must be separated with the use
This is an important step to assure in
of additional viscoelastic. This maneuver
the bag placement of the IOL. Its size should
will push the vitreous back and prevent its
be smaller than the IOL optic. Zetterstrom
352
prolapse into the anterior chamber (Fig. 211). performed using a vitrectomy probe, as
Posterior capsulorhexis is performed by most shown in Fig. 212. Special care should be
surgeons before IOL implantation, as pre- given to removing any vitreous present in the
sented here. Nevertheless, some surgeons do anterior chamber. A so-called “dry” vitrec-
it after IOL implantation, as shown in Fig. 30, tomy, without infusion of fluid, is safely
page 52. The latter procedure may be cum- performed between the anterior and posterior
bersome. capsulorhexis. Viscoelastic is removed to
avoid elevated intraocular pressure after sur-
Anterior Vitrectomy gery.
Using this method it is possible to im-
This important step is performed after plant an IOL in the capsular bag during
completing posterior capsulorhexis and aims primary surgery or in the ciliary sulcus if a
at removing 1/3 of the anterior vitreous gel secondary implantation is scheduled in the
before there is any vitreous presentation. It is future.
Figure 211: Cataract Surgery in Children - Importance of Posterior Capsulorhexis
When the capsular bag is empty of all lens material, viscoelastic is injected to fill the
capsular bag and a posterior continuous capsulorhexis (P) is performed, always smaller than the
anterior capsulorhexis (A). A combination of cystotome first followed by forceps is the technique
preferred by most surgeons. High viscosity viscoelastic (V) is injected to separate both capsules
and to keep the vitreous out of the way.
353
IOL Implantation
Primary IOL implantation into the cap-

sular bag is the procedure of choice. The risk
of contact with vascular tissue and the possi-
bility of inducing chronic inflammation is
reduced as compared with implantation in the
sulcus. For IOL implantation it is important
to extend the incision to 3.5 or 3.8 mm to
facilitate the implantation of a foldable
acrylic IOL. Viscoelastic is injected between
the anterior and posterior capsules to separate
them. The acrylic lens is folded and inserted
by the same technique used in the adult eye
(Fig. 213).
Figure 212 (above): Cataract Surgery in Children
- Anterior Vitrectomy
With the anterior chamber filled with vis-

coelastic an anterior dry (that is, without infusion)
vitrectomy is performed to avoid vitreous (V) rem-
nants in the anterior chamber. This step should help
eliminate any vitreous gel in the anterior chamber
and near the posterior capsule. The vitrectomy
probe (B) is inserted under the anterior
capsulorhexis (A) and at the margin of the posterior
capsulorhexis (P), always with the tip facing up,
taking care not to touch any one of both capsules.
This maneuver is preferably performed before the
IOL implantation.
Figure 213 (right): Cataract Surgery in Chil-

dren - Intraocular Lens Implantation
The anterior chamber and capsular bag are

filled with viscoelastic. IOL (L) implantation
within the capsular bag is the procedure of choice.
It is important to use an acrylic lens. Anterior
capsule (A). Posterior capsule (P).
354
The Posterior Approach to BIBLIOGRAPHY

Cataract Extraction in Children
Alio JL, Chipont E: Cataract surgery in patients
This has become a second option, and with uveitis. Cataract Surgery in Complicated Cases
by Buratto, 2000; 15:193-206.
certainly not the procedure of choice. With
significant advances in cataract removal in Belfort Jr., R: Cataract surgery in patients with
children through the anterior approach, the uveitis. Highlights of Ophthalmology Bi-Monthly
two or three port pars plana vitrectomy with Journal, Vol. 27, Nº 4, 1999.
removal of the posterior capsule and lens
material and IOL fixation in the sulcus is left Buzard K, Lindstrom RL: Refractive cataract sur-
for cases in which a vitreoretinal operation is gery. Highlights of Ophthalmology Bi-Monthly
required as the primary procedure. This is the Letter. 1994; Vol. 22, Nº 11-12, pp. 111-116.
realm of the vitreoretinal surgeon. The ante-
rior segment surgeon feels uncomfortable Centurion V, Lacava AC, De Lucca ES, Barbosa R:
with this approach particularly when the tech- High myopia and cataract. Faco Total by Virgilio
Centurion.
nique done through the anterior segment is
now so effective and the main controversies Colvard DM, Kratz RP: Cataract surgery utilizing
related to this surgery are almost a problem of the erbium laser. In: Fine IH, ed.
the past. Phacoemulsification: New Technology and Clini-
cal Application (Thorofare, NJ: Slack, 1996),
CATARACT SURGERY 161-80.
IN UVEITIS Dodick, JM: YAG laser phacolysis in new cataract

techniques. Boyd’s World Atlas Series of Ophthal-
mic Surgery of HIGHLIGHTS, 1995; 5-130-131.
This is, indeed, one of the most delicate
and complex situations in cataract surgery. In Dodick, JM, Christian J: Experimental studies on
this volume it is fully discussed in pages 31- the development and propagation of shoch waves
33 and Fig. 22 (Chapter 2). created by the interaction of short Nd:YAG laser
pulses with a titanium target: possible implica-
tions for Nd:YAG laser phacolysis of the
cataractous human lens. J Cataract Refract Surg
1991; 17:794-7.
Fenzl RE, Gills III JP, Gills JP: Piggyback

intraocular lens implantation. Current Opinion in
Ophthalmology, Feb. 2000, Vol. 11, Nº 1.
Kershner RM: Refractive cataract surgery. Current

Opinion in Ophthalmology, Feb. 1998, Vol. 9, Nº 1.
355
Khater TT, Koch DD: Pediatric cataracts. Current

Opinion in Ophthalmology, Feb. 1998, Vol. 9 Nº 1.
Koch DD, Lindstrom RL: Controlling astigmatism

in cataract surgery. Seminars in Ophthalmology,
December 1992; Vol. 7, Nº 4 pp 224-233.
Lacava AC, Sanchez JC, Centurion V: High hyper-

opia, cataract, polipseudophakic or piggyback, Faco
Total by Virgilio Centurion.
Management of aphakia in childhood. Focal Points,

American Academy of Ophthalmology, nMarch
1999 (3 Sections) Vol. XVII, Nº 1.
Neto Murta J, Quadrado M: Pediatric lens implan-

tation: technique and results. Atlas of Cataract
Surgery, Edited by Masket S. & Crandall AS,
published by Martin Dunitz Ltd., 1999, 33:291-
300.
Zetterstrom C.: Cataract surgery in the pediatric

eye. Cataract Surgery in Complicated Cases by
Buratto, 2000; 1:1-14.
356
C h a p t e r 13: Manual Extracapsular Techniques of Choice - Planned ECCE - Small Incision ECCE
THE PRESENT ROLE OF

MANUAL EXTRACAPSULARS
Overview rural communities which he spontaneously

serves, he does the “envelope extracapsular
Although phacoemulsification technique” initiated in the 1960’s by Baikoff
followed by implantation of a foldable IOL is and revived in 1982 by Galand. All his
the “state of the art” technique and the residents learn how to perform the planned
operation of choice for many surgeons and extracapsular with 8 mm incision, the enve-
patients, planned extracapsular extraction lope extracapsular, as well as phacoemulsifi-
with an 8 mm incision and implantation of a cation.
rigid posterior chamber IOL is still used for a Barojas and collaborators have se-
vast number of patients. lected the “envelope extracapsular” proce-
As a matter of fact, if we consider the dure for rehabilitation of large numbers of
day-to-day practice as performed by the ma- patients at a time considering cost, time it
jority of clinical ophthalmologists world- takes, safety and good results.
wide, planned extracapsular technique with a
8 mm incision and posterior chamber, in-the- Advances in Manual Extracap-
bag implantation of a rigid PMMA lens or sular
some other type of manual extracapsular
continue to be: 1) the cataract surgical proce- In the past few years, the technique of
dure performed on the largest number of planned ECCE has progressively and
patients who undergo cataract surgery; 2) the substantially improved. In addition, small
surgical technique done by the majority of incision or medium-small incision manual
clinical ophthalmologists throughout the extracapsulars have stimulated the interest of
world regardless of whether they are techni- a good number of clinical ophthalmologists in
cally able to do phacoemulsification. different regions who have chosen to do these
There are many first class surgeons who manual techniques instead of undergoing the
can perform a superior quality phacoemulsifi- learning process of phacoemulsification even
cation but for a large number of patients they though some of these “small incision” manual
need to do manual ECCE. This is particularly extracapsulars are not easy to do. These
true in less economically advanced societies. techniques are presented in this Chapter.
A good example of this situation is the Advances in extracapsular surgery are
experience of Everardo Barojas, M.D., related to better instruments, viscoelastics,
from Mexico, one of Latin America’s most the application of nuclear fragmentation tech-
respected ophthalmic surgeons and teachers. niques, advances in IOL technology, irrigat-
He performs a first class phacoemulsification ing solutions and the methods to minimize
and teaches the technique to his residents. infection and postoperative inflammation as
But in his extensive work with patients in the presented in Chapter 4 of this Volume. The
359
application of these advances is a long step Regional Predominance of

forward for manual extracapsular as well as Phacoemulsification
phacoemulsification, which is a mechanical
extracapsular. As a matter of fact, a good Phacoemulsification is predominant es-
number of steps used in phacoemulsification, sentially in the U.S. and Western Europe,
such as continuous circular capsulorhexis where it has become the number one tech-
have been incorporated into the modern nique for most ophthalmic surgeons. In
methods of ECCE. All of these factors make many instances, this is because their patients
manual extracapsular a very good operation. demand and expect a very rapid visual reha-
The essential difference with phaco regarding bilitation and have the economic means to
results is that with a very well done phaco and receive the benefit of the high technology
topical anesthesia the patient has almost im- required for phaco. In other geographical
mediate visual rehabilitation and minimal in- regions, phacoemulsification continues to
flammation, in contrast to a very well per- gain ground, but essentially in teaching cen-
formed ECCE in which final visual recovery ters and private practice.
may take 6-8 weeks, although the visual Because manual planned ECCE is still
acuity is practically the same at the end of this extensively used, we have selected Professor
period. There may also be more inflamma- Joaquin Barraquer, M.D., from Barcelona
tion with ECCE. to present his technique of a flawless planned
extracapsular. There is no one better suited
for this task.
360
PERFORMING A FLAWLESS
PLANNED EXTRACAPSULAR CATARACT EXTRACTION
With an 8 mm Incision and
Posterior Chamber IOL Implantation
by Professor Joaquin Barraquer, M.D., F.A.C.S.
EDITOR’S NOTE:
Professor Joaquin Barraquer is one of the world’s top master surgeons. He was
one of the key pioneers of ophthalmic surgery under the microscope which led to the
development of microsurgery. The ASCRS selected him as “one of the world`s most
outstanding innovators.” The III International Congress on Advances in Ophthalmol-
ogy, 2000 declared him “Ophthalmologist of the Millennium.”
ANESTHESIA General Anesthesia

(as Performed at the Barraquer
At the Barraquer Ophthalmology Cen- Ophthalmology Center)
ter in Barcelona, we continue to find general
anesthesia administered by an expert anesthe-
Pre-induction
siologist the procedure of choice even with
ambulatory surgery. With this type of anes-
Midazolam (1-5 mg, intravenous,
thesia, the surgeon does not need to depend
anxiolytic).
on the cooperation of the patient. Hypotony
of the eye is excellent. The surgeon can
perform the complete procedure with opti- Induction
mum control and safety.
Nevertheless, because many eye cen- Propophyl (1-3 mg/kg, intravenous, hypnotic)
ters and clinical ophthalmologists throughout Succinylcholine (1 mg/kg, intravenous, mus-
the world routinely use local anesthesia, both cular relaxant for orotracheal intubation).
techniques are here described.
361
Adjunct Medications Awakening and Recovery

Analgesics: alfentanil (0.5-1.0 mg) or
Oxygenation 100% and control of vital
pentazocine (15-30 mg) intravenous.
signs. Cholinesterase inhibitors (neostig-
Neuroleptics: droperidol (2.5-5.0 mg,
mine and/or edrophonium) if curare has been
intravenous)
used.
Vagolyptics: atropine (0.5-1.0 mg, in-
travenous)
Curare: atracurium besylate (0.25- Local Anesthesia
0.50 mg, intravenous as muscle relaxant)
Antiemetics: ondansetron (4 mg) and/or With this type of anesthesia very good
metoclopramide (10 mg) intravenous. hypotony and akinesia can be achieved. If
sedation is adequate but not excessive, mini-
Maintenance mal patient cooperation will be sufficient.
Barraquer believes an expert anesthesiologist
Halogenated ethers for inhalation anes- should always be available to ensure that the
thesia (sevoflurane or isoflurane), occasion- patient is controlled, even if local anesthesia
ally complemented by nitrogen protoxide is used.
(N2O) 50%.
Sedation
Ventilation
Propophyl, alfentanil, midazolam. The
dosage depends upon the patient’s weight
Spontaneous respiration, if possible,
and age.
depending on the type of patient and surgery.
The patient should be oxygenated dur-
Assisted or controlled ventilation if neces-
ing the anesthetic and surgical procedure
sary.
because sedation causes respiratory depres-
sion.
Monitoring
Peribulbar Injection
Electrocardiogram (EKG)
Pulsioximetry (Oxygen saturation)
Two injections are administered: Ante-equa-
Non-invasive blood pressure (NIBP)
tor injection - Inferotemporal Site.
every 3 minutes.
Capnography (expired CO2) and respi-
1. An inferotemporal injection at the inter-
ratory frequency.
section of the temporal lateral third and
Muscular relaxation.
the two medial thirds of the inferior orbit,
just anterior to the equator (Fig. 214). A
23 gauge needle 25 mm long is used.
2. A superonasal injection (Fig. 215). A 25
gauge needle 16 mm long is used.
362
Figure 214 (right): Peribulbar Local

Anesthesia
Inferotemporal injection anterior to the

equator. The needle is advanced just
anterior to the equator of the globe, along
the inferior orbit, but not into the muscle
cone. The anesthetic solution is injected
at this site. The beveled side of the needle
tip is directed toward the globe.
Figure 215 (left): Peribulbar Post-equator

Superonasal Injection.
The needle is directed posteriorly

behind the globe outside the muscle cone
toward the area of the superior orbital fis-
sure. The anesthetic solution is injected just
past the equator.
363
Technique for Peribulbar Extracapsular Cataract

Injection Extraction with an 8 mm
First, the inferior temporal rim of the
Incision (ECCE)
orbit is identified by palpation, and the eye-
ball is displaced with the finger. The needle is At the beginning of the operation, the
always introduced in the direction of the orbit pupil must be adequately dilated (8mm or
until it touches bone. At this point the needle more. We use cyclopegics and tropicamide
is lowered, following the rim of the bone. every 30 minutes, beginning 3 hours before
Three to 4 cc of local anesthesia are injected. surgery. Diclophenac is added to reduce the
Then the same maneuver is performed at the tendency for the surgical maneuvers to cause
superior nasal point. Massage is applied to the pupillary constriction. Atropine is not recom-
globe for a few seconds. A Honan balloon is mended because we want prompt recupera-
placed over the globe with a pressure of about tion of normal pupillary reaction the first day
40 mm for 5 to 10 minutes (Fig. 96). after surgery.
Anesthetic Medications Incision
5 cc lidocaine 2%, plus 5 cc buvicaine A traction suture is applied in the supe-

0.75%, plus hyaluronidase 100 UI plus rior rectus muscle. A fornix-based conjuncti-
adrenaline 1:200 000 (3 to 4 cc in the injec- val flap is prepared. The conjunctiva is sepa-
tion inferiorly and 3 to 4 cc in the injection rated at the limbus either with a razorblade
superiorly. This combination lasts for almost knife or with Wescott scissors. If the scissors
2 hours). are used, the dissection is completed with the
same scissors.
Light bipolar diathermy is used to co-
Monitoring
agulate the bleeding vessels, especially in the
anterior part of the sclera and at the sclerocor-
Electrocardiogram (EKG)
neal limbus, where the incision will be made
Pulsioximetry (Oxygen saturation)
to extract the nucleus and to introduce the
Non-invasive blood pressure (NIBP)
IOL.
every 3 minutes.
An 8 mm-groove is made approxi-
Muscular relaxation
mately 0.5 mm from the limbus with a dia-
364
Figure 216: Incision - Stage 1
A non-penetrating perpendicular incision is performed 0.5 mm behind

the limbus with a diamond blade knife (K). The incision extends from 2 to 10
o’clock (arrow) for a length of 8 mm. This is the first plane of the two-plane
incision A paracentesis is made at the limbus (A.) To simplify Figures 216
and 217, the fornix-based conjunctival flap has not been represented in these
illustrations.
mond knife, a Desmarres scarifier, a dispos- Continuous Curvilinear

able knife, or a razorblade knife. The depth of Capsulorhexis
the groove is approximately two-thirds of the
scleral thickness and represents the first step A viscoelastic substance is introduced
of a two-plane incision to be completed later. in the anterior chamber through a paracente-
This two-plane incision facilitates better ap- sis (Fig. 217) to maintain adequate depth and
position of the wound edges, thereby improv- to facilitate the deep, horizontal incision (sec-
ing wound closure and reducing postopera- ond step) and anterior capsulorrhexis. The
tive astigmatism induced by the sutures. The horizontal incision is started with a dispos-
surgeon should avoid overlapping the able knife at one of the ends of the predeter-
wound edges. (Fig 216). mined groove and continued over approxi-
365
mately 3 mm (Fig. 217). After the the lid speculum does not exert pressure on
capsulorrhexis has been done, as shown the eye, which might induce protrusion or
in Fig. 219 A, B and C, the deep plane of rupture of the posterior capsule.
the incision is completed with scissors The capsulorrhexis can be performed
(Fig. 218). Care must be taken to ensure that by perforating the center of the capsule with a
Figure 217 (above): Incision - Stage 2
A viscoelastic substance is injected with a

cannula through a paracentesis to fill the anterior
chamber. This will maintain the anterior chamber
depth and increase dilation of the pupil. At one end
of the non-penetrating limbal incision, a horizontal
beveled incision is made (D). This will begin the
second plane of the two-plane incision. Fixation
forceps (F).
Figure 218 (below): Incision - Stage 3
The two-plane horizontal beveled inci-

sion is completed (red arrow) with Barraquer’s
scissors (S) in the deep layers of the groove.
366
Figure 219 A-C: The Continuous Curvilinear Anterior Capsulorhexis Technique - Stages 1 - 3
(A) After the tear is started in the center of the anterior capsule, traction is exerted at the 10:00
meridian (X) on the operculum that is doubled on itself. Uttrata forceps (N) are used to grasp the underside of
the capsular flap (C) and the tear is extended in a counterclockwise direction (blue arrow) to produce a
circumferential capsular rupture (red arrow). (B) The tear is continued with the Uttrata forceps in the same
direction (blue arrow) to complete the circular tear (red arrow). (C)The capsulorrhexis is completed, and the
circular operculum is removed.
needle, or cystotome, which is an insulin capsule with adequate forceps such as Uttrata
injection needle, conveniently bent near its forceps. We usually prefer the forceps to the
base to produce adequate angulation for bet- cystotome (Fig. 219 A, B,C).
ter maneuvering (Fig. 97). The bend close to Once the center of the capsule has been
the tip of the needle makes a little hook used ruptured or torn, a small flap of capsular
to exert traction on the capsule fragment. tissue is grasped and pulled in either a clock-
Cystotomes are also available commercially. wise or counterclockwise direction to elimi-
Another way of performing a capsulorrhexis nate the central part of the anterior capsule
is to tear the central part of the anterior (Fig. 219 A,B,C). We attempt to create a
367
circular opening 5.5mm to 6 mm in diameter

(Fig. 220). In cases of very large nuclei, of
capsular pseudoexfoliation, or when some
phacodonesis is present, we prefer to con-
struct a capsulorrhexis with a slightly larger
diameter in order to avoid traction on the
zonules when the nucleus is brought into the
anterior chamber. In these cases a large
capsulorrhexis facilitates mobilization and ro-
tation of the nucleus (Fig. 221).
Figure 220 (above): Continuous Cur-

vilinear Anterior Capsulorrhexis -
Standard Size
The regular curve of the capsu-

lar opening is less prone to radial tears
than the irregular edges of the opening
that result form the can-opener and en-
velope techniques.
Figure 221 (below): Large Continuous

Curvilinear Anterior Capsulorrhexis
This illustration depicts a large

CCC, adequate for removing a large and/or
hard nucleus.
368
Hydrodissection Subsequently, the nucleus is rotated with the

same cannula in clockwise or counterclock-
Next is the hydrodissection. Balanced wise direction, depending on where the
saline solution (BSS+) with epinephrine (di- nucleus has entered the anterior chamber. The
lution 0.06%) is injected with a thin cannula nucleus is lifted slightly during the rotation
(25 G) between the anterior capsule and the maneuver to complete the displacement into
lens cortex (Fig. 222) to separate the nucleus, the anterior chamber (Figs. 223, 224). As the
which tends to pass through the capsule is an elastic structure, even large
capsulorrhexis into the anterior chamber. nuclei can pass through a relatively small
Figure 222 (left): Hydrodissection of the Lens

Capsule from the Cortex - Stage 1
After the continuous curvilinear anterior

capsulorrhexis has been completed, a cannula (C)
is inserted in the anterior chamber. The tip of the
cannula is placed between the anterior capsule
and the lens cortex at the locations represented.
Fluid is injected (arrows) at these locations to
separate the capsule from the cortex. The result-
ing fluid waves can be seen (W). These waves
continue posteriorly to separate the posterior cap-
sule form the cortex.
Figure 223 (right): Hydrodissection - Stage 2
A 25 gauge needle (A) is introduced paral-

lel to the edge of the nucleus (N), and a solution of
BSS+ and epinephrine is injected. This hydraulic
force (arrow) produces a cleavage plane between
the posterior capsule and the posterior surface of
the nucleus. The nucleus passes into the anterior
chamber without tearing the capsulorrhexis.
369
capsulorrhexis without tearing the capsule maintain adequate anterior chamber depth
when a continuous circular capsulotomy during irrigation and aspiration of the cortex
without notches is performed. that remains adherent to the capsular bag. An
Other methods of opening the capsule aspiration probe with a 0.3mm opening at the
are: 1) the envelope technique, which uses a tip is used. This probe has a special cover
more or less straight incision between the with two lateral openings at the inferior end
central and superior third. 2) The can-opener for irrigation to maintain the anterior chamber
technique produces small, less circular cap- depth while the cortical lens matter is aspi-
sule ruptures. These techniques, which are rated (Fig. 225). The height of the bottle is
based on lineal incisions, however, may result adjusted from 20cm to 78cm to increase or
in a higher incidence of rupture or tearing of reduce the irrigation in relation to the depth of
the posterior capsule during the cleaning ma- the chamber. An adequate chamber depth
neuvers of the capsular bag. makes it possible to work with greater safety,
although excessive irrigation may result in
Removal of Nucleus iris prolapse through the wound. This can be
corrected by reducing the height of the bottle.
Once the nucleus has passed into the For aspiration of the lens matter, a variable
anterior chamber, gentle compression is ap- vacuum with an upper limit of 450mmHg is
plied 1mm to 2mm from the inferior limbus applied.
(Fig. 224) with a round-tipped or blunt instru- Once all the lens matter has been re-
ment. The nucleus is displaced upwards moved, the anterior capsule is “polished”
(Fig. 224), resulting in some gaping of the using the same probe and a low vacuum
incision. Simultaneously, the scleral lip of the power between 20mmHg and 60mmHg to
incision is depressed with another instrument avoid capsular retraction and rupture. Care-
such as Colibri or Adson forceps to facilitate ful, exhaustive cleaning of most of the poste-
the expulsion of the nucleus (Fig. 224). Ex- rior capsule surface is essential in order to
pression of the nucleus should never be at- postpone as long as possible the opacification
tempted while the nucleus is still inside the of the capsule and the subsequent Nd: YAG
capsular bag because zonular rupture may laser capsulotomy. The surgeon must be care-
occur, necessitating the continuation of sur- ful not to be aggressive during this step of
gery as an unplanned intracapsular extraction. aspiration-irrigation of the cortex so as to
avoid posterior capsule rupture or zonules
Removal of Cortex - Irrigation rupture during these maneuvers. If this should
occur, vitrectomy would be required, and the
and Aspiration
IOL would have to be placed in the sulcus.
If irrigation-aspiration equipment is not
The anterior chamber is irrigated with
available, the lens matter can be removed
BSS+ and epinephrine (0.06% dilution) to
manually. A cannula and syringe are used to
remove persistent residual lens matter or epi-
gently irrigate, mobilize the lens matter, and
nuclear elements. A nylon 10-0 cross suture is
aspirate it in the four quadrants. A curved
applied in the central part of the incision to
370
Figure 224 (left): Removal of

Nucleus
Once the nucleus is in the an-

terior chamber, nucleoexpression is
performed. Slight compression is ex-
erted with a blunt instrument 1 or
2mm over the inferior limbus (H). the
nucleus is displaced upwards, separat-
ing the lips of the incision. Simulta-
neously, another instrument (F) is used
to depress the scleral lip of the incision
in order to facilitate the expulsion of
the nucleus.
Figure 225 (right): Removal of the

Residual Cortex
The aspiration probe has an

opening 0.3 mm in diameter at the
upper end. It also has a cover or sleeve
with two inferior lateral openings for
irrigation to maintain the depth of the
anterior chamber during aspiration of
the lens matter.
371
probe tip is used for the superior quadrants IOL Implantation

(Fig. 226). The posterior capsule may also be
polished manually using this technique at the The lens is grasped at the superior rim
end of the procedure. In cases of central of the optics with straight forceps. With a
capsular fibrosis, posterior capsulorrhexis can slight inclination, the inferior haptic is intro-
be performed at the end of the procedure or at duced into the capsular bag (Fig. 227). The
a later stage in a Nd: YAG laser capsulotomy. optic is centered with the capsulorrhexis and
A viscoelastic is injected in the capsular rotated using a Sinskey hook until the supe-
bag and the anterior chamber. The surgeon rior haptic is in the correct position inside the
should check carefully to ensure that the bag. The IOL should be implanted horizon-
capsular bag is completely filled with vis- tally. Introduction of the superior haptic may
coelastic. The preplaced cross-point suture is be easier if it is grasped with thin forceps
removed from the wound. without teeth (Fig. 228). The haptic is guided
Figure 226: Irrigation/Aspiration of the Residual Cortex (modification by Malbran).
The residual cortex (C) is removed from the capsular bag with a curved irrigation/
aspiration probe. A slightly curved tip is used to gently aspirate the residual cortex nasally
and temporally. The residual cortex located in the difficult-to-reach areas of the superior
capsular bag is removed using a curved irrigation/aspiration probe tip.
372
Figure 227 (left): Intraocular Lens Implanta-

tion.
After the cataract is removed and vis-

coelastic is injected into the anterior chamber and
the capsular bag, the PMMA (L) lens is grasped
with forceps (F). The inferior haptic (H) is placed
in the capsular bag (C) inferiorly. Forceps are
used to introduce the optic part into the capsular
bag.
Figure 228 (right): IOL Implantation
The superior haptic (H) is grasped

with straight forceps and bent inferiorly (red
arrow) so that the elbow of the haptic can be
directed (blue arrow) into the capsular bag
(C) superiorly.
373
toward the center of the capsulorrhexis and Suturing and Aspiration of the
rotated 90 degrees. The forceps are removed Viscoelastic
from the capsulorrhexis, and the IOL settles
in the capsular bag. The capsulorrhexis is The incision is closed with 5 to 7 nylon
clearly seen in front of the optic part of the radial sutures. The knots must be buried in the
IOL (Fig. 229). Generally, PMMA lenses are sclera (Fig. 229).
used, and the preferred diameter of the optic The viscoelastic material is aspirated.
is 6.5 mm. The anterior chamber is restored to normal
Acetylcholine 1% is applied to induce depth with 1% acetylcholine (lyophilized ace-
4 mm of miosis. Subsequently, a peripheral tylcholine dissolved in BSS) The conjuncti-
iridectomy is performed. val flap is repositioned to cover the incision.
The two extremities of the flap are anchored
with 10-0 nylon sutures.
Figure 229: Conclusion of the Operation
Cross-sectional view. The IOL occu-

pies its normal position within the capsular
bag. The incision is sutured with 10-0 nylon,
preferably radial sutures, and the knots are
buried in the sclera. The fornix-based con-
junctival flap is repositioned to cover the
wound. The flap is anchored with 10-0 nylon
sutures at the two ends of the incision (not
shown in this illustration).
374
THE MANUAL, SMALL INCISION

EXTRACAPSULARS
There is significant interest about these There is a significant learning curve, and
methods. They allow successful removal of experience is required.
the cataract through a small incision and The proposed Mini-Nuc technique must
manually, without the need to use mecha- be performed under positive intraocular pres-
nized equipment. sure during all stages of surgery. The desired
We hereby present the three most IOP is achieved during surgery with the use
widely accepted: 1) Michael Blumenthal’s of an anterior chamber maintaining system,
Mini-Nuc (Israel); 2) David McIntyre’s and controlled by the height of the BSS bottle
Phaco Section (USA); and 3) Francisco (Anterior Chamber Mainteiner (ACM) in
Gutierrez C., Manual Phacofragmentation. Fig. 230).
THE MINI-NUC TECHNIQUE Importance of Constant

Irrigation and Positive 100% IOP
This procedure caught-on in the minds
of many clinical ophthalmologists since its The principle of maintaining positive
inception, 10 years ago. Blumenthal has IOP during cataract surgery is gradually
continuously worked at improving the becoming acceptable to more surgeons, even
method he created and its results. those performing phacoemulsification. In the
mini-nuc technique, positive IOP exists 100%
of the operating time. Any fluid lost during
Principles of the Mini-Nuc intraoperative maneuvers is promptly recov-
Technique ered because of the large internal diameter of
the ACM tubing (“A” in Figs. 230-231). The
The procedure requires only a small steady flow ensures a constant depth of the
incision and no stitches. It has proven to be anterior chamber. This flow continuously
safe surgery. It is possible to use topical washes all debris: blood, pigment, and left-
anesthesia, and rehabilitation is speedy. over cortical material from the eye with low
Moreover, it is cost-effective. There are some turbulence and low fluctuation of anterior
disadvantages, however, of manual ECCE. It chamber depth. Consequently, less postop-
is not an easy technique to learn and perform. erative inflammatory reaction occurs.
375
The BSS bottle can be used as a reser- are made in clear cornea just at the edge of the
voir of pharmacological drugs to be infused blood vessels. The same stiletto knife is used
continuously into the eye. These drugs may for an incision just anterior to the limbus in
include adrenaline 1:1,000,000, to keep the the clear cornea for the purpose of inducing
pupil dilated, antibiotics, and any other drug the ACM cannula (5149 oval Visitec) in the
the surgeon wishes to use. The length of 6 o'clock area (identified as “A” in Fig. 230).
surgery is not critical as the constant positive
IOP keeps the aqueous blood barrier intact; Paracentesis Incision and Fixa-
and the ciliary processes and choroidal, tion of ACM
retinal, and iris vessels are not exposed to a
hypotonic environment at any time. This The most important aspect of the bev-
helps to prevent exudate formation or a eled tunnel paracentesis incision to intro-
worse complication, expulsive hemorrhage. duce the ACM is its length. The incision
Blumenthal considers that positive IOP should be at least 2 mm long before the knife
provides not only a safe milieu and prevents penetrates the AC, and will be 1 mm wide
complications; it is a precondition for con- (Fig. 230-A).
trolled surgery. Because the internal architec- The ACM is introduced into the tunnel-
ture of the eye is not disturbed, planned shaped paracentesis, beveled edge up. When
maneuvers can be carried out safely. it reaches the AC, it is turned beveled edge
down, and the ACM flow is directed towards
SURGICAL TECHNIQUE the iris. The ACM is introduced 2.0 - 2.5 mm
into the AC, and not more. The shallower the
Anesthesia, Paracentesis, ACM depth of the AC, the greater care the surgeon
should take not to exceed these limits. (In
Lidocaine 4% drops are instilled 15 the illustrations, the cannula is shown beveled
minutes before surgery 3-4 times. At present up for clarity but at surgery it should be kept
Esrecain gel is used with each Lidocaine beveled down toward the iris.)
drop. A total of 0.2-0.3 cc of Marcaine 0.5%
with adrenaline is injected subconjunctivally Height of BSS Bottle
between 11:00 and 2:00 in the limbal area,
where diathermy will be applied. During sur- Normally, the BSS bottle should be
gery, 0.2-0.3 cc of intraocular non-preserved located 40 to 50 cm above the eye, keeping
Lidocaine is injected into the tube of the the IOP at 30-40 mm Hg. If intraocular
ACM. It will reach the eye in diluted form. bleeding occurs, raising the bottle will stop
This is very efficient, cost-effective ocular the bleeding. If a posterior capsule tear oc-
anesthesia. curs, the bottle should be lowered to 20 cm.
Two paracenteses are performed at The BSS bottle should be lowered even
10:30 and 2:30 by stiletto knife (identified as further to 10-15 cm when suturing, in order
“D” in Fig. 230). Moderate beveled incisions to achieve the best adaptation of the incision
edges.
376
Figure 230: Creation of the Special Sclero-Cor-

neal Pocket Tunnel Incision - Stage 1
The Anterior Chamber Maintainer (A) is in

place, introduced through a tunnel in clear cornea
which is at least 2mm in length and 1mm wide, near
and parallel to the limbus. The height of the BSS
bottle, connected to the maintainer, controls the in-
traocular pressure. Two 1mm paracentesis incisions
(D) are made at 10:30 and 2:30 just anterior to the
limbus, for instrument access. The main external in-
cision, 0.3mm in depth and 4-5mm long, 1mm be-
hind the limbus is made. A crescent knife (C) dis-
sects the tunnel, first 1mm in sclera, then 2-3mm
forward into clear cornea (1), then extending later-
ally (2) to produce the pockets (P) on both sides.
While performing the pockets, the crescent knife if
retracted laterally and backward (3), creating the
external incision extensions (E) on both sides. Inset
(F) shows the cross section of a scleral tunnel inci-
sion made under low intraocular pressure which is
wavy and uneven. Inset (G) shows incision quality
which is smooth and even, as achieved under high
intraocular pressure from anterior chamber main-
taining system.
The most important concept to keep in ing the AC depth and causing the zonules to
mind is that the height of the BSS bottle can pull the anterior capsule more forcefully.
be changed depending upon the situation. It Blumenthal believes that although
does not need to be standardized, and the capsulorhexis can be done successfully using
surgeon can adjust it according to his/her own forceps with viscoelastic material or even
technique, and varying needs during surgery. BSS only, positive IOP in the anterior cham-
ber provides the best precondition for suc-
Capsulorhexis cessful and controlled capsulorhexis per-
formed through the paracentesis using a cys-
The ACM and positive IOP push the totome.
crystalline lens backward reducing the force
of the zonules exerting pressure on the ante-
rior capsule toward the periphery. This facili- Conjunctiva
tates capsulorhexis performed by a cysto-
tome, and avoids unintended tears toward the A conjunctival flap is cut 1 mm from
periphery of the crystalline lens. Forceps in- the limbus between 11:00 and 2:00. The
troduced through the paracentesis corneal 1 mm of conjunctiva attached to the limbus
tunnel produce outflow of BSS thus reduc- facilitates the postoperative healing process.
377
Healing of conjunctiva to conjunctiva occurs At the bottom of the 0.3 mm deep

quickly and is stable, unlike the healing pro- external cut, dissection is extended anteriorly
cess between conjunctiva and limbus. The until it engages the limbal tissues, which
attached conjunctiva also makes it possible to resist dissection more than scleral or corneal
glue the edges of the conjunctiva by coagula- tissues. In overcoming this extra resistance,
tion the surgeon must take care not to press for-
ward too forcefully, which might cause un-
Sclerocorneal Pocket Primary controlled forward corneal dissection and
Incision and Tunnel premature perforation of the AC. Control of
lamellar dissection at all stages is critical.
Precondition for Utmost Controlled Dissection continues forward for about
Dissection 2 mm in clear cornea. As the dissection
approaches the lateral edge of the tunnel, the
The main reason the ACM is intro- knife is swept sideways 45 degrees, resulting
duced at the beginning of surgery is to keep in a funnel-shaped tunnel (identified as C 2,
the IOP between 30 and 40 mm Hg to make 3 in Fig. 230) . Thus the internal aspect of the
the eye coats taut. The importance of this tunnel is about 25% larger than the external
precondition for the utmost controlled dissec- incision. While the crescent knife is at the
tion in the sclera and cornea should not be lateral edge of the straight external part of the
underestimated (Fig. 230). Most unintended incision, dissection should be carried ob-
misdirected scleral dissection, premature en- liquely backward. In this way the crescent
trance to the anterior chamber, or failure to knife forms a lateral pocket on both sides
achieve a full-size scleral pocket tunnel occur (identified as C 1, 2, 3 in Fig. 230), extending
as complications of dissection in soft, floppy backward for 1 mm on each side. A back-
tissue. ward incision 90 degrees to the limbus such
The sclerocorneal tunnel architecture as hereby described, does not induce astig-
of the primary incision which Blumenthal matic effect. With practice the result should
prefers for manual ECCE begins with an be a well-constructed pocket sclerocorneal
external straight scleral incision 4 to 6 mm tunnel (Fig. 230).
long and 0.3 mm deep (Fig. 230). It should Now the keratome is slid into the
be performed 1 mm behind the limbus at the tunnel (identified as I-K 4 in Fig. 231) with a
surgeon’s choice of location, either 12:00 or slight side to side movement to prevent
temporal. As the external incision is cut premature perforation of the anterior cham-
straight, the distance of this incision varies ber. When the tip of the keratome reaches the
gradually from the limbus. It is 1 mm behind end of the tunnel, the keratome is then tilted
the limbus at 12:00, while on both sides the downward to enter the anterior chamber.
external incision is further away form the After entering the anterior chamber, the
curved limbus, up to 1.5 mm to 2 mm keratome is moved laterally and forward
378
Figure 231 - Creation of the Special Sclero-Cor-

neal Pocket Tunnel Incision - Stage 2
A keratome (K) enters the anterior chamber

to accomplish the internal corneal incision (I - blue
dotted line) curved shape, parallel to the limbus. The
keratome must be moved in a direction slightly away
from the surgeon while moving it laterally (4-arrow)
to produce this curved configuration of the internal
corneal incision. Lateral scleral pockets (P). Ante-
rior chamber maintainer (A). The distance from the
external to internal incision is about 3.5mm to 4mm.
Internal incision (I) length is about 7mm.
(Fig. 231-K-4). This combination of move- Hydrodissection and Nucleus

ments directs the internal incision in curved Dislocation
fashion parallel to the limbus. The procedure
is repeated on the other edge of the tunnel. Hydrodissection is performed through
Thus the extreme edges of the internal inci- one of the two paracenteses located at
sion (temporal and nasal points of entry of the 10:30 and 2:30 (Fig. 230). Professor
AC), are 3.5 to 4.0 mm from the lateral Blumenthal uses a 1 cc syringe attached to a
points of the external incision. A common cannula. A 3-5 cc syringe should not be used,
error in constructing this tunnel occurs when as a sudden surplus of BSS in the crystalline
the keratome, instead of moving laterally and lens might burst the posterior capsule. The
anteriorly, is directed laterally and backward, cannula should be introduced under the ante-
thereby creating a much smaller tunnel. The rior capsule at the 12:00 position. No more
more funnel shaped the tunnel is, the less than 0.1 cc to 0.3 cc of BSS is injected,
astigmatism induced, and the less potential engulfing the lens contents instantly by
there is for BSS leakage from the AC either hydrodissection. In most cases the nucleus
during or after surgery. All these movements tilts forward into the AC at the 12:00 position,
are performed while the eye is fixated with as the BSS fluid accumulates first at this
Bonn forceps, away from the tunnel incision.
379
location (Fig. 232). In cases where the lens while BSS is injected. This will cause the
nucleus is not partially dislocated anteriorly, nucleus to move gradually anteriorly com-
one or two Sinskey hooks are introduced at pletely into the AC (Fig. 232). The use of too
one or both paracenteses located at 11:00 and much force during this maneuver can cause
2:00. Uneven pressure by one hook while the the lens to suddenly touch the endothelium.
nucleus is rotated causes the nucleus to tilt Blumenthal does not remove cortex at
and gradually to dislocate anteriorly. The the center of the lens anteriorly because this
surgeon should make sure that the nucleus cortex protects the endothelium from the
tilts up toward the wound. If it does not, the rough nucleus during movements in the AC.
lens should be rotated further until this align- The lens does not need to be completely
ment is achieved. When the tilt is not suffi- dislocated to the AC before extraction can
cient in the surgeon’s judgment, the bent part begin. When the nucleus is free after rotation,
of a cannula should be introduced under the it can remain partially in the bag and partially
in the AC (Fig. 232).
Figure 232: Hydrodissection of the Nucleus and Epinucleus
The anterior chamber maintainer (A) connected to a BSS bottle maintains and con-
trols intraocular pressure during the circular capsulorhexis. A hydrodissector cannula (H) is
introduced through a paracentesis (D) under the anterior capsule at the 12:00 o’clock position.
Injection of fluid (blue arrows) causes the superior nucleus and epinucleus to become luxated
anteriorly (arrow - 1,2,3), tilting it forward into the anterior chamber. The nucleus and epi-
nucleus are now partly in the anterior chamber and partly in the bag, ready for expression.
Main sclero-corneal pocket incision (I) is shown in cross section.
380
Figure 233: Technique of Nucleus Expression

Using Glide and High IOP - Surgeon’s View
A lens glide (G) is introduced through the

incision to a position just under the superior edge
of the tilted nucleus and epinucleus within the an-
terior chamber. High intraocular pressure from the
anterior chamber maintainer causes the nucleus and
epinucleus (N)(shown in ghost views) to move to-
ward (1-arrow) the open incision. Slight pressure
from a firm instrument (not shown) placed within
the incision on top of the glide may be used to ini-
tiate the movement of the nucleus toward the inci-
sion as it is forced out of the opening by the high
intraocular pressure. As the epinucleus and nucleus
(N) enter the incision tunnel, the epinucleus (E) may
strip off within the scleral pockets (P). The hard
core nucleus continues to exit the incision with the
flow of BSS under pressure (2-arrow). If a large
nucleus will not exit the eye, chipping off a small
triangular piece of nucleus will facilitate expres-
sion of the nucleus (inset below). Anterior
capsulorhexis (C).
Nucleus Expression Using Glide and not used, the nucleus may not move in a
High IOP controlled way towards the incision.
To move the nucleus (with its epi-
Before the lens glide is introduced nucleus) into the wound, slight external pres-
under the nucleus, the surgeon must first sure should be exerted with a closed forceps
assess whether viscoelastic material is needed or other instrument on the glide inside the
in addition to the ACM. Blumenthal consid- tunnel in a stroking pattern. The strokes may
ers using viscoelastic in shallow chambers need to be repeated a few times until the
and in patients with glaucoma that may have nucleus is pushed forward by fluid from the
a small pupil. The glide should not be induced ACM to engage the mouth of the sclerocor-
forcefully as it might engage the nucleus neal tunnel (Fig. 234). At first, BSS still leaks
itself rather than slide under it (Fig. 233). The around both sides of the nucleus. Stroking is
glide should not move too far inferiorly or it continued until the nucleus is well lodged in
may tear the posterior capsule. If a glide is the inner aspect of the sclerocorneal pocket,
381
Figure 234: Technique of Nucleus Expression Using Glide and High IOP - Cross Section View
This cross section view shows lens glide (G) in place for nucleus expression. High in-
traocular pressure from the anterior chamber maintainer (A-arrow) causes the nucleus and epi-
nucleus (1) to move toward (red arrow) the open incision. As the epinucleus and nucleus enter the
incision tunnel, the epinucleus (E) may strip off within the scleral pockets as the hard core nucleus
(N) continues to exit (2) the incision with the flow of BSS under pressure.
and no leakage is observed. Continued pres- which should not change. If the AC col-
sure should not be made in the tunnel when lapses, stop pressing and allow it to reform.
the nucleus is engaged, as pressure in the The preceding description is accurate
tunnel would open the tunnel and new leak- when the tunnel is large enough to allow the
age would begin, preventing nucleus expres- nucleus to pass through the tunnel. During
sion. this move, it sheds any remnants of epi-
Now pressure is shifted out of the tun- nuclear material; in this way the smallest
nel, posteriorly, onto the sclera. This slightly possible nucleus is delivered. The remnants
changes the position of the nucleus in the of the epinucleus are observed as leftover in
tunnel to allow expression. The nucleus the AC; they are soft and easily expressed by
rocks from side to side, and rotates slightly on the hydrostatic pressure itself (Fig. 235).
its axis while finding its way out of the tunnel Their progress is helped by gentle strokes in
(Fig. 234). the tunnel, causing BSS to flow out of the
The amount of pressure to induce can eye. The BSS on its way out engulfs the soft
be assessed by observing the depth of the AC, epinucleus and flushes the epinucleus out.
382
Figure 235: Expression of Epinucleus
If the epinucleus (1) remained in the

scleral tunnel pockets, it may be hydroex-
pressed (2-red arrow) using slight instrument
strokes of a small spatula (S) placed inside
the tunnel. Anterior chamber maintainer (A)
provides pressure to facilitate this expression.
Lens glide (G). Note remaining cortex (C)
within the capsular bag.
Should the nucleus proper be too large to be Epinucleus and Cortex Extraction
expressed, the surgeon has two choices: (1)
Enlarge the inside aspect of the tunnel, not Epinucleus
the external incision; or (2) Perform chipping.
Part of the nucleus is exposed in the incision. Continuous flow and positive IOP in-
A 25 gauge needle is introduced into the flate the capsular bag after nucleus extraction.
nucleus, chipping off a small triangular The soft epinucleus left behind in the AC is
piece. The smallest new diameter of the usually hydroexpressed spontaneously. To fa-
nucleus can be made small enough for the cilitate this maneuver a spatula can be
nucleus to be expressed. introduced through the tunnel (Fig. 235). In
cases where the epinucleus is left in the
capsular bag, manipulation in the bag right
383
and left by the spatula will release the epi- paracentesis port for aspiration allows the
nucleus from its adherence to the cortex and amount of BSS aspirated or lost to be instan-
allow it to be flushed out. taneously replaced by the anterior chamber
maintainer.
The Cortex
IOL Implantation
Blumenthal recommends aspirating
the cortex manually; aspiration is better The leading haptic is inserted into the
controlled using a 5 cc syringe and cannula AC and under the anterior capsule at 6:00
(Fig. 236). The cannula should be introduced o'clock (Fig. 237). The anterior chamber may
from one of the paracentesis sites and not become shallow for a short period during this
from the tunnel because introducing a can- maneuver. For this reason a strong IOL holder
nula through the tunnel may allow BSS to is recommended so that the leading loop can
escape. The resulting instability of the poste- be directed under the capsule even in the
rior capsule would be unfavorable for presence of a shallow AC. When the leading
smooth aspiration of the cortex. Using the loop is stable under the capsule, the IOL
Figure 236: Cortex Removal and Water Jet

Technique to Remove Residual Cortex
A special cannula with a 0.4mm pore

(J), connected to a 5cc syringe is introduced
through a paracentesis (D), where it is used to
aspirate the cortex (B). Next, a hydrodissector
cannula (H) is introduced through the paracen-
tesis (D) and is used to create a water jet burst
of BSS (blue arrows) directed to the posterior
capsule. This forces any cortical material left
over to free itself from its attachments to the
capsule, either in the posterior capsule or lo-
cated in the equator of the lens bag. This pres-
sure and that from the anterior chamber main-
tainer (A) forces these pieces out of the eye.
Anterior capsulorhexis (C).
384
Figure 237: Intraocular Lens Implantation Technique - Stage 1
The intraocular lens is introduced into the anterior chamber using an IOL holder, with the distal haptic
directed posterior to the anterior capsule, and into the 6:00 capsular bag (arrow). When this is achieved, the IOL
holder is released, not before forceps (F) grasp the trailing loop outside the eye to prevent the IOL from springing
out of the bag at 6 o’clock. The anterior chamber maintainer (A) keeps the capsular bag ballooned during implan-
tation. Anterior capsulorhexis (C).
holder is released, but not before forceps (Fig. 238). Blumenthal prefers to have holes
grasp the trailing loop outside the eye to in the loops and one hole in the haptic near
prevent the IOL from springing out of the bag the optic for manipulating the lens into the
at 6:00. A modified Sinskey hook is inserted capsular bag. Blumenthal has seen no ill
through one of the paracenteses, usually at effects resulting from haptic holes.
10:00 for right-handed surgeons and the lens
is manipulated into the bag. The trailing loop When to Use Viscoelastic
is introduced into the AC first. Then the IOL
is rotated while pushing backward (Fig. 238). In cases where any difficulty arises
Thus the trailed loop enters the bag during implantation, especially in young
385
Figure 238: Intraocular Lens Implan-

tation Technique - Stage 2
With the distal haptic already lo-

cated within the capsular bag at 6 o’clock,
the forceps (F) moves the proximal haptic
laterally (1-arrow). A Sinsky hook (S)
placed through the paracentesis (D) en-
gages the haptic hole (H) in the loop.
While rotating the lens (2-arrow), the
proximal haptic is introduced into the an-
terior chamber, compressed with the hook,
directed behind the anterior capsule (3-ar-
row) and into the bag in one motion. An-
terior chamber maintainer (A). Anterior
capsulorhexis (C).
people, or if the anterior chamber is shallow, Pupil Enlarged by Increased IOP

the use of viscoelastic material is indicated. It
is easier to introduce the IOL into the AC in Deepening the AC with the ACM and
the presence of viscoelastic, but manipulation increasing the IOP from 10 mm Hg to 30-40
of the lens into the final preferred position is mm Hg, pushes the iris back and sideways,
more easily achieved in the presence of BSS. dilating the pupil mechanically beyond the
Viscoelastic is not contraindicated during pharmacological effect of the dilatation
manual small incision Mini-Nuc ECCE while drugs. In certain cases the pupil stays extra
using the anterior chamber maintaining sys- dilated at the end of surgery because of a
tem, but the BSS flow should be reduced or phenomenon known as reverse pupillary
stopped. It is better to activate the ACM block. No long-term ill effects arise from this.
system during aspiration of the viscoelastic. After a few minutes the reverse pupillary
This keeps turbulence and fluctuation to a block subsides, as pressure in the posterior
minimum. chamber rises above that existing in the AC.
The block can also be broken mechanically
386
by introducing a spatula under the iris. The procedure is much more effective when the
pupil immediately becomes smaller, and the ACM is used. The freed cortical material is
iris moves forward. aspirated whenever it is separated form the
capsule. Aspiration of cortical material di-
Advantages of the Continuous Flow rectly from the posterior capsule involves
of BSS during Manual ECCE much more dangerous manipulation, as most
capsule tears occur during this stage of the
Removes debris: The anterior chamber surgery.
is washed throughout surgery. All pigment Prevents inflow : Hypotony, even if it
debris is washed out, reducing to a minimum occurs for a very short period, can cause
possible ill effects during the postoperative inflow from outside the eye into the eye. With
period. the ACM system, its active flow prevents
Stops bleeding: When bleeding occurs foreign material from washing into the AC.
in the tunnel or in the anterior chamber during By the same mechanism bacteria are partially
surgery, it can be stopped by increasing the prevented from entering the eye. If an instru-
IOP. Moreover, no blood accumulates during ment does carry bacteria to the AC, the bacte-
surgery, as it is washed out by the continuous ria may be washed out reducing the likeli-
flow. hood of endophthalmitis.
Frees cortex remnants: These rem-
nants find their way out of the eye due to the Complications
continuous flow through the AC. The rest are
Posterior capsule tear: Tears in the
aspirated by a 5 cc syringe with a cannula
posterior capsule are mostly caused by suc-
attached. The aspiration is usually performed
tion with the aspiration cannula. The presence
at the final stage of the surgery before the
of the AC maintaining system during unin-
ACM is pulled from the eye.
tended tear of the posterior capsule pushes the
Removes viscoelastic: Viscoelastic ma-
vitreous face backward. In 70% of cases of
terial can and sometimes must be used during
unintended tear of the posterior capsule, the
the surgery. It can be flushed out by fluid
vitreous face stays intact. When the vitreous
from the ACM or aspirated. Leftover quanti-
face is intact, BSS does not enter the vitreous
ties of viscoelastic are removed from their
body, even if the IOP is 40 mm Hg.
hidden locations with short bursts of BSS
The hypothesis that vitreous hydrates
produced by a 1 cc syringe and cannula.
when in contact with BSS is not true. Hydra-
Cleans posterior capsule: A 1 cc sy-
tion occurs only if the vitreous face is broken.
ringe attached to the hydrodissector cannula
During manual ECCE there is little turbu-
is used to create an intermittent water jet
lence or fluctuation; most of the time there is
effect on the posterior capsule to clean it from
no movement at all. The amount of BSS used
attached cortical material (Fig. 233). This
387
throughout one modern ECCE procedure dur- sule tear during vitrectomy reduces the option
ing 10 minutes of surgery is only 20 cc to 30 of choosing the bag as the best fixation site
cc The amount of flow during each minute of for the IOL.
the surgery is 2 cc to 3 cc. This amount Locating vitreous strands is another
produces the least possible turbulence. Con- very important aspect of the art of vitrectomy.
trolled aspiration using a 5 cc syringe in the Two-handed vitrectomy, during which the
presence of a posterior capsule tear can be surgeon has a spatula in one hand and the
performed without vitreous engagement, and vitrectome in the other, enables the surgeon to
aspiration of cortical material in the presence search for and locate vitreous fibers. Getting
of posterior capsule tear is continued until the rid of all the vitreous strands, whether large
capsule bag is free of cortex, without enlarg- or small, is essential. A quiet milieu allows
ing the tear. the surgeon to search with the spatula care-
The steady condition allows the sur- fully for strands over the iris and at the
geon to perform the most delicate maneuver opening sites of the paracenteses and the
possible, aspiration of cortical material lying tunnel. Eyes after such vitrectomy without
on the vitreous face. This maneuver can be strands in the AC have a very low rate of
done only if the vitreous remains still, with no CME or iris deformation. In cases where the
fluctuation. smallest vitreous strands remain, on the other
Vitreous involvement: When vitreous hand, the incidence of CME is much higher.
enters the AC through a posterior capsule
tear, vitrectomy must be performed. An exist- Expulsive Hemorrhage Minimized by
ing ACM is a great advantage at this stage. Positive IOP: This rare phenomenon can be
Because an imbalance of inflow and outflow reduced to a minimum in routine cataract
would aggravate the situation, Blumenthal surgery, and in complicated or traumatic eyes
recommends the paracentesis entrance for the by using continuous positive IOP during sur-
vitrectome tip. Steady conditions during vit- gery. No hypotony occurs to cause leakage
rectomy ensure the procedure can be per- from, or rupture of choroidal or retinal blood
formed in a controlled manner. Because the vessels, especially when they are arterioscle-
posterior capsule does not move in an uncon- rotic. Therefore expulsive hemorrhage or par-
trolled fashion, enlarging the size of the tear tial choroidal hemorrhage is mostly pre-
can be avoided. Enlarging the posterior cap- vented.
388
THE SMALL INCISION PHACO SECTION

MANUAL EXTRACAPSULAR TECHNIQUE
Overview surgery, using Kelman's phacoemulsification

technique. During the past 20 years he has
We here present the Phaco Section devised a number of instruments and modified
cataract technique as developed by David techniques, resulting in extracapsular surgery
McIntyre, M.D. one of the most talented and with smaller and smaller incisions. Currently
expert cataract surgeons in the U.S. We the incision is self-sealing and just large enough
describe the evolution of his cataract surgery for the IOL implantation.
technique, present highlights of the procedure From the perspective of results with
he has been using for 10 years, suggest how a patients, McIntyre has found no reason to
surgeon can make the transition to the 5.5 mm return to the emulsification of the cataract
wound Phacosection, and outline his surgical nucleus with ultrasonic energy
procedure step by step. (phacoemulsification). At the same time he has
At present McIntyre continues to use personally attempted to develop a number of
a 5.5 mm, non-sutured self-sealing, corneo- mechanical devices to aid in cortex aspiration.
scleral tunnel incision placed temporally under With each device he has reaffirmed that he has
a peritomy, through which extracapsular greater control over the operation when he uses
cataract surgery is performed and a posterior a completely manual technique.
chamber intraocular lens (IOL) is placed in the
capsular bag. The intraocular lens is a 5.5 mm Indications
round, one-piece polymethylmethacrylate
(PMMA) IOL placed in the bag, presently McIntyre strongly believes that a basic
manufactured by Surgidev. advantage of the Phaco-Section is its
McIntyre uses an anterior chamber applicability to all degrees of hardness of
maintainer, capsulorhexis and the nucleus is nucleus, from soft (+) to moderate (++), to
sectioned into 2 or 3 fragments, occasionally 4, fairly hard (+++) and to hard (++++), with truly
with few exceptions in ages under 50-55. minimal variations.
PHACO SECTION MOST

Evolution of Technique IMPORTANT FEATURES
McIntyre’s surgical technique has had The three separate tissue zones of the
a complex evolution. In 1974, he made the lens are shown in Fig. 239 to enhance the
transition from intracapsular to extracapsular understanding of how Phaco Section works.
389
McIntyre believes capsulorhexis

offers several advantages in small
incision phacosection technique. First,
a 6 mm capsulorhexis is large enough
to allow the management of almost all
nuclei by the phacosection technique
(Fig. 241). Secondly, the capsulorhexis
actually gives a stronger margin to the
capsulectomy than any of the "can-
opener" techniques. Consequently,
there is considerably less risk of tears
of the capsulectomy margin extending
around the equator and to the posterior
capsule.
Third, the use of air provides
significant benefit in the capsulorhexis.
Air is maintained in the anterior
chamber very easily after the puncture
incision of the cystotome needle
(Fig. 241). The presence of air in the
anterior chamber makes visualization
Figure 239: The Three Tissue Zones of the Lens and control of the fragment of anterior capsule
This anterior globe cross section shows the three separate much easier for the surgeon. Lying on the
tissue zones of the lens. Portions of the lens are shown removed to surface of the cataract as it is torn around the
reveal the three dimensionality of these tissue zones. The rigid circle, the fragment is very easily visualized.
nucleus (N) is in the center. The second zone is the epinucleus (E),
a firm or heavy gelatin material which is difficult to aspirate. The And finally, and perhaps most
third and outer zone is the cortex (C) which is soft gelatin that is easy importantly, when the fluid is removed from
to aspirate, and lies just under the capsule (D). Note the 6 mm the anterior chamber and is replaced with an air
diameter circular capsulorhexis, which is large enough to allow the
management of almost all nuclei by the phacosection technique. bubble, the magnification effect of the cornea
Air (A) is used to fill the anterior chamber during capsulorhexis to is almost entirely neutralized, so that it is easy
maintain the chamber depth and to eliminate the magnification to understand the actual dimensions. When the
effect of the corneal curvature.
anterior chamber is filled with fluid, the cornea
becomes a 15% magnifier on average, making
the capsulorhexis appear much larger than it
The following are the most important really is.
features of McIntyre’s Phaco-Section surgical
procedure. Completing the Tunnel Incision
Capsulorhexis After the capsulorhexis has been

completed, the surgeon must complete the
This is performed through the incomplete tunnel primary incision into the anterior
tunnel incision that is perforated only by the chamber. There is a paracentesis just to the
cystotome.
390
right end of the tunnel incision, but the tunnel concavity facing the great circle that connects
has been perforated only by a needle (the the two ends of the incision does not allow any
cystotome) up to this point. McIntyre enlarges stretching or raising of the flap. This is the
the primary incision by grasping the margin of reason the superficial layer of dissection in a
the scleral lip with a colibri forceps and passing tunnel has a very firm, unyielding geometry
a 15-degree supersharp blade through the which to resists deformity or increased
cystotome puncture to slightly enlarge the pressure within the globe. As long as the
incision. Then, with the double-bevelled incision is concave to the great circle, a
crescent knife, he enlarges the opening into the satisfactory self-sealing tunnel can be created.
anterior chamber to the full length of the tunnel With the exception of children, the tunnel
incision, which is 5.5 mm to 6 mm (Fig. 241). incision is sutured only in approximately 1
of 300 cases.
The Dynamics of the Self-Sealing
Incision Anterior Chamber Maintainer
McIntyre uses an analogy to help explain The anterior chamber maintainer that
the dynamics of the self-sealing incision. McIntyre uses is a threaded or screw-like tip
Shallowness of the tunnel is important in of metal tubing attached to a silicone tube,
preventing frequent hyphema. Deep tunnels which is then attached to the hub of a needle. It
tend to have frequent hyphemas; superficial can be plugged into a fluid source and has a
tunnels tend not to result in frequent hyphema. flexible connection with the eye (Fig. 241).
McIntyre’s analogy is a great circle, which is The internal diameter of the metal tubing is 0.6
the shortest distance between two points on the mm. The threaded outer surface of the tube is
surface of the sphere, a common concept used able to grasp the corneal paracentesis very
in navigation (Fig. 240). On the eye the ends firmly so that when this has been screwed into
of an incision can be connected by a great circle the cornea it will hold in that position even
around the globe. If any pressures and traction when the eye is rotated rather vigorously.
occur, there is a tendency for a wrinkle to At the conclusion of the procedure it
develop that connects the two ends of the must be unscrewed to be removed. During its
incision along the great circle. introduction the silicone tube and the maintainer
Consequently, if a scleral flap is fashioned tip itself have a stylette passed into them; the
following the curve of the limbus, that scleral resulting rigidity allows the turning process,
flap must be sutured in position because any and a rounded point at the tips allows it to easily
deformity of the globe will cause the eye to pass through the paracentesis. The fluid source
wrinkle along the great circle connecting the for the chamber maintainer is balanced salt
two ends of the incision. The scleral flap solution (BSS), which contains additional
would become a free, non-supporting structure. antibiotics for prophylactic purposes and is
In contrast, a frown-type incision that has a supported on an electric IV (intravenous) pole
391
Figure 240: Straight vs Frown Shaped Scleral Incision
A "great circle" on a sphere, or in this case on an eye, is the circumferential line (L) produced by a plane
(P) which passes through the center (C) of the sphere. The great circle shown on this eye is one which passes through
the area of a planned incision marked by endpoints (A) and (B). The key to the concept of the great circle is that it
is geometrically the shortest distance between two points which lie on that circle. If the surface incision (D - top inset)
forms a concave shape that does not cross the great circle (dotted line), then the superficial flap is quite rigid. If the
incision (E - bottom inset) forms a convex shape from the great circle (dotted line), then there will be no support for
the flap. Note the resulting gape of the incision.
so that the static height, and thereby the Aspiration of the Anterior Cortex and
gravitational force, on the fluid that is entering Epinucleus
the anterior chamber can be easily adjusted.
The infusion tubing that comes from the BSS With the tunnel completely opened and
bottle to the table also has a roller valve so that with the chamber maintainer operating and its
the assistant can turn the maintainer system on pressure somewhat elevated, the surgeon does
and off as needed throughout the procedure. the preliminary aspiration of the cortex and
392
epinucleus overlying the anterior surface of

the firm central nucleus using a 21-gauge
cannula (Fig. 241). McIntyre is careful to
create a gutter or furrow around the
equatorial area of the nucleus, thus allowing
it to more easily come up from the remaining
epinuclear "bowl". This is performed
without any hydrodissection.
Most experienced surgeons are aware
of a complication that is frequently
disastrous for the patient: the combination
of posterior capsule tearing or rupturing
with loss of vitreous and with portions of
nucleus retained in the posterior segment.
McIntyre believes that this
complication indicates potential loss of
control by the surgeon during portions of
the operation when aspiration is being used.
During removal of the lens material, the
cataract should be seen as being formed of
Figure 241: Aspiration of Anterior Cortex and Anterior Epi-
three separate tissue zones (Fig. 239). Starting nucleus
from the center is the nucleus, a rigid material
that is too viscous to allow aspiration. The The following illustration depicts the surgeon's view of a
left eye. Temporal (3 o'clock) is at the bottom and nasal (9 o'clock)
second zone is the epinucleus or, as it is often is at the top. First, an anterior chamber maintainer (M) is inserted
called, the epinuclear bowl. The epinucleus is nasally. A 6 mm circular capsulorhexis (A) is performed. The 5.5
a relatively firm gelatinous material with an mm frown shaped scleral tunnel (T) incision is completed. A
specially sharpened 21 gauge cannula (D) is introduced through a
intermediate degree of viscosity, which can be paracentesis made to the right of the scleral tunnel incision. Inset
aspirated with sufficient vacuum. The third shows detail of the tip of the cannula. The port of the cannula is
zone is the peripheral cortex, which lies just directed posteriorly to aspirate the central cortex (C), and
epinucleus (E) overlying the anterior surface of the firm nucleus (N).
under the capsule surface. This gelatinous A furrow is created around the equatorial area of the nucleus.
zone is of a very low viscosity and is freely
aspirated.
This perspective of the three zones of the instrument clears a portion of the viscous
cataract clearly reveals an important safety epinuclear material, the cortex will then move
factor in aspiration. Whether using manual or through the aspirating system at a much greater
mechanical methods, the surgeon has more velocity, challenging the control of the surgeon
control when aspirating from the less viscous to avoid impaction and probable tearing of the
cortex toward the highly viscous nucleus. posterior capsule.
On the other hand, there is a potential loss
of control and an extreme danger when Phacosection
aspirating from the more viscous element, such
as the epinucleus, toward the peripheral cortex. Following the preliminary aspiration of
In this circumstance when the aspirating cortex and epinucleus from the front surface of
393
Figure 242: Hydrodissection of the Nucleus
A 27 gauge cannula (F) placed

through the paracentesis is used to hydrodissect
the nucleus (N). The cannula is rotated (ar-
row) under the margin of the nucleus nearest
the scleral tunnel incision to tilt it forward. A
small amount of viscoelastic material may be
used to maintain this tilt. Note the epinuclear
bowl (E) in which the nucleus sets. Chamber
maintainer (M).
the nucleus, McIntyre does a hydrodissection Removal of Epinucleus and

of only the central hard nucleus using a 27- Cortical Cleanup
gauge, slightly narrowed and slightly curved
cannula (Fig. 242). With this hydrodissection Following the removal of the divided
he also tilts forward the margin of the nucleus nucleus particles, the epinucleus is then remo-
nearest the incision. Then the nucleus itself ved as a second stage. The epinucleus is
can be divided into a number of fragments hydrodissected from its attachment to the
using the technique called Phacosection peripheral cortex (Fig. 246). In most cases the
(Fig. 243). This term, which McIntyre finds epinucleus is a continuous structure which can
very useful, originated with Peter Kansas in be hydrodissected, brought forward into the
New York. The procedure involves dividing anterior chamber, and hydraulically expressed.
the nucleus into a number of fragments, the The epinucleus is not removed by aspiration.
number being determined by the size and The third stage of the cataract tissue
hardness of the nuclear material, usually 2 or 3, removal is simple aspiration of the residual
occasionally 4. Each of these fragments is then cortex. The only stages of the procedure
individually surrounded by a layer of heavy performed by aspiration are the preliminary
viscoelastic material (Fig. 244) and simply aspiration of the anterior cortex and epinucleus,
extracted from the anterior chamber with their and then the final cleanup of the residual
protective viscoelastic coating using a pair peripheral cortex. In this way the process of
of instruments designed for this purpose aspirating from a more viscous to a less viscous
(Fig. 245).
394
medium is avoided. Thereby, the surgeon

avoids losing control and destroying the
continuity of the posterior capsule.
Transition from Extracapsular

Extraction to Phacosection
McIntyre believes it is easier for

the ophthalmic surgeon who is
accustomed to standard, conventional
large-incision extracapsular surgery to
make the transition to small-incision
phacosection (5.5 mm) than to
phacoemulsification. The small
incision phacosection technique offers
the surgeon some very distinct advantages
on his/her patient’s behalf in comparison
with the conventional large-incision
planned extracapsular. These advantages Figure 244 (above): Surrounding Nuclear
are: more safely, a much more rapid Pieces with Viscoelastic
recovery, a much more durable eye during Each fragment of nucleus is in-
dividually surrounded by a layer of heavy
viscoelastic material via a cannula through
the tunnel incision. The viscoelastic (V) is
shown being placed between the two hard
nucleqr fragments (N). This will assist in
protecting intraocular structures during their
removal. The anterior chamber maintainer
(M) is still turned off.
Figure 243 (left): Phacosection of the Nucleus
A spatula (S) is introduced through the

scleral tunnel incision (T) and placed behind the
nucleus (N). A single cutter (R), also introduced
through the tunnel incision, is used to section
(arrow) the nucleus. The anterior chamb er con-
tains viscoelastic with the anterior chamber main-
tainer (M) turned off during this sectioning.
395
Protocol for Phacosection Surgery

The total small incision self-sealing 8) Any remaining air bubbles and the
phacosection cataract procedure with lens capsule fragment are aspirated through the tunnel
implantation can be summarized in the following incision with a 21-gauge cannula. The chamber
steps: maintainer is elevated to increase the hydrostatic
pressure. Preliminary aspiration of the anterior
1) A standard patient preparation with cortex and the epinucleus down to the face of the
wide dilation of the pupil. Peribulbar anesthesia nucleus is done with the 21-gauge cannula through
followed by 40 minutes of oculopression with an the paracentesis (Fig. 241).
equivalent of 30 mm pressure. The patient is
draped with isolation of the lid margins and 9) Hydrodissection of the firm central
insertion of the speculum. nucleus is done with a 27-gauge cannula through
the paracentesis, tilting forward the equator of the
2) A nasal limbal paracentesis is followed nucleus adjacent to the tunnel (Fig. 242).
by insertion of the anterior chamber maintainer, Hydrodissection is intended to elevate the smallest
which is then turned on (Fig. 241). identifiable nucleus and to tilt forward only the
equator that lies directly in front of the tunnel
3) A temporal limbus based conjunctival incision.
flap of 3 to 4 mm width is made with mechanical
dissection of the limbus and limited bipolar 10) The anterior chamber maintainer is
cautery of the episcleral vessels. turned off. The anterior chamber is deepened
with viscoelastic of high viscosity; a small amount
4) A 6 mm frown incision is marked with is injected behind the nucleus to hold it in the tilted
calipers on the surface of the sclera, avoiding any position if necessary. With a cutting board and a
major scleral vessels (Fig. 240). single nucleus cutter the surgeon reaches into the
anterior chamber (Fig. 243). Depending on the
5) A superficial scleral tunnel is dissected size and hardness of the nucleus, the surgeon
with a crescent blade. A paracentesis is created decides how many cuts in the nucleus will be
to the right side of the incision tunnel. Then needed. With the single cutter he then makes one,
perforation is made through the base of the tunnel two, or three cuts as required. The two instruments
into the anterior chamber at the center of the are withdrawn.
tunnel with a hooked cystotome.
11) Additional viscoelastic is injected
6) The anterior chamber maintainer is and the cannula is used to position the first fragment
turned off. The anterior chamber is inflated with of the cut nucleus that appears most readily
air through the cystotome, and a capsulorhexis of accessible for removal (Fig. 244).
approximately 6 mm diameter is created.
12) With the shield of viscoelastic in
7) The chamber maintainer is turned on. place, the surgeon reaches into the anterior
Perforation is made through the central tunnel chamber with the two nucleus extracting
puncture with a 15 degree super sharp blade, instruments, which look very much like a pair of
followed by the crescent blade to enlarge the spoons. The two spoons surround the fragment of
internal aspect of the tunnel incision to its full nucleus and remove it from the anterior chamber
dimension. (Fig. 245).
396
13) Additional viscoelastic is used to on the introduction forceps. The IOL is introduced
isolate each individual fragment as it is removed under an assisting 30-gauge cannula with the
with the extracting instruments. The average leading haptic placed directly into the nasal
volume of viscoelastic required is .25 ml. capsular bag. The lens optic is steadied with the
30-gauge cannula as the introduction forceps are
14) The chamber maintainer is turned removed. The trailing haptic is placed under the
on. Hydrodissection of the epinucleus is done incision into the capsular bag with a Dusek forceps.
with the 27-gauge cannula and balanced salt The lens is rotated, its position is confirmed, and
solution (BSS). The entire epinucleus is the haptics are placed in the horizontal position.
hydroexpressed with or without the irrigating
spoon (Fig. 246). 18) The conjunctival incision is sealed
with bipolar cautery. The corneal margins of the
15) The residual peripheral cortex is paracentesis are hydrated with a 30-gauge cannula.
aspirated with the straight and curved cannulas The chamber maintainer is removed. The margins
through the paracentesis. of the ACM paracentesis are hydrated with BSS.
16) The posterior capsule is polished 19) Absence of iris incarceration is
with the straight side ported aspirating cannula confirmed. Final re-deepening and inspection of
turned posteriorward and introduced through the the anterior chamber is done through the
tunnel incision. paracentesis.
17) This is followed by inspection, 20) Finally, medications and dressing
irrigation, and positioning of the intraocular lens are applied.
397
Figure 245 (right): Nuclear Fragment Re-

moval
A spatula (S) introduced through the

tunnel incision is inserted under the viscoelastic-
coated nuclear fragment (N). The extracting
instrument (X), shaped somewhat like an in-
verted spoon, is inserted over the nuclear frag-
ment. Then, to extract the fragment, the spatula
(S) is rotated upwards (red arrow) causing the
tips of the instruments to approach one another in
a pincer-like fashion. Both instruments with the
included nuclear fragment are then removed
from the anterior chamber in a straight horizontal
movement (blue arrow), thus preventing both
the instrument and the nuclear fragment from
contacting the corneal endothelium. Note re-
maining nuclear fragment (F) still within epi-
nuclear bowl (E). Anterior chamber maintainer
(M) is still off during this extraction.
Figure 246 (left): Hydrodissection and

Hydroexpression of Remaining Epi-
nucleus
The remaining epinucleus (E) is

hydrodissected as shown using the special
21 gauge cannula (D) introduced through
the tunnel incision. BSS is being injected
through the 27 gauge cannula (F) as well as
the anterior chamber maintainer (M). Work-
ing through the tunnel at this point assures
that leakage will control excessive anterior
chamber pressure. When the epinucleus has
been hydrodissected and is floating in the
anterior chamber, its removal (arrow) is
facilitated with the irrigating spoon (not
shown). The residual peripheral cortex (C)
is then aspirated via cannula through the
paracentesis.
398
the immediate postoperative period, and a major

reduction in the astigmatism effects of the
surgery.
If the surgeon decides to make a transition
from the traditional large incision extracapsular
technique this should be done in a very orderly
way with the following steps: 1)Begin using
the standard incision technique with which the
surgeon is already familiar. 2) After completing
the large incision with pre-placed sutures if that
is the surgeon's custom, begin to practice the
capsulorhexis. 3) When comfortable with the
capsulorhexis technique, begin to aspirate down
onto the surface of the nucleus, tilt the nucleus
forward, perform the phacosectioning
technique, and extract the particles of the
nucleus. This is still done through the full-size
extracapsular incision with which the surgeon
is familiar.
4) When the surgeon is completely
comfortable with all these steps, then he/she
can begin to change the incision technique.
McIntyre suggests that the size of the incision
can first be reduced to about 7.5 mm. A frown
incision can be made, but closed with two
simple interrupted sutures. 5) When the surgeon
is confident this is performed satisfactorily, he/
she can consider moving the incision site to the
temporal limbus and can progressively reduce
the linear dimension of the tunnel. 6) When the
tunnel is approximately 6.5 to 6 mm, the
surgeon will probably continue to put one
suture in the center of the tunnel just to maintain
confidence.
At this point, the surgeon is in fact doing
the current small incision phacosection
technique, and will find it is perfectly safe to
eliminate the use of sutures except in special
circumstances.
399
THE SMALL INCISION MANUAL

PHACOFRAGMENTATION
The small incision manual the AC through the small incision, avoiding the
phacofragmentation (MPF) that we hereby need to enlarge it and convert the surgery to an
present has been designed and developed by ECCE.
Francisco Gutierrez C., M.D., of Spain. It 5) Presumably it is a method easier to
is performed with a 3.2 mm clear corneal master than phaco.
incision, which is the same size as in pha- 6) No less important, it requires no su-
coemulsification. This manual phaco frag- tures or stitches.
mentation (MPF) can also be done with a 3.5
mm scleral tunnel incision, which is the same Experiences with Other Phaco
incision size for phaco when we utilize the Fragmentation Techniques
scleral tunnel technique (Figs. 247 and 248).
In order to overcome the two main draw-
Benefits of (MPF) backs of phaco: 1) difficult learning curve and
2) high cost of equipment, a good number and
As advocated by Dr. Gutierrez C., this variety of techniques for manual
technique provides several important benefits, phacofragmentation have been used in the past.
as follows: The limitations of these techniques have been
1) It can be performed with a small 3.2 related to not being able to sufficiently reduce
mm incision if done in clear cornea and with a the size of the incision because: 1) the instru-
3.5 mm incision if done with a scleral tunnel, mentation was coarse; 2) the nuclear frag-
thereby resulting in minimum astigmatism and ments that were to be extracted from the ante-
rapid recovery (Figs. 247 and 248). rior chamber were too large, usually because
2) It functions well with hard and soft the nucleus was divided into two or three pieces.
nuclei.
3) It requires a low investment in the Why Use Gutierrez' Technique?
equipment and instrumentation.
4) Presumably, it provides a very good
backup when complications arise and pha-
Positive Features of Instrumentation
coemulsification must be discontinued. This
technique helps the phacoemulsification sur- The phacofragmentor designed by
geon in the event of an accidental rupture of the Gutierrez, is manufactured by the English
posterior capsule. Also, the instrumentation firm of John Weiss & Son Ltd., a subsidiary of
facilitates extracting the nuclear fragments from the Swiss multinational Haag-Streit. With it
400
the nucleus is broken into very small 2 x 2 mm and angle of the nucleotome and serves as
pieces that can be extracted through a 3.2 or 3.5 support for phacofragmentation (see "S" in
mm incision (Fig. 247). This results in a Fig. 247).
practically neutral postsurgical residual astig- • Two straight-handled, ophthalmic ma-
matism. nipulators, left and right, with a basket end,
The racquet-shaped design of the which serve to collect the nuclear fragments
fragmentor (see P and B in Fig. 247) keeps the during the nuclear fragmentation (Fig. 250).
nuclear fragments within the racquet, avoiding • Anterior chamber maintainers were
their dispersion as they are removed from the pioneered years ago by Strampelli as well as
AC. Joaquin Barraquer, and their use is always
The phacofragmentor or nucleotome has emphasized by Michael Blumenthal for his
a straight ophthalmic handle, with a 45º angle Mini-Nuc cataract extraction technique. The
at its end, which is 8 mm long and 2 mm wide Gutierrez AC maintainer (ACM) maintains
and racquet-shaped. The racquet is divided in continuous irrigation with BSS in the anterior
four parts by three transverse bars two millime- chamber, creating positive pressure that stabi-
ters apart (Fig. 247) which keep the small lizes the AC depth. During the stages of the
pieces within the racquet. Other important operation in which the maintainer is used, the
instruments are: amount of viscoelastic utilized is less, thereby
• A spatula with a straight ophthalmic reducing costs.
handle, whose end is adapted to the dimensions
Figure 247: Manual Multiphacofragmentation

Technique - Stage 1 - Fragmentation
Following creation of a 3.5mm scleral tun-

nel (I) or 3.2mm corneal incision, continuous cir-
cular capsulorhexis, and hydrodissection of the
nucleus, the nucleus is luxated into the anterior
chamber. After the nucleus is luxated into the
anterior chamber, a high density viscoelastic is
injected into the area surrounding the nucleus to fill
the anterior chamber. The spatula (S) is placed
beneath the nucleus (N). The nucleotome, (or
phacofragmentor) (P) is placed on top of the nu-
cleus. With the nucleus sandwiched between the
two instruments (inset), the nucleotome is pressed
downward toward the spatula (arrow). This sec-
tions the nucleus into four fragments (1,2,3,4)
between the cross bars (B) of the racket shaped
nucleotome.
401
Surgical Technique dium-soft nuclei, before hydrodissection.

Nucleus Hydrodissection and Lux-
It is important to have good pharmaco- ation: After entering the AC with a 3.2 mm
logical mydriasis because the pupil may con- beveled blade, balanced salt solution (BSS) is
tract during surgery. injected with a Binkhorst cannula through the
Incision: This method can be performed corneal or scleral incision between the anterior
through a 3.2 mm corneal incision (clear cor- capsule and the cortex at 12 o'clock.
neal) (Fig. 247) or through a 3.5 mm scleral The BSS must be injected slowly and
tunnel incision (scleral tunnel) 2 mm away continuously until the "wave" of dissection is
from the corneal-scleral limbus (Fig. 248). The visible on the posterior capsule. Injection of
preparatory incision is made without penetrat- BSS is continued until luxation of the nucleus
ing the anterior chamber (AC). begins. If the luxation of the nucleus into the
Capsulotomy: A continuous circular AC is partial, it may be completed by rotating
capsulorhexis is performed with a cystotome the nucleus with a cannula, cystotome or spatula.
through a superotemporal paracentesis. This Nuclear Fragmentation: Once the
capsulorhexis should be sufficiently wide (ap- nucleus has been luxated into the AC, high-
proximately 6 mm) to allow an easy luxation of density viscoelastic is injected into the sur-
the nucleus into the AC. The AC maintainer is rounding area to fill the AC. The nucleus is
used during this step and when aspirating the then fragmented by placing the spatula beneath
anterior cortex and epinucleus in soft and me- the nucleus and the nucleotome on top of it
Figure 248 - Manual Multiphacofrag-men-

tation Technique - Stage 2 - Extraction
While the nuclear fragments (A)

remain with the nucleotome (P), the spatula
(S) and nucleotome are extracted (arrow)
from the anterior chamber through the inci-
sion (I). Notice the remaining nucleus (N)
with center removed, within the anterior
chamber. This procedure is repeated until
the whole nucleus is fragmented and ex-
tracted. With hard nuclei, after capturing the
nuclear fragments (A) with both instruments
(P) and (S), space can be gained by extract-
ing nuclear fragments (A) using only the
nucleotome (P), as hard fragments will re-
main within the nucleotome (P) without the
support of the spatula (S), thus reducing
corneal injury.
402
Figure 249: Manual Multiphacofragmentation

Technique - Stage 2A - Extraction
This cross section shows the extraction

configuration seen in the surgeon’s view of Figure
2. Notice the nuclear fragments (A) sandwiched
between the nucleotome (P) and spatula (S) as
they are extracted (arrow) from the chamber. Part
of the nucleus (N) remains in the anterior chamber
and will be extracted in the same manner.
(Fig. 247). Pressure is then created by slowly Manipulation of Nuclear Fragments:

pressing the nucleotome downward toward the There are right and left manipulators to dis-
spatula until the part of the nucleus in it is place the remaining fragments of the nucleus to
fragmented into four pieces (Fig. 247). The the center of the AC to facilitate their fragmen-
pieces remain within the nucleotome, and tation and subsequent removal (Fig. 250).
with the help of the spatula are extracted Cortex Extraction and Nucleus Re-
from the AC using a "sandwich" technique moval: The lens cortex is aspirated with a two-
(Figs. 248 and 249). This maneuver is repeated way Simcoe irrigation-aspiration cannula
until the whole nucleus is fragmented. (Fig. 251). If small pieces of the nucleus
During nuclear fragmentation it is im- remain in the AC, they can be removed accord-
portant to refill the AC with high-density vis- ing to their hardness in different ways: with the
coelastic as needed to protect the corneal en- nucleotome and the spatula together (sandwich
dothelium and facilitate safe manipulation dur- - Figs. 247, 248, 249) or only with the
ing surgery.
403
Figure 250 - Manual Multiphaco-fragmen-

tation Technique - Stage 3 - Manipulation
of Nuclear Fragments
Left (L) and right (R) curved

manipulators (M) are used to displace (ar-
rows) the remaining fragments of the nucleus
(N) to the center of the anterior chamber.
From there they will be fragmented and ex-
tracted in a similar fashion with the
nucleotome and spatula.
Figure 251 - Manual Multiphacofragmen-

tation Technique - Stage 5 - Removal of Soft
Nuclear Fragments and Cortex
Following removal of the nucleus,

the lens cortex and any soft residual nuclear
fragments (FS) can then be aspirated and ex-
tracted from the anterior chamber with a Simcoe
irrigation-aspiration cannula (A). A Charleux
cannula may also be used (not shown). Lens
cortex beneath the hard-to-reach incision area
can be aspirated with a Binkhorst cannula (B) as
shown.
404
nucleotome, removing the spatula from the AC

once the surgeon has grasped the nuclear
fragment. Removal can also be accomplished
using a two-way (I/A) Simcoe or Charleux
cannula (Fig. 251), or with gentle BSS irriga-
tion of the AC aided by a fine cannula.
Intraocular Lens Implant and Wound
Closure: Viscoelastic is injected into the cap-
sular bag and a foldable lens is implanted.
Sutures are not usually required.
Complications
In Dr. Gutierrez C. experience, com-
plications are rare. There is always the possi-
bility for mild corneal edema if much in-
traocular manipulation is done and for a small
hemorrhage in the anterior chamber if the
instrumental manipulation may causes small
damage to the iris.
Dr. Gutierrez C. recommends that
ophthalmologists beginning to use this method
initially practice with incisions larger than
3.5 mm, progressively reducing the size as they
master the technique.
405
406
C h a p t e r 14: The New Cataract Surgery Developments
THE NEW CATARACT SURGERY

DEVELOPMENTS
Overview 3) The Phaco Tmesis System, of
Aziz Anis.
At present, there are four main avenues
of development for new techniques in cata- 4) Warm Water Jet Technology.
ract surgery. Those who advocate them con-
sider that they might be better than pha- DODICK’S PHOTOLYSIS SYS-
coemulsification. They are: TEM
1) The Laser Techniques Dodick et al use a Q-switched Nd:YAG
laser. The pulsed laser and a specially de-
Two groups of procedures are done signed probe to use this energy are utilized for
with laser: removal of the cataractous crystalline lens.
a) The Dodick Laser Photolysis Sys- The probe has a quartz-clad fiber. The
tem: This is the only one that has been proximal end of the quartz fiber is connected
approved by the FDA in the United States and to the laser source. The fiber enters the probe
is also clinically available in Europe. This through the probe’s infusion port and the
system is manufactured by Laser Corp., based distal end terminates in front of a titanium
in Salt Lake City, Utah. target inside the tip of the probe. This target
b) The Paradigm Nd:YAG Laser Sys- is an essential element of the device (Fig.
tem, also known on the “Phantom”. This is 252).
under investigational development by Para- The titanium target acts as a trans-
digm Medical Industries also of Salt Lake ducer, causing optical breakdown and plasma
City. formation to occur in the aspiration chamber,
and sending out acoustic shock waves config-
2) The Catarex System, being ured by the target’s shape to be maximized at
developed by Richard Kratz et al. the aspirating tip. At the aspirating tip
nuclear material is shattered by the acoustic
waves and evacuated out of the eye.
409
Surgical Technique cone. These shock waves break down the

substance of the cataract (Fig. 252). The
As described by Kanellopoulos et al a fragmented particles of the cataract are then
1.4 mm clear-cornea incision is made for aspirated out of the eye.
insertion of the Dodick photolysis laser-aspi- The same probe is used to aspirate
ration probe. A second, 0.9 mm corneal inci- the cortex.
sion is made to provide irrigation or infusion At present, the incision needs to be
through a second probe. The infusion and enlarged for insertion of a foldable IOL.
aspiration are done after a 6 mm CCC is Industry is working on making foldable
performed. The laser delivers pulsing photic lenses that can be introduced into the eye with
energy, which creates a shock wave that incisions smaller than the 2.8 mm minimum
emanates from the probe tip in a focused used now.
Figure 252: Dodick’s Laser Photolysis
The laser fibre (L) terminates in front of a titanium

target (T) which absorbs the emitted pulsed YAG laser energy
(L). The resultant optical breakdown and plasma formation
create shock waves which travel to the mouth of the aspiration
port shattering the lens material. Suction occurs there and the
cataract is aspirated out of the eye.
410
C h a p t e r 14: The New Cataract Surgery Developments
Advantages endothelial cell loss, in contrast to phaco,

which even in good hands, may have a four
According to Dodick, photolysis has percent endothelial cell loss or more. With
two primary advantages. One is that it will Catarex, since all maneuvering is done inside
allow smaller incisions and two, it generates the capsule with its tight seal, the endothe-
no heat. One of the disadvantages of classic lium should have no damage. The other
phaco is that the wound may be damaged by potential advantage is that by working inside
heat. With laser photolysis, we will not have the capsule this procedure might decrease
any wound burns. posterior capsular tears and eliminate iris
Photolysis is felt to offer more protec- damage. All these potential advantages
tion of the corneal endothelium and presum- should provide us a safer operation.
ably it is a somewhat simpler procedure than Another potential advantage is that it
phaco. is hoped Catarex may be easier than
phacoemulsification, which is a difficult
THE CATAREX SYSTEM operation. If so, this would be a very positive
advance from the perspective of public health
This system is under investigational and the availability to many people that who
development under the leadership of Richard cannot have phaco at present. Hopefully, the
P. Kratz, Shoeila Mirhashemi, Michael cost would be less.
Mittelstein and John Sorensen. Through the
years, Kratz has made several major contri- Aziz PhacoTmesis
butions to improve the techniques of pha-
PhacoTmesis uses a spinning needle
coemulsification.
that also has ultrasound. It is a very powerful
Catarax is a different technology that
cutting tool.
may important advantages over phaco and
ECCE. Water Jet Technology
Potential Advantages and Tech- If you heat water to the right tempera-
nique ture, about 55 to 60 degrees centigrade, you
can appear to melt the lens. There are several
Lindstrom is participating in the in- companies working on a water jet type tech-
vestigational work in animals. As he de- nology to remove cataracts with basically
scribes it, it only requires a 1.0 to 1.4 mm heated balanced salt solution. It appears that
incision. The surgeon makes a one millimeter this can be done without damaging the sur-
incision in the anterior capsule with di- rounding tissues from the heat either by using
athermy, just inside the edge of the iris where an endocapsular method or by having short
he makes the wound. Then he puts in a pulses of the heated material directed at the
device that looks somewhat like a blender cataract with cool material circulating in the
blade into the eye that works through a vortex anterior chamber.
action. This basically breaks up the lens, The latter two methods mentioned
allowing aspiration. above seem to be brilliant ideas but it is
The potential advantage of Catarex unclear whether they can be translated into
seems to be that there should be no corneal practical reality.
411
BIBLIOGRAPHY
Anis, AY: PhacoTmesis. Atlas of Cataract Sur-

gery, Edited by Masket S. & Crandall AS, pub-
lished by Martin Dunitz Ltd., 1999, 12:89-96.
Colvard DM, Kratz RP: Cataract surgery utilizing

the erbium laser. In: Fine IH, ed. Phacoemulsifica-
tion: New Technology and Clinical Application
(Thorofare, NJ: Slack, 1996), 161-80.
Dodick, JM: The Nd:YAG laser phacolysis tech-

nique. Boyd’s World Atlas Series of Ophthalmic
Surgery of HIGHLIGHTS. 1995; 5:130-131.
Dodick JM, Christian J: Experimental studies on

the development and propagation of shock waves
created by the interaction of short Nd:YAG laser
pulses with a titanium target: possible implica-
tions for Nd:YAG laser phacolysis of the catarac-
tous human lens. J Cataract Refract Surg 1991;
17:794-7.
Kanellopoulos AJ, Dodick JM, Brauweiler P,

Alzner, E: Dodick photolysis for cataract surgery.
Early experience with the Q-switched
neodymium:YAG laser in 100 consecutive patients.
Ophthalmology, 1999;106:2197-2202.
Kratz RP, Mirhashemi S, Mittelstein M, Sorensen

JT: The Catarex technology. Atlas of Cataract Sur-
gery, Edited by Masket S. & Crandall AS, pub-
lished by Martin Dunitz Ltd., 1999, 11:85-88.
412

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I

This book was created and written by

Project Director: Andres Caballero, Ph.D

©Copyright, English Edition, 2001. Chapter 6: Phacoemulsification - Why So Important?

The production of this ATLAS is a major enterprise. In addition to our dedicated

Among my closest collaborators in HIGHLIGHTS, Andres Caballero, Ph.D., the

To each person mentioned in this page, on behalf of the thousands of readers of

May "THE ART AND THE SCIENCE OF CATARACT SURGERY"

And, by all means, to the great innovators each of whom developed a

BENJAMIN F. BOYD, M.D., F.A.C.S.

BENJAMIN F. BOYD, M.D., D.Sc. (Hon), F.A.C.S.

Doctor Honoris Causa

Recipient of the Duke-Elder International Gold Medal Award (Interna-

Recipient of The Great Cross Vasco Nuñez de Balboa Panama's Highest

Founder and Chief Consultant, Ophthalmology Center of Clinica Boyd, Panama,

JOAQUIN BARRAQUER, M.D., F.A.C.S., Director and Chief Surgeon,

CRISTELA FERRARI ALEMAN, M.D., Associate Director, Cornea and

Robert C. Drews, M.D., F.A.C.S., F.R.C.Ophth.

Professor Emeritus of Clinical Ophthalmology, Washington University School of

President Elect of the American Ophthalmological Society

Gold Medal of Pan-American Association of Ophthalmology; Rayner Medal, United

EVERARDO BAROJAS, M.D., Dean, Prevention of Blindness and Rehabilitation

PROF. RUBENS BELFORT JR., M.D., Professor and Chairman, Department

RAFAEL CORTEZ, M.D., Director, Ophthalmic Surgery Center (CECOF),

FRANCISCO GUTIERREZ C., M.D., Ph.D, Anterior Segment Surgery and

FRANCISCO MARTINEZ CASTRO, M.D., Associate Professor of

JUAN MURUBE, M.D., Professor of Ophthalmology, University of Alcala and

CARLOS NICOLI, M.D., Associate Professor of Ophthalmology, University of

FELIX SABATES, M.D., Professor and Chairman, Department of Ophthalmology,

JUAN VERDAGUER, M.D., Academic Director, Los Andes Ophthalmological

LIHTEH WU, M.D., Associate Surgeon in Vitreoretinal Diseases, Instituto de

FOCUSING AND OVERVIEW OF WHAT IS BEST

SURGICAL ANATOMY OF THE HUMAN LENS

INDICATIONS FOR SURGERY -

PREPARING FOR SURGERY 37

Making Patients Confident 37

IOL POWER CALCULATION IN STANDARD 39

PREVENTING INFECTION AND INFLAMMATION

PROCEEDING WITH THE OPERATION

PREPARATION, SEDATION AND ANESTHESIA 71

PHACOEMULSIFICATION - WHY SO IMPORTANT?

COMPARING PLANNED EXTRACAPSULAR WITH 83

PREPARING FOR THE TRANSITION

GENERAL OVERVIEW AND STEP BY STEP CONSIDERATIONS 93

INSTRUMENTATION AND EMULSIFICATION SYSTEMS

General Considerations 159

MANAGEMENT OF THE NUCLEUS 176

General Considerations 176

THE ENDOCAPSULAR TECHNIQUES 177

THE HIGH ULTRASOUND ENERGY AND LOW VACUUM GROUP 177

FOCUSING PHACO TECHNIQUES ON THE

MULTIPLICITY OF TECHNIQUES 229

INTRAOPERATIVE COMPLICATIONS 249-268

General Considerations 249

POSTOPERATIVE COMPLICATIONS 269-290

CATARACT SURGERY IN COMPLEX CASES

Aims of this Chapter 295

CATARACT AND GLAUCOMA 302

Overview - Alternative Approaches 302

PHACOEMULSIFICATION IN DISEASED CORNEAS 322

PHACOEMULSIFICATION AND IOL IMPLANTATION 322

Pharmacological Mydriasis 328

TRAUMATIC CATARACTS 333