Cataract Art Science

I
This book was created and written by

Professor Boyd at Miramar Plaza Towers,
overlooking the Panama Canal, the Pacific
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
Spanish Translation: Cristela F. Aleman, M.D.
Medical Illustrations: Stephen F. Gordon, B.A.
Trina Fennell, M.S.
Samuel Boyd, M.D.
Sales Manager:
Tomas Martinez
Marketing Manager: Eric Pinzon
Customer Service
Manager:
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International
Communications:
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ISBN N 9962-613-03-5
Copyright, English Edition, 2001.
Highlights of Ophthalmology Int'l
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South America
OUTLINE OF MAJOR SUBJECTS
Chapter 1:
Surgical Anatomy of the Human Lens
Chapter 2:
Indications and Preoperative Evaluation
Chapter 3:
IOL Power Calculation In Standard

and Complex Cases - Preparing for Surgery
Chapter 4:
Preventing Infection and Inflammation
Chapter 5:
Proceeding with the Operation
Chapter 6:
Phacoemulsification - Why So Important?
Chapter 7:
Preparing for the Transition
Chapter 8:
Instrumentation and Emulsification Systems
Chapter 9:
Mastering Phacoemulsification The Advanced, Late Breaking Techniques
Chapter 10: Focusing Phaco Techniques on the Hardness

of the Nucleus
Chapter 11:
Complications of Phacoemulsification
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 (International 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 Nuez 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 "Contributions 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 Ophthalmology at Four Universities; Past-President, Academy of Medicine and Surgery of Panama;
Honor Member, Ophthalmological Societies of Argentina, Bolivia, Brazil, Canada, Colombia, 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."
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 CARREO, M.D., Assistant Professor of Ophthalmology,
University of Chile; Director, Carreo 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 So Paulo (Escola Paulista de MedicinaHospital So 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 Nios, 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
Anatomical Characteristics of Different Types of Cataract
How Cataracts Respond Differently
Incidence and Pathogenesis
5
7
7
8
CHAPTER 2
INDICATIONS FOR SURGERY PREOPERATIVE EVALUATION
INDICATIONS
Role of Quality of Life
The Role of Visual Acuity
Contrast Sensitivity and Glare Disability
Contrast Sensitivity Characteristics
Relation of Glare to Type of Cataract
Evaluation of Macular Function
PREOPERATIVE GUIDELINES IN COMPLEX CASES
How to Proceed in Patients with Retinal Disease
The Importance of Pre-Op Fundus Exam
Cataract Surgery in Diabetic Patients
Evaluating Diabetics Prior to Cataract Surgery
Importance of Maintaining the Integrity of the Lens Capsule
Significant Increase in Complications Following Cataract Surgery
Appropriate Laser Treatment
Main Options in Management of Co-existing Diabetic
Retinopathy and Cataract
Cataract Surgery and Age-Related Macular Degeneration
RETINAL BREAKS AND RETINAL DEGENERATIONS
PRIOR TO CATARACT SURGERY
Cataract Surgery in Patients with Uveitis
Method of Choice
Diagnosing the Type of Uveitis in the Pre-Operative Phase
Preoperative Management
The Intraocular Lens
Cataract Surgery in Adult Strabismus Patients
Preoperative Judgment
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IX
CHAPTER 3
PREPARING FOR SURGERY
Making Patients Confident
Patients Encounter with the Physician
Ingredients of a Strong Relationship
Evaluating the Patient's Cataract
Approaching the Day of Surgery
Patient's Expectations
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IOL POWER CALCULATION IN STANDARD

AND COMPLEX CASES
39
Postop Refractive Errors No Longer Admissible

The Challenge of the Complex Cases
The Most Commonly Used Formulas
Main Causes of Errors
Targeting Post-Op Refraction
Monocular Correction
Binocular Correction
Good Vision in the Non-Operated Eye
When Cataracts in Both Eyes
IOL POWER CALCULATION IN COMPLEX CASES
Specific Methods to Use in Complex Cases
Practical Method for Choosing Formulas in Complex Cases
High Hyperopia
The Use of Piggyback Lenses in Very High Hyperopia
High Myopia
DETERMINING IOL POWER IN PATIENTS WITH
PREVIOUS REFRACTIVE SURGERY
Methods Most Often Used
The Clinical History Method
The Trial Hard Contact Lens Method
Example as Provided by Holladay
The Corneal Topography Method
THE IMPORTANCE OF DETECTING IRREGULAR
ASTIGMATISM
IOL POWER CALCULATION IN PEDIATRIC CATARACTS
Different Alternatives
Alternatives of Choice
IOL POWER CALCULATION FOLLOWING VITRECTOMY
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CHAPTER 4
PREVENTING INFECTION AND INFLAMMATION
Use of Antiseptics, Antibiotics and Antiinflammatory Agents
Effective Preoperative Antibiotic Treatments
Regimens Recommended
Gills Formulas to Prevent Infection
1) For High Volume Cataract Surgery
2) Non-Complex, Effective and Safe Alternative for
Prevention of Infection
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CHAPTER 5
PROCEEDING WITH THE OPERATION
PREPARATION, SEDATION AND ANESTHESIA
Preparation of Patient
Sedation
Pupillary Dilation
ANESTHESIA
Topical
Selection of Anesthetic Method
Unassisted Topical Anesthesia
The Anesthetic Procedure of Choice
Technique for Irrigation of Lidocaine in AC
Injection of Viscoelastic
What Can be Done with the Combined Anesthesia
Side Effects of the Combined Anesthesia
How to Manage Patients Who Feel Pain and Discomfort
PHOTOTOXICITY IN CATARACT SURGERY
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CHAPTER 6
PHACOEMULSIFICATION - WHY SO IMPORTANT?
COMPARING PLANNED EXTRACAPSULAR WITH
PHACO EXTRACAPSULAR
ADVANTAGES OF THE PHACO TECHNIQUE
MAIN TECHNICAL DIFFERENCES ASSOCIATED WITH PHACO
LIMITATIONS OF PHACOEMULSIFICATION
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CHAPTER 7
PREPARING FOR THE TRANSITION
GENERAL OVERVIEW AND STEP BY STEP CONSIDERATIONS
Equipment - Dependent and Phase-Dependent Technique
Mental Attitude
UNDERSTANDING THE PHACO MACHINE
Becoming Familiar with the Equipment
Two Hands, Two Feet and Special Sounds
Main Elements of Phaco Machines - Their Action on Fluid Dynamics
COMPARISON OF SURGICAL TECHNIQUES FOR
TRANSITION VS EXPERIENCED SURGEONS
Techniques Which Are the Same for the Transition and for
Advanced Surgeons
Techniques that Vary According to the Skill of the Surgeon
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XI
SURGICAL TECHNIQUE IN THE TRANSITION

Anesthesia
The Incision
How to Make a Safe Transition from Large to Small Incision
Role of Conjunctival Flap
Anterior Capsulorhexis
Hydrodissection
THE MECHANISM OF THE PHACO MACHINE
Getting Ready to Use Phaco During Transition
Optimal Use of the Phaco Machine
The Rationale Behind It - Main Functions
Parameters of the Phaco Machine
How to Program the Machine for Optimal Use
Fluid Dynamics During Phaco
Fluidics and Physics of Phacoemulsification
Importance of and Understanding the Surge Phenomenon
Lessening Intraoperative
Complications from the Surge
NUCLEUS REMOVAL - APPLICATION OF PHACO
FRACTURE AND EMULSIFICATION
The Divide and Conquer Technique
Emulsification of the Nuclear Fragments
FINAL STEPS
Aspiration of the Epinucleus
Aspiration of the Cortex
Intraocular Lens Implantation
Removal of Viscoelastic
Closure of the Wound
What to Do if Necessary to Convert
Testing the Wound for Leakage
Immediate Postoperative Management
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CHAPTER 8
INSTRUMENTATION AND EMULSIFICATION SYSTEMS
INSTRUMENTATION
Eye Speculum
Fixation Ring
Knives and Blades
Hydrodissection Cannula
Cystotomes or Capsulorhexis Forceps
Nuclear Manipulators or Choppers (Second Instrument)
Forceps and Cartridge Injector Systems for Insertion of
Foldable Intraocular Lenses
THE PHACO PROBES AND TIPS
Phaco Tips
Surgical Principles Behind the Different Phaco Tips
PHACOEMULSIFICATION SYSTEMS
The Alcon Legacy
The Allergan Sovereign
The Bausch & Lomb - Storz Millennium
XII
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The Pulse and Burst Modes

Differences Between Them
Clinical Applications of the Pulse Mode
Clinical Applications of the Burst Mode
Its Role in Transition to Chopping
Advances with the Sovereign Phaco System
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CHAPTER 9
MASTERING PHACOEMULSIFICATION
The Advanced, Late Breaking Techniques
General Considerations
Trauma-Free Phacoemulsification
Faster Operations
Do They Sacrifice Patient Care?
Readiness and Know-How to Become Efficient
THE ADVANCED, LATE-BREAKING TECHNIQUES
Anesthesia
Fixation of the Globe
THE INCISIONS
The Primary Incision
Essential Requirements for a Self-Sealing Corneal Incision
Position of the Clear Cornea Tunnel Incision
Reservations About the Clear Corneal Incision
Advantages to the Temporal Approach
Importance of the Length of the Tunnel
Placing and Making the Primary Incision
Surgeon's Position
Controversy Over the Strength and Safety of the Wound
Closing a Leaking Wound Without Sutures
THE ANCILLARY INCISION
ANTERIOR CAPSULORHEXIS
Key Role
Technique for Performing a First Class CCC
Size of the Capsulorhexis
STAINING THE ANTERIOR CAPSULE IN WHITE CATARACTS
HYDRODISSECTION - HYDRODELAMINATION
Technique of Hydrodissection
Hydrodelamination
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MANAGEMENT OF THE NUCLEUS
176
Concepts Fundamental to All Techniques
The Essential Principles
THE ENDOCAPSULAR TECHNIQUES
THE HIGH ULTRASOUND ENERGY AND LOW VACUUM GROUP
THE GROOVING AND CRACKING METHODS
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XIII
The Divide and Conquer Four Quadrant Nucleofractis Technique

Principles of the Divide and Conquer Techniques
The Role of D & C Techniques in Cataracts of
Different Nucleus Consistency
Present Role of Original Four Quadrant Divide and Conquer
THE LOW ULTRASOUND ENERGY AND HIGH VACUUM GROUP
THE CHOPPING TECHNIQUES
Main Instruments Used
Surgical Principles of the Original Phaco Chop
Chopping Techniques Presented in this Volume
THE STOP AND CHOP TECHNIQUE
Surgical Principles
Absolute Requirements to Perform the Stop and Chop
Importance of the Phaco Chopper
Highlights of the Stop and Chop Technique
FUNDAMENTAL DIFFERENCES BETWEEN CHOPPING
AND DIVIDE AND CONQUER (D & C) TECHNIQUES
THE CRATER PROCEDURES
The Crater Divide and Conquer (Mackool)
The Crater Phaco Chop for Dense, Hard Nuclei
THE NUCLEAR PRE-SLICE OR NULL PHACO CHOP
TECHNIQUE
Disassembling the Nucleus
How Is the Null-Phaco Chop Done
Potential Complications
Contributions of this Technique
THE CHOO-CHOO CHOP AND FLIP
PHACOEMULSIFICATION TECHNIQUE
Origin of the Name Choo-Choo
Comparison With Other Techniques
Fine's Parameters
THE TRANSITION TO CHOPPING TECHNIQUES
REMOVAL OF RESIDUAL CORTEX AND EPINUCLEUS
INTRAOCULAR LENS IMPLANTATION
The Increased Interest in Foldable IOL's
The Most Frequently Used IOL's
MONOFOCAL FOLDABLE LENSES
THE FOLDABLE ACRYLIC IOL'S
THE FOLDABLE MONOFOCAL SILICONE IOL's
OTHER MONOFOCAL LENSES
The Hydrogel, Foldable Monofocal IOL
The Foldable Toric Lens
Bitoric Lens But Not Foldable
THE FOLDABLE MULTIFOCAL IOL
The Array Multifocal Silicone Lens
How Does the Array Foldable Multifocal Lens Work?
Quality of Vision with Array Multifocal
Patient Selection and Results
XIV
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Specific Guidelines for Implanting the Array Lens

Special Circumstances for Array Implantation
Need for Spectacle Wear PostOp
Halos at Night and Glare
SURGICAL PRINCIPLES AND GUIDELINES FOR
IOL IMPLANTATION
PREFERRED METHODS OF IOL IMPLANTATION
Use of Forceps vs Injectors
Advantages and Disadvantages
New Trends for Folding and Insertion of IOL's
Guidelines for Insertion of Different Types of Lenses
Surgical Technique with Array Lens
Carreo's Technique of Acrylic IOL Implantation
Through a 2.75 mm Incision
Dodick's AcrySof's Implantation Technique
Implantation Technique for Silicone Foldable IOL's
Using Cartridge-Injector System
TESTING THE WOUND FOR LEAKAGE
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CHAPTER 10
FOCUSING PHACO TECHNIQUES ON THE
HARDNESS OF THE NUCLEUS
MULTIPLICITY OF TECHNIQUES
The Essential Criteria for Success
DIFFERENT NUCLEUS CONSISTENCY TECHNIQUES OF CHOICE
Representative Experts
LINDSTROM'S PROCEDURES OF CHOICE
Advantages of the Supracapsular
Disadvantages of the Supracapsular
Contraindications of Supracapsular
HIGHLIGHTS OF THE SUPRACAPSULAR
IRIS PLANE TECHNIQUE
CENTURION'S TECHNIQUES RELATED
TO NUCLEUS CONSISTENCY
CARREO'S NUCLEAR EMULSIFICATION TECHNIQUE
OF CHOICE (PHACO SUB 3)
Adjusting the Equipment Parameters to Remove Cataracts
of Various Nuclear Density
Three Sets of Values Programmed Into Memory
Technique of Choice and Consistency of Cataract
NISHI'S TECHNIQUES OF CHOICE FOR
NUCLEI OF DIFFERENT CONSISTENCIES
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XV
CHAPTER 11
COMPLICATIONS OF PHACOEMULSIFICATION
INTRAOPERATIVE COMPLICATIONS
Main Intraoperative Complications
Incidence
Facing the Challenges
COMPLICATIONS WITH THE INCISION
COMPLICATIONS RELATED TO ANTERIOR
CAPSULORHEXIS
COMPLICATIONS WITH HYDRODISSECTION
COMPLICATIONS DURING NUCLEUS REMOVAL
COMPLICATIONS DURING REMOVAL OF THE CORTEX
COMPLICATIONS DURING FOLDABLE IOL's IMPLANTATION
COMPLICATIONS WITH POSTERIOR CAPSULE RUPTURE
Pars Plana Vitrectomy for Dislocated Nucleus
XVI
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POSTOPERATIVE COMPLICATIONS
269-290
MEDICAL
Cystoid Macular Edema
Diabetes and Cystoid Macular Edema
PHOTIC MACULOPATHY
AMINOGLYCOSIDE TOXICITY
POSTERIOR CAPSULE OPACIFICATION
Overview
Role of IOL in PCO
Role of Continuous Curvilinear Capsulorhexis in PCO
Main Factors that Reduce PCO
PERFORMING THE POSTERIOR CAPSULOTOMY
Size of Capsulotomy
Posterior Capsulotomy Laser Procedure
Complications Following Nd:YAG Posterior Capsulotomy
POSTOPERATIVE ASTIGMATISM IN CATARACT PATIENTS
MANAGEMENT
Procedure of Choice
Highlights of AK Procedure
EXPLANTATION OF FOLDABLE IOL'S
RETAINING THE BENEFIT OF THE SMALL INCISION
RETINAL DETACHMENT
POSTOPERATIVE ENDOPHTHALMITIS
INTRAOCULAR LENS DISLOCATION
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CHAPTER 12
CATARACT SURGERY IN COMPLEX CASES
Aims of this Chapter
Broadening of Indications
Complex Cases Already Discussed in Previous Chapters
FOCUSING ON THE MAIN COMPLEX CASES
THE DIFFERENT TYPES OF VISCOELASTICS
Their Specific Roles
Cohesive and Dispersive Viscoelastics
The Cohesive VES - Specific Properties
The Dispersive VES- Specific Properties
PHACOEMULSIFICATION AFTER PREVIOUS
REFRACTIVE SURGERY
PHACOEMULSIFICATION IN HIGH MYOPIA
CHALLENGES OF PHACOEMULSIFICATION IN HYPEROPIA
REFRACTIVE CATARACT SURGERY
Why and When Do Refractive Cataract Surgery
TECHNIQUE FOR REFRACTIVE CATARACT SURGERY
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CATARACT AND GLAUCOMA
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Overview - Alternative Approaches

COMBINED CATARACT SURGERY AND
TRABECULECTOMY
Indications
Evolution of the Incision for Combined Cataract Extraction
and Trabeculectomy
A. Extracapsular Cataract Extraction with Trabeculectomy
B. Phacoemulsification with Trabeculectomy
Intraocular Lens Implants
Preoperative Preparation
SURGICAL TECHNIQUES STEP BY STEP
ECCE and Trabeculectomy With Single, Unbroken Tunnel Incision
Phacoemulsification With Trabeculectomy
Antimetabolites in Combined Procedures
Results of Combined Cataract Surgery and Trabeculectomy
PHACOEMULSIFICATION IN DISEASED CORNEAS
PHACOEMULSIFICATION AND IOL IMPLANTATION
IN THE PRESENCE OF OPAQUE CORNEA
Overview
Padilhas Timing and Technique
Specific Recommendations
PHACOEMULSIFICATION, IOL IMPLANTATION
AND FUCHS DYSTROPHY
Preoperative Evaluation
Special Precautions During Phacoemulsification
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XVII
PHACOEMULSIFICATION IN SMALL PUPILS

Pharmacological Mydriasis
Mechanical Dilatation with Viscoelastics
Mechanical Strategies
TRAUMATIC CATARACTS
Overview
Assessment of the Injured Eye
Highlights of Examination
Diagnostic Imaging
Combined Injuries of Anterior and Posterior Segment
Traumatic Cataracts in the Presence of Anterior
Segment Penetrating Wounds
MANAGEMENT OF TRAUMATIC CATARACT
HIGHLIGHTS OF SURGICAL TECHNIQUE
The Incision
Lens Removal
Role of Intracapsular Tension Ring in Traumatic Cataracts
Removal of Cortex
Selection of IOL
IOL Implantation
Selection of Viscoelastic in Traumatic Cataracts
Phacoemulsification Advantages in Traumatic Cataract
PHACOEMULSIFICATION IN SUBLUXATED CATARACTS
Strategic Management
MANAGEMENT DEPENDING ON SIZE OF
ZONULAR DIALYSIS
Special Precautions with Subluxated Cataracts
Increasing the Safety of Posterior Lens Implantation in
Extensive Zonular Disinsertion
Fixation of the Anterior Capsule to the Ciliary Sulcus
CATARACT SURGERY IN CHILDHOOD
Previous Controversies Now Resolved
1) Age and Timing for Surgery
Bilateral Cataracts
Unilateral Cataracts
History
Examination
The Special Case of Lamellar Cataracts
Rubella Cataracts
The Need for Close Monitoring
Preoperative Considerations
The Decision to Implant IOLs in Children with Cataract Surgery
Surgical Technique
The Posterior Approach to Cataract Extraction in Children
CATARACT SURGERY IN UVEITIS
XVIII
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CHAPTER 13
THE PRESENT ROLE OF MANUAL EXTRACAPSULARS
Overview
PERFORMING A FLAWLESS PLANNED EXTRACAPSULAR
CATARACT EXTRACTION (with an 8 mm Incision and
Posterior Chamber IOL Implantation)
General Anesthesia
Local Anesthesia
Technique for Extracapsular Cataract Extraction
with an 8 mm Incision (ECCE)
THE MANUAL, SMALL INCISION EXTRACAPSULARS
THE MINI-NUC TECHNIQUE
SURGICAL TECHNIQUE
Anesthesia, Paracentesis, ACM
Capsulorhexis
Conjunctiva
Sclerocorneal Pocket Primary Incision and Tunnel
Hydrodissection and Nucleus Dislocation
Nucleus Expression Using Glide and High IOP
Epinucleus and Cortex Extraction
IOL Implantation
Pupil Enlarged by Increased IOP
Advantages of the Continuous Flow of BSS
during Manual ECCE
Complications
THE SMALL INCISION PHACO SECTION
MANUAL EXTRACAPSULAR TECHNIQUE
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Overview
Evolution of Technique
Indications
PHACO SECTION MOST IMPORTANT FEATURES
Capsulorhexis
Completing the Tunnel Incision
Anterior Chamber Maintainer
Aspiration of the Anterior Cortex and Epinucleus
Phacosection
Transition from Extracapsular Extraction to Phacosection
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THE SMALL INCISION MANUAL PHACOFRAGMENTATION
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Benefits of (MPF)
Experiences with Other Phaco Fragmentation Techniques
Why Use Gutierrez' Technique?
Surgical Technique
Complications
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XIX
CHAPTER 14
THE NEW CATARACT SURGERY DEVELOPMENTS
Overview
DODICKS PHOTOLYSIS SYSTEM
THE CATAREX SYSTEM
Aziz PhacoTmesis
Water Jet Technology
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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 related to lens removal through small, short,
valve like incisions and implantation of foldable intraocular lenses implanted through these
short incisions.
Tackling the Challenges

In this Volume we present what is best
for our patients and how to tackle the challenges with vigor. We present the new developments in preoperative evaluation, the expansion of the indications as the outcomes
have improved, the new, sometimes complex
problems brought by refractive and
vitreoretinal surgery in calculating IOL power.
And we illustrate the steps that remain rather
constant and which apply either to the surgeon
in the process of transition or the experienced
small incision surgeon, vs the methods that do
change and require the skill of an experienced
surgeon.
We also present the anesthetic methods
of choice, the understanding of the phaco
machine, how it works and what the rationale
is behind its optimal use. How to undergo the
safe and successful transition from planned
extracapsular to phaco. The incisions of
choice for most surgeons, the methods that
enhance the performance of capsulorhexis in
complex cases, the modern techniques of
hydrodissection, hydrodelineation and cortex
removal that have stood the test of time and the
advantages and disadvantages of the different
methods of nucleus removal in phacoemulsification.
Role of Small Incision Manual

Extracapsular
Although we provide special emphasis
on how to master phacoemulsification and
foldable IOL implantation, including an indepth analysis of how to prevent and manage
intraoperative and postoperative complications,
we also present to you the small incision manual
extracapsular techniques of proven and lasting
value. For those surgeons who are prevented
by practical considerations, or who simply
prefer to not take the significant step of entering into small incision surgery, the chapter on
how to perform a flawless planned extracapsular with 8 mm incision and its merits is superbly
as presented by one of the world's master surgeons.
IOL's of Choice
In modern cataract surgery it is essential
to discuss the IOL's of choice and their merits.
Selecting the correct lens implant (size of optic,
chemical material, foldable vs non-foldable,
mono vs multifocal) may play a more important role in the final patient's final visual outcome and satisfaction than the specific technique used for phacoemulsification of the
nucleus.
The Best Phaco Technique

The best phacoemulsification technique to use is based on the relation of the type
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

removal for that specific stage of cataract. The
divide and conquer in four quadrants continues
to be the procedure of choice for the beginner
in the transition period or for the surgeon who
does not have a large volume of cataract surgery. The technique for nucleus removal with
one hand continues to be fundamental for each
phaco surgeon to learn. We will also present
the phaco sub-3, phaco chop, phaco pre-chop,
choo-choo chop and flip and the phaco burst,
all of which are techniques for the more
advanced or experienced surgeons. Each has
its merits, effectiveness and limitations.
The Complex Cases

Small incision cataract surgery has significantly changed the approach and management of the complex cases. It is the most
important contribution made in years to a successful and safe combined glaucoma-cataract
operation, to management of traumatic cataracts and cataract surgery in patients with corneal dystrophies.
Pediatric cataracts have not been resolved
with the improved management options and
almost risk-free capabilities of the magnitude
that we have available in adult patients. This,
in part, may be related to the fact that the
postoperative care depends more on the parents than on the surgeon. The previously
highly controversial point of implanting intraocular lenses in children has shifted to a
positive decision on the part of most surgeons
who now agree to implant IOL's in children
when the selection of cases has been done
prudently.
Let us now proceed to discuss each one
of the highlights of modern cataract surgery.
The field is exciting and a source of great
satisfaction to the surgeon who does it well and
with full dedication to the benefit of his or her
patients.
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
of Different Cataracts
Understanding the three-dimensionality
and concentric anatomy of the lens as originally conceived by Henry Clayman, M.D. for
HIGHLIGHTS is fundamental for having a
clear picture of some of the main steps in
performing phaco. I refer to the dissection of
the different structures of the nucleus with
fluid, that is, hydrodissection of the anterior
and posterior capsule from the cortex, separation of the nucleus and epinucleus with fluid
and the different tissue reactions to the forces
presented during phacoemulsification of the
nucleus.
The normal crystalline lens is an avascular structure. As pointed out by Howard
Gimbel, M.D., lens fibers are surrounded by
the lens capsule which is the basement membrane of the lens epithelial cells (Fig. 1). Lens
epithelial cells are located just inside the capsule and exist as a single layer. The epithelial
cells can differentiate into lens fibers, and this
process occurs in an area just posterior to the
lens equator. As new lens fibers are formed, the
central fibers are compacted, forming the
nucleus of the lens. The surrounding densely
packed fibers form the cortex (Fig. 1). Due to
the anatomical arrangement of cells and fibers,
the Y sutures are formed within the lens
nucleus.
For a surgeon not experienced in small
incision extracapsular techniques, there may
be difficulties recognizing the hidden anatomy
of the morbid cataract. It may be difficult to
distinguish what is really anterior capsule, what

is cortex and where the posterior capsule is.
When removing the cortex, we must keep
in mind that its substance is three dimensional
(Fig. 1). As described in this figure, the nucleus
is the pit of the avocado. 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. Figure 1 also shows that the cortex (C)
adheres to the epinucleus and the nucleus. In
order to remove the nucleus by whatever technique you prefer, these nuclear-cortical adhesions have to be broken and out comes the
nucleus, whether by phacoemulsification or by
planned extracapsular.
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. 1). When aspirating the
cortex, it is prudent not to attack the cortex right
on but to get a free edge, which you may attract
to the aspiration port, and peel from its capsule
support.
In Fig. 1 you may see a conceptual cross
section of the anterior globe, with all the structures of the human lens involved in the maneuvers hereby described. 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). 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
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. AP). 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.
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

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
Anatomical Characteristics of
Different Types of Cataract
The lens in cross section is made up of a
concentric series of elliptical rings. Each one
of these rings represents growth of the lens and
the laying down of additional lens material
from the epithelial cells located on the underside of the anterior capsule. In soft to medium
density cataracts, the concentric lamellae of
cataract tissue are not densely packed, so much
of the space inside the cataract is taken up by
moisture. Medium to firm-density cataracts

have concentric lamellae of tissue that are
densely packed together, packed so tight that
there is no room for moisture between lamellae.
How Cataracts Respond Differently

Paul Koch, M.D. emphasizes that each
one of these different types of cataracts responds differently, so surgical forces need to
be applied differently. In breaking the nucleus
the surgeon needs to individualize the operation to take advantage of the natural tendencies
of each type of cataract. Soft to medium
density cataracts are malleable and compliant. We can hold them in the capsular bag and
squeeze them from between neighboring pieces.
Medium to firm density cataracts are more
like rocks. They have rigid form and are much
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 phacoemulsification in the transitional stage or by
surgeons inexperienced in phaco. Difficulties during surgery may arise that can
be characteristic in this type of cataract
such as difficulty in identifying the
capsulorhexis or with the hydrodissection.
rub them against the capsule, the capsule can

break. If we pull them up into the anterior
chamber, the capsulotomy may split. If they
touch the corneal endothelium, they abrade it.
Understanding this surgical anatomy of
the lens and its clinical applications helps significantly in recognizing that each type of cataract acts differently and that our approach
should vary depending on the individual patient (Fig. 2).
INCIDENCE AND
PATHOGENESIS
It is widely known that cataracts constitute the major source of curable blindness worldwide. Not only do they seriously affect large
segments of the population in developing or
less economically fortunate regions but also
the peri-urban areas of large and developed
cities which are equipped with highly trained
ophthalmologists and the latest technology.
For psychological or social reasons difficult to
understand, many blind or almost blind persons living in these peri-urban "belts" do not
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 becomes sometimes very difficult to treat by
phaco, even in skillful hands. Many patients
allow their cataracts to become this much advanced 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 portion of the crystalline lens which, if within the
to cataract formation.
8
BIBLIOGRAPHY
Assia, EI., Legler, UFC., Apple, DJ.: The capsular
bag after short and long term fixation of intraocular
lenses. Ophthalmology, 1995; 102:1151-7.
Boyd, BF.: Cataract/IOL Surgery. World Atlas
Series of Ophthalmic Surgery, published by
HIGHLIGHTS, Vol. II, 1996; 5:5-13.
Series of Ophthalmic Surgery, published by
HIGHLIGHTS,Vol. II, 1996; 5:34-38.
Boyd, BF.: New developments for small incision
cataract surgery. Highlights of Ophthalm. Journal, Volume 27, N 4, 1999;45-46.
Gimbel, HV., Anderson Penno, EE: Cataracts:
Pathogenesis and treatment. Canadian Journal of
Clinical Medicine, September 1998.
Koch, PS.: Simplifying Phacoemulsification, 5th
ed., published by Slack; 1997; 7:85-86.
Lens and Cataract, Basic and Clinical Science
Course, Section 11. American Academy of Ophthalmology, 1998-99.
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
To date there is no established medical
treatment for the prevention or treatment of
cataract formation and thus the treatment of
cataracts remains surgical. Contrary to the
commonly held belief that cataracts must reach
a certain degree of density or become "ripe"
prior to considering cataract surgery, today the
crystalline lens can be removed at virtually any
stage. In fact, refractive lensectomy in which
the clear crystalline lens is removed may be
used to surgically eliminate or significantly
reduce the need for glasses in patients with
very high myopia or hyperopia. In the latter
condition, this may be achieved by implanting
several piggyback lenses within the capsular
bag following clear lensectomy.
Role of Quality of Life

Cataract/IOL surgery improves quality
of life better than any other medical procedure
known to mankind. Cataract surgery is indicated when the patient's quality of life is being
affected by visual impairment, when there is a
diminution in vision if the patient is exposed to
light or at night, and when the preoperative
evaluation indicates that the potential for restoration of sight is good. How much a patient's
quality of life is impaired from a cataract is
relative, varying with the patient's occupation
and age. The key factor is not to wait until a
nuclear cataract becomes hard. With time, the
lens fiber density becomes a hard nuclear
brunescent cataract (Fig. 2) . With most modern phacoemulsification techniques it may be-
come increasingly difficult to perform surgery

if the lens becomes extremely dense or
brunescent.
Waiting too long may require that the
surgeon operate on dense nuclear cataracts,
which increases the risk of posterior capsule
tears, whether we perform planned extracapsular or a phacoemulsification. This complication may lead to other rather serious problems
such as dislocated nucleus, retinal detachment,
macular edema, bullous keratopathy and inflammation.
The Role of Visual Acuity

There are very few strict criteria for recommending cataract surgery. In the United
States, however, many professional review
organizations have indicated that the reduction
of Snellen distance acuity to 20/40 or worse as
a result of cataract is sufficient indication in
and of itself for cataract surgery. This is
generally the minimum standard for driving. In
some of the advanced, developed countries,
being unable to obtain a driver's license may
seriously affect a person's life because he/she
may be disqualified to drive to the market or
shop to purchase food and other materials essential to daily existence. However, in many
cases surgery may be indicated without reduction of visual acuity to the level of 20/40 if the
patient has difficulty performing activities of
daily living. Because patients have varying
occupational and recreational needs, some patients may need cataract surgery prior to having
their vision reduced to 20/40 by standard tests.
In addition, near vision in some cases may be
11
compromised more than distance acuity particularly in the case of central posterior subcapsular cataracts. The trend toward early removal of cataract offers the advantage of
operating on a younger age group, many of
whom are still productive members of society.
Their need for early return to their usual lifestyle is extremely important. The older population, often living alone, also benefits from
early visual recovery. These high expectations
and needs require that the ophthalmic surgeon
perform superior surgery to obtain excellent
postoperative visual acuity and early visual
rehabilitation.
As emphasized by Gimbel, symptoms of
cataracts include complaints of a yellowing of
vision, glare, halos, decreased night vision, and
generally blurred vision in adults. Nuclear
sclerosis which is a typical form of age-related
cataracts may also induce a myopic shift and
patients may give a history of having changed
their glasses several times within a short period
of time. In children cataracts may present as
leukocoria and may result in strabismus and/or
amblyopia if not treated promptly.
Contrast Sensitivity and Glare

Disability
In evaluating a patient with cataract and
in the process of deciding when that person
requires cataract/IOL surgery, it is fundamental to keep always in mind that standard Snellen
acuity measurements do not give any information with regard to symptoms of disabling
glare. As a matter of fact, very good visual
acuity with the Snellen chart in the physician's
examining room may lead the ophthalmologist
to making the wrong decision and recommendations unless he or she takes other factors into
consideration. In later years, we have become
12
increasingly aware that diminished contrast

sensitivity which interferes with sharp vision
under different color backgrounds or target
luminance, is an essential element of sight and
a highly limiting factor in the presence of
cataract. This is perceived by the patient for
example when he or she is unable to read a
computer screen at the airport if the background is light blue and the print is light yellow
even though visual acuity in the physician's
refracting lane was 20/30 or 20/25. The same
for disabling glare.
These are two additional very important
issues in determining when the cataract should
be removed. For many years this judgment has
been based on Snellen visual acuity. But a
patient can score quite well on Snellen acuity
while suffering in real life. Posterior subcapsular cataracts are notorious for interfering
with reading, even when distance vision is
good, and may induce a great deal of glare.
Snellen acuity may be 20/20 or 20/25, but
against oncoming headlights while driving at
night, for instance, the glare may diminish the
functional vision to 20/100 or even 20/200.
People with nuclear sclerosis, the most common form of cataract, tend to be bothered by
decreased contrast sensitivity rather than glare.
Although glare disability and contrast
sensitivity are distinctly different, the terms
often are erroneously interchanged. The testing characteristics of each, however, may overlap, and a reduction in one function often leads
to a diminution in the other, further adding to
the confusion of their differences. As clarified
by Samuel Masket, M.D., glare disability is
a light-induced visual symptom. Contrast
sensitivity testing is a means of vision analysis,
analogous to a markedly expanded form of
Snellen acuity evaluation at varied amounts of
target luminance.
Contrast Sensitivity
Characteristics
Like audiometry, which measures the
sensitivity of the hearing apparatus to stimuli at
different audio frequencies, contrast sensitivity analysis determines the ability of the visual
system to perceive objects of differing contrasts as well as sizes.
A patient who has a reduction in contrast

sensitivity might perceive the small, highly
contrasted targets on a Snellen test line but be
incapable of identifying larger objects at reduced contrast. There are alterations in the
visual system that can cause visual loss that are
not detected by the determination of Snellen
visual acuity but may be evaluated by testing of
contrast sensitivity function. This is unlike
Figure 3 B (below right): Contrast Sensitivity

Recording Chart
The contrast sensitivity recording chart provides four (4) rows of wave gratings. At the recommended 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 contrast sensitivity curve. The functional acuity is determined 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 patients can be established as a functional acuity score
using contrast sensitivity and glare testing.
13
disabling glare, which determines the effect of

extraneous light on visual performance. Contrast sensitivity evaluation is a measurement
of the resolving power of the eye at varied
contrasts between image and background
(Fig. 3 A-B).
A number of useful contrast and glare
sensitivity testing methods have been devised
(Fig. 3 A-B). They are accessible and inexpensive. Unfortunately, standardization of these
techniques has not yet been achieved. It is
essential that the clinician be fully aware of
these two factors that may impinge on the
patient's real vision or quality of vision, in
addition to the Snellen acuity test.
Relation of Glare to Type of

Cataract
Neumann et al. have determined that
nuclear cataract is more likely to be associated with nighttime glare disability, while cortical cataract formation is associated with
daylight glare, and posterior subcapsular cataracts may induce glare disability associated
with bright, direct sunlight or bright central
light sources. Cortical cataracts seem more
likely to cause glare symptoms than nuclear
cataracts. Masket points out that frequently,
patients with dense central posterior subcapsular cataracts frequently retain excellent distance Snellen acuity as measured in the refracting lane, yet they perform poorly on any of the
available glare testing devices. Such patients
14
may have severely lower visual function during daylight driving although they do well with
the Snellen acuity chart. In essence, the Snellen
chart evaluates quantity of vision. Contrast
sensitivity tests evaluate quantity and quality
of vision. The equipment to perform the test is
accessible and inexpensive. It is basically a
chart about 0.3 meters in size and it costs about
US$200.00
In addition to determining visual acuity
by the Snellen chart, contrast sensitivity and
glare disability testing as outllined, all patients
with cataracts should have a thorough history
taken including any systemic or ocular medications being used and any systemic disease for
which they receive treatment. A family history
is also included. The ophthalmologic examination should include intraocular pressure
(IOP) measurements, keratometry, pupil exam,
routine motility testing, and dilated slit-lamp
and funduscopic examinations including indirect ophthalmoscopy to examine the central
and peripheral retina. Ancillary testing such as
visual fields, topography, specular microscopy
for endothelial cell counts, and fluorescein
angiography should be considered in selected
cases. There are many causes for decreased
vision and ,especially in older patients, these
causes may exist concurrently. Age-related
macular degeneration is possibly the most important and difficult to detect because of the
existing opacity of the cataract.
Evaluation of Macular Function

The main preoperative tests to determine
central visual acuity are: 1) the Potential
Visual Acuity Meter (PAM) and 2) the Super
Pinhole. They permit evaluation of the macular function in patients in whom examination
of the macula is difficult due to media opacities. They are more useful when they are
integrated into the total evaluation of the patient.
One of the major problems that all of us
confront as clinical ophthalmologists is that of
patients with cataracts who correct to 20/100 or
20/200 and on whom we are planning to
operate but cannot see the fundus, particularly
the macula. This is aggravated when the patient has a few old small corneal opacities. The
ever-present question is: what is the visual
prognosis if we operate, either by a cataract
extraction or combined with a corneal transplant? What can we anticipate for the patient or
his/her family about future, postoperative vision even if we do not have any significant
operative or postoperative complications? Ultrasonography and clinical tests will give us
only a partial and limited answer.
Since we cannot see the state of the
macula or papilla, we are limited as to the
prognosis. Sometimes we have the pleasant
surprise of obtaining more vision postoperatively than we predicted; in other cases, we face
the unpleasant reality of finding macular degeneration or other lesions in the macula or
optic nerve that result in poor central vision in
spite of a beautifully performed operation.
Any well trained ophthalmologist can

diagnose major lesions of the optic nerve or
retina preoperatively. The major problem is
with the subtle lesions that nevertheless limit
the patient's capacity to read or distinguish
clear images at distance postoperatively.
One of the most important tests for
evaluating macular function in the presence of
a lens opacity dense enough to make our clinical examination of the macula unreliable is the
Guyton-Minkowski Potential Visual Acuity
Meter (PAM).
The Super Pinhole developed by David
McIntyre, M.D., is another highly practical
and useful method to evaluate macular function. The Laser Interference-Fringe Method
has also been previoulsy used but it is less
practical. Most clinical ophthalmologists prefer the PAM test or the Super Pinhole.
The PAM
The Potential Acuity Meter (PAM) is an
instrument which attaches to a slit lamp. It
serves as a virtual pinhole by projecting a
regular Snellen visual acuity chart through a
very tiny aerial pinhole aperture about onetenth of a millimeter (0.1 mm) in diameter. The
light carrying the image of the visual acuity
chart narrows to a fine 0.1 mm beam and is
directed through clearer areas in cataracts (or
corneal disease), allowing the patient to read
the visual acuity chart as if the cataract or
corneal disease were not there (Figs. 4 and 5A
and B). The PAM is taken from its stand and
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

tonometer. The examination takes from two to
five minutes per eye, depending on the density
of the cataract.
As pointed out by Guyton, for the PAM
to work adequately, there must be some small
hole in the cataract for the light beam to pass
through. You may find such a hole even in
cataracts which have media clouding of up to
20/200 and better. When you find it, then you
16
can avoid the light scattering produced by the

opacities. It is this light scattering which washes
out the retinal image and decreases vision behind cataracts. By projecting the image of the
visual acuity chart through one tiny area, we
avoid that scattering effect, and the patient can
see the chart (Figs. 6 A-B and 7 A-B).
How is the instrument operated by the
clinician or an assistant? The device is mounted
on a slit lamp so that the operator can see
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 combined cataract extraction and penetrating
keratoplasty.
17
exactly where the light beam is passing. The

light beam is directed to various parts of the
pupil (Fig. 4, 6-A, 6-B, 7-A, 7-B). It can be
focused in between lens opacities. It is easy to
see when the beam is going in because it
practically disappears (Fig. 6-B). When it hits
an opacity, you can see the opacity light up
(Fig. 6-7). When you move the beam with the
slit lamp control to lucent, non-opaque areas,
you see the beam pierce through (Figs. 6-B and
7-B). It is valuable to observe this because if
you know you are getting the beam through
and the patient still reads poorly, you can be
fairly confident that there will be a poor
result after surgery. If you are not sure
whether the beam is penetrating and the patient
reads poorly, results of surgery will be uncertain. So, the slit lamp monitoring of the light
beam is important.
It is sometimes difficult to find a small

hole in a cataract with density greater then
20/200, although holes have been found in
counting-fingers cataracts. If you obtain good
vision behind any cataract, you have the information you need. As to the visual prognosis
behind very dense cataracts, if you cannot
obtain a good reading, you still do not know
quite where you are.
The instrument is best operated in a darkened room because it is easier to see the light
beam. The best results are obtained with a
dilated pupil because you have a better chance
of finding an appropriate hole in the cataract.
Ninety percent of patients whose best correctable vision is 20/200 and better preoperatively,
achieve the predicted vision or within two lines
Figure 6-A: How the PAM

Works - Slit Lamp View
In Fig. 6-A the ophthalmologist 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 (arrow) is successfully penetrating the
lens at a point where no lens opacities are present, and the beam disappears 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 respond accordingly so that the examiner can determine the potential
visual acuity irrespective of the lenticular opacities.
than the predicted vision after surgery. When

the preoperative visual acuity is worse than 20/
200, only about 60% achieve vision within
three lines of the vision predicted by the PAM.
The vision obtained after surgery is
generally equal to, or better than the vision
predicted with the Potential Acuity Meter. False
positives occur in 10-15% of cases. When the
test is done in cases of cystoid macular edema,
the instrument occasionally indicates better
potential vision than the patient can achieve

with best refractive correction postoperatively.
No single test of visual function, however, is sufficient to mandate surgery. Instead,
it is the visual needs of the patient in combination with careful estimation of the potential for
the return of visual function after surgery that
finally serves as the basis for the ophthalmologist to decide whether surgery is indicated and
useful.
19
Figure 7 A: How the PAM Works Cross Section View

Figures 7 A and 7 B demonstrate in cross-section the views shown
in Figs. 6 A-B. In (A), the light beam
(arrow) can be seen striking a lens opacity (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
WITH RETINAL DISEASE
The Importance of Pre-Op Fundus
Exam
Thorough peripheral retinal examination
should be done before cataract extraction. We
are all proud to be first class clinical ophthalmologists and not think of cataract surgery
only as a mechanical, technical procedure. As
patients live longer, they are apt to have more
preoperative diseases sometimes difficult to
diagnose unless we are on the alert for them.
Because the patient with an even moderate
degree of cataract has reduced clarity of vision,
it is easily possible that recent abnormalities
may not have been observed or reported by the
patient. This is particularly the case with
retinal diseases.
CATARACT SURGERY IN
DIABETIC PATIENTS
Because of the increasing importance
of diabetic retinopathy, both in incidence and
severity, we provide special emphasis to this
disease in considering cataract surgery in complex cases. Cataract and retinovascular complications often co-exist in diabetic patients.
The combination can present problems in determining the cause of decreased vision. Cataract surgery can also result in rapid progression of diabetic retinopathy that may
need treatment with photocoagulation
(Figs. 8 and 9)..
Diabetic patients are very predisposed to

developing cataracts. This is especially true of
younger diabetic patients, who are also highly
predisposed to developing diabetic retinopathy
(diabetes Type I). In a series of diabetic retinopathy and maculopathy patients 15 years
after laser treatment, only 22% of the eyes
maintained clear lenses (Figs. 10 and 11).
Cataracts will often form following vitrectomy
surgery for diabetic retinopathy.
Rarely retinopathy can cause cataracts.
An example would be prolonged vitreous
cavity hemorrhage that results in a partial
opacification of the lens. (Very high risk proliferative diabetic retinopathy - Fig. 12)
Evaluating Diabetics Prior to

Cataract Surgery
Clinically significant macular edema
(CSME) and less obvious macular changes in
non-proliferative retinopathy may be the cause
of decreased vision in addition to the cataract
(Fig. 13).
It is important to listen to the patient's
history when evaluating the cause of visual
deterioration. This can be helpful in deciding
how much of the visual loss may be due to
cataract as opposed to visual damage caused by
retinovascular conditions.
A good fundus examination through a
dilated pupil is essential. In diabetic patients as
in all patients, cataract should be removed
when a patient's visual function does not meet
his/her visual needs and the visual loss is consistent with the cataract. It is very rare that
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 Photocoagulation", Italian Edition by Brancato, Coscas and Lumbroso, published by SIFI).
22
Figure 10 (above right): Focal Photocoagulation for Diabetic Maculopathy

Previous to Cataract Surgery
The laser applications are directed 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

of the diabetic retinopathy can be performed.
Occasionally, cataracts need to be removed
when performing vitrectomy.
It is important that we consider various
diabetic factors in planning cataract surgery
because the retinopathy can influence the
result. We may see increased bleeding and
fibrin formation, especially in the younger patients with active retinopathy and compromised
retinal perfusion.
Importance of Maintaining the

Integrity of the Lens Capsule
Cataract surgery may not only result in
rapid progression of diabetic retinopathy, but
it may also complicate its management and
treatment. Rapid deterioration often occurs
when the lens capsule and zonular integrity

are sacrificed by the cataract surgery such
as with rupture of the posterior capsule.
Retained lens material may produce increased
inflammation, which may further accelerate
this process. While it is important to maintain
an intact posterior lens capsule, it is equally
important to have an easily dilatable pupil and
a clear capsule to allow a good fundus view
through which laser treatment can be performed.
Significant Increase in Complications

Following Cataract Surgery
The progression of retinopathy following cataract surgery may take several forms.
We may see a patient with non-proliferative
retinopathy rapidly develop macular edema
(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 retinopathy. (A) Shows a fundus view of a severe case
of proliferative diabetic retinopathy. There are
preretinal hemorrhages (H) in several locations. 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 macular 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 active 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 macular 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 ophthalmoscopic fundus view above. In (C), there is
pooling of fluid (D) within the inner layers of the
retina. This fluid is trapped between the ganglion 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 cystic. Rafael Cortez, M.D., has observed that
diabetic patients with proliferative retinopathy
(Fig. 12), or non-proliferative retinopathy
(Fig. 13) or even without retinopathy, have a
higher risk of developing a vitreous hemorrhage, rubeosis of the iris and neovascular
glaucoma postoperatively. This risk is particularly high in those patients with proliferative
retinopathy (Fig. 12).
Appropriate Laser Treatment

Most diabetic retinopathy complications
can be prevented by appropriate laser treatment before cataract surgery. Eyes with nonproliferative retinopathy that have clinically
significant macular edema (Figs. 13 and 14)

should receive focal or grid laser treatment
(Figs. 10, 11 and 14) to seal the leakage which
is detectable through fluorescein angiography.
Eyes with severe, non-proliferative (pre-proliferative) diabetic retinopathy (Fig. 15) and
proliferative retinopathy (Fig. 16) should
receive panretinal laser photocoagulation
(Fig. 17) before cataract surgery. This treatment will reduce additional proliferation and
deterioration.
Even with a cataract, laser treatment can
usually be performed with good pupillary dilatation. Krypton red wavelengths are often
successful in penetrating somewhat dense
nuclear sclerotic lenses (Fig. 14). Retrobulbar
anesthesia may be necessary.
25
Figure 14 (above right): Prevention of Diabetic 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-proliferative 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 wavelengths are often successful in penetrating fairly
dense nuclear sclerotic lenses. Laser treatment
must be performed with good pupillary dilatation.
Figure 15 (center): Severe Non-Proliferative Diabetic Retinopathy (Pre-Proliferative).

This photo shows a characteristic severe, nonproliferative 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 KongChan 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 Photocoagulation Before Cataract Surgery

In treating diabetic retinopathy, panretinal photocoagulation 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

Co-existing Diabetic Retinopathy and
Cataract
The first and most successful is to defer
the cataract surgery until laser treatment can be
performed. If there is extensive vitreous hemorrhage or traction retinal detachment, you
may need to combine the cataract removal with

a vitrectomy (Fig. 18).
Intraocular lenses do not present a problem when a patient is going to have a vitrectomy. The visual results of pseudophakic eyes
with diabetic retinopathy complications that
have vitrectomy surgery are essentially identical 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
28
CATARACT SURGERY AND

AGE-RELATED MACULAR
DEGENERATION
RETINAL BREAKS AND RETINAL DEGENERATIONS PRIOR TO CATARACT

SURGERY
Felix Sabates, M.D., has best outlined

the precautions we must take when considering
extracapsular extraction or phacoemulsification in eyes with already present age-related
macular degeneration already present. These
principles are: 1) It is important to study the
macular area in detail prior to cataract surgery
to detect the presence of age-related macular
degeneration. 2) If cataract surgery is performed in the presence of age-related macular
degeneration, special care should be taken to
reduce the possibility of inflammation even
if it would require immediate use of antiinflammatory drugs. 3) Cystoid macular edema
should be aggressively treated, with careful
follow-up emphasized. 4) Cataract surgery
should not be performed on the patient with
active "wet" macular degeneration (Fig. 19)
until it has been brought to a dry stage (Fig. 20).
If there is bleeding from a neovascular membrane, cataract surgery should be postponed
until at least six (6) months after the blood has
completely reabsorbed and there has been
no recurrence of the bleeding has been present.
5) In patients with macular scars (Fig. 20) and
opaque cataracts, surgical removal of the opacified lens with intraocular lens implantation
may be of benefit in recovering some degree of
pericentral or peripheral vision. The smaller
the macular scar, the better the prognosis. No
cataract surgery should be performed unless
the cataract is opaque enough so that when it is
removed, the patient will probably perceive the
benefit of the operation.
The preoperative treatment of these retinal lesions has traditionally come into consideration as a possible means of preventing retinal detachments after cataract extraction, especially in myopes. I refer only to those peripheral retinal degenerations which can be clinically defined and identified, and which have
statistically been linked with retinal detachment following posterior vitreous detachments.
This, therefore, excludes senile retinoschisis,
which has a higher prevalence in the general
population than among patients with a retinal
detachment. What needs to be clarified is the
effect of cataract surgery on the risk retinal
breaks and degenerations present and what
recommendations should be given in regard to
their management prior to cataract surgery.
This requires therapeutic proof that prophylactic treatment significantly lowers this risk below that which the natural course of untreated
lesions would present. There is an increasing
tendency to support the concept that retinal
detachments generally are associated with recent, not old, retinal breaks. At the present time
the picture is not clear. We lack solid reports
supporting the prophylactic treatment of preexisting retinal breaks prior to cataract surgery.
What happens to an eye with lattice degeneration when cataract extraction is performed? Again, we face a lack of valid reports
in the literature to support preventive treatment
prior to cataract surgery. About 90% of eyes
with lattice degeneration do not detach after
small incision cataract extraction even when
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.

Those that do develop a retinal detachment
frequently do not detach from retinal breaks
adjacent to or within the lattice lesions, but
from unrelated areas which previously looked
clinically normal. This has now been observed
by numerous investigators.
Sabates thinks that each case must be
individualized. If a patient has a history of
retinal detachment in one eye and lattice
degeneration with retinal holes in the other eye,
he performs cryosurgery or laser surgery and
closes those holes in the second eye. Usually
cryosurgery is required because the cataract
may preclude the use of laser. The type of tear

present and other factors including the location
of the tear and the existence of high myopia
would influence the ophthalmologist's judgment in deciding when to treat. Fig. 21 shows
the typical retinal tear that he treats, sealed
with cryotherapy.
Since seven to eight percent of the population has lattice degeneration, it is obvious that
not all patients with lattice degeneration should
be treated. Regardless of whether the patient is
treated prior to cataract surgery, those patients
should be followed closely with careful examination of the peripheral retina postoperatively
following cataract removal.
Figure 21: Creating the Chorioretinal Adhesion 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. considers that uveitis is one of the last categories
for which surgeons have advised dont do it
when cataract surgery is considered. Cataract
surgery has been regarded as contraindicated
because of the initial bad results with intraocular lenses (IOLs) in patients with uveitis. Until about 10 years ago, most surgeons
avoided cataract surgery with or without IOL
implantation in these patients.
There was concern about superimposing IOL implantation, with the inflammation which used to accompany it in many
cases, on a seriously compromised and already inflamed eye. This concept has now
changed. The development of current techniques 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 fortunate 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 fundus, denying the ophthalmologist the opportunity to identify macular lesions and
to treat them adequately. When these pa-
Figure 22: Uveitic Cataract

Cataracts caused by an inflammatory uveitic process
generally occur with pigment deposits (P) on the anterior capsule of the lens (C) related to anterior synechiae that can immobilize the pupillary sphincter. The intensive use of topical
steroids for the management of the uveitis can hasten the formation of such cataracts. Cataracts are the major cause of
loss of vision in patients with chronic uveitis. Current techniques for small incision surgery, new types of IOL's and advances in management of uveitis enable their removal where
previously this was contraindicated.
31
tients finally undergo long-postponed surgery, usually with good anatomic success,
central vision may not be recovered because
of irreversible macular damage that had
developed from chronic cystoid macular
edema. Therefore it is critical for both the
surgeon and the patient with uveitis to realize
there is another reason for cataract surgery in
addition to improving vision as much as
possible. Removal of the cataract enables the
the ophthalmologist to examine and treat the
macula in order to forestall damage.
Method of Choice
In theory, removal of the lens as a
whole (intracapsular) could lead to less
inflammation. In fact, careful extracapsular
surgery with adequate cleaning of the lens
material during surgery usually provides a
better outcome. Most surgeons now prefer
phacoemulsification to a classic extracapsular extraction of the cataract even in patients
with uveitis. Belfort believes phacoemulsification leads to faster results and less
inflammation, and he advocates phacoemulsification with or without an IOL.
Intracapsular technique is no longer used
except in some rare cases of lens-induced
uveitis, in which inflammation is caused by
the leakage of protein material from the lens.
Diagnosing the Type of Uveitis in the

Pre-Operative Phase
Belfort emphasizes that in the preoperative phase, it is very important for the
surgeon to determine the exact type of uveitis
the patient has in order to better predict the
surgical outcome and minimize reaction. For
32
instance, patients with ocular sarcoid have a

much worse postoperative course than other
patients. Therefore, a patient with sarcoidosis
and uveitis, even in the absence of important
uveitis, must be approached more carefully
than patients with other types of uveitis.
Other types of uveitis that can be effectively
managed are Fuchs heterochromic cyclitis,
intermediate uveitis, and posterior uveitis as
well as most of the anterior essential uveities.
Behcets disease and other vascular inflammations, which in the past were considered to
have a bad prognosis, have shown much
better results with current techniques.
Preoperative Management
In general, the less inflamed the eye at
the time of surgery, the better the prognosis.
Ideally, every patient should be operated only
after being inflammation-free for at least 3
months, although this is not possible in many
cases. Uveitis is chronic, no matter what dose
of steroids is used, and many patients must be
operated even in the presence of some active
uveitis. The goal is to have the eye as little
inflamed as possible. Preoperative steroids, as
eyedrops or even systemically, as well as
immunosuppressive drugs have to be used in
more severe cases. In patients who do not
respond to steroids alone, Belfort uses systemic oral cyclosporin and oral prednisone
therapy. In 20% of patients the use of an
IOL is not advisable. This includes patients
with granulomatous uveitis such as sarcoid,
Vogt-Koyanagi-Harada syndrome, and sympathetic ophthalmia. Belfort also advises
against using IOLs in patients with juvenile
rheumatoid arthritis, who tend to have a
chronic disease and may develop long-term
complications.
The Intraocular Lens

Currently, IOLs can be used in at least
80% of patients with both uveitis and cataract. Selecting the right type of IOL is very
important. Although PMMA lenses are well
tolerated by the eye with uveitis, they may
lead to more posterior capsule opacification
than other lenses. Belfort recommends not
using silicone in cases of uveitis because
silicone lenses by themselves can cause
uveitis and may aggravate previous intraocular inflammation, especially in heavily pigmented people. Belfort therefore prefers to
use acrylic lenses in these patients. We do
not yet have clinical trials or studies that
establish conclusively the superiority of one
lens material over another. Results appear not
to be better with heparin-coated IOLs than
with PMMA lenses in patients with uveitis.
Considering that heparin-coated lenses are
also more expensive, Belfort does not advocate using them in uveitis.
CATARACT SURGERY IN ADULT
STRABISMUS PATIENTS
Preoperative Judgment
The treatment of co-existing cataract and
strabismus traditionally has been managed with
separate operations. Usually the cataract ex-
traction has been done first, followed later by a

surgical correction of strabismus. As a matter
of fact, we may even hesitate to remove a
cataract in a patient who has had a deviated eye
for a long period for two reasons: First, cataract
removal may result in postoperative diplopia,
and second, it is difficult to predict whether
amblyopia may be present in the deviated eye,
leaving us with a questionable prognosis.
Successful combined cataract and strabismus surgery is highly feasible. The ideal
patient for a combined approach must fill certain prerequisites: one, he or she must have a
congenital strabismus rectifiable by surgery on
a single muscle in each eye. Second, the patient
must have an alternating deviation and equal
fusion potential in each eye, determined either
by knowing the patient's vision before the onset
of the cataracts or by the results of the potential
acuity meter (PAM) that should be about equal
in both eyes (see figures 3 through 7). An equal
potential acuity meter measurement in both
eyes would seem to exclude amblyopia, thereby
improving the chances for an optimal visual
outcome.
During combined cataract and strabismus surgery, if the patient continues to blink or
squeeze the eyelids following the combined
topical and intracameral anesthesia, you can
obtain anesthetic control this a sub-Tenon's
injection of lidocaine as illustrated in Figs. 33
and 34. The effect is almost instantaneous, and
surgery can continue without delay.
33
BIBLIOGRAPHY
Boyd, BF.: Cataract Surgery in Diabetic Patients.
World Atlas Series of Ophthalmic Surgery, published 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, N 1, 1999;2-3.
Charlton, Judie: Cataract surgery and lens implantation. 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., Centurion, 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 Cataract 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
From the minute the patient considers
undergoing surgery, fear is present. There is
fear of the unknown and fear of someone operating on your eye. Jack Dodick, M.D., from
New York, believes in the important influence
of office personnel and environment on making patients confident and comfortable. Dodick
strongly advocates hiring and training highlevel professional staff. When patients interact
with highly competent staff at every encounter,
they tend to conclude that the doctor must be
very good because he has selected and trained
his staff so well. Many doctors pay too little
attention to the impressions staff make on their
patients. They are tempted to cut corners by
hiring clerks at low pay if they fail to realize
that patients impressions of staff are integral
to their impressions of their physician.
In addition, the office environment
should be tasteful. The impression patients
have when they enter the office influences
their feelings about their physician. An office
that is dirty and cluttered reflects poorly on
the practice. Dodick believes that once patients feel respected and comfortable with the
expertise of the physician and his/her staff,
they relax and decide they have come to the
right place.
Patients Encounter with the

Physician
And in the encounter with the physician
patients should feel respected and important.
Even though the waiting room is busy, everything should seem unhurried when the patient is sitting in the chair across from the
physician. The ophthalmologist should convey the impression that, at this time, the
patient is the most important person.
The physicians ability to project a confident manner is also critical to success.
Dodick believes it is an art to convey this
confidence and professionalism to patients. It
is partly done through certain inflections in
the voice; perhaps it is easier to explain in
reverse. Sometimes the doctor who does not
feel totally secure in his ability to produce
results may become a little defensive, and
give more emphasis to potential complications than the real positive benefits of the
operation. Well, you have a cataract. As you
know, you can have it operated on or not, and
there are some complications that sometimes
occur. For example. . . Although potential
complications are in fact true, the chance that
these complications will occur is minimal.
Dodick does not dwell on these rare potential
complications. Instead, he emphasizes the
37
very high probability of positive results when

communicating with patients. He retains a
position of objectivity in order that his own
perspective will not unduly influence the patient. The patient must be informed of potential risks but with modern small incision
cataract surgery, they are very unusual.
Ingredients of a Strong Relationship

The physicians ability to instill confidence and trust in patients, and an ability to
articulately convey his confidence through
the spoken word are the basic ingredients of a
strong relationship between physician and
patient.
A fundamental question is how should
the ophthalmologist approach patients who
measure well on Snellen acuity, but still
complain about their vision because of the
very important factors of contrast sensitivity
and glare we have already discussed. Dodick
follows these basic steps. He first listens to
the patient and tries to make a historical
determination about how happy or incapacitated they are because of their vision. If
patients claim to be very happy with their
vision, Dodick goes no further. He merely
instructs them that they, like everyone over
50, have some lens changes. He explains the
basic anatomy of the human eye (Fig. 1-A),
with its clear windows inside and outside, and
the tendency of the inside window to become
cloudy. The treatment, of course, is to replace
the cloudy window with a clear window and
thereby restore their vision.
In approaching the question of when a
cataract should be removed, Dodick reinforces the concept that in nearly all conditions, cataract surgery is 100% elective. The
time to remove a cataract is the time that
38
patients decide they are unhappy with

their vision. Most people understand this, but
often Dodick hears the question, What
would you do in my position? Dodick
handles this by looking the patient in the eye
and responding: This is a very simple question. If I were very happy with my vision
right now, I would do nothing. If I were
unhappy, I would decide in a minute to have
cataract surgery. Then patients fully realize
that cataract surgery is truly an elective procedure.
Evaluating the Patient's Cataract

Of course, giving patients this choice is
predicated upon the fact that the ophthalmologist has conducted a thorough examination. With slit lamp biomicroscopy posterior
subcapsular cataracts which strongly interfere with vision by inducing a great deal of
glare are very easy to evaluate, whereas
nuclear sclerotic cataracts are often difficult
to evaluate on the slit lamp. People with
posterior subcapsular cataracts can measure
20/20 or 20/25 on Snellen acuity because they
are really looking through the little pinholes
of the posterior subcapsular cages (Fig. 23A-B). The minute they see oncoming headlights while driving at night, for instance, the
glare may diminish their functional vision
to 20/100 or even 20/200. On the other hand,
people with nuclear sclerosis, the most common form of cataract, tend to complain about
contrast sensitivity rather than glare (Fig. 23C-D).
Over the years Dodick has found that a
good way to evaluate lenticular or media
changes is to examine the red reflex of the
patient by holding an ophthalmoscope about
12 to 14 inches from the eye and determining
whether it is a bright red reflex, a gray reflex,
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

indicator of opacity. In some circumstances a
nuclear cataract can be better evaluated with

this technique than with the slit lamp. Dodick
does not rely on tests for contrast sensitivity when evaluating cataracts. Although
conditions of glare can be simulated in a
clinical setting, Dodick relies on the
patients real life test experience instead.
Approaching the Day of

Surgery
Once Dodick and his patient have
reached the mutual understanding that cataract surgery may be beneficial, the patient is
in essence turned over to a series of highly
trained, dedicated, professional staff who
work closely with him. The next person the
patient sees is a highly trained technician. The
technician explains that a measurement is
needed to determine the correct lens to implant into the eye, and they undergo an
ultrasonography scan. When the test is completed, the patient is turned over to the surgical counselor, who has become a master at
making patients comfortable and ready to
approach the day of cataract surgery.
out glasses, by all means do not sacrifice their

near vision just for providing 20/20.
The availability of foldable multifocal
IOL's makes this surgeon-patient understanding even more critical so that the visual
advantages of these lenses need to be fully
appreciated versus the disadvantages which
exist but may be less significant. A similar
situation presents with the alternative of
monovision. If the surgeon contemplates
using this method, which is a good alternative for many patients, it is important to make
sure the patient understands how this works
and be enthusiastic with this alternative. Final visual satisfaction with these methods,
multifocal IOL's and monovision, will depend a great deal on the selection by the
surgeon of the right patient for these alternatives. With multifocal IOL's patients are
happier with bilateral implantation. With
monocular implantation, it is preferable not to
delay surgery in the fellow eye unless there is
a major reason, because most patients feel
very insecure with monocular vision and having only one eye operated.
DETERMINING
IOL
POWER (BIOMETRY)
Patient's Expectations
It is essential to clarify to the patient
what he/she may expect and what not to
expect. Postoperative patient satisfaction is
based on this pre-op surgeon-patient communication and understanding. What are the
patient's daily needs and what final uncorrected visual acuity for distance and near he
would prefer? Does he want to read without
glasses? If so, then he must know he would
not see perfectly clearly for distance. If he/
she are myopes and consequently read with-
40
Ocular biometry must be performed

prior to cataract surgery.
There is no
question that when well selected and properly done the ultrasonic methods afford us
the best way of achieving the desired postoperative refraction. Determination of intraocular lens power through meaningful keratometer readings and axial length measurement
through A-Scan ultrasonography has become a "standard of care". It is a challenging
technique and crucial to the visual result and
patient satisfaction.
Postop Refractive Errors No

Longer Admissible
This is particularly true considering the
high patient's expectations and the minimal
astigmatism created by small incision cataract
surgery, particularly phacoemulsification.
Patients look forward to wearing spectacles
postoperatively only under special circumstances. As emphasized by Centurion and
Zacharias, postoperative refractive errors are
no longer admissible. In small incision techniques, cataract surgery has attained the status
of refractive surgery. Therefore, exact determination of the IOL power to end up with the
specific planned postoperative refraction is
essential. The advent of multifocal foldable
IOL's makes this even more of an important,
though complex subject, as well as operating
on eyes with different axial lengths: normal
(Fig. 24), short as in hyperopia (Fig. 25 A-B),
long as in myopia (Fig. 26).
Figure 24: Determination of IOL Power in

Patients with Normal Axial Length (Normal 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 crystal 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 perpendicularly 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 equipment 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 normal 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

Cases
The use of refractive surgery on the
cornea using a variety of techniques: excimer
(Fig. 27), RK (Fig. 28), Intracorneal Ring
Segments (INTACS - Fig. 29) makes ocular
biometry even more complex. These refractive corneal refractive techniques change the
parameters in these special cases as compared
with those we use for normal eyes and make
these special cases.
Computerized
videokeratography provides additional important data.
The current acceptance of implanting
IOL's in children following pediatric cataract surgery (Fig. 31) and the frequent use
of vitrectomy with the use of silicone oil
(Fig. 32) frequently in Europe and infrequently in the U.S., also add unique and
different difficult challenges, in performing
an exact biometry in every individual
patient's condition. When using ultrasound,
axial length is determined by measurement of
the reflection of the eye tissue interfaces with
the ultrasonic beam (Fig. 24 - arrows). The
A-scan must be carefully calibrated and the
beam velocity must correspond to whether or
not the patient is phakic, pseudophakic, or
aphakic and may need to be modified in the
special cases previously described. The ultrasound probe (T) has a piezoelectric crystal
that electro-mechanically emits and receives
high frequency sound waves. The sound
waves travel through the eye until they are
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 predictability of the refractive target. Probe (P), corneal surface (S).
43
their way (represented by arrows). Assuming

the average velocity of the sound waves in the
eye being measured, and based on the time it
takes for the sound waves to travel back to
the probe (arrows), a distance can be calculated. The ultrasound equipment's computer
can automatically multiply the time by the
velocity of sound to obtain the axial length.
At least three scans should be obtained which
are within 0.15 mm of each other. Gimbel
recommends that the A-scan should be measured twice by independent technicians if the
axial length is unusually short (Fig. 25) (hyperopia) or long (Fig. 26) (myopia) (<22 mm
or >25 mm), or if the difference between the
two eyes is more than 0.3 mm, if the axial
length measurement does not correlate with
the refraction or the patient has difficulty with
keeping the eyes open or with fixation.
The Most Commonly Used Formulas

The most commonly used IOL formula
was developed by Sanders, Retzlaff and Kraff
and is known as the SRK formula, where
p = A - 2.5L - 0.9K. "P" refers to lens implant
power to produce emmetropia, "L" refers to
axial length, "K" refers to average
keratometric readings in diopters and "A" is a
constant that is specific to the lens implant
that is to be used. Several second and third
generation lens power calculation formulas
have been developed including the SRK2 and
SRK/T, Hoffer Q, and the Holladay 2 formulas. Gimbel emphasizes that to avoid errors
in lens power calculations not only must the
biometry be accurate and the correct "A"
44
constant used, but also the estimated anterior

chamber depth (depending on the formula),
preop refraction and age must be taken into
account. Adjustments can also be made for a
specific surgeon's technique.
In the search for continuous refinement
and accuracy of results, new methods based
on laser interferometry may replace ultrasonography in the future.
Main Causes of Errors

Zacharias and Centurion have pointed
out that most postoperative refraction errors
occur not due to errors in the formulas but to
imprecise preoperative measurements. For
each millimeter of error in biometry there is
a -2.5 diopter error in the calculation of the
IOL power. If more than one error occurs in
the same examination there may be significant
postoperative
refractive
errors.
Keratometry in both eyes should be repeated
when:
corneal curvature is less than 40.00 D
or more than 47.00 D;
the difference of the corneal cylinder
is more than 1.00 D between both eyes;
the corneal cylinder correlates poorly
with the refraction cylinder.
During the examination, the patient sits
in front of the skilled technician performing
the ultrasound test. He/she is asked to fixate
at a point straight ahead. The ultrasound soft
probe is positioned axially, touching the corneal epithelium as lightly as possible so as not
to compress and thereby shorten the eye. It is
useful to visualize the procedure laterally to
make sure that the cornea is not being compressed (Fig. 24).
Targeting Post-Op Refraction

This parameter is the only one that the
physician must decide upon by himself and
feed into the computer. All the other parameters are measured or assumed values over
which he has no control. When selecting a lens
implant power Gimbel generally recommends
that the surgeon target mild myopia and thus
avoid inadvertent postoperative hyperopia. A
patient who is hyperopic postoperatively will
need spectacles for clear vision at any range,
whereas a patient who is slightly myopic will
have a range of clear vision corresponding to
the degree of myopia. In all cases the patient
must be counselled with regard to expectations
of refractive changes and they should be counselled that they will generally need reading
glasses or bifocals postoperatively as the implant has no power of accommodation, unless
the patient's targeted postop refraction is around
-2.00 on purpose.
Monocular Correction
Holladay has pointed out that with monocular correction, there are two major considerations for determining what would be the
best postoperative refraction for any patient. If
we are only considering one eye (i.e., the other
eye is amblyopic), targeting the postoperative
refraction for approximately -1.00 to -1.50
diopters is probably the best choice.
This is usually best because most people
have visual needs for both distance and near;
that is, they want to be able to drive and to read
without having to wear glasses. If we target the
patient's post-op refraction for -1.00 to -1.50,
the patient will have 20/20 vision at approximately 2 to 3 feet, 20/30 vision in the distance,
and 20/30 at 14 inches. With a normal size
pupil of approximately 3 mm in the cataract age
group, these visual acuities are adequate with

no additional glasses required. At times when
they might need finer acuity, they can wear
regular bifocals, which will correct them for
distance and near.
In older, more sedentary patients, two
diopters of myopia may be a better goal. For
these patients reading without glasses may be
preferred to distance vision without glasses.
The second reason for targeting the postop refraction to approximately -1.00 to -1.50,
sometimes -2.00 diopters, is that, statistically,
between 70% and 90% of patients will fall
within + or -1.00 diopter error of this desired
postoperative refraction. The errors, as mentioned previously, are primarily a result of our
inability to make exact measurements on the
living eye.
Therefore, the patient will fall between
plano and -2.00 diopters 90% of the time. This
will assure most patients of useful vision without glasses. Hence, the error of the ultrasound
measurement is best handled by choosing the
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
patients will be between -1.00 and +1.00 diopters. When the patient's refraction is on the +1
side, he has less useful vision at any distance
because he is hyperopic and does not have the
ability to accommodate.
Consequently, because it is very undesirable to have a hyperopic correction, targeting for -1.00 not only optimizes the best
vision at all distances but also minimizes the
chance for hyperopia that can result from the
inaccuracies of ultrasonic measurements.
Holladay's recommendation for choosing -1.00 to -1.5 as the postoperative refraction
is based on one eye only, i.e. monocular conditions. When the vision in the other eye is good,
its refraction must be considered for binocular
vision.
45
Binocular Correction
In patients with Binocular Correction:
one overriding rule when choosing an IOL
power is that one should never aim for spectacles which give the patient a difference in the
power between the right and left lens greater
than three diopters. The reason for this is that
even though the patient may have 20/20 vision
in primary gaze, when the patient looks up or
down, the induced vertical prism difference in
the two eyes is so large that it will create double
vision. Therefore, avoid anisometropia.
Good Vision in the Non-Operated Eye
In a patient who has good vision in the
non-operative eye, one must target the intraocular lens power for a refraction within
two diopters of his/her present prescription in
the non-operative eye. This measurement
should be two diopters, not three, due to our 1
diopter A-scan variability. For example, if we
have a patient who is hyperopic and has +5
diopters correction in each eye, we cannot
target the intraocular lens for a postoperative
refraction of -1 diopter because this would
produce a 6 diopter difference between the two
lenses, resulting in double vision or confusion.
Holladay recommends selecting the
intraocular lens power to obtain a refraction
which is approximately two diopters less than
the non-operative eye. Consequently, on our
patient who is +5 diopters in both eyes, we
should target the postoperative refraction in the
eye with the cataract for +3, so ther e is a
90% probability that there will be less than a
3 diopter difference.
In contrast, if the patient were highly
myopic in each eye, for example, -10.00 in both
eyes, we should target the intraocular lens
power to produce refraction of approximately
46
-8.00. We have limited the difference in the

spectacle lenses to a two diopter difference in
the final prescription. Again, we are advised to
target for a two diopter difference, not a three
diopter difference, because there is approximately a one diopter tolerance in the accuracy
of the ultrasonic measurement.
When Cataracts in Both Eyes
If the operation on the second eye is to be
done shortly after the first, the IOL calculation
is made as if he were monocular, as in our
previous discussion.
For example, with a patient +5 in both
eyes, if the second eye is cataractous and it is
planned that the patient would also need cataract surgery in that second eye within a short
period of time, it would be wise to target for
-1 in the first eye. When the vision in the
operated eye exceeds the vision in the other
eye, -1 lenses in both should be prescribed until
the second eye is operated. Soon. This is not
only true with intraocular lens surgery; it is true
in all forms of refraction. The patient needs to
understand what we are doing and to be a part
of the decision process. One should never give
a patient more than a three diopter difference in
his/her spectacles unless he has previously
worn such a prescription. One exception is a
child who is under five or six years of age and
who can adjust to this difference by turning his
head rather than moving his eyes. Another is
the patient with an alternating strabismus.
We must continue in our efforts to avoid
creating astigmatism by our surgery. If the
patient is already astigmatic, try to avoid too
much astigmatic imbalance (high plus at 90 in
one eye and high minus at 90 in the other). This
results in a vertical prism effect in reading and
the need for prescribing a slab off prism. This
problem has fortunately been significantly diminished with small incision surgery, particu-
larly phaco, and with the application of refractive cataract surgery by placing the incision in
the correct axis at the time of cataract surgery.
This we will discuss under the major heading of
"The Incision."
IOL POWER CALCULATION

IN COMPLEX CASES
Specific Methods to Use in
Complex Cases
Considering that there are no specific
methods on which there is full agreement as to
what to do in these patients, and after consulting different authorities in this field, we hereby
recommend the use of third generation formulas, preferably more than one and that the
highest resulting IOL power should be used for
the implant. These formulas are preferably the
Holladay 2, the SRK/T or the Hoffer formulas.
Do not use a regression formula (e.g., SRK I or
SRK II). We also recommend that you use
central topography's flattest curve as a
keratometric method unless you are fortunate
to have all the information needed in order to
use the "historical method." This reading is
fed to the computer utilizing the selected formulas. The computer will then provide you
with the power of the IOL to use.
The modern formulas hereby recommended are already available in most of the
computers available today to calculate IOL
power. You just select the formulas you believe adequate which should be present within
your equipment.
The reason behind all these sophisticated
and very careful IOL calculations in highly
myopic patients with cataract is, of course,
that although the cataract removal by itself can
somewhat compensate for the high myopia, the
advantages of modern technology, the small

incision extracapsulars and careful inspection
of the peripheral retina allow us to perform a
safe lens removal and provide an IOL implantation with a sufficiently desirable power to
provide a specific patient with the very high
quality of vision that we must demand of ourselves for the benefit of our patients.
Practical Method for Choosing

Formulas in Complex Cases
From a practical standpoint, if several
formulas are available to the clinician, the first
choice as recommended by Zacharias and
Centurion are as follows:
short eyes: L <22.00 mm: Holladay 2 or
Hoffer Q. These constitute 8% of cases.
L (axial length) between 22.00 and
24.50 mm; 72% of the cases: mean of the three
formulas: Hoffer, Holladay and SKR/T.
L between 24.50 mm and 26.00 mm;
15% of the cases: Holladay 2 or SRK/T
L higher than 26.00 mm; 5% of the
cases: SRK/T
High Hyperopia
In eyes with short or very short axial
lengths (Fig. 25) the third generation formulas
such as Holladay 2 and Hoffer-Q seem to
provide the best results. Observing high refractive errors in extremely short eyes (<20.0 mm),
Holladay has discovered that the size of the
anterior and posterior segments is not proportional, and has devised certain measurements
to be used to calculate the parameters in these
eyes. Assembling data from 35 international
researchers Holladay concluded that only 20%
of short eyes present a small anterior segment
(nanophthalmic eyes); 80% present a normal
anterior segment and it is the posterior segment
47
that is abnormally short. This means that the

formulas that predict a small anterior segment
in a short eye provoke an 80% error margin, as
they will predict an abnormally shallow anterior chamber which, in turn, can lead to hyperopic errors of up to 5 diopters. The Holladay 2
formula comprises the seven parameters previously described for IOL calculation: axial
length, keratometry, ACD (anterior chamber
depth), lens width, white-to-white corneal horizontal diameter, preoperative refraction, and
age. This new formula has reduced 5 D errors
to less than 1 D in eyes with high hyperopia.
Although biometry is easy to perform,
most errors in hyperopic patients occur because of probe compression. Zacharias and
Centurion emphasize that only the corneal
epithelium should be touched, without any
resulting indentation (Fig. 25-A).
The Use of Piggyback Lenses in

Very High Hyperopia
For very short eyes (<22.00 mm in
length) even though the Holladay 2 or the
Hoffer Q formulas are a significant advance in
calculating the IOL power needed, we do not
have IOLs easily available with a power higher
than +34 diopters because a higher diopter lens
would have a marked, almost spherical curvature, that would cause major optical aberrations. Such lenses can be customized but still
may cause undesirable optical aberrations. In
these cases the piggyback method is employed,
i.e., the implantation of more than one IOL in
a single eye, dividing the total power among
the different lenses, placing 2/3 of the power in
the posterior lens and 1/3 in the anterior lens
(Fig. 25-B).
Gayton (1994) was the first to place two
lenses in a single eye. He observed that placing
multiple lenses in a single eye produces im-
48
proved optical quality because there are fewer

spherical aberrations than with very high diopter lenses.
Measuring the position of piggyback
lenses, Holladay observed that contrary to
what he supposed -- that the anterior lens would
occupy a more anterior position -- what effectively happens is that the anterior lens preserves its normal position while the posterior
lens moves backwards because of the distensible nature of the capsular bag. The latter may
accommodate more than two IOLs and there
are cases of patients with four piggyback lenses
in the same eye.
Holladay's recommendation for calculating the power of lenses with the piggyback
procedure in high hyperopic patients is to add
3 diopters to the total value of the pre-op IOL
power calculation and divide the total by 3,
placing 2/3 of the power in the posterior lens
and 1/3 in the anterior lens. This facilitates
the replacement of the anterior lens, if necessary, as it is the thinnest lens. The 3 diopters
added to the total value are meant to roughly
compensate the hyperopic error resulting from
the space behind the posterior lens. This is
calculated more precisely with the Holladay 2
formula.
Joaquin Barraquer, M.D., in Barcelona,
who often attends very complex anterior segment diseases referred to him from different
parts of the world, has observed a substantial
increase in depth of focus with the piggyback
procedure as compared to the implantation of a
single custom made lens. He has done both
procedures. Barraquer as well as I. H. Fine,
M.D., another master surgeon, are still cautious about the piggyback method. They
feel that it is not yet clear how Elschnig pearls
between the lenses will behave in the postoperative period if there is progressive capsular
fibrosis. Recently, John Gayton, David
Apple et al described the presence of

interlenticular opacification in two pairs of
piggyback lenses that had to be explanted from
2 patients with significant visual loss related to
opacification between the optics. They were
submitted for pathological analysis. Gross and
histopathological examinations were performed, and photomicroscopy was used to document the results.
Gross examination showed accumulation of a membrane-like white material between the lenses. Histopathological examination revealed that the tissue consisted of retained/proliferative lens epithelial cells (bladder cells or pearls) mixed with lens cortical
material.
They recommended three surgical means
that may help prevent this complication: meticulous cortical cleanup, especially in the equatorial region; creation of a relatively large continuous curvilinear capsulorhexis to sequester
retained cells peripheral to the IOL optic within
the equatorial fornix; insertion of the posterior
IOL in the capsular bag and the anterior IOL, in
the ciliary sulcus to isolate retained cells from
the interlenticular space.
Echobiometry in highly hyperopic eyes,
especially microphthalmic and nanophthalmic
eyes, is still far from desirable.
without the use of a personalized correction

factor have yet to be developed. Zacharias and
Centurion emphasize that there are technical
difficulties in performing the echobiometry of
patients with high myopia, especially when
they have a posterior staphyloma. In those
cases they obtain extremely irregular retinal
echoes that cannot provide certainty in terms
of really correct results of the IOL calculation.
In addition, a posterior staphyloma may not
always coincide with the macula, so the higher
measurement is not necessarily the correct one,
as is the case with normal eyes.
In these patients it is useful to perform B
type ultrasound to identify the existence of a
staphyloma and its relation with the macula.
Equally important is to have an ultrasound
probe with a fixation light. The patient is asked
to fixate at the light -- which he will do with the
macula -- facilitating the measurement.
Lacava and Centurion studied 27 myopic eyes with an axial length of more than
26.50 mm, and found that 88% of the patients
with whom they used the SRK/T formula were
within the emmetropic criteria established by
George Waring.
High Myopia
DETERMINING IOL POWER

IN PATIENTS WITH PREVIOUS REFRACTIVE SURGERY
According to Zacharias and Centurion's

experience, results of cataract surgery in highly
myopic eyes with axial lengths higher than
31.0 mm with implantation of low or negative
power IOLs may be successful, without any
more operative or postoperative complications
than normal eyes. The use of the SRK II
formula with an individual surgeon's factor
showed good predictability of the refractive
target (Fig. 26). However, better formulas
Patients who have undergone excimer

laser procedures, radial keratotomy or INTACS
have had modifications to their corneal curvatures (Figs. 27, 28, 29). Accurate keratometric
readings are fundamental in calculating IOL
power. IOL power calculation for cataract
surgery in patients previously submitted to
refractive surgery by modification of the
corneal curvature is a new challenge for the
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 patients' IOL power accurately. The standard
methods used in normal eyes are inadequate 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 reliably with the standard methods. The
data of the corneal curvature obtained
from corneal topography are fed into a
computer using third generation formulas to establish a more dependable calculation 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

undergo refractive surgery are more
phychologically resistant to using spectacles to
correct residual ametropia. Consequently, their
expectations for cataract surgery are unusually
high. 2) So far there is no universally accepted formula to calculate these patients'
IOL power accurately. Routine keratometry
readings do not accurately reflect the true corneal curvature in these cases and may result in
errors if used for IOL calculations. Therefore,

standard keratometry readings should not be
used for IOL calculations in these patients. If
done, the standard IOL power-predictive formulas based on such readings commonly result
in substantial undercorrection with postoperative hyperopic refraction or anisometropia both
of which are very undesirable.
Jack Holladay, M.D., a recognized
authority on IOL power calculations and in all
51
optical-refractive subjects in ophthalmology,

considers that accurate determination of the
corneal power in these patients is difficult and
is usually the determining factor in the accuracy of the predicted refraction following cataract surgery. Providing this group of patients
with the same accuracy of intraocular lens
power calculations as we have provided our
standard cataract patients presents an especially difficult challenge.
Methods Most Often Used

There are three methods to determine the
effective power of the cornea in these complex
cases: 1) the clinical history method, also
termed by Holladay "the calculation method";
2) the contact lens method; and 3) the topog-
raphy method. Holladay believes that the

calculation or "clinical history" method and the
hard contact lens trial are the two more reliable
of the three, because the corneal topography
instruments presently available do not provide
accurate central corneal power following PRK,
LASIK and RKs with optical zones of 3 mm or
less. In RKs with larger optical zones, the
topography instruments become more reliable.
The great majority of cases, however, have had
RK with an optimal zone larger than 3 mm, so
they should also qualify for this method.
The Clinical History Method

The "clinical history" method is the most
often used. In the "historical or calculation
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

be known along with an accurate postoperative
refraction which is not often the case. It is also
important to keep in mind that at present, far
more patients have had RK than PRK and
LASIK combined. Also, our long-term follow-up of RK patients is much greater. The
long-term studies of RK patients reveal that
some have hyperopic shifts in their refraction
and develop progressive against-the-rule astigmatism which may complicate the final vision
of the patient operated for cataract, unless
detected at the time of preoperative evaluation
and corrected. The long-term refractive changes
in PRK and LASIK are unknown, except for
the regression effect following attempted PRK
corrections exceeding 8 D. Whichever procedure the patient has had, the stability or instability of the refraction must be determined.
When using the "clinical history or calculation
method" a subtraction of the spherical equivalent (SEQ) change after refractive surgery from
the original K-reading is done to determine the
new "accurate" corneal curve. This, however,
is not information easily found. It is useful and
can be applied whenever refraction and the Kreading before the keratorefractive procedure
are available to cataract surgeons. If this
information is not available, which is not
unusual, we recommend that the
keratometry be measured with corneal topography and use the flattest curve of this
reading as the new corneal curve to feed the
computer that will then automatically provide
us with the IOL power to use.
Another downfall of the history method
is that cataracts frequently cause induced myopia. This method, however, requires an accurate and stabilized refraction after the
keratorefractive procedure and at the time we
are contemplating cataract surgery. In many
cases, calculation is complicated by the progressive flattening that occurs in about 25% of
RK patients. It is nearly impossible to separate
these two factors and determine the impact of
each on the refraction before cataract surgery.
The Trial Hard Contact Lens

Method
The second method often used, which is
the trial hard contact lens method, requires a
plano hard contact lens with a known base
curve and is limited to patients whose cataract
does not prevent them from being refracted to
approximately +0.50 D. This usually requires
a visual acuity of better than 20/80. The patient's
spheroequivalent refraction is determined by
standard refraction. The refraction is then
repeated with the hard contact lens in place. If
the spheroequivalent refraction does not change
with the contact lens, then the patient`s cornea
must have the same power as the base curve of
the plano contact lens, since the base curve and
front curve are the same in a plano contact lens.
If the patient has a myopic shift in the refraction
with the contact lens, then the base curve of the
contact lens is stronger than the cornea by the
amount of the shift. If there is a hyperopic shift
in the refraction with the contact lens, then the
base curve of the contact lens is weaker than the
cornea by the amount of the shift.
Example as Provided by Holladay
The patient has a current spheroequivalent
refraction of +0.25 D. When a plano hard
contact lens with a base curve of 35.00 D is
placed on the cornea, the spherical refraction
changes to -2.00 D. Since the patient had a
myopic shift with the contact lens, the cornea
must be weaker than the base curve of the
53
contact by 2.25 D. Therefore, the cornea must

be 32.75 D (35.00 - 2.25), which is slightly
different from the value obtained by the historical or calculation method. This method is
limited by the accuracy of the refractions, which
may be limited by the cataract.
The
Method
Corneal
Topography
Current corneal topography instruments

provide greater accuracy, compared to
keratometers, in determining the power of corneas with irregular astigmatism. The computer
in topography instruments provides a very
accurate determination of the anterior surface
of the cornea. The limitation of this method is
that the computer in corneal topography provides no information about the posterior surface of the cornea. In order to accurately
determine the total power of the cornea, the
power of both surfaces must be known.
The Importance of Detecting

Irregular Astigmatism
Holladay has strongly recommended that
biomicroscopy, retinoscopy, corneal topography and endothelial cell counts be performed in all of these complex cases. The first
three tests are primarily directed at evaluating
the amount of irregular astigmatism. This
determination is extremely important preoperatively because the irregular astigmatism
may be contributing to the reduced vision as
well as the cataract. The irregular astigmatism may also be the limiting factor in the
patient's vision following cataract surgery. The
endothelial cell count is necessary to recog-
54
nize any patients with low cell counts from the

previous surgery who may be at higher risk for
corneal decompensation or prolonged visual
recovery.
The potential acuity meter (PAM), super
pinhole and hard contact lens trial are often
helpful as secondary tests in determining the
respective contribution to reduced vision by
the cataract and the corneal irregular astigmatism. The patient should be informed that only
the glare from the cataract will be eliminated.
Any glare from the keratorefractive procedure
will essentially remain unchanged.
IOL Power Calculation in

Pediatric Cataracts
How to optically correct patients with
bilateral congenital cataracts and monocular
congenital cataract has been a major subject of
controversy for many years. Some distinguished ophthalmic surgeons 20 years ago were
strongly against performing surgery in monocular congenital cataract followed by treatment of amblyopia with a contact lens. Visual
results were so bad that children with this
problem must be amblyopic by nature, they
thought, and the psychological damage to the
children and the parents by forcing such treatment was to be condemned.
Surgery of bilateral congenital cataracts
at a very early age followed by correction with
spectacles and sometimes with contact lenses
usually ended with no better than 20/60 vision
bilaterally. This was again a source for belief
that congenital cataracts either unilateral or
bilateral were by nature associated with amblyopia, profound in cases of monocular cases
and fairly strong in bilateral cataracts.
When posterior chamber IOL implantation in adults became established as the procedure of choice, strong influences within ophthalmology were adamantly opposed to their
use in children for the following reasons: 1) the
eye grows in length with consequent significant change in refraction. It was considered
impossible to predict such change and consequently, the accurate IOL power adequate for
each child. 2) There was opacification of
posterior capsule in most cases. This required
a second operation for posterior capsulotomy
and the presence of an IOL would impede
proper surgical maneuvers.
You will not find this concise history in
any other book. I lived through it and therefore
share it with you.
The situation has now significantly
changed. The previous failures with spectacles and contact lenses, the new developments in technology and surgical techniques
and the fresh insight of surgeons of a new
generation has led us to discard the previous
thinking and very definitely implant posterior
chamber IOL's in children. This has been made
possible from the surgical point of view by the
following developments: new medications that
effectively prevent and/or control inflammation; the introduction of posterior capsule
capsulorhexis introduced by Gimbel in
North America promptly followed by
Everardo Barojas in Mexico and Latin
America (Fig. 30); high viscosity viscoelastics
to facilitate intraocular surgery in smaller eyes;
new, more appropriate IOL's for children and
implantation in their capsular bag; more refined technology that leads to a less difficult
calculation of the IOL power.
Different Alternatives
The limitations in calculating these lenses
powers (Fig. 31) is due to the fact that the eye
grows after cataract surgery and therefore refraction will change. Two main methods of
choosing an IOL power for pediatric patients
are available: 1) Make the eye emmetropic at
the time of surgery and thereby treat amblyopia
immediately taking advantage of a much better
visual acuity. This is followed later by an IOL
exchange because of increasing myopia
(growth of the eye).
Even though there are more practical and
efficient techniques for IOL exchange, as devised by Jack Dodick, M.D., this alternative is
second choice.
2) Proceed with incomplete overcorrection of the eye at the time of surgery (treated
with glasses or contact lenses) taking advantage of the trend toward emmetropization
which will occur as the eye grows. By "incomplete" we mean leaving the eyes hyperopic. As the eye grows in length with age (axial
growth), the myopization that takes place in an
eye artificially rendered hyperopic will lead to
emmetropia or close to normal refraction. This
measure avoids myopic anisometropia that may
lead to an undesirable change of IOL surgically. In the meantime, the temporary hyperopia is managed with standard spectacles or
contact lenses.
Alternatives of Choice
In the IOL power calculation in children
younger than 1 year, keratometry is difficult
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. However, the lens continues growing throughout the life of
the individual. In normal conditions, anterior chamber (A) depth is reduced as the lens increases in size.
In pathological conditions such as the presence of cataracts 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 approximately 17.5 mm, at three years of age it may
measure 21.8 mm (X), at ten years 22.5 mm identified in (Y) and in normal adulthood nearly 24 mm
(Z). In selecting the lens power to be used, some surgeons choose to make the child hyperopic (arrows) with
the intention that his growth will compensate hyperopia 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

months. Thus keratometry may be replaced by
the mean adult average keratometry value of
44.00 D. Children less than two years old may
be incompletely corrected +3.00 D to even
+4.00 D; between three and four years old
incompletely correct them +3.00 D in those
closer to three and +2.50 D in those closer to
four. In children closer to six or seven, who
have little chance of recovering from any amblyopia present but who are the ones that more
56
frequently suffer from a unilateral traumatic

cataract, overcorrect them by +1.00 D.
3) A new method of management in
pediatric cataracts is to render the eyes
emmetropic from the very start and when axial
length grows and makes the eye myopic,
proceed to implant a second IOL with negative
or minus power utilizing the piggyback technique and placing the new IOL in front of the
primary IOL (Fig. 25- B).
IOL Power Calculation

Following Vitrectomy
For the most part, IOL power calculation in eyes that develop a cataract following
vitrectomy is straightforward. The intravitreal
gas is reabsorbed and slowly replaced by
aqueous. If silicone oil was used instead of
perfluorocarbons, when the oil is removed,
aqueous fills the vitreous cavity. Since the
refractive indices of aqueous and vitreous are
identical (1.336), no corrections are needed in
the calculation of the IOL power.
But what if silicone oil is present in
the vitreous cavity? Lihteh Wu, M.D., has
pointed out that anywhere from 60% to 100%
of eyes have been reported to develop cataract following silicone oil tamponade. Up to
25% of eyes with silicone oil tamponade,
especially those with retinal detachment secondary to necrotizing retinitis, will require
permanent tamponade. Several authors
have reported unpredictable refractions following cataract extraction in silicone-filled
eyes when traditional formulas are used. In
one study the axial length was measured prior
to silicone oil tamponade, and the IOL power
was calculated using the traditional formulas.
In these eyes the average postoperative refraction was about +4.00 diopters (with a
range of +2 to +6 D). These results were
more hyperopic than had been predicted and
the change is associated with the different
refractive index of silicone oil. If the silicone
oil was later removed then the postoperative
refraction was only off by 0.5 to 1 D.
Drs. Melissa Meldrum, Tom
Aaberg, Anil Patel, and Janet Davis have
described and proposed correction factors for
the calculation of an intraocular lens implant

in a silicone filled eye (Fig. 32). They recommend: (1) the use of a modified ultrasound
velocity in silicone oil in the calculation of
axial length, (2) the use of convexoplano
IOL's, and (3) the addition of a constant to
compensate for the refractive index of silicone oil.
The velocity of sound in a medium is
inversely related to the mediums refractive
index. Since silicone oil has a higher index of
refraction than vitreous, it slows down sound
velocity. For instance, sound velocity in silicone oil is 986 m/s compared to 1532 m/s in
aqueous. If we recall, the velocity of sound is
preset in the computer in the ultrasound
machine. If no modification is made, the eye
appears to be longer than it actually is. Consequently, the wrong IOL may be implanted.
Drs. Meldrum, Aaberg, Patel, and
Davis also explain why the choice of IOL is
important. When convexoplano lenses are
used, the anterior surface of the lens is solely
responsible for the refractive power of the
lens. Thus the presence of silicone oil in the
vitreous cavity has no effect on the refractive
power of the IOL. On the other hand, when
biconvex lenses are used, the posterior surface also contributes to the refractive power
of the lens. The refractive power of the posterior surface depends on the difference between the refractive indices of the IOL and
the vitreous or vitreous substitute. Since silicone oil has a higher index of refraction than
vitreous, the posterior refractive power of the
lens is reduced. The use of a biconvex lens
requires further correction.
Meldrum, Aaberg, Patel, and Davis
make the following recommendations.
57
Measure the axial length using the velocity of

sound in silicone oil.
Calculate the IOL power to achieve emmetropia using the traditional formulas. To this IOL
power, a correction factor must be added to
obtain the IOL power to achieve emmetropia
in silicone oil. The correction factors range
from 2.79 D to 3.94 D, for axial lengths from
20 mm to 30 mm.
Choose a convexoplano IOL if possible. If
another type of le1ns is used, another correction factor must be added to obtain the total
power of the IOL in the presence of silicone
Figure 32: IOL Power Calculation in Patients After Vitrectomy Procedure With
Silicone
If the patient is in the process of
undergoing this procedure it is recommended 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
oil. For a convexoplano lens no additional

correction factor is required.
For instance, let us suppose that a patient
requires indefinite intraocular tamponade with silicone oil and develops a cataract. Using the traditional formulas, assuming that the IOL power is
calculated to be 22 D based on a measured axial
length of 23 mm. To this 22D we must add a
correction factor of 3.64D (Meldrum et al) to correct for the axial length. Thus, for this patient a 25.5
D convexoplano lens should be implanted in order
to achieve emmetropia in the presence of silicone
oil. No additional correction factor for the IOL
design is necessary.
RECOMMENDED READING
Mendicute J, Cadarso L, Lorente R., Orbegozo J,
Soler JR: Facoemulsificacin, 1999.
BIBLIOGRAPHY
Boyd, BF.: Undergoing cataract surgery with a master
surgeon: a personal experience. Highlights of Ophthalm.
Bi-monthly Journal, Volume 27, N 1,1999;3.
Brady, KM., Atkinson, CS., Kilty, LA., Hiles, DA:
Cataract surgery and intraocular lens implantation in
children. Am J. Ophthalmol, 1995;120:1-9.
Buckley, EG., Klombers, LA., Seaber, JH., et al: Management of the posterior capsule during intraocular lens
implantation. Am J Ophthalmol, 1993;115:722-8.
Dahan, E., Drusedan, MUH.: Choice of lens and dioptric
power in pediatric pseudophakia. J Cataract Refract
Surg, 1997;23:618-23.
Gayton, JL.: Implanting two posterior chamber intraocular lenses in microphthalmos. Ocular Surgery News,
1994:64-5.
Gayton JL., Apple DJ., Peng Q., Visessook N., Sanders
V., Werner L., Pandey SK., Escobar-Gomez, M.,
Hoddinott D., Van Der Karr M.: Interlenticular opacification: Clinicopathological correlation of a complication of posterior chamber piggyback intraocular lenses.
J Cataract Refract Surg, 2000; 26:300-336 ASCRS
and ESCRS.
Gimbel, HV: Posterior continuous curvilinear
capsulorhexis and optic capture of the intraocular lens to
prevent secondary opacification in pediatric cataract
surgery. J Cataract Refract Surg, 1997;23:652-656.
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.
Grinbaum A., Treister G., Moisseiev J.: Predicted and

actual refraction after intraocular lens implantation in
eyes with silicone oil. J Cataract Refract Surg, 1996;
22:726-729.
Grusha YO., Masket, S., Miller, KM: Phacoemulsification and lens implantation after pars plana vitrectomy.
Ophthalmology 1998;105:287-294.
Holladay, JT: Intraocular lens power in difficult cases.
Atlas of Cataract Surgery, Edited by Masket & Crandal,
Published by Martin Dunitz, 1999, 19:147-158.
Holladay JT., Gills, JP., Leidlein, J., Cherchio, M.:
Achieving emmetropia in extremely short eyes with two
piggyback posterior chamber intraocular lenses. Ophthalmology, 1996; 103:1118-1123.
Hoffer, KJ: Intraocular lens power calculation for eyes
after refractive keratotomy. J Refract Surg,
1995;11:490-3.
Hoffer, KJ.: The Hoffer Q formula: A comparison of
theoretic and regression formulas. J Cataract Surg.,
1993; 19:700-711.
Hoffer, KJ: Ultrasound velocities for axial length measurement. J Cat Refract Surg, 1994;20:554-562.
Kora, Y., Shimizu, K., Inatomi, M., et al: Eye growth
after cataract extraction and intraocular lens implantation in children. Ophthalmic Surg, 1993;24:467-75.
Lacava AC., Centurion, V.: Cataract surgery after refractive surgery, Faco Total, Editora Cultura Medica,
2000;269-276.
Lyle WA, Jin GJC.: Intraocular lens power prediction in
patients who undergo cataract surgery following
previous radial keratotomy. Arch Ophthalmol 1997;
115:457-61.
McCartney, DL., Miller, KM., Stark, WJ., et al: Intraocular lens style and refraction in eyes treated with
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, Boyds, 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
Use of Antiseptics, Antibiotics
and Antiinflammatory Agents
Endophthalmitis following cataract surgery is a rare complication. When it occurs,
however, it becomes the most serious postoperative complication. We will discuss its prevention in this chapter and its management in
the chapter on Complications from Cataract
Surgery.
The use of preoperative, intraoperative
and postoperative antibiotics and antiinflammatory agents and the very careful cleaning of
the lids are generally accepted as the standard
of care in patients undergoing cataract surgery.
Effective Preoperative Antibiotic

Treatments
There is no agreement as to which is the
most effective type of antibiotic as well as the
dosage and route of administration to prevent
postoperative infectious endophthalmitis. We
do know, however, that aminoglycosides are
toxic to the healing cornea while
fluoroquinolones are not. The former have
also gaps in the antibacterial spectrum of activity and the latter (i.e. ciprofloxacin and
ofloxacin) are more potent for a wide spectrum
of bacteria with less toxicity.
With regard to prophylaxis in an era of
increasing use of small incision cataract surgery where corneal incision without conjunctival protection over it is becoming the proce-
dure of choice for a large number of surgeons

well trained in phaco, the key factors to consider are that most infections come from the
patient's own flora. Consequently, we must
effectively kill bacteria in the skin, lids and
ocular surface before making an incision in the
eye itself. For this purpose, you may place 5%
Betadine solution inside the fornix and leave it
there for 2 minutes before washing it out of the
eye. This is followed by painting the lids with
10% povidone-iodine solution.
Peter McDonnell, MD., has pointed out
that endophthalmitis is difficult to study scientifically, because it occurs so rarely. Al
Sommer, M.D., the Dean of the School of
Public Health at Johns Hopkins University,
has emphasized that to do a prospective, randomized trial in order to prove that a specific
management lowers the risk of endophthalmitis, is close to impossible. There are almost no
scientific data proving that various strategies
clearly reduce the risk of this complication.
Such data are even harder to obtain now because, as incision sizes have gotten smaller, the
risk of endophthalmitis has dropped. But as
incision sizes have dropped, so has the time
that it takes for surgery. This, of course,
reduces the risk.
Henry Perry, M.D., has also brought
out another important point: In patients where
the posterior capsule breaks or there is need for
a vitrectomy, those patients should be treated
with extra antibiotics because the risk for infection significantly increases depending on
whether it is just the capsule that has ruptured
or whether you actually had to do a vitrectomy.
63
Regimens Recommended
Considering that there are so many alternative regimens for minimizing the development of infection, depending on the personal
choices of different successful surgeons, I am
hereby presenting what I consider two alternatives that appear to be effective and safe.
Gills Formulas to Prevent Infection

1) For High Volume Cataract
Surgery
As proposed by James Gills, M.D., after
years of profound clinical analysis of this subject on many thousands of his own patients.
Gills' regime is complex particularly when it
comes to the preparation of two antibiotic mixtures with two antiinflammatory agents
(NSAIDS) for injection into the anterior chamber at the end of the operation. The accurate
preparation, mixture and exact dilution of a
variety of medications that needs to be done
with absolute accuracy and in very small doses
for injection routinely into the anterior chamber is a big step forward in minimizing endophthalmitis, based on Gills' extensive experience. The disadvantage is, however, that such
multiple steps of preparing these mixtures by
operating paramedical personnel in some large
institutions where not only ophthalmic surgery
is performed may be somewhat risky. A small
human error is feasible, particularly on the side
of mistakenly applied larger doses, which may
lead to toxicity of the ocular tissues. In large
private eye centers, where the paramedical
personnel is exclusively dedicated to high tech-
64
nology ocular surgery, Gills outline is an excellent measure to follow. The following is his
step by step procedure.
1) Gills considers that filtering all the
irrigating solutions through a 0.2 micron
millipore filter is a major step forward in
minimizing infection, particularly endophthalmitis. Following his use of filtration, the
incidence of endophthalmitis at Gills Institute
has significantly reduced from 1-2 per 1000,
which was the same as the national average in
the U.S. to an overall incidence of 1 in 8000 to
10,000.
2) After years of successfully using
antibiotics (gentamicin and vancomycin) in the
irrigating solution, Gills has changed to what
he considers maximum security, which is as
follows:
A) Preoperatively, 15 minutes prior to
transfer to the operating room:
a) Neosynephrine 10% one drop.
b) Ocuflox 0.3% mixed with Indocin,
one drop.
This combination of Ocuflox (a
fluoroquinolone) and Indocin (a non-steroidal)
is prepared as follows: Reconstitute 1 mg of
Indocin with Ocuflox. Reinject into Ocuflox
bottle and use one drop of this mixture.
B) In the Operating Room
a) Tetracaine: 0.5% 1 gtt x 3 (3 min.
apart with final drop instilled just prior to
beginning).
b) Betadine BSS: 1 gtt x 3 (2 gtts at the
beginning of the case, 1 gtt at the end).
Preparation: Draw up into the syringe
5 cc of BSS followed by 5 cc of Betadine
solution 10%.
Change needle to 18 gauge filter needle
wil filter and inject into sterile empty vial. Use
the drops on the eye as outlined above but
obtained from this prepared mixture.
c) Cyloxan (antibiotic): Instill one drop

at the end of the operation.
d) Intraocular anesthesia (Intracameral): Irrigated inside the anterior chamber
(see Chapter 6).
Gills no longer uses antibiotics in the
irrigating solution. Instead, he feels there is a
more effective control by using a combination
of antibiotics and antiinflammatory drugs directly injected into the anterior chamber at the
end of the operation. This combination of
drugs is obtained as follows:
f) Post-op Anterior Chamber Injection of Indomethacin, Solucortef and Two
Antibiotics
Draw up 14.4 ml BSS into a syringe and
inject 12.4 ml of this BSS into an empty sterile
bottle.
Use the remaining 2 ml to reconstitute
two 1 mg vials of Indomethacin.
Add both of the 1 ml vials of Indomethacin solution to the 12.4 ml bottle containing BSS making 14.4 ml of total volume.
Add 8 gtts of Solucortef 125 mg/ml
(8 minims using TB syringe), 0.06
Cephtazidime 50 mg/ml.
0.1 ml Vancomycin 500 mg/10 ml to
the 14.4 ml bottle of Indomethacin solution.
Dosage per patient: 0.50 ml of this
mixture is injected into the anterior chamber at
the end of the operation.
g) Recovery Room: Polytracin ointment x 1.
In doses higher than those described in
this outline, Vancomycin and Cephtazidime
would interact and precipitate out of solution.
Gills states that he has no problems with the
minute concentrations used for intraocular injection. At the end of the operation, topical
Betadine drops are instilled in the eye.
Betadine eliminates flora in the cul-de-sac so
they cannot enter the soft eyes that may occur

within the first hour after surgery. During this
critical period it is important to make sure that
the eye is clear and clean.
C) Oral Medications: These are instilled before the antibiotic ointment.
Ibuprofen 200 mg tablet given pre-op
and tablet postop unless contraindicated.
2) Non-Complex, Effective and

Safe Alternative for Prevention of Infection
The regimen that follows is practical and
effective, one which every ophthalmic surgeon
may use with excellent results.
1) Asepsis
Follow the same routine previously
outlined for thorough cleaning of lids and skin
with soap and 10% povidone iodine solutions.
The same applies for use of 5% Betadine 1 drop
topically, Betadine 5% solution inside the
fornix leaving it there for 2 minutes before
washing it out of the eye.
2) Preop antibiotics: none.
3) Filtration of irrigating solution
If the micropore filter is available,
by all means use it as recommended by Gills.
4) Intracameral irrigation at end of
operation
Yes. Irrigate the anterior chamber with
an effective mixture of:
A) One antibiotic and one steroidal antiinflammatory mixture containing:
a) Gentamicin 0.5 ml drawn from
a vial containing 40 mg / ml.
b) Prednisoloneacetate (Depomedrol)
0.5 ml solution from a vial containing 40 mg /
ml.
65
This combination is easy to use, it provides very little risk of confusion and is most
effective.
5) Topical instillation after intracameral irrigation
In cataract surgery there are many ways
to reduce the ocular surface flora which is the
main source of contamination that may lead to
endophthalmitis. It is also quite clear the
usefulness of Povidone-Iodine as an antiseptic
in the skin and lids and Betadine gtts topically
preoparatively as outlined previously. The use
of preoperative antibiotics has never been a
subject of consensus essentially because there
is no fundamental evidence that they really
contribute to minimize the risk of infection.
66
recommended. Both of these antibiotics are

very effective. You may use one or the other.
They may be instilled immediately following
surgery and started four times a day within one
hour of surgery.
Antimicrobials should be used only for
the shortest period of time needed to obtain the
desired effect and should never be tapered
but simply discontinued. Do not prescribe
them at a frequency of less than four times
daily.
Antibiotics in the first seven days may be
used in combination with a steroid. However,
once you discontinue the topical application of
the antibiotic within seven days, if everything
looks well, the patient has to continue with
steroids.
Antibiotics Most Commonly Used
Most Frequently Used Anti-inflammatory Agents
As to the use of postoperative antibiotics

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

The previously widely used practice of
using antibiotics in irrigating solutions are of
questionable value. Their use has not been
proven to be effective, mainly because the
concentration and the duration or the exposure
of the antibiotic to the bacteria is insufficient to
achieve a killing effect. A much better procedure is to instill within the anterior chamber a
combination of antibiotic and antiinflammatory agent as outlined previously. There also
seems to be a general consensus not to use
Vancomycin in the irrigating solutions or for
irrigation of the anterior chamber immediately
following surgery. Prospective studies seem to
indicate some potential toxicity particularly a
clinical significant cystoid macular edema and
decreased best corrected visual acuity in cataract patients receiving Vancomycin in the irrigating solutions as compared with controls.
This is not a proven fact but it is a potential for
concern that has been expressed by the Centers
of Disease Control in the United States.
Patching
Following phacoemulsification, patching is not used unless the patient lives very far
away and may be at risk for trauma during his
trip back home. Practically all patients today
are operated in outpatient surgical centers or
eye clinics that have their own operating room
and they go home without patching and start
using the topical antibiotics and antiinflammatory agents immediately after getting home so
that the medication will start with their effect
immediately.
Postoperative Antiinflammatory
Agents
We already described the use of antiinflammatory agents by irrigation into the anterior chamber immediately following the operation. Gills uses a combination of nonsteroidal antiinflammatory agents (Indomethacin) and a steroidal medication within the anterior chamber, mixed with two antibiotics. In
the other more simple and very effective alternative which we have outlined, 0.5 ml of Prednisolone Acetate (Depomedrol) combined with
0.5 ml of antibiotic (Gentamycin) are irrigated
intracamerally immediately following the operation.
Postoperatively, the most effective antiinflammatory agents is a combination of Prednisolone Acetate 1% q.i.d. gradually tapered
over eight weeks and a non-steroidal antiinflammatory drug such as Voltaren q.i.d. for
two weeks. Either Voltaren or Acular are two
commonly used and effective medications. It
is also known that topical diclofenac can reduce pain, burning and inflammation. It may
also be effective in reducing photophobia after
pupil dilation. The mechanism is not known.
However, the use of diclofenac alone is not
sufficient to eradicate all inflammation. Supplemental topical steroid is necessary to completely control inflammation.
This combination of postoperative medications applied topically not only contribute to
the prevention of inflammation and infection
but also significantly contribute in the patient's
postoperative comfort.
67
BIBLIOGRAPHY
Boyd, BF.: Cataract/IOL Surgery, Section V-A,
World Atlas Series of Ophthalmic Surgery, Highlights 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 Cataract 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 ophthalmic surgery, Ocular Surgery News, Special
Supplement, Jan. 2000.
O'Brien, TP, et al: Antibiotic update, current treatment modalities in ophthalmic surgery, Ocular
Surgery News, Special Supplement, May 1998.
Perry, HD., Hoffman, J. et al: Choosing an antibiotic 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
AND ANESTHESIA
Preparation of Patient
Unless the patient is scheduled for general anesthesia or is likely to be operated under
very heavy sedation (non-airway supported) it
is unnecessary to keep these usually older,
fragile patients fasting for a large number of
hours. This only contributes to fatigue and
anxiety. It is also contraindicated to have the
patients remove all their clothes. This interferes with the patient's sense of privacy and
contributes to further anxiety as to what is to
come.
The patient is made comfortable in the
holding area, where he or she is met by the
attending nurse, who then explains what is
going to transpire. Presurgical checks are
conducted,
and
the
nurse
instills
Neosinephrine 10% and tropicamide 1% two
drops each in order to dilate the pupil and one
drop of antibiotic and of Betadine solution,
depending on the surgeon's preference. This
subject is discussed in Chapter 4. Long
acting pupillary dilating agents such as
cyclopentolate, atropine, homatropine or scopolamine have no role in today`s small
incision surgery.
The patient is then transported to another holding area in the operating room suite
either by walking or on a lounge chair on
wheels. There the patient is met by the anesthesiologist, who explains that an intravenous
line will be started and administers sedative
agents which vary according to the

anesthesiologist's and surgeon's choice. In
the holding area, Jack Dodick, M.D. in New
York, applies a prudent amount of ocular
compression to the eye and orbit for 10-15
minutes. He finds this very beneficial in
lowering the intraocular pressure. This maneuver lowers the volume of the fluid inside
of the eye and orbits thereby leading to a
hypotensive eye. This creates a more favorable surgical environment. This maneuver
was previously done using Honan's ballon in
conjunction with peribulbar or retrobulbar
injection of local anesthetic, procedures no
longer used in small incision cataract surgery.
The patient is made comfortable in the reclining chair which is very much like a first
class seat on an airplane that reclines in an
almost 180 degree position. Other surgeons
prefer to place the patient on an operating
table specially adapted to their needs and
whether they operate from above or on the
side.
Sedation
What sedation to administer depends on
the individual patient's emotional profile,
which the surgeon should have detected during his preoperative evaluation. In most
cases, 5 mg of Valium per mouth on arrival to
the clinic leads to sufficient relaxation so that
he or she feels comfortable during surgery.
Dodick prefers for the anesthetist to administer a small dose, 1 mg, of Versed intravenously. Versed, like Valium, is a member of
the benzodiazepine family, but it has a much
71
shorter half-life. Whereas valium takes up to

24 hours to be metabolized by the liver,
Versed is totally out of the body in less than 2
hours. The patient is totally sedated for about
10 minutes and the patient is wide awake
and alert after 10-15 minutes, which is the
time the operation lasts. The drug is gone
from the system within 2 hours. With valium,
on the other hand, patients sometimes feel
groggy for a day or two.
Pupillary Dilation
Pupillary dilation is critical to the success of ECCE, especially phacoemulsification. Cycloplegic/mydriatic drops, administered preoperatively, effectively dilate the pupil, while topical nonsteroidal antiinflammatory drops can help to maintain dilation during surgery. These medications are instilled
topically at the time of preparation of the
patient before entering the operating room.
ANESTHESIA
Topical
All patients have two or three drops of
proparacaine or tetracaine instilled in the eye,
regardless of the type of anesthesia the
surgeon decides to use. One drop every
minute x 3 is a standard protocol (Fig. 35).
Selection of Anesthetic Method

There are a variety of anesthetic methods known to all of you. We will list them
here and proceed to identify those that no
longer have a place in small incision cataract
surgery. They are:
72
1) Blocks by Injection Anesthesia

with Sharp Metal Needles
a) Retrobulbar: no longer used except
in exceptional cases.
b) Peribulbar: no longer used.
c) Parabulbar: no longer used.
d) Van Lint, O'Brien, Nadbath for
controlling lid contraction: no longer used.
e) Hyaluronidase: after many years of
recommending its use, it has been finally
shown that hyaluronidase is not an important
factor in obtaining akinesia more promptly or
having a more lasting effect.
2) Sub- Tenon's with a Flexible

Needle
This is a highly effective anesthesia
mostly used in combination with topical anesthesia by surgeons who are either beginning
or already are in the transition period of
ECCE to phacoemulsification. This combination is also the procedure of choice by
surgeons who perform extracapsular extraction or small incision manual extracapsular.
Prospective, randomized studies have concluded that single-quadrant, direct subTenon`s injection of anesthetic is as rapid and
effective as retrobulbar injection for cataract
surgery (Figs. 33 and 34). It provides better
anesthesia with comparable akinesia.
The most common complications are
chemosis and subconjunctival hemorrhage,
but no major complications are encountered.
The dispersion of anesthetic fluid under
Tenon's is effective enough to substantially
diminish lid discomfort. For these reasons,
Sub-Tenon's anesthesia using a flexible cannula has replaced retrobulbar and peribulbar
except in very unusual cases.
Figure 33 (above right): Sub-Tenon's

Local Anesthesia with Flexible Cannula - Surgeons View
Forceps (F) lift the conjunctivaTenons 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 cannula (C) is advanced (arrow) through the
buttonhole until conjunctiva and Tenons
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/akinesia 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 anesthetic. The cannula (C) is directed posteriorly and fluid infused (white arrow) in the
sub-Tenons space. Inset 1 shows the flexible nature (black arrow) of the cannula
which provides virtually no risk of globe
perforation or retrobulbar hemorrhage. Inset 2 shows the rounded, blunt tip with Dshaped port of the half-round cannula.
73
Technique
Tenon's
for
Performing
Sub-
When performing a Sub-Tenon's local

anesthesia, 1.5 ml of lidocaine is injected.
Under topical anesthesia, a small incision is
made in the fused conjunctiva/Tenon's capsule 3 mm from the limbus (Fig. 33). If the
surgeon is right handed, it is easier to perform
the incision at the inner lower quadrant between the rectus muscles in the right eye and
at the lower temporal quadrant in the left eye.
If the surgeon is left handed, it would be the
opposite. The surgical plane of Tenon's attachment to the sclera is carefully dissected
and the cannula is advanced through this
apperture (Fig. 34). It is very important
that the cannula is always in sub-Tenon's
plane. Otherwise, if it is only under the
conjunctiva, the flushed anesthetic solution
will backflush or will infiltrate all throughout
the subconjunctival space, where it becomes
ineffective and creates chemosis.
The cannula is advanced under Tenon's
until the conjunctiva/Tenon's fits snugly over
the hub of the 3 cc syringe. 1.5 cc of the
local anesthetic is infused using the "bolus"
technique. The anesthetic is infused quickly
creating a gush of fluid that spreads throughout the retro and parabulbar spaces (Fig. 34).
Unassisted Topical Anesthesia

Most ophthalmic surgeons, when using
unassisted topical anesthesia, in which
only drops are administered, use it only when
performing phacoemulsification and IOL implantation through a clear cornea tunnel
incision. The increased acceptance of topical
anesthesia is directly related to the somewhat
74
wider popularity of the clear corneal tunnel

incision as first emphasized by I. Howard
Fine, M.D., (Oregon, USA).
Most surgeons who use this incision
now do it from the temporal side, which
requires a series of readjustments in the
operating room. This procedure requires
the use of a foldable IOL. A corneal tunnel
sutureless valve incision no larger than
3.0 mm is recommended. Otherwise, corneal
complications may arise and the incision would
not be self-sealing.
Advantages of Unassisted Topical

Anesthesia
This term refers to the use only of anesthetic drops to obtain sufficient anesthesia to
perform the cataract operation. Edgardo
Carreo, M.D., Professor of Ophthalmology
at the Funcacion Los Andes, Santiago, Chile
and a phacoemulsification expert, considers
that the use of topical anesthesia using a clear
corneal tunnel self-sealing valve incision is a
significant advance in cataract surgery. With
topical anesthesia, visual recovery is immediate. Other advantages as outlined by Carreo:
1) It prevents the well-known complications of retrobulbar and peribulbar injections
2) It lowers the time of operating room
use thereby lowering costs.
3) There is no immediate postoperative
ptosis, which with retrobulbar or peribulbar
and Van-Lint-O'Brien infiltrations lasts from
6-8 hours due to temporary akinesia of the lids
(as contrasted with the late postoperative ptosis which is related to the bridle suture on the
superior rectus). It provides for immediate
postoperative visual recovery which, again, is
its main advantage.
Disadvantages of Unassisted Topical Anesthesia

Many surgeons who have performed
cataract surgery utilizing "unassisted" topical
anesthesia, that is, topical drops alone, agree
with Paul S. Koch, M.D., that pure, unassisted
topical anesthesia is fairly disappointing. He
estimates that one out of four patients have
some sensation during the operation. Sometimes, patients feel pressure build up in the eye
during injection of viscoelastic. Some feel iris
manipulation. Others are aware of the sensation of the lens being implanted into the eye.
Koch found that he felt uncomfortable operating on these people, because he never knew in
advance who would be comfortable and who
would not.
Other disadvantages and limitations as
outlined by Carreo are:
1) Only a highly experienced surgeon
should operate with topical anesthesia. The
eye can move, which makes the operation more
difficult. If the eye movement occurs while
capsulorhexis is being done, an undesirable
capsular tear may take place leading to failure
of this important stage of the operation.
2) The most controversial argument
against topical anesthesia is an intraoperative
complication. Consequently, the surgeon must
be highly skilled so as to:
a) expect as few intraoperative complications as possible. b) be able to convert to
another method of anesthesia during the intraoperative stage. Topical anesthesia by itself
may be insufficient for the surgeon to adequately handle intraoperative complications.
3) Topical anesthesia is not indicated in
all patients. This is particularly true in
anxious, stressed patients, people with hearing
limitations, children and very young patients.
4) The presence of a very opaque cataract is a contraindication to the use of topical

anesthesia (Fig. 1-B). This is because the
surgeon depends on the patient's capacity to
visually concentrate on the operating microscope light in order to avoid eye movement
during the operation. If he/she cannot fixate
well on the microscope light and maintain that
fixation, the eye will move. This may lead to
complications.
In essence, adequate selection of patients
is fundamental when considering the use of
topical anesthesia.
The Anesthetic Procedure of

Choice
It is the general consensus today among
surgeons experienced with phacoemulsification that a combination of topical anesthesia
(proparacaine 1% or tetracaine 1%) and 0.5 cc
of 1% unpreserved lidocaine irrigated into the
anterior chamber through a 30-gauge cannula
(Figs. 35 and 36) is the anesthetic procedure of
choice for small incision cataract surgery, particularly phacoemulsification. This important
breakthrough in ophthalmic anesthesia was
introduced by James Gills, M.D. in 1997.
Technique for Irrigation of Lidocaine

in AC
Dodick first makes a clear cornea incision using a 2.7 mm diamond knife. He believes
that the non-preserved lidocaine irrigated into
the anterior chamber anesthetizes the nerves
of the iris and the ciliary body. The pressure
waves that ensue during irrigation and aspiration in the midst of the phaco operation can
sometimes impinge upon those nerve fibers
and lead to discomfort. In addition, Dodick has
75
Figure 35: Topical Anesthesia

Unaided topical anesthesia is now
a commonly used method in small incision 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 topical anesthesia combined with intracameral anesthesia (Fig. 36) in small incision
cataract surgery. This illustration shows
the use of anesthetic drops (A) such as
proparacaine or tetracaine, one drop every 10 minutes, 30-45 minutes preoperatively.
observed that this anesthesia inside the eye

helps dull the patients sensitivity to the bright
light of the microscope by temporarily blocking some photoreceptor cells. The rest of the
operation is continued through the same clear
cornea incision.
Intraocular unpreserved lidocaine irrigated into the anterior chamber as outlined has
been proven safe and convenient.
Even though a few researchers (i.e. Gillow
et al, Boulton et al) have concluded that the
routine use of intracameral lidocaine as a supplement to topical anesthesia in routine
phacoemulsification does not have a clinically
useful role, these experiences constitute a significant minority and are based on postoperative
questioning of patients concerning discomfort
or by well documented trials but in medium
76
number of patients and by different surgeons.

In papers published based on monitoring patient discomfort, not by a subjective
questionaire, but by objectively measuring vital signs during surgery. the data support the
conclusion that patients operated with anterior
chamber irrigation of unpreserved lidocaine
feel comfortable during the procedure, despite
having had no intravenous sedation and regardless of sex or age and dismiss the subjective
nature of postoperative questioning patients
concerning discomfort. In view of the small
controversy existing, we must rely on the proven
extensive experience of well known, prestigious, cataract surgeons such as James Gills,
M.D., and Paul Koch, M.D., here presented.
An alternative technique for intracameral irrigation of 0.5 cc of 1% lidocaine is the
Figure 36: Use of Intracameral Anesthesia

After instilling anesthetic drops on the
conjunctiva and cornea (Fig. 35) the surgeon enters the anterior chamber through the ancillary
incision (I) (Fig. 41-A) using an insulin syringe
with a 30 gauge cannula (C). This maneuver is
one proposed by Paul S. Koch, M.D (Fig. 36).

He uses a 15 blade in his left hand and .12
forceps in the right hand. The blade is placed
where he wants the sideport entry incision and
the forceps 180 away from that, resting on the
peripheral cornea (Fig. 36). The forceps are
only pressed against the cornea. They do not
grab it, because the purpose of the forceps is
only to provide counter pressure for the incision. The blade is then used to make an incision
approximately 1 mm wide and 1 mm long,
beginning in the peripheral clear cornea.
That incision is completely comfortable,
because it is no more than a corneal manipulation, and the cornea is still anesthetized from
the original drops given in the holding unit.
Then, 0.5 cc of 1% unpreserved lidocaine
is irrigated into the anterior chamber through a
done with the aid of fine toothed forceps (F)

in the contralateral side of the ancillary incision acting as counterpressure. One dose of
0.5 ml of 1% unpreserved lidocaine is irrigated into the anterior chamber. The preliminary marking of the main incision is shown
in (A).
30-gauge cannula (Fig. 36). Most of the time,

the patient does not feel anything, but sometimes, either because of intraocular pressure
changes or the effect of direct flow onto the iris,
the patient may feel a little discomfort. This is
not a matter of concern because in a matter of
seconds the discomfort dissapears.
Koch squirts the little extra lidocaine
that remains in the syringe on the surface of the
cornea, providing additional topical effect. The
eye is not paralyzed, and an occasional patient
may move it, but this is not nearly the problem
that it is with topical anesthesia. The lack of
discomfort makes it unnecessary for the patient
to want to move the eye, and Koch as well as
Gills have found that cooperation in keeping
the eye still is excellent.
77
Injection of Viscoelastic
The eye anesthetizes quickly, and the
anesthesia is very profound. Usually in less
than 10 seconds, the eye is already anesthetized, and the viscoelastic injection is performed
quite comfortably.
What Can be Done with the Combined Anesthesia

Because the combination of topical and
intracameral irrigation anesthesia is so effective, the surgeon can perform cataract surgery,
lens implantation, iris manipulation, and even
vitrectomy if a complication arises usually
without any further injection of anesthetic. If a
patient does feel some discomfort, a second
irrigation may be performed. Patients with
mental retardation and those with deafness
have been successfully operated with this anesthetic combination as long as the surgeon takes
the time to explain prior to surgery that he
wanted them to look at the light and keep
looking at the light.
Side Effects of the Combined

Anesthesia
Lidocaine has an effective duration of up
to 4 hours. Patients may not see very well
immediately after the operation, but then a few
hours later the vision really improves. Koch
has concluded that patients have a temporary,
neuro-sensory, retinal blockade causing transient blurring of vision following the operation.
He has postulated that the anesthetic may diffuse back to the retina and perhaps has a direct
effect on the ganglion cells. Gills had a patient
with an open posterior capsule who had significant vision loss for about 24 hours after the
78
operation. This clinical observation may support Koch's hypothesis, because in the absence
of a posterior capsule the lidocaine could diffuse back toward the retina that much more
easily. As the lidocaine wears off, the visual
acuity and contrast sensitivities recover.
How to Manage Patients Who Feel

Pain and Discomfort
If the patient continues to blink or squeeze
the eyelids following the combined topical and
intracameral anesthesia, you can control this
with the sub-Tenon's injection of lidocaine as
illustrated in Figs. 33 and 34. The effect is
almost instantaneous, and surgery can continue without delay.
PHOTOTOXICITY IN
CATARACT SURGERY
Since all cataract surgery is done
under the microscope, we should clarify here
the practical and clinical aspects of light or
phototoxicity from the surgical microscope. It
has been demonstrated that in some patients
and under specific circumstances, toxicity from
the light of the microscope can affect the macula.
This is seen with fluorescein angiography,
which shows an area of pigment abnormality
usually below the fovea. The visual field in
these patients shows that in this area there is
severe to moderate phototoxic damage to the
photoreceptors. Without these tests,
phototoxicity can be difficult to determine and
to see.
The major factors involved with
phototoxicity are the time of exposure, the
tilt and the illumination intensity.
(It is
important to realize how hard it is to get away
from the macular area if we are centered over
the pupil).
The microscope has three light sources:

the two side lights and the coaxial beam. Each
of these light sources produces a focal point of
illumination on the retina. It is not the time
length of the operation that is important. It is
the time the light is focused on one particular area of the retina which is critical.
In addition, within the period which any
one operation lasts, sequential light exposure
to the same retinal area is additive. If we turn
on the light on one spot for three minutes, turn
it off and then turn it on that same spot for
another four minutes, the effects of those exposures are additive. If, in a certain patient and
with a certain intensity of light from the microscope, we expose one macular area during
three minutes, we may have no lesion whatsoever but if the total exposure extends to seven
and a half to eight minutes, a lesion may occur.
In the human eye, with the standard surgical
microscopes on maximum intensity of light,
it probably only takes four to eight minutes
to produce a retinal lesion. Most phototoxic
burns are seen in the inferior part of the fovea.
We should leave the light source on the
lowest setting.
The potential for trouble related to
phototoxicity in cataract surgery is not often
recognized. The patient may have 20/25 vision
postoperatively and still complain that he does
not see adequately. Only after fluorescein
angiography and a visual field can we then
explain why these patients complain. Even the
most experienced of us need to be aware of the
potential for phototoxicity and take the steps to
avoid it.
BIBLIOGRAPHY
Anders, N., Heuermann, T., Ruther K., Hartman,
C: Clinical and electrophysiologic results after intracameral lidocaine 1% anesthesia. Ophthalmology 1999; 106:1863-1868.
Boulton JE., Lopatatzidis A., Luck J., Baer RM.:
A randomized controlled trial of intracameral
lidocaine during phacoemulsification under topical
anesthesia. Ophthalmology, 2000; 107:68-71.
Series of Ophthalmic Surgery, HIGHLIGHTS OF
OPHTHALMOLOGY, Vol. II, 1996; 5:21-22.
Boyd, BF: Significant developments in local anesthesia. Highlights of Ophthalmol. Bi-Monthly Journal, Vol. 23, N 6, 1995 Series, pp 55-62.
Carreo E.: Phacoemulsification Sub-3 technique.
Guest Expert, Boyds BF., The Art and the Science
of Cataract Surgery, Highlights of Ophthalmology, 2001.
Fichman RA: Use of topical anesthesia alone in
cataract surgery. J Cataract Refract Surg, 1996;
22:612-614.
Gillow T., Scotcher SM., Deutsch J., While A.,
Quinlan MP: Efficacy of supplementary intracameral lidocaine in routine phacoemulsification under
topical anesthesia. Ophthalmology, 1999; 106:21732177.
Gills JP., Cherchio M., Raanan MG.: Unpreserved
lidocaine to control discomfort during cataract surgery using topical anesthesia. J Cataract Refract
Surg. 1997; 23:545-550.
Gills JP., Martin RG., Cherchio M.: Topical anesthesia and intraocular lidocaine. Cataract Surgery:
The State of the Art, Slack; 1998; 2:9-17.
Koch, PS.: Anesthesia. Simplifying Phacoemulsification, 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 medications of anesthesia. Current Opinion in Ophthalmology 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 Ophthalmology, Vol. 11 N 1, Feb. 2000.
Tseng SH., Chen FK: A randomized clinical trial of
combined topical-intracameral anesthesia in cataract 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
art" operation of choice for cataract surgery in
academic institutions and private eye centers
worldwide. Ophthalmologists in training (Residencies and Fellowships) receive training in
phacoemulsification first and manual extracapsular as a second choice.
COMPARING PLANNED
EXTRACAPSULAR WITH PHACO
EXTRACAPSULAR
With planned extracapsular extraction
an 8-9 mm limbal incision is performed,
preceded by a conjunctival flap (either limbal
based or fornix based). The anterior capsule is
usually opened with a "can opener"
capsulorhexis technique. Some surgeons have
developed the expertise to do a continuous
circular capsulorhexis. The nucleus is then
expressed with gentle pressure inferiorly such
that the lens is subluxated in its entirety into the
anterior chamber and out of the eye through a
superior limbal incision (Fig. 37). Aspiration
is used to remove the remaining cortex from
the capsular bag and viscoelastic is irrigated
into the anterior chamber and capsular bag
(Fig. 38). A PMMA intraocular lens implantation is performed (Fig. 39) and the
wound is sutured.
In planned extracapsular, which is still
ably and successfully performed by a significant number of ophthalmic surgeons, the final
visual recovery takes place slowly through a

period of 5 to 6 weeks.
In
small
incision
manual
extracapsulars such as with Blumenthal's
MINI NUC and Gutierrez manual
phacofragmentation, a foldable IOL may be
implanted. Both of these procedures are fully
presented in the Section on Manual Extracapsular Extraction in this same Volume following Phacoemulsification. Visual recovery is
much more rapid.
ADVANTAGES OF THE PHACO
TECHNIQUE
The phacoemulsification technique offers the following benefits and advantages over
planned extracapsular as outlined by Edgardo
Carreo: 1) it is performed through an incision 3mm or less in size which is self-sealing
and watertight thereby improving safety during the procedure. 2) It is significantly less
invasive thereby leading to much less ocular
trauma and consequently less postoperative
inflammation. 3) It results in minimal or no
induced astigmatism. 4) It provides much
more rapid visual and physical recovery and
prompt refractive stability. The visual recovery is immediate if topical anesthesia is used.
All these advantages lead to an important increase in the patient's quality of life. In addition, a smaller incision also may reduce the risk
of endophthalmitis.
83
Figure 37: Planned Extracapsular

With planned extracapsular, the anterior
capsule is opened with a "can opener"
capsulorhexis technique. The nucleus is expressed 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

ASSOCIATED WITH PHACO
The opening of the anterior capsule is
done as a continuous curvilinear capsulorhexis
(CCC) as described by Gimbel et al (see Figs.
43, 44, 45). An ultrasonic probe (Figs. 50-A
and B) is used to emulsify the nucleus and
draw it out of the eye through an aspiration
port (Chapter 8). This allows the removal of a
10 mm cataract through a 3 mm incision (or
less). Because the integrity of the anterior
chamber is maintained throughout the procedure, the intraocular pressure is subject to less
fluctuation and poses much less of a risk for
suprachoroidal hemorrhage.
84
Removal of the lens by phacoemulsification is followed by placement of a posterior

chamber foldable intraocular lens implant
through a 3 mm incision. The wound may
require one or no sutures. Variations of
technique may involve a superior limbal incision with dissection of a sclero corneal tunnel
to form a self-sealing valve incision, a clear
corneal incision with corneal tunnel and selfsealing valve incision (with experienced surgeons) and the scleral tunnel incision which is
used increasingly less but is a safe procedure
for difficult cases (Figs. 40, 41, 42). The limbal
and the corneal incision are either placed at 12
o'clock or in the superior temporal quadrant.
The limbal incision and tunnel is the proce-
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 viscoelastic liquid. A cannula (C) is placed
into the capsular bag at position (B) and
viscoelastic (V) injected (arrows). The cannula is inserted across the anterior chamber
to a position (A) and as the cannula is
withdrawn, viscoelastic (V) is injected (arrows). Replaced fluid (F) flows out through
the incision. The viscoelastic will help to
protect corneal endothelium, posterior capsule and iris during insertion and intraocular
manipulation of the lens implant.
Figure 39 (below left): IOL Implantation in

Planned Extracapsular
Following aspiration of the remaining 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 superior loop shown here is then inserted into the
superior capsular bag.
85
dure of choice for surgeons in the transition

stage or who do not have a large cataract
surgical volume because it allows conversion
into extracapsular if necessary. Enlargement of
a corneal incision in order convert to an extracapsular extraction, often results in intolerable
postoperative astigmatism.
Both standard polymethylmethacrylate
(PMMA) or foldable (acrylic, silicone or hydrophilic) intraocular lenses may be used. A
foldable lens allows for an even smaller incision and less risk of postoperative astigmatism
as a result of wound construction. Because of
the watertight wound construction of this
method and the stability of the anterior chamber during phacoemulsification, this technique
is amenable to topical anesthesia in a cooperative patient (Fig. 35) or a combined topical and
sub-Tenon's local anesthesia, (Figs. 33, 34) or
a combined topical and intracameral anesthesia ( Fig. 36) advised by Gills. The choice
mainly depends on the experience and skill of
the surgeon , but there may be special considerations such as difficulty in communication
with the patient and in cases complicated by a
patient's poor general health.
86
tion is equipment and instrument-dependent as

well as team-dependent, because the team assisting with surgery must fully understand all
the steps of the operation and, by all means,
how the phaco machine works.
The Importance of Mental Attitude

Understanding the workings of the phaco
machine requires a complete change in mental
attitude and the undergoing of a rigorous training not only in the surgical technique, but
learning to use two feet (microscope and
pedal) instead of one (microscope). The surgeon must also be attentive to the perception of
different sounds emitted by the machine, each
one signaling a different function and parameters which in turn the surgeon must act upon.
It is essential for the physician to understand
exactly how to obtain the optimal use of the
machine, the rationale behind it, the fluid and
phacodynamic processes within the machine
and the eye and how to manage safely the
equipment, safely, including the various
handpieces and, of course, the phaco power,
and the irrigation and aspiration (see Figs. 49A through 65).
LIMITATIONS OF
PHACOEMULSIFICATION
Motivation to Undertake this Task
Surgeons who have a successful clinical

practice, ample experience and well earned
prestige and are using planned extracapsular
are understandably reticent and apprehensive
about shifting from a technique they already
master to one which depends a great deal on the
understanding of how the phaco machine functions. 50% of the success in doing phacoemulsification depends on the proper use of the
equipment at each stage of the operation. Ophthalmic surgeons are used to depend on their
surgical skill. It is part of their self-esteem. As
emphasized by Centurion, phacoemulsifica-
This is not an easy task. The multiple

mechanical functions of the equipment are not
"friendly" to those physicians who , althoufh
excellent surgeons, are not mechanically
minded. Only the knowledge that such a
change, if successfully done, will be best for
his/her patients can serve as the motivation to
undertake such a significant step.
For all these reasons, many excellent
surgeons decide not to enter into phaco, and
many others have the equipment available in
their eye center or hospital but allow it to
remain idle.
In order to overcome these negative aspects of phacoemulsification, it is fundamental

to have a smooth transition into phaco. In order
to achieve it, it is essential that you read and reread the next chapter (Chapter 7), which presents the very best ways to achieve a successful
transition with little stress or apprehension.
The significant economical savings to

the patient from lost working hours with ECCE
vs almost immediate recovery with phaco and
the improved quality of life with phaco are
other major important contributions. All these
are important features to consider when the socalled expenses for both operations are taken
into account.
Comparison of Costs - Phaco vs ECCE

One of the strong limitations of phaco
has been the cost of not only the phaco equipment but also the supplies related to its use.
This is important for a significant number of
ophthalmologists when operating on patients
who are not economically advantaged.
Fixed Costs with ECCE

Let us analyze, however, the updated
situation related to costs of performing phacoemulsification, and compare it with the costs
of the supplies needed to perform extracapsular extraction. With the latter, there is the cost
of very fine sutures, which are unnecessary in
phaco; there is the cost of local anesthesia
involved with either a retrobulbar or a paraocular
injection versus phaco in which only topical
sometimes with intracameral anesthesia is utilized. The cost of the postoperative injection of
steroid in the fornix often done following extracapsular is also unnecessary with phaco although the trend now is to inject steroid in the
anterior chamber (see Chapter 5). The cost of
even a fairly short stay in the recovery room
following the often used sedation needed with
an extracapsular extraction for anxiety is higher
than in patients with phacoemulsification who
have had only topical anesthesia without sedation and walk to their home within a few
minutes following surgery.
Phaco's Progressively Decreasing

Investment
What about the high expenses with phaco
equipment? There was a time when the equipment or phaco machine required a significant
investment. The supplies or tubing needed for
each patient was also a heavy expense when
performing several cases. All this has changed
due, in great part, to the ingenuity and understanding by the industry that these high expenses and initial investment were a significant barrier which prevented more ophthalmic
surgeons from adopting phaco.
At present, most of the companies that
manufacture phaco units are helping physicians and hospitals to acquire the equipment
and supplies. The equipment is made available
at much more reasonable prices than their real
sales cost, with the understanding that there
will be a monthly utilization by the surgeon of
the phaco supplies of that particular manufacturer. In addition, the manufacturer provides
advice and hands-on-training by experts to the
surgeon so that he/she will be able to enter into
the transition period (Chapter 7) utilizing his/
her own personal equipment acquired from
that manufacturer.
The "tubing" which previously had to be
discarded after each operation is no longer a
problem cost-wise. Now it may be used for as
many as 60 cases in the same day. No re-
87
sterilization is needed. The tubing may be

used without replacement for a complete day
of phaco surgery. Upon completion of all the
phaco cases in one day, the tubing must be
discarded. Therefore, by programming the
surgeons cases accordingly, a great deal of
savings can be made.
All of this makes the phaco technique
more accessible to a larger number of surgeons.
We still have to cope, however, with the needs
of surgeons in countries in which the gross
national product is very low.
Major Limitations in Non-Economically Advantaged Countries

Experts in programs for rehabilitation of
sight in large numbers of indigent patients-such as Francisco Contreras, M.D. in Peru,
Everardo Barojas, M.D. in Mexico, Juan
Batlle, M.D. in the Dominican Republic,
Newton Kara, M.D., in Brazil,-- all of whom
are magnificent surgeons with a large private
practice but also do a great deal of service to the
communities, have stated that most patients in
this category earn no more than US$1.00 (one
dollar) a day and that the maximum that can be
charged to a patient for a cataract operation
should be what that particular patient earns in
one month.
88
This is important information that needs

to be appreciated by cataract surgeons throughout the world interested not only in the progress
of the technology of our profession but also in
the humanitarian aspects of what we do best
which is ophthalmology.
It is also of great interest as outlined by
Contreras that the number of phaco operations being performed has increased in those
countries with the highest gross national product per person. In countries where earnings by
patients are low, phaco is still behind. In many
countries, only 5 to 10% of the population can
afford phacoemulsification in spite of the facilities that we have outlined. Of the rest,
thirty percent of the population has a mid-level
of income, 30% are very poor, and 30% of the
population are in extreme poverty.
As we continue to progress in the technological
developments of ophthalmology, which is a
blessing, we also need to be aware of the
limitations existing in the populations of many
countries throughout the world.
An exemplary case is that achieved by
Professor Arthur Lim, M.D., in Singapore,
who has put together significant funds from
private organizations and has trained large numbers of young ophthalmologists to learn these
modern techniques to combat blindness in South
East Asia and China.
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.
Carreo E.: Phacoemulsification Sub-3 technique.
Guest Expert, Boyds BF., The Art and the Science
Drews, RC: Medium-sized and small incision extracapsular 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 Capsulorhexis (PCCC). World Atlas Series of Ophthalmic 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
BY STEP CONSIDERATIONS
Complete comprehension of what is
presented in this chapter is essential for the
successful undertaking of phacoemulsification.
Before you read it, we strongly recommend
that you first read Chapter 6 which refers not
only to the unquestionable advantages of phaco
but to its limitations, most of which are related
to the challenge of understanding how the
phaco machine works and how to attain its
optimal use.
Equipment - Dependent and

Phase-Dependent Technique
The transition from planned extracapsular extraction to phacoemulsification fundamentally refers to the gradual change that the
ophthalmic surgeon who already masters the
planned extracapsular must undertake in order
to dominate the new technique of phaco, which
is equipment-dependent. This transition should
be progressive and atraumatic. As the surgeon
advances step by step, he or she should never
go on to the following step if he has not
dominated the previous step. This operation
is also a phase-dependent technique, as emphasized by Centurion. Each phase must be
completed with the precision of a watch maker.
If you pass on to the following step without
mastering the previous step, complications may
arise with consequent failure and grief. This
learning curve is achieved with effort, dedica-
tion and proper training to perform each phase

of the transition well.
Outlining the steps necessary in the
transition from extracapsular surgery to phacoemulsification, we will present you a detailed picture of what it really takes to enter
into the transition and to master the learning
curve. We will describe and fully illustrate
each one of the steps in sequence.
For young ophthalmologists who enter
directly into phacoemulsification in their training, this "bitter pill" of changing from planned
extracapsular to phaco is an experience they
will fortunately miss. But when they later
teach others who have not been trained in
phaco, but learned and have spent their career
doing extracapsular instead, they need to recognize - as we do in this presentation - the
difficulties their colleagues face, and teach
accordingly. Extracapsular surgeons still constitute the majority of ophthalmologists worldwide.
Mental Attitude
The surgeon must be absolutely convinced that changing from planned extracapsular to phacoemulsification will be best for his
patients, particularly because of a very rapid
visual recovery and physical rehabilitation back
into normal life. As long as the surgeon is not
completely persuaded of the reasons why he
wants to take this crucial step in his professional development, he will never attain a
positive experience during the transition with
93
maximum safety, low risk and high benefits for

the patient and minimal stress for him/herself.
The fact that phaco also significantly shortens
the waiting period for cataract surgery in the
second eye, that it has 50% fewer complications than ECCE and that the operation can be
done while the cataract is still in its early stages
(20/40 vision, lowered contrast sensitivity and
glare intolerance) should be another strong
incentive to adopt phaco (See Chapter 6). The
usual reasoning that the planned extracapsular
surgeon assumes are thoughts like: "If I do so
well with planned extracapsular, why change?".
This is particularly true when your practice is
mostly composed of private patients, some of
them important persons in the community and
no risks can be taken. The successful extracapsular surgeon continues to find reasons for not
making the change, such as: "I have very little
postoperative astigmatism with planned extracapsular, so why get into the problem of operating with a smaller incision and the difficulties
that may arise?" "The visual recovery comparing the two techniques after several weeks is
about the same; I am not in a hurry for my
patient to attain a prompt visual result as long
as the final visual recovery will be the same."
"It is better for the patient to have a good
planned extracapsular than a bad phaco." "I
know that with planned extracapsular I will
have practically no complications, but I am not
so sure that such will be the case with phaco,
particularly in the early cases."
In essence, the surgeon has to make his/
her decision rationally and on his or her own
initiative. This will provide the stimulus and
the perseverance in order to enter into the
learning curve and the perseverance to eventually master what is considered one of the best
94
operations in the field of medicine. Once the

decision is made, it must be followed through
with firmness and resolve.
UNDERSTANDING THE PHACO

MACHINE
A successful phacoemulsification depends essentially on two factors: 1) the surgeon's
skill; 2) the surgeon's and his team's understanding of how the phaco machine works.
It is fundamental for the surgeon to have
a thorough and practical knowledge regarding
the specific equipment that he is using and how
the technology of phaco machines in general
operates.
Becoming Familiar with the

Equipment
Becoming first familiar with the phaco
machine in an experimental laboratory first, is
the best way to learn and understand how the
equipment works. This has been reemphasized
once and again by Virgilio Centurion M.D.,
one of the world's best cataract surgeons who
has dedicated a great deal of his valuable time
to teach the transition through courses and
publications. His recommendation is to practice first in the laboratory the use of both hands
and the four positions of the phaco machine
foot pedal so as to become familiar, comfortable, and adept with the parameters of the
machine (Figs. 52, 53). For more sensitive
control of the phaco machine foot pedal, use a
shoe with a thin sole (keep it in the operating
room) and use your dominant foot (equivalent
to the dominant hand). Control the surgical
microscope with the non-dominant foot.
Practice using both hands can be attained

with pig eyes and synthetic eyes in synthetic
heads, often coached by the company representative from whom you acquired the phaco
machine and equipment. The surgeon can also
practice with a human ocular globe supplied by
large Eye Banks or with pig eyes removed soon
after the animal is sacrificed. These globes
should be refrigerated, not frozen, with the
cornea protected with a sponge. When placed
in a 700 W microwave oven for 4 seconds, the
lens develops a subcapsular cataract. After 9
seconds, 50% of the lens will be opaque and
hard.
Two Hands, Two Feet and Special

Sounds
The surgeon should dedicate appropriately extensive time in the laboratory towards
acquiring complete self-assurance in the use of
the machine, coordinating his or her hands and
the two foot pedals. Additional time may be
used to practice how to make the new, smaller
incision, the capsulorhexis and other surgical
steps. Phaco is mostly a two-handed technique, so you must become trained and develop
reflexes to use both of your hands and both of
your feet, together.
During training in the laboratory, the
surgeon grasps how the machine works during
each step of the operation, learns the method
for introduction of the phaco tip and the most
comfortable position in which to place the
handpiece; why and when to elevate or lower
the height of the fluid bottle, when to increase
or decrease the flow of fluid or the vacuum and
when to increase or decrease the power of the
phaco. These parts of the learning curve are
mastered in the laboratory so as to really
understand and become fully adept with the
functions of the equipment before entering the
patient's eye.
While learning to use the machine's foot

pedal you must also perceive the significance
of the sounds of the machine which vary
depending on the surgical step or stage, such as
the balance of flow when the phaco tip is not
occluded (Figs. 57, 58), and the sounds alerting
the surgeon to changed in fluid dynamics when
there is occlusion of the tip. In each instance,
the surgeon receives a sonic feedback, constantly informing him about the state of the
fluid dynamics in the eye (Figs. 59, 60). So the
surgeon must learn to use both hands, both feet,
and to listen to the phaco machine.
In essence, experimental training first in
the laboratory is the best investment the surgeon can make to shorten and successfully
transverse the learning curve. It is a necessary
experience to learn the workings of the equipment fully. Its main aim is not that of learning
the surgical technique at this stage. That comes
later. We must not improvise or try to learn
the use of a phaco machine in the operating
room. The surgeon should not begin learning
the use of the machine directly on a patient's
seeing eye.
Main Elements of Phaco Machines Their Action on Fluid Dynamics

In this chapter we will thoroughly discuss the optimal use of the phaco machine and
the rationale behind it, the three elements of
most phaco systems (irrigation, aspiration and
ultrasonic energy), fluidics and phacodynamics, the importance of and understanding of the
Surge Phenomenon. The rationale behind high
vacuum - low ultrasound power technology,
the new technology of the peristaltic pump,
particularly in the three main equipment sources
available such as the Alcon's Legacy 2000,
Allergan's Prestige (and the Sovereign) and
Storz Millennium and some useful informa-
95
tion about the new phaco tips and their contribution toward a better operation.
Hydrodissection and Hydrodelineation
COMPARISON OF SURGICAL
TECHNIQUES FOR TRANSITION
VS EXPERIENCED SURGEONS
These techniques remain essentially the

same for the transition and in advanced surgeons (Figs. 46, 47, 48).
Epinucleus Removal
There are several techniques in phacoemulsification that remain practically the
same for the surgeon who is undergoing the
transition and those who are more experienced.
On the other hand, there are stages of the
operation in which there are definite variations
for the experienced surgeon, some of them
minor, others moderate and others major.
We have divided the subjects into two
(2) groups: 1) those that are the same for all
surgeons and 2) those that vary depending on
the skill of the surgeon for this particular operation.
Techniques Which Are the Same

for the Transition and for
Advanced Surgeons
Capsulorhexis
These parts of the technique are practically the same for both groups, with slight
individual variations (Figs. 43, 44, 45). The
main feature that may vary is the size of the
capsulorhexis. Some very advanced surgeons
do a small capsulorhexis, while in the transition a somewhat larger capsulorhexis is advisable, depending on the size of the IOL to be
implanted.
96
This technique does not vary substantially in the transition from that used by advanced surgeons (Fig. 69).
Cortex Removal
The technique is the same for both groups
(Figs. 70, 71). It is important not to feel overconfident at this stage and by all means avoid being
aggressive.
Techniques that Vary According

to the Skill of the Surgeon
Anesthesia
In the transition, the surgeon may use
parabulbar or Sub-Tenon's (flush) anesthesia
using Greenbaum's cannula (Figs. 33, 34), particularly because conversion to ECCE may be
needed. It is only advanced surgeons who may
use topical anesthesia alone or combined with
intracameral irrigation anesthesia (Figs. 35,
36).

In the transition, the surgeon does need
to fixate the globe, passing a suture through the
superior rectus, versus the experienced surgeon who does not need to do so.
The Incision
Sclero corneal tunnel, limbal tunnel, corneal tunnel: these three types of incisions depend on the skill and experience of the surgeon.
In the transition it is important to use the
stepped incision starting at the limbus and
performing a sclero corneal tunnel based on a
limbal incision, in case there is need to revert
to a ECCE. During the transition, it is always
important for the surgeon to know that he/she
may revert to ECCE whenever they feel uncomfortable with the surgery at any specific
stage. Only more advanced surgeons should do
the corneal incision and tunnel (Figs. 40, 41,
42).
Type of IOL
Foldable lenses should only be used
by advanced surgeons. PMMA oval lenses
5.0 x 6.0 mm are the standard in the transition
(Fig. 72-A).
Nucleus Removal
There are many different techniques that
may be utilized by advanced surgeons. They
will be discussed in a separate chapter. For the
transition, the basic technique to use when
beginning phaco is the "divide and conquer"
into four quadrants. "Divide and conquer" is
usually done with two hands (Fig. 56). The
surgeon must also learn, however, how to perform this technique with one hand.
SURGICAL TECHNIQUE IN THE TRANSITION

Anesthesia
During the transition it is advisable that
the surgeon utilize the type of anesthesia with
which he/she feels more safe and in better
control (Figs. 33, 34). It is unnecessary to add
a new source of stress or immediate change at
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
topical anesthesia because of its ability to provide immediate visual recovery. The combined use of topical anesthesia and intracameral anesthesia is more effective than topical
anesthesia alone and should be tried before the
surgeon attempts to operate using topical anesthesia alone (Figs. 35, 36). I recommend that
you consult Chapter 5 on this important aspect

of the operation.
The Incision
How to Make a Safe Transition from
Large to Small Incision
Role of the Ancillary Incision
This is an important step in performing
phacoemulsification. Although there are techniques to perform it with only one hand, phaco
is fundamentally a two-handed procedure.
The ancillary incision is made before the
main incision is performed. As shown in
97
Fig. 41, this incision serves as an entry for a

second instrument which is necessary for maneuvers to remove the nucleus (Fig. 56). This
wound is also utilized in irrigation of the
anterior chamber with intracameral local anesthetic as explained in Chapter 5 and illustrated
in Fig. 36, and for the insertion of viscoelastic
previous to making the main incision and during several other steps of the operation. However, some advanced phaco surgeons do not
perform hydrodelamination and remove the
epinucleus usually during the emulsification
of the nucleus.
At the end of surgery, the ancillary incision also serves to inject fluid into AC to test for
leaks in the wound (Fig. 73).
The Main Incision

During the early stages of the transition,
the surgeon should plan to start the operation
as a phaco but learn how to convert to the
planned extracapsular he or she is accustomed
to do successfully if this becomes necessary.
This will provide additional comfort and con-
fidence. The surgeon may start with a small

stepped limbal valvulated incision slightly
larger than the phaco tip (Fig. 42) even though
he knows that he plans to convert to his usual
planned extracapsular. It is not advisable to
start the transition with a corneal incision
because, upon enlarging it, the resulting astigmatism may be severe. The more anteriorly
located the incision, the more astigmatism the
patient may end up with. By starting the
transition with a limbal incision, the surgeon
will use the same area for the incision that he is
accustomed to use in his planned extracapsular
but will make the incision valvulated (stepped)
and smaller than th e usual extracapsular
(Figs. 40, 41, 42). The surgeon must master the
technique of the small incision valve like incision 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
convert from phaco to planned extracapsular
and therefore will not need to enlarge the incision, he may choose to make a corneal incision
if he wishes, but not before (Fig. 40-C). This
is what we refer to as a safe transition from a
large to a small incision, a transition that must
Figure 40 A-C (See Facing Page 101): Phacoemulsification Incisions - Surgeons 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 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 introduce a second instrument as shown in
Fig. 67, inject intracameral local anesthesia as shown in Fig. 36 and irrigate
viscoelastic into the anterior chamber.
Figure 41 B: Initial Stages of SelfSealing, 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 chamber 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

progresses in his learning curve (Figs. 40, 41,
42).
Later, as he progresses and learns to
master phacoemulsification, the surgeon is
ready to make two significant changes in the
technique: 1) Operate from an oblique position
and make the incision in the upper right quadrant, temporally as shown in Figs. 41-B and 42;
2) Perform a corneal incision (Fig. 40-C) instead of a limbal incision (Figs. 40-A, 41-B, 42
Role of Conjunctival Flap

In the early stages of the transition, the
surgeon may prefer to start with a small fornix
based conjunctival flap from 10:00 to 2:00
o'clock, and place light cautery under each
edge of the flap. If the limbal incision is
extended because one of the initial phaco steps
becomes a source of problem and there is need
for conversion to ECCE, there will be less
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 prefer 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 Vshaped 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.
This again is a vital step in the transition.
Changing from the can opener capsulotomy
(Fig. 37) to the anterior continuous circular
capsulorhexis (CCC) is one of the fundamental
steps in the transition (Figs. 43, 44, 45). The
surgeon must learn first by practicing
capsulorhexis on the skin of a grape or by using
a very thin sheet of plastic wrap such as the one
that covers some chocolate candies. Once the
surgeon understands the concept of the technique and can do it in the laboratory, he or she
may begin to use it for the patient.
The surgeon must keep in mind that the
space needed to adequately maneuver the cystotome (Fig. 43) or the capsulorhexis forceps
(Figs. 44, 45) in order to do a proper continu-
102
ous circular capsulorhexis is larger than the

wound or paracentesis required to simply introduce a cystotome and perform a can opener
capsulotomy.
It is highly recommended to make the
capsulorhexis under sufficient viscoelastic .
The latter should be injected into the anterior
chamber as a first measure before trying the
capsulorhexis (Fig. 2). It is also fundamental
not to begin with dense, hard cataracts where
it is difficult to see the edge of the capsulorhexis.
It is prudent to try performing this procedure
over and over again in cataracts that are less
dense until the surgeon is able to perform them
in eyes with poor visualization of the edge of
the capsule.
Because the surgeon, in the initial stages
that we are discussing here, will most probably
Figure 44 (above right):Continuous Curvilinear Anterior Capsulorhexis with ForcepsStep 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 extended 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 manner for the remaining 180 degrees, as initially
described by Gimbel.
Figure 45 (below right): Continuous Curvilinear 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

perform two relaxing incisions radially in the
anterior capsule at 10 and 12 o'clock following
the CCC, in order to facilitate the removal of
the complete nucleus with a planned manual
extracapsular. If these relaxing incisions in the
anterior capsule are not done, the surgeon may
confront serious problems in removing the
nucleus (Fig. 37).
Hydrodissection
Once the surgeon is able to perform a
circular continuous capsulorhexis (CCC) without problems, he is ready to go into the next
step, which is hydrodissection (Figs. 46, 47,
48). This step should not be undertaken before
mastering the capsulorhexis. If not, tears in the
anterior capsule may extend towards the equator when performing the injection with fluid to
do the hydrodissection. The surgeon should
have clearly in mind the anatomy of the crystalline lens and what is it that he is after with
hydrodissection (Fig. 1). With this maneuver,
by using waves of liquid (Figs. 46, 47, 48) we
wish to separate the anterior and posterior
capsules from the cortex (Figs. 46, 47) and the

nucleus from the epinucleus (Fig. 48). When
this is achieved, the nucleus is liberated so that
it will be free for the ensuing maneuvers of
rotation, fracture and emulsification, all of
which will come as the next steps in the
procedure (Figs. 55, 56). As long as the
surgeon is not sure that the nucleus has been
freed of its attachments through the
hydrodissection and will rotate easily, he should
not proceed to try to rotate it mechanically
because this may lead to rupture of the zonules.
Also, if the nucleus is not separated from the
cortex by hydrodissection (Fig. 48), the surgeon should not proceed to apply the phaco
ultrasound to the nucleus because he or she
may well meet with complications by extending the effects of ultrasound not only to the
nucleus but peripherally to the cortex. This can
lead to the feared rupture of the posterior capsule. Instead, the surgeon should decide to
convert to a ECCE. Although Fig. 47 shows
hydrodissection through a corneal tunnel
(surgeon's view), keep in mind that all maneuvers during the transition are done with a
limbal incision, as shown in Figs. 40 A, 41, 42.
Figure 46 : Hydrodissection - Stage 1

- Separation of the Anterior and Posterior 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) extends along the posterior capsule, separating 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 cortex at the various locations shown in the ghost
views. BSS is injected at these locations (arrows) 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 Epinucleus 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

PHACO MACHINE
Getting Ready to Use Phaco
During Transition
Optimal Use of the Phaco

Machine
We have already emphasized the crucial

importance of understanding how the phaco
machine works in order for the surgeon to
perform phacoemulsification successfully. This
is a task every cataract surgeon must undertake
when contemplating the use of phaco in his/her
The Rationale Behind It Main Functions
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 variable 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 provided 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
patients. It must be achieved first in an

experimental laboratory before attempting to
operate on humans with seeing eyes, as emphasized by Centurion.
Edgardo Carreo, M.D., one of South

America's top phaco surgeons and teacher,
describes the three main functions of the
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;

and 3) fragmentation of nucleus. This is
clearly shown in Figs. 49-A and 49-B. Irrigation is done with the irrigation bottle,
aspiration with the aspiration pump and
fragmentation with ultrasonic energy
through the titanium needle present in the
phaco tip of the hand piece (Figs. 50-A and

50-B). Many types of phaco tip shapes have
been created to more efficiently handle
nuclear extraction, as shown in Fig. 51. A
command pedal, which is controlled by the
surgeons foot, guides the machine into 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
180 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 mechanism of the handpiece containing the ultrasound
generator. The ultrasound power oscillates between 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 oscillation is axial.(After Seibel, B.S., Phacodynamics,
3rd Ed., 1999, p. 99, Slack, as modified by HIGHLIGHTS).
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- 15 bevel, C-30 bevel, D-45 bevel, E-bent 45 tip, F-rectangular tip, Genlarged 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

irrigation-aspiration and position 3 for irrigation, aspiration and phacoemulsification
(Figs. 52 and 53).
The first function (irrigation) controlled by the foot pedal is provided by a
bottle with BSS. The liquid flows by gravity.
The amount of liquid that reaches the anterior
chamber depends on the height of the bottle,

the diameter of the tubing and the pressure
already existing in the anterior chamber
(Figs. 49-A, 49-B, 54). The flow rate into the
eye is determined by the balance of the
pressure in the tubing - regulated by the
height of the bottle, and the back pressure in
the anterior chamber. When the two are
109
Figure 52 (above left): Basic Phaco Foot

Pedal Functions
The foot pedal controls inflow, outflow, and ultrasonic rates. With the foot
pedal in the undepressed position, the inflow
valve is closed, the outflow pump is stationary, and there is no ultrasonic energy being
delivered to the phaco tip. With initial depression 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 fragmentation.
Figure 53 (below right): New Dual LinearLateral Pedal Control

A new pedal control separates the inflow-outflow and ultrasonic power functions.
The inflow (1) - outflow (2) function is controlled 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 allows 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 maximum inflow and outflow. There are
phacoemulsification maneuvers when this is not
desirable. A low inflow-outflow rate, for instance, may be desired when engaging
ultrasound.
110
equal, there is no flow. If there is leakage or

aspiration of fluid from the anterior chamber,
the pressure there drops, and fluid in the
tubing flows in to restore the pressure in the
AC, and, indirectly thereby, the volume. The
tubing is purposely made wide enough so that
it impedes the flow of the BSS only slightly
under normal rates of flow. It does limit
maximum flow - during anterior chamber
collapse for example, unfortunately, however.
Figure 54: Irrigating Bottle Height Related to Flow Rate Hydrostatic and Hydrodynamic Stages
Bottle height (C) has the important function of providing constant chamber pressure during all phases of surgery,
including during times of sudden changes in outflow rates.
Maintenance of safe intraocular pressure is important in both
"hydrostatic" (A - no fluid moving within the fluidic circuit)
and "hydrodynamic" situations (B - fluid moving within the
circuit). A bottle height of 45cm above the eye will provide an
approximate 30mmHg of intraocular pressure (I) when no
fluid is moving in the circuit (hydrostatic state A) when there
is no aspiration taking place and the aspiration pump (E) is off.
When the aspiration pump (J-arrows) is turned on, (hydrodynamic 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 proportionally 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 aspiration, is provided by a pump, which creates a

difference in pressure between the aspiration
line and the anterior chamber. The pumps
may be a peristaltic pump, a Venturi pump, a
diaphragm pump, a rotary vane pump, or a
scroll pump. The peristaltic pump has
become the most widely known and used.
Many feel it is safer. Just like inflow, a base
level of suction occurs whenever the pump is
activated, depending on how hard the pump is
working. When there is occlusion of the tip
with the foot pedal in the aspiration position
(position 2), the pump will continue to pump
and crate more and more suction until the
material which is provoking the occlusion is
aspirated, or until the suction in the tubing
reaches the maximum that the surgeon has
preset on the control panel (Figs. 59, 60, 61).
This latency period before reaching maximum suction level provides a greater security
margin allowing the surgeon to take immediate action in case the tip grasps (and sucks in)
the iris or the posterior capsule instead of
grasping the lens mass. In order to perceive
what happens to the fluid dynamics when the
phaco tip is not occluded, please see Figs. 57,
58. The reason for limiting the maximum
suction pressure is to limit the rush of fluid
out of the eye the moment the fragment which
occluded the tip is aspirated. This provides
the surgeon the opportunity to stop aspiration
and avoid collapse of the anterior chamber.
The third function of the phaco machine - the production of ultrasonic vibrations leading to fragmentation of the lens is carried out by a crystal transducer located
in the handpiece, which transforms high frequency electrical energy into high (ultrasonic) frequency mechanical energy. The
crystal drives the titanium tip of the phaco
unit to oscillate in its anterior-posterior axis.
112
It is precisely the anteroposterior oscillation

of the phaco tip which produces the emulsification (Figs. 50-B, 55, 56, 67, 68).
Parameters of the Phaco Machine

What are the phacoemulsification machine parameters? How are they utilized?
These parameters need to be set and reset
depending on the type of cataract: soft,
medium-hard, very hard, (as shown in
Fig. 2); the stage of the operation; and also,
importantly, the various situations which the
surgeon must solve. These parameters are:
1) the amount of ultrasonic energy
applied to the nuclear material for its emulsification. It is expressed as a percentage of the
phaco machines available power and it determines the turbulence which is generated in
the anterior chamber during surgery. It is
ideal to use the least amount of power
possible during the operation. This is possible by combining other functions of the
machine and maneuvers within the nucleus to
facilitate fracture and emulsification of the
lens. The use of excess phaco energy may
result in damage to structures beyond the
nucleus, such as the posterior capsule and the
endothelium.
2) The aspiration flow rate. This
measures the amount of liquid aspirated from
the anterior chamber per unit of time. In
practical terms, this determines the speed
with which the lens material is sucked in into
the phaco tip. This is synonymous with the
power of "attraction" or suction of the lens
fragments into the irrigation-aspiration handpiece (Fig. 61). High maximum flow rates
may result in collapse of the anterior chamber
if the irrigation cannot keep up.
3) The third parameter measures the
vacuum or negative pressure created in the
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

force with which the material is fixated onto
the orifice in the phaco tip. This is known as
fixation power or grasp and depends on the
aspiration force (Figs. 59-60, 61). The
higher the aspiration pressure, the more rapid
the aspiration flow, and the less the amount
of time it takes to obtain the maximum
vacuum power. If the occlusion at the tip is
broken or interrupted, due to the negative
pressure in the aspiration line, fluid is
rapidly sucked out of the eye. This may lead
to collapse of the anterior chamber with risk
of damage to the corneal endothelium as well
as the posterior capsule. This is known as the
Surge Phenomenon (Figs. 61-65).
114
in order to keep the nucleus fragments close

to the phaco tip and prevent the vibrating
effect from repelling the fragments from the
tip opening. We need a higher flow of aspiration to bring the fragments of the nucleus to
the tip of the handpiece and make the procedure faster.. In this Memory 2, we also need
higher vacuum since here we need to have
good grasping power to hold the fragments
against the phaco tip so that we can proceed
to emulsify them. Memory 2 is the memory
for fragment mobilization and emulsification.
In Memory 3: removal of epinucleus,
all the parameters are lowered considering
that the epinucleus is soft. Memory 3 is
specifically for the epinucleus, whenever it
exists.
How to Program the Machine for

Optimal Use
Fluid Dynamics During Phaco
We have already discussed the phacoemulsificators settings which include the ultrasonic power, the aspiration flow, which is
the power of attraction and the vacuum,
which is the grasping power.
In order to perform a rational phaco,
we must know how to program or calibrate
the "memory" of the machine. There are
three memories in the machine. Memory 1 is
for sculpting the nucleus( Figs, 55, 56),
Memory 2 is for fragmentation, mobilization
and emulsification of the nuclear fragments
(Figs, 67, 68) and Memory 3 is for removal
of the epinucleus, when this exists (Fig. 69).
In Memory 1: nuclear sculpting, we
need high ultrasound power with low flow
and low vacuum since at this stage we do not
need any fixation or attraction power.
In
Memory 2: nuclear fragmentation, however, we need low ultrasound or phaco power
Michael Blumenthal, M.D., has made

profound studies on this most important subject. Its understanding really makes a difference between success and failure in small
incision cataract surgery, particularly in phacoemulsification.
There are two factors
specifically involved: 1) the amount of inflow and 2) the amount of outflow during
any given period of the surgery. Fluid dynamics are responsible for the following intraocular conditions during surgery: a) fluctuation in the anterior chamber depth; b)
turbulence; c) intraocular pressure.
Blumenthal has pointed out numerous
times that zero fluctuation is the target to be
achieved in surgery, insuring that intraocular
manipulations are most effective and accurately performed as well as keeping steady
and natural the intraocular architecture
and relationship between various tissues
(Figs. 57-60).
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

depth is the consequence of the following
conditions: the amount of outflow exceeds
the amount of inflow in a given period. As a
result, the anterior chamber is reduced in
depth or collapses (Figs. 62 and 63). When
the amount of outflow is reduced below the
amount of inflow, the anterior chamber depth
is recovered (Fig. 65). This phenomenon,
when repeating itself, increases fluctuation.
When fluctuation occurs abruptly, as in the
sudden release of blockage of the phaco tip in
aspiration, this is called Surge (Figs. 61-65).
Fluidics and Physics of

Phacoemulsification
Barry S. Seibel, M.D., in his classic
book Phacodynamics, presents perhaps the
most complete study on the physics on phacoemulsification and the fluid dynamics involved. This must reading for anyone who
wants to delve more deeply into this subject.
Seibel points out that phacoemulsification surgery is essentially the integration of
two basic elements: 1) you use ultrasound
energy in order to emulsify the nucleus; 2)
you utilize a fluidic circuit in order to remove
the emulsified material through a small incision while maintaining the anterior chamber
depth integrity. This fluidic circuit is provided by an elevated bottle of BSS that
produces not only the volume of fluid within
the circuit but also provides the pressure in
order to maintain the anterior chamber hydrodynamically and hydrostatically. When outflow and inflow are balanced, the pressure of
the anterior chamber is proportional to the
height of the bottle (Figs. 49-A, 49-B).
Figure 57 : Fluid Dynamics - Balance

of Flow When the Phaco Tip Is
Unoccluded - Hydrodynamic Balanced 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, inflow (red arrows) from the infusion
bottle (B) will replace (C) the aspirated
fluid at the same rate, to maintain the
constant intraocular pressure determined 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 regulated 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 occluded, the pump produces certain
currents within the anterior chamber, which are measured in milliliters per minute, which are responsible for attracting the nuclear fragments 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.
The Flow pump, responsible for the direct
control of flow, physically regulates the fluid
within the aspiration line by direct contact
between the fluid and the mechanism of the
pump. Even though the scroll pump is the
latest type of flow pump, the one traditionally
known as the peristaltic pump is the more
commonly utilized. One of its important
characteristic is the capacity to control the
flow of fluid as well as the vacuum. This
allows the aspiration flow to be independent
of the height of the bottle of fluid. Nevertheless, it is dependent on the degree of occlusion 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
tip is total (Figs. 59, 60).
These pumps have in common a
drainage cassette adapted to the aspiration
line. The pumps are connected to the cassette
and produce a suction which in turn propor-
Figure 58: Fluid Dynamics - Balance of Inflow and

Outflow During Phacoemulsification - Tip
Unoccluded - Hydrodynamic Balanced System
This view is a close-up complement of what is
illustrated in Fig. 57. The anterior chamber during
phacoemulsification is a closed system in which there
is both intake and output of liquid and where the pressure
must be controlled. With nothing occluding the tip of the
phaco handpiece (P), vacuum pressure is zero (table
point 1), At this point, the inflow (green arrow) equals
the outflow (red arrow) of the phacoemulsification probe,
and the pressure in the eye is maintained and constant
(table levels 2 and 3).
tionally regulates the flow of aspiration when

the port of aspiration is not occluded. When
the port of aspiration is occluded, the flow
ceases and the suction is transferred to the
cassette by means of the aspiration line to the
occluded tip (Figs. 57-60).
117
Figure 59 (above left): Fluid Dynamics - Balance 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 occluding 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 Understanding the Surge Phenomenon

The Surge phenomenon occurs when a
fragment of nuclear material is suddenly displaced from occlusion through the aspiration
tip at the handpiece of the phaco machine,
thereby giving rise to a sudden elevation of

the output of fluid from the anterior chamber
(Fig. 61). The output of fluid suddenly
becomes larger than the input of fluid. This
differential results in sudden collapse of the
anterior chamber and can lead to serious
complications (Figs. 62, 63).
Figure 61: Mechanism of the

Undesirable Surge Phenomenon
One problem area of the
closed phaco system occurs during abrupt dislodging of an occluding piece of lens material so
othat it no longer occluds the
aspiration port of the phaco tip. A
sudden drop in intraocular pressure 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 Phenomenon. (A) Shows a piece of
lens material occluding the aspiration 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 elevated position above the eye.
With sufficient vacuum pressure
from the pump and/or emulsification 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 sudden inflow-outflow pressure differential, 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 endothelial 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,

excess vacuum is zero (0), (Fig. 58) but the
flow of aspiration is very high with a large
quantity of flow going in and out from the
anterior chamber. Note the distinction between the normal suction, or vacuum, pressure which always exists in Positions 2 & 3,
and which must exist to produce the normal
aspiration flow we speak of, with the extra
"vacuum" pressure which builds up when
there is tip occlusion. When the phaco tip is
occluded with nuclear material, the outflow
of fluid stops and the vacuum rises to the
maximum level to which the machine was
originally calibrated and which we previously
described (Fig. 60). This high vacuum aids
the rapid emulsification of the nuclear fragment with or without ultrasound. When there
is much more sudden outflow of fluid from
the anterior chamber than the inflow, the

chamber collapses with possible rupture of
the posterior capsule and damage to the endothelium (Figs. 61-65).
Lessening Intraoperative
Complications from the Surge
As emphasized by Centurion, the latest
generation of phacoemulsification machines
make surge control possible (Figs. 64, 65).
With these machines it is possible to work
with a high vacuum of more than 300 mm
while maintaining a steady flow rate. When
the last part of the nuclear material goes
through the phaco tip, a sensor located at the
aspiration line signals a micro processor to
slow the rate of the pump. Sometimes there is
some reflux in the process of maintaining the
Figure 64: Technical Solution to Prevent

the Undesirable Surge Phenomenon
One technical solution for eliminating the surge phenomenon involves the use
of a high-tech microprocessor. (Fig. A)
When a nuclear piece (F) occludes the aspiration port and then suddenly (B) is aspirated (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 milliseconds, the microprocessor directs the motor
of the pump (P) to slow down. The reduction in aspiration rate resulting from the
slowed pump occurs before the eye can
collapse from any volume differential encountered between sudden inflow and outflow 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 ultrasonic power settings. Surgery becomes safer
and faster.
121
same intraocular pressure. This high speed

mechanism insures that the pressure is always
the same inside the eye.
As emphasized by Barry Seibel, the
surge phenomenon occurs in positions 2 or 3
of the foot pedal when a nuclear fragment
totally occludes totally the phaco tip.
Vacuum builds up in the aspiration line, the
lens material is emulsified sufficiently so that
it is quickly drawn within the phaco tip, the
occlusion is broken, and there is a sudden
surge of aspiration, emptying the anterior
chamber.
The surge phenomenon is more of a

concern when you utilize a conventional tip
with the 0.9 port with high vacuum and flow
of aspiration. It is less of a problem when you
utilize the irrigation-aspiration tip with the
smaller opening (0.3 mm). In addition, it is
possible to diminish the propensity for surge
during phaco by utilizing a more resistant
type of tip such as the Microflow or the
Microseal or with the systems ABS which we
describe in Chapter 8, (Fig. 84).
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
APPLICATION OF PHACO
FRACTURE AND EMULSIFICATION
This is really when the surgeon begins to
utilize the ultrasound energy in the phaco
machine and apply it within the patient's eye.
During the transition period, this is a step that
should be preceded by a good number of hours
of practice in the experimental laboratory until
the surgeon is confident in the application of
the ultrasound energy. It implies that he or she
has been able to successfully perform all the

previous steps over and over again in different
patients. This experience will serve the surgeon as the requisite basis for success in the
emulsification and removal of the nucleus in
the present patient.
In removing the nucleus the surgeon first
attempts to divide the nucleus by fragmenting
it into smaller portions that in due time will
then be emulsified individually (Figs. 55, 56,
66, 67, 68). If the fracture or division of the
nucleus has been incomplete and has resulted
in large pieces or incomplete fractures, the
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

to use so much ultrasound energy that there
may be endothelial damage. Present techniques of phacoemulsification are precisely
geared to avoiding the use of large amounts of
ultrasound energy.
There are different techniques for the
fracture of the nucleus. In the end, the surgeon
will decide which one he prefers or feels more
secure with. Often, it depends on the type and
maturity of the cataract. At this stage of the
transition, when the surgeon is only beginning
in his experience in fracturing and dividing the
lens to apply the ultrasound, the most recommended procedure is to divide it into four
quadrants, the well known "divide and conquer" first presented by Gimbel (Fig. 56).
Later, the surgeon will be able to utilize other
modern techniques which also use high vacuum
and low phaco but which may be too difficult
in the transition.
At this stage of division or fracturing of
the lens in the transition, it is recommended
that the surgeon use Memory 1 of the phaco
machine (Fig. 56) which implies a discretely
high amount of ultrasound, low or no vacuum,
low aspiration and the conventional height of
the bottle (65-72 cms).
The Divide and Conquer Technique

In the "divide and conquer" technique,
the phacoemulsification instrument is used to
create a deep tunnel in the center or the upper
part of the nucleus. The nucleus is split into
halves, sometimes fourths, and even occasionally into eighths. Splitting the nucleus is safer
for the endothelium and easier to learn, especially for the less experienced ophthalmologist
converting from planned extracapsular surgery
to phacoemulsification. It is easier to keep
smaller particles away from the endothelium
124
without having to push them against the posterior capsule than it is to emulsify a large,
cumbersome nucleus.
The nuclear fracturing techniques developed by Gimbel are in part possible because of
the CCC (capsulorhexis) technique that Gimbel
and Neuhann originated. The mechanical
fracturing of the lens causes extra physical
stress within the capsule, and that cannot be
done without great risks of tears extending
around posteriorly unless you have a proper
CCC. There is almost an interdependence of
these two methods. The fracturing techniques
have not only provided more efficiency in
phacoemulsification in routine cases; they have
also made phacoemulsification in difficult
cases safer and more feasible.
Gimbel clarifies that not only are there
lamellar cleavage planes corresponding to the
different zones of the lens, but also there are
radial fault lines corresponding to the radial
orientation of the fibers, as first described by
Drews. Until the development of these nuclear
fracturing techniques we had not taken advantage of this construction (Figs. 55,56,67,68).
The lens fractures quite readily in radial or pieshaped segments (Fig. 67). To accomplish this
radial fracturing, the surgeon must sculpt deeply
into the center of the nucleus and push outwards (Fig. 56). Sculpting is used to create a
trench or trough in the nucleus. Then the
surrounding part is divided into two
hemisections. The separation must occur in the
thickest area of the lens located at the center of
the nucleus (Figs. 103 and 104).
An additional consideration with these
types of nuclear fractures is whether the segments should be left in place until all the
fracturing is complete or whether they should
be broken off and emulsified as soon as they are
separated. With a lax capsule and particularly
with a dense, or brunescent nucleus (Fig. 2),
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 posterior 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 sandwich" 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
aspirationfragmentation 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

segments in place to keep the posterior capsule
protected. The segments are easier to fracture
if they are held loosely in place by the rest of
the already fractured segments still in the bag
(Fig. 105).
Emulsification of the Nuclear

Fragments
If the surgeon has been successful in the
fragmentation of the nucleus, the next step is to
emulsify the pieces of segments of the divided
nucleus. He may do this with the linear continuous mode or with the pulse mode. The
latter done during the transition provides more
security for the surgeon and allows him to use
less ultrasound which is the definite tendency
at present.
The surgeon may later slowly begin to
utilize other more specialized techniques known
as the different "chop" techniques which we
will discuss later. These techniques facilitate
much more the emulsification of the segments
or pieces of the fractured nucleus than the
divide and conquer but they are a little more
complex. During this step of emulsification of
the nuclear fragments, the surgeon may use
Memory 2 in the machine which delivers low
ultrasound, high vacuum, and a larger flow of
aspiration, with a conventional height of the
bottle of fluid (Figs. 67, 68).
FINAL STEPS
Aspiration of the Epinucleus
It is during this specific step that there is
a higher incidence of rupture of the posterior
capsule for the surgeon in the period of transi-
126
tion. This is due to his lack of familiarity with

handling large fragments of epinucleus and
cortex since in the planned extracapsular extraction he is accustomed to remove a large and
complete nucleus that includes all the epinucleus and a significant amount of cortex.
During the transition, the surgeon has to manage safely the irrigation-aspiration handpiece.
Later, when he masters the technique, he may
aspirate the epinucleus and cortex by maintaining the aspiration with the tip of the phaco
handpiece. For this stage of the aspiration of
the epinucleus, the surgeon will use Memory 3
which means very low or no ultrasound power,
a moderate to high vacuum, and high flow of
aspiration, with the bottle of fluid maintained at
the conventional height (Fig. 69).
Aspiration of the Cortex

This step is closely related to the previous one (Figs. 70, 71). There can also be a
larger incidence of posterior capsule rupture
during this stage since the surgeon does not
have the epinucleus as a barrier which up to a
few seconds before was protecting the posterior capsule. The surgeon should use a larger
quantity of viscoelastic whenever required with
the purpose of protecting the posterior capsule.
During the transition period, he may help his
maneuvers by using the Simcoe cannula with
which the planned extracapsular surgeon usually feels safe. This cannula may be introduced
through the ancillary incision. The Simcoe
cannula has the disadvantage, though, that the
aspiration hole or aperture is smaller than that
of the irrigation-aspiration handpiece of the
phaco machine. Consequently, the aspiration
of the masses of cortex may become more
difficult and slow. During this stage, the sur-
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 - Removal 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 oclock 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 significantly 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 surgeon 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 aspects 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

machine which means zero phaco power, maximum vacuum and the highest flow of aspiration as compared with all the previously mentioned memories. The fluid bottle is maintained at the conventional height.
Intraocular Lens Implantation

For the surgeon in the stage of transition,
it is advisable to begin by implanting PMMA
IOLs either of the ovoid shape (Fig. 72-A) or
with round optics of a fairly small diameter.
The ovoid 5 x 6 lens shown in Fig. 72-A is just
right.
Enlarging the Incision and Implanting the Lens

In order to accomplish this the surgeon needs to
extend the small incision with which he started,
128
to 5.2 mm. A 5.2 mm knife blade will do this

most accurately. In extending the arc of the
incision, the surgeon must maintain the valvelike, auto-sealing characteristics present in the
original small incision. The PMMA IOL implantation is performed as shown in Fig. 72-B.
After this stage has been mastered, the surgeon
may then change to implantation of the foldable lenses but this must be done only after the
surgeon is completely satisfied with his phaco
technique.
Removal of Viscoelastic
Throughout the different stages of this
procedure, the presence of viscoelastic in the
anterior chamber is always a measure to keep
in mind in order to prevent or minimize damage
to the surrounding structures during surgical
maneuvers, particularly the corneal endothelium. When removing viscoelastic from the
anterior chamber, the phaco machine must be
in zero phaco or ultrasound, high vacuum, very

low aspiration and the bottle of fluid should be
significantly lower. After all the surgical steps
have been accomplished, it is important, as we
all know, to remove the viscoelastic in order to
avoid a high intraocular pressure postoperatively, with subsequent corneal edema, blurred
vision and pain during the first postoperative
days.
Even though this measure of removing
all the viscoelastic has been emphasized over
and over again in lectures and published papers, there are still surgeons who are not fully
aware of the importance of taking this step and
the consequent complications.
Closure of the Wound

If a good incision has been made, valvelike, auto-sealing and waterproof, no suture
will be absolutely necessary even in those
cases where the wound has been extended to an
arc of 5.2 mm for the PMMA IOL implantation
as shown in Figs. 72-A and B. As long as these
two requisites are met, that is, extending the
incision to 5.2 mm with a special knife blade of
that size and maintaining a valve-like, autosealing incision, there is little danger of complications without sutures. Nevertheless, if
the surgeon is not sure he has made a valvulated
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 introduces 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 Fig. 40-A and 42 A-B), even a 3 mm incision
with no sutures will leak. If so, to leave the
patient without any sutures would be to take an
unnecessary risk. It is more prudent to place
two or three 10-0 nylon sutures in the wound
and they may be removed early in the postoperative stage. This decision really depends on
the ability of the surgeon to create a valve-like,
self sealing incision.
What to Do if Necessary to Convert

When the surgeon decides to convert
from phaco to extracapsular,, viscoelastic is
placed in the anterior chamber. The incision is
130
enlarged to one side and 2 or 3 sutures are

placed (pre or post placed). The incision is
completed to the other side and 2 or 3 more
sutures are put in place (pre or post placed ).
The two superior sutures are placed at either
end of the "valve incision", so that irrigationaspiration (I + A) can be performed unhindered at that site. These two sutures are tied
with a slip knot prior to I & A, and then
loosened to place the IOL. The other sutures
are tied and knots buried before I & A. At the
end of the operation an additional suture can
be placed if the incision is not secure. To
reduce risks, the surgeon may preplace the 3
10-0 nylon sutures across a grove on each side
first, before enlarging the incision.
incision. The small conjunctival flap is then

advanced over the incision.
Before considering that the surgery is

over, it is important to be sure that no leakage
exists either through the main incision or
through an ancillary incision, under the microscope. This is done by cleaning and drying the
incision with a Weck-cell sponge, removing
the viscoelastic and slightly overfilling the
anterior chamber with BSS after the viscoelastic is removed and exerting mild pressure over
the cornea with the sponge (Fig. 73) or using
fine forceps to lightly "dance on" the cornea.
At this time one can observe if there is any
wound leak (Fig. 73). If the surgeon finds that
there is a leak, the best way to solve it is by
injecting BSS into the lips of the incision to
hydrate the tissues and force the incision closed.
This works even better for the small ancillary
Immediate Postoperative
Management
Figure 73:
Incision
After instilling antibiotic ointment and

topical antiinflammatory drops, the eye may be
patched if local anesthesia such as retrobulbar,
peribulbar or sub-Tenon's were used. If only
topical anesthesia or topical combined with
intracameral irrigation anesthesia was used
(Figs, 35, 36), you may leave the patient without any patch. This facilitates the postoperative use of antiinflammatory drops by the
patient.
The use of subconjunctival or parabulbar injection of antibiotics and steroids immediately following surgery, is no longer accepted
as necessary, as was outlined in Chapter 4.
Evaluation of Leak Proof
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, Boyds BF The Art and the Science
of Cataract Surgery of HIGHLIGHTS, 2001.
Benchimol, S., Carreo, E: The transition from
planned extracapsular surgery to phacoemulsification. Highlights of Ophthalmol. International English Ed., Vol. 24, 1996, N 3.
Carreo, E.: From can opener to capsulorhexis: the
crucial step in the phaco transition. Course on How
to shift successfully from mannual ECCE to machine-assisted small incision cataract. AAO, Oct.
1999.
Carreo, E.: Hydrodissection and hydrodelineation.
Guest Expert, Boyds 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 Phacoemulsification. Fifth Edition, Slack, 1997, 8:8798.
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

same instruments that are used in conventional
extracapsular cataract surgery. We will not
refer to them in this chapter because every
cataract surgeon is fully familiar with such
instruments.
This chapter is exclusively focused toward those instruments especially created for
phacoemulsification surgery or those that may
have common features for both techniques,
extracapsular and phaco, but that have required
modifications for the surgeon to undertake
successful phacoemulsification surgery.
There are multiple variations of each
type of instrument. Consequently, rather than
referring to the instruments by the name of their
creators or proponents, we will focus here on
the specific characteristics needed for phaco
surgery. These instruments are:
Its use is optional but it may be quite

helpful during the construction of the limbal or
the clear cornea tunnel incision because it produces fixation of the globe throughout the
circumference of the ring. The most popular
fixation ring is the Fine-Thornton (Fig. 75). If
the surgeon prefers not to use the fixation ring,
the globe may be fixed with very fine 0.12
toothed forceps.
Eye Speculum
It is very important to have the right eye
speculum (Fig. 74). Since topical anesthesia is
utilized by most experienced phaco surgeons,
the speculum must have a lock to prevent the
lids from closing and squeezing during surgery.
The speculum should not interfere with
the surgeon's movements and instrumentation
when operating in the upper temporal quadrant, which is the approach mostly utilized
today.
Knives and Blades

There are two options for the knives and
blades (Figs. 76-77): 1) utilize stainless steel
disposable knives (Fig. 76); 2) use diamond
knives which can be re-sterilized (Fig. 77).
Both types of knives and blades have their
advantages and disadvantages. The selection
really depends on the preference of the surgeon. The disposable stainless steel blades and
knives have reached a very high level of quality
and precision. They may be re-sterilized for a
small number of cases, certainly no more than
four or five. They require a lower initial
investment and less care when handling by the
nurses and assistants. Nevertheless, when we
are going to make a clear corneal incision and
tunnel, it is recommended to use a diamond
knife which can be calibrated (Fig. 77). Those
knives and blades can be manufactured with
different parameters. Those for paracentesis
(Fig. 76 B) have an angulation of 30 degrees.
137
Figure 74 (left): Eye Speculum

Phaco surgery using topical anesthesia
requires that the eye speculum design offer sufficient aperture for operating from the side, which is
always done from 9 to 12 oclock, 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 construction 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

point which is fundamental in the construction
of the tunnel in the incision as shown in Fig. 41B, Chapter 8. The disposable knives with sharp
points range from 2.6 to 3.2 mm (Fig. 76-A).
They are particularly useful in the small incisions when utilizing different sized phaco
probes and tips as shown in Figs. 82 A and B.
The 5.2 mm blunt point blades as shown
in Figs. 76-D may be highly useful to enlarge
the incision in case of PMMA 5.5 mm
intraocular lens implantation or larger as
shown in Fig. 72 A. There is, however, an
increasing tendency to utilize diamond knives
because the surgeon is able to obtain a perfect
incision. The knives also last for a long time.
Consequently, for surgeons who do a major

amount of surgery, the diamond knife may be,
in the end, economically more efficient.
In Fig. 77 you may see diamond knives
designed for various purposes, 77-A for paracentesis or side port incision (also shown during surgery in Fig. 41-A); Fig. 77-B for a
3.2 mm incision or slightly smaller as in
Carreo's Phaco Sub-3 technique, also shown
in Fig. 40 C. Fig. 77-C shows the crescent type
of knife, also seen in the surgical steps in
Fig. 41-B and Fig. 42. Very narrow sharp
pointed blades are being developed to
perform the 1 (one) mm incisions to be used
with Dodick's PhotoLysis recently approved 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 Carreo's Phaco Sub-3. This
knife is also shown in Fig. 42. (C) Crescent diamond 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 Cannula 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 capsule. The surgeon then injects the BSS to separate 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 rectangular and 27 G diameter that facilitates the injection of liquid to separate
the anterior capsule from the cortex. They
are re-sterilizable. They should be connected 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

There are several alternatives to the selection of cystotomes. One group is already
designed and manufactured for this purpose,
with 25, 27 and 30 G calibers. Some surgeons
prefer to bend the tip of an insulin needle,
which provides a very sharp point. The main
characteristic of the cystotome is that it must be
very sharp to facilitate the creation of the first
capsular flap during capsulorhexis and enable
the surgeon to continue performing a curvilinear capsulorhexis. These cystotomes must be
easily adjustable to the needs and comfort of
the surgeon in his/her maneuvers.
As to the capsulorhexis forceps (Fig. 78

B-C) there is a large variety and types of
designs. The best known is the Utratta-Kershner
forceps (Fig. 78-B left). The main characteristic of all capsulorhexis forceps is that they
have very fine, resistant arms and tips that
prevent trapping of the iris. Curved ends are
highly useful so that the surgeon can manipulate more comfortably within the anterior chamber. In any case, they must be easily connected
to a syringe that contains air or balance salt
solution for injection in addition to the conventional viscoelastic, when the surgeon feels it is
needed. There are other very useful
capsulorhexis forceps such as the ones designed 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

(Second Instrument)
These ancillary instruments are absolutely essential in order to adequately perform
the maneuvers necessary to remove the nucleus,
as described and illustrated in Chapter 9. There
is a large variety of types and designs. These
instruments are introduced into the anterior
chamber through the ancillary or side port
incision. The purpose of this second instrument, either the manipulator shown in Fig. 79
or the chopper shown in Fig. 80, is to facilitate

the bimanual maneuvering and rotation of the
nucleus, as well as allowing the chopping of it
intofragments that are going to be emulsified.
In Fig. 79 we show two well known lens
manipulators: 79-A is the Lester instrument
and Fig. 79-B is the Osher. In Fig. 80, you may
see different types of choppers: 80-A the
Fukasaku chopper and 80-B the DodickKamman chopper.
Some of these instruments have a blunt
tip, some longer or shorter length tips. All of
them must have angulation as a common char-
Figure 79: Nuclear Manipulators

(A) Shows the Lester nuclear manipulator. (B) The Osher manipulator. These are two of
the most popularly used ancillary instruments essential 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 ancillary instruments) ustilized by the surgeon in the
bimanual technique of removal of the lens nucleus
with the chopping method as described in Chapter 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 manipulators and the choppers, to use in the procedure that
he/she decides for a specific patient.
acteristic, with the angulated tip being of very

small diameter (0.25 - 0.50 mm). The tip is able
to cut or slice the nucleus. They must have
sufficient strength or resistance in the tip to
create and lead the forces of traction and rotation of the nucleus and they must be smooth and
blunt on the posterior surface in order to avoid
damage to the surrounding tissues. Some surgeons have available both types of instruments, manipulators and choppers, depending
on the type of surgery they are doing, because
although the surgeon has his procedure of

choice, he/she is not bound to rigorously follow
that same procedure in all cataracts. The surgeon has to adapt to different circumstances
and situations.
Other commonly known choppers are
those of Seibel, Nagahara, Nichamin. There
are some hooks that are specifically utilized for
rotation of the nucleus. They need to be
angulated and have the shape of a shirt button.
The best known is the Lester.
143
Forceps and Cartridge Injector Systems for Insertion of Foldable Intraocular Lenses
Small incremental advancements continue to take place for placement of foldable
IOLs through small incisions. There is a
definite trend toward the development of separate instruments for folding and inserting IOLs
rather than using the insertion device to fold the
IOL.
The majority of foldable lenses are inserted either by forceps designed by out-
standing cataract surgeons for this purpose

(Fig. 81) or by a combination of instruments
designed by the manufacturer to facilitate folding and insertion known as cartridge injector
systems. Examples of often used forceps are
shown in Fig. 81 and injectors in Fig. 82.
Dodick prefers to use forceps to implant
Alcon's AcrySof (acrylic foldable IOL). Other
very popular and useful forceps are the Fine
Universal III forceps (Rhein Medical, Tampa,
Fla.) and the Buratto insertion forceps (American Surgical Instruments. Westmont, Illinois).
The latter is used specifically for the acrylic
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 Foldable IOL Implantation System: With very soft tip and
design, the Unfolder Sapphire offers excellent control during
the implantation of Allergans acrylic foldable intraocular
lens. In this surgeons 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 Implantation System: The Monarch systems 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, rotated 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): Alcons 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 positioned 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

Some of the newest advances in lens
insertion technology surround the use of cartridge injector systems. Fine, Lewis and
Hoffman believe that there are many perceived
advantages of implanting foldable IOLs with
injector systems, as compared with folding
forceps. These advantages include the possibility of greater sterility, ease of folding and
insertion, and implantation through smaller
incisions.
Greater sterility with injector systems is
believed to occur because the IOL is brought
directly from its sterile package to its sterile
cartridge and inserted into the capsular bag
without ever touching the external surface of
the eye, as is the case for lenses in folding
forceps. Although this advantage would suggest a lower rate of endophthalmitis with injector systems, recent clinical studies have shown
no significantly different rate of bacterial contamination of the anterior chamber after implantation of silicone lenses with a forceps
versus an injector.
Perhaps the most appealing advantage of
injector systems is that the lens can be loaded
by a nurse or technician without the use of an
operating microscope, further streamlining the
procedure. In addition, inserting foldable lenses
with a cartridge device is generally felt to be
easier than insertion with forceps, and these
lenses can usually be implanted through a
smaller incision when delivered by means of an
injector, compared with an insertion forceps.
146
Allergan's foldable three piece silicone

lens (monofocal or multifocal - AMO Array)
with PMMA haptics may be implanted with
AMO's Unfolder Phacoflex injector system.
Allergan's acrylic foldable IOL (Sensar and
Clariflex lenses) may be implanted with a new
injector now available and known as the
Unfolder Sapphire, as described by Centurion (Fig. 82-A). These injectors are resterilizable (as are the forceps, of course).
Alcons popular 5.5 mm AcrySof IOL
may be implanted with one of its injectors such
as the Monarch (Fig. 82) or with a standard
cartridge through a 3.0 mm incision. Some
have reported injecting this lens through a 2.8
mm incision. Many surgeons use Alcons
Acrypack (Fig. 82) when implanting the
AcrySof lenses. The Acrypack serves to first
fold the IOL. The surgeon then uses a forceps
(Fig. 81) to implant the already folded IOL.
The Alcon AcrySof lens, which requires
3.5 to 4.0 mm incisions for 6.0 mm optics and
3.2 to 3.5 mm incisions for 5.5 mm optics, is
now packaged in a wagon wheel dispenser.
The easiest folding instrument to use for these
lenses is the Rhein folder, because its tips have
been extended to make it easier to remove the
lens from the wagon wheel package. The
forceps can be turned with the tips down in the
nondominant hand. The tips go into the slots on
both sides of the optics, so that the lens can be
picked up and placed on a drop of viscoelastic.
The forceps are then turned so that the tabs are
down. The lens is grasped and folded, and then
the insertion device in the dominant hand is
used to insert the lens.
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

In Fig. 83 you can see two different types
of phaco probes and tips. In Fig. 83 (left), there
is a larger caliber probe with a straight tip.
This is particularly used when the incision is
predominantly limbal. The incision is slightly
larger than the one mostly utilized today which
is the corneal incision shown in Fig. 83 (right).
The probe in Fig. 83 (left) using a standard
phaco tip emits more heat which could harm

the corneal lips. The phaco probe and tip,
shown in Fig. 83 (right), is narrower and can,
therefore, be utilized in smaller corneal incisions such as the 2.6 mm shown in Fig. 83
(right). The popular angled Kelman tip shown
here has a high capacity to cut the tissues and is
very useful in more dense cataracts. It allows
the use of a finer probe because there is less
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. Probes 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 energy 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
The different components of the phaco
probe are shown in Fig. 84 left . Please observe
the standard tip (T). The probe is also shown in
detail in Figs. 50-A and 50-B in Chapter 7.
With the advent of chopping techniques in
phacoemulsification, there has been increasing
interest in the development of new tips for
different uses and purposes. There is a large
variety of phaco tips, and each one has its
reason for being. Chopping procedures are
facilitated by selecting the right tips from a
148
variety of them as shown in Figs. 51 and 84.

Depending on the surgeons technique and
circumstances of the case, they all can contribute to better control in maneuvering of the
nucleus.
In figure 84 (right) and Fig. 51, you may
see the most important tips. Fig. 84 A is the
Microflow tip, 84 B is the Mackhool-Kelman
phaco tip, 84 C is the Aspiration Bypass
System (ABS), 84 D the flare head phaco tip,
and 84 E is the popular Kelman angled phaco
tip. Their specific features are presented in the
caption of Fig. 84.
Surgical Principles Behind the

Different Phaco Tips
they offer more safety and control. The most

popular are:
The different uses for each of these

different tips are described in the caption of
Fig. 84.
The main variations in phaco tips are
related to :1) Angulation. 2) Shape. 3) Size and
4) Thickness. And 5) The existence or not of a
protective insulated cover that facilitates cooling so as to minimize the transfer of heat to the
surrounding tissues, essentially the corneal lips
of the wound.
1) Kelman's
Miniturbosonics
The Importance of Angulation and

Beveling
The more beveled is the tip the larger the
cutting surface and the larger the area which
must be occluded at the tip. Those ranging
from 0 to 15 do not cut much but they occlude
more easily. They are, therefore, ideal for soft
cataracts and for some chopping techniques in
which a maximum capacity for occlusion and
high vacuum is necessary.
Tips with more angulation and bevel
such as 45 degrees have a high capacity to cut
the tissues and are very useful for the maneuvers of phacofracture in dense cataracts and in
the Divide and Conquer techniques.
Nevertheless,these tips offer a higher risk of
posterior capsule rupture precisely because they
are so sharp and highly cutting.
Importance of Shape and Size
New developments are oriented to
microtips and the Mackool system because
Turbosonics
and
These tips have a curved shape that attains larger contact with tissue surface, internal
and external, leading to more cavitation even
though the ultrasound energy used may be the
same as compared when using the standard tip.
Higher cavitation allows destruction of the
nucleus beyond the area of touch.
The miniturbosonics is essentially the
same style of tip but with lesser diameter.
The main advantages of these tips are: 1)
US energy is optimized leading to increased
cavitation. 2) Better cutting and slicing of
tissues in very hard nuclei.
2) Micro Tips
They all have smaller internal and external diameters as compared with conventional
tips. Main Advantages: You can work with
smaller incisions and attain greater stability of
the anterior chamber because these tips have
more resistance to the passing of lens fragments leading to less risk of the Surge phenomenon. They do require, however, more vacuum
in order to obtain similar tissue fixation than
when using a conventional tips.
These micro tips are the ones indicated
for use with the Mackool cassette system that
by definition has tubes with narrower inner
surfaces and thicker outer surfaces, facilitating
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) Allergans 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

dramatic improvements in the technology of
phacoemulsification, involving every aspect
of phaco systems. These range from the phaco
probes and tips all the way down to the foot
pedal. Improvements in the generation and
control of ultrasonic power, fluidics, handpieces
and tips have been made which are extremely
advantageous to the cataract surgeon. We are
all indebted to the manufacturers of our instruments and equipments who have invested
heavily in financing this research and have
attracted the best designers and engineers to
carry on these developments.
150
These systems are able to provide much

more reproduceable energy at each power
setting regardless of the mass and density of
the nuclear material at the phaco tip. Since this
load is continually changing, the system must
be able to adjust. If not, the efficiency of the
equipment is immediately affected.
The main systems available today for
phacoemulsification are provided by the major
players in industry and have very advanced
technology. These systems are the well known
Alcon Surgical LEGACY 20,000 equipment
(Fig. 85-A), the AMO (Allergan) Sovereign
(Fig. 85-B) and the Bausch & Lomb - Storz
Millennium (Fig. 85-C). Allergan's Sovereign

is the top of the line at Allergan. The equipment
known as Diplomax made available for several
years by Allergan is still a useful machine,
more portable and of lower price than the
Sovereign.
How to Select the Right

Equipment for You
In answer to the many questions that we
receive from colleagues throughout the world
as to which machine or equipment to purchase,
we strongly recommend that the first priority
should be to select one of these three, but based
on the quality and availability of service and
technical support that you will be able to
obtain in your community. It is useless to
have a superb phaco machine if that particular
manufacturer provides inadequate technical
support in the area where you practice. Each
one of these three major systems makes available power modulations and advantages such
as auto pulse phaco, burst mode phaco and

occlusion mode phaco which are most important in modern phacoemulsification surgery.
The Pulse and Burst Modes

Differences Between Them
This is one of the most important technological advances in phaco systems, as emphasized by I. Howard Fine, M.D., in the U.S. as
well as by Edgardo Carreo, M.D., one of
South Americas top phaco surgeons. When
you contemplate acquiring a new machine, be
certain that it offers these two modalities.
What is the difference between them? In
Pulse Mode we have linear power for a
fixed interval of the application of that power
(Fig. 86). In Burst Mode, we have fixed
power with a variable interval in the application of that power (Fig. 87). Therefore, Pulse
is a fixed short interval, Burst is a variable
interval.
Figure 86: Concept of Pulse Mode in Phacoemulsification

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 remains 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) during 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 Phacoemulsification

Burst Mode provides more control of
the ultrasonic energy level, which is advantageous 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 position 3, the pause between bursts of the fixed
energy decreases from intermittent bursts to
more frequent bursts, toward ultimately continuous 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 number 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

Mode
Pulse mode provides a great advantage in
mobilizing and removing tissue (Fig. 86). In
the chopping techniques (Chapter 9), at a fixed
pulse rate of 2 pulses per second, the surgeon
chops by stabilizing the nucleus with the chop
instrument in the golden ring. Fine likes to
pull to the side of the phaco needle rather than
to the top of the needle so that after the second
chop, the initial tissue segment is already
lolipopped. (Editor's Note: lolipopped refers
to securely engulfing the tip of the phaco into
the nucleus, like a lollipop or candy sucker on
a stick. The phaco tip is analogous to the stick
and the nucleus is the round candy portion Fig. 88) He does not have to search for the
nucleus, or manipulate it: its already engaged
152
on the phaco tip. The vacuum provides substantial control for holding the tissue between
applications of phaco power, with almost no
potential for chattering. (Editor's Note: chattering refers to when the nucleus bounces
against the phaco tip at a high rate of speed
without emulsifying it as desired, like when
ones teeth chatter when cold - Fig. 89).
When using the LEGACY 20,000 equipment, for instance, Fine can specifically customize the application of the parameters of
phaco power based on differences in the
density and type of cataract tissue he is
removing. This technological advance is also
available in the other outstanding equipment
already mentioned, particularly Allergan's Sovereign and Storz (Bausch & Lomb) Millennium.
The power levels used by Fine are very
low -- very frequently in the low teens. It is rare
Figure 88 (right):
Concept of
"Lollipopping" the Nucleus
Lollipopping the nucleus refers to securely 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 resulting emulsification and extraction. The chattering 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 tissue is efficiently extracted (arrow) as represented by the smoothly rolling ball.
153
for him to have an effective phaco time greater

than 20 seconds and an average phaco power of
more than 20 percent. Meanwhile, the vacuum
is high, 340 mmHg. He minimizes power and
allows high vacuum to do the job.
Clinical Applications of the Burst

Mode
Its Role in Transition to Chopping
Fine believes the easiest way for surgeons to make the transition to chopping (Chapter 9) is to use the burst mode set for singlebursts with the panel control (Fig. 87). He
prefers a burst of 150 ms with vacuum of 400
mmHg. Also, by using Burst mode and a
BiModal sub-mode, Fine can use a higher
aspiration flow rate to attract the epinuclear
ring out of the capsular fornix.
Advances with the Sovereign Phaco

System
Just as there are significant advances and
technological contributions with the prestigious
LEGACY 20,000 machine manufactured by
Alcon Surgical, Allergan has recently brought
into the market its Sovereign. This is really the
top of the line for Allergan in this type of
surgery. It takes into consideration and actually participates in what all surgeons want
which is better and more predictable surgical
dynamics for their cataract patients. This
equipment has superb fluidics and capacity for
programming and provides increasing ease of
cataract removal.
The Sovereign utilizes very effectively
the micro-processor controls and an on-board
computer regulation of all the components,
154
such as fluidics, ultrasonics, footpedal, and

bottle height.
With respect to fluidics, the Sovereign
has a digital peristaltic pump that, because of
its sophistication, is capable of mimicking every other pump system. Its highly developed
responsive fluidics monitoring system, called
the Intellesis, monitors the fluidics 50 times
per second. There is a sensitive control of what
is happening to the vacuum in the anterior
chamber. It also has the ability to respond
rapidly because the pump can reverse, in addition to move forward, slow, and stop. An inordinately stable anterior chamber can be
achieved, with a reduced tendency for vaulting
of the capsule or fluctuations in chamber depth
(See Chapter 7 - Figs. 62, 63, 65). This new
level of control offers optimum safety.
The foot pedal has an on-board computer and is capable of multiple functions
(Figs. 52, 53, 55, Chapter 7). The foot pedal
can be used with either the toe or heel depending on the surgeon's height. Using the foot
pedal, even remote parameters such as bottle
height, can be changed.
Another important feature is the ultrasonics which has expanded from a two-crystal
to a four-crystal handpiece. This four-crystal
handpiece is adaptable to technology from
manufacturers other than Allergan. Many
machines are not designed to use tips from
companies other than the parent company. Fine
likes to use a Kelman bent tip for certain
cases and he can use it with the Sovereign
(Figs. 83-B and 84-E.)
The ophthalmologist acquiring a new
unit is naturally concerned whether the Sovereign can be programmed and used without
extensive study and training in the system. Of
course, every surgeon must understand the
fundamentals of how phaco machines in general work, as presented in Chapter 7. Accord-
ing to Fine, extensive study is not required

because there is a sensor that monitors the
delivery of ultrasound energy. It is difficult to
keep a system that has a changing mass, shape,
and density of material at the tip at its resonance
frequency. But this system monitors, through
its microprocessors, 50 different functions that
are impacting resonance frequency, 500 times
a second, and changes and corrects them
automatically.
Pulse and Burst Modes on the

Sovereign
We have already outlined the great significance and importance of the Pulse and
Burst Modes applicable with Alcon's LEGACY
20,000 equipment, which is a superb machine
(Figs. 86, 87). Fine often combines Pulse and
Burst modes also when using the Sovereign.
Because the power is intermittent and the
vacuum is constant, one advantage of power

modulation is that nuclear material tends to be
kept at the tip. Nuclear material seldom chatters (Fig. 89) and almost never shoots into the
anterior chamber, where it can threaten the
endothelium. Fine feels that the Sovereign
represents a new level of finesse and control
that leads to safety and ease of operation.
Fines Phacoemulsification Parameters
including the Pulse and Burst Modes for Alcons
Legacy 20,000, Allergans Sovereign and Storz
Millennium, are presented in specially designed
Tables in pages 202-203.
Edgardo Carreos Adjustable Burst
Mode Parameters using Alcons Legacy 20,000
are presented in this page.
In essence, we have a wonderful new
menu of remarkably sophisticated, helpful
phaco instrument choices. Each surgeon will
need to make his or her own decision, remembering to consider local service and support.
155
RECOMMENDED READINGS
Buratto, L: Phacoemulsification: Principles and

Techniques, 1998.
Seibel, B.: New phaco tips. Phacodynamics Mastering the Tools & Techniques of Phacoemulsification Surgery, Third Edition, Section One:104111.
Mendicute, J., Cadarso, L., Lorente, R., Orbegozo,

J., Soler, JR: Facoemulsificacin, 1999.
Technical advances in phacoemulsification systems, 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 advanced 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 Phacoemulsification, 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
The Advanced, Late Breaking Techniques
We have presented the step-by-step technique of phaco during the transition including
the fundamental understanding of how the phaco
machine works (Chapter 7). The specific instrumentation, equipments and best systems
used for phacoemulsification are discussed in
Chapter 8.
Regarding instruments and use of equipment, it is essential to keep in mind that we
should first train in order to thoroughly understand and command the subtleties of our
phacoemulsifier before its clinical use. As
frequently emphasized by Centurion, we will
not be able to improvise or try to master it in the
surgical suite.
Advantages of Phaco
It is also generally accepted that the main
reasons why phacoemulsification has stimulated so much interest is because of the following advantages, all of which improve results:
1. Less ocular trauma induced.
2. Less postoperative inflammation.
3. Astigmatism induced is minimal or nil.
4. Postoperative refraction is more promptly
stabilized.
5. Less risk of endophthalmitis.
6. Topical anesthesia can be effectively used.
7. Immediate physical and visual rehabilitation is attained.
Now let us consider fundamental concepts, measures, methods and techniques necessary to follow in order to master phacoemulsification.
Trauma-Free
Phacoemulsification
Considering that this procedure is very
much device-dependent, Centurion establishes
a tripod: physician-technician-machine. By
individually organizing and interrelating the
physician's role, his/her technician's important
input and coordination, the functioning of the
machine and the technique, we are able to
perform the procedure free of trauma to our
patients and less stress to the surgeon. This
may be accomplished without changing the
Operating Center's routine.
In this "trauma-free phaco," it is also
important to achieve the following: 1) no
delays of patients, anesthesiologists or the surgical team. 2) Perform a limited number of
daily procedures with predictable results more
days in the week which is preferable to a
schedule of longer but less frequent operating
days with a much larger volume of operations
in one single day.
Perform 4 (four) cataract surgeries in
one hour is as much as we should aim for. The
objective is not to operate quickly but to take
advantage of the results of a well-trained team
that has adapted well to this system.
159
Faster Operations
Do They Sacrifice Patient Care?
If the operating team is really efficient, speed should not necessarily lead
to lesser results. The key lies in the
adroitness and perfect coordination among
Centurion's "tripod: surgeon-technician-machine". Making an operation safe and effective
should be our primary goal. It is important to
balance time, speed and safety, because in the
end we all should aim for safe operations.
Readiness and Know-How to Become

Efficient
Stephen Lane, M.D., has very positively emphasized that if you want to go faster,
ignore what is happening inside the eye and
concentrate on what is happening in the operating room (OR). Make sure that the OR staff
is proficiently getting the cases in and out and
moving the patients with readiness. If the
surgeon is only working in one room, there is
more time wasted moving a patient from one
room to another, getting a room cleaned up, and
getting the next patient in, than during the
cataract operation itself. There are a series of

steps to make the process flow efficiently.
I. Howard Fine, M.D., has pointed out
that there is an emphasis today of cataract
surgery being likened to a foot race. Some
surgeons show videos with stopwatches. Just
looking at their hands reflects how they rush
rather than doing maneuvers that are appropriate for working inside the eye. Racing the
clock is definitely not good for the patient.
In our teaching, it is important to convey
that endothelial cell loss, iris trauma, incisions
that do not heal, or broken capsules, may result
because of a desire to do faster procedures. As
a matter of fact, complications should be less
because of the advanced technology we currently possess. If you have one or two operating rooms, efficiency is more connected to the
turnover, not necessarily the individual case.
The most practical method to obtain speed with
efficiency is the one recommended by Centurion: use two operating rooms with exactly the
same equipment disposition -- they are cloned
rooms. This saves time because it is not
necessary to change equipment; provides savings in maintenance and, most important: operating room staff can concentrate on the
needs of the patient and the surgical team.
THE ADVANCED, LATE-BREAKING TECHNIQUES

Anesthesia
Advanced or experienced phaco surgeons
may use topical anesthesia alone or combined
with intracameral irrigation anesthesia (Figs.
35, 36). You may find as in-depth discussion
of this subject in Chapter 5. The other alternative, of course, is to have the assistant or anesthesiologist use peribulbar anesthesia, generally Xylocaine 2% + Marcaine 0.50%. This
160
type of anesthesia has the great advantage of

enabling the surgeon to operate without any
intense emotional involvement or requiring the
more active cooperation needed with topical
anesthesia. It is very comfortable to arrive at
the operating room where two or three patients
are already anesthetized and ready to begin
surgery.
The advantages of topical combined with
intracameral vs peribulbar are amply discussed
C h a p t e r 9:
in Chapter 5. For experienced surgeons, the

combined topical-intracameral approach is
much preferred because of immediate visual
recovery.

The experienced surgeon does not need
to fixate the globe with sutures. Fixation by
grasping the superior rectus muscle with forceps and placing a 6-0 silk suture through it,
repeating the same maneuver with the inferior
rectus, is completely outmoded for phacoemulsification. Besides, it leads to postoperative
ptosis in a good number of cases.
Many surgeons utilize the Fine-Thornton
fixation ring (Fig. 75 - Chapter 8), particularly
during the construction of the limbal or the
clear cornea tunnel incision. Other surgeons
prefer to fixate the globe with a forceps.
THE INCISIONS
Phacoemulsification is a two-handed procedure in most cases. Consequently there are
two incisions done:
1) The Primary Incision.
2) The Ancillary Incision.
The Primary Incision

For experienced surgeons, the procedure
of choice is a self-sealing clear corneal, stepped
valvulated incision, performed temporally
(Figs. 90-95). This incision is self-sealing and
heals without sutures. It is shown in Figs. 90
and 91 (surgeon's view). Most surgeons do a
two-step clear corneal tunnel incision as shown
in Fig. 92, cross section view. Others prefer the
three step corneal tunnel incision because they
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

a two-step incision, the length of the tunnel is
slightly larger to ensure that the incision will be
self-sealing. A short tunnel may not self-seal
(Fig. 92).
Essential Requirements for a SelfSealing Corneal Incision

To be safely performed, the clear cornea
tunnel incision must be done with a sharp
diamond knife (Figs. 77, 90, 91, 92, 93)
although the presently available stainless
steel disposable knives are also very sharp
and useful (Fig. 76, Chapter 8). Sergio
Benchimol, M.D., in Brazil, who was one of
the first surgeons to popularize this incision in
South America, starts the surgery with a selfsealing, small, 1 mm paracentesis side port
incision (Fig. 41) and pressurizes the eye with
viscoelastic or saline solution through this side

incision. Then he proceeds to perform the
primary self-sealing corneal incision, as shown
in Figs. 90-93. The two-incision process, the
sharpness and precision of the diamond knife
and even the stainless steel blades, and the
presence of viscoelastic in the pressurized eye
make it possible for a valve-like self-sealing
incision to be made in the cornea without
damaging its structure.
Position of the Clear Cornea Tunnel

Incision
The trend today is to make the clear
cornea incision on the temporal side as introduced by I. Howard Fine and Kimiya Shimizu,
although Shimizu is inclined to perform a single
plane incision, which is not generally accepted
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 (arrow). 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
C h a p t e r 9:
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 extends 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 Corneal 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 cornea 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 cornealscleral tunnel incision.
163
Reservations About the Clear

Corneal Incision
Some surgeons have reservations about the
clear-cornea incision, particularly because of
postoperative astigmatism and endophthalmitis. These used to be two major complications
of clear cornea incisions. These problems have
been almost solved by making the wound as
small as 3.2 mm or less at the temporal site and
by using intracameral antibiotics as discussed
in Chapter 4.
Advantages to the Temporal Approach

1) The approach to the anterior chamber
is easier, especially in patients with a narrow
palpebral fissure (Fig. 94).
2) As inferior duction of the eyeball is not
required with the temporal approach, the iris
plane is always kept at right angles to the
microscope to provide good visibility.
3) As pointed out by Kimiya Shimizu,
the cornea is oval and the optical center of the
cornea deviates to the nasal area from the
Figure 94: Advantages of the Temporal Approach Corneal Incision

There are several advantages to the temporal 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 supraorbital rim can restrict instrument movement
using the 12 o'clock approach. Compare posteriorly 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
C h a p t e r 9:
anatomic center. Therefore, in the temporal

approach, the incision's, the distance is about 1
mm more from the optical center as compared
with a superior incision (Fig. 94). Thus, the
operative invasion to the corneal center is minimal in the temporal incision. As a result,
surgically induced astigmatism is small and
recovery of visual acuity is fast. In addition,
when working on clear cornea at the 12 o'clock
position (closer to the optical axis than the
temporal position) if there is a small amount of
edema near the edge of the incision, being
closer to the optic center of the cornea, may
temporarily interfere with the immediate visual recovery aimed at with topical anesthesia
and clear corneal incision.
4) The wound will not separate when
blinking. The temporal incision, therefore,
facilitates good adaptation of the wound.
5) In addition, there is more space for
the surgeon's hands. The temporal approach
makes the phacoemulsification itself easier
because the eyebrow is not a barrier, and freer
movements are possible.
Additional Patient's Comfort with

Corneal Incision
Jack Dodick definitely prefers to do a
clear cornea incision rather than the scleral
tunnel procedure. Although he considers that
both incisions are excellent and lead to the
same outcome, patients tend to be more comfortable and satisfied with the clear cornea
incision.
Using the scleral tunnel procedure, the
surgeon cuts into the sclera, conjunctiva,
Tenon's membrane, and some blood vessels,
which takes perhaps 1 to 2 weeks to heal.
Although patients do not report having much

pain, they do report a greater sense of awareness or discomfort for at least a week or so
after the scleral tunnel procedure. With the
clear cornea incision, on the other hand, the
epithelium regenerates within 24 hours, much
like it does after a corneal abrasion. Those
patients who undergo a clear cornea incision
report awareness of a sandy sensation which is
virtually gone within 24 hours as the corneal
epithelium is reepithelialized.
In many cases Dodick and many surgeons have done a scleral tunnel operation that
turns out perfectly with 20/20 vision, and the
patient still complains months and maybe even
years later of an awareness or irritation in that
eye. Creating a scleral tunnel wound leaves a
scar at or near the limbus (Fig. 40), which
Dodick believes interferes with tear film distribution. Eventhough it heals beautifully, the
interference with tear flow leaves patients with
a vague awareness or irritation in the eye.
With a clear cornea incision, the limbus
is never invaded, and a vascular scar is never
created. Therefore, tear film distribution is
never disturbed. The final reason Dodick
chooses the clear corneal tunnel is that it is a
much more cosmetic procedure. With the
scleral tunnel incision, patients often have a red
eye. No change is apparent in patients who
have had the clear cornea incision just a few
hours after the operation.
A postoperative photograph showing the
barely visible scar of the corneal tunnel incision on the temporal side is shown in Fig. 95.
In Edgardo Carreo's experience,
phaco through clear cornea is less traumatic,
considering that there is no need for conjunctival 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 Carreo, M.D.)
erative inflammation because there is less

trauma.
The postoperative cosmetic appearance
of the globe is better, the eye looks as if never
touched (Fig. 95). The patient feels more
comfortable because there are no sutures, no
cautery has been done and there is no pain. The
intraoperative time is less because several traditional stages of the operation have been eliminated. Therefore, the cost is reduced.
Importance of the Length of the

Tunnel
Ideally, the part of the corneal tunnel
itself should be about 1.75 mm (Fig. 93). A
shorter tunnel (dotted line in Fig. 92) decreases
the self-sealing rate, although the surgeon's
visibility becomes better. Too long of a tunnel
increases the self-sealing, but corneal folds
sometimes disturb surgeon's visibility. Corneal endothelial damage also becomes greater
as the distance between the phaco tip and
166
corneal endothelium becomes shorter. Thus,

when the surgeon performs a corneal incision
for the first time, it is recommended to make
a rather shorter tunnel and to place 11-0 nylon
single knot without being concerned with selfsealing.
Placing and Making the Primary

Incision
As emphasized by Kimiya Shimizu, the
proper placement of the incision is important.
If it is too anterior, the corneal tunnel becomes
shorter, and the self-sealing effect is decreased.
In contrast, if it is too posterior, conjunctival
bleeding and/or chemosis sometimes occur.
So, before incising the cornea, dry the
incision site, make the vertical first step just
anterior to the terminal conjunctival vessels,
then insert and advance the keratome straight
about 1.75 mm into the corneal stroma. Next,
direct the keratome slightly downwards in the
iris plane to perforate Descemet's membrane.
C h a p t e r 9:
When the tip of the keratome appears in the

anterior chamber, remove the Merocel sponge
and release the counterpressure. After that,
advance the keratome, swinging it to both right
and left sides. By doing this, the incision may
be conducted safely without causing the collapse of the anterior chamber. The length of the
corneal tunnel is usually 1.75 mm, but if it is a
complicated or hard nucleus case, it should be
shorter. On the other hand, when the patient
has good mydriasis or a shallow anterior chamber, the incision site should be a little anterior,
and the corneal tunnel should be longer to
prevent iris damage and/or iris prolapse.
Surgeon's Position
When the operator is right-handed and
he/she is operating the right eye, sit at the 10.30
position. When operating on the left eye, sit at
4:00.
Controversy Over the Strength and

Safety of the Wound
One of the most controversial criticisms
of clear corneal incisions has been their relative
strength compared to limbal or scleral incisions. Mackool has demonstrated that once the
incision width is 3.5 mm or less and the length
of the tunnel 1.75 to 2 mm, there is an equal
resistance to external deformation in clear corneal incisions as compared to scleral tunnel
incisions. Ernest work as well has revealed
that as incision sizes get increasingly smaller,
3mm or less, the force required to cause failure
of these incisions becomes very similar for
limbal and clear corneal incisions. This further
documents the safety of corneal incisions.
The real issue for these various incisions is not healing but sealing. Fine feels
that as long as an incision is sealed at the
conclusion of surgery and remains sealed, the

time before complete healing of the incision is
accomplished is almost irrelevant, especially
since there is still a 6-day period in which
limbal incisions are not healed. An analogy
can be drawn to the sealing that takes place
during LASIK, in which there is no fibrovascular healing of the clear corneal interface, which
has little effect on the strength, effectiveness,
or safety of the wound, and, in fact, is an
advantage by limiting scarring and an inflammatory healing response.
Clear corneal cataract incisions are becoming a more popular option for cataract
extraction and IOL implantation throughout
the world. Through the use of clear corneal
incisions and topical and intracameral anesthesia, we have achieved surgery that is the least
invasive of any kind in the history of cataract
surgery with visual rehabilitation that is almost
immediate. Clear corneal incisions have had a
proven record of safety with relative astigmatic
neutrality utilizing the smaller incision sizes.
In addition, corneal incisions result in an excellent cosmetic outcome.

There are several methods to test the seal
of the incision. For the most practical one, we
refer you to Fig. 73, Chapter 7, and the explanatory text in the same page under this title.
Closing a Leaking Wound

Without Sutures
Professor Juan Murube, M.D.
(Madrid), has demonstrated the effectiveness
of a very comfortable maneuver in order to
close-shut a leaking wound instead of having to
suture it. Although a self-sealing, stepped
valvulated corneal tunnel incision, 3.0 mm or
167
less in size, is very unlikely to leak, there is

always the possibility for this to occur. The
main causes are related to making the corneal
incision larger than 3.0 mm and excessive
trauma to the lips of the wound during surgery
particularly with the phaco probe. These factors may give rise to a continuous loss of
aqueous humor. This may be detected the
following day by means of a positive Seidel
test in which several drops of fluorescein are
instilled over the wound and examination is
performed with ultraviolet light.
Because the aqueous humor escapes
through the wound continuously, the wound is
kept open. Unless this is corrected immediately, the surgeon may have to suture the wound.
The very comfortable and effective maneuver recommended by Professor Murube in
order to close-shut a leaking wound is to place
a Honan balloon over the eye for 30 minutes at

35 mm Hg pressure. At the same time, the
patient is administered orally one tablet of 250
mg of Acetazolamide (Diamox). The way this
works is that the significant intraocular
hypotony produced by the combined use of the
Honan balloon and Diamox results in the
production of a significantly reduced amount
of aqueous humor that is produced with sufficient continuity to reform the anterior chamber
but not in sufficient quantity to seep through
the wound. After a few minutes, the walls of
the wound have had a chance to adhere to each
other, thereby sealing the wound. No further
positive Seidel test is observed even though the
normal intraocular pressure is reestablished.
This maneuver is innocuous and simple as well
as highly effective (Fig. 96).
Figure 96: Murube's Method of Sealing a Leaking Wound with Honan's

Balloon
The combined use of Honan
Balloons 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
C h a p t e r 9:
THE ANCILLARY INCISION

This is an important step in performing
phacoemulsification. Although there are techniques to perform phaco with only one hand,
phacoemulsification is fundamentally a twohanded procedure.
The ancillary or side-port incision is made
before the main incision. It serves as an entry
for a second instrument which is necessary for
maneuvers to remove the nucleus, either nuclear
manipulators (fig. 79) or choppers (Fig. 80).
The location and technique of making the ancillary incision is shown in Fig. 41 A.
In addition to serving as the mode of
entry for the essential second instrument the
ancillary incision is utilized in irrigation of the
anterior chamber with intracameral local anesthetic as presented in Chapter 6 and illustrated
in Fig. 36. It is also the route for the insertion
of viscoelastic previous to making the primary
incision.
At the end of surgery, the ancillary incision is used to inject fluid into the anterior
chamber to test for leaks in the wound, as
shown in Fig. 73.
Making the Ancillary Incision

The steps involved in performing the
ancillary incision are:
1) First, mark the corneal location where
the clear corneal stepped main incision would
be made, which is always between 9 and 12, as
shown in Figs. 41 B and 42. This measure
serves the surgeon for orientation as to exactly
where to place the two incisions.
2) Make the ancillary incision at 3 o'clock.
This is performed with a special 15 degrees
blade designed for paracentesis (Figs. 76 and
77).
ANTERIOR
CAPSULORHEXIS
Key Role
This procedure is also presented in
Chapter 7 for the transition period and illustrated in Figs. 43, 44 and 45. It is generally
agreed that a well performed anterior continuous capsulorhexis is an essential step for the
success of phacoemulsification. The key reasons for being so important is that capsulorhexis
prevents IOL decentration. In cotrast with the
extracapsular extraction and can opener capsulotomy, even when the surgeon was sure that
he/she placed the IOL within the bag during
surgery, sometimes 30 to 40% of cases after
two or three months would have one of the lens
loops protruding out of the capsular bag and
reaching to the sulcus, thereby leading to
decentration. On the other hand, by performing the continuous circular capsulorhexis followed by implantation of the lens within the
bag, the IOL will permanently remain well
centered within the capsular bag. This has been
emphasized time and again by Everardo
Barojas, M.D., one of Mexico's most prestigious cataract surgeons and a good number of
other experts on the subject.
The Role of Viscoelastic in CCC

One of the key steps in achieving a first
class capsulorhexis is to do it with viscoelastic
in the anterior chamber rather than with BSS.
The high density viscoelastic is used not only to
protect the endothelium and other surrounding
tissues but also serves as a third hand that
amplifies the working space and facilitates the
maneuvers of the surgeon's manuevers. It also
169
helps to flatten the anterior capsule. This last

measure facilitates the correct performance of
the procedure.
Technique for Performing a First

Class CCC
Beginning surgeons should be encouraged to use forceps as shown in Figs. 44 and 45.
All cases should be performed with injection of
viscoelastic material in the anterior chamber.
The experienced surgeon may perform the procedure with a cystotome-needle which is a No.
26 needle with the tip bent into a square angle
as shown in Fig. 97.
The CCC utilizing the cystotome needle
and viscoelastic is more safely and effectively
performed using the central punch technique.
This makes the first incision in the center, as
shown in Fig. 98 and not in the periphery, as
was the tendency when the procedure was
developed (shown in Fig. 43). Using the
central punch technique, there are fewer possibilities that a tear will spread to the periphery.
The continuation of the capsulorhexis tear,
once the central punch is done, may be done
clockwise or counter clockwise, as is more
comfortable for the surgeon. Usually, it is
continued in a circular fashion in a counter
clockwise direction as shown in Fig. 99, carefully completing a circle from outwards inward
obtaining a completely closes rhexis (Fig. 100).
It is fundamental to advance the capsular
tear in a well controlled manner. This is achieved
by placing the cystotome-needle against the
surface of the anterior capsule and re-grasping
the tear as many times as necessary to continue
the circular teaar until completing the circle.
A very important part of the first step in
CCC is to be able to obtain the flipping of the
resultant capsular flap once the cystotomeneedle engages the anterior capsule centrally.
170
It is important for the surgeon to see the underside surface of the anterior capsular flap as
shown in Fig. 98.
Some surgeons find that in order to perform the procedure more safely, upon finishing
each one of the circular tears with the Uttrata
forceps and before completing the circle, instead of leaving the capsulorhexis folded, take
it back to the way it was, that is, unfolded. This
makes the next step easier to perform, that is the
anterior capsule, easier to grasp in order to
engage and disengage to provide the best control for creation of a circular opening (Figs. 99,
100).
Size of the Capsulorhexis

For experienced surgeons mastering phacoemulsification, it is generally advisable to
use a 5.5 mm central and completely enclosed
rhexis. This is close to the ideal phacoemulsification technique performed safely within the
capsular bag.
The size of the capsulorhexis, however,
may be better determined by the type of intraocular lens model to be implanted. Carreo
emphasizes that upon using Alcon's foldable
acrylic implant with a 5.5 mm optic, he prefers
a 4.5 mm or 5.0 mm rhexis so that the edge of
the optic is completely covered by the anterior capsule. This helps in preventing fibrosis
which may be produced when both capsules
come into contact. It is also helpful in reducing
glare especially in younger patients who have
more of a tendency for pupillary dilation at
night or in the darkness.
On the other hand, upon using the
silicone foldable lenses, Carreo prefers a
5.0 mm to 5.5 mm rhexis to prevent contraction
of the capsular sac, which may accompany this
type of implant when the diameter of the
capsulorhexis is smaller.
C h a p t e r 9:
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 90 in a vertical motion (arrow).
Figure 98 (center): Continuous Curvilinear Anterior Capsulorhexis 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 Curvilinear Anterior Capsulorhexis

Performed with the Cystotome-Needle
(Step 2)
After injection of viscoelastic, the
surgeon starts with the puncture of the capsule and proceeds to make the first small
flap. When this first flap is turned over, the
tint is clearly seen because the color is detected 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

of the capsulorhexis, is the degree of hardness
of the cataract. In cases where the nucleus is
too hard, Carreo feels that it is more prudent
to perform a rhexis which is not too small,
certainly no less than 5.0 mm in diameter, to
ease performing the phaco chop techniques,
which are the most highly recommended for
treating hard nucleus.
STAINING THE ANTERIOR

CAPSULE IN WHITE CATARACTS
As shown in Figs. 98, 99 and 100, a well
performed CCC allows the coaxial light of the
172
microscope to provide the red reflex of the

fundus. Over this red reflex the anterior capsule and the border of the progressively performed continuous circular capsulorhexis can
be very well visualized. This allows the completion of the circle (Fig. 100) under adequate
visual control. On the other hand, when the
surgeon is dealing with white, hypermature
cataracts that have either been allowed to get
into that advanced stage or have been produced
by trauma, the details and border of the CCC
cannot be well visualized because this white
cataract interferes with fundus reflex . Consequently, the step by step progress in the performance of the CCC is not well visualized.
Accidentally, the edge of the anterior capsule
C h a p t e r 9:
flap could be displaced toward the periphery

and the lens equator. From here, upon performing the maneuvers inherent to phacoemulsification, damage to the posterior capsule could
be inflicted thereby allowing passage of the
vitreous to the anterior chamber or a luxation of
the nucleus into the vitreous or a displacement
of the intraocular lens once inserted. These
important considerations have led to the devel-
opment of a very effective technique to control

the performance of the CCC in white cataracts.
It consists in staining the anterior capsule of the
lens in order to adequately visualize the details
during the performance of the CCC (Fig. 101).
Without the dye it is nearly impossible to
see the anterior capsule. These cataracts are
risky. It is very difficult to distinguish the
anterior capsule from the underlined cortex.
Figure 101 (above right): Murube's Technique

of Staining the Anterior Capsule in White Cataracts to Perform Adequate CCC
White cataracts (L) present a problem because the red reflex is not present making the
capsulorhexis quite difficult and risky. A viscoelastic 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 introduced through the corneal incision over the anterior
capsule (C). Two drops of Trypan Blue are instilled. 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 anterior 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

There is a variety of staining substances
and methods of how to perform the staining.
They have been presented by prestigious ophthalmologists since 1998: in Japan through
Nagoya University School of Medicine; in
Spain, Oscar Asis, M.D.; in Holland, Jerritm
Melles, M.D.; in the U.S., Thomas Oetting
and Rick Nearhing. The most practical and
effective method now being popularized is the
one presented by Prof. Juan Murube (Madrid).
The different staining substances analyzed by
Murube are the following:
1) Fluorescein 2%. This is obtained by
mixing 1 ml of 10% fluorescein for intravenous
use with 2 ml of BSS.
2) Indocyanine Green (ICG): This is
obtained by mixing 25 mg of ICG in 0.5 ml of
an aqueous solvent which might be obtained
from Akorn in Buffalo Grove, Illinois. This
mixture is then diluted in 4.5 ml of BSS.
3) Trypan Blue: Prepared by mixing 1 ml
of trypan blue 0.4% (obtained from Life Technology, Grand Island, New York) in 3 ml of
BSS.
4) Gentian Violet: solution at 0.01 concentration diluted with BSS.
5) Methylene Blue: solution at 0.01 mixed
with BSS.
Murube's research has led him to select
Trypan Blue as the staining solution of choice.
This has been confirmed through the clinical
research of Carlos Nicoli, M.D., in Argentina,
one of South America's top phacoemulsification surgeons. Nicoli emphasizes that Methylene Blue and Gentian Violet are very difficult
to prepare because they must have very specific concentrations. It is fundamental that the
stain used not be toxic to the corneal endothelium. Therefore, it should be prepared at exactly the right concentration. For instance,
174
Methylene Blue, if used, should be a 1% solution while Gentian Violet should be at one part
per thousand. The new research by the Japanese in Nagoya refers to the use of 0.05%
Indocyanine Green solution. The problem
with the latter is that it is very costly. The
Trypan Blue solution is being currently marketed as a nontoxic stain.
Technique for Injection of Staining Solutions

Murube first irrigates a viscoelastic into
the anterior chamber. This is immediately
and partially displaced by an air bubble in
the anterior chamber in order to leave the
corneal endothelium slightly lubricated and
protected by the viscoelastic. A cannula is
inserted through the corneal incision as shown
in Fig. 101 and two drops of Trypan Blue are
deposited over the anterior capsule. The surgeon waits ten seconds. This is followed by
injection again of viscoelastic in order to eliminate the air bubble from the anterior chamber,
the so-called "air exchange". At this time
tinting is not yet detected until the first flap of
the rhexis is done because the tissue absorbing
the tint is not the capsular epithelium but the
internal face of the capsule, visible enough for
the surgeon to see the capsule very clearly and
to proceed to perform the capsulorhexis adequately. Utilizing this technique, when performing the capsulorhexis (Figs. 98, 99, 100)
the surgeon can see that the epithelium behind
the anterior capsule is selectively stained. It is
important to keep in mind that the epithelium is
behind the anterior capsule. When the surgeon
lifts the flap gently, he/she can see the epithelium perfectly stained so he/she may safely
proceed to complete the capsulorhexis.
This technique is considered of great
value, a breakthrough in this step of phacoemulsification.
C h a p t e r 9:
HYDRODISSECTION HYDRODELAMINATION
This next step is of great importance. Its
objective is to separate the capsule from the
cortex and the cortex from the nucleus (Figs.
46, 47, 48). Its significance is related to the
liberation of the adherences which attach the
nucleus to the cortex or the cortex to the capsule, facilitating aspiration (Figs. 1, 46, 47, 48).
The hydric chamber created with
hydrodissection also plays a role in the protection of the posterior chamber and the posterior
capsule during the phacoemulsification maneuvers.
Technique of Hydrodissection
Using a 3 ml syringe with a maximum of
1.5 ml infusion fluid, a 25 G flat tip cannula is
introduced underneath the capsulorhexis (Fig.
78-A). Following Fine and Centurion's recommendations, the anterior capsule is raised
and BSS is infused with light pressure. The
fluid will distribute itself along the posterior
capsule and will drain through the opposite
side. The liquid wave can be seen in the center
of the red reflex (Fig. 46, 47). This process is
repeated at 6, 3 and 9 o'clock keeping in mind
that after infusing, we should press the cataract
against the capsule to avoid elevation of pressure within the capsular bag.
After the liquid wave reaches the area of
the pupillary opening, the syringe is withdrawn and the center of the nucleus is compressed in an attempt to release the adherences
of the cortex to the capsule on the side opposite
to where hydrodissection was begun. After this

maneuver, the surgeon attempts to rotate the
nucleus. If the nucleus was released by complete hydrodissection, it will rotate freely. If
there is no rotation, try a new hydrodissection
located opposite the site of the initial one.
Centurion recommends that after the nucleus
is released, it be rotated four or five times 360.
This releases possible cortex or epinucleus or
capsule adherence. Thus, at the end of nucleus
emulsification there is practically no need to
aspirate cortical remains.
Following hydrodissection, it is essential
to confirm that the nucleus is completely separated from the cortex before proceeding with
the next step, which is management of the
nucleus with the different phaco techniques.
(For the do's and particularly don'ts related to
hydrodissection, it is important to read the text
on this subject in Chapter 7, next to Figs. 46, 47,
48).
Hydrodelamination
Hydrodelamination is the separation of
the nucleus from the soft epinucleus (Fig. 48).
This technique is done after completing
hydrodissection. The same needle (Fig. 78-A)
is introduced beneath the cortex and into the
lens stroma while infusing BSS, which will
delaminate sheets of cataracts, isolating the
nucleus from the epinucleus, forming the golden
ring (Fig. 48 GR).
With present techniques, many surgeons
do not used to perform hydrodelamination following a very well done hydrodissectgion.
They remove the epinucleus usually during the
emulsification of the nucleus.
175
MANAGEMENT OF THE NUCLEUS

At this stage, we proceed with the culminating phase of the operation. The previous
methods of emulsification of the nucleus first
within the anterior chamber and later in the iris
plane are somewhat outmoded with the exception of the supracapsular otherwise known as
the tilt and tumble iris plane technique, which
is still Lindstroms first choice. It is less
demanding. At present, though, the most often
used phacoemulsification techniques in handling the nucleus are performed in the posterior
chamber within the capsular bag. These are
all identified as endocapsular techniques.
They have the advantage of reduced risk of
damaging the endothelium. They also enable
the surgeon to work with a larger opening in the
capsulorhexis which is definitely useful in patients whose pupillary dilatation is not adequate. These methods have the disadvantage
that nucleus manipulation is done closer to the
posterior capsule and more stress is placed on
the zonular fibers, to their consequent risk.
The almost universal use of endocapsular phacoemulsification has been made possible because of innovations in technique and
equipment.
Concepts Fundamental to All

Techniques
Surgical Principles
Almost every contemporary cataract surgeon uses some form of chopping, and all
surgeons who perform chopping use some form
of ultrasound to facilitate the chop. Whether it
be a groove-and-chop, divide and conquer, or a
technique like Fine's quick chop (the choo176
choo chop and flip technique presented in Figs.

122- 126), some form of ultrasound is used for
chopping.
All modern techniques are oriented toward breaking up or disassembling the nucleus
to facilitate its removal from the eye. These
techniques, which rely on mechanical energy,
have been developed to reduce the amount of
ultrasound energy necessary to break up the
hard part of the lens nucleus. In addition,
disassembling the nucleus removes it from the
capsular recesses of the bag, thereby facilitating its removal with the phaco probe.
Nuclear disassembling techniques use
some ultrasound at the beginning of the procedure to create multiple troughs or grooves. A
second instrument such as a spatula or chopper
can then be used to crack or break the nucleus.
In this chapter we present the three groups
of techniques mostly used in advanced phacoemulsification methods for nucleus removal.
You will find the fundamental concepts which
are applicable to all methods and a description of the principles that make these methods
highly successful, all of which have been developed by highly prestigious cataract surgeons. It is by understanding these concepts
that the surgeon will be able to develop one or
two essential techniques and use them as the
methods of choice adapting his/her chosen
procedure to virtually any situation and the
different types of cataract encountered, either
soft, standard or medium-density and the very
hard cataract.
The surgeon will find in this Volume
precisely what he needs to understand and to
adopt the method which he feels more comfortable with and most suitable for his patients. If
a more complete description of the techniques
C h a p t e r 9:
available is desired, we suggest that you refer

to the carefully selected, short list of recommended books and bibliography presented at
the end of the chapter for the method's originators and proponents.
The Essential Principles

1) A general principle for all techniques
to remove the nucleus in phacoemulsification,
either the original four quadrants divide and
conquer and its derivative divide and conquer
(D & C) methods, and the relatively recent
chopping techniques is that it is first essential to
debilitate the core of the nucleus so that the
nucleus can be split into halves, sometimes
fourths (Figs. 67, 103 through 106) and occasionally into eighths. This allows emulsification and aspiration of nucleus segments
(Fig. 105) instead of attempting to carve the
entire nucleus without a planned strategy. This
splitting of the nucleus is safer for the endothelium because it is easier to keep smaller par-
ticles away from the endothelium without having to push them against the posterior capsule.
These essential principles are illustrated in Fig.
103 (The Cracking Effect), Fig. 104 (The Dividing Effect through Opposing Forces), Fig.
105 (The Slicing Process) and Fig. 106 (the
Dividing Process).
2) Smooth sculpting which avoids
nuclear movement and zonular stress is critical to all methods. Well-controlled deep and
central sculpting facilitates cracking in segmentation methods and rim removal in one and
two-handed methods. By using just enough
ultrasound power to embed the phaco tip and
then backing off to the I/A position (standard
pedal position 2), the nucleus can be positively
engaged for rotation and manipulation. This
versatility of the phaco tip is especially important for one-handed techniques as well as chopping techniques.
The principles of mechanical advantage apply to all methods; safety is maximized by using the minimum force and movement required to accomplish a given task.
THE ENDOCAPSULAR TECHNIQUES

THE HIGH ULTRASOUND ENERGY AND LOW VACUUM GROUP
THE GROOVING AND CRACKING
METHODS
The Divide and Conquer Four

Quadrant Nucleofractis
Technique
The first group of endocapsular operations was based on the principle of utilizing
large amounts of phaco energy and low vacuum.
The classical and less complicated technique

of this first group is the Four Quadrants
"Divide and Conquer" described in 1987 by
Howard Gimbel. The principles of this method
are presented and described in figures 56 and
67 in Chapter 7. In order to debilitate and
remove the nucleus, a linear vertical sulcus or
groove is done in the nucleus from 6:00 to
12:00 o'clock and a second groove perpendicular to the first is done, both using the phacoemulsifier probe. The carving of these furrows results in the nucleus being seen with a
cross as shown in Figs. 56 and 67. A second
177
instrument known as the "manipulator" which

is introduced through the ancillary or side port
incision engages the opposite side of the groove
inferiorly (Figs. 67 and 79). The phaco tip is
impaled on one side of the already deep groove
and the manipulator on the opposite side of the
sulcus (Figs. 103 and 104) Both must be

positioned beyond half the depth of the groove.
The sulcus should have been carved with a
width equal to 1.5 diameters of the phaco
sleeve. The depth at which the phaco tip is
impaled is 1.5 times the width of the phaco tip
(Fig. 103).
Figure 103 (above right): Phacoemulsification - 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 (arrows) the nucleus in half pulling the
instrument from periphery to the center. 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): Phacoemulsification - Dividing Effect

Opposing force (arrows) is applied
to both sides of the cracking with the phaco
probe and the help of the chopper. Dividing the nucleus in small pieces will facilitate
its removal with the phacoemulsifier employing less ultrasound and higher vacuum.
178
C h a p t e r 9:
Cracking the Nucleus

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

This cross section view shows the phacoemulsification 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 Conquer and the Continuous Circular Capsulorhexis
As pointed out by Paul Koch, M.D., the
nuclear fracturing divide and conquer techniques developed initially by Gimbel and all
the phacoemulsification techniques that are
designed to move the nucleus through the capsulorhexis are in part possible because of the
development of the continuous circular capsulorhexis that Gimbel and Neuhann originated
individually (Figs. 43-45, 98, 99, 100). The
CCC made nearly obsolete all the existing
phacoemulsification procedures, because each
of them required that the nucleus be prolapsed
out of the capsular bag for each removal, either
in the iris plane or in the anterior chamber
(although the iris-plane tilt and tumble technique is still used by Lindstrom with significant success - Editor). Now that the capsular
bag could be kept intact with a very strong form
of capsulotomy, new techniques were needed
to get the nucleus out of the bag. The mechanical fracturing of the lens causes extra physical
stress within the capsule and cannot be done
without great risk of tears of the anterior capsule extending around posteriorly unless we
have a proper CCC. There is an interdependence of these techniques.
Principles of the Divide and Conquer

Techniques
Gimbel developed the Divide & Conquer techniques to meet the challenge and the
opportunity created by the CCC: to operate
180
within the capsular bag. There are actually two

subdivisions: the trench Divide & Conquer and
the crater Divide & Conquer, but they both
follow two very simple principles:
1) Weaken the radii of the nucleus. This
creates a space in the middle of the cataract in
which other instruments can be introduced to
force (crack) apart the sections of the nucleus
(Figs. 56, 67, 103, 104, 106).
2) Break apart the nuclear parts including
the rim of the nucleus (Figs. 104, 105, 106).
Koch has pointed out that the distinction
between a trench and a crater is not clear-cut.
There is actually a continuum extending from
true trench to true crater.
The Role of D & C Techniques in

Cataracts of Different Nucleus
Consistency
Softer Cataracts (Trench D & C)
Softer cataracts need preservation of
firm tissue so that the cataract can be manipulated. If we remove much of the central nucleus,
all of the firm tissue would be removed, and
any attempt to manipulate it would be difficult.
The instruments we use would go like through
cheese in the remaining soft tissue. Some of the
relatively hard central core is necessary to
resist the instruments, give them something to
press against, and, ultimately, something to
manipulate. Recognizing this, Gimbel recommended the creation of a trench that is really a
narrow pass down the middle of the cataract.
This freed up a little space, but preserved walls
of central nucleus for manipulation. The trench
D & C is indicated for softer cataracts.
C h a p t e r 9:
Dense Cataracts (Crater D & C)

In these cases the strategy is entirely
different. We want to remove as much of the
hard center core of the cataract as possible
during this sculpting phase, leaving only a thin
and soft nuclear rim for later removal. For
these cataracts, a crater Divide and Conquer is
recommended when using D & C techniques.
The nucleus is held in place firmly in the
bag. We can sculpt into the cataract with the
ultrasound energy and remove all of the hard,
dense nuclear core without the cataract moving. That keeps the phaco tip and all of the
debris far away from the endothelium and
allows safe and extensive nucleus removal. It
also allows us to stay away from the posterior
capsule.
As pointed out by Paul Koch, M.D., we
can judge the depth of the sculpting from fairly
distinctive changes in the red reflex. The first
clue to depth is the color of the cataract. We
normally begin with a red reflex, but as soon as
we start emulsifying the epinucleus, the reflex
changes and becomes either burgundy or gray.
As we sculpt down toward the middle of the
cataract, we reach the gray center, and as we get
through that, the reflex starts turning burgundy
again (Fig. 69). Once we reach the posterior
epinucleus, the color is back to red.
If we monitor the color changes as we
sculpt, we can work our way very deep into the
catarac t without the risk of cutting the posterior capsule. We slow down as the color
brightens.
The primary goal of crater creation is
to remove the very dense nuclear core, leaving
only a much softer nuclear rim, thereby converting the cataract from a dense one into a soft
one. The secondary goal is to create a space
below the level of the anterior capsule into

which the rim tissue can be pulled for emulsification. (Editors Note: this technique is not
to be confused with the original crater-bowl
procedure used years ago).
Steps Following the Trench or the

Crater D & C
Once the nucleus is prepared with either
the trench or the crater, the nuclear rim is
broken apart using a unique and clever method
of fracturing it. The phacoemulsification tip is
driven into the remaining broad nuclear rim
and held there with aspiration. A Barraquer
spatula or manipulator (Fig. 79) is placed next
to the phaco tip and poked into the rim right
next to it (Fig. 67). The two instruments are
separated, breaking the rim apart (Fig. 104).
The nucleus is rotated around a bit, reengaged
with th e phaco tip and the Barraquer spatula,
and broken again (Fig. 106 below).
Present Role of Original Four

Quadrant Divide and Conquer
The original, four quadrant "Divide and
Conquer Technique" illustrated in Figs. 56 and
67, 103, 104 and 106 below is now the technique of choice for those surgeons who are less
experienced and are converting from planned
extracapsular surgery to phacoemulsification.
It is the easiest method. The debilitation of the
nucleus is achieved by high doses of ultrasound
energy and the "eating" or emulsification of the
quadrants also requires high ultrasound energy. For this reason we included this technique as the one of choice in Chapter 7 that
covers the stage of Transition.
181
The original four quadrant divide and

conquer technique has the significant importance of having served as the basis for the
proliferation of many variations of the divide
and conquer. Many of them are still useful. It
also provided the insight needed for the
Figure 106: Phacoemulsification - Dividing

Process Chopping vs Divide and Conquer
(Top) The opposing forces in the chopping 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
development of the chopping techniques, beginning with Nagahara's Phaco Chop. The
latter, though, are based on different principles and constitute the group of low ultrasound energy - high vacuum procedures
which at present are the techniques of choice.
C h a p t e r 9:
THE LOW ULTRASOUND ENERGY AND

HIGH VACUUM GROUP
The techniques described in the first group
are known as the grooving and cracking methods. Now it is important for the surgeon to
evolve into the second group, which are the
chopping methods, because chopping enables
you to reduce ultrasound energy in the eye by
using greater mechanical forces - mechanical
forces that will not harm the eye. I. Howard
Fine, M.D., emphasizes that the easier we can
make it to help surgeons transition to chopping,
the better we will be serving our patients.
Innovations in technique have undergone a rapid and important evolution driven by
advances in technology. At the time when the
initial four quadrant technique was introduced
by Gimbel in 1987, the early phacoemulsification machines vibrated at a constant power
with constant aspiration requiring the use of a
large amount of ultrasound power in order to
obtain rapid sculpting of the nucleus using
sharp needles to engage and cut nuclear material. The aspiration mode played a secondary
role, after the material had been emulsified.
The trend now is the opposite, that is, to
use low ultrasound power and high vacuum.
These chopping techniques emphasize the aspiration aspect while the ultrasound power is
utilized as an aid to fragment the hard portions
of the nucleus and to facilitate aspiration of the
nuclear material. This is a significant advance
which allows much more control by the surgeon.
In all modern techniques, the surgeon
uses only sufficient but very small amounts of
ultrasound power to fragment the nuclear material that is occluding the tip of the phaco
needle. The advances in technology that have
made this possible are presented in Chapter 8,
under Emulsification System, and illustrated in Fig. 85.
THE CHOPPING TECHNIQUES

They are all based on the concept of the
Phaco Chop technique initially devised by
Nagahara in 1993. Since then a multiplicity
of techniques that stem from the principles of
the phaco chop have been developed but are
less complex than the original Phaco Chop.
The lens substance, including the nucleus,
has a concentric lamellar and radial structure.
It can be fractured along the direction of the
lens fibers that run from one side of the equator
towards the opposite side, passing through the
center of the nucleus (Fig. 106 above).
Main Instruments Used

In the chopping techniques, two instruments are utilized: 1) the phaco chopper introduced through the ancillary or side port incision, which serves as an ax (Fig. 80). The
phaco tip serves as a chopping block (Fig. 106
above). The nucleus is easily fractured with the
phaco chop technique. The latter is more effective for standard to moderately hard nuclei than
a soft one.
183
184
Surgical Principles of the Original

Phaco Chop
Chopping Techniques Presented

in this Volume
The surgical principle of the original

phaco chop technique is first, after hydrodissection, the phaco tip is placed into the eye and
touches the nucleus as far superiorly as possible, inside the limits of the capsulotomy.
Using a quick burst of phaco energy the tip is
buried securely into the nucleus.
The chopper is inserted through the sideport incision, and placed on the nucleus as far
inferiorly as possible, again right inside the
capsulotomy. It is buried right into the cataract
and then pulled up toward the phaco tip, dividing the cataract . This technique, which was the
basis for all chopping techniques that later
developed, presented two problems: unlike
previous experiences with Divide & Conquer
and In-Situ Fracture, there was no space in the
middle of the cataract for manipulation. When
the surgeon finished chopping the four quarters
and was ready to emulsify one of them, he had
no room to allow it to slide toward the phaco
tip. It was wedged in place in the capsular bag
and did not move easily.
The surgeon had to engage the fragment
and pull it into the anterior chamber for removal, converting the case from one that was
purely endocapsular, to one that was threequarters endocapsular and one-quarter anterior chamber phaco.
The surgeon had divided the nucleus
into fragments, but had no space for maneuverability in order to remove them.
Even though the Phaco-Chop technique
of Nagahara initiated a new era in phacoemulsification, the original procedure had to be
modified in order to overcome the problems
here outlined.
From the large variety of chopping techniques now available, we have chosen five for
presentation in Chapters 9 and 10. They were
all originated by highly prestigious, experienced phacoemulsification experts and represent the direction in which this surgery is oriented. These procedures are: 1) The Stop and
Chop (Paul Koch); 2) The Crater Phaco
Chop (MacKool); 3) The Null Phaco Chop
also referred to as Pre-Slice (Jack Dodick); 4)
The Choo-Choo Chop and Flip (I. Howard
Fine). 5) The Stop and Karate Chop Technique as advocated by Edgardo Carreo, one
of the top phaco surgeons in South America.
His insights are somewhat different than the
top surgeons in North America.
THE STOP AND CHOP

TECHNIQUE
Surgical Principles
This is the main variation of the phaco
chop technique. It is widely used, and was
popularized by Paul Koch. Its most important
contribution is that it facilitates one of the
significant difficulties encountered with the
original phaco chop which is the fragmenting
of the first half of the nucleus and removal of
the first fragment.
A superior quality CCC and a good
hydrodissection are fundamental before managing the nucleus, as in all other phaco operations. After the hydrodissection is completed
(Figs. 46-48, 78-A), Koch usually does not
perform hydrodelineation for this procedure,
C h a p t e r 9:
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 substance, 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 maneuver debilitates the central core of the lens
permitting its easier fracturing with the chopper.
because he is able to chop the nucleus into bitesized pieces. Because he constantly pulls pieces
into the middle of the capsular bag, he does not
need the cushion of epinucleus. All he would
be doing if he created one would be adding one
more step at the end -- removal of epinucleus.
Koch's method is to sculpt a central
groove as if we were doing the classical Nucleofractis or divide and conquer technique but
only one groove is done and not the classical
cross. This creates a space in the center (Figs.
107, 108) which is essential for nucleus manipulation. In softer cataracts, the surgeon
does a lighter furrow or trench while in the
standard two to three plus or even four plus
cataracts, a center crater is done instead of a

furrow.
The deep nuclear sculpting is performed
from 12 o'clock to 6 o'clock, creating a vertical
trough (Fig. 107). A second instrument designed for phaco chop (chopper) is inserted
through the ancillary incision (Figs. 108, 80).
The chopper is inserted underneath the
anterior capsular edge in the lower right quadrant (Fig. 108), advanced out to the periphery
of the capsule (Fig. 109), embedded in the
peripheral nucleus (Fig. 110), and pulled back
to the central groove. This creates a small free
wedges of nucleus, which are easily emulsified
and aspirated (Fig. 111).
185
Figure 108 (above right): Stop and Chop Technique - 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 instrument (chopper) is inserted through the ancillary
incision and placed underneath the anterior capsular edge in the right lower quadrant. It is then
advanced out to the periphery of the capsule, embedded 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 chopper to fracture the nucleus. The surgeon
stops, rotates the nucleus through 90 degrees, 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 Technique - Stage 4 - Creating Free Wedges of Nucleus
The same piece of nucleus is again stabilized 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 periphery. Observe how the chopper is pulled from
the 6 o'clock position under the capsulorhexis towards the center while the phaco probe (P) maintains
the nucleus in a fixed position for firm support.
186
C h a p t e r 9:
Fracturing of the Nucleus

The ultrasound tip and the ancillary chopper fracture the nucleus into two parts by
exerting force toward each other. The surgeon
holds the ultrasound tip steady, which serves as
the firm block holding the nucleus and the
chopper slices the nucleus from the periphery
towards the center of the nucleus. Numerous
bites are performed with the choopper creating
small free wedges to be emulsified (Fig. 111).
Fixating, Rotating and Creating

Small Free Wedges of Nucleus for
Emulsification and Aspiration
At this point, the surgeon stops, rotates
the nucleus through 90 degrees (Figs. 108, 109,
110). He fixates the lower half of the nucleus
with the ultrasound tip and cracks it with a
hook, exerting force toward the ultrasound tip

(Figs. 111, 106 above). The same piece of
nucleus is again stabilized with the phaco tip,
while the phaco chop instrument is advanced
out to the periphery and pulled centrally
(Figs. 110, 111), creating another small free
wedge of nucleus for emulsification and aspiration. The process is repeated until the entire
first nuclear half is removed. The other nuclear
half is rotated into the inferior capsular bag,
and the entire process is repeated (Figs. 108
through 111).
From these four initial fragments, which
can be easily mobilized from the capsular bag,
each piece is further divided into smaller pieces
and eaten with the ultrasound. Thereby, the
importance of the burst action in the phaco
machine, because the surgeon cuts small pieces
and emulsifies, again cuts small pieces and
emulsifies them (See Chapter 8 for Burst Mode
and Pulse Mode). The whole procedure occurs
with no sculpting .
Figure 111: Stop and Chop Technique

- Stage 5 - Chopping and Emulsification
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 process is repeated until the entire remaining
nuclear half is removed.
187
This is the essence of the stop and chop,

one of the most important of the advanced
techniques.
Absolute Requirements to
Perform the Stop and Chop
Although this technique is much less
complex than the original phaco chop, in order
for it to be successful, the following principles
must be attained:
1) Hydrodissection: this stage of the
procedure must be very well done (Figs. 46-48,
78-A). A great deal of the success of this
technique depends on the ability to easily
mobilize the nucleus (Figs. 108-110). We
must be sure that the nucleus can be completely
rotated before beginning its phacoemulsification. The ease with which the nucleus can be
rorated depends on a very well done hydrodissection. Before beginning phacoemulsification of the nucleus, the surgeon should rotate the nucleus two or three times inside the
bag. If the rotation is not easy, then there was
a failure in the hydrodissection maneuver. The
surgeon must not attempt to mobilize the
nucleus mechanically or by force.
2) The Initial Groove: done to create
the space inside the nucleus for it to be
fractured (Figs. 107 - 108). This groove must
be well done to be useful. It allows the
surgeon to free the two sectors easily (Fig. 106
above).
3) Fracturing the Nucleus: when the
surgeon has reached a good depth with the two
instruments, that is, the phaco tip and the ma-
188
nipulator or chopper, he should attempt to

fracture the nucleus (Figs. 103, 104, 106 above).
It is easy to split the nucleus into two parts
because the chopper or manipulator does a
better job separating the nucleus halves than
the olive tip spatula previously used for this
purpose. If there are difficulties and the fracture line is not seen, the initial groove in the
center of the nucleus can be deepened but the
surgeon must pay great attention to the color of
the red reflex to be sure he/she is not too close
to the posterior capsule.
The fracture of the nucleus into two parts
first is the key to the success of the operation.
Only after this will the surgeon be allowed to
proceed making smaller free segments or
wedges by additionally fracturing with the chopper (Fig. 111).
Fracturing with the chopper depends
largely on the instrument insertion depth. Normally, the phaco probe and tip as well as the
chopper should be inserted at a depth about
2/3 the diameter of the phaco tip. Once the
nuclear fragments have been made, the procedure is continued with the usual maneuvers
(Figs. 105 - 111). At the end of nuclear removal, there is a small quantity of residual
material which is then aspirated.
Importance of the Phaco

Chopper
This ancillary instrument is absolutely
essential to perform the chopping technique.
There is a large variety of these phaco choppers. They all look like a golf club and the most
C h a p t e r 9:
effective ones have a somewhat sharp point

1.5 mm in length (Fig. 80). In figures 103
through 121 you may observe the chopper
being used in different techniques. The chopper is inserted through the side port or ancillary incision. The hook or chopper is positioned at 6:00 o'clock underneath the anterior
capsule as far peripheral and deep as possible
(Figs. 105, 110, 111). The shape of the point
is most important. We can chop a soft nucleus
using a sharp point; a wedge shaped tip facilitates chopping of a hard nucleus.
Highlights of the Stop and Chop

Technique
1) It provides excellent stabilization of
the nucleus by fixation with the phaco tip and
slicing and biting with the chopper. The latter
has more of an active role in the procedure than
the ancillary instruments in other endocapsular
techniques. The surgeon uses the two hands in
harmony during the entire phaco nuclear removal.
This also means that the surgeon should
pay very close attention to the chopper, which
needs as much control as the ultrasound tip.
2) Throughout the entire procedure, the
ultrasound energy transmitted to the nucleus is
not transmitted to the epinucleus and the cortex. Therefore, it is not passed on to the
posterior capsule and the zonules because it is
absorbed by the external cortex and the separation induced through hydrodissection
3) How useful is this procedure is in
cataracts of different nuclear consistency
depends on the ability of the surgeon to adapt
his technique to the type of cataract he/she is
operating. The size of the nuclear wedges
created can vary based on nuclear consistency.
This technique is even useful in hard nuclei
using less ultrasound and more aspiration. Hard
nuclei require smaller wedges while softer
nuclei can yield with larger wedges.
The stop and chop technique is useful in
most cataracts with different consistency:
in hard nuclei, in soft and in cataracts with
nuclei of standard consistency. It is a method
that lends itself to wide use. There is greater
ease in dealing with very hard nuclei as
compared with most other techniques.
4) The advantages of this procedure over
the conventional divide and conquer methods
include reduced stress on the capsular bag and
zonular fibers because the use of the chopper
simplifies the fracture.
5) The operation decreases phaco time.
6) It creates less turbulence and consequent complications.
7) Any remaining epinucleus and cortex
is removed in standard fashion.
8) By dividing the nucleus in two halves,
the stop and chop technique facilitates the more
difficult maneuvering encountered by the surgeon in phaco chop.
189
FUNDAMENTAL DIFFERENCES BETWEEN CHOPPING

TECHNIQUES AND DIVIDE AND CONQUER (D & C) TECHNIQUES
The two main groups of techniques utilized in modern, endosacular advanced methods for managing of the nucleus in phacoemulsification are the chopping techniques and its
derivatives and the cracking techniques (divide
and conquer and its derivatives). There are
fundamental differences in regards to their
surgical principles.
Chopping tends to stabilize the nucleus
between the phaco tip and the chopping instrument. Furthermore, mechanical force is directed centripetally as the chopping instrument
cleaves the nucleus (Fig. 106 above). Therefore, minimal force is directed outward
against the capsule periphery. This is in
contrast to cracking methods, during which
the nuclear periphery is pushed outward
against the capsule by the cracking instruments
(Figs. 104, 106 below). As a consequence, any
defect in the capsulorhexis is at greater risk and
may have a tendency to extend to the periphery
and posteriorly with cracking as opposed to
chopping.
Chopping is also a more productive
method than cracking with respect to the need
to use ultrasound power because chopping uses
mechanical force for nuclear segmentation as
opposed to sculpting grooves which are done
with ultrasound, even though modified D & C
techniques do allow the use of low total ultrasound energy because it is not used continuously.
Ultrasound is used more efficiently during chopping because it is applied in the more
effective occlusion mode.
190
Finally, chopping is a more time productive method than cracking in that a segmenting
chop can be made with a single instrument
movement (Figs. 104 above, 111) as opposed
to multiple ultrasonic sculpting passes required
for a groove (Figs. 56, 67). Also, the smaller
chopped fragments are more readily emulsified with less repositioning required as compared to larger quadrants.
In the chopping techniques, the chopping direction is from the equator to the center
(Fig. 104 above). In the divide and conquer
procedures, the cracking is from the center
toward the equator (Fig. 104 below). Therefore, in the divide and conquer procedures, the
surgeon must begin sculpting the center of the
nucleus and debilitating the nucleus at that
stage, making a trench or a crater with ultrasound to start the cracking from the center,
as shown in Figs. 106 below, and 104. In the
chopping techniques, the surgeon sticks the
phaco tip into the nucleus and insert the phaco
chopper into the space between the equator and
the capsule at the 6 o'clock position (Figs. 105,
110, 111). Then the phaco chopper is drawn to
the phaco tip to crack the nucleus. There is no
need of sculpting during this stage of the procedure which is the reason why the phaco energy
can be significantly reduced.
Sculpting with the ultrasound energy is
the easiest and safest step of the operation and
that is why we recommend the divide and
conquer original four quadrant technique for
the transition. There is no ultrasound sculpting
in the stop and chop.
C h a p t e r 9:
THE CRATER PROCEDURES

The Crater Divide and Conquer
(Mackool)
This procedure is based on Gimbel's
Divide and Conquer surgical principles. It is
a modification of the original four quadrant
divide and conquer. Because it is used mostly
for hard nuclei, the center of the nucleus is
weakened in the shape of a small crater by
applying ultrasound energy and proceeding to
crack the nucleus in two halves. This is followed by further cracking into four pieces
using the ultrasound energy with the help of the
ancillary instrument. The pieces are then emulsified.
The Crater Phaco Chop for Dense,

Hard Nuclei
The crater phaco chop is essentially used
in harder, more dense and brunescent cataracts
(Fig. 2) in which a trench or trough or groove
cannot be used because it does not weaken the
entire lens nucleus sufficiently to easily fracture the nucleus. The resulting segments would
be too large to manage safely. This is because
the epinucleus of a hard nucleus is thin and a
hard nucleus has a dual structure consisting of
an outer soft and inner hard nucleus or core.
Also, a hard nucleus is thicker than a soft
nucleus and the posterior part is harder and
more elastic. In these lenses, the phaco chop of
Nagahara or even the stop and chop of Koch
may not be sufficient.
Instead, a small, central crater is sculpted

with controlled amounts of ultrasound energy,
leaving a dense peripheral rim (Fig. 112). After
the central core of the nucleus is removed, the
maneuvering of fracturing can be accomplished
by first placing the chopping instrument under
the anterior capsule at the 6 o'clock position
(Fig. 113). Keeping the phaco tip placed into
the bulkhead of the nuclear rim (Fig. 113), the
vacuum of the tip is used to stimulate division
of the nucleus. No ultrasound is used. The
chopping instrument which has been introduced through the ancillary incision pulls toward the incision (arrow), slightly away from
the phaco tip and gently towards the posterior
capsule. This results in a fracture through the
nuclear rim and any remaining thin nuclear
plate (Figs. 114). The nucleus is then rotated in
order to accomplish additional fracturing of
small segments (Figs. 114, 115). Fracturing is
done with much less ultrasound energy than in
the D & C Crater Procedure.
In the Crater Chop technique, again we
initially debilitate the nuclear core with ultrasound energy. When weakened, the phaco tip
is impaled or firmly buried in the central nucleus
(Figs. 113, 114). Multiple wedges are created
by the continuous process of biting tissue using
the chopper. These small pieces are then
emulsified (Fig. 116).
This Crater Chop technique is not to be
identified as the Crater-Bowl procedure described previously in which a substantial amount
of ultrasound energy was used to debilitate the
central tissue.
191
Figure 112 (above left): Crater Chop

Technique - Stage 1 - Creation of the
Small Crater
The central epinucleus and anterior cortex are removed. The phaco tip
(P) is used for sculpting at the center. A
small central crater is sculpted with controlled 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 Technique - Stage 2 - Fracturing the Nucleus
With coordinated movements the
phaco probe (P) is impaled and buried
through the thickness of the dense periphery. At that time the chopoper (C) is
employed to start the fracture deeply and
vertically from the periphery to the center 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 portions 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
C h a p t e r 9:
When to Remove Nuclear Segments Immediately vs When Leave

them in Place
The entire lens is fractured before any
pieces are removed, maintaining the distention 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 continuous 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 occluded the fragment is advanced toward the center of the
capsular bag with the help of the chopper (C) for complete aspiration with the phaco probe (P).
193
THE NUCLEAR PRE-SLICE OR NULL

PHACO CHOP TECHNIQUE
This technique has been devised by Jack
Dodick, M.D., from New York, one of the
world's experts in cataract surgery. Almost
every contemporary cataract surgeon uses some
form of chopping, and all surgeons who perform chopping use some form of ultrasound to
facilitate the chop. Whether it be a groove-andchop, divide and conquer, or a technique like
Howard Fine's quick chop (the choo-choo chop
and flip technique presented later in this chapter), some form of ultrasound is used for chopping.
Disassembling the Nucleus

Importance in Modern Techniques
All modern techniques are oriented toward breaking up or disassembling the nucleus
to facilitate its removal from the eye. These
techniques, which rely on mechanical energy,
have been developed to reduce the amount of
ultrasound energy necessary to break up the
hard part of the lens nucleus. In addition,
disassembling the nucleus removes it from the
capsular recesses of the bag, thereby facilitating its removal with the phaco probe.
Nuclear disassembling techniques use
some ultrasound at the beginning of the procedure to create multiple troughs or grooves. A
second instrument such as a spatula or chopper
can then be used to crack or break the nucleus.
Dodick now routinely uses the nuclear preslice or null-phaco chop technique except in
hardened, black cataracts. This procedure reduces the amount of ultrasound needed to remove cataracts by phacoemulsification. The
194
actual breaking up of the lens uses no ultrasound at all.

In this technique, Dodick sections the
nucleus into four parts with no ultrasound
using two specially designed hooks (Figs. 117
- 121). It is as safe as any phaco chop, and takes
an equal amount of time.
How Is the Null-Phaco Chop Done

The procedure uses two elongated
Sinskey hooks, which have a 2 mm bend
with a round polished ball at the end
neatly shown in Figs. 119 and 120. The
anterior cortex is vacuumed, and viscoelastic
is placed in the eye. The first hook is introduced through the paracentesis incision parallel to the lens until it is in the capsular bag.
Dodick always does the phacoemulsification
at the 11:00 position, which means the paracentesis incision is at about 2:30 (Fig. 117).
The hook enters the capsular bag and is
rotated 90 degrees so that it engages the
equator of the nucleus. The first hook is now
in place and is pointing toward the optic
nerve.
Then the second hook is introduced
through the phacoemulsification incision,
again parallel to the lens (Fig. 117). It engages the capsular bag and enters it. The
surgeon then rotates the hook 90 degrees so
that the tip faces the optic nerve and engages
the equator of the nucleus below. The hooks
should be about 180 degrees apart. Taking
great care, the surgeon moves the hooks to
bring the tips together (Fig. 118). This process will not tear the posterior capsule, but it
is important not to place the hooks in the
sulcus. As the two hooks are brought together, they bisect the nucleus (Fig. 118).
C h a p t e r 9:
Figure 117: Dodicks 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 choppers. 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
Figure 119 (above): Dodicks NullPhaco Chop Technique - Stage 3 - Fracturing the Inferior Half of the Cataract
The 11 oclock hook is moved
toward 6 oclock and placed in the capsular bag. The second hook is left in the
groove. The two hooks are brought together resulting in a trisection (this part
of lens is cut into three parts).
Figure 120 (below): Dodicks NullPhaco Chop Technique - Stage 4 Fracturing the Superior Half of the
Cataract
Once the inferior half is divided, the surgeon proceeds with the
superior half in a similar manner. The
hooks or choppers are placed at 11
oclock and centrally and drawn together toward the visual axis to complete the disassembling of the entire
cataract.
196
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
extremely low.
C h a p t e r 9:
Dodick disassembles some 1+ 2+

lenses with little or no ultrasound, because
this maneuver not only sections the nucleus
into four parts, it actually dislodges these
parts quite well from the recesses of the
capsular bag (Figs. 120, 121). He brings the
last two quadrants into the pupillary plane
and is able to break them up further with the
aid of a Sinskey hook through the paracentesis incision. When he needs ultrasound in 3+
or 4+ cataracts, he rarely goes above 30 %
ultrasound because the lens is already broken
into four parts (Fig. 121).
Learning and Adjustment

Performing this technique does require
some learning and adjustment. The learning
curve required for this technique is to master
the placement of the two hooks nd to prevent
rotation of the nucleus while it is being
divided. Great care must be exercised in the
placement of the hooks into the capsular bag.
There is a tendency for the nucleus to rotate,
but you soon develop a proprioceptive-like
sense of placing those hooks. If you see or
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 reduces the amount of ultrasound energy introduced into the eye.
197
Once mastered, this technique is highly

reproducible, it takes no longer than any
other chop technique, and reduces the amount
of ultrasound energy introduced into the eye.
It may be a very good alternative procedure
for experienced phaco surgeons.
amount of energy necessary to evacuate the

lens. The technique Dodick describes is one
method of nuclear disassembly. These methods in general dramatically reduce the
amount of energy to break up the nucleus,
leading to clearer corneas and quicker rehabilitation of the patient after surgery.
Potential Complications
To critics, this technique appears dangerous. The belief is that the capsular bag
can be dislocated. However, Dodick has not
found this to be a problem if the recesses of
the capsular bag are identified by vacuuming
of the anterior cortical material and the hooks
are carefully placed in the capsular bag and
not in the sulcus. Critics may point out that
the tip is back toward the posterior capsule,
and the two hooks brought across the nucleus
might rip the posterior capsule. This, according to Dodick, does not happen.
On the contrary, he thinks that this can
actually be a safer procedure, especially in
eyes
with
weak
zonules
and
pseudoexfoliation. Rather than sculpting and
applying pressure toward the zonules, the
vector forces from the special hooks pull
toward the center, reducing stress on the
zonules.
For more dense cataracts (e.g. 3+), he
does use low ultrasound, perhaps 15%, maximum 30%, and again high vacuum, 300 to
400 mmHg, and a high flow rate. To minimize the effect of surge, he uses the
MAXVAC high vacuum tubing and the aspiration bypass ABS tip.
Contributions of this Technique

Dodick's procedure shows that using
mechanical energy to break up the lens in
place of ultrasound is helpful in reducing the
198
THE CHOO-CHOO CHOP AND

FLIP PHACOEMULSIFICATION
TECHNIQUE
This special technique devised by
I. Howard Fine, M.D., head of the Oregon
Eye Institute in Eugene, Oregon and Clinical
Professor at the Oregon Health Science University in Portland, is a chopping technique
that uses power modulations and high
vacuum along with specific maneuvers to
minimize the amount of ultrasound energy in
the eye and maximize safety and control. It is
effective in all types of cataracts and allows
hardened nuclei to be removed safely in the
presence of a compromised endothelium.
This procedure facilitates the achievement of two goals: minimally invasive cataract surgery and maximally rapid visual rehabilitation. It is designed to take maximum
advantage of various new technologies available, mainly the Alcon 20,000 Legacy, the
AMO Sovereign (Allergan) and the Storz
Millennium phacoemulsification systems
(Fig. 85). These technologies include high
vacuum cassettes and tubing, multiple programmable features on all systems, as well as
the Mackool Micro Tip (Fig. 84) with the
Legacy and burst mode and occlusion mode
capabilities with the Sovereign (Figs. 86, 87).
The result is enhanced efficiency, control, and
safety. The procedure is done as shown and
described in Figs. 122, 123, 124, 125, and
126.
C h a p t e r 9:
Origin of the Name Choo-Choo

Fine uses high vacuum and short
bursts, or pulses, of phaco ultrasonic power.
The name choo-choo arises from the resulting sound of the pulse mode (Fig. 125).
The nucleus is continually rotated so that pieshaped segments can be scored and chopped,
and then removed by high vacuum assisted by
short bursts or pulses of phaco. (Editors
Note: scoring the nucleus in this instance
means using the wedge-shaped edge of the
chopper instrument to groove and then cut the
nucleus in half against the countering resistance of the phaco tip which has been securely engulfed in the opposite side of the
nucleus.)
The short bursts or pulses of ultrasound

energy continuously reshape the pie-shaped
segments which are kept at the tip, allowing
for occlusion and extraction by the vacuum.
The size of the pie-shaped segments is customized to the density of the nucleus with
smaller segments for denser nuclei. Phaco in
burst mode (Fig. 125) or at this low pulse rate
(Fig. 86) sounds like choo-choo-choochoo; this is the reason behind the name of
this technique. (Editors Note: for a precise
description and illustration of the pulse and
burst modes, and their clinical applications,
see pages 151-156, and Figs. 86, 87).
The term flip refers to management
of the epinucleus (Fig. 126). Fine considers
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, circular 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. Simultaneously, the 30 degree bevel-down
phaco tip (P) introduced through a clear corneal incision lollipops the proximal nucleus.
The nucleus is scored by bringing the chopper proximally (red arrow) to the side of the
phaco tip, which provides a countering force
(blue arrow).
199
Figure 123 (above): Choo-Choo Chop Technique - 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 separated - 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 Nucleus
In a similar manner to the first chop,
the phaco (P) and chopper (F) are used in combination 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 fashion.
200
C h a p t e r 9:
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 fragmented and aspirated with minimal or no chattering 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 (arrow) the epinucleus. In this more centrally located 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

residual cortex after evacuation of the epinucleus. The epinuclear rim of the fourth
quadrant is utilized as a handle to flip the
remaining epinucleus.
ultrasound energy (grooving) to further disassemble the nucleus.

High vacuum is utilized to remove
nuclear material rather than utilizing ultrasound 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
of the nucleus as in cracking techniques, but
substitutes mechanical forces (chopping) for
202
The parameters used by Fine for this

technique and applied to the three main phacoemulsification equipments are the following:
C h a p t e r 9:
These Parameters are adjusted depending on the hardness of the nucleus. They can be programmed in the corresponding Memory of the equipment.
203
THE TRANSITION TO
CHOPPING TECHNIQUES
In the transition to chopping, Fine recommends the following steps:
Impale the nucleus on the phaco tip
superiorly. If you have not lollipoped the
probe tip deep enough (Fig. 88), return to
position 2 and then go back into position 3.
(Editors Note: lollipoping refers to securely
engulfing the tip of the phaco into the
nucleus, like a lollipop or candy sucker on a
stick. The phaco tip is analogous to the stick
and the nucleus is the round candy portion.)
A burst takes place each time you enter
position 3.
When you have lollipoped deeply
enough (Fig. 88), score the nucleus. (Editors
Note: scoring the nucleus means using the
wedge-shaped edge of the chopper instrument
to groove the nucleus deeply, against the
countering resistance from the lollipoped
phaco on the opposite side of the nucleus.)
Place the chop instrument in the golden ring
(Fig. 75), go from foot position 2 into foot
position 3 and floor it (Editors Note: pushing the pedal fully all the way to the bottom
setting, as when applying full gas pedal pressure in a car). You can chop the nucleus
without having to worry about what your foot
is doing because your foot is on the floor
the vacuum will hold the nucleus as you
manipulate the chop instrument.
Then break the nucleus in half by
separating the two instruments while depressing the chopper and slightly elevating the
phaco needle. You will not have to worry
about what your foot is doing because you are
already in control of the nucleus you will
not have to manipulate your foot at all. This
technique will allow you a much easier transi-
204
tion with fewer factors to worry about.

For mobilizing the nuclear tissue, Fine
likes a burst width of 80 milliseconds in
surgeon control (Fig. 87). Once again, you
can customize your options to control what
happens at the tip. If things are moving along
rapidly, you can depress the foot pedal to foot
position 3 and decrease the interval between
bursts. Or if you feel like things are a little
precarious or there is a very hard piece of
nucleus and you want to avoid chattering, you
can back off a little bit. (Editors Note:
chattering is when the nucleus bounces
against the phaco tip at a high rate of speed
without being emulsified as desired, like
when ones teeth chatter when cold - Fig. 89)
The material will be held very firmly at
the tip with no chatter, and will not emerge
into the anterior chamber. This affords a
much greater level of safety when dealing
with a hard cataract in the presence of endothelial disease.
Once you have taken care of the
endonucleus, you can employ the Bimodal feature using the pedal to vary your aspiration flow
rate in foot position 2. This helps you to mobilize and bring the epinuclear roof out of the
capsular fornix and position it in such a way
that you can trim it. Fine trims the rim of the
epinucleus in three different quadrants and uses
the rim in the remaining quadrant to flip the
rest of the epinucleus (Fig. 126). He brings
the handpiece central and then trims the epinucleus. Once he goes into foot position 3 the
tip clears. As the rim of the epinuclear shell is
removed, the aspiration flow rate causes the
residual cortex to flow over the floor of the
epinuclear plate.
Fine does not usually have to remove
the cortex as a separate step of phacoemulsification. In 70 percent of these cases, he has no
cortex remaining.
C h a p t e r 9:
These types of maneuvers can be done

because there is a stable anterior chamber
with a very low tendency for surge.
The new technology in these advanced
machines and new software allows the surgeon to put into effect the important advance
in performing phacoemulsification, which is
fundamentally cutting power. The surgeon
really has little worry about cutting power
himself because the new software provides
him/her so many more options. With these
recent advances in phacoemulsification systems, the surgeon has indeed a total control
phaco chop. The new type of software described in Chapter 8, Fig. 85, will advance
phacoemulsification in regions of the world
where there is a preponderance of hard cataract with diseased endothelium.
REMOVAL OF RESIDUAL
CORTEX AND
EPINUCLEUS
The surgeon who is learning this technique usually has more cortex to aspirate and
needs to follow a specific technique for removal of the epinucleus. This is discussed in
depth and illustrated in Figs. 69, 70 and 71,
Chapter 7. If not cautiously done, there is a
higher incidence of rupture of the posterior
capsule.
The situation differs for the experienced
surgeon. Due to the importance attributed to
a well-performed hydrodissection and rotation of the nucleus at the end of it, generally
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 oclock, we may remove the residual cortex located superiorly using a
manual aspiration technique with a curved irrigation/aspiration cannula or a standard Simcoe cannula (S). Here the Simcoe cannula is inserted inferiorly through an additional paracentesis (P) which
is a third incision performed between 6 and 7
oclock. It is moved superiorly to remove the residual cortex under the anterior capsule leaves.
Manual technique allows more accurate control.
Another method to attain this is following the procedure shown in figure 71. Again, it is important
not to be aggressive.
aspirated together with the nucleus segments.

The aspiration of cortical remains becomes
unnecessary because they were partially or
totally eliminated during nucleus emulsification. If this does not happen, the tip of the
phaco emulsifier aspirates the free epinucleus
with the pedal on position 2, with the help of
the nucleus manipulator (Figs. 69 and 126).
Once the nucleus has been removed and
the surgeon proceeds to irrigate/aspirate
whatever cortex remains, he/she may become
over-confident thinking that the operation is
practically finished. It is, if the cortex and
epinucleus are then removed with special
care. Always be certain to check the tip of the
I/A phaco tip preoperatively to detect any
206
little barbs or sharp spots that could rupture or

tear the posterior capsule. The Chip and Flip
technique advocated by Fine may be very
useful in this phase (Fig. 126). The entire
epinuclear rim and floor can be evacuated
safely and completely.
If some cortical material remains, particularly in the hard-to-reach superior capsular bag underneath the anterior capsule
leaves, the surgeon proceeds to remove this
residual cortex as shown in Figs. 127 and
128. It is very important not to be aggressive. Do not attempt to clear the very last bit
of cortex remaining because this could lead to
accidental rupture of the posterior capsule.
C h a p t e r 9:
INTRAOCULAR LENS
IMPLANTATION
The Increased Interest in Foldable IOL's
Present trends point to an increasing use
of foldable IOL's for the following reasons:
1) Small incision cataract surgery continues to be on the rise. Patients who are in the
financial, social, business and professional levels to afford phacoemulsification look forward
to a very prompt visual rehabilitation. This can
be made possible only by a successful phaco
with a small, valvulated, self-sealing 3 mm
average incision which requires a first class
foldable IOL (Figs. 90, 91).
Surgeons, therefore, no longer accept
the previous methods of performing a cataract
extraction through a small incision followed by
an enlargement of the wound in order to insert
a 6.0 mm optic PMMA lens. As a consequence,
industry rose to this challenge and has developed high quality foldable IOL's .
2) Through the significant clinical and
laboratory research made by R. Lindstrom,
I.H. Fine, Ernest and Neuhann, Langernman
and other prestigious colleagues, refractive
cataract surgery was developed as a standard
procedure by: a) placing the corneal cataract
incision in the right place. b) developing the
right architectural design of a small self-sealing, valvulated, corneal tunnel incision that can
result in 1.00 D or less of postoperative astigmatism (Figs. 92, 93). This has stimulated the
use of foldable monofocal and multifocal IOL's.
3) Foldable IOL technology has significantly improved associated with the use of
non-toxic, highly biocompatible chemicals
and polymers of which the foldable IOL`s are
made. This is particularly important with the
development of second generation silicone
lenses which have been proven to be non-toxic,
non-inflammatory, non-sensitizing, inert and
available at lower costs.
The Most Frequently Used IOL's

Even though there is a distinct trent towards foldable lenses, PMMA IOL's continue
to be the most frequently implanted intraocular
lenses throughout the world, (except in the
U.S). PMMA IOLs are used more commonly
even in Europe, although to an ever-decreasing extent, as has been pointed out by Tobias
Neuhann, M.D., of Germany, in a classic
study he made of new foldable IOL's (see
bibliography).
The still preponderant use of PMMA
lenses is related to the unquestionable reality
that, for a variety of reasons, extracapsular
surgery is still the cataract operation mostly
used throughout the globe. More than 60% of
very good ophthalmic surgeons perform ECCE
in the majority of patients even though they
may recognize that phacoemulsification is a
better operation especially for of very prompt
visual rehabilitation.
Special Indications for PMMA

Lenses
Richard Lindstrom, M.D. uses foldable 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 placement of the proximal haptics.
Nevertheless, he considers that there still are

indications for the standard PMMA lenses, for
example the secondary anterior chamber lens
implant (Fig. 129). He also uses standard
PMMA intraocular lenses when performing a
triple procedure that includes a penetrating
keratoplasty. In these patients there is no
reason to use a foldable lens. He may use a
7 mm optic modified C loop PMMA lens.
The most widely accepted, major groups

of foldable lenses are made of either acrylic or
second generation silicone (PDMDPS). Each
group has advantages and disadvantages. Other
monofocal lenses creating interest are the
Memory lens, the hydrogel lenses and the toric
lens made by STAAR.
MONOFOCAL FOLDABLE
LENSES
These lenses have a very high refractive

index providing crystal clear vision. Chemically they are closely related to the still generally favored PMMA. Mechanically they are
best described as pliable rather than elastic.
This is clinically important because acrylic
lenses are comsidered by many surgeons as
somewhat bulky when folded and, consequently, difficult to implant through an inci-
An extensive variety of excellent

monofocal foldable lenses are produced by
manufacturers in the US, Germany, France,
Belgium, Switzerland and other countries. They
use the finest technology and front-line engineers, biochemists and designers.
208
THE FOLDABLE ACRYLIC IOL'S
C h a p t e r 9:
sion less than 3.5 mm. We have presented

Carreo's technique in which he describes
how to insert the AcrySof lens through a 2.8
mm incision in Chapter 8. The most widely
used foldable acrylic lenses are the popular
Alcon AcrySof lens model MA30BA, which
has a 5.5 mm optic and PMMA haptics and the
Allergan Sensar AR40 with a 6.0 mm optic.
They both come with very practical folding and
injector systems, the "Acrypack" for Alcon's
AcrySof and the "Unfolder Saphire" for
Allergan's Sensar.
Specific Advantages of Acrylic

Foldables
In addition to providing a very high
refractive index, they are also the first choice
lenses to use in higher risk cases such as
patients with diabetic retinopathy (Figs. 8-17),
chronic uveitis or any candidates for future
vitrectomy with silicone oil.
Another advantage seems to be that
acrylic lenses have a "tacky" surface.
According to Tobias Neuhann, M.D., a
positive consequence of this tackiness is a
mechanical adhesiveness between lens capsule
and IOL, which, in turn, may lead to reduction
of secondary cataract (posterior capsule opacification).
A disadvantage of this tackiness, however, is that a multitude of small particles may
stick to the lens surface and be pressed into the
material with the implantation instruments,
where they remain forever, since they are not
absorbed. For these reasons, injector implantation or disposable implantation forceps are
gaining increasing importance in handling these
lenses (Fig. 82 B and C).
Disadvantages
Foldables
of
Acrylic
Foldable acrylic lenses come in a 5.5 and

a 6 mm optic size. Lindstrom and some other
surgeons prefer the 6 mm optic because the
5.5 mm optic lenses may have problems with
edge glare and unwanted visual images.
Another limitation with acrylic lenses, according to Lindstrom, is that none of the foldable
acrylic lenses will go through an incision smaller
than 3.5 mm. (they are pliable but not elastic Editor) In his experience, you have to make
one of two compromises if you use an acrylic
lens. Either you make the incision larger or
make the optic smaller. 3.5 mm instead of 3.2
or 3.0 mm is not a large difference but still,
with a clear corneal incision, Lindstrom thinks
the smaller the incision the safer it is as far as
sealing of the wound. And if you go to a smaller
optics then you get more symptoms of edge
glare, particularly with younger patients who
have larger pupils.
Edgardo Carreo, M.D., on the other
hand, has developed a technique by which he
implants the foldable acrylic Alcon AcrySof
lens 5.5 mm optic through a 2.75 mm incision.
Carreo's technique is described in this book
in Chapter 8.
THE FOLDABLE MONOFOCAL

SILICONE IOL's
Second generation silicones are gaining in popularity because they are inert and do
not give rise to inflammatory reactions. This
second generation silicone polymer is identified as the PDMDPS.
209
There was a time when the silicone lenses

caused more inflammation or capsular fibroses
but the newer silicones do not do that at least
based on the studies made by Lindstrom and
others. Many surgeons like silicone lenses
because they go through an incision smaller
than other lenses thereby allowing a larger
optic. The favorite lenses are those with 6.0
mm optic or larger.
There are now two companies that have
a 6.3 mm optic silicone lens. One of them is
Staar and the other is Bausch & Lomb. Most
other companies have 6 mm optic silicone
lenses. The most popular monofocal foldable
silicone lenses are Allergan's SI 40 NV and
Bausch & Lomb's LI 61 both of which have a
6 mm optic. The Bausch & Lomb LI 63
silicone lens has a 6.3 mm optic. Silicone
lenses have more elasticity. When the lens is
implanted through an injector, it stretches. So
it can go through a smaller incision. The
Allergan SI 40 NV that has a 6.00 mm optic and
the Bausch & Lomb LI 63 with a 6.3 mm optic
will go through a 3 mm incision with the proper
injector nd cartridge made available by
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
modified C loop silicone lenses are better accepted by the surgeon than the plate haptic
lenses because of less decentration.
The Importance of Cost

An additional advantage of the silicone
lenses is that because many companies make
them, they tend to be less expensive. And so,
if you are in an environment where cost is an
issue, which is just about anywhere in the
world, the new second generation, high quality
silicone lenses on the average can be purchased
for maybe half the price of foldable lenses of
other materials.
210
OTHER MONOFOCAL LENSES

The Hydrogel, Foldable Monofocal
IOL
These lenses swell in water. Their mechanical properties are pliable rather than elastic. Their properties are close to PMMA but
have a hydrophilic surface and may be folded
and inserted through small incisions.
The Foldable Toric Lens

The STAAR toric IOL (AA4203T) combines recent toric technology with a flexible
optic. The toric optic offers three cylindrical
powers (2.5 D, 3.5 D, 4.0 D) as well as
spherical (+14D to +26 D) values, and the plate
haptic possesses large fenestrations designed
for lens fixation in the capsular bag.
The results of this product are encouraging and appear to be stable. This implant
extends the range of refractive lens surgery,
especially in cases where high ametropia is
combined with astigmatism.
Bitoric Lens But Not Foldable

Although we here emphasize essentially
the trends towards the increasing use of foldable lenses, it is important to bring out the
development of the bitoric IOL although it is
not foldable. This lens has been developed by
H.R. Koch and manufactured by Dr. Schmidt
Intraokularlinsen in Germany. The diskshaped PMMA implant consists of two toric
lenses of the same power, both with one
planar and one toric side, which counter-rotate
to produce a variable degree of astigmatic
power. The direction of the haptic defines the
position of the cylindrical axis, and two additional lines in the optical periphery allow an
C h a p t e r 9:
exact intraocular positioning. The range of this

6 mm toric IOL is outstanding: spherical power
between -3.0 D and +30 D combined with
cylindrical power from +1.0 D to +12.0 D. It is
12.5 or 13.4 mm in diameter;
THE FOLDABLE
MULTIFOCAL IOL
The Array Multifocal Silicone
Lens
This is one of the most important developments in rehabilitation of sight and improv-
ing the quality of life following cataract surgery. I. Howard Fine, M.D., and Richard
Hoffman, Javitt and colleagues in the U.S.
and Virgilio Centurion, M.D. in Brazil have
done extensive clinical research on the performance of this foldable multifocal lens and the
benefits of high quality multifocal vision in
their patients.
Having used different kinds
of multifocal IOLs in the past, Centurion is
familiar with the complications in their design.
This new multifocal lens, however, is a refractive molded lens instead of a diffractive lens
(Figs. 130, 131). Its use is recommended by
Centurion for surgeons who are confident
with phacoemulsification and small incision
techniques.
Figure 130 (left): How the Multifocal Array Intraocular Lens Works - Frontal View
The new multifocal Array intraocular lens
has five refractive zones on the anterior surface. Between 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 Intraocular 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 intermediate distances. These aspheric transitions between the
optical zones greatly reduce the halo effect which was
sometimes bothersome using older diffractive designs.
211
212
How Does the Array Foldable Multifocal Lens Work?
Quality of Vision with Array Multifocal
The lens is manufactured by Allergan

Medical Optics. It has a foldable silicone optic
that is 6.0 mm in diameter with haptics made of
polymethylmethacrylate and a haptic diameter
of 13 mm (Fig. 130). The lens can be inserted
through a clear corneal or scleral tunnel incision that is 2.8 mm wide, using the Unfolder
injector system manufactured by AMO
(Allergan) (Fig. 82 A).
There are five zones on the anterior
surface. Between each of them there is a
narrow aspheric transition zone. The 5 dominant zones provide the following: 1) a clear
image for distance (2 zones); 2) one zone for
intermediate distance, and 3) two zones for
near. The Allergan Array Lens differs from
the older diffractive lens designs not only in
having classical optics for the definitive
zones, but in having aspheric transition zones
which, according to Centurion, provide the
patient with a smooth transition between the
images for distance, intermediate, and near
vision, greatly reducing the halo effect which
was sometimes so bothersome with older
designs. Even those patients who may complain of some halos after surgery seldom
report them 2 or 3 months later.
Fine and Hoffman describe the lens as
having an aspherical component and thus
each zone repeats the entire refractive sequence corresponding to distance, intermediate, and near foci. This results in vision over
a range of distances. The lens uses 100% of
the incoming available light and is weighted
for optimum light distribution. With typical
pupil sizes, approximately half of the light is
distributed for distance, one-third for near
vision, and the remainder for intermediate
vision.
Refractive multifocal IOLs, such as the

Array, have been found to be superior to
diffractive multifocal IOLs by demonstrating
better contrast sensitivity and less glare disability. The Array does produce a small
amount of contrast sensitivity loss equivalent
to the loss of 1 line of visual acuity at the 11%
contrast level using Regan contrast sensitivity
charts. This loss of contrast sensitivity at low
levels is present only when the Array is
placed monocularly. This has not been demonstrated with bilateral placement and binocular testing. In addition to relatively normal contrast sensitivity, good random-dot stereopsis and less distance and near aniseikonia
were present in patients with bilaterally
placed implants as compared to those with
unilateral implants.
In a study by Javitt and colleagues,
41% of bilateral Array subjects were found
never to require spectacles, as compared to
11.7% of monofocal controls. Overall, subjects with bilateral Array IOLs reported better
overall vision, less limitation in visual function, and less use of spectacles than did
monofocal controls.
Studies in different parts of the world
report that more than 85% of patients have
20/40 or better vision without correction after
implantation with this lens. All of the 456
patients in the US Clinical Study have J3 or
better, and more than 60% are J2 or J1
without correction. About half are 20/20
without correction.
Patient Selection and Results

Fine and Hoffman emphasize that the
advantages of astigmatically neutral clear
C h a p t e r 9:
corneal cataract surgery have allowed for

increased utilization of multifocal technology
in both cataract and clear lens replacement
surgery. Careful attention to patient selection, preoperative lens power calculations, in
addition to meticulous surgical technique,
will allow surgeons to offer multifocal technology to their patients with great success.
Researchers working with this lens
have the clinical impression that depth of
focus and quality of vision are improved if
the surgeon does a bilateral implantation
and implants the second eye within 4 weeks
of the first implantation. The results seem to
be improved if there is a very short interval
between the first and second eye. (If the
cataract merits removal in both eyes. This is
usually the case when modern small incision
cataract surgery is performed. - Editor).
Of the 350 multifocal lens implantations Centurion has done, about half were
bilateral, and half were monocular. The monocular implantations involved traumatic or
inflammatory cataracts rather than senile
cataracts . He has not yet used multifocal
IOLs in patients with congenital cataracts, but
they work well for monocular implantation
when a patient has one normal eye. Generally patients do not depend upon glasses
much for near vision after the implantation.
With bilateral implantation, the quality of
vision and quality of life of patients improve
considerably. Sometimes they only need
glasses to drive at night and to read very
small print.
Fine and Hoffman point out that the
most important assessment for successful
multifocal lens use, other than patient selection, involves precise preoperative measurements of axial length in addition to accurate
lens power calculations. They have found
applanation techniques in combination with
the Holladay II formula and the Holladay II

back-calculation to yield accurate and consistent results.
Specific Guidelines for Implanting

the Array Lens
Fine and Hoffman have used the Array
multifocal IOL over the last 2.5 years extensively, in approximately 30% of their cataract
patients and in the majority of their clear lens
replacement refractive surgery patients. As a
result of their experience, they have developed specific guidelines with respect to the
selection of candidates and surgical strategies
that enhance outcomes with this IOL.
AMO recommends using the Array
multifocal IOL for bilateral cataract patients
whose surgery is uncomplicated and whose
personality is such that they are not likely
to fixate on the presence of minor visual
aberrations such as halos around lights. Obviously, a broad range of patients would be
acceptable candidates. Relative or absolute
contraindications include the presence of
ocular pathological processes (other than
cataracts) that may degrade image formation
or may be associated with less than adequate visual function postoperatively despite visual improvement after surgery.
Contraindications are age-related macular degeneration, uncontrolled diabetes or diabetic
retinopathy, uncontrolled glaucoma, recurrent inflammatory eye disease, retinal detachment risk, and corneal disease or previous
refractive surgery in the form of radial keratotomy, photorefractive keratectomy, or laserassisted in situ keratomileusis.
Fine and Hoffman also avoid the use of
these lenses in patients who complain excessively, are highly introspective and fussy, or
obsessed over body image and symptoms.
213
They are conservative when evaluating patients with occupations that involve frequent
night driving or that put high demands on
vision and near work (e.g., engineers and
architects). Such patients need to demonstrate a strong desire for relative spectable
independence in order to be considered for
Array implantation.
In their practice, they have reduced
patient selection to a very rapid process.
Once they determine that someone is a candidate for either cataract extraction or clear lens
replacement, they ask the patient two questions: First, "If we could put an implant in
your eye that would allow you to see both
distance and near without eyeglasses, under
most circumstances, would that be an advantage?" Approximately 50% of their patients
say no directly or indirectly. Negative responses may include, "I don't mind wearing
glasses," "My grandchildren wouldn't recognize me without glasses," "I look terrible
without glasses," or "I've worn glasses all
mylife." These patients receive monofocal
IOls. Of the 50% who say it would be an
advantage, they ask a second question: "If
the lens is associated with halos around lights
at night, would its placement still be an
advantage?" Approximately 60% of this
group of patients say that they do not think
they would be bothered by these symptoms,
and they receive a multifocal IOL.
Centurion also emphasizes that these
lenses should not be used in patients with a
basic astigmatism of more than 1.50 diopters.
Prof. Luis Fernandez Vega in Spain
recommends a series of important guidelines
in order to be successful with advanced technology multifocals: 1) Do only bilateral
multifocal implantations in adults. Do not
place a monofocal IOL in one eye and a
multifocal in the other. Otherwise, patients
214
compare the vision between the two eyes and

refer to the differences existing, even though
they may have good visual acuity in both. 2)
Yes, the multifocal IOL does fullfil its optical
purpose both for distance and near. Although
it does not completely prevent the wearing of
spectacles, it does diminish the dependency
on glasses. Clarify this to the patient preoperatively. 3) Select the patient according to
his/her visual needs. 4) Do a very precise
preoperative biometry; 5) Perfect your cataract surgery to end up with less than 1.00 D
astigmatism.
Special Circumstances for Array Implantation

There are special circumstances in
which implantation of a multifocal IOL
should be strongly considered. Alzheimer's
patients frequently lose or misplace their
spectacles, and thus they might benefit from
the full range of view that a multifocal IOL
provides without spectacles. Patients with
arthritis of the neck or other conditions with
limited range of motion of the neck may
benefit from a multifocal IOL rather than
multifocal spectacles, which require changes
in head position. Patients with a monocular
cataract who have successfully worn
monovision contact lenses should be considered possible candidates for monocular implantation. The same is true for certain
professionals such as photographers who
want to alternate focusing through the camera
and adjusting imaging parameters on the
camera without spectacles. In these patients,
the focusing eye could have a monofocal IOL
and the nondominant eye a multifocal IOL.
Fine and Hoffman almost always use the
Array for traumatic cataracts in young adults
in order to facilitate binocularity at near,
C h a p t e r 9:
especially if the fellow eye has no refractive

error or is corrected by contact lenses.
Need for Spectacle Wear PostOp

Prior to implanting an Array lens, they
inform all candidates of the lens's statistics to
ensure that they understand that spectacle
independence is not guaranteed. Approximately 41% of patients implanted with bilateral Array IOLs will never need to wear
eyeglasses, 50% wear glasses on a limited
basis (such as driving at night or during
prolonged reading), 12% will always need to
wear glasses for near work, and approximately 8% will need to wear spectacles on a
full-time basis for distance and near correction.
Halos at Night and Glare
geographical and cultural regions. They have

provided HIGHLIGHTS with the pearls of
the methods that lead them to successful
implantation. They are: Jack Dodick, M.D.,
from New York, I. Howard Fine, M.D.,
from Oregon, and Richard Lindstrom,
M.D., from Minnesotta, three different areas
of the United States. And Edgardo Carreo,
M.D., from South America (Chile).
First, you will find the present status of
the preferred methods of lens implantation,
forceps vs injectors, their pros and cons.
Second, the techniques of implantation of 1)
the Array Multifocal Foldable Lens
(Allergan). 2) The acrylic monofocal lens, in
this case the AcrySof Lens (Alcon). 3) The
silicone monofocal foldable lens (STAAR).
PREFERRED METHODS OF IOL

IMPLANTATION
15% of patients were found to have

difficulty with halos at night, and 11% had
difficulty with glare, as compared to 6% and
1%, respectively, in monofocal patients.
Use of Forceps vs Injectors
SURGICAL PRINCIPLES AND GUIDELINES FOR IOL IMPLANTATION
Many surgeons like to use forceps to

implant the foldable lens, others use injectors.
Lindstrom reminds us that the original instruments available for foldable lenses were
all forceps. Consequently, those surgeons
that used foldable lenses early on got used to
the forceps insertion method (Figs. 133,
134). But there is a disadvantage to the forceps approach. It adds some mass to the
amount of material you are putting into the
eye (Fig. 132) thereby requiring a slightly
larger incision. Another disadvantage of using forceps is that you may touch the lens to
the conjuntiva or sclera before placing it into
the incision. Several studies have shown that
the lens picks up bacteria and mucus and
Just as there are a large number of

methods to disassemble the nucleus there is a
wide variety of techniques to implant the
IOL's, particularly the foldable lenses. What
counts is the results and the feasibility to
achieve a successful implantation.
We present here the surgical principles
and guidelines for implantation of the most
commonly used types of foldable lenses. We
have chosen the principles followed by
highly respected, skilled phaco surgeons who
do a great deal of teaching in addition to
having a large, solid practice in different
Advantages and Disadvantages
215
other debris from the surface of the eye when

you use the typical cross action forceps (Fig.
133). This may increase the risk of postoperative inflammation or infection. For
these reasons, Lindstrom now prefers the
injectors, because you take a sterile lens out
of a sterile package, put it into a sterile
injector and place the lens directly inside the
eye. With the injector you also have less
bulk, thereby requiring a slightly smaller incision (Fig. 132-A).
The reason a good number of surgeons
do not like the injectors is: 1) they got used
to folding with forceps, (Figs. 132-B, 133)
which are convenient and they are used to
them. 2) All the injectors have a small failure
rate. It is very annoying when you load a
lens into the injector and then after placing it
inside the eye, the optic is torn or one of the
lens loops is bent or damaged. Some surgeons do not use injectors because they do
not like the lens failures that occassionally
occur with them. The newer injectors of the
better companies, however, are performing
very well now.
New Trends for Folding and

Insertion of IOL's
The majority of lenses are still folded
and inserted with forceps (Figs. 132-B, 133).
Nevertheless, there is a definite trend toward
the development of separate instruments for
folding and inserting IOLs rather than using
the insertion device to fold the IOL. The
combination of instruments designed by the
manufacturers to facilitate folding and insertion is known as cartridge injector systems
which are then used to implant the IOL.
216
Cartridge Injector Systems

Fine, Lewis and Hoffman believe that
there are many perceived advantages of implanting foldable IOLs with injector systems,
as compared with folding forceps. These advantages include the possibility of greater sterility, ease of folding and insertion, and implantation through smaller incisions as emphasized by Lindstrom (Fig. 132).
Greater sterility with injector systems is
believed to occur because the IOL is brought
directly from its sterile package to its sterile
cartridge and inserted into the capsular bag
without ever touching the external surface of
the eye, as is the case for lenses in folding
forceps. Although this advantage would suggest a lower rate of endophthalmitis with injector systems, recent clinical studies have shown
no significantly different rate of bacterial contamination of the anterior chamber after implantation of silicone lenses with a forceps
versus an injector.
Perhaps the most appealing advantage of
injector systems is that the lens can be loaded
by a nurse or technician without the use of an
operating microscope, further streamlining the
procedure. In addition, inserting foldable lenses
with a cartridge device is generally felt to be
easier than insertion with forceps.
There are no irregular surfaces as may
occur between the surface of the forceps and
the lens. The IOL is lodged inside the cartridge
and injector system.
Allergan's foldable three piece silicone
lens (monofocal or multifocal - AMO Array)
with PMMA haptics may be implanted with
AMO's Unfolder Phacoflex injector system.
Allergan's acrylic foldable IOL (Sensar and
Clariflex lenses) may be implanted with a new
C h a p t e r 9:
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 IOLs . 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

Unfolder Sapphire, as described by Centurion (Fig. 82-A). These injectors are resterelizable (as are the forceps, of course).
Alcons popular 5.5 mm AcrySof IOL
may be implanted with one of its injectors such
as the Monarch (Fig. 82) or with a standard
cartridge through a 3.4 mm incision. Carreo
reports injecting this lens through a 2.8 mm
incision (Fig. 132). Many surgeons use Alcons
Acrypack (Fig. 82) when implanting the
AcrySof lenses. The Acrypack serves to first
fold the IOL. The surgeon then uses a forceps
(Fig. 81) to implant the already folded IOL.
The Alcon AcrySof lens, which requires
3.5 to 4.0 mm incisions for 6.0 mm optics and
3.2 to 3.5 mm incisions for 5.5 mm optics,

when implanted with forceps is now packaged
in a wagon wheel dispenser. The easiest folding instrument to use for these lenses is the
Rhein folder, as recommended by Fine because the tips have been extended to make it
easier to remove the lens from its wagon wheel
packaging. The forceps can be turned with the
tips down in the nondominant hand. The tips
go into the slots on both sides of the optics, so
that the lens can be picked up and placed on a
drop of viscoelastic. The forceps are then
turned so that the tabs are down. The lens is
grasped and folded, and then the insertion
device is used to insert the lens using the
surgeons dominant hand.
217
Guidelines for Insertion of Different Types of Lenses

Surgical Technique with Array Lens
Fine and Hoffman consider it very important that incision construction be appropriate with respect to size and location because the
multifocal Array works best when the final
postoperative refraction has less than 1 D of
astigmatism. They favor a clear corneal incision at the temporal periphery that is 3 mm or
less in width and 2 mm long (Fig. 91). Each
surgeon should be aware of his or her usual
amount of surgically induced astigmatism by
vector analysis. The surgeon must also consider the best meridian in the cornea to place the
incision considering the existing preoperative
astigmatism in order to end up with minimum
postop astigmatism. We discuss this subject
under "Refractive Cataract Surgery" in Chapter 12 (Complex Cases).
In preparation for phacoemulsifiction,
the capsulorhexis must be round (Figs. 44, 45)
and its size should be sufficient so that there is
a small margin of anterior capsule overlapping
the optic circumferentially. This is important
in order to guarantee in-the-bag placement of
the IOL and prevent anteroposterior alterations in location that would affect the final
refractive status. Hydrodelineation and cortical-cleaving hydrodissection are crucial in
all patients because they facilitatelens disassembly and complete cortical cleanup.
Taking the time and care to perform a
careful and effective cortical cleanup as shown
in Figs. 127 and 128, without being aggressive,
may reduce the incidence of posterior capsule opacification, the presence of which,
even in very small amounts, will inordi-
218
nately degrade visual acuity in Array patients. Because of these phenomena, patients
implanted with Array lenses will require YAG
laser posterior capsulotomies earlier than will
patients with monofocal IOLs.
Minimally invasive surgery is key.
Techniques that utilize effective phacoemulsification powers of 10% or less are highly
advantageous and can best be achieved with
power modulations (burst mode or two pulses
per second) rather than continuous phacoemulsification modes (Figs. 86-89, Chapter 8). The
Management of Complications with the Array
Lens is discussed in Chapter 11 (Complications).
Carreo's Technique of Acrylic

IOL Implantation Through a
2.75 mm Incision
Because it is generally considered that
acrylic lenses require a somewhat larger incision (3.4 mm) to be introduced into the anterior
chamber without harming the lips of the wound,
we present Carreo's technique by which he
implants the AcrySof lens (acrylic, Alcon)
through a 2.75 mm incision. This is one stage
of the Phaco Sub 3 method which he advocates.
Carreo from Chile, is a highly skilled cataract surgeon.
Carreo emphasizes that in order to
introduce the acrylic intraocular lens through
very small incisions, as is the case in Phaco Sub
3, using adequate technique and equipment is
imperative. Otherwise, the implantation could
cause severe trauma to the corneal margins of
the wound and the endothelium as well as
leading to an undesired increase in the size of
the incision. Before implantation, a generous
amount of viscoelastic should be injected into
the capsular bag and the anterior chamber.
C h a p t e r 9:
Foldable Acrylic Lens of Choice

Carreo's experience is based on the use
of Alcon's AcrySof lens model MA30BA
(5.5mm optic, total length 12.5mm, PMMA
haptics).
Implantation Technique
The lens is folded with forceps (paddle), placed
parallel to the haptics (longitudinal implantation technique). The implantation forceps
(Buratto) are used to grasp the lens so that the
haptics are perfectly parallel to the fold, going
through the center line of the optic, and reaching the edge.
Correctly grasping the Buratto forceps is critical to penetration with the
AcrySof through a 2.75mm incision. If the
lens fold is not completely symmetrically, an
edge is produced that impedes its introduction.
If the jaws of the forceps are at an angle to the
lens fold, a separation is created between the
faces, which may make the lens impossible to
introduce through a small incision.
The surgeon proceeds with the Buratto
forceps placed in such a way that the lens fold
stays on the left. It is very important that the
first haptic enters the anterior chamber before
the optic. Otherwise, the lens may be damaged
if the haptic is trapped with the optic inside the
corneal tunnel. Then the surgeon inserts the
optic by exerting pressure and using slight
lateral movements along the corneal tunnel.
The spatula, introduced through the lateral
paracentesis, exerts firm and constant
counterpressure. (In order to exert adequate
counterpressure, the lateral paracentesis must
be placed 60 degrees from the main incision.)
This pressure and counterpressure maneuver is
another key aspect of successful implantation
of the AcrySof MA30BA through a 2.75mm

corneal incision without complications.
Before completing the insertion of the
optic, which should be very controlled so as not
to penetrate abruptly into the anterior chamber
and risking the integrity of the posterior capsule, the surgeon puts the haptic under the edge
of the capsulorhexis so it can be placed in the
capsular bag.
Once the optic is in the anterior chamber,
the Buratto forceps are rotated 90 degrees in
this position, and they are released so the lens
unfolds (Fig. 133). Due to the thin incision, the
lens tends to be trapped in the claws of the
forceps. To release it, the surgeon pushes gently downward with the spatula. Now the forceps may be withdrawn, and the lens continues
to gradually unfold (Fig. 133). The second
haptic is immediately grasped with KelmanMcPherson forceps to introduce it into the
anterior chamber. Aided by the spatula, using a
bimanual maneuver, the implantation is completed by placing the lens optic first and then
the second haptic into the capsular bag (Fig.
134).
Implantation of the AcrySof MA30BA
lens through a 2.75mm corneal incision is not
easy, but Carreo emphasizes that if the
described technique is followed step by step,
the surgeon can perform it without injuring
corneal tissues. However, when dealing with
AcrySof MA30BA lenses stronger than 24
diopters, Dr. Carreo prefers to use a slightly
larger incision (3.0mm) because the greater
thickness of these lenses may make them difficult or impossible to implant through a 2.75mm
incision. (Editor's Note: as pointed out at the
beginning when describing the acrylic IOL's
implantation, most expert surgeons find it very
difficult or unfeasible to implant an acrylic lens
through a 3.0 mm incision using forceps without harming the lips of the wound - Fig. 132).
219
Once the implantation is complete, the

viscoelastic is carefully removed from the anterior chamber and from the capsular bag. The
surgeon must take care not to leave viscoelastic
material behind the intraocular lens. (It is necessary to push the implant optic gently backward with the cannula to force the evacuation
of the viscoelastic through the capsulorhexis
opening.)
Finally, balanced saline solution is injected through the lateral paracentesis to ensure that the incision is perfectly self-sealing.
Dodick's AcrySof's Implantation

Technique
Special
Features
AcrySofs Implantation
About
could conceivably interfere with visual acuity.

A second measure taken by Dodick to
facilitate this lens' entry into the wound after
folding and holding it with forceps is to pinch
the lead edge of the lens with a second
forceps, to make the "nose" conform into a
bullet or missile shape. This facilitates entry
into the eye. Once the nose enters into the
eye, the rest of the lens follows with great
facility (Fig. 133).
Dodick uses folding and insertion
forceps to insert the lens. They must be very
fine folding forceps so as to add very little
bulk to the combination of lens and forceps
that have to enter through the small wound
(Fig. 132).
Dodick's Three Stage Implantation
When handling the lens, it is important

to keep in mind that especially in high powers
up to 30 diopters, this is a thick lens. This
makes folding more difficult. Jack Dodick,
M.D., has found that pre-warming the lens
dramatically facilitates the ease of the fold.
This is done at his institution (Manhattan Eye
and Ear Hospital) by placing it in a warm
environment such as on top of a sterilizer that
has an ambient temperature between 100 and
105 degrees. This seems to soften the material
and facilitates the gentle folding of the lens,
making it much easier to implant especially
for high diopter lenses which are more difficult to fold.
It is also important to keep in mind that
if the surgeon performs rapid folding of a
cold lens, this may leave striae in the lens that
220
Dodick likes to divide the implantation

of the lens into three stages once it is in the
anterior chamber. First, when the lead haptic is
in the capsular bag, the lens is allowed to
unfold. Stage two is the implantation only of
the optic. Stage three, once the optic is implanted the surgeon inserts the superior haptic
by rotating it in with the Lester hook or placing
it with a Kelman-McPherson forceps. Dodick
considers that a common mistake when implanting any soft foldable IOL, is to implant
it in only two stages. Once the inferior haptic is
placed into the capsular bag, some surgeons
proceed immediately to try to place the optic
and the superior haptic in one second stage. His
experience has taught him that implantation
becomes simpler and more controlled by dividing it into the three stages described.
C h a p t e r 9:
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 (arrows) inside the capsular bag as shown. Widely
used cross-action forceps presented in this
figure (Burattos 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 appearance of the corneal incision (C).
221
Implantation Technique for

Silicone Foldable IOL's Using
Cartridge-Injector System
Lindstrom prefers to implant these lenses
with a cartridge injector system. Since the
second generation silicone lenses are very flexible, they stretch when implanted through a
cartridge-injector system, providing the surgeon with the advantage of inserting the lens
through a smaller incision (Fig. 132-A).
Carreo's technique for implantation of
silicone foldable lenses starts with the injection
of viscoelastic in the anterior chamber, the
capsular bag and into the cartridge. Once viscoelastic has been injected into the cartridge,
the lens is loaded carefully so that both sides are
inserted into the lateral channels. The car-
tridge is then closed and placed in the injector. In order not to enlarge the incision,
Carreo considers that it is essential to introduce the tip of the cartridge a few millimeters
into the anterior chamber, as its thickness increases towards the back (Fig. 132-A). With
the injector in place, the lens is advanced through
the cartridge. Once it begins to unfold in the
anterior chamber, it is guided with the first
haptic under the edge of the capsulorhexis and
placed in the capsular bag. Once it is unfolded,
the empty cartridge is removed. Using a spatula
introduced through the lateral paracentesis, the
second haptic is gently pushed downward and
backward to be placed in the capsular bag as
well.
For you to have a mental picture of the
concept of foldable lens implantation, we refer
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
C h a p t e r 9:
TESTING THE WOUND FOR

LEAKAGE
If the corneal incision has been performed
adequately, following the principles outlined
in Figs. 90, 91, 92, 93, the surgeon should have
a self-sealing stepped valvulated corneal tunnel incision. These incisions should not leak
but there is always the possibility that this may
occur. Consequently, we must test the wound
for leakage as shown in Fig. 73 and explained
its accompanying text.
Following the removal of viscoelastic
from the anterior chamber and capsular bag,
BSS is injected through the paracentesis. If the
surgeon finds that there is a leak (Fig. 73) there
are two ways to seal the incision without having to suture it: 1) Inject BSS into the lips of the
incision to hydrate the tissues and seal the
wound. 2) Use Professor Juan Murube's
maneuver for the combined placing of a Honan
balloon over the eye for 30 minutes at 35 mm
Hg pressure and administering orally one tablet of 250 mg Acetazolamide (Diamox).
The way Murube's clever maneuver
works is explained in Fig. 96 and accompanying text. In the remote case that the corneal
incision leaks and, even more remote, that the
two methods for sealing described here do not
work and there is a need to suture the incision,
it is recommended that the surgeon place one
single radial suture.
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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
TECHNIQUES
Visiting prestigious eye centers and
through personal communications with a
number of expert consultants throughout the
world, it is interesting to observe how many
different techniques and modifications of the
basic phacoemulsification procedures have
been developed. They all work well, if used
in skilled hands. In addition, watching videos
of phaco procedures performed by outstanding cataract surgeons from different regions,
cultures, races and economic status of their
countries, surgeons who perform a thousand or more cataract operations a year,
we find them using techniques that are quite
different from each other. Some use low
vacuum, others use high vacuum, one uses a
60 phaco tip while the next one uses a 0 (zero)
degree tip for the same type of cataract. One
would do a supracapsular while the other
emphasizes the need to do all cataracts using
an endocapsular technique. Some are cracking, some are chopping.
The Essential Criteria for Success

The revealing experience is that the great
majority of their cases have very good results
and the operated eyes look very well. What
we learn from this experience is that each
surgeon has developed a technique with which

he/she feels comfortable, that works best for
him/her and that fills the essential criteria of
not damaging the posterior capsule, the
iris and/or the corneal endothelium.
DIFFERENT NUCLEUS
CONSISTENCY TECHNIQUES OF CHOICE
In Chapter 9, in discussing the Management of Disassembling the Nucleus, we presented the surgical principles of the major,
late-breaking techniques mostly used now,
showing how they work and how they
are performed. These can be classified as:
1) Divide and Conquer (D & C) techniques
and 2) the chopping procedures based on
modifications of the Phaco Chop of Nagahara
(Japan). Most of the now extensively used
techniques that we present in Chapter 9 have
been developed by pioneers and distinguished
surgeons from North America (Gimbel from
Canada; and Paul Koch, MacKool, Dodick,
and I. Howard Fine, from the U.S.). Many
other prestigious surgeons from all continents
have made substantial contributions to render
this step of the operation more effective and
less risky.
Now let us try to get into the crucial
subject that most ophthalmic surgeons want
229
to know: What are the procedures of choice

when we need to remove nuclei of different
consistencies?
The answer is that this is not a mathematical formula whereupon the techniques
can be categorized based exclusively on how
hard a nucleus we are going to operate. But the
subject is sufficiently clear to allow us to
present highly useful guidelines, based on the
extensive experience of highly recognized surgeons. This is what we are providing you here.
In Chapter 9, you can find the guidelines
and surgical principles of the techniques most
surgeons use now and what consistency of
cataracts do better in general with the major
techniques such as D & C operations, the Stop
and Chop, the Crater Chop, the Null-Phaco
Chop and the Choo-Choo Chop and Flip. A
variety of other procedures not described in
Chapter 9 are modifications of the fundamental techniques and carry the name of the surgeon who sponsors the procedure.
Representative Experts
Confronting Nuclei of Different
Hardness
Now let us focus more specifically on
the procedures of choice of some highly representative experts from different regions of the
world regarding the operation they use when
confronting nuclei of different consistencies. These surgeons are: Richard
Lindstrom, M.D., from the U.S.; Lucio
Buratto, M.D., from Europe (Italy); Okihiro
Nishi, M.D., from Japan, Edgardo
Carreo, M.D., (Chile) and Virgilio
Centurion, M.D., (Brazil) the latter two representing different regions and cultures of
South America. Each one of these surgeons
230
has performed many thousand phacoemulsification procedures. They are highly successful and their concepts are solid. What we
present in this Chapter is how each one of
these five (5) prestigious surgeons perform
phaco, with emphasis on nucleus removal
when faced with the five types of cataracts that
we are all familiar with, based on different
nucleus consistency.
You may observe that each one of them
has a different procedure of choice. I will
confirm that they are all successful. This
experience may serve the ophthalmic surgeon
as guidelines within which to select the technique he/she feels more comfortable with and
that may serve the patients best. A great deal
depends on where you practice, what equipment and facilities you have and the type of
cataracts you mostly do.
LINDSTROM'S
OF CHOICE
PROCEDURES
1) For Soft and Medium Density (standard) Cataract: the supracapsular iris-plane
procedure (Figs. 136-139).
The supracapsular operation is popularly known as the "tilt and tumble" technique.
It is performed on the iris plane and is not
endocapsular.
2) Posterior capsular cataract or the
cataract in a young patient with relatively
soft nucleus without much ultrasound power
needed: the supracapsular iris plane technique.
3) For Very Hard Nuclei: the Stop and
Chop (an endocapsular technique) described
in Figs. 107-111).
Lindstrom considers that a clear cornea incision is not indicated when doing the
stop and chop in very hard nuclei. He uses a
corneo-scleral incision and larger amounts of
viscoelastic. More ultrasound energy is needed

to disassemble these very hard nuclei with
more danger of wound burn and endothelial
damage. The sclera is more resistant to the
heating up of the wound than is the cornea. In
addition, by moving back to the sclera you are
farther away from the corneal endothelium
with less risk of damage, particularly in patients with borderline corneas.
Advantages of the Supracapsular

Lindstrom notes that supracapsular
techniques enjoy increasing popularity. A
slightly larger anterior capsulorhexis (5.5 to
6.0 mm), is necessary. This allows the sur-
geon to bring a part of the nucleus or the whole

nucleus in front of the anterior capsular ridge
(Figs. 136-137).
In addition, Lindstrom considers that
with the endocapsular techniques the number
of posterior capsular tears with or without
vitreous loss is higher for most surgeons because they are working inside the capsular
bag. With a supracapsular technique the
nucleus is up closer to the anterior chamber so
the incidence of posterior capsule tears is reduced. It is also a very easy technique to learn.
For a beginning surgeon the endocapsular techniques are more difficult to teach and need a
longer learning curve and more time to perform (see Chapters 7 and 9).
Figure 136: Lindstroms Supracapsular

(Tilt and Tumble) Technique
Following clear corneal temporal
incision (T), superior limbal counterpuncture for secondary instrumentation (S), and
5.5 or 6.0 mm circular capsulorhexis (C), a
Pearce hydrodissection cannula (H) is introduced between the nucleus (N) and capsule. 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 Technique. Viscoelastic is introduced beneath
the nucleus and into the chamber (not
shown).
231
Figure 137: Phacoemulsification of the First

Half of the Nucleus - Lindstroms Supracapsular (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

The disadvantage of the supracapsular
technique is that you are working much closer
to the corneal endothelium. The surgeon must
be very careful in his technique and should not
perform it on a very hard nucleus. With the
modern technology available in the phaco
machines (Chapter 8) and the adequate use of
viscoelastic we have another margin of security to protect the endothelium.
Another measure that helps a good deal
to protect the endothelium is to do the phacoemulsification with the bevel of the tip down
or to the side. You have the alternative of
placing the phaco instrument in the eye with the
232
bevel anterior, bevel to the side, bevel down

or bevel close to you. There is a little spray
that comes out of the phaco tip when you are
doing the surgery. We want that spray to go
away from the corneal endothelium so it is
important to place the bevel to the side or the
bevel down technique in using supracapsular
technique.
Contraindications of Supracapsular
Lindstrom performs the supracapsular
technique in all cataracts except: 1) Patients
who have cornea guttata, Fuchs' dystrophy or
low endothelial counts. 2) Very hard cataracts.
HIGHLIGHTS OF THE
SUPRACAPSULAR IRIS PLANE
TECHNIQUE
The main steps are illustrated and explained in Figs. 136-139. The surgeon needs
to become quite adept at hydrodissecting until
the nucleus is lifted, which is the first step
prior to tumbling the nucleus in a supracapsular

approach. Rather than completing the tumbling of the entire nucleus, Lindstrom supports the nucleus in the plane of the iris and
anterior capsular leaflet and then emulsifies
half of it (Figs. 136-137). With a much smaller
nuclear remnant, he tumbles the remaining one
half upside down and completes the emulsification (Figs. 138-139).
Figure 138 (left): Tumbling the Remaining
Half of the Nucleus - Lindstroms Supracapsular (Tilt and Tumble)
One half of the nucleus has been removed, 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 Lindstroms 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
233
In this operation, it is important to make

a slightly larger anterior CCC (5.5 to 6.0 mm).
If a small anterior capsulorhexis is done, the
hydrodissection step where the nucleus is tilted
can be dangerous and rupture the posterior
capsule during hydrodissection could be possible. If a small anterior capsulectomy is
inadvertently created, Lindstrom favors converting to an endocapsular phacoemulsification technique or enlarging the capsulorhexis.
If he is unable to tilt the nucleus with either
hydrodissection or manual technique, he will
also convert to an endocapsular approach.
Occasionally the entire nucleus will
subluxate into the anterior chamber. In this
setting, if the cornea is healthy, the anterior
chamber roomy, and the nucleus soft, he will
often complete the phacoemulsification in the
anterior chamber keeping the nucleus away
from the corneal endothelium. The nucleus
can also be pushed back inferiorly over the
capsular bag to allow the iris plane tilt and
tumble technique to be completed.
CENTURION'S TECHNIQUES
RELATED TO NUCLEUS
CONSISTENCY
1) For soft nucleus (+) Centurion's
procedure of choice is the flip and chip (Fine
- see Figs. 122-126).
2) For intermediate nucleus (++) (those
not hard enough to be chopped), Centurion
performs the classical divide and conquer
(Figs. 56, 67, 103, 104, 206 below).
Because Centurion does not perform
hydrodelamination, he usually removes the
epinucleus during emulsification of the
nucleus. If the hydrodissection was well done,
usually irrigation-aspiration (I/A) will not be
necessary.
234
3) For hard nucleus (+ + + and above)

Centurion's favorite technique is the Phaco
Quick Chop, as developed by Pfeifer. The
parameters he prefers are based on the different machines that he uses and are presented.
The main difference between this technique and other phaco chop procedures are:
1) The placement of the chopper is in the
center of the lens, and not under the anterior
capsule. 2) The movement of the chopper is
vertical, instead of horizontal as in other
phaco chop techniques.
Highlights of Other Steps in

Centurion's Technique
Anesthesia: For routine cases he recommends topical anesthesia. Peribulbar is used
for special situations, such as subluxated lens,
white cataract, combined cataract- glaucoma
surgery and so on.
The Ancillary Incision: Usually, he
sits at the head of the patient, performing
first the ancillary incision and injecting a
viscoelastic substance. This incision is
placed 80 away from the primary incision,
which is usually located between 10 and 11
oclock (Fig. 41).
The Primary Incision: Is a one step
incision between 10 and 11 o'clock performed with the 3.0 mm clear path (Asico)
diamond knife (Figs. 41, 42).
Capsulorhexis: He refills the anterior
chamber with more viscoelastic and performs a 5.5 mm capsulorhexis, with a cystotome.
Hydrodissection: The next step is the
cortical cleaving hydrodissection, as described by Fine. The nucleus must be totally
or completely free inside the capsular bag. At
this time, he rotates the nucleus once or twice
clockwise or anti-clockwise.
IOL Implantation: he injects viscoelastic. For routine cases Centurion uses

foldable IOLs. He has been working with
silicone IOL's for many years and is very
confident with the implantation technique
using the unfolder through 3.0 mm incision.
It is not necessary to enlarge the incision

during the implantation. In his experience,
with the acrylic lens it is necessary to enlarge
to 3.5 mm to implant the Sensar (Allergan)
and 3.75 mm with the AcrySof (Alcon).
235
236
CARREO'S NUCLEAR
EMULSIFICATION TECHNIQUE
OF CHOICE (PHACO SUB 3)
For the latest concepts on surgery related to density of cataracts, I also refer you
to page 7. Carreo's Phaco Sub 3 is a
phacoemulsification procedure performed
through an incision of 3 mm or less. There
are other modifications of the phaco technique also identified as "Phaco Sub 3." His
goal is to make it as uninvasive as possible.
He follows all the parameters appropriate
for the entire spectrum of nuclear density
that have proven to be efficient, safe, and
replicable by other surgeons. Obviously, in
order to achieve good surgical results, it is
imperative that the phaco machine settings
are perfectly adjusted to the needs of each
type of nucleus and to the requirements of
each step of the technique. Carreo uses
the Legacy 20,000 equipment (Alcon).
Adjusting the Equipment

Parameters to Remove
Cataracts of Various Nuclear
Density
It is important to keep in mind that the
basic parameters of the phacoemulsifier are
the ultrasound power, the vacuum, and the
aspiration flow. These are amply discussed
and beautifully illustrated in pages 112-114,
119-122 and Figs. 83, 84, 61-65.
Three Sets of Values

Programmed Into Memory
Carreo uses the following criteria:
three sets of values programmed into the
memory in the Legacy 20,000. These parameters are set according to the degree of
hardness of the cataract. They are:
Memory 1: Use high ultrasound power

to enable a quick (continuous mode) nuclear
sculpt or chisel and lower levels of vacuum
and aspiration flow (Fig. 56). There is no
need for great grasping or fixation power, or
power of attraction in this stage of the technique.
Memory 2: For capture, mobilization

and emulsification of nuclear fragments
(pulse mode) (Figs. 67, 68) it is necessary to
have high vacuum levels and aspiration flow
in order to achieve considerable grasp and
fixation power. It is also necessary to have
little ultrasound power so that the nuclear
fragments that are free are not propelled from
the phaco tip by excessive vibration.
Memory 3: Is intended for the removal

of soft material like the epinucleus, and uses
much lower values in all settings, in pulse
mode (Fig. 69).
Height of the bottle (infusion): 75 cm to
85 cm.
Phaco tip: Kelman type (curved) ABS Micro
Tip with a 30-degree tip (Fig. 84).
If a good hydrodissection is performed
with the cortical cleaving technique, it is
possible to remove the epinucleus along with
237
238
the nuclear material in the majority of medium hard cataracts and in virtually all hard
cataracts.
of the phaco tip and to provide protection to

the corneal endothelium.
Working with well-programmed

memories is a great advantage when using
the Phaco Sub 3 Technique. By eliminating
filtration through the surgical wound, the
smaller incision directs the flow of liquid
and nuclear fragments towards the micro tip
for aspiration, making the phacoemulsification procedure more efficient. That is, there
is no competition between the flow of liquid
toward the surgical incision and the flow
toward the phaco tip, which can occur with
larger, leaking incisions. Also, the more
hermetic incision of Phaco Sub 3 reduces the
amount of liquid circulating in the eye during surgery and maintains a deeper and more
stable anterior chamber. This helps preserve
the integrity of the corneal endothelium and
the posterior capsule, which, undoubtedly,
confers greater safety to the technique.
(Editors Note: see Chapter 7 for a very
well illustrated presentation of the fluidics of
phacoemulsification).
While performing Phaco Sub 3 it is
very important to keep in mind that a lateral
movement of the micro tip must be avoided
so as not to enlarge the incision during
surgery. It is therefore necessary to always
keep the micro tip working from 12
oclock to 6 oclock without lateral movement. This explains the great importance of
a second instrument (manipulator or chopper), introduced through the lateral paracentesis to facilitate rotation, mobilization maneuvers, and nuclear fracture.
Before beginning nuclear emulsification, regardless of the technique used, the
surgeon should always inject viscoelastic in
the anterior chamber to ease the penetration
Technique of Choice and

Consistency of Cataract
SOFT CATARACTS (grade 1 - 2
nucleus)
Carreo recommends Fines Chip
and Flip because the nuclei are not very
hard and generally cannot be fractured (Figs.
122-126). With this technique, it is important
to
use
hydrodissection
and
hydrodelamination maneuvers. Hydrodissection makes free nuclear rotation within
the
capsular
sac
easier,
and
hydrodelamination clearly outlines the separation between the harder inner nucleus and
the softer epinucleus that surrounds it. The
gold hydrodelamination ring denotes the
limit to which it is possible to emulsify the
nucleus without risking capsular damage
(Fig. 48).
First Step (memory 1: vacuum 0
to 10 mm Hg, aspiration flow 18 cc/min,
U/S power 60%).
With a manipulator introduced
through the lateral paracentesis, the nucleus
is gently moved toward 12 oclock to allow
the micro tip, maintained in a central position, to emulsify the inner nucleus ring at 6
oclock without the risk of reaching the
capsular fornix. Then, with the manipulator,
the nucleus is rotated in order to place other
nuclear fragments in position to be emulsified. The microtip must not be advanced
past the gold hydrodelamination ring. This
maneuver is repeated until the entire inner
nuclear ring is completely removed.
Second Step (memory 2: vacuum

200 mm Hg, aspiration flow 25 cc/min, U/S
power 40%, 6 - 8 pulses/sec).
The manipulator is inserted into the
cleavage
plane
obtained
through
hydrodelamination and is passed behind the
residual nuclear fragment (chip). The chip is
lifted and taken to the center of the capsular
sac. It is here that the chip may be emulsified with greater safety.
Third Step (memory 3: vacuum
power 30%, 6 - 8 pulses/sec).
The center of the epinucleus is pushed
toward 6 oclock with the manipulator. Sliding the epinucleus out of the upper capsular
fornix, the microtip can pull the epinucleus
up toward the main incision using aspiration
only (phaco pedal in position 2). The epinucleus is then folded over itself top-down
(flip), using the spatula and the microtip.
This moves the nucleus away from the posterior capsule. Once the flip maneuver is
completed, the epinucleus is removed safely
by simple aspiration or using low power
ultrasound (Figs. 122 126).
MEDIUM DENSITY
CATARACTS (grade 2 - 3 nucleus)
For cataracts with a medium-hard
nucleus, Carreo prefers to use Shepherds
Quadrant Nuclear Fracture technique,
which is a variation of Gimbels original
Divide and Conquer procedure (Fig. 67)
which is a grooving and cracking method.
Carreo considers that Shepherds technique has become the nuclear fracture
technique most widely used by phaco surgeons because of its simplicity and the high
level of safety it provides. The nucleus is

soft enough to allow quick sculpting with
low ultrasound. At the same time it is hard
enough for the surgeon to create fractures
without difficulty (keep in mind that soft
grade 1 (+) cataracts cannot be fractured).
Furthermore, with grade 2-3 nuclei, no excessive pull is exerted on the zonule while
the fragments are sculpted, which can occur
with harder nuclei.
In general, all of the nuclear fracture
techniques (Fig. 106) aim to divide the
nucleus in multiple fragments to allow their
removal through the small circular aperture
of the capsulorhexis and also to make phacoemulsification more efficient inside the
capsular bag (Fig. 105). Phacoemulsification of small fragments of nuclear material
is faster than emulsification of an entire
nucleus. The procedure is therefore quicker,
and the ultrasound time is reduced. The
fragments are mobilized more easily within
the capsular bag and it is possible to take
them to the center without much difficulty
(Fig.111). This allows them to be removed
in a safe zone, eliminating the risk of injury
to the posterior capsule or the corneal endothelium.
In Quadrant Nuclear Fracture, the
nucleus is divided into four parts, which are
then moved individually toward the central
safe zone to be emulsified (Fig. 105).
to 20 mm Hg, aspiration flow 25 cc/min,
U/S power 70%):
A manipulator is introduced through
the side port incision to rotate the nucleus
(Figs. 56 and 67). Moving the microtip
from 12 oclock to 6 oclock, thin and deep
grooves are carved until a cross is formed
(Fig. 67). Ideally, these grooves should
239
extend almost to the edge of the

capsulorhexis (to avoid the peripheral capsule), and should be deeper in the middle
than in the periphery (to respect the curve of
the posterior capsule) (Figs. 103, 104). They
should also be slightly thicker than the ultrasound tip (including the silicone sheath) and
should be 80%-90% of the depth of the
nucleus (Fig. 103). The visualization of the
red reflex at the bottom of the groove indicates adequate depth to the surgeon.
Second Step:
Once the cross is formed (Fig. 67), the
nucleus is divided into four quadrants. The
phaco tip and the manipulator are placed at
the bottom of the groove at 6 oclock and are
pushed in opposite directions (with a direct
or crossed maneuver) (Fig. 104). The separation results in a fracture line, which extends
from the periphery to the center of the posterior nuclear wall (Fig. 104). After the
nucleus is rotated 90 degrees, fractures are
performed until the nucleus is divided into
four fragments (Fig. 105). The fracture
should include all the nuclear material; all the
fragments must be separated in order to
ensure a good result. Before continuing to the
next step, the surgeon should mobilize the
quadrants with the spatula in the capsular bag
to ensure that there are no connections between them (Fig. 105).
Third Step (memory 2: vacuum
power 50%, 6 - 8 pulses/sec) (Fig. 67)
The microtip is directed toward 6
oclock, and the phaco pedal is in position 2
(irrigation/aspiration without ultrasound).
The first quadrant is captured by placing the tip in contact with nuclear material to
generate occlusion (Figs. 59, 60). For greater
240
safety, the surgeon may first lift the corner

of the quadrant with the spatula to distance
it from the posterior capsule. With harder
cataracts, sometimes simple aspiration is not
enough to occlude the opening of the
microtip. Apply a few ultrasound bursts
(phaco pedal in position 3) to grasp the
nuclear material and generate occlusion
(Figs. 52, 53). Once occlusion is achieved
and the phaco pedal is again in position 2,
the surgeon should wait until the vacuum
reaches the aspiration line. This makes it
possible to hold the quadrant firmly on the
opening of the tip. At this precise moment,
relying on good grasping force, the surgeon
can pull the quadrant toward the central safe
zone. The quadrant should be completely
controlled by the manipulator in order to
avoid turbulence and contact. Then the
quadrant is emulsified with the machine in
pulse mode (Fig. 86). With large and hard
fragments, it is useful to use chop maneuvers (with the same chopper or secondary
instrument) in order to divide the quadrant
into smaller fragments, to make the surgery
quicker and easier (Figs. 105, 106). The
procedure described is repeated for the other
quadrants until the entire nucleus is emulsified.
HARD CATARACTS (grade 3-4
nucleus)
With hard cataracts, Carreo prefers
to use chopping techniques. They offer
clear advantages over the divide and conquer procedures in the management of this
type of nucleus (See pages 177-182). As a
method of nuclear fragmentation, the chopping techniques derived from Nagaharas
original Phaco Chop considerably reduce
the power and total time of phacoemulsification, thereby reducing the tension on the
zonules and the posterior capsule and confining the entire phacoemulsification procedure to the central 3 mm of the pupil (Fig.
183).
Three important features of the chopping techniques are important to emphasize:
1.
Chopping is a completely different method than nuclear fracture. It basically
consists of making cuts following the natural cleavage of the lens ( similar to cutting a
log with ax blows) (see page 183).
2.
In order to lend itself well to the
chop maneuver, the nucleus must have a
firm consistency.
3. The conservation of energy gained
by not carving grooves (D & C) makes
chopping particularly indicated for the management of hard nuclei.
The Stop and Karate Chop

Carreos preferred chopping technique is the Stop and Karate Chop, which
is a combination of Kochs Stop and Chop
and Nagaharas Karate Chop. He finds it
is a very safe procedure combining the advantages of both techniques.
Without a doubt, Kochs Stop and
Chop noticeably simplifies Nagaharas
original Phaco Chop technique by creating
an initial groove (Fig. 107) which, in turn,
creates a space in the nucleus, making the
chopping maneuvers, mobilization, and
nuclear fragment emulsification much
easier. This explains its great popularity as a
chop technique (page 184). At the same
time, Karate Chop, which corresponds to a
modification introduced by Nagahara to his
original Phaco Chop, offers a greater advantage by confining the chop to the central
region within the limits of the capsulorhexis.
This means the surgeon avoids the need to
reach dangerously with the chopper under the
anterior capsule, toward the lens equator, to
create the fracture.
The Stop and Karate Chop technique
basically consists of three steps, which are
the sculpting or chiseling of the central sulcus (Fig. 107, page 185) in order to fracture
the nucleus in two halves, the chopping of
the two hemi-nuclei, (Fig. 106, page 182)
and the mobilization and ulterior emulsification of the nuclear fragments (Fig. 111).
(Editor's Note: from the practical point of
view, these are the same principles of the
Stop and Chop (pages. 184-188), except that
the direction of the cut in the Phaco Chop
technique goes from the equator towards the
center of the nucleus, while the Karate
Chop goes from the anterior pole to the
posterior pole).
First Step (memory 1: vacuum
20 mm Hg to 30 mm Hg, aspiration flow
30 cc/min, U/S power 80%):
The procedure is initiated by chiseling
a central sulcus with the microtip toward 6
oclock (as if it were nuclear fracture in four
quadrants) (Fig. 107). The chiseling is completed toward the other extreme after rotating
the nucleus 180 degrees aided by the chopper
introduced through the side port incision
(Fig. 109). Once the desired depth is obtained, the nucleus is divided into two halves.
It is fractured with the phaco tip, and the
chopper is placed in the bottom of the sulcus.
The surgeon must ensure that the halves are
completely separated (Fig. 106). From this
time on, no more sculpting or cracking is
241
done, and the chopping maneuvers are

initiated. (Hence, the Stop and Chop designation by Paul Koch).
power 60%, 6 to 8 pulses/sec):
The nucleus is rotated 90 degrees so
that it is in a horizontal position to ease the
grasp of the distal hemi-nucleus with the
microtip. The phaco pedal is in position 2
(irrigation-aspiration), the microtip is placed
against the wall of the sulcus in its central
portion while ultrasonic pulses (phaco pedal
in position 3) are applied, and the nuclear
material is grasped. Once occlusion is
reached, the pedal is returned to pedal position 2 in order to increase the vacuum and
obtain good fixation at the microtip. Now
the choopper is sunk into the nuclear material slightly in front of the microtip. By
pulling the instruments in opposite directions (the chopper towards the left and the
microtip toward the right), the surgeon fractures the distal hemi-nucleus into two halves
(Fig. 111, page. 189). The nucleus is then
rotated 180 degrees, and the procedure is
repeated so as to fracture the other heminucleus in two halves as well. The nucleus
ends up divided into four quadrants.
Carreo prefers not to remove the quadrants immediately. Keeping all the pieces
within the capsular bag stabilizes the second
hemi-nucleus at the moment the chop is
performed, making the maneuver easier. It
is very important to ensure that all four
quadrants are completely independent of
each other. Introducing the chopper directly
into the nucleus, without having to reach the
periphery to carry out the fracture, as with
242
the Phaco Chop, is what prompted

Nagahara to call this modification of his
technique the Karate Chop.
Third Step (memory 2 is maintained: vacuum 400 mm Hg, aspiration flow
40 cc/min, U/S power 60%, 6 to 8 pulses/
sec):
Once the nuclear division is complete,
the quadrants are mobilized. They are captured with the microtip and pulled to the
central safety zone, where they are emulsified. In order to capture the quadrants, the
surgeon grasps the nuclear material by applying some ultrasonic pulses (Fig. 105)
(phaco pedal in position 3). Once occlusion
is achieved, the vacuum is increased (phaco
pedal in position 2) to ensure grasp at the
microtip. The maneuver is repeated until all
fragments are removed. As with Shepherds
Quadrant Nuclear Fracture, any large
nuclear fragments present should be divided
using chopping maneuvers to speed the procedure.
The presence of a central sulcus plays
a fundamental part in the development of the
Stop and Karate Chop technique, as space
is created within the nucleus (Fig. 107).
With the occlusion of the tip, it is easier to
perform the chop, to move the nucleus posteriorly, and to remove the fragments.
VERY HARD CATARACTS

(4-5 grade nucleus):
In these extremely hard nuclei (rubra
and nigra cataracts), that represent a great
challenge for the phaco surgeon, Carreos
technique of choice is Crater and Karate
Chop, which is a combination of Gimbels
Crater Divide and Conquer with

Nagaharas previously mentioned Karate
Chop. The key to success with these very
hard nuclei lies in reducing the nuclear volume as much as possible while maintaining a
peripheral nuclear ring firm enough to perform chopping maneuvers geared to creating
the fractures (See pages. 191-193 for reference of the very similar Crater Phaco Chop
Technique - Editor).
The basic steps for the Crater and
Karate Chop technique are the sculpting of
a very deep central crater, the chopping of
the peripheral nuclear ring to create multiple
fragments, and finally, the mobilization and
emulsification of these fragments (Fig. 112116 for reference).
mm to 30 mm Hg, aspiration flow 30 cc/min,
U/S power 90%):
Directing the microtip always towards
6 oclock, the surgeon sculpts a crater in the
central nuclear zone, using rotation maneuvers to facilitate and deepen it. (The use of
ultrasound for a prolonged amount of time
during this step of the technique is not risky
because the nuclear sculpting is performed
inside the capsular sac, far away from the
corneal endothelium.) In order to fracture, it
is necessary to centrally sculpt very deeply
(until the red reflex appears in the bottom)
while maintaining enough dense material in
the nuclear periphery.
power 70%, 6 to 8 pulses/sec):
The microtip is placed against the wall
of the central crater at 6 oclock, and ultrasound pulses are applied (phaco pedal in
position 3). The nuclear material is impaled.

Once occlusion is reached, the pedal is
placed in position 2 to increase the vacuum
in the aspiration line and firmly attach the
nucleus to the opening of the microtip. The
chopper is then introduced into the nuclear
edge in front of the microtip (Karate Chop
technique, without taking the chopper to the
equator underneath the anterior capsule.)
The instruments are pulled apart to complete
the first fracture. The nucleus is rotated, and
the maneuver is repeated in order to make
the second fracture, creating the first fragment. The process continues until the
nucleus is divided into multiple fragments
(five or more). The surgeon must ensure that
there are no connections between them. The
harder the nucleus, the smaller and more
numerous the fragments must be in order to
make them more manageable. While making subsequent chopping maneuvers, it is
useful to leave the fragments in place to
keep the capsular bag well-distended. This
reduces the possibility of an inadvertent cut
into the posterior capsule with the phaco tip.
Third Step (uses memory 2:
vacuum 400 mm Hg, aspiration flow
40 cc/min, U/S power 70%, 6 to 8 pulses/
sec):
Once the nucleus is fragmented,
Carreo proceeds to move each individual
fragment toward the center to emulsify it.
(Because very hard fragments are involved,
it is advisable to inject viscoelastic to protect
the corneal endothelium). The tip is placed
against the nuclear fragment at 6 oclock,
and ultrasonic pulses are applied (phaco
pedal in position 3) to capture the fragment.
Then the vacuum is allowed to increase
243
(phaco pedal in position 2) to reach a firm

grasp at the microtip opening. The fragment
is then pulled toward the center, into the
safety zone, to be emulsified. The nucleus
244
is then rotated in order to place another

fragment at 6 oclock. The procedure is repeated until all the fragments are completely
removed.
NISHI'S
TECHNIQUES
OF
CHOICE FOR NUCLEI OF
DIFFERENT CONSISTENCIES
Nishi uses two different techniques
depending on nucleus consistency.
1) Soft (+), Standard (++):

In these groups, Nishi uses a modification of the Divide and Conquer procedure
(Figs. 56 and 67) and sometimes Fine's
Choo-Choo Chop and Flip technique (Figs.
122-126) using high vacuum and low ultrasound energy from the very beginning
(vacuum 170 mm Hg, energy up to 60%
using Allergan's Diplomax phaco machine).
High energy is not necessary for those nuclei, and it is cumbersome for the surgeon to
switch on from high vacuum-low energy to
low vacuum-high energy.
2) Moderately Hard to Hard

Nucleus (+++):
In cases with moderately hard and
hard nucleus, higher energy up to 80%
(even 100%) is used for rock-hard nucleus,
taking care not to burn the wound. This
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 energy 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.
BIBLIOGRAPHY
Buratto, L: Buratto's elective techniques for phacoemulsification according to grades of hardness of
nuclei. Phacoemulsification: Principles and Techniques by Lucio Buratto, 1998; 6:166-170.
Carreo, E.: Nuclear emulsification technique of choice
(Phaco Sub 3). Guest Expert The Art and the Science of
Cataract Surgery of HIGHLIGHTS, 2001.
Centurion, V.: Centurion's technique related to nucleus
consistency. Guest Expert The Art and the Science of
Cataract Surgery of HIGHLIGHTS, 2001.
Lindstrom, R.: Lindstrom's procedures of choice. Guest
Expert The Art and the Science of Cataract Surgery of
HIGHLIGHTS, 2001.
Lindstrom, R: Tilt and tumble phacoemulsification.
Clear Cornea Lens Surgery, edited by I. Howard Fine,
Slack, 1999;9:99-119.
Lindstrom, R: Tilt and tumble phacoemulsification.
Operative Techniques in Cataract and Refractive Surgery. Vol. 1, N 2 (June), 1998: pp. 95-102.
Nishi, O: Nishi's technique of choice related to nucleus
of different consistency. Guest Expert The Art and the
Science of Cataract Surgery of HIGHLIGHTS, 2001.
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
Even in the most experienced hands complications occur. The best management of
complications is to avoid them. When
unpreventable, a well thought out, carefully
executed plan can give very good visual results.
When using topical anesthesia, the patient is an active participant in the procedure.
Complications can occur when patients move
their head, body, or eye, cough, or squeeze their
eyelids. Consequently, they should be fully
educated and carefully selected. We should
provide proper education in advance about
what will be experienced so that the level of
anxiety will be low. When speaking with the
patient, the surgeon should sound calm and in
control. If patients sense the surgeon's anxiety
they may become more anxious, further limiting their ability to cooperate. When patients
become over sedated they may fall asleep and
might awake disoriented. The best way to keep
patients from waking up suddenly is to keep
them from falling asleep.
In cases under topical anesthesia, excessive globe movement can impair the safe
completion of the operation. If the patient is
unable to hold the eye steady, or if they are
perceiving discomfort from the surgery, augmenting the anesthesia with a subtenon, peribulbar, or retrobulbar block may be helpful. This
can be accomplished quite safely when a selfsealing wound is done.
Main Intraoperative
Complications
The main complications are related
to the following phases of the operation:
1) complications related to the incision.
2) Those associated with anterior capsulorhexis.
3) Complications consequent upon rupture of
the posterior capsule. 4) Complications related to emulsification and removal of the
nucleus through different techniques. We also
need to confront the complications related to
hydrodissection and/or hydrodelineation, those
that occur during the process of aspiration of
the cortex, intraocular lens implantation and
the difficulties of the operation when the pupil
is small.
Incidence
As pointed out by Howard Gimbel,
M.D., the incidence of intraoperative complications will vary to some degree with the
surgeons experience and the type of procedure performed as, for instance, when a sclero
corneal tunnel is performed versus a clear
corneal incision. It will also vary depending
on the anatomic characteristics of the individual eye as in small pupils and hypermature
cataracts. Intraoperative complications are
also related to the type of anesthesia utilized
but this has been significantly diminished by
combining topical and intracameral local anesthesia which is used in most cases, or using
this combination with sub-Tenons anesthe-
249
sia when desired (Chapter 5). Since retrobulbar or peribulbar anesthesia are practically no
longer used in phacoemulsification, even by
those who are starting in the transition period,
the risks of globe perforation or retrobulbar
hemorrhage have practically disappeared.
Facing the Challenges

Virgilio Centurion, M.D. from Sao
Paulo, Brazil, one of Latin Americas most
experienced and didactic anterior segment surgeons, has dedicated years of research and
teaching on how to master phacoemulsification. This includes being prepared for the
challenges of the intraoperative complications,
which are different than those we were accustomed to face with planned extracapsular.
Centurion emphasizes that each cataract operation presents its own challenges, and that
even though we have reached a very advanced
level of safety and predictability with phacoemulsification, it is important that we keep
in mind the complications that may arise so as
to minimize situations that may bring the level
of stress to a peak in the operating room.
COMPLICATIONS WITH THE

INCISION
Too Short and Shallow or Too
Large
Lindstrom points out that the most frequent complication he has with the clear
corneal incision is that he either makes the
width of the incision a little bit too short, or
the dissection too shallow or too beveled
250
(Fig. 140). Or else, he makes the incision a

little bit too large. If it is too shallow or
beveled, it will become a non self-sealing, nonvalvulated wound. If it is too large, a persistent
iris prolapse may occur. You may try to ignore
it but it keeps coming back.
With a superficial, shallow incision, you
may manage it as shown in Fig. 140. Simply
abort the superficial tunnel, go back to the first
or initial vertical groove of the incision (300
microns depth) corresponding to 1/2 the corneal thickness and place the blade deeper,
forming a second tunnel with the correct depth
located below the first or superficial tunnel
(Fig. 140).
If you are having a very difficult time
with an incision, the best thing to do is to close
that incision with one or two vicryl sutures
which will eventually dissolve and move over
to another nearby spot and start over. With a
clear corneal incision, starting over only takes
a short additional time (Fig. 141).
Problems from Incorrect Placement and Performance of Incision

In Fig. 142 you may see a summary of
the problems in creating the sclero corneal,
limbal and corneal tunnel incisions. The
correct placement and structure of each incision is presented in Fig. 40. A key element
in the success of phacoemulsification is to
obtain a good internal valve incision.
As Centurion has emphasized, it is
only by experience and extreme care that we
develop a sense of feeling of the ideal
depth, that is, the one which will not endanger
the intraocular tissues and will ensure a good
tunnel protection.
C h a p t e r 11:
Figure 140 (left): Complications while Making a Clear Corneal Incision - Too Shallow
and Short
The corneal tunnel incision should be
self-sealing and valvulated, at about 300 microns 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 superficial tunnel.
Figure 141 (right): Problems From Incorrect 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 corresponding 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 parallel 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
Descemets membrane (D), another common error that can be avoided by use of abundant
viscoelastic. (Original illustration by HIGHLIGHTS, based on principles from Virgilio
Centurion's book titled "Complicaes Durante
a Facoemulsificao".)
251
Figure 142: Complications during Incision - Closing of the Improper 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
Membrane
An occasional but important complication is detachment of Descemets membrane,
as shown in Fig. 143. The main causes are: 1)
ocular hypotension while dissecting the tunnel
or while constructing the internal part of the
tunnel to make the valve-like incision. The
injection of viscoelastic through the side port
of the incision before performing the primary
incision can prevent this from happening. 2)
The introduction of the blade in the wrong
direction when constructing the internal part of
the incision (Figs. 140, 142 and 143). 3) The
forced introduction of the phaco tip or foldable
lenses in a tight incision. This may be avoided
by being very careful during entry of the tip, by
252
lubricating the tunnel with viscoelastic and by

very careful folding of the IOL and lubrication
either of forceps or the injector, in order to
attain a non-traumatic introduction and implantation of the IOL.
Important: During the dissection of
the internal step of the incision which leads to
the formation of the internal valve (V), the
intraocular pressure must be either normal or
slightly high and the tip of the blade must be
directed towards the pupil and follow a
parallel path toward the pupil as shown in
Figs. 140, 142 and 143. Use abundant viscoelastic in order to keep Descemets membrane where it belongs until the conclusion of
the surgery.
A detachment of Descemets membrane
discovered postop, is an important complica-
C h a p t e r 11:
tion when it occurs because it may be

followed by corneal edema and even
inflammation. If it occurs, topical antiinflammatory medications are sometimes useful.
If the detachment is significant, however,
(Fig. 143) there may be corneal decompensation progressing to bullous keratopathy which
may eventually require a penetrating graft.
Precautions with Closure of the

Incision Upon Conversion
Conversion to extracapsular is not infrequent when you start in the transition period
and may be necessary even in the hands of a
more experienced surgeon upon the development of complications. If the incision is corneal, move to the limbus. Other surgeons
prefer the scleral tunnel incision or the tunnel
starting at the limbus or about 1 to 1.5 mm
from the limbus. When converting, enlarge the
incision for the extracapsular at the limbus.

The nucleus and cortex are removed and the
IOL implanted. When suturing, it is important
to close the wound by placing the interrupted
sutures radially. When you get to the junction
between the part of the incision where the
tunnel was started and the limbus, suture it as
shown in Fig. 144. The arrow shows conversion when the initial incision was a sclerocorneal tunnel. Unless properly sutured, the valve
may leak at this site.
Heating the Wound

Very occasionally, if one is not careful,
you can heat the wound. It looks like you
cauterized the cornea. That is not such a
problem during the surgery but this wound
may well leak. If that occurs, at the end of the
operation, the surgeon has to close the wound
by suturing but will not be able to perfectly
Figure 143: Complications with the Tunnel Incision - Detachment of Descemet's

Membrane
A detachment of Descemet's membrane (D) may be observed during construction of the valvulated incision, manipulation 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

this may induce a large astigmatism. The most
practical approach is to suture the anterior
edges of the tunnel to the posterior surface of
the wound using a mattress suture. A little
gap will remain in almost every setting but you
can create a sealing incision. You should
expect a small to moderate amount of astigmatism, but the good news is that it will go away
with time. It is only a temporally induced
astigmatism. The difficulty is to get that
incision to seal.
Management of Leaking
Incisions with a Positive Seidel
Infrequently, a clear cornea incision or a
scleral tunnel incision larger than 3 mm in
width may show leaking of fluid one day
postoperatively. This is either secondary to an
incision larger than planned and not sutured, or
by too much trauma in the lips of the wound
usually by the phaco tip.
When this leaking occurs, it may be
immediately detected by instilling a drop of
fluorescein and observing the patient under
ultraviolet light. The problem with these
patients is that the constant escape of aqueous
humor keeps the wound open and may require suturing of the incision which certainly
is a nuisance.
Prof. Juan Murube, M.D., from
Madrid recommends a very ingenious maneuver in order to close the leaking wound
without having to re-suture the incision. He
places a Honan balloon (Fig.96) over the eye
for 30 minutes at a pressure of 35 mm Hg and
at the same time administers 1 tablet of
acetazolamide, 250 mg orally (Diamox). The
hypotony produced when the Honan balloon
is removed makes the aqueous humor (that is
254
constantly being produced and was causing

the positive Seidel) remain in the anterior
chamber. The anterior chamber has the opportunity to reform. After a few minutes,
when the intraocular pressure returns to normal, the walls of the incision have come
together and adhered, without any further
positive Seidel. This ingenious maneuver is
simple and avoids having to re-suture the
patient.
COMPLICATIONS RELATED TO
ANTERIOR CAPSULORHEXIS
It is generally agreed that this is the
procedure of choice to open the anterior capsule.
In most cases, it allows the phaco
technique to be performed within the capsular
bag and, consequently, the maneuvering and
instrumentation does not affect the surrounding tissues particularly the corneal endothelium. Capsulorhexis also allows an almost
perfect positioning of the intraocular lens. As
emphasized by Centurion, when the surgeon
dominates the technique of capsulorhexis, cases
of decentration, capture and/or subluxation of
the IOL are rare.
Main Complications
The main complications may be related
to: 1) the size of the capsulorhexis. It may be
either too large or too small. This is due to a
technical mistake either in the judgment of the
surgeon or in performing the technique. The
ideal diameter of capsulorhexis ranges from
5 to 6 mm. Centurion advises that, when there
is doubt, check the diameter of the capsulotomy by holding a compass over the cornea.
When the capsulorhexis is too small, less than
5 mm (Fig. 145), problems may arise during the
manipulation of the nucleus and the IOL im-
C h a p t e r 11:
Figure 144: Precautions with Closure of the Incision Upon Conversion

The wound is closed with interrupted 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. Otherwise, the valve may leak. (Courtesy
of Virgilio Centurion, M.D., from his
book titled Complicaoes Durante a
Facoemulsificaao.)
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 successful results of surgery, and IOL implantation may be more difficult.
255
plantation may be more difficult to the extent of

compromising the final result of the surgery.
If it is considered to be small, perform a
small lateral cut in the capsulorhexis with
Vannas scissors at 10 o'clock (Fig. 146).
Afterwards, perform a second and wider anterior capsulorhexis with the Uttrata forceps at
12 o'clock which will prevent or eliminate
the likelihood of stenosis of the opening
(Fig. 147). This is also a good option on what
to do if there is some discomtinuity or small
tear identified in the anterior capsulorhexis.
When the capsulorhexis is too large
(Fig. 148), larger than 6 mm, some difficulties may arise in stabilizing the nucleus after
hydrodissection with a tendency for the
nucleus to move into the anterior chamber.
Thic could possibly endanger the corneal
endothelium and other surrounding structures
and emulsification would need to be done in
the anterior chamber. Maintain sufficient
viscoelastic between the lens and the endothelium.
Lindstrom considers that if the
capsulorhexis is really large (Fig. 148) it is
not a major problem although there is a
tendency to develop a higher rate of capsular
opacity because
the border of the
capsulorhexis is not placed over the edge of
the posterior capsule.
Another problem that Lindstrom has
commonly encountered is the chamber will
shallow as you are doing the capsulorhexis,
particularly in younger eyes. The way to
avoid this is that as you see the chamber
shallowing, put more viscoelastic in it and
put it more centrally in the younger eye.
Another complication is that the
capsulorhexis will tear into the zonules. If
256
that occurs, Lindstrom goes back to the

beginning, makes a little cut with Vannas
scissors at the edge of the rhexis (Fig. 146) in
the other direction from where the extension
into the zonules occurred and enlarges the
rhexis around the opposite way (Fig. 147). In
these cases, the surgeon may have to presume that there was a little radial tear to start
and must be very careful with the next step,
the hydrodissection, because most probably
there is a weak spot in the anterior capsule.
In that case you should probably not use a
plate haptic lens.
Preventing Rhexis Complications by

Tinting
One of the major advances in performing
circular continuous capsulorhexis (CCC) in
hypermature cataracts which are either totally
white or very dark is the tinting of the anterior
capsule.
In these eyes, the fundus reflex
cannot be seen by the coaxial light of the
microscope. When the reflex is not present, it
is extremely difficult to see in order to complete the circular capsulorhexis. Tinting of the
anterior capsule through various substances
such as Fluorescein 2%, Indocyanine Green,
Trypan Blue, Gentian Violet, or Methylene
Blue is a new development to improve the
visibility of the anterior capsule during CCC.
Professor Juan Murube, M.D., in Madrid and
Professor Carlos Nicoli, M.D., in Buenos
Aires both definitely prefer the use of Trypan
Blue as the best coloring substance for this
purpose. They place the tinting substance over
the anterior capsule when the anterior chamber
is full of air as advised by Murube. The technique is shown in (Figs. 101, 102, page 173).
C h a p t e r 11:
Figure 146 (above): Management of Small

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 phacoemulsification or a tendency for the nucleus to move to
the anterior chamber during the operation.
257
COMPLICATIONS WITH
HYDRODISSECTION
What we try to accomplish with
hydrodissection is that by irrigating with a
stream of BSS immediately under the anterior
capsule, we produce a separation of the rest of
the lens from the anterior capsule, including the
nucleus and cortex, and separation of the
cortex from the epinucleus.
If you are doing an endocapsular technique, sometimes it is difficult to get the nucleus
loose by hydrodissection. Sometimes surgeons
will stop because they find it is taking them
longer than they expected and are not sure how
to proceed. If the surgeon stops to the extent of
discontinuing hydrodissection, this makes the
rest of the operation much more difficult and
risky. Lindstrom emphasizes that one should
continue to hydrodissect and do so in different
areas until one is sure the nucleus is loose and

will rotate. Having a loose nucleus by
hydrodissection is one of the keys to success
with the endocapsular technique. If the
surgeon does not get the nucleus loose it leads
to complications in the next step.
Centurion emphasizes that if the nucleus
does not spin freely within the capsular bag it
is due to incomplete hydrodissection. It is
important not to try to rotate the nucleus mechanically at this stage but, instead, repeat the
hydrodissection maneuver and/or introduce in
the anterior chamber a Sinskey hook through
the main incision and another hook through an
ancillary incision as shown in Fig. 149. The
hooks are fixed at opposite sides of the nucleus.
In Fig. 149 the arrows indicate the direction of
the spin of the nucleus when a slight traction is
applied but this is done after a repeat
hydrodissection. For this procedure, the anterior 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
C h a p t e r 11:
Figure 150: Proper Depth of the Lens

Groove for Divide and Conquer Technique
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 opposing forces applied to both sides of the
groove to fracture the nucleus.
Centurion emphasizes not to proceed

to the next stage, which is nucleus removal
through phaco, without being sure that the
nucleus is free. In traumatic or congenital
cataracts be particularly careful when performing hydrodissection due to the possible
fragility of the posterior capsule.
COMPLICATIONS
NUCLEUS REMOVAL
DURING
Before proceeding with phacoemulsification of the nucleus, it is assumed that the

surgeon has performed correctly all the previous phases of the operation. Upon entering
this crucial stage of the operation, the surgeon
may have difficulty in fracturing the nucleus.
That usually is caused by having performed
too shallow a groove within the lens, not deep

enough to allow fracturing of the remaining
nuclear bed.
If the surgeon is using the "Divide and
Conquer" technique, the reliable point of reference when performing the groove, is the tip
of the phacoemulsifier as shown in Fig. 150.
The tip of the phacoemulsifier should penetrate the central region of the nucleus 1 1/2
to 2 times the diameter of the tip of the
phacoemulsifier (Fig. 150). The arrows in
this figure show the direction of opposing
forces applied to both sides of the groove in
order to fracture the nucleus. As this proceeds, the red reflex becomes redder (Also
see Figs. 104 page 178, and 106 page 182).
The most serious complication of nucleus
removal is rupture of the posterior capsule,
which we address separately in this chapter.
259
Surgeon's Fatigue
Lindstrom points out that another preventive measure to avoid complications during nucleus removal is that in the more
difficult eyes, the surgeon fatigues, or gets
tired. When this happens, he stops and rests.
The minute you think you do not seem totally
comfortable and your movements get a little
awkward he recommends stopping and put
some viscoelastic in the eye. Use two instruments to rotate the nucleus into a more favorable position (Fig. 149) and then start again.
In some difficult eyes Lindstrom may restart
and stop even two or three times. Maybe that
means the case took four minutes longer but
this is not important. In those really difficult
eyes it can mean the difference between success and failure. In some complications
symposia, if you observe the live surgery
you can see the tremors of some surgeon's
hands when it is taking them a long time in
difficult cases, and they get awkward and
uncomfortable, they just cannot get the
nucleus into the right position. In those cases
Lindstrom thinks if you just stop and rest for
a minute, put a little viscoelastic, take your
time and be patient until being able to rotate
the nucleus (or other difficult maneuvers) you
can save yourself and the patient a great deal
of problems.
COMPLICATIONS DURING
REMOVAL OF THE CORTEX
After the nucleus has been removed, it is
important that the surgeon remain concentrated
on proceeding with skill and attention to every
detail to the end stages of the operation. It is
natural for some surgeons to consider that
immediately after removing the nucleus, the
main steps of the operation have been con-
260
cluded and it is time to relax. Not so. An

unpleasant rupture of the posterior capsule
may occur during the following step, which is
removal of the cortex.
Lindstrom emphasizes that for most
people removing the cortex is "easy" but many
of the series in the world literature will show
that as many posterior capsules are torn during
cortical removal as are during the nucleus removal. The hard part is over but do not loose
concentration. Slow down, and make sure you
do this step properly. The cortex usually is
quite easy to remove but most of the difficulty
and risk occurs when trying to vacuum clean
the posterior capsule. Lindstrom is not convinced that it makes any difference to vacuum
clean the posterior capsule because this is not
where the source of the eventual opacification
of the posterior capsule. He discourages
aggressive vacuuming of the posterior capsule.
If you are going to do it be very certain that
there is no barb or sharp point on the tip of the
I/A. He has seen many capsules torn by a little
barb or sharp tip on the I/A tip particularly
during the vacuum cleaning.
COMPLICATIONS
DURING
FOLDABLE IOL's IMPLANTATION
Wrong
Decentration
IOL
Power
and
To prevent complications, the key is to

get the lens symmetrically into the capsular
bag or symmetrically into the ciliary sulcus if
for some reason the surgeon feels insecure
about the capsular bag being intact. This requires being very observant that there is a good
capsular rim and certain that you are placing
the complete lens at the bottom of the capsule.
C h a p t e r 11:
Also, be sure you have the correct lens

and correct lens power. Surgeons who receive
many referrals from other colleagues consider
that the most common reasons they have to
operate in order to change an IOL are: 1) error
in lens power calculation during the previous
operation and 2) late decentration or subluxation.
because they are not within the central zone;

and 2) others have suffered significant tears
and have had to be removed during surgery,
requiring that a new lens be inserted. These
tears might have been due to the lack of lubrication with viscoelastic or because the surgeon did not use the proper technique of insertion.
Asymmetric Capsulorhexis
Importance of Warming Acrylic

IOL's
Sometimes, a decentration of the IOL

occurs because there is an asymmetric
capsulorhexis. The margins of the rhexis are
not over the optic on all sides. Consequently,
one side gets underneath the lens, it fibroses
and pushes the lens aside. If for some specific
reason the haptics were placed in the sulcus,
sometimes the sulcus can be very large, as in
myopes, and there can be an area of disinsertion.
Upon using acrylic lenses, they should

be warmed before folding and implantation.
This measure provides easier folding and a
slower unfolding. If we attempt to fold and
implant an acrylic IOL at room temperature,
the lens presents resistance to folding and a
certain resistance to unfolding.
Management of Complications
with Array Multifocals
Deficient Intraoperative Handling

Carlos Nicoli, M.D., one of Argentina's
most prestigious cataract surgeons, finds that
the intraoperative complications with foldable
IOL`s are not significant but we do have to be
alert as to problems arising from intraoperative
handling of the lenses, the instruments used to
fold the lenses, the injectors and the forceps.
Heavy or high density viscoelastics placed
within the plastic injectors have led to breakage
of the injector at the time of insertion. In
addition, if the surgeon does not have enough
experience with the injectors, he may scratch
the lens optic. Also, if we grasp the lenses with
forceps without a stop at the tip, the optics can
be scratched at the time of folding.
Nicoli points out that tears may occur in
lenses at the time of insertion. They may be:
1) partial tears where vision is not affected
As emphasized by Fine and Hoffman,

in situations in which the first eye has already
received an Array lens implant, complications
management must be directed toward finding
the way to implant an Array IOL in the second
eye. Under most circumstances, capsule
rupture will still allow for implantation of
an Array lens as long as there is an intact
capsulorhexis. Under these circumstances,
the lens haptics are implanted in the sulcus, and
the optic is prolapsed posteriorly through the
anterior capsulorhexis. This is facilitated by a
capsulorhexis that is slightly smaller than the
diameter of the optic (Fig. 145) in order to
capture the optic in essentially an in-the-bag
location. If full sulcus implantation is used,
then an appropriate change in the IOL power
will have to be made to compensate for the
more anterior location of the IOL within the
261
eye. When vitreous loss occurs, a meticulous

vitrectomy with clearing of all vitreous strands
must be performed.
Iris trauma must be avoided because the
pupil size and shape may affect the visual
function of a multifocal IOL postoperatively.
If the pupil measures less than 2.5 mm impairment of near visual acuity may ensue owing to
the location of the lens rings serving near visual
acuity (Figs. 130, 131).
For patients with small postoperative
pupil diameters affecting near vision, a mydriatic pupilloplasty may be tried successfully
using the Argon laser.
COMPLICATIONS WITH
POSTERIOR CAPSULE
RUPTURE
Maintaining the integrity of the posterior
capsule is a must because the incidence of
retinal complications is higher when there is
posterior capsular disruption. We specifically
refer to cystoid macular edema and retinal
detachment.
The disruption of the posterior capsule
may occur at any stage of the operation, at the
beginning, in the mid stage upon removing
the nucleus and in the late stage when aspirating the cortex. Adequate management can
provide satisfactory vision.
A tear in the posterior capsule is most
frequent for surgeons who are beginning in
the process of transition or who are doing
their first cases. It mostly occurs when
finishing the nucleus and epinucleus removal
and during the phase of aspiration of the
residual cortex. The tear is usually located at
12 oclock or nearby.
262
Higher Risks for Posterior

Capsule Tear
Carlos Nicoli, M.D., points out that
posterior capsular tears have an incidence of
approximately 3%. This is the maximum
acceptable. There is a much lower incidence
with surgeons of considerable experience.
Above 3%, we must investigate what we are
doing wrong.
Nicoli emphasizes that there are also
situations which we should detect at the time
of preoperative evaluation because they favor
a high risk of posterior capsule tear. The
most important are: 1) patients with history
of trauma who may have zonular dialysis;
2) patients with pseudoexfoliation; 3) hard
cataracts with large nuclei; 4) patients with
larger axial length; 5) posterior subcapsular
cataracts have an inherent weakness of the
posterior capsule. In the latter group, one
must be very careful not to perform
hydrodissection and delamination techniques
because they might stimulate the formation
of a capsule tear not perceived by the surgeon.
Capsule Rupture Early

When it occurs early, at the beginning
of nucleus phacoemulsification, it does so
more frequently with soft nuclei. The surgeon miscalculates his maneuvers, is very
stressed, applies too much phaco power or a
disproportional vacuum all of which lead to
fast aspiration and emulsification of part or
the whole nucleus, epinucleus and cortex.
The posterior capsule comes along with all
these structures.
Another cause for capsule rupture early
C h a p t e r 11:
is that the surgeon has sculpted deeply in a

soft nucleus. By and large, tears occur in the
central region and in a circular or oval shape
(Fig. 151). In order to manage this complication, Centurion advises to stop everything,
do a so-called "dry vitrectomy" in which no
infusion is used or a limited vitrectomy with
very low flow system. It is also essential to
use small amounts of viscoelastic under the
nucleus fragments to push the vitreous and
lens fragments away from the posterior capsule tear (Fig. 151). Nevertheless, if vitreous is already prolapsed, this must be solved
first. The experienced surgeon may then
proceed with phacoemulsification decreasing
significantly the phaco power, or convert to
an extracapsular (Fig. 144). If this complication happens during the transition, the wisest
decision is to convert.
Capsule Rupture During More

Advanced Stages of Nucleus Removal
When using the divide and conquer
or the chopping techniques, if there is a
capsular tear during phacoemulsification of
one of the nucleus quadrants, the tear in
the posterior capsule may or may not be
perceived by the surgeon. If the
phacoemulsifiers efficiency is reduced to the
extent that aspiration no longer occurs, we
must always be suspicious that we have a tear
in the posterior capsule and vitreous blocking
the port. In these cases, Centurion again
recommends to stop, inject viscoelastic, by
all means identify the site and the size of the
tear, perform anterior vitrectomy, inject vis-
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 material (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 carefully continuing with phacoemulsification decreasing significantly the phaco power. It depends on the
surgeon's experience.
263
coelastic again, and proceed to luxation of the

remaining parts of the nucleus into the anterior chamber with a bimanual maneuver (Fig.
152). If the tear is fairly large and not
sufficient posterior capsular support remains,
an IOL may be placed in the sulcus if the
anterior capsule is intact.
In case the surgeon does not feel safe
enough to proceed with phacoemulsification,
he can always convert to extracapsular as
long as the incision has been made in the
limbus and not in the cornea. He may also
enlarge the limbal incision to remove the rest
of the nuclear pieces (Fig. 144).
In the presence of a large tear of the
posterior capsule, it may be unrealistic and
risky to implant an IOL completely within
the bag. As a matter of fact, some of the more
frequent cases of tears result in partial absence of the upper half of the capsular bag. In
such cases, after infusion of viscoelastic and
vitrectomy and being sure that the anterior
capsule is intact, you may implant a PMMA
IOL by securing the superior haptic in the
sulcus by a single suture as shown in Fig. 153
and utilizing the remaining inferior part of
the capsular bag as a support for the inferior
haptics (Fig. 153). Some surgeons prefer to
implant both loops symmetrically in the sulcus in such cases.
Nuclear Fragments Dislocated

Into Vitreous
A non perceived or inadvertent major
tear of the posterior capsule or of the zonule
when beginning to manage the nucleus or half
way through the nucleus removal may lead
to having pieces of nucleus or the entire
nucleus fall into the vitreous. The most
important measure is to identify the location of the rupture and discontinue ultra-
264
sound energy. Then immediately proceed to

clean the anterior chamber from all nucleus
fragments present. If the nucleus or fractions of it are free or connected to capsular
residues and present in the anterior third of
the vitreous chamber, viscoelastic may be
placed behind them for support and an anterior vitrectomy performed using a vitrectomy
instrument plus viscoelastic, trying to pull the
nucleus into the anterior chamber and then
finish the phacoemulsification. On the other
hand, if the nucleus is in a deeper location
within the vitreous cavity (Fig. 155), it is
strongly advised to perform only an anterior
vitrectomy for removal of the fragments
present in the anterior third of the vitreous
cavity, remove the cortex and implant an
intraocular lens as shown in Figs. 152, 153,
156. Refer the patient to a posterior segment surgeon. Do not attempt to remove a
nucleus which has fallen into the vitreous
yourself unless you have experience with
vitreoretinal surgery. The surgeon must see
what he does and certainly doing attempts in
the dark may lead to very severe and irreversible vitreoretinal lesions that definitely
jeopardize the outcome.
Capsule Rupture During Cortex

Removal
Rupture of the posterior capsule while
removing the cortex
is frequently at 12
oclock and may be due to the use of very
high aspiration parameters, usually 400 to
500 mm Hg (Figs. 71 and 128).
If the capsule is ruptured during the
aspiration of cortex and vitreous enters the
anterior chamber, the first step is to perform a
"dry anterior vitrectomy" or an anterior vitrectomy with very low flow system and
proceed to implant the intraocular lens which
C h a p t e r 11:
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 performed. Viscoelastic is infused in the anterior
chamber. One alternative is for the lens fragments (F) to be moved or luxated by the surgeon
to the anterior chamber with a bimanual maneuver. 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

capsule defect (Fig. 154). Aspirating the cortical residues at 12 oclock is technically
difficult (Fig. 128), but may be more difficult
if there has been an incomplete
hydrodissection or a small capsulorhexis
(Fig. 145). In Fig. 154, you may see that the
surgeon is aspirating the cortical residues
after a posterior capsule rupture with an IOL
placed to protect the posterior capsule defect
as a shield so that aspiration can continue.
Then the cortical residues at the 12 oclock
position are aspirated with a curved cannula.
In order to prevent posterior capsule
rupture during the stage of cortex I/A, it is
essential not to be aggressive in attempting to
remove all the remaining cortex and not to do
the "vacuum cleaning" process. This is risky
and does not constitute the main source of
posterior capsule opacification postoperatively.
Pars Plana Vitrectomy for

Dislocated Nucleus
Significant Factors Related to
Outcome
Lihteh Wu, M.D., after reviewing the
world literature, reports that immediate pars
plana vitrectomy offers no visual advantage
over delayed vitrectomy. As a matter of fact,
sometimes it is necessary to wait for the
intraocular pressure to be controlled and for
the corneal edema to resolve. Borne,
Tasman et al in a classic paper published in
"Ophthalmology" in June 1996 in a retrospective review of 121 eyes that underwent pars
plana vitrectomy for removal of retained lens
fragments as a result of phacoemulsification
Figure 154: Aspiration of Cortical Residue 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
C h a p t e r 11:
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

that the timing of vitrectomy does not have a
statistically significant impact on visual outcome. Neither the type of intraocular lens nor
the timing of lens implantation significantly
altered the final visual acuity. Most eyes with
retained lens fragments do well after vitrectomy, with the majority recovering good vi-
sion (Fig. 155). However, the risk of retinal

detachment (RD) is increased, and visual
outcome may be adversely affected if RD
occurs.
The Wills Eye Hospital team also emphasized that during cataract surgery, the surgeon must avoid aspirating (without cutting)
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

to dislocate posteriorly should be made only
with vitrectomy handpieces. The use of lens
loops, forceps, and other instruments that
have the potential to engage and pull on
vitreous gel should not be used. A complete
limbal vitrectomy should be performed before any lens placement and the absence of
vitreous to the wound or other anterior struc-
268
tures should be confirmed at the time of

wound closure. Last, indirect ophthalmoscopy with scleral depression should be performed at the end of the procedure or by a
retinal specialist to identify any retinal tears
because these will require at least laser or
cryo retinopexy.
Figure 156 represents an IOL fixated to
the sulcus after vitrectomy.
C h a p t e r 11:
POSTOPERATIVE COMPLICATIONS
Despite the technological advances
that have made cataract surgery an operation
with such a high rate of success, postoperative complications still occur although less
frequently. For didactic purposes, we have
divided them into medical and surgical complications.
MEDICAL
Incidence
Professor Juan Verdaguer, M.D., from
Chile points out that the incidence of this
complication has decreased due to improved
surgical techniques and better management of
complications.
Although the incidence of angiographic
CME has been estimated in about 20% in
pseudophakic patients, clinically significant
macular edema with reduced visual acuity
occurs approximately in 1% of cases undergoing uncomplicated extracapsular cataract
surgery.
CME is more common following complicated extracapsular and phacoemulsification procedures, particularly if the posterior capsule was ruptured, with vitreous loss
and implantation of an anterior chamber lens
and related complications typical of the transition period from extracapsular to phacoemulsification. If vitreous loss occurs, the
incidence of clinically significant CME increases up to 8%.
CME remains a significant cause of
unexpected poor visual acuity after uneventful, uncomplicated cataract surgery.
Pathogenesis
Characteristically, fluorescein angiography demonstrates leakage from the
parafoveal retinal capillaries and from optic
nerve capillaries. If the patient is examined
right after fluorescein angiography, dye leakage into the aqueous humor can be easily
seen; consequently, there is evidence of a
generalized increased ocular vascular permeability. Histopathological studies have demonstrated expansion of the extracellular space
in the outer plexiform layer of the fovea
(Henle fibers), giving rise to cystoid spaces
(Fig. 175 A). There may be also some degree
of subretinal fluid.
The pathogenesis of aphakic and
pseudophakic CME is not known. Inflammation of the iris is considered an important
factor in the pathogenesis; the irritated iris
releases a number of inflammatory mediators
that may be involved in CME. Inflammatory
mediators, such as prostaglandins, diffuse
269
into the vitreous cavity and into the retina,

causing the disruption of the blood-retinal
barrier at the macular and optic nerve capillaries.
Chronic iris irritation by entrapment of
iris to the wound with a peaked pupil, vitreous adherence to the wound with iris traction,
anterior chamber intraocular lenses and iris
clip lenses may trigger the release of these
inflammatory mediators.
Clinical Findings
The patient may complain of blurred
vision four to six weeks after surgery, or
much later in the postoperative period. In a
patient who has undergone uncomplicated
cataract surgery, the surgeon will be surprised by an unexpected and uncorrectable
reduced visual acuity, in the range of 20/30 20/60. Most patients will have a white eye
and only a few will show some mild form of
anterior segment irritation. A few patients
may show some vitreous inflammatory cells.
Clinically, CME may be easily overlooked, unless the macular area is carefully
examined at the slit lamp with a Goldman
contact lens or similar. The macula appears
thickened, with intraretinal cystoid spaces, in
a honeycomb pattern; the foveal reflex is lost
(Figs. 157 A, B, C). A few patients show
evidence of epiretinal membrane formation,
with cellophane-like reflexes.
Fluorescein angiography is diagnostic.
Early phases demonstrate a very slow leakage
from the parafoveal retinal capillaries. In the
later frames, the dye fills the cystoid spaces;
270
the hyperfluorescent spaces are separated by

a dark hypofluorescent stellate figure. The
angiographists should be aware of the probably diagnosis to avoid missing the later
frames that will show this characteristic petaloid or floral pattern (Fig. 157 B).
Late leakage of optic nerve capillaries
is also demonstrable in the late frames; however optic nerve swelling is usually not noticeable ophthalmoscopically.
Fluorescein angiography may be the
only means of making the diagnosis of CME
if the media is hazy.
Clinical Course
Most patients will experience spontaneous recovery of visual acuity and resolution
of CME during the first year after surgery
(Fig. 158). Patients with persistent CME
after 6 months may develop permanent
loss of vision ("chronic CME"). These
patients may develop a lamellar macular hole
or pigment epithelial changes.
Treatment
Verdaguer clarifies that current therapeutic intervention for prophylaxis and treatment of CME are based on blocking the
inflammatory mediators that may be involved in CME, mainly the prostaglandins.
Prostaglandins are synthesized from
arachidonic acid released from cell membranes by phospholipase A 2. Cyclo-oxygenase converts arachidonic acid to cyclic intermediates and then to prostaglandins.
C h a p t e r 11:
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

arachidonic acid from cell membranes, by
blocking phospholipase A 2. Non steroidal
antiinflammatory drugs are cyclo-oxygenase
inhibitors, blocking the synthesis of prostaglandins.
Prophylactic Treatment
A randomized clinical trial by Flach et
al demonstrated that cyclo-oxygenase inhibitors (COI) alone used prophylactically reduced the incidence of CME after cataract
surgery. Ketorolac tromethamine 0.5% ophthalmic solution was administrated three
times daily beginning one day before surgery
and continued for 19 days postoperatively.
Given the relatively low incidence of CME in
uncomplicated cataract surgery, prophylactic
treatment is seldom used.
272
Treatment of Chronic CME

Pooled data from randomized clinical
trials indicate a treatment benefit in terms of
improving final visual acuity by two or more
lines. These studies report the efficacy of a
combination of corticosteroid and cyclooxygenase inhibitors (COI, or NSAID's). In
all but one trial, COI was tested alone with
good results. Since there might be a synergistic effect, the following approach is suggested:
1.
Topical corticosteroids, prednisone acetate 1% four times daily + topical COI
(diclofenac sodium 0.1% or flurbiprofen sodium 0.03% or ketorolac tromethamine 0.5%)
four times daily. The treatment is maintained
at least for two months, with careful monitoring of the intraocular pressure. If the patient
has a steroid pressure response, treatment
C h a p t e r 11:
should be limited to topical COI. In case of

favorable response, the regime is tapered very
slowly. If there is no response at two months,
the following interventions could be considered, without discontinuing the initial treatment.
2. Periocular steroid injections limited
to a maximum of three.
3. Carbonic anhidrase inhibitors may
work in a few patients but may be poorly
tolerated.
4. Surgery should be considered only in
patients with surgical complications that have
modified the anatomy of the anterior segment
and only if a well conducted pharmacological
therapeutic trial has failed.
In patients with vitreous incarceration
in the wound, Nd:YAG vitreolysis may be
tried, but is difficult. An anterior vitrectomy,
with repair of vitreous adhesion to the wound
or iris may be the procedure of choice in these
cases. More extensive surgery may be required if there is significant lens malposition.
Diabetes
Edema
and
Cystoid
Macular
Verdaguer is an authority on diabetic

retinopathy. He emphasizes once again that
patients with preexisting diabetic macular
edema are at substantial risk for worsening of
the macular edema following cataract surgery. Moreover, diabetics are probably more
susceptible to pseudophakic CME. The two
conditions, diabetic macular edema and postsurgical CME may, in fact, coexist in a given
diabetic patient. Patients with lipidic exudates, retinal hemorrhages, perifoveal
microaneurysms, diffuse or focal leakage at
angiography will have a predominantly diabetic macular edema. Patients without these
characteristics, a petaloid pattern of leakage
at the macula, and disc leakage, will have a

predominantly postsurgical CME.
Treatment Recommendations
1.
Optimize medical treatment.
(metabolic control, arterial hypertension,
dislipidemia, anemia).
2.
Use topical steroids and COI, to
treat the presumed pseudophakic CME.
3.
Laser photocoagulation, focal or
grid, if there are leaking microaneurysms or
diffuse leakage, with lipid exudation and retinal hemorrhages.
PHOTIC MACULOPATHY
The intense illumination system of
modern operating microscopes may induce
photochemical retinal injury. The first cases
of phytotoxicity after uneventful cataract surgery were described by McDonald and Irvine
(1983).
Photochemical vs Photothermal
Damage
Verdaguer clarifies that photochemical
injury is different from photothermal damage
(photocoagulation). Photocoagulation occurs
after brief and intense light exposure; photochemical injuries develops after prolonged
exposure at intensity too low to induce photocoagulation. Photocoagulation induces an
immediate visible reaction; photochemical
damage is not immediately recognizable.
In photochemical injuries, light activation of cell molecules generates oxygen singlets (free oxygen radicals). These are very
toxic and induce oxidation and damage of cell
components.
273
Shorter wavelengths carry most energy

(UV and blue visible light) and are more
likely to produce photochemical damage.
Incidence
Juan Verdaguer points out that the
incidence of photoretinal injuries during extracapsular cataract surgery has been estimated at 7 to 28% in different series. Photic
retinal injury did not develop after phacoemulsification in one series, with careful
limiting of coaxial exposure time and microscope irradiance.
Risk Factors
The main risk factors associated with
photochemical damage are duration of the
exposure (longer surgery time) and intensity
of the operating microscope illumination.
Longer surgery times have been associated with increased incidence of retinal photochemical injuries. However, the complication has occurred in short, uneventful procedures. Therefore, the skilled, rapid, experienced surgeon, should not disregard the dangers of photoxicity.
Clinical Findings
The patient may complain of a scotoma
that may be central or paracentral, in correspondence to the retinal injury location. A
few patients may give a history of postoperative erithropsia. In other cases the main
complaint may be unexpected poor visual
acuity, if the injury is near the fovea.
Visible changes at the retina will be
apparent 24 to 48 hours following exposure.
In the early postoperative period the lesion
appears a subtle creamy deep, pale oval lesion, usually just below or above or temporal
274
to the center of the fovea. If the eye is

infraducted by a superior rectus suture, the
lesion will be located below the macula.
Fluorescein angiography will show intense staining of the oval plaque. Cicatricial
changes are apparent within the first week,
with pigmentary mottling and athropic
changes of the pigment epithelium within a
sharply demarcated oval area. The lesion
shows a highly characteristic leopard-skin
appearance.
The scotoma fades rapidly and the
visual acuity may improve, unless the lesion
is large and involves the macula. Fluorescein
angiography will reveal changes restricted to
the oval scar, with window defects and
blocked fluorescence corresponding to the
areas of hyperpigmentation (Fig. 159).
Preventive Measures
The illuminating light should not be
brighter than necessary and the cornea
should be covered whenever the surgeon is
not working intraocularly. A finger blocking
the light may suffice.
Indirect illumination, instead of coaxial illumination should be used during
closure of surgical wound in extracapsular
procedures, since the risk is maximal following implantation of the lens, with the light
clearlu focused directly on the retina.
Tilting the microscope toward the surgeon and infraduction of the globe may
displace the light below the fovea.
Small incision phacoemulsification
technique is less likely to induce light toxicity, since the instruments remain in the visual
axis most of the time and operating times are
reduced in the hands of experienced surgeons. There is no treatment for this
complication.
C h a p t e r 11:
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

hidroxchloroquine,phenotiazines, allopurinal,
etc., should be discontinued before surgery,
since they may potentiate photic damage to
the retina.
AMINOGLYCOSIDE
TOXICITY
Aminoglycosides have been widely
used in the prophylaxis and treatment of
ocular infections. Macular infarction is a
severe complication that has been mainly
associated with the administration of gentamicin, but has also been reported after use
of amikacin and tobramycin.
Juan Verdaguer emphasizes that
aminoglycoside toxicity may be related to:
1) Intravitreal injections in endophthalmitis treatment regimes. Toxicity may

follow administration of gentamicin at recommended doses. Verdaguer has seen this
complication after intravitreal injection of
0.15 mg of gentamicin, a dose previously
considered safe.
Treatment of post surgical endophthalmitis should include the intravitreous injection of an antibiotic which acts effectively
against gram-positive organisms (vancomycin) and one that is effective against gram
negatives, since gram-negative endophthalmitis is much more common. Given the
very narrow safe therapeutic window of
aminoglycosides, a good choice would be a
cephalosporin such as ceftazidime. If the
surgeon is confronted with an acute postsurgi-
275
cal endophthalmitis and ceftazidime is not

available, an aminoglycoside should be included in the intravitreous injection, at the
lowest effective dose (100 mg of gentamicin
or 400 mg of amikacin). Even at these doses,
toxicity cannot be ruled out.
2) Prophylactic intravitreous injections in severe trauma cases. Verdaguer
has seen this complication after a prophylactic intravitreous tobramycin injection.
Aminoglycosides should not be used
intravitreally for prophylactic purposes.
Endophthalmitis is a treatable disease and
aminoglycoside
toxicity
is
not.
(Campochiaro et at).
3) Following uncomplicated subconjunctival injection after routine cataract surgery. 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,
create a one way valve, allowing subconjunctival antibiotics and access into the anterior
chamber. Subconjunctival antibiotic injections, if used, should be placed in the quadrant opposite to the wound.
4) Dilution errors in intravitreal injections.
5) Inadvertent intraocular injection due
to confusion with miochol or other substances.
If the mistake is discovered during 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
macular area. (Intravitreal aminoglycosides

tend to settle on the posterior pole in the
supine position). Examination reveals milky
white opacification of the retina, a cherry red
spot and a few blot retinal hemorrhages. The
appearance is similar to that seen in central
retinal artery occlusion, but limited to the
posterior pole. It also differs from branch
retinal arterial occlusion, since the infarction
involves the retina both above and below the
macula. Fluorescein angiography reveals
sharply demarcated central area of occlusion
of the retinal vessels and some perivascular
leakage (Fig. 160).
Figure 160: Aminoglycoside Toxicity 2 Months after

Intravitreous Injection of Gentamicin
Vascular occlusion involving the temporal vessels (Macular infarction). (Courtesy of Prof. Juan
Verdaguer, M.D.)
C h a p t e r 11:
The condition is untreatable and irreversible. Optic atrophy and atrophic and
pigmentary retinal changes develop later.
POSTERIOR
CAPSULE
OPACIFICATION
Overview
Okihiro Nishi, M.D., is a renowned
authority on this subject because of his extensive research and revealing findings. Nishi
has emphasized that posterior capsule opacification (PCO) is the most frequent postoperative complication associated with decreased vision in cataract surgery. Itoccurs
with an incidence of up to 50% within 5 years
after surgery.
Various mechanical, pharmaceutical
and immunologic techniques have been applied in attempts to prevent PCO by removing
or killing residual lens epithelial cells
(LECs), but none has been confirmed to be
satisfactorily practical, effective and safe for
routine clinical practice. Nishi emphasizes
that the most effective approach to reduce or
delay the incidence of PCO is by inhibiting
the migration of LECs and not by killing the
cells.
Main Causes of PCO

Recent clinical, pathological and experimental studies have emphasized that PCO
is usually secondary to a proliferation and
migration of residual lens epithelial cells.
(LECs).
How LECs Invade the Posterior

Capsule
Nishi has pointed out that residual
LECs proliferate at the pre-equatorial germinative zone and migrate posteriorly onto the
posterior capsule postoperatively. In addition, when the anterior capsule comes into
contact with the posterior capsule, the LECs
underneath the anterior capsule also migrate onto the posterior capsule abundantly, before the two capsules adhere and
grow together. The apposition of the anterior
capsule and the posterior capsule can induce
fibrotic PCO.
Role of IOL in PCO

When the IOL is in the capsular bag
the optic can separate both capsules, and
interferes with the LEC migration from the
anterior capsular edge onto the posterior capsule. The inhibition of migrating LECs and
the separation of the capsules by the IOL
optic are the main reasons why the incidence
of PCO is significantly lower in eyes with
an IOL than in those without one.
Specific Features of the AcrySof

and PCO
Nishi points out that the AcrySof IOL
reportedly has a significant low incidence of
PCO. His recent studies indicate that this
effect may be due to the sharp and rectangular
edge design of the AcrySof IOL. His histopathologic findings of the lens capsule con-
277
taining an AcrySof IOL in rabbits disclose

that the lens capsule wrapped the IOL so
firmly that it conformed faithfully to the
rectangular sharp optic edge of the IOL
and that migrating LECs were apparently
inhibited at this capsular bend or angle
created by the sharp edge and posterior
capsule by contact. The creation of such a
bend or angle in the posterior capsule requires a well-centered CCC, smaller than
the IOL optic, so that the CCC edge is in
apposition to the optic.
On the other hand, the role of this lens
may be dependent not only on the rectangular
edge design but also on the features of the
IOL acrylic material, such as adhesiveness.
The AcrySof IOL has triple the adhesiveness
to a collagen film compared to a PMMA IOL.
The adhesiveness may also help to facilitate
the creation of the bend. Moreover, the
acrylic material itself may have effects on the
inhibition of migrating LECs. This adhesiveness property of the acrylic lens, which we
described as "tackiness" in Chapter 9 under
"Advantages and Properties of Acrylic
Lenses" merits further investigation. This
"tackiness" or adhesiveness seems to play a
role in the positive effects of the AcrySof
lens. If so, then this might be a factor of
particular importance for the use of acrylic
lenses and designs of future IOL's.
From the analysis provided here, it is
clear that the preventive effect on PCO of an
AcrySof IOL may be both design and material dependent.
278
Role of Continuous Curvilinear

Capsulorhexis in PCO
Nishi emphasizes that continuous curvilinear capsulorhexis (CCC) can contribute
to reduce PCO because it facilitates the implantation of an IOL symmetrically in the
capsular bag maintaining it there without
decentration. It is extremely important to
create a well-centered CCC of the correct size
for the prevention of migrating LECs. The
CCC edge should be smaller than the IOL
optic and cover its margin (Fig. 145). A
decentered, oversized CCC or incomplete
CCC with a radial tear (Fig. 146) may result
in the apposition of both capsules. Even
though the defective area lies in a very limited circumference, the LECs migrate from
the edge of the anterior capsule onto the
posterior capsule, causing PCO.
Main Factors that Reduce PCO

Nishi clarifies that there are three key
factors that play an important role in reducing
the incidence of PCO: 1) the design of the
IOL, which results in the creation of a sharp
bend in the capsule. The discontinuous,
rectangular bend or angle in the posterior
capsule interferes with the proliferation of
LECs. 2) The material of the IOL, which
points to the benefits of some acrylic because
of
its
adhesive
properties
and
biocompatibility (less fibrosis). 3) The surgical technique which emphasizes a perfectly
C h a p t e r 11:
centered CCC of smaller size than the IOL

optic.
In addition, Nishi strongly recommends a NSAID for 3 months postoperatively, in order to reduce postoperative inflammation with conversion of mononuclear
cells into fibroblasts, and possibly proliferation of residual LECs.
Visual Loss from PCO Differential Diagnosis

It is often a rather difficult clinical
judgment to determine if the capsule opacity
is in fact responsible for the patient`s decreased vision. The principal misdiagnosis is
to believe that the capsule is responsible for
the problem when, in fact, the patient has
developed a cystoid macular edema which
may be difficult to detect because of the
posterior capsular opacity. When in doubt, a
pre-capsulotomy fluorescein angiography is
appropriate to determine if macular edema is
present.
PERFORMING THE POSTERIOR

CAPSULOTOMY
Size of Capsulotomy
Some prestigious anterior segment surgeons have advocated not dilating the pupil
for performing a YAG posterior capsulotomy.
Many patients' pupillary openings are not
located in the exact anatomical center of the
iris. Once the pupil is dilated, it can be
difficult to identify where the true pupillary
opening was located.
Nevertheless, there are important

contraindications to making a small capsulotomy. The most important are: 1) Difficulties
in the evaluation of the retinal fundus. 2) The
center of the capsulotomy may be clear following treatment but the rest of the capsule
remains opaque, and sometimes with a crystalloid appearance. Patients with macular
degeneration, for example, may see better
when the capsulotomy is wide enough to
prevent contrast reducing haze from the residual hazy peripheral capsule. In those cases
it is better to dilate the pupil 4-5 mm preoperatively in order perform a more effective
treatment.
Dodick generally makes a capsule
opening the size of a normal pupil, 3-4 mm at
the most.
Posterior Capsulotomy Laser

Procedure
Timing
Alice McPherson, M.D., was one of
the first retina specialists to demonstrate that
retinal detachment could be precipitated by
early YAG laser posterior capsulotomy. She
has advised waiting approximately 4-6
months after cataract surgery to perform a
YAG laser posterior capsulotomy. The prior
dictum to wait one year, was done to be sure
all inflammation was finished, in order to
avoid cystoid macular edema.
McPherson has pointed out that once a
capsulotomy is performed, the pseudophakic
eye is actually like an aphakic eye. Keeping
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

vitreous traction on the periphery. After the
YAG capsulotomy is done, any predisposing
factor can increase the potential for a retinal
detachment or cystoid macular edema.
Technique
Use the lowest level energy pulse that
will open the capsule, usually 1 mJ. An
280
adequate opening can be made with 10 laser

applications or less, depending on how
taught the capsule is. A cruciate pattern is
recommended, starting in the periphery at 12
o'clock, working down across the center of
the capsule toward 6 o'clock, and complete
the cross from 3 to 9 o'clock (Fig. 161). The
capsule will usually retract further after completing the capsulotomy.
C h a p t e r 11:
Complications Following Nd:YAG

Posterior Capsulotomy
Intraocular Pressure Elevation
The most common complication is a
transient pressure elevation. This must be
anticipated and treated prophylactically. The
most effective method is to instill one drop of
brinzolamide or dorzolamide 30 minutes before and one drop following the laser procedure. Patients at higher risk of developing
transient elevation of the intraocular pressure
are those that have anterior chamber intraocular lenses and patients with pre-existing glaucoma.
Retinal Detachment
A higher percentage of pseudophakic
detachments occurs in cases with a history of
fellow eye detachment, preexisting retinal
disease such as lattice degeneration and retinal holes, or in eyes with axial lengths above
25 mm. Retinal detachments associated with
Nd:YAG laser posterior capsulotomy occur
most often within the first 6 months following
capsulotomy.

It is not well-known yet whether
Nd:YAG laser capsulotomy can induce the
formation of cystoid macular edema (CME)
in a quiet eye. Anterior segment inflammation can occur after laser capsulotomy, and
inflammation has been identified as an etiologic factor for CME especially if laser treatment has been more intensive than the parameters already established. In addition, prolapse of vitreous anteriorly through the capsu-
lotomy or a disruption of the anterior hyaloid

might produce posterior retinal traction, another possible cause for CME. Thus, a potential relationship does exist. In suspicious
cases only a fluorescein angiogram after the
treatment may provide the answer.
POSTOPERATIVE
ASTIGMATISM IN
CATARACT PATIENTS
With present advances in small incision
cataract surgery, particularly with clear corneal incisions, postoperative astigmatism following phacoemulsification should be minimal. A well trained surgeon creates an astigmatically neutral incision to prevent an induced astigmatism.
If astigmatism is present preoperatively,
the surgeon addresses the problem at the
time of cataract surgery. By placing the
corneal incision in the indicated axis, preexisting astigmatism and cataract surgery are
performed simultaneously. This latter subject
which we term "Refractive Cataract Surgery"
is addressed at the beginning of Chapter 12
(Cataract Surgery in Complex Cases).
MANAGEMENT
Astigmatism, either preexisting that
was not fully corrected or induced may be
managed after cataract surgery either with
incisional refractive surgery (astigmatic keratotomy) or with excimer laser (LASIK or
PRK).
How to Proceed
Wait a minimum of three months following 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 astigmatism or correct an astigmatism induced during
the cataract operation, which is usually related 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 accurate as when treating spherical corrections,
myopic astigmatism treatment has been increasingly 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
against the rule, paired with-the-rule incisions are done because they can augment the
astigmatism-reducing effect (Fig. 162-C)
Oshika et al in Japan reported a prospective evaluation of predictability and effectiveness of arcuate keratotomy treating
corneal astigmatism after cataract surgery in
282
Figure 162: Correcting Astigmatism Following Cataract

Surgery
Figures 162 A and B show the use of excimer laser in
postoperative astigmatism. The actual surgical procedure for
astigmatism, either LASIK or PRK, is the same as for
spherical ametropias. In LASIK, when treating simple or
compound myopic astigmatism, the excimer beam (L) also
flattens the steep axis. Figure C shows the additional relaxing
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, although not as predictable.
C h a p t e r 11:
104 eyes. They concluded that astigmatic

keratotomy in pseudophakic eyes is less predictable than that in eyes with idiopathic
astigmatism, but the procedure is sufficiently
effective in reducing the residual astigmatism
after cataract surgery. Individual nomograms
are necessary for astigmatic keratotomy in
eyes with naturally occurring and postsurgical astigmatism. In figure 164 we present
Richard Lindstrom's nomograms.
Key Factors in the Effects of

Astigmatic Keratotomy
These are related to the diameter of the
optical zone utilized (Fig. 163), and the
length and depth of the incisions. In correcting postoperative astigmatism a common
choice is a 7 mm optical zone to avoid

visual aberrations with a smaller optical
zone. The effect of these arcuate relaxing
incisions is titrated by the length of the incisions (Fig. 164).
Highlights of AK Procedure
Anesthetize the eye with the topical
anesthetic of your choice. The center of the
pupil is marked with the tip of a .12 mm
forceps which has been painted with Gentian
violet. A 7 mm (or the diameter selected)
optical zone marker (Fig. 163) is centered
over the pupil and pressed down. The axis of
the steepest meridian is identified with two
marks, 180 apart, over the 7 mm optical
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:
30 arc= 2.0 mm
45 arc= 2.5 mm
Make one or two arcuate incisions

(Fig. 162-C) in the 7 mm zone according to
the nomogram (Fig. 164). The wound is
inspected and irrigated.
EXPLANTATION OF
FOLDABLE IOL'S
RETAINING THE BENEFIT OF
THE SMALL INCISION
The problem arises once a flexible
IOL has been implanted and there is need
to remove it. How can we proceed to
explant the IOL while retaining the benefits
of small incision cataract surgery? Jack
284
60 arc= 3.0 mm
90 arc= 3.5 mm
Dodick, M.D., and Susan Batlan, M.D.,

recently developed a technique to solve this
situation.
The Most Common Indications

for Explantation
The most common indications for explantation are dislocation or improper fixation, chronic inflammation, anisometropia,
improperly oriented haptics, a defective intraocular lens, and haptic breakage.
Flexible intraocular lenses, which are
being used with increasing frequency with
small incision cataract surgery, are introduced
into the eye through a 3.0 to 3.4 mm wound.
Explantation without enlarging the wound is
C h a p t e r 11:
certainly desirable in order to retain the benefit of the small incision.
Problems Presented by
Traditional Techniques
Explantation has usually been a delicate
problem to handle. The techniques suggested
for this purpose have been technically difficult and risk compromising the corneal endothelium and posterior lens capsule.
Most procedures for intraocular lens
explantation have included enlarging the
wound and extruding the unfolded intraocular
lens in one piece or bisecting the intraocular
lens under viscoelastic with Vannas scissors
before removal through the wound. The need
to enlarge the wound, however, defeats the
purpose of small incision cataract surgery

because the original wound needs to be enlarged from 5.0 to 6.0 mm to facilitate intraocular lens removal.
Description of New Technique

Because the average central anterior
chamber depth is usually 3.0 mm it is difficult
to invert the intraocular lens to properly reorient the haptics. Further, removal of the
intraocular lens in one piece is not possible
without enlarging the wound size, even if it is
a flexible IOL.
Dodick and Batlan first deepen the
anterior chamber and expand the lens capsule
with a superior quality viscoelastic. They
then incise the IOL optic along its radius with
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 maintained in cases where it is necessary to remove a foldable intraocular lens. First, the
anterior chamber is deepened with viscoelastic. 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 halfbisected optic will then hinge at the center
when explanted (see Fig. 166).
285
maneuver allows the lens to be folded in half,

and creates a lens with no part greater than
3 mm in width. The superior haptic is then
grasped with Kelman-McPherson forceps and
the intraocular lens, with the optic folded in
half, is gently pulled through the incision.
The elastic properties of the flexible IOL
enable the surgeon to deform the optic and
remove the intraocular lens in one piece
(Fig. 166)
By utilizing this technique for explantation of a foldable IOL following small incision cataract surgery, the surgeon does not
compromise the integrity of the original
wound, posterior lens capsule, or corneal
endothelium.
RETINAL DETACHMENT
Risk Factors
Cataract extraction is a well-known
risk factor for the development of a
rhegmatogenous retinal detachment (RRD).
Anywhere from 20% to 40% of RRD occur in
eyes that have undergone cataract surgery
(Fig. 167).
Incidence
The incidence of RRD following
ECCE and PCIOL implantation has been
reported to be between 0.25% and 1.7%. The
incidence of retinal detachment is less in
patients with uncomplicated phacoemulsification because this procedure is performed
through a self-sealing, watertight small incision with improved safety during the procedure. It is also significantly less invasive.
The rate of RD associated with
phacoemulsification greatly increases in the
286
presence of rupture of the posterior capsule

particularly when lens fragments are mixed
with the vitreous. What to do and what not to
do is addressed in this same chapter under
Intraoperative Complications of Phacoemulsification - Posterior Capsule Rupture. This is an uncommon complication but
it does occur in the initial stages of the
learning curve during the transition from
ECCE to phacoemulsification.
Clinical Course of RD
Patients typically complain of photopsias,
floaters, scotomas and blurry vision. Previous
reports have emphasized the poorer outcome
of surgery for RRD in pseudophakic eyes as
compared to phakic eyes. These authors experience is that peripheral capsular opacification, lenticular remnants and the optical effects induced by the rim of the IOL impair
visualization of the small peripheral retinal
breaks by indirect ophthalmoscopy, thereby
interfering with the vitreoretinal surgeon's
best performance.
In the present practice of clinical ophthalmology, repair of retinal detachment is
routinely referred by the cataract surgeon to a
vitreoretinal surgeon.
POSTOPERATIVE
ENDOPHTHALMITIS
By definition, endophthalmitis refers
to the presence of an inflammatory reaction in
both the anterior and posterior segments of
the eye. Its etiology may be infectious or
noninfectious. The infectious nature of endophthalmitis is one of major concern to
ophthalmic surgeons. Fortunately, it has become a highly infrequent complication.
C h a p t e r 11:
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 quadrant 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 endophthalmitis include bacterial and fungal organisms. Depending on its time course, endophthalmitis may be further classified as acute or
chronic. The speed with which the patient
develops symptoms is directly proportional to
the virulence of the organism.
Relative Virulence of Organisms

Highly virulent organisms that are
commonly isolated include Staphylococcus
aureus, Streptococci and Gram negative
rods. Staphylococcus epidermidis is a little
less virulent and happens to be the most
common organism isolated. Propionibacterium acnes and fungi present in a more
indolent manner. Noninfectious causes include retained lens fragments. According to
Professor Juan Verdaguer, the most common endophthalmitis is the one produced by
gram-negative organisms.
Clinical Findings and Source

of Infection
In acute cases, the patient often complains of progressive worsening of vision,
redness, ocular discharge and increasing ocular pain. Examination often reveals eyelid
edema, chemosis, corneal edema, intense cell
and flare, iris hyperemia, vitritis and hypopyon. Visual loss is often secondary to the
release of toxins and the inflammatory reaction. The main sources of infection are the
normal bacterial flora in the lids and conjunctiva. Scrubbing the lids with povidone 5%
just prior to surgery is an effective way of
reducing the bacterial load.
288
Management and Visual

Outcome
The management of acute postoperative bacterial endophthalmitis has been influenced by the results of the Endophthalmitis
Vitrectomy Study. This study provides essential information for the understanding of
how to proceed in the care of patients with
this potentially devastating complication. Its
guidelines are as follows: 1) A vitreous
specimen needs to be obtained for culture
and sensitivity as soon as possible (Fig. 168).
2) Intravitreal amikacin (0.4 mg / 0.1 mL)
and vancomycin (1.0 mg / 0.1 mL) must
be injected after the specimen is obtained
(Fig. 168). 3) If the initial visual acuity was
hands motion or better, study results suggest
that the visual outcome is the same whether
or not immediate pars plana vitrectomy is
done. 4) Vitrectomy is indicated in those
eyes with initial visual acuity of light perception or worse. Systemic antibiotics did not
affect the visual outcome of patients in the
study. 5) The visual outcome was better in
those eyes with better visual acuity at presentation, underscoring the need for early diagnosis.
In the cases where fungal or P. acnes
endophthalmitis is suspected, a vitrectomy is
usually indicated with the injection of
intravitreal antibiotics or antifungals.
INTRAOCULAR LENS
DISLOCATION
Posterior dislocation of an IOL is an
uncommon complication of cataract surgery.
Its frequency appears to have increased in the
C h a p t e r 11:
Figure 168: Technique of Vitreous Tap

in Diagnosis and Intravitreal Administration 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 cavity. 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. Another syringe is attached to the needle and
amikacin (0.4 mg / 0.1 mL) and vancomycin (1.0 mg / 0.1 mL) are injected
intravitreally immediately after the vitreous specimen is obtained.
past few years as more surgeons enter into the

inevitable steep learning curve of phacoemulsification in which posterior capsule ruptures
may occur. The great emphasis given to the
Transition into Phaco in Chapter 7 of this
Volume is precisely oriented toward facilitating a successful and comfortable approach to
this procedure.
Symptomatology
The patient with intraocular lens dislocation
often complains of sudden loss of vision due
to the uncorrected aphakia. If complications
such as retinal detachment, cystoid macular
edema or vitreous hemorrhage occur, the patient may also complain of loss of vision. If
the IOL is mobile in the vitreous cavity, it
may be observed by the patient as a huge
floater. Posterior capsular rupture or zonular

dialysis are usually present. The IOL may be
freely mobile in the vitreous cavity, may be
fixed to the retina, or may be seen hanging
with one haptic attached to the posterior
capsule, iris or ciliary body.
Management
Observation can be recommended if the
IOL is not mobile and there are no retinal
complications, but this would defeat the purposes of the operation. We can not expect the
patient to be satisfied with aphakic spectacle
correction or contact lenses.
Several surgical options are available.
These include removal, exchange or repositioning of the IOL. Repositioning of the IOL
into the ciliary sulcus or over posterior capsu-
289
lar remnants with less than a total of 6 clock

hours of inferior capsular support is not a
stable situation. Many of those repositioned
IOLs will end up dislocating again.
Transcleral suturing (Fig. 156) or IOL exchange (removal of the dislocated IOL and
placement of a flexible open loop anterior
chamber IOL) is recommended in these cases.
Current models of AC IOLs often do not
result in the same types of complications as
older models. Instead of risking another
posterior dislocation of an IOL, these lenses
should be considered if adequate capsular
support is lacking. The Kelman type of
anterior chamber lens has been a good option
for years. The Nu-Vita aphakic IOL may be
soon available. (The Nu-Vita phakic anterior
chamber IOL's have highly acceptable results
in phakic patients). If the IOL is fixed in
position, out of the way, some surgeons leave
it alone and implant a second IOL.
The Role of Silicone Plate IOL's

Silicone plate lenses deserve special
attention because progressive contracture of
the anterior capsulorhexis opening (purse
string) may occur more commonly when
they are used. This increases the tension on
the IOL and causes it to bow posteriorly.
Dehiscence anywhere in the capsular bag
allows release of tension through expulsion of
the implant. The anterior segment surgeon
should be advised to avoid implantation of a
flexible silicone plate IOL if there is a break
in the posterior capsule, a radial notch or a
tear in the anterior capsular rim or zonular
dialysis. Small capsulorhexis openings
should be avoided in these cases.
290
BIBLIOGRAPHY
Bartz-Schmidt KU, Kirchhof B, Heimann K: Primary vitrectomy for pseudophakic retinal detachment. Br. J Ophthalmol, 1996;80:346-349.
Borne, MJ., Tasman W., Regillo, C., Malecha, M.,
Sarin, Lou: Outcomes of vitrectomy for retained
lens fragments. Ophthalmology, 1996;103:971976.
Centurion V, Lacava AC, Sanchez JC, Oliveira
Mode, EA: IOL explantation. Faco Total by Virgilio
Centurion.
Chan KC: An improved technique for management
of dislocated posterior chamber implants. Ophthalmology, 1992 Jan; 99(1):51-57.
Endoophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study
Group. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of post-operative bacterial endophthalmitis.
Arch Ophthalmol 1995; 113:1479-1496.
Fastenberg DM, Schwartz PL, Shakin JL, Golup
BM: Management of dislocated nuclear fragments
after phacoemulsification. Am J Ophthalmol 1991;
112:535-539.
Gass JDM, Norton EWD: Cystoid macular edema
and papilledema following cataract extraction: a
fluorescein funduscopic and angiographic study.
Arch Ophthalmol 1996; 79:646-661.
Gonzalez GA, Irvine AR: Posterior dislocation of
plate haptic silicone lenses [letter]. Arch Ophthalmol
1996 Jun; 114(6):775-776.
Hayashi K, Yahashi H, Nakao F, Hayashi F: Reduction in the area of the anterior capsule opening
after polymethilmethacrylate, silicone, and soft
acrylic intraocular lens implantation. Am J
Ophthalmol 1997; 123:441-7.
C h a p t e r 11:
Joo CK, Shin JA, Kim JH: Capsular opening contraction after continuous curvilinear capsulorhexis
and intraocular lens implantation. J Cataract Refract Surg 1996 Jun; 22(5):585-590.
Ravalico G, Tognetto D, Palomba MA, Busatto P,

Baccara F: Capsulorhexis size and posterior capsule opoacification. J Cataract Refract Surg. 1996;
22:98-103.
Learning DV: Practice styles and preferences of

ASCRS members - 1994 survey. J Cataract Refract Surg 1995; 21:378-385.
Schneiderman TE, Johnson MW, Smiddy WE, et

al: Surgical management of posteriorly dislocated
silicone plate haptic intraocular lenses. Am J
Ophthalmol 1997 May; 123(5):629-635.
Mittra RA, Connor TB, Han DP, et al: Removal of

dislocated intraocular lenses using pars plana vitrectomy with placement of an open-loop, flesible
anterior chamber lens. Ophthalmology 1998;
105(6):1011-1014.
Nishi, O: Prevention of posterior capsule opacification after cataract surgery: theoretical and practical solutions. Atlas of Cataract Surgery, Edited
by Masket S. & Crandall AS, published by Martin
Dunitz Ltd., 1999, 24:205-212.
Smiddy WE: Modification of scleral suture fixation technique for dislocated posterior chamber
intraocular lens implants [letter]. Arch Ophthalmol
1998 Jul; 116(7):967.
Smiddy WE, Ibanez GV, Alfonso E, et al: Surgical
management of dislocated intraocular lenses. J
Cataract Refract Surg 1995 Jan; 21(1):64-69.
Wilkinson CP: Pseudophakic retinal detachments.
Retina 1985; 5:1-4.
Nishi, O: Removal of lens epithelial cells by ultrasound in endocapsular cataract surgery. Ophthalmic
Surg. 1987; 18:577-80.
Nishi O, Nishi K, Fujiwara T, Shirasawa E: Effects
of diclofenac sodium and indomethacin on proliferation and collagen synthesis of lens epithelial
cells in vitro. J Cataract Refract Surg 1995;
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
after cataract surgery: a prospective evaluation of
predictability and effectiveness. Ophthalmology,
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Powe NR, Schein OD, Gieser SC, et al: Synthesis
of the literature on visual acuity and complications
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Team. Arch Ophthalmol. 1994; 112:239-252.
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

in depth how to evaluate the patient preoperatively (Chapter 2), how to calculate the
correct IOL power in standard and complex
cases (Chapter 3), prevent major complications such as infection (Chapter 4), and how
to proceed with the operation by using
adequate, modern anesthesia and to make the
operating room efficient (Chapter 5). Why
phacoemulsification is so important (Chapter
6), how to make the transition from ECCE to
phacoemulsification with minimum risk to
the patient while minimizing mental and
emotional trauma to the surgeon (Chapter 7),
what are the best instruments and equipments
to use in phacoemulsification (Chapter 8), are
all essential experiences and information for
the modern cataract surgeon. In addition, you
may also find the state of the art phacoemulsification techniques and facilitate your
understanding of each group of procedures so
that you can establish a basis for your own
selection of the procedure that will lead you
to master phacoemulsification (Chapters 9
and 10). Finally, a discussion of the most
important complications you may encounter
in phacoemulsification and in planned
extracapsulars and how to manage them successfully is presented in Chapter 11.
Aims of this Chapter

Based on the tools and concepts provided in Chapters 1-11, in this Chapter we
carefully consider, in depth, powerful techniques available today which allow the use of
phacoemulsification in the management of
complex, and more challenging cases.
Broadening of Indications
As emphasized by Miguel Angelo
Padilha, M.D., F.B.C.S., one of Brazils
most prestigious anterior segment surgeons,
the progressive mastering of phacoemulsification (Chapter 9) by an increasing number of
surgeons in various parts of the world allows
indications for this procedure to broaden rapidly extending to the complex cases that were
previously considered a contraindication to
phaco. Patients with very hard cataracts,
classified as rock hard cataracts, eyes with
shallow anterior chamber, pseudoexfoliation,
subluxated cataracts, cornea guttata, corneal
dystrophies, corneal transparency alterations,
as well as small pupils, were previously considered contraindications to the use of this
technique.
295
In this chapter, we intend to provide the

cataract surgeon with practical clinical
observations, strategies and surgical
techniques leading to safe and efficient
management of cataract surgery in special
situations that we refer to as the Complex
Cases. Although much of the focus is on
phacoemulsification, many of the approaches
to complex cases here presented are also
applicable to manual extracapsular.
Complex Cases Already Discussed in

Previous Chapters
viscoelastics years ago as his third assistant. Viscoelastics are very important for
cataract surgery, whether in routine or complex cases. Their main uses are for maintaining the anterior chamber depth, protecting the
endothelium, as aids during capsulorhexis,
hydrodissection, phacoemulsification, with
I/A, maintaining the capsular bag fully open
a intraocular lens during insertion, unfolding,
and positioning of the IOL.
They have a special place in this chapter because their adequate use has become
even more valuable and indispensable in the
management of complex cases.
They are: 1) Cataract surgery in

patients with diabetic retinopathy (pages
21-27, Figs. 8-18).
2) In age-related
macular degeneration (pages 28-29, Figs.
19-20). 3) In the presence of retinal breaks
(pages 28-30, Fig. 21). 4) In uveitis (pages
31,33, Fig. 22). 5) In adult strabismus with
partial amblyopia (page 33). 6) Determining
IOL power in complex cases (pages 48-58,
Figs. 24-32).
Cohesive and Dispersive

Viscoelastics
FOCUSING ON THE
MAIN COMPLEX
CASES
The Cohesive VES Specific Properties
THE DIFFERENT TYPES OF

VISCOELASTICS
Their Specific Roles
For years we have generally referred to
viscoelastics (VES) as highly valuable protective and space-maintaining substances.
Joaquin Barraquer, M.D., referred to
296
In the past few years, industry has

refined viscoelastics, and made their properties more specific so that we now have available two main groups, each type better than
the other for specific functions. As clarified
by Buratto, these groups are: 1) cohesive,
2) dispersive.
The better known cohesives are those

with high viscosity, such as Healon GV,
Healon, Provisc, Amvisc Plus, Amvisc, and
Biolon. They are very useful in creating
space and stabilizing the tissues, increasing
mydriasis, supporting the nucleus during
capsulorhexis, deepening the anterior chamber, separating synechiae, opening the capsular bag and maintaining this space during
implantation of the IOL.
The cohesive viscoelastics maintain
space really well because the molecules hold
themselves together. They are also quite easy
C h a p t e r 12:
to remove. If you are trying to create a space

such as when opening the capsular bag, or
deepening the anterior chamber, then the cohesive viscoelastics are going to work better.
each particular case. Each surgeon must be

sufficiently trained to choose the most appropriate substance for the individual patient and
the specific technique.
The Dispersive VESSpecific Properties
PHACOEMULSIFICATION
AFTER PREVIOUS
REFRACTIVE SURGERY
The dispersive VES are those with

lower viscosity and lower cohesiveness.
They break up easily when injected into the
eye and therefore disperse in small fragments. This group includes Viscoat (Alcon),
Vitrax (Allergan) and the methylcellulose
products. These substances form a layer that
will adhere and coat the posterior surface of
the cornea to protect the endothelium during
phacoemulsification, or from other instrumentation during manual ECCE. They help in
capturing nuclear fragments. They are also
valuable if the phacoemulsification tip accidentally catches the iris, in zonular disinsertion and rupture of the posterior capsule.
The dispersive viscoelastics are excellent coaters. If you aim to reduce the
friction between the intraocular lens optic and
the injector, so you are less likely to tear the
intraocular lens, Lindstrom uses a dispersive
viscoelastic. Or, if you are operating on an
eye with a dry or somewhat opaque surface,
placing a few drops of the dispersive viscoelastic on the surface clears the view significantly. If you tear the posterior capsule,
but have not lost vitreous yet, if you again
inject a dispersive viscoelastic, it can stay in
the eye over the tear and the capsule, to hold
vitreous back and protect the capsule while
you carefully remove the nuclear remnants or
a little cortex. That can be very helpful.
But the dispersives are a little more
difficult to remove and they do not maintain
space as well. Consequently, the choice of
VES varies with the surgical requirements of
The primary challenge in operating on

patients who have already had radial keratotomy (RK) or excimer laser surgery is selection of the appropriate lens power. As the
corneal curvature is altered, the usual predictive formulas have also been altered. Standard ultrasound A-scan technology and corneal curvature are still used to estimate the
appropriate lens implant for reaching the target refraction. In addition, if the fellow eye
has not had refractive surgery, that eye is also
measured.
We have already discussed this subject
in practical and specific terms for the clinician in pages 50-54 and presented the methods and formulas most often used. Since
there is no universally accepted formula to
calculate these patients IOL power accurately, we present here the method used by a
master cataract surgeon to solve this problem.
Jack Dodick, M.D., has found the
following procedure quite effective. He implants a specifically designated lens under
topical anesthesia with sutureless clear corneal wound. Following the operation, the
patient is taken to an autorefractor just minutes after surgery. If there is a high ametropia
present, the patient returns to the table, the
eye is again prepped, the lens is removed and
replaced with one of the appropriate power. In
patients with high myopia, for example, the
surgeons best judgment about lens implant
power can be considerably off target because
297
of untoward circumstances like a staphyloma.

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

Myopia
Phacoemulsification in patients
with high myopia presents additional challenges. Patients with high myopia have
globes which are elongated (green arrows)
and have thinner sclera. As the phacoemulsification 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
C h a p t e r 12:
high vacuum to bring the nucleus up into the

pupillary plane earlier than with a normal or
emmetropic eye. Phaco chop helps further by
cutting the nucleus in several pieces and
bringing these pieces up into the pupillary
plane with high vacuum.
The challenges in calculating the correct IOL power in high myopia are discussed
on page 50.
CHALLENGES OF
PHACOEMULSIFICATION
IN HYPEROPIA
The challenge in hyperopia is somewhat different. Dodick refers to these as
crowded eyes because all of the small anatomical structures are in a smaller, confined
space. Positive pressure is more likely to
occur. Dodick makes two fundamental adjustments in technique when dealing with an
extremely hyperopic eye. First, he dehydrates
the vitreous with an osmotic agent such as
Mannitol. Secondly, he tries to compress the
eye and to express some of the unbound
water in the vitreous with a compressive
device like an Honan balloon (Fig. 96). He
leaves this Honan balloon on at about 35 to
40 mm Hg for 20 to 30 minutes. These two
preparatory steps help reduce the volume of
the eye and soften the eye prior to nucleus
removal.
The challenges in calculating the correct IOL power in high hyperopia are presented on page 48. The pros and cons of
piggyback lenses in very high hyperopia are
discussed on page 49.
REFRACTIVE CATARACT
SURGERY
Why and When Do Refractive
Cataract Surgery
Richard Lindstrom, M.D. has become an advocate of what he calls refractive
cataract surgery, by which we mean trying
to improve the patients astigmatism at the
time of cataract surgery.
In his extensive research and clinical
experience, about 70% of the cataract patients
that he operates have less than one diopter of
astigmatism preoperatively and about 30%
have more than one. He does not make any
astigmatic corrections in those that have less
than one diopter. That is good enough for
20/30 uncorrected visual acuity. Lindstrom
becomes somewhat more aggressive with
astigmatism when there are two diopters or
more before the cataract operation. His goal
is to reduce it to one diopter; not to try to
correct it all, just to get it down into a
reasonable range. He advises making the
combined operation for cataract and astigmatism only when performing phacoemulsification.
As a matter of fact, he advises against
it if the phacoemulsification incision, is
enlarged to place a 6.5 or 7 millimeter optic
PMMA IOL or when a planned ECCE is
performed. In such cases, he recommends,
doing the cataract surgery, see what you get,
and then fix it later if there is a problem.
Most patients adapt to glasses. This is be-
299
cause with an incision of this size, it is almost

impossible to plan the refractive operation.
The range of effect on astigmatism with such
incisions is significant. With a planned extracapsular wound one patient might change a
diopter and another might change four diopters.
TECHNIQUE FOR
REFRACTIVE CATARACT
SURGERY
Surgical Principles
Lindstroms surgical principles and
technique are as follows:
1) Move the cataract 3 mm tunnel
incision to the steeper meridian (Fig. 170).
He thinks of this small wound as an astigmatic keratotomy. This will reduce the
present astigmatism by 0.50 diopters. If the
patient has 1 diopter of plus cylinder at axis
90, and a 3 mm cataract incision is made at
axis 90, he/she will end up with only a 1/2
diopter of cylinder. If they have +1 diopter at
180 and the 3 mm cataract/IOL incision is
moved over to the temporal side where the
steeper meridian is located, they will end up
with only +1/2 diopter of astigmatism at 180
which is good enough for 20/20 vision uncorrected. Lindstroms approach is to make
them better, not to correct all the astigmatism.
If they have 1.5 diopters, they will end up
with 1 diopter cylinder and that is acceptable.
But if they have 2 diopters to begin with, they
will end up with 1.5 diopters and that is
outside his goal. Lindstroms outcome goal
is 1 diopter astigmatism or less.
2) If more than 1.0 diopter of astigmatism would remain, Lindstrom applies the
300
principles of astigmatic keratotomy at the

time of surgery. He does this very conservatively. The cataract wound becomes one
astigmatic keratotomy. On the opposite side,
at a 7 mm optical zone, he will make a small
2 mm corneal incision to correct 1 diopter or
a 3 mm long incision to correct 2 diopters of
astigmatism in the cataract age group. This
becomes a second astigmatic keratotomy
(Fig. 170).
If the patient preoperatively has 3
diopters of astigmatism, Lindstrom places
the 3 mm cataract/IOL incision again on the
steeper meridian. This brings the astigmatism
down to 2-1/2. If he wants the patient to end
up with 1/2 diopters instead of 2 1/2 diopters
of astigmatism, he makes a small 3 mm, nonperforating corneal incision with a diamond
knife on the opposite side of the cataract
incision at a 7 mm optical zone (Fig. 170).
Surgical Procedure
Lindstrom sets the depth of the diamond blade at 600 microns. In that area on
the average the cornea is about 650 microns
thick so it is a very safe setting so as not to
perforate the cornea. This incision can be
done at the very beginning of the surgery.
The first thing to do is make this little tiny
cut. The other alternative is to complete the
cataract operation, firm up the eye, and make
that tiny cut at the end, but that may be more
difficult.
The exact location of this cut in the
cornea is 3.5 mm from the center of the
cornea. By using a 7 mm optical zone, the
cut is really 3.5 mm from the center of the
cornea. The diameter of the cornea is 12 mm.
The limbus is 6 mm from the center.
C h a p t e r 12:
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
Figure 170 (above)): Technique for Refractive Cataract Surgery
At the 7 mm optical zone (dotted line), a 30

arcuate cut is equivalent to a 2 mm straight cut
(A). At the 7 mm optical zone, a 45 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
arcuate.
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 incision 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 145 (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 cataract 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

instead of arcuate. With this technique he
tries to make things safe and better for the
patient, not perfect, and without doing any
harm. This means trying to bring a patient
from 3.5 diopters of astigmatism down to
one, in order to improve the quality of his/her
vision. He finds that he can enhance the
results to the point now where about 85% to
90% of the patients will have 1 diopter or less
of astigmatism.
Lindstrom finds that these tiny incisions programmed as outlined here are a very
powerful tool and seem to be very safe. He
has not observed any major complications

such as poor wound healing, infection or
perforation.
Full Refractive Correction of

the Cataract Patient
By selecting the correct IOL power
even in complex cases as outlined in pages
45-54, correcting the preexisting astigmatism
as discussed here and further enhancement
with the use of toric foldable IOLs if necessary (see Chapter 9), we have the means to
create in our patients the truly refractive
cataract operation.
CATARACT AND GLAUCOMA

Age related cataract and primary
open-angle glaucoma or chronic angle closure glaucoma often coexist in the older
population. With increasing longevity this is
becoming more prevalent. The management
of such cases has been controversial because
medical or surgical therapy of one condition
often affects the other.
Most of the concepts and techniques
presented in this chapter are based on the
experiences and observations of Maurice H.
Luntz, M.D., Chief of the Glaucoma Service
at the Manhattan Eye and Ear Hospital in
New York.
Overview - Alternative
Approaches
When cataract and glaucoma coexist
but the glaucoma is uncontrolled or poorly
controlled, one approach is to give priority to
control of the glaucoma either with additional medication or if this is not possible,
302
with laser trabeculoplasty or filtration surgery. Luntz believes that this approach has
its drawbacks. Medical therapy for glaucoma
may necessitate miotics, which tend to reduce
visual acuity regardless of preexisting lens
opacities, and may encourage an acceleration
of cataract progression. Surgical therapy of
glaucoma may be associated with increased
lens opacification, especially if the surgery is
complicated by inadvertent lens trauma but
even in the absence of lens trauma. Subsequent cataract extraction, even if a functioning bleb and good drainage are obtained,
results in loss of the bleb in approximately
10% of eyes, and inability to restore control
of the glaucoma.
When the indications for cataract extraction are present but the glaucoma is controlled medically, the most common approach
has been to remove the cataract and continue
medical management of the glaucoma. Intraocular pressure is more easily controlled in
some eyes after lens extraction but a significant number of these patients will require
C h a p t e r 12:
glaucoma surgery as early as 3-6 months after

standard cataract extraction . The patient then
faces a second surgical procedure with its
attendant risks soon after the first operation.
An alternative approach is combined
cataract and glaucoma surgery. Most surgeons are now oriented toward this approach.
Excellent results are reported with extracapsular cataract extraction and trabeculectomy
(Luntz and Stein, 1988; Simmons, 1992) and
phacoemulsification with trabeculectomy.
The combined procedure is used in those
patients in whom IOP runs above the upper
limit of the target IOP for that patient, or in
whom good control of IOP necessitates the
use of three or more different drugs. In those
patients in whom IOP is well controlled using
no more than two different drugs, phacoemulsification alone will generally maintain adequate postoperative control.
COMBINED
CATARACT
SURGERY AND
TRABECULECTOMY
In this chapter, we will first present
the evolution of the different types of Combined Procedures for Cataract Extraction and
Trabeculectomy as described by Luntz, to
provide you with an instant mental picture of
the different approaches to this problem, the
latest being combining phacoemulsification
with a tunnel incision and trabeculectomy.
Considering that this Volume covers all major, widely accepted cataract surgery procedures, we present the advanced techniques in
combined surgery for glaucoma with phacoemulsification as well as with planned extracapsular. The evolution of the different
types of combined cataract extraction-trabeculectomy is presented in Figs. 172, 173,
174, 175, the combined extracapsular extraction with trabeculectomy step by step in
Figs. 176 through 181, and phacoemulsification combined with trabeculectomy step by
step in Figs. 182 through 187.
Indications
The indications based on Luntzs observations are: 1) Any eye with open angle
glaucoma and cataract in which surgery is
required for the cataract, even if the glaucoma
can be medically controlled but requires more
than two medications to do so. If combined
surgery is not done, many of these eyes will
require glaucoma surgery at a later date,
exposing the patient to two surgical procedures where one would have sufficed. An
exception to this are those patients in whom
IOP with three medications runs in the very
low teens (10-11mm Hg).
2) Eyes with uncontrolled glaucoma
requiring glaucoma surgery and significant
cataract with corrected vision of 20/40 or less,
reading 6-pt. print or less or with poor glare
tolerance.
Evolution of the Incision for

Combined Cataract Extraction
and Trabeculectomy
The combined operation for cataract
and glaucoma constitutes two procedures performed at the same surgical session. The
technique for each procedure remains unchanged but the surgical incision needs to be
modified using either separate incisions for
each procedure (Fig. 172) or combining the
incisions for each operation into one compound incision (Figs. 173, 174, 175).
303
A. Extracapsular Cataract
Extraction with Trabeculectomy
1. Separate Incisions
The cataract and trabeculectomy incisions are made separately at different sites.
The cataract incision is made in the cornea and
is a single 11 mm chord length corneal cataract
incision. A 3 mm x 3 mm lamellar scleral
trabeculectomy flap is made separately in the
upper nasal quadrant in the sclera under fornix
or limbus based conjunctival flap (Fig. 172).
This approach has the disadvantage that it
necessitates a corneal cataract wound for
extracapsular surgery. This type of incision is
no longer popular because of its tendency
toward higher levels of astigmatism in the
early postoperative phase before the corneal
sutures are removed. This approach is a good
technique for those surgeons using a small
corneal incision for phacoemulsification combined with trabeculectomy (Fig. 187).
2. Compound Incision
By the term compound incision we mean
that the surgeon combines a limbal 2-plane
cataract incision of 9.5 mm or 10 mm chord
length with a 3 mm x 3 mm 1/2 thickness
lamellar scleral flap for the trabeculectomy
(Fig. 173). Luntz prefers to place a trabeculectomy flap in the center of the cataract
incision and this is a generally favored technique (Fig. 173). When the trabeculectomy
flap is placed in the center of the cataract
incision and the cornea-scleral trabeculectomy
block measuring (2 mm x 2 mm) is removed
from the scleral bed before removing the
cataract, the total surface area of the cataract
incision is increased at the site of maximum
thickness of the lens during extraction for
304
intracapsular surgery or of a nuclear extraction for extracapsular surgery, thus facilitating their removal. This allows the use of an
incision of smaller cord length - namely, 9.5
mm instead of the usual 11 mm chord length
(Fig. 173).
Luntz points out that a matter of
great importance in the architecture of this
compound incision is that the continuity of
the limbal scleral incision for the cataract
removal is broken in the center by the intrusion of the trabeculectomy flap with its two
radial incisions which are placed 3 mm apart.
By breaking the continuity of the limbal
scleral incision (the cataract portion of the
incision) we introduce an element of instability into the incision. Part of the incision is
parallel to the limbus (the cataract incision)
and part of the incision is radial to the limbus
(the trabeculectomy incision). Where the two
meet at each side of the trabeculectomy
scleral flap the incision, when stressed postoperatively (for example by squeezing of the
eyelid or distortion of the globe) they can
shift horizontally, vertically or obliquely,
causing postoperative oblique or against the
rule astigmatism. The ability of the incision
to shift vertically is magnified if the cataract
and trabeculectomy incisions meet at the limbus at a 90 angle. To minimize this effect,
Luntz recommends that the cataract incision
should be curved into the trabeculectomy
incision forming a convex curve on each side
of the cataract trabeculectomy incision junction (Fig. 173). This curving of the incision
reduces any tendency for vertical shift. This
can be enhanced by careful attention to placement of the interrupted sutures at the time of
suturing the incision. Additional stability is
imparted to the incision by placing the interrupted 10-0 nylon sutures radially in the
cataract portion of the incision, and by placing the sutures in the curved junction between
C h a p t e r 12:
Figure 172 A (left): Evolution of Types of

Combined Cataract Extraction-Trabeculectomy Surgery - Type 1- Individual Surgical
Sites - Surgeons 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 technique at the limbus. Note separate 3 mm by 3
mm scleral flap (F) and 2 mm by 2 mm trabeculectomy window (W). Iridectomy (I). Limbus based conjunctival flap.
Figure 172 B (right): Evolution of

Types of Combined Cataract Extraction-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 procedure when using two individual surgical sites. Note the scleral trabeculectomy flap (F) separate from corneal cataract incision (C). Trabeculectomy window (W). Iridectomy (I). Limbus based
conjunctival flap.
305
the cataract and trabeculectomy portions at

45 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 cataract 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 incision (Figs. 174, 175).
Figure 173 A (above) : Evolution of Types of

Combined Cataract Extraction-Trabeculectomy
- Type 2- Combined Incision - Surgeons View
A combination of the cataract extraction
and trabeculectomy incisions is seen in this
surgeons 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 Combined Cataract Extraction-Trabeculectomy - Type 2Combined Incision - Cross Section View
This cross section view allows prompt identification 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
C h a p t e r 12:
Figure 174 A (left): Evolution of Types of

Combined Extracapsular Cataract Extraction-Trabeculectomy - Type 3- Single, Unbroken Tunnel Incision - Surgeons View
Development of the scleral tunnel incision for phacoemulsification has simplified the
incision for combined extracapsular cataract extraction 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, penetrating 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 performed under this scleral flap, contained within
the scleral bed. Iridectomy (I) shown in Fig. 174B. Fornix based conjunctival flap.
Figure 174 B (right): Evolution of Types of

Combined Extracapsular Cataract ExtractionTrabeculectomy - 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 cataracttrabeculectomy into a single,

unbroken incision
Instead of making the cataract portion of the incision at the limbus, the cataract
incision is moved posteriorly to a position
1.5 mm or 2 mm posterior and parallel to the
limbus. This is the preferred incision for
extracapsular cataract surgery with trabeculectomy (Fig. 174).
A trabeculectomy block of 2 mm
x 2 mm can be excised out of this scleralcorneal bevel (Figs. 179, 180) without the
necessity of cutting a separate trabeculectomy
flap in the sclera (Fig. 173). The end result is
a trabeculectomy block dissected within the
scleral cataract incision which is a simple,
unbroken incision (Fig. 180) adding significantly to the stability of the scleral incision
and reducing the amount of postoperative
astigmatism.
B. Phacoemulsification with
Trabeculectomy
This is presently the preferred technique for those with experience in phacoemulsification surgery. It results in the
least level of postoperative astigmatism and
rapid visual rehabilitation.
The most popular incision is similar
to the one shown in Fig. 177 except that the
pocket incision is made to a chord length
between 3.1 mm and 6 mm rather than the
10 mm chord length incision used for extracapsular extraction. The chord length of this
incision will depend on the size and type of
intraocular lens used. Thus, for a foldable
silicone or acrylic IOL, a 3.5 or 4 mm chord
length will be used; whereas, for a PMMA
308
lens a 5.5 or 6 mm chord length incision

would be used.
The trabeculectomy block is removed
from the scleral bevel within the incision as
described previously in Figs. 179, 180. (For
details of the surgical technique see Phacoemulsification Cataract Incision with Trabeculectomy later in this chapter, Figs. 182,
187.
Intraocular Lens Implants

Luntz considers that the indications
for implanting an intraocular lens are the
same in glaucoma patients as in non-glaucoma patients. The posterior chamber intraocular lens is preferable. Anterior chamber
lenses (Kelman-Multiflex - Editor) have been
successfully used where a posterior chamber
lens cannot be safely used, for example,
where the anterior and posterior capsule have
been extensively torn and will not support a
posterior chamber intraocular lens in the bag
or in the sulcus. (This subject is discussed in
detail in pages 118-123 - Editor).
Preoperative Preparation
Pilocarpine drops should be stopped
24-48 hours before surgery in order to facilitate pupillary dilatation at the time of surgery.
If preoperative intraocular pressure is high it
should be reduced prior to surgery with intravenous Mannitol (1.5 g./kg. body weight) or
with oral glycerine 75 cc. Topical steroids
(Prednisolone 1% q.i.d.) and topical nonsteroidal antiinflammatory drops are given 24hours before surgery and continued for 1 to 2
weeks after surgery. This reduces postoperative inflammation and may diminish the incidence of cystoid macular edema.
C h a p t e r 12:
Figure 175 A (right): Evolution of Types of Combined 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-Trabeculectomy - Type 4 - Tunnel Incision
for Phacoemulsification and Trabeculectomy - 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 surgeons view in
Fig. 175 A.
309
SURGICAL TECHNIQUES
STEP BY STEP
The following is a summary of the
two main procedures step-by-step as recommended by Luntz.
ECCE and Trabeculectomy

With Single, Unbroken Tunnel
Incision
Conjunctival - Tenons Flap
(Fornix-based) (5x-7x Magnification)
If Mitomycin is to be used Luntz
prefers to apply it to the conjunctival surface
before raising the conjunctival-Tenons flap
(see section on antimetabolites further in this
chapter).
A superior rectus bridal suture is optional. The fornix-based conjunctival-Tenons
flap with a 12 mm cord length is raised at the
superior limbus. The flap is dissected posteriorly to further expose the sclera. Adequate
hemostasis and clearing of the sclera is obtained.
Luntz considers that the fornix-based
conjunctival flap has many advantages compared to a limbus-based flap:
1) There is better exposure and visualization of the operative field.
2) The possibility of damaging the
conjunctival flap during dissection, particularly producing a buttonhole is eliminated.
3) A fornix-based flap is technically
easier to dissect than a limbus-based flap,
especially when operating in an area of
scarred conjunctiva, either from previous surgery or trauma. It also offers better exposure
of the surgical area.
310
4) The fornix-based conjunctiva flap

adheres and scars at the limbus. As a result,
the bleb forms posteriorly producing a diffuse, well-vascularized low-profile bleb
well behind the limbus. There is less possibility of developing a thin high-profile
avascular anterior bleb which overhangs the
cornea, which has the added risk of microscopic perforations of hypoxic conjunctiva
and possible intraocular infection.
5) The posteriorly situated bleb and
the scar at the limbus allow safe and early
contact lens fitting if a contact lens is required.
6) Tenons fascia is minimally traumatized.
Scleral-Corneal Incision
(7x-10x Magnification)
A 1/2-thickness scleral groove is cut
in the exposed sclera using a diamond knife
blade or a crescent knife blade 1.5 mm posterior to the surgical limbus, extending for 9.5
to 10 mm cord length parallel to the limbus
(Fig. 176). At the center point of the incision
(12:00 oclock position) a crescent knife
blade is used to dissect a scleral tunnel just
anterior to the corneal vascular arcade which
is then dissected to each side across the cord
length of the incision (Fig. 176). A 3.1 mm
keratome is introduced into the tunnel at 12
oclock and advanced to the anterior limit of
the tunnel in the cornea (Fig. 176). Pressing
the point of the keratome downward toward
the iris, the keratome is advanced and penetrates the cornea into the anterior chamber
with the tip of the keratome 45 to the iris
plane (Fig. 177). At this point, the direction
of the keratome tip is changed to run parallel
to the iris surface and the keratome is advanced fully into the anterior chamber to
C h a p t e r 12:
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 oclock and 3:00 oclock meridians.
Figure 177 (below): Combined Extracapsular Cataract Extraction - Trabeculectomy Procedure With Single, Unbroken
Tunnel Incision - Step 3
Figure 176 (above): Combined Extracapsular

Cataract Extraction - Trabeculectomy Procedure With Single, Unbroken Tunnel Incision
- Steps 1 and 2
A 3.1 mm keratome (K) is introduced

into the tunnel at the 12 oclock 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 advanced into the anterior camber (inset -2 ) to
complete the 3.1 mm incision. The keratome
is removed and the anterior chamber is filled
with viscoelastic.
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 oclock position), a crescent 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
(10x Magnification)
incision into the anterior chamber with a 1.5 2 mm wide scleral-corneal bevel (Fig. 174).
A 27-gauge needle with the tip bent to

90 is introduced into the anterior chamber
and a can-opener capsulotomy or preferably
a large capsulorhexis, depending on the
surgeons preference is performed.
Trabeculectomy
(10x Magnification)
Completion of Sclero-Corneal
Incision (10x Magnification)
The scleral flap is lifted and microsurgical corneal-scleral scissors are introduced
into the scleral-corneal incision cutting to the
left and right, completing the incision into the
anterior chamber for the entire cord length of
the original scleral groove (Fig. 178). The
final result is a 9.5 to 10 mm cord length
The anterior chamber is filled with

viscoelastic . A 2 mm x 2 mm block of tissue
is excised from the scleral-corneal bevel at
the 12:00 oclock position using a LuntzDodick microsurgical punch (Katena). The
posterior limit of the excised scleral-corneal
block reaches to the scleral spur (Figs. 179,
180).
The trabeculectomy opening located in
the center of the scleral-corneal incision reduces resistance of the scleral bevel to passage of the lens nucleus from the eye and
facilitates its removal.
Figure 178: Combined Extracapsular Cataract Extraction - 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 introduced 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
C h a p t e r 12:
Figure 179 (left): Combined Extracapsular

Cataract Extraction - Trabeculectomy Procedure - 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 oclock 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 Extracapsular Cataract Extraction - Trabeculectomy

Procedure - Step 6
This surgeons 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 surgeon then performs an extracapsular cataract
extraction and IOL insertion using his/her preferred technique. A peripheral iridectomy
under the trabeculectomy is essential.
313
Figure 181: Combined Extracapsular Cataract

Extraction - Trabeculectomy Procedure - Step 7
This surgeons 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

and Cortex. Insertion of IOL
The surgeon proceeds with extracapsular cataract extraction and insertion of an IOL
using his/her preferred technique.
midway across the iris from the right side

with a Vannas or DeWecker scissors, and then
moving the iris to the right and completing
the iridectomy cut.
Closure of the Cataract-Trabeculectomy Incision (5x Magnification)
Iridectomy (10x Magnification)

Following insertion of the IOL a peripheral iridectomy is made within the trabeculectomy opening ensuring that the base of
the iridectomy is wider than the trabeculectomy opening (Fig. 173-A). This is achieved
by grasping the iris near its root at the center
of the trabeculectomy opening, bringing it out
of the eye and moving to the left, cutting
314
Closure is achieved using interrupted

10-0 nylon sutures, one interrupted suture on
either side of the trabeculectomy opening
leaving the trabeculectomy opening and adjacent scleral bevel unsutured (Fig. 181). The
interrupted sutures are placed through the
full thickness of the scleral flap at the limbus
and through the posterior scleral incision
(Fig. 181). The sutures are not tightly tied,
C h a p t e r 12:
but tied to achieve tissue apposition without

crimping the scleral flap and are buried
in the sclera. It is desirable to inflate the
anterior chamber with balanced salt solution
to achieve a good positive intraocular pressure before tying these sutures.
An alternative is to use one horizontal
suture through the scleral flap and scleralcorneal bevel on either side of the trabeculectomy opening.
Closure of the Conjunctivo-Tenons

Flap (5X Magnification)
An uninterrupted 10-0 nylon suture
running from the limbal sclera to conjunctiva
closes the conjunctival incision. These sutures should be tightly tied, particularly if an
antimetabolite is used.
Phacoemulsification With
Trabeculectomy
This procedure is shown in Figs. 182
through 187.
Conjunctivo-Tenons Flap
A 6 mm fornix-based flap is raised in
the same way as described previously for the
combined extracapsular extraction and trabeculectomy. Luntz technique when using
antimetabolites is that if mitomycin is to be
used it is applied before raising the conjunctival flap.
Scleral-Corneal
Magnification)
Incision
(7x-10x
Luntz performs a 1/2-thickness vertical

scleral groove, 5.5 mm or 6.0 mm cord
length, depending on the diameter of the IOL
to be used, or 3.5 mm cord length if a foldable
IOL is used, which is cut in the exposed
sclera in the superior half of the globe,
1.5 mm posterior to the limbus using a crescent blade or diamond blade (Fig.182). The
crescent knife then dissects under the anterior
lip of the groove to within the corneal vascular arcade extending the dissection on either
side to the limits of the incision (Fig. 182).
Using a Superblade, a paracentesis incision is made at the 9:00 oclock and 3:00
oclock meridians.
A 2.5 mm keratome is inserted into the
scleral-corneal incision at the 12:00 oclock
meridian advancing the keratome to the edge
of the incision just anterior to the corneal
vascular arcade (Fig. 183). The tip of the
keratome is pushed toward the anterior
chamber, it is withdrawn slightly and the
anterior chamber is penetrated with the
keratome tip 45 to the iris plane. At this
point, the keratome tip is raised so that the
keratome advances fully into the anterior
chamber parallel to the iris plane producing a
2.5 mm tunnel incision (Figs. 183, 177
Insets).
315
Figure 182 (left): Combined Phacoemulsification Cataract Extraction - Trabeculectomy Procedure - Steps 1 and 2
A 6mm cord length fornix based conjunctival 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 oclock position), a crescent 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).
Figure 183 (right): Combined Phacoemulsification Cataract Extraction - Trabeculectomy

Procedure - Step 3
A 2.5mm keratome (K) is introduced into
the tunnel at the 12 oclock 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 chamber. 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
C h a p t e r 12:
Corneal Tunnel Incision and

Separate Trabeculectomy
For cataract and glaucoma surgery the
3.0 - 3.5 mm tunnel intracorneal incision
placed in the temporal cornea can be used
with a trabeculectomy performed separately
and superiorly (Fig. 187).
Capsulorhexis, Phacoemulsification, Nucleofractis, Infusion/ Aspiration and IOL Insertion (10x-15x

Magnification)
Using the scleral corneal tunnel incision (Fig. 184), the surgeon performs the
above procedures according to his/her preferred method.
Trabeculectomy is not performed prior

to lens removal in order to maintain a watertight tunnel incision for the phacoemulsification.
The 2.5 mm tunnel incision is enlarged
to a 6 mm incision for insertion of a 6 mm
IOL. If a 5 mm IOL is used, a 5 mm incision
is made; and if a foldable lens is used the
incision can be reduced to 3.5 mm.
Trabeculectomy (10x-15x
Magnification)
Following insertion of the IOL the anterior chamber is filled with viscoelastic and a
trabeculectomy is made within the scleral
bevel of the tunnel incision using the same
technique as described in Figs. 175 and 179.
The next step is an iridectomy insuring that
the iridectomy base is wider than the trabeculectomy opening, as previously described
(Fig. 184).
Figure 184: Combined Phacoemulsification

Cataract Extraction - Trabeculectomy Procedure - Step 4
This figure shows the final configuration of the
combined Phacoemulsification Cataract Extraction - 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

(5x Magnification)
An interrupted 10-0 nylon suture is
placed through the scleral incision on either
side of the trabeculectomy as described in
Fig. 185. The trabeculectomy and adjoining
scleral-corneal bevel is left open without sutures. The knots should be buried. The
scleral flap can also be left unsutured but
Luntz has found a high incidence of postoperative bleeding and hyphema in these eyes.
The 3.5mm incision or the 6 mm scleral flap
are left unsutured only if the surgeon anticipates that freer drainage of aqueous through
the trabeculectomy opening will be required
early in the postoperative period. However,
the disadvantage of an unsutured scleral flap,
particularly the 6 mm scleral flap, is that the
anterior chamber may be shallow or flat in the
immediate postoperative period. To overcome
this problem, one or two releasable 10-0
nylon sutures should be used (Figs. 186 A-B).
These have the advantage that the anterior
chamber is very unlikely to shallow postoperatively, because the scleral incision is partially sutured, and, at the same time, the
sutures can be easily removed in the postoperative period if and when more drainage
through the filtering procedure is required.
The releasable sutures are placed as follows:
the 10-0 nylon suture (Luntz prefers a CU-5
needle) is loaded backwards in the needle
holder. The suture is placed through the
posterior lip of the scleral incision and then
through the anterior lip of the incision (posterior lip of the trabeculectomy flap) and exteriorized through the anterior lip. A second bite
is taken at the limbus and into adjacent cornea
in a radial direction and is exteriorized. A
third bite is then taken at the point where the
suture exits from the cornea, and this bite in
318
the cornea is horizontal to the limbus

(Fig. 186). The free end of this nylon suture
entering into the posterior lip of the scleral
incision is held with tying forceps. Three
throws are made, and the tying forceps then
engages the portion of the suture that is
exteriorized between the anterior lip of the
scleral incision and the limbus. This portion
of the suture is then pulled through the three
loops held in the other tying forceps, and a
bow knot is tightened, apposing the two lips
of the scleral incision. The free end of the
nylon suture from the bow tie is cut, and the
free end of the nylon suture on the cornea is
cut. The radial and horizontal suture in the
cornea eliminates a free end of nylon suture
on the cornea behaving as a windshield wiper.
Two such releasable nylon sutures are placed
in the incision at the same locations as shown
for the interrupted sutures in Fig. 185. (The
above technique is the method described by
Allan E. Kolker, M.D.).
Conjunctival Closure
(5x Magnification)
The conjunctiva is closed with an
uninterrupted 10-0 nylon suture as previously
described.
(Editors Note: in patients with glaucoma and cataract, one of the most difficult
problems to deal with is the management of
the small pupil. This important subject is
discussed separately in this same chapter.)
Antimetabolites in Combined
Procedures
Luntz believes that antimetabolites
should be used routinely in combined cataract
and trabeculectomy as the result is better.
C h a p t e r 12:
Figure 185 (left): Combined Phacoemulsification Cataract Extraction - Trabeculectomy

Procedure - Step 5
This surgeons 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 properly 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 incision (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
Surgeons in general will vary in their
choice of an appropriate antimetabolite depending on the age of the patient and their
own personal experience. For the combined
cataract and trabeculectomy procedure, Luntz
uses mitomycin-C routinely, as the results of
the procedures are better with the use of an
antimetabolite. There is a remote possibility
of teratogenesis and the development of cancer many years following application of this
drug. For this reason, and particularly so in
children, an informed consent is required
before Mitomycin-C is applied.
When using Mitomycin, Luntz preferred technique is to soak a Weck cell sponge
into a solution of 0.4% Mitomycin-C. The
soaked Weck cell sponge is placed on the
conjunctival surface at the site selected for
surgery. It is held on the conjunctiva for oneminute and then replaced with a freshly
soaked Weck cell sponge for a further oneminute, and this is repeated a third or fourth
time giving a total application time of three or
four minutes. Following this, the conjunctival surface is vigorously lavaged with balanced salt solution to remove all traces of the
drug.
Some surgeons have used a topical
application of 5-FU intraoperatively with a
Weck cell sponge soaked in the drug,
similar to the way Mitomycin-C is used.
The effectiveness of this method is still
undecided.
320
Results of Combined Cataract

Surgery and Trabeculectomy
In Luntz experience, the results of
combined cataract surgery and trabeculectomy have been consistently good. In a study
combining extracapsular cataract extraction
with posterior chamber intraocular lens implant and trabeculectomy, 38 eyes were followed for up to 46 months, with a mean of
16.4 months. The average preoperative intraocular pressure was 20.5 mm Hg and the
average postoperative pressure was 14.5 mm
Hg, a statistically significant change. The
mean number of medications preoperatively
was 2.3 and postoperatively at the end of the
follow-up period this had still dropped to a
mean of 1.42.
There was no significant change in the
visual field graded from the preoperative to
the postoperative level.
Visual acuity,
which averaged 20/120 preoperatively,
improved to an average of 20/50
postoperatively.
Simmons et al (1992), have also reported good results with few complications
using extracapsular cataract extraction with
posterior chamber intraocular lens and trabeculectomy (as well as phacoemulsification
and trabeculectomy -Editor).
In Luntz studies, the complications
associated with combined ECCE and trabeculectomy (and (phacoemulsification and
trabeculectomy) were surprisingly few and of
no greater severity than would have been
C h a p t e r 12:
expected from the cataract surgery or the

glaucoma surgery alone. Intraoperative complications specific to the combined operation
were not observed. The complications that
were seen were similar to those associated
with a trabeculectomy or extracapsular cataract extraction alone.
Immediate postoperative problems
consisted of corneal edema of mild degree
which rapidly resolved, and iritis which
caused no long-term problems. Contrary to
what was anticipated, the performance of a
radial iridectomy and its repair by suturing
the iris when this procedure was chosen by
the surgeon did not cause an increase in the
level of postoperative iritis. None of the

patients had shallow or flat anterior chambers
postoperatively, which can be attributed to
good apposition and closure of the cataract
wound.
When using antimetabolites, if a significant leak from the conjunctival wound
does occur this will in most cases require
surgical repair. Surgical repair entails resuturing the incision. In severely affected
eyes, the conjunctiva at the site of the leak
becomes friable and normal conjunctiva is
rotated from the fornix or moved across as a
flap from the adjacent temporal or nasal
conjunctiva.
Figure 187 : An Alternative Technique of Phacoemulsification Using Tunnel Intracorneal

Incision Combined with Separate Trabeculectomy
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
AND IOL IMPLANTATION
IN THE PRESENCE OF
OPAQUE CORNEA
Overview
Most of the concepts and techniques
presented on this subject are based on the
extensive clinical experience and research of
Professor Miguel Angel Padilha, of Brazil.
For many years, a triple procedure involving
a corneal transplant, cataract extraction and
intraocular lens implantation regularly entailed an open sky extracapsular cataract extraction. This technique exposed the open
eye for a long period of time, while the
surgeon performed the anterior capsulotomy,
extraction of the cataract nucleus, aspiration
of the cortical material and the implantation
of the intraocular lens. Only then is the
donors cornea placed and adequately sutured. During this period, the eye is subjected
to considerable risk, including the greatly
feared complication of expulsive hemorrhage.
Padilhas Timing and Technique

When the cornea is opaque to the
extent of preventing visualization of the anterior chamber, no other alternative is left than
to proceed with the surgical timing and steps
322
described above: a corneal trephining first,

followed by open sky extracapsular extraction, intraocular lens implantation and suturing the donor cornea to the recipients cornea
to complete the operation.
If the cornea is reasonably transparent, allowing the surgeon to visualize the
structures of the anterior chamber (Fig. 188)
Padilhas procedure of choice is removal of
the cataract by phacoemulsification first
which is a pressurized, much safer system,
continued by IOL implantation and last, completing the penetrating graft, as first recommended by Enrique Malbran, M.D., from
Argentina in 1995.
Step 1: Incomplete trephining of the
moderately opaque cornea reaching half
depth (Fig. 188). Step 2: Viscoelastic is
injected into the anterior chamber through a
side port incision. A Valvulated self-sealing
scleral tunnel incision 2 mm posterior to the
limbus, is performed, as shown in Fig. 40-B.
Step 3: CCC with a bent needle used as a
cystotome and long Kelman-McPherson forceps, preceded by injection of viscoelastic
(Figs. 97, 44, 45). Step 4: The remaining
phases of phacoemulsification are completed
in a routine way, followed by the implantation
of an PMMA or foldable intraocular lens,
depending on the experience of the surgeon
(Fig. 189). A miotic agent is injected
intracamerally. Step 5: Padilha checks the
hermetic closure of the sclero-corneal tunnel.
The wound may or may not be closed with a
horizontal suture depending on how sure the
C h a p t e r 12:
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 scleralcorneal tunnel incision, a valvulated self-sealing 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 anterior chamber is again filled with viscoelastic. The next step is the implantation of a PMMA or a foldable intraocular lens (L), depending on the preference
of the surgeon. Tunnel incision (W).
323
surgeon is of its complete sealing. He proceeds with the removal of the opaque corneal
button using a disposable Beaver knife and
Castroviejos scissors (Fig. 190). The surgeon completes the procedure by bringing
together the edges of the donor and recipient
corneas, using 16 interrupted 10.0 nylon
monofilament sutures. This approach undoubtedly reduces the long period of time
during which the eye remains exposed, thus
making surgery much safer.
Specific Recommendations
1) Padilha strongly recommends that
the phaco procedure not be done using a clear
cornea incision. Complications or difficulties
may arise at the time of performing the
penetrating graft. Consequently, use the
sclero-corneal tunnel incision shown in Fig.
40-B.
2) The technique of phacoemulsification must be endocapsular, within the capsular bag, using the surgeons procedure of
choice for management and disassembling
the nucleus. This is with the purpose of
preventing additional damage to the corneal
endothelium. If necessary, the nucleus may
be dislocated into the anterior chamber where
it can be removed or into the iris plane
(using Lindstroms iris-plane techniques Figs. 136-139, Chapter 10). But repeatedly
lubricating the cornea with dispersive viscoelastic.
3) If corneal edema deriving from the
corneal disease itself is present and interferes
with visualization of the intraocular maneuvers, the corneal epithelium may be completely removed to facilitate the surgeons
adequate view of surgical maneuvers and
instrumentation. (Editors Note: placing dispersive viscoelastic over the cornea will further 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 proceeds 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
C h a p t e r 12:
PHACOEMULSIFICATION,
IOL IMPLANTATION AND
FUCHS DYSTROPHY
These patients demand a meticulous
preoperative evaluation before cataract surgery. This should not be limited to a good
biomicroscopic examination with the slit
lamp. Specular microscopy and corneal
pachymetry may provide additional information of value to decide if a cataract extraction
is sufficient or if a triple procedure is the most
appropriate. These diagnostic examinations
should be made if the equipment is available.
In the majority of patients, however, a
detailed biomicroscopy may be sufficient to
determine the amount of guttata and the extension of the corneal edema.
Role of Specular
Biomicroscopy and Pachymetry
In performing specular biomicroscopy, counting the endothelial cells is not
sufficient to guarantee that an eye with corneal disease will withstand surgical trauma
without developing further corneal edema,
or even worse, bullous keratopathy in the
future. Analysis of the cell morphology provides important additional information for
predicting the nature of postoperative complications after phacoemulsification or any other
intraocular surgery.
Pachymetry
offers
a
dynamic
evaluation of these same corneas. Repetitive
measures of the thickness of the diseased
cornea may demonstrate how well its fluid
system functions.
If there is considerable corneal edema,

with an endothelial cell count of less than
500/mm2 and a central pachymetry up to 610
micra, the procedure of choice is performing
combined surgery consisting of penetrating
keratoplasty, cataract extraction and IOL
implantation.
Special Precautions During

Phacoemulsification
1) The presence of cornea guttata or
Fuchs dystrophy is not a contraindication to
phacoemulsification, but it does require
additional specific precautions. The surgeon
must significantly decrease turbulence and
maintain the anterior chamber with a
sufficient quantity of BSS and viscoelastic to
prevent contact between the nuclear
fragments and the endothelium, particularly
at the stage of aspiration of cortical remnants.
2) In corneas with Fuchs dystrophy, it
is very important
to use dispersive
viscoelastic for better adherence to and
protection of the diseased endothelium. Be
attentive in case the viscoelastic comes out
through the wound. This makes it necessary
to reintroduce it fairly often during the
surgical procedure. This should be done
through the sideport incision (Fig. 191). The
phaco or the I/A tip should be kept
functioning within the anterior chamber
avoiding its removal and reinsertion back and
forth through the main incision. This could
lead to additional trauma.
3) During phacoemulsification, the
maneuvers should be very delicate, using
techniques that reduce the time and power of
the ultrasound. Padilha considers that the
phaco fracture or divide-and-conquer
techniques, are the most indicated. When
325
emulsifying the last quadrant the surgeon

must prevent fragments from moving into
the anterior chamber and touching the
endothelium (Fig. 192).
The ideal
procedure is to maintain a high vacuum
power (150 mmHg or higher), keeping nucle-
ar fragments attached to the titanium tip and

set in motion the pulse system of the
equipment. If such fragments should move
into the anterior chamber, dispersive
viscoelastic substance should be used to
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, decreasing 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), keeping lens fragments attached to the phaco tip
(P), and use the pulse system of the equipment. If such fragments should tend to
move into the anterior chamber (white arrow), the dispersive viscoelastic (V) should
be once more irrigated into the anterior
chamber to protect the endothelium.
326
C h a p t e r 12:
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,

the first step should be the introduction of a
cohesive viscoelastic (VE)
inside the
capsular bag to maintain the posterior
capsule well distended, especially if a
foldable lens is to be implanted (Fig. 193).
The next step is to lubricate the injector with
dispersive viscoelastic to facilitate the
delivery of the lens from inside the injector
with the bag.
At the end of surgery, the aspiration of

the cohesive VE will be easier and faster than
the dispersive VE. In order to protect the
cornea from any damage, the dispersive VE
should not be removed aggressively although
all VES should be removed. Administration
of carbonic anhydrase inhibitors and
betablockers
during
the
immediate
postoperative period is always recommended
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

pupil be well dilated. Adequate exposure
of the lens and the anterior capsule is
essential. Padilha first tries to obtain a
pharmacological mydriasis. He uses a
combination of Phenylephrine 10%,
Tropicamide 1% ( Mydriacyl R ), and a
prostaglandin
inhibitor
such as
Indomethacin
or Flurbiprofen 0.03%
(Ocufen R ), which is administered every 15
minutes during 1 hour before surgery.
Among the two inhibitors, Padilha prefers
Ocufen R, for better maintenance of
the
mydriasis. This pharmacological
combination is administered if, of course, no
cardiovascular contraindications exist.
If this combination of medications is
not effective, unpreserved adrenaline 1:1000
diluted in 10 ml of BSS may be injected into
the anterior chamber at the beginning of
surgery.
In patients who have a certain degree of

iris atrophy that may be related to advanced
senility, post uveitis, trauma or the long term
use of miotics in glaucomatous eyes, the
following options are available to obtain adequate exposure of the lens and the anterior
capsule.
Mechanical Dilatation
Viscoelastics
with
In the presence of iris adhesions to the

anterior lens capsule, Luntz mechanically
separates them using a viscoelastic passed
through a cannula. Once the synechiae have
been separated, intracameral Epinephrine
(adrenaline) is injected and in many instances
the pupil will dilate adequately.
328
1. Stretching the Pupil

The pupil in most patients can be
stretched to an adequate dilatation using two
Kuglin hooks as advocated by Maurice
Luntz, M.D. One Kuglin hook is inserted
into a preformed temporal paracentesis and
advanced to the opposite nasal pupil margin
where the Kuglin hook engages the pupil
margin (Fig. 194). The second Kuglin hook
enters the anterior chamber through a preformed nasal paracentesis, is advanced across
the anterior chamber to the opposite temporal
pupillary edge, which it engages (Fig. 194).
Both Kuglin hooks are now pushed toward
the limbus, stretching the pupil horizontally until maximal stretching is achieved.
There will inevitably be some small sphincter
tears.
Both Kuglin hooks are now removed
from the anterior chamber and re-entered into
the anterior chamber through two preformed
keratome incisiona one at 12 oclock and the
other at 6 oclock (Fig. 195). One Kuglin
hook is advanced across the anterior chamber
to engage the pupil margin at 6 oclock, and
C h a p t e r 12:
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 paracentesis, 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, stretching the pupil horizontally until maximal
stretching is achieved.
Figure 195 (right): Stretching the Pupil Vertically with Two Kuglin Hooks
Both Kuglin hooks are now re-positioned
through keratome incisions at 12 and 6 oclock.
One Kuglin hook is advanced across the anterior
chamber to engage the pupil margin at 6 oclock,
and the second Kuglin hook engages the pupil
margin at 12 oclock. 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

margin at 12 oclock. Both Kuglin hooks are
again pushed toward the limbus, facing each
other, at 6 and 12 oclock, thereby stretching
the pupil vertically (Fig. 195). Once the maximal vertical extension is achieved, the Kuglin
hooks are retracted. Intracameral epinephrine
is injected, followed by intracameral viscoelastic. In those eyes in which the pupil
margin in not significantly fibrosed and not
too spastic, this maneuver can achieve a
sufficiently dilated pupil to proceed with phacoemulsification.
The technique using
Kuglin hooks has also been advocated by
Miguel Padilha, M.D.
2) Mechanical Pupillary Dilators

In those cases in which the pupil
margin is fibrosed or very spastic, one of the
following procedures may be necessary.
A) Plastic Iris Hooks (AlconGrieshaber) are inserted through four paracentesis incisions in the cornea (Fig. 196) as
advocated by Luntz as well as Padilha. The
hooks engage the pupil margin at the 10:00
oclock, 2:00 oclock, 4:00 oclock and 8:00
oclock meridians, and the pupil is forcibly
enlarged by pulling the hooks outward and
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 Retractor 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 oclock meridians. The
hooks (H) are inserted through the paracentesis incisions (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 surgeons
view of the final configuration of the retractors and
the resulting pupil shape.
330
C h a p t e r 12:
Figure 197: Phacoemulsification in Small Pupils Beehlers Pupil Dilator

The Beehlers 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

fibrosed this method will not achieve adequate pupil dilation, or the pupil margin may
be severely traumatized.
Padilha considers that, of all the available mechanical resources, the one that has
contributed the most safety and satisfaction in
the management of small pupils is the flexible
iris retractor (Alcon-Grieshaber) (Fig. 196).
These retractors are extremely useful, even if
placing them requires extra time. After the
placement of the first or the second retractor,
the anterior chamber may need to be refilled
with viscoelastic to facilitate the introduction

of the other two.
B) The Beehler Pupil Dilator

Padilha uses this instrument when the
other options outlined above have not been
effective. This dilator, made by Moria, in
France, allows dilatation in three directions
with only one maneuver (Fig. 197). Moreover, it provokes a discrete retraction of the
iris in the direction of the corneal or scleral
tunnel incision.
331
C) The Silicone Expander Ring

In more severe cases, Padilha uses a
silicone ring with an indentation, which fits
all along the edge of the pupil. This presents
some advantages. Using this technique the
iris fits like a tire around the ring, which is
like an iron wheel (Fig. 198). Among its
disadvantages is the fact that it can loosen
itself easily with intraocular maneuvers during the phaco procedure. Known as
Graethers pupil expander (EagleVision
#1540) it has three components: the preloaded expander, a disposable insertor and a
glide retractor of the iris. (The use of this ring
is controversial - Editor).
Padilha emphasizes that stretching

maneuvers using mechanical dilators may
induce a certain degree of iris atony. This
predisposes the iris margins to insinuate into
the titanium tip, during the phaco maneuvers,
leading to injury of the sphincter and the iris
tissue. The same can occur with sector iridectomies, which can also predispose the iris to
the development of synechiae to the anterior
capsule during the postoperative period, requiring the administration of miotic drops for
some time.
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
C h a p t e r 12:
TRAUMATIC CATARACTS
Overview
Highlights of Examination
The complex repair of an eye injury is

best when a team which shares anterior and
posterior segment skills work together in
primary and secondary management.
Almost all bad results following ocular
trauma occur in injuries involving the posterior segment, particularly when the lens is
also damaged
The ophthalmologist must examine the

patient carefully. The examination should
begin with an assessment of the visual
function, if there is light perception or light
projection. The prognosis is better if there is
good light projection. Then the eye should
be examined in the usual way with the direct
ophthalmoscope and the slit lamp. In many
cases the fundus cannot be visualized because of the presence of opaque media: cornea, lens, and vitreous hemorrhage. The
presence of a foreign body must be definitely
excluded. It is important to search for anatomically related trauma. Individual intraocular structures are not often damaged
alone.
In severe injuries, the full extent of
damage is obscured by blood or opacities in
the media . Special assessment is needed
before planning surgery to establish the extent of damage and the visual potential.
There may be no light perception in the
presence of a complete vitreous hemorrhage until the hemorrhage clears. In such cases
diagnostic imaging is invaluable.
Assessment of the Injured Eye

The circumstances of the injury and the
early clinical assessment give important information that will determine the early management and help to predict complications.
As pointed out by Michael RoperHall, M.D., an accurate history is essential.
This can be very helpful in indicating the
nature and extent of injury. The true history
is sometimes elusive, especially when children are involved, or there is potential for
litigation.
The injuries that cause traumatic cataract occur not only from serious penetrating
trauma, but also from blunt injury. Most
blunt injuries are not severe enough to cause
rupture of the sclera. In evaluating and
managing all blunt injuries, it is important to
recognize that each ocular tissue, from the
cornea to the posterior choroid, may have
been damaged by the impact. Therefore,
management is based on identifying the affected tissues, understanding the pathophysiology of events that can occur after a blunt
injury, and anticipating possible secondary
complications.
Diagnostic Imaging
B-scan ultrasonography should be
used to identify the presence of a foreign
body and where is it precisely located, the
amount of vitreous hemorrhage present and
the condition of the retina. Ultrasound imaging also demonstrates changes in lens position; posterior rupture of the lens; cyclitic
333
membrane; hemorrhage into the vitreous;

separation of the vitreous from the retina; and
retinal detachment, which are obscured to
direct examination (Fig. 199).
Combined Injuries of Anterior and

Posterior Segment
A damaged lens mixed with blood and
vitreous needs prompt and adequate surgery.
Failure to remove this debris encourages
fibrosis with a cyclitic membrane causing
ciliary body detachment and hypotony eventually leading to retinal detachment and phthisis bulbi.
Traumatic Cataracts in the

Presence of Anterior Segment
Penetrating Wounds
Main Objectives
In anterior segment injuries the initial
objectives are watertight repair of the corneal
wound, restoring normal depth to the anterior
chamber, intensive antibiotic treatment to
prevent infection and intense antiinflammatory therapy from the very start. The further
goals are to manage the cataract adequately,
reduce secondary damage by minimizing excessive corneal scarring; assuring a clear,
adequately sized and cosmetically and optically desirable pupillary opening; and preventing further damage to the anterior chamber angle that could result in glaucoma.
Often all of these objectives can be
achieved at the time of initial wound repair
although in some cases further surgical
procedures are needed. The traumatic injury
may have caused a lens anterior capsular
334
defect either from a blunt rupture or a sharp

laceration.
MANAGEMENT OF
TRAUMATIC CATARACT
Robert Stegmann, M.D., has very extensive experience in trauma cases. He believes that the prognosis for a traumatic cataract can be the same as for a routine senile
cataract if the traumatic cataract is handled
properly. This excludes cases in which there
is damage to the posterior segment, the vitreous has become cloudy, or the retina is damaged from the same trauma, or where infection has occurred.
Small Wounds in Anterior

Capsule
In many cases a penetrating wound in
the cornea and lens is small, the lens material
still remains within the capsule and, even
though cloudy, it may not escape through the
tiny capsular tear (Fig. 200). Prof. Giora
Treister from Israel recommends that in such
cases, the lens be left alone during the first
surgical intervention. He repairs the primary
wound and goes no further at this time
because generally these are the worst conditions for operating on the eye. The tissues are
swollen and irritated, and perhaps even infected. The trauma may have occurred at
night. In case of unexpected complications,
the most experienced surgeons are not on
duty.
If it is not absolutely necessary to go
further with the initial procedure, Treister
recommends that it will suffice to close the
primary wound and to concentrate on proper
reconstruction later.
C h a p t e r 12:
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; posterior 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 examination. 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

Damaged
Timing for Primary Lens

Extraction
If the anterior capsule is more widely

damaged and lens material is present in the
anterior chamber, (Fig. 201) Treister removes all the lens material during the first
surgical intervention and examines the posterior segment with the indirect ophthalmoscope. If the trauma is confined to the anterior
segment, the vitreous is clear, the retina is
attached without retinal tears and no foreign
body is seen, a posterior chamber lens is
implanted .
John Alpar, M.D., who has extensive

experience with traumatic cataracts, considers that a primary lens extraction should
occur any time the lens is so damaged that its
particles are mixed with anterior chamber or
vitreous material. The lens should also be
removed in cases of subluxated lens following trauma. The advantages of a primary
operation in these cases are that postoperative inflammation is reduced, rehabilitation
time is faster, and later examinations, including 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
C h a p t e r 12:
The most important indications for

primary operation are signs that point to the
likelihood of a ruptured posterior capsule
with vitreous already entering the chamber.
More Extensive Damage

Affecting Posterior Capsule
In case of perforation of the lens with
an opening also in the posterior capsule,
Treister as well as Stegmann in South
Africa remove the vitreous from the anterior
chamber (if present) with a vitrector together with the lens material but try to preserve the posterior lens capsule, or part of it,
for sulcus-placed posterior IOL implantation.
Specific Problems with

Traumatic Cataracts
Paul Koch, M.D., points out that
zonules are often torn and there may be
significant risk of collapse of the posterior
capsule as well as vitreous prolapse around
the equator of the lens. Consequently, in the
preoperative evaluation with the slip lamp,
look carefully for evidence of zonulysis.
HIGHLIGHTS OF
SURGICAL TECHNIQUE
The Incision
A sclero-corneal tunnel (Fig. 40-B) is
definitely the incision to be used. A corneal
tunnel incision is contraindicated.
The
conjunctiva must be treated very delicately.
Some of these patients may develop second-
ary glaucoma and might need a filtering

operation at a later date.
In many cases the anterior capsule has
been perforated. A CCC may be quite difficult and sometimes risky. Paul Koch has
advocated that a better way to open the
unsupported part of the anterior capsule ruptured zonules is to use capsule scissors. A
puncture can be made in the anterior capsule,
scissors introduced with one blade through
the puncture, and a snip capsulotomy performed. Koch points out that pulling inward
to create a capsulorhexis with a needle or
forceps could be dangerous, dislocating the
lens beyond the point of recovery.
Other parts of the capsule, where the
zonules are intact, may be opened in the usual
fashion.
The circular anterior capsulotomy
should be made large enough so that the
nucleus can be floated out of the bag with
hydrodissection. Typically this occurs easily
because the nucleus is white, soft and fluffy.
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
successful capsulotomy.
Lens Removal
In the presence of traumatic cataract,
phacoemulsification is done in the anterior
chamber. Once the nucleus enters the anterior
chamber, viscoelastic can be placed above
and below it, protecting the cornea and pushing 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 implantation. 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) properly positioned within the distended bag.
The intracapsular ring distributes the forces
(arrows) inside the capsular bag, thereby
making it possible to work safely. Asymmetrical collapse of the bag and
decentration of the IOL is prevented.
possible. In a young patient the nucleus is

usually very soft and is amenable to many
different options. For a patient with an intact
capsulorhexis, phaco-aspiration of the
nucleus is safe and effective. If an anterior or
posterior capsular tear is present, then manual
aspiration with a Simcoe-style cannula affords greater control. Dry aspiration of the
soft nucleus under viscoelastic material offers
excellent control, especially in the most complicated cases, as advocated by Snyder and
Osher.
Role of Intracapsular Tension

Ring in Traumatic Cataracts
This is an important advance in
cataract surgery. The ring is a relatively
338
recent development, as advocated by Robert

J. Cionni, M.D., in the U.S. and Okihiro
Nishi, M.D., in Japan. This device maintains
the shape of the bag during and following
extracapsular surgery or phacoemulsification
in traumatic cases or in patients with subluxation or pseudoexfoliation. It has important
implications in terms of preventing IOL dislocation, decentration, tilting, further zonular
dehiscence, and posterior capsule opacification.
The capsular tension ring (or
intracapsular ring), is an open circular
PMMA haptic (Fig. 202). It can distribute the
forces inside the capsular bag, thereby making it possible to perform surgery safer, and
decentration of the IOL is prevented.
In the management of traumatic cataracts, the ring is placed in the bag for support,
C h a p t e r 12:
provided that there is an intact anterior capsulotomy and posterior capsular bag. In some
cases it will be easy to place it prior to
emulsification of the nucleus, while in other
patients it is better to place it prior to cortical
aspiration. This will stabilize the capsule and
support the areas lacking zonules. Once the
capsule is secure, the cortex can be removed
and the implant placed. If necessary the ring
can be sutured transsclerally..
Removal of Cortex
After nucleus removal, before proceeding with cortical aspiration, inspect the posterior capsule carefully to be sure that there are
no tears as a result of the injury, particularly a
blunt injury, where tears might be hidden.
If the capsule is intact, proceed as usual,
following the principles and techniques outlined in Figs. 127 and 128. In case of doubt
about the effects of automated irrigationaspiration, you may use the manual aspiration
with the Simcoe-type cannula, as shown in
Fig. 128. This allows a greater degree of
control.
Selection of IOL
Traumatic cataracts may be associated at a late date with some vitreoretinal
complications. PMMA and acrylic lenses are
well tolerated by the eye and preferred by the
vitreoretinal surgeons. Since traumatic cataracts are not uncommonly associated with
some degree of traumatic mydriasis, a 6.0
mm or larger diameter IOL optic is a prudent
choice.
IOL Implantation
With the support and stability of an
intracapsular tension ring, the placement of
the IOL in the capsular bag is indicated and

desirable. If an intracapsular ring is not
available and only a small area of zonular
dehiscence is present, slowly unfolding the
implant or very gently placing a rigid lens
with soft loops will minimize the stress on the
intact remaining zonules.
Ciliary sulcus placement of a posterior
chamber implant is still possible in the setting
of a posterior capsular tear or zonular dialysis
(Figs, 153, 154, 156). If the anterior
capsulorhexis is intact, yet a severe posterior
capsule break exists, the haptics should be
placed in the sulcus. It may be possible to
capture the lens optic posteriorly into the
capsulorhexis. This will provide adequate
support and will prevent the lens from subsequently dislocating.
If the capsulorhexis is incompetent or
larger than the implant optic, sulcus fixation
with a large diameter implant can be utilized.
Selection of Viscoelastic in
Traumatic Cataracts
In those eye centers where the two main
types of viscoelastics are available (dispersive and cohesive), the following are good
choices as advocated by Snyder and Osher:
1) When the hyaloid face is partly exposed, a
highly retentive (dispersive) viscoelastic
agent such as Viscoat (Alcon) or Vitrax
(Allergan), may tamponade the vitreous and
keep it back. The dispersive agents also
protect the endothelium well. This may be
particularly important in cases in which the
endothelial cell density has been reduced by
the trauma. 2) On the other hand, the space
retaining qualities and ease of removal typical
of highly cohesive viscoelastic agents, such
as Healon GV (Pharmacia & Upjohn), make
these agents more appropriate for the lens
implantation stage of the procedure.
339
Phacoemulsification Advantages in Traumatic Cataract

Traumatized eyes with potentially
weakened zonules are at greater risk for suprachoroidal hemorrhage. Maintaining a
closed system as provided by phacoemulsifi-
cation reduces the risk of expulsive hemorrhage. In addition, a closed system allows
compartmentalization within the anterior segment. If the posterior capsule is broken or if a
zonular dehiscence is present, viscoelastic
tamponade of the vitreous can be best maintained in the setting of a closed system.
PHACOEMULSIFICATION IN
SUBLUXATED CATARACTS
Strategic Management
Phacoemulsification is performed in a
totally closed system, where the ultrasound
tip blocks the incision, allowing the volume
of aspirated masses to equal the volume of
liquid injected into the anterior chamber, thus
maintaining stable intraocular pressure
throughout the surgery. The space available
for disassembling the cataract is extremely
small, limited anteriorly by the corneal
endothelium and, posteriorly, by the posterior
capsule.
If the zonules sustaining the crystalline lens are weak, broken or nonexistent, in
part or totally, or when the posterior capsule
is ruptured, a delicate and risky situation may
arise unless we are ready to manage it effectively.
MANAGEMENT DEPENDING ON
SIZE OF ZONULAR DIALYSIS
When confronted with a zonular
rupture, Padilha recommends adopting the
following strategies:
1)
If during
biomicroscopy at the office, under mydriasis
and with a slit lamp, a small or moderate
zonular dialysis is detected, which does not
340
extend to more than 45 of the crystalline

lens circumference, and we can see an
excellent red retinal reflex, it is almost
certain that a phacoemulsification can be
accomplished safely.
The hydrodissection must separate the
lens capsule from the cortex by injecting
balanced salt solution (BSS) under the anterior capsule, and the hydrodelamination must
attain consistent detachment of the nucleus
from the epinucleus (Fig. 203).
The sharp separation of these structures
will significantly reduce the tension on the
fragile zonules during disassembling of the
nucleus and aspiration of the residual cortex.
2. a) If the damage to the zonular fibers
extends to more than 45 and the cataract has
a hard nucleus with a retinal reflex turning
brown, or b) the dialysis extends to 180,
the insertion of an intracapsular tension ring
(Fig. 202) will be extremely useful to better
support the crystalline bag throughout the
surgical procedure, reducing the chances of
dislocation of the cataract into the vitreous.
This is true even in cases of soft cataract. The
use of the intracapsular tension ring is also
valid for cases with pseudoexfoliation and
ectopia lentis as in the Marfan syndrome
and others.
C h a p t e r 12:
3.
On the other hand, if there is a
very extensive damage to the zonular fibers
with a dialysis of more than 180, Padilha
considers that phacoemulsification or even a
planned extracapsular extraction may not be
sufficiently safe, even with the help of the
intracapsular tension ring (Fig. 202), espe-
cially in cases of hard cataracts. In these

patients, Padilha advocates performing an
intracapsular extraction associated with a
Kelman anterior chamber implant, or a
posterior chamber lens fixated to the sclera
(Fig. 156). He considers this to be a more
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

Subluxated Cataracts
Padilha points out that some important
issues should be considered when subluxated
cataracts are approached.
Anterior Capsulotomy
Anterior capsulotomy should be
performed as a continuous curvilinear
capsulorhexis (CCC). The surgeon needs to
use extreme caution starting with a bent
needle and completing it with this same
instrument or with the Uttratas or similar
forceps.
If any problem arises at the time of
the anterior capsule perforation with the cystotome (bent-needle) the surgeon may begin
the capsulorhexis with a pinch-type forceps
such as the Kershner capsulorhexis cystotome-forceps (Rhein Medical). The maneuvers should be executed very carefully and
smoothly so as to prevent further damage to
the zonules. The diameter of this capsulotomy should not be very large. Reaching the
equatorial region must be avoided at all costs.
(Editors Note: I also refer you to the discussion of Traumatic Cataracts complicated by
some zonular dialysis, in which Paul Koch
recommends using scissors to perform the
anterior capsulotomy so as to not exhert
further pressure on the weakened zonules
with the maneuvers of a standard
capsulorhexis.)
Characteristics of Viscoelastics
Used
Another important issue involves the
use of viscoelastic substances. It is important
to combine one viscoelastics with cohesive
342
properties, with another of dispersive

properties, which scatters and adheres to instruments or tissues. While the latter will
protect the damaged zonular area, by adhering to adjacent tissues of that region and
helping prevent an eventual escape of the
vitreous, the cohesive viscoelastic will press
down upon the anterior face of the crystalline
lens, transforming it into a convex surface,
and facilitate making the CCC. Such convexity will help channel the zonular tear in the
direction of the center of the capsule and
not toward the periphery because of the centrifugal force generated above the surface
(Fig. 204). (Editors Note: A very clear
definition of the qualities of the cohesive and
the dispersive viscoelastics, and how they
differ from one another, is presented at the
beginning of this Chapter).
Additional Measures to Reduce

Risks
1) Padilha recommends that the phacoemulsification incision, whether in clear
cornea or a scleral tunnel, should be placed
as far away (circumferentially) as possible
from the damaged zonular region. This is to
prevent extension of the zonular dialysis by
the insertion and withdrawal of instruments in
the interior of the eye precisely in the most
affected area. If the zonular rupture is located
in the superior quadrants a superior temporal
incision will make surgery more demanding
and risky.
2) To further reduce risks, Padilha
advises the use of disposable plastic flexible
iris retractors, which will help sustain and
stabilize the crystalline bag. The flexible
hooks are anchored in the borders of the
CCC, in exactly the way we use them in
C h a p t e r 12:
Figure 204 (left): Subluxated Cataracts - Use of

Dispersive Viscoelastic
An important issue involves the use of viscoelastic 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 damaged zonular area and lessening the chances of an
eventual vitreous escape.
Figure 205 (right): Subluxated Cataracts - Helping 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

196) except that the retractors are placed in
the margins of the anterior capsulotomy
instead of the margins of the pupil.
3) During disassembling of the nucleus,
maneuvers to rotate the nucleus should be
reduced to a minimum. In order to prevent the
need for these maneuvers, hydrodissection
and hydrodelamination should done carefully
but thoroughly.
4) Padilha recommends that the
intracapsular tension ring be introduced after
the hydrodelamination is completed
and
before emulsification (Fig. 202). This is another very important measure to provide support to the capsular bag. Usually the ring is
held by a long Kelman-McPherson forceps
and introduced clockwise. When operating on
the right eye using a superior sclerocorneal
tunnel incision, the ring is moved 1 hour in
the direction of 3 oclock and 6 oclock. A
spatulapreferably Kochs spatulais used
to facilitate the insertion of the ring in the
correct position inside the bag. These rings
come in different sizes. They are produced
by Morcher GmbH, Germany, and Corneal,
France, and will be commercially available
through Alcon in the near future.
If an accidental cataract subluxation
occurs during a conventional cataract surgery, the surgery must be interrupted and the
ring should be introduced as described above.
In these cases, Padilha prefers to implant a
one-piece intraocular lens, all PMMA, inside
the capsular bag and to make its length coincide with the meridian where the zonular
rupture occurred.
344
Increasing the Safety of

Posterior Lens Implantation in
Extensive Zonular Disinsertion
In those cases where a more extensive
zonular disinsertion is present, it is important
to create safer conditions to implant a lens in
the posterior chamber. Variations and constant improvements of this technique have
been presented at various meetings and publications by many authors, especially Drs.
Jorge Villar-Kuri, from Mexico, Robert
Osher, from the United States, Yoshihiro
Tokuda, from Japan, Charlotta Zetterstrom,
from Sweden, among others.
Some guidelines are basic and very
important in these extreme situations,
including cases of Marfans syndrome. The
surgeon should always opt for a small
capsulorhexis using a bent needle, and carry
out the hydrodissection very carefully.
Padilha considers there are at least
three options in order to increase the safety
of the posterior chamber lens implantation.
The first consists in totally removing the
capsular bag following removal of the
cataract. This could be indicated in certain
situations where the lens is too dislocated
either superiorly or inferiorly, and vitreous
loss is present. Following a generous anterior
vitrectomy using an automated vitrector,
the intraocular lens is sutured to the sclera,
(Fig. 156).
C h a p t e r 12:
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 Cataracts - Fixation of the Anterior Capsule

to the Ciliary Sulcus - Stage 2
A prolene 10-0 suture (P) is carefully 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

the Ciliary Sulcus
The second option to increase the
safety of the posterior lens implantation and
to prevent it from dislocating is to actually
suture the anterior capsule to the ciliary sulcus. This is done so that when the IOL is
sutured and implanted, it will remain in place.
This technique involves making two incisions

in the anterior capsule, through the small
CCC (Fig. 206), as in the intercapsular technique advocated some years ago by Sourdille
and Galand. The borders of the free edge of
the capsule should be folded and sutured to
the sclera at the opposite side of the luxation,
as suggested by Villar-Kuri . The step-bystep technique is shown in Figs. 206-210.
345
Figure 208 (above): Subluxated Cataracts - Fixation of the Anterior Capsule to the Ciliary Sulcus Stage 3
Viscoelastic is reinjected in the anterior chamber. 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 - Fixation 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 surgeons
choice (L) is implanted, placing it in a position perpendicular to the disinsertion. The primary incision is
closed with a horizontal 10-0 nylon suture (N).
346
C h a p t e r 12:
CATARACT SURGERY IN CHILDHOOD

Previous Controversies Now
Resolved
Cataract surgery in the pediatric patient
and the post op management of these children
is still a complex problem, but significantly
less than up to five years ago. The difficult
controversies previously existing regarding
finding solutions for their visual recovery
have been solved in most cases. These controversies are:
1) Age and Timing for Surgery

Bilateral Cataracts
It is now generally agreed that early
cataract surgery in bilateral cataracts and
immediate optical correction can prevent
otherwise irreversible deprivation amblyopia
in the child born with dense cataracts. Unless this is done, children with bilateral cataracts who undergo surgery later in childhood
or in their teens recover only limited visual
acuity, usually an average of no better than
20/60. Optimum optical correction following
surgery is more effectively done today with
IOL implantation.
In infants with bilateral cataracts, despite an increased complication rate, surgery
must be performed within the first months of
age to avoid irreversible amblyopia.
Cataract surgery in children over the
age of 1 year is less complex with a higher
success rate and with fewer complications in
the postoperative period. It is best to perform
surgery in both eyes at the same sitting.
Sterility must be maintained during the whole
procedure in bilateral cases. This requires

changing all instruments and sterile clothing
of the surgeon, nurse and patient between
eyes. Patching is not indicated. General
anesthesia is used in all cases.
Unilateral Cataracts
Unilateral congenital cataract presents a
more challenging problem, since even a mild
cataract will cause irreversible deep amblyopia in one eye if not treated. Treatment is
based on surgery within two months of life,
prompt optical correction with intraocular
lens implantation and aggressive occlusion
therapy with frequent follow-up have been
successful in several series.
Preconditions to be Met for

Useful Vision
In cases of unilateral cataracts, if
cataract surgery with IOL implantation is not
done very early in life, the chances of
achieving good vision are slim. It is possible
to achieve useful vision in some children
with monocular congenital cataracts provided
certain important preconditions are met. The
most important is the age at which the surgery
is undertaken along with equally important
immediate optical correction and occlusion
therapy as emphasized by Noel Rice, M.D.
at Moorfields Eye Hospital in London and
Eugene Helveston, M.D. in the U.S. years
ago. These preconditions continue to be
valid. It is essential first to provide a focused
image and second, eliminate suppression.
This triumverate or troika of
treatment is the key to success. To a great
347
extent, the ophthalmologist depends on other

professionals who determine when the cataract is identified and referral takes place. If
the child does not present to the ophthalmologist within the optimal period for surgery and
optical rehabilitation, clearly the ophthalmic
surgeon is considerably constrained in the
quality of care he/she can provide. Timing is
absolutely the key. If the surgeon decides to
operate on a unilateral cataract, the family
needs to expect the very high likelihood of
only a helper eye, and not an eye that will
have very good vision. It is important to
acknowledge this limitation.
Role of Parents
Their role is absolutely essential for
achieving a good result. The surgeon would
be wise to take this factor into consideration
before undertaking treatment. Parents who
do not understand what they and the child
need to go through for pre and postoperative
management to prevent and conquer amblyopia, become the first contraindication to
surgery. This is particularly important in
unilateral cataracts in which prolonged amblyopia treatment is essential.
Importance of Asymmetrical
Visual Input
The period of sensitivity of the visual
system and its responsiveness to the development of vision through having a good visual
input in humans is still not precisely determined, but we know that it is most responsive during early infancy, and it falls off
rapidly during the first year of life. The
clinical research made by Rice at Moorfields
and Von Noorden in the U.S. determined
348
that the implications of asymmetrical input

into the visual system are vitally important,
particularly in relation to unilateral congenital cataracts.
When Should We Not Operate?

Any unilateral lenticular opacity that is
moderately severe will cause amblyopia. If
management as here described is not possible very early in life, it may be best if we
advise against it. Very mild unilateral lenticular opacity, may be best left alone. Removing a small unilateral cataract that causes
a small degree of amblyopia creates aphakia,
which may lead to even more amblyopia,
unless we implant the adequate IOL and
undertake aggressive occlusion therapy.
History
In the workup of a child with cataract,
a detailed history is necessary. It is important to determine whether the cataract is
progressive, particularly in older children.
Contrary to some earlier teaching, we now
know that bilateral cataracts are often progressive. Frequently, in children from ages
3 to 6 and even of high school age, vision is
gradually diminished bilaterally because of
progressive congenital cataracts.
As pointed out by Charlotta
Zetterstrom, M.D., PhD, of Stockholm,
Sweden, in a clinically healthy child, an
extensive preoperative evaluation to establish
the cause for the cataract is not routinely
necessary. Congenital cataracts are frequently inherited as an autosomal dominant
trait but a recessive inheritance also occurs.
C h a p t e r 12:
It is important, to rule out metabolic disorders, genetically transmitted syndromes, intrauterine infections and ocular conditions
with associated anomalies.
Examination
The workup of the congenital cataract
patient continues with the office examination. Infants with congenital cataracts generally resist having their eyes examined, and
do not cooperate with the examining physician. This causes considerable stress in the
family. The ophthalmologist must use special examination techniques. First, the light
should be turned down to low levels of
illumination, which causes the eyes to open
immediately. Direct illumination is used to
determine the extent of the opacity.
The red reflex should first be determined by direct ophthalmoscopy with the
pupil undilated. The cataract is often most
dense in the central part of the lens and after
dilatation it seems to be less significant.
While the newborn child is awake it is also
important to assess visual function, if possible, with a Teller acuity card. Watch for the
ability to fix and follow with an object that
attracts attention. Clarify with the parents
whether they have had any visual interaction
with the child.
Children with significant bilateral congenital cataracts may seem to have delayed
development as well as obviously impaired
visual behavior. Children with monocular
cataracts often present with strabismus,
which however may not develop until severe
irreparable visual loss has occurred. Children with monocular cataract are almost always detected much later than cases with
bilateral cataract. The presence of nystagmus
at the age of 2-3 months generally indicates a

poor visual prognosis.
Complete examination of infants with
dilated pupils often requires sedation or general anesthesia and can be performed during
the same anesthesia as the surgery although,
if possible, days before surgery, so that the
surgeon can be better informed to enable
him/her to make adequate decisions, and to
inform the parents properly.
Measurement of the corneal diameter,
intraocular pressure using a handheld tonometer, type and density of the cataract by
photography, are all part of a good examination in these patients. Zetterstrom emphasizes that when the clarity of the media
permits, indirect ophthalmoscopy may reveal
persistent fetal vessels or other posterior segment abnormalities that may have an impact
on the visual outcome. A-scan measurement
of the axial length, and keratometer readings
are done. These are essential measurements
for contact lens and IOL power calculation.
Newborn eyes with congenital cataract are
shorter and have a smaller corneal diameter
compared to controls (Fig. 31 and text pages
54-56).
A B-scan ultrasound is also performed
in cases in which visualization of the retina is
impossible, in order to determine whether
there are retinal abnormalities, masses, or the
presence of hypoplastic primary vitreous.
Helveston considers it important to determine the intraocular pressure because there is
a significant relationship between reduced
corneal diameter, intraocular pressure, and
the presence of glaucoma. One of the most
serious problems in the management of congenital cataracts, particularly bilateral congenital cataracts, is the glaucoma that may
occur 5 to 10 years after successful cataract
349
surgery treatment. This glaucoma resembles

chronic simple glaucoma in the adult patient.
While the intraocular pressure may show
only a modest increase, glaucoma in children
can be extremely resistant to successful treatment. If not controlled, it can cause the same
type of atrophy in the optic nerve that occurs
in chronic simple glaucoma.
The Special Case of Lamellar

Cataracts
Saunders, the founder of Moorfields
Eye Hospital, determined 200 years ago that
lamellar cataracts often do not interfere at all
or at a rather insignificant level with visual
development. The lamellar cataract looks
central and quite dense on retroillumination,
but is revealed under slit-lamp illumination
as definitely lamellar. Children with lamellar
cataracts usually achieve very good vision if
these cataracts are operated on much later in
life, even late in childhood or the teens or
twenties. Patients do not usually develop
nystagmus and often achieve normal or near
normal vision. The corollary is that there is
no need to operate on these children in early
infancy. The prognosis is better if operated
when older, when visual development is
complete. An accurate calculation of IOL
power can be made, with a better visual
result.
In his clinical research, Rice observed
that in many children with lamellar cataracts,
if ophthalmoscopy is undertaken even with a
reasonably dilated pupil, the view of the
fundus is often extremely obscured; in fact,
there may not even be any red reflex. If eyes
are examined fully, however, it can always
be seen that there is clear cortex. If there is a
reasonable view of the peripheral fundus
350
through the peripheral lens, there is no indication for precipitous and early surgery.
Such cases can be treated very conservatively.
These patients often have vision sufficiently reduced in primary and early secondary school years to benefit from cataract
removal and IOL implantation between ages
5 and 15 or even a little earlier.
Rubella Cataracts
These cataracts used to be an important
source of blindness. Rubella cataracts tend to
be bilateral and progressive and result in a
membranous type of partially resolved cataract, posterior synechiae, and chronic uveitis.
For the past 25 years, since rubella immunization has been available, rubella cataracts
have been virtually nonexistent. The key
point in managing these rubella cataracts is
not to aspirate them incompletely because
eventually the eyes are lost. The process of
aspiration reactivates the virus.
The Need for Close Monitoring

These children should be closely monitored. This includes evaluating visual development to be sure it is proceeding in a
satisfactory manner. The surgeons responsibility is to both nurture the process of sight
and to help prevent amblyopia. Otherwise,
the outcome will be poor because of insufficient attention to the anti-amblyopia treatment.
The most important relates to the calculation and selection of the type of IOL to
C h a p t e r 12:
be used and its correct power. The method

and the considerations relating to IOL power
calculation in pediatric cataracts is amply and
clearly presented in pages 54, 55, 56 and Fig.
31, page 56.
The Decision to Implant IOLs

in Children with Cataract
Surgery
How to optically correct patients with
bilateral congenital cataracts and monocular
congenital cataract has been a major subject
of controversy for many years. Some distinguished ophthalmic surgeons 20 years ago
were strongly against performing surgery in
monocular congenital cataract followed by
treatment of amblyopia with a contact lens.
Visual results were so bad that children with
this problem must be amblyopic by nature,
they thought, and the psychological damage
to the children and the parents by forcing
such treatment was to be condemned.
Surgery of bilateral congenital cataracts at a very early age followed by correction with spectacles and sometimes with
contact lenses usually ended with no better
than 20/60 vision bilaterally. This was again
a source for the belief that congenital cataracts either unilateral or bilateral were by
nature associated with amblyopia, profound
in cases of monocular cases and fairly strong
in bilateral cataracts.
When posterior chamber IOL implantation in adults became established as the
procedure of choice, strong influences within
ophthalmology were adamantly opposed to
their use in children for the following reasons: 1) the eye grows in length with consequent significant change in refraction. It was
considered impossible to predict such change
and consequently, the accurate IOL power

adequate for each child. 2) There was
opacification of the posterior capsule in most
cases. This required a second operation for
posterior capsulotomy and the presence of an
IOL would impede proper surgical maneuvers.
The situation has now significantly
changed. The previous failures with spectacles and contact lenses, the new developments in technology and surgical techniques
and the fresh insight of surgeons of a new
generation have led us to discard the previous
thinking and to consider the implantation of
posterior chamber IOLs a very positive development in children. This has been made
possible by the following developments: 1)
new medications that effectively prevent and/
or control inflammation. 2) The introduction
of posterior capsule capsulorhexis
by
Gimbel in North America promptly followed by Everardo Barojas in Mexico and
Latin America (Fig. 30). 3) High viscosity
viscoelastics to facilitate intraocular surgery
in smaller eyes. 4) New, more appropriate
IOLs for children and implantation in the
capsular bag. 5) Refined technology that
leads to a more precise calculation of the IOL
power.
A Major Controversy No More

The controversy as to whether to implant IOLs or not in the management of
cataract surgery in children has been almost
resolved. At present, most surgeons place
intraocular lenses, whether treating congenital cataracts or traumatic cataracts, following
evidence that they can be safely tolerated in
most children. The informed consent discussion with the parent or guardian, however,
should include the fact that intraocular lenses
351
have still not been approved by the FDA for

use in children. This is a matter of particular
importance in the U.S.
The previously existing controversy of
the timing of the IOL implantation in children has also been resolved as a consequence of experience. Intraocular lens implantation may be significantly easier at the
time of cataract extraction than at a later date,
since iridocapsular adhesions and fusion of
the anterior and posterior capsular flaps make
a subsequent secondary implant procedure
more challenging.
Surgical Technique
The Incision
A sclero-corneal tunnel 3.5 to 3.8 mm
wide is the procedure of choice (Fig. 40-B).
Manage the conjunctiva very carefully in
case the patient develops secondary glaucoma
later in life. Because the sclera is soft and
elastic in children, it is hard to achieve a selfsealing incision. Consequently, the incision
should be sutured.
The Anterior Chamber and Pupil

High-viscosity viscoelastic material is
used because the anterior chamber is shallow
in these small eyes. If the pupil is small,
stretching the pupil with flexible iris retractors (Alcon-Grieshaber) can be very helpful
(Fig. 198). They are placed before the continuous anterior capsulorhexis is performed.
This is an important step to assure in
the bag placement of the IOL. Its size should
be smaller than the IOL optic. Zetterstrom
352
points out that the anterior capsule is thick

and elastic in children and a capsular tear can
easily extend out to the equator.
A central puncture is made with a cystotome and the leading edge of the capsule is
grasped with forceps. Several repeated
grasps are recommended to avoid extension
to the equator and to assure maximal control.
The capsulorhexis should be kept small because it usually enlarges due to the inherent
elasticity of the capsule. (See figures 97, 98,
99, 100 for CCC with cystotome and 45, 46
with forceps).
Nucleus Removal
After an appropriate hydrodissection,
the removal of the nucleus and cortex in the
majority of cases can be performed using an
I/A probe with a 0.5 mm orifice, because for
the most part the congenital cataract is usually very soft. Occasionally the cataract is
hard and has to be disassembled and removed. All the lens cortical material must be
aspirated in order to reduce postoperative
inflammation (Fig. 128, page 206). Proliferation of cells leading to a secondary cataract
formation is more aggressive in the younger
child.
Posterior Capsulorhexis
In children a posterior capsulorhexis
combined with an anterior vitrectomy are
necessary to produce a clear optical axis and
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
to close. Moreover, the anterior and posterior capsules must be separated with the use
of additional viscoelastic. This maneuver
will push the vitreous back and prevent its
C h a p t e r 12:
prolapse into the anterior chamber (Fig. 211).

Posterior capsulorhexis is performed by most
surgeons before IOL implantation, as presented here. Nevertheless, some surgeons do
it after IOL implantation, as shown in Fig. 30,
page 52. The latter procedure may be cumbersome.
Anterior Vitrectomy
This important step is performed after
completing posterior capsulorhexis and aims
at removing 1/3 of the anterior vitreous gel
before there is any vitreous presentation. It is
performed using a vitrectomy probe, as

shown in Fig. 212. Special care should be
given to removing any vitreous present in the
anterior chamber. A so-called dry vitrectomy, without infusion of fluid, is safely
performed between the anterior and posterior
capsulorhexis. Viscoelastic is removed to
avoid elevated intraocular pressure after surgery.
Using this method it is possible to implant an IOL in the capsular bag during
primary surgery or in the ciliary sulcus if a
secondary implantation is scheduled in the
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 capsular bag is the procedure of choice. The risk
of contact with vascular tissue and the possibility 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 viscoelastic an anterior dry (that is, without infusion)
vitrectomy is performed to avoid vitreous (V) remnants 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 Children - 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
C h a p t e r 12:
The Posterior Approach to

Cataract Extraction in Children
This has become a second option, and
certainly not the procedure of choice. With
significant advances in cataract removal in
children through the anterior approach, the
two or three port pars plana vitrectomy with
removal of the posterior capsule and lens
material and IOL fixation in the sulcus is left
for cases in which a vitreoretinal operation is
required as the primary procedure. This is the
realm of the vitreoretinal surgeon. The anterior segment surgeon feels uncomfortable
with this approach particularly when the technique done through the anterior segment is
now so effective and the main controversies
related to this surgery are almost a problem of
the past.
CATARACT SURGERY
IN UVEITIS
This is, indeed, one of the most delicate
and complex situations in cataract surgery. In
this volume it is fully discussed in pages 3133 and Fig. 22 (Chapter 2).
BIBLIOGRAPHY
Alio JL, Chipont E: Cataract surgery in patients
with uveitis. Cataract Surgery in Complicated Cases
by Buratto, 2000; 15:193-206.
Belfort Jr., R: Cataract surgery in patients with
uveitis. Highlights of Ophthalmology Bi-Monthly
Journal, Vol. 27, N 4, 1999.
Buzard K, Lindstrom RL: Refractive cataract surgery. Highlights of Ophthalmology Bi-Monthly
Letter. 1994; Vol. 22, N 11-12, pp. 111-116.
Centurion V, Lacava AC, De Lucca ES, Barbosa R:
High myopia and cataract. Faco Total by Virgilio
Centurion.
Colvard DM, Kratz RP: Cataract surgery utilizing
the erbium laser. In: Fine IH, ed.
Phacoemulsification: New Technology and Clinical Application (Thorofare, NJ: Slack, 1996),
161-80.
Dodick, JM: YAG laser phacolysis in new cataract
techniques. Boyds World Atlas Series of Ophthalmic Surgery of HIGHLIGHTS, 1995; 5-130-131.
Dodick, JM, Christian J: Experimental studies on
the development and propagation of shoch waves
created by the interaction of short Nd:YAG laser
pulses with a titanium target: possible implications 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, N 1.
Kershner RM: Refractive cataract surgery. Current
Opinion in Ophthalmology, Feb. 1998, Vol. 9, N 1.
355
Khater TT, Koch DD: Pediatric cataracts. Current

Opinion in Ophthalmology, Feb. 1998, Vol. 9 N 1.
Koch DD, Lindstrom RL: Controlling astigmatism
in cataract surgery. Seminars in Ophthalmology,
December 1992; Vol. 7, N 4 pp 224-233.
Lacava AC, Sanchez JC, Centurion V: High hyperopia, cataract, polipseudophakic or piggyback, Faco
Total by Virgilio Centurion.
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American Academy of Ophthalmology, nMarch
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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
Although phacoemulsification
followed by implantation of a foldable IOL is
the state of the art technique and the
operation of choice for many surgeons and
patients, planned extracapsular extraction
with an 8 mm incision and implantation of a
rigid posterior chamber IOL is still used for a
vast number of patients.
As a matter of fact, if we consider the
day-to-day practice as performed by the majority of clinical ophthalmologists worldwide, planned extracapsular technique with a
8 mm incision and posterior chamber, in-thebag implantation of a rigid PMMA lens or
some other type of manual extracapsular
continue to be: 1) the cataract surgical procedure performed on the largest number of
patients who undergo cataract surgery; 2) the
surgical technique done by the majority of
clinical ophthalmologists throughout the
world regardless of whether they are technically able to do phacoemulsification.
There are many first class surgeons who
can perform a superior quality phacoemulsification but for a large number of patients they
need to do manual ECCE. This is particularly
true in less economically advanced societies.
A good example of this situation is the
experience of Everardo Barojas, M.D.,
from Mexico, one of Latin Americas most
respected ophthalmic surgeons and teachers.
He performs a first class phacoemulsification
and teaches the technique to his residents.
But in his extensive work with patients in the
rural communities which he spontaneously

serves, he does the envelope extracapsular
technique initiated in the 1960s by Baikoff
and revived in 1982 by Galand. All his
residents learn how to perform the planned
extracapsular with 8 mm incision, the envelope extracapsular, as well as phacoemulsification.
Barojas and collaborators have selected the envelope extracapsular procedure for rehabilitation of large numbers of
patients at a time considering cost, time it
takes, safety and good results.
Advances in Manual Extracapsular

In the past few years, the technique of
planned ECCE has progressively and
substantially improved. In addition, small
incision or medium-small incision manual
extracapsulars have stimulated the interest of
a good number of clinical ophthalmologists in
different regions who have chosen to do these
manual techniques instead of undergoing the
learning process of phacoemulsification even
though some of these small incision manual
extracapsulars are not easy to do. These
techniques are presented in this Chapter.
Advances in extracapsular surgery are
related to better instruments, viscoelastics,
the application of nuclear fragmentation techniques, advances in IOL technology, irrigating solutions and the methods to minimize
infection and postoperative inflammation as
presented in Chapter 4 of this Volume. The
359
application of these advances is a long step

forward for manual extracapsular as well as
phacoemulsification, which is a mechanical
extracapsular. As a matter of fact, a good
number of steps used in phacoemulsification,
such as continuous circular capsulorhexis
have been incorporated into the modern
methods of ECCE. All of these factors make
manual extracapsular a very good operation.
The essential difference with phaco regarding
results is that with a very well done phaco and
topical anesthesia the patient has almost immediate visual rehabilitation and minimal inflammation, in contrast to a very well performed ECCE in which final visual recovery
may take 6-8 weeks, although the visual
acuity is practically the same at the end of this
period. There may also be more inflammation with ECCE.
360
Regional Predominance of
Phacoemulsification
Phacoemulsification is predominant essentially in the U.S. and Western Europe,
where it has become the number one technique for most ophthalmic surgeons. In
many instances, this is because their patients
demand and expect a very rapid visual rehabilitation and have the economic means to
receive the benefit of the high technology
required for phaco. In other geographical
regions, phacoemulsification continues to
gain ground, but essentially in teaching centers and private practice.
Because manual planned ECCE is still
extensively used, we have selected Professor
Joaquin Barraquer, M.D., from Barcelona
to present his technique of a flawless planned
extracapsular. There is no one better suited
for this task.
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.
EDITORS NOTE:
Professor Joaquin Barraquer is one of the worlds 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 Ophthalmology, 2000 declared him Ophthalmologist of the Millennium.
ANESTHESIA
At the Barraquer Ophthalmology Center in Barcelona, we continue to find general
anesthesia administered by an expert anesthesiologist the procedure of choice even with
ambulatory surgery. With this type of anesthesia, the surgeon does not need to depend
on the cooperation of the patient. Hypotony
of the eye is excellent. The surgeon can
perform the complete procedure with optimum control and safety.
Nevertheless, because many eye centers and clinical ophthalmologists throughout
the world routinely use local anesthesia, both
techniques are here described.
General Anesthesia
(as Performed at the Barraquer
Ophthalmology Center)
Pre-induction
Midazolam
anxiolytic).
(1-5
mg,
intravenous,
Induction
Propophyl (1-3 mg/kg, intravenous, hypnotic)
Succinylcholine (1 mg/kg, intravenous, muscular relaxant for orotracheal intubation).
361
Adjunct Medications
Analgesics: alfentanil (0.5-1.0 mg) or
pentazocine (15-30 mg) intravenous.
Neuroleptics: droperidol (2.5-5.0 mg,
intravenous)
Vagolyptics: atropine (0.5-1.0 mg, intravenous)
Curare: atracurium besylate (0.250.50 mg, intravenous as muscle relaxant)
Antiemetics: ondansetron (4 mg) and/or
metoclopramide (10 mg) intravenous.
Maintenance
Halogenated ethers for inhalation anesthesia (sevoflurane or isoflurane), occasionally complemented by nitrogen protoxide
(N2O) 50%.
Ventilation
Spontaneous respiration, if possible,
depending on the type of patient and surgery.
Assisted or controlled ventilation if necessary.
Monitoring
Electrocardiogram (EKG)
Pulsioximetry (Oxygen saturation)
Non-invasive blood pressure (NIBP)
every 3 minutes.
Capnography (expired CO2) and respiratory frequency.
Muscular relaxation.
362
Awakening and Recovery

Oxygenation 100% and control of vital
signs. Cholinesterase inhibitors (neostigmine and/or edrophonium) if curare has been
used.
Local Anesthesia
With this type of anesthesia very good
hypotony and akinesia can be achieved. If
sedation is adequate but not excessive, minimal patient cooperation will be sufficient.
Barraquer believes an expert anesthesiologist
should always be available to ensure that the
patient is controlled, even if local anesthesia
is used.
Sedation
Propophyl, alfentanil, midazolam. The
dosage depends upon the patients weight
and age.
The patient should be oxygenated during the anesthetic and surgical procedure
because sedation causes respiratory depression.
Peribulbar Injection
Two injections are administered: Ante-equator injection - Inferotemporal Site.
1. An inferotemporal injection at the intersection of the temporal lateral third and
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.
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 fissure. The anesthetic solution is injected just
past the equator.
363
Technique for Peribulbar

Injection
First, the inferior temporal rim of the
orbit is identified by palpation, and the eyeball is displaced with the finger. The needle is
always introduced in the direction of the orbit
until it touches bone. At this point the needle
is lowered, following the rim of the bone.
Three to 4 cc of local anesthesia are injected.
Then the same maneuver is performed at the
superior nasal point. Massage is applied to the
globe for a few seconds. A Honan balloon is
placed over the globe with a pressure of about
40 mm for 5 to 10 minutes (Fig. 96).
Anesthetic Medications
5 cc lidocaine 2%, plus 5 cc buvicaine
0.75%, plus hyaluronidase 100 UI plus
adrenaline 1:200 000 (3 to 4 cc in the injection inferiorly and 3 to 4 cc in the injection
superiorly. This combination lasts for almost
2 hours).
Monitoring
Electrocardiogram (EKG)
Pulsioximetry (Oxygen saturation)
Non-invasive blood pressure (NIBP)
every 3 minutes.
Muscular relaxation
364
Extracapsular Cataract
Extraction with an 8 mm
Incision (ECCE)
At the beginning of the operation, the
pupil must be adequately dilated (8mm or
more. We use cyclopegics and tropicamide
every 30 minutes, beginning 3 hours before
surgery. Diclophenac is added to reduce the
tendency for the surgical maneuvers to cause
pupillary constriction. Atropine is not recommended because we want prompt recuperation of normal pupillary reaction the first day
after surgery.
Incision
A traction suture is applied in the superior rectus muscle. A fornix-based conjunctival flap is prepared. The conjunctiva is separated at the limbus either with a razorblade
knife or with Wescott scissors. If the scissors
are used, the dissection is completed with the
same scissors.
Light bipolar diathermy is used to coagulate the bleeding vessels, especially in the
anterior part of the sclera and at the sclerocorneal limbus, where the incision will be made
to extract the nucleus and to introduce the
IOL.
An 8 mm-groove is made approximately 0.5 mm from the limbus with a dia-
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
oclock (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 disposable knife, or a razorblade knife. The depth of
the groove is approximately two-thirds of the
scleral thickness and represents the first step
of a two-plane incision to be completed later.
This two-plane incision facilitates better apposition of the wound edges, thereby improving wound closure and reducing postoperative astigmatism induced by the sutures. The
surgeon should avoid overlapping the
wound edges. (Fig 216).
Continuous Curvilinear
Capsulorhexis
A viscoelastic substance is introduced
in the anterior chamber through a paracentesis (Fig. 217) to maintain adequate depth and
to facilitate the deep, horizontal incision (second step) and anterior capsulorrhexis. The
horizontal incision is started with a disposable knife at one of the ends of the predetermined groove and continued over approxi-
365
mately 3 mm (Fig. 217). After the

capsulorrhexis has been done, as shown
in Fig. 219 A, B and C, the deep plane of
the incision is completed with scissors
(Fig. 218). Care must be taken to ensure that
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 incision is completed (red arrow) with Barraquers
scissors (S) in the deep layers of the groove.
366
the lid speculum does not exert pressure on

the eye, which might induce protrusion or
rupture of the posterior capsule.
The capsulorrhexis can be performed
by perforating the center of the capsule with a
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

injection needle, conveniently bent near its
base to produce adequate angulation for better maneuvering (Fig. 97). The bend close to
the tip of the needle makes a little hook used
to exert traction on the capsule fragment.
Cystotomes are also available commercially.
Another way of performing a capsulorrhexis
is to tear the central part of the anterior
capsule with adequate forceps such as Uttrata

forceps. We usually prefer the forceps to the
cystotome (Fig. 219 A, B,C).
Once the center of the capsule has been
ruptured or torn, a small flap of capsular
tissue is grasped and pulled in either a clockwise or counterclockwise direction to eliminate the central part of the anterior capsule
(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 construct 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 rotation of the nucleus (Fig. 221).
Figure 220 (above): Continuous Curvilinear Anterior Capsulorrhexis Standard Size

The regular curve of the capsular opening is less prone to radial tears
than the irregular edges of the opening
that result form the can-opener and envelope 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
Next is the hydrodissection. Balanced
saline solution (BSS+) with epinephrine (dilution 0.06%) is injected with a thin cannula
(25 G) between the anterior capsule and the
lens cortex (Fig. 222) to separate the nucleus,
which tends to pass through the
capsulorrhexis into the anterior chamber.
Subsequently, the nucleus is rotated with the

same cannula in clockwise or counterclockwise direction, depending on where the
nucleus has entered the anterior chamber. The
nucleus is lifted slightly during the rotation
maneuver to complete the displacement into
the anterior chamber (Figs. 223, 224). As the
capsule is an elastic structure, even large
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 resulting fluid waves can be seen (W). These waves
continue posteriorly to separate the posterior capsule form the cortex.
Figure 223 (right): Hydrodissection - Stage 2

A 25 gauge needle (A) is introduced parallel 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

when a continuous circular capsulotomy
without notches is performed.
Other methods of opening the capsule
are: 1) the envelope technique, which uses a
more or less straight incision between the
central and superior third. 2) The can-opener
technique produces small, less circular capsule ruptures. These techniques, which are
based on lineal incisions, however, may result
in a higher incidence of rupture or tearing of
the posterior capsule during the cleaning maneuvers of the capsular bag.
Removal of Nucleus
Once the nucleus has passed into the
anterior chamber, gentle compression is applied 1mm to 2mm from the inferior limbus
(Fig. 224) with a round-tipped or blunt instrument. The nucleus is displaced upwards
(Fig. 224), resulting in some gaping of the
incision. Simultaneously, the scleral lip of the
incision is depressed with another instrument
such as Colibri or Adson forceps to facilitate
the expulsion of the nucleus (Fig. 224). Expression of the nucleus should never be attempted while the nucleus is still inside the
capsular bag because zonular rupture may
occur, necessitating the continuation of surgery as an unplanned intracapsular extraction.
Removal of Cortex - Irrigation

and Aspiration
The anterior chamber is irrigated with
BSS+ and epinephrine (0.06% dilution) to
remove persistent residual lens matter or epinuclear elements. A nylon 10-0 cross suture is
applied in the central part of the incision to
370
maintain adequate anterior chamber depth

during irrigation and aspiration of the cortex
that remains adherent to the capsular bag. An
aspiration probe with a 0.3mm opening at the
tip is used. This probe has a special cover
with two lateral openings at the inferior end
for irrigation to maintain the anterior chamber
depth while the cortical lens matter is aspirated (Fig. 225). The height of the bottle is
adjusted from 20cm to 78cm to increase or
reduce the irrigation in relation to the depth of
the chamber. An adequate chamber depth
makes it possible to work with greater safety,
although excessive irrigation may result in
iris prolapse through the wound. This can be
corrected by reducing the height of the bottle.
For aspiration of the lens matter, a variable
vacuum with an upper limit of 450mmHg is
applied.
Once all the lens matter has been removed, the anterior capsule is polished
using the same probe and a low vacuum
power between 20mmHg and 60mmHg to
avoid capsular retraction and rupture. Careful, exhaustive cleaning of most of the posterior capsule surface is essential in order to
postpone as long as possible the opacification
of the capsule and the subsequent Nd: YAG
laser capsulotomy. The surgeon must be careful not to be aggressive during this step of
aspiration-irrigation of the cortex so as to
avoid posterior capsule rupture or zonules
rupture during these maneuvers. If this should
occur, vitrectomy would be required, and the
IOL would have to be placed in the sulcus.
If irrigation-aspiration equipment is not
available, the lens matter can be removed
manually. A cannula and syringe are used to
gently irrigate, mobilize the lens matter, and
aspirate it in the four quadrants. A curved
Figure 224 (left): Removal of

Nucleus
Once the nucleus is in the anterior chamber, nucleoexpression is
performed. Slight compression is exerted with a blunt instrument 1 or
2mm over the inferior limbus (H). the
nucleus is displaced upwards, separating the lips of the incision. Simultaneously, 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

(Fig. 226). The posterior capsule may also be
polished manually using this technique at the
end of the procedure. In cases of central
capsular fibrosis, posterior capsulorrhexis can
be performed at the end of the procedure or at
a later stage in a Nd: YAG laser capsulotomy.
A viscoelastic is injected in the capsular
bag and the anterior chamber. The surgeon
should check carefully to ensure that the
capsular bag is completely filled with viscoelastic. The preplaced cross-point suture is
removed from the wound.
IOL Implantation
The lens is grasped at the superior rim
of the optics with straight forceps. With a
slight inclination, the inferior haptic is introduced into the capsular bag (Fig. 227). The
optic is centered with the capsulorrhexis and
rotated using a Sinskey hook until the superior haptic is in the correct position inside the
bag. The IOL should be implanted horizontally. Introduction of the superior haptic may
be easier if it is grasped with thin forceps
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 Implantation.

After the cataract is removed and viscoelastic 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

rotated 90 degrees. The forceps are removed
from the capsulorrhexis, and the IOL settles
in the capsular bag. The capsulorrhexis is
clearly seen in front of the optic part of the
IOL (Fig. 229). Generally, PMMA lenses are
used, and the preferred diameter of the optic
is 6.5 mm.
Acetylcholine 1% is applied to induce
4 mm of miosis. Subsequently, a peripheral
iridectomy is performed.
Suturing and Aspiration of the

Viscoelastic
The incision is closed with 5 to 7 nylon
radial sutures. The knots must be buried in the
sclera (Fig. 229).
The viscoelastic material is aspirated.
The anterior chamber is restored to normal
depth with 1% acetylcholine (lyophilized acetylcholine dissolved in BSS) The conjunctival 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 occupies 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 conjunctival 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

methods. They allow successful removal of
the cataract through a small incision and
manually, without the need to use mechanized equipment.
We hereby present the three most
widely accepted: 1) Michael Blumenthals
Mini-Nuc (Israel); 2) David McIntyres
Phaco Section (USA); and 3) Francisco
Gutierrez C., Manual Phacofragmentation.
There is a significant learning curve, and

experience is required.
The proposed Mini-Nuc technique must
be performed under positive intraocular pressure during all stages of surgery. The desired
IOP is achieved during surgery with the use
of an anterior chamber maintaining system,
and controlled by the height of the BSS bottle
(Anterior Chamber Mainteiner (ACM) in
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
inception, 10 years ago. Blumenthal has
continuously worked at improving the
method he created and its results.
Principles of the Mini-Nuc

Technique
The procedure requires only a small
incision and no stitches. It has proven to be
safe surgery. It is possible to use topical
anesthesia, and rehabilitation is speedy.
Moreover, it is cost-effective. There are some
disadvantages, however, of manual ECCE. It
is not an easy technique to learn and perform.
The principle of maintaining positive

IOP during cataract surgery is gradually
becoming acceptable to more surgeons, even
those performing phacoemulsification. In the
mini-nuc technique, positive IOP exists 100%
of the operating time. Any fluid lost during
intraoperative maneuvers is promptly recovered because of the large internal diameter of
the ACM tubing (A in Figs. 230-231). The
steady flow ensures a constant depth of the
anterior chamber. This flow continuously
washes all debris: blood, pigment, and leftover cortical material from the eye with low
turbulence and low fluctuation of anterior
chamber depth. Consequently, less postoperative inflammatory reaction occurs.
375
The BSS bottle can be used as a reservoir of pharmacological drugs to be infused

continuously into the eye. These drugs may
include adrenaline 1:1,000,000, to keep the
pupil dilated, antibiotics, and any other drug
the surgeon wishes to use. The length of
surgery is not critical as the constant positive
IOP keeps the aqueous blood barrier intact;
and the ciliary processes and choroidal,
retinal, and iris vessels are not exposed to a
hypotonic environment at any time. This
helps to prevent exudate formation or a
worse complication, expulsive hemorrhage.
Blumenthal considers that positive IOP
provides not only a safe milieu and prevents
complications; it is a precondition for controlled surgery. Because the internal architecture of the eye is not disturbed, planned
maneuvers can be carried out safely.
SURGICAL TECHNIQUE
Anesthesia, Paracentesis, ACM
Lidocaine 4% drops are instilled 15
minutes before surgery 3-4 times. At present
Esrecain gel is used with each Lidocaine
drop. A total of 0.2-0.3 cc of Marcaine 0.5%
with adrenaline is injected subconjunctivally
between 11:00 and 2:00 in the limbal area,
where diathermy will be applied. During surgery, 0.2-0.3 cc of intraocular non-preserved
Lidocaine is injected into the tube of the
ACM. It will reach the eye in diluted form.
This is very efficient, cost-effective ocular
anesthesia.
Two paracenteses are performed at
10:30 and 2:30 by stiletto knife (identified as
D in Fig. 230). Moderate beveled incisions
376
are made in clear cornea just at the edge of the

blood vessels. The same stiletto knife is used
for an incision just anterior to the limbus in
the clear cornea for the purpose of inducing
the ACM cannula (5149 oval Visitec) in the
6 o'clock area (identified as A in Fig. 230).
Paracentesis Incision and Fixation of ACM

The most important aspect of the beveled tunnel paracentesis incision to introduce the ACM is its length. The incision
should be at least 2 mm long before the knife
penetrates the AC, and will be 1 mm wide
(Fig. 230-A).
The ACM is introduced into the tunnelshaped paracentesis, beveled edge up. When
it reaches the AC, it is turned beveled edge
down, and the ACM flow is directed towards
the iris. The ACM is introduced 2.0 - 2.5 mm
into the AC, and not more. The shallower the
depth of the AC, the greater care the surgeon
should take not to exceed these limits. (In
the illustrations, the cannula is shown beveled
up for clarity but at surgery it should be kept
beveled down toward the iris.)
Height of BSS Bottle

Normally, the BSS bottle should be
located 40 to 50 cm above the eye, keeping
the IOP at 30-40 mm Hg. If intraocular
bleeding occurs, raising the bottle will stop
the bleeding. If a posterior capsule tear occurs, the bottle should be lowered to 20 cm.
The BSS bottle should be lowered even
further to 10-15 cm when suturing, in order
to achieve the best adaptation of the incision
edges.
Figure 230: Creation of the Special Sclero-Corneal 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 intraocular 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 incision, 0.3mm in depth and 4-5mm long, 1mm behind the limbus is made. A crescent knife (C) dissects the tunnel, first 1mm in sclera, then 2-3mm
forward into clear cornea (1), then extending laterally (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 incision 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 maintaining system.
The most important concept to keep in

mind is that the height of the BSS bottle can
be changed depending upon the situation. It
does not need to be standardized, and the
surgeon can adjust it according to his/her own
technique, and varying needs during surgery.
Capsulorhexis
The ACM and positive IOP push the
crystalline lens backward reducing the force
of the zonules exerting pressure on the anterior capsule toward the periphery. This facilitates capsulorhexis performed by a cystotome, and avoids unintended tears toward the
periphery of the crystalline lens. Forceps introduced through the paracentesis corneal
tunnel produce outflow of BSS thus reduc-
ing the AC depth and causing the zonules to

pull the anterior capsule more forcefully.
Blumenthal
believes
that
although
capsulorhexis can be done successfully using
forceps with viscoelastic material or even
BSS only, positive IOP in the anterior chamber provides the best precondition for successful and controlled capsulorhexis performed through the paracentesis using a cystotome.
Conjunctiva
A conjunctival flap is cut 1 mm from
the limbus between 11:00 and 2:00. The
1 mm of conjunctiva attached to the limbus
facilitates the postoperative healing process.
377
Healing of conjunctiva to conjunctiva occurs

quickly and is stable, unlike the healing process between conjunctiva and limbus. The
attached conjunctiva also makes it possible to
glue the edges of the conjunctiva by coagulation
Sclerocorneal Pocket Primary

Incision and Tunnel
Precondition for Utmost Controlled
Dissection
The main reason the ACM is introduced at the beginning of surgery is to keep
the IOP between 30 and 40 mm Hg to make
the eye coats taut. The importance of this
precondition for the utmost controlled dissection in the sclera and cornea should not be
underestimated (Fig. 230). Most unintended
misdirected scleral dissection, premature entrance to the anterior chamber, or failure to
achieve a full-size scleral pocket tunnel occur
as complications of dissection in soft, floppy
tissue.
The sclerocorneal tunnel architecture
of the primary incision which Blumenthal
prefers for manual ECCE begins with an
external straight scleral incision 4 to 6 mm
long and 0.3 mm deep (Fig. 230). It should
be performed 1 mm behind the limbus at the
surgeons choice of location, either 12:00 or
temporal. As the external incision is cut
straight, the distance of this incision varies
gradually from the limbus. It is 1 mm behind
the limbus at 12:00, while on both sides the
external incision is further away form the
curved limbus, up to 1.5 mm to 2 mm
378
At the bottom of the 0.3 mm deep

external cut, dissection is extended anteriorly
until it engages the limbal tissues, which
resist dissection more than scleral or corneal
tissues. In overcoming this extra resistance,
the surgeon must take care not to press forward too forcefully, which might cause uncontrolled forward corneal dissection and
premature perforation of the AC. Control of
lamellar dissection at all stages is critical.
Dissection continues forward for about
2 mm in clear cornea. As the dissection
approaches the lateral edge of the tunnel, the
knife is swept sideways 45 degrees, resulting
in a funnel-shaped tunnel (identified as C 2,
3 in Fig. 230) . Thus the internal aspect of the
tunnel is about 25% larger than the external
incision. While the crescent knife is at the
lateral edge of the straight external part of the
incision, dissection should be carried obliquely backward. In this way the crescent
knife forms a lateral pocket on both sides
(identified as C 1, 2, 3 in Fig. 230), extending
backward for 1 mm on each side. A backward incision 90 degrees to the limbus such
as hereby described, does not induce astigmatic effect. With practice the result should
be a well-constructed pocket sclerocorneal
tunnel (Fig. 230).
Now the keratome is slid into the
tunnel (identified as I-K 4 in Fig. 231) with a
slight side to side movement to prevent
premature perforation of the anterior chamber. When the tip of the keratome reaches the
end of the tunnel, the keratome is then tilted
downward to enter the anterior chamber.
After entering the anterior chamber, the
keratome is moved laterally and forward
Figure 231 - Creation of the Special Sclero-Corneal 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). Anterior 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 movements directs the internal incision in curved
fashion parallel to the limbus. The procedure
is repeated on the other edge of the tunnel.
Thus the extreme edges of the internal incision (temporal and nasal points of entry of the
AC), are 3.5 to 4.0 mm from the lateral
points of the external incision. A common
error in constructing this tunnel occurs when
the keratome, instead of moving laterally and
anteriorly, is directed laterally and backward,
thereby creating a much smaller tunnel. The
more funnel shaped the tunnel is, the less
astigmatism induced, and the less potential
there is for BSS leakage from the AC either
during or after surgery. All these movements
are performed while the eye is fixated with
Bonn forceps, away from the tunnel incision.
Hydrodissection and Nucleus

Dislocation
Hydrodissection is performed through
one of the two paracenteses located at
10:30
and 2:30 (Fig. 230). Professor
Blumenthal uses a 1 cc syringe attached to a
cannula. A 3-5 cc syringe should not be used,
as a sudden surplus of BSS in the crystalline
lens might burst the posterior capsule. The
cannula should be introduced under the anterior capsule at the 12:00 position. No more
than 0.1 cc to 0.3 cc of BSS is injected,
engulfing the lens contents instantly by
hydrodissection. In most cases the nucleus
tilts forward into the AC at the 12:00 position,
as the BSS fluid accumulates first at this
379
location (Fig. 232). In cases where the

nucleus is not partially dislocated anteriorly,
one or two Sinskey hooks are introduced at
one or both paracenteses located at 11:00 and
2:00. Uneven pressure by one hook while the
nucleus is rotated causes the nucleus to tilt
and gradually to dislocate anteriorly. The
surgeon should make sure that the nucleus
tilts up toward the wound. If it does not, the
lens should be rotated further until this alignment is achieved. When the tilt is not sufficient in the surgeons judgment, the bent part
of a cannula should be introduced under the
lens while BSS is injected. This will cause the

nucleus to move gradually anteriorly completely into the AC (Fig. 232). The use of too
much force during this maneuver can cause
the lens to suddenly touch the endothelium.
Blumenthal does not remove cortex at
the center of the lens anteriorly because this
cortex protects the endothelium from the
rough nucleus during movements in the AC.
The lens does not need to be completely
dislocated to the AC before extraction can
begin. When the nucleus is free after rotation,
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 controls intraocular pressure during the circular capsulorhexis. A hydrodissector cannula (H) is
introduced through a paracentesis (D) under the anterior capsule at the 12:00 oclock 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 epinucleus 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 - Surgeons 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 anterior chamber. High intraocular pressure from the
anterior chamber maintainer causes the nucleus and
epinucleus (N)(shown in ghost views) to move toward (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 initiate the movement of the nucleus toward the incision 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 expression of the nucleus (inset below). Anterior
capsulorhexis (C).
Nucleus Expression Using Glide and

High IOP
Before the lens glide is introduced
under the nucleus, the surgeon must first
assess whether viscoelastic material is needed
in addition to the ACM. Blumenthal considers using viscoelastic in shallow chambers
and in patients with glaucoma that may have
a small pupil. The glide should not be induced
forcefully as it might engage the nucleus
itself rather than slide under it (Fig. 233). The
glide should not move too far inferiorly or it
may tear the posterior capsule. If a glide is
not used, the nucleus may not move in a

controlled way towards the incision.
To move the nucleus (with its epinucleus) into the wound, slight external pressure should be exerted with a closed forceps
or other instrument on the glide inside the
tunnel in a stroking pattern. The strokes may
need to be repeated a few times until the
nucleus is pushed forward by fluid from the
ACM to engage the mouth of the sclerocorneal tunnel (Fig. 234). At first, BSS still leaks
around both sides of the nucleus. Stroking is
continued until the nucleus is well lodged in
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 intraocular pressure from the anterior chamber maintainer (A-arrow) causes the nucleus and epinucleus (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 pressure should not be made in the tunnel when
the nucleus is engaged, as pressure in the
tunnel would open the tunnel and new leakage would begin, preventing nucleus expression.
Now pressure is shifted out of the tunnel, posteriorly, onto the sclera. This slightly
changes the position of the nucleus in the
tunnel to allow expression. The nucleus
rocks from side to side, and rotates slightly on
its axis while finding its way out of the tunnel
(Fig. 234).
The amount of pressure to induce can
be assessed by observing the depth of the AC,
382
which should not change. If the AC collapses, stop pressing and allow it to reform.
The preceding description is accurate
when the tunnel is large enough to allow the
nucleus to pass through the tunnel. During
this move, it sheds any remnants of epinuclear material; in this way the smallest
possible nucleus is delivered. The remnants
of the epinucleus are observed as leftover in
the AC; they are soft and easily expressed by
the hydrostatic pressure itself (Fig. 235).
Their progress is helped by gentle strokes in
the tunnel, causing BSS to flow out of the
eye. The BSS on its way out engulfs the soft
epinucleus and flushes the epinucleus out.
Figure 235: Expression of Epinucleus

If the epinucleus (1) remained in the
scleral tunnel pockets, it may be hydroexpressed (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

expressed, the surgeon has two choices: (1)
Enlarge the inside aspect of the tunnel, not
the external incision; or (2) Perform chipping.
Part of the nucleus is exposed in the incision.
A 25 gauge needle is introduced into the
nucleus, chipping off a small triangular
piece. The smallest new diameter of the
nucleus can be made small enough for the
nucleus to be expressed.
Epinucleus and Cortex Extraction

Epinucleus
Continuous flow and positive IOP inflate the capsular bag after nucleus extraction.
The soft epinucleus left behind in the AC is
usually hydroexpressed spontaneously. To facilitate this maneuver a spatula can be
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 epinucleus from its adherence to the cortex and
allow it to be flushed out.
paracentesis port for aspiration allows the

amount of BSS aspirated or lost to be instantaneously replaced by the anterior chamber
maintainer.
The Cortex
IOL Implantation
Blumenthal recommends aspirating
the cortex manually; aspiration is better
controlled using a 5 cc syringe and cannula
(Fig. 236). The cannula should be introduced
from one of the paracentesis sites and not
from the tunnel because introducing a cannula through the tunnel may allow BSS to
escape. The resulting instability of the posterior capsule would be unfavorable for
smooth aspiration of the cortex. Using the
The leading haptic is inserted into the

AC and under the anterior capsule at 6:00
o'clock (Fig. 237). The anterior chamber may
become shallow for a short period during this
maneuver. For this reason a strong IOL holder
is recommended so that the leading loop can
be directed under the capsule even in the
presence of a shallow AC. When the leading
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 paracentesis (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 located in the equator of the lens bag. This pressure and that from the anterior chamber maintainer (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 oclock. The anterior chamber maintainer (A) keeps the capsular bag ballooned during implantation. Anterior capsulorhexis (C).
holder is released, but not before forceps

grasp the trailing loop outside the eye to
prevent the IOL from springing out of the bag
at 6:00. A modified Sinskey hook is inserted
through one of the paracenteses, usually at
10:00 for right-handed surgeons and the lens
is manipulated into the bag. The trailing loop
is introduced into the AC first. Then the IOL
is rotated while pushing backward (Fig. 238).
Thus the trailed loop enters the bag
(Fig. 238). Blumenthal prefers to have holes

in the loops and one hole in the haptic near
the optic for manipulating the lens into the
capsular bag. Blumenthal has seen no ill
effects resulting from haptic holes.
When to Use Viscoelastic

In cases where any difficulty arises
during implantation, especially in young
385
Figure 238: Intraocular Lens Implantation Technique - Stage 2

With the distal haptic already located within the capsular bag at 6 oclock,
the forceps (F) moves the proximal haptic
laterally (1-arrow). A Sinsky hook (S)
placed through the paracentesis (D) engages the haptic hole (H) in the loop.
While rotating the lens (2-arrow), the
proximal haptic is introduced into the anterior chamber, compressed with the hook,
directed behind the anterior capsule (3-arrow) and into the bag in one motion. Anterior chamber maintainer (A). Anterior
capsulorhexis (C).
people, or if the anterior chamber is shallow,

the use of viscoelastic material is indicated. It
is easier to introduce the IOL into the AC in
the presence of viscoelastic, but manipulation
of the lens into the final preferred position is
more easily achieved in the presence of BSS.
Viscoelastic is not contraindicated during
manual small incision Mini-Nuc ECCE while
using the anterior chamber maintaining system, but the BSS flow should be reduced or
stopped. It is better to activate the ACM
system during aspiration of the viscoelastic.
This keeps turbulence and fluctuation to a
minimum.
386
Pupil Enlarged by Increased IOP

Deepening the AC with the ACM and
increasing the IOP from 10 mm Hg to 30-40
mm Hg, pushes the iris back and sideways,
dilating the pupil mechanically beyond the
pharmacological effect of the dilatation
drugs. In certain cases the pupil stays extra
dilated at the end of surgery because of a
phenomenon known as reverse pupillary
block. No long-term ill effects arise from this.
After a few minutes the reverse pupillary
block subsides, as pressure in the posterior
chamber rises above that existing in the AC.
The block can also be broken mechanically
by introducing a spatula under the iris. The

pupil immediately becomes smaller, and the
iris moves forward.
Advantages of the Continuous Flow

of BSS during Manual ECCE
Removes debris: The anterior chamber
is washed throughout surgery. All pigment
debris is washed out, reducing to a minimum
possible ill effects during the postoperative
period.
Stops bleeding: When bleeding occurs
in the tunnel or in the anterior chamber during
surgery, it can be stopped by increasing the
IOP. Moreover, no blood accumulates during
surgery, as it is washed out by the continuous
flow.
Frees cortex remnants: These remnants find their way out of the eye due to the
continuous flow through the AC. The rest are
aspirated by a 5 cc syringe with a cannula
attached. The aspiration is usually performed
at the final stage of the surgery before the
ACM is pulled from the eye.
Removes viscoelastic: Viscoelastic material can and sometimes must be used during
the surgery. It can be flushed out by fluid
from the ACM or aspirated. Leftover quantities of viscoelastic are removed from their
hidden locations with short bursts of BSS
produced by a 1 cc syringe and cannula.
Cleans posterior capsule: A 1 cc syringe attached to the hydrodissector cannula
is used to create an intermittent water jet
effect on the posterior capsule to clean it from
attached cortical material (Fig. 233). This
procedure is much more effective when the

ACM is used. The freed cortical material is
aspirated whenever it is separated form the
capsule. Aspiration of cortical material directly from the posterior capsule involves
much more dangerous manipulation, as most
capsule tears occur during this stage of the
surgery.
Prevents inflow : Hypotony, even if it
occurs for a very short period, can cause
inflow from outside the eye into the eye. With
the ACM system, its active flow prevents
foreign material from washing into the AC.
By the same mechanism bacteria are partially
prevented from entering the eye. If an instrument does carry bacteria to the AC, the bacteria may be washed out reducing the likelihood of endophthalmitis.
Complications
Posterior capsule tear: Tears in the
posterior capsule are mostly caused by suction with the aspiration cannula. The presence
of the AC maintaining system during unintended tear of the posterior capsule pushes the
vitreous face backward. In 70% of cases of
unintended tear of the posterior capsule, the
vitreous face stays intact. When the vitreous
face is intact, BSS does not enter the vitreous
body, even if the IOP is 40 mm Hg.
The hypothesis that vitreous hydrates
when in contact with BSS is not true. Hydration occurs only if the vitreous face is broken.
During manual ECCE there is little turbulence or fluctuation; most of the time there is
no movement at all. The amount of BSS used
387
throughout one modern ECCE procedure during 10 minutes of surgery is only 20 cc to 30

cc The amount of flow during each minute of
the surgery is 2 cc to 3 cc. This amount
produces the least possible turbulence. Controlled aspiration using a 5 cc syringe in the
presence of a posterior capsule tear can be
performed without vitreous engagement, and
aspiration of cortical material in the presence
of posterior capsule tear is continued until the
capsule bag is free of cortex, without enlarging the tear.
The steady condition allows the surgeon to perform the most delicate maneuver
possible, aspiration of cortical material lying
on the vitreous face. This maneuver can be
done only if the vitreous remains still, with no
fluctuation.
Vitreous involvement: When vitreous
enters the AC through a posterior capsule
tear, vitrectomy must be performed. An existing ACM is a great advantage at this stage.
Because an imbalance of inflow and outflow
would aggravate the situation, Blumenthal
recommends the paracentesis entrance for the
vitrectome tip. Steady conditions during vitrectomy ensure the procedure can be performed in a controlled manner. Because the
posterior capsule does not move in an uncontrolled fashion, enlarging the size of the tear
can be avoided. Enlarging the posterior cap-
388
sule tear during vitrectomy reduces the option

of choosing the bag as the best fixation site
for the IOL.
Locating vitreous strands is another
very important aspect of the art of vitrectomy.
Two-handed vitrectomy, during which the
surgeon has a spatula in one hand and the
vitrectome in the other, enables the surgeon to
search for and locate vitreous fibers. Getting
rid of all the vitreous strands, whether large
or small, is essential. A quiet milieu allows
the surgeon to search with the spatula carefully for strands over the iris and at the
opening sites of the paracenteses and the
tunnel. Eyes after such vitrectomy without
strands in the AC have a very low rate of
CME or iris deformation. In cases where the
smallest vitreous strands remain, on the other
hand, the incidence of CME is much higher.
Expulsive Hemorrhage Minimized by
Positive IOP: This rare phenomenon can be
reduced to a minimum in routine cataract
surgery, and in complicated or traumatic eyes
by using continuous positive IOP during surgery. No hypotony occurs to cause leakage
from, or rupture of choroidal or retinal blood
vessels, especially when they are arteriosclerotic. Therefore expulsive hemorrhage or partial choroidal hemorrhage is mostly prevented.
THE SMALL INCISION PHACO SECTION

MANUAL EXTRACAPSULAR TECHNIQUE
Overview
We here present the Phaco Section
cataract technique as developed by David
McIntyre, M.D. one of the most talented and
expert cataract surgeons in the U.S. We
describe the evolution of his cataract surgery
technique, present highlights of the procedure
he has been using for 10 years, suggest how a
surgeon can make the transition to the 5.5 mm
wound Phacosection, and outline his surgical
procedure step by step.
At present McIntyre continues to use
a 5.5 mm, non-sutured self-sealing, corneoscleral tunnel incision placed temporally under
a peritomy, through which extracapsular
cataract surgery is performed and a posterior
chamber intraocular lens (IOL) is placed in the
capsular bag. The intraocular lens is a 5.5 mm
round, one-piece polymethylmethacrylate
(PMMA) IOL placed in the bag, presently
manufactured by Surgidev.
McIntyre uses an anterior chamber
maintainer, capsulorhexis and the nucleus is
sectioned into 2 or 3 fragments, occasionally 4,
with few exceptions in ages under 50-55.
surgery, using Kelman's phacoemulsification

technique. During the past 20 years he has
devised a number of instruments and modified
techniques, resulting in extracapsular surgery
with smaller and smaller incisions. Currently
the incision is self-sealing and just large enough
for the IOL implantation.
From the perspective of results with
patients, McIntyre has found no reason to
return to the emulsification of the cataract
nucleus with
ultrasonic energy
(phacoemulsification). At the same time he has
personally attempted to develop a number of
mechanical devices to aid in cortex aspiration.
With each device he has reaffirmed that he has
greater control over the operation when he uses
a completely manual technique.
Indications
McIntyre strongly believes that a basic
advantage of the Phaco-Section is its
applicability to all degrees of hardness of
nucleus, from soft (+) to moderate (++), to
fairly hard (+++) and to hard (++++), with truly
minimal variations.
Evolution of Technique
PHACO SECTION MOST

IMPORTANT FEATURES
McIntyres surgical technique has had

a complex evolution. In 1974, he made the
transition from intracapsular to extracapsular
The three separate tissue zones of the

lens are shown in Fig. 239 to enhance the
understanding of how Phaco Section works.
389
Figure 239: The Three Tissue Zones of the Lens

This anterior globe cross section shows the three separate
tissue zones of the lens. Portions of the lens are shown removed to
reveal the three dimensionality of these tissue zones. The rigid
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
third and outer zone is the cortex (C) which is soft gelatin that is easy
to aspirate, and lies just under the capsule (D). Note the 6 mm
diameter circular capsulorhexis, which is large enough to allow the
management of almost all nuclei by the phacosection technique.
Air (A) is used to fill the anterior chamber during capsulorhexis to
maintain the chamber depth and to eliminate the magnification
effect of the corneal curvature.
The following are the most important

features of McIntyres Phaco-Section surgical
procedure.
Capsulorhexis
This is performed through the incomplete
tunnel incision that is perforated only by the
cystotome.
390
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 "canopener" 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
and control of the fragment of anterior capsule
much easier for the surgeon. Lying on the
surface of the cataract as it is torn around the
circle, the fragment is very easily visualized.
And finally, and perhaps most
importantly, when the fluid is removed from
the anterior chamber and is replaced with an air
bubble, the magnification effect of the cornea
is almost entirely neutralized, so that it is easy
to understand the actual dimensions. When the
anterior chamber is filled with fluid, the cornea
becomes a 15% magnifier on average, making
the capsulorhexis appear much larger than it
really is.
Completing the Tunnel Incision

After the capsulorhexis has been
completed, the surgeon must complete the
tunnel primary incision into the anterior
chamber. There is a paracentesis just to the
right end of the tunnel incision, but the tunnel

has been perforated only by a needle (the
cystotome) up to this point. McIntyre enlarges
the primary incision by grasping the margin of
the scleral lip with a colibri forceps and passing
a 15-degree supersharp blade through the
cystotome puncture to slightly enlarge the
incision. Then, with the double-bevelled
crescent knife, he enlarges the opening into the
anterior chamber to the full length of the tunnel
incision, which is 5.5 mm to 6 mm (Fig. 241).
concavity facing the great circle that connects

the two ends of the incision does not allow any
stretching or raising of the flap. This is the
reason the superficial layer of dissection in a
tunnel has a very firm, unyielding geometry
which to resists deformity or increased
pressure within the globe. As long as the
incision is concave to the great circle, a
satisfactory self-sealing tunnel can be created.
With the exception of children, the tunnel
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 dynamics of the self-sealing incision.
Shallowness of the tunnel is important in
preventing frequent hyphema. Deep tunnels
tend to have frequent hyphemas; superficial
tunnels tend not to result in frequent hyphema.
McIntyres analogy is a great circle, which is
the shortest distance between two points on the
surface of the sphere, a common concept used
in navigation (Fig. 240). On the eye the ends
of an incision can be connected by a great circle
around the globe. If any pressures and traction
occur, there is a tendency for a wrinkle to
develop that connects the two ends of the
incision along the great circle.
Consequently, if a scleral flap is fashioned
following the curve of the limbus, that scleral
flap must be sutured in position because any
deformity of the globe will cause the eye to
wrinkle along the great circle connecting the
two ends of the incision. The scleral flap
would become a free, non-supporting structure.
In contrast, a frown-type incision that has a
The anterior chamber maintainer that

McIntyre uses is a threaded or screw-like tip
of metal tubing attached to a silicone tube,
which is then attached to the hub of a needle. It
can be plugged into a fluid source and has a
flexible connection with the eye (Fig. 241).
The internal diameter of the metal tubing is 0.6
mm. The threaded outer surface of the tube is
able to grasp the corneal paracentesis very
firmly so that when this has been screwed into
the cornea it will hold in that position even
when the eye is rotated rather vigorously.
At the conclusion of the procedure it
must be unscrewed to be removed. During its
introduction the silicone tube and the maintainer
tip itself have a stylette passed into them; the
resulting rigidity allows the turning process,
and a rounded point at the tips allows it to easily
pass through the paracentesis. The fluid source
for the chamber maintainer is balanced salt
solution (BSS), which contains additional
antibiotics for prophylactic purposes and is
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

gravitational force, on the fluid that is entering
the anterior chamber can be easily adjusted.
The infusion tubing that comes from the BSS
bottle to the table also has a roller valve so that
the assistant can turn the maintainer system on
and off as needed throughout the procedure.
392
Aspiration of the Anterior Cortex and

Epinucleus
With the tunnel completely opened and
with the chamber maintainer operating and its
pressure somewhat elevated, the surgeon does
the preliminary aspiration of the cortex and
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
three separate tissue zones (Fig. 239). Starting
from the center is the nucleus, a rigid material
that is too viscous to allow aspiration. The
second zone is the epinucleus or, as it is often
called, the epinuclear bowl. The epinucleus is
a relatively firm gelatinous material with an
intermediate degree of viscosity, which can be
aspirated with sufficient vacuum. The third
zone is the peripheral cortex, which lies just
under the capsule surface. This gelatinous
zone is of a very low viscosity and is freely
aspirated.
This perspective of the three zones of the
cataract clearly reveals an important safety
factor in aspiration. Whether using manual or
mechanical methods, the surgeon has more
control when aspirating from the less viscous
cortex toward the highly viscous nucleus.
On the other hand, there is a potential loss
of control and an extreme danger when
aspirating from the more viscous element, such
as the epinucleus, toward the peripheral cortex.
In this circumstance when the aspirating
Figure 241: Aspiration of Anterior Cortex and Anterior Epinucleus

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)
is at the top. First, an anterior chamber maintainer (M) is inserted
nasally. A 6 mm circular capsulorhexis (A) is performed. The 5.5
mm frown shaped scleral tunnel (T) incision is completed. A
specially sharpened 21 gauge cannula (D) is introduced through a
paracentesis made to the right of the scleral tunnel incision. Inset
shows detail of the tip of the cannula. The port of the cannula is
directed posteriorly to aspirate the central cortex (C), and
epinucleus (E) overlying the anterior surface of the firm nucleus (N).
A furrow is created around the equatorial area of the nucleus.
instrument clears a portion of the viscous

epinuclear material, the cortex will then move
through the aspirating system at a much greater
velocity, challenging the control of the surgeon
to avoid impaction and probable tearing of the
posterior capsule.
Phacosection
Following the preliminary aspiration of
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 (arrow) 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

of only the central hard nucleus using a 27gauge, slightly narrowed and slightly curved
cannula (Fig. 242). With this hydrodissection
he also tilts forward the margin of the nucleus
nearest the incision. Then the nucleus itself
can be divided into a number of fragments
using the technique called Phacosection
(Fig. 243). This term, which McIntyre finds
very useful, originated with Peter Kansas in
New York. The procedure involves dividing
the nucleus into a number of fragments, the
number being determined by the size and
hardness of the nuclear material, usually 2 or 3,
occasionally 4. Each of these fragments is then
individually surrounded by a layer of heavy
viscoelastic material (Fig. 244) and simply
extracted from the anterior chamber with their
protective viscoelastic coating using a pair
of instruments designed for this purpose
(Fig. 245).
394
Removal of Epinucleus and

Cortical Cleanup
Following the removal of the divided
nucleus particles, the epinucleus is then removed as a second stage. The epinucleus is
hydrodissected from its attachment to the
peripheral cortex (Fig. 246). In most cases the
epinucleus is a continuous structure which can
be hydrodissected, brought forward into the
anterior chamber, and hydraulically expressed.
The epinucleus is not removed by aspiration.
The third stage of the cataract tissue
removal is simple aspiration of the residual
cortex. The only stages of the procedure
performed by aspiration are the preliminary
aspiration of the anterior cortex and epinucleus,
and then the final cleanup of the residual
peripheral cortex. In this way the process of
aspirating from a more viscous to a less viscous
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 patients behalf in comparison
with the conventional large-incision
planned extracapsular. These advantages
are: more safely, a much more rapid
recovery, a much more durable eye during
Figure 244 (above): Surrounding Nuclear

Pieces with Viscoelastic
Each fragment of nucleus is individually 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 contains viscoelastic with the anterior chamber maintainer (M) turned off during this sectioning.
395
Protocol for Phacosection Surgery

The total small incision self-sealing
phacosection cataract procedure with lens
implantation can be summarized in the following
steps:
1) A standard patient preparation with
wide dilation of the pupil. Peribulbar anesthesia
followed by 40 minutes of oculopression with an
equivalent of 30 mm pressure. The patient is
draped with isolation of the lid margins and
insertion of the speculum.
2) A nasal limbal paracentesis is followed
by insertion of the anterior chamber maintainer,
which is then turned on (Fig. 241).
3) A temporal limbus based conjunctival
flap of 3 to 4 mm width is made with mechanical
dissection of the limbus and limited bipolar
cautery of the episcleral vessels.
4) A 6 mm frown incision is marked with
calipers on the surface of the sclera, avoiding any
major scleral vessels (Fig. 240).
5) A superficial scleral tunnel is dissected
with a crescent blade. A paracentesis is created
to the right side of the incision tunnel. Then
perforation is made through the base of the tunnel
into the anterior chamber at the center of the
tunnel with a hooked cystotome.
6) The anterior chamber maintainer is
turned off. The anterior chamber is inflated with
air through the cystotome, and a capsulorhexis of
approximately 6 mm diameter is created.
7) The chamber maintainer is turned on.
Perforation is made through the central tunnel
puncture with a 15 degree super sharp blade,
followed by the crescent blade to enlarge the
internal aspect of the tunnel incision to its full
dimension.
396
8) Any remaining air bubbles and the

capsule fragment are aspirated through the tunnel
incision with a 21-gauge cannula. The chamber
maintainer is elevated to increase the hydrostatic
pressure. Preliminary aspiration of the anterior
cortex and the epinucleus down to the face of the
nucleus is done with the 21-gauge cannula through
the paracentesis (Fig. 241).
9) Hydrodissection of the firm central
nucleus is done with a 27-gauge cannula through
the paracentesis, tilting forward the equator of the
nucleus adjacent to the tunnel (Fig. 242).
Hydrodissection is intended to elevate the smallest
identifiable nucleus and to tilt forward only the
equator that lies directly in front of the tunnel
incision.
10) The anterior chamber maintainer is
turned off. The anterior chamber is deepened
with viscoelastic of high viscosity; a small amount
is injected behind the nucleus to hold it in the tilted
position if necessary. With a cutting board and a
single nucleus cutter the surgeon reaches into the
anterior chamber (Fig. 243). Depending on the
size and hardness of the nucleus, the surgeon
decides how many cuts in the nucleus will be
needed. With the single cutter he then makes one,
two, or three cuts as required. The two instruments
are withdrawn.
11) Additional viscoelastic is injected
and the cannula is used to position the first fragment
of the cut nucleus that appears most readily
accessible for removal (Fig. 244).
12) With the shield of viscoelastic in
place, the surgeon reaches into the anterior
chamber with the two nucleus extracting
instruments, which look very much like a pair of
spoons. The two spoons surround the fragment of
nucleus and remove it from the anterior chamber
(Fig. 245).
13) Additional viscoelastic is used to

isolate each individual fragment as it is removed
with the extracting instruments. The average
volume of viscoelastic required is .25 ml.
14) The chamber maintainer is turned
on. Hydrodissection of the epinucleus is done
with the 27-gauge cannula and balanced salt
solution (BSS). The entire epinucleus is
hydroexpressed with or without the irrigating
spoon (Fig. 246).
on the introduction forceps. The IOL is introduced

under an assisting 30-gauge cannula with the
leading haptic placed directly into the nasal
capsular bag. The lens optic is steadied with the
30-gauge cannula as the introduction forceps are
removed. The trailing haptic is placed under the
incision into the capsular bag with a Dusek forceps.
The lens is rotated, its position is confirmed, and
the haptics are placed in the horizontal position.
15) The residual peripheral cortex is

aspirated with the straight and curved cannulas
through the paracentesis.
18) The conjunctival incision is sealed

with bipolar cautery. The corneal margins of the
paracentesis are hydrated with a 30-gauge cannula.
The chamber maintainer is removed. The margins
of the ACM paracentesis are hydrated with BSS.
16) The posterior capsule is polished

with the straight side ported aspirating cannula
turned posteriorward and introduced through the
tunnel incision.
19) Absence of iris incarceration is

confirmed. Final re-deepening and inspection of
the anterior chamber is done through the
paracentesis.
17) This is followed by inspection,

irrigation, and positioning of the intraocular lens
20) Finally, medications and dressing

are applied.
397
Figure 245 (right): Nuclear Fragment Removal

A spatula (S) introduced through the
tunnel incision is inserted under the viscoelasticcoated nuclear fragment (N). The extracting
instrument (X), shaped somewhat like an inverted spoon, is inserted over the nuclear fragment. 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 remaining nuclear fragment (F) still within epinuclear bowl (E). Anterior chamber maintainer
(M) is still off during this extraction.
Figure 246 (left): Hydrodissection and

Hydroexpression of Remaining Epinucleus
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). Working 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
phacofragmentation (MPF) that we hereby
present has been designed and developed by
Francisco Gutierrez C., M.D., of Spain. It
is performed with a 3.2 mm clear corneal
incision, which is the same size as in phacoemulsification. This manual phaco fragmentation (MPF) can also be done with a 3.5
mm scleral tunnel incision, which is the same
incision size for phaco when we utilize the
scleral tunnel technique (Figs. 247 and 248).
Benefits of (MPF)
As advocated by Dr. Gutierrez C., this
technique provides several important benefits,
as follows:
1) It can be performed with a small 3.2
mm incision if done in clear cornea and with a
3.5 mm incision if done with a scleral tunnel,
thereby resulting in minimum astigmatism and
rapid recovery (Figs. 247 and 248).
2) It functions well with hard and soft
nuclei.
3) It requires a low investment in the
equipment and instrumentation.
4) Presumably, it provides a very good
backup when complications arise and phacoemulsification must be discontinued. This
technique helps the phacoemulsification surgeon in the event of an accidental rupture of the
posterior capsule. Also, the instrumentation
facilitates extracting the nuclear fragments from
400
the AC through the small incision, avoiding the

need to enlarge it and convert the surgery to an
ECCE.
5) Presumably it is a method easier to
master than phaco.
6) No less important, it requires no sutures or stitches.
Experiences with Other Phaco

Fragmentation Techniques
In order to overcome the two main drawbacks of phaco: 1) difficult learning curve and
2) high cost of equipment, a good number and
variety of techniques for manual
phacofragmentation have been used in the past.
The limitations of these techniques have been
related to not being able to sufficiently reduce
the size of the incision because: 1) the instrumentation was coarse; 2) the nuclear fragments that were to be extracted from the anterior chamber were too large, usually because
the nucleus was divided into two or three pieces.
Why Use Gutierrez' Technique?

Positive Features of Instrumentation
The phacofragmentor designed by
Gutierrez, is manufactured by the English
firm of John Weiss & Son Ltd., a subsidiary of
the Swiss multinational Haag-Streit. With it
the nucleus is broken into very small 2 x 2 mm

pieces that can be extracted through a 3.2 or 3.5
mm incision (Fig. 247). This results in a
practically neutral postsurgical residual astigmatism.
The racquet-shaped design of the
fragmentor (see P and B in Fig. 247) keeps the
nuclear fragments within the racquet, avoiding
their dispersion as they are removed from the
AC.
The phacofragmentor or nucleotome has
a straight ophthalmic handle, with a 45 angle
at its end, which is 8 mm long and 2 mm wide
and racquet-shaped. The racquet is divided in
four parts by three transverse bars two millimeters apart (Fig. 247) which keep the small
pieces within the racquet. Other important
instruments are:
A spatula with a straight ophthalmic
handle, whose end is adapted to the dimensions
and angle of the nucleotome and serves as

support for phacofragmentation (see "S" in
Fig. 247).
Two straight-handled, ophthalmic manipulators, left and right, with a basket end,
which serve to collect the nuclear fragments
during the nuclear fragmentation (Fig. 250).
Anterior chamber maintainers were
pioneered years ago by Strampelli as well as
Joaquin Barraquer, and their use is always
emphasized by Michael Blumenthal for his
Mini-Nuc cataract extraction technique. The
Gutierrez AC maintainer (ACM) maintains
continuous irrigation with BSS in the anterior
chamber, creating positive pressure that stabilizes the AC depth. During the stages of the
operation in which the maintainer is used, the
amount of viscoelastic utilized is less, thereby
reducing costs.
Figure 247: Manual Multiphacofragmentation

Technique - Stage 1 - Fragmentation
Following creation of a 3.5mm scleral tunnel (I) or 3.2mm corneal incision, continuous circular 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 nucleus. With the nucleus sandwiched between the
two instruments (inset), the nucleotome is pressed
downward toward the spatula (arrow). This sections the nucleus into four fragments (1,2,3,4)
between the cross bars (B) of the racket shaped
nucleotome.
401
Surgical Technique
It is important to have good pharmacological mydriasis because the pupil may contract during surgery.
Incision: This method can be performed
through a 3.2 mm corneal incision (clear corneal) (Fig. 247) or through a 3.5 mm scleral
tunnel incision (scleral tunnel) 2 mm away
from the corneal-scleral limbus (Fig. 248). The
preparatory incision is made without penetrating the anterior chamber (AC).
Capsulotomy: A continuous circular
capsulorhexis is performed with a cystotome
through a superotemporal paracentesis. This
capsulorhexis should be sufficiently wide (approximately 6 mm) to allow an easy luxation of
the nucleus into the AC. The AC maintainer is
used during this step and when aspirating the
anterior cortex and epinucleus in soft and me-
dium-soft nuclei, before hydrodissection.

Nucleus Hydrodissection and Luxation: After entering the AC with a 3.2 mm
beveled blade, balanced salt solution (BSS) is
injected with a Binkhorst cannula through the
corneal or scleral incision between the anterior
capsule and the cortex at 12 o'clock.
The BSS must be injected slowly and
continuously until the "wave" of dissection is
visible on the posterior capsule. Injection of
BSS is continued until luxation of the nucleus
begins. If the luxation of the nucleus into the
AC is partial, it may be completed by rotating
the nucleus with a cannula, cystotome or spatula.
Nuclear Fragmentation: Once the
nucleus has been luxated into the AC, highdensity viscoelastic is injected into the surrounding area to fill the AC. The nucleus is
then fragmented by placing the spatula beneath
the nucleus and the nucleotome on top of it
Figure 248 - Manual Multiphacofrag-mentation 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 incision (I). Notice the remaining nucleus (N)
with center removed, within the anterior
chamber. This procedure is repeated until
the whole nucleus is fragmented and extracted. With hard nuclei, after capturing the
nuclear fragments (A) with both instruments
(P) and (S), space can be gained by extracting nuclear fragments (A) using only the
nucleotome (P), as hard fragments will remain 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 surgeons 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

pressing the nucleotome downward toward the
spatula until the part of the nucleus in it is
fragmented into four pieces (Fig. 247). The
pieces remain within the nucleotome, and
with the help of the spatula are extracted
from the AC using a "sandwich" technique
(Figs. 248 and 249). This maneuver is repeated
until the whole nucleus is fragmented.
During nuclear fragmentation it is important to refill the AC with high-density viscoelastic as needed to protect the corneal endothelium and facilitate safe manipulation during surgery.
Manipulation of Nuclear Fragments:

There are right and left manipulators to displace the remaining fragments of the nucleus to
the center of the AC to facilitate their fragmentation and subsequent removal (Fig. 250).
Cortex Extraction and Nucleus Removal: The lens cortex is aspirated with a twoway Simcoe irrigation-aspiration cannula
(Fig. 251). If small pieces of the nucleus
remain in the AC, they can be removed according to their hardness in different ways: with the
nucleotome and the spatula together (sandwich
- Figs. 247, 248, 249) or only with the
403
Figure 250 - Manual Multiphaco-fragmentation Technique - Stage 3 - Manipulation

of Nuclear Fragments
Left (L) and right (R) curved
manipulators (M) are used to displace (arrows) the remaining fragments of the nucleus
(N) to the center of the anterior chamber.
From there they will be fragmented and extracted in a similar fashion with the
nucleotome and spatula.
Figure 251 - Manual Multiphacofragmentation 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 extracted 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 irrigation of the AC aided by a fine cannula.
Intraocular Lens Implant and Wound
Closure: Viscoelastic is injected into the capsular bag and a foldable lens is implanted.
Sutures are not usually required.
Complications
In Dr. Gutierrez C. experience, complications are rare. There is always the possibility for mild corneal edema if much intraocular 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
3) The Phaco Tmesis System, of
Overview
Aziz Anis.
At present, there are four main avenues
of development for new techniques in cataract surgery. Those who advocate them consider that they might be better than phacoemulsification. They are:
1) The Laser Techniques

Two groups of procedures are done
with laser:
a) The Dodick Laser Photolysis System: This is the only one that has been
approved by the FDA in the United States and
is also clinically available in Europe. This
system is manufactured by Laser Corp., based
in Salt Lake City, Utah.
b) The Paradigm Nd:YAG Laser System, also known on the Phantom. This is
under investigational development by Paradigm Medical Industries also of Salt Lake
City.
2) The Catarex
System, being
developed by Richard Kratz et al.
4) Warm Water Jet Technology.

DODICKS
TEM
PHOTOLYSIS
SYS-
Dodick et al use a Q-switched Nd:YAG

laser. The pulsed laser and a specially designed probe to use this energy are utilized for
removal of the cataractous crystalline lens.
The probe has a quartz-clad fiber. The
proximal end of the quartz fiber is connected
to the laser source. The fiber enters the probe
through the probes infusion port and the
distal end terminates in front of a titanium
target inside the tip of the probe. This target
is an essential element of the device (Fig.
252).
The titanium target acts as a transducer, causing optical breakdown and plasma
formation to occur in the aspiration chamber,
and sending out acoustic shock waves configured by the targets shape to be maximized at
the aspirating tip. At the aspirating tip
nuclear material is shattered by the acoustic
waves and evacuated out of the eye.
409
Surgical Technique
As described by Kanellopoulos et al a
1.4 mm clear-cornea incision is made for
insertion of the Dodick photolysis laser-aspiration probe. A second, 0.9 mm corneal incision is made to provide irrigation or infusion
through a second probe. The infusion and
aspiration are done after a 6 mm CCC is
performed. The laser delivers pulsing photic
energy, which creates a shock wave that
emanates from the probe tip in a focused
cone. These shock waves break down the

substance of the cataract (Fig. 252). The
fragmented particles of the cataract are then
aspirated out of the eye.
The same probe is used to aspirate
the cortex.
At present, the incision needs to be
enlarged for insertion of a foldable IOL.
Industry is working on making foldable
lenses that can be introduced into the eye with
incisions smaller than the 2.8 mm minimum
used now.
Figure 252: Dodicks 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
According to Dodick, photolysis has
two primary advantages. One is that it will
allow smaller incisions and two, it generates
no heat. One of the disadvantages of classic
phaco is that the wound may be damaged by
heat. With laser photolysis, we will not have
any wound burns.
Photolysis is felt to offer more protection of the corneal endothelium and presumably it is a somewhat simpler procedure than
phaco.
THE CATAREX SYSTEM

This system is under investigational
development under the leadership of Richard
P. Kratz, Shoeila Mirhashemi, Michael
Mittelstein and John Sorensen. Through the
years, Kratz has made several major contributions to improve the techniques of phacoemulsification.
Catarax is a different technology that
may important advantages over phaco and
ECCE.
Potential Advantages and Technique

Lindstrom is participating in the investigational work in animals. As he describes it, it only requires a 1.0 to 1.4 mm
incision. The surgeon makes a one millimeter
incision in the anterior capsule with diathermy, just inside the edge of the iris where
he makes the wound. Then he puts in a
device that looks somewhat like a blender
blade into the eye that works through a vortex
action. This basically breaks up the lens,
allowing aspiration.
The potential advantage of Catarex
seems to be that there should be no corneal
endothelial cell loss, in contrast to phaco,

which even in good hands, may have a four
percent endothelial cell loss or more. With
Catarex, since all maneuvering is done inside
the capsule with its tight seal, the endothelium should have no damage. The other
potential advantage is that by working inside
the capsule this procedure might decrease
posterior capsular tears and eliminate iris
damage. All these potential advantages
should provide us a safer operation.
Another potential advantage is that it
is hoped Catarex may be easier than
phacoemulsification, which is a difficult
operation. If so, this would be a very positive
advance from the perspective of public health
and the availability to many people that who
cannot have phaco at present. Hopefully, the
cost would be less.
Aziz PhacoTmesis
PhacoTmesis uses a spinning needle
that also has ultrasound. It is a very powerful
cutting tool.
Water Jet Technology

If you heat water to the right temperature, about 55 to 60 degrees centigrade, you
can appear to melt the lens. There are several
companies working on a water jet type technology to remove cataracts with basically
heated balanced salt solution. It appears that
this can be done without damaging the surrounding tissues from the heat either by using
an endocapsular method or by having short
pulses of the heated material directed at the
cataract with cool material circulating in the
anterior chamber.
The latter two methods mentioned
above seem to be brilliant ideas but it is
unclear whether they can be translated into
practical reality.
411
BIBLIOGRAPHY
Anis, AY: PhacoTmesis. Atlas of Cataract Surgery, Edited by Masket S. & Crandall AS, published by Martin Dunitz Ltd., 1999, 12:89-96.
Colvard DM, Kratz RP: Cataract surgery utilizing
the erbium laser. In: Fine IH, ed. Phacoemulsification: New Technology and Clinical Application
(Thorofare, NJ: Slack, 1996), 161-80.
Dodick, JM: The Nd:YAG laser phacolysis technique. Boyds 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 implications for Nd:YAG laser phacolysis of the cataractous 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 Surgery, Edited by Masket S. & Crandall AS, published by Martin Dunitz Ltd., 1999, 11:85-88.
412

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This book was created and written by

OUTLINE OF MAJOR SUBJECTS

Surgical Anatomy of the Human Lens

Indications and Preoperative Evaluation

IOL Power Calculation In Standard

Preventing Infection and Inflammation

Proceeding with the Operation

Phacoemulsification - Why So Important?

Preparing for the Transition

Instrumentation and Emulsification Systems

Mastering Phacoemulsification The Advanced, Late Breaking Techniques

Chapter 10: Focusing Phaco Techniques on the Hardness

Chapter 12: Cataract Surgery in Complex Cases

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

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

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

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

IOL POWER CALCULATION IN STANDARD

Postop Refractive Errors No Longer Admissible

SURGICAL TECHNIQUE IN THE TRANSITION

The Pulse and Burst Modes

MANAGEMENT OF THE NUCLEUS

The Divide and Conquer Four Quadrant Nucleofractis Technique

Specific Guidelines for Implanting the Array Lens

CATARACT AND GLAUCOMA

Overview - Alternative Approaches

PHACOEMULSIFICATION IN SMALL PUPILS

THE SMALL INCISION MANUAL PHACOFRAGMENTATION

FOCUSING AND OVERVIEW OF WHAT IS BEST

Tackling the Challenges

Role of Small Incision Manual

The Best Phaco Technique

of cataract to a specific method of nucleus

The Complex Cases

SURGICAL ANATOMY OF THE HUMAN LENS

distinguish what is really anterior capsule, what

Figure 1: Three-Dimensionality of the Lens - Clinical Applications

adhesions have to be broken down before the

moisture. Medium to firm-density cataracts

How Cataracts Respond Differently

Figure 2: Dense, Nuclear Brunescent

rub them against the capsule, the capsule can

INDICATIONS AND PREOPERATIVE EVALUATION

Role of Quality of Life

come increasingly difficult to perform surgery

The Role of Visual Acuity

Contrast Sensitivity and Glare

increasingly aware that diminished contrast

A patient who has a reduction in contrast

Figure 3 B (below right): Contrast Sensitivity

Figure 3 A (above left): Importance of Testing for

disabling glare, which determines the effect of

Relation of Glare to Type of

Evaluation of Macular Function

Any well trained ophthalmologist can

manner as the detachable type of Goldmann

can avoid the light scattering produced by the

Figure 5 A (above left): Concept of the

Figure 5 B (below right): Concept of the

exactly where the light beam is passing. The

It is sometimes difficult to find a small

Figure 6-A: How the PAM

Figure 6-B: How the PAM Works