CATARACT

SURGERY
FOR
GREENHORNS

Thomas A. Oetting
C ATA R A C T S U R G E RY F O R G R E E N H O R N S

Thomas A. Oetting, MS, MD

University of Iowa
VAMC Iowa City

Iowa City, Iowa

November, 2012

Copyright ©
Thomas A. Oetting, MS, MD
 Contents

1. Training Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1. First Year – Beginner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2. Second Year – Advanced Beginner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3. Third Year – Proficient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2. Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.1. Classic Types of Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.1.1. Nuclear Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.1.2. Posterior Subcapsular Plaque (PSCP) . . . . . . . . . . . . . . . . . . . . . . . . 8
2.1.3. Cortical Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2. Evaluation of Patients with Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2.1. Symptoms of a Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2.2. Indications for Cataract Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2.3. General Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.4. Past Ocular History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.5. Preoperative Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.3. Difficulty Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

3. Preoperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.1. Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.2. Selecting the Intraocular Lens (IOL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2.1. Brief History of the IOL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2.2. Today. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2.3. IOL Material Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2.4. IOL Design Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.2.5. Four Things You Need to Know to Calculate Correct IOL Power . . . . . . . . 17
3.2.6. Estimating the IOL Power for Emmetropia . . . . . . . . . . . . . . . . . . . . . 19
3.2.7. Selecting the IOL Power for Your Patient . . . . . . . . . . . . . . . . . . . . . . 19
3.3. Operating Microscope Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

4. Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.1. Retrobulbar Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.2. Subtenon’s Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4.3. Topical Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

5. Cataract Surgery – Old School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

5.1. ICCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
5.2. Planned ECCE (with Nucleus Expression) . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5.3. Manual Small Incision Cataract Surgery (MSICS) . . . . . . . . . . . . . . . . . . . . . 28

6. Phacoemulsification – Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

6.1. Paracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
6.2. Place Ophthalmic Viscoelastic Device (OVD) . . . . . . . . . . . . . . . . . . . . . . . . 32
6.3. Wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
 6.4. Capsulorhexis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
6.5. Hydrodissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.6. Phacoemulsification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6.7. Cortical Aspiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6.8. Fill Bag with OVD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6.9. Lens is Placed into Capsular Bag . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.9.1. Special IOL Placement Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . 42
6.10. OVD is Removed with I/A Device. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
6.11. Sutures are Tied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
6.12. Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

7. Phaco Machine Settings Primer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

7.1. Four Main Components and Software to Tie Them Together. . . . . . . . . . . . . . . 45
7.2. Phaco Pumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
7.2.1. Vacuum Based Pumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
7.2.2. Flow Based Pumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
7.3. Ultrasound Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

8. Ophthalmic Viscoelastic Devices (OVD) . . . . . . . . . . . . . . . . . . . . . . . . . . 50

8.1. Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
8.2. Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
8.3. Adaptive OVD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
8.4. Arshinoff Shell. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

9. Capsular Staining . . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

9.1. Trypan Blue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
9.2. Indocyanine Green (ICG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
9.3. Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

10. Routine Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

10.1. Phacoemulsification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
10.2. Large Incision ECCE or ICCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

11. Principles of Anterior Vitrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

11.1. Vitreous Presenting Early in Case – While Most of Crystalline Lens is in Eye . . . . 60
11.2. Vitreous Presenting Mid Case – While Removing Cortical Material . . . . . . . . . . 62
11.3. Vitreous Presenting Late in the Case – While Placing IOL . . . . . . . . . . . . . . . . 63
11.4. Staining the Vitreous with Triamcinolone . . . . . . . . . . . . . . . . . . . . . . . . . . 64
11.5. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

12. Conversion to ECCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

12.1. Patients at Risk for Conversion to ECCE . . . . . . . . . . . . . . . . . . . . . . . . . . 66
12.2. Indications for Conversion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
12.3. Converting to Subtenon’s Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
12.4. Converting the Wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
12.5. Removing the Lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
12.5.1. Removing Lens with Intact Capsule Complex. . . . . . . . . . . . . . . . . . . . 69
12.5.2. Removing Lens with Vitreous Present . . . . . . . . . . . . . . . . . . . . . . . . 69
 12.6. Placement of the IOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
12.7. Postoperative Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
12.7.1. First Postoperative Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
12.7.2. Week 1 Postoperative Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
12.7.3. Week 5 Postoperative Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
12.8. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

13. Approaching Different Kinds of Cataract. . . . . . . . . . . . . . . . . . . . . . . . . . 72

13.1. Ectopia Lentis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
13.2. Intumescent Cortical Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
13.3. Hypermature Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
13.4. Morgagnian Cataract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
13.5. Anterior Polar Cataracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
13.6. Posterior Polar Cataracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
13.7. Perforating and Penetrating Injury of the Lens . . . . . . . . . . . . . . . . . . . . . . . 75
13.8. Diabetes Mellitus and Cataract Formation. . . . . . . . . . . . . . . . . . . . . . . . . . 76
13.9. Cataract Associated with Uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
13.10. Exfoliation Syndrome (Pseudoexfoliation) . . . . . . . . . . . . . . . . . . . . . . . . . . 77
1. Training Plan

Our training plan sets up Dreyfus stages for the acquisition of the skill of cataract surgery
and more specifically phacoemulsification. A beginner has some skills in the wet lab and can
do parts of cases. An advanced beginner can do simple cases with one hand. A proficient
surgeon can do routine cases with both hands and some complex cases. Residents would not be
expected to be an expert who could do routine cases with little thought and develop techniques
for more complex cases. Each stage has expectations associated with it.

1.1. First Year – Beginner

Expectations following the first year or at “Beginner Stage”:

• know accepted names of all instruments in VA cataract tray
• describe all steps of phacoemulsification cataract surgery
• describe common complications of cataract surgery
• demonstrate ability to fold and insert IOL into capsular bag
• demonstrate ability to prep and drape eye
• demonstrate ability to drive operating microscope
• demonstrate ability to place a single suture
• demonstrate ability to remove OVD
• demonstrate ability to perform Nd:YAG capsulotomy
• manage routine cataract patients postoperatively
• describe findings of CME on OCT and FFA
• describe common complications of Nd:YAG capsulotomy
Resources to develop these skills:
• wet lab fully equipped, dedicated facility at VAMC, work in wet lab w/ cadaver or pig
eyes
• [Link] or download to iPad using
iTunes
• [Link]
Phacoemulsification/[Link]
• [Link]
• iPod with greenhorn series: ICCE, ECCE, prep, RB, AEL, microscope, my first cataract
• “Backing in” (doing parts of cases) – concept developed by Mark Wolken MD
– VA rotation – Wednesday, backing into 3rd year cases to slowly do more of “back” of
case
– UIHC Dr. Kutzbach – Monday AM, backing into cases
• M&M Conf Practice Based Learning, every 10 weeks
• Phaco Course Madison Wisconsin (UW, UI, MCW residents), lectures 1⁄2 day / wet lab 1⁄2
day

1
 Expectation Assessment Resources
iPod,
Know accepted names of all instruments in VA demonstrate in
Greenhorns,
cataract tray. OR
[Link]

Describe all steps of cataract surgery. oral Greenhorns

Describe common complications of cataract
oral Greenhorns
surgery.
wet lab,
Demonstrate ability to fold and insert IOL into demonstrate in
iPod,
capsular bag. OR
Greenhorns
demonstrate in iPod,
Demonstrate ability to prep and drape eye.
OR Greenhorns
wet lab,
Demonstrate ability to drive operating micro- demonstrate in
iPod,
scope. OR
Greenhorns
demonstrate in
Demonstrate ability to place a single suture. wet lab
OR, wet lab
demonstrate in
Demonstrate ability to remove OVD. wet lab
OR, wet lab
Demonstrate ability to perform Nd:YAG capsu- demonstrate in
lotomy. clinic
Manage routine cataract patients postopera- demonstrate in
Greenhorns
tively. clinic

Describe findings of CME on OCT/FFA. oral

Describe common complications of Nd:YAG cap-
oral Greenhorns
sulotomy.

Table 1. Expectations following the first year – “Beginner Stage”

1.2. Second Year – Advanced Beginner

Expectations following the second year or at “Advanced Beginner Stage”:

• know name of all instruments on all VA eye trays
• consent patient for routine cataract surgery
• perform 5 uncomplicated phaco cases (attending may assist with 2nd hand) < 45 min
• describe steps to convert to ECCE
• describe technique of anterior vitrectomy
• demonstrate ability to perform IOLMaster
• demonstrate ability to place multiple sutures efficiently
• demonstrate ability to use capsular dye

2
Resources to develop these skills:
• wet lab fully equipped, dedicated facility at VAMC, work in wet lab w/ cadaver or pig
eyes
• [Link] or download to iPad using
iTunes
• [Link]
Phacoemulsification/[Link]
• [Link]
• Observed Professional Communication Competency Consent feedback on EPIC
• OR formative feedback form for portfolio
– VA rotation – Wed and Friday AM, observe 3rd year 1st case
– VA rotation – Thursday AM, Dr. Oetting, 1–3 cases (Dr. Oetting will help with
second instrument at first usually with retrobulbar anesthesia), all cases video taped
for review
– UIHC rotation – Tuesday, Dr. Johnson transition to topical anesthesia, deliberate
practice on capsulorhexis, video formative feedback
• M&M Conf Practice Based Learning Competency, every 10 weeks
• Phaco Course Madison Wisconsin (UW, UI, MCW residents), advanced lectures 1⁄2 day /
wet lab 1⁄2 day
• texts in library: David F. Chang. Phaco Chop: Mastering Techniques, Optimizing
Technology, and Avoiding Complications. 1st edition. Slack Inc, 2005; Barry Seibel.
Phacodynamics: Mastering the Tools and Techniques of Phacoemulsification Surgery. 4th
edition. Slack Inc, 2005.

Expectation Assessment Resources

Know name of all instruments on all VA eye iPod,
oral
trays. [Link]

Consent patient for routine cataract surgery. Jan Full iPod

formative iPod,
Perform 5 uncomplicated phaco cases < 45 min.
feedback forms Facebook
Greenhorns,
Describe steps to convert to ECCE. oral
Facebook
Greenhorns,
Describe technique of anterior vitrectomy. oral
Facebook
Demonstrate ability to perform IOLMaster for
observe in clinic clinic staff
AEL.
Demonstrate ability to place multiple sutures
observe in OR wet lab
efficiently.
Greenhorns,
Demonstrate ability to use capsular dye. observe in OR
Facebook

Table 2. Expectations following the second year or at “Advanced Beginner Stage”

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1.3. Third Year – Proficient

Expectations following the third year or at “Proficient Stage”:

• understand IOL selection
• consent patient for complex cataract surgery (e.g. CTR, ICG)
• perform 5 phaco cases with 2 hand < 30 min
• demonstrate or deeply understand conversion to ECCE
• demonstrate or deeply understand anterior vitrectomy
• demonstrate or understand sulcus IOL placement
• understand phacoemulsification machine settings
• understand OVD selection
• demonstrate ability to use iris hooks
Exceptional samples of behavior rarely seen during third year “Expert Stage”:
• demonstrate ability to use McCannell suture
• demonstrate ability to use CTR
• demonstrate ability to do very efficient cataract surgery < 15 minutes
• demonstrate ability to use phaco chop techniques
• staff first years during portions of cataract surgery
Resources to develop these skills:
• wet lab fully equipped, dedicated facility at VAMC work in wet lab w/ cadaver or pig eyes
• [Link] or download to iPad using
iTunes
• [Link]
Phacoemulsification/[Link]
• [Link] e.g.: transition to phacochop, phaco chop
with OZil®
• OR learning with formative feedback form for portfolio
– VA rotation – Wednesday AM, Oetting, 4–10 cases, develop ability to use second
instrument, develop skills to do topical cases, transition to chopping technique
– UIHC comprehensive rotation – Thursday, Kitzmann, 2–5 cases, emphasis on chopping
and efficiency
– UIHC comprehensive rotation – Friday, Oetting, 2–5 cases, emphasis on complex
cases and efficiency
• M&M Conf Practice Based Learning Competency, lead conference every 10 weeks, open
discussion of complicated cases at UIHC and VAMC UI during rounds
• Phaco Course Madison Wisconsin (UW, UI, MCW residents), advanced lectures 1⁄2 day /
wet lab 1⁄2 day

Expectation Assessment Resources

Understand IOL selection. oral Greenhorns

Consent patient for complex cataract surgery
oral
(e.g. CTR, ICG).
Formative
Perform 5 phaco cases with 2 hands < 30 min.
Feedback Form

4
Demonstrate or deeply understand conversion to Greenhorns,
oral
ECCE. Facebook
Demonstrate or deeply understand anterior vit- Greenhorns,
oral
rectomy. Facebook
Demonstrate or understand sulcus IOL place- Greenhorns,
oral
ment. Facebook
Understand phacoemulsification machine set- Greenhorns,
oral
tings. Facebook
Greenhorns,
Understand OVD selection. oral
Facebook
Greenhorns,
Demonstrate ability to use iris hooks. observe in OR
Facebook

Table 3. Expectations following the third year or at “Proficient Stage”

5
 Typical % Resources
Dreyfus Expected samples of rotation grads to grow
Level
Stage behavior for this level at this at this beyond
level level this level
books,
starting Desire to learn. n/a video,
observe
Demonstrate sterile technique,
know all instruments in tray, books,
assistant know all steps of cataract video,
VA 1st yr
Novice surgeon surgery, demonstrate prep and wet lab,
drape, demonstrate IOL fold, observe
demonstrate RB injection.
wet lab,
wet lab Demonstrate microscope use, video,
VA 1st yr
surgeon pig/cadaver eye with faculty. back into
cases
wet lab,
Demonstrate suture technique,
neophyte video,
demonstrate IOL placement, VA 1st yr
Beginner surgeon back into
demonstrate use of I/A device.
cases
Demonstrate 5 cases < 45 wet lab,
min, know steps to convert to video,
basic
ECCE, know steps for vitreous develop
cataract VA 2nd yr 100%
loss, demonstrate use of cap- non-
surgeon
sule dye, demonstrate effective dominant
Advanced consent. hand
Beginner
assistant Demonstrate capsulorhexis video,
topical during topical case, assist UI 2nd yr 100% deliberate
surgeon efficient cataract surgeon. practice
Demonstrate 5 cases < 30
min using both hands, demon-
strate topical cases, demon-
two
strate the use of small pupil
handed VA 3rd yr 95% video
techniques, demonstrate the
surgeon
use of CTR, demonstrate chop-
ping techniques, demonstrate
Proficient
IOL suturing techniques.
VA 3rd yr
advanced video,
DM 3rd yr 50%
surgeon practice
UI 3rd yr

6
 efficient
innova- Demonstrate 5 cases < 15 min, video,
Expert graduates rare
tive develop new techniques. practice
surgeon

Table 4. Summary of cataract training plan

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2. Assessment

2.1. Classic Types of Cataract

Type Age of onset Symptoms

myopic shift,
blurred vision,
nuclear 60 – 70
loss of blue/yellow color
perception
glare,
posterior
40 – 60 diminished reading,
subcapsular
monocular diplopia
glare,
cortical 40 – 60
monocular diplopia

Table 5. Classic types of cataract

2.1.1. Nuclear Cataract

Epidemiology/risk factors:
• age
• riboflavin, Vit C, Vit E and carotene may decrease risk of nuclear sclerosis
• cigarette smoking increases the risk of nuclear sclerosis
Symptoms/history:
• gradual progressive loss of vision
• second sight – development of myopia due to increased lenticular refractive index
• monocular diplopia
• decreased color discrimination, especially blue
Clinical features:
• central yellow to brown discoloration of the lens
• myopic shift – increased AP diameter better converging lens
• bilateral
• decreased penetration of cobalt blue slit beam through lens

2.1.2. Posterior Subcapsular Plaque (PSCP)

Epidemiology/risk factors:
• younger patients than with nuclear or cortical cataracts
• diabetes mellitus
• radiation
• corticosteroids
• uveitis including RP

8
 • smoking
Symptoms/history:
• progressive loss of vision, sometimes rapid
• glare, halos
• monocular diplopia
Clinical features:
• axial opacity of the posterior cortical material
– initially an iridescent sheen appears in the posterior cortex
– followed by granular and plaque like opacities
• can be confused with posterior polar cataract and Mittendorf dot
• can see with direct but best viewed with red reflex through slit lamp

Figure 1. A) Using direct to see PSCP, B) view through direct, C) view through slit lamp

2.1.3. Cortical Cataract

Epidemiology/risk factors:
• younger patients than with nuclear cataracts
• diabetes mellitus
• sunlight
• trauma
• smoking
Symptoms/history:
• progressive loss of vision, sometimes rapid
• glare, halos
• monocular diplopia
Clinical features:
• opacity of the cortical fibres from posterior to central
• sometimes wedge shaped forming cortical spokes
• can progress to intumescent or hypermature cataract
• usually medial and inferior from UV exposure

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 Figure 2. Cortical cataract: A) right eye, B) left eye

2.2. Evaluation of Patients with Cataract

Ask yourself!
• Is the cataract causing the visual decline?
• Is the cataract secondary to a systemic or ocular condition?
• Could the eye/patient survive cataract surgery if indicated?

2.2.1. Symptoms of a Cataract

Visual acuity:
• usually a gradual decline over years
• w/ post subcapsular cataract (PSCC) VA can decline over days
• often near VA decline is greater than far VA decline in PSCC
Glare:
• night driving problems, halos, especially with PSCC and cortical
Myopic shift:
• “second sight”, especially in nuclear sclerotic cataract
Diplopia:
• monocular, especially in PSCC and cortical

2.2.2. Indications for Cataract Surgery

Functional, functional, functional!

Document difficult with reading, driving, glare, recognizing faces, diplopia.
Must document functional decline (in Iowa with form w/ patient’s signature).
Best corrected visual acuity ≤ 20/50 at far or near usually acceptable to insurance.
Best corrected visual acuity > 20/40, documentation of disability even more important.
Uncommon indications:
• lens induced disease, e.g. glaucoma
• medical need to visualize the fundus (e.g. diabetes, AMD)

10
2.2.3. General Issues

Can your patient lay flat for 30–60 minutes?

• worry with back pain, COPD, CHF
• could their family MD help optimize their breathing or pain?
Can your patient lay still?
• worry with young males, tremor, claustrophobia
• consider general anesthesia
• jiggly spectrum: young men worst > young women > old women > old men least jiggly
(yes, I am making wild generalizations – so what?)
Look at medicine list.
• Coumadin, Plavix, or ASA and if so can they/should they stop? Lots of evidence that it
is not necessary to stop, esp Aspirin and Coumadin. Plavix is more scary.
• Flomax (and other alpha antagonists for BPH) – associated with Intraoperative floppy iris
syndrome (IFIS). Consider iris retractor or Malyugin ring. Stopping doesn’t help though.
• Chronic steroid use – usually no need for stress steroid unless general anesthesia.
Latex (pretty much assumed now) and drug allergies.
Can your patient tolerate their postoperative care?
• Do they need help putting in their drops?
• monocular patients may need significant postop help (e.g. admission) if patched postop
• sleep apnea patients may have trouble postop if sedated

2.2.4. Past Ocular History

See section on cataract in special circumstances.

• h/o glaucoma, steroid response – risk factors for postop pressure spike
• h/o RD, tears, lattice, high myopia – risk factors for RD
• h/o DM, uveitis, CME in other eye, ERM – risk factors for CME in this eye
• h/o DME, CME, ERM, AMD – avoid multifocal

2.2.5. Preoperative Exam

Manifest refraction in both eyes.

• fellow eye refraction may be needed to help with IOL power selection
• does VA with best correction decline with glare testing – room lights on and trans-
illuminator 45 degrees off axis through phoropter with best refraction
• when vision is poor – document no improvement with +/− 3 diopters

11
Pupils:
• RAPD – as always critical – especially if patient’s vision remains poor after surgery
• dilated pupil size – useful when selecting among surgeons (see difficulty factors)
CVF – LP in all four quadrants in dense cataracts (instead of echo).

Keratometer readings of both eyes:

• do prior to other K manipulations if possible
• consider on axis surgery
• consider toric IOL
Topography:
• especially when considering toric IOL
• look for keratoconus and irregular astigmatism
External exam:
• abnormal tear function, lid malposition/exposure, blepharitis/spasm
• prominent brow/deep socket – think temporal and retrobulbar block or schedule for next
resident
Slit lamp exam:
• cornea – guttata, PPMD, MDF, exposure problems
• lens hardness, phacodonesis, PXF, r/o posterior polar, phacodonesis
Gonioscopy:
• important if you may need to place an AC lens, esp with:
• h/o uveitis (possible anterior synechiae)
• h/o DM (may have neovascularization of iris)
• h/o weak zonules (more like to have AC IOL placement)
Dilated fundus exam:
• not mandatory if you or trusted colleague have looked back recently
• dilation the day before will inhibit dilation the day of surgery (not huge deal)
• does the poor view match the poor vision
• look carefully at pts with AMD, DM, and ERM, consider preop OCT
• document normal macula, ON, PVD if present
Special tests:
• potential acuity meter – projects an eye chart around lens—rarely helpful
• pin hole with near card and bright light – good performance predicts good postop VA
• dense lens, no view – consider B scan echography (can skip with no RAPD and light
projection in all four quadrants)
• specular microscopy for endo cell count rarely needed (e.g. FDA Studies, Fuchs’)
• consider pachymetry in patients with corneal edema (e.g. Fuchs’)

2.3. Difficulty Factors

Why assess the difficulty factors preoperatively?

• which surgeon should do case (e.g. attending vs. 1st year resident)

12
 • estimate length of case
• determine need for additional supplies/equipment
• determine the type of anesthesia
Difficulty factors (in decreasing order of importance):
• zonular laxity (PXF, h/o trauma, Marfan’s)
• small pupil – consider why? PXF, DM s/p laser, CPS, alpha blocker (e.g. tamsulosin)
• cannot lay flat for very long (e.g. COPD, claustrophobia, tremor, severe obesity)
• poor red reflex – white/black cataract making CCC difficult
• big brow limiting superior access
• narrow angle limiting AC space
• predisposition to corneal decompensation (e.g. guttata, PPMD, hard nucleus)
• past surgery such as existing trab or past PPVx
• predisposition to exposure (e.g. BOTOX® , past lid trauma, DM)
• anticoagulants (e.g. Coumadin, ASA)
• monocular

Factor Surgeon Time Equipment/Anesthesia

Iris or capsule retractors to hold cap-

sule.
Capsular tension ring (CTR).
zonular laxity > 100 cases double Ready for glued or sutured IOL or
sutured (Cionni) CTR, CTS.
Ready for ICCE, e.g. cryo.
Consider RB.
Stretch Pupil (avoid w/ Flomax).
Consider Malyugin ring.
small pupil > 50 cases add 50%
Consider iris retractors.
Consider RB.
Consider Malyugin ring (use small-
est ring you can).
alpha blocker Consider iris retractors diamond
tamsulosin (IFIS > 50 cases add 50% (one hook under main incision).
risk) Consider single iris retractor.
Intracameral epi-/lidocaine.
Consider RB.
trypan blue (or ICG).
poor red reflex > 20 cases add 50%
Consider RB.
Consider RB to prolapse anterior.
big brow > 20 cases add 25% Operate temporal.
Consider sup/inf bridal sutures.

13
 Consider smaller phaco tip.
Beware of IFIS.
Consider iris hooks diamond config-
narrow angle > 50 cases add 25%
uration.
Consider BSS+ (w/ glutathione).
Arshinoff soft shell w/ OVD.
Consider BSS+ (w/ glutathione).
predisposition K Phaco chop.
> 50 cases 0%
decomp Arshinoff soft shell w/ OVD.
Consider ECCE , MSICS.
Avoid fixation ring.
Avoid conj manipulation.
existing trab > 20 cases 0%
Malyugin w/ small pupil.
Suture wound following surgery.
Topical w/ long eye to avoid RB.
past PPVx > 20 cases 0% Possible CTR.
Careful during I/A.
MAC.
cannot lay flat > 100 cases 0%
Consider general.
Topical to avoid injection risk.
anticoagulants > 20 cases 0% If needed, subtenon’s infusion.
Plavix is most scary.
Topical for faster rehabilitation.
monocular > 100 cases 0%
Try to forget about it.

Table 6. Difficulty factors in cataract surgery

US Medicare Coding Issues:

• 66984 – typical code for cataract surgery
• 66982 – complex cataract surgery
– surgeon fee 40% more than 66984, facility fee is the same
– indications:
∗ small pupil – used Malyugin ring, hooks, or stretched pupil with device like
Beehler
∗ weak zonules – used capsular tension ring (CTR), CTS
∗ white cataract – used trypan blue stain
∗ pediatric cataract – especially with risk of amblyopia
• see these guidelines: [Link]
025c-404e-a68a-72411d20221b

14
3. Preoperative

3.1. Consent

Most important part of preoperative visit.

5 essential parts of a consent:
• identify yourself
• describe all options – cataract surgery or hold off on cataract surgery
• describe the procedure
• describe potential risks – 1/100 chance vision will be worse after surgery
• describe potential benefit – 9/10 chance vision will be normal with glasses following surgery

Talk your patient through the procedure briefly:

• we replace your cloudy natural lens with a clear artificial lens
• use the words: injection(w/ RB), cut, and possible stitches in your discussion
• no we don’t use the laser (much confusion about Nd:YAG for secondary cataract will be
femto)
• we may patch your eye overnight following the surgery
• we will prescribe new glasses when the eye is stable (2–4 weeks postop)
• mention comorbidity such as AMD or glaucoma
Benefits:
• 95% better than 20/40
• 96% better vision than preop
• I lower these percents with increasing retinal or optic nerve disease
Risks:
• 1% vision worse than preop
• death (< 1:100,000)
• loss of eye (< 1:10,000)
• irregular pupil (1:100)
• after cataract (1:20 requiring laser in 2 years, depends on the IOL)
Document:
• functional visual disability, give examples
• complete consent form legibly
• in patients chart write something like: :
“I discussed the risks and benefits of cataract surgery with Mr. Jones and his son in terms
they seemed to understand. Mr. Jones expressed to me that he understood the small but
real risk of surgery, including loss of vision as outlined in the consent form, and he decided
to have surgery.”

15
3.2. Selecting the Intraocular Lens (IOL)

3.2.1. Brief History of the IOL

Harold Ridley placed first lens in 1949, a huge PMMA IOL (about the size of the crystalline
lens).
1950s rigid anterior chamber (AC) IOLs were used with ECCE and ICCE:
• bullous keratopathy was common
• chronic inflammation led to CME and glaucoma
Later, iris fixation lenses were used to avoid contact with the angle:
• some IOLs would suture onto the iris; others would clip on like Artisan today
• these lenses would frequently dislocate
Closed-loop flexible anterior chamber (AC) lenses were next:
• kept PK surgeons in business
• caused UGH syndrome (Ellingson syndrome)
Foldable IOLs came in the ’90s and allowed smaller incisions.
Multifocal and toric IOLs came more recently.
Rare and weird names for IOL: pseudophakos, lenticulus.

3.2.2. Today

Modern open-loop flexible AC IOLs are a great success.

The development of viscoelastics (OVDs) allows safe placement :
• posterior chamber lenses are most commonly used today
• 3 basic materials – PMMA, acrylic, silicone
• PMMA is the time tested material but requires a large incision
• use the largest optic that can fit incision, e.g. 6.5 or 7 for ECCE
• most surgeons use foldable acrylic or silicone lens to allow small incision
Accomodating IOL (CrystaLens™ ) approved by the FDA; better ones coming.
Multifocal (ReSTOR® , ReZoom® , Array® ) and toric lenses (STAAR® , Alcon) are available.

3.2.3. IOL Material Considerations

Lens material Advantages Disadvantages

time tested,
cheapest,
PMMA wound size ≥ optic diameter
little inflammation,
less dysphotopsia
injectable, cost,
acrylic
least inflammation dysphotopsia

16
 more inflammation,
cost,
silicone oil (for RD repair)
silicone injectable,
adheres to IOL and becomes
less dysphotopsia
opaque

Table 7. IOL material considerations

3.2.4. IOL Design Considerations

Lens material Examples Advantages Disadvantages

smaller incision,
single piece Alcon (SA60AT, not good in sulcus –
easy to insert,
acrylic SN60WF) haptics too thick
stable in bag for toric
not good in sulcus,
smallest incision,
plate haptic STAAR® be careful with Nd:YAG
easy to insert
cap – can fall posterior
Alcon
larger incision,
(MA60BM),
3-piece OK for sulcus take care w/ haptics
AMO (SI-40,
when inserting
Sensar™ , AR40)
Alcon (SA60AT,
square edge less PCO more dysphotopsia
SN60WF)

round edge AMO SI-40 less dysphotopsia more PCO

Table 8. IOL design considerations

3.2.5. Four Things You Need to Know to Calculate Correct IOL Power

1) Desired postoperative SE

Mild myopia like −0.50 to −1.00 is a reasonable plan. Why?

• myopia is better than hyperopia if your calculations are off
• −1.00 gets you about 20/40 at far and you can see well at mid distance
• a spectacle overcorrection of −1.00 will eliminate induced IOL mag
Go for the plano gold OU (reading glasses at near or mutlifocal).
Go for monovision.
• mini monovision: one eye plano, one about −1.00 or so (common with CrystaLens™ –
maybe because it doesn’t really work that well)
• standard monovision: one eye plano, one about −2.00 or so
• dominant eye usually set for far
Match the other spectacled eye as anisometropia > 3.0 is not well tolerated.

17
2) Axial eye length (AEL)

Contact probe ultrasound AEL device.

• contact probe on eye measures distance to fovea
• pushing on the eye w/ probe creates error of AEL too short – myopic surprise!
• re-measure when AEL difference between eyes > 0.3 mm
• re-measure when AEL < 22 or > 25 mm
Laser interferometry (IOLMaster, LENSTAR LS 900® ).
• best technique: quick, little error, clean
• less dependant on technician for accuracy
• fails in dense NS or even mild PSCP
Immersion ultrasound.
• gold standard when in doubt
• cylinder placed on eye, filled with fluid, and probe immersed in fluid, but the probe does
not contact the eye
• some technician skill required, but not prone to error from pushing on eye
• do immersion whenever patient gets B-scan for a dense cataract

3) The power of the cornea

Keratometric measurement of both eyes – should be about the same.

• autorefractor
• IOLMaster measures K’s for you
• keratometer
• corneal topography (especially with toric or multifocal IOL)
Difficult when patient has had refractive surgery – long story.
Pls see amazing web site by Warren Hill: [Link]
htm

4) The postoperative position of the IOL (effective lens position)

The more anterior the IOL, the less power the IOL needs.
• e.g. IOL placed in the sulcus needs less power
• AC depth is a factor in some IOL formula (e.g. Holladay 2)
Goal is to place a posterior chamber (PC) lens.
• these can end up in the bag (best) or sulcus (anterior to ant. capsule)
• placement of IOL measured for bag in the sulcus results in myopic surprise
– decrease power by 0.5 to 1 diopter (shorter eye larger shift)
– if primary lens is a single piece acrylic (e.g. SN60WF) have 3-piece available for sulcus
– see: [Link]
Always plan to have available anterior chamber (AC) lenses.
• these are placed anterior to the iris w/haptics that settle into the angle
• these are used when the capsule is lost and cannot hold an IOL
• when too small they can tilt and when too large they can hurt
• place peripheral iridotomy before AC IOL to prevent iris bombé

18
3.2.6. Estimating the IOL Power for Emmetropia

Formulas started with a theoretical model by Fydorov, Collenbrander et al, 1970s.

Based on geometric optics:

N N
IOL = −
AEL − ACD K − ACD

IOL – expected power of IOL for emmetropia postop

N – aqueous and vitreous refractive index
ACD – postoperative AC depth of the IOL
AEL – axial eye length as measured via an ultrasound device
K – average of the two keratometric axes

But you don’t know ACD or postoperative depth of the IOL preop!

SRK – classic regression formula (developed in 1980 by Sanders, Retzlaff, and Kraff):

IOL = A-constant - 2, 5 × AL - 0, 9 × K

A-constant – a parameter of the IOL’s effective position (e.g. PC

IOL Alcon SN60WF: A-constant = 118.7; AC IOL Alcon MTA:
A-constant = 115.3)
Note: An error of x in axial eye length results in an error of 2.5x in IOL power. SRK falls apart
in predictive value with eyes w/ AEL < 22 mm and > 24.5 mm. Common board question, so
just know it!

Modern regression algorithms are more accurate:

• SRK/T is best for high myopes
• shorter eyes are tricky for regression formulas
– some short eyes are proportional and regression works
– some short eyes are egg shaped with standard sized AC but short regression fails
– formulas like the Holladay 2 use AC depth or white to white to better predict the
effective lens position in short eyes
– see dr. Hill: [Link]

3.2.7. Selecting the IOL Power for Your Patient

The SRK computes the lens power for emmetropia, but you may have a different goal.

The U/S or IOLMaster produces a table with IOL power mapped to desired postop SE.
• roughly a change in IOL power of 1.5 produces a change of 1.0 in glasses
• e.g. formula gives 19 diopters for emmetropia; about 20.5 will give −1.00 SE p/o
• if your estimated IOL power is unusual, you are probably wrong
• double check your calculations

19
 • trust what happened w/ the other eye’s IOL if applicable
• if the eye seems too short, ask yourself was the patient hyperopic as a young person (e.g. in
the big war before the myopic shift from the cataract)
Estimate the power for both the AC and the PC lens. Compare several formulas.

Then, if convinced that the calculations are right, make sure that all potentially needed
IOL powers are available in the OR.
• you will need a posterior chamber lens for the bag (1-piece or 3-piece)
• you will need a 3-piece IOL for the sulcus
– the more anterior sulcus lens will need 0.5–1.0 less diopters of power than it would if
placed in the bag
– cannot use 1-piece acrylic (Alcon SA60AT or SN60WF) in sulcus
• you will need an AC IOL
– typical AC lenses come in 3 diameters: 12.5, 13.0, and 13.5 mm
– sized at surgery by adding 1 mm to the “white to white” limbal diameter

3.3. Operating Microscope Basics

Learn how to use your foot pedal and practice before your first case.

Scheme 1. Typical Zeiss’ foot pedal

Ask yourself: “Where will I be sitting?”

Position Advantages Disadvantages

If surgery causes iris trauma,
lid covers iris.
If surgery requires lots of su-
tures (e.g. ECCE), lid covers Brow can get in the way.
superior
sutures. Bleb can get in the way.
Easy to place legs (don’t have
to go under head).
May allow incision on axis.

20
 Sometimes hard to get legs un-
Avoid brow. der table.
temporal
Avoid bleb. Iris trauma can cause glare.
May not allow incision on axis.

Table 9. Advantages and disadvantages of surgeon position

Proper sequence to adjust equipment to your body:

1. Place retrobulbar block first (give it time to work while setting up scope).
2. Put assistant’s eyepiece and camera on proper side of microscope.
3. Push center focus and center XY position buttons on microscope (may be same button).
4. Adjust your ocular inter-pupillary distance and zero both objectives.
5. Lower surgeon’s chair.
6. Raise bed height to just allow both feet under bed onto both pedals.
(a) Dominant foot – phaco pedal (most people).
(b) Non-dominant foot – microscope footswitch (most people).
(c) Take off shoes (wear white Nike crew length socks – yes, women too)
7. Manually move entire microscope (not with footswitch), so that you are in focus.
8. Raise surgeon chair height enough to allow surgeon to see comfortably into oculars.
9. Prep and drape.

21
4. Anesthesia

Method Action Advantages Disadvantages

risk of globe perforation,
akinesia,
risk of optic nerve injury,
anesthesia,
great for starting surgeons, risk of muscle damage,
mydriasis,
retrobulbar block proptosis, risk of retrobulbar
proptosis,
makes case easy hemorrhage,
decreases
patch postop,
photosensitivity
conjunctival chemosis
anesthesia,
no risk of globe perforation, conjunctival chemosis,
+/− mydriasis,
little risk of muscle damage, red conjunctiva,
subtenon’s block +/− akinesia,
no risk of optic nerve injury, postoperative discomfort,
decreases
easy to do after placing drape patch postop
photosensitivity
anesthesia,
+/− mydriasis, hard to get to a good block,
no risk of optic nerve injury,
peribulbar block +/− akinesia, conjunctival chemosis,
little risk of globe perforation
+/− decrease in patch postop
photosensitivity
case is harder,
topical anesthesia, quick rehab – no patch,
epithelial toxicity – coat w/
intracameral mydriasis no risk of orbital injury
OVD
case is harder,
quick rehab – no patch,
topical anesthesia epithelial toxicity – coat w/
no risk of orbital injury
OVD

Table 10. Local anesthesia methods in cataract surgery

4.1. Retrobulbar Procedure

Pros:
• great for long cases (> 45 minutes)
• great for inexperienced surgeon (get akinesia, proptosis)
• proptosis helps to increase exposure
• quiets nystagmus (can be used for Nd:YAG laser w/ nystagmus also)
Cons:
• blood thinners (+/- sev. studies show bleeding risk low for ASA & Coumadin)
• monocular (RB injection can force admission until patch removed)
• risk of globe injury, especially with long eyes
• tricky with patients following scleral buckle

22
Procedure:
1. Place 1 gtt of topical anesthetic into both eyes.
2. Clean lower lid with alcohol wipe.
3. Fill 5 cc syringe with mixture of lidocaine/bupivacaine/widase without epinephrine.
4. Place blunt 23 gauge needle on needle (blunt needle limits risk of globe perforation).
5. Start at the lateral lower lid about 3/4 of the way from the medial side.
6. Use the index finger of non-dominant hand to create space between floor and globe.
7. Aim perpendicular to lid until passing through the septum (1st pop).
8. Then redirect more superiorly advancing about 1 – 1.5 inches (2nd pop) into muscle cone.
9. First pull syringe back to ensure you are not in a blood vessel.
10. Inject 4 cc slowly into retrobulbar space.
11. Retract needle until just under skin to level of orbicularis mm.
12. Inject remaining 1 cc to block facial nerve to prevent squeezing.
13. Have patient look straight ahead during procedure.
14. Apply pressure on closed eye for a minute or so – be alert for retrobulbar hemorrhage.
15. See video at: [Link]

Figure 3. Retrobulbar procedure

4.2. Subtenon’s Procedure

Pros:
• great when topical case is getting complicated (e.g. convert to ECCE, ant vit)
• great for pts on blood thinners to limit risk of retrobulbar injection
Cons:
• conjunctiva gets red
• postop foreign body sensation
• conjunctival chemosis can be a problem
Procedure:
1. Give topical anesthesia (probably already done if converting from topical case).
2. Prepare 3 cc syringe with lidocaine/bupivacaine or use preservative free lidocaine.

23
 3. Place lacrimal cannula with gentle curve to approximate that of the globe (also can get
Masket cannula (or others) designed for this purpose).
4. Pick a quadrant for the block (best to go for a lateral quadrant to avoid oblique mm).
5. Have the patient look away from the chosen quadrant to increase exposure.
6. Use .12 forceps to retract conjunctiva.
7. Make small incision down to sclera with Westcott scissors.
8. Redirect Westcott scissors with curve down and bluntly dissect through quadrant.
9. Dissect past the equator (similar to using Stevens tenotomy scissors in peds/retina).
10. Use .12 forceps on posterior conjunctiva for counter traction.
11. Place cannula through incision and direct past the equator before injecting.
12. Inject the anesthetic which should flow easily and cause minimal chemosis.
13. If anesthetic does not flow easily, dissect further posterior with Westcott scissors.

Figure 4. Subtenon’s procedure

4.3. Topical Anesthesia

Pros:
• experienced fast surgeon
• monocular patients get fast rehab
• great for long eyes to limit risk of injection
• decreased risk of retrobulbar bleeding injection (esp. with Plavix > ASA ≥ Coumadin)
Cons:
• greenhorn surgeons need akinesia
• cannot use in patients with nystagmus
Intracameral:
• 1% nonpreserved lidocaine in anterior chamber can supplement topical
• many studies have shown no comfort benefit of intracameral
• helps with mydriasis
• if the case is long or if iris is moving, it seems to help in my hands
• usually placed just after paracentesis
• use about 0.5 cc of preservative free 1% lidocaine (can add epinephrine )

24
• may sting a bit so I usually warn the patient: “I’m giving you the rest of the numbing
medicine and you may feel it for a second or two and then it will do its magic”

Agent Instructions Pros Cons

1 gtt q 5 min (3 times), 15–30 stings,
tetracaine cheap
min preop epithelial toxicity
stings,
tetracaine gel apply 15–30 min preop better anesthesia expensive,
may block prep
1 gtt q 5 min (3 times), 15–30 cheap, less anesthesia,
proparacaine
min preop less stings epithelial toxicity
can distort view,
great anesthesia,
lidocaine gel apply 15–30 min preop comes in large tube,
easy
may block prep

Table 11. Agents for topical anesthesia

25
5. Cataract Surgery – Old School

ICCE = intracapsular cataract surgery – lens with capsule removed.

ECCE = extracapsular cataract surgery – lens removed and much of lens capsule left in place.
• planned ECCE done with expression of nucleus through large incision
• Manual Small Incision Cataract Surgery (MSICS) through self sealing incision
• phacoemulsification – ultrasound device breaks up nucleus through small incision
PPLx = pars plana lensectomy, usually at time of vitrectomy for another problem.

Method Indications Advantages Disadvantages

high risk vit loss (20%),
no risk of secondary
astigmatism,
ICCE weak zonules cataract,
delayed visual rehabilitation,
inexpensive
AC or sutured IOL
very hard lens, least equip needed,
astigmatism/sutures,
ECCE poor K easy on K endo,
delayed visual rehabilitation
endothelium post chamber IOL
little astigmatism,
very hard lens, quick visual rehab,
poor K no sutures (usually),
MSICS incision is toug
endothelium, inexpensive,
budget easy on K endo,
post chamber IOL
expensive instrumentation,
fast visual
Phaco most cataracts U/S can be hard on K endo,
rehabilitation
long learning curve
weak zonules, expensive instrumentation,
PPLx OK if lens goes south
during vitrectomy hard to place IOL in bag

Table 12. Types of cataract surgery

5.1. ICCE

Indications:
• rarely indicated today – I do about one case a year
• unstable lenses with severe zonular laxity
Be careful:
• children
• capsular rupture
• high myopia
• Marfan’s

26
 • vitreous present
Preop:
• orbital massage or osmotic agents to reduce vitreous pressure
Anesthesia:
• retrobulbar and lid block
• rarely general anesthesia, e.g. claustrophobia, dementia, tremor
Procedure:
1. Superior bridle suture.
2. May need a scleral support ring in high myopes.
3. Peritomy of about 170 degrees.
4. Limbal incision of about 170 degrees chord length in the 11–12 mm range.
5. Safety sutures are preplaced – usually 7-0 vicryl.
6. Small peripheral iridotomy is placed.
7. Alpha-chymotrypsin was placed to degrade zonules (no longer avail in US).
8. Anterior surface of the lens is dried with a cellulose sponge.
9. Cryoprobe is placed on mid-periphery of the lens and frozen.
10. Lens is removed with a side to side motion through incision.
11. Wound is closed with safety sutures.
12. Vitreous is attended to if needed.
13. Anterior chamber lens is placed after placing PI with anterior vitrector.
14. Wound is closed with 10-0 nylon.

Figure 5. ICCE with cryoprobe

5.2. Planned ECCE (with Nucleus Expression)

Indications:
• still indicated today (small incision variant, MSICS, very popular worldwide)
• hard lenses with tentative corneal endothelium
Contraindications:
• poor zonular support

27
 • soft lens
Preop:
• consider orbital massage or osmotic agents to reduce vitreous pressure
Anesthesia:
• retrobulbar and lid block
• subtenon’s block
• rarely general anesthesia, e.g. claustrophobia, dementia, tremor
Procedure:
1. Superior bridle suture.
2. Peritomy of about 170 degrees.
3. Initial limbal groove in sclera with a chord length in the 11 mm range.
4. Initial entry into anterior chamber to allow capsulotomy (3 mm).
5. Instill viscoelastic.
6. Remove anterior capsule (usually with can opener approach).
7. Mobilize lens (physically with cystitome or with hydrodissection – be careful).
8. Extend initial incision to full length of groove (with scissors or knife).
9. Safety sutures are preplaced, usually 7-0 vicryl.
10. Lens removed w/ lens loop or w/ counter pressure technique.
11. Wound is closed with safety sutures.
12. Cortical material is removed using I/A device (either automated or manual).
13. Instill ophthalmic viscoelastic device (OVD).
14. Lens is placed in the posterior chamber.
15. Wound is closed with 10-0 nylon.
16. OVD is removed.

5.3. Manual Small Incision Cataract Surgery (MSICS)

Indications:
• budget constrained
• hard lenses with tentative corneal endothelium
Contraindications:
• soft lenses
Preop:
• consider orbital massage or osmotic agents to reduce vitreous pressure
Anesthesia:
• retrobulbar and lid block
• subtenon’s block
• rarely general anesthesia, e.g. claustrophobia, dementia, tremor
Procedure:
1. Superior bridle suture (if incision is superior).
2. Peritomy of about 170 degrees.
3. Make frown shaped incision to reduce astigmatism.

28
 4. Center of frown incision is 1–2 mm posterior to limbus.
5. Frown incision is 6–7 mm wide.
6. Incision dissection is carried into cornea widely to about 10 mm width.
7. Instill viscoelastic.
8. Initial entry into anterior chamber to allow capsulotomy with keratome.
9. Remove anterior capsule (large CCC, can opener, other).
10. Mobilize lens (physically with cystitome or with hydrodissection with CCC).
11. Lens removed w/ irrigating lens loop under lens.
12. Allow fluid pressure too push lens out of eye.
13. Cortical material is removed using I/A device (either automated or manual).
14. Instill ophthalmic viscoelastic device (OVD).
15. Lens is placed in the posterior chamber.
16. Wound may seal or use a couple of 10-0 nylon sutures.
17. OVD is removed.
18. Reapproximate the conjunctiva.

Figure 6. Frown incision in MSICS

29
6. Phacoemulsification – Step by Step

Please read:
• Paul S. Koch. Simplifying Phacoemulsification: Safe and Efficient Methods for Cataract
Surgery. 5th edition. Slack Inc, 1997.
• Bonnie An Henderson. Essentials of Cataract Surgery. 1st edition. Thorofare NJ, Slack
Inc, 2007.
• David F. Chang. Phaco Chop: Mastering Techniques, Optimizing Technology, and
Avoiding Complications. 1st edition. Slack Inc, 2005.
• David F. Chang, Terry Kim, Thomas A. Oetting. Curbside Consultation in Cataract
Surgery. 1st edition. Thorofare NJ, Slack Inc, 2007.
Indications:
• almost all cataract surgery
Contraindications:
• few, maybe: almost no zonular support or extremely hard lens
Anesthesia:
• topical +/− intracameral non preserved lidocaine
• retrobulbar and lid block
• subtenon’s block
• rarely general anesthesia, e.g. claustrophobia, dementia, tremor

Potential What to do about it?

complications
Delay case and consider canthotomy/lysis.
retrobulbar hemorrhage
Check IOP.
Delay case and cryo/laser area.
inject/perforate eye ball
Pray, call risk management.
Carry on, will get better.
incomplete block
Inject some more.

subconjunctival heme Forget about it.

Table 13. Complications of retrobulbar anesthesia

Rarely superior bridle suture (infraducts eye to allow superior exposure).

30
 Potential What to do about it?
complications
drive needle into
Delay case and cryo/laser area.
vitreous

subconjunctival heme Forget about it.

Table 14. Complications of superior bridle suture

6.1. Paracentesis

With 75 blade, or some other sharp knife, mark 75 w/ ink.

Fixation with 0.12 forceps or with fixation ring.
Paracentesis is relative to main incision so plan ahead.
For Seibel chopper should be 60 degrees from main incision.

Potential complications What to do about it?

put in wrong place make another

too small make another

too big suture later

nick capsule include in removed capsule

nick iris forget about it

Table 15. Complications during paracentesis

If topical, instill lidocaine (1% non-preserved in TB syringe w/ Troutman 27 G). Some

debate about utility.

Potential What to do about it?

complications

stings Re-assure patient.

Wash out AC and pray.
put in wrong medicine
Call risk management.
epithelial toxicity from
Coat w/ dispersive OVD.
topical

Table 16. Complications of topical anesthesia

31
6.2. Place Ophthalmic Viscoelastic Device (OVD)

Arshinoff soft shell technique: 1st dispersive (e.g. Viscoat® ), then cohesive (e.g. Healon® ).
Allows dispersive to coat corneal endothelium to protect from U/S energy.
Allows cohesive to maintain chamber during the first part of procedure.
Or use just one. Healon® is cheapest at our VA.

Potential What to do about it?

complications
shoot loose cannula into
Tighten it better next time.
eyeball
Suck out the air with syringe or place OVD distal
air bubbles
and force out.

Table 17. Complications during placement of OVD

6.3. Wound

3 major categories (very similar): limbal, scleral, and corneal.

Style Advantages Disadvantages

induces astigmatism,
easy to convert to ECCE,
always requires suture,
instruments don’t distort
limbal iris prolapse more common,
cornea,
conj manip and cautery,
great for greenhorns
eye is red after surgery
hard to convert to ECCE,
technically difficult,
rarely induces astigmatism, iris prolapse more common,
scleral
seals nicely conj manip and cautery,
instruments distort cornea,
eye is red after surgery
hard to convert to ECCE,
technically difficult,
no cautery or conj manip, instruments distort cornea,
cornea
eye is white after surgery astigmatism with wide
incision,
increased endopthalmitis?

Table 18. Types of incision in phacoemulsification

32
Limbal incision:
• peritomy of 4–7 mm depending on IOL size
• cauterize sclera
• 1⁄2 depth groove into limbus with crescent blade or 64 beaver
• enter eye with keratome (sized for phaco needle)

Potential What to do about it?

complications
Usually no big deal.
groove too deep
W/ iris prolapse move elsewhere.

nick capsule Include in CCC.

nick iris Forget about it.

Table 19. Complications during limbal incision

Scleral tunnel:
• peritomy of 4–7 mm depending on IOL size
• cauterize sclera
• 1⁄2 depth groove into sclera with crescent blade
• tunnel at 1⁄2 depth through sclera into cornea with crescent blade
• enter eye with keratome (sized for phaco needle)

Potential What to do about it?

complications
“Is that ciliary body?”,
groove too deep
Close and move incision.

shred scleral flap Tunnel further into cornea.

wound too wide Partial suture to maintain AC.

nick capsule Include in CCC.

nick iris Forget about it.

Table 20. Complications during scleral tunnel

Corneal incision:
• 1⁄3 depth tunnel into cornea with keratome
• enter eye with keratome

33
 Potential What to do about it?
complications

shred flap Move and/or suture.

too wide Move and/or suture.

Move or re-enter shorter.
tunnel too long
Funnel internal section wider.
Suture and move.
tunnel too short Use iris hook under wound to prevent iris pro-
lapse.

start too posterior Peritomy to prevent conj donut.

nick capsule Include in CCC.

nick iris Forget about it.

Place air and position head to tamponade.
Descemet’s detachment
Place SF6 gas (1⁄3–1⁄2 AC).

Table 21. Complications during corneal incision

6.4. Capsulorhexis

Most important part of the procedure.

Anterior chamber must be filled with viscoelastic.
Two basic techniques: continuous curvilinear capsulorhexis (CCC) and can opener.

Style Advantages Disadvantages

easy to do,
increased risk of vitreous loss,
red reflex not required,
can opener IOL is less stable,
allows ECCE nucleus
increased risk of PCO
expression
hard to do,
less risk of vitreous loss, may need capsular stain w/
CCC IOL is very stable, poor red reflex,
less PCO needs relaxing incisions for
ECCE

Table 22. Capsulorhexis styles

Goal is CCC with a central circular opening slightly smaller than the optic diameter.
Three basic techniques for CCC (best way to learn about this is to watch video):

34
 • cystitome - initial cut and control of tear with cystitome (best with cohesive OVD)
• combo – initial cut w/ cystitome, most of tear w/ forceps (most common technique)
• forceps – sharp forceps cut and then grab capsule to complete tear
• femtosecond laser – cheating

Potential What to do about it?

complications
Capsular stain (e.g. trypan blue).
poor red reflex
Side light with corneal opacity
Add OVD – most important Grab close to tear
and redirect Little technique – pull flap in op-
starting to go radial
posite direction then central and tear will often
turn back
Use scissors to restart in other direction.
Relaxing tear 180°across.
Can opener and conversion to ECCE.
radial tear Debulk sculpting out bowl prior to hydrodissec-
tion.
Wide groove, divide, prior to hydrodissection.
V groove with no hydrodissection.

too small Enlarge after placing IOL.

Forget about it.
too large Nucleus may easily prolapse during hydodissec-
tion.
Use iris or capsule hooks to stabilize.
Use iris hooks with CTS to stabilize.
Early capsular tension ring (w/ or w/o Cionni
zonular laxity
mod).
Sutured capsular tension segment (CTS).
Place CTR or CTS after cohesive viscodissection.

Table 23. Complications during capsulorhexis

6.5. Hydrodissection

Second most important of procedure.

Skip with posterior polar, perforating lens trauma or early post-vitrectomy cataract.
Balanced salt solution in 3 cc syringe with Troutman 27 G or similar, little waves of these steps.
Inject fluid just under capsule to cleave cortex from capsule.
Gently press on lens.
Look for a fluid wave. Don’t stop till you get enough. Don’t stop till you get enough.
Rotate lens to ensure the job is done.

35
May prolapse lens with a large capsulorhexis – not always bad.

Potential What to do about it?

complications
Try again in different spot.
Increase force.
no fluid wave
Use bursts and gently push on nucleus between
bursts.
Release AC pressure thru paracentesis.
Rock lens to release BSS trapped in bag and free
posterior pressure.
iris prolapse
Prevent by removing dispersive OVD over lens
and iris before hydrodissection.
Subincisional iris hook.
Brown tech. or Pop’n’Chop.
prolapsed nucleus Flip into ciliary sulcus.
Push back into bag.
Too late but was this s/p vitrectomy, trauma or
posterior polar cataract?
blowout post capsule Clean up the Vit in AC, place IOL.
Call your friendliest Vit surgeon (this is their
job, don’t worry about it).

Table 24. Complications during hydrodissection

6.6. Phacoemulsification

Goal is to remove lens with the minimum ultrasound (U/S) damage to the cornea.
Trend is to use increasing vacuum and decreasing U/S power to remove nucleus.
Energy can be torsional (Alcon, AMO) or longitudinal (standard U/S).

Energy Advantages Disadvantages

torsional material flows to tip, tip can become occluded,
(e.g. OZil® ) may be cooler bored hole larger than tip
more power, pushes material away from
longitudinal
nice to bore for occlusion, tip,
(traditional)
nice for grooving may be hotter

Table 25. Types of ultrasound energy delivery during phacoemulsification

Phacoemulsification of the nucleus can be done:

• endocapsular – keeping the nucleus in bag during phaco

36
 • supracapsular – prolapsing nucleus into sulcus during phaco
• AC shell - prolapsing shelled out nucleus into AC
• 1⁄2 bag 1⁄2 AC – tipping nucleus on side 1⁄2 in bag, 1⁄2 in AC – Brown, Pop’n’Chop

Phaco location Advantages Disadvantages

tear ant capsule with chopper
or phaco tip,
endocapsular energy away from cornea
nuclear pieces tight in bag –
jigsaw puzzle problem
less risk of hitting ant cap, U/S energy close to cornea,
supracapsular
no jigsaw problem nuclear flip close to cornea
slow,
AC shell little stress on bag energy close to cornea,
old school
no jigsaw problem,
1
⁄2 bag 1⁄2 AC energy closer to cornea
less risk of hitting ant cap

Table 26. Locations of nucleus phacoemulsification

Many ways to disassemble nucleus:

• Sculpt and prolapse – sculpting out a bowl and then collapsing material into center
• Divide and conquer – classic technique, must know
• V groove – old school, useful when hydrodissection is not possible
• Chopping – horizontal chop, vertical (quick) chop, stop’n’chop

Fragmentation
Advantages Disadvantages
style
slow,
sculpt and
can do with one hand energy close to cornea,
prolapse
lots of U/S power
classic,
divide and easy to do,
lots of U/S power
conquer energy away from cornea,
can do with one hand
does not require
hydrodissection,
slow,
V groove does not require rotation,
lots of U/S power
useful with known capsule
damage

37
 fairly easy to do,
stop’n’chop needs two hands
less U/S power
little stress on bag, hard to do,
least U/S power, needs two hands,
chop
fast, hit ant capsule with chopper,
easy on zonules jigsaw problem

Table 27. Nucleus fragmentation styles

Potential What to do about it?

complications
Increase bottle height.
chamber instability, Decrease vacuum (and flow rate w/ peristaltic).
post-occlusion surge Check irrigation tubing for kinks.
Wounds too big? – Suture end.
Carefully proceed, or
tear anterior capsule consider conversion to ECCE.
Consider V groove technique.
Strongly consider conversion to ECCE, or
clean up the Vit in AC, place OVD, consider
tear posterior capsule continued phaco (advanced).
Use IOL as scaffold.
Don’t let the AC shallow, use OVD if possible.
Increase aspiration flow rate and vacuum.
Reprime vacuum (esp w/ Venturi system).
Check aspiration tubing.
pieces won’t come to tip
Add longitudinal phaco (tip occluded).
Remove second instrument, esp if paracentesis is
leaky.
Widen wound and continue.
Stop lifting up on needle.
wound hot
Clear out OVD (especially dispersive).
Suture at end (may need horizontal mattress).
Fluid out > in, so check lines, wounds, bottle.
Choroidal hemorrhage – check red reflex.
shallowing of chamber
Misdirected BSS posteriorly – wait it out.
Fluid trapped under lens – rock it to release.

Table 28. Complications during phacoemulsification

38
6.7. Cortical Aspiration

Aspiration to grab and peel the cortex off the capsule, not suck it off the capsule.
Dangerous procedure – common time for vitreous loss in experienced surgeon.
Subincisional removal is most difficult, esp with small rhexis.
Adequate hydrodissection makes this step easier.

Potential complications What to do about it?

Increase bottle height.

Check tubing and fluid level of BSS bottle.
chamber instability
Wound too big? – Suture end.
Decrease vacuum or flow rate (peristaltic).
catch posterior capsule Reflux fluid.
(“spider sign”) Continue and keep aspiration port up.
Capsular tension ring.
Place 3-piece IOL w/ haptics in area of weakness.
grab capsule and tear zonules
CTS if zonular loss > 3 clock hours.
Place dispersive OVD in weak area.
Don’t let the AC shallow (use OVD if possible).
Anterior vitrectomy.
Convert tear into continuous circular tear (rare).
tear capsule
Dry removal of residual cortex with cannula.
Consider sulcus IOL.
Miochol at end of case.
Hydrodissect area through paracentesis, try
again.
residual subincisional cortical Use 90 degree angled I/A handpiece.
material Place OVD and carefully use J cannula.
Place IOL and use optic to shield capsule, try
again.

Table 29. Complications during cortical aspiration

6.8. Fill Bag with OVD

Form bag, not sulcus.

Use cohesive OVD in bag.
Consider dispersive OVD adjacent to wound to seal – Arshinoff shell.
Place OVD ahead of the cannula – don’t pierce the post capsule with cannula.
Make sure the cannula tip is firmly attached to syringe or it will shoot off.

39
Wound may need to be extended to allow placement of the lens

PMMA (doesn’t fold) IOL needs slightly more than optic size.
Old school now – forceps loaded IOLs need 3.5 mm or so to insert.
Most injected IOLs don’t need extension from incision for phaco needle.
A bit bigger, well constructed wound seals better than stretched small wound.

6.9. Lens is Placed into Capsular Bag

PMMA IOL:
1. grasp IOL and trailing haptic with forceps (e.g. Kelman-McPherson)
2. place leading haptic into bag, optic into AC, release forceps
3. place optic into bag
4. place trailing haptic into bag with hook or forceps
Folded IOL:
• folded and placed in special forceps
• incision size grows a bit with increased power of IOL – 3.5 mm range
• moustache style fold: wider incision, but haptics flow into bag (great when suturing IOL
to the iris with no capsule)
• axial style fold: smaller incision, but haptics need guidance

Scheme 2. IOL implantation with forceps: A) moustache style fold, B) axial style fold

Injected IOL:
• most common – many different systems
• single piece acrylic (SA60AT, SN60WF) and plate IOL – most simple
• 3-piece IOL requires some haptic care and manipulation
• be careful of Descemet’s membrane w/ IOL insertion (especially w/ injectors)

40
Scheme 3. IOL implantation with injector: A) toe up on injector can tear Descemet’s membrane, B)
toe down slips under Descemet’s membrane

Is the IOL right side up?

• correct side up looks like “7-O-Leven” (have you heard of 7-11 stores?)

Scheme 4. A) IOL with correct side up (top haptic looks like a 7, optic looks like an O, bottom
haptic looks like an L), B) IOL is designed for right handed surgeon to easily rotate, C) when upside
down the IOL looks like an S, so Stop

Upside down angulated 3-piece IOL creates myopic shift w/ anterior IOL shift.

Scheme 5. IOL in capsular bag: A) right side up, B) upside down

Make sure that both haptics are in the bag:

• may need to add OVD – often some is lost during insertion of IOL
• most common cause of decentration: one haptic in bag, one in sulcus
• bag has less space than sulcus – 1⁄2 in, IOL shifts toward sulcus haptic

41
 Scheme 6. IOL in capsular bag: A) centered, B) decentered, 1⁄2 in bag

Rotate IOL, so that haptics are 90° from the wound:

• set yourself up for the next step – irrigation and aspiration (I/A)
• allows I/A tip to get under IOL to remove OVD under IOL
• frees most common site of residual cortical material from haptic

6.9.1. Special IOL Placement Conditions

Anterior capsular tear:

• single-piece acrylic in the bag – creates little tension on the bag
• 3-piece with both haptics in the sulcus
Zonular dialysis:
• capsular tension ring with any IOL
• 3-piece IOL with PMMA haptic oriented toward weak area of zonules
• consider CTS
Posterior capsular tear before IOL is placed - stable or round hole:
• dispersive OVD in the post capsular hole – gently place IOL into bag
• place 3-piece IOL in sulcus +/− capture of optic by centered CCC
Posterior capsular tear before IOL is placed – large tear:
• dispersive OVD in the post capsular hole
• place 3-piece IOL in sulcus +/− capture of optic by centered anterior CCC
Posterior capsular tear after 3-piece IOL is placed in bag (rare):
• dispersive OVD in the post capsular hole
• gently move 3-piece IOL into sulcus
• consider optic capture by centered anterior CCC
• if sulcus is not stable, then use iris sutures
Posterior capsular tear after single piece IOL is placed in bag (rare):
• dispersive OVD in the post capsular hole
• gently prolapse optic anterior and capture with CCC (if possible)
• if CC is not stable remove IOL and replace with 3-piece in the sulcus
No capsular support:
• AC IOL, 3 sizes depending on white to white size (simple)
• iris sutured PC IOL (need to know how to do this)
• scleral sutured PC IOL
• classic Wagoner AAO study, no difference in the above
• Agarwal technique with haptics in scleral pocket with glue
• iris clip IOL (Artisan – not approved by FDA for aphakia yet)

42
 Potential What to do about it?
complications
Can leave as is – accept myopic shift, or take one
haptic out of wound with hook:
place IOL upside down 1. Fill with OVD above and below IOL.
2. One hook above and one below – flip IOL.

Fill with OVD – rotate into bag with hook.

inadvertent sulcus If a 3-piece can leave in sulcus w/ myopic shift.
placement Do not leave single piece acrylic (SA60AT) in
sulcus.
Usually one haptic in sulcus one in bag – dial
both into bag or both into sulcus.
Possible zonular dialysis:
• if nearly centered, leave it alone
• rotate IOL carefully for best centration,
w/ 3-piece haptics best at weak area
IOL doesn’t center • check wound for vitreous
• consider late placement of CTR or CTS
• place miochol to help check for vitreous
Haptic damage (especially with 3-piece IOL):
• may have to replace IOL
• could capture with centered anterior cap-
sule
Use care not to extend tear.
tear in Descemet’s Place air bubble at end of case – postop position
wound up – bubble seals tear.
If not central, forget about it.
marred IOL
If central, exchange IOL.
Rotate haptic 90 deg from wound.
lens material behind
Toe down with I/A and get under IOL.
IOL
With asp hole showing at all times, aspirate.

Table 30. Complications during IOL implantation

Sutures are preplaced (if needed)

Preplace 10-0 nylon sutures while OVD maintains chamber.

Usually need 2 interrupted or one X suture with 6 mm scleral tunnel.
Usually need 1 interrupted suture with 3 mm limbal wound.
Usually need no sutures with proper 3 mm wound of cornea or sclera.
Can use 10-0 vicryl sutures with children.

43
6.10. OVD is Removed with I/A Device

As always, keep aspiration port up.

Go under IOL to remove OVD, esp if you have been having IOP problems postop.

Potential What to do about it?

complications
Increase bottle height.
Check tubing and fluid level.
chamber instability
Wound too big? – Suture end.
Decrease vacuum.
Reflux fluid.
catch iris
Continue and maintain your bearings.

grab capsule and tear

Capsular tension ring.
zonules
Place dispersive OVD in weak area.

Table 31. Complications during OVD removal

6.11. Sutures are Tied

3/1/1 for 10-0 nylon in the sclera.

2/1/1 for 10-0 in clear cornea to allow small knot to rotate and bury.

6.12. Other

Give antibiotic drops, rarely subconjuntival antibiotics.

Consider postoperative povidine iodine.
Consider lubricating cornea w/ dispersive OVD (e.g. OcuCoat® ).
Patch to protect cornea if retrobulbar or subtenon’s was used.

44
7. Phaco Machine Settings Primer

7.1. Four Main Components and Software to Tie Them Together

Pump – most important variable:

• parameters depend on tubing diameter and compliance
• parameters depend on phaco needle diameter
• allows removal of the emulsified lens material
• set low during sculpting and higher during quadrant removal and chopping
Irrigation system:
• typically is just an adjustable bottle held higher than eye to allow infusion of fluid
• machine can adjust bottle height
• machine can turn fluid on and off
Ultrasound (U/S) handpiece:
• vibrates needle at a set rate in the 20,000 to 40,000 Hz range
• increasing the U/S power increases the excursion of the needle, not frequency
• with increasing load (e.g. big chunks of lens) the frequency/excursion may not keep up
• modern multiple crystal hand pieces can better handle load
• some machines (e.g. Alcon and AMO) have both longitudinal and torsional power
Footswitch:
• typically controlled with dominant foot (w/o shoes)
• accelerator like pedal is common across all brands
• position 0 – everything is off
• position 1 – irrigation is on, no pump, no U/S
• position 2 – irrigation is on, pump is on, no U/S
• position 3 – irrigation is on, pump is on, U/S is on

7.2. Phaco Pumps

Look over the classic definitive text: Barry Seibel. Phacodynamics: Mastering the Tools and
Techniques of Phacoemulsification Surgery. 4th edition. Slack Inc, 2005.

Flow rate – amount of fluid passing through the tubing (cc/min), also aspiration flow rate.
Vacuum – difference in fluid pressure in two points, e.g. tip of needle and AC (mmHg).

7.2.1. Vacuum Based Pumps

E.g. Venturi pump (Stellaris, Accurus), diaphragm. Increasing pump power increases vacuum
directly, flow rate indirectly.
Venturi pump requires external source of compressed air or compressor.
This has limited acceptance of this pump (ASC may not have air lines).

45
Compressed gas flows over open top of rigid cassette attached to tubing.
Flow of gas creates vacuum much as flow over airplane wing creates lift.
Flow rate is a function of vacuum and resistance of flow and not directly set.
Roughly analogous to electric current voltage relationship (Ohm’s law):

U – voltage (analogous to vacuum)

I=
U I – current (analogous to flow rate)
R R – resistance (analogous to tubing and oc-
clusion)

More flow (cc/min) with less resistance (fixed vacuum).

More flow (cc/min) with more vacuum (fixed resistance).

Pump settings:
• no settings for flow rate, only vacuum
• fixed:
– no matter how deep you are in position 2 or 3, vacuum is fixed
– great for chopping and quadrant removal
• variable:
– vacuum increases from 0 to max as you push on the pedal
– great for I/A (can slowly increase vacuum to just what you need)

7.2.2. Flow Based Pumps

E.g. peristaltic pump (Infiniti, Sovereign, Legacy).

Increasing pump power increases flow rate directly and vacuum indirectly.
Vacuum is dependant on resistance of flow.
Roughly analogous to electric current voltage relationship (Ohm’s law):

U – voltage (analogous to vacuum)

U =I ×R I – current (analogous to flow rate)
R – resistance (analogous to tubing and oc-
clusion)

More vacuum with more resistance (fixed flow rate).

More vacuum with more flow rate (fixed resistance).

Pump settings:
• set vacuum cutoff and flow rate
• vacuum cut off:
– seems like you are setting the vacuum
– really setting the vacuum at which the pump stops
– increasing the vacuum does not increase pump speed
– flow rate or aspiration flow rate (AFR) sets pump speed cc/min
• w/ modern peristaltic pumps (e.g. Infiniti) for each foot pos you can have :
– fixed or variable flow

46
 – fixed or variable vacuum cut off
Flow rate Vacuum cut off Comment/Application

Independent of depth in foot posi-

fixed fixed tion.
Low numbers good for sculpting.
More depth, higher vacuum cut off.
fixed variable Limited control.
Typical I/A setting on Alcon 20,000.
More depth, faster pump.
variable fixed More control, pump speed changes.
Bimodal setting on Alcon 20,000.
Both change with depth in foot pos.
variable variable
Feels like a Venturi pump.

Table 32. Application of different flow rate and vacuum cut off settings

Pump Pros Cons

Less post-occlusion surge. Need source of compressed

vacuum
Better for vitreous removal. gas.
(e.g. Venturi)
Material comes to tip easily. Need rigid cassette.
Post-occlusion surge.
flow Better for sculpting.
Need occlusion for vacuum to
(e.g. peristaltic) No need for compressed air.
build.

Table 33. Phaco pump comparison

7.3. Ultrasound Control

Four axial ultrasound modes: continuous, pulse, burst, and hyperpulse.

Now some machines also have some rotary (OZil® on Infiniti) or oscillatory (AMO) motion.

Continuous:
• phaco is on in position three
• usually increasing U/S power with depth into foot position 3
Pulse:
• phaco pulses with duty cycle on and off
• usually with equal on and off time or 50% duty cycle (time on/cycle time)
• usually the rate is fixed (Hz)
• usually increasing U/S power with depth into foot position
Burst:
• bursts of power come with off time that decreases with depth into foot position

47
 • usually when floored in position 3 – U/S power becomes continuous
• U/S power is fixed
Hyperpulse:
• uses short on time pulses e.g. 25% on; 75% off
• fixed duty cycle; fixed pulse rate; usually high frequency like 200 Hz
• usually increasing U/S power with depth into foot position 3
Torsional:
• OZil® uses rotary motion of angled (Kelman type) tip rather than longitudinal U/S power
• AMO oscillatory system does not require Kelman tip
• can use supplemental longitudinal to clear and prevent occlusion

Mode Advantages Disadvantages Applications

continu- repels nuclear material,
simple sculpting
ous hot
can repel nuclear choo-choo chop,
longitudinal

pulse less hot

material segment removal
less hot,
burst chopping
holds material well
followability w/ long off
hyper- sculpting,
cycle,
pulse bimanual small incision
cool with long off cycle
torsional

followability (doesn’t just OK for chop,

continu- can get clogged,
push material away), great for segment
ous additional expense
may be cooler removal

Table 34. Ultrasound modes

B&L Vacuum Flow

Type U/S Comment
Millennium (mmHg) (cc/min)

sculpt 15 n/a continuous

100 – 2nd yr at 100,
segment removal n/a pulse 4 Hz
150 3rd yr at 150

chop 150 n/a pulse 4 Hz choo-choo chop

I/A 500 n/a n/a default settings

Vacuum Flow
B&L Stellaris Type U/S Comment
(mmHg) (cc/min)

sculpt 15 n/a continuous

pulse 60 Hz
segment removal 175 n/a
30% on

chop 175 n/a pulse 4 Hz choo-choo chop

48
 I/A 500 n/a n/a default settings
Alcon Legacy Vacuum Flow
Type U/S Comment
20 000 (mmHg) (cc/min)

sculpt 50 22 continuous

segment removal 40 400 pulse 4 Hz good 3rd yr settings

could increase to 50
chop 40 400 burst
mmHg/500 ml/min
epinucleus
30 300 bimodal
removal

I/A 500 50 n/a default settings

Vacuum Flow
Alcon Infiniti Type U/S Comment
(mmHg) (cc/min)
longitudi-
sculpt 80 F 20 F hyperpulse continuous
nal
longitudi-
grab for chop 350 F 35 F burst 50 ms
nal

remove pieces 350 S OZil® 35 F continuous

epinucleus
300 V OZil® 30 F continuous
removal

I/A ≥ 500 V 50 V n/a default settings

n/a = not applicable; F = fixed; V = variable

Table 35. My typical settings

49
8. Ophthalmic Viscoelastic Devices (OVD)

Two basic categories:

1. Cohesive:
• high molecular weight, high surface tension, e.g. Healon®
• big, bulky, and likes to touch itself
2. Dispersive:
• low molecular weight, low surface tension, e.g. Viscoat®
• smooth and likes to touch others

Scheme 7. OVD continuum

8.1. Indications

Different jobs demand different OVDs:

1. Maintain space (e.g. AC during rhexis, bag during IOL insertion) – cohesive best.
2. Create space (e.g. creating sulcus, shift lens material) – cohesive best.
3. Sealing off (e.g. sealing capsular tear, keeping iris tag away) – dispersive best.
4. Tamponade (e.g. protect corneal endothelium, lubricate cornea) – dispersive best.

Step Cohesive Dispersive

Easy to fill AC.

Must completely fill AC.
CCC Can suddenly lose OVD
Stays in AC.
through wound.
Stays on endothelium.
Particles can stick to endothe-
phaco Goes away with first vacuum.
lium.
Increased risk of burn.
Easy to open/maintain bag. Hard to remove residual mate-
IOL insertion
Easy to remove material. rial.

Table 36. Differences between cohesive and dispersive OVDs during different surgical steps

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8.2. Removal

Dispersive harder to remove:

• short molecules don’t string along together into port during I/A, but
• short molecules create less postop IOP spike
Cohesive is easier to remove:
• longer molecules string along together into port during I/A
• longer molecules block the trabecular meshwork for big IOP spike

8.3. Adaptive OVD

Properties of dispersive OVD at high shear rate (e.g. during phaco) and of cohesive OVD at low
shear rate (e.g. during IOL placement) – e.g. Healon® 5.
Very long fragile chain molecules that break with flow rate.
Difficult to remove.

8.4. Arshinoff Shell

Phase I during CCC:

1. First place dispersive OVD (magenta on scheme 8.).
2. Then place cohesive OVD just over lens (blue on scheme 8.).
3. Then dispersive is pushed up to coat endothelium.
4. As soon as phaco starts, cohesive is aspirated and dispersive coating remains.
Phase II during IOL insertion:
1. First place cohesive OVD in the bag.
2. Then place dispersive OVD just inside wound to seal prior to IOL placement.
3. When IOL is inserted, dispersive helps to keep cohesive in place (bag formed).

51
Scheme 8. Arshinoff Shell technique

52
9. Capsular Staining

The white cataract used to be the most feared cataract surgery to perform.
Capsular staining has changed these cases from complex to routine.
Capsular stains (ICG and trypan blue) are useful whenever capsule is hard to see:
• classic white cataract
• traumatic cataract with possible anterior capsular tear
• dark red or brown cataract with limited red reflex
• started rhexis and then loose capsule in an area of dense lens
• useful for delineating anterior capsular trauma

9.1. Trypan Blue

VisionBlue® – premixed and approved by the FDA (2005) making it cheaper, better, and faster
than ICG.

Figure 7. Capsulorhexis after capsular staining with trypan blue

9.2. Indocyanine Green (ICG)

Reference: Horiguchi M et al. Staining of the lens capsule for circular continuous capsulorrhexis
in eyes with white cataract. Arch Ophthalmol. 1998;116:535–7. ICG is used to stain the lens
capsule, but is rarely used with trypan blue available now.
Stain may be harmful to the retina, so use the least amount possible.
Preparation:
• draw up 0.5 cc of aqueous solvent (comes with ICG) into syringe
• place aqueous solvent into vial of 25 mg ICG and shake
• draw up 4.5 cc of BSS into syringe

53
 • place BSS (original article was BSS+, but BSS is OK) into ICG vial and shake some more
• Osm 270 (plasma 285) with a concentration 0.5%

9.3. Surgical Technique

Surgical technique is the same for either stain:

1. Place paracentesis and fill anterior chamber with air.
2. Can place some dispersive OVD at wound if air leaks.
3. Drop/rub ICG solution or trypan blue onto anterior capsule w/ cannula.
4. Wash out stain with BSS through paracentesis and remove bubble.
5. Fill anterior capsule with OVD.
6. Make typical wound into anterior chamber.
7. Perform CCC (capsule will be green or blue, lens will not).
Remember: you can add stain later if you need more or if you realize that it would be helpful
even after you have gotten started.

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10. Routine Postoperative Care

10.1. Phacoemulsification

Usually 2 or 3 postoperative visits:

• same afternoon 4–6 hours later (to catch IOP peak) or next AM
• (optional) one week later (to check on inflammation)
• 3–4 weeks later to give glasses

Day 1

RAPD, VFF to CF.

VA:
• expect about 20/40, better w/ PH
SLE:
• expect corneal edema proportional to ultrasound time
• expect epitheliopathy from the topical anesthetic
• 1–2+ cell and flare
• look for K abrasion, especially if patched
• look for retained material in inferior angle
IOP:
• < 8 mmHg: look hard for leak with Seidel test
• 9 – 29 mmHg: probably OK
• > 30 mmHg: start with Cosopt, Alphagan, recheck in 45 min
• > 40 mmHg: suppress aqueous and bleed aqueous through paracentesis until pressure is
stable (< 30), recheck in 45 min or so, consider seeing the next day
• lower these guidelines in patients with h/o DM, AION, etc.
Fundus:
• usually can see fundus w/o dilation
• document no RD or choroidal effusion/hemorrhage
Plan:
• antibiotic 1 gtt qid for a week
• prednisolone acetate taper 1 gtt qid for a week, then tid for a week
F/u:
• 2–4 weeks later in routine cases
• one week later with IOP spike, vitreous loss, h/o uveitis
• next day with wound leak, big corneal abrasion, etc.
Give a simple large print postoperative instruction sheet.

55
Week 1

RAPD, VFF to CF.

VA:
• expect about 20/30, PH 20/20
SLE:
• expect little corneal edema and trace to 1+ cell and flare
Consider fundus exam with poor vision, DM, floaters, etc.
Plan:
• taper prednisolone acetate
• stop antibiotic
F/u:
• usually 3–4 weeks later
• full activity

Week 2–4

RAPD, VFF to CF.

VA:
• expect about 20/25, PH 20/20
MR:
• consider suture induced astigmatism
Plan:
• give MR for glasses
F/u 1 year.

10.2. Large Incision ECCE or ICCE

Usually at least 3 postoperative visits:

• same afternoon 4–6 hours later (to catch IOP peak) or next AM
• one week later (to check on inflammation)
• 4–5 weeks later to check astigmatism for suture removal or give glasses
Much of the emphasis is on suture removal for astigmatic control.

Day 1

RAPD, VFF to CF.

VA:
• expect about 20/200, better with PH
SLE:
• expect significant corneal edema, 2–3+ cell and flare

56
 • look for K abrasion, esp if patched
IOP:
• < 8 mmHg: look hard for leak with Seidel test
• 9 – 29 mmHg: probably OK
• > 30 mmHg: start with Cosopt, Alphagan, recheck in 45 min
• > 40 mmHg: suppress aqueous and bleed until pressure is stable (< 30), consider seeing
the next day
• lower these guidelines in patients with h/o DM, AION, etc.
Fundus:
• usually can see fundus w/o dilation
• document no RD or choroidal effusion/hemorrhage
Plan:
• floroquinolone 1 gtt qid
• prednisolone acetate 1 gtt qid
• cyclogyl 1% bid
F/u:
• one week later usually
• next day with wound leak, big corneal abrasion, etc.
Give a postoperative instruction sheet.

Week 1

RAPD, VFF to CF.

VA:
• expect 20/100 and about 20/50 w/ PH
• keratometry for fun – expect about 7 diopters
• don’t waste time with refraction
SLE:
• expect little corneal edema and 1–2+ cell and flare
Fundus:
• usually can see fundus when on cyclogyl
• document no RD
Plan:
• d/c antibiotic (tell pt to keep bottle in refrigerator for suture removal)
• d/c cyclogyl if inflammation is less than 1+; o/w continue
• taper prednisolone:
– 1 gtt qid for 7 more days, then
– 1 gtt tid for 7 days, then
– 1 gtt bid for 7 days, then
– 1 gtt qd for 7 days, then
– discontinue
F/u:
• 5 weeks later (allows healing time before suture removal)

57
Week 6

RAPD, VFF to CF.

VA:
• expect 20/80 and about 20/40 w/ PH
Keratometry:
• expect about 5.0 diopters at 90
• don’t get confused and read backwards (e.g. for 5.0 at 90: left dial could read 40, right
dial reads 45)
MR:
• start with streak retinoscopy or auto refract (usually on w/ clear media)
• start with 2⁄3 of cyl from K’s and adjust SE to -1.0 (usually very close)
SLE:
• look at the wound and decide which sutures look tight
Suture lysis:
• indicated when cyl is ≥ 2 diopt. on MR, or ≥ 3 on K’s (if you did not do MR)
• if less than 2 on MR, stop, high fives, don’t cut anything
• remove tightest suture near axis of cylinder on K’s
• only cut one suture at week 6–8 visits
• can cut two beyond week 8
• if tight axis is between sutures, cut both (think vectors)
Plan:
• full activity
• antibiotic drop 1 gtt qid for 4 days (following each suture removal)
F/u:
• if no sutures need to be removed (will never happen), give glasses – usually +2.5 add with
MR
• f/u 1 year.
• otherwise return every 1–2 weeks for additional suture lysis

After that

You really have about three choices (don’t stall):

1. Pull a stitch (i.e. cyl at axis of stitch is greater than 2 on MR).
2. Give glasses (i.e. no stitch to pull or cylinder is less than 2 on MR).
3. Get OCT, because you suspect CME.
Don’t waste time thinking about other possibilities – not everybody is going to be 20/20.

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11. Principles of Anterior Vitrectomy

We will cover the causes and signs of vitreous prolapse and the principles of anterior vitrectomy
in various situations.1-3 This handout is modified from my blog1 which also includes video and
may be of some interest to those learning about anterior vitrectomy.

Causes of vitreous prolapse. The vitreous either comes around the zonules or through a
tear in the posterior capsule. Posterior capsular tears are caused commonly by: anterior tear
extending posteriorly (most common), posterior tear secondary to phaco needle being too deep,
a chopper or from the I/A instrument, or a pre-existing injury (e.g. posterior polar cataract,
iatrogenic from PPVx, or from penetrating lens trauma). Zonular problems are often pre-existing
such as from trauma, PXF, or Marfan’s but can also be iatrogenic from forceful rotation of the
lens or pulling on the capsule during I/A.

Signs of vitreous prolapse. The first sign of vitreous prolapse is denial. Something seems
wrong, but you can’t quite pin point the issue. At first you deny that an issue exists, but soon
it becomes clear. Less mysterious signs of vitreous prolapse include: the chamber deepens, the
pupil widens, lens material no longer centered, particles no longer come to phaco or I/A, and
the lens no longer rotates freely. When you suspect vitreous prolapse, you should keep the
chamber formed by placing dispersive OVD into the eye before removing the phaco needle or
I/A from the eye and can check the wound with a WECK-CEL® sponge for vitreous.

Principles of anterior vitrectomy. The key to a successful anterior vitrectomy is to control

the fluidics of the eye. The first step is to close the chamber. Resist the temptation to use the
larger phaco wound for the vitrector; instead make a new paracentesis just big enough for the
vitreous cutter. You may need to close the original wound if it is not well constructed, but
usually you will not need to suture the original wound as long as it stays water tight during the
anterior vitrectomy.

The second step is to separate the irrigation device from the aspiration/cutting device (this is
standard on modern phaco machines). In general, you will want to place the vitreous cutter
low (at the level of the posterior capsule) while holding the irrigating cannula high (anterior
chamber) which allows you to create a pressure differential such that the vitreous is encouraged
to move posteriorly toward the aspiration/cutter and away from the anterior chamber.

Scheme 9. Anterior vitrectomy: A) close the chamber, B) separate irrigation and cutter, C) cut low,
irrigate high

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In general, the bottle height should be low – just high enough to keep the AC formed and not
so high that fluid is forced out around the instruments which can bring vitreous with it. The
smaller the bore of the infusion cannula, the higher the bottle height will need to be. The
higher the vacuum, the higher the bottle height will need to be. The cutting rate should be as
high as possible when cutting vitreous and low when cutting cortical lens material or removing
viscoelastic. We will separately discuss early, mid, and late case vitreous loss below.

11.1. Vitreous Presenting Early in Case – While Most of Crystalline

Lens is in Eye

This is the worst time for vitreous to prolapse. The strategy will depend on how the vitreous
presented. If the vitreous has come from a strike in the posterior capsule while grooving or
from a radial tear which has gone posterior with almost all of the lens remaining, then one
should strongly consider converting to ECCE. If the pieces are smaller, then another option
is to sequester the residual nuclear material with viscoelastic or an IOL scaffold,4 perform the
anterior vitrectomy, and continue with slow motion phacoemulsification.5 If the vitreous has
come from loose zonules, then the solution may be better support of the capsule with a capsular
tension ring (CTR), a capsular tension segment (CTS), or capsular hooks.

Conversion to ECCE for early vitreous loss:

1. If topical, consider adding a subtenon’s injection. Incise conjunctiva in a quadrant and
dissect posterior to the equator and place 2 cc non-preserved lidocaine behind the eye.
2. Use only viscous dispersive viscoelastic (e.g. Viscoat® ) from this point forward as it causes
less ocular hypertension and sticks to other structures.
3. Consider closing the temporal incision with 10-0 nylon and make a separate incision with
peritomy superiorly or extend the existing temporal wound along the limbus to about 6
mm (if nucleus is already in quadrants) or 11 mm (if whole).
4. Use viscous dispersive viscoelastic (e.g. Viscoat® ) to lift lens up near the wound and to
displace the vitreous more posteriorly.
5. May need WECK-CEL® vitrectomy to clean up the wound if the vitreous has presented
through the main wound. Viscoelastic may help push vitreous out of wound.
6. Use lens loop to remove residual lens material.
7. Have Westcott scissors ready when looping out lens to cut vitreous.
8. Close with 7-0 vicryl safety sutures. For 11 mm wound use 3, one at center and one on
either side 3 mm away (allows removal of center suture to place 6 mm IOL)
9. May need to add some 10-0 nylon at wound edges to get watertight.
10. Bimanual closed chamber anterior vitrectomy (as above).
11. Dry removal of residual cortical material with syringe on standard 27 gauge cannula or
use 23 gauge Visitec cortex extractor cannula. Can also viscodissect cortical material.
12. Use J cannula or paracentesis if needed for subincisional material.
13. Consider staining vitreous with triamcinolone (see below).
14. Place IOL if possible in sulcus (adjust power) or use an AC IOL (don’t forget peripheral
iridotomy).
15. Miochol to bring pupil down. Use prior to AC IOL or after sulcus IOL is placed.
Sequestered phacoemulsification for early vitreous loss:
1. If topical, do subtenon’s injection. Incise conjunctiva in a quadrant and dissect posterior

60
 to the equator and place 2 cc non-preserved lidocaine behind the eye.
2. Use only viscous dispersive viscoelastic (e.g. Viscoat® ) from this point forward as it causes
less ocular hypertension and sticks to other structures.
3. Use viscoelastic to lift lens material into the anterior chamber.
4. If the material heads south, don’t chase it and leave it for the vitreous surgeons.
5. Try to wedge the residual lens material into a safe position anterior to the iris and away
from the posterior capsular tear.
6. Make separate 1.5 mm incision for anterior vitrectomy.
7. Separate irrigation (through paracentesis) and asp/cutter (through larger paracentesis).
8. May need to suture original wound to keep chamber formed.
9. Irrigate away from the sequestered material and cut/suck in the area of the posterior
tear/hole.
10. Try to get some of the residual cortical material with the anterior vitrector or with removal
of residual cortical material with syringe on 27 gauge cannula or 23 gauge Visitec cannula
with viscoelastic to support chamber (dry technique).
11. Consider staining with Kenalog (see below).
12. Replace viscoelastic often to keep residual material sequestered.
13. Consider placing a 3-piece IOL in the anterior chamber or sulcus and below the residual
material as a scaffold for residual material to prevent the material from dropping posterior.5
14. Now, with anterior chamber free of vitreous and lens material sequestered from tear with
IOL scaffold or viscoelastic, use slow motion phaco to remove (low bottle height, low
vacuum).
15. If pieces are small, you can use the Malyugin ring inserted to grab nuclear bits (Neuzil
technique).
Vitreous presenting early due to zonulopathy:
1. If topical, consider subtenon’s injection. Incise conjunctiva in a quadrant and dissect
posteriorly to the equator and place 2 cc non-preserved lidocaine behind the eye.
2. Use triamcinolone stain to identify vitreous and area of weak zonules (see below).
3. Trim with anterior vitrector under viscoelastic with anterior approach or consider pars
plana approach (if comfortable with this technique).
4. Sideways Arshinoff shell to force dispersive viscoelastic into area of weak zonules. First
place dispersive in area of weak zonules, then place cohesive across from weak area forcing
dispersive into area of weak zonules sealing it off.
5. Perform CCC if not already done.
6. Use cohesive viscodissection between capsule and the cortical material to allow space for
CTR or CTS.
7. Place CTR with lead eyelet of the ring heading out of inserter toward the area of weak
zonules to minimize stress of insertion.
8. Use hooks or a sutured CTS to support the CTR if needed during the rest of the case.

61
 Figure 8. Capsular hooks: A) hooking of the capsule, B) hooks keep lens in place during I/A

11.2. Vitreous Presenting Mid Case – While Removing Cortical Ma-

terial

This seems to be the most common time for vitreous loss. Often one will get the posterior
capsule just as the last nuclear fragment is taken. Of course there is no reason to convert to
ECCE in this case. The following steps are usefull:1

Posterior capsule damage noted while removing cortical material:

1. Place Viscoat® in area of tear or dialysis before removing instruments.
2. Make separate 1.5 mm incision for anterior vitrectomy.
3. Separate irrigation (through paracentesis) and asp/cutter (through larger paracenetesis).
4. May need to suture original wound to keep chamber formed.
5. Irrigate high and cut/suck low – creates a pressure gradient to push the V back.
6. Settings: low vacuum in 100 range, low bottle height in 50 range, max cut rate.
7. Try to get some of the residual cortical material.
8. Dry removal of residual cortical material with syringe on 27 gauge cannula or 23 gauge
Visitec cannula.
9. Use J cannula or paracentesis if needed for subincisional material.
10. Consider staining with Kenalog (see below).
11. Place IOL if possible in sulcus (adjust power) or use an AC IOL (don’t forget peripheral
iridotomy).
12. Miochol to bring pupil down. Use prior to AC IOL or after sulcus IOL is placed.
Zonular defect while removing cortical material:
1. Place Viscoat® in area of weak zonules before removing instruments.
2. Make separate 1 or 1.5 mm incision for anterior vitrectomy.
3. Separate irrigation (through paracentesis) and asp/cutter (through larger paracenetesis).
4. May need to suture original wound to keep chamber formed.
5. Irrigate high and cut/suck low – creates a pressure gradient to push the V back.
6. Consider using iris hooks to support capsule.
7. Consider placing CTR after cohesive viscodissection. Henderson CTR is a nice choice in

62
 this setting (ring has ripples to ease cortex removal following placement).
8. Place a 3-piece IOL with haptics toward weak area if small defect, place CTR if less than
4 clock hours, or place sutured CTS if 4–7 clock hours.
9. Miochol to bring pupil down.

11.3. Vitreous Presenting Late in the Case – While Placing IOL

This is the least problematic and least common time to loose vitreous. The main issue is to
make sure the IOL is stable while attending to the vitreous and then to secure a proper IOL in
either the AC, sulcus, or bag.1 The strategy will depend on whether the vitreous is presenting
through a later tear or zonular weakness (more common).

Posterior capsular tear with late vitreous loss:

1. Place Viscoat® in area of tear before removing instruments.
2. Make separate 1 or 1.5 mm incision for anterior vitrectomy.
3. Separate irrigation (through paracentesis) and asp/cutter (through larger paracenetesis).
4. May need to suture original wound to keep chamber formed.
5. Irrigate high and cut/suck low – creates a pressure gradient to push the V back.
6. Settings: low vacuum in 100 range, low bottle height in 50 range, max cut rate.
7. If the sulcus can support an IOL, then:
• move existing 3-piece IOL into sulcus.
• replace existing single piece acrylic (SPA) IOL with 3-piece for sulcus as you should
not place SPA in the sulcus.6
• consider reverse optic capture (ROC) of SPA optic if CCC is round and centered by
pulling SPA anterior captured by CCC.7
• with 3-piece IOL in sulcus and round and centered CCC, best course is to displace
optic posteriorly which seals off anterior chamber.
8. If the tear in the posterior capsule is round and secure, consider placing IOL in bag:
• place Viscoat® in hole
• gently place IOL into the bag (usually SPA is more controlled)
9. Miochol to bring pupil down.
Zonular defect with late vitreous loss:
1. Place Viscoat® in area of weak zonules before removing instruments.
2. Make separate 1 or 1.5 mm incision for anterior vitrectomy.
3. Separate irrigation (through paracentesis) and asp/cutter (through larger paracenetesis).
4. May need to suture original wound to keep chamber formed.
5. Irrigate high and cut/suck low – creates a pressure gradient to push the V back.
6. Settings: low vacuum in 100 range, low bottle height in 50 range, max cut rate.
7. Place a 3-piece IOL with haptics toward weak area if small defect; place CTR if less than
4 clock hours; or place sutured CTS if 4–7 clock hours
8. Miochol to bring pupil down.

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11.4. Staining the Vitreous with Triamcinolone

Scott Burk at Cincinnati Eye described using triamcinolone (not approved by the FDA for this
indication) to stain vitreous to better visualize vitreous prolapsed into the anterior chamber.8
As triamcinolone is not approved by the FDA for this indication and as some retinal surgeons
have had sterile and even infectious endophthalmitis with triamcinolone injection, its use is
controversial. However, I find it to be a very useful adjunct to anterior vitrectomy. You can
simply dilute the nonpreserved triamcinolone (FDA approved for posterior segment inflammation)
1:10 (e.g. Triesence).

An alternative to the more expensive non preserved triamcinolone is to wash the preservative off
the triamcinolone using a filter as described by Burk and then dilute 1:10 as described below:
1. TB syringe to withdraw 0.2 ml of well shaken triamcinoloone 40 mg/ml.
2. Remove the needle and replace with a 5 (or 22) micron syringe filter (e.g. Sherwood
Medical).
3. Depress the syringe so the large triamcinolone molecules will be stopped by the filter while
the preservative and solvent will pass through the filter.
4. The triamcinolone will be trapped on the syringe side of the filter.
5. Transfer the filter to a 5 ml syringe filled with balanced salt solution (BSS).
6. Gently force the BSS through the filter to further rinse off preservative.
7. Repeat rinsing a few times.
8. Place a 22 gauge needle on the distal end of the filter.
9. Draw 2 ml of BSS into the syringe through the filter to resuspend the Kenalog.
10. The Kenalog (now without preservative and diluted 1:10) will stain vitreous white.

Figure 9. Kenalog injection into anterior chamber

11.5. References

1. Thomas A. Oetting. Cataract Surgery for Greenhorns, available at:

[Link]
html
2. Arbisser LB, Charles S, Howcroft M, Werner L. Management of vitreous loss and dropped
nucleus during cataract surgery. Ophthalmol Clin North Am. 2006;19(4):495–506.
3. Bonnie An Henderson. Essentials of Cataract Surgery. 1st edition. Thorofare NJ, Slack
Inc, 2007.

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4. Kumar DA, Agarwal A, Prakash G, Jacob S, Agarwal A, Sivagnanam S. IOL scaffold
technique for posterior capsule rupture. J Refract Surg. 2012;28(5):314–5.
5. Osher RH. Slow motion phacoemulsification approach. J Cataract Refract Surg. 1993;19(5):667.
6. Chang DF, Masket S, Miller KM, Braga-Mele R, Little BC, Mamalis N, Oetting TA,
Packer M. ASCRS Cataract Clinical Committee. Complications of sulcus placement of
single-piece acrylic intraocular lenses: recommendations for backup IOL implantation
following posterior capsule rupture. J Cataract Refract Surg. 2009;35(8):1445–58.
7. Jones JJ, Oetting TA, Rogers GM, Jin GJ. Reverse Optic Capture of the Single-Piece
Acrylic Intraocular Lens in Eyes With Posterior Capsule Rupture. Ophthalmic Surg Lasers
Imaging. 2012;6:1–9.
8. Burk SE, Da Mata AP, Snyder ME, Schneider S, Osher RH, Cionni RJ. Visualizing
vitreous using Kenalog suspension. J Cataract Refract Surg. 2003;29(4):645–51.

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12. Conversion to ECCE

Conversion to ECCE often comes at a difficult time. The lens is about to fall south, the
vitreous has prolapsed and the surgeon is stressed. Understanding the steps and process of
conversion to ECCE is essential and study before the crisis will help soothe the stress when
this inevitable process occurs. We will cover several areas: identifying patients at risk for the
need for conversion to ECCE, indications for conversion, conversion from topical to subtenon’s,
wound preparation, expressing the lens material, closure of the wound, placement of the IOL,
postoperative issues and a brief section on anterior vitrectomy.

12.1. Patients at Risk for Conversion to ECCE

One of the most important parts of the preoperative process for cataract patients is to assess
the difficulty factors (see section on difficulty factors) that may lead to conversion to ECCE
or otherwise complicate the procedure. You may want to add operative time to your schedule
or ask for additional equipment. You may want to change to a superior limbal wound which
facilitates conversion to an ECCE rather than a temporal clear corneal incision. You may want
to do a retrobulbar block rather than topical anesthesia as the case may last longer or is more
likely to become complicated. Or, you may want someone more experienced to do the case.

Difficulty Factors1 (in decreasing order of importance):

• zonular laxity (PXF, h/o trauma, Marfan’s)
• rock hard lens (red or black lens)
• pupil size (why is it small? – PXF, DM s/p laser, CPS, floppy from Flomax)
• cannot lay flat for very long time (e.g. COPD, claustrophobia, tremor, severe obesity)
• big brow limiting superior access
• narrow angle limiting AC space
• predisposition to corneal decompensation (e.g. guttata, PPMD, hard nucleus)
• poor red reflex, white/black cataract making CCC difficult
• past surgery such as existing trab or past PPVx
• predisposition to exposure (e.g. BOTOX® , past lid trauma, DM)
• anticoagulants (e.g. Coumadin, ASA)
• monocular

12.2. Indications for Conversion

Conversion to ECCE is indicated when phacoemulsification is failing. Sometimes this is due

to a very hard lens which does not submit to ultrasound or a lens that is hard enough that
the surgeon is concerned that the required ultrasound energy will harm a tentative cornea,
e.g. Fuchs’ endothelial dystrophy or posterior polymorphous dystrophy (PPMD). Sometimes
one will convert to ECCE when an errant capsulorhexis goes radial, especially with a hard
crystalline lens when the surgeon is concerned that the risk of dropping the lens is too great

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with continued phacoemulsification. Rarely now with trypan blue dye, a surgeon will choose to
convert to ECCE when the anterior capsule is hard to see and capsulorhexis must be completed
with the can opener technique. More often the conversion is indicated when the crystalline lens
is loose from weak zonules or a posterior capsule tear which make phacoemulsification less safe
than extending the wound and removing the residual lens material. Indications for conversion
to ECCE include:
• hard crystalline lens or unstable endothelium
• radial tear in anterior capsule with hard lens
• poor visualization despite trypan dye
• posterior capsular tear
• zonular dialysis

12.3. Converting to Subtenon’s Anesthesia

Often we convert cases from topical clear corneal to ECCE. While the ECCE can be done
under topical, it is usually more comfortable and safer to give additional anesthetic which is
typically a subtenon’s injection of bupivacaine and lidocaine. This will provide some akinesia
and additional anesthesia. There is usually subconjunctival hemorrhage and if the injection is
made too anterior, it can cause chemosis and ballooning of the conjunctiva. The steps of the
subtenon’s injection are outlined in the anesthesia section above.

12.4. Converting the Wound

The major step toward converting to ECCE is to either extend the existing wound or close and
make another. The ECCE will require a large incision of from 9–12 mm which is closed with
suture. The decision to extend the existing wound or make a new wound hinges on several
factors: location of the original wound, size of the brow, past surgical history, and possible need
for future surgery.

Advantages of making new Advantages of extending

Original wound
wound for ECCE wound for ECCE
Allows limbal incision superior.
Allows lids to cover suture.
Protects existing trab.
temporal Should iris damage occur, it will be
Avoids big brow.
superior.
Simple to start fresh.
superior temporal Already have sup incision.
None.
left eye No need to change position.
Allows limbal incision superior.
Allows lids to cover suture.
inferior temporal Protects existing trab.
Should iris damage occur, it will be
right eye Avoids big brow.
superior.
Simple to start fresh.

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 Already have sup incision.
superior None.
No need to change position.

Table 37. Advantages of making new or extending existing wound for ECCE

Making a new incision during conversion is identical to that for a planned ECCE. The
original incision is closed with a 10-0 nylon suture. The surgeon and microscope are rotated as
the surgeon should sit superior. The steps to make a new superior incision are:
• conjunctival peritomy of about 170 degrees
• use 64 or crescent blade to make limbal groove with a chord length of 11 mm
• bipolar cautery for hemostasis
• use keratome to make initial incision starting in groove into AC
• extend initial incision to full length of groove (with scissors or knife)
• safety sutures are preplaced, usually 7–0 vicryl
Extending an existing incision can be tricky and the technique is different for scleral tunnels
compared to clear corneal incisions. However, in both cases the original extension is brought to
the limbus. In the case of an original scleral incision, the incision is brought anterior to join
the limbus on either end before extending along the limbus for a chord length of about 11 mm.
In the case of an existing corneal incision, the corneal incision is brought posterior toward the
limbus before extending the wound along the limbus for a chord length of about 11 mm. When
iris hooks are being used in a diamond configuration, the wound can be extended to preserve
the subincisional hook and the large pupil.2
• conjunctival peritomy of about 170 degrees
• use 64 or crescent blade on either side of the existing wound to make a limbal groove with
a chord length of 11 mm
• bipolar cautery for hemostasis
• use crescent to bring existing scleral wound anterior or existing corneal wound posterior
to join limbus
• extend initial incision to full length of groove (with scissors or knife)
• safety sutures are preplaced, usually 7–0 vicryl

12.5. Removing the Lens

One has to be far more careful when removing the nucleus during the typical conversion to
ECCE which comes along with vitreous loss. First, the anterior capsule must be large enough
to allow the nucleus to express which may require relaxing incisions in some cases. When the
zonules are weak or the posterior capsule is torn, the lens cannot be expressed with fluid or
external pressure as is often done with a planned ECCE with intact capsule/zonules. After any
vitreous is removed (see below), the lens must be carefully looped out of the anterior chamber
with minimal pressure on the globe. If the posterior capsule and zonules are intact, than the
lens can be expressed as described with a planned ECCE.

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12.5.1. Removing Lens with Intact Capsule Complex

• mobilize lens (physically with cystitome or with hydrodissection – be careful)

• lens removed w/ lens loop or w/ counter pressure technique
• wound is closed with safety sutures and additional central vicryl suture
• cortical material is removed using I/A device (either automated or manual)
• instill ophthalmic viscoelastic device (OVD)
• lens is placed in the posterior chamber
• wound is closed with 10-0 nylon and vicryl sutures are removed
• OVD is removed

12.5.2. Removing Lens with Vitreous Present

• mobilize lens with Viscoat® cannula – tip lens so that wound side is anterior
• slip lens loop under lens, toe up, remove lens
• wound is closed with safety sutures and additional central vicryl suture
• anterior vitrectomy (see below)
• cortical material is removed using dry technique or anterior vitrector
• instill ophthalmic viscoelastic device (OVD)
• lens is placed in the sulcus or in the anterior chamber
• wound is closed with 10-0 nylon and vicryl sutures are removed
• OVD is removed

12.6. Placement of the IOL

IOL selection with ECCE conversion depends on the residual capsular complex. The key to
IOL centration is to get both of the haptics in the same place: either both in the bag or both in
the sulcus.

When the posterior capsule is intact following a conversion to ECCE, the anterior capsular
opening is usually poorly defined which can make bag placement difficult. If the anterior capsule
and thus the bag is well defined, then place a single-piece acrylic IOL without folding it directly
and gently into the bag using Kelman forceps.

When the posterior capsule is intact and the anterior capsule is poorly defined, then place a
3-piece IOL in the sulcus, such as a large silicone IOL or the MA50 acrylic, by placing these
directly and unfolded into the sulcus with Kelman forceps. Make sure that both haptics are in
the sulcus.

When the posterior capsule is damaged, if enough anterior capsule and posterior capsule is left
to support the IOL, define the sulcus with Viscoat® and place the IOL directly in the sulcus.
Make sure both haptics are in the sulcus. If the IOL does not seem stable, then place McCannel
sutures to secure the IOL to the iris or remove and replace with an AC IOL (don’t forget to
place a PI with vitrector).

When the capsule is severely damaged and cannot support an IOL, then place the IOL in the

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anterior chamber. Use Kelman forceps to place the IOL, then secure the chamber and use
a Sinskey hook to place the AC IOL into its final position (don’t forget to place a PI with
vitrector).

12.7. Postoperative Issues

Postoperative care for patients following conversion from phaco to ECCE is a bit more com-
plicated and focuses on preventing cystoid macular edema and limiting induced astigmatism.
Often, the care is very similar to that of a planned ECCE with about 3 postoperative visits:
one the same day or next, one a week later, and one about 5–6 weeks later. Depending on the
amount of astigmatism, the patient may require several visits to sequentially remove sutures
while eliminating induced astigmatism.

12.7.1. First Postoperative Visit

Often on the same afternoon 4–6 hours following surgery or next morning with the primary
emphasis to check the IOP, look for wound leaks and scan for residual lens material or vitreous
in the anterior chamber. Most wound leaks should be sutured, but if the AC is not formed,
closing these is mandatory. Residual nuclear material should be removed in the next few days if
present, but residual cortical material will often dissolve away with little inflammation. You
would expect poor vision in the 20/200 range due to astigmatism and edema. The anterior
chamber should be formed and typically has moderate cell (10–20 cells/hpf with 0.2 mm beam).
If the IOP is less than 10, search hard for a leak using Seidel testing. If the IOP is in the 10–29
range, all is probably OK unless the patient is a vasculopath and then the upper limit of IOP
tolerance should be lowered. If the IOP is in the 30–39 range, consider aqueous suppression.
If the IOP is > 40, than consider aqueous suppression and bleeding down the IOP with the
paracentesis or anterior chamber tap. The IOP should be rechecked 60–90 minutes later to
ensure success with your treatment. Look at the fundus and rule out retinal detachment and
choroidal effusion or hemorrhage. Typically, patients are placed on prednisolone acetate 1% 1
drop 4 times a day, cyclogyl 1% 1 drop 2 times a day, and an antibiotic 1 drop 4 times a day for
the next week.

12.7.2. Week 1 Postoperative Visit

The vision and pressure should dramatically improve in patients over the next week where you
have converted to ECCE. The vision should be in the 20/100 range with an improvement with
pin hole to 20/50. The vision is usually limited by residual edema and astigmatism. In a study
of our ECCE we found about 7 diopters of cylinder at the one week visit. You should expect
very little inflammation and document that no RD exists. Search for residual lens material in
the anterior segment and posterior pole. You can discontinue the cyclogyl and the antibiotic.
Slowly taper the prednisolone acetate like 1 gtt qid for 7 more days, then 1 gtt tid for 7 days,
then 1 gtt bid for 7 days, then 1 gtt qd for 7 days, then discontinue. If the patient is at risk for
CME (e.g. vitreous loss), then keep on prednisolone qid and start a non steroidal like acular 1
gtt qid until the next visit 4–6 weeks later.

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12.7.3. Week 5 Postoperative Visit

The vision should continue to improve as the astigmatism settles and the cornea clears further.
The eye should be comfortable. The vision should be in the 20/80 range with an improvement
to 20/40 with pin hole. In our study the astigmatism induced by ECCE sutures was about 5.0
diopters at the incision. The anterior segment should be quiet and the IOP normal (unless the
patient is a steroid responder). Consider CME as a possibility in patients where conversion was
required as these cases are often long and can involve vitreous loss (with OCT, FFA, or clinical
exam).

But the main issue is astigmatic control with suture removal. Use keratometry, refraction, streak
retinoscopy, or topography to guide in suture removal. If the keratometry is 45.00 at 90, and
40.00 at 180 then look for tight sutures at around 90 degrees (12 o’clock) that are causing 5
diopters of cylinder. You can take only one suture at 5 weeks, then can take maybe 2 at a
time by 8 weeks. The plan is to remove a suture and see how the cornea settles. When the
astigmatism is less than about 1.0 to 1.5 diopters you should stop. Use antibiotic drops for a
few days after suture removal. After this visit, you should consider the following choices with
each visit (don’t waste too much time thinking about other possibilities and remember not
everybody is going to be 20/20):
1. pull a stitch (i.e. cyl at axis of stitch is greater than 1 on MR),
2. give glasses (i.e. no stitch to pull or cylinder is less than 1 on MR),
3. get FFA or OCT because you suspect CME.

12.8. References

1. David F. Chang, Terry Kim, Thomas A. Oetting. Curbside Consultation in Cataract

Surgery. 1st edition. Thorofare NJ, Slack Inc, 2007.
2. Bonnie An Henderson. Essentials of Cataract Surgery. 1st edition. Thorofare NJ, Slack
Inc, 2007.

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13. Approaching Different Kinds of Cataract

13.1. Ectopia Lentis

Displacement of the lens:

• subluxed – partially displaced within pupillary aperture
• luxated or completely displaced from the pupil (congenital, developmental, or acquired)
Epidemiology:
• traumatic most common
• greater than 50% of patients with Marfan’s syndrome exhibit ectopia lentis
Pertinent clinical features:
• sub- or total luxation of the lens
• phacodonesis
• marked lenticular astigmatism
• iridodonesis
• impaired accommodation
Non-traumatic (differential diagnosis):
1. Primarily ocular.
• pseudoexfoliation
• simple ectopia lentis
• ectopia lentis et pupillae
• aniridia
• congenital glaucoma
2. Systemic.
• Marfan’s syndrome
• homocystinuria
• Weil-Marchesani syndrome
• hyperlysemia
• Ehlers Danlos
• sulfite oxidase deficiency
Surgical therapy options:
• ICCE
• Phaco/ECCE
1. Attend to any vitreous in anterior chamber – staining with Kenalog.
2. Iris hook stabilization of capsular.
3. Capsular tension ring with or without Cionni modification.
4. IOL in bag – mild cases aided by CTR/Cionni ring or CTS.
5. Iris fixated posterior or anterior IOL.
6. Angle supported IOL.
7. Sulcus sutured posterior chamber IOL.
8. Contact lens or spectacles.

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13.2. Intumescent Cortical Cataract

Etiology:
• opacification of the cortical lens fibers
• swelling of the lens material creates intumescent cataract
Clinical features:
• initially vacuoles and water left in the lens cortex
• wedge shaped opacities or cortical spokes
• progresses to form white intumescent cortical cataract
• risk of phacolytic glaucoma
Risk factors:
• smoking
• ultraviolet light exposure
• diabetes mellitus
• poor nutrition
• trauma
Phaco/ECCE:
• capsular staining techniques
• capsulorhexis techniques
– initial small tear
– removal of liquid cortical material to relieve capsular tension
– liberal use of viscoelastic material
Complications of surgery:
• increased risk of capsular radial tear
• increased risk of vitreous loss
• increased risk of loss of lens material into vitreous

13.3. Hypermature Cataract

Etiology:
• opacification of the cortical lens fibers
• swelling of the lens material creates intumescent cataract
• degenerated cortical material leaks through capsule leaving wrinkled capsule
Pertinent clinical features:
• wrinkled anterior capsule
• increased anterior chamber flare
• calcium deposits in lens
• white cortical material
• risk of phacolytic glaucoma
Phaco/ECCE:
• capsular staining with trypan blue
• capsulorhexis techniques
– initial small tear

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 – removal of liquid cortical material
– use of viscoelastic material in anterior chamber and bag
Complications of surgery:
• increased risk of capsular radial tear
• increased risk of vitreous loss
• increased risk of zonular dialysis
• increased risk of loss of lens into the vitreous

13.4. Morgagnian Cataract

Etiology:
• opacification of the cortical lens fibers
• can be swelling of the lens material as in intumescent cataract
• can be wrinkled capsule as in hypermature cataract
• hallmark – liquified cortex allows nucleus to move freely in bag
Pertinent clinical features:
• wrinkled anterior capsule
• increased anterior chamber flare
• dense brown nucleus freely moving in capsular bag
• calcium deposits within the lens
Phaco/ECCE:
• capsular staining techniques
• capsulorhexis techniques
– initial small tear
– removal of liquid cortical material
– use of viscoelastics material in anterior chamber and bag
• stabilize nucleus with viscoelastic
Complications of surgery:
• increased risk of capsular radial tear
• increased risk of vitreous loss
• increased risk of zonular dialysis
• increased risk of loss of lens into the vitreous

13.5. Anterior Polar Cataracts

Etiology:
• opacity of the anterior subcapsular cortex and capsular
• bilateral
• non progressive usually
• frequently autosomal dominant
Clinical features:
• usually asymptomatic – good vision

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 • central opacity involving the anterior capsule
• associated with microphthalmos, persistent pupillary membrane, anterior lenticonus
• differential diagnosis includes penetrating capsule trauma
Phaco/ECCE – w/ capsulorhexis start away from polar cataract, make bigger and go around
polar cataract if possible.

13.6. Posterior Polar Cataracts

Etiology:
• opacity of the posterior capsular cortex and capsule
• familial, autosomal dominant, bilateral; sporadic, unilateral
• slowly progressive
Pertinent clinical features:
• good vision, but at nodal point, more symptomatic than anterior polar
• central opacity involving the posterior capsule
• glare
• differential diagnosis includes:
– posterior subcapsular cataract
– penetrating capsule trauma
– Mittendorf dot
Phaco/ECCE:
• no hydrodissection
• sculpt out a bowl to relieve capsular tension or use the V groove technique
• gentle hydrodelineation and slow careful viscodissection
• leave central opacity or take at the end of surgery
Complications:
• increased risk of posterior capsular tear
• increased risk of vitreous loss
• increased risk of loss of lens material into vitreous

13.7. Perforating and Penetrating Injury of the Lens

Etiology:
• penetrating injury results in cortical opacification at site
• rarely can seal resulting in a focal opacity
• usually progresses to complete opacification
Pertinent clinical features:
• focal cortical cataract
• white cataract with capsular irregularity/scar
• full thickness corneal scar
Laboratory testing:
• B-scan ultrasound – posterior capsule intact? Intraocular foreign body?

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 • CT scan to rule out intraocular foreign body
Phaco/ECCE:
• capsular staining to identify traumatic tear
• treat similar to posterior polar cataract:
– no hydrodissection if posterior penetration suspected
– consider use of viscodissection and hydrodelineation
• usually can aspirate in younger patients without need for nucleofractis
Complications:
• increased risk of anterior radial capsular tear
• increased risk of vitreous loss
• increased risk of lens material in vitreous
• increased risk of retinal detachment

13.8. Diabetes Mellitus and Cataract Formation

Etiology:
• increased aqueous glucose concentration drives glucose into lens
• glucose converted into sorbitol that is not metabolized by lens
• sorbitol creates an osmolar gradient forcing hydration of the lens
• this sorbitol induced lenticular hydration:
– decreases accommodation
– changes the refractive power of the lens
– generates cataract
Pertinent clinical features:
• snowflake or true diabetic cataract:
– bilateral
– posterior and anterior subcapsular, cortical vacuoles and clefts
• typical nuclear, cortical or posterior subcapsular cataracts
Phaco/ECCE:
• indicated when view of posterior pole is poor
• standard technique
• consider monofocal acrylic IOL with any retinopathy
Complications:
• exacerbation of diabetic macular edema:
– focal or grid laser therapy prior to surgery if indicated/possible
– anti-VEGF agents commonly used prior to surgery
– sutured wound to allow early laser therapy if indicated
• increased risk of cystoid macular edema:
– pretreatment with steroid and non-steroidal drops
– prophylactic treatment for 1–3 months with steroid and/or non-steroidal drops
• can present with rapid white cataract under tension:
– will need trypan blue (or ICG, but this is not approved by the US FDA)
– be careful with initial capsule tear as it is prone to go radial (Argentinean flag sing)
– make an initial tear, remove anterior cortical material, then add more OVD

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 – consider very viscous OVD like Healon® 5 or Healon® GV

13.9. Cataract Associated with Uveitis

Etiology:
• posterior subcapsular cataract:
– initially an iridescent sheen appears in the posterior cortex
– followed by granular and plaque like opacities
• may progress to or involve anterior subcapsular cortical fibres
• may present as cortical cataract without posterior subcapsular component
• associated with uveitis and corticosteroids to treat uveitis
• may progress rapidly to a mature cataract
Pertinent clinical features:
• central opacity of the posterior cortical fibers
• cortical cataract
• posterior synechiae
• pupillary membrane
• anterior chamber cell or flare
Prior to phaco/ECCE:
• several months without inflammation
• 1 week prior to surgery suppress immune system
– topical agents in those patients who are typically quiet with topical agents alone
– oral prednisone in those that typically require oral steroid with a flare
– consider intraoperative IV steroids
Phaco/ECCE:
• synechiolysis with viscoelastic agents/hooks
• may require iris hooks to stabilize floppy iris and control pupillary aperture
• capsular dye to allow continuous tear
• IOL material: acrylic, heparin coated PMMA better than silicone
• consider aphakia in children with JRA
Complications:
• increased risk of postoperative inflammation
• increased risk of postoperative pressure spike
• increased risk of cystoid macular edema
• consider using steroid and non-steroidal drops for months following surgery

13.10. Exfoliation Syndrome (Pseudoexfoliation)

Etiology:
• systemic disease in which a fibrillar material is deposited in the eye:
– similar material to the basement membrane proteoglycan
– the material is found throughout the body
• within the eye the fibrillar material comes from the lens capsule, iris, and ciliary body

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 • the zonules are weak in this condition
• often asymmetric or even unilateral
• glaucoma develops when the fibrillar material blocks the trabecular meshwork
Epidemiology:
• patients tend to be over 60 years of age
• geographic clustering suggests a hereditary pattern (in Scandinavia for example, pseudoex-
foliation causes 75% of glaucoma)
• glaucoma develops in 22–82% of patients with exfoliative material
• increased incidence of age related cataract
Pertinent clinical features:
• ground glass appearing deposition of fibrillar material on anterior lens capsule:
– iris may sweep material into rings on the lens capsule
– best viewed with dilation
• transillumination defect and fibrillar material at the pupillary margin
• open angle with brown clumps of fibrillar material on trabecular meshwork
• flakes of fibrillar material on corneal endothelium
• evidence of zonular weakness:
– phaco- or iridodonesis
– lens subluxation or even luxation
Phaco/ECCE:
• use of iris hooks for capsular support during phacoemulsification
• use of capsular tension ring with or without Cionni modification
• placement of AC IOL, sutured Cionni ring with capsular IOL, sutured PC IOL
• sutured iris IOL
• consider surgery sooner, while zonules are relatively strong
• minimize zonule stress during surgery
Complications of phaco/ECCE:
• increased risk of capsular radial tear
• increased risk of zonular dialysis
• increased risk of loss of lens material into vitreous
• increased risk of late dislocation of IOL capsular bag complex into vitreous
• postoperative intraocular pressure spike:
– completely remove OVD
– intraoperative miotic and postoperative aqueous suppressant

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