Even though Jack Nicklaus won 18 major championships in his career and is a member of the World Golf Hall of Fame, he never balked at taking a lesson or two to stay on top of his game. This drive to get better, even when you appear to be at the pinnacle of your profession, is an attribute shared by the best surgeons, as well. Maybe you're proficient in dividing a nucleus but would like to protect the capsule better, or maybe you're surgeries are safe but you feel that they could be quicker and more efficient. Whatever the case, there's often a new pearl out there for you to find; you just have to know where to look. In this article, we've gathered the techniques of several skilled phaco surgeons that you can use in your personal campaign to be the best.
Preparation and Initial Steps
Surgeons say that where you start often determines where you finish with a cataract case, and offer these tips for the pre-phaco phase of the procedure.
Kevin Miller, MD, the Kolokotrones Professor of Clinical Ophthalmology at UCLA's Jules Stein Eye Institute, says a good outcome can depend on something as easily overlooked as patient comfort. "I'm particular with the patient being comfortable," says Dr. Miller. "You need to make his or her back comfortable, which I do by placing pillows under the patient's knees and a stiff towel under the head. I frequently see patients on a hard, flat, uncomfortable gurney that might induce them to shift their bodies at the wrong moment during a case."
In order to perform an effective phaco, the surgeon needs to see the eye's structures as clearly as possible. However, this isn't always easy, as corneal scarring, surface irregularities or haze can make visualization difficult. There are steps you can take to get a better view, however. "A critical step in the procedure is creating a well-sized, centered, complete capsulorhexis," says Christopher Connor, MD, adjunct associate professor at
"When staining alone isn't enough, I use an anterior chamber 25-gauge light pipe called an 'Anterior Beam,' [Dutch Ophthalmic Research Corp.], Dr. Connor continues. "This device is designed specifically for use by anterior segment surgeons, and has a shielded top surface to avoid light scatter off the cornea and into the surgeon's eyes. Its tip is tapered for passage through a standard sideport incision. It casts a bright fiber optic light beam forward and down. This light can penetrate even the densest of corneal opacities to aid in the capsulorhexis, the removal of the cataractous lens and the placement of the IOL. the light is flexible enough to be bent to even hook itself into a sideport incision for hands-free use. The crosslighting that the anterior beam provides can also confirm an intact posterior capsule and illuminate vitreous strands with the same clarity as a slit lamp. No vitreous dyes are needed if you encounter vitreous, since the anterior beam can often allow you—under direct visualization—to just move or displace it with viscoelastic without having to resort to vitrectomy."
Managing the Lens
Surgeons emphasize the importance of paying attention to the initial stages of the procedure in order to make the later stages—specifically, phaco—go more smoothly.
If you do hydrodissection, Dr. Miller says to keep a steady hand. "I see residents and fellows who have an almost compulsive need to wiggle the needle while doing their hydrodissection," he says. "But doing that creates a space that becomes the path of least resistance for the fluid wave, causing the fluid to reflux back toward the tip. In terms of safety, keep an eye on subincisional iris as you hydrodissect. When you inject the fluid, something has to leave the space the fluid occupies, and the first thing to leave the eye is the viscoelastic right over the iris."
When it comes to phaco technique,
Dr. Fishkind gets more aggressive for the medium and hard lenses. "For these types of nuclei, I think vertical chopping is the quickest and easiest way to remove them," he says. "Since you use so much mechanical energy to break up the cataract, you use much less ultrasound energy and, therefore, there's less damage to the iris, the blood-aqueous barrier and the endothelium. For the moderate cataract, I use a Nagahara-style chopper that has a blunt end. There's no need to use a sharp-ended chopper, even for hard cataracts, in my opinion. It's only the rock-hard ones for which I'll use a Nichamin sharp chopper. The other instrument advice I'd offer for vertical chopping is to make sure there's a millimeter to 1.5 mm of exposed phaco tip. With the sleeve back a good bit, this allows enough of the tip of the needle to get into the cataract and really hold it for chopping.
"On moderate to hard cataracts," Dr. Fishkind adds, "I generally make one vertical chop, dividing the nucleus in half, and then bring an entire half of endonucleus into the anterior chamber at the plane of the iris. There, I'll use some horizontal chops to break it into smaller pieces that are more quickly emulsified. I then do the same for the other hemisphere."
Finally, when faced with a rock-hard nucleus, Dr. Fishkind recommends using a sharp chopper. "The trick with these is to make all the chops first until the nucleus loses its rigidity," he explains. "It becomes flexible because now it's in multiple small pieces. I then bring up small fragments one at a time and emulsify them at the plane of the iris."
Due to the nature of his technique, Dr. Fishkind uses a zero-degree phaco tip for almost all of his cases. "This puts power directly in front of the phaco tip, which I think makes it easier to do these vertical chopping maneuvers," he says. "This is because it's easier to get into the nucleus and hold it with a zero-degree tip. I also use a 20-ga. tip, since the smaller tip holds onto fragments better once they're mobilized. For harder nuclei, I use more power to get into the nucleus for the chopping and also use higher vacuums; my vacuum is 325 mmHg and power is about 30 percent. For moderate lenses, my vacuum goes down to about 275 mmHg and power to 20 percent. For actually getting into lens material and holding it for the chop, I don't use either elliptical or torsional phaco.
Instead, I just use standard longitudinal to get in and hold the material. Once I crack it and start to mobilize fragments for actual emulsification, then I'll put elliptical or torsional back in."
For his surgeries,
"When you're performing this maneuver, once you tilt the cataract up, you get the edge of it and start performing phaco around the edge," explains Dr. Grayson. "Use the manipulator to rotate it so that the part that was in the bag is now more toward the phaco probe and emulsify that. Once you've got most of the edge emulsified, you can then go through to the center. You're not really creating a groove or wedge in it, but instead going from the periphery into the center. You can use a higher vacuum to help pinwheel the nucleus, but the manipulator is very good at helping get it right onto the phaco probe. You tend to be in a higher vacuum state, which, on an older machine might have been a disadvantage. However, with the newer machines, each has chamber stability mechanisms that work well to manage high vaccums." In terms of machine settings for
Dr. Grayson's phaco tilt, on a peristaltic system he says flow is 42 cc/min. and vacuum is around 375 to 400 mmHg. "The phaco power is usually in some kind of variable duty cycle that allows you to use higher phaco power when the probe senses a higher vacuum state, right when you're aspirating the lens," Dr. Grayson explains. On a venturi machine, he says the vacuum should be set at a level of 400 mmHg.
To aid in lifting maneuvers, Dr. Connor developed the Connor Wand (Rhein Medical), in which he has a financial interest. "Sometimes the phaco tip isn't the safest way to lift either part or all of the cataractous lens during extraction," Dr. Connor says. "The wand has a polished balled tip and gently curved neck that allow the surgeon to safely place it between the posterior capsule and the nucleus and use it to lift the cataract up to a more central safe zone. The nuclear plate can also be back-cracked with the wand from behind by pulling the plate up against the phaco tip, sectioning the nucleus without the need for a sharp chopper."
Tricky Situations
Though advice on surgical maneuvers can be helpful in streamlining the routine phaco case, it's often in the difficult cases where these pearls become even more valuable. Here is some advice on dealing with your non-routine cases.
Dr. Connor says your capsulorhexis doesn't have to be compromised in cases of bloated intumescent cataracts. "The intumescent cataractous lens presents a potentially difficult challenge as the opening intralenticular pressure can be elevated," he says. "This can lead to a rapid radial tear of the anterior capsule at the instant of the initial puncture to begin the capsulorhexis. Flattening the swollen anterior capsule with the fellow hand as you make the capsulorhexis, what I call the 'touchdown' technique, or the use of a heavier viscoelastic can help, but often the pressure is too great to counter and the errant tear occurs anyway.
"A maneuver which I have found works dramatically is a two-stage rhexis technique called a 'lensostomy,' " Dr. Connor continues. "In this technique, the surgeon uses the phaco tip to initiate a punch entry through the anterior capsule before the capsulorhexis.
The aspiration from the live phaco tip decompresses the swollen lens. The tip makes a perfect circular opening in the center of the anterior capsule. I usually have stained the anterior capsule first with Trypan Blue to enhance visualization because there may be 'lens milk' within the cataract that can lessen visibility. The Trypan Blue also has a lacquering effect on the capsule that helps stiffen the tissue. Once the quick punch entry is made by the phaco tip and the nucleus is decompressed, I reinitiate the rhexis with a scissors or cystotome. I use forceps to complete the rhexis tear for 360 degrees around the punch entry, and I make sure to fully encircle the initial punch hole within the capsulorhexis flap. I've used this technique without an errant tear on over a dozen intumescent lenses."
After the endonucleus has been removed, Dr. Fishkind says some medium-density cataracts may leave a large epinuclear plate behind. In such cases, he puts the machine into foot-position zero so that the vitreous comes forward and supports the posterior capsule. He then uses the phaco tip to engage the central part of the endonuclear cortex complex and gently pushes it away from the incision until the anterior part of it scrolls around and presents itself in the capsulorhexis. "I can then grab epinucleus and start to emulsify it safely, since it's away from the posterior capsule and the equator. It's right in the middle where I can easily remove it," he says.
After the Phaco
Near the end of the case, Dr. Fishkind uses an unorthodox approach to irrigation/aspiration and cortical cleanup that he says is not only effective, but also helps him avoid breaking the capsule. "First, the key to getting cortex is a good cortical cleaving hydrodissection earlier on in the case," says Dr. Fishkind. "If you've done that well, all cortex will be loosened from the capsular bag and that makes cortical cleanup exceedingly easy. The second thing I do that's really different from the norm is I don't do any I/A until after the implant is in the capsular bag. So, after I've emulsified the epinucleus and any cortex associated with it, I use the Terry Squeegee [Alcon]—a silicone sleeve that fits over a 27-ga. cannula—on a 3-cc syringe of BSS. I gently inject the BSS into the anterior chamber while I run the squeegee over the posterior capsule to clean off the lens epithelial cells, particulates, fibrils and whatever else is on it. If there's cortex present, I'll separate it from the capsular bag and clean the central bag. Then, I put the OVD in, literally pushing whatever cortex is there out into the equator, and I place the implant. I remove the OVD with a 0.3-mm I/A tip. I'll then do the I/A, removing any strands of cortex, debris and lens epithelial cells. So, I have the lens implant to hold the capsule back away from the tip, and with a good cortical cleaving hydrodissection the I/A step is simple."
Dr. Fishkind says there are some instances where this post-implant I/A maneuver doesn't go that smoothly, though. "Sometimes the cortex will get wound around the haptic of the lens," he says. "So, when you try to aspirate it, it won't come out. In this case, you just have to be a little more tenacious and go after it a little harder, and it will eventually come out. Or, you can wiggle the implant a little bit as you do the I/A to loosen the material from around the haptic. The other potential issue is that sometimes the cortex will be stuck to the bag at the edges of the implant and it will be hard to get out. Then, you just have to move the implant away and gently vacuum the material off of the bag."
Whether you've performed 10 phacoemulsification cases or 10,000, these surgeons' advice should help you take your technique to a higher level. And if you have any questions about one of their maneuvers, just look around at the next ophthalmology meeting—you'll find these experts taking lessons right beside you.