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The art of cataract surgery is an ongoing process of improvement for an ophthalmologist. Even when things become "routine," there are new and unexpected events that can occur that will challenge the best surgeon. Having performed more than 1,000 cataract surgeries over the last four years, here are the top ten pearls I've learned from my senior partner and mentor, Arthur J. Weinstein, MD, and friend, Alan Crandall, MD, Moran Eye Center, University of Utah.
Pearl #1: Detecting a loose lens
This can present as difficulty with puncturing the anterior capsule or more wrinkling than usual during the capsulorrhexis. A great suggestion by my senior partner, Dr. Weinstein, is to intentionally make the capsulorrhexis larger because, in this circumstance, there is a tendency to create a smaller capsulotomy.
Pearl #2: Shallow chamber in one eye
This could be suggestive of a loose lens that is displaced anteriorly or prior cataract surgery in the contralateral eye. If the anterior chamber depth is shallow, this may require the use of a cystotome only and may need viscoelastic material placed in the eye after 50 percent completion of the capsulotomy.
Pearl #3: Using the Akahoshi prechopper
This prechopper is used for 2–3+ nuclear sclerotic cataracts. It creates four equal fragments and minimizes the amount of ultrasound power. The prechopper is not effective in 1+ and 4+ nuclear sclerotic cataracts because the lens material is too soft and hard, respectively. It should not be used in cases where a prior vitrectomy has been performed or there is a history of loose lens (trauma, pseudoexfoliation and advanced age).
Pearl #4: Soft Cataract, 1+ NS with 4+ PSC
If you are experiencing difficulty removing the subincisional cortical material, the reason may be poor hydrodissection. In these cases, ensure adequate hydrodissection. Hydrolineation is so easy to achieve in this type of case that one has the tendency to proceed without adequate hydrodissection, causing more effort and time to be spent removing the subincisonal cortex. To avoid this, always ensure adequate hydrodissection.
Pearl #5: Posterior polar cataract
Perform hydrodilenation only. Hydrodissection can create an opening in the posterior capsule. You’ll need consent for a vitrectomy. Typically, an anterior vitrectomy is not needed and the intraocular lens can be placed in the bag, assuming it is stable.
Pearl #6: Loose bag and difficulty removing cortical material
Remove the cortex material tangentially to the capsulorrhexis to minimize the amount of stress on the bag, as recommended by Greg Ogawa, MD. Create a large capsulotomy and prolapse the lens into the anterior chamber to minimize stress on the bag. My mentor, Dr. Weinstein, reports that loose bags have the tendency for a small capsulotomy, therefore, intentionally create it slightly larger. I. Howard Fine, MD, Richard S. Hoffman, MD, and Mark Packer, MD, also recommend capsular tension rings.
Pearl #7: Iris prolapse from main wound
Remove fluid from anterior chamber and replace with viscoelastic material. If the iris prolapse is worsened by viscoelastic material, then there is likely too much present in the anterior chamber. This can be removed through the paracentesis wound.
Reduce phaco parameters (lower bottle height, reduce vacuum and irrigation) and be sure to turn off irrigation to the phaco machine before removing from the eye. This will minimize the amount of iris prolapse. If the iris prolapse still persists throughout the case, place a subincisional iris hook through a different entry wound (i.e., one that is posterior to the main wound).
Pearl #8: Tamsulosin (Flomax) and other alpha blockers during cataract surgery
Get the patient’s consent to possibly use iris hooks. If poor dilation is present at the time of surgery, use preservative-free Lidocaine with epinephrine intracamerally. If there is no improvement with dilation, then place iris hooks. There is no benefit of discontinuing the medication prior to the surgery.
Remember, it is the size of the capsulotomy that increases risks for complications and not necessarily the pupil size. Therefore, create a capsulotomy large enough to minimize any capsular damage. In some cases, the capsulotomy might be larger than the poorly dilated pupil. If the pupils appear relatively well dilated at the beginning of the surgery and preservative-free Lidocaine with epinephrine is instilled and the iris moves easily with fluid in the anterior chamber, this is suggestive of a pupil that will be floppy as the procedures proceeds. In this case, use the iris hooks. Some ophthalmologists also suggest using Atropine. In either case, do not stretch the pupil.
Pearl #9: Patient moves during the surgery
Assuming the sedation is perfect, minimize loud noises in the operating theater to prevent patient from moving. Select music that is smooth and does not have high notes, such as the song "Brass Monkey." Encourage the patient to breath slowly and concentrate on his or her breathing. Rest your hands on the patient’s head so that the instruments in the eye move with patient’s head movement.
Pearl #10: Case almost complete until posterior capsule was torn
This is most likely due to a barb on the tip of the I/A. To avoid this, check instruments prior to surgery and/or use a silicone coated I/A tip. A torn capsule can be caused by nearly any metal instrument.
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About the author: Robert F. Melendez, MD, is a full-time comprehensive ophthalmologist with emphasis on cataract and refractive surgery. He is a partner at Eye Associates of New Mexico, an assistant clinical professor at the University of New Mexico department of surgery/division of ophthalmology and a member of the YO Committee.