Tips for safer phaco of hard cataracts

This letter responds to an article in the October 2009 issue of the Journal of Cataract & Refractive Surgery that describes a technique to improve the control and safety of phacoemulsification during hard nucleus cataract surgery. The letter is an excellent communication of the technique that I have used for years.

In response to the comment in the article that excessive ultrasound energy might be used in phacoemulsification of hard nucleus cataracts, the letter's authors explain that they have a trick to reduce the ultrasound energy used. Once they capture the nucleus fragment with the phaco tip, they compress it toward the phaco tip to make it crack into smaller fragments. They then use ultrasound energy to remove the mixture of small nucleus fragments and nucleus powder. This reduces the ultrasound energy because some of the nucleus has been emulsified by the compression.

They also explain their methods for dealing with the posterior bridging strands that connect nucleus fragments. The first is to capture a single nucleus fragment and pull it to the central anterior chamber. The chopper is then moved into the gap left between the pulled nucleus fragment and the adjacent nucleus fragment to cut the bridging strands beneath the pulled fragment.

If this does not work, they try to remove the hard nucleus and leave a shell of thin epinucleus consisting of pieces of thin nucleus attached to each other by the bridging strands. Ophthalmic viscosurgical device is injected into the space between the posterior capsule and the shell, which pushes the posterior capsule away while elevating the shell to the iris plane. This enables the phaco tip to enter the anterior chamber without irrigation. The chopper is used to ''feed'' the center of the shell. Phacoemulsification of the shell can be completed with minor ultrasound energy.

No abstract is available.