Lecture: My Best Cataract Case in the Past Two Years: Lessons Learned that Changed My Practice

During this live webinar, a panel of experts will discuss and review an interesting case that had unique teaching value either with a new technology or technique used in the care of a patient. In these case-based presentations, each speaker will demonstrate a new lesson learned on their phaco journey either through complication management or incorporating a novel strategy in surgical planning & care. Being a phaco surgeon is a lifelong commitment to learning new ways to improve your outcomes, enhance your surgical team, and grow both as a student & teacher. A live question and answer session will follow to address clinically relevant pearls for practice with open chat available to all those who attend.

Dr. Haripriya Aravind, Aravind Eye Hospital, Chennai, India
Dr. Prashant Garg, LV Prasad Eye Institute, India
Dr. Vaishali Vasavada, Raghudeep Eye Hospital, India


[Hunter] Thank you, Lawrence, for getting us started with our last webinar of 2021. It has definitely been a rollercoaster of a year. I’m very excited that we’re ending the year with an exclamation point, a big exclamation point, with some of the best cataract surgeons and some of the best cataract surgical trainers in the world. We have Dr. Haripriya, Dr. Prashant Garg, and Dr. Vasavada joining us. They’re each going to present a very special case or a special surgical consideration as you plan your cataract cases. And then we’re going to have a Q&A session for each of them at the end.

Our first speaker is Dr. Haripriya, who certainly needs no introduction. She will be talking about subluxated cataracts, how to plan and manage them intraoperatively. Dr. Aravind, thank you so much for joining us and the screen is over to you, madam.

[Haripriya] Thank you, Hunter, and Cybersight for this wonderful opportunity. I hope my slides are visible. I’m going to be talking on subluxated cataracts and capsular bag stabilizing devices today.

I’ll be delving more on cases which have more severe zonulysis. Starting with indications for surgery in patients with lens subluxated. Indications would include patients who have defective vision, even if they have a graft subluxated. Which could be either because of the cataract or the aphakic status. If they have double vision, or if the nucleus is either in the anterior chamber or in the vitreous cavity.

It’s important to have a complete preoperative analysis. To look for everything from the cornea status, the status of the iris and the pupil, the anterior chamber depth which could either be too deep or shallow based on where the lens is. Presence of vitreous in the AC that will help know how to approach the cataract, and the need for vitrectomy as we start the surgery. When coming to the lens we look at the type of subluxation, if it is more localized, in which case it may be either mild, moderate, or severe. Or it could just be a diffuse subluxation as we would see in patients with pseudoexfoliation and pseudophakic lenses.

The important aspects when coming to dealing with surgery, I would go step by step. The most important aspect would be to do a good capsulorhexis. Because if you want to use any of the devices like a CTR or hooks, a capsulorhexis is mandatory. A lot of effort is taken to ensure we use good viscoelastic so you can make a complete adequate sized rhexis. If required, use a stain as well as this could help not just in the rhexis, but also to insert your hooks and the CTR as well.

When dealing with the rhexis, you would normally like to use a high molecular weight viscoelastic. And start the rhexis away from the site of the zonular dialysis. This is because you have good countertraction at the site where the zonules are there. And then move towards the site of subluxation but make it much smaller at the site. Because there’s a high risk that the rhexis might run away. One has to be sure that you are not making it too large at the site because we don’t want to have a rhexis extension.

The other important aspect after we have the rhexis complete is to plan for the devices. The two most important devices would be to use the capsular tension ring and to use the hooks. The capsular tension ring comes as a PMMA ring and we have the eyelets such that they just cross when placed in the capsular bag. Based on the capsular bag size, we may have an option of different size of CTR. Most cases would just work well with 11, 13 size CTR. In myopes, you could use a 12, 14.5. And in small lenses, pseudophakic eyes and nanophthalmos, one could use a 10, 12.5 size capsular tension ring.

The second important aspect is to use capsular retractors. I also use iris retractors to support the capsular bag. This tends to work well. I use the Graeve Havard hooks. And I feel this is extremely important. I would say even more than the CTR I was talking of case, because using the hooks can help in rhexis completion to insert your CTR and during the phacoemulsification as well. And once these hooks are in the place, this will tend to stay until the end of surgery until the IOL is placed in the bag. Because even if you have the CTR in place, the capsular bag can still be wobbly. You want to have these hooks to be able to support the bag until you place the IOL.

This, again, is a patient who has more than six clock hours of zonular dialysis. I’m injecting high molecular weight viscoelastic to the site but I’m trying to push the lens down, there’s a lot of tilt here. The rhexis, as mentioned earlier, you would start it at the site which is away from the area of maximum zonular loss. You will not make it too small because you want to have enough working space. But again, you risk the chance of extension if you make it too large as well, so you want to make it just right. Kind of have a right balance. Once the hooks are in place, the first thing I would think of is to use the hook. This is a regular iris hook, Graeve Havard hook, and this is going through a 6.7 millimeter stab incision. These are inserted about one hook for every two clock hours. In this video it has been placed at the limbus, but it can go a little more periphery, a little more posteriorly, more on the sulcus side when you want to grab the rhexis margin.

After the hooks are in place, before inserting the CTR, I prefer to do a hydrodissection. Again, hydro has to be done very well in these cases because there’s a difficulty in removing the cortex once the CTR is in place. So I’m going to hydro. You can also see the limbal point. After this point I would like to insert the CTR and I prefer to insert the CTR manually. Not go in through the main tunnel with the injector but go into the side port because this way the chamber is well-formed. Make sure the leading eyelet goes in the bag. And when dilating the trailing eyelet I would use the help of a second instrument, the Sinskey hook to support the CTR from the exterior side. This can also help to ensure the trailing eyelet goes in the bag. So it doesn’t slip into the sulcus or into the anchor, so you ensure the CTR goes in the bag.
Sometimes you find that in patients who have a more severe subluxation a CTR itself may not be enough for a capsular bag stabilization, more so in the postoperative period. Because if you have a patient with progressive zonular loss, like a patient with Marfan syndrome or pseudophakic lens, or even a large dramatic subluxation, a young patient, then you’ll have the concern that this IOL capsular bag complex wouldn’t be centered or dislocate after a couple of years. I think what is very useful is to use other devices. And one certain device is the Cionni ring. And the Cionni ring is basically a CTR which has a loop on the interior, either one or two loops are there. And this can be used to fix the ring to the scleral wall. And this will ensure your bag is well-centered.

Before the ring is inserted in the capsular bag, you find that a trail has already been passed, it’s preinstated. The ring would go into the capsular bag and the loop on the Cionni ring would come onto the sulcus. And once it’s in the sulcus, the ring is fixed to the sleeve so the capsular bag and the Cionni ring and the lens are finally well centered.

This is the case which has the most severe subluxation and as you can see the lens is still pink posteriorly. This is a gross subluxation. If you have a good amount of viscoelastic, you always have to use forceps in these eyes because the zonules are very weak and have more of a centrifugal force. Remember not to make the rhexis too large at the site of maximum zonulysis. Here I’m trying to insert the iris hook onto the rhexis margin but the lens is more posterior.

One tip here is to lift the capsular bag gently with a spatula, use your non-dominant hand and lift the capsular bag and a spatula is safe because it’s a blunt instrument. And as you lift it you can then place your hook to hold onto the rhexis. You now have support anteriorly to support the capsular bag. And here I’m using about four hooks for this patient. Hydrodissection is done at this point. Hydro has to be good here. This patient I’ve not used a CTR yet, because I would like to insert a Cionni ring.

When doing phacoemulsification, one has to be careful to remember that the zonules are weak. But just see once you have the right settings, if my IOB is lesser than what I would normally have. Lower flow rate, lower vacuum. But once you have your settings in place and slow motion phacoemulsification the capsular bag is kind of stable because of these hooks. These hooks have to be there to prevent any lens bubbling to give stability to the lens bag. But one has to remember to keep the phaco tip more towards the center, we do not want to have too much turbulence in the anterior chamber and remove all the nucleus and the epinucleus.

At any point in time if the intravitreal prolapse, one obviously would have to do a vitrectomy and then continue with phacoemulsification. The ring is not in place yet, cortex is aspirated, and this can be difficult when you have weak zonules. More so if you have the CTR in place, but very gentle aspiration. As you can see there’s no equatorial support here because we have no ring and that means the fornix of the bag can come towards the pupillary center. We may have to inject viscoelastic in between a couple of times just to ensure dialysis does not enlarge.

After the cortex is aspirated, I am reinserting the Cionni ring with a 9.0 prolene. How do we insert it? I like to insert it through the main tunnel because we have this additional loop. And the other tip I would like you to remember is that you have to insert such that the convex part of the ring is inserted first. That is the direction you would take. Once that is done, the training eyelet is also dialed into the bag. The CTR I would like to go in through the side port, but the Cionni ring has no option. You have to have an adequate sized incision. I would prefer a 2.8 millimeter incision. Ensure the ring, both the eyelets are in the capsular bag. Once the loop is brought into the sulcus, you can do this by just retracting the rhexis margin with a Kuglen’s hook and bring this loop into the sulcus. And to the area where there is maximum subluxation. At the site where you want to fix the capsular bag must lead up.

To fix it I’m doing the Hoffman’s pocket which is wonderfully done by Richard Hoffman, this is something that will enable to not go into the pocket. I’m passing a 26 gauge needle about 2.5 millimeter from the limbus to railroad this suture needle which has been passed through the main incision. And the second needle is also retrieved from the main tunnel through the scleral bed using the 26 gauge needle. Once this is done, the suture, which is in the pocket, the two ends of the suture are then brought out using a Kuglen’s hook. And once that is done, the two ends are then tied together. So a couple of knots, about five or six knots will secure the bag. All the time have an eye on the bag to see. We don’t want to pull the bag way too close to the site where it’s being fixed. But you have to have a more central rhexis as much as possible.

Again, the hooks go back. I remove the hook when I’m centering it but once I place the lens, to place the lens it’s always good to have as less stress on the capsular bag as possible. The hooks go back, a three piece IOL is placed in the bag. Why a three piece? Because in spite of the Cionni ring, there may be an IOL decentration later on. In case that happens it’s easier to fixate a three piece IOL. Either the iris or to the sleeve, so that’s why the three piece IOL has been offered for.

This is the postoperative picture of a patient. You may also consider using a double loop Cionni if you have a more gross subluxation. For example a child with Marfan syndrome. Most of these patients would tend to have some form of post op complications. The other most commonly you could have raised IOP and secondary glaucoma, which is not uncommon in these patients who tend to have other comorbidities as well. Capsular phimosis can also happen, PCO is a higher risk. And of course there’s a risk of capsular bag IOL complex decentration of this location.
But if one does take a little effort for the pre op workup and meticulous surgery and adequate follow up, we can give these patients a good outcome. Thank you.

[Hunter] Thank you, Dr. Haripriya, that was a beautiful presentation and certainly I appreciated how you talked about surgical planning. Going slow, keeping control, having several options with the hooks, with the rings. I think all of that is very important.
Our next speaker, we’re moving from zonules to corneal endothelium, is Dr. Prashant Garg, who certainly needs no introduction. He’s the director of LV Prasad, he’s a good friend of Orbis and has been all around the world on the plane. Dr. Garg, thank you so much for joining us today, we very much look forward to your talk.

[Prashant] Thank you, Hunter Cherwek, greetings from Hyderabad. And first of all I’d like to thank Cybersight for including me in this wonderful program where I had the opportunity to hear other two colleagues as well.
Let me begin this talk by a case of a 70-year-old lady who had poor outcome after cataract surgery in one of the eyes and now has developed poor vision even in the other eye. The corneal picture was in the operated eye, as shown on this slide. This is the status of the other eye. Cornea looks compact, the lens showed nuclear sclerosis. However, a careful retroillumination showed metal beaten appearance. And when we focused the illumination towards corneal endothelium, this beaten metal appearance was much more obvious.

The question is what are the possible causes of this poor outcome in the eye that was operated first? I’m sure you will all realize that such poor outcomes are because of a prolonged, complicated surgery. Similar situation can occur in toxic anterior segment syndrome, or any other cause that can result in endothelial cell loss. But one of the other causes that’s becoming important, particularly with the corneal showing a beaten metal appearance is a Fuchs endothelial dystrophy.

The second question that we need to answer in this patient is how are we going to manage or take care of the second eye such that we do not end up having the same situation as the previous eye? The first thing that is most important is that we should be aware of this condition which is called as Fuchs endothelial dystrophy. It is a condition which causes progressive loss of endothelium and in the later part, when the critical mass of endothelial cells is lost, it results in corneal edema. And this condition poses unique challenges if it remains unidentified.
It can result in prolonged corneal edema, it can also lead to irreversible corneal edema. And in some cases, you may be lucky but it lead to corneal edema in the later part of, for a few months the cornea had been clear. One must remember that the signs of Fuchs endothelial dystrophy appear before symptoms. And therefore most clinicians tend to confuse a reduction in vision primarily to cataract and are not able to identify and then subsequently end up having these complications.
It is very important that we perform a thorough clinical examination including a slit beam evaluation of corneal endothelium in every patient of cataracts.

Subsequently if you identify these metal beaten appearance on the corneal endothelium, you must assess the function, as well as the morphology of corneal endothelium using a specular microscopy as well as pachymetry.

And the third step, you must then classify the patients into the severity grade. The most milder form of endothelial dystrophy is where the patients have no corneal edema, corneal thickness is less than 580 micron and the endothelial cell count is more than 1,500 cells per square millimeter.

In a grade two, the patient usually complain of morning blurring of vision. And as shown in this video you will be able to see some stripe indicative of mild corneal edema. The pachymetry should be less than 620 microns for you to grade it moderate or grade two. And the endothelial cell count may be less than 1,500 but more than 1,200.

However, in the severe grade of Fuchs endothelial dystrophy, you will have obvious corneal edema as shown in this video. That will result in corneal thickness of more than 620 micron and endothelial cell counts are usually less than 800 cells per cubic millimeter.
Once you have classified the disease, as an extra step you must decide on the management of the case. And the management is based on the severity of endothelial dysfunction and the cataract grade.

Different surgical options that are available to manage these cases of combined cataract and Fuchs endothelial dystrophy are performing cataract surgery alone, cataract surgery followed by corneal surgery if required, and a third option is to do combined cataract and corneal surgery. But how do we make that decision? In a grade one where you have no corneal edema and corneal thickness is less than 580 micron, you can go ahead with the cataract surgery alone but you need to take some consideration for protecting compromised corneal endothelium.
In grade two, you have both options and it will primarily be dependent upon the grade of the cataract. Depending upon the grade of nuclear sclerosis or hardness of the cataract, you can plan to do combined surgery. Or if you are convinced that endothelial density is good and thickness of the Descemet’s membrane is not visually compromising, you can counsel the patient for cataract surgery with an option of doing corneal surgery in case corneal edema appears. With Descemet’s membrane endothelial keratoplasty, there is a tilt toward advising combined surgery even in this grade of Fuchs endothelial dystrophy.

However, the decision is much straightforward in grade three Fuchs endothelial dystrophy because the cornea is already edematous and therefore you will have to take care of cataract as well as corneal disease.
Once you have decided on cataract surgery alone in grade one or grade two, some of the factors or the planning and preparation that will be necessary are number one, decide about the technique of cataract surgery based on the severity. In milder cataract or less dense cataract, phacoemulsification is always superior. However, if you have moderate grade of Fuchs endothelial dystrophy and cataract is brunescent, it is always advisable to perform combined procedure rather than cataract surgery alone.

Even while performing cataract surgery, you will like to modulate power such that there is the endothelial cell loss is reduced. You may switch to the pulse mode or the burst mode of cataract surgery. In addition, you have to use viscoelastic and soft-shell technique comes very handy in these situation where you have a cohesive viscoelastic in the center surrounded by a dispersive viscoelastic that is retained in the eye for a much longer period of time and continue to provide protection to this compromised endothelium. You may have to fill the anterior chamber with viscoelastic repeatedly in order to provide necessary protection.

If after doing a good cataract surgery, the patient has developed postoperative corneal edema, there is no need to panic. We start these patients on a conventional postoperative regimen. And if you are lucky the corneal edema will resolve and the patient will gain vision. However, if the edema is persistent, and is not resolving, you can subsequently do a Descemet’s stripping, endothelial keratoplasty, or Descemet’s membrane keratoplasty. And most of these patients regain very good visual acuity postoperatively.

In summary, what we learned today from this case is that an early diagnosis is crucial and for that a good clinical examination plays a crucial role. The choice of surgical procedure depends upon the stage of the dystrophy as well as the density of cataract. You may consider modifying cataract, you must consider modifying cataract surgery so as to reduce endothelial cell loss. A good preoperative counseling will help good postoperative management of these cases. Thank you very much for your kind attention.

[Hunter] Professor, that was fantastic. I think one of the things I saw on both your talk and Dr. Haripriya’s is the importance of quality viscoelastic. When you know you have a compromised eye, whether it’s the endothelium or the zonules, having good, quality viscoelastics are critical. I also think the workup, and I liked how you classified or stratified the patients based on what you found preoperatively so you don’t have postoperative surprises.

I’m very, very grateful to have Dr. Vasavada join us. She is a master surgeon, I’ve been in the OR with her before. I love when I watch her operate, she changes her parameters and has more settings and is the most controlled surgeon I’ve seen with different settings and parameters for cataract surgery. Dr. Vasavada, thank you so much for joining us, thank you for all that you do for cataract training. Over to you, madam.

[Vaishali] Thank you very much, Hunter. Thank you, always, Cybersight and most importantly Hunter. And thank you for those words of praise. But really I feel intimidated presenting after Dr. Haripriya and Dr. Prashant Garg. And I think it’s easier for me because they talked about preventing complications and I’ll talk about what I do very often that is what you do when you create a complication.

My case today is going to be something that I started off as a very routine cataract case. A young lady, bilateral posterior subcapsular cataracts and she had preexisting regular corneal astigmatism. We have planned a toric multifocal IOL in this case. Now what we will see is what happens when you expected a smooth sailing surgery and then it doesn’t end up that way and the capsule ruptured. This is just to show that this is a kind of a very soft, juicy cataract and you will not be worried about how technically you can perform this case.
What we do and this is one of our trainee surgeons here, and what we do is what we call a nuclear or modified divide-and-conquer type of a technique where we do a deep sculpting with very, very low parameters. And as Hunter pointed out, the flow rate here is about 14 and very low vacuum and low ultrasound energy, only 20% of torsional ultrasound because we don’t want to eat through that nucleus. The idea is to perform a deep sculpt so that horizontal separation of the heminuclear becomes very easy.

Now here I think what is very important is as you can see the first, the two halves are being created and everything looks fine. What we do need to remember is that when you’re sculpting, the capsule is not straight, it has a curve. When you sculpt, you need to follow that curve otherwise you could end up in trouble. And as you can see here, the surgeon is very confidently going ahead and it’s a cortical cataract so the red glow is not perfect, especially after a hydrodissection. But you can see that things are happening quite okay. Although we can not really see what is happening at the base, or at the very deepest level.

Having created four quadrants in the nucleus, then the surgery moves forward. And now the removal of these fragments has started. Again, modest parameters, everything looks very much in control, the anterior chamber is not fluctuating too much. But keep your eye open on this side, something seems to have come up but the surgeon has still not noticed because the nucleus is rotating very smoothly and quadrant removal is being performed. As more and more of the nucleus this piece goes in, that’s when probably things have become clearer and the surgeon will notice what is actually going on behind. And you can see by now most of us can make out this area of the posterior capsule rupture. And it is only now that it actually becomes clear and you know that something is going wrong. But the surgeon still goes ahead, hesitating a little bit, not sure what to do.

I think that is one important thing I wanted to point out. There will be times when you may not be sure of the degree or the presence of a posterior capsule rupture. If there is anything, don’t try to over manipulate, inject the dispositive viscoelastic and then come out like the surgeon did and then try and see, you may even use the forceps to move your globe to enhance the red glow visibility.

Now, I have a poll question if Lawrence could help us put it up. When do you think the PCR may have occurred? I think most of us have figured it by now, but do you think it’s too much of a deep sculpting or do you think it was too much energy or vacuum during removing this very jelly-like fragment that caused the PCR?
[Hunter] You can now start answering the question. And we have about 30 seconds to poll and then Dr. Vasavada will continue to talk. Dr. Vasavada, I love how you were demonstrating going slow. I think that’s one of the things that I appreciate as the audience is answering this question. I definitely think one of the things all the surgeons have done in complicated cases is talk about not losing control. Taking time. When you do have a PCR or notice something, not losing control. Here are your answer, Dr. Vasavada. What was your opinion and what did you see?
[Vaishali] I think what I realized retrospectively after watching the video, is it was probably the deep sculpting when the last piece is being separated. Like I said, the capsule typically is curved and when you sculpt, if you’re going flat, if you’re not following the curve of that and if you go flat, you’re more likely to rupture the capsule mechanically or with your ultrasound energy. In my opinion, this happened because of the deep sculpting and not during fragment removal.

Now the thing is, how do you move forward? You know you have a PCR, half of your nucleus is still inside the capsular bag and you don’t see any obvious vitreous coming into the anterior chamber. What will you do? The best thing has been shown also by Dr. Haripriya and Dr. Prashant, is to inject good viscoelastic. Ideally it will be, this was dispersive viscoelastic, but even if you don’t have access to that, inject whatever you have and then only come out of the eye. The next step which I find very useful now is to inject triamcinolone acetonide. And thanks to our lab we now have a preservative-free version available. We don’t need to dilute or have a compounding pharmacy make it. It’s ready-made. And we just about 0.1mL of this through a sideport, of course. We now want to be very conscious to not use the main port as much as possible. Even though it’s a self-sealing 2.2 millimeters incision.

And we can see here that there is not much vitreous presenting, but once you have such a big rupture, it is crucial to perform an anterior vitrectomy before we perform any kind of maneuvers. And I think it may be very tempting to enlarge the incision and sort of do an extracapsular or an SIC as a kind of nucleus delivery at this stage. But that is something we should all shy away from and try and avoid in these cases because then you are surely inviting much more vitreous and also probably enlarging the capsular rupture.
Another poll question. Once you have a PCR with some fragment already in the bag, what would be your preferred method of anterior vitrectomy? Would you bimanual limbal or pars plana? And we can have the audience work on that.

[Hunter] Yes, Dr. Vasavada. And while the audience is answering, I think you raised a really good point. You want chamber stability and control. As soon as you have egressive fluid out of the chamber, the vitreous is going to follow and potentially enlarge that rupture. Keeping control, using OVD to fill space, not immediately pulling your instruments out of the eye, I think those are all critical things. Another thing you mentioned, I just want to reinforce because I’ve seen it so many times, is where people put the protractor through the main wound and now you have all this fluid gushing out. If you’re not comfortable using the limbal or a paracentesis, putting a stitch through the main wound so you have better chamber stability is probably the best thing. And I think we have the answers up now for you, Dr. Vasavada.

[Vaishali] I think we have almost equally divided. Both are good, provided as Hunter said, use the side ports. It’s always crucial to do a bimanual vitrectomy and not use the main port. If you do, please take one or two sutures depending on the size of your incision, and then go through it. But as you will see in this case, I find and most surgeons at our center, we have learned a very hard way that performing pars plana vitrectomy as a cataract surgeon I am not a trained retinal surgeon, is not that difficult because here the aim is just to perform a limited anterior vitrectomy. You don’t have to do a core vitrectomy. All we need to modify in our technique is do a conjunctival peritomy and about 3.5 to 4 millimeters behind the limbus you put in an entry either with your MVR knife, about a 1.2 millimeter knife. Or if you have access to a self-sealing Trocars you could use one of those. The good part is that most phaco machines today are compatible with 23 gauge vitrectomy. So you don’t really need to have a specialized vitrectomy machine, you can use your phaco machine and use the vitrector probe that is available.

What you will need to do is use the irrigation through the corneal side port and the vitrector through the Trocar or the MVR knife as you will see here. One big challenge is to create that pars plana opening. And you can see this Trocar in this soft, open eye. If you have a Trocar it’s sometimes very difficult, so that’s why I said you can always open up the conjunctiva and make a stab knife entry, there is nothing wrong about that. As you see here, the vitrector is coming from behind and the irrigation is from above. And the stain triamcinolone is helping us to visualize. Why should we do this opposed to a limbal approach? Because here you are pulling the vitreous down into the cavity rather than a limbal where we are pulling it up more towards the anterior chamber. That I think is a good idea. And yes, it sounds a little scary to begin with but it’s not difficult to learn if you practice it gradually whenever the situation arises.

I would like to use the maximum cut rate possible on my machine which in this case is 4,000. The vacuum has to be modest, let’s say about 350-400. But the irrigation pressure, your water height or your IOP need to be low and your flow rate needs to be low because you don’t want too much movement happening in the anterior or posterior segment. But what you do need is a high cut rate because we don’t want to aspirate, we want to cut that vitreous attachments.

Once the vitrectomy is done, then we proceed with phaco as normal but again, going very, very slow. The intraocular pressure has been lowered to 20. And the thing is, because there is no vitreous you are not worried about pulling in anything. It’s the same thing if you tried to do without an anterior vitrectomy, you are definitely pulling in more vitreous and therefore in the long run, chances of detachments, macular edema, glaucoma, all these are going to be much more. And we are using a very low flow rate, low vacuum, and required energy to try to remove this. And you see that in spite of this huge open capsule, nothing is going behind. It’s not like the side instrument is doing anything. Also, if you notice here the irrigation has been separated from the phaco probe. That means the irrigation is being used through the side port and the phaco probe is acting as an aspirating device. Something like the bimanual phaco or the phaco which was very popular several years back.

We’ve managed to remove the entire nucleus without causing any further damage to the eye. Now the stage of cortex removal. Here again, bimanual irrigation/aspiration I find very useful because it allows the closed chamber and it allows us stress-free access to 360 degrees. Try and remove as much from the area away from the PCR so that the cortex that you remove last should be the one in the area of PCR. In case something goes wrong you still have removed the rest of the cortex. And here also, keeping your irrigation in the middle of the eye to keep the chamber formed and not allowing it to prolapse. Sometimes I don’t want to use too much vacuum so I will also mechanically feed the cortex into the aspiration port because I want to work at a modest vacuum, about 150 as you see here.

Now the last poll question. Once you have cleared the bag and now remember that this was supposed to be a toric intraocular lens, would you still go ahead with the, any form of a single piece hydrophobic or a hydrophilic acrylic IOL? Or would you do a ciliary sulcus implantation and just leave it there or capture it through the anterior capsulorhexis now? I just want to find out what the audience would think.

[Hunter] And while they’re polling, I think one of the things that I really appreciate about your entire hospital and eye center, Dr. Vasavada, is how you record every single surgery. You never know when you’re going to have a teaching case or a complication. And those are the ones that you’re going to learn the most from. Your center has amazing surgical videos and I just encourage everyone listening to constantly be recording and going back and looking at your surgical videos.

[Vaishali] I think most of us would, and I would agree, would either do a ciliary sulcus implantation or put the entire IOL in the sulcus and capture the optic through the anterior capsulorhexis. But there is also the option of doing a posterior capsulorhexis in this situation if you can. And then I’m not sure whether I’d be able to do this. What I am doing is I’m using microincision forceps and pulling the margins of this there, because it’s a rough edge. I’m trying to convert it into a strong posterior capsulorhexis.

Let’s say I can’t do that, I still have a good anterior capsulorhexis and I can still do the sulcus implantation. Yes, not every time you can do this, but it’s worth trying in certain situations. And fortunately we could manage on both sides to create a strong margin and therefore now a single piece of hydrophobic acrylic toric IOL is being implanted. No financial interest. But the point here is that you have to, you might enlarge your incision a little bit because you don’t want a very jerky IOL implantation. Even if you are doing a three piece IOL, and very slowly dilate into position.

This is something that is controversial, some people might not agree with my decision of putting a single piece lens in the capsular bag. But because I could create a posterior capsulorhexis on both sides, at least almost, I felt more confident. But yes, just doing a three piece, any form of a three piece foldable, or a single piece PMMA IOL in the ciliary sulcus is still, I think, a very, very good idea. The other point I just wanted to highlight is even if it’s a 2.2 millimeter incision, I move to suture it because these wounds you don’t want to leak. And once the IOL is in the bag I’m going to do a reverse optic capture. That means push the optic up through the anterior capsulorhexis so that this toric lens is not going to rotate any further.
But like I said, this is not something that you need to do. Now you could do a bimanual irrigation/aspiration or even use your vitrector in the I/A cut mode where you aspirate and cut. Finally, you want to hydrate the wound and maintain a chamber before you come out of the eye. And this is what the eye looks like to our good fortune, three months and six months down the line. Doing very well.

I just want to add one or two points before I end. What I think is very, very important is to have a so-called “PCR ready kit.” Because every time, especially if your staff is new, even if you will be the most experienced surgeon, they sometimes go into a panic mode. There should be a separate set of instruments and devices which you will need if something goes wrong like a suture, triamcinolone. Never come out without injecting any viscoelastic and never inject a single piece lens, hydrophilic or phobic acrylic IOL in the ciliary sulcus. Thank you.
[Hunter] Thank you so much, Dr. Vasavada. What a great set of videos. Again, just stressing the importance of surgical planning, knowing the anatomy, whether it’s the zonules, the endothelium, or the posterior capsule. We’ll start with Dr. Haripriya, as she began, with some questions. One was, how would the density of the cataract affect your planning when you know that you have preoperative zonulopathy or zonular weakness?

[Haripriya] Yeah, that’s a good question. I think when you have a more hard lens, once would have to stabilize the capsular bag. I would use a CTR there. The cataract which was just shared, that cataract was not very hard so I chose to use a Cionni ring. And a Cionni ring is best placed when the capsular bag is empty after you remove the nucleus. But if it’s a hard lens, I would like support in the capsular fornix so I’d use a CTR. And if there is a need to fix the capsular bag through the sclera, I would use a capsular tension segment and then fix the capsular bag through the sclera. But yes, the cataract density would matter so it would change the plan. A soft lens, a Marfan’s patient, you may not need the CTR. But all patients, the first device to go in for me would be the hooks to support the bag.
[Hunter] That’s fantastic. One other question that also came up, and I know that you had a bit of a table that looked if the patient was myopic or their axial length. How do you size the CTR? If you know that you’re going to be putting in a CTR preoperatively, what are you doing on your work up or your clinical exam to get the right CTR for the right patient?

[Haripriya] I think 95% of the time it’s one standard size. The recommendation from Morcher is if you have an axial length of 24-28, then you would go with an 11,13 CTR. What 11 and 13 means is it’s 11 millimeters when it’s in the bag when the CTR is compressed. The ideal placement is that the eyelets of the CTR should just cross. That’s where you have the support equatorially all around. That’s the size it should have. That is what I think would work in most cases. Even with slightly smaller eyes this should work. But in very large eyes, in myopic eyes, then I think one should go in for the large CTRs. But I think it’s rare. In most instances 11,13 would be fine to have as a backup. And maybe if you want at 12,14. The small rings would only be required in pseudophakic eyes and in very small eyes, maybe in children or something. Even in those eyes there is no harm in using a little larger CTR. You could always place 11, 13 instead of a 10,12 so you may not actually have to have it in your inventory. Between these two you can manage.

[Hunter] Yeah, I think that’s really important. I find a lot of people don’t know if they have a CTR in their inventory until they need one urgently. Just like Dr. Vasavada said. Having a kit ready, having high quality OVDs, like Dr. Garg said, is critical.

One thing I’d like to hear from Dr. Prashant or Dr. Vasavada, Dr. Haripriya made it look easy. I find, or I’ve seen so many times, the challenge is getting a good capsulorhexis. You don’t have the counter traction, it’s hard to get a centered CCC when it’s dislocated and you can’t see it. She made it look easy, but do you all have any tips or tricks or pearls to mention about doing a capsulorhexis on a patient with known zonular weakness or zonulopathy?

[Prashant] I think the trick was addressed by Haripriya also. It is always good to start the capsulorhexis away from the zonular weakness site. I think that’s the first trick. And as you are approaching to the site of zonular dialysis or weakness, you will be able to see that there is a difficulty in ripping the capsule. In that situation, if you are facing that, switch over from the 26 gauge needle to using a full capsulorhexis forcep and try to complete the capsulorhexis. It usually is depending upon how much zonular dialysis you are facing and difficulty you are facing.

[Hunter] And if you see that clumping or if you see the wrinkles before the leading edge, putting back in your OVD. I find a lot of times people are not reinjecting and that could be a secret to smoothing out that carpet where you lack that countertraction from zonules. I’m sorry, Dr. Vasavada, did you want to add something here?

[Vaishali] I just wanted to add two things. I really find it difficult if it’s a large area of subluxation, to make the initial entry or the puncture sometimes is difficult. Instead of normally I would use a 26 gauge cystotome, but if that doesn’t happen, I wouldn’t hesitate in using an MVR style knife to clear the initial puncture. Because you don’t want to push the nucleus too much in trying to make that puncture. The other thing that I find useful because I am not as skilled as Dr. Haripriya, she made it look like child’s play. What I also do if it’s like Dr. Garg said, if it’s very difficult in the area of big zonules, I would take two sideports and two microincision forceps. With one hand I would pull the capsule or sort of support it and then with the other keep doing the rhexis to give some sort of a countertraction. These are two things I have found very useful when you’re not as experienced or if the case is really difficult.

[Hunter] No, I think those are great tricks. Moving on to the cornea. I know, Prashant, you have spent your life worrying about endothelial cells. A few quick questions that people came up. If we don’t have the ability to quantify through machines, the endothelial density or the endothelial health, how can you get rough approximations with the clinical exam with guttata density? And can we still move forward with phaco alone with mild guttata? Those would be combining two questions from the audience.

[Prashant] I think these are very interesting questions and the parameters that one should take into account is the history of morning blurring of vision. And number two, if the density of guttata are kind of covering more than six millimeter of the central area, then they are likely to lead to corneal edema postoperatively. And then if you do a good clinical examination you will be able to see those striae that I tried to show in my video. The history of morning blurring of vision, guttata is spreading into the central six millimeter of the cornea, and presents of striae on clinical examination are the signs that this cornea is compromised and phacoemulsification may lead to corneal edema.

[Hunter] Yes, sir. And one thing I’d like to ask, maybe you and then the others, Dr. Haripriya and Dr. Vasavada, is there anything you do differently with the post op medications? Do you add more steroids, do you add anything differently for patients who you know have already compromised corneas? Is there anything you do differently postoperatively?

[Prashant] Earlier we used to give them more intensive corticosteroids but we have found that if the endothelial cell count or the corneal edema is mild, to moderate their recover, even with the conventional postoperative regimens. I do not modify my regimens, I observe these patients over six weeks period and you find that those cases which have reasonable visible corneal endothelial will recover those patients.

[Hunter] And Dr. Vasavada or Haripriya, is there anything you do differently with known compromised endothelial cells either preoperatively, intraoperatively, or post op?

[Haripriya] I think we very well discussed intraoperative that I would take a lot more effort to ensure the phaco probe is at a deeper plane. Obviously that is something we want to be as far away from the cornea as possible, so try to opt for a chop technique, try to have good viscoelastic, it was emphasized adequately. And keep, make sure at no point you have to lift your probe. Which means you have to have very good chamber stability. Have the right flow rates in place so your probe can remain at the iris plane. That is very important for me.

[Hunter] And Dr. Vasavada, any tricks for you about protecting those endothelial cells?

[Vaishali] I think two things in the preoperative period, if I have a serial follow of the patient, then I would try to push them for surgery and not wait until the very advanced stage. Because in our part of the world, particularly, especially if they find out that there is another comorbidity they’re really scared. When you talk to them about the possible DSEK or DMEK, they may want to delay the surgery. One thing that I would like to discuss with the caregivers and the patient is don’t wait too much and get it at a reasonable time then your chances of iatrogenic injury are lesser. And also the second thing in postoperative as we talk about probably in the first 24 hours, I would add an IOP lowering agent like a timolol or something because I don’t want any additional endothelial edema. Otherwise I don’t think, everything was very well said and I would not change the postoperative regimen much.

[Hunter] Yeah, and one of the questions, Prashant, that was asked during your talk was do you see a role, or does femtosecond-assisted surgery, does that help? Is that something you’d put in your planning with a patient with known compromised endothelial cells?

[Prashant] That’s a wonderful question. The addition of the femtosecond laser, nucleotomy is very useful in these patients because the nuclear fragmentation is already done and therefore you are likely to consume less of phaco energy and more of aspiration of these pieces. If one has an access to femtosecond machine, then they should definitely advise these patients to undergo that procedure.

[Hunter] Yeah, and going back to Dr. Haripriya, I know some people with known zonulopathy actually use the femtosecond for the CCC, because they don’t make it look like Dr. Vasavada said, like child’s play. I know that femtosecond sometimes have a role in the challenging cases. Either reducing the CDE or the difficulty in getting a well-centered CCC.

The last question for you, Prashant, was about DWEK. Is there a role, and obviously there’s been an explosion of lamellar procedures over the last 15 years. What procedures is your go-to for a patient with known Fuchs dystrophy? What is your best corneal procedure or the one that you feel more comfortable with a planned phaco and lamellar procedure?

[Prashant] I think if I talk about three years earlier we were doing DSEK with the phacoemulsification and after the advent of DMEK, we have switched over to DMEK and phacoemulsification. The advantage is that you have lesser risk of allograft rejection and the cornea regains thickness very quickly. The need for long term corticosteroid is reduced drastically. I have not tried doing descemetorhexis alone and I think that procedure probably will be difficult to combine with phacoemulsification.

[Hunter] Yeah, I would agree and I think, Prashant, I’ve worked with you a lot around the world. You’re extremely good at speaking to the family and the patients. I think letting patients know that they may need a second procedure and getting the expectation in their head ahead of time is important. So that if three years, five years down the road they already know that their cornea’s already compromised and trying to do too much and too many different procedures at the same time can be challenging especially when you’re still learning all these new techniques.

Dr. Vasavada, one of the questions that came up during your PCR talk was the use of a scaffold IOL, so that before removing residual fragments do you see any advantages of trying to place an IOL in the eye beforehand? Maybe you can talk about what is a scaffold IOL and when you might use that intraoperatively.

[Vaishali] That’s a great question. First of all, what do we mean by a scaffold? In the good old days there used to be a sheet glide and now you could use an IOL. Basically when you have a rupture like you saw with my case, and you still have a large chunk of the cataract remaining inside the bag, you put in an IOL and you slide it in behind the residual nucleus. and then you emulsify that nucleus in front of the intraocular lens. That is what is the whole concept of intraocular lens scaffold.

Personally speaking, I have never done it and I’m not a very big fan of this technique for two reasons. Number one, because if there is vitreous in the eye, unless if you want to use a scaffold, please use it, but only after performing an anterior vitrectomy. Most people tend to think that once you have a mechanical barrier, just because you can’t see the vitreous it’s not there and it’s not affecting your postoperative outcome. I think that is a trap that we don’t want to fall into. You may do an adequate vitrectomy and then inject the IOL behind the remaining lens material and then emulsify it in front. I don’t use it. If I did have to use it, maybe I would use it where there’s completely no capsular support, but then the thing is the stability of that IOL is also an issue. I have seen cases where that scaffold IOL can drop into the retina and then you add one more surgery where you could have managed without that. Personally, for me, I am not a big fan of any either a glide or an IOL. I would rather if it drops, I will let it drop and then have a retinal surgeon handle it in a much more elegant manner postoperatively to or three days down the line, if I don’t have access to a retinal surgeon right away. But I would appreciate madam and sir’s comments on this.

[Haripriya] I would agree with all the points which Vaishali shared. I would use a scaffold sometimes. I think a case like this would be a good case because there was no vitreous which is just very well managed. Once the vitreous is taken care of, one can ensure. But again, you have to ensure your wound size is not enlarged. It has to be a 2.8 or a 2.2 because otherwise you can’t emulsify the nucleus. Your wound has to be good and you have to ensure your lens doesn’t, again, slip into the bag or something. You should be careful to place it either in the anterior chamber or in the sulcus and then do the emulsification. It’s an extra, one more thing in the eye, one has to be aware of it which means you’ll have less space to work, which can make it safer but also that you’ll also have to be careful about the endothelium.
[Hunter] Dr. Garg, did you have any experience or any comments there with scaffold IOLs?

[Prashant] No, I have not used a scaffold IOL because I feel the same as Vaishali said that if you have left some vitreous there, it will give you a false sense and you most likely are going to be pulling or putting a lot of traction on the vitreous body. I usually do the complete vitrectomy first and then once your vitrectomy is done, the capsular opening stabilizes very well and you can use bimanual for your phacoemulsification as well as cortical aspiration.

[Hunter] Thank you so much. Dr. Haripriya, we do have a question and again, you make it look easy. With a known zonular dialysis case, do you do anything differently with a hydrodissection? Do you do smaller bursts, more rotation? And what do you do with lens rotation? Do you still do that after a hydro? I guess the question is, do you modify either your hydrodissection or your lens rotation in a known case of zonular dialysis?

[Haripriya] Yeah, the hydrodissection is a very important step. I think it’s a very relevant question because of the lack of zonules the additions are much stronger between the capsule and the cortex. Hydrodissection has to be done. The placement is important. We don’t want to insert the fluid at the site of going to the zonules, it has to be in the capsular bag. Identify your rhexis rim and then inject the fluid. Again, as you suggested, using small bursts of fluid is good instead of having an overzealous hydrodissection. But at the fill-in site, you ensure you’re doing a good hydrodissection a small amount of fluid. Rather have spurts of fluid in different directions and ensure this is complete.

In terms of nucleus rotation, I don’t do the rotation normally for the routine cases but for someone who does it for all cases, I would suggest you continue doing it in these patients as well. At the same time, please remember the zonules are weak so one would have to be careful, use two instruments, bimanual rotation very gently. The reason I’m saying it is you don’t, it’s probably safer to do it mechanically with your Sinsky rather than trying to do it for the first time with your phaco probe. If you are a surgeon who would do it before your phaco would start, I would say do continue, but be a little bit more gentle.

[Hunter] Thank you so much. I’m going to ask all three of you all. I know that Dr. Haripriya, you mentioned how you start or place the beginning of your CCC based on the location of the zonular dialysis. One question from the audience is do you change the incision location based on the location of zonular weakness? I’m going to ask all three of you all and again, we’ll start with Dr. Haripriya and then Preshant and then Dr. Vasavada. If and how does zonular dialysis affect your wound location?

[Haripriya] My preferred incision site is obviously temporal. The only time I would change my site and go superior is if there is a temporal zonular dialysis. The reason being I don’t want to enter straight where there could be a vitreous prolapse. I would like to enter at the site where this is not the site of maximum zonular loss. In that case I would go at the superior site. But besides that, I have no other indication for changing my incision site. The only thing I don’t want to encounter as I enter is vitreous. That’s the only thing I would like to avoid if I can. But if there’s a large dialysis, both superiorly and temporally, there’s obviously no other option but to go with the temporal route.

[Hunter] Prashant, do you have any comments there?

[Prashant] No, I think I use the same strategy. That my preferred site of incision is temporal and I may switch my capsulorhexis from the side port and the main port depending on the ease with which I can do the rhexis.
[Hunter] And Dr. Vasavada, any other tricks or tips that you have to offer here?

[Vaishali] I think I agree, same, temporal. Unless you also because vitreous, like Dr. Haripriya said, and if you need to fix it, any of the rings or devices on the temporal side, you want to leave that side empty. Most leads temporal or otherwise superotemporal.
[Hunter] We have, obviously at Cybersight we have a consult service and we often get some of the most challenging questions asked. Very rare syndromes or rare findings that they want to consult experts like the panel here. Two very specific questions we have in the Q&A that are pretty rare diseases. And the first one is ICE syndrome: Iridocorneal Endothelial Syndrome. We’ll start with the cornea expert. Prashant, do you do anything, is there any special recommendations you have? I know you talked about corneal compromise with Fuchs dystrophy. With ICE syndrome, is there anything you do differently as you plan your cataract surgery? Then again I’d like to hear from Dr. Haripriya and Vasavada.

[Prashant] If the patient, I use the same algorithm even for the ICE syndrome that you need to assess the endothelial function beforehand. You should also look at the degree of synechiae and iris tremulousness because these are the factors that are going to make our surgery more difficult. But once you have done that, and the pupil is dilating then you can go ahead with the routine capsulorhexis and phacoemulsification. However, in some of these patients the pupillary dilation becomes a challenge. Or at times the iris is so tremulous that it keeps getting into the phacoemulsification port. And if you notice any of these signs, it is safer to put the iris hook in order to keep iris away from the phacoemulsification site, then go ahead with the cataract surgery. Always remember that postoperatively some of these patients develop raised intraocular pressure and you need to monitor very closely these spikes in intraocular pressure and manage them appropriately.

[Hunter] Thank you, Prashant. And Dr. Haripriya, is there anything you do when you’re looking at a patient with ICE syndrome as you plan your surgery on how to protect the cornea or how to get the iris out of the way during surgery? Is there anything you do differently?

[Haripriya] I don’t think I have anything more to add. I think Prashant has very clearly said exactly what I would be concerned with. IOP, endothelium, iris, I would look at all this with viscoelastic. In terms of nanophthalmos I would probably look at doing a Vscan pre op. I may work with the VR surgeon to have a sterostomy done. That would help me have a much better anterior chamber, especially when doing very small eyes like 16 millimeters, 17 millimeters. There’s a very high chance of an expulsive hemorrhage. I would ensure I would have them with sterostomy, posterior sterostomy and then perform the phacoemulsification.

[Hunter] And Dr. Vasavada, anything you’d do differently with either a patient with ICE syndrome or nanophthalmos?

[Vaishali] No, I think everything has been well discussed. ICE syndrome, everything was well laid out. Nanophthalmos, yes, same thing. These are the cases, ICE syndrome and nanophthalmos, which also brings out an important point that it’s good to have, not only a cataract surgeon, but the other expert like corneal surgeon, or the retinal surgeon with you. Co-management is something that really gets highlighted in these cases and you can only give really good outcomes when you’re co-managing with the right experts. I would have a retinal surgeon. And again, the use of heavy viscoelastic in this, visco adaptive would be my choice along with a disposable ability to coat the endothelium. And then the other issue, obviously, is the IOL power calculation and what kind of lens you would put. But that’s a little more non-surgical thing. But I think these are the two main issues.

[Hunter] That’s fantastic. I mean I can’t thank you all enough. I know all three of you are incredibly busy as surgeons, as trainers, and hospital leaders. We answered, I think, all the questions. Sorry, we got one more! All right. Dr. Vasavada, I’m going to have you answer this one. In many of our operating rooms they may not have the automated vitrector. And so if there’s not a vitrectomy machine, how do we manage vitreous prolapse? What is your management strategy when there’s not an automated vitrector?

[Vaishali] I think that’s a great question because there are parts of the world and country where you may not have at that time access to a vitrector. The best you can do would be one thing I would never do is a weak or a sponge vitrectomy. I would go through a side port, I would probably enlarge if you don’t have a microincision scissors. Enlarge a side port and use the scissors to excise as much vitreous using a gentle spatula retraction. Although it’s not ideal. But I would, if possible, even if i can transport the patient maybe in a couple of days to a center where there is a vitrector. I would not be very enthusiastic in proving a point and putting in an IOL at any cost. Try and remove as much vitreous manually as you can. And if you feel that a lot of the cortex or the lens fragments are left behind, close the eye, suture it up, give good anti-inflammatory and IOP treatment. And if possible, please, even if it means sometimes doing it at your other hospital expense, let the patient travel to a center where they can do a good cleanup and then put in the IOL in the sulcus. That would be my genuine recommendation.

[Hunter] No, that’s fantastic, I agree. One thing people don’t realize is the Weck-Cel or the cotton bud, as you touch it against the vitreous, the absorption actually pulls traction as soon as they touch.

Again, I just want to end this incredible webinar, as we began, by thanking all of you all for taking the time. I want to thank all of our attendees from all over the world. We had a great year, even though 2021 was a challenging year. We’ve had a great year on Cybersight and we want to thank everyone for making that possible. Again, Prashant, Dr. Vasavada, and Dr. Haripriya, we hope all of you, your team and your families have a very healthy and happy new year. And thank you for all your do in global ophthalmology.

[Prashant] Thanks, Hunter and from our end also, to you and all the members of the Cybersight and their families, as well as all the participants have a wonderful year. Hopefully we should see the end of the pandemic and we should be able to meet in person.

[Hunter] Yes.

[Vaishali] Yeah, hoping the same.

[Haripriya] Thank you so much.

[Vaishali] Thank you, thank you, Hunter. And thanks for the incredible work you do even on a personal level, thank you.

[Hunter] I hope everyone has a good year and this is our last webinar of the year. Thank you, Lawrence, for seeing every single one of us through this webinar. Have a great day, everyone, and thank you for your questions and participation.

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December 21, 2021

Last Updated: October 31, 2022

1 thought on “Lecture: My Best Cataract Case in the Past Two Years: Lessons Learned that Changed My Practice”

  1. I found it exciting that you can separate the irrigation from the phaco probe. Is there only aspiration via the phaco probe? If ultrasound is also used, shouldn’t one fear a wound burn?


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