Surgery: Achieving Excellence in Cataract

This video is related to the Achieving Excellent in Cataract Manual.

Presented by Dr. Michael Colvard, the video has the following steps:


  • Incision Construction: Dr. Michael Colvard
  • Incision Construction: Dr. Michael Colvard
  • Capsulorhexis: Dr. Howard V. Gimbal
  • Hydrodissection and Hydrodelineation: Dr. Howard Fine
  • Basic Divide and Conquer Technique: Dr. Michael Colvard
  • Capsular Tension Rings: Dr. Patrick J. Riedel


  • Loading of different IOLs: Dr. Marion Tennison Taylor
  • Insertion of IOLs: Dr. Richard S. Hoffman


(To translate please select your language to the right of this page)

DR COLVARD: Hi. My name is Mike Colvard, and I’d like to welcome you to this video supplement of Achieving Excellence in Cataract Surgery. Our goal is to help you to become a better cataract surgeon by breaking down the fundamental aspects of the procedure into steps that are both easily understandable and reproducible. To do this, we’ve enlisted the help of some of the world’s finest eye surgeons, each one of whom is either the originator, or one of the earliest proponents of the techniques that they’ll be discussing in this video. And I would like to take this opportunity to thank, in order of their appearance, Dr. Howard Gimbel, Howard Fine, David Chang, Mark Packer, Patrick Riedel, and Richard Hoffman for the fantastic job that they’ve done in putting this video together. I would also like to congratulate you for all the hard work that you’ve done to get where you are today, and to thank you in advance for all that I know that you’ll do for ophthalmology. Because, of course, you are the future of ophthalmology. Continue to work hard, learn everything there is to know today, and then move it forward and make us better. Take care of yourself, as well as your patients, best wishes to you, and thanks.

For the corneal incision, I like to begin the procedure by stabilizing the globe with a ring holder, and then we begin at the limbal arcade, with a blade that’s selected which is precisely matched to the width of the phaco device. This position gives you the strongest, the most structurally sound clear corneal incision. So you begin at the arcade, and then drop your wrist, and then direct the blade anteriorly through the stroma of the cornea, to a length that is equal to the width of your blade, and then you raise your wrist, follow the plane of the iris, parallel to the iris, now enter the anterior chamber, and this should give you an incision that is square. That is to say, the incision is as long intrastromally as it is wide. This gives you a very strong, structurally sound incision. Then at the conclusion of the procedure, you want to irrigate the side port. I use a bimanual I and A system, so there are two side ports. And then you hydrate the primary incision. Now, if you’ve constructed a very sound square incision, this should be absolutely watertight, and you need to challenge the incision rigorously. If the incision is not properly constructed, or if for any reason it leaks with pressure, you should just put a suture in the incision.

I like to use scleral incisions, especially if I’m operating superiorly. This comes in handy if you like to operate on the steep axis. And you can do a scleral incision even under topical anesthesia, but it’s helpful if you just create a little bleb, conjunctivally, with 2% Xylocaine, and this gives you really good anesthesia of the sclera. Then you’d like to make your peritomy, and ideally, you’d like to get under Tenon’s, of course, so that you get right to bare sclera in the first pass. This doesn’t always happen, but the more you do it, the more often you are able to get to sclera on the first pass. And then you create a peritomy that’s roughly equal to your incision. You want to cauterize lightly. Too much cauterization can result in some scleral shrinkage and induce astigmatism, and also, it can make your incision gape as well. Now, the incision should be placed 1 or 2 millimeters posterior to the limbus, and you’ve got to be careful not to make this groove too wide. If you make it too wide, and you dissect into clear cornea wider than your keratome, your incision then can leak during the case, and you can lose chamber. We then use a crescent blade carried into clear cornea. You want to go at least another 1.5 millimeters into clear cornea. You check that carefully. And then use your keratome to actually enter the anterior chamber, so you follow the same tract that you’ve made, and again, you tilt the blade so that you’re parallel to the plane of the iris, and enter the anterior chamber. This should give you a rock solid incision. Once again, the incision should be at least as long as the width of the incision.

DR GIMBEL: I’m Howard Gimbel, and it’s a pleasure to share with you some video clips on anterior capsulorrhexis, CCC, and posterior continuous curvilinear capsulorrhexis, PCCC. I think that the globe should always be fixed with the second hand. It can be done with forceps, as illustrated here, or with a fine Thornton ring. My preference is to puncture the capsule with the capsulorrhexis forceps, and then carry it in a counterclockwise direction, but what direction and where to start is entirely surgeon preference. This next clip shows the eye fixed with a fine Thornton ring. You can see the puncture with the capsulorrhexis forceps. A little push ahead creates a triangle with the vertical tear in the capsule that’s easily grasped with the capsulorrhexis forceps. A radial tear perpendicular to the incision can be hard to grasp the edge of the capsulorrhexis. It’s important to size so that optic capture or rhexis fixation, as Tobias Neuhann termed it, can be utilized if necessary, if the posterior capsule is compromised. Rather than puncturing with the forceps, a sharp cystotome is necessary in younger children or in children in general, and in younger adults, where the zonules are loose or traumatized, because there’s no tension on the capsule. And the capsule can be tough in traumatic cases. So this is a traumatic cataract in an 11-year-old, a very cooperative child that we are doing under topical anesthesia. So you can see we’re holding the eye with the second hand. And taking the tear very cautiously. Because the zonules are more elastic, the capsule is more elastic, and one has to stop and inspect to see where the tear is progressing, relieving the tension, because the capsule can be pulled centrally, and the tear be going out farther than expected or visualized. So a much more deliberate, cautious approach in a child and a young person. Trypan Vision Blue is a real asset for the white cataract. The viscoelastic I prefer in this type of cataract in young people, and for me in general, is Healon 5 or Healon GV, a very cohesive viscoelastic. Because it has the most pressure effect to flatten the capsule, to avoid radializing tears when puncturing the capsule, and when taking the tear around the circumference. You can see that with that viscoelastic, the Trypan Blue can be just smeared onto the capsule, under the Healon, without staining the cornea. And I usually aspirate a little bit, which was edited out here. And then add more viscoelastic before starting the capsulorrhexis, to make sure that there’s good pressure to flatten the capsule and keep the contents, if liquid, in the capsule. Do not allow to obscure the view when continuing the tear. So with the proper viscoelastic, one can achieve a successful CCC, even in a very intumescent, liquid cataract. The same techniques for anterior capsulorrhexis can be applied to the posterior capsule. Here you see the completion of a child PCCC, done purposely to use optic capture and avoid secondary opacification of the visual axis. But here’s a young adult with a posterior capsular fibrotic plaque. This could be left and YAG’d later, but also it can be removed with PCCC technique. You saw that after the initial puncture, the Healon is put through the small opening to protect the vitreous face, while the PCCC is continued and completed. So the vitreous is undisturbed, whereas a YAG capsulotomy would disturb it. So anterior and PCCC are essential, and allow capsule fixation if in-bag fixation is not possible. Thank you.

DR FINE: Hydrodissection was first described by Faust and later by Hirschman as a method of mobilizing the lens within the capsular bag. It essentially utilized an injection of fluid through the soft cortical layer of the lens, which then allowed for the nucleus and epinucleus to be rotated. At the time that I was doing phacoemulsification and utilizing hydrodissection, I became aware that the most common way for me to rupture capsules during phacoemulsification surgery was during the cortical clean-up portion of the surgery, and so I became very motivated to find a way of removing the capsular cortical connections during hydrodissection. The technique involves tenting up of the anterior capsule with a 26-gauge cannula that has the bend close to the hub, rather than close to the tip, and then by injecting carefully with continuous pressure a fluid stream under the capsule, peripheral to the cortex, in such a way that the fluid went around the cortical layer of the lens, filled the posterior capsule, and came up to the equatorial region of the lens, where it was stopped by the capsular cortical connections. If one continues to irrigate fluid at that point, the lens will be subluxed or hydroexpressed out of the capsular bag. However, if as the fluid becomes loculated in the posterior capsule and reaches the equator, the lens starts to move forward and the capsulorrhexis appears to enlarge — at that point, if one takes the needle and depresses the lens posteriorly toward the optic nerve, the fluid will be forced circumferentially around the equator of the capsule, and flow out of the capsulorrhexis. It will rupture the capsular cortical connections in the equator of the capsule, as it comes around and flows out of the capsulorrhexis. What one sees immediately is a return to the original size, smaller size, of the capsulorrhexis, and radial striations, as cortical fibers are washed centrally. I usually repeat this in at least an additional distal quadrant, so that I have done cortical cleaving hydrodissection fluid waves in both distal quadrants, and then I will attempt to rotate the lens to document that indeed I have completed my hydrodissection appropriately. At that point, I will perform hydrodelineation. I do that by moving midway between the center of the lens and the edge of the capsulorrhexis, aiming toward the central plate of the lens, and as the lens starts to move, I am aware that I’m at the junction between the soft epinucleus and the more firm endonucleus. At that point, I turn the cannula parallel to the harder endonucleus, and do a backward and forward, to and fro maneuver to create a tunnel at the outer edge of the anterior surface of the endonucleus. I then back the cannula out, leaving about a millimeter of space before I inject, so I am injecting into a relatively empty space, and the fluid coming out of the cannula will find the path of least resistance, which is always the junction between the endonucleus and the epinucleus. I will then repeat that in a second or third quadrant. Usually in a soft lens, one will immediately see a golden ring. In a firmer lens, one might not see a golden ring, because the separation of these two layers is more peripheral, and may be hid by the iris. However, sometimes one will see an arc, a dark arc, and one can then repeat those injections at one or the other edge of the arc, until circumferentially, there has been a contiguous circle of hydrodelineation, demonstrating completion of the separation of the epinucleus from the endonucleus. I then usually rock the nuclear complex to further separate endonuclear/epinuclear connections, and then proceed with the phacoemulsification. Once endolenticular phacoemulsification has been completed, the epinucleus is removed, and for me, I usually remove it by aspirating the roof and rim of the distal quadrant in foot position 2, pulling it centrally, and then, as I go into foot position 3 and mobilize that roof and rim of the epinuclear shell, mini-surges take place, which are associated with a washing around the floor of the epinucleus, of the cortex within that quadrant. I do that in three quadrants, and I use the fourth quadrant of epinuclear roof and rim as a handle. I engage it in foot position 2, pull it centrally, while at the same time, with my second handpiece, push the floor of the epinucleus away from the incision, in such a way as to flip the epinucleus, remove it from its proximity to the posterior capsule, and then aspirate it or remove it with very low powers of phacoemulsification. In about 70% of cases, there is no cortex left after trimming and flipping the epinuclear shell. For those 25% to 30% of cases in which there is cortex remaining, I will do one of several things. The most common method, if there’s a lot of cortex, is to inject Viscoat through the floor of the cortical envelope, and this will result in a spread of the Viscoat laterally and vertically upward in such a way as to drape the floor of the cortical envelope on top of the capsule. One can then implant the IOL. The cortex will drape on top of the optic of the IOL, where it can easily be mobilized, along with residual viscoelastic. This adds incredible safety to cortical clean-up, because it’s almost impossible to rupture the posterior capsule when the cortex is on top of the optic. If I have just a quadrant, I may just remove that with an I and A handpiece, and frequently if there are just a few wispy strands of cortex, I will implant the IOL, and just go after them as I go around removing the residual viscoelastic. The wispy strands are much thinner than cortex that is removed in the usual manner, and as a result, I use a 0.2-millimeter opening in my aspiration handpiece. This is a technique that I first published in 1991, and you will see in some of the following footage the use of scleral tunnel incisions, rather than clear corneal incisions, because I was using this technique at the time. I was still doing scleral tunnel incisions, before I had described clear corneal incisions. This has been an enormous advantage for me, in terms of dramatically reducing the incidence of posterior capsule rupture during phacoemulsification. I hope it turns out to be an advantage for you as well.

The anterior capsule is elevated, and gentle irrigation sends a posterior fluid wave that ruptures posterior capsular cortical connections. The lens bulges and is decompressed, rupturing equatorial and anterior capsular cortical connections. A second fluid wave is sent posteriorly in the opposite quadrant, and once again, the bag is decompressed. The same 26-gauge blunt cannula is used for hydrodelineation, dividing the nucleus circumferentially into a central, more compact nuclear mass, surrounded by a soft epinuclear shell. Following endolenticular phacoemulsification of the central harder portion of the nucleus, the residual epinuclear shell is flipped upside down and aspirated with most of the cortex attached to the epinuclear bowl. In this case, we can see that once the epinucleus is removed, the bag is clean of cortex, except for the quadrant to the right. The cortical connections in that quadrant have been loosened. The posterior capsule will now be polished, and Viscoat will be utilized to drape the cortex over the anterior capsular flap, and then to deepen the capsular bag for lens implantation. The residual cortex will be removed with residual viscoelastic, under the protection of the posterior chamber implant. In a second case, we send a fluid wave posteriorly, resulting once again in bulging of the lens within the capsular bag. This is decompressed, after which a second cortical cleaving hydrodissection injection is done in the opposite inferior quadrant, and once again, the bag is decompressed. The same cannula is used to perform hydrodelineation, which in this case results in a striking golden ring. After removing the central hard portion of the nucleus, the epinuclear shell is flipped and removed, and in this case, we see that the bag is totally clear of any residual cortex.

DR COLVARD: After we’ve made our incisions, we begin the capsulorrhexis. The ideal capsulorrhexis is about 5 millimeters in diameter. This will cover the edges of the intraocular lens and help prevent capsular opacification. If you make the capsulorrhexis smaller than this, it’s really hard for you to get to the nucleus to mobilize the quadrants during phacoemulsification with divide and conquer. And if you make it much wider, you begin to have more difficulty controlling the capsulorrhexis, and it’s easier to lose the rhexis and create a posterior tear. Next we perform hydrodissection. And with hydrodissection, we really create this cortical cleavage that allows you to move the nucleus. You place fluid that lifts the nucleus slightly, then you tamp this down, and this frees the nucleus so that during the case you can place very little stress on the zonules. Now, this is an important thing to do, particularly beginning. I’d like for you to place a little viscoelastic in the anterior chamber, and then using your chopper, check to be sure that the nucleus is spinning freely. Taking that extra moment to do that ensures that you will not be placing a lot of stress on the zonules. If the lens doesn’t move freely, then go ahead and continue your hydrodissection. Then, using moderate flow, low power, and low vacuum, begin sculpting the grooves. Low vacuum will allow you to create the grooves, without engaging or grabbing the nucleus. You start the groove at the proximal margin of the capsulorrhexis and carry the groove across the distal margin. Use a phaco power only as you sculpt forward. This will reduce the phaco time and help to limit the phaco energy released in the anterior chamber. Carry this groove posteriorly, until you see a good fundus reflex. As a rule, the depth of the groove should be about three times the width of the phaco tip. You then rotate the nucleus 90 degrees and repeat the same groove, starting proximally. At the edge of the capsulorrhexis. And then distally to the distal edge of the capsulorrhexis. And what you’re doing, of course, is creating, essentially, a cross or an X, which divides the nucleus into quadrants. When you make these grooves, be sure to carry the groove all the way across the central part of the X, so that you don’t leave a big mound of nuclear material right in the center. This makes cracking the nucleus more difficult. Now, the cracking procedure — put the instruments at the very bottom of the groove and lift up a little bit, and this creates a nice radial crack in the nucleus. So at the very bottom, spread and lift. If you place the instruments too shallow, the crack will not occur. You’ll tend to compress the bottom of the nucleus. Now you switch your device to phaco 2, which has higher vacuum, higher flow, but one of the beauties of divide and conquer is that you don’t have to use very high vacuums in order to bring the nucleus forward, in most instances. And then you take each quadrant out, and you see you have very good stability of the anterior chamber. And you can work in the iris plane. This is not only a very safe technique, but it’s also one that’s very kind to the corneal endothelium.

DR RIEDEL: This video will demonstrate the injection of a capsular tension ring in a case of compromised zonules. Being demonstrated is the universal injector. The eyelid hook can be seen in an extended and retracted position. A StabilEyes 13-millimeter capsular tension ring was utilized in this case. The capsular tension ring container can be used as a platform for loading the ring. A dollop of viscoelastic is placed on the container, and the capsular tension ring is placed in the viscoelastic. This serves to stabilize the ring, while the leading eyelet is captured with the injector hook. The capsular tension ring should be easily withdrawn into the injector, with no evidence of resistance. The injector is then placed into the anterior chamber, and the capsular tension ring is pushed into the capsular bag. Some displacement of the capsular bag can be seen during this part of the procedure. The trailing eyelet usually pops off the hook with ease, but a second instrument can be used as needed to facilitate this maneuver. This is a case of a routine phacoemulsification with obvious zonular instability. During the initiation of the capsulorrhexis, the cystotome produces significant striae. In addition, the nucleus can be seen to wobble slightly. These are clear signs of zonular instability. In addition, during phacoemulsification, the nucleus can be seen pulling to the surgeon’s right with a large gap noted to surgeon’s left. This is an indication of either absent or significantly weakened zonules. Phacoemulsification and irrigation and aspiration were gently used to remove the remaining nuclear fragments. At this point, it was determined that a capsular tension ring could be safely inserted. In this case, a Morcher 14C ring was utilized. The capsular tension ring is placed on a small dollop of viscoelastic to allow the eyelets to overhang the well. The injector hook can then easily grasp one eyelet and pull the capsular tension ring into the device. The inserter will then be placed into the anterior chamber, and the capsular tension ring will be injected into the bag. During this maneuver, the anterior capsulorrhexis will be noted to displace slightly. This can be slightly unnerving to the novice surgeon, but is typical of capsular tension ring placement. The trailing eyelet usually pops off the injector hook, as demonstrated in this case, but occasionally a second instrument must be utilized. As evidenced here, a significant increase in stability of the bag is noted after placement of the capsular tension ring. This allowed for easy and safe removal of the remaining cortical material. This case has demonstrated some of the classic findings of zonular instability in a routine phacoemulsification case.

MS TAYLOR: We’re gonna demonstrate loading AMO’s Tecnis one-piece acrylic IOL. We’re gonna be using the One Series cartridge, and the Emerald Series AR injector system, and it has a series of grooves in the plunger, which causes an advance and retract cycle in the plunger tip, while the implanter just rotates forward in a twist motion. So taking the One Series cartridge, the ZCB00 lens can be lifted from its packaging materials, and placed next to the cartridge itself. The barrel and the channels of the cartridge are filled with viscoelastic. There’s no need to place OVD on top of the optic or the haptics themselves. The lens is then lifted and placed into the cartridge channel, immediately adjacent to the picture of the lens on the cartridge wing. The far side or the distal side of the lens can be held down gently, as the wing of the cartridge is lifted upwards, folding both edges of the optic underneath the channel ridges. The leading haptic can be folded back onto the optic itself, lifting the wings of the cartridge slightly, to hold it in place. The trailing haptic can be folded upwards as well, forward, onto the optic. The whole unit can be held in place as the wings are lifted, closing the cartridge. We want to ensure that the haptics are not caught within the wings themselves. The whole unit is then placed within the tip of the injector. The plunger, with its unique ridges that causes that advance-retract motion, is pushed forward, engaging. The plunger is pushed forward, causing that advance-retract action, while the implanter is simple rotating forward. Being acrylic, the action is very stiff. Then the lens is delivered into the eye.

This is the Emerald Series Unfolder. It’s for AMO’s three-piece acrylics. The ZA9003, AR40E, and NxJ1. Fill the cartridge, this barrel and two channels, with viscoelastic. And a dollop in the middle. With a smooth lens loading forceps, you can lift the lens from its packaging. And place it in the center of those two channels. You want to press down on the sides of the optic, trapping the acrylic optic underneath the ledges. This lens wants to fold upwards instead of downwards, just what you want, so you need to press on the center of the optic, while lifting the wings of the cartridge, to get that to kind of taco or fold downwards instead of upwards. Guide the leading haptic into the barrel of the cartridge. And make sure that trailing is out, which is easily does. Fold it and insert it snugly into the injector. Ensure that the trailing haptic is up over the side of the cartridge. At the injector. So that it will not be caught by the plunger. Advance the lens with a twisting motion. It’s a very stiff acrylic lens, so the action is going to be very stiff, both during loading and injection of the lens into the eye. And just stop before the leading haptic exits the tip of the cartridge.

This is the AMO Silver Series Unfolder for the Clariflex SA40 array and Z9002 IOLs. The first step is to place the Teflon tip on the injector rod and ensure that it is secured in place. The cartridge is then removed from the packaging, and the barrel of the cartridge is filled with viscoelastic. The two channels on either side of the wings are also filled with viscoelastic, and a small dollop is added on the central ridge. Using a smooth lens-loading forceps, the lens is removed from the package. In this case, the lens is inverted upside down, but it will be placed in its proper orientation. And it’s transferred to the center of the cartridge, resting on the central ridge. Initially holding the wings of the two channels spread wide, depress the sides of the optic under the ledges of the two channels, and then bringing the wings partially together, this will hold the lens in place. Place the leading haptic inside the barrel, trapping it in an extended position. And check that the trailing haptic exits the rear of the cartridge. Close the wings of the cartridge, and then inspect the leading haptic to ensure that it is in an extended position. Next, insert the cartridge firmly into the injector, ensuring that the trailing haptic rests to the side of the injector, out of the way of the plunger. Advance the plunger, moving the lens forward toward the tip of the cartridge, stopping before the leading haptic exits the tip. The action should be very smooth, which is characteristic of foldable silicone intraocular lenses.

This is Alcon’s single-piece acrylic loading system. It’s a green Monarch 2, and it uses a C cartridge. There’s a little C on the cartridge, on one of the trailing pieces, as well as showing a picture of the orientation of the lens. First, fill the cartridge about 2/3 full with viscoelastic of some sort. Put some dots of viscoelastic on the trailing, leading, and optic, to help facilitate the unfolding of this lens later, when it’s in the eye. Lift the lens from its packaging. And using the back end of the cartridge, fold the leading haptic over the optic, as it’s inserted into the opening of the cartridge. Advance the lens with your smooth forceps, until just the trailing haptic sticks out, and then fold that one up over the optic as well, capturing it inside. Advance the lens within the cartridge, trapping those haptics up over the optic. Snap the cartridge into the injector. And advance the lens up the cartridge. There’s a twist action to get it to get right to the tip.

This Purple Monarch system uses a B cartridge, and it does say B right on the packaging. But it also has a little B right on the cartridge itself. It’s a little bit larger cartridge than for the Green Monarch system. This is used for loading Alcon’s three-piece acrylic lenses. MA30AC, MA60D3. Start by filling the cartridge full of viscoelastic. Here’s a little picture of the correct orientation of the lens on this cartridge. It’s about 2/3 full of viscoelastic. And with a smooth lens loading forceps, lift the lens from this packaging. And insert into the cartridge. Press down on the center of the optic with the smooth forceps, sliding the lens forward only enough — so only enough of the trailing haptic is left out to hook onto the plastic prong at the rear of the cartridge. Just that tailing portion is sticking out. We call this the bird perch, like a little bird sitting on a perch. So there is just the tip of that trailing haptic. Right around that little plastic prong. Snap the cartridge firmly into the injector. And advance the plunger and lens in a twist action until the leading haptic is seen to be nearing the front of the cartridge.

This is Bausch and Lomb’s three-piece silicone lens loading system. It’s called a preloaded lens. The lens comes in a little plastic preloaded cartridge cassette bank that is snapped into the injector. So this is the Easy28 disposable cartridge unit/injector together. So this one starts with a generous bed of viscoelastic, with special attention under this ridge. This is where the optic will be placed. Before placing the optic, the lens itself, you want to make sure that the plunger tip and the leading haptic puller are just exactly adjacent to where the lens is gonna go. The lens comes in this little cartridge. The top is removed with a rocking motion. There’s the lens. The white label is to the right of the tip, facing away from the folding plunger. So it snaps right on. This part of the pre-lens loaded system is right adjacent to this little tab down here, on both sides. So lifting up on this little stop, you want to advance this folding plunger, until it stops against the cartridge, right here. Watch that. It stops. And then again with a rocking motion take off the preloaded top, and the lens will stay where it belongs. At this point, you want to make sure that the lens’s haptics are overlying or on top of the leading haptic puller in the plunger. It looks like it did end up that way. You might have to manipulate them just a little bit, if they’re not there. And then continue to depress the lens folding tab or plunger all the way. Next, advance the lens, and you’ll want to be watching all the way, so that all the haptics are going together, and see through the plastic, where the trailing and the leading haptic are advancing, all as one unit. If they don’t for some reason, it’ll be pretty easy to see that the lens — the haptics are crunched in there. And they’re not. So once it gets a little further down, you want to leave room to unfurl that leading haptic with the puller. It’s easiest if you push down a little bit, which gets that little pulling nub up against and ensures that you’re actually pulling out the leading haptic. And then backfill the tip with viscoelastic. You can see that all the haptics are undamaged in here.

DR HOFFMAN: When folding acrylic or silicone intraocular lenses manually, we ordinarily would use two separate instruments: A loading instrument such as the Nichamin III loader, and an inserting instrument. In this case, the Nichamin II inserter. Lenses can be folded in three different configurations. When folding a lens across the 12 and 6 o’clock axis, the lens is first placed on a hard surface, and then, using the loading instrument, the lens is grasped and folded so that the fold is across the 6 and 12 o’clock meridian. In this case, the lens will be folded in a configuration that gives a leading and trailing haptic. This configuration is ideal for placing a lens in the ciliary sulcus. Ordinarily, when we implant foldable lenses, the fold is placed to the right during insertion into the eye. However, when a lens is folded across the 12 and 6 o’clock axis, the fold is placed to the left, so that when the lens is inserted into the eye and unfolded, the leading haptic is placed under the anterior capsulorrhexis or under the iris, and the lens will unfold in the proper orientation. Folding a lens across the 3 and 9 o’clock axis will result in a configuration with both haptics pointed inferiorly. This configuration is ideal for inserting a lens into the eye with the haptics behind the iris, and the optic captured in front of the pupil for iris fixation. This configuration can also be used for placing the lens in the capsular bag. When folding a lens obliquely across the 10 o’clock and 4 o’clock axis, both haptics will again be oriented downward, in this case in a saber configuration. This configuration is ideal for placing the lens in the capsular bag. After insertion into the eye, both haptics are placed through the anterior capsulorrhexis, and the fold is then placed superiorly, and as the lens is unfolded, the haptics will draw the optic down through the anterior capsulorrhexis, so that dialing of the trailing haptic is not necessary.

The AMO Tecnis single piece acrylic intraocular lens can be easily injected through a 2.7-millimeter incision, utilizing the Unfolder Emerald Series AR injection system. Clockwise rotation of the injector handle causes an initial clicking sensation, as the patented grooves within the piston alternate an advance and retract motion of the insertion rod. This motion prevents override of the IOL with the injector rod, and so the IOL is advanced into the injector cartridge, at which time the rod movement becomes a smooth advance motion. The acrylic IOL slowly unfolds within the capsular bag. Placement and centration of the IOL can be accomplished with a Lester hook, or the irrigation and aspiration cannula.

In this example, the entire intraocular lens will be injected into the eye using the cartridge injector. The leading haptic of this acrylic ReZoom lens is injected into the capsular bag, with the haptic pointed to the left in the proper orientation. The lens is then placed within the capsular bag, and the injector rod is retracted beyond the trailing haptic, and then injected through the opening of the cartridge, placing the trailing haptic within the capsular bag, through the anterior capsulorrhexis.

Supporting the globe with a blunt instrument placed through the paracentesis, the cartridge is inserted through the main incision, and the lens is injected into the eye with the leading haptic in the proper orientation directed to the left. The optic is then unfolded within the capsular bag, and the injector rod and cartridge are removed from the globe. The lens is dialed into the capsular bag by placing a Lester hook at the junction of the optic and the trailing haptic, and with a slight downward pressure, a clockwise rotation of the haptic will place the trailing haptic through the anterior rhexis, and the entire lens will be in the capsular bag.

This is a patient who developed a capsular tear early in her surgical procedure, and eventually required implantation of a sulcus IOL. A bimanual microincision phacoemulsification technique is being utilized in this patient. The first chop was made without any problem, and it is most likely during the second chop that a tear in the posterior capsule was created. You can see with removing of this quadrant of endonucleus that there is an enhanced red reflex, corresponding to an opening in the posterior epinucleus, and most likely the posterior capsule. At the time of the procedure, there was no difficulty noted. However, during trimming of the epinucleus, it became apparent that there was a discontinuity in the posterior capsule. It is at this part of the procedure where most novice surgeons make the same mistake: We remove the instruments from the eye and look down in disbelief, as the vitreous comes forward through the opening in the posterior capsule and pours out of our incisions. The secret for dealing with a torn posterior capsule, whether proceeding with a bimanual or a coaxial technique, is to keep the infusion in the eye and keep the eye pressurized. Under most circumstances, a pressurized eye will keep the vitreous from coming forward through the opening in the posterior capsule. In this case, as much epinuclear material as possible is removed with the bare phaco needle, and then a dispersive viscoelastic is injected into the capsular bag, as the irrigator is left in the eye. Once the posterior capsule is tamponaded with the viscoelastic and the eye is pressurized, the irrigator can then be removed safely with less likelihood of prolapse of vitreous into the anterior chamber. A side-irrigating cannula is gonna be placed through the right hand incision, and then the aspirating cannula is placed through the left hand incision, and using this bimanual technique, the cortex is then removed, starting with the cortex most distal from the tear in the upper left quadrant. If vitreous presented, the irrigator would be left in the eye, and a bare vitrector would be placed through the left hand incision, followed by tamponade of the posterior capsule with additional viscoelastic. But in this case, all of the lens material was removed without vitreous loss. Again, the irrigator is left in the eye, and additional viscoelastic is placed in the capsular bag to tamponade the large tear in the posterior capsule. A small quantity of viscoelastic is placed between the anterior capsule and the iris to facilitate sulcus implantation. The incision is widened to approximately 3 millimeters, so that no stress is placed on the globe during insertion of the cartridge injector. The secret for implanting a lens in the sulcus using a cartridge injector is to inject the lens with the leading haptic in the proper orientation, directed to the left, and place the leading haptic underneath the iris, in front of the anterior capsulorrhexis, and as the lens optic is unfolding, place the optic under the iris, so that it does not flip in the upside down configuration. Once the optic is unfolded, the trailing haptic can then be dialed safely into the sulcus, between the anterior capsule and the iris. The optic is then centered and prolapsed through the anterior capsulorrhexis, using the Lester hook to depress each edge of the optic, posteriorly. When the optic is captured through the anterior capsulorrhexis, aspiration of residual viscoelastic material can then be performed safely, using the I and A handpiece, with less likelihood of vitreous coming into the anterior chamber. This is followed by injection of Miochol, and then stromal hydration, to facilitate self-sealing of the clear corneal incision. This is another example of a torn posterior capsule that was not appreciated until after the epinuclear material was removed from the eye. The irrigating chopper is left in the anterior chamber, and as much epinuclear material as possible is removed with the bare phacoemulsification needle. A dispersive viscoelastic is then injected into the capsular bag to tamponade the tear in the posterior capsule, and the irrigating chopper is removed from the globe. Bimanual irrigation and aspiration is then utilized to remove the remaining cortical material. By keeping the eye inflated throughout the entire procedure, the vitreous remains in the posterior chamber. Viscoelastic is placed between the anterior capsule and the iris, distal to the incision, and in the subincisional area, to aid in implantation of the foldable IOL into the ciliary sulcus. An incision slightly larger than usual is made to avoid excessive pressure on the globe, which should keep the vitreous from prolapsing into the anterior chamber. The lens is injected with the leading haptic directed to the left, and as the optic unfolds, it is pushed under the iris, so that it will remain in the proper orientation. The trailing haptic is then easily dialed into the ciliary sulcus, using a Lester hook. The optic is prolapsed through the anterior capsulorrhexis, and residual viscoelastic is removed, using the I and A handpiece.

March 1, 2018

Last Updated: October 31, 2022

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