During this live webinar, different phaco techniques for different kinds of cataract, from soft, medium to hard, brown or black, posterior polar, intumescent, or with weak zonules are discussed.

Lecturer: John E. Downing, MD, FACS, Clinical Professor at Vanderbilt University School of Medicine. In private practice in Bowling Green, KY, USA

Transcript

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DR DOWNING: Okay. Good morning! Happy you could join us this morning. I want to talk a little bit about the need for learning different kinds of techniques for phacoemulsification. Now, as you begin doing it, you will find a technique that works for you most of the time, and that’s what you’ll use most of the time. But there are special circumstances where you need to learn to do cataracts in different ways to avoid different problems. Divide and conquer is a technique that’s very old, but still works very well. And it’s still the favorite technique for many experienced phaco surgeons. It’s usually safe, it’s relatively easy to learn, and it’s a good fallback if you’re having a problem with another technique, often. To do divide and conquer, you make four deep grooves in the cataract, in a cross shape. Then you separate these into quadrants and emulsify each quadrant. You can handle them usually pretty easily that way, and rotate them. And this is an example of a divide and conquer technique. I already made the capsulorrhexis, done hydrodissection. You want to make sure the lens will rotate freely, because you have to bring the material around in front of the phaco tip. Vacuum off any soft cortex or epinucleus off of the hard nucleus. And then make deep grooves, centrally. You want to go in phaco while you’re going forward. Go back to irrigation or just aspiration on the movement back toward you. You don’t want to stay in phaco. And then you get down to where you have a good red reflex. Put your two instruments in the groove. And separate. And you can usually see that it’s cracking. If it doesn’t crack, it almost always means you’re just not deep enough. So you have to go back and deepen until you have a good even red reflex all the way across. But usually do it very slowly when you get deep. Then crack your second quadrant, rotate another 90 degrees, and deepen and extend that first groove that you made in the other direction. It’s a good idea to make your grooves a little wider than your phaco tip. Because you have your sleeve, and you can see better that way. Generally try to make it about one and a half widths of the phaco tip, to be able to get down in it and see exactly where you are better. But only go into phaco while you’re going forward. Gently separate. And you can see it split. Then we’re going around one more time. And go into your quadrant removal mode, with increased power and vacuum. And emulsify each quadrant. Just rotate it around in front of you, and work over remaining lens material as much as you can, to keep the chamber — the posterior chamber — deep and the capsule back. When you get close to the end, make sure that you keep your second instrument deep to your phaco, so that if you do get a surge at the very end, you won’t grab capsule and tear it. Then you just remove cortex, put in viscoelastic, insert your lens. It’s a good idea, after you’re pretty experienced with one technique — say the divide and conquer — to learn some chopping techniques. Chop mechanically substitutes phaco energy for mechanical energy. So you use a lot less phaco energy. It’s usually a little bit faster, once you learn to do it. And a good transition, going from divide and conquer to a chop technique, is Koch’s stop and chop.>> And use my chop to split the nucleus in two. Just like I would for any typical nuclear cracking technique. And then I stop! (squealing brakes) and from now on, I chop. I rotate the nucleus clockwise, about 30 degrees. I bury the phaco tip about a third of the way across the nuclear half, stick in my chopper, and chop. A nuclear piece is chopped off, and is already impaled on the phaco tip. A burst of phaco energy, and it’s gone. I rotate the nucleus some more. And chop off another small piece. I buzz this. And it’s gone. I continue to work my way around the cataract. Bury the chopper, pull it towards the tip, chop! Separate. Remove. Bury the chopper. Pull it towards the tip. Chop. Separate. Remove. Bury the chopper. Pull it towards the tip. Chop. Separate. Remove. The pieces come easily. They are not trapped together like a jigsaw puzzle. The operation is easy! If I have a very hard cataract, I just chop it into smaller pieces. If I have a soft cataract, I can chop it into bigger pieces, if it needs to be chopped at all. And more than anything I’ve done before, this procedure is safe, accurate, and reproducible.

DR DOWNING: And it’s usually relatively easy to do a stop and chop, in moderately hard cataracts. If they’re very soft or very hard, it’s a little more difficult. For harder lenses, Dr. Richard MacKool makes a pit in the center of the lens, to be able to hold it better with the phaco tip, and then chops off pieces. And this does usually work pretty well for harder cataracts.

>> My hydrodissection cannula is elevated. The nucleus flows up. Push it back down. Do the same thing on the other side.

DR DOWNING: He’s just making sure he has good hydrodissection. And then he injects some viscoelastic under the capsule, nasally. It gives you some space. Helps you avoid tearing the anterior capsule also.

>> That incision is now sealed. It’s not leaking.

DR DOWNING: And that’s what you want in phaco, is you want a stable chamber and a sealed wound, with very little leakage.

>> The handpiece cuts through it easily. Here I’m impaling using 250 millimeters of vacuum. I hold it still as I chop.

DR DOWNING: And with hard cataracts particularly, it’s a good idea to chop your pieces all the way around, before you start removing pieces. It helps them rotate better.

>> Quadrant removal.

DR DOWNING: So he’s increasing his power and his vacuum.

>> You can see the vacuum in both settings. You can see the infusion bottle height is around 130. I also feel the zonule is a little on the lax side here. I’m gonna draw this quadrant centrally and then remove it. Now, if you watch carefully, you’ll notice absence of chattering and torsional. The next segment I’m gonna remove using traditional ultrasound. This is all traditional ultrasound.

DR DOWNING: Longitudinal ultrasound.

>> You can see the brunescence out to the crater of this lens.

DR DOWNING: Just removed the pieces a little bit at a time.

>> If you run that video in slow motion later, you’ll see how the last piece chattered a little bit. Back to torsional. Just remove alternate segments. This is torsional. Absence of chattering will be obvious to you. Back to traditional ultrasound. This is a burst of 30%. I think you can also see that this is not removing the nucleus as efficiently as torsional. It’s slower. If I go to higher power, I’ll get more chattering. So right now I stay at 30%. See the chattering of that piece? And now let’s go to torsional. In the last quadrant here.

DR DOWNING: You want to hold the pieces on with vacuum, and then just use ultrasound for a second or two at a time. Then go back to aspiration and hold it as the vacuum builds, and then phaco another second or two. But only go into phaco when you have material held on the tip. Dr. David Chang pioneered a procedure called horizontal quick chop, where you don’t have to make a groove. It’s usually very quick. It’s also a little bit scary at first, because you have to pass the chopper under the iris peripherally, where you can’t really see it. So you have to feel it. Initially it’s good to only use it on pupils that dilate really well, and often you can see out the equator with those. The horizontal quick chop works well with a large variety of cataracts. You don’t do any grooving. But you must penetrate and hold the lens firmly with vacuum, before you pull the chopper in toward the tip, and separate. Dr. Chang has an excellent book, Phaco Chop, which gives detailed tutorials on learning how to do quick chop. And there are also quite a few videos on YouTube. Vacuum off the cortex and anterior epinucleus. Pass your chopper out to the equator. Burrow in with your phaco. Let the vacuum build. Just bring your chopper in straight to the tip, and separate. Then you can pull a piece in and emulsify it. Chop off another piece. And hold it centrally, and emulsify it. In all phaco techniques, you want to keep the depth of your phaco tip about iris level. At that level, you’re about equal distance from the endothelium and the posterior capsule. It’s the safest area to work. And again, work over remaining pieces of lens material as long as you can, because this keeps the bag open and holds the capsule back, so you don’t aspirate it. Some movement like that, I think, frequently helps reposition material. And we’ll go into mostly aspiration, epinucleus mode, and remove the epinucleus. And sometimes if you get good cortical cleaving hydrodissection, you don’t have any remaining cortex. Doesn’t happen frequently, but it’s nice when it does. Vertical quick chop is a variation on the chopping technique. Usually works better with harder cataracts than horizontal chop does. Because with horizontal chop, sometimes with very hard nuclei, you’ll leave a large posterior plate. It doesn’t go all the way through to the capsule. And it can be pretty difficult to manage sometimes. One way to handle it is to inject viscoelastic under it, to bring it forward, so you don’t have to be back, pushing on the capsule. But vertical chop usually splits all the way, because there’s the natural cleavage plane, if you remember how the lens forms — then there are natural vertical cleavage planes. So here’s Dr. Chang, doing his vertical quick chop.

>> Phaco quick chop. We impale the nucleus with the phaco tip. We use a very sharp-tipped chopper, like a Sinskey hook with a sharp tip, to descend right into the nucleus, creating a fracture that we can extend all the way through the posterior plate, with sideways separation of the tip. You can see this go all the way back to the posterior part of the nucleus. In this way, we actually bisect the nucleus completely in half, without having to do any sculpting, even with a very thick, dense, brunescent lens such as this. This process is then repeated over and over again, until we have divided the nucleus into progressively smaller, pie-shaped pieces, again, without the requirement for doing any sculpting. This particular case I will show you unedited, so that you can see just how efficient and consistent a process this is. This technique is good for dense lenses, because, unlike with horizontal chopping, where the instrument tips move towards each other in the horizontal plane, here the instrument tips move towards each other in the vertical plane, and this gets this fracture started in a direction that is gonna pass from front to back. One obvious benefit is that we are really reducing the phaco time and power enormously by not having to do sculpting, and instead relying on manual energy to fragment the nucleus. Now, once we pull this piece out, I’m gonna switch to the other end of the double ended chopper that bears my name. This is a Microfinger, and what I’ve just demonstrated here I call horizontal chopping, where you hook the equator of the material. Once you have little free-floating fragments, this works better, because with horizontal chopping, you’re sandwiching the piece of nucleus in between the two instrument tips, so that it cannot escape. I now change to another memory setting, phaco 2, which works better here for aspirating the creases out of the capsular bag. This particular setting uses a new phaco modality called WhiteStar, and this is a cold phaco modality. In other words, there is no heat generated by the tip, because of the unique pulse mode paradigm that it comes with. It’s like a hyperpulse mode, so that instead of the six pulses per second, we’re approaching more in the range of 50 pulses per second, whereby the heat never really builds up, and you avoid cavitation, so there’s no — pulling cavitation away that tends to drive lenses away from the tip. Another advantage you can see here in the phaco chop is that we really reduce stress on the capsule and on the zonules. Because all the energy is not only manual, but the manual forces are directed inwardly, one instrument against the other instrument. There’s no movement to push the lens into the capsule or the zonule, which is what really occurs during sculpting of a very brunescent lens. So in addition to reducing phaco power, it increases our safety in this situation. So high vacuum gives us good purchase up here. Although the inclusions are partial. It helps to reduce the amount of phaco energy needed to move pieces through the tip. But as we get less and less nucleus still left in the eye, we’re going to move to a third setting, whereby the vacuum is gonna be reduced down to 200 millimeters of mercury. In the cornea you see phaco 3 now. It’s this third memory setting. So we want to avoid any surge, because the posterior capsule is now exposed, since all of the nucleus and epinucleus is gone. In the middle of the left hand side, you see the phaco time is down below 9 seconds.

DR DOWNING: Sometimes you’re going to run into patients with loose zonules, either from trauma or problems like pseudoexfoliation or patients with retinitis pigmentosa. They typically have very loose zonules. Rotating the lens after hydrodissection, so you can bring pieces around to get to them with the phaco tip, is stressful to the zonules. And in cases with weak zonules, there are techniques that you can do where you hydrodissect and hydrodelineate, but don’t rotate, and this is one.

>> A vertical groove is created slightly to the right of the center of the nucleus. Grooving is performed at zero vacuum, approximately 80% to 90% of the nucleus. Know that we are making a vertical groove in the nucleus. But that is not in the center of the nucleus. It’s offset. To the right, approximately 30% of the radius of the nucleus. What we want to do is we want to divide the nucleus into three roughly equal pieces by volume.

>> Additional viscoelastic is inserted, and the groove is split with a nuclear crack.

>> Now we have roughly one third to the right and two thirds here. We then make a second groove at approximately a 30-degree angle to the first groove. And roughly 80 to 90 (inaudible).

>> The second groove is cracked after additional viscoelastic. In approximately three roughly equal pieces.

>> The one in the center is shaped like a piece of pie.

>> A Sinskey hook is used to position the pieces of nucleus. The central fragment is displaced under high vacuum. High vacuum and minimal phaco power are used for movement.

>> Once that fragment is taken in, you can often turn down the vacuum and do aspiration and take in the second two fragments, which usually come easily. Note the fragment to the right is now spontaneously dislodged by the movement of the two of them. And we did not have to do any manipulation to free that fragment. Approximately 30% of the radius from the center of the nucleus to the right, 30% of the way, and make the first groove, you then swing over at a 30-degree angle, and make the second groove, and that will give you three equal pieces.

DR DOWNING: And you can hydrodissect or viscodissect the side piece, if they aren’t freed up. And it can be a very useful tool. There’s a procedure called prechop, which Dr. Akahoshi invented, and it works very well with soft lenses, works well with lenses up to at least between a grade 2 and 3. Above that, it’s hard to get into the nucleus with the prechopper, unless you use a counterchop, which you can do. But I like it for softer to moderately hard lenses. And this is what a chopper looks like. You have a sharp tip. This is a blunt side here. And it’s a cross section. So when you squeeze, it separates the two end pieces. Okay. And this is showing you a little more of the case. It’s doing the capsulorrhexis to begin with. Then hydrodissection. There’s a fluid wave across, then gently depress and let that fluid come around forward. And putting some more viscoelastic on top, and you penetrate with your sharp tip, and split, then split the proximal piece, and the distal one. And then he goes back sometimes and splits those end pieces, which makes it easier to get those out, since they’re smaller. And works pretty much anteriorly, to remove the pieces. And they’ll usually start to come in very nicely like that. So this can be a very quick and a very efficient way of doing phacoemulsification. Here’s another. It’s really nice, the way that they usually split like that. And they usually split all the way through. And this one, he didn’t make a second chop there. Still was able to pull these forward. Chop nasally — it does help. Okay. And inserting a foldable lens. And this is a multifocal. You can see it very nicely in the bag. Posterior polar cataracts are a whole different animal. Posterior polar cataracts are congenital cataracts, which have a plaque on or in the posterior capsule. Now, they usually don’t interfere much with vision, unless you begin to get posterior subcapsular plaques around them. This frequently seems to happen in a patient’s 30s or 40s. And you need to use a different technique. You need to work from the inside out. Do not hydrodissect! You hydrodelineate. Work from the center out. And this is showing Dr. Uday Devgan’s technique for doing posterior cataracts, which works very well. And these are examples of posterior polar cataracts.

>> In this case, we see a primarily posterior polar cataract, with surrounding posterior subcapsular changes. These recent PSC opacities have caused the patient to seek cataract surgery. We’ll go ahead and we’ll perform hydrodelineation.

DR DOWNING: He’s going down to hard nucleus and hydrodelineating it from the cortex and epinucleus.

>> This can be accomplished by keeping the cannula within the confines of the capsulorrhexis. The central endonucleus is then removed with the phaco probe. Any technique is acceptable here, as long as we’re careful not to exert pressure on the posterior capsule. Once the endonucleus is removed, we’ll use OcuCoat, which is a very dispersive viscoelastic, to viscodissect. We’re dissecting between the anterior capsular rim and the cortex and remaining lens endonucleus. We do this in all four quadrants, and in this manner, we’ve completely loosened up all cortex and all endonucleus without ever touching the posterior capsule. We then place the IA probe in the eye, keeping it very central and away from the capsule at all times, and we simply aspirate the epinucleus and cortex which remain. In these cases of posterior polar cataract, the posterior capsule tends to be really weak and very fragile at the site of the opacity, and sometimes even absent it. But using the OcuCoat for viscodissection, we’re able to perform a very slow and controlled separation of the lens cortex and epinucleus, away from the capsule. In addition, we never ever have to touch the posterior capsule. If there is a slight break of the capsule, the OcuCoat, as it dissects posteriorly, will automatically tamponade this area. Once the lens cortex is finally removed, we can use the capsular bag to implant the lens. While implanting the lens, it’s important to use a technique that doesn’t exert stress or strain on the posterior capsule. In this case, we’re using the Soflex lens, with the end port injector, which places it in a planar manner. Thanks for your time.

DR DOWNING: So you use a dispersive viscoelastic, like OcuCoat or Viscoat, and work inside out. After you get all the central part, then you viscodissect under the capsule with the dispersive viscoelastic, to separate it from the plaque, and that also helps cover the plaque and protect it. Intumescent cataracts are also a different problem. These are very mature cataracts. Hypermature, often. They have liquefied cortex around the very central hard nucleus, which is very hard, actually, and the liquid cortex absorbs fluid, apparently, because you have increased pressure in them. When you’re trying to do a capsulotomy, they can tear out peripherally and around, and you can lose a nucleus pretty easily. If you’re using Trypan Blue and they tear out, you get what’s called the Argentinian Flag Sign, which is a strip of blue with white on either side. And we’ll show you that. It’s very important to pressurize the anterior chamber with viscoelastic to counteract the pressure inside the lens. And initially just make a small opening. A small X incision decreases the peripheral forces just a couple of millimeters. Then you want to aspirate the liquid cortex. You have to rock the lens and try to get as much of the liquid cortex from behind the hard nucleus as possible. Otherwise, you’ll still have increased pressure. Then, once you get rid of the excess pressure, you can make a capsulorrhexis and proceed. It’s a little easier to make the capsulorrhexis if you fill the capsular bag with viscoelastic, before making it. It’s easier to pull against.

>> There are various types of cataract. The one that creates fear in a beginner surgeon’s mind is an intumescent cataract, because it makes the CCC a difficult one. The difference between a normal lens and an intumescent cataractous lens is the raised intralenticular pressure, which makes the CCC difficult. The cataract looks mature on cross examination, but on slit examination, the anterior cortex and nucleus appears clear, while there is a fluid collection between cortex and the posterior capsule. This is the first stage of intumescent cataract, where the fluids start forming between cortex and the capsule. With time, the entire lens becomes soggy, and it becomes full blown intumescent cataract. With increasing intralenticular pressure, there is also shallowing of anterior chamber, and later it may give rise to glaucoma. We have to protect the shallow anterior chamber and increased intralenticular pressure. So how to tame this intumescent cataract? Let’s go step by step. Step one: First we have to create two small side port incisions and then do proper staining of the capsule. Creating these small side ports helps us in having control in the anterior chamber, because viscoelastic will not come out through these small incisions. Also, a good staining of capsule under air, using Trypan Blue, is important, because this staining makes the capsule a little bit thicker, and also, it is easy to maneuver a stained capsule. So this is how we stain the anterior capsule, using Trypan Blue for 20 to 30 seconds. If we don’t do closed chamber maneuvers, as in this case, I’m trying to achieve CCC with open incision. There is a higher risk of radial extension of the tear.

DR DOWNING: And there’s the Argentinean Flag Sign.

>> Step two. Visco attack. To counteract the intralenticular pressure, the technique of my choice is using soft shell technique. In soft shell techniques, we use a high density dispersive agent such as Viscoat and below this, over the anterior capsule, we’ll inject a high molecular weight cohesive viscoelastic such as hyaluronic acid. Until the anterior chamber is filled.

DR DOWNING: Healon 5 works very well, if you have it available.

>> There is a counterpressure which is created over the anterior capsule, to counteract the raised intralenticular pressure. To demonstrate this technique, I’m injecting Viscoat until the air bubble is out. After Viscoat is injected, I am injecting hyaluronic acid over the anterior lens capsule. Step three. Cruciate puncture. Now, once you make an opening in the anterior capsule, because there is a pressure gradient between the intralenticular elements and the outside of the chamber, there is a tendency of the fluid inside the lens to flow out through this opening, and during this movement there is a high chance that there might be radial extension of the opening. When you make a single opening, there is more forces interacting on the edges, which makes the radial extension easier. But if you make a cruciate kind of incision, where there are multiple tears in the center, the force gets divided, and there is a less likelihood of extension of any of the tears. To demonstrate here, I have made a cruciate incision in the center of the anterior capsule. Because of the cruciate incision and also presence of high molecular weight viscoelastic in the soft shell technique, the fluid comes out through this opening very, very slowly, in a controlled manner, and also, there is no radial extension. Step four: Deflate and tap. Now, initially, we have to use 27-gauge cannula to aspirate out the anterior cortex, and then we have to tap the nucleus down, so that the fluid trapped between the nucleus, cortex, and the posterior capsule comes out into the anterior part. These maneuvers will help us taking that intralenticular pressure down. So this is how we do it. We use 27-gauge cannula, again from this small side port, to take out the midperipheral cortex. By doing that, we also tap the nucleus down. Once a bit of cortex is out, we again inflate the anterior chamber, and again we go from the other side port to take out the cortex from the other part of the lens. If we don’t do that, then there might still be some intumescent left at the other part of the lens, from where there might be some radial extension. Step five: Strokes from the periphery. Despite taking out the cortex from anterior and posterior part of the lens, there are still some fluid pockets left in the periphery. And these pockets can cause radial extension. To remove these pockets, we have to gently nudge the peripheral capsule, using visco-cannula. Flattening it out. Also inject a little bit of Viscoat on this, so that at the end of the step, the anterior capsule will become flat all throughout. So this is the tamed lens, with no intumescence left. Now we can use the cystotome or Micro Capsulorhexis forceps. Doing CCC in this stage is very, very easy, because there is no intumescence left. So there is no need…

DR DOWNING: Then you can remove the remaining hard nucleus using any technique that you wish. Sometimes it’s rock hard. Sometimes it’s very soft. Dark brown or black cataracts are a problem. These are usually very hard. They usually have a large nucleus, but little or no cortex and weak zonules. So in my experience, it’s been safer to go ahead and do the manual small incision extracapsular incision in dark brown or black cataracts, rather than phaco. Otherwise you have a high risk of losing the nucleus back in the vitreous. Questions. Number one. And if you will answer these, one, two, three, or four: What is a good basic technique for learning to do phaco? Vertical chop. The Koch stop and chop. Prechop. Or divide and conquer. Click on your answer, and then we’ll see how much agreement we have here. Divide and conquer. Okay, very good. Number two. What’s a good technique for learning how to chop cataracts? Horizontal chop, vertical chop, the Koch stop and chop, or prechop? Click your answer. Very good. 52%. It’s a little difficult to learn horizontal chop early on, unless you have a good bit of experience with procedures like the divide and conquer. Vertical chop is possible, but again, it’s a little harder. Prechop is one that is certainly a possibility. I think the easiest is the Koch stop and chop. Now, for posterior polar cataracts, you should avoid hydrodelineation, hydrodissection, chopping techniques, or viscodissection? Give us your opinion. Exactly. Very good. Avoid hydrodissection, because you can make a quick hole in the posterior capsule while you still have all the lens material. Excellent. Okay. Four. What is a good technique for patients who have zonular weakness, dehiscence, pseudoexfoliation? Divide and conquer, trivide and conquer, vertical chop, or prechop? Okay. Trivide and conquer. Yes, because you don’t have to rotate, which is stressful on the zonules. Okay. My last question. Five. What’s a good technique for very soft cataracts? Manual incision cataract, Koch stop and chop, prechop, or vertical chop? Good. Prechop works very well with soft to medium hard cataracts. Okay. Then let me look at questions that were submitted.

>> Dr. Downing, you can stop sharing your screen. We have about nine questions so far.

DR DOWNING: Okay. I have several that were submitted ahead. Let me see if I can go through some of those. Let me do that first. Do you think that using femtosecond-assisted laser is using? Do you think that using femtosecond-assisted laser is useful? I learned the technique. I did it for a couple of years. I stopped, because I didn’t think it offered any advantage. It’s very expensive for the patient and the surgeon. I think in a few years, it probably will be the way to go, but for now, I don’t think it’s that useful. Okay. Cataracts with pseudoexfoliation. I use a technique where you don’t have to rotate. Like the trivide. There’s a question about how to deal with anterior capsular tears, which happen during capsulorrhexis. The Little Maneuver, which you pull back in a reverse way and then in, works well. You can look that up on YouTube.

>> Dr. Downing… If you want to just move back a bit, we kind of lost your face on camera.

DR DOWNING: Oh, I’m sorry. I’m having to lean forward to be able to see the questions.

>> There’s actually ten live questions, if you want to go through those first. So you can open the Q and A box right in Zoom.

DR DOWNING: Okay.

>> Can you see those?

DR DOWNING: Okay. The best way to manage nucleus emulsification if the rhexis is small. You can enlarge it. If you use a scissor and make a snip in one side, to form a little triangle, then you can walk it around and enlarge it. And it can be very dangerous to try to do emulsification through a small rhexis. If you’re not able to pull the edge of the rhexis margin while doing rhexis, what could be the possible causes? Okay, probably you have loose zonules, is the most common. And the other is making sure that you’re pulling in the correct direction. You want to be pulling close to the surface of the lens and trying to shear around. If it doesn’t come with considerable pulling, it’s probably a good idea to just switch and do a can opener kind of procedure. Best technique to do to place a Malyugin ring — that’s a whole separate about 10 or 15-minute lecture. There are some good videos on YouTube for that. Best technique to handle posterior polar cataract? Work from the inside out. And avoid hydrodissection. Do viscodissection near the end. Technique is better for beginners… I find it’s easier to learn and teach the divide and conquer than anything else that I’ve used. Phaco settings for direct vertical chop? You have to use a pretty high vacuum. And I think using the longitudinal phaco to burrow in, rather than torsional, helps hold the lens better. And you just burrow in to bury the metal end of the tip, let the vacuum build, and then you can chop. Okay. The tunnel here is similar. It’s peripheral. I like to make a three-plane incision at the edge of clear cornea, or slightly limbal. I think they heal better and they seal better. Strategies for floppy iris. Whoops. I just lost a little bit there. Technique for floppy iris. Generally use capsule hooks. Not capsule. Iris hooks. Or a Malyugin ring or the I-Ring, which is similar. And use lots of viscoelastic. That usually helps. But they can be very difficult. Flip and chip? Sometimes it does work very well. I don’t have much recent experience with it. Okay. With hard cataract, I will do bigger capsulorrhexis. Which technique is preferable for combined cataract and glaucoma? I’m not an expert on that at all. I have been doing some of these… Minimally invasive glaucoma surgery, along with cataract surgery. And those generally seem to help. Okay. How to wash the cortical matter in posterior? Okay, when there’s a hole, I would try to put in a dispersive viscoelastic like Viscoat over the hole. And try to plug it as well as you can with that, and then I like bimanual IA there, if you have it. You can separate the infusion and the aspiration, and I think you can stay away from the hole a little better. If you do get Viscoat coming… Not Viscoat. If you get vitreous coming forward, toward the wound, you do have to clean all that up, and make sure there’s no vitreous traction at the end. Okay. Repeat the answer. Which technique is better for beginners? In my experience, the divide and conquer, where you make a crossed grooves and separate into quadrants. Seems to be easier to teach. And to learn. Okay. Did I put a Wong incision above the main incision? I’m not sure what a Wong incision is. If you’re asking about prechop, no, I need some… You need to let me know exactly what a Wong incision is. What about IOL scaffolding? Wonderful procedure. If you have a problem and a capsule tear, put in viscoelastic before you take out your phaco tip. And generally I will put in a three-piece lens, and then remove the rest of the lens material. If you can get any harder lens material above the lens elevated with viscoelastic, that’s a good idea. Yeah. Using an IOL scaffolding is excellent, sometimes. Okay. Technique to enlarge rhexis. In premature entry of main phaco port. If you’re getting a problem with iris prolapse, then sometimes it’s a good idea to close that incision and make another one to one side of it. Technique to enlarge the rhexis… I like to use an intraocular scissor to make a snip in the side, and then you should be able to shear it around. Just take your time. You can do that easier, once you have a lens in. A posterior chamber lens in. By the way. Best way to ease occlusion during chopping. Try to let your vacuum build. Use vacuum to hold the pieces you did not want to press down. You want to keep your forces as much horizontal as you can, possibly. Okay. How to manipulate the nucleus, if you have a plate or you have a piece there. Putting visco under it. You viscodissect, go out under the capsule, peripherally. And if you have an area where you have some clear capsule, often going in that area, you can inject directly on top of the capsule, and push it up, or otherwise, if you have a plate all around, try to do it like you do hydrodissection. Go under the anterior capsule peripherally. Go out, and then inject viscoelastic. Usually that’ll bring it up. Okay. Technique I like better for removing the cortex. I like both. Bimanual and coaxial. If I have any kind of problem, I will switch to the bimanual. Okay. How can you convert from phaco — to go back from phaco to small incision cataract? You need to take a course in it. There actually is very detailed — there are very detailed videos on Cybersight. For manual sub small incision. If you can visit somebody who is doing it, and let them show you, or take a course at a meeting, it’s probably the best way to deal with that. Okay. Option to place the intraocular lens in case of posterior chamber rupture with vitreous loss? Generally you want to use a three-piece lens in the sulcus. It’s generally not safe to put a lens in the capsular bag. With a capsule tear. And make sure that you have all the vitreous cleaned up, with no traction to the wound or a side port. Okay. Technique to handle a capsule tear. That is pretty much the same, regardless of what kind of problem you have. We can talk about that one of these days, about techniques for managing capsule tears, which are very common, unfortunately. Cause of Descemet’s stripping? Probably using a dull knife to go in, or not having your cannula that you’re injecting with far enough in the eye, so that you’re actually pushing it loose. That’s really pretty rare with small incisions. Best incision for preventing iris prolapse? Okay. I feel strongly that the best kind of entry incision is a limbal incision with a groove going forward, then in stroma, for about the same distance as the width of your keratome, and then going in, so you have a fairly long wound in stroma. The biggest reason for iris prolapse is making your entry too peripherally. Opinion regarding use of anterior chamber maintainer? It can be very helpful sometimes. I highly recommend it if you’re having any problem keeping the chamber stable. How to deal with floppy iris during phaco? If you’re in phaco, and you realize you have a floppy iris, you want to fill the chamber with viscoelastic, come out, and put in iris hooks. That usually will manage it okay. It’s pretty hard to put in a ring, once you have a capsulorrhexis, and not get the capsulorrhexis involved in it. Mature hard cataract, if it’s a brown or black cataract, I think it’s safer to do SICS. What gauge cannula is best for port hydration? I like a 30. A 27 works fairly well, but a smaller one… You get quicker hydration, I think, and sealing. Okay. That’s those. Do we have time for me to look back at questions that we had ahead?

>> Dr. Downing, I can share my screen for you, if you have a couple more minutes.

DR DOWNING: Okay, yep. Okay. Let me see if I can get up here where I can see the questions. Hey, thank you. Yes. Super. Okay. Correct technique for hypermatures? I think the phaco that I showed is very good. You’ll be able to look at that on Cybersight, in the next day or so. And there are several good videos. Again, YouTube is a super source with the internet. It’s amazing, the availability of teaching videos. Okay. Femtosecond laser. It’s an interesting technique. I don’t so far see that much advantage to it, and the expense is a major problem. Incision… Uh-huh. Incision techniques to manage astigmatism. Smaller incisions are better. You get less induced astigmatism if you operate temporally than if you operate superiorly. It’s a fair amount. But I strongly recommend operating temporally. Because you don’t induce nearly as much astigmatism with your surgery. Hard cataracts. I think that the small incision extracapsular is probably safer. How do you do posterior capsulorrhexis? It’s tricky. You want to have a lot of viscoelastic in. And if you can get a little edge on the tear, you have to do it very slowly, and you pull in more than you have to with an anterior capsulorrhexis. Anterior capsule tears, which happen during capsulorrhexis. Try to be very gentle. Stay away from it. Try not to have any surges, which can cause the capsule to tear around posteriorly. If it doesn’t tear posteriorly, I would try to orient the feet of the lens away from the tear, 90 degrees from the tear, and generally it doesn’t cause any problems. How to do chopping with a torsional… You can do chopping with the torsional. Your initial chop is probably a little easier to do with just longitudinal. But you can do it with a torsional too. Okay. Current machine settings using your boss’s settings. See what part of the case works well for you. Places where you’re having a problem… Vary your settings, and see what does work better with you. You do need — the next, 11, how do you tackle phacodynamics? You need to understand phacodynamics, really, before you start trying to do phaco surgery. There is a lecture on Cybersight about phacodynamics, that I did several months ago. 12… That’s a tough situation. If you don’t know how to start, and you don’t have money to go for training, it’s very difficult to learn to do on your own. Is anybody else around who is doing phaco, who could help you get started? I would guess that’s probably the best thing. Okay. Difference between phaco 1, 2, 3… You’re probably talking about foot pedal position. Foot off the pedal is called 0. You push down a little bit, you’ll hear a click. That lets fluid into the eye. Push down a little further, that’s called position 2. It adds aspiration. Push down a little bit further, 3. It adds phaco power. Divide and conquer still good? Absolutely. Lots of very good surgeons just use divide and conquer. Whatever works for you. Try different techniques. See what works best for you. Better to chop the nucleus or sculpt it during phaco? It depends on the technique that you want to use. You do need to try to have a specific technique that you aim — step 1, 2, 3, about how you do it. So it varies depending on the technique. 16, management of hypermature cataracts. We talked about that. Be very careful about your initial entry into the lens. Make sure you have the anterior chamber well pressurized with viscoelastic, before you do it. Make a small initial central opening in the capsule. Then remove as much of the liquefied cortex as you can. Nucleus management. Depends on how hard the nucleus is. And the type of technique you’re using. I’d maybe recommend reviewing the lecture on Cybersight in a day or two, and try to match the type of procedure you’re doing with the hardness of the cataract. Explain the following: Phaco in posterior polar. White, milky. Argentinean flag sign. I would look for management of hypermature cataracts, intumescent. The video that I showed is excellent, I think, in the way it goes through it step by step. I would look at the lecture again on Cybersight, in a day or two, when Lawrence gets it posted. Ptosis, postoperatively, is common, unfortunately. The thing that has made the biggest change to me is switching from injection anesthesia to topical. The incidence of ptosis has been considerably less, and I’m not positive why. Technique of implanting and rotating a foldable lens. That’s sort of a different lecture. Phaco… Oh, okay. Technique for phaco for cataract after vitrectomy. You want to try to remove it before it gets too hard. They can get hard over just a few months after vitrectomy. You have to be very slow and gentle, because you don’t have any vitreous back there to help stabilize things. You have a higher incidence of posterior capsule tear. Use lots of viscoelastic and work slowly. Difference between superior and temporal incision. You get much less astigmatism operating temporally. This is true with either phaco — and particularly with small incision extracaps. You can get much better results with SICS, particularly if you operate temporally. What do you do if you have air in the anterior chamber. A pretty big bubble. If it is, you just aspirate it out. If it’s postop, don’t worry. It’ll go away. Okay. What do I think about? Okay, the MiLoop. I’ve used a similar technique years ago, and it really works pretty well. Particularly for hard cataract. There have been several iterations of that over the last 30 years or so. There was a wire that was used when I did it, and it was probably 30 years ago. Best affordable phaco technology. There is a machine which is less… Considerably less expensive than the others. I have not used it. But I understand it works well. I can’t offhand… Remember the name. If you will ask that on Cybersight, I will look up the name for you. What’s the best chopper? I use a Koch-Nagahara, primarily. There are lots of good ones. It’s a sharp on the inside chopper, with a rounded bottom. But it’s not a ball bottom. It’s just the same size. Best sort of cataract for a beginner is a grade two or so. What is a moderately hard cataract, but not extremely. Most common cause of a nucleus drop during phaco — getting a posterior capsular tear, and not recognizing it. Sometimes it happens suddenly, though, and you don’t know what’s going to… If you get a surge in… Not a surge. A pop, a sudden dilation of the iris, and then it goes back down, that almost always means you have a posterior capsule tear. Or if the lens either becomes suddenly a lot more mobile, or suddenly a lot less mobile, those are signs of a posterior capsule tear. A technique with pseudoexfoliation… I would try to avoid rotating. The side rotate technique works pretty well. Second instrument I use? Usually the Nagahara chopper. Technique for soft cataract? I like the prechop, if you can get it. Get the prechop instrument. If you can’t, you can usually remove those pretty well, just with aspiration, and very little phaco. Just sort of bow them out, and when you get out fairly far, go to IA. But take your time. They usually are hard to get to rotate. Preferred technique for soft cataract — again, I prefer prechop if it’s available. What’s the limit of phaco? I don’t like to do phaco in dark brown cataracts or black cataracts. It’s very difficult and dangerous. You can do pretty hard cataracts, though, up short of that. What’s the first technique I used for phaco? The technique I learned first is no longer around. We would prolapse the upper pole of the lens into the anterior chamber and phaco it there. The primary technique I use is divide and conquer in the average lens. I also like horizontal phaco chop a lot. Okay. Is that it?

>> Yeah, Dr. Downing. I think that’s a good place for us to stop.

DR DOWNING: Okay.

>> Thank you so much.

DR DOWNING: You’re very welcome.

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March 16, 2018

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