Surgery: Phacoemulsification using Divide and Conquer Technique

This video demonstrates a phacoemulsification in a 65-year-old man with cataract in the right eye. Dr. Haldipurkar demonstrates a good capsulorhexis and the divide and conquer technique of nucleus removal.

Surgery location: on-board the Orbis Flying Eye Hospital in Chittagong, Bangladesh
Surgeon: Dr. Suhas Haldipurkar, Laxmi Eye Institute, Mumbai, India


Dr. Suhas Haldipurkar: Well, this patient, 65-year-old male came for right cataract. Side ports should be on either side, not too far away from the main incision. I would prefer to do rhexis understanding. Initially I did my rhexis with viscoat, which is dispersive because I wanted bit of viscoelastics to stay in the eye while my phaco procedure is on. That’s the only thing that can really protect me from damage to the endothelium. The rhexis should not be too big. I would aim for five, 5.25. And that’s the ideal size because you would want proper, adequate overlap. Not too little an overlap or not too much. If the adequate overlap doesn’t exist, there’s always a chance for the optic to slightly tilt.

That’s a beautiful rhexis and I appreciate you putting back in OVD. How important do you think a hydro dissection is? Do you think that’s a very important step?

Well, I will do minimal hydro enough for me to see the hydro wave crossing across and then just rock the nucleus. And this is kind of enough for me. Most of the peripheral, Aadhesions are broken and then I fill the eye with little viscoelastic. This time I’m using healon.

And I appreciate that you’re doing pre phaco now, not only to remove some of the OVD to avoid a burn, but also to clear some working space.

Yes. So now I have cleared the endo nuclear part. All the loose cortex and nucleus is cleared and I’m ready to take on. I would prefer to do a four quadrant here.

NI think divide and conquer is always a safe technique. And you can do it in every case.

And one of the things you can help us with is how do you gauge the depth of your trench?

Well, one thing I purely go with a change in the color.

Keeping either side of the walls to be quite vertical and straight. But very often, if you make too wide a tunnel at times it’s difficult to crack them. Now at this stage, it’s adequately deep enough, and I’ve seen the beginning of change of color and after the first round of trench is complete, I take a call whether I wish to go through another round or continue with cracking. Now at this stage, since the rhexi swas well centered, I can do a typical crisscross.

Normally when you make your trench, the distal part really gets deeper, the proximal part needs to be treated again,

This is where your hydro really comes in, but you have such good lens mobility, you’re not putting any stress on the zoles. So I really appreciate your excellent hydro.

And now I come to the depth of the trench and with the two instruments properly placed, I try and crack it. If I don’t get a proper crack, that’s an indication that I still need to go deeper. I normally strive for a clean cut, which sometimes you get. In this particular case, I have not got it. It doesn’t really matter because the nucleus is not very hard.

There is the full crack. Back home, do you do stop and chop or phaco chop?

I prefer to do phaco chop, simply because it saves on the amount of energy that you’ll be using. And number two, it’s also quicker. So when you use a technique which is quicker, there’s less amount of fluid that’s going through the eye.

Do you find that the first quadrant is always the most difficult? Once you get that you have more mobility and more space?


And I like how you bring the quadrant to the central safe zone where you have small depth and you’re furthest away from the posterior capsule.

You would always bring them in the center and use your second instrument to cut it further into another smaller pieces, where the chop is holding back the piece. The front piece is what you emulsify so that you don’t have pieces floating in the anterior chamber. And your phaco tip is not making much of a movement. It stays in the center all throughout, and most of the maneuverability is done with your second instrument.

With the last piece, do you like to sometimes go to epi nucleus or at least do you recommend that for starting doctors to go to epi just to protect from the bag?

No, I would keep the same settings with parameters load. But at this stage, sometimes when you have small chunks left, I go to epi nucleus. But then it’s safer for a beginner not to dabble with this. It’s safer that you go to IA and do it. Sometimes when your second side port is slightly big, and if the iris has a tendency of floppiness, the iris tends to come into the side port.

And are you going to put in OVD or do you just go straight to IA now?

I put healon just to protect the endothelium and then go with the IA.

You were talking about intraoperative miosis, and I know during your side port you had a little bit of the iris prolapse. If we were having iris constriction right now, what would you be doing so that you could still have good view of the case and be able to get the IOL in?

If I can still see part of my rhexis, I would not bother to dilate it because most of my cortical wash is already done. So I just have to get the lens into the back. This is a time when I would use my visco to do visco mydriasis, but very often if I still have to do a bit of cortical wash left, or if I’m planning to put a toric lens, then this is a time when I use intracameral epittrate and try and dilate. And it’s very effective in dilating. But very often I’ve seen some of these pupils, which are constricted when you go with your irrigation, the pressure of fluid itself is sometimes slightly dilated enough to carry on with your function. But the problem comes when you have to put a toric and the pupil has really come down because you want to see those marks on the toric. Sometimes, I may have to use one of the devices if it’s so very important.

So you just got to my point about why this step is sometimes critically important with small pupils, during a toric case. And especially with your toric lenses, it’s important to remove the OVD from behind the lens. How do you do that? What technique do you do? Do you rock and roll? What do you do to remove OVD from behind

First I remove it from anterior. And then I go with the single IA. This is just the irrigation and that I’ll demonstrate just now. Now, it’s not difficult yet because the pupil is dilated, but still what I do is, I stop the irrigation a bit, try and press the lens down, and here I go under and start irrigation. This I do as a routine for all the cases because I have realized that some of visco still stays behind. It always has to be taken out. And now most of the viscoelastic from the eye is out, and what I need to do is just hydrate the floor of my wound. So that gives me some amount of closure, and then I go for hydration of the side parts. I realized one thing, phaco is such that each step leads to some problem in the next. In this case, to start with, my tunnel was slightly short. I would like to say that your side port should be as snugly fitting as possible, especially the left one. Because that’s where a lot of leakage happens, which goes unnoticed.

Thank you so much.

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Last Updated: March 12, 2024

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