Cataract Surgery Pearls for the Young Ophthalmologist

By Robert F. Melendez, MD

Pearl 1: Loose lens: Pearls to detect a loose lens. 1) Difficulty with puncturing the anterior capsule. 2) During the capsulorrhexis, there is more wrinkling than usual. Recommendation: My senior partner, Arthur J. Weinstein, MD taught me to intentionally try to make the capsulorrhexis larger because in this circumstance, there is a tendency to create a smaller capsulotomy.

Pearl 2: Shallow chamber in one eye, why? This could be suggestive of a loose lens that is displaced anteriorly and/or prior cataract surgery in the contralateral eye. If the anterior chamber depth is shallow, this may require the use of a cystotome only and may need viscoelastic material placed in the eye after 50% completion of the capsulotomy.

Pearl 3: What is the Akahoshi prechopper? This prechopper is used for 2-3+ nuclear sclerotic cataracts and creates four equal fragments and minimizes the amount of ultrasound power. The prechopper is not effective in 1+ and 4+ nuclear sclerotic cataracts because the lens material is too soft and hard, respectively. It should not be used in cases where a prior vitrectomy has been performed and a history of loose lens (trauma, pseudoexfoliation, and advanced age).

Pearl 4: Soft cataract, 1+ NS with 4+ PSC. Why am I having difficulty removing the subincisional cortical material? Reason: Poor hydrodissection. In these cases, assure adequate hydrodissection. Hydrolineation is so easy to achieve in this type of case that one has the tendency to proceed only to have created more effort and time removing the subincisonal cortex. Solution: Ensure adequate hydrodissection.

Pearl 5: Posterior Polar Cataract. Perform Hydrodilenation only. Hydrodissection can create an opening in the posterior capsule. Consent for a vitrectomy. Typically, an anterior vitrectomy is not needed and the intraocular lens can be placed in the bag assuming it is stable.

Pearl 6: Loose bag and difficulty removing cortical material. Remove the cortex material tangentially to the capsulorrhexis to minimize the amount of stress on the bag as recommended by Greg Ogawa, MD. Create a large capsulotomy and prolapse the lens into the anterior chamber to minimize stress on the bag. My mentor, Arthur J. Weinstein, MD, reports that loose bags have the tendency for a small capsulotomy, therefore, intentionally create it slightly larger. Capsular Tension Rings are recommended by I. Howard Fine, MD, Richard S. Hoffman and Mark Packer, MD

Pearl 7: Iris prolapse from main wound. Remove fluid from anterior chamber and replace with viscoelastic material. If the iris prolapse is worsened by viscoelastic material then there is likely too much present in the anterior chamber. Remove through the paracentesis wound. Reduce Phaco parameters (lower bottle height, reduce vacuum, and irrigation). Turn off irrigation to the phaco machine before removing from the eye. This will minimize the amount of iris prolapse. If the iris prolapse still persists throughout the case, place a subincisional iris hook through a different entry wound (i.e., that is posterior to the main wound).

Pearl 8: Tamsulosin (Flomax) and other alpha blockers during cataract surgery. Consent the patient for possible hooks. If poor dilation is present at the time of surgery, use preservative free Lidocaine with epinephrine intracamerally. If no improvement with dilation, then place iris hooks. There is no benefit of discontinuing the medication prior to the surgery. Remember, it is the size of the capsulotomy that increases risks for complications and not necessarily the pupil size. Therefore, create a capsulotomy large enough to minimize any capsular damage. In some cases, the capsulotomy might be larger than the poorly dilated pupil. If the pupils appear relatively well dilated at the beginning of the surgery and preservative free Lidocaine with epinephrine is instilled and the iris moves easily with fluid in the anterior chamber, this is suggestive of a pupil that will be floppy as the procedures proceeds. Recommendation: Iris Hooks. Some recommend Atropine. Do not stretch the pupil.

Pearl 9: Patient moves during the surgery. Assuming the sedation is perfect, minimize loud noises in the operating theater to prevent the patient from moving. Select music that is smooth and does not have high notes such as the song “Brass Monkey.” Encourage the patient to breath slowly and concentrate on their breathing. Rests hands on the patient’s head so that the instruments in the eye move with patient’s head movement. When in doubt, block the patient and tape the head. In some cases, there may be rhythm to the madness. For example, in one of my cases, the patient would consistently move every 25 seconds. Once we identified it, the anesthesiologist would count for me and give me a 10 and 5 second alert and I would remove the instruments from the eye until he was still.

Pearl 10: Case almost complete until posterior capsule was torn. Cause?
A barb on the tip of the I/A. Solution: Check instruments prior to surgery and/or use a silicone coated I/A tip. A torn capsule can be caused by nearly any metal instrument. Consider using a sleeve around the tip of the instruments.

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About the Author: Robert F. Melendez, MD is a full-time comprehensive ophthalmologist with emphasis on cataract and refractive surgery. He is a partner at Eye Associates of New Mexico and an Assistant Clinical Professor at the University of New Mexico Department of Surgery/Division of Ophthalmology. He has performed over 1000 cataract surgeries over his first four years of practice and is sharing his Top Ten Pearls he learned from his senior partner and mentor, Arthur J. Weinstein, MD and friend, Alan Crandall, MD, University of Utah.