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Stop, drop and roll: Premium cataract surgeons remain prepared

Surgeons should know a variety of phaco techniques so they are ready for any situation.

Every day a premium cataract surgeon steps into the OR, he or she must remain prepared for the unexpected even in “routine” cases, although nothing is ever routine in our premium world. It makes me think of the classic fire preparedness drill — stop, drop and roll within seconds of being unexpectedly caught on fire. Although our OR environment hopefully isn’t ever on fire, there are many situations during cataract surgery in which we feel our clothes or brain is truly on fire. Remember, premium surgeons have premium technology and expertise at our beck and call to stop, drop and roll through the situation at hand, no matter what. In this installment of my Premium Channel column, I want to review several of the phacoemulsification techniques available, whether femtosecond laser was utilized or not, as the fragmented or unfragmented cataract still has to be successfully removed from the eye to achieve that premium outcome.

The good news is we have come a long way, as our pioneers started cataract surgery using a Fugo blade to cut across half the cornea to perform intracapsular techniques, which evolved to extracapsular techniques, with which most of us are quite familiar. Eventually, phacoemulsification came to the market with a rocky start, but thanks to the late Charles Kelman and his fortitude, we turned the chapter and accepted innovation in the phacoemulsification world. The evolution from small-incision to microincision cataract surgery, with main incisions less than 2 mm, has led to even more efficient ways to remove the cataract due to better visibility, fluidics and chamber stability, and ultimately less induced astigmatism.

There are so many techniques and variants, some of which include the classic divide and conquer, horizontal chop, vertical chop, stop and chop, bowl technique, and flip and chop. So, what is the best technique? This is where stop, drop and roll comes into play as there is no one technique or right answer to this question, other than whichever technique or combination of techniques allows the premium surgeon to remove the cataract safely and successfully without complication.

I typically will utilize multiple techniques in a single procedure, and the technique I start with may depend on the type of cataract (dense nuclear, posterior polar, dysfunctional clear lens, etc) being removed; as the procedure progresses, the lens may behave differently, requiring a change in technique on the fly. Also, each premium surgeon is trained to be better with certain techniques and is more comfortable doing one over another. Phaco flip, coined by David Brown, works well for softer cataracts and is easy to learn but poses increased risk to the endothelium if the surgeon is not careful when flipping the lens into the anterior chamber. Horizontal chop, created by Nagahara, is more technically difficult but results in use of much less phaco power/energy, although at times you could lose the view of the chopper tip under the iris. This is still my main go-to procedure in most of my cataract cases today. Vertical chop is slightly more difficult to perform than horizontal chop, but it allows for full visualization of the chopper rather than extending it into the periphery under the iris; like horizontal chop, it results in much lower phaco power being utilized. The classic divide and conquer is how most of us learn phacoemulsification initially and is the easiest to learn, but it results in higher phaco power utilization, so combining it with one of these other techniques is probably the best approach in the end for faster visual recovery.

Adding femtosecond laser fragmentation of the lens into the mix makes all of these procedures even easier with even less phaco power being utilized, especially in denser cataracts, as I presented at the American Society of Cataract and Refractive Surgery meeting in 2018. Day 1 postoperative uncorrected visual acuity was statistically significantly three lines better in LOCS III grade 5 to 6 cataracts when femtosecond laser fragmentation was performed before microburst phacoemulsification with the Stellaris Elite platform (Bausch + Lomb). Corneal edema was 16% lower, but the difference was not statistically significant.

Some other points to consider intraoperatively in high myopia cases: prevent overdeepening the anterior chamber by lowering the bottle height and maintaining continuous irrigation; lift the iris to prevent reverse pupillary block; use a Kelman-style curved phaco tip or MICS phaco tip; and perform thorough hydrodissection due to zonular laxity in many of these cases. In high hyperopia cases, the anterior chamber is typically crowded and shallow, and positive pressure from the vitreous increases iris prolapse. Preoperative intravenous mannitol or intraoperative intravenous lidocaine 100 mg works well to decompress the vitreous cavity, with the latter working fast intraoperatively. Sometimes a pars plana vitrectomy is needed to alleviate this positive vitreous pressure before even performing the cataract removal.

In the end, as premium surgeons, we need to always be prepared to stop, drop and roll no matter the situation and to put out the fire before it is too late. Be safe, my friends.

Disclosure: Jackson reports he is a consultant for Bausch + Lomb.

Every day a premium cataract surgeon steps into the OR, he or she must remain prepared for the unexpected even in “routine” cases, although nothing is ever routine in our premium world. It makes me think of the classic fire preparedness drill — stop, drop and roll within seconds of being unexpectedly caught on fire. Although our OR environment hopefully isn’t ever on fire, there are many situations during cataract surgery in which we feel our clothes or brain is truly on fire. Remember, premium surgeons have premium technology and expertise at our beck and call to stop, drop and roll through the situation at hand, no matter what. In this installment of my Premium Channel column, I want to review several of the phacoemulsification techniques available, whether femtosecond laser was utilized or not, as the fragmented or unfragmented cataract still has to be successfully removed from the eye to achieve that premium outcome.

The good news is we have come a long way, as our pioneers started cataract surgery using a Fugo blade to cut across half the cornea to perform intracapsular techniques, which evolved to extracapsular techniques, with which most of us are quite familiar. Eventually, phacoemulsification came to the market with a rocky start, but thanks to the late Charles Kelman and his fortitude, we turned the chapter and accepted innovation in the phacoemulsification world. The evolution from small-incision to microincision cataract surgery, with main incisions less than 2 mm, has led to even more efficient ways to remove the cataract due to better visibility, fluidics and chamber stability, and ultimately less induced astigmatism.

There are so many techniques and variants, some of which include the classic divide and conquer, horizontal chop, vertical chop, stop and chop, bowl technique, and flip and chop. So, what is the best technique? This is where stop, drop and roll comes into play as there is no one technique or right answer to this question, other than whichever technique or combination of techniques allows the premium surgeon to remove the cataract safely and successfully without complication.

I typically will utilize multiple techniques in a single procedure, and the technique I start with may depend on the type of cataract (dense nuclear, posterior polar, dysfunctional clear lens, etc) being removed; as the procedure progresses, the lens may behave differently, requiring a change in technique on the fly. Also, each premium surgeon is trained to be better with certain techniques and is more comfortable doing one over another. Phaco flip, coined by David Brown, works well for softer cataracts and is easy to learn but poses increased risk to the endothelium if the surgeon is not careful when flipping the lens into the anterior chamber. Horizontal chop, created by Nagahara, is more technically difficult but results in use of much less phaco power/energy, although at times you could lose the view of the chopper tip under the iris. This is still my main go-to procedure in most of my cataract cases today. Vertical chop is slightly more difficult to perform than horizontal chop, but it allows for full visualization of the chopper rather than extending it into the periphery under the iris; like horizontal chop, it results in much lower phaco power being utilized. The classic divide and conquer is how most of us learn phacoemulsification initially and is the easiest to learn, but it results in higher phaco power utilization, so combining it with one of these other techniques is probably the best approach in the end for faster visual recovery.

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Adding femtosecond laser fragmentation of the lens into the mix makes all of these procedures even easier with even less phaco power being utilized, especially in denser cataracts, as I presented at the American Society of Cataract and Refractive Surgery meeting in 2018. Day 1 postoperative uncorrected visual acuity was statistically significantly three lines better in LOCS III grade 5 to 6 cataracts when femtosecond laser fragmentation was performed before microburst phacoemulsification with the Stellaris Elite platform (Bausch + Lomb). Corneal edema was 16% lower, but the difference was not statistically significant.

Some other points to consider intraoperatively in high myopia cases: prevent overdeepening the anterior chamber by lowering the bottle height and maintaining continuous irrigation; lift the iris to prevent reverse pupillary block; use a Kelman-style curved phaco tip or MICS phaco tip; and perform thorough hydrodissection due to zonular laxity in many of these cases. In high hyperopia cases, the anterior chamber is typically crowded and shallow, and positive pressure from the vitreous increases iris prolapse. Preoperative intravenous mannitol or intraoperative intravenous lidocaine 100 mg works well to decompress the vitreous cavity, with the latter working fast intraoperatively. Sometimes a pars plana vitrectomy is needed to alleviate this positive vitreous pressure before even performing the cataract removal.

In the end, as premium surgeons, we need to always be prepared to stop, drop and roll no matter the situation and to put out the fire before it is too late. Be safe, my friends.

Disclosure: Jackson reports he is a consultant for Bausch + Lomb.