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Inside Eyetube.net | Feb 2013

New in the Cataract Toolbox

Surgeons provide a step-by-step analysis of some of the most watched videos on Eyetube.net.

Thierry Amzallag, MD


To protect the corneal epithelium during cataract surgery, I present a technique called “corneal on-demand irrigation system” that allows the surgeon to irrigate the cornea as often as necessary without the risk of collapsing the anterior chamber. As the video demonstrates, I use a corneal knife to create a 2-mm longitudinal slit 2 mm from the axis of the irrigation halls on the anterior face of the silicone sleeve (Figure 1). This system uses some of the irrigation flow from the ultrasound handpiece. By moving the ultrasound probe 1 to 2 mm forward and backward, I can irrigate the cornea during the sculpting and quadrants phase of phacoemulsification. The level at which I withdraw, angulate, and rotate the handpiece allows me to control the exact zone and quantity of the corneal epithelium that is irrigated (Figure 2). This technique is a simple innovation that protects the corneal epithelium perioperatively, thus leading to patients' satisfaction on the first postoperative day. In addition to standard cataract cases, it is particularly useful for hard nuclei and long, delicate procedures. The same principle can be applied when removing the cortical material.

Thierry Amzallag, MD, is a cataract surgeon at the Ophthalmic Institute of Somain, France. Dr. Amzallag may be reached at thierry.amzallag@institut-ophtalmique.fr.

Carol A. Drake, MD


This video shows cataract surgery in a 6-year-old with megalocornea (14 mm), microspherophakia (8-9 mm), and congenital hypoplasia of the dilator pupillary muscle. He had peripheral transillumination defects of the iris and marked iridodonesis. His vision was 20/80 OD and 20/60 OS due to posterior subcapsular cataracts.

Procedures on both eyes were similar. I enlarged the non-dilating pupil with iris hooks. As shown in the video of the surgery on the patient's left eye, the edge of the capsular bag reaches the tips of the hooks. I stained the anterior capsule with capsular dye and performed a circular tear capsulorhexis. It was critical to keep the capsulorhexis small. With 23-gauge instrumentation and a bimanual technique, I removed the cataract. A Softec hydrophilic acrylic IOL (Lenstec Inc.; Figure 3) was implanted in the left eye. On the first postoperative day, the patient's visual acuity was 20/40 OS.

The Softec's hydrophilic material made its insertion less traumatic and resulted in less ovaling of the bag in comparison to the AcrySof hydrophobic IOL (Alcon Laboratories, Inc.), which was used in the right eye. I performed Nd:YAG capsulotomies in both eyes 6 months postoperatively. The patient is now 7 years old with a refraction of +0.75 D sphere OD and +0.25 +0.50 X 9 OS with a visual acuity of 20/20-2 in each eye. There is almost no iridodonesis.

Carol A. Drake, MD, is a partner at First Eye Associates in Omaha, Nebraska. She acknowledged no financial interest in the products or companies mentioned herein. Dr. Drake may be reached at caroldrakemd@gmail.com.

R. Bruce Wallace III, MD


I encourage surgeons who may be on the fence about performing limbal relaxing incisions (LRIs) with presbyopia-correcting IOLs for their cataract patients to embrace the technique. As I mention in my video, there are video-based online resources that feature myself or other experienced surgeons that demonstrate how to use LRIs in combination with presbyopia-correcting IOLs. One of my videos even teach viewers how to set up an LRI wetlab at home. Additionally, instrument kits such as Storz Ophthalmic Instruments' Wallace LRI Kit are available to help surgeons readily equip their ORs with the best available tools.

R. Bruce Wallace III, MD, is the medical director of Wallace Eye Surgery in Alexandria, Louisiana. Dr. Wallace is also a clinical professor of ophthalmology at the Louisiana State University School of Medicine and at the Tulane School of Medicine, both located in New Orleans. He is a consultant to Bausch + Lomb. Dr. Wallace may be reached at (318) 448-4488; rbw123@aol.com.

Jeffrey Whitman, MD


The enVista IOL is the first single-piece hydrophobic acrylic IOL to be approved by the FDA as a glistening-free lens. The enVista has an especially hard surface that resists dents and scratches from instruments and folding. It is also aberration free. I was fortunate to be the first in the United States to implant the enVista after the clinical trials.

When the enVista is ready for insertion, I begin by creating a 2-mm entry wound with a diamond blade. I had already filled the capsular bag with viscoelastic. Using a plunger-type injector, I insert the enVista via a wound-assisted technique, in which only the tip of the injector is engaged into the operative wound (Figure 4). The lens is then injected into the anterior chamber and positioned into the capsular bag using a Connor Wand (Rhein Medical). I position the IOL during the 20 to 30 seconds it takes for the IOL to unfold. After the lens is positioned, I use I/A to remove the viscoelastic. Hydrating the Wong incisions that I created at the main wound and at the paracentesis concludes the case.

Jeffrey Whitman, MD, is the president and chief surgeon of the Key-Whitman Eye Center in Dallas. He is a consultant to Bausch + Lomb. Dr. Whitman may be reached at (800) 442-5330; whitman@keywhitman.com.

Section Editor Elena Albé, MD, is a consultant in the Department of Ophthalmology, Cornea Service, Istituto Clinico Humanitas Ophthalmology Clinic, Milan, Italy. Dr. Albé may be reached at elena.albe@gmail.com.

Section Editor Damien F. Goldberg, MD, is in private practice at Wolstan & Goldberg Eye Associates in Torrance, California.

Section Editor Mark Kontos, MD, is the senior partner at Empire Eye Physicians in Spokane, Washington. Dr. Kontos may be reached at (509) 928-8040; mark.kontos@empireeye.com.

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