Black Catarock Phaco

Steven G. Safran, MD

A 95-year-old with a hypermature cataract was referred for cataract surgery. Dr. Safran carries out a reverse slope sculpting technique with a Stellaris (Bausch + Lomb) 2.2-mm purple tip and then implants a Tecnis ZCB00 lens (Abbott) in the capsular bag. He performs a limbal relaxing incision to complete the procedure.

“Wonderfully controlled surgery. I prefer a complete circumferential disassembly without sculpting. Debulking the endonucleus (tearing or peeling small sections with superficial cracks) while leaving the nucleofied endonucleus in position to protect the capsule and zonules until the end also alleviates the need to aggressively separate sections stressing capsule. Dr. Safran shows the attention to detail that leads to day 1 clear corneas even in these extreme cases.”—Lisa Brothers Arbisser, MD

What to Do When: Steps to Manage Complications During Manual SICS Surgery

By Prathmesh Mehta, MD

This compilation video demonstrates complications commonly encountered during cataract surgery and their appropriate management. If the surgeon recognizes these minor issues quickly and manages them properly, dreaded problems like posterior capsular tears and a dropped nucleus can be avoided, and the case can be salvaged with a good visual outcome.

“I’m not an expert on this subject, but I believe, today, all residencies should teach the SICS [small-incision cataract surgery] technique as a rescue for complicated surgery, for dealing with catarocks in some circumstances, and in settings where modern functional phacoemulsification equipment isn’t readily available.”—Lisa Brothers Arbisser, MD

SMILE for Me

By Renato Ambrosio Jr, MD, PhD

The video describes the evolution of and rationale for femtosecond laser-assisted small-incision lenticule extraction (SMILE). It focuses on the benefits of SMILE related to corneal biomechanics and the ocular surface from basic science to clinical results. Current limitations and insights into future improvements are discussed.

“SMILE recently earned FDA approval. I am excited to offer this to my patients, and I think it will be an outstanding form of refractive surgery for myopia.”— Uday Devgan, MD

A New Device to Explant IOL

By David Pérez Silguero, MD

This video illustrates different techniques by which to explant IOLs and explains their downsides. Dr. Pérez Silguero introduces a new lens loop device he designed to assist with the explantation of IOLs. The device securely holds the lens while it is cut with Vannas scissors. The instrument is easily inserted through a 2.2-mm paracentesis. It reportedly entails a very short learning curve and does not require other expensive devices.

“The beauty of eye surgery is that it is always improving. This video demonstrates a simple but elegant new instrument that facilitates safer and more controlled intracameral IOL cutting and explantation.” —Robert J. Weinstock, MD

Phaco Chop Cataract Surgery

By Alex W. Cohen, MD, PhD

Dr. Cohen demonstrates one technique for performing phaco chop.

“Nicely done! It is so important [that] people learn to chop, as it is even more endothelial friendly to switch to chop from divide and conquer than it is to use femtolaser nucleofractis. Vertical chop without a sharp instrument is very safe, as all work can be done central to the capsulorhexis at or below the iris plane. There are many additional maneuvers that can be used to further enhance the technique. Back cracking allows the section to be engaged from the center, cross-action chop doesn’t tilt a dense nucleus or require maintenance of suction during the chop, and circumferential disassembly allows debulking from inside-out in brunescent nuclei.”¹—Lisa Brothers Arbisser, MD

1. Arbisser L. Advanced phaco techniques for brunescent nuclei: cross-action chop circumferential disassembly. In: Chang D. Phaco Chop and Advanced Phaco Techniques: Strategies for Complicated Cataracts. 2nd ed. Thorofare, NJ: Slack; 2013:221-228.

27-Gauge Scleral Fixation of Akreos Lens With Gore-Tex Suture<

By Michael A. Klufas, MD, and Pradeep S.

The case involves a 16-year-old girl with a history of an intraocular foreign body status post lensectomy, buckle, and vitrectomy. She presented 1 year later for consideration of a secondary IOL. The surgeon fixated an Akreos AO60 lens (Bausch + Lomb) to the sclera with a Gore-Tex suture (W.L. Gore & Associates) using the EVA 27-gauge vitrectomy system (DORC).

“This video demonstrates an amazing and innovative way of scleral fixation of an IOL. This is a great technique. I did it for the first time last week, and it is now my go-to way of IOL fixation in cases where there is no capsular support. I have previously enjoyed using the iris suturing of IOLs, scleral suturing, and also the glued-IOL technique, but this new technique is the best.”—Uday Devgan, MD

Brown Cataract Phaco Chop

By Michael Patterson, DO

Dr. Patterson shares a technique for chopping a brown cataract into eight to 12 segments and emulsifying it in an efficient and safe manner.

“This is a talented young surgeon who presents a safe and effective way to deal with dense brunescent cataracts. Michael is the son of ophthalmologist Larry Patterson, MD, and there’s no doubt that he will surpass his dad in his surgical accomplishments.—Uday Devgan, MD

Implantation of a Combined Iris Prosthesis and IOL Through a 2.4-mm Incision

By Ulrich Spandau, MD

Explosive trauma left a 25-year-old man with aphakia and partial aniridia. Dr. Spandau fixates an MA60AC IOL (Alcon) onto a foldable iris prosthesis from HumanOptics (not available in the United States). Then, the combined IOL and iris prosthesis are inserted with a regular injector and sclerally fixated.

“This video demonstrates a clever method of fixating an iris prosthesis to an IOL to cover a traumatic iris defect. When insufficient iris tissue remains for a reconstruction, this may be an alternative.”—Steven J. Dell, MD

A Side-by-Side Comparison: With Omidria and Without

By Robert J. Weinstock, MD

A split-screen presentation contrasts cataract surgery with and without the use of Omidria (phenylephrine and ketorolac injection; Omeros) 1%/0.3%. Omidria is indicated for maintaining pupillary size by preventing intraoperative miosis and reducing postoperative ocular pain.

“Wonderful video showing what a study done by Frank Bucci, MD, shows (personal communication): that we can markedly reduce the need for pupil expansion devices by using Omidria. In the [United States] only, we haven’t had access to commercially prepared intracameral phenylephrine, which is more effective than epinephrine. We’ve known for years about topical preoperative [nonsteroidal anti-inflammatory drugs] and blocking prostaglandin release to avoid intraoperative miosis. It would be expected that bathing structures with irrigation fluid containing these compounds should be more effective yet. I hope economics won’t prove a barrier to this helpful adjunct to cataract surgery, which will play a role in complication prevention and make routine cases more seamless.”—Lisa Brothers Arbisser, MD

How to Use the APX 200 Pupil Expanding Device

By Ehud I. Assia, MD

Dr. Assia provides instructions and pearls for using the APX 200 Pupil Expanding Device (APX Ophthalmology), which was designed to provide dilation in cases of a small pupil or intraoperative floppy iris syndrome. The instrument’s unique design reportedly makes its insertion and removal fast and easy.

“I believe this pupil expander to be superior to iris hooks. In cases where a Malyugin Ring [MicroSurgical Technology] is inadvisable due to an already open capsule, vitreous loss, or a large floppy pupil, this would be a wonderful option. The instruction offered is clear and comprehensive.”—Lisa Brothers Arbisser, MD