Cataract Surgery Techniques

Pre-op Prep - Eyes on Prize

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Phaco Phun - The Modern Chop

Gold standard: Ultrasonic lens emulsification & aspiration.

• Principle: Ultrasonic fragmentation & aspiration of lens.
• Incision: Small, self-sealing (e.g., 2.2-2.8 mm clear corneal).
  • Benefits: Rapid healing, ↓ astigmatism, often sutureless.
• Core Steps:
  • Corneal Incisions (Main & Side-port).
  • Anterior Capsulorhexis (CCC): Crucial for IOL stability.
  • Hydrodissection & Hydrodelineation: Separates layers, aids rotation.
  • Nucleus Management (Phacoemulsification):
    • Techniques: Divide & Conquer, Stop & Chop, Direct Chop.
    • Goal: Efficient removal, ↓ energy (protects endothelium).
  • Cortical Aspiration (I/A).
  • IOL Implantation (in-the-bag).
  • Wound Hydration/Sealing.

⭐ Phacoemulsification offers faster visual recovery and significantly less surgically induced astigmatism compared to older techniques like ECCE.

• Phaco Power Modulation: Pulse/Burst modes ↓ total energy.
• FLACS: Femtosecond laser can automate incisions, capsulorhexis, lens fragmentation.

Manual Marvels - Classic Cuts

• ECCE (Extracapsular Cataract Extraction):

  • Large 10-12 mm superior limbal incision.
  • Anterior capsulotomy (can-opener/envelope), nucleus expression, IOL implantation.
  • Multiple sutures (e.g., 10-0 nylon); results in higher Surgically Induced Astigmatism (SIA).
  • Indications: Very hard (Grade 4-5) cataracts, subluxated lens, situations where phaco is not feasible.

• MSICS (Manual Small Incision Cataract Surgery):

  • Valvular, self-sealing sclero-corneal tunnel (5.5-7 mm).
  • Nucleus hydrodissected, prolapsed to AC, delivered via tunnel (e.g., Blumenthal, Fishhook techniques).
  • Often sutureless or single suture; significantly ↓ SIA & faster visual recovery compared to ECCE.
  • Advantages: Cost-effective, excellent for mature cataracts, ideal for high-volume settings.

⭐ MSICS is the most common cataract surgery in developing countries, offering near-phacoemulsification outcomes at a significantly lower cost.

Laser & Oopsies - Future & Fixes

• Femtosecond Laser (FLACS):
  • Precision: Capsulorhexis, corneal incisions, lens fragmentation.
  • Pros: ↓ Phaco energy, astigmatism control, better IOL centration.
  • Cons: Cost, ↑ time, risks (capsular tags, miosis, OBL - Opaque Bubble Layer).
• Intraoperative Complications & Fixes:
  • Posterior Capsular Rupture (PCR):
    • Signs: Deep AC, pupil snap, vitreous.
    • Manage: Anterior vitrectomy, IOL (sulcus/ACIOL/scleral-fix).

    ⭐ PCR: Most common intra-op issue causing vitreous loss. Risks: hard nucleus, PXF.

  • Dropped Nucleus: Pars plana vitrectomy (PPV).
  • Suprachoroidal Hemorrhage: Close wound, sclerotomies.
• Postoperative Complications & Fixes:
  • Endophthalmitis: Intravitreal antibiotics ± vitrectomy. Prophylaxis: Intracameral Abx.
  • TASS: Sterile inflammation (12-48h). Potent topical steroids.
  • CME (Irvine-Gass): Topical NSAIDs, steroids.
  • PCO: Nd:YAG laser capsulotomy (commonest late).
• Future: Advanced IOLs (EDOF, trifocal), AI, robotics.

High-Yield Points - ⚡ Biggest Takeaways

• Phacoemulsification: Most common technique, uses ultrasonic energy.
• MSICS: Cost-effective for mature cataracts, sutureless option.
• PCO (Posterior Capsular Opacification): Most frequent long-term complication, treated with YAG capsulotomy.
• Endophthalmitis: Vision-threatening infection, requires prompt intervention.
• Biometry: Essential for accurate IOL power calculation and refractive outcome.
• FLACS: Laser-assisted precision for capsulorhexis and corneal incisions.
• ECCE/ICCE: Older methods with larger incisions, now largely replaced by phaco/MSICS.