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Cataract Surgery Techniques and Innovations

US Sensory Disorders Review, 2006:24-6 DOI:
Received: January 12, 2011 Accepted: January 12, 2011

Cataract surgery and phacoemulsification techniques have advanced dramatically over the past 10 years.The concept was first introduced by Dr Charles Kelman,1heralding the era of modern cataract extraction and paving the way for small incision surgery. Since then, the trend has been toward smaller incision surgery with less induced astigmatism and less traumatic surgery by using ultrasound assisted phacoaspiration instead of vacuum-assisted phacoemulsification. Recent refinements in power modulations have led most surgeons to use techniques that utilize less phacoemulsification energy and thus reduce thermal energy delivery and injury to the eye.2,3 This is carried out either by using mechanical forces to disassemble the nucleus or by using higher vacuum levels to aspirate the nucleus or a combination of both. This paper will describe QuickChop phacoemulsification and bimanual microincisional phacoemulsication techniques, which attempt to simplify each stage of the operation, in order to minimize trauma and achieve the optimal outcome.

QuickChop Phacoemulsification Technique
There are many challenging scenarios that cataract surgeons can encounter when performing phacoemulsification surgery. It is important when dealing with any challenging case to be aware of what one is confronting and to have a game plan to facilitate the surgery. Although most surgeons are most comfortable when using a certain technique, it is essential to be flexible and able to vary technique depending on the situation. Pre-operative assessment of the patient both in determining the type of cataract and the morphology of the eye—axial length, zonular instability, post-traumatic, post-surgical—will help in determining how to proceed with the case.

Pre-operative treatment with topical medications can make the intra-operative and post-operative course more predictable. Topical non-steroidal antiinflammatory (NSAID) agents are helpful in maintenance of intra-operative mydriasis. They also assist in control of post-operative inflammation, thereby reducing the need for long-term topical steroid usage. NSAIDs have also been proven to help in the prevention of chronic macular edema.4 Preoperative NSAIDs can be given four times a day, starting the day prior to surgery and to continuing immediately after surgery for a month.The use of preoperativeantibiotics, such as the fluoroquinolones, may also help prevent post-operative infections. Fluoroquinolones can begin a day prior to surgery and be continued after surgery along with a steroid drop that begins after surgery, for two weeks.

Surgery is performed using a clear cornea temporal approach. Topical tetracaine is usually adequate for satisfactory anesthesia. However, if iris manipulation is to occur or if the patient is particularly sensitive, then intracameral non-preserved 1% lidocaine may be injected at the start of the case.A side port incision is made on the left with a 15-degree metal blade.The anterior chamber is then filled with a cohesive viscoelastic such as Amvisc Plus (Bausch and Lomb), which allows maximum chamber and iris stability. However, if there is any indication of corneal compromise, Arshinoff ’s soft shell technique5 is preferred, utilizing a more dispersive viscoelastic such as Viscoat (Alcon) as an adjunct to help in coating the corneal endothelium.With Arshinoff ’s technique, the dispersive viscoelastic is injected initially to fill about half of the anterior chamber, followed by a cohesive viscoelastic that will force the dispersive up against the cornea. If the eye has a shallow anterior chamber or the pupil is small then one of the newer viscoadaptive substances (Healon 5, iVisc Phaco) can be used to assist in deepening the anterior chamber and stretching the pupil due to its ability to better retain a given space.Then a clear corneal temporal incision is made.