David M. Dillman

Cataract surgery has changed for the better in the 12 years since the publication of the first edition of this book. Preoperative testing and imaging, the phaco machines, the microscopes, intraoperative aberrotomy, and femtosecond laser–assisted surgery are just a few of the advances that have been made.

But in other ways, not much has changed in cataract surgery since the first edition. Most of the issues that were discussed in the first edition remain issues for discussion in this edition. The factors that surgeons considered then as they prepared for cataract surgery are the factors they still consider today.

Thus, this chapter addresses some of the issues that were addressed 12 years ago but now in the context of the new technologies that are available today.

Controversies

There are two technologies that remain controversial. They have already been discussed in other chapters, with some authors having positive feelings about them and others negative. These are technologies that I use, and they are part of my current approach to complication prevention and management.

The first controversial technology is femtosecond laser–assisted cataract surgery (FLACS). Like many other surgeons, I was initially skeptical about FLACS. But then I consulted the surgeons who were the early adapters. I observed five surgeons performing FLACS in about one hundred surgeries, and then discussed the procedure with them. I concluded that FLACS was a positive advance, and 3 years ago I learned to perform it.

As my understanding of the technology and my ability to apply it has improved over time, I have become increasingly more reliant on it to help prevent complications. FLACS facilitates performing routine cases, and is especially helpful with difficult cases, such as dense lenses, weak zonules, and poor surgical visualization. If a patient’s insurance does not cover FLACS, I deeply discount my fees or, in a few cases a month, I assess no fee at all. I lose money on these cases, but that indicates how highly I value the technology of FLACS in preventing complications.

The second controversial technology is intraoperative aberrotomy. Initially, it was not very good; it was cumbersome to use and not very reliable. But, as with other technologies, it quickly improved, and now I find it to be much easier and faster to perform and quite reliable. I cannot imagine doing cases involving a post-refractive intraocular lens (IOL), a multifocal IOL, a toric IOL, or even a distance vision monovision IOL without the availability of intraoperative aberrotomy. It also helps avoid IOL power and orientation (toric) complications.

Granted, both technologies add time and cost to each cataract surgery. But I am convinced that the benefits easily outweigh those downside factors.

Two Basic Philosophies

Two basic philosophies underpin my approach to cataract surgery and complication prevention. Although technologies have changed over time, these philosophies have not; if anything, they have strengthened, because as technology advances it is more and more tempting to hide behind it.

The first philosophy is to “major in the minors,” that is, to pay a lot of attention to seemingly small details. The second philosophy, closely aligned with the first, is to focus on what is important at each step of the procedure. This helps prevent complications.

Surgical Procedures

One-Handed Two-Hand Phaco

The success of the phaco procedure depends on the surgeon’s ability to understand and control the phaco fluidics. Many variables are involved, and today’s phaco machines are very good at self-regulating them. But they cannot control incisional leakage.

Phaco fluidics have been discussed elsewhere in this book, so I am going to focus on just one aspect—incisional leakage, and especially leakage through the side-port incision. By side-port incision, I am referring to the incision made a few clock hour positions to the side of the primary phaco incision for traditional coaxial phaco.

Incisional leakage has an untoward effect on phaco fluidics, regardless of the location of the leakage. We can create a well-balanced phaco incision and still negatively influence fluidics by creating an unnecessarily large side-port incision. When we create a side-port incision, how large should it to be: 0.5 mm? 1.0 mm? 1.5 mm? One of the advantages of FLACS is that this incision will be the exact size we want. But what is the appropriate size? It depends on what is used as the second instrument. It should be just big enough to allow entry and exit of the second instrument. I have used many of the choppers, manipulators, and rotators available today, and I find that a side-port incision no greater than 0.5 mm is a very close approximation of the appropriate size. And yes, there is a meaningful difference between a 0.5-mm and a 1.0-mm side-port incision in performing a successful surgery.

The No-Excuse Hydrodissection

The Colvard Maneuver

Excellent mobility of the cataract within the capsular bag is an essential precursor to all endocapsular phaco techniques, even those that are a part of FLACS. Mobility of the lens within the capsular bag is a function of hydrodissection, thus making hydrodissection a crucial (but often underappreciated) step. It is an excellent way to help prevent complications.

The presence of a posterior fluid wave is not proof that the hydrodissection has been successful. The only way to be assured of successful hydrodissection is to actually test for and prove mobility. There are many ways to do so; I simply use my hydro-dissection cannula before removing it from the eye. But what if the nucleus will not spin easily, that is, without putting stress on the zonules or posterior capsule. What if you have tried straight cannulas and curved cannulas, and you have tried it inferiorly and superiorly, and still the nucleus will not spin! This happens more frequently with FLACS, because of the gas bubbles between the cataract and the central posterior capsule, so I tend to be less aggressive in using hydrodissection. The answer is what I have termed the “Colvard maneuver.”

In the early days of phaco, Michael Colvard developed an ingenious little device, the phaco shield, that was placed between the cataract and the central posterior capsule. When the shield is properly placed, it becomes impossible to break the posterior capsule by phacoing through the cataract. By placing the phaco shield, we create space between the cataract and anterior capsule. I applied the concept to hydrodissection—hence, the Colvard maneuver.

The Colvard maneuver is simple; all we are doing is creating space. In situations in which we cannot obtain good hydrodissection, and cortical and epinuclear material is fluffing up, making visualization increasingly difficult, we should simply refrain from further efforts. Instead, we should ask for the phaco handpiece, and in foot position 2, aspiration, simply remove as much cortex and epinucleus as we can, not just centrally, but as far out into the periphery as possible. The peripheral material can be approached by gently putting the phaco tip just short of the capsulorrhexis/capsulotomy.

Once this is done, it is often possible to easily rotate the cataract within the bag with the phaco tip in foot position 1, irrigation. If not, simply re-form the anterior chamber with the viscoelastic of your choice, and complete the hydrodissection with the cannula of your choice. I have so much faith in the Colvard maneuver that the first patient I used it on was my mother; I tried and tried to hydrodissect, and her cataract did not respond. So I did the Colvard maneuver, and lo and behold, I obtained excellent hydrodissection with excellent mobility of the lens.

The Clandestine Wraparound Tear

The Little Dutch Boy Maneuver

In my experience, the most underrecognized etiology for a posterior capsular tear is an anterior capsular tear that has become a wraparound tear. One current criticism of the FLACS capsulotomy is that there are more anterior capsule tears than with traditional capsulorrhexis, but that has not been my experience. Nonetheless, regardless of how it occurred, it is very important that we keep anterior capsular tears anterior only and not allow them to wrap around to the equator and posterior capsule. I find that the best way to do this is to prevent the capsular bag from sudden decompression. This often happens when the phaco handpiece or irrigation and aspiration (I/A) handpiece is removed from the eye. I vividly remember a case I did in 1996 in which I knew there was a tear in the anterior capsule early on. I was able to do the phaco. I was able to remove all of the cortex without difficulty. However, as I pulled the I/A handpiece out of the eye, I could see the anterior capsular tear wrap around and create a significant tear in the posterior capsule. I vowed I would never let that happen again.

What I learned to do is simple but effective. In the presence of a known anterior capsule tear, or even if I suspect an anterior capsule tear, I do not allow the capsular bag to suddenly decompress. I make sure it always has support. I call this the “Little Dutch Boy” maneuver with the analogy of trying to keep a small hole from becoming a huge hole with bad consequences.