Surgery: Phacoemulsification in a Subcapsular Cataract

Cortical cataract with a subcapsular dense cataract. Her nucleus is N2, so it’s not a very dense nucleus. We’re gonna stain the capsule also. So now we’re gonna put some Viscoat, which is dispersive viscoelastic. Now we’re doing again the soft shell technique. We’re pressing the Viscoat against the cornea. And we’re gonna do our main incision. Again, we go intrastromally, or intralamellarly, and we go into the eye. That creates a good beveled incision. So now we have our bent needle. We’re gonna go in with our cystotome. Start in the center. Make a clean cut. And then lift the flap. So we’re gonna try to make this one a little bit bigger. So as I said, we’ll grab it. The farther we are from our edge, the larger the rhexis. Don’t be afraid of grasping it many times. Again, what we want is to be a nice circular capsulorrhexis. And we’re gonna finish it. For hydrodissection, we go in with our cannula, press on the anterior capsule, fall back, and then we should see the wave go through. I haven’t seen it. So I’m gonna put a little bit more. There it goes. So now we know that the nucleus is loose. Which is good. And next we’re gonna do again our prechop technique. The Dodick prechoppers. We’re going through the paracentesis. Go underneath the anterior capsule. Bend. Bring them together. Fracture them. And we do the same down here. So we have now three segments of the nucleus. So again, as I said before, have our irrigation ports towards the side. So here I’ve removed the anterior cortex, as you can see. And now we see the nucleus over here. The quadrant that I’m removing. As you see, it comes out pretty easy. You don’t have to do much effort to remove it. Then we go for the second piece. Here we have it. As you can see, I always work in the center. It makes it much easier. And once I have the piece, then I go to position 3. So here, you know, we’ve removed most of the nucleus. I go to position 3. Occlude my tip. And then once I do that, I go from behind, and fracture it with a second instrument. I like to use this Sinskey hook, because it’s, again, very convenient. It’s atraumatic. The tip is short. And we just have one piece left. As you can see, I never go searching for the pieces. I just let them flow to the tip. I keep my tip in the center. And that makes the procedure very safe. So now we’re gonna do our bimanual I and A. To peel the cortex, it’s like peeling an orange. We go under the anterior capsule. Just grasp it and very gentle — peel it to the center. When we’re in the center, we increase our aspiration to aspirate the cortical material. Here we do the same. If you just get your tip without aspirating, you see that the court material will get into the tip. Look, if I bring it close and just aspirate a little bit, it’ll come to the tip, and then I can actually remove it quite easily. I’m getting the ones at 12:00. So having a bimanual I and A helps in the sense that you have good access to all parts of the capsular bag. So as you saw, prechopping the cataract makes it actually quite fast and easy. You cannot do this prechop in every cataract. You have to do it in the ones — again, very dense cataracts, it’s better to do a horizontal or vertical chop. And very soft cataracts, it’s better to do a supranuclear technique. So the lens is mounted. We’re gonna put the tip of our injector here — we’re gonna do the injection of the lens assisted by the wound. Light, firm pressure. And start injecting. So as you can see, the lens is upside down. So I’m gonna flip it. The advantage of this lens is that it’s very malleable. You can really move it very easily. So now we have it on the right position. And now we’re gonna aspirate our viscoelastic. Viscoelastic. We have a little viscoelastic left. So as you can see, it was a very straightforward procedure. Very safe. And we’re finished.