Surgery: Phacoemulsification in Cortical Cataract

A cortical and mostly subcapsular cataract. We see how the correction is opaque, coming to the center. And back with the reflex, we see that it’s a dense subcapsular cataract. The hardness of the nucleus — it’s not so dense. We classify it as an N2. I like to use the Barraquer classification from Barcelona, which goes from 1 to 10. So in this classification, it is very important to understand the hardness of the nucleus. Because it’ll allow us to choose the preferred technique for the nuclear disassembly. So this one is more of a softer nucleus. So first what I like to do is to do two paracenteses. In these cataracts, always a good idea to stain the capsule. So now we’re gonna put some Viscoat, which is dispersive viscoelastic. I like to do the soft shell technique. So it basically coats the endothelium. And then we’re gonna place some Provisc, which is a cohesive viscoelastic. The advantage of the cohesive is it pushes — again, creates space, pushes the Viscoat towards the endothelium, with a very good coating. And now we’re gonna perform our main incision. So we’re gonna go lamellar, and then we go into the anterior chamber. By doing that, we made it in two steps, and it creates a good beveled self-sealing wound. Here because the eye is still, we actually don’t need to fixate it with forceps. We’re gonna have to do a small incision in the center. And then we’ll lift a little flap of the anterior capsule. Once we lift it, we can basically push it. So now we grab the edge of the flap and we pull. So the farther away we are from the edge, the less control we’ll have on the capsulorrhexis. The shorter the distance, the more control that we’ll have. So as you can see here, I grasp it, and then the pull that I have to do is when we’re at this stage — is towards the center. And here’s a very good trick for hydrodissection. What we want to do is go with the cannula. Apply the tip of the cannula on the anterior capsule. Then go backwards and inject. And you’ll see the wave go in. And now we know that we’ve loosened that nucleus. Here we’ll do it again. And here we’re gonna do a technique that’s a nuclear prechop. So we fill the anterior chamber, again, with some viscoelastic, to generate good space. I like to use these prechoppers. They’re called Dodick prechoppers, as you can see. So I go through the paracentesis. Get under the capsule. And engage the nucleus in the equator. Then I’ll go through the main incision. And do the same opposite. And bring them together. And break the nucleus in two. And then I’ll do the same over here. Engage it and break the nucleus. So now we have three pieces. We’ve prechopped the nucleus. And again, if we have prechopped it, it actually makes our procedure much, much easier. So a good recommendation is to have the opening of the sleeve towards the side. We don’t want that liquid pouring into the endothelium. So now we’re gonna proceed and remove each of the quadrants. Very gently. We grab. And here they come. So here we’ve got the first one, which makes it actually very, very easy. As you can see, I find that the anterior chamber is collapsing slightly. So I’m gonna raise the IOP to 75. That way, I have a more stable chamber. So here, we’re gonna go for the second piece. We removed one. Again, it’s a very gentle maneuver. You don’t have to do anything forceful. Trying to rotate the nucleus. So here we’ve dislodged it from the cortex, and here, we got it. So now we have the second piece out. And we can proceed to remove the last piece. So now I’ve got the last piece, and I go ahead and chop it. As I said, it’s not a very, very dense nucleus. Dense enough for us to remove it. So this is the epinucleus, as you can see. So here we grab it. Very gently. And bring it in through the rhexis. Held myself with the second instrument. So here in this portion of the procedure, we have again our flow very low. We don’t want to really do anything fast or rush it. We want it to be very safe. Sometimes, as you probably noticed, they’re stuck to the capsule. So very gently, we just move them and try to dislodge them from the capsule. So here, as you saw, our hydrodissection — it was good, but it wasn’t complete. So it left some of the cortex attached at this point. And that made it a little bit difficult to remove it. But again, with patience, if you just try to dislodge them, disengage them, it’ll work perfectly. Sometimes the cortical material is tougher than even the nucleus. And now we have it. It’s always important to use your second instrument, again, to fit the pieces into the phaco tip. And then we’re finished. So now we’re gonna do a bimanual I and A technique. We can actually fill in the anterior chamber with viscoelastic. Fill in the bag. So we want the pressure inside the eye to be actually firm, because we’re gonna push the lens into the eye. So we want it to be firm. So here we’re gonna implant the lens. Always directing the lens towards the posterior portion of the eye. So it goes into the bag. As you can see, initially it was slightly blind, but we were able to do it. So here we’re removing the viscoelastic. It’s important to remove it completely. We don’t want post-op hypertension. I like to get under the lens. And remove the viscoelastic from under. And once we’ve finished, as you can see, the chamber is very stable. The capsule is perfect. The lens is in the bag. So we’re gonna hydrate the paracentesis. I don’t like to hydrate the main incision, as it’s beveled. So we really don’t need it. And we finish our case.