If the zonular structures are intact and normal, the anterior lens capsule should be taught, especially after instillation of viscoelastic.…
Little Technique to Rescue a Runout Capsulorhexis
The first time that I saw Brian Little, FRCS, FRCOphth demonstrate the technique for rescuing a runout capsulorhexis, I was…
When to Revert to a Can-Opener Capsulotomy
We have learned from the past two days of videos, that it is sometimes wise to revert to a can-opener…
Complications from a Failed Capsulorhexis
There is a great deal of learning from this video where a failed capsulorhexis leads to a host of issues…
A Bad Capsulorhexis leads to Trouble
Today we present another case, submitted by an anonymous surgeon for review. We applaud this surgeon for sharing this complicated…
Flip and Chop for Highly Efficient Cataract Surgery
Phaco flip is an efficient procedure since the initial hydro-dissection brings the nucleus out of the capsular bag. If we…
Persistence during Phaco Chop is critical
It is critical that you not give up on phaco chop as a technique but also within a surgical procedure.…
Poor Draping leads to more Complications
This case should be a routine, straightforward surgery with a low chance of complications. But that changes when the draping…
Vertical Chop Technique for Efficient Surgery
The vertical chop technique is a favorite of mine, particularly when there is sufficient nuclear density to allow the chop…
Please do NOT use the iris to guide Capulorhexis size!
Many surgeons use the iris or pupil size as a guide for capsulorhexis creation — but you should not. Do…
How to deal with a Mis-loaded IOL
There are occasions when we will be handed an IOL which has been loaded incorrectly into the injector system. It…
Switching from Vertical Chop to Horizontal Chop
Sometimes cataract surgery is like playing basketball or soccer: you know many different techniques and special moves, but the key…
Small Pupil Flomax Adventures (without a ring!)
This is a really fun cataract surgery. After tens of thousands of cases, an unusual or challenging clinical situation really makes…
Use the Chopper for Hemi-Nucleus Management
The chopper can do so much more than chop. It can be used to fixate the eye via the paracentesis,…
Shifting the Phaco Incision to treat Astigmatism
Our phaco incisions always have some degree of astigmatic effect by causing relaxation of the corneal curvature at that axis.…
Four Quadrant Chop & Conquer Technique
Many ophthalmologist in training start out by learning the four quadrant divide-and-conquer technique, which has a long history of being…
Pupil Stretch using Capsulorhexis Forceps
To stretch a small pupil, you actually don’t need special instruments. Using two instruments such as choppers, hooks, or manipulators,…
Why did this Phaco Chop fail to split the cataract?
In order to do a successful phaco chop, we need to make sure that the high vacuum level of the…
Using Purkinje Images for IOL Centration
Intra-ocular lens implants which are well-centered can provide better quality of vision for our cataract surgery patients. In the ideal…
Why you MUST learn Phaco-Chop (Resident Case)
A critical part of being an accomplished ophthalmologist is keeping up with the advances in your field. For cataract surgery,…
Avoiding Iris Prolapse when Sealing the Incision
When doing cataract surgery in patients with floppy iris syndrome, the iris has a tendency to prolapse via the phaco…
Tips & Tricks for Using Pupil Expansion Devices
While I don’t use them often, pupil expansion devices such as the Malyugin ring, are useful when performing cataract surgery…
Pupil Size in Pseudo-Exfoliation Cataract Surgery
Pseudo-exfoliation (PXF) syndrome can make cataract surgery more challenging because of the concomitant issues that exist in these eyes. The…
Treating Iris Bleeding during Cataract Surgery
Typically, modern day phacoemsulification cataract surgery is relatively bloodless because we are making incisions in the cornea and then operating…
Cataract Surgery after Pars Plana Vitrectomy
Three key points to consider when you perform cataract surgery in an eye with prior pars plana vitrectomy: Check the…
Hidden Nuclear Fragment during Cataract Surgery
When we break up the cataract during phaco surgery, we create many small little pieces which are then aspirated from…
Check under the Iris for Hidden Cortex Material
When performing cataract surgery for an eye with a moderate or small pupil, be sure to check under the iris…
Hydration & Sealing of Corneal Phaco Incisions
A properly constructed phaco incision will allow good access to the anterior chamber for cataract surgery and then will seal…
Ocular Albinism Cataract Surgery
Ocular albinism poses a number of challenges for cataract surgery. The patient often has concomitant nystagmus, underlying amblyopia, macular issues,…
Cataract Surgery in Retinitis Pigmentosa
While retinitis pigmentosa is considered a rare disease, it occurs with enough frequency that every cataract surgeon will encounter it…
Fixing a Radialized Capsulorhexis in manual ECCE
When I first started teaching residents about 20 years ago, we would have the residents do about 10 surgeries of…
Cracking the Posterior Plate in a Dense Cataract
With a dense brunescent cataract, one of the primary challenges is cracking the fibrous posterior plate of the nucleus. Using…
Dealing with Conjunctival Chemosis
We have covered the topic of the rules for an ideal phaco incision and one of them is to barely…
Bimanual Irrigation / Aspiration for Cortex
For most cases a coaxial arrangement of both the phaco and irrigation / aspiration (I/A) handpieces works very well. However,…
Floppy Iris Syndrome with Phaco Chop
We have a fun case here: the patient has a long-time history of Flomax (tamsulosin) use which limits his pupil…
What if the Capsulorhexis is too big?
Ideally, the capsulorhexis diameter should be slightly smaller than the optic diameter so that we can achieve 360° overlap. But…
For the Capsulorhexis: Femto or Forceps?
Was the capsulorhexis show in this photo done with a femtosecond laser, a micro-pulse electrical zap, or simply with capsule…
Surgical Exposure is Critical in Cataract Surgery
Head positioning and exposure of the surgical field is important for success in phacoemulsification. The patient should be supine with…
One-Chop Technique for Phaco Surgery
For a cataract with moderate nuclear density, splitting the nucleus into two halves can be sufficient for removal with phacoemulsification.…
Soft Posterior Polar Cataract Technique
This is a patient with a history of high hyperopia (+7.5 of hyperopia) and posterior polar cataracts since childhood. The…
Flatten the Anterior Lens Capsule with Viscoelastic
Using a Viscoelastic (also called Ophthalmic Visco-surgical Device, or OVD) to flatten the anterior lens capsule is a critical step…
Novice Surgeon attempts a Dense Brunescent Cataract
Today we feature a brave and talented young surgeon who has only about 30 cataracts of experience so far. And…
Managing Mild Iris Prolapse during Phaco
The iris can prolapse any time that a pressure gradient exists in front of, and behind the iris tissue. This…
Wound-Assist Technique for IOL Delivery
The switch from large-incision manual extracap cataract surgery to smaller-incision phacoemulsification was helped tremendously by the advent of foldable IOLs.…
Management of the Hemi-Nucleus in Cataract Surgery
Whether you do phaco chop or stop-and-chop, you will be left with two halves of the nucleus which then need…
Lifting the nucleus up though a small pupil
Here at CataractCoach, we have featured videos showing how to hydro-dissect a nucleus up, out of the capsular bag and…
Expansion Ring for Small Pupil Cataract Surgery
For small pupil cases, I prefer to do stretching in order to expand the pupil and then I can proceed…
Can we prevent negative dysphotopsia?
Jack Holladay, MD, MSEE was instrumental in describing the causes of negative dysphotopsias with his enigmatic penumbra explanation. Sam Masket…
IOL Calculations in Ultra High Myopia
Most people consider high myopia to be about -10 diopters or greater. We have covered this topic extensively in the…
Beginning Surgeon Stop-and-Chop Case
We did a survey recently and about 20% of our viewers indicated that they wanted more videos of novice surgeons…
Cataract Surgery with Traumatic Zonular Loss
Are you ready for a challenge? This patient is a relatively young construction worker who sustained a blunt traumatic ocular…
Adapting your Phaco Chop Technique to each Eye
I encourage ophthalmologists in training to learn multiple different nucleo-fractis techniques so that they can tailor the cataract surgery to…
Hydro-delineate if the Capsulorhexis is too small
Hydro-delineation is a valuable tool particularly in cases where the capsulorhexis is small because it allows us to separate the…
Hydro-Dissection versus Hydro-Delineation
Once the capsulorhexis has been created, it is helpful to use balanced salt solution to loosen and separate the cataract…
Hands or Machines: What is more important?
There is an old saying, “a good workman never blames his tools,” and that holds true for ophthalmic surgery as…
Cataract Surgery with Glaucoma Shunts
Los Angeles is an amazing city which is very diverse and when I am teaching the UCLA ophthalmology residents, we…
Phaco Incision Size: is smaller always better?
When it comes to incisions in the eye, it would seem that smaller is better. But is that always the…
The Patient Refuses Refractive Correction!
This 75 year old patient needs cataract surgery because her best corrected vision is 20/50 and it is becoming increasingly…
Draping is an Important Step of Surgery
Though we don’t often show the process of draping for cataract surgery, it is an important step of the procedure.…
The Adherent Posterior Capsule Plaque
This patient had a long-standing cataract with a very dense 4+ posterior sub-capsular component. Pre-operative vision was barely counting fingers…
Removal of a Posterior Capsule Plaque
When we remove the cataractous lens there is sometimes a posterior plaque that is adherent to the capsule. How do…
Technique for using Diamond Keratomes
Diamond keratomes are my favorite instrument for creating the main phaco incisions because they are exquisitely sharp and they make…
Particles in the Vitreous during Cataract Surgery
These small particles appeared in the anterior vitreous during what appeared to be a routine and uncomplicated cataract surgery. The…
Misloaded IOL in a Floppy Iris Cataract Case
Even the best surgical technicians can have a case where the IOL is misloaded into the injector. It is up…
Solution for Incomplete Phaco Chops
You’re an experienced phaco chop surgeon and you come across a case where you just cannot get the chop to…
IOL Power Estimation after Radial Keratotomy
My technician brought the patient to our biometer (Haag-Streit Lenstar) and it simply would not read the corneal power for…
Cataract Surgery Challenges with Prior Radial Keratotomy
This patient had prior RK (Radial Keratotomy) done a few decades ago for the treatment of myopia. The patient was…
Cataract Surgery after 20-cut Radial Keratotomy
We have covered the topic of cataract surgery in eyes with prior radial keratotomy (RK) but this case is unusual…
Some Simple Ophthalmology Mathematics
Ophthalmology has a large degree of math, particularly when it comes to refractive surgery. Our most commonly performed and most…
Surgically Treating Residual Astigmatism
Which do you choose: Limbal Relaxing Incision (LRI) or Laser Vision Correction (LVC) for treatment of residual astigmatism after cataract…
Routine Dense White Cataract Surgery
Finishing up our week of routine cataract cases, today we are reviewing dense white cataracts. In some parts of the…
Routine Phaco Chop Cataract Surgery
Continuing with our series about routine cataract cases, today we present a routine phaco chop surgery. The cataract is chopped…
Routine Flip-and-Chop Cataract Surgery
We have previously featured an instructional video for the Flip-and-Chop method of cataract surgery and there was a very strong…
Routine Toric Case with Surgeon-Loaded IOL
Again, time to learn from a routine case — this is the type of case that is your “bread…
Why I love Routine Cataract Cases
Many of the articles and videos here at CataractCoach.com feature unusual, difficult, or challenging cataract cases. These are fun videos…
What does the patient actually see?
When we examine patients, we are looking at their eyes and their pathologies from the outside seeing in. We can…
Bimanual Dexterity Improves Ocular Surgery
I tell my first-year ophthalmology residents to start doing daily tasks such as eating food, shaving, and brushing teeth with…
Surgical Approach for a Morgagnian Cataract
With a white cataract, typically the cortical layers opacify and may partially liquify, and that can make the surgery more…
Lost Capsulorhexis – here is the Solution
This patient is having cataract surgery but during capsulorhexis creation, the flap edge seems to get lost. And due to…
Cortical Spokes blocking the view for Capsulorhexis
In this cataract surgery, which is otherwise routine, the cortical spokes of the cataract are blocking the view right…
Basics of Limbal Relaxing Incisions (LRIs)
Every incision that is made in the cornea has an effect on its shape and therefore the astigmatism. For a…
Cataract Surgery after Prior Vitrectomy
Cataract surgery in an eye which has undergone a prior pars plana vitrectomy is different in many ways, including lens…
Cataract Surgery Learning Grid
During ophthalmology residency, residents are exposed to cataract surgery in steps, starting from the most basic and ending with advanced…
What I learned about Ophthalmology at age 5
I only remember a few things about kindergarten: playing handball during recess, watching Matilda eat paste, and learning the golden…
Cataract Surgery in Marfan Syndrome
Patients with Marfan Syndrome have a congenital, progressive weakness in the zonular structures which support the crystalline lens. As such,…
Temporal vs Superior Phaco Incisions
[Click link below for full video] Some surgeons prefer to make a superior phaco incision while others prefer a temporal…
Beginning Surgeon Cataract Case Analysis
Becoming proficient at cataract surgery is not easy and the learning curve is quite steep, particularly at the beginning. We…
How to remove stubborn sub-incisional cortex
During cataract surgery it is important that we remove all of the lens cortex in order to minimize post-operative inflammation…
Posterior Capsule Rupture & Anterior Vitrectomy
Early in the learning curve of cataract surgery, beginning surgeons end up with a posterior capsule rupture about 5% of…
Preventing and Treating Capsular Phimosis
The capsular bag contracts when we remove the thick cataract (4+ mm thick) and replace it with a thin IOL…
Comparison of Night Vision with Different IOLs
Patients often ask me if any of the new lens designs will give them youthful vision. The truth is that…
CataractCoach.com celebrates 100 articles/videos!
Thank you to all of our readers for their support over the past three months! We have kept up with…
Should you do a Primary Piggyback IOL?
In highly hyperopic eyes and nanophthalmic eyes the required IOL power can be very high, sometimes in excess of +40…
Cataract Surgery in Small, Hyperopic Eyes
Small eyes make cataract surgery more difficult in many ways: there is less working room in the eye, the IOL…
Salzmann Nodules and Cataract Surgery
Salzmann nodules occur at the limbus or peripheral cornea and can disrupt the ocular surface, even causing an irregular ocular…
Ocular Fixation during Capsulorhexis
Sometimes, even with systemic sedation, patients can have a strong Bell’s reflex under topical anesthesia and that makes it difficult…
Rescuing the Radialized Capsulorhexis
The capsulorhexis is an important early step of cataract surgery because it gives strength to the capsular opening so that…
Quiz: Persistent Corneal Edema – Why?
This 70 year old patient had successful cataract surgery about one month ago. There were no complications. The patient has…
YAG Laser Capsulotomy Techniques
Posterior capsule opacification (PCO) is common after cataract surgery. Even a perfect surgery by a master surgeon still leads to…
Soft Cataract Supra-Capsular Technique
How do you approach a soft cataract, such as a posterior sub-capsular or primarily cortical cataract, with very little nuclear…
Pre-Chopper Technique for Phaco Surgery
The Pre-Chopper instrument was developed by Takayuki Akahoshi MD from Japan and it allows the cataract nucleus to be divided…
Soft-Shell Technique for Viscoelastics
The Soft-Shell Technique for viscoelastic use in cataract surgery was developed by Dr. Steve Arshinoff as a method of getting…
Air Bubbles to Monitor Viscoelastic Retention
Does viscoelastic stay inside the eye when we inject it there to protect the corneal endothelium? Or does it get…
Dispersive vs. Cohesive Viscoelastics (OVDs)
Viscoelastics, also referred to as OVDs (ophthalmic visco-surgical devices), are viscous substances that allow us to make phaco-emulsification easier and…
Nucleus Chop with a 27g Cannula
It is the beginning of the academic year, which in the USA runs from July 1 (start) until June 30…
Efficient Cataract Surgery for Spastic Patient
Rushing during surgery, especially cataract surgery, is a bad decision. It can lead to complications which can cause a poor…
Self-Critical Analysis of Cataract Surgery
For surgeons it is important to be self-critical in oder to continually advance our surgical skills and judgment. The goal…
Flip and Chop early in the Learning Curve
Phaco Chop is my preferred technique of nucleus removal during cataract surgery because it is safe, efficient, and uses much…
Cataract Surgery in Fuchs’ Corneal Dystrophy
Fuchs’ endothelial dystrophy is a disorder in which the corneal endothelium becomes progressively weak, leading to corneal decompensation and decreased…
Phaco Chop with Floppy Iris Syndrome
Many of our male patients take medications to help with urinary flow such as alpha-1 antagonists, the most common of…
Cataract Surgery is always Teamwork
When we watch videos of cataract surgery it seems like a solo act by the surgeon. While the surgeon is…
Basic Principles of Ophthalmic Suturing
I tell my residents that no one is born knowing how to place 10-0 nylon sutures, but rather it is…
Single-Piece Acrylic IOL Injector Loading
All beginning cataract surgeons must know how to load the IOL into the injector for cataract surgery. While this seems…
Slow Motion Analysis of Phaco Chop
When we are watching a cataract surgery video to learn techniques from others, it is often difficult to understand the…
Cataract Surgery with a very shallow Anterior Chamber
This small eye suffered from angle closure and subsequent development of a white cataract. The angle closure was successfully treated…
Cataract Surgery Technique in Highly Myopic Eyes
We have previously featured an article about doing cataract surgery in these highly myopic eyes, so we will focus on the surgical…
Cataract Surgery in Keratoconus
Patients with keratoconus, like all patients, eventually develop cataracts. However, cataract surgery in these keratocomic eyes is not the same…
Slow Motion Analysis of Phaco with EDOF IOL
Among our most popular features is the slow motion analysis of cataract surgery: when we slow down the video, we…
Choosing Refractive Targets to maximize Depth of Field
From this photo it is obvious that the aperture size of a camera makes a large difference in the depth…
Why did we get a Phaco Wound Burn?
The cornea is a very delicate tissue: it’s thin, clear, avascular, and susceptible to damage, particularly from the heat that…
Divide-and-Conquer Technique
To facilitate removal of the cataract nucleus with the phaco probe, it is helpful to divide it into quadrants or…
Recovering from a Hole in the Posterior Capsule
The posterior capsule is very thin (usually about 4μm) and very delicate and in the course of cataract surgery, it…
Stop-and-Chop Technique for Cataract Surgery
The Stop-and-Chop technique for nucleus removal during cataract surgery blends aspects of the Divide-and-Conquer method with some Phaco Chop. Some…
Complex Cataract: multiple challenging issues
This patient had a large rhegmatogenous retinal detachment repaired a few years ago with a successful pars plana vitrectomy. The…
A Sudden Sneeze or Cough during Cataract Surgery
Patients often ask us, “What happens if I have to sneeze or cough during cataract surgery?” And it’s a valid…
Another Corneal Laceration with Traumatic Cataract
Another patient presented to our resident ophthalmology clinic with a 1 day history of doing construction work on a roof…
3 Golden Rules for Patient Discussions
Physicians need to understand importance of patient discussions regarding surgery Letting patients speak, making a specific recommendation, and explaining what…
Why is phaco chop not working here?
This patient certainly needs cataract surgery because the dense nucleus has a large degree of central opacity and that has…
Femto Laser Incisions: Good or Bad?
The femtosecond laser is a powerful tool for ophthalmic surgery. While its use in creating corneal refractive surgery is widely…
Bleeding from Pupil Expander! Now What?
Pupil expansion devices can be helpful to provide sufficient dilation in cataract surgery. This video features guest surgeon Ravi D. Goel,…
What is the secret to a perfect capsulorhexis?
When I examine an eye that had previous cataract surgery years ago, I see two things: the incision and the…
The Curse of the Baby Rhexis
This case is brought to you in conjunction with EyeGuru.org, an excellent resource for both ophthalmologists in training and ophthalmologists…
Corneal Laceration with Ruptured Lens Capsule
At our busy UCLA-affiliated teaching hospital, Olive View-UCLA Medical Center, we frequently get severe ocular trauma including ruptured globes. We…
A Cataract is not always what it seems…
Since we’ve spent so many years studying ophthalmology, the subtleties of our field become second nature to us. We can…
Slow Motion Analysis of Cataract Surgery
There is a lot to be learned from slow-motion analysis and this applies to cataract surgery as well. Think of…
Step-by-Step Technique for Toric IOLs
Toric IOLs can provide the added benefit of addressing astigmatism at the time of cataract surgery. They are available in…
Alignment and Centration of Toric Multi-Focal IOLs
[From CataractCoach.com] New technology has given us the ability to address corneal astigmatism and presbyopia with a toric multi-focal IOL.…
Nevus of Ota Cataract Surgery
Nevus of Ota refers to hyperpigmented lesions on the sclera as well as peri-ocular skin. The color tends to…
3 critical differences in Cataract Surgery for patients over Age 90
Average life expectancy is at an all-time high in the US at 79, with even better news for…
I teach all young surgeons these 3 Tenets for Success
It’s hard to boil down decades of a career into three easy tenets, but the key principles needed for surgical…
The Informed Consent Process for Cataract Surgery
As ophthalmologists, we know the most about cataracts and the potential benefit to our patients of any planned cataract…
Video Review: Posterior Polar Cataract Bowl Technique
This video is from Dr. Ravi Prasad Challa from Hyderabad, India and it shows his bowl technique for performing cataract…
50 Articles / Videos on CataractCoach.com
CataractCoach.com was launched in May and we have kept up with the goal of posting a new teaching article /…
3 tricks for Small Pupil + Flomax Cataract Surgery without Expanders or Iris Hooks
Can you do cataract surgery in an eye with a small pupil without having to use expanders or iris…
If you see VMT on OCT, do not do cataract surgery!
When we do cataract surgery, we remove a relatively thick human, crystalline lens and we replace it with a…
20% of Cataract Patients have an Epi-Retinal Membrane
We must critically evaluate the retina before cataract surgery. When our cataract patients report a decline in vision it is…
The Rule of Nines for Sulcus IOL Power
From CataractCoach.com: With newly developed methods of IOL power calculation, we are approaching 90% or higher accuracy of achieving +/-…
Congratulations new ophthalmology graduates: Are you ready for your first job?
The academic year in the US ends on June 30, which means that every July a new group of about…
Improving Efficiency in the Operating Room
Keep track of all times during your next surgery date to see where you can make improvements. A good surgeon…
3 Rules for Maneuvering Instruments in the Eye
Intra-ocular procedures pose the surgical challenge of working within a very small space with limited room in which to maneuver…