The eye is like an under-inflated balloon: the low pressure inside allows it to absorb most jabs without being punctured.…
What beginner mistakes do you see in this pic?
Learning intra-ocular surgery is not easy and it can take years just to be comfortable with just the basics. Look…
IOL Calc Quiz: Why such different results?
A fan of CataractCoach has asked for input regarding the IOL calculations for his patient with steep keratometry. When he…
OCT analysis of Pseudo-Exfoliation Cataracts
Patients with pseudo-exfoliation (PXF) syndrome are known to have deposits of fibrillar material throughout the anterior segment. This is most…
Various Approaches to removing the Epi-Nucleus
When we perform hydro-delineation, we separate the dense endo-nucleus from the relatively soft epi-nucleus. This is helpful in multiple different…
Guest Surgeon: Femto & Capsular Tension Segments
This is a tricky case: a traumatic cataract with extensive zonular loss and weakenss in a younger patient with high…
Twist Technique to Easily Explant the IOL
There are times when we need to explant an IOL from the eye. This can be at the time of…
Double Capsulorhexis to prevent Capsule Run-Out
using the double capsulorhexis technique to deal with an errant tear in cataract surgery
Proper Form for using a Keratome Safely & Precisely
you must learn proper form for keratome use in cataract surgery
Guest Surgeon: Cataract with prior Trabeculectomy
This is a great video submitted by Dr. Mohammed Ghoneem from Alexandria, Egypt where he shows his method for successful…
Be Cautious with the Wrinkly Old Bag
This is one wrinkly old bag! Of course, we are referring to the capsular bag in this cataract surgery. This…
Cataract Surgery and Pars Plana Vitrectomy
There are cases where a patient has both anterior and posterior segment pathology and doing both a cataract surgery plus…
Hydro-delineate for a dense central nucleus
When you see a patient with a dense central endo-nucleus, there are characteristic findings: a lens periphery that is relatively…
Ruptured Capsule Rescue & Anterior Vitrectomy
Very important learning case of a posterior capsule ruptured then a rescue including anterior vitrectomy.
What is the 7L rule for haptic orientation?
You must know instantly if the IOL is being implanted in the eye correctly. We have explained how the IOL…
Resident Surgeon Struggles with Phaco Chop
In this anonymous video, a resident surgeon struggles with phaco chop. It is not an easy technique to learn, which…
Cataract Surgery in Pigment Dispersion Syndrome
Cataract surgery in patients with Pigment Dispersion Syndrome can be challenging due to the anatomic changes which have happened over…
Inject more OVD before manipulating the IOL
When we insert the IOL, sometimes viscoelastic will be lost via the main incision. This can happen if we gape…
Use the Chopper to protect the capsular bag
We work in a very tiny space of just a fraction of a milliliter: the volume of the anterior chamber…
Technique to suture an IOL to the iris
Sometimes, the IOL can dislocate after surgery and in the case of a three-piece IOL, we can easily suture the…
Understanding Reflux Mode during Phaco
Reflux mode is when you use the foot-pedal to reverse the fluidic pump of your phaco machine. Instead of aspirating…
use of an AC maintainer in Cataract Surgery
An anterior chamber maintainer is an additional infusion cannula which is inserted via the cornea or limbus in order to…
Focal lens opacity after intra-vitreal injection
This patient had multiple prior intra-vitreal injections for macular disease and now presents to you for cataract surgery. Upon examination…
What is the secret to patient fixation during surgery?
Many ophthalmologists have asked me how my patients are able to maintain fixation during cataract surgery under topical anesthesia. In…
Failure to Pivot in the Incision causes Issues
One of the most common mistakes made by novice surgeons is the failure to pivot in the incision. This causes…
Use of a Simcoe Cannula in Cataract Surgery
This video features guest surgeon Rob Melendez MD from New Mexico, USA. Dr. Melendez is a highly talented surgeon with…
The posterior capsule is wide open – now what?
This is a great learning case from one of our young surgeons in training. The video is 14 minutes long…
Prevent posterior extension of a capsular break
This is a resident case that you really must learn from, even if you are an expert. During nucleus removal…
Bimanual Irrigation / Aspiration Technique
Bimanual irrigation / aspiration can be helpful to access a full 360 degrees of cortex, keep the anterior chamber maintained,…
Beginning Surgeon Learns Phaco Chop – so can you!
You’ve seen countless videos of phaco chop, but you seem to be stuck in a mode of less efficient techniques…
Controlled IOL delivery during Cataract Surgery
In the past few days we have shown cases where the IOL delivery was less than ideal. This resulted in…
Good versus Bad Corneal Phaco Incisions with OCT
The phaco incision is critical to the success of the cataract surgery. It gives us controlled access to the cataract,…
Misloaded IOL leads to fractures of the optic
In this case, an ophthalmologist in training is performing this surgery during his residency program. The case looks great, but…
Misloaded IOL shoots out of the injector
The new scrub technician was working with us for the first time. She had previously assisted with ophthalmology surgeries in…
Mystery Case: What are these linear marks?
You’re doing a routine case and it is progressing beautifully. A good incision, a centered 5-mm capsulorhexis, efficient nucleus removal,…
How to safely remove a nuclear piece near the incision
Sometimes during cataract surgery a small piece of lens material, typically a small nuclear chip, can get stuck in the…
Quiz: Should you implant a Toric IOL in this eye?
The patient is 70 years old and the corneal scar of the left eye is about 80% depth within the…
I missed this Posterior Polar Cataract
This case caught me by surprise: in the pre-operative notes this was listed as a posterior sub-capsular cataract, but when…
Posterior Polar Cataract by Resident in Training
This is another case of a posterior polar cataract, this time performed by a resident in training. She does a…
Expert Technique: Small Pupil & Dense Cataract
Very experienced surgeons never rest — they are always looking to learn more. Like you, I learn a lot from…
Measure the Capsulorhexis for best results
The capsulorhexis is important for successful cataract surgery because it gives the capsular opening strength during cataract removal and allows…
Why is this patient yelling at me and the staff?
This is a routine cataract surgery that goes well and without complications. What is unusual about this case is the…
OCT analysis of a corneal phaco incision
For teaching my resident surgeons who are completing their years of ophthalmology training at our UCLA hospitals, we have recently…
Avoid Posterior Pressure from the Speculum
We need to place a lid speculum to get the best exposure for cataract surgery, but if we crank it…
Pupil Ring placed in one movement, but there is a catch…
I wanted to try a new technique: placing all 4 scrolls of the Malyugin ring on the iris in one…
Descemet Detachment at the Phaco Incision
When we construct our corneal phaco incisions, we must be careful to give them the proper architecture and form. We…
Radial Wrinkles mean aspiration of the capsule!
These radial wrinkles emanating from the port of the irrigation/aspiration probe are in the posterior capsule. This happens when we…
IOL Calculation Quiz: Ultra-High Myopia
Happy New Year! We are introducing a new feature to CataractCoach.com for 2019: critical evaluation of biometry, IOL calculations, and…
Why is the pupil peaked during this cataract surgery?
The iris is a fluid tissue that moves within the eye in response to the fluidic changes of cataract surgery.…
Adjusting the sleeve of the Phaco and I/A tip
For coaxial instruments like the phaco probe and the irrigation/aspiration probe, what is the best position for the silicone sleeve…
Should we do bilateral same-day cataract surgery?
On rare occasions, I will do immediate, bilateral sequential cataract surgery so that a patient can have both right eye…
After the chop, you must physically separate the nucleus
When doing phaco chop, remember that you must still physically push apart the nuclear halves to achieve complete separation and…
Which direction do you rotate the IOL?
Which way should you rotate the IOL, clockwise or counter-clockwise? The answer is… it depends. If the IOL haptics are…
Should you use 2 hands for the capsulorhexis?
The capsulorhexis is one of the most important and most challenging steps of cataract surgery. When you are performing the…
Loose Zonules become evident during Capsulorhexis
This is a patient who had an unremarkable pre-operative consultation for cataract surgery, but when we came to the operating…
Moderate Floppy Iris Syndrome: Avoiding Prolapse
This patient took Flomax (tamsulosin) a few years ago for a brief period of time. He later stopped the medication…
Cataract Surgeons are Refractive Surgeons
Cataract surgeons are certainly refractive surgeons and we can correct large degrees of myopia, hyperopia, and astigmatism during our lens-based…
Important Lesson from a Misloaded IOL
I had a case recently, where the surgical assistant told me that he was having difficulty loading the IOL into…
An easy way to help seal the phaco incision
If your phaco incision is properly constructed, it will typically seal quite well without the use of sutures. We can…
How far into the eye do you insert the keratome?
When making your phaco incision, it is important to have the appropriate tunnel length as well as incision width. We…
Novice Surgeons: Spiral Out the Capsulorhexis
When you watch experienced surgeons doing a capsulorhexis, it looks so easy. The anterior capsule is opened, a flap is…
Persistent attachments with femto-laser capsulotomy
This young patient (about 40 years old), developed a white cataract which has severely impaired vision in this eye for…
Routine case, but what’s this line on the capsule?
This is a perfectly routine cataract case and it goes beautifully. But then, at the end of the case with…
This is why I do LRIs at the end of the case
Limbal relaxing incisions (LRIs) are useful for treating mild to moderate degrees of corneal astigmatism at the time of cataract…
Pre-Chop the Nucleus to Help a Novice Surgeon
Today we have a video of a novice surgeon operating together with an experienced surgeon. The key maneuver in this…
Critical Lesson: Giving the Benefit of the Doubt
Sometimes you will examine a patient who had surgery elsewhere and you can tell that there were challenges and complications.…
Match the Phaco Incision to the Limbal Relaxing Incision
We know that the phaco incision will cause some degree of corneal flattening and this has the ability to alter…
How important is Capsule Polishing in Cataract Surgery?
In modern day cataract surgery, we remove the lens material which keeping the capsular bag to hold the IOL. How…
Cataract Surgery in Deep Set Eyes
Performing intra-ocular surgery in a deep set eye is challenging because the access is limited. In the case shown here,…
Making the Ideal Single-Plane Phaco Incision
Many of the more advanced cataract surgeons prefer a single-plane phaco incision because its consistent architecture makes for great sealing.…
Why did the IOL Haptic get stuck to the Optic?
We use thin IOLs which are then placed into injectors which roll, fold, or compress the them so that…
Guest Surgeon: Capsular Bag Power Wash Technique
Our guest surgeon, Dr. Anton A. Eijpe from the Netherlands, demonstrates his technique of capsular bag power washing using balanced…
How to Split the Cataract if the Chop is incomplete
Sometimes when we perform phaco chop, the lens does not fully divide. The chop scores and partially splits the nucleus,…
Complete Toric IOL Case: from Marking to Alignment
Toric IOLs allow us to surgically treat corneal astigmatism at the time of cataract surgery thereby providing our patients with…
Phaco Flip in Post-Vitrectomy and Flomax Cases
Phaco flip has an advantage over other methods of nucleus division: the cataract is already partially out of the capsular…
I/A Only Technique for a Very Soft Cataract
This patient is young, about 30 years old, and he developed a very dense and large posterior sub-capsular opacity which…
Horizontal Phaco Chop for Efficient Cataract Surgery
The original phaco chop technique described by Dr. Nagahara in 1995 was the horizontal chop. This involves holding the lens…
Making the Capsulorhexis without a Cystotome
The classic teaching is to use a cystotome (a sharp, bent 25ga or 27ga needle) to puncture the anterior lens…
Guest Surgeon: White Cataract Stop-and-Chop
It is good to learn from various techniques from many different surgeons. You get to see the differences and similarities…
Should you try to rescue a dropped nucleus?
For most situations, I recommend that if the cataract nucleus drops into the vitreous cavity due to a ruptured posterior…
Wait! Is the Posterior Capsule Ruptured?
In this video which was submitted anonymously, the guest surgeon had a routine case with an intact capsulorhexis. But then…
Hydro-delineate if the Capsulorhexis appears small
In this picture, the capsulorhexis appears to be on the small side, but it is actually just about perfect with…
IntraCameral Medications during Cataract Surgery
Putting medication directly into the anterior segment of the eye can be very effective. There are many different medications that…
How to inject a 3-piece IOL when the haptics twist
When we inject a three-piece acrylic IOL into the eye, we must be very careful to ensure that the IOL…
Tips & Tricks for High-Power IOL Delivery
A high-power IOL is not the same as an IOL with an average power, primarily because the increased power of…
Thank you for our first 200 posts on CataractCoach.com
Today we celebrate the 200th post on CataractCoach.com since we started just 6 months ago. We have kept up with…
Use Multiple Small Chops for a Brunescent Cataract
In previous videos, I have shown my technique for breaking up a dense brunescent cataract with a fibrous and tough…
Resident IFIS / Iris Prolapse Cataract Case
Intra-Operative Floppy Iris Syndrome (IFIS) occurs primarily with the use of systemic tamsulosin (Flomax), a medication that aids in urinary…
If the view is cloudy, remember the capsulorhexis margins
When the cortex gets opaque, it makes the visualization poor because it blocks the red reflex from retro-illumination. Sometimes, the…
Phaco Chop with Surgeon-Loaded Toric IOL
Yesterday’s video was a complete toric IOL case from marking to alignment, however the IOL was loaded by the technician…
The Angle Sweep Technique to Remove Viscoelastic
When we fill the eye with viscoelastic, we push it with the greatest force into the opposite angle of the…
Learning from an External View of Phaco Chop
Most of the videos on this site are taken through the operating microscope. This gives the view of exactly what…
Traumatic Cataract: What is your surgical approach?
This 42 year old patient sustained an airbag injury to his face a few months ago. He noted cloudy vision…
Radial Wrinkles are a sign of Weak Zonules
If the zonular structures are intact and normal, the anterior lens capsule should be taut, 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…