Try this technique to increase safety and provide the best visual outcome for your patients with posterior sub-capsular cataracts. (scroll down for full surgical video)
You’ve seen this type of patient many times: a relatively rapid decline in vision over the course of weeks or months with increased glare and issues with oncoming light. With the high contrast Snellen chart, the patient may still be able to achieve 20/40 vision, but with glare testing that drops rapidly, often to 20/200 or worse. These patients are also on the younger side of the spectrum and they may have higher demands for their vision since they are still driving and working. In order to maximize the margin of safety for these posterior sub-capsular cataract (PSC) patients, we can use specialized techniques during cataract surgery.
When we examine these patients at the slit-lamp microscope, the nucleus has only mild to moderate sclerosis and opacity, while there is a central, granular opacity at the posterior capsule. PSC cataracts are associated with diabetes, use of corticosteroids, retinitis pigmentosa, vitamin D deficiency, high myopia, and more.
Typical techniques of nucleus division such as vertical chop, horizontal chop, and divide-and-conquer do not work well if the cataract is primarily PSC with very little nuclear sclerosis. In a young patient with minimal nuclear sclerosis and a soft lens, the groove in divide-and-conquer would have to be very deep, almost the full thickness of the lens, and very close to the posterior capsule in order to get the halves to separate.
For these cases, a better technique may be to use hydro-dissection and hydro-delineation to bring the soft nucleus out of the capsular bag an into the iris plane where it can be aspirated easily. This creates a larger space between the cataract material and the posterior capsule to help avoid inadvertent touching and rupture.
Watch the video here to see how I approach these cases, and then please leave a comment at the end of this post to tell me your technique. Thank you.
Excellent sx ,Sir.
Supracapsular phacoemulsification is the best approach to prevent swiss cheese in bowl or plate .
Yes, I certainly agree. Young surgeons in training should learn to master many different techniques to successfully operate on many different types of cataracts.
I will also perform both hydrodissection and hydrodelamination . Epinucleus management is little bit tricky. I prefer to do viscodissection of the epinucleus before aspiration. With viscodissection once the one edge of the epinucleus bowl comes out of the capsular fornix rest of the epinuclear bowl can be flipped and safely aspirated.
Good ideas. Thank you for your comment.
Great technique. Thank you for teaching me it back in residency at Jules Stein in 2007. It is my go to choice for soft cataracts. Like all good surgeons it is also wise to have a back up. In particular, if my rhexxis is on the smaller size (less than 5 mm) it makes it more difficult to safety prolapse the nucleus into the anterior chamber. In those situations I will do a gentle hydrodissection attempt (not firm enough to cause possible lens block and pc rupture) to prolapse the lens. If it doesn’t prolapse I then viscodelineat the lens and groove 1 or 2 deep segments. I then attempt to crack those segments. If segments are too soft to safety crack I then do a modified horizontal chop. In other words I gain purchase / aspirate mid nucleus bringing it central while I place my ball tipped chopper (Seibel or other) peripherally under the capsule and chop the segments and feed it to my phaco probe. Then I do not hesitate to remove the sticky epinucleus that can sometimes remain on these softer often younger cataracts with my soft tip I/A. Sometimes helps to rough up the cortex inder polish mode prior to IAing it. Thanks again for being an amazing teacher Dr Devgan!
Great technique. Thank you for teaching me it back in residency at Jules Stein in 2007. 🙏
It is my go to choice for soft cataracts. I prefer a rhexxis size of 6 mm for prolapsing Out of the bag. Like all good surgeons it is also wise to have a back up plan. In particular, if my rhexxis is on the smaller size (less than 5 mm) or the nucleus is deceivingly more dense than anticipated it makes it more difficult to safety prolapse the nucleus into the anterior chamber. In those situations I will do a gentle hydrodissection attempt (not firm enough to cause possible lens block and pc rupture) to prolapse the lens. If it doesn’t prolapse I then viscodelineat the lens and groove 1 or 2 deep segments. I then attempt to crack those segments. If segments are too soft to safety crack I then do a modified horizontal chop. In other words I gain purchase / aspirate mid nucleus bringing it central while I place my ball tipped chopper (Seibel or other) peripherally under the capsule and chop the segments and feed it to my phaco probe. Then I do not hesitate to remove the sticky epinucleus that can sometimes remain on these softer often younger cataracts with my soft tip I/A. Sometimes helps to rough up the cortex inder polish mode prior to IAing it. Thanks again for being an amazing teacher Dr Devgan!
Final edit 😀
Great technique. Thank you for teaching me it back in residency at Jules Stein in 2007. 🙏
It is my go to choice for soft cataracts. I prefer a rhexxis size of 6 mm for prolapsing Out of the bag. Like all good surgeons it is also wise to have a back up plan. In particular, if my rhexxis is on the smaller size (less than 5 mm) or the nucleus is deceivingly more dense than anticipated it makes it more difficult to safety prolapse the nucleus into the anterior chamber. In those situations I will do a gentle hydrodissection attempt (not firm enough to cause possible lens block and pc rupture) to prolapse the lens. If it doesn’t prolapse I then viscodelineate the lens in order to make good space between the nucleus and epinucleus (using the epinucleus as a barrier between my phaco probe and capsule) prior to making 1 – 2 deep grooves. I then attempt to crack those segments. If segments are too soft to safety crack I then do a modified horizontal chop. In other words I gain purchase / aspirate mid nucleus bringing it central while I place my ball tipped chopper (Seibel or other) peripherally under the capsule and chop the segments and feed it to my phaco probe. I literally allow the nucleus to fold like a hinge in the grooves I had made. Then I do not hesitate to remove the sticky epinucleus that can sometimes remain on these softer often younger cataracts with my soft tip I/A. Sometimes helps to rough up the cortex inder polish mode prior to IAing it. Thanks again for being an amazing teacher Dr Devgan!
Thanks Dr Khoubian. I appreciate your participation on my new website. Please come back often and tell your colleagues!
Sir, in continuation to this video,sometimes there is posterior capsular opacification of posterior capsule or remnants of cataract which are very sticky to PC and if the case is for Multifocal IOL then it becomes dilemma to put this lens or to go for monofocal iol. How do you deal with these situations?? Is posterior capsulorhexis an option ??