With a dense brunescent cataract, one of the primary challenges is cracking the fibrous posterior plate of the nucleus. Using a traditional divide-and-conquer, stop-and-chop, or even quick-chop technique can be difficult because the chop or cracking starts anterior and will not propagate well to the posterior plate. To address this issue, Dr Paulo Falabella and Professor Milton Yogi have developed the retrochopper, which is placed behind the prolapsed nucleus to start the chop in the dense posterior plate.
I agree with this approach and in this case, in order to access the posterior aspect of the lens nucleus, the chopper is used to secure the lens equator and then the entire cataract is dialed out of the capsular bag and then tilted. At this point, my standard chopper is used to break apart the nucleus starting from the posterior plate. This nucleus is dense and it requires many chops to break it up into smaller pieces which can then be phaco-aspirated.
For dense brunescent cases, the key points for the cataract surgery are:
- create a sufficiently large capsulorhexis, at least 5mm in diameter. Even larger such as 5.5 or 6mm would be even better
- use a good dispersive viscoelastic to protect the corneal endothelium from ultrasonic energy
- employ phaco power modulations such as burst, pulse, and variable duty cycle to limit the total phaco energy placed in the eye
- be careful not to cause a phaco wound burn by using a larger silicone sleeve and having a slightly leaky incision
- if needed, re-coat the corneal endothelium with dispersive viscoelastic during the case to protect it
- there will be very little cortex so be careful when removing the last nuclear piece to avoid contact with the posterior capsule
- these patients may have more inflammation and require a longer or more potent course of steroids to aid in healing
Click below to watch the video of this dense brunescent cataract surgery
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Excellent case. As the nucleus stands vertical in the bag, are you concerned about capsular bag tension posteriorly?
There was an amazing video from Bob Osher MD (one of my favorite mentors of all time) who go cadaver eyes, took out the cataracts, and then placed actual small rocks and pebbles from his garden into the capsular bag. These were tossed around inside the eye with high flow infusion and he proved that the capsular bag would not break from contact with a cataract or cataract piece, even if the nucleus was as dense as a rock. I’m convinced!
Wow…great case. Are you concerned about the enormous stress on the zonules during the flip? It looked like the lens was pulled towards the surgeon at least 2 mm
Good points. No more capsular stress than doing divide and conquer where the pieces are separated and outward force is placed on capsule. At the end of the case the zonular integrity looks good.
According to my practice, there is no posterior plate problem. The problem is wholly hard cataract itself, and the solution is “to solve the lens”. Though, all we know there are very lot to comment about very hard cataracts, firstly I think any technique must be possible to apply all cases; otherwise there must be a second technique ready along with it. 1.Could we apply any force in case of zonular weakness to bring that kind of lens(es) out of the bag? Would it be safe for zonules? 2.Could we turn the lens upside down in case of shallow AC or again, bring the lens out of the bag?
I think; 1.We must be using vertical and horizontal direct chop techniques very effectively 2.And we also must be ready for limitless improvisation while using these techniques, “~no-names”. The main sensor to rely on is not in the phaco; it is us. We must watch the “answers” within the eye for what we did and what we get, and change the decisions momentarily and continuously. My basic algorythm, shortly, is, 1.”what the posterior plaque do to us?” “it limits the movements of the lens especially for not directing to phaco tip” 2.”Why?” “Because it holds other parts all together so the lens remains as a whole” 3.”Okay, then make the posterior plaque {leave alone}”.
Then we need a series of improvisations and we must be ready for them.
Best regards,
Erhan Peksen MD