Review: External View of Cataract Surgery Steps

Two of the most critical steps in cataract surgery are the main phaco incision and the capsulorhexis. Properly completing these two steps sets up the rest of the surgery for success. A good incision allows us to access the anterior chamber, keeps the surgical fluidics stable, and allows for easy insertion of the IOL. This incision will also seal well with a minimal astigmatic effect. The capsulorhexis is important for its strength and resistance to tear out during nucleus removal and to securely hold the IOL optic for a stable and predictable refractive outcome.

Watching these two steps from an external angle, outside of the microscope view, shows us the subtleties in the positioning and movement of the instruments.

For the phaco incision:

  • the fixation ring gently holds the eye without pushing it into the orbit
  • the keratome is used to make a fine, partial depth groove at the gray line near the limbus
  • the appropriate angle between the keratome and ocular surface is achieved
  • controlled insertion of the keratome at the correct angle creates a good tunnel length
  • the keratome is only inserted until its widest part penetrates the anterior chamber

For the capsulorhexis:

  • the forceps always pivot within the incision, not hitting the sides of the wound
  • the forceps do not push down or lift up on the incision
  • the pivoting motion allows the circular capsulorhexis to be completed
  • controlled movement of the forceps tips makes for control of the capsulorhexis

click below to learn from this external view video:


  1. The inner lip of my 2.8 mm incision is mostly visible as a signature couple of months down the line but not seen in the cases done by a well known surgeon in this area. Why? Dr Sumeet Chopra

    1. A lot depends on your incision architecture. If the inner lip near Descemet membrane is too thin, too thick, or irregular, then you can get this effect. Looks for triplanar incision video here and try that. Or submit a video we we can analyze your technique.

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