This is a complete cataract case featuring a nucleus that is too mushy to chop, so I revert to the tilt and tumble technique described years ago by Dr Dick Lindstrom. This makes for an efficient removal of the lens and still delivers a clear cornea for this soft nucleus. This technique involves tilting the nucleus out of the capsular bag and into the iris plane. The phaco probe is then used to emulsify the nucleus with the second instrument stabilizing the nucleus and feeding it into the phaco needle tip. No chopping or mechanical disassembly of the nucleus is required and only one phaco setting is needed (high vacuum, high flow, moderate phaco power). Tilt and Tumble is most suitable for soft to moderate nuclear densities, which is the most common type of cataract encountered in the USA.
“Tilt and Tumble phacoemulsification is a supracapsular approach that is quite easy and straightforward to learn. It is especially helpful for the softer nucleus, but the skilled surgeon can use it for firmer nuclei using modern viscoelastics, bevel down and a second instrument to hold the nucleus back from the cornea. A tilted nucleus with the phacoemulsification probe held above the iris plane is also helpful in IFIS and small pupil cases. Many of my fellows have adopted this approach for the majority of their cases, as have I.”
Richard Lindstrom MD, personal email, July 2019
This technique is also very efficient and routine cases can be completed in under 10 minutes and often under 5 minutes. But speed is not the goal — safety is. By operating at the iris plane, the phaco tip is farther from the posterior capsule and an extra margin of safety is achieved.
When you try this technique, I have the following suggestions:
- choose a lens of 1+ to 3+ nuclear sclerosis for your initial cases
- make a sufficiently large capsulorhexis of 5 to 5.5 mm in diameter
- use gentle hydrodissection to partially prolapse the nucleus out of the capsular bag
- use extra dispersive viscoelastic to hold the nucleus and protect the corneal endothelium
- choose phaco settings of high vacuum 400+ mmHg with 20g tip, 35+ cc/min flow rate, and moderate phaco power with modulations.
- use the chopper or second instrument to keep the nucleus on edge and central
- keep the phaco tip at the iris plane without coming close to the corneal endothelium
