Three “Secret” Cataract Surgery Maneuvers
These Subtle Techniques Enhance Control, Visibility, and Safety
Cataract surgery has undergone remarkable refinement over the past decades, yet some of the most elegant maneuvers remain those that are not routinely emphasized in textbooks or lectures. These micro-techniques, sometimes passed from mentor to trainee in the operating room, can profoundly influence fluidics control, visualization, and efficiency. Three of my favorite secret techniques are: (1) repositioning cortical opacities to enhance red reflex during capsulorhexis; (2) the strategic lateral displacement of a hemi-nucleus during phaco chop to facilitate extraction of the other half; and (3) flipping the epi-nucleus up to enable safer removal while protecting the capsular bag. Though subtle in appearance, each maneuver reflects years of collective surgical experience and represents the type of nuanced thinking that distinguishes advanced cataract surgeons.
Mobilizing Cortical Opacities to Improve Visualization for Capsulorhexis
One of the realities of performing cataract surgery is that cortical opacities, subcapsular changes, or even the milky liquefied lens cortex can severely diminish the red reflex. A poor red reflex is not simply an irritant; it is a recognized risk factor for errant capsulorhexis creation, radial tears, and unstable capsular dynamics. A clever maneuver that many experienced surgeons employ is to gently shift or “push aside” superficial cortical opacity after the anterior chamber has been stabilized with viscoelastic. (figure 1)
The principle is to temporarily redistribute the liquified lens cortex that makes up these cortical opacities, moving it laterally or peripherally so the capsule becomes more visible in the intended path of the capsulorhexis. By changing the local density and position of cortical material, surgeons can gain a clearer view of the anterior capsule margin and enjoy a more robust red reflex. This technique is particularly beneficial in eyes with cortical spokes or liquefied cortical material that tends to billow anteriorly. By nudging the opacity out of the visual axis with a cannula or instrument, the surgeon creates a temporary “window” through which the capsulorhexis becomes much easier to initiate and control. Although seemingly simplistic, this maneuver reduces stress during one of the most delicate portions of cataract surgery and can be especially useful during resident teaching.
Creating Space During Phaco Chop by Pulling One Nuclear Fragment Laterally
Phaco chop is one of the most efficient, energy-sparing methods of nuclear disassembly, but its success depends heavily on intelligently using space within the capsular bag. After the nucleus is divided into two primary hemispheres, a common challenge is insufficient working room for emulsifying or elevating subsequent fragments. Even with good chop execution, the nuclear pieces may remain tightly packed, limiting mobility.
A sophisticated yet under-taught maneuver is to temporarily pull one of the initial post-chop fragments slightly to the side with the chopper. (figure 2) This lateral displacement of just a millimeter or two creates a very meaningful gap or working corridor. The surgeon can now elevate the adjacent nuclear half or fragment more freely. It also reduces zonular stress by decreasing the need for excessive manipulation inside a cramped capsular bag. Importantly, this maneuver is not about extracting the displaced fragment immediately. Rather, its role is strategic. By creating that initial gap, the surgeon gains access to the next quadrant, making vertical or horizontal chops easier to propagate and safer to remove. The technique becomes especially valuable in dense nuclei, where every millimeter of space is precious. It also harmonizes beautifully with modern phaco fluidics by reducing the need for forceful mechanical movements that could destabilize the bag.
Flipping the Epi-nucleus Forward for Controlled and Safer Removal
Once the nucleus has been removed, the surgeon faces the deceptively simple next step: epi-nucleus removal. The epi-nucleus is softer and more pliable than the nucleus, but its broad, bowl-shaped configuration means that careless aspiration can allow the phaco tip to contact the posterior capsule. Posterior capsular rupture during epi-nuclear removal remains a well-recognized complication.
A subtle yet highly effective maneuver is to elevate or “flip” the epi-nucleus forward, bringing it into the safer central anterior space before aspiration. (figure 3) This creates two major advantages: protection of the posterior capsule and improved followability. By flipping the epi-nucleus anteriorly, the surgeon physically separates it from the posterior capsule, greatly reducing the chance that the phaco or aspiration port will inadvertently engage the capsule. Once elevated, the epi-nucleus is more responsive to aspiration with the phaco probe. Instruments do not need to reach deep into the bag, and fluidics become more predictable because the material is in a more centralized position. This technique is especially useful in cases with weak zonules, shallow bags, or dense epi-nuclear plates. It reduces stress on the capsular apparatus and facilitates a smooth transition to cortical cleanup.
While cataract surgery is often taught as a series of standardized steps, true mastery comes from adopting the nuanced maneuvers that improve visualization, safety, and flow. The three techniques described, shifting cortical opacities during capsulorhexis creation, laterally displacing a nuclear fragment during chop, and flipping the epi-nucleus for safer removal are examples of the quiet “secrets” that experienced surgeons use intuitively. Discussing and teaching these subtle strategies helps raise the collective standard of cataract surgery and ensures that the next generation appreciates not only the science of the operation but also the art.
