Use the chopper to protect the capsular bag during phaco

The chopper can do so much more than just divide the nucleus into pieces. The chopper can fixate the eye, … More

How big can we make the capsulorhexis?

Just how big can we make the capsulorhexis? It is a balance: the larger the capsulorhexis, the easier it is … More

Quiz: Cataract Surgery in Fuchs’ Corneal Dystrophy

Look carefully at the picture and tell me what you would do differently for this cataract surgery. This patient has … More

Hand Positioning during Cataract Surgery

When performing micro-surgery, particularly intra-ocular surgery like cataract surgery, a high level of precision is required. The surgeon’s hand positioning … More

Review: Solution for the Dense Nuclear Posterior Plate

Looking at this image should intimidate beginning cataract surgeons: this is a whitish-brown totally opaque cataract and it is a … More

Quiz: Why does the red reflex change during surgery?

This is a routine cataract surgery, but there is a limited red reflex during the surgery. This is sometimes due … More

Avoiding Iris Prolapse & Damage in Blue Eyes

We always want to perform a minimally invasive and minimally traumatic cataract surgery. We want to be safe, efficient, and … More

Analysis of a Resident’s 50th Cataract Surgery (Part 2)

Continuing from the previous post, this is part 2 of 2 of the analysis of a resident’s 50th cataract surgery. … More

Analysis of a Resident’s 50th Cataract Surgery (Part 1)

This is Part 1 of 2 where we are analyzing an anonymous resident’s 50th cataract surgery, which is very early … More

The Most Extreme Myopia that I’ve seen in 20+ years

An average eye has an axial length of about 23 to 24 mm, but this patient had an axial length … More

Capsulorhexis in 12 consecutive cataract surgeries

Seeing the same step of surgery performed over and over again can help beginning surgeons learn the subtleties of the … More

Review: 3 Rules for Making Phaco Incisions

Over the last two decades, cataract surgery has evolved from scleral incisions to corneal incisions, from retrobulbar anesthesia to topical … More

Quiz: It’s a good incision so why did the AC collapse?

Quiz time! Watch this brief video carefully and figure out why the anterior chamber collapsed after this resident surgeon made … More

Learning to be consistent: 12 consecutive incisions

We aim to be consistent in our surgeries so that we can make a well-constructed incision each and every time. … More

Anterior Vitrectomy & Sulcus IOL with Optic Capture

With vitreous prolapsed into the anterior chamber, we must perform a vitrectomy before placing the IOL in the eye. In … More

Review: Phaco Incision paired with LRI for Astigmatism Correction

We know that the phaco incision will cause some degree of corneal flattening and this has the ability to alter … More

Collapse of the capsular bag during cortex removal

This is a continuation of the case from yesterday, you can review it here. In that case, the phaco probe … More

The Chop failed because the nuclear halves did not separate

The phaco chop technique is like splitting firewood: the instrument creates the initial cleavage plane which then must be propagated … More

Phaco Fundamentals Part 10: Sample Phaco Settings

In the last of our 10 part series on Phaco Fundamentals, we present a video showing specific starting settings for … More

Guest Surgeon: Cataract with Fibrotic Anterior Capsule

In rare cataract cases, particularly those from prior trauma, we can get fibrosis of the anterior capsule. This makes the … More

For ultra high myopes, do not aim for plano!

For patients with a large degree of myopia, undergoing cataract surgery can be life changing because in addition to fixing … More

Review: Fully Separate Nucleus after the Phaco Chop

When doing phaco chop, remember that you must still physically push apart the nuclear halves to achieve complete separation and … More

Guest Surgeon: Recover from the Argentinian Flag Sign

In our many videos about white cataracts (full series can be found here), we know that one of the biggest … More

Phaco Fundamentals Part 9: Longitudinal & Torsional Ultrasound

Ultrasonic vibrations are traditionally delivered in a forward-and-back longitudinal manner. We can also deliver these vibrations is a circular manner … More

Guest Surgeon: The UltraChopper for Dense Cataracts

Professor Luis Escaf from Barranquilla, Colombia presents a case here of a dense cataract with a small pupil. He uses … More

Rescue this White Cataract Capsulorhexis

Our CataractCoach.com readers understand the challenges of white cataracts and in particular, intumescent white cataracts. With a capsular bag that … More

Higher Infusion Pressure Helps in Floppy Iris Cases

In our phaco fundamentals series, we have explained the basics of choosing fluidic parameters for the phaco machines. These settings … More

Review: Give the First Surgeon the Benefit of the Doubt

Sometimes you will examine a patient who had surgery elsewhere and you can tell that there were challenges and complications. … More

Guest Surgeon: Chopping a Dense, Leathery Cataract

When we describe a cataract nucleus as leathery, we mean that it is fibrous in nature and our chops and … More

Opaque Cortical Cataract Cases can be Challenging

The cortical cataract changes look like spokes of a wheel and they can cause issues for both the patient and … More

Phaco Fundamentals Part 8: Variable Duty Cycle

The range of programmability of the pulse and burst phaco settings has expanded considerably. While previous generations of phaco platforms … More

Guest Surgeon: Soft Posterior Polar Cataract Surgery

We have featured many videos about posterior polar cataracts and the techniques that can be used to successfully operate on … More

The ideal Angle of Approach for the phaco incision

The angle of approach of the keratome will determine the tunnel length of our phaco incision. If the angle is … More

Review: How to make a single-plane phaco incision

Many of the more advanced cataract surgeons prefer a single-plane phaco incision because its consistent architecture makes for great sealing. … More

Posterior Capsulorhexis for a posterior capsule plaque

If there is a central posterior capsule plaque that cannot be removed with the suction from the irrigation/aspiration probe, we … More

Resident Case: Adherent Posterior Capsule Plaque

Sometimes we can have a plaque of cataract material that is adherent to the central posterior capsule. There are ways … More

Phaco Fundamentals Part 7: Ultrasound Power Modulations

The phaco ultrasound probe delivers energy into the eye that can be used to break up the cataract to facilitate … More

Guest Surgeon teaches us Cataract Surgery Efficiency

We can always learn from fellow surgeons, particularly from those who are truly experts in the field. I recently met … More

Review: Complete this case without vitreous prolapse

This is a great learning case from one of our young surgeons in training. The video is 14 minutes long … More

Quiz: What is this dark spot and what is the danger?

This is a complicated case sent to us for review by an anonymous surgeon. You can also submit a video … More

Aspiration Flow Rate should be high during final I/A

As we have learned from the phaco fundamentals videos / articles here on CataractCoach, setting the correct fluidic parameters is … More

Phaco Fundamentals Part 6: Adjusting Fluidic Paramters Intra-Op

We must learn to adjust phaco fluidic parameters during surgery. This helps to tailor the surgery to the specific eye … More

What is your ideal Cataract Surgery case? Why?

What is your ideal cataract surgery case? Not your fastest case. Speed does not matter. Efficiency does, but that’s a … More

Malyugin Ring for Pupil Expansion in Cataract Surgery

A well-dilated pupil facilitates cataract surgery and if the patient has a small pupil there are multiple options for safely … More

Review: Multiple Small Chops for a Dense Cataract

In previous videos, I have shown my technique for breaking up a dense brunescent cataract with a fibrous and tough … More

I just cannot chop this cataract – you’ll never guess why!

This seemed like a routine cataract surgery, but I was wrong. I just could not seem to chop this cataract … More

Phaco Incision OCT & Live Video Analysis

The phaco incision is part of your signature which links you to the patient’s eye forever. Your incision will forever … More

Phaco Fundamentals Part 5: Choosing Fluidic Parameters

Now that you have a good understanding of the principals of the fluidics involved in phaco surgery, let’s look at … More

Pars Plana Anterior Vitrectomy & IOL Retrieval

While most cases of vitreous prolapse during a complicated cataract surgery can be effectively address via limbal incisions, there are … More

Methods for IOL calculations after prior LASIK

The three main factors in IOL calculations are corneal power, axial length, and effective lens position. Prior LASIK makes this … More

Review: Four Quadrant Chop-and-Conquer

The idea behind divide-and-conquer makes a lot of sense: divide the nucleus into four quadrants which are more easily phaco-aspirated … More

Resident Posterior Polar Cataract with Hydro-Delineation

With a posterior polar cataract, the posterior capsule can be weak, fragile, or even focally absent and this poses challenges … More

Quiz: Why did we miss the post-op target of plano?

There are many methods of IOL calculations and with every generation, these get more refined and more accurate. Most surgeons … More

Phaco Fundamentals Part 4: Poiseuille’s Equation

Modulating Fluid Flow: Poiseuille’s Equation The basic equation that governs all fluid flow during phacoemulsification surgery is Poiseuille’s Equation. You … More

Ahmed Valve Placement for Neo-Vascular Glaucoma

This patient has a history of severe diabetic eye disease including proliferative retinopathy and prior pan-retinal photocoagulation as well as … More

How to suture the Phaco Incision with 10-0 Nylon

This video is special because we have two different camera angles: the view through the operating microscope as well as … More

The Importance of Networking with your Colleagues

While the professor:resident and mentor:fellow relationships are very valuable for learning in the early stages of your career, you will … More

Review: Cracking the Posterior Plate in a Dense Cataract

With a dense brunescent cataract, one of the primary challenges is cracking the fibrous posterior plate of the nucleus. Using … More

Run Away Capsulorhexis: What is your next move?

This patient has an intumescent white cataract and our surgeon, an ophthalmology resident with about 200 cataract surgeries completed, wishes … More

Incomplete Femtosecond Laser Capsulotomy

We have studied intumescent white cataracts many times here on CataractCoach and we know that the primary challenge is that … More

Phaco Fundamentals Part 3: Peristaltic vs Venturi Pumps

Peristaltic and Venturi Fluid Pumps With modern-day techniques of phaco-assisted aspiration of cataracts, one of the most important concepts in … More

Cataract Surgery after Macula-Off Retinal Detachment

A macula-off retinal detachment usually means a more limited visual prognosis because the critical central vision has been permanently altered … More

How to Flip Up the Epi-Nucleus for easy removal

Hydro-delineation can be helpful to separate the dense endo-nucleus from the epi-nucleus of the cataract. This makes is a bit … More

What IOL Power do you choose for this patient?

This 60 year old patient is seeing you in consultation for cataract surgery. He has a significant posterior subcapsular cataract … More

Review: Do not use the pupil to size the capsulorhexis

Many surgeons use the iris or pupil size as a guide for capsulorhexis creation — but you should not. Do … More

Sometimes Even Experts Struggle during Surgery

As we gain more experience and hone our surgical skills, we achieve the state of flow where the procedure progresses … More

Resident Case: Iris Prolapse during Cataract Surgery

When we encounter iris prolapse in a patient with a light-colored iris, we must be very careful because any iatrogenic … More

Phaco Fundamentals Part 2: Foot Pedal & Inflow/Outflow

Part 2 in our series focuses on the Foot Pedal Position and then balancing Inflow versus Outflow to achieve stable … More

Guest Cataract Surgery: Tiny Pupil with Synechiae

This patient had a prior uveitic episode which resulted in the formation of posterior synechiae, where the iris, at the … More

Position your phaco incision to nick limbal vessels

I saw a patient recently who had femtosecond laser assisted cataract surgery a month prior by an unknown surgeon. The … More

Surgical Peripheral Iridotomy using 23g Vitrector

There are times when you will need to make a surgical iridotomy either during cataract surgery or as a stand-alone … More

Be Careful if you see the Hole Punch Sign during Phaco

In your first 1000 cataract surgeries, the most common cause of a posterior capsule rupture is iatrogenic damage from the … More

Embed the phaco probe in the nucleus without ultrasound

The classic teaching for phaco chop and quadrant removal is to embed the phaco probe into the nuclear piece by … More

Phaco Fundamentals Part 1: Choosing Steps of Surgery

Every Wednesday, we are going to start a new module to teach Phaco Fundamentals of machine parameters, including fluidics and … More

Chopper placement is critical to nucleus division

The placement of the chopper is critically important to achieving division of the cataract nucleus with the phaco chop technique. … More

Converting from Phaco to Manual ECCE Surgery

While it is rare, there are times when it is important to convert from a phaco approach to a manual … More

If your Phaco Chop fails, simply revert to Stop-and-Chop

Sometimes we attempt to use phaco chop to divide the cataract nucleus, but we are just not able to achieve … More

Double Capsulorhexis for Intumescent White Cataract

Intumescent white cataracts pose a challenge because the lens cortex has degenerated so much that is has liquefied. This creates … More

Small Pupil, Dense Cataract, Corneal Scar, Glaucoma

The key to approaching a difficult surgery is to use a stepwise approach. In the case presented here, we have … More

Position the head so the iris is parallel to the floor

Proper positioning of the patient for cataract surgery is important for the comfort of the patient and the surgeon, but … More

The iris/pupil can hold the nucleus during phaco

Today we have an unedited video of a routine case in a patient with floppy iris syndrome due to Flomax … More

Ovoid Pupils in Cataract Surgery – What Happened?

What is happening in these cataract surgery patients with prior Flomax (tamsulosin) use? Why are the pupils ovoid in shape? … More

Left-Handed versus Right-Handed with Phaco Incisions

It can be helpful to place our phaco incisions on the steep axis of cornea astigmatism in order to provide … More

Learning from the IOL Calcs of the First Eye

Even with the best methods of IOL calculations (new generation formulae, artificial intelligence methods, and more), there will still be … More

Traumatic Cataract: What is your approach?

This patient had a traumatic injury to his eye 40 years ago and never sought the care of an ophthalmologist … More

Bleeding in the Anterior Chamber during surgery

It is unusual to encounter bleeding in the anterior chamber during cataract surgery, but rarely it does happen. The typical … More

Intentional Capsule Puncture with a Phaco Probe

For intumescent white cataracts we must take special precautions. The capsular bag is fluid-filled and pressurized and there is the … More

Intumescent White Cataract with lots of Milk

This patient has an intumescent white cataract and there is a large volume of liquefied lens cortex. We have shown … More

Femtosecond Laser Capsulotomy for White Cataracts

With an intumescent white cataract, we know that the capsular bag is filled with fluid — liquefied lens cortex material. … More

IOL Calc Quiz: hitting plano in a high hyperope

Here is your challenge. You’re operating on a patient who is highly hyperopic (wearing +6.50 OD and +7.00 OS for … More

The incision and capsulorhexis are your signature

I like to think of the phaco incision and the capsulorhexis as my “signature” on every cataract surgery that I … More

Pearls for Using Iris Hooks to Expand Small Pupils

Sometimes, the best approach to expanding a small pupil for cataract surgery is to use iris hooks. These are small, … More

How to Tame Iris Prolapse at the Start of Surgery

When the iris prolapses through the incision, it is due to one principal issue: a gradient whereby the pressure behind … More

Pearls for Using Multi-focal IOLs (bifocal, trifocal)

For now, among the more reliable ways to address presbyopia is implanting a multi-focal IOL. These are typically diffractive in … More

Probe Placement to Facilitate Phaco Chop

Placement of the phaco probe and the chopper are critical to facilitating the phaco chop procedure. One of the big … More

Quiz: Can you spot the potential complication?

In this case, everything seemed routine and it progressed quite smoothly. A nice incision, an accurate capsulorhexis, efficient nucleus removal, … More

Achieving the State of Flow in Cataract Surgery

The psychological state of Flow is described as “energized focus, full involvement, and enjoyment” of the action being performed. Some … More

White Cataract Posterior Capsule Rupture!

In this anonymous video from a surgeon in training, we have quite the challenge: a dense white cataract surgery where … More

Never make your phaco incision like this!

In this anonymous video we have a phaco incision that is very poorly made. The placement is too far from … More

Posterior Polar Cataract with Central Capsule Defect

We have highlighted multiple different posterior polar cataract cases, which warrant reviewing. These include: Soft Posterior Polar in a younger … More

IOL Calc Quiz: Why are the eyes so different?

This patient has similar cataracts in both eyes and is preparing for cataract surgery with you. The biometry has been … More

For loose zonules, bring the nucleus up and out

In this seemingly routine case, we find that the anterior lens capsule wrinkles when we attempt the capsulorhexis. This means … More

Cataract Surgery in a younger patient with prior PPV

As we demonstrated recently, cataract surgery in a younger patient (under age 50) can be different than in the typical … More

Technique for PSC Cataract Surgery in younger patients

Posterior SubCapsular (PSC) cataracts are more commonly found in our younger patients and in particular, they can cause difficulty with … More

If your incision has bad construction, try again

As you are making your phaco incision, judge the architecture and if it is not good, then stop and do … More

Suture Complications after Cataract Surgery

Depending on the size and architecture of our incisions for cataract surgery, sutures may be required to ensure adequate closure … More

Optimizing Surgical Flow for Efficiency & Safety

Establishing a consistent routine in the operating room is the key for both increased efficiency as well as increased safety. … More

Flip and Chop Phaco is Ideal for Routine Cases

The flip and chop phaco technique has been presented here before on many occasions because it is such an efficient … More

Use the Chopper to Push Nuclear Pieces to the Probe

The chopper is used for many different functions during cataract surgery, beyond just chopping the nucleus into smaller fragments. Cataract … More

How to fix Iris Prolapse in Cataract Surgery

In this resident performed surgery, we encounter iris prolapse after too much hydro-dissection. This results in the iris prolapsing out … More

Cataract Surgery after Prior Uveitis Issues

Doing cataract surgery in an eye with a prior history of uveitis can be more challenging than a typical case. … More

Wrinkled Anterior Lens Capsule – be careful!

poor zonular support cataract surgery

Exquisitely sharp blades are needed for eye surgery

The eye is like an under-inflated balloon: the low pressure inside allows it to absorb most jabs without being punctured. … More

What beginner mistakes do you see in this pic?

Learning intra-ocular surgery is not easy and it can take years just to be comfortable with just the basics. Look … More

IOL Calc Quiz: Why such different results?

A fan of CataractCoach has asked for input regarding the IOL calculations for his patient with steep keratometry. When he … More

OCT analysis of Pseudo-Exfoliation Cataracts

Patients with pseudo-exfoliation (PXF) syndrome are known to have deposits of fibrillar material throughout the anterior segment. This is most … More

Various Approaches to removing the Epi-Nucleus

When we perform hydro-delineation, we separate the dense endo-nucleus from the relatively soft epi-nucleus. This is helpful in multiple different … More

Guest Surgeon: Femto & Capsular Tension Segments

This is a tricky case: a traumatic cataract with extensive zonular loss and weakenss in a younger patient with high … More

Double Capsulorhexis to prevent Capsule Run-Out

using the double capsulorhexis technique to deal with an errant tear in cataract surgery

Proper Form for using a Keratome Safely & Precisely

you must learn proper form for keratome use in cataract surgery

Guest Surgeon: Cataract with prior Trabeculectomy

This is a great video submitted by Dr. Mohammed Ghoneem from Alexandria, Egypt where he shows his method for successful … More

Be Cautious with the Wrinkly Old Bag

This is one wrinkly old bag! Of course, we are referring to the capsular bag in this cataract surgery. This … More

Cataract Surgery and Pars Plana Vitrectomy

There are cases where a patient has both anterior and posterior segment pathology and doing both a cataract surgery plus … More

Hydro-delineate for a dense central nucleus

When you see a patient with a dense central endo-nucleus, there are characteristic findings: a lens periphery that is relatively … More

Ruptured Capsule Rescue & Anterior Vitrectomy

Very important learning case of a posterior capsule ruptured then a rescue including anterior vitrectomy.

Resident Surgeon Struggles with Phaco Chop

In this anonymous video, a resident surgeon struggles with phaco chop. It is not an easy technique to learn, which … More

Cataract Surgery in Pigment Dispersion Syndrome

Cataract surgery in patients with Pigment Dispersion Syndrome can be challenging due to the anatomic changes which have happened over … More

Use the Chopper to protect the capsular bag

We work in a very tiny space of just a fraction of a milliliter: the volume of the anterior chamber … More

Understanding Reflux Mode during Phaco

Reflux mode is when you use the foot-pedal to reverse the fluidic pump of your phaco machine. Instead of aspirating … More