What am I thinking while doing cataract surgery?

It’s time for a fun video — what am I thinking while performing cataract surgery? I like the operating room … More

Review: Anterior Vitrectomy & Sulcus IOL Placement

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

Beginner Surgeon attempts a dense white cataract

Dense white cataracts are challenging for multiple reasons: the opaque lens blocks any red reflex, the capsular bag may be … More

Calibrating your mental capsulorhexis calipers

Our ideal capsulorhexis will overlap the optic edge for 360 degrees in order to hold the IOL securely in a … More

Optimizing the Red Reflex during Surgery

Illumination through the ophthalmic microscope is important for visualization during cataract surgery. We use a combination of both coaxial and … More

Two-Step Technique for PSC & NS Cataract

We have shown videos for soft posterior subcapsular cataracts where we prolapse the entire lens out of the capsular bag … More

The Chop will not propagate through the cataract

With a dense cataract, a fibrous posterior plate can develop within the lens nucleus. This makes is challenging to split … More

Vertical Chop & Horizontal Chop in the same case

Phaco chop is my preferred method of nucleo-fractis for cataract surgery. It is safe, efficient, and minimally invasive, significantly reducing … More

Review: Adjusting the phaco tip & I/A tip

For coaxial instruments like the phaco probe and the irrigation/aspiration probe, what is the best position for the silicone sleeve … More

Let’s watch a resident perform divide-and-conquer

Many residents choose divide-and-conquer as the first nucleo-fractis technique to learn during residency training. This technique has been featured here … More

Tilt and Chop – a SupraCapsular Technique

Supracapsular phaco techniques are in closer proximity to the corneal endothelium, which can be damaged by the ultrasonic energy from … More

Quiz: What size is this Capsulorhexis?

We want a capsulorhexis to be just large enough to overlap the optic of the IOL in order to hold … More

SupraCapsular Technique for Softer Nuclei

For a relatively soft nucleus, such as in a younger patient with primarily posterior subcapsular cataract changes, the supracapsular technique … More

The Viscoelastic Wave for Dispersive Agents

When we inject the dispersive viscoelastic at the beginning of the case, our goal is to protect the corneal endothelium … More

Adjust the speculum to make access easier

We often will move the positions of our incisions to provide a better result for the patient or a more … More

Review: Making the ideal single plane incision

This is such an important step of cataract surgery that we must review it again as our residents are beginning … More

Removing the last nuclear piece

When we break the cataract nucleus into smaller fragments, we can sometimes have one of these small pieces stuck in … More

Descemet Membrane Endothelial Keratoplasty

The skills learned from cataract surgery, such as working within the anterior chamber and pivoting within the incisions, can be … More

Quiz: Why won’t this nucleus rotate?

This patient has a relatively opaque cataract with a pre-operative vision of only counting fingers. When we go to perform … More

Understanding Force Directions in Phaco Chop

Many resident surgeons find it challenging to learn the technique of phaco chop because of the force vectors which are … More

Adjust the Phaco Probe Angle during Chop

The phaco probe angle changes during the procedure. When we embed the phaco tip into the nucleus, the probe is … More

For wandering eyes, fixate with the chopper

Under topical anesthesia, there are some patients who have a difficult time holding still during critical parts of the surgery … More

Review: How to hydrate and seal the phaco incision

A properly constructed phaco incision will allow good access to the anterior chamber for cataract surgery and then will seal … More

Quiz: What is this large central opacity?

Quiz time: What is this large central opacity seen in the anterior chamber? The patient is scheduled for cataract surgery … More

Doing Cataract Surgery on a Cataract Surgeon

It is always an honor when fellow ophthalmologists ask you to perform their cataract surgeries. It can also be stressful … More

Sub-Tenon’s Anesthetic Injection Technique

Placing anesthetic agents in the retro-bulbar space provides excellent anesthesia and akinesia during ocular surgery. We have previously shown the … More

For a Dense Cataract should we fix the astigmatism?

This patient has a dense, white cataract with a pre-op vision of just Counting Fingers at 1 meter (CF at … More

Review: Beginning Surgeon Learns Phaco Chop

You’ve seen countless videos of phaco chop, but you seem to be stuck in a mode of less efficient techniques … More

Quiz: Which eye do you fix first?

This patient needs surgery on both eyes. The right eye has a cataract which is limiting the vision to 20/80 … More

Different Career Paths for Surgical Learning

The path to learning surgery is a long and challenging one. True success requires years of dedication and the passion … More

The Patient Experience at our Surgery Center

I made a video for patients as a step-by-step guide to the experience having cataract surgery at our surgery center … More

Side View shows the Phaco Probe at a flat angle

While we do hold the phaco probe with a pencil grip, we do not use the same angle as writing … More

Foot Pedal Position during Phaco Chop

Learning phaco chop will make your cataract surgeries safer, more efficient, and more enjoyable to perform. And of course, phaco … More

Dense Morgagnian Cataract with Capsule Break

With a Morgagnian cataract, the entire cortex becomes liquified and then the remaining lens nucleus floats within this fluid. In … More

Cataract Surgery in Pseudo-Exfoliation Syndrome

We often encounter patients with Pseudo-Exfoliation Syndrome, often abbreviated as PXF, which makes cataract surgery significantly more challenging. The PXF … More

What’s on my Cataract Surgery Instrument tray?

In this video I take you through my instrument tray for routine cataract surgery. As you can see in this … More

Review: Divide and Conquer Phaco Technique

Every July, we mark the beginning of the academic year in the USA and this is when our residents progress … More

Tilt and Tumble Phaco Technique

The Tilt and Tumble phaco technique is a very efficient and safe method of nucleus removal. First described many years … More

Guest Surgeon: Pre-Pocket Phaco Incision Technique

Dr. André Berger from São Paulo, Brazil has developed a new technique for creating a corneal phaco incision: the Pre-Pocket … More

Quiz: Why is the posterior capsule wrinkled?

This seemed like a totally routine case. Good incision, good capsulorhexis, efficient nucleus removal, and complete cortex removal. There was … More

Foot Pedal Positions for Learning Phaco Chop

Cataract surgery requires both hands and both feet of the surgeon in order to perform the modern techniques. It seems … More

Cataract surgery after prior trabeculectomy

A well-functioning trabeculectomy surgery is a delicate balance between the aqueous production and the additional outflow via the filtering bleb. … More

External View of Critical Cataract Surgery Steps

Two of the most critical steps in cataract surgery are the main phaco incision and the capsulorhexis. Properly completing these … More

Review: Basic Principles of Suturing with 10-0 Nylon

I tell my residents that no one is born knowing how to place 10-0 nylon sutures, but rather it is … More

Superior Incision: Hand Position & Microscope Views

While I prefer the temporal approach for routine cataract surgeries, some surgeons prefer a superior incision. Many beginning surgeons who … More

Simultaneous Hand Position and Microscope View

For young ophthalmologists, learning how to hold the instruments and position the hands during cataract surgery can be difficult to … More

Proper Hand Positioning in Cataract Surgery

This is a special video because the camera is focused on my hands for the entire surgery, from placing the … More

Do not retract the phaco probe or you may lose infusion

When we break up the cataract using the phaco chop technique, we can end up with smaller nuclear pieces which … More

Technique for Retrobulbar Anesthetic Injection

To perform a safe cataract surgery and to keep the patient comfortable and pain-free, we need to give a sufficient … More

Review: Learning Grid for Cataract Surgery

July 1 is the beginning of the academic year for our ophthalmology residents and it is an important time to … More

Quiz: What is this white material floating around?

Quiz time: What is this white material as seen in this aphakic eye? The 75 year old patient was noted … More

Analysis of a Resident’s 60th Cataract Surgery

As we get close to starting the academic year in the USA (which runs from July 1, 2019 to June … More

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