Watching amazing intra-ocular acrobatics during a challenging cataract case is exciting and makes for a great video, but those cases…
Close Up: Technique for Phaco Incision
We have shown many videos about the importance of the phaco incision. It is part of the signature that you…
Quiz: iris is prolapse & bleeding – now what?
Quiz time: This patient has floppy iris syndrome from tamsulosin use and you are experiencing iris prolapse during his cataract…
Capsulorhexis technique with just forceps
In more than 99% of my cataract surgery cases, I do not use a cystotome to start the capsulorhexis. I…
Surgeon Ergonomics for Ocular Surgery
As an ophthalmic surgeon, you will spend a large part of your future in the operating room performing delicate ocular…
When should we leave “good enough” alone?
When should we leave “good enough” alone? Ophthalmologists tend to be perfectionists in nature and I certainly fit that description.…
Review: An easy way to help seal the incision
If your phaco incision is properly constructed, it will typically seal quite well without the use of sutures. We can…
Sit temporal but operate using WTR incisions
With-the-rule (WTR) astigmatism is where the steep axis is at or near the 90 degree axis. Placing incisions on the…
Secrets to Avoid Corneal Edema after Cataract Surgery
Corneal edema can occur after cataract surgery due to a number of factors such as a higher degree of ultrasonic…
Quiz: What are these spots seen during surgery?
During cataract surgery for this patient, everything seemed relatively routine. The patient is elderly with some zonular laxity, but even…
Use the Chopper to Lift Nuclear Pieces Up
In cases where the capsulorhexis is small or where the nucleus is particularly large, it can be difficult to bring…
Learn the Pupil Stretch Technique
Stretching the pupil during cataract surgery is a safe and effective way to improve access via mechanical dilation. While there…
Analysis of a Divide-and-Conquer Cataract Case
This anonymously submitted video is from a surgeon who is 5 years into practice after the culmination of her training.…
Review: Embed the phaco probe without ultrasound
The classic teaching for phaco chop and quadrant removal is to embed the phaco probe into the nuclear piece by…
How to Save this Run-Out Capsulorhexis
This case is performed by a junior resident who has done about 20 cases so far. The trouble starts when…
Lysis of Synechiae and Capsule Staining under Iris
This patient had a prior episode of anterior segment inflammation which caused synechiae to develop, with adhesion of the iris…
Quiz: Why does this pupil look irregular?
This patient is undergoing a combined cataract surgery with a pars plana vitrectomy. Two novice surgeons are operating: a senior…
Combined Phaco + MIGS for cataract + glaucoma
Cataract surgery alone is a powerful technique for lowering intra-ocular pressure, particularly in patients with glaucoma. By replacing the 4+…
Combined Phaco + DMEK Surgery for Fuchs’ Dystrophy
This patient has a cataract as well as Fuch’s corneal dystrophy. Her pre-operative corneal pachymetry is almost 700 microns centrally…
What is the correct way to hold a fluid syringe?
When we have a syringe that is filled with liquid, be it balanced salt solution or visco-elastic, we have a…
Review: Cataract Surgery in Deep Set Eyes
Performing intra-ocular surgery in a deep set eye is challenging because the access is limited. In the case shown here,…
Paired Phaco Incisions to Treat Astigmatism
Cataract surgery is our most powerful refractive procedure based on the spherical power that we can correct. Anything from –30…
Does Capsule Polishing prevent capsular opacity?
There has been much debate around the issue of polishing of the undersurface of the anterior capsular rim, yet there…
Resident Double Capsulorhexis for White Cataract
We know that intumescent white cataracts have a pressurized capsular bag with the milky white, liquefied cortex material. And we…
Guest Surgeon Efficient Divide-and-Conquer
After thousands of cases, surgeons become very efficient and can complete cataract procedures with fewer instruments and less surgical trauma.…
Two important danger signs in traumatic cataract
Guest surgeon and expert Ashraf Armia MD shows us two very important danger signs in a traumatic cataract case: wrinkles…
Surgical Approach to a Traumatic Cataract
When we are faced with a traumatic cataract, there are many factors to consider. The easiest issue is the lens…
Review: 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 be visible…
Why are we making a small capsulorhexis?
In many previous videos, we have explained why it is important to have a sufficiently large capsulorhexis. For an optic…
Linear marks seen during cortex removal
For surgeons with just a few years of experience, the part of cataract surgery where a posterior capsule break is…
Quiz: What is going on with this IOL haptic?
The surgery has gone very smoothly and the senior resident is doing a great job. The incisions are good, the…
Phaco Chop without using the phaco probe
This is a cataract surgery performed by a resident in training and the patient is known to have Fuchs’ corneal…
Achieving a complete hemi-nuclear split
When performing any nucleo-fractis technique, it is imperative that the nucleus be completely subdivided prior to removing the halves, quadrants,…
Resident surgeons must learn to load the IOL
The surgeon must know how to do every single part of the surgery, including setting up the phaco machine and…
Review: Cataract Surgery in Patients age 90+
Average life expectancy is at an all-time high in the US at 79, with even better news for people who…
Resident Surgeon takes on a Dense White Cataract
It is a pleasure to show you this video where one of my senior residents performs and excellent cataract surgery…
Slow motion analysis of posterior capsule rupture
Watching surgical video of cases is very helpful to understand the how and when of the complications of cataract surgery.…
Quiz: What is the huge danger seen in this photo?
This surgery is being performed by a senior resident and it starts off great. It is a dense white cataract…
Novice surgeon performs cataract surgery
This video was anonymously submitted by an ophthalmology trainee outside of the USA. He has completed about 90 cataract surgeries…
Analyzing a resident Stop-and-Chop case
Most of the uncut surgical videos that are shown here are very efficient and complete cases can be performed in…
Toric IOL with intra-operative aberrometer use
Guest Expert John Hovanesian MD implanting a Toric IOL with aberrometer guidance Dr. Hovanesian is a well-known and much respected…
Review: Temporal vs Superior Phaco Incisions
Some surgeons prefer to make a superior phaco incision while others prefer a temporal approach. Is there a substantial difference…
Advice for young ophthalmologists for future success
Today we celebrate our 500th post with keen advice for young doctors. We did it. We have published a cataract…
Milky fluid leaks out of the intumescent cataract
We have explained over the course of many videos that intumescent white cataracts are challenging. One of the primary considerations…
Quiz: For a pupil like this, what is your approach?
With time, young ophthalmologists develop surgical judgment and they are able to look at a case and decide what approach…
Cataract Surgery using a Scleral Tunnel Incision
Twenty years ago, when I did my residency training at the Jules Stein Eye Institute at the UCLA School of…
Where did the hemi-nucleus go?
This video was submitted by Dr Ravi Prasad Challa from India and it showcases a very rare complication: a break…
Pars Plana Anterior Vitrectomy can be very helpful
When the capsule breaks during cataract surgery and the vitreous prolapses into the anterior segment, it is important to clear…
Review: Be Careful if you see the Hole Punch Sign
In your first 1000 cataract surgeries, the most common cause of a posterior capsule rupture is iatrogenic damage from the…
Alcon PanOptix Trifocal IOL Performance
In the USA, the FDA has recently approved the Alcon PanOptix IOL for use in cataract surgery. This is a…
How to rescue this capsulorhexis before it runs out
Performing the capsulorhexis is one of the most stressful steps for new ophthalmologists who are beginning to learn cataract surgery.…
Quiz: How to fix iris prolapse at the incision
The iris is a kinetic and flowing structure that moves during pupil constriction and dilation. But the iris can also…
Phaco Flip & Chop is great for Beverly Hills Cataracts
Often, the density of the nucleus and the severity of the cataract relates to the patient’s access to healthcare. In…
Synechiae & Small Pupil solved with the B-Hex ring
This video features guest surgeon Neto Rosatelli MD from Brazil showing us his approach to cataract surgery in a uveitic…
Solving a tough case of Hexagonal Keratotomy
Featuring guest surgeon: Arun Gulani MD from Jacksonville, Florida, USA This complex case involved a patient who underwent hexagonal keratotomy…
Top 5 Cataract Surgery Tips for Millennial Surgeons
For the Millennial Eye Live 2019 meeting, I am presenting this talk about my top 5 tips for young surgeons…
Retained Cortex leads to trouble and macular edema
In this anonymously-submitted case, a small amount of lens cortex was left in the capsular bag at the time of…
Checking under the Iris for Hidden Cortex
In cases where the pupil does not dilate fully, it can be difficult to see the entire capsular bag to…
Quiz: What happens with insufficient hydro-dissection?
What happens if the hydro-dissection is insufficient during cataract surgery? The cortex and epi-nuclear shell remain very adherent to the…
Flip up the epi-nucleus for easy aspiration
In some cataract cases it is helpful to perform hydro-delineation to separate the dense endo-nucleus from the softer epi-nucleus. Once…
Evaluating Radial Keratotomy for Cataract Surgery
Radial keratotomy (RK) is an out-dated kerato-refractive surgery where radial incisions were made in the cornea in order to cause…
Needle Puncture for Intumescent White Cataracts
An intumescent white cataract is where the cortex has become opaque and liquified which increases the pressure within the capsular…
Review: if the chop fails, 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…
Cataract Surgery with High Power IOL placement
Cataract surgery can provide an incredible refractive result, particularly for small eyes which are highly hyperopic. We can correct 10…
Should we chop in the bag or above the bag?
Should we chop the nucleus within the capsular bag or should we bring the nucleus partially out of the capsular…
Quiz: A shallowing capsular bag during cortex removal
The irrigation / aspiration probe is placed in the eye and we begin cortex removal. But as we try to…
Tracing a Circle to make the Capsulorhexis
A very simple technique for new surgeons who are struggling with the capsulorhexis is to trace the intended path with…
Overlay the keratome to plan out the incision
In all surgeries, you must make the effort to create a great incision, which I have previously described as part…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
Descemet Membrane Endothelial Keratoplasty
The skills learned from cataract surgery, such as working within the anterior chamber and pivoting within the incisions, can be…
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…
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…
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…
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…
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…
Cataract surgery & Phakic IOL removal
Posterior chamber phakic lens implants can effectively treat a large degree of myopia while retaining the accommodation of a youthful…
Capsular Tension Rings in Cataract Surgery
Capsular tension rings are flexible plastic loops which are designed to exert outward force at the capsular bag equator to…
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…
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…
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…
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…
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…
Which viscoelastic for the IOL injector?
We know that a dispersive viscoelastic will protect the corneal endothelium better during phacoemulsification of the lens nucleus. And a…
Does age make a difference in IOL surgical planning?
We have some amazing surgical technology now with IOLs that give a wide range of vision and can even help…
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…
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…
Take Pride in your Cataract Surgery Signature
Many ophthalmologists will perform tens of thousands of cataract surgeries during their careers and each of these procedures can improve…
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…
Review: How to load and inject a single-piece IOL
Let’s review a routine case, this time with a toric IOL. All surgeons in training must know how to properly…
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…
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…
Quiz: What is the Problem that you see here?
This video has been sent to us by an anonymous resident surgeon in training. During this case there was a…
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…
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…
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…
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…
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…
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…
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…
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…
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.…
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…
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…
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…
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…
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…
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…
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…
Options for IOL Explant: Twist or Cut
In rare cases, we may need to explant the IOL and replace it with a different IOL for a different…
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…
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…
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…
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,…
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…
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…
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…
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…
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…
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…
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.…
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…
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…
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…
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…
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…
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.…
Switching from a Toric IOL to a spherical sulcus IOL
We recently featured a four-part series of a single, complicated cataract case in which the phaco probe punctured the posterior…
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…
Posterior Capsule Break with a Toric IOL in the bag
The posterior capsule sustained a break during phaco which was near the capsular bag equator and not immediately noticeable to…
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…
IOL Calcs: PLUS Precision Ladas Universal Superalgorithm
The future of IOL calculations is with methods that can evolve. A static formula is a time-limited method which will…
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…
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…
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…