If there is a central posterior capsule plaque that cannot be removed with the suction from the irrigation/aspiration probe, we…
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…
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…
We must Align and Center a Toric Diffractive IOL
With new technology IOLs, we have the ability to address corneal astigmatism as well as provide a wide range of…
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…
LensGen Juvene IOL presentation from 2019 ASCRS meeting
For those of you who missed the 2019 ASCRS Meeting (American Society of Cataract & Refractive Surgery) meeting in San…
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…
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…
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…
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…
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…
Quiz: Why won’t this IOL stay centered?
This case seemed 100% normal. Reasonable dilation, good zonular support, 5-mm round capsulorhexis, phaco chop, and a normal capsular bag.…
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…
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…
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…
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…
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…
Old IOL explanted, then new IOL sutured to the Iris
This patient had a prior cataract surgery with a single-piece acrylic IOL precariously placed into a compromised capsular bag. This…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
Incomplete Femtosecond Laser Capsulotomy
We have studied intumescent white cataracts many times here on CataractCoach and we know that the primary challenge is that…
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…
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…
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…
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…
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…
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…
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…
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…
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…
Why Lens Geometry is important for IOL Calcs
The geometry of the IOL is important for IOL calculations and it must be taken into consideration. Yet, we learn…
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…
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…
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…
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…
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…
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.…
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…
Quiz: Which ACIOL is in the correct orientation?
An anterior chamber IOL (ACIOL) is rarely used, but in cases with no capsular support, it can be very helpful…
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…
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…
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…
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…
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…
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?…
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…
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…
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…
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…
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…
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…
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.…
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…
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…
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,…
Dual Optic, Curvature Changing, Full Range Presbyopic IOL
Imagine an IOL for cataract surgery that mimics the human lens with the ability to give a wide range of…
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…
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…
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…
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,…
Why implant an IOL if the power is Zero?
Sometimes, in a very myopic eye, the desired IOL power will calculate to zero diopters. An IOL of zero diopters…
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…
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…
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…
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…
Would you implant a CTR: Capsular Tension Ring?
This challenging cataract case has loose zonular architecture globally, not focally. There is no prior trauma and there is not…
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…
Quiz: Why does the IOL optic look cloudy?
This patient had cataract surgery with the same IOL about 18 years ago and she did very well for many…
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…
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…
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…
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…
Misloaded IOL rips open the posterior capsule
An anonymous surgeon submitted a video of a complication that happened with a misloaded IOL injector. We are thankful for…
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…
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.…
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…
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…
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…
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.…
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.…
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…
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…
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…
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…
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…
Twist Technique to Easily Explant the IOL
There are times when we need to explant an IOL from the eye. This can be at the time of…
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…
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…
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…
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…
Ruptured Capsule Rescue & Anterior Vitrectomy
Very important learning case of a posterior capsule ruptured then a rescue including anterior vitrectomy.
What is the 7L rule for haptic orientation?
You must know instantly if the IOL is being implanted in the eye correctly. We have explained how the IOL…
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…
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…
Inject more OVD before manipulating the IOL
When we insert the IOL, sometimes viscoelastic will be lost via the main incision. This can happen if we gape…
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…
Technique to suture an IOL to the iris
Sometimes, the IOL can dislocate after surgery and in the case of a three-piece IOL, we can easily suture the…
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…
use of an AC maintainer in Cataract Surgery
An anterior chamber maintainer is an additional infusion cannula which is inserted via the cornea or limbus in order to…
Focal lens opacity after intra-vitreal injection
This patient had multiple prior intra-vitreal injections for macular disease and now presents to you for cataract surgery. Upon examination…
What is the secret to patient fixation during surgery?
Many ophthalmologists have asked me how my patients are able to maintain fixation during cataract surgery under topical anesthesia. In…
Failure to Pivot in the Incision causes Issues
One of the most common mistakes made by novice surgeons is the failure to pivot in the incision. This causes…
Use of a Simcoe Cannula in Cataract Surgery
This video features guest surgeon Rob Melendez MD from New Mexico, USA. Dr. Melendez is a highly talented surgeon with…
The posterior capsule is wide open – now what?
This is a great learning case from one of our young surgeons in training. The video is 14 minutes long…
Prevent posterior extension of a capsular break
This is a resident case that you really must learn from, even if you are an expert. During nucleus removal…
Bimanual Irrigation / Aspiration Technique
Bimanual irrigation / aspiration can be helpful to access a full 360 degrees of cortex, keep the anterior chamber maintained,…
Beginning Surgeon Learns Phaco Chop – so can you!
You’ve seen countless videos of phaco chop, but you seem to be stuck in a mode of less efficient techniques…
Controlled IOL delivery during Cataract Surgery
In the past few days we have shown cases where the IOL delivery was less than ideal. This resulted in…
Good versus Bad Corneal Phaco Incisions with OCT
The phaco incision is critical to the success of the cataract surgery. It gives us controlled access to the cataract,…
Misloaded IOL leads to fractures of the optic
In this case, an ophthalmologist in training is performing this surgery during his residency program. The case looks great, but…
Misloaded IOL shoots out of the injector
The new scrub technician was working with us for the first time. She had previously assisted with ophthalmology surgeries in…
Mystery Case: What are these linear marks?
You’re doing a routine case and it is progressing beautifully. A good incision, a centered 5-mm capsulorhexis, efficient nucleus removal,…
How to safely remove a nuclear piece near the incision
Sometimes during cataract surgery a small piece of lens material, typically a small nuclear chip, can get stuck in the…
Quiz: Should you implant a Toric IOL in this eye?
The patient is 70 years old and the corneal scar of the left eye is about 80% depth within the…
I missed this Posterior Polar Cataract
This case caught me by surprise: in the pre-operative notes this was listed as a posterior sub-capsular cataract, but when…
Posterior Polar Cataract by Resident in Training
This is another case of a posterior polar cataract, this time performed by a resident in training. She does a…
Expert Technique: Small Pupil & Dense Cataract
Very experienced surgeons never rest — they are always looking to learn more. Like you, I learn a lot from…
Measure the Capsulorhexis for best results
The capsulorhexis is important for successful cataract surgery because it gives the capsular opening strength during cataract removal and allows…
Why is this patient yelling at me and the staff?
This is a routine cataract surgery that goes well and without complications. What is unusual about this case is the…
OCT analysis of a corneal phaco incision
For teaching my resident surgeons who are completing their years of ophthalmology training at our UCLA hospitals, we have recently…
Avoid Posterior Pressure from the Speculum
We need to place a lid speculum to get the best exposure for cataract surgery, but if we crank it…
Pupil Ring placed in one movement, but there is a catch…
I wanted to try a new technique: placing all 4 scrolls of the Malyugin ring on the iris in one…
Descemet Detachment at the Phaco Incision
When we construct our corneal phaco incisions, we must be careful to give them the proper architecture and form. We…
Radial Wrinkles mean aspiration of the capsule!
These radial wrinkles emanating from the port of the irrigation/aspiration probe are in the posterior capsule. This happens when we…
IOL Calculation Quiz: Ultra-High Myopia
Happy New Year! We are introducing a new feature to CataractCoach.com for 2019: critical evaluation of biometry, IOL calculations, and…
Why is the pupil peaked during this cataract surgery?
The iris is a fluid tissue that moves within the eye in response to the fluidic changes of cataract surgery.…
Adjusting the sleeve of the Phaco and I/A tip
For coaxial instruments like the phaco probe and the irrigation/aspiration probe, what is the best position for the silicone sleeve…
Should we do bilateral same-day cataract surgery?
On rare occasions, I will do immediate, bilateral sequential cataract surgery so that a patient can have both right eye…
After the chop, you must physically separate the nucleus
When doing phaco chop, remember that you must still physically push apart the nuclear halves to achieve complete separation and…
Which direction do you rotate the IOL?
Which way should you rotate the IOL, clockwise or counter-clockwise? The answer is… it depends. If the IOL haptics are…
Should you use 2 hands for the capsulorhexis?
The capsulorhexis is one of the most important and most challenging steps of cataract surgery. When you are performing the…
Loose Zonules become evident during Capsulorhexis
This is a patient who had an unremarkable pre-operative consultation for cataract surgery, but when we came to the operating…
Moderate Floppy Iris Syndrome: Avoiding Prolapse
This patient took Flomax (tamsulosin) a few years ago for a brief period of time. He later stopped the medication…
Cataract Surgeons are Refractive Surgeons
Cataract surgeons are certainly refractive surgeons and we can correct large degrees of myopia, hyperopia, and astigmatism during our lens-based…
Important Lesson from a Misloaded IOL
I had a case recently, where the surgical assistant told me that he was having difficulty loading the IOL into…
An easy way to help seal the phaco incision
If your phaco incision is properly constructed, it will typically seal quite well without the use of sutures. We can…
How far into the eye do you insert the keratome?
When making your phaco incision, it is important to have the appropriate tunnel length as well as incision width. We…
Novice Surgeons: Spiral Out the Capsulorhexis
When you watch experienced surgeons doing a capsulorhexis, it looks so easy. The anterior capsule is opened, a flap is…