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…
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…
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…
Basics: How to Load and Inject a Three-Piece IOL
In the USA, the most commonly used IOL in routine cataract surgery is a single-piece acrylic IOL. These IOLs work…
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…
Quiz: What is the problem here? Look Carefully!
This case seemed like a routine cataract surgery. Everything went smoothly. A good incision, a nice round capsulorhexis, easy removal…
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…
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…
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…
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…
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…
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.…
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…
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…
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…
The IOL is stuck in the incision! What should we do?
This valuable teaching video was submitted by an anonymous resident who is still in training. In this surgery, a smaller…
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…
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…
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.…
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…
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…