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…
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