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Cataract surgery, while performed without complications the majority of time, does not always result in perfection. Below are listed what I consider the top five pearls for success with cataract surgery.
1) Do not progress to the next step until the first step in completed well. It seems at first that this is obvious to us all, but upon reflection of a tough case, surgeons can almost always recount where things became difficult. "I should've have used hooks at the beginning", "I should've positioned the patient better" is a frequent statement by our residents after complicated cataract surgery. If, however, surgeons ensure that one step is completed successfully before the following, mistakes will occur less frequently.
2) Perform a good capsulorhexis. A good opening in the anterior capsule not only allows for easy removal of the cataract, but also facilitates placement of an intraocular lens. A rhexis that is too small will cause more stress on the bag/zonule complex during nucleus disassembly, and a large rhexis may not allow the lens to remain in the capsular bag properly. In addition, an irregular rhexis can develop radial tears with rupture of the posterior capsule. To ensure a good capsulorhexis, several steps should be followed. First, pupil dilation should be large enough to visualize the anterior capsule. This can be obtained with iris hooks or Malyugin ring (Microsurgical Technology), but, in cases of borderline dilation, higher molecular weight viscoelastics such as Healon 5 (Abbott) can be used to mechanically dilate the pupil. If the rhexis is too small, a new tear can be performed and used to enlarge the opening in the anterior capsule. If the rhexis is becoming too large or moving toward the periphery, a rescue maneuver can be employed which has been well described by Dr. Little (Little capsulorhexis tear-out rescue. Little BC, Smith JH, Packer M. J Cataract Refract Surg. 2006 Sep;32(9):1420-2.)
3) Don't be afraid to use a little "Shugar". The late Dr. Joel Shugar will be remembered for many things, among which is his intracameral cocktail to maintain pupil dilation and decrease iris tone. To create epi-shugarcaine, 9 mL of BSS Plus are mixed with 4 mL of 1:1,000 bisulfite-free epinephrine and 3 mL of 4% preservative-free lidocaine. A small aliquot is injected into the anterior chamber at the beginning of the case and allowed to "marinate" with the iris for at least 15 seconds before proceeding. In my experience I have found this regimen to be 100% successful in patients with a history of flomax use whose pupils dilate sufficiently at the time of surgery. A great demonstration of the effect of shugarcaine is demonstrated in these videos:
Both of these videos are from the same patient but in the first case only intracameral lidocaine was given. In the second surgery, intracameral shugarcaine was given. The difference is dramatic, and is now the reason I use shugarcaine as my intracameral injection on all cataract patients.
4) Hooks aren’t just for the iris. While iris hooks are very effective at enlarging the pupil to allow adequate visualization of the cataract surgery, hooks may also be used to stabilize the capsule. Specific capsule hooks are commercially available such as the Mackool Cataract Support System (FCI Ophthalmics) which have a better angle for securing the capsule, but in cases where they are not available traditional iris hooks can be used to engage the pupil. In cases of pseudoexfoliation with weak zonules, securing the anterior capsulorhexis with four hooks provides tremendous stabilization of the bag and minimizes further stress on the zonules with surgery.
5) Better equipment = Better results. Our technology is ever expanding, and with each breakthrough are patient outcomes continue to improve. Virtually all phacoemulsification machines have been modified to improve fluidics – examples include Bausch & Lomb’s Stellaris capable of 1.8mm incisions and Alcon's Infiniti capable of torsional phacoemulsification – but our choice of viscoelastics continue to improve as well, providing the perfect "tool" for each "job" we need them for. Diamond blades, and diamond-esque blades such as the BD Atomic Edge series provide less traumatic incisions which should heal faster and provide less corneal nerve damage. Furthermore, I predict that intraoperative aberrometry devices, such as the Orange (Wavetec Vision), will become more affordable and readily available, allowing us to titrate refractive error to an even greater degree before the patient has even left the operating room.
There are, of course, many other pearls for success in cataract surgery. For me, following the above has allowed me to improve my surgical outcomes and patient experiences. Ultimately, however, we should all create our own pearls for ourselves and to share with our colleagues so that we may all become better surgeons.
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Have a clinical or surgical pearl for cataract surgery? Please add it in the comments below.