The best ideas are often not only the most creative, they’re the most efficient as well. There’s a story about a New York City executive who was going to Asia for two weeks on business. She went to her Wall Street bank and requested an immediate loan of $5,000. When asked for collateral, she offered the keys to her Rolls Royce and said, “You keep it until I pay off the loan.” So, the bank gave her the money and parked the car in their underground garage. Two weeks later, the executive was back, bringing in a check for $5,000 plus $15 interest. The loan officer took the payment, then said, “I’m sorry, but I have to ask, you’re obviously wealthy. You own a Rolls. Why did you need to borrow $5,000?”

“I didn’t,” she answered, “but where else could I park that car in Manhattan for two weeks and pay only $15?”

Ideas, processes, and techniques that add efficiency and creativity to our cataract surgeries are the footings of this text. In this chapter I describe my personal observations regarding prevention and damage control. Indeed, Ashleigh Brilliant has advised, “If you can’t learn to do it well, learn to enjoy doing it badly.” While that may hold true for such joyous activities as playing golf (based upon my personal experience and which explains the sports analogies in this chapter), it would not be acceptable for the enhancement and preservation of vision. Thus, my objective here is to surf through the multiple steps in the cataract removal process and to click onto those that I feel I have at least some potential to be helpful with. This chapter is devoted either to preventing problems or, if they do occur, to recognizing them early and nipping them in the bud before they get bigger.

PATIENT SELECTION AND SCHEDULING

I have been fortunate to have been exposed to several surgeons who I consider to be masters of phacoemulsification. I have learned much from them. And I have observed a common denominator among them: they all major in the minors; that is, they pay a lot of attention to seemingly small details. Even things as basic as patient selection and scheduling should remain in the forefront. Since 1986, I have been employing what I call an individualized “phaco note.” It is created at the time of the preoperative office examination, and is a written game plan for each patient. It includes such things as characteristics of the cataract, how well the pupil dilates, the type of phaco needle to be used, the form of anesthesia to be employed, the planned incision characteristics, and any special considerations (Fig. 28–1). This special considerations section can contain a vast array of information; for example (1) difficult access characteristics such as deep-set eyes, prominent brows, or unusual positioning requirements secondary to back, neck, or breathing abnormalities;

(2) delicate corneal conditions such as guttatae, scarring, or thinning; and (3) the need for special instrumentation such as a prechopper, a pupil stretcher, or a vitrectomy kit.

The benefits of this phaco note are many. It helps me to begin the visualization process, much as a professional athlete does. Because a copy of it is given to the operating room personnel well in advance, it helps them to have the proper positioning alternatives, special instruments, etc., readily available. And, lastly, it provides a template for my scheduling technicians. I don’t care how many thousands of golf

holes I might have played in my life, the next time out I still would prefer to start the round with several “easy” holes, that is, holes that I have a reasonable chance to par or birdie. I definitely don’t want to start off with a 600+ yard par 5 with a narrow fairway, out-of-bounds both right and left, to an island green the size of a postage stamp! The same with my cataract surgery days. The scheduling technicians know how to interpret these phaco notes and they will make every effort to schedule our cases starting with those that I feel will be technically the easiest to the most difficult. In fact, just to be absolutely certain, there are occasions on which I make notation in that special considerations section to the effect “schedule as the last case of the day.”

I would never entirely discount the role of luck. But there is also no doubt that the more we can displace luck with preparation and the more we major in such minors as patient selection and scheduling, the greater the potential for a successful surgical outcome.

THE GREAT GAME OF PHACO

If phaco was a game, winning or losing it would pivot around the surgeon’s ability to understand and control phaco fluidics, and what a complex subject it is! So many variables influence it. Many have been covered in Chapter 25. But let me underscore the prevention aspect of being positive that our phaco incision size properly matches our phaco tip/ handpiece configuration. Over the last year, I have visited many operating rooms to observe surgery. I have seen great techniques and beautiful outcomes. But I’ve also seen missed opportunities to prevent snafus. Phaco incision size is a common one, especially with clear cornea or near-clear incisions.

My personal bias is toward standard phaco tips with an internal diameter of 0.9 mm. With those, I recommend an internal phaco incision width of 2.8 mm. A larger incision allows for excessive incisional outflow and compromised fluidics. A smaller incision risks restricted outflow and the possibility of a

corneal burn. With the downsized phaco tips (as small as 0.6 mm internal diameter) the internal phaco incision might need to be as small as 2.4 mm. The point is that the incision size should be based upon science and not habit. It’s a tough game to win if you go to the plate with two strikes against you.

ONE-HANDED TWO-HANDED PHACO

Before I get off my incision size soapbox, let me also make some comments regarding the side-port incision employed by surgeons who prefer the twohand techniques. Incisional leakage has an untoward effect on phaco fluidics, and the eye doesn’t much care about the location of the leakage. We can create the most balanced phaco incision in the history of cataract surgery and still negatively influence fluidics by creating an unnecessarily large side-port incision. If you routinely create side-port incisions, exactly how large do you intend it to be: 0.5 mm, 1.0 mm, 1.5 mm? Or are you like I was for too many years, when I just took the knife I was handed and poked it in? I had so much incisional leakage through the side port that it put Old Faithful to shame. Thankfully, those days are gone.

What is the appropriate side-port incision size? It is dependent on what is used as a second instrument. It should be just big enough to allow entry and exit of the second instrument. And although I’ve not used every chopper, manipulator, and rotator on the market (there are not enough days in one’s lifetime to do so!), I’ve used many of them, and a side-port incision of no greater than 0.5 mm is a decent approximation. I can hear some of you already, “Come on, Dave, you’re telling me there’s a meaningful difference between a 0.5 mm and a 1.0 mm side incision?” But we’re majoring in minors here. It’s not necessarily a back-breaker, but it can be a back-acher.

One last thought about this now properly sized side-port incision: don’t use it unless something truly contributory is happening through it. For too many years I would place the second instrument

through the side port at the beginning of the phaco process and leave it in the eye until the end. Then I realized that it was the presence of the second instrument (especially through a too-large side incision) that was causing side-incision leakage and causing the posterior capsule to come forward! So I ask myself constantly, “Is my second instrument really advancing this phacoemulsification in a safe and positive fashion, or am I leaving it in the eye simply because it’s convenient to do so?” Although at first it may seem to be an inconvenience to be putting your second instrument in and out of the eye, you will notice improved fluidics with it out of the eye. This will result in improved followability and chamber stability (assuming there is the proper phaco incision/ phaco tip combination).

THE NO-EXCUSE HYDRODISSECTION:

THE COLVARD MANEUVER

Excellent mobility of the lens within the capsular bag is an essential precursor to all endocapsular phaco techniques. Mobility of the lens within the capsular bag is a function of hydrodissection, and to ignore its importance should bring to mind this football story that occurred during Joe Namath’s senior year at the University of Alabama. His coach, the legendary Bear Bryant, was lecturing his team about the importance of going to class. “I don’t want no dumbbells on this team,” Bryant warned, “If there is a dumbbell in this room, I wish he would stand up.” At which point Namath rose to his feet. “Joe, how come you’re standing up?” asked Bryant. “You’re not dumb.” Namath replied, “I know, Coach, I just hate to see you standing there by yourself.” To attempt endocapsular phacoemulsification without knowing that the cataract is free and mobile is, well, dumb. This single area of prevention might result in the greatest amount of damage control on a “pound for pound” basis.

The only way to be assured of successful hydrodissection is to actually test for mobility. I do it with my hydrodissection cannula. What if the nucleus won’t easily spin (i.e., without putting stress in the zonules and capsular bag). The answer is what I call the Colvard maneuver. Several years ago Dr. Michael Colvard developed an ingenious little device to help either surgeons transitioning into phacoemulsification from planned extracapsular cataract extraction or residents who had no surgical experience. He called this device the Phaco Shield. It is a very thin piece of dark blue silicone that is to be placed under the inferior anterior capsule and then advanced until it rests centrally in a position between the posterior capsule and the cataract. Therefore, when properly

placed, it would be a virtual impossibility to break the posterior capsule by phacoing through the cataract. In an effort to assist Mike’s clinical evaluation of the Phaco Shield, Mike visited Danville and taught me how to properly place it in the bag. Subsequently, I was able to apply those new skills to hydrodissection and develop the “no-excuse” hydrodissection via the Colvard maneuver. And, here’s why: in an effort to place the Phaco Shield, a fair amount of space needs to be created. Therefore, the first step in the placement of the Phaco Shield is to take the irrigation and aspiration (I&A) handpiece and to rather aggressively remove as much cortex and epinuclear material as one possibly can. Dr. Colvard taught me that this can be safely accomplished not only centrally, but also under the anterior capsule and out into the periphery as well. And, that’s the key to the no-excuse hydrodissection. When you are in that situation in which no matter what you try, you just cannot get good hydrodissection, and cortical and epinuclear material are starting to fluff up, simply refrain from further efforts at that time and ask the scrub nurse to take the I&A lines off the phaco handpiece and transfer them to the I&A handpiece. Employing the I&A handpiece with the same high vacuum and high flow settings that you would normally use for cortical removal, aggressively remove as much cortex and epinucleus as you possibly can. “Why not just do to it with the phaco needle in foot position 2?” you might ask. The answer is that the objective is to remove cortex and epinucleus not only from the very center, but also under the anterior capsule and as far into the periphery as possible. To do so with the phaco needle would almost assuredly tear the anterior capsule. To be successful, it will be necessary to constantly turn the opening of the aspirating port so that it faces all directions, including port down. Once done, it is necessary to at least partially refill the anterior chamber with the viscoelastic agent of your choice. Then returning to the hydrodissection cannula again, place it under the anterior capsule, slide it out toward the periphery, and try hydrodissection again. To date, I have never had this fail. In fact, how much do I believe in this maneuver? I used it on my own mother’s first eye. I tried and tried to hydrodissect, and the cataract apparently didn’t care that I was sweating blood. Therefore, I did the Colvard maneuver and, lo and behold, the next attempt at hydrodissection resulted in wonderfully comforting mobilization.

THE CLANDESTINE WRAPAROUND

The most underrecognized etiology for a posterior capsular tear is an anterior capsular tear (recognized

or unrecognized) that has become a wraparound tear. It is very important that we keep anterior capsular tears anterior only and not allow them to wrap around to the equator and posterior capsule. My experience has led me to believe that the best way to do that is to prevent the capsular bag from sudden decompression. This often happens when the phaco handpiece or I&A handpiece is removed from the eye. I vividly remember a case I did in which I knew there was a tear in the anterior capsule early on. I was able to do the phaco. I was able to remove all of the cortex without difficulty. However, as I pulled the I&A handpiece out of the eye, I could see the anterior capsular tear wrap around and create a significant tear in the posterior capsule. I vowed I would never let that happen again.

What I learned to do is simple but effective. In the presence of a known anterior capsular tear, or even if I suspect an anterior capsular tear, I simply try not to allow the capsular bag to decompress. I try to make sure it always has support. Each time I feel it is necessary to remove either the phaco handpiece or the I&A handpiece (by far the most common would be at the conclusion of the phaco or cortex removal, but occasionally at other times as well), I will go to foot position 1 (irrigation only). Next I pause with the tip of the handpiece resting quietly in the center of the anterior chamber. I then ask the scrub nurse for a viscoelastic agent. (They all work fine for this application, but I prefer one that stays in the eye, and thus one with low cohesion such as a chondroitin sulfate/sodium hyaluronate combination.) With my dominant right hand, I hold the phaco or I&A handpiece in the eye, foot position 1, and I hold the viscoelastic syringe with my left hand. I insert its cannula into the eye through the side-port incision and

inject the viscoelastic (Fig. 28–2). After a moderate amount of viscoelastic has been injected, I go to foot position 0 (i.e., the irrigation inflow is stopped), but the phaco or I&A handpiece stays in the eye “plugging” the phaco incision. More viscoelastic is injected until I feel the capsular bag has been stabilized. Then I remove the phaco or I&A handpiece and hand it off to the scrub nurse.

I repeat that series of maneuvers, using viscoelastic to prevent forward movement of the capsular bag that will inevitably create an extension of the anterior capsular tear, as often as is needed until the intraocular lens (IOL) has been implanted into the capsular bag. The IOL provides the added support necessary to keep the anterior capsular tear anterior from that point on.

Comedienne Rita Rudner made the observation: “I think men who have a pierced ear are better prepared for marriage. They’ve experienced pain and bought jewelry.” Hopefully, you’ve never experienced the pain of a wraparound tear. Now you will be better prepared for that next anterior capsular tear.

CORTEX

Let me ask your opinion. Do you think more capsules are broken during phaco or during the I&A of cortex? (Remember, don’t ask for another’s opinion unless you’re ready for the worst. A poet complained to Oscar Wilde about the neglect of his poems by the press. “It’s a complete conspiracy of silence. What should I do, Oscar?” “Join it,” replied Wilde). Well, if you said during removal of the cortex, I will join you. So, the question then is “Why”? Is removal of cortex more technically challenging than doing pha-

coemulsification? I don’t think so. Let me repeat a thought I expressed earlier in this chapter. If phaco was a game, winning or losing it would pivot around the surgeon’s ability to understand and control phaco fluidics. And that is true for cortex removal. If cortex removal was a game, winning or losing it would pivot around the surgeon’s ability to understand and control cortex removal fluidics. I believe that if we drop the ball during I&A, it most likely will be the fluidics ball.

Many surgeons feel the newer two-handed techniques for cortex removal are upgrades over more conventional methods because they have good fluidics inherently built into them. So, for those of us who are still using the traditional I&A handpiece through the phaco incision to address the cortex, let me now share a couple of prevention thoughts.

The first key area to address is the configuration of the I&A handpiece. The inner aspiration sleeve can be a variety of shapes (straight, curved, angled) and likely has a 0.3-mm opening (although some surgeons prefer a 0.4-mm opening, which is fine as long as they remember they are entering a different fluidics game with a larger opening). They all work nicely. The key element, however, is not the inner sleeve but rather the (irrigating) outer sleeve. It’s the outer sleeve that most influences the amount of incisional leakage through the phaco incision during cortex removal. So, let me ask you another question! Do you use a Calvin Coolidge outer sleeve or a Durwood Merrill outer sleeve? Let me explain.

Of all America’s presidents, “Silent Cal” Coolidge had by far the biggest reputation for reticence. Unlike today’s politicians, he rarely uttered anything unnecessary. Once, at a dinner party, the woman next to him said, “Mr. President, I made a bet that I could get more than two words out of you.” Coolidge looked her right in the eye and said: “You lose.” If you are using a metal outer sleeve, you lose. That is, you lose the opportunity to exert maximal control over cortex removal fluidics. Incisional leakage has an untoward effect on fluidics. The metal outer sleeve simply cannot “plug” the phaco wound (assuming a phaco incision of 2.8 mm or greater) and significant incisional leakage takes place. The result could be a collapsing capsular bag, which both makes access to the cortex more difficult and threatens posterior capsule capture with the possibility of tearing. Understandably, the bigger the phaco incision, the greater the threat. A 3.2-mm incision becomes more problematic than a 3.0-mm incision, which is more problematic than a 2.8-mm incision. Even with my customary 2.8-mm phaco incision, the metal outer sleeve allows for way too much incisional leakage.

Durwood Merrill is a professional major league baseball umpire who is still active. During his rookie year, he found himself behind the plate for a game when a young fastballer by the name of Nolan Ryan was on the mound. The second pitch of the game was so fast Merrill never saw it. He froze, unable to make the call. After a seeming eternity, he finally yelled, “Strike!” At which point the batter backed out of the box and said, “Ump, don’t feel bad. I didn’t see it either.” That’s how I feel about incisional leakage during cortex removal. I don’t want to see it. Consider this: a small amount of incisional leakage is still necessary to assist in the proper cooling of the phaco tips in use at the time of this writing. But there is no heat created by the automated I&A of cortex process, so any incisional leakage is counterproductive. That is why I suggest using “Durwood Merrill” outer sleeve. It is nothing more than a silicone outer sleeve, essentially identical in design to the outer sleeve used on the phaco tip. The expansive silicone has a higher probability of plugging the phaco incision and inhibiting incisional leakage. Once again, phaco incision size comes into play. This silicone outer sleeve will be more efficacious with a 2.8-mm phaco incision than a 3.0-mm incision, and so on.

I am continually amazed by the number of surgeons I encounter who don’t know silicone outer sleeves exist for I&A. They exist for every phaco machine. Let me once again encourage their use. It’s the right call.

One other thought regarding cortical cleanup. Consider the recalcitrant cortex, that sticky stuff that just won’t cooperate with the surgeon. This is definitely the time to be a lover and not a fighter. As Mae West answered the query as to how she reached the pinnacle of her profession, “I climbed the ladder of success wrong by wrong.” To be aggressive and defiant at this point (of course, at any point) is simply wrong. Let me outline a series of simple maneuvers to assist in the taming of recalcitrant cortex. The first is the most difficult: simply leave it alone! For some reason, there seems to be some kind of a macho attitude when it comes to cortex removal. It’s almost as if the cortex has thrown down the gauntlet and we must conquer it at all costs. Here is where someone as obscure as Zsa Zsa Gabor can help us with her observation “macho does not prove mucho.” Leave it alone. Let it think it won that battle; we’re still going to win the war. Next, use your viscoelastic agent to viscodissect the stubborn cortex off the posterior capsule and up into the capsular fornix. Because it is often the subincisional cortex that is recalcitrant, this maneuver is almost always best accomplished through the side-port incision. The objective is to get viscoelastic under the leading edge of the remaining

cortex (Fig. 28–3A). Then create an advancing wave of viscoelastic that will peel the cortex off and deposit it in the fornix (Fig. 28–3B). Next, continue on with the viscoelastic injection until the capsular bag is nicely formed and ready for the next step—IOL implantation. The IOL will assist in keeping the bag formed and in isolating the posterior capsule from the action to follow.

The next step is optional and is determined by just how “sticky” the cortex was to begin with. If I feel it was really socked in, even though I loosened it with viscodissection, next I’m going to loosen it more by employing manual irrigation, not manual aspiration. I’m going to gently squirt some balanced salt solution right into its belly. The objective is to both loosen and hydrate the cortex to greatly improve its accessibility. (I learned to do so by watching an old

movie of Harold Ridley doing cataract surgery in the 1950s. Once he removed the nucleus, he removed all the cortex by gentle irrigation. He used no aspiration whatsoever!) A whole host of different cannula styles can be used to accomplish this irrigation. It can be approached through both the phaco and the side-port incisions. As a general rule of thumb, I use a U-shaped cannula through the phaco incision (Fig. 28–4). With the last step it is time to win the war. Returning to the automated I&A handpiece, the remaining cortex is removed. Often this is best accomplished by using one of the curved or angled aspiration tips.

Almost always this series of maneuvers will deal with recalcitrant cortex, but not 100% of the time. Occasionally, I find it necessary to manually re-irri- gate, to “fluff it up” some more. And, almost always