adequately, does the patient just need to be reminded to lift the chin, or should the headrest be adjusted or head pillow be removed?

The most important advance in cataract surgical access, in my opinion, has been the shift to temporal incisions. A superior incision requires rotation of the eye downward, with degradation of the optics, loss of red reflex, and often an arcus senilis or superior pannus obscuring the surgeon’s view. The temporal incision, in contrast, allows the eye to be positioned with a vertical optical access aligned with the operating microscope. A deep-set eye or prominent orbital rim no longer presents an obstacle. In setting up for surgery, the surgeon must observe the position of the operating microscope itself; the optical axis of the microscope must be precisely vertical if the eye is to be properly positioned (Fig. 29–2).

SPECIAL MANEUVERS

The most important thing a surgeon can do to minimize a complication is to remain calm and focused; in fact, the surgeon must be more calm during a crisis than when things are going well. The surgeon must personally assume an aura of complete control. To do that, the surgeon must have technical mastery of the procedure, including complication manage-

ment, but also the combination of mental strength and confidence to allow the technical competence to function.

The most critical techniques for salvaging a phacoemulsification cataract extraction that is going badly are the steps that stabilize the nucleus when the capsular bag has a posterior rupture:

1.Inject viscoelastic through the paracentesis to stabilize the anterior chamber before withdrawing the phaco tip (Fig. 29–3).

2.Inject more viscoelastic around and behind the nucleus (Fig. 29–4).

3.As soon as access allows, insert a narrow Sheets’ glide behind the remaining nuclear fragments that have been elevated by the viscoelastic (Fig. 29–5).

4.Reduce irrigation flow by lowering the bottle, and reduce vacuum and aspiration rates to very low levels. These settings can always be increased if needed as the case progresses, but high settings may cause irreversible extension of a capsular tear or loss of nucleus into the vitreous cavity (Fig. 29–6).

5.Do not hesitate to make a pars plana sclerotomy about 3.0 mm posterior to the limbus. This open-

A

B

FIGURE 29–3 (A) If a posterior capsular break or zonular dehiscence is suspected, viscoelastic should be injected through the paracentesis before withdrawing the phaco tip and infusion to prevent shallowing of the anterior chamber. (B) If the anterior chamber shallows, vitreous will herniate through the posterior capsular tear, often extending the tear.

FIGURE 29–4 (Top) Injecting a retentive, low molecular weight viscoelastic behind the nucleus will help block vitreous from herniating through the posterior capsule defect and slightly elevate the nucleus.

FIGURE 29–5 (Bottom) A Sheets’-type glide is then passed between the posterior capsule and remaining nucleus. The phaco tip with very low flow settings can then be re-introduced to remove remaining nuclear and epinuclear fragments.

This chapter describes my current technique used to perform “routine” temporal clear corneal phaco surgery. The focus is on subtle points of the procedure that help to make the procedure easier, avoid trouble, and in general lead to the most reproducible outcomes. I then review the common difficult situations faced by today’s phaco surgeon, and discuss the principles and pearls that can make dealing with these trying situations easier.

ROUTINE CLEAR CORNEAL

PHACO SURGERY

If you have ever had the opportunity to observe a true master of phacoemulsification perform surgery, you likely have wondered, as I have, why it is that they can consistently achieve flawless results with aplomb and ease. The answer, of course, is to be found in their attention to detail. In the following discussion, the procedure itself, will be broken down into its basic components, and those details that I have come to rely upon to keep me out of trouble will be emphasized.

TOPICAL ANESTHESIA

The advantages of noninjection anesthesia to both patient and surgeon are numerous. A common denominator for success, for both the novice as well as experienced surgeon, is proper patient selection. In fact, after approximately four years of performing topical (and later intracameral) anesthesia, my percentage of noninjection cases began to approach the

98% level. I realized that my surgery had become less enjoyable. This was due to “pushing the envelope.” I was in reality operating on some patients who were not appropriate candidates. In recognition, I now approximate a 90% topical frequency. This has greatly improved the efficiency and enjoyment of my surgery. The point is that patient selection is the key! It’s basically no fun chasing after a roaming eye or fighting nearly constant blepharospasm. With experience, the selection criteria can be refined into a simple form to accurately predict how well a given patient will tolerate noninjection anesthesia. My assessment is based on several simple and routine elements of the preliminary exam and how the patient reacts to them.

NONINJECTION ANESTHESIA—

SELECTION CRITERIA

If the patient exhibits unusual blepharospasm or a marked Bell’s phenomenon during biomicroscopy and, in particular, indirect ophthalmoscopy, the patient is almost always deemed an inappropriate candidate for topical anesthesia. I further empower my surgical assistants who perform our biometric measurements to designate on the chart that the patient exhibited poor cooperation, and I adhere to their recommendations.

When switching to the use of no injection anesthesia, draping of the eyelids may become a challenging part of the procedure. I am a firm believer in the necessity of sequestering the lid margin under a plastic drape. Great care is taken, therefore, to carefully place the drape over the lid margin. This often re-

quires extra effort when orbicularis function is intact. If the patient shows an unusual reaction to draping and the insertion of the speculum, it is the final chance to “bale out” by converting to injection anesthesia.

ANESTHETIC TIMING AND AGENT

The next important point is that it actually takes very little topical anesthesia to adequately anesthetize the eye for intraocular surgery. I have found that nearly any common topical anesthetic will do, but the important point is not to overdo it. Administering two to three drops of any topical agent just prior to performing the surgical prep, only a minute or two before actually beginning surgery, is best. If instilled too early, despite insisting that patients keep their eyes closed, they will still gaze about the room curious about the unfamiliar situation and surroundings. Excessive drying of the epithelium will undoubtedly ensue. This may potentially compromise intraoperative visualization as well as increase postoperative discomfort.

PATIENT SENSATION

Another important clinical point is that the sensation that is most profound to the patient while under topical anesthesia involves stretching of the zonular apparatus. This is most likely to occur in high myopes and in patients who have had previous vitreous surgery. I find that topical anesthesia may still be used in these cases, but great care must be taken to gradually deepen the anterior chamber, trying to avoid a sudden and severe stretch placed upon the zonules. Even in routine cases, patients may note some sensation when the irrigation and aspiration (I&A) is first placed into the eye following phacoemulsification. It is at this point during the procedure that the greatest hydrostatic tension is placed upon the zonules. Therefore, I find it helpful to instill additional intracameral anesthesia during the exchange of the phaco to I&A instrumentation. The increase in anterior chamber volume due to the additional anesthetic and BSS will also help to blunt the sudden pressure and volume rise that occurs upon reentering the eye.

The surgeon should be aware of an interesting phenomenon that occurs in an eye that has previously undergone vitrectomy surgery. Shortly after adopting noninjection anesthesia, I had the surprise to learn that in the postvitrectomized state, intracameral anesthesia can very efficiently diffuse to the retina and cause amaurosis despite an intact posterior capsule. Similarly, if a capsular rent occurs intraoperatively,

particularly if a vitrectomy is required, diffusion may again occur. Patients should be warned of a temporary diminution or loss of their vision. To my knowledge, no untoward sequelae have ever been documented following this phenomenon. In fact, I have personally employed topical and intracameral anesthesia in planned posterior vitrectomy cases.

EXPOSURE AND INSTRUMENTATION

It is well recognized that one of the greatest advantages of the temporal approach is better access to the globe and improved exposure and intraoperative visualization. In fact, once surgeons have accomplished this somewhat challenging transposition, they will likely find that they abhor the superior approach. In transitioning to a temporal approach, several challenges arise: positioning one’s knees under the operating table, acquiring adequate wrist support, and shifting personnel and equipment into a new workable configuration. Once these major hurdles are met, several additional subtle challenges are recognized. One of these is that access to the side-port incision, which is now either at the 6 or 12 o’clock position, may be difficult. In addition previous instrumentation design for a superior approach may no longer be optimal for temporal surgery.

A number of specialized speculae have been designed for the temporal approach. One, a modification to the classic Kratz-Barraquer wire lid speculum, works well in most patients. This is made of a heavier gauge metal making it more resistant to blepharospasm. In addition, the temporal aspect is angulated posteriorly, over the lateral canthus, such that it is out of the way of incoming instrumentation. I also use a similar design with a locking mechanism for those patients who are truly squeezers; however, if I have adhered to the preoperative selection criteria, this situation rarely arises because the squeezing patient should have been scheduled to receive injection anesthesia.

Another important issue when working temporally is fixation of the globe, particularly under noninjection anesthesia. My preference has been to use a slightly modified Fine-Thornton fixation ring. The upper surface has 10-degree markings, whereas the undersurface of the ring has been highly polished to minimize conjunctival trauma. Mild downward pressure of the ring is typically all that is necessary to stabilize the globe. These modified rings also serve as arcuate gauges when performing perilimbal relaxing incisions. Other surgeons have recommended fixation by placing an instrument through the side port or simply using a gloved finger placed over the nasal bulbar surface. In an effort to mini-