mize trauma to both the paracentesis and main incision, I try not to instrument either, except during intraocular lens (IOL) insertion when it may become necessary to lift the anterior wound edge to facilitate folding instruments.

One challenging new peculiarity of the temporal approach is access to the side-port incision. When operating superiorly there was unlimited access to the paracentesis. Now, however, access to the 6 or 12 o’clock position may be hampered by either the lid speculum or the orbital rim, particularly in deep-set eyes or in individuals with narrow palpebral fissures. For this reason, additional modifications to conventional instrumentation may be of help. These include nuclear manipulators that have a more vertical angulation to better fit down into a deep-set eye. Also, modified irrigating cannulae with shortened tips will facilitate placement through side-port incisions.

Always important is the detail of patient positioning. One must ensure that the patient’s neck is neither hypernor hypoextended. My operating room personnel labor over this detail (after years of my urging them to do so!). I further employ a subtle but helpful maneuver taught to me by Bruce Wallace (Alexandria, LA). By slightly tilting the head toward the side that the surgeon is sitting on, there is significant improvement of visualization as well as the ergonomic positioning of the microscope. There is a tendency during surgery for the patient to move away from the surgeon, so we routinely place a very light strip of tape over the patient’s forehead as a friendly reminder to maintain the position.

Lastly, to improve efficiency and logistics in the operating room, all right eyes are scheduled together as are the left eyes, to avoid having to make unnecessary changes to the positioning of the equipment and instrumentation.

INCISION

One certainly does not need to extol the many virtues of clear corneal incisions, as they have now been elaborated upon extensively. A simple point, however, should be stressed: proper sizing of an incision (to the phaco needle and sleeve combination that is used) is of paramount importance to achieve optimal fluidics. Too tight an incision risks a corneoscleral burn, but the more common tendency is to use an incision size that is slightly too large and therefore may lead to unnecessary leakage. When working through an unobstructed single plane temporal clear corneal incision, I find that a 2.8-mm incision works best with most standard diameter phaco tips. A 2.5-mm incision is typically used with the

“micro” tips. A grooved incision tends to gape more and will therefore behave as if it were a slightly larger incision.

Equally important, keep in mind that most sideport manipulators will pass through an incision of 0.5 to 0.7 mm, thus making the standard 1-mm sideport incision far too large and, hence, leaky.

CAPSULORRHEXIS

The key to performing a good, consistent capsulorrhexis is maintenance of a deep anterior chamber. For this reason, my personal preference is to use a cystotome needle that is attached directly to a viscoelastic cannula. In this way, the anterior chamber can be immediately redeepened if shallowing occurs or if extension of the tear is imminent.

My standard capsulorrhexis technique begins centrally with a circumlinear puncture creating a flap that is then folded over upon itself and advanced with the needle utilizing a shearing rather than a tearing force. Generally, one or two additional injections of viscoelastic are used during completion of the tear. Previously torn and bunched up capsule is pushed centrally, clearing the way for the leading edge of the tear. The torn segment of capsule is also removed from the anterior chamber. This ensures that the tear has been completed 360 degrees. If this is not done, sooner or later, after entering the eye with infusion, the incomplete capsular tear will inevitably progress to the equator with the introduction of the phaco handpiece. Additionally, when removing the torn capsule, gentle pressure on the posterior lip of the incision allows decompression of the anterior chamber. This makes the next step of the procedure, hydrodissection, safer.

HYDROSTEPS

Thorough hydrodissection is of great importance to ensure trouble-free phacoemulsification. In fact, inadequate hydrodissection may often be traced back as being the cause of a subsequent complication. Adequate hydrodissection should be confirmed by visualizing free and easy rotation of the lens within the capsular bag. I personally continue to revel in the efficiency of cortical cleaving hydrodissection as taught by Howard Fine (Eugene, OR). Without irrigation I place a flattened hydrodissection tip under the anterior capsular leaflet and inject gently. Two separate irrigation points 180 degrees apart ensure adequate hydrodissection. Each time, the lens is balloted in a posterior direction, causing the injected fluid to pass up and around the equatorial region, lysing cortical capsular adhesions.

Hydrodelineation, on the other hand, tends to be an optional step. I personally employ this maneuver in all endocapsular techniques. I enjoy working within the safe confines of the epinuclear shell. Also, with modern chopping techniques, I find that removing segments of the endonucleus is facilitated by virtue of smaller segment dimensions. Some surgeons bristle at the thought of having to deal with the epinucleus. This is in actuality easily accomplished, again as taught to us by Fine, by simply trimming the epinuclear bowl in all four quadrants and then allowing it to collapse and flip in upon itself.

PHACOEMULSIFICATION

Variations on the original Nagahara phaco chop technique abound today. My personal preference is for a subtle but important variation on the traditional chop technique called “quick chop,” a term coined by David Dillman (Danville, IL). This technique, with slight variations, was described contemporaneously by several surgeons, including Thomas Neuhann (Germany), Vladimir Pfeifer (Slovenia), Abhay Vasavada (India), and Hideharu Fukasaku (Japan). Several key points pertain to all phaco chop techniques.

First, one should get in the habit of exposing more of the phaco needle (beyond the leading edge of the silicone sleeve) to allow for a deeper purchase of the nucleus. I personally find that a 15to 30-degree bevel tip is optimal. Although 0-degree tips may occlude better, a small bevel can be used to help manipulate nuclear fragments. After chopping, it is best to try to tip up cleaved segments for purchase rather than allow them to tumble forward. This may be facilitated by using the manipulator to push the chopped segment out toward the equator of the bag, which in turn causes the posterior apical aspect to slide upward.

Another helpful hint involves rotation of the bevel such that optimal apposition occurs with chopped segments. This requires rotation of the phaco instrument along its long axis, and will in essence create a 0-degree tip when the bevel is placed parallel to the presenting surface or facet of the chopped segment. Occlusion is thus maximized.

Perhaps the most important point in all disassembly techniques involves the discipline to ensure that each successive cleavage plane is complete in its separation from one pole of the nucleus to the other and from anterior to posterior. This may require placement of the instruments deeply into the fault line that has been created, and then lateral separation in several different locations to ensure that the division

plane propagates entirely through the posterior nuclear plate. Complete separation is confirmed by visualization of the red reflex. This separation must occur on each successive chop and division, or the result will be multiple, partly separated peripheral segments, connected centrally and posteriorly—a conformation that resembles a tulip or garlic clove.

One of the most common complaints voiced during the transition to the traditional Nagahara phaco chop technique involves placement of the chop instrument around the edge of the nucleus in the capsular bag periphery. Upon examination of the bag anatomy and curvature and design of most choppers, it becomes apparent that this potentially dangerous maneuver may be safely carried out by carefully angulating the instrument such that the proximal handle of the instrument is brought back toward the surgeon, causing the distal tip of the chop instrument to assume a plane parallel to the iris (Fig. 30–1A). At this point, excursion out under the anterior capsule to the periphery may be safely made without snagging the capsule or prematurely engaging the nucleus. Once out and around the endonucleus, the handle of the instrument is brought upright once again, thus causing the distal tip to pass around the equator of the lens (Fig. 30–1B). The chop can then be made against the impaled phaco tip.

Alternatively, this maneuver may be achieved by adopting the phaco quick chop technique. The chop instrument is placed just in front of or to the side of the centrally impaled phaco needle. The chop instrument is pressed downward, toward the optic nerve, and pushed outward. The phaco tip, impaled in the bulk of the nucleus, is elevated and pushed outward, away from the chopper (Fig. 30–2). One subtle key with these maneuvers is to use the side-port incision as a fulcrum such that the heel of the instrument— that portion outside of the incision—elevates as the distal tip passes downward into the lens. Otherwise, depression of the paracentesis site will cause a distorted view of the anterior chamber. Additionally, a more pointed or faceted tip, as opposed to the blunted tip designed for safety during traditional phaco chop, is best for this technique.

Preplacement of a groove or central sculpting can be quite helpful to the surgeon making the transition from a standard divide and conquer approach to a chopping technique. The veteran phaco chop surgeon will often utilize central debulking when dealing with extremely dense nuclear cataracts. This will allow for the initial chop to be performed on less nuclear bulk, thus creating more space and requiring less physical energy to create the initial cleavage plane.

I&A

Many surgeons continue to utilize I&A instrumentation with a metal sleeve rather than a silicone sleeve, and therefore incur unnecessary incisional leakage. I find that a 45-degree angled diamond-dusted tip, used with a standard silicone sleeve, allows excellent access to 360 degrees of the capsular fornix. Rarely, recalcitrant, usually subincisional cortex will remain,

and I call upon a simple manual maneuver to remove this material. Viscoelastic is first used to push the posterior capsule downward in the area of the cortex. A double-bent 27-gauge cannula attached to a TB syringe half filled with BSS is then placed through a side-port incision. This provides for access to the subincisional area. Light pressure on the plunger of the syringe allows for delicate loosening of the cortex by irrigation to then allow purchase and stripping out of the fornix by lightly pulling back on the plunger. The cortex is then brought up and into the anterior chamber where removal can then be completed with the I&A tip. This same technique is used to remove cortex when faced with a breach in the posterior capsule or when faced with weakened zonules (see below).

The concept of bimanual instrumentation is also sound to both prevent incisional leakage and gain complete access to the capsular fornices; however, the instrumentation can be unwieldy, particularly when placed through side-port incisions at the 6 and 12 o’clock positions because of orbital rim, lid, and speculum obstruction.

FIGURE 30–2 The chopper tip is placed left of but near the embedded phaco tip. The chopper is pushed posteriorally into the nucleus while the nucleus is held in place or elevated with the phaco tip. Simultaneously, the chopper is moved down and left while the phaco tip is moved up and right. This will create a split in the entire nucleus between both instruments.

The most common problems incurred during placement of an IOL involve either poor loading of the implant or an attempt to place the lens through too small an incision. Studies have now well documented that traumatic wound stretching may occur. It is wiser to slightly oversize the incision rather than attempt to squeeze an implant through too tight a

wound. Forcing a folded lens through a snug incision may cause premature IOL release, tear the incision, or create a Descemet’s detachment.

When loading a foldable IOL, either with manual inserting instrumentation or an injector delivery device, the implant should be resting flat and planar on the loading surface. Most inserters have markings to ensure that the implant is well centered. When utilizing an injector delivery system, if undue resistance is encountered during insertion, as the IOL passes down the barrel, it is best to stop, remove the device, and reload the injector. Resistance to IOL passage often is secondary to malposition of the IOL or overriding of the plunger or obturator. Persistence in the injection of the IOL may deliver into the anterior chamber a torn or otherwise damaged IOL. Removal will then become mandatory.

When grasping three-piece foldable IOLs for manual insertion, a familiarity with the subtleties of different biomaterials and IOL design is helpful. Most implants have a “sweet spot” somewhere on the folded optic that will provide for the most secure grip with manual inserting forceps. This is, in general, closer to the fold on silicone IOLs, and further toward the open edge on acrylic implants. Silicone’s slippery surface requires the implant and instrumentation to be kept dry, and acrylic’s tacky surface and tendency to mar call for wetting and lubrication with viscoelastics.

On rare occasions, the surgeon may be confronted with delivery of an inverted IOL. Worse yet, a damaged IOL may require removal and replacement. Two tricks that have been taught to me by T. Neuhann (Munich, Germany) have proven to be invaluable in these awkward situations.

First, in the case of an “upside down” delivery, following generous deepening of the anterior chamber with viscoelastic, the optic can be flipped over, right side up, using two manipulators placed through side-port incisions. The axis of rotation of the lens optic should be at the plane of the iris. Given an optic radius of 3.0 mm, and an anterior chamber (AC) depth of 4 to 5 mm there should be at least 1.0 to 1.5 mm of additional space within the viscoelastic-deep- ened aphakic chamber.

Second, when faced with the need to remove a foldable IOL, in particular a silicone IOL, the optic does not need to be entirely bisected to preserve the small incision. Rather, by just obtaining a cut 2.0 to 3.0 mm in length and then firmly grasping an edge, the optic will elongate and pass through the incision. Alternatively, specialized instrumentation is available to aid in bisecting the lens (Chu Lens Scissor, Rein Medical, Inc., Tampa, FL).

In the case of an acrylic implant, after appropriate positioning within the anterior chamber, the IOL

may be folded intracamerally over a thin spatula placed through a paracentesis port 180 degrees away from the main incision and then removed through the unenlarged wound.

WOUND CLOSURE

Much debate has taken place over the question of clear corneal incision integrity. My personal experience has been that if incision width is kept under 4 mm and tunnel length maintained at least as long as 1.5 mm, these wounds, regardless of whether or not a “groove” is utilized, prove to be safe and secure. I do find stromal hydration helpful even if the incision appears to be watertight. By bringing the roof and floor of the tunnel into strict apposition, a more secure closure is obtained. I also take time to hydrate the side-port incision. This incision, if checked, often leaks more than the main phaco incision due to intraoperative manipulation at this less accessible site. Another pearl for obtaining good closure is to slightly hyperinflate the chamber and then slowly release fluid through the side-port incision until a normal intraocular pressure is obtained. This maneuver will help to close the internal lip of the phaco incision to promote a watertight seal.

DIFFICULT SITUATIONS

Of all the benefits that contemporary clear corneal small incision surgery offers, none is greater than the markedly reduced rate of complications. Nonetheless, even the most experienced surgeon will on occasion encounter trouble. What then distinguishes master surgeons is their ability to retain a sense of equipoise and methodically work through the challenge. By utilizing proper instrumentation, technique, and most importantly maintaining a closedchamber environment, the surgeon retains control over the intraocular milieu and can thereby dictate the eventual outcome. Armed with a thorough understanding of these surgical strategies, this sense of confidence and equanimity may be engendered by both novice as well as experienced phaco surgeons.

MANAGEMENT OF THE BROKEN

POSTERIOR CAPSULE AND ADVANCED

VITRECTOMY TECHNIQUE

Admittedly, each case and anatomic scenario involving a broken posterior capsule is unique; however, several fundamental surgical principles apply universally. When followed, these principles allow surgeons to achieve the following goals: (1) safe and

thorough removal of all lens material; (2) as indicated, removal of presenting vitreous without imparting unnecessary retinal traction forces; and (3) avoidance of further enlargement of the posterior capsular tear.

First, one must have the discipline to stop working as soon as a problem is sensed. This does not necessarily mean removal of instruments from within the eye because abrupt shallowing of the anterior chamber may extend the tear. Rather, filling of the anterior chamber with viscoelastic through the sideport incision may then permit removal of the phaco or I&A instrument without incurring sudden hypotony. At the same time, viscoelastic is used to tamponade the anterior hyaloid face and stabilize any remaining lens material. Time then exists for careful assessment of the pathology, which will then dictate subsequent surgical strategy. It should be noted that a low-viscosity, less cohesive and highly dispersive viscoelastic (such as Viscoat) helps to form a better “plug” in a capsular break and tamponade the anterior hyaloid face. Indeed, when faced with these challenging situation, surgeons’ two best allies may be their viscoelastic and a (modified) lens glide.

In an effort to avoid enlarging the capsular tear, the surgeon must be dedicated to the maintenance of a truly closed-chamber environment. Although aided by small, self-sealing incisions, further maneuvers must utilize truly watertight incisions. This condition helps permit the next surgical principle to take place, that is, the minimizing and eliminating infusion. These two concepts are the essence of avoiding extension of the capsular tear. If significant nuclear material is present, a decision must be made regarding further phacoemulsification. This depends on the surgeon’s experience and the anatomic particulars of the case; however, if conversion is felt to be necessary, generously enlarge the incision. Astigmatic concerns may be addressed at a later time. Care should also be taken to avoid pressure on the globe when removing lens material; viscodissection and instrument-aided nucleus removal is preferable. A modified lens glide (Visitec) may be called into use to both support and aid in removal. Alternatively, the lens glide may be used as a “pseudoposterior capsule” (see Chapter 18), allowing further phacoemulsification to be performed. This must be carried out in a low-flow state.

For residual cortex, I strongly advocate a manual technique of removal or at least mobilization, with automated I&A only being performed after the implant has been placed and the pupil constricted. If the I&A handpiece is used in a routine fashion, the associated high flow will undoubtedly cause extension of the tear. Alternatively, if the anterior hyaloid face has been broken, cortex may be removed utilizing the vitrectomy instrument. The manual technique first employs

viscodissection between cortex and posterior capsule, then placement of a double-angled 27-gauge cannula through side-port incisions. Simcoe or Binkhorst cannulas may be substituted. As noted previously, the cannula attached to a BSS-filled TB syringe provides for gentle infusion to loosen cortex, then the cortical strands may be stripped from the capsular fornix and brought up into the anterior chamber. Complete removal at this point is not necessary. Additional viscoelastic is placed as necessary to tamponade the anterior hyaloid face and maintain chamber volume.

If vitreous is present, a vitrectomy is mandated. Many authors (Fishkind, Koch, Osher) have expounded the virtues of a bimanual, two-port vitrectomy, yet most cataract surgeons still rely on what is familiar and superficially easier to use—a unimanual, coaxial vitrectomy instrument. Unfortunately, this approach is inefficient, potentially more dangerous, and much more likely to lead to enlargement of the capsular rent. By simply separating the infusion line from the vitrectomy instrument, a more controlled and effective vitrectomy can be carried out. Various anterior chamber maintainers are available. Self-maintaining cannulas have the advantage of freeing-up one hand, but I prefer to maintain bimanual control over the eye. A blunt-ended 21-gauge infusion cannula is ideal (Storz no. E4421-S21, Fig. 30–3). The standard infusion line connects easily to this simple instrument, and is then placed through the side-port incision. The infusion rate is lowered to a level that simply maintains volume as material is removed. A microvitreo-retinal blade is then used to make a separate stab incision at the limbus to permit placement of a 20-gauge (posterior segment) vitrectomy cutter (Fig. 30–4). These incisions must be snug and watertight. If not self-sealing, the phaco incision must be sutured. Vitreous removal should be performed at low (50 to 100 mm Hg) vacuum settings with high (400 to 1500 cpm) cutting rates. If lens material is to be removed, the cutting rate is reduced and vacuum carefully and gradually increased.

Alternatively, the cutting instrument may be placed through the pars plana (Fig. 30–5). This has the advantage of accessing the subincisional area where residual lens material often resides, and permits efficient removal of anterior chamber vitreous by drawing it down and posteriorly, often limiting the total amount of vitreous that is removed. Understandably adverse to anterior segment surgeons, an incision placed through the pars may be safely and easily accomplished. Following a small conjunctival peritomy, calipers are used to carefully measure 3.5 mm posterior to the limbus. A massive vitreous retractor (MVR) blade is then used to make a stab incision, keeping the blade perpendicular to the eye wall. The metal tip of the blade should be visualized

through the pupil to be sure that entry is complete. Once the vitrectomy is completed, the incision is freed of any remaining vitreous and closed with a suture. Following IOL placement, a miotic is gradually instilled. Viscoelastic is removed with the vitrectomy instrument, with meticulous attention directed toward the pupil and wounds to be sure that all vitreous has been removed. Shallowing of the AC must be avoided to prevent further vitreous prolapse; temporary air injection followed by a gradual fluidair exchange may be useful. Rapid stromal hydration of limbal incisions is also helpful. Watertight wounds, as always, should be confirmed. Postoperatively, steroid and nonsteroidal antiinflammatories

FIGURE 30–4 Maximal control during anterior vitrectomy is obtained through the use of a closed-chamber system. The inflow and vitrectomy are performed through separate paracentesis. If the main incision is not watertight, it should be sutured.

should be vigorously employed, and cycloplegic and antihypertensive agents considered.

Despite a breech in the posterior capsule, the control rendered through closed-chamber surgical techniques may allow for a final outcome that is indistinguishable from an uncomplicated case.

THE MATURE CATARACT

In rural Northwestern and Central Pennsylvania, where my practice is located, the mature cataract is not an extinct entity. These cases, although very challenging, are rewarding. Utilizing advanced equipment, instrumentation, and surgical technique, outcome is usually comparable to standard density cataracts.

It is important to differentiate between the white or intumescent cataract and the rock-hard mature, dark brown, or even black nuclear cataract (see Chapter 16). The white cataract is a fairly straightforward condition once the capsulorrhexis is completed. These lenses divide nicely with minimal force or difficulty. On the other hand, the mature nuclear cataract can be most frustrating and, unfortunately, is often accompanied by weak zonules and a thin tenuous posterior capsule.

When facing these cases, it is important to be armed with contingency plans. Depending on the surgeon’s experience, one may opt to approach these eyes through a scleral tunnel incision making conversion easier should it become necessary. Experienced surgeons, however, may feel comfortable working through a temporal clear corneal incision, and if a change in strategy becomes necessary, this incision can be closed and a second scleral incision crafted to allow manual extraction.

Obtaining an adequate capsulorrhexis is perhaps the most important step when dealing with these difficult cases. Visualization is hampered due to the lack of a red reflex, and many surgeons have proffered the following tips over recent years. Together, they form an armamentarium by which the surgeon, if patient, can generally obtain a satisfactory anterior capsulectomy. These modifications to standard technique include working under very high magnification, slowing the zoom speed of the microscope, and turning the operating room lights off for better illumination. One of the most helpful techniques that I have found utilizes oblique lighting to offset the torn edge of the capsule. This can be accomplished either with auxiliary side lights on the microscope if available, or through the use of an endoilluminator held by an assistant. When using oblique lighting, it has been recommended that the main microscope light be turned off; however, I find it most useful to moderately dim the main axial light and then position the endoilluminator at the limbus, frequently varying its angle and clock hour location. A skilled assistant is priceless in this situation. Numerous dyes have also been successfully applied to the capsule for better visualization including fluorescein, indocyanine green (ICG), and trypan blue. ICG is readily available and should be used in all intumescent cataracts. It is mixed as described in Chapter 5. Finally, in the case of an intumescent lens, upon initial puncturing of the capsule, lens “milk” may present and obscure the view. One should stop and lightly aspirate this material, and I prefer to do this manually because high flow and volume with automated I&A could cause the partial central tear to wrap around posteriorly.

FIGURE 30–5 Placement of the vitrector through the pars plana may be useful to draw vitreous back behind the plane of the posterior capsule. In addition, it may be used to remove subincisional cortex.

For capsulorrhexis in the presence of a brunescent cataract, maintenance of a deep anterior chamber is crucial for successful completion of the capsulorrhexis, particularly in this setting where the nucleus is typically large with a convex anterior curvature. One must take advantage of the differing physical characteristics of viscoelastics. Arshinoff’s soft-shell technique is quite helpful wherein a highly dispersive viscoelastic is placed to protect the corneal endothelium, and a more cohesive material is placed below to maintain space (Chapter 24). Also, working though a very small incision to prevent extrusion of the viscoelastic is helpful. As previously noted, I prefer to utilize a cystotome with the viscoelastic syringe placed directly upon it. The viscoelastic can be injected during the capsulorrhexis and almost serves as a second intracameral hand to direct the torn edge of capsule. I try to “stand the capsule up” toward the dome of the cornea, which allows better visualization with the oblique illumination. I try to make the rhexis slightly larger, 5.5 to 6 mm, in these situations. This helps prevent problems with both the hydrodissection and phaco. It is not uncommon to take 5 or 6 minutes to complete a capsulorrhexis in difficult eyes.

Mature lenses are typically loose within the capsular bag. However, hydrodissection should not be ignored. It is performed gently because zonular and capsular strength is often compromised.

Because of the extreme mass and density of these lenses, central debulking is commonly needed. Making a preliminary groove or sculpting a central crater may accomplish this. Adequate phaco power should be used such that the lens does not chatter and is not pushed about. This can be aided by utilizing a more highly beveled or Kelman-style angulated phaco

needle. Continuous phaco power rather than pulse mode is utilized. Low flow and vacuum are also used during this step.

The lens is debulked as far posteriorly as possible. Breaking through the posterior nuclear plate and visualizing the red reflex under high magnification will facilitate creation of additional division planes.

At this point, one can choose to commence cracking or chopping. I find the phaco quick chop to be highly applicable in this setting. At this time it is beneficial to switch to a less-beveled phaco needle, increase vacuum, decrease phaco power, and switch to pulse mode. Only small segments are chopped due to the bulk and density of these lenses. Each successive division plane must be created and confirmed to be through and through the dense posterior nuclear plate. It is remarkable how resistant the leathery posterior nuclear fibers can be.

Cortical removal is typically straightforward in these cases except that dense, adherent posterior plaques or pearls are often encountered. Because of weak zonules and a generally floppy posterior capsule, it my be necessary to temper performance of aggressive maneuvers. For similar reasons, the choice of the implant should be carefully made because increased capsular fibrosis due to weak zonules and capsule may be expected in the postoperative state.

ZONULAR DIALYSIS

Zonular weakness and/or dialysis (see Chapter 17) remains one of the more challenging situations confronted by today’s cataract surgeon. In years past, phacoemulsification was often considered to be contraindicated in this setting, and surgeons opted (and referred) for a pars plana and lensectomy approach or even considered intracapsular techniques. Today, with improvements in instrumentation and equipment along with refinements in surgical technique, most cases involving compromised zonules may be safely managed by phacoemulsification. However, these challenging cases require several important modifications in technique.

Although seemingly awkward, incision placement is best located 180 degrees away from the area of dialysis. This reduces intraoperative stress to the area of the weakened zonules. Otherwise, the to- and-fro motion that occurs with the phaco instrument will cause further damage to the already weakened zonular capsular attachments.

Immediately following creation of the paracentesis a dispersive viscoelastic is placed within the AC and over the area of zonular weakness and exposed hyaloid face. Hypotony is to be avoided. A small

amount of presenting vitreous may be buttressed by the viscoelastic, avoiding an immediate vitrectomy. If significant vitreous is present anterior to the plane of the lens capsule, then a closed compartment, twoport vitrectomy should be carried out, preferably through the pars plana. Following stabilization of the vitreous face, the anterior chamber is filled further with a more viscous cohesive agent, to take advantage of the characteristic space maintenance and optical clarity.

The capsulorrhexis is then begun with an initial tear directed toward the area of weakened zonules, thus avoiding further disinsertion at this early stage of the operation. Gentle, slow tearing of the capsule is then carried out, often aided by the use of intraocular scissors. An argument may be waged for the use of a “mini-capsulorrhexis” to reduce infusionrelated turbulence; however, with generous use of viscoelastic, chamber stability can be maximized and a large capsulorrhexis is preferred, thus facilitating lens removal. Gentle but very thorough hydrodissection is then performed.

Phacoemulsification should be carried out slowly, avoiding excess turbulence and maneuvering. Modern phaco instrumentation with enhanced fluidics is essential in these cases. One must be extremely careful carrying out rotational maneuvers, watching closely for imparted stress to the zonules. Nonrotational techniques (Fine’s chip-and-flip, Gimbel’s phaco sweep, etc.) may be preferable. Softer lenses may be completely hydroor visco-maneuvered out of the capsule and into the AC, avoiding further capsule manipulation and possible extension of the dialysis. Recently, John Shepherd has described the use of disposable iris retractors to “hook” the edge of the anterior capsulorrhexis, and thus stabilize the capsular bag during phaco and cortex removal.

Removal of cortex is best performed in a manual fashion, in that vacuum settings for conventional automated I&A are much too high and would likely result in a further breach in capsular and zonular support. I recommend cortical viscodissection followed by manual stripping of cortical fibers out of the capsular fornix using an angled cannula placed through side-port incisions. Automated I&A may be used with low vacuum settings after placement of an endocapsular ring.

Prior to placing an IOL, iris manipulators should be used to carefully inspect the integrity of the capsule. The choice of IOL is then made. In general, a one-piece, all-polymethylmethacrylate (PMMA) IOL with a broad modified C-shaped haptic is safest, with placement of one haptic directly into the area of zonular dialysis to help extend and support this sector of weakened capsule. Incision placement opposite from the zonular dialysis thus aids in placing