the leading haptic directly into the desired location. Dialing or rotation of the IOL must be avoided. Larger optics should be considered because late decentration is possible despite all precautions.

Recently, an endocapsular ring made of PMMA has become available from Morcher (Stuttgart, Germany); however, final Food and Drug Administration (FDA) approval is pending in the United States. This ring is placed within the bag and supports the equatorial portion of the capsule. Placement is carried out under viscoelastic utilizing lens hooks such as an Osher Y-Hook and Lester Manipulator, or through the use of an injector delivery device made by Geuder. Some surgeons advocate early placement of the ring, after performing the capsulorrhexis, to best stabilize the weakened capsular zonular network. Alternatively, ring placement may be performed following phacoemulsification, prior to cortex or epinucleus removal, to help prevent collapse of the bag during this potentially dangerous step. If

ovaling of the capsulorrhexis is seen, suspect that a portion of the ring resides within the sulcus and not completely in the bag. The IOL is then placed following confirmation that the ring is properly located. Viscoelastic removal is then carried out gradually to avoid hypotony and the possibility of late vitreous prolapse (a separate AC maintainer is quite helpful). A miotic should be used in these cases.

CONCLUSION

Armed with a thorough understanding of the planned phaco technique, the surgeon should be able to avoid most complications. However, when faced with an unexpected complication, the surgeon must carefully evaluate alternatives, and be ready and able to deviate from the intended plan. Armed with the knowledge of the steps necessary for management of complications, and with appropriate attention to detail, the surgical result should, rival that of the uncomplicated case.

Compared to other methods of nucleus disassembly, phaco chop reduces ultrasound power, total ultrasound time, and stress on the zonules. This chapter focuses on preventing complications in two areas— in high-risk cases or situations, and when learning or performing phaco chop.

“NONSTOP” PHACO CHOP—

TECHNIQUE AND RATIONALE

In 1993, Kunihiro Nagahara (Japan) introduced the concept of phaco chop at the Third American-Inter- national Congress on Cataract, IOL and Refractive Surgery, in Seattle, Washington. Nagahara observed that a chopping force oriented parallel to the lens lamellae (“with the grain”) splits the nucleus along a natural cleavage plane. Other variations such as “snap and split” and “phaco quick chop” utilize the same principle1 (see Chapter 13).

Nagahara’s technique is “nonstop” phaco chop because it eliminates the initial groove and crack required by the four-quadrant divide and conquer2,3 and “stop and chop”4 techniques. Like sawing through a log lying on its side, multiple sculpting passes— against the grain—are needed to create an adequately deep groove for cracking. Phaco chop would be analogous to placing the log upright on one end and chopping it with an ax. One strike, parallel to the grain, splits the log in half.

The initial chop completely bisects the nucleus without any sculpting. The chopping instrument passes peripherally beneath the anterior capsule, and hooks the

equator of the nucleus (Fig. 31–1). I use a Lieberman microfinger for chopping, because its slender, curved tip is ideally shaped for this maneuver. The proximal nucleus is deeply impaled with the phaco tip. The chopping instrument is pulled toward the phaco tip causing an initial compression, followed by a fracture (Fig. 31–2). Upon contact, there is a slight lateral separation of the two tips to propagate the fracture through the proximal remainder of the nucleus (Fig. 31–2). This manual energy, generated by one instrument pushing against the other, replaces the need for ultrasound energy to subdivide the nucleus.

After the nucleus is rotated, a pie-shaped piece is created by the second chop (Fig. 31–3). Although this first piece is the most difficult to remove, the strong holding force afforded by high vacuum will usually elevate it out of the bag. Alternatively, the curved tip of the microfinger can slip behind the equator of this nuclear piece to manually tumble it forward into the anterior chamber. Each subsequent piece is chopped and removed by repeating these steps.

In addition to requiring less phaco power and time,5–7 chopping minimizes the stress placed on the zonules. Like a vise holding a piece of wood, it is the zonules and capsule that anchor and fixate the nucleus as the groove is sculpted by the phaco tip. With chopping, however, it is the phaco tip against which the chopping instrument pushes. These manual forces are directed centrally inward rather than outward toward the zonules and capsule. These differences in zonular stress can be clearly appreciated when sculpting and chopping are filmed in cadaver eyes from the Miyake-Apple viewpoint.

PHACO CHOP FOR HIGH-RISK

CASES AND SITUATIONS

The attributes of decreased zonular stress and decreased phaco power define the indications for phaco chop. Although advantageous for routine cases, phaco chop is most valuable for complicated cases or situa- tions—those that entail greater risk of posterior capsule rupture or corneal decompensation.

SMALL PUPILS

Small pupils increase the complication rate for two reasons.8 First, physical working space within the pupillary plane is limited, making it easier to aspirate or phaco the iris. Nonstop phaco chop eliminates the need to phaco near or behind the iris because the phaco tip stays within the central 3 mm of the pupil. Second, visualization of the lens is impaired.9 The peripheral lens is hidden by the iris, and

the intensity of the red reflex is significantly reduced with each millimeter decrease in pupil diameter.

A poor red reflex makes it difficult to judge the depth at which the phaco tip is sculpting. This is a problem for the cracking technique, which requires an adequately deep central trough. In contrast to sculpting, phaco chop is a more kinesthetic technique in which visualization of the depth of the two instrument tips is less important. It is only necessary to visualize that the chopper is passing beneath the anterior capsule as it hooks the equator of the nucleus.

MATURE WHITE OR BROWN

CATARACTS

Mature white cataracts present multiple problems.10 The absence of a red reflex makes it very difficult to visualize, and therefore perform a capsulorrhexis. The best solution is the use of indocyanine green11 or trypan blue12 dye to stain the anterior capsule. An absent red reflex also precludes visualization of the depth of the phaco tip during sculpting. One lacks the increasingly brighter red reflex that appears as the posterior capsule is neared. As stated earlier, chopping relies more on tactile than on visual clues.

Finally, these nuclei are often very large and brunescent. Firm, solid nuclei more effectively transmit the forces of phacoemulsification and other manipulation directly to the zonules and posterior capsule. This includes the forces of nuclear sculpting, cracking, and rotation. There is correspondingly less epinucleus present to cushion the capsule from these stresses. The added phaco time and energy neces-

FIGURE 31–3 Chopping steps repeated after slight rotation.

sary to remove these brunescent nuclei also increase the potential for endothelial cell loss.13

The ability of phaco chop to reduce the amount of nuclear sculpting, the total phaco time and energy, and the stress on the zonules is a particular advantage in these high-risk eyes.14 If a can opener capsulotomy is necessary, outward cracking motions should be minimized as much as possible, in favor of chopping maneuvers.

LOOSE ZONULES

Cataracts with loose zonules are among the most challenging to emulsify.15–18 Predisposing factors include exfoliation, advanced age, trauma, retinopathy of prematurity, and prior intraocular surgery (e.g., prior vitrectomy or trabeculectomy). Loose zonules pose three sets of problems for the phaco surgeon. First, the nucleus, epinucleus, and cortex do not easily separate from a capsule that is not firmly anchored. This makes it difficult to rotate the nucleus, and subsequent aspiration of the epinucleus and cortex may pull the anterior or posterior capsule centrally together with the lens material.

Second, the weakened zonules may break more easily.19,20 Aspirating the anterior capsule, or adherent lens material may dehisce the zonules in that region. Pushing the nucleus against the capsular bag (as with sculpting), or forceful nuclear rotation may shear zonules 180 degrees away. Finally, less centrifugal tension by the zonules allows the flaccid central posterior capsule to trampolene forward. Folds of redundant posterior capsule may be

D

aspirated by the phaco or irrigation and aspiration (I&A) instruments.

Phaco chop greatly reduces the stress placed on the zonules and capsule by replacing sculpting and cracking forces with the manual forces of one instrument pushing against another.21 Unlike with cracking, these manual forces are directed centripetally inward, rather than outward toward the zonules.

PROBLEMS WITH CAPSULORRHEXIS,

POSTERIOR CAPSULE INTEGRITY,

OR HYDRODISSECTION

Failure to properly complete these preliminary maneuvers predisposes the eye to complications. Because the capsulorrhexis resists tearing,22 a single radial tear is precarious because all of the stress placed upon the capsule is transmitted to that single weak point. Overly forceful maneuvers—sculpting, rotation, or cracking—can cause an anterior radial tear to extend around the equator into the posterior capsule. Nonstop phaco chop eliminates the need for cracking, which, by stretching the capsulotomy, is particularly risky with a single radial tear.

Chopping is the safest technique if one has elected to continue phacoemulsification in the presence of a posterior capsule rent or a zonular dialysis. It avoids any stress on the posterior capsule and can be performed with the phaco tip held in a stationary position away from the zonular or capsular defect.

Hydrodissection to enable rotation of the nucleus is a prerequisite for safe cracking techniques. However, it may not be possible to rotate a very soft nucleus, or a nucleus in a patient with loose zonules. Because of its versatility, the microfinger can per-

FIGURE 31–4 (continued) (D) Incorrect: The phaco tip is not deep enough into the nuclear material, and in addition is too central to adequately create a chop.

form the first two chops without the need for rotation. After the initial chop, the phaco tip is redirected toward one side, and the second chop is made one to two clock hours away from the first. The initial pieshaped piece can then be aspirated or tumbled out.

COMMON PITFALLS IN LEARNING

PHACO CHOP

Phaco chop fractures nuclei along natural cleavage planes defined by the orientation of the lens lamellae. It requires that the bulk of the endonucleus be sandwiched and compressed between the chopper tip and the phaco tip. With proper instrument positioning, this compression force will create a fracture. The denser the nucleus, the more compression force is required. If the two instrument tips are not deep enough prior to initiating the chop, they will deflect across the anterior endonucleus without compressing and fracturing it (Fig. 31–4A,B).

PITFALLS AND HOW TO RESOLVE THEM

Not Hooking the Nucleus Equator with the Chopper

Passing just beneath the anterior capsule, the chopper enters and occupies the safety of the epinuclear space. This prevents the capsulorrhexis from being distended and torn. The maneuver is contraindicated in a large, brunescent nucleus with no epinucleus for this reason. Fearful of distending and tearing the peripheral capsule, the novice may fail to place the chopper tip peripheral enough and deep enough. The chopper will then skim over rather than penetrate the nucleus (Fig. 31–4A).

Insert the chopper tip first. This optimizes visualization for the most intimidating step of the chop, and allows one to test whether the chopper tip has hooked the equator. If it has, the nucleus moves with slight motion of the chopper.

Elevating the Chopper Tip as the

Chop is Performed

Despite proper initial placement, elevation or outward tilting of the tip as it chops prevents it from compressing and penetrating the central endonucleus. The chopper tip will only scratch or score the anterior surface of the nucleus. This tendency comes from fear of puncturing the posterior capsule with a deeply positioned chopper tip.

It is typically more than 4.5 mm from the anterior to the posterior capsule at the center. Even without the anterior epinucleus, this makes it difficult for a 1.5 mm long chopper tip to perforate the posterior capsule. This can be best demonstrated by touching the posterior capsule with the chopper tip after the nucleus has been removed but while the phaco tip remains in the eye in position 1. That the tip must travel surprisingly far to do this confirms the safety of this maneuver.

Chopper Shaft Presses Down on the

Limbus During the Chop Motion

Compressing the limbal side-port incision causes corneal striae, globe rotation, and posterior pressure. Chopping is an advanced maneuver of the nondominant hand. It presupposes dexterity and comfort in bimanual maneuvers that is best mastered with fourquadrant divide and conquer.

Prior to the critical first chop, take some “practice” chops just above the nucleus within the anterior chamber. This verifies that the ergonomics of the nondominant hand and the side-port incision will permit proper orientation of the chopper.

Chopper Placed Outside the Anterior Capsule into the Zonular Space

Poor visualization of the anterior capsule (e.g., small pupils) or an insufficient epinucleus (large brunescent nuclei) are predisposing factors for this complication. The chopping attempt will cause a local zonular dialysis that appears as a peripheral area of clear red reflex (Fig. 31–4C).

Place the chopper tip first if visualization is difficult. Palpating and hugging the anterior nuclear surface with the chopper tip as it moves peripherally will facilitate its passage beneath the anterior capsule. A slight pulling motion of the chopper can confirm its proper position. The nucleus should move apart from the anterior capsule.

Phaco Tip Is Too Superficial and Central

With firm nuclei of increased diameter, the phaco tip must be deep and proximal to sandwich as much of the endonucleus between the two instrument tips as possible. Sculpting habits give rise to an incorrect tendency to advance the phaco tip centrally and superficially while in position 3 (Fig. 31–4B). If so, the ensuing chop will only compress the anterior nucleus and will fail to fracture the endonucleus.

With large, firm nuclei, keep the phaco tip just within the proximal capsulorrhexis edge and aim it toward the optic nerve.

Inability to Remove the First Piece

With firm, large nuclei, the pieces fit tightly within the bag, like pieces in a wooden jigsaw puzzle. Insufficient holding force results in the piece getting knocked off of the phaco tip before it is fully lifted out.

The larger and firmer the nucleus is, the smaller the first piece should be. High-vacuum and smaller phaco tips increase holding force and maneuverability, respectively. Burst mode (if available) can enhance the phaco tip’s purchase of firm nuclear material. As an alternative, the microfinger can be used to manually tumble the piece out. Although the pie-shaped piece somersaults forward, it is pivoting upon its apex. This prevents the sharp apical tip of the fragment from getting close to the posterior capsule.

A SAFE STRATEGY FOR LEARNING

PHACO CHOP (NAGAHARA

TECHNIQUE)

The complication rate is always higher during the learning phase. Mastering any new phaco technique is simplified and facilitated by optimal case selection. Large pupils with softer and smaller endonuclei are important, along with avoidance of problem characteristics (e.g., exfoliation, high axial length, poor corneal clarity, deep-set eyes, uncooperative patients, etc.). A large capsulorrhexis and a well hydrodissected, rotating nucleus makes phaco chop easier. Thorough hydrodelineation facilitates visualization of the endonucleus to hook the chopper around the equator.

The most difficult steps of nonstop phaco chop are the initial ones—the initial chop through the entire unsculpted nucleus, and the removal of the first piece. Because each subsequent step becomes progressively easier, the safest game plan for transitioning would be to learn the steps in reverse order starting with the easiest maneuvers first.

Step 1 Master the four-quadrant divide and conquer technique (4Q D&C). Sculpting a deep trough constitutes, in essence, a lamellar dissection of the nucleus. Experience with 4Q D&C therefore teaches us the dimensions and relative density of all varieties of nuclei. Furthermore, if a chopping attempt fails, one can revert to sculpting a trough for cracking as a backup technique.

Step 2 While performing 4Q D&C, try using a microfinger or chopper to tumble one of the quadrants out. As mentioned earlier, this maneuver can be used to tumble chopped pieces anteriorly out of the bag if aspiration attempts fail.

Step 3 While performing 4Q D&C, aspirate and elevate one quadrant into the pupillary plane. Instead of simply emulsifying it, chop it in half. With visualization of the entire piece and no anterior or posterior capsule to worry about, one can concentrate on the positioning of the chopper, and the feel of the chopper cutting through nuclei of different density. Use the second quadrant to similarly experiment with the orientation of the chopper tip as it cuts.

Step 4 After removing two quadrants, don’t sculpt a groove into the remaining heminucleus. Instead, impale the center of the heminucleus, and pull it into the center of the pupil. One can now proceed to chop it into thirds with full visualization of the equator, and without having to pass the chopper tip peripherally beneath the anterior capsule.

Step 5 Learn and master “stop and chop.” Sculpt an adequately deep groove to crack the nucleus in half. Then rotate slightly, “stop” sculpting, and chop the remaining halves. Although this requires placing the chopper peripherally beneath the anterior capsule and around the nucleus equator, it is easier than nonstop chopping for three reasons. First, one needs only to chop across one-half of the nucleus diameter. Second, adequate depth of the phaco tip is ensured by placing it into the trough and up against the side of the heminucleus. Finally, the trough provides vacant space from which to easily maneuver out the first chopped fragment.

Step 6 Eliminate all sculpting by bisecting the entire nucleus with an initial deep chop. A large pupil and capsulorrhexis and a well-hydrodelineated nucleus optimize visualization of instrument placement, and constitute the ideal learning conditions. Softer, smaller endonuclei should be mastered before progressing to firmer and larger endonuclei. If the initial chop fails, one can begin sculpting a trough and convert to the “stop and chop” technique.

PHACO QUICK CHOP

This excellent variation of chopping was conceived by Vladimir Pfeifer (Slovenia), and renamed “phaco quick chop” by David Dillman. William Maloney designed the “quick chopper” specifically for this technique. This instrument is configured like a Sinskey hook, but has a sharpened tip.

Whereas the microfinger or Nagahara-style chopper moves centrally from the periphery toward the phaco tip, the quick chopper spike descends from above and impales the nucleus just in front of the centrally buried phaco tip (Fig. 31–5). The most important step is to embed the phaco tip as deeply into the endonucleus as possible. One should be able to elevate the lollipopped nucleus upward toward the cornea. Retracting the silicone sleeve for increased tip exposure, and using burst mode if available, helps. Depressing the sharp spiked tip downward, while simultaneously lifting the nucleus upward, creates a shearing force that fractures the nucleus; 50% of this force comes from the phaco tip lifting and 50% from the quick chopper depressing. Once the fracture begins to propagate, a slight sideways separation of the instrument tips extends the fracture deeper until the entire nucleus is cleaved in half.

Like chiseling a block of stone or ice, the sharp tip can be used to shear off “bite sized” pieces of variable size. Perhaps the name “phaco spike” or “phaco chisel” would have better conveyed the mechanics of this technique. Rather than passing peripherally underneath the anterior capsule, the sharp quick chopper tip stays central to the capsulorrhexis. This is the safest way to chop a nucleus with little to no epinucleus. If the quick chopper tip is not sharp enough, it may knock brunescent nuclear material off the phaco tip, rather than splitting it. For this reason, I have modified the Maloney quick chopper to make it even sharper.

Because of the direction that the two instruments travel during the chop, I refer to Nagahara-style chopping as “horizontal” chopping and to Pfeiferstyle quick chopping as “vertical” chopping.

COMPARISON OF HORIZONTAL AND

VERTICAL CHOPPING

These are both advanced techniques with a steeper learning curve compared with 4Q D&C. The same strategy outlined for learning Nagahara-style chopping is appropriate for learning Pfiefer-style quick chop. While both methods share the common advantages of “nonstop” chopping outlined above, there is value in mastering both variations because each has its relative merits and drawbacks. Understanding these relative strengths and weaknesses will help in avoiding complications. Because horizontal chopping is better suited for softer and smaller nuclei, I believe that it is the easier method to learn first.

Like all phaco techniques, both methods entail some risk of capsular or zonular rupture. Horizontal chopping requires peripheral placement of the microfinger or chopper within the capsular bag. Inad-

vertently chopping from outside of the capsulorrhexis will cause a localized zonular dehiscence. If this occurs, one can continue to chop, but an endocapsular tension ring may be necessary. The risk of vertical chopping is that a firm nucleus can be pushed so far posteriorly that it ruptures the posterior capsule. This can occur if it is not adequately impaled and supported from below by the phaco tip. The downward pushing force of the chopper must be borne by the phaco tip, and not the posterior capsule.

WHEN HORIZONTAL CHOPPING

WORKS BETTER THAN VERTICAL

CHOPPING

Soft Nuclei Vertical chopping generates a shearing force to snap the nucleus in half. As with cracking, this is difficult with soft nuclei, which are not firm or brittle enough. One can snap a cracker in half, but not a piece of bread. The microfinger or horizontal chopper is able to slice through a soft nucleus, rather than fracture it.

Deep Anterior Chambers (e.g., High Myopes, Postvitrectomy Eyes) The phaco tip does not need to be as deep for horizontal chopping as it does for vertical chopping. This is particularly true with softer and medium-density nuclei. The more posterior the nucleus sits, the more difficult it is to embed the phaco tip deep enough to lift the nucleus for a vertical chop. With horizontal chopping, it is more important for the chopper tip to be as deep as possible. The ergonomics of the microfinger or horizontal chopper facilitate deep enough placement in these eyes.

Very Small Pupils A very small pupil or capsulorrhexis prevents the quick chopper tip from getting peripheral enough to chop firmer and larger nuclei. Horizontal chopping, unlike vertical chopping, does not require visualization of the chopper tip at the start of the chop. Being more kinesthetic than visual, a horizontal chop may be initiated blindly behind the iris, as long as initial placement of the chopper tip underneath the capsulorrhexis edge is confirmed.

WHEN VERTICAL CHOPPING WORKS

BETTER THAN HORIZONTAL CHOPPING

Difficulty Visualizing the Capsulorrhexis Edge (e.g., Anterior Cortical Spokes, Poor Corneal Clarity) It is crucial that the microfinger or horizontal chopper pass beneath the anterior capsule. It this can’t be visually confirmed, it may be safer to perform verti-

cal chopping to avoid peripheral placement of the chopper.

Brunescent Nuclei Like a chisel, vertical chopping can create smaller fragments to maximize emulsification efficiency. This versatility is helpful when dealing with a dense and bulky nucleus.

Little or No Epinucleus The microfinger or horizontal chopper passes into and occupies the epinuclear space. The thinner the epinucleus, the more difficult this maneuver is. With the largest nuclei, lack of a sufficient epinucleus may cause the instrument to overdistend and tear the capsulorrhexis. Vertical chopping avoids instrumentation in the peripheral fornices of the capsular bag.

CONCLUSION

By reducing phaco power and zonular stress, nonstop phaco chop provides enormous advantages for complicated and higher risk cases. This justifies its inclusion in our surgical armamentarium. Mastering the steps in reverse order and understanding the principles and common pitfalls facilitate the transition to phaco chop. Horizontal and vertical chopping are complementary variations offering different advantages but common benefits.

REFERENCES

1.Vasavada AR, Desai JP. Stop, chop, chop, and stuff. J Cataract Refract Surg 1996;22:526–529.

2.Gimbel HV. Divide and conquer nucleofractis phacoemulsification: development and variations. J Cataract Refract Surg 1991;17:281–291.

3.Shepherd JR. In situ fracture. J Cataract Refract Surg 1990;16:436–440.

4.Koch PS, Katzen LE. Stop and chop phacoemulsification. J Cataract Refract Surg 1994;20:566–570.

5.Pirazzoli G, D’Eliseo D, Ziosi M, Acciarri R. Effects of phacoemulsification time on the corneal endothelium using phacofracture and phaco chop techniques. J Cataract Refract Surg 1996;22:967–969.

6.DeBry P, Olson RJ, Crandall AS. Comparison of energy required for phaco-chop and divide and conquer phacoemulsification. J Cataract Refract Surg 1998;24: 689–692.

7.Ram J, Wesendahl TA, Auffarth GU, Apple DJ. Evaluation of in situ fracture versus phaco chop techniques. J Cataract Refract Surg 1998;24:1464–1468.

8.Lumme P, Laatikainen LT. Risk factors for intraoperative and early postoperative complications in extracapsular cataract surgery. Eur J Ophthalmol 1994;4: 151–158.

9.Joseph J, Wang HS. Phacoemulsification with poorly dilated pupils. J Cataract Refract Surg 1993;19:551– 556.

10.Vasavada A, Singh R, Desai JP. Phacoemulsification of white mature cataracts. J Cataract Refract Surg 1998; 24:270–277.

11.Horiguchi M, Miyake K, Ohta I, Ito Y. Staining of the lens capsule for circular continuous capsulorrhexis in eyes with white cataract. Arch Ophthalmol 1998;116: 535–537.

12.Melles G, de Waard P, Pameyer J, Beekhuis W. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg 1999;25:7–9.

13.Hayashi K, Nakao F, Hayashi F. Corneal endothelial cell loss after phacoemulsification using nuclear cracking procedures. J Cataract Refract Surg 1994;20: 44–47.

14.Vasavada A, Singh R. Step-by-step chop in situ and separation of very dense cataracts. J Cataract Refract Surg 1998;24:156–159.

15.Naumann GOH. Exfoliation syndrome as a risk factor for vitreous loss in extracapsular cataract surgery (preliminary report). Acta Ophthalmol Suppl 1988;184: 129–131.

16.Lunne P, Laatikainen L. Exfoliation syndrome and cataract extraction. Am J Ophthalmol 1993;116:51–55.

17.Osher RH, Cionni RJ, Gimbel HV, et al. Cataract surgery in patients with pseudoexfoliation syndrome. Eur J Implant Refract Surg 1993;5:46–50.

18.Fine IH, Hoffman RS. Phacoemulsification in the presence of pseudoexfoliation: challenges and options. J Cataract Refract Surg 1997;23:160–165.

19.Moreno J, Duch S, Lajara J. Pseudoexfoliation syndrome: clinical factors related to capsular rupture in cataract surgery. Acta Ophthalmol 1993;71:181–184.

20.Chitkara DK, Smerdon DL. Risk factors, complications, and results in extracapsular cataract extraction. J Cataract Refract Surg 1997;23:570–574.

21.Masket S, ed. Consultation section: cataract surgical problem. J Cataract Refract Surg 1998;24:1289–1298.

22.Gimbel HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg 1990;16:31–37.

Page numbers in italics indicate figures or tables.

A

Acute intraoperative suprachoroidal hemorrhage (AISH), 67–73

choroidal vascular fragility, 68–69, 69 etiology, 67, 67

expulsive hemorrhage, 72–73 incidence, 69

intraoperative diagnosis, 70 management, 70–72, 71–72 pressure differential, 67–68 prevalence and occurence, 68 prevention, 69

risk factors, 69

Admission note, complication prevention and damage control, 257

Akinesia, injectible ophthalmic anesthesia complications, 9 Aminoglycosides, endophthalmitis vitrectomy study (EVS),

216

Anterior capsular fibrosis, intraocular lens implantation, 145,

146

Anterior capsular optic capture, continuous curvilinear capsulorrhexis, 44

Anterior capsular tears

choo choo chop and flip technique, 92, 93 continuous curvilinear capsulorrhexis, 42, 43 cortical (intumescent) mature cataract, 111–112 phaco chop complication, 95–96, 95–96

phaco flip, 103

posterior capsular tears, 250–251, 251 stop and chop phaco, 88–89

Anterior capsule, “nonstop” phaco chop and location of, 274, 276

Anterior chamber

depth of, horizontal chopping criteria, 278 internal incision proximity, 32–33 intraocular lens

implantation, decentration complications, 148–149 properties of, 155

phacodynamic complications, fluid-induced collapse, 194–195

posterior capsular tears, nuclear fragments in, 132 shallow-chamber hypotony, 238–239

secondary causes, 240–241 trabeculotomy complications, 227

Antibiotics, endophthalmitis vitrectomy study (EVS), 215 Anticoagulants, injectible ophthalmic anesthesia and continu-

ation of, 2

Aphakic iris-supported IOP implantation, 146–147, 147 Aphakic patients, intraocular lens implantation, 155 Aqueous misdirection syndrome, shallow-chamber hypotony,

240–241

Arcus, phacoemulsification, 169

Aspiration line obstruction, phacodynamic complications, 196–197

Asteroid hyalosis, posterior capsular tears, 124–125, 125 Astigmatic keratotomy, phacoemulsification, 176–177 Astigmatism, transscleral posterior chamber ocular lens selec-

tion, 156–157

Atkinson retrobulbar block, gobal needle penetration, 217–218,

218

Atonic pupil, 10

Autologous blood injection, conjunctival leak, 239 Axial length

phaco flip contraindications, 103 silicone oil vitrectomy replacement, 142

282 • INDEX

Binkhorst “iris-clip” IOL, implantation, 146 Blebitis, nonpenetrating trabecular surgery, 234–244

Bleeding, nonpenetrating trabecular surgery (NPTS), 235–236 Blepharitis, preoperative treatment of, 255

Blepharospasm, topical anesthesia contraindication, 260 Bowman’s membrane, anatomy, 166

Brainstem injection, injectible ophthalmic anesthesia, 9 Brunescent nuclear cataracts

capsulorrhexis with, 268 management, 112–113, 113 vertical chop indications, 279

BSS replacement material Fuchs’ corneal dystrophy, 171 IOL selection criteria, 142

vitrectomy, refractive index, 140 Bullous keratopathy

endothelial damage, 180 phaco chop, 168

C

“Can-opener” capsulotomy technique, cortical (intumescent) mature cataract, 112

Capsular bag anatomy, 56, 57

hydrosteps complications, cortex-capsular separation, 58–59,

60

intraocular lens implantation complications, 149, 150, 152–153, 153

stop and chop phaco, hydrodissection and nucleus elevation, 86, 87

Capsular block syndrome, hydrosteps complication, 59–60, 61 Capsular tears

nonpenetrating trabecular surgery (NPTS), 236 vitreous loss, 134–135

Capsular tension rings

continuous curvilinear capsulorrhexis complications, 44–45,

45

IOL replacement, 152–153, 153

zonular compromise, 119–121, 119–121, 270 Capsule, anatomy, 123

Capsulorrhexis

clear corneal phaco surgery, 262 mature cataracts, 268–269 zonular dialysis, 269

cortical (intumescent) mature cataract, 109–112 Fuchs’ corneal dystrophy, 171

horizontal vs. vertical chopping and, 278–279 “nonstop” phaco chop complications, 275 posterior capsular tears, 126

posterior polar cataract, 108 pupil stretching, 53

stop and chop phaco, 85 zonule-compromised surgery, 117–118, 118

Capsulotomy noncontiguous, phacoemulsification, 79 Capsulotomy size, phacoemulsification, 81 Cataractogenesis, categories, 75–77, 76

Cataract size, continuous curvilinear capsulorrhexis and, 38, 40

Cavitational energy, choo choo chop and flip technique, 93 Certified registered nurse anesthestists (CRNAs), 2

Chemical mycotoxicity, injectible ophthalmic anesthesia complications, 9

Choo choo chop and flip anterior capsular tears, 92, 93 cortex mobilization, 93 incomplete chops, 92–93 phaco energy application, 93 segment mobilization, 93 technique, 90–91, 91–92

Chop techniques, nuclear mature (brunescent) cataracts, 113–114

Choroidal vascular fragility, 68–69, 69

Chronic glaucoma, posterior segment lens retention, 205

Chu foldable lens cutter, transscleral posterior chamber intraocular lens (TS PCL) implantation, 161

Cionni ring model, zonular compromise, 121, 121–122 Clear corneal phaco surgery

complications, 265–270

broken posterior capsule, advanced vitrectomy, 265–267,

267

mature cataract, 267–269, 269 zonular dialysis, 269–270

incision inaccuracies, 32 routine procedures, 260–265

anesthetic timing and agent, 261 capsulorrhexis, 262

exposure and instrumentation, 261–262 foldable IOL insertion, 264–265 hydrosteps, 262–263

incision techniques, 262 irrigation and aspiration, 264

noninjection anesthesia selection, 260–261 patient sensation, 261 phacoemulsification, 263–264, 264

topical anesthesia, 260 wound closure, 265

sutureless cataract surgery, 29–30, 29–31 Coaxial alignment, guidelines for, 257 Coaxial infusion, vitrectomy with, 135–136

Compartment syndrome, injectible ophthalmic anesthesia complications, 9

Conjunctival ballooning, topical anesthesia, 20

Conjunctival buttonhool, nonpenetrating trabecular surgery (NPTS), 227, 229

Conjunctival hydration, wound construction and closure complication, 33–34

Conjunctival leak, nonpenetrating trabecular surgery (NPTS), 239

Constant-state intraocular pressure, infusion/aspiration balance, 134, 134

Continuous-tear curvilinear capsulorrhexis (CCC) cataract size and type, 38, 40

complications

anterior capsular IOL optic capture, 44, 45 anterior capsular tears, 42, 43

intraocular lens selection, 42–43, 43 noncontinuous capsulorrhexis, 42 peripheral tear extension, 37–38 posterior capsule tears, 43 posterior capsulorrhexis, 43–44, 44

postoperative complications, 46, 46–47 research background, 36

YAG capsulotomy, 46–47 zonular dialysis, 44–46, 45

zonule abnormalities, 41 intraocular lens optic size, 40–41 intumescent cataract, 41–42

phaco chop complications, anterior capsular tears, 95–96 small-pupil cases, 38

surgical technique, 37, 38–40 Copeland “Maltese cross” IOL, 146 Cornea

anatomy, 166–167, 167 astigmatic keratotomy, 176–177

Descemet’s membrane complications, 171–176 epithelial protection, 177

Fuch’s dystrophy, cataract surgery, 169–171 limbus anatomy, 167

phaco-induced entothelial damage, 179–181 toxic anterior segment syndrome, 177–179 visualization difficulties, 167–169

arcus, 169

banded keratopathy, 169 bullous keratopathy, 168 epithelial irregularities, 168–169 stromal scarring, 168

surface irregularities, 168

Corneal endothelium, phaco chop damage, 99 Corneal exposure, injectible ophthalmic anesthesia, 10 Corneal incision

phaco flip, 100–101 stop and chop phaco, 85

Corneal tunnel incision, anatomic classification and location, 31

Cortex mobilization

choo choo chop and flip technique, 93 phacoemulsification, 251–254, 252

Cortex removal, posterior capsular tears, 131 Cortical cleaving hydrodissection

soft cataracts, 106 techniques, 57, 57–58

zonule-compromised surgery, 117–118 Cortical (intumescent) mature cataract

management, 109–112, 110–112 removal, 269

Cortical viscodissection, zonule-compromised surgery, 118 Corydon cannula, stop and chop phaco, hydrodissection, 86 Coumadin, nonpenetrating trabecular surgery (NPTS) com-

plications, 223

Cyanoacrylate tissue glue, conjunctival leak, 239 Cyclodialysis, nonpenetrating trabecular surgery, 241 Cyclooxygenase inhibitors (COX-2), nonpenetrating trabecu-

lar surgery (NPTS) complications, 223–224

Cystic macular edema (CME), continuous curvilinear capsulorrhexis, posterior capsular tears, 43

D

Debulking techniques, mature cataracts, 268–269 Decentration

intraocular lens, 148–149

posterior segment complications, 207–213

transscleral posterior chamber intraocular lens (TS PCL) implantation, 163

Deep scleral flap, nonpenetrating trabecular surgery (NPTS), 234–235

Deep sclerectomy procedure

INDEX • 283

glaucoma management, 225–226, 228–229 nonpenetrating trabecular surgery (NPTS), 234–235 thin dep scleral flap, 235

Delayed-onset endophthalmitis, 216, 216 Dense cataracts, stop and chop phaco, 87–88 Descemet’s detachment

nonpenetrating trabecular surgery (NPTS), 236–237 phacoemulsification, 174–176, 177

wound construction inaccuracy, 32, 34 Descemet’s membrane

anatomy, 166

Fuchs’ corneal dystrophy, 169–170 incision location, 31

phacoemulsification, complications, 171–173, 171–174 Descemet’s window

nonpenetrating trabecular surgery failure, 242–243 NPTS-superficial scleral flap, 234

perforation, 235

nonpenetrating trabecular surgery (NPTS), 235 viscocanalostomy procedure, 226

Diplopia, injectible ophthalmic anesthesia complications, 9 Dispersive/cohesive viscoelastics

background, 182–183, 183

soft shell technique, 186–189, 187 Dropped nucleus, vitreous loss and, 139

E

Ectopic injection, injectible ophthalmic anesthesia, 3 Endonucleus, choo choo chop and flip technique, 90–91 Endophthalmitis

delayed-onset endophthalmitis, 216, 216 nonpenetrating trabecular surgery, 234–244 posterior segment complications, 212–213

clinical diagnosis and microbiological confirmation, 213,

213

endopothalmitis vitrectomy study (EVS), 214–215, 214–216

incidence, 213

transscleral posterior chamber intraocular lens (TS PCL) implantation, 162, 162

Endophthalmitis vitrectomy study (EVS), posterior segment complications, 214–216, 215–216

Endothelium anatomy, 166

Fuchs’ corneal dystrophy, 170–171 phaco-induced damage, 179–181

transscleral posterior chamber ocular lens selection, 156–157 Epinephrine, injectible ophthalmic anesthesia, ocular blood

flow compression, 9–10 Epinucleus

lack of, vertical chop indication, 279

phacodynamic complications, vacuum management, 198–199, 199

stop and chop phaco, removal, 89

Epithelial dystrophy, phacoemulsification, 168–169 Epithelial edema, Fuchs’ corneal dystrophy, 170 Epithelium

anatomy, 166, 166 irregularity, 168–169

protection during phaco procedures, 177 Exchange techniques, intraocular lens

posterior segment complications, 208–212, 209–211

284 • INDEX

Exchange techniques, intraocular lens (continued)

transscleral posterior chamber intraocular lens (TS PCL), 159, 161

Explantation techniques, transscleral posterior chamber intraocular lens (TS PCL) implantation, 159, 160

Expulsive hemorrhage, acute intraoperative suprachoroidal hemorrhage (AISH), 72, 72–73

Extracapsular cataract extraction (ECCE)

continuous curvilinear capsulorrhexis complications, 46 posterior capsular tears, 126

Sheets’ glide, 127–128, 127–128 posterior segment lens retention, 206

Extraocular muscle paresis, injectible ophthalmic anesthesia complications, 9

Eyedrops, nonpenetrating trabecular surgery (NPTS) complications, 224

Eyelids, positive pressure complications, 63–64 Eyelid squeezing, topical anesthesia, 19–20 Eye movement, topical anesthesia, 18, 18–19

F

Facial nerve block, injectible ophthalmic anesthesia, 10 Fiber tissue glue, conjunctival leak, 239

Fine/Nagahara chopper, choo choo chop and flip, 90–91 Flow management, phacodynamic complications, 195–196 Flow pump, phacodynamic complications, 195

Fluid dynamics

phacodynamic complications flow management, 195–196

ultrasound management, 200–202 vacuum management, 199–200

positive pressure complications, 64 Fluid misdirection syndromes

hydrosteps complication, 60, 61

positive pressure complications, 64–67, 65–66 environmental conditions, 65

etiology, 64–65 treatment, 65–67, 66

Foldable intraocular lens, 28

clear corneal phaco surgery insertion, 264–265 flipping or removal techniques, 265

loop-haptic lenses, implantation techniques, 148 materials and positioning, 140–141

operative complications, 145 removal techniques, 151–152, 153

Force-puncture continuous-tear curvilinear capsulorrhexis (CCC), 37, 38

Fuchs’ corneal dystrophy endothelial damage, 179–181

phacoemulsification complications, 169–171 phaco flip contraindications, 103

Fuchs’ endothelial dystrophy Healon5 techniques, 191 phacoemulsification, 179–181

soft shell dispersive-cohesive viscoelastic technique, 188 Full-thickness procedures, glaucoma management, 225

G

Gas vitrectomy replacement, IOL power calculations, 142 General anesthesia, ocular anesthesia vs., 25 Gimbel-modified Kraff-Utrata forces, continuous-tear curvi-

linear capsulorrhexis (CCC), 37, 38

Glaucoma

phacotrabeculectomy complications blebitis and endophthalmitis, 243–244 bleeding complications, 235–236 broken capsule, vitreous loss, 236 cyclodialysis, 241

deep scleral flap, 234–235

deep spherectomy procedure, 225–226 Descemet’s detachment, 236–237 failure complications, 241–243

intraoperative complications, 227–229, 228 iris prolapse, 232–234

management procedures, 225

miotic and topical eyedrop usage, 224 postoperative complications, 237–240 predisposing conditions, 224–225 preoperative assessment, 223–224 scleral flap problems, 229, 232

shallow or flat anterior chamber, 240–241 symptomatic filtering blebs, 243 trabeculectomy procedure, 226–227 viscocanalostomy procedure, 226, 230–231

posterior segment lens retention, 205

Global fixation, clear corneal phaco surgery, 261–262 Global perforation

injectible ophthalmic anesthesia, 4–6 postserior segment complications, 217–218, 218

Global torsion, posterior capsular tears, 121 Glycosaminoglyoside (GAG) chains, vitreous body, 133 Gonioscopy, transscleral posterior chamber ocular lens selec-

tion, 157

Guttata

Fuchs’ corneal dystrophy, phacoemulsification procedures, 169–171

preoperative assessment, 255 Guttataless Fuchs’ corneal dystrophy

phacoemulsification, 170

toxic anterior segment syndrome (TASS), 178

H

Haptic lenses

operative complications, 145 properties of, 140–141

repositioning techniques, 210–211, 210–211 scleral suture fixation, 210–211, 211

transscleral posterior chamber intraocular lens (TS PCL) implantation

distal haptic preparation, 157–158, 158 proximal haptic preparation, 158, 159

Hard lens, phacoemulsification and, 81–82 Healon5, 189–192

biomechanical properties, 189–191, 190–191 removal, 191–192, 192

research background, 182

Schlemm’s canal/trabecular meshwork rupture, 237 surgical applications, 191, 192

Healon GV, Schlemm’s canal/trabecular meshwork rupture, 237

Heminuclear chop, nuclear mature (brunescent) cataracts, 114, 114–115

Higher viscosity-cohesive viscoelastics, properties, 184–185 Honan balloon, zonule-compromised surgery, 117

Horizontal phaco chop, vs. vertical chop, 278–279 Hyaluronidase

injectible ophthalmic anesthesia, allergic reactions, 3 topical agent toxicity, 21, 21

Hydrodelineation, 58, 59

clear corneal phaco surgery, 263 Hydrodissection

clear corneal phaco surgery, 262 mature cataracts, 268–269

Colvard maneuver, 250 incomplete, 79, 80

“nonstop” phaco chop complications, 275

nuclear mature (brunescent) cataracts, 112–113, 113 phaco flip, 100–101

complications, 103

positive pressure complications, 65 posterior polar cataract, 107–108 soft cataracts, 105–106

incomplete hydrodissection, 106–107, 107 stop and chop phaco, 86

techniques, 56–58, 57–58 Hydrosteps

capsular anatomy, 56

clear corneal phaco surgery, 262–263 complications

capsular block syndromes, 59–60, 61 cortex-capsular bag separation problems, 58–59, 59 fluid misdirection syndromes, 59, 60 noncontinuous capsulorrhexis, 60–61, 61

posterior capsule rupture, 61–62 hydrodelineation, 58, 59–60 hydrodissection technique, 56–58, 57 pupil stretching, 53–54

Hyphema

phacotrabeculectomy, 237–238

Hypotonous maculopathy, nonpenetrating trabecular surgery (NPTS), 240

Hypotony, shallow anterior chamber, 238–239

I

Immediate preocclusion, phacodynamic complications, 196,

197

Incision depth and width

clear corneal phaco surgery, 262 wound construction and closure, 33

Incomplete chop, choo choo chop and flip technique, 92–93 Indocyanine green dye

continuous curvilinear capsulorrhexis, intumescent cataract, 41–42

cortical (intumescent) mature cataract, 111–112, 112 mature cataracts

clear corneal phaco surgery, 268–269 “nonstop” phaco chop complications, 273

Inferotemporal block, injectible ophthalmic anesthesia, 4, 5 Infusion/aspiration balance, vitreous loss, 134, 134 Injectible block, defined, 1

Injectible ophthalmic anesthesia anatomic considerations, 6, 6–7 anticoagulation considerations, 2 atonic pupil, 10

brain stem anesthesia, 9 caregiver role, 2–3

INDEX • 285

cataract surgery, 1 complications, 3 corneal exposure, 10

extraocular muscle paresis, 9 facial nerve block, 10

globe penetration and perforation, 3–6 diagnosis, 7

ocular blood flow limitation, 9–10 oculocardiac reflex, 10

optic nerve injection, 9 patient movement, 6–7 prevention of complications, 8

retro/peribulbar injection, 3–4, 4–5 sedation and monitoring, 3 subconjunctival hemorrhage, 8–9 treatment, 7–8

Intracameral anesthesia patient sensation, 261 topical anesthesia, 15 toxicity, 20

Intracapsular cataract extarction (ICCE), acute intraoperative suprachoroidal hemorrhage (AISH), 69

Intraocular lens (IOL)

BSS refractive properties, 140 continuous curvilinear capsulorrhexis

anterior optic capture, 44 complications, 42–43, 43 optic size, 40–41

postoperative decentration, 46, 46

dislocation, posterior segment complications, 207–213 clinical characteristics, 207–208

endophthalmitis, 212–213

management guidelines, 208–212, 209–211 postoperative complications, 211–212 surgical outcomes, 211

Fuchs’ corneal dystrophy, insertion techniques, 170–171 implantation techniques

Descemet’s membrane complications, 172–174, 172–174 injector complications, 145

loop haptic IOL, 147–148, 151

operative lens complications, 144–145, 145–146 operative ocular complications, 144, 145 Phakic IOL, 146–147, 146–147

posterior chamber IOL, 147

postoperative IOL complications, 148–150, 149–151 repositioning, 150

research background, 144 zonular dialysis, 269–270

iris problems, 55

matrial and position, 140–141

posterior segment lens retention and insertion of, 205–206 power calculations

gases, 142 silicone oil, 142

removal techniques, 150–153, 151–152 replacement

intraoperative, 152, 152 postoperative, 152–153, 152–153

shape selection criteria, 140 silicone oil

compatibility, 141 refractive index, 141

286 • INDEX

Intraocular lens (IOL) (continued)

zonule compromise, selection and insertion, 119 Intraocular pressure (IOP)

acute intraoperative suprachoroidal hemorrhage (AISH), 67–68

shallow anterior chamber hypotony, 238–239 Intraoperative monitoring

acute intraoperative suprachoroidal hemorrhage (AISH), 70, 70

ocular anesthesia, 25

Intravenous (IV) sedation, injectible ophthalmic anesthesia, 3 Intumescent cataract

continuous curvilinear capsulorrhexis, 41–42 cortical mature cataracts, 109–112, 110–112

Iridodialysis, procedures, 54 Iris conditions

capsulorrhexis technique, 38, 40, 53 pupil stretch, 53

cataract surgery and management of, 49 etiology, 49

hydrosteps technique, 53–54 intraocular lens selection, 55 iridodialysis, 54

iris stretch techniques, 50–52, 51 Beehler dilator, 51, 51 micro-iris retractors, 52, 52

irrigation and aspiration, 54–55 lysis of synechiae, 49–50, 50 multiple sphincterotomies, 52

nonpenetrating trabecular surgery (NPTS), iris prolapse, 232–234

phacemulsification damage, soft shell dispersive-cohesive viscoelastic technique, 188–189

phaco chop damage, 99

phacodynamic complications, vacuum management, 198–199, 199

phacoemulsification, 54 postoperative care, 55 preoperative management, 49 prolapse, 54

sector iridectomies, 52–53, 53 silicone pupil expander, 52 suture techniques, 55

toxic anterior segment syndrome (TASS), 178 Iris prolapse, management of, 54

Iris-supported intraocular lens, implantation techniques, 146–147, 147

Iris-sutured fixation, intraocular lens repositioning, 209 Irrigation and aspiration (I&A)

clear corneal phaco surgery, 264 cortex mobilization, 252, 252–254

Descemet’s membrane complications, 172–174 Healon5 viscosity, 189–191

iris problems, 54–55

positive pressure complications, 65

posterior capsular tear and reduction of, 258–259, 259, 266 toxic anterior segment syndrome (TASS), 178

vitrectomy with, 138 vitrectomy without, 138, 138

Irrigation fluid pooling, posterior capsular tears, 124 Ischemia, injectible ophthalmic anesthesia, ocular blood flow

compression, 9–10

K

Karate chop technique, phaco procedures, 94–95 Kelman-McPherson forceps, iris stretch, 50 Keratoconus, phacoemulsification complications, 168 Kuglen hook technique

iris stretch, 49–50, 50

posterior capsular tears, Sheets’ glide, 127–128, 128

L

Laryngeal mask anesthesia, topical anesthesia adjunct, 17, 17 Late postocclusion, phacodynamic complications, 197, 198 Leathery nucleus, phaco chop complications, 98, 98–99

Lens, consistency, phacoemulsification and, 80–81 Lens capsule, anatomy, 36–37, 37

Lens dislocation

anatomic and etiologic factors, 116, 117

transscleral posterior chamber intraocular lens (TS PCL) implantation, 163

Lens fragments. See Nuclear fragments

Lens Opacities Classification System (LOCS), preoperative cataract assessment, 255–256, 256

Lens tilt, transscleral posterior chamber intraocular lens (TS PCL) implantation, 162–163

Lidocaine, Rosenthal deep topical, fornix-based “nerve block” anesthesia (RTDNBA), 15–16

Limbal extraction, posterior segment lens retention, 205–206,

206

Limbal side-port incisions, “nonstop” phaco chop complications, 276

Limbus

anatomic relationships, 167 parallel sutures, iris problems, 55 wound closure and construction, 31

Loop haptic intraocular lenses implantation techniques, 147–148

complications, 149, 149–151 operative complications, 145 replacement, 153

Lower-viscosity dispersive viscoelastics, properties, 185, 185–186

Lysis of synechiae, small pupil conditions, 49–50, 50

M

Manual dissection, stop and chop phaco, 86–87, 87 Massive vitreous retractor (MVR) blade

primary transscleral posterior chamber intraocular lens (TS PCL) implantation, 162

vitrectomy, posterior capsular tear management, 266–267 Mature cataract

complications, 112

clear corneal phaco surgery, 267–269

cortical (intumescent) cataracts, 109–112, 110–112 management, research background, 109 “nonstop” phaco chop complications, 273 nuclear (brunescent) cataract, 112–113, 113 phaco flip contraindications, 102–103

surgical management, 113–115

Medial block injection, injectible ophthalmic anesthesia, 4, 4 Memory settings, phacoemulsification techniques, 256–257 Microfinger techniques, “nonstop” phaco chop, 271, 272 Micro-iris retractors

iris stretch, 52, 52

zonule compromise, 119, 119 Miotics

nonpenetrating trabecular surgery (NPTS) complications, 224

vitrectomy, posterior capsular tear management, 267 Morcher ring

continuous curvilinear capsulorrhexis complications, 44– 45, 45

zonular compromise, 119–121, 119–121, 270 Multiple sphincterotomies, iris stretching, 52, 53

Myopia, ocular penetration, injectible ophthalmic anesthesia, 6

N

Nagahara phaco chop

clear corneal phaco surgery, 263 technique and rationale, 271, 272–273 training guidelines, 276–277

Nd:YAG capsulotomy

continuous curvilinear capsulorrhexis, 46–47 cortical (intumescent) mature cataract, 112

Near-clear corneal incision, sutureless cataract surgery, 29,

30

Needle-tap technique, posterior segment endophthalmitis, 213

Noncontinuous capsulorrhexis

continuous curvilinear capsulorrhexis complication, 42 hydrosteps complication, 60–61, 61

Noninjection anesthesia. See Topical anesthesia Nonpenetrating trabecular surgery (NPTS) complications

blebitis and endophthalmitis, 243–244 bleeding complications, 235–236 broken capsule, vitreous loss, 236 cyclodialysis, 241

deep scleral flap, 234–235

deep spherectomy procedure, 225–226 Descemet’s detachment, 236–237 failure complications, 241–243

intraoperative complications, 227–229, 228 iris prolapse, 232–234

management procedures, 225

miotic and topical eyedrop usage, 224 NPTS-superficial scleral flap, 234 postoperative complications, 237–240

conjunctival leak, 239 hyphema, 237–238 hypotonous maculopathy, 240

shallow anterior chamber-hypotony, 238–239 suprachoroidal effusion, 240

predisposing conditions, 224–225 preoperative assessment, 223–224 scleral flap problems, 229, 232

shallow or flat antereior chamber, 240–241 symptomatic filtering blebs, 243

thin deep scleral flap, 235 trabeculectomy procedure, 226–227

viscocanalostomy procedure, 226, 230–231

Nonsteroidal antiinflammatory drugs (NSAIDs), nonpenetrating trabecular surgery (NPTS) complications, 223–224

“Nonstop” phaco chop, technique and rationale, 271, 272–273 Nuclear emulsification

INDEX • 287

cortical (intumescent) mature cataract, 111–112 nuclear mature (brunescent) cataracts, 113–114 posterior capsular tears, 126 zonule-compromised surgery, 118

Nuclear fragments

phacodynamic complications, 201–202, 202 posterior segment retention, 204–205

clinical features, 205

management guidelines, 206–207, 207 surgical indications, 205

surgical techniques, 205–206, 206 vitrectomy outcomes, 206

posterior capsular tears

anterior chamber penetration, 132 vitreous cavity penetration, 131

Nuclear mature (brunescent) cataract, management, 112–113,

113

Nucleus

“nonstop” phaco chop complications, equator locations, 274, 275–276

phaco flip technique, 101

posterior capsular tear and stabilization of, 258–259,

258–259

stop and chop phaco density, 87–88 elevation, 86, 87

O

Occlusion, phacodynamic complications, 196, 197 Ocular anesthesia, systemic complications

general anesthesia vs. orbital block, 25 intraoperative monitoring and treatment, 25 preoperative evaluation, 24–25

prevalence and classification, 26

Ocular blood flow, injectible ophthalmic anesthesia and limitation of, 9–10

Ocular compression device, injectible ophthalmic anesthesia, 5, 9–10

Ocular penetration, injectible ophthalmic anesthesia, 4–6 Ocular perforation, injectible ophthalmic anesthesia, 4–7 Oculocardiac reflex, injectible ophthalmic anesthesia, 10 Olive-tipped cannula, phaco tilt and tumble, 101–102, 102 “One-stitch” closure technique, 28

Ophthalmic viscosurgical devices (OVDs) classification, 183–184, 183–184

content, molecular weight, and zero-shear viscosity, 183 dispersive/cohesive elastics

background, 182–183, 183

soft shell technique, 186–189, 187 Healon5, 189–192

biomechanical properties, 189–191, 190–191 removal, 191–192, 192

surgical applications, 191, 192

higher viscosity-cohesive viscoelastics, 184–185 lower-viscosity dispersive elastics, 185–186 pseudoplasticity, 183, 184

research background, 182 surgical applications, 185, 185

Optic nerve sheath injection, injectible ophthalmic anesthesia, 9

Ostia, Schlemm’s canal, nonpenetrating trabecular surgery, 237

288 • INDEX

P

Parabulbar anesthesia, 16 Paracentesis, trabeculotomy, 227 Pars plana incisions

IOL repositioning, 210, 210

posterior capsular tear management, 258–259, 259 posterior segment lens retention, 205–206 two-handed vitrectomy technique, 137–138

vitrectomy, posterior capsular tear management, 266–267,

268

Patch graft technique, wound gape repair, 34–35 Patient movement. See also Eye movement

injectible ophthalmic anesthesia complications, 6–7 topical anesthesia, 16–17

Patient positioning, clear corneal phaco surgery, 262 Patient sensation, topical anesthesia, 261 Perfluorocarbon installation

posterior capsular tears, vitreous cavity penetration, 131 posterior segment lens retention, 205–206, 206

Peribulbar injection, injectible ophthalmic anesthesia, 4, 5 Perioperative monitoring, injectible ophthalmic anesthesia,

3 Phaco chop

anterior capsul visualization, 274, 276 bullous keratopathy, 168

capsulorrhexis, posterior capsule integrity, and hydrodissection complications, 275

chopper positioning, 274–275, 275 chopper tip elevation, 276

clear corneal phaco surgery, 263, 264 complications, 95–99

anterior capsule, 95–96, 95–96 corneal endothelial/iris damage, 99 posterior capsule rupture, 98, 98–99 zonular dialysis, 96–97, 96–98

high-risk conditions loose zonules, 273, 275 mature cataracts, 273 small pupils, 272–273

high-risk patients, 272–275

horizontal vs. vertical chopping, 278–279 karate chop alternative, 94–95

limbal sidee-port incision compression, 276 mechanism, 94

memory settings, 256–257

Nagahara technique, 263, 271, 272–273, 276–277 “nonstop” technique, rationale, 271, 272–273 nuclei removal, 276

nucleus equator location, 274, 275–276 quick chop technique, 263, 277, 277–278

tip centralization and superficiality, 275, 276 Phacodynamic complications

fluidic complications

flow management, 195–196 vacuum management, 197–200

occlusion, 196, 197

postocclusion surge, 196–197, 198 preocclusion surge, 196, 197 pump types, 195

research background, 194–195 ultrasonic complications, 200–202

Phacoemulsification

acute intraoperative suprachoroidal hemorrhage (AISH), 69–70

astigmatic keratotomy complications, 176–177 capsulotomy noncontiguous, 79 cataractogenesis, 75–77, 76

clear corneal phaco surgery, 263, 264 zonular dialysis, 269

complications, 77

corneal complications, 167–169 arcus, 169

banded keratopathy, 169 bullous keratopathy, 168 epithelial irregularities, 168–169 stromal scarring, 168

surface irregularities, 168 cortex mobilization, 251–254, 252

Descemet’s membrane complications, 171–173, 171–174 endothelial damage, 179–181

epithelial protection, 177

Fuchs’ corneal dystrophy, 169–171 historical background, 79

incision size, 249–250

incomplete hydrodissection, 79, 80 lens consistency, 80–81

patient selection and screening, 248–249, 249 positive pressure complications, 65 posterior capsular tears

continuation following, 126–127 Sheets’ glide, 128–129, 128–129

posterior plate/separating quadrants, 83 pupil stretching, 54

quadrant mobilization and emulsification/removal, 84 technique problems, 81–83, 82

tip/handpiece configuration, 249

toxic anterior segment syndrome (TASS), 177–179 Phaco flip

complications, 103–104 contraindications, 102–103 techniques, 100–101, 101

Phaco needle bevel, phacodynamic complications, vacuum management, 199–200, 200

Phaco tilt and tumble complications, 103, 103–104 contraindications, 102–103 techniques, 101–102, 102

Phacotrabeculectomy

glaucoma management, 225, 227 intraoperative complications, 227–237

conjunctival buttonhole, 237, 239 iris prolapse, 232–234

scleral flap complications, 239, 242 postoperative complications, 237–240

Phakic intraocular lens, implantation techniques, 146–147 Photophobia, topical anesthesia, 19–20

Phototoxicity, topical anesthesia, 19–20 Pinpoint (Fukasaku) anesthesia, 16 Plate-haptic lenses

implantation techniques, 147–148 operative complications, 145, 146, 150–151 removal techniques, 152

Platelet aggregation inhibitors, nonpenetrating trabecular surgery (NPTS) complications, 223–224

Plavix, nonpenetrating trabecular surgery (NPTS) complications, 223–224

Positive posterior pressure, continuous-tear curvilinear capsulorrhexis (CCC), 37–38, 39

Positive pressure complications

acute intraoperative suprachoroidal hemorrhage (AISH), 67–73

choroidal vascular fragility, 68–69, 69 etiology, 67, 67

expulsive hemorrhage, 72–73 incidence, 69

intraoperative diagnosis, 70 management, 70–72, 71–72 pressure differential, 67–68 prevalence and occurence, 68 prevention, 69

classification, 63

fluid misdirection syndrome, 64–67, 65–66 mechanical/external causes, 63–64

Posterior assisted levitation, posterior capsular tears, 130–131 Posterior capsular fibrosis/haze, continuous curvilinear cap-

sulorrhexis, 46–47 Posterior capsular tears

anatomy, 123

anterior capsular tears and, 250–251, 251 assisted levitation, 130–131

bimanual limbal anterior vitrectomy, 129–130, 130 continuous curvilinear capsulorrhexis, 43–44, 44 cortex removal, 131

ECCE conversion, 126 etiology, 125

extracapsular extraction, Sheets’ glide, 127, 127–128 hydrosteps complication, 61–62

management of, 265–267, 267

“nonstop” phaco chop complications, 275 nuclear emulsification, 126

phaco chop complications, 98–99 phacoemulsification, 126–127

Sheets’ glide, 128–129, 129–130 predisposing factors, 124–125, 125 pseudo-posterior capsule, 127 ruptur signs, 123–124, 124

salvaging techniques, 258–259, 258–259

soft shell dispersive-cohesive viscoelastic technique, 188 surgical management, 125–126

vitreous loss, 135, 135 vitreous nuclear loss, 131–132

Posterior capsulorrhexis, continuous curvilinear capsulorrhexis complications, 43–44, 44

optic capture, 45

Posterior chamber intraocular lens (PCL) decentration complications, 149, 149 implantation techniques, 147 properties of, 155

transscleral fixation, 155–156 anatomic considerations, 156 complications, 162–163

lens selection criteria, 156–157 primary implantation, 162 secondary implantation, 157–161

transscleral fixation, patient selection and preoperative evaluation, 156

INDEX • 289

Posterior plate/separating quadrants, phacoemulsification sculpting, 83

Posterior polar cataract, 105–106, 106 surgical technique, 107–108

Posterior segment complications delayed-onset endopthalmitis, 216, 216 endophthalmitis vitrectomy study, 214–216 global penetration, 217–218, 218 intraocular lens dislocation, 207–213

clinical characteristics, 207–208 endophthalmitis, 212–213

management guidelines, 208–212, 209–211 postoperative complications, 211–212 surgical outcomes, 211

research background, 204 retained lens fragments, 204–205

clinical features, 205

management guidelines, 206–207, 207 surgical indications, 205

surgical techniques, 205–206, 206 vitrectomy outcomes, 206

suprachoroidal effusion/hemorrhage, 217 Posterior subcapsular cataract, histopathology, 107

Postocclusion surge, phacodynamic complications, 196–197,

197–198

Preoperative assessment

complication prevention and damage control, 255–257 cortical (intumescent) mature cataract, 110

glaucoma procedure complications, 223–224 injectible ophthalmic anesthesia, 1–2

ocular anesthesia, 24–25 small pupil conditions, 49

transscleral posterior chamber ocular lens, 156–157 Pressure differential, acute intraoperative suprachoroidal hem-

orrhage (AISH), 67–68 Pseudoexfoliation

lens dislocation, 116 posterior capsular tears, 131

Pseudoplasticity

Healon5, 189–191, 190–191 viscoelastics, 183–184, 184

Pseudo-posterior capsule, posterior capsular tears, 127 Pump characteristics, phacodynamic complications, 195

obstructions, 196

Pupil circlage, iris problems, 0

Pupillary block, shallow-chamber hypotony, 240–241 Pupil ovalization, phakic lens implantation, 146, 146 Pupil size

capsulorrhexis technique, 38, 40, 53 pupil stretch, 53

cataract surgery and management of, 49 etiology, 49

hydrosteps technique, 53–54 iris stretch techniques, 50–52, 51

Beehler dilator, 51, 51 micro-iris retractors, 52, 52

lysis of synechiae, 49–50, 50 multiple sphincterotomies, 52

“nonstop” phaco chop complications, 272–273

phaco chop, horizontal vs. vertical chopping and, 278 phacoemulsification, 81

phaco flip complications, 103

290 • INDEX

Pupil size (continued)

posterior capsular tears, 125 postoperative care, 55 preoperative assessment, 255 preoperative management, 49 sector iridectomies, 52–53, 53 silicone pupil expander, 52 stop and chop phaco, 88

Q

Quadrant mobilization, phacoemulsification sculpting, 84 “Quick chop” technique

clear corneal phaco surgery, 263 guidelines for, 277–278

R

Regional anesthesia, positive pressure complications, 64 Releasable suture techniques, trabeculotomy procedure, 227,

232–233

Removal techniques Healon5, 191–192

intraocular lens, 150–152, 151

posterior segment complications, 208–212, 209–211 Replacement techniques, IOL

intraoperative techniques, 152 postoperative techniques, 152, 152–153

Repositioning techniques, intraocular lens, 150, 150 posterior segment complications, 209–210, 209–211

Retinal detachment (RD)

continuous curvilinear capsulorrhexis, posterior capsular tears, 43

posterior segment complications, 212, 212 posterior segment lens retention, 206–207, 207

Retrobulbar hemorrhage, injectible ophthalmic anesthesia, 8 Retrobulbar injection, injectible ophthalmic anesthesia, 4, 5 Rhexis size, phaco flip complications, 103

“Rock ‘n’ roll” removal, Healon5, 192, 192

Rosenthal deep topical, fornix-based “nerve block” anesthesia (RTDNBA), 15–16, 16

eyelid squeezing, photophobia, and phototoxicity, 19–20

S

Schlemm’s canal/trabecular meshwork nonpenetrating trabecular surgery, 237 rupture, 237

Scleral suture fixation

intraocular lens repositioning, 209–210 IOL repositioning, 210–211

Scleral tunnel incision, mature cataracts, 267–269 Sclerectomy, scleral flap problems, 233–234 Sclerocorneal frown incision, 29, 30, 31

inaccuracies, 32

Sclerocorneal incision, sutureless cataract surgery, 28–29, 30 Sclerokeratectomy, deep sclerectomy procedure, 226 Sculpting techniques, phacoemulsification, 81–83, 82

Sector iridectomies, suture/sutureless techniques, 52–53 Sedation procedures

injectible ophthalmic anesthesia, 3 topical anesthesia, 17

Segment mobilization, choo choo chop and flip technique, 93 Sharp needle technique, injectible ophthalmic anesthesia, 3–4,

4–5

Sheets’ glide

posterior capsular tear and insertion of, 258, 258 posterior capsular tears

extracapsular extraction, 127–128, 127–128 phacoemulsification, 128–129, 129 pseudo-posterior capsule, 127

Side-port incision, clear corneal phaco surgery, 262 Silicone oil

IOL selection criteria, 142 vitrectomy replacement

axial length measurements, 141–142 IOL compatibility, 141

properties and refractive index, 141

Silicon pupil expander, small pupil management, 52

Sinskey hook, posterior capsular tears, Sheets’ glide, 127–128,

128

Sliding flap technique, wound gape repair, 34, 35 Small pupil. See Pupil size

Soft lens, phacoemulsification and, 81 Soft nucleus

anatomy and pathophysiology, 105–106, 106 complications, incomplete hydrodissection, 106–107, 107 horizontal chopping for, 278

posterior polar cataract, 107–108 posterior subcapsular cataract, 107 surgical technique, 106

Soft shell technique broken zonules, 188

dispersive/cohesive viscoelastics, 186–189, 187 Fuchs’ endothelial dystrophy, 188 phaco-induced iris damag, 188–189

posterior capsular holes, 188 research background, 182

“Soft shell” technique, cortex removal, posterior capsular tears, 131

Speculum (speculae)

positive pressure complications, 63–64 temporal incisions and, 261

Staar collagen sponge, deep sclerectomy procedure, 226,

228–229

Standard operative procedure, phacoemulsification techniques, 257–258

Staphylomata, ocular penetration, injectible ophthalmic anesthesia, 6, 6

Stop and chop phaco

anterior capsule split, 88–89 complications, 85–86

dense nucleus, 87–88 hydrodissection, 86 manual dissection, 86–87 pupil size, 88

technique overview, 85 thick epinucleus removal, 89

Stroma anatomy, 166

scarring of, 168

Stromal hydration, sutureless cataract surgery, 29 Subconjunctival hemorrhage, injectible ophthalmic anesthesia

complications, 8–9

Subluxated IOLs, repositioning techniques, 209–210 Subscapular cataracts, anatomy and pathophysiology, 105–106 Subtenon’s (parabulbar) anesthesia, 16

Sulfur hexafluoride gas (SF6), Descemet’s detachment management, 175

Suprachoroidal effusion/hemorrhage nonpenetrating trabecular surgery (NPTS), 240 posterior segment complications, 217

Sutureless cataract surgery

clear corneal incision, 29–30, 29–31 intraocular lens repositioning, 209 sclerocorneal incision, 28–29

Suturing techniques

posterior segment complications, 211–212 releasable trabeculotomy procedure, 227, 232–233

transscleral posterior chamber intraocular lens (TS PCL) implantation, 159, 161

Symptomatic filtering blebs, nonpenetrating trabecular surgery, 243

Systemic disease, injectible ophthalmic anesthesia complications, 2

retrobulbar hemorrhage, 8

Systemic sedation, topical anesthesia, 17

T

Tamponade technique, positive pressure complications, 65–66,

66

Temporal incision

clear corneal phaco surgery, 261 as standard proceduree, 257, 258

Tetracaine, toxicity, 20

Ticlid, nonpenetrating trabecular surgery (NPTS) complications, 223–224

Topical anesthesia

clear corneal phaco surgery advantages, 260

patient sensation, 261 selection criteria, 260–261 timing and agent, 261

conjunctival ballooning, 21

eyelied squeezing, photophobia, and phototoxicity, 20–21 eye movement, 19

complications, 20, 20

virtual reality device, 18, 18–19 intraoperative experience, 17–18

laryngeal mask anesthesia as adjuncct, 17, 17 noninjection techniques, 14–16

intracameral technique, 15 topical drop, 14–15

operating room environment, 18 patient selection, 17

pinpoint (Fukasaku) anesthesia, 16 preoperative assesssment, 16–17 prevalence of techniques, 15

Rosenthal deep topical, fornix-based “nerve block” anesthesia (RTDNBA), 15–16, 16

subtenon’s (parabulbar) anesthesia, 16 systemic sedation, 17

topical gels, 16 toxicity, 21–22

Toxic anterior segment syndrome (TASS) endothelial damage, 180 phacoemulsification, 177–179

Toxicity, topical anesthesia, 20–21, 21 Trabeculotomy

INDEX • 291

bleeding complications, 236 failure of, 241–242, 242–243 glaucoma management, 226–227 iris prolapse, 232–234

postoperative complications, hyphema, 237–238 scleral flap problems, 229, 232, 233

Transscleral posterior chamber intraocular lens (TS PCL) complications, 162, 162–163

decentration, 162 dislocation, 162 lens tilt, 162

vitreous hemorrhage, 162 indications, 155–156

primary implantation technique, 162 secondary surgical technique, 157–161

distal haptic preparation, 157–158, 158 insertion technique, 158–159, 160–161 IOL exchange, 159, 161

proximal haptic preparation, 158, 159

Trauma, Fuchs’ corneal dystrophy, phacoemulsification, 170 Trough dimensions, phacoemulsification sculpting, 83 Trypan Blue Stain

continuous curvilinear capsulorrhexis, intumescent cataract, 41–42

mature cataracts

clear corneal phaco surgery, 268–269 “nonstop” phaco chop complications, 273

Two-handed vitrectomy technique, 136–138, 137 Type IV collagen, lens capsule anatomy, 36–37

U

Ultrasonic fragmentation, posterior segment lens retention, 205–206, 206

Ultrasound power

phacodynamic complications, 200–202 phacoemulsification sculpting, 81

Ultrasound tip design, phacoemulsification sculpting, 81 Ultrata Foldable Lens Cutter and Retriever, transscleral poste-

rior chamber intraocular lens (TS PCL) implantation, 161

Utrata forceps, iris stretch, 50

Uveitis-glaucoma-hyphema (UGH) syndrome, transscleral posterior chamber intraocular lens (TS PCL), 155–156

V

Vacuum level anagement

phacodynamic complications, flow management, 195–196 phacoemulsification sculpting, 81, 83

Vacuum level management, phacodynamic complications, techniques, 197–200, 199

Vacuum pump, phacodynamic complications, 195 Vertical phaco chop, vs. horizontal chop, 278–279 Virtual reality device, topical anesthesia, 18, 18–19 Viscocanalostomy, glaucoma management, 226, 230 Viscoelastic

cataract surgery damage repair, research background, 182 classification, 183–184

clear corneal phaco surgery irrigation and aspiration, 264 zonular dialysis, 269

content, molecular weight, and zero-shear viscosity, 183 cortex mobilization, 253–254

292 • INDEX

Viscoelastic (continued)

Descemet’s membrane complications, 174, 174–175 dispersive/cohesive elastics

background, 182–183, 183

soft shell technique, 186–189, 187 endothelial damage, 180

Healon5, 189–192

biomechanical properties, 189–191, 190–191 removal, 191–192, 192

surgical applications, 191, 192

higher viscosity-cohesive viscoelastics, 184–185 lower-viscosity dispersive elastics, 185–186 posterior capsular tear and insertion of, 258, 258 pseudoplasticity, 183, 184

surgical applications, 185, 185

Visual acuity, posterior chamber IOL dislocation, 211, 211 Vitrectomy

absence of irrigation, 138, 138

BSS replacement refractive index, 140 coaxial infusion, 135–136

dropped nucleus, 139

gas replacemnt, intraocular lens power calculations, 142 intraocular lens

material and positioning, 140–141 shape selection, 140

irrigation with, 138

posterior capsular tear management, 265–267, 267 posterior segment lens retention, 206 postoperative care, 138–139

silicone oil replacement

axial length measurement, 141–142 intraocular lens compatibility, 141 intraocular lens power calculations, 142 refractive index, 141

two-handed incision, 136–138, 137 Vitreous body

anatomy, 133

infusion/aspiration balance, 134–135 management of, 133–134

postrior capsular tears, nucleus loss into, 131 semielasticity, 135, 136

Vitreous hemorrhage, transscleral posterior chamber intraocular lens (TS PCL) implantation, 163

Vitreous loss

capsular fracture, nonpenetrating trabecular surgery (NPTS), 236

complications following, 133 dropped nucleus, 139

Vitreous management, zonule-compromised surgery, 118 Vitreous penetration, posterior capsular tears, Sheets’ glide,

129, 130

Vitreous valve removal, positive pressure complications, 66,

66

W

Worst-Fechner “lobster-claw” IOL, implantation, 146, 147 Worst “two-loop” medallion IOL, 146

Wound burn

phacodynamic complications, 201–202 wound complications, 34

Wound construction and closure clear corneal phaco surgery, 265 complications

burn injuries, 34

conjunctival hydration, 33–34 descemet’s detachment, 34 inaccuracy complications, 32–33 tunnel hemorrhage, 35

gape repair techniques, 34–35 incision location, 31

“one-stitch” closure, foldable intraocular lens, 28 sutureless cataract surgery, 28–31, 29–30

X

Xylocaine, topical gel anesthesia, 16

Z

Zero-shear viscosity, higher viscosity-cohesive viscoelastics, 185

Zonular dialysis

clear corneal phaco surgery, 269–270 continuous curvilinear capsulorrhexis, 44–46 micro-iris retractors, 119, 119

phaco chop complications, 96–98, 97–98 Zonule

anatomic abnormalities, continuous curvilinear capsulorrhexis, 41

compromise and dislocation

anatomic and etiologic considerations, 116, 117 capsular tension rings, 119–122, 119–122

IOL selection and insertion, 119 micro-iris retractors, 119, 119 patient evaluation, 116–117 surgical management, 117–118, 118 vitreous management, 118

fracture, soft shell dispersive-cohesive viscoelastic technique, 188

“nonstop” phaco chop complications with loose zonules, 273, 275

weakness or absence, phaco flip contraindications, 103