the required depth and holding the capsule far from the phaco tip. The fluid infusion due to pressured infusion is sufficient for 0.7mm MICS. The end of the Stinger is equipped with a pointed tip which is angled downwards. It enables breaking masses with ease and guides them to the aspiration hole (Fig. 1.14).

1.3.4 Surgery

1.3.4.1 Incision

A biplanar valved incision is made with a 1 mm keratome. The preference of one of the authors (Amar Agarwal) is a sapphire knife or a stainless-steel knife. A tight incision is mandatory in 0.7 mm MICS. Illfitted incisions would not seal the anterior chamber when gas forced infusion is used in 0.7 mm MICS. The viscoelastic is then injected inside the eye. This will distend the eye so that a clear corneal incision can be made easily. One clear corneal incision will be made between the lateral rectus and the inferior rectus and the other between the lateral rectus and the superior rectus. This way, the movements of the eye can be controlled during surgery. The incisions should be made 90° apart and the leading incision should be made at the positive meridian. This incision is used for IOL implantation.

1.3.4.2 Capsulorhexis

The capsulorhexis is then performed of about 5–6 mm. This is done with a needle or with MICS forceps. A straight rod is inserted through the second incision and held in place with the left hand to stabilize the eye. This is the Globe stabilization rod. The advantage of this is that the movements of the eye can be controlled

while working, without any anesthesia or under topical anesthesia.

1.3.4.3Hydrodissection

Hydrodissection is performed after removing the small amount of viscoelastic from the anterior chamber. The fluid wave should pass under the nucleus. Both incisions are suitable for the purpose of hydrodissection and even the subincisional areas can get easily hydrodissected. The problem is that there is not much space for fluid escape through the 1 mm incision. Careful hydrodissection and fluid control during these maneuvers can avoid complications.

1.3.4.4 Prechopping

Prechopping is a maneuver that can decrease ultrasound surgery time and power use. The advantages of bimanual prechopping are the following:

1.Reduction of phaco time

2.Reduction of US power

3.Decrease in surgical time

4.Decrease of rotational maneuvers at the nucleus, eventually important in cases with poor or damaged zonnula

For these maneuvers we need tools – prechoppers. One of the authors (Jorge Alio) concludes that one-hand choppers are not recommended because of lesser efficacy of this action and inadequate zonullar stress in hard cataracts. For small incision surgery, bimanual prechopping is safer and more efficient.

To perform prechopping in 0.7mm surgery, we use two Alio-Scimitar MICS Prechoppers (Cat. No. K3-2324 Katena Inc, Denville, NJ) or Alio-Rosen MICS prechoppers (Katena Inc) (Fig. 1.15)

Fig. 1.15 Alio Scimitar prechopper and Alio-Rosen Phaco prechopper for microincision cataract surgery (Katena Inc)

Fig. 1.16 Bimanual use of Alio’s Scimitar prechoppers

Fig. 1.17 0.7 mm MICS started, 0.7 mm irrigating chopper and 0.7 mm phaco tip without the sleeve inside the eye. (Instruments are made by MST)

The shape of the Scimitar Prechopper is designed to perform and facilitate 700 μm surgery. The Scimitar Prechopper has a curved tip with a blunt end and a sharp inferior edge. The choppers are crossed by situating them symmetrically opposite each other (Fig. 1.16). Then the cuts are made by gently crossing the prechoppers. The cuts are made from the perimeter to the center of the nuclei. The internal edge is sharp and this facilitates incisions of lens masses. The mass is cut into two dividing hemispheres. The nucleus is then rotated 90° and then prechopping is repeated for the second time as described earlier.

1.3.4.5 Phacoemulsification

The 22 (0.7 mm) gauge irrigating chopper connected to the infusion line of the phaco machine is introduced with a foot pedal on position 1. The phaco probe is connected to the aspiration line, and the 0.7 mm phaco tip without an infusion sleeve is introduced through the clear corneal incision (Fig. 1.17).

Using the phaco tip with moderate ultrasound power, the center of the nucleus is directly embedded, starting from the superior edge of the rhexis, with the phaco probe directed obliquely downwards towards the vitreous according to one of the authors (Amar Agarwal). The settings at this stage are 50% phaco power, 20 mL/ min flow rate and 100–200 mmHg vacuum. Using the karate chop technique the nucleus is chopped [17]. Thus the whole nucleus is removed (Fig. 1.18).

The other method is to aspirate the nuclear fragment with the phaco tip after successful prechopping. The nuclear fragment lifted by the phaco tip and aspiration is broken with the help of the Alio Stinger Irrigating Chopper. The Stinger cannula is equipped with the hook at its end, which facilitates fragmentation of the nucleus. Small fragments of the nuclei are aspirated by high vacuum, practically without using U/S power.

Cortical wash-up is then done with the bimanual irrigation aspiration (0.7 mm set) technique (Figs. 1.19 and 1.20). During this whole procedure gas forced infusion is used.