The use of capsular tension rings (CTR) depends if the nucleus is subluxated because of the capsular retraction or if the zonular support is felt to be very weak.

The decision of the IOL is still a point of discussion, if you have to enlarge the main incision or if you make a new one between your two incisions, only to insert your IOL.

7.3.8 Conclusion

The author had been doing Biaxial since October 2002 and MicroBiaxial since November 2005 and in December 2005, switched entirely to Microincision and stopped performing Coaxial. This means that any kind of cataract, be it the hypermature type, could be extractedbyPhacoemulsificationthroughMicroincision with Biaxial or MicroBiaxial technique.

These techniques are very reliable and safe, if one understands the fluidics more than just the power modulation, because with only the pulse mode, it is possible

to perform this technique. There is not a single case reported with corneal burn with Biaxial. This technique does not need the obligatory power modulation software in the machine. Of course, it would be better if it is available, however, if the surgeon can control solely the fluidics, he can avoid the instability of the anterior chamber thus causing less endothelial and uveal trauma. There will be no turbulence, and the followability and the holding power remain identical. It should not be forgotten that the hypermature cataracts are different from any of the regular cataracts. The red reflex is absent, the anterior capsule is very thin and fragile and there is that great chance of producing a peripheral tear. A large capsulorhexis is recommended to supply enough room to remove the pieces from the bag, to the iris plane to emulsify them. Most of the zonular support is weak. The hardness of the cataract and its adherence to the posterior capsule are potential difficulties, which can increase the energy delivered, and the surgical time.

It is possible to overcome these difficulties with the MicroBiaxial technique because of the following reasons:

•Smaller incisions mean a less invasive approach

•True anastigmatic incisions. It does not matter if the position is temporal or superior. It is possible to induce only 0.06 D

•True water-tight incisions

•Less possibility of iris extrusion even in intraocular floppy iris syndrome (IFIS)

•Higher resistance to postoperative trauma

•Minimum uveal trauma because of minimal turbulence

•Less amount of endothelial cell loss because of minimal turbulence and low U/S emission

•Corneal stability and faster visual recovery

•Deep anterior chamber all throughout the surgery

•Less BSS consumption in each case. Only 60–80 mL of BSS is used in regular cases and 120 mL in hypermature cataracts

•Less fluctuation and mobilization of vitreous, because of the stability of the anterior chamber during the whole procedure. It is better in refractive lens exchange (high myopes and hyperopes) and in patients with previous retinal tears or retinal surgery

•Increased intraocular pressure can be avoided depending on the high In-flow in coaxial, thus can be used in glaucoma patients. It also keeps a safe range of retinal irrigation, that is, 3 min at 70 mmHg. Outside this range, one can cause retinal damage. With the biaxial technique, one can obtain between 20 and 30 mmHg during the surgery. In Coaxial, it can rise to 60 mmHg or more, so the risk of retinal and optic nerve damage is greater

•Better maintenance of the anterior chamber with viscoelastic during the capsulorhexis, when introducing a CTR and when managing cases with small pupils

•the capsulorhexis can be made from both incisions

•The hands can be easily switched in Phaco

•It is possible to perform this technique with any machine

•Hyperpulses is not a necessity

•Easier removal of subincisional cortex

•The irrigation is a third instrument

•The main incision helps to mobilize fragments

•Theoretically less incidence of endophthalmitis

•Indicated in cases of previous PKP, RK or Seton devices

•Better control in uveal effusion

•Better management of complications

•Easier to teach in right and left handed Residents or fellows

•There are good softwares and new machines which can hasten the learning curve

Author’s final comment: The author hopes that with this chapter and this whole book, more and more surgeons will take the challenge and make this next step in the future of cataract surgery. It is so easy to fall in false belief that microincision cataract surgery is not good enough and to question its’ usefulness when the perfect IOL has not been developed. However, it can be recalled that in the beginning of phacoemulsification when only rigid IOL’s existed, incisions were likewise enlarged. But still, many surgeons believed that its’ benefits over extracapsular surgery, though were not so evident at the start, were a hundred-fold and that, in the future, its’ impact on the way the ophthalmologists treat cataract patients will be immense. This is true likewise with microincision cataract surgery. The IOL technology, as of the moment, is not a plus factor of this technique. The biggest advantage of this technique is the calm intraocular environment that it offers during the whole procedure that increases the safety of the surgery and as a result, improves the visual outcome of the patient.

Take Home Pearls

ßHypermature cataracts are more difficult and challenging. Special care has to be taken.

Regarding the incision, precalibrated knifes should be used to obtain more anterior chamber stability, to avoid leakage.

ßDuring capsulorhexis, it always helps to stain the capsule even if it has some red reflex. This

gives the surgeon more control and safety during this step.

ßThe major goal in intumescent cataracts is to decrease the intracapsular pressure to avoid

peripheral tears and to avoid any subcapsular fibrosis and peripheral traction in hard ones without cortex.

ßHydrodissection is mandatory to mobilize the nucleus in hard cataracts. Though in intumescent

cataracts, it is seldom necessary, it always helps to be sure that the nucleus is free from adherences before starting phacoemulsification.

ßFinally during phaco, one can use any technique, however the “safe chop” is the recommended

one in these cases.

References

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