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204 C. Schäferho and T. Neuhann
how much one has operated), can also be managed in this way. Ideally, one has attended wet
labs before the first phacoemulsification and
observed and assisted as much as possible with
their mentor. The preparation as a surgeon is
addressed in Chap. 7.
One must also be thoroughly familiar with
devices such as the phaco machine, the instruments, and the microscope.
It is advisable to approach cautiously. It is
worth investing the time to assist as an “OR
nurse.” This provides security regarding the
surgical procedure and the instruments. It is
helpful to watch as many operations as possible by experienced surgeons through the
observer. Experience shows that it is easier to
learn cataract surgery step by step. After learning to drape a patient sterilely and insert the lid
speculum, one can begin to perform the paracenteses. Once the beginner masters this safely,
the first injections of suprarenin and viscoelastic can be practiced. This is followed by the
performance of the capsulorhexis until all surgical steps have been learned. Detailed descriptions can be found, for example, in “Cataract
and Lens Surgery in Ophthalmology” by M.
Shajari, B. Zuberbühler’s “Cataract Surgery,”
or “Phacoemulsification and Intraocular Lens
Implantation” by M. C. Knorz.
20.2 Microscope
Before starting the operation, one should sit down
calmly and comfortably and adjust the microscope to their needs. Since operations take longer
at the beginning, this avoids tension. Most microscopes can be operated with a footswitch, allowing refocusing even while working in the eye.
20.3 Phaco Machine
Every surgeon should perfectly know the technique of the phaco machine, the setting parameters, and their significance. The phaco machine
should initially be set conservatively for a
beginner. With increasing experience, the settings can become more advanced and aggressive. In our experience, the representatives of
the machine manufacturers are very cooperative
and are happy to assist with the first operations.
The phaco device controls the irrigation (i.e.,
the flow of fluid into the anterior chamber), the
strength of aspiration (i.e., the suction of lens
fragments and fluid), and the strength and frequency of the ultrasound necessary for the emulsification of lens particles. The phaco machine
is controlled via a footpedal which either activates the irrigation first, then the aspiration,
and the phacoemulsification with increasing
strength from top to bottom, or activates the irrigation first, then increasingly the aspiration in
two stages from top to bottom, and activates the
phacoemulsification by tilting the footswitch to
the side. The interaction between irrigation and
aspiration is called fluidics. This ensures a stable anterior chamber. The fluidics influence the
“followability,” i.e., the bringing of lens parts to
the phaco tip, and the “holdability,” i.e., the ability to fix a lens fragment sucked onto the phaco
tip to emulsify it afterwards. To support this, the
fluid flow is directed so that the fluid flows out
of the side openings of the sleeve and flushes
lens fragments towards the phaco tip through a
circular fluid movement. Further details can be
found in Sect. 4.2 on the phaco machine.
20.4 Selection of Patients
Dry runs (non-sterile) with the surgical
microscope before the first operation are
strongly recommended.
The structure and function of the surgical microscope are described in detail in Sect. 4.1.
When selecting the first patients, a few points
should be considered:
• The cataract should be moderately
advanced. If the cataract should be moderately advanced. If the cataract is too dense,
20520 My First Phaco—How Do I Prepare?
complications are more likely: During capsulorhexis, the red reflex may be missing, making it difficult to see the rhexis edges. The
higher phaco energy required for lens emulsification can lead to endothelial damage of
the cornea. Additionally, the pressure on the
zonular fibers during phacoemulsification can
be too high, making normal posterior chamber lens implantation impossible, as the capsular bag can no longer hold the artificial lens
• If the cataract is too “soft,” dividing the
nucleus can be difficult because there is no
good counterforce for the instruments.
•
Especially as a beginner, one should avoid
indications with an above-average success
expectation, such as a clear lens exchange
and the implantation of premium lenses, as
the patients’ expectations are very high for
such procedures.
• The pupil should dilate sufficiently, as cataract surgery becomes more complicated with
a narrow pupil due to the poorer view.
• Comorbidities, such as cornea guttata or
pseudoexfoliation syndrome, which can be
associated with loose zonules, make pressure
increases more likely and the rhexis more
prone to tearing outward, should be reserved
for more advanced colleagues. Previous surgeries, such as vitrectomized eyes where the
vitreous body is missing as a counterforce,
also make zonular fiber injuries more likely.
Previous trauma can also loosen the zonular
fibers, and even with careful surgery, vitreous
prolapse can occur.
For the first cataract surgeries, the selection
of patients should be done carefully and in
consultation with the mentor!
20.5 Checking the Indication
Before starting the surgery, it must be ensured
that the correct patient with the correct IOL lens
is operated on the correct eye. The best way to
check this is to have the patient state their name,
date of birth, and the eye to be operated on, and
compare this with the documents.
20.6 Draping the Patient
There are different drapes. Most have an adhesive
film that is stuck to the disinfected area. Then the
film must either be cut open or, if already preperforated, torn open. As with all further steps,
strict adherence to hygiene is essential. Chap. 3
describes asepsis and antisepsis in the OR.
20.7 Inserting the Eyelid Speculum
When inserting the eyelid speculum, have the
patient look down and slide the upper arm of
the speculum under the upper eyelid. In the next
step, the patient looks up, and the lower arm is
slid under the lower eyelid. This eye movement
avoids corneal injuries.
As little manipulation as possible should be
done on the eyelids, as this can express bacteria into the conjunctival sac and thus into the
surgical area.
An overview of different eyelid speculums can
be found in Sect. 5.5.2.
20.8 Paracentesis
Paracenteses are needed to inject viscoelastic,
saline solution, or VisionBlue into the eye, as
well as to introduce smaller instruments into the
eye, such as the Push-Pull during phacoemulsification and, if necessary, a bimanual irrigation and
aspiration. The size of the paracenteses depends
on the instruments to be used or the diameter of
the bimanual suction-irrigation (Chap. 13 ).
The number and location of the paracenteses
depend on the subsequent planned surgical steps.
Typically, the paracentesis is performed
60°–90° offset from the planned main incision.
The eye is fixed with a forceps (e.g., colibri forceps) with the second hand. The incision should
be horizontal, parallel to the iris, and peripheral
through the cornea. If the incision is too peripheral, the iris can be injured by the paracentesis
206 C. Schäferho and T. Neuhann
knife, or the iris may push towards or through
the incision over time. This risk is especially
present with a floppy iris. Additionally, an incision leak can cause the conjunctiva to be undermined and inflated.
If the incision is too central, the patient can
be disturbed by corneal scars. A nonoblique
incision is more difficult to seal.
20.9 Main Incision
Nowadays, a clear cornea or limbal corneal
incision is usually performed. The phaco tunnel
should be self-sealing and is usually stepped.
An angled keratome is typically used (Chap.
13). The blade has a width of approximately
2.5 mm. The incision width must be matched
to the size of the phaco tip. First, one punctures the cornea or the cornea-near sclera at
the peripheral edge at a 70° angle to the corneal surface, then guides the blade 2 mm parallel to the corneal surface, and then punctures
vertically into the anterior chamber. Due to
this stepping, the incision can self-seal through
the intraocular pressure on the inner lip of the
wound. During the incision, the eye should be
fixed, for example, with a colibri forceps. The
location must be chosen so that the phacoemulsification can be performed comfortably.
Sclerocorneal or scleral incisions are nowadays
mostly performed only for selected indications,
such as the implantation of a non-foldable lens.
If the clear cornea incision is performed too
short, it is difficult to seal. The more peripheral
the tunnel incision, the lower the astigmatic
effect. An overview of the incision instruments
can be found in Chap. 5.
20.10 Viscoelastics
Viscoelastics are substances that are, on the one
hand, viscous, i.e. thick, and on the other hand,
elastic (Chap. 11). They serve to maintain the
stability of the eye. Due to their viscosity, the
eye does not collapse when paracenteses or main
incisions are opened with instruments. They are
divided into cohesive and dispersive viscoelastics. Sodium hyaluronate, chondroitin sulfate,
and hydroxypropyl methylcellulose are used.
Cohesive viscoelastics are more stable in their
form, while dispersive ones are somewhat more
fluid.
20.11 Preparation of the Capsulorhexis
To optimally perform the capsulorhexis, the
pupil must be sufficiently dilated. Preoperatively,
this can be done locally with tropicamide
(Mydrum) and phenylephrine (Neosynephrine)
eye drops. Intraoperatively, epinephrine
(Suprarenin, diluted 1:10) or Mydrane (a combination of tropicamide, phenylephrine, and
lidocaine) is injected. This is injected into the
anterior chamber through a paracentesis. If the
pupil is not sufficiently dilated, the Malyugin
ring or iris retractors are available. To prevent the
anterior chamber from collapsing, a viscoelastic
is injected afterward. Hyaluronic acid derivatives
or methylcellulose are commonly used. In Chap.
11, intraocularly used medications are discussed
in detail.
20.12 Capsulorhexis
The capsulorhexis suggested by Neuhann is
still the standard for opening the anterior capsule. This can be performed either with a curved
cannula or forceps needle. The ideal size of the
capsulorhexis is approximately 5 mm in diameter. This ensures that the posterior chamber lens,
which usually has an optic diameter of 6 mm,
is circularly covered by the anterior capsule. If
the opening is smaller, capsular phimosis with
tearing of the zonular fibers can occur due to
scarring of the capsular bag. If the opening is
too large, the posterior chamber lens can more
easily dislocate into the anterior chamber or tilt,
causing higher-order aberration errors. If one
punctures too deeply into the lens, the lens can
swell, and the edge of the rhexis is no longer
visible. If the rhexis runs too far outward, the
folded edge of the rhexis is pulled centrally. If
there is a tear in the anterior capsule, the tear
can extend to the posterior capsule, resulting in
vitreous prolapse and the sinking of lens remnants into the vitreous cavity.
In principle, the rhexis can be best controlled
if one pulls the capsule close to the edge of
the rhexis towards the center with a needle or
forceps.
20.13 Hydrodissection and Hydrodelineation
Hydrodissection is the separation of the lens
cortex from the lens capsule. This is necessary
so that the nucleus can be properly processed. A
blunt irrigation cannula is guided under the edge
of the rhexis. The dissection is performed by
careful irrigation with a saline solution. Ideally,
one can see the fluid wave flowing over the
anterior capsule and the lens equator between
the posterior capsule and the lens towards the
irrigation cannula. If this is not the case, one
should start again at another point and irrigate
again. The nucleus should be able to be rotated
within the capsular bag. If irrigated too forcefully, the pressure that builds up in the capsular
bag can cause the posterior capsule to rupture.
If too much volume is injected, the lens nucleus
can luxate forward, which can result in a tear of
the anterior capsule. In this case, the lens should
be pushed back either with the irrigation cannula or with viscoelastic. After the dissection,
hydrodelineation follows. The lens cortex is
penetrated while irrigating and the lens nucleus
is separated from the lens capsule. One should
see the fluid waves flowing in the interface here,
too. This also makes it easier to process the
nucleus. Figure 20.1 shows the hydrodissection.
20720 My First Phaco—How Do I Prepare?
Fig. 20.1 Separation of the lens capsule from the lens
during hydrodissection
20.14 Phacoemulsication, Divide
and Conquer
In phacoemulsification, there are various
techniques by which the lens is fragmented
and aspirated. The phaco tip works through the
lateral outflow of saline solution, which flows
back circularly to the tip of the phaco tip and is
supposed to carry lens fragments with it. This is
shown in Fig. 20.2. Firmer fragments are supposed to dock onto the phaco tip and are then
Extensive hydrodissection and hydrodelinea-
tion are crucial prerequisites for gentle work
within the capsular bag!
Fig. 20.2 Circular fluid flow from the lateral openings
of the sleeve to the phaco tip
208 C. Schäferho and T. Neuhann
thickness deep. Figure 20.3 shows the correct
division. Since the lens is approximately 6 mm
deep in the center and decreases in thickness
towards the edge, and the width of the phaco
tip is about 1 mm, one can estimate intraoperatively how deep the trench has been “dug” in the
center of the lens. However, the lens thickness
can vary depending on age and cataract. If the
trench is deep enough, one attempts to divide the
lens by manipulation with a second instrument,
e.g., a Push-Pull. An overview of the instruments can be found in Chap. 5. Figures 20.4,
20.5, and 20.6 show the “cracking” of the lens.
If the instruments are placed too high, the lens
will not be cracked but only flipped downwards,
which can tear the posterior capsule. This is
shown in Fig. 20.7.
Fig. 20.3 The correct division of the lens into four fragments. Based on the thickness of the phaco tip, the depth
of the trench in relation to the lens can also be estimated
If this is successful, the lens is rotated and
one half is divided again. The technique of rotating the lens is shown in Fig. 20.8. This quarter
can then be aspirated and phacoemulsified. It
is best to dock the fragment in the middle or in
the lower third. This is shown in Figs. 20.9 and
20.10. Only with complete occlusion can the
lens be emulsified. It has proven effective to
protect the capsule and iris with a second instrument by positioning it under and behind the lens
fragment when a lens fragment is aspirated by
the phaco tip. This way, even if there is a sudden increase in vacuum because either the occlusion is suddenly interrupted or the fragment is
completely removed, the posterior capsule is not
sucked into the phaco tip. During phacoemulsification, the fragment to be emulsified must first
be firmly aspirated to the phaco tip, otherwise
it will be pushed away by the water flow. Only
then can it be emulsified. With a second instru-
Fig. 20.4 The fragmentation of the lens with crossed
instruments
ment, the lens fragments may need to be rotated
into the correct position. If the phaco tip is
applied too high on the core fragment, the pos-
emulsified with ultrasound. It has proven beneficial for beginners to work bevel-up (the opening
of the phaco tip points upwards), as the posterior
capsule is less likely to be aspirated.
For beginners, the “Divide-and-Conquer”
technique is the most suitable. First, the lens
is divided in the middle by a trench using the
phaco tip. This should be at least ¾ of the lens
terior capsule can be torn by a sharp edge of the
lens core. This is shown in Fig. 20.11.
The goal is to create an occlusion of the aspiration opening by a lens fragment so that the
vacuum can build up. The irrigation should at
this moment only replace the fluid that escapes
through the incision. Once the lens fragment
is fixed by the vacuum, one begins to break it
Fig. 20.5 The fragmentation of the lens with parallelguided instruments
20920 My First Phaco—How Do I Prepare?
halves are rotated about 50° and each half is
divided into several small fragments and emulsified. In the “direct chop” technique, the phaco
tip is deeply embedded in the center, the auxiliary instrument is guided to the opposite side
under the lens, and both instruments are worked
against each other.
When learning phacoemulsification, the
“divide-and-conquer” technique is preferred
for beginners. The first trench (depending on
the core’s consistency) should be sufficiently
deep and as centered as possible so that it
halves the core.
20.15 Irrigation/Aspiration
Once the lens core is removed, irrigation and
aspiration are easiest for the beginner with a
bimanual irrigation-aspiration system. The
instruments are inserted through the paracenteses. The aspiration is placed under the edge
of the anterior capsule and the lens cortex is
aspirated. Then the cortex is “peeled” towards
the center. This also loosens the cortical remnants on the posterior capsule. Cell residues
and deposits on the capsule can be carefully
mobilized with the roughened underside of the
instruments and then aspirated. Remaining lens
residues can lead to inflammatory reactions and
cause a pressure increase due to swelling.
Fig. 20.6 The “cracking” of the lens using the phaco tip
and a second instrument
down and aspirate it through emulsification. If
contact with the lens fragment is lost or the fragment is emulsified, the vacuum drops abruptly
and the aspiration increases rapidly. The latter
is referred to as a “surge” and can lead to a collapse of the anterior chamber.
An alternative technique is “stop & chop.” As
with “divide and conquer,” a trench divides the
lens into two halves, which are “cracked.” The
If the posterior capsule is accidentally aspi-
rated, the aspiration is immediately stopped
(switch to “reflux” if necessary). If the aspiration handpiece is pulled back in this situation, a capsule defect occurs.
20.16 Polishing the Capsule
Using a blunt irrigation cannula, the posterior capsule is polished with a hard water jet
of NaCl solution. This serves as a prophylaxis against posterior capsule opacification.
Care must be taken to ensure that the pressure
210 C. Schäferho and T. Neuhann
Polishing the posterior capsule with a roughened
aspiration handpiece has also proven effective.
20.17 Implantation of the Posterior Chamber Intraocular Lens
Many lenses are now delivered “preloaded,”
so the shooter used to implant the lens can be
prepared with just a few steps. Depending on
the lens type, there are different techniques.
Here, too, reference should be made to the representatives of the lens manufacturers. There
are shooters for rotating or pressing. The rotating shooters are easier to control. Once all cortical remnants are removed and the posterior
capsule is polished, viscoelastic is introduced
Fig. 20.7 The incorrect attempt to divide the lens with
instruments placed too high. As a result, pressure is only
applied to the lower part of the lens, compressing it in
this area instead of dividing it, similar to a hinge
Fig. 20.8 The figure demonstrates rotating the lens core
into the correct position using the phaco tip and an auxiliary instrument
exerted by the irrigation is not too high, so that
the posterior capsule is not damaged. It should
also be ensured that the irrigation cannula is not
tilted and is securely attached to the syringe.
Otherwise, the built-up pressure can injure all
structures in the eye if the cannula is dislodged.
into the anterior chamber and the capsular bag,
the tip of the shooter’s cartridge is inserted into
the phaco tunnel up to the middle of the capsular bag, and rotation begins. The slow release of
the lens from the cartridge allows precise control to ensure that the anterior haptic lies directly
under the anterior capsule and the lens does not
unfold “upside down.” When rotating the lens,
the shooter can also be slowly retracted a bit.
By manipulating the opening lens with the cartridge, the posterior haptic of the intraocular lens
can be pushed under the anterior capsule into the
capsular bag. If this does not succeed, it can also
be done before aspirating the viscoelastic with
the bimanual irrigation-aspiration system or the
viscoelastic needle. This is achieved by slightly
rotating the lens and simultaneously pressing
the posterior haptic down a bit. When using a
press injector, care must be taken to implant the
lens slowly and evenly. If resistance suddenly
decreases during implantation, the sudden pressure can injure the iris or capsule. The intraocular lens can also be implanted using a folding
forceps. In this case, the lens is folded to about
half its diameter and must be implanted through
a correspondingly larger incision of about 3 mm.
For the implantation of non-foldable lenses, the
incision must be enlarged to the size of the optic,
usually about 5–6 mm. The last two methods
Fig. 20.9 The correct aspiration of a lens fragment in
the lower third while protecting the posterior capsule
with a second instrument
21120 My First Phaco—How Do I Prepare?
have become very uncommon due to the significantly easier implantation with the injector.
An overview of intraocular lenses is provided in
Chap. 10.
20.18 Removing the Viscoelastic
Removing the viscoelastic is particularly important because any remaining residues in the eye
can lead to a massive increase in pressure, usually within the first two days. Through the paracenteses, the viscoelastic can be conveniently
flushed out with the bimanual irrigation-aspiration system. Behind the lens, it is best to flush
from both sides with irrigation, as the posterior
capsule can be aspirated and torn with the aspiration handpiece.
20.19 Sealing the Incision and the Paracenteses
Fig. 20.10 The correct docking of the phaco tip to the
lens in the lower third. This fixes the lens core without
stressing the capsular bag
Fig. 20.11 If a lens half is aspirated incorrectly in the
upper third, a potentially sharp lower edge can tear the
posterior capsule due to tilting of the lens
The paracenteses are sealed by entering the incision with a syringe filled with NaCl solution
and hydrating the stroma (by injecting fluid into
it) to swell until it turns slightly whitish. The
main incision usually does not need to be sealed.
If necessary, the sealing of the phaco tunnel can
be checked by applying pressure to the wound.
If a fistula results from the main incision, a
small air bubble can be inserted into the anterior
chamber. In the upright position of the patient,
with an incision in the upper area, the lower lip
is pressed against the upper lip, thereby sealing
the incision.
20.20 Postoperative Antibiosis
According to the guidelines of the German
Ophthalmological Society (GOS), it is recommended to administer cefuroxime into the anterior chamber at the end of the operation and to
treat locally with a combination of antibiotic
and steroid eye drops. Examples include DexaGentamicin eye drops, Isoptomax eye drops, or
Inflanefran forte eye drops with, for example,
212 C. Schäferho and T. Neuhann
Ofloxacin eye drops or Oftaquix eye drops.
Mydriatics such as Cyclopentolate eye drops,
BoroScopol eye drops, or Atropine eye drops are
usually not necessary but can be given prophylactically to patients with known iritis. For steroid responders, non-steroidal anti-inflammatory
drugs such as Nevanac eye drops, Yellox eye
drops, or Voltaren eye drops can also be used.
20.21 Femtosecond Laser Cataract Surgery (see also Sect. 21.2 )
In 2008, Nagy clinically applied a femtosecond
laser in the context of cataract surgery. The use
of the femtosecond laser can reduce the operative risk through more precise procedure. With
the laser, self-sealing corneal incision profiles
can be created, a more precise circular opening of the lens capsule for central lens positioning, targeted fragmentation of the lens, which
reduces the ultrasound energy during phacoemulsification, and arcuate keratotomy to influence corneal astigmatism can be performed. Not
all steps need to be performed with the laser.
The execution of corneal incisions is controversially assessed by some surgeons, as the incisions can only be made corneally, not limbal.
In principle, the use of the femtosecond laser
facilitates cataract surgery. During capsulotomy
with the femtolaser, one must check whether
the “rhexis” is complete. Hydrodissection must
be carried out very carefully. “Cracking” the
nucleus is usually no longer possible or necessary, as the fragments can be individually aspirated. During phacoemulsification, one should
be particularly cautious due to the pre-fragmentation of the lens nucleus and use little energy to
protect the posterior capsule.
Further Reading
1. „Katarakt- und Linsenchirurgie in der Augenheilkunde“
by M Shajari, 2023, ISBN - 13: 978-3662624579
2. „Kataraktchirurgie“ by B Zuberbühler, 2008, ISBN 13: 978-3540799436
3. „Phakoemulsifikation und IntraokularlinsenImplantation“ by M C Knorz, 2004, ISBN-13 :
978-3922777670
The First Surgeries Are Completed, What Comes Next?
Thomas Hammer, Frank Wilhelm, Armin Scharrer,
Alexander Petzold, Erik Chankiewitz, Arne Viestenz,
Heiko Philippin, Karin Knoll and Martin Nentwich
Contents
21.1 Complication Management......................................... 214
21.2 Incorporation of new tools into the surgical process ..................... 218
21.3 Observerships ................................................... 221
21.4 Operating Abroad ................................................ 223
References and Further Reading .......................................... 228
21
T. Hammer
Klinik und Poliklinik für Augenheilkunde,
Universitätsklinikum Halle/Saale, Martin-LutherUniversität Halle-Wittenberg, Halle/Saale, Germany
e-mail: thomas.hammer@uk-halle.de
Augenarztpraxis, Augenzentrum “Frohe Zukunft”, Halle/
Saale, Germany
F. Wilhelm ()
Greifswald, Germany
A. Scharrer
DOC—Deutsche Gesellschaft für
Ophthalmochirurgie e.V. Neuwieder Straße 9,
Nürnberg, Germany
e-mail: armin.scharrer@augen-scharrer.de
A. Petzold
Augenzentrum am Johannisplatz, Leipzig, Germany
E. Chankiewitz
Augenklinik, Städtisches Klinikum Braunschweig
gGmbH, Braunschweig, Germany
e-mail: erik@chankiewitz.de
A. Viestenz
Klinik und Poliklinik für Augenheilkunde,
Universitätsklinikum Halle/Saale, Halle/Saale,
Germany
H. Philippin
Klinik für Augenheilkunde, Universitätsklinikum
Freiburg, Freiburg, Germany
e-mail: heiko.philippin@uniklinik-freiburg.de
The first operations under the supervision of a
mentor have been successfully completed. Now
it is time to gain experience, get routine into the
processes, and continue to develop. The following chapter will explain that careful planning of
interventions – especially in complicated initial
situations – can be as helpful as in the management of complications.
To expand their surgical spectrum, every surgeon should continuously inform themselves
about innovations and try to observe experienced colleagues in the operating room. In this
International Centre for Eye Health, London School of
Hygiene & Tropical Medicine, London, Großbritannien
CBM e. V., Bensheim, Germany
K. Knoll
Christoffel-Blindenmission Deutschland e. V.,
Bensheim, Germany
e-mail: karin.knoll@cbm.org
M. Nentwich
Augenklinik, Universitätsklinikum Würzburg, Würzburg,
Germany
e-mail: nentwich_m@ukw.de
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_21
213