Even the hardest cataracts can be fractured

COSTA DO SAUIPE, Brazil — Cataracts can be fractured, regardless of hardness, thanks to newer techniques, said Jose Claros Bernal, MD.

“When the cataract is very dense, when there are small limy deposits on the surface of the capsule, and when the pupils do not dilate, we may wonder if the surgery is even possible,” Dr. Bernal told attendees here at the Brazilian Congress of Cataract and Refractive Surgery.

He says that if the capsulorrhexis can be done, 90% of the procedure has been accomplished. If the nucleus can be turned and the ocular structures are still stable, then the surgeon knows the procedure can be done.

“We need to take our time and do the surgery carefully. But there must be enough depth for the process of fracture and emulsification,” he says.

The fracturing maneuver is key, he said.

“No matter how hard the cataract is, it can be fractured, even if you need to use scissors,” Dr. Bernal said. “If the cataract is extremely hard, I make a deep ‘ditch’ that is wide enough, wider than the tip of my ultrasound, so that I can reach the bottom without pushing the nucleus.” He said the maneuvers must take place mainly in the central zone, and it is important to make a capsulorrhexis of at least 5.5 mm to 6 mm in diameter. A capsulorrhexis of 4 mm makes maneuvers more difficult.

In hard cataracts, the distal section is usually elastic, he said.

“In that case we use 500 mm Hg vacuum, stabilize the nucleus and do the fracture. Once I stabilize the first half with the hand piece, using only aspiration, I use my spatula to complete the fracture,” said Dr. Bernal. The resistance from the bottom part of the nucleus is broken, and that makes the maneuver much easier. He said the surgeon must remember to keep adding viscoelastic for added protection.

“The main thing is,” he says, “that today no cataract can resist ultrasound with the appropriate technique and a good viscoelastic.”