Special techniques used to conquer white and black cataracts with phaco

Liquefied cortex or dense black nuclei may seem to be barriers to phaco, but these pearls can lead to success.

Phacoemulsification is accepted worldwide as a technique for cataract removal. However, in removing especially mature white and black cataracts, there can be many complications.

After encountering several problems with white and black cataracts, I developed specific techniques for their removal. I have used these techniques since 1995 in removing more than 400 white cataracts and 300 black cataracts.

The white cataract

---In removing these cataracts, complications may occur.

In the white cataract, after Fukasaku's pinpoint topical anesthesia is used, a single-hinged clear corneal incision is performed. There are many important points to be aware of in the subsequent surgical steps.

During capsulorrhexis, for instance, the white color of the cortex and the presence of dispersed liquefied cortex can obstruct your vision during surgery. Additionally, fragile and fibrotic capsules can increase the chance of radial tears.

I use the grasp technique for this step. After viscoelastic is injected into the anterior chamber, I use Utrata forceps to grasp the anterior capsule, and I hold onto the anterior capsule flap with the forceps. This allows me to perform continuous curvilinear capsulorrhexis even though dispersed liquefied cortex obscures visualization.

In some cases, the liquefied cortex is so dispersed, before performing the capsulorrhexis I use the irrigation and aspiration tip or phaco tip to aspirate the milky cortex. Then I re-inject viscoelastic into the anterior chamber, both above and within the capsular bag, and perform the capsulorrhexis.

When a radial tear occurs, there are many methods to manage this complication. One can use scissors or microscissors to cut the capsule and start the tear in a new direction. One can use a bent needle to make a new tear in another site on the capsule. One can use the anterior vitrector, with separate infusion port, to cut the remaining capsule in a circular pattern. This technique also can be performed in cases of fibrotic or calcified capsules.

The hydrodissection step can be skipped, because most of these nuclei will already rotate freely. Instead, irrigate and aspirate out the remaining cortex to improve visualization.

For nucleus removal, I use an elevate-and-chop technique. After removal of the liquefied cortex, the phaco tip is embedded into the central nucleus. One side of the nucleus is elevated until its equator is up over the pupillary plane, then a chop is performed from the equator to the central nucleus.

Advantages of the elevate-and-chop technique include good visualization during the chop; ease of chopping and cracking from the equator toward the central nucleus; decreased chance of capsular rupture by the chopper; and no stretching of the capsule and zonules. The technique can be performed in cases of radial tear and in small pupil cases.

After the chopping and cracking are done, the pieces of nucleus can be emulsified in the posterior chamber.

The black cataract

Problems with brunescent and black cataracts include hard and sticky nucleus fibers, thin capsules and weak zonules, and a large mass of nucleus and epinucleus. The large mass of the nucleus means we encounter an increased anterior-to-posterior diameter of the nucleus, some degree of capsular stretching and limited space for manipulation. So I created a technique to address these problems called the transverse cracking and serial chop.

To begin, I perform central sculpting of the nucleus. Then I make a transverse crack; I embed the phaco tip in the upper part of the nucleus and pull the lower part of the nucleus with a Sinskey hook or chopper. This makes the nucleus separate into two pieces.

Then I perform a serial chop. In this method, I embed the phaco tip and perform a chop, then embed the tip again and perform a second chop, and then again for a third chop. After this, I have three small pieces of nucleus. It is easy to manipulate the third piece of the nucleus first because it is moved into the center more easily than the other pieces. I call this the connecting effect. I emulsify the third, second and first pieces sequentially. After I have emulsified the first three pieces, I use a chop or elevate-and-chop technique to manage the remaining nucleus.

Advantages of transverse cracking are that it decreases the mass of the core nucleus, which increases space for manipulation and destroys the hard and sticky nucleus fibers in the core nucleus; and it divides the nucleus without rotation.

Advantages of the serial chop are that it destroys the core nucleus with multiple embeddings of the phaco tip; rotation of the nucleus occurs automatically; and you can manipulate the third piece easier because of the "connecting effect."

Using these techniques to approach these types of cataract, I have found that I can decrease phaco time, decrease operative time and decrease the number and severity of complications.

Dr. Jongsareejit uses Utrata forceps to grasp the anterior capsule. He holds onto the anterior capsule flaps with the forceps.	In some cases the liquefied cortex is so dispersed, before performing the capsulorrhexis, Dr. Jongsareejit uses the irrigation or phaco tip to aspirate the milky cortex.	Scissors or microscissors can be used to cut the capsule and start the tear in a new direction.
Use a bent needle to make a new tear in another site on the capsule.	Use the anterior vitrector with separate infusion point to cut the remaining capsule in a circular pattern.	After removal of the liquefied cortex, the phaco tip is embedded into the central nucleus.
One side of the nucleus is elevated until its equator is up over the pupillary plane, then a chop is performed from the equator to the central nucleus.	Advantages of the elevate-and-chop technique include good visualization during the chop.	After the chopping and cracking are done, the pieces of nucleus can be emulsified in the posterior chamber.
Problems with brunescent and black cataracts include hard and sticky nucleus fibers, thin capsules and weak zonules, and a large mass of nucleus and epinucleus.	The large mass of the nucleus means we encounter an increased anterior-to-posterior diameter of the nucleus, some degree of capsular stretching and limited space for manipulation.	To begin, I perform central sculpting of the nucleus.
Then perform a serial chop. In this method, embed the phaco tip and perform a chop, then embed the tip again and perform a second chop, and then again for a third chop.		Using this connecting effect. I emulsify the third, second and first pieces sequentially.

For Your Information:

• Amporn Jongsareejit, MD, can be reached at Mettapracharak (Raikhing) Hospital, Sampran, Nakornprathom, Thailand, 73210; (66) 3-4225417-20; fax: (66) 3-4321243; e-mail: ampornj@hotmail.com. Dr. Jongsareejit has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.