Jules Stein Eye Institute

The intumescent white cataract poses challenges during many different steps of surgery. This begins in the preoperative period where biometry is compromised by the completely opaque media and continues into surgery where the absence of a red reflex decreases visualization. But probably the most important step of surgery is creation of the capsulorrhexis, which is difficult due to the pressure gradient created by a fluid-filled capsular bag.

The femtosecond laser can be a useful tool for cataract surgery. In routine cataract cases, the benefit is typically mild and in expert hands may not provide a meaningful improvement over manually performed steps of surgery. For this reason, in most of my cataract cases, I do not find myself using the femtosecond laser during cataract surgery. But in certain challenging cataract cases, the femtosecond laser can be helpful in producing a better outcome and avoiding certain complications.

There is a pride that we feel as surgeons when our patients can read the 20/20 line without glasses after surgery. Achieving true emmetropia for the lower-order aberrations of sphere and cylinder puts the Snellen chart clearly in focus. For our younger patients undergoing keratorefractive surgery, having a perfect plano outcome is great because they still have a large amount of accommodation, providing a wide range of vision from far to near. But for cataract patients, plano may not be the best refractive outcome for every patient.

We know that patients who underwent prior corneal refractive surgery pose more of a challenge when it comes to performing IOL calculations for cataract surgery. The reason is that the anterior surface of the cornea has been steepened while the posterior surface has been untouched. Thus, the typical ratio of anterior to posterior curvature has been altered, and our instrumentation has a difficult time accurately determining total central corneal power.

Many patients desire a refractive correction at the same time as cataract surgery. This makes sense because we can correct a large degree of spherical refractive error as well as astigmatism with proper planning. The phaco incision that we use during cataract surgery can have a significant effect on the astigmatism of the eye, and it needs to be accounted for in our calculations.

Over the last two decades, cataract surgery has evolved from scleral incisions to corneal incisions, from retrobulbar anesthesia to topical anesthesia, and from rigid IOLs to injectable IOLs. Currently, most surgeons use a corneal incision during cataract surgery because it allows less anesthesia, faster recovery, enhanced access to the anterior chamber and excellent visual outcomes. Residents now start learning cataract surgery with corneal incisions and then learn scleral tunnels later in their training. But be warned that a poorly constructed corneal incision can start a cascade of problems during cataract surgery and could put the patient at a higher risk for complications. I have developed three rules of corneal incisions to help young surgeons learn this critical step of cataract surgery.