incision with voiceover.mp4

Step 1: Creating Incisions in Cataract Surgery

Sideport with 1.0 mm blade + Temporal Main Incision with 2.2 or 2.4 mm Keratome

🎯 Purpose:

Establishing precise, self-sealing corneal access is the foundation of a successful cataract surgery. These incisions provide safe, stable entry points for instruments and optimize chamber control throughout the procedure.

🟦 A. Sideport Incision (Paracentesis)

Instrument: 1.0 mm sideport blade (MVR or stab knife)
Recommended Location: Superotemporal and or inferotemporal (depending on the operating eye and hand dominance of the surgeon), some surgeons prefer to have two sideports. supero and inferotemporal from the beginning of the procedure for accessing the eye.

Steps:

Stabilize the globe using a cotton-tipped swab, Weck-Cel or conjunctival fixation.
Enter ~1 mm anterior to the limbus at a 45° angle.
Tunnel through the corneal stroma and enter the anterior chamber without pressing too steeply.
Direct the blade toward the center of the pupil.
Stay parallel to the iris plane.

Pearl:
Avoid entering too anteriorly (which increases leak risk) or too posteriorly (which limits maneuverability and may lead to iris prolapse).

🟦 B. Main Incision – Temporal Clear Cornea (2.2 or 2.4 mm Keratome)

Instrument: 2.2 or 2.4 mm bevel-up single-use keratome
Recommended Location: Temporal

Steps:

Create a smooth three-plane incision:
1. Epithelial entry: Use the side or tip of the blade to score the epithelium just anterior to the limbus
2. Stromal tunnel (at least 2 mm long): Angle the tip of the blade upward, meaning the heel downward, and proceed into the stroma. Some keratomes have a horizontal mark on the front surface that can be used as a guide for the size of the stromal tunnel.
3. Full entry into the anterior chamber: Angle the tip downward toward the anterior capsule and enter the AC. During withdrawal of the keratome, be conscious not to enlarge the wound size. Withdraw in the exact path of entry.

Pearl:
Avoid intraoperative Descemet detachment by not forcing instruments through the main incision—instead, gently track the instrument along the tunnel edge, using well-constructed incisions and controlled entry/exit.

❌ Common Pitfalls to Avoid:

Overly short tunnel → wound leak
Ragged or shelved entry → unstable chamber
Long tunnel → poor access, poor visibility

🟦 C. Wong Incision (Hydration Pocket Technique)

Performed prior to the main incision

Purpose:

Enhance wound sealing by creating a small anterior stromal pocket — a hydration trap — that improves closure with minimal fluid.

Steps:

Before making the main incision, use the tip of your keratome (bevel-up).
Gently place the keratome just anterior to your intended main wound site, in the mid-peripheral clear cornea.
Create a small intrastromal nick or partial tunnel — 1–1.5 mm long, not full thickness.
Avoid entering the anterior chamber — stay within the stromal roof.
Proceed with your 2.2 or 2.4 mm main incision as usual, just posterior to the Wong nick.
At the end of surgery, hydrate this pocket instead of the main wound edge to seal.

Pearl:

This method allows for tighter wound sealing with less corneal edema or distortion at the visual axis. Especially useful in eyes with thin corneas or short tunnel architecture.

capsulorhexis with voiceover.mp4

Step 2: Creating a Continuous Curvilinear Capsulorhexis (CCC)

🎯 Purpose:

To create a strong, well-centered anterior capsule opening that enables safe nucleus removal, optimal IOL positioning, and long-term centration — all while maintaining capsular integrity.

🛠️ Instruments:

Cystotome (27G bent needle)
Utrata forceps

🟦 Step-by-Step Technique:

Stabilize the anterior chamber with an OVD (e.g., Healon or Viscoat).
Ensure a deep, stable chamber with good red reflex.
Optional: Stain the anterior capsule with trypan blue for improved visibility in dense or mature cataracts.
Puncture the center of the anterior capsule using a cystotome.
Create a small flap by teasing upward and sideways.
Grasp the flap with Utrata or continue with cystotome.
Begin tearing in a smooth curvilinear fashion, keeping the tear within the pupil margin.
Use subtle wrist rotation and forward motion to guide the tear in a circular path.
Aim for a 5–5.5 mm capsulorhexis, ideally centered on the visual axis or slightly nasal.
Complete the circle, gently overlapping the starting point.
Re-center with forceps as needed if drift occurs.

✅ Pearls for Success:

Keep the tear peripheral but visible — don’t chase too far out or it may run.
Maintain chamber stability; re-inject OVD if the chamber shallows.
In mature cataracts or poor visibility, use dye.
A well-sized, centered CCC is critical for safe hydrodissection and IOL centration.

⚠️ Common Pitfalls to Avoid:

Tear runs out to the periphery → Risk of posterior capsular rupture
Chamber collapse during CCC → Can lose control of the flap.
Oversized CCC → May compromise IOL stability or lead to optic capture

💬 Pro Tip:

For learners, marking the ideal rhexis size on the cornea (e.g., with calipers or a 5.5 mm ring or digital markers) helps develop consistency and control.

hydrodissection with voiceover.mp4

Step 3: Hydrodissection

🎯 Purpose:

To gently separate the lens cortex and epinucleus from the capsular bag, allowing free rotation of the nucleus and safe phacoemulsification.

🛠️ Instruments:

Hydrodissection cannula (blunt tip, 27G)
Balanced salt solution (BSS) in a 3 or 5 cc syringe

🟦 Step-by-Step Technique:

Insert a hydrodissection cannula through the main incision.
Advance the cannula under the capsulorhexis edge, aiming toward the equator of the lens at approximately 3 or 9 o’clock.
Inject a small, steady bolus of BSS.
Look for a fluid wave traveling beneath the nucleus toward the opposite side.
Wait for the wave to complete; do not inject too forcefully to avoid posterior capsule rupture or iris prolapse.
Gently depress the lens centrally with the cannula to check for mobility or rebound.
Optionally repeat at a second quadrant (e.g., 6 o'clock) if the nucleus is still stuck.

✅ Pearls for Success:

The goal is to free the cortex and nucleus, not inflate the bag.
In dense or brunescent lenses, ensure the wave travels fully across — incomplete waves risk capsular tears.

⚠️ Common Pitfalls to Avoid:

Injecting too forcefully → posterior capsular blowout
Too shallow cannula placement → fluid refluxes anteriorly, no dissection
No rotation → cortex still adherent, do not proceed to phaco

💬 Pro Tip:

If you don’t see a wave, don’t panic. Withdraw, re-inject in a different spot, and always check for rotation before proceeding to phaco.

phacocop voiceover.mp4

Step 4: Phaco Chop

🎯 Purpose:

To efficiently divide the nucleus into manageable fragments using controlled ultrasonic energy and a mechanical chopping maneuver — minimizing energy use, improving followability, and preserving corneal clarity.

🛠️ Instruments & Settings:

Phaco tip: 30° or 45°, bevel down
Chopper: Nagahara or straight vertical chopper
Settings (typical):
- Phaco power: 30–60% (depending on density)
- Vacuum: 400–450 mmHg
- Aspiration Flow Rate: 30–40 cc/min
- Torsional or Burst mode

🟦 Step-by-Step Technique:

Center the nucleus and fill the chamber with dispersive OVD if needed.
Embed the phaco tip into the central nucleus, using high vacuum and minimal ultrasound to hold firmly.
Introduce the chopper through the sideport and position it just beyond the phaco tip on the equator of the nucleus.
While maintaining occlusion, pull the chopper toward the phaco tip in a quick, deliberate motion — this creates a mechanical cleave through the nucleus.
Separate the two halves gently using a spreading or lateral motion.
Rotate the nucleus 90°, then repeat the chop to divide further into quadrants or sextants.
Continue emulsifying and removing each piece with minimal energy, using vacuum for followability.

✅ Pearls for Success:

Achieve firm occlusion before initiating the chop — this is critical.
Ensure the chopper is deep enough to engage the posterior plate — not just the surface.
Use minimal ultrasound once the nucleus is split; let the vacuum do the work.
Ideal in dense lenses, shallow ACs, and weak zonules where rotation is limited.

⚠️ Common Pitfalls to Avoid:

Poor tip occlusion → chop fails, phaco tip displaces
Superficial chop → partial split, nucleus stays intact
Overuse of energy → endothelial trauma, wound burn risk
Excessive pressure on zonules during chop

💬 Pro Tip:

Practice “power hold” — use vacuum to lock the nucleus, then chop cleanly.

i&A voiceover.mp4

Step 5: Cortex Removal – Irrigation & Aspiration (I&A)

🎯 Purpose:

To safely and thoroughly remove residual lens cortex from the capsular bag, creating a clean and clear environment for IOL implantation and reducing the risk of postoperative inflammation and posterior capsular opacification (PCO).

🛠️ Instruments & Settings:

I/A handpiece (bimanual or coaxial)
Vacuum: 350–450 mmHg
Aspiration Flow Rate: 25–35 cc/min
Bottle height or infusion pressure: Adequate to maintain anterior chamber stability

🟦 Step-by-Step Technique:

Insert the I/A handpiece through the main incision in coaxial mode or through two paracenteses in bimanual mode.
Begin with subincisional cortex, or more commonly, start opposite the incision for better visualization and chamber stability.
Engage the cortex near the capsular fornix, aspirate gently, and strip centrally using a circular sweeping motion.
Proceed clockwise or counterclockwise around the bag, aspirating quadrant by quadrant.
Carefully polish the anterior and posterior capsule — avoid polishing the capsule aggressively.
Irrigation keeps the chamber formed while aspiration removes cortex — maintain steady foot control to prevent chamber collapse or surge.
Once cortex is removed, withdraw slowly, maintaining irrigation to prevent chamber shallowing.
Use an irrigation cannula to power wash the capsule through the main incision.

✅ Pearls for Success:

Always keep the port facing cortex, not the posterior capsule.
Use low vacuum near the posterior capsule to avoid aspiration of the bag.

⚠️ Common Pitfalls to Avoid:

Sudden surge or collapse → posterior capsular rupture
Incomplete cortical cleanup → risk of PCO
Aspiration too close to the capsule → PC repture
Excessive rotation/torsion of handpiece → wound stretching or iris trauma

💬 Pro Tip:

Use a second instrument (spatula or manipulator) through the sideport to help break down dense residual epinucleous or cortex.

IOL voiceover.mp4

Step 6: Intraocular Lens (IOL) Insertion

🎯 Purpose:

To safely implant the intraocular lens into the capsular bag with precise positioning, ensuring long-term centration, stability, and optimal visual outcomes.

🛠️ Instruments & Materials:

Preloaded IOL injector system or manually loaded cartridge
Intraocular lens (single-piece or three-piece)
Viscoelastic (cohesive recommended for bag inflation)
Second instrument (e.g., Sinskey hook, manipulator)

🟦 Step-by-Step Technique:

Fill the capsular bag and anterior chamber with cohesive OVD (e.g., ProVisc, Healon) to maintain space and protect the corneal endothelium.
Prepare the IOL and injector system, ensuring correct orientation of the haptics and optic. Remove air bubbles from the cartridge tip.
Insert the injector nozzle through the main incision with care not to distort the wound. Advance bevel-down to the anterior chamber.
Inject the IOL slowly and in a controlled fashion, allowing the leading haptic to enter the bag smoothly, followed by the optic and trailing haptic.
Use a second instrument through the sideport to guide or dial the trailing haptic gently into the capsular bag.
Verify that both haptics are fully in the bag, optic is centered, and there’s no tilt.

✅ Pearls for Success:

Use a cohesive OVD for easy removal and clean IOL unfolding.
Angle the injector 45 degrees towards the center of capsule.
If using a wound-assisted technique, apply gentle counterpressure to prevent wound stretch.
Always verify IOL orientation — especially with toric lenses.

⚠️ Common Pitfalls to Avoid:

Incomplete delivery → trailing haptic remains in sulcus
Overloading OVD → capsular distension or difficulty removing viscoelastic
Rotating toric lenses before full unfolding → axis misalignment
Poor centration → optic capture or dysphotopsias postoperatively

💬 Pro Tip:

For toric IOLs, align to the pre-marked corneal axis only after full viscoelastic removal and final rotation. Always finalize centration with both haptics fully expanded.

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