Tilt and Tumble Phacoemulsification: Coaxial and Bimanual

Cataract Surgery, 3rd Edition

PART IV – Phacoemulsification

Chapter 18 – Tilt and Tumble Phacoemulsification: Coaxial and Bimanual

Elizabeth A. Davis, MD, FACS,
Dennis C. Lu, MD,
David R. Hardten, MD, FACS,
Richard L. Lindstrom, MD

Contents

	•	Indications
	•	Preoperative Preparation
	•	Operative Procedure
	•	Bimanual Technique
	•	Postoperative Care
	•	Conclusion

CHAPTER HIGHLIGHTS

	≫	Prolapsing the nucleus equator for ouside-in phaco
	≫	Hydrodissection method
	≫	Capsulorrhexis requirements
	≫	Coaxial and bimanual technique comparison

The technique of tilt and tumble is a modified form of supracapsular phacoemulsification. It uses a technique to tilt one pole of the nucleus above the anterior capsule. Phacoemulsification is then performed while supporting the lens in the iris plane with a nucleus rotator.

In the following paragraphs this procedure will be described and illustrated with both a coaxial and a bimanual technique.

Indications

The indications for the tilt and tumble phacoemulsification technique are quite broad. It can be utilized in either a large or small pupil situation. Some surgeons favor the technique with small pupils where the nucleus can be tilted up such that the equator is resting in the center of the pupil and is then carefully emulsified. It does require a larger continuous-tear, anterior capsulectomy of at least 5mm. If a small anterior capsulectomy is created, the hydrodissection step of tilting the nucleus can be dangerous, and it is possible to rupture the posterior capsule during the hydrodissection step. If, inadvertently, a small anterior capsulectomy is created, it is probably safest to convert to an endocapsular phacoemulsification technique or enlarge the capsulorrhexis. If it is not possible to tilt the nucleus with either hydrodissection or a manual technique, the surgeon should also convert to an endocapsular approach. Occasionally, the entire nucleus will subluxate into the anterior chamber. In this setting if the cornea is healthy, the anterior chamber deep, and the nucleus soft, then the phacoemulsification can be completed in the anterior chamber supporting the nucleus away from the corneal endothelium. The nucleus can also be pushed back inferiorly over the capsular bag to allow the iris plane tilt and tumble technique to be completed.

In patients with severely compromised endothelium, such as Fuchs' dystrophy or previous keratoplasty patients with a low endothelial cell count, endocapsular phacoemulsification is preferred to reduce endothelial cell loss. In a normal eye, corneal clarity on the first day postoperatively is excellent. Nevertheless, the tilting and tumbling maneuvers do increase the chance of endothelial cell contact of lens material compared to an endocapsular phacoemulsification. Therefore, the endocapsular technique should not be employed in eyes with borderline corneas or shallow anterior chambers.

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Preoperative preparation

The patient enters the anesthesia induction or preoperative area and Tetracaine drops are put in both eyes. The administration of these drops increases the patient's comfort during the placement of the multiple dilating and preoperative medications, decreases blepharospasm and also increases the corneal penetration of the drops to follow.

The eye is dilated with 2.5% neosynephrine and 1% cyclopentolate every 5 min for three doses. Additionally, preoperative topical antibiotic and anti-inflammatory drops are administered at the same time as the dilating drops. The authors favor the combination of a preoperative topical antibiotic, topical steroid and topical non-steroidal. The rationale for this is to pre-load the eye with antibiotic and non-steroidal prior to surgery. The pharmacology of these drugs and the pathophysiology of postoperative infection and inflammation support this approach. An eye that is pre-loaded with anti-inflammatories prior to the surgical insult is likely to have a much reduced postoperative inflammatory response. Both topical steroids and non-steroidals have been found to be synergistic in the reduction of postoperative inflammation. In addition, the use of perioperative antibiotics is supported in the literature as reducing the small chance of postoperative endophthalmitis. Since the patient will be sent home on the same drops utilized preoperatively, there is no additional cost.

Our usual anesthesia is topical tetracaine reinforced with intraoperative intracameral 1% non-preserved (methylparaben free) xylocaine. For patients with blepharospasm a “miniblock” O'Brien facial nerve anesthesia, utilizing 2% xylocaine with 150 units of hyaluronidase per 5cc of xylocaine, can be quite helpful in reducing squeezing. This block lasts 30–45 min and makes surgery easier for the patient and the surgeon. Patients are sedated prior to the block to eliminate any memory of discomfort. One way to determine when this facial nerve block might be useful is to ask the technicians to make a note in the chart when they have difficulty performing applanation pressures or A-scan because of blepharospasm. In these patients a mini facial nerve block can be quite helpful.

In younger anxious patients and in those with difficulty cooperating, the authors perform a peribulbar block. Naturally, general anesthesia is used for very uncooperative patients and children. While this is controversial, in some patients where general anesthesia is chosen and a significant bilateral cataract is present, the authors will perform consecutive bilateral surgery completely re-prepping and starting with fresh instruments for the second eye. Again, this is a clinical decision weighing the risk-to-benefit ratio of operating both eyes on the same day versus the risk of two general anesthetics.

Upon entering the surgical suite the patient table is centered on pre-placed marks so that it is appropriately placed for microscope, surgeon, scrub nurse and anesthetist access. The authors favor a wrist rest, and the patient's head is adjusted such that a ruler placed on the forehead and cheek will be parallel to the floor. The patient's head is stabilized with tape to the head board to reduce unexpected movements, particularly if the patient falls asleep during the procedure and suddenly awakens. A second drop of tetracaine is placed in each eye. If the tetracaine is placed in each eye, blepharospasm is reduced. A periocular prep with 5% povidone-iodine solution is completed. The ocular surface and fornices are not irrigated with povidone-iodine. Under topical anesthesia the authors have found that the patients note a significant burning. If a few drops leak into the eye this is certainly acceptable.

An aperture drape is helpful for topical anesthesia to increase comfort. It has been noted by the authors that when the drape is tucked under the lids this often irritates the patient's eye and also reduces the malleability of the lids, decreasing exposure. Since it is important to isolate the meibomian glands and lashes, a Tegaderm adhesive cut in half for the upper and lower lids may be used.

Balanced salt solution is used in all cases. For the short duration of a phacoemulsification case, BSS plus does not provide any clinically meaningful benefit. The authors place 0.5cc of the intracardiac non-preserved (sodium bisulfate free) epinephrine in the bottle for assistance in dilation and perhaps hemostasis. Heparin sulfate 1mL (1000 units) is also added to reduce the possibility of postoperative fibrin. This is also a good anti-inflammatory and coating agent. At this dose there is no risk of enhancing bleeding or reducing hemostasis.

The lids are separated with a Lindstrom/Chu aspirating speculum (Rhein Medical). A final drop of tetracaine is placed in the operative eye or the surface is irrigated with the non-preserved xylocaine. The authors do not like to utilize more than three drops of tetracaine or other topical anesthetic, as excess softening of the epithelium can occur, resulting in punctate epithelial keratitis, corneal erosion and delayed postoperative rehabilitation.

Operative procedure

The patient is asked to look down. The globe is supported with a dry Merocel sponge, and a counter puncture is performed superiorly at 12 o'clock with a diamond stab knife (Osher/Storz). The incision is about 1mm in length (Figure 18-1). Approximately 0.25mL of 1% non-preserved methylparaben free xylocaine is injected into the eye (Figure 18-2). The patient is advised that they will feel a “tingling” or “burning” for a second, and then “the eye will go numb.” This provides a psychological support for the patient that they will now have a totally anesthetized eye and should not anticipate any discomfort. The patient is told that while they will feel some touch and fluid on the eye, they will not feel anything sharp, and if they do, the anesthesia can be supplemented. This injection also firms up the eye for the clear corneal incision. The authors do not find it necessary to inject viscoelastic prior to constructing the corneal wound.



Figure 18-1 Counterpuncture site of 1mm is made with a diamond stab knife.



Figure 18-2 Preservative-free xylocaine is injected intracamerally.

A temporal or nasal anterior limbal or posterior clear corneal incision is performed. Care is taken not to incise the conjunctiva, as this can result in ballooning during phacoemulsification and irrigation aspiration. Some surgeons define this as being a posterior clear corneal incision and others as an anterior limbal incision. The anatomical landmark is the perilimbal capillary plexus and the insertion of the conjunctiva. Since the incision is into a vascular area, long-term wound healing can be expected to be stronger than it is with a true clear corneal incision. True clear corneal incisions, such as performed in radial keratotomy, clearly do not have the wound-healing capabilities that a limbal incision demonstrates where there are functioning blood vessels present.

The anterior chamber is then entered parallel to the iris at a depth of approximately 300μ. This creates a hinge type of incision (Figure 18-3).



Figure 18-3 A clear corneal incision is made temporally in right eyes and nasally in left eyes.

In right eyes the incision is temporal, and in left eyes, nasal. This allows the surgeon to sit in the same position for right and left eyes. The nasal cornea is thicker, has a higher endothelial cell count and allows very good access for phacoemulsification. The nasal limbus is approximately 0.3mm closer to the center of the cornea than the temporal limbus, and this can, in some cases where there is excess edema, reduce first-day postoperative vision more than one might anticipate with a temporal incision. There also can, in some patients, be pooling of irrigating fluid. For this reason, an aspirating speculum is useful. It is also helpful to tip the head slightly to the left side. Nonetheless, in left eyes a nasal clear corneal approach is an excellent option, particularly for surgeons who find the left temporal position uncomfortable.

In some patients it may be safest to create a corneal scleral incision. Examples of these include patients who have had a previous radial keratotomy or demonstrate findings of peripheral corneal ulcerative keratitis, in some patients with very low endothelial cell counts, and any case where there is any significant peripheral pathology or thinning. The anterior limbal or posterior corneal incision described above can be made temporally, nasally, in the oblique meridian or even superiorly without induction of significant corneal edema or endothelial cell loss.

The incision, if it is 3mm in length, tends to cause an induction of 0.25 ± 0.25diopters (D) of astigmatism. If the incision is placed on the steeper meridian, the astigmatism can, therefore, be expected to be reduced to somewhere between 0 and 0.50D. An incision in the 3mm range will almost always be self-sealing. With modern injector systems most foldable intraocular lenses can be implanted through a 3mm anterior limbal incision.

In select patients an intraoperative astigmatic keratotomy can be performed at the 7–8mm optical zone. This can be done at the beginning of the operation. The patient's astigmatism axis is marked carefully using an intraoperative surgical keratometer which allows one to delineate the steeper and flatter meridian and not be concerned about globe rotation. One 2mm incision at a 7–8mm optical zone will correct 1D of astigmatism and two 2mm incisions will correct 2D of astigmatism in a cataract-age patient. One 3mm incision will correct 2D, and two 3mm incisions 4D. One can combine a 3mm and a 2mm incision to correct 3D. Larger amounts of astigmatism can also be corrected utilizing the Arc-T nomogram. Depending on the age of the patient one can correct up to 8D of astigmatism with two 90° arcs. Many surgeons have moved to a more peripheral corneal limbal arcuate incision, but the authors favor the 7–8mm optical zone because of years of experience with this approach. There certainly is a variation in response, but there have not been any significant, induced complications with this approach. The outcome goal is 1D or less of astigmatism in the preoperative axis. It is preferable to under-correct rather than over-correct. The key in astigmatism surgery is “axis, axis, axis.” If one is not careful in preoperative planning and the incision is placed more than 15° off axis, one is better avoiding this approach.

The anterior chamber is constituted with a viscoelastic. Studies carried out by the authors have not found any significant difference between one viscoelastic or another in regards to postoperative endothelial cell counts. Amvisc Plus works well and 0.8 cc can be obtained at a very fair price.

Next a relatively large diameter continuous tear anterior capsulectomy is fashioned (Figures 18-4 and 18-5). This can be made with a cystatome or forceps. The optimal size is 5–6mm in diameter and inside the insertion of the zonules (usually at 7mm). Larger is better than smaller, as there is less subcapsular epithelium and thus lower risk of capsular opacification. Additionally, a larger capsulorrhexis makes for an easier cataract operation. With this technique there has not been any change in the incidence of intraocular lens decentration. With some intraocular lenses the capsule will seal down to the posterior capsule around the loops rather than be symmetrically placed over the anterior surface of the intraocular lens. These eyes do extremely well and this might be preferable to having the capsule anterior to the optic. This is also certainly a controversial position.



Figure 18-4 A continuous curvilinear capsulotomy is made with a cystatome.



Figure 18-5 The capsulotomy is optimally 5–6mm in diameter.

Hydrodissection is then performed utilizing a Pearce hydrodissection cannula on a 3 cc syringe filled with BSS. Slow continuous hydrodissection is performed gently lifting the anterior capsular rim until a fluid wave is seen. At this point irrigation is continued until the nucleus tilts on one side, up and out of the capsular bag (Figure 18-6). If one retracts the capsule at approximately the 7:30 o'clock position with the hydrodissection cannula, usually the nucleus will tilt superiorly. If it tilts in another position, it is simply rotated until it is facing the incision (Figure 18-7).



Figure 18-6 Continuous slow hydrodissection leads to tilting of the nucleus out of the bag.



Figure 18-7 The nucleus is rotated to face the incision.

Once the nucleus it tilted some additional viscoelastic can be injected under the nucleus pushing the iris and capsule back. Also, additional viscoelastic can be placed over the nuclear edge to protect the endothelium. The nucleus is emulsified from outside–in while supporting the nucleus in the iris plane with a second instrument, such as a Rhein Medical, Storz Lindstrom Star or Lindstrom Trident nucleus rotator (Figure 18-8). Once half the nucleus is removed, the remaining one half is tumbled upside-down and approached from the opposite pole (Figure 18-9). Again, it is supported in the iris plane until the emulsification is completed (Figure 18-10). Alternatively, the nucleus can be rotated and emulsified from the outside edge in a carousel or cartwheel type of technique. Finally, in some cases, the nucleus can be continuously emulsified in the iris plane if there is good followability until the entire nucleus is gone.



Figure 18-8 The nucleus is supported during phacoemulsification with a second instrument.



Figure 18-9 The second half of the nucleus is tumbled upside down.



Figure 18-10 Emulsification is completed in the iris plane.

This is a very fast and very safe technique and, as mentioned before, it is a modification of the iris plane technique taught by Richard Kratz in the late 1970s and 1980s. It is basically “back to Kratz” with help from Brown and Maloney in the modern phacoemulsification, capsulorrhexis, hydrodissection and viscoelastic era. Surgery times now range between 4 and 7 min with this approach rather than 10–15 min for endocapsular phacoemulsification. In addition, the capsular tear rate has now gone under 1%. Therefore, the authors find this technique to be easier, faster and safer. It is true that in this technique the phacoemulsification tip is closer to the iris margin and also somewhat closer to the corneal endothelium. There is, however, a significantly greater margin of error in regards to the posterior capsule. Care needs to be taken to position the nucleus away from the corneal endothelium and away from the iris margin when utilizing this approach.

If the nucleus does not tilt with simple hydrodissection, it can be tilted with viscoelastic or a second instrument such as a nuclear rotator, Graether collar button or hydrodissection cannula.

The dual function Bausch & Lomb Millennium™ is excellent for all cataract techniques including “tilt and tumble.” The vacuum is set with a range of 325–400mm Hg and the ultrasound power set in a pulse mode from 10% to 30%. The foot pedal is arranged such that there is surgeon control over ultrasound on the vertical or pitch motion of the foot pedal, and then on the yaw or right motion foot pedal, there will be vacuum control. This allows very efficient emulsification, and the Millennium ™ is currently the authors' preferred machine. The microflow plus needle with a 30° angle tip works well with the Millenium.

Following completion of nuclear removal, the cortex is removed with the irrigation aspiration hand piece. The authors prefer a 0.3mm tip and utilize the universal hand piece with interchangeable tips. A curvilinear tip is used for most cortex removal. Sub-incisional cortex can be aspirated with a Lindstrom right angle sand blasted tip currently manufactured by Rhein and Storz (Figure 18-11). If there is significant debris or plaque on the posterior capsule, one can attempt some polishing and vacuum cleaning but not so aggressively as to risk capsular tears.



Figure 18-11 Subincisional cortex is removed with a right angled tip.

The anterior chamber is reconstituted with viscoelastic and the intraocular lens is inserted utilizing an injector system (Figures 18-12 and 18-13).



Figure 18-12 The intraocular lens is inserted with an injector system.



Figure 18-13 The lens is centered in the capsular bag.

Excess viscoelastic is removed with irrigation aspiration. Pushing back on the intraocular lens and slowly turning the irrigation aspiration to the right and left two or three times allows a fairly complete removal of viscoelastic under the intraocular lens.

The authors favor injection of a miotic and tend to prefer carbachol over miochol at this time, as it is more effective in reducing postoperative intraocular tension spikes and has a longer duration of action. It is best to dilute the carbachol 5:1, or one can obtain an excessively small pupil which results in dark vision for the patient at night for 1–2 days. The anterior chamber is then refilled through the counter-puncture and the incision is inspected. If the chamber remains well constituted and there is no spontaneous leak from the incision, wound hydration is not necessary. If there is some shallowing in the anterior chamber and a spontaneous leak, wound hydration is performed by injecting BSS peripherally into the incision and hydrating it to push the edges together. We suspect that within a few minutes these clear corneal or posterior limbal incisions seal, much as a LASIK flap will stick down, through the negative swelling pressure of the cornea and capillary action. It is important to leave the eye slightly firm at 20mm Hg or so to reduce the side effects of hypotony and also help the internal valve incision appropriately seal.

At completion of the procedure another drop of antibiotic, steroid and non-steroidal is placed on the eye. Additionally, one drop of an anti-hypertensive such as Betagan or Alphagan is applied to reduce postoperative intraocular tension spikes.

Bimanual technique

Recently, the concept of bimanual sleeveless phacoemulsification, which has been promoted by Amar Agarwal, has led to the development of sub-1mm incision phacoemulsification.^[1] New skills must be learned and several alterations in the technique must be made when incorporating the technique (tilt and tumble or any other) to bimanual sleeveless microphacoemulsification:

	1.	Three 1mm stab incisions are made to allow for the sleeveless phaco probe, the irrigating second instrument, and the anterior chamber maintainer.
	2.	It is because the smaller incision cannot accommodate current capsulorrhexis forceps, that the authors prefer the use of a cystotome to perform the capsulorrhexis. New designs for microincision capsulorrhexis forceps have recently been developed, but typically require a steeper learning curve.
	3.	The instruments will behave as if they are “oar-locked” by the small incisions and, thus, the surgeon must adapt to the reduced mobility of the instrument.^[2]
	4.	Probably the skill that is most foreign to ophthalmologists is learning how to use the irrigating second instrument and learning how to use irrigation itself as a tool.^[3] It is because the irrigation is no longer coaxial with the phaco probe, that it may be used to drive material towards the phaco tip rather than away from the tip as in coaxial irrigation sleeves. Other novel uses of the irrigating second instrument include using the irrigation to flip the epinucleus, as Fine has described.^[3] In addition, the irrigation may be used to drive the iris away from the phaco tip as in pseudoexfoliation cases with small pupils.
	5.	Microphacoemulsification is a truly bimanual procedure where the instruments may be interchanged between any of the incisions. For example, removal of subincisional cortex may be accomplished by interchanging the irrigating and aspirating handpieces in order to obtain better access to the cortical material. Similarly, interchanging the phaco probe and the irrigating second instrument may be necessary in certain situations, such as in the cases of zonular dialysis where traction may be relieved doing this maneuver. Consequently, right-handed surgeons must learn how to phaco with the left hand and left-handed surgeons must learn how to phaco with the right hand.

Operative procedure

The preoperative preparation is no different when adapting the tilt and tumble technique to a bimanual sleeveless microphacoemulsification technique. A counterpuncture is performed superiorly at 12 o'clock with a diamond stab knife. Preservative-free lidocaine is injected into the eye. Two additional stab incisions of approximately 1mm in width are created in clear cornea for insertion of the phaco probe and the anterior chamber maintainer (Figure 18-14). The stab incision for the anterior chamber maintainer is placed inferiorly at 6 o'clock. For the phaco probe, we perform a temporal (2 o'clock) or nasal (10 o'clock) anterior limbal or posterior clear corneal incision in a direction that is paralleled to the iris plane. The direction of this incision prevents an excessively long tunnel and thereby minimizes “oar-locking,” but is shelved enough to be self-sealing.^[3] Incision size is critical in bimanual phacoemulsification, as a too large incision compromises anterior chamber stability while a too small incision causes oar-locking of the instruments. Care must be taken not to incise the conjunctiva as this can result in ballooning during the procedure. Some surgeons define this as being a posterior clear corneal incision and others as an anterior limbal incision. The anatomical landmark is the perilimbal capillary plexus and the insertion of the conjunctiva. When the incision is made, there will be a small amount of capillary bleeding. Since the incision is into a vascular area, long-term wound healing can be expected to be stronger than it is with a true clear corneal incision. The anterior chamber is then constituted with viscoelastic. A dispersive viscoelastic may provide protection to the endothelium. Ocucoat (Bausch & Lomb, Miami, FL) has proved to be an excellent viscoelastic and can also be utilized to coat the epithelial surface during surgery. This eliminates the need for continuous irrigation with BSS. It gives a very clear view. It is also economically a good choice in most settings. Amvisc Plus also works well.



Figure 18-14 Three port microemulsification. The nucleus is supported during phacoemulsification with a second instrument.

As in coaxial tilt and tumble, a relatively large-diameter, continuous-tear, anterior capsulectomy is fashioned. It is because the 1mm incision cannot accommodate comfortably traditional capsulorrhexis forceps, that the capsulorrhexis may be completed with a cystotome or a bent needle.^[3] Alternatively, the surgeon may learn how to use the newer forceps specifically designed for microincision phacoemulsification.

Hydrodissection is then performed as described above in the coaxial technique. During the hydrodissection, the posterior lip of the wound is depressed in order to prevent the anterior chamber from becoming too deep, which may cause excessive stress on the zonules or disrupt the posterior capsule. However, with the small incisions of microphacoemulsification, depression of the posterior lip may not be as easy.

The anterior chamber maintainer is then inserted through the inferior paracentesis. The authors prefer to use an anterior chamber maintainer designed with screw-type threads on the infusion tip in order to secure the device within the paracentesis.

A deep anterior chamber is paramount in the tilt and tumble technique. Thus, it is preferable to use an anterior chamber maintainer inserted through a third port, as it provides superior chamber stability over two port techniques that rely solely on the irrigation from current 20-gauge irrigating second instruments. The nucleus is then emulsified from outside–in while supporting the nucleus in the iris plane with an irrigating second instrument, such as a nucleus rotator.

When utilizing a peristaltic machine, a high flow rate is used, which enhances followability. It is best to set the bottle high in order to maintain a deep anterior chamber, particularly if one chooses to undertake bimanual sleeveless phacoemulsification without an anterior chamber maintainer.

The Storz Millennium™, which features Concentrix™ that provides both flow (as in peristaltic pumps) and vacuum (as with a venture pump) response, has the dual linear system that is excellent for all cataract techniques including “tilt and tumble,” as it permits simultaneous linear control of ultrasound and vacuum or flow. The authors set the maximum vacuum in the range of 250–300mm Hg, with the bottle height between 120 cm and 130 cm, which facilitates maintenance of a deep anterior chamber. The maximum ultrasound power is typically set at 60%, with average use of 11–15%, depending upon the density of the cataract. As with standard phaco, performing the microphacoemulsification technique (sleeveless phaco tip), we take care to avoid the use of excessive ultrasound power in order to prevent wound burn. In addition, caution must be exercised with higher vacuum levels as it is possible to core through the nucleus and aspirate the iris margin if very high vacuums are utilized.

Following completion of nuclear removal, the cortex is removed with bimanual irrigation and aspiration. In the absence of an anterior chamber maintainer, the irrigating second instrument may provide irrigation through the paracentesis port while the aspiration device is inserted through the main incision. However, in the presence of an anterior chamber maintainer, irrigation from the second instrument is not necessary (Figure 18-15). Cortical and epinuclear removal is then performed in the usual manner. For subincisional cortical material, the irrigation and aspirating devices may be interchanged through their respective incisions in order to gain better access. If there is significant debris or plaque on the posterior capsule, one can attempt some polishing and vacuum cleaning but not so aggressively as to risk capsular tears. Often there is an unexpected small burr of sharp defect on the irrigation–aspiration tip, which results in a capsular tear following a surgery that otherwise went well.



Figure 18-15 Subincisional cortex is removed with the aspiration hand piece. Irrigation is provided by the anterior chamber maintainer.

Although intraocular lenses (IOLs) that can be inserted through small incisions are under development, current IOLs cannot take advantage of microincision surgery. Thus, one of the stab incisions must be enlarged to allow for insertion of the IOL. Alternatively, a new incision may be created, which ensures a well-constructed, self-sealing incision that has not been previously stretched by oar-locked instruments.^[1] After the capsular bag is reconstituted with viscoelastic, the intraocular lens is inserted utilizing an injector system. The remainder of the surgery is completed as above for the coaxial technique.

Postoperative care

No patch is routinely utilized for the topical and intracameral approach. If a mini-block of the lids has been performed, this will wear off in 30–45 min, and there is usually adequate lid function for a normal blink at the completion of the procedure. Patients are advised that they will have some erythropsia, meaning they will see a pink after-image for the rest of the day, but usually this will resolve by the next morning. They are also told that their vision may be a little dark at night from the miotic, and not to be concerned if they wake up at night and their vision seems dimmer.

The patient is seen on the first day postoperative and then at approximately 2–3 weeks postoperatively. At this time a refraction, slit lamp, and funduscopic examination is performed. If there is no inflammation, patients are seen again 1 year postoperatively. If at 3 weeks there is still persistent inflammation, additional postoperative anti-inflammatory medications are recommended, and the patient is asked to return again in 2–3 months.

Topical antibiotic, steroid and non-steroidal, are utilized twice a day, usually requiring a 5 cc bottle and 3–4 weeks of therapy. Occasionally a second bottle of steroid and non-steroidal antibiotic is necessary if flare and cell persist at the 3-week examination. There are minimal restrictions, including a request that there be no swimming and no very heavy lifting for 2 weeks. The authors consider the ideal postoperative refractive spherical equivalent for a monofocal lens to be -0.62 D with less than 0.50 D of astigmatism in the same axis as existed preoperatively. Most patients can see 20/30+ and J3+ with this type of correction. Monovision can be utilized in the appropriate settings. Good results can also be obtained with an accommodating or multifocal IOL.

The second eye is done at ≥2 weeks postoperatively, except in rare situations. Any YAG lasers are deferred for 90 days in order to allow the blood–aqueous barrier to become intact and capsular fixation to be firm.

Conclusion

The authors hope that other surgeons will find this approach to cataract surgery useful. These techniques must be personalized, and every surgeon will find that slight variations in the technique are required to achieve the optimum results for their own patients in their own environment. Continuous efforts at incremental improvement result in meaningful advances in the surgeon's ability to help the cataract patient obtain rapid, safe, visual recovery following surgery.

References

[1]. Agarwal A., Agarwal S., Narang P., Narang S.: Phakonit: phacoemulsification through a 0.9mm corneal incision. J Cataract Refract Surg 2001; 27:1548-1552.

[2]. Ronge L.: Step-by-step guide to micro phaco. EyeNet 2004; 8:23-26.

[3]. Ifft D.: Bimanual microincision phaco. Ophthalmology Management 2003.45-56.November

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Contents

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Cataract Surgery, 3rd Edition

PART IV – Phacoemulsification Chapter 18 – Tilt and Tumble Phacoemulsification: Coaxial and Bimanual

PART IV – Phacoemulsification

Chapter 18 – Tilt and Tumble Phacoemulsification: Coaxial and Bimanual