Patient Management
Managing Hard Cataracts
An experienced surgeon shares what he's learned about this challenging surgery.
By Alan Aker, M.D., F.A.C.S., Boca Raton, Fla.

A number of years ago I gave a presentation titled "Challenging Cases for the Advanced Phaco Surgeon." I mentioned that it was important to approach these difficult cases with a sense of humility, and that I began each surgery with prayer to ask for God's help and guidance. Jim Gills was present; his appropriate comment was that the Bible teaches us that "pride goes before a fall." I'm sure that most experienced phaco surgeons would agree that a dark, brunescent cataract should be approached with respect and a sense of humility.

I've developed my own approach to removing this type of cataract over the past 20 years. Although my approach may not be unique, I believe it contains some pearls that could be helpful when you find yourself faced with a similar challenge.

With that in mind, here are some of the strategies I employ when dealing with a dark, brunescent cataract.

Preparing for surgery

First of all, knowing how difficult surgery on a given cataract might be -- and being honest about the level of your own abilities -- is extremely important. It's reckless to take on a challenge that's beyond your skill and training. (As always, our first guideline is to do no harm.)

Pre-op assessment of the challenge you face should be accomplished by carefully examining the patient, and asking the right questions, such as:

• What is the status of the patient's cornea?
• What is the integrity of the zonules?
• Is the patient monocular?
• Are there any indications of prior ocular surgery?
• If the fellow eye has had prior surgery, can you learn from that procedure or outcome?
• Does your examination show pseudoexfoliation or any phacodonesis?
• Have you found posterior synechiae or a peripheral iridectomy?
• Does the patient have any other medical conditions that might make the case more challenging, such as respiratory difficulties or back problems?
• Is the patient's mental status normal?

If the cataract density and pupil size preclude a view of the retina during routine pre-op evaluation, I'll obtain a B scan along with the IOL measurement. Before coming up with an operative plan, I also check the endothelial cell count, pachymetry and how well the pupil dilates.

Choosing the best technique

The most dramatic improvements in my approach to treating dense cataracts came from changing my phaco technique.

After several years of prolapsing the superior pole, I became a student of Howard Gimbel's "divide and conquer" technique. With this very controlled approach, I was able to safely remove even rock-hard cataracts. However, despite wonderful results (and being very comfortable with the technique), I eventually began to study David C. Brown's "phaco flip" technique.

The phaco flip technique allows much more rapid removal of even the most dense cataracts because the softer peripheral cataract is emulsified first. The extensive and time-consuming carving of a central crater is eliminated. As a result, the most dense, brunescent lens adds only a minute of additional phaco time, which represents a significant advance in this type of surgery. (In addition, I don't have to contend with sharp pie-shaped edges over the posterior capsule.)

Because of its safety and efficiency, phaco flip has become the technique I use for all cataracts, except extremely soft PSC cataracts.

In terms of making the incision, the temporal clear cornea approach has many obvious advantages. These include:

• a better red reflex
• no problems with a deep sulcus or prominent brow
• less positive vitreous pressure
• the ability to eliminate pooling of irrigating solution
• no ballooning of the conjunctiva from the irrigation solution.

For all of these reasons, I perform the procedure through a temporal clear corneal incision.

Managing other potential problems

Two issues that often further complicate surgery on a dense cataract are small pupil size and corneal health concerns.

Small pupils. Surgeons used to deal with this problem by using keyhole and sector iridectomies, as well as various types of manual stretching. (I used iris clips for several years.)

Today I routinely use the Beehler pupil dilator. This is a far more elegant way to manually stretch the pupil, and it usually produces an acceptable, roundish pupil post-op. If the pupil is only mildly dilated once the Beehler has been used, I use the viscoelastic to further dilate the pupil. (Occasionally, this type of stretching causes a flail iris; in such cases it's important to avoid engaging the iris with the phaco tip or incarcerating the iris in the clear corneal incision.)

Low endothelial cell counts. As I mentioned earlier, performing endothelial cell counts and pachymetry preoperatively is absolutely imperative because a cornea may appear clear and still have a low cell count. Surgery on a very dense cataract, even performed by very skilled surgeons, involves a longer phaco time and additional risk to the endothelium. I believe that an excessive amount of irrigation fluid (indicative of a prolonged procedure) can have a deleterious effect on the cornea, especially during the I/A procedure when the irrigation stream is aimed up at the endothelium.

If the cornea is compromised, as evidenced by low endothelial cell density or increased corneal thickness, I use Viscoat or Duovisc along with BSS+ to protect the cornea during the procedure. In patients with seriously compromised cell counts or increased corneal thickness, I use additional Viscoat during the phaco procedure, and sometimes during the I/A portion of the case as well.

Getting the patient on your side

Whenever I'm planning to perform surgery on a patient with diminished cell counts and a dense cataract, I discuss the situation with the patient at length. I believe it's very important to give the patient a clear understanding of the additional challenges posed by a dense cataract, by explaining the nature of the cataract and how it puts the cornea, posterior capsule and sometimes the iris at risk for injury during surgery. I also mention the possibility that the patient might need a penetrating keratoplasty in the future (with or without the cataract surgery).

Of course, it's important to say all of this in the right way. My goal is to let the patients know what I will face as a surgeon -- including all the precautions I'll be taking to ensure that the surgery will produce the good result they want. I try to explain all of this gently, so as to inform but not alarm the patient. (Needless to say, the surgery will become even more difficult if the patient is terrified.)

The nice thing about this type of approach, when it's done in the right way, is that the patient has a greater appreciation for an excellent result following successful surgery. And if some difficulty occurs during the procedure, the patient won't be as alarmed or jump to the conclusion that you haven't done your job correctly.

Doing our best

I hope this brief description of my strategies and technique will provide some useful pearls for those times when you find yourself dealing with a particularly tough cataract case. Shared experience -- along with a little humility and faith -- can do a lot to help produce the excellent results that you and your patient want.

Dr. Aker practices at the Aker Kasten Vision and Laser Center in Boca Raton, Fla.