LEO Clinical Topic Update

Cataract

Richard Tipperman, MD
Wills Eye Hospital
Medical College of Pennsylvania
Philadelphia, Pennsylvania

This Clinical Topic Update was reviewed by the

American Society of Cataract and Refractive Surgery

Thomas J. Liesegang, MD
Senior Secretary for
Clinical Education
Gregory L. Skuta, MD
Secretary for
Continuing Education
LEO Committee
Stephen C. Pflugfelder, MD
Chair
Jane C. Edmond, MD
Tamara Fountain, MD
David T. Jones, MD, PhD
Judy E. Kim, MD,
H. Michael Lambert, MD
Gary S. Schwartz, MD
Academy Clinical Education Staff
Kathryn A. Hecht, EdD
Vice President
William M. Hering, PhD
Director of Programs
Judith Revord
LEO Program Manager
Ellen Khalifa
Electronic Media Manager
Hal Straus
Director of Publications
Ruth Modric
Production Manager
Justin Ross
Publications Assistant
Copyeditor
Jeff Van Bueren
Cataract
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Copyright © 2001 The American Academy of Ophthalmology.
All rights reserved.
2
Contents
Introduction 5

Advances in Clinical Diagnosis 5

Measurement of Visual Function 5

Biometry/Keratometry 6

Intraocular Lens Power Calculations 6

Advances in Medical Management 7

Anesthesia 7

Postoperative Medication 8

Advances in Surgical Technique 8

Capsulorrhexis 8

Phacoemulsification Technique 8

Machine Design 9

Incision Construction 10

Management of Astigmatism in the Cataract Patient 10

Advances in Intraocular Lenses 10

Foldable Intraocular Lenses 10

Other Advances 11

Management of Complications 12

Dislocated Nuclear Fragments 12

Thermal Burn 12

Posterior Capsule Tears and Anterior Vitrectomy 13

Endophthalmitis 14

Cataract 3
 Intraocular Lens Problems 15

Special Situations 15

Patients with Diabetes 15

Patients with Small Pupils 15

Patients with Pseudoexfoliation 16

Patients Who Have Undergone Radial Keratotomy (RK) 16

Patients with Silicone Oil 17

Important Clinical Trials 17

References 18

Related Academy Materials 24

Cataract 4
Introduction

P hacoemulsification has become the predominant technique for cataract

extraction; this has occurred because of advances in small-incision surgery,
which include improved wound construction, foldable intraocular lens design,
and improved anesthetic techniques. This Clinical Topic Update is designed to
review these advances and to discuss other major issues for cataract surgery in
general.

Advances in Clinical Diagnosis

Measurement of Visual Function

A lthough measurement of Snellen visual acuity has traditionally been the

basis for evaluation of visual ability, there are many patients with excellent
Snellen acuity who have significantly compromised visual function. Increasingly,
patients are being evaluated with glare testing, contrast sensitivity function
testing, and standardized questionnaires in an attempt to document their visual
difficulties.
Decreased visual function secondary to glare is a common symptom of
patients with cataracts. Often the patient’s visual dysfunction in bright situations
is much worse than the visual acuity observed in more forgiving lighting
situations, such as a darkened examination lane. Glare disability can be measured
by a variety of techniques, including formal equipment such as a Brightness
Acuity Tester or informally simply by measuring Snellen visual acuity with and
without direct lighting. It is important to evaluate and document the patient’s
symptoms of decreased visual function as a result of glare, in order to assess their
potential reversibility with cataract surgery.1−3
Contrast sensitivity is also used to assess the visual function of patients with
cataracts. Contrast sensitivity measures the patient’s visual function in day-to-day
activities by assessing the ability to perceive a variety of coarse, intermediate, or
fine details presented at differing levels of contrast to the background
illumination. Glare testing can be combined with contrast sensitivity testing to
further evaluate visual function.4
In addition to these objective measurements, the patient’s visual difficulties
can be measured subjectively using standardized questionnaires.5,6 These
questionnaires attempt to evaluate real-life visual function by reviewing day-to-
day activities such as driving, reading, and writing. The questionnaires are
helpful not only for evaluating patients prior to cataract surgery but can be
helpful in evaluating postoperative outcomes as well.
In addition, outcomes measurement is being used to evaluate the results of
cataract surgery.7−11 Not only can data be acquired regarding
intraoperative/postoperative complications and final visual acuity but also
changes in quality of life as a result of surgery can be measured. These studies
have shown significant improvements in overall quality of life following cataract
surgery in the first eye and an even more significant improvement when surgery
in the second eye is completed.

Cataract 5
Biometry/Keratometry

In most cataract patients, standard keratometry is used to measure corneal

curvature. In some cases, however, videokeratography may be more helpful,
especially for a patient with poor mires on standard keratometry.
Videokeratography can reveal irregular astigmatism that is not otherwise
observable clinically.
In most instances, the patient’s axial length measurements and keratometry
readings correlate with the patient’s clinical presentation.12 Axial length
measurements greater than 25 mm or less than 22 mm are uncommon as are
keratometry measurements greater than 47 diopters or less than 40 diopters. In
the majority of patients, the difference in axial length between the two eyes will
be less than 0.3 mm.
Axial length is measured using a-scan ultrasonography. Recently, a
noncontact technique has been developed that uses laser interferometry to
measure axial length.13 This technique may prove advantageous in a highly
myopic patient with a staphyloma, because the a-scan will just measure the
maximum axial length while the optical measurement will measure the distance
to the fovea.

Intraocular Lens Power Calculations

The early IOL power calculation formulas were mainly linear regression
formulas derived from clinical data. Modern IOL power formulas are derived
from both clinical and theoretical optics. Such formulas include the Holladay
formula, the Hoffer-Q formula, and the SRK/T formula.14−16 These modern
theoretical formulas are more accurate than the linear regression formulas,
especially for highly myopic or hyperopic eyes or when a non-emmetropic
postoperative result is desired.
Each theoretical formula uses a variableA-constant, surgeon factor, or
anterior chamber depththat relates to the position of the IOL within the
posterior chamber. This variable will differ with different-style IOLs and also
with different surgical techniques for cataract removal and IOL implantation.
Surgeons can customize their own A-constant by reviewing approximately 20
cataract procedures performed with a specific IOL. The actual postoperative
refraction can be compared with the anticipated refraction and a new A-constant
can be derived.12
The surgeon should remember that placing the IOL in the sulcus rather than
in the capsular bag will move the optic of the IOL more anteriorly and thus will
require a reduction in the strength of the IOL. Depending on the A-constant of
the specific IOL, the IOL power may need to be decreased by an amount varying
between 0.5 and 1.5 diopters.17,18 The Holladay Consultant program uses a
variable “effective lens position” (ELP) to help improve the accuracy of these
calculations.

Intraocular Lens Power Calculations Following Refractive Surgery.

Refractive surgical techniques for myopia work by flattening the central cornea
and creating an aspheric area in the peripheral cornea. Standard keratometry
measurements evaluate an annular zone, the diameter of which varies according
to corneal curvature; in general, these measurements tend to underestimate

Cataract 6
 corneal power in patients who have undergone a refractive procedure. Two
separate approaches have been developed to allow for accurate IOL power
calculations in patients who have undergone incisional keratorefractive
procedures.19,20
The first approach may be used if the patient’s K readings prior to refractive
surgery are known. The overall spherical change in the patient’s refraction (at the
corneal plane) following refractive surgery can be subtracted from the patient’s
presurgical K readings to yield calculated K readings. The calculated K readings
can then be used in standard IOL power calculations to derive the appropriate
IOL power.
In the second approach, a rigid contact lens is used to calculate the power of
the corneal curvature. Initially, a manifest refraction is performed for the patient.
A plano hard contact lens of known base curvature is then placed on the patient’s
eye and the refraction is repeated. If the refraction does not change, the central
corneal curvature is equal to the base curve of the contact lens. If there is a
change in the overrefraction, the difference between the overrefraction and the
initial refraction is added to the base curve of the contact lens to derive the
central corneal power. If a plano contact lens is not available, the refractive
power of the contact lens used should be subtracted from the overrefraction. This
technique may be difficult to use because it may be hard to obtain an accurate
endpoint for the refraction if the patient has a significant cataract.
In patients who have undergone refractive surgery, it can be difficult to
determine appropriate keratometry values to utilize for IOL power calculations.
This difficulty occurs because the standard keratometry measurements
traditionally used are usually no longer an accurate measurement of the refractive
power of the cornea. A variety of techniques exist for determining the “new”
keratometry values that can be used for IOL power calculations. These
techniques and a comprehensive summary of this topic are covered thoroughly in
a current Academy Focal Points module.21

Advances in Medical Management

Anesthesia

T opical and intracameral anesthesia have become increasingly popular for

small-incision cataract surgery.22−24 These techniques can be used with both
scleral tunnel incisions and clear corneal incisions. Advantages of these
techniques include the avoidance of the complications of orbital injections;
increased safety for patients on anticoagulants; the ability of the patient to assist
the surgeon by moving the eye in a direction requested by the surgeon; and
immediate recovery of vision for a monocular patient. Potential disadvantages
include lack of globe akinesia (producing ocular movement at unwanted times)
and inadequate anesthesia for difficult or complicated cases.
Topical anesthetics can be administered in drop form prior to the initiation of
surgery. In addition, 2% lidocaine jelly may be administered to the eye prior to
surgery as well.25 With intracameral anesthesia, preservative-free 1% lidocaine is
instilled into the anterior chamber through a paracentesis incision. No statistically
significant reduction in endothelial cell count has been reported with this
technique.

Cataract 7
Postoperative Medication

Postoperative medications for cataract patients have typically included antibiotics

and corticosteroids. The nonsteroidal anti-inflammatory medications diclofenac
and ketorolac have also been found to be effective anti-inflammatory agents for
postcataract inflammation.26,27 These anti-inflammatory agents (as well as
corticosteroids) may also be used preoperatively in patients at high risk for
inflammation. Ketorolac is available in a preservative-free form for highly
sensitive patients.
Several newer ophthalmic corticosteroids (rimexolone and loteprednol) are
also available for postoperative use.28−30 In patients with a propensity for
corticosteroid-induced IOP elevations, the tendency of these agents to elevate
intraocular pressure has been shown to be similar to that of fluorometholone.

Advances in Surgical Technique

Capsulorrhexis

A continuous curvilinear capsulorrhexis has many potential benefits compared

with a multiple-tear or “can opener” capsulotomy opening.31 These benefits
include (1) the capability for nucleus manipulation without the fear of causing
posterior extension of a radial tear in the anterior capsule; (2) a smooth,
continuous capsular edge, which avoids the flaps and tags associated with a can
opener capsulotomy that can interfere with aspiration of peripheral cortex; (3)
less tractional force exerted on the zonules; (4) improved centration of the IOL
when it is placed within the capsular bag; and (5) in cases where posterior rupture
occurs, the intact anterior capsular ring can be used to support a sulcus-fixated
posterior chamber IOL.

Capsular Staining. The technique of capsular staining has revolutionized the

performance of capsulorrhexis with mature cataracts and in other instances where
visualization of the anterior capsule is limited. By staining the capsule with a
vital dye, the capsule becomes easily visible against the nucleus proper.32−34
Indocyanine green (ICG) works extremely well as a capsular dye and is nontoxic
when mixed in appropriate dilution. To reconstitute the dye, 0.5 cc of the
supplied diluent is added to the ICG powder and then 4.5 cc of balanced salt
solution is added. The solution should be shaken vigorously to make all the
powder go into solution. Only a small quantity of ICG (usually less than 0.3 cc)
is needed to stain the anterior capsule. Trypan blue has also been used for
capsular staining and has the advantage of coming premixed in small aliquots.
(Unfortunately, however, trypan blue is considered by the FDA to be a
pharmaceutical agent and is not approved for use in the United States.)

Phacoemulsification Technique

Many modern surgical techniques for cataract removal share a similar strategy in
that they accomplish removal of the nucleus by using natural cleavage planes
within the nucleus to mechanically divide the lens into multiple pieces.35,36 Once
the lens is divided into small fragments, the individual pieces can often be

Cataract 8
 removed by means of high vacuum rather than by high phacoemulsification
energy.
The best known of these techniques have been described as “divide and
conquer,” “phaco-chop,” and “stop-and-chop.” Although there are numerous
variations, the basic concepts remain the same. In classic divide-and-conquer
technique, two deep intersecting grooves are sculpted at right angles to each
other to form a cross. The phacoemulsification needle tip and a second
instrument are placed at the base of each groove and an outward pressure against
the walls of the groove is applied to split the lens. (Alternatively, there are many
“nucleus cracking” instruments that can be placed in the groove to accomplish
the same task.)
In “chopping” techniques, the phacoemulsification needle is purposely buried
into the lens proper, and a second instrument that can pierce the lens is then
inserted into the lens near the needle tip. A fracture plane is then created as the
two instruments are brought toward each other.
In the presence of a single radial tear, divide and conquer can be performed if
the forces are directed appropriately. It is possible for a radial tear in the anterior
capsule to extend posteriorly, with subsequent vitreous prolapse and possible
nucleus dislocation.
In another technique, termed “phaco flip,” the nucleus is hydrodissected and
prolapsed out of the capsular bag. As the nucleus is being prolapsed it is also
flipped over so that the posterior surface of the lens is now anterior. (The surgeon
must ensure that the capsulorrhexis opening is large enough to allow for prolapse
of the nucleus.) The lens is then positioned in the sulcus region in the anterior
chamber and phacoemulsification is begun.

Machine Design

Early phacoemulsification techniques relied very heavily on machine power or

energy to achieve removal of the cataractous lens. Newer phacoemulsification
techniques place a much greater emphasis on vacuum for nucleus removal. High
levels of vacuum allow nuclear fragments to be removed with only minimal use
of phacoemulsification energy.
However, when high levels of vacuum are used there is the potential for large
shifts in the fluid dynamics of the anterior chamber. These shifts can cause
transient collapse of the corneal dome, nuclear fragments to hit the endothelium,
or the posterior capsule to become engaged by the phacoemulsification needle.
As a result, stability of the anterior chamber is essential for phacoemulsification
to be performed safely.
Depending on the type of phacoemulsification machine used, the surgeon
will be able to control the stability of the anterior chamber by varying such
machine parameters as vacuum, infusion, aspiration flow rate,
phacoemulsification energy, and the relationship of the incision and paracentesis
size to the diameter of the surgical instruments. The interrelation of these and
other variables will depend mostly on the type of pumping systemperistaltic,
rotary vane, venturi, or concentric scrollused by a particular machine.37 It is
essential that the surgeon understand the interaction of these parameters in the
particular machine being used in order to achieve maximum anterior chamber
stability during surgery.

Cataract 9
Incision Construction

Clear corneal surgery through a temporal approach has become increasingly

popular through the 1990s. Advantages of this technique include reduced
astigmatic effect (especially with against-the-rule astigmatism), improved
accessibility to the surgical incision, improved red reflex, and better drainage of
irrigating fluid from the surgical field.38−41 A variety of techniques have been
described for the creation of these incisions. The incision may be located within
true clear cornea or at the posterior limbus (“near-clear” incision).

Management of Astigmatism in the Cataract Patient

By manipulating the size, location, and configuration of the cataract incision, the
patient’s pre-existing astigmatism can be reduced.42,43 Shorter or more posterior
incisions tend to induce less astigmatism; longer or more anterior incisions tend
to induce more astigmatism.
In the past, large-incision cataract surgery through a superior limbal approach
tended to result in a long-term against-the-rule increase in astigmatism. However,
as incision size has become progressively smaller, the actual cataract incision has
begun to exert less and less of an effect on patients’ underlying astigmatism.
Additionally, temporal incisions do not seem to promote an increase in the
tendency toward against-the-rule astigmatism.
A patient’s intrinsic astigmatism can still be modified with small-incision
cataract surgery through the use of either limbal relaxing incisions or astigmatic
keratotomy.44,45 These incisions can be performed at the time of cataract surgery,
based on known nomograms to modify the corneal astigmatism.

Advances in Intraocular Lenses

Foldable Intraocular Lenses

F oldable IOLs have become the predominant lens in use for cataract surgery
because of all the advantages of small-incision surgery. Currently, foldable
IOLs with traditional haptics are available in acrylic, in silicone, and in collamer
material. Plate-style IOLs are also available in silicone and collamer.
Silicone IOLs are contraindicated in patients who have had silicone oil used
as a vitreous substitute, because of the high affinity of the silicone oil for the
silicone optic.46 The oil will tend to form droplets on the IOL, which can cause a
reduction in overall visual acuity. These droplets can attach so tenaciously to the
IOL that it can be impossible to remove them surgically with irrigation/aspiration
devices. Therefore, the surgeon should carefully consider the use of silicone
foldable IOLs in patients at risk for developing complicated vitreoretinal
problems or advanced diabetic retinopathy.
Plate-style silicone IOLs are designed for capsular bag implantation only and
should not be used in the presence of either a posterior capsule tear or incomplete
capsulorrhexis.47 Recently, the size of the positioning holes on the wings of the
plate haptic has been enlarged to allow for better capsular bag fixation where the
anterior capsule fuses to the posterior capsule. Plate-style IOLs can be inserted

Cataract 10
 with an injection device, which allows their use through incisions smaller than
3.0 mm.

Other Advances

Toric IOLs. A foldable, silicone, plate-style IOL is now available for correction
of astigmatism at the time of cataract surgery. The lens comes in all standard
ranges of spherical powers and either a 2.0 or 3.5 dioptric cylindrical component.
This will correct 1.5 and 2.3 diopters of astigmatism at the corneal plane. The
lens achieves this correction by having the long axis oriented in the axis of the
corneal astigmatism. Although postsurgical rotation of the IOL is uncommon,
potential errors in correction of the refractive error can occur if the IOL is not
oriented appropriately at the time of placement or if it rotates a significant degree
away from the desired axis later.

Multifocal IOLs. The Array lens is a silicone-optic, foldable, zonal progressive

IOL.48,49 The IOL is weighted toward distance function so that patients typically
have full distance vision. The degree of near and intermediate vision varies with
the individual patient. In general, patients will have a greater depth of focus with
a multifocal lens than with a standard monofocal lens. Some patients with a
multifocal lens will still require spectacle correction for near work. There have
been reports of decreased contrast sensitivity and increased glare associated with
the Array IOL. Unwanted optical images have been the major reason for
explantation of this lens.50
The Array IOL is implanted in an identical fashion to other three-piece-
design foldable IOLs. However, there are some significant differences from
standard foldable IOLs with regard to its use. When choosing lens power, the
surgeon should aim for a plano or slightly hyperopic postoperative refraction to
allow for the maximum patient benefit from the near function of the lens. A
slightly hyperopic postoperative refraction will tend to minimize postoperative
halos. In addition, any residual astigmatic error will compromise the multifocal
effect of the lens. Lastly, it is generally not recommended that patients with a
monofocal IOL in their contralateral eye receive a multifocal IOL in their
operative eye.

Heparin-Surface-Modified IOLs. One of the potential problems with any

material implanted within a biological system is the development of an
inflammatory response. This type of reaction is quite rare with IOLs in general;
IOLs are well tolerated even in patients with uveitis. Nevertheless, there are some
patients who do develop postoperative inflammation and inflammatory
precipitates on the IOL that seem to be related to a tissue-implant reaction.
Heparin-surface-modified IOLs are polymethylmethacrylate (PMMA) IOLs
that have had their surface treated so that the IOL optic is more hydrophilic than
a standard PMMA IOL.51,52 This is believed to reduce the cell adherence and
other potential postoperative inflammatory conditions such as breakdown of the
blood−aqueous barrier. This lens is currently available as a one-piece IOL.

Piggyback IOLs. The term “piggyback IOL” describes a technique in which

more than one IOL is placed within the posterior chamber.53−55 This can be done
either as a primary or as a secondary procedure. Potential indications for

Cataract 11
 piggyback IOLs include highly hyperopic patients (where an IOL is not available
in a high enough power) or the correction of an IOL power miscalculation. In the
second case, the necessary power of the correcting piggyback IOL is calculated
and the IOL is inserted as a secondary IOL on top of and to correct the previously
implanted IOL, thus avoiding the necessity of performing an IOL exchange.
In the past, both IOLs were placed in the capsular bag or one was placed in
the bag and one in the sulcus. However, in the past year there have been reports
of interpseudophakic lenticular opacification with piggyback IOLs where both
IOLs were placed in the capsular bag.56−58 An epithelial cell proliferation similar
to the type that occurs with posterior capsule opacification can form in between
the two piggyback IOLs and can lead to a reduction in visual acuity. This
phenomenon does not seem to occur when one IOL is placed within the capsular
bag and the other is placed within the sulcus.

Management of Complications
Dislocated Nuclear Fragments

P osterior dislocation of nuclear fragments or of the entire nucleus is one of the

more feared complications of phacoemulsification surgery.59,60 Nuclear
fragments retained within the vitreous have the potential for producing an
inflammatory response that can lead to glaucoma, cystoid macular edema, and
corneal edema. In most cases, it will be necessary to remove nuclear fragments
that have dislocated into the vitreous. Small pieces of cortical material that
dislocate into the vitreous may resorb without sequelae. In some patients,
however, pieces of cortical material can produce an inflammatory response
similar to dislocated nuclear material.
For fragments that are not deep in the posterior chamber, viscoelastic can
often be used to float the pieces into the anterior chamber where they can
ultimately be removed after an adequate anterior vitrectomy has been performed.
When attempting to remove these fragments, the surgeon should try to minimize
any excess traction on the vitreous that is likely to be present through the opening
in the posterior capsule. If nuclear or cortical fragments dislocate deep into the
vitreous, the anterior segment surgeon should avoid an overly aggressive removal
of these fragments. In such a case, it may be more prudent for the surgeon to
clear the anterior chamber of vitreous and cortex with an automated vitrectomy
instrument, place the IOL if possible, and then refer the patient for vitreoretinal
consultation.
Immediate removal of the dislocated fragments may not be necessary if there
is not significant inflammation or elevated IOP. Although patients who have had
dislocated lens fragments need to be followed closely, it does not appear to be
necessary to remove the retained fragments on the same day as the initial cataract
surgery.

Thermal Burn

A thermal or “phaco” burn is a complication unique to phacoemulsification.61−63

During surgery, the irrigating fluid that accompanies phacoemulsification
normally dissipates heat generated by the phacoemulsification needle. Anything

Cataract 12
 that disrupts this irrigating fluid will allow the needle to generate heat, which can
burn or melt the tissue in the incision through which the phacoemulsification
needle is inserted. Thermal burn can occur very rapidlywithin 1 to 3 seconds of
cessation of irrigation.
Loss of irrigation may occur for a number of reasons. The tubing can kink or
disconnect from the handpiece. If the pump on the phacoemulsification machine
fails, then there will be no aspiration/inflow and, as a result, no outflow of fluid.
Obstruction of fluid flow through the flexible sleeve with too small an incision
will also result in loss of irrigation. Lastly, obstruction of the phacoemulsification
tip by viscoelastic at the start of surgery may also cause a thermal burn. This is
especially likely when the surgeon is using a highly retentive viscoelastic agent
with a low flow/vacuum setting.
Thermal burn may be avoided by ensuring that the phacoemulsification
handpiece is working properly, prior to inserting the needle into the eye. Also,
irrigation/aspiration can be used to clear some of the viscoelastic from the
anterior chamber prior to initiating phacoemulsification. Several
phacoemulsification needles, including the microseal and microflow tips, have
been designed to try to help reduce the potential for thermal injury. These tips
work by helping to avoid loss of infusion due to incision compression either by
insulating the phacoemulsification needle with a second rigid (titanium) sleeve or
with grooves along the phacoemulsification needle.
One of the early warning signs that a thermal burn may develop is a problem
with irrigation or aspiration leading to the production of “lens milk,” a bright
white suspension of lens material produced when infusion or aspiration is lost. If
this lens milk forms, the surgeon should cease phacoemulsification and check to
ensure that irrigation and aspiration are occurring spontaneously.

Posterior Capsule Tears and Anterior Vitrectomy

If a tear is noted in the posterior capsule during surgery, the surgeon should
promptly stop the phacoemulsification and assess the situation with regard to the
size of the opening and the amount of remaining lens material. Viscoelastic
material can be helpful in such a situation to stabilize the remaining crystalline
lens as well as to tamponade the capsular opening and to prevent migration of
vitreous into the anterior chamber. The surgeon’s goals at this point should be to
prevent the posterior dislocation of lens material, to remove as much of the
crystalline lens as possible, and to preserve the remaining posterior and anterior
capsular support in order to allow implantation of a posterior chamber IOL if
possible.64,65
Sometimes it may be safest to enlarge the incision and to use a combination
of viscoelastic and lens loop to remove the lens material. A Sheets glide can be
placed underneath the lens material to facilitate removal. In other cases, it may be
possible to continue phacoemulsification; if so, the infusion rate should be
lowered to decrease the risk of nuclear loss posteriorly. Remaining cortical
material can be removed by manual dry aspiration with viscoelastic protection.
Cortical material remote from the capsular tear should be removed first and
should be stripped toward the opening to avoid any extension of the posterior
capsule rent.
If vitreous presents through the rent in the posterior capsule, it is usually
necessary to perform an anterior vitrectomy. This can be performed as a “dry”

Cataract 13
 vitrectomy, using viscoelastic to maintain the anterior chamber so that fluid
inflow does not promote further prolapse of vitreous through the capsular
opening into the anterior chamber. Alternatively, a bimanual anterior vitrectomy
can be performed, in which a low flow of infusion is delivered by a cannula
inserted into the anterior chamber through a paracentesis incision. This method
allows removal of the vitreous that has prolapsed through the opening in the
posterior capsule without further hydrating the vitreous in the posterior segment.
Using these techniques, a minimum of additional vitreous will prolapse through
the opening in the posterior capsule.
It is not always necessary to perform anterior vitrectomy when there is
vitreous prolapse through a posterior capsular rent. If the prolapse is mild and
occurs late in the surgery, it can sometimes be controlled by injecting a
viscoelastic agent to displace the vitreous posteriorly and to tamponade the
opening.

Endophthalmitis

Numerous perioperative and intraoperative regimens have been developed to try

to decrease the incidence of endophthalmitis.66−74 Some of these regimens have
been proven in studies to have a positive effect while others have not. Sterile
diluted povidone-iodine solution instilled onto the conjunctiva prior to surgery
has been shown to decrease the incidence of endophthalmitis. The role of
antibiotics in the infusion fluid at the time of surgery is less clear. Some studies
have demonstrated a beneficial effect for the addition of antibiotics to the
chamber infusion fluid.75 However, laboratory studies have not conclusively
demonstrated this effect. In addition, there is concern that the routine use of
prophylactic antibiotics may contribute to the emergence of resistant bacterial
organisms. Nevertheless, some surgeons now routinely use antibiotics in their
infusion fluid.
In patients who do develop endophthalmitis, the role of antibiotics and
vitrectomy in their management was examined by the Endophthalmitis
Vitrectomy Study. In 420 patients who had clinical evidence of endophthalmitis
within 6 weeks of cataract surgery, there was no difference in final visual acuity
or media clarity with or without the use of systemic antibiotics. In patients whose
initial visual acuity was hand motions or better, there was no difference in visual
outcome whether or not immediate pars plana vitrectomy was performed or the
patients were treated with a vitreous tap and injection of intravitreal antibiotics.
However, in the subgroup of patients who initially had light-perception-only
vision, immediate pars plana vitrectomy produced a threefold increase in the
frequency of achieving 20/400 vision or better, almost a twofold chance of
achieving 20/100 vision or better, and a 50% decrease in the frequency of severe
visual loss as compared with patients who were treated with just a vitreous tap or
biopsy. The authors concluded that routine immediate pars plana vitrectomy is
not necessary in patients with better-than-light-perception vision but is of
substantial benefit in patients who present with endophthalmitis and light-
perception-only vision. In addition, the authors concluded that systemic
antibiotics are not necessary in the management of endophthalmitis.

Cataract 14
Intraocular Lens Problems

The most common IOL-related complications include (1) implantation of the

incorrect power, producing symptomatic anisometropia; (2) optic decentration,
resulting in unwanted optical images; and (3) chronic inflammation, with
secondary cystoid macular edema related to mechanical uveal chafe.76,77 At times
these problems can be managed conservatively. For example, symptoms related
to anisometropia can sometimes be reduced to an acceptable level by separate
near and distance spectacles, the use of bicentric grind/slab off lenses, or a
contact lens. Unwanted optical images can be treated with a topical miotic in
drop or ointment form. Topical corticosteroids alone or in conjunction with
topical nonsteroidal anti-inflammatories may stabilize an eye that has evidence of
uveal chafe and low-grade inflammation.
Even if eyes with IOL problems respond well to conservative management,
they should be followed clinically for any progression of the problem such as
increased inflammation, decreased acuity, elevated intraocular pressure,
development of cystoid macular edema, or compromise of the corneal
endothelium. If there is progression of any of these conditions, surgical
intervention with IOL repositioning, exchange, or explantation may be justified.

Special Situations
Patients with Diabetes

A patient with diabetic retinopathy should have a complete retinal

examination prior to cataract surgery. If clinically significant macular edema
or neovascularization exists, appropriate laser photocoagulation should be
performed prior to cataract surgery. The patient should be counseled that in some
instances there can be dramatic acceleration of diabetic retinopathy following
uncomplicated cataract surgery.78,79 These patients need to be followed carefully
postoperatively and laser therapy should be started when indicated. Significant
risk factors for worsening of retinopathy following cataract surgery include
preoperative retinal status (nonproliferative retinopathy and proliferative
retinopathy have a poorer prognosis) and rupture of the posterior capsule. Many
surgeons will avoid placing a silicone IOL in a diabetic patient who is at high
risk for proliferative disease, in case the patient subsequently requires posterior
segment surgery with silicone oil.

Patients with Small Pupils

In patients with poorly dilated pupils, cataract surgery can at best be technically
challenging and at worst, very complicated.80−83 In such patients, there are several
ways to enlarge the pupil to allow surgery to be performed more safely. The goal
is to enlarge the pupil to allow adequate visualization intraoperatively and
postoperatively while still leaving the patient with a cosmetically acceptable
appearance. In some cases, the pupil may be constricted by posterior synechiae;
these can be lysed with a cannula and the pupil subsequently enlarged with
viscoelastic. In other instances, the pupil can be stretched with manipulators
similar to those used to position IOLs. The manipulators are placed at the iris

Cataract 15
 sphincter at 6 and 12 o’clock and the iris is pushed toward the limbus and held
there briefly; this procedure is then repeated at 3 and 9 o’clock. Postoperatively
the pupil will be round, mid-dilated, and somewhat atonic. Multiple
sphincterotomies can also be used to help dilate the pupil. If these
sphincterotomies are only half the width of the iris sphincter then the pupil will
often remain round and functional postoperatively. Finally, iris retractors can be
used to dilate the pupil. The retractors are inserted through paracentesis incisions
and placed over the iris sphincter to retract it peripherally.

Patients with Pseudoexfoliation

In patients with pseudoexfoliation syndrome, cataract surgery is associated with

an increased risk of intraoperative and postoperative complications.84 Besides an
increased association with elevated intraocular pressure, these patients often
dilate poorly and have shallow anterior chambers and narrow angles. Perhaps the
greatest risk is that pseudoexfoliation patients tend to have weaker zonules. This
weakness can present initially to the surgeon as difficulty in performing
capsulorrhexis. Because there is poor zonular countertraction, it can be difficult
to initiate the capsular tear. Also, the lens may move excessively during the
capsulorrhexis. Other signs of zonular weakness intraoperatively may include a
floppy capsular bag and difficulty with cortical aspiration.
It is important to adequately hydrodissect the lens in a patient with
pseudoexfoliation, because if the cortical-capsular adhesions are not adequately
broken, nuclear rotation maneuvers will place excessive traction on the zonular
apparatus. A larger-than-normal capsulorrhexis may help to facilitate the surgery
and to minimize the effects of late postoperative capsule contraction syndrome
related to poor zonular countertraction.
If zonular dialysis occurs intraoperatively, it may still be possible to place an
IOL within the capsular bag. In such a case, an implant should be used that has
excellent haptic memory so that it can hold the capsular bag in place. The haptics
should be oriented in the same axis as the zonular dialysis so that the capsular
bag will be maintained in the appropriate position; this will help prevent late
contraction of the capsular bag.

Patients Who Have Undergone Radial Keratotomy (RK)

The most challenging part of cataract surgery in patients who have undergone
RK involves selection of the appropriate IOL power.21 Prior to surgery the
physician should have a frank discussion with the patient, describing the strong
possibility that a second procedure (IOL exchange or piggyback IOL) may be
required to correct any residual refractive error. Keep in mind that patients who
were willing to undergo RK to correct a refractive error are usually not tolerant
of a non-emmetropic postoperative result.
In most instances the intraoperative portion of the procedure is unremarkable.
If a clear corneal incision is being used, an attempt should be made to avoid
having the incision intersect with any of the previously placed RK incisions.
Dehiscence of an RK incision has been described at the time of surgery and can
be managed by suturing the incision.85
Postoperatively it is quite common for these patients initially to be hyperopic
because of the tendency for the central cornea to flatten.19 Even if the patient is

Cataract 16
 significantly hyperopic it is best to wait at least several weeks before
contemplating surgical intervention (IOL exchange or piggyback IOL) because
of a tendency for the cornea to re-steepen with time and the hyperopia to regress.

Patients with Silicone Oil

Patients with cataracts and previously placed silicone oil pose clinical problems
preoperatively, intraoperatively, and postoperatively.86−88 Axial length
measurements in patients with silicone oil can be difficult because of the
admixture of oil and aqueous along with the different velocity of sound in
silicone oil compared with vitreous. The reliability of axial length measurements
can be improved by measuring the patient in two separate positions and adjusting
the ultrasound velocity to compensate for the speed of sound in silicone oil.
Implant power calculations are also more difficult for patients with silicone
oil. Because the silicone has a higher index of refraction than aqueous or
vitreous, the IOL will have a lower effective power. In general, the postoperative
refraction tends to be 3 to 4 diopters more hyperopic than would be predicted
with a standard theoretical IOL power calculation. Patients with silicone oil
should be apprised of the difficulty of achieving a desired postoperative aim
because of the potential for imprecision in IOL power calculations.
Intraoperatively, it is common for the silicone oil to migrate into the anterior
chamber. The oil looks very similar to oil admixed with water and can easily be
aspirated with either a phacoemulsification needle or an irrigation/aspiration tip.
At the conclusion of cataract surgery it is very common for the posterior
capsule to be extremely opacified and fibrotic secondary to the silicone oil.
Although a variety of instruments and techniques can be used to attempt to
remove the fibrosis, it is often not possible to clear the posterior capsule. As a
result it is quite common to have to perform a Nd:YAG laser capsulotomy in the
very early postoperative period.

Important Clinical Trials

T he capsular tension ring, which is currently awaiting FDA approval, is a

PMMA endocapsular ring designed to stabilize the capsular bag in patients
with compromised zonules.89 The ring can be placed at any time during surgery
once the capsulorrhexis has been completed. When used prior to nucleus
removal, it is believed to help stabilize the capsular bag, to prevent further
zonular compromise, and to help avoid vitreous prolapse through an area of
zonular dialysis. During IOL implantation the endocapsular ring helps the
capsular bag maintain a circular contour to facilitate IOL implantation in the bag.
Postoperatively the capsular tension ring helps achieve long-term IOL
centration.The Cionni ring is a modification of the endocapsular ring that permits
suturing of the tension ring to the ciliary sulcus.90

Cataract 17
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Cataract 18
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Cataract 20
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Cataract 22
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Cataract 23
Related Academy Materials
Academy Statements
Cataract in the Adult Eye. Preferred Practice Pattern. 1996.
Cataract Surgery in the Second Eye. Information Statement. 1999.

Basic and Clinical Science Course

Lens and Cataract. Section 11. Updated annually.
Optics, Refraction, and Contact Lenses. Section 3. Updated annually.

Focal Points: Clinical Modules for Ophthalmologists

Balyeat HD. Cataract Surgery in the Glaucoma Patient, Part 1: A Cataract
Surgeon’s Perspective. Vol XVI, Module 3. 1998.
Byrnes GA. Evaluation of Impaired Visual Acuity Following Cataract Surgery.
Vol XIV, Module 6. 1996.
Fishkind WJ. The Torn Posterior Capsule: Prevention, Recognition, and
Management. Vol XVII, Module 4. 1999.
Hoffer KJ. Modern IOL Power Calculations. Vol XVII, Module 12. 1999.
Lane SS, Schwartz GS. IOL Exchanges and Secondary IOLs: Surgical
Techniques. Vol XVI, Module 1. 1998.
Masket S. Cataract Incision and Closure. Vol XIII, Module 3. 1995.
Nichamin LD. IOL Update: New Materials, Designs, Criteria, and Insertional
Techniques. Vol XVII, Module 11. 1999.
Ruttum MS. Childhood Cataracts. Vol XIV, Module 1. 1996.
Sanders DR, Retzlaff JA, Kraff MC. A-Scan Biometry and IOL Implant Power
Calculations. Vol XIII, Module 10. 1995.
Skuta GL. Cataract Surgery in the Glaucoma Patient, Part 2: A Glaucoma
Surgeon’s Perspective. Vol XVI, Module 4. 1998.
Smiddy WE, Flynn HW Jr. Managing Retained Lens Fragments and Dislocated
Posterior Chamber IOLs after Cataract Surgery. Vol XIV, Module 7. 1996.

Monograph
Stamper RL, Sugar A, Ripkin DJ. Intraocular Lenses: Basics and Clinical
Applications. Ophthalmology Monograph 7. 1993.

Multimedia
Lane SS, Crandall AS, Koch DD, Steinert RF. Cataract. LEO CD-ROM. 1999.

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Self-Assessment
Lane SS, Skuta GL, eds. ProVision: Preferred Responses in Ophthalmology.
Series 3. 1999.
Skuta GL, ed. ProVision: Preferred Responses in Ophthalmology. Series 2. 1996.

Videotapes
Byrne SF. A-Scan Biometry. Clinical Skills Series. 1998.
Carlson AN. Managing IOL Complications: Achieving Capsular Bag Fixation.
Annual Meeting Series. 1996.
Fine IH. Choo-Choo Chop-and-Flip Phaco: In Cornea Plana Functioning
Filtering Bleb. Annual Meeting Series. 1998.
Koch DD, Kohnen T, Pena-Cuesta R. Pediatric Cataract and IOL Surgery.
Annual Meeting Series. 1995.
Lane SS, Koch DD. Current Techniques in Phacoemulsification. Clinical Skills
Series. 1999.
Mead MD, Steinert RF. Scleral Suture Fixation of Posterior Chamber
Intraocular Lenses. Clinical Skills Series. 1997.
Osher RH. Cataract Surgery Plus. Annual Meeting Series. 1996.
Osher RH. Complications During Phacoemulsification. Clinical Skills Series.
1999.
Osher RH. The Mature Cataract and Its Sharp Edges: Fact or Fiction. Annual
Meeting Series. 1998.
Osher RH. Original Approaches to Complications Following Cataract Surgery.
Annual Meeting Series. 1998.
Singer JA. AutoCrack Phaco: The Lensquake. Annual Meeting Series. 1998.
Singer JA. The Incision Decision. Annual Meeting Series. 1997.
Singer JA, Fine IH, Miyake K. Cortical Cleaving Hydrodissection: How to Make
It Work. Annual Meeting Series. 1999.
Steinert RF, Wright PL. Making the Transition to Phacoemulsification. Clinical
Skills Series. 1999.
Vanetti C, Camesasca FI, Gramigna M. AcrySof Removal with Folding in the
Anterior Chamber. Annual Meeting Series. 1999.
Zushi I, Yabe N, Kumano Y, et al. A Technique for Repositioning Dislocated
Intraocular Lenses and Transscleral Fixation within the Anterior Chamber.
Annual Meeting Series. 1999.

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