This month I demonstrate the use of the Trendelenburg position in order to gain adequate access to a “deep set” eye during cataract-implant surgery with toric IOL implantation . The pupil dilates only moderately, and possible pharmacological causes of poor dilation are discussed: several techniques that increase and/or maintain pupil size are demonstrated, as are methods to chop the nucleus and protect the posterior capsule during subincisional cortex removal.
Using a 2.4mm incision, I remove a fairly dense, 3+ brunescent nuclear cataract from a patient whose other eye has only peripheral vision. I demonstrate using trypan blue to aid visualization of the capsulorhexis, and show how an OVD can be used to actually reposition an anterior subcapsular opacity prior to creating the capsulorhexis. A detailed presentation of the impale and chop technique follows with additional pearls including how to keep the phaco tip cool, and the advantage of using a slightly oversized surgical glove.
In our inaugural episode of Mackool Online CME, I demonstrate my standard technique for cataract removal with, in this case, implantation of a Toric IOL. Emphasis is placed on the creation and fluidics of the side port incision, proper alignment of the infusion sleeve prior to phaco, the correct foot position settings I use when chopping the nucleus and final positioning of the toric iol.