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Phakonit: phacoemulsification through a 0.9 mm corneal incision
Phakonit: Phacoemulsification through a 0.9 mm corneal incision Amar Agarwal, MS, FRCS, FRCOphth(Lon), Athiya Agarwal, MD, Sunita Agarwal, MS, FSVH(WG), FRSH(Lon), DO, Priya Narang, MS, Sameer Narang, MS, DO ABSTRACT Advances in technique and equipment have led to a significant increase in the popularity of phacoemulsification and have increased its safety and efficiency. We describe a technique, phakonit, in which the lens is emulsified through a 0.9 mm clear corneal temporal incision. A cortical wash with bimanual irrigation/aspiration is followed by enlarging the incision to 2.0 mm and inserting a Staar sub-2.0 mm foldable intraocular lens. Phakonit is a safe, precise method of phacoemulsification with minimal intraoperative or postoperative complications. J Cataract Refract Surg 2001; 27:1548 –1552 © 2001 ASCRS and ESCRS
S
ince the introduction of phacoemulsification by Kelman, the technique has gradually evolved. Phacoemulsification revolutionized the management of cataract with the emergence of small incision corneal valve surgery and implantation of foldable intraocular lenses (IOLs). There has been a shift from peribulbar to topical anesthesia and from scleral to corneal tunnel incisions. Currently, the most preferred incision in the United States is the clear corneal, and most incisions are designed to be self-sealing.1 With the advances in phaco machines and tips, the size of clear corneal incisions has decreased from 3.2 mm to 2.8 mm to 2.6 mm. We describe a technique, phaAccepted for publication April 13, 2001. From Dr. Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai, India. Presented at the Symposium on Cataract, IOL and Refractive Surgery, Seattle, Washington, USA, April 1999, and the annual meeting of the American Academy of Ophthalmology, Dallas, Texas, USA, October 2000. None of the authors has a financial or proprietary interest in any material or method mentioned. Reprint requests to Dr. Amar Agarwal, Dr. Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai 600086, India. E-mail: agarwal@giasmd01. vsnl.net.in. © 2001 ASCRS and ESCRS Published by Elsevier Science Inc.
konit, in which the cataractous lens is emulsified through a 0.9 mm clear corneal temporal incision. The term phakonit is derived from phacoemulsification (phako) being done with a needle (N) through an incision (I) and with the phaco tip (T).
Surgical Technique Phakonit can be performed using any type of anesthesia. Viscoelastic material is injected with a 26gauge needle through the site of the side port entry (Figure 1) to inflate the anterior chamber and prevent its collapse. A blunt straight rod is passed through the paracentesis to achieve akinesia, and a clear corneal temporal valve is made with a purpose-designed 0.9 mm microkeratome (Figure 2). The anterior chamber is reformed with viscoelastic substance and a continuous curvilinear capsulorhexis (CCC) created with a 26-gauge needle. Hydrodissection is done with a flat cannula (Figure 3), and the nucleus is rotated with a Y spatula. After the side port is enlarged with a 15-degree disposable side-port blade, an 18-gauge irrigating chopper is connected to the infusion line of the phaco machine and introduced into the anterior chamber with the foot 0886-3350/01/$–see front matter PII S0886-3350(01)00922-1
TECHNIQUES: AGARWAL
Figure 1. (Agarwal) Viscoelastic is material injected with a 26gauge needle.
Figure 2. (Agarwal) A clear corneal temporal incision is made with a 0.9 mm microkeratome.
Figure 3. (Agarwal) A CCC is created and hydrodissection performed.
Figure 4. (Agarwal) An irrigating chopper is introduced through the side port, and the phaco tip without an infusion sleeve is inserted through the corneal incision.
pedal in position 1. The phaco probe is connected to the aspiration line, and a 15-degree standard phaco tip without an infusion sleeve is introduced through the 0.9 mm incision (Figure 4). With the phaco tip set at moderate ultrasound (US) power, the center of the nucleus is directly embedded. Starting from the superior edge of the capsulorhexis, the phaco probe is directed obliquely downward until the tip is occluded, establishing a firm hold on the nucleus. The settings at this stage are phaco power, 70%; aspiration flow rate, 24 mL/ minute; and vacuum, 110 mm Hg. To avoid excessive pressure on the posterior capsule, the nucleus is slightly lifted. With the irrigating chopper in the other hand, the nucleus is chopped with a straight downward motion and split using the chopper and
the embedded phaco tip. The nucleus is rotated 180 degrees and chopped again so that it is split into 2 halves. Using the same technique, 3 pie-shaped quadrants of each half of the nucleus are created. With a short burst of energy at pulse mode, each pie-shaped fragment is lifted and brought to the level of the iris, where it is further emulsified and aspirated sequentially in the pulse mode (Figure 5). A cortical wash is done using standard bimanual irrigation/aspiration (I/A) (Figure 6). A Staar sub2.0 mm foldable IOL is inserted after the incision is enlarged to 2.0 mm. The viscoelastic material is removed and stromal hydration performed by injecting fluid into the sides of the clear corneal incision (Figure 7).
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001
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TECHNIQUES: AGARWAL
Figure 5. (Agarwal) The nucleus is emulsified.
Figure 6. (Agarwal) Bimanual I/A is performed. Note that no corneal burn is present.
Results Phakonit was performed in 305 eyes over 1 year. The mean patient age was 61 years ⫾ 8.1 (SD) (median 60 years, range 46 to 86 years). Patients with congenital eye or adenexa lid abnormalities, corneal dystrophy or degeneration, preexisting corneal opacity, glaucoma, signs of previous uveitis, complicated or traumatic cataract, vitreous opacity or degeneration, or retinal disorders were excluded. Also excluded were patients with a systemic disorder such as diabetes mellitus, hypertension, ischemic heart disease, tuberculosis, or asthma. All patients had a slitlamp examination, applanation tonometry, and indirect ophthalmoscopy. Patients in whom the view of the fundus was obscured because of lenticular changes had B-scan ultrasonography to rule out other posterior segment pathology. Preoperatively, patients were placed into 1 of 4 groups according to nuclear density: Group A, gray cataract (86 patients, 28.2%); Group B, yellow– gray cataract (135 patients, 44.3%); Group C, yellow– orange cataract (68 patients, 22.3%); Group D, hard, brunescent cataract (16 patients, 5.2%). The nucleus was successfully emulsified in all cases. Best corrected visual acuity (BCVA; Snellen) was measured preoperatively and 1 day, 1 month, and 3 months postoperatively. Table 1 shows the BCVA over time by cataract density. Preoperative acuity ranged from finger counting to 20/30. One day postoperatively, BCVA was 20/40 or better in 80.2%, 80.7%, 77.9%, and 75.0% in Groups A, B, C, and D, respectively. At 1 month, it was 20/40 or better in 83.7%, 85.1%, 82.3%, and 81.2%, respec1550
Figure 7. (Agarwal) A plate-haptic foldable IOL is implanted and stromal hydration performed.
tively. At 3 months, it was 20/40 or better in 89.5%, 86.7%, 85.2%, and 87.5%, respectively. Three patients (0.9%) developed cystoid macular edema that resolved in 2 cases. The other patient developed age-related macular degeneration. Five patients (1.6%) had posterior capsule rupture during phacoemulsification or bimanual cortical aspiration, and 18 (5.9%) had corneal edema postoperatively that resolved spontaneously. There were no cases of significant corneal burns. No eyes had clinically significant burns. The wound integrity in terms of the valve effect was good, and there was no significant induced astigmatism. The surgeon encountered no difficulty performing phakonit through a 0.9 mm incision. The incision provided good access to the eye for intraoperative manipulations.
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001
TECHNIQUES: AGARWAL
Table 1. Best corrected visual acuity over time. Number of Patients
BCVA
Postoperative Preoperative 1 Day 1 Month 3 Months
Group A (n ⫽ 86) 20/20–20/40
39
69
72
77
20/40–20/80
47
16
10
2
20/80–20/200
0
1
0
0
—
—
4*
7*
20/20–20/40
43
109
115
117
20/40–20/80
86
22
12
4
20/80–20/200
6
3
1
1
⬍20/200
0
1
1
1
Lost to FU
—
—
6
12
20/20–20/40
0
53
56
58
20/40–20/80
27
11
7
5
20/80–20/200
39
4
2
1
⬍20/200
2
0
0
0
Lost to FU
—
—
3
4
20/20–20/40
0
12
13
14
20/40–20/80
0
3
2
1
Lost to FU Group B (n ⫽ 135)
Group C (n ⫽ 68)
Group D (n ⫽ 16)
20/80–20/200 ⬍20/200
3
1
1
1
13
0
0
0
BCVA ⫽ best corrected visual acuity; Group A ⫽ gray cataract; Group B ⫽ yellow– gray cataract; Group C⫽ yellow– orange cataract; Group D ⫽ hard, brunescent cataract; FU ⫽ follow-up
Discussion In ophthalmology, perhaps no other surgery has changed as rapidly in the past few decades as cataract extraction.2 The clinical benefit was the strongest factor in the decision to change from extracapsular cataract extraction to phacoemulsification.3 Phacoemulsification is now the preferred technique as it offers significant benefits to both surgeon and patient. Today, the axiom in the rehabilitation of cataract patients is that small is beautiful. There are 2 basic considerations in achieving this goal: removal of the cataractous lens and insertion of an IOL through the smallest possible incision.4 Phakonit fits these criteria as the crystalline lens is emulsified through a 0.9 mm incision.
Figure 8. (Agarwal) The irrigating chopper has a sharp cutting edge.
Phakonit is a version of phacoemulsification with the main difference being that the phaco tip is used without the infusion sleeve. A purpose-designed 18gauge irrigating chopper (Figure 8) has the dual function of anterior chamber maintainer and chopper. The instrument has a sharp cutting edge on the end and 2 side ports on either side for continuous infusion of fluid. The phaco probe is embedded with a single burst of US energy, and the chopper’s sharp edge smoothly cuts the dense central core of the nucleus without exerting excessive pressure on the zonules. Five to 6 small, pieshaped fragments are created, and each is aspirated and emulsified in the pulse mode. In cases with partial or complete obstruction of the aspiration port, the wound temperature is significantly lower in the pulse mode than in the nonpulse mode, preventing thermal burns of the wound.5 Removing the silicone sleeve from the phaco tip reduces the length of the incision to 0.9 mm. The sleeve prevents thermal burns by insulating and continuously irrigating the vibrating tip, reducing the temperature rise from US vibrations. A constant flow of irrigation fluid is required for sufficient cooling of the phaco needle.6 Adequate cooling of the vibrating tip is ensured by continuous infusion of fluid into the eye by the irrigating chopper and at the site of the incision as the assistant continuously pours cooled balanced salt solution (BSS威) over the phaco needle. The bimanual setup provides an unobstructed intraocular view that is enhanced by the use of smaller instruments. There was no postocclusion surge and the normal working (fluidics and mechanics) of the ma-
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001
1551
TECHNIQUES: AGARWAL
chine was not meddled with. The followability of the nuclear pieces through the phaco tip improved as the pieces of the nuclei were not pushed away by the infusion fluid. The phaco times were comparable to those of the standard phacoemulsification technique. Phakonit reduces the phaco energy used and shortens the total energy time. After the nucleus is chopped into small, pie-shaped fragments, each fragment is emulsified in pulse mode. The pulse mode increases the followability and safety margin and decreases the effective energy time.7 Foldable IOL technology has caught up with lens extraction techniques and has solved some, although not all, the demands of cataract surgery.8 The phakonit technique necessitates the insertion of an IOL through a 0.9 mm incision. At present, the Staar sub-2.0 mm foldable lens, the smallest commercially available IOL, is used in phakonit. With the change in the trend from small incision (⬎2.0 mm) to minimal incision (⬍2.0 mm) surgery,9 phakonit offers a new modality in the management of cataracts of all densities. This technique combines a very small incision with existing phaco technology without loosing the ability to efficiently remove brunescent nuclei. It is a reproducible, safe, and easy procedure with minimal intraoperative or postoperative complications. However, a learning curve is associated with conversion to this technique, and a clear understanding is required to prevent complications.
1552
References 1. Leaming DV. Practice styles and preferences of ASCRS members—2000 survey. J Cataract Refract Surg 2001; 27:948 –955 2. Dada VK, Sindhu N. Management of cataract—a revolutionary change that occurred during last two decades. J Indian Med Assoc 1999; 97:313–317 3. Gonglore B, Smith R. Extracapsular cataract extraction to phacoemulsification: why and how? Eye 1998; 12:976 – 982 4. Sachdev MS, Venkatesh P. Phaco intraocular lenses. In: Agarwal S, Agarwal A, Sachdev MS, et al, eds, Phacoemulsification, Laser Cataract Surgery and Foldable IOLs, 2nd ed. New Delhi, Jaypee Brothers, 2000; 416 – 427 5. Yamagami S, Yamagami H. Direct measurement of wound temperature during phacoemulsification. Ophthalmologica 1998; 212:50 –52 6. Alzner E, Grabner G. Dodick laser phacolysis: thermal effects. J Cataract Refract Surg 1999; 25:800 – 803 7. Grover AK, Kapur KB. Stop and chop technique. In: Agarwal S, Agarwal A, Sachdev MS, et al, eds, Phacoemulsification, Laser Cataract Surgery and Foldable IOLs, 2nd ed. New Delhi, Jaypee Brothers, 2000; 170 – 174 8. Rosen ES. Face to face with IOLs (editorial). J Cataract Refract Surg 1999; 25:729 9. Alio´ JL, De Iomo V. Cataract surgery with Dodick laser photolysis. In: Agarwal S, Agarwal A, Sachdev MS, et al, eds, Phacoemulsification, Laser Cataract Surgery and Foldable IOLs, 2nd ed. New Delhi, Jaypee Brothers, 2000; 263–270
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001
S
ince the introduction of phacoemulsification by Kelman, the technique has gradually evolved. Phacoemulsification revolutionized the management of cataract with the emergence of small incision corneal valve surgery and implantation of foldable intraocular lenses (IOLs). There has been a shift from peribulbar to topical anesthesia and from scleral to corneal tunnel incisions. Currently, the most preferred incision in the United States is the clear corneal, and most incisions are designed to be self-sealing.1 With the advances in phaco machines and tips, the size of clear corneal incisions has decreased from 3.2 mm to 2.8 mm to 2.6 mm. We describe a technique, phaAccepted for publication April 13, 2001. From Dr. Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai, India. Presented at the Symposium on Cataract, IOL and Refractive Surgery, Seattle, Washington, USA, April 1999, and the annual meeting of the American Academy of Ophthalmology, Dallas, Texas, USA, October 2000. None of the authors has a financial or proprietary interest in any material or method mentioned. Reprint requests to Dr. Amar Agarwal, Dr. Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai 600086, India. E-mail: agarwal@giasmd01. vsnl.net.in. © 2001 ASCRS and ESCRS Published by Elsevier Science Inc.
konit, in which the cataractous lens is emulsified through a 0.9 mm clear corneal temporal incision. The term phakonit is derived from phacoemulsification (phako) being done with a needle (N) through an incision (I) and with the phaco tip (T).
Surgical Technique Phakonit can be performed using any type of anesthesia. Viscoelastic material is injected with a 26gauge needle through the site of the side port entry (Figure 1) to inflate the anterior chamber and prevent its collapse. A blunt straight rod is passed through the paracentesis to achieve akinesia, and a clear corneal temporal valve is made with a purpose-designed 0.9 mm microkeratome (Figure 2). The anterior chamber is reformed with viscoelastic substance and a continuous curvilinear capsulorhexis (CCC) created with a 26-gauge needle. Hydrodissection is done with a flat cannula (Figure 3), and the nucleus is rotated with a Y spatula. After the side port is enlarged with a 15-degree disposable side-port blade, an 18-gauge irrigating chopper is connected to the infusion line of the phaco machine and introduced into the anterior chamber with the foot 0886-3350/01/$–see front matter PII S0886-3350(01)00922-1
TECHNIQUES: AGARWAL
Figure 1. (Agarwal) Viscoelastic is material injected with a 26gauge needle.
Figure 2. (Agarwal) A clear corneal temporal incision is made with a 0.9 mm microkeratome.
Figure 3. (Agarwal) A CCC is created and hydrodissection performed.
Figure 4. (Agarwal) An irrigating chopper is introduced through the side port, and the phaco tip without an infusion sleeve is inserted through the corneal incision.
pedal in position 1. The phaco probe is connected to the aspiration line, and a 15-degree standard phaco tip without an infusion sleeve is introduced through the 0.9 mm incision (Figure 4). With the phaco tip set at moderate ultrasound (US) power, the center of the nucleus is directly embedded. Starting from the superior edge of the capsulorhexis, the phaco probe is directed obliquely downward until the tip is occluded, establishing a firm hold on the nucleus. The settings at this stage are phaco power, 70%; aspiration flow rate, 24 mL/ minute; and vacuum, 110 mm Hg. To avoid excessive pressure on the posterior capsule, the nucleus is slightly lifted. With the irrigating chopper in the other hand, the nucleus is chopped with a straight downward motion and split using the chopper and
the embedded phaco tip. The nucleus is rotated 180 degrees and chopped again so that it is split into 2 halves. Using the same technique, 3 pie-shaped quadrants of each half of the nucleus are created. With a short burst of energy at pulse mode, each pie-shaped fragment is lifted and brought to the level of the iris, where it is further emulsified and aspirated sequentially in the pulse mode (Figure 5). A cortical wash is done using standard bimanual irrigation/aspiration (I/A) (Figure 6). A Staar sub2.0 mm foldable IOL is inserted after the incision is enlarged to 2.0 mm. The viscoelastic material is removed and stromal hydration performed by injecting fluid into the sides of the clear corneal incision (Figure 7).
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001
1549
TECHNIQUES: AGARWAL
Figure 5. (Agarwal) The nucleus is emulsified.
Figure 6. (Agarwal) Bimanual I/A is performed. Note that no corneal burn is present.
Results Phakonit was performed in 305 eyes over 1 year. The mean patient age was 61 years ⫾ 8.1 (SD) (median 60 years, range 46 to 86 years). Patients with congenital eye or adenexa lid abnormalities, corneal dystrophy or degeneration, preexisting corneal opacity, glaucoma, signs of previous uveitis, complicated or traumatic cataract, vitreous opacity or degeneration, or retinal disorders were excluded. Also excluded were patients with a systemic disorder such as diabetes mellitus, hypertension, ischemic heart disease, tuberculosis, or asthma. All patients had a slitlamp examination, applanation tonometry, and indirect ophthalmoscopy. Patients in whom the view of the fundus was obscured because of lenticular changes had B-scan ultrasonography to rule out other posterior segment pathology. Preoperatively, patients were placed into 1 of 4 groups according to nuclear density: Group A, gray cataract (86 patients, 28.2%); Group B, yellow– gray cataract (135 patients, 44.3%); Group C, yellow– orange cataract (68 patients, 22.3%); Group D, hard, brunescent cataract (16 patients, 5.2%). The nucleus was successfully emulsified in all cases. Best corrected visual acuity (BCVA; Snellen) was measured preoperatively and 1 day, 1 month, and 3 months postoperatively. Table 1 shows the BCVA over time by cataract density. Preoperative acuity ranged from finger counting to 20/30. One day postoperatively, BCVA was 20/40 or better in 80.2%, 80.7%, 77.9%, and 75.0% in Groups A, B, C, and D, respectively. At 1 month, it was 20/40 or better in 83.7%, 85.1%, 82.3%, and 81.2%, respec1550
Figure 7. (Agarwal) A plate-haptic foldable IOL is implanted and stromal hydration performed.
tively. At 3 months, it was 20/40 or better in 89.5%, 86.7%, 85.2%, and 87.5%, respectively. Three patients (0.9%) developed cystoid macular edema that resolved in 2 cases. The other patient developed age-related macular degeneration. Five patients (1.6%) had posterior capsule rupture during phacoemulsification or bimanual cortical aspiration, and 18 (5.9%) had corneal edema postoperatively that resolved spontaneously. There were no cases of significant corneal burns. No eyes had clinically significant burns. The wound integrity in terms of the valve effect was good, and there was no significant induced astigmatism. The surgeon encountered no difficulty performing phakonit through a 0.9 mm incision. The incision provided good access to the eye for intraoperative manipulations.
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001
TECHNIQUES: AGARWAL
Table 1. Best corrected visual acuity over time. Number of Patients
BCVA
Postoperative Preoperative 1 Day 1 Month 3 Months
Group A (n ⫽ 86) 20/20–20/40
39
69
72
77
20/40–20/80
47
16
10
2
20/80–20/200
0
1
0
0
—
—
4*
7*
20/20–20/40
43
109
115
117
20/40–20/80
86
22
12
4
20/80–20/200
6
3
1
1
⬍20/200
0
1
1
1
Lost to FU
—
—
6
12
20/20–20/40
0
53
56
58
20/40–20/80
27
11
7
5
20/80–20/200
39
4
2
1
⬍20/200
2
0
0
0
Lost to FU
—
—
3
4
20/20–20/40
0
12
13
14
20/40–20/80
0
3
2
1
Lost to FU Group B (n ⫽ 135)
Group C (n ⫽ 68)
Group D (n ⫽ 16)
20/80–20/200 ⬍20/200
3
1
1
1
13
0
0
0
BCVA ⫽ best corrected visual acuity; Group A ⫽ gray cataract; Group B ⫽ yellow– gray cataract; Group C⫽ yellow– orange cataract; Group D ⫽ hard, brunescent cataract; FU ⫽ follow-up
Discussion In ophthalmology, perhaps no other surgery has changed as rapidly in the past few decades as cataract extraction.2 The clinical benefit was the strongest factor in the decision to change from extracapsular cataract extraction to phacoemulsification.3 Phacoemulsification is now the preferred technique as it offers significant benefits to both surgeon and patient. Today, the axiom in the rehabilitation of cataract patients is that small is beautiful. There are 2 basic considerations in achieving this goal: removal of the cataractous lens and insertion of an IOL through the smallest possible incision.4 Phakonit fits these criteria as the crystalline lens is emulsified through a 0.9 mm incision.
Figure 8. (Agarwal) The irrigating chopper has a sharp cutting edge.
Phakonit is a version of phacoemulsification with the main difference being that the phaco tip is used without the infusion sleeve. A purpose-designed 18gauge irrigating chopper (Figure 8) has the dual function of anterior chamber maintainer and chopper. The instrument has a sharp cutting edge on the end and 2 side ports on either side for continuous infusion of fluid. The phaco probe is embedded with a single burst of US energy, and the chopper’s sharp edge smoothly cuts the dense central core of the nucleus without exerting excessive pressure on the zonules. Five to 6 small, pieshaped fragments are created, and each is aspirated and emulsified in the pulse mode. In cases with partial or complete obstruction of the aspiration port, the wound temperature is significantly lower in the pulse mode than in the nonpulse mode, preventing thermal burns of the wound.5 Removing the silicone sleeve from the phaco tip reduces the length of the incision to 0.9 mm. The sleeve prevents thermal burns by insulating and continuously irrigating the vibrating tip, reducing the temperature rise from US vibrations. A constant flow of irrigation fluid is required for sufficient cooling of the phaco needle.6 Adequate cooling of the vibrating tip is ensured by continuous infusion of fluid into the eye by the irrigating chopper and at the site of the incision as the assistant continuously pours cooled balanced salt solution (BSS威) over the phaco needle. The bimanual setup provides an unobstructed intraocular view that is enhanced by the use of smaller instruments. There was no postocclusion surge and the normal working (fluidics and mechanics) of the ma-
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001
1551
TECHNIQUES: AGARWAL
chine was not meddled with. The followability of the nuclear pieces through the phaco tip improved as the pieces of the nuclei were not pushed away by the infusion fluid. The phaco times were comparable to those of the standard phacoemulsification technique. Phakonit reduces the phaco energy used and shortens the total energy time. After the nucleus is chopped into small, pie-shaped fragments, each fragment is emulsified in pulse mode. The pulse mode increases the followability and safety margin and decreases the effective energy time.7 Foldable IOL technology has caught up with lens extraction techniques and has solved some, although not all, the demands of cataract surgery.8 The phakonit technique necessitates the insertion of an IOL through a 0.9 mm incision. At present, the Staar sub-2.0 mm foldable lens, the smallest commercially available IOL, is used in phakonit. With the change in the trend from small incision (⬎2.0 mm) to minimal incision (⬍2.0 mm) surgery,9 phakonit offers a new modality in the management of cataracts of all densities. This technique combines a very small incision with existing phaco technology without loosing the ability to efficiently remove brunescent nuclei. It is a reproducible, safe, and easy procedure with minimal intraoperative or postoperative complications. However, a learning curve is associated with conversion to this technique, and a clear understanding is required to prevent complications.
1552
References 1. Leaming DV. Practice styles and preferences of ASCRS members—2000 survey. J Cataract Refract Surg 2001; 27:948 –955 2. Dada VK, Sindhu N. Management of cataract—a revolutionary change that occurred during last two decades. J Indian Med Assoc 1999; 97:313–317 3. Gonglore B, Smith R. Extracapsular cataract extraction to phacoemulsification: why and how? Eye 1998; 12:976 – 982 4. Sachdev MS, Venkatesh P. Phaco intraocular lenses. In: Agarwal S, Agarwal A, Sachdev MS, et al, eds, Phacoemulsification, Laser Cataract Surgery and Foldable IOLs, 2nd ed. New Delhi, Jaypee Brothers, 2000; 416 – 427 5. Yamagami S, Yamagami H. Direct measurement of wound temperature during phacoemulsification. Ophthalmologica 1998; 212:50 –52 6. Alzner E, Grabner G. Dodick laser phacolysis: thermal effects. J Cataract Refract Surg 1999; 25:800 – 803 7. Grover AK, Kapur KB. Stop and chop technique. In: Agarwal S, Agarwal A, Sachdev MS, et al, eds, Phacoemulsification, Laser Cataract Surgery and Foldable IOLs, 2nd ed. New Delhi, Jaypee Brothers, 2000; 170 – 174 8. Rosen ES. Face to face with IOLs (editorial). J Cataract Refract Surg 1999; 25:729 9. Alio´ JL, De Iomo V. Cataract surgery with Dodick laser photolysis. In: Agarwal S, Agarwal A, Sachdev MS, et al, eds, Phacoemulsification, Laser Cataract Surgery and Foldable IOLs, 2nd ed. New Delhi, Jaypee Brothers, 2000; 263–270
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001