 Hi, I'm Dr. Lloyd Williams. I'm the editor of the Moran Core International. Welcome to our site. Hopefully this material will be very helpful in helping you progress as you train to become an ophthalmologist and to cure blindness throughout the world. Today we're going to talk about cortex removal and capsule polishing. These are two very important steps of cataract surgery and mastering these steps will help improve the quality of your surgeries and your outcomes. Cortex removal is generally the last step in the removal of the lens portion of a cataract surgery and it's a very important step in order to have a good outcome. One reason is because retained cortex can lead to severe inflammation in the eye and even cause a patient to go blind. Therefore it's very important to remove all the cortex after a cataract surgery. Number two, retained cortex increases the risk of posterior capsule opacification which in the developing world particularly in cases where patients may not have access to a YAG laser can lead to blindness after the cataract surgery because of the opacification of the posterior capsule. Also, although small amounts of retained cortex can be sometimes absorbed by the eye, there is a modest transient increase in inflammation associated with retained small fragments of cortex and if you aren't able to see a patient with adequate follow-up or with adequate steroid eye drops, this extra inflammation could cause cystoid macular edema or other things that can result in decreased vision in your patients. Sometimes there is a piece of cortex that you're unable to remove without significant risk to the posterior capsule or to the zonules and in that case you may have to balance the risk of zonular loss or posterior capsule breakage against the risk of leaving a small amount of cortex behind. Here we have a video of cortex removal. This shows a technique that I like to use but there are many different techniques. I like to start with the IA handpiece or irrigation aspiration handpiece in an area of the cortex that is very easy for me to reach. You'll see that if you watch the vacuum on the side I put the the opening of the IA handpiece where I want it to be and then engage the vacuum to attach the cortical material to the IA handpiece. In addition I like to sweep somewhat tangentially to the arc of the capsule rexis so that the forces of pulling the cortex distributed among many areas of the zonules rather than just one focal area of the zonule and that's useful to help protect the zonules from the forces generated by stripping the cortex. In general the subincisional cortex the area just below the incision is the hardest to get to and so after I we'll go back a little bit after I get an area where it's easy for me to reach and I have a loose edge that's not attached to other cortex I believe that makes it easier to strip the cortex out so I'll start in an area where it's easy to get the cortex and then when I have that free edge I'll move into the subincisional cortex as you can see I just did here. I like to turn the port so that it faces the edge of the cortex exactly and engage and then as I'm stripping the cortex out I'll rotate the port of the IA handpiece away from the posterior capsule so it's pointed up so that once I pull the cortex into the IA handpiece I'm not likely to grasp the posterior capsule at the end of that. So we'll move on to another example this is cortical removal after femtosecond laser cataract surgery so here you see that the edges of the capsule the edges of the capsule here are smooth instead of ragged edges like with the conventional fecal emulsification those smooth edges can be a little bit harder to grab and add some challenge to removing the cortex and but in this case I take the same approach where I sweep tangentially start from an area that's easy to get to and work my way to the subincisional making sure that as I'm pulling the pieces out I'm rotating the tip upwards so that I'm not likely to grab the posterior capsule you'll notice here that I have a IA handpiece tip which has a bend to it that bend enables me to get the posterior cortical material a little bit easier some people prefer a straight tip some people prefer a tip with a 45 degree angle bend and some people actually will use the irrigation in one hand and an aspiration in the other hand in a method called bimanual and the bimanual technique allows you to have two small wounds so that when you can't get the subincisional on one side you switch hands and put the piece across so that you never actually have to get cortical material from underneath your wound because you're able to switch hands and switch which hand contains the aspiration port some surgeons advocate polishing that the anterior capsule there are some advantages to this number one it reduces anterior capsule fibrosis number two it reduces anterior capsule phymosis both of these processes can sometimes de-center a lens and in particular if you have a multifocal lens a torac lens or or another type of premium intraocular lens these lenses when de-centered can result in decreased best visual acuity and other aberrations that can affect the quality of vision for your patient in addition polishing the anterior capsule generally improves the ease of intraocular lens exchange if at some point in the future you were to need to do that there is no indication as of yet that it reduces posterior capsule of pacification polishing the anterior capsule can be done with a irrigation aspiration tip and polish mode which is a low vacuum mode or it can also be done with a capsule sweep or other devices in this surgical video we'll see removal of subincisional cortex after laser assisted cataract surgery and we'll see some things to avoid and we'll also see how to polish the capsule so here I'm grasping the cortex in an area that is easy for me to get to and then I'll move towards the subincisional cortex I do find subincisional cortex more difficult with femtosecond laser surgery on the side of the screen you can note that the top box shows me what the intraocular pressure is the middle box shows me the aspiration rate and the bottom box shows me vacuum there's no vacuum when the tip doesn't have something in it because you need to occlude the tip in order to build vacuum so we've gone around the eye and removed almost all of the cortex but when you see me remove the eye handpiece you'll see that there's a piece of cortex that remains right underneath the incision and that's right there so I'm going to make another attempt to get that piece but if it's too difficult or I'm worried about capturing the or tearing the posterior capsule what you can do is put in your viscoelastic now I'm adding provis viscoelastic here once once I fill the bag with viscoelastic I'm going to use a capsule sweep through the main incision to polish the under surface of the capsule so I've put the sweep in the bag and lifted it up just slightly to wipe the cells off the inside of the capsule then through the side port I can get the sub incisional and you can still see a little bit of cortex located right under the incision now I'm going to insert my one-piece acrylic lens once inserted it will begin to open up inside the eye and I I like to position it with a BSS cannula but you can position it with a variety of instruments including a Sinsky hook, a Kuglen hook or anything else that that you may have learned that works well for you in this case I've rotated the lens so that the haptics located right now to the left and to the right on the screen the haptics will not be impeding my ability to remove the cortex and I've moved the lens over so that it protects that area now I've inserted the IA handpiece in position zero I go immediately to position two with the tip located right at the edge of the cortex and it sucks it up right away the lens is now in place in the bag all the cortex is removed I'm removing the viscoelastic and we have ourselves a good case here so for those of you who were paying close attention you may have noticed early on in the case that I caught the capsular bag and you can see here with it paused that the capsular bag has little wrinkles that are all coming towards the IA handpiece you need to be very careful not to do this and if it happens most foot pedals have a setting where you can kick the pedal to the left or the right it be you should be aware of how your foot pedal works and that will cause fluid to come out of the tip rather than be pulled into the tip and allow you to let go of the posterior capsule without causing any damage in this case if you grab the posterior capsule you should not panic you should immediately pause don't move your hand don't pull on the capsule and kick the pedal over so that you'll allow that to be released if you happen to notice a tear in the capsule which can happen at a point like this then you should put viscoelastic in the eye before removing any of your instruments and make sure that the that you don't allow the eye to become depressurized so we'll look at that one more time and we'll also look at the removal of epinucleus at the same time as removal of cortex so here you can see the much thicker material is epinucleus and there's also cortex and as I go around I use the exact same technique and I pull both cortex and epinucleus into the IA handpiece and using these same techniques you should be able to easily remove cortex and epinucleus at the end of any of your cases now you can see a few strands on the back of the capsule in general you should not chase these strands although if there's dense material you may try to remove it chasing these strands can sometimes result in what you're going to see in just a second here which is right there again I've grabbed the capsular bag so my advice in this case is to when you finish the case and you've removed all the cortex to just take your instruments out and not keep moving around inside the eye and trying to get that one little last thing where you might end up causing a problem and as I call it snatching defeat from the jaws of victory in this case we didn't break the posterior capsule and we have an excellent result so in summary there are many different techniques and instruments this is one technique and I think this is a good one but you may find that other methods work well for you femtosecond laser cataract surgery and conventional fecal emulsification as well as small incision extra capsular cataract surgery each have their own unique aspects to removing cortex and you should be aware of each of them and be prepared for whichever type of case you're going to be involved in tangential traction on the cortex will result in less stress on the zonules by distributing that stress over more zonules rather than just in a focal defined area if you can't get a difficult piece of cortex and you're at risk of damaging the posterior capsule what you can do is place the lens and then get the cortex using the lens to protect the posterior capsule don't chase small strands like we saw in the previous case and thus risk ruining what was otherwise a good case remove posterior plaques that may be present in the center portion or the visual axis but if they're too tightly adherent to the posterior capsule don't pull on it until it breaks you can come back a month or two later and do a gag capsuleotomy in order to remove that posterior plaque that's better than breaking the posterior capsule and having to do a vitrectomy some surgeons advocate polishing the anterior capsule it's something that I commonly use in my practice but it's probably not necessary and so you you'll have to make a judgment about that for yourself so this is Lloyd Williams I hope this has been a very useful talk for you and I congratulate you on your studies and I wish you all the best in becoming an ophthalmologist thank you very much