 Hello, I'm Dr. Lloyd Williams. I'm in private practice in Salt Lake City, and I'm going to show you an example of how I like to do a cataract surgery. Keep in mind on this website you'll see many, many different ways of doing cataract surgery, and to some extent you have to find your own. To some extent it depends on who trains you, but this is a technique that works very well for me, and most of the pieces of this I learned from Alan Crandall and Bob Sione. So we'll just start looking at the video here. This is a nasal lid speculum. It's a Sione lid speculum, and I'm sitting temporarily. I prefer to sit temporarily in my cataract surgeries. Some people prefer to sit superiorly. I'm using a 1mm blade here to make my paracentesis, and the patient is under just topical anesthesia. So they're still able to move their eye around. There's no block or anything. I generally don't fixate the eye when I'm making my incision. I just ask the patient to hold still, and I find that if you do it quickly, there's generally no problems with that. Now I'm injecting lidocaine with preservative-free epinephrine. This gives me a little bit more anesthesia for the patient. Sometimes it stings, and so sometimes you'll have to warn the patient that this is going to sting. Next, I inject viscoelastic into the anterior chamber. I like to start on the far side and use the viscoelastic to push the lidocaine and BSS and aqueous out of the eye. And then I'll stabilize the eye with the viscoelastic cannula when I come with a keratome. Sometimes I use a diamond keratome. Sometimes I use a metal keratome as you see here. I make a bi-planar wound, so I go in sort of along the plane of the cornea. When I reach the mark on the metal blade, then I dive into the anterior chamber. Once that's complete, I pull both instruments out of the eye. Now this ring is a marker that I use to mark a 5mm capsule rexis, and that helps me get a very round rexis and a rexis which is the right size every time. I like to make my rexis with the uterata forceps, and in addition I start the rexis with the uterata forceps by making a little nick, and then I pull the rexis around. I begin by making a small pull to the right and then try to sweep most of the way through the subincisional in one movement and try to re-grab maybe two or three times throughout. But if I'm having difficulty with the rexis wanting to run out, I'll re-grab more and more often. Obviously the goal here is a nice round rexis that's the right size so that you'll have some overlap on the optic, but not very much overlap anywhere. I find that that last little bit at around 2 o'clock in the image is the place where I'm most likely to have run out, so I try to be very careful there to be pulling the uterata forceps towards the inside. Now this is a Chang cannula with BSS, and I use the Chang cannula for hydro dissection, and there you saw a nice wave of hydro dissection. You don't want to do this too vigorously because you don't want to damage the posterior capsule, but if you do it just gently, you should be able to get a nice hydro dissection. I usually hydro dissect on both sides of the lens to make sure that the lens is definitely free. And I also tend to tap down just a little bit if the patient doesn't have zonular weakness or pseudo exfoliation to make sure that there's no fluid behind the lens. Now I'm using an Akihoshi pre chopper. This is a technique I use in a soft to moderate lens. If I'm doing a much harder lens, I'll cut a groove with the FAKO handpiece. When you're rotating, you want to make sure that you put the tip in the lens, but don't push down too hard. If you push down too hard, what you'll get is you'll be pushing the lens against the posterior capsule, and it makes it more difficult to rotate. As you do this, you want to make sure you get a complete crack, and you also want to try to not stir up too much of the cortical material. As you can see, I've stirred up enough cortical material that the view isn't that great anymore. But if you can manage to not stir up very much of that, you'll have a really nice view of the cracks. If the view is too bad for you to see what's going on, you can put a little bit more viscoelastic in the middle, and that viscoelastic will push the cortex out of the way and restore your excellent view of those pieces. Now I'm coming in with the FAKO emulsification handpiece. This is through a 2.4mm wound, which is what I prefer. I think that if I were doing smaller wounds, the fact that I would have to enlarge the wound later to insert the lens is just an extra step. So in order to avoid extra steps, I just use the same size wound that I'm going to later use to insert the lens. I cleaned up some of the cortex there with the FAKO tip in order to make sure that the cortex isn't blocking my view. And now I'm trying to find a piece which is nicely mobile, and here we have this one that came out nicely, and now we're going to eat that piece with the FAKO emulsification handpiece. Once you're able to get one of the pieces out, I generally think your case is going to be much easier after that. Generally I find the first piece is the hardest piece to get out. I'm using a second instrument to help using that with my left hand to help rotate the lens around. If the lens is soft enough, I find I can lift up the whole hemisphere once I've taken the two smaller quadrants out. So oftentimes I won't bother to cut that last piece if it's soft enough and mobile enough that I can bring it up through the capsule rexus without having any difficulty or without overly stretching the rexus. Obviously if there's zonulopathy, pseudo-exfoliation or trauma or other things where you have weakness of the zonules, you'll want to be more careful with that. As you use your FAKO emulsification handpiece, in general you want to keep that handpiece tip right in the middle of the eye, well above the posterior capsule so that you don't grab the posterior capsule and rupture it with your FAKO handpiece. In addition, you want to come out in position one. You don't want to come out in position zero so that the anterior chamber stays inflated and you want to make sure that you pull your second instrument out before you take the FAKO out so that if the chamber does shallow, you don't end up damaging the posterior capsule with your second instrument. Now I'm using the IA tip and as you saw in my video on cortical removal, I like to go to a section of cortex which is very easy for me to get to first and when I can take that out, then I get a nice area so that one of the edges of the subincisional cortex is nice and clear of any attachments when I'm going to take the more difficult subincisional cortex. I also use an IA handpiece which is curved just a little bit so I find that helps me get the subincisional cortex better. When you first grab the cortex, you can cause less zonular trauma by grabbing it and moving your IA handpiece in a sweeping tangential motion rather than pulling straight that will distribute the force over more zonules. Also notice that as I'm taking the rest of the piece out, I'm rotating the IA handpiece so that the open portion of the IA handpiece is not pointed straight down at the posterior capsule so that when it finally takes that piece of cortex, the next thing it does is grab the posterior capsule. So I want to rotate that up so that when the last piece of cortex comes into the tip, it doesn't suck the capsule up with it. Now I'm going to put in some provis visceral acid. Make sure that I fill the bag nicely with it. I use provisc at this stage because the provisc is much easier to take out of the eye. We use the viscote at the earlier stage because the viscote tends to stay in the eye more. Now that I have the eye nicely inflated, we're going to do a polish of the underside of the anterior capsule. This is a capsule sweep and so I'm sweeping around to make sure that I sweep under my side port incision. Then we'll go to the side port incision and get the rest of the capsule, particularly the part which is under the main incision. I think that sweeping the anterior capsule helps you with reduction of summering's ring and reduction of phymosis and capsular fibrosis and could make a IOL exchange if it were ever necessary in the future more easy to do. Now I'm inserting a one-piece acrylic lens. This is a SN60WF. I'm using a wound assist because my wound is just the same size as the D cartridge so I can't put the D cartridge all the way in, but if you press it up nicely against the wound, you're able to insert the lens into the eye very well. I like to position it with the BSS cannula and then often we'll hydrate the wound a little bit so that after I finish my cleanup of viscoelastic and pull the IA handpiece out, the chamber doesn't shallow because the wound's already been a little bit pre-hydrated. By using the BSS cannula, then it's one less step of having to pass an instrument off and grab a new instrument. And so here I'm just hydrating the wound a little bit. Then we'll use the IA handpiece to get out the rest of the viscoelastic. At this stage, you just want to make sure you get all the viscoelastic out. You can go behind the lens with the IA handpiece. I don't think that's always necessary. You can use a rock and roll technique which is what I generally do where you press on one side of the optic which I just did there and you press on the other side to make sure that you get all of the viscoelastic out of the bag. I also want to go around the anterior chamber and make sure that I haven't left any viscoelastic in the anterior chamber, particularly viscote which can still be left up adherent to the endothelial surface of the cornea. Now I'm going to hydrate the wound again and hydrate the side incision and then we'll check the pressure. If the pressure is very high, we burp through the side incision. I'm also making sure that the lens is in the right position. So you saw as I checked the eye pressure there that it was high. So we're letting some fluid out of the side wound. One thing that the high eye pressure tells me is it tells me that my wounds are sealed if they weren't sealed the eye pressure wouldn't have gone up. So now I check again, it looks like a normal physiologic pressure. We generally use a Wexel tapping on both of the incisions to make sure that they stay dry. There's no fluid coming out of them. At this point I will inject 0.1cc of Vigamox into the anterior chamber. This has been demonstrated in some of the European trials to reduce the risk of endopthamitis. And then we'll check the pressure one more time. It's a little high so we burp some fluid. One last pressure check and everything's good. We'll put some Vigamox and Prednisolone on the eye, take out the lid speculum and we're all done. So again, this was I'm Dr. Lloyd Williams and this is how I do a routine cataract case on a patient with outzonylopathy and with a moderately dense lens. I hope this has been very helpful for you. I think this is a very useful and efficient technique and can give you cases that take about 7 to 9 minutes. Thanks very much.