This document discusses techniques for performing cataract surgery on soft cataracts. It notes that soft cataracts in younger patients are becoming more common. Standard phacoemulsification techniques like chopping and cracking require a harder nucleus. For soft cataracts, the document recommends techniques like tilt and tumble, phaco flip, soft chop, and nucleus prolapse that rely more on hydrodissection and manipulation of the nucleus rather than cracking. It emphasizes the importance of thorough hydrodissection when operating on soft lenses. The document also provides guidance on viscoelastic use and phacoemulsification settings for gentle removal of soft cataract material.

1. Soft lens should not be hard work
Dr. Sanjay Kumar Gupta
M S (Ophtho.)
Agrawal Eye and Skin Hospital, Kota & Bundi

2. Why worry about the soft lens
- patients are now presenting with early cataract
-concept of surgery of hard hypermature cataract is
now loosing popularity
-Surgeons are now more proficient in refractive
lens surgery beyond cataract surgery
-Complaints of glare and difficulty in driving has
driven the pts for early cataract removal

3. Difficulty in soft cataract
• At 30-40 yrs age - spongier lens
• At 60-70 yrs age – hard Lens
• cataract surgeons are used to routine chopping &
cracking a nucleus
• D & C, Phaco chop require a nucleus with
hardness

4. Hydrodissection
• Do hydrodissection & hydrodelineation both
• Surround the entire nucleus with fluid
• Tend to have sticky cortex adherent to the
nucleus & capsular bag – difficult to get
adequate hydrodissection
• Hydro dissection in multiple region not just in
1 or 2 spot but should be 4 or 5.
• Try to get as much rotation as possible

5. Hydro dissection
• It is very difficult to engage the nucleus
material with whatever instrument you’re
using to rotate the nucleus becoz it is so soft
• So it just runs right through the nucleus and
doesn’t separate itself from the cortex &
capsule
• Getting a good hydrodissection will reduce the
problems later

6. Techniques of phaco in soft cataract
• 1. Irrigation Aspiration
• 2. Tilt and Tumbling
• 3. Phaco Flip
• 4. Soft Chop
• 5. Phaco Chip and Flip
• 6. Divide and Conquer
• 7. Supracapsular Phaco

7. Tilt & Tumble technique
• Modified form of supracapsular phaco
• Tilt one pole of the nucleus above the ant
capsule
• Require large rhexis 5 to 5.5 mm
• Slow continuous Hydrodissection is performed
after tenting ant capsular rim- see the fluid
• nucleus tilt on one side up and out of the
capsular bag
• Nucleus is rotated to face the incision

8. Tilt and tumbling method

9. Tilt and tumbling

10. Phaco Flip
• Complete hydrodissection
• With lens spatula or kuglen hook, engage the
nucleus at 12 o clock and push the nucleus
towards 6 o clock  allow the inferior pole to
come out of the rhexis  nucleus is now
resting like a coin with inferior equator facing
back of cornea
• Routine phacoemulsification started
• Use dispersive viscoelastics to avoid
endothelial damage

11. Nucleus prolapse technique
• Simplest technique
• First do hydrodissection
• Then rotate or spin the lens
• Then do hydrodelineation and allow the
nucleus to prolapse with the fluid wave
• Leaving the epinuclear plate into the bag
• Phaco setting vaccum linear- 0-350, asp flow-
30, power minimal

12. Soft chop
• No vaccum
• Phaco tip can rapidly move through the soft lens
material into the cataract
• Phaco tip just hold and support the lens nucleus while
slicing through the lens with chopper moving the
chopper in a horizontal fashion just to the left of the
phaco tip
• The lens does not always dramatically break into pieces
• Nucleus usually comes into AC during soft chop

13. video

14. Viscoelastics
• Always use sodium hyaluronate 1.4% for
rhexis (cohesive)
• Use dispersive visco like viscoat to prevent
endothelial damage
• Soft shell technique is what we recommend
• Vaccum – high
• Asp flow rate – high
• Power - low

15. • thanks for sincere listening