What are the recommended techniques and methods for cataract surgery, including phacoemulsification and intraocular lens (IOL) implantation?

Advances in Cataract Surgery Techniques: Phacoemulsification and IOL Implantation

Phacoemulsification with posterior chamber intraocular lens (IOL) implantation is the recommended technique for cataract surgery, offering superior uncorrected visual acuity outcomes compared to manual small-incision cataract surgery. 1

Phacoemulsification vs. Manual Small-Incision Cataract Surgery

Phacoemulsification demonstrates several advantages over manual small-incision techniques:

• Higher proportion of patients achieving uncorrected visual acuity ≥6/18 at 6 weeks (81.08% vs. 71.1%) 1
• Lower average astigmatism (1.1D vs. 1.2D) 1
• Better refractive outcomes with more precise IOL positioning

While both techniques show similar safety profiles with best-corrected visual acuity reaching ≥6/18 in 98.4% of cases for both methods, phacoemulsification results in better uncorrected vision, making it the preferred choice for most patients 1.

Advanced Applications of Phacoemulsification and IOL Implantation

High Myopia Management

Refractive lens exchange (RLE) using phacoemulsification with IOL implantation has emerged as an effective option for high myopia:

• Provides excellent intraocular optics compared to laser refractive surgery in high myopia 2
• Modern IOL formulas have improved predictability of refractive outcomes 2
• Offers presbyopia correction options through multifocal/accommodating IOLs or monovision 2

The risk of pseudophakic retinal detachment in high myopes has been significantly reduced with proper preoperative posterior segment evaluation and follow-up until complete posterior vitreous detachment 2.

Glaucoma Management

Combined approaches have shown efficacy in managing glaucoma alongside cataracts:

1. Phacoemulsification with endoscopic ciliary process photocoagulation:

   • Demonstrated 57% reduction in intraocular pressure (from 31.4 mmHg to 13.5 mmHg) 3
   • 50% of patients achieved good IOP control without medication 3
   • Minimal complications with improved visual acuity 3

2. Phacoemulsification with endoscopic goniosynechialysis (EGSL) for advanced PACG:

   • Effective reduction in peripheral anterior synechiae (mean difference: 202.7°) 4
   • Significant decrease in IOP (mean reduction: 9.4 mmHg) 4
   • Reduced need for IOP-lowering medications (mean reduction: 2.0 drugs) 4

Astigmatism Correction

Toric IOL implantation during phacoemulsification has expanded applications:

• Effective for irregular astigmatism with regular central component 5
• Significant reduction in residual astigmatism (from 1.99 ± 1.26 D to 0.65 ± 0.57 D) 5
• Improved objective visual quality indicators including modulation transfer function, Strehl ratio, and visual acuity at various contrast levels 5
• High patient satisfaction with postoperative VF-14 scale score of 83.99 ± 14.58 5

Clinical Pearls and Pitfalls

Pearls:

• Thorough preoperative assessment is crucial, especially in high-risk cases like high myopia
• Toric IOL rotation should be minimized (average rotation: 3.17 ± 2.01°) 5
• Combined procedures can address multiple ocular conditions simultaneously

Pitfalls to Avoid:

• Phacoemulsification may cause more immediate postoperative corneal edema compared to manual techniques 1
• Posterior capsular rents occur in both techniques but require careful management
• Potential complications of combined procedures include anterior chamber hemorrhage and exudation 4
• Posterior capsular opacification remains a common long-term complication 4

Decision Algorithm for Cataract Surgery Technique

1. Standard cases: Phacoemulsification with monofocal IOL implantation
2. Astigmatism ≥1.0D: Consider toric IOL implantation
3. High myopia: Phacoemulsification with careful IOL power calculation and posterior segment evaluation
4. Coexisting glaucoma:
   • Open-angle glaucoma: Consider combined phacoemulsification with endoscopic ciliary process photocoagulation
   • PACG: Consider phacoemulsification with EGSL
5. Irregular astigmatism with regular central component: Phacoemulsification with toric IOL implantation