Posterior polar cataract: Hydrodissection and nucleus rotation in manual small-incision cataract surgery not a taboo with proper fluidics

A posterior polar cataract is a discoid posterior polar plaque-like cataract with a thin and fragile to absent posterior capsule with adherent acellular opacity to the capsule reported in the literature. It is a stationary or slowly progressive opacity. A higher risk of complications such as posterior capsular tear and nucleus drop makes this a challenging surgery. The techniques described in the literature include bimanual irrigation aspiration, leaving the plaque for later Yag, bimanual micro phaco, Lambda technique with dry aspiration, Phaco if opacity <4 mm and soft nucleus, pars plana vitrectomy (PPV), pars plana lensectomy (PPL) if opacity >4 mm and soft nucleus, intra-capsular cataract extraction (ICCE) and scleral fixated intraocular lens (IOL) if opacity >4 mm with the hard nucleus, viscodissection, 3 ports PPL, PPV, low parameters phaco, modified epinucleus removal, inverse horse-shoe technique, standard phacoemulsification, chip and flip for soft cataracts, stop and chop for hard cataracts, layer-by-layer phacoemulsification, standard lens aspiration, pars plicata posterior vitrecto-rhexis, manual small-incision cataract surgery, and conventional extracapsular extraction. A posterior capsule rupture rate of 0 to 36% is reported in different series for cataract extraction. To prevent this dreaded complication, surgeons used many modifications. Minimal hydrodissection in posterior polar cataract extraction was described by Fine et al. The authors describe a technique of low flow manual small-incision cataract surgery with minimal hydrodissection and nucleus rotation with no associated posterior capsule rent. This demonstrates that if the fluidics is understood and corrected, then minimal hydrodissection and nucleus rotation is not taboo in posterior polar cataract extraction by manual small-incision cataract surgery.

Tunnel-floor entry continuous curvilinear capsulorhexis technique: Rhexis in a controlled and stable anterior chamber always

Continuous circular capsulorhexis (CCC) was demonstrated independently by Thomas Neuhann, Kimiya Shimizu, and Howard Gimbel in the 1980s and it finds mention in the landmark paper by Gimbel and Neuhann. The authors describe a technique of achieving the rhexis in a stable, viscoelastic-filled anterior chamber using the tunnel floor as the entry. This gets covered by the roof of the tunnel postoperatively and, therefore, does not leak. There is no oar-locking or striae even when cystitome goes beyond the edge of the tunnel. As there is no escape of the viscoelastic substance, there is no change in the pressure or shallowing of the anterior chamber. It is a useful technique for beginners. It is of great help in difficult cases like intumescent cataracts, shallow anterior chambers, hyperopes, nanophthalmos, pseudoexfoliation, small non-dilating pupils, intraoperative floppy iris syndrome (IFIS), and phacomorphic glaucoma.