Soft Cataract SupraCapsular Technique

How do you approach a soft cataract, such as a posterior sub-capsular or primarily cortical cataract, with very little nuclear density? Using the standard methods such as Phaco Chop, Stop-and-Chop, or Divide-and-Conquer may not work well because they all rely on a minimum level of nuclear density in order to propagate the chop or the crack. A better approach in these patients is a supra-capsular technique where the nucleus is prolapsed out of the capsular bag and brought to the iris plane.

The key to the surgery is to have a sufficiently large capsulorhexis and then to do slow and steady hydro-dissection to separate the cataract from the capsular bag. Further hydro-delineation can help further break apart the cataract. For both of these, I use a 3 cc syringe with a 27 ga blunt cannula and balanced salt solution. The technique is slow and steady, not forceful.

The danger of using a standard in-the-bag phaco technique is that due to the soft nature of the cataract the phaco probe can power right through the lens material and puncture the posterior capsule. This can lead to a host of complications and a poor visual outcome for the patient.

The supra-capsular technique is closer to the corneal endothelium but since the cataract is soft, there is a minimal amount of ultrasonic energy used. Often the ultrasonic energy is zero since the cataract can simply be aspirated by the phaco probe with vacuum only.

The results of supra-capsular phaco for soft cataracts are great: clear corneas, high margin of safety, highly efficient, and excellent visual results for our patients.