Cataract surgery has gone through an enormous evolution over the past 40 years. We have witnessed the changing of the guard from intracapsular to extracapsular cataract surgery and the development of anterior and posterior chamber IOLs.

Since the early 1990s, we have shifted to small-incision phacoemulsification and are implanting foldable IOLs. Today, microincision cataract surgery is gaining more interest among cataract surgeons. The newest-generation phaco machines, IOL designs, and injection systems have helped cataract surgeons perform phacoemulsifcation routinely, and without great difficulties.

But, everybody faces extraordinary situations once in a while. We all see patients with challenging or complicated cataracts, and we all end up in a complicated situation during cataract surgery. In this issue, some of our highly respected colleagues will review a variety of challenging and complicated cataract cases.

Managing simultaneous bilateral cataracts still remains controversial; in some countries, national ophthalmic society guidelines prohibit this treatment. In this issue, John Chang, MD, discusses its benefits versus potential risks and disadvantages. Pediatric cataract surgery is a sub-subspecialty—performed by a limited number of surgeons—with very specific surgical requirements and challenges. Charlotta Zetterström, MD, PhD, gives us an update on this very demanding type of surgery and its postoperative follow-up.

Following the ESCRS endophthalmitis study, Peter Barry, FRCS, describes his own protocol to minimize the incidence of endophthalmitis. He also emphasizes the importance of a well-sealed incision. Personally, I fully agree that this aspect deserves more attention. Many colleagues underestimate the potential weakness of a suboptimal constructed clear corneal incision.

I highly recommend reading the article on anterior vitrectomy by Som Prasad, MS, FRCS(Ed), FRCOphth, who describes his approach of dealing with a posterior capsular tear and vitreous loss in a systematic and practical way. This educational article may help us to obtain more consistent patient outcomes.

Posterior chamber plate-haptic lenses are no longer widely used. For those who may still encounter a malpositioned plate-haptic lens, Boris Malyugin, MD, PhD, proposes his strategy to fixate such a dislocated IOL in situ. At the end of his article, he mentions that his technique is very challenging. I believe him! In an upcoming issue, we will present a mini focus on treating other types of malpositioned IOLs.

In my opinion, one of the greatest advances in phaco technology is the development of torsional ultrasound. I was an early investigator of this exciting new technology and therefore not completely unbiased. Nevertheless, the OZil (Alcon Laboratories, Inc., Fort Worth, Texas) oscillatory ultrasound modality is a powerful new tool to tackle all kinds of challenging cataract cases. The OZil low-fluidics strategy has been sight-saving in many cases in our clinic.

Luis J. Escaf, MD, gives us a view on the future of handling rock-hard cataracts. His invention (Ultrachopper, manufacturer and Dr. Escaf have signed a confidentiality agreement) is a fantastic idea that divides very dense nuclei into multiple pieces. It is essential to obtain completely free and mobile nuclear fragments before emulsification. Currently, we all struggle to crack or chop dark brown cataracts. I had the opportunity to evaluate this new device last year, and I am enthusiastic about it! Unfortunately, it is not expected to be on the market until mid-year 2008.

Future innovations and new surgical techniques will most likely continue to improve the way we help our cataract patients. I greatly appreciate the efforts of the many colleagues from around the world and the engineers of the ophthalmic industry who help us to accomplish this goal.

I hope that this issue will be helpful to you in your daily practice, and I look forward to reading future contributions to this journal.