EasyPhaco technology (Oertli Instrumente AG, Berneck, Switzerland) allows coaxial phaco with high vacuum and high fluid flow through a 2.5- mm wound. This cataract platform offers superb followability combined with good anterior chamber stability. It makes fragment removal easy and efficient.

I have used several techniques and platforms in the past. Before EasyPhaco was available, coaxial microincision cataract surgery (MICS) was my standard phaco technique. Coaxial MICS is efficient for small incisions, but because I enlarge the wound to implant my preferred lenses, I now favor the efficiency of EasyPhaco. Based on the efficacy of this technology, I have significantly reduced phaco energy levels with EasyPhaco, leading to even better results on postoperative day 1.

I teach cataract surgery to surgeon trainees using this technology, and I find that its ease of use facilitates learning the steps of phacoemulsification surgery. Some of the phaco pointers that I teach are outlined in this article.

TECHNIQUE AND MATERIALS
Surgical preparation. This is an essential step for the prophylaxis of endophthalmitis. I do not use antibiotics preoperatively unless the patient presents with significant blepharitis. I use 10% povidone iodine to thoroughly disinfect the area around the eye. I pay close attention to rubbing the skin and allowing time for the agent to dry. Additionally, I use 1% povidone iodine eye drops for the conjunctiva. This is followed by careful draping of the eye, including covering the eyelashes.

Incision size. I use a 2.5-mm single-step clear corneal incision. The placement of the incision is determined by the keratometry readings, with the aim of reducing existing corneal astigmatism. In some teaching cases, I use a sclerocorneal tunnel to demonstrate the technique.

Capsulotomy. I prefer a simple bent needle rather than capsulorrhexis forceps. When operating under topical anesthesia, capsulorrhexis creation can be the most dangerous step of the procedure if the patient moves his eye. In this case, the needle is much safer than forceps.

I believe that young surgeons should master capsulorrhexis with a bent needle first. With routine use, one can be nearly as fast as with forceps. I like to place the needle on the viscoelastic syringe because it is essential to maintain chamber depth at all times. I use Vision Blue Staining Solution (DORC International BV, Zuidland, Netherlands) in dense cataracts and high-frequency Klöti capsulotomy (Oertli) to finish the rhexis if things go wrong. In case high-frequency capsulotomy is unavailable, I use a classic can-opener technique to finish opening the capsule.

Nucleus mobilization. I prefer to perform complete hydrodissection and avoid hydrodelineation because it is bothersome to remove the epinuclear shell afterward.

Nucleus removal. Because I teach cataract surgery to beginners, I prefer a clean, standard, four-quadrant divide-and-conquer technique for nucleus removal. I still think it is the safest and most efficient technique for a wide range of cases and should be taught to beginners. In my own cases, I usually evolve into a variation of phacochop or pre-chop.

Cortical clean-up. I use a rough-tipped irrigation and aspiration instrument with a bimanual I/A technique. This allows safe clean-up and polishing of the anterior and posterior capsules without needing to use multiple instruments.

IOL insertion. I prefer hydrophobic acrylic IOLs for routine cases. An up-to-date IOL should offer a sharp edge, an aspheric optic design, and a large optic (ie, at least 6 mm). The efficacy of blue-light filters is not evidence- based, but I still use yellow lenses in most cases. For IOL implantation, I do not like to enlarge the wound. The implantation technique and lens should be tailored to the phaco technique used. Of course, injectable lenses (resulting in a hole in one in most cases) are state of the art, and a preloaded lens is also nice to have.

Wound closure. In most cases, the wound is sealed tight. In cases where it is not, I like to use a bit of air in the anterior chamber to seal it from the inside for 1 day. Regarding antibiotic prophylaxis, I follow the European Society of Cataract and Refractive Surgeons (ESCRS) guidelines and use intracameral cefuroxime (1.0 mg cefuroxime in 0.1 mL saline 0.9%). I patch the eye with tobramycin/dexamethasone ointment. I carefully lift the upper lid over the eye and make sure that there is a fair amount of ointment on the wound and paracenteses.

DIFFICULT CASES
Surgeons must develop a routine technique that works in difficult cases as well as standard cases. In my opinion, if a surgeon resorts to unfamiliar techniques in these situations, the risk of failure is higher. I still use my needle rhexis, divide-and-conquer-chop technique in difficult cases. However, I pay extra attention to perfect hydrodissection, careful cracking, and extra-gentle cortical cleanup. And, of course, I use technical variations such as pupil dilators, a highly viscous ophthalmic viscosurgical device, or capsular tension rings based on the situation.

DOWNSIDES?
Some surgeons who prefer to implant lenses through a smaller incision may find it a drawback that the EasyPhaco technology requires a 2.5-mm wound. In my case, the challenge I face with this platform is that it is almost too easy for teaching. For example, all that is required to remove the quadrants is to keep the phaco tip on the level of the rhexis and to push on the footpedal. The machine removes the quadrants almost by itself, and chasing the fragments is not needed. If beginners start with a technique this easy, they may not be prepared to master more difficult techniques in the future.

Florian Sutter, MD, is a Consultant in the Department of Ophthalmology, University Hospital Zurich, Switzerland. Dr. Sutter states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: florian@sutter-adler.ch.