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Today's Practice | Jan 2014

Evolving Techniques for IOL Implantation

In the beginning, IOL implantation was cumbersome, but today's methods are practical.

When I started practicing cataract surgery in the 1980s, use of a phaco device for nucleus removal was not practical. Because the technology was new and its use was limited to a small number of cataract surgeons, phacoemulsification techniques were not well developed.


The first phaco procedure I learned was cumbersome. First, a 6.5-mm incision with blade and scissors was created. Capsulotomy was performed with a can-opener technique, and no hydrodissection was used. In order to maintain anterior chamber stability during the phacoemulsification phase, two silk sutures were used to temporarily reduce the 6.5-mm incision to a size of about 3.0 mm. These would be removed if the surgeon had to convert to extracapsular cataract extraction (ECCE)—which happened often. If phaco was successful, the cortex was removed with a one-piece I/A device.

Because no ophthalmic viscosurgical device (OVD) was yet available, the PMMA IOL was commonly implanted into the sulcus under air. The procedure was completed by closing the large incision with a continuous suture, which could induce up to 6.00 D of astigmatism.


Over the years, my personal phaco technique—just like phaco technology—has evolved. I have developed a method that works for me, and, for the past few years, my technique has not changed much. It starts with a circular capsulorrhexis, which I create with a cannula inserted through a 0.4-mm incision. The cannula is attached to the irrigation handpiece of the phaco machine, and I do not use OVD for this stage of surgery unless the anterior chamber does not deepen sufficiently with the irrigation pressure or I suspect that the capsule may tear due to intracapsular pressure from a hypermature cataract. Both of these scenarios are rare.

In eyes with corneal opacity, white cataract, or progressive pseudoexfoliation, I stain the capsule with trypan blue dye, without an air bubble, to aid with the capsulorrhexis. The dye is rinsed out with balanced saline solution.

Incision size and location vary depending on the case. I typically use a 2.4- to 2.8-mm scleral tunnel incision placed at the 12-o’clock position. I use a clear corneal incision in the approximately 20% of patients with glaucoma or suspected glaucoma. I prefer the sclerocorneal incision because of its lower risk of endophthalmitis. My methods of hydrodissection, phacoemulsification with a divide-and-conquer technique, bimanual cortex removal, and IOL implantation under OVD all follow current worldwide standards.


Compared with the cumbersome phacoemulsification technique that I learned in the 1980s, the most important and practical evolutions in cataract surgery are the self-sealing incisions, circular capsulorrhexes, and foldable IOLs in use today. Microincisions of less than 2.0 mm are of comparatively minor importance, as they have not significantly improved refractive predictability or complication rates, nor have they reduced surgical time.

I implant aspheric IOLs relatively rarely, mainly to avoid the symptoms of night myopia. When I do use an aspheric IOL, it is carefully chosen based on the patient’s corneal tomography and ray tracing. In the vast majority of patients, however, I feel that the pseudoaccommodation provided by a spherical IOL is more beneficial. Additionally, I only implant multifocal IOLs in patients who have a multifocal IOL implanted in their first eye by another surgeon and who request the same IOL in their second eye. I implant toric IOLs, but less frequently than I see an indication for their use. The reason for my reservation is that they are not reimbursed very reasonably in our country.

Paul-Rolf Preussner, MD, PhD, practices at the University Eye Hospital, Mainz, Germany. Professor Preussner states that he has no financial interest in the products or companies mentioned. He may be reached at pr.preussner@uni-mainz.de.