No fancy tools, no extra cost—just genius tips from cataract surgery’s global leaders.
Some surgeons make cataract surgery look deceptively simple, and in this session, chaired by Prof. Graham Barrett (Australia), Dr. Abhay Vasavada (India) and Prof. Ronald Yeoh (Singapore), the world’s leading surgeons revealed the subtle maneuvers and pearls that can transform surgical practice. Each speaker had just four minutes to share one powerful tip delegates could use tomorrow in the OR without expensive equipment.
Primary posterior capsulorhexis for perfect centration
Prof. Burkhard Dick (Germany) opened with his approach to primary posterior capsulorhexis for long-term stability and prevention of posterior capsule opacification. “The aim of this case and this technique is to have instant refractive stability, perfect centration forever as well as no PCO,” he said.
He detailed how he begins with two paracenteses and a self-bent 27-gauge needle, carefully elevating the posterior capsule while avoiding overfilling with OVD. “You elevate, you do not overfill, and you just wipe it to the side—then you’re always safe,” he advised. Once the posterior rhexis is complete, he prefers a three-piece IOL, though he noted that a one-piece can also be centered securely.
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Impale, pull, rotate
Prof. Chee Soon Phaik (Singapore) captivated the room with a deceptively simple tip for cases of weak zonules, which she described as “nucleus rotation pseudoelasticity.” She explained, “When you try to rotate, it bounces back to the original position.” Instead of relying on additional capsule hooks, she proposed a practical maneuver: “Impale with my port on the side, and then I swivel it round, bring it inwards and then without letting go of my vacuum, I chop.”
This technique, she explained, allows the nucleus to be rotated centripetally without pushing against fragile zonules. “You do not actually push against the capsular bag equator,” she emphasized.
Managing subluxated lenses with capsule retractors
From Austria, Prof. Claudette Abela-Formanek shared strategies for handling traumatic or congenital subluxated lenses. “When you remove the vitreous from the anterior chamber, do not remove all the vitreous from behind it because the lens will just fall backwards,” she cautioned. Using capsule retractors and careful hydrodissection, she demonstrated how to stabilize and remove such lenses while avoiding vitreous loss.
For secondary implantation, she favored four-point fixation, often with a MicroPure or Soleko lens, and described her experiences using both Prolene and Gore-Tex sutures. “This is actually a very easy method and it’s fantastic,” she concluded, showing long-term results in patients with Marfan syndrome and other complex cases.
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Safe disenclavation of iris-fixated lenses
Prof. Sri Ganesh (India) addressed complications in iris-claw lens fixation. He highlighted the challenges of repositioning lenses without damaging the iris. “It’s very difficult to disenclavate a lens… and you can’t reuse this lens,” he said, showing dramatic cases of iris trauma from attempted removal.
His solution, the “drainage technique,” involves using a 27-gauge needle via the pars plana to gently disengage the haptic from the iris. “This is a very safe technique of disenclavation and then removal,” he noted, adding that it allows surgeons to re-fixate or replace the lens without risking catastrophic complications.
Hydrodelineation for safety
Dr. Ruth Lapid-Gortzak (Netherlands) advocated for routine hydrodelineation. She described the “golden ring” as a key sign of a complete delineation and showed how the technique reduces stress on the capsule. “It separates the nucleus from the epinucleus with BSS. We have the epinucleus forming a shell in which it’s safer to do phaco,” she explained. Even in hard nuclei, she said, the delineation line—sometimes golden, sometimes black—offered both guidance and protection.
Cataract surgery behind corneal scars
Dr. Artemis Matsou (Greece) presented her approach to cataract surgery in eyes with dense corneal scarring, performed in combination with keratoplasty. “The problem is that you cannot visualize it,” she said, describing how she uses deep lamellar dissection under intraoperative OCT to improve the view while maintaining corneal stability.
“The key is not to go too deep because if you reach Descemet’s membrane, it will not endure the turbulence of phacoemulsification.” She stressed that the technique is best suited for surgeons with corneal expertise but encouraged colleagues to “work with your corneal colleagues” when faced with such cases.
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Don’t miss the epinucleus
Prof. Jong Suk Song (South Korea) offered a cautionary tale from a young trainee’s first case. The surgery seemed successful, but the patient’s vision dropped postoperatively because a thick epinucleus had been left behind. “Yes, there is an epinucleus left in the capsular bag, but she didn’t notice it,” he explained.
He demonstrated how to recognize and avoid this pitfall: “When you perform the nuclear rotation after hydrodissection and delineation, you have to pay attention to the remaining thickness of the epinucleus around the nucleus.” He urged experts to look for capsular wrinkles as a clue and to always remove the epinucleus fully to prevent complications.
The ‘One’ technique
Dr. Stephen Cook (South Africa) distilled his philosophy into a minimalist concept he called “One.” Using only one blade, one rhexis maneuver and one-handed pre-chop phaco, he emphasized efficiency, economy of movement and fewer instruments. His message underscored the session’s theme: simple steps can dramatically improve safety and reproducibility.
“Side-port syndrome” and wound architecture
Runner-up in the audience vote, Dr. Thanapong Somkijrungroj (Thailand) tackled what he called “Sipe-port syndrome,” the difficulty of accessing the anterior chamber through an improperly sized side port. He explained, “When we enter the chamber, we cannot enter it because the wound is too small.”
Using careful analysis of wound architecture, he recommended adjusting blade entry angles to achieve the ideal size. “0.6 to 0.8 millimeters is a very good size,” he advised, noting that too small a port restricts instruments while too large risks leakage and instability.
The “Yowsa” technique
Prof. Gerard Sutton (Australia) presented the “Yowsa” technique for cortical aspiration. “You yips, occlude, you wiggle, you sweep and you aspirate” was designed to improve efficiency and safety in cataract surgery. He also emphasized the use of an IOL scaffold during lens exchanges to protect the capsule and reduce vitreous loss.
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Heads-up display (HUD) surgery
Prof. Hisaharu Suzuki (Japan) showcased the potential of heads-up display (HUD) technology. “Use of HUD brings about a variety of advantages to eye surgery,” he said, noting enhanced visualization through digital filters, improved ergonomics and flexibility for both surgeon and patient positioning. “This can alleviate stress due to reduced visibility,” he explained, adding that HUD may shape the future of cataract surgery training and practice.
The second port technique
Assoc. Prof. Prin Rojanapongpun (Thailand) closed with a straightforward yet powerful solution for removing stubborn sub-incisional cortex. When coaxial I&A fails, he simply creates a second port opposite the main incision and reorients his aspiration tip.
“The beauty of this technique is that it’s very easy. It’s very efficient, you don’t need any training to do that, and it eliminates all the trauma of the cornea and iris,” he explained. He acknowledged that he uses it rarely but emphasized its value as a rescue technique for residents and less experienced surgeons.
The verdict
After all twelve speakers had shared their wisdom, delegates cast their votes. The winner of the Wisdom from the Gurus session was Prof. Chee Soon Phaik for her innovative “impale, pull, rotate” maneuver, with Dr. Thanapong Somkijrungroj earning runner-up honors for his insights into side port optimization.
The session reinforced the timeless lesson that even in an era of high technology and advanced devices, the greatest wisdom often lies in the simplest, most elegant solutions.
Editor’s Note: The 37th annual meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2025) is being held from 21-23 August in Ahmedabad, India. Reporting for this story took place during the event. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.