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We describe a technique that relocates the phacoemulsification process outside the capsular bag by transposing the nucleus through an intact 5.0 to 6.0 mm capsulorhexis. The upside-down nucleus is then returned to the posterior chamber, positioned above the anterior capsule in the "supracapsular space" where it remains throughout the phacoemulsification procedure of choice: cracking, chopping, manual prechoping, or traditional sculpting. The chief advantage of supracapsular phacoemulsification is greater efficiency, which is manifested in reduced emulsification time and energy. Disadvantages include the possibility of mild postoperative corneal edema during the earliest part of the learning curve, as well as inadvertent damage to the iris in cases with suboptimal pupil dilation.

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We evaluated three general strategies for dealing with astigmatism control following phacoemulsification with posterior chamber intraocular lens surgery: (1) a neutral wound closure to minimize surgically induced cylinder; (2) wound revision techniques to minimize residual postoperative cylinder; (3) astigmatic keratotomy incisions to treat preexisting astigmatism. With the neutral wound closure, mean postoperative keratometric cylinder averaged less than 1 diopter (D). In the presence of moderate preoperative astigmatism (1.0 D to 1.9 D), the wound revision technique tended to undercorrect, while the astigmatic keratotomy tended to overcorrect. However, the keratotomy procedure resulted in less postoperative cylinder. For cases with substantial preoperative astigmatism (greater than or equal to 2 D), the astigmatic keratotomy groups corrected more of the preoperative cylinder, which resulted in a greater proportion of cases with less than 1 D of postoperative cylinder and a smaller proportion with more than 2 D. Results suggest that astigmatic keratotomy is a useful adjunct to correct preexisting astigmatism in cataract patients. However, this procedure as any incisional refractive surgery technique has a certain amount of inherent biological variability.

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