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Editorial 
 
 

March of Time 
 
 
Innovations in Cataract removal methods have been and 
are an ongoing process all along. 

Transitions from couching to intracapsular, 
extracapsular, IOL transplantation and somewhat recently 
to Phacoemulsification were undertaken with traditional 
anxiety and reluctance because of the realization that 
progress is inevitable and while remaining static would 
mean becoming decades behind the progressing world. As 
a matter of fact if one has not changed his surgical 
technique in the last three to four years he is already left 
behind one generation, likely to be labeled as outdated and 
under a serious threat of getting out of business. 

Once convinced of the benefits of Phacoemulsification 
and having crossed the hurdle of learning curve we soon 
became comfortable and confident with this technique 
passing on the benefits of Phacoemulsification to our 
patients who are now lot more happy, satisfied and 
unsacred of undergoing cataract surgery. 

We kept on improving our techniques every now and 
then from divide and conquer to chopping with lesser use 
of ultrasonic power aided by pulse, burst and now micro 
pulse, micro burst modes, along with availability of better 
machines providing safer fluidic controls etc. 

The main advantage of Phaco over ECCE was smaller 
incision with more secure wound, less induced 
astigmatism with fewer post operative complications 
particularly the dreaded post operative endophthalmitis. 

6.5mm Phaco incision size required for rigid IOL was 
soon reduced to 3.2 mm with the availability of foldable 
lenses and in this technique the Phaco tip had an irrigation 
sleeve over it hence called co-axial Phaco emulsification. 
Further reduction in incision size to less than 2mm 
required irrigation through chopping instrument while the 

Phaco tip was used without a sleeve to negotiate through 
very small incision and hence called bimanual or non co-
axial technique and through this small incision thin 
rollable lenses could be inserted with all the advantages of 
micro incision surgery (Phaconit or micro incisions 
surgery). 

With the availability of even thinner rollable IOL, there 
is further tendency towards even smaller incision (micro 
incisions about 1.5 mm and even recently about 700 micron 
micro phaconit) using the bimanual or non co-axial 
technique. Despite these enthusiastic recommendations of 
micro incision and bimanual technique the dilemmas with 
it are no less trivial due to inherent problems of wound 
leakage around the sleeveless tip, insufficient infusion 
through chopper with more chances of chamber instability, 
instances of wound burn and chattering of leas pieces, with 
resultant sub optimal operative outcomes. 

Hence a newer thinking is developing with the 
recommendations of constructing micro incision (sub 2 
mm even upto 1.5 mm similar to bimanual technique) but 
with micro coaxial system using finer tips with thinner and 
narrow bore sleeves retaining the benefits of coaxial system 
along with micro incisions providing better fluidic control, 
securer wounds, practically astigmatism neutral, with lesser 
incidence of post operative complications retaining the 
possibility of using thin reliable IOLs with already proven 
stable and predictable optical qualities or choice of 
implanting newer thinner foldable lenses. 

 
 

M Lateef Chaudhry 
Editor in Chief 

Pakistan Journal of Ophthalmology