Phaco for soft lenses

Alot is written about phaco on hard lenses; but, in many ways the soft lenses are the most dangerous.  Soft lenses tend to jump to the phaco needle which can lead to capsule rupture.  soft lenses are hard to crack which can make the divide and conquer very difficult.  Here i discuss 2 strategies for soft lenses to increase safety for these tricky lenses.

Prolapse.  The simplest strategy for very soft lenses is to simply prolapse the soft lens into the anterior chamber.  even better is to prolapse just the nucleus.  First i like to hydrodissect, careful to keep the cannula over the lens, to avoid prolapse.  then spin the lens.  Then perform hydrodelineation and allow the nucleus to prolapse into the anterior chamber.  in a perfect world you can just prolapse the nucleus (sometimes soft lenses have a denser central core) and leave the epinuclear material in the bag.  Then remove the nucleus with the phaco needle with epinuclear settings (linear control of vacuum 0-350, asp at like 30-35 fixed, little power or ozil).   remove the epinuclear material with the phaco needle and a shizzle manuever or with the I/A tip.

Soft Chop.   The technique I like best for the soft lens is to use a soft chop with no vacuum.  avoiding vacuum is very important as the phaco needle can rapidly move through the soft lens material into the capsule.  The idea is to use the phaco needle to hold and support the soft lens while slicing through the lens with the chopper.  as you can see in the video below, you will not be able to use the usual chop where you embed and hold the nucleus and cannot use a vertical chop.   instead the phaco needle simply supports the lens and the chopper goes deep (I like the Siebel chopper) and moves in a horizontal fashion just to the left of the phaco needle moving to the left when reaching the needle to split the lens.  the lens does not always dramatically break into pieces.  however after you slice the lens into pieces (i usually use 6) you will find that the lens will come into the anterior chamber with epinuclear setting (similar to those above).  often the nucleus comes first leaving the epinuclear material which comes in a separate step using a shizzle or the I/A tip.