Remove the cortex safely taking into account that this process is different from the usual cortical clean-up.
The cortex will have been cut flush with the capsule thereby eliminating the cortical strands that are usually easily aspirated in manual cataract surgery.
The cortex may be removed either using a bimanual or co-axial irrigation and aspiration technique.
The secret is to engage the cortex and use a side to side motion to loosen and then strip the cortex from the capsule. I have found that this step is very efficient at removing the cortex, especially if 60 to 90 degrees of cortex is removed in each “sweep”. This certainly reduced the operation time and improves the safety of this stage of the operation.
When using bimanual irrigation and aspiration I ensure that the aspiration cannula is always in my dominant right hand when starting to remove the cortex. My two side port incisions are 120 degrees apart. This allows more than 180 degrees of cortex to be removed in only two quick movements with the modification mentioned above. If the remaining cortex which is now 180 degrees from the “cleaned capsule” and nearer to my dominant hand is stuck to the capsule, it is easily “flushed up” with BSS injected from a 2 ml syringe placed into the incision where the irrigation cannula was. This allows the cortex to be aspirated quickly and safely when the aspiration cannula is swapped to my non dominant hand.
Attempting to peel the cortex towards the center of the capsule as performed with manual phaco surgery is sometimes unrewarding.
Stripping the cortex circumferentially and not towards the center of the posterior capsule cannot be emphasized enough.
Flushing the cortex off the posterior capsule is sometimes easier and safer than aspirating it off the capsule.