A simple and safe approach of phacoemulsification cataract surgery in hard brown cataracts with different complexities using the Two-Y crushing technique: A report of two cases

Case 1: Two-y crushing technique in hard brown cataracts with successful hydrodelineation

A 64-year-old male presented with a brown cataract in his right eye, with a best-corrected visual acuity (BCVA) of 6/60 (−0.50 × 60) and normal intraocular pressure (IOP). The fundus examination was normal. Phacoemulsification cataract surgery was performed using the Two-Y crushing technique [Video 1]. Under topical anaesthesia, side ports were created at the 2’O and 9 O’clock positions, and a 2.2 mm clear corneal main port incision was made at the 11 O’clock position, followed by a 6 mm continuous curvilinear capsulorhexis. Hydrodissection followed by hydrodelineation was successfully performed, indicated by the formation of a golden ring [Figure 1a]. Dispersive viscoelastic (viscodissection) was injected into the golden ring (epinucleus cleavage plane), which completely disassembled the endonucleus [Figure 1b]. A one-Y rotator was passed beneath the nucleus through the 2 O’clock side port to lift and prolapse the nucleus into the anterior chamber [Figure 1c]. Another Y rotator was inserted through the 9 O’clock side port to crush the nucleus into multiple pieces [Figure 1d], similar to bi-hand crushing as similar to the Two-Y crushing technique^[10] in case of posterior polar cataract. Initially, on the first attempt, the crack did not fully occur due to the hardness of the cataract; however, the second attempt was successful. The cataract was leathery in nature, and multiple attempts were made to crush the endonucleus into smaller pieces with complete or incomplete separations. The crushed nucleus was easily removed by phacoemulsification in the iris plane [Figure 1e]. During phacoemulsification, the chamber remained stable, with the protective epinucleus sheet safeguarding the posterior capsule. Later, the epinucleus sheet [Figure 1f] was removed using irrigation and aspiration, followed by the implantation of a single-piece intraocular lens (IOL) [Figure 1g]. The cumulative dissipated energy (CDE) was 10.77. On the postoperative day (POD) 1, the cornea was clear, and the patient achieved a vision of 6/6 (Plano) with normal IOP [Figure 1h].

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Figure 1:

(a-h) (a) The successful hydrodelineation indicated by golden ring. (b) Successful viscodelineation using Hydroxypropylmethyl cellulose (HPMC) 2%, which completely disassembled the endnucleus from the epinucleus. (c) The prolapse of the nucleus using the Y rotator. (d) The manual crushing of the nucleus using Two-Y rotators. (e) The emulsification of the nucleus using phaco probe in the iris plane. (f) The removal of epinucleus using irrigation and aspiration. (g) The implantation of the single-piece intraocular lens in the capsular bag. (h) The clear cornea at post-operative day 1.

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Case 2: Two-y crushing technique in hard, deep brown cataract without successful hydrodelineation

A 72-year-old male presented with a deep brown cataract [Figure 2a] in his left eye, with a BCVA of 6/60 (+1.00 Dioptre sphere/−1.00 Dioptre cylinder × 90) and normal IOP. On posterior segment examination, only a hazy view of the optic disc was visible, and a B-scan was normal. Phacoemulsification cataract surgery with IOL implantation using the Two-Y crushing technique was performed under a peribulbar block [Video 2]. In this procedure, hydrodissection was successful, but hydrodelineation did not occur due to the thick and adherent epinucleus with the endonucleus, which is typically seen in deep brown cataracts. Sculpting was attempted but failed with parameters set at torsional (100) and longitudinal (10) because of the hardness.

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Figure 2:

(a-j) (a) The deep brown hard cataract. (b) Prolapsing one nucleus half after successfully cracking into the anterior chamber using a Two-Y rotator. (c) The crushing of one nucleus half into multiple pieces using a Two-Y rotator. (d) Phacoemulsification of the crushed nucleus half in the iris plane. (e) The implantation of intraocular lens (IOL) into the bag. (f) The IOL unfolded below the second nucleus half. (g) The crushing of the second nucleus half was carried out using Two-Y rotators. (h) The phacoemulsification of the second half nucleus in the iris plane. (i) The implanted single-piece IOL in the capsular bag with the ports are sealed. (j) shows the clear cornea at post-operative day 3.

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Consequently, the longitudinal parameter was increased to 40, allowing the phaco needle to embed into the nuclear material and crack the nucleus into two halves [Figure 2b] using the second instrument (direct chop). The cracking could also have been accomplished by making a deep trench followed by lateral separation. One half was brought into the anterior chamber and crushed into smaller pieces using the Two-Y rotator [Figure 2c]. By injecting hydroxypropylmethyl cellulose (HPMC) 2% beneath the first heminucleus, it was lifted away from the posterior capsule and subsequently brought into the anterior chamber with the Y rotator. The crushed nucleus was easily removed by phacoemulsification in the iris plane with parameters of torsional (100) and longitudinal (10) [Figure 2d]. Viscoelastic (sodium hyaluronate 1.4%) was injected into the bag, pushing the remaining half to one side, and a single-piece IOL was injected into the bag in the space [Figure 2e]. The IOL was adjusted to unfold and spread below the remaining nucleus (IOL scaffold technique^[5]). The IOL was implanted before phacoemulsification of the second piece to provide a protective sheet in the absence of the cushion effect from the epinucleus [Figure 2f]. The second half was then brought into the anterior chamber and crushed into multiple pieces using the Two-Y rotators [Figure 2g], followed by phacoemulsification in the iris plane [Figure 2h]. At the end of the procedure, the ports were hydrated [Figure 2i]. The total CDE count was 20.60. On day 1, there was mild central corneal oedema, which completely resolved by day 3 [Figure 2j], with a BCVA of 6/6 (+0.50 DS/−1.50 DC × 110) and normal IOP.