Dear Dr Syed,

  Greetings !

I would prefer to do phaco due to multiple reasons

a. closed chamber technique - safety concerns especially in uncontrolled IOP, old , uncontrolled HT, obese settingsf

always there is a small risk of intraocular hemorrhage

b. Definitely corneal endothelial damage is more in phaco

which can be reduced by AC deepening procedures- like

preop IV Mannitol, Tab Diamox, Soft shell Technique of VES (dispersive under the cornea followed by cohesive in the centre of AC)

keeping the phaco probe directed away from Cornea at the pupillary or in the bag level, Direct phacochop technique etc. one can minimize trauma to endothelium

c. Experience in phaco surgery is important  

d. Intumescent cataract will usually be soft in nature 

hence can be managed by less phaco power avoiding corneal damage

e.Femto phaco will help to reduce the effective phaco time and help in a successful capsulorhexis

f. In Very dense cataracts with non dilating pupils, its still very good to consider a Conventional ECCE after controlling maximally the IOP and deepening the anterior chamber

Hope I have shared few of my views 

Thanks Dr Sunil. Usually these patients are old with poor IOP control for a few days. Their endothelium must be already in a bad state. What is the deciding factor whether to do Phaco or ECCE?

I prefer doing ECCE+ PC IOL.  the nucleus is very dense  and capsule is very fragile so ECCE is better choice. 

I agree and  prefer doing ECCE+ PC IOL

Thank you for your inputs Drs Ebrahim and Marianne. I think we can select some patients for phaco, but leave the others to a good ECCE. That is the recommendation from cornea specialists I have met.

Thanks Dr Syed Shoeb Ahmad,

Due to lens intumescence in Phacomorphic glaucoma and inducing narrow angle , PE is difficult and corneal endothelial damage is very high. An extracapsular approach typically is used for cataract extraction .so , I prefer ECCE procedure.

In general, I would prefer phaco because the conjunctiva remains untouched. You might need to do a trabeculectomy later. The only exception is for me a large brown nucleus which requires too much US time during phacoemulsification - in this case I usually do SICS.

Thank you for your input Dr Philippin. I think SICS is an interesting procedure. How well does it go in phacomorphic cases? Any higher rates of PC rent noted?

I prefer SICS over ECCE in cases with a shallow AC - such as phacomorphic glaucoma. I do not notice a different rate of PC tears between the phaco and SICS.

Thank you again, Dr Philippin

Always Phaco.

phacoemusification is better than ECCE

Dear Dr Vejarano and Shenoy, thank you for your responses. Astigmatically phacoemulsififcation is better but we should consider ECCE in some cases where the corneal endothelium may not be healthy enough.

I agree that dependent on the quality of endothelium the less traumatic surgery should be chosen. Phako is relatively safe if you stop in short Intervalls to refill the anterior chamber with viscoelastic to protect the endothelium over the total phako time. By doing so the endothelium is well protected against cavitation and heat. We prefer methylcellulose as protective viscoelastic. 

Thank you Dr Thomas for your comment. Do you think Healon GV would be more protective in such cases ?

under controlled measures like use of visco, sufficient bottle height, optimum phaco power, phaco can be performed

Though there are some exceptions, Phaco should be preferred surgery over ECCE is phacomorphic glaucoma.

As it is a close chamber procedure, also carries less risk of suprachoroidal haemorrhage.

Very small pupil with large brown nucleus, very poor cornea etc cases can be done with ECCE or SICS.