Further thoughts about the cortex: Robert H. Osher's Superb Deliberations Revisited.

The numerous authors of this communication, numerous because of their respect for Robert H. Osher, were pleased to read his recent exposé on lens cortex.1 The authors concur that while removal of the cataract nucleus is safe and effective nowadays, even with leathery nuclei, its completion is precisely not the time for the cataract surgeon to heave a great sigh of relief. Despite Professor Osher stating that cortex removal in just a few seconds is “one of the most satisfying steps in cataract surgery,” the authors thoroughly agree that this is precisely the time point during the phacoemulsification procedure that requires the greatest vigilance. Professor Osher points out that cortical removal has benefitted substantially by switching from a metal to silicone irrigation/aspiration tip, describing the facility of his J-cannula (B&L E6312 Crestpoint MMP243) for a subincisional cortex. Historically, this is reminiscent of the Irvine-Francis J-cannula published by the authors themselves in 2003, using left-handed and right-handed cannulae for this purpose.2 This cannula had its irrigating port directly alongside the aspirating port, facilitating safe loosening and removal of the subincisional cortex. Adequate cortex removal minimizes late displacement of the intraocular lens, which can be attributed largely to asymmetric fibrosis of the remaining cortex over time. Furthermore, adequate cortex removal probably assists in obviating cystoid macular edema. In addition, Professor Osher's silicone irrigation/aspiration may not only facilitate polishing the posterior capsule but may also help to prevent posterior capsular tears. Thus, Professor Osher remains absolutely dead right: It is inappropriate for the surgeon to heave a great sigh of relief immediately after successful nuclear removal. He also points out that with smaller pupils, it may be difficult to establish that the peripheral cortex has been removed. Professor Osher highlights that “one excellent clue is the presence of subtle microstriations on the posterior capsule.” While the authors have only recently been apprised of this observation, their approach with such pupils has always been to achieve adequate pupillary dilation intraoperatively using a pupil expander such as a Malyugin ring or similar or iris hooks. The authors know that Professor Osher has always recommended slowing down the operation if it has become tough. The surgeon should not aim to finish the phacoemulsification operation in the hallowed 6 minutes, but aim to complete a technically perfect phacoemulsification procedure, even in a patient with a miosed pupil. In the authors' hands, this has affected a corrected distance visual acuity of logMAR −0.2 at 1 month postoperatively in over 92% of all phacoemulsification cases in their large reported series.3 The authors, working out of the largest tertiary referral teaching hospital in Australia possessing a discrete department of ophthalmology, have had the benefit of invention of trypan blue by Professor Minas Coroneo for phacoemulsification surgery.4 Using trypan blue may also improve cortex identification. The authors commend Professor Osher for his wisdom in this and indeed in many aspects of cataract surgical management, where excellence in surgical and visual outcomes could arguably be the undisputed goal.