Endothelial protection is always important, though in a patient with severe corneal dystrophy and a shallow anterior chamber, it is even more critical. In this case, I discuss several pearls for safe removal of the nucleus in a patient with a severely compromised endothelium.

We start our 4th season with a very interesting case! My preoperative plan was to use a toric IOL in this 89 year old patient with a very dense cataract. After discovering a complete lack of zonular support, I perform a vitrectomy and change my lens choice to an AC IOL. I discuss control of the remaining astigmatism near the end of the procedure.

Ocular trauma suffered 30 years ago has left this young man with a calcified and partially resorbed cataract, advanced phacolytic glaucoma and complete absence of zonular support. Completing our 3-part
series of complicated cases, this video begins with a discussion of
the preoperative OCT image. During the procedure I discuss its formidable challenges and explain the methods necessary to remove the extremely rigid lens.

Continuing with complicated cases, this month I demonstrate removal of a dense cataract in an eye with zonular laxity and a possible preexisting posterior capsule defect. Techniques employed include hydrodelineation, insertion of capsule retractors, and insertion of a capsular tension ring.

We will finish up our year with 3 rather complex cases. This month, our 57 year old patient is extremely anxious about having cataract surgery. She had uveitis and glaucoma in childhood for which a nasal thermal sclerectomy was performed at the age of 8. She subsequently developed a cataract, but opted to postpone surgery until the lens had become quite dense. She has a low endothelial cell count, possibly as a result of prior uveitis and/or intraocular surgery. Because of patient movement during the early stages of the procedure, we use tape to restrain head movement and I deliver a retrobulbar block to improve her ability to remain stationary.

We change it up a bit this month by showing 2 implantations of a stent into the trabecular meshwork in eyes with glaucoma. The first case shows a straightforward insertion, and the second demonstrates successful insertion after failure of the initial attempt.

The cataract and IOL insertion of each case were routine, so we present only the MIGS portion of each case.

For our viewers who have requested complexity, this one certainly fits the bill: a highly myopic eye with previous retinal detachment, scleral buckle and partial pars plana vitrectomy, residual anterior vitreous opacification, shallow anterior chamber, convex anterior capsule, extreme zonular weakness, infusion misdirection syndrome and 3 diopters of astigmatism requiring toric IOL implantation. Whew!

This is a routine case during which I discuss anticipation and prevention of problems caused by patient coughing, infusion misdirection syndrome, and finally the intracameral antibiotic controversy.

In this case I demonstrate techniques used to remove a dense nucleus in an eye with pseudoexfoliation. Signs of Infusion Misdirection Syndrome and methods to protect the posterior capsule when this problem exists are also presented.

After first removing the anterior subcapsular cataract in a highly myopic patient, I then demonstrate the use of intraoperative aberrometry to confirm the toric IOL power calculation. Discussions include how to best manage a significantly deep chamber and how to correct the rare occurrence of a toric IOL that rotates postoperatively.