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.

In order to perform cataract surgery upon this non-English speaking patient, I first have to remove an iris-fixated anterior chamber lens implanted 11 years previous. This case highlights removal of the phakic IOL, the value of a translator during surgery and the use of intraoperative aberrometry to determine the correct IOL power.

This case demonstrates the use of intraoperative aberrometry plus the Aphakic Refraction Technique to best determine the final IOL power in a keratoconic eye. Tips for visualization, a comparison of phaco chop and divide and conquer and the advantages of a high IOP setting round out this very educational case.

Patience is a critically important trait for all surgeons to develop and maintain. In this patient, Dr Mackool demonstrates its value during removal of a red/brunescent cataract in a one-eyed patient.