Blinded by White: Cracking the Mature Cataract Safely (Presentation and Discussion)

王孟祺 Meng-Chi WangTaiwan Speaker Blinded by White: Cracking the Mature Cataract Safely (Presentation and Discussion)This is an unusual white cataract with posterior synechiae and silicone oil in the vitreous cavity following previous retinal detachment surgery.Before starting the procedure, we noticed some emulsified silicone oil at the apex of the anterior chamber.I injected trypan blue through the side port to stain the anterior capsule, followed by OVD injection from the opposite angle to replace and remove the dye as well as the silicone oil.After using a flat needle to separate the posterior synechiae, four iris hooks were placed to enlarge the small, fixed pupil. Unfortunately, the initial staining was insufficient, so I performed a second capsule stain.At this point, wrinkles and fibrosis over the anterior capsule were noted, so I decided to use an MVR blade to create the initial cut for the CCC.The anterior capsule had thickened significantly, making it hard to tear. After several unsuccessful attempts to tear the anterior capsule with the CCC forceps, I switched to microscissors to complete the capsulorhexis as round as possible.Regrettably, it was not possible to complete the capsulorhexis on the opposite side, so I attempted to use the CCC forceps once more. Fortunately, I was finally able to complete the capsulorhexis, although it was quite small and irregular. Since the anterior capsule was quite thick, I was not concerned about causing a radial tear during hydrodissection.It was quite easy to rotate the nucleus afterwards.Since the nucleus was rock-hard, I attempted to use the stop-and-chop technique, initiated by a long and deep sculpting.If the sculpting is not deep enough, it will be difficult to crack and completely bisect the hard nucleus.Take your time and spread your phaco tip and second instrument along the trench, section by section.Afterwards, rotate the nucleus 90 degrees away. At the same time, the milkified cortex was floating outside the capsule.I buried the phaco tip as deep as possible into the center of the nucleus. This allowed me to hold the nucleus firmly and chop it vertically without detaching it from the phaco tip.After cracking the nucleus into smaller pieces, I was able to manage each piece within the central pupillary area safely and efficiently.It is important to separate the leathery tethering part of the posterior pole completely; otherwise, it will be difficult to keep the nucleus pieces under control. If you follow this principle and take your time, you will be able to complete emulsification safely and effectively within the limited space, with a CDE of only 18.77. Another surprise emerged after I cleaned the nucleus: I found a large central fibrotic plaque on the posterior capsule, with nearly no epinucleus or cortex remaining. Silicon oil was shiny behind the posterior capsule.In this situation, it’s impossible to perform primary posterior continuous curvilinear capsulorhexis (CCC); therefore, I decided to use a YAG laser to open the posterior capsule one month later.Following the injection of OVD into the capsular bag, an aspheric hydrophobic intraocular lens (IOL) was implanted smoothly.After removing the iris hooks, I used micro scissors to trim the redundant tags from the CCC margin.The entire procedure was completed with stroma hydration for the main wound and all side ports. We could notice the dense fibrotic plaque over the central axis during the slit lamp examination the day after surgery. However, the central visual axis could still become clear after YAG capsulotomy, and fundus photography could be taken beautifully.