Abstract

Challenges in managing hard cataract
1. Incisional burns
2. Poor red reflex impeding capsulorhexis
3. Capsular lenticular block causing PCR
4. Leathery posterior plate
5. Endothelial cell loss
6. Thin capsule & weak zonules
Strategies
1. Hydrating incision during phaco
2. Trypan blue staining of the anterior capsule for adequate size rhexis & also to increase visibility of capsular edges during chopping
3. Maximally retentive viscoelastic is used
4. 5.5 mm well centered rhexis as large rhexis reduces stress on zonules
5. During hydrodissection use limited fluid & tap center of elevated nucleus to avoid capsular-lenticular block causing PCR
6. Nucleus management
a. Deep trench – Low vacuum and high power, continuous mode
b. Vertical chop with long & sharp chopper tip
c. Multi level chopping
d. Gentle lateral separation
e. Posterior plate separation
f. High vaccum, moderate power in burst mode
g. Total seperation of fragments
h. Deep plane phaco
i. Chopper shield -protects endothelium