CASE PRESENTATION
A 54-year-old white male presented with complaints of a bilateral, gradual, painless, progressive decrease in his vision that made it difficult for him to drive and perform daily functions. This case discusses the treatment of his right eye. The patient exhibited no other relevant health issues. Upon slit-lamp examination, the visual acuity in his right eye was light perception, and the fundus was not visible. All other readings such as IOP and motility were normal, and his cornea appeared healthy, with no evidence of pseudoexfoliation.

Regarding surgical planning, it is important to note that, at the time, my staff and I had no access to intracapsular dyes such as trypan blue.
HOW WOULD YOU PROCEED?
1. Would you attempt this procedure using phacoemulsification?
2. Would you use extracapsular cataract extraction?

SURGICAL COURSE
I began with phacoemulsification. Because my practice lacked intraocular dye, I used a technique available at the time that involved a vitreous light pipe. This light pipe shines externally, sideways through the eye (similar to a flashlight), to better illuminate the structures within the anterior segment (Figure 1). It offers better visualization of the anterior segment compared with the diffuse light of an operating microscope. To use the device, one must turn the light of the microscope off and direct this hand-held pipe's light source at the anterior capsule.

I made a 3-mm incision and began the capsulorhexis. I could see that the nucleus was completely white. One difficulty of working with this type of cataract is that its intumescence places significant pressure on the bag, so surgically stabbing it may split the capsule. Regardless of the availability of capsular dye, capsular tears tend to radiate very quickly out of control. Using a more cohesive viscoelastic may increase the pressure on the anterior capsule and therefore help prevent radialization during the capsulorhexis (I used Amvisc Plus [Bausch & Lomb Surgical, San Dimas, CA] in this case). A capsular tear occurred, and the radialization combined with poor visualization forced me to abandon the capsulorhexis.

I switched my technique to a postage-stamp capsulotomy and performed a supercapsular tumble technique (Figure 2). The nucleus exited fairly easily without vitreous loss or further complications. I used a standard supercapsular nuclear removal technique for phacoemulsification. Finally, I inserted an injectable silicone IOL into the posterior bag.

OUTCOME
On the first postoperative day, the eye's UCVA was 20/50, and the IOP was normal. The IOL's centration was good. The patient's postoperative BCVA was 20/20, and he was pleased with this outcome.

DISCUSSION
Whenever visualization is poor, the surgeon should proceed more slowly. This entire case took approximately 15 to 20 minutes to complete. I would also like to stress that there are ways to visualize the anterior capsule without capsular dye, and a vitreous light pipe can be useful in this situation. It is possible to perform phacoemulsification on dense cataracts, even without obtaining a perfect capsulorhexis. Charles Kelman, MD, first taught the procedure through a postage-stamp capsulotomy, and although some surgeons experience higher complication rates using this approach, it is still viable. n

Y. Ralph Chu, MD, is Medical Director of the Chu Laser Eye Institute in Edina, Minnesota, and is Clinical Assistant Professor of Ophthalmology at the University of Minnesota. He holds no financial interest in the products mentioned herein. Dr. Chu may be reached at (952) 835-0965; yrchu@chulasereye.com.