•Insert the phacofragmentor and remove the lens material.

–Use the “nibbling” technique, advancing the probe in small and gradual steps, not by making long tunnels in the lens. This technique increases the chance that the port is always occluded.

–Try to avoid losing large nucleus pieces into the vitreous; if this occurs, follow the steps described below (Sect. 38.4).

–Any lost cortical material will be removed during PPV.

•After the nucleus has been removed, the residual cortex can be extracted with the probe.

•Make a decision about the capsules (see Sects. 38.2.1 and 38.6).

38.3.2 Lens in Vitreous

•Complete the vitrectomy first, including the creation of a PVD.

–Use TA to ensure that no vitreous is left on the posterior retina.

–Remove all or at least most of the vitreous in the periphery (sub/total PPV).

•Adjust the machine settings.

–Do not use phaco power exceeding 20%.

–Temporarily increase the infusion pressure: if the phaco probe’s tip is in BSS (i.e., not occluded by lens material), the eye may collapse.

•Insert the phacofragmentor. Using aspiration only, pick up the lens particles from the retinal surface, bring them in the midvitreous cavity, and only then activate the ultrasonic energy. Use the minimal amount of ultrasound.

–The technique is very similar to that described above (Sect. 38.2.2), except that with ultrasonographic power, it is possible to break even hard lens particles into small pieces; however, crushing helps in minimizing the total amount of ultrasonic energy needed.

•Once all lens material is out, inspect the retinal periphery with indentation and (at least consider to) perform endolaser cerclage to reduce the risk of the postoperative RD.

38.4IOL Implantation: Whether and When16

38.4.1In-the-Bag IOL Implantation at the Conclusion of the Cataract Removal

This is the “default action,” performed in all routine phaco cases.

16 None of these is an absolute rule.