Sometimes, even with systemic sedation, patients can have a strong Bell’s reflex under topical anesthesia and that makes it difficult to complete critical steps of the surgery such as the capsulorhexis.
Bell’s reflex (also called Bell’s phenomenon or palpebral oculogyric reflex) is when the eye moves to upgaze upon attempted closure of the eyelids. Topical medications such as tetracaine only provide anesthesia but do not prevent movement of the eye by the patient. We can convert to a retro-bulbar block which would provide akinesia as well as anesthesia or the anesthesiologist can give a deeper level of sedation.
But there is an easier solution that tends to work well: use the chopper to fixate the eye via the paracentesis. This avoids using forceps to grasp conjunctiva which could lead to pain and subconjunctival hemorrhage. Once two instruments are in the eye such as the phaco probe and the chopper during nucleus removal, the eye is automatically fixated at two points and will not move.
Click below to watch the video of this technique: