While it is rare, there are times when it is important to convert from a phaco approach to a manual extra-capsular cataract extraction (ECCE). This is one of those times: we have a dense cataract in the setting of a wide open capsular bag. Removing the nucleus via manual extraction will likely pose less risk of retained lens fragments and will give the patient a better outcome.
This is a skillset that every ophthalmologist must learn. The key point is to abandon the original corneal phaco incision. The corneal phaco incision is typically less than 3 mm wide and we need an incision which is at least double or even triple that width, depending on the size of the remaining nuclear pieces. While you could enlarge the temporal corneal phaco incision to 3.5 mm or maybe even 4 mm, it is not advisable to go larger than this due to issues with sealing, astigmatism, and healing.
When we note that the capsule is wide open and that most of the cataract is still inside the eye, care is taken to use viscoelastic to bring the nucleus up into the anterior chamber and then support it with even more dispersive OVD. Now we can create a superior scleral tunnel incision of about 7 mm wide externally and we shape it like a funnel so that the internal opening is larger.
A lens loop is used to bring the remaining large nuclear pieces out of the eye and then a wave of dispersive viscoelastic is used to express the smaller pieces as well. A thorough anterior vitrectomy is performed using 23 gauge instrumentation via two smaller incisions. Avoid using the larger incisions for the vitrectomy since they will tend to leak excessively.
Once the vitreous has been cleared from the anterior segment, an ACIOL is placed securely. Since there was some temporal iatrogenic damage to the iris, there was no need to perform a surgical peripheral iridotomy.
The patient is doing well and the resident who performed this surgery learned a tremendous amount. Click below to learn from his video: