Quiz: What is this dark spot and what is the danger?

This is a complicated case sent to us for review by an anonymous surgeon. You can also submit a video (anonymously if you would like) by following these instructions. The patient had a prior full-thickness corneal transplant and now has an opaque white cataract. The danger sign is a dark spot that appears during phaco. Can you guess what is happening here? And can you predict what will happen next?

Click the video below to learn from this important case:

Dr Neto Rosatelli has an important comment:

Very illustrative case, Dr Devgan! The dark spot is an area of nucleus material reabsorption frequently found in cases of traumatic cataract with capsular rupture. An alternative approach would be to immediately tamponade the preexisting capsular defect (perhaps due to a penetrating injury – that would explain both the posterior capsular defect and the previous need for a penetrating keratoplasty…) with OVD, then carefully move the very soft nucleus fragments to the anterior chamber and/or through the incision with the help of a chopper or other manipulating instrument, or even just by viscodissecting and gently burping them. Any aspiration at that moment should be done very slowly in dry mode technique, which ensures much more control and avoids unintended vitreous aspiration. After that, perhaps an IOL scaffolding phaco and irrigation/aspiration technique could provide great protection allowing complete cleanup. Nevertheless, the case ended very well, and congratulations to the surgeon for the great recovery and preparing the eye to the posterior segment surgeon! Great lesson! It is always easy to second guess the surgeon in hindsight, isn’t it? We all have been there, in the heat of the moment having to quickly establish a new course of action to a surgery that isn’t going the intended way. Someone already said: “A good surgeon learns from his mistakes. An excellent surgeon learns from other surgeon mistakes”. These complication cases you show are priceless. Thank you for your effort on this superb channel Dr Devgan!

stable IOL at the end of the case with a white reflex from the nucleus in the vitreous

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