When you are mobilizing a dense nucleus and you briefly see a bright, clear, crescent-shaped red reflex, you can be assured that trouble is brewing. This bright flash of the red reflex is because we are seeing the absence of zonular support and extensive damage to the capsular support.
In the picture above, we can see this red reflex area of absent zonular support as well as the capsular bag equator and the cataract lens equator. This patient has a history of severe pseudo-exfoliation and very weak zonular support. In the clinic during the pre-operative exam, the patient had a 2 mm anterior chamber depth while seated at the slit-lamp microscope. In the operating room, when we inject viscoelastic, the anterior chamber deepens to 4 mm which indicates severe zonular laxity.
There are other clues as well, such as the anterior capsular wrinkling upon attempted creation of the capsulorhexis. When we see the clear, crescent-shaped red reflex, we can be sure that there is virtually no zonular support. We abandoned the corneal phaco incision and created a superior scleral tunnel to perform manual extraction of the nucleus. After an anterior vitrectomy, an anterior chamber IOL was placed. Other options include scleral fixation of the IOL like the Yamane or Agarwal technique.
Click below to learn about this very important sign during cataract surgery: