We have all experienced it: a nucleus that it too soft and gummy to divide in the capsular bag and so we keep bowling it out until we are left with this challenge. The nuclear shell is in the capsular bag, very close to the posterior capsule, and there does not seem to be a good way of bringing it out. This is a common situation early in the careers of young ophthalmologists, but it can happen to any cataract surgeon.
Believe it or not, the “bowl technique” was actually quite popular in the years before nucleo-fractis became adopted as the primary technique. These elder ophthalmologists would use just one incision (and one hand) to apply phaco energy to bowl out the nucleus. Then once the walls were thin enough, the bowl would be collapsed on itself to then be aspirated. A lot of phaco energy, fluid flow, and time was spent in this endeavor, but it did work.
If you are stuck in this situation with a bowled out nucleus, there are a few techniques that can help. We can perform additional hydro-dissection (or visco-dissection with a dispersive OVD) to bring the nuclear shell out of the capsular bag, or we can apply vacuum (without phaco power) to the rim of this bowl to bring it centrally and then into the iris plane.
Click below to learn how to manage the bowled out nucleus: