Cataract Quiz: When did the break happen?

This patient has a relatively dense cataract and requires a toric IOL for 2 diopters of regular corneal astigmatism. When you perform the capsulorhexis, it looks great and it is completely round and continuous with a 5 mm diameter. But later in the case you notice a break in the anterior capsular rim. When did this happen? And more importantly, how will you finish this case and place the toric IOL haptic at the area of anterior capsular breakage?

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  1. Thank you for your videos, I have used them to learn flip and chop as I was primarily using a horizontal chop technique. I believe this may be the first complication I have seen from you regarding nucleus prolapse. I am trying to form in my mind relative contraindications for nucleus prolapse. After much research on, I have come up with the following 1) narrow AC, 2) endothelial dystrophy/cell loss, 3) small capsulorhexis (less than 5mm). I am now considering dense nucleus as a relative contraindication, however I have seen your videos of prolapsing dense nucleus out of bag to access posterior plate. Was this just bad luck? If you were planning to flip and chop with this dense nucleus would you have done anything different like more hydrodilenation, or slightly over sized rhexis? Thanks again

  2. Dear dr Uday Devgan,

    First of all i would like to thank you for sharing great learning videos evey single time. Since i started following your site i have not missed a single video from you. I think that every case is a learning point to become a better surgeon.keep up the good work!
    I wonder if the tear was initiated by prolapsing the nucleus out of the bag. Why did this happen in this case? The size of the rhexis was big enough to perform a safe prolaps of the nucleus. The capsule is not a rigid structure so it will follow the curvature of the lens without radializing. dr Osher once said that you can put rocks in the capsular bag without damaging the CCC.
    I think that not prolapsing the nucleus out of the bag was the cause of the rupture, but probably touching the anterior capsule with either the hydrodissectioncannula, the phacotip or the chopper. During the high speed video it is not possible for me to detect a capsule touch. It would be interesting to slowspeed the video in order to search for the incident. During the prolapse it is not Obvious that the anterior capsule is ruptured.
    Afterall you saved this eye form a residual astigmatism by perfect and gentle handeling of the toric alignment.

    Kind regards

    1. Great comments. Thank you. I suspect it was the chopper tip coming into contact with the anterior capsular rim. They key is managing this so that the rest of the case goes well. The patient did great and achieved excellent vision without any issues.

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