This subtle sign indicates weak zonules!

This is a very subtle sign — looking at this title pic, we see a demarcation line just inside the iris edge. The anterior chamber was filled completely with dispersive viscoelastic using our method of performing a fluid exchange with the OVD wave. This fills the AC entirely with dispersive OVD and leaves it at a physiologic pressure in preparation for making the main phaco incision. Once we make the incision and start the capsulorhexis, we notice that the cataract moves slightly posterior and the AC deepens. This allows the little bit of residual aqueous that was in the posterior chamber behind the iris, to come forwards. And this is what we see at the tips of the blue arrows in this title photo.

This is a subtle, but critical sign, that you need to be able to recognize. You won’t find this in a textbook! I am committed to teaching the world all of the surgical pearls, tricks, and techniques that I have learned over the past 20+ years!

click below to learn this subtle sign indicating weak zonular support:


  1. At which stage of this procedure, will you consider inserting an endocapsular ring. Would you use capsular tension supports?

    1. it can — it depends on the case. make sure the hydrodissection is thorough to minimize the risks

  2. Great case! At the end of a case, any recommendation on how to leave the anterior chamber in an eye prone to reverse pupillary block? If I lift up on the block, the chamber often shallows. As I refill the chamber, I find the chamber often prone to return to a reverse pupillary block position.

    1. at the very end of the case, go inside the AC via the paracentesis using BSS on a 27g cannula.
      Tent up the opposite iris to fix the reverse pupillary block and then slowly inject to keep the AC formed and sufficiently deep.

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