This 30 year old patient has a tough situation: bilateral white cataracts with high pressure within the capsular bag. There is no intumescent fluid layer present in this lens, but rather the entire soft lens was swollen which increased the pressure within the capsular bag. For the first eye, when an attempted puncture of the anterior lens capsule was performed, the anterior capsule ripped uncontrollably as shown in the inset picture here. When that video was posted, we received lots of good advice from our CataractCoach subscribers.
In the first eye surgery, we increased the pressure in the anterior chamber to about 50 mmHg using viscoelastic via a single, small paracentesis. One surgeon suggested avoiding making the paracentesis and instead just poking the 25 or 27g needle through the limbus. Another surgeon recommended that a large 18g needle would be a better choice.
Some people recommended giving intravenous mannitol ahead of time which would desiccate the vitreous and create more room, but it would still not likely decompress the capsular bag. Someone suggested doing a partial anterior vitrectomy via a pars plana entry to, again, decompress the vitreous, but it would not likely affect the intra-capsular pressure.
An alternate form of capsulotomy creation such as a femtosecond laser or a zepto device. Those would be good options, but these surgeries are performed by our UCLA ophthalmology residents at a county facility where we do not have access to these technologies.
Our decision was to use the phaco probe to puncture the anterior lens capsule as we previously demonstrated in this video. We made sure to keep the infusion pressure high at 90 mmHg or higher (which is equivalent to a bottle height of 120 cm or more) and then created a small initial capsulorhexis which we then enlarged after IOL insertion. This worked very well and the patient did great.
click to see how we prevented the uncontrolled capsular rip in this tough case: