This patient has a very dense, brunscent, fibrous cataract in the left eye. Fortunately, the right eye has a moderate cataract which is allowing the patient to have at least some useful vision. At the pre-operative consultation it is important to look for issues that may affect the surgical outcome. Was there trauma? Is there phacodonesis? Is the anterior chamber of normal depth? Is the cornea normal including the endothelial surface? What is the posterior segment like: any view of the retina? And even externally, since the visual acuity is so greatly diminished in this eye, is there sensory exotropia?
When we look closer at the left eye, we note that there is a brown hue to the central nucleus so we call this a brunescent cataract. As these types of cataracts get worse, this brown color becomes darker, even turning the color of Coke, Pepsi, or root beer.
There are some important pearls to keep in mind when you are performing cataract surgery in a case like this. The most important one is that the cataract will be fibrous and resistant to chop propagation. In routine phaco chop, the vacuum holding power of the phaco probe is sufficient to fixate the nucleus as the chopper splits it. But in this case, the 500mmHg of vacuum will not be enough so we need to trap the cataract nucleus between the chopper and the phaco probe so that we can apply a higher degree of mechanical force to split the nucleus.
click to learn pearls for cataract surgery with a dense, brunescent nucleus: