Many years ago when phaco techniques were first being developed, some surgeons elected to do phaco in the anterior chamber. There was enough room to prolapse the entire nucleus into the AC and then it could be emulsified and aspirated away with less risk of it going into the vitreous cavity. This seemed to work well, but there was a high degree of post-operative pseudophakic bullous keratopathy (PBK) associated with it. And this was before the advent of lamellar corneal transplantation (meaning no DSEK or DMEK), so these PBK patients ended up receiving a full-thickness penetrating keratoplasty (PKP). Not ideal.
But what about now when we have so many advances such as better viscoelastics to protect the corneal endothelium, phaco power modulations to limit ultrasound energy, and powerful fluidics so that we can remove more of the cataract with aspiration? I know that I will get some grief from our cornea specialist fans, but in this case I elected to do phaco in the anterior chamber. And, yes, the patient had a completely clear cornea on post-op day 1.
I did take some special precautions to ensure this great outcome and I do not intend to regularly perform phaco in the AC, but every once in a while this can make a very tough case a bit easier with less risk to the patient. You’ll see what I mean in the video.