This lens is so loose that it is shaking around inside the eye – a severe case of phacodonesis. This is going to make the entire surgery far more challenging. How would you handle this case? What are your plans for the IOL? Lots of options in this tough case. In Los Angeles, I would send this patient to my vitreo-retinal colleague for a pars plana lensectomy and vitrectomy and have him suture in an IOL using 4 point fixation and intra-scleral Gore-tex sutures. I would choose the IOL power so the patient ended up a bit myopic (-1 to -2 range) and then once healed, I would offer the patient LASIK if a refractive goal of emmetropia is desired. I have done this in the past and patients have been amazed at the refractive outcome. With the sutured IOLs, the post-op refraction is not as easy to predict, but by aiming for mild myopia and then using the excimer laser, we can really nail that perfect plano outcome and even clean up residual astigmatism. What would be your choice? Leave a comment below. Thank you.