When dealing with a white cataract, a central fibrotic plaque can make a standard capsulorhexis nearly impossible. After staining the capsule with trypan blue to improve visualization, your first step is to create a small central nick in a clear area of the capsule using a sharp cystotome. Instead of immediately pulling with forceps, insert a thin, blunt spatula through the incision and gently slide it into the sub-capsular space. Use a sweeping, tangential motion to dissect the fibrotic membrane away from the underlying cortex and the peripheral capsule. This blunt cleavage plane allows you to mobilize the plaque without putting undue stress on the zonules. By carefully separating these adhesions, you transform a rigid, unpredictable membrane into a manageable flap. Once the fibrotic area is freed, you can use micro-scissors to finish the cut or forceps to complete a controlled, 5mm CCC. Remember: Slow is smooth, and smooth is fast. (I love that saying which I learned from friends in the USA armed forces)
