The patient presents with obvious compromized zonular integrity. She should be examined for all genetic, metabolic, endocrine, and other abnormalities associated with poor zonular integrity.
My approach would be to use a bimanual microincision surgical technique using 2, 1.1 mm incisions approximately 90 degrees apart in the temporal periphery. I would follow all management guidelines for addressing posterior polar cataracts published in a paper by Fine and coauthors.1 Those guidelines include taking extreme care to not overpressurize the anterior chamber or capsular bag, using minimal hydrodissection and hydrodelineation, using power modulations to reduce US energy, performing viscodissection as a primary technique to mobilize the epinucleus and cortex, and keeping a protective layer over the posterior polar region until the conclusion of the extraction procedure to minimize the risk for loss of lens material into the vitreous cavity in case of a capsule defect.
I would place sodium hyaluronate 3%–chondroitin sulfate 4% (Viscoat) through 1 of the microincisions starting in the distal angle of the anterior chamber, expressing aqueous as the expanding wave of OVD approached the opposing paracentesis. I would take care not to overfill the anterior chamber. I would then use a Fine/Hoffman microincision capsulorhexis forceps (#DF-0002, MicroSurgical Technology), which does not challenge the zonules because the surgeon simply opens the forceps and pinches the capsule, capturing a knuckle and allowing the capsule to be torn in a continuous curvilinear fashion. I would then use capsule hooks to stabilize the capsule, after which I would do minimal hydrodissection in multiple locations, taking care that no fluid moves across the posterior capsule. This would be followed by hydrodelineation. The total amount of fluid for both hydrodissection and hydrodelineation would be about 0.2 mL.
Next, I would horizontally chop the endonucleus, again using bimanual microincision phacoemulsification techniques. The horizontal chopping would put no additional pressure on the zonules because the nucleus is trapped between the chop instrument, which stabilizes the endonucleus during embedding of the phaco tip, and then the horizontally directed forces for chopping are directed toward the center of the nucleus with no downward pressure. After mobilizing the endonucleus, I would viscodissect the periphery of the epinucleus and aspirate or phaco it and then with additional Viscoat, elevate the posterior plate of the epinucleus and remove it with aspiration or mild phacoemulsification. I would trim the posterior cortex circumferentially with bimanual aspiration and irrigation and then, with Viscoat, elevate the posterior plate of the cortical envelope.
After removal of the cortical plate, assuming that no opening of the posterior capsule had occurred, I would fill the bag and the anterior chamber with sodium hyaluronate 1% (Provisc), make a 2.5 mm temporal clear corneal incision with a 3D bimanual diamond phaco blade (#03-3011, Rhein Medical), and insert 2 Ahmed capsular tension segments in opposite sides of the bag and suture them to the sclera to stabilize the capsule. I would then remove the capsule hooks. I would implant a single-piece acrylic IOL with the haptics folded behind the optic because the lens can be inserted directly in the capsular bag without a trailing haptic, which would have to be compressed or dialed into the bag, again minimizing stress on the capsular bag.
If a posterior capsule rupture occurred during the procedure, I would bring the lens up into the anterior chamber and perform phacoemulsification there. This is much more easily done with bimanual microincision instrumentation than with coaxial phacoemulsification. I would then perform a pars plana vitrectomy with a 25-gauge, high-speed vitrector (BV25, Bausch & Lomb) and use an anterior chamber multiflex IOL or a 3-piece acrylic foldable IOL sutured to the iris.
The advantages of bimanual microincision phacoemulsification for this procedure are that with a posterior polar cataract, not only does the surgeon have to avoid putting downward pressure on the lens, potentially rupturing a weakened or defective posterior capsule, he or she also has to avoid shallowing the chamber and forward movement of the lens, which can also open a weakened or defective posterior capsule. Bimanual microincision phacoemulsification techniques allow the surgeon to keep the irrigating chop instrument in the eye throughout the procedure and with the other hand, remove the phaco instrumentation, add OVD, or exchange the phaco tip for an irrigation/aspiration (I/A) tip without ever shallowing the chamber.
1. Fine IH, Packer M, Hoffman RS. Management of posterior polar cataract. J Cataract Refract Surg 2003; 29:16-19