This case of blunt trauma with secondary cataract presents significant, specific surgical challenges. The first step is to counsel the patient about the higher risk for intraoperative complications and to manage the expectations about the postoperative vision prognosis. It is good that the macula is structurally intact and the retina attached, with no suprachoroidal or subretinal hemorrhage. The pupil shows traumatic mydriasis and is typically semidilated and likely to remain so because of sphincter ruptures, which the slitlamp examination showed. Glare and dysphotopsia might therefore be a problem.
For an eye injured by blunt trauma, gonioscopy is a key component to preoperatively assess the presence and extent of angle recession. The risk for developing glaucoma is related to the extent of the recession, so lifelong annual follow-up for glaucoma surveillance is advisable if recession is present over more than 90 degrees. If it extends for 360 degrees, the assessment can be ambiguous because the angle appears uniform and resembles a wide uveal band. Always look at the angle in the fellow eye for reference. Using an angle-supported AC IOL is contraindicated when angle recession is present but could be preferred in eyes with diffuse zonular damage and lens instability.
Typically the anterior chamber deepens after significant diffuse zonular rupture from blunt trauma, although the lens can move forward under gravitational influence, as in this case, and cause capsular block. The mobile lens reduces the predictability of the effective lens position and therefore also of the target refraction if the IOL is placed in the capsular bag.
I would make the main incision and 2 side ports and then 4 paracenteses in a diamond configuration relative to the incision in preparation for the iris hooks, which will also be useful as capsule anchors to stabilize the lens to the sclera during phacoemulsification. Before injecting the OVD, I would flush the anterior chamber using triamcinolone to check for prolapsed vitreous. Next, I would inject phenylephrine if the pupil had not opened enough to perform a 4.0 to 5.0 mm capsulorhexis. Trypan blue staining at this stage is a useful adjunct, particularly to enhance the visibility of the edge of the capsulorhexis for later, when engaging the capsule anchors. With the capsule stained and iris hooks in place, the capsulorhexis will likely be straightforward unless the lens instability is extreme, when countertraction is minimal and the bag must be stabilized by using the hooks to anchor the capsulorhexis edge as the capsulorhexis progresses.
Thorough subcapsular cortical cleaving hydrodissection will mobilize the nucleus in the bag to allow easy rotation with minimum zonular stress. The subcapsular plane then can be opened using an OVD to prepare for the implantation of a CTR to support the damaged zonular complex and also drum-skin the inevitably lax posterior capsule. This will facilitate the cortical stripping and reduce the risk for posterior capsule aspiration and rupture.
In cases such as this one, when zonular instability is an issue, a sulcus-mounted 3-piece IOL is the best option. There is no point in risking decentration or dislocation of the IOL by implanting it in the capsular bag.