A 54-year-old man presented to my clinic reporting a progressive decrease in vision in his left eye (OS) in the past year. His vision in this eye had been partly compromised after a perforating ocular trauma 15 years ago, for which he had not undergone surgery; he noted it had significantly worsened over the past 12 months.

Upon examination, the patient had a BCVA of 20/25 in his right eye (OD) and light perception OS. He had 1+ nuclear sclerosis in the right eye. In his left eye, he had a nasal pterygium, a transparent cornea with peripheral leukoma at 10 o’clock, a formed anterior chamber with no cells or flare, anterior synechiae in the 3-mm peripheral cornea from 10 to 12:30 o’clock, corectopia, and a white cataract. Phacodonesis was not present.

Ultrasound revealed a silent vitreous chamber and attached retina and choroid. Topography showed regular corneal astigmatism of 1.30 D @ 150. Therefore, I planned this patient’s cataract surgery based on three factors: (1) traumatic cataract, (2) white cataract, and (3) visually significant regular corneal astigmatism.

Although phacodonesis was not present, given the patient’s history of trauma, I had capsular tension hooks and a capsular tension ring in the operating room in case I needed them. Additionally, I made sure to manipulate the capsular bag as gently as possible to avoid zonular stress.

With regard to the white cataract, my surgical steps were as follows.

1. I began by opening my secondary incision and injecting diluted adrenaline into the anterior chamber.

2. I filled the anterior chamber with a single air bubble and stained the anterior capsule with trypan blue. The increased anterior chamber pressure created by the air bubble improves staining.

3. After re-forming the anterior chamber with a single air bubble, I performed my main incision and filled the anterior chamber with a high-viscosity cohesive ophthalmic viscosurgical device (OVD).

4.I started the capsulorhexis using a cystotome and aspirated part of the liquefied cortex with a cannula filled with balanced salt solution to decrease intracapsular tension before proceeding.

5. I used Utrata forceps to create the capsulorhexis and stopped to aspirate the cortex with a cannula whenever there was increased pressure caused by the underlying liquefied cortex.

6. After completing the capsulorhexis, I used my phaco handpiece to finish aspirating the liquefied cortex, which prevents the need for hydrodissection in these cases and results in a freely rotating nucleus.

7. In this specific case, I decided to use the stop-and-chop technique for phacoemulsification.

8. I aspirated the cortex using my secondary instrument to expose the cortex located below the iris.

9. I injected a toric IOL, aspirated the OVD from below the lens and from the anterior chamber, and aligned the lens with the desired meridian.

At the end of surgery, I closed the main wound with a 10-0 nylon suture. I also sutured the area adjacent to the corneal scar, which partially opened during phacoemulsification.

On postoperative day 1, the patient had a UDVA of 20/25 OS.