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August 2012 EW RESIDENTS 61 vitrectomy handpiece. The IOL haptics can then be placed in the ciliary sulcus ± optic capture through the capsulorhexis. Dr. Naseri: This is not an un- common situation with residents learning the skill of "upslope sculpt- ing" as part of the divide and con- quer or stop and chop technique. We teach that downslope sculpting must cease once the surgeon passes the midpoint of the nucleus, but it can sometimes be difficult for trainees to recognize when they have passed that point, which takes continued on page 62 Elizabeth Yeu, M.D. Assistant professor of ophthalmology Cullen Eye Institute Baylor College of Medicine, Houston selection would depend on the status of the bag, but ciliary sulcus placement would likely be possible. Much more likely in this scenario is the formation of a round hole in the posterior capsule. Unlike a tear, a small round hole in the cap- sule has little likelihood of propaga- tion unless it is put under severe duress. Vitreous prolapse is also less likely unless vacuum is applied directly to the area surrounding the hole or the anterior chamber is allowed to collapse. In a case such as this I would only do a couple of things differently. I would proceed with nuclear disassembly and re- moval in a standard fashion. How- ever, when it came time to switch instruments in the eye (from phaco to I/A), I would make every certainty that the anterior chamber does not collapse. I would consider adding viscoelastic through the side port in- cision prior to removal of the phaco handpiece to be absolutely certain. Chamber collapse could potentially allow vitreous to present. I would also avoid any capsular polishing. Some would advocate converting a small posterior capsular hole into a posterior capsulorhexis, but I tend to think less is more. If after epinucleus and cortical removal you are left with a small hole and no vitreous prolapse, I would have no problem injecting a one-piece IOL into the bag. In the event vitreous presents, suture the main wound, perform a bimanual anterior vitrectomy, and remove residual cortex with the