Eyeworld

From a machine settings standpoint, "I generally use intraocular tools to keep the iris out of the surgical area," Dr. Park said. But if machine settings need to be changed, she said she would maintain vacuum but lower IOP and aspiration flow settings. Zonulopathy can complicate creation of the anterior capsulotomy, nuclear disassembly, cortical removal, and IOL placement/positioning. Dr. Khandelwal said the first clue that you're dealing with zonulopathy intraoperatively is trampolining or an unusual experience when attempting the capsulotomy. In nuclear disassembly, zonulopathy can make hydrodissection incomplete, and pieces can get stuck in the equator (not coming to the phaco tip). She said to remove cortical material toward areas of zonulopathy rather than away from them to avoid pulling on them and making it worse. As for settings, Dr. Khandelwal said when she sees a piece stuck in nuclear removal, she'll yaw her foot pedal to the right in segment mode to add a little vacuum, being careful to watch the bag to avoid creating more issues. She cautioned about surge upon occlusion break that can make zonulopathy worse. If she thinks fluid is moving behind the zonules, Dr. Khandelwal said she'll lower her vacuum set- tings, which will lower the overall settings to accommodate the lower vacuum setting. In cases of severe zonulopathy, she'll adjust settings and use tools, such as capsule stabiliz- ers and capsular tension rings. Power modulation in the setting of white cataracts was presented by Dr. Pettey, who discussed a case caused by blunt trauma, presenting with a little vitreous hemor- rhage, an acute white cataract, and a possible posterior polar cataract and diabetic retinopathy in the fellow eye. Dr. Pettey noted that retina was involved in this case, placing ports from the beginning. He then discussed how cases with potential pre-existing capsular rent should be approached with a non-rotational nuclear disassembly and removal tech- nique. The case proceeded and indeed did have a pre-exist- ing rent; however, all lens material was safely removed and a sulcus lens placed using an optic capture technique. Dr. Parkash spoke about methods that he modifies for complex cases, specifically a rock hard cataract. He said he always stains the capsule with trypan blue in these cases, creates a large 5.25–5.5 mm capsulorhexis, avoids hydro- dissection when he can't see the posterior capsule, and performs a longitudinal phaco chopping technique with a pointed chopper at high vacuum, separating pieces at different planes. Once the pieces are separated, he reduces the vacuum and takes out the central nuclear core. "Then I come out with a stratified nuclear emulsification technique, separating the nucleus from the epinucleus using high vacuum settings." He switches to an epinucleus setting to remove the epinucleus while protecting the capsule. "We have to structure the plan, control the execution to secure an optimal outcome," Dr. Parkash said. Dr. Pettey shared tips on phacodynamics in the setting of a white cataract. Source: Jeff Pettey, MD © Copyright 2026 ASCRS. All rights reserved. The views expressed here do not necessarily reflect those of the staff and leadership of EyeWorld and ASCRS and in no way imply endorsement by EyeWorld and ASCRS. THANK YOU TO THE SPONSORS OF THIS SYMPOSIUM "We have to structure the plan, control the execution to secure an optimal outcome." —Rohit Om Parkash, MBBS, MS

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