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posterior capsular leafs, I would use either a 25-gauge needle or Slade LASIK cannula on a dispersive viscoelastic. I would try the latter cannula first at the junction of where the CTR is jutting out from the capsular bag. "If I can reopen the bag I would place a Mackool capsular support hook under the IOL and inferiorly to give countertraction and hold the bag in position. I would then reposition the CTR in the bag using MST forceps [Redmond, Wash.]. I would possibly put the lens in the bag if there was adequate support. I would replace the Mackool hook with an Ahmed segment and sew it into place after preparing a scleral flap using a 9-0 prolene." Dr. Masket's thoughts: "You'll need iris hooks to see what you are doing. I would attempt to reopen the bag; the best tool is the Slade femto spatula. If successful, use capsule hooks to support the bag and drop the CTR and IOL in the bag and sew the CTR to the sclera with two lasso sutures by whatever means you prefer. Alternative to the lasso is one or two Ahmed segments. Assuming that you cannot salvage the bag, sew the CTR and IOL loops to the sclera with the same two lasso sutures and 'clean up' the bag with the 23-gauge vitrector via the pars plana." And finally Dr. Raviv's commented on this case: "This is a case where intraoperative findings will direct the surgical direction of action. The main question is whether the capsular bag is stable for IOL fixation. At five months, natural fibrosis may stiffen the bag sufficiently to overcome sectoral zonular loss. "If this was the case, dissecting open the bag would likely be difficult without first explanting the IOL. I would opt for creating a central capsulotomy with a 23-gauge vitrector (preferably via an unimpeded pars plans approach) for posterior optic capture. I would also explant the CTR, which poses a posterior dislocation risk. "If the entire bag complex was loose, I would explant the CTR, irissuture fixate the IOL and likely excise the remaining capsule." What was done Iris retractors were placed to improve visualization and the capsular bag was reopened using a 26-gauge spatulated LASIK cannula with dispersive viscoelastic. The point of entry into the bag was the point of exit of the CTR. After the capsular bag was reopened the CTR was removed through a temporal incision and then redirected into the capsular bag where it was placed 360 degrees after reinflation of the bag. At this point the IOL was retrieved and the superior haptic sutured to sclera while the optic was buttonholed into the capsular bag. Although the IOL appeared stable at this point I was concerned about some possible tilt due to the lack of inferior zonules, and it also looked under the microscope like there was a rather large gap between the inferior part of the IOL and the back of the iris. I was concerned that this could lead to a hyperopic outcome and induce some astigmatism so I decided to lasso the inferior haptic above the capsular bag to the CTR within it together to sclera. An LRI was placed at the end of the procedure to address corneal astigmatism. A vitrectomy was not required in this case. The patient ended up with an excellent, uncomplicated anatomic and visual outcome with 20/25 uncorrected vision on postoperative day one. This case highlights the importance of evaluating patients carefully prior to surgery to develop a plan and then having a variety of surgical techniques that can be called upon as options as the anatomic realities are unveiled in the operating room. All the consultants on this case drew from their own range of surgical skills to come up with plans and backup plans and that is a lesson the rest of us can take with us to the OR next time we face a difficult case. EW Editors' note: Drs. Hannush, Hedaya, Masket, and Raviv have no financial interests related to this article. Contact information Hannush: sbhannush@gmail.com Hedaya: edwardhedaya@gmail.com Masket: avcmasket@aol.com Raviv: Tal.Raviv@NYLaserEye.com Safran: safran12@comcast.net .EW 2HEIN® 2ESPOSABLE +NIVES Front View s s s s s s s +ERATOMES 3IDEPORTS 4RAPAZOIDS 3POONS #RESCENTS 3TABS 2ESTRICTED 3TABS s 0 ATENTE D $ "L ADE S $ E S IG NE D 4O # RE ATE ! 3UPERIOR 3ELF 3EALING )NCISION 5NIQUE ! S Y M MET R IC A L $ " EVEL S 0 U SH 3T ROMA ) N 4 H RE E $ I RE C T ION S # RE AT I NG ! - ORE 4OR T U ROU S 0 AT H &OR &LU ID % G RE S S ION s 3PECIAL (ANDLES !RE !UTOCLAVEABLE !ND 2 E U S A B L E ! L L O W I N G - U L T I P L E 5 S E S 4O " R I N G 4HE #OST 0ER #ASE $OWN s !V A I L A B L E 3 T E R I L E 0 E R " O X ) N ! 6A R I E T Y / F 3IZES ,ABELED &OR 2EUSE s 2 E U S A B L E !UTOCLAVEABLE -ADE )N 4HE 53! ! N D !V A I L A B L E & O R ! 3 U R G I C A L % V A L U A T I O N 7IT HOUT /BLIG AT I O N Call 727-209-2244 For More Information. 3360 Scherer Drive, Suite B, St. Petersburg, FL 33716 s 4EL s &AX %MAIL )NFO 2HEIN-EDICALCOM s 7EBSITE WWW2HEIN-EDICALCOM *Patent Number RE 37,304 3TYLIZED %YE 2HEIN -EDICAL 1345 Rev.A BABC