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99 EW RESIDENTS February 2015 of surgery so they are not put back into circulation and they can be properly evaluated. When reviewing the video look for any sign of anterior chamber instability, iris movement such as bouncing of the iris or change in pupil size, or frank deepening and shallowing of the chamber. The potential causes of AC instability Register Now! Be part of the excitement in Guadalajara, Mexico: • Hundreds of scientific sessions led by internationally- renowned experts on topics like cornea and refractive surgery, pediatric ophthalmology, and oculoplastics. • Network with more than 7,000 ophthalmologists from over 120 countries. • More than 100 exhibiting companies displaying the very latest cutting-edge products and services in ophthalmology. /attendwoc /attendwoc World Ophthalmology Congress ® of the International Council of Ophthalmology Host: Mexican Society of Ophthalmology Co-host: Pan-American Association of Ophthalmology Reserve your place today: woc2016.org include: excessive wound leakage, low bottle height and high aspira- tion flow rates. We will also review continued on page 100 forward movement of the capsule with extension of the tear and the delivery of vitreous into the anterior chamber. Instead, the best response is to maintain the chamber pres- sure by continuing the irrigation. Through the side port fill the AC and bag with a viscoelastic (pref- erably a dispersive). While doing this we can inject a small amount of viscoelastic through the tear into Berger's space pushing the hyaloid face and vitreous posterior. As we inject the viscoelastic, we can ask the scrub tech to slowly reduce the bottle height, reducing the irrigation pressure as we replace the balanced salt solution with viscoelastic. Once the chamber is filled with viscoelas- tic, we can safely remove the I/A or phaco needle and have a stable AC. Now breathe. In this case we are lucky to have a small tear with a flap, no vitreous and very little cortex. The small amount of cortex can wait because the focus is on stabilizing the tear. We can use Utrata forceps to grab the flap and keep it folded over and gently tear a small posterior contin- uous circular capsulorhexis (CCC). It is important not to distort the wound to prevent anterior chamber shallowing. Once the posterior capsule has been stabilized, we can proceed with IOL placement. If the posterior capsulorhexis is small, it's possible to place a 1-piece IOL in the bag. If it is large or we were unable to complete a CCC, we should not put the 1-piece in the bag but switch to a 3-piece IOL, placing the haptics in the sulcus with optic capture by the anterior capsulorhexis. After the lens is placed, we will use a bimanual I/A on lower settings to gently re- move the viscoelastic and the small amount of remaining cortex. Post- operatively we treat the patient for potential pressure spike due to the possibility of retained viscoelastic. Now that the case is finished, it is time to review the surgical video and inspect the instruments and discuss the best way to prevent this from happening again. When we look at the video we will look for signs of unbalanced fluidics, post-occlusion surge, or a burr on a metal I/A tip. If there is any question about the I/A tip or phaco needle, it is important to pull them at the end

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