For softer posterior polar cataract multiple techniques have been described. What should be the strategy to deal with hard 3+ posterior polar cataract during phacoemulsification?
My surgical technique for this special case is to use a lateral 23 G anterior chamber endoilluminator which increases significantly the surgeon's three-dimensional perspective. Frontal illumination as provided by the surgical microscope is ideal for capsulorhexis, but this frontal light makes the sculpting, fragment extraction and posterior capsule polishing less precise as images are presented in two-dimensions only.
I use lateral illumination by inserting a 23 G endoilluminator probe into the anterior chamber through a paracenthesis, this significantly enhances the three-dimensional quality of the images, allows a better depth perception and increases the details of the lens structures, specially the posterior capsule. In these types of cases where the removal of the posterior cataract is difficult I strongly recommend the advantages of Lateral Illumination as it significantly enhances the visualization of it.
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Large capsulorhexis and multiple hydro delineation waves performed gently. Try to prolapse the smallest central ring nuclear piece first and emulsify it. Then using epinuclear settings engage the more peripheral rings. Obviously avoid hydro dissection.
Do only hydrodissection with smallest central ring. excavate this and then work with chip technique.
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