Cataract surgery should be 10 minutes - maybe even less if you're lucky and good - in and out. But they're not all that easy: Zonules weaken, bags tear, pupils refuse to open. Fortunately, you have plenty of options when it comes to techniques and products for ensuring good outcomes. Here's your guide to managing seven types of complex cataract cases.

Vitrectomized eye
The problem: After a patient's had a vitrectomy to clear blood and debris from the eye, remove an epiretinal membrane or repair a macular hole, he'll likely develop a cataract within a year. "And these cataracts aren't soft," says Neal Nirenberg, MD, FACS, an ophthalmologist with East Valley Ophthalmology and Warren Hill, MD, in Mesa, Ariz. "They're a very hard, nucleosclerotic kind, which are harder to do."

On top of that, you're faced with a paucity of vitreous gel, which means less support for the bag. "The whole lens iris diaphragm moves posterior, so you end up working in a deeper situation," says Dr. Nirenberg. "And you never know whether [during the vitrectomy] zonular trauma occurred."

The solutions: Dr. Nirenberg says the first thing he does on such a case is lower the bottle; because you're working without the safety net vitreous provides, "higher pressure is just likely to push everything back there," he says.

Another trick he recommends is turning up the phaco power; while you risk more corneal edema with a power increase, you tend to be working a bit deeper, so you can get away with it, says Dr. Nirenberg.

"You really don't want to do any maneuvers that push down on the lens," he explains. "So instead of doing deep grooves on the lens, I just kind of shave it until I have a fairly deep groove, then use a cystotome to open the anterior capsule - those are the sharpest instruments I can get to open the capsule with very little downward pressure. You should attempt to crack the nucleus horizontally." Vertical chopping procedures create downward pressure on the lens and should be avoided in these cases, he says.

White cataract
The problem: The cataract is cortically mature and turns white. Because of this, visualization of the capsulorhexis is difficult, and there is a complete absence of red reflex.

The solutions: "Pre-operatively, you can do an ultrasound to help the surgeon get a good visualization in the back of the eye so you don't get a big surprise when you go in," says Gina Stancel, HCRM, CST, COA, the surgical administrator for David C. Brown, MD, at the Eye Centers of Florida in Fort Myers. "Most measuring devices have settings for dense or hypermature cataracts and give a good probability of getting an accurate reading."

Intraoperatively, staining the cataract is the answer. "The best way to visualize the cataract is with Trypan Blue, which just got approved," says Dr. Nirenberg. "It's great stuff." ICG is another dye option.

However, Trypan is far less expensive, about one-third the cost of ICG. "The IGC dye is $85 per small vial now that it comes in single-use - when it was multi-dose, it cost more than $300 per vial," says Linda Phillips, RN, the administrator at Castleman Surgery Center in Southgate, Mich.

Before the capsulorhexis, you put the dye on the capsule and leave it in place for about a minute, which lets you visualize the anterior capsule. The hypermature cataracts are very soft and filled with white fluid, says Ms. Stancel, and have a tendency to produce high intraocular pressure.

"When the fluid comes out, you might want to go in with the IA tip and suck it out before continuing the case," advises Dr. Nirenberg.

Pseudoexfoliation
The problem: This is a defect of the lens capsule, says Dr. Nirenberg, and it makes patients more prone to glaucoma. "Lens capsules are very fragile, so you have a high risk of posterior capsular rupture, and a lot of times there's zonular weakness and the potential for a dislocated lens implant," he says. "These can be the toughest, because often, until you get in the eye, you just don't know what you're dealing with."

The solutions: When you have poor zonular support, there are a few things you can do. "You can try a thicker viscoelastic to hold the bag open," says Michelle Akler, MD, an ophthalmologist at Castleman Surgery Center. "Or you can use a capsular tension ring."

Capsular tension rings cost about $200 each, says Ms. Phillips, and you have to buy a minimum of five. Plus, there's a one-time cost of $525 for the microinserter. "My issue with the CTRs is that they increase your cost per case, and it's a cost you have to eat," she says.

If you're not keen on that kind of economic inefficiency, there are other ways to deal with pseudoexfoliation.

"Before I start, I have three lens implants available in the OR," says Dr. Nirenberg. "One that I'll put in the bag if all goes well; one to put in the sulcus if I lose capsular support; and one to put in the anterior chamber if everything goes south."

He says you might be best off using a three-piece PMMA optic with prolene haptics, and using the haptics to expand the bag and hold it in place a bit better. Dr. Nirenberg also recommends you do these cases under lower bottle heights as well, and consider doing a larger capsulorhexis than usual.

"Sometimes, at the end of these cases, the patients are more prone to pressure elevations," says Dr. Nirenberg. "Acetazolamide (Diamox) post-op or in the evening can take care of that."

Small pupils
The problem: Due to trauma or long-time use of glaucoma medications, the pupil won't dilate.

The solutions: "Iris retractors are great but time consuming," says Ms. Stancel. "They pull back the iris, but can make it uneven, difficult and delicate to do. A CTR makes a perfect semicircle for a more normal dilation."

According to Ms. Phillips, a package of five iris retractors runs in the neighborhood of $78.

Other options: The Beehler pupil dilator, which through the use of several hooks even distributes the pressure of the iris, and Kuglen or Lester hooks.

"When I use the hooks, I call it the twin-pupil stretching technique," says Dr. Nirenberg. "I put in two hooks through the superior corneoscleral incision and use the push-pull method to stretch the pupil vertically. Then I make two sideport incisions, one at 3 o'clock and one at 9 o'clock, and insert the Kuglen hooks and stretch the pupil horizontally. I've never had a problem doing that."

Brunescent cataract
The problem: Also known as nucleosclerotic, this develops in mature cataracts and involves the hardening and darkening of the lens.

The solutions: "Nobody likes doing the really hard ones," says Dr. Nirenberg. "I use high phaco power, but with these - unlike vitrectomized eyes - you're working close to the cornea. So partway through, I'll stop and refill the anterior chamber, near the cornea, with viscoelastic."

In addition, he says, such cataracts tend to be leathery, and it's hard to crack the nuclear plate - so you might have to groove a lot deeper than normal. You might also need to break the cataract into six or eight pieces instead of four.

"On these rock-hard ones, when you a have all this nucleus, there's usually less cortex and epinucleus, which protect the posterior capsule, so I inject a little viscoelastic into the bag behind it to create an artificial epinucleus between the bag and the posterior nucleus," says Dr. Nirenberg.

Posterior polar cataract
The problem: A congenital weakness on the posterior capsule leaves the eye prone to capsular ruptures.

The solutions: The best route here is to go with a low flow. "Do a really gentle hydrodissection," says Dr. Nirenberg. "And when you're stripping the cortex, you want to strip toward where the defect might be, and remove the peripheral cortex first. That way you're working on the easier areas first.

"If you have a rupture at the end, you're in a better situation than if you just strip away and have a rupture in the beginning," he says.

Post-RK patients
The problem: After radial keratotomy, there are several slashes around the cornea. Even though they are healed, they are still vulnerable to pressure and can re-open. In addition, "lens calculations are a nightmare," says Ms. Stancel.

The solutions: Other than slowing down and taking extra care to not cause any trauma to the wound edges, "the surgeon needs to stay away as much as he can from the incisions when he makes his clear corneal approach," says Ms. Stancel. "Sometimes they have to adjust their incision site slightly or even adjust the limbal incision."

Your best bet
Obviously you need to be prepared in the OR, with extra sterile supplies close at hand in case you need them. But nothing can replace "a surgeon with a cool head," says Ms. Stancel. "That's the best thing for the OR."