Most cataract surgeries conform to normal surgical patterns. However, in some situations, there can be factors which make surgery more challenging. These include the presence of corneal endothelial damage, small pupils, total white cataracts, loss of the normal lens supports, and others.

In these challenging situations, an alteration in the standard surgical approach may be required. Depending on the condition being tackled, a variety of surgical tools and techniques may be required to successfully complete the procedure.

In eyes with preexisting corneal endothelial damage, the use of an investigation termed specular microscopy is critical, as it allows a quantitative estimation of the number of endothelial cells in the cornea. This in conjunction with pachymetry to assess corneal thickness helps plan the surgery. During surgery, the use of special viscoelastics can help protect the corneal endothelium.

In eyes with small pupils, the use of special hooks that allow retraction of the iris, will allow better visualization during surgery. Similarly, in eyes with a white cataract, the use of a blue dye enhances visualization of the the capsule of the lens and promotes safe surgery.

In eyes with poor lens supports, recent advances allow the safe implantation of IOLs with the help of special devices termed “capsular tension rings”. These rings stretch the lens capsular bag into a normal position and ensure that the IOL has adequate support within the eye. Thus, there are currently a number of advanced approaches that allow safe and successful surgery even when the cataract is complicated by the above factors.

The use of Microincision Cataract Surgery and a good phacoemulsifier can help facilitate the performance of successful cataract surgery in such situations. The use of an advanced microscope to enhance visualisation of ocular structures can also help. Finally, a well equipped operation room with access to good viscoelastics like chondroitin sulfate and sodium hyaluronate, hooks, Cionni rings, and various forms of Capsular Tension rings are required in these eyes.