Phaco surgery can be challenging in eyes with reduced visualization due to media opacity such as corneal scar, dense cataract, or small pupil. Having proper tools for the job make a huge difference in the outcome. I have found that a good operating microscope with coaxial illumination and superior optics make life easier for the operating surgeon and ensures a good outcome for the patient.

Below we discuss a case of dense cataract with extensive corneal scarring in the right eye. A video of the procedure may be viewed at www.eyetube.net/video/cataractremoval- with-lumera-700-in-corneal-opacity-case/.

The patient experienced chemical burns about 15 years ago and recovered fairly good vision after treatment. However, he began to notice gradual visual loss over the past 3 years. On examination, the patient had a dense corneal scar (due to the chemical burn) with a grade 4 cataract in his right eye. BCVA was counting fingers at 3 m.

We knew that the challenge in this patient would be performing phaco with poor visualization due to the dense corneal scar. Regular illumination offered a very poor red reflex (Figure 1), so we opted to use the stereo coaxial illumination available on the OPMI Lumera 700 (Carl Zeiss Meditec, Jena, Germany), which dramatically improves red reflex and visualization (Figure 2).

Under topical anesthesia, a 2.8-mm temporal clear corneal incision was made (Figure 3), followed by capsulorrhexis with a 26-gauge needle (Figure 4). Under standard illumination, hydrodissection would have been difficult; however, the good red reflex provided by the stereo coaxial illumination facilitated seamless visualization of the fluid wave during this step (Figure 5). The nucleus was then rotated.

Phacoemulsification of the dense grade 4 nucleus was performed with quick-chop technique using a 15° tip (Figure 6). Multiple chops with a sharp chopper were needed to break up the nucleus into small pieces for emulsification. Cortical clean-up was made easy by the superior red reflex (Figure 7), and a three-piece acrylic foldable lens was implanted into the capsular bag (Figure 8). The wound was hydrated and closed.

CONCLUSION
The patient recovered nicely after surgery, and BCVA in the operated eye is 20/40. This difficult procedure was facilitated by the excellent stereo coaxial illumination and optics of the OPMI Lumera 700 operating microscope (Figure 9)

Sri Ganesh, MBBS, MS, DNB, is Chairman and Managing Director, Nethradhama Super Speciality Eye Hospital, Karnataka, India. Dr. Ganesh states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +91 80 2608 8000; fax: + 91 80 26633770; e-mail: chairman@nethradhama.org.

TAKE-HOME MESSAGE
• Stereo coaxial illumination improves red reflex and visibility, facilitating intraoperative maneuvers.
• The use of proper tools help the procedure to go smoothly