![bounce break bounce break](https://images.nintendolife.com/screenshots/24546/large.jpg)
Once the nucleus was evacuated, I instilled Triessence (triamcinolone acetonide Alcon Laboratories, Inc.) diluted 10:1 with balanced saline solution to identify any prolapsed vitreous. I decreased the fluidics to slow motion, and, making sure to establish flow in the OVD-filled environment to avoid a wound burn, fed the soft nucleus into the phaco tip with the chopper. I then instilled Miochol E (acetylcholine chloride intraocular solution Bausch + Lomb) to bring the pupil down behind the nucleus and compartmentalize the presumed prolapsed vitreous. In this case, I was able to push the vitreous back with dispersive OVD, complete the hemisphere dissection with my chopper and OVD cannula, and tire-iron one and then the other soft nucleus fragment into the anterior chamber without losing the integrity of the anterior continuous curvilinear capsulorrhexis (CCC). When I say the word timing, my nurses and techs know to get the Vit Kit, which consists of the tools that might be needed to combat vitreous loss, and to expect a longer procedure time. We are all accustomed to practicing for cardiac arrest and fire drills similarly, because vitreous loss is rare, we should have our team practice what to do in a seamless fashion in a case like this.
BOUNCE BREAK CODE
I contend that surgeons should occasionally run what I call a Code V. Once the situation is static after OVD injection, the instruments can be safely withdrawn, allowing thoughtful inspection and planning. If the phaco tip is withdrawn and the chamber shallows, because vitreous follows a gradient from high to low pressure, the break in the capsule will expand and vitreous will follow out the incision. The first thing to do in the event of a complication like this is to stabilize the anterior chamber by trading the phaco chopper for a cannula (Figure 1C) filled with a dispersive ophthalmic viscosurgical device (OVD). Below I outline the appropriate steps to manage this difficult situation.
![bounce break bounce break](https://www.reviewjournal.com/wp-content/uploads/2015/04/web1_he-springbreak_004_2.jpg)
The sooner there is recognition, the more likely an optimal outcome can be achieved. I caught this surgical nightmare on video (/?v=bewen), and it now serves as a reminder that you do not want to blink during cataract surgery, because if you missed the sudden redistribution of fluid and the pupil expansion and chamber bounce lasting only a second (0:25 into the video Figures 1A and 1B), you might not immediately see the complication.
BOUNCE BREAK FULL
This is one of the worst times to break the capsule, as the full nucleus is present. In this case, because of a high rise time and vacuum, after just two bursts the phaco needle emptied and sucked in the rest of the lens and the posterior capsule. Subsequent vertical chops use minimal ultrasound to complete disassembly and allow removal. My technique involves using burst mode to penetrate to the middle of the nucleus in a controlled fashion with a Kelman tip, facilitating a vertical chop of the nucleus into hemispheres. During the first day of a learning curve for a new phacoemulsification machine, the settings were aggressive.
![bounce break bounce break](https://www.cliqtosave.com/media/catalog/product/cache/7cbacd5d199bfd66104c2f98c0cf8344/b/o/bo-1004-bkyl_1.png)
I recently operated on a young male myope with a grade 3+ hazy white nuclear sclerosis that was softer than anticipated.