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The PMMA Puzzle: Advanced Phaco Technique in a Complex Case

Mokhtar Abushanab, MD, and Jluwi Saud Almasaud, MD

This video demonstrates a specialized technique for managing a cataract in the presence of a phakic anterior chamber PMMA IOL. Traditional approaches such as ECCE or smaller incisions with suturing followed by phacoemulsification can result in corneal astigmatism and an unstable anterior chamber. This video shows an alternative method using a scleral tunnel incision to optimize outcomes.

A scleral tunnel incision is created, matching or slightly exceeding the size of the PMMA IOL. Through this, a standard phaco incision is made using a keratome. Capsular stain is injected to enhance visualization, followed by anterior chamber washout and OVD injection to maintain space and protect ocular structures. A precise capsulorhexis is performed, followed by phacoemulsification. Note the presence of an air bubble in the anterior chamber—its stable position confirms adequate OVD filling. Once the bubble dissipates, additional OVD is replenished to ensure chamber stability.

Irrigation and aspiration remove residual cortical material. A foldable PC IOL is then implanted into the capsular bag. This step safeguards the posterior capsule during subsequent extraction of the phakic IOL. The scleral incision is carefully widened. A Sinskey hook and McPherson forceps are used to externalize the superior haptic. However, the inferior haptic is found adherent to the iris—a challenge requiring meticulous dissection. A corneal paracentesis allows insertion of pannus scissors. The IOL is secured with serrated forceps, and the embedded haptic is divided before the IOL is fully extracted. Remaining adhesions are released, and the residual haptic is delivered. The anterior chamber is irrigated, and incisions are hydrated and tested for leakage. An air bubble is injected to reform the chamber. Finally, the conjunctival peritomy is closed with an 8-0 Vicryl suture.

Posted: 8/01/2025