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Cataract Surgery in Deep Set Eyes

[full article at CataractCoach.com] Performing intra-ocular surgery in a deep set eye is challenging because the access is limited. In the case shown here, the patient has age-related loss of orbital fat as well as a prominent brow, both of which cause the eye to be set deeply into the orbit.  Access is a challenge and limits the view and the ability to maneuver instruments within the eye. There are few things we can do to improve the situation: Sitting temporally and making the phaco incision at the temporal limbus will allow much better access to the anterior chamber as well as better positioning of the instruments. Though I prefer topical anesthesia for the vast majority of cataract surgeries, this is a case which could benefit from a retro-bulbar anesthetic injection. The addition of 5 cc or more of anesthetic to the retro-bulbar space will bring the globe forward and induce a mild, temporary proptosis.  Choose a phaco method such as phaco flip or flip-and-chop, which brings the nucleus out of the capsular bag. This allows the surgeon to work at the iris plane. Doing a traditional in-the-bag chop or divide-and-conquer technique will necessitate having instruments even deeper within the eye.