Phako/BANG — Tips on Managing Chemosis and Correcting Haptic Placement

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Case Overview

This annotated surgical case shows a combined phacoemulsification and BANG (Bent Ab-interno Needle Goniotomy) procedure in a patient with asteroid hyalosis. Along the way, we encounter two common intraoperative challenges: conjunctival chemosis (ballooning) and an IOL haptic that ends up in the sulcus instead of the capsular bag.

Dealing with Asteroid Hyalosis

In patients with asteroid hyalosis, your red reflex and contrast during surgery are significantly reduced. In severe cases, the reflex can be nearly absent, making capsulorhexis particularly challenging. In this case, the hyalosis was moderate — you can still see, but the capsulorhexis edges aren't as crisp as usual, and the result may not be perfectly round.

Managing Chemosis (Conjunctival Ballooning)

During hydrodissection, you may notice the conjunctiva ballooning up — this is chemosis caused by BSS tracking under the Tenon's capsule. If left unmanaged, it progressively worsens and can obstruct your surgical field.

The Fix: Open the Conjunctiva Early

Take a chopper (or similar instrument) and make a small opening in the conjunctiva at the limbus. Then massage the sub-Tenon's fluid out. Remember: Tenon's capsule acts like a sponge — it's not one fluid-filled cavity. You need to actively squeeze the fluid out. Do this early and repeat as needed throughout the case.

Haptic Misplacement — Recognizing and Fixing It

After removing the lens nucleus and cortex, the IOL is injected. In this case, since a BANG procedure follows, the IOL is placed using a spatula rather than the injector's plunger (to avoid pushing the lens too far).

The first sign something isn't right: the lens doesn't rotate as smoothly as expected. On closer inspection, the capsulorhexis edge shows an irregular triangular shape in one area — a telltale sign that the haptic is in the sulcus rather than the bag.

Step-by-Step Correction

1. Stop and assess. Don't keep manipulating blindly.
2. Remove air bubbles — use a half-filled BSS syringe to aspirate any bubbles obscuring your view. Always improve visibility first.
3. Zoom in and trace the capsulorhexis edge to confirm the haptic location.
4. Use a hook to capture the haptic elbow and guide it into the bag. If you can grab the haptic without disturbing the anterior capsule, it confirms the haptic was indeed in the sulcus.
5. Push the elbow in first, then use the hook to tuck the rest of the haptic into the bag.

The BANG Goniotomy

With the phaco portion complete, it's time for the glaucoma component. BANG stands for Bent Ab-interno Needle Goniotomy — essentially using a bent 27-gauge needle to incise the trabecular meshwork from inside the eye.

Technique Highlights

• Refill the angle with dispersive viscoelastic (2% hyaluronic acid) for better visualization
• Bend a 27-gauge needle at 90° — this acts as a budget-friendly Kahook Dual Blade alternative
• Tilt the patient's head and use a goniolens to visualize the trabecular meshwork
• The pigmented TM should be clearly visible — slice it open with the needle tip

Critical Tip: Instrument Rotation

A common mistake during BANG is pulling the needle laterally through the phaco wound. This creates poor access to the TM on the far side. Instead, keep the needle in the wound and rotate it so the tip sweeps to the opposite side. This gives you better reach and a more controlled incision of the meshwork.

You may notice some TM tissue hanging into the anterior chamber afterwards. In the author's experience, this does not cause significant inflammation and can be left in place.

Final Steps

After completing the goniotomy, tilt the patient's head back to a neutral position, remove the viscoelastic thoroughly, and close. The combined procedure addresses both the cataract and the glaucoma in a single session.