Should you go behind the IOL to remove viscoelastic in cataract surgery?

Surgeons in training often ask, "Do I needå to remove the viscoelastic from behind the IOL at the end of the case?" And the answer is not as simple as it seems. While I do this maneuver in nearly 100% of my cataract surgeries, it is not easy for a less experienced surgeon to do so.

We have to weigh the risks versus the benefits of going behind the IOL versus simply rocking the optic back and forth to remove the viscoelastic. If you have performed less than 50 cataract surgeries and you are early in the learning curve, then it may be too much of a risk for damaging the capsular bag when the IA probe tip is placed behind the optic. Retained viscoelastic can induce a post-operative pressure spike as the thick material attempts to go through the trabecular meshwork. It can also cause unintended refractive effects if the capsular bag stays distended or if the viscoelastic allows the optic to shift or move. For a toric IOL or a diffractive multifocal IOL, where optic centration and rotational positioning is critical to the refractive success, removing the viscoelastic is a must.