Multiple pit-drilling phacoemulsification for complex hard nucleus cataract in elderly patients: a case report

Ultra-elderly patients with small pupils, shallow anterior chambers and gradeⅤbrunescent nuclear cataract represent an extremely high-risk subtype of cataract surgery, with markedly elevated risks of intraoperative complications including corneal endothelial injury, posterior capsule rupture, nucleus descent and Descemet’s membrane detachment. Conventional pre-chopping techniques have significant technical limitations in such anatomically constrained and high-risk eyes. This study aims to present the technical details, quantified intraoperative parameters, safety advantages, and three-month standardized follow-up outcomes of modified multiple pit-drilling phacoemulsification in the management of extreme complex grade Ⅴbrunescent nuclear cataract in a 95-year-old diabetic patient. A 95-year-old female patient with a 15-year history of type 2 diabetes mellitus presented with long-standing bilateral progressive visual loss. Preoperative ocular examination revealed multiple compound high-risk factors in the right eye, including gradeⅤ brunescent nuclear cataract, small pupil, shallow anterior chamber, short axial lengths, and reduced corneal endothelial cell density. Modified multiple pit-drilling phacoemulsification, instead of conventional pre-chopping strategy, was performed combined with intraocular lens implantation. Standardized follow-up assessments were conducted at postoperative day 1, 1 month, and 3 months. No severe intraoperative or postoperative complications occurred. The patient showed typical visual changes of ultra-elderly patients with initial visual improvement followed by mild stable decline caused by age-related macular degeneration, rather than surgical trauma. Multiple pit-drilling phacoemulsification is safe and effective for ultra-complex gradeⅤbrunescent nuclear cataract in ultra-elderly diabetic patients with small pupils and shallow anterior chambers. Unlike conventional forceful pre-chopping, this technique achieves stepwise intranuclear volume reduction and tension release, maintains continuous anterior chamber stability, minimizes mechanical and thermal endothelial trauma, and reduces the risk of capsular rupture and zonular injury. It provides a reliable and individualized surgical option for extreme high-risk complex cataract surgery and has promising clinical application value.