When performing cataract surgery for an eye with a moderate or small pupil, be sure to check under the iris for any residual cortex. The lens cortex at the capsular bag equator can be hidden by the iris tissue if the dilation is insufficient. In this case, we have a reasonable 5 mm pupil and the capsular bag appears completely empty when inflated with cohesive viscoelastic. 

When the IOL is inserted, the chopper is used to dial it into the capsular bag. Then the same instrument is used to lift up the iris to look for residual cortex. In this case, we see cortical material that is hiding at the capsular bag equator in the nasal quadrant. The irrigation-aspiration probe is used to remove it and then the iris is lifted again to confirm success. The remainder of the case goes well and the patient has an excellent visual outcome. 

The next time you're dealing with a small or moderate sized pupil, be sure to check for residual cortex material.

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