nucleus drop

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PowerPoint Presentation:

Dropping a whole or part of nucleus -serious complication -increases post op vn threatening complication

Types :

Types Dislocation of intact lens with the capsule 1.couching 2.traumatic 3.other systemic diseases Dislocation of lens fragment or full nucleus 1.nonphaco ECCE 2.phaco

In phaco:

In phaco Hydrodissection – blocked outflow, injection of too much fluid, inherent weak post capsule Rotation of nucleus during trenching During phaco chop During emulsification in setting 2 During irrigation & aspiration

PowerPoint Presentation:

Fate of dropped nucleus – tolerated/ vitritis Clinical features – dv , redness, pain S/L – ciliary congestion, corneal edema, AC reaction, pupil- regular/irregular Raised IOP Vitritis I/O – vitritis & location of nucleus fragment

Risk factors :

Risk factors Preoperative - History / signs of vitreous loss in opposite eye, PPC, hard cataract, total cataract, traumatic cataract, subluxated lens, small pupil, vitrectomised eye, pseudoexfoliation , proptosis , high myopia, eyelid abnormalities such as shortening of palpebral fissure, proptosis , pt with short thick neck.

Risk factors :

Risk factors Operative - inexperienced surgeon, topical anaesthesia in uncooperative pt, radial tear in rhexis , vigerous hydro, inability to judge depth during sculpting, continued aspiration after fragment removal

Early recognition of PC rupture / zonular dialysis is key to avoid nucleus drop:

Early recognition of PC rupture / zonular dialysis is key to avoid nucleus drop Signs of early PC rupture - 1.sudden deepening of chamber, with momentary pupil dilatation 2.sudden transitory appearance of clear redreflex peripherally acquired difficulty to rotate a previously mobile nucleus 4.partial descent of the nucleus into the ant vitreous 5.excessive lateral mobility / displacement


Complications Intraocular inflammation – 70% Secondary glaucoma – 50% Corneal edema – Retinal detachment – 1.5% Choroidal effusion – 4.5% CME – 3%

Management of PCR:

Management of PCR At whatever stage the tear is discovered, establishment of semiclose pressurized system is necessary. If tear is discovered during phaco emulsification, residual nuclear material may be removed by emulsification or converting to an ECCE technique. Cortical aspiration – low flow irrigation, Dry aspiration

PowerPoint Presentation:

Low flow bimanual vitrectomy

PowerPoint Presentation:

If tear is identified when both the nucleus and vitreous are present in ant segment 1.Posterior Assisted Levitation (PAL) may be helpful. 2.Introduce sheets glide b/w the nucleus and tear. 3.Convert the linear tear into a post capsulorhexis .

IOL placement:

IOL placement If rent is small with well defined margins place iol in the bag. If tear is large with peripheral extension & poorly defined borders, iol is placed in the ciliary sulcus .

Management of nucleus drop :

Management of nucleus drop 1. Favit technique 2. PPV&Phacofragmentation cryoextraction 4.Removal by PFCL 5.Removal by Endoscopy 6.PAL

Favit technique:

Favit technique Remove the cortex to obtain clear media Start ant vitrectomy , then go for midvitrectomy,then post vitrectomy Clear vitreous fibrils around the nucleus, Lift the nucleus into ant chamber, Depend upon hardness of nucleus emulsify / deliver it by extending the incision Perform an iridectomy Implant IOL in the sulcus .

PowerPoint Presentation:

Removal by cryoextraction - Removal by PFCL – works well for rock hard nucleus Removal by endoscopy – suited for eyes with severe corneal opacities, marked miosis , prominent iris synaechiae , IOLopacities

PowerPoint Presentation:

PAL- metal spatula is inserted through a parsplana incision & the nuclear fragments manipulated anteriorly to iris plane. CHOP STICK technique VISCOAT PAL technique -

Timing of surgery:

Timing of surgery Dropped nucleus is not an emergency however best time remain debated.



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