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Dropped Nucleus Management

This document discusses the management of a dropped nucleus during cataract surgery. It defines a dropped nucleus as loss of part or all of the lens nucleus into the vitreous cavity. Risk factors and complications are discussed. Primary management by the anterior segment surgeon includes clearing the vitreous from the anterior chamber and securing any remaining lens material. Definitive management involves a pars plana vitrectomy by a vitreoretinal surgeon to remove the dropped nucleus fragments. With timely and appropriate management, good visual outcomes can be achieved in 60-80% of dropped nucleus cases.

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Niloy Basak
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664 views32 pages

Dropped Nucleus Management

This document discusses the management of a dropped nucleus during cataract surgery. It defines a dropped nucleus as loss of part or all of the lens nucleus into the vitreous cavity. Risk factors and complications are discussed. Primary management by the anterior segment surgeon includes clearing the vitreous from the anterior chamber and securing any remaining lens material. Definitive management involves a pars plana vitrectomy by a vitreoretinal surgeon to remove the dropped nucleus fragments. With timely and appropriate management, good visual outcomes can be achieved in 60-80% of dropped nucleus cases.

Uploaded by

Niloy Basak
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

MANAGEMENT OF

DROPPED NUCLEUS
CHAIRMAN
P R O F D R . D I PA K K U M A R N A G
P R O F E S S O R A N D H E A D, R E T I N A
D E P T, N I O & H

M O D E R ATO R
D R . M D. H A F I Z U R R A H M A N
A S S I S TA N T P R O F E S S O R , R E T I N A D E P T,
NIO&H

PRESENTER
DR. SOHEL MAHMUD
F C P S PA R T- 1 1 S T U D E N T, N I O & H
WHAT IS NUCLEUS DROP?
Loss of a part or the whole lens nucleus in the vitreous cavity
MECHANISM OF NUCLEUS DROP
 Large posterior capsular tear
 More rarely- following zonular dialysis
WHY NUCLEUS DRIFT TOWARDS
VITREOUS CAVITY ?
 Researcher Robert Osher
 Experiments on cadaveric eyes
 If vitreous undisturbed- it will give support
 Older vitreous – due syneresis – allow easier passage of nucleus
into posterior segment
 High aspiration and post-occlusion surge – pull supporting vitreous
towards PHACO tip - allowing nucleus drop
INCIDENCE
 British Ophthalmological Surveillance (BOSU)

 The Incidence of nucleus drop following a posterior capsular tear is


0.3% (2-3/1000)Operations/year for Phacoemulsification Surgery
RISK FACTORS
PREOPERATIVE
 Increasing age  Previous vitrectomy
 Pseudoexfoliation  Marfan's syndrome
 Brunescent/white cataract  Posterior polar cataracts
 Previous trauma  Trainee surgeon
 Glaucoma
 Tamsulosin use
 Small/large eye
RISK FACTORS CONT…
INTRAOPERATIVE
 Visible tears in the posterior capsule
 Occult tears of the posterior capsule
 Radial progression of an anterior capsular tear
 Equatorial or posterior rupture of the capsule by the PHACO tip
 Posterior capsule torn by an instrument
 Zonular dialysis larger than 3 clock hours
COMPLICATION OF DROPPED NUCLEUS
 Intraocular inflammation (uvetis/vitritis)- 70%

 Secondary glaucoma – 50%

 Corneal edema – 35%

 Retinal detachment – 1.5%

 Choroidal effusion – 4.5%

 Cystoid macular edema – 3%


SIGNS OF IMPENDING NUCLEAR DROP
 Runaway capsulorrhexis
 “Pupil snap” sign
 Difficulty in rotation of nucleus
 Nuclear tilt
 Receding nucleus
MANAGEMENT OF DROPPED NUCLEUS
DEPENDS ON-

 The stage of the operation


 The amount of the lens fragment dropping into vitreous
 Whether vitreoretinal surgical help is available
PRIMARY MANAGEMENT BY THE
ANTERIOR SEGMENT SURGEON
 At this point, the situation is still entirely salvageable. So, stay calm.
 Resist the urge to chase after the dropped fragments

 Move the nuclear fragments to a safe position if possible

 Use ophthalmic viscosurgical device to freeze the frame

 Avoid unnecessary manipulation

 Allow time to reassess the situation


 Residual nuclear material should be removed by either
phacoemulsification or converting to an ECCE technique

 If phacoemulsification – low bottle height and moderate vacuum

 Cortical aspiration by low flow irrigation-aspiration or dry aspiration

 Vectis delivery for cases convert to ECCE

 Bimanual vitrectomy

 Secure the wound


BIMANUAL ANTERIOR VITRECTOMY
 It should be performed through the two paracentesis avoiding the use
of the main incision

 Using a Low Bottle height, High Cut rate and low Suction, the anterior
chamber should be cleared of Vitreous

 Triamcinolone acetonide can be use for better visualization of vitreous


to ensures thorough vitrectomy
 The cutter is first passed through the rent in posterior capsule to
remove adequate vitreous

 This will ensure removal of all prolapsed vitreous in the anterior


chamber and prevent further vitreous prolapse and the
enlargement of PCR
IOL IMPLANTATION CONTROVERSY
• BOSU data suggest-all IOLs inserted at the time of cataract surgery,
77% were removed or replaced upon subsequent PPV

• Most vitreoretinal surgeons currently agree that placement of a secure


IOL at the time of primary surgery is advisable as long as it is stable
IOL IMPLANTATION OPTIONS
Key points before taking decision to implant IOL during
primary surgery-

 Integrity of capsular bag and capsulorrhexis margin

 Location and size of posterior capsular tear

 Degree of visibility permitting an accurate assessment of capsular


integrity

 Size and hardness of dislocated lens fragment


 Visibility is too poor or lack of capsular support or hard nuclear
fragments have dislocated - postpone IOL implantation

 Visibility is good, PCR is small- conversion to posterior continuous


curvilinear capsulorrhexis (PCCC) is feasible - a single piece PCIOL
can be placed in the bag

 PCR is large/peripheral- a PCCC is not feasible - visibility is good -


capsulorehexis margin is intact - after adequate anterior vitrectomy- a
three piece PCIOL can be implanted in the sulcus with optic capture
POST-OPERATIVE MANAGEMENT

 Post-operative anti-inflammatory medications

 Post-operative anti glaucoma medications

 Patient counselling

 Referral to vitreoretinal surgeon as early as possible


DEFINITIVE SURGERY- PARS PLANA
VITRECTOMY
 Surgery done by vitreo-retina surgeon. So, presence of a vitreo-retina
surgeon’s availability in the team cataract surgeons is ideal.

 Timing of surgery depends on an individual case bases, vitrectomy for


dislocated nuclear fragments can be delayed upto 3 weeks without
significant difference in the visual outcome.
PRE-OPERATIVE ASSESSMENT
Following information should be provided by anterior segment
surgeon while referring the patient to vitreoretinal surgeon

 Amount/type/hardness of retained lens material


 Presence/absence of an IOL implant
 Assessment of capsular support
 Calculated IOL power
 Well secured wound
The following factors should be assessed before a definitive
surgery by vitreoretinal surgeon-

 Integrity of the cataract wound

 Slit-lamp examination to assess corneal clarity, degree of anterior chamber


inflammation and intraocular pressure

 Indirect ophthalmoscopy to assess nuclear fragment as well as to exclude


peripheral retinal tears, retinal detachment or choroidal detachment

 B-Scan ultrasonography in cases of media haze (corneal oedema or


associated vitreous haemorrhage)
SURGICAL PROCEDURE
 A three-port pars plana vitrectomy is the procedure of choice and
standard of care

 Hybrid or mixed gauge (23 and 25-gauge) vitrectomy is performed with


a single large port for introduction of fragmatome
STEP 1: PARS PLANA VITRECTOMY

Key points-

 Remove all the vitreous from anterior chamber

 Intravitreal triamicinolone acetonide could be utilized for better


visualization of vitreous

 All the vitreous attachment to the nucleus should be removed

 If fragmatome is being used then induction of PVD is must and


vitreous base should be trimmed
STEP 2: REMOVAL OF NUCLEUS

Incase of soft nucleus –

 Removed by vitrectomy cutter (low cut rate - 600-800 cuts/minute)

 Few drops of PFCL can be used as a cushion

 Light pipe can be used to crush the nucleus against the cutter probe
Incase of hard nucleus-

 Perform adequate vitrectomy first

 Use ultrasonic fragmatome to manage nucleus

 Few drops of PFCL can be used as a cushion

 Or delivering the nucleus via limbal route


STEP 3: PERIPHERAL EXAMINATION BY INDENTATION

 Locate any pre existing breaks

 Localize any unknown breaks caused during the surgery

 Manage them by barraging them with laser intra operatively

 Reducing chances of post operative retinal detachment


VISUAL OUTCOME

 Visual acuity of 6/9-6/18 is achieved in 60-80 % cases with dropped


nucleus

 Appropriate and timely management can restore good visual outcome


TAKE HOME MESSAGE
THANK YOU

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