NUCLEUS

DROP

Mechanism

• large posterior capsular tear• more rarely, following zonular

dialysis

Superficial tunnel

Tunnel rupture during phaco

A/C collapse(unstable)

Quadrant removal/ I-A

Chance of PC capture by phaco

Small CCC

Relaxing incisions (blumenthal tech)

Hydrodissection

Continuous irrigation

Relaxing extends posteriorly PCR

Prevention : beer can opener

from side port if hydrodissection done @ 3 / 9 o’clock , canula prevents nucleus to pop out of bag + fluidics from ACM – PCRPrevention : Hydro , from side port, @ 6 o’clock

Novice phaco surgeon

Cant control foot pedal well

Irrigation OFF while making trench / quad removal

PC captured in phaco probe

• Inadvertent hydrodissection in the presence of a posterior polar cataract.

• Sub incisional co axial I/A or blind I/A beneath pupil with full vaccum – capture PC.

• Inadvertent IOL insertion – injures PC by haptic / dialer

Risk factors

result in loss of the capsulorhexis or later capsular tears• corneal scarring, • Small pupil, • dense nucleus• previous vitrectomy

MANAGEMENT

• At this point, the situation is still entirely salvageable.

• The key point is that appropriate management of the case by a vitreoretinal surgeon is likely to result in a good visual outcome.

• However, inappropriate and/or inexperienced intervention may result in serious complication, which will compromise the outcome.

• The cataract surgeon should therefore resist the temptation to ‘chase’ nuclear fragments or perform procedures outside his/her expertise.

• An anterior vitrectomy, preferably with separate irrigation cannula or anterior chamber maintainer, should be performed to clear the wound from vitreous strands.

• Where there is an intact capsulorrhexis a 3 piece foldable lens can be placed in the ciliary sulcus and capture of the optic by the capsulorrhexis may be used to stabilise the lens

Early Intervention by VRS if :

• the large amount of lens matter present

• Anterior retinal tears• Early RD• IOP cannot be controlled by medical

means• marked inflammatory response

Delayed Intervention

resolution of corneal oedema & acute postoperative inflammation.

allow the retained lens material to soften

aid its removal

• Higher incidence of long term complications such as uveitis, glaucoma and corneal oedema with delayed surgery, particularly where surgery is delayed by more than four weeks.

• The aim should be to operate in the first 2 weeks.

• Nuclear pieces of size less than 25% of the whole nucleus may not cause significant inflammation and may eventually be reabsorbed if left

• Three-port pars plana vitrectomy• Induce pvd - vitreous should be

removed from around the lens fragments to minimise retinal traction.

• If the lens matter is soft it can be removed with the vitreous cutter. Otherwise ultrasonic fragmentation, using a phacofragmatome