50 News EYE on TECHnology ProperNUCLEUS management of a posteriorDROP capsular rent is vital to avoid complications by Soosan Jacob MD hen a posterior capsule leading haptic of the IOL to be injected gently rupture (PCR) is noted and in a controlled manner into the anterior Fig 1A: A posterior capsular rent is seen with retained cortex, Fig 1B: The vitrector probe is used to perform anterior epinucleus and a retained nuclear fragment. Flaps seen are for vitrectomy and remove cortex and epinucleus by alternating it prior to nucleus removal, chamber over the iris and under the nuclear later fixation of a glued IOL due to the absence of an adequate between cutting and aspiration modes. The vitrector may also be the aim of the surgery fragments. While injecting, the injector tip capsular support in this case introduced through a corneal incision Wshould be to try and remove the nucleus in should be placed within the anterior chamber a safe manner without allowing any pieces and wound assisted implantation should be to drop into the vitreous (Fig 1A). Various avoided to prevent uncontrolled entry and techniques have been described to try and consequent drop of the IOL into the vitreous. prevent a nucleus drop after PCR. This A globe stabilisation rod may also be placed includes innovative techniques such as the through the side port under the IOL optic to HEMA lifeboat proposed by Dr Keiki Mehta, stabilise the IOL as it unfolds in the anterior phacoemulsification using a Sheet's glide etc. chamber (Fig 2A). The IOL Scaffold described by Prof Amar In cases with a good pupillary tone and Agarwal is a technique recently introduced a pupillary size between 5.0 to 6.0mm, the for utilising in such a situation. This involves second haptic may also be placed over the using an IOL as a scaffold beneath the nuclear iris under the nucleus fragment (Fig 2B). If pieces to prevent them from falling into the not, and in cases of floppy iris syndrome, the vitreous cavity. This technique is suitable for second haptic is allowed to trail outside the Fig 1C: The nucleus is supported by the vitrector Fig 1D: The nucleus is placed temporarily on the iris surface and is brought forwards into the anterior chamber before proceeding with the IOL scaffold technique retained fragments up to hemi-nuclei or soft eye through the main port and the surgeon by posterior assisted levitation whole nuclei. In case of large hard nuclei, centres the optic over the pupil by engaging it removal of the fragments via an extended at the haptic-optic junction using a dialler. corneal section is still preferred. The nuclear fragments are then emulsified When a PCR is noted, it is essential not over the optic, which acts as a scaffold and to reflexively pull out the phaco probe in a prevents fragments from falling down while panic. The second hand should be used to being emulsified (Fig 2C,D). The optic also instil a dispersive viscoelastic into the anterior compartmentalises the eye and prevents chamber via the side port before withdrawing vitreous from further prolapsing into the the probe. This prevents a sudden shallowing anterior chamber or getting aspirated into the of the anterior chamber, extension of the phaco probe during emulsification. It further posterior capsular rent and vitreous loss. acts to divert the irrigation fluid away from the In case of a PCR with an intact anterior vitreous cavity thus preventing hydration and hyaloid face, a breach in the hyaloid face prolapse of the vitreous. The torn posterior may be prevented by this simple step. The capsule is kept safely away from the phaco Fig 2A: The IOL is injected gently over the iris while a globe Fig 2B: In case of pupils with a good tone and a size between dispersive OVD is also instilled over the probe and chances for the anterior capsular stabilisation rod stabilises it from below. The leading haptic is 5-6mm, the second haptic may also be placed over placed on the iris and the second haptic is allowed to trail outside the iris underneath the nuclear fragment rent with the dual objective of preventing remnants getting accidentally aspirated into the corneal incision further vitreous loss as well as to act as a the phaco probe are decreased. Once the scaffold to prevent nuclear fragments from fragments are emulsified, the IOL is dialled falling posteriorly into the vitreous cavity. into the sulcus and any further anterior The fragments may be further tackled by IOL vitrectomy if required is performed. scaffolding, depending on the size and density If capsular support is not adequate for of the nucleus. sulcus fixation of the IOL, the IOL scaffold In this technique, the nuclear pieces are technique can still be performed and the first brought up into the anterior chamber IOL can be secondarily fixated to the sclera and placed temporarily over the iris prior via a glued IOL technique. In this case, to phacoemulsification. Preservative free diametrically opposite lamellar scleral flaps triamcinolone acetonide is then used to are created at the beginning of surgery and the stain the vitreous, and anterior vitrectomy is IOL scaffold technique as described previously performed using low flow settings. Epinucleus is then proceeded with. Once the nuclear Courtesy of Soosan Jacob MD and cortex aspiration are carried out using the fragments have been removed, 20-gauge Fig 2C: The IOL acts as a scaffold supporting the pieces during Fig 2D: The IOL scaffold also acts as a barrier and decreases vitrector probe, switching between cutting and sclerotomies are created under the scleral flaps emulsification and preventing drop into the vitreous cavity vitreous hydration and prolapse, vitreous aspiration into the phaco aspiration modes (Fig 1B, C, D). Adequacy of and the haptics of the IOL are exteriorised probe as well as unintentional damage to the capsular remnants during emulsification. After nucleus emulsification, the haptics capsular sulcus support is assessed. under the scleral flaps using the handshake are dialled into the sulcus or secondarily fixated depending on the The IOL is then pre-placed and utilised technique. They are then tucked using the degree of capsular support as a scaffold after coating the cornea with Scharioth intra-scleral tuck into 26-gauge dispersive viscoelastic. This is done after tunnels made at the edge of the scleral flaps enlarging the main port minimally to allow the and the flaps are sealed with glue. Dr Soosan Jacob is a senior consultant at Dr Agarwal’s Group of Eye Hospitals, Chennai, India. EUROTIMES | Volume 17 | Issue 6.