Transcript Nucleus prolapse into AC

Dr. Navin Gupta M.S.
Shankar Netrika Eye
Hospital, Mumbai
Nucleus Prolapse into
anterior chamber
Nucleus prolapse into
AC
• One of the essential features of
SICS absent in ECCE
• Takes some experience to
master
• Can be done both with
canopener capsulotomy and
capsulorhexis.
In Canopener
capsulotomy
• Mainly mechanical. Hydro
procedures not used.
• Instruments: Sinskey hook or
cystitome
• Important to visualize periphery
of ant capsule.
• Sinskey hook is positioned to
reach equator of nucleus. Best
between 9 to 12 clock hrs.
Hooking the nucleus
• Peripheral Ant Surface- good for
NS III n IV. More stress on
zonules n post capsule.
• Equator
• Undersurface of equator- last 2
put lesses stress on zonules
Mechanical prolapse
into AC
• After hooking, nucleus pushed
towards opp clock hr.
• Visualize equator.
• Lift and rotate (clock or
anticlockwise).
Mechanical prolapse
Problems in mechanical
prolapse
Cheese Wiring
• Peeling or fragmentation of
cortex n epinucleus as shreds.
• Happens with soft cataracts.
• Solution- use hydro procedures
for soft cats.
Slipping back of uplifted
pole
• Once a pole is out, dialing force
should be upwards.
• Injecting visco between nucleus
n iris (bed-sheeting) also helps.
Churning of cortex
• In soft catracts
• Solution- aspirate n wash off
superficial loose cortex before
the mechanical prolapse.
Nucleus keeps rotating
• Seen in hypermature, brown n
black cats where there is less
cortex.
• Solution- inject visco beneath
prolapsed nucleus.
• Pass vectis beneath nucleus
and prolapse it.
Small pupil
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Enlarge pupil:
Preop NSAIDS drops
Intracameral epinephrine
Sphincterotomies
Stretch pupilloplasty Kuglen’s
hook
• Sector or key-hole iridectomy
Bimanual technique
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2 instruments
Sinskey hook (rt hand)
Cyclodialysis spatula (lt hand)
Hook engages nucleus. Push to 6
o’clock. Upper pole seen. Spatula
inserted under it. Pole lifted up.
Nucleus dialled out.
• Compliacations: zon dialysis,
iridodialysis, endoth damage,
nucleus drop.
In capsulorhexis
• Fair estimation of nucleus size
is important
• Hydroprocedures are the
method of choice here.
Hydrodissection
• Hydro cannula tip placed
between cortex n capsule. Fluid
injected. Cannula taken to
opposite pole, fluid injected till
fluid wave lifts up the opp pole.
Then using Sinskey hook,
nucleus is dialed out.
Tumbling Technique
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In only soft cataracts
Only very skilled surgeons
Perfect size rhexis
Initially hydrodissection is done. One
pole is lifted up. Now with the
cannula, pole of the nucleus in bag is
pressed down and moved across
simultaneously, tilting the nucleus.
Tumbles into AC.
Complications
hydroprolapsing
• Small/incomplete rhexisinability to prolapse
• Nucleus stuck in rhexis, half
inside half outside bag. Make
small relaxing cuts. Gently coax
nucleus out bimanually.
• Radial tear extending to post
capsule
Specific techniques for
particular types of
cataracts
Hypermature Cataracts
• No cortex. Nucleus tends to
rotate in the bag.
• Use Simcoe cannula. Fluid kept
on full flow. Simcoe passed
under nucleus. Mechanically
lifted up.
Soft cataracts
• Difficult due to cheese wiring
• Do hydrodissection n
hydrodilineation and tumble
nucleus into AC.
Post Polar Cataracts
• Do not hydrodissect.
• Do only hydrodelineation
• Bimanual technique to prolapse.
Subluxated cataracts
• Experienced surgeon.
• Good hydrodissection n
delineation.
• Bimanual technique