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Corticocapsular adhesions are a snag in phacoemulsification
They make rotation of the nucleus difficult. Preop diagnosis, anticipation during surgery and a simple surgical technique can solve the problem.
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Phacosurgeons recognize the value of rotation of the nucleus at various steps of the surgery. It is invaluable for the performance of endocapsular phacoemulsification. Rotation indicates complete separation of the nucleus from the capsular bag and ensures performance of stress-free phaco. When the nucleus is free from the capsular bag, any maneuver on it transmits minimal or negligible stress to the zonules.
However, at times we encounter a situation where in spite of good cortical-cleaving hydrodissection, there is difficulty in rotation of the nucleus. This is the situation where one should think of corticocapsular adhesion.
As the name suggests, a corticocapsular adhesion (CCA) is an adhesion formed between the lens capsule and the adjacent cortical layer. A firm CCA obstructs the uniform buildup of hydraulic pressure between the posterior capsule and the cataract. This keeps the nucleus anchored to the capsule at the site of the CCA so that the nucleus resists rotation. It is easy to understand that any further attempt at rotating the nucleus is both futile and dangerous. Stressful rotation leads to zonule stretch and can even lead to zonulolysis.
Diagnosis
In a pilot study comprised 180 consecutive eyes undergoing phacoemulsification at our center, we found that CCA was present in 20% of the eyes.
On slit-lamp biomicroscopy in case of a CCA, there is no visible distinction between the capsule and the adjacent opaque cortical layer. Depending on the region of the capsule involved in forming the CCA, it can be classified into three types: anterior, equatorial and posterior.
Anterior CCAs are easiest to diagnose where they can be visualized at 12 × magnification with the slit beam incident on the anterior capsule at a 45° angle (figure 1).
Equatorial CCAs are more difficult to diagnose. However, their presence can be revealed when the eye is examined obliquely with the patient looking in extreme gaze, bringing the area of interest into view (figure 2). But more often than not equatorial CCAs come as surprise to the surgeon when he or she practically has to drag the cortex or epinuclear mold. The forceful attempt at removal can threaten the integrity of the capsular bag and zonules. Such epinuclear molds invariably have a roughened outer surface with a furry appearance.
Posterior CCAs can be diagnosed with direct focal examination and can be easily differentiated from posterior subcapsular cataract and posterior polar cataract.
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Unlike a CCA, in the case of a pure cortical opacity a clear space of translucence can always be visualized between the cortical opacity and the capsule (figure 3).
In a masked study of 76 patients with CCA where the surgeon was masked to the identity of the CCA, we found that CCAs could be diagnostically predicted in 86.84% of patients. We found that equatorial CCAs alone or in combination with other types of CCAs were present in 95% of the eyes. Anterior CCAs were present in 50% of the eyes and posterior CCAs were present in 52% of the eyes. In this study we found that rotation was not possible in 48% of eyes, while it was judged to be difficult in 40% and easy in only 12% of the eyes.
Solution
Preoperative diagnosis and its anticipation during surgery will help the surgeon cope with this snag in phacoemulsification.
Multiquadrant hydrodissection is the answer to this snag. We have found the use of right and left Binkhorst J-shaped cannulas very useful. Along with this, focal hydrodissection at the site of adhesion is very effective in breaking the adhesion. Therefore, a struggle during rotation is an indication for employing multiquadrant hydrodissection.
A judicious combination of multiquadrant and focal hydrodissection should usually result in successful rotation.
Summary
Corticocapsular adhesions are adhesions between capsule and the cortex that often cannot be broken by a single hydrodissection. They make rotation of the nucleus difficult and stressful to the zonules.
Multiquadrant hydrodissection along with focal hydrodissection at the site of adhesion is useful in cleaving these adhesions apart.
For Your Information:
- Abhay R. Vasavada, MD, MS, FRCS, Deepa Goyal, MD, MS, Raminder Singh, MD, MS and Lajja Shastri, MD, MS, can be reached at Iladevi Cataract & IOL Research Centre, Gurukul Road, Ahmedabad-380 052, India; +(91) 079-7490909, +(91) 079-749-2303; fax: +(91) 079-741-1200; e-mail: shail@ad1.vsnl.net.in.