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Posterior-assisted levitation best solution for dropped nuclei, surgeon says
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HONG KONG — Posterior-assisted levitation is the preferred method to retrieve a nucleus or dropped posterior chamber IOL that has fallen into the posterior chamber during phacoemulsification, according to a surgeon here.
Soon-Phaik Chee, MD, of the Singapore National Eye Center, described her method and gave pearls for posterior-assisted levitation, or PAL, at the World Ophthalmology Congress here.
In her method, originally described by Charles D. Kelman, MD, in 1996, Dr. Chee first fills the anterior chamber with dispersive viscoelastic. Then she inserts a 1-inch 25-gauge needle through a 3.5-mm incision in the limbus and guides the needle behind the nucleus or IOL. The needle is carefully inserted behind the nucleus. Dr. Chee does not inject any more viscoelastic until the nucleus is guided back into the anterior chamber and retrieved.
"The procedure must be performed as soon as possible, and the nucleus fragment or [posterior chamber] IOL must be identifiable through a surgical microscope," Dr. Chee said.
"You must be very careful when putting the needle in and observe in what direction the lens has descended, so that the needle can best support it," she said.
"Move the eye in the direction of the fragment using forceps, and indent the sclera with a cotton tip," she said.
She said she introduces a Sinskey hook to position the fragment in the anterior chamber "OVD trap" while the needle is being removed.
Dr. Chee offered surgical pearls for this technique, including bending the distal shaft of the needle; avoiding injecting viscoelastic into the vitreous cavity; delaying vitrectomy until after removal of the nucleus fragment or posterior chamber IOL; attempting PAL only once; and seeking a retinal consult postoperatively to check for any retinal tears that may have occurred.
PAL is contraindicated if the surgeon cannot see the fragment, if the nucleus or IOL is touching the retina, or if a single attempt has failed.
Dr. Chee reviewed cases at the SNEC between 1996 and 2006. She found two out of 14 cases had a complication. One case had a macula-off pseudophakic inferior retinal detachment at 20 months. The other was minor and resolved.