Technique prevents nucleus drop through capsular tear

Viscoelastic is injected through the pars plana to create a raft under the nucleus. A small glide can give further support during surgical manipulations.

Issue: February 1, 2001

ByMichela Cimberle

MILAN, Italy — When dealing with a hard cataract, complications resulting from a posterior capsule break can be prevented using a simple technique described at the Satelcataract meeting here.

“Instead of using instruments to support the nucleus,” said Richard Packard, FRCOphth, of Princess Christian’s Hospital, Windsor, England, “I inject viscoelastic through the pars plana, between the hyaloid and the posterior capsule, with a hypodermic needle. This way you can stabilize the break, push the vitreous face back and create a kind of a raft supporting the nucleus, so that there is no risk of it dropping back into the vitreous. Emulsification can then be safely carried out.”

Mr. Packard recommends the use of Viscoat (chondroitin sulfate, sodium hyaluronate, Alcon) for this technique. “Viscoat doesn’t need to be removed. Thanks to its lower molecular weight, it can be safely left in the vitreous cavity,” he said.

Bimanual technique

To minimize stress, Mr. Packard uses a bimanual technique to crack the nucleus. Once the nucleus is divided into two heminuclei, one half is lifted out of the bag and chopped. More viscoelastic can be injected for further support at this stage.

“While doing this, the second half of the nucleus is still held safely in the bag by the Viscoat. When its turn comes to be lifted up and out of the bag to be emulsified, the viscoelastic may tend to come out with it. In this case, a glide can be inserted through the cataract incision to protect the break and give further support to what is left of the nucleus. Emulsification can then be safely finished off on top of it. I normally use a 6-mm glide and cut it in half so that I can retain a small incision,” Mr. Packard said.

The cortex is then gently aspirated, using a dry aspiration technique. This is a particularly delicate stage, as the vitreous tends to ooze out of the break. If this happens, a bimanual vitrectomy is required. Finally, a foldable lens is inserted.

“Thankfully, this problem doesn’t arise too often. However, I applied these maneuvers in about six cases. They were all potential disasters which were prevented with very good final results,” Mr. Packard said.

Hard nucleus is seen dropping to right after posterior capsule rupture.	Needle enters at pars plana.
The nucleus is lifted up on a raft of Viscoat.	Phaco is able to continue safely.
The nucleus is divided.	The first half of the nucleus is removed.
The second hemi-nucleus supported on glide.	The second half of the nucleus is removed.
Bimanual removal of cortex is performed.	Bimanual vitrectomy is performed.
AcrySof IOL is implanted into sulcus with optic capture in the capsulorrhexis.	The final result: disaster was averted.

For Your Information:

Richard Packard, FRCOphth, can be reached at Princess Christian’s Hospital, 12 Clarence Road, Windsor, Berkshire SL4 5AG, England; (44) 1753-829204; fax: (44) 1753-831185; e-mail: eyequack@vossnet.co.uk; or at the Arnott Eye Centre, 22A Harley Street, London WIN 2BP, England; (44) 207-580-1074; fax: (44) 207-255-1524; e-mail: arnotteyecentre@compuserve.com. Mr. Packard has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.