Displacement of nuclear fragments into the vitreous complicating phacoemulsification surgery in the UK: clinical features, outcomes and management

Nucleus drop following phacoemulsification surgery: Incidence, risk factors and clinical outcomes

PURPOSE

To determine the incidence, risk factors and clinical outcomes in patients with nucleus drop (ND) following phacoemulsification surgery at a tertiary care ophthalmic institute.

METHODS

Medical records of patients with ND during phacoemulsification between January'2019 and December'2022 were reviewed retrospectively. Incidence of ND was calculated overall, and according to surgical expertise levels and surgical steps. Associated pre- and intra-operative risk factors were assessed. Clinical outcome parameters [best-corrected visual acuity (BCVA) and intraocular pressure (IOP)] were compared with respect to timing of PPV (immediate vs early vs delayed), location (sulcus vs scleral fixated-IOL) and timing of IOL placement (primary vs secondary).

RESULTS

Among 93,760 phacoemulsifications, ND was noted in 130 patients (0.1%). Significant direct and associated pre-operative risk factors were advanced cataract, glaucoma, posterior polar cataract, and diabetes mellitus. Junior medical consultants had 40 ND (mostly in non-complex cases), whereas senior medical consultants had 90 ND (mostly in complex cases). ND most frequently occurred during emulsification of nuclear fragments. Sulcus placement of IOL during primary surgery yielded significantly better visual outcome compared to secondary procedures, although timing of PPV had insignificant effect. 77.1% had BCVA of 6/12 or better at final follow-up. Timing of IOL implantation, PPV, and type of IOL did not have any significant effect on IOP.

CONCLUSIONS

Though the incidence of ND is low, it is a dreaded complication. Accurate pre-operative evaluation, risk stratification, distribution of cases among surgeons based on their surgical expertise, and immediate or early management of ND yields better anatomical and functional outcomes.

INTRAVITREAL CHOPPING OF DROPPED NUCLEUS WITH A NITINOL INTRAOCULAR FOREIGN BODY FORCEPS: AN ALTERNATIVE TECHNIQUE FOR THE MANAGEMENT OF RETAINED NUCLEUS FRAGMENTS

PURPOSE

To evaluate the efficiency and safety of using an intraocular foreign body forceps with two nitinol loops at its tip to capture and chop dropped nucleus (DN) during vitrectomy as an alternative method and to evaluate the outcomes and complications of this surgical technique.

METHODS

The eyes that underwent 23-gauge vitrectomy with removal of DN using nitinol forceps with a minimum follow-up time of 1 year are included in this study. The efficiency of surgical technique and anatomical and functional results with complications is recorded.

RESULTS

Nine patients with a mean age of 73.11 ± 2.15 years were included in this study. The mean time between DN and vitrectomy was 7.67 ± 3.74 (5-14) days. In all eyes, DN was easily chopped and removed with aspiration. Argon laser photocoagulation was performed in 4 eyes (44.44%) during surgery. All eyes were followed up for a mean time of 21.11 ± 12.36 (12-48) months. The mean preoperative best-corrected visual acuity increased significantly during the postoperative follow-up ( P < 0.001). No complications related to the cataract surgery or DN removal were observed.

CONCLUSION

Surgical removal of DN with the help of these forceps with nitinol loops is found to be safe and effective in this study. This method avoids ultrasonographic energy and enables 23-gauge vitrectomy without a fragmatome.

[Retained lens fragments after cataract surgery: Comparison of same-day versus delayed vitrectomy]

PURPOSE

To evaluate and to compare functional outcomes and complication rates of the same-day versus delayed pars plana vitrectomy (PPV) for intravitreal retained lens fragments after cataract surgery.

METHODS

Retrospective comparative series of 135 eyes with retained lens fragments that underwent PPV between August 2014 and July 2016. Sixty-two eyes received same-day PPV (group 1) and seventy-three eyes underwent delayed PPV (group 2). Outcome measures included best-corrected visual acuity (BCVA) at 6 months and postoperative complications.

RESULTS

The mean time to PPV in group 2 was 4.3±5.3 days. Mean axial length, lens fragment size and surgical technique were comparable in both groups. At 6 months, BCVA was 0.27±0.40 logMAR in group 1, and 0.35±0.30 logMAR in group 2, with no significant difference (P=0.205). Fifty-one (82.2%) eyes in group 1 and 53 (72.6%) eyes in group 2 achieved BCVA of+0.30 logMAR (20/40) or better (P=0.183). The most common complications were macular edema, elevated intraocular pressure>25mmHg, and retinal detachment occurring respectively in 10 (16.1%) eyes, 4 (6.4%) eyes and one eye (1.6%) in group 1 and 11 (15.0%) eyes, 5 (6.8%) eyes and 2 (2.7%) eyes in group 2. Overall, the complication rate was similar in both groups (P=1).

CONCLUSION

Our study shows that visual acuity outcomes and complication rates were similar regardless of timing of the PPV. The optimal timing of surgery remains a multifactorial decision involving patient preferences, transportation, surgeon availability and severity of the initial presentation.

Dropped Nucleus during Cataract Surgery in South India: Incidence, Risk Factors, and Outcomes

Purpose: To determine incidence, risk factors for, and outcomes of dropped nucleus (DN) during cataract surgery.Methods: This is a matched case-control study at the Aravind Eye Hospital in Madurai, India. Out of 184 consecutive DN cases, 171 were included. The case immediately preceding the DN case by the same surgeon served as matched concurrent control. The proportion of cataract surgeries with DN was calculated with a 95% confidence interval (CI). Conditional logistic regression was used to generate odds ratios for potential risk factors.Results: Among 415,487 consecutive cataract surgeries, incidence risk of DN was 0.044% [95% CI 0.038%, 0.051%], or 0.44 per 1,000 surgeries in 52 months. Significant preoperative risk factors were posterior polar cataract (adjusted odds ratio [aOR] 21.73, p = .003); suspected loose zonules (aOR 8.85, p < .001); older age (aOR 1.57, p = .001); and presence of diabetes mellitus (aOR 1.79, p = .03). Associated intraoperative complications included zonular dialysis (OR 34.49, p < .001), vitreous disturbance (OR 193.36, p < .001), and posterior capsule rent (OR 384.39, p < .001). Phacoemulsification and manual small incision cataract surgery did not significantly differ in DN incidence. DN most commonly occurred during nucleus removal (35.1%) or during/immediately following hydrodissection (24.0%). Visual outcomes of DN were worse than controls on average, but 51.9% achieved visual acuity 20/40 or better at 1 month.Conclusions: DN occurred rarely, with low absolute risk even when a strong risk factor was present. Nearly all cases followed posterior capsular rent or zonular dialysis, usually with observed vitreous loss. In spite of increased risk of postoperative complications in the DN group, the majority achieved favorable results.

Evaluation of Functional Outcomes and OCT-Biomarkers after Intravitreal Dexamethasone Implant for Postoperative Cystoid Macular Edema in Vitrectomized Eyes

Purpose

To evaluate the efficacy of dexamethasone implant (DEX) for the treatment of postoperative cystoid macular edema (PCME) in vitrectomized eyes and to investigate visual and morphological OCT predictive factors.

Methods

In this retrospective study, eyes with PCME after vitrectomy were treated with at least one DEX injection and were observed over 12 months. Indications for surgery were epiretinal membrane (ERM) or rhegmatogenous retinal detachment (RRD) without macular involvement. Prior treatments, if any, were noted. Best corrected visual acuity (BCVA), central foveal thickness (CFT), and OCT morphology including the presence of intraretinal cysts/fluid or subretinal fluid (IRF/SRF) and ellipsoid zone (EZ) continuity were evaluated. Correlations between OCT measures and visual outcomes were analyzed by the generalized estimating equations procedure.

Results

Forty-six eyes with ERM and 15 eyes with RRD were enrolled. The ERM group was more likely to gain BCVA than RRD (odds ratio (OR), 1.168; 95% confidence interval (CI), 1.003–1.360; p=0.046). The absence of SRF (OR, 0.860; 95% CI, 0.743–0.995; p=0.043) was predictive of worse BCVA, whereas the integrity of EZ (OR, 1.094; 95% CI, 0.951–1.257; p=0.209) or naïve status (OR, 0.946; 95% CI, 0.871–1.137, p=0.853) was not. Eyes with a worse baseline BCVA were more likely to gain >1 line after 12 months (OR, 1.485; 95% CI, 1.171–1.884; p=0.001).

Conclusion

The efficacy of the treatment of PCME in vitrectomized eyes seems to be affected by baseline BCVA, the absence of SRF, and the indication for surgery. Naïve status appears not to play any significant role in the prediction of BCVA. This trial is registered with DRKS00018955.

Scleral patch grafting for scleral wound thinning after pars plana phacoemulsification and aspiration: A case report

RATIONALE

Here we report the case of a patient who required closure with an autologous scleral patch graft during reoperation after developing marked scleral thinning in the late stage after pars plana phacoemulsification and aspiration (PPPEA). To the best of our knowledge, this is the first reports of the procedure being used for the treatment of a thinned scleral section post PPPEA.

PATIENT CONCERNS

This study involved a 73-year-old woman who had undergone vitreous surgery combined with PPPEA for retinal detachment in her right eye 8 years earlier and subsequently underwent intraocular lens (IOL) ciliary sulcus suture fixation.

DIAGNOSES

She became aware of visual disturbance in her right eye and slit-lamp examination revealed the dislocation of the IOL.

INTERVENTIONS

To remove the dislocated IOL and resuture the nasal loop back onto the ciliary sulcus of the patient's right eye, a 25-guage trocar was placed on the superior temporal side.

OUTCOMES

Subsequent removal of the trocar from the patient's right eye left an approximately 3-mm-wide oval-shaped gap at the trocar insertion site due to extreme thinning of the sclera in that area; that is, the location where the PPPEA was performed. Since suture fixation failed to stop intraocular fluid leakage, an inferior free half-thickness scleral flap was created to patch the scleral wound. Postsurgery, the leakage in that eye stopped and the intraocular pressure was stable. No complications were observed during the 1-year-postoperative follow-up period.

LESSONS

Since thermal injuries during PPPEA may lead to postoperative scleral thinning, surgeons should avoid the site of a prior PPPEA when constructing a scleral wound during reoperation.

Investigation of scleral thermal injuries caused by ultrasonic pars plana phacoemulsification and aspiration using pig eyes

PURPOSE

The purpose of this study was to investigate the thermal injuries caused by ultrasonic pars plana phacoemulsification and aspiration (PPPEA) using pig eyes.

METHOD

Using a 20-gauge (G) vitrectomy system (Accurus^®, Fragmatome; Alcon Laboratories) in both the 'open-tip' and 'closed-tip' techniques, PPPEA was performed in pig eyes and the subsequent thermal injuries generated around the scleral wound were measured by infrared thermal imaging (thermography). Post surgery, the state of the scleral wound was observed under a microscope, and a tissue slice containing the scleral wound was then prepared and observed under an optical microscope.

RESULTS

Thermography measurements revealed a slight temperature rise around the scleral wound in the open-tip case, yet a marked temperature rise in the closed-tip case. The scleral wound incision produced by the open tip was linear, while that produced by the closed tip was expanded. Histological examination revealed mild degeneration of the sclera around the wound in the open-tip case, yet marked tissue degeneration by thermal injuries in the closed-tip case.

CONCLUSION

Our findings showed that in PPPEA, the temperature of the tip of a 20G vitrectomy system rapidly increases due to the closed-tip technique, thus producing obvious thermal damage to the scleral wound. In order to prevent thermal injuries to the scleral wound during PPPEA, it is important to shorten the time of ultrasonic oscillation during surgery as much as possible while the tip is occluded with nuclear fragments.

Intravitreal Phacoemulsification with Pars Plana Vitrectomy for Management of Posteriorly Dislocated Nucleus or Lens Fragments

Purpose

Dislocation of crystalline lens nucleus/fragments into the vitreous cavity during phacoemulsification is a potentially serious, sight-threatening, uncommon complication of cataract surgery. It is associated with significant intraocular inflammation and can lead to poor visual outcome. The current study assesses the outcome of immediate intravitreal phacoemulsification with pars plana vitrectomy in management of posteriorly dislocated nucleus/lens fragments.

Methods

In this retrospective case series, records of 23 patients who underwent immediate pars plana vitrectomy and intravitreal phacoemulsification for removal of dislocated nucleus/lens fragments at the same sitting of phacoemulsification were reviewed. Data including patients’ preoperative and postoperative vision and intraoperative and postoperative complications were recorded.

Results

The mean follow-up period was 16.5 months (range, 5–31 months). Preoperative visual acuity ranged from 0.05 to 0.5. The final postoperative visual acuity ranged between HM and 1.0. Fifty-two percent of eyes (12 eyes) had a final postoperative visual acuity of 0.5 or better. Complications included 2 cases of cystoid macular edema and 2 cases of retinal detachment.

Conclusions

Immediate vitrectomy and intravitreal phacoemulsification is a surgical option in the management of posteriorly dislocated nucleus/lens fragments without much risk of retinal damage. It is relatively safe and most patients achieved a good visual outcome. The risk of postoperative complications including uveitis, secondary glaucoma, and cystoid macular edema could be minimized.

Visual and Anatomical Outcomes of Pars Plana Vitrectomy for Dropped Nucleus after Phacoemulsification

Purpose:

To determine the prognostic factors and visual and anatomic outcomes of pars plana vitrectomy (PPV) in patients with dropped nucleus following complicated phacoemulsification (PE).

Methods:

The records of patients with complicated PE who underwent PPV to remove posteriorly dislocated nucleus fragments from January 2011 to December 2014 were retrospectively reviewed.

Results:

Of 43 patients, 36 patients (36 eyes) were included with mean age of 73 ± 9.5 years and mean follow-up duration of 23.8 ± 15.3 (range 4–53) months. The mean interval between cataract surgery and PPV was 11.5 ± 9.6 (range 1–45) days. The pre-PPV mean best-corrected visual acuity (VA) was 1.04 ± 0.24 logMAR, which improved to 0.46 ± 0.18 logMAR (P < 0.001). Pre-PPV VA ≥20/200 was significantly associated with good final VA ≥20/40 (P = 0.002). Implantation of intraocular lens (IOL) at the time of complicated PE and complicated course after PPV were significantly associated with poor visual outcome of <20/40 (P = 0.041 and P < 0.001, respectively). However, the timing of PPV, route of nucleus removal, and final IOL status were not significantly associated with the visual outcome. The most frequent causes of poor visual outcome were optic atrophy, cystoid and/or diabetic macular edema, history of rhegmatogenous retinal detachment, and pre-existing eye disease (age-related macular degeneration).

Conclusion:

PPV for dropped nucleus was associated with improved VA. Better pre-PPV VA was associated with good visual outcome, while inserting IOL at the time of complicated PE, and complicated course after PPV were associated with poor visual outcome.

SUTURELESS CLEAR CORNEAL ULTRASONIC FRAGMENTATION FOR RETAINED LENS FRAGMENTS: A Pilot Study

PURPOSE

To describe the safety and efficacy of removing posteriorly dislocated lens fragments with the use of intravitreal ultrasonic fragmentation through a limbal, clear cornea self-sealing incision.

METHODS

Patients presenting with posteriorly luxated nuclei were enrolled in this prospective case series. Preoperative examination included evaluation of the corneal endothelium by means of specular microscopy. A 3-port 25+ pars plana vitrectomy was initially performed. Following vitrectomy, sclerotomies were sealed using scleral plugs and a limbal/clear corneal incision was performed for the insertion of the fragmatome probe. The incision was slightly larger (1 mm) than the diameter of the fragmatome probe (20 gauge = 0.81 mm) to avoid wound overheating. At the end of the procedure, an appropriate intraocular lens either sulcus-fixated or angle-supported was implanted. Primary outcome measures were mean postoperative best-corrected visual acuity, intraoperative or postoperative complications, and intraoperative challenging features.

RESULTS

In all eyes, fragmentation was completed successfully with a mean total ultrasound time of 113.4 seconds. Nucleus density was ≥3 in all cases (mean ± SD = 3.8 ± 0.4). Intraoperative challenges included viewing difficulties because of corneal distortion, fragment turbulence, and leakage through the limbal incision potentially compromising fundus visualization. There was statistically nonsignificant reduction in endothelial cell density ranging between 1932 ± 187 cells per square millimeter preoperatively to 1789 ± 213 cells per square millimeter at the first month postoperatively (P = 0.79).

CONCLUSION

Clear corneal, sutureless ultrasonic fragmentation seems to be a novel, safe, and efficient method for the removal of hard posteriorly dislocated lens fragments, sparing the need for a 20-gauge scleral port.

Small-gauge transconjunctival vitrectomy with phacoemulsification in the pupillary plane of dense retained lens matter on perfluorocarbon liquids after complicated cataract surgery

BACKGROUND

To evaluate the visual outcomes, efficacy, and complications of 23-gauge pars plana vitrectomy followed by phacoemulsification using torsional ultrasound of dense retained lens matter on perfluorocarbon liquids (PFCLs) after complicated cataract surgery.

METHODS

The case notes of 34 consecutive patients operated upon with retained lens matter after complicated cataract surgery by one surgeon were reviewed. Twenty-one of the 32 cases were able to be managed using the vitrectomy cutter alone, but 13 cases with dense lens matter were managed using 23-G vitrectomy followed by torsional ultrasound of the retained lens via the original corneal incision after floating it up to the pupillary plane on PFCLs. Case notes of these 13 patients were reviewed to ascertain clinical features, results, and any complications.

RESULTS

The mean age of the 13 patients was 79 years. The procedure was completed in all cases without using an intravitreal fragmatome. All cases were aphakic prior to vitrectomy surgery. Ten patients had a sulcus fixated IOL inserted at the time of vitrectomy and three had an angle-supported anterior chamber IOL inserted. Mean post-operative visual acuity at 3 months was 0.24 (median 6/9). Eleven of the 13 patients (85 %) had a best postoperative corrected visual acuity of ≥6/12. One patient developed cystoid macular oedema that was successfully treated. There were no cases of retinal detachment.

CONCLUSION

The outcome of 13 patients operated on with transconjunctival vitrectomy with phacoemulsification of dense retained lens matter on top of PFCLs is described. The technique was used successfully, with good visual acuity outcomes and a low complication rate.

Complications of cataract surgery

Modern cataract surgery is safe in more than 95 per cent of patients. In the small number of cases where a serious complication occurs, the most common is an intra-operative posterior capsular rupture. This can lead to vitreous loss or a dropped nucleus and can increase the risk of post-operative cystoid macular oedema or retinal detachment. Post-operatively, posterior capsular opacification is the most common complication and can be readily treated with a YAG capsulotomy. The most devastating complication is endophthalmitis, the rate of which is now significantly decreased through the use of intracameral antibiotics. As a clinician, the most important step is to assess the patient pre-operatively to predict higher risk individuals and to counsel them appropriately. In these patients, various pre- or intra-operative management steps can be taken in addition to routine phacoemulsification to optimise their visual outcome.