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.

Management of dislocated nucleus with corneal opacity by combined deep anterior lamellar keratoplasty, pars- plana vitrectomy and phaco-fragmentation.

A 32-year-old man presented with bilateral diminution of vision for 10 years. Visual acuity was light perception in both eyes with inaccurate projection in the oculus dextrus(OD) and accurate projection in the in oculus sinister (OS). Intraocular pressure was 6 and 12 mm Hg in the OD and OS, respectively. Slit-lamp examination revealed the presence of leucomatous corneal opacification with microcornea in oculus uterque (OU). Both eyes had a dislocated nucleus in the vitreous cavity on ultrasound B-scan with advanced cupping in the right eye. Ultrasound biomicroscopy revealed ciliary body atrophy in the OD and preserved ciliary processes (two quadrants) in the OS. In view of a partially preserved ciliary body function and a potential for gaining useful vision, we planned surgical intervention in the left eye. Deep anterior lamellar keratoplasty with pars planavitrectomy (PPV) and phacofragmentation of the nucleus was done. Donor lamellar graft was sutured after completion of PPV and nucleus fragmentation. The patient regained useful ambulatory vision postoperatively with clear corneal graft.

Management of Nucleus and IOL Drop.

BACKGROUND: Thirty six cases of lenticular nucleus drop following phacoemulsification and 43 cases of posterior dislocation of intraocular lens (IOL) inclusive of two paediatric cases were managed by a modified vitrectomy procedure without using perfluorocarbon liquid (PFCL). METHODS: In these cases the incision was placed inferotemporally at pars plana. The limbal sites of the earlier cataract surgery were utilised as the other two ports. In either case adequate vitrectomy was performed first. In cases of nuclear drop, the nucleus was impaled (speared) with a micro vitreo retinal blade and brought into the anterior chamber from where it was delivered out. In cases of IOL drop the same was picked up by an intra-vitreal forceps. RESULT: Of the 77 adult cases treated 57 (74%) of the eyes had a visual recovery of 6/18 or more. CONCLUSION: Prompt surgical management in cases of nuclear drop or posterior dislocation of IOL yields good results.

Spontaneous levitation of dropped nucleus on first post-operative day.

A 60-year-old male patient presenting with gradual painless progressive diminution of vision was diagnosed with nuclear sclerosis grade III (LOCS). Intra-operatively, there was a nuclear drop into the vitreous cavity. The patient was left aphakic and was deferred for further vitreoretinal procedure the next day. On first post-op day, the nucleus fragment (of roughly the same size that had dropped into the vitreous) was seen in the anterior chamber. A gentle ultrasonography B-Scan done for posterior segment evaluation was anechoic. Incision was enlarged and viscoexpression of the nucleus fragment was done followed by thorough anterior vitrectomy. Post-operatively, dilated full fundus examination showed clear vitreous cavity without any evidence of retinal tear or detachment. This was later confirmed by an anechoic ultrasonography B-Scan. After 2 weeks, three-piece foldable IOL was placed in the sulcus with posterior optic capture and the patient attained a best-corrected visual acuity of 6/9P.

Iris Claw versus Scleral Fixation Intraocular Lens Implantation during Pars Plana Vitrectomy.

PURPOSE: To compare the outcomes of iris claw anterior chamber intraocular lens (IC-ACIOL) with that of scleral fixation posterior chamber intraocular lens (SF-PCIOL) implantation during pars plana vitrectomy (PPV) as initial surgery to correct aphakia. METHODS: Twelve patients with complicated cataract surgery or trauma who hadsuffered nucleus, whole crystalline lens or intraocular lens (IOL) drop into the vitreous cavity, and undergone PPV with IC-ACIOL implantation over a period of one year were evaluated for the purpose of this study. Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), central corneal thickness (CCT), spherical equivalent (SE) refractive error, astigmatism and complications were recorded. The results were compared to outcomes of another group of 13 patients who had previously undergone PPV with SF-PCIOL implantation. RESULTS: Mean improvement of UCVA was greater in IC-ACIOL eyes as compared tothe SF-PCIOL group (-1.17±0.28 versus -0.89±0.21 logMAR, P=0.01), corresponding values for postoperative BCVA were 0.24±0.17 and 0.44±0.22 logMAR (P=0.041), respectively. Average postoperative SE was comparable in the IC-ACIOL and SF-PCIOL groups at 0.6±1.03 and 0.56±1.23 diopters, respectively (P=0.290). However, 10 (83.3%) IC-ACIOL eyes versus 6 (46.1%) SF-PCIOL eyes had SE within 1 diopter of emmetropia (P=0.048). Mean postoperative increase in CCT was comaparble between the study groups (P=0.126). CONCLUSION: In the absence of sufficient capsular support, the use of an IC-ACIOLfor correction of aphakia during PPV can be a good alternative and seems to entail better visual outcomes as compared to SF-PCIOL.