When the nucleus drops during Cataract Surgery

Every cataract surgeon knows that while complications are rare, if you do a significant volume of surgery, then you’ll certainly encounter your share of complications. With experience, the complication rate declines and it can be less than 1%, but it is still never zero.  It has been said that the two types of doctors who never have surgical complications are those who don’t operate and those who aren’t quite fully truthful.

This is a case where the patient has pre-existing weakness due to suspected old trauma. The posterior capsule breaks unsuspectingly during hydro-dissection and then before the nucleus can even be chopped into halves, it slips through this defect and falls into the vitreous cavity.

This is a known complication of cataract surgery and the key it to do what is best for the patient. We need to accept that the nucleus is now in the vitreous and the patient will need a full pars plana vitrectomy and lensectomy with a retinal specialist. As cataract surgeons, we need to finish cleaning up the anterior segment from the prolapsed vitreous and the remaining lens cortex. Then a three-piece IOL should be implanted securely and the incision sutured shut.

Risky procedures should be avoided: do not chase after the nucleus, do not fish in the vitreous cavity, and do not deny that there is a complication. Take your time, do what is best for the patient, and be honest. Stand by your patient, be there to hand-off care to the retinal specialist, and have faith. In this case, the patient did great, achieving excellent vision after the completion of the pars plana vitrectomy. And the good news is that the patient no longer has the floaters which were so bothersome prior to cataract surgery.

Figure: The nucleus has dropped through a defect in the posterior capsule and it is now in the mid-vitreous. The best course of action is be a pars plana vitrectomy / lensectomy in the next day or two while the cataract surgeons cleans up the anterior segment and implants the three-piece IOL securely. The patient will do fine and recover excellent vision.

Watch the full video with voiceover here:

Uday Devgan, MD is in private practice at Devgan Eye Surgery in Los Angeles, partner at Specialty Surgical Center in Beverly Hills, Chief of Ophthalmology at Olive View-UCLA Medical Center, and award-winning Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine.