Should you try to rescue a dropped nucleus?

float up dropped nucleus 161 title

For most situations, I recommend that if the cataract nucleus drops into the vitreous cavity due to a ruptured posterior capsule, the surgeon should leave it alone and refer the patient to a vitreo-retinal colleague for a proper pars plana vitrectomy and lensectomy.

This was demonstrated nicely in this video where the anterior segment was cleaned up, a partial anterior vitrectomy was done, a sulcus IOL was securely placed, and the incision was sutured. The patient then had a vitrectomy for removal of the retained lens nucleus and she has since recovered excellent vision. That is what I recommend.

But what if you are in a remote location without access to a vitreo-retinal surgeon and at a facility where there is no equipment to do a pars plana vitrectomy?  This is the situation where Dr. Saurav Piya works in Nepal.

Here are his thoughts:

I have discovered a technique of hydro-levitation of lens drop with hydro-canuula during phaco emulsification. I do thorough extensive anterior vitrectomy first before this maneuver to prevent capture of any vitreous strand. I have reviewed my cases and followed up up to 3 months and examined with 90D on full mydriasis with no post op complications. In addition I have made SICS tunnel with a keratome and placed a single piece foldable in the sulcus as 3-piece foldable lens is not available in our country. Placement of single piece lens in the sulcus has been practiced in our centre by our senior ophthalmologist for the past 5-7 yrs with good outcomes.  So with regards to what has been shown in studies, I also place single-piece foldable IOL in the sulcus when there is PCR.

Watching his video, you can see that vigorous irrigation can float the nucleus back up to the anterior segment where it can be retrieved from the eye. Is this a reasonable approach?

In my situation, there are a dozen vitreo-retinal specialists to whom I could refer a private patient from my clinic. Even at our UCLA teaching hospital, we have vitreo-retinal faculty and fellows who would be happy to perform the pars plana vitrectomy and lensectomy.  In my case, I do not recommend an attempt to float the nucleus back up with vigorous hydration. The risks of having vitreous traction, giant retinal tears, and permanent vision loss are too high. Once the nucleus becomes entangled in vitreous, it is not easy to retrieve it.

But in the case of Dr. Piya, where there is no vitreo-retinal surgeon available and no vitreo-retinal equipment, this technique may be reasonable. Let me know your opinion.

Click below to watch this technique of hydro-levitation of a dropped lens nucleus:

3 Comments

  1. I agree with you, Dr. Devgan. It is always better to minimize the risk, but sometimes it is justified to do when vitreo-retinal surgery isn’t easily accessible. In that case the vitreous is quite thick and the nucleus stays anteriorly. The situation is much worse when vitreous is liquified and nucleus sinks. Hydro-levitation technique is probably not gonna work and only fishing technique can retrieve the nucleus, but having phaco probe so deep could cause more vitreous entrapment (on the other hand, the more it liquified the less vitreous strands we have). I live in a rural area of Russia and performed both techniques one time with no complications afterwards (thanks to God), but I was not happy to do those stressful maneuvers. Thanks Dr. Saurav Piya for sharing his case and Dr. Uday Devgan for such a great work you are doing teaching us every day.

    Dr. Anton Chudin, Russia

    1. Thank you Dr Chudin! Please feel free to submit a video of your surgery as well. We would be honored to feature it.

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