How to safely remove a nuclear piece near the incision

Sometimes during cataract surgery a small piece of lens material, typically a small nuclear chip, can get stuck in the angle of the eye near the phaco incision. Ideally, the infusion ports on our phaco sleeve will cause fluidic currents within the anterior chamber which will bring these cataract pieces to the phaco tip. But sometimes, with viscoelastic in the angle, these pieces can seem to get stuck.

The instinct is to retract the phaco probe and then pivot the tip to access the stuck nuclear piece. The problem with this is the potential loss of infusion as the ports get pulled back into the corneal stroma our even outside the eye. This will cause a sudden collapse of the anterior chamber and could even result in a posterior capsule rupture, vitreous loss, and other complications.

A better option would be to use the second instrument, typically a chopper or spatula, to push the nuclear piece out of the angle and into the center of the anterior chamber. This works well for most situations, but when access to the nuclear piece is blocked by the phaco probe.

My advice for surgeons in training is to withdraw the phaco probe from the eye completely, then use balanced salt solution (in a 3 cc syringe with a 27g blunt cannula) to push the nuclear piece into the central anterior chamber. This is very safe and controlled and is easy to perform with no additional instrumentation,

Click below to see how to manage a nuclear piece stuck near the incision: