EyeWorld Asia-Pacific September 2021 Issue

CATARACT 22 EWAP SEPTEMBER 2021 by Ellen Stodola EyeWorld Editorial Co-Director Contact information Devgan: devgan@gmail.com Oetting: oetting143@gmail.com Yeoh: ersryeoh@gmail.com This article originally appeared in the July 2021 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Handling a dropped nucleus A ccording to Ronald Yeoh, MD, dropped nuclei are one of the more unpleasant complications that can happen during cataract surgery. While uncommon, the consequences of a dropped nucleus are significant, he said, and may require vitreoretinal intervention to retrieve the nucleus from the retina and for associated retinal complications, like retinal detachment and macular edema. “I have certainly encountered cases where the nucleus was ‘dropping,’ but early recognition of this state of affairs can lead to retrieval of the nucleus before it has dropped to the retina,” he said. “Hence the importance of recognizing the scenarios in which it is most likely to happen so that surgeons can avoid the drop entirely or be prepared such that in the event of an impending drop, the nucleus can be retrieved by using a technique like posterior-assisted levitation.” Dr. Yeoh noted that nuclei drop when the anterior chamber is pressurized by a phaco tip in the presence of an unsuspected and undetected posterior capsule rupture. “Most times, if the posterior capsule ruptures during the phaco chopping or removal of the nucleus stage, the surgeon is aware of it and takes great care to stop the nucleus falling back by using some form of scaffolding or OVD to trap the nucleus before proceeding,” Dr. Yeoh said. “It’s when the PCR is undetected that nuclei tend to drop.” When you do encounter a dropped lens, Thomas Oetting, MD, said that it’s important to try to fight the natural instinct to dive after the piece that’s fallen. You have to take a few deep breaths, and rather than focus on the personal disappointment of this complication, make sure everything is safe for the patient moving forward. This problem where lens material falls posteriorly can occur at the very beginning of the case or it can occur at the very end, Dr. Oetting said, noting a recent trend of a dropped lens at the beginning of surgery during hydrodissection, particularly in patients who have had a lot of intravitreal injections. “This is an interesting problem, and it’s a relatively new problem because so many patients are getting intravitreal injections for a variety of conditions,” he said. Uday Devgan, MD, agreed that the hydrodissection step may be when a dropped nucleus would occur. This is a high risk, he said, because you’re pressurizing the capsular bag. Conditions that put patients at risk for a dropped nucleus Dr. Oetting elaborated on how intravitreal injections may put patients at increased risk of a dropped nucleus. The intravitreal injections may be placed a bit too anterior and the posterior Dropped lens on the retina. Source: EyeRounds.org, University of Iowa