Ординатура / Офтальмология / Английские материалы / The Art of Phacoemulsification_Mehta, Alpar_2001

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the nucleus and the cortical material stay in the same place in the posterior chamber. Inadvertent and inopportune surgical movements will now precipitate a problem with the nucleus luxating into the vitreous.

If the nucleus is likely to drop into the vitreous or has luxated into the vitreous, its technique of management has been discussed later in this chapter.

Problems and their Management during Phacoemulsification of the Nucleus

Essentially phacoemulsification can be divided roughly into two eras: The Pre-Chop and the Post-Chop era.

The Pre-Chop era was dominated by the methods of grooving and splitting and then finally flipping. It is still a common technique in use today in India and thus is being evaluated in detail.

Problems with Nucleofractis and in situ (Four quadrant) Phaco Fracture Technique

Nucleofractis or divide and conquer was first commenced by Gimbel 1986 subsequently modified as a 4 quadrant or in-situ method are perhaps some of the most common techniques being used in India. They were the precursor to the Nagahara chop technique, which has literally revolutionized the Phaco surgical scene.

Hydrodelineation in this procedure is very useful as it tells the surgeon how far he or she can go into the periphery without any risk. The phaco settings should be set at 75 percent power but with minimal aspiration and a low flow rate.

Be always sure to have a perfect hydrodissection. The nucleus should spin like a top in the bag. In both the nucleofractis as well as the 4-quadrant technique, the problem always has been, the depth of the grooving should be adequately deep to get to the thickness level for a proper split to develop. For a proper groove, one needs to shave off the nucleus, layer by layer, taking care not to bury the tip, making sure only the lower third of the tip is occluded. The bottom of the groove is typically at the level of the posterior Y-suture. The red reflex can also be used to gauge the depth of the groove. It gets progressively brighter as the midline is passed. Care should as always be exercised that the grooving is done in a bowl fashion, deeper in the middle but shallower in the periphery.

As a routine, make all the four grooves meet in the middle and communicate with each other prior splitting. This will make sure that the crack or split goes all the way to the bottom. It is important if one is to achieve a good split that the surgeon places the tips of both his or her cracking instruments at the base of the groove. The cracking or splitting can be done effectively in two ways.

•A direct split, i.e. the instruments are placed at the base of the groove (a blunt dissector or chopper in the left hand, the phaco tip in the right hand) and the groove walls are separated.

•In a contralateral split, the two instruments at the base of the groove cross over themselves, i.e. the phaco tip, though held in the right hand, presses the left sides of the groove and vice versa.

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In a soft cataract, a direct split is easier. In a hard cataract, better leverage is obtained with the contralateral split.

Cracking the lens through both the grooves fully, convert the round grooved nucleus into a four-piece pie. Now, rather than trying to pull out the piece with the phaco, (a dangerous and often futile maneuver), lever out the tip of one piece using the left hand held, blunt probe. Let the tip impinge onto the phaco tip; turn on U/S and phaco it out. The phaco settings at this time should be changed, high

aspiration rate, a high flow rate and moderate phaco power. Most surgeons nowadays, who are still utilizing this technique, make only a single

groove, split the nucleus apart and then at this stage turn the nucleus high around, using the phaco chopper in the left hand impale the nucleus, and then chop it into two or more parts. Its saves a great deal of time and works equally well.

For harder cataracts Gimbel had in 1992, devised the Down-slope technique. The technique involved pushing the nucleus downwards towards 6.00 O’clock with the spatula while the grooving is done. It had many advantages. It was a safer, better-controlled maneuver and could get the groove done longer, and deeper and thus making splitting hard cataracts easier.

A further modification of the above technique was the Crack and Flip technique (Fine, Maloney and Dillman, 1992). Once again a variation of an established technique done to compensate for the problems in the previous methods. The grooving and cracking as per the previous techniques, the residual epinucleus is flipped out by gently holding it using low aspiration with the phaco and with the other hand rolling it or flipping it out. This solves the often-problematic epinucleus removal.

The Flip method enhancing safety for epinucleus removal, is a useful technique, and should be in every surgeon’s armamentarium.

Complications with the Phaco-Chop Techniques

The Post-Chop era of phacoemulsification commenced with Nagahara describing it at the ASCRS meeting at Seattle in 1993. A novel, new approach by chopping a nucleus into its component parts directly. The entire concept was that the nucleus is held firm by the phaco tip while a sharp tipped chopper is used to score the surface of the nucleus and then split it down. It made a world of difference as grooving was unnecessary and there was no need to go into the depths of the groove for the cracking. The risk to the capsule dropped drastically. In addition, the surgery became, more predictable and faster. Even the hardest lens could now be chopped (at least partially).

Managing problems with the phaco chop technique

Fixation of the nucleus Unless it is properly fixated, the nucleus would slide off the phaco tip. It makes it easier to use the tip with the bevel forwards rather than down. Place the tip on the surface of the nucleus just within the rhexis at the 12.00 O’clock position, turn the phaco power on so that the tip sinks into the nucleus and wait till the suction builds up to its maximum preset limit. Keep the tip pressed down gently and only then position your chopper for the next step.

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Selection of the chopper The chopper has to be sharp to score the nucleus. The tip has to be at least 1.5 mm long. It is preferable if the tip is slightly flattened so that resistance will be encountered with side movement, which will make the chopping easier. The novice often errs on the side of using a short, blunt chopper, a guaranteed recipe for failure. If possible, the chopper should have its flat side slightly skewed by 20 degrees. Since the chopper and the phaco tip will be separated by an angle of usually 30 degrees, skewing the angle of the flat sharp side of the chopper makes for easier chops especially in hard cataracts. A single point of caution: to keep the tip of the chopper sharp, always leave it covered by a silicone tip when not in use.

There are places where a blunt chopper proves useful

•Tangential chop technique. The chop goes tangentially against the substance of the lens

•When the fragment are small, but the cataract is hard, a sharp sided, blunt tip chopper is preferable as it can repeatedly make into thin slivers the hard cataract and allow easy aspiration with the phaco tip.

•In soft cataract where there is a risk of the chopper sinking through the substance

of the lens. Here if the chopper tip is sharp, the capsule is at risk.

•In anterior chamber phaco, when the lens is rotated into the anterior chamber, one goes from the side and does a peripheral chop to prevent accidental corneal touch. The lens is spilt from the sides; the blunt tip prevents entanglement and injury to the iris.

Placement of the chopper tip The chopper is inserted flat through the side port incision, taking care that the iris does not entangle in the sharp chopper tip during insertion. Once the nucleus is fixated, go back from the tip by 3.00 mm and impact your chopper in the nucleus. This distance of 3.00 mm from the phaco tip is usually enough. It is unnecessary to go under the capsule to the equator of the nucleus,

Now place the sharp edge of the chopper against the nucleus, press gently downwards and pull towards the phaco tip, While the Phaco tip holds the nucleus steady, the chopper first scores the nucleus, and then buries itself deeper, in the manner of a plough. When close to the phaco tip, the chopper is moved to the left, while the phaco tip moves to the right, splitting the nucleus into two. The action is almost like splitting a log of wood after embedding an axe into it. The important step is to keep the downward pressure on the chopper as it moves towards the phaco tip. That particular movement buries the chopper deep in the nucleus. Also remember to allow both the instruments to separate so that the cleft deepens.

Proper holding of the nucleus for a chop One of the common complaints is that the nucleus shifts off the phaco tip preventing the execution or completion of a proper chop. This is because of an inadequate impalement of the phaco tip. To get a proper impalement the phaco tip must be buried in the depths of the nucleus. To get a proper depth, two steps are important: first as one enters the eye, on the surface of the nucleus, swirl the tip around without ultrasound—this will remove the superficial epinucleus exposing the harder nucleus below; and now,

PREVENTION OF COMPLICATIONS AND THEIR MANAGEMENT IN PHACOEMULSIFICATION 405

the second step, with a little ultrasound power make a shallow saucerized space in the middle. With your phaco tip bevel, facing forwards apply the phaco tip just ahead of the upper (12 O’clock) edge of the rhexis and with a single burst of ultrasound bury it in the nucleus. Wait until the suction rises to its preset limit and then proceed with the chopping.

It is also possible to bury the phaco tip in the nucleus, bevel down. Many surgeons advise it as it prevents too deep a placement of the tip with relation to he nucleus.

The only disadvantage is that with the bevel-down technique, the suction needs to be kept much higher or as one tries to chop, the nucleus simply drops off the

tip.

Rather than making a direct impalement (bevel down or up, at the surgeons discretion) many authorities (Koch et al) Stop and chop) recommend that a shallow groove be first prepared, turn the lens at 90 degrees to the groove and then impale in the substance. In this way, the nucleus is held firmly and with hard lenses, the chop can be done with adequate force.

Rotation following the phaco chop Rotation of the nuclear fragments in the bag can be a problem sometimes as after dismantling the pieces the place in the capsular bag becomes very, limited. A simple technique is to lever out one tip of the chopped piece with the tip of the chopper, and to phaco it off. Automatically space is increased, and it makes more room for better rotation and more place for the segment to move when they are being chopped which leads to better and deeper chops.

Chopping very hard nuclei (6 +) is very difficult. This is because of the harder central nuclear zone, which has a different density and therefore does not chop through. To remove it, many new techniques have been developed. The “shelling” technique (Mehta, 1997) is perhaps the easiest. Make a central chop, and then extend it to the side. This will expose the central nucleus. Phaco this central nuclear zone separately with simple aspiration and ultrasound. This part of the nucleus is a homogenous material and does not need to be chopped. This now leaves an empty bag of nucleus, which is flipped over, and phacoed.

Another, more innovative method is the “saddle hump” technique. It is based on the concept, that if one breaks the binding of a book, the pieces come apart and then can be easily tackled. In the saddle hump technique, (Mehta, 1999) the edges of the nucleus are clipped or lifted off with a special chopper, and gradually the lens is unraveled. The surface is phacoed separately as is the central area. The deeper posterior nuclear material is flipped over and then phacoed. Both techniques have been described in Chapter 28 on Suprahard Cataracts: Their Evaluation and Management.

To convert or not to convert. Aye that’s the question

Whether it makes sense to continue a difficult case, or to call it a day and convert to a standard ECCE, is a decision every surgeon needs to make for himself. He or she has to consider the patient, the density of the cataract, the state of the corneal endothelium, (consideration is even more critical if this is the only eye of the patient). Against this has to be balanced the surgeon’s knowledge, his or her faith in his

or her own skills, his confidence in himself and his ability to handle a complication if it precipitates.

Another important point to consider is the machine, which is being used by the surgeon. Some machines have very good fluidic control and exceptionally fine ultrasound and aspiration ability, and automated anti-surge controls. (The Alcon Legacy, the Allergan Sovereign and Diplomax and the Storz Millennium). Tackling a difficult case with these units will naturally be far easier than doing it with a

small economical machine, which does not have the appropriate capabilities. That is not to decry some of the smaller machines, which work perfectly well, but in a difficult situation the better the machine the more superior are your chances of staying on the top of a difficult phaco situation.

In a hard cataract, an intact, well-designed, capsulorrhexis is mandatory. No rhexis: abort and convert, for inevitably, in a majority of cases you will land up in trouble.

The moment for conversion is when the surgeon starts feeling unhappy with the situation—too hard a lens, a nucleus refusing to chop and fragment, a rhexis which is inadequate, an eye not responding as it should, a patient who is becoming difficult, all tell the surgeon that it is the time he or she reconsidered his or her options. It makes more sense to convert. If any doubt exists regarding the integrity of the zonular or even, the bag, in a very hard cataract it is grounds for immediate conversion.

Problems in Conversion to ECCE

A hard nucleus is also unfortunately a large nucleus, with negligible buffering epicortical material. Hence, if it is to be extruded from the bag, you will need to cut the edge of the rhexis in at least three locations, two clock hours apart. Failure to do so will lead to an inadvertent intracapsular extraction and/or a vitreous break. Do also remember that with an intact capsule, the hydrodynamics of nuclear expression are quite different and simple pressure or counterpressure will not work. You will need to manually shift the lens into the anterior chamber by rotating it out and only then expressing it out or hydroexpressing by a side port retainer (Blumenthal). At this stage, the use of viscoelevation is very useful. Inject viscoelastic at the edge of the nucleus. If the bag is intact, the nucleus will float (Visco-levitate; Kelman: Mehta) into the anterior chamber. Another simple way is to do a supracapsular tumble (Maloney, 1998) , following a rhexis multiple cuts, and shift the lens in front of the anterior capsule. At this point, one can phaco it or extrude it out of the anterior chamber in a sliding ECCE technique.

Managing the intact posterior capsule It is important than that the posterior capsule remains clear so that the visual axis is not impaired by any opacity. A certain percentage of capsules will always opacify. The younger the patient the quicker the capsule opacifies. In a young child of 2 to 4 years, the capsules will opacity in just a few months. Between the ages of 5 and 15, the average opacification time is about 10 to 15 months. A young adult between the ages of 20 to 40 years

PREVENTION OF COMPLICATIONS AND THEIR MANAGEMENT IN PHACOEMULSIFICATION 407

will opacity in about 2 to 3 years. Those between the ages of 40 and 60 are likely to opacify in about 4 to 6 years while those over the age of 60, many last for many years before the need arises for the capsule is to be managed. Lest it be misinterpreted that all capsules opacify, the average percentage runs between 30 and 50 percent depending on age. The younger patient’s capsules all opacify, while in the older + 60 age group hardly 8 to 10 percent opacify. It would therefore make sense that the capsule is managed to as soon as it tends to start becoming opaque.

Treatment of this opacity can be done during surgery (intraoperative capsulotomy) or as a secondary procedure, done at a later date (postoperative capsulotomy). There

are some patients in whom the capsule should always be left intact even subsequently. Those with high myopia especially with retinal changes or who have had a past history of retinal detachment, either in that eye or even the other eye, those who have had cystoid macular edema (CME) in the other eye and those in whom there is a possibility of a future fistulizing operation.

Though for practical purposes a capsulotomy may be needed in future, the surgeon must try minimizing the possibility of capsular thickening by leaving the capsule as clear as possible. Among the methods, which can be utilized, are to do an excellent irrigation/aspiration to remove all cortical material, which may reduce the spontaneous reabsorbance. Polish the capsule to eliminate as many proliferative cells as possible to avoid the secondary opacification of the posterior capsule. It is also imperative that all viscoelastic substances, which had been utilized during surgery especially at the time of implantation, be meticulously removed as this leads to opacification.

Cleaning the capsule can be done in following ways.

•With a hand-blasted or a diamond tipped irrigating cannula

•With a ring polisher, which will permit, polish of the posterior as well as the anterior capsule

•With the automated capsule polisher and in which the vacuum is kept at 5 mm Hg.

•With an ultrasound polisher, which has rounded, tip and which can be moved over the capsule, which shakes the cells loose.

Intraoperative Primary Posterior Capsulotomy

It can be done in a variety of instruments however the most frequently used instrument is a fine needle (26 G), which can be attached on a syringe filled with viscoelastic.

Method of Polishing the Capsule

•The Kratz cannula is a simple irrigation cannula that is blunt at the tip. The roughening has been generated by sandblasting the tipped end. It is important that in using this cannula, the flat surface be kept parallel to the capsule, and it should be moved gently so that it does not fold or ruck the capsule and tear it. (The term “rucking” needs some explanation. Rucking is the term which is

408 THE ART OF PHACOEMULSIFICATION

applied to forward bunching of the tissues. If one runs a finger over a loose sheet of cloth, in advance of the finger the cloth bunches and forms ripples. This is termed as rucking)

•Diamond impregnated polishers should be used with great caution as they go through the capsule very easily. They are to be used only when the encrustation on the

capsule is very thick and one needs to lift off the encrustation. With a diamondimpregnated polisher you do not scrape the polisher over the capsule as you will immediately tear the capsule. You only gently get to the edge of the encrustation and try to lift it off.

•Vacuum capsule polishers are essentially the standard Irrigation/aspiration handpieces, with a 0.3 mm port. The irrigation is diminished to 30 cm and the vacuum is kept very low at 5 to 10 mm Hg with a very low flow rate of 5 to 8 ml/min. The orifice is oriented onto the capsule and while aspirating, it is gently moved over the surface of the capsule. It is important not to ruck the capsule. The secret of using this technique is to take your time. It works well and all the fragments from the anterior capsule as well the posterior capsule can be gently removed. It is important that the tip be kept moving when the suction is on. If it is left stationary for any length of time, the capsule is liable to be trapped in the orifice and may be torn if suddenly pulled. In addition the irrigating bottle are kept low at the level where the capsule becomes flat, and does not bulge backwards.

•The ultrasound polisher is essentially a blunt needle with rounded tip and roughened, connected to the ultrasound handpiece. It must be used only after the manual vacuum polishing of the capsule is complete as by itself it is unable to complete the entire job. It shakes off the final loose cells and is like a mopping up type of operation. The U/S needs to be set to the minimum of 5 percent (depends from machine to machine).

It is important that the maximum possible magnification be utilized with which the surgeon feel is comfortable so that the small deposits, and areas of opacified cortex can be identified and removed. If the cortex is very transparent, avoid trying to polish it as it only puts the integrity of the capsule to risk. The pressure exerted by the polishing/cleaning instrument should be such as to encourage only blunt dissection and should be able to abrade off the particles without damaging the capsule.

The key to evaluate the quantum of pressure applied to the capsule during the polishing phase is by looking for the circular reflex on the capsule around the tip of the polishing instrument. Normally the circular halo should not exceed 3 to 4 mm. any more and you are applying too much pressure. Looking at the halo will also tell you how clean the capsule is and if there are any residual debris left, or if it is uniform and regular, and free of any deposits

In case of any resistance encountered while polishing the capsule, immediately desist from polishing further because the polisher may have insinuated itself into the capsule. The watchword for capsule polishing is caution.

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The capsule is best kept under slight tension by raising the irrigation bottle until the capsule is perfectly flat. The risks of breaking of the capsule increase if the pressure of the irrigation fluid is kept too high, which will make the capsule deeply concave, or if the irrigation is too low, which will make the capsule convex.

Causes for Rupture of the Posterior Capsule

•Accidental momentary touch with the ultrasound phaco tip This should, in theory,

have no effect as contact of the posterior capsule with a smooth rounded phaco tip, with the ultrasound on, provided it is not moved, should cause no damage.

In practice however, no phaco tip is perfectly smooth. After some usage (in most

countries, tips are used till they literally die out), the tip is scratched and has multiple sharp edges at the tip. If the suction is not too high one may still get away with a small round hole with an intact hyaloid membrane, but invariably, due to the high suction combined with the high volume of infusate, complicated with tip movement, the tear invariably is complicated by the presence of vitreous.

• The laceration of the capsule during chopping It occurs when the chopper is taken too far into the periphery and the chop includes the edge of the rhexis. If the chopper is very sharp, only a capsular edge tear will occur, but if, as is frequent, it is slightly blunt it will avulse the capsule. It also occurs when splitting the pie sectors into smaller bits prior aspiration with minimal ultrasound. It can be prevented by more attention on the part of the surgeon with better light and sharper visibility with higher magnification.

•Discontinuity of the anterior capsule with a tear that extends backwards involving the posterior capsule invariably occurs when the capsulorrhexis has been made improperly, or the edge of the rhexis has run off into the periphery. In these patients, any intracameral gymnastics leads to tear extension with a posterior capsular tear in consequence.

•Zonular disinsertion especially when the zonules are weak as in cases of pseudoexfoliation or in cases of hypermature old neglected cataracts or following injury. However, not technically a posterior capsular rupture it behaves in an identical manner.

Signs of a Posterior Capsular Rupture

The most common sign is deepening of the anterior chamber and shift of the irislens diaphragm backwards. The chamber is likely to become deep irregularly. In addition, the nucleus and the cortical fragments seem to move slowly by themselves. Nuclear rotation if attempted will show restriction of movement. When left after rotation the fragments partially creep back to their initial places. These changes are because of the admixture of the vitreous in the anterior chamber.

Another important sign is that the phaco will stop working because of vitreous in the phaco tip. If the capsule ruptures towards the end of the phaco procedure, this may even be the earliest sign. Occasionally a small piece or even, if the surgeon is unfortunate, a large piece of nucleus will luxate or drop into the vitreous cavity.

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The moment there is any doubt about a posterior capsule rupture, even if little, it is important to immediately stop the phaco, take the phaco tip out of the anterior chamber. Continuance of the phaco procedure will lead to extension of the tear with severe complications with a dropped nucleus and admixture of the cortical remnants in the vitreous with vitreous in the anterior chamber.

Managing the Broken Posterior Capsule

The rupture of the posterior capsule with its attending complications is one of the most feared complications of Phacoemulsification

The management is dependent on whether the hyaloid face is intact, the size of the tear, the stage at which the phacoemulsification procedure has reached and the complications which have ensued prior the surgeons recognition of the posterior capsular rupture

Rupture of the Posterior Capsule without Hyaloid Face Rupture

If the capsule gives way at an early stage of the nuclear phacoemulsification, it is important to inject viscoelastic below the nuclear fragment and gently try to maneuver the fragments in to the anterior chamber. If Viscoat is available, it is an ideal material, but in its absence frozen (iced) methylcellulose will work. If the nucleus is hard and the size is big or the rhexis size is small, you may need to give two relaxing cuts at the edge of the rhexis to permit the nucleus to float out with a little help from a spatula. Never inject viscoelastic under the lens as the pressure of the viscoelastic will rupture the hyaloid face and complicate matters. It is best not to exert any pressure on the hyaloid face, nor on the posterior capsule, as it will cause the tear to enlarge in size. A spatula in one hand and a sharp chopper in the other will coax the nucleus in the chamber.

Once the nucleus is brought in the anterior chamber, we have three alternatives.

•The simplest is to remove the nucleus by extending the incision. Again, apply no counter pressure. Work the nucleus out, under the cover of a little viscoelastic, with the edge of the sharp chopper to maneuver it, and roll it out sideways. Following its removal do a gentle irrigation /aspiration to remove the cortical remnants. The IOL can be fitted in front of the anterior capsule as a sulcusfixated IOL.

•In case the surgeon is confident of his or her own abilities and the nucleus is not too hard, he or she may continue phacoemulsification in the anterior chamber. The nucleus once again needs to be maneuvered into the anterior chamber and a lens glide needs to be slid between the nucleus and the posterior capsule. You may also utilize Miochol or injectable (unpreserved) Pilocarpine 0.5 percent. Lower the bottle, cut down the aspiration rate to 12 mm Hg, decrease the suction to 100 mm Hg (in the Alcon Legacy with the 0.9 mm tips), an ultrasound power to 40% and gently do a phacoemulsification. Chop the nuclear fragments into little bits and phaco them.

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•If most of the nuclear material had already been removed prior the break, continue with the phacoemulsification, after placing a bolus of iced methylcellulose or Viscoat at the broken site and after lowering the bottles ( I/2 meter above the patients eye), gently proceed with the cortical remnants removal and implant the IOL in the sulcus.

If one is confident of one’s abilities to do the I/A in these circumstances, dry (under viscoelastic) cortical aspiration can be carried out. Inject viscoelastic from

the side port and at the same time continue to gently aspirate out all the cortical remnants. Be extremely careful. No sudden surge in pressure must occur, as the

hyaloid is very fragile

Rupture of the Posterior Capsule, with Hyaloid Face Rupture, but without Luxation of Nuclear Material into the Vitreous

Immediately stop any irrigation in the eye. The entire secret of handling the situation is to use, as far as possible, zero fluid. We can consider three situations,

•If the opening is small and the lens fragments are not too big (i.e. we had almost reached

the end of phacoemulsification when the tear occurred

As a first step , inject viscoelastic under the fragments to support them. Next, try to work the fragments one by one into the anterior chamber. If the fragments are not coated with vitreous and the surgeon was alert and responded immediately to the capsular break, the Viscoat or methylcellulose will force the fragments gradually up in the anterior chamber. Try to work as many of the nuclear fragments as possible up into the anterior chamber. Next, place more viscoelastic and then insert your phaco tip, with only aspiration, irrigation should be very minimal and via the side port and only allowed in when the phaco tip U/S functions and when the suction is gently on, suck. Use gentle suction with only an occasional burst of low-intensity ultrasound. There is always the question of a corneal burn occurring with little or no irrigation, but remember a burn only occurs if the intensity of ultrasound is over 30 percent and is a continuous burst.

Alternatively, you may open the incision to 6 mm and gradually with a thin blade wire vectis and spatula remove the fragments. Subsequently inject viscoelastic and do a “dry” vitrectomy, remove all the fragments. Let your vitrectomy go 5 mm deep into the vitreous, under the capsular tear, again do a little dry vitrectomy. Keep a BSS-filled syringe in your hand and only replenish the chamber if the chamber starts to collapse and fill in just enough so that the chamber fluctuation is minimized and the chamber is well maintained. This semi-dry vitrectomy technique works great and you will be able to remove virtually all the remnants and the cortical material with no problems.

•If the nuclear fragments are very large, i.e. the break occurred, but the fragments do

not show signs of an incipient luxation

Here it is important to first inject viscoelastic under the fragments and support them with a thin blade spatula and gradually maneuver them into the anterior chamber. The Incision is now widened to accommodate the lens nucleus for its