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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 106  |  Issue : 3  |  Page : 146-149

Safety and efficacy of phacoemulsification in the vitreous cavity for dropped nuclear fragments


Department of Ophthalmology, Mansoura Ophthalmic Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission15-Mar-2013
Date of Acceptance06-Jul-2013
Date of Web Publication28-Feb-2014

Correspondence Address:
Mohammed M Elwan
Mansoura Ophthalmic Center, Mansoura University, Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.127359

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  Abstract 

Purpose
The aim of this study was to evaluate the safety and efficacy of intravitreal phacoemulsification for dropped nucleus or nuclear fragments into the vitreous cavity.
Materials and methods
This was a prospective interventional study that included 25 patients with dropped nuclear fragments after phacoemulsification; before vitrectomy, all patients were subjected to a full ophthalmological examination including visual acuity, intraocular pressure, anterior segment examination, fundus examination, and then after standard pars plana vitrectomy, a phaco tip devoid of its sleeve was used, and intraoperative and postoperative complications were recorded.
Results
Twenty-five patients, mean age 63.1 ± 3.3 years, were studied. The median interval between nuclear drop and vitrectomy was 14 days. The mean follow-up period was 114.3 ± 34 days. Best-corrected visual acuity (BCVA) improved significantly from a preoperative mean value of 0.008 ± 0.009 to a postoperative mean value of 0.08 ± 0.05. Intraoperative complications were two cases of retinal breaks. Postoperative complications were transient ocular hypertension in three patients, transient hypotony in four patients, and vitreous hemorrhage in three eyes that resolved spontaneously.
Conclusion
Intravitreal phacoemulsification for dropped nucleus or nuclear fragments is safe and effective and resulted in visual improvement.

Keywords: Dropped nucleus; phacoemulsification; vitrectomy


How to cite this article:
Elwan MM. Safety and efficacy of phacoemulsification in the vitreous cavity for dropped nuclear fragments. J Egypt Ophthalmol Soc 2013;106:146-9

How to cite this URL:
Elwan MM. Safety and efficacy of phacoemulsification in the vitreous cavity for dropped nuclear fragments. J Egypt Ophthalmol Soc [serial online] 2013 [cited 2019 Aug 19];106:146-9. Available from: http://www.jeos.eg.net/text.asp?2013/106/3/146/127359


  Introduction Top


Despite the high safety profile of phacoemulsification as a common technique for cataract surgery, it may be associated with serious complications [1].

Dropped nucleus or its fragments into the vitreous cavity may result in poor visual outcomes because of elevated intraocular pressure (IOP), cornea edema, uveitis, rhegmatogenous retinal detachment, cystoid macular edema, and other sequelae [2],[3],[4].

Development of techniques and instruments in the vitreoretinal field has led to improved surgical results with the least possible complications; consequently, more active surgical options have been used in dropped nucleus or nuclear fragments into the vitreous cavity [5].

The aim of the current study was to evaluate the safety and efficacy of pars plana vitrectomy and intravitreal phacoemulsification for dropped nuclei or nuclear fragments into the vitreous cavity.


  Materials and methods Top


Twenty-five patients with dropped nuclei or nuclear fragments were included in this study between August 2009 and January 2011. Patients in whom fragmatome probe or vitrectomy alone was used were excluded from the study; patients with cortical material only in the vitreous, proliferative diabetic retinopathy, and retinal detachment were also excluded from the study.

Patients' demographic data including age, sex, time between cataract surgery and vitrectomy, preoperative best-corrected visual acuity (BCVA), intraocular lens (IOL) implantation, IOP, size of nuclear fragments in the vitreous, presence of cornea edema, and uveitis were recorded; use of perfluorodecalin, occurrence of retinal break, or any intraoperative complications were also recorded. Final BCVA at 3 months postoperatively were evaluated in addition to any postoperative complications during the follow-up period.

A detailed fundus examination was performed preoperatively to identify the number and location of nuclear fragments and to rule out any retinal breaks.

The surgical technique consisted of standard 20-G three-port pars plana vitrectomy and complete removal of vitreous strands adherent to the dropped fragments. A phacoemulsification handpiece (Millennium Microsurgical System REFCX600; Bausch & Lomb Incorporated, Rochester, New York, USA) devoid of its sleeve was used through the sclerotomy site, the dropped fragments grasped by the phacoemulsification tip, and phacoemulsification was performed in the mid or anterior vitreous cavity. Low-power setting was used to avoid propulsion of nuclear fragments. The phacoemulsification machine power and aspiration were set at 40-45% and 100-150 mmHg, respectively. A small amount of perfluorodecalin was injected in some cases over the optic nerve to protect the macula against the ultrasonic energy and mechanical trauma from the lens fragments. After the vitrectomy and lensectomy were completed, a thorough peripheral examination with scleral depression was performed and peripheral vitrectomy was carried out to eliminate any kind of peripheral vitreous traction. If there was any break, endolaser treatment was performed. At the end of surgery, placement of the IOL was performed in the sulcus if there was an intact capsulorhexis rim. Postoperative treatment included dexamethasone eye drops every 4 h and moxifloxacin hydrochloride eye drops for 2 weeks. Patients were instructed to follow-up at 1 day, 1 week, 2 weeks, 1 month, and 3 months postoperatively. At each visit, patients were subjected to a thorough ophthalmological examination including a visual acuity test using a Snellen chart, applanation tonometry, slit-lamp examination, and fundus examination.

A paired t-test was used to analyze data using the SPSS statistical software (version 16; SPSS, Chicago, Illinois, USA). P values less than 0.05 were considered significant. Mean and SD was used to describe quantitative data; proportions (numbers and percents) were used to describe qualitative data.

This study received approval from the local ethics committee, Faculty of Medicine, Mansoura University. Written informed consent was obtained from all participants after a detailed explanation of the nature of the study was provided.


  Results Top


Twenty-five patients (25 eyes) including 13 (52%) men and 12 (48%) women, mean age 63.1 ± 3.4 years, were studied. The demographic data and clinical characteristics of all patients are shown in [Table 1].
Table 1: Clinical characteristics and demographic data of the patients

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The median interval between nuclear drop and vitrectomy was 14 days (ranging from 2 to 45).

The mean follow-up period was 114.3 ± 34 days. Before vitrectomy, IOP was high in 12 patients (48%) and uveitis was present in six patients (24%). Hard PCIOL was implanted in 16 patients (64%). Perfluorodecalin was used in five patients (20%). The mean preoperative BCVA was 0.008 ± 0.009 and improved to 0.08±0.05 at 3 months postoperatively and this was considered statistically significant as the P value was 0.000.

The dropped fragments were found in 16 patients (64%) and 1/2 nucleus in five patients (20%) and 1/4 nucleus in four patients (16%).

Intraoperatively, two patients developed peripheral retina breaks; each of them received endolaser around the edges of the break.

Postoperatively, three patients developed transient ocular hypertension that normalized without medication, vitreous hemorrhage in three patients that resolved spontaneously within 3 weeks, and transient ocular hypotony in four patients.


  Discussion Top


Dislocated lens fragments in the vitreous cavity is an uncommon event that occurs in 0.2-1.5% of cases during phacoemulsification surgery [6],[7],[8].

Pars plana vitrectomy was aimed at posterior vitreous removal to avoid traction during removal of dropped fragments [9].

Soliman Mahdy et al. [10] used an intravitreal sleeveless phacoemulsification tip for dropped nuclear fragments. Rhegmatogenous retinal detachment occurred postoperatively in two out of 23 patients. They concluded that pars plana vitrectomy with intravitreal phacoemulsification is a safe and effective surgical option for dropped nucleus or lens fragments without much risk of retinal damage.

Ruiz-Moreno et al. [11] carried out their study on 18 patients with retained nuclear fragments using vitrectomy and an intravitreal phacoemulsification probe devoid of its sleeve and reported one case of retinal detachment and four cases that needed medical control of IOP.

In the present study, we had only two cases of peripheral retinal breaks intraoperatively without retinal detachment and we had no postoperative cases with retinal detachment until the end of the follow-up period.

Postoperative complications were transient in this study and were comparable with Mutoh et al. [12], but they reported IOL dislocation in two cases and one case of retinal detachment.

Ruiz-Moreno and colleagues reported a mean final BCVA of 20/45 and BCVA of 20/40 or better in 33% of cases. In the present study, although the postoperative BCVA had improved statistically significantly as compared with preoperative BCVA, it was much less than that in the study of Ruiz-Moreno and colleagues because first, we had 10 high myopic eyes with macular affection, and second, the time interval between cataract surgery and vitrectomy in the study of Ruiz-Moreno and colleagues was shorter (mean 8 days, range 0-24 days), with less incidence of complications before vitrectomy. The time interval in this study was more than 20 days in seven cases, with a median duration of 14 days, range 2-45 days.

This is in agreement with Salehi et al. [13], who concluded that delaying vitrectomy for more than 1 week was associated with poor visual outcome.

Timing of pars plana vitrectomy remained controversial. Some studies had suggested that visual outcomes are better if vitrectomy is carried out within 2 weeks [14]. Other studies found that the timing of vitrectomy did not have an effect on the final visual outcome [15].

In the present study, better visual results were obtained in cases of early vitrectomy especially within 1 week; thus, vitrectomy should be performed as soon as the condition of the eye allows intervention.


  Conclusion Top


Pars plana vitrectomy and intravitreal phacoemulsification using a phaco tip devoid of its sleeve is a safe and effective method for the removal of dropped nucleus or nuclear fragments.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Gilliland GD, Hutton WT, Fuller DG. Retained intravitreal lens fragments after cataract surgery. Ophthalmology 1992; 99:1263-1267.  Back to cited text no. 1
    
2.Kim JE, Flynn HW Jr, Smiddy WE, Murray TG, Rubsamen PE, Davis JL, et al. Retained lens fragments after phacoemulsification. Ophthalmology 1994; 101:1827-1832.  Back to cited text no. 2
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3.Borne MJ, Tasman W, Regillo C, Malecha M, Sarin L. Outcomes of vitrectomy for retained lens fragments. Ophthalmology 1996; 103:971-976.  Back to cited text no. 3
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4.Margherio RR, Margherio AR, Pendergast SD, Williams GA, Garretson BR, Strong LE, et al. Vitrectomy for retained lens fragments after phacoemulsification. Ophthalmology 1997; 104:1426-1432.  Back to cited text no. 4
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5.Seo MS, Yoon KC, Lee CH. Phacofragmentation for the treatment of a completely posterior dislocation of the total crystalline lens. Korean J Ophthalmol 2002; 16:32-36.  Back to cited text no. 5
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6.Oh J, Smiddy WE. Pars plana lensectomy combined with pars plana vitrectomy for dislocated cataract. J Cataract Refract Surg 2010; 36:1189-1194.  Back to cited text no. 6
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7.Aasuri MK, Kompella VB, Majji AB. Risk factors for and management of dropped nucleus during phacoemulsification. J Cataract Refract Surg 2001; 27:1428-1432.  Back to cited text no. 7
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8.Kageyama T, Ayaki M, Ogasawara M, Asahiro C, Yaguchi S. Results of vitrectomy performed at the time of phacoemulsification complicated by intravitreal lens fragments. Br J Ophthalmol 2001; 85:1038-1040.  Back to cited text no. 8
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9.Ghasemi Falavarjani K, Hashemi M, Jalili Fazel A, Modarres M, Nazari H, Parvaresh MM. Pars plana vitrectomy and intravitreal phacoemulsification for dropped nuclei. J Ophthalmic Vis Res 2012; 7:125-129.  Back to cited text no. 9
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10.Soliman Mahdy M, Eid MZ, Shalaby KA, Hegazy HM. Intravitreal phacoemulsification with pars plana vitrectomy for management of posteriorly dislocated nucleus or lens fragments. Eur J Ophthalmol 2010; 20:115-119.  Back to cited text no. 10
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11.Ruiz-Moreno JM, Barile S, Montero JA. Phacoemulsification in the vitreous cavity for retained nuclear lens fragments. Eur J Ophthalmol 2006; 16:40-45.  Back to cited text no. 11
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12.Mutoh T, Matsumoto Y, Chikuda M. Use of pars plana vitrectomy with phacoemulsification in vitreous cavity to treat complete posterior dislocation of lens. Clin Ophthalmol 2011; 5:937-940.  Back to cited text no. 12
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13.Salehi A, Razmju H, Beni AN, Beni ZN. Visual outcome of early and late pars plana vitrectomy in patients with dropped nucleus during phacoemulsification. J Res Med Sci 2011; 16:1422-1429.  Back to cited text no. 13
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14.Monshizadeh R, Samiy N, Haimovici R. Management of retained intravitreal lens fragments after cataract surgery. Surv Ophthalmol 1999; 43:397-404.  Back to cited text no. 14
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15.Kim JE, Flynn HW Jr, Rubsamen PE, Murray TG,Davis JL, Smiddy WE. Endophthalmitis in patients with retained lens fragments after phacoemulsification. Ophthalmology 1996 ; 103:575-578  Back to cited text no. 15
    



 
 
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