Dr. Navin Gupta M.S.Shankar Netrika EyeHospital, Mumbai

Nucleus Prolapse intoanterior chamber

Nucleus prolapse into AC

• One of the essential features of SICS absent in ECCE

• Takes some experience to master• Can be done both with canopener

capsulotomy and capsulorhexis.

In Canopener capsulotomy

• Mainly mechanical. Hydro procedures not used.

• Instruments: Sinskey hook or cystitome• Important to visualize periphery of ant

capsule.• Sinskey hook is positioned to reach

equator of nucleus. Best between 9 to 12 clock hrs.

Hooking the nucleus

• Peripheral Ant Surface- good for NS III n IV. More stress on zonules n post capsule.

• Equator• Undersurface of equator- last 2 put

lesses stress on zonules

Mechanical prolapse into AC

• After hooking, nucleus pushed towards opp clock hr.

• Visualize equator.• Lift and rotate (clock or

anticlockwise).

Mechanical prolapse

Problems in mechanical prolapse

Cheese Wiring

• Peeling or fragmentation of cortex n epinucleus as shreds.

• Happens with soft cataracts.• Solution- use hydro procedures for

soft cats.

Slipping back of uplifted pole

• Once a pole is out, dialing force should be upwards.

• Injecting visco between nucleus n iris (bed-sheeting) also helps.

Churning of cortex

• In soft catracts• Solution- aspirate n wash off

superficial loose cortex before the mechanical prolapse.

Nucleus keeps rotating

• Seen in hypermature, brown n black cats where there is less cortex.

• Solution- inject visco beneath prolapsed nucleus.

• Pass vectis beneath nucleus and prolapse it.

Small pupil

• Enlarge pupil:• Preop NSAIDS drops• Intracameral epinephrine• Sphincterotomies• Stretch pupilloplasty Kuglen’s hook• Sector or key-hole iridectomy

Bimanual technique

• 2 instruments• Sinskey hook (rt hand)• Cyclodialysis spatula (lt hand)• Hook engages nucleus. Push to 6

o’clock. Upper pole seen. Spatula inserted under it. Pole lifted up. Nucleus dialled out.

• Compliacations: zon dialysis, iridodialysis, endoth damage, nucleus drop.

In capsulorhexis

• Fair estimation of nucleus size is important

• Hydroprocedures are the method of choice here.

Hydrodissection

• Hydro cannula tip placed between cortex n capsule. Fluid injected. Cannula taken to opposite pole, fluid injected till fluid wave lifts up the opp pole. Then using Sinskey hook, nucleus is dialed out.

Tumbling Technique

• In only soft cataracts• Only very skilled surgeons• Perfect size rhexis• Initially hydrodissection is done. One

pole is lifted up. Now with the cannula, pole of the nucleus in bag is pressed down and moved across simultaneously, tilting the nucleus. Tumbles into AC.

Complications hydroprolapsing• Small/incomplete rhexis- inability

to prolapse• Nucleus stuck in rhexis, half inside

half outside bag. Make small relaxing cuts. Gently coax nucleus out bimanually.

• Radial tear extending to post capsule

Specific techniques for particular types of cataracts

Hypermature Cataracts

• No cortex. Nucleus tends to rotate in the bag.

• Use Simcoe cannula. Fluid kept on full flow. Simcoe passed under nucleus. Mechanically lifted up.

Soft cataracts

• Difficult due to cheese wiring• Do hydrodissection n

hydrodilineation and tumble nucleus into AC.

Post Polar Cataracts

• Do not hydrodissect.• Do only hydrodelineation• Bimanual technique to prolapse.

Subluxated cataracts

• Experienced surgeon.• Good hydrodissection n

delineation.• Bimanual technique