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Manish Nagpal MD, FRCS
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Posterior polar cataracts present a special challenge to phaco surgeons because of posterior capsular dehiscence. A slow-motion phaco technique, low infusion and vacuum settings are used to protect the capsule. Despite precautionary measures, it is still possible for the nucleus to drop. This video submitted by Manish Nagpal, MD, demonstrates how to manage this complication and proceed with IOL implantation.
Posted: 10/26/2010
Manish Nagpal MD, FRCS
Posterior polar cataracts present a special challenge to phaco surgeons because of posterior capsular dehiscence. A slow-motion phaco technique, low infusion and vacuum settings are used to protect the capsule. Despite precautionary measures, it is still possible for the nucleus to drop. This video submitted by Manish Nagpal, MD, demonstrates how to manage this complication and proceed with IOL implantation.
Posted: 10/26/2010
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Luis Daniel Holfuin
10 years ago
ACRYSOF IQ WITH SQUARE EDGE CAN LEAD TO PIGMENT DISPERSION AND GLAUCOMA YEARS AFTER THE SURGERY.
Manish Nagpal
14 years ago
thank you for your comments Ahmed. Yes AC maintainer is a good idea and i have myself used it in some of the cases for the same reason that while fragging at times you have to be careful that the IOP does not fall below normal due to high vacuum and relatively lower infusion and hence the Maintainer would compensate for the same
Ahmed El-Sawy Habib
14 years ago
Excellent video, I watched your video after I had a similar case last week which was managed the same way as your case apart from implanting a 3 piece foldable lens. In my case I used an AC maintainer for Irrigating fluid, a 23G trocar and canula for endoillumination and a 20G sclerotomy for the fragmatome. In my opinion the 25G canulla for irrigation wouldnt be sefficient to compensate for the high vacuum you need to hold the dropped nucleus during fragmentation, hence in such cases I use an AC maintainer through a 19G corneal side port. As I perform the phaco and the vitreoretinal maneuvers , I tend to implant IOL after nucleus phragmentation to make maximum use of the AC maintainer fluid.
Gustavo Castro
14 years ago
This lens cannot be placed in the sulcus (transilumination defects, pigmentary glaucoma, UGH Syndrome). This was confirmed in a lot of studies and video presentations all around the world. In this situation the least dangerous solution for the patient probably would be placing a foldable 3 piece IOL in the sulcus with the optics captured behind the capsulorexis to avoid vitreous to prolapse to AC and to provide long term centration.
aziz çil
14 years ago
if I were you, When I realized the posterior capsule rent, I would take precautions to prevent posterior dislocation of nucleus.thus second procedure might be unecessary.
Manish Nagpal
14 years ago
well...i am a dedicated vitreo retinal surgeon and the surgeon who did the phaco is actually one of the best in the field!!! However i am sure we all have a lot to learn and it would be a great service to all of us if you could put up a nice video on eyetube demonstrating these special skills and premonitions that you are suggesting!!!!
NIKETU SHAH
14 years ago
excellent video manish.... but would it not make more sense to remove the dropped nucleus first and then go for a secondary iol ?
Manish Nagpal
14 years ago
thank you for your comments but i prefer that my referring anterior segment surgeons preplace the IOL before i intervene since i would do half as good a job of trying to place an IOL in a compromised support situation at the end of a vitrectomy......
NIKETU SHAH
14 years ago
fair enough...makes sense.... thanks once again for the video...
Manish Nagpal
14 years ago
thank you for your comments....
George Tanaka
14 years ago
Agree with that implantation of 3 piece lens is preferred in these cases instead of single piece acrylic. Technically, it is not an UGH syndrome as was seen with older model IOLs. Its a pigment dispersion syndrome caused by the bulky haptic of the single piece acrylic IOL against the posterior pigmented layer of the iris itself resulting in transillumination defects anterior to the haptics. I think optic capture is a good idea as well and probably easier with a 3 piece IOL. Great video.
salim gigani
14 years ago
Thank you Sir for the excellent video. As usual it was an excellent surgery to watch. Reminds me of all this of my fellowship days with you. Waiting eagerly for the next visual treat. Best of Luck. Salim Gigani
Manish Nagpal
14 years ago
thank you..yes the suggestion is quite good and IOL capture could definitely be an option in this situation...
Nadav J Belfair
14 years ago
Excellent video and technique. may I suggest stabilizing the IOL using Optic capture? Belfair Nadav
Brandon Posvar
14 years ago
I have to question/disagree with implantation of one piece acrylic IOLs in the sulcus. I've had to reposition an IOL with a haptic out of the bag causing UGH syndrome (sometimes you can see the shape of the haptics as a transillumination defect in these irides). If you only have a one piece available, a better option would be to prolapse the optic anteriorly through the rhexis, with the haptics posterior to the rhexis. Thanks for the clear video.
ari weitzner
14 years ago
agreed. i recently saw a patient who had ugh syndrome due to acrysof in sulcus. required lens exchange. patient very angry with first surgeon who was not aware of it. i think acrsof in sulus is absolutely, not relatively, contraindicated.
Manish Nagpal
14 years ago
Thank you for your comments. In this video my personal connection is based on the posterior segment intervention and i agree with your concerns. My anterior segment collegue who used to be confortable placing these IOLS has also switched to 3 piece ones following similar concerns. This video was actually done more than a year back and i think there is full agreement in the fact that 3 piece lenses should be placed as compared to a single piece to avoid future inflammation in these eyes. Thank you for pointing this out......Manish
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