J CATARACT REFRACT SURG - VOL 32, JANUARY 2006

Staining of vitreous with triamcinolone

acetonide in retained lens surgery
with phacofragmentation
Suleyman Kaynak, Lider Celik, MD, Nilufer Kocak, MD, F. Hakan Oner,
Tulin Kaynak, MD, Guray Cingil

PURPOSE: To evaluate the beneficial effects of triamcinolone-assisted vitrectomy during manage-

ment of retained nuclei with phacofragmentation.
SETTING: Dokuz Eylul University, Medical Faculty, Ophthalmology Department, and Retina Eye Center,
Izmir, Turkey.
METHODS: Twelve eyes of 12 patients were operated on between January 2002 and September 2003.
Eleven patients were referred because of nucleus drop during phacoemulsification surgery. Six of these
patients had mature white cataracts, and in 5 cases total nucleus luxation into vitreous cavity had
occurred. In 1 case, approximately half of the nucleus was luxated. Five of the referred patients had pseu-
doexfoliation (PEX), 3 of whom also had phacodonesis. All of these patients had luxated nucleus
segments of more than half. One patient was referred with an intraocular lens (IOL) implanted in the sul-
cus region. One patient who was not referred also had PEX, iridodonesis, and phacodonesis; total drop of
nucleus had occurred in this case. All patients were treated with pars plana vitrectomy with triamcino-
lone acetonide staining of the vitreous material and phacofragmentation of the dropped nucleus seg-
ments. In 2 cases, transscleral foldable IOL fixation surgery was combined simultaneously. One patient
already had an IOL at the time of referral. Nine patients were left aphakic for secondary procedures.
RESULTS: All patients except 1 with subretinal neovascular membrane achieved best corrected visual
acuities of equal or better than 0.5. No intraoperative or postoperative retinal complications were
observed after 9 to 15 months of follow-up.
CONCLUSION: Staining of the vitreous material with triamcinolone acetonide during vitrectomy and
phacofragmentation surgery for luxated nuclei helped in total removal of the vitreous body, thus pre-
venting the aspiration of peripheral vitreous fibrils by the phaco tip, which might induce retinal de-
tachment intraoperatively or postoperatively.
J Cataract Refract Surg 2006; 32:56–59 Q 2006 ASCRS and ESCRS

Phacoemulsification surgery has been the preferred method
of cataract removal, especially during the past decade. A
major change in management of cataracts is earlier surgery,
before the nucleus becomes harder, because this allows
faster surgery with less ultrasound energy delivered to the
ocular tissues. There are patients, however, especially
from rural areas, who already have mature cataracts at
the time of first admittance. This obviously creates difficul-
ties during surgery. Other ocular conditions that may
present alone or in combination are pseudoexfoliation
syndrome (PEX); iridodonesis-phacodonesis, which resem-
bles the presence of zonular weakness; zonular dialysis; lens
subluxation; and posterior polar cataracts, all of which
may be addressed as the precursors of a probable intraop-
erative complication along with the mature white cataract.
The luxation of the nucleus material is not a rare
complication of phacoemulsification procedures (0.3%
to 1.1%)1,2 and requires vitreoretinal surgical interven-
tions.3–6 Phacofragmentation combined with pars plana
vitrectomy (PPV) is the preferred surgical method but
results in retinal detachment in some cases.7–9
PATIENTS AND METHODS
Twelve eyes of 12 patients who were operated on between
January 2002 and September 2003 were included in this study as

Q 2006 ASCRS and ESCRS 0886-3350/06/$-see front matter

Published by Elsevier Inc. doi:10.1016/j.jcrs.2005.10.028

56
 VITREOUS STAINING IN RETAINED LENS SURGERY

a retrospective chart review. Patients mean age was 77.9 years Table 1. Demographic data and preoperative information of patients.
(range 72 to 85 years), and 7 were men and 5 were women. Demo-
graphic data and preoperative information are presented in Table 1. Zonular Nucleus
Eleven patients were referred because of nucleus drop during Patient Age (Y) Sex PEX Weakness Mature Drop
phacoemulsification surgery at other centers. Six of these patients
had mature white cataracts at the time of first admittance, and in 5 1 79 M ÿ C C Total
cases, total nucleus luxation into vitreous cavity had occurred at 2 81 M C ÿ ÿ Three fourths
the beginning of the phaco procedure after incomplete capsulo- 3 74 F C C ÿ Three fourths
rhexis. In 1 case, about half the nucleus was luxated through a pos- 4 72 M ÿ ÿ C Total
terior capsule rupture. Five of the referred patients had PEX, 3 of 5 77 M ÿ ÿ C Total
whom also had phacodonesis. These patients were reported to 6 85 F ÿ C C Half
have nuclear sclerosis of at least grade 3. All these patients had 7 84 F C C ÿ Three fourths
luxated nucleus segments of more than half. One patient was re- 8 79 M C C ÿ Total
ferred with a foldable intraocular lens (IOL) implanted in the 9 81 M ÿ ÿ C Total
sulcus region. Of these 11 patients, 2 had intraocular pressures
10 73 F ÿ C C Total
(IOPs) of 25 mm Hg and 26 mm Hg, respectively, at the time of
referral. None of the patients presented with a high degree of cor- 11 78 M C C ÿ Half
neal edema that would interfere with fundus visibility during vit- 12 72 F C ÿ ÿ Three fourths
rectomy. No cases of retinal detachment (RD) were detected. All PEX Z pseudoexfoliation
referred patients were operated on within 3 days after their admit-
tance to our clinic. The average time between the complicated first
operation and the PPV was 3.7 days (range 2 to 7 days). One
patient, who was not referred (was a patient at the clinic), also macular region. Phacofragmentation was applied to remove
had PEX, iridodonesis, and phacodonesis. Total drop of nucleus the nucleus material. Perfluorodecalin liquid was aspirated. In
with capsule occurred in this patient as a result of loss of zonular the last 2 cases, transscleral fixation of a 3-piece hydrophobic
attachments during capsulorhexis. The operation was converted acrylic foldable IOL was performed through a 3.5 mm clear cor-
to PPV and phacofragmentation. neal incision after the haptics were tied with a 10-0 polypropylene
All patients were treated with PPV with triamcinolone aceto- suture. One patient already had an IOL in the sulcus at the time
nide staining of the vitreous material and phacofragmentation of of referral. Previous cases were left aphakic for secondary opera-
the retained nucleus segments. All operations were performed tions. Sclerotomies were closed with 6-0 polyglactin (Vicryl).
by the same surgeon. After pupil dilation with phenylephrine, The conjunctiva was closed with 8-0 Vicryl. The operations
tropicamide, and cyclopentolate, all referred patients received were ended with subconjunctival injection of antibiotics and
retrobulbar injections of the local anesthetic agents prilocaine steroids.
(Citanest) and bupivacaine hydrochloride (Marcaine). The con- The postoperative follow-up included topical antibiotics and
junctival sacs were irrigated with 5% diluted polyvinylpyrolidone steroids for about 4 to 6 weeks. Two patients had fairly high pre-
iodine solution. Regional disinfection of the periocular adnexa operative IOPs that stabilized below 20 mm Hg approximately 5
was done with polyvinylpyrolidone iodine solution, and the eye- to 6 days after vitrectomy surgery with the use of topical glau-
lashes were draped. After insertion of the eye speculum, conjunc- coma medication. Two patients had surgical procedures, in-
tival dissection and cautery for hemostasis were performed. In the cluding simultaneous transscleral fixation of foldable IOLs.
last 2 cases, scleral flaps were prepared at 3 to 9 positions for si- One patient already had an IOL implanted in sulcus during re-
multaneous transscleral IOL fixation. The scleral irrigation port ferral. Eight patients received secondary IOL implantations 4
was stabilized, and core vitrectomy was applied. The cutting to 6 months after the first surgery. Five of these patients had
rate was 800 to 1200 cuts per minute, and the vacuum was set transscleral fixation of poly(methyl methacrylate) IOLs, and
at 200 mm Hg. One milliliter of triamcinolone acetonide was in- 2 had foldable IOLs. One patient had enough capsular rem-
jected into the vitreous cavity, which stained the remaining vitre- nant for foldable IOL implantation in the sulcus. One patient
ous material and allowed better visualization of peripheral did not want to have another operation in his eye; this patient
portions. The triamcinolone-stained vitreous material was re- used an aphakic contact lens for visual rehabilitation.
moved with a vitrectomy cutter (Accurus, Alcon) as much as pos-
sible, especially at the periphery near the sclerotomy regions.
After it was confirmed that no vitreous fibrils were present to be RESULTS
aspirated by the phaco tip, 2 or 3 mL of perfluorodecalin liquid
No intraoperative or postoperative retinal complica-
was injected to raise the luxated nuclear material away from the
tions were observed. The mean final visit was at 11.3
months (range 9 to 11 months). All patients except 1
achieved a best corrected visual acuity of 0.5 or better at
Accepted for publication June 29, 2005. the time of last visit. One patient who had a mature white
From the Ophthalmology Department, Dokuz Eylul University, cataract in which the fundus could not be observed preop-
Medical Faculty, Izmir, Turkey. eratively also had a large subretinal neovascular membrane.
No author has a financial or proprietary interest in any material or This patient’s acuity was 0.05 on the Snellen chart, even af-
method mentioned. ter photodynamic therapy application. The preoperative
Reprint requests to Lider Celik, Retina Goz Merkezi 1488 Sk. No: IOP elevations in 2 patients continued after the PPV sur-
3 35220 Alsancak, Izmir, Turkey. E-mail: lidercelik@retina-gm.com. gery until the end of the fifth to sixth day and could be

J CATARACT REFRACT SURG - VOL 32, JANUARY 2006 57

 VITREOUS STAINING IN RETAINED LENS SURGERY

controlled by topical antiglaucoma medication. None of the be removed adequately by PPV. The last complication
patients required secondary operations for treatment of mentioned might induce peripheral retinal tears, which,
postoperative complications. The data regarding the sec- in turn, could be the reason for retinal detachment. Once
ondary interventions for refractive rehabilitation and visual the phaco tip aspirates any vitreous fibrils, it is almost
results are presented in Table 2. impossible to remove them through back flush because of
the adhesiveness of the vitreous fibrils. The insertion of
manipulators to get rid of these fibrils further increases
DISCUSSION
the risk for tractional forces on the retina. Thus, the best
The luxation of nuclear, epinuclear, and cortical material way to prevent such unwanted situations is complete re-
into the vitreous cavity during phacoemulsification surgery moval of peripheral vitreous material at the vitreous base
may be encountered in some cases that already have predis- by making it visible.
posing factors such as mature white cataracts, PEX, zonular Intravitreal injection of triamcinolone acetonide has
weakness or dialysis, or posterior polar cataracts. The luxated been introduced for less invasive treatment of some retinal
cortical elements alone can be left without surgical interven- inflammatory and edematous conditions.11–13 It has also
tion because they can be reabsorbed spontaneously, although been demonstrated that intravitreal triamcinolone injec-
they cause a somewhat exaggerated inflammatory response.9 tion shows the presence of vitreal remnants after PPV sur-
Nucleus segments greater than one fourth of the total gery.14 Triamcinolone injection into the vitreous cavity is
should be removed by PPV because of the risk for chronic reported to be beneficial during peeling of epiretinal mem-
inflammation and secondary glaucoma.10 The nuclear branes and internal limiting membrane.15
material in the vitreous cavity should be extracted first after Triamcinolone particles increase the visibility of trans-
the vitreous body is removed by PPV. The second interven- parent structures by adhering to them. We tried to com-
tion generally is injection of perfluorocarbon liquid to cre- plete the retained lens operations with better cleaning of
ate a safe place between the nuclear material and the the vitreous base by using triamcinolone acetonide as a con-
macula region and is not compulsory. The removal of lux- trast enhancer. In this retrospective study, we observed no
ated nucleus by phacofragmentation3–6 seems to be a rea- retinal complications, including detachment arising from
sonable approach because it requires a decreased amount phacofragmentation. The single case of subretinal neovasc-
of perfluorocarbon liquid during surgery and eliminates ular membrane was probably present before the cataract
the need for a large corneal–scleral incision. The disadvan- surgery. Although not presented in this study, we know
tages, however, are the probability of causing a tissue burn from experience that the removal of luxated nuclear mate-
at the sclerotomy site, difficulty of keeping the nuclear rial by PPV and phacofragmentation is associated with sub-
material stable at the tip, damage to the macula from ultra- sequent development of RD in some cases. Kim et al.,3
sonic power, and aspiration of vitreous fibrils that could not Margherio et al.,4 Gilliland et al.,5 and Borne et al.6 state
that the postoperative incidence of RD after PPV for re-
Table 2. Secondary interventions and BCVAs at last examinations.
tained nuclear fragments is approximately 3% to 10%. In
their series of 62 patients, Kim et al.3 reported that 1 patient
Secondary had RD during presentation and 2 had RD after PPV surgery
Patient Intervention Date* Last Visit* BCVA for retained lens removal, which corresponds to a 4.9% in-
1 PMMA TSIOL 6 10 0.63 cidence of RD generally and 3.2% after PPV surgery. This
2 PMMA TSIOL 6 12 0.5 complication occurs probably because of unrecognized
3 None† d 12 0.8 tractional forces on the peripheral retina from the adhered
4 PMMA TSIOL 5 10 0.63 vitreous fibrils on the nucleus material or the aspiration of
5 PMMA TSIOL 6 10 0.8 them by the phacofragmentation tip. In our practice, we be-
6 PMMA TSIOL 5 11 0.05 lieve that vitreous remnants at the far periphery of the ret-
7 Fold. TSIOL 4 13 0.8 ina near the ora serrata are important factors in retinal tear
8 Fold. TSIOL 4 15 0.63 formation. It is well known that vitreoretinal attachments
9 None d 9 0.5
are stronger at this location. Any inadvertent tractional
10 Fold. TSIOL 4 11 0.5
11 Fold. TSIOL Simultaneous 12 0.63
force exerted over the retina with pulling of the fibrils at
12 Fold. TSIOL Simultaneous 9 0.8 the vitreous base may result in severing the retina. Along
with the injection of triamcinolone into the vitreous cavity,
BCVA Z best corrected visual acuity; Fold. TSIOL Z foldable transscleral the transparent fibrils, which are difficult to detect with the
intraocular lens; PMMA TSIOL Z poly(methyl methacrylate) transscleral
intraocular lens naked eye, are made visible, thus allowing the surgeon to
*Months after first surgery remove them totally. External indentation is also helpful
†
IOL implantation before referral during cleaning of the vitreous base, which allows the

58 J CATARACT REFRACT SURG - VOL 32, JANUARY 2006

 VITREOUS STAINING IN RETAINED LENS SURGERY
surgeon to be more secure in inserting a phacofragmatome
tip into the vitreous cavity. At least 1 predisposing factor for
retinal tear formation during retained lens surgery can be
eliminated by triamcinolone-assisted PPV.
The prevention of peripheral retinal traction during
the removal of the nucleus might in turn reduce the risk
for RD. The increased safety of the procedure allows the
cataract surgeon to implant an IOL after partial or total nu-
cleus luxation if there is adequate capsular remnant and
refer the patient to the vitreoretinal specialist. This study
lacks the statistical proof of this observation. The beneficial
effect of triamcinolone-assisted vitrectomy during the
removal of luxated nuclear material could also be shown
statistically by comparing the results with those of nonas-
sisted PPVs.
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