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INSIDE EYETUBE.NET | JUL/AUG 2013

Practical Management of a
Dropped Nucleus

Pointers from a vitreoretinal specialist.

Christopher Gorman, BSc (Path), MB ChB (Hons), FRCO

phth

The dropped nucleus, one of the most feared

complications of modern cataract surgery,
became an issue only after the advent of
phacoemulsification. Prior to this, dropped
nuclei rarely occurred because the entire
lens was expressed through a large corneal
wound, without intralenticular
manipulations, in a technique called
extracapsular cataract extraction (ECCE).
Increased pressure in the posterior segment
inevitably directed the lens forward and
through the incision. Although vitreous loss
was a complication of ECCE, the constant
posterior-to-anterior pressure gradient
ensured that the nucleus was delivered
externally and did not drop into the
vitreous.

In modern phaco surgery, by comparison,

the surgical wound is essentially sealed
during the operation, with fluid infusion
administered to maintain anterior chamber
pressure. A dropped nucleus can occur in
two ways. First, if the zonules are weak, an
anterior-to-posterior pressure gradient can
push the nucleus posteriorly. Second, a
dropped nucleus can be a result of the
procedure, as the capsule is at risk of
damage from manipulations of
intralenticular instrumentation during
phacoemulsification. The posterior capsule
separates the vitreous from the active
operation, but the capsule may be breached.
In these cases, the dense nucleus or nuclear
fragments are free to sink into the less-dense
vitreous body and are simultaneously
restricted from escaping anteriorly by the
capsulorrhexis barrier and the pressure
gradient in the eye.

PRACTICAL MANAGEMENT USING A DETAILED

PLAN

Published studies reassure us that the

incidence of dropped nucleus is low,1-3 and
the multiple benefits of phaco surgery,
compared with older techniques, more than
compensate for the risk. However, any
cataract surgeon who has a reasonable case
volume and who operates on a spectrum of
case complexity will at some point
experience a dropped nucleus. Therefore,
anyone performing cataract surgery must
have a detailed plan to deal with this
complication.

Practical management of a dropped nucleus

is best divided under five headings: (1)
preoperative risk management, including
learning how to communicate to high-risk
patients; (2) mandatory preparations,
including devising an emergency plan of
action; (3) intraoperative course, including
enacting the emergency plan and making
sure the surgeon and sta! react
appropriately in a dynamic and stressful
situation; (4) postoperative management,
including managing potential postoperative
problems, communicating with the patient,
and referring to the local retinal surgeon;
and (5) reflection and learning, including
learning how to prevent or better manage a
similar case in the future.

PREOPERATIVE RISK MANAGEMENT

Risk factors. The published incidence of

posterior lens dislocation ranges from 0.3%
to 1.1%.4,5 Ocular risk factors include small
pupil size, pseudoexofoliation, deep-set
eyes, traumatic cataract, hard nucleus, and
intraoperative floppy iris syndrome. Patient-
specific factors include confused patients,
claustrophobia, and age greater than 90
years.

Plan ahead. Advanced planning for

individual risk factors is warranted to ensure
e"cient, safe, and stress-free surgery. Take
small pupils as an example. First, presence
of a small pupil should be identified during
preoperative assessment. Second, the
records system must reliably warn the
operating surgeon of the condition in
advance of the operation. Third, the surgeon
must be familiar with a variety of techniques
to manage this condition. Last,
communication with the surgical team
should clearly identify the at-risk patient on
the operating list, and the surgical team
should ensure that appropriate equipment is
available.

The exact details of what procedure to

perform, what equipment to use, and how
communications are relayed should be
reviewed at the local level; however, an
important stipulation is that these types of
communications are proven to work.
Policies should be in place for the risk
factors listed above. Some warrant specific
measures, but others, such as patient age
greater than 90 years, are di"cult to modify.
This does not mean that the outcome
cannot be optimized.

Is it safe to proceed with surgery? Risk

factors tend to summate. In extremely high-
risk cases, it is important that surgery be
justified. Be warned, the confused 90-
yearold patient with a dense
pseudoexfoliative lens in his or her one good
eye, 6/9 vision with mild cataract, and
agerelated macular degeneration has a high
potential risk for a dropped nucleus—among
other complications.

Always ask: Is it safe to proceed with

surgery? In other words, if a dropped
nucleus occurred, could you honestly tell the
patient and his or her family that the
operation was planned in the patient’s best
interest? Additionally, remember that some
of the factors that make cataract surgery
di"cult make vitreoretinal surgical
management of the dropped nucleus
similarly di"cult.

Communicate with the patient. A patient

is often keen to proceed with surgery even
after he or she has been informed of the high
risk for complications. The object is not to
deter the patient from having surgery but to
ensure proper understanding of the risks.
The discussion should be recorded and
included in the consent process. This is not
just defensive medicine, as surgical
complications are potentially stressful to the
surgeon.

Keep a cool head. Good outcomes require a

cool head. Therefore, during the operation is
not the time to be worrying about if the
patient was appropriately informed and
consent was attained. Save unnecessary
stress by avoiding surgery in high-risk cases
just before a public holiday or other times
that retinal coverage may be limited.

MANDATORY PREPARATIONS

Ask the appropriate questions. Every

profession has a unique set of mandatory
preparations. For instance, before every
flight, airline sta! members instruct
passengers what to do in case of a plane
crash, and as part of their training pilots
practice crash landings in a flight simulator.
However, neither the pilot nor the crew
expects to crash. Eye surgeons and the
surgical team should learn from this. Is the
operating room (OR) sta! rehearsed in
setting up the anterior vitrector? Is the
surgeon familiar with machine settings? Is
there a plan in place for using the vitrector?
Can the surgeon manage a posterior
capsular tear and rescue a di"cult situation
before a dropped nucleus develops? If the
answers are unclear, arrange sta! training
and invite a company representative to
demonstrate vitrectomy with the proper
equipment. Additionally, have the OR sta!
rehearse the dropped nucleus scenario.

Liaise with a retinal service. It is a good

suggestion to liaise with a local retinal
service and establish a protocol for referring
a patient with a dropped nucleus, as services
di!er with regard to how soon they
intervene, whether they prefer a lens to be
placed in the eye, and what minimum
information should accompany the patient’s
file. It is always easier if the first time
speaking with a retinal service is not to ask
for help in a disaster case.

INTRAOPERATIVE COURSE

Two categories. In my experience, dropped

nucleus cases referred for retinal surgery fall
into two categories: well-managed and
poorly managed. With the latter, it is likely
that surgical trauma occurred and the
surgeon struggled to execute an emergency
procedure. Stress plays a major role in the
outcomes in these cases, as it can interfere
with cognitive processing. When something
goes wrong during surgery, keep in mind
that even good surgeons can make bad
decisions. Avoid getting angry with yourself
or the eye; instead, concentrate on the
preparations you have in place to resolve the
complication. Another good defense is
taking on only appropriate cases.

Surgical objectives. Once a dropped

nucleus occurs, the first rule is to accept it.
Then remove all instruments from the eye,
maintain composure, and plan what to do
next. Remember that, at this stage, it is not
having the problem that is a measure of
professional competence but how the
complication is managed. Going back to the
airline industry analogy: Can you safely land
the crippled plane?

If the nucleus has dropped into the vitreous,

it will need referral for retinal surgery.
Ignoring it at this point in the operation is
the best course; do not give in to the
temptation to fish into the vitreous cavity
with the phaco tip for nucleus material.
Because the patient most likely is under
local anesthesia, take care to transmit a calm
and professional atmosphere. Most patients
figure out there is a problem, and what they
want is reassurance that the problem is
being addressed. An increasingly concerned
and agitated patient is likely to move more
often, making the surgical challenge more
di"cult. The OR sta! must be made aware
of the problem, and the team needs to focus
at this stage, enacting the prepared plan
quietly and e"ciently.

The basic surgical objectives include these:

Clean the anterior vitreous away from the

wound and pupil with an anterior vitrector;

If soft lens matter remains, a careful

attempt at removal is appropriate, so long
as traction on the vitreous is avoided.
Triamcinolone injection can help to
identify vitreous. If you are unacquainted
with this technique, make plans to practice
it before the next case. One alternative to
an anterior vitrectomy approach is to use a
posterior cutter and trocar system with
infusion through the anterior chamber. If
this equipment is unfamiliar, consider
observing its use in a retinal OR;

Ensure that the corneal wound is sealed

and the pupil (if undamaged) is round; and

Avoid unnecessary trauma or stress to the

corneal endothelium and iris.

The ideal situation. What all retinal

surgeons hope for in these cases is a
relatively quiet eye with a clear cornea, good
intraocular pressure (IOP) control, and a
round pupil. If only small amounts of lens
material are in the vitreous and an IOL can
safely be placed in the eye without
compromising outcomes, most retinal
surgeons would be in favor of implantation.
On the other hand, a whole dense nucleus in
the vitreous presents challenges, as the
fragmatome is insu"cient for handling
dense nuclei. In these cases, the surgeon
may have to resort to floating the whole lens
out of the eye and delivering it through a
corneal wound. Obviously an IOL would not
be helpful in this circumstance. Fortunately,
very dense cataracts are rare in the
developed world, but when they do appear
they are more likely to drop during
phacoemulsification.

POSTOPERATIVE MANAGEMENT

Risk for complications. A case complicated

by vitreous loss and dropped nucleus is at
risk for postoperative complications such as
raised IOP, cystoid macula edema, and
uveitis. These eyes also can develop retinal
detachment and, as a further complication,
venous occlusive disease. If only a very small
chip of nucleus is lost in the vitreous, an IOL
can be placed and the eye monitored
carefully postoperatively. If the eye appears
to be settling without further complications,
conservative treatment is appropriate.
However, any sign of IOP problems or
inflammation requires a vitreoretinal
consult. In all other cases of dropped
nucleus, urgent vitreoretinal referral is
appropriate. The increasing tendency is for
retinal surgeons to operate as soon as
possible on dropped nucleus cases,
obviously depending on workload. General
agreement is that the maximum wait for
retinal surgery is 1 week.

Lens material in the vitreous. An eye with

lens material in the vitreous is especially
vulnerable to postoperative complication.
Until the retinal service can receive the
patient, the duty of the operating team is to
manage the eye for complications such as
elevated IOP and uveitis. More specific roles
and responsibilities must be established
with the retinal surgery service. Exact
medications vary, but common forms
include frequent topical steroids and
antibiotics and oral and topical IOP-
lowering medications. IOP must be checked
regularly and actively managed. It is
debatable to admit a patient into the
hospital in this period, but allowing a patient
to go home is not an excuse for failing to
monitor the eye. In the case of a sick patient
who cannot self-medicate and who lacks
social support, extra care and likely
admittance to a ward until vitreoretinal
surgery can be performed is advised;
patients with a dropped nucleus often fall
into this category. Poor management in the
time before surgery can lead to poor
outcomes.

Other considerations. It is di"cult for any

surgeon to admit to the patient and his or
her family that a problem has occurred, but
shirking this responsibility will only bring
repercussions later. Avoid blaming other
team members for the problem, as this
destroys morale. If the patient was identified
as high risk beforehand and consented
appropriately, he or she will likely be
understanding. Show concern, and allow the
patient to ask questions. Be positive, and
clearly set out a plan for how the problem
will be managed.

REFLECTION AND LEARNING

A caring doctor and conscientious surgeon

naturally feels disappointed after surgery has
not gone well. It is best to use the case as a
learning experience, for the benefit of future
patients. Asking what went wrong and why it
went wrong can provide insight for future
procedures. Should you have operated on
this case? Could extra measures have been
taken to reduce the risk? Could you have
managed the complication better? Do you
need to learn new techniques? Did the team
respond well in a proficient manner?
Involving the team in a constructive
debriefing is, in my opinion, mandatory.

Christopher Gorman, BSc (Path), MB ChB

(Hons), FRCOphth, is a Consultant
Ophthalmic Surgeon at Glamorgan House Spire
Cardi! Hospital, Cardi!, United Kingdom. Dr.
Gorman states that he has no financial interest
in the products or companies mentioned. He
may be reached at e-mail:
chris@cardi!eye.co.uk.

Narendran N, Jaycock P, Johnston RL, et al. The Cataract

National Dataset electronic multicentre audit of 55,567
operations: risk stratification for posterior capsule rupture and
vitreous loss. Eye (Lond). 2009;23(1):31-37.
Mahmood S, von Lany H, Cole MD, et al. Displacement of
nuclear fragments into the vitreous complicating
phacoemulsification surgery in the UK: incidence and risk
factors. Br J Ophthalmol. 2008;92(4):488-492.
von Lany H, Mahmood S, James CR, et al. Displacement of
nuclear fragments into the vitreous complicating
phacoemulsification surgery in the UK: clinical features,
outcomes and management. Br J Ophthalmol.
2008;92(4):493-495.
Leaming DV. Practice and preferences of ASCRS members –
2003 survey. J Cataract Refract Surg. 2004;3:892-900.
Pande M, Dabbs TR. Incidence of lens matter dislocation
during phacoemulsification. J Cataract Refract Surg.
1996;22:737-742.

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INSIDE EYETUBE.NET | JUL/AUG 2013

Strategies for Managing

Concurrent Cataract and
Macular Hole

Surgeons describe how they manage a

patient who presents with a visually
significant cataract and an impending
macular hole that is confirmed by OCT.

George Beiko, BM, BCh, FRCSC; Steven J. Dell, MD; Parag

A. Majmudar, MD; Keith A. Warren, MD; and Je!rey
Whitman, MD

GEORGE BEIKO, BM, BCH, FRCSC

This is not an infrequent finding in patients

who are referred for cataract surgery. The
clue, clinically, is that the patient’s decrease
in vision is out of line with the degree of
nuclear sclerosis or lenticular opacity. I
always look at the macula with a 60.00 D
lens at the slit lamp prior to surgery (as I
was trained in the dark ages before
technology). If the macula is suspicious,
then I perform optical coherence
tomography (OCT) to confirm the presence
of a macular hole. Once the diagnosis is
made, I refer the patient to my preferred
vitreoretinal surgeon for management; he is
a very capable surgeon who does excellent
cataract surgery. He will perform combined
cataract surgery with implantation of an IOL
and internal-limiting membrane peeling,
saving the patient from trips to the
operating room. I am intrigued by
ocriplasmin (Jetrea; Thrombogenics), but, as
it is e!ective in only a minority of patients, I
await guidance as to who would be an ideal
patient for these injections.

STEVEN J. DELL, MD

When this situation occasionally comes up, I

send the patient to a retinal colleague to set
proper expectations and fully define the
extent of the pathology. Typically, with
vitreomacular traction, cataract surgery will
precipitate a posterior vitreous detachment,
and the resulting retinal status is
unpredictable preoperatively. I explain to
the patient that there is no way to remove
the cataract without eventually creating a
posterior vitreous detachment, which could
result in a macular hole. Even if the patient
were to develop a macular hole, a retinal
surgeon would want the cataract removed
before addressing the retina.

I also tell the patient that there is poor

correlation between the appearance of the
retina on the preoperative OCT and visual
acuity after cataract surgery. My favorite way
to explain things like this is as follows: Two
things are wrong with the eye, which is like a
tall glass that is filled with two liquids, vodka
and water. There is no way to tell how much
is vodka or water unless the vodka is
distilled o! and the amount of water that is
left over is measured. The leftover water is
the problem with the retina.
IN THIS ISSUE NEXT ARTICLE
This is a di"cult clinical situation, but with