|Year : 2012 | Volume
| Issue : 2 | Page : 83-86
Phacoemulsification in cases of pseudoexfoliation using in situ nuclear disassembly without nuclear rotation
Mohamed A. E. S. Mahdy
Department of Ophthalmology, Rustaq Hospital, Rustaq, Sultanate of Oman, and Department of Ophthalmic, Al-Hussein University Hospital, Al-Azhar University, Cairo, Egypt
|Date of Web Publication||4-Aug-2012|
Mohamed A. E. S. Mahdy
Department of Ophthalmology, Al-Hussein University Hospital, El-Darrasa, Cairo, Egypt
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: The purpose was to assess the safety and frequency of intraoperative complications of phacoemulsification using an in situ nuclear disassembly technique in pseudoexfoliation (PEX) cases.
Setting: The work was done in Rustaq Hospital, Rustaq, Sultanate of Oman.
Materials and Methods: This prospective, interventional, noncomparative study included 103 cases of cataract with pseudoexfoliation that underwent phacoemulsification with in situ nuclear disassembly using Alcon Infinity machine with Ozil handpeice and Kelman-style 45° phacoemulsification tip.
Results: Of the 103 cases, 55 males (53.4%) and 48 (46.6%) females, one case developed posterior capsular rupture, and four cases developed zonular dehiscence that was partial in three cases and >180° in one case only. The best corrected visual acuity (BCVA) 4 weeks postoperatively using logMAR notation was as follows: 66 cases (65.1%) had BCVA of 0.30 or better (logMAR notation), and 37 cases (35.9%) had BCVA of 0.48 or less.
Conclusion: Safe and efficient phacoemulsification without nuclear rotation could be achieved in cases pseudoexfoliation in which zonular weakness is a concern by utilizing the versatility of Kelman style phaco tip to do lateral sweep sculpting and in situ cracking techniques. It prevents zonular stress by avoiding manipulation or rotation of the nucleus in cases.
Keywords: Cataract surgery - phacoemulsification, nuclear disassembly, pseudoexfoliation, zonular weakness
|How to cite this article:|
Mahdy MA. Phacoemulsification in cases of pseudoexfoliation using in situ nuclear disassembly without nuclear rotation. Oman J Ophthalmol 2012;5:83-6
|How to cite this URL:|
Mahdy MA. Phacoemulsification in cases of pseudoexfoliation using in situ nuclear disassembly without nuclear rotation. Oman J Ophthalmol [serial online] 2012 [cited 2020 Aug 8];5:83-6. Available from: http://www.ojoonline.org/text.asp?2012/5/2/83/99369
| Introduction|| |
Zonular dehiscence or weakness is a potential risk during cataract surgery and might end with significant intraoperative morbidity such as vitreous loss, dropped nuclei/lens fragments,  and late postoperative intraocular lens dislocation or subluxation. Nuclear manipulations are disadvantageous and represent a major risk for stressing the lens zonules when manipulating the nucleus in cases with weak zonules as eyes that have sustained trauma, eyes with pseudoexfoliation syndrome (PEX), and in patients with Marfan syndrome. ,,,,
Although capsular tensions rings (CTRs) may help the surgeon more evenly distribute forces exerted on the zonules,  they are best used once the nucleus is removed. 
Cortical cleavage hydrodissection might help to speed the procedure in eyes that do have capsule-zonular disorders. However, it is not necessary in all cases with PEX.
Many techniques have been described for in situ nuclear disassembly. ,, One of them is a technique which allows for safe debulking of two-thirds of the nucleus by removal of a deep, central, equilateral triangular wedge of nucleus with no manipulation or rotation. This is followed by cracking the remaining peripheral nuclear rim into three equal segments. Each segment is easily gripped, and pulled into the central cavity for safe endocapsular phacoemulsification using short bursts of phaco power.  Another technique described is an in situ nuclear disassembly technique using a simplified form of sculpting and cracking, enhanced by phacoemulsification technology with a Kelman-style tip. The technique does not require mobilization or rotation of the nucleus within the capsular bag, and hydrodissection is optional. The technique requires a Kelman-style-curved tip and takes advantage of the versatility of the curved phacoemulsification needle for sculpting and cracking. 
The chief advantage of in situ nuclear disassembly is that it minimizes stress to the capsule and zonules by reducing intracapsular lens manipulation, specifically rotation of the nucleus, and eliminating hydrodissection in certain cases. In addition, in situ nuclear disassembly requires no special tools. ,
The current study will assess the safety and frequency of intraoperative complications of phacoemulsification using the in situ nuclear disassembly technique without nuclear rotation in pseudoexfoliation (PEX).
| Materials and Methods|| |
One hundred and three patients with cataract and pseudoexfoliation not associated with any degree of lens subluxation were consecutively recruited from patients attending Rustaq General Hospital, South Batinah Region, Sultanate of Oman during the period January 2008-August 2011. [Table 1] shows the patients' demographic characteristics. Twenty-six cases (25.2%) had visual acuity counting fingers or hand motion, 31 cases (30.1%) had logMAR Visal acuity (VA) 1.3, 33 cases (32.04%) had VA 1.0, and 13 cases (13.3%) had VA 0.8-0.48 LogMAR notation. The nuclear hardness varied from grade I to grade IV.
The participants underwent phacoemulsification with in situ nuclear disassembly, intraoperative complications were noted and postoperative visual outcome was evaluated as well.
The research follows the tenets of the Declaration of Helsinki after approval of the study protocol by the Scientific and Research Committee of the Rustaq Hospital and Directorate of Health Affairs, South Batinah Region, Sultanate of Oman. Informed consent was obtained from all patients enrolled in the study after the nature and possible consequences of the procedures had been explained.
History of vitrectomy, retinal reattachment surgery, trabeculectomy, or ocular trauma.
Anesthesia; Local peribulbar anesthesia was used in all patients where a mix of 2% lidocaine (Pharmaceutical Solution Industries, Jeddah, KSA) and 0.5% bupivacaine (Hospira, Inc., Lake Forest, USA), a mixture of 50/50 was used. A combination of tropicamide 0.5%, and phenylephrine 2.5% was applied topically 60, 45, 30, and 15 minutes before surgery to dilate the eye. The surgery was then proceeded as scheduled and all patients received subconjunctival injection of Dexamethasone+ Gentamycin injection at the end of the surgery.
A standard clear corneal (temporal or superotemporal) incision was performed using a 2.2 mm ClearCut blade . Two side ports were created with a 1.0 mm ClearCut blade approximately 90° on either side of the main incision. A dispersive ophthalmic viscosurgical device (OVD), Viscoat (sodium chondroitin sulphate and sodium hyaluronate) (Alcon Laboratories (S.A.) (Pty) Ltd) was used during the earlier phase of surgery. Later on, during subsequent phases of surgery a cohesive OVD, Provisc (sodium hyaluronidate) is used to deepen the anterior chamber and to expand the capsular bag for implantation of the intraocular lens. Continuous curvilinear capsulorhexis is made using a bent 25-gauge insulin needle. Hydrodissection was done using the same cannula of viscoelastic in most of cases. The nucleus is not rotated. A technique similar to that described by Koplin et al. was used.  However, the Ozil handpiece and Kelman style-curved 45° phacoemulsification tip with a Micro-Smooth ULTRA Infusion Sleeves is used to sculpt a standard central vertical groove 80-90% deep along the full extent of the nucleus. The Alcon's INTREPID Fluidic Management System (FMS) with noncompliant tubing was used to provide enhanced chamber stability. Then the phacoemulsification tip was repeatedly rotated to the right side, sweeping the curved Kelman tip into the heminucleus to create a lateral groove that is perpendicular to the central vertical groove and extend 3.0-4.0 mm long at approximately 80% depth and divides the right heminucleus into quadrants. The same was repeated in the left heminucleus.
The initial vertical groove is cracked into two hemispheres as usual (applying equal but opposite force against the grooved walls), lateral pressure exerted by the phacoemulsification tip on the base of the right-hand wall and a side port manipulator on the base of the left side.
The Kelman-style tip and side port manipulator are then placed within the lateral groove in the right heminucleus. The right heminucleus is split into two distinct quadrants. The phacoemulsification tip is used to push the distal quadrant away from the surgeon while the side port manipulator pulls the proximal portion toward the surgeon. The same was repeated with the left heminucleus which is cracked in the same manner.
Each of the four quadrants is captured by the phacoemulsification tip, drawn to the pupillary center, then chopped using a chopper against the phacoemulsification tip utilizing the standard machine settings for torsional quadrants removal. The curved Kelman 45° tip is rotated slightly to the right and placed in the horizontal groove to occlude the tip, build vacuum, and bring the first distal quadrant into the pupillary center. The tip is then rotated to the left to bring the distal inferior left-hand quadrant into the pupillary center in the same manner. The other two quadrants are then manipulated to bring them into the pupillary area aided with the manipulator then removed with the phaco tip. This is followed by cortical clean up using bimanual I/A handpieces and capsular bag expanded with cohesive OVD followed by posterior chamber intraocular lens insertion.
The routine postoperative treatment was as follows: topical steroids in the form of prednisolone acetate 1% eyedrops/2 hourly for the first 3 days then 3 hourly for another 3 days, then 4 hourly for 10 days. Topical antibiotic drops (ofloxacin 0.3%) were used 4 times day. One capsule of 100 mg sustained release nonsteroidal anti-inflammatory drug (diclofenac sodium) was used as single oral dose for 5 days in all cases.
The statistical package for social sciences version 14.0 (SPSS 14.0, SPSS Inc., Chicago, IL) was used to perform statistical analysis. A significant difference was taken to be the one in which the P value was ≤ 0.05.
| Results|| |
The patients' demographic characteristics are shown in [Table 1].
Of the 103 cases, 55 were males (53.4%) and 48 (46.6%) females. The mean age was 60.53 (SD + 9.73).
[Table 2] shows the best corrected visual acuity (BCVA) 4 weeks postoperatively using logMAR notation and its relation to the preoperative comorbidity factors. It shows that sixty-six cases (65.1%) had BCVA of 0.30 or better (logMAR notation), and 37 cases (35.9%) had BCVA of 0.48 or less. Four cases (3.9%) had postoperative BCVA of 0.00 (logMAR notation), 29 cases (28.2%) had 0.18, 33 cases (32%) had 0.30, 14 cases (13.6) had 0.48, 17 cases (16.5%) had 0.60, and 6 cases (5.8%) had BCVA 0.80.
|Table 2: Post-operative visual outcome (logMAR notation) and number of cases with preoperative ocular comorbidity in relation to different levels of visual acuity|
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The intraoperative complications developed in five cases. One case developed posterior capsular rupture, and four cases developed zonular dehiscence that was partial <90 degrees in three cases and >180° in one case only.
| Discussion|| |
Many techniques of nuclear disassembly had been described earlier. ,, A technique that is not much different from that used by Koplin et al.  had been used in the current study. The current technique utilizes the advantages of divide and conquers technique while the disadvantages of nucleus rotation are avoided. The use of dispersive OVD to coat the corneal endothelium added a safety factor to the technique which is specifically important in cases with bad corneas as it was the case in this study population.
Also, avoiding nuclear rotation has an added safety as it minimized additional trauma and zonular stress which is also especially important in cases of pseudoexfoliation in which the zonules are already weak and susceptible to zonular dehiscence and dialysis.
An additional safety factor was made possible by the unique combination of efficient torsional phacoemulsification technology in the Infinity machine (Alcon, Inc.), which minimizes repulsion and maintains the nuclear fragments close to the phacoemulsification tip in the center of the pupil, the curved Kelman-style 45° degrees phacoemulsification tip and the small incision with stable anterior chamber due to less wound leakage.
It is shown that the visual outcome in our study revealed that 66 cases (65.1%) had BCVA of 0.30 or better (logMAR notation), and 37 cases (35.9%) had BCVA of 0.48 or less. The cause for that could be attributed to the preoperative comorbidity factors shown in both [Table 1], [Table 2]. In the previous studies of woodlief et al.  and Koplin et al.,  no data were available about the visual outcome. In the study by woodlief et al.  there were variable degrees of lens hardness but no mention about the proportion of each nuclear hardness in the study, in addition no mention also about the preoperative comorbidity factors specifically the corneal status, all these factors contributed to the visual outcome in the current study. In the study by Koplin et al.,  no data were available about the patients' characteristics, preoperative comorbidity or visual outcome and also no mention about the intraoperative complications. The same applies to the article presented by Kim et al. 
The intraoperative complications that had been faced in the current study were not significant especially if we considered that all cases has pseudoexfoliation with already compromised zonules, and also it did not prevent in the bag intraocular lens implantation. The current study intraoperative complications were comparable and less than that reported by Shingleton et al.  They reported a need for vitrectomy in 19.6% of high risk group and 2.0% of non-high risk group with evidences of zonular affection. In another study by Hyams et al., the rate of intraoperative complications in patients with pseudoexfoliation (5.8%) and 4.0% in patients without pseudoexfoliation.  In contrast, the current study there were only a need for vitrectomy in one case (<1.0%) and zonular dehiscence in four cases that needed no vitrectomy. One of the limitation of this study is that it did not include comparative control group of PEX cataracts wherein the conventional surgery with standard nuclear rotation and chopping technique was performed.
| Conclusion|| |
The current technique offers a safe and efficient phacoemulsification without nuclear rotation in cases pseudoexfoliation in which zonular weakness is a concern by utilizing the versatility of Kelman style phaco tip to do lateral sweep sculpting and in situ cracking techniques. It minimized zonular stress by avoiding manipulation or rotation of the nucleus in these cases.
| References|| |
|1.||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;20:115-9. |
|2.||Alfaiate M, Leite E, Mira J, Cunha-Vaz JG. Prevalence and surgical complications of pseudoexfoliation syndrome in Portuguese patients with senile cataract. J Cataract Refract Surg 1996;22:972-6. |
|3.||Moreno J, Duch S, Lajara J. Pseudoexfoliation syndrome: Clinical factors related to capsular rupture in cataract surgery. Acta Ophthalmol (Copenh) 1993;71:181-4. |
|4.||Fine IH, Hoffman RS. Phacoemulsification in the presence of pseudoexfoliation: Challenges and options. J Cataract Refract Surg 1997;23:160-5. |
|5.||Hyams M, Mathalone N, Herskovitz M, Hod Y, Israeli D, Geyer O. Intraoperative complications of phacoemulsification in eyes with and without pseudoexfoliation. J Cataract Refract Surg 2005;31:1002-5. |
|6.||Nagashima RJ. Decreased incidence of capsule complications and vitreous loss during phacoemulsification in eyes with pseudoexfoliation syndrome. J Cataract Refract Surg 2004;30:127-31. |
|7.||Moreno-Montanes J, Rodriguez-Conde R. Capsular tension ring in eyes with pseudoexfoliation. J Cataract Refract Surg 2002;28:2241-2. |
|8.||Tribus C, Alge CS, Haritoglou C, Lackerbauer C, Kampik A, Mueller A, et al. Indications and clinical outcome of capsular tension ring (CTR) implantation: A review of 9528 cataract surgeries. Clin Ophthalmol 2007;1:65-9. |
|9.||Woodlief NF, Woodlief JM. Endocapsular deep-wedge-removal phacofracture. J Cataract Refract Surg 2009;35:1656-8. |
|10.||Koplin RS, Anderson JE, Seedor JA, Ritterband DC. In situ nuclear disassembly: Efficient phacoemulsification without nuclear rotation using lateral sweep sculpting and in situ cracking techniques. J Cataract Refract Surg 2009;35:1487-91. |
|11.||Kim DB. Cross chop: Modified rotationless horizonal chop technique for weak zonules. J Cataract Refract Surg 2009;35:1335-7. |
|12.||Shingleton BJ, Marvin AC, Heier JS, O'Donoghue MW, Laul A, Wolff B, et al. Pseudoexfoliation: High risk factors for zonule weakness and concurrent vitrectomy during phacoemulsification. J Cataract Refract Surg 2010;36:1261-9. |
[Table 1], [Table 2]