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Inside-out delineation
Inside-out delineation Abhay R. Vasavada, MS, FRCS, Shetal M. Raj, MS A technique of achieving precise hydrodelineation, in which fluid is injected from the inside of the nucleus to the outside, is described. The desired thickness of the nucleus–epinucleus bowl can be accomplished because the right-angled cannula can direct the fluid in the desired plane. This technique is useful in eyes with posterior polar cataracts and in eyes with dense cataracts in which aggressive phacoparameters are necessary for their removal. J Cataract Refract Surg 2004; 30:1167–1169 2004 ASCRS and ESCRS
T
he recommended surgical strategy for phacoemulsification in eyes with a posterior polar cataract is to avoid corticocleaving hydrodissection.1–4 Instead, conventional hydrodelineation is performed.2,4–6 With the latter, there is a possibility of fluid being injected inadvertently into the subcapsular plane, leading to unwarranted hydrodissection. We propose a technique, inside-out delineation, to precisely delineate the central core nucleus.
Surgical Technique After continuous curvilinear capsulorhexis, a hydroprocedure is avoided. A central trench is sculpted with walls on the left and right sides. A specially designed right-angled cannula is mounted on a 1 cc syringe filled with fluid. The cannula penetrates the central lens substance through the right wall of the trench. The fluid is then injected rapidly. A delineation is produced by the fluid, which traverses from inside to outside. The plane of injection is decided, depending on the density of the cataract. Because this is done under direct vision, a desired thickness of nucleus–epinucleus cushion can
Accepted for publication October 8, 2003. From the Iladevi Cataract and IOL Research Centre, Ahmedabad, India. I. Howard Fine, MD, reviewed the manuscript. Reprint requests to Abhay R. Vasavada, MS, FRCS, Iladevi Cataract and IOL Research Centre, Gurukul Road, Memnagar, Ahmedabad 380 052, India. E-mail: [email protected]. 2004 ASCRS and ESCRS Published by Elsevier Inc.
be achieved. A golden ring within the lens is evidence of successful delineation (Figure 1). Fluid injection can be repeated in the left wall of the trench with another right-angled cannula. The central nucleus can be consumed within the nucleus–epinucleus bowl using any technique with which the surgeon is proficient. Nevertheless, techniques that avoid rotation of the nucleus and do not transmit stress to the capsular bag during separation of the nucleus are preferred. Depending on the density of the cataract, the slow-motion technique7 or the step-by-step chop in situ and lateral separation technique is preferred.8
Discussion In this technique, delineation is produced by injecting fluid from the central core of the nucleus to the outside, unlike in the conventional technique, in which fluid is injected from the outside to the inside. With the latter, there is a possibility of inadvertent subcapsular injection in an attempt to delineate. This can lead to posterior capsule rupture. With our technique, the surgeon has the option of injecting fluid into the desired plane for cleaving the nucleus with precision. Moreover, because this is done under direct vision, it provides superior control. This is particularly important for emulsification of posterior polar cataracts (Figure 2). With the right-angled cannula, the fluid jet is directed perpendicular to the lens fibers, and this cleaves the fibers more effectively against the curved cannula (Figure 3). Multilamellar hydrodissection9 separates 0886-3350/04/$–see front matter doi:10.1016/j.jcrs.2003.10.034
TECHNIQUES: VASAVADA
Figure 2. (Vasavada) In posterior polar cataracts, the intralenticular delineation is precise with the inside-out technique.
Figure 1. (Vasavada) The right-angled cannula is introduced in the central lens substance after sculpting. The golden ring indicates the endpoint of inside-out delineation.
multiple sheets of cortex. With the inside-out delineation, it is possible to produce more than 1 cleavage plane (Figure 4) by injecting fluid at various depths into the wall of the trench. We used this technique in 25 consecutive eyes with a typical posterior polar defect. The incidence of posterior capsule rupture was 8% (2 of 25). Moreover, with a conventional technique of delin-
eation in a dense cataract, it is difficult to introduce the cannula to a significant depth to achieve a thick epinucleus bowl/cushion. It can be accomplished with less difficulty by using the inside-out technique. The resulting thick nucleus–epinucleus bowl gives additional safety in these cataracts in which aggressive phacoparameters are necessary for their removal. Although we have not used this technique to remove subluxated cataracts, we believe it can be safely used in subluxated cataracts with a dense nucleus. Similarly, this technique has potential for emulsification of traumatic cataracts with prexisting posterior capsule rupture.
Figure 3. (Vasavada) Photomicrographs comparing the direction of the fluid jet within the lens substance with the 2 cannulas. A: The jet of fluid with a right-angled cannula is effective because it is perpendicular to the lens fibers. B: With the curved cannula, the fluid jet is tangential to the lens fibers and is thus imprecise and not as effective.
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tion, which allows the surgeon to precisely delineate the nucleus of a desirable size at desirable depths.
References
Figure 4. (Vasavada) Multiple golden rings are evidence of multiple cleavage planes, which are achieved by injection of fluid at various depths in the wall of the trench.
The limitation of this technique is that sculpting is a prerequisite for its implementation. In essence, this technique is intralenticular delinea-
1. Fine IH. Cortical cleaving hydrodissection. J Cataract Refract Surg 1992; 18:508–512 2. Fine IH, Packer M, Hoffman RS. Management of posterior polar cataract. J Cataract Refract Surg 2003; 29:16–19 3. Osher RH, Yu BC-Y, Koch DD. Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture. J Cataract Refract Surg 1990; 16:157–162 4. Vasavada AR, Singh R. Phacoemulsification in eyes with posterior polar cataract. J Cataract Refract Surg 1999; 25:238–245 5. Hayashi K, Hayashi H, Nakao F, Hayashi F. Outcomes of surgery for posterior polar cataract. J Cataract Refract Surg 2003; 29:45–49 6. Allen D, Wood C. Minimizing risk to the capsule during surgery for posterior polar cataract. J Cataract Refract Surg 2002; 28:742–744 7. Osher RH. Slow motion phacoemulsification approach [letter]. J Cataract Refract Surg 1993; 19:667 8. Vasavada AR, Singh R. Step-by-step chop in situ and lateral separation of very dense cataracts. J Cataract Refract Surg 1998; 24:156–159 9. Kock DD, Liu JF. Multilamellar hydrodissection in phacoemulsification and planned extracapsular surgery. J Cataract Refract Surg 1990; 16:559–562
J CATARACT REFRACT SURG—VOL 30, JUNE 2004
1169
T
he recommended surgical strategy for phacoemulsification in eyes with a posterior polar cataract is to avoid corticocleaving hydrodissection.1–4 Instead, conventional hydrodelineation is performed.2,4–6 With the latter, there is a possibility of fluid being injected inadvertently into the subcapsular plane, leading to unwarranted hydrodissection. We propose a technique, inside-out delineation, to precisely delineate the central core nucleus.
Surgical Technique After continuous curvilinear capsulorhexis, a hydroprocedure is avoided. A central trench is sculpted with walls on the left and right sides. A specially designed right-angled cannula is mounted on a 1 cc syringe filled with fluid. The cannula penetrates the central lens substance through the right wall of the trench. The fluid is then injected rapidly. A delineation is produced by the fluid, which traverses from inside to outside. The plane of injection is decided, depending on the density of the cataract. Because this is done under direct vision, a desired thickness of nucleus–epinucleus cushion can
Accepted for publication October 8, 2003. From the Iladevi Cataract and IOL Research Centre, Ahmedabad, India. I. Howard Fine, MD, reviewed the manuscript. Reprint requests to Abhay R. Vasavada, MS, FRCS, Iladevi Cataract and IOL Research Centre, Gurukul Road, Memnagar, Ahmedabad 380 052, India. E-mail: [email protected]. 2004 ASCRS and ESCRS Published by Elsevier Inc.
be achieved. A golden ring within the lens is evidence of successful delineation (Figure 1). Fluid injection can be repeated in the left wall of the trench with another right-angled cannula. The central nucleus can be consumed within the nucleus–epinucleus bowl using any technique with which the surgeon is proficient. Nevertheless, techniques that avoid rotation of the nucleus and do not transmit stress to the capsular bag during separation of the nucleus are preferred. Depending on the density of the cataract, the slow-motion technique7 or the step-by-step chop in situ and lateral separation technique is preferred.8
Discussion In this technique, delineation is produced by injecting fluid from the central core of the nucleus to the outside, unlike in the conventional technique, in which fluid is injected from the outside to the inside. With the latter, there is a possibility of inadvertent subcapsular injection in an attempt to delineate. This can lead to posterior capsule rupture. With our technique, the surgeon has the option of injecting fluid into the desired plane for cleaving the nucleus with precision. Moreover, because this is done under direct vision, it provides superior control. This is particularly important for emulsification of posterior polar cataracts (Figure 2). With the right-angled cannula, the fluid jet is directed perpendicular to the lens fibers, and this cleaves the fibers more effectively against the curved cannula (Figure 3). Multilamellar hydrodissection9 separates 0886-3350/04/$–see front matter doi:10.1016/j.jcrs.2003.10.034
TECHNIQUES: VASAVADA
Figure 2. (Vasavada) In posterior polar cataracts, the intralenticular delineation is precise with the inside-out technique.
Figure 1. (Vasavada) The right-angled cannula is introduced in the central lens substance after sculpting. The golden ring indicates the endpoint of inside-out delineation.
multiple sheets of cortex. With the inside-out delineation, it is possible to produce more than 1 cleavage plane (Figure 4) by injecting fluid at various depths into the wall of the trench. We used this technique in 25 consecutive eyes with a typical posterior polar defect. The incidence of posterior capsule rupture was 8% (2 of 25). Moreover, with a conventional technique of delin-
eation in a dense cataract, it is difficult to introduce the cannula to a significant depth to achieve a thick epinucleus bowl/cushion. It can be accomplished with less difficulty by using the inside-out technique. The resulting thick nucleus–epinucleus bowl gives additional safety in these cataracts in which aggressive phacoparameters are necessary for their removal. Although we have not used this technique to remove subluxated cataracts, we believe it can be safely used in subluxated cataracts with a dense nucleus. Similarly, this technique has potential for emulsification of traumatic cataracts with prexisting posterior capsule rupture.
Figure 3. (Vasavada) Photomicrographs comparing the direction of the fluid jet within the lens substance with the 2 cannulas. A: The jet of fluid with a right-angled cannula is effective because it is perpendicular to the lens fibers. B: With the curved cannula, the fluid jet is tangential to the lens fibers and is thus imprecise and not as effective.
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J CATARACT REFRACT SURG—VOL 30, JUNE 2004
TECHNIQUES: VASAVADA
tion, which allows the surgeon to precisely delineate the nucleus of a desirable size at desirable depths.
References
Figure 4. (Vasavada) Multiple golden rings are evidence of multiple cleavage planes, which are achieved by injection of fluid at various depths in the wall of the trench.
The limitation of this technique is that sculpting is a prerequisite for its implementation. In essence, this technique is intralenticular delinea-
1. Fine IH. Cortical cleaving hydrodissection. J Cataract Refract Surg 1992; 18:508–512 2. Fine IH, Packer M, Hoffman RS. Management of posterior polar cataract. J Cataract Refract Surg 2003; 29:16–19 3. Osher RH, Yu BC-Y, Koch DD. Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture. J Cataract Refract Surg 1990; 16:157–162 4. Vasavada AR, Singh R. Phacoemulsification in eyes with posterior polar cataract. J Cataract Refract Surg 1999; 25:238–245 5. Hayashi K, Hayashi H, Nakao F, Hayashi F. Outcomes of surgery for posterior polar cataract. J Cataract Refract Surg 2003; 29:45–49 6. Allen D, Wood C. Minimizing risk to the capsule during surgery for posterior polar cataract. J Cataract Refract Surg 2002; 28:742–744 7. Osher RH. Slow motion phacoemulsification approach [letter]. J Cataract Refract Surg 1993; 19:667 8. Vasavada AR, Singh R. Step-by-step chop in situ and lateral separation of very dense cataracts. J Cataract Refract Surg 1998; 24:156–159 9. Kock DD, Liu JF. Multilamellar hydrodissection in phacoemulsification and planned extracapsular surgery. J Cataract Refract Surg 1990; 16:559–562
J CATARACT REFRACT SURG—VOL 30, JUNE 2004
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