Nucleus Nucleus Extraction Extraction TechniquesTechniques

Dr. Navin GuptaDr. Navin Gupta

Shankar Netrika Eye Shankar Netrika Eye Hospital, Mumbai Hospital, Mumbai

Nucleus ExtractionNucleus Extraction

Irrigating vectis techniqueIrrigating vectis technique Phacosandwich techniquePhacosandwich technique Phacofracture techniquePhacofracture technique Modified bluementhal techniqueModified bluementhal technique Fish hook techniqueFish hook technique

Irrigating VectisIrrigating Vectis

Time tested techniqueTime tested technique Most commonly used in SICS.Most commonly used in SICS. Vectis 4 mm width 8 mm length.Vectis 4 mm width 8 mm length. Ant surface has slight concaveAnt surface has slight concave Ant end has 3 small irrigating ports, Ant end has 3 small irrigating ports,

0.3 mm.0.3 mm. Post end attached to syringe Post end attached to syringe

Surgical techniqueSurgical technique

Visco injected liberally first above n Visco injected liberally first above n then below nucleus.then below nucleus.

Vectis inserted under nucleus.Vectis inserted under nucleus. SR suture pulled tight, vectis SR suture pulled tight, vectis

withdrawn without irrigating till withdrawn without irrigating till upper pole of nucleus engaged in upper pole of nucleus engaged in tunnel. Irrigation started, vectis tunnel. Irrigation started, vectis slowly withdrawn pressing post slowly withdrawn pressing post scleral lip. scleral lip.

AdvantagesAdvantages

Single instrumentSingle instrument AC remains formedAC remains formed Tunnel wall takes up the brunt of Tunnel wall takes up the brunt of

trauma. Endothelium spared.trauma. Endothelium spared.

DisadvantagesDisadvantages

Risk of iridodialysisRisk of iridodialysis PC rentPC rent Endothelial damage if visco not Endothelial damage if visco not

enough.enough. Crushing of inferior irisCrushing of inferior iris

Phacosandwich Phacosandwich techniquetechnique

Uses vectis (solid or irrigating) n Uses vectis (solid or irrigating) n Sinskey hookSinskey hook

Visco injected above n below nucleus.Visco injected above n below nucleus. Vectis inserted below nucleusVectis inserted below nucleus Sinskey hook inserted carefully above Sinskey hook inserted carefully above

with dominant hand.with dominant hand. Nucleus sandwitched.Nucleus sandwitched. Assistant pulls SR and globe inferiorlyAssistant pulls SR and globe inferiorly

At the same time.At the same time. In this process, epinucles n In this process, epinucles n

portion of cortex gets sheared portion of cortex gets sheared off.off.

Many prefer to express the Many prefer to express the epinucleus with visco injection epinucleus with visco injection followed by thorrough cortical followed by thorrough cortical wash. wash.

ComplicationsComplications

Breaking up of nucleusBreaking up of nucleus Inferior irididialysisInferior irididialysis DM strippin while DM strippin while

introducing Sinskey into introducing Sinskey into already crowded ACalready crowded AC

Phacofracture techniquePhacofracture technique

Bisector techniqueBisector technique Trisector techniqueTrisector technique Phacofracture at the exitPhacofracture at the exit Wire-loop techniqueWire-loop technique Phacosalute n fracture Phacosalute n fracture Used in soft n mod hard catsUsed in soft n mod hard cats Nucleus is fragmented in AC Nucleus is fragmented in AC

Bisector techniqueBisector technique

Solid bisector inserted beneath Solid bisector inserted beneath nucleusnucleus

Bisector carefully introduced above.Bisector carefully introduced above. Both moved towards each other Both moved towards each other

gently till the bisector cleaves its gently till the bisector cleaves its way through nucleus towards vectisway through nucleus towards vectis

Two halves seperated and brought Two halves seperated and brought out using sandwitch techniqueout using sandwitch technique

Trisector techniqueTrisector technique

Trisector has a tip with 2 long limbs Trisector has a tip with 2 long limbs sharpened inferiorly.sharpened inferiorly.

Solid vectis inserted below nucleus. Solid vectis inserted below nucleus. Trisector passed over nucleus. Trisector passed over nucleus. Trisector pressed down, cuttin the Trisector pressed down, cuttin the nucleus into 3 pieces. nucleus into 3 pieces.

Phacofracture at exitPhacofracture at exit

With the help of irrigating vectis, With the help of irrigating vectis, nucleus is expressed. Half way nucleus is expressed. Half way through at the exit it is fractured. through at the exit it is fractured. Other half pushed back into AC with Other half pushed back into AC with visco, realigned and then extracted visco, realigned and then extracted with irrigating vectis.with irrigating vectis.

Wire-loop techniqueWire-loop technique

Nuclear snare is used made from 32 Nuclear snare is used made from 32 gauge stainless steel wire.gauge stainless steel wire.

Wire loop positioned around Wire loop positioned around nucleus, loop is shortened n it nucleus, loop is shortened n it cheesewires through nucleus. Thus cheesewires through nucleus. Thus nucleus is divided into 2. Each piece nucleus is divided into 2. Each piece is delivered with forcepsis delivered with forceps

Phacosalute n fracturePhacosalute n fracture

Not practised here.Not practised here. Nucleus aligned vertically and Nucleus aligned vertically and

superior portion then amputed or superior portion then amputed or pinched off usin capsule forceps.pinched off usin capsule forceps.

Modified Bluementhal Modified Bluementhal

Uses AC maintainer throughout. Uses AC maintainer throughout. Hollow tube of 0.9 diameter. Attached Hollow tube of 0.9 diameter. Attached to BSS bottle suspended 60 cms above to BSS bottle suspended 60 cms above pts eye. Plastic glide 3 mm wide, 0.3 pts eye. Plastic glide 3 mm wide, 0.3 mm thick n 3 cms long inserted under mm thick n 3 cms long inserted under the nucleus, half way through. Bottle the nucleus, half way through. Bottle height raised. Pressure applied on the height raised. Pressure applied on the scleral side of glide. Intermittent taps scleral side of glide. Intermittent taps will push out the nucleus.will push out the nucleus.

Modified bluementhalModified bluementhal

Fish Hook TechniqueFish Hook Technique

30 G needle is bent in the form of fish 30 G needle is bent in the form of fish hook n used fro extraction.hook n used fro extraction.

Envelope capsulotomy done.Envelope capsulotomy done. Upper pole of nucleus brought in to AC.Upper pole of nucleus brought in to AC. Fish hook is entered into AC, Fish hook is entered into AC,

manoeuvred under the nucleus and manoeuvred under the nucleus and nucleus is hooked.nucleus is hooked.

Nucleus is slided out by applyin slight Nucleus is slided out by applyin slight pressure on post lip of tunnel.pressure on post lip of tunnel.