Nucleus Extraction Techniques Dr. Navin Gupta Shankar Netrika Eye Hospital, Mumbai
Nucleus Extraction • Irrigating vectis technique • Phacosandwich technique • Phacofracture technique • Modified bluementhal technique • Fish hook technique
Irrigating Vectis • Time tested technique • Most commonly used in SICS. • Vectis 4 mm width 8 mm length. • Ant surface has slight concave • Ant end has 3 small irrigating ports, 0.3 mm. • Post end attached to syringe
Surgical technique • Visco injected liberally first above n then below nucleus. • Vectis inserted under nucleus. • SR suture pulled tight, vectis withdrawn without irrigating till upper pole of nucleus engaged in tunnel. Irrigation started, vectis slowly withdrawn pressing post scleral lip.
Advantages • Single instrument • AC remains formed • Tunnel wall takes up the brunt of trauma. Endothelium spared.
Disadvantages • Risk of iridodialysis • PC rent • Endothelial damage if visco not enough. • Crushing of inferior iris
Phacosandwich technique • Uses vectis (solid or irrigating) n Sinskey hook • Visco injected above n below nucleus. • Vectis inserted below nucleus • Sinskey hook inserted carefully above with dominant hand. • Nucleus sandwitched. • Assistant pulls SR and globe inferiorly
At the same time. • In this process, epinucles n portion of cortex gets sheared off. • Many prefer to express the epinucleus with visco injection followed by thorrough cortical wash.
Complications • Breaking up of nucleus • Inferior irididialysis • DM strippin while introducing Sinskey into already crowded AC
Phacofracture technique • Bisector technique • Trisector technique • Phacofracture at the exit • Wire-loop technique • Phacosalute n fracture • Used in soft n mod hard cats • Nucleus is fragmented in AC
Bisector technique • Solid bisector inserted beneath nucleus • Bisector carefully introduced above. • Both moved towards each other gently till the bisector cleaves its way through nucleus towards vectis • Two halves seperated and brought out using sandwitch technique
Trisector technique • Trisector has a tip with 2 long limbs sharpened inferiorly. • Solid vectis inserted below nucleus. Trisector passed over nucleus. Trisector pressed down, cuttin the nucleus into 3 pieces.
Phacofracture at exit • With the help of irrigating vectis, nucleus is expressed. Half way through at the exit it is fractured. Other half pushed back into AC with visco, realigned and then extracted with irrigating vectis.
Wire-loop technique • Nuclear snare is used made from 32 gauge stainless steel wire. • Wire loop positioned around nucleus, loop is shortened n it cheesewires through nucleus. Thus nucleus is divided into 2. Each piece is delivered with forceps
Phacosalute n fracture • Not practised here. • Nucleus aligned vertically and superior portion then amputed or pinched off usin capsule forceps.
Modified Bluementhal • Uses AC maintainer throughout. Hollow tube of 0.9 diameter. Attached to BSS bottle suspended 60 cms above pts eye. Plastic glide 3 mm wide, 0.3 mm thick n 3 cms long inserted under the nucleus, half way through. Bottle height raised. Pressure applied on the scleral side of glide. Intermittent taps will push out the nucleus.
Fish Hook Technique • 30 G needle is bent in the form of fish hook n used fro extraction. • Envelope capsulotomy done. • Upper pole of nucleus brought in to AC. • Fish hook is entered into AC, manoeuvred under the nucleus and nucleus is hooked. • Nucleus is slided out by applyin slight pressure on post lip of tunnel.