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EW CATARACT 34 August 2018 and lets the surgeon retrieve it via the anterior chamber." Management of events if the nucleus has dropped Once the nucleus has dropped, it is a different scenario. Management begins with clearing any vitreous, demarcated with triamcinolone, from the anterior chamber. The sur- geon needs to manage postoperative inflammation and IOP rise. A refer- ral to a vitreoretinal surgeon should be done for a pars plana vitrecto- my. "What you never do is put the phaco probe into the vitreous cavity or even the anterior chamber when vitreous is present to try and remove the fragments of nucleus because you will cause vitreoretinal trac- tion and potentially a retinal tear/ detachment, Dr. Rosen said. "Also, you should not put an infusion fluid into the vitreous cavity in an attempt to flush the fragments out into the anterior chamber. Doing this will risk producing a retinal tear and detachment." The potential problems of a dropped nucleus include corneal failure, uveitis, vitritis, glaucoma, cystoid macular edema, retinal detachment, and endophthalmitis. Before nucleus removal, the surgeon must check IOP and uveitis. The corneal edema should be allowed to clear and dexamethasone taken every 1–2 hours. Surgery to remove the nuclear fragments should be performed within 3 weeks, although Dr. Rosen aims for surgery within 10 days, then considers a secondary IOL. A study on individuals with retained lens fragments who had pars plana vitrectomy showed that earlier surgery results in better visual outcomes. The median interval be- tween cataract surgery and PPV was 12 days. Visual acuity was >20/40 in 29 (9%) patients preoperatively and in 190 (56%) at last follow-up (P<0.001). Visual acuity was <20/200 in 224 patients (66%) preoperatively and in 67 (20%) at last follow-up (P<0.001). 1 A second, unrelated clinical trial corroborated these findings for visual recovery as well as the postoperative risk of uveitis, IOP rise, and retinal detachment. In the study's late vitrectomy group, 66.6% of eyes developed persistent uveitis, 53.3% of eyes showed elevated IOP, and five eyes had retinal detach- ment. In the early PPV group, 16.6% developed uveitis and 20% showed elevated IOP, with only one eye hav- ing retinal detachment. The final visual acuity was 20±50 in early PPV and 20±200 in late PPV group. 2 Should a lens be implanted as a primary procedure? IOL implantation has to be careful- ly considered. Dr. Rosen said, "My view about primary IOL implanta- tion is that you need 240 degrees of capsule, at least, to support a three- piece IOL, otherwise you need to consider using an iris supported or anterior chamber IOL. If there is a significant amount of lens material in the vitreous cavity, and a vitrec- tomy is likely, a lens implant should not be inserted. EW References 1. Scott IU, et al. Clinical features and out- comes of pars plana vitrectomy in patients with retained lens fragments. Ophthalmology. 2003;110:1567–72. 2. Salehi A, et al. Visual outcome of early and late pars plana vitrectomy in patients with dropped nucleus during phacoemulsification. J Res Med Sci. 2011;16:1422–9. Editors' note: Dr. Rosen has no finan- cial interests related to this article. Contact information Rosen: phrosen@rocketmail.com The dropping continued from page 30 Are you a fan of EyeWorld? Find us on Facebook at facebook.com/ EyeWorldMagazine

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