Eyeworld

May 2011 by Matt Young EyeWorld Contributing Editor Phacoemulsification sleeve frequently overlooked prior to use A lthough clinical staff must examine surgical instru- mentation before use, a re- cent report recommends taking time to explore one element that tends to be overlooked: the phacoemulsification sleeve. "In addition to examining the ir- rigation and aspiration of the pha- coemulsification probe, we recommend sparing a few seconds to inspect the phacoemulsification sleeve for leaks or cracks," according to the study, published online in No- vember 2010 in BMC Ophthalmology. The phacoemulsification sleeve "tends to be overlooked due to its complementary nature," the report noted. In the report, a sleeve fracture led to the distal portion remaining inside the anterior chamber upon re- moval of the phacoemulsification probe. What happened? During the case, surgery was per- formed in the left eye of a 58-year- old woman with grade II nuclear sclerosis and grade I cortical cataract. "Towards the end of segment re- moval, the anterior chamber (AC) was noted to be unstable," reported lead study author Jennifer W.H. Shum, M.B.B.S., ophthalmology de- partment, United Christian Hospital, Hong Kong. "The followability and aspiration of nuclear fragments also appeared to be impaired. There was a sudden backflow of balanced salt solution emerging from the corneal incision. The AC was still formed at this stage. The surgeon then at- tempted to withdraw the pha- coemulsification probe out of the incision." There was resistance to with- drawal, however, as the sleeve was jammed against the cornea. "This resistance suddenly gave way upon increased traction with re- sultant severance of the silicone probe sleeve, the distal part of which remained inside the anterior cham- ber," Dr. Shum reported. A surgeon recovered the frag- ment by first using an OVD to re- form the anterior chamber. The retained sleeve was then retrieved with forceps through the corneal in- cision. The incision did not need to be widened. No additional smaller sleeve fragments were found in the ante- rior chamber. The incision was closed with a suture and the patient had uneventful recovery, improving to 20/25 in her left eye at 3 months post-op. Likely causes Dr. Shum suggested that a small par- tial-circumferential fracture of the phacoemulsification sleeve was probably present before surgery. Sur- gical stress likely extended the frac- ture. "This explains the smooth inser- tion of the probe on commence- ment of surgery, and the uneventful chopping," Dr. Shum reported. "At some point, the fracture size was sig- nificant enough as to impair the structural turgidity of the sleeve. We believe that the fractured distal part of the sleeve was jammed in the in- cision. Since the sleeve was elastic, it was possible that the distal part of the sleeve was still in the AC and the break was exposed outside of the in- cision. This could explain the initial backflow of [balanced salt solu- tion]." As the phacoemulsification probe was withdrawn, complete sev- erance of the sleeve occurred. Dr. Shum was unaware as to how the fracture occurred, but sus- pected it was either something re- lated to the manufacturing process or induced trauma when the pha- coemulsification sleeve was applied to the probe by the scrub nurse. "We therefore advise careful in- spection of all instruments before in- troducing them into the eye," Dr. Shum concluded. In the event that sleeve fracture 672062PI_2_23x12_5.pgs - Thu Feb 10 11:21:06 PST 2011 Last summer, Dr. Johansson's office noticed a problem with the phacoemulsification equipment when preparing for a coaxial micro-incision surgery. The operation staff observed that the protection chamber and one silicone sleeve were firmly attached to each other inside the package. The very thin silicone sleeve could have been easily damaged during handling and separation of the two items. In this case, the equipment was exchanged completely, and the observation was reported to the manufacturer. The surgery was uneventful Source: Bjorn Johansson, M.D. continued on page 26

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