Nucleus managemen: The nucleus was flipped up and rotated with the help of an I.O.L. dialer and subsequently prolapsed into the anterior chamber.3 Viscoelastic is placed both anteriorly and posteriorly.This step is essential to avoid endothelial damage .The nucleus was extracted by following technique. Microvectis or lens loop- This instrument is insunated underneath the nucleus and nucleus was expressed by gently applying forward and backward pressure after injecting viscoelastic into the anterior chamber. Sometimes the epinucleus or portion of the cortex will be sheared off by the anterior lip of the incision without damaging to the endothelium. The remaining portion of cortex can be easily rotated and extracted after injecting viscoelastic,whereas epinucleus which is always soft can be removed by viscoexpulsion or can be aspirated with 0.5 I/A canula.
(i)Nucleus capture (phaco sandwich):: In this technique lens loop or irrigating vectis is placed behind the nucleus and an I.O.L. dialer / sinskey hook is placed anterior to it and by using bimanual technique the nucleus is delivered through the tunnel.
(ii)Phacofracture: The hard nucleus is divided into two with the help of irrigating vectis/ lens loop/nucleus vectis (kansas) which is placed behind the lens and sinskey hook or sharp phaco chopper is used to break the nucleus which were expressed subsequently by either techniques described above.
The cortical remnants were aspirated as usually using simcoe 0.5mm I/A canula. In no case a side port entry was made during these procedures.
I.O.L. Implantation: Viscoelastic material was injected into the capsular bag and in the anterior chamber before I.O.L.implantation. The I.O.Ls used were mainly Eye Of care, Appalens,and IMD lenses with 5.5 to 6.5mm optics and 12.5mm to 13.5 mm overall diameter. In 40 eyes I.O.L.were implanted in the sulcus(image2) and in 60 eyes,implanted in the bag. Viscoelastic was aspirated and anterior chamber was formed either with balanced salt solution or air bubble injected through tunnel itself(image3)
Closing the conjuctval flap: The conjuctival flap was closed with bipolar wet field cautery following subconjuctival injection. The subconjuctival injection constitutes dexamethasone 0.5ml and gentamycin 20 mg, injected into the upper bulbar conjuctive after which eye patching applied with a pad.
Results? In 82% of cases the visual acuity corrected after one month was 6/18 or better. In 8 (8%)cases the best corrected visual acuity was less than or equal to 6/60 because, 4 cases had irreversible corneal oedema and 2 cases had decentred I.O.L. and 2 cases had dense post capsular opacification. Corneal oedema was seen in 10(10%) eyes during early post opertive period.
Complications: The most common complication was endothelial damage in 4 cases.Inferior iridodialysis in 2 cases and cyclodialysis in 3 cases.Hyphema and iritis encountered in 4 and 6 cases respectively. Out of 4 cases of PC rent vitreous loss was seen in three cases,I.O.L. decentred in 2 cases ,one had dislocation of I.O.L. which was explanted during surgery.