|
| |
| CASE REPORT |
|
| Ahead of print publication |
|
|
Trocar blade-assisted skewer technique for phacoemulsification of a dislocated lens
Laura Liu1, Yih-Shiou Hwang2, Wei-Chi Wu2, Chi-Chun Lai3, Jorn-Hon Liu4
1 Department of Ophthalmology, Linkou Medical Center, Chang Gung Memorial Hospital; School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan
2 Department of Ophthalmology, Linkou Medical Center, Chang Gung Memorial Hospital; College of Medicine, Chang Gung University, Taoyuan, Taiwan
3 College of Medicine, Chang Gung University, Taoyuan; Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
4 Department of Ophthalmology, Cheng Hsin General Hospital, Taipei, Taiwan
| Date of Submission | 03-Oct-2022 |
| Date of Acceptance | 05-Jan-2023 |
| Date of Web Publication | 27-Feb-2023 |
Correspondence Address:
Laura Liu,
No. 5, Fu-Hsing Street, Kuei Shan, Taoyuan 333
Taiwan
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/tjo.TJO-D-22-00138
A posteriorly dislocated lens is often managed with a fragmatome through a pars plana approach because it is difficult to manage anteriorly. The lens often sinks to the surface of the retina or floats around in the vitreous cavity during pars plana lensectomy. Mechanical trauma can occur while removing the dislocated lens fragments. However, sometimes the lens can be confined to the anterior vitreous cavity even though the zonules are completely disrupted. It would be ideal if there was a simple way to stabilize and support the lens so that the lens could remain in the posterior chamber while phacoemulsification is performed through a corneal incision as usual. We describe a technique using a trocar blade to stabilize the lens while performing phacoemulsification through a corneal incision. We found it to be a useful and safe instrument to support the subluxated lens during phacoemulsification.
Keywords: Dislocated lens, pars plana vitrectomy, phacoemulsification, surgery, trocar blade
How to cite this URL:
Liu L, Hwang YS, Wu WC, Lai CC, Liu JH. Trocar blade-assisted skewer technique for phacoemulsification of a dislocated lens. Taiwan J Ophthalmol [Epub ahead of print] [cited 2023 Apr 2]. Available from: https://www.e-tjo.org/preprintarticle.asp?id=370660 |
| Introduction | |  |
A dislocated lens is often difficult to access with phacoemulsification even though sometimes it is still confined to the anterior vitreous cavity. It would be ideal if there was a simple way to maintain the lens at the posterior chamber for phacoemulsification. There have been some modified techniques reported in the past to manage a dislocated lens anteriorly. The use of perfluoro-n-octane (PFO) liquid to float a dislocated lens to the pupillary plane for phacoemulsification through cataract incision has been reported by many groups to be a successful approach.[1],[2],[3],[4],[5] This demonstrates that management of a dislocated lens through the anterior approach is feasible. However, the lens floats around due to the lack of a counterforce to stabilize it, which makes lens removal less efficient. Furthermore, it may be difficult to remove the PFO droplets completely at the end of the surgery if the vitreous cannot be completely removed.[6],[7] This may cause some visual disturbance.
Pars plana stabilization of the dislocated lens using a microvitreoretinal (MVR) blade for pars plana lensectomy (PPL) has been proposed in the past.[8],[9] The benefit of this technique is that a counterforce is provided by the blade so that the lens can be stabilized for phacoemulsification. However, this has not been widely used possibly because the MVR blade is long, which carries the risk of intraocular injury while performing PPL. Microincision vitreoretinal surgery (MIVS) uses a trocar blade instead of an MVR blade for creating sclerotomy. We found a trocar blade to be a good alternative to a MVR blade for pars plana stabilization of a dislocated lens for phacoemulsification [Figure 1]. | Figure 1: The trocar blade was directly skewered into the lens to keep it at the pupillary plane for phacoemulsification
Click here to view |
| Case Report | | |
A 70-year-old female with underlying diabetic mellitus and end-stage renal disease was referred due to zonular disruption found during the grooving step in previous cataract surgery in her right eye. Preoperative best-corrected visual acuity was hand motion. Complete zonular disruption was found, which made it difficult to perform routine phacoemulsification [Video 1, Supplemental Digital Content through the link https://youtu.be/kc1OdUyw9Is]. Because the original corneal incision was at the temporal side, to use the same incision for phacoemulsification, a 23 gauge trocar was set at the superonasal for placement of the supporting trocar blade. The trocar blade was then used to directly skewer the nucleus of the lens as much as possible [Figure 2]. A Sinskey hook provided counterforce while the trocar blade punctured through the lens. Phacoemulsification was performed with the lens skewered on the trocar blade. The lens needs to be removed from the peripheral to the center to keep the lens in one piece during the phacoemulsification so that it does not separate into small pieces or fall off the trocar blade. To do so, the lens needs to be rotated periodically to let the distal part of the lens turn to the pupil center and is thus accessible for the phacoemulsification handpiece. Lens rotation can be done simply by twisting the trocar blade. One needs to gradually work toward the area close to the trocar blade. When the last part of the lens is to be removed, withdraw the trocar blade slightly to move the residual lens fragment closer to the tip of the blade for better exposure. While taking out the last piece of the lens, keep the vacuum power on at all times to prevent the last piece from falling into the vitreous cavity. | Figure 2: The trocar blade was directly skewered into the lens while phacoemulsification was performed. The black arrowhead indicates the tip of the trocar blade
Click here to view |
The residual lens fragments that dislocated into the vitreous cavity were taken out through a 1 mm sclerotomy after pars plana vitrectomy (PPV), using the phacoemulsification handpiece with the sleeve removed. Viscoelastic agents were used to maintain the anterior chamber (AC) and protect the corneal endothelium throughout the procedure. No complications were encountered during and after the surgery. Uncorrected visual acuity improved to 20/400 1 week after surgery. However, the patient declined further clinical follow-up and surgical intervention due to her systemic conditions.
| Discussion | | |
We have described a technique using a trocar blade for stabilizing the lens at the pupillary plane for cataract removal through a corneal approach. This technique is particularly useful for a lens that has lost all zonular support but is still confined to the anterior vitreous cavity that is difficult to access under routine cataract surgery settings.
The benefit of using this technique is that the lens can be stabilized for phacoemulsification without it floating around in the vitreous cavity, thus, potentially less time and effort is required to pursue the lens and there is less chance of retinal injury.[10],[11] In addition, there is a better chance that the sclerotomies can remain as microincisions because the small fragments of the lens that dislocated onto the surface of the retina during phacoemulsification can sometimes be removed simply with a small-gauge vitrector. The benefit of keeping the MIVS is that the vitreous around the sclerotomies is trocar protected and thus lowers the risk of iatrogenic retinal injuries.[12],[13] However, in our case, the lens fragments eventually dislocated into the vitreous cavity requiring PPL. This was due to the grooving done during previous surgery, causing part of the lens to fracture during phacoemulsification. We found that it is critical to begin the phacoemulsification beginning from the distal point to where the lens is skewered and not to attempt to divide the lens into fragments. This can be done by twisting the trocar blade periodically during the phacoemulsification process to rotate the distal part of the lens to turn into the pupil area, thus being accessible for the phacoemulsification handpiece. Take out the lens from the peripheral first and then gradually toward the trocar blade.
There are some advantages of using the trocar blade as a support for the lens. First, the technique is easy and intuitive. The lens is skewered onto the trocar blade with a little assistance from a Sinskey hook providing a counterforce. Second, it is safe to use. The built-in stopper of the blade prevents the blade from going further into the eye. It is very unlikely to cause any intraocular damage as long as the tip of the blade is kept pointed toward the center of the pupil.[14] Third, the trocar blade is readily available in a standard vitrectomy pack. There is no need to purchase a new instrument. The 23 gauge trocar system is the one we use in this case. However, we think that smaller gauge systems would work similarly because trocar blades are made with the same length.
A critical point to successfully and safely utilize this lens-support technique is that the vitreous that has herniated into the anterior segment must be removed before lens removal. It is critical to prevent retinal breaks caused by vitreous traction during phacoemulsification, so herniated vitreous must be removed with a vitrector before phacoemulsification. However, complete PPV can be performed right before pars plana removal of the posteriorly dislocated lens fragment. We found this to be a feasible strategy.
The limitation of the trocar blade-assisted skewer technique includes first, it is not possible to skewer a lens that has fallen deep into the vitreous cavity. Because the length of the trocar blade is short, it is not possible to reach a lens that is too far from the anterior vitreous cavity. Second, it is not possible to skewer a very soft lens, because a soft lens does not create sufficient friction between the lens and the blade. However, a soft lens can likely be removed with a pure aspiration of a phacoemulsification handpiece or vitreous cutter. In this case, the lens is unlikely to float around once the instrument engages the lens and can be removed efficiently. Third, the technique cannot be used if the plan of the surgery is to rescue the capsular bag by tension ring and/or tension ring segments. The technique is based on skewering the nucleus of the lens so the posterior capsule will be punctured during the skewering process. There is no intention of keeping the capsular bag. In such a case, an alternative technique such as the use of capsular tension hooks for maintaining the lens at the pupillary plane might be more feasible.
We found using a trocar blade to assist phacoemulsification to be a helpful, simple, and safe technique in the management of a dislocated lens.
Declaration of patient consent and ethical approval
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
This report does not contain any personal information that could lead to the identification of the patient. This study was approved by the Institutional Review Board of Chang Gung Memorial Hospital, Taoyuan, Taiwan (Approval number: 2101220033).
Acknowledgments
We would like to thank Ping-hung Lin for Medical illustration.
Financial support and sponsorship
Nil.
Conflicts of interest
Dr. Yih-Shiou Hwang and Dr. Chi-Chun Lai, editorial board members at Taiwan Journal of Ophthalmology, had no roles in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
| References | | |
| 1. | Millar ER, Steel DH. Small-gauge transconjunctival vitrectomy with phacoemulsification in the pupillary plane of dense retained lens matter on perfluorocarbon liquids after complicated cataract surgery. Graefes Arch Clin Exp Ophthalmol 2013;251:1757-62.  |
| 2. | Yoshida K, Kiryu J, Kita M, Ogura Y. Phacoemulsification of dislocated lens and suture fixation of intraocular lens using a perfluorocarbon liquid. Jpn J Ophthalmol 1998;42:471-5. |
| 3. | Watanabe A, Gekka T, Tsuneoka H. Treatment of a dislocated lens by transcorneal vitrectomy and bimanual phacoemulsification. Clin Ophthalmol 2014;8:1539-42. |
| 4. | Tzamalis A, Symeonidis C, Brazitikou IP, Tzetzi D, Chalvatzis N, Androudi S, et al. Sutureless clear corneal ultrasonic fragmentation for retained lens fragments: A pilot study. Retina 2017;37:494-9. |
| 5. | Yi QY, Huang J, Chen N, Li WD, Chen LS, Wang YY, et al. Managing dislocated hard lens nuclei: 23-gauge vitrectomy and lens extraction via a corneoscleral limbal incision versus 23-gauge vitrectomy and phacofragmentation. J Cataract Refract Surg 2019;45:451-6. |
| 6. | Scott IU, Murray TG, Flynn HW Jr., Smiddy WE, Feuer WJ, Schiffman JC. Outcomes and complications associated with perfluoro-n-octane and perfluoroperhydrophenanthrene in complex retinal detachment repair. Ophthalmology 2000;107:860-5. |
| 7. | Yoo JH, Nam KY, Lee SU, Lee JE, Lee SJ. Complications caused by perfluorocarbon liquid used in pars plana vitrectomy. KMJ 2015;30:123-30. |
| 8. | Braunstein RA. The skewer technique for removal of the dislocated lens. Retina 1995;15:264-5. |
| 9. | Yata K, Tanikawa A, Hori K, Nakamura A, Yamada H, Horiguchi M. Intravitreal bimanual surgery for residual lens fragments and displaced crystalline lenses. Ophthalmic Surg Lasers Imaging 2009;40:331-5. |
| 10. | Garg SJ, Lane RG. Pars plana torsional phacoemulsification for removal of retained lens material during pars plana vitrectomy. Retina 2011;31:804-5. |
| 11. | Chiang A, Garg SJ, Spirn MJ, Hsu J, Lane RG, Regillo CD, et al. Removal of posterior segment retained lens material using the OZil torsional phacoemulsification handpiece during pars plana vitrectomy. Invest Ophthalmol Vis Sci 2011;52:6114. |
| 12. | Neffendorf JE, Gupta B, Williamson TH. Intraoperative complications of patients undergoing small-gauge and 20-gauge vitrectomy: A database study of 4,274 procedures. Eur J Ophthalmol 2017;27:226-30. |
| 13. | Chen GH, Tzekov R, Jiang FZ, Mao SH, Tong YH, Li WS. Iatrogenic retinal breaks and postoperative retinal detachments in microincision vitrectomy surgery compared with conventional 20-gauge vitrectomy: A meta-analysis. Eye (Lond) 2019;33:785-95. |
| 14. | Liu L, Wang NK, Chen YP, Chen KJ, Chou HD, Yu-Chuan Kang E, et al. Trocar blade-assisted scleral fixation for an incomplete dislocated intraocular lens. J Cataract Refract Surg 2021;47:e40-3. |
[Figure 1], [Figure 2]
|
