Chopstick technique for nucleus prolapse in cases of hypermature cataract during manual small-incision cataract surgery.

Abstract

Dear Editor, We read an interesting article by Anand et al.[1] on the fish hook technique for nucleus management in manual small-incision cataract surgery (MSICS), and we must congratulate the authors for bringing out this important overview. Nucleus prolapse and delivery techniques in MSICS have undergone continued transformations and innovations to make the steps easier and less cumbersome with good intraoperative and postoperative outcome. Here, the authors, having performed nearly 50,000 MSICS combinedly, want to share their important technique of nucleus prolapse in hypermature cataract cases during MSICS. Since the nucleus is mobile in hypermature cataract cases, this technique is very handy in preventing intraoperative complications in a difficult scenario. In this technique, the eye is dilated with tropicamide 0.8% and phenylephrine 5% and blocked under sub-tenon’s anesthesia (2% plain lignocaine with 150 IU hyaluronidase). Conventional MSICS is performed through a superior sclerocorneal tunnel.[2] After putting the superior rectus bridle suture (4-0 silk) and clamping the suture, conjunctival peritomy is performed from 10 o′ clock to 1 o′ clock to expose the base sclera. The peritomy is fashioned using conjunctival scissors (Surtex®McPherson-Westcott) and forceps. This is followed by cauterization of the superficial conjunctival plexus using a bipolar cautery with vertical strokes. Approximately 1.5 mm behind the limbus, a partial-thickness scleral incision is made at about one-third of the scleral thickness. A 6.5–7 mm linear incision is fashioned behind the blue–white junction. Further, the sclerocorneal tunnel is formed with a sharp crescent blade. Approximately 45° angled sclerocorneal pockets are made on both ends of the incision to facilitate nucleus delivery. Next, a clear corneal side-port incision is made at 8 o′ clock with a 15° blade. This is followed by instillation of 0.1 ml dilute adrenaline, air bubble with 0.1 mm trypan blue (0.06%) to stain the anterior capsule, anterior chamber is washed with balanced salt solution (BSS), and the instillation of viscoelastic hydroxypropyl methylcellulose (2% HPMC) in that order. Next, the anterior chamber entry is made using a 2.8-mm beveled down keratome, and the corneal entry is made till the limbus to prevent nucleus engagement in the tunnel. In the next step, the anterior lens capsule is first punctured in the center using a bent 26 G needle (cystitome) to drain the milky cortex. The cortex is drained by pushing a controlled jet of BSS with a 5-ml syringe. Next, the viscoelastic is put, and the rhexis is performed using Utrata’s forceps. In the case of phacodonesis, capsular wrinkling while starting rhexis, and suspected zonular weakness, we either used the can opener capsulotomy or envelope technique to expose the nucleus. In small pupil and pseudoexfoliation cases, we either perform multiple sphincterotomies or use the stretch pupilloplasty technique.[3] After completing the rhexis, the bag is again filled with viscoelastic using the sinkey hook and iris spatula; the nucleus is prolapsed out from the capsular bag in a chopstick fashion. The blunt iris spatula is placed below the nucleus abutting the posterior capsule using the nondominant hand, and the sinskey hook is placed above the nucleus using the dominant hand. This step mimics the chopstick used by the Chinese community for eating food, hence we named this the chopstick technique [Fig. 1]. After prolapsing the nucleus in the anterior chamber, the nucleus extraction is performed either by viscoexpression or by using irrigating wire Vectis. Next, a thorough cortical wash is performed and a polymethylmethacrylate (PMMA) single-piece intraocular lens is implanted in the capsular bag. This is followed by anterior chamber formation, closure of peritomy, and instillation of 0.1 ml intracameral moxifloxacin. We did a three-piece intraocular lens (IOL) implantation in the sulcus in cases with a can opener and envelope capsulotomy.Figure 1: (a and b) Digital images depicting nucleus being wheeled out of the capsular by the chopstick technique using an iris spatula in the nondominant hand and sinskey in the dominant hand. (c and d) Digital schematic image of the eye depicting nucleus being prolapsed with the help of the chopstick techniqueFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.