Retained Nuclear Fragments

We read with interest the brief communication on a nuclear fragment in the scleral tunnel1 and would like to report our experience with retained nuclear fragments. We reviewed the video recordings of 1000 cases of phacoemulsification with foldable intraocular lens (IOL) implantation performed by a single experienced surgeon (V.K.D.) between January 1997 and December 1999. In 65 eyes, retained small nuclear fragments were present after phacoemulsification but before aspiration of the viscoelastic material after IOL implantation. The most common site of the fragments was the 2:30 side port (33 eyes) followed by the 12 o'clock incision (21 eyes), over the iris (8 eyes), and under the iris (3 eyes). The fragments were detected during the terminal stages of phacoemulsification, just before the exit of the phaco probe (40 eyes), during irrigation/aspiration (17 eyes), following irrigation/aspiration (5 eyes), and following foldable IOL implantation (3 eyes). The side port and the main tunnel incision are the potential recesses in which the small nuclear fragments may be retained due to the vortex-like conventional flow of the irrigating fluid in the anterior chamber. They may also get lodged over the iris crypts or under the iris, especially if the pupil is small. In 2 or 3 eyes in which the nuclear fragment lodged under the iris, the pupil was small. In 27 of 33 eyes in which the nuclear fragment was present under the side port or main incision, the nuclear fragment was dislodged by forward and backward movement of the phacoemulsification probe and the side-port chopper and were subsequently phacoemulsified. In 3 eyes, the retained nuclear material was dislodged by forward and backward movement of the phaco probe and was subsequently pushed into the phacoemulsification probe by the chopper. In 8 eyes the retained nuclear material was present over the iris; it was syringed out with a 2 cc disposable syringe filled with balanced salt solution (BSS®) in 4 eyes and viscoexpressed with the help of a viscoelastic injection in 4 eyes. A 2 cc disposable syringe filled with BSS was also used to aspirate the small retained nuclear fragments under the iris in 3 eyes. The small retained nuclear fragments were detected after foldable IOL implantation in 3 eyes and were subsequently expressed out with the help of viscoelastic material. Although no retained nuclear material was detected postoperatively in any of the 1000 cases, our experience highlights the potential sites of retained small nuclear fragments. Furthermore, we recommend that forward and backward movements of the phaco probe and the side-port manipulator be performed routinely while exiting at the conclusion of phacoemulsification to avoid complications of retained nuclear fragments postoperatively. Vijay K. Dada MBBS, MS Namrata Sharma MD Tanuj Dada MD New Delhi, India