Pars plana vitrectomy is a microsurgical procedure to remove the vitreous body through the pars plana. The document outlines the history, indications, risks, pre-operative assessment, surgical procedure, complications, and outcomes of pars plana vitrectomy for dropped lens fragments following cataract surgery. Key points include performing vitrectomy within 1 week of a dropped nucleus for best visual outcomes, using fragmatomes or vitrectomy cutters to remove fragments, examining the periphery for retinal tears, and achieving useful vision in 60-80% of cases with timely intervention.
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PARS PLANA VITRECTOMY FOR LENS DROP.pptx
1. PARS PLANA VITRECTOMY IN LENS
DROP WITH VIDEO DEMONSTRATION
PRESENTED
BY
DR. AVURU CHUKWUNALU JAMES
1ST FEBRUARY 2023
2. OUTLINE
Introduction and brief over view of pars plana vitrectomy
Lens fragments/nucleus drop, risk factors and precautions
Timing of pars plana vitrectomy
Pre-operative assessment
Surgical material and instrument set-up
Intraoperative options for nucleus removal
Surgical procedures
Visual outcome and challenges
Conclusion
References
3. INTRODUCTION/ADVANCES
Pars plana vitrectomy is a microsurgical procedure for removal of
the vitreous body via the pars plana.1,2
The pars plana is a safe zone that avoids damage to the retina or
crystalline lens
Sclerostomies are created: 3mm, 3.5mm, 4mm lens status
David Kasner described vitrectomy using an open-sky technique
in 1969.2
Robert Machemer created the first closed system vitrectomy
setup in 1971 –using 17-gauge instruments with a pars plana
approach with IOP control
4. PPV HISTORY OF ADVANCEMENTS
Conor O’Malley and Ralph Heintz developed the modern-day
three-port vitrectomy system in 1974 USING 20G instruments.
Robert Machemer and Dyson Hickingbotham developed trocar-
cannula system
Gholam Peyman and Claus Eckard; 23-gauge instrumentation
Gildo Fujii and Eugene de Juan; 25-gauge instrumentation
Yusuke Oshima and colleagues; 27-gauge instrumentation in
2010
5. INDICATION—Retinal detachment
Rhegmatogenous RD –
Uncomplicated.3
Posterior breaks
Multiple breaks in
different meridians
RD Associated vitreous
hemorrhage
RD with no breaks seen
6. INDICATIONS—Retinal detachment contd
Rhegmatogenous RD –
Complicated RD.2,3
Severe proliferative
vitreoretinopathy
grade C or more
Giant retinal tear
Tractional RD threatening
fovea
7. INDICATIONS-OCULAR TRAUMA
Severe ocular trauma with
intraocular foreign body (IOFB).2,3
Trauma associated with
endophthalmitis
IOFB impacted on retina or in
vitreous
Trauma with vitreous
hemorrhage)
Large, nonmagnetic or organic
IOFB
12. LENS FAGMENTS AND NUCLEUS DROP
Posterior dislocation of a part or the whole Lens
nucleus into the vitreous cavity.4
The Incidence of nucleus drop following a PCR is 0.3%-
1.1%.5 0.68% for SICS.6
Nuclear material is poorly tolerated in the eye; however,
epinucleus followed by cortical material, are better
tolerated.
Lens fragments less than 2 mm in size can often resolve
with medical management
When fragments are larger than 2 mm in size or when the
entire lens/capsule complex has descended posteriorly,
vitreoretinal intervention is usually required.5
13. Risk factors for lens drop- pre-operative
TYPES OF CATARACT;
Mature or Hypermature cataracts
(posterior capsule may be thin and
the zonules weak
Traumatic cataract; posterior
capsule or zonule may be damaged
posterior polar cataracts
SMALL PUPILS;
Pseudoexfoliation; weak zonules
DM, Posterior synechiae, longterm
use of pilocarpine, senescence,
congenital( coloboma)
14. Risk factors for lens drop- pre-operative
factors contd
HIGH AMMETROPIA;
A small eye with a crowded
anterior segment
large eye with a loose
capsule
PREVIOUS VITRECTOMY; Lack of
vitreous support
CONNECTIVE TISSUE DISEASES;
e.g Marfan's syndrome
AGE
15. Risk factors for lens drop-intraoperative
SURGEON’S EXPERIENCE AND
INSTRUMENTS
Posterior extention of capsular
tear during anterior
capsulotomy or its radial
Progression
Visible tears in the Posterior
capsule during hydrodissection
A posterior capsule torn by an
instrument or a sharp
A zonular dialysis larger than 3
clock hour during manipulations
Problems of shallow anterior
chamber
16. lens nucleus/cortex drop- without intervention
Some lens fragments absorb and
cause no complication and others
do not absorb and cause
complications
Floaters
Raised IOP/ glaucoma
Corneal edema (33-85%)
Uveitis/ phacoanaphylactic
endophthalmitis
Cystoid macular edema (7-41%)
Retina breaks and detachment (7-
8%)
17. Tips and management by the cataract
Surgeon
Early ecognition of posterior capsular
(PC) tear reduces chances of vitreous loss
and dropped fragment.
Signs of Posterior Capsular rupture
Sudden deepening of anterior
chamber, with slight dilation of pupil.
Sudden, transitory appearance of a
red reflex peripherally.
difficulty in holding nuclear fragments
descent of the nucleus away from the
instruments
Pupillary snap sign
18. Decision making by cataract surgeon
intraoperatively and before refferal
Size of dropped lens material
Prolapsed vitreous or not( anterior vitrectomy machine, sponge and
scissors vitrectomy)
Adequate capsular support or not
Primary objective is retrieval of retained nucleus fragment without
aspirating vitreous
Retained fragments can be brought into anterior chamber by the use
of Ophthalmic Viscoelastic Device (OVD).
Availability and proximity to a vitreoretinal surgeon
19. CONTD
Even If Nucleus has dropped in the Vitreous cavity and optimal Three
Port Parsplana vitrectomy is immediately not available, then
Minimizing collateral damage by safe Management of Anterior
Vitreous
Cortical Clean-up
Ensure stable IOL implantation, wherever possible
Tight wound closure with suture
Remove viscoelastic from the anterior chamber
Provide referral for prompt vitreoretinal consultation
20. TREATMENT-
medical
The aim is to treat secondary complications such as intraocular
inflammation and elevated IOP
Topical Non steroidal anti-inflammatory drugs or topical steroids to
control inflammation
Cycloplegic agents
Topical +/- oral IOP lowering drugs and topical/systemic steroids
Prophylactic topical antibiotics- routine post op medication
21. TIMING OF PPV FOR LENS FRAGMENTS/NUCLEUS
DROP
TIMING.5,7
Delayed Vitrectomy; Glaucoma and Corneal edema may
result
Availability of a Vitreoretinal specialist
Vitrectomy for dislocated nuclear/ lens fragments should
be done ideally within 1 week
Can be delayed up to 3 weeks without significant
difference in the Visual Outcome
22. Pre-Operative assessment-Must be in
referral form
Sent to vitreoretinal Surgeon; should include.
Amount of retained lens material
Type of retained lens material
Hardness of retained lens material
Presence/absence of an IOL implant
Assessment of Capsular Support
Calculated IOL power.4,5
23. Pre-Operative assessment(VR surgeon)
Visual acquity
Slit lamp Examination; eternal
eye, anterior and posterior
segment
1. Assess corneal clarity
2. Integrity of the cataract wound
should be verified.
3. Grade the degree of anterior
chamber inflammation
4. Intraocular Pressure. 4,5
Indirect Ophthalmoscopy
1. Assess nuclear fragments
2. Exclude Peripheral Retinal
tears,
3. Retinal Detachment or
Choroidal detachment.4,5
24. Pre-Operative assessment contd
B-Scan Ultrasonography in cases of
Media haze.4,5
corneal oedema
Vitreous Haemorrhage
Size of lens
RD
Other routine investigations-
Optimize patient for surgery-
FBC, FBS, RVS, Serum E/U/Cr,
ECG-individually tailored to
health condition
25. Surgical Procedure/materials/set-up
A three-port pars plana Vitrectomy is
the procedure of choice and standard
of care.
Vitrectomy machine and
consumables
Trocar and cannular
Connection for fluid
Air tube connector(If FAE is
needed- RD)
Connecting tube for oil, heavy
liquid or gasses
Connection for light/ illumination
Connection for endolaser probe
26.
27.
28. Surgical Procedure/materials/set-up
contd
Hybrid or mixed gauge
vitrectomy is performed with
an active 20 G port for
introduction of a Large–bore
Fragmatome
A fragmatome is similar to a
PHACO probe without an
infusion Sleeve.8,9
29. Procedure- pars plana vitrectomy
Choice of anaesthesia
Routine cleaning and
drapping
Set up of microscope/ BIOM
Creating sclerostomies -
various port sizes vis-à-vis
wound size and choice of
instruments
30. Procedure- tips
Smaller gauge systems allows for
faster visual recovery and less
post-operative inflammation but
may preclude removal of
moderate-sized or denser lens
fragments
larger lens fragments-
phacoemulsification probe or 20-
gauge fragmatome. 4,5, 8,9
31. Highlights of key points
Remove all the vitreous from Anterior
Chamber/ primary cataract wound (if
present)
Intravitreal Triamicinolone acetonide;
better visualization of vitreous.
Core vitrectomy: All the vitreous
attachment to the lens fragment/nucleus
must be removed– tractions
Induction of PVD is a must in an eye with
no complete PVD
Once core and peripheral vitreous are
removed, then removal of lens material
follows
32. Removal of dropped nucleus/lens
fragments
Soft nucleus/ lens fragment
a. Vitrectomy cutter
Hard Nucleus
a. Fragmatome
b. Removal from limbal route
b. Removal from limbal route
I. Floatation with PFCL
II. Use of pick/MVR blade to
elevate
III. Elevating Nucleus/lens fragment
by active suction(flute cannular)
IV. Adjunctive devices; “Frag Bag” , a
retractable basket made from
nitinol allows retrieval and
stabilization of the lens material in
the mid-vitreous cavity
33. Removal of soft dropped nucleus/lens
fragments
Removal by Vitrectomy cutter
Key Points : – Cut rate should be
low near 600-800 cuts per minute
with suction on the higher side.
Few drops of PFCL can be used as
a cushion to prevent the nucleus
pieces falling directly over the
macula and causing damage to it.
Light pipe can be used to crush the
nucleus against the cutter probe
for easy cutting
34. Removal with Fragmatome
PhacoTip without Sleeve
Perform vitrectomy (as stated
earlier) prior to use of an
ultrasonic fragmatome-
Reducing fragmentation power to
only 5 -10 % facilities nuclear
extraction by continuous
occlusion of the suction port and
avoidance of projectile
fragments
Use a small bubble of PFCL for
protecting retina from projectile
nuclear fragments
35. Removal/Delivery via limbal route
Vitrectomy as stated earlier
Elevating Nucleus by active
suction with the hard tip flute
cannula and bringing it to
anterior chamber.
Using a pick/MVR blade to
elevate it in the anterior
chamber. This may cause damage
to underlying retina.
36. Using PFCL(Perfluorocarbon liquid) to
float the nucleus
All the nuclear fragments floats above
the bubble and can be removed
it can be utilized with accompanying
retinal detachment.
Caution; nuclear fragments tends to
slip over the meniscus to the
periphery, hence meticulous
examination of periphery also help in
visualization and removal of these
fragments
Meticulous removal of PFCL must be
ensured at the completion of procedure-
prevent ocular toxicity.
37. Peripheral examination intraop
INDENTATION;
I. Locate any breaks pre-existing or
surgically inadvertently caused
II. Manage breaks by barraging them
with laser intra operatively
III. Reduces chances of post operative
retinal detachment
40. Visual Outcome Post PPV For Nucleus
Drop
With adequate management, a Visual Acuity of 6/12 is achievable in
60-80 % cases with dropped nucleus
Outcome in
Early vs Late PPV. 7 - 60 eyes; 30eyes PPV in 1week and 30 eyes
PPV > 1week(Iran): Visual outcome 6/18 vs 6/60
Dhaka, Bangladesh.12 -3yr review of outcome of dropped lens in Dhaka,
Bangladesh- 32 eyes. Phacos. 6/18 or better in 10%. LP and NPL 9% each.
Nigeria(LUTH).6 4 eyes. 3 had PPV. CF and HM
41. CONCLUSION
Pars plana vitrectomy surgery is an essential part of an
ophthalmic unit.10
Developing the vitreo retinal units in order to improve vision
in cases such as lens nucleus/ fragment drop is vital
Availability of VR centres and timely intervention can result in
retaining useful vision.
42. REFERENCES
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Available from
https://eyewiki.aao.org/Pars_Plana_Vitrectomy#:~:text=Pars%20plana%20vitrectomy%20(PPV)
%20is,in%20a%20controlled%2C%20closed%20system.
3. Wong TY. Ophthalmology examination review. 2nd Ed.Indications for vitrectomy. Page 191.
4. Michael J, Venincasa, Bs, Jayanth S, Rahul T. Surgical Management of a Dropped Lens
as a Complication of Cataract Surgery. Retina physician. May 1, 2018. Available from
https://Venkateswaran N, Medina-Mendwww.retinalphysician.com/issues/2018/may-2018/surgical-
management-of-a-dropped-lens-as-a-complic
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PMID: 32576724; PMCID: PMC8439552.
43. REFERENCES contd
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237-240
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nucleus during phaecoemulsification. J Res Med Sci. 2011 Nov:16(11): 1422-1429
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PMC3582012.
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13. Dhanashree Ratra, Vineet Ratra,Sukant Pandey Sankara Nethralaya, Chennai.
Management of Dropped Nucleus and Retained Lens Fragment.
eOphtha.April 1st, 2021. Available from
https://www.eophtha.com/posts/management-of-dropped-nucleus-and-retained-lens
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Posteriorly Dislocated Lenses. AAO.EyeNet Magazine. October 2017. Available
from https://www.aao.org/eyenet/article/management-of-posteriorly-dislocated-
lenses-fragment