1. Nucleus Extraction Techniques Dr. Navin Gupta Shankar Netrika Eye Hospital, Mumbai

2. Nucleus Extraction Irrigating vectis technique Irrigating vectis technique Phacosandwich technique Phacosandwich technique Phacofracture technique Phacofracture technique Modified bluementhal technique Modified bluementhal technique Fish hook technique Fish hook technique

3. Irrigating Vectis Time tested technique Time tested technique Most commonly used in SICS. Most commonly used in SICS. Vectis 4 mm width 8 mm length. Vectis 4 mm width 8 mm length. Ant surface has slight concave Ant surface has slight concave Ant end has 3 small irrigating ports, 0.3 mm. Ant end has 3 small irrigating ports, 0.3 mm. Post end attached to syringe Post end attached to syringe

4. Surgical technique Visco injected liberally first above n then below nucleus. Visco injected liberally first above n then below nucleus. Vectis inserted under nucleus. Vectis inserted under nucleus. SR suture pulled tight, vectis withdrawn without irrigating till upper pole of nucleus engaged in tunnel. Irrigation started, vectis slowly withdrawn pressing post scleral lip. SR suture pulled tight, vectis withdrawn without irrigating till upper pole of nucleus engaged in tunnel. Irrigation started, vectis slowly withdrawn pressing post scleral lip.

8. Advantages Single instrument Single instrument AC remains formed AC remains formed Tunnel wall takes up the brunt of trauma. Endothelium spared. Tunnel wall takes up the brunt of trauma. Endothelium spared.

9. Disadvantages Risk of iridodialysis Risk of iridodialysis PC rent PC rent Endothelial damage if visco not enough. Endothelial damage if visco not enough. Crushing of inferior iris Crushing of inferior iris

11. Phacosandwich technique Uses vectis (solid or irrigating) n Sinskey hook Uses vectis (solid or irrigating) n Sinskey hook Visco injected above n below nucleus. Visco injected above n below nucleus. Vectis inserted below nucleus Vectis inserted below nucleus Sinskey hook inserted carefully above with dominant hand. Sinskey hook inserted carefully above with dominant hand. Nucleus sandwitched. Nucleus sandwitched. Assistant pulls SR and globe inferiorly Assistant pulls SR and globe inferiorly

12. At the same time. At the same time. In this process, epinucles n portion of cortex gets sheared off. In this process, epinucles n portion of cortex gets sheared off. Many prefer to express the epinucleus with visco injection followed by thorrough cortical wash. Many prefer to express the epinucleus with visco injection followed by thorrough cortical wash.

14. Complications Breaking up of nucleus Breaking up of nucleus Inferior irididialysis Inferior irididialysis DM strippin while introducing Sinskey into already crowded AC DM strippin while introducing Sinskey into already crowded AC

15. Phacofracture technique Bisector technique Bisector technique Trisector technique Trisector technique Phacofracture at the exit Phacofracture at the exit Wire-loop technique Wire-loop technique Phacosalute n fracture Phacosalute n fracture Used in soft n mod hard cats Used in soft n mod hard cats Nucleus is fragmented in AC Nucleus is fragmented in AC

16. Bisector technique Solid bisector inserted beneath nucleus Solid bisector inserted beneath nucleus Bisector carefully introduced above. Bisector carefully introduced above. Both moved towards each other gently till the bisector cleaves its way through nucleus towards vectis Both moved towards each other gently till the bisector cleaves its way through nucleus towards vectis Two halves seperated and brought out using sandwitch technique Two halves seperated and brought out using sandwitch technique

18. Trisector technique Trisector has a tip with 2 long limbs sharpened inferiorly. Trisector has a tip with 2 long limbs sharpened inferiorly. Solid vectis inserted below nucleus. Trisector passed over nucleus. Trisector pressed down, cuttin the nucleus into 3 pieces. Solid vectis inserted below nucleus. Trisector passed over nucleus. Trisector pressed down, cuttin the nucleus into 3 pieces.

20. Phacofracture at exit With the help of irrigating vectis, nucleus is expressed. Half way through at the exit it is fractured. Other half pushed back into AC with visco, realigned and then extracted with irrigating vectis. With the help of irrigating vectis, nucleus is expressed. Half way through at the exit it is fractured. Other half pushed back into AC with visco, realigned and then extracted with irrigating vectis.

22. Wire-loop technique Nuclear snare is used made from 32 gauge stainless steel wire. Nuclear snare is used made from 32 gauge stainless steel wire. Wire loop positioned around nucleus, loop is shortened n it cheesewires through nucleus. Thus nucleus is divided into 2. Each piece is delivered with forceps Wire loop positioned around nucleus, loop is shortened n it cheesewires through nucleus. Thus nucleus is divided into 2. Each piece is delivered with forceps

24. Phacosalute n fracture Not practised here. Not practised here. Nucleus aligned vertically and superior portion then amputed or pinched off usin capsule forceps. Nucleus aligned vertically and superior portion then amputed or pinched off usin capsule forceps.

25. Modified Bluementhal Uses AC maintainer throughout. Hollow tube of 0.9 diameter. Attached to BSS bottle suspended 60 cms above pts eye. Plastic glide 3 mm wide, 0.3 mm thick n 3 cms long inserted under the nucleus, half way through. Bottle height raised. Pressure applied on the scleral side of glide. Intermittent taps will push out the nucleus. Uses AC maintainer throughout. Hollow tube of 0.9 diameter. Attached to BSS bottle suspended 60 cms above pts eye. Plastic glide 3 mm wide, 0.3 mm thick n 3 cms long inserted under the nucleus, half way through. Bottle height raised. Pressure applied on the scleral side of glide. Intermittent taps will push out the nucleus.

26. Modified bluementhal

27. Fish Hook Technique 30 G needle is bent in the form of fish hook n used fro extraction. 30 G needle is bent in the form of fish hook n used fro extraction. Envelope capsulotomy done. Envelope capsulotomy done. Upper pole of nucleus brought in to AC. Upper pole of nucleus brought in to AC. Fish hook is entered into AC, manoeuvred under the nucleus and nucleus is hooked. Fish hook is entered into AC, manoeuvred under the nucleus and nucleus is hooked. Nucleus is slided out by applyin slight pressure on post lip of tunnel. Nucleus is slided out by applyin slight pressure on post lip of tunnel.