1. Dr. Navin Gupta M.S. Shankar Netrika Eye Hospital, Mumbai Nucleus Prolapse into anterior chamber

2. Nucleus prolapse into AC
One of the essential features of SICS absent in ECCE
Takes some experience to master
Can be done both with canopener capsulotomy and capsulorhexis.

3. In Canopener capsulotomy
Mainly mechanical. Hydro procedures not used.
Instruments: Sinskey hook or cystitome
Important to visualize periphery of ant capsule.
Sinskey hook is positioned to reach equator of nucleus. Best between 9 to 12 clock hrs.

4. Hooking the nucleus
Peripheral Ant Surface- good for NS III n IV. More stress on zonules n post capsule.
Equator
Undersurface of equator- last 2 put lesses stress on zonules

5. Mechanical prolapse into AC
After hooking, nucleus pushed towards opp clock hr.
Visualize equator.
Lift and rotate (clock or anticlockwise).

6. Mechanical prolapse

7. Problems in mechanical prolapse

8. Cheese Wiring
Peeling or fragmentation of cortex n epinucleus as shreds.
Happens with soft cataracts.
Solution- use hydro procedures for soft cats.

9. Slipping back of uplifted pole
Once a pole is out, dialing force should be upwards.
Injecting visco between nucleus n iris (bed-sheeting) also helps.

10. Churning of cortex In soft catracts
Solution- aspirate n wash off superficial loose cortex before the mechanical prolapse.

11. Nucleus keeps rotating
Seen in hypermature, brown n black cats where there is less cortex.
Solution- inject visco beneath prolapsed nucleus.
Pass vectis beneath nucleus and prolapse it.

12. Small pupil Enlarge pupil: Preop NSAIDS drops Intracameral epinephrine
Sphincterotomies
Stretch pupilloplasty Kuglen’s hook
Sector or key-hole iridectomy

13. Bimanual technique 2 instruments Sinskey hook (rt hand)
Cyclodialysis spatula (lt hand)
Hook engages nucleus. Push to 6 o’clock. Upper pole seen. Spatula inserted under it. Pole lifted up. Nucleus dialled out.
Compliacations: zon dialysis, iridodialysis, endoth damage, nucleus drop.

14. In capsulorhexis Fair estimation of nucleus size is important
Hydroprocedures are the method of choice here.

15. Hydrodissection
Hydro cannula tip placed between cortex n capsule. Fluid injected. Cannula taken to opposite pole, fluid injected till fluid wave lifts up the opp pole. Then using Sinskey hook, nucleus is dialed out.

16. Tumbling Technique In only soft cataracts Only very skilled surgeons
Perfect size rhexis
Initially hydrodissection is done. One pole is lifted up. Now with the cannula, pole of the nucleus in bag is pressed down and moved across simultaneously, tilting the nucleus. Tumbles into AC.

17. Complications hydroprolapsing
Small/incomplete rhexis- inability to prolapse
Nucleus stuck in rhexis, half inside half outside bag. Make small relaxing cuts. Gently coax nucleus out bimanually.
Radial tear extending to post capsule

18. Specific techniques for particular types of cataracts

19. Hypermature Cataracts
No cortex. Nucleus tends to rotate in the bag.
Use Simcoe cannula. Fluid kept on full flow. Simcoe passed under nucleus. Mechanically lifted up.

20. Soft cataracts Difficult due to cheese wiring
Do hydrodissection n hydrodilineation and tumble nucleus into AC.

21. Post Polar Cataracts Do not hydrodissect. Do only hydrodelineation
Bimanual technique to prolapse.

22. Subluxated cataracts Experienced surgeon.
Good hydrodissection n delineation.
Bimanual technique

23. THANK YOU