From the Guidelines
A nucleus drop during cataract surgery is a serious intraoperative complication requiring immediate management, and prompt referral to a vitreoretinal surgeon is essential, ideally within 24 hours, as delayed management increases the risk of permanent vision loss 1. When the crystalline lens nucleus or fragments fall into the vitreous cavity, the anterior segment surgeon should not attempt to retrieve the dropped nucleus but should stabilize the eye by performing a partial anterior vitrectomy, placing the intraocular lens if the capsular support is adequate, and closing all wounds securely. Some key considerations in the management of nucleus drop include:
- Stabilizing the eye to prevent further complications
- Prompt referral to a vitreoretinal surgeon for pars plana vitrectomy to remove the lens fragments
- Postoperative management with medications such as prednisolone acetate 1% drops, moxifloxacin 0.5% drops, and atropine 1% drops to reduce inflammation and pain, as well as oral acetazolamide 250mg twice daily for 3-5 days to control intraocular pressure 1. The importance of prompt management cannot be overstated, as delayed referral to a vitreoretinal surgeon can lead to increased risk of complications such as glaucoma, corneal edema, and retinal detachment, ultimately resulting in permanent vision loss. Key aspects of patient care include:
- Informing the patient about the complication, its implications, and the need for additional surgery to optimize visual outcomes
- Ensuring the patient understands the importance of prompt follow-up and adherence to the postoperative medication regimen
- Coordinating care with the vitreoretinal surgeon to ensure seamless management of the complication.
From the Research
Intraoperative Complication: Nucleus Drop
- Nucleus drop is a rare but serious complication that can occur during cataract surgery, with an incidence risk of 0.044% [95% CI 0.038%, 0.051%] or 0.44 per 1,000 surgeries 2.
- The management of nucleus drop requires a well-rehearsed plan, including preventative measures, early recognition, damage control, and resolution 3.
- Significant preoperative risk factors for nucleus drop include posterior polar cataract, suspected loose zonules, older age, and presence of diabetes mellitus 2.
- Associated intraoperative complications include zonular dialysis, vitreous disturbance, and posterior capsule rent 2.
- Nucleus drop can occur during various stages of cataract surgery, including nucleus removal and hydrodissection 2.
- Visual outcomes of nucleus drop are generally worse than controls, but 51.9% of patients can achieve visual acuity 20/40 or better at 1 month 2.
Management and Treatment
- A pars plana approach to anterior vitrectomy with staining of the prolapsed vitreous is the most effective technique for managing nucleus drop 3.
- Referral for a standard three-port posterior vitrectomy with fragmenter as needed is recommended once a fragment is lost to the posterior segment 3.
- The use of an interior vitrectomy machine and availability of vitreo-retina surgeons for urgent assistance are crucial in managing nucleus drop 4.
- Careful patient selection for small incision cataract surgery (SICS) and the use of continuous curvilinear capsulorhexis are advocated to minimize the risk of nucleus drop 4.
Risk Factors and Associations
- Cataract surgery itself is a potential risk factor for retinal detachment, particularly after intraoperative capsule complications 5.
- Myopic patients should be treated with caution, as it cannot be concluded that Nd:YAG capsulotomy does not increase the risk of retinal detachment in this cohort 5.
- Silicone tamponade and transscleral retinal cryotherapy are risk factors for subsequent cataract surgery after vitrectomy for diabetic retinopathy 6.