Clinical Report* Using the anterior segment vitrectomy for super-milk surgery, nuclear fall, Xu Guoxu, Xu Guozhen, Li Chunhua, Chen Liqun, An Xiaoling, Wang Jie, crystal falling into the vitreous is the most serious and difficult to treat complication in phacoemulsification. Some of these difficult complications can be simplified by combining the previous section with the necessary techniques. The situation and treatment results of the 4 patients who were treated and treated in our treatment are as follows: 34 years old preoperative: right eye vision: manual or 30cm in front of the eye, the incision and capsulorhexis are smooth during operation, and the anterior capsule is torn open. It is 5mm, after the water separation and the first step, the nucleus is smooth, and the nuclear fall suddenly occurs during the nucleus. After careful observation, the crystal nucleus falls vertically and the sac is still attached to the posterior sac near the equator. An edge can be seen, the patient's vitreous body has not been liquefied significantly. The anterior segment dry glass is used. After the pupil area and the front and middle vitreous bodies are removed, it can be seen that the falling nuclei quickly float to the pupil area, and the viscoelastic agent is injected into the crystal. After the crystal is moved into the anterior chamber by the rear method, the incision is enlarged to remove the core. The remaining steps are completed in the usual way.
Example 2 male 79 years old preoperative: left eye visual acuity: pre-eye index / 50m preoperative pupil dilation is not large, 5mm, incision and capsulorhexis are smooth, 5mm capsulorhexis is slightly smaller, water separation is smooth, in the first step of nucleus, When the nucleus just opened, the nuclear suddenly fell into the vitreous. When the eye was observed, the crystal was located in the central nasal side of the vitreous body. It was not close to the retina, tilted, and the vitreous was partially liquefied. The anterior segment of the dry glass was used to cut the pupil. After the vitreous resection of the area and the crystal, the crystal floats close to the edge of the nasal side of the nose, and the two-hand method is used. One is facing the crystal to inject the viscoelastic agent, and the truncated nucleus is used to move the crystal nucleus into the pupil area, expanding After the incision, the crystal was taken out as a crystal. The remaining steps are done in the usual way.
Case 3 crystal soft nucleus fell into the vitreous to observe the case, preoperative VD0.12 at the end of the emulsification, the posterior capsule rupture and a small soft core fell into the vitreous. At that time, the flat concave lens was visible under the microscope in the posterior pole of the eyeball. 1/5 nuclear-sized gray-white soft core, according to the principle of treatment, the advantages and disadvantages, not rushed to the vitreous cutting out, follow-up observation after surgery, except for the uveal inflammatory response lasting a little longer, the other is normal, after 3m Visual acuity of 0.6 cases of 4 crystal nucleus falling into the vitrectomy, VS: HM / anterior, phacoemulsification occurred after the crystal nucleus split 1/2 large hard nucleus into the vitreous, due to poor vitreous conditions, The liquefaction is heavy, and the nucleus immediately falls to the retina surface. According to the principle of treatment, the vitreous cleavage of the posterior segment is followed by the emulsification of the nucleus by the heavy water and the posterior chamber emulsification technique, and then the posterior chamber type ciliary sulcus is implanted to complete the operation. The next day after surgery, the visual acuity reached 0. 5 Discussion (1) Causes of nuclear fall: high risk factors for posterior capsule rupture, such as small pupil, exfoliation syndrome and swollen crystal nucleus. The capsulorhexis is small and the pressure in the capsular bag is too high after the water is separated. The pressure in the nucleus exceeds the rupture of the posterior capsule. The dysfunction during surgery, improper myopia, high myopia, cataract in over-ripening period, detachment of the suspensory ligament, etc. The cause of the fall. (2) Indications for successful use of anterior segment vitrectomy/dry vitrectomy: 1 posterior capsule rupture, nuclear fall, but not yet reached the fundus retina or posterior vitreous; 2 patient vitreous conditions are acceptable, no liquefaction or only partial liquefaction; 3 The dislocated crystal can be seen under the microscope and before the middle. This technique is not recommended for the lens core to fall to the posterior vitreous or to the retina. Once the crystal core is safely raised to the anterior chamber, it can be treated by two methods: the crystal core is soft and broken, and the operation can be continued by using a skateboard (artificial posterior capsule) plus super-milk method; the crystal nucleus is large and swollen, and the extracapsular surgery method can be used. To complete the surgery. Blocking anesthesia under the Tenon membrane (2% lidocaine 1mL) should be performed when converting to ECCE incision (3) Avoiding the method: the diameter of the capsulorhexis should not be too small, and the complicated cases should not be forced when the surgical technique is not skilled. Such as over-mature and mature cataract, patients with subluxation of crystal, water should not be excessive when water injection, intraoperative operation should be light, the operation range should not be too large. If the capsular tension ring is used, the safety of the operation can be further improved.
(3) In the course of super-milk surgery, if the nucleus is opened and emulsified more than 1/2, and there is a tendency for posterior capsule rupture and nucleus to sink, the emulsification should be stopped immediately, and the anterior segment vitrectomy should be changed immediately. The vitreous body before the remnant nucleus is removed. At this point, it can be found that the crystal broken nuclei will float to the pupil area, and then the viscoelastic agent can be injected under it and the broken nuclei can be moved into the anterior chamber. Move out. (5) After the occurrence, try to take out according to the method described in this article. If it is unsuccessful, it can be solved by using the posterior section of the glass in two weeks. In the absence of support from the posterior capsule, it is dangerous to attempt to poke the lens nucleus with a phacoemulsification head. Directly lowering the amount of perfusion will increase the rupture of the posterior capsule and further reduce the lens nucleus. At the same time, a large diameter ultrasound needle is used. Attracting the vitreous body causes a large area of ​​retinal detachment. (6) Dr. Chang (David F. Chang), clinical professor of ophthalmology at the University of California, San Francisco, USA, introduced a modified Pal capture technique that prevents nuclear sinking. It is especially effective when the crystal nucleus floats to the side or begins to tilt. Application, the effect will be better, the success rate will be higher.
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