eyeCONNECTIONS
Managing a retained nuclear chip

This post-op surprise requires careful maneuvering

Do I see what I see? Modern phaco machines continue to make for more and more efficient nucleus delivery. However, during the process, while we have our eyes on the task at hand, small fragments of nucleus can lodge themselves in out-of-the-way places.
Consequently, the case is complete and sent to post-op, while a small chip goes undetected. Overnight, and with patient movement the next day or week, the chip suddenly appears in the anterior chamber, often unnoticed against a dark iris until a small amount of corneal edema is seen at 6 o’clock. Several colleagues on the ASCRS eyeCONNECT listserv share their experience and suggestions to manage this post-op surprise.

I saw a patient for a post-op day one check after routine cataract surgery. There was slightly more inflammation than usual and a small nuclear chip in the inferior angle. The chip measured about 0.5 mm at the slitlamp. Is this small enough to observe, treat with ample steroids, and will it melt away, or is this something that I should go back and remove. If so, how soon?
Jay Futterman, M.D.
Gresham, Ore.

I would take the patient back to surgery and remove the chip. It will not likely dissolve, and it can result in prolonged inflammation, possible corneal decompensation, and often a secondary pressure elevation.
David H. Aizuss M.D.
Encino, Calif.

I agree with removal of the chip. Cortex is another issue, but a nuclear chip can lead to more problems. I had a similar case, and it took awhile to find the fragment. The patient was very upset and threatened legal action because I left behind part of the cataract. In this day and age, I think you are on thin ice watching a nuclear fragment.
Robert Broderick, M.D.
Manhasset, N.Y.

This case also provides for a valuable pearl. In post-routine cataract extraction/IOL insertion patients who either have persistent corneal edema or more likely new edema not present immediately after surgery, look for a nuclear fragment or chip(s). They often hide in the angle and can sometimes be difficult to see. Gonioscopy can be helpful.
Jeffrey Horn, M.D.
Nashville

Dr. Horn is exactly right, and I might add that the video probe of an endoscopic cyclophotocoagulation (ECP) unit is a great device to explore behind the iris where these fragments can also migrate and go undetected.
Robert Broderick, M.D.

This is a good place for biaxial removal if you have the setup. Especially with the Crystalens (Bausch & Lomb, Aliso Viejo, Calif.) or a one-piece AcrySof Toric SN60T3 (T4,T5) (Alcon, Fort Worth, Texas), lens movement can occur with the larger coaxial infusion aspiration technique and chamber fluctuations. It would require a second 1-mm paracentesis, but when positioned appropriately in the best axis, one will have direct access to the fragment across the anterior chamber, and it is then easy to mash the chip into the aspiration tip.
William Myers, M.D.
Skokie, Ill.

I agree with Dr. Myers that the bimanual technique offers more control—the sudden rush of fluid from the coaxial handpiece may chase it to another location where you will have trouble finding it. Maneuvering it into the center of the anterior chamber with an adequate amount of viscoelastic material also helps.
For the aspiration cannula, I would recommend a 22-gauge curved thin-walled cannula that Katena (Denville, N.J.) makes for me. The opening is fairly large, and it will make it easier to hold onto the chip and “potato mash” it as Dr. Luther Fry has recommended previously (see below).
S. Jerome Holtz, M.D.
Bloomfield, N.J.

Even a small nuclear chip will not absorb. Although it may not cause corneal or pressure problems, it will be there forever, so take the patient back and aspirate it at your earliest non-emergent convenience to save yourself the aggravation. (The potato masher maneuver is done with a spatula through the side port and irrigation/aspiration [I/A] tip). I had one case (co-managed) who was sent back three years post-op when a funny yellow thing was noted in the inferior angle. It aspirated just like a fresh chip. The cornea and pressure were OK, so they don’t always cause problems. However, I think they more often do than don’t.
I now see all my patients the afternoon of surgery. If there’s a chip (which I see more often than I would like to admit—maybe one out of 200 cases), I immediately take them back and aspirate it. I don’t know how these chips can hide, as I usually can’t see them when I review the video.
Luther Fry, M.D.
Garden City, Kan.

The literature and my experience dictate that at least half of small chips (smaller than .75 mm) will resorb over six to 12 weeks. The decision to re-operate should be based on increasing focal corneal edema inferiorly (over the chip in the lower angle), increasing IOP, uncontrolled inflammation, patient discomfort with “watching and waiting,” and, the least, surgeon discomfort with the latter.
Samuel Masket, M.D.
Los Angeles

I have handled this over the years in all ways. I once watched one resorb over six months, nursing it along using Pred Forte (prednisolone acetate ophthalmic suspension, Allergan, Irvine, Calif.). I now just take the patient back to the OR and get rid of the problem. The swallowing of the pride that you missed one is tough but the better road to go. I know it is more difficult to wrestle with it over time.
J. E. “Jay” McDonald, M.D.
Fayetteville, Ark.

Coincidentally, I had a case recently with otherwise uneventful surgery, and during the I/A portion, a piece of cortex or nucleus (I’m unsure which) peeked out from under the iris. Then, when going after it, it retreated back under, never to appear again. My best efforts to find it, including forceful irrigation, hunting with I/A, and the phaco tip with vacuum were to no avail, and there came a point where I had to cease. I imagine this happens from time to time without our knowledge until when or if it makes its appearance later, but what else can one do besides monitoring for reappearance, including with the use of gonioscopy? Even if more intense or longer duration of post-operative inflammation occurs, what more can be done except use the endoscope to search or assume it’s under there stimulating inflammation and suppress it with steroids until it invisibly and presumptively absorbs?
Mitchell Gossman, M.D.
St. Cloud, Minn.

I agree with Dr. Masket. If the chip looks darker yellow, it is more likely to be central nuclear and more likely to cause a problem. Epinuclear chips and cortex resolve. I have had four to five of these over the years. Two required surgery a la Dr. Masket’s indications. A partner had one that couldn’t be found on return to the OR. Constrict the pupil, and trap it in a visco cushion as a first step to be sure it doesn’t go flying off somewhere when you enter with I/A.
Donald Savage, M.D.
Kingston, Pa.

Editors’ note: The physicians who participated in this month’s column have no financial interests related to their comments.

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Contact information

Aizuss: DAizuss@pacbell.net
Broderick: brodeyes@aol.com
Fry: LuFry@Fryeye.com
Futterman: drfutterman@yahoo.com
Gossman: mgossman@esppa.com
Holtz: Lesnsholtz@aol.com
Horn: jeff.horn@bestvisionforlife.com
Masket: sammasket@aol.com
Myers: wmyers@merle.it.northwestern.edu
Savage: donaldjsavage@gmail.com

ABOUT THE AUTHOR

J.E. “Jay” McDonald II, M.D., is the EyeMail editor. He is director of McDonald Eye Associates, Fayetteville, Ark. Contact him at 479-521-2555 or
mcdonaldje@mcdonaldeye.com.