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Modern cataract surgery does not allow for any residual cortical matter in the anterior or posterior chamber, not even in the capsular bag. But for a beginner, a residual cortex in the eye is preferable to a ruptured posterior capsule and its associated complications. Therefore, the surgeon can stop and allow a minor complication (retained cortical material) to prevent posterior capsular rupture.
A 52 year old female patient was operated for posterior subcapsular cataract in her right eye. Her left eye had previously gone into phthisis bulbi 5 years earlier; she underwent a 360° buckling with vitreoretinal surgery in her left eye for traumatic total retinal detachment 6 years earlier.
The surgery was performed by a resident eye surgeon who was in the learning stage of phacoemulsification. During cortical aspiration, the matter at the 12 o’clock position was proving difficult to handle for the surgeon. The surgeon therefore thought, in the best interest of the patient, that the amount of sub-incisional cortical matter (approximately 2 clock hours, extending up to the capsulorhexis margin towards the centre) would absorb over time. He did not take the risk of further manipulations and getting a posterior capsular tear.
The surgeon increased the size of the corneal incision and implanted the all-PMMA (Single-piece, Biconvex, Mod C Step Vault, from AI Optics Ltd, India) intraocular lens. (The patient could not afford any other lens and the above lens is available free of cost for deserving patients in our centre.) The wound was closed with 10/0 monofilament Nylon sutures.
The first postoperative day did not reveal any unusual inflammation. The eye was quiet on third postoperative day (first follow up). At second follow up (10th postoperative day), the operated eye revealed a white, fluffy mass (Fig 1) in the anterior chamber. This cottonwool ball-like mass was diagnosed to be retained sub-incisional cortical lens matter based on normal anterior segment and fundus findings. The IOP was 28 mm Hg in her right eye. Because of the raised IOP and the one eyed status of the patient, immediate removal of cortical lens matter was planned. The side port was used to aspirate cortical matter with topical 0.5% oxybuprocaine (proparacaine) eye drops, using a 23 gauge canula. Postoperatively there was normalisation (off oral medications) of raised IOP within 48 hours. All sutures were removed after 6 weeks (Fig 2). The final best corrected visual acuity was 6/6.
The case is reported to highlight the importance of complete removal of cortical matter. The reason for difficulty in aspirating sub-incisional cortex in our case was inferiorly decentralised capsulorhexis and corneal oedema at the incision site. Other reasons that can hamper the removal of such cortex could be positive vitreous pressure, long tunnel, fluid leakage due to divarication of incision lips, small capsulorhexis, probable miosis and corneal folds.1 The raised IOP in our case could be due to obstruction of trabecular meshwork by lens debris and inflammatory components in the form of foamy macrophages and lens particles2 and reduction of outflow facility of the anterior chamber angle. Lens debris was seen as a fluffy pseudohypopyon layer in the inferior anterior chamber; this can cause a mistaken diagnosis of postoperative endophthalmitis if associated with anterior uveitis.
The full visual recovery seen in our case could be attributed to immediate surgical intervention. The lens cortex retained in the eye after cataract extractions usually undergoes lyses by aqueous but may persist.3 The techniques that can be used to aspirate such sub-incisional cortex could be widening of the incision, mobilisation of the mass with IOL, verticalisation of irrigation/aspiration tip, using 180° bent canula by Binkhorst, bent and angled coaxial cannulas, and bimanual (one for irrigation and one for aspiration) technique.
The authors do not have any proprietary or financial interest in any product. The did not receive any public or private support.