|Year : 1983 | Volume
| Issue : 7 | Page : 917-919
Tapping of fluid pockets-a better method of management of vitreous loss in cataract surgery
AP Shroff, OP Billore, AK Dubey, CB Patel
Rotary Eye Institute, Navsari, Gujarat, India
A P Shroff
Rotary Eye Institute, Navsari, Gujarat
|How to cite this article:|
Shroff A P, Billore O P, Dubey A K, Patel C B. Tapping of fluid pockets-a better method of management of vitreous loss in cataract surgery. Indian J Ophthalmol 1983;31:917-9
|How to cite this URL:|
Shroff A P, Billore O P, Dubey A K, Patel C B. Tapping of fluid pockets-a better method of management of vitreous loss in cataract surgery. Indian J Ophthalmol [serial online] 1983 [cited 2013 May 21];31:917-9. Available from: http://www.ijo.in/text.asp?1983/31/7/917/29705
Many suggestions have been recommended to minimise the chances of vitreous escape, still' a surgeon is always anxious during lens delivery.
"Don't get afraid of vitreous or it will make you afraid ever." We have followed this principle in 25 cases and have gone rather deep into the vitreous cavity to tap one or more aqueous pockets by a 20 guage needle and instead of keeping the pupil constricted, kept it dilated for obvious reason.
| Material and methods|| |
In our series of either preplaced continuous or preplaced multiple interrupted corneo-scleral sutures, the wound was loosely closed by pulling the suture/s at the time ofvitreous loss.
A thoroughly autoclaved 20 guage straight and about 2 inches long needle with 2 ml. empty syringe was introduced through corneo-scleral wound from temporal side into vitreous chamber (through pupil) for about 10 mm depth. Enough fluid (1 to 2 cc) was tapped from aqueous pockets into the syringe so as to have absolutely flat AC and concave cornea with round pupil. Air was introduced into the anterior chamber to form chamber and to build up the volume of eye ball too. Sutures were tied and wound was secured well With placing few more stitches if so required. In case vitreous mass lying over the sclera, outside the wound and if it would resist to retract back, vitrectomy was done to remove that mass with iris scissors and procedure was continued as above. Post operatively cases were treated with heavy steroids, antibiotics and antiflaugestics.
We have carried out this procedure in 25 cases where 14 were male and 11 were female; 15 were right eyes and 10 were left eyes. In 22 cases lens was delivered intracapsularly and in 3 cases there was accidental extracapsular extraction. [Table - 1].
We have graded vitreous loss according to its presentation viz Grade 1: Vitreous in anterior chamber. Grade 2 : Vitreous had presented in the wound along with lens delivery. Grade 3 : Vitreous and escaped outside the wound, on the sclera.
| Observations|| |
Though the age varies from 45 to 74 years, 16 cases were in youngest group. While two other groups had almost equal no. of cases [Table - 2].
18 cases had vitreous loss of Grade I where anterior chamber became deep just after intra capsular lens delivery while the wound was being closed. Method mentioned earlier was just enough to tackle the situation.
Grade 2 vitreous loss was observed in 4 cases and loosely tying sutures and tapping aqueous pockets were just enough to make chamber flat and cornea concave.
3 cases had vitreous loss outside the wound, on the sclera (Grade 3) where undue pressure was involuntarily exerted and facial block was fading away. Wound was loosely secured and vitreous present and sclera was cut with scissors and removed with swab. Fluid pockets were tapped as mentioned earlier and chamber could be made flat, cornea became concave and pupil was almost brought in the centre and was almost circular. [Table - 2].
Post operative period was excellent for 23 cases. Post operative inflammation and mild sepsis each in either case was noted where vitreous loss was +++, i.e. Grade 3.
Slit lamp examination revealed absence of vitreous in anterior chamber in 23 cases where there was Grade 1 and 2 vitreous loss, and only a small hole (made by needle) could be visualised just posterior to the pupillary area. In 3 cases where there was Grade 3 loss, vitreous did present in the anterior chamber but was away from corneal endothelium. In the last group of course two cases pupils had a notch in upper part suggesting small vitreous bands still present but showed no signs of corneal oedma atleast for the period of 9 to 12 months.
Visual recovery was remarkable in 17 cases of Grade 1 (i.e. 6/9 to 6/51), while 6 cases improved upto 6/24 to 6/12. Though vitreous loss was +++ in Grade 3, and post operative complications, vision could still be improved to 6/36. [Table - 3].
Indirect ophthalmoscopic examination al intervals in all cases in the post operative period for about 6 to 24 months did not show vitreous traction on retina. Though 6 months follow up in Grade 2 and 3 vitreous loss group is still short to predict any long term effect
Semi-dilatation of pupil on the table and in immediate post operative period brought quite surprising results and all cases had full air in anterior chamber on 1st dressing.
| Discussion|| |
We agree to the fact that vitreous loss is more common in younger age groups because of strong zonules. Moreover undue pressure and inadequate facial block really play very significant role in this catastrophy.
Tapping of aqueous pockets from the vitreous chamber mainly produces vacuum, thereby negative pressure inside the chamber which helps in withdrawing the prolapsed vitreous behind the iris pupil. Moreover keeping the comeo-scleral wound closed further helps to maintain negative pressue inside the vitreous chamber.
Dilatation of pupil helps in retaining air in anterior chamber because anterior and posterior chamber with dilated pupil becomes Only a single chamber and air being lighter, always occupies upper portion. Therefore, a little large amount of air can be injected in the chamber safely to raise the eye ball volume adequately.
Contrary to this excessive constriction of pupil (which is usually recommended in votrepis loss) does not only separate two chambers but probably helps in going air into the posterior chamber because of negative pressure still existing inside. This subsequently pushes iris forward and makes the chamber flat, which may lead to formation of peripleral anterior synechias and permanent rise of IOP. Profound vitreous loss cannot be managed satisfactoraly as could be visualised by irregular pupil and poor visual recovery and we believe closed anterior vitrectomy by vitrophage may be better answer, but the later technique requires extensive instrumentation and greater skill. This simple technique we believe and recommand, is very useful in majority of such cases.
| Summary|| |
25 cases who had undergone cataract surgery, had vitreous loss to a smaller or. greater extent and could be well managed by a simple technique of tapping the aqueous pockets from vitreous chamber by a 2 mm syringe and 20 gauge needle. Post operative follow up revealed anterior chamber free of vitreous in a significant number of cases with good visual recovery.
[Table - 1], [Table - 2], [Table - 3]