|Year : 2009 | Volume
| Issue : 1 | Page : 23-25
Nucleus management with Blumenthal technique: Anterior chamber maintainer
Krishan PS Malik1, Ruchi Goel2
1 Safdarjung Hospital, Vardhman Mahavir Medical College, New Delhi, India
2 Guru Nanak Eye Center, Maulana Azad Medical College, New Delhi, India
|Date of Submission||18-Jan-2007|
|Date of Acceptance||16-May-2007|
|Date of Web Publication||12-Dec-2008|
513/514, First Floor, Double Storey, New Rajinder Nagar, New Delhi-110 060
Source of Support: None, Conflict of Interest: None
The Blumenthal`s 'Mininuc' technique enables nuclear expression through a 5-6.5-mm sclerocorneal tunnel incision using a Sheet's lens glide and anterior chamber maintainer (ACM). A 6-mm or larger capsulorrhexis, reduction in nuclear size by hydroprocedure and its manipulation manually into the anterior chamber are performed. The nucleus is expressed out of the chamber by use of hydrostatic pressure created by balanced salt solution delivered continuously through the ACM. This continuous flow from ACM to anterior chamber keeps the eye under positive pressure physiological state besides clearing the chamber of cortex, blood and pigments offering excellent visualization. The procedure, with an initial learning curve, is highly effective, applicable to all grades of cataracts, has minimum intraocular instrumentation resulting in an early rehabilitation of the patient.
Keywords: Anterior chamber maintainer, blumenthal, scleral tunnel, lens glide
|How to cite this article:|
Malik KP, Goel R. Nucleus management with Blumenthal technique: Anterior chamber maintainer. Indian J Ophthalmol 2009;57:23-5
|How to cite this URL:|
Malik KP, Goel R. Nucleus management with Blumenthal technique: Anterior chamber maintainer. Indian J Ophthalmol [serial online] 2009 [cited 2020 Apr 7];57:23-5. Available from: http://www.ijo.in/text.asp?2009/57/1/23/43047
The success of a cataract surgery is determined in terms of quicker visual and functional recovery. This is closely related to the size of the wound. In the early 1980s, phacoemulsification was the only available technique for achieving a small incision. Alternative methods were then introduced and Keener  in 1983 used a constricting wire loop. Fry  gave the phacosandwich technique and Peter Kansas  proposed the technique of phacosection. But it was the development of the sclerocorneal pocket tunnel incision by Kratz  which revolutionized the non-phaco manual small incision cataract surgery (MSICS).The novel innovation of anterior chamber maintainer (ACM) by Blumenthal  in 1987 was another cornerstone which permitted a high-pressure and high-flow system, providing a physiological environment throughout the surgery requiring minimal intraocular instrumentation. The purpose of this article is to describe the detail of nucleus delivery by the Mininuc technique of Blumenthal.
| Mininuc Technique|| |
The Mininuc technique can be performed under peribulbar or topical anesthesia. A normotensive state facilitates the construction of sclerocorneal pocket tunnel, delivery of nucleus and expression of epinucleus.  A sclerocorneal pocket tunnel is dissected with an external incision varying from 5-6.5 mm depending upon the size of the endonucleus.  Creation of large side pockets is essential for accommodating the largest of nuclei [Figure 1]. 
Two small beveled entries are made using a 19 or 20G microvitreoretinal (MVR) knife in the cornea adjacent to the limbus. The side port at 10 o'clock can be used for performing capsulotomy, hydrodissection, nuclear manipulation, aspiration of cortex and dialing of intraocular lens (IOL) in the bag. Another port is created at about 5 o'clock in the left eye and 7 o'clock in the right eye for introducing the ACM into the anterior chamber connected to the balanced salt solution (BSS) bottle 50 to 60 cm above the eye for building up sufficient hydropressure. 
The ACM is a hollow steel tube with a 0.9-mm outer diameter and 0.65-mm inner diameter. 
A continuous curvilinear capsulorrhexis (CCC) created under viscoelastic or fluid is preferred, though a can-opener or envelope can also be made. In a milky hypermature cataract, CCC performed under fluid through ACM can be advantageous as it washes away the white milky fluid improving the visualization of capsulorrhexis edge. 
Anterior chamber is entered by forward cutting movements using 3.2-mm keratome to produce a smooth cut which is parallel to the limbus in the cornea.
Hydrodissection and hydrodelineation are performed separating the anatomical layers of the lens from the hard core nucleus facilitating nuclear prolapse from the bag into the anterior chamber through the CCC [Figure 2].  Adequacy of hydroprocedures can be checked by bimanual rotation of nucleus using two dialers [Figure 3]. 
I Nucleus from posterior to anterior chamber
Anterior chamber is filled with viscoelastic. The free nucleus is lifted out of the bag by a Sinskey's hook introduced through the side port while taking care not to injure the capsulorrhexis margin [Figure 4]. Once a pole is prolapsed out of the bag the nucleus is wheeled out like a tube from a tyre. In the anterior chamber, viscoelastic is injected in front of and behind the nucleus to protect the endothelium.
II Nucleus from anterior chamber to delivery out of the eye
The nucleus is mounted on a lens glide, a piece of plastic 2 cm long, 4 mm wide, 0.3 mm thick, designed by Sheets in 1978  is introduced between the nucleus and the iris through the main port. The presence of the glide prevents the nucleus from being misdirected at 12 o'clock position averting a possible zonulysis. 
The ACM flow is put on and intermittent pressure is applied on the lens glide at 12 o'clock position. The point of pressure is gradually shifted posteriorly. The nucleus moves and gets engaged into the tunnel through a large (8-mm) inner opening of the tunnel, travels outwards and is eventually expressed. Raising the bottle height hastens the movement of nucleus. The remaining epinucleus and cortex can be hydroexpressed or aspirated.  Failure to engage could be due to inadequate internal wound, leaking port or vitreous in the anterior chamber.  Whenever the viscoelastic is injected into the anterior chamber, the ACM should be closed, otherwise all the viscoelastic will be expressed out of the eye during any manupulation in the anterior chamber.
Iris repositor is used instead of lens glide for railroading the nucleus.
In hard cataracts or leaking ports, viscoelastic is injected through the ACM (instead of BSS) continuously, which pushes the hard, large nucleus into the tunnel.
Once the tip of a hard nucleus presents at the outlet, it is engaged with a 23G needle and wheeled out. Debulking can also be performed by chipping off pieces from the presenting portion, pushing the nucleus back and re-engaging the reduced diameter.
The ACM is connected to the BSS and flow is started, cortex is aspirated by an olive-tipped cannula through the side port. This provides easy access to the cortex in the capsular bag all around, especially at 12 o'clock position and the deep anterior chamber guards against posterior capsular tear.
Intraocular lens implantation
The ACM is removed and chamber is filled with viscoelastic material. Alternatively, IOL can be implanted with ACM with flow of BSS alone. The IOL is implanted within the bag and side ports hydrated. The wound if required is closed with an infinity shaped '∞'; suture and conjunctiva repositioned with the help of bipolar cautery.
Endothelial cell loss by Blumenthal Technique
The endothelial cell loss reported by George et al , in nuclear sclerosis Grade 3 or less is 4.21% (SD: 10.29) at six weeks.  Wright et al , found a mean central and superior cell loss of 16% and 22% respectively at three months when only fluid was used.  The authors observed a cell loss of 5.5% at three months when viscoelastic was used for nuclear delivery.  Further studies are required for establishing the role of viscoexpression using ACM in hard cataracts.
| Conclusion|| |
The Blumenthal technique is innovative, highly effective, reproducible in all grades of cataract, involving minimal intraocular manipulation which can be performed in physiological conditions of a closed system.
| References|| |
Keener GT Jr. The nucleus division technique for small incision cataract extraction. In: Rozakis GW, Anis AY, editors. Cataract surgery: Alternative small incision techniques. Indian ed. Jaypee Brothers; 1995. p. 163-95.
Fry LL. The Phacosandwich technique. In: Rozakis GW, Anis AY, editors. Cataract surgery: Alternative small incision techniques, Indian ed. Jaypee Brothers; 1995. p. 71-110.
Kansas P. Phacofracture. In: Rozakis GW, Anis AY, editors. Cataract surgery: Alternative small incision techniques. Indian ed. Jaypee Brothers; 1995. p. 45-70.
Bryant WR. The scleral pocket incision. In: Rozakis GW, Anis AY, editors. Cataract surgery: Alternative small incision techniques. Indian ed. Jaypee Brothers; 1995. p. 1-43.
Blumenthal M, Moissiev J. Anterior chamber maintainer for extracapsular cataract extraction and intraocular lens implantation. J Cataract Refract Surg 1987;13:204-6.
Malik KP, Goel R. Our technique of Small incision cataract surgery using anterior chamber maintainer: Modified Blumenthal technique. In: Manual of small incision cataract surgery. New Delhi: CBS publishers; 2003. p. 123-35.
Natchiar G. Nucleus extraction. In: Manual small incision cataract surgery an alternative technique to instrumental phacoemulsification. India: Aravind Publications; 2000. p. 25-30.
Malik KP, Goel R. Techniques of non phaco small incision cataract surgery (SICS). In: Dutta LC, editor. Modern Ophthalmology, 3rd ed. Jaypee Brothers; 2005. p. 378-86.
Malik KP, Goel R. Versatility of anterior chamber maintainer in SICS. In: Garg A, Fry L, Carmona FJ, Pandey SK, editors. Clinical practice in small incision cataract surgery. Jaypee Brothers; 2004. p. 437-9.
Trivedi N. Blumenthals technique in MCIS. In: Garg A, Fry LL, Carmona FG, editors. Step by step manual phaco. Jaypee Brothers; 2006. p. 188-220.
Blumenthal M, Ashkenazi I, Assia E, Cahane M. Small incision manual extracapsular cataract extraction using selective hydrodissection. Ophthalmic Surg 1992;23:699-701.
Sheets JH, Maida JW. Lens glide in implant surgery. Arch Ophthalmol 1978;96:145-6.
Blumenthal M, Ashkenazi I, Fogel R, Assia EI. The gliding nucleus. J Cataract Refract Surg 1993;19:435-7.
Blumenthal M, Assia E, Neuman D. Lens anatomical principles and their technical implications in cataract surgery: Part II, The lens nucleus. J Cataract Refract Surg 1991;17:211-7.
Malik KP, Goel R. Modified Blumenthals technique. In: Singh K, editor. Small Incision Cataract Surgery. Jaypee Brothers; 2002. p. 117-22.
George R, Rupauliha P, Sripriya AV, Rajesh PS, Vahan PV, Praveen S. Comparison of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery. Ophthalmic Epidemiol 2005;12:293-7.
Wright M, Chawala H, Adams A. Results of small incision extracapsular cataract surgery using the anterior chamber maintainer without viscoelastic. Br J Ophthalmol 1999;83:71-5.
Malik KP, Goel R. Endothelial cell loss. In: Manual of small incision cataract surgery. CBS Publishers; 2003. p. 67-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
|This article has been cited by|
||Feasibility and Complications between Phacoemulsification and Manual Small Incision Surgery in Subluxated Cataract
| ||Ruchi Goel, Saurabh Kamal, Sushil Kumar, Jugal Kishore, K. P. S. Malik, Sonam Angmo Bodh, Smriti Bansal, Madhu Singh |
| ||Journal of Ophthalmology. 2012; 2012: 1 |
|[VIEW] | [DOI]|
||Use of the Anterior Chamber Maintainer in Trabeculectomy Following Vitrectomy
| ||Yuhong Wang, Li Nie |
| ||Current Eye Research. 2011; 36(3): 232 |
|[VIEW] | [DOI]|
||Outcome of dual infusion through irrigating chopper in conventional phacoemulsification
| ||Wahab, S., Faiz-ur-Rab, K., Das Hargun, L. |
| ||Journal of the Pakistan Medical Association. 2011; 61(2): 145-148 |
||Nucleus management with blumenthal technique: Anterior chamber maintainer
| ||Agrawal, R. |
| ||Indian Journal of Ophthalmology. 2010; 58(1): 85-86 |
||Blumenthal technique and its modification: The glory of anterior chamber maintainer
| ||Sahu, S.K., Das, S., Rath, S. |
| ||Indian Journal of Ophthalmology. 2010; 58(1): 86 |
|| Extracapsular cataract extraction with less incision versus the conventional performed by residents | [Cirugía de extracción extracapsular de catarata con incisión pequeña versus convencional, realizadas por residentes]
| ||Arrazola-Vázquez, J.C., Morfín-Salido, I.L., Moya-Romero, J.O. |
| ||Revista Mexicana de Oftalmologia. 2010; 84(1): 25-29 |