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   Table of Contents      
SURGICAL TECHNIQUE
Year : 2020  |  Volume : 68  |  Issue : 10  |  Page : 2202-2204

Sinskey hook and viscoelastic assisted posterior capsular plaque extraction


Department of Ophthalmology, Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Submission08-Nov-2019
Date of Acceptance01-Mar-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Rinky Agarwal
Cornea, Cataract and Refractive Services, Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India institute of Medical Sciences, Ansari Nagar, New Delhi - 110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2013_19

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  Abstract 


Posterior capsule plaques (PCPs) are a rare cause of suboptimal vision after eventless cataract surgery. While these can be managed with posterior capsulotomy, violation of the posterior capsular integrity and associated vitreous disturbances may lead to sight-threatening complications. Viscoseparation and peeling of PCPs with the aid of retinal end-grasping forceps and irrigation and aspiration have also been described in adults for getting rid of PCPs with minimal disturbance of PC and vitreous. While Sinskey hook (SH) has been used to peel PCPs in children, the combined use of SH with viscoseparation for removal of PCP, particularly for adults, remains vaguely described in the literature. Presently, we describe a method of SH and viscoelastic assisted PCP extraction (SVAPE) in adult eyes with centrally located PCPs.

Keywords: Posterior capsular plaque, posterior capsule, Sinskey hook, viscoelastic


How to cite this article:
Agarwal R, Dhull C, Siddhu N, Jain V, Sharma N. Sinskey hook and viscoelastic assisted posterior capsular plaque extraction. Indian J Ophthalmol 2020;68:2202-4

How to cite this URL:
Agarwal R, Dhull C, Siddhu N, Jain V, Sharma N. Sinskey hook and viscoelastic assisted posterior capsular plaque extraction. Indian J Ophthalmol [serial online] 2020 [cited 2020 Oct 31];68:2202-4. Available from: https://www.ijo.in/text.asp?2020/68/10/2202/295690



Posterior capsule plaques (PCPs) are a rare cause of suboptimal vision after eventless cataract surgery.[1],[2] These can be managed with posterior capsulotomy performed either in the primary (with cystitome and Utrrata forceps, vaccuum or vitrectome assisted capsulorrhexis) or in the secondary (membranectomy or laser capsulotomy) sitting.[3],[4] However, primary capsulotomy can violate the integrity of posterior capsule (PC), cause vitreous disturbance, and necessitate vitrectomy.[5] While these can be undertaken in patients already planned for vitrectomy (for example, children), loss of PC integrity may prevent successful in-the-bag placement of intraocular lens (IOL) and may also result in sight-threatening complications due to vitreous loss. Second, not all PCPs can be amenable to secondary capsulotomy due to its thickness, size, and adhesions with PC and carry the risk of IOL damage.

Viscoseparation and peeling of PCPs with the aid of retinal end-grasping forceps and irrigation and aspiration (IA) probe in the primary sitting has been described in adults for getting rid of PCPs with minimal disturbance of PC and vitreous.[2],[6] While Sinskey hook (SH) has been used to peel PCPs in children, the combined use of SH with viscoseparation for removal of PCP, particularly for adults, remains vaguely described in the literature.[6],[7] Presently, we describe a method of Sinskey hook and viscoelastic assisted PCP extraction (SVAPE) in adult eyes with centrally located PCPs [Table 1].
Table 1: Clinical data of patients subjected to SVAPE technique

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  Surgical Technique Top


In eyes with residual PCP after phacoemulsification, a plane is created between the PCP and the PC by gently and carefully lifting one of its margins away from the PC with the aid of SH. Following this, a VES (preferably a cohesive VES) is injected (using 30-gauge cannula) underneath this lifted edge to mechanically dissect the PCP away from the PC [[Figure 1] and [Figure 2], Video 1]. The PCP is further dissected with short side-wards motions of SH at either margins of the lifted plaque till a sufficiently large flap that can be lifted easily with micro-forceps or IA probe is created. The choice of forceps or IA probe depends on the size, thickness, and adhesions of PCP. Following this, the posterior chamber IOL is safely injected in the bag and wound hydrated or sutured.
Figure 1: Animated lateral (a-c) and supine microscopic (d-f) views showing steps of SVAPE technique; intraoperative appearance of posterior capsule plaque (PCP) (a and d); lifting its edge with Sinskey hook (b and e); injection of viscoelastic underneath the lifted edge (c and f)

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Figure 2: Intraoperative appearance of PCP (a); lifting its edge with Sinskey hook (b); injection of viscoelastic underneath the lifted edge (c); removal of residual PCP with micro-forceps (d); complete removal of PCP (e); intraoperative appearance after its complete removal (f)

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We have employed this technique in seven patients with successful in-the-bag IOL implantation and noted good gain of visual acuity and a clear and intact PC till 3-month follow-up [Figure 3] and [Table 1].
Figure 3: Intraoperative appearance of posterior capsule before (a-c) and after (d-f) removal of PCP with SVAPE technique

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  Discussion Top


As thick PCPs can cause visual disturbances in the postoperative phase and may not always be amenable to laser capsulotomy, leaving them in situ during primary cataract surgery may not be desirable. However, as previously mentioned, inadvertent PC tear can occur during removal of these plaques, especially if they are large and/or densely adherent to the PC. Initial separation of PCP with a blunt instrument such as SH in our technique may be associated with minimal damage to the PC in comparison to other techniques where a cystitome is used to puncture the PCP or PC. We believe that this may allow for a safe in-the-bag placement of IOL and also aid in preventing resultant complications associated with vitreous disturbances. In addition, mechanical dissection of PCP away from the PC by use of VES and sidewards dissection of its margins with SH in our technique may reduce adhesions between these two structures. This may decrease the risk of inadvertent PC tear by circumventing the need for forceful adhesiolysis sometimes required with direct peeling of PCP with forceps. This technique may be particularly advantageous in silico ne oil-filled eyes where inadvertent rupture of PC during PCP removal can result in unplanned loss of oil and also while operating cataracts secondary to ocular trauma where the PCP may be densely fibrous and adherent to the PC.


  Conclusion Top


To conclude, SVAPE can be a useful technique of plaque removal in adult eyes with centrally located PCPs. However, while this technique can be employed for all types of PCPs anterior to the PC, the PCPs located posterior to the PC may not be amenable to this technique and may require capsulotomy. In addition, larger comparative studies are required to evaluate the long-term effects of this technique on the postoperative visual outcomes and the clarity and integrity of PC.

Acknowledgement

We thank our Institute for allowing us to continue with our research work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vasavada A, Chauhan H, Shah G. Incidence of posterior capsular plaque in cataract surgery. J Cataract Refract Surg 1997;23:798-802.  Back to cited text no. 1
    
2.
Joshi RS. Primary posterior capsular opacification in Indian rural population undergoing cataract surgery for hypermature senile cataract. Clin Ophthalmol 2013;7:1605-8.  Back to cited text no. 2
    
3.
Biró Z, Kereskai L, Tsorbatzoglou A, Vasavada AR, Berta A. Histological examination of primary posterior capsule plaques. J Cataract Refract Surg 2007;33:439-42.  Back to cited text no. 3
    
4.
Praveen MR, Shah SK, Vasavada AR, Vasavada VA, Asnani PK, Anwar I, et al. Incidence, management, and postoperative outcomes in pediatric eyes with coexisting posterior capsule plaque and cataract. J Cataract Refract Surg 2010;36:2094-9.  Back to cited text no. 4
    
5.
Vasavada AR, Praveen MR, Jani UD, Shah SK. Preoperative prediction of posterior capsule plaque in eyes with posterior subcapsular cataract. Indian J Ophthalmol 2006;54:169-72.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Landa G, Pham K. Manual removal of primary posterior capsular plaques using retinal end-grasping forceps. Ophthalmol Ther 2017;6:351-3.  Back to cited text no. 6
    
7.
Khokhar SK. Atlas of Pediatric Cataract. Springer, 2019. p. 157.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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