Button Nucleus Prolapse: A Safer Approach for Hard Nucleus in Manual Small Incision Cataract Surgery

Manual small-incision cataract surgery is a widely used technique in developing countries, offering a cost-effective and efficient approach to cataract removal without compromising surgical outcomes. One of the challenges faced by surgeons, especially novices, is safely prolapsing the nucleus from the capsular bag into the anterior chamber while minimising zonular stress and preventing complications such as zonular rupture or posterior capsular rupture. This study introduces a ‘button nucleus prolapse’ technique aimed at reducing zonular stress during nucleus prolapse, particularly in mature, hard cataracts. Unlike traditional rotational or bimanual prolapse methods, this technique involves translational movement using a 26-gauge cystotome or Sinskey hook to gently lever the nucleus out of the capsular bag, followed by a second hook to prolapse the nucleus into the anterior chamber like a button. This technique offers a promising approach to minimising zonular stress, reducing the risk of posterior rupture and improving outcomes in manual cataract surgery.