A simple technique for nucleus extraction from the capsular bag in manual small incision cataract surgery

Dear Editor, Preserving the architecture of the capsular bag permits IOL implantation within the capsular bag, and increases the safety and efficacy of extracapsular cataract surgery. This paper describes a safe, repeatable way of extracting the nucleus from the capsular bag. Two paracenteses are created at 900sub to the main wound and a rhexis decentered towards the main incision is performed. After thorough hydrodissection is performed to ensure that the nucleus is freed from its capsular attachments and rotates freely within the capsular bag, two Sinskey hooks are introduced through the paracenteses, and the one held in the left hand is slipped under the rhexis with the tip held horizontally and pointing towards the wound (Figure 1a). The tip is advanced until the pole of the lens is reached, extrapolating the position of the tip using the distance from the pupillary margin as a guide, and it is then turned posteriorly to engage the substance of the nucleus at the equator of the lens (Figure 1b). Continued rotation moves the superior pole of the nucleus towards the margin of the rhexis and the surgeon then lifts the hook anteriorly to bring the superior pole of the nucleus into the anterior chamber (Figure 1c). The second hook held in the right hand is placed underneath the elevated superior pole of the nucleus to keep it above the margin of the capsulorhexis, and to prevent it from falling back into the bag when the first hook is retracted. The first hook is then disengaged from the nucleus and used to dial the nucleus out of the capsular bag (Figure 1d).Figure 1a: Sinskey hook passed under the subincisional rhexis margin. 1b: Sinskey hook advanced till superior pole of the nucleus and tip rotated posteriorly. 1c: Further rotation and lifting of hook elevates pole of nucleus out of the capsular bag. 1d: Second hook is placed under elevated pole of nucleus to keep the pole elevatedThe viscoelastic in the anterior chamber provides protection for the endothelium, even when this maneuver is performed with dense nuclei, with insignificant changes in the postoperative endothelial counts (unpublished data). Ideally, a rhexis size of 6 to 6.5 mm would be required for very dense nuclei, while a rhexis of 5 to 5.5 mm should suffice for less dense nuclei. However, an equivalent nucleus can be extracted through a smaller opening with this technique, than would be possible with the hydrostatic expression1 or tumbling techniques.2 This approach can be used with a small pupil, when the rhexis margin is spilt in one or more places, and in eyes with compromised zonular status. We have performed nearly fifty procedures using this technique, including the difficult situations described, with no complications.