Risk Factors for Retained Nuclear Fragment

By Anonymous

One of my personal loves is looking at a cataract patient post-op day one and seeing a nice chunk of nucleus staring at you from the inferior anterior chamber. This happens on occasion to us all and we can usually point to the reason why it occurred. It is important to remember that nuclear fragments will not go away with steroids, so you need to go back to the OR and get it. ASAP. So back to why this happens. With this particular patient, the reasons were simple. To start, she had a lighter iris that can “camouflage” pieces of the lens that are sitting against it. She also had dense arcus senilus that can hide pieces of the lens behind it. You’d be amazed how big a piece of nucleus can hide behind arcus. I remember, during phaco, seeing a piece of nucleus go over to the side towards the angle while chopping. I finished chopping and phaco and didn’t see the piece in the area that I had previously. I thought to myself that it had likely flushed out and I had emulsified it. I swept through that area with the phaco on aspiration and no piece came to the tip. Then was rewarded the next day…

Always be meticulous about looking for pieces of lens that you’ve seen go into the angle. You can be surprised by the size of the lens material hiding there. If you are fairly certain that there is a piece, you can even lightly sweep with your second instrument. Risk factors include a lighter iris, dense arcus, and a poorly dilating iris. All can hide lens fragments. And if you do find a present in the anterior chamber on post-operative day one, don’t sweat it. Take the patient back to the OR immediately and things will be fine.