1.
PARS PLANA VITRECTOMY IN LENS
DROP WITH VIDEO DEMONSTRATION
PRESENTED
BY
DR. AVURU CHUKWUNALU JAMES
1ST FEBRUARY 2023

2.
OUTLINE
 Introduction and brief over view of pars plana vitrectomy
 Lens fragments/nucleus drop, risk factors and precautions
 Timing of pars plana vitrectomy
 Pre-operative assessment
 Surgical material and instrument set-up
 Intraoperative options for nucleus removal
 Surgical procedures
 Visual outcome and challenges
 Conclusion
 References

3.
INTRODUCTION/ADVANCES
 Pars plana vitrectomy is a microsurgical procedure for removal of
the vitreous body via the pars plana.1,2
 The pars plana is a safe zone that avoids damage to the retina or
crystalline lens
 Sclerostomies are created: 3mm, 3.5mm, 4mm lens status
 David Kasner described vitrectomy using an open-sky technique
in 1969.2
 Robert Machemer created the first closed system vitrectomy
setup in 1971 –using 17-gauge instruments with a pars plana
approach with IOP control

4.
PPV HISTORY OF ADVANCEMENTS
 Conor O’Malley and Ralph Heintz developed the modern-day
three-port vitrectomy system in 1974 USING 20G instruments.
 Robert Machemer and Dyson Hickingbotham developed trocar-
cannula system
 Gholam Peyman and Claus Eckard; 23-gauge instrumentation
 Gildo Fujii and Eugene de Juan; 25-gauge instrumentation
 Yusuke Oshima and colleagues; 27-gauge instrumentation in
2010

5.
INDICATION—Retinal detachment
 Rhegmatogenous RD –
Uncomplicated.3
 Posterior breaks
 Multiple breaks in
different meridians
 RD Associated vitreous
hemorrhage
 RD with no breaks seen

6.
INDICATIONS—Retinal detachment contd
 Rhegmatogenous RD –
Complicated RD.2,3
 Severe proliferative
vitreoretinopathy
grade C or more
 Giant retinal tear
 Tractional RD threatening
fovea

7.
INDICATIONS-OCULAR TRAUMA
 Severe ocular trauma with
intraocular foreign body (IOFB).2,3
 Trauma associated with
endophthalmitis
 IOFB impacted on retina or in
vitreous
 Trauma with vitreous
hemorrhage)
 Large, nonmagnetic or organic
IOFB

8.
INDICATIONS- proliferative
vitreoretinopathies
 DM, CRVO, BRVO, SCR,
ROP etc
 Vitreous haemorrhage
 Tractional RD
 NVG with vitreous
haemorrhage

9.
INDICATIONS- Macular diseases
 Epiretinal membrane
(ERM)
 Macular hole

10.
INDICATIONS-POSTERIOR SEGMENT
INFLAMMATION
 Chronic posterior segment
inflammation/vitritis
 Therapeutic and
Diagnostic vitrectomy

11.
INDICATIONS- Complications of anterior
segment surgery:
 Postoperative
endophthalmitis
 Dropped nucleus
 Massive expulsive
hemorrhage
 Malignant glaucoma

12.
LENS FAGMENTS AND NUCLEUS DROP
 Posterior dislocation of a part or the whole Lens
nucleus into the vitreous cavity.4
 The Incidence of nucleus drop following a PCR is 0.3%-
1.1%.5 0.68% for SICS.6
 Nuclear material is poorly tolerated in the eye; however,
epinucleus followed by cortical material, are better
tolerated.
 Lens fragments less than 2 mm in size can often resolve
with medical management
 When fragments are larger than 2 mm in size or when the
entire lens/capsule complex has descended posteriorly,
vitreoretinal intervention is usually required.5

13.
Risk factors for lens drop- pre-operative
 TYPES OF CATARACT;
 Mature or Hypermature cataracts
(posterior capsule may be thin and
the zonules weak
 Traumatic cataract; posterior
capsule or zonule may be damaged
 posterior polar cataracts
 SMALL PUPILS;
 Pseudoexfoliation; weak zonules
 DM, Posterior synechiae, longterm
use of pilocarpine, senescence,
congenital( coloboma)

14.
Risk factors for lens drop- pre-operative
factors contd
 HIGH AMMETROPIA;
 A small eye with a crowded
anterior segment
 large eye with a loose
capsule
 PREVIOUS VITRECTOMY; Lack of
vitreous support
 CONNECTIVE TISSUE DISEASES;
e.g Marfan's syndrome
 AGE

15.
Risk factors for lens drop-intraoperative
 SURGEON’S EXPERIENCE AND
INSTRUMENTS
 Posterior extention of capsular
tear during anterior
capsulotomy or its radial
Progression
 Visible tears in the Posterior
capsule during hydrodissection
 A posterior capsule torn by an
instrument or a sharp
 A zonular dialysis larger than 3
clock hour during manipulations
 Problems of shallow anterior
chamber

16.
lens nucleus/cortex drop- without intervention
 Some lens fragments absorb and
cause no complication and others
do not absorb and cause
complications
 Floaters
 Raised IOP/ glaucoma
 Corneal edema (33-85%)
 Uveitis/ phacoanaphylactic
endophthalmitis
 Cystoid macular edema (7-41%)
 Retina breaks and detachment (7-
8%)

17.
Tips and management by the cataract
Surgeon
 Early ecognition of posterior capsular
(PC) tear reduces chances of vitreous loss
and dropped fragment.
 Signs of Posterior Capsular rupture
 Sudden deepening of anterior
chamber, with slight dilation of pupil.
 Sudden, transitory appearance of a
red reflex peripherally.
 difficulty in holding nuclear fragments
 descent of the nucleus away from the
instruments
 Pupillary snap sign

18.
Decision making by cataract surgeon
intraoperatively and before refferal
 Size of dropped lens material
 Prolapsed vitreous or not( anterior vitrectomy machine, sponge and
scissors vitrectomy)
 Adequate capsular support or not
 Primary objective is retrieval of retained nucleus fragment without
aspirating vitreous
 Retained fragments can be brought into anterior chamber by the use
of Ophthalmic Viscoelastic Device (OVD).
 Availability and proximity to a vitreoretinal surgeon

19.
CONTD
 Even If Nucleus has dropped in the Vitreous cavity and optimal Three
Port Parsplana vitrectomy is immediately not available, then
 Minimizing collateral damage by safe Management of Anterior
Vitreous
 Cortical Clean-up
 Ensure stable IOL implantation, wherever possible
 Tight wound closure with suture
 Remove viscoelastic from the anterior chamber
 Provide referral for prompt vitreoretinal consultation

20.
TREATMENT-
medical
 The aim is to treat secondary complications such as intraocular
inflammation and elevated IOP
 Topical Non steroidal anti-inflammatory drugs or topical steroids to
control inflammation
 Cycloplegic agents
 Topical +/- oral IOP lowering drugs and topical/systemic steroids
 Prophylactic topical antibiotics- routine post op medication

21.
TIMING OF PPV FOR LENS FRAGMENTS/NUCLEUS
DROP
 TIMING.5,7
 Delayed Vitrectomy; Glaucoma and Corneal edema may
result
 Availability of a Vitreoretinal specialist
 Vitrectomy for dislocated nuclear/ lens fragments should
be done ideally within 1 week
 Can be delayed up to 3 weeks without significant
difference in the Visual Outcome

22.
Pre-Operative assessment-Must be in
referral form
 Sent to vitreoretinal Surgeon; should include.
 Amount of retained lens material
 Type of retained lens material
 Hardness of retained lens material
 Presence/absence of an IOL implant
 Assessment of Capsular Support
 Calculated IOL power.4,5

23.
Pre-Operative assessment(VR surgeon)
 Visual acquity
 Slit lamp Examination; eternal
eye, anterior and posterior
segment
1. Assess corneal clarity
2. Integrity of the cataract wound
should be verified.
3. Grade the degree of anterior
chamber inflammation
4. Intraocular Pressure. 4,5
 Indirect Ophthalmoscopy
1. Assess nuclear fragments
2. Exclude Peripheral Retinal
tears,
3. Retinal Detachment or
Choroidal detachment.4,5

24.
Pre-Operative assessment contd
 B-Scan Ultrasonography in cases of
Media haze.4,5
 corneal oedema
 Vitreous Haemorrhage
 Size of lens
 RD
 Other routine investigations-
 Optimize patient for surgery-
FBC, FBS, RVS, Serum E/U/Cr,
ECG-individually tailored to
health condition

25.
Surgical Procedure/materials/set-up
 A three-port pars plana Vitrectomy is
the procedure of choice and standard
of care.
 Vitrectomy machine and
consumables
 Trocar and cannular
 Connection for fluid
 Air tube connector(If FAE is
needed- RD)
 Connecting tube for oil, heavy
liquid or gasses
 Connection for light/ illumination
 Connection for endolaser probe

26.
Surgical Procedure/materials/set-up
contd
 Hybrid or mixed gauge
vitrectomy is performed with
an active 20 G port for
introduction of a Large–bore
Fragmatome
 A fragmatome is similar to a
PHACO probe without an
infusion Sleeve.8,9

27.
Procedure- pars plana vitrectomy
 Choice of anaesthesia
 Routine cleaning and
drapping
 Set up of microscope/ BIOM
 Creating sclerostomies -
various port sizes vis-à-vis
wound size and choice of
instruments

28.
Procedure- tips
 Smaller gauge systems allows for
faster visual recovery and less
post-operative inflammation but
may preclude removal of
moderate-sized or denser lens
fragments
 larger lens fragments-
phacoemulsification probe or 20-
gauge fragmatome. 4,5, 8,9

29.
Highlights of key points
 Remove all the vitreous from Anterior
Chamber/ primary cataract wound (if
present)
 Intravitreal Triamicinolone acetonide;
better visualization of vitreous.
 Core vitrectomy: All the vitreous
attachment to the lens fragment/nucleus
must be removed– tractions
 Induction of PVD is a must in an eye with
no complete PVD
 Once core and peripheral vitreous are
removed, then removal of lens material
follows

30.
Removal of dropped nucleus/lens
fragments
 Soft nucleus/ lens fragment
a. Vitrectomy cutter
 Hard Nucleus
a. Fragmatome
b. Removal from limbal route
b. Removal from limbal route
I. Floatation with PFCL
II. Use of pick/MVR blade to
elevate
III. Elevating Nucleus/lens fragment
by active suction(flute cannular)
IV. Adjunctive devices; “Frag Bag” , a
retractable basket made from
nitinol allows retrieval and
stabilization of the lens material in
the mid-vitreous cavity

31.
Removal of soft dropped nucleus/lens
fragments
 Removal by Vitrectomy cutter
 Key Points : – Cut rate should be
low near 600-800 cuts per minute
with suction on the higher side.
 Few drops of PFCL can be used as
a cushion to prevent the nucleus
pieces falling directly over the
macula and causing damage to it.
 Light pipe can be used to crush the
nucleus against the cutter probe
for easy cutting

32.
Removal with Fragmatome
 PhacoTip without Sleeve
 Perform vitrectomy (as stated
earlier) prior to use of an
ultrasonic fragmatome-
 Reducing fragmentation power to
only 5 -10 % facilities nuclear
extraction by continuous
occlusion of the suction port and
avoidance of projectile
fragments
 Use a small bubble of PFCL for
protecting retina from projectile
nuclear fragments

33.
Removal/Delivery via limbal route
 Vitrectomy as stated earlier
 Elevating Nucleus by active
suction with the hard tip flute
cannula and bringing it to
anterior chamber.
 Using a pick/MVR blade to
elevate it in the anterior
chamber. This may cause damage
to underlying retina.

34.
Using PFCL(Perfluorocarbon liquid) to
float the nucleus
 All the nuclear fragments floats above
the bubble and can be removed
 it can be utilized with accompanying
retinal detachment.
 Caution; nuclear fragments tends to
slip over the meniscus to the
periphery, hence meticulous
examination of periphery also help in
visualization and removal of these
fragments
 Meticulous removal of PFCL must be
ensured at the completion of procedure-
prevent ocular toxicity.

35.
Peripheral examination intraop
 INDENTATION;
I. Locate any breaks pre-existing or
surgically inadvertently caused
II. Manage breaks by barraging them
with laser intra operatively
III. Reduces chances of post operative
retinal detachment

36.
COMPLICATIONS OF PROCEDURE
 Raised Iop
 Retinal Tear
 Hypotony
 Choroidal Effusion
 Suprachoidal Haemorrhage
 Vitreous Haemorrhage
 Endophthalmitis
 Cystoid Macula Edema
 Optic Neuropathy
 Phototoxicity

37.
Visual Outcome Post PPV For Nucleus
Drop
 With adequate management, a Visual Acuity of 6/12 is achievable in
60-80 % cases with dropped nucleus
 Outcome in
 Early vs Late PPV. 7 - 60 eyes; 30eyes PPV in 1week and 30 eyes
PPV > 1week(Iran): Visual outcome 6/18 vs 6/60
 Dhaka, Bangladesh.12 -3yr review of outcome of dropped lens in Dhaka,
Bangladesh- 32 eyes. Phacos. 6/18 or better in 10%. LP and NPL 9% each.
 Nigeria(LUTH).6 4 eyes. 3 had PPV. CF and HM

38.
CONCLUSION
 Pars plana vitrectomy surgery is an essential part of an
ophthalmic unit.10
 Developing the vitreo retinal units in order to improve vision
in cases such as lens nucleus/ fragment drop is vital
 Availability of VR centres and timely intervention can result in
retaining useful vision.

39.
REFERENCES
1. Connecticus retina consultants. Pars plana vitrectomy. Available from
https://www.ctretina.net/contents/procedures-surgeries/pars-plana-vitrectomy
2. Dan Gong, ., Alex Kozak, Vinay A. Shah , Leo A. Kim, Dan Gong. Pars Plana Vitrectomy. EyeWiki.
Available from
https://eyewiki.aao.org/Pars_Plana_Vitrectomy#:~:text=Pars%20plana%20vitrectomy%20(PPV)
%20is,in%20a%20controlled%2C%20closed%20system.
3. Wong TY. Ophthalmology examination review. 2nd Ed.Indications for vitrectomy. Page 191.
4. Michael J, Venincasa, Bs, Jayanth S, Rahul T. Surgical Management of a Dropped Lens
as a Complication of Cataract Surgery. Retina physician. May 1, 2018. Available from
https://Venkateswaran N, Medina-Mendwww.retinalphysician.com/issues/2018/may-2018/surgical-
management-of-a-dropped-lens-as-a-complic
5. ez C, Amescua G. Perioperative Management of Dropped Lenses: Anterior and Posterior Segment Considerations
and Treatment Options. Int Ophthalmol Clin. 2020 Summer;60(3):61-69. doi: 10.1097/IIO.0000000000000322.
PMID: 32576724; PMCID: PMC8439552.

40.
REFERENCES contd
6. Rotimi-Samuel Adekunle, Onakoya Adeola Olukorede, Aribaba Olufisayo Temitayo, Musa
Kareem Olatubosun, Alabi A Sunday, Akinsola Folashade Nucleus drop during small incision
cataract surgery: A report of four cases. Bolanle 2015 | Volume: 22 | Issue Number: 4 | Page:
237-240
7. Salehi Ali e’tal. Visual outcome of early and late pars plana vitrectomy in patients with dropped
nucleus during phaecoemulsification. J Res Med Sci. 2011 Nov:16(11): 1422-1429
8. Nene AS et al. Phaco-handpiece usedas a Fragmatome for managing nucleus drop. Indian J
Ophthalmol. 2023 Jan;71(1):320.
9. Gilliland GD, Hutton WL, Fuller DG. Retained intravitreal lens fragments after cataract
surgery. Ophthalmology. 1992;99(8):1263–1267; discussion 1268–1269. [PubMed] [Google
Scholar]
10. Sunday OT. Should Posterior Vitrectomy be Made a Priority in Ophthalmic Facilities of Sub Sahara Africa? Open
Ophthalmol J. 2013;7:1-3. doi: 10.2174/1874364101307010001. Epub 2013 Jan 16. PMID: 23459116; PMCID:
PMC3582012.

41.
11. Nakasato H, Uemoto R, Kawagoe T, Okada E, Mizuki N. Immediate removal of posteriorly
dislocated lens fragments through sclerocorneal incision during cataract surgery. The
British journal of ophthalmology. 2012;96(8):1058–1062. [PubMed] [Google Scholar]
12. Olokoba, Lateefat & Islam, Md & Nahar, Nazmun & Mahmoud, Abdulraheem &
Olokoba, Abdulfatai. (2017). A 3-Year Review of the Outcome of Pars Plana
Vitrectomy for Dropped Lens Fragments after Cataract Surgery in a Tertiary Eye
Hospital in Dhaka, Bangladesh. Ethiopian Journal of Health Sciences. 27. 427.
10.4314/ejhs.v27i4.14.
13. Dhanashree Ratra, Vineet Ratra,Sukant Pandey Sankara Nethralaya, Chennai.
Management of Dropped Nucleus and Retained Lens Fragment.
eOphtha.April 1st, 2021. Available from
https://www.eophtha.com/posts/management-of-dropped-nucleus-and-retained-lens
14. Yu Qiang Soh, Daniel S.W, Edmund Y.M. Wong. Diagnosis and Management of
Posteriorly Dislocated Lenses. AAO.EyeNet Magazine. October 2017. Available
from https://www.aao.org/eyenet/article/management-of-posteriorly-dislocated-
lenses-fragment

42.
THANK YOU