Abstract
Purpose
To describe a rare complication of phacoemulsification (Phaco) cataract extraction.
Observations
A phaco tip fracture occurred during the sculpting of the nucleus in a cataract extraction surgery of a 60-year-old woman. The surgeon introduced the second instrument through the side port to retrieve the broken portion of the tip while maintaining it inside the sleeve.
Conclusions and improtance
Phaco tip fracture is a rare but serious complication that all cataract surgeons should be able to manage safely. Main risk factors for phaco tip fractures are: Aspiration Bypass System (ABS) phaco tip design and sterilization and reuse of instruments. A step by step plan of action was described in detail for a surgeon to manage a phaco tip fracture which mainly consists of removing the fractured phaco tip while it is still inside the sleeve to prevent any touch between the sharp broken edge of the tip and any intraocular component.
1
Introduction
The standard of care for surgical cataract extraction is phacoemulsification. In the following, we describe a rare complication of phacoemulsification surgery and propose a way to manage it.
2
Case presentation
A 60-year-old woman was admitted for phacoemulsification surgery of the left eye. Preoperative ophthalmological examination was insignificant: her best distance-corrected visual acuity was 20/40 in the right eye and 20/60 in the left eye; slit lamp examination revealed a bilateral corticonuclear cataract. Intraocular pressure and fundus examination were normal bilaterally. Her past medical, surgical and ophthalmological histories were insignificant.
Surgery was performed on the left eye under topical anesthesia with 2% Xylocaine gel. Paracentesis, temporal corneal incision, continuous curvilinear capsulorrhexis, hydrodissection and hydrodelineation were then performed uneventfully. Phacoemulsification was then carried out using a round tip 20-gauge Aspiration Bypass System (ABS) phaco tip (Infiniti, Alcon laboratories, Inc., Fort Worth, TX, USA) on the standard handpiece of the Alcon Infiniti phacoemulsification machine. During sculpting, the followability of the nucleus was poor and there was no vacuum build up in system. A break of the phaco tip, while it was still inside the sleeve, was detected by the surgeon. The break was transverse and located at the distal quarter of the phaco tip ( Fig. 1 ). The surgeon then inserted a Lebuisson manipulator (Moria/Microtek Inc., Doylestown, PA, USA) through the side port and used it to stabilize the broken distal end of the phaco tip inside the sleeve ( Fig. 2 ). He then slowly retrieved the phaco tip through the main incision while maintaining the broken end inside the sleeve using the Lebuisson manipulator. The phaco tip was replaced with a new one and nuclear sculpting was attempted again. On the second attempt of sculpting, followability was still poor and the machine signaled an error. The surgeon then manually flushed the handpiece, using a 5 ml syringe containing balanced salt solution, through the aspiration port. While flushing, resistance was initially felt and then dissipated concomitantly with small metallic foreign bodies going out of the phaco tip. To eliminate the risk of metal foreign bodies being entrapped inside the tubes, tubing was changed and the system tested successfully. The surgery was carried out with no further complications. Ophthalmological examination of the patient was normal 48-h postoperatively with uncorrected visual acuity of 20/30. Ophthalmological examination remained stable through 1 month postoperatively except for an ameliorated uncorrected visual acuity of 20/20.
