Origin of intraocular metallic foreign bodies during phacoemulsification

Retained foreign objects after routine cataract surgery: a systematic review

PURPOSE

Retained foreign objects (RFOs) can place patients undergoing cataract surgery at risk for significant vision-threatening complications. In this systematic review, we examine the characteristics, clinical outcomes, and management of RFOs originating from surgical instruments or the surgical field after routine cataract surgery.

METHODS

Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, we searched five databases in June 2023. The inclusion criteria were peer-reviewed, full-text, English-language articles describing RFOs after routine cataract surgery. Studies that described non-routine cataract surgeries, patients with a history of ocular trauma, or organic RFOs were excluded. Two investigators independently extracted data and appraised the methodological quality of each study using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

RESULTS

Twenty-eight studies were included in our qualitative synthesis describing metal, fiber, and plastic RFOs. Typically, the RFOs were detected during surgery or slit-lamp examination. Presentations of patients with metal or fiber RFOs varied, with some being asymptomatic. Patients with plastic RFOs were usually symptomatic, often with decreased visual acuity and/or anterior chamber inflammation. Metal RFOs may have originated from metal fatigue from prolonged instrument usage and contact between surgical instruments, fiber RFOs from surgical wipes and gauzes, and plastic RFOs from instrument wrapping and intraocular lens defects. Factors such as location, biocompatibility, and secondary intraocular inflammation influenced the decision to surgically remove RFOs. Following surgical removal, the signs and symptoms resolved in most patients with RFOs. The studies' GRADE ratings indicated limitations in risk of bias and imprecision.

CONCLUSION

The presentation and management of RFOs varied depending on the type of material. To prevent RFOs, clinicians should carefully inspect surgical instruments and packs and use fiber-free wipes, towels, and gauzes. Future studies should investigate the efficacy and cost-effectiveness of different RFO prevention strategies.

"Phacoemulsification tip fracture and how to manage it."

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.

Intraocular foreign bodies after cataract surgery

Intraocular foreign bodies after cataract surgery are relatively frequent, and there are many cases published in the literature on this topic. Different kinds of foreign bodies of various materials can be found, and some of them with the ability to produce side effects. Their extraction is recommended whenever possible, always individualising each case. It also recommended to carry out preventive measures in all surgeries for their prevention. In this work a review is presented on the topic, considered important due to the possible ocular complications that can occur.

Intraoperative fracture of phacoemulsification tip

Phacoemulsification (phaco) is an established procedure for cataract extraction and has undergone a significant advances in techniques, machines and phaco tips. The Aspiration Bypass System (ABS) phaco tip was introduced for phacoemulsification in 1998. The ABS tip allows fluid to be drawn through the opening when the phaco tip is occluded by nuclear material. The ABS tip allowed the safe use of high vacuum and flow rates and improved chamber stability by decreasing surge and therefore reducing intraoperative complications. To date, no disadvantages of ABS tips have been reported. We report a unique case of an intraoperative break of an ABS phaco tip during routine cataract surgery.

Intraoperative fracture of phacoemulsification sleeve

Background

We describe a case of intraoperative fracture of phacoemulsification sleeve during phacoemulsification surgery.

Case presentation

Phacoemulsification surgery was performed in the left eye of a 58-year-old lady with grade II nuclear sclerosis & grade I cortical cataract. Towards the end of quadrant removal, there was anterior chamber instability with impaired followability of nuclear fragments. The distal part of the fractured sleeve remained inside the anterior chamber upon removal of the phacoemulsification probe. The retained sleeve was retrieved with a pair of forceps through the corneal incision site, which did not require widening. There was no missing fragments retained intraocularly and the patient had an uneventful recovery with vision of 20/25 at three months post-operatively.

Conclusion

Phacoemulsification sleeve fracture is an uncommon complication. With early identification of this condition and proper management, major complications can be avoided.

Migration of retained broken chopper tip after phacoemulsification

We report removal of a retained broken chopper tip after phacoemulsification. Although the foreign body was thought to be stable in the ciliary sulcus 2 months postoperatively, it dislocated into the anterior chamber 8 months later. It was removed with a microforceps under gonioscopic visualization. Although previous reports suggest that retained metallic fragments after phacoemulsification can be left in place if they are difficult to access and appear stationary, our case highlights the potential for long-term instability. We therefore recommend consideration of surgical removal with the use of gonioscopic, endoscopic, or posterior segment visualization systems, as required.

Second instrument tip breaks during phacoemulsification

BACKGROUND

Second instrument tip breaks during phacoemulsification are complications that are anecdotally recalled, yet little information exists on why and how often they occur, whether they are consistently tracked, and how they are managed. They may be an underreported, but potentially serious, complication of phacoemulsification.

METHODS

We surveyed 114 cataract surgeons in Ontario to determine reported rates of second instrument tip breaks, their management, and presumed etiology. We reviewed 4 Toronto cataract centres for incident reports, instrument sterilization processes, and purchase histories. Using scanning electron microscopy (SEM), we compared the characteristics of a broken Sweeney tip to new and used second instruments.

RESULTS

Of the 35 surgeons responding to the survey, 34% had experienced a second instrument tip break during their careers. Approximately 73% (16 cases) of the 22 cases reported were managed successfully during the procedure by the primary surgeon, 14% (3 cases) required imaging by computerized tomography or x-ray, and another 14% (3 cases) required pars plana vitrectomy for tip retrieval. Purchase histories revealed that 1 Sweeney hook was exchanged monthly, equivalent to 100 to 150 surgeries. SEM of new and used second instruments revealed signs of metal fatigue on both new and used second instruments.

INTERPRETATION

Although both physicians and hospitals lack a method for ensuring quality control of second instruments, approximately one third of cataract surgeons encounter second instrument tip breaks during the course of their careers. Although most cases are managed intraoperatively, consistent hospital tracking records and standardized instrument inspection by institutions and surgeons are needed to determine how these complications occur and to establish protocols for complication reporting and management.