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Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 677-679

Push down technique in phacoemulsification without reversal of tarsorrhaphy: A case report

Dr Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India

Date of Submission29-Oct-2020
Date of Acceptance04-Feb-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Dhivya Ashok Kumar
Dr Agarwal's Eye Hospital and Eye Research Centre, 222, TTK Road, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2760_21

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Tarsorrhaphy usually reduces the palpebral aperture width and often requires reversal during cataract surgery and reformation. We present a case of phacoemulsification with intraocular lens implantation performed without reversal of tarsorrhaphy with the “push down technique” in a patient with cataract with left facial nerve palsy after surgical excision of acoustic neuroma. The phacoemulsification was performed in the small aperture by the push down technique, whereby the eyeball is manipulated by pushing down the phacoemulsification probe and the second instrument. The simple technique prevented an unnecessary additional surgical procedure and facilitated early rehabilitation.

Keywords: Early Rehabilitation, lateral tarsorrhaphy, narrow palpebral fissure, phacoemulsification in narrow aperture, push down technique

How to cite this article:
Kumar DA, Selvaraj JR, Narasimhan S, Agarwal A. Push down technique in phacoemulsification without reversal of tarsorrhaphy: A case report. Indian J Ophthalmol Case Rep 2022;2:677-9

How to cite this URL:
Kumar DA, Selvaraj JR, Narasimhan S, Agarwal A. Push down technique in phacoemulsification without reversal of tarsorrhaphy: A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Oct 6];2:677-9. Available from: https://www.ijoreports.in/text.asp?2022/2/3/677/351150

Facial nerve palsy reduces the ocular defense mechanisms by hampering lid closure and spread of tears across the surface and facilitating entry of foreign bodies.[1] Facial nerve palsy resulting from removal of tumors reduces lacrimal secretion.[1] Greater superficial petrosal nerve, which supplies parasympathetic fibers to the lacrimal gland, is proximal to the geniculate ganglion and is affected in these tumors.[1] Permanent tarsorrhaphy is the savior in these post-surgical patients to fight the dual attack of decreased lacrimation and defective eyelid closure. Tarsorrhaphy can be temporary or permanent depending on the cause of the facial nerve palsy and the reversal is decided upon patient recovery.[2] Tarsorrhaphy decreases the dimensions of the palpebral fissure and alters the ergonomics of the phacoemulsification surgery. We describe the “push down technique” of phacoemulsification in patients with lateral tarsorrhaphy without reversal, which has not been reported earlier in literature.

  Case Report Top

A 62-year-old female with complaints of diminished vision in the left eye of 1 year duration presented to our hospital. On examination, her visual acuity in the left eye was finger counting close to face with nuclear sclerosis grade 3 with dense posterior subcapsular cataract. She had permanent lateral tarsorrhaphy in place [Figure 1] with mild lagophthalmos 2 mm. Fundus examination was hazy due to the cataract, and her intraocular pressure in the left eye was within normal limits. She had nuclear sclerosis grade 2 cataract in the right eye with best corrected visual acuity of 6/9. The horizontal palpebral aperture height measured was 30 and 20 mm in the right and left eyes, respectively. The vertical fissure height was 10 and 7 mm in the right and left eyes, respectively. After physician's opinion and informed consent were taken, phacoemulsification with Intraocular lens (IOL) in left eye was planned.
Figure 1: (a) Preoperative and (b) postoperative (6 months) colour photographs of the patient

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Under peribulbar anesthesia with sterile aseptic precautions, the operating field was prepared. Universal eye speculum (adult) was used to separate the lids. Side port incision was made at superior 2 o′clock position of the cornea, and rod in the side port was used to push the globe down. With the rod pushing the globe down, curvilinear capsulorhexis was done using a cystitome. A 2.8-mm, clear corneal main port incision was made at 10 o′clock position. Hydro-dissection and delineation were done. During the phacoemulsification step, the phaco probe (in the main port) and the chopper (side port) were manipulated to push the eyeball sequentially down [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d unlike the routine procedure. Phacoemulsification was performed with stop and chop technique [Figure 3]a and [Figure 3]b, and intraocular lens was implanted in the capsular bag after cortical aspiration. After washing the viscoelastic device, the anterior chamber was reformed with balanced salt solution. The eye was patched after subconjunctival antibiotic steroid injection.
Figure 2: Illustration of the push down technique. (a) Exposure after speculum application in a normal palpebral aperture. (b) Exposure after speculum application after lateral tarsorrhaphy. (c) Normal phacoemulsification technique. (d) Push down technique

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Figure 3: Intraoperative external photographs showing the positioning of instruments and globe (a and b)

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On the first postoperative day, she had mild striate keratopathy in the central cornea and was started on topical antibiotic steroid combination drops, 5% sodium chloride eye drops, and topical 1% carboxymethyl cellulose lubricant. In her follow-up visit 6 months post-surgery, the patient had best corrected visual acuity of 6/6 and N6 with specular count of 1175 cells/mm3. Anterior segment optical coherence tomography was within normal limits [Figure 4].
Figure 4: Immediate (a) and 6 months postoperative (b) anterior segment optical coherence tomography, and clinical picture at 6 months (c)

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  Discussion Top

Narrow palpebral fissure can be a congenital or an acquired condition. It is often noted in conditions like microphthalmos, nanophthalmos, children with fetal alcohol syndrome, status post-lateral tarsorrhaphy, post-trauma, and chemical injury, post-leprosy, and so on. Nanophthalmic eyes respond disastrously to the intraocular surgeries, resulting in vision-threatening complications.[3] In nanophthalmic and microphthalmic eyes, along with narrow palpebral fissure, there is crowding of the anterior chamber structures, which makes the manipulation of nucleus difficult in the eye. In eyes post-tarsorrhaphy, there is no crowding of anterior chamber structures, thus making manipulation of nucleus in the eye a possibility.

Pushpoth et al.[4] described lateral canthotomy in a patient before phacoemulsification surgery, followed by lateral tarsal strip to reattach the lower lid. There have been a few surgical demonstrations describing the usefulness of a pediatric eye speculum for better exposure in patients with narrow palpebral fissure and for the prevention of eye squeezing in patients with narrow palpebral fissure by using intravenous midazolam, thereby relaxing the eyelids and facilitating exposure. Other possible techniques that can be tried are changing the surgeon's position, placement of tractional sutures, and the use of self-retaining eye speculum.

Percentage of endothelial cell loss is significantly higher after phacoemulsification in nanophthalmic eyes.[5] This could be explained by the smaller anterior chamber with narrow working space, which makes the fluidics of phacoemulsification to cause more endothelial loss. In our technique, endothelial damage was reduced by pushing and holding the nucleus away from the corneal endothelium. Though initially cell loss was noted, cornea recovered in the postoperative period. Hence, the technique has to be cautiously performed in eyes with shallow anterior chamber or preoperative low endothelial cell count. Moreover, the maneuver can be performed only in eyes with stable capsular bag and preoperative healthy corneal endothelium.

  Conclusion Top

In our push down technique, without the use of any other special equipment, we manipulate the eye by pushing the globe slightly downward using the phacoemulsification probe and the second instrument, thereby increasing the visibility. Our technique can be used irrespective of the surgeon's positioning and incision position. With use of less phacoemulsification energy and proper use of viscoelastic agents, corneal endothelium protection can be achieved. This technique can be used in phacoemulsification surgery in patients with narrow palpebral fissure without cantholysis or reversal of tarsorrhaphy, especially in eyes where reversal of tarsorrhaphy is not permissible because of permanent nerve damage.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Wesley RE, Klippenstein KA, Glascock ME, Jackson CG, Fezza JP. Lateral tarsorrhaphy in management of facial palsy. ANN Ophthalmol 2000;32:95-7.  Back to cited text no. 1
Rajak S, Rajak J, Selva D. Performing a tarsorrhaphy. Community Eye Health 2015;28:10-1.  Back to cited text no. 2
Singh OS, Simmons RJ, Brockhurst RJ, Trempe CL. Nanophthalmos; A perspective on identification and therapy. Ophthalmology 1982;89:1006-12.  Back to cited text no. 3
Pushpoth S, Tambe K, Sandramouli S. Lateral cantholysis for cataract surgery. Ophthalmic Surg Lasers Imaging 2008;39:225-7.  Back to cited text no. 4
Rajendrababu S, Wijesinghe HK, Uduman MS, Kannan NB, Mishra C, Prajna L. A comparative study on endothelial cell loss in nanophthalmic eyes undergoing cataract surgery by phacoemulsification. Indian J Ophthalmol 2021;69:279-85.  Back to cited text no. 5
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