Chapter 9

REMOVAL OF TH
E EPINUCLEUS
REMOVAL OF THE EPINUCLEUS
After removal of the nuclear quadrants, t
here will be residual lens matter left in th
e capsular bag. This will always comprise
some cortex, the removal of which is desc
ribed in the next chapter. However, if you
achieve a thorough hydro delamination, t
here will also be a significant amount of e
pinucleus which you will need to remove.
 In terms of its characteristics, it is helpful to think of epinucleus as lying somewhere b
etween nucleus and cortex. Your supervisor should help you to distinguish these type
s of lens matter. The following points should prove helpful.

Consistency. Epinucleus is softer than nucleus, but harder than cortex. These types of lens matt
er therefore behave differently when they are engaged by an instrument or when BSS circulates t
hrough the AC
Location. Cortex is the most peripheral lens matter in the capsular bag - it lies up against the cap
sule. The nucleus forms the centre of the lens. Epinucleus is situated between cortex and the nuc
leus.
Colour. Epinucleus and cortex lack the characteristic brownish colour that the nucleus has wh
en nuclear sclerosis is present.

Identifying Epinucleus
 Instruments

As with the phaco hand piece, irrigation is gravity fe
1 d and is activated by depressing the foot pedal into
Position 1. The rate of irrigation does not alter if the
foot pedal is depressed further within Position 1.
Aspiration is activated by engaging Position 2 wit
h the foot pedal (irrigation continues to run). This
2
is signalled by a constant sound output from the
phaco machine. Higher rates of aspiration are ge
nerated by depressing the pedal further (as whe
n using the phaco probe)

if the I/A aspiration port is occluded by lens matt

er while you aspirate, vacuum is generated in the
case of a peristaltic machine). Increasing the aspi
ration rate generates higher vacuum. The increas
e in vacuum is signalled by a rise in pitch of the s
ound output.

Straight I/A: (I/A = irrigation/aspiration) The safest way to

remove epinucleus is to use the straight I/A handpiece. T
his has two irrigation ports and an aspiration port
 Instruments
I/A mode Second Instrument
I/A mode refers to the programmable machine setti The second instrument is the same as that used
ngs that apply when using this instrument. As with t during phacoemulsification (Fig 8.2).
he phaco modes, values can be pre-programmed to
suit your preferences. You can also adjust the settin
gs intra-operatively while performing I/A.

Typical values are:

• Max aspiration rate: 25cc/min

• Max vacuum: 500mmHg

• Bottle height: 65-105cm

Straight I/A: (I/A = irrigation/aspiration) The safest way to remove epinucleus is to use the str
aight I/A handpiece. This has two irrigation ports and an aspiration port
 METHOD

03
Position the I/A tip close to the corneal section and en
gage Position 1 with the pedal, activating irrigation.

02
Accept the straight I/A probe in your right hand. This is h
eld like a pen, as for the phaco probe. The aspiration por
t must face upwards.

01
Ask the assisting nurse to select 'I/A mode'
– the machine will give audio confirmatio
n.
 METHOD 0 Position the tip of the second instrument ju
st deep to the safe zone, in the centre of th
e AC (Fig 9.6) if not, try a slightly higher aspi

6
ration rate

0 Accept the second instrument in

your left hand and insert it into t

5
he AC via the paracentesis.

0 With irrigation running, insert the probe

via the corneal section. Depressing the fl

4
oor of the corneal wound gently with the
tip aids its smooth passage under the ro
of of the section into the AC (Fig 9.5).
 METHOD 0 The epinucleus will occlude the
port and you will hear the pitc
h of the audio output rise as v
acuum is generated, giving you

9
a 'grip on the epinucleus

Still irrigating only, advance the I

0 When the I/A tip reaches the epi
nu cleus, activate aspiration. Use

8
a low rate initially
/A tip towards the epinucleus sit

0 uated at the 5 o'clock position, o

pposite the corneal section. the I
/A probe thus passes over the ti
p of your second instrument Ke
once the port is occluded and
vacuum has been generated,
maintain aspiration but do not
ep a safe distance away from th

7
attempt to aspirate the epinucl
e capsulorhexis margin eus by increasing the rate yet
 METHOD

10 With epinucleus engaged, withdraw the I/A tip back to the safe zone. if you lose
grip on the lens matter, try again with a higher aspiration rate

Notice how the epinucleus is now wrapped around the tip of the seco
nd instrument, as shown in Fig 9.7 & 9.8. Now use the following mano

11 euvre to free the epinucleus in the subincisional region:

move the tip of the second instrument a few millimetres towards the
5 o'clock position and then back again (double headed arrow, Fig 9.8).
Repeat it few times as necessary

12 As the subincisional epinucleus is freed, increase the aspiration rate to aspirat

e lens matter engaged at the I/A tip

1 2
Position the second instrument tip ju
st deep to the safe zone.
4 5
Once in the safe zone, increase the a
spiration rate as necessary to aspirat
e the epinucleus.
If there are any residual pieces of epinucleus after the
above manoeuvre, proceed as follows:
3
With the pedal in Position 1, advance
the I/A tip to the targeted lens matte Activate aspiration to engage the epi
r. n ucleus and draw it to the safe zone
6
If residual epinucleus remains subinc
Once all the epinucleus has been asp
isional, it may be easier to use the 9
irated, return to irrigation only and r
0° I/A, which is described in chapter 1
emove the second instrument from t
0.
he AC. Proceed to remove the cortex
as described in the next chapter.
 Using the Phaco Probe to Remove Epinucleus

Advantage
Disadvantage
Epinucleus is aspirated more readily through the phaco tip tha
n the smaller I/A aspiration port. In cases where epinucleus is
Using the phaco probe may be more dangerous
unusually hard, you may encounter difficulty aspirating it with
the I/A probe. Using the phaco probe in such cases may be eas
ier.
 METHODS
This is similar to the method described for the straight I/A.

• Position the phaco tip in the safe
zone, and the second instrumen
t tip just deep to this.
• Irrigating only, advance the phac
o tip towards the epinucleus clos
est to the 5 o'clock position.
• Keep a safe distance from the ca
psulorhexis margin and posterio
r capsule → this is especially im
portant if the epinucleus is positi
oned more peripherally in the ca
psular fornix.
• Now activate low rate aspiration, such that epi
nucleus becomes engaged at the phaco tip
• With epinucleus engaged, draw the phaco tip
back to the safe zone. Increase aspiration to
maintain a grip if necessary
• Then proceed using a similar technique to tha
t described for the I/A probe.
• Once all the epinucleus has been aspirated, re
turn to irrigation only. With irrigation running,
withdraw the second instrument and then the
phaco probe from the AC

12
 POTENTIAL PITFAL
LS
 use high rates of aspiration only when necessary and only in the safe zone
1
 always keep the tip of the second instrument deep to the I/A or phaco probe

2
 keep the I/A aspiration port directed upwards and in view

 if you choose to use the phaco probe, take special care when initially engaging the
3 epinucleus
→ if you use a high aspiration rate at this point, you may inadvertently aspirate the
epinwhen using the second instrument in combination with the probe to dislodge th
4
e epinucleus from the subincisional region, use repeated small movements to mini
mise stress placed on the zonules

5  when using the second instrument in combination with the probe to dislodge the
epinucleus from the subincisional region, use repeated small movements to mini
mise stress placed on the zonules