Surgery: Pediatric Nuclear Cataract with Posterior Element

This is a 2-year-old patient who presented with a unilateral cataract. The cataract was mostly nuclear but there was also a significant posterior component to it. Dr. Ali aspirated the lens and found a calcified plaque adherent to the posterior capsule. He performed a primary posterior capsulotomy and a limited anterior vitrectomy to clear the visual axis and then implanted an IOL utilizing the technique of haptic capture.

Surgery Location: on-board the Orbis Flying Eye Hospital in Vietnam
Surgeon: Dr. Asim Ali, University of Toronto, Toronto, Ontario, Canada
Narration: Dr. Daniel Neely, Indiana University, USA


Dr. Ali: So, this is a two-year-old girl who has a cataract to the left eye. The right eye is normal. Mother reports that the cataract has been there, noticeable for at least a few months. Now there’s also a left exotropia suggesting that the vision has been impaired for some time by this cataract. A lot of this cataract is nuclear, but there’s also a significant posterior element. We’ll be using vision blue in this case, and so we’re putting some air into the anterior chamber, and then injecting our vision blue beneath the air onto the anterior lens capsule to help with our visualization, given the denseness of this cataract, I like to make the side port paracentesis infratemporally If possible, and you can see that we’re working through that right now. Once the capsule is stained, the viscoelastic is being placed in, to displace the dye and the air bubble.

We will be making our main incision superiorly, through clear cornea just anterior to the termination of the limbal vessels. This is mostly a uniplanar somewhat Biplanar incision. And then using a bent tip needle cystitome to initiate our anterior capsulotomy which we will complete with utrata forceps. In this particular case, we don’t have small incision capsulorhexis forceps available to us, but that would certainly be an option. Benefit of that would be able to keep the incision smaller. You can see how much trypan blue assists with visualization during this capsulotomy. Being only two years of age, one has to be careful to continuously direct this capsulotomy tear, back in towards the middle, so that we can avoid any radial extensions. The anterior capsule of young children is very elastic, tends to want to go radial. So, you want to direct it centrally, but you also want to keep plenty of viscoelastic in the anterior chamber, to keep that anterior lens capsule flat.

We’re doing some gentle hydrodissection here, you would have to be careful about this, if there’s any question about the posterior capsule being involved. And now we’re partially closing the incision, so that we don’t have too much egress of fluid during the lensectomy portion. And again, that’s where, if you have the small incision capsulorhexis forceps you don’t need to have a larger wound for the utrata forceps and you can keep the incision more watertight. But here we’ve used utrata and a 2.5-millimeter incision. So now we’re putting a temporary suture to approximate the corneal edges and maintain our anterior chamber.

I like to use an anterior chamber maintainer as it frees up both of my hands for the vitrector. And here you can see our viscoelastic gets flushed out. Largely using aspiration to remove the lens material. Sometimes you have to use the cutter to get a particularly stubborn piece of cortex or some of the nuclear materials a little more dense. But in general, we’re trying to use aspiration here. A lot of times these white cataracts are progressive. They start with some kind of posterior capsule abnormality. And it seems to be the case here. There’s a small opening in the preexisting opening and the posterior capsule beneath this calcific area. So that didn’t happen during the surgery. That’s just where the cataract has probably come from. It’s a good chance this was a posterior lenticonus type cataract with some thinness of the posterior capsule that progressively weakened over time. And as a result, fluid started passing into the lens and it became opaque and calcified here. Alternatively, this could have been a posterior polar cataract, as eye seems to be of normal size. So certainly, whatever cataract is here probably was not very advanced in terms of being a congenital cataract. Most likely this is a progressive, preexisting condition, such as a posterior lenticonus or posterior polar cataract. So we’re putting a little bit viscolastic in here.

And we’ve got plenty of capsular support here. So, placing IOL will not be a problem, you can see the anterior capsulorhexis is intact, where I’m indicating, so there’s space to put the lens in. So what you can do here is place the IOL with haptics oriented so that they remain covered by the capsulorhexis.

Prior to starting the procedure, we did biometry, and keratometry and axial length measurements. So, we’ve selected a lens to give us a postoperative refraction of plus approximately plus two, to allow for some myopic shift over time. And one of the nice things about this lens, as you can see, it opens very slowly. So, when you have these posterior capsule or anterior capsular abnormalities, you can very gently place the lens and get them situated without extending any radial tears in the capsules. And now that the lens is secure in the bag, I’m going to again, kind of re approximate this wound, so that we can do some additional cleanup of the posterior capsule. So, we have our wound stabilized here and now we’re going to get back in with vitrectomy handpiece. And what we’re doing is, we’re reaching behind the lens implant. And we’re going to do a primary posterior capsulotomy and some limited anterior vitrectomy, to clear the visual axis.

You can see that calcific area is being removed, it’s really adherent part of the posterior capsule. So, it was going to have to be cut open regardless. And we just slowly move around in, in circles removing vitreous, it’s very difficult to see the vitreous Of course. So, some of this is especially in young children like this. So, some of this is just a matter of spending some time in the central visual axis to remove that vitreous. When we use a high cut rate, I would say 500 is a minimum and I actually like to use cut rates that are more like 1250 to 2500, so that we limit to any pulling of the vitreous in the these young children, they have such a dense vitreous, you also want to try and limit how high you go up on the aspiration, while you’re doing that.

You can see our visual axis is looking pretty clear. What we’re doing in this case now is, I am capturing the IOL optic into that posterior capsular opening. This position is the lens at the same plane as it would be if it was in the bag. So, you don’t really need to make any lens calculation adjustments, also helps to prevent lens epithelial cell migration across the lens surface. You can see there towards the end; I also enlarge the anterior capsular opening just a bit.

And so, I just want to summarize what we did here, it is unilateral cataract and a child with a white lens. We found that the back of the lens was a calcified plaque involving the posterior capsule and we did not want to remove the entire plaque, that would have meant removing the entire posterior capsule or a large portion of it. So, we put the lens into the bag with the posterior optic capture with the haptics inside the bag. This way the anterior and posterior capsules will fuse but then the optics will remain Central and just checking the lens to see if it’s captured posted early. And if the chamber is formed. I’m going to check the wounds and now I’m going to give Subconjunctival injections and that is the end of our surgery.

3D Version


July 20, 2018

Last Updated: October 31, 2022

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