In this highly interactive and clinically-based webinar, Dr. Wilson will discuss his current techniques for surgical planning and the technologies he uses in pediatric cataract surgery. This webinar will largely be case-based with surgical videos. These videos will demonstrate all aspects of his cataract care pathway in children including biometry to IOL formulas, his complete surgical procedure, and his standard post-op care of his patients in the first six months after surgery. This talk will define the clinical and surgical pearls that Dr. Wilson has accumulated throughout his career, which he hopes you will consider when treating pediatric cataracts. (Level: All)
Lecturer: Dr. M. Edward Wilson, Ophthalmologist, Storm Eye Institute, USA
Transcript
DR. WILSON: Welcome, everyone from various time zones around the world. I appreciate you joining me today. We’re gonna talk about pediatric cataract surgery and some of my favorite techniques and technologies that I use today.
Now, this month Orbis and Cybersight, we’re celebrating Dr. Gene Helveston. Dr. Helveston was the founder of Cybersight and did great things for Orbis. I’ve worked with him for many, many years. He’s happily in retirement. This is a picture of him with one of our very best donors, Dr. Edgar Miles who supported my research for many, many years and this is Dr. Helveston telling him in a dinner why it’s so important to donate money to the preservation of sight in children. And so, that was Gene, he was always there to help you raise money and to also build up Cybersight as you can see. And just for a personal touch as we get started, one of my hobbies is wild wife photography. I live in an area on the East Coast of the United States where very close to home I have abundant wildlife that I can photograph. If you happen to be on Facebook, I just post all these when I take them as part of my morning walk series and they’re on Facebook for anyone to enjoy. Now, back to pediatric cataracts. Now, I’ve organized this talk in sort of — to talk about these patients in three buckets. The blue, very early onset cases of pediatric cataract that for me come in usually in the first three or four months of life. Then in the yellow, you have the group that is more toddlers, more preschool, early school age. And then the older children who admittedly we treat a little bit more like adult cataracts. Although there’s still some real differences, as we’ll go over. Now, I’ll use this in the talk two or three different times. The best possible operation is not necessarily the best operation possible. Now, what that means is there may be a best possible operation. And there may be an operation they like to use at home if I have the best microscope, I have the machinery, and the assistance that I need. But if I’m operating somewhere else, that may not be the best operation possible. You have to decide, based on your own experience, your equipment. What is the best operation possible? And that’s a lesson that I try to teach my fellows. We — I usually take them down to places like Guatemala. We do surgery in very different situations. And I know all of you have different equipment, different microscope, lighting and things. You have to decide: What is the best operation that’s possible for you? Now, here’s the first audience question. 4-month-old with total white cataracts in both eyes. Would you: Leave this baby aphakic, and use contact lenses, use this baby aphakic and use glasses. Would you implant and aim for emmetropia, or implant an IOL and aim for a moderate hyperopia? Let’s see what the group online has to say about this case and then I’ll show you what I did. Now, admittedly, there’s no right answer. Just really depends on your situation and okay. So, aphakic with glasses, a little bit of a lead there. But relatively few would impact an IOL.
All right. Here’s the case. White cataract. And a pretty calcific capsule, as you can see. I’m using a 25-gauge vitrector to cut the capsule and perform a vitrectorhexis and then remove the rest in the eye to remove the cortex so I don’t have to come in and out multiple times. As you see, I prefer bimanual techniques. You may do it differently. So, then I go directly to the posterior capsule. And I’m trying to cut the posterior capsule matching the anterior capsule. And I did a vitrectomy. Now here I’ve got a three-piece intraocular lens. And with that calcific capsule, you can tell that the optic capture is somewhat difficult, but doable? You know? I don’t want to show a case that goes too perfect. This is sort of real life. Now, why did I do this? Was, for me, a little unusual. It may not be so unusual to you. But this was a family from — a rural family. They were from pretty far away in the United States. I just judged that contact lenses and maybe even glasses were out of their reach. So, I placed an intraocular lens with bicapsular capture. I put intracameral antibiotics in the eye. I’m using this is a Dextenza, a dexamethasone insert that goes into the lacrimal puncta. And I sent this child home with no drops. Sob with the intracameral antibiotics took care of this. usually don’t use post-op antibiotic drops. And I use the insert. If I don’t create a lot of trauma, the insert works well. So, that’s unusual for me. As you’re aware, the infant aphakia treatment study showed that leaving these kids aphakic might be better as far as returning to the operating room. But it’s not necessary for the visual outcome. In fact, I was a part of the infant aphakia treatment study. And we found at the end, both 5-year and 10-year data that the visual acuity outcome — now, these were unilateral cataracts — but the visual outcome did not change whether you implanted an IOL or not. But there were many more returns to the operating room with the IOL group. Still, the best operation possible might not be the best possible operation. In the individual case. the American Academy of Ophthalmologies ophthalmic assessment program did say that leaving these children aphakic in under 7 months was preferable. And I think that the practice pattern down below that shows that after the results of the infant aphakia treatment study, that intraocular lenses in early infancy dropped off at least for us in the United States. Here was the big issue. The big issue is the earlier you operate a cataract, the more the cells in the lens equator are active. And they’re producing lens cortex. I clean the capsular bag as to the best of my ability there’s always gonna be a few cells left in the equator. And those cells are active. So, when you get this material, it you leave a child aphakic and the anterior and posterior capsule go together, they are trapped in a ring and it be evacuated later if necessary. And the capsule sticks to itself, better than a capsule sticks out IOL. You can’t get that good adhesion and it will fluff out and get into the visual axis. That’s the issue.
And this is from the pediatric eye disease investigator group. They had quite a large cohort from practices around the country. My practice is not part of this cohort. But you can see that in the 6 to 12 months, you’re starting to get 35% implant, but not much lower than that. And then after that, almost all of them are implanted in the 1 to 4, 4 to 7, and 7 to 13 group. This was unilateral and pretty much the same thing with bilateral. I showed you what I do — what I did with that particular 4-month-old infant. This is what I do much more commonly. And this is at home a family that I know I can follow-up with. And I know they can handle a contact lens. This is my normal surgery. This sort of 5 to 8 weeks, you know, we’re waiting a little longer these days in bilaterals. But this is one time in, one time out. 25-gauge vitrector, irrigating cannula. Anterior capsulorhexis. Anterior vitrectorhexis. Posterior on vitrectorhexis directly — anterior vitrectomy. It’s a fast surgery. Little trauma to the eye as long as you stay off the iris. And I put the contact lens on at the end of the surgery. No patch, no shield. You can return the baby to mom. I put intracameral antibiotics in. And I put intracameral non-preserved dexamethasone into the anterior chamber. This is the one day post op for that child without having to take a patch and shield on. That’s what I normally do. Now, to facilitate that, we developed a lens constant for the SilSoft contact. You may not have access to this contact lens. It is a silicon contact lens. It’s now in the packaging on the top. It used to be in a bottle. It’s now in this foil. I use a 7.5 base curve for all babies. Because their corneas are steep. Transition them to a 7.7 at about 18 to 24 months. I used the lens constant 111.9 in my IOL. Just put it right in the holiday formula, whatever formula you would like. And it tells me what contact lens to place on the eye. I leave that first contact lens in for a month. Then I teach the parents how to take it out and clean it once a week. It’s a very nice system. But as I said in that first case report, doesn’t work for everybody.
Now, another reason that I like the contact lens option — and even our Medicaid families can handle this contact, and we’re fortunate that in the United States, the Bausch + Lomb company has a patient assistance program. Which means that once we show a level of poverty, they will give them two free contact lenses per quarter. The contact lenses have to be changed a lot. So, here’s the other problem with implanted early in life is this is a graph of how rapidly contact lens power changes. So, you get — you get all of these changes. So, really, until the child gets over 2 or so, predicting what power implant to put in can be very difficult. And so, I like to leave them aphakic and implant them later. And this is a contact lens. You could also use glasses and then you could change the glasses as things go along. Now, in that first case, the reason I did bicapsular capture, that may not have been something that you were expecting, it allows the capsular bag to seal just like in aphakia. The lens is in the sulcus. And the optic is captured through both capsules. What I found is, most of those I’m getting close to emmetropia. I’m going to have to exchange them some years later for myopia. In the captured positions in the capture with the sulcus, it’s pretty easy to exchange. And what I usually do is un-capture the optic. Cut the lens in half, pull it out. Very little trauma. Then I reopen the Soemmering ring. And my next implant is often in the capsular bag. Don’t forget about aphakic spectacles. They work great. And they certainly do for me in bilateral cases. Any little bit of trouble with the contact lenses, I go to aphakic spectacles. Most of my patients end up at some point during growth, they end up with a secondary implant. But as you know, it’s not necessary. Some people do great with aphakic spectacles over the long-term. But I would say the majority of the ones that I leave aphakic, I’m planning at some point to finish the job, do the second part, which is the implant. I tell parents: You will probably get an implant. The question is just: Is it better now? Or is it better later? Okay. Let’s move to a secondary implant. Here is the case. This is the way the child looks. This child is 5 years old and we are ready for a secondary implant. This child has done well with contact lenses and backup glasses. Here’s the audience question: Would you put a three-piece lens in the sulcus? Put a single-piece lens in the sulcus? Put a single-piece lens in the capsular bag? Or put a three-piece lens in the capsular bag? And remember the best possible operation is not necessarily the best operation possible. Your answer is certainly going to depend on your experience. What lenses you have available. And your expertise. Single piece IOL in the capsular bag. Very nice. So, that is — that’s my most common technique. But I see that three-piece IOL in the sulcus is also very common. And it beat out the bag by 2%. That’s great. Because those are both really correct answers. It really depends a little bit on the case. All right. Here’s this case. What you’ll notice is in this particular case, there’s very little Soemmering ring. Everything is pretty flat. In this case, I could probably separate the leaflets and blow them up with some viscoelastic and try to get in there. It’s not worth it. If it’s not lumpy, if it’s flat, just put the lens in the sulcus. Now, I think what will surprise you is my favorite lens in the sulcus in this situation is actually a single piece IOL. This is the — this is a Rayner IOL. It’s a hydrophilic acrylic. But it’s a particularly nice hydrophilic acrylic. And I like the haptic design. There’s nothing wrong with the three-piece lens in the sulcus. But if I put the three-piece lens in the sulcus, I’m going to do everything I can to capture is in in the capsulorhexis. This is a probable with those that are not 3D captured. I have foundational and others have found that this is the only three-piece lens that I trust if the sulcus. And I have been doing this with this lens for many years and it works great. And from the sulcus, it’s also easy to exchange if they happen to be a teenager or young adult and they don’t like their myopia. I do — I do suture the wounds. I use 10-O Vicryl because I don’t have to go get it. You can use nylon, but you have to do the sutures to get it out. I like 10-O have Vicryl. The characteristics are not as easy as nylon, but it dissolves on its own. That’s my preferred. I admit that I do more secondary IOLs in the capsular bag than I do in the sulcus. But in this situation, where there’s not a big Soemmering ring, it’s a lot less surgical trauma to go ahead and place the lens in the sulcus and make it easy later if you need to exchange it.
Here’s — this is my more common situation. If I do — if I do a surgery — the earlier I do the surgery. So, say this is in the first two months, I usually end up with a Soemmering ring. I have matched the anterior and posterior capsulorhexis on purpose to leave this to make it easy to dissect. This is just an NVR blade. I’m making an initial opening above the white ring, so that I can get into the Soemmering ring. And I’m using a 25-gauge vitrector. I’ve tried scissors, I’ve tried carving with the MVR. Tried all of those. This is the way I like to do it. I turn the 25-gauge vitrector on its side. Once I’m in that space, I just stay in that space 360 and it pops open the anterior capsule. And now I have a new anterior capsule opening that I can see all the way around. Now, once you open that up, you got to clean it. You’ve got to get rid of all of that lens material and it will surprise you how much — this is not residual cortex. This is new cortex that has been re-proliferated from the cells that you can’t get out no matter how well you clean the capsular bag. I meticulously work my way around and aspirate all that cortex. Now, I still like using the vitrector with the cutter off. Because you got to — an opening in the — in the center. And if any vitreous comes forward, you just turn the cutter on, clear that vitreous and go back to aspiration mode. Don’t put in an aspirator and then all of a sudden you’ve got some vitreous stuck in your aspirator. You need to have a cutter in there. This is showing the new anterior capsule opening. Now, if the white ring is in the visual axis or two narrow, wait to cut that white ring out until after the lens is in the capsular bag. Because it’s a pretty secure floor right now. So, leave it there. At the very end, when I’m taking my OVD, my viscoelastic out, that’s when I can trim that white capsule if it needs trimming. Now, this is a single piece lens. I would not put in the sulcus. This lens is going in the capsular bag. And I was careful to put the viscoelastic in the capsular bag so that I lifted, created some separation, I lifted my new anterior capsule edge so I’m sure that those haptics are in the capsular bag. I rotate the lens so that I can get under the optic to remove OVD without running into a haptic. And I’m gonna do that from my wound. I may — I make the IOL wound just as one of the paracentesis, I just enlarge it. So, here, I’ve removed viscoelastic. Now I can remove viscoelastic under the lens. And I could turn the cutter on if necessary. And then that’s the way the case looks at the end. So, that’s my more common. Now let’s move to the second category. So, the second category is this yellow kind of from 7 months or 6 or 7 months through about 6 years. It’s — it’s in an area where, yes, we usually put in a — an intraocular lens. All right. This is my most common procedure. But not my only procedure. Manual capsulorhexis. Bimanual aspiration of the lens. Bimanual in the capsular bag and pars plana posterior capsulectomy. This requires a good microscope with a good red reflex view. The reason I like this is because it gives me more control. I’ve removed all the viscoelastic before I go pars plan. I’m not using a trocar. It’s not necessary. That’s for tool transfer. Retina docs do tool transfer. If you’re only in one time in and one time out, I used a 25 gauge MVR and a 25-gauge vitrector and this gives me more control. But it’s not the only way that I do things. Now, here’s a 5-year-old bilateral cataracts. Let’s see what you would do. Leave the posterior capsule intact. It’s a 5-year-old. Might be able to sit for YAG. I would perform a posterior capsulectomy and a anterior vitrectomy from the back or the front. Or I would perform a manual PCCC without a vitrectomy. This is a bilateral case, 5 years old. It depends on whether you think at age 5 that the vitrectomy is necessary or not. Okay. Posterior capsulectomy and anterior vitrectomy. 66%. That’s what I would normally do also. But I’ll show you what I did do. This is a very recent case. And I chose to do it this way, you know, we’re working with the fellows. Not everybody has a really good instrument to do a vitrectomy. They want to know how young — this is about as young as I would go. But we do cases like this in part as a test to those who really prefer to not pull out the vitrector unless they have to. And I think below about age 3 or 4, I think a vitrectomy is necessary. But if you want to take the extra time, even in this 5-year-old, it is perfectly acceptable to do what has been called hyaloid sparing. That’s, you know, I’m not sure that this reduces the risk of retinal attachment later on. Vitrectomy does not cause retinal detachments. Traction causes retinal detachments. So, if you have a good, high-speed cutter and you’re careful and you don’t have any vitreous wick to the wound, you are doing a very safe operation. If you’re doing hyaloid sparing, yes, that might be nice. But for me, when I’m then taking the viscoelastic out, I worry a little bit about pulling inadvertently some vitreous forward, having a wick to the wound, which then increases my risk of a retinal detachment. So, here’s what I did in this case. I did a manual posterior capsule opening. I’m going leave — I put a dispersive viscoelastic. I made this opening with the MVR blade with an upward movement. I put some — this is a cohesive viscoelastic in the capsular bag. But I put a dispersive viscoelastic through the opening to push the vitreous space back. I chose to use a single-piece implant. I didn’t do optic capture. I’m not sure that optic capture helps you a lot. It certainly centers the lens well, but then you have to use three piece lens. These single piece lenses don’t capture very well. This is a perfectly good operation. As my fellows know, it’s actually faster to do the pars plana operation I showed you the first time. Now, again, I have been using a lot of these dexamethasone implant inserts. You may not have access to it. But I send a lot of these kids home with no drops. Because intracameral antibiotics in the — in the — at the end of the surgery, non-preserved dex at the end of the surgery and a Dextenza for the long-term release of dexamethasone. And then I can send them home with — with no drops. All right. Here is another case I just wanted to show you. This is also a case. I just edited this this past weekend. And this is just to show an example. Again, I made — I’m doing a manual capsulorhexis. On my Zeiss microscope, I have this overlay. And I don’t know. I like using this overlay. I can set the dimensions of this overlay to help guide my — my capsulorhexis. As you know, capsulorhexis in children is more difficult because the capsule is very elastic. And so, having a guide, going slow, pulling toward the center. Now, also notice that I’m removing the cortex in the periphery first. In children, they have soft sclera. You get some scleral collapse. That’s why you get vitreous up-thrust. It’s not posterior vitreous pressure so much. It’s scleral collapse and formed vitreous. The formed vitreous makes the posterior capsule come up and be convex. So, to keep the posterior capsule back, I remove the middle lens. It’s keeping it out of the way. I remove the periphery. I like bimanual aspiration. These are both 23-gauge matching — they’re matching so I can switch hands if I need to. Now I’m putting the viscoelastic not in the capsular bag. Put the viscoelastic, if you’re gonna do a primary capsulorhexis, use the viscoelastic. You want to put it on top of the anterior capsule and not over-fill. So, here again, I’m doing this small opening. Dispersive viscoelastic. It needs to fill the area — needs to separate and push back the vitreous space in the area where my posterior capsulotomy is going to be. Now, if you have a posterior polar cataract or a persistent field vasculature or something where you know likely the relationship between the posterior capsule and the face is not normal, you’re going to need to do a vitrectomy. That was not the case here. And the reason I’m showing this case is I did choose to use a three-piece lens and do the posterior optic capture. I capture the optic in the — in the posterior rhexis. And it’s an alternative. It’s one that many of you have better access to three-piece lenses. And not as good an access to the single piece lenses. So, this is something that you can — you can certainly do. I probably have done — I know I’ve done over a thousand — probably 12 to 1500 of the pars plana type. So, that’s still my most common. But here, you know, you just — the openings of the capsular openings are a little oval because the haptic is in a soft eye. And I’m just gonna capture the optic here. And I usually at this point, I’m gonna remove the viscoelastic. But I’m gonna — in the capsular bag — but I’m gonna leave the viscoelastic that is under the lens. And this pretty easily captures — and I think we can move on for the sake of time. All right. Audience question. 6-year-old — now we’re moving a little older — 6-year-old with a sudden white cataract. Would you: Manual aspiration, IOL, YAG later. Vitrector aspiration, posterior capsulectomy, vitrectomy and IOL. Phaco-aspiration, IOL, manual PCCC, no vitrectomy. What would you do in this case? 6-year-old, sudden white cataract. The history is that this cataract came on all of a sudden. And it just was noticed to be white. All right. Vitrector aspiration, posterior capsulectomy and vitrectomy. I agree with that. This case is a ruptured — spontaneously ruptured posterior less than that globus as I like to call it. White cataract all of a sudden. No history of trauma. Could be a history of trauma. But I couldn’t see — there was no history of trauma. I use the vitrector as an aspirator. Because I know I’m going to get lens. There’s the fish tail sign right there. We have lens vitreous admixture. Don’t go in with an aspirating cannula and find yourself with a mixed aspirate. I use the vitrector so I can use bursts of cutting any time I need. And you can see I can then clean up all of that. Now, it’s interesting, but in kids, I find that even though this had not been ruptured for very long, the ruptured posterior capsule edge, fibrosis pretty quickly. And it’s actually quite stable. So, it’s — it didn’t extend. It was this shape, this sort of American football shape. And I was able to just stay away from it. Clean everything up. And still use the capsular bag. And so, I put the viscoelastic in the capsular bag. I oriented the haptics so that they would respect that wider opening. And I chose to use the Rayner lens because it’s the one lens that I really like for in the capsular bag. But if in the eye I decide that the posterior capsule is just not a reliable floor, this is a lens that I could pull up and put in the sulcus and not just cut it out and change lenses. And I put a little triamcinolone in the eye to try to give a little bit more coverage. So, in this group, this yellow group where we’re in this up to three to age 6 or 7, I like a posterior capsulectomy. Manual or mechanical. But we know you’re gonna get some pearls form. I like this. Now, let’s move to the final category which is the green. The older kids. This is where you might leave the posterior capsule intact by routine. And yes, you can do that. This is a series of pictures. I get referred a lot of these cases. So, if you leave the posterior capsule intact and it’s a child, even an older child, if you are gonna perform a Y AG capsulotomy, you need to do it early when it first starts to opacify, because it guess thick. It builds up and it’s a layer of cortex. When it’s too thick for the YAG. Sometimes they’re sent to me. It’s a quick operation. I go in pars plana and I clean it up. Either that happens or this happens. This was a successful YAG. This happened to be a YAG laser that one of my fellows did. The patient complained of all of these floaters. And nothing was getting out of the way. It didn’t fall to the bottom of the eye. And we ended up having to clean it up with a pars plana vitrectomy anyway. What I’m saying here is that it’s okay to do — to leave the posterior capsule intact. That’s okay. However, it — I’m just doing less YAG lasers and more primary posterior capsule openings. And as the kids get older, the — the manual capsulorhexis becomes a little bit more go-to for me. Now, let’s just touch on a few things before we finish. Toric IOLs, are they okay for kids? Yes. They’re okay. We are studying keratometry over the child’s life. They’re stable. After age 3 or 4, the K readings don’t change very much. My problem is that it just costs too much. At least in the United States. So, there’s nothing wrong with it. Just for me, the elephant in the room is cost. And I can’t seem to get these companies to donate them for free. And in the United States, they cost money. And so, we don’t use them as often as I would like to. What about multifocals? I don’t have time to talk about multifocals. But I do not like them in kids. Because the lenses perform poorly when the eye grows. And the refraction becomes myopic. Then you have multiple images, none of which are on the retina. So, I don’t like them. But some of the newer IOLs, this is an Eyhance. Some of the new multifocal, newer monofocal. This is a newer monofocal that is really giving us in the older kids better intermediate vision, better distance vision. And they still perform well if the child becomes myopic. And believe me, this is what happens in the second decade. People think that there’s not much growth, there is. There’s a lot of growth and it’s variable. And so, you really — this is just axial length from age 10 to 20. These are real patients. And we’ve done multiple axial lengths, IOL master. I just want to touch on a couple of specialty things. I like — I like the artisan lens. In a case where the capsular bag cannot be salvaged, I tend to do a — an aspiration of the lens inside the capsular bag. Again, this is one time in, one time out. Two small openings in the capsular bag. And I aspirate within the capsular bag. And then I clear the lens. And then I put the artisan lens in. Now, you might like the artisan lens on the back of the iris. But we have a restriction from the FDA. And I’m not allowed to do that., so I have to put it on the front of the iris. In rare cases — and here is an article I wanted to mention to you. That there is now an article on the safe approach of using the Yamane flanged intra-scleral technique in children. This is a children case series. And yes, we do that sometimes. Here was a case that after multiple — after trauma and multiple surgeries has a glaucoma. A valve in, all that, of course, doesn’t qualify for an artisan. And I did a Yamane technique. And it went fine. It’s not my go-to in children. The sclera is soft. Even with an AC maintainer. It’s a little more difficult to — to do the technique and avoid tilt. But this — this is certainly doable. I don’t know in the future, I may do more of these. If you — if you have access to the artisan, it’s probably better. This — this went fine. I don’t have to finish the — you know what these look like in adults. But don’t do this. So, this is something I used to do. Angle-supported anterior chamber lenses in a growing eye. Even if they are fit properly, they do well for about 3 years, at least in my experience. And then a lot of them end up needing to be exchanged. Look how much this lens has rotated. If you look carefully at the haptic position, this lens rotated, the pupil is slightly oval. And I almost never see cystoid macular edema in a child, but I have seen it with supported anterior lenses. One more quick thing. IOL power selection. This is one of the things that we like to use. We developed a formula, regression formula, to predict axial growth over time in an individual patient. I used this formula. And I can predict the axial length at age 20 at the end of growth. Then I can put that axial length into my IOL formula. And I can select, if I choose, an IOL that will be perfect when the child is 20 years old. We just completed — we have a research fellow who is doing a sabbatical from Brazil. He has a big database of his own. We’ve used his database recently to validate this formula. He also has another formula. We’re running both of them, and he is giving us very similar answers. So, I think that’s a good way to go. And you could find this in the — in the AJO.
And as you saw in the videos, I like physician administered medicines. What that means is put whatever you can put intracameral so that you don’t have to rely on parental compliance. We have two sustained release drugs. Dextenza goes in the lacrimal puncta and the other is — slow release dexamethasone I like to reduce the number of — the number of medicines that I have to put in. This is a Dextenza. I think I already showed you that on the other videos. We published some early results and now I have many, many more patients with the Dextenza. Occasionally we have to supplement with drops, but I’m amazed how well it does. Lastly, moxifloxacin in the anterior chamber is safe. This is a nice safety study focusing on children. I like moxifloxacin because it does not require dilution. There are no dilution errors. And I put it intracamerally. And then I don’t send the parents home with any drops, typically. But I will supplement with drops if I think that the healing is going slower than I would like. And finally, special thanks to Rupal Trivedi, she is my research assistant. She and I worked together for almost 25 years and we still meet all week long trying to see what you’re doing in the literature and seeing what we should be doing studies on. So, I really want to acknowledge her as my research associate. Now, do we have some questions to answer? Do I have a minute or two left here?
LAWRENCE: Yep. So, Dr. Wilson, you can go ahead and stop your screen share. We do have some questions open if you have some time.
DR. WILSON: Stop share. Okay.
LAWRENCE: So, if you want to open up the Q&A box, there’s about 14 questions currently.
DR. WILSON: Oh, good. All right. What is the dose of intracameral dexamethasone? That — it comes in 40 milligrams per cc. I put a tenth of a cc. So, it’s 4 milligrams. It’s 4 milligrams of dexamethasone. Make sure it’s non-preserved. The sometimes what you would put subconj has preservative in it. But it’s very ease to get non-preserved dex. I put in a tenth of a cc along with my tenth of a cc antibiotic. What is IOL. I used that as an abbreviation for intraocular lens. That just means intraocular lens. In bilateral cataracts, is it necessary to do patching before surgery? No. I don’t think so. I know that was in vogue for a while. I don’t do that. I just wait. It doesn’t seem to affect the prognosis if you wait until the appropriate time. So, I don’t do pre-surgery patching. And the model is the C-flex, it goes by a few different things. But the Rayner C-flex is the model that we’ve proven and others in Europe have proven is acceptable for the sulcus. They sell it as an in the bag lens. But it’s acceptable for the sulcus. All right. Let’s see… do I prefer Yamane technique to iris claw? You know, I like iris claw better. But it’s because I’ve done about 150 of them. We haven’t had it — had access to it for a time. I used to do sutured lenses. I don’t do that anymore. I think sutured lenses are disappearing. Will disappear at some point around the country. So, my adult colleagues would prefer Yamane. I may prefer it once I get better at it. Admittedly, I haven’t done enough of them. And the sclera is soft in kids so I worry about tilt. Let’s see. Age for unilateral cataracts, IOL. It depends on the circumstance. But I think between 7 and 12 months I start putting it in all of them. But I’ll certainly do it earlier if required. But I think the returns to the operating room — we did the toddler aphakia and pseudoaphakia study. The tasks. That showed that after 7 months the returns to the OR decreased dramatically. And that it was more okay to put the lens in the capsular bag. And so, I do. Do you prefer pars plana to lensectomy? I don’t. I’m an tear your segment surgeon. Even in persistent field vasculature, even the really dense PHPV, I do my lensectomies from an tear your approach. I know retina colleagues would differ. But in some of those cases, you’re not sure where the pars plana is when there’s persistent field vasculature. I prefer the anterior approach. I’ve never had a problem. I’ve never had to refer a lensectomy to a retina doctor. We can do them ourselves as anterior surgeons. Even with the PHPV and the vasculatures. Do you have any studies showing effect on endothelial cell count? Our study that came out on artisans, we did have endothelial cell count. We show that the endothelial loss was no greater than with an intraocular lens. I realize that’s different than an angle-supported lens. Perhaps having that knuckle of iris protects it from rubbing. If you rub and you have an angle-supported lens, I know you’re going to destroy endothelial cells. But the artisan seems to do well. I know in the United Kingdom and other places, they prefer to put the artisan on the back of the iris. That protects the endothelium. I don’t have that option because our FDA won’t allow us to do that. I can’t do that. How do you manage amblyopia after surgery? In the babies, I start patching one hour per day per month of life. 2 hours in a 2 month old, 3 hours in a 3 month old, until we get to half the waking hours. And then I leave it at half the waking hours until I can titrate it down if the response is really good. That’s for unilateral cataracts. And it’s difficult. It is really difficult. And it’s — it’s so hard when you’ve done a perfect surgery at the right time. And have patching failures and dense amblyopia. I know how frustrating that is. But fortunately we do much, much better with the bilaterals. I do YAG capsulotomies for any child 5 years and above that can cooperate. Is that okay? It it’s perfectly fine if they cooperate. My experience has been that the kids don’t come in earlier to do that really easy YAG. And then we just pour in a lot of energy. And sometimes they end up with floaters. And sometimes I have to go to surgery and do a pars plana cleanup. My bias has been — we still do a lot of YAG lasers. But my bias has been to go ahead and take the extra time to do a capsulotomy in the operating room and just be done with it. And that is because I’m comfortable with it. And I know I’m not increasing the risk to the patient. General anesthesia, I see a Spanish question. I definitely use general anesthesia for my pediatric cataracts. I use general anesthesia for older kids too. I’m just spoiled, I guess. Because they can use a laryngeal mask airway and it’s perfectly safe. The older kids you could probably do — I don’t. And there’s a question about the foldable iris claw lens. The Artaflex. I would love to use it. But I don’t have access to it. It’s not available in the United States. We have only access to the rigid one via a compassionate use protocol. It’s not on the market in the US. So, I would love to try it. But I don’t have — I don’t have access to the foldable iris claw. There’s a question about — let’s see. There was a question about using bag-sparing in a sub-luxated lens with tension rings and Gore-Tex suture and all of that. Yes, I do that once in a while. But usually those are mild cases that end up going to my adult colleagues as they get older. And they do the bag-sparing. The ones that get sent to me are usually so loose that they’re afraid to do bag-sparing. So, I don’t have as much experience with the bag-sparing. There’s a question about how many minutes to do the vitrectomy. You know, I can’t tell ya. I just know that if your cutter is high-speed, as it should be, the higher the better, you have to move the vitrector around to sort of — and the vitreous is somewhat invisible. I don’t stay back there more than about 30 seconds to a minute. And I don’t get — I don’t — I can’t remember getting — ever getting a pupillary block in an aphakic child. If you want to learn how much to remove, then dilute some triamcinolone, dilute it maybe 1 to 10, just a little bit of white. Put it back there so that it makes the vitreous visible and then practice taking enough of a vitrectomy before it’s gone. What about IOLs in children older than 10? I’ve used those, but only if it’s an older child and I have proven with IOL master at least a year apart, I’ve proven that the eye is not growing. I have seen eye growth even into the early 20s. I think those adult lenses, as I said, they do poorly when the eye becomes myopic. If you’re sure, based on serial axial length measurements that growth has stopped, then you can go ahead and use it. I think in older teenagers, they’re okay. I think most of the multifocal technology will be gone in the years to come. It is flawed technology. It’s the best we’ve got right now. There are some lenses coming on the market like the jelly-C and a few others that will supplant it. I think that we’ll remember all of them, EDOF, trifocal, multifocal, all of those as a historical phase we went through for older patients who were willing to put up with the dysphotopsia. And they gained from it, but very new ophthalmologists want them in their own eyes. So, I have a little bit of a bias against anything that splits the light and causes multiple images. Your brain has to pick the one and then you’ve got a moving target. If you put them in a 10-year-old, then you better tell them that when the eye grows, they’re gonna be unhappy and they may be more glasses-dependent than if they were a mild myope with a monofold. You go back and exchange the lens, whatever. It’s just something that I don’t do until I’m sure that the eye has quit growing. And I just are did a fly-in patient cataract. I put a monofocal in. But the dad had a trifocal. He had his — not a trifocal. It’s one of the early multifocals. He had the surgery done when he was a teenager, and he hates it. Yes, he can read. But he can’t drive at night. And he doesn’t want his lens exchanged. So, anyway, that’s my beef on that. Don’t feel bad if you’re not using the latest technology. Because sometimes in the next decade it’s gonna be gone anyway. All right. Let’s see… would you agree that putting an IOL, then doing pars — then doing PPC and anterior vitrectomy? Yes, that’s fine. You can — it’s just your personal choice. You can put the lens in first. Go under the lens and cut the posterior capsule and do the anterior vitrectomy. That’s fine. I find that I have better control if I do it first and then I put the IOL in. That’s personal choice. And I know a lot of people who put the IOL in, then go under and do the — do the posterior capsule. That’s — that’s perfectly fine. And I don’t think there’s an advantage or disadvantage one way or the other. I think you just — whatever you feel comfortable with. I just don’t — I don’t like it as much that way.
What is a best approach of a posterior capsulotomy? Limbal or pars plana? For me, it’s pars plana. I’m not afraid of the pars plana. I — here’s the reason I like it better. There’s less chance when you remove the vitrector of dragging inadvertently the vitreous up to your wound and then having to do all these maneuvers to clear the wound. Steve Charles, who does pediatric retina and adult retina. But Steve Charles is sort of a guru in pediatric retina. He taught me that if you’re gonna cut vitreous, cut it where it lives. Don’t drag it through the anterior chamber. What I like to do is finish the surgery just like we’re going to lever the posterior chamber intact. Get it all out so I don’t need to go back in, and leave the posterior and then go pars plana. When I finish, there’s no chance of dragging anything into the anterior chamber. I don’t have to go back into the anterior chamber at all. It’s scary at first. But we’re preparing a publication. Rupal has been looking at all of these and I think it’s over 1200 with good, long follow-up of pars plana, posterior capsulectomy showing an amazing profile over time. You can do it from preference because it’s maybe the only thing you feel comfortable. But then you have to almost put in triamcinolone to find vitreous. You don’t want to find that in one day or one month and have to go back to the operating room. For those who can’t — let’s see… for those who can’t get single-piece Rayner, can we use three-piece? Yes. Three-piece lenses are perfectly fine for in the sulcus. But they tend to move around a little more in my experience. They tend to de-center a little bit more. The sulcus is quite large compared to the capsular bag. So, if possible, if you need to put a — a three-piece lens of any sort in the anterior chamber, try to capture it through either anterior capsulotomy, the posterior capsulotomy or both. That’s my recommendation. Now, the reason people use three-piece lenses is because most three-piece lenses are posterior angulated. You cannot do that with a single piece. Posterior angulation helps to prevent pupillary capture. I was on call, saw a patient in the emergency room. This was last year. The surgeon had operated earlier that day and was not reachable. And they had put the three-piece lens in upside down. And the vaulting, the angulation, was now going up toward the pupil. And, of course, it caused a pupillary block. And extremely high pressure in an uncomfortable patient. But that’s why. And it’s perfectly fine. Could you tell me — let’s see. Some surgeons prefer to do PCC after IOL — yeah. That’s fine. And that’s — I think I answered that one already. Let’s see if I can find… now, I don’t want to get too far into traumatic cataract and the classifications. I think every pediatric traumatic cataract is unique. I would say that no matter where you are you have to have a cutter. You have to have a vitrectomy cutter. I know that in adult surgery you can do perfectly fine without a lot of technology. Pediatrics is different. And you really need a cutter. Now, when I’m in remote locations, like I mentioned, Guatemala, the machine I take with me is an Birtley machine. The cataracts. Birtley makes a machine, it’s very rugged. Reboots fast. Works in a dusty environment. Comes in a Pelican case that you can roll on to the airplane or in the back of your car. So, and relatively inexpensive with reusable tubing and all that. So, there are good vitrectomy cutters. You’re gonna need them for trauma. You’re gonna need them for a lot of the younger kids. And although you don’t have to use it in every case, I think if you’re doing pediatric cataracts, partner with the retina docs. They’re gonna have a cutter. Use the machine they use. I like the machines the retina docs use. Most of them have a Venturi pump that works so much more efficiently in pediatric cataracts. You can use a phaco machine, yes. Not ideal. It would be ideal to partner with the vitreoretinal folks than to partner with the adult phaco surgeons. But you can get by if it’s just with a phaco– with a phaco machine. Now, and what is the optimum age for IOL implantation in children? I think, you know — I think most everybody would say that they are going to put a primary IOL in as long as there’s enough capsular support, above age 2. I would feel very comfortable going down further than that. Because I think that at about 7 to 12 months is when things seem to change as far as re-proliferation of cortex and returns to the operating room so, I think the only children that should go without an IOL are those with inadequate capsular support or the very, very young. Do you give oral steroids for post-op treatment? I don’t. I’m not critical of people who did. I mean, it just depends on how much inflammation you get. Inflammation comes from iris manipulation. But even if I use iris hooks, or an iris expander, I tend not to go to oral steroids. I don’t think I’ve used oral steroids in a single case in, I don’t know, 20 years. But it’s okay if that’s what you need to do. Now, try, if you use oral steroids, try to maybe use some triamcinolone. It will stay around for about a week or so. Try and use some triamcinolone or a tenth of a cc or even less. Sometimes even less than a tenth of a cc. And maybe you won’t need that. If you get used to reducing the number of times you go in and out of the eye and reducing the chamber bounce. All right. Tight fit incisions. If you’re getting a lot of leak and a lot of chamber bounce, flat chamber, full chamber, flat chamber, full chamber, during your surgery, that’s your iris manipulation. That’s where you’re getting your fibrin. That’s where you’re getting your inflammation. It means that you have to have incisions that match the instrument that’s going in and you have a stable chamber during the whole surgery. And if your pupil dilates even reasonably well, you just won’t get enough inflammation to require oral steroids. So, that — that’s what I would just try to — try to not get so much inflammation. Do you think aphakic glaucoma has come down of late? I do. I do think it’s come down. First of all, the intraocular lens is not protective for glaucoma after cataract surgery. Second, we know that if we delay the surgery a little bit, we are getting less glaucoma. So, I think we used to operate very, very early. Then we moved the unilaterals out to maybe 5 weeks? Maybe now we’re moving them out to 6? 6 or 7 weeks. The bilaterals may be out to 8 or 10 weeks. Every week that you delay seems to reduce the incidence of glaucoma. But I can also tell you that surgery that creates a lot more inflammation and having to do multiple surgeries, that increases the rate of glaucoma. These are eyes at risk. For me, eyes at risk for glaucoma are microphthalmia. My eye that I operate in after 4 months is pretty much zero. Microphthalmic, they are immature, you can tell that because the iris is immature without the almost smooth. Those are the ones at risk. They can get glaucoma even 10 years after surgery. Happens later. Now, the analogy I use for parents is I say, we have to keep watching your child because the trabecular meshwork is immature. Like having hair in the bathtub drain. Babies don’t make — as a child gets older, it’s a high flow system. As the system gets higher flow with the immaturity of the trabecular meshwork might not hold and your pressure can creep up. Even years after the surgery in an eye at risk. But a full-sized eye with a lamellar cataract, those are not at risk. You still take pressures, but rarely do they get glaucoma. I think we understand a little bit better about how to treat it and about how to diagnose aphakic glaucoma. Or what they’re now calling glaucoma after cataract surgery. Now, let’s see… at what age would you stop worrying about a primary capsular and an tear your vitrectomy. Really my answer is usually about 8? 7 or 8. But even a teenager, if the teenager is not a well-behaved teenager, if it’s a teenager that I don’t think is gonna come back for follow-ups at the right time. I tell ya, this, you know, doing — once you get used to doing a primary posterior capsule opening with or without a vitrectomy, I just get more peace of mind. And so, any child, you know, there are some — there are some adult surgeons who say that we should be doing primary posterior capsule openings manually in adults. And that put YAG out of business. You know? I’m not sure that you would go that far. But I — after about age 8, I often leave the posterior capsule intact. But I think about follow-up and how much energy I’m gonna need if they come in late to get the YAG and sometimes I just want to take the extra few minutes and just treat them like they were younger. And then not worry about it. And I remember a case of a teenage girl. I couldn’t polish the posterior capsule very well on one of her eyes. So, I did a primary PCCC, posterior capsulotomy. The other eye I left intact. It polished well. I ended up doing the YAG 18 months after surgery. But during those 18 months, she kept telling me how much better and clearer and sharper she could see out of the eye that didn’t have a posterior capsule. Because even before it opacifies, it’s there. It’s not always perfectly clear. And yet you can’t justify doing anything, but the patient is having to see through it. So, you know, I have — with more and more experience, I think about taking posterior capsules a lot. And you may not be in that situation. But if you are, people shouldn’t be critical of you. And I’m not critical of people, even if they leave a 5-year-old with an intact capsule. If thing the child sat still for the IOL master and they’re gonna sit still, you know, for the YAG, that’s fine. I just would just as soon not chase the child around the YAG if I don’t have to. Do you use a 25-gauge vitrector? I do. Now, this is really just logistics. I operate where pediatric retina docs also operate. And so, they order 25-gauge vitrectomy packs. And I don’t really want to just have a whole bunch of extra packs. I just use what they use. So, my irrigation aspiration hand pieces that I prefer are 23-gauge. Matching 23-gauge. But I use a 25-gauge vitrector. I like that for pars plana because it’s a smaller opening. And I actually have found that even in the toughest membranes, it will still beat those membranes. You can use whatever you have, use 20-gauge, 23-gauge. I use 25-gauge all the time. And I’ve not found a membrane that the 25-gauge vitrector can’t tackle. And now I use very high — at least 7500 cuts a minute. You should use the highest cut that your machine allows. What intracameral antibiotic do you prefer? And this really depends on your availability. You may like Seraquil from triaxone. I use moxiflozacin. Non-preserved moxiflozacin because it is — it doesn’t require any dilution. What we do is our pharmacist in the OR will take a bottle of branded Vigamox, it has no preservative. He’ll take that one bottle and he’ll make aliquots in little syringes. At the same time he’s making all these aliquots for individual cases, he puts a little bit of that bottle on to a plate. A culture plate. As soon as that culture plate shows no growth, he releases all those syringes. And then we have a syringe at the end of surgery that we can put a tenth of our cc in and then I don’t send them home with any antibiotic drops. Intracameral, I would not do a case without intracameral antibiotics, I’ll tell you that. And if you look at the literature, there’s very little evidence that post operative topical antibiotic drops do anything. That’s presuming you have a sealed wound. And you get very little concentration into the anterior chamber. It’s better to put that 10,000 times higher concentration when you put it intracameral. You get an immediate kill of any bacteria that you may have introduced into the eye during surgery. So, I’m a big proponent of intracamerals and I use moxiflozacin. And I don’t use post-ops. Okay. What’s the vitrectomy cut rate? Highest you can get. Whatever your machine will allow. Higher the cut, the safer the vitrectomy. Because you don’t get a — don’t get — you get less traction. So, the traction is the key. Old vitrectomy units had too slow a cut rate and there was traction involved and that’s what caused the risk of retinal holds. Let’s see… in what type of cataract surgery do you perform an intraoperative iridectomy? I do that when I’m doing an artisan lens. Because it’s an anterior chamber lens. I might do one in a difficult uveitis case. But rarely. When I do a peripheral iridectomy, I cut a nice little round small hole in the iris. I don’t do it manually with scissors. I hope nobody does that anymore. But just use the vitrector. It makes a nice iridectomy. But I use the artisan lens or maybe in some inflamed trauma eyes or eyes with uveitis. Why is the Rayner lens more stable in the sulcus but not others? You know, I think — I don’t know if it’s the hydrophilic properties, it may be. Or it may be just the haptic design. People found out just by experience that the standard haptic design that’s on the Alcon lens and the other Bausch +& Lomb lenses have too much rubbing on the iris. I’m not completely sure whether it’s just the haptic design or just the hydrophilic properties. I just know that it’s trusted in the sulcus where other lenses are not. And I hate to lump them all together. They’re not all hydrophobic acrylic single-piece lenses are the same. But anyway, I’ve just found — and that’s just a pearl that the Rayner C-flex works well in the sulcus. Do you see a high inflammatory reaction in 10/0 Vicryl in these kids? That’s an interesting question. It’s a fascinating question. I would say no. Vicryl dissolves by hydrolysis. I’ve never seen any inflammation to a Vicryl suture. I’ve used 10/0 Vicryl for 30 years. I’ve not seen an inflammatory reaction to 10/0 Vicryl. That kind of surprises me. What you’ll see is it is harder to bury the knots. It’s harder to adjust the tension on the knots compared to nylon. So, I miss that, but Vicryl works fine. I — I’ve not had any inflammatory reactions to Vicryl. So, if you’re afraid to use it for that reason, I would just say, give it a try. And use it in some cases and see what happens. But I think the majority of surgeons that do pediatric cases in the United States use 10/0 Vicryl. We don’t like to have to go back to sedation or anesthesia to take out sutures in kids that can’t cooperate. So, you know, that’s the — that’s that. Okay. Let’s see if — have I gotten all of them? I haven’t been hitting the button to — to say answer live. But I think these — these that are on I have answered. Well, good. Thanks for staying a little longer. I really do appreciate having an audience and having people who are interested in doing pediatric cataracts. Because it’s a lot of work. And it’s time consuming. And I know that the burden of adult cataracts is so great that it takes quite a bit of dedication to — to be willing to do these pediatric cases and follow them so closely. So, thank you.
