During this live webinar, the panel of experts will cover various techniques in the areas of anterior capsulotomy, IOL placement, and posterior capsular management. Questions received from registration and during the webinar will also be discussed.
Dr. Donny W. Suh, Ophthalmologist, University of California at Irvine, USA
Dr. Srijana Adhikari, Ophthalmologist, Tilganga Institute of Ophthalmology, Nepal
Dr. Ramesh Kekunnaya, Ophthalmologist, LV Prasad Eye Institute, India
DR. SUH: Hi, good morning, good evening, or good afternoon. I’m very honored to be joining a wonderful speakers today. We will be talking about the pearl — surgical pearls of congenital cataract surgeries. So, let me share my slides first. Okay. We have lots of — we’ve got lots to talk about and I’m truly excited. We’re going to try to finish in 60 minutes. First before I start, I would like to thank the — thank everyone for your support. We have over 2,000 I think I was told that we had 2066 professionals that signed up for this meeting. Probably over many, many countries. And Orbis is — we have our reach in almost every single country around the world. And I just couldn’t be more honored and more excited to be part of Orbis. And I would like to thank our co-presenters. They don’t need much introduction. Srijana Adhikari from Tilganga Institute from Nepal. Which I think is one of the best institutes in the world. And Ramesh Kekunnaya. He is the chief and also the director of LV Prasad Eye Institute in India. Again, I think it’s one of the best institutes in the world. And I am from Gavin Herbert Eye Institute. And I’m gonna be talking about some of the surgical pearls. We only have about 15 minutes for each one of us to talk about these important topics. So, I’m going to be talking about the anterior capsule. And Ramesh will be talking about IOL selections and placement. And Dr. Adhikari will be talking about posterior capsule and vitreous management. We are not going to be talking about the entire cataract surgical pearls. But focusing on these topics. If there are topics that you would like for us to address in the future, then you could leave us a comment. I’m gonna be asking eight quick questions and I only give you 10 seconds to respond. If you could read these questions. Please let us know. I am a general ophthalmologist, optometrist, pediatric ophthalmologist on orthopedic optist, doctor in training or other. Great. The majority of us are general ophthalmologist and pediatric ophthalmologist. The next is I perform congenital cataract and roughly the volume, one a month, one a week, two to three a week, four to five a week, more than five a week. Okay. Perfect. Next is how do you perform — for those who perform the surgeries — how do you perform the anterior capsulotomy. Since most of you are general ophthalmologists. You are comfortable with, the curvilinear, vitrectorhexis. Can opener? Diathermy. Other? This is what I expected. Next do you perform dye assisted capsulotomy in congenital cataract cases? For those who perform the surgeries. Majority says yes. And what do you use for the staining? ICG? Autologous blood, fluorescein, gentian trypan blue. And how do you measure the capsule? Obviously for more who are general ophthalmologists. You’re not used to removing the posterior capsule. But for the congenital cataracts, management is very important. It looks like the answer kind of goes all over the place. Never remove, place IOL first, move with a vitrector, and manual, and place IOL — okay. Perfect.
What age do you perform — at what age do you perform the primary posterior capsulotomy with interior vitrectomy? For those who manage the posterior capsule which the vitrectomy? What age? Okay. Up to 3. Okay. Next question, the last question. Is: After what age do you do primary posterior capsulotomy without anterior vitrectomy? Meaning you just leave the vitreous alone and you just simply remove the posterior capsule? At what age? 1 through 5. Okay. So, it looks like it’s greater than 5. Okay. Perfect. All right. We’re gonna go ahead and get started. Thank you. That kind of gives us an idea of where the audience understanding is and we can taper our talk. I have been doing congenital cataract surgery for 23 years. And I’m just going to tell you, although I had excellent training, the danger is always lurking around. You think everything is going to go okay and bam, something comes and bites you. And these things are sometimes very unpredictable. So, in my opinion, the success hinges on the planning. So, what I mean by that is that hope for the best. But plan for the worst. I think this is truly the key to success in this congenital cataract surgeries. What I mean by that is first you need to test the water. Before you start the case, I think just the planning portion I think is just as important as the procedure itself. So, assess the anterior chamber depth. How shallow is it? And the size of the pupil. Is it something that you feel comfortable doing a cataract surgery? In many of these congenital cataract patients, they tend to have smaller pupils. And if you’re not able to dilate, that’s going to cause a significant problem. And size of the eye. Especially in a persistent fetal vasculature. And the location of the cataract, and the opacity. And especially the traumatic cataracts. It’s one of the most common cause of cataracts as you know. We have to worry about the zonules status. Where is the torn zonules that you have to be concerned about? And then anterior segment dysgenesis. This may not be very obvious. In patients with the defects or ciliary body defects or lens defects, it’s very easy. But there may be some corneal dystrophy that you’re not aware of. Recently I had a patient that developed a corneal edema that didn’t resolve and needed corneal transplantation. And view of the posterior capsule and the vitreous can be difficult. Especially for the dense cataracts. You have no idea what the posterior capsule status is. Unless you’re performing an ultrasound, you may not know. Then the second tip is along with the planning, I think it’s extremely important to keep your technique as simple as possible. Steve Jobs said that the — keeping things simple is actually much harder than keeping things complex. Keeping things simple not just it makes you plan ahead easier. But if you run into trouble, you will know. You will have a plan A, plan B, and plan C, all planned out. But if you’re making things very complicated, it can actually get very, very confusing. Not just for you, but for the people that are assisting you. And then third tip, have the favored instrument ready. Whatever it is. And sometimes your OR may not have these instruments for you. Then you may have to go out and purchase them on your own. You know? That’s perfectly okay. And these have — for these small eyes, micro utratas, a microforceps. There are many out there. I think it’s extremely helpful and there are different companies that make these. And by the way, none of us have any financial interest. Then if you’re going to be making a larger incision that’s greater than 1.8 millimeters, you would use a regular utrata which I think is just fine. But I think it’s very important that you have your favorite instrument ready. But also, make sure they work. You know? Some of these, you know, I’ve actually seen some of the poll answers. And some of you do one surgery a month. Or one or two cases a month. Well, in those cases, these instruments may be put aside and may not be well-kept. And sometimes these tooth or the tip do not meet. And it can make the case extremely frustrating. So, having some backup instruments is extremely critical. So, let’s talk about the anterior capsule surgical management. What makes the surgery so difficult? The anterior chamber in these smaller eyeballs is definitely shallow. It’s a smaller eye. And the sclera is less rigid with a lower pressure. And on cop of that, the lens is more convex-shaped, and the anterior capsule is thinner and more elastic. As you can see, it’s a combination of these four things that can make the tear run in unusual fashion compared to the adult patients. And on top of that, the lens, you may not be able to see the posterior capsule. So, the — so, a hydrodissection can be somewhat challenging and maybe even dangerous. Let’s talk about the viscoelastic. They mostly fall into one of two categories. Dispersive and co-he’s sieve. And some viscoelastic are hybrid. Which is okay. For those learning the cataracts and for the beginners, I definitely think that cohesive viscoelastic would definitely make things easier.
Because what it does, with the cohesive, higher molecular weight that tends to deform the lens and make the lens flatter. As a matter of fact, if you over-inflate the anterior chamber, instead of being convex, you can even make it concave. So, when you’re tearing the anterior capsule, you will tend not toward peripherally, but more centrally. That’s a tip I would like to recommend to you. If you want to have the tear run more centrally, toward the center, over-inflating the anterior chamber just slightly with the high molecular weight OVD can be very, very helpful. And also, while you’re doing it, you’re stretching the anterior capsule and making it more taut. So, what you’re doing is you’re — when you’re cutting something, watch. See? With my right hand, I’m pulling in downward fashion. But you need the counter-traction with my left hand here. So, if there is no left hand, it’s much harder to tear. So, by providing this — by flattening the anterior capsule and keeping it taut, you’re creating a counter-traction to make the tear more controllable. And these are the list of the high molecular weight. And this is what the anterior lens looks like. So, when you’re tearing in this direction to the left, there has to be a counter-traction. Without the counter-traction, you are not gonna tear anything in any controllable fashion. So, that’s where the tear goes in the blue line. So, in a convex, smaller congenital cataract, when you’re pulling in this direction, there is gonna be a radial force toward the equator because it’s in a slope fashion. So, what’s happening is that you’re not cutting in a straight fashion like this. You’re cutting more at an angle. And, of course, the tear is gonna be more at an angle as you can see here, okay? So, the tear is gonna go more toward the equator in this fashion. So, if you want to pull — if you pull in this direction — if you want the tear to go in this direction, you have to go more centripetally, towards the center. But not always pulling towards the center. It’s a force along with a centrifugal force. Constantly changing the direction. Think about this. You’re not pulling towards the centrifugal, and going central and — constantly changing directions. And also, the — so, this is how I create the inter-capsulotomy. I create — I find the center of the pupil and I go slightly higher and slightly nasal. And then I make a 1 millimeter — excuse me — a .5 mull meter horizontal and then upward incision. So, basically what you’re doing — what I’m doing is that I’m creating a flap. Some people talk about just trying to make it like a small smile. But for me, it’s harder for me to create that flap that I can grasp on. I go horizontal. Sometimes I even go slightly inferiorly. But mostly, it’s horizontal, then upward. .5, .5, and trying to create that flap. And once I create that flap, then I tend to go counterclockwise direction. I have done both. Clockwise/counterclockwise. But for me, I’m a right-handed person, going counterclockwise initially helps me to — to avoid the blind spot that I would create in the inferonasal quadrant initially. And then as I’m pulling, I’m always doing the centripetal and tangential force. And I’m aiming for about 5 millimeters. That’s the ideal size. It’s very important, especially for the beginners, to do a frequent grasping. When I first started, I think I grasped more than eight times. What you’re doing is you’re trying to grasp closer to the initiation of the flap. So, you’re getting closer so that you can have more control. And then viscoelastic. So, as you’re creating this — creating this cover — the covering of the caps-, some is leaving and becoming more convex again. So, the longer you take to create this capsulorhexis, more is leaving than exiting. Don’t be afraid to add additional viscoelastic to flatten or to make the lens more concave. And another thing that I just want to make sure that I tell you is when I’m training my fellows and my residents, styles they’re very uncomfortable and then they’re holding their breath. So, make sure you breathe. And do it slowly. And then if you’re not in a comfortable position. Ergonomically, if you’re not comfortable, this whole thing is going to be very uncomfortable. Make sure you have the microscope, your chair, the bed, everything in the right height so that you’re completely comfortable. And I think this is one of the biggest steps that I can tell you. And also, as you’re creating this flap, and if you see it going radially, more centripetally towards the equator, don’t even think about trying to — especially for the beginners — you can inject more viscoelastic to make it more concave. But if you see things that are not going well, just stop. And then come out and just rethink. And then always have these microscissors or micro retinal scissors or just micro capsulotomy scissors always ready. This is something you can purchase. I would make an incision and redirect it in this fashion. And then re-grasp, and then complete the task. And there are different types of microscissors that’s available. And some people avoid the curvilinear vitrectorhexis all together and go to the — I think it’s okay. And people have different preferences. Many places around the country I think, you know, we are using 23 gauge. But around the world, I know that many are using 20 gauge vitrector. And try trypan blue, it may stiffen the anterior capsule, I don’t think it does. I have done thousands of these try pan blue and I don’t see much of a difference, but I think it improves the visualization. I do like, you know, especially in these very dense — especially in these white cataracts, it helps me to see where the edges are. And then the — if you feel that the iris is — the pupil is too small, and you don’t feel comfortable, and after you inject viscoelastic and you’re trying to enlarge the pupil. It doesn’t enlarge because of posterior synechiae, or trauma. Don’t think twice about the pupil dilater. There are many out there. If you can’t see the edge of the flap, there’s no way the case is gonna go smoothly. So, it’s very important. So, tips. So, while I’m playing this. Cohesive viscoelastic. Especially for the beginners. And I think as you have more experience, then I don’t think it really matters too much. But for the beginners, cohesive viscoelastic. Try to make sure you get that. And then try to use the trypan blue. As you can see there, even for these — it’s not a dense cataract. But you can see the capsule — you have a better visualization. And also, pull more centrally. But it’s more central and tangential force. Okay? It’s a combination of those. If it tends to go more peripherally, you’re pulling more towards the center. But if the tear is going more towards the center, then you want to do it more tangentially. And it’s a combination of that that will help you to create this nice circular opening. And make sure you take frequent bites and try to get closer to the edge of the flap. Which will give you a better control. Thank you! We’re gonna have Ramesh talk about lens management. Thank you! Let me just stop sharing. Okay. Ramesh, will be talking as our next speaker. I think he’s getting things ready. Again, thank you very much. You know, I think we had my guess — we had 2066 people registered and I think we had many people from all over the world. And I suspect it’s over about 90 countries. And so, I’m just truly, truly excited that we are here today and sharing some of the pearls. Okay, Ramesh, please.
DR. KEKUNNAYA: Thank you, Dr. Suh. I will be talking about some tips about IOL placement. Various techniques which works for me. This is a step already different steps in pediatric cataract surgery. I’m only going to focus on the IOL implantation as well as lens aspiration. So, you have this set of incisions. Corneal, scleral, superior, temporal, all that is there. Once you have this capsulorhexis, we have to do the lens aspiration. In most of the cases, it’s better to suture, especially in infants and toddlers. So, if you see what power is introduces and what is the different types of lens power calculation. So, there is no consensus yet because all of them have a equally similar absolute prediction., so one of the simplest formulas you can use is age plus under-correction to 7. This is one of the rough ways to estimate what kind of intraocular lens we are going to put. We have even validated. A 1-year-old child, followed them for 8 years or 10 years and then seen the validation of these guidelines. So, very quickly going through some of the steps. I’m not going to cover the anterior capsulorhexis. One thing people ask: Do we have to do a hydro– most of the time, it’s not required. In my personal view, I never do any kind of hydrodelineation or hydrodissection procedure. These come very easily. Maybe less than 5% of the cases we have to use some kind of powered — for that. Once you have that, you can most the posterior capsule again. I’m not going into detail. Once you have this opening there, one of the simplest ways of implanting the lens is the haptic should go into the back. After you inflate the overall bag, the leading haptic, if it goes inside along with some portion of the optic. Then your implantation becomes very easy. Training haptic, you can just imagine. This is one of the surgeries which I’ve done during the hospital program. It was in Bangladesh. As you can see, the training haptic, you can just nudge it in. And then you have this in the bag implantation of the lens. One of the tips I would like share here is you — in addition to doing a lens aspiration — this is one maneuver I do it where the under-surface of the anterior capsule is polished very nicely to the wall. With the lower aspiration, we can aspirate all of these lens and the cells. Because this makes, you know, the future length of the problem less and less complications along with this. So, this is one of the maneuvers I do. It takes really a lot of time compared to a lens aspiration. This is one thing I feel it is helping. We have to do it in both the sides. So, once you have done that, you know, aspiration, then you have the — either one piece lens, I do not have any financial interest in this lens. People have done optic capture, and lenses and also in the back. So, this is again, I’m showing the implantation technique. With the leading haptic going in sideways. You need to have this picture of the bag inflated so there’s no panic to keep the lens in the bag. You know, you can see that 25% of the lens is in the bag. What you have to do is, again, decrease sometimes. You can see in this case what is happening the haptic has not gone inside completely. The trailing haptic. You have to use an instrument where you have to just go inside. Use viscoelastic and then just match this lens. Because, I’m again showing the implantation of the lens in the back. Because this is live, what is happening. Sometimes you will not have this whole lens coming. Just nudge it. And then this is also a useful technique in posterior — you can see all the optic and haptic junction. And then for the pressure, no real dialing is required. You just have to guide it inside the bag. Once up done, the ripping is complete, just position the lens and put the suture and hydrate the section. So, this is the way you can implant the lens in posterior capsulotomy, I’m not going with that, we are going to touch that topic. I just want to make sure one more way of implanting the three-piece lens. In this case, what I’m trying to do is capture. I’m just running through it again. So, that you can see. Just like this so that the haptic goes behind the posterior capsule. This is the way you can do optic capture. Especially when you use three piece lens in the sulcus. It will be really useful. There are different types of posterior lens. The lens aspiration as well as the implantation technique is different depending upon the stage of this. You can see the first picture and the second and third picture showing this stage and the sign. And the corresponding scan and the VM and the Pentacam picture. When you have an intact capsule. As you can see, it’s a big creator of the weakness of the posterior capsule. What you can do is you can implant the lens in these kinds of cases. Just implant as usual. Because the crater is so large, if you try to do PPC there, the whole lens can collapse. And you will have a drop. Once you have done that, that crater part, you can go through the retractor as Dr. Suh said. I generally use 25 gauge. And you can see, behind the lens you can go and then complete this procedure. Sometimes capsule defect will be there. You can see the sign in the second video. In these cases, you need to be careful. Once you aspirate everything, do a vitrectomy. And even at this stage, you can decide whether you’re going to implant a three-piece lens or a single-piece lens. In this patient, I’m implanting a three-piece lens. You can see, again, so that the posterior capsule and the anterior capsule is in the bag, and if there’s any weakness there, you can complete the vitrectomy there.
One simple tool I use in my practice. This is persistent — vasculature as you can see here. After doing this case, this case was a simple, minor, I must say. I used this endocautery, and I used this peek-a-boo sign, you can do an intro examination of the posterior in an inexpensive way. Just by injecting the air, you can just microscope and you can vet it. This is one of the surgeries I wanted to show because sometimes the anterior and the posterior capsule can be joined together. What I do in this case is I use a endocautery. This is one of my colleague’s surgery. You can see, she is trying to do this cautery everywhere. Using this. You know? so what about it this is already cauterized so that we will not have any kind of bleeding. See that? That’s the point where you can use this endocautery. So, after doing it, there is no lens you can do a lens aspiration and implantation in this patient. You can see the elongated process of the ciliary processes. And then you might have to use, as Dr. Suh showed, you need to have different instrumentation for doing pediatric cataract. And these instruments become very handy in each of these cases. And finally, you might have to get around it using a vitrector. And this is similar, we could implant this in this patient. And sometimes there will be a nightmare where your pupil is not dilated. So, probably you have to use some kind of hooks. I typically use the iris hook in this kind of situation. You can see, once I use the hook, pupil is dilated nicely. I can see the whole part of the lens and I can do the lens aspiration capsulorhexis and trying to do the rhexis part and do it. That’s the other types. One question always asked is whether to implant the lens in an infant or not? This is the criteria I use. The preoperative factors. Interoperative factors and the socio-economic factors. If these things are taken care, in this case, as you can see, biometry is good. No ocular comorbidities. Intra-operative, no complication. I probably put in the implant. There are newer techniques, I will not touch because of the want of time. There is Zepto, as you can see here. Capsulotomy. These are all instruments. If you don’t have experience probably an older age group, you can use this. Because in pediatric cataract surgery, anterior capsulorhexis is the most difficult part. In 90 seconds, you can get an equally good capsulorhexis. Only thing is, it is expensive. And this is not possible in very, very small kids. Because intended capsulorhexis becomes a little bit bigger. That’s the problem what you have with this kinds of recent advances in pediatric cataract surgery. You can see the capsule is there. So, this is the long-term of this patient. And you can use some of these patients. And in the lens also, you can use this kind of procedure. And you can get a good capsulorhexis. And in this patient, after polishing, I’m trying to put it in the bag lens. You can see this. This is one of the patients where I’m trying to do the capsulorhexis. But the doctor from Belgium, she’s dropped this in the back. In the long-term, the visual access is very, very minimal. I would say until nil with this kind of lenses. This is the long-term follow-up. You can see this patient for a period of time, what has happened. I just wanted to show always expect the unexpected. So, I just wanted to show this complication just to watch the video. So, at this stage because of the irrigation flow was more, you can see the lenses syncing. So, what to do in these situations? The best thing is a good vitrectomy. And then fishing this is not a good idea. Because this can happen when you do a thousand cases or 2,000 cases. Or it can be a single case. As we call in the retinal surgeries, you can see what happened. Lens is trying to come up.
So, what happened in this case is the lens nearly drowned. But some unusual mystery happened. The lens came up on its own. The things are there. I just wanted to show that. And the last slide I wanted to show is whenever you follow-up on this patient, do a real follow-up. REAL is the mnemonic, visual acuity, eye pressure, alignment, and IOL-related parameters. Every time, check this on follow-up. So, this is important. And it’s a long journey from this baby to get to this over a 20 year period. It’s a long journey. But it’s challenging. With the help of ophthalmologists around the world, pediatric ophthalmologists or general ophthalmologists, we can provide good care to provide very good vision for these children. This is one of the families where, you know, all the four children have cataracts. And then we implanted the lens when they are 2 or 3 months of I think. And they are enjoying good vision. Thank you so much.
DR. SUH: That was excellent, Ramesh.
DR. KEKUNNAYA: I would like to invite —
DR. SUH: Go ahead, sorry.
DR. KEKUNNAYA: No, I just wanted to invite Dr. Adhikari to give a talk on the post capsular management and vitrectomy. And then we can have questions and answers. Thank you so much.
DR. SUH: Great talk, thank you.
DR. ADHIKARI: Thank you, Dr. Suh, Dr. Ramesh. Now I’m going to talk about a posterior cap shoe layout management. Good afternoon, good morning, and good evening everywhere. I’m Dr. Srijana Adhikari from Nepal. I don’t have any conflicts or finances to close. When we do posterior capsule management, why is it important? The incidence is 100% in children without the posterior capsule management. Even with the best surgical approaches, the incidence reduces, but it’s still most common after cataract surgery. How it offers? The etiology is the retained epithelial cells that proliferate and migrate on to the posterior capsule surface. The it doesn’t opacify. And then the anterior epithelial cells, A-cells, undergo fibrous metaplasia and are — and then the equatorial lens bow cells, E-cells. And most of the time we see these posterior capsular opacities after cataract surgeries in pediatric. Most the key factors for magistrate. What are the most important things whenever we talk about posterior capsular management, is age of the child and the surgical procedure. That is primary posterior capsulotomy or anterior vitrectomy, a mandated teen procedure and should be in feed atypical RCPLX cataracts. And the others, the management and others which I will talk about later. And other factors that are required for the prevention of the posterior capsule opacities. And the important roles are the types of IOLs that we use, the placements of the IOL, the cortical cleanup and management of the post operative inflammation. These are important to prevent posterior capsular opacity in pediatric cataract. And till what age should it be done? And how much to remove? And which approach? So, now let’s talk about the age of the posterior capsule management. So, PPC, posterior papillary — it’s done up to 8 years. That is a common practice. The reason beyond this, the child would be cooperative enough for subsequent laser treatment. And also the PCO formation becomes less frequent or thinner. But the question arises: A cooperative child at age of 5 years, would you do the primary posterior capsulotomy or just leave? One thing you should be very careful about is being cooperative for the eye capsulotomy should not be the only deciding factor. Because the PCO formed is very thick, fibrotic, and difficult to break with the YAG laser. And another important thing is the YAG does not break the anterior vitreous face opacification, and that should be kept in mind. That’s a chance of recounter PCO. If you plan toot YAG, sometimes the decision may be wrong. You have to be very careful in these situations. Now sometimes in older children more than 8 years, 7, 8 years, we have to do primary posterior capsulotomy like in children with a nystagmus where it’s difficult to do a YAG capsulotomy. And similarly with mental retardation. Or poor follow-up, like in countries sometimes the children cannot come for the follow-up and we cannot monitor the posterior capsular opacity. And sometimes if there’s pre-existing posterior capsular defect, and if that’s flutter, defect, you been controlled capsule extension, PHPV. And sometimes we have to do the management even in the older age as well. And now another thing is whether PPC with or without vitrectomy. Usually the common practice is with the vitrectomy up to the age of 5 years. And without vitrectomy only the posterior capsulotomy from 5 to 8 years. That is rough of 8 years. But it depends on the clinical practice and the judgment their decisions. And be evaluated that vitreous prolapse should be ruled out, if it’s there, it should be managed very properly. Now the techniques of primary posterior capsulotomy. That’s how to perform that? That’s one manual continuous curvilinear capsulorhexis with needles, and radio-frequency diathermy which is popular. And the manual capsulotomy, the use of cohesive viscoelastic substance helps to manage the capsule. And we have to be careful in looking at the signs of vitreous prolapse. The shape of the anterior and posterior capsule should be look at. It can be eugenic regular. And vitreous can be there. And triamcinolone helps a lot. And it is looking at the vitreous. And the size, how large? Centered and around 4.5 to 5 millimeter diameter. If you are planning to leave the child, both the capsules can be of equal size. And sufficient to put secondary lens in implantation afterwards. And then the limbal or pars plana. There’s no significant different between the two. They commonly prefer the limbal. And how much to do or what to depth? It is not possible to measure exactly. So, the experience you can learn by the experience. But you don’t have to go very deep in the core vitrectomy. Just the anterior of the vitreous that is lying around the vitrectomy that is there you can do up to those. Now the limbal. Let’s talk a little bit about limbal approach. It is easy. Sufficient enough to — for this limbal approach. And to remove a small portion of the anterior vitreous in the cataract surgery. And it can be done — PPC orb vitrectomy before the IOL implantation or after the IOL implantation. If you are doing before the IOL implantation, which is a common practice, but sometimes the IOL in the bag is a little difficult and needs a practice. But easy to do optic capture in these situations. And if URBEST doing posterior capsular and vitrectomy after the IOL implantations, then IOL insertion in the bag is easy. Because you will get in the bag. But getting beneath the IOL, getting — may cause decentrations of the IOL. And manual CCC is very difficult. So, this is the limbal approach. And another approach is the pars plana approach. Which some of the surgeons use this. And it is also popular. And in this case, either PPC/vitrectomy after the IOL implantation can be done, or no IOL in this case, lensectomy is planned, then it can be done. There is a less chance of vitreous prolapse and large opening can be made without dropping the IOL or the decentral of the IOL. But little extra training is needed for the anterior segment surgeon. And the entry site is very important because we are working on a very small children, so, how much posterior to go from the limbus to the — it varies in different ages so we have to know that very carefully. 2 millimeter posterior limbus in younger than 1, 2.5, 1 to 4 years, and we have to take these things into account. Now the optic capture has been explained by Dr. Ramesh. And this is one of the techniques in which — to prevent the posterior capsular opacity and the studies show an equal out. Optic capture, a little difficult procedure. But with the training, you can do very quickly and you can learn. And this is an easy way to event the posterior capsular opacity and it’s a popular technique. Now, some not very commonly practiced techniques of posterior capsular management. Posterior vertical capsulotomy with optic entrapment. I mention them, and bag in the IOL. That’s what Dr. Ramesh explained about that technique. He explained that. And it is a bag in the lens that also parentheses the PCO. Cortical cleaving hydro dissection, sutureless vitrectomy, and sealed capsule irrigation if use the device. This is not common techniques that have been available in the literature. Now, possible downside of the PPC and anterior vitrectomy. Can be sis today macular if we are opening the vascular and the retinal detachment. But the risk is small and equal to capsular. Without any doubt, we can very easily and we have to mandatorily do posterior capsulotomy and anterior vitrectomy in smaller children. And some of the videos I just to want show how I do — how I prefer to do the management of the posterior capsule. To me, this is a regular case. But slightly unusual because the pupil was difficult to dilate. I just put diluted — and just asking from my nearby anesthetic colleagues. And most of the cases, I do anterior capsular to the — and with a similar 23 gauge cannula. Remove the cortical matter. And then on — after that, after removing the cortical matter, I put the lens first. Most of the time I put the IOL first. And then just lens in the bag. And then the posterior capsule. This is my regular case. Sometimes we get the large posterior lentiglobus. You don’t now if there’s a defect or not, how much defect there is. In this case, there was a large posterior defect and the vitreous was coming in. In this case, the cannula becomes handy in these cases. I did vitrectorhexis and then cleaned with the cannula. And after this, found there was a large posterior capsular defect in the capsules. In this situation, what I did was I just put the lens in the sulcus. That is this is the type of lens that we produce in our lab. It requires a lens that can be very easily go into the sulcus and then that’s — and after that, I closed my case. So, this is how I managed the posterior capsule. Another case of the posterior capsule. Pre-existing capsular plaque was there. And then I did a manual — this vitrectorhexis, and then the resilience left after and after the insertion, the capsular plaque was removed. It was smaller in this case. But it could be managed. It was manageable.
So, these are some of the easy techniques that you can follow which I follow usually in my — in my cataract surgery cases and then we go — we need the lenses. If you are using the vitrector to remove the capsule, it is easy. But if you are doing the manual with the use of the forceps, then it is difficult to go beneath the capsule. If you are doing manual posterior capsule, then it is visible to do it before the IOL implant. This is another case in which the both anterior and posterior are fused together. You can manage the posterior and anterior together. And cut the anterior and posterior capsule with the vitrector. And since we are not putting it in this case, I made a large opening of both the anterior and the posterior capsule together. And then for the subsequent IOL implant later. This is a traumatic cataract. And the posterior capsule in these situations. Only after the opening. So, the — I did again the opening of the anterior capsule. It was quite fibrotic, thick. And after the aspiration of the lens, what I found was there was a thick block under the posterior capsule and at the same time the anterior and posterior capsule was fused together in that part. That’s why there was no proper back to implant it in the intraocular lens. In this situation, I put the lens in the sulcus. And so, three pieces, I will sometimes it’s available, sometimes it’s difficult to be available in our setup. So, we put our own product, our own IOL lab product. So, this is the lens that I used. And then after that, I went beneath the — beneath the lens to remove that plaque that is used anterior and posterior capsule because of the trauma. Which I knew only after opening of the — and this is one of the cases where sometimes we really now these days, previously we used to put a lot of PM into lenses. And now left it, this is one technique I wanted to show. This is a post-trauma cataract. And the lens was removed in the first setting and then there was a thick fibrotic membrane had developed in the posterior capsule. So, in this situation, what I did, I made the scleral tunnel and put the lenses. This is useful where it’s difficult to find out the lenses. And then we did the posterior capsule which can be done easily when you use the lenses. This is another case. So, in summary, I just to want tell that posterior capsule management is one of the most important steps in successful cataract surgery in children. And age is an important deciding factor. And surgeons can choose a suitable option depending on the individual case, available facilities, and their level of experience.
So, thank you so much for your attention.
DR. SUH: Thank you. Okay. These were just excellent, excellent talks. I just couldn’t be any happier. Thank you very much. We had some excellent questions. So, we’re gonna address a few of those questions. Before I start, Ramesh, are you on? I don’t if he had to leave. The lens floating back up, you know, I actually had a similar situation where the lens dish dropped the lens. You know? Putting an IOL after you do capsulotomy and vitrectomy. And if sometimes if you don’t put enough viscoelastic, the lens can drop. Especially if it gets tilted. And pointing in one direction. But I had a situation where actually it floated up. And it was — I’m glad that he was able to share that. Okay. So, first question is that in case you don’t have a portable keratometer, and many paces don’t have a portable keratometer, these things cost 5 to $10,000. What do you do? Srijana?
DR. ADHIKARI: Thank you, Dr. Suh for the question.
DR. SUH: Yes.
DR. ADHIKARI: If it’s not able, we rely on actual length only. That is a thing required even in adult cataract surgery. If it’s not there, the portable keratometer, you can use the actual length scans are portable ones. You can use that and measure the IOL and use the formula that is called Dan’s formula which is available. And I most of the time use. And according to the age of the child, reduced by 10%. If it is less than 2 years, less my 25%. And between 2 years to 10 — 8 years, you’d use the IOL power. Whatever comes to. 10% and after 8 years, just put —
DR. SUH: I’m gonna keep it very simple. Yes, I agree. I think these are definitely possible. Because I’ve actually done medical mission programs all over the world. And there are some places that just don’t have a portable keratometer. And I typically use an average. 43 to 44 as an estimation. But the length is important. That’s the main factor that determines the power. But there are many people that I know would approximate the IOL power. And how do you control the post-op inflammation? Ramesh I think is — I think he may have left. So, Srijana? How to control the post inflammation. Keep it simple.
DR. ADHIKARI: We just regularly put steroid drugs. We tell the patient to put every one hour on so they can put in every two or three hours and then four times a day antibiotic. And use — three times a day. And follow-up after three or four days. Most of the time the first post operative will be clear. And the inflammation starts to grow in three or four days and you call the patient at that time. You start the signs of inflammation, start with oral. That’s how I manage. Most of the time it works.
DR. SUH: As you can see, Srijana is a very passionate person and can’t keep the answer short. Post-op inflammation is a significant problem for pediatrics and there are different ways of addressing it. And I inject sub conjunctival or cannulas. If that’s not available, frequent drops are crucial. And then for people with the — who use PMMA lenses, what’s the size of the IOL implanted?
DR. ADHIKARI: The size is the optic diameter is 6 millimeter most of the time.
DR. SUH: Yep. For us in the US, we don’t have that option of getting different lens diameters. It’s pretty standard. If you have a patient with a micro ophthalmic, or smaller eye, may not be able to place —
DR. ADHIKARI: But our lab, if we can request, we can make 5 millimeter.
DR. SUH: Srijana is in a unique situation, they make their own IOLs. Extremely cost effective. Unfortunately most of us are not in that situation. I’m gonna go — just one last question. There’s so many questions. And for the future — future better of Cybersight webinar, I think we’re gonna give a talk for 30 minutes and then address these questions. And because there are so many great questions. And that we just don’t have time to address. Multifocal IOL. What do you think? Srijana?
DR. ADHIKARI: Yeah, I use multifocal in older children only. Not in the smaller children. After 8, 9 years most of the time. And you can use after 4, 5 years when they start to go to schools. Not in the younger children. These are the lenses that we are using newer. These are new things introduced in the country for the last 4 or 5 years only. That’s why in older children we use.
DR. SUH: So, one of the things that Ramesh brought up is extremely crucial, getting rid of the epithelial cells underneath the anterior capsule. If you’re not meticulous in removing those epithelial cells, they can develop significant phimosis or significant opacities and easily result in decentrations. And these multifocal IOLs, or any type of IOLs that helps you with a lack of accommodation, centration is extremely critical.
DR. ADHIKARI: Yes.
DR. SUH: So, any — just even slightest decentrations can cause a blurring effect. So, if you are considering it, make sure that you have a very stable and — the — that’s well-formed anterior capsule and remove any of the epithelial cells underneath the interior capsule. If the case didn’t go well and you’re not confident that the lens is going to be centered, or if you weren’t able to remove all the epithelial cells, then I would advise against it. Well, thank you very much, everyone. And I — you know, I’m so glad — there’s so many great questions. And obviously this is a top take many people have interest in. And we will arrange a future meeting with our excellent speakers. And hope to see you. And again, I just to want say that thank you very much for all your support for Orbis. And we are gearing up to — for another exciting year in 2024. So, I hope to get to see many of you in-person. Thank you, everybody! Thank you, Srijana. Great job. Ramesh, great job. Thank you.
DR. ADHIKARI: Thank you so much.