In this presentation, Dr. Kekunnaya discusses various dilemmas faced in the management of pediatric cataract.
Lecture location: on-board the Orbis Flying Eye Hospital in Chittagong, Bangladesh
Lecturer: Lecturer: Dr. Ramesh Kekunnaya, L V Prasad Eye Institute, Hyderabad, India
December 28, 2017
I would like to show some of the dilemmas in, pediatric catarct management, mostly in the form of, videos again.
Everything is in a dilemma, but I am going to show some things which I felt it’s a dilemma.
So this is a standard one.
This is one of the dilemma.
For anesthesia point of view, do you use laryngeal mask to use intubation?
Do you use ketamine?
I’ve done one of the program where ketamine was used. It’s a catastrophic situation where you cannot use these kinds ofthings. These are the things you need to discuss with your because, you need to know what kind of anesthesia, Laryngealmask, If you use on that, I was saying, the e t c o two, n tidal carbon dioxide for any intraocular surgery should be in therange of thirty five to thirty eight. Which you can discuss with the anesthesiologist, especially when you are doing aposterior capsulotomy.
Surgery, whether you are going to do a manual or with rvitreorhexis.
People do everything with the detractor. No issues, but you need to have adequate instruments for this.
Foldable or PMMA. These are all the dilemmas we have.
But who decides for this? We only have to decide which one to use.
Bilateral simultaneous cataract surgery, which I have already discussed.
This I’ve shown, I I just want to show, the surgery here. And this is the size of the the lens here.
The pupil, very small pupil. What we do here, we have to put a iris hook. That day, we saw a Rubella Cataract. This ishow we need to do this kind of, cases.
Iris hooks, you can dilate the pupil without damaging the pupillary fibers.
So combination of microcornea, microphobia, and meiotic people, very diagnostic of lowy syndrome, if there are femalecarriers having white speck like dots. So examining the parents and the mother is important. You can see once I put this,you see the size of the lens. Very, very small.
These are all situations you need to keep on observing. Keep on observing. Then you will find, okay, this case is a little bitdifferent.
So how do you do it? Dialema, whether you’re going to do an aspiration? It’s so fiber lens. I’ll use a retractor here.
So trying to use a detractor, trying to aspirate everything with that. You can see it does not aspirate so well because theopening is here, not at the end. It makes a difference because it won’t create so much suction.
For you to aspirate everything. And once you do, you can do everything with the Victor. This is a Victor axis.
Vitris, the the the aspiration with the retractor, with rector may be with the retractor. With one instrument, you can do thewhole surgery.
So that’s after that, you can remove it and you can continue. If you want to do a pupil or plastic, you can do it becauseOnce you remove it, if the pupil does not dilate, you need to do a pupil or plastic. You need to dilate the pupil. Otherwise,it may not be enough.
I l or not, we have already discussed. We do not want this kind of situation.
So this is one of the studies from US, the I a t s, the situation is different there. They are all unilateral cataract eyes.
If you see unilateral cataract eyes, they are more difficult eyes because they have associated microconia. Somebody said,PHPV.
So the complications are going to be a little bit high.
So it also depends upon the post operative medications what you use. We cannot manage our patients with four timessteroids, not possible.
We use at least eight to ten times steroids for these patients.
So one of the thing is it’s relatively easy surgery doing a FAQ.
Less time consuming easy to change the glasses, but changing glasses again costs for the patient. It may be difficult.Contact lens mainly difficult situation in most of the situations.
Efekiya has more risk of glaucoma or a period of time. Surfekiya is a protective thing for preventing glaucoma.
And these are the, these are the benefits of implanting a lens in a child.
And these are the problems.
So I would say summarizing intracleans implantation trend is increasing.
It has to be decided on case to case basis.
One must acquire adequate skills before doing it. Otherwise, FAKEA is a safe alternative.
You cannot chase every case with the implantation.
This is a scenario, five year old girl coming to you with asking for intraocular lens.
Second intraocular lens, this is the case already we have seen.
Why do we take out that the matter around that lens. This is the second situation.
I’m using a anti chamber maintenance. I’m reviewing the Sineke here. If you look at the anti capsular excess size here, it’smuch bigger.
So here also, we try to cut this.
This is the instrument I was saying. You can go inside and cut nicely It’s not very expensive, very, very cheap.
Then you can it’s not coming here. You can see, you can take out this. This is a repeat capsular excess for this patient.
So I’m trying to do the, rexis here.
Then do a vitrectomy and see how thick the doughnut around that.
Why I care to remove it because it can cause a posterior or anti vaulting of the lens, especially in this case, it can causeanterior vaulting of the lens.
So I try to remove it, which not fall into the wet rest cavity. The you have to be extremely careful that it does not fall.
We are trying to remove it, see this.
It’s not easy. It takes one to one and a half hours do the whole surgery. So you need to be patient here.
And then in this case, you cannot implant in the back. What you do you open a three piece lens, implant in the sulcus sea.As you do more, you see almost more than a primary cataract.
Why I do take it out, I’ll show you in the next picture. One other patient, what has happened. Sometimes you need toremove it like a nucleus delivery. It won’t come to your routine, see that that’s the that’s the wound there. Trying to removeit.
See, sometimes you need to use the Sinskay hook. And after that, you do a vitrectomy.
And in this case, I am implanting a lens, which is a three piece lens, not possible to implant a other lands.
So if you implant sometimes, you will see when the people is really delighted they complain that this white is the sea.
This is inevitable. We cannot enlarge that and so that Iowa will come. But some patients, if you don’t do it, this is whatthey come up with. You implant in the sulcus, but it keeps on. Even if when you take a picture, it looks like he has acataract, but he has good vision the written surgeons, if they want to do any laser, this child might develop a diabetes, whoknows, then it becomes difficult. So I try to aspirate everything and then do it.
This is the case. This is exactly somebody asked in the audience, whether you’ll implant a black bag or sulcus when youhave a fusion of the entry capsule and the post capsule.
This is the cataract, and this part is the most dense part of the cataract. So you need to analyze, look into the situation, andthen I’m trying to lift it up, see there, see it’s adherent there, completely adherent. But with some force, it’s coming there.Can you see be very, very, very gentle here.
It comes to your forceps, but it’s not you cannot pull it like that because whole bag will come out. So slowly try to I triedto lift it after some time. It was not possible. So then what we did, we tried to take out the cortical matter as we did in theother case, right, in the morning.
So we try to remove it around that.
Anybody would do it differently at this point of time.
Then I’m trying to complete the excess around that. This is what exactly I was saying. When you have a excess, which isnot possible within that range, I’m trying to do their excess afterwards.
This is what somebody was asking. When you have a thick plaque like that, can you take out with the pit tracker? Wecould take it out. We have an eye stresses never give up in this kind of surgeries.
Be patient, you will be there step by step, you can implant in the back. Now, you have an axis there. You have an entrycapsular axis. We’re trying to implant the lens and lodge it I have opened a single piece lens that directly goes into thebag.
This is a implantation in the bag. At the beginning, we thought it’s not possible you have to take everything with theVictor. If you do that, it’s not possible. See that?
Finally, I use SIMCO. Yesterday, Doctor. Marisol was saying, you can use SIMco. It’s very much because it won’t causetoo much of fluctuation in the pressure.
So then always implant.
This is the membranous cataract in a nine year old girl.
How do you tackle the capsule, again, the question in the bag or sulcus?
Nine year old Rubella cataract becomes extremely unstable.
You can see the when I’m trying to do our access here, You can see the equator is coming. It’s so friable lens here.
See that? Can you see just that?
It won’t. It’s not possible to do our access here. What is safe is try to do a return access here.
Try to remove as much as possible, safely implant lens in the sulcus, not possible to implant lens in the bag, in this kind ofsituation.
So I am trying to clean it up so that the the central access is clear and then try to open up a lens, which is c.
When I’m doing that, from nowhere the blood entered.
These are all practical situations. It can happen.
There is lot of vessels here it bled into that.
Air tamponoid is good. Air makes it, you know, a little bit easier. So these are all sometimes we cannot predict the bloodcan go from the vessels from here. These are all the practical situations we can get into This is the haptic of the lens. Icalled with the forceps, and I tried to leave it there.
So this is a three piece. No way you can implant in the bag in a, so unstable cataract there. So that’s the end of the surgery.
Ratinoblastoma, they can also develop cataract.
What incision I would go for a clear cornea because you don’t want to disturb the sclera as as much as possible. How doyou take the capsule?
PPC, yes or no? Depends upon the oncologist advice.
If they think that their tumor has resolved completely, then I’ll do a access, do a PPC.
Otherwise, I will not. But if you do a rexis or a PPC, send vitreous samples to theopathologist because this vitreous cellsneeds to be checked for retinoblastoma cells, very, very important in a retinoblastoma cataract.
I’ll just show one example. This is the n of Thomasai already one eyed patient, developed radiation induced, cataract, youcan see. I’m going clear kernel, I try to do clear kernel as much as possible because all these children might require atrabeculectomy later on. So keep this clear eye intact as much as possible.
So clear kernel, this is the capsular excess.
You can see the yellowish glow behind because the regressed tumor is there already. It’s not enrolling the macula. That’swhy for a better visualization, we are trying to do a Lexus here. I’ll just excuse me.
First for this case, So this lens material is like diabetic cataract, retinal blastoma cataracts are like diabetic cataract. Theywon’t come to your by manual so easily. So we are trying to remove it. Once you this is very typical of retinoblastoma, aswell as juvenile diabetes mellitus cataract patients.
They have very typical cheesy consistence of this cataract. So once you have that, you are implanting a lens.
That’s, again, in the in the back, single piece lens.
You are trying to match the lens and you’re doing the Vitrectomy here because the the cataract was already theretinoblastoma was already regressed.
This is the case I was showing, spontaneous rupture of entry capsule cannot happen without trauma. This patient hasAlport syndrome. You can see both eyes.
Immediately, you should send these patients to pediatric as well as nephrologist.
Still, you’ll have to take care of. This is what I was saying, the curled scissor. It’s so curved. You can go intracameral.
You can cut it you can fashion is the way you want. There is a left sided as well as right sided. This is the capsular axis.You can hold it like this.
This makes your surgery easier.
And then you are trying to aspirate everything here. So you may not have a good anti capsule you still have to managethese patients. So this is the way I did a limited empty capsular axis wherever it is there.
And then the next steps are very similar. This is Alport syndrome. Postic capsule is not weak in anti alport syndrome. It’sonly the anti capsule.
Are trying to aspirate all the part here.
We can see trying to polish the anti capsule, whatever is remaining.
So this is the capsular part, which is intact here, and this part has deficient anti capsule here.
Then trying to do a post primary post to capsulotomy with the Sistito may enter, and then trying to do the Vitrectomy.
And then implantation again in the back because I had more than two hundred degrees of intact capsule even in this case.Once you have that, you can implant it, there So this case, the lens opened up in an opposite fashion. This is what I’mgonna show in this case.
So lens opened up in opposite fashion. So with the two hand technique, by inflating the anti chamber, you can flip itbecause you have two choice here to come back come out, take out the lens or flip it. This is the without touchingendothelium, you need to do it. This is the way you do it. Sometimes these are the situation we get into. I’m showing itbecause if you have this kind of situation, what do you do?
So this is flipped now. And then I’m trying to implant it in the back. You can see it’s going inside, and this is the trailinghaptic.
And then SIMCO is a very good instrument in this kind of situations where you don’t want any kind of, complications.
Yeah. This is, Stickler syndrome.
This is that Lowy syndrome.
Microphirovica is one of the situations where the lens is oblaxated anteriorly or posteriorly.
Always, there is a question whether the retinal surgeon will do or a antsegment surgeon or pediatric ophthalmologist willdo. I usually take care of these patients with the anterior route. I just wanted to show you a video this is a micros farifichere. The lenses come into the anti chamber, try to make a this is for the anterior chamber maintenance, you maintain it.Most of these cases, we can take out we can do a enzectomy in this case.
I call it as clutch and conquer technique, clutch with your anti capsular forceps, and concur with your witrectomy. Youaspirate, as well as Retrectomy mode, you can eat everywhere. You can aspirate the whole lens with this clutch andconcur technique using a anti chamber maintenance.
So this way, microsporofakia, you don’t have to refer all these patients who are surgeon, you can do it yourself in, most ofthe situations.
This I’ve already shown Yeah.
Some of the complications, just watch this video.
There is some music.
Music changes means there is something happening.
No problem. Brexis is okay.
Very atypical contracts.
I thought it’s supposed to be in the corners.
It is postlandic honors.
So this elliptical opening was easy enough. You can put it in the back.
You don’t have to put it in the sulcus in these kind of situations. It’s a very early hosted lenticornis.
Hosted lenticornis can come in different states.
So This is what I’m going behind and trying to enlarge that so that you need a bigger home.
So that’s the end of the surgery.
This is very dangerous case. Just look at it.
That case was not so difficult.
This may take some problems in this case.
You can No problem, This is a titanic that has gone inside.
That’s the opening.
The plunger just gave away it’s there in the I call the retinal surgeon.
It’s there in the so what you do is we could see the lens here.
The retinue surgeon said So do the detector, protect me from this without doing rechecter me, don’t select.
I have a retinue surgeon sitting next to me, then only we did some. We did a cryo here. We same length, it has notchanged it.
You have it happening here.
We put the switcher.
We applied dryer here. This is the first post op So just you can have these surprises, but don’t panic.
Just be cool and we can hand in this reference. This is after one month, you can see that opening.
Lens is in the bag. Same length. I did not. Take it different follow ups. We can look at the Mac I just want to make surethat pictures tells everything. The the videos speaks maybe two thousand words or three thousand words. So you will beable to see these things, in most of this is over.
Yeah. Any questions on that? You had some question on that case. Right?
Exactly. This is what I called the the Malaysian flight with went. We didn’t know for some time. I did the indirect I didn’tknow where the lens is, but it was in the silary body area, stuck like that. It’s like in India, they make tandoori breads, theystuck it on this micro the clay oven. It’s almost like that.
This, I think, already have seen this patient.
I will yeah. When you have a plaque like that, somebody was asking me the question, this is within that five millimeter.It’s just like we need to remove that plaque.
You see when we stain that, it does not take stain.
You see the peripheral part takes, but I open from here, And then what I had to do is just take the plaque out. You have tobe gentle, try to take the plaque out completely and that’s enough.
If it is this size, if it is beyond that, you need to use a scissor.
So this is where we did the capsule I would say plaque ectomy rather than capsular capsulotomy or, and then the rest ofthe surgery is almost similar for this patient.
Yeah. That’s it.