This video demonstrates a cataract surgery in a healthy child who presented with unilateral membranous congenital cataract. There may have been an unseen trauma in this child which could have caused cataract. A 3-piece IOL was inserted in the sulcus due to a big calcification plaque in the posterior capsule that needed pars plana vitrectomy and posterior capsulorrexis done with the vitrector.
Surgeon: Dr. Asim Ali | University of Toronto, Canada
DR ALI: So this child essentially presents with a unilateral left sided membranous cataract. There’s no — his prior history of any trauma or any previous red eye, inflammation. The child is entirely healthy. And there is some posterior synechiae there. Which you can see. And a little bit of band keratopathy. But the other eye is completely normal. And there’s no other signs of inflammation in this eye at all. So we’re not entirely sure what happened. We were wondering whether there was some previous unseen trauma, and that can definitely happen sometimes with children. So the lens is mostly resorbed, so we have mostly a fibrous area centrally, so we’re gonna remove that plaque and place a lens in the sulcus and capture it. And I’m only using two small incisions to make this part easier. I will enlarge the superior wound to put the IOL in. So I’ve just placed a bit of viscoelastic underneath the iris here. Everything else here looks very good. Because we’re gonna be placing this lens in the sulcus, I just want to make sure that the entire sulcus is free. Because otherwise if you don’t, and if there are any adhesions, what ends up happening is the lens can become decentered. So I’m looking at what the spatula is doing. And I’m also feeling. And I don’t feel anything there. What I’ll do is I’m actually gonna do — is the cutter to do the rhexis, because there is a fibrotic plaque. So I don’t think the Utrata will do very well there. So we’re just gonna move on to do the… With the vitrector first. So I’m just going in to enlarge the capsulorrhexis. As you can see, there’s not much room here. This is the posterior capsule, just behind me. So normally you wouldn’t remove the capsule like this. But because the anterior and posterior capsule have been fused, it’s okay to do it this way. You can see there’s a fold here in the capsule. Some of this material is very calcific. There’s this sort of calcific — it’s almost crystalline material here, that’s just coming loose. Yeah. It looks almost like crystals. Now, we are gonna put the lens in the sulcus. But the reason for removing all of this cortical material is that it can come out of the bag later, prolapse into the visual axis, so as much as possible, it’s better to remove it now. Yeah. I’m trying not to cut any of this material away. I’d like to aspirate it. Because we’re gonna open up the posterior capsule. We can either place the lens before or after a vitrectomy. It might be easier to do it before the vitrectomy. And I’m going to switch my infusion and my irrigation as well. You can see just next to where my cutter is the anterior and the posterior capsule are fused together. And we’re gonna use that to keep everything stable. More of this very crystalline material here. I don’t know if it comes out on the microscope, but it’s very, very brightly colored, and so it has a very iridescent sheen to it. Can I get the viscoelastic, please? Now you can turn it off. As it’s turned off, I just place a little bit in there, and it just stabilizes it. Again, I don’t like to have the chamber shallow. We’re just gonna complete the removal of the rest of this material here. Most of it has been removed. All that’s left is this fibrotic material. And I think we can open the lens now. We’re gonna have to keep some of this fibrotic material. I think we’ve removed enough. We can turn off the infusion now. The advantage of doing this now is that because the posterior capsule is not open, it’s easier to place the lens. We’ll put a little bit of viscoelastic in the sulcus. So if we’re using a folding lens, it’s easier if we just enlarge it, just a little bit more. So this is the 2.75 keratome. And this is a plus… So we’re gonna be using a three-piece lens for the sulcus. And once it’s in place, we’re gonna cut open the posterior capsule. Just do an anterior vitrectomy. So we’re just gonna introduce this in the eye. Get some countertraction here. And then make sure the lens goes into the sulcus. So the lens is in the sulcus right now. So right now, going underneath, to make an opening in the posterior capsule… So when the incisions are smaller, there’s a much more stable chamber. So I’m trying to close the large incision somewhat. And because I enlarged the wound, I’m gonna put in three sutures in total. And a stitch at the infusion. The last time, that got cut or pulled out. But this time we’ll hopefully use that. Everything we’re using is 10-0 vicryl. We’re just gonna keep this along, so that’s less likely to… Sometimes when you’re pushing the infusion in, it gets pushed aside or gets cut. Now we’re gonna open the posterior capsule and do a vitrectomy, and also remove that membrane, as much as possible. So I’m making sure my cutter is on. I want to go underneath the IOL. Now, I’ve already made that opening there, you can see. So you work around the edges to enlarge the posterior opening. I was just asked a question about the size. You don’t need to remove all of that white material. You just have to remove enough that you can safely place the IOL behind it and capture it inside. That fibrous material really helps to stabilize the IOL. And there’s some whitish areas in the red reflex here, and I can’t see what they are. They’re fairly posterior. So I’m not going to go after them. They may represent old blood or very old vitritis. I can’t tell.>> So you see blood in the vitreous?
DR ALI: It might be, yes. But it’s very far back, and I don’t have the biome. So I’m only gonna go after what I can see. So I’m just checking right now, and the opening is still too small to capture the implant. So I’m gonna enlarge it some more. So this goes… Just tucking one side in. Okay. And then we’re just gonna push the lens, and there’s the other side. Okay? So the lens is in the sulcus right now. It’s a little bit decentered, but I don’t want to cut this too much. The capsule will tear. So I think it’s in a good position. And it’s nicely captured there, so it won’t move anymore. Okay? So we’re just going to suture… Get the 10-0 again, which is gonna suture the main wound. The reason for capturing — helps keep the lens centered. And also helps keep it away from the iris. If you don’t leave any viscoelastic in, your IOP won’t go up. And the pressure hasn’t remained low in this eye. So we had a little bit of blood — I don’t know if you saw that — from the iris earlier. It’s not gonna bleed now, because we haven’t let the pressure in the eye go down. And if there’s no viscoelastic, the pressure shouldn’t go up. So I don’t routinely put them on, like, Miochol or anything. We don’t really need to do that there. So the lens is decentered slightly, temporally, but I think if we go in, the risk is ripping there, and the lens might become destable. So I’m happy with that there. Or I’m happy with the lens in its current position. And centrally, it’ll be well centered in the pupil. Can I have the injections, please? And we’re just injecting dexamethasone. And I stopped using gentamicin as much, because it can… There’s a theoretical risk of it causing retinal damage. So not that you would do that here, but I’d rather avoid using that agent at all. Cefazolin, there’s no such risk. So we just have to watch her postop for any inflammation. Okay? So she may need more steroid. So we’ll just have to watch and see. Okay. Great. Thank you very much.
June 19, 2017