This is a case of four-year-old boy, who had a history of whitish reflects in both eyes, for two months only, that’s a little bit atypical feature about this patient. The lens is a bit swollen, sometimes you can get that better information on the table. One of the clues to differentiate between post lenticonus and intumescent lens at this stage, the anterior capsule will be completely flat in post lenticonus. Because lens goes behind the vitreous, there is already an opening here. If you can see, I’m just rotating it, it looks a little bit swollen. So, chances of posterior lenticonus is less, obviously you can see the cataract is total in both eyes. The lense is totally white here. So, I’m going to inject vision blue and stain the capsule. Obviously, you need to wash all the time. You can always rotate this globe whichever direction you want with the second instrument. This is extremely important, to begin the capsulorhexis I make initial neck like that.
And then I use this capsulorhexis forceps, you can see it has got a good grasp here and it’s vertically down that makes your capsulorhexis is little bit easier. If it is horizontal, you might have to bend it so here it becomes a little bit easier for you to do it. I’m going to enter and I’m going to grab this, you can see this is the initial opening I’m going to do. You can see it is coming from the other side but still doesn’t matter. You have to grasp and regrasp and try to complete it. You can see you’ll have to grasp and regrasp. Change your direction each time if you’re re grasping. Obviously it’s a bit swollen, so you have to be careful, don’t do at a time take your time, grasp and re grasp and then complete this. And with the same flow you can remove this capsule. So you can see the part of the lenses coming out.
So if it was completely intumescent I would have aspirated a little bit of lens matter before beginning with the capsulorhexis. Here I did not do it because it’s not completely swollen like a circle. When you do a biometry, you have a clue what is the lens thickness, your biometry machine, most of them have something called lens thickness LT. General thickness in a child is around 3.5 to 3.8, If it is any way beyond that, for example, say 4 or 4.2, definitely you need to aspirate little bit.
Second side port incision using a myringotomy, you can make it at this stage. And when you come back, you can just give us a small little bit cut so that your instrument goes very easy and smooth. The next step is using bimanual irrigation and aspiration technique. I sprayed the periphery first, and then come to the center because that acts as a scaffold and if it is a possible posterior lenticonus, you might avoid that part going down. That’s the technique I use, I aspirate the periphery first. And then come to the center.
And you should be able to turn your poat wherever you want. This 360 degree moment is very important, as you can see here, as I’m taking the superior part, the whole nucleus is there. It’s very soft most of the times. It’s a little bit leathery, trying to aspirate it but it’s not aspirating completely. it’s definitely leathery, that’s why it is not intumescent. At this point of time, probably it’s best to pause. Inferiorly at six o’clock you can feel the whole nucleus and obviously with the perception of your both, the hands you know, this is not the typical material which will come off very easily. So I will use a little bit of phaco energy to take it out.
I am now doing the main port incision with a keratome, usually I don’t do this step at this stage. Generally, I don’t do this step till I do the PPC. Again, that’s wto step, one and then down. These are all things that you don’t expect at the beginning because there is no way I can say that this is the firm nucleus which is not breaking with the bimanual. We don’t have to chop this so I will use a little bit of Pghhaco energy to take it out. I need the second instrument as this nucleus is floating, which was not expected.
Sometimes, this cortical matter can go in like that, we can see a strand there. I’m going back to the bimanual now there, is some cortical matter left at 12 o’clock and there is some little bit firm cortical matter inferiorly. I am going to take both of them out now.
This is a little bit thick part here, sometimes this can be there. WIth the capsular polishing, I try to remove the cells as much as possible. We may not be able to take them out completely but try to remove the visible epithelial cells under the surface of the anterior capsule, as much as possible.
We will try to do the posterior capsularhexis and then implant the lens. I am opening the posterior capsule now, you can see the opening, I need to rotate sometimes to see that. The next step is to grab the poster capsule, just remember – the more viscoelastic you put, the deeper you have to go.
Can you see it’s coming in the anti-clockwise direction, so this is again grasp and regrasp.
So, it looks bigger, but I think in my opinion, it closes whatever small size you make it, so bigger, the better. And obviously there has to be some place to insert your lens obviously, don’t make it so big that you can’t implant a lens as such. You can see this is again a slow process, take your time, grasp and re grasp.I just do a limited anterior vitrectomy, you don’t have to go very deep, rule of thumb is around anterior 1/3. You go with the maximum vitrectomy available in your machine which makes your life easier and faster. Initially it can be like this, flat towards the vitreous, facing towards retina. Then you need to see this vibration of the poster capsule, that means still there is some vitreous remaining. From here till here, I come like this. And then again I chage the port like that, this is for the 12 o’clock or 11 o’clock and then if you want to see again I’m turning almost 360 degree and turning towards this so, that this part is taken care of.
Your pincer grip should be good, and you should be rolling this. This is directed towards almost seven o’clock now. And then same way you can come till two o’clock and then one o’clock. I am very close to the PC, I’m behind the PC now. I don’t see any moment of poster capsule almost in 360 degrees, this is an important step to know that you’re almost full because you don’t want to overdo it because your globe will become soft, and it’s not required to do too much of vitrectomy.
I’m kind kind of inflating the bag, I’m trying to inflate everywhere so that I can go in and place this leading haptic like this. I just want to go there, hit the anterior capsule, and hit it hard, so that it is in the bag. Suppose this is the leading haptic, go there and push it anteriorly, because if you push it anteriorly your lens is not going to go posteriorly. Push it up so that your two thirds of the lens goes inside, once it goes putting the trailing haptic is just you know, completion of the nudging or rotation. don’t rotate too much unless it’s required. So, we are going to implant a lens, this is plus 20.5. So, we have already made this incision before, and we have to go as down as possible. You can see this is going down, it is just that your forceps and rhexis is in a stable position, it won’t go beyond this you need to lift it up and then put it inside again.
Somebody was suggesting that you can do vitreo rhexis. The problem with vitreorhexis is, you may not have stability of the posterior capsule, it may not be so good. So, this is one of the advantage of doing a primary posterior capsulorhexis because it will be very stable. You can see the leading haptic is in the bag, there. And the trailing is above the bag, this is the trick, you have to put it inside here, it’s almost inside now. Check for yourself in all all directions. It’s in the bag. The posterior capsule is a little bit ablong now, we need to clear it off. You can repeat your vitrectomy and then complete this surgery.
you can see this part is still not gone inside. So you need to make sure that it’s it’s in the bagk. This is a technique where you go behind the lens.
So this part, you need to clear.
So check exactly by going behind the lens because, sometimes this part can go beneath it as you can see here, this is a little bit behind that.
This part is inside, this part is inside, you can see here and it’s inside. So, this you have to make sure before closing. You can see this part is inside and this part is inside. Ideally, I would not touch this Iris because it’s not a good idea to touch. Since the dilatation is not there, we need to check this dilatation part.
Change your technique or whatever procedure during surgery because it’s always gives you a surprise, take adequate care postoperatively. In this case, I will give four times a day antibiotics and prednisone eight times per day and then I will use a dilating drop, maybe cyclopentolate or homatropine for one two weeks – depending upon the availability. Dilating drop is very important in addition to steroid. I will give a Subconjunctival dexamethasone as well as cefuroxime, these are the two injections I give because it gives some protection, till the child is recovering.