This video demonstrates lens aspiration, primary posterior capsulotomy, anterior vitrectomy and an IOL insertion in a 4-year-old girl who presented with developmental cataract in both eyes.
Surgery Location: on-board the Orbis Flying Eye Hospital, Mandalay, Myanmar
Surgeon: Dr. Ramesh Kekunnaya, L V Prasad Eye Institute, Hyderabad, India
She’s 4 years old, and she has bilateral cataract, which is almost similar. You can see the morphology. It’s acquired. Also, we can call it as developmental cataract. So we are gonna do lens aspiration, primary posterior capsulotomy, anterior vitrectomy, and we are going to implant a lens in the back. So once I have done the stab injury, I’m going to inject the viscoelastic. I’m using Provisc here. You can see it deepens the anterior chamber. At the same time it can mechanically dilate the pupil a little bit more. In this case, you have a predetermined capsulorrhexis size, because you can see this nuclear border. That’s the size that we are going to achieve in this particular case. So you can see this shiny surface here. I’m gonna make a stab incision there. And now I’m gonna use that rhexis forceps. Grasp it here. You can see the rhexis has started. So grasp, regrasp. In the beginning stage, if you’re not comfortable, you can use Trypan blue as well. I use this shining surface of the anterior capsule as a guide. We don’t expect much extension at this age. They are more elastic, compared to adult cataract surgery. And they can run away very, very easily. If they become older, as in this case, it’s not so much elastic. I don’t generally do hydrodissection. Most of the patients, it’s not required. So this is the bimanual technique. You can see I’m trying to aspirate the periphery first. Because this will prevent rupturing of posterior capsule, because this nucleus acts as a scaffold to prevent any kind of rupture. I really have to feel it. It’s like a small pull. You can see there are at least 6 to 7 stones are there in the anterior chamber. This is very, very unusual. At least, I’m seeing for the first time. If the nucleus is very calcified, I use phaco. In my experience, 10% of the pediatric cataract surgeries, they need some kind of phaco energy to take it out. What we’ll do now is we will remove the pearls, and then continue with the vitrectomy. This is a very unusual scenario. Pearl picking. We have removed most of it. I’m trying to go ahead and do the lens aspiration. Don’t be surprised. We might have some more of this material coming. Can you all see this additional tag? Just make it round. So what we are going to do here is: The posterior capsulotomy now. Can you see the nick that I made on the posterior capsule? I’m trying to get hold of that capsule. Any patient with age less than 8 years, I will do a primary posterior capsulotomy and vitrectomy. But in patients — even if they are 12 years, if they have nystagmus, I definitely do a posterior capsulotomy and vitrectomy. Probably we need to extend it with the vitrector. The capsulorrhexis was not gripping it. And when you do too much, the vitreous can come with that. So when it comes, it’s best to stop that, because it can cause traction on the vitreous base. The leading haptic goes underneath the anterior capsule there. Once you put it there, the leading haptic and the trailing haptic comes into that position. So you don’t have to do so much of a rotation. You can just nudge it in, as we are trying to do it here. So the lens is there in the bag. Then you can see I’m just nudging the lens there. And then going behind. Your probe should be directed wherever you want to enlarge it. I’m enlarging it on this side. There are some viscoelastic remaining. So I need to take it out. So this is the final step before closing. I do a little bit of capsule polishing of the anterior capsule. Because a lot of epithelial cells — they proliferate from this area. So I inject this air just before suturing. So when you are suturing, it should not be full thickness. This is very, very important. It should be partial thickness. Because later, when you take out the suture, it might enter the AC, and you might have some risk of infection. But before closing pediatric cataract, just make sure that it’s not leaking. You have to see for yourself that everything is fine. If in doubt, always take a suture. It’s extremely important that you bury the suture. And take out this air bubble. And give some injection. Either intracamerally or subconjunctival. I usually give Vigamox and steroid. Why it is important? The child may not allow to put the eye drops in the immediate post-op. At least for 24 hours, you have some steroid there, and you have some antibiotic as a protection, especially for the first day.
October 4, 2019