Surgery: Paediatric Cataract Surgery

Hi. My name is Doug Frederick, and I’m a pediatric ophthalmologist, and we’re gonna be showing you, a way to do a cataract extraction in a child using low tech.

So here you see we’re using a standard, limbal peritomy.

Again, I always like to put my incisions covered by conjunctiva.

So you can see we’ve done some Wedfield caurtery. Now we’re using crescent blade turned upside down to make a groove at the posterior surgical limbus.

And again, we want a two planed incision here. So it’s important not to go too far posterior. You don’t need to use a a very, large shelf because it’s hard to get the cortex out.

And it’s hard to manipulate the the simcose. If you’re too far posterior, as well as you will get some premature entrance into the anterior chamber. So here you can see we’re making a nice shelved incision, and again, using the blade. We can see it have a little aggressive aqueous there, so that means we enter the anterior chamber.

We enlarge our incision using a MVR blade. Now you’ll see we don’t go all the way into the anterior chamber. We are entering just enough to make room for the simcose. If we make it too large, go all the way in, then we’re gonna get too much leakage around the simcose.

So here we’re using a disco, dispersive, viscoelastic.

This is a bent, twenty five gauge needle, for a cystitome. So with a small incision like this, it’d be hard to get the utrata forceps in. If you have fancier capsular forceps, you can use those. But I think it’s important to see that even in a child, with an elastic capsule, you can use a bent needle to slowly, create a nice round, continuous curvilinear capsulorrhexis. You can see the key here is is that we’re frequently adding viscoelastic to keep the chamber deep. And have nice control. And again, frequently repositioning the needle tip, so that you don’t have too long of a flap of caps that you’re pulling on, go back to the junction, and take your time.

So here you can see we’re gonna get to a little tricky point, where the rhexis seems to want to start tearing out to the periphery. So what do you do? Again, add more viscoelastic, get control of the situation, put your, you know, right at that junction to get it going in the right direction. Once you’ve redirected it, you can see the tear going in the right direction now, then you can go back to your same technique where you have a little bit of a lead, on the caps are flapped, and always when in doubt pulling in towards the center of the eye, rather than pulling outward so that you don’t extend the rexis in the wrong direction.

Remember, you can always make the rhexis larger.

It’s very hard to make it smaller. And again, having a nice, continuous capsulorrhexis will make it much more reliable that the implant will stay into the capsular bag and not prolapse and give you iris capture later on.

So you can see we’re about ready to complete the rhexis, you can see there’s a beautiful rhexis.

Again, you might think this is a little bit on the small side, but in a child, that’s okay. Because again, they’re going to be rubbing their eyes and prolapse of the IOL is to be avoided.

So here you can see we’re using an old technique. This is a simcoe, irrigation aspiration handpiece. Using a syringe to create the suction.

And again, the key to the simcoe is reaching in far into the sulcus, in pulling out nice chunks at a time. You try and pull out as much of the peripheral cortex before you debulk the central, part.

And again, it’s not uncommon, to have a little bit of cortex, superiorly, or sub incisionally.

If you have a J hook, you can use that. But remember that the cortex usually is not problematic. It’s not inflammatory in a child. And it always does go away. It’ll be part of the submarine’s ring that will be covered by the the iris.

Here you can see where I am planting a single piece acrylic intraocular lens. It fits well within the bag. You can see our rhexis is still nice and, round. There’s no tears.

And here you see, again, once you have the implant in the bag, you can go back and try and debulk some of that residual cortex. It’s always important to remember to achieve the mission first. And the mission here is to remove the cataract and get the lens safely implanted.

Because well, I was having a little chamber control. We closed the wound. We put a use a 10-0 vicryl to make the wound a little bit smaller. Here you can see a little bit more control. It allows us to get that last little little bit of cortex out.

And then we close with the 10-0 vicryl Suture, so that, you have no openings, nothing that can leak, decrease your chance of endophthalmitis, decrease your chance of a flat chamber and hypotony post operatively. Okay. Thank you very much.