This video demonstrates the implantation of a scleral fixated IOL in an aphakic eye of a patient who had a previous eye trauma. The haptics of the 3-piece lens were passed through pars plana and then the tips were melted in order to hold them in place.
Surgery location: on-board the Orbis Flying Eye Hospital in Binh Dinh, Vietnam.
Surgeon: Dr. Larry Benjamin, Stoke Mandeville Hospital, Aylesbury, UK
(To translate please select your language to the right of this page)
DR BENJAMIN: So this gentleman’s had trauma, previous trauma. He’s aphakic. And there’s a dense corneal scar here. With vitreous to the wound. And all we’ve done is put an anterior chamber maintainer in. So, yeah, the fluid is flowing, and the vitrector is cutting, I think. Yeah, yeah. So I’m just trying to figure out where the lens is gonna go. Hang on a second. That way and that way. So if I put it there, I can… Needle… I’ll need… The lens to sit…
>> Excuse me? How old is the patient?
DR BENJAMIN: So I think I’ll need a paracentesis about here.
>> Excuse me? Can I ask a question?
DR BENJAMIN: Yes, sure.
>> How old is the patient?
DR BENJAMIN: How old is the patient?
>> Yes. I need to know.
DR BENJAMIN: Anybody know how old the patient is?
>> Is it an old man or a young boy?
DR BENJAMIN: 55 years old.
>> Okay, thank you.
DR BENJAMIN: If I could have the vitrector — or some triamcinolone first. Some triamcinolone on a Rycroft would be great. Thanks. So we’re gonna put some triamcinolone into the AC. We know there’s vitreous to the wound here, but I just want to see if there’s anything else around. And this will tell us. Some BSS. Is that BSS? Thank you. So you put it in and flush it out, and that will tell you… Jackie, is the infusion off at the moment? Okay. Let’s have the vitrector, then. And what’s the cut rate set at? Okay. And the infusion is on? What’s the vacuum on at the moment? Okay. If we could have the keratome, please, and the lens open.
>> Could you please state what you are going to do in this patient?
DR BENJAMIN: Yes, please. So…
>> Excuse me?
DR BENJAMIN: It might be best if we go there. Yes, we can.
>> Can you hear me?
DR BENJAMIN: Yes, we can hear.
>> Okay. Could you please tell me what are you going to do in this patient?
DR BENJAMIN: I’m going to do a corneal wound. So I can put the implant in.
>> Are you using a scleral fixated IOL?
DR BENJAMIN: No, I’m going to put a corneal wound in. But it’s a scleral fixation of the lens. Just trying to work out where best to put the implant in. Because I’m probably gonna have to fix the lens there and there. So I’m gonna put the wound here. And some Healon, please. Thank you. Some water on the cornea. Some water, please. Thank you. Let’s see if I can free up any of these adhesions. It’s fairly well stuck. The iris is stuck to the cornea very firmly. I’m just gonna leave that alone. This is a C or D? C? You have? All the way? All the way? And then I just need the lens first. It’s quicker if I don’t. Just put this over here. Now, before I do this, I’m just going to orientate the lens, so I know what I’m going to do in terms of its fixation. I think I’m going to fix it like that. Just some water on the cornea again, please. In that direction. So we want… The wound to go… Here. And here. So to do that, we’re gonna need to have… The other way up. Shouldn’t matter. So I’m gonna put it into a needle there. And then a needle there. Okay? All right. Thanks. It’s not in yet. This won’t go in. Oops. That way up. Yeah. This is a bit bent, unfortunately. Yeah. It is. Is it? What’s this one? That’s a Monarch, isn’t it? Yeah. This is a C cartridge, is it? Definitely. Let’s just have a look. No, that’s a D. It’s a D cartridge. Yeah. That’s why it doesn’t fit. Yeah. I don’t think we’ll go through a D. I think it might be all right. Let me just check. I haven’t pushed it down yet, so it should be okay. Thanks. Yeah. That’s better. So this is a C cartridge. And that was a D. And this is for the C. Well done. Yeah. Still not working, though. I think the C cartridge is slightly damaged. Have you got an artery clip? I’ll just bend this up a little bit. An artery clip. Yeah. So this has become a bit bent, unfortunately. I might need one. I’ll just see if I can unbend it. Yeah. That’s okay. I’m not supposed to do that, am I? Okay. So I’m gonna try and get this into… Let’s have the Healon again for a moment. Is the infusion on, still? It is, isn’t it? Yeah. Okay. Yeah. I just need a bit more. Can we turn the infusion off for a minute, Jackie, please? Thanks. Gives us a bit more space. And… Can I have the dialer quickly, please. It’s backwards at the moment. That’s better. Okay. So… I just need to orientate the lens now, so we can grasp the leg. Okay. So if I could have that 27-gauge needle now, and the microforceps open. Grasping forceps. Let’s have a look at the 25. And then if I could just have the grasping forceps, I just need to see how big they are. No, the micrograsping forceps. The 23-gauge. 25, sorry. Yeah. Just want to see if I can get those through the wound. That’s okay. And… I’m gonna need to put the needle through there. Okay. So just let me have a bit more Healon. I’ll use those in a moment. And then dialing hook again, please. Can you ask if he’s all right? Ask him if he’s all right? So try and keep his eye very still for me. Can I have Healon again? If I could have that needle, the 27-gauge needle I just put down… I just need it on its own, really. 25. And then just let me… That should go in there all right. And then the grasping forceps again. And so we put this about a millimeter or 2 millimeters back from the limbus.
>> About 2 millimeters?
DR BENJAMIN: Yeah. And then we’ve got to try and feed the haptic into that needle. Doesn’t want to go in like that, does it? Can you put the infusion on for me, please? Thank you. Tricky to grasp this. Just move that around a bit. Okay. I think what I’m gonna do is… I’ll just have the… Hang on a second. Let me just see. I’m going to come at that from there. Let’s take that back a little bit. So let me just have the MVR blade again, please.
>> MVR blade?
DR BENJAMIN: Yes, please. So this is the fiddly bit of the operation. I’m trying to orientate the haptic into the needle. Full of Healon now. So perhaps if I put it there… So I make this one the top. There. Can I have the dialer, please, quickly, in my right hand? Thanks. And the grasping forceps again, please. Grasping forceps for me. I’m gonna need that hot point diathermy, please. Leave it dry just for a minute. I don’t know if you can see that. You don’t actually have to touch the end of the leg. It just melts.
>> You burned the end of the haptic?
DR BENJAMIN: Say again?
>> You burned the end of the haptic? Is it right?
DR BENJAMIN: Say again? I can’t hear you.
>> You burned the end of the haptic?
DR BENJAMIN: What’s she saying? So you don’t burn it. You just melt it. You hold the cautery close to it, and it melts it. So we need to put the other needle just there. And then getting that other needle in is gonna be difficult. Can I just have the dialer again for a second? So… So we’ve got to put the other one there. And then I think I’ll have to put the graspers in. And then the needle. Okay. I think you end up bending one of the legs. So let’s have the 27-gauge again. Have you got a new one of those? Just so I can — the 25, yeah. That’s a new one, is it? And the artery clips, again? Artery forceps? You’ve got to bend it. And so it’s got to come in that way. So… And then, if we come in there… And then we should be able to get that into there, hopefully. Jackie, can I have a second pair of these graspers, please? Thanks. Not probably gonna go, is it? Some water on the cornea, please. I can’t get it in. Just lay that on there again for a moment.
>> It’s okay now. Thank you very much. Thank you.
DR BENJAMIN: I need a runner. Mohammed, in the changing room is my computer bag. In the front pocket is my Mac laptop. Could you just bring it in for me? No, in the changing room. I’m just gonna look at this video. I think I might be able to get… If I take this leg out here… That might be easier.
>> Hello. Hello.
DR BENJAMIN: So we’re just deciding where to bring the second leg out.
>> This is Wai-Ching. Wai-Ching Lam from the University of Hong Kong. Can I make a couple of suggestions that may make it a little easier? Because I think the approach now is a little awkward. So you can…
DR BENJAMIN: To what? Sorry?
>> The approach is somewhat awkward. So the inferior needle puncture site you can use an MVR knife to make a wound so that you can put the forceps in. And then it probably will be easier if you grasp the inferior haptic from a new wound — from a wound at 12:00. To bring that in. And have the forceps, another forceps, from the 6:00, to grab that haptic. Because you were having trouble seeing where the haptic is. So instead of using a needle, which is difficult to feel with a curved haptic, at 6:00, make a stab incision with the MVR knife, and then put in your other fine forceps, and then…
DR BENJAMIN: Grasp the haptic.
>> Exactly. Grasp the 6:00 haptic from 12:00. Push it down. But you leave yourself a long end, so that the 6:00 forceps can grasp it. Then you’re able to externalize it.
DR BENJAMIN: So I’m not quite with you. You’re saying put another —
>> Take the MVR knife.
DR BENJAMIN: At 6:00.
>> At 6:00. So that your forceps can insert easier. You don’t have to struggle through the small puncture wound.
DR BENJAMIN: And then use the forceps — the trouble I had was getting the forceps in at 6:00, because the (inaudible) is in the way. That’s the problem. So what I might do is make a wound over here and take the end of the haptic out this way. But I’m just having a look at… If you could press the spacebar for me. S-L-A-C-K-S. S-L… A-C-K-S. Slacks. K-S. Enter. S-L-A-C-K-S. And then if you close all that down… Close it down. Yeah. Red spot. And put the yellow one on for a moment. And just open the Orbis Vietnam folder. And the… Where it says “needle”. It’s one of the — yeah. Just open that for me. Press play. Yeah. Just move it along a bit. Because the first bit is… Move it along. Keep going. Keep going. A bit more. Okay. Leave it there. A bit more. Actually, move it along a bit more. Move it a bit more. Yeah, that’s all right. Straightening the leg out there. Just put some water on the cornea for me. Yeah, he bends the leg. That’s the thing. That’s what he’s doing. Yeah. So it has to be opposite. So he does — he bends the leg the wrong way, doesn’t he? That’s what he’s doing. Yeah. Yeah. So if we put a needle in, opposite this wound, which is there, and take the forceps… Let’s have the dialer again for a second. The dialer. Sorry. Thanks. Do you have a caliper on there? Let’s have the caliper. I’ll put it on 2. Make sure we’re doing that at the right distance. So I put the needle in through there. We’ve got to get that leg. So I think we’re gonna have to bend the leg of the implant to get it out. The trouble is, because of this scarring here, it’s sort of limiting access a little bit.
>> So if you make your wound with the MVR knife, you have more space to externalize that angle, that haptic.
DR BENJAMIN: Yes, but then it’ll be too big for the — the haptic will just slip back through again, I think.
>> No, because it’s a slit wound. And you’re using a — what, 23-gauge MVR knife?
DR BENJAMIN: 20-gauge we’ve got.
>> Yeah, 20-gauge.
>> Okay. Do they have a 23-gauge MVR knife? Alcon makes them.
DR BENJAMIN: Yeah, I don’t think we’ve got one, is the trouble. So the wound has to be opposite the other haptic, which is there.
DR BENJAMIN: The difficulty is getting the leg to bend around into the needle.
>> You won’t be able to get it through the needle. You have to externalize with the forceps, because the haptic angles away from 6:00.
DR BENJAMIN: Yes, it does.
>> So the only way —
DR BENJAMIN: But the trouble is, I can’t get the — because of his nose, I can’t get the forceps in, unless I bend them. Let me try and bend them. They still sort of work. I might be able to do it like that. Yeah.
>> The 20-gauge MVR knife wound is a slit wound, so it should not be a problem.
DR BENJAMIN: Okay. Well, let’s try that. You haven’t got a smaller one? No?
>> If they have a trocar, if they have a 23-gauge trocar, that also can work.
DR BENJAMIN: Do you have a trocar? Let’s try that.
>> Use a 23-gauge trocar.
DR BENJAMIN: They’re a bit rounder, though, aren’t they?
>> Yeah, but you don’t leave the trocar in. You use that as a knife to make the 23-gauge puncture. Your needle is round. So it’s the same thing. So you pull your — afterwards, you don’t leave the cannula in. You pull the cannula out. We just want to make a wound.
DR BENJAMIN: Yes, no. I understand. I just… That’s the valved one. Yeah, yeah, yeah. We don’t want to leave it in, really, do we? Well, let’s leave it in for a minute. And I don’t suppose this forceps goes through there, does it? Or does it? It’s a 23-gauge forceps.
>> Yeah, the 23-gauge forceps. It will go through.
DR BENJAMIN: This is a 25-gauge forceps.
>> Yeah. So if you want, you can pull the cannula out. So that you don’t have to worry about the haptic part.
DR BENJAMIN: Yes. I’m just wondering whether that might just give us a bit more…
>> Yeah, yeah. That’s true.
DR BENJAMIN: And then you’ve got another 23-gauge forceps. Is the infusion on at the moment? It is, isn’t it? Yeah. Okay. So let me just have the MVR blade again.
>> The MVR, not the Bascom?
DR BENJAMIN: The MVR. The MVR blade. I’ve got a wound there already. Put that through.
>> If you grab it there, and then you can switch — you can just change the forceps again. So you grab it from 6:00. Because you fixate it. And then you can regrab it with your 12:00 forceps. Then you can release your 6:00 forceps. Grab the tip.
DR BENJAMIN: Yeah, yeah. Grab it again. It’s just… The forceps are not working brilliantly, because they’re bent.
>> Yeah. You got it. So when you pull out, you have to pull it out a little slower. Because you have to get through that cannula. And then you pull your orange cannula out at the same time. You don’t need that cannula anymore. Because that could get caught. Your haptic. So take the forceps… You can pull that cannula up on the shaft of your 6:00 forceps.
DR BENJAMIN: Sorry, say that again?
>> Pull the 6:00 cannula out. You don’t need that anymore.
DR BENJAMIN: Say again, sorry. Just say it again.
>> You don’t need the cannula anymore.
DR BENJAMIN: So that’s coming out.
>> Yeah, so then you can pull it out gently. Because the cannula can actually create a stop of your haptic coming out. Basically you want to disinsert the cannula.
DR BENJAMIN: Yes. I’m trying to get it off the…
>> And you just slide it along your forceps.
DR BENJAMIN: Yeah, I’m trying to do that. That’s it.
>> And once you have it out of the wound, then you can just externalize your…
DR BENJAMIN: Well done. Thank you for that.
>> Looks good.
DR BENJAMIN: Can I have the cautery? Thank you for your help and advice. Never be afraid to ask for help, everybody. Cautery. Thanks. I’ll just make it a bit more melty. All right. Subconj. Okay. I’ll take that out now. Infusion off, please.
>> Infusion off, thanks.
DR BENJAMIN: Okay. It looks stable, I think. Can I have the subconj, please? Subconj. Say again?
DR BENJAMIN: Say again? Yes, please. Can I have some tetracaine, please? Yeah. Thanks. Thank you. And the other one. Thanks. And some amox drops. Okay.
May 31, 2017