This child has a traumatic cataract which is iridescent. This eye also has band keratopathy and a corneal scar. An anterior capsulotomy was done and the fibrosed posterior capsule was removed. A 3-piece IOL was implanted utilizing the technique of haptic capture.
Surgery Location: on-board the Orbis Flying Eye Hospital in Vietnam
Surgeon: Dr. Asim Ali, University of Toronto, Toronto, Ontario, Canada
Narration: Dr. Daniel Neely, Indiana University, USA
This young boy has a traumatic cataract. He fell down and something hit his eye. I’m adding a little bit of tetracaine here. And you can see that he has some band keratopathy and this corneal scar, and the iris is drawn up into the angle beneath the keratopathy and the scar and his pupil is pulled up. He has some synechiae between his iris and the lens capsule. And this child also has these crystallin deposits. The cataract itself has so many different colors, it’s a bit iridescent, doing to MVR blade incisions here. Our air bubble for some try pan blue to stain the capsule in this difficult case. And now we’ll place our viscoelastic to deepen the anterior chamber and remove the air bubble.
I was going to break the adhesion tear, corneal scars here so there’s no real benefit to dividing the adhesions between the cornea and this patient. We’re not planning to do anything surgically with this pupil. So we’re going to be mostly just breaking the synechiae so that we can implant the lens in the sulcus. Now we also may do some optic capture with this. There are multicolored cataracts, something called a Christmas tree cataract that’s associated with atopic dermatitis. But this one is traumatic, there’s almost nothing left between the capsular leaflets, it’s just completely a membranous cataract. Here we’re kind of exploring our anterior capsule, I’m just underneath the anterior capsule here, really not much to it, the lens is largely already reabsorbed. So, there’s really not much space, we are injecting a little viscoelastic between the capsular leaflets through the anterior capsule here and I’m just in front of the posterior capsule, using this viscoelastic to inflate the space between the capsular leaflets. So really not much lens material remains at all.
The anterior capsule is right here, it’s not displaced, it’s just separating the two from each other. So superiorly there is now a space but inferiorly the capsule is just completely fused together. And it’s not going to come apart, it’s not going to separate. I’m just cutting through the anterior capsule here. Opening up the anterior capsule using the cutter since it’s really not possible to tear capsulotomy in this fibrotic state. And we’ll just keep working with that and support facing upward as much as possible. And about there, the capsulotomy is complete. And I’ll try to remove most of this lens material using aspiration, I’m going to add a separate port here. So I can use this sinskey hook in my left hand and retract this Iris. See if there’s any additional lens cortex down near that we’re not getting a good visualization of given the fact that the iris is incarcerated and that corneal laceration.
And we’re getting a little bit of lens material out of there. But again, so much of this has been reabsorbed already. You can see this membrane here trying to separate that from the anterior capsule, which is adherent to some degree to the posterior capsule as well here. Sometimes these little membranes can be rolled off and just stripped free of the capsule, but I think we’ll end up needing to cut this anyways. So we’ll use the vitrector to do that. I’m just trying to aspirate out as much of the lens material as we can here. And I’m doing this very slowly because the visibility is rather limited. Now introducing a light pipe now, this will help us see the capsule structures just a little bit better. You can see most of the posterior capsule is very fibrosed.
Again, there isn’t much less material here at all. So, I think we should just go ahead and implant the lens, and it’s helpful because we have the scar here. And there’s question about the scar being visually significant, well, the scar in this case is below the central visual axis and this central cornea is clear. So it’s doesn’t appear that we really need to do anything with the iris and the pupil itself. And it’s just not necessary. Because of the scarring there inferiorly, he won’t have any visual distortions through that portion optically. So using a keratin to create our lens implant incision, again, you can see the posterior capsule is very heavily fibrosed and just removing that fibrotic material.
When placing a lens in the sulcus, it’s preferable to have these thin haptics, as you see on this three piece lens. There is less bulk that goes into the sulcus with these, there are some significant adhesions in this case between the cornea and the capsule, and the sulcus is somewhat obliterated. These synechiae, as long as we’re not pushing on the lens, we don’t really have to do anything about them. Just need to have it opened up enough to be able to get the lens in. Can also use a blade or interocular scissors to slice, those synechiae. I like to do this with blunt dissection as much as possible.
It’s easier to do this with the posterior capsule intact than to wait and try it do it with the posterior capsule open especially because the pupil is small. So, we’re getting our lens in place now. So, I’m just going to rotate the lens and get it situated well in the sulcus. Make sure there’s some space there. The lens is in the sulcus now, seems to be centering nicely. We are going to close this wound off partially, so we have less prolapse of iris tissue, especially as we turn our irrigation back on, we’re going to recenter our lens a little bit. And I’m going to place the cutter exactly where we need it to be before the infusion comes on. And we’ll be opening the posterior capsule to do a anterior vitrectomy getting some of this viscoelastic out of the anterior chamber here so that our fusion is flowing freely. And currently I’m working behind the lens optic, so there’s no risk, and I’m going to be hitting the iris. As you can see here, we’re behind it.
And I’m now opening that posterior capsule and enlarging it, so that we have a clear visual axis and red reflex is looking good. We’ll use our light pipe here to check, make sure everything is in good position. So even though there’s all this fibrotic area and fairly the lens is in good position, so there’s really no reason to cut this area more or disturb this distorted pupil. In this case, it would just risk bleeding, further damage to the corneal epithelium. Everything seems to be in good order there, everything’s well situated.
We’ll be putting a little miochol in to see if we can bring the pupil down a little bit, to help keep this sulcus lens in place. The pupil has been very floppy throughout this case, and then fusion is off now. This allows us to do two things, first of all, allows us to kind of recenter his pupil and the iris. And the second thing is to make sure that there’s no vitreous coming around the lens to the wound. I don’t think there would be in this case, but it’s always best to check before you close your incision.
Some of the pressure has been starting to form in the chamber and just watching the IOL very carefully. With all this manipulation that can sometimes just move out of position like it did there. That looks better now. So we have the optic captured nicely. So we have good chamber depth. There’s a question of whether because he has a corneal scar, whether he needs something done with a pupil again, pupiloplasty or an iridectomy of some kind. But one of the reasons that I selected his case is he has enough clear cornea in the center that he can see. So hopefully when the cataract procedure is removed, he has enough of a visual axis there to see well.
So just to summarize, this is a traumatic cataract in a young male. The lens is in good position and optic captured. There’s some space centrally so the patient can see. Postoperatively, I would use cyclogyl once a day. We are doing our final injections here. The two important things I would mention are, do the minimum that you need to do for the child to see and second of all just remove as much lens material as you can to avoid a lot of post operative inflammation.
August 7, 2018