Lecture: Congenital Cataracts: Surgical Pearls

[Donny] Good morning or good afternoon or good night, wherever you are. Thank you very much for joining us for the Cybersight webinar. And I will first, let me share my slides. My name is Donny Suh and I would like to thank you for all of our support, from the bottom of our hearts. We have a wonderful Orbis staff working tirelessly to fight blindness around the world. And we are going to have a very exciting webinar with three excellent speakers, and myself. First, we have Dr. Scott Larson from Iowa City, Iowa. And Serena Wang from Dallas, Texas. And Luis Javier Cardenas Lamas, it’s kind of a mouthful, he’s from Guadalajara, Mexico. We have an exciting program for all the audience today and I’m very, very excited.

What we’re going to be focusing on is how, when, why, and what? We’re going to mainly focus on surgical pearls. First we’re going to talk about anterior capsulotomy, how to perform? And then we’re going to talk about posterior capsulotomy and when to perform? And instrumentations and why being a minimalist is better. And that’s going to be presented by Serena. And then lastly, our anchor, IOL selections and what to choose is going to be presented by Dr. Larson.

Before we start, I would like to, for one minute, I would like to ask this question. I would like to see who we are giving a talk to. If you could select, I am, and one of those. I’m going to give you 10 seconds, please. Okay, great. We have many general ophthalmologists and we have some optometrists, pediatric ophthalmologists and we have doctors-in-training residents, that’s great. All right, so let’s go to the next one.

I perform congenital cataract surgery, typically less than five years of age, how many do you do per week or month? If you could just select one. And again, I’m going to give you 10 seconds. And these numbers can vary very differently depending on locations. Okay, great. All right, so we have many who perform none, but probably are trying to perform, trying to learn, that’s great. And we have many who perform one a month, or one a week. Okay, great.

And how do you perform anterior capsulotomy? For those who do perform this surgery. There are many different techniques available. Curvilinear capsulorhexis, vitrectorhexis, can opener, and two incision push and pull TIPs. And there are modified versions of it. And fempto-second, plasma blade, and pulse capsulotomy, and diathermy, or others. If you can pick one for the ones who perform this surgery, I would appreciate.

And the answer is, okay, curvilinear capsulotomy. That’s great.
Now we’re going to go to the next one. Do you perform dye assisted capsulotomy in congenital cataracts, yes or no? Or sometimes.
Okay, and the answer is, yes, perfect.

And lastly, if yes, what do you use? I’ll give you 10 seconds, then we’ll start the talk. ICG, autologous blood, fluorescein, gentian violet, trypan blue, or others. And for those who use them and the answer is trypan blue, that’s great.
All right, let’s get started.

Just like anything, to have a successful surgery, planning is extremely critical and this is what I think of when I do congenital cataracts. When things go well, it’s great, but at a split of a second, things can go badly, as you know. And you have to anticipate what could happen. I think that’s the key to success. You have to modify your surgical techniques depending on the anterior chamber depth, size of the pupil, the size of the eye. And location of the cataract. Is it in the nucleus, cortex, or in the posterior capsule? And if it’s a trauma-related cataract, what’s the status of the zonules? What’s the status of the posterior capsule and the anterior segment dysgenesis and corneal opacity?

And I think, in my opinion, I would love to hear the other panelists, but keeping it simple is actually the key. Simple can actually be harder than complex. And Serena’s going to talk about that.
Let’s talk about my focus is going to be on anterior capsulotomy. And why is this so difficult in pediatric patients? And for those physicians-in-training, the reason we have a specialist typically for pediatric cases is because they are different. We use different instruments, it’s a different technique. But also, actually, the eyeball is not just simply smaller, but the anterior capsule is thinner and it’s more elastic, and it’s convex in shape. And it tears, once it starts tearing, it wants to go peripherally toward the equator. And on top of that, the anterior chamber is much shallower, about three millimeters. And then the intraocular pressure is typically lower. And in combination with the less rigid sclera, the vitreous can easily prolapse forward. And then on top of that, many of these cataracts are very white. So the reflex is very poor.

The first tip that I’m going to give you is that dispersive versus cohesive, and as you can see with the cohesive OVD or viscoelastic device, you can see it’s firmer because it has the high molecular weight. And what it does is that the convex lens with the heavier OVD, you can flatten it and make it easier for yourself as you perform the capsulotomy. And also as you flatten it, it keeps the anterior capsule taut. So that when you tear it makes it easier, because it gives you that counter traction.

Here’s an adult lens. When you’re trying to perform the anterior capsulotomy, so as you pull, if you can just follow me, actually I have these things prepared right now. I got a piece of paper. When things are flat like this, and you’re trying to tear something, you actually need a counter traction. You actually need a counter traction, just like this. There’s a pulling force and there’s a counter correction. But if you’re trying to do this on a flat surface, you can easily create a linear tear very easily, as you can see.

But, in a congenital cataract where the lens is more convex-shaped like this, it’s more spherical. So you’re not really tearing an anterior capsule in a flat surface anymore. It’s actually sloped like this, it’s sloped. When you’re trying to tear something, there is an additional force that plays a role. That’s actually the additional vector force that’s going toward the equator, toward inferior. So as you’re holding and you’re holding this at a slope, as you’re tearing, you see you’ll tend to go… It’s actually almost impossible to tear it straight. I’m sorry it doesn’t show very well. But you just have to trust me. So it’s actually, it’s almost it wants to go toward the equator, toward the bottom.

You have to keep that in mind as you’re tearing the anterior capsule. It tends to go more peripherally. As you pull this way, because of this force going inferiorly, it wants to go peripherally. And that makes it very dangerous because once it starts going peripherally, it’s actually hard to redirect it. Because as you go more peripherally, it’s even more sloped, you see? There’s more slope.
So the way that you do this, is that if you want to go in this direction, you actually have to pull almost 45 degrees or 90 degrees away from it this way. Because you have to counteract this force that’s going toward the equator. Pull more centrally, 45 to 90 degrees from the intended direction. And then another thing you can do is that you can use this heavy viscoelastic that’s cohesive to flatten it. If the lens is like this, what you’re doing with the viscoelastic is that you’re flattening it so that the peripheral, the vector force that’s going toward the equator, you’re trying to eliminate that.
And also, take frequent bites because remember as I’ve told you, the anterior capsule is very soft, it’s extremely elastic. As you hold the anterior capsule as you tear, if you hold it further away you have less control. You want to get as close as possible to the point of the tear to have a better control. Remember, it’s not a race.

Then hydrodissection may or may not be necessary but it’s important to remove all the lens cortex because of an inflammatory response. But what’s more important is that as you can see, we have these epithelial cells that go all toward the equator. After you make the opening, these epithelium needs to be cleaned and removed with the aspiration. If you leave any of this epithelium behind, that’s what causes the significant inflammation and also residual submarines or other types of opacities on the anterior surface or even in the posterior surface of the lens. Cleaning up and doing a good job and removing this epithelium is truly, I think, is critical to prevent recurring fibrosis. Or even potentially, I think, glaucoma of these cells blocking the trabecular meshwork.
Ideally you want to make the anterior capsule about five millimeters. But this is easier said than done. But I try to go for five, but if you make it four millimeters, it’s okay. It’s not the end of the world. But ideally you want to go for about five and posterior capsule around four. And I would love to hear what Luis says about that.

And vitrectorhexis is actually using a vitrector to remove the anterior capsule has been recorded to be superior in some studies. And it’s nice because it’s quicker, simpler, because you don’t have to go in and out with the multiple instruments. And also if there’s any fibrosis within the anterior capsule, due to PHPV or persistent fetal vasculature, you can remove it at the same time.
And if you have a small pupil, anything less than four millimeters, you’re asking for disaster. If the pupil doesn’t dilate very well and if the pupil is less than four millimeters, and you’re going for the anterior capsule, that’s five millimeters, that has shown to cause higher complications. Because you’re trying to rip this anterior capsule blindly. You have to figure out what’s causing the small capsule, if it’s a posterior synechiae, break it. And try to use additional viscoelastic to enlarge. But if you’re not able to do that, there are many different types of devices that’s available to enlarge the pupil. Here’s a John Graether, Graether hooks, this is just a regular iris hooks. Whatever you can, and you need to make that pupil bigger, as big as possible.
And then trypan blue has been shown to stiffen the anterior capsule. And it can actually prevent the unwanted tears of the capsulorhexis. But there is some concern of trypan blue resulting in toxicity to the corneal endothelium. So air bubble protecting the endothelium, I think, is helpful.

Here’s a trypan blue. And it actually helps you to see better. Especially if you have an old microscope. Some of the places that I visit in Africa, these microscopes are actually, I’ve seen one that was almost 30-40 years old. And it doesn’t have the best resolution. Having a trypan blue, I think is a key, as you can see there.
And the one lastly, I just want to show you, I’m in the process of developing a new pediatric anterior capsule micro-scissors. And this is a pig eye and it’s a specially designed scissor that can create a circular capsulorhexis without any type of flaps. This is actually different than retinal scissors, it doesn’t close completely. And as you close the scissors completely, that’s what causes the tear at the tip. So it doesn’t close completely and as you can see, you can actually go around and make a circular capsulorhexis. And I’m going to say I am actually fine-tuning some of the details. But it should be available soon.

Okay, well, thank you!
I’m going to hand it over to Luis and he’s going to talk to us about the posterior capsulotomy. While he’s putting up the slides, in some places the cohesive viscoelastic is not available. And I don’t think it’s essential that you use the cohesive viscoelastic. Because in some places it’s not available. And also feel free to ask questions, we have a Q&A, so you can start posting your questions and I’ll read them later. Go ahead, Luis.

[Luis] Thank you very much, Donny, for the invitation. I will talk about the management of posterior capsulotomy and other aspects.
The posterior capsule affects the final outcome of the surgery. It’s very important to know the importance of taking care of visual development in kids. The posterior capsulotomy and vitrectomy are extremely important. And the posterior capsule opacification is the most frequent complication. We need to know that, we need to prevent amblyopia.

The PCO, the factors to the development of opacification are the age at the time of the surgery, the smallest patient have more risk. Associated ocular anomalies, cortical cleanup, the management of the posterior capsule and vitreous, the type of intraocular lens, surgical trauma. And do remember management of the anterior vitreous also affects the outcome of pediatric cataract surgery. The inflammatory response, again, in small children is intense. And fibrous membranes may form on the anterior surface, resulting in visual axis opacification. The purpose of the surgery is to avoid the posterior capsule opacification to obtain a clear visual axis.

It’s very important to know that the PCO is directly related with amblyopia. So we need to make our posterior capsulotomy, vitrectomy, and IOL implantation as easy as possible. So the surgeons should decide the best technique in each case and their experience level.

Manual posterior continuous capsulorhexis is the gold standard, because it produces a perfect ground and it’s more resistant. But sometimes it is difficult. The correct procedure is simpler, centric, and with the perfect size. The procedure should be made with perfect visibility, also with the new instrumentation it is easier.

Remember the posterior capsule is four times thinner than anterior. My personal technique is to try to remove the plaque with the cystotome and remove with the anterior vitrector. Then, make the anterior victremony, removing the center anterior vitreous, without removing the peripheral or posterior vitreous. We need to identify, perfectly, the anterior surface and remove it. Opacification after there was a posterior capsulotomy and anterior vitrectomy, is attributed to an insufficient vitrectomy. Some surgeons like to inject triamcinolone into their vitreous. Personally, I don’t like to use that.
Some surgeons have avoided, if you can see there, if you can see of opening of posterior capsule without vitrectomy during their procedures. When the capsulotomy is not combined with anterior vitrectomy, the incidence of capsule closure is up to 60%. In this chart, we can observe the higher percentage of visual axis opacification when only capsulotomy is done without vitrectomy. The surgical removal of the posterior capsule and anterior vitreous has long been considered the gold standard in pediatric cataract surgery. In this chart, we can see, sorry, the lowest percentage of visual axis opacification when the capsulotomy is combined with anterior vitrectomy.

Then intraocular lens, where and when? I’m not going to talk much about it because Dr. Larson will talk about it. Today, the most commonly used in pediatric cataract are acrylic hydrophobic because the material is most comfortable with the capsule. But the higher price sometimes limits its use. For acrylic hydrophilic are a good option too. They are safe in pediatrics. Remember, the surgical technique is the most important to prevent opacification than the type of the lens. The lens should be injected always into the capsular bag with or without optical capture. I implant the lens only in patients older than six months and with anterior posterior axis longer than 19 millimeters.

I don’t implant the lens in little eyes because of the risk of developing glaucoma. We can use contact lens or glasses for visual rehabilitation and, of course, patch.
If you have a little eye, do cataract surgery, don’t inject the lens, go to visual rehabilitation, wait until two years, make a better IOL calculation, and make a secondary implant trying to dissect both capsules.

What else? Do you inject transep steroid after cataract surgery? My personal suggestion is to inject one centimeter of dexamethasone to avoid the super inflammation one day after the surgery.

The next topic is YAG laser. Some surgeons decide don’t make capsulotomy because the lens is more stable, so we can use the YAG to make a primary capsulotomy or secondary capsulotomy. Some patients don’t cooperate to these procedures. In some countries it is possible to make it under anesthesia and Mexico is difficult. So I select the patients very well when they are older than four years old so I can work with them very well.

I operated this patient when he was seven years old. I didn’t make a posterior capsulorhexis by the age. Two years later, vision started to decrease so I made a capsulotomy with YAG laser and this is the result. Even though primary posterior capsulotomy with anterior vitrectomy is effective for prevention of posterior opacification, sometimes the reopacification is a fact. So YAG laser is an option.

Don’t forget the intraocular pressure after the surgery.

In summary, select the best technique in your hands, make posterior capsulotomy and anterior vitrectomy, think in YAG laser, and remember a successful result is to individualize.

This is my hospital in Guadalajara, it was founded in 1787, and those are my friends in different parts of the world. I’m sure we will see again soon, face to face. Thank you very much for attending this webinar. Thank you very much.

[Donny] Thank you, Luis, that was awesome, that was great. By the way, Guadalajara is actually, it’s a beautiful city. And I encourage everyone to visit. It should be on your bucket list. Great, thank you. Serena, would you talk to us about how to be a minimalist during an instrumentation, please?

[Serena] As Dr. Suh said, thank you, first of all, for inviting me to be part of this webinar. Just want to share after many years doing pediatric cataracts, my little tips on how to do surgery easy and quick, safe and good outcome, hopefully. And also with minimal instruments. I really do very little instrument on my surgery.

Here when I’m talking, in the background, show off my surgery. This is typical of my day. The typical pediatric cataract surgery I do between age probably seven months to five, six year olds. I’m doing more posterior capsulotomy now you see this, anterior capsulotomy. I use this micro incision of forceps. I do a lot of single incision surgery. But, you know, I think it’s perfectly fine with bimanual. Most people feel more comfortable with bimanual. But the principle’s all the same. I’m going to focus more about these cortical cleanups.

So it can be done really easy and quickly. Once you know how to do this technique it’s really not that difficult. Then typically after, I do the removal inside, spend lots of time to polish the peripheral. Don’t have any cells left in there or as less as possible. Now I’ll go to continue to posterior capsulotomy and your vitrectomy with the same instrument, same vitrector. I don’t come out of the eye at all, almost, until I’m ready to put intraocular lens implant.

I do a good anterior vitrectomy first then I enlarge this posterior capsule opening, just slightly smaller than the anterior capsule. And in the same wound, I would just inject some Healon to open up the back. Now inject lens in the back. Some people really worry about this, but I just think it’s just a matter of getting comfortable. It’s really not hard. After you do a few, you feel comfortable. This step is a little tricky, you try to wash out your Healon behind the lens and front lens. Then this one I typically just lower my infusion and carefully do it. It’s not hard. After that, you just close the wound. This is how the eye, I use 10-0 vicryl to close the eye. I always do it. I don’t really have much inflammation after the surgery. Those kids do really well next day.

The next one, this is how my OR cataract tray look like. This is all knobs for microscope and there’s a few things here you see. Knives and just speculum knots, very simple instrumentation. This one is after taking the knob off, it’s really not missing much there. Very few instrument.

I have this, people probably have seen this, but I just want to focus today, talk about the cortex removal. If you occlude your tip, then you increase your aspiration. Wait for the cortex coming to your port, you don’t have to strip them. They’ll come. Once you start a motion, they’ll all just follow you come out. It’s just like a motion, sweep out, like vacuum machine, vacuum out. It doesn’t matter, use bimanual, single incision technique. Because some people like bimanual because you can switch hands. And sometimes they’re sticky, so be careful, you just have to really be patient. They’ll come to you.
So you, if you have a block, you can turn on your vitrector for a second. Then on the tip, then you can continue.

And then very important to go back to all the periphery to make sure you clean all the periphery. Here’s my, I use 20 gauge, so it doesn’t matter what gauge you use, the recommendations you really using size knife. It’s very important to pediatric surgery, very tight wound because they’re very soft eyes. They have a tendency to bouncing around. You really don’t want eye bouncing around so tight wound is the key.

You notice I don’t do hydrodissection. One of the reasons, lots of those pediatric cataracts they have posterior capsule abnormalities. It’s so common. I see more that have problems then don’t. Some of them you can identify before your surgery, sometimes you don’t know until you take the lens out. This is the same thing. So this patient have a big posterior lenticonus, so you just take your time. We can just roll real fast, so you take your time, get all those cortex out. Then because very important to do subincisional first, because that’s the most difficult part to get it out. You have lots of cortical materials, lens material, in the center that help you protect you so you don’t have, you have lower chance to open the posterior capsule unintentionally. We do open all the time, but when we’re ready to open up (laughs) we want to open up, not before we do.

So here, you can see this lens after you remove the posterior capsule, have a big dent on that. This is one I just go on continue, I don’t come out of the eye. Keep the eye really steady. If you come out, everything will move forward. Then you go ahead to do a posterior capsulotomy and anterior vitrectomy. Then you can put the lens in the back. This patient is very young, so there’s no lens that you can see. This is how the eye looked like at the end.

See, here’s another one. This is a single incision. I do a lot of single incisions because they’re fast and quick. The same way, you see I did a subincisional first. Then I very, very carefully clean all the periphery cortex. If you miss a piece, you just come back to clean it. With this motion you get them out pretty straightforward. Just take a little practice. See this eye, remove the entire center part of the lens.

Here’s my setting, I see some people have questions about what setting I use. My vitrector cuts go up to 2000, then the vacuum up to 330. Then the infusion, irrigation, I’ve been using those settings for years, I don’t really change anything. Just use the pedal up and down to control your level of aspiration and vitrectomy.

This is the instrument and little detail, just microincision Utrattas. I think this is really a key for pediatric cataract surgery. You don’t want to have a big incision for your anterior chamber bounce up and down. This is a small incision, very controlled. Here’s the sleeve for the funigauge. I don;t think they have 23 or 25 gauge, I don’t know why we can’t make them so we should be able to get them. Someone want to make them? (laughs)

There’s different knives we use. So here I just have a quick, show you how to put the lens in the back. You really want to inflate the rim of your back and you injector tip up, upwards so you don’t really dive in. You tip up and you make sure the front part in the back. And the back part opens up pretty slowly, so you have time to put it in. And let it open up slowly. I do inject also for the three piece lens. I don’t know. But this lens you can see you have to open the wound up a little bit with a 3.5 millimeter keratome, injecting the sulcus. And I typically just put the Trinity haptics in the sulcus. If it did not go where it’s supposed to like this, then you can just use your little hook, repositioning it back in.

After all those years of practice, I just really not using too many instruments. This is my injector. This one can go both MA system or as in system.

To wash off the wound, sometimes can be a little bit intimidating because you have posterior capsule opening already. But I put a suture in first, then lift the lens, wash it underneath. I do decrease my infusion at this time, lower infusion, and wash out. If you see a little vitreous, not panic, just do a little additional vitrectomy, clean that vitreous. So this is how the eye look like at the end. I do a little injection, subconj injection, some people don’t do that anymore. But I’m still always doing them.

The tip is keep your eye really fixating manually. Kid’s asleep, so don’t fear to hold their eyes. It’s okay, we do adult cataract surgery, we don’t touch the eye because they’re topical anesthesia. You really want to maintain a stable anterior capsule, you really want a tight-fitting wound. You don’t want to go in and out of the eye very many times because everytime you come out, the pressure goes down. Everything behind eye move forward. That makes surgery difficult. When you start having vitreous all over the place. And keep your irrigation above the vitreous level. Don’t ever irrigate the vitreous. I use anterior capsulorhexis with microincisional forceps. I might do a lot of capsule vitrectomy, capsulorhexis and thinks vitrector’s great. I’m glad we use vitrector to do repeat cataract surgery. It really makes things so much easier.

Again, lens aspiration, you want really start from periphery and go in the center. This can avoid lots of if you have posterior capsule abnormality, you can actually pretty much save it. Anterior capsule use the vitrector, but I don’t have objections if you want to go back in to do a capsulorhexis with rhexis forceps. I think that’s probably always a person’s experience.

That’s it! I’m making this short, quick, and I’m happy to answer any questions you have.

[Donny] Great job, great job, thank you. Let’s actually have Scott bring up his slides and then let’s finish all the talks, and then we can have a little discussion. Great! Serena, you make everything look so easy. I think that’s the key. Do whatever you feel comfortable. And I think especially for new surgeons, this can be very intimidating experience. But I think that’s why you have to stick to something that you know how to do and feel comfortable. I think that’s the key. Great.

[Serena] Yes.

[Scott] Thank you, Dr. Suh, and Dr. Wang, and Orbis. We appreciate the opportunity to share some thoughts. I’m going to talk to you a little bit about intraocular lenses and more about the lenses themselves and maybe some pearls about those.

When you’re thinking about lens power, which is one of the most important things to decide related to the lenses, you need to decide what your goals are. Most of us, I think, and I prefer to do this, is to shoot for delayed emmetropia. So you’re trying to put a lens in that will give them a better potential for vision throughout their lifetime and maybe even uncorrected good vision throughout their lifetime. There may be a time to think about immediate emmetropia and I think that probably shouldn’t be your primary goal most of the time, but that may be related to treating amblyopia. Certainly may give you an easier ability to calculate the lens power that you want. But you’re guaranteed to have myopia afterwards, most likely, so you have to have a plan in mind for what you’re going to do there.

There’s a growing number of IOL power formulas. And this is getting very complicated. The most recent formulas like the Kane formula uses fancy math and deep learning and artificial intelligence, things like that. The question is, what lens formula to use? As you know, we need to have certain information to plug into the formulas. You’ll need a keratometry, axial eye length, and IOL related constant. And the newer ones require anterior chamber depth. But when you look at these power formulas related to pediatrics, there are more IOL formula errors, less predictability, and not all have been studied in children very well. So we have to keep that in mind.

Is there a best power formula in children? The Infant Aphakia Treatment Trial which had a lot of study design advantages, used the Holladay 1 formula. But in a analysis after the fact, the SRK/T formula was pretty much equivalent for those children. The most recent study by Chang et al, compared eight different formulas that you can see there in children less than eight years old and used a one month post op time point. And they found the SRK/T was better in children less than two years old or with smaller eyes and the Barrett and Haigis in older kids with larger eyes.

I have actually stuck with the SRK/T given that there isn’t a great amount of evidence for others. But I do use, I look at most of the formulas when I calculate. As you may be doing, as you’ll do this lens calculation with the child under anesthesia so there’s a fair amount of pressure to make a decision quickly. I like to use this free website, eyecalcs, to put in the numbers and you get several different responses quickly. You can look at Barrett and the Kane formula on their own website. But I typically look at the SRK/T.

Partial coherence interferometry has really made IOL calculations quicker and easier for children that can sit at the machine and are cooperative. This is the IOL Master, which I have access to. And it gives you all the numbers and does the calculation for you if you preset which formula you’d like to use. I realize that may not be available, nor even possible in some children. You need a way to do keratometry accurately. I had a keratometer that lasted me about 20 years, but then just died and so I had to get a new one, and I’ve been using this Nidek version which is great because it takes multiple readings for you quickly. But you do have to get used to the numbers and how it works.

Also, a way to do an A-scan, and I believe you should be using immersion technique. I teach all of our trainees the ability to do it themselves. Although in some big centers you may have an ultrasound technician that is available to help you do that. Either way, you’d like to be able to get accurate readings reliably.

You’ve decided you’ve got your data and hopefully it’s good, now what lens power do you shoot for? I highly respect Dr. Wilson’s data and I usually take his advice. This is a table that you can see from Dr. Wilson’s suggested residual refraction. But there are reasons you may want to adjust this. If there is amblyopia, you may want to reduce the number. What’s the fellow eye like? Do they need to depend on this eye? What’s their assumed compliance with glasses? And maybe think about the parental refractive error and other circumstances. So it’s not an easy decision to make about the IOL power and the power that you choose, if you look at these tables, will be based on an average and how many of us are actually average? It’s not perfect.

The lens material is important to consider if you use a silicone lens and there’s a possibility of needing silicone on the eye, you’re going to have more trouble with deposits. Although regular lens seems, or other lenses seem to get bubbles too with silicone often. They can, if an open capsule is present, you can have opacification with an air-fluid exchange. Retina surgery and silicone lenses don’t mix very well.

Hydrophobic acrylic, I do use some of those lenses. But those are more notorious for apacities, calcification, and absorbing dye like fluorescein and trypan blue. So probably the preferred material is hydrophobic acrylic which opacifies less often.
PMMA, of course, is a great material but it’s not foldable and so you’re going to have to make a larger incision. But it will sit there inert forever.

Just a quick note on blue blocking IOLs. As many of you are probably in my situation where you’re at a big center and most of the cataracts surgery’s done on adults. And so the decision for what lenses are available and what instrumentation is available is driven by a decision in this large group. I recently had to confront this idea of should we get rid of all of our clear lenses and use all blue blocking lenses? And I think the interesting thing is to look at why these have come about. The original studies showed that rodents were exposed to prolonged blue light had retinal oxidative stress and it was assumed that that was similar to what was happening in adults with age-related macular degeneration. But you should know that there isn’t evidence that blue blocking lenses prevent macular degeneration in humans. And it does reduce contrast sensitivity.

And another little bit of evidence was interesting, although not conclusive, blue light may inhibit myopic progression in growing eyes. You can see this study of spectral transmission of light. These are the blue wavelengths that a child’s lens transmits the majority of blue light. But this curve here shows you have 75-year-old and this is a 53-year-old. Most blue blocking lenses transmit somewhere between a 53-year-old eye and a 75-year-old eye. Children’s lenses are clear, they’re not yellow. I do worry about implanting basically a cataract back into a child. So without more evidence, I try to restore normal physiology and use clear lenses.

Lens design is really important and it’s driven by where you intend to put the lens. And I think the goal should be to mimic the normal anatomic position whenever possible. And you do have to be careful about haptic design if you have a lens you’re placing in the sulcus. The single piece lenses are usually not designed for sulcus use. Please consult with the manufacturer so that you’ll have their recommendations. If you’re thinking about sulcus placement, usually I’m using a larger optic size which is 6.5 millimeters and that’s available to us. There are, certainly, lenses that are designed for sulcus implantation and so you have to know about that. Available powers is really important, you have to know what your consignment is and what’s available to you. Because, as you make your lens power calculation in the operating room, you may find that you don’t have a lens that’s appropriate. And so don’t open the eye until you know you’ve got that ready to go, in your hands, and good to go.

Other designs like Iris Claw and angle supported lenses. I don’t have access to Iris Claw, but I know others in the meeting do. I don’t know if you can advance ahead. You may have seen this video floating around about eye rubbing in an MRI and it’s just horrifying to see how this eye gets squished just with eye rubbing. And so I do worry about lenses that aren’t in their normal anatomic position. And, of course, children are going to test the system. And they’re going to make it hard. They’re going to be doing things that we wish they wouldn’t be doing that could put the lenses in a bad place. So you have to keep that in mind and do what you feel is comfortable and appropriate for the child. Next slide please.

These are the lenses I have on hand. And I’d like to have all of them available to me because you don’t know exactly what’s going to happen during the case. Ideally you’d have access to a lens you could put in the bag, a lens you can put in the sulcus, and a lens, if you had to, you could fixate in some way. And these are the ones I have available to me because of our set up that I explained. If you want to click ahead.

I do like to use this lens, this is B&L Akreos, it’s a hydrophilic acrylic, so it has some downsides, but it’s foldable and you can suspend it with suture fixation. But I don’t have it available to me. I have to order it in advance so I can’t get it on short notice. Next click.

And as I’m experimenting with the Yamane technique in children, which I do have some concerns about, this lens may be a better choice. Because when you burn the haptics, it makes this nice little cap that may be hard to pull through the sclera as you can see there. So you have to think about all those issues related to lens design and where you’re going to put the lens. Next slide, please.

And just to finish up, I do think you should be thinking about IOL injectors. I first trained when we were folding lenses manually and I felt really comfortable with that. And as I put a three piece lens that’s sort of springy in an IOL injector, you can end up with surprises. But you’re going to have smaller incisions, less traumatic situations if you can use an injector. Even for those three piece lenses. But be prepared for the problems, especially when you have trainees in the mix. You have to be prepared for an upside down lens, haptic damage, optic damage and lens going array in the vitreous. So just be ready for all those things.

My last little pearl is strongly consider an AC maintainer for secondary IOLs and complex cases. I use the trocar anterior chamber maintainer and I use it in the posterior chamber as well. Because it’s on my set, I have it, it’s available to me. You may have another option, but I would really think about developing a way to do that. Because if you can dial in the intraocular pressure that you want, you will have a more easy situation with these really elastic, floppy eyes.

Thank you, those are my pearls.

[Donny] Okay! Thank you, Scott, that was excellent. Obviously, we all have a few questions. We’re going to actually try to answer about 10 questions from the audience. And then if any one of you have questions for each other, then we could talk about that. First, the last question is that I want to ask a multifocal IOL for pediatric patients and if you do put it in, how do you suggest patient selection and IOL power formula. I’m going to give that question to Scott.

[Scott] Yes, thank you. I think there’s reasonably that multifocal IOLs are bad in children that are in the amblyogenic age. You’re giving them multiple images, I think that’s probably not a great choice. Potentially a choice for a child who’s already maybe a teenager or something. I personally don’t implant them. So I can’t give personal experience. I just have reservations about the whole set up and predicting outcomes in children.

[Donny] I agree with that completely. Next question. If a child is less than six months of age, with unilateral congenital cataract, should we implant IOL and how do we calculate the power? Serena, what do you think?

[Serena] Well, if you do look at the IETS study, it says no. But I think this is a case basis. What your patient comes from, what access they have? I think it’s all your decision. I think if it’s not completely not okay to do lens, I think if it’s a particular situation you could consider lens, that’s the best choice. But the calculation, just like everybody else, I don’t know other people, I calculate all my lenses under anesthesia. Just like Scott, I have a handheld keratome and A-scan calculated right there and I’ll put the lens in there.

[Donny] That’s right, okay, great. Would either one of you put IOLs in anyone less than six months of age?

[Serena] I would do them with special cases, not everyone.

[Donny] Scott, Luis?

[Luis] No, I don’t.

[Scott] I would under certain circumstances. It does depend on the family and if you think you’re going to get… We have a great contact lens team, but I do think that rehabilitation is easier in cases when IOL’s present.

[Donny] Yeah, I agree with that. Scott, does the IOL design affect visual axis obscuration? And which design do you recommend in pediatric cases?

[Scott] Yeah, I think there’s plenty of evidence that the square edge design is what you’d want in the bag. And you will prevent that the best. You can use three piece design and optic capture, which there’s evidence that that can prevent opacification. And so I think those are definitely good options.

[Donny] Right, I agree. Some of these questions, if you just go back to our video, I think that answer, you’ll be able to find the answer. If I don’t cover your question, if you could go back, okay, please? Is there any difference to do posterior capsulotomy before or after IOL implantation with any advantages? Basically, doing these posterior capsulotomy before or after IOL implantation, is there any advantage or disadvantage? And what do you prefer? And we already know how Serena does it. Scott and Luis?

[Scott] I’ll let Luis go first.

[Donny] Okay.

[Luis] I prefer to make first the posterior capsulotomy and then inject the lens. I think you can control better the position of the lens.

[Scott] I’ll just be the counterpoint to that. I do a lot of cataract surgery with a fellow, beginning pediatric cataract surgeon. And I believe that if I have an access to the capsule after the IOL’s in, through the pars plana, we have a really stable situation and it’s very safe. So I actually make a pars plana incision with a trocar lately, this is what I’ve been using. And then put the lens in and then take out the capsule and a little bit of the vitreous through the pars plana. And it sounds, maybe, scary for an anterior segment surgeon but it’s not. It’s very, very stable, and anyway. It depends on what instruments you have, what machines you have available, I think too.

[Luis] I think this is different. In my case, for example, I don’t have a pars plana vitrector. I only have an anterior vitrector and I think it’s, in my case, first we need to make the capsulotomy and then the intraocular lens. But I think that if you have the other option, it’s excellent.

[Donny] Scott, the only comment that I have is, first of all, I actually have done both. Doing a pars plana approach I think is excellent, I think it’s safe for the majority of the cases. But if you suspect any type of abnormalities, including a PFV with the anterior displacement or pulling anterior displacement of the retina. I think those are some tricky cases because you can potentially, you don’t exactly know where the retina ends and starts. In patients with the PFV, I probably would be very cautious about doing a pars plana approach. What do you think, Scott?

[Scott] Absolutely. That is a set up for-

[Donny] A disaster.

[Scott] Problem sometimes. I’ve been trying to do some imaging in that area with high frequency ultrasound to see if I can tell if the retina’s being pulled up. But in PFV, those are my only scenarios where I’ve had retinal detachment post surgery too. And even with the retina surgeon in the mix. Yeah, you have to be very careful in that setting, I agree.

[Donny] Yeah, yeah. Actually I had one retinal detachment case and that was because of that. Okay. And I’m going to answer two more questions and then let’s ask each other some questions, and then we can end it.

When is it okay not to place a suture to the wound? I’m going to say anterior segment, comments? Serena, when is it okay not to place a suture to the wound?

[Serena] I never not put suture in the wound unless it’s just a paracentesis wound. For children, their tear shield is different with adults, very elastic. It’s actually, like Scott showed the picture of the rubbing the eye, wouldn’t that scare you? I always put suture, I can sleep that way, so, I never not put a suture for any wounds like 20 gauge. Any wound.

[Donny] Thank you, thank you. Serena, I think that’s an excellent comment. I have to tell you something. I actually went to India and did a procedure with a surgeon. I’m not going to tell you who that was, but he told me that he never places suture and he never had complications. And I said, “Okay, well…” So anyway, he did the procedure and I saw the patient post op day number one, and there was an iris prolapsing out of her wound.

(Luis laughing)

And I guess, you know, and then I found out that some of the surgeons never see the patient post op! How do you know? I’m a firm believer of placing sutures. Because just like what Scott just showed, kids can be pretty aggressive. Even with the Fox Shield, these things can fall off, and they can rub, and increase intraocular pressure, and then things can prolapse. And I’ve seen it, I’ve seen the complications, so I agree with that.

And last question. In places where they do not have a vitrector, which is I’m going to say, probably 50% of the locations that I’ve been to, they don’t have a vitrector. They don’t have these expensive Allergan and Alcon machines. What would you recommend?

I actually have some experience with this, but Luis? Do you have any comments?

[Luis] I think the best option is not to open the posterior capsule and wait to the opacification and then send the patient with retinal specialist to make the capsulotomy and the anterior vitrectomy by pars plana.

[Donny] Well, I think that’s an excellent option. But I do have to tell you, this is the reality. I’ve actually been to a place in South America where the land is completely landlocked and there’s no way that the patients, or anybody, can leave this area because they’re surrounded by the river, the Amazon River and also the mountains. So this is actually a long time ago, we actually used Simcoe for the entire case. And as a matter of fact, around the world, Simcoe is probably the most commonly used device for congenital cataracts. Just FYI. Because the Simcoe, it just works beautifully, as you know. Just like Serena’s device. Instead of using a suction, you’re using your finger. You’re using your finger to irrigate. And I think in many cases, in my opinion, I think it’s even safer. Long time ago we would just do a simple Simcoe and then do a manual posterior capsulotomy and then leave the posterior, the anterior hyaloid face of the vitreous intact. So we just leave it untouched. And, of course, these patients probably developed significant opacities in the future. But at least they’re not blind, at least they’re not blind.

In India, I would say the most commonly performed procedure is that they use a Simcoe and then they do a manual capsulotomy and they go in with the vitrector. Just for, we’re talking, they do it for probably 10 seconds, 10-15 seconds. And they do a limited vitrectomy and they come out. And the whole procedure is extremely quick, extremely quick. But that’s probably the most commonly performed procedure that I know of in many parts of the world.

Serena, I’m going to ask you a question and then we could ask each other questions. You have a very good surgical technique. The only thing that the audience should know is that the coaxial sleeve that you have shown, it has to be special ordered. I think you’re getting it easily because you’re used to using it and you have the Alcon company just right next door. But for many of us, actually, it’s a special order. The 20 gauge, I was told by the Alcon rep that they’re even considering, I don’t know how long the 20 gauge device is going to be around, but at least the sleeve, it has to be ordered special, especially. Just FYI for people.

And then also when you put the lens in, after you put the lens in, do you place the vitrector behind the IOL to aspirate the residual viscoelastic underneath the lens at all? Or do you mostly actually aspirate the Healon just anterior to the lens?

[Serena] No, you lift up the lens, wash underneath.

[Donny] Okay, great, great. I’m going to just tell you, I’m a chicken. So I don’t lift the lens because I did that one time and then I dislodged the lens and then tore the posterior capsule. So I probably do leave a little bit of viscoelastic behind. But knock on wood, as long as you watch the intraocular pressure post op, I’ve not had any complications. Some of these patients, I do know I leave some of the viscoelastic behind.

[Serena] Yeah, I think that’s okay. We actually tolerate some, as long as you don’t leave a lot.

[Donny] No, no, no, that’s right.

[Serena] You just lower your irrigation so you don’t push your lens down. Then you do a controlled, yes.

[Donny] Yeah, yeah, I think that is the key. You need to lower your bottle, you need to lower your bottle and lower your-

[Serena] Lower pressure.

[Donny] Yeah, lower pressure.

By the way, your settings were excellent. Remember, around the world, the Alcon machine may not be available. So depending on the machines that you use, of course, you have to customize the settings accordingly. And also, even if it’s the same Alcon machine, depending on the instruments, and also depending on the cannula that you use, you have to use different settings. So I think that’s important.

Any other comments? Luis, any questions?

[Luis] No, that’s perfect. Congratulations to all of you. Wonderful lectures and I learned a lot.

[Donny] Thank you. Scott, any questions? I cannot hear, your microphone.

[Scott] Thank you, thanks for the opportunity. I love to see Dr. Wang’s videos too.

[Donny] Yes, yes! Thank you. I always learn a lot after these webinars, it’s great. And like I said, this webinar is going to be saved under the Cybersight Orbis platform. And so we can watch it anytime.

Thank you very much and I look forward to seeing you again at the future meetings and also hopefully you’ll accept the future invitation for the future Cybersight webinar. Thank you, guys.

[Serena] Thank you!

[Luis] Thank you very much, friends! Thank you, Donny. Thank you, Scott. Thank you, Serena.