During this live webinar, Dr. Suh and Dr. Wang will discuss various surgical techniques and potentials for pitfalls during surgery, when and how to place the IOL, and post operative management. 30 minutes of Q&A.

Lecturers:
Dr. Donny Suh, Chief of Pediatric Ophthalmology and Adult Strabismus, Children’s Hospital and Medical Center, Omaha, USA
Dr. Serena Wang, Associate Professor at UT Southwestern Medical Center, Texas, USA

Transcript

DR SUH: Hi! Good morning! I’m Dr. Donny Suh. I’m very excited to do our second webinar on congenital cataract, surgical techniques and instruments part 2. Just a second. Can everybody mute? Serena can you mute your computer? Thank you! Perfect. I’m Donny Suh. I’m a professor at the University of Nebraska, and chief of ophthalmology at the children’s hospital. And Dr. Serena Wang is an associate professor at the southwestern Medical Center in Dallas, Texas. And we have a very exciting program prepared for you. First, I would like to take a quick question. I am… Blank. Please. I’m gonna give you ten seconds. So we’re gonna have five questions. And I would like to know who we are talking to. We have 1700, 1,700 participants registered today. So we have mostly general ophthalmologists, and we have optometrists and pediatric ophthalmologists, and then we have other specialists. Next is timing of surgery. When do you perform unilateral cataract surgery? At birth? Or wait until 2 weeks, 2 to 6 weeks, or 7 to 8 weeks, around 2 months of age? Number 5 is around 3 months of age, 9 to 12 weeks. I’m gonna give you 10 seconds. And these questions are based on the questions that were requested on the survey. And it looks like most perform between 2 to 6 weeks. Which is actually pretty consistent with what I do. Okay, next. I would like to ask: Timing of bilateral cataract. If it’s a bilateral cataract that’s visually significant at birth, when do you do the first eye? I know in some countries, they do both eyes at the same time. But for this question, when is the time of the first cataract surgery? At birth? Less than two weeks? Two to six, seven to eight, nine to twelve weeks? For bilateral cataracts. The answer looks about the same. 2 to 6 weeks is the most common and then 7 to 8 weeks. At what age do you try to place the IOL in congenital cataracts? For unilateral cases. Again, the questions are never, right at birth, or the 7 to 12 months, 13 to 24 months, and then greater than 2. Or do you just prefer no IOL? Perfect, so most people place it if they’re greater than 2. So they leave them aphakic, it looks like, ’til 2 years of age. Okay, great. Next question is for the bilateral cataracts. For bilateral cataracts, when do you place the IOL? Never, from birth to 6 months, 7 to 12 months, 13 to 24 months, greater than 2, or prefer no IOL for bilateral cases? This is a question for visually significant cataract, and for those who perform the cataract surgeries. And the response. So again, the response is pretty dominantly — 58% says greater than 2 years of age. Okay, great. So just in general, this is what I do. Again, there’s no right and wrong answer. For the unilateral dense congenital cataracts, for the most part, I think for unilateral, I do between 4 to 10 weeks of age for healthy babies. And of course, if there’s any medical problems that would require delay, then we may have to do it later. The studies have shown that the risk of glaucoma with earlier cataract surgery is higher if it’s performed at less than 4 weeks of age. So that’s the reason why I try to avoid cataract surgeries before then. And for the bilateral dense cataracts, it’s between 2 to 3 months. And I usually wait only about 2 to 4 weeks between the cases. Bilateral surgery on the same day is typically not recommended. But in certain countries, where the cost and the risk of anesthesia is high, or is not available, is not readily available, then they would have no choice but to perform the surgeries on both, in the same setting. And this does happen. Even in this country. In terms of the surgery, the success truly depends on the planning. The planning is the most critical part. And because a lot of things can happen with these congenital cataract surgeries. And the danger always is lurking. Things can happen very, very quickly, as you all know. And with proper planning, you can avoid these disastrous situations. So the planning makes you avoid you playing with fire. So we’re gonna talk about the planning. So when you plan these surgeries, you have to modify the surgical technique based on what you’re dealing with. And what are some of the things that I think about, when I’m looking at the cataracts? I look at the anterior chamber depth. Is it deep enough for me to be able to perform the surgery? Would I have to deepen it? Am I gonna be able to place the IOL? So the size of the pupil. I have a very low threshold of placing pupillary dilators. Iris hooks or whatever that’s required to dilate the pupil. Because I think in my opinion the most important part of the cataract surgery, in pediatric patients, like in adults, is the anterior capsulotomy. And if you don’t have a good view of the anterior capsule, the surgery could go — become disastrous, in a matter of a second. And is the eyeball big enough? Where is the location of the cataract? Where is the opacity? The poster capsule? The anterior capsule? The nucleus? Am I able to see the posterior capsule and appreciate the lenticonus? Is it gonna rupture? Is there significant trauma that affected the zonules? Significant anterior segment dysgenesis? Is the iris healthy enough? Is there posterior synechiae? And I look for anatomical abnormalities. After all these things in my mind, I develop a surgical plan. The important thing is: Whatever you plan, you have to keep it simple. Steve Jobs said: If you can get there and keep it simple, you can move a mountain, and I firmly, firmly believe this. You want to keep it as simple as possible. The four prognostic factors include unilateral cases. Treating amblyopia for these patients can be somewhat challenging. So the visual outcome may not be as good as for the bilateral cataracts. Smaller eyes. Whether it’s a microphthalmia, or persistent fetal vasculature. They tend to have a worse prognosis, because there’s a significant anatomical abnormality. Associated with ocular abnormalities like the Peters anomalies. Systemic disease, in patients, for example, with a juvenile idiopathic arthritis, with the inflammation. For surgical considerations, placing IOL or no IOL. It’s a concern. This is one of the questions that many of you brought up. Relative contraindications include children with chronic inflammatory disease such as JIA. I used to be a lot more daring 20 years ago, when I started working. So if the patient was under control and there was absolutely no inflammation within three months, I used to put IOL, but now I think I tend to be just a little bit more conservative. The three months went to six months and nine months, and now I’m at a point where if there’s any history of significant anterior uveitis, I tend to not place IOL. Of course, there are other mitigating factors. But I tend to go against the IOL placement. But what are some of these mitigating factors? I’m gonna talk about them in a little bit. If the eyeball is 9 millimeters or less, then I typically do not place IOL. IOL considerations. If there are unilateral cases, I tend to put the IOL sooner than later. Because these patients — you’re gonna have to deal with anisometropia. With a significant anisoconia, you’re increasing the issues. Nystagmus, contact lenses are gonna be difficult. Dry eye, sicca or any dry eyes due to different metabolic disorders or different autonomic dysfunctions, I tend to consider placing an IOL, because contact lenses are gonna be very difficult. If they live in a dirty, sandy living condition, like for example northern Africa, where it’s very windy and there’s a lot of sand in the air, those patients I tend to lean towards placing an IOL. Limited access to contact lenses. In some places around the world, the aphakic contact lenses, the SilSoft, those lenses are not available, or the cost is limiting, so those patients in those situations, I would place an IOL. Compliance concerns. Behavioral issues with ADHD or autism. Or other types of developmental delays. And constant follow-up, if it’s an issue — IOL I tend to put in. So typically I place them in 7 months or older. Because the studies have shown that there’s a higher need for repeat surgery. Not so much complications, but repeat surgeries, if it’s performed less than 7 months of age. With the fibrosis of the anterior hyaloid, of the vitreous, resulting in repeat vitrectomy or repeat surgeries. So I typically do not place IOL in anyone less than 7 months of age. If the corneal diameter is less than 9, I do not. But in some situations, like the mitigating factors that I just showed you, the PC IOL lens diameter is 8 millimeters. So you can potentially remove the haptics and place just the lens inside the bag. I’ve actually seen that happen when I’ve visited India. And 3 IOL calculations dilemma. How to measure axial length. What formula they use. And what power do you aim for. So this is actually some of the common questions that I was asked. So I just wanted to spend just a few minutes. Conventional ultrasound biometry. Applanation versus immersion technique. And optical biometry. For pediatric patients, most commonly, we use applanation technique. Because it’s most convenient. And it’s accurate, if it’s performed by the trained biometrist. But you have to make sure you don’t compress the cornea when you do this. You really have to have the excellent technique to do this. Immersion technique is perfectly acceptable. The optical biometry is typically not performed in pediatric patients, just because many of them — we actually have to put them to sleep. Because we cannot perform the axial length and keratometry in an office setting. Remember, 1 millimeter error in the axial length calculations results in 3 diopters of refractive errors. Depending on which direction. If it’s a short eye in pediatric patients, that error — every 1 millimeter, you’re gonna be off by 3.75 diopters. So that’s pretty significant. So you’ve got to be very careful. Two schools of thought. Do you aim for emmetropia or low power IOL? This is just a matter of preference. But emmetropia is — if you implant 28 diopters, producing emmetropia at 8 months of age, this will most likely result in -7 by the age of of 3. So this is a pretty significant myopia you’re gonna have to deal with. You’re basically committing these patients to most likely contact lens fitting for the rest of their lives. These are some of the things you have to think about. So what I typically do — this is the target refraction that I aim for. Somewhere in this range. So typically, 1 I do — just remember the number 6. 6-1. So I go for 5 diopters. So 2, I have 6-2 is 4. So that’s what I go for. I subtract the age from 6. And that’s pretty close to the approximation. But that’s the table that I go by. Formula. I pretty much use SRK-T. There’s no one formula that’s far superior to the others. But typically Hoffer Q in a baby with a very short axial length, I use Hoffer Q. But SRK-T is what I use. But you do end up with refractive surprises. And I’ve had my share. There are many reasons out there. But I would say this is one of the biggest ones. A posterior staphyloma that you may have overlooked. And if you aim the ultrasound when you’re performing the ultrasound biometry, and if you missed the small posterior staphyloma, you may get a number that may not be optimal. Surgical techniques. Dr. Wang is gonna go over this in a little bit more detail later. But like I said, removing the anterior capsule is truly — I think, in my opinion — is the most critical. Because that kind of sets the tone for the entire surgery. The capsulorrhexis is difficult. It is truly difficult. And it’s different in adult patients. Why? It’s thinner, elastic, and it has more convex — it’s more convex shaped. It tears easily. Because it’s thin and it’s more elastic. And it’s got a radial force. The anterior chamber is shallow in a smaller eye. And then also the sclera is less rigid, with a low IOP. So as you’re manipulating the tools, it tends to collapse and blur your vision easily. And then you don’t get that nice bright red reflex on retroilluminations. Because most of these congenital cataracts are visually significant and have white cataract. So what are some of the tips? As you all know, we have a dispersive and cohesive types of viscoelastics. And the cohesive — for example, the Healon, the Healon GV, those are the ones that are heavier. More cohesive properties, as you can see here. It’s more of a gelatinous consistency. So it tends to form the anterior chamber better. So it makes the surgery easier. However, it tends to be a little bit more expensive. And it is not readily available around the world. So most people that are performing these surgeries — they have to resort to the dispersive OVD, which I think works just fine. Once you get the hang of it, I think it works well. And the Trypan blue — not only it stains the anterior capsule, but it does make it, I do think, slightly stiffer. I don’t know if I truly believe that. I don’t know if I truly believe that. But I do think that it does make the tear just slightly easier. Consistent with a literature search. And so this is what you want to end up with. Something somewhat circular. Anterior capsulorrhexis. About 5 millimeters. The adult lens — I just want to show you — it’s fairly flat. The anterior surface is fairly flat. So when you’re trying to perform the tear in one direction, there’s a counterforce that’s going in the opposite direction. When you’re trying to tear paper… You actually need countertraction and traction. For example, like this. That countertraction has to go in the opposite — completely opposite, 180 degrees opposite direction — before you can make this tear. However, in pediatric patients, the anterior surface is pretty convex. So when you’re trying to make a tear in one direction, there’s a countertraction, but also there’s another force, a radial force, that’s going toward the equator. Toward the center of the lens. So that’s why the net vector force is actually slightly in a diagonal fashion. And that is the reason why it is very easy for you to go and tear into the periphery toward the equator. So the direction of the pull should be about 45 degrees. 45 degrees in this way. If you do it 90 degrees, it actually makes it — you can end up with the capsulorrhexis that’s just small. So what happens when you do 45 degrees? The tear — you want to go in this direction. Excuse me. Okay. Anyway, so you want to go 45 degrees. Because to counteract the radial force. The lensectomy — make sure you remove all lens cortex. They tend to have vigorous inflammatory conditions. And posterior capsule management. I typically remove posterior capsule if I cannot perform the YAG laser within one year. So if they’re less than 5 years of age, or if they’re not gonna be cooperative with the laser, I go straight to the posterior capsulotomy and vitrectomy. By the way, it’s not advisable to remove the posterior capsule without removing the anterior vitreous. I know people do that, and I do think that at least in my experience the anterior hyaloid, the anterior surface of the vitreous, tends to opacify pretty quickly in those situations. YAG problems — the problem with a YAG is that it does tend to recur. So it is not unusual for you to use a YAG on the same patient two or three times. When you’re doing the posterior capsulotomy or capsulectomy with a vitrectomy, the ideal diameter of the anterior capsulotomy is 5 millimeters in diameter. Because remember, the lens diameter, the PC IOL diameter, is 6 millimeters. So if you make the anterior capsule opening bigger than that, there’s a chance of prolapse. So you want to make it ideally 5 millimeters. The posterior capsule opening, the ideal diameter, is about 4 millimeters. You want to make it slightly smaller. So that you don’t have any problem with the lens dislocating. And understand when you are doing these surgeries, understanding the surgical equipment is extremely critical. And Serena is gonna talk about that for the next 20 minutes, and then we’re gonna address many of the questions. Thank you. Serena? Go for it. You need to turn on your speaker.

DR WANG: Okay. Here’s my slides you. Pediatric instruments and techniques I have kind of developed over the years. I went through a lot of complicated ways. I finally figured out this easy way to do it and make things uncomplicated. Hopefully some of you can think that’s interesting. Here’s the first slide. This is my cataract tray. Surgery tray. Not very complicated. Only a few things on there. After we remove those knobs. That’s all we have. So I’m gonna go through each of them, and also my surgical videos. We’ll see how we do those uncomplicated pediatric cataract surgeries. This is the lid speculum I like to use. People like different ways. This one is small. It works even for very small children, like newborns. And this is called Alfonso without tabs. This is 0.12 forceps. I always have two in my tray. They’re very important essential instruments for pediatric cataract surgery. I think we are really taking advantage of general anesthesia. You can actually hold the eye instead of the eyeball wobbling around. Like Dr. Suh just talked about, the counterforce. 180 degrees away, you hold the eye. You can keep the eye really steady. And make your surgery much easier and more controlled. I use these 0.12 forceps to do that. Here’s some knives I use. And you can see the first ones are called the supersharp blades. We use these for paracentesis. The second is the 2.5 millimeter keratome. I use this for my bag lens. The SN series for the in the bag lens. This is a bigger knife. 3.5 millimeters. I use that for sulcus lens or three piece, where you need a slightly bigger incision for that. Here are some pictures of the knives. I don’t know what brand you use. The principle is the same. Just the size matters. So here — I want to show this important instrument I like to use. I don’t know if you can see this. It’s called the microincision capsular forceps. Here we go. This very important instrument — for me, I have used this for the past 15 years to make a capsulorrhexis so much easier and more controlled. Versus making a big incision to try to do this. Because this microincision forceps makes your anterior chambers very stable. Which is pretty much the key for pediatric cataract. Especially infantile cataract surgery, because their eye is very soft. Very bouncing, you know, unstable. If you keep your incisions really small, this is much easier. You can see you would do capsulorrhexis motions — almost always pull toward the center. Toward the center. Otherwise, it will run out. VisionBlue is really good if you need that. It will help you. This particular forceps is a Hoffman capsulorrhexis 23 gauge. There are different versions. I also have two different tips. One is scissors. A normal scissors on this one. And this is a side cut scissor. You’ll see those instruments are really, really helpful when you do complicated cases such as PFV and pupillary membranes. And you can use those to help you do the procedure better. Here’s the lens aspiration. This instrument is just a vitrector we all use, pediatric cataract surgeons. We’re very familiar with this. I use the irrigation sleeve over it. You can see this is a picture here. You’ll pull it over it. It’s coaxial. So you make an incision. Again, pay attention to — I’m always holding the eye. You can take advantage of that, because the kid is asleep. And you’ll start with the periphery. You use a quick sweep motion. A sweep around the periphery. And again, it’s very important for pediatric cataract surgery — you really want to make a clean, clean surgery. Even if you do a really good surgery, they still can rejuvenate the cortex. So this is just quickly showing that being done. I’ve been doing this technique for the past 15 years. I think it works really good. If you have trouble getting the subincisional cortex, those old good instruments are still very helpful. When I was a resident, learning to do the phaco, this is what we used for I/A. This had a 90-degree — a different angle of aspiration tips. It can help you get this cortex out. I haven’t used this for many, many years, but it’s always available. Here, sometimes I do also — I also do bimanual procedures. When I don’t put an artificial lens, I just do bimanual. You can do bimanual even with a lens. You just have a larger incision. This is what I use. I like to use 20 gauge. You can use 23 and 25 gauge. I’ve tried all of them, but they’re not as efficient. The 20 gauge is so efficient. It gets the cortex out so much faster. So here. But most important is the way you do it. I have this separate irrigation cannula. But those are important. Whatever gauge you use, you want to choose the same size of knife. You want to keep your wounds tight. So you have a very steady anterior chamber. This one — I also use mostly 20 gauge. The irrigation cannula is 20 gauge. It’s just the same. So here’s anterior capsular vitrectorhexis here. I use the irrigation cannula on my left hand, and my right hand uses a vitrector. You can use again 23 or 25 gauge, but 20 gauge works great. You’re gonna close your wound anyway. So you want to choose whatever is the most efficient tool to get it done. So I’ll just give you a nice anterior capsulorrhexis. Then you can do the same way. Oh, this is the same video. Apologize for that. Lens aspiration. The same. You start from the periphery. And go all the way across. I like to do just clockwise. You can do anti. Whatever works for you. I like to clean my subincisional first. Because that’s the most difficult part to do. So the advantage for the bimanual procedure is you can switch hands. If you’re having trouble getting subincisional cortex out, you can switch hands and start from the other end. And that will help you take the cortex out. I think whatever way works for you is the best way to do the pediatric cataract surgery, or any kind of surgery. You will develop your own way. And find what is best, the most efficient way to work on this. And for this particular case, I just take out the center and then do more on the periphery. It’s very important that you clean the periphery more. Make sure everything is clean, clean, clean. Before you move on to the next step. So then you can continue to do your vitrectomy. And this one is the same technique. I’m showing the bimanual, because I think more people use bimanual than my coaxial technique. So you can just continue. You don’t have to take out the instruments now. Just keep going. After you do the cortical, you make a small cut in the posterior capsule, and do a really generous vitrectomy. Then you enlarge the posterior capsule, just slightly smaller than your anterior capsule. If you don’t put a lens in, fine. If you’re going to put a lens in, in the future, you’ve left a very good support for the future IOL implant. Here’s my tray. I have the 20 gauge. I use Constellation. But over the years, I’ve used all kinds of machines, Legacy, and most of the machines we use are Alcon systems. I use adult machines as well. It’s all the same. The principle is the same. You just want to do — here is the other — the next instrument on my tray is the injector for the IOL. This Monarch III system, this system can do a sulcus lens and bag lens, so you don’t have two different injectors anymore. So if I use an Alcon lens, it just uses a different cartridge. The B cartridge for the sulcus lens and D cartridge for the bag lens. And also here, there are three different manipulators. Kuglen, Maloney, whatever you like. This is anterior and posterior — both capsules open. But you want to inject the lens in the bag. The key for this is you lift up your tip. You don’t dive your lens into the vitreous. You actually lift the tip up and put it in the bag. With the Alcon lenses, the AcrySof — they’re so soft. You open the lenses up very slowly. You have time to position them. You open up the sulcus, and this cartridge is bigger. You have to enlarge the wound a little bit. But I was using the same injector. The MacPherson forceps is really helpful. You position the haptic and put it in the sulcus. But if it doesn’t go into the sulcus, you can use the Sinskey hook or Maloney to reposition it. I recommend to you — I always suture the wound. You are taking care of children, infants, toddlers, they don’t really know they’re not supposed to rub their eyes. Even if you make a small incision, I always close the wound. There’s no downside to closing the wound. But I’m always using absorbable suture here. This one is vicryl suture. 10-0 vicryl. These are holders, tying forceps. Here I’m showing you — I place the suture first. Then I wash out the viscoelastic. I use the Healon for everything. So I washed out the Healon from in front and behind the lens. And you tie the wound. Tie it up with this one stitch. This stitch will dissolve itself after a week or two. Sometimes a little longer. But it will be gone by itself. You don’t want to put those kids to sleep again. Because of this suture. So that’s how they look. There’s other things on my tray, like these little scissors. This forceps — some of the corneal surgeons like to use this to close the wound. Dialysis spatulas will be useful if you do a traumatic cataract or something. Make sure there’s no synechiae. Position the iris. This is what the 10-0 vicryl suture looks like on the bimanual procedure. Very important technical points. After so many years of surgeries, I think this will help you. You want to keep the eye fixated manually. You want to take advantage of the patient’s sleep. So you hold the eye. You maintain a very stable anterior chamber. This is pretty much the key for pediatric cataract surgery. You want your chamber stable. You have a stable chamber, everything is easy. Otherwise you have a bouncing chamber. Tight fitting wounds. That means your incision wound and instrument fit. If you do 20 gauge, you use 20 gauge. 25 gauge, 25 gauge incision. Minimize times in and out of the eye. This is very important. You don’t want to go in and out of the eye a lot. Every time you go in and out, you change the anterior chamber pressure. Your chamber collapses. Posterior vitreous moves forward. Causes a big mess. So your instinct — an inexperienced surgeon, my fellows, when we do surgery, if something unexpected happens, the first thing you do is take the instrument out. Don’t do it. The first thing you is stop and take a deep breath. So that’s important. And anterior capsulorrhexis with microincision forceps. Try it out if you haven’t done it. It’s really great. It’ll help you a lot. Lens aspiration, starting from the periphery. This is very different from adults. With adults, you take your nuclear out and start from the center out to the periphery. But children, they have a gel-like lens material. So you do a quick clean up and start on the periphery. I don’t do hydrodissection anymore. There’s nothing wrong if you want to do it, but this to me is unnecessary. With the periphery cleaning motion, I can get all the cortical clean. And some of the congenital abnormalities may have a weak posterior capsule, or even an opening. If you have a big hydrodissection, you might push everything back into the vitreous. You don’t want to do that. I also continue my posterior capsulotomy with the vitrector when I’m already there with my vitrector in my hand. I don’t come out and fill up the bag with Healon and redo the posterior capsulorrhexis. I think it makes the actual step unnecessary. But if you do it that way, it’s nothing really wrong. We’re all surgeons. Whatever works best for you, that’s the best way to do surgery. Here I want to show a quick surgery. For an IOL case. That supersharp blade opens the wound. Healon. I use Healon, injected into the anterior chamber, I open the anterior capsule with the cystotome. But you can use the forceps, already sharp, to open this. You can even save this step. So look. The motion is really — push-pull. Because the capsule is so easy to turn out. Very different than with adults. So enlarge the wound. Notice this. My second instrument — I’m always holding this eye steady for me. For adults, you do a paracentesis, you put a second instrument. I don’t think that’s necessary for me. But there’s nothing wrong to do that too. So here, see, cleaning the peripheral cortex. And I edited this, but the real surgery doesn’t take much longer than this, typically. The entire surgery takes typically less than 20 minutes to do it, even with a posterior capsulotomy and anterior vitrectomy. As we all know, it’s not about how quickly you do surgery. It’s about how efficient — you do a good job, give kids good vision, and minimize the complications you have to go back to in the future. So here I continue. I don’t take my instrument out of the eye. I continue going to the posterior capsule, and make a posterior small capsular opening, and start on the vitrectomy. And after the vitrectomy, I enlarge the posterior capsule opening. To just slightly 1 millimeter smaller than my anterior capsule opening. That will make it easier for me to inject my lens in the bag. If you make it too big, sometimes it’s hard to do it. There’s a small learning curve for that. My fellows, typically after a few cases, they can do it really well. You just keep those few key points I mentioned and it will help you out. So now, lens, Healon in the bag, now I’m gonna inject this lens. Really nice opening of the bag. It’s very important — your bag opens up well for you. So you put this lens in the bag. Tip up. Again, tip up. Don’t dive into the vitreous. Put it in the bag. And then you position it nicely in the bag. And you wash them. I put the suture, wash the Healon from the top and bottom of the lens, and here is how it looks at the end. So then here — iris hook — Dr. Suh mentioned it’s really important — a lot of pediatric eyes don’t really look that beautiful for you. Their pupil after dilation is 3 or 4 millimeters. You need the iris hook to help you open it. This is the intraocular cautery. This will be very helpful when you do some complicated cases, like this, PFV. You use the iris hook to open up your wound. I’m not gonna go through this — it’s a long case. I use the vitrector to open the anterior capsule, clean the cortical material. This is such a bad PFV, I wasn’t planning to keep any of my lens materials there.

DR SUH: Serena, can you hear me okay? I think time is up. Can you wrap in the next —

DR WANG: Okay, yeah. I’m almost done. So I’m just showing you this quick — this cautery here. You can see how the cautery works. Then the vitrectomy. Okay. So here, next one is — here’s my tray. All the instruments on the tray, if you want. Take a look. See if there’s anything useful for you. Here are some pictures of my surgeries. They’re not particularly picked. It’s just daily worked. Okay, thank you, Dr. Suh. I hope you have a good day.

DR SUH: For the next 15 minutes, I’m just gonna go over the questions. Serena, can you hear me okay?

DR WANG: I can hear you very well.

DR SUH: If I say anything that you disagree with, please chime in. So I’m just gonna go over some of these — actually, there were some excellent questions. I just want to tell you that this is recorded. And so it is gonna be posted, and you’re gonna be able to play it on Facebook. Or LinkedIn. So please go back to the — some of the questions that were asked, we actually addressed it. We may have gone so fast that you missed it. But if I tell you that it was covered on the video, you can go back and see it, if it was covered. And also, I want to thank Lawrence. He is our IT person. And he actually helped to put this thing together. And he is one of those behind the scenes guys who does an amazing job. So Lawrence, thank you very much. So I’m gonna just read some of these questions. How technically do you enlarge the posterior capsulotomy with the vitrector? Mechanically, using aspiration, or other cuts? When you’re doing a posterior capsulotomy or capsulectomy with the vitrector, you’re only using the cutting machine. You’re not aspirating. Because you don’t want to cause any traction on the retina. So it’s just cutting and suction motion. Okay? And then do you also clean the equatorial part of the anterior capsule? Yes. It is very important to remove, just like Dr. Wang said, it is very important to remove all the cortex. Especially at the equator. Because that’s where the progenitor cells are. So you want to make sure you want to polish — after you finish, polishing the surface underneath the anterior capsule, all the way to the equator, I think, is critical. This is my opinion. That actually — I think that if you don’t do a good job with this, the chance of opacity and even glaucoma, I think, is higher. I think that’s extremely important. After hydrodissection, do you aspirate the center of the lens and shape the lens into a cart wheel? Dr. Wang actually removed the peripheral cortex first. Before removing the nucleus. That’s exactly what I do. In adult patients, the lenses are stiffer. They’re harder. So most people, for adult cataracts, they remove the nucleus. And try to collapse the peripheral cortex. But in pediatric patients, because the lens is so soft, it’s actually, I think, far more advantageous to remove the cortex in the periphery, especially the subincisional cortex. Because that is truly the most difficult part to remove. So with the lens in place, it is easier to place the aspiration, the I/A, right at the subincisional cortex, because the lens is actually pushing it in that direction. And it is actually giving you countertraction. So remember, it’s the traction and countertraction. You always want to think about that. So when you’re cutting, removing, anything, you want to take advantage of the countertraction from the lens, the nuclear material, to remove the subincisional cortex. So I typically remove the cortex first. Why do you use the vicryl suture to close the wound? Is it important? I have done surgeries in 40 different locations around the world. And I am gonna tell you: The surgical techniques are very, very different, in different places around the world. As a matter of fact, I’m not gonna tell you where, but in some places, they never use vicryl sutures. Because it is expensive. 10-0 vicryl suture is actually very expensive. They never use it. Even in congenital cataract. But the thing is: They do these surgeries in 5 minutes. And they do it very quickly. And they try to minimize the surgical incision site. So they feel pretty comfortable not placing any suture. And in — I think they have done 200,000 cases of congenital cataracts. They have never had a case of endophthalmitis. So after witnessing that, I’m gonna just tell you that… Is it a must? I don’t think so. But I do think that it’s highly recommended, placing a vicryl suture. If it is available. Definitely available. I would recommend it, because the eyeball, the sclera tends to be soft. And it tends to collapse more easily. Especially in patients with Down syndrome or patients with any type of chromosomal abnormalities, or developmental delays, they’re gonna be pretty aggressive with eye rubbing. So I think that having the vicryl suture there would just make me feel better. Another question is: Would the vicryl suture cause scarring and white opacity at the surgical incision site? No. As long as you don’t encapsulate and catch the conjunctiva and accidentally place the conjunctiva on the cornea, no. It shouldn’t really result in significant opacity. And remember, just like Dr. Wang and I — we go from 12:00 incision, so the eyebrow, the eyelid, covers the surgical incision site very nicely. Have you tried a pars plana approach on patients in whom you’re not placing an IOL? Yes, I actually used to do a pars plana approach in the past. But I just don’t feel that it is necessary. In my opinion. Again, it’s a matter of preference. And I think it’s an excellent procedure, and it is a safe procedure. But just like Dr. Wang said, you want to make the procedure as simple as possible. With less movement going in and out. So pars plana approach — I just felt that it requires an additional surgical incision site. So I don’t do it. But those cases went beautifully. Do you use a triamcinolone after the procedure? Yes. I do — sorry, excuse me. (phone ringing) Sorry. Do you use triamcinolone after the procedure? Yes, I actually inject it intracamerally, and also subconj. Serena, do you use triamcinolone?

DR WANG: Only in traumatic cases. Really no need. Those kids do really well. I do subconjunctival injection of some steroids.

DR SUH: I actually take care of a lot of patients with developmental delays. These patients — I am concerned that they might not be able to place the eye drops. So I actually do intracameral. But I don’t think it’s essential, no. I think just like Serena, subconjunctival or just frequent eye drops of prednisolone acetate or phosphate every hour, for about a week, I think, is sufficient. Because the intracameral triamcinolone is extremely expensive. So then let me just see. Postphaco… Do you perform iridectomy? No. Again, I think when I was trained, when I was in training, 25 years ago, we used to do iridectomy on every patient, because of the concern of the angle closure. Because of the iris bombe. No, these procedures — I cannot remember — I have never regretted for not performing iridectomy. Serena?

DR WANG: Yeah, only with very small eyes, when I put the IOL in the eye when they’re very small. I do a peripheral PI. But not routinely.

DR SUH: And what is the best age of implantation IOL in pediatric patient cataract surgery? I think we went over that, so please go back to the slides. And do you use triamcinolone especially in rubella cases? So for rubella cataracts, especially in certain places, like in Vietnam, or certain places in Southeast Asian countries, South America, they have fairly high cases of rubella, because of lack of vaccinations. But I think it’s improving. For those cases, it is very important that you make sure that you do not have any ladies who are pregnant or possibly pregnant in the OR. So I make sure that I remove them from the operating room. And I typically — I actually do use triamcinolone in rubella cases. But these patients do require closer observations after the surgery. How many days or weeks… Okay. How many days do you wait between the right and left eye for bilateral cataracts? So like I said, I personally — do I have anything against doing cataract surgeries on the same day? For bilateral cases? No. I do not. If you look at the literature, I do see — we don’t have enough evidence to really say — you know what? That is a malpractice. No. I don’t believe that. And in certain situations, I think bilateral cataract surgeries in the same setting is warranted. But I would recommend that you change the drapes, change the IV bag, change the entire setting. To reduce the risk of endophthalmitis. In these pediatric patients. But I personally typically wait about — between 2 to 4 weeks. Between the cases. Right and left eye. Serena?

DR WANG: I do one week apart. To avoid — yeah. To avoid amblyopia.

DR SUH: Perfect. And then I’m gonna see… I think that’s it. So it is 9:00. As you know, I am by the book. It
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I actually like to stay on time. I know some of you, it’s very early in the morning. And some of you, it’s very late in the evening. And again, I love doing this. I love Dr. Wang, who is a very experienced surgeon. And if you are interested in hearing more about the congenital cataract surgeries, a particular aspect of the surgeries or anything else, please post — Orbis has a Facebook, LinkedIn, and other social media. So please let us know. And we read every single one of those comments. So please, if you’re interested, we would love to do it again. And I hope you guys have a great day. Thank you!

DR WANG: Thank you! Thank you, everyone.

DR SUH: Lawrence, can you turn on your mic?

>> Thank you both.

DR SUH: Thank you very much, Lawrence, for all you do.

>> No problem. I’m happy. Bye-bye.

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August 21, 2020

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