This video demonstrates an AC IOL implantation in a 73 year old male with aphakia. He had a complicated cataract surgery previously.
Surgery location: on-board the Orbis Flying Eye Hospital in Binh Dinh, Vietnam.
Surgeon: Dr. Larry Benjamin, Stoke Mandeville Hospital
DR BENJAMIN: So we just started, and put some triamcinolone into the eye, to see if there’s any vitreous in the anterior chamber. I’m gonna make a second stab incision for the vitrectomy.
>> Great. If you could speak a little bit louder for us — awesome. Thank you so much.
DR BENJAMIN: A second stab incision for the vitrectomy. But interestingly, it doesn’t look like there’s any… Could I just have the triamcinolone again? Sorry to… Thanks. So I’m just gonna put some more triamcinolone in, just to check for vitreous.
>> So you inject the triamcinolone into the anterior chamber?
DR BENJAMIN: Inject it into the anterior chamber. And if there’s vitreous there, it will show up. But it looks to me as though the anterior hyaloid face is still intact. So there’s no vitreous around. So what I might do now is put some viscoelastic into the anterior chamber, to deepen it. And then I’m going to need to put a secondary implant in. So I’m going to use an anterior chamber implant. Then I just need to support the iris here, because it’s a little bit ragged. So I’m going to put a suture through here, just to support the iris. But I’ll just open the eye first. I think you’ll see… Can I just… Ordinary Healon, just to start with? Do you have ordinary Healon? Please. A drop on the cornea, please. Thanks.
>> Dr. Benjamin, if we could ask that you just speak a little bit clearer, louder, and so that we could have our translator translate.
DR BENJAMIN: Of course. So we’re going to put some viscoelastic into the eye. Which we’re just waiting for. And that will deepen the anterior chamber. So you caught the fact that the anterior hyaloid face is intact? It seems as though there’s no free vitreous in the anterior chamber. Thanks. Could I just have a drop on the cornea again? A bit warm in here, isn’t it? The iris is pretty firmly stuck to the anterior hyaloid face. Just seeing if I can… Better just to leave it alone, actually. And I can maybe put the AC lens in that way. So I think I’m going to do a corneal section, because there’s a lot of scarring up here on the sclera. 0.12 again, please. Thanks.
>> So you make the corneal incision?
DR BENJAMIN: I think so. You can see here there’s a lot of scleral thinning. Although there is a scleral section here. But this is all very thin. You can see through the sclera there. So I’m just gonna do a corneal section and suture it, I think. Could I just have a calipers, please, to measure the eye? So for an anterior chamber lens, we measure the horizontal white to white measurement. In other words, one side of the cornea to the other. And then we add a millimeter.
>> So you measure the diameter of the cornea for the anterior chamber length?
DR BENJAMIN: That’s right. White to white. But horizontally.
>> And then you plus 1 millimeter?
DR BENJAMIN: Yes. So that’s 11.5. So we want to have a 12.5-millimeter implant. 17.5. 12.5-millimeter overall diameter. And, Jackie, do we have a diamond blade, by any chance, or not? Okay. Might I have a new 15-degree blade, then? Just to open the cornea. Because I think that one will probably be a little blunt. Thank you. So the… Could I just have the calipers again, please? Could you still hear me in there? Have I been turned down? Can you still hear me? No? Probably a good thing.
>> Yes, yes.
DR BENJAMIN: You can. Okay. So that’s 7 millimeters. The chrome is coming off these calipers a little bit.
>> So the length of the incision is 7?
DR BENJAMIN: So the size of the implant is 6 millimeters.
>> Oh, 6. Why you do 6?
DR BENJAMIN: But I’m doing a chord. Yes? I’m not doing a straight across incision. So we’ll do a backwards sloping corneal section.
>> Dr. Benjamin, there is a question for you. Why don’t you use the — you fixate the IOL to the sclera? Why do you use an anterior chamber lens?
DR BENJAMIN: Really because of the… What’s happening in the anterior chamber, I think. The iris is stuck to the anterior hyaloid face. So we would have had to rupture the anterior hyaloid face and do a vitrectomy.
>> Okay, thank you.
DR BENJAMIN: But you could have used a scleral lens. It’s another option. And Healon. And then the lens open. Thanks. And… Move the microscope. 17.5. And a 12.5-millimeter diameter.
>> Yes, correct.
DR BENJAMIN: And these lenses are vaulted forwards, so if you look at the design… Just give that a wish for me, please. Just the lens, rather than the eye. And have you got a Y pusher or anything? No, the Y pusher, the double-ended instrument. A touch of Healon again quickly, please. I call it a Y pusher. I don’t know what it’s really called.
>> Can we do iris-claw in this case? Iris-claw IOL in this case?
DR BENJAMIN: An iris what? Sorry?
>> Iris-claw? Iris-claw IOL in this case?
DR BENJAMIN: I’m not sure what you’re asking me.
DR BENJAMIN: Did you call it an iris bar?
>> She’s asking why you’re not using an iris-claw.
DR BENJAMIN: The iris-clip lens? I’ve given up using those, because many of them dislocate. And they also cause a little bit of chronic blood-aqueous barrier breakdown. And sometimes you get atrophy of the… Sinskey hook. You can get atrophy of the iris around the clip. It can dislocate years later. So these are supposed to go in horizontally, because that’s the measurement that we took. The Healon again, please. I’ll just leave it like that, I think. Okay. We’ll just have the Healon again. And the suture, the 10-0 nylon suture, please. Can you cut it in half for me?
>> This is an angle-supported IOL?
DR BENJAMIN: Yes, it is.
>> And it is stable? Does it move away when the patient wakes up and walks around?
DR BENJAMIN: It shouldn’t move, because we’ve measured it. And that’s the purpose of measuring it, is that you want it stable in the anterior chamber. So if you measure the horizontal white to white measurement and add a millimeter, then that should be stable.
>> Thank you.
DR BENJAMIN: Me. It’s probably fine. Yeah. It’s me. These forceps are not meeting for tying, unfortunately. I’ll take the plain ones. I’ll use the plain ones. Sorry. Thanks. Those are not plain. Where are the plain tying forceps? Yeah. Yeah. The jaws are not meeting, unfortunately. So for these sutures, it’s really important to try to keep it astigmatically neutral, because we don’t want to induce a lot of astigmatism. And so you have to lay it down at the tension that you want it. And then, if you tie a reef knot or a square knot, this is a 2-1-1 knot. So it’s like a reef knot. So you have to see that circle.
>> 2-1-1? Not 3-1-1?
DR BENJAMIN: No, this is 2-1-1. Because the wound is closed. So there’s no tension in the wound. And so you don’t need the tension of the 3-1-1 to close it. So if I need to close a wound, I generally use… This is dripping all over my foot. Thanks. So you have to make sure they’re square knots or reef knots. 0.12? I’ll try that. Thank you.
>> Can we use a running suture in this situation?
DR BENJAMIN: Can we what? Sorry?
>> Excuse me, can we use a running suture in this situation?
DR BENJAMIN: You can, you can. I tend to get better results with interrupteds. That’s a plain. Have you got another 0.12? That’s plain. Thanks. That’s better. You might get away with 3 sutures. Probably not… It’s important to make these radial with the center of the cornea. And I have a method of tying reef knots which works quite well. And what I do is… I form a loop with the suture like this. So you hold the suture and you hold this instrument near to the wound. And you get a loop coming up off the eye. Which I call the Loop of Benjamin. And then you can put your forceps through there, and it does the turns for you. It’s very easy to get the turns. And then you swap your hands over. Bring the loop back. This is the reverse Loop of Benjamin. Swap the hands again. There’s the circle that you have to see. Make sure it’s a reef knot. And then you can pull it as hard as you like, and it won’t tighten any more, because it’s locked at that tension. Thanks. If I could get the forceps… So the scissors again, please. I’ll put one more on the other side. That may be enough. Might need another one there. We’ll see. There’s that — that one’s leaking. Or was that me doing that with my foot? I’m sorry. Okay. I’ve put my foot a bit — okay. Sorry about that. I wondered why I was getting a wet foot, but now I know. I’ve only myself to blame. Yeah. That’s still dripping. But it’s not me this time.
>> No, it’s just… It’s the…
DR BENJAMIN: Circulating nurse. The scissors again, please. Quite a nice way to pick up the needle with 10-0 nylon is to balance it on the cornea, and you can pick it up in any direction by pirouetting it round, by spinning it round like that. I’m gonna remove this suture and replace it with two others. A drop on the cornea. Thank you. You read my mind. The scissors. Thanks. Thank you. Yeah. I’m not going to suture the iris now, because it’s stuck to the — I was worried that this bit of iris was loose here. And wouldn’t support the implant. But it’s stuck to the anterior hyaloid face. So I think it’ll be all right. The scissors, please? Can I have the plain tying forceps, please? Plain tyers? We’ve got to bury these knots, and the best way to bury knots is to… Actually, I could use the needle holders, if you’ve got no plain — have you got plain ones. Okay. No, that’s good, that’s good. Just have some water on the cornea. You turn the knots to the end of the wound. You take ahold of the other end of the knot. And you pull it firmly like that. And that usually buries it. I want to flick it. Yeah. So he’s got a broad iridectomy here, effectively. So no. I mean, he could… I suppose he could, because he’s got adherence to the anterior hyaloid, he could. But his pressure’s been okay up ’til now, and he’s got lots of little holes in the peripheral iris here that it’s like iridectomies. So I think he should be okay. Can we just have the vitrector? We were going to use the vitrector to take the fluid out. Although… I need a bit more… Thanks. So I just… I don’t need a cut, actually. I just need aspiration. So if you could turn the cut off…
>> That’s the cut.
>> So you’re going to irrigate the Viscoat?
DR BENJAMIN: The other way around, maybe. Can you turn the cut off for me? That’s possible? Can you turn the cut down to zero? Cut rate. Okay. 1 is fine. It’s still on 4,000. Oh, sorry. You’re gonna have to… Press it again. Yeah. That’s it. Perfect. Say again?
>> Because of the sound…
DR BENJAMIN: Yeah, yeah. You can hear it. That’s right. I’ll just have some BSS now, please. On the Rycroft. And then the subconj. Let’s have the dialing hook for a second, please.
>> The audience in the classroom — they have a question.
DR BENJAMIN: Yeah.
>> Okay. In this case, this is a distortion of the iris. So they have two parts of the iris. One part — the patient will look through the IOL. The other part — the patient cannot look through the IOL. Will he develop diplopia after the surgery?
DR BENJAMIN: I don’t think so.
>> I mean —
DR BENJAMIN: Yes, I don’t think so. Because his pupil, his eyelid will cover most of the aphakic segment. And the aphakic segment will be very blurred. So he may get a little bit of glare. But I think it’s… We used to do, in the old days… We used to do a broad iridectomy, quite often, when we did intracapsular surgery. It was the same sort of thing. And they didn’t usually get problems.
>> Okay. Thank you.
DR BENJAMIN: Just a bit more fluid, please. Some in there. Just a little bit. I’ve got a Rycroft. Thanks.
>> You think that’s enough?
DR BENJAMIN: Yeah. I hope so. It’s a shallowish anterior chamber, but I think that will be stable.
>> Do you want another drop?
DR BENJAMIN: Okay. I think we’re done. If I could have the subconj, please.
>> You don’t want more?
DR BENJAMIN: I think we’ll be all right, actually. Yeah. Yeah. Just finished. Okay. What’s that one? So because he’s had a sub-Tenon’s injection, that area of the conjunctiva will be nice and numb, so it’s quite a good place to put a subconjunctival injection. Can you feel that? Can you ask him if he felt that? Did he feel it?
>> Can I have a question? What type of local anesthetic do you use in this case?
DR BENJAMIN: Say that again, sorry. Repeat the question, please.
>> What type of local anesthetic are you using in this case?
DR BENJAMIN: So this is a sub-Tenon’s. And I think just lignocaine.
>> Why don’t you use a retrobulbar anesthetic?
DR BENJAMIN: So my standard anesthetic for local is sub-Tenon’s now, because it’s very safe. It’s very effective. And you need very small volumes. You can get away with 1 or 2 mils of lignocaine for a cataract, and that’s usually enough. And there’s no chance of globe perforation. Very comfortable for the patient. You do get a small conjunctival wound here, but that usually heals very quickly.