1. 1. Complete hydrodissection is always helpful in making the overall procedure easier and safer. Because these lenses are so often soft the lens nucleus during hydrodissection often pops up and out of the bag so frequent pushing of the lens posteriorly is a nice technique not so much to enhance the fluid wave but to “decompress” the bag to prevent forward movement of the lens/nucleus.

    2. I would defend the use of a scleral incision in young patients even if they have aniridia and potential gimbal issues. The incision is small – 2.4mm in this case so significant disruption of the conjunctiva is minimal, cautery is light and the incision is more stable and watertight in the sclera than it is with a clear cornea incision in a young patient with low corneal/scleral rigidity. Scleral incisions also heal more quickly. These are all important factors in young patients who are more likely to rub their eyes and be involved in minor trauma around their eyes in the postoperative period. In adults I would have no qualms using a clear corneal incision.

    3. I have found 7 year olds to be very cooperative at the slit lamp especially since the surgeon will have seen them on multiple occasions pre and post operatively. The child becomes very familiar and at ease with the doctor. In my experience PCO does not occur for several or more years and I have never had a difficult time with Yag. Because PCO can occur within weeks after surgery in younger patients (2 years of age and younger) and difficulty getting them to the Yag laser I do recommend the technique described or use of a posterior casulorhexis and prolapse of the optic behind the rhexis.

  2. 3 comments / differences:

    1. A good 4 quadrant hydrodissection is useful in children / soft cataracts. Else, it takes forever to get the epinucleus and cortex out. I would especially target the superior sub incisional area during hydrodissection. Of course, you need to bear in mind that sometimes the nuclear material pops out of the bag in children but it is not a big concern. The technique of completing the hydrodissection by pushing the lens after the “wave” doesn’t work well in children.

    2. I would prefer a clear corneal incision in aniridia. The use of cautery and suturing of scleral tunnel and conjunctiva creates more damage to the limbal area. The post-operative peri-limbal inflammation is higher with scleral tunnel. A sutured corneal incision will hold well in a 7 year old.

    3. Aniridia is often associated with macular issues. photosensitivity and nystagmus. This makes Yag laser capsulotomy very difficult. I would have done a primary posterior capsulotomy with anterior vitrectomy in this case to eliminate the risk of PCO.

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