Cataract surgery in a 3-year-old child with unilateral white cataract of unknown etiology. It was a challenging case as the lens contents were liquefied. It is removed with a vitrector technique. A primary posterior capsulotomy was performed before placing the IOL in the sulcus. Non-preserved triamcinolone is used to stain the vitreous for anterior chamber cleanup.
Surgeon: Dr. Daniel Neely, Indiana University
DR NEELY: It’s a completely white cataract, and this patient is 3 years of age, and it’s a unilateral cataract. So the capsule is intact, and it’s been stained. We have the 20-gauge vitrector. We’re gonna enlarge the wound slightly. It’s a little tight. That’s always a balance. You don’t want it too loose, or it’ll leak too much. Because these vitrectors don’t have a sleeve on them, so they’re not exactly watertight. So I’m going up slowly in the vacuum, until it engages. I think with a vitrector, you always want to start in the center, and enlarge it. There’s our white lens material. You can see that this lens is largely liquefied. Look how much of that came out just opening. There was no washing out. It just came out on its own as soon as that — there’s a 1-millimeter opening right here in the middle, and as soon as that anterior capsule was opened, all that liquid material came out. So that lens is really liquefied. So that’s going to — a large part of that’s already come out now. You can see how all that liquid white material came out. It seems that the bag is very empty right now. And my concern is there’s nothing to keep the posterior capsule away from the instrument now. So what I’m going to do, to help keep that posterior capsule away from the instrument, I’m gonna go through that opening and put viscoelastic into the bag. So the goal here is to try and make this anterior capsulotomy a little safer. And now we’re gonna have to be really careful to not take the aspiration up too high, or it’ll pull that posterior capsule up to the instrument. It certainly makes for a challenging case, to have the lens be so liquid. And as I’m doing this, some of the viscoelastic that I put in is going to come out. So I’m gonna stop, and I’m gonna put some more in. I’ve got to tell you, it’s a very interesting case. I’ve not seen one exactly like this, where so much of it was this liquid. All of a sudden, the cataract was gone. It kind of makes sense, because maybe this is a trauma case. The other eye is normal. So it’s not metabolic. The other thing that’s interesting — this eye is pretty normal-sized. So that makes it less likely to have been a congenital cataract. So it’s a very interesting cataract. You can just imagine trying to tear this. I mean, this is a really difficult capsulotomy, because there’s nothing in the lens. I kind of like to get this rounded out a little bit, before I manipulate it. So I’m gonna try and get this upper area… And again, I’m barely engaging the aspiration. I just want to pull the capsule in, barely. I mean, the capsule seems to be really fragile. So that’s a bit of a concern. I’m debating what to do with the lens here, still.
>> Are you thinking of sulcus now?
DR NEELY: I’m considering it. I think where we are right now, I can still have one in the bag, but I still have to kind of evacuate the bag a little bit more. And I think the posterior capsule has opened a little bit right here. In a couple places. Yeah. I think the posterior capsule is opened in a couple places. I think the best thing to do here is to maybe try and just aspirate a little bit of this lens material, put the lens in the sulcus, and then finish opening up that posterior capsule. There’s a little bit of an opening here. And I think there’s a small nip in it here. And this anterior capsule is really… It’s really thin. And it wants to really just move… It’s thin, very much like an older person’s capsule. Okay. I’ve turned the cutter off. And actually, I think was I’m gonna do is just leave that liquid material in there. So I don’t have to manipulate this. I’m probably gonna just go ahead and enlarge the wound. I see that it’s extended. I think what I might do, at this point, is just enlarge the posterior capsule opening, and then put the lens in the sulcus and have done this from the front, rather than the back. I think that’s gonna be the safest approach at this point. All right. So let’s go. Change to the posterior settings. Well, this is really unique. This is quite interesting, to see how this behaves. We’re changing the machine to posterior settings. So we’re increasing the cut rate, since we’ll be in the vitreous. As I mentioned before, we’ll take that cut rate up to at least 500. And that’s what we have now. Right. Here’s the capsule opening. Some water on. Great. Thank you. All right. So I’ve got cutter on. And I’m just gonna enlarge this, so that it goes central, rather than out towards the edges. Now, in some cases like this, I would do what we call optic capture. Where you put the haptics in the sulcus and the optic in the bag. But not in this case. If you have an adult-style lens, where you’ve torn a nice, strong circular capsulotomy, that’s a nice technique, to have a sulcus lens be positioned in the bag. Okay. So we’re kind of rounding this out, so that the two are somewhat equal. But, again, we want to be conservative with how much we manipulate this. So I’m thinking that’s probably pretty decent. I want a lot of support as we go in with this lens. So go ahead and open the backup lens. So I’m gonna use the MA60. I’m gonna fold it manually. The one we’ve been injecting is the SA or SN one-piece lens. But like I mentioned, that’s not a good sulcus lens. It’s too thick. As I pull out, I’d like to have the viscoelastic in my hand. We’ve just lowered our infusion pressure. I want to try and limit how much this capsule trampolines up and down. Now go infusion-off. What you see here is that this is why I don’t like doing the posterior capsulotomy first. We’ve got some vitreous that’s followed the instrument out. So what we need to do is… I’m putting the vitrector back through the capsulotomy, to try and pull any vitreous backwards, away from the wound. All right. So I want the vitreous to go backwards, towards the vitrector. So that it pulls away from the wound, and where we’re planning to put the lens implant. I’ve got a very unstable capsule. The anterior capsule didn’t stay where we had it. It’s now kind of run out. It’s gone out this way. So we’re really trying to limit how much movement we get, with the chamber getting shallow and deep. So what I’ve done is I’ve pulled the instruments out, because I want to sweep up here at the top. There’s some indication, just by the shape of things, that there might be vitreous strands forward. What I want to do is I want to sweep from this side port. I want to see if we have any strands that are coming up to the 12:00 wound. Because our next step is to enlarge the wound and place our lens implant. So I’m gonna sweep one more time. Then I’m going to enlarge the wound. Going underneath the wound, and then sweeping back across. And it seems clean to me right now. There is a strand of vitreous here in the middle. But there’s nothing coming up to the wound right now. And I’ve got a lot of viscoelastic in the eye. So this is a bit of non-preserved triamcinolone.
>> So what is interesting is that in this case, the vitreous itself looks liquefied as well. It’s not only the lens.
DR NEELY: Yeah. Still trying to decide why all that is. I don’t really have a good answer right now. I’m just gonna sit here a bit and keep cleaning up this vitreous as much as possible. What we’ll do next — once I’m kind of finished with this vitrectomy portion here, I’ll enlarge the wound, I’ll put a bit of viscoelastic in the sulcus, deepen that opening… You can see there’s a bit of vitreous, particularly right here, around the 12:00 position, that’s still pulling into the vitrector. Yeah. The main concern, if you have vitreous to the wound, I think, has to do with a couple things. One: If you have vitreous to the wound, it kind of keeps that wound from being watertight. So you can have potential for microorganisms to migrate along that vitreous. And you can also have traction on the vitreous over time, that leads to retinal breaks and tears.
>> Is CMO more common in children or less common?
DR NEELY: You know, I don’t think we know. The problem is it’s harder to diagnose in children. Now, people are starting to do OCTs on them more frequently, postop. But I think historically, it’s been underdiagnosed.
>> For that reason, if you’re doing a pediatric cataract on a uveitis patient, would you just prophylax it? Give them some triamcinolone or dexamethasone?
DR NEELY: Absolutely. So if someone is a uveitis patient, you would like for them to be quiet for a while. If you’re doing a juvenile rheumatoid arthritis cataract, you would like them to be quiet for six months before you do the cataract surgery, first of all. Selling, you don’t put a lens implant in those kids.
>> So after using the triamcinolone, what is the percentage for the risk for raising the intraocular pressure?
DR NEELY: Well, I don’t know that I can say what the percentage is. The duration of the steroid-induced glaucoma doesn’t happen from having steroids for a week or two. It happens from having steroids in chronic use. There’s a little flap area right here I’d like to clean up just a touch. That’s also where that vitreous kind of hiding out, under the edge right there. Okay. Now go ahead and turn that infusion off. And I’ll take the viscoelastic. You can see how the vitreous anteriorly here at the 12:00 area has been stained with the triamcinolone. And then we have the other triamcinolone, which is more posterior, which is giving that white reflex. All right. I’ll take a 3-2 keratome. Gonna enlarge our wound here. All right. So this is, again — this is gonna be a foldable lens. You can inject this, but I like that less for trying to get this into the sulcus. And to facilitate things, I’m just gonna extend this wound a little bit. There’s a view of our lens.
>> So you’re using the three-piece?
DR NEELY: Yes, that’s right.
>> Somehow. Okay.
DR NEELY: So I’m folding this lengthwise. Transfer it to the insertion forceps here. Leading haptic is in the sulcus. And I want this to open above the posterior capsule and anterior capsular openings. So I’m just kind of trying to keep that stable, while I withdraw. All right. Now I’ll take the… You have like a Kelman insertional forceps? So now we need to get this other haptic into the sulcus. So I’m gonna flex this down. And now we’re just gonna dial it a little bit. Just get it centered.
>> Dr. Neely, for putting in a sulcus lens, the calculation, when you reduce the power — is it the same for adults as in children?
DR NEELY: The answer is yes and no. So typically, when you put in a sulcus lens in an adult, you reduce it by 1 or 0.5 diopters, right? What it really depends on is what the power of the lens is. The higher plus your lens is — so, like, a 30 lens needs to be reduced by 1.5. A +22 lens I think you would reduce by about 1 diopter. And then a low power lens you might reduce only by half a diopter. So because we use high power lenses in pediatrics a lot, sometimes you’re reducing it by 1 or 1.5, which might be more than you would reduce it in a typical adult case. Let me go ahead and close this upper wound. I’m gonna go ahead and secure the wound a little bit, so we can make things a little more stable. And once this wound is watertight, then we’ll take that residual viscoelastic out. We should probably use Miostat also, I think. Let’s go infusion off now. So I would like to bring the pupil down. Again, I just want to stabilize this lens before I take out that anterior chamber maintainer. And this will also help us tell if we have any vitreous strands up front, because if there’s vitreous coming to the wound, the pupil will peak. Bringing that down a bit. I’ll take the vitrector and I’ll take some of this viscoelastic out. You know, I want to take some of this viscoelastic, but in some ways I don’t mind leaving a little bit of viscoelastic, because that’ll help keep the chamber stabilized. But we don’t want a pressure spike from all this viscoelastic, so I’m just letting this pupil come down a little bit. See how much it’s gonna go. Looks like it’s kind of stalling out here a bit. And then I’m just gonna evacuate the viscoelastic that we have up here, anteriorly. And then we’ll pull this and close that. Let’s go up on the infusion pressure now. So let’s take the pressure up to 25. So I lowered the pressure when I was tying. So I could tie at a normal pressure. Now I’ve gone back up, so I can help keep the chamber formed. Because I’m sneaking in here like this. Take that pressure up to 30. And I’m curious if my infusion might be blocked from the viscoelastic. I think it is. The Healon GV is nice, but it’s so thick that it will actually plug the infusion. So I’m gonna pull this out and see if it’s running. I’m just gonna kind of milk this. Our infusion is open. Is that correct? I’m also resting on the front surface of the lens, to help keep it from coming forward, while I take this viscoelastic out. Let me have BSS on a cannula. I’ll hydrate this top wound before I pull out. A little stromal hydration here in the corners of the wound. All right. So we expect this is probably going to shallow when I pull the anterior chamber maintainer out. So I’ve got my hydrodissection cannula ready, so I can reform — you see, that buys us a little time until I get a suture in here. So anyone who ever said pediatric cataracts aren’t fun is wrong. There are a couple other cases where, even in adults, the vitrector is nice. So trauma cases. Those are really difficult to manage, because of the capsule changes. And so trauma, and then people that have metabolic cataracts. Metabolic cataracts, where the lens becomes swollen, just kind of like this one looked like. Although it wasn’t too swollen anteriorly. Some of those lenses have so much pressure on them that when you try to do them with the cystotome, they just split across the front. But if you use a vitrector, it makes a round hole, and it makes it less likely to have a radial run. So I’m only injecting antibiotic here subconj. We have a lot of steroid inside the eye, of course.