This video demonstrates a cataract surgery in a 5-year-old girl with congenital cataract. A vitrector is used for anterior capsulotomy and lens aspiration followed by IOL placement in the capsular bag. Her younger sibling was operated for a similar kind of cataract with the addition of a primary posterior capsulotomy and you can watch that surgery by clicking here.
Surgeon: Dr. Daniel Neely, Indiana University
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DR NEELY: So this is the sibling of the last patient. This young girl is 5 years old. Same similar kind of cataract, only maybe it’s not quite as liquefied. We’re starting off the same way. Clear corneal incisions, with the MVR blade. We’re gonna use the Trypan blue to stain the capsule again. And now we’ll wash the stain out. And we’ll insert our anterior chamber maintainer. And again, to remind you of the settings, we’ve got 250 on our cut and maximum 250 on our aspiration. We’ve just cleaned out the rest of the stain. And now we’ll do the capsulotomy. And again, we’re just gonna use the minimum aspiration that it takes to engage this capsule. And we’ve just got the central capsule open. You can see how funny this capsule behaves. It gets real stringy. So again, you see we’re trying not to disturb the underlying lens as we go around this capsulotomy. Just real important not to aspirate too much, because it’ll pull the back lens right up through the vitrector. And we’re almost to a size that I’ll be happy with. Just a little bit more here. Just a very friable capsule here. So we’re turning the cutter off now. We’re gonna go to aspiration. Turn the cutter on. We’ve got a little bit of a radial extension here. So I’ve turned the cutter back on. I’m gonna round this out. All right. So we want to try to stay away from that area as much as possible. Let’s take the cutter off. So when you have these kind of capsular leaflets, you can’t always see those, and so you want to try and aspirate underneath the capsule edge as much as possible. You see this lens, compared to her brother’s… Not quite as liquefied. We’ll try and tease this out and have it follow itself out as much as possible.
>> Doctor, excuse me. Someone is asking: What kind of cataract is it? Milkier? Or posterior pallor? Zonal?
DR NEELY: This is kind of combined. Most of the opacification is in the cortex here. Just outside the nucleus. You can see these funny opaque areas. They’re like little specks here, little rocks. And here’s the lens nucleus. You can see the sutures in it. We’re at the posterior suture here. Of the nucleus. And again, you can see this is a really deep eye. I’m gonna switch hands here, so I can get up under this 12:00 area a little better. I’ve got a little bleeding on the conjunctiva, I think from the fixation forceps. Again, subincisional — always the toughest place to work. Here’s that large plate coming out. And you can see I’m using the cutter here to get rid of this thicker stuff. Again, we’re working around that area where the capsule is out a little bit. Looks pretty good. I don’t think we have any loose radial areas. It’s just elongated. But you can see how sticky that is. Look at those strands that are pulling off. All right. So at this point, we’re going to put the viscoelastic in. I’ll turn the infusion off. All right. So this is an Alcon SN-60, which is the same lens from the last case. It’s that Monoblock. This is a +26 that we’re using. And what I’m going to do is I’m going to inject this, and then this young lady is a little bit older than the last patient we did. She’s five. A five-year-old, you figure you probably have about a year until the capsule opacifies. So she probably can cooperate with a YAG laser later, if needed.
>> One of us is asking when do you prefer to perform the YAG capsulotomy?
DR NEELY: Well, I think the answer to that is probably the same no matter how old they are. It’s when they need it. So usually in a child… I would say it’s similar to an adult, although you might have a higher threshold for the visual acuity dropoff. But usually when the vision drops off to 20/40 or 20/50 you’ll do the YAG. Now, in a child like this, though, it’s gonna be a little bit different, because this child’s gonna have amblyopia. You’re not talking about someone who has 20/20 visual acuity. So you’re gonna have to be guided by your ability to perform refraction and how blurry you think the view in and out is on your clinical exam. All right. So I’ve got my suture in. I’m gonna dial this lens just a little bit more. These haptics don’t really put much pressure on the bag. But if you have any pressure, you want it closer to where the irregularity is. I don’t really want to manipulate this too much, but I’m going to just finish this rotation. All right. So we’ll close this down. Then we’ll get our viscoelastic out, then we’ll put in a little Miochol, bring the pupil down. So just everything we can do to help stabilize that implant. Trying to hold the lens back a little bit while I aspirate this viscoelastic. Sometimes the viscoelastic will plug the vitrectomy piece, so we may have to check this and see if it’s plugged or not. And it looks like we’ve got some viscoelastic in the vitrector, so we’re gonna flush it out here. There. You can see the — so the capsulotomy goes around, and it’s just kind of egg-shaped right there. But we don’t have any running edge, so we’re in good shape there. But we just still want to be careful with it.
>> So you’re injecting the Miostat?
DR NEELY: We are, yeah. Got a little air bubble. But we’re fine. Start to bring our pupil down here a little bit. And I’m gonna take the infusion out now, and we’ll take a 10-0 vicryl. Put in our last suture. And you can see that chamber likes to come forward. Let me have BSS on a cannula. This is a 10-0 vicryl. Right. So again, this spares you from having sutures that break or sutures that are too tight. It’s a great suture for pediatric cataract surgery. And again, we’re closing all of the incisions, because of just the tendency for it to be leaking. So again, postoperative medications will be antibiotic, 4 times a day, and a topical steroid every couple hours for the first couple weeks. Now, postoperatively, these two children, ages 4 and 5, they have a lot of irreversible amblyopia, but they have some amblyopia that you can recover from. So you want to start patching them as soon as possible.
June 19, 2017