Surgery: Congenital Cataract with Pupillary Membrane
This is a cataract extraction surgery in a 6-year-old girl, with congenital cataract and pupillary membrane. The membrane was carefully removed and the cataract was aspirated. An IOL was placed in the capsular bag and the wounds were closed with sutures.
Surgery location: on-board the Orbis Flying Eye Hospital in Trujillo, Peru
Surgeon: Dr. Stephen Lane, University of Minnesota
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DR LANE: Yes, this is a 6-year-old little girl, and you can see that she has a pupillary membrane, with persistence from her embryologic failure to regress. As a result, she has a central opacity and all these iris strands, and decreased vision as a result of that. So our goal is to cut the strands and perform a capsulorrhexis around the outside of that, remove the lens, and place a focusing lens implant. The key will be to remove those without rupturing the capsule. So as in all children, I perform a little conjunctival peritomy, and we’ll do a scleral tunnel incision, and we will plan to place a suture at the end. We probably will make several paracenteses to allow access for our microscissors to cut those little membranes, those little strands. And so just performing a scleral tunnel… So you can see I’ve switched to a forceps that doesn’t have teeth. This is very gentle, for handling conjunctiva. A lot of glaucoma surgeons actually use this, because it’s very gentle, and it also won’t tear up the wound. So we go just into clear cornea. Now I’ll take a paracentesis knife. And so we want to try and make some of these incisions in locations that will help us to lyse these little membranes all the way around. So most of the — I’ll probably be able to access most of them from the superior area. I might need to get a little bit over this way. So we’ll probably make one sort of over here. And one over here. And I’m gonna actually — the eye has gotten quite soft, so we’re gonna go ahead and fill this with OVD, with Viscoat. And you can see I’m just gonna come up underneath here, and sort of lift this up. You can see that I can lift this and actually inject viscoelastic underneath those strands, which will make it much easier for me to cut them. And I’m not gonna go all the way in with the keratome, because I want to have a fairly maintained chamber. So I just sort of wiggle the knife a little bit, to the point — you can just see the tip. And that’s where we’ll enter. And again, I’m not gonna go all the way in for the full length at the moment, because I want to work through a fairly small incision. I’m gonna take the Viscoat back and put a little bit now under these little strands, so that I can cause some separation. So these are disposable microscissors, and you can see they’re very tiny little blades. And we’re just gonna walk around and cut them all off, right at the edge of the pupil. And we just have to be very careful to avoid hitting the capsule. So I’m lifting up, every time I make a cut. One left. Over on this side. So now it might be a little easier to go through — and you can see the scissors is so small that it will fit through a paracentesis. So we’ve actually cleared that pretty well. If you remember, I didn’t make a full incision with the keratome. I opened it just slightly. So now we’ll go ahead and open this to the full extent so that we can get our I&A in. I don’t think we’ll have to do much phaco. So now we’ll go all the way in. Create the entire incision. Now I’ll take the capsulorrhexis forceps, please. I will bend a cystotome. I just want to see if I can peel this off. No, you can see this really isn’t gonna peel off. If it tears a little bit, I really don’t care, because that’s where I’ll start the capsulorrhexis. So now I’ll take a little more Viscoat. And we’ll just fill this. And then we’ll do the capsulorrhexis. So we were quite successful. You can see all along, little tiny bleeding spots, all along the iris. So I’ll bend my cystotome. And again, we just have to make sure that we make our capsulorrhexis, which won’t be too difficult, larger than the size of that membrane. So I still think we can start pretty much in the center. Now the capsulorrhexis forceps. And again, this will be very elastic. And so we’re just gonna go very slowly, because we don’t want this to tear out to the periphery. We want to make it large enough, but not too big. Those of you who have done animal surgery on pig eyes, the capsule in a child is very much like that. So you can see we’ve incorporated the membrane within the capsulorrhexis. And so, because this is gonna be very soft, we’re just gonna use I&A. We don’t need any phaco. We don’t need any phaco power. So once again, we’ll use continuous irrigation. And I could have hydrodissected, I suppose. But it’s really not gonna be necessary, because it’s soft enough, it’s like doing I&A for cortex. And we just sort of work around it. As we thin it out, it’ll fold in on its own. We don’t really have to go much outside the middle. So we’ll remove some of the little strands of cortex, under polish. I do like to get these lens epithelial cells in young children, because, again, I think it decreases some inflammation. Decreases the chance of capsular phimosis as well. And, again, children are very similar in their inflammatory response to some of those conditions, like pseudoexfoliation. So, again, I think it’s important, even when you do something fairly simple, like put Provisc in, a couple of important principles: You want to get the air out, so you want to see just a little bit. And then you want to just put it right at the wound, so that you don’t catch the iris. You can see there’s a little bleeding off to the right there. And so now we’ll put the lens in, and you can visualize the lens. You should always take a look at the lens in the cartridge to make sure that the orientation is correct and that the haptics are tucked. And so I like to just rotate these lenses a little bit. And then we’ll go to the viscoelastic setting on our I&A, which it is at, and we will remove the viscoelastic first. And this is why I like to use Provisc for this step, because it’s much easier to remove than Viscoat. And then I like to just push the lens down a little bit, to seat it at the base of the capsule. Sort of forgot — a better plan is to put the suture in and then take the viscoelastic out. And here the capsule’s captured just a little bit. That happens sometimes. And so the thing to do is just to tap it down and uncapture it. And we’ll just put a little X suture in here. And, again, just kind of get it out from underneath the Tenon’s there. Tenon’s is very thick in children. And so it doesn’t have to be a very tight suture. Just enough to oppose the wounds, so that, if they rub it in the first few days, it will hold. That’ll soften up. I’ll take just a little scissors. I’ll just cut the Tenon’s a little bit. Just sort of estimate where we want this to be closed. But we want to make it — a good closure makes it more comfortable for the patient. And, again, this is Tenon’s here. So we really want to try and get to the conjunctiva, which is really here, to close that. We can incorporate a little Tenon’s, which is fine, and we’ll, again, try and bury the suture so that it’s not uncomfortable, even though it’s vicryl, which is much more comfortable than, say, a nylon suture or a prolene suture. And she’s got the same condition, I think I mentioned, in the other eye. So I think it’s going to be important for her other eye to get operated on reasonably soon. Again, probably within the month. So that we don’t interrupt her binocular vision. So you can see that the cataract part of this procedure is really the minor part of it. It’s removing that membrane and providing a clear avenue for light to pass through, which she now has, and should have significantly improved vision. I believe her vision was somewhere in the 20/100 neighborhood. And then you can see that the lens is still captured in the capsule a little bit, down inferiorly. And then — let me have the BSS and the syringe one last time. So we’ll just reestablish the correct intraocular pressure. And there we go!