Surgery: Infantile Cataract, IOL, and Primary Posterior Capsulotomy: Vitrector Technique

DR NEELY: This patient is 15 months of age and has — you can see kind of a nuclear cataract here. Bit of a nuclear cataract, more on this side than the other. It’s also involving the cortex around the nucleus. So because of the age, we’re going to use a vitrector, again, to do a vitrectorrhexis. This is bilateral but very asymmetric. We’re using a 20-gauge self-retaining anterior chamber maintainer. Also known as a Lewicky. Okay. Infusion is on 30 millimeters of mercury. On. And I’ll take the vitrector now. So that’s a continuous infusion. It’s not run by gravity. It’s run by the machine. And it keeps the pressure at the exact pressure that you want. So we can dial it up and down during the procedure. Intraoperatively, we’re running a pressure of 30. So I’m engaging the capsule now. It’s a cut rate of 250. And we’ll just circle around until it gets larger. The wound is a little tight right now. Debating whether or not to loosen this up. I think I will. It’s causing a lot of distortion as I manipulate in and out a little bit. We don’t want to make this too large, because then it’ll leak, and you’ll get a lot of fluctuation in the chamber depth. So continuing to circle around. Again, trying not to engage too much with the lens material at this point. Again, our target is to get this capsulotomy about 4.5 to 5 millimeters. And trying not to have any strands of capsule floating around. And I’m mostly happy with that. At this point, I’m going to go to the aspiration only, and I’m gonna just make a little room here in the middle first. And just kind of going up slowly on my aspiration, as much as needed to see the lens material coming this. I’m gonna try to get this subincisional material here first. Got a little stromal edema of the cornea there, from the fluid flow. We’ll try and get this area cleaned out here. Again, this is while the rest of the lens is keeping the posterior capsule back. I’ve just changed the position of my port so it’s facing into the lens material, kind of horizontally, now. Just going in and kind of breaking off little pie-shaped pieces here. Once you get that going, it’s nice to kind of hang onto these pieces, and use it to pull the rest of the material out. So try not to let go of this. A little water on the cornea. Trying to use this to roll the cortex out from the top, from the 12:00 area. You’ve kind of got the aspiration maxed out right here, and it’s not going anywhere, so I’m gonna kick the cutter on for a moment. The zonules. Well, they’re relatively robust. Like most things in kids, they’re a little more forgiving than in adults. All right. So I may just take this big piece, and I may switch my instruments around to get the 12:00 here. Turn the cutter back on and get this nucleus out of the way. You’ll notice any time the cutter is on, it’s facing upward. And you see this thick nucleus is having a little bit of difficulty going down the cutter. I may have to let go of it and reengage it in another spot. There. Just kind of moved things around, so it’ll start to pull it in. All right. I’m gonna switch down here for a moment. Things look good, so we’re gonna go ahead and prep our lens here. And I’m gonna use this approach to get better access. Yeah. We don’t have the advantage in vitrectors of having curved instruments, so you need to have — kind of plan out your incision site so that you can get to these areas.>> So normally do you polish the capsule?

DR NEELY: Well, in this case, I usually don’t, because when you polish, you’re usually polishing the central portion of the capsule. And we’re just gonna open this capsule up from the pars plana side. I think we look pretty good there. All right. So the infusion is off. I’m gonna go in with a little viscoelastic here. Injecting as I go in, so we don’t get into the posterior capsule until it gets pushed back a little bit. All right. I’m going to enlarge my wound now. I just touched the surface there a little bit. So we’ll just go… This is a 3-2 keratome. This is the Alcon SN-60, foldable acrylic. Nice because of its compact size and slow opening characteristics. Right. This is a 24-diopter lens. So at 15 months, we are targeting about 4, 4.5 diopters of residual hyperopia. That’s what we want the refractive error to be in one month from now. These are small eyes, and having this advantage is helpful. We’ll get that under the capsule edge here. Right here at the widest part of the lens. There. We finally got that shoulder under there. So now we know we’re in the bag. Look how much room that lens takes up in this little baby eye. That’s why these flexible lens implants are such an advantage, because these haptics are actually coming back onto the optic. And if you have stiff haptics, you’re really working to get that in there. This was hard to get in there as it was. So that’s gonna continue to open. I’m just gonna leave those haptics alone. They’ll continue to unfold. All right. I’m gonna preplace the 10-0 vicryl. All right. So let’s go ahead and turn the infusion back on. We’re gonna flush out this viscoelastic and then tie this into position. You don’t want to leave that viscoelastic in there, of course. Not only will it be a pressure problem, but it will be pushing things posteriorly, while you open up the posterior capsule. All right? I’m gonna take my infusion pressure down a little bit, while I tie this knot. So we’ve set the pressure to a normal intraocular pressure. About 20. And that way you know the suture will be about the right tension when the eye is normally repressurized. All right. So we’re gonna take down… For the pars plana entry in this age, we need to be back about, oh, 2.5 millimeters from the limbus. So I’m going to take down a little bit of conjunctiva here. I’ll take a 0.2 with the Westcotts. So I’m not gonna go directly over the superior rectus here. I’m gonna go slightly temporal. I need to be back about that far. We’re spreading through our Tenon’s here to get down to some bare sclera. I think I’m gonna excise a little bit of the sclera so it’s not in the way when we’re closing up. Or this Tenon’s, rather. I don’t think it’s quite there. There we go. Yep. Better. Okay. Now back to cautery. All right. So there’s my 2.5 from the limbus. Right there. All right. I’ll take the MVR blade. So plant our tip. We’re gonna aim towards the optic nerve, more or less. You don’t want to get into the bag. See this blade enter back there, and we can see it behind the lens. So now we’ve got a higher cut rate of 500, and let’s take the… The infusion is at what, 20 right now? Got the opening right here. I’m just gonna open this a little bit more. The bag may have been further back with the viscoelastic that’s in it. So I’m just gonna open up a little bit here. With these small eyes, the reason you want to aim so posterior is because the lens takes up a very large portion of the ocular contents, anteriorly. All right. There’s our capsulotomy coming out here. Getting it a little bit wider. And we want to keep this large enough that it won’t just opacify. So it’s generally gotta be about just a little bit smaller than your anterior capsulotomy. We certainly don’t want it too large, to destabilize your lens. And I’m also making sure to kind of flatten that eye out once in a while, to make sure these are lined up with each other. And I think I’m gonna leave this one about here. I’m going to pull out. And let me have the Weck-Cel. Let’s go down on infusion pressure now. Drop it down to… Yeah. Go down to about 15 on infusion pressure. So we’re dropping the infusion pressure down some more, so that it doesn’t push vitreous out the sclerostomy while we’re closing. These 9-0 nylons occasionally will come through the conjunctiva on children. But… It seems to be… It’s a little bit stronger than using that 10-0 vicryl, like what I have in the cornea. I find that when I’m trying to close the sclerotomy with the vicryl, the 10-0 vicryl, it’ll frequently break. So this is just a little more robust. So we’ll put a single vicryl across this, and then we’ll take our infusion out and we’ll close that wound. So I’m gonna get the BSS and a cannula ready before I pull this infusion out. What you see is that, again, with that soft sclera, soft cornea, that this tends to collapse once you pull the infusion out. Maybe it’s… Go ahead and throw some Miochol in here. That’ll help stabilize this lens. So we’ve got a nice small… A couple of tips here. We’ve got a nice smallish anterior capsulotomy. That gave me a little bit of trouble putting the lens in, but in this step, where we’re taking the infusions out, it really becomes your friend, because it keeps the lens back. So we’re gonna reinforce that support by bringing the iris down a little bit. Let’s go infusion off. Infusion on. Yeah. Just turn it on for a moment. I want to deepen this up. Okay. I’m gonna pull it out now. So you can see again there’s that collapse that we’re always fighting against. So I’m gonna do the stromal hydration, try and stiffen things up, until we get our suture in there.

>> What is the rate of the endophthalmitis among the pediatric population, postop?

DR NEELY: Well, yeah. It’s low. I think I’ve seen maybe two cases of endophthalmitis after cataract surgery in the 18 years that I’ve been in practice. And I’ve seen one case after strabismus surgery. So those are pretty low numbers. But yeah, it can happen. One of the cases that I saw, cataract surgery, was when the 25-gauge vitrectors first came out, and they were closing them without sutures. I think that probably has something to do with all that elastic sclera not really closing up like it does in an adult, and it probably gave access to the microorganisms. So that was another reason why we abandoned the 25-gauge vitrector. Put a little more pressure in here, and then bury this knot a little bit. We used to routinely leave large air bubbles in the eyes overnight, to help keep the chambers formed. Don’t find we have to do that anymore with the smaller incisions. Adding in our Kefzol and dexamethasone now. Subconj.