This video demonstrates a congenital cataract surgery in a 4-year-old boy who presented with total cataract and a slightly swollen lens. After initial bimanual aspiration of cortex, the lens nucleus was more dense than expected and phacoemulsification was performed to remove the remaining lens matter. A manual tear primary posterior capsulotomy was performed and an IOL was inserted in the bag.
Surgery Location: on-board the Orbis Flying Eye Hospital, Mandalay, Myanmar
Surgeon: Dr. Ramesh Kekunnaya, L V Prasad Eye Institute, Hyderabad, India
This is a case, a four-year-old boy, who had a history of whitish reflex in both eyes since two months only. That’s a little bit atypical feature about this patient. The lens is a bit swollen. Sometimes you can get that better information on the table. One of the clues to differentiate between posterior lenticonus and an intumescent lens, at this stage: The anterior capsule will be completely flat in posterior lenticonus, because the lens goes behind the vitreous. There’s already an opening. Here, if you can see, I’m just rotating it. It looks a little bit swollen. So chances of posterior lenticonus is less. Obviously you can see the cataract is total in both eyes. The lens is totally white here. So I’m going to inject VisionBlue. And stain the capsule. Obviously you need to wash all the time. You can always rotate this globe, whichever direction you want, with the second instrument. This is extremely important to begin the capsulorrhexis. I make an initial nick, like that. And then what I use… This capsulorrhexis forceps. You can see it has got a good grasp here. And it’s vertically down. That makes your capsulorrhexis a little bit easier. If it is horizontal, you might have to bend it. So here it becomes a little bit easier for you to do it. I’m going to enter. And I’m going to grab this. You can see this is the initial opening I’m gonna do. You can see it is coming from the other side. But still doesn’t matter. You have to grasp and regrasp. And try to complete it. You can see you have to grasp and regrasp. Change your direction each time, if you’re regrasping. Obviously it’s a bit swollen, so you have to be careful. Don’t do at a time. Take your time. Grasp and regrasp. And then complete this. And with the same flow, you can remove this capsule. So you can see the part of the lens is coming out. So if it was completely intumescent, I would have aspirated a little bit of lens matter before beginning with the capsulorrhexis. Here I did not do it, because it’s not completely swollen like a circle. When you do a biometry, you have a clue what is the lens thickness. Your biometry machines, most of them, have asking called lens thickness. “LT”, it is written. General thickness in a child is around 3.5 to 3.8. If it is in any way crossed beyond that, for example, say 4 or 4.2, definitely you need to aspirate a little bit. Second side port incision. Using a myringotomy, you can make it at this stage. And when you come back, you can just give a small little cut, so that your instrument goes very easy and smooth. The next step is using bimanual irrigation and aspiration technique. Aspirate the periphery first. And then come to the center, because that acts as a scaffold, and if it is a possible posterior lenticonus, you might avoid that part, going down. So many times that’s the technique I use. I aspirate the periphery first. And then come to the center. And you should be able to turn your port wherever you want. This 360-degree moment is very important, because as you can see here, as I’m taking the superior part, the whole nucleus is there. It’s a very soft one, most of the time. It’s a little bit leathery. Trying to aspirate it. But its not aspirating completely. It’s definitely leathery. Because that’s why it is not intumescent. At this point of time, probably it’s best to pause. Inferiorly, at 6:00, you can feel the whole nucleus. And obviously with the perception of both the hands, this is not the typical material which will come off very easily. So I will use a little bit of phaco energy to take it off. Can I have the keratome, please? What is different here is you need to make this main port incision at the beginning. Generally I don’t do this type. Still I do the PPC. Again, that’s two step. One, and then down. These are all things you don’t expect at the beginning. Because there is no way I can say that this is a firm nucleus. Which is not breaking with the bimanual. We don’t have to chop this. So I will use a little bit of phaco energy to take it out. Okay. I need the second instrument, because you know, it flowed. This nucleus flowed so much. This is unexpected. Sometimes this cortical matter can go in like that. Can you see a strand there? I’m going back to the bimanual now. There is some cortical matter left at 12:00, and there is some a little bit firm cortical matter inferiorly. Both of them I’m going to take it out now. This is a little bit thick part here. Sometimes this can be there. So can I have the polishing? I try to remove the cells as much as possible. It’s not that in total we can take it. Just under the surface of the capsule, anterior capsule, remove as much as is visible lens epithelial cells. But in a child, you try to give whatever is best possible on the table. We will try to do the posterior capsulorrhexis, and then implant the lens. Opening of the posterior capsule now. You can see the opening. I need to rotate sometimes to see that. The next step is to grab the posterior capsule. More viscoelastic you put, the deeper you have to go. Just remember that. Can you see? It’s coming on the anticlockwise direction. So this is again grasp and regrasp. So it looks bigger. But I think in my opinion it closes whatever small you size you make it. So the bigger the better. And obviously there has to be some place to insert your lens. Obviously. Don’t make it so big that you can’t implant the lens as such. You can see this is again a slow process. Take your time. Grasp and regrasp. I just do a limited anterior vitrectomy. We don’t have to go very deep. Rule of thumb is around anterior one third. You go with the maximum vitrectomy available in your machine. Which makes your life easier and faster. Initially, you can be like this. Flat. Towards the vitreous. Facing towards the retina. And you need to see this vibration of the posterior capsule. That means still there are some vitreous remaining. And I come from here ’til here. I come like this. And then again I change the port like that. You know? This is for the 12:00 or 11:00. And then if you want to see, again I’m turning almost 360 degrees. And turning towards this. So that this part is taken there. Your pincer grip should be good, and you should be rolling this. See? This is directed towards almost 7:00 now. And then same way you can come ’til 2:00, and then 1:00. See? I’m very close to the PC. I’m behind the PC now. I don’t see any movement of posterior capsule. Almost 360 degrees. This is an important step to know that you’re almost full. Because you don’t want to overdo it. Because your globe will become soft. And it’s not required to do too much of vitrectomy. I’m kind of inflating the bag. I’m trying to inflate everywhere, so that I can go in, and place this leading haptic like this. If you can see… I just want to go there, hit the anterior capsule, and hit it hard, so that it is in the bag. Suppose this is the leading haptic. Go there and push it anteriorly. Because if you push it anteriorly, your lens is not gonna go posteriorly. Push it up so that your two thirds of the lens goes inside. Once it goes, and the trailing haptic is just completion of the nudging or rotation, don’t rotate too much unless it’s required. So we are going to implant the lens. This is +20.5. So we have already made this incision before. And we have to go as down as possible. You can see this is going down. Adjust your forceps, and the rhexis is in a stable position. It won’t go beyond this. You need to lift it up, and then put it again inside. Somebody was suggesting that you can do vitreal rhexis. The problem is, with the vitreal rhexis, you may not have stability of the posterior capsule. It may not be so good. So this is one of the advantages of doing a primary posterior capsulorrhexis, because it will be very stable. You can see this — the leading haptic here — it’s in the bag there. And the trailing is above the bag. Can you see? This is a trick where here you have to put it inside. It’s almost inside now. Check for yourself in all directions. It’s in the bag. The posterior capsule is a little bit oblong now. We need to clear it off. You can repeat your vitrectomy, and then complete the surgery. You can see this part has still not gone inside, so you need to make sure that it’s in the bag. This is a technique where you go behind the lens. So this part you need to clear. So check exactly by going behind the lens. Because sometimes this part can go beneath it, as you can see here. This is a little bit behind. Can you see? This part is inside. This part is inside. You can see. And here it’s inside. So this — you have to make sure before closing. You can see this part is inside. And this part is inside. Because ideally I would not test this iris. Because it’s not a good idea to touch. Since the dilatation is not there, we need to check this dilatation part. Change your technique or whatever procedure during surgery. Because it always gives you a surprise. Take very good care, postoperatively. Like, in this case, I will do 4 times a day antibiotics and prednisolone, 8 times per day. And then I will use dilating drops. Maybe cyclopentolate or home atropine, depending upon the availability. Maybe for two weeks. One to two weeks. Because dilating drops are very important, in addition to steroid. I will give a subconjunctival dexamethasone as well as cefuroxime. These are the two injections I give. Because it gives some protection ’til the child is recovering.
November 9, 2019