This is a cataract extraction in an 8-year-old child who presented with a nuclear lamellar cataract. The lens was aspirated and an IOL was implanted in the capsular bag. Both anterior and Posterior capsulotomies were performed. The side port incisions were hydrated and the scleral wound was closed using a suture.
Surgery Location: on-board the Orbis Flying Eye Hospital, Ulaanbaatar, Mongolia
Surgeon: Dr. Jonathan Song, University of Southern California, USA
DR SONG: So this is a healthy young man, eight years old, who was found to have what looks like a nuclear lamellar cataract. He has it in both eyes. His vision has dropped. He does have a little evidence of vernal. He has little bumps here. It looks like Trantas dots. So he might have some vernal or inflammation before. But in either case, we’re gonna remove the cataract first. The way I like to do cataract is do a scleral incision for my lens implant. The next part of the surgery is really made for just the lensectomy part. Whether you’re putting in a lens or not, this is the same way we would do it. And we’re gonna use a vitrectomy style of lens removal, but we’re gonna use mostly vitrectomy and aspiration and irrigation. So here’s the vitrector. So he’s cutting like this. We’re cutting a hole in the capsule already. Okay. That’s a pretty good size. So now I’m gonna turn the cutter off and just use the A&I. Now I’m just sucking out the lens. Remember, children’s lenses are very soft. I like to strip cortex by going side to side and peeling it off. I’m gonna take the nuclei now. Okay. Now I have access to the other half of the lens. This two-part technique really allows you to really get in there. And we mentioned how in cataracts we like to remove all cortical material. That way you can cause less inflammation. So that looks pretty good. There’s some cortex here. So that’s pretty much done. The lens is out. We’ll open up the bag. Then now we’ll open the scleral incision. That’s the only time we really need to open the scleral incision, is really to put in the lens. Point straight down and go straight in. This is a 2.75 incision. The bag is intact, so we’re gonna put the lens inside the bag. So the IOL types — in children, you should put in acrylic lenses. That’s pretty well shown, that acrylic lenses work best in children. If you don’t have access to foldable lenses, then a single-piece PMMA is very useful. So here I’m just closing this incision site. So the idea of really doing the anterior vitrectomy is to cut the posterior capsule and at the same time do a core vitrectomy to break the anterior hyaloid, so there’s no scaffolding for those lens particles to regrow. So the way we do it is actually the viscoelastic in the front — so I’m gonna go around the lens. So I go behind it. So now I’m enlarging my posterior capsule opening. I like around 4 millimeters. Then I’m gonna go deeper in there. Do a core vitrectomy to break the anterior hyaloid. So you see we have anterior capsulotomy, posterior capsulotomy. That’s all done. Then I’m gonna take out the viscoelastic from the front. If I see any vitreous come in front, I can turn it back to cutter, like right now. If you do a good cleanout, like we have done, take out all the cortical material, you should not have much inflammation. So I just put them on combined antibiotic-steroid eye drops four times a day for about two weeks. And you should get very little inflammation from this. Amblyopia-wise, he is eight years old, so chances are he is not gonna develop amblyopia. So his vision should return pretty quickly. Because we don’t have stitches on the cornea or anything, and we do a scleral incision, we’re not gonna get much astigmatism at all. So they can get glasses usually within a couple weeks, if they need it. Because he’s older, I was able to hydrate the wound and get it closed very quickly, so the chamber is maintained already, and we have a nice capsulorrhexis, so we don’t really need Miostat if we don’t have it. But I’m gonna put it in just to get the pupil down. In a young child, because the chamber collapses, it’s useful to use Miostat or Miochol just to bring down the pupil. The central visual axis is clear now. We have anterior capsulotomy, posterior capsulotomy, so pretty much hopefully this is the only surgery he’s gonna need. And that’s it. And we’ll patch him for 24 hours. All right. Thank you very much.
September 10, 2018