This interesting case is an usually mature, dense cataract in a 12 year-old. The density of the nucleus required conversion from IA to phaco…a technique that the surgeon estimates is required in less than 2% of pediatric cataract cases.
Surgery location: on-board the Orbis Flying Eye Hospital in Chittagong, Bangladesh
Surgeon: Dr. Ramesh Kekunnaya, L V Prasad Eye Institute, Hyderabad, India
Dr. Ramesh Kekunnaya: This patient had one eye surgery done already. She’s 12 years old. Did not consult anyone until the last two months. Vision is perception of light only. Good pupillary reaction. We did the B-scan, which is normal. We checked the right area that is pierceable. Again, a very delayed presentation.
And if you look at the cataract, again, looking at the morphology, it’s near total cataract. Probably towards the lamina to begin with. You can see the margin here. Over a period of time it has become a cataract. I can see some calcified material within the lens. We had average keratotomy of 45. The axial length is 23.6, which I guess it’s normal for this age group of 23 years. And we checked the fundus. It is normal in the right eye.
This is nystagmus. And she also has additional esotropia of 20 prism diameters. This case is a white cataract. You will not be able to visualize the capsule nicely. That’s why we have to take a decision on staining this anti capsule. But if you carefully see at this point in time, I don’t see any block there. So, we should be having a normal rhexis in this case. We’ll see how it goes.
So, we are going to inject the air bubble. I’m going to inject the blue here. You can see that the air bubble is injected just to prevent any damage to the endothelium. So, you can see a jet pipe coming now. That’s the blue.
Then you need to wash this material. Again, I use the BSS wash as much as possible before you go ahead with the viscoelastics. So, one of the things, what we really check in this kind of situation is to better have the lens thickness. Otherwise you will not be sure that whether it is intimus or blocked.
So, next I’m going to make a small nick. So, you will have wondered why I’m making that central one. Because these cases we’ll never know that the intraocular pressure is very high.
Sometimes it can be very high. Because unless I have the lens thickness, I’m not sure.
So, if the central area, if I make an incision, by the time it reaches the periphery, I can somehow catch it. This is a hypothesis, why I started with the center.
And you do an orange peel technique to spiral it out if you need to make it larger?
Exactly. If I think at some point in time it’s smaller, I’ll do that orange peel technique. You can see the acute angle, I’m trying that. In this case, I’m not seeing it clearly. So, I need to be very, very careful here.
Always the last part is the most important part. It’s kind of orange peel. Trying to match up with that curvature. So, viscoelastic, I take it out because it causes less intraocular pressure.
What were you using to size or estimate the dimensions —
For your capsulorhexis with the white cataract?
What I was looking at, the edge of the lens. Even if it is a total cataract, there is some edge there. I was having that as a reference when I was doing the rhexis there.
My first question is, when you modified the technique from aspiration to phaco mode, why didn’t you do the hydro dissection? Is there any particular indication?
I don’t generally do hydro dissection. The reason is that we never know what’s the status of the capsule. It can even posterior lenticonus. One thing it is, once I know it’s moving freely, probably I could have done it retrospectively. But I’m never sure of the post extracapsular status. That’s why I don’t do it. And this is one or two-person operate on a cataract, where you face the difficult situation of the hard nucleus. This is not the norm. If you ask many pediatric ophthalmologists, they won’t get into this kind of situation. It’s only a rarity.
Sir, my second question is —
In this particular case, in this situation, can we use that direct chop or modified chop instead of going for the whole nucleus with the phaco?
Yeah. We can use one of the choppers. Definitely. But they’re not as hard as a that, right? But they’re not as soft as pediatric cataract. So, I go with the mid-level instrument where it can help me to crack the nucleus as well as here what we require is just a little bit of a an edge. There are three ways to take it out. One, I a analyze the incision, and I can make into pieces. This doughnut, I can make into three quadrants. Or I can make it into one big quadrant and make — split it and take it as a nucleus. The third thing was the phaco. So, we use the phaco as one of the modalities here. I think that typical choppers are not really required in this kind of situation.
So, extremely unstable nucleus as well as bag-less. It’s a hard nucleus. Two parts in the time of pediatric cataract, I use the phaco. This is one of them. This is stuck to the capsule along with the visco. So, that’s what happens.
I think both in your first case and this case you have shown the importance of OVD.
And taking your time and not forcing things —
But kind of just gently teasing things around.
It’s very, very important.
So, this piece is going away. So I wanted to come to the main port. It might come away with the incision, what we have here. Superior part, I think, it’s not coming. So —
But it’s out of the visual axis.
It’s out of the visual axis. As we discussed in the morning, it’s only for the prevention of the phimosis as well as when this girl grows up —
Should she require any kind of laser, I want to clear as much as possible. That’s the only thing in my mind when I do this obsessive polishing of this capsule.
This is extremely important. I’m pushing the anti capsule here.
Pushing it. Push that so that it goes into the bag. Because you don’t want this to go into the PPC, especially any open PPC.
I just pushed it a little bit and then it goes inside. And the intraocular lens, what they are putting is 20.5.
So, sir, one of the questions I’ve always had, if you had a really calcific plaque that was just not coming off with, you know, irrigation, aspiration, polishing —
Wouldn’t come off with visco or any of the visco dissections —
What do you do with a pediatric eye? Do you leave it? Do you try to include it in your PCC?
If it is in the visual axis, I would include in the PCC. Or I’ll take it out with the retractor.
If it does not come out in conventional techniques —
I will use the retractor. I have done some of the cases completely with the retractor. Everything. Aspiration too. Anti capsulorhexis to post capsular rhexis. We still need to do some of the cases. And some part of the U.S. and UK they do the whole surgery with the retractor. One of the things we need to remember in developing countries is, that retractor is not disposal. Many people use it for many cases, especially in developing countries. And as you use it for more cases, is becomes blunt. It’s not as sharp as when you use it for the first time.