Surgery: Pediatric Lamellar Cataract

Dr. Ramesh Kekunnaya: This is a case of lamellar cataract in a 4-year-old girl. And she has a vision of [inaudible]. She fixates very well. Her parents don’t have any kind of opacity. And her base scan was normal. And we did the biometry as well. The biometry was four to one, and the

So, we are going to [inaudible] 4.5. So, what you’re going to make is two MAR incisions. You’re going use the viscoelastic to make the anterior chamber deep. This viscoelastic has the property of dilating as well as deepening the antechamber. So it’s a dilate property that makes our things easier.
And is that visco — is that a cohesive or a dispersive?
This is a cohesive one. This is probably a VISCOAT. So, this is a curator, which is available in this microscope. It makes things easier to do the rhexis. So, you can see the central nevus. So, I’m going to make a small opening here.
So, this is the end grasping vitreoretinal forceps, what we’re trying to use here.
There’s a question in the audience.
Yes, please.
As we know that the VISCOAT has a coating of the endothelium more than forming the anterior chamber.
Yeah.
More goes by the healon, the —
Yeah.
So, why are you using VISCOAT for this case?
Exactly. We can use one of that. So, it’s not that we are using too much of phaco power in this case. So, any one of them can be used. So, this was one of the available things, so, I used it. So, in the initial part of the training, if somebody wants to use Viscomet, that’s fine too in this kind of situation.
So, this, I need to make the incision a little bit bigger. Later I can implant the lens from the same incision if you want. So, that’s the advantage of that.
You can faintly see the edges here.
We have a pretty good visualization here in the classroom. How is the consistency of the capsule? Is looks pretty soft. It doesn’t look like a friable or —
Yeah. It’s quite okay. It’s totally different from a frontline cataract where it will be very friable. so, if you aim at the size of the nucleus, you will go bigger than that. That’s what happens usually. So you can see — you will see the last part is still there. So, I need to take it out. So, in the initial part of the training, it’s better to go in and come out as much as you want. You want this rhexis to be clear, round and regular. Whether the hydro procedure is required. In a kid, probably it’s not required. Because it may not make anything better for you. In an adult, probably it’s required.And you you’re just using bimanual.
Bimanual.
And this seems very soft, is that correct, sir?
Usually a very soft cataract. I tried to aspirate the peripheral part first and then come to the center.
Yes, sir.
The reason is that the nucleus, access the tamponade against the posterior capsule. So that makes the life a bit easier. But sometimes the nucleus can just pop up. Just like a lollipop. It can just come up. So, it’s okay even if it comes up. But as much as possible, if you can avoid that, that’s fine. So, right now you can see that the nucleus is coming in the way. So, you can push it back and go for the other cortical matter. Or you can just aspirate it. It’s the most important and probably the hardest part of the pediatric cataract. Otherwise it’s quite soft.
And do we know the etiology or the cause of this cataract?
Yeah. This particular case, we tried to look at many of the possible etiologies. We examined. We really don’t know the etiology in this particular case. So, around 40-50% of the developing cataracts, we don’t know the etiology in kids. Next generation sequencing for the genetic test, if you it, probably you might get — but what about clinically possible? We are doing in this case. We did not see any physical abnormality in the face or systemic examination. But most of these cases, what we see, very — we don’t have any specific cause in these kind of children. Unilateral, it’s a different ball game.
Yeah.
So their etiology is a little bit different.
Right.
So bilateral means you think of systemic disease. So, we have to think of more of syndromic things in a bilateral. But still, in spite of all that, most of these cases are idiopathic.
So, this is taking a little bit long because we have increased the size due to the difficulties, what we had in the anterior capsular rhexis. So, whatever the depth you have, you can have the complete depth with this larger incision. So, it will take some time. And you have to be patient and then you can give a better outcome for these patients.
And, sir, I know every patient is different.
Yes.
But back home in your practice —
Yes.
What age do you do a primary vitrectomy capsulotomy, are able to get them to do a YAG capsulotomy?
Typical textbook says we should not do primary capsular vitrectomy after 6 years of age. What we have seen in our country is even after 8 years, 9 years, they develop this capsular opacity. So, I do it until 8 years of age or so.
Is it just the posterior capsule that’s — or also the anterior hyaloid?
It’s even the hyaloid. We did the study just doing PPC as well as without a vitrectomy. Still, we had opacification in this case. So, I think it’s a combination of both the cells migrate from the vitreous and acts as a scaffold and it comes. Right now what I am doing is I am polishing the anterior capsule. The posterior part of the anterior capsule. There are tiny epithelial cells you can see.
We’re able to see it very clearly, sir. Do you think this helps with both PCO and late decentration? Do you think removing the epithelial cells help with decentration, or no?
It helps to prevent posterior capsular opacification. These lens epithelial cells are like stem cells. They can proliferate over a period of time and they can come behind your capsule and we have to clear it as much as possible within the limitation.
I’m trying to remove — see — in this area, if you see, these are the cells. It takes more time, but I think it’s worth it, removing all of these cells as much as possible. Just a few cells are left. I’m a little bit persistent about that. So, I do it in every case. I think it helps. We’ll implant the lens now. Yes, 24.5. We are going to put the hydro phobic single piece lens. Yeah. I will, in this case. Because the capsulorhexis forceps does not have a vertical dip. So, if there’s there, I will be happied to a posterior capsular rhexis.
So far no questions. When you’re doing your posterior capsulotomy, capsular — anterior vitrectomy —
Yep.
How big an opening do you want for the posterior capsular rhexis? And how much — how deep do you go? Where does your probe go relative to the posterior capsule?
Yes. With regards to the size, I used a 2.5 millimeter earlier. But what we thought down the line is that they get the most over a period of time. So, now I aim somewhere between 3.5 to 4 millimeter. Around 1.5 millimeter less than the anterior capsular rhexis size. How deep? Just behind the posterior capsule. I don’t do a very deep vitrectomy. What we need to cut is the posterior hyaloid face. You need to cut. You need to be at the surface of the posterior capsule. Don’t have to go behind. What I usually tell my fellows is that when you inject with scleritic, the posterior capsule bows down. It becomes convex. Just make it flat after the vitrectomy.
So, the first target is just to push this guy in. And then he can just put it in. No need to rotate too much on the anterior cataract. I go pass — or do I go vitrectomy? What I find is my personal preference is through this point. It makes things easier because I do not have one more incision here. I go with one incision. We are at the linear 3,000 cut rate. So, my cut rate varies between 1,000 to 3,000. So, this is a linear cut, which makes my life easier. I have total control to go between 1,000 to 3,000. What I am trying to go here, just — this is an important step. I’m going behind this anterior capsule. Trying to go. Press the — there. And the probe goes there. And that way the eyeball moves a little bit. The lens moves a little bit. And then I start the capsular rhexis. You can see that opening there.
So, this is my initial opening. So, I go to the hole cut rate, and then I go inside. I increase the cut rate. Now I’m close to 3,000.
And, again, you don’t feel a need to go very deep into the vitreous.
Look at the level. I’m just behind the capsule. I used to do very deep. Then what happens is that your — the eye becomes so soft you can’t even implant the lens. So, it’s not even required to disturb the vitreous so much. So, at this point of time I’m done with the left part of this capsule rhexis.
Yes, sir.
You can see I’m stopping here for a bit. I’m turning this. You can see. This is a finger moment, not an elbow moment. This is very important. Sometimes in the initial part. This mention is so good that it just shaves off this posterior capsular rhexis. Again, I do not have any financial interest, but it makes my life very easy. Again, I’m stopping a little bit here. And then my fingers rotate on this direction. Yeah.
Now you can see I’m almost reaching the end point. When I’m at 3,000 here. I’m just at 3,000 here. Your posterior capsule should not flap. Because there should not be any capsule or strands coming in between. So, this is almost the end of that. So, when you come out, try the centration of this lens. So, this is the last time you’re in the anterior chamber. When I come out, what I do is I inject air with the other hand. And then I suture.
So, again, viscoelastic, when you put at this point in time, it will disturb — you have to go again. So, one step less.
At some point you are going to take out the suture. Just make sure that you’re not full thickness. I’m going partial thickness here.
Oh, partial thickness. Okay.
The reason is, I’m going to take it out one day. When you take it out, I don’t want the infection from cornea to go into the intracameral area and cause infection. But you need to be very, very careful that you are partial thickness. Not full thickness. Very, very important.
But what sutures do you use on a child? Do you use absorbable? Do you use — what do you prefer to use?
Yeah. Again, Bangladesh is almost similar to India. In India we use 10-0 nylon. The reason is chances for infection. When I was in the U.S., the fellowship there, 90% of the patients get the suture. So preference is definitely 10-0 nylon.
Thank you, sir.