This is a phacoemulsification surgery in a 7-year-old patient with a mature cataract. After the lens was aspirated, we found a tear on the posterior capsule and that may have been caused by trauma. That tear in the capsule may have caused the cataract. An IOL was implanted and the tear in the capsule was expanded.
Surgeon: Dr. Larry Benjamin, Stoke Mandeville Hospital, Aylesbury, UK
DR BENJAMIN: So this is a young man with a mature cataract. We don’t know why. He’s not atopic. And as far as we know, he’s never had steroids. So, you have to be a bit careful not to go too wide with the capsulorrhexis. So, I tend to try and spiral it outwards like this. It’s going very slowly. And then every now and then you have to pull it backwards, just to get the trajectory right.
His mother noticed this, she says, a couple of weeks ago. My guess is it’s been there for a lot longer, because it’s quite a dense, white cataract. So, with these pediatric cataracts, the capsule is much more elastic than usual. And the VisionBlue helps to stiffen it up a little bit.
And the hydrodissection, please.
And then I use the phaco probe. Some people just aspirate pediatric cataracts, but sometimes they’re much harder than they look. And I tend to use the phaco probe, because it’s a very good aspirator, and if I need any phaco power, then it’s there.
Okay. So, we’ll just try the IA now, please. Are we on IA? Cortex. That’s great. Thank you. Do you notice how the anterior chamber has deepened a lot, when I put the infusion in? And that’s due to reverse pupil block. And I’m gonna use what’s called the Cionni maneuver, described by Bob Cionni, to lift the iris up, and that shallows the chamber again.
So it looks to me like it’s got some sort of breach in the posterior capsule here. There’s a little — it looks like a little membrane there, doesn’t it? So maybe that’s why he’s got a cataract. He may have had a breach in the capsule from trauma or something. It’s difficult to know what to do with that bit, because I’m not sure if it’s part of the posterior capsule or… Or what. So I think what I’m gonna do is put a lens in the eye now. 24.5 MA 60 AC.
And… So that may be the posterior capsule that’s broken there. And that may be the anterior hyaloid face that’s behind. Difficult to know, really.
Question: Doctor, we have a question from the classroom, wondering about the membrane, and if you’re going to leave it or take it out.
DR BENJAMIN: Yes. So, I think that there… That line there, I think, a tear in the posterior capsule. I think this is posterior capsule here. And underneath, it’s probably the anterior hyaloid face of the vitreous. So that explains why he’s got a cataract. So, what I’m gonna do is put a lens into the bag. He’s already got a hole in the posterior capsule. Which is what I was going to do anyway. I was going to make a primary posterior rhexis. So when the lens is in, I’ll just try and extend that hole behind the lens.
So we’ve got the C cartridge? Thank you. Has that got Healon in? I tend to use these lenses in children, because the legs are children. The haptics are thinner. And sometimes in children the capsular bag is too small.
So these lenses are not designed for injection, but they can be injected through a C cartridge. You’ll see the cartridge has a C on it here. So the tip is a little bit wider than the D cartridge, which we use for adults. So you have to make sure the trailing haptic is underneath the injector, like that. And then you also have to — no, that’s not gonna work. Hang on a minute. Can I have the McPhersons again, quickly.
You have to try and make sure that the leading haptic is unfolded in the tip. So you can see at the moment it’s curled up. And you just unfold it like that with a Sinskey hook. And it will make some very odd acrobatic turns, as it goes into the eye. It’s a little bit of a tight fit, the C cartridge in the eye, but it usually does go. And then as the lens goes in, you have to rotate the cartridge.
So that haptic’s in the bag.
It’s turning the wrong way. It’s that way. Okay. So the leg needs flipping over. That’s it.
And then I’ll have the rhexis forceps, please. This is a little bit tricky, because you’ve got to get under the lens. And just extend that rhexis.
Question: So you try to remove the membrane under the IOL?
DR BENJAMIN: Yes. I think this is the posterior capsule. I was going to do a primary posterior capsulorrhexis. But he already has a hole in the capsule, so I’m just making it bigger.
Question: Why don’t you just leave the posterior capsule membrane and do a laser YAG later on?
DR BENJAMIN: You could. If you leave the posterior capsule, it will opacify at this age, in all patients. So if he’s able to sit at the laser and cooperate, then you could do that. But he wasn’t a very cooperative patient. So my anticipation was that he would probably be better off having this done. Because he’ll probably need a laser within the year, I would think, if we didn’t do that. And he’s not terribly cooperative. So it’s nice just to get it out of the way. So in an older child, I would leave it, if they are eight or nine and cooperative, you can just do an YAG laser later.
Question: But why you put the IOL inside first?
DR BENJAMIN: Sometimes, if you don’t, then what happens is the leg of the implant can go into the vitreous. So there now is the posterior rhexis.
Question: Why would you not consider putting a multifocal IOL in a child of this age?
DR BENJAMIN: Yes, it’s a good question. I would, in the UK that’s what I would do. There is not a lot of data about how well they work but its something to consider. You also have to consider the various problems you can get with multifocal IOLs. They are not perfect lenses by any means but certainly that’s a consideration. We haven’t got them here as far as I know and that’s the reason. If he wants to read with both eyes, he will have to have a plus lens in front of the left eye.
Question: Why don’t you use triamcinolone to make sure there’s no vitreous in the anterior chamber?
DR BENJAMIN: Because at this age, the vitreous is very thick. And it doesn’t tend to come into the anterior chamber. It’s very formed and solid, like a jelly. And so they don’t tend to get vitreous coming into the anterior chamber.
Question: I just wanted to know: How old is the patient?
DR BENJAMIN: 7. 7 years old. Yeah. So he either had a congenital defect in his posterior capsule, or he must have had trauma, I think. Because that was why he had a cataract in this eye. He’s obviously got a tear in his posterior capsule.
Question: So you think that this is a congenital condition?
DR BENJAMIN: Maybe. My guess is it might have been due to trauma. Because firstly, his mother said the cataract came on very quickly. And the other thing is the other eye is completely normal. And there’s no other reason why he’s developed a cataract, that I could find. So it would explain everything if he had a recent trauma. So I’m just gonna give him half the dose of subconj.