This video demonstrates a phacoemulsification surgery in a mature cataract. This cataract was unusual and was completely liquefied, the cataract was aspirated and an IOL was placed in the bag.

Surgery location: on-board the Orbis Flying Eye Hospital in Trujillo, Peru

Surgeon: Dr. James Lehmann, San Antonio, USA


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Dr. James Lehmann: As you can see, this is a mature cataract. A couple of things to remember when you’re doing cataract surgery on a mature cataract. There can be a lot of tension built up in the capsule. And so, when you’re making the rhexis, which we’ll get to in a little bit, you want to make a small rhexis to start. I always start with a paracentesis using a 15-degree blade. And then we’re going to put in some vision blue. And then use BSS on a 27-gauge cannula and then rinse it out.
Next, is a dispersive viscoelastic. And I start at the other side of the anterior chamber, pushing out the remaining blew dye that was that the aqueous. Next, I fixate the globe. And use a 2.65 millimeter keratome to make a wound at the temporal limbus. And now here comes the critical step. Using the cystotome, I try to nick it in the center and try to avoid the Argentinian flag sign. The way you can do that is have a lot of viscoelastic in the anterior chamber pushing down keeping counterpressure on the bag. But not much cortex flew up, so it look like we’re safe. Still, there’s a tendency for the rhexis to run out on a mature cataract. Also, it can be very friable. So, I make a very small rhexis and then I kind of spiral it out. So, you can see, I’m kind of starting with a — almost like a 4-millimeter rhexis here, and then as I get more confident that we’re towards the end, then I can make it bigger.
So, trying to grab the flap there. I see it’s already kind of wanting to run out there. Bring in to me now. Right now we’re at about a 5-millimeter rhexis. And then, see? There, it looks like it wants to run out. So, you need to turn the flap over so that you have some more control. You don’t just pull. The thing would run out. And then in the end there we end up with about a nice 5-millimeter, 6-millimeter rhexis.
So, the next step involves hydro dissection, of course. And one thing I learned back in residency was you don’t have to do hydro dissection on a mature cataract because the cortex is already liquefied and the nucleus would be mobile. And it looks like there’s not much nuclear material in there. It’s all been liquefied. The decision was made to just use the IMA hand piece and not do any phacoemulsification.
Now, this is highly unusual. Even a mature cataract, it can be a dense cataract underneath or it can be a real light cataract. But to have one that’s totally gone and just liquefied cortex. That’s a bit unusual.
And then you can see the red reflex there and then the cortex just kind of fluffy. The posterior capsule is intact there. You can see some PSC-type changes. And this case kind of went from being scary to being very straightforward when there was no nuclear material to fiddle with. So, I think I’m just getting the rest of the cortex. And the technique to remove cortical material, of course, is to go under the anterior capsule, or leaflet there, and then pull kind of up and to the middle once you have a strand.
Oftentimes you’ll find some contraction and some scarring of the capsule and or some calcification-type changes that don’t respond nicely to irrigation aspiration. And so, you don’t to want get too aggressive and tear the capsule. You can also leave that sub incisional cortex and go ahead and put the lens in the bag. And that allows you to have some barrier between you and the posterior capsule. Another option would be to use bimanual irrigation aspiration. That makes life easier in these scenarios.
So, that’s a cohesive viscoelastic, in this case, Provisc, to expand the bag. A nice, central capsulorhexis there. And then the lens we’re going put in is going to be an SA-60AT lens. A one-piece acrylic lens. Probably the most popular IOL in the world. IOL comes into the eye nicely, unfolds slowly, and then we’re going to put it in position. And I’m going to put the haptics at 12 and 6:00 so I can go sub-incisionally and get that cortex. If I put the haptics at 3 and 9:00, it would be obstructing my ability to get the cortex that’s sub-incisional.
So, I’ll switch now to the INA hand piece. So, getting all the viscoelastic out. And then we’re just going to grab that last piece here. So, at the end of the cases, what I normally do is I do stromal hydration of the main wound and the paracentesis. You can inject Vigamox to the anterior chamber. About .22ccs of that. And then firm up the eye. Make sure that it stays firm and that you don’t have leakage of the wound.


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January 30, 2018

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