This video demonstrates surgery in an eye with traumatic cataract, vitreous prolapse, fibrotic capsule, zonular dialysis and an atonic pupil. The fibrotic subcapsular plaque prevented completing a continuous capsulorhexis but an adequate anterior capsulotomy was achieved. A moderate zonular dialysis was also present, which was managed with viscoelastic and a capsular tension ring (CTR). Vitrectomy was done, and pupil cerclage was performed for the atonic pupil.
Surgeon: Dr. Ike K. Ahmed, University of Toronto, Canada
This is a case of a traumatic cataract. You’ll see there’s vitreous prolapse present inferonasally, fibrotic capsule, zonular dialysis, and atonic pupil as well. You’ll see throughout this case. We’ll start off with injection of some triamcinolone to localize and visualize the vitreous. We’ll inject it in a dilute formulation, and then irrigate some BSS in the anterior chamber to isolate where these triamcinolone crystals will localize and stain the vitreous. Viscoelastic is injected, and will release some of the posterior synechiae present on the pupil margin, and there you can see some vitreous present at the inferonasal pupil margin, as well as the edge of the lens seen, as you see here. It’s almost about 120 degrees or greater zonular dialysis. We’ll also add some capsular staining, which will help for the capsulorrhexis shortly, with some Trypan blue, and then irrigating, and then some viscoelastic to stabilize the chamber. You’ll see here that the capsule is fairly fibrotic. We decided to do the capsulorrhexis first, prior to vitrectomy, because the vitreous is off to the side. We want to try to get the rhexis done first. It’s really difficult. Very difficult to initiate the rhexis. We’re gonna use some sharp microscissors to actually start the capsulorrhexis on the one side. You can see it’s quite difficult to get even with direct puncture. We do get initial tear, and we’ll use a couple microforceps and capsulorrhexis to start the tear by pulling in opposite directions. And the rhexis starts out — it tears out a little bit here. You can see here superiorly. And we basically move to a stretch technique to basically continue the rhexis, and then turn the flap over to a shear technique. This rhexis is very difficult. There’s a central subcapsular scar present. There’s folds in the capsule here. And really this capsule does not tear normally. And you can see that the zonules are quite deficient there, particularly inferiorly here, with extra stress being placed on the zonules during the capsulorrhexis. And we’re trying to here again use the stretching technique to propagate that tear, but you see it becomes very difficult to do, particularly with that fibrotic nubbin of tissue present there centrally. And we use some traction and a microforceps in another direction. You can see we’re still not able to get that rhexis continued here. At this point in time, you can see the edge of the lens sort of coming forward now, from the inferior side, indicating the broad irido — sorry, zonular dialysis present here. We will then proceed to use a pair of microscissors to complete the rhexis here, as we see, to basically cut the remaining stalk that’s left, and we have now a capsulorrhexis, a discontinuous one and an irregular one, although there’s no obvious runout. It is irregular and somewhat asymmetric. At this point now we’ll proceed to do some limited vitrectomy here, using a bimanual technique through the limbal incisions. And here we’re basically just using more cutting here, to basically trim the vitreous from the pupil margin. Being very careful not to aspirate, of course, the capsule or the iris with the cutter. And it does help to use the irrigating cannula here, to push the iris away from the cutter, and also to use it as a sweeping technique as well. We’ll then basically keep the chamber formed, before pulling out with irrigation by injecting viscoelastic, and coat the area of the dialysis with some dispersive viscoelastic. At this point in time, after hydrodissection and viscodissection, to help mobilize the lens, we will proceed to phacoemulsification. The lens itself is moderately dense. We proceed to a vertical chop and crack the lens in half. And we’re gonna actually do a little bit of a heavy flip here, bringing each hemisection one at a time to the iris plane, to phaco and emulsify the lens. You can see we’re keeping our phaco tip away from the inferior side. You’ll see the capsular bag coming forward. It’s about 120 degrees or so of dialysis present. And we’re putting some viscoelastic in here to keep the chamber formed and keep the bag formed and keep the capsule away from the phaco tip. Again, working on the superior side of the bag to avoid aspiration. Now, we did not put a CTR in here at this point, because we were uncertain as to whether we would successfully be able to place a CTR in, with an irregular capsulorrhexis. And we decided to basically go after the lens first, before putting a CTR in, knowing that we do risk, of course, capsular trauma. Fortunately, the phacoemulsification proceeded uneventfully, and we’ve kept the chamber formed by injecting viscoelastic before pulling out. And now we’ll basically remove the cortex. Now, this is certainly a hazardous point in time. And we decided to use a manual technique, using a 27-gauge cannula to aspirate the cortex, as opposed to using an automated IA tip. You can see we’re very carefully and slowly removing the cortical fibers and fragments that are present on the capsule here, by simply irrigating and aspirating these cortical pieces. We basically use irrigation and aspiration here, pushing back and forth. The capsule you can see come forward here. To basically pick off some of that cortex present on the capsule. And we do want to make sure we clear the capsule of most cortex. All of it, as we can. There’s a bit of fibrosis present there. You can see it fairly. And we’re gonna leave some of that, but most of the cortex you can see we’ve basically vacuumed off with the cannula here. And at this point in time, we’ll reinflate the capsular bag with some cohesive viscoelastic. We’ve decided now to place the CTR. Now, there’s certainly a question to use a CTR in the presence of an irregular or discontinuous rhexis. The rhexis is obviously not quite curvilinear, but it doesn’t run out in any direction at this point, so we basically place the CTR by injecting it towards the dialysis. You see the bag has now expanded. The capsule seems to be well supported. And we will then place a single piece lens into the bag, keeping the haptics in a position that they will be overlapped or covered by the capsule shelf, as you’ll see here, present here at the 3 and 9 position. IOL is now well positioned, and we’re happy with that. Put a little bit of Miochol in to see how much we can bring that pupil down, although we do know it’s atonic. And then we’ll finish off with just trimming whatever vitreous may be present in that inferior and inferonasal quadrant. Using a dry technique under viscoelastic, using the Kuglen hook to push away the iris there. This is a safe way to remove the vitreous without risking — or minimizing the risk of iris trauma. We will now proceed to a pupillary cerclage technique, which you’ll see here, using a 10-0 prolene on a curved CIF4 needle. We’re using three incisions actually for this, and we’re basically passing the needle in a running sort of baseball stitch fashion to essentially create a pursestring around the pupil margin. You can see we’re grabbing the iris, the pupil margin, about a millimeter from the edge, and you can see we’ve gone from our right hand to our left hand. And we’re also using the microforceps very importantly here, to actually move the iris and position it to the tip of the needle. So the needle does less movement than often the actual iris forceps, to bring the iris tissue to the needle. So certainly the needle is a large, long needle. Hard to maneuver in the anterior chamber, but it can be certainly held in position while the iris is brought to the needle, as you saw, with the iris forceps. It’s a double armed here. We’ll go through the same paracentesis initially there nasally, and then we’ll then proceed, and again, in similar fashion, running a baseball type stitch, heading toward the temporal wound here. And again, switching hands back and forth, using the microforceps to bring the iris to the needle, as mentioned, is a nice technique to be able to minimize the movement of the needle. And then using a docking needle to come out through the main incision, to avoid trapping the needle in any corneal tissue. We now have one remaining area of the pupil to suture. And we’ll again use the same technique. In this case, using the left hand here again, to manipulate the needle in the anterior chamber. The needle goes up and down, while the forceps bring the iris to the needle. Basically, we want to take as many bites as we can. And this will minimize some of the jagged appearance that may occur on the pupil margin during the final suture time. At this point now we can tie the suture. We’re gonna use a modified McCannel or a McAhmed technique. Loop of the suture outside the eye, and then bring the knot through the wound into the eye, to the point of contact at the pupil margin, and then we can titrate the tension, aiming for about a 3.5 millimeter pupil size here, by adjusting it with the microtier. We will then lock the suture. In this case, a 3-1-1 knot, and then we’ll basically trim the knot with a pair of microscissors. So we’ll be able to manage this case of traumatic cataract, zonular dialysis, vitreous prolapse, fibrotic anterior capsule, and atonic pupil, using microinstruments, using fluidic principles, vitrectomy, capsular tension ring, and iris pupillary cerclage, to repair this eye.
November 18, 2019