This video demonstrates a phacoemulsification surgery in a patient who presented with a posterior subcapsular Cataract after a prior angle closure glaucoma surgery.

Surgery Location: on-board the Orbis Flying Eye Hospital, Mandalay, Myanmar
Surgeon: Dr. Charith Fonseka, Nawaloka Hospital, Colombo, Sri Lanka


>> This looks like a patient who’s had prior angle closure.

DR FONSEKA: Yes, that’s absolutely right. And you can see the area of iris atrophy there. The posterior synechiae. And the laser iridotomy done on the right over there. You can see the little hole there. So I’m just going to angle it slightly away from that position, if possible. So let’s go in. I’m angling it slightly away. And because the anterior chamber is slightly shallow, incision length is a tad shorter than usual. So this is VisionBlue. I’m just going to put a little bit in. Try to deepen the anterior chamber as much as possible. Trying to break those synechiae with the second instrument. Or I can use the forceps. That’s what I’m trying to do. So we can just pull that away and pull this away. And then you can see there’s a little tendency to prolapse. So I’m gonna use a little more Viscoat to deepen the anterior chamber now. So again, the rhexis — you have to be very, very careful in these cases, because the anterior chamber is shallower than usual. And there’s always a possibility that it can run off. So I’m going very, very slowly. And sometimes it’s better to keep the rhexis a tinge smaller, and increase it in size later on, if required. So let me see. We still have a little bit of iris prolapse. Not a lot. I’m just going to leave that as it is. So this part is a little difficult, because you have to be very, very careful. If the lens is subluxed, it can cause further problems. I did not notice any movement while I was doing the rhexis, so I do not expect — but still, I’m going to take great care during the hydrodissection. Unlike my usual method, I’m just doing multiple small squirts, rather than trying to get the lens to rotate. So a little bit of hydrodelineation also here. Because I don’t really want to stress the capsular bag complex too much. Okay. Once we have that, there’s a little more Viscoat in this. I’m just going to use that here, on the subincisional area. Right? I don’t want to damage the iris. So refill that. And I’m going in with my usual parameters. If I have any problem, I’m just going to come down, as and when that happens. So again, remove a little bit of viscoelastic to get the flow going. Very, very important. Otherwise, it can clog the tip, as well as cause a burn. So there is a little bit of phacodonesis here. I have an option of putting in the iris hooks. But let’s see how it goes. So this is one of the situations where I prefer to debulk the nucleus as much as possible, because you do get some space then, and you can work away from the corneal endothelium. This is a case where I’m not really interested in getting the nucleus to rotate. Now that I have some space, I’m just going to see whether I can get a little more hydrodissection in. Because there is space, so I’m going to dislodge that nucleus. Now I can get it to rotate. You’ve got to be prepared for any eventuality in these types of cases, because of the problems that can crop up. So that’s tumbled, that last part of the nucleus. The problems with the previous — when the patient has a history of angle closure attack — is that sometimes they can have zonular dehiscence, and that has to be always kept in mind, when proceeding with the phaco. These are shallow anterior chambers, so I need to make sure that both the endothelium, as well as this, are protected. So only very, very short bursts, and you can either have it on machine, or you can use the foot pedal to control all the parameters. We got the iris freed. So let’s go and take the cortex out. You need to be very, very careful and pull tangentially, rather than radially. Of course, it’s always possible to do a test and see whether that is required. So let me see. And then the tangential is rather like that. So go in that direction. Rather than pulling it this way. So it’s always better to strip it that way. Because we don’t want to increase. I’m not sure which area, if at all, is subluxed. So that is why you need to be very careful, 360 degrees. Sometimes these subluxations are progressive. And the patient can come up several years later with clinically evident subluxation. So very important to try and preserve. If there is zonular dehiscence, try to preserve as many zonules as possible. So we can pull it this way, tangentially, and we can pull it that way tangentially. That rocking motion helps it to come off. Once it comes off, then that’s reasonably easy. And then this last part — I’m just going to go there again. Try to get the anterior skirt. So one of the important things which I like to see at this stage of the procedure is some residual viscoelastic on the cornea. That means I’m still having a lot of corneal protection, and if I don’t see that, you can see the residue of viscoelastic there. If I don’t see that, then I wouldn’t hesitate to top it up. I’m just gonna inject the Provisc. You can see a slight trickle of blood there, where the synechiae was broken up. In a subluxed — if there’s a possible subluxation, the injection of the lens should be very, very controlled. Very gentle. And sometimes it might be better to keep it in the anterior chamber, and then tuck it in very gently. Because lens going into the bag, unless it’s very, very controlled, that itself can cause a stress on the capsule. Now, I’m just going to use it through the side port, rather than the main incision, because — and I’m just going to gently nudge this lens in. And that’s in the bag. Now, one of the challenges in this case is to remove the viscoelastic. I’d rather remove it than not remove it. But at the same time, I need to be extremely careful. If I can’t get it in without causing damage, I’m just going to leave it as it is. I can get it in. And I can take that viscoelastic out. This patient is a monocular patient. The right eye has a 0.9 cupping, and she has very poor vision on that side, again, due to the angle closure attacks, which had not been — which probably — she had a chronic type of angle closure, subacute, which she has lost. So there’s a little bit of — you can see that floppy iris trying to come in through this. This patient’s cup to disc ratio was reasonably okay. The patient was on antiglaucoma. So let’s see how it goes. Hopefully she can be off her medication.

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January 1, 2020

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