Surgery: Posterior Polar Cataract Surgery using a Vitrector with IOL implant + Posterior Capsulotomy using a Vitrector and Anterior Vitrectomy
This is a 12-year-old boy with a history of developmental delay and bilateral posterior polar cataracts. A lensectomy was done with a vitrector and an IOL was implanted in the bag. A Pars plana posterior capsulotomy and an anterior vitrectomy were performed because the patient may not cooperate for YAG capsulotomy at a later stage.
Surgeon: Dr. Asim Ali, University of Toronto, Toronto, Ontario, Canada
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DR ALI: This is a 12-year-old boy with a history of developmental delay. He has bilateral posterior polar cataracts. And the plan today is to implant a lens in the bag, and I’ll be doing a pars plana capsulotomy and anterior vitrectomy. He will not sit for a YAG capsulotomy later, we expect, so we’ll do it all in one procedure. So before we go in the eye, I’m just gonna create a little peritomy. Yes. So the question is: This is a posterior polar cataract, and the patient’s at risk for PC rupture. So that’s why we just have to be careful with that. The iris is normal. Just widely dilated. You can see that there’s some cortical spokes on this posterior polar cataract there. This is 3.5. Just proceed with the rest of the case for now. We don’t have to remove — deal with every bleeder. We can deal with that later, if we need to. Okay? So it’s important in these cases to keep the infusion anterior. I don’t like to run a posterior infusion, unless you’re very comfortable visualizing the entry site. You run the risk of causing retinal complications. If I do this, I always do an anterior — an AC maintainer, rather than try to do a pars plana infusion. The question is why we’re doing all this. It’s because he’s mentally retarded, so he’s not going to… When we assessed him, we felt that he would not sit for a capsulotomy. So it’s better in my mind to do it now than to wait until later. We can do a very limited hydrodissection. So we have to make sure that the wave we put in doesn’t go around. It goes right about ’til there and stops. So I didn’t go all the way around the back. Because you do run the risk of blowing out the posterior capsule. So I’ll stop there. Yeah, I don’t want to do too much. I think if I can remove most of the lens without too much hydrodissection — normally I like to do a lot more. The worry is, if I use a lot of pressure, then I will blow out the posterior capsule. Again, we’re gonna be removing the posterior capsule, but the risk — you do run the risk of taking fragments and losing them. So you want to have this controlled as much as possible. Will you turn on the infusion, please? Much easier to put the infusion in if you have it running. Sometimes you can remove a lot of the periphery. What I’ll do here is I’m gonna remove some of the central lens material first. I’m trying not to remove the cortical material at the posterior portion of the lens, intentionally. Although that would make it faster. And the reason is that there may be an opening in the posterior capsule. It can enlarge very quickly. Once the fluid starts to circulate. So I usually save that until the end, when I’m pretty happy with most of the removal of the lens material. Looks like I freed up that portion there. But I’m just looking underneath, to make sure there’s nothing in there. It’s gonna make things a bit easier. The goal is to try to remove as much as you can, before you get to that point. If there is a posterior capsular break, you’ll see a round hole sometimes. Or even a membrane in the anterior vitreous. And the posterior capsule is not broken, which is good. Yeah. It all looks very clear. If we’re gonna take out the posterior capsule, I just want to show you — there’s different ways of doing it. So some people will do it — an anterior approach. The other way is to do it posteriorly. And I’ll just show you how we do it posteriorly. We can talk about — yeah, there’s different ways. I’m just gonna do it this way, just for — it’s actually, if you’re learning, I find that this is the easiest way to do it, to do it from behind. That’s what I think, anyways. So what I was saying was… If we’re gonna take out the posterior capsule, and normally for a 12-year-old boy, I wouldn’t do this, but this is because of his particular situation. We’re gonna do that. So there’s two basic ways of doing it. You can do it from the front, or behind the lens. You can also do it before or after implanting the lens. And what I was saying was… And I’ve done all of these things… And you can also do it manually or with a vitrector. So there’s many different possibilities. Or ways to do this. But what I was saying was I’m just gonna show how to do it from behind. And I find that that actually, overall, at least, it seems to have the least number of complications, if you do it carefully. If you try to do it from the front, it can be very quick, but you can… You run the risk of dislocating the lens. Or causing vitreous to come forth. And get incarcerated in the wounds. So what we’ll do in this situation is we’ll implant the lens first, into the capsular bag, and essentially complete the anterior portion of the procedure, and then go from behind and open the capsule. So we’re gonna be implanting a one-piece in the bag. You don’t want to do wound assist here. As much as possible. I want to really place it inside the bag. With these lenses, it’s quite easy. As much as possible, I like to place my sutures when there’s viscoelastic. We’ll remove… We’re gonna turn on the infusion when we tie. It’ll help to flush some of the material out and prevent a lot of it just going to the back. So I often like to do an X shape or a cross. A cross bite. Just to make the tension equal on both sides. It’s just easier, quicker to close. Just one knot. Turn on the infusion as well. So a lot of it will come out. So we don’t have to worry about what’s in the AC. So we just turned off the infusion, just to prevent the eyes from draining too hard. It’s hard to tie. You end up making the knots too loose. So the advantage in these cases is that you can just bury the stitches underneath the conjunctiva there. And then we can turn on the infusion again. Yep. 3.5. So it’s just off here a little bit. Can I get that 20-gauge MVR? So we go in parallel, right angles to the sclera. And you want to raise your hand flat. You want to be able to see the tip there. Okay. Make sure you’re in the right spot. And then we just use the cutter to go in and go behind the lens. You can use a trocar for this too, if you’re comfortable. That’s another way of doing the same thing. Hopefully you can all see the opening there in the posterior capsule. We’ll make a small opening first. And then do an anterior vitrectomy. The vitreous in children doesn’t behave like it does in adults. It’s a lot more solid. So you have to move the cutter around a lot more. If you only do a limited vitrectomy, then you leave some scaffolding behind for capsular opacity. So I’m just slowly enlarging the posterior capsule, capsular opening. Normally you want it a little bit smaller than the anterior capsular opening. One thing: When you make your — especially your posterior opening — you want to make it very smooth and you don’t want to make it too large. Because you can push the lens backwards, if it’s really big. So just about what we have there is good. And then he won’t get posterior opacification. And even if he gets Elschnig’s pearls, then they will fall off and they won’t go into the vitreal axis. They’ll fall off into the vitreous instead. They won’t cause any harm. I think that’s… Can everyone see that? They’re fairly well aligned there. So now I’m done, and I’m just gonna keep it cutting, as I come out. Just to prevent vitreous from getting incarcerated in your wound. Because that’s a potential complication. And I’m just using the cutter at the opening. That’s the reason why — any technique that you use, even if you’re coming from the front, you need to be sure that you don’t incarcerate vitreous. And now we have to test it for vitreous. Can I get a Weck-Cel, please? Okay. So there’s no vitreous there. So this is partial thickness. So I use a larger… I use an 8-0, usually. Because I don’t want this wound to leak. I’m keeping the infusion running in this situation, because I really want to make sure that I don’t have a leaky wound here. You can use a trocar as well, if you’re comfortable with that. The only thing I would recommend, even if you use a trocar, and you’re not used to suturing your wounds, in a child, I would always suture with my wounds. Because they do open up, and that’s what our vitreoretinal surgeons do at our hospital with the children. And I have seen, even when they’re sutured, these scleral wounds gape, when I go back on these eyes for other surgery later on. I’m not ever as comfortable with the trocar, because I like to be able to suture these wounds tight. I don’t think that they ever are as good. But there’s nothing wrong with it. You just have to use… This is 8-0 or 7-0. And make sure it’s really nice and tight, and watertight. The wounds, they’re not sutureless wounds, even with the trocar, in children. Because the sclera is much more elastic. So they do tend to spread a lot more. So that’s the reason. I’m just comfortable doing this. I’m just going to check the wounds here. The scleral wound is not leaking at all, which is important. Just put another stitch here. Can I put the 10-0, please? So you have to be very careful about the wounds in children. It’s very easy for them to leak. And the children will, after waking up, can cry or scream or rub their eyes, and they’re often difficult to examine right after surgery. So you really want to make sure everything is open, because they’re at greater risk for dehiscence, because of eye rubbing. And also for infections. Just gonna move this stitch a bit further back. Same thing with this one here. So we’re just gonna close the conjunctiva. And you can cover up all of your sutures in this situation with the conjunctiva. So he’ll be a lot more comfortable, postoperatively. Yeah. So I’ve taken a little bit of a scleral bite here, just to sort of hold it. So I like to make sure the conjunctiva is well closed. The assumption is this child may at some point need other surgery. You never know. And I do… Especially if you do glaucoma, you appreciate conjunctiva that’s closed and not scarred up. So in children, glaucoma after cataract surgery is a big cause of… Is a major complication of cataract surgery. So you have to prepare for it, even though he’s an older child. We just have to use the 10-0 again. So we have one thing left. Could you just remove that, please? Thank you. So the lens will shift. And shallow very, very quickly. Can I get the suture back, please? So there’s a leak here. Yeah, same one back. That’s why we always check. And it was too loose. So we’ll just put another one in. So just to summarize, this is just the last stitch going in. So this is a boy with posterior polar cataracts. And we did a lensectomy. With IOL. And pars plana posterior capsulotomy and anterior vitrectomy. Let’s just check our wounds again. All right. That’s it. We’re done. Okay. Thank you. Let’s do the injections.