This video demonstrates lens aspiration, primary posterior capsulotomy, anterior vitrectomy and an IOL insertion in a 8-year-old girl with Rubella Syndrome.

Surgery Location: on-board the Orbis Flying Eye Hospital, Mandalay, Myanmar
Surgeon: Dr. Ramesh Kekunnaya, L V Prasad Eye Institute, Hyderabad, India

 

Transcript

8-year-old girl. She had cataract surgery in the left eye. Possibly rubella syndrome. She was TORCH positive. Her refraction today is -2 with +2 at 90 degrees. That amounts to a +2 of cylinder at 180 degrees. And since the child is 8 years old, I’m not going to undercorrect in this patient. We are going to implant a 24 diopter lens. And you can see the size of the nucleus here. It looks like more of a nuclear cataract in this case. So we are going to inject viscoelastic. This will deepen the anterior chamber. When I am injecting fully, it’s dilating the pupil as well. So you can see that shiny surface. This is what I use, generally. As initiation of the capsulorrhexis. This is where you make the first nick. You can see the nick very nicely here. So whenever I grasp and regrasp, it tends to go a little bit down there, and you need to pull it towards the center. That’s the completion of rhexis. And go on to the periphery. I always finish the periphery, and then keep the nucleus as a scaffold. So now almost 360 degrees we have removed. But you can see how hard it is. This can happen in rubella cataract sometimes. They are a bit hard. So now this is the stage where we can aspirate everything. Do a little bit of capsule polishing. It’s good. Because you take away all the lens epithelial cells, which can proliferate in the future. Whenever you see this iris coming up, so you need to always check what is the end tidal CO2. Sometimes you need to keep it down. Iris can become a little bit flabby. This you can expect in rubella syndrome patients. See, the iris is quite flabby in this case. You can see? We will do the primary posterior capsulorrhexis in this patient. Posterior capsulorrhexis is much easier than the anterior capsulorrhexis. You can see I’m putting so much traction. It still does not extend so much. So in this case, I will do the vitrectomy. So you can see… Go ahead. And then initially you’ll be doing viscectomy, then vitrectomy, then you will reach deep. Then only you will see the vitreous. You can still see the dog-ear coming from the iris. So this is something you need to be careful. And the idea is to inflate the bag. Because you have a vitrectomy already done. You need to inflate the bag as much as possible. Inject the Viscoat directly into the bag. The leading haptic should go inside this area. The leading haptic should go inside, and then you can push it anteriorly. That makes sure that you are in the bag. And also it makes sure that you’re not going behind the posterior capsule. So these things are very, very crucial, because otherwise your lens can go into the vitreous cavity. So what I make sure to land inside the bag is: Once the leading haptic comes out, I push it against the posterior surface of the anterior capsule. So this is my goal, to keep this haptic there, because when I’m pushing now, I’m not going behind the vitreous. I’m just in the bag. I’m pushing the bag there. Not the vitreous. I’m not going posteriorly, but at the same time, I’m trying to open this lens. This has opened into the bag. Can you see that? This particular lens — there are some issues with the loading, but still we need to manage. Sometimes these things happen. The optic is not still in the bag. Still the edges are still out. So we need to really make sure that they are inside. You can use this viscoelastic. Most of it — it’s inside. You can see some twisting of the superior haptic. So that — we need to nudge it inside. The temperature difference can make it a little bit rigid. So this is extremely important. This part can try to go inside. So you need to be extremely careful. This, you can see, it’s centered. It’s in the bag. Can you notice something here? The posterior capsule at 9:00 is not perfectly round. This is a sign that the vitrectomy is not complete. So we need to have vitrectomy to be done, and then we can go ahead. This iris is perfectly okay. Sometimes the iris is not so good. So if you manipulate too much, they can have more inflammation. If I have a normal surgery, as I’m having here, maybe once or twice the iris prolapses in this case. I would probably put this child on 8 times steroid. That is prednisolone acetate. And maybe a cyclopentolate eye drops, 3 times, and a Vigamox. But if you’re doing surgery which is a little bit of stormy course, the patient had, then I would do even 10 to 12 times, depending on the case. Oral steroids, I don’t give it routinely. So one observation, what you are seeing here, is the iris is flabby. Can you see? It’s coming to your ports all the time. Let’s put one suture. Before that, I want add, please. Partial thickness. And partial thickness. 90%. Because this is a problem. You won’t find it now. When you’re trying to remove the suture, I think it’s extremely important. So there’s no leak there. This looks good. Looks good. Thank you.

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October 4, 2019

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