Surgery: Secondary IOL in Traumatic Cataract

DR SONG: This is a five-year-old little girl who had a knife to the eye. And you can see the primary repair was just repaired for the ruptured globe. Then they had a hydration of the cataract, and she underwent cataract extraction lensectomy about five days later. So normally what we do is we wait about a month in children. Then we remove the stitches. And primary repair of a ruptured globe — we don’t put in a lens at that time. We wait until suture removal. So I’m gonna remove this one stitch here. I’m gonna remove the rest of the stitches at the very end. In secondary lens implants, I like to do scleral tunnels in children. Even primary lens implants, I like scleral tunnel incision rather than clear cornea. So in children, the limbus is a little further back. The Tenon’s, and about 1 to 2 millimeters. So you go further back out. And you cut down to sclera. I tunnel across. And peritomy-wise, you have to pull up. That’s the only way to get conjunctiva off the limbus. So I always pull up. So you can use a regular knife. I like to do a three-step incision off the sclera. In children, if you do a clear cornea, you have to be pretty clear cornea, or the iris will come out. This way the iris will tend to stay in, if you do a nice scleral incision. Limbus, about 2 millimeters. I do about a 4-millimeter incision. And you want to go flat. You want to tunnel up the sclera. Tunnel until about clear cornea. And you leave that alone. That’s really just for lens implantation. So this is a 20-gauge MVR blade. We’re gonna make two ports. Whenever we do a lensectomy in children, we always do a two-port incision. So if you’re not gonna put in a lens, we don’t do the scleral incision. So here are some iris strands I can cut. The great part about using vitrectomy for almost everything in children is you have an infusion that maintains the chamber. So here’s some synechiae. If it’s tough and you need to cut it, you can put in an MVR blade. I’m just cutting that. It wasn’t breaking for me, so I’m trying to cut that open a little bit. Okay. That looks pretty good, actually. So if you notice, after I released all the synechiae, the iris came together a little bit. That’s enough sulcus. So we’re good, actually. Put some viscoelastic, open up the sulcus area. Follow the scleral incision. Then once you hit the end, you tilt up. Then you go in. That’s the third step. So here’s the lens. We put in a three-piece lens. No single-piece lenses in the sulcus. So this is a B cartridge. So the way you put it in — you just align it the same way. Don’t bend the haptics. This is a three-piece lens. Make sure it’s seated in. Okay. And make sure that this haptic is still on this side of it. Then you’ll see the lens move forward. When you shoot it in, the rotation is quite different. See how it bends? So you have to rotate it out this way. That’s in the sulcus. See how I’m rotating it back, and slowly I’m rolling it. One haptic’s in the sulcus already, so here I’m going to the optic-haptic junction and just rotate it in. Pop it in place, hopefully. So in children, you have to suture most incisions. Their sclera is too soft. They’re not gonna be sutureless, no matter how small the incision is. I don’t like clear corneal surgery that much, because you have to suture, no matter what. Even if it’s a small incision surgery, you have to suture it. So it’s a nice stitch. If you just want to run one stitch across. So now I’m gonna take out the viscoelastic using the vitrector. I can kick it off. I set my vitrector up to where I can kick it off, so I can use irrigation-aspiration. But the vitreous won’t come forward. So the whole idea in a child is to do a core vitrectomy. And the reason you want the core is because that’s scaffolding for PCO to form or the lens material to block access again. But the vitreous won’t come forward like you see in adults. So that’s usually not the case. But you can use triamcinolone. Just to see the vitreous. If you wanted to. Here there was a little strand of vitreous. I just cut that. So I keep going back and forth between IA and vitrectomy here. And that works very well for me. To make sure I don’t have any vitreous in the front. I use a steroid-antibiotic combination four times a day for about two weeks. If you do a good cleanout of the lens material, you shouldn’t get much inflammation, and they should do quite well. So not to worry about that. And because I buried all my stitches, if I did have to suture my wounds, I would use 10-0 vicryl. I don’t have to take them back for suture removal. And I’m gonna close this conj with 8-0 vicryl, so I don’t have to worry about it. Right now I’m just going to remove the rest of the sutures on the cornea, and that’s pretty much the case. Five years old. Especially with the central visual axis scar. So she has a relatively high risk for amblyopia. So we have to watch her closely. Once this clears in a couple weeks, I will start patching her. Make sure she does not start forgetting to use this eye. The sequence of a traumatic cataract here was perfect. You’ve repaired the ruptured globe first, followed by lensectomy. You need to leave it aphakic until you’re ready to remove the stitches a month later. So this worked out perfectly, the sequence, for this. So now she’ll have a nice secondary lens. We’ll remove all the stitches. So hopefully this will be the last surgery she’s gonna need. All right. Very good. Thank you so much.