This presentation reviews the unique aspects of pediatric cataract and IOL implant surgery, emphasizing critical differences between pediatric and adult patients when it comes to surgical technique, intraocular lenses and postoperative management. The presentation also includes a video demonstration of vitrector surgical technique for children under 5 years of age.

Lecturer: Dr. Daniel Neely

Technical Aspects of Pediatric Cataract Surgery (Live Training Event with the Orbis Flying Eye Hospital) 03/28/2017 from Cybersight on Vimeo.


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DR NEELY: Well, greetings to everyone. It’s a pleasure to join all of you. And this is a first for Orbis and for Cybersight. Today we have the Flying Eye Hospital in Qatar, where it’s about 12:00 noon. And then I’m joining you from my home location in Indianapolis, and then we have the rest of you joining us from around the world. So this is the first time for us to deliver a presentation to the Flying Eye Hospital, remotely. So it’s an exciting new element, adding to our webinar repertoire. Today we are going to talk about pediatric cataracts. And I’ll go ahead and go into my screen share here. As Dr. Maria said, I’ve been out on quite a few programs and I’ve done quite a few consults with all of you around the world, so I have a good feel for the challenges that you face. And this is a tremendous problem. But it mostly boils down to a couple small things. Some very basic technique issues, and then access to patients. Getting to them in a timely manner. Access is difficult to fix, but the technique issues are very simple to fix. And in this course, for the next 45 minutes, we’ll have an interactive dialogue here, where I’ll tell you what I do, and I’d like to hear from you what you do. And then I’d like for all of us to talk about this together and share tips with each other. Because there’s always more than one way to do this. I think that’s a really important take-home message here. There’s no right or wrong way to do this. There are some basic fundamentals. But all of us can learn from each other. And so I’ll be taking questions from you, remotely as well as in the classroom, and we’ll have a little dialogue on this. One of the first things we’ll do is talk about our first poll question. And this is — let’s get a feel for who-all is joining us today. I know we have a mixed group there in the Flying Eye Hospital. But we would like to hear from people joining us remotely. What are your roles? Are you an ophthalmologist? Are you an ophthalmologist in training? Perhaps a nurse. Or an optometrist. And so you can go ahead and register your role here. And then we can go ahead and we’ll reveal that to everyone. In the Flying Eye Hospital, Maria, who do we have there? What does our group look like there?

>> Okay. So… Please raise your hand if you are in eyecare. We have no one here in eyecare. Ophthalmologists? Okay. We have several. I think most. So we will win. In training? Nobody is in training. Nurses? And optometrists? Okay. So most of us are ophthalmologists.

DR NEELY: Okay. And of course, as you would expect, that is mostly our group. And then we have mixed group members, and a few of us are joining us as nurses, optometrists, and ophthalmologists in training. And what we’ll be talking about will be applicable to everyone. Although of course some of the surgical techniques will be particular to the ophthalmologists and ophthalmologists in training. So the three… The four major elements here are the anterior capsule, removal of the lens material, intraocular lenses, and management of the posterior capsule. And I have some questions that have been submitted ahead of time. What I will do is I will break with each of these subsections. Once I finish it, we’ll take questions. And I have some videos to share with you as well today. So please submit your questions, and we’ll talk about these as we go. What we’re going to focus on is: How do each of these four steps differ from adults? So we’ll just dig right into the anterior capsule management. Now, with the anterior capsule, of course you have a couple options. One is the very traditional continuous curvilinear capsulorrhexis. The bent-tip needle cystotome, and forceps, or the vitrectorrhexis. And the vitrectorrhexis is what we want to talk about mostly today, because that’s what’s different, and it’s one way to facilitate — especially cataract surgery in younger children. And the decision as to which of these two techniques I use is usually age-based. And we’ll talk about that. Before we go into what I do, let’s see what everyone out here is doing. Which technique do you currently use when you’re doing an anterior capsulotomy? And we’re gonna restrict this question to just younger children. Because in an 8-year-old, it’s not really different than in an adult. But it is different in a 3-year-old. So what do you do? Do you do a manual tear with a cystotome needle and forceps in a child under 5 years of age? Do you use the vitrector to do a vitrectorrhexis, or do you cut the anterior capsule with some other instrument, perhaps? And we’ll go ahead and take our voting now. Maria, any thoughts from the audience as to what people are doing currently? Anyone want to volunteer what they like to do?

>> Manual tear with… So option number one.

DR NEELY: Okay. Is anyone in the Flying Eye Hospital using a vitrector, currently, for the anterior capsule?

>> No.

DR NEELY: Okay. Excellent. And do we have any poll results? Here we go. And just like on the Flying Eye Hospital, most of our audience is using the manual tear. And so I think this is a good topic for us to discuss. All right. So the continuous curvilinear capsulorrhexis — why do we do that? Because it’s strong. It’s very strong. It’s resistant to tearing. But the problem is, in these young children, in these very young children, the capsule is very elastic. There’s a lot of radial tension driving the capsule to go radial. And so that makes it very difficult to tear a capsulotomy in an infant or a 1-year-old or a 2-year-old. And sometimes even older than that. So I want to go into this a little bit more. You know, when you tear an adult or teenage capsule, you have this tangential direction of pull. Where you’re leading that edge around. And you’re kind of pulling — not towards the middle, but you’re pulling towards the periphery. But on children, it’s almost like you’re trying to rescue the rhexis all the time. And in infants, you’re pulling the capsulotomy back to the middle all the time. So, again, it really is like a rhexis rescue maneuver. And otherwise, that capsulotomy just wants to go out peripheral. So here is… Oh, and before we show you the video, one of the things I like to do, to help minimize these things, is use a very high viscosity cohesive viscoelastic. I like to use Healon GV, in particular, because you really want to keep that lens capsule flat, and push back, to diminish any of those radial forces. And then, again, pulling back towards the middle all the time. And let’s see if we can get our video to run here. And so here you can see that the capsulotomy is going here, but the forceps are pulling way in toward — really across the middle of the lens the whole time. To lead this capsulotomy around in a circle. So obviously that’s quite a bit different than what you’re going to do in an adult. So tips here: Lots and lots of viscoelastic. I think you can’t be afraid to put more viscoelastic in all the time. I think unlike adults, where you might tear this around in just a few grabs of the capsule, you want to regrasp this and redirect it quite frequently. And so you might just be tearing a very few click hours, before you regrab. And this I think is risky, what’s being done right here. Where you have quite a bit of reach, and not grabbing too close to the end of the capsulotomy. So this is why it’s difficult. You can see that this just looks — this doesn’t look pleasant. It’s not round. It was difficult to do. And it’s like you’re on edge the whole time. And this is where the vitrectomy instrument is really quite handy. I will use this pretty much in all children, up to 5 years of age. Some people like it for just really younger children. 2 years of age and less. But what happens is, by using the vitrector, the vitrector cuts. And it takes these little cuts out of the capsule. And because there’s no pulling involved, you’re able to control that and have these kind of jagged edges. But the edges, you’ll see, are all pointing back in towards the middle. So it’s actually quite strong. And here you can see these bites have been taken out of the anterior capsule, and just the anterior surface of the lens. Using a vitrector. There are different vitrectors, and they’re going to have different settings. Some of the more common ones are — some of the maybe older vitrectors, like the Alcon Accurus, which is a fixed. It’s not a variable. By that, I mean the infusion pressure and the vacuum and the cut rate are all fixed with the pedal. So if I’m using a fixed-rate machine like that, I’ll set that at a cut rate of about 250. And then I’ll set that maximum vacuum, rather than aspiration, the vacuum at 250. And just take little bites. And you’re just trying to use just enough vacuum that you can engage that anterior capsule. If you have a variable machine, like the newer ones, like the Constellation, then I do use some different settings, like you see here. But the key concept is to start in the middle and just kind of make this larger. Let’s just go ahead and go to our next slide here and look at this video while we talk about it. Because it’s 5:00 a.m. here, you will see me hoisting this very large cup of coffee quite frequently. So my infant cataracts — I do with a near clear corneal stab incision. Typically just to front of the limbal vessels. I sometimes use an anterior chamber maintainer like this. And sometimes I will use a bimanual technique. But here’s our vitrector. And I’m starting a little bit at the far edge here. You can either start in the middle or at the far edge. Starting at the far edge is sometimes helpful, because it’s easier to engage the capsule as you’re pulling the vitrector back towards you. And you can see it’s just taking these little scalloped bites. And then I kick that cutter off and just go to aspiration now. So you don’t want to be cutting once you start getting into the lens material. But switching over to aspiration now, to do the lensectomy with the vitrector. So you’re using the cutting function to allow you to open the capsule. And then you’re using the aspiration to do the lensectomy. All with the same instrument. When you have an anterior chamber maintainer like that, it allows you to put two hands on the vitrectomy handpiece, and for some people, that feels a lot more comfortable. And then you can see there is some cutting going on. But of course, I’ve got the port facing upward when I do that. Sometimes you’ll find the lens material is rather dense, and doesn’t aspirate quite easily. And that’s when it’s nice to be able to kick that cutter on like this. And it’ll just chew it up and pull it in. But, again, only when that port is facing upward. So this is a very nice, efficient technique for taking the lens out. Especially if you’re then going to use the vitrector to open the posterior capsule, which we’ll talk about later. All right? And this was just a posterior lenticonus, lentiglobus-type cataract. So that was kind of a combo there, of removal of lens material and the anterior capsule, all at the same time. Let’s see if we have any… Do we have any questions from the audience at this point in time?

>> No, I think we’re good.

DR NEELY: Okay. I want to show you one little… Detail about this. And I’m drawing a little picture right now. So when you cut the capsulotomy with a vitrector, that’s what it looks like. All right? And that looks jagged, compared to a continuous curvilinear capsulorrhexis that you might tear. But the key element here is that I’d like to point out that you see how the tags, when you cut it — these tags are all facing inward. Because those tags are facing inward, the capsulotomy is strong. And that’s different than if those tags were facing outward. All right. So then let’s talk about the lens material. I’ve shown you that I like to use frequently the vitrector, but I’d like to hear what other people use to remove lens material. And again, I’m going to restrict this to younger children. What are you doing in this youngest age group? Less than 5 years of age. So this is our next poll question. I see that we have one question submitted remotely. And I will look at that while we’re answering the poll question. Do you like to do manual I/A, or like a Simcoe? Do you like to use an automated I/A, like doing cortical clean-up on an adult cataract? Vitrector? Is anyone using a phaco tip? I know some people will use phaco tips. And while we’re looking at those poll questions, I have a question from an audience member. And that question: What is the appropriate size of the capsulorrhexis? And I think that’s a good question. The appropriate size of the capsulorrhexis — you don’t want it too small. Because sometimes these capsulotomies will become phimotic, and they’ll shrink down. And then you have something that’s very small to work through. It works okay from a vision standpoint, usually. But it’s hard to do retinoscopy through. So the ideal size is a little bit smaller than your IOL optic. You don’t want it to be the same size as the IOL optic or larger, because then when you’re doing the posterior capsulotomy later, a lot of times that lens implant is wanting to come forward. Especially since children have such elastic sclera and cornea. A lot of times their wounds will leak, and the chambers will shallow, and it pushes that lens implant forward. So you would like to have that capsulotomy small enough — 5 millimeters — so that that lens is stable back there and not pushing forward. Let’s go ahead and answer our poll question now and share the results with everybody. And so most of us are doing manual I/A. We do have some using the automated machine, and then a small percentage, about 14% of you, are currently using the vitrector, and no one is using the phaco. I think people that use a phaco tip — you can get away with that if you’re really a good surgeon. I think it’s quite dangerous, though. And I have never, ever done a pediatric cataract even in a teenager that required anything other than aspiration. If you’re using aspiration, and you have trouble getting the lens to aspirate, you simply need to get an aspiration handpiece or tip that has a larger port on it. Those ports, the openings at the end, come in different sizes. They can be 0.2, 0.3, 0.5 millimeters, and just get a larger one. Double checking the rest of our questions here. This one has more to do with posterior rhexis. I’ll come back to this in just a little bit. And let’s keep moving here. So aspirating the lens material… Again, there are different sized ports if you’re doing an I/A type. If you’re using a vitrector, especially in these younger children, you generally want the larger sized vitrectors. So 20 or 23 gauge. Anything smaller than that, the 25s and 27s — it’s very hard to get this thick lens material to go through it. And also, the viscoelastic, if you’re using something like Healon GV, it will plug the vitrectors. It will plug the infusion lines. And so just be aware of that. That sometimes you need to flush these things out, if it seems like things are stuck. Older children — once you get above 5 years of age, for me, the technique is identical to an adult. At least, the aspiration portion of an adult cataract surgery. Bimanual. In the recent year or so, I have switched over to a bimanual technique. And this is from Ed Wilson at South Carolina, a world famous pediatric cataract surgeon. And he’s doing a very difficult cataract here, with a PHPV. But you can see he’s got the infusion line in his left hand over here, and then he’s got the vitrector in his right hand, over here. And the nice thing about this — it’s a little more challenging. Because you have to pay attention to more than one instrument at a time. But it allows you to switch these two. Because the hardest part of any cataract is getting the lens material underneath your vitrector or underneath your aspiration handpiece. So right here, this subincisional lens material — that is always the most difficult. I like to start with it, so I can get it out of the way first, while you have all the other lens material holding things back. But if you have this bimanual technique, you can start in this position and do the easy stuff across to the other side of the eye, and then you can switch. You pull out the left one, and you put it in on the right. You pull out the right one and put it in on the left, and now you can use your vitrector to reach across with your left hand and do the easy stuff on the opposite side of the eye there. I think that’s the real major advantage of this bimanual technique, once you get a little bit comfortable with that. In children, older children, so this is not the best resolution, but here you can see I just have a standard automated I/A tip, and this would be a cataract that I would say is in an 8-year-old child. We’re just gonna aspirate it. It’s hard to see the port, but we are using a larger sized port tip there, to aspirate that thicker lens material. But this is all I do. I just tear the rhexis, and then take out the automated I/A from the anterior segment machine, aspirate the lens material, put in an IOL, and done. So that is very similar to an adult cataract. Intraocular lenses. All right. Let me double check our questions. Any question about aspirating lens material from the Flying Eye Hospital audience?

>> We’re okay, Dan.

DR NEELY: Okay. So we’ll continue on. Intraocular lenses. This is always a hot topic. So let’s take a little poll here. Our audience: Do you currently place intraocular lenses in infants? Because this is really where it’s not clear what the right answer is. In a 2-year-old, I pretty much always will put a lens implant in. And certainly in an 8-year-old, in a 16-year-old, I always will. But in these 1-year-olds and these 6-month-olds, that’s where there’s not really a right or wrong answer. So what are people doing? Tell us if you never put a lens implant in an infant. Do you do it only if it’s unilateral? Or do you just do it all the time, if it’s unilateral or bilateral? And then we’ll share these results with you in just a second.

>> Over here, Dan, it’s option number 1. No, almost never.

DR NEELY: Almost never. Okay. And for a long, long time, that’s what we’ve done. And here you can see for much of our remote audience, it’s almost never as well. 50% almost never put a lens implant into an infant. And then we have another 30% doing it if it’s unilateral, and 20% doing it pretty much if all cases. And we’ll talk about: What are the factors that influence this? And again, I think you need to emphasize — there’s no right or wrong answer. But there are factors that influence your decision. Those factors are the age of the patient, big difference between a 6-month-old, versus a 6-year-old, as to how they do. Bilateral versus unilateral. For me, that’s a big one. Size of the eye. Corneal diameter. So if the corneal diameter is less than 10 millimeters, these lens implants that we use are all pretty much standard sizes. They’re adult sizes. There are no pediatric lens implants that are smaller. So if the lens implant or if the corneal diameter is less than 10 millimeters, a lot of times, these lens implants don’t fit. Especially if it’s kind of a rigid one-piece, like a lot of us use. Because they’re inexpensive. Now, if you have a super flexible lens implant, then you can put them in a smaller eye, but I’ve seen implants where the eye was so small that the haptics were coming back onto the optic. They couldn’t even open. So a small eye is not really a great candidate. Plus small eyes like that are really at high risk for glaucoma later on. So it’s just kind of a recipe for having trouble. Availability of aphakic glasses or contact lenses. Now, for a lot of you out there, this is a big deal. If you can’t get aphakic glasses and you can’t get replacement aphakic glasses or you can’t get aphakic contact lenses, then there’s a lot greater incentive to do lens implants. Because otherwise, this kid has no chance. If they’re just aphakic all the time, then you might as well not take the cataract out. So parental resources and abilities — that’s the same thing there. For me, I can get contact lenses and glasses easy. But sometimes I have parents who can’t afford to buy those things, or they just can’t handle it. They’re just not up to the task of dealing with the contact lens. The infant aphakia treatment study, which was done in the United States — this was children getting lens implants less than 6 months of age. And it was unilateral cases only. And what we learned from that was that the visual outcomes seemed to be about the same with unilateral cataracts in infants getting lens implants, versus a contact lens. But that the surgical reoperation rate and the surgical complication rate was higher in the intraocular lens implant group. Now, so a lot of people in the US, at least, backed off on doing unilateral cataract IOL implants in infants. But that’s really… You know, it wasn’t that big of a difference. And if you’re faced with not being able to optically correct someone, or not knowing if you’re ever gonna see them in follow-up, then a lens implant may not be the worst thing if the world. So I think you have to take all these things into consideration and decide what you think is right for this — for your setting and for your family. When you do use a lens implant, there are some considerations. And some of these boil down to cost. You know, sometimes we just don’t have a choice. We have to use whatever is cheap and available in our hospital. If you can pick, then I have some certain preferences. And some of these have to do with the materials and the flexibility. We also have to think about the target refractive error. And a lot of you submitted questions in advance about target refractive error in intraocular lens formulas, and let’s touch on that, because that’s a big deal. My two favorites for putting in the posterior capsule are these one-piece acrylic, and these two models were made by Alcon, but there are others out there. I like these because they’re extremely flexible. Perhaps square edges help limit posterior capsule opacification. They go through small incisions. The thing that I like of all these features, the thing that I like the most is that these lenses open slowly. So if you have an open posterior capsule, because you’ve opened it, or because there was a defect there, like a posterior lentiglobus, or if you have a vitrectorrhexis anterior capsulotomy, or you’ve got a radial tear in your anterior capsule, you don’t want to be jamming a big old lens implant in there, or having something that’s gonna open violently. That just turns a bad situation worse. These lenses — you fold them up, and those haptics will stay on top of the optic, and the optic will stay folded for a long time. And you can place it in the bag, get a Sinskey hook dialed into position, and still those legs are just slowly opening. And it gives you a lot of control over placing this implant. So I do have a bias. These are my two favorites. However, the three-piece lens, which is what I used 20 years ago, when I was in residency, is actually a really nice lens too. Again, it’s foldable. The thing about this is that it’s got these thin haptics. Now, the thin haptics are a double-edged sword. The thin haptics let you put this in the sulcus. Those other two lenses, those monoblock, one-piece lenses — those haptics are really thick, and it’s not recommended to put those in the sulcus. You might be able to get away with it, but you’re asking for trouble in terms of chafing on the iris. Stability. These thin haptics — so they allow you to put it in the sulcus, but sometimes they also are fragile and they’ll crimp. And there’s nothing more aggravating than getting a lens in the eye and seeing that one of the haptics is broken. It is injectable. So if you have the right cartridge, you can inject these. And that’s probably a nice option. One of my favorite things with this lens implant is to do optic capture. So if you’re one of these people who is not comfortable using a vitrector, pars plana, after the lens implant is in, to open the posterior capsule, or if you have a posterior lentiglobus defect, or some other open capsule, even in an adult patient, if you have a posterior capsule rupture, what you can do is use this lens and place the haptics in the sulcus, and then tuck the optic back into the posterior capsule. Again, that’s another good reason to have an anterior capsulotomy that’s smaller than that optic, because you want to be able to have it — keep that optic back in the bag with this optic capture technique. So I think that’s a real plus for this lens. And I know some people — one of my friends, Ken Nischal, likes this lens, and he uses it as his primary all the time, because as he says, you never know what you’re going to encounter, once the lens is in the eye. And it gives him a lot of flexibility to do several different types of placement. Multifocal IOLs. Multifocal IOLs in general are not recommended. Now, some people may disagree with that, and some people use them all the time. But the problem here is — if you put lenses into a child, that eye is still growing. So the advantages of the multifocal IOL are almost immediately gone. Multifocal IOL — if you’re able to target emmetropia, and now have a multifocal range, and the eye is not gonna grow, that works. So a teenager or an adult — fine. No problem. But you put this into a 2-year-old, it’s gonna be in focus for about 2 months, and then it’s out of focus, and you still need glasses and you still need a bifocal. So you didn’t really gain anything. And also, trying to do retinoscopy through all these multifocal rings is not easy. The reflex is very distorted. And so these are the reasons why multifocals are generally avoided in younger children. IOL calculations — another big problematic area. First of all, in order to do these in a lot of the younger kids, you need a handheld keratometer. And there aren’t very many models of these, and they’re hard to come by. So a handheld keratometer, or you can take a traditional Goldman keratometer and mount it vertically on a stand, to where you can use it on a supine patient. But not all of us have that option. A-scan biometry. Immersion or contact works fine. We know from adult studies that immersion is more accurate, so it’s preferable. I’ve looked at this in pediatric studies, and it didn’t really seem to make a big difference. Why did immersion not really make a difference? Because there’s so many variables in these kids. There’s a lot of slack in the system, and it just buries that advantage. But it is better. And sometimes you can get better readings on — especially small eyes or abnormal eyes. If you’re using immersion and it doesn’t work, switch to A-scan — to contact, and vice versa. I will use them interchangeably. It seems like sometimes one eye will read and the other won’t. Calculation formulas. I’ve also looked at this. In my patient population, I’ve found no real advantage to any of the lens calculation formulas over the other. So there might be a slight advantage to the Holladay formula or the SRK-T versus things like the SRK-2 or the Hoffer Q. And a lady by the name of Deb Vanderveen has found that maybe the Holladay was a little bit better, but there’s not a huge difference here. Now, why are there not some big advantages? Well, you know, the problem is: All of these lens implant formulas are designed for adult-sized eyes, and they’re designed for eyes where you’re targeting emmetropia. And we’re frequently not doing that. And that’s our refractive target. Which is our next little topic here. There are two schools of thought. What target do you give for the lens implant? Well, some people say target emmetropia even in a 2-year-old. That way the eye is in focus when they’re sensitive to amblyopia. And you get better amblyopia treatment early on. Then later on we’ll deal with the high myopia that results. I would say that that is not the most common school of thought — at least in the US. And most of the cataract surgeons that I know do this targeting residual hyperopia. And what does that mean? That means you’re going to anticipate that the eye is growing. And so you’re going to leave the — you’re going to target leaving that child hyperopic. And you’re gonna correct the difference with glasses or contact lenses. And then as that eye grows, the lens implant power becomes closer to what’s needed as a teenager or adult. And so if you look at this — and this is what was done in the United States infant aphakia treatment study. In the infants, they targeted leaving them hyperopic. So instead of targeting emmetropia as your outcome, you were making these kids a +7 or a +5. And then correct the difference with glasses or contact lenses. And then that eye would grow, and then later on, they wouldn’t need anything. So you can see that the younger they are, the higher the residual refractive error which is targeted, and then as you get to be about 8, 9, 10 years of age, you’re going towards emmetropia as your target. So a teenager — eye will target emmetropia. And this is a rough guideline. This is not a strict guideline. Okay? There are always other factors that come into play here. You don’t know how much this child is going to grow. You don’t know what the influence of having myopic parents might be. Secondary effects of glaucoma. Axial length changes, corneal curvature changes, this strange process of emmetropization, where eyes grow at a variable rate, trying to negate refractive errors. All of these things are factors that you have some concept of, but you can’t control. And that’s why it’s not really clear what the right targets are. All right. So… Marie, any questions from the audience? I’m going to review our remote audience questions here. I have one question about using dyes to stain the capsule for vitrectorrhexis. If I have a white cataract, or a membranous cataract, I will use Vision Blue, or one of the other vital dyes, to stain the capsule. I think it’s quite helpful. If the capsule is clear, not really a big advantage to it. So I would say that the answer for capsular staining is: If it was an adult cataract you were gonna stain, it’s the same. Someone has a question about elaborating on PFV versus PHPV. So these two abbreviations. PFV, persistent fetal vasculature, and PHPV, persistent hyperplastic primary vitreous — these are the same condition. Just the terminology has changed to PFV, persistent fetal vasculature, in recent years. Essentially you have a vascular membrane, which is on the posterior side of the lens. And sometimes there’s a stalk going to the optic nerve. The problem with these eyes is they tend to be very small and prone to glaucoma, and also, they tend to have traction on the ciliary processes, and so even in eyes with poor vision potential, we like to take these membranes off, so that they don’t cause contraction of the ciliary processes, and that can lead to phthisis and loss of the eye. I have a question about choice of incision. Clear corneal or scleral. I think it doesn’t really matter. I use clear corneal, because I have access to the folding IOLs. And a 3.2 millimeter incision, closed with an absorbable suture, through clear cornea, in an infant, has about 0.5 diopter of astigmatism. If you have to use a one-piece non-folding IOL, I would put it through a small scleral tunnel. The question about: Do you recommend the clear intraocular lenses or the yellow-tinted intraocular lenses? You know, I honestly don’t think it’s a big deal one way or the other. All of these lenses have UV blocking built into them, and I think that’s the big deal. But that doesn’t mean that they have to be tinted. My hospital has the yellow ones. I don’t think it really matters. I would be comfortable with using either one. At what age do you put an IOL in an infant? Well, depends. Like we’ve said, I’ve put them in as young as three weeks of age. And the child did great. But I think that there’s not an absolute answer to that. I think you just have to make that decision based on all those factors we talked about, and it’s really a case by case basis. All right. And I’m gonna go back to this next section, so we can see a few videos. We have until about… We have about another 15 minutes. So we’ll keep moving here. We don’t even have that. We have less than that. We have ’til about… 5 minutes. So let’s keep rolling. All right. I’m gonna skip the poll question, so we can save a little time here. Why do we open the posterior capsule? It’s because they all become opaque. Here we go. We’re at 5 years of age. Or, rather, 5 years of follow-up. 60 months postcataract surgery. And you can see the capsules are crystal clear at first, and then within just a couple years, right here, half of them are opaque. And then within 3, 4, 5 years, all of them are opaque. So unless you think someone can sit at a YAG laser, you really need to open that posterior capsule. And for me, that cutoff, again, is about 5 years of age. If someone is under 5, I will open the posterior capsule. If someone is older than 5, I will leave the posterior capsule intact. Some people will open the posterior capsule on all children up to 8 years of age. But I think it really just depends on what your options are for opening that posterior capsule afterward. Even if you think the person — the kid could sit at a YAG laser, sometimes these posterior capsules are so thick that they’re almost impossible to get through with a laser. When you’re opening the posterior capsule, it doesn’t really matter what size vitrector you use. Because I do the lens with a 20-23, I just keep using one of those. But you could switch to a smaller vitrector. And keep in mind that when you are now working in the vitreous or the posterior capsule, you want a very high cut rate. So the cut rate is a minimum of 500. And I usually will use somewhere between 1250 and 2500. Faster is better, as long as it will engage the capsule. Okay? And then the aspiration range is anywhere from 0 to 300. And that’s the vacuum range, actually. And then if you’re using an Accurus or something fixed, it’s about 100. All right? So I like to do this through the pars plana, after the lens implant is in. That’s intimidating to some people, but I find this works quite well in terms of lens stability. Pars plana incision — these kids are small. There may not even be a pars plana yet. There might be just a pars plicata. So you can see in a child less than 1 year of age, I’m making that entry only 1.5 millimeters posterior from the limbus. And then as they get a little bit older, we start creeping that incision back a little bit further. Even at 4 years of age, we’re still not more than about 3 millimeters back. You want to make sure you’re aiming very posterior, so you don’t hit the edge of the capsular bag. I keep the anterior chamber maintainer. And so one of the very first things we want to do is get flow between the front and back of the eye, so we’re opening the posterior capsule centrally. Right away. And the posterior capsulotomy is then enlarged, so that it’s about 4 millimeters or so in diameter. And I find that using a vitrector allows me to control that. The other way to do this is to tear it manually. Before you put your lens implant in. Here we have the lens implant in already. And we’re working behind it. And I think that’s the advantage of the vitrector type pars plana approach. Bimanual — if you’re using the bimanual technique, you can do the same thing. Leaving the anterior chamber maintainer here. And then our vitrector in the back. And I’m going to skip this video and go to our next one. Well, let’s watch this for a minute. Because this is the vitrector technique. Let’s get our lens in. All right. So the lens is in. I opened up the conjunctiva. And just do a little bit of cautery here. Measuring back. And we’re probably gonna be about 5 minutes over when we’re finished, between the next couple videos that I want to show you here. Want to make sure we can see our blade as we go in, and then we’ve got our vitrector, and immediately we’re gonna open this area right there, where that posterior lenticonus, lentiglobus was. One key piece of advice about posterior lentiglobus: You don’t want to do hydrodissection, because it will blow out that capsule area right there. So that’s the only time I don’t do that in children. But here you can see — we’re just trying to get a little bit of an opening there so that our fluid can go from the front to the back. And then we’re simply going to enlarge that. And the advantage here is that the vitreous likes to follow the instruments. So if you’re doing this from the front, through the corneal incision, before you put your lens implant in, a lot of times that vitreous wants to come to your corneal incision, and then you’re putting your lens implant in, and the vitreous is getting around your lens implant. Those things aren’t insurmountable, but you just have to pay attention to them. But that is the reason why a lot of people like to do this pars plana approach. All right. Dr. Nihal Shakankiry in Egypt — I’ve seen her do these surgeries before, and this is a recent video she sent us. She is perhaps the most elegant pediatric cataract surgeon I have seen. So I want to share this new video with you. So she did a lens implant incision there, and she did a peripheral incision, and now she’s just going in with the small incision rhexis forceps, and she’s tearing her capsulotomy. And you can see she’s rather adept at it. And even here, though, she’s still kind of pulling it in towards the middle a little bit. And here she’s doing a little hydrodissection. Look how she mobilizes that lens nucleus. I like this move. So she’s got that dialed out of there already. And she’s got the bimanual technique. So she’s got her aspiration in her left hand and then she’s got her irrigation over here on the right. And these instruments are from Bruder. I just purchased these recently. I really like these. That aspiration tip she’s using has kind of a rough surface to it. And so it helps to mobilize the lens material out of there quite nicely. So she likes to open the posterior capsule before putting the lens implant in. And this is the part that I want to share with you in particular. Here she’s going in, putting her viscoelastic in the posterior capsule, and now she’s going back in with her cystotome, and she’s going to tear the posterior capsulotomy manually. So she’s gonna make a very small opening in the posterior capsule. And then she’s injecting her viscoelastic through that opening, to lift the posterior capsule off of the anterior vitreous face, and now she’s gonna tear that capsulotomy. And if someone didn’t have access to a vitrector, this is one way, of course, to open that posterior capsule. Doesn’t get rid of the problem that the anterior vitreous face is still there. And that the cells can migrate across that. And, in fact, you see she likes to use a vitrector and go in and clean up that anterior vitreous face. Because that vitreous face, it’s sitting there, and the lens epithelial cells will migrate across — much like they can the posterior capsule. But opening that posterior capsule manually will be better than nothing. Because otherwise it’s just gonna be a super dense secondary opacification. So she’s got a very nice anterior and posterior capsulotomy. You can see she’s left the posterior one smaller. And that’s because you still need to put your lens in. So you don’t want a great big dissect back there while you’re placing your lens. And for those people also, if you have a vitrector, but you’re not comfortable going pars plana, then this is a nice way to get into the technique of using the vitrector from the front. So a little more viscoelastic separating her anterior and posterior capsule leaflets. Getting her lens. And I’ll just kind of get you up to that… Okay. So lens injection. So this is the part that I think is a little bit dicey. It’s why I like to go pars plana. But you can see she’ll handle this quite nicely. Making sure she gets that leading haptic in between those capsular leaflets. She’s torn these capsulotomies manually, so the anterior one at least is going to be very strong. That posterior capsule is still going to be a little bit… You know, they’re a little bit fragile. And you just don’t want to hit them with the edge of the lens. So here she’s got the leading half in, and now she’s going to tuck in her trailing haptic. And so I think this is a very nice technique that people want to get into the habit of opening a capsule and doing a vitrectomy can do this. And I’m gonna roll ahead and we’ll take a few more questions. Sutureless — I suture all of my sclerotomies, and it’s because kids’ sclera tends to leak. Kids’ corneas tend to leak. I like to use an absorbable 10-0 or 9-0 vicryl on the cornea, and then I use a 9-0 nylon on the sclera. I just think there’s a risk of endophthalmitis. You can use anterior segment machines. The settings are up right here. I won’t really go into this, but each of the machines will be different. You have to control the aspiration rate. That’s the one thing that’s different than using a vitrector. So you have the cut rate, the vacuum, and the aspiration flow rate. And that’s the part that gets a little bit dicey with the anterior segment machines. Subluxated lenses — I like to use a vitrector for these. We’ll touch on this quickly. Here you can see we’ve made a small cut. And we’re aspirating the lens through that small incision in the lens, so we’re not doing an anterior capsulotomy. We’re just making an opening big enough to get the vitrector in there, and to cut and aspirate the lens material out. This allows you to do the lensectomy without pulling on the vitreous. And it allows you to — you can see we’ve made the incision where the lens was subluxated the most. So that you’re reaching up across the iris on the opposite side. So it allows you to reach the lens material which is behind the iris still. And by using a vitrector and aspirating the lens within the capsule, and then using the cut function to remove all of the lens capsule, that allows you to avoid aspirating and pulling vitreous and getting these retinal detachments along the vitreous base, which has always been the big problem with Marfan’s syndrome and subluxated lenses in general. All right. So I apologize that I had to speed it up there a little bit. But the good news is: All of this stuff is available on Cybersight. Currently we have a manual available. This manual, pediatric cataract manual, has all of the step-by-step instructions for doing these procedures. So it’ll walk you through it, so you can learn to do this and have all the measurements and references that we gave there. And also we have a teaching manual online program, which we launched soon, and that will have all the new videos available. And so be looking for that within the next few months. All right? I’ll look for the questions here before we wrap this up. Any questions from the classroom? Here’s a question about: Which is the best handheld keratometer? I’m only aware of one, which is the Nidek. Is it necessary to do a posterior capsulotomy in traumatic cataract? I think again that decision is only based on if the posterior capsule is opaque or if the patient is very young. I tend to see it necessary in some traumatic cataracts. I tend to see it necessary in posterior lentiglobus cases, because they get to that cone, and the cone is cloudy, and you need to remove that central opacification.

>> Dan, we have a question here.


>> They ask: What kind of lens do you prefer to use in patients with uveitis?

DR NEELY: None. So I think if someone has active uveitis — so we see this most commonly with the juvenile idiopathic arthritis patients — I think that you don’t want to put a lens implant in, unless they’ve been quiet for a long time. You can sometimes get away with that. But if you put a lens implant in someone with active uveitis, you’re just asking for a dense membrane, and ending up with a phthisical eye. So I like to see them be quiet for more than just months. I like to see them be quiet for a year or more. And I hit them heavy with steroids, when they get a lens implant. So if someone has a uveitis-induced cataract, I would take it out and leave them aphakic, and I would use aphakic glasses or contact lenses until that eye has settled down.

>> And if you put a lens in, and they have been quiet for over a year, what type of lens do you prefer?

DR NEELY: If they’ve been quiet, I don’t think I have a preference. Yeah. I don’t use anything different than my standard lens. I’ll hit them with some oral prednisone pre-op, and taper it off postoperatively, and I might have the rheumatologist bump up their systemics. Otherwise… But I don’t use a particular lens for these patients. Okay? Okay. Well, I appreciate everyone’s time. And we’ll let everyone switch out, and we’ll get ready for our next group. Thank you.

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March 28, 2017

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