This is a cataract extraction surgery in a 7-year-old boy with posterior capsular cataract, with a history of congenital cataract. The lens was extracted carefully and an IOL was implanted in the capsular bag.
Surgery location: on-board the Orbis Flying Eye Hospital in Trujillo, Peru
Surgeon: Dr. Stephen Lane, University of Minnesota
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Dr. Stephen Lane: This is a 7-year-old young man with a history of congenital cataracts and I think you can probably see very clearly that he’s got a very dense posterior capsular cataract and probably this represents a posterior polar cataract. His vision is poor. This is, he actually has this bilaterally.
So, we are operating on his right eye today and what I’m going to do is, I’m concerned that because it’s a posterior polar cataract, that I may very well have to do something to the posterior capsule, either because there’s an opening in the capsule from its posterior polar cataract or that very dense plaque that you see, we will not be able to peel off and that will have to do a posterior capsulectomy. To do that, I’m making a little larger peritomy because I may have to do a vitrectomy through the pars plana and, probably will be somewhere over here will be my entry point and if I do have to do that, it’s easier to do the dissection ahead of time rather than do it once the eye has already been opened and operated on. So, we’ll plan ahead. Hopefully this won’t be necessary to utilize but if it is, we’re ready for it.
And so, like any young child he has a very thick tenon’s. So, I’m going to do a scleral incision, I should stay just slightly behind the blue white junction.
We’ll be putting in a suture because this is a child and I’m concerned about eye rubbing.
And so we’ll just do this scleral tunnel type of incision.
I’ll make two side ports and again we may use by bimanual. Now this isn’t going to require much phaco energy because it’s going to be a very soft lens.
Now I’ll take the viscoelastic and this is viscoat.
And so now we’ll enter with the keratome, we will enter the anterior chamber with a keratome. And I’ll just get the capsulorhexis started. Now remember this being a child will have a very elastic capsule and so we’ll start once again somewhere toward the middle. And then we’ll switch to the capsularhexis forceps. And so we’re going to try and make the capsularhexis relatively small.
No hydrodissection and we don’t want to Hydrodissect because if there is a opening in the capsule, we can blow right through the capsule by hydrodissecting. We want to be very gentle with this and the last part that we want to do is that central area where you see the posterior capsular opacity. It is not perfectly round but not too bad.
Now because this is very soft, we are going to try and just aspirate this with irrigation and aspiration, rather than use any phaco. And so you can see I am working out toward the edge and we’ll work peripherally toward the center. And you can see it’s very soft so it’s aspirating quite nicely.
You can see that lift it off. And so because it lifted off, we will go ahead and remove it, it’s free from the posterior capsule.
I think that the co-axial works better in this case than bimanual although bimanual is not a bad technique, if there was some residual cortex that needed to be removed under the incision or something like that. I will be very careful in polishing, probably one of those things that you would best be just leaving alone. Try and get as much of the opacity as possible but you can see it’s perfectly intact and very clear. Now the other thing that I’m going to do that’s a little different than usual is that rather than just pull out of the eye is, that I’m going to insert OVD right now,
so that there won’t be a collapse. And that way there’s no collapse of the eye, that might if there was a weakness in the capsule caused the capsule to break.
And so now we will put the lens in and you can visualize the lens, you should always take a look at the lens in the cartridge to make sure that the orientation is correct and that the haptics are tucked.
And so, I like to just rotate these lenses a little bit. Actually, you know what I’m going to do.
I’m going to use, let me have the suture first and then we’ll go in between the suture to remove the viscoelastic.
We will use a suture, this is 9’0 vicryl, so it will dissolve on its own, it won’t be necessary to remove it. And so again it’s easier to put the stitches in with the viscoelastic in place that forms the eye. So will remove the viscoelastic from the front of the eye. And then we’ll come down and nudge the lens, come up underneath and remove the viscoelastic and a little of the pigment that was there and re-center the lens. Will take the BSS in a syringe, hydrate the incisions. Fortunately, we didn’t have to use these so there’s not much, mainly we will use this to fill.
The question was when should we, when should the other eye be done? And I think ideally the next eye should be done at about a week. And I will use one more vicryl to close the conjunctiva.
Question: Just one question. Why do you use to two paracenteses?
Dr. Lane: Because I was anticipating having to do bimanual I&A if I needed it. And that’s why I always do two paracenteses because I anticipate that I’m going to probably use that most often. But in this case, it wasn’t needed.
July 26, 2017