This is a case of long anterior zonules with pigment dispersion glaucoma and a visually significant cataract. It was decided that the patient required cataract extraction and we decided to perform concomitant STREAMLINE® SURGICAL SYSTEM Canaloplasty to decrease intraocular pressure. In the setting of long anterior zonules, the capsulorhexis should be smaller to avoid the anteriorly positioned zonules which can redirect the leading edge of the rhexis. This video shows the proper technique for both cataract surgery as well as STREAMLINE® canaloplasty.
Speaker: Dr. Malik Y. Kahook, Professor of Ophthalmology, University of Colorado, USA
This is Malik Kahook from University of Colorado, and I’d like to present a case I recently did with our glaucoma fellow, Haran Gabrijesus. Titled visually significant cataract with long interresonules and pigment dispersion.
I’m going to focus on how long interreson influence cataract surgery, but if you wanted to learn a little bit more about the specifics of long and horizontals, please go to my YouTube channel and see a full talk on the topic.
It relates to cataract surgery, long anterior zonules encroach more than one point five millimeters onto the anterior capsule relative to the equator of the lens. This can sometimes be several millimeters more than the usual one point five millimeters. And you can imagine that this will influence the creation of the capsular exos as the leading edge of the anterior capsule might actually be redirected by these anteriorly displaced samuels. In order to overcome this, One typical technique is to create a smaller capsular axis than as usual. This could range in size from three and a half to four and a half millimeters. And I’ll show an example of that in the upcoming case.
So we start off as usual by creating a paracentesis.
We then use trypan blue. And the reason for this is if we respect any issues with creation of the capsular axis. It’s good to have great visualization of the interior capsule.
The tri pan blue is then removed from the interior chamber followed by injection of a dispersive viscoelastic.
A two point four millimeter keratome blade is then used to create a clear corneal incision, and this is followed by oration of a capsular axis with a cystotome and duet forceps. This is sped up, of course, but the point here is frequent regrasping of the anterior capsule, and also making sure that we don’t direct the leading edge into the zonual. So this is about three and a half to four millimeters in size. Followed by hydride section, and then a divide and conquer technique to remove the cataract. Now since this is a smaller rexis, there might be some difficulty removing the quadrants, and I’m gonna slow it down over here just to show you that. So the first quadrant as it’s coming out has to be redirected to the side and then brought above the enter capsule. From this point forward, the cataract surgery removal is pretty routine.
We segment the lens into quadrants followed by removal of the cortex and then Vista lens, twenty one diopters placed in the capsular bag. This particular patient had elevated intraocular pressure compared to goal, and we plan streamlined canaloplasty with four different applications to treat several degrees of the canal.
After the last application, an incisional goniotomy is performed by directing the cannula to the right and left in order to open up the communication between the anterior chamber and the canal. This is an image of the eye before the surgery was started just so that you could see what the episclateral veins look like and that there was no blanching for three hundred and sixty degrees. Now compare that to this image. The important point of what you’re seeing here is that there is several areas of blanching of the episclateral vessels indicating communication between the anterior chamber and the episclural venous system.
The remaining viscoelastic is then removed with the irrigation aspiration.
The wounds are checked to make sure that they’re watertight, and that’s the end of the case. I’d like to point out other educational resources like KEO GT dot com, You can visit my YouTube channel as well as follow me on Twitter and Instagram for more educational material. Thank you very much.