This live webinar will discuss the step-by-step surgical technique of basic, straight forward congenital cataract cases with and without intraocular lens implantation. Postoperative visual rehabilitation will also be discussed.
Lecturer: Dr. Nihal Shakankiry, Professor of Ophthalmology, University of Alexandria, Egypt
DR SHAKANKIRY: My name is Nihal Shakankiry, I’m professor of ophthalmology in Alexandria University in Egypt, and before I start, I would like to thank Cybersight for offering me this opportunity to speak about the congenital cataract surgery, and actually the lecture is dedicated to the young ophthalmologists and residents. Congenital cataract is not a simple irrigation/aspiration surgery and an easy surgery. You have to be extensively meticulous and careful when dealing with these young angels in order to perform a cataract surgery without complications. But there are a certain few tips I want to discuss with you before the surgery. You have to go for proper systemic evaluation. Because one third of bilateral congenital cataracts are associated with systemic anomalies. It is very important of course to control these anomalies first, and to know the diagnosis. For example, if you see here, this is a baby with jaundice, and there is even discoloration of the cataract with jaundice. And you have to wait until the jaundice disappears, and then you go for the cataract surgery. But if you don’t know that these cases — some of them are associated, for example, with hepatosplenomegaly, together with the congenital cataract or cytomegalovirus infection, so if you don’t know this, you may risk the life of the baby. Another example here, a congenital cataract with a routine lab investigations are normal, but in some cases, can you see here — that is what is called carpopedal spasm. If you don’t know this is hypoparathyroidism, you may risk the life of the baby during anesthesia due to tetany. You have to know what is the etiology. For example, if you have here a sort of oil droplet congenital cataract, and then it changes to total, if you don’t know that this is a galactosemia, when given galactose free diet, the cataract may disappear. If you don’t know that this is galactosemia, you could have done unnecessary cataract surgery. Another baby with a congenital cataract, having here an anomaly in the hand. And with an x-ray, there is absent radius. So if you don’t know that this is a TAR syndrome, thrombocytopenia with absent radii, during surgery, you may face intractable hemorrhage. But when you work as a team, together with your pediatrician and pediatric anesthesiologist, here, a baby a few weeks after surgery, a few months, four years after surgery, six years after surgery with secondary IOL implantation, and eight years after surgery, coming to the clinic for the first time, walking with straight legs. And ten years after surgery, with straight hand and arm. He is not visually handicapped nor physically handicapped. This is the importance of working together as a team. Preoperatively, of course you have to control any septic foci. For example, boils, conjunctivitis, before dealing with cataract surgery. Or even problems — for example, this is a baby with Patau syndrome, surgery was delayed for six months before proceeding with the cataract and glaucoma. And she was the first baby to have a DCR at the age of six months. You have to be sure this is a cataract. Sometimes, for example — this case was referred to us as a complicated cataract. But actually, it is not. UVM revealed that it’s sort of an epilenticular membrane and the lens is crystal clear. So during surgery, it is possible to peel off the membrane. And here you have a crystal clear lens. This is another eye, one year after surgery. This is another eye, as referred as a complicated cataract. And here at conclusion of surgery, you have a crystal clear lens. Also, we should know whether the cataract — when is the cataract indicated? So indications of the cataract surgery. If you can measure the visual acuity and it is less than 6/18, you go for the cataract surgery. But if 6/18 or more, of course, you should not operate. Why? Because 6/18 and the accommodation is preserved is better than 6/6 without accommodation. If the cataract is total, surgery is indicated. If the cataract is associated with sensory squint, esotropia, or exotropia, it is indicated for surgery. If the cataract is associated with nystagmus, definitely there is poor vision bilaterally, so you have to go for surgery. Here comes another indication for surgery, which is resistance to occlusion. For example, when you have the baby with unilateral congenital cataract, and there is no squint, and you cannot judge. When you occlude the normal eye, you find that the baby resists this occlusion, because of poor visualization in the cataractous eye. So it becomes indicated for surgery. Another indication is the obstruction of the central 3 to 5 millimeters red reflex on ophthalmoscopy. This is the 3 to 5 millimeter red reflex on ophthalmoscopy. So when you see here, this is a bilateral congenital cataract, lamellar opacity, but it does not obstruct the visual axis. You may use the camera of your phone to see the red reflex, close the light, and you take photography. Here there is bright red reflex. There is no cataract. And here this is total cataract. Here again, this is bilateral lamellar cataract. But here does not obstruct the visual axis and it is in the left eye. Here it is starting to obstruct the visual axis. This is bilateral lamellar cataract which obstructs the visual axis in both eyes. So it’s a very simple way, in order to know before examination of the child, just dilate the child and take photography. You can even see the morphology of cataract by this way. Here it is a lamellar opacity, with intranuclear calcification. It is a lamellar opacity with intralamellar opacification. Here again with the same way — the child has a total cataract here, and you can see here there is a defect in the other eye. So it’s a congenital cataract with a large posterior capsular defect. So this is a central opacity, but does not meet the central 3 to 5 millimeter red reflex. So it is not indicated for surgery. These are central opacities, but they do not obstruct the visual axis, so they are not indicated for surgery. It does not obstruct the central 3 to 5 millimeter red reflex, so it is not indicated for surgery. But take care. Sometimes peripheral opacities associated with a persistent vasculature may cause a corrugation of the posterior capsule, leading to astigmatism, which is not amenable to be corrected by glasses, so it becomes indicated for surgery. This is a central tiny opacity, less than 3 millimeters. It is not indicated for surgery. But take care. You have to know where is the site of the opacity. This is a tiny opacity. Not indicated. Again, this is a small opacity. But it is indicated. Why? Because the first opacity is related to the anterior capsule. It is anterior polar cataract. Away from the nodal point. So it is not indicated for surgery. But the second one is a posterior polar opacity, related to the posterior pole of the lens, very near to the nodal point, and that’s why it becomes indicated for surgery in some cases. So when you are gonna work pediatric cataract or pediatric cataract surgery, you should have a hand held slit lamp, in order to examine the eye of the child, to know the morphology and the site of the corneal opacity. This is anterior polar cataract which is not indicated for surgery. But take care. You should look at the same time for the posterior capsule. It is associated with a polar opacity of the posterior capsule. They are on the same axis. That is why it was hidden. So you have to focus on both capsules, in order to diagnose any opacity like that. So it is indicated for surgery. This is a lamellar cataract, which is not indicated. And this is a lamellar cataract which is indicated for surgery. But sometimes we have an opacity like that, and we cannot judge, and we cannot measure visual acuity in uncooperative children. So what to do? Here comes the indication, which is poor visualization of the macular area by direct ophthalmoscopy. You look through the opacity by the direct ophthalmoscope to see the macular area and the fovea. If you can see the fovea and the macular area clearly so the child can see you clearly, if you look through the opacity and you cannot see the macular area and the fovea clearly, so the baby cannot see you too. You all know that these types of congenital cataract are not indicated for surgery. The anterior polar cataract, the coronary cataract, and the blue dot cataract. However, we’ve been following cases over the past 27 years. We find that most cataracts may progress with time. Coronary cataract may increase in density. Like that. Or may become associated with other cortical opacities and lenticular opacities, and become indicated for surgery. Blue dot cataract may increase in density over time or may develop another type of cortical opacities that become indicated for surgery. Spoke-like cataract. May increase with time, in extent, and may even proceed to total cataract. Sutural cataract. May be associated with other congenital opacities. Like that. That may increase with time, and here associated with the lamellar opacity, we found that some cases may even develop opacities around the sutures. And may proceed to total cataract. Anterior polar cataract — definitely it is not indicated for surgery. But sometimes it is large like that, and protrudes into the anterior chamber. This is anterior polar cataract, and this is a pyramidal cataract. We call it a pyramidal cataract. If the pyramidal cataract is less than 3 millimeters, it is not indicated for surgery, because it is related to the anterior capsule and far away from the nodal point. But the majority of these cases, they start to develop subcapsular opacities that increase by time, and sometimes they develop vacuolar opacities underneath the anterior capsule, and these vacuoles increase with time and extend circumferentially, obstructing the visual axis, and they become indicated for surgery. So we have to follow these pyramidal cataracts for life, because they may become indicated for surgery in the future. (audio drop) and develop the subcapsular opacity that totally occlude the visual axis and the child came complaining of dense amblyopia. So all cases of pyramidal cataract should be followed. Look at this baby with bilateral pyramidal cataract. A few months later, she developed exophoria in the right eye, and upon diagnosis here, upon examination, we found that she developed a subcapsular opacity. And we did her cataract surgery immediately. Ten years after surgery, she’s perfectly okay. Another point is the anterior polar cataract. You have to go for refraction in these cases. Why? Some cases are associated with what is called lenticonus. Conical protrusion of the anterior capsule. Leading to high astigmatism that may be amblyogenic, and we have to go for surgery. Like for example in Alpert syndrome. Also you should take care of the lamellar opacity. This is a classic lamellar opacity. They usually present with the wide varieties of morphologies. They may have a clear central part or opacified central part. They may be a beautiful disc of diffuse opacities without Reiter’s. Or may be associated with Reiter’s. They may be associated with polar cataract, intralenticular cysts, nuclear opacities with variable sizes and shapes. It may be circular, it may be triangular like that. And even sometimes associated with intralamellar calcification. It may progress with time like that, and may proceed with the double lamellar opacity. Or may present from the start single lamellar opacity, double lamellar opacity, triple lamellar opacities, or triple lamellar opacities with an opacified center. They may present with a wide variety of density of the lamellar opacity. Faint or very dense like that. They vary also in size. They may be small in size or may be large in size. They may vary in the extent of the lamellar opacification. They usually start by faint opacities like that, that are not indicated for surgery. But you have again to follow up these cases closely. Because they may progress. They may develop intralamellar opacities like this. And here seen against red reflex. And even tiny dots — they are done like that, in a lamellar fashion. Also may change with time. They may range from tiny lamellar opacities, dot-like opacities not indicated, and they may increase in density and become indicated for surgery. So lamellar opacity may increase in the extent — you can see here less than half, more than half, three quarters, more than three quarters, proceeding to whole opacification of the lamellar opacity. And diffuse lamellar opacity may increase in density also, proceeding to total lamellar opacity, calcification of the lamellar opacity, proceeding with other types of lenticular opacity. Here it was a lamellar and then changed to total. And they may increase even to intumescent opacities. Like this baby, this child was diagnosed before as having lamellar opacity, which is not indicated for surgery. However, within a few months, she came with a total opacity, bilateral, and you can see here head trauma, because the baby cannot see properly. This is concerning the preoperative examination. If we come to the surgery, we’ll speak about some tips concerning the cataract surgery with IOL implantation. In infants or children where we tend to implant, the aim of the surgery: You want to have 5 millimeter anterior rhexis to cover the IOL optic. 4 millimeter posterior capsulorrhexis, and a good anterior vitrectomy, and then we will implant the IOL inside the capsular bag. This is the ideal surgery. How to proceed? We start by the side port, using MVR knife 20 gauge. And then inject the viscoelastic. And then go with the other side port. Using a keratome, 3 millimeters. Anterior capsulorrhexis. As we said, the anterior capsulorrhexis should be exactly 5 millimeters. Why? To avoid seeing this terrible picture of capsular fibrosis and capsular phimosis. How to do it? We go… If the cataract is total, we stain the anterior capsule by Trypan blue stain, and then we proceed with the microrhexis. Forceps, proceeding doing a 5 millimeter anterior capsulorrhexis. Again, we start by the cystotome. We make a smooth tiny paracentral tear and then we go with the microrhexis forceps. We go tangential, and then we pull towards the center, because the capsule is very elastic. Pull towards the center. Pull towards the center. Until we achieve a beautiful 5 millimeter anterior rhexis. When we have the lamellar opacity, 5 millimeters in diameter, this is a beautiful landmark for the anterior capsulorrhexis. We follow the edge of the lamellar opacity, until we achieve exactly 5 millimeter rhexis. This is another lamellar opacity, 5 millimeters. We make a paracentral tear. And then we go with the microrhexis forceps, proceed out, until we reach the edge of the lamellar opacity. And then follow the lamellar opacity carefully. Like that. Until we make exactly 5 millimeters anterior rhexis. If the lamellar opacity is totally opacified, we can go a little bit outside, to have this 5 millimeter anterior rhexis. Why? As I told you, in order to cover the IOL optic, because the IOL optic is 6 millimeters — but if we have a double lamellar opacity, follow the inner lamellar opacity, because the inner lamellar opacity is 5 millimeters. If we have a lamellar opacity which is 3 millimeters in diameter, we have to go a little bit outward in order to achieve the 5 millimeter or the anterior rhexis will cover the IOL optic. Supposing after IOL implantation we found that the anterior rhexis is small. We have to increase it. How? We cut the edge of the rhexis, and then with the microrhexis forceps, we enlarge it to the desired size. Hydrodissection. With the irrigation cannula, we go underneath the anterior capsule at 6:00 like that, elevate the anterior capsule a little bit and then we inject. We will not see a wave. We’ll see the viscoelastic emerging from the wound. And then we go for hydrodelineation. But we should take care. Look to the morphology of the cataract before surgery. If you look here, you can see an elliptical line. It coincides with a congenital posterior capsular defect, so in these cases it is contraindicated to go for hydrodissection and hydrodelineation. Irrigation/aspiration. Meticulous irrigation/aspiration should be done, following by polishing of the back surface of the anterior capsule. See, these are lens epithelial cells that have to be polished. This part is polished. This part is not yet polished. It has to be polished extensively to have a crystal clear capsular bag. Look here with magnification. We removed all lens epithelial cells. Why? To avoid capsular fibrosis, which may prevent good visualization of the retina if needed later on during retinal examination. And if we don’t polish, years after surgery, despite having anterior and posterior rhexis, lens epithelial cells can grow over the anterior surface of the lens, from unpolished anterior capsule, and sometimes may grow anterior to the IOL and posterior to the IOL. Despite having anterior and posterior capsulorrhexis, that we have to go to aspirate these pearls to clear the visual axis. Posterior capsulorrhexis. There is no role of leaving the posterior capsule intact in children. (audio drop) will lead to posterior capsule opacification in 100% of eyes. Whereas posterior capsulorrhexis, despite the mass of pearls, we’re gonna have a clear visual axis along life. Also, YAG laser capsulotomy in children may be associated with difficulties and complications. It’s not always simple and easy to perform YAG laser capsulotomy in a child. IOL pitting may occur. And IOL cracks necessitating IOL exchange. And sometimes we have to go for surgery. This is a posterior capsule opacification. We go underneath the IOL to aspirate the pearls. And with a cutter, to perform a capsulectomy and anterior vitrectomy to clear the visual axis. So it is better to go from the start for 4 millimeter posterior capsulorrhexis. How to perform? We go with the cystotome, with the bent tip like that. And then we hook the posterior capsule and then tent it, we make a tent like that, and then tear it into a triangular tear. Through this tear, we just approach the edge of the tear, and we do inject viscoelastic into the Berger space. If you can see this halo, this is viscoelastic into the Berger space. If you do this, the posterior capsulorrhexis is gonna be very easy, and you will exactly have a 4 millimeter posterior rhexis. The key of success of this point and the ease comes from what? Here the triangular tear. When you come to inject viscoelastic, don’t go into tear. Don’t dip the cannula into the anterior vitreal space. You inject, and you’re gonna see this beautiful ring. As long as you see this ring, it means you’re in the right space, exactly the right space, the Berger space, between the posterior capsule and the anterior vitreous space. You can perform the posterior rhexis at this point very easily. Frequent reclasping and just a 4 millimeter posterior rhexis. You start… You just put the rhexis like that. And hold the edge of the tear. You go towards the periphery first. It is not elastic as the anterior capsule. Until your frequent regrasping and then here, frequent regrasping. You follow parallel to the edge of the anterior rhexis. Hold it again. Pull tangential. And then, as long as you’re gonna finish it here, you have to pull towards the center. Regrasping. Hold it. Pull towards the center. Look here. You have to pull towards the center. It will be a beautiful 4 millimeter posterior capsulorrhexis. Anterior vitrectomy. Start first with dry vitrectomy to avoid overhydration of the vitreous and avoid vitreous prolapse into the anterior chamber. And then introduce the BSS. The irrigating cannula. There is no need to go for intracameral steroids. Even if you have a vitreous prolapse, you can see it. Here can you see the edge of the posterior rhexis started to go like that? There is a vitreous strand here. There is no need to use intracameral steroids. How to proceed with this case? Go with a dry vitrectomy near the edge of the rhexis and eat up the vitreous. It will turn into a circular rhexis. If it turns into a circular rhexis like that, it means there is no vitreous in the anterior chamber. Another point. You have to go for a very good anterior vitrectomy. I prefer to go even beyond the edge of the posterior rhexis. Why? Because years after surgery, lens epithelial cells will grow over remnants of anterior vitreous space here. Here there was improper vitrectomy at the edge of the posterior rhexis. See? This is improper vitrectomy and lens epithelial cells grow over these remnants, and it may obstruct the visual axis. Despite having posterior capsulorrhexis. But when we go for a very good vitrectomy, lens epithelial cells stop at the edge of the posterior rhexis. Here, beautiful. Posterior rhexis. And even if the posterior capsulorrhexis is small, you’re gonna have a beautiful clear visual axis because the vitrectomy was done properly. IOL implantation. We inject viscoelastic inside the capsular bag. And then we inject single piece intraocular lens, and the key of success here is what? Look here. Inject just underneath the anterior capsule. If the lower haptic is injected just underneath the anterior capsule, then you will implant the IOL easily. It will unfold, and then you proceed with the fork. Lower haptic introduced inside the capsular bag. And then the upper haptic is pushed inside the capsular bag. And here with magnification. The IOL is beautifully placed between the anterior and posterior capsulorrhexis. Concerning the multipiece intraocular lens, we either use the forceps… But take care. If you’re gonna use the forceps, the lower haptic should be guided by a spatula. To lie just posterior to the anterior capsule. And then we push the IOL until this haptic-optic junction is inside the capsular bag. Then comes the upper haptic. Use a Volk to push the haptic midway from the haptic-optic junction and the tip of the haptic. You push it forward until the haptic-optic junction is inside the capsular bag. Leave, the IOL will be inside the capsular bag. Or you may use the injector. Here the haptic, again, it has to be exactly underneath the anterior capsule. Once it is underneath the anterior capsule, you inject the IOL. After unfolding, the second step, you have to introduce the haptic-optic junction. How? Push the IOL inside the bag. Now this haptic-optic junction is inside the bag. Comes the upper haptic. The upper haptic, again, midway between the haptic-optic junction and the tip. With this fork, you push forward. Until the haptic-optic junction, this one is inside the bag. Forward, forward. Leave. The IOL will be implanted safely between the anterior and posterior capsule. Here a lamellar opacity, before. At conclusion of surgery. Lamellar opacity before. At conclusion of surgery. Again. Before and at conclusion of surgery with a cortical opacity. At the end of surgery. Beautiful anterior and posterior rhexis. Again, after surgery here. A lamellar opacity with intralamellar calcification. After surgery, triple lamellar opacity. Beautiful IOL placed between the anterior and posterior rhexis. So you can use multipiece intraocular lens or single piece intraocular lens inside the capsular bag. Let’s see after surgery. A few months after surgery, lens epithelial cells start to grow from the periphery. And here tiny lens epithelial cells — we have clear visual axis. More lens epithelial cells along here. Dense lens epithelial cells, but they respect the visual axis. Can you see here? The IOL, years after surgery, between the anterior and posterior rhexis, and here the lens epithelial cells, localized area of lens epithelial cells. It may be dense. Taking just part of the capsule like that. It may be diffuse. This eye five years after surgery. Can you see diffuse opacification? But with clear visual axis. This is five years after surgery. Can you see these tiny pearls here? And they stop at the edge of the rhexis. Again, five years after surgery, here with magnification. Five years after surgery, colonies of pearls. But we have beautiful clear visual axis. And here ten years after surgery, extensive pearls. But still maintaining clear visual axis. And this is the multipiece intraocular lens. A few months after surgery. A few years after surgery. Lens epithelial cells respecting the visual axis. And 10 years after surgery. Extensive fibrosis and extensive pearls. But again, attaining clear visual axis. Now we can speak about the cataract surgery without IOL implantation. In babies, where we intend to go for cataract surgery only, and fit the babies with aphakic spectacles, the aim of surgery here is quite different. We want to go forward. 6 millimeters anterior rhexis. 6 millimeters posterior rhexis. Combined with anterior vitrectomy. How to proceed? We have here a case of a lamellar opacity. We go through two corneal wounds. I prefer corneal wounds using MVR knife 20 gauge. So this is 0.9 millimeter in diameter. And then we go for the anterior capsulorrhexis. Start by making a small tear. This is a lamellar opacity of 5 millimeters. And I want to make a rhexis 6 millimeters. So we go outside the lamellar opacity. Frequent regrasping. And then… This is a 6 millimeter anterior rhexis. It will be 6. But if we have the opacity, 6 millimeters, so we proceed with the rhexis just at the edge of the opacity. Like that. So this will be 6 millimeters in diameter, anterior rhexis. We polish the back surface of the anterior capsule to remove all lens epithelial cells, to have a crystal clear bag. And then we proceed with the anterior — the posterior capsulorrhexis. As we said before, hook the posterior capsule. Elevate it. Elevate more. Tent it. This is a tent. Increase the tent. More tenting. Until we make this triangular tear. It is very important not to dip the cystotome into the anterior vitreous space. We don’t want to open the anterior vitreous space. Again, we inject viscoelastic here into Berger’s space, and then we proceed with the rhexis. We go out until we reach the edge of the anterior rhexis. And then we proceed with the posterior rhexis. Here the posterior rhexis — but it needs a little bit dilatation. No problem. During vitrectomy you may increase the posterior capsulorrhexis to the desired size. As I told you, the key of success in these cases is during injection, you have to be sure that you are injecting into Berger’s space. So when you see this bubble again, you are in the right space. This will make the posterior capsulorrhexis very easy to handle in these young infants, proceeding with 6 millimeter posterior rhexis, combined with anterior vitrectomy. So to conclude, for surgery, in these infants, 6 millimeter anterior rhexis, 6 millimeter posterior rhexis, combined with anterior vitrectomy. Why? Because going for too small anterior rhexes like that, what is gonna happen? Capsular phimosis will occur, and you have to cut the phimotic capsule and eat it up with a cutter to clear the visual axis. So you have to go for a second resurgery. And why? Not too large. Not larger than 6 millimeters. It has to be exactly 6 millimeters. Because if we go for more than 6 millimeters, the capsular ring will retract. See here? The capsular ring will retract. Here, retract. Why? Because the anterior and posterior rhexes were originally larger than 6 millimeters. What is gonna happen? A time of secondary IOL implantation, it will be quite difficult. You will have to implant the haptic over a retracted capsular ring. The capsular ring is larger than the IOL optic. So this will make the secondary IOL implantation a little bit difficult. Why anterior vitrectomy is important? To go for anterior vitrectomy, despite having large anterior rhexes, yes, it is very important, and it has to be very good anterior vitrectomy. Because lens epithelial cells, despite doing posterior rhexes and anterior rhexes, they may grow over remnants of anterior vitreous space. And sometimes become… Sometimes increase and obstruct the visual axis. So in these cases, as I said, anterior (audio drop) 6 millimeters combined with anterior vitrectomy. When you do this, what’s gonna happen? In time, the 6 millimeter rings will shrink, and it’s going to be a beautiful capsular support, 5 millimeters in diameter. At time of secondary IOL implantation, you may implant the IOL beautifully in the center. Like that, supported by a 5 millimeter sulcus here. Capsular ring. And the IOL is 6 millimeters. And if you want to refine your surgery, why is it important to go for polishing of the back surface of the anterior capsule in these cases? Because if you don’t polish, you will have in the future a very thick Soemmering ring. At time of secondary IOL implantation. But when you polish, at time of secondary IOL implantation, you’re going to have a beautiful capsular support, where you can implant the IOL over it. It is extremely thin capsular support, beautiful secondary IOL implantation. Moreover, and sometimes it is ideal, thin, and 5 millimeters, so when you inject the IOL and sulcus, you can easily push the IOL optic behind this ring and performing optic capture technique in secondary IOL implantation. Postoperative visual rehabilitation. For cases with bilateral aphakia, we fit the babies immediately with aphakic spectacles. Here, before and after. The choice of the frame and the glasses. The frame — this is the ideal frame to be choosing. It has to be all plastic. Fit beautifully over the nose. And it has to cover the eyebrows. It is suitable for infants below one year of age. And even beautiful for those younger than 6 months. What about glasses? Ultrathin high definition glasses is the best. Look here. This is a conventional glass. This is a 20 diopter glasses. And this is 20 diopter. This is ultrathin high definition glasses. It fits perfectly for children, for infants below 1 year of age, and for infants below 6 months of age. These glasses are +20. It is suitable for even the preterm babies. And it is suitable for older children. And it may delay the IOL implantation, because we can make also these ultrathin high definition multifocal glasses in older children. Unilateral aphakia. We fit them also with ultrathin high definition glasses. And see here, when we fit them with the ultrathin high definition, together with amblyopia therapy, we may achieve straight eyes in these aphakic eyes. Here an eye with ultrathin high definition achieving straight eyes. This is another baby with microphthalmia and congenital cataract. Good amblyopia therapy and unilateral aphakic glasses. Here, straight eyes, waiting for secondary IOL implantation in the future. A few months after surgery, still maintaining straight eyes. This is another baby with congenital cataract and exotropia. Immediately after surgery, there was no fixation. Just a few weeks after surgery, she has a beautiful fixation. With this ultrathin high definition glasses. And here, after secondary IOL implantation, still maintaining straight eyes. For children with bilateral pseudophakia, we fit them with multifocal glasses, with +3 near add. With unilateral pseudophakia, we fit them with the undercorrection in the glasses. We go for amblyopia therapy. Along 9 years. And here attaining straight eyes, together with amblyopia therapy. This is another baby with congenital cataract and sensory exotropia, immediately after surgery. Amblyopia therapy was done. And here ten years after surgery, he has a beautiful clear visual axis and straight eyes. You have to ensure if you’re gonna work on congenital cataract, you have to ensure to go for a very long term follow-up exam. Here before and ten years after surgery. Ten years after surgery. 15 years after surgery. Here 17 years after surgery. They are all doing fine. But sometimes we have to go for even 20 years after surgery. And she brought us her baby, with bilateral congenital cataract. And this is my baby, operated upon 22 years after surgery. Here and then operating his baby. Why? Why this very long term follow-up? Because sometimes complications do occur. This is a baby before surgery. Four years after surgery. Six years after surgery. Ten years after surgery. She was perfectly okay. Secondary IOL implantation. And then she was lost during the follow-up period, and came 17 years after surgery. With very thick glasses and exotropia. She developed secondary open-angle glaucoma. So when dealing with congenital cataract, you have to be extensively meticulous and careful. You have to go for early diagnosis. And you should not forget the systemic work-up. You have to go for a good systemic work-up. To avoid complications during surgery. You have to go for the suitable surgical technique. If you’re gonna implant IOLs, with the rhexis, the anterior should be 5. The posterior should be 4. And implant inside the capsular bag, together with anterior vitrectomy. If you are not going to implant, it should be 6 and 6. Both rhexes, together with anterior vitrectomy. You have to ensure very long term follow-up exams. Why? Because as you saw, complications may occur years and years after surgery. Like open-angle glaucoma. And you have to ensure the compliance of the parents with the amblyopia therapy. Because without amblyopia therapy, it’s as if you did nothing. And finally, to conclude again, you have to be very meticulous and careful to perform a safe and sound surgery, so these adorable babies, when they are no longer visually handicapped after cataract surgery, and it is really a beautiful feeling, to see the reaction of the baby seeing for the first time and wearing the spectacles for the first time. And to see this baby so surprised when seeing for the first time, and then maintaining this beautiful smile along the follow-up periods. And this is another baby wearing the spectacles for the first time. And seeing the world for the first time. He is astonished. Beautiful smile. Looking to the side. And then increasing the large huge beautiful smile. Using his both hands and he is so happy. And then maintaining the smile. It is something adorable when you perform a cataract surgery and you prevent blindness. I wish you all to perform cataract surgery without any complications, and thank you very much for your kind attention.
>> Thank you, Dr. Nihal. We have about 30 questions, if you have some time to go through some of the questions.
DR SHAKANKIRY: The first question is: What are the precautions during secondary IOL implantation, either during first surgery or during secondary IOL implantation later on? With primary cataract surgery, the anterior and posterior rhexes and vitrectomy, it’s going to be very simple. Gonna take just minutes to go. As long as you don’t have any complications. The certain precautions is: You’re gonna have good anesthesia with good muscle relaxants, in order to avoid a high vitreous pressure, and it’s gonna be very simple and easy to go for the secondary IOL implantation. Here at what time do you stain the capsule in congenital cataract routinely? No. I only stain when we have a total cataract. Otherwise, I don’t stain. Where is your preferred surgical position in congenital cataract? At 12:00. How do you have enough anterior vitrectomy? Yes, it is an important question. You have to go for removing a saucer part of the anterior vitreous. You go with the tip. With the vitrectomy inside, just a few millimeters. You can judge. Inside into the anterior vitreous. 1 or 2 millimeters. And removing a part of the vitreous. As I told you, you’re gonna have… There is no need for staining. You can remove all vitreous. You can see the effect of the vitreous in the anterior chamber by kinking of the posterior rhexis. So it’s like a saucer part of the anterior vitreous. Why? When to implant and when not to implant, concerning IOL implantation, it depends upon the bilaterality of the cataract. If the cataract is bilateral, the youngest age to implant is 2 years of age. Why? Because 80% of eye growth occurs in the first two years of life. It is better if the baby is younger than 2, to go for the cataract surgery first, and then we have the beautiful ultrathin high definition glasses. And then after the age of 2 years, you can implant. Because if you implant younger than two years of age, you’re gonna be faced with a myopic shift soon. Concerning unilateral congenital cataract, you are first below two years of age — you are close to implant. At what age? Not less than 6 months. I don’t implant less than 6 months. What do you prefer corneal ones? I prefer anterior approach. It’s very simple and easy to go through the cornea. I don’t like to go through the pars plana. You can do all manipulations through the anterior chamber. Because actually, I did present the straightforward cases. There are many difficulties and many varieties of congenital cataract that has to be dealt with. I cannot of course present all this in this lecture. So when we have difficult cases, it’s better to proceed through the anterior approach, to do all manipulations through the anterior chamber. And as I told you, the anterior vitrectomy is controllable. You saw the cases. And you saw postoperative photos. There is no vitreous in the anterior chamber. And you can control the vitrectomy through anterior approach. Secondary IOL is only in sulcus. No, as I told you, if you have a thin capsular support and it is 5 millimeters in diameter, you can implant the IOL in sulcus and perform optic capture technique. Otherwise, it is beautifully implanted inside the sulcus. Topical medication. How long do you prescribe topical medication? This is a very important question. Number one, I don’t use intracameral steroids. Number two, I inject short acting steroids. And not long acting steroids during surgery. Number three, I taper steroids, along a period of one and a half to two months. And I don’t use systemic steroids. I only use systemic steroids and long acting subconjunctival steroids in cases of uveitic glaucoma. Otherwise, no. Why? Because some babies may develop steroid induced glaucoma. And what is more common is Cushing. Your baby may develop Cushing and you don’t know. So it is preferable not to use steroids that frequently. I don’t use it. Single piece hydrophobic intraocular lens is recommended? Yes. Either a single piece or a multipiece. As I did present. Hydrophobic acrylic lenses inside the capsular bag. I prefer the single. But I can implant both. And of course, concerning the secondary IOL implantation, it has to be multipiece IOL. Time between the primary and secondary surgery? As I told you, the primary surgery — once the baby has cataract unilateral or bilateral, I prefer to go at the age of 2.5, 3 months and not younger. Because proceeding with a cataract surgery very early in the first few weeks, you’re gonna increase the risk of secondary glaucoma. Markedly. I prefer to defer the surgery a little bit, when they are 2.5 or 3 months old. And then the secondary IOL implantation. After the age of 2 years. You can do it at the age of 2, 3, 4. It depends upon the compliance of the baby or the child with the spectacles. How do you choose the IOL power and what do you aim for? Concerning biometry in children, the majority of children are done under general anesthesia. Number one, the eye should be central. Number two, measure the curvature of the cornea using handheld keratometer and the axial length with hand scanned ultrasound. When you come to measure the curvature of the cornea, the pupil should be closed. Because you’re not measuring the visual axis. You’re measuring the pupillary axis. So the pupil has to be closed. Number three, when you put the A-scan over the cornea, you measure from the side. And you put it perpendicular over the cornea. I aim — this is how to measure — I use SRKT. And SRK2. For average axial length. For short eyes, I use Hoffer Q, and then I aim for — if the child is less than 2 years of age, I aim for undercorrection, 4 to 5 diopters. And not more than 4 to 5 diopters, anisometropia between both eyes. And if I’m faced with a myopic shift, it’s very simple to go for IOL exchange, a few years after surgery. Above two years of age, I aim for emmetropia. Do you give steroids preoperatively, systemically? No. Any complications with femtosecond? No. Why femto? The surgery is very simple and easy. To perform with a rhexis, anterior and posterior. I never used a femto, proceeding with a cataract case. What is your comment on vitrectorhexis? Of course, if you have difficult with manual capsulorrhexis, you can go with a cutter. But I prefer to go with a manual rhexis. It is very controllable. You can go for the exact size you want. Thank you for the presentation. At what age do you use IOL at primary surgery? Primary surgery, as I said… 6 months in unilateral cases. And 2 years in bilateral. Child growth and myopic shift? There is no problem with myopic shift. We can be in the future… If I have the chance, we can present how we go for IOL exchange in cases of myopic shift. Duration of occlusion therapy. I prefer four hours a day. And I can gradually taper, when the child fixes. And I continue the amblyopia therapy until the age of nine years. Intracameral antibiotics? We have intracameral. I don’t inject. We have antibiotics inside the solution, the irrigating solution. OVD — I don’t use heavy viscoelastic. The sodium hyaluronate, the usual one. What type? Provisc. Refraction? Lateral aphakia? I do refraction for the bilateral aphakia immediately after surgery. And fit them just a few days after surgery. I fit them with the bilateral aphakic spectacles. How do you correct near vision? Concerning the aphakic spectacles, the babies below two years of age… If, for example, if the refraction is +15 and +18, I do +17. This is below two years of age. After two years of age, I fit them with -1 diopters myopia. And I have the multifocal. You can fit them with aphakic multifocal ultrathin. Aphakic multifocal glasses. They are beautiful. For children with pseudophakia, if it is unilateral, I fit them with the undercorrection, aiming for emmetropia. If they are bilateral pseudophakic and older than 2 years of age and I made undercorrection or emmetrope, I fit them with the glasses with multifocal glasses, and with the near add, +3. Do you use sutures? Of course. I missed this in the lecture. This is very important. Of course. You should close all wounds. Even the side ports. The main wound and the side ports. Do you hydrate? Never hydrate the wound. And you should leave the eye full. Never soft. Why? And why not even… You have to close the side ports. Because slight shallowing, postoperatively, for a few minutes, maybe half an hour or something like that, and the eye is soft, this will incite fibrinous reaction and you will see inflammation on the second postoperative day. So it’s better to leave the eye sutured and full. And the pressure is full. In order to not see inflammation in the second day. Do you ever use aphakic contact lenses? Well, actually, it is not available in Egypt. And I don’t think it’s a good choice for our patients in Egypt. The weather, the humidity. The availability. So I never use aphakic contact lens. Do you prefer bag in the lens technique? No, I never did such a thing. For polar cataract? Well, maybe if I have the chance to present another presentation about polar cataract and defects on how to proceed with these cases. It’s a very long lecture, and we may present it later on.