This video demonstrates a lens extraction, IOL implantation and a primary posterior capsulotomy in a child with infantile cataract.
Surgery Location: on-board the Orbis Flying Eye Hospital in Can Tho, Vietnam
Surgeon: Dr. Douglas Fredrick, Mount Sinai School of Medicine, USA
Hi. My name is Doug Frederick. I’m a pediatric ophthalmologist. And today, we’re going to be showing a case of a pediatric cataract, infantile cataract where we’re going to do a lens extraction, IOL implantation, and a primary posterior capsulotomy.
So, the first thing we do when you’re going to be placing an implant in a child is, you always prepare the incision that you’re going to use to implant the lens. Now, I always like to have my larger incisions or any incision for that matter, covered by conjunctiva.
So I only use clear corneal incisions on my paracentesis are on my small incision instruments. If I have to make anything larger than a stab incision, I’ll always perform a limbal peritomy and use a small scleral tunnel. So here you can see we’re using, bipolar wet field caurtery to categorize the vessels.
Here you can see we’re making the groove for the lens implant, and we’re going at the posterior surgical limbus. Don’t go too far posterior or your iris will prolapse out. In here, we’re using a crescent blade to create. This is about a two point four millimeter incision.
You don’t need to worry about astigmatism, because you’re going to use vicryl sutures.
And now you can see we’ve made two clear corneal incisions, and we’re gonna be using a by manual irrigation aspiration technique. So you can see on the right hand side, that’s the irrigation. And on the left hand side, and that’s the aspiration needle. It’s actually not just the aspiration needle, but there’s a vitrector.
There’s a twenty three gauge vitrector. And we’re using that to create an anterior capsulotomy. So you can use that to chop open your your capsulotomy. You can see the chamber is nice and well formed. Once you’ve formed your capsulotomy, we turn off the cutting mode, and now we’re just doing, aspiration.
Now, a twenty three gauge tip takes longer than a twenty one or a twenty gauge vitrector, but not as long as twenty five gauge. So twenty three gauge is about the right size for doing, infantile and pediatric cataract. So you see, you take your time. Occasionally, I will turn on the cut mode if I have some sticky cortex that doesn’t want to come. But we always do that in the safety of the center of the chamber.
You can see, we have the irrigation, on the right hand side, on your screen, the aspiration vitrector on the left hand side, and what’s nice about the bimanual technique, you can switch. So here you can see we’ve switched sides. Now the cutter aspirator is on the right hand side of your screen and the irrigation on the left hand side of your screen. So it’s easy to get, three sixty degrees all the way around and get all the cortex out, well, the sulcus.
And you take your time. There’s no rush, when you’re doing a pediatric cataract. Again, just as you’ve seen before, We always like to pull the cortex out of the sulcus before debulking the center of the cataract because we want some of that material to preserve the posterior capsule and make sure you don’t accidentally cause a nick in the posterior capsule. So wait till the end before you get rid of the stuff in the center.
Here you can see we’ve switched back once again. Irrigation is on the right hand side and the aspirator is on the left hand side to get that last little bit of cortex.
You can probably tell, that the the rhexis has tore out a little bit, going to the the right hand side. That’s okay. It’s extremely uncommon for a anterior capsule tear to extend all the way posterior and lose vitreous.
Doesn’t really happen, because we’re not really putting much pressure in the bag. Now we’re using a keratome, that we use to create the wound, to put our, implant in. We’re using a foldable, one piece acrylic lens that we’re putting into the capsular bag.
And even with the bag torn like this, it’s very uncommon for the Iowa to prolapse outside of the bag. During either the course of the surgery or post operatively.
But you can see now we’re using the kuglen Hook to center the IOL within the capsular bag. You can use a Sinsky hook, but either device will work well.
Here we see we’ve switched the Sinsky hook to get it nicely centered. And you see that it’s going to center well. Now we close the wound partially.
We don’t close it all the way, but we we close it enough so we go back to our side port incisions. So we’ve closed the central wound. And now you can see I’m going behind the implant, with the cutter device. And we’re going to see if we can get that capsular the primary capsulotomy started with a cutter.
And sometimes in children, the capsular bag is so elastic. It’s hard to get that initial cut.
So you’ll see we put some viscoelastic behind the implant, and, again, we’re using a assisted tone needle just to start the posterior capsulotomy. Now, some people will show you videos of people doing a primary capsulotomy, That’s difficult, and it does tend to tear out. So all we’re doing is using this to get started to purchase an edge so that the vitrector will cut the posterior capsule better. So you can probably see that.
There’s a little opening. And now we’ve gone back with our cutter. You can see the port is faced downward. We have lots of viscoelastic between the IOL, the implant, and the posterior capsule.
And we’re going to start just by doing a low aspiration. You don’t need a lot of suction on this, because you don’t want to bring vitreous forward.
You also are controlling how much irrigation we have. So again, We don’t wanna overhydrate the vitreous. And we go around and around, in the same way we created the anterior capsulotomy, enlarge in the posterior capsulotomy, taking the time, and again, using a high cutting rate and not too much aspiration. And you can see we have a nice central opening, you want to make your posterior capsidolotomy around five millimeters. It’s unusual to get phimosis and intraocular lens subluxation or dislocation in a child because the bag will shrink right around that implant well. It does stay in in place much better than in your adults who might have, zonular issues.
So again, you can see we’re behind the lens, taking our time, We have good control of the anterior chamber.
We put some viscoelastic in, as well as some miochol. You see the pupil coming down, and you can there’s a little bit of the pupil that’s not coming down all the way. So we’re going to go back with our vitrector, our cutter, just to make sure that there’s no vitreous strands here. So a little bit of chopping to make sure there’s no vitreous strands. Now you can see that the pupil is nice and constricted.
We always close our wounds with a child, never leave a wound open. All we use is a 10-0 vicryl, both for your cornea, as well as for your limbal based scleral incisions.
And again, I always use a corticosteroid. I like beta methazone, and you can use subconjunctival antibiotics or you can use intercameral moxifloxacin or cefuroxime, if you can get it made prepared for you.
Okay. Thank you very much.