Tom is a courageous and engaging young man with advanced Duchenne’s Muscular Dystrophy. Years of steroid treatment have caused him to develop extremely dense cataracts and he is now legally blind. Severe muscular atrophy has left him quadriplegic with very significant respiratory problems that do not permit him to lie flat. Furthermore, even mild sedation could result in life-threatening oxygenation problems.
In this video our team performs cataract surgery without any sedation. Significant assistance is rendered by his mother, an RN who has essentially dedicated her life to caring for her severely disabled son. During the procedure, reverse Trendelenburg positioning, a positive pressure breathing apparatus and special draping to prevent claustrophobia enabled us to optimize his comfort and safety.
Tom now has 20/20 distance and near vision in both eyes without glasses, His remarkable bravery in dealing with this dreaded disease and the dedication of his mother are more than inspirational, and their joy at the recovery of his sight was wonderful to behold. From the vantage point of this surgeon, I can only attest to what my dedicated colleagues already know; this is why we became physicians.
This patient underwent cataract-implant surgery 3 weeks ago, has severe negative dysphotopsia and, fortuitously, a mild hyperopic refractive error.However, the preexisting capsulorhexis is too small to permit the optic to be captured. In this video I demonstrate rhexis enlargement prior to successful capture of the lens optic.
This patient has pseudoexfoliation, shallow anterior chamber, dense nucleus, lax zonule and poor pupillary dilation. I have previously demonstrated the use of capsular retractors for zonular laxity, but here we will see the latest version of these devices as modified by Dr David Chang. I also discuss the causes of chopping difficulties, demonstrate “verticalizing” the chopper, use of a CTR, and discuss IOL selection based on intraoperative findings.
Episode 11: Full Thickness (Penetrating) LRIs to Correct Astigmatism During Multifocal IOL Insertion
During this case I demonstrate the differences between phaco aspiration vs phacoemulsification of the nucleus, as well as the use of Penetrating Limbal Relaxing Incisions to control astigmatism in a multifocal IOL patient. The PLRI nomograms may be downloaded by clicking on the “PLRI Nomogram” button on this page.
Case Description: This man is being treated with Rapaflo because of partial urinary obstruction as a result of benign prostatic hypertrophy, and the drug has caused the iris to become extremely floppy. The video demonstrates several techniques that minimize the chance of iris damage and/or prolapse. A method of toric IOL positioning at the correct meridian in the presence of a miotic pupil is also demonstrated, as are several methods that can be used to maintain pupil dilation in this situation.
Case Description: Here is a very unusual case! This 62 year old man has a cataract and severe keratoconus with a refraction of -20.00 D, -11.00 D of cylinder, and K readings in the 80s! However, he is a very successful hard contact lens wearer and therefore does not require corneal transplantation. I demonstrate how to improve corneal-induced visualization problems during phaco-IOL surgery, and select an IOL with a power that would leave him approximately emmetropic should he eventually undergo transplantation. In the meantime he will remain a successful hard contact lens wearer with improved vision because of the cataract extraction.
Episode 8: Cataract Removal with Insertion of Two iStents for Treatment of Secondary Pseudoexfoliative Glaucoma
Case Description: This female patient presents with very obvious pseudoexfoliation and cataract. While paying attention to her suboptimal zonular status, using my chop technique, I remove her cataract, demonstrate the insertion of 2 iStents to treat her Secondary Pseudoexfoliative Glaucoma and complete the case with IOL implantation.
An 87 year old patient presents with a dense brunescent nuclear cataract, pseudoexfoliation and a central corneal dry spot with opacification. Enhancing my visualization is key, as is being able to constantly visualize the edge of the anterior capsule during phacoemulsification. The use of my second instrument to protect the posterior capsule is also discussed.
Utilizing high vacuum, removal of a 2+ nuclear cataract is accomplished without ultrasound.
This patient exhibits severe corneal gutatta with an endothelial cell count of 368 cells/sq mm, and an extremely shallow anterior chamber. I first perform a pars plana vitrectomy to deepen the anterior chamber followed by cataract surgery using techniques intended to protect the already compromised endothelium. Because of the patient’s anatomy, I again choose to use the Trendelenburg position to obtain better access to the eye. I think you will really enjoy this case!