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!
Pseudoexfoliation and a large nucleus that masks zonule laxity is the situation with this eye in which the anterior capsule behavior during capsulorhexis doesn’t alert the surgeon to the true status of the zonule. Using Trypan Blue, 360º viscodissection, a back crack technique, special techniques to rotate the nucleus, capsule retractors and a CTR, I am able to perform zonule-friendly phaco and IOL insertion in an eye that continues to bring surprises throughout the case. The video is necessarily a bit long but I think you will really enjoy this one!
This month I demonstrate the use of the Trendelenburg position in order to gain adequate access to a “deep set” eye during cataract-implant surgery with toric IOL implantation . The pupil dilates only moderately, and possible pharmacological causes of poor dilation are discussed: several techniques that increase and/or maintain pupil size are demonstrated, as are methods to chop the nucleus and protect the posterior capsule during subincisional cortex removal.
Using a 2.4mm incision, I remove a fairly dense, 3+ brunescent nuclear cataract from a patient whose other eye has only peripheral vision. I demonstrate using trypan blue to aid visualization of the capsulorhexis, and show how an OVD can be used to actually reposition an anterior subcapsular opacity prior to creating the capsulorhexis. A detailed presentation of the impale and chop technique follows with additional pearls including how to keep the phaco tip cool, and the advantage of using a slightly oversized surgical glove.
In our inaugural episode of Mackool Online CME, I demonstrate my standard technique for cataract removal with, in this case, implantation of a Toric IOL. Emphasis is placed on the creation and fluidics of the side port incision, proper alignment of the infusion sleeve prior to phaco, the correct foot position settings I use when chopping the nucleus and final positioning of the toric iol.