I always performe anterior vitrectomy by pars plana aproach, irrigation in clear cornea/limbud and vitrectomy in pars plana. It is safer and faster, eliminates the entire vitreous prolapse from behind, minimal traction in posterior segment. I believe every ophthalmic surgeon that performe cataract surgery should master this approach
yes, good thoughts. I do this as well for my cases. In this case the resident wanted to stick to limbal incisions. I will post a video of this technique that you describe in the near future.
I have actually extended a clear corneal incision laterally by taking the blade posterior into sclera as I go. You wind up with a blend of a clear corneal component and a variation of a scleral tunnel at the two sides. In other words you DON'T just extend along the corneal limbus in a concentric fashion. The external lip is straight and tangential and in to the sclera at the left and right sides. You can get a lens loop or a fish hook in there to get the remnant out and not risk dropping pieces. Close it with a single X 10-0 at the center of the incision. It works fine, I've only done it two or three times in the current era of clear corneal incisions, but it does work. Back in the early days of foldable implants with a scleral tunnel, occasionally we had to convert, so we just extended the incision laterally. That was in essence MSICS that we can do today if needed. This extension of a clear corneal incision laterally is basically a very anterior version of that.
To enlarge the wound and convert to sics versus to do phaco in AC with support depends on the grade of nucleus and also skill of surgeon.. In this case of a relatively hard catatact probably converting would have been safer for corneal endothelium.. Also since pcr was big there was the risk of nucleus drop during continuing emulsification.. But Dr. Uday sir u managed it very well.. How was the post op result?
really i would make a scleral tunel and finish the case wit extracapsular aproach... specially in countries where corneas are a luxury... thanks for sharing
When there were more than one heminucleus and posterior capsule ruptured, we would give cohesive viscoelastic under the nuclear material, place an three piece intraoculer lens in the sulcus (under the remaining nuclear pieces) and emulsify those by taking care of not to move the lens (a nightmare scenario would be nucleus and intraocular lens drop, though). This technique is published by Agarwall at al and called as 'iol scaffold technique'. However, that's a good video, appreciated, congrats sir.
that is also a good approach -- the IOL can help form a barrier to keep the nuclear piece in the anterior segment. The only difficulty is that in this case there is already vitreous prolapse. Putting in the IOL would be challenging due to the vitreous prolapse.
I heard about this technique once , how can we remove the remaining cortex in the capsule ? Should we remove it before the IOL implantation while still we have parts of the nucleus or after IOL implantation ?
@@alisalih8935 Once the nucleus removed, every surgeon took a deep breath and would go on his own way. After the nucleus emulsification,I give triamsinolone in the anterior chamber, decentralize the intraocular lens, remove the prolapsing viteous strands in the AC, aspirate the remaining cortex and positioned the three piece lens in the sulcus.
@@alisalih8935 cataractcoach.com/2019/02/04/ruptured-capsule-rescue-anterior-vitrectomy/ and cataractcoach.com/2019/01/22/the-posterior-capsule-is-wide-open-now-what/
Nice video and illustration . In the mentioned settings of anterior vitrectomy probe when we have vitreous cutter in position 2 , will it aspirate the cut vitreous or will just cut it then it will be aspirated in position 3 ?
two modes: Anterior vitrectomy: position 1: irrigation, 2: vit cutter, 3: aspiration (to remove vitreous) and I/A cut: position 1: irrigation, 2: aspiration, 3: vit cutter (to remove cortex)
Why dont you take over the case and finish it faster and with less trauma? What are the postop medication that you give to such complicated cases? Thanks
I certainly help the resident surgeon and you will notice three hands working at many points during the surgery. I am scrubbed with the resident (we use a teaching microscope with two surgeon capability) and I help tremendously. But the young surgeon must learn to handle these tough complications. In just a few months this doctor will begin a solo career and won’t have an assistant in the operating room!
Uday Devgan I agree that everyone should learn how to deal with complicated cases...i just think that in such a complicated case and with a starting surgeon its best if its completed by a professor or a more senior surgeon...avoiding complications is more important to be taught first
@@mohammedghoneem yes, good point. This is a chief resident surgeon who is only a few months away from graduation. This surgeon has already done 200+ cataract surgeries. If it was a first year resident with < 10 surgeries completed, I would certainly just finish the case.
Ninh Tran Completely unrelated question. We are lucky there was no radialization of the rhexis upon forceps anterior capsule puncture. How did we determine this wasn’t an intumescent lens? Would it be wise to use a cystitome (before making main incision) to test for lens leakage?
Yes good points. There is a good article to help differentiate white cataracts. See here cataractcoach.com/2018/05/28/not-all-white-cataracts-are-the-same/
It depends. Sometimes Alcon MA60 with Monarch and B or C cartridge. Other times AMO J&J AR40 with the butterfly injector, or B&L SofPort Li61AO with that injector
Good observation - the red reflex has a whitish tinge to it. In this case, examination of the posterior segment showed only proliferative diabetic retinopathy with extensive fibrovascular changes including a tractional macular detachment. These fibrovascular changes caused the whitish reflex seen in the video.
I always performe anterior vitrectomy by pars plana aproach, irrigation in clear cornea/limbud and vitrectomy in pars plana. It is safer and faster, eliminates the entire vitreous prolapse from behind, minimal traction in posterior segment. I believe every ophthalmic surgeon that performe cataract surgery should master this approach
yes, good thoughts. I do this as well for my cases. In this case the resident wanted to stick to limbal incisions. I will post a video of this technique that you describe in the near future.
Great work deserve to salute you sir and your team.
I have actually extended a clear corneal incision laterally by taking the blade posterior into sclera as I go. You wind up with a blend of a clear corneal component and a variation of a scleral tunnel at the two sides. In other words you DON'T just extend along the corneal limbus in a concentric fashion. The external lip is straight and tangential and in to the sclera at the left and right sides. You can get a lens loop or a fish hook in there to get the remnant out and not risk dropping pieces. Close it with a single X 10-0 at the center of the incision. It works fine, I've only done it two or three times in the current era of clear corneal incisions, but it does work. Back in the early days of foldable implants with a scleral tunnel, occasionally we had to convert, so we just extended the incision laterally. That was in essence MSICS that we can do today if needed. This extension of a clear corneal incision laterally is basically a very anterior version of that.
To enlarge the wound and convert to sics versus to do phaco in AC with support depends on the grade of nucleus and also skill of surgeon.. In this case of a relatively hard catatact probably converting would have been safer for corneal endothelium.. Also since pcr was big there was the risk of nucleus drop during continuing emulsification.. But Dr. Uday sir u managed it very well.. How was the post op result?
really i would make a scleral tunel and finish the case wit extracapsular aproach... specially in countries where corneas are a luxury... thanks for sharing
That is an excellent approach also.
When there were more than one heminucleus and posterior capsule ruptured, we would give cohesive viscoelastic under the nuclear material, place an three piece intraoculer lens in the sulcus (under the remaining nuclear pieces) and emulsify those by taking care of not to move the lens (a nightmare scenario would be nucleus and intraocular lens drop, though). This technique is published by Agarwall at al and called as 'iol scaffold technique'. However, that's a good video, appreciated, congrats sir.
that is also a good approach -- the IOL can help form a barrier to keep the nuclear piece in the anterior segment. The only difficulty is that in this case there is already vitreous prolapse. Putting in the IOL would be challenging due to the vitreous prolapse.
I heard about this technique once , how can we remove the remaining cortex in the capsule ? Should we remove it before the IOL implantation while still we have parts of the nucleus or after IOL implantation ?
@@alisalih8935 Once the nucleus removed, every surgeon took a deep breath and would go on his own way. After the nucleus emulsification,I give triamsinolone in the anterior chamber, decentralize the intraocular lens, remove the prolapsing viteous strands in the AC, aspirate the remaining cortex and positioned the three piece lens in the sulcus.
@@alisalih8935 cataractcoach.com/2019/02/04/ruptured-capsule-rescue-anterior-vitrectomy/
and
cataractcoach.com/2019/01/22/the-posterior-capsule-is-wide-open-now-what/
Nice video and illustration . In the mentioned settings of anterior vitrectomy probe when we have vitreous cutter in position 2 , will it aspirate the cut vitreous or will just cut it then it will be aspirated in position 3 ?
two modes:
Anterior vitrectomy: position 1: irrigation, 2: vit cutter, 3: aspiration (to remove vitreous)
and
I/A cut: position 1: irrigation, 2: aspiration, 3: vit cutter (to remove cortex)
Why dont you take over the case and finish it faster and with less trauma?
What are the postop medication that you give to such complicated cases?
Thanks
I certainly help the resident surgeon and you will notice three hands working at many points during the surgery. I am scrubbed with the resident (we use a teaching microscope with two surgeon capability) and I help tremendously. But the young surgeon must learn to handle these tough complications. In just a few months this doctor will begin a solo career and won’t have an assistant in the operating room!
Nice answer sir! very good teacher
Uday Devgan
I agree that everyone should learn how to deal with complicated cases...i just think that in such a complicated case and with a starting surgeon its best if its completed by a professor or a more senior surgeon...avoiding complications is more important to be taught first
@@mohammedghoneem yes, good point. This is a chief resident surgeon who is only a few months away from graduation. This surgeon has already done 200+ cataract surgeries. If it was a first year resident with < 10 surgeries completed, I would certainly just finish the case.
Uday Devgan great surgery and great desicion making...he was lucky to have you!
Would you please till us about the parameters you used. Thank you very much.
Ninh Tran
Completely unrelated question. We are lucky there was no radialization of the rhexis upon forceps anterior capsule puncture. How did we determine this wasn’t an intumescent lens? Would it be wise to use a cystitome (before making main incision) to test for lens leakage?
Yes good points. There is a good article to help differentiate white cataracts. See here
cataractcoach.com/2018/05/28/not-all-white-cataracts-are-the-same/
Hello Dr Devgan. Which 3 piece IOL model and which cartridge do you use?
Thanks
It depends. Sometimes Alcon MA60 with Monarch and B or C cartridge. Other times AMO J&J AR40 with the butterfly injector, or B&L SofPort Li61AO with that injector
Nice!
thank you!
Doctors be watching this Tutorial before surgery 😄
Hope so!
my heart tells me that there was dropped epinuclues into vitreous appears at min. @4:50 to @5:05
Good observation - the red reflex has a whitish tinge to it. In this case, examination of the posterior segment showed only proliferative diabetic retinopathy with extensive fibrovascular changes including a tractional macular detachment. These fibrovascular changes caused the whitish reflex seen in the video.