Try this technique to increase safety and provide the best visual outcome for your patients with posterior sub-capsular cataracts. (scroll down for full surgical video)
You’ve seen this type of patient many times: a relatively rapid decline in vision over the course of weeks or months with increased glare and issues with oncoming light. With the high contrast Snellen chart, the patient may still be able to achieve 20/40 vision, but with glare testing that drops rapidly, often to 20/200 or worse. These patients are also on the younger side of the spectrum and they may have higher demands for their vision since they are still driving and working. In order to maximize the margin of safety for these posterior sub-capsular cataract (PSC) patients, we can use specialized techniques during cataract surgery.
When we examine these patients at the slit-lamp microscope, the nucleus has only mild to moderate sclerosis and opacity, while there is a central, granular opacity at the posterior capsule. PSC cataracts are associated with diabetes, use of corticosteroids, retinitis pigmentosa, vitamin D deficiency, high myopia, and more.
Typical techniques of nucleus division such as vertical chop, horizontal chop, and divide-and-conquer do not work well if the cataract is primarily PSC with very little nuclear sclerosis. In a young patient with minimal nuclear sclerosis and a soft lens, the groove in divide-and-conquer would have to be very deep, almost the full thickness of the lens, and very close to the posterior capsule in order to get the halves to separate.
For these cases, a better technique may be to use hydro-dissection and hydro-delineation to bring the soft nucleus out of the capsular bag an into the iris plane where it can be aspirated easily. This creates a larger space between the cataract material and the posterior capsule to help avoid inadvertent touching and rupture.
Watch the video here to see how I approach these cases, and then please leave a comment at the end of this post to tell me your technique. Thank you.