This is a great video submitted by Dr. Mohammed Ghoneem from Alexandria, Egypt where he shows his method for successful cataract surgery in an eye with a small pupil, a shallow anterior chamber, and a prior trabeculectomy. We even have iris prolapse to further complicate the situation.
The challenges are dealt with systematically, one by one:
- small pupil: two iris hooks are used to help open the pupil. Typically we use four hooks, but in this case, the two hooks are sufficient. Other options include pupil stretching and pupil expansion rings.
- prior trabeculectomy: this area serves as an outflow pathway and that can make intra-operative phaco fluidics less balanced. Placing viscoleastic in the angle at the trab site can help limit the fluidic loss. Just remember to fully aspirate and remove the viscoelastic at the end of the case so that the trab will function normally post-op.
- shallow AC: by doing phaco in the capsular bag and not at the iris plane or in the AC, the shallow architecture is less of an issue.
- large nucleus: Using the divide-and-conquer technique has the advantage of debulking the central endonucleus prior to creation of the quadrants. With phaco chop, each quadrant would be 25% of the cataract volume, but with divide-and-conquer, the grooves have already removed about 20% of the nucleus volume, so each quadrant will be smaller, about 20% of the cataract volume.
We thank Dr. Ghoneem for his excellent video and we encourage you to submit your surgical videos as well. Videos can be attributed to you or can be anonymous, as you desire.
Click below to learn from this challenging cataract case: